key: cord-0006966-pjddd1ft
authors: nan
title: CIRSE 2012 ABSTRACTS & AUTHOR INDEX: September 15-19 Lisbon, Portugal
date: 2012-09-05
journal: Cardiovasc Intervent Radiol
DOI: 10.1007/s00270-012-0437-6
sha: 0389e091fcfdd388dae118a95a3e8cecd0299ae3
doc_id: 6966
cord_uid: pjddd1ft

nan

1. To review indications for transplant nephrostomy 2. To review technique and results for transplant nephrostomy 3. To review complications of transplant nephrostomy and how to deal with them Concerning renal transplantation, advances in the management of graft rejection have led to improved graft and patient survival rates; however, other types of complications have now become more apparent, e.g. vascular or urological. The most common urological complications following renal transplantation are ureteral obstruction and leak, constituting a significant problem on renal graft's survival. The most important aspects of these complications are early diagnosis and prompt treatment since any retard in their management may lead to renal graft dysfunction or even graft loss. Development in interventional radiology has provided minimally invasive means to treat urological complications with low complication rates. Urological complications including urinary leaks and ureteric obstruction represent the most important subgroup of nonvascular problems. As recorded in most recent studies their incidence ranges from 3% to 8% [1, 2] . The traditional method of treatment of these complications has been surgical revision, which entails an increased risk of graft loss. With the development of percutaneous modes of treatment, interventional radiology offers a viable alternative to surgery, with lower complication rates. Ureteric obstructions that are generally classified as early (3 months) depending on when they occur in relation to the time of transplantation have various causes. Nevertheless, as many studies highlight the significant difference between them in practice is that early stenosis tends to be a result of mechanical causes, such as kinks, edema, blood clots or restrictive submucosal tunnel, whereas late stenosis is provoked by generalized or focal fibrosis resulting from ischemia or rejection [3, 4] . Consequently, the majority of early obstructions are likely to resolve with percutaneous management while late obstructions are prone to recurrency due to fibrotic surrounding environment that cannot be eliminated with any procedure. The most common location of obstruction is at the distal ureter and the uretero-vesical junction and it seems that ischemia resulting from problems in operative technique during harvesting or from high dose of immunosuppression is a major etiological factor for these segmental stenoses [3, 5, 6, 7] . Clinical, laboratory and imaging manifestations of obstructive uropathy, commonly used for proper diagnosis are tenderness or discomfort over the kidney, decrease in urine output, elevated serum urea and creatinine values, hydronephrosis on renal scan, pelvicalyceal dilation on ultrasound examination and relatively normal blood flow on color Doppler ultrasound. There should be high suspicion of this complication in order to be differentiated from rejection, since delay in accurate diagnosis and inappropriate antirejection therapy may result in loss of transplanted kidney as well as increased patient morbidity and mortality. Percutaneous management of ureteral stenosis consists of percutaneous nephrostomy, balloon dilation, insertion of the double J stent and rarely metallic stent placement. Percutaneous nephrostomy is a well-established therapy for urinary drainage in patients with supra-vesical urinary tract obstruction, and for urinary diversion, as in patients with urinary fistulae, leaks, or hemorrhagic cystitis as well as for stone removal and other endoscopic procedures. The other major urologic complication of renal transplantation, id urine leakage, is also prone to percutaneous S4 C RSE CIRSE Abstract Book treatment through nephrostomy and antegrade ureteral endoprosthesis placement, with almost the same technique with that we describe thereafter. In particular, although there is technical diversification among interventional radiologists according to each one's experience, a commonly adopted procedure includes puncture of a dilated calyx by a 22g needle under U/S guidance, as it is usually suggested in any type of nephrostomy. Ultrasound examination is done before in any case, in order to exclude a possible collection in the vicinity, the interference of gut between the graft and the anterior abdominal wall, etc. The calyx to be punctured must be closer to the anterior abdominal wall, without anything like gut or liquid collection interfering between the abdominal wall and the graft, and must also have a straight continuity with the renal pelvis and the ureter, in order to avoid kinking of the guide wires that may lead to complications or failure of the procedure. When the needle tip is within the collecting system, urine is aspirated and contrast medium is injected. If there is no dilation of the collecting system of the transplanted kidney, as in cases with urine leaks, there could be a modification of the method, either to search for a non-dilated calyx with the ultrasound beam, try to get in and, instead of urine aspiration, proceed directly with small diluted contrast medium injections, to verify position in collecting system, or otherwise to delineate the collecting system after intravenous injection of the contrast medium, and try to puncture the calyx with the Ciba needle under fluoroscopic guidance. After verification of correct placement of the Ciba needle into the collecting system, a short 0.18-in guide wire is inserted through the Ciba needle and the calyx up to the renal pelvis or the upper third of the ureter, over which a three-part system sheath is advanced into the renal pelvis. Anatomical information and an assessment of the rate of flow of contrast down the ureter into the bladder are provided from antegrade pyelograms. Afterwards, when there are no signs of hematuria, pain or infection, selective catheterization of stenotic area usually follows. Tract dilation follows and a percutaneous nephrostomy tube is placed at the end. After careful and thorough investigation of the literature, we have assumed that technical success rate of percutaneous management is significantly high (from 58% up to 95%) [7, 8, 9] resulting in amelioration of renal graft function. With regard to procedure-related complications, most studies mention minor complications without permanent damage to the transplanted kidney. The overall complication rate reported by Bhagat et al. [4] was 27% (12 of 45 patients): 7 patients developed infections which resolved with antibiotics, 2 patients experienced urinary leakage at nephrostomy treated adequately by replacing the nephrostomy catheter with another of larger diameter, whereas 3 others necessitated antegrade percutaneous replacement of the catheter. Thus, percutaneous management of ureteral stenosis ameliorates graft function with a low complication rate and low risk of the graft's survival. During the past nine years in our department 47 nephrostomies were performed in 45 patients with renal transplantation. The puncture of the safest calyx was performed using the Seldinger technique as described above. In 44 patients a ureteral endoprothesis was placed through the nephrostomy pathway. A nephrostomy tube placement was possible in all cases (technical success 100%). In 41 patients renal function was ameliorated (91.1%). 1 patient (0.02%) presented massive hemorrhage which was successfully treated with percutaneous intra-arterial superselective catheterization and embolization of the punctured branch of the renal artery. No deaths were assessed to the method (procedure-related mortality was 0%). In conclusion, we suggest that the percutaneous approach is the first-line treatment of choice for ureteral obstruction following kidney transplantation as it shows a low risk for the graft's survival, ameliorates renal function and shows low immediate and long-term complication rates. Surgery should be reserved only for patients who fail to benefit from interventional treatment for its higher rate of graft dysfunction, loss and recurrence. 

Ureteric strictures: how to treat them

Interventional Radiology, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom.

Learning Objectives 1. To review assessment and imaging work-up of ureteric strictures 2. To review technique and results of IR for ureteric strictures 3. To review complications of IR for ureteric strictures and how to deal with them Renal transplantation can make a huge difference to the quality of life for patients with chronic renal failure. There are many reasons for a renal transplant to fail or function poorly and there are numerous postoperative complications. Ureteric problems are the most common and often arise from the vesicoureteric anastomosis. These are most frequently due to ischaemia or technical problems at the time of surgery. Complications at the anastomosis occur in reported incidences of 0 to 33% and present with renal functional impairment due to obstruction, or urine leaks presenting as increased drain output or intra-abdominal collections. Some centres routinely stent transplant ureters in an attempt to reduce the incidence of these complications. When complications occur it is important that they are managed appropriately and using techniques to minimise the need for future intervention and surgery. Initial management of most ureteric strictures is by transplant nephrostomy. These are usually straightforward as the transplant is easily accessible and doesn't move. If the patient is septic I do not perform a nephrostogram due to the risk of sepsis and defer until the kidney has been decompressed for a few days. The ureter can then be assessed with a good quality antegrade study prior to any further intervention. Alternative imaging can be performed with CT or MRI, which can be useful to assess any extrinsic causes of ureteric obstruction. On occasion, cone beam CT performed with an antegrade study can provide useful insight into the aetiology of obstruction. thrill accounting for an arterio-venous fistula. In the long-term secondary rupture of a pseudo aneurysm, cardiac failure due to highflow fistula or progressive renal failure due to a steal phenomenon can be observed. From a pathological point of view, the most common finding are AVF but other lesions can be as well observed, with a lower frequency. These findings can be a false aneurysm and / or an arterio-caliceal fistula (3) Arterio-caliceal fistula even if they likely exist in 100 % when hematuria is present, are seldom demonstrated using imaging because there flow is slow and they may be intermittent. Pseudo-aneurysms are more frequent and are caused by hemorrhage triggered by biopsy-induced damage of the arterial wall. In the course of repair, the endothelium is dissolved leaving a sac continuous with the endoluminal space (4) . Most of them spontaneously thrombose but larger one (> 6 ml i.e. 2.25 cm in diameter) will require treatment by embolization as the risk of rupture is increased at this size (4, 5) . The management is decided as a function of clinical and anatomical parameters. The indication of embolization is not always easy to retain. In case of acute bleeding, embolization should be performed if the bleeding is life or graft threatening. If the bleeding is mild, and the patients have only mild symptoms, a watchful protocol should be proposed. Spontaneous cessation of the bleeding can occur and regular duplex US should be performed in addition to the routine clinical follow-up. As described earlier, in case of pseudo-aneurysm, it is the size of the growth rate of the pseudo aneurysm that will mandate embolization. Large (6ml) pseudo aneurysms should be embolized while small ones can be managed by simple repeated surveillance. When an AVF is discovered during the work up of a progressive deterioration of the renal function, the indication for embolization should be discussed as a function of the size and hemodynamicity of the fistula . Careful discussion of the indication is of importance because embolization carries the risk of renal infarction as it is not always possible to close the fistula without losing some side branches and some kidney parenchyma. In addition, embolization requires using of iodine contrast media that can in itself increase the renal failure. The discussion of the role of the AVF in the deterioration of renal function lies on the potential steal of the renal blood flow from the nephron into the draining vein. Therefore, assessing the hemodynamicity of the AVF is very important. It has been proposed that color duplex ultra-sound can play a role in assessing the relevance of an AVF. The comparison of the main renal artery resistive index (RI) compared with that of the non-AVF associated segmental arteries has a good chance of identifying the hemodynamic relevance of an AVF (2) . Because of early venous drainage in the fistulized arteries, the tissue is underperfused, explaining renal failure (so called steal phenomenon). While in the main renal artery the RI is at least 0.05 higher than in segmental artery, this number is not approached compared with the non-AVF associated segmental normal arteries. Schwartz tested this sign in 4 patients and correctly predicted the success of coiling in all 4 cases (2) . In other words, if a patients presents with an isolated AVF with no other finding, RI measures should be performed. If the main renal artery RI is not at least 0.05 higher than RI in the non-fistulous segmental branches, then hemodynamic relevance of the fistula should be retained and embolization should be performed with a good chance to improve renal function. Other indications which are seldom present can be hypertension by a steal phenomenon that will trigger renin secretion in the ischemic kidney or high-output cardiac failure. The strategy for embolization should follow certain basic rules. First, one should understand that because the biopsy needle will traverse a relatively large amount of tissue, multiple lesions are frequent. This translates into the need of careful assessment of the angio-anatomy and in the need to always check by a global angio with injection into the main renal artery trunk at the end of embolization to make sure that the lesions have all been treated. This is particularly relevant in the acute setting where all AVF and all pseudo-aneurysm should be treated. Usually, the fistula has a caliber large enough to contraindicate the S7 CIRSE 2012 SS/FC/HL/HTS/CM use of liquid or particulate embolics (spheres of PVA). The most frequent material to be recommended are fibered coils and gelfoam. In order to spare as much as possible the RT, microcatheter approach is mandatory in order to be as selective as possible. The use of detachable coils can be of great interest at least for the first coil in order to avoid embolization through the fistula into the venous circulation (6) . Packing of a pseudo-aneurysm is not necessary and represents more a waste of time and money. Once the fistula has been successfully occluded, a selective angiographic control into the main renal artery is needed in order to rule out the presence of another fistula or pseudo-aneurysm that the initial control may have missed (often, the main fistula will steal the flow of contrast and will not allow to depict all fistula). A common trap is also the presence of more than one main artery and the whole kidney inflow should be carefully assessed using multiple injections and projections. Technical success rate is around 90 % and clinical success rate has been reported in small series between 60 and 90 % (2, 6, 7) In brief, a small AVF with no clinical consequence discovered incidentally will not need any treatment while a large one with acute severe bleeding will mandate emergent embolization. Patients presenting with a an AVF should undergo duplex measurements of RI and in case of an RI in the main renal artery not reaching the level of the RI in a normal segmental arteries + 0.05; embolization should be performed in case of renal failure with the aim to improve renal function indication for embolization. Only in specific cases the embolization will be turned down because of clinical conditions.

To discuss what constitutes an off label use of an IR device 2.

To give examples of off label IR device use 3. To discuss the consequences of off label use of IR devices On-label use of a product requires that devices and drugs are used for the correct indication, in the correct anatomy, in the method described in the Instructions For Use (IFU), using the recommended ancillary products. However, modern IR has been largely built on innovation and imagination since Charles Dotter performed the first angioplasty. Every case in IR provides a slightly different technical challenge and procedural success may require the off-label use or modification of a medical device and interventional radiologists pride themselves on their innovative skills and ability to use a device in a different way to achieve their aims or get themselves out of trouble. However, there are serious unexpected potential consequences of modifying medical devices, and UK physicians are warned that "following modification of a CE-marked medical device, the healthcare organization and/or professional could be deemed to be the manufacturer of a new device and may therefore be subject to the requirements of the Medical Devices Regulations." Despite these warnings, audit has shown that off-label use and device modification are common in IR. But radiologists should be very concerned about any and all off-label device usage in their practice. Good practice dictates that the IFU for all devices and drugs used should be read. Radiologists should distinguish between established and nonestablished off-label use but often this cannot be clearly defined.

In the absence of specific advice from national bodies and professional societies, it is left to the individual to decide and, if there is any doubt, to seek the opinion of the risk-management team in their trust. It is time for professional bodies like CIRSE to lobby the industry to negotiate the IFU process.

by a second hospital staff member who signs the form as a witness. The appropriate time for obtaining consent in major procedures is advised as more than 24 hr before the planned procedure, to allow the patient time to digest available information and make an informed decision [2] [3] . When a delay in treatment would jeopardize the health of a patient, and the patient is unable to give informed consent, an exception to the requirement for obtaining informed consent from the patient is made. If the patient is unable to consent and has a legally authorized representative who is available to consent, the treating physician must obtain the informed consent of the representative. When informed consent cannot be obtained from the patient or from his or her legally authorized representative, the physician treating the patient should determine the immediacy of the need for treatment. A physician may provide any treatment or perform any procedure immediately required to prevent serious disability or death or to alleviate great pain and suffering. During the course of an operation or a procedure, a physician may perform any procedure that becomes necessary because of a condition discovered or arising during the operation or the procedure that presents an immediate threat to the life or the health of the patient [4] . The need for immediate treatment is documented in the patient's medical record. Documentation includes all information establishing the nature, immediacy, and magnitude of the problem, and the impossibility of obtaining consent under the circumstances. Any consulting physicians should enter their findings and recommendations in the record. All notes should show the date and time that the determinations were made [5] [6] .

The consent form has two purposes: to minimize legal liability and, more importantly, to inform the patient. A consent form without documentation that specific complications have been discussed would have questionable value [2] . The law applied when exposed to a legal claim also varies among European Nations; however, there are some issues, which are probably consisted among nations. Eventually a lawyer will check for errors or inconsistencies in the patient records and the consent form. The consent document should be available and is often crucial for assessing the chance of a legal claim or for subsequent court decisions. A complete consent form plays an integral role in protecting the physician against claims such as that complications were not explained or alternative therapy was not mentioned. An explained complication puts the physician in a stronger legal position [7] . The legal assessment of a case when a procedure was performed without informed consent or missing components related to a complication is evident. Such a procedure is considered a physical injury to a patient with subsequent potential legal consequences such as a shift in the burden of proof [8] [9] [10] [11] . 1. Principle: particle size and injection technique: To start particle embolization, we should note two fundamental principles in advance. Firstly, the diameter of each target vessel is not uniform even in the same lesion. Second, the commercially available particles have more or less size distribution. Therefore, to perform embolization with particles safely, the following points should be considered: 1) never use particles for lesions with arterio-venous shunting (AVshunt). 2) Start with bigger particles to avoid passage into systemic circulation. However, these need some annotations as follows: 1) early venous drainage must be distinguished from AV-shunt under DSA. Early venous drainage is the finding of intra-venous contrast media passing through terminal capillary vessels where particles never pass through. So we can use particles for cases with early venous drainage. 2) Embolization with bigger particles easily leads to proximal embolization, which cannot stop the inflow of blood to the target area with feeder communications. Generally, except for simple feeders without communications, embolization with bigger size particles is not successful to occlude target vessels effectively. Many cases are associated with communications between feeding vessels in the target lesion. Smaller particles are recommended for use because they can reach closer to the target terminal vessels, resulting in effective embolization. On the other hand, we should bear in mind that smaller particles always have the risk of passage into systemic circulation. To perform embolization with smaller particles, there are two technical points to be followed: 1) Inject slowly. If being infused too fast, particles easily flow into the communicating vessels and migrate to the non-targeted vessels. 2) Use diluted particle-suspension. If suspension density is thick, the particles aggregate to lead proximal embolization. Usually, the recommended minimum particle size is 75-100 microns for liver and 250 microns in other regions to avoid the risk of particles passing into the systemic circulation. In case some events occur, such as decrease of arterial oxygen saturation suggesting particles migration into systemic circulation, we should stop injection of particles of the size immediately. As imaging modalities to evaluate particles passing into systemic circulation, pre-procedural scintigraphy with 99m-Tc-MAA, intra-procedural CT and DSA during injection of particle suspension may be employed. Unfortunately, these imaging modalities cannot be carried out as routine procedures; thus there is no perfect modality available at present.

The goal to terminate injection of particles is disappearance of target vessels and/or tumor stains on DSA image. If such image cannot be obtained with some adequate volume of particles, it means the particle size was too small. Additional injection is recommended with bigger sized particles. However, we should also consider the risk for undesirable proximal embolization.

If there is no risk of particles passing through into systemic circulation, slowly injecting small particles with highly diluted suspension seems to be favorable to achieve better results. However, considering high volume of contrast media and radiation exposure, it is not ideal. To challenge these issues, the following techniques are recommended: 1) Prepare half-diluted particle-suspension as "parent suspension". (If you want to inject 10 times diluted particle-suspension, prepare 5 times diluted particle-suspension). 2) If blood flow velocity does not change, inject parent suspension mixed with the same dose of saline using a small syringe without fluoroscopic examination. Once per 2-5 times injection, evaluate the blood flow velocity using parent suspension mixed with the same dose of contrast media. During injection, rotating or gently shaking the syringe is always necessary to keep the homogeneous status of particle-suspension.

3) When the blood flow velocity becomes decreased, use the parent suspension with the same dose of contrast media, or perform the standard DSA with contrast media. In summary, the keys of embolization with particles are as follows: 1) appropriate size selection of particles that can reach closer to the target terminal vessels without passing into systemic circulation. 2) Adequately diluted particle-suspension and injection speed to avoid undesirable proximal embolization. 3) Injection technique to evaluate blood flow velocity with minimum volume of contrast media and radiation exposure.

hour. This takes about 14 hours and will be finished by 7 am the next day so that the completion thrombolysis can be performed as first case. The dose of Urokinase per hour is 70k units per hour. I almost always place a retrievable IVC filter to prevent pulmonary embolism. The next day preliminary venography can be performed through the infusion catheter, but in more complex cases changing from the 6Fr sheath to an 8Fr angled 55cm guide catheter allows more control and lower volume injections of contrast. It allows aspiration and also a wide range of devices to be used including Angiojet and Trellis devices. These devices can be operated in a way to contain the lytic agent for lysis and then allow aspiration to reduce the total lytic dose to the patient. The angle of the guide catheter also allows rotation during use of the Angiojet so that larger-diameter vessels can be treated more effectively. I use an angioplasty balloon wherever there is persistent narrowing and to help fragment remaining thrombus. If the iliac veins are irregular or narrow I have a low threshold for stenting. It is better to stent longer than shorter, and at the IVC junction, the end of the stent must be matched to the lateral wall of the common iliac vein, not the medial wall. This prevents underplacement and restenosis. Once I have established good flow from calf to IVC, anticoagulation is continued with compression stockings and mobilisation as soon as the popliteal vein puncture has sealed. These patients also benefit from referral to lymphoedema specialists as they provide excellent management of soft tissue oedema which may persist for several days or weeks. At about 1 month the patients return to have their IVC filter removed from a jugular approach. Counselling about DVT is given as they have a higher incidence of further DVT than the normal population. At this time coagulation studies can be performed to identify any thrombophilic tendency.

Surgical reconstruction carries a significant risk of complications and results in many series have been disappointing. In the 1990s an alternative therapy has emerged to treat chronic long-segment iliocaval venous occlusions, namely endovascular recanalisation and stenting. This treatment strategy has been proven to be efficacious in the short term, in many cases with a dramatic reduction in symptoms and a significant increase in quality of life. Several studies have shown very satisfactory results during long-term follow-up. Work up: In our institution the work up of patients with symptomatic chronic ileocaval venous obstruction includes a full (family) history and physical examination. All patients are referred to a dedicated vascular diseases physician to evaluate the presence of any coagulopathy. The imaging work up includes at least a CT of the abdomen and pelvis and a venous duplex ultrasound of both legs. The CT is crucial to identify any external compression for instance by a previously unexpected malignancy, but it also serves to identify any anatomical variant that may have played a causative roll and will inevitably be important for the planned endovascular procedure. It is important to have adequate venous contrast filling distal to the diseased segment to establish the site of venous access during the intervention. A delayed-phase CT may therefore be necessary. In some cases an additional venogram is made before the actual intervention. Procedure: Most patients in our series are on oral anticoagulants at the time of treatment. If not then 100 mg/d apirin is prescribed indefinitely. During the procedure 5000 IU of heparin is administered iv. The procedure is performed under local anaesthesia. As with all procedures in our angiosuites a peripheral iv drip is installed pre procedurally. As the recanalisation of long-standing venous occlusions entails disrupting intravascular adhesions between the front and back walls, venous recanalisations are generally markedly more painful than arterial recanalisations. iv pain medication should therefore be at hand and offered liberally. Some centres perform these procedures under epidural or even general anaesthesia. If the occlusions extend into the common femoral veins, the patient is positioned prone on the angiography table to facilitate access to the popliteal veins, which are punctured under ultrasound guidance. In all other cases, the patient is positioned supine and the femoral veins are accessed bilaterally. In some cases a jugular access may also prove necessary. Phlebograms are made to assess the extent of the disease. Passing of the occlusions is generally performed using a hydrophilic stiff guidewire (Terumo, Tokyo, Japan). A predilatation with an undersized balloon is performed (8mm). Subsequently, the entire segment is stented using self-expandable large-size stents with a high radial force. In the beginning of our series we used the Wallstent (Boston Scientific, Natick MA), which was the only selfexpandable stent available at that time. As this stent has an inherently unpredictable foreshortening during deployment, we currently use the Sinus-XL stent (Optimed, Ettlingen, Germany) which is available in sizes up to 34 mm. A postdilatation with a large-size balloon is finally performed and control phlebograms are made of the entire outflow to the right atrium. A satisfactory result is obtained if rapid uninterrupted outflow is seen and the pre existent collateral varices are not opacified. Learning Objectives 1. Principles and techniques of biliary drainage 2. To review techniques to access the non-dilated biliary tract 3. To review outcomes and complications of treatment Many of the principles of biliary intervention parallel those in the adult population although there are fundamental differences that need to be addressed and understood. The principle differences relate to the range of developmental and acquired biliary disorders that present to the interventional radiologist, their relative rarity outside specialist paediatric liver centres and the differing presentation of these disorders across neonates, infancy, childhood and adolescence. In addition, the developmental biliary disorders may be part of a more complex developmental disorder of the liver and this may influence the indications and interventional technique. The best example of this complexity is biliary atresia. This may form part of the biliary atresia splenic malformation syndrome where situs inversus, polysplenia, malrotation and caval interruption may be associated anatomical anomalies. A second example is the Caroli malformation which may the presenting pathology of a wider ductal plate malformation which could include congenital hepatic fibrosis and renal cystic disease. A further example of this clinical and anatomical complexity is in premature neonates presenting with the inspissated bile plug syndrome where sepsis, assisted ventilation and parenteral nutrition may result in the early presentation of a choledochal malformation or pancreatico-biliary junctional anomaly which would not normally have declared clinically until later life. In all these clinical scenarios percutaneous biliary intervention may be necessary in diagnosis or as a therapeutic manoeuvre to clear the inspissated bile and relieve the obstructive jaundice. A second group where biliary intervention is required is in those children who have previously undergone reconstructive biliary surgery, principally for these developmental disorders. These children require diagnostic or therapeutic biliary intervention either to diagnose or treat strictures. it may be necessary to clear calculi that have formed as a consequence of these strictures or within dilated ectatic ducts which may form part of the intrahepatic component of the original choledochal malformation. A third group to consider is those children who have undergone liver transplantation and develop a biliary complication. There are modified paediatric surgical techniques of splitting donor organs followed by implantation of orthotopic segmental or auxiliary grafts in metabolic disorders or acute liver failure. These may present a diagnostic and interventional challenge as percutaneous intervention is the primary management of many complications thereby reserving surgery for where interventional radiology has failed. In paediatric recipients the objective is to maintain normal liver function and optimal quality of life through childhood, into adolescence and adult life. Therefore, the threshold for confirming, excluding or treating a biliary stricture is low and any impairment of graft function with histological features of biliary injury may require investigation with percutaneous cholangiography. Independent of the pathological disorders is the importance of obtaining informed consent from the parents and the timing and participation of the interventional radiologist in this governance process. A second important and debatable issue is when it is acceptable and necessary to deploy implantable devices such as metallic biliary stents. The principles of the actual technique mirror those in adults. Pre-procedural steps include prophylactic antibiotics and adequate hydration. All procedures require a general anaesthetic with the technique allowing suspended respiration. In most cases of intervention this should be preceded by an MRC. This allows safe planning of the approach under ultrasound guidance. This is of particular importance if there is a dual duct anastomosis as may be the surgical anatomy in left lateral segment grafts where segments II and III may be separately anastomosed to the roux loop. MRC also provides the map of any hidden or undrained biliary segments which may be the important pathological finding and the necessary site for intervention. In the majority of cases the ducts are undilated and measure 2 mms or less. It is therefore often helpful to opacify the ducts with a 23-gauge Chiba needle and leave this in position to intermittently distend the ducts and then use a conventional fine needle introduction system. This will then allow deployment of balloons, stents or transhepatic drains as necessary. The potential complications also mirror those in adults so fundamental to successful outcome and low morbidity is standardised post procedural aftercare and the prompt treatment of these, particularly bleeding and sepsis. This presentation will describe the approach to interventions within the described disorders and will provide guidance not only on technique but also the appropriate indications and importance of consistent selection criteria.

SS/FC/HL/HTS/CM captured by the snare. The wire is then pulled up viathe esophagus and out of the mouth. The gastrostomy tube (12 or 16 French) has a long self-dilating portion with a fixed loop at its tip. With this fixed loop the gastrostomy tube is attached to the looped wire using a slip knot. The G tube is then pulled into the mouth, down the esophagus and into the stomach with traction on the anterior abdominal wall. The tube is pulled into its final position once the internal bumper is felt to engage the anterior wall of the stomach. An external bumper is fitted over the tube and advanced to the skin insertion site to stabilize the stomach firmly against the abdominal wall. No sutures are needed to fix the tube in position. This technique may result in a lower risk of intraperitoneal contamination with gastric contents due to the lack of need for track dilatation or other tube manipulation during the procedure. More importantly, this technique provides a very stable tube that a very low risk of inadvertent loss during the immediate post-procedure period or even later and allows for easy conversion to a gastrojejunostomy tube. If a gastrojejunostomy tube is required for the primary procedure, a 5/6F Corflo enteric tube (Viaysis, San Diego, CA) can be coaxially advanced through the antegrade gastrostomy tube once appropriate jejunal access is obtained with a directional catheter. Procedure: Retrograde technique preparation phase for the remainsthe same with need for colonic delineation and US imaging of the liver and spleen. An NG tube is placed in the gastric lumen for air insufflation of the stomach. Unlike the antegrade technique the stomach is punctured with sterile technique using an 18-gauge needle that contains a pediatric retention suture (Cope pediatric gastrointestinal suture anchor set, Cook, Bloomington, IN). Non-ionic iodine contrast material is injected to confirm the intra-gastric position of the needle, and one retention suture is deployed into the stomach with a 0.035-inch straight guidewire. A fascial dilator is then used to dilate the track to the size of the gastrostomy tube. The gastrostomy tube (8) (9) (10) (11) (12) F Ultrathane MAC-LOC Dawson-Mueller pigtail tube, Cook, Bloomington, IN) is introduced over a guidewire or via a sheath in the case of a gastrostomy button (Kimberly Clark, Roswell, GA) . The retention suture is usually released 14 days post procedure.

Using the retrograde technique a directional catheter and guidewire can then be introduced and maneuvered into the proximal jejunum. The appropriate gastrojejunostomy catheter (8.5 or 10-F Ultrathane pediatric gastrojejunostomy catheter: Cook, Bloomington, IN or pediatric Carey-Alzate tube, Cook, Bloomington, IN) can be introduced over a guidewire during the initial access [4] . Complications: The use of enteral tubes is associated with a variety of complications related to either their initial placement or longterm use and are thus reported as early or late (2-4 weeks after initial placement) complications. Other reports will subdivide the complications into major versus minor [5] . In the largest pediatric retrospective study of enteral access in children, Friedman et al. [6] described 253 tubes (208 G tubes, 41 GJ tubes) placed in children using the retrograde technique. Major complications were identified in 5% of patients, including peritonitis in 3%, subcutaneous abscess (2%), septicemia (1%), gastro-intestinal bleeding (0.4%) and 1 death related to tube insertion (0.4%). No perforation or intestinal obstruction was encountered. Minor complications were seen in 73% of patients, but the majority of these were related to tube maintenance problems such as tube dislodgement (37%), tube leakage (25%), G tube site infection (25%), tube migration (12%), tube obstruction (12%), intussusception (8%) and other including vomiting, abdominal pain, pain at site and bleeding at site (37%). With the retrograde technique it is not uncommon to see some free intra-abdominal air immediately after the procedure. Late or increasing pneumoperitoneum, however, may represent unrecognized bowel perforation or ongoing leak around the G tube site [7] or intermittent tube migration in and out of the tract [8] . In comparison, Towbin et al. described their early experience with the antegrade technique with 24 children [3] . No major complications were seen and 3 skin infections were seen.

Tube dislodgement: If a G/GJ tube dislodges from a mature tract, it is appropriate to replace the tube in the tract immediately after dislodgement as the risk of creating a false tract is minimal. It is critical that a device is placed in the tract which has a French size as close to the dislodged enteral tube as possible to avoid the risk of tract contracture. Should this occur, the tract will need to be dilated to replace the same size feeding tube which can be painful and will most likely require the child to be sedated. If the tract is not mature (i.e. less than 4 weeks old), tube replacement needs to be performed or confirmed with imaging guidance as replacement may result in false tract formation. It is inadvisable to inflate the balloon of a replacement device in a non mature tract until placement is confirmed. The tube can simply be taped to the skin until placement is confirmed. In case of difficult pyloric access, the use of an 8F directional catheter or gastric cannula may be used to overcome a G stoma tract directed towards the fundus. Tube leakage: In the case of tube leakage, several issues need to be addressed. Excessive leakage may lead to patient discomfort and skin breakdown and infection which are difficult to treat [5] .

Leakage is also more frequently seen in patients who are malnourished, have experienced significant weight loss or who are immunocompromised and consequently prone to poor wound healing. When investigating tube leakage a thorough review of the patient's medications and skin care should be performed. In addition visual, inspection of the gastrostomy site should be performed to evaluate for signs of infection, granulation tissue or malfixation of the tube or balloon retraction in the superficial tissues. If necessary, we may place a Hollister disc (Hollister Inc., Libertyville, IL) to safely secure the tube in place and to prevent further pistoning/keyholing of the tube in the stoma tract. Surgical revision may be necessary in some patients [9] . Site Infection: Stoma site infection in children is seen in onefourth of the patients [6] . G tube infection will typically present with spreading erythema and induration, purulent discharge, pain at the stoma site and fever [5] . Cellulitis at the gastrostomy stoma may be bacterial (as described above) or may be chemical (secondary to gastric juices leaking in the subcutaneous tissues). Clinically they are very difficult to distinguish. In practice, antibiotic therapy will be administered for both. If the infection does not respond to local wound care and oral antibiotics, a culture needs to be obtained. In cases where a subcutaneous abscess may have formed, this needs to be drained. Granulation tissue: This can be successfully treated with silver nitrate cauterization. When assessing a stoma site it is important to differentiate between granulation tissue and gastric prolapse. Gastric tissue has identifiable rugae and can be visualized prolapsing through the stoma. Gastric prolapse has a reported incidence of 1. To review current techniques and the tools available 2. To describe different types of catheter insertion 3. To become familiar with innovative techniques for "impossible" venous access Conventional techniques and equipment: Interventional radiology (IR) techniques are increasingly being used for central venous catheter (CVC) insertion in children for many reasons, most of them assumed rather than proven. These include fewer procedural complications, higher success rate irrespective of number of previous catheterizations, more accurate catheter tip position, better cosmetic results and higher venous patency after removal. IR techniques involve the use of ultrasound guidance for venous access, usually followed by fluoroscopy (and sometimes venography) for manipulation of guidewires and positioning of the catheter tip. The most commonly used sites of puncture are the internal jugular, common femoral and arm veins. In small children it is best to use a micropuncture system (21-gauge needle or 22-gauge cannula, 0.018-inch guidewire), and only exchange for a bigger guidewire if a larger catheter (>7 Fr) is to be inserted. As in adults, a peel-away sheath is usually used for tunnelled catheters. Anaesthetic practice varies widely. General anaesthesia is usually better for tunnelled catheters, but peripherally-inserted central venous catheters (PICCs) can be inserted using local anaesthetic with or without sedation. Different types of catheter: A very wide range of PICCs is now available. The choice of PICC will depend on the size of the child and its proposed use. Most tunnelled CVCs are cuffed and are intended for indefinite use. Single-, dual-or triple-lumen Hickman catheters are most often used in patients requiring parenteral nutrition, chemotherapy or bone marrow transplantation. Dual-lumen CVCs with offset tips are used for haemodialysis and occasionally plasmapheresis. Implantable venous port devices are extremely useful in children who require intermittent central venous access. Innovative techniques: Central venous access may become challenging in children who have had many previous CVCs (or attempted insertions), particularly if these were not done using IR techniques. Various innovative IR techniques are used to overcome these problems. These can be considered under three headings: the use of unconventional veins, the use of collateral venous pathways, and recanalization of occluded central veins. Unconventional veins: The brachiocephalic (innominate) veins should usually be the first choice when the internal and external jugular, subclavian and common femoral veins are all occluded or unavailable for other reasons. These are easy to see and puncture with ultrasound in children, and even large catheters can be inserted and removed without bleeding complications (unpublished data on 290 procedures from our centre). The hepatic veins are easy to puncture, but in small children tunnelled transhepatic catheters have a tendency to migrate to the peritoneal cavity, and we avoid this approach where possible. A direct translumbar approach to the inferior vena cava has been used in children, but is rarely necessary. Collateral veins: Chronic venous obstruction inevitably leads to the enlargement of collateral pathways, which may be used for central venous access. In the neck, the anterior jugular vein and jugular arch may be punctured for CVC insertion. Tributaries of the azygos vein including superior and posterior intercostal veins may be used when the level of obstruction is above the azygos confluence with the superior vena cava. When the external iliac vein is occluded the obturator vein can often be identified with ultrasound in the adductor compartment of the thigh . When this vein can be punctured it S17 CIRSE 2012 SS/FC/HL/HTS/CM is usually easy to pass a guidewire up the internal and common iliac veins and insert a CVC.

Unblocking of thrombosed veins, by itself or in combination with the use of collateral veins, is a very useful method of re-establishing access in the "impossible" patient. This requires puncture peripheral to the occlusion and production of a venographic roadmap to facilitate its crossing. Access from both sides of the obstruction is often helpful. Blunt recanalization (with the usual end of a guidewire) is almost always successful in fresh thrombus, but is also often adequate in subacute occlusions. When this does not work, sharp recanalization (with the sharp end of the guidewire, or with an intravascular needle) may be attempted, usually with biplane fluoroscopy. More recently we have used a radiofrequency wire to cross chronic occlusions. Sometimes it is necessary to insert stents after recanalization. It is important to realise that although these are unlikely to remain patent, they are very useful for future access. If the peripheral end of the stented segment can be visualized with ultrasound, it can be accessed with a needle. Once the needle is inside the stent it is certain to be intravascular, and it can therefore be safely advanced using fluoroscopy (biplane where appropriate) to access the central venous circulation.

Hepatic RFA: how I do it

Dept of Radiology, Minimally Invasive Therapies and Nuclearmedicine, SLK-Clinics GmbH Heilbronn, Ruprecht-Karls-University Heidelberg, Heilbronn, Germany.

Learning Objectives 1. To discuss indications and contraindications for RFA of liver tumours 2. To describe requirements for pre-treatment imaging 3. To describe available devices for RFA and how to select them according to tumour characteristics Image-guided ablation by means of thermal procedure has increased in importance over the past 15 years into an effective therapy for the treatment of hepatic, renal, and pulmonal malignancies. In the 90s, radiofrequency (RF) ablation of malignant liver tumors has been studied within feasibility studies and first long-term results have been reported during the 90s. For image-guided hepatic tumor treatment using RF-ablation, up to six RF-applicators may be positioned into the targeted tumor using imaging for guidance. A coagulation necrosis takes place in the surrounding tissue after energy application by temperature between 60° and 100°C; an irreversible protein denaturation as well as a destruction of the DNA structures occurs. One challenge for hepatic RF-ablation is the dual blood flow of the liver. The arteries and especially the portal vein blood flow leads to a significant loss of produced heat through transport (perfusion mediated cooling) or direct cooling (heat sink effect), the so-called thermal convection. This heat loss markedly reduces invivo the size of the coagulative necrosis. Hence, the change in the blood flow by way of a reduction in the perfusion would offer a further possibility to increase the size of the thermal-induced lesion. At least, one of the most important purposes in the field of liver RF-therapy is to obtain a complete destruction of the pathological tissue within one setting. In the case of liver malignancy larger than 3.5 cm, there is a large risk that the tumor will not be fully destroyed through thermal ablation in one setting. However, the used imaging modality, the skill of the interventionalist, and the patient selection play a significant role in the success of thermoablation. Hence, a combined therapy, e.g. embolization with RF-ablation can lead to improved clinical results. At least, the use of image procedure for the monitoring of RF-ablation needs to be critically viewed. US has its major limitations due to the acoustic shadow and the hyperechoic signal produced during RF ablation, which means that the delineation of the tumor remains difficult to determine during ablation. CT often has not enough sensitivity for the detection of the tumor due to the equilibrium phase. This is especially true if several tumors have to be treated in one setting. RF-ablation under MRI appears to be very promising due to its intrinsic excellent soft-tissue contrast, multiplanar capabilities, and high spatial resolution. electrode when you are performing overlapping ablations. Lesions may be difficult to accurately see and target with non-contrast CT and image guidance may become obscured with ultrasound. Recent technological advances allowing the use of CT fluoroscopy and PET/ CT fusion during ablation may be used to increase accuracy of tumor targeting. The evaluation of the ablation defect by imaging is critical and should be performed after each ablation session. A 3-phase contrast-enhanced CT at the end of the ablation is the author's recommendation and should be performed in every case unless if there is a clinical contraindication to the administration of contrast. Passing the electrode through liver parenchyma and tract ablation is recommended whenever possible to diminish the possibility of track seeding as well as bleeding. Earlier reports of alarming needle tract seeding rates were observed after ablation of subcapsular HCC. Lesions at difficult locations such as at the liver dome, diaphragm or segment 2 lesions near the pericardium pose several technical challenges and may be associated with increased risks. Several techniques can be used to overcome these challenges: use of general anesthesia for respiration control, pre-ablation arterial embolization with radiopaque particles (or lipiodol) for lesion identification (especially for echo-poor lesions), use of single electrode (no tines) probes or microwave ablation instead of RFA. Hydrodissection performed with the instillation of Dextrose (D5 W) can be used to push the liver away from the dome or from an adjacent organ such as the pericardium. CT fluoroscopy and MRI guidance may also diminish difficulties when targeting lesions in difficult locations. In general, every effort should be made to perform a safe ablation with clear margins. Liver tumor ablation is a relatively low risk procedure. The following table shows the types and reported rates of complications as well as relevant risks factors that may predispose to a complication.

Risk factor(s) Risks of percutaneous RF ablation specifically for HCC The most severe complication is liver failure that can be fatal. This is an extremely rare complication; however, the risk increases as the hepatic reserve decreases and the ablation volume increases. For patients with compensated liver function and single ablation the risk of liver failure is reported to be about or less than 1%. Risks related to any liver tumor ablation Proper procedure planning and prophylactic techniques such as hydrodissection will keep complications low and will allow the performance of safe ablations even when the lesions are in challenging positions. Pneumothorax during ablation of liver lesions can occur when treating lesions near the diaphragmatic dome. Similar to lung ablation, thoracostomy will manage the pneumothorax and will allow the completion of the ablation treatment in the vast majority of patients. Liver abscess is probably the most common complication in patients with compromised sphincter of Oddi (after any biliary intervention S19 CIRSE 2012 SS/FC/HL/HTS/CM such as stent placement, or reconstruction, post-Whipple procedure). In this particular subset of patients the risk of abscess formation after any locoregional hepatic treatment including ablation is very high approaching 80%. Proper identification of this population and coverage with bile excreted antibiotics is essential to decrease this risk. Follow up Most centers advocate an initial follow up with contrastenhanced CT or MRI at 4-8 weeks after ablation and every 3 months thereafter. It is important to use the initial post-ablation scan as a new baseline for all future comparisons. According to ablation reporting standards this initial post-ablation imaging scan should be used for the evaluation of technique effectiveness that is represented by an ablation defect completely covering the lesion and no evidence of residual tumor. The ablation defect and the lack of contrast enhancement are considered surrogates for tumor necrosis and effective ablation. The ablation defect should be larger than the original lesion. Ideally it should provide a uniform margin around the tumor of 10 mm. A 5-mm margin is considered the minimum technical requirement for ablation with curative intent. Subsequent scans should show a reduction in size of the ablation defect albeit unpredictably. After ablation, tumor markers and PET scans can be used to detect residual or recurrent disease; especially for PET avid lesions such as colon and breast metastases. As a matter of fact in these types of lesions PET CT may detect local tumor progression (recurrence) earlier than dynamic CT or MRI. Evidence-based practice For hepatomas smaller than 3 cm in patients who are not liver transplant candidates, RFA has been repeatedly shown to be equivalent to surgical resection with fewer complications. Several series have also shown that ablation may provide further survival benefit to patients with larger hepatomas when added to an embolization treatment including small particle bland embolization and TACE. Series of ablation for colon cancer liver metastases (CLM) up to 3 cm have shown comparable results to historic survival data after hepatectomy despite a relatively higher rate of local tumor progression after percutaneous ablation. Most recent studies applied a clinical risk score system that correlated well with local tumor progression free and overall survival after percutaneous RF ablation of colon cancer liver metastases recurring after hepatectomy. Similar to previously described surgical risk score, the modified clinical risk score took into consideration the presence of lymph node involvement at the time of the primary tumor resection, the disease-free interval from time of primary diagnosis to the detection of liver metastasis, the size of the tumor and the total number of liver tumors at the time of the ablation. Patients that accumulated a low risk score (up to 2 risk factors) had prolonged survivals when compared to those with scores of 3 or higher. It is reasonable to offer ablation as the first treatment of a small CLM within the concept of the "Test of time". This concept requires very close follow-up of the treated patients. Those that recur locally must be retreated with ablation or surgery. Those who recur in multiple sites and often extrahepatic sites are not candidates for locoregional treatment but have been spared an unnecessary hepatectomy that carries significant morbidity and not negligible mortality. Finally, those that remain without recurrence are considered treated by the ablation and must continue follow-up for several years. The Test of time approach originally described by Livraghi et al, for the management of CLM patients awaiting resection is a valuable concept that allows the tumor to declare its true nature while the liver disease is controlled. This can be applied in several types of tumors with liver only metastases that undergo any IR locoregional treatment for tumor control.

In conclusion, percutaneous ablation is an excellent therapeutic option for well-selected patients that have relatively small tumors that can be ablated with sufficient margins (at least 5 mm all around the tumor). In such cases one might consider ablation instead of surgery within the concept of the "Test of time" and well regimented clinical and imaging follow-up for the prompt detection and retreatment of any recurrence.

38. Goldberg In press. is therefore both a diagnostic and a therapeutic procedure in such patients. Few studies have compared angiography and embolization with surgery for GI-hemorrhage, but the available evidence (mainly for upper GI-hemorrhage) suggests that angiography and embolization are not inferior to surgery. In poor surgical candidates there is a clear advantage for angiography and embolization. For lower GI-hemorrhage good comparative literature is lacking, but the diagnostic potential of angiography is strongly in favour of performing angiography and embolization before considering surgery. Surgery should always be available as a back-up procedure when angiography and embolization fail, and it is therefore wise to always involve surgery early in the treatment of GI-hemorrhage. With the increasing role of CT-angiography algorithms may of course change.

In some situations surgery may be preferred over angiography and embolization, such as hemorrhage from a tumor, which may be difficult to embolize and would require resection anyway. In summary, most treatment algorithms will include endoscopy as a first line diagnostic test as well as treatment for GI-hemorrhage. Angiography should be the next step when endoscopy fails at obtaining hemostasis, when bleeding recurs after al least two endoscopic attempts at treatment or when the bleeding site cannot be reached endoscopically. Angiography and embolization should be used as the initial treatment modality when bleeding is suspected from pancreas, bile ducts or visceral (pseudo) aneurysms or when anatomy precludes endoscopy. Surgery should be reserved for cases where both endoscopy and angiography and embolization fail or in cases where resection of a bleeding lesion (e.g. tumor) is required. Of course such an algorithm can only be implemented when IR offers 24/7 service and skilled operators.

Radiology, The Royal Marsden Hospital, London, United Kingdom.

1. To understand the concept of different embolics 2. To understand the specific caveats of different embolics 3. To learn about the results of the current literature Recent advances in microcatheter technology, development of newer embolic agents and evolution of interventional skills have made transcatheter embolization the gold standard treatment for life-threatening gastrointestinal haemorrhage (GI) refractory to endoscopic haemostasis. Transcatheter embolization in GI haemorrhage is associated with an initial bleeding control rates 69-100%, with most series achieving more than 80% technical success. Clinical success rates range from 52 to 98% with most reports showing success rates between 70 and 80%. Every effort should be made to perform embolization as soon as possible after bleeding onset and to aggressively correct coagulation disorders since these two factors are the main predictors of early re-bleeding and poor outcomes. Selection of embolic agent remains a matter of debate and coils; particulate material such as resorbable gelatin sponge, and nonresorbable polyvinyl alcohol (PVA) or trisacryl gelatin particles have all been used alone in conjunction with various rates of success. Liquid agents such as N-butyl 2-cyanoacrylate (NBCA) glue or ethylenevinyl alcohol copolymer (Onyx®, Micro Therapeutics, Inc., Irvine, CA, USA) have also been used successfully mainly for upper GI haemorrhage. The selection of the adequate embolic agent is strongly dependent on the location of the bleeding site, selectivity of the microcatheter position in relation to the source artery, and the interventional radiologist's expertise. Microcoils have been widely considered to be the workforce for both upper and lower GI tract haemorrhage embolization. The main advantages of using coils are that they can be delivered in a very precise fashion and carry very low risk of infarction because of the preservation of the microvasculature. Owing to the great number of disposable microcoils,

C RSE CIRSE Abstract Book variants may be chosen that re-form to the exact size of the respective artery. They may have thrombogenic fibers to facilitate occlusion of the vessel and they may offer the option of detachability and retrievability. A further striking benefit is that microcoils may serve as an intraoperative marker if focal segmental resection seems inevitable. The main drawback is that they are permanent and may preclude re-accessing the vessel in the future should it prove necessary. Another disadvantage is that coil application is dependent upon vessel diameter and intrinsic blood clotting and rebleeding could occur in cases of severe coagulopathy. Particles such as PVA particles and tris-acryl gelatine microspheres may be of advantage when a flow-directed strategy is favorable, e.g. bleeding tumours. These agents have been used successfully in treating gastrointestinal haemorrhage, usually through a microcatheter and at a site distal to major vessels [60] . Only larger particles (> 500 μm) should be used to decrease the risk of ischemia from normal tissue devascularization. However, because PVA particles are only indirectly visible, they are difficult to control. In addition, if smaller PVA particles are selected, there seems to be an increased risk of ischemia because the intramural collateral microcirculation may be impaired. It is also supposed that larger PVA particles may fragment and approach the submucosal plexus. Gelatin sponge is the main temporary embolic agent used worldwide. It has the advantage that after resorption, flow will be restored weeks after embolization. Furthermore, it is readily available, cheap and unlikely to cause ischemia. The disadvantages are that it requires some time to prepare appropriate-sized particles and the pace of recanalization is unpredictable. A few studies have showed that there is a higher rate of bleeding recurrence when gelatin sponge is used alone. Gelatin sponge as the only embolic agent guarantees only short-term results and should probably be avoided. Good results have also been reported with NBCA glue, especially in the upper GI bleeding. The use of NBCA glue is particularly of interest in hemodynamically unstable patients and in cases of underlying coagulopathy. However, the use of NBCA glue requires training and considerable experience, given the risk of bowel infarction and glue reflux into other vessels. Reflux of NBCA may also result in its polymerization to the catheter tip. This bit of NBCA may then be stripped from the catheter during catheter retraction, resulting in nontarget embolization. The use of a proper technique, including prompt removal of the catheter after injection as well as aspiration of the guide catheter after microcatheter removal, can significantly reduce this risk. Another drawback is the potential risk of bowel stenosis over the long term. Onyx® seems to have great potential as a liquid embolic agent in embolotherapy of acute arterial gastrointestinal bleeding. In the only published study the success rate was high (81%) and the complication rate was almost nil. The main advantages of Onyx® are its nonadhesive properties, high radiopacity and long solidification periods. These properties of Onyx® compared with acrylic glues make the embolization procedure more controllable and predictable. The excessively high price is currently the main limiting factor in the widespread use of Onyx for this application. 1. To learn how to define the treatment indication 2. To understand how to select the systemic or endovascular way of treatment 3. To learn how to select the endovascular choice of treatment based on clinical setting Treatment algorithms in the acute stroke setting are primarily tailored according to the time elapsed from symptom onset to admission. In patients presenting within 3 hours of symptom onset, systemic thrombolysis by intravenous recombinant tissue plasminogen activator (rtPA) can be administered unless there is a contraindication to the therapy. Intravenous rtPA, which is currently the only approved treatment for acute ischemic stroke, given at a dose of 0.9 mg/kg (10% given as a bolus, remainder given over 1 hour, maximum dose 90 mg) within 3 hours of symptom onset has been shown to significantly improve functional outcome at 3 months when compared with placebo [1] [2] [3] . Meta-analysis of randomized trials of intravenous rtPA (NINDS, ECASS-I, ECASS-II, ATLANTIS) show an absolute increase of ~12% in number of patients achieving a modified Rankin Scale between 0 and 2 with intravenous rtPA treatment compared with placebo [1] [2] [3] . However, only less than 5% of patients with ischemic stroke can be treated with intravenous rtPA in the real-world setting either due to the narrow therapeutic time window or contraindications for treatment [4] . Furthermore, the effectiveness of intravenous thrombolysis is poor in patients with proximal arterial occlusions; intravenous rtPA establishes recanalization in less than 25% of patients with internal carotid artery or middle cerebral artery occlusion [5] . Although the percentage of patients receiving systemic thrombolysis might increase in the near future by extension of time window for treatment to 4.5 hours after symptom onset, based on the results of the ECASS-3 trial [6] , there will still be a significant number of patients with acute ischemic stroke who will not receive intravenous rtPA or will not benefit from this treatment. Intra-arterial thrombolysis is considered as an attractive therapeutic option in such patients. The only prospective randomized trial that tested the efficacy and safety of intra-arterial thrombolysis was the PROACT-II trial, which compared intra-arterial prourokinase plus heparin with heparin alone in ischemic stroke patients secondary to middle cerebral artery occlusion admitted within 6 hours of symptom onset [7] . 40% of the patients in the prourokinase arm had a modified Rankin scale of 0-2 at 3 months, while 25% of the patients in the heparin only arm had favorable outcome. Despite these results, the treatment was not approved by the FDA and intra-arterial prourokinase did not become a standard of care in patients presenting within 6 hours of symptom onset. Until now, no placebo-controlled trial has evaluated the use of intra-arterial rtPA in the setting of acute ischemic stroke. Similarly, no placebo-controlled trial has been performed with mechanical clot retrieval devices. However, the MERCI clot retriever and the Penumbra system have been approved by the FDA as thrombectomy tools for clot removal from cerebral blood vessels, based on prospective, nonrandomized multicenter trials showing the efficacy and safety of these devices in patients with large vessel occlusions presenting within 8 hours of symptom onset [8, 9] . Recently, by the completion of the SWIFT trial the Solitaire revascularization device has also applied the FDA for clearance to be used in the acute stroke setting. Bridging of intravenous thrombolysis and intra-arterial treatment is also a therapeutic alternative in patients unresponsive to intravenous rtPA. A pilot study has shown the feasibility and safety of intra-arterial treatment after intravenous rtPA [10] . The ongoing multi-center randomized IMS-III trial is now testing the efficacy of this approach versus intravenous rtPA alone. Intravenous rtPA is the standard of care for all eligible ischemic stroke patients presenting within 3 hours of symptom onset.

The selection of patients that should be treated by systemic thrombolysis is clearly outlined in the current acute ischemic stroke management guidelines [11] . On the other hand, the selection of patients for intra-arterial thrombolysis is a challenging process. A number of clinical or imaging criteria are currently used to guide clinicians to identify patients that could benefit from intra-arterial thrombolysis, albeit no level I evidence is present for the efficacy of this treatment in such patients: Patients with acute ischemic stroke presenting within 3 hours of symptom onset, but who have contraindications for systemic thrombolysis might be considered for intra-arterial thrombolysis. In patients with recent history of surgery, gastrointestinal or genitourinary hemorrhage, myocardial infarction or coagulopathy systemic side effects can be minimized by intra-arterial thrombolysis, during which a low dose of fibrinolytic agent is used or no fibrinolytic is used at all. The site of arterial occlusion is a key-factor in the decision algorithm for intra-arterial thrombolysis. This therapeutic option is considered for patients with proximal arterial occlusions and high clot burden, like internal carotid artery, middle cerebral artery stem and basilar artery occlusions. The vascular status should be evaluated by a non-invasive method like computerized tomography angiography, magnetic resonance angiography or transcranial Doppler ultrasonography in all patients with acute ischemic stroke for the possibility of an intra-arterial intervention. As there is currently no randomized trial comparing the efficacy and safety of intravenous thrombolysis vs. intra-arterial thrombolysis, it is unknown whether patients with proximal arterial occlusions should be directly taken to the angiography suite even if admitted within 3 hours of symptom onset. However, bridging of intravenous and intra-arterial thrombolysis can always be considered as an option in such patients. Aside from arterial status, the presence of salvageable brain tissue is critical to attain maximum benefit from intra-arterial thrombolysis. The presence of clinical-diffusion mismatch, diffusion-perfusion mismatch or CBV-MTT mismatch can be used to identify patients with significant amount of ischemic penumbra that might be salvaged by recanalization and reperfu-1. To learn the indications of IR treatment of acute stroke 2. To learn the contraindications of IR treatment of acute stroke 3. To learn how to define treatment indications and contraindications based on evidence We will discuss the indications and contraindications for endovascular treatment of ischemic stroke, based on the literature and our experience of more than 4 years, and that are summarized below: Indications: 1. Age: 18 through 80 years. 2. A National Institute of Health Stroke Scale (NIHSS) score≥8 or lower if there was fluctuation of symptoms. 3. Time from symptom onset <8 hours in the anteriorcirculation and <12hours in the posterior circulation. There is nowadays a trend towards shifting the time limit for a "penumbra-based" selection of candidates with multiparametric imaging techniques (PWI-MRI and CTP). 4. Absence of large signs of ischemia on admission brain imaging (non-enhanced CT ASPECTS ≥7 or MR diffusion-weighted lesion <50% of the middle cerebral artery territory). 5. Demonstration of large vessel occlusion in the anterior or posterior circulation either by CTA, MRA or transcranial color-coded Duplex sonography. Treatable vessels are: terminus internal carotid artery (ICA), tandem proximal ICA/middle cerebral artery, middle cerebral artery M1 and M2 divisions, and vertebrobasilar system. 6 . Contraindication to IV fibrinolysis as: recent surgery, disease or condition that carries risk of bleeding (INR> 1.7 or elevated APTT, platelet count <100,000, doses of LMWH in last 12 h, treatment with any of the new anticoagulants dabigatran, apixaban, ribaroxaban, etc., previous coronary or carotid revascularization, stroke in last 6 weeks, tumors, recent trauma, etc.). 7. Basilar artery occlusions within <12 hours from symptoms onset, or within the first 48 hours if the onset of the neurological deficit is progressive, fluctuating, or preceded by TIAs. 8. Patients who have not recanalized with IV fibrinolysis (rescue therapy). If the start of the rescue (endovascular therapy) is delayed more than 90 minutes from start of administration of IV alteplase, or has exceeded the time window of 4.5 hours of symptoms onset, an additional multiparametric neuroimaging test is warranted, prior to the IA rescue, preferably a multimodal RMI to better patient selection. Contraindications: 1. Minor stroke or lacunar infarct suspected.

SS/FC/HL/HTS/CM 2. Patients with seizures at onset of stroke, unless it is proved the presence of cerebral ischemia or arterial occlusion neuroimaging/ neurosonology. 3. Should be excluded abolition of brainstem reflexes or presence of large hypodensity on CT or extensive injury in DWI. 4 . Systolic blood pressure >185 or diastolic blood pressure >110 or aggressive IV therapy needed to reduce the blood pressure (>2 doses IV or need continuous infusion). 5. Blood glucose level <50 or >400 mg/dl. 6 . Anticoagulation with INR>3, Heparin and APTT>2 times the normal limit. 7. Low molecular weight heparin (dose anticoagulants) in the last 12 hours. 8. Platelets <30,000. 9. Known bleeding diathesis with INR>3. 10. CT ASPECTS <7 or evidence of ischemic injury in the Flair MR sequence or absence of DWI-PWI mismatch. 11. Intracranial hemorrhage in admission neuroimaging. 12. Absence of arterial occlusion, visualized by angioTC/MRA, or else by TCD. 13 . Proximal stenosis to the arterial occlusion that may hinder the passage of the mechanical thrombectomy device. This is a relative contraindication because angioplasty can be performed before passing the device. 

Organisational aspects of providing an IR stroke service

Dept. of Neuroradiology, University Erlangen-Nuremberg, Erlangen, Germany.

Learning Objectives 1. As an interventionist who wants to start a stroke practice, to learn what one needs to establish in an angiography lab in terms of equipments and tools for an efficient stroke team 2. As an interventionist who wants to start a stroke practice, to learn how to organize interdisciplinary logistics for efficient stroke service 3. To learn what the optimal workflow of stroke service can be The management of acute ischemic stroke is rapidly developing. Clinical data suggest that interventional stroke treatment may provide superior clinical outcomes when compared with intravenous thrombolytic therapy only. However, organized and comprehensive stroke care is currently delivered in only a few cerebrovascular centers providing an efficient system for rapid diagnosis and especially dedicated interventional stroke treatment. Delivery of expert and timely neuroendovascular interventions to a large number of acute stroke patients is challenging. This objective has fueled the concept of regional stroke centers of excellence for comprehensive care of these patients. The current presentation focuses on the organisational aspects necessary for providing a neurointerventional radiology stroke service. There are a number of key areas supported by evidence-based medicine necessary for a high-level interventional stroke service. As a precondition, a neurointerventional stroke service has to be organised within a multidisciplinary acute stroke team with stroke-trained physicians, ideally stroke neurologists and nurses, with an in-house emergency department, established intravenous rt-PA protocols, rapid laboratory testing, and advanced neuroimaging capabilities. At least brain CT imaging -ideally multimodal MRI using perfusion imaging and various types of cerebral angiography -should be available 24h/7d with imaging priority for stroke patients. In the crucial patient selection for subsequent aggressive therapies the combination of various imaging techniques may help to differentiate patients who may profit from intravenous or interventional therapy in an even extended time window from those who do not. Most importantly, a team of specialized neurointerventionalists -ideally also familiar with the wide spectrum of intracranial endovascular techniques -is available 24/7 with access to interventional angiographic infrastructure. In addition to neurointensive care, a stroke unit or intermediate care beds for close follow-up monitoring and postinterventional care, other components such as neurosurgery, anesthesiology and vascular surgery are considered necessary in an neurointerventional stroke center. Other elements crucial to organized stroke care include the pre-and postclinical phase with triage and diagnosis in the field, telemedicine, transportation, triage and imaging in the emergency department, rehabilitation, prevention and reimbursement issues. Administrative support, strong leadership, and continuing education are additional important elements for a high-level interdisciplinary stroke center. Integration of these elements into a coordinated hospital-based program or system is likely to improve outcomes of patients with strokes and complex cerebrovascular disease who require the services of a dedicated stroke center. This again emphasizes the importance of a multidisciplinary collaboration on professional as well as societal levels. To learn about technical aspects of contralateral and ipsilateral approach 3. To learn how to decide between the ipsilateral and the contralateral approach Endovascular treatment of iliac disease including the aortic bifurcation is well established and represents the therapeutic option of choice with regard to the TASC 2 classification. Even in numerous so-called TASC D lesions, an endovascular solution becomes possible due to the permanent device improvement.

Step by step planning the procedure is warranted and includes decision making of the access route. When expanding endovascular treatment options for our patients, choosing the right access or a combination of different access routes is directly related to the technical success of lesion crossing and technical success of the entire procedure. In general, four different access locations are indicated for the iliacs including the aortic bifurcation: retrograde left and right side transbrachial access (alternatively transradial access) as well as the left and right groin. Whereas transbrachial results always in antegrade lesion crossing, groin access might complete a procedure from retrograde or antegrade approach, meaning a cross-over approach. The more complex lesions are the more complex access planning might be. For iliac artery stenosis treatment, decision making might be rather easy while the vessel at lesion site is patent and therefore lesion passing by guide wire can be rather easy; the level of lesion decides whether an antegrade or retrograde approach is warranted. Especially if a retrograde route is indicated, when lesion is located close to the inguinal ligament and the beginning of the common femoral artery, two access possibility exists, the contra lateral groin or the transbrachial route. The latter one might be indicated in severely scarred or diseased groin(s), in difficult anatomies like sharp bifurcations or severely elongated iliacs and when previous implants like stents, kissing stents or endoprosthesis after EVAR procedures make the cross-over procedure impossible. For iliac artery occlusion treatment (including flow-limiting dissection), decision making for access route is rather the same like for stenosis treatment. However, predictability for successful lesion crossing from the chosen access routed is lower. This means, the operator has to take other access routes or a combination of access routes into consideration, and as well as more devices than a catheter and a guide wire might be needed to complete lesion passing. If the aortic bifurcation is diseased, decision making seems rather similar like for iliac occlusions; the cross-over approach is likely not indicated. The lecture will be completed by an algorithm including a decision tree for choosing the appropriate access.

Vascular and Interventional Radiology Unit, Department of Radiological Sciences, Sapienza -University of Rome, Rome, Italy.

Learning Objectives 1. To learn when to stent and when not to stent 2. To learn how to select the appropriate balloon and stent 3. To learn about the results and complications Percutaneous transluminal angioplasty (PTA) and stenting used for focal iliac artery stenosis are well acceptable treatment modalities. They can be used not only as a stand-alone procedure but also as a viable option for improving inflow in patients with more distal peripheral diseases. The preferred approach for iliac artery interventions is from the ipsilateral common femoral artery (CFA). Thus, the lesion is crossed in a retrograde fashion. Even when dealing with total common iliac artery (CIA) occlusions this approach is advantageous because access to the lesion is short and straight. In many instances of total occlusions the guidewire follows a subintimal path during the retrograde attempts and in this condition it may be very difficult to redirect the guidewire into the true lumen of the vessel. So an antegrade approach from the contralateral CFA is more advisable because it can surely be successful. Once the lesion has been crossed, it can be managed either with PTA or with the use of a stent. Angioplasty is more indicated in case of lesions of the external iliac artery (EIA) but it can also be done along the entire iliac axis in preparation of a secondary stenting. Technical success rates in the most series are >90% and 5-year patency rates range from 54% to 93% with a mean of 72% in a review of almost 2.000 cases of iliac angioplasty carried out by Beckers. Stenting is particularly advisable in case of arterial obstruction, of long segment disease, and in the presence of a fresh thrombus because balloon inflation can be the cause of distal embolization. Stent placement is also indicated to manage technical failure, a PTA complication, recurrent stenosis and flow-limiting dissection. Bosch et al. reported a 4-year success rate for iliac angioplasty of 44-65%, which increased to 53-77% after stent placement. Murphy et al deployed stents in 90 iliac arteries in 65 patients with claudication and found 1-year, 2-year, 3-year, 4- year patency of 77%, 71%, 62%, 62%, respectively. Lesions of the CIA, involving the aortic bifurcation are treated using the "kissing balloons" technique. Simultaneous balloon dilatation at the origins of both CIAs is recommended even in the presence of a unilateral lesion, to protect the contralateral CIA from dissection or plaque dislodgement with subsequent embolization. As calcified lesions, typically occurring at the aortic bifurcation, are not amenable to balloon dilatation alone, the "kissing stents" technique is usually applied. Introduction Atherosclerosis affecting the origins of the iliac arteries at the aortic bifurcation is common and we have two basic techniques to manage this pattern of disease. Charles Dotter introduced the concept of percutaneous arterial dilatation in 1964. Andreas Gruentzig developed the ballon dilatation catheter and performed the first angioplasty, in a coronary artery, in Switzerland 1977. Dilatation of the iliac arteries has since been shown to be a simple and durable technique to provide symptomatic relief for patients suffering from both claudication and critical limb ischaemia. Charles Stent, a London dentist, developed a material that would reliably make dental impressions. This material was used to support the tissues of patients undergoing facial reconstruction after terrible gunshots received in the trenches during the First World War. The term stent has subsequently been adopted by clinicians using devices to maintain patency of internal tubes. Palmaz the first to describe a series of patients with stents at the aortic bifurcation. These two therapies are mature and it would be nice to think that we have ample data an which to make decisions on how to manage our patients. Unfortunately data are thin. There are no large series providing convincing outcomes, and certainly no trials comparing therapeutic strategies. The particular interest in this area of disease is the perceived need to either inflate two balloons at the bifurcation simultaneously (kissing balloons), or place stents in the distal aorta into both iliac arteries that will move the aortic bifurcation proximally (kissing stents). This abstract and subsequent presentation at CIRSE 2012 will summarise the data, cast some perspective upon this from the authors experience, and hopefully provide a sensible approach. We will presume that there is no need to rehearse the argument that endovascular is preferred to open surgery.

There is concern that because the disease affects the origin of the iliac bifurcation, if the disease were to be treated by angioplasty on one side only, there could be either embolisation down the contralateral limb or prolapse of disease from the treated iliac to the contralateral side. None of this appears to be evidence based. When both legs are symptomatic due to significant origin iliac artery disease, and the need is to treat both iliac arteries, then there is no down-side to using a kissing technique. When one iliac is tight and the other does not require intervention, then there is clearly a need to balance intervention upon an asymptomatic lesions against the potential complication of iliac intervention. Embolisation is rare during angioplasty of iliac stenoses and considerably reduced when managing occlusions if primary stenting is performed. The prolapse of atherosclerosis across the bifurcation is a risk that is only very occasionally seen. An early paper, for which we no longer have the reference, indicated that if the contralateral stenosis is less than 50% there is no risk of plaque prolapse. Taking this to heart we have not

Abstract Book used a kissing technique for the last 15 years of practice when managing bifurcation disease when the contralateral side did not need treating and the contralateral stenosis was less than 50%. We have never seen significant prolapse and never had reason to doubt that strategy. Complications do occur at either the intervention or access site when treating asymptomatic iliac disease. It would seem therefore that there is little justification in using a kissing balloon technique unless either both sides need treatment clinically or the contralateral stenosis is very tight.

Given the length of time that angioplasty has been used for aortic bifurcation disease the quality of available data is lamentable. Kissingballoon angioplasty is the preferred technique and what data there are would indicate that the patency at this siteis as good as elsewhere in the iliac system. In particular 93%, 90% and 76-92% at 1, 2 and 3 years (1) (2) (3) (4) . Primary success is difficult to assess given the artifice of describing a residual stenosis as failure. However with modern techniques and experience 100% of stenoses are crossed and dilated.

With the eager trend to embrace technology there are more reports of kissing stents at the aortic bifurcation than simple angioplasty. These data would indicate patencies at 1, 2, 3, 5 and 10 years to be in the region of 81-89, 50-89, 79, 82 and 68%(5-9) . Kissing stents have the peculiar long term complication of one stent compressing the other. Haulon suggested that there was a trend to better patency with balloon expandable rather than self expanding stents and this would make sense given that this is ostial disease that suffers from this competitive compression (7) . In addition there is probably a marked fall in patency if stents extending into the aorta cross each other (7). What appears from these rather limited data is that stents do not have any patency advantage compared to simple angioplasty. What is our preference? 1. There are no good published data to show that primary stenting for stenoses is better than simple angioplasty. Neither are there any data to show that a residual gradient in any way predicts a poor outcome. That is why nature gave us remodeling. 2. We know that primary stenting is the preferred method to treat occlusions. 3. Therefore angioplasty is used for stenoses and stents are used for occlusions. 4. If the disease is purely unilateral then there is no need for kissing anything. 5. If the contralateral disease is less than 50% and asymptomatic then there is no need for any kissing. 6. If the contralateral disease does not require treatment but is very high grade (e.g. > 90%) then we will protect the contralateral side with an angioplasty balloon. 7. If there are bilateral significant stenoses that are symptomatic then kissing angioplasty is to be preferred. If there is recoil with recurrence of symptoms then balloon expandable stents are used. 8. If both legs are symptomatic, and one iliac is stenosed and the other occlude we believe that in the majority of cases, with good technique, the stent can be placed so that it is not overhanging the contralateral iliac. We will therefore stent the occlusion and angioplasty the stenosis. 9. We hate bilateral occlusions. 1. To review the different imaging modalities for malfunctioning access assessment 2. To describe the typical clinical features of peripheral stenosis and occlusion 3. To illustrate typical central venous pathologies Talking about imaging malfunctioning dialysis fistulas, the first question we have to answer is: "When to refer the patient for evaluation and treatment in suspected vascular access problems?" The nephrologist has two powerful tools for the identification of problematic vascular access: monitoring and surveillance. Monitoring is defined by examinations and evaluation by means of physical examination, blood pressure measurement and bleeding time. Surveillance is a periodic evaluation by special tests such as ultrasound dilution, static venous pressure and Duplex ultrasound. One should not respond to a single isolated abnormal value. With all techniques, prospective trend analysis of the test parameter has greater power to detect dysfunction than isolated values alone. Once there are persistent abnormalities in any of the monitoring or surveillance parameters, a prompt referral for access imaging should be made. Overall, there are mainly two different imaging modalities to evaluate suspected malfunction of dialysis fistulas: ultrasonography (US) and angiography (DSA). Cross-sectional imaging modalities such as computed tomography (CT) and magnetic resonance imaging (MRI) play only a minor role in imaging of dialysis fistulas. Ultrasonography: Whenever stenosis is suspected, US can be performed to locate and to quantify the degree of diameter reduction due to the stenosis. US in the hand of an experienced clinician or vascular technician is an adequate diagnostic tool except for hand arteries and central veins and can be helpful in defining thrombus S31 CIRSE 2012 SS/FC/HL/HTS/CM extent. Angiography is not necessary if duplex indicates a stenosis at the arteriovenous anastomosis in forearm fistulae, which usually are only amenable to surgical revision by proximal re-anastomosis. Duplex examination is especially valuable in detecting stenoses and to perform flow measurements in non-maturing AV fistulae in which iodine injection should be avoided, because of the risk of renal function deterioration. Recently, duplex was suggested as the initial imaging modality of dysfunctional fistulae, but complete access should be depicted at DSA to detect all significant stenoses eligible for intervention. Angiography: Diagnostic angiography with iodinated contrast agents without subsequent dilatation or surgical revision is not advised. However, angiography is typically performed before, during and after dilatation or percutaneous thrombolysis and after surgical thrombectomy in order to guide the treatment and depict inflow as well as residual stenoses and/or clots or central venous obstruction. To avoid impairment of residual renal function, the use of carbon-dioxide as contrast medium is strongly recommended. As an alternative, diluted iodine may be used, with a low risk of further renal function detoriation. In order not to miss arterial inflow stenosis by diagnostic angiography, the brachial artery should be punctured at the height of the elbow for contrast administration. By introduction of a up to the central arteries, also the subclavian and axillary arteries can be imaged. Particular attention is paid in this session on the problem of central venous stenosis (CVS). Due to multiple central venous catheters and pacemaker wires, CVS is a problem that we face more and more often. In this session you will learn at which point of time imaging of suspected malfunctioning dialysis fistulas is mandatory. We will discuss the pros and cons of the 

Best practice guidelines for malfunctioning AV fistula

Dept of Diagnostic and Interventional Radiology, Helios Klinikum Wuppertal, University Hospital Witten/Herdecke, Wuppertal, Germany.

Learning Objectives 1. To describe the background and contents of the EBPG Guidelines 2. To give an overview of the interdisciplinary recommendations 3. To pinpoint the recommended strategies for access creation and complication management Vascular access management is central to maintain the dialysis patients' wellbeing and quality of life. To provide a straight-forward reference ranging from patient referral, vascular access planning, treatment and treatment of complications, the European Best practice Guidelines (EBPG) were published recently to reflect European practices and experience. They differ from the North American per-spective (DOQI and K/DOQI) with their preference of grafts and catheters as opposed to the native AV fistula. For the IR of special interest are peripheral and central obstructions and occlusions, which are a frequent problem in patients with end stage renal disease (ESRD) requiring hemodialysis. Rapid diagnosis and treatment of access-related complications are essential to preserve long-term access function. In addition, a thorough knowledge of minimally invasive percutaneous recanalization techniques is of paramount importance for the interventional radiologist. In this lecture, the guidelines which can offer a basis for reliable and safe patient handling are presented in the following order: 1. patient referral, 2. pre-operative evaluation, 3. strategies for access creation, 4. surveillance of vascular access, 5. diagnosis of stenoses in AV fistulae and AV grafts, 6. treatment of stenosis and thrombosis in AV fistulae and AV grafts, 7. diagnosis and treatment of central venous obstruction, 8. diagnosis and treatment of access-induced ischaemia, 9. central 

How I manage the thrombosed dialysis fistula/graft

Dept. of Radiology, Clinique St-Gatien, Tours, France.

Learning Objectives 1. To review the different treatment possibilities in the occluded access 2. To present the available evidence for treatment 3. To give an overview on iatrogenic complication management The different treatment possibilities in the occluded access Indications and contraindications Acute thrombosis of the vascular access means that usual dialysis is not possible. In cases of hyperkalemia or fluid overload, urgent dialysis has to be performed through a temporary central line (preferably the femoral vein). In all other cases, rapid declotting of the vascular access prior to dialysis is preferable whenever possible in order to avoid central catheterization. A thrombosed access can be declotted either by conventional surgery, by endovascular means, or by a combination of both. The literature reports conflicting results and it is impossible to state that one approach is superior to the others since success rates and outcomes are extremely operator-dependent. Infection of the vascular access is the only universal contraindication to percutaneous techniques in view of the risk of fatal bacteremia and overall because the infected segment of vessel cannot be removed (1) . An area of skin necrosis in cannulation areas is the result of chronic venous hypertension and indicates an outflow stenosis which was overlooked by nephrologists and caused acute thrombosis. This is a relative contraindication to percutaneous treatment when this area has more than 3 mm in diameter. The risk is the detachment of this segment of dead skin during declotting maneuvers, resulting in massive external bleeding which has to be controlled either by suture of the skin or placement of a covered stent through the breach. A better and more durable surgical revision of this area will have then to be performed rapidly. Allergy to iodine does not exist. In cases of a history of allergy to a iodinated contrast medium, a different molecule can be injected. Recent surgery (for example, a patient referred for early rethrombosis after surgical thrombectomy) is a contraindication for local injection of thrombolytics but not for mechanical thrombectomy, although the area of surgical approach is a fragilized zone where S32 C RSE CIRSE Abstract Book endovascular maneuvers will have to be performed with extreme caution. Immature fistulas, i.e. recently created autogenous fistulas, that were never been previously cannulated are a relative contraindication to percutaneous thrombectomy because the results are usually poor, with a high rate of initial failures (2) . The small, spastic and fragile arterialized vein is usually difficult to cannulate and responds poorly to dilation, with a high proportion of ruptures despite the use of small diameter balloons (4 to 6 mm). Big aneurysms and overall aneurysmal degeneration of the vein are predictors of major difficulties in the process of removal of the thrombus. Aneurysms usually grew slowly with time and local chronic low flow on contact with the aneurysmal wall frequently resulted in the creation of layers or thrombi of different ages, similar to those developing in aortic aneurysms. These layers of old thrombi are usually so tough that they are impossible to lyse chemically or to break using currently available mechanical devices. During declotting maneuvers, fresh clots are relatively easily removed but these tougher older clots are often fragmented in still wall-adherent but instable pieces that can secondarily detach and embolize into the outflow. These embolic bullets can result in the reocclusion of the fistula if their diameter is bigger that the diameter of the outflow vein and they are in all cases non-desired pulmonary embolic events. Faced to these tough-threatening old thrombi, the interventional radiologist has only one therapeutic option: to trap them with a stent. However, stent placement to imprison such clots nested in aneurysms is possible only if there is a sufficient length of relatively normal diameter vessel to anchor stent extremities upstream and downstream from the aneurysm, which is rarely the case at the arteriovenous anastomosis. This is major challenge when the whole vein developed aneurysmal degenerescence as we can see it mainly in brachial-cephalic fistulas, sometimes in radial-cephalic or ulnar-basilic fistulas. A clotted fistula or graft can be declotted up to 4 weeks after the onset of thrombosis using endovascular techniques. The need for such delayed treatment can occur in 2 circumstances: -patients in intensive care units after major surgery having caused fistula thrombosis, which means that the fistula will be declotted only when the patient can be transferred to an angiography suite.

-non-dialyzed ESRD patients, which include previously undialyzed patients and patients with a failing transplanted kidney. The fistula will have become thrombosed between 2 monthly medical appointments and the patient is frequently unable to say when the fistula stopped running. It has been reported that prosthetic grafts can be declotted many years after onset of thrombosis, an approach which is questionable in view of the risk of embolization of tough endovascular debris into the lungs (3). In summary, temporary contraindications to declot include hyperkalemia and fluid overload, the only absolute contraindication is infection of the vascular access, relative contraindications are the presence of an area of skin necrosis, never previously cannulated immature native fistulas, aneurysms of more than 5 cm in diameter, thrombosis of more than 1 month. Thrombolytic drugs or mechanical thrombectomy? Percutaneous declotting of a dialysis access is usually an outpatient procedure although overnight hospitalization has been reported and is still used by some teams using thrombolytic drugs. There are 2 mandatory stages in the treatment of a thrombosed access: 1) removal of clots and 2) treatment of the cause of the thrombosis, which in all cases is a tight underlying stenosis with a native fistula. Some prosthetic grafts might get thrombosed with no concomitant significant stensosis on the circuit. Removal of the thrombus is performed in the literature by pharmacological, mechanical means, or the combination of both. Historically, in the early 1980s, radiologists used thrombolytic drugs (streptokinase, urokinase) but mechanical methods appeared soon after (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) . Today, it can be said from the current literature that thrombolytics are not mandatory for the successful recovery of thrombosed fistulas and grafts although many teams still use them. Unlike mechanical methods, thrombolytics have contraindications: recent surgery, severe hypertension, cerebrovascular disease. The actual effectiveness of the different techniques of removal of the thrombus is tested only in fistulas with a large clot burden. In prosthetic grafts and in many native fistulas, it has been since long proven that the small clot burden (or residual clots after any previous thrombectomy technique) can be simply mechanically pushed into the outflow veins and finally embolized into the pulmonary circulation with little, but not without, risk of clinical complications (16) (17) (18) (19) . This rough treatment of residual clot cannot be performed in cases of a significant residual clot burden (19) . However, no technique, open surgery included, can claim not to cause any small pulmonary embolism. Where are we today, 20 years after the first publications? Mechanical methods are in the lead, especially manual catheter-directed thromboaspiration in Europe, the Arrow-Trerotola PTD in the USA (9, 11) . Unfortunately, there are many dialysis centres that do not work with interventional radiologists and thrombosed fistulas are frequently abandoned.

Reports on the success and patency rates after declotting of dialysis accesses are extremely variable in the literature because there are wide variations in the populations studied (20) . The location and nature of the vascular access (forearm/upper arm, native/prosthetic), the location of the stenosis (artery or vein, peripheral or central vein), the ages of the vascular access and of the patient, and the presence of comorbidity (diabetes, smoking, hypertension, cardiovascular disease) affect the success and the outcome of all percutaneous procedures. The available literature shows that the results of endovascular treatment are significantly better than conventional surgery in all kinds of native fistulae (21) . Thrombosed fistulae should therefore be referred to an interventional radiologist whenever possible. For prosthetic grafts, conventional surgery might be slightly more effective than endovascular treatment, but it is also more invasive since it reduces the venous capital of the patient each time. It can be said that the immediate success rates for declotting are best in prosthetic grafts (close to 100%), but there is a high rate of early rethromboses (ranging from 16 to 70% at 1 month), largely influenced by the problem of residual clots. In contrast, immediate failure is not uncommon in native fistulae (1 to 30%) but with a low rate of early rethromboses (21) . Despite usually lower success rates, primary patency rates of declotted native fistulas are rapidly better than those of declotted prosthetic grafts. Stenoses frequently recur but there is no consensus to date about the value of prophylactic dilations as long as the vascular access allows efficient dialysis. Including early failures, primary patency rates reported at 1 year were about 50% for forearm fistulae, 35% for upper arm fistulae and 25% only for prosthetic grafts in the largest comparative series published to date (22) .

The specific casualties reported in the literature have been due to bacteraemia and pulmonary embolism (16) (17) (18) . A breach in the sterile technique is always possible and this is the reason why antistaphylococcal antibiotics are usually recommended at the initiation of the procedure. In addition, these fresh clots lying under the skin may be colonized by germs. It is extremely difficult to avoid iatrogenic pulmonary embolism during the declotting of any dialysis access. The risk of fatal bronchospasm in reaction to a small to moderate embolism in debilitated patients is the reason why anticoagulation (at least 3,000 units of heparin) is mandatory. Severe hand ischemia is a potential major complication encountered only in accesses fed by the brachial artery (23) . It can result from inadvertent migration of a small thrombus from the juxta-anastomotic vein or graft into the distal brachial artery during catheterization or thrombectomy maneuvers. It can also result from the dissection of the artery at the anastomosis during initial catheterization maneuvers in cases of anastomotic stenoses. In cases of difficulties for passing such stenoses, it is recommended to cannulate the brachial artery distal to the anastomosis and to use this retrograde approach from the artery to pass the anastomosis in an antegrade (direction of the flow) fashion.

Iatrogenic arterial embolism is relatively easily treated by aspiration after cautious pushing of an 8F catheter through the anastomosis down to the level of the embolized clot (24) . The technique of backbleeding has also been advocated (25) . Local infusion of thrombolytics is cumbersome, time-consuming and rarely effective. The use of a Fogarty catheter can create a local dissection. The major risk is to overlook this iatrogenic embolism which can become symptomatic hours after the end of the examination. When it comes to declot an access fed by the brachial artery, it is recommended to check the status of the forearm arteries before and after all thrombectomy maneuvers. Delayed hand ischaemia can complicate excessive dilatation of a peripheral stenosis in cases of poor arterial supply to the hand, mainly in elbow fistulae. It is usually recommended to dilate juxta-anastomotic stenoses of elbow fistulas to no more than 6 mm. Dilatation-induced rupture can lead to the loss of the vascular access if the guidewire is inadvertently removed with no possibility or re-passing the stenosis. The best prevention of such inadvertent removal of the wire is to dilate over metallic, not hydrophilic, wires. Rupture of the vein can also generate significant haematoma with blood depletion or pseudoaneurysm in high flow fistulae. Haematomas and pseudoaneurysms can occur at puncture sites. The best prevention is to leave a small subcutaneous tunnel between the skin and any venous entry point. This allows for safe placement of a final purse-string suture (26) . Stents can migrate into central veins, right heart or pulmonary arteries when the diameter of the vein was underestimated. They also can become infected or there can be ulcerations of the skin when they are placed in a superficial location. These are the reasons why we must avoid to place them in cannulation areas, especially in skinny patients. 15:2029 -2036 . 24. Trerotola S, Johnson M, Shah H, Namylowski J, Filo R (1997 Incidence and management of arterial emboli from hemodialysis graft surgical thrombectomy. J Vasc Interv Radiol 8:557-562. 25. Turmel-Rodrigues L, Beyssen B, Raynaud A, Sapoval M (1998) Thromboaspiration to treat inadvertent arterial emboli during dialysis graft declotting. J Vasc Interv Radiol 9 :849. 26. Trerotola S, Johnson M, Shah H, Namylowski J (1998) Backbleeding On the other hand, the classical imaging features of HCC with the presence of arterial hypervascularity and early washout are diagnostic in patients with underlying cirrhosis. Arterial hypervascularity is the increased enhancement of the lesion in the hepatic arterial phase compared to the signal/density of the surrounding liver. This pattern is due to the predominant arterial vascularity of the HCC compared to the non-cancerous liver. Washout is demonstrated in the delayed phase for both CT and MRI at 2-3 minutes following the IV administration of contrast. In the presence of these features the presence of elevated AFP (>200ng/mL) is no longer considered necessary in cirrhotic patients. In addition, size alone is a risk factor. For lesions >2cm with increased levels of AFP one imaging modality demonstrating the typical features is considered adequate for establishing the diagnosis. Reasons for atypical imaging characteristics include lesion heterogeneity and necrotic areas. However, for lesions <2cm 41-62% lack typical hypervascularity or early washout or both. The incidence of small nodules of a diameter equal or smaller than 2 cm is increasing especially in screened populations with chronic HCB or HBV infections. The distinction between HCC and dysplastic nodules is difficult if AFP is low. To avoid biopsy for lesions <2cm two imaging modalities with typical features are necessary and in the revised version of AASLD guidelines any lesion larger than 1cm that demonstrate the typical features described above can be considered as HCC and treated as such even with a single imaging modality. In the presence of atypical findings a different imaging modality should be considered and only if atypical findings are confirmed again biopsy is recommended. It has to be noted that contrast enhanced ultrasound (CEUS) is not included in the AASLD guidelines. For hypovascular lesions the need of Kuppfer-specific contrast agents is essential for the non-invasive approach and in the absence of elevated AFP biopsy may be required to differentiate from cholangiocarcinoma and metastatic disease. If the lesion demonstrates a lack of uptake of Kupffer-specific MRI agents the lesion may be regarded as HCC but biopsy cannot be excluded. For lesions <1cm close follow up is recommended. In patients without underlying diffuse liver disease, cirrhosis biopsy is necessary to establish the diagnosis in the absence of elevated AFP. 

TACE and radioembolization: competitors or complementary?

Institut für Diagnostische und Interventionelle Radiologie und Nuklearmedizin, Klinikum Bogenhausen, Munich, Germany.

Learning Objectives 1. To discuss indications and contraindications of transcatheter therapy 2. To analyse the results of trials with conventional chemoembolization, radioembolization, and drug eluting beads 3. To understand the role of transcatheter therapy in the management of HCC According to several national and international guidelines for the treatment of HCC, the size and number of hepatic tumors, and the patients' performance conditions mainly rule the therapy algorithm Following these guidelines, roughly estimated 20% of the patients are candidates for a locally defined removal of the tumor(s) by ablative or resecting methods inclusively liver transplantation since tumor load is limited and liver function largely preserved. However, the majority of the patients will present with an advanced tumor stage hindering a sufficient tumor control by minimal-invasive or surgical treatment. In these cases, mainly trans-arterial therapy techniques are applied. Even if these techniques are in use for more than 30 years there is no general consensus on how a trans-arterial chemoembolization/embolization (TACE, TAE) should be performed. In consequence, substantial data exist on TACE but also quite a number of technical regimens on TACE (e.g. embolization only with Lipiodol, Lipiodol + particles, different particle sizes, lobar-, segmental-, tumor-selective administration etc.), blurring the evidence on the therapeutic efficacy of TACE. Nevertheless, the meta-analysis of TACE-studies can prove a superiority over best supportive care in Transplant 2009; 9: 1920 -1928 . Introduction Acute ischemic stroke may be a devastating disease and is today the third leading cause for death in the western world responsible for 10-12% of the overall mortality. As neuroprotection has never worked in human trials, focus has shifted towards recanalization strategies. Reperfusion of the parts of the brain that suffers from ischemia by recanalization of the occluded artery is the most effective therapy for acute stroke patients. By restoring blood flow to the threatened tissue before progress to infarction, reperfusion therapies reduce the final infarct size and enable better clinical outcome. Recanalization can basically be achieved in three different ways: by intravenous thrombolysis, intra-arterial thrombolysis and by mechanical thrombectomy.

In several randomized control studies, intravenous (i.v.) thrombolysis with alteplase (recombinant tissue plasminogen activator -rt-PA) has proven efficient and safe. Initially, the positive effect of the treatment was shown significant within 3 hours of stroke onset but more recently the window has been extended to 4.5 hours. The indication for i.v. treatment with alteplase is ischemic stroke within 4.5 hours with intracranial haemorrhage (ICH) being excluded by computed S36 C RSE

Abstract Book tomography in which also <1/3 of the middle cerebral artery (MCA) territory should be clearly infarcted. In spite of proven clinical efficacy, >50% of i.v. treated stroke patients remain disabled or die. Unfavourable outcome is more likely in patients with severe neurological deficits, higher age and persistent arterial occlusion. Partial or complete recanalization by i.v. alteplase is especially unlikely in proximal large vessel occlusions, only achieved in 10% of occluded internal carotid arteries and in 25% of occluded proximal MCAs. The numbers needed to treat for death and dependence are high and increases with time; <90 min=4, 90 min-3 hours=7 and 3-4.5 hours=14. Intravenous alteplase in the posterior circulation for basilar artery occlusion (BAO) has bad outcome with high mortality and low percentage of independent patients at 90 days followup. In summary, i.v. thrombolysis is a proven therapy that should be executed on all eligible patients, at least in the anterior circulation. Because of the low efficacy with high numbers needed to treat, as well as the many exclusion criteria for treatment, i.v. thrombolysis is, however, clearly not enough treatment for many patients. It is consequently important to offer non-eligible patients as well as non-responders additional or alternative treatment modalities. Treatment with i.v. thrombolysis has never been proven to increase the complication rate for mechanical thrombectomy and should therefore not discourage the neurointerventionalist from such a procedure.

Alteplase (rt-PA), recombinant prourokinase as well as urokinase or streptokinase can be used for intra-arterial (i.a.) thrombolysis. Three randomized trials, PROACT I, PROACT II and MELT, have studied the efficacy in MCA occlusions with the infusion starting within 6 hours of symptom onset. Treated patients in PROACT II had higher recanalization rates and better 90 days outcomes than the control group but a higher occurrence of symptomatic intracranial haemorrhage (ICH). The IMS and IMS II studies investigated the combination of i.v. and i.a. thrombolysis. In these studies, the patients received i.v. alteplase followed by the same drug additionally administered i.a. Treated patients in both studies had significantly better outcome than placebo-treated patients in a large rt-PA stroke trial (NINDS) and a similar rate of symptomatic ICH compared with actively treated patients from that same trial. For BAO, i.a. thrombolysis has similar bad outcome figures as i.v. thrombolysis, i.e. high mortality rate and very few independent patients at 90 days follow-up.

As mentioned above, mechanical thrombectomy may be a treatment option firstly for patients that are excluded from intravenous treatment, e.g. presenting >4.5 hours after ictus or with an unclear time of onset, but secondly also in patients in which the intravenous infusion does not or may not work. Patients with NIHSS ≥ 12, which is indicative of a large vessel occlusion, especially if the length of the thrombus is > 8 mm are unlikely to respond to i.v. treatment. There are no randomized controlled studies for mechanical thrombectomy but the technique has been evaluated in two prospective, non-randomized trials: the MERCI-trial and the Multi-MERCI trial. In both these studies included patients were those with large vessel occlusion in which mechanical thrombectomy could be started within 8 hours after symptom onset. MERCI-trial patients were rt-PA ineligible whereas the Multi-MERCI trial also included patients that had been unsuccessfully treated with i.v. rt-PA. These trials showed higher recanalization rates compared with control patients from the PROACT II study, a reasonably good percentage of independent patients at 90 days follow-up but a higher mortality rate as compared to actively treated patients in PROACT II. The penumbra pivotal stroke trial and in the penumbra POST trial evaluated a thrombus aspiration technique. Both studies revealed a very high rate of recanalization but the percentage of independent patients at 90 days were relatively low in the pivotal trial with a high mortality rate comparable to that in multi-MERCI. The 90-day outcome was markedly improved in the POST trial with also a decreased mortality. To learn when to use it Objective: We present our experience and the evolution in mechanical revascularization in acute stroke with different techniques in 200 cases. Introduction: In recent 3 years, treatment of severe acute ischemic stroke came into the hands of interventional neuroradiologists. First generation thrombectomy devices and techniques such as MERCI or PENUMBRA were replaced by the breakthrough of the stent-like retrievers. Initially used as immediate flow restoration devices to potentiate the effect of local chemical thrombolysis, stentrievers showed the ability to take out the entire clot. We present our experience through 3 years of thrombectomy in 200 patients and describe the technical evolution. Methods: 200 patients underwent mechanical revascularization in acute stroke. All patients had major vessel occlusions and were treated with stent retrievers (Solitaire 195, Aperio 5) . Intravenous lysis was given in the half of patients, intraarterial chemical lysis in12 patients. A balloon guiding catheter for flow arrest was used in 141 procedures. Double devices were used in 10 cases. Results: Complete racanalization of the target vessel and the cranial vessels was obtained in 93.5% of cases. Immediate thrombectomy without any i.a. drug or waiting period was successful in one maneuver in 60% of the cases. The other patients could be treated with repeated thrombectomy maneuvers with the same device or other devices. The use of a balloon guiding catheter led to a decrease in the maneuvers required, resulting in an overall decrease of treatment time. Learning Objectives 1. To understand the mechanisms of complications in endovascular stroke treatment 2. To learn how to avoid complications in terms of right patient and tool selections 3. To learn how to manage the complications when it happens 1. Failure 2. Haemorrhage parenchymal and subarachnoid 3. Embolisation 1. Failure can be due to treating a patient outside the therapeutic window, or due to poor patient selection. A supportive and close working relationship with interested stroke physicians is essential in correct and optimal patient referral. We routinely perform a CT angiogram (CTA) extending from the heart to the skull vertex. Careful examination of the CTA will identify thrombus in the heart, cervical arteries and intracranial arteries. It will also give a picture of the collateral arteries. The presence of collateral vessels is a good marker of future success and may prolong the therapeutic window. Good technique including balloon occlusion of the cervical artery with aspiration will improve results. Careful and non-traumatic placement of the stent distal to the thrombus with slow withdrawal into the thrombus is important. We leave the stent for 3-4 minutes in the thrombus before slow withdrawal with proximal aspiration to optimise clot removal. Complete clearing of the arteries with routine use of the TICI scoring system is essential. 2. Haemorrhage will occur as breakthrough bleeding on reperfusion of established infarction. Management of blood pressure postprocedure and neurosurgical decompressive craniectomy is all that can be offered the patient. Avoiding the complication means excellent patient selection, minimising delays to treatment and being aware of the collateral circulation or more importantly lack of collateral flow. Minimising the use of procedural heparin and intra-arterial tissue plasminogen activator (tPA) is also important. Subarachnoid haemorrhage is a feared complication and can be minimised by good technique with minimum arterial trauma. It is clearly less common with the newer, softer stent devices. Avoiding the very distal placement of a stent and consideration of a wire and intra-arterial tPA combination instead of very small vessels will reduce trauma. While most of our patients are managed with local anaesthetic conversion to general anaesthetic and the availability of an anaesthetic service is essential in restless or confused patients. Continued attempts to treat restless patients under local anaesthetic will lead to higher failure rates and more subarachnoid haemorrhage. The most difficult cases with more device passes will have a higher subarachnoid haemorrhage rate. Finally, as with parenchymal haemorrhage limiting tPA and heparin use will reduce the incidence of subarachnoid haemorrhage. 3. Embolisation due to distal clot propagation in the same vessel or into another arterial territory can occur. Both leaving the stent for 4 minutes and slow withdrawal, coupled with balloon occlusion and continuous aspiration at the proximal end will reduce this complication. This should also allow saddle type emboli in the terminal internal carotid, middle and anterior cerebral arteries be removed in a single attempt. A good clinical result is best achieved with a good TICI clearing score and this means treating distal and new emboli.

Is our work supported by evidence?

Interventional Neuroradiology, University of Berne, Berne, Switzerland.

Learning Objectives 1. To get a neurologic perspective for previous revascularization trials 2. To understand where evidence based medicine stands in acute stroke treatment 3. To learn how we make decision for stroke treatment supported by evidence The first case reports on embolectomy and thrombectomy in acute stroke patients date back to 19881. Since then, techniques of endovascular stroke treatment have evolved and have been investigated in various trials. A milestone was the PROACT II trial2, a randomized controlled trial (RCT) on intra-arterial thrombolysis (IAT) in acute stroke patients suffering from middle cerebral artery (MCA) occlusions. The clear evidence for a beneficial outcome within the IAT group was found compared to a placebo group; 40% of the patients in the treatment group recovered to modified Rankin score of ≤2 at 90-day follow-up versus 25% in the placebo group. The positive effect on favorable outcome has been confirmed by a metaanalysis3 on the three larger IAT trials PROACT I, II and the MELT study. These results sparked the discussion on the use of endovascular treatment and its selection criteria in comparison to intravenous thrombolysis (IVT). The large trials on IVT suggest that patients presenting beyond a time window of 4.5 h after onset of symptoms and those suffering from large vessel occlusion might be favorable for IAT 4, 5. However, studies comparing the effect of IAT and IVT in clinical studies are rare. The SYNTHESIS trial6 found a 26% difference in favorable clinical outcome in a RCT comparing IVT and IAT in patients with acute MCA occlusions, not reaching statistical significance. A retrospective study on the outcome of patients' clinical symptoms of MCA occlusion and hyperdense artery sign on CT treated either with IAT or IVT stated a 30% in favorable clinical outcome after IAT compared to IVT in a center comparison in Switzerland7. The recent development of mechanical thrombectomy (MT) has undoubtedly increased the clinical application of endovascular stroke treatment. Both trials on the use of the MERCI devices as well as the trial on the Penumbra device have shown the efficacy of these approaches in acute stroke treatment. Nevertheless, no randomization to IVT has been performed and the historical comparison to outcome data on systemic approaches was not overall convincing. Clinical results did not show the expected correlation between high recanalization rate of MT and an increase of favorable clinical outcome of the treated stroke patients. Furthermore, a previously unknown spectrum of interventional complications was illustrated. The most recent development of a novel group of thrombectomy devices is the stent retrievers. The available clinical data are still few. The largest retrospective data on the use of stent retrievers from 8 European centers including 141 patients found a high recanalization rate of 86% (TICI ≥ 2b) but more importantly a conduction of high recanalization rates into good clinical outcome (mRS ≤ 2: 55%)8. Other single center studies came to comparable results and the number of stroke patients being treated with this novel technique is increasing steadily. Although the clinical efficacy of these new techniques has been shown in retrospective and prospective case series, to date, no RCT comparing MT and IVT has been performed. Therefore, from the perspective of evidence-based medicine, the MT has not proven to be superior to IVT in the vast majority of stroke cases in the anterior circulation and within the 4.5 hours time window. More large multicenter series are necessary to elucidate the clinical role of MT in the majority of stroke patients with proximal MCA and basilar artery occlusions. Unfortunately, due to the rapid rate of evolution, as well as the many Learning Objectives 1. To learn about qualification and responsibilities of personnel 2. To learn about marketing tools: tips and tricks 3. To learn how to work with the radionuclide department: practical tools and issues Principles of transarterial radioembolization:

The pathological-anatomical substrate allowing for transarterial therapies, such as transarterial tumor embolization utilizing 90Yttrium resin microspheres, is based on the dual blood supply of the liver and the fact that most hepatic malignancies derive their blood supply almost exclusively from the hepatic arteries. Beside transarterial chemoembolization (TACE) in otherwise non-treatable hepatocellular carcinomas, most trans-arterial chemotherapy regimens applied to various tumor entities in the past were ineffective or resulted only in a minor response in the majority of the cases. External beam hepatic radiotherapy is limited in efficacy in the presence of multifocal or large tumors in the liver since the radiation exposure of normal hepatocytes results in liver insufficiency before achieving tumor kill. From the above discussion it is evident that the dual characteristics of hepatic tumor altered arterial supply and susceptibility to radiation can be exploited. Combining a high energy radiation source to an appropriately sized trans-hepatic arterial administered embolic microscopic particle would allow radiation to be delivered preferentially to the tumor. A beta-emitter, such as 90Yttrium, would create a zone of high radiation exposure confined to the vicinity of the tumor while maintaining non-tumorous hepatic parenchymal exposure to sub-critical levels. This forms the premise behind selective internal radiation therapy or SIRT. Millions of microspheres, measuring about 30μm in diameter incorporating 90Yttrium, are injected via a hepatic arterial catheter to the arterial supply of the tumor. SIRT is a technique that allows high average doses of radiation (200 to 300 Gy) to be given to liver tumors with minimal serious effect on the nontumorous liver. 90Yttrium, an almost pure beta-emitter is produced by neutron bombardment of yttrium-89 in a reactor. 90Y has a physical halflife of 64.2 hours. The average/maximal penetration range is 2.5 mm and 11 mm, respectively, in tissue. One gigabecquerel delivers a total absorbed radiation dose of 50 Gy/kg. In therapeutic use in which the isotope decays to infinity, 94% of the radiation is delivered in 11 days.

In order to deliver 90Yttrium resin microspheres safely and effectively, harnessing the skills of many different specialties are paramount.

Interventional radiologists, surgical oncologists, medical oncologists, nuclear medicine physicians, medical physicists and radiation safety experts bring invaluable expertise to the treatment process. In this presentation, an overview on the collaboration between different specialities, marketing strategies, patient considerations and environmental aspects will be presented and discussed. Learning Objectives 1. To learn how to select the patient: Indications and contraindications for radioembolization of liver tumours 2. To discuss how to perform the preliminary angiography evaluation 3. To describe how to make a treatment plan Y90 radioembolization is being used increasingly worldwide for the treatment of primary and secondary hepatic tumors. Interventional oncologists can optimize the results and patient care for this therapy with careful patient evaluation, patient selection, and pre-procedure planning. The following offers a brief outline of the pre-radioembolization process. Patients being considered for radioembolization need thorough clinical, laboratory, and imaging evaluation. The clinical evaluation should focus on performance status as patients with ECOG performance status of >2 should not be offered therapy. The presence of specific symptoms such as pain, fatigue, and anorexia should also be assessed and managed appropriately. Any recent trends and rate of change of symptoms are extremely important indicators as rapidly declining patients should be treated with caution. The patient's entire oncologic history should be reviewed including diagnosis, staging, and all prior treatments. A complete imaging and laboratory evaluation is also required. Current (within 30 d) high-quality dual phase cross-sectional imaging (CT or MRI) should be reviewed to assess for hepatic tumor burden, extra hepatic disease, and response to prior therapy. PET scans are often useful in metastatic disease for complete staging. Laboratory evaluation should include hematologic, electrolyte, and liver function parameters as well as tumor markers. Hepatic reserve is usually determined by a combination of bilirubin, INR, transaminases, and albumin. As with the patient's clinical status, recent laboratory trends are important to note. If a patient is deemed eligible for radioembolization based on the evaluation described above, the next steps include pre-procedure angiography, shunt study, and individual dosimetry. Pre-procedure angiography is performed to assess hepatic vascular anatomy, assess for anatomic variants and extrahepatic vessels, and to determine the exact anatomic location for safe administration of the Y90 microspheres. The effect of prior systemic therapy on the hepatic vasculature is evaluated as well. Extra-hepatic vessels deemed to be at risk for non-target microsphere deposition are embolized at this point. A Tc-MAA shunt study is then performed with injection in the planned treatment location(s). The lung shunt fraction is then calculated to be used for dose calculation as well as excluding patients with very high shunts. Dose calculation is the final pre-treatment step. This is performed using the manufacturer's suggested algorithm accounting for tumor burden, target volume, lung shunt and other factors.

Research support for clinical trials from the manufacturers of both Y90 devices, Sirtex and Nordion. 

During last decades the management of the patient with symptomatic disc herniation, especially with low back pain and sciatica, has gradually changed to become more conservative. In fact, several studies have shown that the natural history of disc herniation is favorable since in most cases a spontaneous clinical remission is shown after some weeks [1] [2] [3] . Furthermore, at follow-up with magnetic resonance imaging (MRI) the spontaneous disappearance or reduction of the herniated volume has been demonstrated in 63% of cases [4] . This phenomenon is caused by the degeneration of the discal matrix and supported by a process of phagocytosis explained by the fact that the nucleus pulposus is antigenically segregated. Further studies have shown that there are similar results over time between surgical and conservative treatment [5] [6] . These considerations, also united to the evidence that surgery is associated with not negligible risk of failure, have favored the development of noninvasive treatments. The intervertebral discs, together with the ligamentous and articular elements of the posterior arch allow flexion and rotation movements of the spine. The disc is formed from an outer fibrocartilaginous portion (the so-called "annulus"), which adheres (upwards and downwards) to the cartilaginous portions of the vertebral bodies and (posteriorly) to the posterior longitudinal ligament; inside the annulus is contained the nucleus pulposus, which is composed of collagen fibers in a proteoglycans matrix which contains water and this explains the typical hyperintensity on MRI T2-weighted images. Theoretical assumptions underlying the discal treatment with ozone All interventional techniques of approach to discopathy and its consequent herniation are directed to the reduction of discal-radicular conflict through a decompressive action which can be pursued using several means. In case of ozone treatments, we deal with its chemical and physical action, causing reduction in the volume of the treated disc(s) and consequent reduction of nerve root compression. Therefore, the rationale of percutaneous disc procedures is not the removal of the hernia, but rather to obtain sufficient analgesia to avoid surgery, while the hernia undergoes a spontaneous resolution in accordance with its typical natural history. Often the procedures are combined with epidural periradicular injections of steroids, in order to reduce the symptoms not only through the reduction of the discal-radicular conflict but also through the reduction of local inflammation [7] . Ozone is an unstable form of oxygen that reacts with the organic molecules containing double or triple bonds through a redox reaction defined ozonolysis [8] . The intradiscal presence of ozone results in fragmentation of proteoglycans inside the nucleus pulposus, with consequent liberation of water and dehydration. The fibrillary matrix of the nucleus pulposus, then, undergoes a progressive degeneration with the development of necrosis and vacuolar replacement by fibrous tissue [9] . The effect of this process is a gradual and slight decrease of disc volume, usually sufficient to determine sensitive reduction of nerve root's compression, venous stasis and edema of the root. The volumetric reduction of the disc is completed in about 5 weeks. Another mechanism of action is in-hibition of the synthesis and release of prostaglandins, bradykinin, and other algogenic molecules by direct ozonolysis; it also seems to be confirmed that ozone increases the release of antagonists of proinflammatory cytokines. These mechanisms can justify the administration of O 2 -O 3 in epidural and periradicular space, because it induces a reduction of chemical radiculitis, which is a major cause of radicular pain and its chronicity [10] . The anti-inflammatory effect is of rapid onset and early reduces the symptoms as they progress in their effects on the disc. Interventional techniques for the treatment of disc herniation are addressed to patients with back pain associated with radiculopathy and coherent symptoms with imaging findings at MRI or CT. There is classically an indication to treat only contained herniations (i.e. the ones where there is no complete interruption of the annulus); in fact, when treating not contained herniations a minor efficacy of the procedure is expected because there is already communication between the nucleus pulposus and the epidural space and, thus, there is an already existing way of discal decompression. As a consequence of much higher risk of iatrogenic damage, cervical herniations are much less frequently treated by ozone than the lumbar ones; nevertheless, in selected patients with symptomatic cervical herniations and corresponding radiculopathy resistant to drug and physiatric therapy in the absence of compressive myelopathy and significant spondylosis can be a valid indication for treatment by experts operators. General contraindications include coagulopathy, low platelets, known allergy to drugs to be administered, local or systemic infections, lack of cooperation. When simultaneous injection of steroids is planned, systemic contraindications to these medications should be excluded. Clinical contraindications include: paralyzing sciatica, acute cauda equina syndrome, acute or progressive motor deficit; in these cases surgical treatment is indicated. Administration of O 2 -O 3 is contraindicated in patients affected by favism. The presence of free and migrated fragments has to be considered as relative contraindication, because being separated from the rest of the disc, they cannot benefit from discal decompression produced by the ozone. However, in these patients there is always an indication to inject steroids in the vertebral canal to obtain reduction of inflammation during the period of natural resorption of the fragment. Moreover, in well-selected cases, and always under CT guidance, there is also the possibility of injecting directly O 2 -O 3 inside the migrated fragment, to obtain its lysis. In case of canal stenosis and marked degenerative changes, vertebral procedures directed to the disc are generally contraindicated for the limited possibilities of obtaining a clinical benefit, unless they are performed in the context of a multifactorial treatment aimed at all the causes of pain that extends to a rehabilitation program. If the patient has already undergone surgery at the level responsible for the symptoms, usually a percutaneous disc treatment has limited effectiveness because the pain is often caused by epidural tissue hypertrophy, fibrosis and adhesions, associated or not with recurrent herniation (part of failed back surgery syndrome, FBSS). Discal interventional procedures do not require a particular preparation. If the patient is under antiplatelet or anticoagulant therapy it is appropriate to suspend them. To prevent infectious complications the procedures must be performed under wide spectrum antibiotical coverage. The percutaneous approach to the disc is similar for all procedures, and can be performed under fluoroscopic or CT guidance, or under combined guidance.

For procedures at lumbosacral level, the patient is placed in supine position, with a small pillow under the abdomen to expand the posterior portion of the intervertebral space. Access is paravertebral posteriorly and ipsilaterally to the symptomatic side. After a first CT scan is acquired at the level to be treated, the skin over the area is prepped and draped in sterile fashion; then a local anesthesia of the soft tissues is made by direct subcutaneous injection. After that, a 22G spinal needle is progressively directed (following the tilt angle of the gantry) towards the intervertebral disc, as near as possible to S42 C RSE

Abstract Book its internal portion. The navigation of the needle is checked with a low dose CT scan, and if necessary, corrected. When entering inside the nucleus pulposus, another CT scan is acquired and then a mixture of local anesthetics (≈2 mL, Mepivacaine 2% or Ropivacaine 2%), steroids (≈2 mL Triamcinolone with concentration of 40mg/mL ) and O 2 -O 3 (≈3-5 mL, with a concentration of 28 μg/mL) is injected through the needle. Negative aspiration for blood should be performed prior to inject, to confirm being positioned outside the vascular space. At the end of this injection, and after pulling back the needle, a last CT scan can be acquired to demonstrate the end of the procedure and the first signs of intradiscal vacuum, due to ozone diffusion. For cervical level interventions, it is of crucial importance the quickness of the whole procedure, because the patient will be asked (staying in supine position) not to move and swallow. Very useful in this case is the use of a biplane angiograph, which easily allows to simultaneously check the path of the needle on the anterior-posterior and on the latero-lateral plane. The needle is inserted into the cervical level with front access. The operator manually spreads apart the larynx and the neurovascular bundle and the needle is inserted medially to the sternocleidomastoid. The needle is advanced in front projection with the beam parallel to the disc. The initial target is the upper part of the lower vertebra to have a better perception of depth reached, then once it reaches the vertebra, the needle is slightly retracted and moved cranially; crossing the anterior longitudinal ligament and the annulus is felt a modest resistance. In comparison to the lumbosacral intervention described above, no local anesthetics will be injected at cervical level.

The short-term success rate after surgery for lumbosacral disc herniation is estimated at 95%, with a 2 to 6% incidence of true recurrence of herniation. The success rate drops to 80% over time owing to the onset of symptoms linked to failed back surgery syndrome (FBSS), a condition characterized by recurrence of disc herniation and/or hypertrophic scarring with severe symptoms in 20% of patients [11] [12] . All percutaneous procedures are mildly invasive, requiring only a short hospital stay. By avoiding the spinal canal, these techniques also eliminate the risk of postoperative scarring that has been associated with surgery and which is often responsible for recurrence of pain. Percutaneous techniques can also be repeated in the same patient without eliminating the option of traditional surgery. The success rates reported with ozone treatment vary from 65 to 80% with excellent or good results [11] . In addition, epidural steroid injections under CT or fluoroscopic guidance may also be used to minimize radicular pain. In some cases, 18-month follow-up at MRI reported good and stable outcome up to 72% of treated patients with no evidence of peri-procedural major complications [13] . This, in addition to the low cost of technique and to its repeatability, has to be considered a further and definitive evidence of the validity of ozone therapy. To review and present recent studies on percutaneous disc treatments A variety of minimally invasive techniques have been investigated over the years as a treatment of back pain related to disc disease. In case of no response to these treatments, besides the classical surgical intervention, new therapeutic options have been proposed secondary to the progress in interventional imaging. A mixed substance exploiting the chemical properties of a radiopaque gelified ethanol and intra-discal corticosteroid injection are one of the intradiscal therapies options. The criteria of inclusion are: patients suffering from lumbar sciatica or lumbocruralgia with disco-radicular conflict documented by MRI, radiculalgia worse than the lumbar pain, resistance to well-performed medical treatment including scannerguided infiltration, VAS higher than 6, satisfactory hydration of the disc (intra-discal T2 hypersignal), discal height preserved. The procedure is performed in an interventional scanner room (Light speed GE) in an arc X unit after surgical sterilisation of the room and isolation fields of the scanner. The patient is placed in procubitus on a ventral block to reduce the lumbar curvature and makes the passage of the needle easier. Periradicular and epidural leakages were observed in 30% and 5% of our series. The results in our series show a satisfactory result in 60% with a decrease of the initial VAS of more than 50%. Randomized clinical trials are important to assess treatments of painful conditions and low back pain. Due to the expected placebo effect, the subjective nature of pain assessment in general, the variable natural history of low back pain often responds to conservative care. After the commercial withdrawal of Chymopapain, the need for new substances to treat intervertebral disk hernias is important, the role of such procedure will probably find an important place in the arsenal of percutaneous treatment of herniated disk.

Infiltrations and RF for facets and nerve roots D.K. Filippiadis; 2 nd Department of Radiology, University General Hospital "ATTIKON", Athens, Greece.

Learning Objectives 1. To present imaging features that differentiate facet from disc disease 2. To present different treatment for facet disease 3. To present ablation and its role among facet treatment It is estimated that approximately 70-90% of the population will experience at least once during their lifetime an episode of lumbago, whilst 15-40% of the population will have an episode of neuralgia. Discogenic pain accounts for 15-36% of these cases and lumbar facet syndrome for 15-40%. Symptoms due to these pathologies may be overlapping (constituting the diagnosis a quite difficult task) and at the same time refractory to conservative therapy. Sicard was the first one who performed epidural injections in 1901, administrating cocaine for pain management. The first epidural corticosteroid administration was performed in 1952. Steroids decrease neutrophils aggregation and suppress inflammatory protein release by mast cells and macrophages, thereby decreasing inflammatory cell activity. Percutaneous epidural (transforaminal, intralaminar and caudal) or facet joint steroid infiltrations are minimally invasive therapeutic or diagnostic procedures that involve injection of glucocorticosteroid with or without local anesthetic inside the epidural space or the zygapophyseal joints of the spine. The main purpose of this treatment is to control painful symptoms during the acute phase until natural recovery occurs (in this case injectate consists of 1.5 cc of corticosteroid mixed to 1 cc of local anesthetic). In our department usually we mix 1.5 cc of Cortivasol to 1 cc of Lidocaine Hydrochloride 2% and the injectate is delivered by means of a 22G spinal needle. Concerning cervical spine infiltrations we do not use local anesthetic (but dilute steroid with normal saline) since in cases of epidural dispersion respiratory depression might occur due to C3, C4 and C5 nerve root anesthetization. Furthermore, in thoracic and lumbar spine, infiltrations can be performed as diagnostic tests (1.5 cc of local anesthetic is solely injected) in order to verify the controlled anatomic structure as a pain source of back pain or neuralgia. Indications for transforaminal infiltrations (selective nerve root blocks) include the presence of radiculagia refractory to a 3-4 weeks of conservative treatment, postoperative patients with recurrent pain and patient with radiculgia and multilevel imaging abnormalities including foraminal stenosis (diagnostic -to define levels of interest for potential surgery). Indications for epidural (intralaminar) infiltrations include spinal nerve root compression or inflammation, spinal stenosis and low back pain (of unknown etiology) refractory to conservative medical treatment. Postoperative fibrosis, adhesive arachnoiditis and spinal stenosis are indications for caudal infiltrations. Finally, indications for facet joint infiltrations include degenerative arthritis or inflammatory facet joint arthropathy (spondyloarthropathy, rheumatoid polyarthritis) of the facet joint which may result in unilateral or bilateral paravertebral low back pain (may be aggravated on extension or rotation, during rest in any posture, upon changing positions from sitting to standing), deep, dull pain limited to low back, buttock and hip (pain referral in a non-radicular pattern until knee joint but never more distally). In the cervical spine facet joint syndrome produces unilateral or bilateral paravertebral neck pain with or without headaches and cutaneous pain, decreased range of neck motion, local tenderness over the facet joint(s) of interest with a pain referral in a non-radicular pattern until shoulder girdle or elbow but never more distally. Contraindications are those that, in general, govern any minimally invasive technique such as a patient unwilling to consent to the procedure, coagulopathy, local or systemic infection and allergy to any component of the injected mixture. Imaging guidance ensures the safety and efficacy of these techniques. Infiltrations can be performed under fluoroscopy (radiation exposure for both patient and IR), computed tomography ± CT fluoroscopy (higher radiation exposure for patient and for IR), cone beam CT (lower radiation doses -CT like images) and magnetic resonance (no radiation, higher cost, longer duration). Concerning fluoroscopy, facet joint infiltrations are performed by means of a direct puncture of the target point at 45º angulation of the fluoroscopy beam (Scottie dog projection). Transforaminal infiltrations are similarly performed; however, A-P and lateral projections are necessary as well. Epidural and caudal infiltrations are performed under fluoroscopic guidance with alternating A-P and lateral projections. In all cases contrast medium and fluoroscopy verify the desired needle position (intra-articularly, intra-foraminaly, inside the epidural space), the needle's extravascular positioning and provide some idea for the potential distribution of the injectate. Concerning CT-guidance, patient is placed once again prone on the table and 3-mm thickness images are performed for determining entry site and approach angle. Target points include the lower posterior recess of the facet joint, the lower and posterolateral part of the foramen and intra-epidural (as well as extradural) needle positioning in epidural infiltrations. Contrast medium is used at foraminal and caudal infiltrations but is not necessary for facet joint infiltrations since CT clearly demonstrate the intraarticular needle positioning. Air is used as contrast medium at lower lumbar levels (below L2-L3 level) and iodinated contrast medium is used at cephalad levels. Specifically for facet joints the commonly used injectate may be changed to sodium-hyaluronate solution (which seems to produce a more significant and longer lasting pain reduction). Furthermore, synovial cysts of facet joints may produce symptoms and treatment includes direct cyst puncture and steroid injection (with single or double needle technique). In cases where results of facet joint infiltrations are not optimal denervation of the joint is the next step, either by medial branch block (similar results) or by radiofrequency denervation. The target point is the notch between the transverse process and the superior articulating process. Keep in mind that facet joints are innervated by nerve branches from 2 (and occasionally 3) subsequent levels (e.g. L4-L5 joint receives innervation from L3 and L4 nerve branches), therefore the process must be performed at the corresponding levels. Alternative denervation therapies include alcohol injection and kryorhizotomy. Most recently, MR-guided HIFU (high intensity focused ultrasound) has been applied in the treatment of facet joint syndrome. In general, percutaneous steroid infiltrations constitute a safe technique where clinically significant complications are quite unusual with a threshold ≤0.5%. There are two types of potential complications that are associated with percutaneous epidural steroid infiltrations: intra-operative (associated with needle placement) and postoperative (infection, bleeding and those associated with the injectate administration). In all the cases that epidural steroids where administered within the therapeutic doses, no complications were noted. However, there are reports of brain and spinal cord infarction post-cervical transforaminal non-soluble corticosteroid infiltrations and paraplegia post-lumbar transforaminal non-soluble corticosteroid infiltrations. There are a total of 12 paraplegia cases reported in the literature. Unpublished data indicatively report that the ratio S44 C RSE

Abstract Book of paraplegia cases to the number of consecutive epidural infiltrations performed since 2000 in 3 extensively experienced medical centers are 0/4300, 2/1330 and 1/7900. The proposed pathophysiology involves intravascular injection of prednisolone acetate into a radiculomedullary artery. No such reports are found for soluble corticosteroid infiltrations. Infection, immediate and generally transient painful reaction with a latter acute stage of arthritis which regresses in 24-48 hours, needle misplacement and allergic reactions are further potential complications. It is suggested that image-guided percutaneous epidural steroid infiltrations are more effective concerning pain reduction and mobility improvement than placebo, local anesthetic alone or bed rest. Following an average of 6-13 days post the infiltration session, 65% of patients experience at least 50% of pain reduction, an improvement that lasts for an average of 15 months. Meta-analyses upon epidural steroid infiltrations report a 14% positive treatment effect over placebo and provide evidence suggesting that these injections constitute an excellent therapy for pain management. In addition, it is reported that a 30% of surgical candidates decide against surgery after epidural infiltration sessions. Controversy is raised concerning the most appropriate route selection. In comparison to transforaminal infiltrations, both interlaminar and caudal ones do not provide any diagnostic benefit. In addition, interlaminar and caudal infiltrations are governed by a higher risk of extra-epidural and intravascular needle position. Finally, due to epidural fibrosis or adhesions, it is possible that the injectate will never reach the target site.

In conclusion, image-guided epidural (transforaminal, intralaminar and caudal) or facet joint steroid infiltrations are safe and efficient diagnostic and therapeutic techniques for the management of neck/back pain and neuralgia especially when these symptoms are refractory to the initial conservative therapy. To discuss the indications in regard to other treatment (medical, surgical other percutaneous intervention) 3. To review literature and show possible future developments Back pain problems affect an ever increasing population worldwide and accounts for major economic expenses in the western world. Some benign pathologies may become life-impairing and require much more than just symptomatic medical treatment. More serious conditions such as tumor or fractures may also be extremely painful and require adequate treatment. Interventional radiology currently offers a wide range of non-invasive treatments that have proven to improve the quality of life with reasonably low morbidity. The possible causes of lumbar spine pain are innumerable and include mechanical, chemical, neoplastic, socio-economic and even psychological entities. Therefore, the work-up of such patients requires a broad spectrum of medical skills. The herniated disc is a common pathology that may have a strong impact on the quality of life. The burden on countries' social and economic systems is very heavy, with repeated and often long work absences. As the disc dissolves itself in two to four years, many treatments are conservative and focus on easing the pain without addressing the actual pathophysiologic cause. Disc-related symptoms can range from almost-asymptomatic to severely debilitating. In cases of intractable pain and/or neurologic deficit symptoms (i.e. paresis) a surgical treatment might be necessary and should be offered in a minimal-invasive fashion. If conservative medical treatment fails, and no absolute indication to surgery is evident, minimal invasive interventions can be used; usually, local image-guided injection of anti-inflammatory (steroids) drugs in combination with local pain medicine is helpful and widely used, however, with conflicting results. The following pathophysiologic mechanisms of disc-related back pain are discussed: -gangliar compression, -deformation and stretching of ligaments and anulus fibrosus, -deformation and stretching of nerves at the level of the thecal sac, -secondary ischemic changes of the nerve due to compression, -ischemic changes of the nerve due to venous stasis. The complex mechanism of pain due to nerve compression includes also biochemical factors as well as cell-mediated and bio-humeral mechanisms. The primary goal of mechanical decompression in disc herniation is reduction of the volume of the nucleus pulposus and therefore the reduction of local flogosis. Different mechanical devices are available with different peculiar aspects. We will discuss the Dekompressor (Stryker company) which consists of a rotating helical probe for percutaneous discectomy that allows The device can be used in fluoroscopy or in CT guidance; we prefer CT-guided interventions in all cases due to the higher local image resolution.

With proper use of radiation protection devices and protocols, the radiation dose to the patient and also to the operator can be reduced. Contraindications as well as typical indications will be discussed. Special emphasis is put on the clinical evaluation of patients as well as on the importance of high quality imaging studies prior to possible treatment.

The clinical results of this particular device are presented. The rare risk of clinically relevant complications will be discussed. These complications should not exceed 1% of patients treated. Chemical, thermal and biochemical methods of discal decompression will not be discussed in this lecture.

Modern closure devices have enabled EVAR to be a true IR procedure

Sheffield Vascular Institute, Northern General Hospital, Sheffield, United Kingdom.

Interventional radiology is defined as the performance of procedures using catheter or guide wire combinations, and image guidance (1) . Endovascular aneurysm repair (EVAR) was first introduced in 1987 (2) in Russia and subsequently in Argentina and the USA in 1991. Since then there has been an enormous development of the devices, and the procedures have become established in modern practice. The early devices were exclusively designed for abdominal aortic aneurysms, but as the techniques and technologies have evolved EVAR has been applied to the thoracic aorta, iliac aneurysms and other areas of the body. Early devices were prone to problems with structural malfunctions, but also, whilst they were deliverable from a femoral or conduit approach, the delivery systems were large (typically in excess of 20F). This required the use of formal surgical arterial exposure, which allowed the procedure to be less invasive than traditional open repair, but nevertheless one that required the skills of both open surgery and interventional radiology. Over time devices have been developed with a reduced delivery profile for all types of EVAR, including the abdominal and the thoracic aorta, with abdominal devices being frequently delivered on devices under 20F and thoracic devices under 24F. Simultaneously, with the development of devices with smaller delivery profiles, there has been an expansion of the opportunities for the closure of larger arterial access sites using percutaneous techniques. In the early days of percutaneous access, pressure haemostasis was relied upon close up to 10F or even 12F holes, and this required compliant patients who were able to undertake up to 12 hours of bed rest, and the risk of significant groin haematoma or bleeding was high with the larger holes. In an effort to try to reduce the risk of larger puncture sites, and to allow the percutaneous closure of larger access points that lead to the development of a series of arterial closure devices are available in modern practice. This list is by no means exhaustive, but the majority of these devices either enhance the ability to apply pressure, or deliver a form of plug which prevents bleeding from the arteriotomy. The suture-mediated devices utilise the placement of one or two sutures which are applied to actively close the arteriotomy following completion of the procedure. The most commonly used are the Perclose/Proglide (the Proglide is an updated version of the Perclose), which are single suture devices, or the Prostar which is a dual suture device. The Proglide is designed for use with smaller access sites, but two have been used together by many operators for larger hole closure (off label). The suture-mediated devices can either be placed at the end of a procedure to close smaller holes or alternatively can be "preplaced" for closure of access sites of up to 24F. "Pre-closure" means that the device/s are deployed via a smaller pilot hole. This is typically 6F for Proglide and 10F for the Prostar. The same access site (guidewire access is maintained in position throughout) is then dilated up to the size necessary for placement of the EVAR device. The sutures are then tied once the EVAR procedure has been completed.

The delivery and device placement of the EVAR is inherently an IR procedure, the reason for surgery and surgeons being involved in these repairs was an issue of gaining and closure of the access. For EVAR to be a true IR procedure one of two circumstances must be met. Either: 1. The devices must be deliverable using percutaneous closure devices or 2. Interventional radiologists be able to safely perform open arterial exposure (predominantly at the femoral artery). It is true of any procedure undertaken in medicine that there are potential complications and technical difficulties which may arise which may need the help of other specialists. For example, a chest drain insertion may be complicated by intercostals artery bleeding, which requires embolisation. Thus, it is not incumbent upon an interventional radiologist to be able to manage directly every possible complication; he/she must be able to manage the likely or predictable problems and to have access to help whenever needed. Can EVAR be done using percutaneous closure devices?

In order that EVAR can be considered truly a percutaneous procedure, all of the devices used for a particular patient must be deliverable through access holes which can be percutaneously closed.

Abdominal EVAR, which is the most commonly practiced form of EVAR, is usually performed via two access site, one of which is larger than the other. Therefore, the larger device section must be deliverable percutaneously.

As has been noted above, using a pre-closure technique access holes up to 24F in size can be closed. Modern EVAR devices fall well within this size limitation. Therefore, does this mean that all abdominal EVARs can be done percutaneously, and therefore be within the true IR environment? Not all patients are suitable for placement of these devices (often because of significant common femoral calcific arterial disease, depth of the femoral artery or iliac tortuosity), and indeed like all devices these can occasionally fail to deploy effectively. Series reported in the literature suggest that if pEVAR is considered to be suitable, success rates can be high. Jahnke et al (3) (4) used the Prostar in 14-24F devices, and in 500 patients had 96% success also. This group found that calcification in the anterior wall of the common femoral artery and operator experience were the variables predicting a need for open surgical bail out, but that the sheath size was not related and nor was patient obesity. The Canadian experience described by Grenon (5) was for 93% success for pEVAR as indeed was the success rate in Skowash et al's series (6) in 2005. Mattias (7) reports an even higher (98%) success with the Prostar device in 308 patients, but that 6 pseudoaneurysms occurred subsequently. Somewhat less successful were McDonnell et al (8) who considered 85% of their EVAR population to be also suitable for percutaneous procedures, 29% needed open surgical repair. Krajcer (9) reported to the International Society of Endovascular Specialists meeting, the experience from the Texas Heart Institute. They had performed 991 pEAVRs out of a total EVAR population of 1379 (72%). Percutaneous EVAR resulted in a reduced procedure time, need for blood transfusion, length of hospital stay, groin infection, neuropathy and need for embolectomy. There was, however, a small (0.6%) increased risk of pseudoaneurysm formation. Their experience was that the sheath size did not alter the rate of complications. In a systematic review in 2010, Malkawi et al (10) concluded that the overall reported success of pEVAR was 92%; however, a lower number (72%) was found if it was considered successful if only the entire procedure (both sides) was performed percutaneously. They also found a better outcome by the use of Proglide rather than Prostar and that compared with open EVAR, pEVAR had less wound complications, shorter operative time, shorter length of stay and less access site complications. They also recommended that ultrasound be used to guide access as this reduced the complications (particularly with the larger sheath sizes), which was described by Arthurs et al in 2008 (11) .

For many years it has been common practice for many groups of doctors to perform formal arterial and venous exposure. Venous access in difficult circumstances has utilised formal cut down, and cardiologists performed numerous coronary angiograms via brachial artery cut downs, prior to the development of percutaneous devices. It has not generally been part of interventional radiology training to learn to perform formal arterial exposure and control; however, many interventional radiologists have surgical training prior to specialising in Radiology, or have the basic skills to learn arterial exposure, which is generally regarded as a relatively simple surgical procedure. However, IRs are unlikely to be performing sufficient numbers of surgical exposures, as the majority of attempted pEVARs will be successful, as indicated above. It is also likely that the majority of exposures will be performed for failed percutaneous closure, which is a more difficult circumstance than a elective cut-down. Adding to this that IRs are also unlikely to be performing more technically challenging open surgical procedures, and the likely complication rate associated with this practice would be expected to be unnecessarily high. Conclusions pEVAR seems to realise a number of the advantageous features that were envisaged:

However, not all patients who are suitable for EVAR are also suitable for pEVAR, and when this is attempted not all are successful. It remains unclear as to the features which make pEVAR likely to be unsuccessful; sheath size, femoral artery calcification and obesity seem to be the likely factors. traditional vascular surgeons to embrace the techniques, or to learn the basic guidewire-catheter skills required to practice. Even they should now realize that endovascular surgery is here to stay, and that endovascular skills are an integral part of contemporary vascular patient care. Indeed, open vascular surgery may become confined to those anatomically unsuitable for minimally invasive techniques, or those in whom the endovascular solution has failed. Both will represent a diminishing proportion of the vascular interventional workload. The question posed is whether the radiologist and the surgeon should still work together since the advent of modern closure devices for large calibre delivery devices.

There are significant geographical variations in practice. In some countries, endovascular techniques have been widely adopted into clinical practice. Some vascular surgeons have been quick to learn the fundamental skills required to perform endovascular surgery without reliance on a radiologist for every case. In the UK, current practice in many major vascular centres is for the surgeon to perform the groin cut-down, and the radiologist who has planned the case, and chosen the stent graft components, to come into perform the aneurysm repair, leaving the surgeon to repair the artery at the end. This current schism represents a very arbitrary division of labour which creates discontinuity in patient care. Furthermore, this form of 'collaboration' is outdated, financially non-viable in the long term, and risks the future of vascular surgery as a speciality. The idea that one set of clinicians assesses and counsels the patient, and another performs the procedure, is a failed paradigm. To quote a text on endovascular skills, 'anyone with skills to make a 6 inch long incision should be able to learn the intricacies of working through 6 French incisions' (2) . There is little doubt that a collaborative approach in terms of planning and decision making is beneficial, especially for complex pathologies. However for most aneurysms, the basic planning of an endovascular repair, the decision-making regarding stents grafts, and the performing of the procedure should be within the remit of any endovascular practitioner, who could be a radiologist or a surgeon. The key is acquiring the right skill mix in a structured training programme. This can only be achieved by close collaboration between the surgeon and the radiologist. The National Health Service is in financial difficulties with many hospitals struggling to cut costs without sacrificing patient care. The creation of Foundation Trusts gives individual hospitals new financial freedoms including the ability to retain financial surpluses to reinvest in local health care (3). This will drive efficiency and drive a higher level of accountability within individual care groups. In the UK, the system of remuneration for endovascular aneurysm repair currently involves a tariff payable for each case, paid by the local primary care trust to the surgical care group within the hospital. The cost-effectiveness of endovascular repair is therefore partly driven by the ability to perform the case within the tariff. In many centres, while the tariff received by the surgical group may cover the performance of the repair, cross charging by the radiology department for involvement in the endovascular procedure can run into thousands of pounds, rendering the case financially non-viable. This sort of accountancy is hindering the joint collaborative approach to endovascular cases. Successful, high-quality endovascular practice depends on creating the correct working environment and acquiring the necessary skills. From a radiology perspective, one could argue that they should take the cases. If surgeons fail to awaken to the changes taking place they may lose their endovascular practice altogether. Endovascular delivery devices are getting smaller. Even with the current sheath sizes many are switching to a percutaneous approach and demonstrating superior results, with cost savings due to reduced length of stay, and fewer complications (4) . Delivery devices are now under 20 French in many cases, and 12 French systems are in the pipeline. This will increase the applicability of the percutaneous approach. Furthermore, it is recognised that a high standard of imaging quality is essential for good endovascular practice (5) . In many units this is still under the auspice of the radiology departments. Surgeons need to push for the formation of true hybrid suites, with high standards of imaging in a theatre environment, controlled jointly by surgeon and radiologist.

In those countries where surgeons and radiologists have led the endovascular revolution, the results are often superior. Indeed, the UK had some of the poorest outcomes from aneurysm surgery. Increasing the proportion of patients undergoing endovascular repair, adopting the multi-disciplinary team approach in most hospitals, has led to a halving in aneurysm-related mortality. The Vascunet data demonstrated a 7.2% mortality in the UK compared to 1.6% in Italy (6) . However, this has dropped to 2.4% in the latest Vascular Society report. At St Georges Vascular Institute, the vascular surgeons perform the endovascular aneurysm repairs in a hybrid theatre, with a full stock of endovascular devices, and access to workstations to plan each case. The majority are performed using percutaneous closure devices. We provide structured training for both surgical and radiology trainees. All cases are planned and discussed in a joint multi-disciplinary meeting and complex cases performed as a team. We have some of the best results in contemporary practice, in terms of perioperative mortality, technical success rate, and reintervention rates. This is not typical. In the UK at the moment there is a dearth of structured, formal endovascular teaching for vascular surgical trainees (7, 8) . Vascular training remains within the remit of general surgery. Trainees rely on fellowships to visit the few centres where a structured endovascular training approach is in place. Despite, surgeons often complete training without sufficient experience to embark on single handed endovascular practice. Many resort to travelling overseas, especially to Australia and the Unites States, to get hands-on experience in large numbers of endovascular procedures. A proposed joint training structure for vascular surgeons and interventional vascular radiologists (9) has not been accomplished but should happen. So for me the answer to the question posed is easy. I have no doubt a collaborative approach is beneficial in terms of planning, training and outcomes in complex cases. Any vascular surgeon who wants to continue providing a therapeutic service to their patients must acquire the necessary skills to perform endovascular procedures. It is equally essential that the national vascular surgical societies develop a training strategy for the surgeons and radiologists of the future to work together. Without this, we may as well keep vascular surgery within the remit of general surgery, and go back to performing hernia repairs and cholecystectomies. Key points · Endovascular technologies have redefined the management paradigm for vascular disease. · Successful, high-quality endovascular practice depends on creating the correct working environment and acquiring the necessary skills. · Anyone who is trained to do endovascular procedures, whether surgeon or radiologist, should be able to do so safely. · However, a dual radiology-surgical approach may provide the best outcomes and environment for training.

The title of this debate suggests that new information is available regarding the cost effectiveness of EVAR since the publication of the randomised controlled trials: EVAR 1, DREAM, OVER and ACE (1) (2) (3) (4) (5) . Cost effectiveness can only be meaningfully assessed by randomised controlled trials which have been planned from the outset to assess the relative cost and efficacy of the two procedures. The only new randomised data published recently is the long-term results of the EVAR trials which have been extrapolated to include lifetime projected costs (6) . The unit for measuring health is the QALY -quality adjusted life years. In the UK a cost per QALY of more than £20,000-30,000 is not thought to be cost effective. There are many methods to perform model-based cost effectiveness analyses, and depending upon the assumptions made the same data can be manipulated to show almost any desired outcome. For example, the data for intervention on asymptomatic carotid stenoses can produce costs per QALY ranging from £5,000 (highly cost effective) to £200,000 which is highly cost ineffective. Model-based methodology can therefore not be used to substitute for randomised trials as evidence for health economic decision making. The EVAR 1 trial was set up to establish the safety, efficacy and cost effectiveness of EVAR compared with open surgical repair to treat infrarenal abdominal aortic aneurysms. The primary outcomes were operative, all cause and aneurysm-related death. Secondary outcomes were graft-related complications and reinterventions, healthrelated quality of life, adverse events, costs and cost effectiveness. The trial started in September 1999 and closed recruitment in August 2004. Patients had to be at least 60 years old with an aneurysm which measured a minimum diameter of 5.5cm. The aneurysm had to be suitable for endovascular repair and the patients had to be fit for surgery. Quality of life was assessed with the European Quality of Life-5 Dimensions (EQ-5D) and Short Form questionnaire -36 items. The cost was based on the costs of staff and consumables for each procedure in every centre. Cost-effectiveness was assessed using QALYs. Patients were analysed by intention-to-treat randomised group. In conclusion, EVAR is not cost effective. In every cost effective analysis EVAR is dominated by open repair as the initial costs are cheaper, the initial benefit in terms of mortality is lost, the number of complications and reinterventions are higher and the number of aortic ruptures is higher after EVAR. In addition, EVAR cannot be used to treat aneurysms unsuitable for endovascular repair. The EVAR 2 trial showed that EVAR carries no benefit in treating aneurysms in patients unfit for open repair. Patients having EVAR must have life long surveillance and even this may not detect patients at risk of aortic rupture. Secondary interventions undertaken for surveillance detected complications may also not prevent aortic rupture. What has changed in favour of EVAR since the randomised trials? In short nothing. The devices are now more expensive than in 1999-2004. The expected competition from new devices has not lead to a fall in the cost of endovascular devices. The devices used in the trials are much the same as in use today. New endografts are coming onto the market, but the emphasis is on lower profile rather than durability. There are good reasons to think that lower profile devices will be less durable. The stents will be smaller and more prone to fracture and the fabric will be thinner and more prone to lose integrity. The durability of new EVAR devices remains unproven. More patients are being treated outside the manufacturer's instructions for use with an increase in endoleaks and subsequent aneurysm rupture (10) . The length of stay in hospital has reduced for both open repair and EVAR patients since the trials. Cell savers have been established in routine open surgical repair reducing the cost and increasing the safety of blood transfusion. Finally, EVAR is applicable only in patients with good anatomy. In open surgery short necks can be easily dealt with by moving the proximal clamp above one or both renal arteries. Iliac aneurysms can also be treated without embolising the internal iliac. Given the proven durability of open repair, the only surveillance that is required is a single CT scan every 5-10years. An additional problem with EVAR is that even with surveillance scans showing satisfactory results, patients still unexpectedly rupture their aneurysms. EVAR is established in clinical practice but it would be foolish to believe it is more cost effective than open repair as all the available evidence points to the contrary.

C RSE CIRSE Abstract Book developing metastatic bone disease during their lifetime has also increased. Bone metastases can severely impair mobility and significantly contribute to a general decrease in quality of life. Current treatment strategies embrace analgesics, chemotherapy, hormonal therapy and bisphosphonates for systemic therapies, and radiation therapy, percutaneous ablation and surgical stabilization for local control. At present, external beam radiation therapy (EBRT) is the treatment of choice for clinically active bone metastases; however this proved to be ineffective in 20-30% of the patients and only temporarily effective in 27% of cases. In addition to relapse and retreatment, there is an increased risk of pathologic fracture in the peri-radiation period. The fracture rate reported in radiation studies is generally in the range of 1% to 8%. The hyperemic response weakens the adjacent bone and increases the risk of spontaneous fracture. Furthermore, patients who have recurrent pain at a site previously irradiated may not be eligible for further radiation therapy secondary to limitations in normal tissue tolerance. Magnetic Resonance-guided Focused Ultrasound (MRgFUS) is an non-invasive treatment modality that combines high intensity focused ultrasound that non-invasively heats and destroys targeted tissue and Magnetic Resonance Imaging (MRI) which allows to identify and target tumors and provides real-time temperature monitoring of the treated tissue. Combining thermal ablation using advanced acoustic transducer technology with the anatomic, functional, and thermal guidance possible with MRI methods allows accurate targeting, realtime temperature monitoring, and closed-loop control of energy deposition. MRgFUS is currently under evaluation and in constant development for the treatment of solid tumors in the brain, breast, liver and pancreas, while it has been already clinically approved in the EU for treatment of uterine leiomyomas and palliative care of bone metastases. Initial studies demonstrated MRgFUS to be effective for pain control through thermal cell death and periosteal denervation induced by cortical heating relative to acoustic energy absorption; moreover, high-intensity focused ultrasound beam can penetrate through the cortical bone to medullary space producing thermal necrosis into cancer tissue. We sought to evaluate the clinical performance of MRgFUS in the primary treatment of painful bone metastases and the potential of this technique in obtaining local control of bone metastases. Energy delivered during MRgFUS treatment and accumulated inside the pathologic soft tissue of the metastases can create variable amount of tissue necrosis thus attempting local tumor control. The use of non perfused volume as immediate predictor of tumor necrosis and thus of the efficacy of the treatment might play an important role in future patient management avoiding to persisting with a potentially ineffective treatment and consequences such as toxic effects and morbidity, accelerated tumor growth, delay in potentially effective treatment and unnecessary expense. We demonstrated local tumor control yielded by a reduction of lesion viability following MRgFUS procedure (NPV: 46.4 ± 23.9%) and by re-mineralization of spongious bone according to MDA criteria (6/18 patients) . In our experience MRgFUS can be safely and effectively used as primary treatment for pain palliation in patients with bone metastases and has a potential role in local tumor control.

Pancreas and liver

Unit of Interventional Radiology, IEO Istituto Europeo di Oncologia, Milan, Italy.

1. To review the indications to HIFU of liver and pancreatic cancers 2. To describe the technique, limitations and complications of focused ultrasound 3. To present results of focused ultrasound in liver and pancreatic cancers as compared to other technique The possibility that focused ultrasound therapy might be developed as a result of controlling local heating phenomena was introduced by Lynn et al. in the 1940s, but the technique was not developed at that time because of inadequate targeting methods. The advent of more sophisticated imaging has led to a resurgence of interest in HIFU. Unlike radiofrequency or cryoablation, which are also used to ablate tumors, HIFU is completely non-invasive and can be used to reach tumoral areas that are deep within the body if there is an acoustic window for allowing the transmission of ultrasound energy. Preliminary reports underline a reduced toxicity with HIFU ablation compared with other ablation techniques because of the non-invasive nature of the procedure. First devices never used widely in clinical practice were trans-rectal probes, which have been used predominantly to treat the prostate cancer. Extracorporeal devices are significantly larger and can be used to treat a variety of problems, most commonly intra-abdominal solid tumors. As a result, these extracorporeal devices use transducers with a longer focal length and use US or MRI for targeting the organ. Combination between imaging and technologies for local therapy has made ablative procedures more reliable and practical, allowing for safe and feasible application of HIFU treatments in clinical practice. USgHIFU has been used to treat patients with various kinds of malignancies, including liver, pancreas, breast, kidney, bone, and soft tissue both in Asia and Europe. Investigation and applications of HIFU are growing rapidly worldwide. Pancreatic cancer is the fourth leading cause of cancer deaths in Europe and in the United States. Unfortunately, most pancreatic cancers are not curable and are rarely operable. Current treatment options for pancreatic cancer include surgery, radiation, and chemotherapy. Due to the poor long-term prognosis of patients with advanced pancreatic cancer, research is continuously looking 

Stroke prevention: where do we stand in 2012?

Detection of supra-aortic atherosclerotic disease and plaque morphology with non-invasive imaging

Department of Diagnostic and Interventional Radiology, University of Technology, Aachen, Germany.

1. To understand where the non-invasive angiography (CTA, MRA) stands in early detecting the supraaortic stenosis to prevent the incoming or recurrent stroke 2. To understand basic pros and cons of CTA and MRA 3. To learn if and how the imaging would detect an atherosclerotic plaque which is more prone to create a stroke Atherosclerosis is a systemic disease, which commonly affects the carotid arteries. Subsequent stroke is a leading cause of death and long-term morbidity. There are approximately one million strokerelated events per year in the US alone. Often atherothromboembolism from a focal atherosclerotic plaque at the carotid bifurcation causes stroke and carotid stenosis and is often present in these patients. Commonly used non-invasive imaging techniques for diagnosis of significant carotid artery stenosis include Doppler ultrasonography (DUS), digital subtraction angiography (DSA), MR angiography (MRA), and multislice CT angiography (CTA). DSA is still considered the standard of reference for evaluation of carotid artery stenosis. However, it comes with a risk of neurological complications, which is estimated to be in the range of 0.05 to 0.5%. DUS is not capable of imaging all vessels that are relevant for the brain's blood supply. Therefore, in clinical routine practice, non-invasive imaging techniques, such as MRA or CTA are widely used for establishing the diagnosis and subsequent treatment planning. Traditionally, the degree of luminal stenosis has been used as marker for the stage of disease. However, prospective clinical trials have shown Learning Objectives 1. To understand basic pharmacologic specifications of antiaggregation and anticoagulation agents in regards to pre-stenting or perioperative stroke prevention 2. To learn the limitations of medical treatment in preventing stroke with a critical extra or intracranial stenosis 3. To learn when the medical treatment should be the treatment of choice to avoid unnecessary intervention Large clinical trials have shown that Clopidogrel alone or Dipyridamole in combination with Aspirin is equally effective in the long-term prevention of recurrent stroke. However, we now know that the risk of recurrent stroke is particularly high in the first few weeks following a stroke or TIA. This has led to the suggestion that more intensive antiplatelet regimes should be used during this phase. This is analogous to acute coronary ischaemia where intensive medical regimes (with or without surgical or radiological intervention) are used initially, followed by less intensive regimes after the first few months. There is little data from large clinical trials in stroke examining this hypothesis. Studies in stroke patients with both symptomatic carotid stenosis and middle cerebral artery stenosis have shown that the combination of Aspirin and Clopidogrel is more effective than Aspirin alone in reducing asymptomatic cerebral emboli. Such asymptomatic emboli predict recurrent stroke risk. Large phase 3 clinical trials are now determining whether such regimes, given in the first 24-48 hours post-stroke and TIA, reduce the clinical endpoint of recurrent stroke. These include POINT assessing Aspirin and Clopidogrel versus aspirin alone, and TARDIS assessing triple therapy with Aspirin, Clopidogrel and Dipyridamole. Patients with large artery stroke due to carotid, vertebral or intracranial stenosis have a particularly high risk of recurrent stroke. Large trials have shown carotid endarterectomy reduces stroke risk in symptomatic carotid stenosis and is slightly better than carotid stenting. Surgical access to the vertebral arteries is more difficult, but stenoses can be treated with stenting. Current trials (VIST and VAST) are determining whether stenting is better than medical therapy alone for symptomatic vertebral stenosis. Disclosure I was CI for CARESS and on the steering committee for CLAIR-both trials examined the effect of clopidogrel and aspirin versus aspirin alone on embolic signals in large artery stroke and TIA. For the former I received reimbursement from Sanofi for my role.

that the majority of patients with a history of recent transient ischemic events or stroke suffer only mild-to-moderate carotid stenosis. Using conventional stenosis criteria, in many of these symptomatic individuals, the severity of disease would be underestimated. These patients would falsely be considered to have early-stage carotid artery disease. Consequently, improved criteria for identifying the high-risk carotid plaques independent of the extent of stenosis are needed. Histological studies from different vascular territories have led to the hypothesis that plaques with large lipid-rich necrotic cores, thin fibrous cap, extensive plaque neovasculature, intraplaque hemorrhage and vessel wall inflammation pose an increased risk for plaque rupture and ischemic events. These plaques are considered "vulnerable". Despite the widespread consensus on the importance of the characteristics of the "vulnerable plaque", there is a lack of reliable imaging tools for in vivo plaque characterization. Over the past decade MRA and more recently CTA have been identified as promising tools for assessing plaque morphology and composition in the search for the "vulnerable plaque". Only recently radionuclide imaging such as positron emission tomography (PET) and single-photon emission computed tomography (SPECT) entered the field of plaque imaging with their ability to image molecular markers of inflammation or apoptosis. MRA and CTA may roughly be considered equal for assessing the degree of carotid stenosis [1] . However, MRA has been shown to accurately identify key carotid plaque features, such as a lipid-rich necrotic core, intraplaque hemorrhage, neovasculature and vessel wall inflammation [2] . In contrast, CTA proved perfect for identifying calcified lesions, but due to a relevant overlap in the attenuation values associated with lipid-rich necrotic core, connective tissue, and hemorrhage, its reliability for identifying these components is limited [3] , although morphologic characteristics, such as plaque ulceration are known to closely correlate with intraplaque hemorrhage [4] . Almost a decade ago, high-resolution MR imaging proved its ability to accurately classify human carotid atherosclerotic plaques according to the American Heart Association classification [5] . MRA therefore permits distinguishing advanced lesions from early and intermediate atherosclerotic plaques. Its ability to visualize molecular targets in atherosclerotic lesions renders MR imaging the most versatile tool for plaque imaging [6] . It has been shown that "vulnerable plaques" are more prone to the slow flow phenomenon during carotid artery stenting (CAS) and intraplaque hemorrhage which is thought to be associated with embolization during carotid endarterectomy (CEA) [7] . These results, however, are (1) not yet confirmed by randomized studies and (2) unlikely to affect the need for treatment in case of a significant carotid artery stenosis. Nevertheless, reliable plaque analysis is likely to alter treatment decisions, particularly in patients with a limited degree of stenosis but high-risk types of plaques. Due to the current complexity of MR plaque imaging, it is not yet widely used in clinical routine practice. Moreover, imaging is only one piece of the puzzle. A careful clinical workup with a thorough neurological assessment remains a mainstay in the diagnosis of carotid artery disease and the gatekeeper for imaging tests. So far MRA is the only candidate for an in vivo assessment of the "vulnerable plaque". For several reasons there is no consensus regarding the use of such a test in clinical routine and several tasks lie ahead. Most importantly, a validated and generally accepted comprehensive plaque score is needed as foundation for future clinical trials. While the available data on the prognostic impact of plaque imaging are promising, it is limited with respect to the number of patients and ischemic events. Thus, larger studies are needed to prove that specific baseline plaque features are associated with an increased risk for future ischemic events.

SS/FC/HL/HTS/CM a result of atherosclerosis affecting the legs only and additionally on the major features of diagnosis and management, allowing for easier propagation and use. Contents of the 7 sections were "epidemiology of peripheral arterial disease", "management of cardiovascular risk factors and coexisting disease", "intermittent claudication" (defined as muscle discomfort in the lower limb reproducibly produced by exercise and relieved by rest within 10 minutes), "chronic critical limb ischemia" (CLI, defined through typical chronic ischemic rest pain or patients with ischemic skin lesions, either ulcers or gangrene due to PAD with presence of symptoms for more than 2 weeks), "acute limb ischemia" (ALI, defined as sudden decrease in limb perfusion which could threaten limb viability), "revascularization" and "non-invasive vascular laboratory and imaging". In this FC lecture, the TASC A-D classification of aortoiliac lesions and of femoral popliteal lesions will be presented and the relevance of the classification for intervention and revascularization discussed, including the statement that endovascular procedures are recommended for comparatively mild lesions, while surgery is recommended for patients with severe occlusions or stenoses. Indications for conservative, interventional and/or operative treatment options and approaches in acute limb ischemia, chronic critical limb ischemia and for intermittent claudication will be put forward.

1. To learn about the benefit of re-entry devices 2. To learn when to stop 3. To learn how to recognize lesions in which recanalization is likely to fail

No abstract available.

Logistics of providing an EVAR service for ruptured AAA

Division of Diagnostic and Interventional Radiology, University Hospital Zürich, Zurich, Switzerland.

1. To learn how to set up a service to treat ruptured AAA 2. To learn which equipment you must stock to treat ruptured AAA 3. To learn the experience of treating ruptured AAA An ongoing decline in the incidence of clinically relevant abdominal aortic aneurysms (AAA) has been observed over the past decade in the U.K. (1) . A U.S. community hospital discharge database disclosed also the same trend with a decline of ruptured AAAs by onethird between 2001 and 2009 (2) . The exact reasons for this decline are not well known, but the reduced AAA mortality is attributed to a change in the smoking habits of the patients and the higher numbers of elective, preventive AAA treatments in the high-age population. Concurrently, the share of patients undergoing endovascular instead of open EVAR is steadily increasing. In a recent survey of centers committed to an endovascular-first treatment approach, the percentage of patients treated by stent-grafts ranged between 28 and 79% . The mean 30-day EVAR-mortality was 19.7% (3) . The introduction of a rAAA treatment algorithm favoring endovascular repair has resulted in significant overall reduction in mortality in centers with a large experience in open as well as endovascular repair (4, 5) . These multidisciplinary protocols define all the steps of the rAAA management (6, 7) . CT-angiography has to be obtained immediately in any patient with a suspicion of a rAAA as the anatomy is currently the most important determinant in the treatment choice. The emergency staff will alert the on-call vascular surgeon and/or the interventional radiologist including the operating room staff and radiographers. Obviously, round-the-clock availability of the involved specialists within 30 to 40 minutes should be warranted. Maintaining a low systemic blood pressure by limited fluid resuscitation or even pharmacologic pressure lowering may minimize further blood loss (hypotensive hemostasis). The choice of the anesthesia (local vs.

11. Get out of the profunda femoris artery (after antegrade puncture (1). Lesions may be stenoses or occlusions, or are most commonly a combination of both. For the revascularization procedure 4-and 5-F systems can be used. We prefer to work with 0.035´´ guidewires in the SFA. Recanalization procedures are typically performed with hydrophilic wires. Stenotic lesions are passed intraluminally, whereas occlusions may be recanalized intraluminally or subintimally. Before the recanalization of an occlusion is started, the operator should identify the level of vascular reconstitution which determines the area where the artery should be re-entered in case of subintimal guidewire passage. If the true lumen can not be reassessed at the desired level reentry devices may be helpful. Alternatively retrograde recanalisation via a transpopliteal approach may be successful (2) . After successful guidewire passage PTA is performed. We prefer 8-15 cm long balloons and inflation times of 2 min. and more. However, despite long pre-dilatation stent insertion is performed routinely in lesions > 8 cm (3) . Whenever possible we try to avoid stenting the proximal popliteal artery. Although encouraging results have been reported for drug eluting stents recently (4) we use bare Nitinol stent routinely. We try to avoid multiple overlapping stents and use long stents if necessary. Especially with these long stents attention must be paid to a smooth insertion procedure and stretching or crushing of the stent should be avoided. With proper application long stents reveal patency rates comparable to prosthetic bypass surgery (5) . All patients are on aspirin as a pretreatment medication. During the intervention 3 000 -5 000 IU heparin are given intra-arterially. When the procedure is finished the patients are loaded with 300 mg Clopidogrel and dual platelet aggregation inhibition is maintained for 6 weeks and a single platelet inhibition with aspirin lifelong is prescribed thereafter. In addition to that statins are prescribed whenever necessary. (1, 2) . According to the literature, 30-day mortality of RAAA is somewhere between 20-50% on average (3) . The more established therapy of patients with RAAAs is still open surgery though EEVAR is increasing (4) (5) (6) . Some studies indicate that EEVAR of RAAA may have a lower 30-day-mortality than open surgery (3, 4) , whereas others found no significant difference. A study providing level 1a evidence is still awaited. One major problem is that it may be considered unethical to randomize patients with RAAA who are on the edge of death into a prospective study. The argument is that instead of losing valuable time definite treatment should be offered without delay. Bias caused by selection of less hemodynamically unstable or more hemodynamically stable patients for EEVAR is assumed to explain the favourable 30-day mortality of EEVAR compared with open surgery that was found in several studies with an evidence level > 1 (1) . Only a few prospective randomized trials have been performed or are ongoing. In a smalllevel 1-b-study that recruited 32 patients Hinchliffe and coworkers found a 30-day-mortality of 53% in both groups (7) . In the Amsterdam (Ajax) trial that primarily included 80 patients, no significant difference between both treatment groups was found either (8) . The prospective randomized French ECAR trial (9) and the Improve trial (10) have not yet been finished, or final results have not been published. According to the literature, between 30-100%, realistically > 50% of patients are eligible for EEVAR (5, 11) . A first triage is needed to decide whether a patient with a RAAA should be treated at all. If treatment is planned, in the next step it has to be decided whether the patient is suitable for EEVAR. A grading of the clinical state of the patient may be helpful to find the best therapy. There are various scoring systems claiming to predict clinical outcome of patients with RAAA (12) . Well known are the "Hardman index" and the "Glasgow Aneurysm Score". The Hardman index includes the factors age, blood hemoglobin level, creatinine level, loss of consciousness after arrival, and electrocardiographic ischemia. The Glasgow Aneurysm Score includes the factors age, shock, myocardial disease, cerebrovascular disease, and renal disease. However, both scoring systems were found to be only poor predictors of mortality. Reportedly, the "Edinburgh Ruptured Aneurysm Score", including the factors blood hemoglobin level, blood pressure, and Glasgow Coma Scale, may be more useful (12) . Information provided by relatives, family doctors, and/or others on the patient's state of health should be taken into consideration for the decision on the type of therapy which has to be made in agreement with the patient and his/her relatives whenever possible. If a patient suffers from an inoperable malignant tumour, an advanced incurable neurologic or other systemic disease, such as M. Alzheimer or M. Parkinson, and his/her quality of life is already markedly reduced conservative, therapy may be an option. If the patient is severely hemodynamically unstable, i.e. systolic blood pressure < 60 mm Hg, with episodes of cardiac arrest, and/or critical cardiac arrhythmia, and/or unconsciousness, the majority of groups will perform open surgery without delay. However, there a few groups at the fore-front of EEVAR claiming that just these patients may benefit from endovascular therapy general) depends on the operator's expertise (femoral cut-down or percutaneous "preclosing" technique) and on whether the patient is at rest and sufficiently oxygenated under deep analogsedation. In hemodynamically unstable patients temporary transfemoral aortic occlusion with a large compliant balloon may help. In order to keep the balloon in the desired position in a healthy, usually suprarenal, aortic segment a long sheath and a stiff guide-wire are advantageous. The stent graft placement itself is as in an elective procedure. Therefore, the device one feels most comfortable with and which fits best the vascular anatomy should be chosen. The percentage of individuals having a short or a large infrarenal anchoring neck is higher in ruptured aneurysms, so off-the-shelf availability of largediameter stent grafts with a transrenal fixation is recommended. Particularly in women the introduction size of the stent grafts may represent a iliac artery complication source. Anyway, the newer device generations differ little in their maximal introduction diameters. As bifurcated stent grafts are associated with less complications than aorto-uni-iliac prostheses most operators favour these devices also for rAAAs (8) . During the postoperative care bladder pressure monitoring to assess for the abdominal compartment syndrome (ACS) is mandatory. ACS has been recognized as a serious problem related to EVAR of rAAAs. In our experience the ACS was associated with a fourfold mortality increase (9) . In order to plan open or percutaneous abdominal decompression therapy (including correction of endoleaks) of the ACS we perform a control contrast CT angiography immediately after all EVARs.

C RSE CIRSE Abstract Book docking site for the contralateral leg is not necessary (16) . In hemodynamically more stable patients, aortobiiliac systems are also useful. Naturally, conversion to open surgery has to be avoided; however, if a type 1 endoleak is found during the intervention that cannot be closed by endovascular means conversion is advisable. A disadvantage inherent to EEVAR is the persistent intraabdominal hematoma which may lead to abdominal compartment syndrome, indicated by symptoms of organ failure and/or increase of bladder pressure (> 20 mmHg) (4, 5, 13) . Therefore, EEVAR patients require close control of their abdominal state on the ICU including measuring of bladder pressure. If abdominal compartment syndrome is clinically suspected, open surgery has to be performed urgently. Finally, it was surmised that patients with RAAA may be divided into 3 groups (11) . One group of patients will die regardless whether open surgery or EEVAR is chosen for therapy, one group will survive regardless of the type of therapy, and only a third group of unkown size may really benefit from EEVAR. The aim will be to spot these patients. (4) . Aortic balloon occlusion may help to stabilize circulation in these patients. If the patient is moderately hemodynamically unstable ( systolic blood pressure > 60 and < 100 mm Hg) and vascular anatomy is suitable, the decision on the type of therapy has to be made depending on the circumstances of the case and the local situation. If the patient is hemodynamically stable (systolic blood pressure ≥ 100 mg), conscious, without episodes of cardiac arrest and/or critical cardiac arrhythmia and vascular anatomy is suitable, EEVAR may be performed. It is not clear how to treat patients with renal insufficiency stage 3 (GFR < 60 ml/min/1.73 m2) or stage 4 (GFR < 30 ml/ min/1.73 m2) who have a large (supply of > 1/3 of one kidney) lower pole renal artery that would be covered by the stentgraft in EEVAR. It is known that open surgery in patients with pre-existing renal insufficiency is afflicted with increased mortality. However, EEVAR will further decrease renal function either. Besides clinical contraindications for EEVAR which are mainly relative and debatable, there are also some anatomical contraindications which are still more or less absolute. Patients with an infrarenal neck length < 1 cm, angulation between infrarenal neck and aneurysmal body < 120 °, diameter of the infrarenal neck > 32 mm, diameter of the iliac arteries < 6 mm or severe stenosis and/or tortuosity of both iliac arteries > 90° should be treated with open surgery. Treatment of patients with RAAAs is multidisciplinary and collaborative, and it will become even more collaborative if EEVAR is to be launched. It is advisable to set up a RAAA working group at ones hospital to start EEVAR. Doctors and nursing/technical staff from the departments mainly involved with RAAA patient management, the department of vascular surgery, radiology, anesthesiology, and emergency, should be included in the group. The task of the working group is to develop and implement a structured treatment pathway adapted to the local situation (13) . The treatment pathway that has to accepted by all participating groups should be clear, fast, simple, and secure. It was reported that a structured treatment pathway decreased 30-day mortality of RAAA considerably if EEVAR was applied, whereas open surgery results remained unchanged (14) . Prerequisites for EEVAR are a local stock of endovascular prostheses of different sizes, preferably in a consignment store close to the theatre, a 24-hour CTA service, and a 24-hour availability of interventionalists and technical staff experienced in endoluminal aortic interventions. Particularly the latter may be a problem since at least two interventionalists are needed to guarantee a 24-hour service 365 days of the year. It was shown that it is possible to acquire a CT angiography (CTA) in more than 80% of patients with RAAA (11) . A fast multi-slice CT scanner favourably with > 16 slices/rotation is useful. The scanner should be sited close to department of emergency and the theatre. Ideally, the CT is integrated into the theatre. Interpretation of a CTA may be difficult and diameter measurements from CTAs may vary considerably between the same and even more between different observers (15) . Therefore, it is important that the staff is trained in the interpretation and measuring of CTAs. It is useful to set up a regular training to standardize the proceeding and improve outcome (6) . Interventions should not be performed in a angiography suite but in a theatre with high-quality fluoroscopic equipment, preferentially in a hybrid operating theatre. Regardless of the final therapy, in patients with RAAA fluid infusion should be minimized, and the systolic blood pressure should be kept ≤ 100 mmHg to avoid secondary free rupture of a primarily contained ruptured AAA (4). One should start the intervention with local anesthesia first; later, the intervention may be continued under general anesthesia (4, 5) . It is a matter of debate whether general anesthesia is necessary for precise implantation of the endograft particularly in cases with a short infrarenal neck. In the early period after introduction of EEVAR one should confine to one type of endovascular device. The literature indicates that at least in severely hemodynamically instable patients an aortouniiliac system is preferable to an aortobiiliac system since implantation is easier and occlusion of the aneurysm is achieved faster; the chance to find a suitable iliac access vessel is twice as high, and probing of the S57 CIRSE 2012 SS/FC/HL/HTS/CM strategy is associated with improved survival of patients with ruptured aneurysms. By September 2011 approximately 270 had been randomized in 22 approved trial centres across the UK. The rate of randomization into the trial represented just over half of the patients with ruptured AAA presenting to these centres. Reasons for a failure to randomize are varied but include insufficient resource to allow endovascular repair in a substantial proportion. The interim results of the study are not available and will not be released until recruitment has finished and an analysis performed. There are several sub-studies in progress. Core laboratory analysis of pre-operative CT scans will define the anatomical characteristics of ruptured AAA and preliminary results suggest that ruptured AAA have significant morphological challenges with shorter, wider and more conical necks than a typical population of non-ruptured AAA. A Delphi consensus is underway to define the best pathway for transfer of patients with ruptured AAA. The IMPROVE trial will provide real life data on all patients presenting to trial centres with ruptured AAA and will define whether and endovascular strategy results in mortality improvements in a national setting. The care protocols used in the IMPROVE trial, with permissive hypotension, anatomical guidelines for endovascular repair and preference for avoidance of general anaesthesia until there is control of the aorta may contribute to improved survival in both arms of the trial.

Department of Radiology, Hospital S. João -Porto, Porto, Portugal.

1. To discuss causes of VAA 2. To discuss indications including size, gender etc. for VAA treatment 3. To indicate which aneurysms can be managed conservatively and follow-up protocols Visceral artery aneurysms (VAAs) are generally defined as aneurysms that involve the branches of the celiac, superior mesenteric, inferior mesenteric or renal arteries. VAAs are rare with a reported incidence of 0.01 to 0.2% on routine autopsies. However, VAAs are clinically important and potentially lethal; 22% of all visceral artery aneurysms present as clinical emergencies; 8,5% result in death. VAAs include both true aneurysms, limited by all three layers of the arterial wall, which undergo progressive dilation and wall thinning, and pseudoaneurysms (VAPAs), where there is a tear of the vessel wall and a periarterial hematoma, corresponding to a contained rupture of the artery that is lined by adventitia or by perivascular tissues. Most VAAs are secondary to vessel wall degeneration, and demonstrate deficiency or the arterial media with loss and/or fragmentation of elastic fibers and reduced smooth muscle. Arteriosclerosis, congenital syndromes, fibromuscular dysplasia, gestational alterations, and collagen disorders are other possible causes of VAAs. Pseudoaneurysms can develop as a result of blunt or penetrating trauma, inflammation, infection, vasculitis, and iatrogenic trauma secondary to surgical, endoscopic and radiological procedures. As a result of improvements in cross-sectional imaging technology including ultrasound (US), multidetector computed tomography (MCDT) and magnetic resonance imaging (MRI), VAAs are diagnosed with increased frequency. The main indication for treatment is the size of the aneurysm. Because of the lack of data on the natural history of untreated aneurysms, there is debate regarding the size criteria for intervention vs. surveillance. The general consensus is that . Pseudoaneurysms are often associated with trauma, but they may be due to dissection and should in general be treated. Surgical and endovascular treatment of VAAs share the common goal of preventing aneurysm expansion and rupture. Treatment of VAAs, either by surgery or endovascular procedures should be individualized depending on the location of the aneurysm, regional vascular anatomy, and associated or coexisting conditions. High-resolution multiplanar cross-sectional imaging answers questions concerning access vessel pathology, vessel tortuosity, suitability of a particular treatment strategy, collateral blood flow and may reveal any other aneurysms. Operator ability to treat VAAs requires knowledge of vascular anatomy and collateral pathways, training in the catheterization of visceral arteries, familiarity with various interventional tools, and experience in complex embolization and stenting procedures. Many of the embolic agents used to treat VAAs, such as coils and some liquid agents like Onyx, create radiographic artifacts on follow-up imaging and may mask VAA reperfusion or aneurysm sac growth. As a result, there is no agreed protocol for imaging after endovascular treatment. Possible followup imaging may include magnetic resonance imaging (MRI), computed tomography (CT), or ultrasound (US) at 6-month or, more frequently, annual intervals, according to site and body habitus.

when a true aneurysm is 2 cm or larger, irrespective of anatomical site, the rupture risk is probably sufficient to indicate treatment. Aneurysms smaller than 2 cm are generally observed by serial imaging close watch. Other indications for treatment include symptomatic patients and documented evidence of growth of the aneurysm. In addition, most interventionalists treat smaller true aneurysms (1-2 cm or even less) in women of childbearing age, pregnant women and liver transplant recipients; rupture of splenic artery aneurysms in pregnant women is associated with maternal and fetal mortality.

Whereas the decision to intervene on a true aneurysm may depend on a size threshold above which the potential for rupture increases, it is generally advised that all pseudoaneurysms should be treated, whatever their size or location. In contrast to splenic artery aneurysms, which are historically the most common VAAs, hepatic artery aneurysms, are the most frequently reported VAAs during the past two decades, owing to the growing use of percutaneous biliary procedures, liver transplantation, and nonoperative management of blunt abdominal trauma. True splenic artery aneurysms (SAA) are the most common type of VAA, accounting for up to 60% of all VAAs, with an estimated prevalence of less than 0,1%. They may be associated with other mesenteric aneurysms (3%) and with renal artery aneurysms (4%). SAAs are 3 to 4 times more common in women than man and are associated with multiparity. Pseudoaneurysms of the splenic artery are generally caused by inflammation, infection including pancreatitis and trauma. Pseudoaneurysm size does not correlate with risk of rupture. Indications for treatment of SAAs are symptomatic aneurysms (LUQ pain radiating to the left shoulder), aneurysms with more than 2 cm diameter, smaller aneurysms in women of childbearing age, and patients with SAA who are candidates for liver transplantation. Hepatic artery aneurysms (HAA) are the second most common true VAA. True HAAs are more common in man than in women (ratio of 3:2), occur mainly in patients aged between 60 to 70 years, and are commonly associated with hypertension in up to 72% of patients. Up to 31% of patients with HAA have VAAs at other sites, but most HAAs are solitary and are due to atherosclerosis. Other etiologies include connective tissue diseases like polyarteritis nodosa, fibromuscular dysplasia, and mycotic aneurysms. True HAAs are 4 times more frequent in the extrahepatic than the intrahepatic arteries. Fifty percent are the result of percutaneous biliary interventions. The main risk factors for HAA rupture are the presence of multiple HAAs and nonatherosclerotic etiology. Mortality rates of up to 21% have been reported for ruptured HAA. The majority of HAA are found incidentally on axial imaging. Rapidly expanding aneurysms may manifest with back or abdominal pain. When rupture occurs, hemorrhage is more common into the biliary tree than to the peritoneum, and it may present with jaundice, biliary colic and upper gastrointestinal hemorrhage. The indications for HAA are similar to those for all VAAs. True aneurysm of the celiac artery (CAA) are rare (approximately 4% of all VAA), although true and false aneurysms involving the branches of the celiac artery are more common. True CAAs are usually atherosclerotic in etiology. Most CAAs are asymptomatic and are found incidentally on crosssectional imaging. Symptomatic CAAs may mimic acute pancreatitis.

CAAs are strongly associated with other aneurysms, including aortic, renal, femoral, and popliteal aneurysms. True and false aneurysms of the SMA (SMAA) are rare. They usually involve the most proximal 5 cm of the SMA. Underlying etiologies include atherosclerosis, collagen vascular disease, cystic medial dysplasia, polyarteritis nodosa, and infection. SMAA may be incidental finding on axial imaging or may present with abdominal pain and bleeding. True gastroduodenal aneurysms (GDA) and pancreaticoduodenal aneurysms (PDA) are relatively uncommon but well described in the presence of celiac artery stenosis or occlusion. Pseudoaneurysms of the GDA and PDA are much more common. They usually have an inflammatory or infectious etiology like pancreatitis and as with all pseudoaneurysms, they should be treated irrespective of size. Renal artery aneurysms (RAA) account for 22% of all VAAs. The main causes are

Basic principles of treatment of visceral artery aneurysms

Radiology Department, Mater Misericordiae University Hospital, Dublin, Ireland.

Learning Objectives 1. To discuss surgical treatments and imaging requirements for treatment 2. To describe embolization methods, stent assisted coiling, covered stents, flow divertors 3. To discuss the use of glue/onyx and other embolic material Visceral aneurysms may be classified based on a number of criteria: 1. True/Pseudo-aneurysms 2. Shape/Configuration (Saccular/Fusiform) 3. Size (Small, large, giant) 4. Vessel/Organ of origin (Systemic/pulmonary artery) 5. Pathophysiology (Congenital, Acquired (Iatrogenic/Trauma, Mycotic) The lesions may be congenital (e.g. Loeys Dietz) or acquired. The latter may be vasculitic (PAN, Wegener, mycotic, Rasmussen), atherosclerotic (penetrating ulcer) or traumatic (blunt, penetrating and iatrogenic). Presentation may be symptomatic bleeding or masseffect and increasingly as an asymptomatic, incidental-imaging finding. All modalities have a role in imaging assessment (Doppler/CTA/ MRA/DSA/Fluoro CT). Imaging is central to detection, characterization, therapy planning and follow-up. The optimal modality is based location, body habitus, the need for frequent imaging and local resources/availability. We find 3D MIP/VRT CTA the single most effective comprehensive test, which is sensitive, specific and reproducible obviating the need for exhaustive DSA and permitting more selective goal-directed catheter intervention. Full imaging assessment should produce a clear description of; site (vessel of origin, feeding/ draining vessels, access), size and temporal change, multiplicity, configuration (size, shape, neck, thrombus, mass-effect) and flow. We shall discuss optimal image acquisition and processing. Though visceral artery aneurysms may fall between different organ specialists on presentation their ultimate therapy is very much within the realm of IR, which has greatest exposure and is best placed to assess the need to treat. The indication for treatment is guided by the risk of rupture which itself is based on the nature of the aneurysm and the patient medical state. In particular we consider symptoms, size, and temporal change. Patient anxiety and comorbid conditions are a very real consideration. The individual organ aneurysm has low incidence and variable presentation to multiple specialists means the pathophysiology and natural history of many is a data-free zone leaving empiric precedents to guide much of modern practice for small-and medium sized lesions. Options for therapy include conservative observation, endovascular/percutaneous therapy, surgical approaches and hybrid combined IR/surgery. Modern decision trees consider IR the first line therapy with surgery for back up. The temptation to convert straightforward surgical candidates to complex endovascular approaches should be avoided. Specific therapies are largely guided by the initial imaging assessment and causation. Patient selection for IR involves aneurysm accessibility, the ability to deliver therapy and the risk to end organ. All IR therapies seek to thrombose the aneurysm by direct endovascular or percutaneous thrombosis (thrombin/glue/onyx or coils) or thrombosis by exclusion from flow (stent). The IR skill set for all aneurysms is within the remit of most practitioners comfortable with micro catheter/ wire and percutaneous techniques. IR pitfalls include difficult configuration, inability to decompress giant aneurysms, mass effect and some inflammatory pseudo aneurysms. We shall illustrate these principles through case illustration. Visceral aneurysms are frequent and increasingly the preserve of IR. Knowing when not to treat is as important as therapy itself. A range of diagnostic and IR skill sets

Abstract Book important side branches is to use a covered stent. If the aneurysm is close to the renal hilum and near important side branches, a flowdirected stent may be a simple solution whether the aneurysm is wide necked or not. Other viable options are to fill the sac with onyx, whilst maintaining patency of the adjacent side branches with balloon catheters to avoid reflux of onyx out of the aneurysm or placing a bare stent across the neck and filling the sac with coils placed through the open mesh. Narrow-necked aneurysms, irrespective of location, can be treated by coiling preferably with detachable coils. The outcomes of both laparoscopic surgical and endovascular techniques are excellent in experienced hands with minimal morbidity and mortality reported.

Management of pseudoaneurysms related to acute pancreatitis Learning Objectives 1. To discuss treatment options for renal artery aneurysms including surgery 2. To discuss, using examples, the technical methods used for treating artery aneurysms 3. To discuss outcomes of surgical and IR treatments Renal artery aneurysms account for approximately a quarter of all visceral artery aneurysms. The main causes for true aneurysms are atherosclerosis, fibromuscular dysplasia and the arteritides. Treatment is indicated for aneurysms of any size in a woman who wishes to become pregnant; otherwise, a 2cm or larger diameter is usually quoted as a threshold size. Treatment by surgery or endovascular means is indicated if the aneurysm is symptomatic. Pseudoaneurysms are usually associated with trauma and in general should be treated. There has been a shift in management from surgical to endovascular as development of new technologies means that these aneurysms can be safely treated using minimally invasive techniques with preservation of the majority of renal parenchyma. Endovascular techniques have the advantage of being performed under local anaesthetic with a very rapid recovery. Surgery for these aneurysms traditionally involves resection followed by reconstruction with a vein patch or end-to-end anastamosis for saccular aneurysms, or aortorenal bypass for fusiform or dissecting aneurysms. Ex-vivo surgery is required for the complex distal aneurysms involving several branches. This requires renal explantation, ex-vivo renal preservation and reconstruction of the artery followed by heterotropic autotransplantation. This can be done laparoscopically as a minimally invasive procedure with good results, minimal morbidity and reduced hospital stay of 4 days. The endovascular treatment method depends on whether the aneurysm involves a peripheral intrarenal branch vessel, the main renal artery itself, or the bifurcation of the main renal artery. Aneurysms of intrarenal branches are the most straightforward to treat as the renal artery is an end artery and occlusion of the feeding vessel will occlude the aneurysm. Particles, glue and coils are all suitable embolics and the aim of treatment is to preserve as much renal parenchyma as possible and so microcatheters are required for very distal embolization. Large aneurysms associated with an arteriovenous fistula are treated with detachable coils or plugs to reduce flow with or without adjunctive glue or onyx to prevent migration into the venous system. Aneurysms of the main renal artery require patency of this artery to be maintained whilst excluding the aneurysm sac. A variety of strategies can be used depending on the anatomy. If the aneurysm is fusiform, then only exclusion by a stent graft is feasible. If saccular, there are several options. The simplest solution for an aneurysm involving the main renal artery away from the hilum or S61 CIRSE 2012 SS/FC/HL/HTS/CM liver function, disease confined to the liver and good renal function. Threshold parameters for liver function include: bilirubin <2-3mg/ ml, AST > 5X upper limit of normal, ALT > 5X upper limit of normal. For patients with HCC the diagnosis should be confirmed with typical imaging features (hypervascularity and early washout)in two imaging modalities if AFP is below 400ng/ml in the presence of chirrhosis for lesions >2cm. If typical features in two imaging modalities are present in cirrhosis the diagnosis is established regardless of AFP levels. In lesions >2cm and in the presence of AFP>20O ng/ml typical features in two imaging modalities are adequate. For HCC in cirrhosis patients with BCLC B are eligible but BCLC A disease can also be treated with chemoembolization if they are not candidates for surgical resection, liver transplantation, or local ablation (curative treatments). Exclusion criteria include extrahepatic disease (for HCC), ECOG>2, any contraindication to arteriography, creatinine>2mg/dl, contraindidication to doxorubicin -if it is necessary (White Blood Cell count (WBC) <3000 cells/mm3, absolute neutrophil <1500 cells/ mm3 cardiac ejection fraction <50%),or incorrectable impaired clotting. Vascular invasion with tumor within the main portal vein is not an absolute contraindication but alteration of the dose should be made. The protocols of chemoembolization are many and this is the main drawback of this technique. Adriamycin 30-60mg, ethiodized oil 10-15cc, and 10ml of non ionic contrast is commonly used while in metastatic disease a combination of 5-Fluo-rouracil 1gr, mitomycin 10mg and ethiodized oil and 10ml of non ionic contrast is commonly used. Following the administration of these emulsions particle embolization is done with gelfoam or polyvinyl alcohol particles. In chemoembolization with drug eluting beads (DC Bead or Hepasphere) the loading is performed with 100-150mg of doxorubicin or 100-200mg irinotecan for HCC or metastatic disease respectively. Before the procedure patients must receive adequate antiemetics, analgesia and prophylactic antibiotics with cephalosporine and metronidazole. To follow up post embolization MDCT or MRI should be performed one month post the procedure to evaluate for local response.

Tips and tricks for difficult procedures 

How to decide between RFA, radioembolization and TACE

Institut für Diagnostische und Interventionelle Radiologie und Nuklearmedizin, Klinikum Bogenhausen, Munich, Germany.

Learning Objectives 1. To analyse the indications and the role of radioembolization with respect to other therapies 2. To analyse the main limitations and pitfalls of the three different approaches 3. To provide an algorithm for treatment selection based on the results from available literature as well as on personal experience

No abstract available.

should always be discussed by a muldisciplinary dedicated team, including interventional radiologists, hepatologists, oncologists, liver surgeons and so on. According to the European guidelines, TACE represents the first-line treatment modality in intermediatestage HCC patients, represented by patients not suitable for curative treatments yet in good clinical conditions (performance status 0), with well-preserved liver function (Child-Pugh score ≤7) and without portal invasion or extrahepatic tumour spread. However, this stage includes an heterogeneous group of patients and should be further discriminated on the basis of other clinical and anatomical parameters. From a clinical point of view, it has been recognized that severe comorbidities and renal failure may represent contraindications to TACE; moreover, in daily clinical practice, even patient's social environment, compliance and understanding of treatment end-points can be crucial in the selection process and in managing patient's expectation, and should be discussed by the Tumour Board. From an anatomical point of view, state-of-the-art cross-sectional dynamic CT or MR is fundamental to stage the tumour, in terms of nodules number, size and location, and to verify tumour vascularization. It is well known that nodules larger than 10 cm, massive infiltrative tumoral replacement of both liver lobes and tumour hypovascularity all represent negative prognostic factors for tumour response and post-TACE survival. Together with the assessment of tumoural extension, morphology and enhancement pattern, evaluation of arteries and veins is required. The presence of untreatable large varices, conditions severely impairing the portal flow and/or arterovenous fistulas might contraindicate TACE and should be recognized on pre-treatment CT or MR. Finally, the identification of the arteries feeding to tumour as well as of all possible anatomical variants of the celiac trunk and hepatic arteries is an essential part of treatment planning. For instance, the pre-procedural visualization of extrahepatic collateral arteries feeding the tumour is able to reduce overall procedural time and improve treatment success. Thus, the proper selection of HCC patients for TACE requires adequate pretreatment imaging and a dedicated multidisciplinary team. 

How to perform a typical TACE procedure K. Malagari; 2 nd Dept. of Radiology, University of Athens Medical School, Athens, Greece.

Learning Objectives 1. To discuss imaging guidance in performing TACE 2. To discuss how to perform TACE and potential complications 3. To analyse the results of trials with conventional TACE and DEB-TACE in HCC Chemoembolization has many protocols but the main elements of this treatment is the administration of a chemotherapeutic agent in an emulsion containing ethiodized oil followed by particle embolization. This mixture achieves both local ischemia or anoxia and local cytotoxicity to the tumor as it achieves very high local concentration of the chemotherapeutic resulting in tumor death. The more important eligibility criteria is documentation of the disease, good S62 C RSE

Computed tomography: CECT is at present the best imaging technique to evaluate patients suspected of having acute pancreatitis. A monophasic CT protocol after intravenous contrast administration is usually sufficient for the diagnosis and severity assessment of acute pancreatitis. Typically, scans are performed during the pancreatic phase (delay of 40-50 seconds) or portal venous phase (delay 60-70 seconds). Dual-phase studies are recommended in case of hemorrhage, ischemia or suspicion of a pseudoaneurysm. CECT establishes the diagnosis of acute pancreatitis or may provide an alternative diagnosis. CECT is also beneficial for staging morphologic severity of acute pancreatitis. However, CECT, obtained within the first 72 hours after onset of symptoms may fail to show major morphologic changes in patients with clinically severe acute pancreatitis; in particular the presence or true extent of parenchymal necrosis may go unrecognized on early CT. A follow-up CECT obtained 5 to 7 days later would be required to better determine the morphologic severity of disease. CECT is also useful for follow-up and evaluation of local and other pancreatic complications and for guidance of interventional procedures. Major disadvantage of CECT is the limited capability of differentiating fluid from nonliquid material in peripancreatic collections. (8) MR Imaging: MRI has gained a more prominent role in the assessment of acute pancreatitis. The presence and extent of pancreatic necrosis and peripancreatic collections can be evaluated with equal accuracy compared with CECT. (9) In fact, MRI is better in detecting mild acute pancreatitis. (10) Due to its inherent tissue contrast resolution capability, MRI is also superior to CECT in determining whether collections contain fluid or nonliquid material. Hence, MRI has been shown to accurately predict drainability of collections. (11) In addition, MRI is capable of detecting pancreatic duct disruption by using an MRCP sequence. In approximately 30% of patients with severe acute pancreatitis, disruption of the pancreatic duct was reported. (12) Recognizing pancreatic duct disruption has therapeutic implications, because early diagnosis of ductal leakage demands a more definitive therapy (e.g. transpapillary stent placement). The major disadvantages of MRI include the longer scanning time (which can pose a problem for very ill patients), motion artefacts, the need for specialized MRI-compatible monitoring equipment in critically ill patients, and high costs if routinely used. Moreover, sensitivity of MRI in detecting gas bubbles is inferior to CECT, whereas image-guided percutaneous intervention is easier to perform with CT. Therefore, at present, MRI is mainly used as problem solving tool in acute pancreatitis. Classification of severity: The 1992 Atlanta Symposium defined acute pancreatitis and classified pancreatic complications based on clinical criteria. (13) Better understanding of the pathophysiology of acute pancreatitis, improved diagnostic imaging, and the development of minimally invasive radiologic, endoscopic, and operative techniques for the management of local complications have made it necessary to revise the Atlanta Classification. Nowadays, clinical staging, localization and classification of morphologic changes as well as defining the inter-relationships between pancreatic collections and adjacent structures have become essential in decision making in patients with severe acute pancreatitis. Severity of acute pancreatitis can be described in terms of clinical severity parameters, such as death and persistent SIRS and organ failure, whereas morphologic severity is characterized by pancreatic parenchymal necrosis and peripancreatic collections. The clinical severity parameters are equally important in the early phase and late phase of severe acute pancreatitis. Conversely, morphologic severity becomes clinically important in the later phase of acute pancreatitis when infection of necrosis occurs and intervention is contemplated. Morphologically, acute pancreatitis is traditionally divided into interstitial (normal enhancing pancreas) and necrotizing pancreatitis (presence of perfusion defects of pancreatic parenchyma). According to the latest revision of the Atlanta Classification patients with peripancreatic necrosis only (without necrosis of the pancreatic parenchyma) are also classified as necrotizing pancreatitis.

Imaging of pancreatitis: who requires treatment?

Department of Radiology, St. Antonius Hospital, Nieuwegein, Netherlands.

Learning Objectives 1. To discuss classification based indications and techniques available 2. To discuss the role of MR or CT in decision making 3. To discuss how to monitor the success of percutaneous treatment Introduction: Acute pancreatitis is a relatively common, potentially life-threatening disease. It is the third most common gastrointestinal disorder requiring acute hospitalization in the United States, with annual costs exceeding $2 billion. (1, 2) Approximately 20% of patients develop severe acute pancreatitis, elicited by a sustained systemic inflammatory response syndrome (SIRS), which precedes the development of (multi)organ failure or death. Severe acute pancreatitis is associated with a mortality of 15-30%, whereas mortality of mild acute pancreatitis is only 0-1%. (3, 4) Organ failure is the most important determinant for mortality in acute pancreatitis. (4, 5) However, in around 30% of patients with necrotizing pancreatitis secondary infection of necrosis occurs, mostly between the second and fourth week after onset of disease.(4) If left untreated, mortality of infected necrosis approaches 100%. (3) In most Western countries, gallstones are the cause of pancreatitis in approximately 50% of patients and alcohol in 20%. In about 20% of cases the cause remains unknown (idiopathic). The remaining 10% constitutes a rather large group of possible causes of acute pancreatitis, which include hypercalciemia, hypertriglyceridemia, medications, hereditary causes, among others. (6) The clinical diagnosis of acute pancreatitis requires two of the three following conditions: 1) characteristic abdominal pain suggestive of acute pancreatitis, 2) serum amylase and/or lipase, three or more times the upper limit of normal, and 3) characteristic findings of acute pancreatitis on contrast-enhanced computed tomography (CECT), MR imaging, or transabdominal ultrasonography (US). (3) Usually, the first two criteria are present and CECT is not required for diagnosis. It takes at least 72-96 hours of disease for a CECT scan to demonstrate clinically relevant morphologic changes like intra-and/or peripancreatic necrosis or peripancreatic collections. Severe acute pancreatitis runs a biphasic clinical course with concomitant peaks in mortality. The first phase (i.e. 1-2 weeks after onset of symptoms) is characterized by SIRS. Organ failure in the SIRS phase is usually not related to infection but rather a direct result of severe systemic inflammation. Half of deaths occur during this phase due to (multi)organ failure. The second phase (i.e., after 1-2 weeks) is characterized by a counteractive anti-inflammatory response syndrome (CARS). Organ failure in the CARS phase is related to infections, such as infected necrosis. The second peak in mortality is largely attributed to infection of necrosis, in particular when accompanied by organ failure. (7) Diagnostic imaging: Imaging modalities commonly used for the diagnosis and severity assessment of acute pancreatitis include US, CECT, and MR imaging. Ultrasound: In the initial phase of acute pancreatitis, US is primarily used for assessment of biliary stones and biliary obstruction, thereby enabling to elucidate the etiology of pancreatitis. US may also be used for characterization of pancreatic collections by differentiating fluid from nonliquid material. Furthermore, US can serve as an imaging guide during diagnostic or therapeutic interventions. Major disadvantage of US remains the limited visibility in a large proportion of patients with severe acute pancreatitis.

after onset of disease, with a mortality rate of 25%. (21) Based on the current literature, postponing intervention, preferably until 4 weeks after onset of disease, is widely accepted as the strategy of choice. The length of the interval between onset of symptoms and timing of intervention is mainly determined by the completeness of encapsulation and the clinical condition of the patient. This policy is obviously only applicable to the subset of patients who survive the initial phase of SIRS and develop infection of necrosis in the phase of CARS. In the end, for the best outcome in patients with severe acute pancreatitis, management and close collaboration of a multidisciplinary team, involving gastroenterologists, intensivists, surgeons, and (interventional) radiologists is mandatory.

First phase: Mild and severe acute pancreatitis are initially (first 1-2 weeks) treated by conservative measures including sufficient fluid resuscitation, adequate pain relieve, oxygen administration, (enteral) feeding, and intensive care support in case of organ failure. (3, 6, 7) Antibiotic prophylaxis in an attempt to lower the rate of infectious complications in (predicted) severe acute pancreatitis has been the subject of many randomized trials. A recent updated meta-analysis clearly demonstrated no beneficial effect in the routine use of systemic antibiotic prophylaxis. (14) In the first phase, there is no room for radiologic, endoscopic or surgical intervention aiming at removing necrosis, i.e. the necrosis is mostly sterile in this phase, and patients with sterile necrosis can be treated conservatively. Treatment of acute life-threatening complications, like bleeding, perforation of a hollow viscus organ, and abdominal compartment syndrome, is the only justification for intervention in this early (SIRS) phase. (15) Percutaneous drainage may seem alluring, but sterile collections may become iatrogenically contaminated by the percutaneous drains. A recent randomized study, actually advocating the strategy of draining sterile collections, reported on a significant increase in infected necrosis due to the practice of routine percutaneous drainage. (16, 17) Second phase: In the absence of infected necrotizing pancreatitis, treatment remains conservative. Documented infection (by fine needle aspiration or 'gasbubbles' on CECT, usually a pathognomic sign of infected necrosis) or suspected infection of pancreatic or peripancreatic necrosis in combination with systemic signs of infection, therefore, represents the accepted indication for radiologic, endoscopic or surgical intervention. Once the stage for intervention has been reached, there is a choice between (minimally invasive) surgical, endoscopic and radiologic percutaneous techniques. (15) A recent Dutch multicenter randomized trial in patients with documented or suspected infection of necrosis compared primary open necrosectomy with a minimally invasive "step-up approach". (18) The step-up approach consisted of percutaneous or transgastric drainage, followed if necessary, by drain-guided minimally invasive necrosectomy. A significant difference in major complications and costs was observed, all in favour of the 'step-up approach'. In addition to the aforementioned advantages of the step-up approach, 35% of patients who were treated by the step-up approach did not need any further intervention than percutaneous drainage only. A recent systematic review also suggested that percutaneous drainage can be the only treatment needed in up to 55% of patients with necrotizing pancreatitis. (19) Finally, a multicenter series from the USA and Canada found that 25% of 40 patients with infected necrotizing pancreatitis can be treated with percutaneous drainage alone. (20) Therefore, the step-up approach should be considered the new treatment paradigm for infected pancreatic necrosis. The overall message of these studies is that in patients who do not improve after technically adequate percutaneous drainage, necrosectomy should be performed as the next step. The percutaneous drain together with the CECT scan can then be used as a roadmap for further (open or minimal invasive) necrosectomy or endoscopic transluminal/transgastric necrosectomy. Timing and choice of the type of intervention under close guidance by a multidisciplinary team are crucial. A systematic review of cohort studies concluded that postponing interventions until the intra-and/or extrapancreatic collections are encapsulated, which usually takes 3 to 4 weeks, is beneficial because it allows for an easier necrosectomy. (21) In necrotizing pancreatitis, such fully encapsulated collections are now called 'walled-off necrosis or WON'. In some scenarios, encapsulation of pancreatic collections may not have been completed, when clinical deterioration occurs. In order to postpone surgical intervention and to prevent bacteraemia or sepsis, administration of antibiotics is a valid option that allows for further encapsulation, under guidance of a CECT scan performed at regular intervals. In the previously mentioned review, necrosectomy was performed at a median of 27 days

C RSE CIRSE Abstract Book of a pseudocyst with the pancreatic duct, and weeks to months for pseudocysts with a persistent communication to the pancreatic duct. In these situations, other interventions and medical therapies can be used in addition. Complications of drainage of pancreatic collections or pseudocyst are various. Contamination of an existing sterile collection during needle aspiration or catheter placement has been reported but is uncommon. Haemorrhagic complications can occur from the procedure itself or from the primary process or as a result of both. Laceration of a vessel or rupture of a pseudoaneurysm can be encountered. Damage to adjacent small bowel or colon has also been reported but should be avoided with careful preprocedural planning and careful procedural performance. Fistulous connection to the intestine has also been reported. Percutaneous drainage of pseudocysts is associated with a success rate of up to 90%. The management of patients with collections associated with severe acute pancreatitis is labour intensive for interventional radiologists, and an MDT approach with surgical colleagues is essential for success. Sometimes the necessity for surgical intervention arises after many weeks of supportive care with catheter drainage and the patient undergoes a necrosectomy.

How to treat pancreatic necrosis: IR vs. surgery vs. combined therapy

Dept. of Radiology, Wythenshawe Hospital, Manchester, United Kingdom.

Learning Objectives 1. To discuss indications, techniques and tools available 2. To describe the best approach for drainage 3. To review the results and clinical follow-up Pancreatic necrosis is the most feared complication of acute pancreatitis from whatever cause. It can be detected reasonably accurately by contrast-enhanced CT provided the examination is not undertaken too early in the disease process. From 48 to 72 hours onwards CT will give an accurate reflection of the percentage volume of pancreatic necrosis which itself helps grade the severity and give a prediction of possible morbidity and mortality from the disease. Biological parameters defining the patient's status are essential during this period as any indication of infection within the necrotic pancreas mandates intervention. Sterile pancreatic necrosis can be managed expectantly but brings with it a high risk of ultimate pseudocyst formation which requires separate management dependent upon particular clinical features. The development of infected necrosis significantly worsens the outlook for the patient. Traditionally, infected necrosis has been dealt with by open surgery with debridement, perhaps repeated, of the pancreatic bed to remove necrotic material. This may entail the provision of laparotomy to allow repeated surgical access. If the patient survives, long-term complications of this intensely invasive surgical approach are not uncommon. More recently, radiological-guided drainage with the initial placement of one or more percutaneous drainage catheters followed by track dilatation and the placement of larger drains has gained acceptance as a less invasive method of dealing with pancreatic necrosis which has become infected. The development of this approach has done much to reduce the morbidity associated with surgical intervention whilst maintaining the benefits of drainage. Finer details regarding technique will be discussed. There has also developed a vogue for trans-gastric endoscopic access to infected pancreatic necrosis with direct endoscopic excision of infected material. This technique and its benefits compared with other minimally invasive techniques will be discussed. It is fair to say that in recent years the successful management of infected necrosis in a minimally invasive fashion has become an important factor in the improved outlook for patients with this once deadly complication. 

Interventional Radiology, St James Hospital, Dublin, Dublin, Ireland.

Learning Objectives 1. To review how to prepare for difficult drainages 2. To describe image guidance methods for access 3. To review techniques for drainage in specifically challenging cases Acute pancreatitis is a common disease process and can vary from mild to severe in its manifestations. Mild pancreatitis is generally adequately managed with supportive measures and by addressing the underlying causative process. Severe pancreatitis is life threatening and often requires prolonged complex management including a host of supportive measures such as the provision of cardiopulmonary support, management of complications and the provision of TPN, etc. Interventional Radiologists play an important role in the management of the sequelae of acute pancreatitis, such as necrosis, pseudocyst, and abscess formation. Computed tomography (CT) is the modality of choice for guidance of pancreatic interventional procedures, although US, fluoroscopy, and indeed combined modalities are often used also. Careful assessment of the patients' bloods and coagulation parameters is important and correction of any coagulopathy is advisable. We aim for a PT of 1.5 or less and platelets greater than 80,000 although the needs are assessed on a patientby-patient basis in case of extreme emergency. The patient requirements for supportive care during the procedure should be assessed as well as the likely requirement for positioning of the patient. The requirement and the safety of administering analgesia and sedation should be assessed. Careful preprocedural planning of the access route is essential to avoid complications and review of preexisting imaging will help to avoid inadvertent involvement of surrounding vital structures. Infection of a necrotic pancreatic collection has a high mortality rate and the presence of infection should be determined with CT-guided needle aspiration. Catheters of 10-16 F are generally sufficient for drainage; however, for highly viscous collections catheters up to 24 F are sometimes required. Use of multiple catheters is often required to effect complete drainage. Percutaneous access is generally via the left anterior pararenal space for distal body and pancreatic tail collections and through the gastrocolic ligament for pancreatic head and body collections. A transgastric approach can be used for lesser sac collections and more creative forms of access are sometimes required for very complex cases.

Contrast-enhanced CT has a lesser role due to the high intravenous contrast dose and the ionizing radiation dose particularly when considering that many pancreatic transplant recipients have a history of renal insufficiency and, not infrequently, have concomitant renal transplants. When compared with renal transplantation, Doppler ultrasound has a lesser role because of obscurity from adjacent bowel and (possibly) the more complex nature of the vascular surgical anatomy. As a result, contrast-enhanced high-resolution magnetic resonance angiography (MRA) has become the primary noninvasive imaging evaluation of vascular complications after pancreatic transplantation. The advantages of MRA is that it can characterize the vascular complication, define anatomical details, evaluate the pancreatic transplant parenchyma (viability and inflammation / pancreatitis), evaluate concomitant renal transplants (vascular and parenchymal), and evaluate inflow aorto-iliac disease. Overall, the endovascular experience of managing vascular complications postpancreatic transplant is scant. Percutaneous angioplasty for pancreatic artery stenosis has been described in the literature in less than 5 patients and has a high technical success rate (100%, n=5/5) with a high clinical success rate. Catheter-directed thrombolysis for pancreatic artery thrombosis has poor technical results (n=0/3) (this is similar to the experience for the pharmaco-mechanical lysis of thrombosed hepatic arteries in liver transplant recipients), and pancreatic artery thrombosis continues to be the major vascular complication leading to graft loss. Trans-catheter embolization for arterio-venous fistulae and pseudoaneurysms are technically successful (n=5/5) with good clinical outcomes for arterio-venous fistulae. A single successful declotting of the venous outflow of a pancreatic transplant has been reported. However, the clinical utility of this procedure is ill-defined and the clinical outcomes are unknown. In conclusion, endovascular management is a useful technical tool that is technically effective in all vascular complications following pancreatic transplantation with thrombolysis for pancreatic artery thrombosis being the only exception. Due to this, trans-catheter thrombolysis should be used judiciously (case-by-case basis). Clinically, angioplasty for pancreatic artery stenosis and embolizations for arteriovenous fistulae appear to have a favorable clinical outcome with preservation of graft function. However, more data and expansion of the clinical experience are required to fully evaluate the clinical utility and outcome of these procedures.

How to manage complications after pancreatic transplantation

Department of Radiology, University of Virginia, Charlottesville, VA, United States of America.

Learning Objectives 1. To describe the most frequent complications related to pancreatic transplantation 2. To review current techniques and the tools available 3. To present clinical outcome and complications Pancreatic transplantation is a definitive treatment for diabetes and is increasingly being utilized to treat type-1 diabetes mellitus. Pancreatic transplantation is a technically challenging surgery and vascular complications are the most common cause of early graft failure. Complications following pancreatic transplantation are classified into vascular and non-vascular complications. Non-vascular complications include pancreatitis, leaks, and post-operative collections (hematoma, seroma, lymphocele, or pancreatic pseuodocysts). Interventional radiology management of non-vascular complications is confined to percutaneous collection drainages and percutaneous pancreatic graft biopsies. Unlike non-vascular complications, interventional radiology (minimally invasive percutaneous procedures) is specific for particular vascular complications. Vascular complications represent more than 50% of early (within 6 months from transplant) and less than 10% of late (after 6 months from transplant) pancreatic graft failure. Graft thrombosis is a poorly defined collective term referring to pancreatic graft arterial thrombosis and/ or graft vein thrombosis. Graft thrombosis is the most devastating of post-transplant vascular complications to the pancreatic graft. Individually, post-pancreatic transplant vascular complications (besides the collective entity: graft thrombosis) include pancreatic artery stenosis (PAS) or thrombosis (PAT), pancreatic vein (graft portal vein) stenosis (PVS) or thrombosis (PVT), arterio-venous fistulae (AVF), pseudoaneurysms (PsA), gastrointestinal bleeding (bleeding), and iliac inflow disease. The finding of a fistulous component (AVF) associated with a psuedoaneurysm (internal rupture of a pseudoaneurysm into adjacent vein) has been noted by prior authors and is not a surprise in the setting of pancreatitis and/or iatrogenic trauma. Knowledge of the pancreatic vascular surgery anatomy is vital for the adequate endovascular or surgical management of these complications. Endovascular management of these complications run the gamut of endovascular procedures and techniques including stent placement for iliac artery inflow disease, angioplasty for pancreatic artery stenosis, attempted catheter-directed thrombolysis for pancreatic artery thrombosis and embolization for arteriovenous fistulae, pseudoaneurysms or active bleeding. Rarely are catheter-directed interventions used for pancreatic transplant venous disease. Vascular complications present with pancreatic graft dysfunction in the form of insulin dependence. This is either primary (author's term: never achieved insulin dependence after pancreatic transplantation) which is immediately post-transplantation or secondary (author's term: after achieving insulin dependence after pancreatic transplantation) which occurs later in the post-transplantation period. Pancreatitis may also be associated with vascular complications: either as a cause or effect. In addition, pseudoaneurysms of the pancreatic artery or adjacent native iliac arteries and branches may present with gastrointestinal bleeding, pelvic bleeding and hypovolemia. Non-invasive Imaging modalities used to evaluate for vascular complications after pancreatic transplantation include Doppler ultrasound, magnetic resonance imaging (MRI) and, less commonly, contrast-enhanced computer tomography (CT). In addition, radio-isotope scans for lower gastrointestinal bleeding can be used to evaluate for (localize the bleeding: pancreatic transplant source versus extra-pancreatic source) potential occult insidious bleeding which may occur from within the pancreatic transplant.

Abstract Book rasympathetic pathway mediated by nitric oxide signal in order to allow smooth muscle cell relaxation of pudendal arterial walls, and cavernosa and spongiosum corpora. Muscle relaxation involves pudendal arteries and arterioles dilatation, expanding of sinusoids in erectile tissue, compression of the subtunical venular plexuses between tunica albuginea and peripheral sinusoids and stretching of the tunica to its capacity, thus reducing dramatically venous outflow, increasing PO2 from 35 mmHg to 90 mmHg and increasing intracavernous pressure in relation with erect state, with peaks higher than systolic pressure during the full-erection phase. Molecular mechanisms of smooth muscle relaxation are regulated by cytosolic-free Ca++, induced by parasympathetic NO signaling. The second messengers involved in smooth muscle relaxation are cAMP and cGMP. They activate cAMP-and cGMP-dependent protein kinases, which in turn phosphorylate certain proteins and ion channels, resulting in opening of the potassium channels and hyperpolarization, sequestration of intracellular calcium by the endoplasmic reticulum, and inhibition of voltage-dependent calcium channels, blocking calcium influx. The consequence is a decrease in cytosolic-free Ca++, and smooth muscle relaxation. Calmodulin then dissociates from myosin light-chain kinase and inactivates it. Myosin is dephosphorylated by myosin light-chain phosphatase and detaches from the actin filament, then the muscle relaxes and erection is obtained. Detumescence comprises three phases: transient intracavernosum pressure increases at the beginning of smooth muscle contraction with a closed venous system, then slow pressure decreases while slow opening venous system and fast pressure decrease with total venous outflow capacity. In the absence of erection, in the flaccid state, penile erectile tissue and arterial wall smooth muscles are moderately contracted. Contraction can be more effective in cold water, for example. Smooth muscle contraction is also regulated by cytosolic-free Ca++. Norepinephrine from nerve endings and endothelins and prostaglandin F2α from endothelium activate receptors on smooth muscle cells to increase inositol triphosphate and diacylglycerol resulting in release of calcium from intracellular stores such as sarcoplasmic reticulum and/or opening of calcium channels on the smooth muscle cell membrane leading to an influx of calcium from extracellular space. This triggers a transient increase in cytosolic-free Ca++. At the elevated level, Ca++ binds to calmodulin and changes the latter's conformation to expose sites of interaction with myosin light-chain kinase. The resultant activation catalyzes phosphorylation of myosin light chains and triggers cycling of myosin crossbridges along actin filaments and the development of force.

In addition, phosphorylation of the light chain also activates myosin ATPase, which hydrolyzes ATP to provide energy for erectile muscle contraction.

Quality of erection depends on quality of arteries, including pudendal arteries and branches destinate to the two corpora cavernosa and the corpus spongiosum. Penile erectile tissue deterioration sounded on erection quality, especially in cases of tunica albuginea (Lapeyronie disease) or erectile tissue fibrosis. Besides psychological aspect, hormonal impregnation and quality of stimulation necessary for sexual desire, erection requires integrity of neurological structures involved. Finally, outside of pure psychological or iatrogenic etiology, arterial pathology is the most common etiology of erectile dysfunction, far exceeding neurological and related impairment of the erectile bodies (3). Atherosclerosis is in most of cases a global disease of all arteries. Atherosclerosis and traumatic arterial disease of pudendal arteries and their branches can decrease the arterial flow to the sinusoidal spaces, thus decreasing erection rigidity. The incidence and age at onset of coronary disease and ED are similar. (1), as a symptom of endothelial dysfunction, and should be considered like premonitory sign of coronary or peripheral vascular disease and diabetes.

Erection needs sensory stimulation, central nervous system and spinal-cord centers spread through the autonomic nervous system pa-

SS/FC/HL/HTS/CM

Is there a role for IR in the management of vascular impotence?

Radiology, University of British Columbia Hospital, Vancouver, BC, Canada.

Learning Objectives 1. To learn the potential role for IR 2. To learn techniques how IRs can treat vascular impotence 3. To learn situations where IRs cannot help An erection occurs when psychic or physical stimulation induces nervous impulses which cause dilatation of penile arteries, relaxation of cavernosal sinusoids, and reduction in venous outflow. Vasculogenic impotence can either be due to arterial inflow obstruction, venous incompetence, a mixture of both etiologies, or in a small number of cases due to the fibrosis of the corpora cavernosa. The role of interventional radiology has waxed and waned, largely becauseof successful treatment with medication. There are isolated applications of interventional procedures for rare, select cases. For venous insufficiency, cavernosometry is the measurement of intracavernosal pressures during infusion of graded amounts of saline to assess venous leak or penile deformity. Cavernosography the infusion of contrast to document through which structures the venous leak or penile deformity, usually after injury, is occurring. Only small numbers of patients have been found to have focal abnormalities of arterial inflow that are amenable to angioplasty and those that have been treated in the overwhelming majority of cases have rapidly failed, probably because the vessels treated are quite small. It is much more common to encounter diffuse disease.

Recently, treatent of arteriogenic impotence regained momentum with the ZEN study, using a zotarolimus-eluting in the internal pudendal artery in 30 men. At 3 months, 59% reported an improvement in erectile function, however it is telling that a new trial, IMPASSE has been started. It is an angiography study focused on establishing normal pelvic anatomy and variants as well as prevalence of pathology in men with and without erectile dysfunction and will not involve stent implantation.

Steering committee member, Cook Medical Advisory Board member, Boston Scientific

Interventional Radiology, St. James's Hospital, Dublin, Ireland.

1. To learn about the pathophysiology of priapism 2. To learn the treatment options for priapism 3. To learn how IRs can treat priapism High flow priapism (HFP). Priapism is defined as ongoing penile erection for greater than 6 hours in the absence of physical or psychological stimulation within 4 hours. The name of the condition derives from the Greek fertility god Priapus. There are two types of priapism: low flow and high flow. Low flow priapism is the common type, representing between 80 and 90% of cases. It is very frequently related to background haematological conditions and/or malignancy. The conditions typically associated are Sickle Cell Disease (SCD), thalassaemia and leukaemia. The clinical hallmarks are severe pain, absence of sexual activity and relevant background medical condition. High flow priapism is much less frequently seen in clinical practice. It represents approximately 10-20% of cases. It almost always results from direct trauma (straddle injuries most commonly) to the cavernous artery or one of its branches with secondary development of a direct arterial fistula into the corpus cavernosum. It is not associated with background cavernous arteries has been found in impotent patients with atherosclerosis. Focal stenosis of the common penile or cavernous artery is most often seen in young patients who have sustained blunt pelvic or perineal trauma. Tobacco may adversely affect erectile function not only by decreasing arterial flow to the penis but also by blocking corporeal smooth muscle relaxation and thus preventing normal venous occlusion. Therefore, erectile dysfunction can be a manifestation of generalized or focal arterial disease. Mechanisms of arteriogenic ED are in relation with increased peripheral vascular resistance. Those mechanisms comprise structural changes in relation with decrease in oxygen tension in erectile tissue with decrease of PGE2 formation and synthesis of TGF-b1-induced collagen with decrease of trabecular smooth muscle content and diffuse venous leakage, enhanced sympathetic nerve activity linked to hypertension with vasoconstriction of erectile tissue, and impaired endothelium-dependant vaso-dilatation associated with arterial common risk factors (5).

In conclusion, vascular impotence is frequent and multifactorial, frequently linked to vascular risk factor with most representative is the metabolic syndrome. Multi-modality treatment consists in prevention and decrease of vascular risk factors, stopping smoking and daily physical exercises. IPDE5 can improve erection and perhaps endothelial dysfunction. Although surgical revascularization procedures do not demonstrate efficacy, except in few selected cases (6) , and are today almost abandoned, interventional radiology procedure for erectile tissue revascularization could be a new option in some selected cases.

C RSE CIRSE Abstract Book been proposed. Using this definition, vaginal deliveries have a 3.9% incidence of hemorrhage and cesarean deliveries a 6.4% incidence. The WHO defines PPH as blood loss > 500 ml after vaginal delivery and 1000 ml after caesarean section. However, blood loss is often dramatically underestimated leading to unexpected hemorrhagic shock disseminated intravasal coagulopathy (DIC). Postpartum hemorrhage is divided into early (≤ 24 h after delivery) and late (>24 h up to 6-12 weeks after delivery). Early postpartum hemorrhage is far more common than late postpartum hemorrhage. Common causes for PPH can be divided into the four "T" categories: Tone (uterine atony; 80% of cases), Tissue (retained placental fragments), Trauma (laceration of the lower genital tract / birth canal), Thrombin (coagulopathy). Less common causes include uterine inversion and uterine rupture. Management and approach should be directed towards the suspected etiology. The armamentarium in the treatment of PHH includes management of hemodynamic shock, uterine revision, uterotonic drugs /surgical repair vaginal packing, vascular ligations (uterine, hypogastric arteries), transarterial embolization and hysterectomy. From this list it is evident that treatment of PPH is a multidisciplinary task including obstetricians, gynecologists anesthesiologists and interventional radiologists. Transarterial embolisation is an effective but an underused method to control PPH. Short-term occlusion is required and resorbable embolisation agents such as gelatin sponge fragments (Gelita, Gelfoam, Spongostan, Curaspon) prepared as pledgets, torpedos or a slurry are commonly used. In unusual circumstances (rupture, pseudoaneurysm, AVM) particles (non spherical PVA, spheres), acrylic glue or coils may be needed.

In cases of abnormal placentation calibrated microspheres are used to devascularize the placental tissue. The success rates for arterial embolization range from 85 to 95%, with time elapsed from the start of the procedure to hemostasis averaging 1 h. Advantages of embolotherapy include obviating the need for exploratory surgery, easy identification of the site of bleeding, high degree of effectiveness (even in cases in which the exact bleeding site is not demonstrable angiographically), and preservation of the uterus and thus fertility. Potential complications include pelvic infection, embolization ischemia and the theoretical risk of contrast nephrotoxicity.

medical conditions and the corpora do not become ischaemic. The clinical hallmarks are that it is generally not painful, the patients frequently remain sexually active and there is a history of a straddle injury. The clinical presentation of HFP is not usually directly following the trauma but frequently presents 2-4 days after the injury. It can also have a chronic recurring presentation with interval partial detumesce. Treatment options: Until recently there were three treatment options: mechanical compression of the fistula, pharmacological with corporal injection of alpha agonists, surgical ligation of the internal pudendal or cavernosal arteries. However, these options were frequently unsuccessful and if successful (surgical ligation in the majority of cases) often resulted in permanent sexual dysfunction. Transcatheter embolization was first used in the late 1980s for the treatment of HFP.

With the improvement in the angiographic equipment, microcatheter technology and refinement in the embolic agents available, embolization is now accepted as the treatment of choice. Interventional radiology (IR) is now at the forefront of the treatment of HFP. Many series have been published on the different techniques for catheterization and the optimal embolic agents. The initial cases were performed using autologous clot. However, this had a high failure rate. Nonpermanent agents such as gelfoam have traditionally been the main agent. Microparticles and glue are not usually used. A combination of gelfoam and microcoils is probably the most frequently used agents. Return to full sexual function is the normal outcome in HFP treated by embolization. This return to function can take several months posttreatment. In this presentation at the upcoming CIRSE congress I will go through the pathophysiology and treatment options for HFP. I will then outline how IR can be used to treat HFP.

Radiology, University Clinic Charité, Berlin, Germany.

1. To describe the etiology of post partum haemorrhage and the indications for embolization 2. To describe techniques and results of interventional management 3. To show cases that went wrong Post partum hemorrhage -excessive bleeding after childbirthremains the most significant cause of maternal mortality and morbidity worldwide. "More than half of all maternal deaths occur within 24 hours of delivery, most commonly from excessive bleeding. It is estimated that, worldwide, 140,000 women die of postpartum hemorrhage each year -one every 4 minutes. Although many risk factors have been associated with postpartum hemorrhage, it often occurs without warning" [1, 2] . Different definitions of postpartum hemorrhage (PPH) exist. A 10% change in hematocrit between admission and the postpartum period or a need for erythrocyte transfusion has S69 CIRSE 2012 SS/FC/HL/HTS/CM or in combination, with the outcome usually monitored under fluoroscopic guidance using low dose techniques. Foam in varying mixtures is typically used for 'direct' percutaneous sclerotherapy.

Complications of venous embolisation can occur but are rare and can be minimised with careful technique. They are most commonly related to the site of venous puncture or embolisation of non-target organs. The management of complications will be discussed. An understanding of pelvic venous anatomy is essential. The most important target veins are the ovarian veins and the gonadal branches of the anterior division of the hypogastric veins including internal pudendal, obturator and communicating thigh branches. The pattern of venous abnormalities will be discussed. The incidence of the main veins involved in one of the largest series in the world is left ovarian (80%), right hypogastric (62%), left hypogastric (54%) and right ovarian (41%) and these occur in varying combinations. Transcatheter embolisation typically uses the transjugular or transfemoral approach with each offering specific advantages. 'Direct' puncture, in particular, of vulval or thigh varices, and its indications will be discussed. The aim of all ablation techniques is to ensure complete 'coverage' of the length of the entire abnormal venous segment. Follow up is again both clinical and assisted by non-invasive imaging prior to formal, typically endovenous, treatment of lower limb varicosities as well as any persisting vulval varices usually with foam sclerotherapy as appropriate.

In summary, pelvic venous reflux is increasingly being recognised as a major contribution of labial and thigh varices. The condition is often associated with pelvic venous congestion and is easily amenable to embolotherapy using a transvenous approach. The aim is to completely eliminate all significant truncal pelvic vein reflux using conventional techniques ensuring complete treatment of all abnormal venous segments prior to commencing treatment of lower limb varicosities usually arising from incompetent greater and lesser saphenous veins. Percutaneous embolotherapy is usually reserved as an adjunctive procedure to obliterate any residual reflux in labial and thigh branches. The techniques utilised and the embolic agents employed have been available for many years but accurate and useful pre-operative imaging is essential. Complications are rare and easily managed.

Labial and thigh varicosities: the role of pelvic embolotherapy

Interventional Radiology, The Royal Surrey County Hospital & St.

Luke's Cancer Centre, Guildford, United Kingdom.

1. To describe the rationale of pelvic embolization 2. To discuss the pros and cons of transvenous vs. percutaneous approach 3. To show demonstrative cases Pelvic venous congestion and its effects including its association with vulval and lower limb varicosities is underestimated. In some series, 1 in 7 women presenting with lower limb varicosities has evidence of pelvic venous incompetence/reflux. Of these, the vast majority have undergone vaginal deliveries at parturition. Patients with pelvic venous incompetence feeding into thigh varicosities are typically female, multiparous, experienced vaginal deliveries at parturition and often either have lower limb varicosities or have undergone previous varicose vein surgery. The pathophysiology has been attributed to damaged valves, the "nutcracker" phenomenon causing reversed venous flow, previous iliofemoral venous thrombosis or previous pelvic surgery. The condition is of multidisciplinary interest to gynaecologists, vascular surgeons, pain specialists and interventional radiologists. It has a myriad of manifestations although the two main presentations are chronic pelvic pain and vulval/lower limb varices. The latter is increasingly being recognised by vascular surgeons and interventional radiologists performing endovenous techniques for varicose veins. Labial and thigh varices may be the initial presentation of pelvic venous incompetence a priori but are also a particularly common finding in patients with recurrent lower limb varicosities despite previous surgical intervention. Diagnosis is achieved with clinical evaluation and using non-invasive imaging such as transvaginal duplex sonography, contrastenhanced CT or MRI scanning. The results of these investigations and the impact on lifestyle will help determine if specific intervention is appropriate. Formal phlebography is usually unhelpful unless performed with the patient performing the Valsalva manoeuvre, but even then is suboptimal. Treatment options include surgical intervention and embolotherapy. First line intervention is usually image-guided transvenous ablation of the refluxing truncal pelvic veins. These veins are not amenable to a direct percutaneous approach. Once truncal reflux has been eliminated, and the vulval and thigh varices have been decompressed, these may then be treated using an adjunctive procedure such as phlebectomy or foam sclerotherapy. The aim of transvenous embolisation is the elimination of all truncal venous reflux but in reality, patients often have minor persisting reflux requiring an adjunctive percutaneous procedure. The commonest embolic agents employed for transvenous ablation include coils, gelfoam and liquid sclerosants either used in isolation

CT could be used before PAE to identify variations of the vascular anatomy and aortoiliac atherosclerotic diseases but the risk of contrast media use is a concern in elderly patients. Severe comorbidities such as heart disease, atherosclerosis, penile prosthesis, severe urethral stricture, artificial urinary sphincter, or ASA class group V are not contraindications for PAE. Prostate embolization can be indicated in patients with small or large prostates and does not manipulate the urethra, thereby avoiding urethral stenosis. Additionally, PAE can be repeated in the future, if necessary. Exclusion criteria are metal implants or other contraindications for MRI, neurogenic bladder or other non-BPH causes of LUTS, and notably asymmetric prostate, which is indicative of severe unilateral atherosclerosis. Initially, the blood supply to the prostate is mapped by angiography of the iliac vessels and the prostate arteries. The main challenge of PAE is navigating within the narrow, tortuous, atherosclerotic vessels, which can make visualization and selective catheterization of the prostatic arteries difficult. Bilateral identification and study of the inferior vesical artery, superior vesical artery, obturator artery, middle rectal artery and internal pudendal artery is essential and should be performed using a microcatheter if possible for better results and to avoid complications. We have used tris-acryl microspheres due to their predictable location of embolization, but other embolic agents can be used. The PAE procedure takes on average two hours to perform. In order to provide good orientation to the prostate site, for better understanding of feeding arteries and related structures in the pelvis and to reduce the risk of non-target embolization complications, we introduce a Foley balloon into the bladder of each patient and fill it with contrast medium. Additionally, this allows patients to void normally during and after PAE, without straining to urinate. The urinary catheter is removed six hours after the intervention. In our initial prospective, single site, phase 2 study from 2008 to 2011, we included 11 patients with acute urinary retention due to BPH who had been managed by medical treatment and indwelling urethral catheters and were waiting for TURP. International Prostate Symptom Score (IPSS) ranging from best to worst (range, 0-35), QoL (range 0-6) and urodynamic testing were used to assess the outcome. Ages ranged from 59 to 78 (mean, 68.5 year-old) and prostate size ranged from 30 to 90 grams. Patients underwent physical examination, PSA measurement, transrectal US and MRI. Twelve PAE procedures using 300-500μm Embosphere® Microspheres were performed in 11 patients under local anesthesia. Technical success (bilateral PAE) was 75% and clinical success (catheter removal and symptoms improvement) was 91% (10/11 patients). Patients urinated spontaneously between 4-25 days (mean, 12.1) after catheter removal. The most frequent related symptoms due to PAE were mild anal, urethral and retropubic pain, but opiate medication was not necessary and no major complication was observed. Minimum rectal bleeding (a teaspoon amount) was observed in 3/12 (25%), diarrhea in 2/12 (16.6%) and focal bladder ischemia in 1/12 (8.3%) procedures. The single incidence of bladder ischemia resolved spontaneously and did not require treatment.

In a recent presentation Pisco presented data on 152 patients treated with particle PVA. Ages were 47-85 years (mean 72.6), and of the patients 18 had indwelling urinary catheters and 8 had undergone previous partial prostatectomy. Follow up ranged from 1-30 months (mean 9.4 months). Technical success, defined as embolization of at least one prostatic artery, was achieved in 135/152 patients (93.8%). Clinical success was highest at 3 months with 84.3% (86/102 patients) demonstrating improved symptoms, which decreased to 70% (7/10 patients) between 24 and 30 months. One patient experienced a 1.5 cm² bladder wall ischemia that was treated by surgical removal. Minor complications in this cohort included urethral burning, urinary infection, hematuria, hemospermia, balanoprotastites, rectorrhagia, inguinal hematoma and pain. In our initial study, follow-up ranged from 17-46 months. Most important gland shrinkage was observed during the initial six-month follow-up, and both US and MRI showed a mean of 30% volume reduction in the

Embolization for prostate gland hyperplasia: is there any evidence?

Interventional Radiology, University of Sao Paulo Medical School, São Paulo, Brazil.

Learning Objectives 1. To describe the rationale of prostate embolization 2. To describe techniques and results of interventional management 3. To show demonstrative cases The standard management of benign prostatic hyperplasia (BPH) is based on the overall health of the patient, on the severity of the lower urinary tract symptoms (LUTS) and on quality-of-life considerations. The American Society of Urology (AUA) guidelines indicate that patients with mild LUTS secondary to BPH (AUA-SI score <8) and patients with moderate or severe symptoms (AUA-SI score ≥8) who are not bothered by their LUTS should be managed using a strategy of watchful waiting. If the patient elects interventional therapy and there is sufficient evidence of obstruction, the patient and urologist should discuss the benefits and risks of the various interventions. Despite the advances since the 1990s in effective drug treatment and minimally invasive procedures, Transurethral Resection of the Prostate (TURP) developed in the 1920s remains the treatment of choice when medical management fails. TURP is performed under direct endoscopic visualization with an electrocautery tool to remove prostate tissue. While considered a safe technique with a mortality rate below 0.25%, it is not without adverse events. The most frequent complications are ejaculatory disorders (up to 50%), early urinary incontinence (30 to 40%), acute urinary retention caused by blood clots (2 to 5%), sexual impotence (up to 5%), and the need for blood transfusions (0.4 to 7%). Patients who have undergone TURP require surgical retreatment for LUTS symptoms in 3-14.5% of cases. Minimally invasive techniques have been developed as alternative treatments for LUTS, such as transurethral microwave thermotherapy and laser ablations, but they involve introducing energy into the gland and all require access through the urethra. Complications from these procedures are similar to TURP. Prostatic artery embolization (PAE) is a promising minimally invasive alternative procedure for BPH, which has been shown to be safe and effective in both animal models and clinical investigations. Until the recent clinical investigations, PAE was used principally to control massive hemorrhage after prostatectomy or prostate biopsy. In publications and scientific presentations, Carnevale et al. have reported successful PAE outcomes of improvement of LUTS symptoms and patient quality of life, prostate volume reduction averaging 30%, and low rates of adverse events. Pisco et al. have reported similar outcomes.

The normal human prostate is composed of a combination of glandular, fibromuscular (stromal) and smooth muscle cells. Benign prostatic hyperplasia is due to a proliferation of glandular elements, stromal elements, or both, resulting in the formation of large, discrete nodules in the periurethral region of the prostate. The blood supply to the prostate arises from the anterior branch of the internal iliac artery, mainly by the inferior vesicle artery, which subsequently branches into the urethral and capsular vessels. Minor prostatic vessels also arise from the internal pudendal, obturator, umbilical and middle hemorrhoidal arteries. Benign prostatic hyperplasia treatment with PAE requires a trained interventional radiologist because of the prostatic vascular anatomy. Before PAE, patients should undergo a work up that includes medical history, especially as related to LUTS, digital rectal examination, PSA measurement, US, MRI, uroflowmetry, and urodynamic analysis. Computed tomography (CT) may be used for better understanding of the iliac artery anatomy but it is not essential. We believe MRI with perfusion and diffusion techniques is the best imaging for prostate evaluation and (2) 

Interventional Radiology and Neuroradiology Department, Medical University in Lublin, Lublin, Poland.

1. To describe the clinical presentation of recurrence and their physiopathology 2. To describe the diagnostic imaging in intention to treat them 3. To show interventional management by means of cases A varicocoele is an abnormal dilatation of the pampiniform venous plexus, draining blood from the testicles. This plexus is a venous net arising from the testicular venous outflow. It extends from the scrotum through the spermatic cord and forms the spermatic vein. The spermatic vein runs through the inguinal canal and into the retroperitoneum. On the left, the spermatic vein usually drains into the left renal vein whereas on the right directly into the infrarenal inferior vena cava. Primary varicocoeles are formed as a result of spermatic vein valvular insufficiency, which leads to enlargement of the pampiniform plexus; however, Ahlberg, who introduced spermatic venography, proved that retrograde flow and varicocoele can occur even with competent valves. They can be bypassed by anastomoses with the renal vein or its intrarenal and perirenal branches. Varicocoeles occur in approximately 15 -20% of the male population worldwide. In the majority of patients they are unilateral left-sided. The aim of treatment of varicocoele was exclusion of blood retrograde flow into the pampiniform plexus from the spermatic vein and pre-existing collateral veins. There are two treatment options for varicocele: percutaneous occlusion by intravenous injection of various materials to close the veins supplying varicoceles or their surgical ligation or clipping. Percutaneous embolization of the internal prostate size until last imaging follow-up. PAE produced significant PSA reduction after procedure and continued over time. Before PAE the mean PSA was 10.1ng/mL, increased to a mean of 85.6 ng/ mL 24 hours after embolization due to ischemia and inflammation, dropped to a mean of 3.5 ng/mL one month after the procedure (P= 0.003), and stayed at normal levels over one-year followup. One-year follow-up urodynamic findings after PAE showed that maximum flow rates (Q max) improved significantly (P= 0.009), with statistically significant reduction of the detrusor pressure (P= 0.007) and post void residual volume (P= 0.04). Clinical overall improvement in LUTS at one-year follow-up was assessed by IPSS (mean, 2.8; P= 0.04) and QoL (mean, 0.4; P= 0.001) and the one-year urodynamic data corroborated the clinical improvement. No erectile dysfunction was observed and all patients reported a high degree of satisfaction (pleased or delighted) after PAE. In our study, no symptom recurrence over time was observed, suggesting that PAE can be a longlasting therapy. In our experience, BPH can be safely treated by PAE with low side effect rates, without the concern of impotence, incontinence and retrograde ejaculation, reducing prostate volume by more than 30% over time, with sustained LUTS relief and increased QoL. Techniques like using a 2.4 French or smaller microcatheter for distal prostatic arteries catheterization and calibrated embolic agents for embolization appears to reduce PAE-related complications. Better long-term results and lower recurrence rates can be achieved performing bilateral prostatic branch embolization and predictable embolic agents. Most importantly, a collaborative effort between urologist, diagnostic radiologists and interventional radiologist is key. These data suggest that PAE can be a very effective and safe minimally invasive treatment for patients with symptomatic BPH. Minimally invasive treatments for BPH continue to be part of the therapeutic armamentarium for managing LUTS. However, costs, changes in reimbursement, QoL and unanswered questions regarding durability of success have tempered the initial enthusiasm for this class of therapy. Nevertheless, PAE has emerged as a new alternative of treatment for symptomatic patients. The initial promising results support the need for a larger study comparing PAE with TURP, the AUA gold standard treatment. Carnevale and colleagues have begun a randomized comparison study of PAE with TURP for reducing symptoms from LUTS due to BPH. Future large studies with long-term follow-up and more data supporting PAE are necessary to validate current observations. As of March 2012, Carnevale and colleagues have treated close to 40 patients with nearly 4 years of follow-up in the first patients, with all patients having a minimum of 17 months' follow-up in the phase II study. This patient population has sustained LUTS relief and improved overall QoL without LUTS recurrence. These data suggests that PAE can be a very effective and safe minimally invasive treatment for patients with symptomatic BPH.

Dept. of Radiology B, Hôpital Civil, Strasbourg, France.

Interventional radiology is at the forefront of a paradigm shift in the treatment of tumors and related diseases. Advances in imaging and other technologies have enabled dramatic developments across all interventional treatments, especially the management of musculoskeletal tumors. Innovations in image-guided, percutaneous techniques are enabling an ever-increasing range of treatment options. But imaging capability is only part of the equation: advances in instrumentation and clinical collaboration are also required. New instruments and devices yet to be developed will enable further improvements and new treatments, and a combination of surgical and interventional techniques are on the horizon; multimodality OR rooms, large bore CT, MRI, hybrid ultrasound with fusion---where are we now, and where will we go next? Interventional radiology is poised to define the new horizon. The road ahead reaches as far as our imaginations will take us. spermatic vein is a safe and effective minimally invasive procedure with very low morbidity and complication rates and providing high long-term success rates. Embolization of varicocoele requires selective catheterization of the internal spermatic veins followed by its occlusion for which purpose foam sclerosant and/or coils or combination of two are most commonly used. Treatment of the varicocoele is limited by the presence of anatomic variants or aberrant supplying veins, which make catheterization and embolization of the internal spermatic vein difficult or even impossible. Also the anatomic anomalies of the inferior cava vein, reported in 4.4 -11% of the population, can cause difficulties in diagnostic and endovascular management of varicocoele. Therefore interventional radiologists must have a good knowledge of anatomic variants of the internal spermatic veins. Frequency of these anatomical variants ranges from 5 to 14%. Percutaneous treatment of varicocoele has reported recurrence rates at 1 -20% in the recent literature. Symptoms of recurrence are scrotal pain and palpable mass in scrotum or combination of both. Recurrence can be due to failure in embolization technique (inappropriate embolization material) leading to recanalization of initially well-embolized veins; however, this is a very rare incidence. Most recurrent varicocoeles occur as a result of failure to eliminate collateral supply to the spermatic vein in the abdomen or pelvis. Recurrence from saphenofemoral collateral circulation or from the internal iliac veins is most often reported. Multiple collateral veins may arise between the spermatic vein origin and the deep inguinal ring. These are running parallel or perpendicularly to the spermatic vein and include retroperitoneal, perirenal and lumbar veins. Treatment of recurrent varicocoele begins with spermatic vein venography performed from the femoral or jugular approach. Diagnostic venography requires the patient to perform a Valsalva maneuver. When venography is done by hand injection of contrast medium into the renal vein close to the spermatic vein outlet it is usually insufficient to visualize all aberrant veins and collateral supply. Peripheral position of the catheter tip in the renal vein during the injection of contrast medium allowing filling of the main renal vein, its hilar and intrarenal branches is therefore advocated. Percutaneous puncture of a dilated pampiniform plexus vein under ultrasound guidance may be used in certain of cases. This is performed by puncture with a micropuncture needle, introduction of a 0.018-inch guidewire, followed by placement of the 3F microcatheter. This method should be considered for cases in which access to the spermatic venous system is not possible by traditional routes. Direct puncture of the pampiniform venous plexus under ultrasound guidance may reveal recurrent varicocoeles supplied by anastomoses from the ipsilateral saphenous and femoral veins to the pampiniform plexus. A complete venographic study should include also a venogram of the contralateral spermatic vein and of the iliac vein in order to confirm that there is no aberrant venous drainage. According to classification of the spermatic vein proposed by Bahren, type B anatomy is the most common predictor of varicocoele reccurence. Embolization can be employed in the treatment of the patients with post-embolization or post-surgical recurrent varicocoeles as the only technique that allows accurate assessment of the spermatic vein anatomy and its collateral routes. Recurrent varicocoele can be treated by embolization with success rate in the range of 60 -94% depending on possible access to the draining veins that were overlooked at the time of initial treatment or to those that recanalized and enlarged after first procedure.

SS/FC/HL/HTS/CM level of "scientific" evidence. The VAPOUR trial in Sydney, Australia and VERTOS4 trial in the Netherlands are placebo-armed RCTs of vertebroplasty in acute fractures and are currently enrolling. These will soon provide definitive evidence regarding the place of vertebroplasty in acute fractures. In the interval, vertebroplasty is recommended for painful acute vertebral fractures less than 6 weeks old where the pain control is inadequate with conservative measures or when the patient is unable to ambulate due to fracture pain. There is little doubt that vertebroplasty can control the acute pain syndrome associated with the most painful acute fractures and afford early ambulation and hospital discharge. (9):1330-33. Disclosure I am Principle Investigator in the VAPOUR trial (Vertebroplasty for Acute Painful Osteoporotic fractURes). This trial is funded by an independent research grant from CareFusion, who make vertebroplasty products.

Radiology, AZ Sint Lucas Gent, Gent, Belgium.

This abstract, aimed at current practitioners of vertebroplasty, highlights recent changes in patient work-up and procedural techniques that have streamlined the authors' clinical practice. Preprocedural work-up, including history, physical examination, and adjunctive imaging techniques, is discussed. After finishing the VERTOS II trial we were able to give you our experience in treatment vertebral fractures in comparison with other devices as kyphoplasty. Also, the postprocedural issues are noted, including risk of subsequent fracture after vertebroplasty, long-term outcome of cement in the vertebral body, and utility of prophylactic vertebroplasty. Finally, the current state of evidence in support of the efficacy of vertebroplasty is discussed, with particular attention to the need for ongoing clinical trials. We like to stress the important therapeutic benefit that vertebroplasty has shown us in the daily spinal VCF's practice. Background: The heterogeneity of patients with osteoporotic vertebral compression fractures (VCF) necessitates a tailored approach of balancing the benefits and limitations of available treatments. Current guidelines are divergent, sometimes contradictory, and often insufficiently detailed to guide practice decisions. This lecture aimed at establishing treatment recommendations at the patientspecific level. Methods: Using the RAND/UCLA appropriateness method (RAM), a European multidisciplinary panel of 12 experts assessed the appropriateness of non-surgical management (NSM), vertebroplasty (VP) and balloon kyphoplasty (BKP) for 128 hypothetical patient profiles. These were unique combinations of clinical factors considered relevant to treatment choice (time since fracture, MRI findings, impact and evolution of symptoms, spinal deformity, ongoing fracture process, and pulmonary dysfunction).

There is still an indication for vertebroplasty after the randomised trials -Con

Medical Director, Geriatric Center Leopoldstadt, Vienna, Austria.

Vertebroplasty, first introduced in the treatment of vertebral haemangioma, has become a common procedure for treating painful vertebral osteoporotic fractures. Whereas over the years data in the literature were consistent regarding efficacy and safety of this procedure in providing pain relief, two recent RCTs found no beneficial effect of this procedure when compared to a sham operation. In a sharp contrast and adding to the conflicting results, the also recently published VERTOS -II study showed a clear benefit in pain reduction over the duration of one year. Long-term safety has been assessed by a RCT published this year; this study confirms the efficacy of vertebroplasty to diminish back pain very quickly but on the other hand showed a clear increase in the incidence of subsequent vertebral fractures, giving rise to the question whether in fact a quick benefit is traded for a lasting deleterious effect on patients' health when undergoing vertebroplasty. In the same time reports of side effects like cement embolism are also published in increasing numbers. In summary, the conflicting data in the literature do not allow to establish indications and recommendations for this technique at the current time. It might be that older and frail patients may really benefit from vertebroplasty; the faster recovery and better mobility can help to avoid disability. However, the risk/benefit ratio as well as patient selection criteria remain unclear and therefore the widespread use of vertebroplasty cannot longer be recommended. New interventional techniques are arising as well and could also possibly yield better and less conflicting results thereby ending this ongoing uncertainty. 

There is still an indication for vertebroplasty after the randomised trials -Pro

Interventional Radiology, St George Private Hospital, Sydney, NSW, Australia.

Vertebroplasty is an effective technique to reduce pain in patients with acute, non-united osteoporotic vertebral fractures who have uncontrolled pain. In this context the vertebroplasty procedure confers excellent analgesia, prevents ongoing vertebral body collapse and often restores lost vertebral height -by "reducing" the fracture. To learn about special devices used in BTK lesions Infrapopliteal PTA is almost exclusively performed from the ipsilateral approach. If there is a concomitant lesion in the femoropopliteal arteries, it is of course treated first. In the case of SFA occlusion recanalization, we often use self-expanding stents to prevent distal embolization during (repeated) passage of BTK angioplasty balloons. While, for dilatation of the infrapopliteal arteries, we prefer dedicated balloons compatible with 0.018" guidewires, coronary balloons 0.014" compatible, usually monorails, are sometimes used for very distal lesions. As a rule, we try to approach as many BTK arteries as possible, no matter how long the occlusion, and even if the distal arteries are compromised, as we believe that even partial recanalization can bring more blood to the collaterals. Our aim is to pass the guidewire/balloon intraluminally although, especially in occlusion recanalization, subintimal passage is possible. We always start with ballooning; the size of the balloon is slightly larger than the diameter of the artery. We keep the balloon inflated for 30-60 seconds; in the case of visible dissections, we repeat the dilatation and prolong the time of inflation to 2-3 minutes. In the event a suboptimal outcome, we use stents. We prefer self-expandable stents; the size of the stent is 1-1.5 mm larger than diameter of the artery to be stented. Should the wire fail to pass through the occlusion, the passage can be attempted from the periphery of the artery. Once the lesion has been crossed, the wire is usually manipulated up to the sheaths in the femoral artery (through-and-through guidewire) and the dilatation is performed in an antegrade fashion. In the case of restenosis, a drug-eluting balloon can be used, some authors recommend using DEB as the primary measure, but there is no evidence supporting this approach. Drug-eluting stents are rarely used and again, their use is not confirmed by any study. In the case of total SFA occlusion, a popliteal artery can be approached either by puncture or from surgical cut-down (with BTK PTA later continuing with femoropopliteal bypass 

When kyphoplasty and stentoplasty are a better solution than vertebroplasty

Orthopädische Chirurgie, Klinik Sonnenhof, Bern, Switzerland.

No abstract available. To learn about the definition of treatment success Endovascular treatment of infrapopliteal or below the knee (BTK) arteriosclerotic disease is recommended for patients with critical limb ischemia (CLI) and diabetic foot syndrome only. There is no proven evidence for endovascular therapy of infrapopliteal disease in patients with intermittent claudication. Before any treatment decision is made treatment of risk factors such as diabetes, wound debridement, antibiotic therapy and imaging with CTA or MRA are required. CLI patients usually have multilevel arteriosclerotic disease. The most common combination is stenosis/occlusion of the superficial femoral artery (SFA) and stenosis/occlusion of more than one infrapopliteal artery. If a patient has a wound revascularization of the artery which supplies the local angiosome should be tried first. However, if revascularization of the angiosome supplying artery fails, revascularization of other infrapopliteal arteries will improve the collateral flow. An endovascular first strategy is chosen in most of these multimorbid patients. In complex situations such as long SFA occlusions and tibial artery occlusions and if the patient has a vein, bypass surgery may be preferred. In the BASIL trial, a randomized trial of PTA versus bypass surgery in patients with CLI, it was concluded that patients with a life expectancy of more than 2 years and a vein as conduit should undergo bypass surgery.

Technically an antegrade approach is preferred for complex revascularizations of tibial arteries. However, a cross over access with a long sheath or guiding catheter is possible as well. In some patients a retrograde pedal access is needed if the antegrade approach fails. Small guidewires (0.018", 0.014"), balloons and if necessary for bailout stents should be used.

Upon request Disclosure Member of SAB of WL Gore, Abbott Vascular, Boston Scientific International S75 CIRSE 2012 SS/FC/HL/HTS/CM use of a 4 F glide catheter and a 0.035 straight glide wire can be useful. After crossing the lesion, a 0.014 wire will be inserted through the 4 F diagnostic catheter, and low profile balloon will be used. In selected cases and much rarely, low profile crossing micro catheters can be used. Sub-intimal recanalisation will be reserved to failure of intra-luminal passage and in this case either a standard 0.035 J glidewire or a 0.014 heavy wire will be needed together with a coaxial low profile balloon. After full angioplasty stent can be indicated in case of severe recoil or dissection, both of them being uncommon in this type of lesion. In this case we generally use balloon expandable low profile stents. The use of drug-eluting stents and drug-eluting balloons has not been fully validated and will be reserved for restenotic lesions. The use of double approach using a complementary retrograde puncture at the ankle of the anterior or posterior tibial artery is seldom needed in this case. 

How to treat long lesions

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

1. To learn about the recanalization technique for long lesions 2. To learn how to avoid failures 3. To learn about results and complications Background: Multiple trials have investigated endovascular treatment options in infrapopliteal lesions. Lesion length has always been one criterion; however, it was limited in most of these studies to rather focal and short segments treated. However, especially patients with diabetes mellitus present with long diffuse arteriosclerotic disease below the knee. This biological background of infrapopliteal arterial disease might have influenced an obvious change in paradigms for the treatment of long infrapopliteal lesions: the revised TASC-II guidelines state an "increasing evidence to support a recommendation for angioplasty in patients with CLI and infrapopliteal artery occlusion'' and lesion length is no longer used to determine a recommendation for treatment. Techniques: Dedicated devices for infrapopliteal use in longer lesions have been developed. Low profile balloons in length up to 20cm contribute substantially to the successful treatment of long BTK lesions. Currently, dedicated guide wires for long chronic total occlusions (CTO wires) have been developed and can successfully be used in infrapopliteal arteries. CTO wires start 0.014 inch diameter and have a range of tip loads from 3 to 25g. These wires are designed to cross lesions within the lumen. Although basically a true lumen approach will mostly be considered as a first line technique for longer lesions, it is acceptable if not beneficial to carry out angioplasty for longer segments from a subintimal tract, by using a hydrophilic guide wire. To learn how the treatment should be tailored to the clinical situation 3. To learn about results and complications Short lesions are stenosis or occlusion of less than 5 cm. They can be either isolated (i.e. short lesion in one vessel with the 2 other below the knee (BTK) arteries fully patent) or part of more complex lesions involving lesions of the 2 other BTK arteries. The patient should be prepared by low dose aspirin orally and clopidogrel 75 mg pd starting the day before. Once arterial access has been gained, anticoagulation uses IV heparin as a bolus (we usually use 2000 IU at the beginning of the intervention, and reinject 1000 IU every hour). In contrast to more complex lesion in which only antegrade femoral puncture allows optimal control on guide wires and balloons, controlateral approach can be used. Forty-or 45-cm long sheath preferably 5 F is inserted in case of antegrade approach. Prevention of contrast media nephrotoxicity is used according to the ESUR guidelines with interruption of diuretics, hydratation and avoidance of nephrotoxic drugs. In case of short stenosis, careful guidewire stenosis crossing will be performed with either an 0.014 or a 0.018 guide wire and a rapid-exchange balloon will be used. If the lesions are very tight and severely calcified, low profile coronary balloons can be useful. Another possibility is to use over-the-wire balloons that yield more pushability while providing low profile and excellent crossability. In this case antegrade puncture is the preferred approach. In diabetic patients, in particular, the use of a cutting balloon can be proposed with upsides (no dissection) and downsides (cost, no proven effect on restenosis). In case of total occlusion, the preferred approach should be intraluminal first, using a heavy 0.014 or 0.018 wire, with a coaxial low profile balloon. In case of failure, the S76 C RSE

Abstract Book smaller studies that have reported complications of IVC filters. In addition, although the FDA MAUDE database was also analyzed, denominators for the complications studied remain closely guarded intelligence and thus complication rates could not be based on this data. In clinical practice there is elevated concern about these newer devices. (AM J MED) Hopefully, in the near future better data will become available on optional IVC filters. The Cardiovascular and Interventional Society of Europe is concluding a filter retrieval registry, and the Society of Interventional Radiology in collaboration with the Society of Vascular Surgery is about to initiate a general filter registry. PREPIC 2 is recruiting patients in Europe, and a similar study is under consideration by the National Institutes of Health in the USA (5), IVC filters are safe devices that prevent pulmonary embolism.

The best results will be obtained when they are used for appropriate indications, patients are followed closely, and optional filters are either removed or converted when the patient is no-longer at risk of PE.

posterior tibial artery through the pedal arch. Such techniques facilitate the recanalization of long segments of infrapopliteal pedal and plantar arteries. Finally, drug-coated balloons have recently come in use and might be a new strategy for the treatment of long segmental lesions as well. The use of stents in BTK lesions has proved to be sufficient for bail out strategies; however, they have not been used in long tibial arterial disease systematically. Conclusion: Despite the fact of high restenosis rates after treatment of long infrapopiteal lesions, there is current evidence that with the use of dedicated techniques and devices good clinical results can be achieved.

OHSU Hospital, Dotter Interventional Institute, Portland, OR, United States of America.

The debate over the safety and efficacy of inferior vena cava (IVC) filters is based on one prospective randomized trial, a large body of retrospective data, and widespread concerns about safety of some newer devices (1) (2) (3) (4) . In the most famous of all filter studies, the PREPIC trial, all of the study subjects had venous thromboembolism (VTE) and were candidates for anticoagulation (3). The presence of the filter (mostly permanent in this study) was the variable factor. At 8 years, the overall incidence of VTE (deep vein thrombosis (DVT), IVC thrombosis, and pulmonary embolism (PE) combined) was the same in the filter and the non-filter groups (36.4% vs 35.4%). The patient with filters had more DVT and IVC thrombosis, but the patients without filters had significantly more PE. There were no differences in overall mortality or post thrombotic syndrome (PTS) between the two groups. The PREPIC trial therefore provides level 1 evidence of the efficacy of IVC filters, and the negligible impact of these devices on overall risk of recurrent VTE or PTS. The introduction and adoption of optional filters; devices that can be retrieved or converted to a non-filtration state -has further complicated the discussion on IVC filters. Angel et al., in a systematic review of optional filters, found that these devices perform well as filters (i.e. protect the patient from PE) (2) . The overall reported complication rates were in the expected ranges for migration, perforation, fracture, and penetration. However, this analysis excluded many of the S77 CIRSE 2012 SS/FC/HL/HTS/CM being used in patients at high risk of pulmonary embolism such as patients with multiple trauma or patients treated for venous thromboembolism who underwent major surgery. Some data already suggest that vena cava interruption is associated with a decrease in the risk of pulmonary embolism after multiple trauma, but in these studies, patients with filters were compared with historical controls in an area where care is changing rapidly 6 . Patients receiving anticoagulation for a previous episode of venous thromboembolism are sometimes offered a vena cava interruption, but this is not a universal practice and recent data suggest that the risk of recurrent venous thromboembolism is low in this context. In conclusion, vena cava filters are increasingly being used in patients with or at high risk of pulmonary embolism. There is still a lack of adequate data to substantiate most of these indications; some are not easily evaluable but randomized controlled trials are needed and feasible in most of these indications. 

Carotid stenting should be offered to symptomatic patients instead of endarterectomy: con P.R. Taylor Vena cava filters are used since many years for the treatment and prevention of venous thromboembolism. The main indications for vena cava interruption are the following: proximal deep vein thrombosis and/or pulmonary embolism in patients with an absolute contraindication to anticoagulant treatment, objectively documented recurrent venous thromboembolism despite adequate anticoagulant treatment, patients with venous thromboembolism who are at high risk for recurrent venous thromboembolism and primary prevention in patients at high risk for venous thromboembolism. None of these indications is based on solid grounds. IVC filters have been mostly evaluated in retrospective or prospective uncontrolled series in mixed populations and there is to date only one randomized controlled trial evaluating vena cava interruption in patients with proximal deep vein thrombosis 1 . As a result, most international guidelines on vena cava interruption are given with a low grade of evidence 2 . The use of vena cava interruption varies by a large extent between countries without clear evidence for differences in the epidemiology of venous thromboembolism between these countries and this is probably related to the lack of adequate data on their efficacy and safety. The use of vena cava filters in patients with venous thromboembolism and absolute contraindication to anticoagulant treatment is probably the less debated indication for their use. This indication is mainly based on the pioneering trial by Baritt and Jordan published 50 years ago, showing that when untreated, patients with pulmonary embolism have a 50% recurrence risk and a 25% risk of death 3 . This study was done in patients with clinically diagnosed pulmonary embolism and neither initial diagnosis nor recurrent pulmonary embolism was objectively confirmed. In the modern area where even subsegmental PE is diagnosed on multidetector computed tomography of the chest, the case fatality and recurrence rates are much lower 4 . In addition, little is known on the recurrence and case fatality rates of patients with proximal deep vein thrombosis or pulmonary embolism treated with vena cava interruption only. Thus the international guidelines recommend the use of vena cava interruption in this setting with a grade IB 2 . Recurrent venous thromboembolism is nowadays very unusual in patients receiving adequate anticoagulant treatment. In recent controlled trials the 6-month recurrence rate is usually of about 2% 4 . The reason for placing a vena cava filter in these patients is that a first recurrent event may increase the risk of subsequent recurrences, but this has never been confirmed. In a small series of patients with cancer who had a recurrent venous thromboembolism despite anticoagulant treatment, the change of anticoagulant drug or an increase in the dose of anticoagulant treatment is associated with a low risk of subsequent recurrence 5 -4.5 points, respectively) , whereas the effect of peri-procedural myocardial infarction was less (-3.0 points). Minor stroke also significantly affected mental health at one year (-3.4 points).

The rate of restenosis was three times higher after balloon angioplasty with and without stenting compared with endarterectomy in the randomized CAVATAS study (8) . The SPACE trial also showed a higher restenosis rate after stenting 11.1% versus 4.6% after endarterectomy (p<0.0009) (9) . One of the interesting features of the analysis of the randomised trials is that endarterectomy results are improving over time, whereas stenting results have remained static. Endarterectomy can be taught and disseminated to junior trainees, whereas there is a much longer learning curve required for stenting. Perhaps, the underlying thinking of carotid stenting with distal protection is wrong. The SAPPHIRE trial showed erroneously that distal protection was beneficial. The later trials show that stenting has at least twice the stroke rate of endarterectomy. The ICSS showed that stenting with distal protection caused 12 times the number of MRI-detected ischaemic cerebral lesions (and three times the number without protection) when compared with endarterectomy. A small randomised trial also showed that stenting with distal protection devices has a higher rate of MR-detected cerebral ischaemic lesions (29%) when compared to non-protected stenting (18%) although this failed to achieve statistical significance probably due to small numbers (10) . However, distal protection was associated with more transcranial Doppler-detected emboli which did achieve significance (p=0.01). Flow reversal seems the best option to prevent cerebral emboli and avoidance of the aortic arch would also be logical. Transcervical carotid stenting with flow reversal has been shown to have reasonable results in high risk patients older than 70 years where stroke/death/MI rates of 5.1% can be achieved (11) . It is likely that carotid stenting will become safer in the future as the technology evolves and patient selection improves. The most important objective in carotid intervention is the prevention of stroke and death. At present for symptomatic patients endarterectomy is safer than stenting. The recent randomised trials say so as does the Cochrane review and four recently published meta-analyses (12) (13) (14) (15) (16) .

trial which led the FDA to approve the use of carotid stenting for both symptomatic and asymptomatic patients (1) . A robust article appeared in Circulation citing the many flaws of this study (2) . Only 334 patients out of a total of 2294 patients were randomized and >70% of the patients were asymptomatic. At one year the authors changed the statistical analysis and the endpoints by adding non-Q-wave myocardial infarctions (determined by a two-fold elevation in creatinine kinase with a positive MB fraction) to stroke and death. This allowed a significant difference to be reported for the composite primary end point of 12.2% for stenting and 20.1% for endarterectomy with a significance of p<0.05. These results have never been repeated in subsequent randomised trials. The problems with the methodology and the relationship of the principle investigator with the cerebral protection device used (co-inventor) and the company sponsoring the trial (they bought the technology from him) make it a worthy subject to teach "how not to perform a clinical trial" (too many vested interests). Fortunately, more recent trials are much better designed than SAPPHIRE. EVA3S was a multicentre French randomized non-inferiority trial of symptomatic patients with >60% stenosis treated within 120 days of the index event (3). The primary endpoint was all stroke and death which affected 9.6% of stented and 3.9% of endarterectomy patients (unadjusted RR 2.5 95% CI 1.2-5.1). Myocardial infarction affected 1 stented patient (0.4%) and 2 endarterectomy patients (0.8%, p=0.62). Embolic protection was used in 78.4% of patients increasing to 97.7% when their use was made mandatory. The trial was stopped early on the grounds of safety and futility. SPACE was a multicentre German/Swiss/Austrian randomized noninferiority trial on symptomatic patients with a >70% stenosis within 180 days of the index event (4). The primary endpoint was 30-day ipsilateral ischaemic stroke and death. This affected 6.8% of stented and 6.3% of endarterectomy patients. As there were no significant differences in any of the primary or secondary endpoints the trial was stopped as it failed to demonstrate the non-inferiority of stenting. ICSS was a randomized trial of symptomatic patients with a >50% carotid stenosis treated within 12 months of the index event (5) CREST was a multicentre USA randomised study which included both symptomatic and asymptomatic patients (7). Symptomatic patients were treated within 180 days of the index event and the degree of stenosis had to be >50% on angiography or >70% on duplex or >80% on CTA or MRA. Stenting was associated with an almost two-fold increase in peri-procedural stroke and death rate compared with endarterectomy: 6.0 +-0.9% versus 3.2% +-0. To understand the role of combination therapies in liver tumours For patients with unresectable tumours confined to the liver, the administration of chemotherapy directly in the liver artery (HAI, hepatic arterial infusion) appears logical for several reasons: HAI decreases drug dilution, metabolism and elimination before reaching the liver, increases local drug concentration enhanced by the preferential tumor blood flow, and decreases systemic concentrations due to hepatic clearance [1] [2] [3] [4] . As the majority of the blood supply of the liver tumours comes from the hepatic artery, whereas the normal liver obtains most of its blood supply from the portal vein [5] , they are ideal targets for anti-tumor drugs administered via the IAH route. HAI have been evaluated for the treatment of primary liver tumours such as cholangiocarcinoma [6] and hepatocarcinoma with portal vein thrombosis (that contraindicates trans-arterial chemo-embolization) [7] [8] [9] . HAI have also been evaluated for different types of liver metastasis (gastric [10] , pancreatic cancers [11] ) but most of the studies are about the treatment of colorectal liver metastasis. Many drugs have been used for HAI such as 5-fluorouracil (5-FU), 5-fluoro-2'-deoxyuridine (FUDR, a pyrimidine antimetabolite transformed to 5-FU in the liver) oxaliplatin, irinotecan, mitomycin, gemcitabin. For colorectal liver metastases, systemic 5-FU was the main treatment for more than 40 years. This is why 5-FU and FUDR were the two first drugs used for HAI. Their use was supported by pharmacological results that demonstrated a hepatic extraction ratio of 19-51% for 5-FU and 94-99% for FUDR, resulting in a systemic levels with HAI that is about 60% for 5-FU and 25% for FUDR of the corresponding systemic levels with systemic infusion [12] . This is why most studies in the literature deal with HAI of 5-FU or HAI of FUDR. More recently, oxaliplatin has also demonstrated a significant pharmacokinetic advantage when use through HAI route compared with systemic administration [3] . These pharmacological advantages of HAI have resulted in a significant increase of the ORR. A study of the Cochran [13] pooled data from 10 studies that compared IV and IAH of 5-FU or FUDR and showed that the overall response rate (ORR) was significantly in favour of HAI compared with systemic infusion (43% vs. 18%). The overall survival (OS) was higher for HAI but the difference was not significant (16 months vs. 12 [14] . They reported an ORR of 92%, a 57% conversion-to-resection rate and a very high OS (50.8 months). The second one reported that ORR was 90% for the association of HAI oxaliplatin and systemic 5-FU + cetuximab, allowing surgical resection of initially unresectable metastases in 48% of the patients [15] . These results offer a real chance for resection for patients with initially unresectable liver colorectal metastases allowing long-term overall survival (5-years OS: 58%-71%) [16] [17] . HAI may also be considered as second-line therapy. Indeed, thanks to the greater local concentration of the cytotoxic agent, the ORR was up to 54% with HAI of oxaliplatin even in patients who are not any more responder to systemic oxaliplatin [18] . Studies [14, 19, 20] show significant ORR (64-88%), conversion-to-resection rate (35-47%) and OS (27-35 months) with this approach in second-line setting. Last but not least, HAI must be considered as adjuvant treatment after hepatic resection. Actually two randomised controlled trials [21] [22] and two recent studies [23] [24] , using modern drugs regimen, show a significant increase in hepatic, overall disease-free survival after HAI plus systemic chemotherapy compared with systemic chemotherapy alone.

The main drawbacks that hampered the dissemination of HAI are due to the necessity of the placement of an intra-arterial catheter connected to a subcutaneous port: firstly because during a long time the implantation of this device has required laparotomy and secondly because of the frequent premature discontinuation of the treatment due to catheter failure. For example, in a randomized controlled study including 290 patients, comparing HAI of 5FU to systemic 5FU, 50 patients never started HAI and 39 had to stop before the completion of the sixth course due to catheter failure. The median number of courses received was 2 [25] . However, recent advances in minimally invasive techniques have allowed the percutaneous placement of the intra-arterial catheter. This technique is highly feasible (94% of success) under local anesthesia by an interventional radiologist [26] and have demonstrated a significant better functionality compared to surgical placement (9.18 vs. 5.95 courses of HAI, p = 0.004) [27] . Based on this technical improvement, the interventional radiology is in the way to become a key point in the success of HAI.

lied. In addition, in a high proportion of cases the disease recurs after a radical therapy. Transcatheter arterial chemoembolization (TACE) is the current standard of care for patients presenting with large or multinodular HCC and relatively preserved liver function, absence of cancer-related symptoms, and no evidence of vascular invasion or extrahepatic spread (2) (3) (4) . The rationale for TACE is that the intraarterial infusion of a drug such as doxorubicin or cisplatin with or without a viscous emulsion, followed by embolization of the blood vessel with gelatine sponge particles or other embolic agents, will result in a strong cytotoxic effect combined with ischemia (5). The survival benefit of transarterial embolization (TAE) or TACE has been the subject of a few randomized controlled trials (RCT) that provided contradictory results (1). A cumulative meta-analysis of these studies, however, has clearly shown that 2-year survival of patients with HCC not suitable for radical therapies treated with arterial embolization or chemoembolization is improved compared with conservative management of suboptimal therapies (2) (3) (4) . However, the survival benefit of conventional TACE -including the administration of an anticancer-in-oil emulsion followed by embolic agents -reported in randomized controlled trials and meta-analyses was described as modest. Various strategies to improve outcomes for this patient group have become the subject of much ongoing clinical research. The introduction of embolic, drug-eluting beads (DEB) for transarterial administration has been shown to significantly diminish the amount of chemotherapy that reaches the systemic circulation compared with Lipiodol-based regimens, thus increasing the local concentration of the drug and the antitumoral efficacy (6) . In a multicenter phase 2 RCT including 201 European patients ("PRECISION V"), use of doxorubicin-eluting beads resulted in a marked reduction in liver toxicity and drug-related adverse events compared with conventional TACE with doxorubicin (7). The mean maximum aspartate aminotransferase and alanine aminotransferase increase in the DC Bead group were 50% and 41% less than in the conventional TACE group (p < 0.001). Owing to the improved safety and tolerability profile, high-dose doxorubicin treatment could be applied according to the planned schedule in the whole drug-eluting bead group, resulting in consistently high rates of objective response and disease control in all subgroup analyses. Contrary to the observation in the DEB arm, the objective response rate (ORR) and the disease control rate (DCR) for conventional TACE in the subgroups of patients with more advanced disease were significantly reduced (p = 0.038 for ORR; p = 0.026 for DCR), although the differences were not statistically significant in the overall patient population (ORR, 52% vs 44%; DCR, 63% vs 52%). An important limitation of any TACE regimens is the high rate of tumor recurrence. In RCTs, a sustained response lasting more than 3-6 months was observed in only 28-35% of the patients who received conventional TACE, and in non-responders no survival benefit was identified compared with best supportive care (1) . Even in those patients in whom initial response was achieved, the 3-year cumulative rate of intrahepatic recurrence reached 65%, with recurrent tumor showing significantly shorter median doubling time (8) . As a result, the 3-year survival rate of TACE-treated patients did not exceed 26-29% (1). Increased understanding of the molecular signalling pathways involved in HCC has led to the development of molecular targeted therapies aimed at inhibiting tumour cell proliferation and angiogenesis. Sorafenib, a multi-kinase inhibitor with antiangiogenic and antiproliferative properties, has been shown to prolong median overall survival and median time to radiological progression compared with placebo in RCTs and has become the current standard of care for patients with advanced-stage tumors not suitable for surgical or loco-regional therapies (2) (3) (4) . Tumor recurrence following TACE is characterised by increased VEGF production and subsequent angiogenesis. Moreover, TACE increases VEGF expression in the residual surviving cancerous tissue (8) and induces expression of other pro-angiogenic factors, such as hypoxia-inducible factor 1 alpha (8) 

Combining TACE and anti-angiogenic therapy

Diagnostic Imaging and Intervention, Pisa University School of Medicine, Pisa, Italy.

Learning Objectives 1. To describe the rationale for combining TACE and anti-angiogenic therapy 2. To analyse the results of trials using TACE and anti-angiogenic therapy 3. To understand the role of combination therapies in liver tumours Hepatocellular carcinoma (HCC) is the sixth most common cancer and the third leading cause of cancer-related death (1) . Unlike most solid cancers, future incidence and mortality rates for HCC were projected to largely increase in several regions around the world over the next 20 years, mostly as a result of the dissemination of hepatitis C virus infection. Despite the widespread implementation of surveillance programs of at-risk populations, the majority of patients with HCC are diagnosed late, when curative treatments cannot be app- 

Combining ablation and thermally sensitive drug carriers

Department of Surgery, Queen Mary Hospital, Hong Kong, Hong Kong.

Learning Objectives 1. To describe the rationale for combining ablation and thermallysensitive drug carriers 2. To explain the materials and mechanisms for combining ablation and thermally-sensitive drug carriers 3. To understand the role of combination therapies in liver tumours No abstract available.

Targeting tumour metabolism with transcatheter therapy Learning Objectives 1. To describe the rationale for targeting tumour metabolism with transcatheter therapy 2. To explain the materials and mechanisms for drug delivery 3. To explain how to evaluate response to treatment and analyse the results Hepatocellular carcinoma (HCC) is one of the most highly lethal malignancies in the world making it the third most common cause of cancer-related mortality worldwide. In the United States, the incidence of HCC is on the rise, secondary to a concomitant rise in hepatitis C viral (HCV) infection; in the past 2 decades the incidence of HCV-related HCC has tripled.1 Overall survival remains poor at less than 9 months2 and largely depends on the stage of the disease; patients with intermediate-stage disease have better 3-year survival expectancies than patients with advanced-stage disease (50% vs. 8%, respectively) In addition, the vast majority of patients are diagnosed at the advanced stage of the disease because of the asymptomatic nature of the disease, as well as because of the lack of an early-detection marker for HCC. Despite recent advances in therapeutic strategies, treating HCC remains a daunting task because of its aggressive nature-more specifically the risk of local invasion, metastatic spread, and the high rate of recurrence after curative therapies-as well as because HCC is largely refractory to systemic properties would appear as a rational approach. The availability of DEB, that ensure a minimal systemic exposure to the chemotherapeutic agent at the time of the TACE, is appealing for combination regimens, based on mechanisms that are theoretically synergistic. DEB-TACE has been shown to be safe and effective, with significantly reduced systemic drug exposure compared to conventional TACE regimens. Sorafenib has demonstrated efficacy and safety in patients with advanced HCC, with activity on both tumor cells and endothelial cells. In a prospective, single-center phase 2 study conducted at the Johns Hopkins University School of Medicine, safety and response of a combined protocol involving sorafenib 400 mg twice per day and DEB-TACE were assessed in 35 patients (9) . Although most patients experienced at least one grade 3 to 4 toxicity, most toxicities were minor (grade 1 to 2, 83% vs grade 3 to 4, 17%), and preliminary efficacy data were promising. The phase 2 randomized, double-blind, placebo-controlled SPACE study (Sorafenib or Placebo in Combination with DEB-TACE for Intermediate-Stage HCC) is the first global trial on the use of TACE in the treatment of HCC (10) . The objective of the study was to evaluate the efficacy and safety of sorafenib in combination with DEB-TACE in patients with intermediate-stage HCC. The study was conducted at 85 sites across Europe, North America, and the Asia-Pacific region. Patients were eligible if they had asymptomatic, unresectable, multinodular tumors without vascular invasion or extrahepatic spread; Child-Pugh A liver functional status; and ECOG performance status 0 (10). Patients were randomized to receive sorafenib 400 mg bid or matching placebo continuously (1 cycle = 4 weeks) until progression. All patients received DEB-TACE (150 mg doxorubicin) 3-7 days after first dose of study drug, and then on day 1 (± 4 days) of cycles 3, 7, and 13, and every 6 cycles thereafter. Patients were allowed optional DEB-TACE sessions between cycles 7 and 13 and cycles 13 and 19, if deemed necessary by the investigator. The primary endpoint was TTP by independent review (predefined alpha = 0.15). Secondary endpoints were overall survival, time to vascular invasion or extrahepatic spread, time to untreatable progression, and safety (10) . Of 452 patients screened, 307 were randomized to sorafenib (n=154) or placebo (n=153). The hazard ratio (HR) for TTP was 0.797 (95% CI, 0.588, 1.080; p = 0.072). Median TTP (50 th percentile) was 169 days / 166 days in the sorafenib and placebo groups, respectively; TTP at the 25 th and 75 th percentiles (preplanned) was 112 days / 88 days and 285 days / 224 days in the sorafenib and placebo groups, respectively. There were no unexpected safety findings. Median treatment duration in the sorafenib and placebo groups was 4.8 and 6.3 months, respectively, and median daily dose of study drug was 566 mg and 791 mg, respectively (10) . Several questions remain as we attempt to improve treatment outcome in HCC patients. The pathophysiologic complexity of HCC, balanced with a goal of providing effective tumor therapy with preservation of organ function, makes optimal treatment choice a clinical challenge. An understanding of exactly which features of HCC and patient health may predict the clinical outcome of combination regimens is essential for prescribing individualized, evidence-based therapeutic strategies.

SS/FC/HL/HTS/CM apoptosis in a dose-dependent manner. Further investigation with radiolabeled 3-BrPA identified the glycolytic enzyme, GAPDH, as the primary intracellular target of this agent. The binding of 3-BrPA to GAPDH caused inhibition of the enzyme activity and, therefore, glycolytic ATP production leading to apoptotic cell death.8Imageguided procedures, especially intra-arterial therapies, play a key role in the treatment of patients with liver cancer. The advantage of locoregional approaches is that they provide not only access to the core but also to the edge of the tumor. In addition, much greater drug concentrations can be achieved within tumors while minimizing systemic exposure. As a result, intra-arterial delivery of 3-BrPA was tested in various animal models of liver cancer. Results were extremely encouraging as tumors were successfully eradicated, in most cases significantly prolonging survival in the process. Some animals were even cured despite the fact these tumors are extremely aggressive. Unlike other alkylating agents, 3-BrPA demonstrated tremendous specificity in molecular targeting, enforcing its antitumorigenic effects by promoting energy depletion, disruption of redox balance, and induction of intracellular stress in a concurrent fashion. Therefore, it appears that 3-BrPA is an extremely promising agent because of its tumor selectivity and ability to promote a multipronged antitumor effect. In summary, despite cancer's extreme genetic heterogeneity, the reliance on glycolysis for energy needs and growth is a common pathway that most cancer cells share. As a result, targeting this pathway for therapeutic means is extremely attractive. A new agent 3-BrPA, which specifically inhibits this glycolytic pathway in tumors has already shown great promise in several animal models of liver cancer and could have a significant effect on the survival of patients with liver cancer. Clinical trials are to begin soon. (5): 510-517. Disclosure I am one of the patent holders for 3-bromopyruvate and founder and CEO of PreScience, the company that has an exclusive license from Johns Hopkins for the compound 3-bromopyruvate.

chemotherapy. Thus, an effective therapeutic strategy targeting HCC-specific or HCC-related pathway(s) is clearly needed. Furthermore, to make things even more challenging, because HCC typically occurs in the setting of underlying liver disease (cirrhosis), potential new drug candidates would have to also exhibit an extremely favorable toxicity profile. Tumor metabolism: One of the most important phenotypes exhibited in cancer is the up-regulation of the major energy-producing pathway, glycolysis. This altered tumor-specific glycolytic phenotype, first discovered by the German scientist Otto Warburg 3 decades ago, plays a crucial role in several biosynthetic processes that facilitate uninterrupted tumor growth and is an indispensible "metabolic event" critical for the sustained growth and invasion of tumors. Given the inefficiency of glycolysis compared with oxidative phosphorylation (2 ATP vs. 36 ATP molecules produced per glucose molecule, respectively), one could wonder why cancer cells prefer glycolysis. The main reason for this preference is that the cancer cells are able to generate ATP through glycolysis at a much faster rate than oxidative phosphorylation to meet the energy demands of aggressive malignant growth. Increased glucose metabolism via glycolysis provides cancer cells with essential substrates for rapid proliferation, ribose for nucleic acid synthesis (producing molecules like NADPH), and pyruvate for cell membrane assembly. Furthermore, an abundant supply of glucose also facilitates the metabolism of glucose via the pentose phosphate pathway (PPP), which is involved in several biosynthetic processes, as well as cellular defense (antioxidants) against reactive oxygen species (ROS). It is well known that HCC cells exhibit the high glycolytic rate of other aggressive malignant tumors through differential expression of enzymes involved in the first step of glucose metabolism. Indeed, whereas normal liver cells rely on glucokinase (type IV hexokinase) to catalyze the first step of glycolysis, HCC cells markedly up-regulate the expression of a different isoform, specifically type II HK (HK II), while substantially down-regulating glucokinase. Similarly, other glycolytic enzymes such as glyceraldehyde-3 phosphate dehydrogenase (GAPDH), LDH, and others are also up-regulated during the malignant transformation of HCC. The disparity in glycolytic rate between tumor cells and normal cells resulting in an increased demand for glucose by cancer cells has already been used diagnostically by positron emission tomography (PET) for tumor imaging with the glucose analog fluorodeoxyglucose (FDG) but has never been exploited as a potential therapeutic target. In fact, because this finding is so ubiquitous in cancer, it is considered a "biochemical signature" of tumor cells. This is why tumor metabolism has been aptly described as "cancer's Achilles' Heel,"4 suggesting it as a possible therapeutic target. Because malignant cells become addicted to glycolysis and dependent on this pathway to generate ATP, inhibition of glycolysis would severely abolish ATP generation in cancer cells and thus preferentially kill the malignant cells while sparing healthy surrounding cells. Targeting glycolysis for the treatment of cancer should, therefore, be a promising novel therapeutic strategy. Targeting Tumor Metabolism: A New Class of Anticancer Agents. Renewed research interest on tumor metabolism combined with a growing understanding of the molecular mechanisms involved in the regulation of tumor glycolysis5 contributed to the development of agents targeting glycolysis. Although some of these agents were evaluated in preclinical tumor models for their therapeutic potential,6 most did not make it into the clinic because of a lack of efficacy and the presence of significant toxicities. Recently, however, one such metabolic blocker, 3-bromopyruvate (3-BrPA), a halogenated analog of pyruvic acid, has gained considerable attention because of its significant antitumor effects and its low toxicity profile.7 The addition of the halogen bromine to the monocarboxylic acid, pyruvate, results in alkylating properties of the compound. As a result, 3-BrPA will bind to its target by forming an irreversible chemical bond. In vitro testing against human HCC cells demonstrated that 3-BrPA inhibits glycolysis and blocks ATP production, causing

Having said that, patients with very large uteri and fibroids will likely have less uterine and fibroid shrinkage [3] , less long-term satisfaction [4] and tend to have less symptom improvement [5] than others, although there is no evidence that these patients are more likely to have a complication [6, 7] . Certain anatomic subtypes need special consideration. Intracavitary fibroids appear more likely to be expelled in the weeks and months after embolization and this is more likely to be a clinical issue with larger fibroids. If the fibroid is small enough, hysteroscopic resection is an alternative. Since the early days of UAE, pedunculated serosal fibroids, particularly with a narrow attachment, have been suggested as a contraindication due the potential risk of detachment [8] . At least two studies have called that presumption into question [9, 10] , with no instances of detachment in these patients and clinical outcomes are similar to other types of fibroids. One class of fibroids, cervical fibroids, has also been investigated and although the data are few, it does appear that these are not as well treated with embolization as other types of fibroids [11] . Finally, adenomyosis commonly is encountered in patients undergoing evaluation for uterine embolization. There is now considerable evidence suggesting that it can be treated successfully; It appears that the outcomes may not be as durable as they are with fibroids, but symptom relief can be achieved with embolization [12] .

The ideal patient is one who is past childbearing, symptomatic from fibroids, and who does not want a hysterectomy. Among these factors, childbearing is the most complex from a decision-making perspective. For women who are surgical candidates and have a strong desire for pregnancy, the current evidence suggests that myomectomy should be the first choice. A randomized comparison of the reproductive outcomes of uterine artery embolization and myomectomy has shown an advantage for myomectomy in pregnancy rates and pregnancy outcomes [13] . Having said that, there are women who have such large or extensive fibroids that surgery is not feasible. For these women, uterine embolization may be preferred. Also, women who have had prior uterine surgery may be less ideal candidates for repeat surgery and might benefit from embolization. Another key patient preference that needs consideration is the patient's view of the nature of the intervention choices and their outcomes. For the woman who wants a guaranteed and permanent solution to heavy menstrual bleeding, hysterectomy is the best choice. In many cases, this can be accomplished either laparoscopically or transvaginally. Many other patients absolutely do not want to lose their uterus and for these embolization is preferred. Some wish to become pregnant, but are not operative candidates. For some women in this circumstance, embolization may be the best choice. Contraindications: Every patient undergoing UAE needs to have pregnancy excluded. This may be done with either a urine or serum pregnancy test. In our practice, this is done on the morning of the procedure. The next absolute contraindication is current known or suspected gynecologic malignancy. Therefore, complex cystic masses suspicious for ovarian malignancy need to be diagnosed prior to UAE. This may require surgery. Similarly, a patient with irregular bleeding, endometrial malignancy or pre-malignant conditions should be considered and appropriate testing done. Finally, although rare [14] , leiomyosarcoma does occur and it can be difficult to distinguish from a leiomyoma. Usually leiomyosarcoma presents as a large heterogeneous mass within the uterus, often with areas of hyper-enhancement and hypo-enhancement [15] . Unfortunately, there is overlap with the MRI appearance of benign fibroids and a definitive diagnosis may require biopsy or surgical resection. Finally, current uterine or adnexal infection is also a contraindication to treatment, at least until treated. Once infection has been cleared, there should not be any barrier to UAE. Summary: While uterine embolization can be performed in any woman who has fibroids, it is not an appropriate choice for some and therefore careful evaluation of a patient's symptoms, uterine To describe the consequence in real life Uterine embolization is now broadly accepted as an effective therapy for most women presenting with symptomatic fibroids. However, clearly not all women presenting for consideration for the procedure would be best served with embolization. Hysterectomy, myomectomy, endometrial ablation and pharmacologic management are all alternatives that might be considered for patients that we evaluate. An audit of our own consultations over a 15-month period revealed that approximately one-third of the patients that we evaluated were given a primary recommendation for treatment other than uterine embolization. Patient Evaluation: Ideally, the evaluation of patients interested in uterine embolization should be a collaborative effort between an interventional radiologist and a gynecologist. At a minimum, women considering UAE as a treatment option should be evaluated by an interventional radiologist who must consider the patient's presenting symptoms, imaging findings, and patient preferences. Combining these together, a suitable recommendation can be reached in most cases. Either ultrasound or magnetic resonance imaging (MRI) is used to evaluate patients at the time of consultation. It is important for the interventionalist to review those images, as the judgment for treatment can be difficult based on the report alone. The imaging study should be of high quality as the recommendation may vary significantly based on the study findings. In that regard, MRI may have an advantage over ultrasound based on its superior spatial resolution, and the utility of MRI in clinical decision-making in uterine embolization has been studied and confirms the impact it has on management of these patients [1] . It has the disadvantage of higher cost and some patients may have claustrophobia during the examination. Ultrasound is an acceptable alternative to MRI if carefully done with quality equipment and in many areas is more available than MRI. Patient Selection: The decision about suitability of a patient for treatment with UAE may be broken down into 3 parts: presenting symptoms, uterine anatomy, and patient preferences. Fibroid Symptoms: First, current practice dictates that only symptomatic patients should be treated. Typically, fibroids cause heavy menstrual cycles, with an increase in the length of the cycle and the number of heavy days of bleeding. Bleeding between menstrual periods is less typical and raises the possibility of other diagnoses. Other symptoms include pain, pressure and urinary symptoms and these usually are proportional to the size and location of the fibroids. For example, a patient may have pain and tenderness at the time of her cycle over a prominent fibroid. Rarely, the asymptomatic fibroid patient may seek treatment for UAE for hydronephrosis; this patient may benefit from a reduction in the size of the fibroids and uterus, with a recent study suggesting that hydronephrosis nearly always resolves after embolization due to this shrinkage [2] . Anatomic Considerations: There are some anatomic considerations in patient selection, although both single and multiple fibroids can be treated with UAE and all fibroid locations (submucosal, intramural and subserosal) may be successfully treated with embolization. 

Is UAE effective for adenomyosis?

Radiology, St. Elisabeth Hospital, Tilburg, Netherlands.

Learning Objectives 1. To describe how to recognize adenomyosis 2. To describe the end points and find out whether they are different from UFE 3. To present the outcomes of UFE in the current literature ADENOMYOSIS is a benign invasion of endometrium into the myometrium that results in a diffusely enlarged uterus that microscopically exhibits ectopic non-neoplastic endometrial glands and stroma surrounded by the hypertrophic and hyperplastic myometrium (Bird et al. 1972 ). This benign disease has either a focal or diffuse distribution in the uterine wall. Adenomyosis may occur alone, but is more frequently accompanied by fibroids in up to 55% of cases. Women with symptomatic adenomyosis suffer predominantly from heavy menstrual bleedings and dysmenorrhoea. Diagnose adenomyosis: In women with suspected adenomyosis, the first-line imaging technique is usually transvaginal ultrasound (TVUS). TVUS is inexpensive and readily available. Fundamental TVUS signs are 1) increased myometrial echogenicity or linear hyperechoic bands extending deep into the myometrium, indicating the presence of islets of ectopic endometrial tissue, 2) hypoechoic areas in the myometrium compatible with hyperplasia of the muscle tissue surrounding the ectopic tissue, 3) anechoic areas due to glandular dilatation or myometrial cysts, 4) poor definition of the junction zone, and 5) enlargement of the uterus with asymmetrical thickening of one of the walls. The presence of at least three of these signs is highly suggestive of adenomyosis. Sensitivity, specificity and accuracy of TVUS for adenomyosis vary between 80 and 86%, 50 and 96% and 68 and 86%, respectively. Magnetic resonance imaging (MRI) is particularly useful both in doubtful TVUS cases and in providing a complete evaluation of the disease with its panoramic views. With T2-weighted images and contrast-enhanced T1-weighted MRI, the thickness of the junction zone can reliably be measured; a thickness over 12 mm is considered diagnostic for adenomyosis. The presence of foci of high signal intensity within the myometrium constitutes an additional, but not a mandatory criterion. MRI is a reliable modality for diagnosing adenomyosis, with a sensitivity varying in the literature between 78 and 88% vs. the 53 and 89% for TVUS and a specificity of 67-100% vs. 67-98% for TVUS. MRI can categorize adenomyosis as focal or diffuse and can be repeated in time to evaluate the effect of treatment. Uterine Artery Embolization procedure: Before UAE, patients are prepared with or without intravenous antibiotic prophylaxis, sedation with 2.5-5 mg midazolam when required and a urinary bladder catheter. An applicable and accepted approach of UAE for adenomyosis is the bilateral UAE carried out after establishing arterial access to the common femoral artery. Selective catheterization of both anatomy and preferences is important to ensure that an appropriate patient recommendation can be made. This lecture is intended to introduce the interventionalist to some of the key issues in that decision making process.

C RSE To make recommendations regarding the optimal treatment strategy 3. To review limitations of the major trials Uterine fibroid embolisation is an established treatment option for women with symptomatic fibroids who wish to avoid conventional surgery. However, in order for patients to make an informed choice they need to be informed of the evidence available. This session aims to update doctors with the evidence available so that they are in a secure and confident position to fairly and openly inform patients. To maintain the highest standards only randomised controlled trials will be discussed as these alone permit a non biased "head to head" comparison of the treatment options. There are to date 5 published RCT`s (1) (2) (3) (4) (5) , one Cochrane review with an update (6) and one separate meta-analysis (7). This trials update will be divided into two parts. UFE vs. Hysterectomy and UFE vs. Myomectomy UFE vs. Hysterectomy There are 3 RCTs comparing hysterectomy with UFE (1-3). Collectively they randomised 300 patients. Two (REST, EMMY) were multicentred (1) (2) and the other single centre (3). The trials all took place during the "learning curve" of the procedure (1999) (2000) (2001) (2002) (2003) (2004) . This may be reflected in the technical success rate which varied from 95 to 97% and might be regarded as low by modern standards. Methodology and outcome measures differed but the results are surprisingly consistent. QoL was similar in both groups together with patient satisfaction scores. UFE showed a significantly shorter hospital stay and more rapid return to normal activities compared with hysterectomy. Complications rates varied between studies but on balance there were no significant differences between the two treatment options. Complication type was very different and the time gap to a complication was also different with surgical complications usually appearing within the traditional 30-day window, but UFE complications more commonly featuring over a much longer time window. Two of the trials have recently reported 5-year outcomes (8) (9) . The need for further invasive treatments was significantly higher in the UFE group than the hysterectomy group (OR 5.79 95% CI 2.65-12.65) (7) . There was no procedure-related mortality or pelvic malignancy reported in any arm of any trial. The need for re-intervention led to a loss of the initial cost benefit of UFE over surgery, the two techniques being cost neutral at 5 years (8) . The Cochrane review pointed out the relative small numbers in all these trials together with a lack of "blinding" introducing potential detection bias (6). UFE vs. Myomectomy There are 2 RCTs, the "MARA" trial from the Czech republic (4) and the FUME trial from the U.K. (5) . Both are single-centre studies. From the outset these are much more difficult trials to conduct. Ideally pregnancy outcomes are needed. However, often the intention to become pregnant is at best variable and often aspirational. Large numbers with long follow-up are required. The FUME trial excluded those intending to become pregnant. Both were small, MARA (121), FUME (163) with short-term follow-up. The MARA trial reported significantly superior pregnancy outcomes with myomectomy compared with UFE. Both trials showed equivalent QoL. The FUME trial was the first to use the validated fibroid specific UFSQol. Recovery and return to normal activities was faster with UFE, but the need for re-intervention was significantly higher compared with myomectomy. The Cochrane review commented that the single trial (MARA) looking at fertility issues limited any conclusion to be made uterine arteries is performed under fluoroscopic imaging. A microcatheter is used at the operator's discretion. Embolization is performed by using a particulate embolic agent. The most widely used embolic agent is non-spherical polyvinyl alcohol particles ranging from 255 to 900 microns in size (Popovic et al. 2011 ). Others prefer the use of spherical embolics, calibrated microspheres, ranged in size from 500 to 700 microns, in order to facilitate deep penetration into the small afferent arterioles of adenomyosis. In contrast to the perifibroid vascularization pattern of uterine fibroids, adenomyosis has a deep and more diffuse distribution of parallel afferent arterioles throughout the myometrium. The difference in vascularisation might explain the reported higher failure rate after UAE in women with adenomyosis compared with UAE for fibroids. The angiographic end-point of embolization is complete stasis of flow of contrast in the ascending segment of both uterine arteries. The stability of the end-point is regularly checked after 5 min and additional particles injected if the end-point is not reached. During and after embolization, intravenous narcotics and non-steroidal anti-inflammatory drugs are administered for adequate pain control.

There are no randomized, blinded, controlled trials assessing the efficacy of UAE as a treatment for adenomyosis. Popovic et al. published a complete and detailed meta-analysis on UAE for the treatment of adenomyosis. The analysis included 15 studies with a total of 511 patients, published between 1999 and 2010.

-UAE results in pure adenomyosis: Short-term follow-up after UAE in pure adenomyosis resulted in improvement of symptoms in 83% of women with a median follow-up of 9.4 months. The uterine volumes decreased by 25 to 32%. Mid-and long term results, after a median follow-up of 40.6 months, showed sustained improvement in the vast majority.

-UAE results in adenomyosis with fibroids: Short-term results in patients with adenomyosis with fibroids demonstrated clinical improvement in 93% of women with a median follow-up of 10.7 months. Long-term follow-up (34.2 months) showed that 82.4% of women reported sustained significant improvement of symptoms after UAE. In conclusion: During the past decade, the UAE technique has undergone several refinements and extended its application beyond the embolization of fibroids. Now, also patients with pure adenomyosis or adenomyosis with fibroids are potential candidates for UAE. Clinical and symptomatic improvements have been reported by many studies regarding UAE for adenomyosis. UAE has minimal side effects, is cost-effective and preserves fertility. Therefore, UAE is an attractive treatment option and a valuable alternative to hysterectomy. Learning Objectives 1. To review the current anatomical and clinical indications for pedal angioplasty 2. To understand the current role of non-invasive imaging modalities 3. To provide recommendations for 2012 imaging and patient selection standards Crural vessel occlusive disease is a common finding in patients presenting with symptomatic chronic critical limb ischemia (CLI). Treatment options for this patient group are associated with high morbidity and mortality rates. Infrapopliteal angioplasty is today considered as first-line therapy for treatment of patients presented with CLI due to multilevel arterial obstructive disease, especially in cases with lesions involving the infrapopliteal arteries. Recanalization of multiple stenoses and chronic occlusions may nowadays be accomplished in more than one tibial artery in the interest of preventing limb loss by minimally invasive means. Arterial obstructions may affect the distal tibial arteries at the malleolar level, or even extend below the ankle and involve the dorsalis pedis and plantar arteries. Distal anastomosis during bypass surgery may be technically challenging in case of extensive medial wall calcifications or even impossible if an appropriately healthy distal vessel conduit is absent. Pre-treatment imaging in patients scheduled to undergo BTK interventions should offer accurate information regarding both the inflow and outflow infrapopliteal arterial status. Evaluation of the iliac, common/superficial femoral and popliteal arteries is essential for BTK treatment and procedural planning. Patency of the iliac and common femoral arteries is of practical importance as it should determine the most favourable strategy using an ipsilateral antegrade or contralateral retrograde common femoral approach.

Optimal pre-procedural imaging should also identify the anatomy and extent of the infrapopliteal arterial lesions providing detailed information of the distal foot vasculature. The multilevel distribution of the disease may be assessed by invasive and non invasive imaging methods such as Digital Subtractive Angiography (DSA), Multi-Detector Computed Tomography Angiography (MDCTA), various techniques of Contrast-Enhanced Magnetic Resonance Angiography (CE-MRA, 3D-time resolved CE-MRA with real time triggering) and High Frequency Duplex Ultrasound (HF-DU). Choosing the most advantageous pre-procedural imaging modality should be based on the advantages and disadvantages of each method. Although the above-mentioned non-invasive modalities are very effective in evaluating the large diameter above the knee arteries, small-calibre BTK vessels are best demonstrated using time-resolved CE-MRA and super-selective DSA with the catheter positioned above the tibial trifurcation. CE-MRA has been reported to detect significantly more distal pedal arteries than selective DSA. On the other hand, invasive DSA has the advantage of immediate on-site treatment and MRA evaluation of in-stent stenosis is poor. CTA is a fast noninvasive modality, but it requires high contrast media volume, exposes patients to high doses of radiation, and is limited by smallcaliber, heavily calcified arteries. HF-DU is operator-dependent and although the infrapopliteal arterial evaluation is compromised by inflow occlusions, it can be very useful in assessing pedal artery morphology. Finally, the pre-procedural imaging of patients suffering from severe stage 3 or 4 chronic kidney dysfunction and pre-dialysis regarding the effects of UAE on fertility and future pregnancy (6) . This lack of certainty has prompted the funding and subsequent launch (2012) of the largest UFE trial to date. The U.K. led FEMME trial aims to randomise 650 women between UFE and myomectomy and is currently open for recruitment (12) . Conclusion: Medicine is increasingly all about choice and as always the final picture remains incomplete. Although the most recent trial has just begun, it seems unlikely there will be much enthusiasm for any further RCTs so we live with the data already available. The less invasive nature of UFE over surgery is widely acknowledged and needs to be balanced against the need for more re-intervention. Informed physicians should inform patients and informed patients make their own informed decision.

C RSE

Abstract Book approach offers a better controllability, a better push and therefore in the end a shorter, more straightforward and more successful intervention. However, in a more and more obese patient population, crossover procedures will increase. Distal access routes are reserved for special cases, especially if an antegrade recanalisation is not possible. Low profile balloons with long balloon length and dedicated catheter-guidewire combinations are standard equipment for difficult cases nowadays. There are rapid exchange systems on the market, best used in combination with guiding catheters, and overthe-wire systems. Whereas standard 0.014" or 0.018" wires are sufficient to recanalise most stenotic lesions, a broader range of wires is needed to cross longer occlusions, especially more stiffer wires up to a size of 0.035". Low profile support catheters with tapered tip have increased the recanalisation rate and the controllability in the periphery. For patients with severe calcifications not amenable for standard, plain balloon angioplasty, focal pressure balloons ("cutting balloons" of different types) have been developed. In addition, minimising of catheters for atherectomy and ablation techniques made it possible to use these devices also in the peripheral circulation. However, using these techniques might lead to higher complication rates especially because of more perforations and peripheral embolisations. Subintimal angioplasty has shown promising results, especially for long lesions. Although this can be conducted with standard equipment, specially minimised material, as for example dedicated reentry catheters for coronary interventions, have been developed and are available. Plain balloon angioplasty may lead to suboptimal results, especially if flow-limiting dissections occur. Years ago these dissections have to been dealt with using coronary stents, which are far from being optimised for distal leg arteries. Nowadays special self-expanding stents with longer stent length are available for lower extremity procedures resulting in an increased technically success rate. Although there is a lack of carefully conducted controlled trials, there are a couple of standard drugs used periinterventionally. Platelet aggregation inhibitors in combination with anticoagulants, i.e. heparin, are standard based on worldwide experience. When long complex lesions have been treated or there is flow limitation more aggressive antithrombotic regimes (i.e. low-molecular-weight heparin in combination with ASS and clopidogrel) could be applied. For more distal procedures vasodilatory drugs are used in more and more cases. Fibrinolytic drugs are not used on a regulatory basis but can be useful for complicated cases with thrombembolic impairment of the microcirculation. Especially in older patients, sedation and analgesia might be beneficial and sometimes necessary to avoid patient movement. There is no consensus if LMWH (low-molecular-weight heparin) or UFH (unfractioned heparin) is better for posttreatment antithrombotic prophylaxis; there are a couple of slightly different protocols, and it is not sure which patients do benefit from prolonged anticoagulation. One problem still is the relatively high restenosis rate treating distal lesions, although this seems not lead to a lower limb salvages rate in comparison with surgical procedures. On the other hand, a relatively high rate of resubmissions and revascularisation procedures increase complications rates and overall costs of angioplasty as the treatment of choice. Drug-eluting balloons, drug-eluting stents and different drug protocols have been tested to improve the patency rates after successful angioplasty. Especially the delivery of paclitaxel to the vessels wall shows promising results in a handful of trials. However, long-term results have to be presented before advocating routine use of these devices, especially when keeping in mind the higher rate of thrombotic complications in cardiac interventions. Patients with critical limb ischemia caused by crural and pedal atherosclerosis have a high burden of comorbidities and a relevant mortality. Therefore, adequate patient selection and premedication as well as periinterventional patient monitoring ARE critical for a good clinical outcome and a low complication rate. A lot of diabetic patients suffer from chronic renal failure, so hydration and a careful technique reducing the amount of potential nephrotoxic 

Department of Diagnostic and Interventional Radiology, Klinikum Luedenscheid, Lüdenscheid, Germany.

Learning Objectives 1. To give an overview of the available equipment for pedal angioplasty 2. To review "must-know" periinterventional drugs 3. To describe patient monitoring periinterventionally The aim of crural and pedal angioplasty is to achieve an optimal runin and a sufficient run-off to enable the ischemic lesions in critical limb ischemia to heal and rescue the threatened limb. Therefore, pedal and crural angioplasties are often conducted in combination with more proximal interventions, but these are beyond the scope of this session. To achieve a sufficient run-off is often the technically most challenging part of the intervention. Unfortunately, there is a limitation of available data for crural and pedal angioplasty. There is a lack of randomized data and therefore comparison of different material, approaches and drug treatments is not possible with an evidence-based approach. Therefore the following statements and recommendations are mainly based on data from observational studies and some meta analysis. Recent developments have broadened the portfolio of material for interventionalist, enabling a higher recanalisation and technical success rates. Different systems for contralateral cross over, ipsilateral antegrade and ipsilateral retrograde (i.e. distal puncture) have been developed and further improved. The primary access route is still also a matter of choice, but most interventional radiologists agree that an antegrade S89 CIRSE 2012 SS/FC/HL/HTS/CM and magnification techniques. Lesions are generally approached with a system consisting of hydrophilic .014-inch guidewires, supported by low-profile balloon catheter, specifically designed for BTK interventions, in various lengths. Local injection through the balloon catheter can also be used to confirm the correct intraluminal position before inflation. Inflation times are recommended between 60 and 180 seconds, with a pressure rate between 7 and 10 atm. The balloon size for foot vessels and plantar arch is usually 2 to 3 mm. In cases where PTA alone is insufficient, dedicated stents may be used to solve local problems. Other techniques, which include pedal revascularization, are subintimal angioplasty, and transpedal access techniques. Subintimal arterial flossing with antegrade-retrograde intervention (SAFARI) might be used when there is a failure to reenter the distal true lumen or when there is only a limited segment of the patent distal target artery available for reentry. In such a case retrograde access can be obtained in the distal target artery, such as the dorsalis pedis, and a retrograde, potentially subintimal, channel can be created. A guide wire can then connect the retrograde and antegrade channels simultaneously and create a "flossing" guide wire. This tract can be further treated by appropriate endovascular techniques. Access from pedal arteries, including their revascularization, might also be used in cases in which it is necessary to use a retrograde approach coming from the plantar arch to treat the anterior or posterior tibial artery as the target vessel when antegrade crossing becomes impossible. Conclusions: Pedal angioplasty should be considered in a global concept, when dealing with the treatment of peripheral arterial occlusive disease. Techniques and device selection for treatment of pedal arteries should be considered in the setup of BTK interventions. Main goals remain the improvement or optimization of vascular outflow, improvement of the level of oxygen tension, and consequently the wound healing process of the foot, particularly when angiographic and clinical results of above-the-ankle PTA remains insufficient. contrast media are required. Modification and treatment of the risk factors of atherosclerosis seem to be trivial, but especially in patients treated inter-disciplinary there is still room for improvement, especially because of communication barriers.

How I do it

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

1. To describe the speaker's approach regarding treatment indication and selection process 2. To describe the devices used for tackling the obstruction 3. To describe the speaker's approach in case primary recanalization fails Background: Since the introduction of endovascular therapy to the treatment of critical limb ischemia (CLI), interventions in below the ankle arteries were basically limited to the treatment of anastomosis-related problems after pedal bypass. PTA has been used as a repair technique for restenosis in pedal anastomosis after distal pedal bypass surgery. Until now pedal occlusive disease has remained as one of the least treated territory regarding endovascular techniques. However, below-the-ankle techniques have gained enormous interest within the past few years and are nowadays performed routinely using a total pedal approach. Techniques: With the introduction of new techniques and low-profile devices endovascular techniques have gained access to pedal interventions and represent a probably underestimated field with amazingsolutions. Starting with the pre-evaluation and patient selection, in patients with long occlusions of below-the-knee (BTK) vessels, foot vessels should critically be examined and imaged coincidentally, as the patency of plantar arch vessels provides essential blood flow to both the forefoot and the calcaneal region. Treatment of below the knee vessels becomes only effective when the outflow conditions are optimized.Discussing modern concepts of endovascular treatment below the knee, de novo lesions in pedal arteries should therefore be considered in a global therapy concept in patients with critical limb ischemia (CLI), Rutherford category 4-6, on the basis of non-healing gangrene and/or ulcerations of the foot associated with a critically low level of oxygen tension (TcPO2). Regarding technical concepts for such indications Manzi, Fusaro et al. described the pedal-plantar loop technique, which consists of the recanalization of both pedal and plantar arteries and their anatomical anastomoses. This technique was designed for patients with extensive trophic alteration of the foot requiring the maximum improvement in blood flow support. The pedal-plantar loop technique might be used for the antegrade recanalization of the anterior tibial artery and the dorsalis pedis followed by retrograde recanalization of the plantar artery and then of the distal posterior tibial artery or for antegrade recanalization of the posterior tibial artery and the plantar artery followed by retrograde recanalization of the dorsalis pedis and then of the distal anterior tibial artery. Antegrade femoral puncture is essential for performing BTK and pedal procedures. Devices are used on a 4 or 5F basis. Baseline angiograms should be performed including the pedal arteries in a clear overview Learning Objectives 1. To learn the principles of endografting in dissection 2. To assess the evidence for short vs. long segment endograft coverage 3. To learn whether there is a difference for acute vs. chronic dissection About 15 years ago, uncomplicated Type B dissections were managed conservatively. As opposed to this, complicated type B dissections per force required invasive treatment. Patients with rupture, impending rupture (heralded by a rapid increase in the diameter of the false lumen) or with persistent intractable pain were treated with immediate open surgical repair. Dissections with associated branch vessels ischemia were treated similarly with emergent intervention (1) . The morbidity and mortality of open surgical repair in patients with distal ischemia being high (2, 3) , the management of these patients passed into the hands of the interventionist, particularly in centres possessing adequate expertise in performing balloon fenestration of the intimal flap and true lumen stenting (4) . This scenario changed in the late nineties. Initial reports on stent grafting for proximal entry closure in type B dissections in humans appeared at the turn of the century (5, 6, 7) . Whereas the report by Nienaber and colleagues dealt with uncomplicated sub-acute or chronic dissections (7), Dake and colleagues reported on acute dissections and addressed in part, the role of stent grafting in relieving branch vessel ischemia (6) . Furthermore, reports with small patient numbers are also available suggesting the possible utility of stent grafting in ruptured type B dissections (8, 9) . The hypothesis which favours stent grafting is that closure of the proximal entry tear leads to thrombosis of the false lumen; this in turn stabilizes the dissection thus preventing progressive aneurysmal dilatation of the false lumen. An extension of this hypothesis supports the role of endografts in the acute setting of aortic rupture, where false lumen thrombosis may be expected to seal the rupture site. A further postulate based on experimental results is that stent grafting may help in treating ischemic complications resulting from true lumen collapse (10) . Studies so far with relatively small patient numbers have proved these hypotheses and postulates to be correct but only in parts; accordingly, the success of stent grafting alone has differed from one clinical setting to the other. A differential analysis of the

Department of Radiology, Henri Mondor Hospital, Créteil, France.

Learning Objectives 1. To review the outcomes of pedal angioplasty 2. To illustrate potential complications of the various approaches 3. To describe how to deal with minor and major complications Introduction: The Number of patients suffering of peripheral arterial-occlusive disease (PAD) continues to grow all across the globe. Revascularization in patients with PAD and critical limb ischemia (CLI) is realized to prevent limb loss and major amputation (MA) and also to improve patient life quality and to prolong survival. The Trans Atlantic Inter-Societal Consensus document (TASC II) recommendations for femoropopliteal stenotic or occlusive lesions are clear. On the contrary, the recommendations for infra-popliteal disease are not as clear because of limited data on the efficacy of tibial artery endovascular intervention for CLI in terms of wound healing and limb salvage. Complications: the rate of complications varies between 2 and 4 %. Most of those complications are related to general complications of the patient population at high risk (Sudden death, Myocardial infarction, Left ventricular failure, Acute renal failure, infection, pulmonary oedema…) Direct PTA-related complications are < de 1% (groin hematomas, Distal thrombosis or embolism, Access site pseudoaneurysms). Those complications required a specific therapy or a prolonged hospital stay; other complications are not reported in the literature such as vessel rupture and perforation because of the absence of their clinical impact. Results: Intervention feasibility and technical success rate vary in series between 80 and 95%. There is a high rate of primary restenose or rethrombosis Clinical recurrence rate remains acceptable15 to 20%. If clinical recurrences occur, a second Intervention can be successfully performed. Limb Salvage rate is between 80 and 90%. Angiosome concept divided the foot into six angiosomes depending on pedal arteries' vascularization. Targeting vessels' PTA based on angiosome distribution may improve those results. Technical improvements are already available with dedicated introducers, catheters, guide wires, balloons and may lead to a higher rate of technical and clinical success during interventions. The use of bare stents or coated stents showed better short-and mid-term patency but did not prove better clinical outcome. Conclusion: Revascularization plays a crucial role in the treatment of ischemic lower extremity wounds. PTA of the infrapopliteal vessels can be performed safely, with a low periprocedural morbidity and mortality. The quality of subsequent wound care is also a critical component in promoting healing and avoiding further tissue loss. Many factors are involved in the choice of target artery for revascularization; consideration should be given to revascularization of the number of arteries and to prefer the artery directly feeding the ischemic angiosome as an additional consideration in planning lower extremity revascularization. Excellent assisted patency and limb salvage can be achieved with close follow-up and additional PTA if necessary. clinical outcomes in various patient sub-groups suggests that stentgrafting may be helpful in the sub-group of patients with rupture or impending rupture (9) . Distal branch vessel ischemia in the acute or sub acute setting can also be relieved by stent-grafting; however, further peripheral interventions in the form of true lumen stenting or balloon fenestration may be necessary to optimize the outcome in upto 50 % of the cases (4, 6, 9) . Controversy exists regarding the usage of stent-grafts in chronic type B dissections. The same holds true for uncomplicated acute or sub-acute cases. The randomized INSTEAD trial in this sub-group of patients failed to demonstrate the superiority of stent grafting over conservative management in improving overall clinical outcome; the complication rate was higher in the stent graft arm (11) . The backdrop of these results may be useful in answering the question: Do we know as yet how much of the aorta to cover in dissection? If the question were to be answered with a brash "Yes," it would just provide proof to the age old axiom: True knowledge is modest and weary; ´tis ignorance that is bold and persevering. By the same measure, an absolute "No" would be digressing from the truth. So the answer has to be "Partly; in certain sub-groups yes, in others not quite so". In an attempt to arrive at an appropriate answer, one must consider that most recent publications dealing with the topic are single arm studies or reports on selected non-randomized patient cohorts with small patient numbers (12) (13) (14) (15) . Consequently, drawing of definite inferences should be exercised with caution. To decide how much of the aorta to cover with the stent graft or stent, it is imperative to bear the aims of therapy in mind. These are primarily relief of branch vessel ischemia as well as prevention of ruptures not only in the acute setting, but also in the chronic phase resulting from false lumen expansion.

It is now generally accepted that stent graft closure of the proximal entry site alone is not adequate for relieving branch vessel ischemia in all cases. Consequently, the endograft often has to be supplemented with distal bare metal stents. The concept is logical and has proved to be of clinical benefit (6, (12) (13) (14) (15) . In this context, the answer to the question as to how far down one should stent the true lumen appears to be as follows: down to the level of the ischemic vessels at least. One expects this hypothesis to be confirmed by further studies in the future. However, the procedure may entail stenting across the origins of other branch vessels. Furthermore, it tends to disregard branch vessels arising exclusively from the false lumen. The fate of these vessels at long-term follow-up presently remains indeterminate. The issue could possibly be managed by choosing bare metal stents with diameters which do not completely obliterate the false lumen. Let us come to the topic of aortic remodelling. Early experience has demonstrated successful thrombosis and shrinkage of the false lumen in the thoracic aorta following proximal entry closure with stent grafting (5, 7) . However, the abdominal false lumen remained patent in all but one of Dake´s 19 patients (6) and all of Czermak´s patients (16) . A similar observation was reported by Hausegger and colleagues (17) . As a logical consequence distal bare metal stenting was introduced to optimize outcome in this sphere as well with stenting in certain cases going down to the level of the iliac vessels. The cosmetic effect of the procedure on the appearances of the true and false lumina at imaging is impressive, with a marked increase in the true lumen size and a concomitant decrease of the false lumen size (12) (13) (14) (15) . Whether this optical improvement translates directly to a corresponding clinical benefit remains to be seen, especially with regard to late rupture. Although the procedure may help in tiding over the acute situation in cases with rupture or impending rupture, it does not reliably prevent delayed rupture at follow-up (13, 15) . From the available evidence in literature so far, it is presently premature to comment whether stent grafting with supplemental bare metal stenting of the true lumen would favourably influence the long-term outcome with respect to late rupture. The fenestrations should ideally be positioned close to the aortic wall and the ostium of the target vessel, and the graft needs to be repositioned to allow for catheterization of each target vessel. The longer the distance between the fenestration and the ostium of the target vessel, the more unstable the connection becomes between the bridging covered stent and the nitinol-reinforced fenestration.

In contrast, branched grafts are grafts with incorporated branches and are used in thoraco-abdominal aneurysms, where the distance between graft and target vessel is too long to use a fenestration. Branches provide a better fixation and sealing with the bridging covered stents. Downward-facing branches are obviously very suited in combination with visceral arteries pointing downwards at their origin (e.g., the celiac artery). It is accepted that branches need some "space", as they should not be squashed against the aortic wall. One way to achieve some extra room for the branches is to taper down the diameter of the main graft. In chronic dissections, the four visceral branches of the aorta are usually involved. One specific feature in this pathology is the narrow true lumen. Due to this narrow true lumen, a fenestrated graft seems more suitable than a branched graft. Downward-facing branches, as mentioned above, may be needed when the take-off angle of the visceral artery makes it necessary to catheterize the vessel from above. Extra room, besides tapering down the main graft to the maximum, can be achieved using a tube graft first with a distal landing zone a few cm above the visceral branches of the aorta. This should carefully widen the true lumen and allow for the branched graft to open completely. Experience has shown that only a small channel is needed for catheterization and that the bridging graft can open the true lumen further. Another second specific feature in chronic Type B dissections is that the aortic visceral branches do not always originate from the same lumen. Especially the left renal artery is often originating from the false lumen with the other three vessels arising from the true lumen. Using a fenestrated graft then means using a technique to perforate the dissection flap in order to switch from one lumen to the other. This can be achieved by puncturing the dissection flap with a needle (e.g., TIPPS needle) or the stiffer backside of a wire. Guiding sheaths can be used for more support. After ballooning, the channel can be used to insert and deploy a bridging covered stent. Initial experience: Experience is growing after a few initial successes, because more patients do present with post-dissection aneurysms. The grafts used are usually grafts including both fenestrations and downward-facing branches. In some cases the celiac artery can be sacrificed because of a high-grade stenosis. This allows using a triple fenestration graft with three fenestrations for the superior mesenteric artery and the two renal arteries. This design only needs a double femoral approach and no upper approach. In the first 10 patients, the technique was successful, with a good clinical outcome. No mortality or major morbidity was noted. However, endoleaks were seen in five patients. Not surprisingly, type II endoleaks are probably to be expected as the graft fills the true lumen and compresses the false lumen only slightly. Indeed, the chronic dissection flap is usually fairly thick and stiff and will not allow for complete obliteration of the false lumen. Whether a type II endoleak in the false lumen of a chronic dissection aneurysm is persistent and requires additional treatment in the future remains to be determined. To learn how to place branched/fenestrated endografts in chronic thoracoabdominal dissection 3. To review the data of branched/fenestrated endografts in chronic thoracoabdominal dissection Introduction: Type B dissections are usually classified into acute and chronic (more than 2 weeks from the onset of symptoms). For complicated acute Type B dissections, urgent treatment is indicated. Acute complications include rupture, abdominal end-organ ischemia (such as liver, bowel or kidneys), lower limb ischemia, and although rare also spinal ischemia. Pleural effusion as a precursor to rupture and persistent thoracic pain are more and more also considered an indication for treatment. Uncomplicated type B dissections can be treated medically, but it seems appealing to cover the entry tear with a stent-graft in order to promote thrombosis of the false lumen, and subsequent remodelling of the aorta. Longterm results of medically treated uncomplicated type B dissection may indicate that treatment in all cases is unnecessary. Estrera et al. reported an early mortality in medically treated uncomplicated type B dissection of only 1.2%. 1 Winnerkvist et al. reported the long-term outcome in 66 patients who were all treated conservatively at the time of onset. 2 Over a 10-year period, 82% remained free of dissection-related death. Only 15% of patients had a chronic dissection aneurysm exceeding 6 cm in diameter. A randomized controlled trial (ADSORB) has addressed whether acute uncomplicated type B dissections would benefit from preventive endovascular treatment, and results are awaited soon. Clearly, identification of a subgroup of patients with increased risk of aneurysm formation that would therefore benefit from early endovascular treatment would be beneficial. Sueyoshi et al. showed that patients with a perfused false lumen demonstrated continued aortic expansion. 3 Songet al. showed evidence that an initial false lumen diameter that exceeds 22mm in the thorax had significantly reduced event-free survival. 4 Endovascular repair of aneurysms has proved to be a viable alternative to open surgery. 5, 6 Evolution towards fenestrated and branched stent-grafts made it possible to treat all types of aneurysms involving the visceral arteries. Results are consistent, and durability of both fenestrated grafts for complex abdominal aortic aneurysms, and branched grafts for thoraco-abdominal aortic aneurysms (TAAA) have been demonstrated. [7] [8] [9] [10] [11] [12] Treating chronic Type B dissection aneurysms remained contraindicated for a longer time but slowly first attempts and later literature reports emerged. 13 Treatment indication for chronic Type B dissection: The main and probably only indication to treat a "chronic" Type B dissection is aneurismal degeneration. This aneurismal enlargement usually occurs over years and not within a couple of weeks. All other potential indications for treatment after the initial acute Type B dissection are relatively rare (late malperfusion, impending rupture or pleural effusion, persistent pain). In addition they occur rather soon after initial onset of symptoms. Therefore, it must be understood that this report discusses the late complication of acute type B dissection rather than the early complications that can occur later than two weeks from onset. A definition including sub-acute Type B dissection may be needed to fill the gap between the acute dissection and the "true" chronic dissection. If one accepts that treating a chronic Type B dissection is treating a post-dissection aneurysm, it logically To learn how to perform the chimney technique 3. To learn the data on outcomes of the chimney technique Introduction: Standard aortic stent grafts rely on a seal in an infra renal neck and transrenal fixation. In short or poor-quality necks, failure rate of EVAR is high. Fenestrated or branched endografts (FBE) have been developed to treat short or no-neck aneurysms with promising medium-term results. However, anatomical limitations, cost, long planning and manufacturing times can limit applicability. The chimney technique (Ch-EVAR) involves placement of a stent or chimney graft (CG) parallel to the main endograft to extend the proximal sealing zone while maintaining side branch patency. Originally developed as a bail out for misplaced endografts to rescue a covered side branch, planned Ch-EVAR has evolved as a potential alternative to FBE in certain situations. This has mainly been to extend the landing zone for short-necked thoracic and abdominal aortic aneurysms. However, modified Chimney-Sandwich techniques have been described to treat thoraco-abdominal aneurysms and to maintain internal iliac patency as an alternative to iliac branch grafts. Principles of the Technique: Ch-EVAR involves placement of single or multiple stents parallel to the main endograft to extend the proximal sealing zone while maintaining side branch patency. Snorkels are covered stents that extend above the proximal edge of the endograft while periscopes extend below the distal edge. Sandwich grafts are covered stents positioned in between two main body components to maintain side branch patency mid graft. There is a potential for gutters between the chimney and main grafts and therefore an endoleak channel may occur .The use of more conformable aortic stent grafts and increased graft oversizing may reduce this. Technique: The target vessels (usually renal arteries) are catheterised from the left brachial approach. After exchange to a stiff 0.035 guidewire a 7 F sheath (70-90cm) is placed into the renal artery and a covered stent positioned inside the sheath. Usually covered balloon expandable stents V12 atriums 38mm long or fluency stents 40mm long of appropriate diameters are used. The aortic stent graft is then fully deployed across the target vessel and any top cap retrieved. The renal sheath is then retracted while renal stents are stabilised and then ballooned into place. Once satisfactory CG position and flow are confirmed at angiography simultaneous ballooning of the aortic and chimney grafts is performed to mould the sealing zone .Guide wire access into the CG is maintained until the remainder of the aortic stent graft is deployed and final angiograms performed. If multiple CGs are needed simultaneous access from the right brachial artery will be required. A bare-metal self-expanding stent can be used to reline the covered stent if there is a risk of kinking. Pre procedural imaging of the aortic arch vessels and thoracic aorta is recommended. Tracking large sheaths around the aortic arch and into the target vessels can be problematic as with thoraco-abdominal branch graft procedures and the use of co-axial sheaths and a flow of the spine and prevent paraplegia. Obviously type I endoleaks at the level of the target vessels are also an inherent risk, as it is sometimes difficult to gauge the length of the covered stent needed. In one case the length of the bridging covered stent proved too short, resulting in a type I endoleak. This was treated with a longer bridging covered stent in a second intervention. Interestingly, a high proportion of patients have been treated with a stent-graft in the acute setting of the Type B dissection. In all of them, the proximal entry tear was well taken care of, with a good sealing in the proximal descending aorta. Nevertheless, the lack of distal sealing did result in a growing aneurysm, finally requiring treatment. The advantage of the already present proximal stent-graft is the availability of a long proximal neck. The distal landing zone usually varies between the distal abdominal aorta, to the common iliac arteries, or even to the external iliac arteries. In our series, two patients with initial large type II endoleaks had a complete resolution of the endoleak with disappearance of the false lumen on computed tomography at one year. This may be an indication that initial type II endoleaks filling the false lumen may fade away with remodeling of the aorta. Conclusion: Fenestrated and branched stent-grafts are certainly an option to treat chronic post-dissection aneurysms, as open treatment usually presents with high-risk or no option at all.

C RSE

Abstract Book deployed into the left ventricle for zone 0 pathologies. The major acute complications include retrograde dissection (with rupture, haemopericardium, etc), stroke, and renal impairment. Interestingly, paraplegia is rare after endoluminal treatment of aortic arch disease. High-risk patients for paraplegia (planned extensive aortic coverage, previous aortic surgery) may have prophylactic cerebrospinal fluid drainage -other cases would undergo post-procedural drainage in the event of a paraparesis.

There has been a change in the approach to left subclavian artery revascularization when coverage of the artery ostium is necessary during thoracic endografting. Rather than routine pre-procedural left subclavian artery revascularization for all cases, a selective approach is recommended for higher-risk patients. Left subclavian coverage with prophylactic carotid-subclavian bypass should be considered in patients with the following: Mortality was similar in both groups but morbitity lower in the Ch-EVAR group.GG patency was 84% at 12months. Some series report high complication rates from brachial access including strokes, especially when multiple CGs are needed as this requires bilateral brachial access. Other significant complications reported include renal artery perforations and renal infarctions. Conclusions: Ch-EVAR is an emerging technique to extend the proximal sealing zone in short-neck aneurysms in the acute setting or when FBE are unavailable or anatomically unsuitable. It involves the use of readily available equipment but still requires a short neck below the chimney to achieve a seal. In the short-term chimney graft patency is surprisingly good; however, reported type 1 endoleaks in some series are high and there is concern about long-term durability and chimney/endograft compatibility. Ch-EVAR is worthwhile considering alongside all treatment options in certain anatomical and clinical situations. Disclosure I have been paid fees for speaking and proctoring by William Cook Europe and for speaking, proctoring and consulting by Lombard Medical.

Will there be a practical branched/fenestrated solution for aortic arch disease?

Radiology, Auckland Hospital, Auckland, New Zealand.

1. To learn about new concepts for treating aortic arch disease 2. To learn how to treat aortic arch disease with current devices available 3. To discuss the data on available devices for treating aortic arch disease In the past decade, endoluminal repair of descending thoracic aortic pathologies has become common with proven advantages over open surgery. However, endografts require an adequate zone of normal aorta as a proximal landing zone to seal. Pathologies involving the aortic arch (including aneurysmal degeneration, dissection and traumatic injury) often lack an adequate proximal sealing zone. To deal with this, several endovascular techniques have been developed, including branch artery occlusion, debranching with extraanatomical bypass, chimney techniques as well as fenestrated and branched endografts. These will be reviewed. The proximal landing zone of an endograft treating aortic arch disease can be categorized by the Ishimaru Classification:

arch arteries including the innominate artery the left common carotid and subclavian arteries

The aortic arch is a very challenging environment to deploy an endograft. The great hydrostatic systolic pressures and afterload effects on the left ventricle are significant issues. Temporary cardiac arrest or rapid pacing is often used. Precurved stiff guidewires and flexible sheaths are extremely helpful in delivering these grafts. Guidewires may be looped in the ascending aorta for zone 1/2 pathologies, but To discuss what is the role of imaging in patient selection 3. To clarify the complementary role of ablation in the management of lung cancer as compared with other treatments Lung tumour represents the neoplasm with the major incidence and mortality rates worldwide (1.35 million new cases annually and 1.18 million of deaths), with the highest frequency in Europe and the United States of America [1] . In Italy, from 1998 to 2002, lung cancer was found to be the fourth tumour in frequency among cancers diagnosed in women (4.6% of all female cancers) and third in males (14.2% of all male cancers), establishing the most frequent cause of cancer death in men [2] . Among the different histological types, the most common are non-small cell lung cancer (NSCLC) and among these, adenocarcinoma is the most frequent (30-40%) [2, 3] . The lung is a frequent site also for metastases, which occur in 30% of all cancers, especially from haematogenous spread. Patients with non-small cell lung cancer (NSCLC) have a median survival of 6 to 8 months, and 1-year survival rate for only 10-20% [4] . The standard treatment for stages I, II and IIIa NSCLC is surgical resection, the unique approach with cure prospective and long-term survival [5] . Radiotherapy and chemotherapy are frequently used as adjuvant and/ or neoadjuvant therapies to surgery [6, 7, 8] . However, only about one-third of the patients are eligible for surgery, and most of them have advanced disease at diagnosis [9] . Almost all patients have some comorbidities as poor pulmonary function, poor clinical conditions or advanced age and do not have sufficient clinical reserves to withstand a lobectomy or pneumonectomy [10] . Therefore, these patients are often treated with radiation therapy or palliative treatment [11, 12] . Unfortunately, chemotherapy and external beam radiation therapy did not influence significantly the outcomes of patients with unresectable disease; in addition, greater efficacy in these therapies is often accompanied by significant toxicity, especially for patients with associated comorbidities. There is no gold standard treatment for inoperable patients both, thanks to their advanced disease and also owing to high surgical risk due to poor clinical conditions [13] . Therefore, the use of alternatives to conventional therapies such as percutaneous ethanol injection (PEI), thermal laser ablation, cryoablation, radiofrequency (RFA) and microwave (MWA), proves to be a good treatment option. Among these different therapies, the RFA has enjoyed a longer application and greater success, and was promptly introduced into clinical practice [14, 15] . The latest advancements in minimally invasive treatment for lung cancer are the MWA, which offer many of the RF benefits associated with theoretical advantages [16] . Rose et al. [17] proposed guidelines for papers about lung tumours thermal ablation. Patient selection was emphasized once thermal ablation is not a gold standard treatment of lung cancer; the patient selection criteria should always be clearly described. The first point is regarding biopsy; that should always be performed to confirm the diagnosis of malignancy [18] . In our study, biopsy was performed in all patients as for the majority of papers in Literature, though some of them use only clinical evidence as disease confirmation in case of metastatic lesions histologically known or recurrences, without performing biopsy [19] [20] [21] [22] [23] [24] [25] [26] [27] [28] [29] [30] . Coagulation disorders may exclude patients from selection for Tim Chuter has pioneered much of the early branch graft work in the aortic arch. He believes the complexity and stroke risk of branched endografts in the aortic arch increases exponentially with each additional branch. He therefore proposes that the safest strategy is to limit the stent graft to a single side branch and use extra-anatomical arterial bypass. For zone 0 coverage, Chuter developed with Cook Medical a bifurcated graft delivered the innominate or right common carotid arteries. A graft extension (e.g. Cook Zenith TX2) through the arch and into the descending thoracic aorta can then be delivered from the groin. This technique avoids a sternotomy and aortic clamping. Subsequently, Cook has developed internal/external branch grafts for the aortic arch. These devices allow branch grafting of multiple arch vessels. The internal branches allow treatment of non-aneurysmal aortic pathologies. None of these devices from Cook are available commercially as yet and <50 branch graft cases have been performed worldwide to date. Other companies such as Medtronic and Gore have branch graft prototypes in development and these will be demonstrated.

For patients with very proximal ascending aortic and aortic valve pathologies, hybrid procedures utilizing an elephant trunk endograft with extra-anatomical bypass and graft extension from below can be utilized. This can be done as a single-or two-stage repair.

Surgical repair of zone 0-2 aortic disease usually requires cardiopulmonary bypass and deep hypothermic circulatory arrest. 30-day mortality is quoted from 0 to 16.5% and for stroke from 2 to 18%. Patel et al. (University of Michigan) reviewed their 17-year experience of open arch reconstruction, involving 721 patients, and reported a 30-day mortality rate of 5% and stroke rate of 4.7%. There were no reported cases of paraplegia. The results were durable with an actuarial 10 years survival of 65%.

Endoluminal repair of aortic arch pathologies remains challenging. There has been much progress made but a commercially available device is still not available. The best strategy is likely to be a single-branch device that can be combined with debranching and extra-anatomic bypass procedures to treat a range of aortic arch pathologies. 16 thermal ablation therapy [31] [32] [33] , as reported in 9 papers, and some of them defined also an maximum INR value. CLINICAL CRITERIA: All patients who are supposed to undergo ablative therapies should not be subjected to conventional treatment or should have not answered to these treatments [32, 34, 35] . This decision is usually undertaken by a multidisciplinary team; in our case, the reference clinician (oncologist or pneumologist), the thoracic surgeon, the interventional radiologist and the anesthesiologist. Of the 24 studies analyzed, this information is found only in 12 studies [13, 23, [27] [28] [29] [30] [36] [37] [38] [39] [40] . The clinical criteria fundamentally consist in poor lung function (for which most centres establish an inferior limit of 1 L,), the chronic obstructive pulmonary disease, and the different comorbidities changeable from Centre to Centre, responsible, in most of the cases, for ascertaining inoperability; the detected comorbidities were cardiopathies, haepatic cirrhosis, chronic renal insufficiency, hemodynamic disorders, multiple sclerosis, aortic aneurysm, carotid stenosis, congestive heart failure, low "performance status", stable angina, valvular heart disease and high cardiac risk [13, 19, 20, 24, [26] [27] [28] [29] [30] 36, 39, [41] [42] [43] [44] [45] [46] . It is paramount that the decease risk for comorbidities do not exceed the decease risk for the tumour; otherwise, the patient automatically cannot be considered a candidate for thermal ablation [47] . Advanced age is considered in few studies [13, 21, 22, 47] as an inoperability criterion; in our study it is indirectly considered. The employment of thermal ablation for lung metastasis is widespread and shows excellent results [13, 20, 48, 49] , in accordance with our study results. None of our patients underwent the thermal ablation procedure for surgical refuse; this "inoperability" reason was present in 18 [19, 20, 22, 23, [26] [27] [28] [29] [30] [36] [37] [38] [39] [40] [41] [42] [43] [44] [45] of the 24 reported studies. RADIOLOGICAL CRITERIA: Radiological selection criteria are lesions diameter, disease extension (number of lesions per hemithorax and extrapulmonary lesions) and adjacency to large vessels (>3 mm), heart and trachea [9, 49, 50] . The lesion diameter should not overcome 6cm if with a curative purpose, and when lager than 3 cm, it is preferable the MWA employment [20] [21] [22] [51] [52] [53] [54] [55] [56] [57] . There are some divergences about the maximum number of lesions accepted for hemithorax; some centres accept until 9 lesions, our centre until 4 [34,35] . Extrapulmonary lesions are another divergence issue; some centres consider it as an inclusion criterion [13, 19, 28, 30, 32, 34, 3644, 58, 59 ] and other ones, as an exclusion criterion [27, [40] [41] [42] 46, 60] . Our centre understands that, if controlled and recent, the extrapulmonary lesion does not exclude thermal ablation therapy, even if with palliative purpose, in accordance with findings of other studies [9, 32, 34, 58, 59] . The majority of the Centres exclude the patients with lesions in adjacency to heart, large vessels and trachea [13, 19, 22, 29, 30, 38, 39, 47, 60] ; some studies report central ablations with success [60] as our study, which reports the success of a case in adjacency to supra-aortic trunks. In our study, there is the choice between RFA and MWA. Multiple are the advantages offered by microwave technology: lager volume of necrosis, reduction of procedure duration, mayor temperature to target lesions, the possibility to employ multiple antenna simultaneously, efficacy in lesions with cystic component and/or in adjacency to vessels > 3cm and less intraprocedural pain [49, 51, 61, 62, 63] . For minor lesions (< 3 cm) not close to vessels > 3 mm, it is immaterial whether one or the other technique [51] is employed. The failure of conventional therapies is another indication to thermal ablation [13, [20] [21] [22] 24, 26, 29, [37] [38] [39] 41, 42, 45, 48, 59, 64] . The refusal to undergo surgery [31, 35] is another important thermal ablation criterion related in Literature despite there being no cases in our study.A clear exposition of selection criteria is still not a routine for Authors. For that reason is not momentarily possible to establish unambiguous thermo ablative therapies indications criteria. Whereas, it is necessary a randomized controlled study to comparing RFA and MWA to evaluate the best choice for the patient. In a near future, could be interesting to perform a randomized study comparing surgery and thermal ablation. Kobayashi K, et al. (2006) Percutaneous CT-guided radiofrequency ablation of pulmonary malignant tumors: preliminary report. Intern Med 45 (2) 

C RSE CIRSE Abstract Book larger margin is advocated in primary lung cancer. There is a delay of several minutes between the delivery of heat and the development of the GGO. CT fluoroscopy at 1 minute intervals is used to monitor the ablation process. In areas where a very careful ablation is required, I will treat for a period of time and then wait a few minutes to see the full effect of the GGO before deciding where more treatment is required. Intermittent spiral CT for multiplanar evaluation of the ablation effect is also useful.

Detailed knowledge of the device used is critical for good ablation. There is substantial variability not only between technologies but also between devices both in the treatment parameters and in the resultant ablation geometry.

Many centres use expandable devices available in various sizes with a manufacturer recommended treatment protocol that variously monitors end temperature or changes in impedance to direct the ablation. Straight electrodes are more versatile than expandable devices and can be deployed into more areas of the lung. Expandable devices are generally not advocated adjacent to the diaphragm, pleura or central structures. Two or 3 straight sequentially activated electrodes are required for larger tumours.

There are several different devices on the market working at different frequencies, different powers, and with no, gas or water cooling. They vary markedly in their efficacy and their usage and it is paramount that the interventional radiologist understands the device he/she is using. For example, the high power Microsulis device can produce very large, tear shaped, areas of ablation in a short time. As a result short treatments of 20 -30 s are recommended followed by a delay of several minutes to see the treatment effect. The 3.7 cm CoVidien MW device produces a long, narrow ablation and is best used as a multiple applicator treatment when simultaneous activation of two or three antennae can produce very high temperatures and a more spherical ablation. The 2-cm CoVidien antenna also produces a more spherical ablation and is generally used in smaller tumours.

For most tumours, multiple cryoprobes are required. The long treatment cycle using a double or triple freeze thaw cycle (7) means that in practice multiple probes are positioned at the start of the treatment and usually a single treatment cycle is performed. This is in sharp contrast to the other thermal techniques which are often reiterative and therefore more versatile. Cryoablation is associated with less intra-procedural and post-procedural pain but with more a longer period of non-specific systemic malaise. There is a higher incidence of haemorrhagic complication and no ability to cauterise therefore I tend to avoid cryoablation in patients with a haemorrhagic tendency.

Whenever possible the treating needle should be heated prior to removal to minimise the possibility of tumour seeding.

Perhaps surprisingly pneumothorax is not inevitable, in fact, it has a reported incidence of less than 40%. Drain placement will depend on the size, speed, timing of the pneumothorax and the patients underlying pulmonary reserve. If a moderate pneumothorax develops early in a treatment it may be necessary to position a drain and place on mild suction (-1 to -2 kPA) to allow continued needle placement and to finish the treatment. Pneumothorax may develop after removal of the needles so it is worth a repeat check 5 minutes after needle withdrawal. In patients with good respiratory reserve, I place drains for pneumothoraces >30-40%. Repeat chest X-rays are performed at 4 hours. Most pneumothoraces resolve after a short period of intercostal drainage and the majority of patients are discharged on day 1. Occasionally low level suction is required. Prolonged air leak is unusual and is mostly seen in patients with

Special Xray, UCH, University College London Medical School and Hospitals, London, United Kingdom.

Learning Objectives 1. To describe techniques and devices used in lung ablation 2. To describe the imaging findings during and after lung ablation 3. Tips and tricks in challenging cases Lung ablation is the fastest growing area in tumour ablation, a recent spate of technical and practical enhancements has resulted in ever more patients who can be treated. Yet, there are still not enough centres offering ablation and still many untreated patients who would have benefited.

Local success of ablation depends on tumour size and location. Ablation has been successfully applied to <3 -3.5cm tumours, either primary or secondary (1, 2) . Larger tumours are usually ablated in conjunction with another therapeutic modality such as radiotherapy (3). Location next to >3 mm diameter blood vessels or bronchi can, but not necessarily, result in incomplete ablation (4) . Local recurrence is higher in primary lung cancer than in metastases and so a larger ablative margin is recommended. Standard work up prior to ablation includes full staging, documentation of the medical history, specific questions about previous thoracic events such as surgery and asthma/COPD, lung function testing and routine laboratory work. CT, MR and/or PET are used to ensure full knowledge of all tumours; size, location and accessibility. The optimal candidate for ablation has small volume disease, with either no or treatable extra-pulmonic disease. Radiofrequency, laser, microwave and cryoablation have all been used successfully in lung ablation. HIFU is reserved for superficial chest wall or pleural-based masses. Regardless of the ablation technology, CT guidance is used to introduce needles into the tumour with the aim of producing complete 3-D coverage of the tumour and a margin. The advent of CT fluoroscopy allows real-time, mm precision in needle deployment. Choice of needle positioning will depend on the geometry of the tumour and the geometry of the thermal effect.

The patient should be positioned to allow access to all areas to be treated, for multiple tumours requiring both anterior and posterior intercostal approaches the lateral position is often the best. Needle entry is chosen to avoid vessels and fissures and to minimise the length of aerated lung to be traversed (5) . Tumours are heavier than the normal lung parenchyma and will change position with gravity. The retrocardiac tumour that appears easy to treat in the supine position can fall forward to rest on the posterior wall of the heart in the prone position. To a degree the change in the relative position of the tumour can be anticipated, alternatively scans can be performed in the anticipated treatment position to optimise the approach.

General anaesthesia is required for long treatments involving ablation of large or multiple tumours and for the treatment of tumours in painful locations, for example adjacent to the diaphragm or pleural surface. Conscious sedation and local anaesthesia are adequate for small treatments and for parenchymal tumours. Cryoablation is less painful than the other thermal techniques and can be used with conscious sedation in larger tumours or painful locations in patients who are not fit for anaesthesia.

During ablation I use the development of a penumbra of ground glass opacification (GGO) around the tumour to define the ablation zone (6) . Several studies have shown that the outer 5 mm of the ground glass region contains inflammatory and viable tumour cells so a minimum margin of 5 mm is required in metastatic disease. A

SS/FC/HL/HTS/CM rounded by air can be harder due to high impedance. Maximising contact of the soft tissue of the tumour with the centre of the active electrode will optimise the impedance profile and facilitate deposition of RF energy. Impedance can be reduced by performing a hot tip ablation prior to a cooled ablation or injecting very small amounts of N/Saline around the active electrode. Microwave or cryoablation is less vulnerable to this problem. Treatment of tumours in contact with blood vessels is associated with a higher local recurrence rate. Sometimes it is possible to position the patient such that the tumour is no longer in contact with a blood vessel or to manipulate the needle to move the tumour away from the vessel for the period of the treatment. Alternatively, "overtreatment" next to a vessel or on both sides of a vessel can negate the cooling effect and result in a complete ablation. 

Dept. of Interventional Radiology, Institut Gustave Roussy, Villejuif, France.

Learning Objectives 1. To present the results of RFA for primary and secondary lung cancer 2. To give an update on the complementary role of RFA with other treatments 3. To present the complications of RFA for lung cancer RFA provides 80 to 90% complete ablation at 2 years for tumors of less than 2 cm in most reports. The rate of complete ablation decreases when size of the tumor increases to be around 60% for tumors measuring 4 cm. For primary NSCLCC, the treatment is applied in non surgical candidates and the overall survival reported after RFA is in between 36 and 58%. The 3-year overall survival is reported to be better for small-size tumor (stage 1A) than for Stage emphysema/COPD and/or when a large ablation has been performed across a fissure. There is a small incidence of delayed pneumothorax post-ablation so I recommend a repeat chest X-ray 7 days post-procedure in all patients.

The ablation cavity can become infected even several months after the procedure. This is particularly true if there is communication to a bronchus (a cavitating ablation zone) and when patients have underlying lung disease and recurrent chest infections. Prompt introduction of oral antibiotics usually resolves the situation without recourse to drainage but infected cavitating ablation zones, as with other cavitating lesions in the lung (aspergilloma/TB), can result in haemoptysis secondary to recruitment of the bronchial arterial circulation. In this situation haemoptysis can be massive (>500 ml) and potentially fatal. Small volume haemoptysis is common in the first few days post-ablation, but if delayed, fresh haemoptysis occurs, particularly if associated with evidence of infection, CT angiography for evaluation of the ablation zone and the bronchial/intercostal circulation with a view to prompt arterial embolisation are required.

Phrenic, recurrent laryngeal, sympathetic chain and brachial plexus injury have all been described post-ablation (8) . Knowledge of the neural anatomy is required and it is necessary to ensure that these structures are protected from thermal injury or the ablation should not be performed.

The ablated zone becomes homogenous over the first few weeks, sometimes starting with the development of a contiguous outer rim. A smooth, thin, enhancing rim of granulation tissue is common in the first few weeks. Subsequently, the dead ablated tissue shrinks/ stabilises and may reduce to a linear scar. Tumour recurrence is readily identified as solid, nodular enlargement of the ablation zone, or a change in the shape of the ablation zone secondary to growth in one area. Careful comparison to previous imaging looking for interval change allows the early diagnosis of recurrence and repeat ablation. Communication to a bronchus will result in cavitation. Infection can be identified by enlargement of the ablation zone which often fills with fluid and gas bubbles and the development of a smooth, enhancing outer rim. There may be oedema in the surrounding parenchyma. Rupture of the abscess into the pleural space can result in effusion/empyema. Follow-up CT scans at 2-6 monthly intervals are routinely performed in all patients and the ablation zone can be assessed at this time. The interval between scans will depend on the type of tumour, shorter intervals for primary lung cancer and most sarcomas, longer intervals for low grade tumours, e.g. adenoid cystic metastases. Tumour recurrence usually shows enhancement relative to the ablated tissue so pre-and post-contrast imaging makes it easier to interpret the post-ablation appearances. A negative PET can be reassuring in a previously PET positive lesion although the resolution of PET and the acquisition of data during quite breathing mean that CT has much better resolution and is more accurate in small tumours. Focal, nodular, high SUV FDG uptake suggests tumour recurrence. PET scans may show low grade FDG avidity secondary to inflammation post-ablation and this can persist for months or years. PET findings should be correlated with the CT imaging to avoid misdiagnosis of tumour recurrence. Adjunctive measures Ablation next to a vulnerable structure can only be performed if the vulnerable structure is protected. Various techniques are available. I use air or glucose to provide a buffer between the ablation and the vulnerable structure. The patient's position may need to be modified, e.g. treatment of a central tumour may best be achieved with the tumour-bearing lung side down such that injected air will track along the non-dependent pleural surface producing a buffer between the ablation and the mediastinum. RF ablation of very small tumours where the ablation needle is sur-S100 C RSE

Abstract Book ses bronchial and/or airway stenosis or vessels are good target to treat by transarterial approach. Patients who cannot be treated by standard therapies with any causes including poor general condition, allergic reaction for anticancer drugs were also indicated. A total of 30 patients with mediastinal lesion who were treated in our institution were evaluated. Mean age was 60 years. Reduction in tumor size was evaluated by RECIST criteria. The clinical efficacy was assessed by reduction of symptoms. Treatment methods: The specific techniques for the treatment of lung cancer were composed of microcatheters, diagnostic modalities and spherical embolic material. The microcatheter provides safe and selective access to the peripheral arteries to the mediastinal arteries such as bronchial, internal thoracic and inferior phrenic arteries. The angiography suites combining CT scanner provided us excellent images for each blood supply to the lesion. CT scan during selective infusion to the target lesions helped us to avoid non-target embolization of normal organs or spinal circulation. A small dose of anti-cancer drugs, including cisplatin, docetaxel, antracycline, fluorouracil or their combination was infused. Embolization by spherical embolic materials (HepaSphere, QuadraSphere) was followed after infusion of drugs. Endpoint of embolization was elimination of tumor vasculature. After treatment we followed up patients with CT examination in every month and repeated the same procedure in case of necessity. Results: Lung cancer was basically hypervascular. Nodular lesions in the lung field were enhanced by bronchial arterial infusion CT in 90% of cases. The lesions infiltrating to the mediastinum were usually fed by arterial circulation through bronchial, intercostal, branches from subclavian artery and inferior phrenic arteries. No serious complication such as spinal cord injury or systemic embolization was experienced. Detection of shunting from artery to pulmonary vein was very important to avoid systemic embolization. Minor complications were mainly caused by the anticancer drugs. The tumor reduction in a month was CR; 0%, PR; 13%, SD; 87%, PD; 0%; however, more than 10% tumor reduction was obtained in 50% of patients. The clinical symptoms were improved in 14 out of 21 patients (67%). Reduction of respiratory distress or control of hemoptysis was usually controlled immediately after the procedure. The obstructive pneumonia was also well controlled by re-opening effect of bronchial air-way. Conclusion: Transarterial management of lung cancer patients who had mediastinal infiltration or lymph node metastases was well controlled in reduction of symptoms by transarterial approach. The treatment procedures were feasible in almost patients. The adverse effect caused by the procedure was negligible. The role of interventional radiologists was tremendously high to offer treatment to advanced lung cancer patients.

Medical advisor for Merit Medical in Salt Lake City IB or II NSCLC. Comorbidities and patient selection have high impact on survival. For lung metastases, there is growing evidence of survival after RFA, close to what was reported in large surgical series even if no comparative data exist. Age, disease-free interval, tumor size and tumor numbers which have been reported as predictive of survival after surgical metastasectomy are as well independent predictors of survival after RFA of lung metastases. The ideal candidate has less than 3 tumors of less than 3 cm. One of the beauties of RFA is that it can be easily repeated in case of occurrence of new metastases which is difficult with surgery due to the aggressiveness of the procedure. The same applies to stereotaxic radiation therapy where multiple irradiation results in toxicity to lung parenchyma, skin or mediastinum. The role of RFA is debated and its role in conjunction with chemotherapy and targeted therapy has to be evaluated. Follow-up with CT led to some delayed discovery of incomplete treatment, 4 to 12 months (mean±SD = 7.66 ±2.77) after RFA.

PET-CT appears promising to provide early evaluation of treatment response, but timing of PET after ablation is a key factor because G6PD uptake is highly increased 1 to 3 weeks after ablation with an SUV ratio of 5 and higher between RF ablation zone to muscle. Side effects and complications of RFA remain minor and allows treating patients with poor pulmonary function and comorbidities. Minor changes are found in patients with larger tumors or emphysema.

After RFA there is no or very minor changes in post-ablation respiratory test and consequently major benefit of lung RFA to treatment of NSCLC is that it allows curative treatment in non-surgical early NSCLC. Moreover, this excellent tolerance allows safe treatment of single lung patients. New ablation techniques are under evaluation to overcome major limitation of RFA, namely heat sink effect close to large vessels or steep decrease in efficacy for tumor larger than 3 to 4 cm. These techniques include microwave ablation that allows to destroy larger tumor, cryotherapy that is less painful and allow treatment of tumor close to the pleura under conscious sedation, and IRE that due to non thermal destruction has specific features such as no heat sink effect, preservation of the vascular and tracheo-bronchial tree and nerve. The exact role of each of these ablation techniques has to be further evaluated in the spectrum of local treatment of lung tumors. No comparative data exist with other local therapy, namely stereotaxic body radiation, and such studies are needed to have evidence-based medicine supporting the use of lung RFA in primary and metastatic disease. Disclosure Lecturer for Boston Scientific; Lecturer for Covidien

Embolization: is there a role?

Radiology, Gate Tower Institute for Image Guided Therapy, Izumisano, Japan.

1. To define the rationale for embolization/chemoembolization in lung cancer 2. To describe techniques, embolics and drugs used in lung embolization/chemoembolization 3. To give an update on results and complications Introduction: Patients with primary lung cancer, who have recurrence after standard therapy including radiotherapy, systemic chemotherapy and surgery, are usually not indicated to any kind of treatments. The best supportive care is only one treatment we can offer to them. But recent improvement of techniques for interventional radiology makes it possible to access the lesion transarterially. We have been trying to manage lung cancer patients with clinical symptoms by targeting the lesions which threaten patients' life or impair patients' QOL. Patients: Mediastinal invasion or lymph node metastasis which cau-S101 CIRSE 2012 SS/FC/HL/HTS/CM

Institute of Radiology, University of Turin, Orbassano, Italy.

1. To describe the techniques of RF ablation of the kidney 2. To present the imaging problems before and during ablation 3. To present results of RF ablation for renal tumours (series and trials) Patient selection for renal ablation (RA), e.g. RFA and cryotherapy (other image-guided percutaneous techniques, such as MWA, laser ablation and high-intensity focused ultrasound, are still experimental) should include patients who are poor operative candidates, as for renal insufficiency and/or comorbidity, and patients at high risk for the development of additional tumors (i.e. hereditary RCC), but RA is also an evolving nephron-sparing option for other indications (e.g. small tumors in transplanted kidneys), up to be extended to healthy patients with cortical neoplasms ≤3 cm. In these cases, comparison with surgery shows that RA provides lower complication rates and costs. Whenever possible, a pre-treatment biopsy should be carried out before RA, except for hereditary tumors. Many different devices can be used to perform a RA; particularly, several applicator types (mono/bi/multipolar; internally cooled or openperfused; single electrode-needle or multitined expandable electrodes) are available for RFA; also, there are different algorithms to RF deployment, based on tissue impedance or monitored temperatures. In recent years, MWA is growing in tumor ablation, including RA. In our experience, mostly monopolar multitined electrodeneedle RF devices were used. Patients routinely undergo RFA during analgosedation. All image-guidance methods (US, CT, MR) can be used for RA, at the discretion of the operator. Due to a specific experience and the demonstration that US were not less favorable than other techniques, we usually perform US-guided RA, with CEUS as an adjuvant when small parenchymal hypovascular tumors (e.g., papillary RCC) are not well visible at non-contrast US. We choose CT guidance in selected cases, as deep posterior left mid-kidney tumors. In order to enhance the results and avoid complications, we use some tricks, as simple electrode torquing, transhepatic approach, hydrodissection (injection of nonionic solution through a fine needle inserted between the tumor and the organ deemed at risk, bowel firstly) or gas-insufflation. Moreover, pyeloperfusion (retrograde infusion of chilled water) is useful to protect the collecting system from thermal injury in case of central tumors, at the best during ureteroscopy. After RA, a dynamic CT/MR follow-up is recommended, although recent studies suggest that CEUS is accurate enough for early diagnosis of residual tumor and can be used as an effective alternative in patient with renal failure. The timing of the first scan should be at 1 month at the latest; to perform imaging at 6-month intervals after absence of viable tissue could be appropriate considering the slow growth rate of small RCC.

How to perform a typical cryoablation To provide an algorithm for treatment selection based on the results from available literature as well as on personal experience Percutaneous ablation of renal lesions should be performed only if a complete and curatively intended intervention can be achieved in a single session. For this, several aspects have to be considered. Characteristics of applied energy: Hyperthermal RF ablation causes coagulation necrosis by protein denaturation and carbonisation. For complete necrosis, RF ablation should be repeated once in an single probe position. Heat is painful and requires a thorough analgesia/GA. Cryoblation is applied by multiple thin (18 Gauge) probes cooled by high-pressure Argon gas utilizing the Joule Thompson effect. Cold does not hurt and requires only few analgesic efforts. The ice formation is perfectly visualized by US, CT or MRI. Tumor size: Many lesions smaller than 2 cm in diameter are benign or of uncertain histology. The natural history of small lesions and the biological situation of elder patients must be taken into account. Tumors which are ideally suited for thermal ablation are small, well delineated and oval or elliptic-shaped. Using RF ablation, tumor size should not exceed 3.7 cm in diameter, whereas lesion up to 4 cm and beyond can be covered by cryoablation. The shape of the resulting necrosis zone of each method must be taken into account for the planned procedure. Elliptic-shaped lesions are good candidates for RF ablation using single, monopolar needles. Using multitined cryoablation probes, also irregular or ovally shaped lesions can be covered well. Tumor location: If lesions grow exophytically or are located excentrically, complications or incomplete ablation are rare. Damaging of adjacent structures like bowel, adrenals or pancreatic tail can be avoided by CO2-or hydrodissection. Lesions in a central position, especially those with contact to the collecting system, must be treated carefully and should not be treated by hyperthermal ablation (and if, then after previous embolisation). Cryoabation is injurious to the collecting system and should be preferred in critical cases. Costs: RF Ablation requires a probe, a HF generator and electrical energy. Thus, it is simple and cost effective. Cryoablation is technically challenging and cost intensive. As it is significantly less frequently used than RF, the costs are at least more than double as high as for RF. Conclusion: RF is more frequently used and cost effective than Cryoablation, but is limited to small lesions in uncomplicated location. Cryoablation allows a perfect visualisation of the ice and allows treating larger and more centrally located tumors, but is more expensive. 

C RSE CIRSE Abstract Book some cases they may cause significant morbidity and even mortality in both adults and children. Radiologists may become involved in the care of these patients when imaging or imaging-guided therapy is requested; therefore, knowledge of the imaging and treatment of these patients is essential. In the past, the nomenclature for classifying these lesions was often used inappropriately, which caused considerable confusion. Several systems have been proposed to classify vascular anomalies so far. In 1982, Mulliken and Glowacki classified vascular anomalies as either vascular malformations or hemangiomas (1) . In 1993, Jackson et al. reclassified vascular anomalies according to their flow dynamics as low-flow or high-flow malformations (2) . In 1996, these classifications were adopted and expanded based on cellular features, flow characteristics, and clinical behavior by the International Society for the Study of Vascular Anomalies (3) . The main locations of vascular anomalies are the head and neck (40%), extremities (40%), and trunk (20%). Vascular malformations arise from dysplastic vascular channels and exhibit normal endothelial turnover and enlarge in proportion to the growth of the child. They do not involute and remain present throughout the patient's life. Conversely, hemangiomas are benign vascular tumors of infancy and childhood consisting of cellular proliferation and hyperplasia. They tend to be small or absent at birth and are characterized by a two-stage process of growth and regression. Most of the hemangiomas make invasive treatment unnecessary. Vascular malformations occur as a result of direct microscopic connections between arteries, veins, and lymphatic vessels without the normal capillary bed. The area of confluence is called a nidus, where arteriovenous shunting occurs. Vascular malformations can be classified as either lowflow or high-flow lesions; malformations with arterial components are considered high-flow lesions and those without arterial components are considered low-flow lesions. Multiple imaging modalities should be used to evaluate characteristics of the lesions. However, the most useful non-invasive imaging techniques are ultrasonography (US) and MRI. US coupled with color Doppler US allows initial assessment and provides valuable information about the degree of vascularity, but it has the disadvantage of a limited field of view, restricted penetration, and operator dependency. These disadvantages can be overcome with MRI, which allows determining the extent of lesions and the relationship to adjacent structure. In addition, time-resolved MR angiography provides information about the hemodynamics. Conventional radiography plays only a small part in the diagnosis. Phlebography and angiography are important for preoperative assessment and as a precursor to interventional procedure. Complete destruction of the nidus is the only potential cure. Sclerotherapy using different agents, such as absolute ethanol, polidocanol, n-butyl cyanoacrylate, etc., is accepted as an independent therapy. In addition, flow reduction might be necessary by means of embolotherapy depending on the type of vascular malformation. Sclerotherapy has also been implemented as a pre-or postoperative adjunct therapy. But, vascular malformations have a high recurrence rate because they originate from the mesenchymal cells at an early stage of embryogenesis. Improper treatment often rapidly stimulates quiescent vascular malformations, making the condition worse.

In conclusion, vascular malformations are rare and therefore necessitate a dedicated team by surgeons, internal medicine specialists, interventional radiologists, and psychiatrists for optimal care. US and MRI are useful tools to assess the extent and vascularity of the lesions. Conservative treatment is recommended in most cases, particularly for patients with tolerable symptoms. Patients with clinically significant symptoms might be treated by a combination of sclerotherapy, embolotherapy and surgery, which, however, is associated with a high recurrence rate.

Tips and tricks and how to manage complications

Department of Radiology, Southampton University Hospitals NHS Trust, Southampton, United Kingdom.

Learning Objectives 1. To discuss common complications and their incidence 2. To discuss the role of ancillary techniques in avoiding complications 3. To discuss the management of complications Image-guided renal tumour ablation is steadily entering established practice given increasing numbers of T1a (<4cm) renal tumours detected in an often elderly population. These tumours are of uncertain growth potential, but active surveillance can be onerous on both patient and radiologic resources and standard, or even laparoscopic, partial nephrectomy-with its risk of warm ischaemic injury, often in the setting of diminished renal function-also proving a problematic therapeutic option. All such tumours should be amenable to percutaneous, image-guided ablation with careful patient positioning and anaesthetic support. Formal general anaesthesia in a stable prone-oblique position over the course of 90 minutes to 2 hours permits time for diligent probe positioning and retroperitoneal, carbon dioxide gas and/or hydrodissection using 2% contrasttinted fluid. Thorough displacement of adjacent thermally sensitive structures then permits aggressive and adequate treatments with only very occasional subtotal treatments. Biopsy should be reserved until after probes are positioned to avoid the problem of obscuring haematoma. Treatment dosimetry is critical and cryoablation by virtue of the radiologically, well-visualised, iceball undoubtedly aids thorough and effective treatments. Particular care needs to be taken with regards to the thermally sensitive colon and pelvi-ureteric junction (PUJ). The latter should be anticipated prior to treatment and a retrograde ureteric catheter placed with warmed (or chilled) normal saline irrigated through the PC system to reduce the risk of PUJ injury. This should be replaced with a temporary ureteric stent at the end of the procedure for ~3 months. The author feels that routine prone-oblique general anaesthesia is essential to good outcomes from image-guided renal tumour ablation and requires full discussion with anaesthetic services for routine provision. reaction is less common. Polidocanol has an anesthetic effect, can cause hypotension and bradycardia, and reversible cardiac arrest has been reported after its administration 3 . To increase the volume and effect of detergent sclerosants, they may be mixed with gas to form a foam, for example polidocanol or STS may be mixed with sterile air or CO 2 . The use of foam has the advantages of an increased active surface area, greater adhesion, longer duration of action, and vasospasm induced by foam injection. Hence, enhanced efficacy can be achieved with lower volumes and lower concentrations of sclerosant, leading to improved outcomes in large VMs compared with liquid sclerotherapy. In the Tessari method, sclerosing foam is generated using a three-way stopcock and two disposable plastic syringes 4 . One syringe contains the liquid sclerosing solution and the other contains gas. The liquid-to-air ratio varies from 1:4 to 1:5. Foam is then generated by pumping the contents backwards and forwards between the syringes during 20 passages. In our institution 3% polidocanol is mixed with CO 2 at a liquid to air ratio of 1 to 4. Less than 5 mL of foam is used per injection for adults with an interval of 5 minutes between injections. The severity of pain on injection of ethanol during sclerotherapy warrants general anesthesia. However, detergent sclerosants only cause mild to moderate pain on injection and therefore patients can tolerate with intravenous analgesics. Direct puncture of a VM is usually performed with a fine needle under ultrasound guidance, and blood is aspirated to confirm that tip of the needle is within the lumen. Contrast medium is injected to observe the volume, shape, and blood flow of the VM and draining vein under fluoroscopy or digital subtraction angiography (DSA). If rapid outflow is observed, a tourniquet or manual compression is used to control the blood flow. Then sclerosant is injected under DSA. Several punctures may be needed to fill the lumen of multilocular lesions. If the VM lies within a limb, a compression garment can be applied to reduce the volume of thrombosed lumens after sclerotherapy, with the exception of the forearm where a compartment syndrome can develop (Volkmann contracture). Several studies have quantified the improvement in patient outcomes after sclerotherapy along with adverse events and side effects. Yakes reported symptom resolution in 90% of 36 patients with extremity VMs after ethanol sclerotherapy 5 . A complication rate of 10% was observed in over 600 procedures, which included blisters, skin necrosis, muscle contracture, nerve injury, cellulitis, deep venous thrombosis, pulmonary embolism, and cardiopulmonary collapse. Berenguer and colleagues have reported similarly positive outcomes of ethanol or STS sclerotherapy in 40 patients with craniofacial VMs: 75% of interventions were rated as curative or markedly improving symptoms 6 . In this series there were 20 cases (50%) of blistering, 11 cases (28%) of hemoglobinuria, 5 cases (13%) of deep ulceration, 3 cases (7.5%) of nerve injury and 3 cases (7.5%) of infection. Good results after polidocanol and EO sclerotherapy have also been reported without serious complications [7] [8] [9] . Cabrera and colleagues reported good results using polidocanol foam sclerotherapy for 50 patients, including those with Klippel-Trenaunay syndrome 10 

Department of Radiology, Kawasaki Hospital, Kawasaki Medical School, Okayama, Japan.

1. To review the technique of sclerotherapy in low-flow vascular malformations 2. To review the results of sclerotherapy in low-flow vascular malformations 3. To review the complications of sclerotherapy in low-flow vascular malformations and how to prevent them Sclerotherapy is a mainstay in the treatment of low-flow vascular malformations. This presentation focuses on sclerotherapy for venous malformations (VMs). Indications for sclerotherapy of VMs include symptoms such as pain, swelling, hemorrhage, or dysfunction of adjacent organs. Ethanol and detergent sclerosants (for example polidocanol, sodium tetradecyl sulfate (STS), and ethanolamine oleate (EO)) are amongst the sclerosants used to treat VMs, but their availability in different countries is dependent upon local regulatory authorities. Absolute ethanol is the strongest sclerosant, 3% STS and 5% EO have more moderate effects, and 3% polidocanol is weaker still. Sclerosants act by causing endothelial damage, resulting in thrombosis of the VM lumen. Each sclerosant has characteristicside effects.Ethanol extravasates through venous walls, causing adjacent skin necrosis or nerve injury. It may have profound systemic side effects and can cause cardiovascular collapse if a large amount is injected intravascularly. The total dose of 1 mL/kg absolute ethanol per session should never be exceeded 1 . Patients who receive up to 1 mL/kg during embolization and sclerotherapeutic procedures may have elevated serum ethanol levels that could put them at risk of respiratory depression, cardiac arrhythmias, seizures, rhabdomyolysis, and hypoglycemia 2 . Of the detergent sclerosants, EO can provoke hemolysis, resulting in hematuria and acute renal failure. Renal protection can be afforded by prophylactic treatment with intravenous fluids, urine alkalization 1 , and intravenous administration of haptoglobin. EO is also toxic to the lungs, resulting in pulmonary edema. STS can cause anaphylaxis, although an allergic S104 C RSE CIRSE Abstract Book

Whom should I treat and whom should I refer to an expert?

Imaging, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom.

1. To review proper infrastructure and set-up for treating AVM 2. To review problems and challenges encountered when running an AVM practice 3. To review indications for referral to an expert centre The spontaneous response to this question is that all patients with a systemic vascular malformation should be treated at a tertiary referral centre by an expert; even on further reflection, it is difficult to think of a situation-outside an emergency life-threatening complication-when one could argue that it would be reasonable to manage someone with a condition of which one has little or no previous experience. It is important to recognise the following facts about vascular malformations: although often symptomatic, the majority do not pose a threat to life; the best imaging modality depends upon the type of malformation and the findings on clinical examination; the wrong treatment will frequently make symptoms much worse and can endanger life; many do not actually require treatment and are best managed conservatively. Gone are the days when little was known about the natural history of vascular malformations results and imaging studies showed that 16% (25/158) of patients had a "good response". They concluded that ethanol sclerotherapy should be performed in selected patients in order to obtain the best outcomes and minimize complications. Statistically significant predictors of a "good response" to ethanol sclerotherapy were female gender, no or delayed visualization of a drainage vein on initial direct puncture venogram, and a well-defined margin on magnetic resonance (MR) imaging. Goyal and colleagues have also assessed the predictors of good response for ethanol sclerotherapy in 59 pediatric patients followed up from 1 to 5 years 13 . Lesion size and patient symptoms were assessed, with excellent or good results seen in 35 patients (59%). In their study, lesions were graded with MR imaging on the basis of margins and size: grade 1, well defined, less than or equal to 5 cm; grade 2A, well defined, greater than 5 cm; grade 2B, ill defined, less than or equal to 5 cm; and grade 3, ill defined, greater than 5 cm. There was a strong association between this proposed MR imaging classification and the results of percutaneous sclerotherapy. An excellent response was seen in most small welldefined VMs, and a poor result was seen in most large infiltrating lesions. We have evaluated the predictors of a good response in pain relief after polidocanol sclerotherapy with a mean follow-up of 46 months 8 . Twenty-six (90%) of 29 patients experienced an improvement in pain after sclerotherapy. Among the 24 patients for whom pain scores were measurable, a reduction in pain intensity of 50% or more was achieved in 16 (67%). Predictors of a good response using univariate analysis were small size (equal to or less than 10 cm), a well-defined margin, and good stasis of sclerosant during sclerotherapy. There is no standard to assess treatment outcome of sclerotherapy. Presently, assessments include questionnaires based on patients' own assessments of their symptom improvements and satisfaction, pre-and post-treatment photography, and radiologic imaging. Standardized evaluation methods will be needed to allow more accurate and precise measurement of patient outcomes, to ensure that sclerotherapy treatments are underpinned by the best evidence. Complications resulting from sclerotherapy include skin necrosis, peripheral nerve injury, deep venous thrombosis, compartment syndrome and muscle contracture, which can develop with use of any sclerosants to varying degrees. Since extravasation of sclerosant can result in skin necrosis or nerve injury, patients should be carefully observed using fluoroscopy or digital subtraction angiography during injection. The presence of a draining vein should be established with contrast medium in advance of sclerosant injection. Injection of sclerosant should be terminated when flow into the draining vein can be seen. If the VM drains in close proximity to deep veins, compression of the draining vein using a tourniquet or forceps with gauze can be helpful to minimize the flow of sclerosant into deep veins. However, compression by a tourniquet may cause stagnation of venous blood in deep veins, predisposing the patient to a deep venous thrombosis. Furthermore, release of the tourniquet can cause hemodynamic disturbance when a large amount of sclerosant, thrombi, and debris enter the systemic circulation. Therefore, the time length of tourniquet application should be limited as needed. If patients are at risk of compartment syndrome or airway obstruction, systemic corticosteroids (dexamethasone, 0.1 mg/kg every 8 hours) should be administered before the procedure and for the subsequent 24 hours, followed by a tapering dose of oral corticosteroid 1 . Muscle contracture can occur after sclerotherapy in VMs with intramuscular components. Rehabilitation may be recommended in consultation with orthopedic specialists as needed.

To minimize the risk of complications, the volume of sclerosant per injection and per session should be limited. In conclusion, recent studies show good results in 60-90% of patients undergoing sclerotherapy for VM. Predictors of a good response to sclerotherapy are small size and well-defined margins. A better understanding of the risks and benefits of sclerotherapy is still needed to ensure the best patient outcomes while minimizing complications.

SS/FC/HL/HTS/CM (according to the ATLS protocol), the diagnostic workup generally involves a clinical examination and bedside diagnostic imaging which may include chest and cervical spine radiographs, diagnostic peritoneal lavage (DPL) or the preferred focused assessment with sonograpy for trauma (FAST) (in the event of abdominal trauma). This may then be followed by computer tomography (CT) and/ or angiography. In reality, however, the mean starting time for the first CT is 82 minutes with the imaging work-up completed, on average, 114 minutes after admission to the trauma unit. 2. This is mainly due to the historically remote location of the CT scanner in the Radiology Department, usually some distance from the Trauma unit. The challenge for each imaging department is therefore to deliver a complete imaging service to the trauma patient in the shortest possible time. This could result in a reduction of mortality from 15% to 8,6%. 3. The widespread availability of multi-detector computer tomography (MDCT) has changed the management of patients having sustained major trauma. 4. Instead of relying on the outcome of examinations such as conventional radiography, FAST and DPL, the patient, once stabilized, is preferentially sent for multi-detector Computed Tomography. With this approach CT scanning can get underway on average 8 minutes after arrival at the trauma centre and be completed after 13 minutes. This results in an average stay of 38 minutes (in the emergency room) instead of 87 minutes. 3. To achieve this necessitates the placement of a CT scanner in the emergency room (ER) and for resuscitation of the patient to begin on the CT table. This has serious cost implications as the CT scanner is solely utilized for emergency room patients. For a trauma centre with limited funding the Amsterdam Trauma Workflow Concept could be an alternative, with a sliding gantry CT scanner servicing two mirrored rooms, thus opening up a second room for regular scheduled patients. 5. Logistically difficult and time-consuming patient transfer between the ER and CT room is also eliminated. Central to the diagnostic imaging of a trauma patient is the correct imaging protocol. Here we find the time-honoured dictum of clinical examination followed by CR images of the chest, lateral of the cervical spine and pelvis followed by a DPL or FAST and then the CT, challenged by the single whole body CT or Pan Scan. Utilization of the single body CT protocol could save a lot of time but at the expense of cost and radiation to the patient. 6. The selective usage of CT could reduce both cost and radiation exposure to patients without increasing the mortality, with the caveat that a certain amount of pathology will be missed. The potential for important injuries missed is around 17%, but there has been no consensus that this will increase mortality. 7. Protocols for imaging need to be tailored for each institution with a balance between the availability of resources and timely imaging. The trauma imaging protocol used at our institution includes a chest radiograph and lateral of the cervical spine in the ER, bedside ultrasound where cardiac injuries are suspected, and optional transfer to the CT scanner next door for a contrast-enhanced CT, depending on the injuries and the severity of the injury score. Detecting bleeding at CT is of particular interest to the interventional radiologist as bleeding can be addressed utilizing endovascular technique, in line with the American College of Surgeons recommendations on treatment of trauma-related bleeding. MDCT is now the mainstay of trauma imaging and can detect in vivo bleeding of as little as 0,35ml/min. 8. Imaging findings indicative of active bleeding, as seen on abdominal CT, include a focal jet of extravasating contrast material and/or a high-density area of extravasated contrast within a hematoma. 9. Other CT signs are disrupted vessels, false aneurysms and dissections. A thoracic aorta injury is indicated by a wide mediastinum, pseudoaneurysm, intimal flaps, aorta or branch vessel contour abnormalities, pseudocoarctation and an intraluminal thrombus. 10 . For injuries to the cervical arteries the following signs are useful: partial or complete occlusion, intimal injuries, anteriovenous fistula, luminal calibre changes and active bleeding.11. In the extremities similar signs are observed with downstream trombo-embolism also occasionally seen.12. For the interventional and their management and when it was, therefore, felt reasonable to 'have a go' because no one knew any better. Not only are there now tertiary referral centres that specialise in the management of patients with vascular malformations but, with electronic communication and the ability to rapidly transfer large image datasets, it is much easier to seek and obtain advice. It is important to resist the pressure from patients, their relatives and, indeed, from colleagues in other disciplines from whom a patient may have been referred, to offer treatment without seeking such advice. It is worthwhile discussing imaging in more detail at this point. Low-flow malformations are relatively straightforward. Fat-suppressed magnetic resonance sequences will generally show the full extent of this type of malformation in beautiful detail and there are no concerns with ionising radiation. Although not all patients with this type of malformation require imaging, particularly if treatment is not deemed necessary after clinical assessment, no harm has been done. Catheter angiography plays no part in the assessment of low-flow malformations but, unfortunately, this study is still sometimes performed. The imaging of high-flow lesions is more complicated. MR rarely provides useful additional information for lesions of this type even when the decision has been made that treatment is necessary. The exquisite angiographic images with 3D reconstructions that can be obtained by contrast-enhanced multidetector computed tomography (MDCT) has resulted in a marked increase in the number of CT examinations that accompany patients being referred to a tertiary referral centre. Not only is this examination rarely helpful, it also involves a not insignificant radiation dose to the patient, who is often young. The only indication for CT is when there is bone involvement and in such situations an unenhanced study is all that is necessary. Catheter angiography provides all the necessary information about the anatomy of the arteriovenous communications within a vascular malformation that are so important when deciding upon the best method of treatment. It does not, however, provide any information about the need for treatment, which is a decision based upon symptoms and clinical signs. It should not, therefore, be performed unless treatment is considered necessary and then, usually only at the time of first treatment. It is clear from what I have said above that all patients with a vascular malformation should be discussed with and, in the majority of cases, seen and assessed by an 'expert'. The question is whether, having done so, it is reasonable for any treatment to be performed at the referring hospital. This clearly depends upon a number of factors including the complexity of the case and the experience of the radiologist planning to perform the procedure, but many low flow lesions can be managed in this way, particularly as multiple treatment sessions and long-term followup are often necessary. Most high-flow lesions, however, should be treated at the tertiary referral centre. with hepatic and renal trauma Solid organ injury is seen in patients following both blunt and penetrating abdominal trauma. The liver is the commonest organ involved, followed by the spleen and then the kidneys. Historically, management was based around a policy of a low threshold for laparotomy in patients with abdominal trauma. It became clear that there was a significant negative laparotomy rate with such a surgically focused approach and that a non-therapeutic laparotomy was associated with significant rates of complication. Over the past 20 years there has been a progressive move from operative to nonoperative management of abdominal solid organ trauma. This has been aided by improvements in intensive care management, as well as advances in CT scan technology and wider experience and availability of embolisation techniques. As clinical signs can be difficult to assess with accuracy and are sometimes unreliable in assessing the presence or severity of intra-abdominal injury, non-invasive imaging has been crucial in the early assessment of patients, allowing more accurate assessment of the nature and extent of injuries sustained. The management algorithm for patients with abdominal trauma is based on their presenting haemodynamic status and findings on CT scanning. Patients who remain haemodynamically unstable despite resuscitative measures should go straight to the operating theatre for damage control laparotomy. This will allow surgical packing or repair (if appropriate) of any solid organ injury. The patient should then undergo a post-operative CT scan to identify if they would benefit from adjuvant post-operative embolisation, such as those with any deep injury, especially in the case of liver trauma, which may not have been evident at laparotomy. Those patients who are stable at presentation or who can be stabilised and maintained in permissive hypotension with on-going fluid resuscitation (the 'metastable' patient) should undergo an urgent CT scan. If the CT scan demonstrates active arterial phase contrast extravasation, the patient can be transferred to the angiography suite for embolisation of the bleeding site. If the CT also demonstrates other injuries that will require surgical intervention, e.g. bowel injury, the patient should be transferred to theatre following successful embolisation for these to be treated. If no additional 'surgical' injury is identified, the patient can then continue with non-operative management with close observation of vital signs and a low threshold for re-imaging, should the clinical situation change. The embolisation technique employed will differ between the liver and kidney due to the differences in their blood supplies. The liver has a dual blood supply and there are intrahepatic collaterals between the branches of the hepatic artery. These are important factors to consider when embolising the traumatised liver. The dual blood supply will allow the liver to tolerate relatively proximal embolisation without hepatic necrosis, in the presence of an intact portal vein. The vessel beyond the site of bleeding (the 'back door') will also need to be embolised prior to embolising the inflow (the 'front door'). If only the inflow is occluded, the distal vessels may re-perfuse via retrograde flow with resultant on-going bleeding that can no longer be accessed for further embolisation. On the other hand, the renal arteries are true end arteries and, as such, only the inflow vessel needs to be embolised for effective treatment. However, the lack of any collateral network radiologist to be involved in the management of a trauma patient, the individual needs to have a fundamental knowledge of the logistics involved in the imaging of a trauma patient and be involved in the planning of the imaging and IR services for the trauma department. This will facilitate the establishment of effective imaging protocols and the availability of a sustainable and timely interventional service, based on the resources and needs of a specific department/ unit.

SS/FC/HL/HTS/CM either because they are bleeding from an isolated splenic trauma or because the splenic trauma is at high risk of secondary rupture. For the first indication, embolization is usually decided on the evidence of contrast extravasation on CT and then transferred to the angiosuite. For the second indication, decision is based on the theoretical risk of the secondary rupture in function of the AAST classification of splenic trauma. Grades 1 and 2 carry little risk of secondary rupture and usually not considered for embolization. Patients with trauma grade 3, 4 and 5 have a high-to very-high risk of secondary rupture and may benefit from a proximal embolization. Although we do not have randomized trial supporting this statement, it seems that the rate of secondary rupture is significantly diminished when proximal embolization is performed. Nevertheless, secondary ruptures are described despite adequate embolization; therefore, patient surveillance is still necessary. Splenic embolization is usually performed only in patients in stable hemodynamic conditions; however, recent reports suggest that this technique is also useful in patients with unstable hemodynamic conditions due to active bleeding. According to the WHO there are 10 million injuries and 300,000 deaths per year worldwide in traffic accidents. Trauma is the leading source of death under 45 years in developed countries. When a patient arrives into the emergency room and during the initial resuscitation procedures a first diagnostic survey must be done with total body CT whenever possible to identify those major injuries that may require a lifesaving emergent surgical intervention. After thoracic trauma, tamponade and abdominal hemorrhage, pelvic fracture is the third priority in the management of polytrauma patients. The presence of pelvic trauma adds significant morbidity and mortality and isolated pelvic fractures are also a major problem. Pelvic ring fractures with major ligament disruptions (APC II, LC II, vertical shear) or acetabular fractures involving the anterior column trigger major bleeding and require blood transfusions. Uncontrolled pelvic hemorrhage has a high mortality rate and 60% of early deaths in pelvic trauma are due to bleeding; otherwise, bleeding is the most treatable cause of death. Car and motorcycle accidents, falls and pedestrians being run over are the most frequent involved mechanisms for pelvic trauma. IR plays a well-established role and embolization is an accepted alternative to surgery for patients with active pelvic bleeding.

For injury detection CTMD has a higher sensitivity and specificity than the physical and clinical examination. A CT protocol with multiphase acquisitions and multiplanar and volume reconstructions are mandatory in these patients. CT angiography should be part of the protocol. Interventional radiology (IR) has no primary role during the initial management of these patients at the emergency room. In traumatic pelvic hemorrhage venous bleeding occurs in 80 -90 % of cases. Presacral venous plexus and bleeding directly from fractured bones are the most common sources of venous bleeding. Conservative management with blood transfusions, pneumatic mandates very selective embolisation of the feeding vessel(s) as distally as is possible and avoidance of any non-target embolisation. With the use of embolisation techniques, non-operative management can be successfully achieved in the vast majority of patients with hepatic or renal trauma. Non-operative management was initially successfully utilised in patients with low grade injuries (grades I and II). The use of angiography and embolisation has improved the success of non-operative management in this patient cohort and has also allowed its extension to patients with higher grade injuries (grades IV and V) and those who transiently respond to fluid resuscitation. It is important to remember that embolisation is not without risk. Significant complications can be seen following hepatic embolisation, including major hepatic necrosis. Risk factors for necrosis include post-operative and proper hepatic artery embolisation as well as embolisation in higher grade injuries. With appropriate clinical and image directed triage, and meticulous angiographic technique, embolisation has proven to be an extremely useful adjunct in the non-operative management of patients with liver and renal trauma. 1 To compare proximal and distal embolization and review indications for each technique Embolization of splenic trauma has two aims: the first being to stop bleeding and the second one is to prevent secondary bleeding in the following days after the procedure. The potential benefit of embolization as compared with surgical splenectomy is to maintain spleen function. Splenectomy can have severe complications ranging from septic syndrome, to thromocytemia, pancreatic fistula and portal vein thrombosis. This also mandates to maintain a certain degree of vascularization to the spleen to keep enough viable tissue to maintain splenic functions. Proximal splenic embolization is defined by an occlusion of the trunk of the splenic artery. A catheter is positioned in the artery and the occlusion can be achieved using coils or plugs placed in the splenic artery trunk. Attention must be paid to anatomical variants of the splenic artery branches, i.e. the superior branch of the splenic artery that can also vascularize the stomach and the transverse pancreatic artery. Embolizing the splenic artery allows to decrease blood pressure in the distal branches by a factor of 2 aiming to help healing of the fractured parenchyma. Catherterization of the splenic artery is usually done quickly, in less than 15 minutes allowing rapid efficacy. Distal splenic artery is defined by occlusion of distal branches of the splenic artery that are ruptured by the trauma. This means that the ruptured branches are identified and selectively embolized one by one. This procedure is usually performed in case of active bleeding identified on angiograms while suspected on CT after contrast injection. Distal and proximal splenic embolization can be combined in the same procedure. The distal embolization is used to treat active bleeding and proximal aims to prevent rebleeding. Indications of these procedures are still discussed. The patients that benefit the most are the one that avoid surgery by doing embolization. In other words, patients that would anyhow necessitate laparotomy for another lesion like a mesenteric laceration should not be embolized but be treated by surgery during the same procedure. Patients are selected S108 C RSE

Abstract Book recanalization mainly in the presence of coagulopathy. It is an appropriate embolic material when the bleeding point is located at a distal branch inaccessible to the microcatheter. Coils and microcoils are appropriate for focal bleeding where selective catheterization is possible or to embolize proximal vessel in order to reduce the perfusion pressure. If blood flow pressure is high and coagulopathy is present, residual flow through the coils may persist. Calibrated synthetic microspheres are useful for distal diffuse multiple small bleeders and large diameter particles should be used (>500 μ). Liquid embolic agents, NBCA and EVOH, are in our experience more effective and feasible than others agents in terms of hemostasis and prevention of recurrent hemorrhage. It works for distal and for proximal occlusions, for focal and diffuse, with an immediate effect, and is not conditioned by the coagulopathy. Combinations of different agents are feasible and may be done to achieve simultaneous distal and proximal embolization. In special cases temporal inflow arterial occlusion balloon allows the patient to be stabilized during treatment. Stent grafting may be considered to maintain distal flow of the main pelvic arteries and in case of threatening pseudoaneurysm. Embolization is contraindicated in patients who are severely unstable. These patients with major and multiple injuries require emergency surgery and intensive care support. When bleeding sources are multiple and from different sites embolization is not indicated.

Embolization is very effective in controlling arterial bleeding with success rates of 80 -95%. However, global survival rates are quite variable and depend on the number and extent of other organ injuries, patient hemodynamic status, the delay between trauma and embolization, the experience and availability of the IR team and the number of vessels involved. Complications after embolization are usually minor and occur in less than 10% of cases. Besides the puncture site-related complications, distal necrosis is a possible complication of any embolization but is not frequent in the pelvic area. Nontarget embolization due to unintentional reflux of the embolization material into the femoral artery can cause leg ischemia. Sciatic and sacral plexus palsy has been reported. Sexual dysfunction is more likely the result of nerve injury and pelvic fracture.

antishock garment and external fixation for unstable pelvic fractures is usually enough for venous bleeding control. As the hematoma grows, intrapelvic pressure increases causing hemostasis. Most persistent pelvic bleeding is due to internal iliac artery branch tears, and those patients are the best candidates for treatment by embolization. Pelvic CT angiography may guide the clinical decisions for patients with blunt and penetrating pelvic trauma. It has capability to differentiate between venous and arterial active hemorrhage, the quantification of blood loss and the severity of injury to major arteries. Prior to embolization, CTA is also very useful to determine the precise location of the injured arterial branch. We must keep in mind that sometimes several branches may be affected. In case that extravasation is not seen, the progression of the hematoma in a CT control is an important finding and can be explained by intermittent bleeding. The "Cut off" sign may be present and indicates arterial transection or dissection that could evolve into pseudoaneurysm or active bleeding when the blood pressure goes up and the blood clots dislodge. In addition to the information obtained from CT we also have to take into account the blood requirements. More than 4 packed cells per day or 6/48 Hs directly related to pelvic fracture is another indication for embolization. There are some algorithms for the management of patients with pelvic fractures but in short we can summarize the indications for embolization in pelvic trauma as follows: 1. Primary management in a hemodynamically unstable patients with isolated pelvic fracture and no relevant injuries in the rest of the whole body. 2. Primary management in a hemodynamically stable patient suffering from blunt or penetrating pelvic trauma with active arterial bleeding depicted on CTMD.

3. Secondary management when active arterial bleeding is not detected but some hours or days after admittance the red cell count decreases and/or the pelvic hematoma size increases. 4. Secondary management in venous active bleeding when conservative and orthopedic treatments have failed. 5. As secondary rescue manoeuvres when bleeding control surgery fails. Embolization may be the only option. 6. "Prophylactic" embolization may be justified in some particular cases with no active bleeding but high risk of rebleeding because of "cut off" sign, coagulopathy or previous cumarin treatments.

If the previous CTA is clear enough we can go directly into a selective catheterization of the injured vessel avoiding the pelvic angiography and saving time and iodinated contrast. We do selective runs of both internal iliac arteries. We should pay attention to extravasations of contrast medium but also to the "cut off" signs. We recommend a crossover 6F guiding catheter or long braided sheath located in the trunk of the internal iliac artery. We will be able to perform selective and control angiograms from the side port of the 6F device. In a second step we will advance as selective as possible a co-axial either 4 F hydrophilic catheter or microcatheter. Only in those patients severely hypotensive, a quick non-selective occlusion is justified. We must remember that our goal is bleeding control. The former surgical ligation of proximal internal iliac artery is ruled out due to its poor results. If we make a proximal truncal occlusion we will preclude further interventions and persistent pelvic bleeding will be possible through collaterals. The choice of embolic agent and technique depends on the site and type of injury, clinical scenario, available options and personal experience. To choose the embolic agent we will consider the bleeding severity and we need to know if it is focal or diffuse, proximal or distal. We will also consider if there is a venous hemorrhage associated. The pelvis is quite resistant to ischemia so we will be able to perform more aggressive embolizations than in other organs or territories. Gelatin sponge is the most popular embolic agent; it is cheap and easily available although it may fail due to reabsorption and vessel S109 CIRSE 2012 SS/FC/HL/HTS/CM governing bodies, and the study was registered at www.clintrials. gov (#NCT00673985). Patients with de novo or restenotic lesions > 50% (including total occlusions) up to 150 mm in length in the SFA and/or proximal popliteal arteries were at least 18-years-old, had symptoms of intermittent claudication (Rutherford categories 1-3), were candidates for angioplasty or stenting, and had at least one patent infrapopliteal runoff vessel to the foot were eligible for inclusion in the study. Patients were excluded if they had critical limb ischemia; were suffering from renal failure, hepatic insufficiency, or were receiving dialysis or immunosuppressive therapy; had aneurismal disease or thrombus that could not be resolved in the area to be treated; or had poor inflow. Target lesions were examined angiographically to verify stenosis or restenosis > 50% and a total lesion length of no more than 150 mm. More than one lesion in the target vessel could be treated, as long as the total length of the lesions did not exceed 150 mm. Patients were randomized to either the angioplasty or stent groups after the most distal lesion was crossed with an angioplasty balloon. Patients received a minimum of 81mg of acetylsalicylic acid and 75mg of Clopidogrel (per day) starting the day of the procedure. In addition, unfractionated heparin was recommended during the procedure to maintain an activated clotting time (ACT) > 250 seconds. Angioplasty of the target lesion(s) was performed with an appropriately sized balloon, and post-PTA angiography was performed to access angioplasty success and to evaluate specific lesion characteristics (analyzed by the angiographic core laboratory, Cardiovascular Research Foundation, New York, NY). Following successful PTA, patients randomized to the primary stent group received a LifeStent Self-Expanding Stent; post-dilation of the stent was left to the discretion of the investigator. Stent sizes available for the study were the 6 and 7 mm diameters in 40, 60, and 80 mm lengths. Since the longest stent used in the trial was 80 mm, multiple stents were either overlapped or deployed separately to treat longer lesions. Endpoints: the primary effectiveness end point in this study was the rate of target lesion revascularization (TLR) at 12 months postprocedure. Secondary endpoints included primary patency at using duplex ultrasonography (DUS)at 6 and 12 months, and clinical success and quality of life assessments using the Short Form 8 Question Heath Survey (SF-8) and the Walking Impairment Questionnaire (WIQ) at 6, 12, 24, and 36 months. Clinically driven TLR was reported at 2 and 3 years, defined as any repeat percutaneous intervention or bypass surgery of the target lesion or vessel due to a return of ischemic symptoms. Freedom from all-cause death and major adverse clinical events (MACE) were assessed through 36 months post-procedure. MACE was defined as 30-day death, and 24-or 36-month stroke, myocardial infarction, emergent surgical revascularization, significant embolization in the target limb, thrombosis of the target vessel, and worsening of one Rutherford category of chronic limb ischemia. X-rays of the stented limbs were taken at 6, 12, and 18 months post-procedure and assessed for stent fractures by the X-ray core laboratory (Cardiovascular Research Foundation Angiographic Core Laboratory, New York, NY). Anterior-posterior and lateral views were taken at the highest magnification possible in straight leg and bent-knee positions (90 degrees of flexion) while maintaining the entire stent in the field of view. Stent fractures were classified by anatomic location (proximal, mid, or distal SFA or proximal popliteal) and type (Type 1-4).12 Statistical analysis: all end points were analyzed on an intentionto-treat basis. The value α=0.05 was used to determine significance and confidence intervals were set at 95%. Descriptive data were presented as means + standard deviation (SD 

Bare stents -RESILIENT trial, etc.

Vascular and Interventional Radiology, Baptist Cardiac and Vascular Institute, Miami, FL, United States of America.

Learning Objectives 1. To review the bare stent trial designs 2. To review the outcomes of the bare stent trials 3. To learn an overview of the bare stent trials conclusions LifeStent versus balloon angioplasty for obstructive lesions in the superficial femoral artery (SFA) and proximal popliteal artery: three-year results from the RESILIENT randomized trial Purpose: percutaneous transluminal angioplasty (PTA) has been relatively effective for focal SFA lesions (< 4 cm), but an analysis of published results of PTA alone for longer lesions (mean: 8.7 cm) revealed a primary patency rate of 33% at one year[i]. There are limited data comparing the longer-term outcomes following these two treatment strategies. The randomized RESILIENT study (Randomized study comparing the self-expanding lifestent vs. angioplasty alone in lesions involving the SFA and/or proximal popliteal artery) compared primary nitinol stent implantation with angioplasty in claudicants for the treatment of obstructive lesions in the SFA and proximal popliteal artery. The 12-month freedom from target lesion revascularization (87.3% vs. 45.2%, p < 0.0001) and primary patency (81.5% vs. 36.7%, p < 0.0001) were significantly better for the stent group compared with the angioplasty group. This report summarizes the long-term clinical outcomes of the RESILIENT trial. Patients were followed for three years after intervention. Additional radiographs of the stented limbs were obtained at 18 months to evaluate potential late-onset (beyond 12 months) stent fractures.

Methods & materials: the study design, methods, and statistical plan were previously reported in the publication of the RESILIENT 12-month results [ii] . To summarize, 206 patients with intermittent claudication (Rutherford 1-3), obstructive lesions of the superficial femoral artery (SFA) and/or proximal popliteal artery, and at least one-vessel runoff to the foot were randomized (2:1 ratio) at twenty-four centers in the United States and Europe to treatment with either a self-expanding nitinol stent after pre-dilation (LifeStent Self-Expanding Stent, Bard Peripheral Vascular, Tempe, AZ) or angioplasty. All patients were informed of the risks and benefits of participating in the study, gave written informed consent, and agreed to be followed for 3 years following the intervention. The protocol was approved by the institutional review board or ethics committee at each study site, all study procedures were conducted in accordance with good clinical practices and the applicable laws of various S110 C RSE CIRSE Abstract Book ultimately requiring femoropopliteal bypass surgery. The Kaplan Meier curves for probability of freedom from TLR following both PTA and stenting leveled off after 12-18 months, supporting the notion that if a patient remains patent beyond the time period of neointimal proliferation, sustained clinical benefit will result. Concerns still exist about the potential for nitinol stents to fracture and the clinical implications of femoropopliteal stent fracture. The fracture rate with the LifeStent in the current study, however, was only 3.1% at 12 months and 4.1% at 18 months. While limited conclusions can be drawn from only 12 fractures, factors previously associated with an increased risk of fracture (stent elongation, stent overlap, deployment within heavily calcified lesions) were also associated with stent fracture in the RESILIENT study. Although a direct causative link cannot be established, all six Type 4 fractures were observed in stents that had been elongated at deployment, a problem more common with the first-generation delivery system. Improvements in stent delivery systems as well as increased operator experience should reduce the future likelihood of inappropriate stent elongation during deployment. Conclusion: long-term follow up from the RESILIENT trial demonstrated that the initial benefit of primary stenting over PTA for moderate length lesions in the SFA and proximal popliteal artery was maintained at 3 years. The favorable clinical outcomes seen in the RESILIENT trial along with the low rate of stent fracture are encouraging and support the role of an endovascular strategy for patients with SFA and/or proximal popliteal artery lesions and lifestyle limiting claudication. 

Falk Cardiovascular Research Center, Stanford University School of Medicine, Stanford, CA, United States of America.

Learning Objectives 1. To review the drug eluting stent trial designs 2. To review the outcomes of the drug eluting stent trials 3. To learn an overview of the drug eluting stent trials conclusions Background: sustained benefits of drug-eluting stents in femoropoplitealarteries have not been demonstrated. This prospective, multinational, randomized study was designed to compare the 12-month safety and effectiveness of a polymer-free, paclitaxel-coated nitinol drug-eluting stent (DES) with percutaneous transluminal angioplasty(PTA) and provisional bare-mental stent (BMS) placement in patients with femoropopliteal peripheral artery disease. Methods and results: patients were randomly assigned to primary DES implantation (n=236) or PTA (n=238). Demographics and lesion characteristics were similar between groups (e.g., average lesion length, approximately 65±40mm). One-hundred-twenty patients had acute PTA failure and underwent secondary random assignment to provisional DES (n=61) or BMS (n=59). Primary end points were the 12-month rates of event-free survival and patency in the primary DES and PTA groups. Compared with the PTA group, the primary DES group exhibited superior 12-month event-free survival (90.4% versus 82.6%; P=0.004) and primary patency *83.1% versus 32.8%; P<0.001), satisfying the primary hypotheses. In the secondary evaluations, (1) the primary DES group exhibited superior clinical with provisional stent implantation to that of primary stent implantation was also performed. In this analysis, use of a bailout/provisional stent was not considered a TLR or immediate (day 0) loss of primary patency. Results: 78.2% patients were assessed at 36 months. Over the course of the study, 15 patients died, 20 patients withdrew consent to be evaluated, and 10 patients were lost to follow-up. There were no overall differences in the patient populations or lesion characteristics at baseline; the angioplasty group did, however, have a higher pre-existing incidence of hypertension than the stent group (p = 0.03). The freedom from TLR was significantly better for the stent group than the angioplasty group throughout the course of the study (p < 0.0001). Freedom from TLR for the stent group at 24 months post-procedure was 77.8% and at 36 months was 75.5% as compared with 41.8% for the angioplasty group at both time points. Only five patients in the RESILIENT study ultimately required femoropopliteal bypass surgery. The remaining patients undergoing TLR were treated with a variety of endovascular techniques at the discretion of the investigator. Clinical success was also significantly better for the primary stent group than for the angioplasty control group at both 24 and 36 months post-procedure. Clinical success in the stent group at 24 months was 68.6% compared with 25.4% for the angioplasty group (p < 0.0001), and at 36 months was 63.2% for the stent group versus 17.9% for the angioplasty group (p < 0.0001). There were no significant differences in Quality of Life (QOL) measures between the two treatment groups. Both groups demonstrated significant improvements in QOL (i.e., both SF-8 and WIQ) at 24 and 36 months compared with baseline. In a post hoc analysis comparing primary stent implantation to PTA plus provisional stent implantation, the freedom from TLR at 36 months was 75.5% for the primary stent group compared with 70.1% for the PTA plus provisional stent group (p = ns). Clinical success at 36 months was 63.2% for the primary stent group compared with 47.5% for the PTA plus provisional stent group (p = ns). Safety: there were no peri-procedural deaths in either study arm or deaths within the first 30 days following the procedure. At 36 months, the probability of survival was 90% for the stent group and 91.7% for the angioplasty group (p = 0.71). Of the 15 deaths, none were deemed device-related by the clinical events committee. In addition, there was no statistically significant difference between the composite major adverse clinical event (MACE) rates for the treatment groups throughout the course of the study. Freedom from MACE at 36 months for the stent and angioplasty groups was 75.2%. Stent fracture analysis: patients with stents underwent radiographic evaluation for stent fracture analysis at 6, 12, and 18 months post procedure. At 18 months, 291 stents in all phases and arms of the RESILIENT study (i.e., stents from the feasibility trial, roll-in/training cases, bailout stents from the randomized trial, and the primary stent randomization group) were evaluated by the X-ray core laboratory. 12 stent fractures were noted in 11 patients. Only 3 new fractures were identified from the 12-to 18-month evaluation periods. 6 stents in 6 patients had Type 1 (i.e., single-strut) fractures, 5 stents in 4 patients had Type 4 fractures (i.e., multiple strut fractures with stent displacement), and 1 stent in 1 patient had both a Type 1 and Type 4 fracture. None of the patients with stent fractures experienced a revascularization procedure through 24 months post-procedure, and the freedom from TLR in the stent fracture group at 36 months was 90% (estimated by Kaplan-Meier analysis). Discussion: the RESILIENT study demonstrated that for lesions up to 15 cm in length in claudicants in the SFA and/or proximal popliteal artery, use of the LifeStent Self-Expanding Stent provided superior outcomes at 12 months compared with balloon angioplasty (i.e., freedom from TLR and primary patency were significantly better in the stent group).5 Analysis of longer-term results from the RESILIENT trial demonstrated a sustained benefit of femoropopliteal stenting over PTA out to 3 years. The need for clinically driven TLR at 3 years was only 24.5% with only five patients in the RESILIENT study Learning Objectives 1. To review the drug eluting balloon trial designs 2. To review the outcomes of the drug eluting balloon trials 3. To learn an overview of the drug eluting balloon trials conclusions Introduction: over the recent years endovascular therapy of peripheral arterial disease improved significantly. Although there are two major limitations of endovascular therapy in the femoropopliteal region, A) the first problem was its lower technical success rates when treating long occlusions. Long occlusions could often not be passed or reentry was difficult. This problem could be widely solved through retrograde approaches and the introduction of new devices like Outback™ (Bausback et al.) . Since then primary success rates of endovascular therapy is more than 95%, so it could become the preferred therapy to treat even challenging lesions (Norgren et al.) .

(B) The second limitation is its low long-term success with restenosis rates of 60%, the highest rate in the different arteries of the body (Laird) . Until today no satisfying solution which solves this problem could be introduced into clinical practice. Drug eluting balloons: mechanisms of restenosis involve clotting, cell recruitment and activation as well as cell proliferation and matrix synthesis (Haudenschild) . Nitinol stents have been shown to reduce rates of restenosis and target lesion revascularization in patients undergoing endovascular treatment of femoropopliteal lesions (Schillinger et al.) . However, intravascular stenting brings a foreign body in contact to the vessel wall; this reduces early elastic recoil but also increases intimal injury and inflammation leading to neointimal hyperplasia (Bavry et al, Joner et al). Furthermore, if there is need for a surgical bypass there are fewer possibilities because of the foreign material in the vessel. Drug eluting balloons (DEB) bring some important advantages over other endovascular methods such as standard angioplasty or different stenting technologies: -DEB deliver the antiproliferative drug homogeneous to the vessel wall; in drug-eluting-stents the drug is only delivered from the stent struts -An immediate drug release without using a polymer which can induce inflammation and late thrombosis -No risk of stent fracture or stent thrombosis; thus further endovascular therapy or bypass surgery can be carried out easier -No foreign material left behind in the body -Potential of reducing dose and duration of dual antiplatelet therapy -And most important, it can lower restenosis rates in target peripheral arteries compared with standard PTA treatment After positive findings from coronary studies and in porcine models of peripheral arteries, two randomized trials (THUNDER and FEMPAC) were started to compare Paccocath® paclitaxel coated balloon with standard uncoated balloon catheters (Tepe et al., Werk et al.) . In THUNDER, at six-month follow-up, patients treated with Paccocath® were found to have significantly less late lumen loss in the treated lesion. Furthermore, at 6 and 12 months the angiographic late lumen loss measured by quantitative core lab analysis remained significantly lower than in the control group. The study is still ongoing; 5 year data, which have not yet been published, show that the advantage for DEB remains high. In FemPac, the results of THUNDER were confirmed: significant lower late lumen loss at six months and significant lower target lesion revascularization (TLR) rates in the follow-up until 24 months. Nevertheless the lesion length was shorter than in the THUNDER trial. Both THUNDER and Fempac demonstrated that, similar to coronary artery lesions, (3) the stent fracture rate (both DES and BMS) was 0.9% (4/427). Conclusions: Femoropopliteal peripheral artery disease treatment with the paclitaxel-eluting stent was associated with superior 12-month outcomes compared with PTA and provisional BMS placement. Introduction Directional atherectomy is a percutaneous technique which involves excision and debulking of atheromatous material from diseased vessels to create a smooth luminal surface. It was developed in the late 1980s to treat restenosis and to reduce complication rates of PTA (1, 2) . The aim of atherectomy is to achieve controlled removal of atheroma from the vessel lumen using a catheter-based endarterectomy device. Theoretical advantages include a greater immediate technical success rate by reducing stretch injury on arterial walls and limiting intimal dissection, and by reducing elastic recoil and therefore reducing acute occlusion and restenosis rates. Atherectomy has been used in both coronary and peripheral arteries.

Of the early atherectomy devices The Simpson atherectomy device was the most widely used and investigated. Several clinical studies evaluating the Simpson AtheroCath reported impressive initial success rates, ranging from 82 to 100% (2) (3) (4) (5) (6) . However, there are inconsistent intermediate patency rates among authors ranging from 35 to 93%. Two studies compared the outcomes of atherectomy with standard percutaneous angioplasty. Kim et al evaluated the results of atherectomy alone using the Simpson device with atherectomy combined with standard PTA (5) . They reported patency rates of 92%, 84% and 84% at 1, 2, and 3 years, respectively, for lesions treated with atherectomy alone, and 78%, 67% and 57% for lesions treated with atherectomy and percutaneous angioplasty. These outcomes contradict a prospective randomised trial of 73 patients, which compared PTA with atherectomy, which showed a cumulative 2-year patency rate of 35% in lesions treated with atherectomy and 56% in those treated with balloon angioplasty (6) .

Other atherectomy devices such as the Transluminal Extraction Catheter also demonstrated promising initial technical and clinical short-term exposure of occluded peripheral arteries with Paclitaxel may be sufficient to inhibit the process of restenosis. In the LEVANT trial, patients who were predilated with an undersized balloon were then randomized to be treated either with the Paclitaxel MOXY™ balloon or with standard balloon. Results are not yet published, but 6-month data were presented by Scheinert on TCT 2010. LEVANT confirmed the results of THUNDER and FemPac with significant less late lumen loss and TLR at six months. Recently, results of PACCIFIER trial have been reported on CIRSE 2011. Patients were randomized to be treated either with an In.Pact balloon or with standard PTA. Preliminary data report about significant less binary restenosis and late lumen loss at six months in patients treated with DEB. To sum up, four randomized clinical trials approved the superiority (regarding late lumen loss and TLR rates) of DEB over standard PTA for the treatment of femoropopliteal occlusive disease. All four studies reported about superiority during a follow-up period of six months, two trials reported about an advantage until 24 months after the intervention and one trial (THUNDER) even showed a long lasting advantage of five years after intervention for DEB treatment. Furthermore it has been shown that DEBs are safe and do not bring additional risks to the patients. To our knowledge until today no results of randomized clinical trials showed that angioplasty with DEBs is inferior to standard endovascular treatment in the femoropopliteal vessels. Like in every new medical technique, material or drug, criticism and skepticism are expressed regarding the use of DEB technology in the clinical routine. First, the current data from the randomized trials mentioned trials evaluated lesions with a mean lesion lengths of 5-8 cm.

Real world data will be available for a controlled one arm study treating 1500 patients -also long lesions, in-stent restenosis and heavy calcified arteries will be enrolled. Second, in severely calcified arteries DEBs might be less effective because of a lower drug concentration reaching the vessel wall. Furthermore, in THUNDER and FemPac patients with severe calcifications in the treated lesions were not enrolled. A possible approach to solve this problem is to pretreat the vessel with a directional atherectomy device like Turbohawk™. With this device long and diffuse calcified femoropopliteal lesions could be treated successfully (Zeller et al.) . The combination therapy of mechanical atherectomy followed by DEB drug delivery is investigated in the DEFINITIVE™ AR study (NCT01366482). The randomized study is ongoing and will randomize 100 patients with calcified lesions either to receive a DEB only or an atherectomy followed by DEB. The combined approach of these two methods could help to overcome the limitations of the respective method. In times of economic and financial crisis and huge national debts in Europe and in the US, economic and financial arguments become more and more important in the health sector. The lower costs for repeated interventions could outweigh the higher costs of DEBs. In addition, costs for the DEB technology will most likely drop because of competing companies.

in 20%, anterior tibial artery in 10% and posterior tibial artery in 6%. Predilatation was required in 33% of lesions, adjunctive percutaneous transluminal angioplasty was used in 39%, and 4% required stent placement for dissection. Initial technical success with a residual stenosis of less than 30% was achieved in 98% of lesions. Primary patency rates were 67% at 1 year, and 60% at 2 years, with cumulative event-free survival rates of 58 +/-8% at 1 year, and 46 +/-9% at 2 years. The largest data for the SilverHawk atherectomy device have come from the observational non-randomised TALON (16) . Nineteen institutions participated in this multicentre registry, which reported 6and 12-month outcomes in 601 patients who had 1258 symptomatic lower limb lesions in 748 limbs, treated by atherectomy. The mean length of the treated lesions was 62.5 +/-68.5 mm above the knee and 33.4 +/-42.7mm below the knee. Technical success was achieved in 97.6% of procedures and residual stenosis of less than 50% was achieved in 94.7% of lesions. Adjunctive therapy was required in 21.7% of lesions, and stent placement in 6.3% of the treated lesions. Outcome data at 6 months were available from 248 patients, which showed a rate of survival free from target lesion revascularisation of 90%. At 12 months, the available data from 87 patients showed that 80% of these patients survived free from target lesion revascularisation. Multivariate analysis identified several predictors of target lesion revascularisation at 6 months, including a history of myocardial infarction or coronary revascularisation, multiple atherosclerotic lesions and increasing Rutherford category. In addition, lesion length >50mm was associated with a 2.9-fold increased risk of target lesion revascularisation, and lesions greater than 100mm with a 3.3-fold increased risk. Despite the promising short to midterm outcomes reported here, there are several important limitations to the TALON registry. There were no inclusion or exclusion criteria, and recruitment into the registry was not necessarily consecutive. In addition, data from only 87 (14.5%) of the total 601 patients were available for follow-up at 12 months, rendering the reported outcomes unreliable, and therefore unlikely be an accurate reflection of the true rate of survival free from target lesion revascularisation. The largest single centre series was published by McKinsey et al in 2008. His group treated 275 patients with 579 lesions by primary atherectomy with optional use of adjunctive techniques for residual stenoses. The 18-month primary and secondary patency for all lesions was 52.7% and 75%, with a 30-day mortality rate of 1.8% and a reintervention rate of 25.3% and 30.1% for claudicants and CLI patients, respectively (17) . Despite the reasonable patency rates at a respectable mean follow-up period of 12.5 months, the results are no better than conventional PTA. Other recent studies have demonstrated that directional atherectomy has no additional benefit compared with percutaneous transluminal angioplasty, and poses a greater risk of peripheral embolisation (18) (19) (20) . Several studies have recorded the significance of distal embolisation as a complication of atherectomy. Suri et al (21) used distal embolic protection in the popliteal artery in 10 patients, who underwent femoropopliteal atherectomy with adjunctive percutaneous transluminal angioplasty or open common femoral endarterectomy. Debris comparable to pieces normally removed from the SilverHawk chamber was retrieved from the filter in every case.

To date, there is no convincing evidence that atherectomy, whether used alone or in combination with adjunctive percutaneous transluminal angioplasty, produces any significant mid-or long-term benefit over angioplasty alone in the treatment of peripheral arterial disease. Although promising outcomes have been reported in early and more recent studies, the overall data in the available literature are highly variable and incongruent. Moreover, it is evident that distal embolisation is a common occurrence, with unknown clinical consequences.

success rates, ranging from 79 to 92%. However, limited short-and mid-term outcomes were disappointing, with a 1-year patency rate of 51% (7, 8) . The results using the Trac-Wright Catheter device showed widely differing immediate and midterm outcomes with severe complications such as perforation and dissection (9) . Similarly, studies using the Auth Rotablator device reported poor mid-term patency ranging from 31 to 61% at 1 year and 12-18% at 2 years, and significant complications including haemoglobinuria, thrombosis, embolisation and perforation (9, 10) . The overall inconsistency in reported patency rates and the frequent complications led to the conclusion by most interventionalists that atherectomy offered no advantages over the less expensive and simpler angioplasty balloons. This resulted in the technique falling out of favor in the mid 1990s and the procedure was more or less abandoned during the next two decades.

In 2003, the SilverHawk directional atherectomy catheter (EV3, Minneapolis, MN, USA) was approved by the US FDA for the treatment of peripheral arterial disease. The device is a low-profile, monorail rapid-exchange system with a 135-cm flexible shaft that can be introduced through a 6-to 8-Fr sheath and tracked over a 0.014-inch guidewire. The catheter tip consists of a tubular housing, which contains a rotating blade proximally and a nose cone that acts as the plaque collection chamber more distally. The proximal end of the catheter is attached to a battery-powered motor that powers the device. When the device is activated, the distal tip of the nose cone is deflected away from the plaque, which pivots the catheter against the lesion, and exposes the cutting blade. The blade rotates at 8,000 rotations per minute and as the catheter is slowly advanced across the length of the lesion, it shaves off the occlusive plaque from the vessel wall and packs it into the distal nose cone. Multiple passes are made through the lesion and the catheter is rotated to allow plaque excision in all quadrants. The excised atherosclerotic material is removed from the nose cone intermittently, as necessary. The SilverHawk system has undergone several changes since its approval, including an improved flushing system and torque transmission. It is also available in a range of diameters and catheter lengths, which, in turn, determine the sheath size, excision diameter and plaque storage capacity.

Several studies have reported the use of the Silverhawk device in femoral, popliteal and tibial arteries ( Table 2) . Early experience was reported in a series of publications by Zeller et al (11) (12) (13) (14) (15) . In one study, 71 femoropopliteal lesions were treated with an average stenosis length of 48 +/-64 mm (11) . Of these, 42% were de novo lesions, 38% were native vessel restenoses and 20% were in-stent restenoses. Residual stenosis following atherectomy alone was less than 50% in 96% of treated lesions, and in less than 30% in 76% of lesions. Adjunctive PTA was performed in 58% of lesions and stents were inserted in 7% of lesions. At 6 months, restenosis was seen in 27% of de novo lesions, 41% of native vessel restenoses, and in 36% of in-stent restenoses. Clinically, the ankle-brachial index was significantly improved in all groups, and more than 80% of patients were either asymptomatic or had no significant claudication. A subsequent study by the same authors (12) reported 12-and 18-month outcomes for 131 lesions, (34% involving de novo stenoses, 33% involving restenoses and 33% involving in-stent restenoses). 1-year primary patency rates were 84%, 54% and 54% for the three groups, and 2-year patency rates were 73%, 42% and 49%, respectively. The authors concluded that the best outcomes of SilverHawk atherectomy are seen in de novo lesions than restenotic lesions in the femoropopliteal segment. Three studies of short-to long-term experience in the treatment of infrapopliteal segments were also reported by Zeller (13) (14) (15) . They treated 49 infragenicular lesions in 36 patients with a mean lesion length of 48 +/-28mm by atherectomy. The target lesion was in the popliteal artery in 12%, tibioperoneal trunk in 51%, peroneal artery S114 C RSE

Radiology, UCSD Health Sciences, San Diego, CA, United States of America.

Learning Objectives 1. To understand the potential of oncolytic viral therapy 2. To explain the indications, materials and mechanisms of oncolytic viral therapy 3. To report on clinical results of oncolytic viral therapy and address its role in future The fundamental principle behind oncolytic viral therapy is that many viruses can selectively infect, replicate, and cause cell lysis within tumors that have genetic pathways that are up-regulated and down-regulated differently than non tumor host tissues. Viruses are selected that have an innocuous clinical course in humans and limited ability to undergo intracellular replication in normal tissues. Since patients have effective humoral and cellular immune mechanisms to clear circulating viruses, at present interventional radiologists are center stage given their abilities to deliver the viruses directly to the tumors, either via transarterial or intratumoral injections. Although it has been recognized since 1904 that viral infections or vaccinations occasionally can induce clinical remissions in patients with malignancies, especially those of hematopoietic origin, it has only been since 1997 that the technology of selective gene deletion and insertion has allowed production of safe, immunologically armed viruses. The results of two representative oncolytic virotherapy trials will be presented, involving two different viruses, one delivered transarterially, the other via direct intratumoral injection. Onyx-015 is a live, replication-competent Adenovirus attenuated with a E1b-55kD gene deletion (reference 1). The virus was injected via a transcatheter route into the hepatic artery in 35 patients with chemorefractory liver metastases from a GI primary. Nearly all patients developed flu-like fevers and chills, but no serious complications occurred. 43% of patients demonstrated a diameter reduction of at least 10% (responders). Median survival was 143 days in the 57% of nonresponders and 475 days in the 43% of patients who were responders (p<0.0001). JX-594 is a live, replication-competent Vaccinia virus that has had the thymidine-kinase gene deleted and an hGM-CSF gene inserted. This virus is injected directly into the tumors. The HEP-007 trial involved 34 patients with liver predominant HCC that had failed an accepted first line therapy. It was a multiinstitutional, multi-national Phase II randomized, prospective dosefinding trial comparing 1x108 pfu vs 1x109 pfu as a monotherapy. Interim results from the first 26 patients were presented at ASGCT 2011. All patients experienced flu-like symptoms. No grade 4 or 5 toxicities were reported. The 1x108 cohort had a median survival of approximately 6 months that closely followed the Kaplan-Meier survival curves for the large randomized, prospective SHARP and Asia-Pacific Sorafenib trials. Alternatively, the 1x109 cohort had a median survival of at least 30 months. When selecting candidates for oncolytic virotherapy, a number of unique factors need to be considered in order to optimize safe and effective outcomes. Examples include prior exposure to the virus (e.g., HSV I), immunocompromised status (e.g. HIV, potential organ transplantation, steroids), conditions that could predispose to dissemination (e.g. eczema with Vaccinia), and concurrent anti-viral therapy (e.g. HBV, HCV, HIV). If oncolytic virotherapy is proven safe and effective in large randomized prospective trials, some of which are underway, this therapy could potentially be a major game changing technology for local regional therapies. For example, the biological selectivity of transarterially delivered viruses Learning Objectives 1. To identify selection criteria and contraindications for portal vein embolization 2. To select adequate interventional technique (portal access route and embolic material) 3. To discuss how we can predict and improve the outcomes Portal vein embolization (PVE) has been used for several years in an attempt to increase future liver remnant volume (FLRV) in cases of major liver resection. The embolization of one or more liver segments causes atrophy and the compensatory enlargement of the remaining liver. The volume increase is related to an effective embolization, which depends on the use of the appropriate technique and embolizing agents. To achieve the best results, the interventional radiologist must be aware of the anatomic variants of the portal system, should have deep knowledge of the available materials, and dominate the techniques of embolization with the use of all the different tools at his/her reach. Patient selection is crucial, and has to take place in a multidisciplinary environment, involving at least surgeons, oncologists and diagnostic and interventional radiologists. For this selection, everyone involved should be aware of contraindications and limitations of the technique, including chemotherapeutic regimens, or underlying disease, that may affect liver regeneration. In this way, the multidisciplinary team tries to predict the results of PVE on an individual basis for each patient. Contraindications for the procedure can be assessed with imaging and laboratory tests. Invasion of the portal vein in the side to be resected is a contraindication. There are some relative contraindications, which can be assessed on pre-procedural tests. Tumor extension to the FLR has to be evaluated, as it can change the surgical approach. Coagulopathy, portal hypertension, and renal failure can contraindicate the procedure. Detailed evaluation of the portal anatomy and the degree of liver involvement should be ascertained on a pre-treatment CT scan or MRI. With this information the IR team will plan the access route and the technique to access the segmental branches it wishes to embolize. In this first evaluation, the sizes and types of embolizing materials can be selected. In the angio suite, the IR team will access the portal vein via the planned route. In the authors' experience, puncturing an ipsilateral peripheral branch is the preferred approach. With ultrasound guidance, one can reduce the rate of complications and, hopefully, the procedure time. With a reverse curve catheter, the selection of the vessels to be embolized is made. At our institution, PVA embolization particles and coils are used to embolize the intended segments. Options include the use of cyanoacrylate, alcohol, embolizing polymers or vascular plugs. There is a low rate of complications, ranging from 9 to 13%. They include, as with all transhepatic procedures, subcapsular hematoma, hemoperitoneum, hemobilia, vascular fistula, pneumothorax and sepsis. Portal vein thrombosis can occur. Non-target embolization is rare. The use of new technologies, such as rotational-CT may improve the technique, either by better results or by faster procedure. Even for uptake in tumors with no replication capability in non-cancerous tumorous tissues would eliminate the necessity for embolization of hepatosplanchnic (aka hepatoenteric) arteries, as is frequently necessary for Y90 radioembolization. Additionally, the feature of secondary infection of additional tumors after cell lysis of the initial targeted tumor for interstitial delivery allows treatment of far larger and more numerous tumors than is practical for thermal ablative techniques. Given the novelty of the technology and the challenge of safe and predictable production, transportation, and on site dose preparation of viruses, the issues of universality of availability and the cost of treatment are not known. 1. To describe evolution, concepts and potentials for chemosaturation 2. To describe how to perform hepatic chemosaturation 3. To present the results of clinical studies The evolution, conceptual basis, and clinical applications of percutaneous isolated liver perfusion (also known as Hepatic Chemosaturation) are briefly outlined. Basic principles, device evolution, and current practice patterns are reviewed. The chemosaturation procedure can be repeated and is minimally invasive and image guided, in contradisctinction to the open surgical version of isolated liver perfusion. The technique and pitfalls are outlined as well as step-by-step recipe for the IR physician. Tools to mitigate risk of complications will be reviewed, as well as pitfalls to be avoided. Public clinical results to date will be referenced, as well as potential future areas of study. Percutaneous hepatic chemosaturation is a truly regional therapy with ultra-high dose chemotherapy delivered to the entire liver before being filtered and removed with an extracorporeal circuit.

C RSE CIRSE Abstract Book

How to assess diabetic foot problems clinically

Internal Medicine, Maastricht University Medical Center, Maastricht, Netherlands.

Learning Objectives 1. To understand the clinical patterns of diabetic foot disease 2. To learn about the different forms of diabetic ulcers 3. To understand the treatment options Introduction: Diabetic foot ulcers are one of the most feared complications of diabetes, resulting in a high burden of disease for both the patient and the health care system. It is estimated that approximately 25% of all diabetic patients will develop a foot ulcer and that 1 in 15 will loose (part of) their leg. These ulcers tend to heal slowly, during this period patients need intensive treatment, are limited in mobility and have a marked loss in quality of life. In the past the foot was the Cinderella in diabetes care and diabetes research, but this relative neglect, by both doctor and patient, has clearly changed in the last decades. In particular, the founding of the multidisciplinary International Working Group of the Diabetic Foot (IWDGF) has resulted in the production of evidence based, international, guidelines on the management of diabetic foot ulcers. From pathophysiology to management: Treatment of diabetic foot ulcers is based on relative simple set of principles and with such a structured approach healing rates of more than 70% should be obtained. Biomechanical relief: Diabetic foot ulcers are usually caused by a combination of factors. In more than 60% of the patients the ulcer is caused by the combination of neuropathy, deformities and a minor trauma (frequently ill-fitting shoes). The vast majority of patients with a foot ulcer have diabetic neuropathy, which results in loss of sensation, muscle weakness and autonomic neuropathy. Due to the motor weakness and foot deformities, the foot is abnormally loaded during walking. But, due to the loss of protective sensation the patient does not feel any warning symptoms with a poorly healing ulcer as the final result. The first cornerstone in treatment is therefore pressure relief, as no treatment can compensate for the continuous biomechanical stress during standing and walking. Several measures can be taken to protect the ulcer from external forces. For neuropathic plantar ulcers the total contact cast (TCC) or an alternative casting technique should be seen as the gold standard, with up to 90% healing rates. The TCC is a non-removable plaster cast that is molded to the contours of the foot in order to redistribute the plantar pressure and the cast will also restrict walking. One of the explanations of the efficacy of a TCC or other irremovable casts is the simple fact that they cannot be removed by the patient. Once a cast is made removable, patients wear the off-loading device in only a minority (28%) of the steps taken each day. Finally, there also appears a barrier at the level of the health care professionals. As shown in the Eurodiale study a cast was prescribed in only 35% of the patients with a neuropathic foot ulcer treated in European diabetic foot centers, with a range of 0-68% between the participating centers. Off-loading and protection of non-plantar ulcers is usually less problematic and can be achieved using felt, special orthoses and/or shoe adaptations, resulting in sufficient pressure relief to enable healing. Improvement of skin perfusion: Restoration of skin perfusion is the second cornerstone in the treatment of diabetic foot ulcers. The presence and severity of peripheral arterial disease (PAD) is one of the major determinants of the outcome of diabetic foot ulcers. Of all patients with a foot ulcer, approximately 10% have a ischemic ulcer, 30-40% have a neuro-ischemic ulcer and the rest have a neuropathic ulcer. Although there are no major differences in the histology of PAD between diabetic and non-diabetic patients, PAD in diabetes does have specific characteristics. The proximal vessels are filling all the criteria for a successful procedure, the volume obtained after PVE can be insufficient to allow a major liver resection. Some novel techniques, such as the right hepatic vein embolization (HVE) described by Dr. Hwang's team, are now used to accelerate FLRV increase. The authors will try to review all these items, hoping to achieve better patient and technique selection and, consequently, improve the outcome. To learn about disease patterns Aim: Diabetes-related foot disease is a major health problem leading to significant morbidity and cost. If high risk populations could be identified and treated before they develop foot complications this would have the potential to significantly reduce the burden of foot disease and amputations. We examined the evidence to support population-based screening programs.

The MEDLINE and EMBASE databases were searched for articles from January 1970 to February 2012 to identify studies assessing the impact of screening on lower limb complications in patients with diabetes. Foot screening was defined as combined risk stratification and intervention to prevent foot complications in a population of people with diabetes mellitus. Articles reporting singularly on stratification of risk factors to predict subsequent complications and those studies not reporting major and/or combined major and minor (total) amputation were excluded. Results: Only two randomized control trials were identified demonstrating patient benefit from screening in the setting of a general secondary care diabetes clinic and renal dialysis unit. A further four before and after studies suggested benefit from primary care or regional screening. One study tried to address confounding from general improvements in the provision of diabetes foot care separately from screening. All the observational studies were prone to significant confounding by their design.

The evidence base for formal national primary carebased foot screening of all patients with diabetes is weak. More focused research is needed to confirm that general populationbased screening in the community effectively prevents diabetesrelated complications of the lower extremity. Limited evidence suggests that screening of high risk populations of patients may be justified.

ted during their course and apart from ischemia, infection is a major cause for a lower leg amputation. Unfortunately, due to neuropathy and ischemia, patients can have few local signs or symptoms, such as pain or redness. Moreover, in >50% of patients with a deep foot infection, systemic sings of infection, such as fever or elevated CRP, are absent. The foot consists of several compartments and once a deep compartment is infected the intra-compartmental pressures will rise due to oedema, resulting in a vicious circle of capillary failure, necrosis and progressive infection. Early diagnosis of such infections is therefore critical to halt the progressive tissue loss. In case of a superficial ulcer, oral antibiotics aimed at Gram positive cocci will usually suffice. Surgical drainage with decompression of the infected compartment is frequently necessary in patients with a deep foot infection and in severe infections a partial foot amputation may be necessary to save the leg. Patients with infections in subcutaneous tissues are treated with intra-venous broad-spectrum antibiotics until the results of the culture are known, as these infections are usually polymicrobial. In particular, the combination of infection and PAD is associated with a poor prognosis and should be seen as a medical emergency. In the large-scale Eurodiale study, the outcome of diabetic foot infections was, in general, relatively good, but poor results were obtained in patients with the combination of PAD and infection. The major and minor amputation rates after one year were 10% and 44%, respectively, when both were present in the same patient. In these patients with infected, deep (neuro-)ischemic ulcers immediate drainage with removal of all the necrotic tissues should be considered and iv antibiotics are started after material is obtained for culture. At the same time the work-up for a vascular intervention should be performed and if deemed necessary a revascularisation procedure should be performed once the infection is under control and the patient is stabilised. Time is tissue in this phase. Once blood flow is restored to the foot, either by bypass-surgery or an endovascular procedure, and infection is treated a final foot operation with soft tissue and skeletal reconstruction can be necessary to create a foot that remains functional. Wound care: Once the ulcer is off-loaded, infection is controlled and perfusion is improved, the wound should be treated at least once a week with mechanical removal of all necrotic tissue. In this phase it is also essential to create an optimal milieu for wound healing, with strict metabolic control of the diabetes, treatment of heart failure or poor nutritional state, anemia, etc. Although many wound products have been advocated in the treatment of diabetic foot ulcers, the available evidence is usually thin or the beneficial effects are relatively small. Organisation of care: Treatment of foot ulcers and prevention of amputations require a structured, multidisciplinary approach. Multiple disciplines are involved such as internists, surgeons, podiatrists, intervention radiologists, specialised shoemakers, etc. In each hospital treating patients with diabetic foot ulcers a well-coordinated structure has to be present, with clear definition of the role of the different team members and with optimal logistics. Several studies have shown that with such a multidisciplinary team approach a marked reduction (>50%) in the number of lower leg amputations can be achieved. relatively spared, with extensive, diffuse and usually bilateral lesions in the vessels of the lower leg. Although the disease mainly affects the vessels below the knee, the foot arteries are frequently spared. The media of the vessels is frequently calcified (Mönckeberg's sclerosis) due to autonomic neuropathy. Only a minority of patients have intermittent claudication and due the neuropathy many have no rest pain despite the presence of severe ischemia. Although many patients have signs of PAD, this does not preclude healing. As shown in a casting study, optimal off-loading can result in ulcer healing in the majority of patients with a neuro-ischemic foot ulcer, but without critical limb ischemia, although the time to heal was longer compared to patients without PAD. Diagnosing PAD is usually not the problem in patients with diabetes but assessing its severity and, in particular, its influence on the wound healing potential of an ulcer is frequently difficult. Clinical examination is of limited value, the intra-and inter-observer variability of this examination is not optimal. Non-invasive vascular assessment plays therefore an important role in the vascular work-up. Unfortunately, determination of the Doppler ankle pressure is also of limited value as Mönckeberg's sclerosis can lead to a falsely elevated ankle-brachial index. An ABI of <0.6 or an absolute ankle pressure of <70-80mmHg indicates significant ischaemia with a low probability of wound healing. ABI values or ankle pressures above 0.6 or 70mmHg provide very limited information about the wound healing potential, and other methods such as toe pressures and transcutaneous pressure of oxygen (tcPO2) can provide additional information. When toe-pressure or tcpO 2 pressures are < 30mmHg, the chance of healing is low and angiography should be considered. However, given the limitations of these techniques, angiography should always be considered in any ulcer that does not heal within 4-6 weeks despite optimal therapy. When angiography is performed it is essential that both inflow and outflow into the foot are adequately visualised, inadequate visualisation of foot arteries can result in unnecessary lower leg amputations. If PAD of sufficient severity to impair wound healing is identified, revascularization (endovascular or bypass) should be considered in all ambulatory patients. Bypass grafting using autologous vein and balloon angioplasty represents the most commonly used techniques. Limb salvage rates as reported in several studies are between 78 and 85% at 1 year. The aim of revascularization is to restore direct pulsatile flow to at least one of the foot arteries, preferably the one feeding the wound. In recent decades interesting results have been reported on endovascular approaches. In general, when endovascular revascularization and open repair or bypass of a specific lesion give equivalent short-term and long-term results, endovascular techniques should probably be used first, given their lower risks and costs. There are currently no randomized controlled clinical trials comparing open with endovascular revascularization techniques in diabetic patients with an ischemic foot ulcer, but the major outcomes of both techniques appear similar. Both techniques are complimentary, and both should be considered in each patient. The vascular specialist treating a diabetic patient with a (neuro-)ischaemic foot ulcer should be competent in both open and endovascular therapies, or the patient should be treated by a multidisciplinary team that can provide the most appropriate therapy. In case series where angioplasty was the preferred first-line option for revascularization, this approach appeared feasible in most patients, and favourable results were obtained; bypass surgery was only required in a minority of these patients. Another interesting new development is the stimulation of collateral formation in the ischemic leg. Several studies suggest that intramuscular injection of autologous bone marrow or peripheral blood mononuclear cells into the affected leg might improve peripheral blood flow and prevent amputations in patients with critical limb ischemia. However, RCTs with sufficient number of patients are needed before definite conclusions can be drawn about the efficacy of this new treatment modality in diabetic patients with (neuro-)ischemic foot ulcers.

The majority of foot ulcers will become infec-

Epistaxis is the #1 ENT emergency. The lifetime risk for epistaxis is 6% and the cases that require treatment predominantly occur in the elderly. It is self-limiting in most cases and the etiology is either (1) idiopathic (65%), (2) traumatic/iatrogenic (25%) or (3) hereditary hemorrhagic telangiectasia (10%). Local triggers for epistaxis are anatomic defects of the nasal septum, trauma, surgical complications, vascular malformations or neoplasms. Systemic triggers are hypertension, specific drugs (anti-platelet therapy, warfarin, cocaine), hereditary hemorrhagic telangiectasia or other hemostatic disorders. Hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber syndrome) is characterized by the following diagnostic criteria:

(1) epistaxis, (2) telangiectasias (multiple; lips, oral cavity, fingers nose), (3) visceral lesions, GI telangiectasia and/or AVMs (pulmonary, hepatic, cerebral, spinal) and (4) a positive family history. Anterior bleeding from Kiesselbach's plexus is much more common, less severe, often self-limiting and conservative treatment with local pressure, anterior nasal packing and cautery are very effective. Posterior bleeding, often fed by the sphenopalatine artery, is much more severe and often requires additional treatment by endoscopic surgical ligation or endovascular embolization. Surgical arterial ligature can comprise occlusion of the external carotid artery, the internal maxillary artery and/or selective ligation of the sphenopalatine artery. It is highly effective (89%) and has a low rate of complications (e.g. paresthesia, sinusitis, fistula formation). The indication for IR for epistaxis is posterior epistaxis that was refractory to standard treatments. Its advantages over surgical ligation are the direct route to the target lesion, treatment also of the collateral blood flow, lesser costs and a shorter hospital stay.

Radiologie Interventionnelle, CHC Liège, Hopital Erasme Bruxelles, Liège, Belgium.

1. To learn about non-invasive diagnostic tools in diabetic foot 2. To learn about CTA and MRI in the evaluation of the diabetic foot 3. To learn about the role of angiography Foot complications, the foremost cause of morbidity, mortality and disability in diabetics, often lead to lower extremity amputations, although prompt and accurate diagnosis and treatment reduce the need for amputation. The diagnostic work-up includes two main categories of explorations: a) non-invasive techniques clinical techniques (Ankle-Brachial Index, ABI), capillaroscopy, transcutaneous oxygen pressure (TcPO2), laser flowmeter, and pulse volume recordings, each one has its own advantages and disadvantages that will be compared briefly. b) Imaging techniques. As a Radiologist, the author will mainly describe different imaging capabilities and will propose some algorithm to finally lead to diagnosis and treatment. "Diabetic foot" involves critical lower limb ischemia and soft tissue ulceration frequently associated with osteomyelitis. Both have to be detected as soon as possible, so repeated examinations including non-invasive techniques and cautious clinical examination are necessary, and if an ulceration is visible or if critical limb ischemia is suspected imaging techniques are indicated to establish diagnosis of osteomyelitis and to demonstrate as clearly as possible the anatomical vascular tree to planify the best treatment to increase distal perfusion blood pressure. Pedal ulcers, the most common complication of diabetic forefoot are portas of entry for infection. As most patients lack clinical signs and symptoms imaging is crucial. 1. Imaging osteomyelitis: if plain film radiographs might be useful for anatomical information, they are neither sensitive nor specific. Nuclear tests as labelled leucocyte scintigraphy and more recently SPECT/CT are valuable for diagnosis and follow-up. MRI with multiple planes in T1, T2, inversion recovery and T1 post-intravenous gadolinium with fat saturation offers exquisite anatomical detail which is invaluable for guiding surgical management. Pathology and imaging of the forefoot and mid foot will be described. 2. Imaging vascular tree: detection of critical lower limb ischemia is not the appendage of diabetics, but these are vascular characteristics which modify the imaging work-up for those particular patients. Despite stenosis in large arteries might be present, distal microangiopathy is common in diabetes, so the exploration has to be as distal as possible. Calcifications and megacalycosis are frequently extensive, it leads to choose some imaging technique not influenced by calcium. Early venous return in diabetics (with or without ischemia and ulcer) indicates high temporal resolution technique to differentiate arteries from veins. Duplex scanner remains an important first-step helping clinicians and completing non-invasive armamentarium. MRA with its calcium independency and 4D time-resolved technique is superior to CTA for lower limb stenosis assessment in diabetics, some chosen examples will support this affirmation. Potential complications, pitfalls or contraindications have to be estimated (renal insufficiency, stents, etc.). Digital subtracted arteriography (DSA) is the gold standard, it has to be precise and selective to image distally, so it is classically dedicated to endovascular treatment, except in cases of unsatisfactory imaging (MRA or CTA) especially for distal tibial and pedal arteries, which are actually treatable by endovascular techniques as far as in the foot. The couple MRI and MRA seems to be the best choice if they are available. Selective and distal angiography remains very useful especially in case of distal recanalisation and is frequently performed in the same session.

artery of foramen rotundum originates posteriorly from the distal part of the maxillary artery and belongs among dangerous anastomosis to the intracranial circulation in case of embolization. It also acts as a pathway for revascularization when the maxillary artery is occluded too proximally (12) (13) (14) . The facial artery supplies the external anatomical structures of the nose. The superior labial artery arising from the facial artery is rarely visible on angiograms. In case of recurrent epistaxis the facial artery becomes the significant feeder of the distal territory of a proximally occluded maxillary artery. The internal carotid artery: The anterior and posterior ethmoidal arteries are branches of the ophthalmic artery, a branch of the internal carotid artery. They arise from its intraorbital segment and anastomose with nasal branches of the sphenopalatine artery. The ethmoidal arteries are visible only in the presence of hypervascularized tumors of the nasal cavity or in proximal occlusion of the maxillary artery. The ophthalmic artery could be the branch of the external carotid artery in rare congenital anomaly. The vidian artery is a branch of the petrosal segment of the internal carotid artery. It goes in horizontal vidian canal to supply the mucosa of the sphenoid sinus. However, it is seen rarely on angiograms. The carotid siphon and cavernous sinus are both in close proximity to the sphenoid sinus. Therefore, ruptured aneurysms or injury (15) of the artery can result in massive epistaxis. Failure to recognize dangerous anastomoses due to incomplete angiogram or inadequate analysis is a frequent cause of ischemic neurological deficit after embolization in the skull base (16, 17, 18, 19) . 1. To review vascular anatomy relevant to IR for epistaxis 2. To review variant anatomy relevant to IR for epistaxis 3. To review relevant collateral arterial pathways The majority of epistaxis has its origin in the anterior septal area. Hemorrhage from this region can be usually treated well since it is readily accessible if bleeding does not resolve spontaneously. The anterior epistaxis is not an indication for angiography and endovascular therapy. In approximately 5% of epistaxis, the origin of the bleeding is located more posteriorly on the nasal cavity. This socalled posterior epistaxis requires posterior nasal packing and/or endoscopic cauterization (1, 2) . If these measures fail, subsequent treatment can consist of endoscopic cauterization or ligating of responsible nasal artery as near as possible to the bleeding point. Surgical ligating of the artery that is at a distance from the bleeding point has to be avoided since it limits access for endovascular therapy and seems to be less effective because of the rich cross-circulation from the other side (3) . The endovascular therapeutic embolization of the epistaxis has gained acceptance during last 30 years (4). Since angiographic imaging of the extravasation point is rare, familiarization with and understanding of the arterial anatomy is essential for safe and effective endovascular therapy (5) (6) (7) (8) (9) (10) (11) . Specific angiographic signs include a tumor blush, telangiectasias, a traumatic pseudoaneurysm or even contrast extravasation. The selective internal carotid artery angiography can reveal another source of epistaxis such as a mycotic or traumatic aneurysm. The arterial supply to the nasal cavity includes branches from both the external and the internal carotid arteries. The external carotid artery originates from the bifurcation of the common carotid artery and lies anteriorly to the internal carotid artery in the majority of patients. The internal maxillary artery or the maxillary artery is the largest branch of the external carotid artery. The second most important branch of the external carotid artery which is relevant to epistaxis is the facial artery, the former "external maxillary artery". The external carotid artery: The maxillary artery is divided anatomically into three major portions based on its relationship the external pterygoid muscle. The first (mandibular) and second (pterygoid) portions are proximal to and in contact with this muscle, respectively. The most distal part (pterygopalatine) is beyond the external pterygoid muscle and within the pterygopalatine fossa. The sphenopalatine artery, which arises medially through its foramen, serves as the major supply to the nasal conchae, the region of choane and nasal septum via the lateral and medial branches. The descending palatine artery, which arises inferiorly, runs in the pterygopalatine canal around the posterior limit of the nasal cavity. The S120 C RSE CIRSE Abstract Book a vertebral or Berenstein catheters amongst other shaped catheters. A microcatheter that will allow the use of particles of up to 500 microns and a range of compatible guidewires will be required. The choice of microcatheter will also depend on the intended embolic agent. A co-axial catheterisation technique is usually used employing a guide catheter and microcatheter. A 5-French guide catheter with a large internal lumen will allow guiding contrast injections as well as constant flush via the side arm of a rotating haemostatic valve. This will ensure that the dead space between the guide catheter and microcatheter is continuously flushed to prevent thrombus accumulation and to minimise the risk of inadvertent embolisation by the formation of pericatheter thrombus. Vasospasm is a common consequence of catheter manipulation, particularly in the external carotid artery (ECA) branches. Gentle microcatheter and guidewire movement can help to minimize this phenomenon. Clumsy movements may incite severe vasospasm in the ECA and result in the inability to image distal vessels or the impossibility to navigate and embolise distally. Glyceryl trinitrate, nimodipine or other vasodilators can be administered to treat this. It is vital that there is free blood flow around the guide and microcatheter throughout the procedure. A wedged catheter or stasis due to spasm will both encourage non-target embolisation and will support recruitment and filling from other collateral branches that may be more difficult or impossible to access. Complete bilateral internal and external carotid angiography is imperative before undertaking embolisation because bleeding may originate from unsuspected sites such as an accessory meningeal artery or the infraorbital artery. It will also identify intracranial artery anastomoses and particularly those potentially dangerous ophthalmic branches that establish extra-to intracranial anastamoses. The most useful angiographic projection of the ECA is the lateral view, which profiles nearly all vessels. However, distal portions of the IMA are best demonstrated on frontal and oblique frontal views. Selective angiography of ECA branches should be performed formulated by a plan based on the non-selective ECA angiographic findings. ICA angiography is imperative. Although rare, aneurysms of the ICA can present with epistaxis. In addition, demonstration of ICA anatomy including vessel occlusion prior to embolisation is important because of the presence of ECA-to-ICA anastomoses and demonstration of the supply to the ophthalmic artery. Treatment of uncontrolled primary haemorrhage. The specific technique of delivery of the embolic material will have an influence on both the outcome and complications. The guide catheter should be located with its tip just within the external carotid artery and not advanced distally where it may reduce flow or incite vasospasm. The microcatheter should be advanced into the branch supplying the area of abnormal mucosa. There should be rapid flow around the microcatheter, the catheter should not be "wedged", and this can be assessed by injecting co-axially from the guide catheter. When a suitable position has been achieved then the embolic material is drawn up. Spherical particles are easy to use, should stay in suspension if mixed with an appropriate concentration of contrast medium and should not block the microcatheter if both are sized correctly. The embolisation is performed under fluoroscopic visualisation and will normally require that a subtraction angiographic run is performed during injection or that subtracted roadmap fluoroscopy is performed. The choice is at least partly dependent on the angiographic equipment and partly the preference and experience of the operator. What should be visible in the field of view is the target territory, the tip of the microcatheter and a segment of vessel proximal to the tip containing the microcatheter. During injection of the opacified embolic mixture the contrast should be observed flowing away from the catheter tip and washing into the target territory. As the embolisation progresses then the "blush" of abnormal mucosa will change, if Roadmap imaging is used the mucosal blush will intensify, if subtracted acquisitions are used the blush will increase during the run but become less during each subsequent run and embolic injection. In either case flow 

Standard embolization procedure

Radiology, Royal Free Hospital NHS Trust, London, United Kingdom.

1. To review technique and embolization materials for IR for epistaxis 2. To review results of IR for epistaxis 3. To review complications of IR for epistaxis Whenever an endovascular procedure is contemplated the coagulation profile and renal function should be assessed in addition to the usual laboratory investigations performed as part of the diagnostic pathway to determine the cause and severity of the epistaxis. Appropriate measures should be instituted to correct coagulopathic states and transfusion needs. Patients with renal impairment are at risk of iodinated contrast-induced nephropathy and appropriate pre-and post-procedural measures such as adequate hydration should be instituted. Equally importantly, the referring clinicians should be made aware of the possibility of this condition in order that it is managed appropriately if it occurs. The current indications for transarterial embolisation include: coagulation or tamponade and after abnormal coagulation has been corrected. Relative contraindications include: be considered as an alternative. Technique: medication General anaesthesia is the preferred state for facial interventional procedures and is mandatory when the airway is compromised by severe bleeding. It will be used routinely in children and in those adjudged to be poorly compliant patients. If sedo-anaesthesia is attempted then rigorous monitoring of the patient should be performed throughout the study to assess haemodynamic status and control the transfusion of blood and blood products. Intravenous opiates in combination with sedatives such as benzodiazepines are usually administered per procedurally and are often used as a premedication to general anaesthesia. Anti-inflammatory analgesics are often necessary after the procedure as patients may experience temporo-facial pain. Heparin should be administered to prevent the formation of thrombus on the catheter, which could result in inadvertent embolisation. If available, an activated clotting time (ACT) should be used to control heparin administration. Technique: angiographic Prior to angiography, nasal packing with radio-opaque materials such as BIPP-drenched swabs should be replaced with non-opaque material such as paraffin gel gauze. Suitable selective angiographic catheters for bilateral ECA and ICA diagnostic angiography include S121

The vessel is then ligated by the surgical team as a planned procedure and this may temporarily or permanently reduce the frequency or volume of haemorrhage. tion, angiography is repeated to confirm that the ophthalmic supply has been disconnected. It will also usually show that the ECA supply has increased and that these branches are now easier to navigate and allow safe embolisation. two strategies can be employed. 1. Embolise the ECA component and leave the anterior ethmoidal supply to be surgically ligated immediately afterwards. 2. If the operator is experienced at intracranial navigation then the vessel can be accessed using a double marker catheter with the goal of performing distal ophthalmic occlusion or ideally anterior ethmoidal occlusion. Clearly, the occlusion must be performed distal to the central retinal artery. Meticulous catheter care must be employed and the vessel occluded with a neuro retrievable, repositionable detachable coil.

mic artery unless there is an immediate threat to life and even then with the proviso that the patient has had the opportunity to discuss, and agree to, the increased risk of stroke and visual loss during the consent interview. Complications usually require only simple analgesia.

hard palate necrosis, its occurrence can only be minimised by careful attention to avoid excessive vessel occlusion. Plastic surgical repair may be required 1. In the nasal cavity this is achieved by transposition of a vascularised mucosal flap. 2. Skin necrosis may require resection, skin or vascular pedicle grafting.

bolisation of the vasa-nervorum of facial nerve branches, and blindness, all the results of non-target embolisation. from the microcatheter will begin to slow. Perhaps paradoxically, the slower the flow then the more conspicuous does the embolic material become. When flow is very slow and mucosal opacification minimal then further injection must stop. Care must be taken to prevent complete stasis. If stasis does occur then no more injections should be made through the microcatheter. The dead space of the microcatheter is in the order of 0.3ml and this will contain numerous embolic particles. If forward flow has stopped then injecting the microcatheter with contrast or even flushing it with saline will result in these particles refluxing back around the microcatheter tip and into the next forward flowing branch with inevitable non-target embolisation. The volume of particles that can be injected before flow slows is very highly variable. Great care must be taken when the flow begins to slow and, whereas, initially up to two or three syringes of particles may be injected without much appreciable change in flow velocity when slowing is first observed very small additional amounts, perhaps 0.1 to 0.2 ml can suddenly result in stasis. The volume of particles required to achieve debranching of the target is very variable. In some cases 0.5ml of particle suspension will be sufficient whilst in others 5-10ml will be required. Spherical particles (300-500 microns) are often suitable and can be used with standard microcatheters without occluding them. Larger particles will be needed where there is arteriovenous fistulation or if a very extensive lesion is shown. Larger particles will result in occlusion of larger, more proximal vessels and fewer are needed to slow the flow. The goal is to reduce the perfusion pressure in the abnormal tissue and not to infarct it. Stop when the feeding vessel is debranched but not occluded. Treatment of focal active extravasation that is the result of vascular disease or trauma. The goal here is to approach as close as possible to the point of extravasation and then block the bleeding vessel. If a distal superselective position is achieved then blocking the vessel with a liquid agent such as a cyanocrylate retarded with Lipiodol or OnyxTM are highly effective. Coils and particles may be used. Stop when the feeding vessel is occluded. Treatment of haemorrhage from tumour. The vascular anatomy of the tumour is defined by detailed angiography and vessels that supply the bulk of the tumour are chosen for treatment. It is vital to remember that the goal in these cases is to make surgery safer and that no risks are justified. Particles are usually used with a similar technique employed to that in the treatment of mucosal extravasation. Particles are washed into the tumour bed by embolising into a flowing vessel. Injection is terminated when the feeding vessel is debranched but there is still a little forward flow in the parent artery. The volume of embolic mixture required is very variable and the use of larger particles, 700-900 microns, is frequently justified. Stop when the feeding vessels are debranched but not occluded. Dealing with a large ophthalmic supply A large ophthalmic supply through an anterior ethmoidal artery is frequently seen when there is a high flow nasal lesion such as developmental vascular malformation or traumatic arteriovenous fistula. It is also seen in HHT and particularly when there has been treatment by proximal vessel ligation or previous embolisation. It may be safe to navigate the ophthalmic artery, the risks increase very markedly and it should be avoided if at all possible. When working closely with a team of experienced head and neck surgeons then the safest policy is to arrange for surgical ligation of the vessel via medial orbital access. The timing of this should be discussed with the clinical team, if there is no acute pressure to control haemorrhage such as when there has been frequent minor or moderate recurrent haemorrhage then performing angiography as a diagnostic procedure will identify the vessel if present.

planned.

C RSE To learn an overview of the PTA and bare stent trials conclusions Critical limb ischemia (CLI) is a serious condition affecting a growing number of patients worldwide, particularly as diabetes becomes a larger epidemic. A quarter million amputations are performed annually in the United States and Europe, and this number is even greater worldwide, resulting in a huge social and economic burden with a serious compromise in quality of life. Beyond lifestyle changes and medical therapy, arterial revascularization is a mainstay in the management of patients with CLI due to below-the-knee (BTK) disease in order to improve functional class and prevent complications possibly leading to amputation and limb loss. Surgical bypass grafting has long been considered the "gold standard" for BTK revascularization. CLI patients have extensive multivessel disease and challenging lesions, particularly in diabetic and renal failure patients. The BASIL study showed that in CLI patients, lower limb bypass and balloon angioplasty were associated with similar outcomes in terms of amputation-free survival. If untreated, CLI patients have a 1-year amputation rate of 50% or greater, with associated high morbidity and mortality rates. Limb salvage by surgery or endovascular techniques has improved the quality of life for patients, as well as 5-year survival rates. In CLI patients, endovascular techniques have been associated with lower morbidity and mortality rates than bypass surgery. Numerous endovascular techniques have shown limb salvage rates of >90% in CLI patients. Angioplasty (PTA) has been shown to lead to early risk of suboptimal result due to fibrotic or calcific lesions, abrupt vessel closure due to flow-limiting dissection or thrombus and late restenosis/re-occlusion due to recoil, constrictive remodelling and/or hyperplasia. Technical success rates of infrapopliteal PTA range between 80 and 100%. In a meta-analysis infrapopliteal PTA was compared with popliteal-to-distal vein bypass grafts: PTA primary patency at 6 months was 77% ± 7.0% and 58.1% ± 4.6% at 12 months significantly lower than bypass surgery with a primary patency rate of 85.8% ± 2.1% at 6 months and 81.5% ± 2.0% at 12 months. However, no significant differences were observed for limb salvage at 6 

Diagnostic Radiology, American University of Beirut Medical Center, Beirut, Lebanon.

Learning Objectives 1. To review variant and difficult anatomy when treating epistaxis 2. To review pitfalls and ways to deal with them when treating epistaxis 3. To review ways to avoid complications when treating epistaxis Vascular access in the treatment of epistaxis: how to tackle difficult anatomy Although most patients requiring treatment for epistaxis fall within the young to middle age group, difficulties in reaching the target vessel may be encountered. Pre-procedure CT angiography is a useful tool in identifying the pathology as well as providing detailed roadmap for the interventional radiologist to plan the procedure and is recommended whenever possible. If there is suspicion of aortoiliac disease then CTA should include that segment in addition to the aortic arch and neck vessels. Access problems can be approached as follows: 1-Problems with the femoral artery access: occlusion/stenosis/tortuosity of one or both iliac arteries or the abdominal aorta. Various strategies are available including consideration of a different approach such as brachial, radial or direct common carotid punctures. For severe stenoses consideration may be given to placement of stents in the stenosed access vessel. Tortuosity may be overcome through the use of coaxial systems and long sheaths. 2-Problems with the selective catheterization of the neck arteries: depending on the configuration of the aortic arch different shape catheters particularly the sidewinder variety and the use of long sheaths are frequently sufficient. Right brachial approach may be considered for accessing the left common carotid artery in the bovine arch variation. 3-Diffuclties in selecting the artery supplying the point of bleeding: different types of microcatheters/wires are available that make selection almost always successful. The outer and inner lumen of the microcatheter should be checked to ensure compatibility with the guide catheter and the intended embolization material particularly coils. In case Onyx is considered the microcatheter must be compatible with this material. 4-Venous access may be required in cases of fistulas such as carotid cavernous connections. Trans femoral approach is easiest but direct puncture of the ophthalmic vein may be considered if the femoral vein access is not possible or the route to the cavernous sinus is not available. 5-Direct puncture of isolated false aneurysms may be entertained. The distinction between normal mucosal blush and abnormal vascularity may be difficult at times; however, multiple views should clarify the anatomy. Choose the best projection that shows the parent artery and the branches that lead to the point of abnormality. All along meticulous technique and the use of heparinized saline flushing will reduce the likelihood of unwanted embolization particularly to the internal carotid artery territory. Microwires and microcathters should be advanced with care to avoid spasm. Hydrophilic wires facilitate catheterization but they may cause perforation or dissection. In case of spasm removal of the catheter and intrarterial injection of vasodilators is sometimes required. 

later in the present article. Most importantly, the patients' quality of life may also be dramatically improved if we prevent recurrent ischemia or even improve wound healing of ischemic ulcers. Three multicenter randomized trials (the YUKON-BTX, the DESTINY and the ACHILLES trials) are now available and have paved the way for high level of evidence about infrapopliteal use of drug-eluting stents. First, the outcomes of the YUKON-BTX multicenter randomized trial were published. The trial was designed to investigate the below-the-knee (BTK) performance of the novel polymer-free sirolimus-eluting YUKON-BTX stent (Translumina GmbH, Hechingen, Germany) versus the uncoated balloon expandable YUKON stent in 161 patients suffering from both CLI and intermittent claudication (IC). The 1-year follow-up was available in 77.6% of the patients and revealed a significantly higher primary patency rate in the sirolimus-eluting stent group (80.6%) than in the bare metal stent group (55.6%, p=0.004). As a result, a significantly superior clinical improvement of the patients enrolled in the DES YUKON BTX arm was demonstrated by a higher Rutherford category change. The median (interquartile range) change in Rutherford-Becker classification after 1 year was -2 (-3 to -1) in the YUKON stent group and -1 (-2 to 0) in the bare metal stent group, respectively (P= 0.004). The DESTINY (drug eluting stents in the critically ischemic lower leg) was the second large multi-center randomized trial investigating infrapopliteal DES application and was launched by Abbott Vascular. The DESTINY trial compared the performance of its Xience V everolimus-eluting balloon-expandable coronary stent with a Multilink Vision bare metal balloon-expandable coronary stent in below-the-knee arteries. The DESTINY trial took place in 7 centers throughout Europe randomizing 140 patients on a 1:1 basis. Between 2008 and 2009, 74 patients were randomized in the Xience V arm and 66 patients in the bare Multilink Vision stent arm with a maximum of 2 stents implanted in up to 2 lesions per subject (maximum lesion length of 40 mm).

After 1 year, everolimus-eluting stents achieved a strong inhibition of restenosis with a significantly reduced in-stent diameter stenosis (21±21% vs 47±27%; p< 0.0001) and mean in-stent late lumen loss (0.78±0.63mm vs 1.41±0.89 mm; p=0.001). Although major extremity amputations were rare in both groups (two in the control group and one in the Xience V group), improved vessel patency resulted in a considerably higher freedom from repeat target lesion revascularization; i.e. 91% for Xience V vs 66% for Vision (p=0.001). Cordis sponsored the ACHILLES study, which was a multicenter open-label randomized trial comparing the performance of its sirolimus-eluting balloon-expandable coronary and infrapopliteal stent (CYPHER SELECT sirolimus eluting stent) with plain balloon angioplasty in patients with BTK obstructive disease and Rutherford category 3-6 clinical symptoms. The ACHILLES study took place in 17 European centers and randomized 200 patients with de novo or restenotic (>70%) tibioperoneal or other tibial lesions on a 1:1 basis. Inclusion criteria allowed for a maximum of 2 vessels in 1 limb to be treated with a maximum of 4 stents for up to 2 lesions per subject (maximum lesion length of 90 mm). Still not available as a peer-review publication, we presented the final clinical outcomes of the study in last year's CIRSE 2011 annual meeting, Munich, Germany. More than 60% of the patients in both arms were suffering from CLI. Ninetynine patients were randomized to SES, and 101 patients to PTA. Eight patients crossed over to the sirolimus stent arm for bailout. Immediate success rate (residual stenosis <30%) was significantly higher in case of primary placement of a sirolimus-eluting stent (95.5% vs. 58.2% in the balloon group, p<0.001), and acute luminal gain was also higher according to residual post-procedural stenosis as calculated by quantitative analysis (13.3±14 .3% in the CYPHER arm vs. 25.9±15.2% in the control arm, p<0.001). The 12-month angiographic and clinical follow-up was available in 74.7% of the cases. The 12-month preliminary result regarding the primary endpoint of in-segment binary restenosis on an intention to treat basis was significantly inferior in the CYPHER group compared to plain balloon angioplasty (19.4% vs. 41.9%, p=0.006, respectively) . Driven by the Rutherford class 4, 82 patients (68.3%) were Rutherford class 5, and 17 patients (14%) were Rutherford class 6. There were 76 patients (63.3%) with one-vessel runoff, and the mean stented vessel length was 7.6 cm. At 6-month follow-up there were 36 target lesion revascularizations (31.3%), of which, 21 (18.3%) were symptomatic. There were seven major amputations (6.1%), four target and vessel revascularizations (3.5%). Wound healing data showed that 68 wounds (53.5%) were 100% healed, 43 (33.9%) had significantly decreased wound areas, and 16 (12.6%) had increased wound areas at 6-month follow-up. However, before stenting, the vessel should be adequately pretreated with balloon angioplasty-scoring balloons if the lesion is rigid and calcified-and debulked with atherectomy devices if the lesion is complex, heavily calcified, or if a long chronic total occlusion is present. This will allow for proper stent expansion and sizing and will help prevent stent elongation, which could increase restenosis and stent fracture rates. Obviously results will be better if an adequate runoff is present. It is also important to adequately treat significant inflow and outflow disease before stenting. Favourable data have been reported by Bosiers et al. on 20 patients with CLI treated with bioabsorbable metallic stents, which hold the promise of enabling non-invasive and repeated treatment of severe atherosclerotic disease without the need to implant a permanent material. 1. To review the drug eluting stent trial designs 2. To review the outcomes of the drug eluting stent trials 3. To learn an overview of the drug eluting stent trials conclusions Modern critical limb ischemia management algorithms endorse an "endovascular first" strategy of treatment. The advent of stents coated with anti-restenotic agents that are gradually eluted to the vessel wall has revolutionized modern endovascular therapies. Several single-center, nonrandomized cohort series have provided compelling data about the short-to mid-term safety and effectiveness of drug-eluting stents (DES) in below-the-knee lesions and have fuelled further large-scale research. Arguably, improved limb salvage remains the cornerstone endpoint for the evaluation of all new infrapopliteal instruments and technologies for critical limb ischemia (CLI) treatment. Nonetheless, inhibition of neointimal hyperplasia by DES not only leads to improved vessel patency but above all to sustained clinical improvement as will be elaborated S124 C RSE CIRSE Abstract Book superior in long lesions, too. It is the question whether the promising results that have been obtained in the superficial femoral artery may be transferred to below the knee? A single center study including mostly patients with critical limb ischemia and diabetes has compared regular angioplasty (POBA BTK) vs DEB angioplasty (DEB BTK) of lower limb arteries. Lesion length was 183 mm (POBA BTK) compared to 173 mm (DEB BTK). At the 3-month follow-up restenosis >50% was found in 69% of cases (POBA BTK) compared to 27% of cases (DEB BTK) with a 61% of restenosis reduction using DEB below the knee. In addition, the length of restenosis was significantly shorter with 64 mm compared to 155 mm. The 12-month follow-up showed clinical improvement of 91% of patients with a complete wound healing in 74% of patients. The re-intervention rate was 17%. 4 patients only underwent amputation below the knee or forefoot. Three of those patients showed a patent-treated artery at angiography. Although the number of studies examining the outcome of DEB below the knee is small there is a trend showing better results of DEB compared to regular angioplasty. The patency of the treated vessel segments seems to be higher; however, it is not yet obvious whether the improved patency following DEB may be translated in a better clinical outcome on a long term basis.

Do the trials support the use of stem cell and gene therapy?

Dept of Cardiac Radiology, All India Institute of Medical Sciences, Delhi, India.

1. To learn about stem cell therapy in the BTK circulation 2. To learn about gene therapy in the BTK circulation 3. To learn the trial data on stem cell therapy and gene therapy in BTK occlusive disease Management of advanced obstructive peripheral vascular disease affecting the infra-popliteal segments poses tremendous challenges. Surgical and endovascular options have limited value in view of the frequent unfavorable image morphology characterized by diffuse, multi-focal and multi-segment occlusive lesions with poor or absent distal run-off vessels. Approaches involving angiogenesis and cell-based therapies have emerged as a new frontier in this treatment and may have the potential to fulfill a crucial clinical need in these patients. Therapeutic angiogenesis using recombinant proteins and genes amplifies adaptive neovascularization and perfusion in tissues compromised by ischemia. There is evidence to suggest that administration of growth factors can be employed to significantly improved angiographic outcomes, the ACHILLES trial was the first ever BTK trial to provide evidence of sustained clinical improvement in terms of both Rutherford classification improvement and better wound healing outcomes after independent adjudication by an expert diabetic foot specialist. Claudication symptoms (Rutherford class) and the rate of closed wounds were numerically lower in the as-treated population at 1 year, albeit on the verge of statistical significance (p=0.077 and p=0.088, respectively). Finally, a post-hoc life-table analysis of the composite endpoint of event-free survival as defined by freedom from death, TLR, bypass surgery, major amputation, or Rutherford Class ≥ 4, showed a significant difference in favour of the sirolimus-eluting stent group after 1 year follow-up (p=0.028). In conclusion, current evidence, including 3 large-scale randomized trials, supports primary use of olimus-eluting stents for focal obstructive infrapopliteal lesions. Further technical and cost-utility issues remain to be addressed before their wider adoption in the everyday treatment of more diffuse BTK disease. 

Zentralinstitut für Radiologie und Neuroradiologie, Krankenhaus Nordwest, Frankfurt am Main, Germany.

Learning Objectives 1. To review the drug eluting balloon trial designs 2. To review the outcomes of the drug eluting balloon trials 3. To learn an overview of the drug eluting balloon trials conclusions Infrapopliteal balloon angioplasty has reduced the rate of lower limb amputations significantly. Technical success of infrapopliteal limb angioplasty is >90% for stenoses and 60-78% for artery occlusions, respectively. Early clinical success is 99% for stage III disease according to Fontaine and 90% for stage IV disease. Although only 40-50% of treated vessel segments remain patent within the following months limb salvage is as high as 85-97% and 72-87% after 1 and 2 years of angioplasty, respectively. Long-term limb salvage after initial infrapopliteal angioplasty even reaches 83% (5-years). Two randomized multi-center trials (THUNDER and FemPac) comparing percutaneous balloon angioplasty (POBA) versus angioplasty using drug-eluting balloons (DEB) in the superficial femoral artery show significant better results for the treatment with drugeluting balloons. After 6 months the rate of restenosis is only 17% and 19% (DEB) compared to 44% and 47% (POBA), respectively. After 24 months there is still a significant better outcome of DEB compared to POBA in short lesions up to 7,5 cm length. According to more recent studies DEB of the superficial femoral artery is Special Session Acute lower limb ischaemia

Radiology, Hull Royal Infirmary, Hull, United Kingdom.

1. To review the current literature on lower limb thrombolysis 2. To describe conflicting evidence regarding treatment 3. To give recommendations on how to deal with acute ischaemia in 2012 Acute lower limb ischaemia (ALLI) may be defined as rest pain or other features of severe ischaemia, of less than two weeks duration, in a limb that was previously symptom free or affected by intermittent claudication. The reported incidence is in the region of 1 per 5000 of the population per year and diabetic patients are more frequently affected. In current clinical practice, ALLI is most often due to in situ thrombosis in diseased atherosclerotic vessels. This may be precipitated by other factors such as hypotension during surgery or low-output cardiac failure and is also associated with malignancy. Embolic occlusion now accounts for a much smaller proportion of cases of ALLI and other causes such as trauma and extrinsic compression are very rare, usually occurring in younger patients. The severity of ALLI is often classified according to SVS/ISVS guidelines, in order to distinguish those patients in whom endovascular treatment should be considered from those who may require emergency reconstructive surgery or even amputation. In clinical practice, the limb may be considered as viable, threatened or irreversible, depending on the degree of ischaemia. It is in the first two of these groups that thrombolytic therapy may be considered if there are no contraindications. A number of factors, such as the presence of pre-existing collateral vessels, will affect the haemodynamic consequences of acute arterial occlusion. In a patient with sudden embolic occlusion, in the absence of preformed collaterals, the consequences are likely to be more severe than for a patient who develops thrombosis in situ following a history of claudication. The acutely ischaemic limb presents with pain, pallor, sensory and motor impairment. Calf tenderness and swelling reflect irreversible ischemia but in the patient with sensory impairment and only early motor changes, there is the potential for limb salvage. The use of thrombolytic therapy has been widely reported in the management of ALLI. However, despite the volume of published data describing the use of thrombolytic therapy in this condition, some uncertainty and concerns remain regarding its efficacy and applicability. augment perfusion and collateral flow. A large number of growth factors have been shown to demonstrate angiogenic potential. Among them, vascular endothelial growth factor (VEGF) and fibroblast growth factor (FGF) have been best characterized. Many clinical phase 1 and 2 trials have evaluated the safety and efficacy of this approach with mixed results. Some studies have shown an improvement in rest pain and limb integrity. There is emerging evidence to suggest that the effect of this therapy may be more pronounced in Berger's disease than in atherosclerosis. In trials in which no statistically significant difference in the amputation rate was observed between the treatment and control arms, significant improvement in clinical symptoms was nonetheless observed in those who received the growth factors. Even though there are potential risks of gene therapy, no significant increase in mortality has been recorded in any angiogenic gene therapy trial. In addition, there is no in vitro or in vivo data to suggest that methods of therapeutic angiogenesis increase the risk of neoplastic growth or metastasis. However, longer-term follow-up may be needed to resolve this issue. The doses of VEGF used in human studies have also not shown any risk of angioma formation in the treated limbs. In addition, there is no evidence to suggest that a transient increase in the levels of circulating VEGF and FGF levels achieved during treatment is risky with respect to plaque angiogenesis and atherogenesis. So far, no significant increase in mortality related to athero-thrombotic events has been reported in any angiogenic gene therapy trial. Therapeutic angiogenesis using stem cells has the potential to rewrite the treatment algorithms in patients with critical or chronic limb ischemia. Stem cells from embryonic tissue have pluri-potent potential and may provide better clinical outcomes. However, their use is associated with serious ethical issues and potential danger of differentiation into unfavorable cell types. Hence, most clinical experience is based on the use of adult stem cells usually derived from the bone marrow or peripheral blood. Most clinical studies and trials have shown varying degrees of benefit in terms of relief of symptoms, improvement in indices such as the ankle-brachial pressure index, transcutaneous oxygen pressure measurements, and collateral number and density, among others. This is despite the fact that the type of stem cells used (peripheral blood or bone marrow derived) may not be the best in terms of efficacy or CD+34 count, the doses used may well be sub-optimal, the best route of administration (intra-arterial, intramuscular or other) is still under investigation, the optimal outcome measures have yet to be identified and the optimal duration when the outcome is most visible has also not been defined. The outcomes of this therapy may be improved by the application of imaging technologies that allow the investigators to track the location, engraftment, and survival of the administered cell population. However, optimal imaging technique to track these cells remains elusive. Despite these limitations, most studies have shown substantial improvement in clinical outcomes. There is some evidence that the patients with Burgers' disease may respond better to this therapy than those with atherosclerosis. Although proof from large randomized trials for both the above therapies is still inconsistent, both treatments have shown the ability to improve perfusion by inducing arteriogenesis, angiogenesis or vasculogenesis. Further, pre-clinical studies with combination of cell and gene therapy have also shown encouraging results. This may be an alternative option to address the limited number and function of progenitor cells in elderly patients and those with co-morbidities. Further research will define the role of this strategy in suitable patients. At this time, there is inconsistent evidence of therapeutic efficacy of gene therapy in patients with limb ischemia. The evidence for cell-based therapies is more encouraging. There is a need for optimized trials to define the treatment algorithms in these patients. 

C RSE CIRSE Abstract Book piration embolectomy and mechanical thrombectomy are widely used although there is little or no convincing evidence that any specific approach yields significant clinical advantages. While rt-PA is the most commonly used lytic agent with in the United Kingdom, urokinase has been widely used elsewhere. Heparin is often administered in addition to the thrombolytic agent although again, no good evidence is available to support this strategy.

In the majority of cases of ALLI, thrombolysis will successfully remove occlusive thrombus and reveal any underlying causative lesions, which can be managed by endovascular means in most patients. Failure to uncover an underlying stenosis is associated with a poorer prognosis. It should be remembered that catheter-directed thrombolysis is a diagnostic as well as therapeutic procedure. Incomplete thrombolysis should not necessarily be regarded as a treatment failure as it often allows clearance and identification of distal runoff vessels for subsequent surgical bypass grafting. Thrombolysis rarely, if ever, compromises later operative interventions. Acute lower limb ischaemia continues to be associated with a significant mortality despite the improvements in management and treatment options that have developed in the past three decades. This may, in part, be due to ALLI presenting in an increasingly elderly population with advanced atherosclerotic disease and important comorbidities. In 2012, catheter-directed thrombolysis has a key role in the management of these patients and although randomised trials have failed to demonstrate its superiority over surgery, it is widely regarded as first line treatment for properly selected cases.

The key to successful thrombolytic therapy is joint management between vascular surgeons and radiologists. This liaison allows the tailored management of each patient with clearly defined expectations and endpoints. Clear data regarding choice of thrombolytic agent, optimal dosing schedules and adjunctive therapeutic techniques are as yet lacking and require further evaluation. Further direct comparative studies between surgery and thrombolysis are unlikely to be undertaken, but refinements in patient selection criteria may further improve outcomes for thrombolytic treatment of ALLI.

Early reports concerning the use of thrombolytic therapy for acute arterial occlusion appeared as early as 1956, but with poor reported clinical outcomes and high complication rates. Catheter-directed thrombolysis was introduced in the 1970s and over the next 15 years, clinical interest in the use of thrombolysis as an alternative to surgery in ALLI intensified. Although numerous cohort studies suggest that thrombolytic therapy offers reduced mortality and better limb salvage rates, only three studies undertaken in the 1990s provide randomised data comparing thrombolysis with surgery. The first of these trials, known as the Rochester study, compared the use of urokinase to open surgery in 114 patients with severely threatened limbs. A dramatic difference in 12-month survival was seen, with 84% of patients treated by thrombolysis surviving compared to 58% of those who underwent surgery. This appears to have been due to a high incidence of cardiorespiratory deaths in the patients undergoing open surgery even though limb salvage rates were very similar for the two groups. The next randomised study was the STILE trial (Surgery or Thrombolysis in the Ischaemic Lower Extremity) which included 393 patients, some of whom had ischaemia of greater than 14 days duration. The results of this study showed that amputation-free survival did not differ significantly between surgery and thrombolysis. However, subgroup analysis suggested that in patients with a shorter duration of ischaemia, thrombolysis reduced the amputation rate and was also more effective in graft occlusions. The third randomised study was the TOPAS trial, which was conducted in two parts. The second phase of the study compared surgery with thrombolysis using urokinase in 544 patients. At a mean follow-up of one year, it was found that amputation-free survival did not differ significantly between the two patient groups. Importantly, however, it demonstrated the reduced need for open surgical procedures in patients who underwent initial thrombolytic therapy. Of course, several aspects of these studies can be criticised. Inclusion criteria were variable and in some patients the duration of ischaemia was considerably greater than two weeks. The thrombolytic protocols used were variable, even within trials, and differ significantly from those in current practice. In the STILE study, it was reported that the radiologist failed to cross the vessel occlusion and commence thrombolysis in almost thirty percent of the cases randomised to lytic therapy, a situation that would be very unlikely in modern interventional practice. Endovascular techniques have been considerably refined since the early 1990s and reported complication rates have significantly declined. Numerous reported cohort studies suggest that thrombolytic therapy should be offered as first-line treatment for patients with ALLI in whom there are no contraindications and the limb is viable. An analysis of almost 2000 cases concluded that limb salvage rates and mortality were significantly better for patients treated by thrombolysis compared to surgery although again, inclusion criteria and treatment schedules were not uniform in the studies which were included. Faced with the patient suffering from acute lower limb ischaemia, it is apparent that the initial clinical assessment is crucial to deciding upon appropriately tailored therapy. The decision to embark on thrombolytic therapy depends not only on the viability of the affected limb but also on the patient's comorbidities and any other practical problems, such as restlessness or confusion, which might prevent safe and effective completion of treatment. Prior to the commencement of catheter-directed thrombolysis, careful discussion is needed between the referring team and the interventional radiologist, as well as ensuring that a proper level of monitoring and nursing care is available. Attention should be given to monitoring fluid balance and ensuring that adequate analgesia is provided, as it is not uncommon for limb pain to increase during the early stages of thrombolytic treatment. Different thrombolytic schedules and techniques such as accelerated lysis have been described. Adjunctive techniques including as- 

Acute aorto-iliac occlusion: is there a role for IR? (Occluded EVAR limbs, etc.)

Radiology, University Hospital of South Manchester, Manchester, United Kingdom.

Learning Objectives 1. To depict the different iatrogenic and non-iatrogenic elicitors of acute aortoiliac occlusion 2. To review current literature on how to treat aortoiliac occlusion 3. To carve out the future role of IR in handling acute aortoiliac pathology Introduction: Since the publication of the DREAM and EVAR trial results, there has been a large increase in the number of EVAR performed. While operative mortality and morbidity is lower than open repair EVAR carries a significant risk of its own specific complications that require re-intervention. Although the incidence is low, iliac limb occlusion is one of the more common problems requiring intervention. The aim of this presentation is to outline the scope of the problem, how to reduce the incidence of limb occlusion and how to treat it if it does occur. The problem: Iliac limb occlusion has been reported as occurring in 0.5-11% of patients. First generation devices carried the highest incidence, particularly those with unsupported iliac limbs such as the Ancure device. It was realised early on that this was due to twisting or kinking of the fabric and the incidence of this complication could be reduced using fully supported limbs or by placing bare metal stents to support the fabric in those designs which were not fully stent supported. However, the incidence of limb occlusion was still 6.4% in the DREAM trial and 2.6% in EVAR trial. Predisposing factors: Graft design is an important factor. The incidence is much lower with more recent designs. It remains to be seen whether the incidence of limb thrombosis falls even further with the latest generation of low profile, highly flexible devices. Cochennec found that patient co-morbidities and smoking were not related to limb failure, although occlusions were more common in younger patients (mean age 68 vs 72 years). Other factors increasing the risk of limb occlusion include small iliac diameter, tortuosity, narrow/ calcified aortic bifurcation, angulation of the common iliac artery and extension of the graft to the external iliac. Female gender is an association, but this may be related to small vessel size. Disease in the run off vessels, including the external iliac and common femoral arteries is important. If the aneurysm sac shrinks significantly this can lead to conformation changes of the stent which may pre-dispose to limb occlusion. Prevention: Clearly, it is important to do everything possible to maintain patency of the limb. When possible, the lower end of the graft should land in the common iliac artery. Several systems have

Radiology, Kantonsspital St. Gallen, St. Gallen, Switzerland.

1. To describe the speakers approach regarding treatment indication and selection process 2. To describe the devices used for tackling the occlusion 3. To describe the speaker's approach in case the primary recanalization attempt fails Years ago, systemic intravenous infusion for limb artery occlusion was investigated but that method has been almost completely abandoned; it is inferior to intra-arterial infusion for leg arterial occlusion because the initial lytic success rates are lower and the complication rates are higher. Initial technical success of thrombolytic therapy is defined as the restoration of anterograde flow with complete or near complete lysis of the thrombus. Thrombolytic drugs in clinical use for leg arterial occlusion are streptokinase (SK), urokinase (UK), extracted from human urine or from long-term cultures of human neonatal kidney cells, and recombinant human tissue-type plasminogen activator (rt-PA). The learning objectives of that short talk will be to demonstrate our method of choice to remove pathologic thrombotic material and to facilitate restoration of vascular patency. Therapeutic thrombolysis is defined as enzymatically induced or as accelerated dissolution of the thromboembolus. In some patients, thrombolysis will show an underlying lesion that subsequently requires endovascular or surgical treatment. There should be a multidisciplinary approach to thrombolytic therapy, which should involve angiologists, hematologists, interventional radiologists and vascular surgeons. It is difficult to define success or failure of thrombolytic therapeutic interventions because meanwhile in most of the cases the thrombolysis is accompanied by mechanical thrombectomy or aspiration therapy. The primary endpoint of thrombolytic interventions in lower limb ischemia is amputation-free survival of the patient. Other secondary endpoints should be kept in mind (e.g. decreased requirements for surgery, replacement of surgery by the endovascular interventions, restoration of the useful limb function. Several different techniques are published: regional intra-arterial infusion (nonselective and selective intra-arterialinfusion), the guidewire traversal test (failure to traverse a clotted vessel with a guide wire does not preclude successful urokinase fibrinolytic therapy in a substantial percentage of patients), intrathrombus infusion, intrathrombus "bolusing" and "lacing technique" will be mentioned. The management of complications and contraindications will be pointed out. A variety of several specifically designed infusion catheters are currently available. Many of these "infusions systems" can be used for both conventional slow-infusion and pulsed-infusion methods. High dose, bolus, or pulse-spray methods may be used to treat the severely ischemic leg. However, caution should be exercised if a surgical option can achieve a more favourable outcome in a shorter period of time (e.g., the white limb secondary to a large proximal embolus), a situation with a usually very rapid and successful outcome if treated by standard surgical techniques. Different methods will be noted to prevent distal embolisation of thrombus material during the thrombolytic procedure. Postprocedural anticoagulation therapy is appropriate and should be continued until the underlying lesion (cause of occlusion) has been corrected. Patients with arterial occlusive disease have a 2-3fold increase in death rate concerning cardiac disease. Aspirin reduces the odds of suffering fatal or nonfatal vascular events by roughly 25% and should be initiated rapidly unless contraindicated.

C RSE 

The spectrum of interventional oncology

Division of Diagnostic Imaging and Intervention, University of Pisa, Pisa, Italy.

1. To describe the spectrum of interventional procedures used in cancer treatment 2. To discuss the role of interventional oncology procedures with respect to medical, radiation, and surgical oncology treatments 3. To review treatment algorithms that have incorporated interventional oncology options as standard of care in cancer treatment

No abstract available.

Interventional oncology: the pieces of the jigsaw

Department of Radiology, St. James's University Hospital, Leeds, United Kingdom.

1. To discuss all the components of interventional oncology 2. To describe synergies of interventional oncology procedures with medical, radiation, and surgical oncology treatments 3. To discuss future scenarios for the evolution of interventional oncology Interventional oncology has no curriculum and no syllabus and there is a danger that these are developed without regard to the skills required of an interventional radiologist or the knowledge required of an oncologist. IO practitioners will therefore be low level iliac limbs as large as 28mm. So it is possible to land in common iliac arteries of up to 24mm. When the graft is extended to the external iliac artery it is important to ensure there is no kinking at the iliac bifurcation and place a bare metal stent if this occurs. The stiff wires used for stent-graft delivery can straighten out the iliac system. When the completion angiograms are done it is important to replace them wires for soft wires that allow the iliac arteries to recoil to their natural curve. The angiograms should include oblique views of the iliac vessels. If the aortic bifurcation is narrow, then it is essential to oblique the tube to open out the bifurcation of the stentgraft to ensure that there is no compression of one or both limbs. If kinking or compression of the stent graft is seen then it is important to place a bare metal stent or do balloon angioplasty to resolve the problem. If the stenosis is at a heavily calcified aortic bifurcation it may be necessary to use high pressure balloons to "crack" the bifurcation, the stent grafts will prevent bleeding. When the patient returns for follow-up CT it is important to examine the scans for graft stenosis, compression or kinking so action can be taken to prevent failure. One study found graft stenosis or kinking to develop in 5.5% patients in the first year of follow-up. Kinking is associated with a large amount of sac shrinkage as this leads to deformation of the stent graft. Treatment: Options include conservative, endovascular and operative management. Patients presenting with late occlusions may only have symptoms of claudication. These patients can be managed according to their symptoms. As the incidence of limb occlusion is small, particularly with modern, fully supported devices, there are no comparative data to provide an evidence base for one treatment over another. It appears that treatment depends on the preference of individual surgeons or radiologists and the equipment available if mechanical thrombectomy is used. All methods have a high rate of success. Surgical: Bypass grafting by femoro-femoral crossover graft provides a reasonable patency rate. The advantage of surgery is that the femoral artery is explored so that if the cause is atheroma or an intimal flap raised during deployment then this can be treated with endarterectomy at the same time. The disadvantage is that it is more invasive, requires exploration of both femoral arteries and caries a risk of wound or graft infection. Axillofemoral bypass will be necessary if the whole grafts occlude. Fogarty embolectomy can restore patency if performed early. Catheterisation of the stent-graft can be difficult if performed with a standard Fogarty balloon and the catheter may get caught on the endoskeleton of certain grafts. When used on a limb with an anastomosis there is a theoretical risk of dislocating the limb producing a type 3 endoleak. It is therefore important that this is carried out under fluoroscopic guidance and that over the wire embolectomy balloons are used. Following recanalisation, angiography needs to be performed to identify the cause of the occlusion and then to treat this appropriately with angioplasty or stenting. Endovascular: The options include thrombolysis, mechanical thrombectomy with or without angioplasty or stenting of the underlying lesion. Cocchenec preferred thrombolysis from a brachial approach for occlusions less than 14 days. They had no complications associated with this but others (Bohannon) do report distal embolisation. Mechanical thrombectomy has usually been performed with the Angiojet catheter (Possis), although aspiration thrombectomy with a large sheath has also proved successful. Whatever technique is used for recanalising the limb it is important to review the completion angiograms and image the patent limb to ensure there is not a problem on that side that may need preventative treatment. This is especially important if this side is going to be the donor vessel for a crossover graft. Conclusion: Limb occlusion of EVAR is relatively uncommon. The incidence decreased sharply when fully supported iliac limbs began to be used. It remains to be seen whether the latest generation of flexible stent-grafts reduces the incidence further. Careful exami-S129 CIRSE 2012 SS/FC/HL/HTS/CM vival compared with best supportive care. On the other hand, indications to TARE in HCC have still to be defined, although it appears to be a highly appealing treatment modality in patients with advanced-stage disease, particularly in the case of branch portal invasion without extrahepatic tumour spread. In adjunct to current guidelines, transarterial treatments of HCC are widely adopted in several different clinical scenarios in daily practice. In the setting of early-stage HCC, transarterial treatments represent effective options in patients in the waiting list for liver transplantation, being able to control tumour growth and reduce drop-out rates, particularly when the waiting time exceeds six months. Moreover, a considerable number of early-stage HCC patients is excluded from any potential curative treatment (resection, percutaneous ablation, liver transplantation) either for clinical or anatomical factors; in these conditions, transarterial treatments might represent the only available treatment modality, providing a valuable means to control tumour extension and favourable survival outcomes. 

Division of Oncology, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia.

1. To describe the chemotherapy background required for interventional oncology practice 2. To describe the radiation therapy background required for interventional oncology practice 3. To discuss why such knowledge is key to success Radiologists practising interventional oncology can provide major options for treatment to people with cancer. It is implicit that the understanding of cancer biology and its natural history is essential in order to make informed decisions about care. It is also most important to integrate interventional options into the overall care of patients. Well run multidisciplinary teams comprising all relevant specialists are in an excellent position to consider appropriate treatment options for their patients and to make these recommendations. Interventional oncologists making decisions in isolation is undesirable---just as it is for any oncologist. Interventional oncologists need to consider how much involvement they are going to seek in managing patients and in being responsible for their care. The use of the term "oncologist" should impart a responsibility for care throughout their course of treatment that extends far beyond the technical delivery of treatment. This has implications across the whole spectrum for interventional oncologists from education and training programs to the organisation of the service. 

Radiologia Albertoni, Azienda Ospadaliero-Universitaria di Bologna, Bologna, Italy.

Transarterial radioembolization (TARE) is defined as the transarterial injection of micron-sized embolic particles loaded with a radioisotope. In Yttrium-90 (90Y) TARE, implantable radioactive small (20to 40μm) microspheres are delivered into the hepatic arteries feeding the tumors, so that nodules are treated irrespective of their number, size, or location. The high-energy radiation source 90Y emits a tumoricidal dose of beta-radiation (100-1,000+ Gy), far in excess of the doses delivered safely with external beam radiation therapy, over a finite range (mean tissue penetration, 2.5 mm; maximum, 11 mm), therefore exposure to the parenchyma is limited (1) . The treatment algorithm is analogous to that of transarterial chemoembolization (TACE). There are two distinct aspects to the procedure: the injection of permanent embolic-glass/resin particles (i.e., "embolization") as the vehicle and the delivery of radiation via this embolic vehicle ("radio-"). The Barcelona Clinic Liver Cancer (BCLC) staging system for HCC (2, 3) defines five stages with progressively worse prognosis. For patients not eligible for curative resection or liver transplantation but still have their disease confined to the liver, liver-directed therapies such as RF-ablation and TACE play an important role in reducing tumor burden, providing palliation of symptoms, and increasing survival (4) . TARE is another liver-directed therapy (5,6) whose role in unresectable liver disease has been evaluated mostly in patients with larger, infiltrating and/or multifocal disease (7) . Previous experiences have shown that TARE produces clinically significant reductions in tumor burden among patients with HCC (8, 9) that help downstaging patients for radical therapies (10) that can be performed in the presence of portal vein thrombosis (11, 12) , and can be safely applied to patients who have cirrhosis with good liver function (1, 7, 8) , with survival results similar to TACE (13, 14, 15) but with longer time-to-progression and less toxicity than TACE (16) . In a large European multicenter analysis (17) 

Department of Nephrology, University Medical Center, Utrecht, Netherlands.

For decades, it has been known that sympathetic hyperactivity, which is generated in the central nervous system (CNS), is a common finding in hypertensive patients. There is clear evidence that the kidneys are involved in the pathogenesis of this sympathetic hyperactivity. Afferent (from the kidneys towards the CNS) nerve activity stimulates the CNS to increase central sympathetic outflow. Already limited kidney injury (not necessarily affecting kidney function) may result in this increased afferent nerve activity. The efferent (away from the CNS) sympathetic activity is directed to many organ systems, also including the heart, resistance vasculature and the kidneys. It results in hypertension, left ventricular hypertrophy, increased peripheral and renal resistance, sodium retention, insulin resistance and kidney failure. Deliberate disruption of the function of the renal nerves results in a drop of blood pressure. In the previous century this was done by surgical procedure. Recently, catheter-based renal denervation was introduced. First, results suggest that a considerable and sustained blood pressure reduction can be obtained by a single treatment session. It is likely that also other disease conditions characterized by sympathetic hyperactivity, such as heart failure, chronic kidney disease and obesity/metabolic syndrome may benefit of this treatment. The presently available data provide sufficient rationale for much further research on this methodology. Despite the availability of multiple classes of orally active antihypertensive treatments, resistant hypertension remains an important public health issue in 2012. The failure of purely pharmacological approaches to treat resistant hypertension has stimulated interest in invasive device-based treatments. A new catheter system using radiofrequency energy has been developed, allowing a percutaneous endovascular approach to renal denervation and providing patients with resistant hypertension with a new therapeutic option. To date, this technique has been evaluated only in open-label trials including small numbers of highly selected uncontrolled hypertensive patients with suitable renal artery anatomy. The available evidence suggests a favorable blood pressure (BP)lowering effect in the short-term and a low incidence of immediate local and endovascular complications. This follow-up period is, however, too short for the detection of rare or late-onset adverse events Published studies are subjected to several limitations inherent to their open-label design subject to expectation, performance and evaluation biases, potentially jeopardizing their internal validity and decreasing the degree of BP reduction we can expect to be achieved. Furthermore, the evaluation of the BP effect of renal denervation was mainly based on office BP measurement, a primary outcome that is subjected to observer bias. As expected, the BP-lowering effects of renal denervation, as assessed by ambulatory BP monitoring in few patients were smaller than those evaluated by office BP measurement. Finally, the external validity of the studies is also limited because they included a small sample of highly selected patients (mainly obese, Caucasian patients with resistant hypertension despite treatment with ≈5 antihypertensive drugs, a glomerular filtration rate >45 ml/min and a suitable renal artery anatomy) making it difficult to extrapolate the results to the general population of patients with resistant hypertension. In this context, there are strong arguments against the widespread and uncontrolled use of this procedure in routine practice: an unknown benefit/risk ratio, inconsistency and unpredictability of the BP response, absence of markers of primary success of the procedure, absence of cost-effectiveness evaluation, higher risk when renal denervation is performed by interventionalists less skilled at patient selection and performance of the procedure. The best way to ensure the rigorous follow-up of patients after renal denervation would therefore be to include them in clinical trials or international registries. 

How bad is RF for the renal artery?

Abteilung für Elektrophysiologie, Deutsches Herzzentrum München, Munich, Germany.

No abstract available.

Department of Cardiology, University Medical Center Utrecht, Utrecht, Netherlands.

Background: In recent years, it became clear that activation of the sympathetic nervous system (SNS) is an important factor in the development and progression of systemic hypertension. Also, the degree of SNS activation correlates with the severity of blood pressure elevation. Sympathetic overdrive is also associated with targetorgan damage related to chronic hypertension. The response of the kidneys to SNS signaling is one mechanism by which sympathetic activation increases blood pressure. Clinical findings/procedure: A percutaneous approach has been developed using radiofrequency energy to disrupt renal sympathetic nerves. The first (pre)clinical studies showed this technique to be safe, illustrated by a lack of vascular or renal injury. More importantly, renal denervation resulted in a significant reduction in systolic and diastolic blood pressure on top of maximal medical therapy, which has now shown to persist through out 24 months followup. Renal denervation may also positively influence other organ systems, in which we know sympathetic nerve activity plays a role. This includes sleep apnea, insulin resistance, heart failure and even metabolic changes in polycystic ovary syndrome. Conclusion: Renal sympathetic denervation has shown to positively influence the decremental effects of the SNS on (therapy resistant) hypertension. This novel treatment modality may decrease the comorbidity and even mortality in these patients. 

centration of fibrinolytic is present in the portomesenteric venous system with lower systemic concentration. Local fibrinolysis can be performed through the superior mesenteric artery or directly through the portal vein via a transhepatic or transjugular route. Fibrinolysis through the SMA seems to be more effective to reach the distal branches of the mesenteric veins. In general, transhepatic approach is the most frequently used. It is easier than transjugular approach but has a greater risk of bleeding. The thrombus is recanalized with guide wires and a multiperforated catheter is inserted to perfuse urokinase or rtPA. Pharmacologic thrombolysis is an effective technique for treating acute PVT but severe hemorrhagic complications occurred in more than 30% of cases, so it is recommend to use this technique for severe cases. The efficacy of thrombolysis is related to the time over which the thrombus has developed. The best results are obtained when the thrombus is less than 14 days. Only very slight response can be expected after 40 days. The main complications of local fibrinolytic treatment are related to transhepatic puncture, which may cause intra-peritoneal bleeding (3). Mechanical percutaneous thrombectomy is performed usually in conjunction with other treatments as local fibrinolysis or balloon dilatation and stent placement. Balloon dilatation with stent placement is the technique of choice for dealing with residual thrombosis with stenosis or tumor invasion or local inflammatory processes. Mechanical recanalization devices can be divided into devices that perform thrombectomy by direct contact (angioplasty balloon, fixed or rotating wire baskets and pigtail catheters), hydrodynamic thrombectomy devices and rheolytic thrombectomy devices (based on flow). It is also useful to try to remove part of the thrombus by aspiration. Balloons used ranged usually from 8 to 10 mm diameter and stent is self-expandable. When mechanical thrombectomy devices are used, there is a potential risk of damaging the vessel, which may predispose to rethrombosis.

Although the presence of PVT is regarded as a relative contraindication to TIPS, it can be very useful in cirrhotic patient with portal hypertension. TIPS in these cases need to be inserted by an experimented team.

Centro Hepato-Bilio-Pancreático, Hospital Curry Cabral, Lisbon, Portugal.

Learning Objectives 1. To review the etiology of Budd Chiari syndrome and indications for treatment 2. To describe the techniques for SHV and IVC PTA/stenting 3. To describe the results and the management of complications Hepatic venous outflow obstruction causes a post-hepatic/postsinusoidal form of portal hypertension. It generally manifests clinically by massive ascites, hepatomegaly and abdominal pain and less frequently by jaundice, splenomegaly and variceal bleeding, depending on the acuteness of onset and the previous liver and portal system integrity. This clinical picture is known as Budd-Chiari syndrome, first described independently by the two authors in the nineteenth century. Venous outflow obstruction can have multiple Learning Objectives 1. To present an update of recent trials and meta-analysis 2. To describe the indications, techniques and devices for recanalizing portal and mesenteric vein occlusion 3. To describe the techniques of thrombectomy and thrombolysis Portal vein thrombosis (PVT) leads to complications of portal hypertension which causes bleeding through varices. Eight to 20% are idiopathic, in adults. PVT is associated with cirrhosis and its incidence increases as the disease progresses. The prevalence in patients with cirrhosis and hepatocarcinoma is as high as 44%. The other causes are neoplasm, coagulation disorders and inflammatory-infectious abdominal causes (1). The acute and chronic forms of PVT are differentiated by the length of time over which they develop. In acute stage, symptoms are generally nonspecific. If the thrombus extends as far as the distal mesenteric branches, it may cause ischemia or infarction of the mesenteric vein which leads to abdominal pain, nausea, vomiting and ascites. The existence of peritoneal irritation and ascites indicates necrosis of the wall and perforation. In these cases, surgery is required with 13 to 50% mortality reported. In the chronic form, symptoms are usually due to portal hypertension, principally bleeding through varices (2) . Imaging techniques are essential for the diagnosis of PVT because the clinical manifestations are minor and unspecific. Four anatomic categories related to the extent of PVT have been defined and have clinical relevance for both prognosis and treatment: grade I, thrombus limited to the portal vein, grade II, thrombus extending to the superior mesenteric vein, grade III, thrombus spreading diffusely through the splanchnic venous system but with the presence of large collaterals, grade IV, as grade III but without collaterals. The first approach for treating acute PVT is to start anticoagulation with heparin at once. The aim is to maintain the activated partial thromboplastin time (aPTT) at twice its normal level. Once the thrombosis is resolved, heparin is replaced by oral anticoagulants for 6 months. Anticoagulation alone results in resolution of PVT in up to 80% of cases. In chronic forms of PVT, anticoagulation is more controversial, because portosystemic variceal collaterals have developed, which confer a greater risk of bleeding. Selective administration of local fibrinolysis ensures that a high con-S134 C RSE CIRSE Abstract Book both preoperatively and perioperatively to prevent renal failure due to hemolysis attributable to the red cell membrane destroyed by EOI. Recently, foam style of sotoradecol was reported for B-RTO in USA. 2) Occlusion of GV: (1) A 6F occlusion balloon catheter with a balloon diameter of 20 mm and balloon length of 20 mm is frequently used through an 8F preshaped guiding sheath. A balloon diameter of 10 mm or over is required. A wedge catheter facilitates the procedure and requires less EOI (downgrading technique). (2) Checking the development of collateral veins/angiography under balloon occlusion of the GR shunt reveals many collateral veins. The inferior phrenic vein is the largest in number, and the pericardial vein is frequently dilated in the angiographic images. Sclerosant injected under these circumstances does not flow into the gastric varices but drains into the inferior vena cava and the azygos venous system from the collateral veins. Therefore, it is necessary to occlude the collateral veins carefully. We grade the collateral veins and occlude the collateral veins accordingly 1). Contrast X-ray examination of the shunt is performed under balloon occlusion to grade the development of collateral veins and the gastric varices. The grade 1 and 2 collateral veins rarely need occlusion, but grade 3 and higher veins require occlusion. For large collateral veins, coils were used. For grade 2 to 4, the downgrading technique is performed once, and if this is successful, less or no occlusion of the collateral veins is required. (3) EOI injection can surely be performed without excessive venous occlusion if a microcatheter is superselectively inserted from inside the balloon catheter into the gastric varices to inject or fill EOI. We have set the maximum injection volume of EOI at 20 ml. The gastric varices are opacified by the imaging ability of EOI. After EOI injection, the catheter is placed for 5 hours or longer under balloon occlusion. After that, we confirmed obstruction of GR shunt injecting small amount of contrast media. Then the balloon is deflated and removed.

The items summarized below were analyzed in 279 patients who underwent B-RTO for GV since 1992. 1) Technical success rate: 95.3% (success was defined as the disappearance or marked reduction of the varices after single or repeated B-RTO procedure[s].) 2) Hepatic encephalopathy: 12 out of 15patients (80%) showed improvement in the encephalopathy. 3) Approximately 36.5% of esophageal varices are aggravated, for which endoscopic treatment may be required. In the Lg-cf type, the gastric varices are thought to be worse in the route from the left gastric vein to the esophageal vein. 4) Changes in liver function: The increased portal blood flow improves the hepatic reserve. In this study, 45.3% (82/181 patients) showed an improvement in liver function. Liver volume increased in 91% of patients with average liver increase of 12.4%. 5) Porto-systemic encephalopathy through mesocaval shunt was treated by B-RTO, and success was gained in 86%. Clinically, 94.1% was successful. 6) Liver cancer, which is known to be a prognostic factor, was seen in 42 cases.

: Hematuria frequently appears, but it rarely leads to renal failure when haptoglobin is concomitantly used. Pulmonary embolism may occur, so balloon occlusion for long time is essential. Abdominal pain immediately after ethanol injection occurs very frequently, so analgesics are necessary. 6. Conclusions: B-RTO is used to embolize the varices from downstream, in contrast to PTO, which embolizes the varices from upstream. B-RTO can be employed not only for gastric varices but also for duodenal varices and mesocaval shunt. Our results showed very excellent effects for gastric varices, suggesting the first choice of treatment for GV. In many cases, the portal blood flow becomes hepatopetal again, and half of the patients that underwent B-RTO showed a secondary effect of improvement in liver function, revealing that B-RTO has a therapeutic effect on liver cirrhosis. The acute form develops generally as an acute thrombosis of the SHIVC or HV. The chronic form is conditioned by inflammation and/ or fibrosis of the intrahepatic veins. More than 50% of the cases are idiopathic. Conditions as hypercoagulopathy, polycythemia, injury to venous outflow (radiation treatment, post-transplant anastomotic venous dysfunction), tumor thrombosis and membranous suprahepatic SHIVC might be implicated in the development of this condition. Severe cardiac conditions as right heart failure or constrictive pericarditis might also be a more indirect cause. Intervention radiology might have an important role in the diagnosis and treatment of Budd-Chiari syndrome: through a Jugular access (sometimes assisted by percutaneous anterograde HV access), cavography and selective hepatic venography aided by pressure gradient measurement are preformed to evaluate the level and cause of the obstruction and the possibility of treatment which might include the correction of underlying stenosis or webs, by stenting, or angioplasty, or, in those cases with acute thrombosis of the hepatic veins, recanalization by local thrombolytic agents administration and/or thrombus aspiration. TIPSS might has a role in those cases where massive ascites is a dominant feature although, in general, this procedure is more technical demanding in this setting than usually. (4) . Median overall survival from date of first treatment of 9 months was observed. Kim studied 49 intrahepatic cholangiocarcinoma patients receiving either transcatheter arterial chemoinfusion, chemoembolization, or both and reported a median survival of 12 months from first chemoembolization (5) .

Other studies have shown a median survival of 12-21 months after chemoembolization treatment for intrahepatic cholangiocarcinoma (6) (7) (8) . Burger et al utilized a 3-drug/iodized oil regimen with tris-acryl gelatin microspheres, and showed a median survival of 23 months from date of diagnosis for 17 patients (9) . An alternative to chemoembolization for unresectable hepatic malignancies is yttrium-90 radioembolization. Two cohort studies documenting treatment results in intrahepatic cholangiocarcinoma have been published (10) (11) . The first demonstrated partial response in 6 patients (27%), stable disease in 15 patients (68%), and progressive disease in 1 patient (5%). In the second, 25 patients underwent resin-based (90)Y radioembolization. The median survival after radioembolization was 9.3 months. Two factors were associated with an improved survival: peripheral tumor type (vs. infiltrative, P = .004) and Eastern Cooperative Oncology Group performance status of 0 (vs. 1 and 2, P < .001). A partial response to treatment was observed in 6 patients (24%), stable disease in 11 patients (48%), and progressive disease in 5 patients (20%).

Radiology, University of Pennsylvania, Philadelphia, PA, United States of America.

Learning Objectives 1. To describe treatment techniques 2. To discuss indications for IR vs. endoscopic treatment 3. To review the outcomes and complications Unresectable intrahepatic cholangiocarcinoma is a uniformly fatal disease with a poor prognosis. External beam radiation and systemic therapies have limited impact, with 1-and 2-year survival of approximately 25% and 13%, respectively (1, 2) . Reports of systemic chemotherapy for treatment of biliary cancer include the more common extrahepatic tumors such as Klatskin tumors, ampulla of Vater carcinoma, and gallbladder carcinoma, none of which are amenable to chemoembolization therapy and have a different prognosis than intrahepatic tumors. Therefore, direct comparison to systemic therapy series is not possible. In the largest published multicenter series, 62 patients were chemoembolized with a CAM/Lipiodol/PVA regimen (3), 37 had pathologically proven cholangiocarcinoma, and 25 had poorly differentiated adenocarcinoma of unknown primary, likely cholangiocarcinoma. 30-day disease-specific mortality was 0%. 45 patients were evaluable for RECIST response: 11% (n = 5) partial responses, 64% (n = 29) stable, and 24% (n = 11) progressed. Median TTP from first chemoembolization was 8 months, with 28% free of progression at 12 months. Median survival from time of diagnosis was 20 months, with 1-, 2-, and 3-year survival of 75%, 39%, and 17%, respectively. Median survival from time of first chemoembolization was 15 months, with 1-, 2-, and 3-year survival of 61%, 27%, and 8%, respectively. There was no statistically significant difference in survival between patients with cholangiocarcinoma and those with poorly differentiated adenocarcinoma. Patients who also received systemic chemotherapy had improved overall survival (median 28 vs 16 months, P = .02; HR, 1.94; 95% CI, 1. 13-3.33 ). The importance of local tumor control is reinforced by the limited impact of extrahepatic metastases on survival. Although the cohort with metastases trended to poorer survival, the difference did not reach statistical significance. This emphasizes that the major cause of mortality among patients with primary hepatic cancers is local progression to liver failure and supports the concept of regional therapy in this disease. In S136 C RSE CIRSE Abstract Book time of palliated patients varied greatly from 3 to 35 months. Randomized trials that compared surgical palliative bypass procedures and endoscopic placement of plastic prostheses showed equal clinical efficacy. Plastic prostheses placement is associated with a reduced risk of complications, although with a higher risk of recurrent biliary obstruction because of occlusion. Endoscopic route is often used for implantation of SEMS; however, the relief of all obstructed biliary branches is more technically difficult because of complexity of hilar tumors, therefore specific approaches of stent implantations or only selective decompression of biliary tract has to be chosen. Randomized studies with currently available 6F SEMS, which allows parallel implantations in endoscopical way, are expected. When comparing implantations of SEMS percutaneously and endoscopically in older studies, benefit of percutaneous approach was more obvious. Newer studies confirm similar stent patency, complication rate and survival of patients, but favor percutaneous approach in technical success of drainage procedures. We emphasize maintaining of bile duct patency the most for reaching long-term survival. Plastic prostheses or external/internal percutaneous catheters are preferred as definitive treatment for patients with a prognosis of less than 3-4 months. In prolonged palliative therapy (more than 6 months) they have to be repeatedly replaced due to lumen obstruction (3 times narrower than SEMS) and thus compared to SEMS are cost ineffective. Based on our experience there is also higher tolerance and compliance of the patient when using a metal stent. Covered metal stents were historically disadvantaged because of potential migration and cost, while benefit of improved stent patency was not clear. We do not recommend the use of covered metal stents in palliation of hilar cholangiocarcinoma due to occlusion of side-branches. Improving prognosis of patients with tumors of subhepatal space can be observed with the use of modern means of chemotherapy, locoregional chemotherapy and methods of external radiotherapy. Because of prolonged survival of these patients we see obstruction of a metal stent more frequently. The average stent patency in studies (7.5-9.5 months) varies widely and depends also on the technical execution and potential brachytherapy after insertion. Obstruction of metal stent may occur due to intimal hyperplasia, tumor ingrowth or stent can be obstructed by detritus. In a group of 58 patients, which were introduced selfexpandable stents at our center in the reference period of 2004 to 2008, the obstruction of the stent was observed in 38% of patients. The early stent obstruction during the 5 months of implantation occurred in 14% of patients. Management of stent obstruction resulted in a significant increase of the number of nonvascular interventions for patients and also increased the cost of palliation of the disease. External beam radiotherapy and mainly intraluminal brachytherapy can extend stent patency and therefore the quality and survival of patients. The advantage of brachytherapy with 192 Ir is the possibility of delivering higher doses of radiation, in a short time, without significant irradiation of normal tissues. However, the radiation dose given by brachytherapy is limited to a maximum of 1 or 2 cm in depth. Between the years 1997 and 2000, we showed the benefit of brachytherapy in prospective randomized study. In the group of patients treated with combined radiotherapy and with stent implantation the mean survival was 388 days. In the group of patients treated only with stent insertion the mean survival was 298 days. In these cases, we used percutaneously implanted SEMS, intraluminal brachytherapy total The most common symptom of cholangiocarcinoma is painless jaundice. Even though the cause of jaundice could be a small-size tumour, the unfavourable localisation of the common perihilar type greatly influences the prognosis of patients. Hilar cholangiocarcinoma (Klatskin type tumor) arises from the epithelium of the intrahepatic bile ducts and more than 95% of them correspond to adenocarcinomas (other rare types are squamous cell carcinoma, undifferentiated carcinoma, papillary carcinoma, etc.). Hilar cholangiocarcinoma is predominantly a slowly growing tumor with longitudinal spreading along the bile ducts. This type of macroscopic appearance corresponds to periductal-infiltrating type. Typical mass forming lesion with rich fibrous stroma is more common on periphery of liver.

A modified Bismuth-Corlette classification is widely used for the description of tumors invading hilus of liver. It is essential for preoperative planning of surgical, multimodality treatments as well as sole palliative procedures. The key issue of all techniques (palliative and curative) is to achieve accurate bile duct patency. Bile duct obstruction, if not adequately compensated, can result in intrahepatic cholestasis with significant reduction of the patient's quality and length of life. Long-term survival (survival of 5 years and more) of patients with hilar cholangiocarcinoma depends primarily on surgical treatment. However, Bismuth type III tumors are resectable at the cost of hemihepatectomy or extended hemihepatectomy, and Bismuth type IV tumors are resectable only in selected cases and the peak incidence of cholangiocarcinoma in Western countries between 60 and 70 years of age favours only limited interventions of surgeons. Median survival of resected patients due to more aggressive surgical approach and improved perioperative care rise from 16 to 30 months in the last 20 years as referred from Italian centres. R0 resection margins still mean only possible chance of cure for cholangiocarcinoma with median survival up to 47 months with significant drop to 17 months in R1 resection margins. T stage, lymphatic node status and histopathological grade are widely accepted independent factors of patients' prognosis. Especially, histopathological grade as an independent factor of prognosis is frequently missing in descriptions of patient groups referred to multimodal palliative treatments. Currently, a wide choice of palliative treatments of biliary obstruction is offered. In addition to palliative surgical procedures, there are many endoscopic therapeutic methods (e.g. nasobiliary drainage, implantation of plastic prostheses or selfexpandable metallic stents (SEMS)) and percutaneous therapeutic methods such as percutaneous drainage (PTBD) and implantation of plastic endoprostheses or metallic stents. There are several competing techniques and interventions for palliative treatment of hilar cholangiocarcinoma such as chemotherapy (intravenous, intraarterial, chemoradiation), biologic therapies, radiation therapies (external beam, intraluminal brachytherapy), photodynamic therapies and intraluminal radiofrequency ablation and they -with the exception of intravenous chemotherapy -cannot be considered as standard care. More often they are so-called tailored oncological therapies. The majority of patients are treated in clinical trials with protocols which vary considerably and the results of trials are often limited because of small number of involved subjects with variable performance status. Median survival S137 reported median of overall survival. The potential benefit of regional chemotherapy with port system implanted percutaneously in intrahepatic cholangiocarcinoma was also reported by Tanaka et al. with a 26-month mean overall survival. All in all, intra-arterial therapies (chemoembolizations and chemoperfusions) offer a potential benefit and prolonged survival for patients with an unresectable cholangiocarcinoma. We prospectively evaluated the effect of intraarterial chemotherapy on patients with SEMS implantation and radiotherapy. Hilar involvement with mass-forming and periductal infiltrating types of cholangiocellular carcinoma was predominant (84%). The median overall survival from diagnosis of disease for all patients was 13.5 months. The median overall survival times for patients with intraarterial chemotherapy were 25.2 months and 11.5 months for patients with systemic chemotherapy only. The 1-, 2-, and 3-year survival rates were 88.2%, 52.9%, and 10.1% and 43.5%, 25.4, and 0%, respectively. In addition, a remarkable minimal survival time of 11 months was reached in a group of patients with a complex oncologic therapy.

Promising results have been shown in articles in Radiotherapy and Oncology. The median survival of patients with Klatskin type tumors reached 34 months in novel retrospective studies of stereotactic fractionated radiotherapy. Studies with hypofractionated stereotactic Body radiotherapy combined with chemotherapy (gemcitabine) in a very small group of patients reported a median time to progression of 30 months, with a two-year survival and four-year survival 80% and 30%, respectively. The photodynamic therapy is limited to superficial tumour areas and is to be accompanied with additional interventions to biliary system. The median survivals have varied between 12 and 16 months in several studies and have not clearly shown the advantage in a large group of patients.

In conclusion, favorable prognosis for patients with unresectable hilar cholangiocarcinoma can be achieved using a complex tailored oncological therapy. Later retrospective studies with stereotactic radiotherapy have shown very promising results and randomized studies of this are critically needed. In future trials, it is necessary to count not only on diagnosis and localizations of cholangiocarcinoma but also on morphological characteristics (growth pattern, vascularisation) and grade of tumor, which can greatly influence the prognosis of patients as shown by the results from large studies of the resectable disease.

C RSE CIRSE Abstract Book electrode for heating biological tissue. We have been able until now to connect a multifilament stent with a RF generator and to use it as the active, non-isolated end of a RF-electrode.

To test this possibility, liver samples ex-vivo were used and numerical simulations were made. The final results were compared and revealed satisfactory and promising use of tubular electrodes for this kind of application. This kind of electrode is made from interlaced nitinol wires, forming a flexible tube that can be easily folded. This study is about the impact of the mesh density of the electrode on tissue heating. Results show that higher density mesh leads to a larger and more regular lesion. However, a high number of helices do not imply a significant large lesion. The in vitro demonstration of this fact experimentally in animal liver induced a circumferential tubular-shape necrotic area/rim around the stent. We could prove that the thickness of this "necrotic tube" is proportional to the potency (energy x time) applied to the stent. It is a known fact that "in vitro" induced necrosis does not correspond to living liver once one must have in account respiratory movement, heat sink effect if major vessels are located near to the stenosis, correct stent positioning regarding stenosis length, etc. Nevertheless, the results already achieved allow us to proceed in order to apply this technique directly during or immediately after the release of stents in the treatment or palliation of malignant tubular strictures of neoplastic etiology. So, the referred technique might be used for treating carcinomatous stenosis (oesophageal, colonic, duodenal / enteric, ureteral, etc.) and also of course bile duct cancer. Better said it can be applied in any tumour in which for palliation of tubular stenosis we introduce a stent.

With appropriate devices this technique will be used in recanalization once a RF-generator could be reconnected percutaneously with previously inserted stents in order to achieve and regain duct patency.

Photodynamic therapy

Department of Gastroenterology, University Hospital Insel, Bern, Switzerland. 

1. To learn about experimental work on applying RF ablation to implanted biliary stents 2. To review the published experience of this technique 3. To discuss possible advantages and disadvantages of these new techniques vs conventional IR management The main indication for percutaneous biliary decompression and drainage is the non-surgical palliation of malignant biliary obstruction. Whenever possible, definitive drainage should be established by internal drainage with an endoprosthesis. Because of the significantly lower mortality rate the traditional treatment of surgical biliary-enteric anastomosis should be replaced by percutaneous or retrograde endoscopic placement of an endoprosthesis. Further indications are bile leakages after surgery or trauma which may also be treated with catheter drainage. Endoprosthesis placement can be done by different approaches depending on the site of the obstruction and on the radiologist's skill to perform the procedure. The insertion of multiple endoprosthesis permits to bypass the obstruction of the biliary tree relieving patient symptoms. Tumor overgrowth is more common as obstructive cause then tumor ingrowth in the re-occlusion of inserted stents. They might be recanalized with percutaneous insertion of other endoprosthesis by several approaches. In our series biliary duct patency was achieved with a single stent in 91% of the patients. Recanalization was needed in 33% of the patients. The use of biliary endoprosthesis in adults presenting with hilar cholangiocarcinoma with segmental invasion should definitely be treated by percutaneous inserted self-expandable stents. The knowledge of several recanalization techniques may be useful to the interventional radiologist in order to perform a better aid to the patient. Occluded stents should be returned patent or bypassed, thereby maintaining palliation of symptoms, improving life expectancy and quality. Best survival rates are linked to the capability of recanalization techniques. The knowledge of several recanalization techniques may be useful to the interventional radiologist in order to perform a better aid to the patient. We are developing a new technique based on thermal ablation using radio-frequency that aims postponing stent occlusion. In the last decade, the study of methodologies for heating biological tissue has been an area of most interest in biology and medicine. As a result, the number of electrode solutions has grown in the past years. In this work, we study the capability of using a tubular Learning Objectives 1. To describe the state-of-the art imaging techniques after liver thermal ablation and response criteria 2. To discuss the optimal timing of imaging in relation to therapy and follow-up strategies 3. To learn about future imaging potential and developments In patients with hepatic malignancies, liver resection continues to be the standard for curative care. However, most of the patients are not candidates for surgical therapy, either because of poor hepatic function, of advanced nature of the disease at presentation, or due to the location of the tumor [1] . Therefore, minimally invasive strategies have gained increased attention as therapeutic options for both primary and metastatic hepatic malignancies (mainly from colon cancer and neuroendocrine tumors) [2] [3] [4] . Out of these locoregional therapies, tissue thermal ablation has gained wide access during the last decades. The aim of these thermal techniques is to induce cellular necrosis and achieve cytoreduction. Possible benefits of imageguided ablation therapies over surgery include reduction in morbidity and mortality, local control of HCC while awaiting transplantation and decrease in duration of hospital stay [5, 6] . Assessment of tumor response after ablation therapies is important in determining treatment success and in guiding future therapy. The traditional and accepted criteria to determine tumor response in oncology, namely the World Health Organization criteria and Response Evaluation Criteria in Solid Tumors (RECIST), rely on decrease in tumor size as evidence of successful therapy [7] . However, decrease in viable cell mass is not necessarily reflected by changes in tumor size, and tumors may not decrease in size after minimally invasive therapies despite the fact that they are nonviable [8, 9] . On this basis the European Association for the Study of the Liver (EASL) agreed that estimating the reduction in viable tumor volume should be considered the optimal method for assessing local response to treatment in patients with HCC [10] . The use of MRI, using conventional T1 and T2WI and dynamic contrast-enhanced imaging, for the assessment of tumor response after thermal ablation therapies for liver malignancies, is considered one of the most accurate methods in early detection of residual or recurrent tumors, so that further treatment can be planned [11] . Familiarity with post-interventional MRI findings is crucial for the accurate interpretation of these examinations. Local thermal ablation therapies include techniques which use heat (radiofrequency [RF] ablation, microwave ablation, laser ablation, irreversible electroporation); or cold (cryoablation) [12, 13] . Among all the ablative techniques, RF ablation is the one most widely used for both primary and secondary malignances of the liver [11, 14, 15] , but all techniques produce coagulation necrosis, and demonstrate similar imaging features on follow-up studies [15, 16] . After ablation, the post-procedure necrotic cavity must exceed the tumor margins by 0.5 to 1cm. In the early post-ablation period (up to one week after ablation), the necrotic cavity shows variable signal intensity changes on T1 and T2WI. Variability in T1-and T2-signal intensity of the necrotic cavity may mask residual tumor. Thus, contrastenhanced MRI must be performed for accurate analysis, because it is difficult to interpret unenhanced MRIs in this early period. Also, gas bubbles may be seen in the ablation zone, which should disappear within a few days. Gas bubbles appear as signal-void round S140 C RSE

Abstract Book the reproducibility of ADC measurement [22] . Recent studies have reported that contrast-enhanced ultrasound (CEUS) can provide valuable information on the ablation effects faster and at lower cost than computed tomography or magnetic resonance imaging [23] . However, disadvantage of CEUS is that the technique cannot examine total liver parenchyma for disease progression (e.g. new lesions) a fact true for CT and MR imaging. In conclusion, MRI plays an important role in the follow-up of patients after thermal ablation therapies for hepatic neoplasms. During the last two years DW-MR imaging proved its promising character for the noninvasive assessment of tumour response to thermal ablation and prediction of tumor response. Recently, CEUS is a promising new imaging modality for assessment and prediction of tumor response but further studies are necessary for improving image quality and thus increasing the accuracy of the technique.

areas on both T1-and T2WI. Perfusion abnormality (wedge-shaped enhancement of the liver parenchyma adjacent to the ablation zone on arterial phase images) is also a temporary and early finding following ablative therapies and usually vanishes by 30 days after the procedure. A thin rim surrounding the necrotic cavity can be seen in the early period which has low signal intensity on T1-, and high signal intensity on T2WI and corresponds to vascularized inflammatory reaction, hemorrhage, and granulation tissue. This perilesional rim shows moderate to intense enhancement on arterial-dominant phase images, better seen at later post-contrast images. This rim is thin (1mm) and regular and generally disappears by six months after ablation. This enhancing rim should not be confused with peripheral tumor regrowth which appears irregular and thicker. Additionally, an ill-defined perilesional enhancement can be seen on arterialphase images, reflecting inflammatory changes, which also gradually disappear in 3 to 6 months following therapy. The necrotic cavity does not enhance on postcontrast images and shows variable T1-signal intensity, determined by the stage of hemorrhage, whereas T2hyperintensity appears when liquefactive necrosis is present, while T2 hypointensity is indicative of coagulative necrosis. Two months after treatment, RF-treated areas become hyperintense on T1WI (due to hemorrhage or proteinaceous material), and hypointense on T2WI (coagulative necrosis) with no evidence of enhancement, corresponding to effective treatment. Marked T2-hyperintensitysignifies liquefactive necrosis or bilomas and not residual tumor which always show only moderate increase in T2WI signal. The probe track creates a linear parenchymal defect extending from the liver surface into the post-ablation cavity is hypointense on both T1 and T2WI, and does not show enhancement on post-contrast series although the liver parenchyma surrounding the probe track may show some enhancement because of edema and inflammation. The successfully ablated zone either remains with similar immediate post-therapy dimensions, or gradually shrinks in size usually within 6 to 12 months after ablation. Moreover, small necrotic cavities may cause capsule retraction, or may disappear completely. After 4-6 months inflammation has resolved and image interpretation is easier. On MRI, the ablated area shows more homogeneous T1-hyperintense and T2-hypointense signal, facilitating the depiction of possible residual tumor. The residual focus or tumor recurrence exhibits moderately high signal intensity on T2WI and shows enhancement on arterial-phase images. An increase in the size of the necrotic cavity is also another sign of recurrence. Local recurrence is almost always depicted at the periphery of the necrotic area, either as irregular thickening or a new tumor nodule. Three different patterns of local recurrence on follow-up are defined: nodular, halo, or gross-enlargement type. The nodular type is characterized by a new mass on the border of the ablation cavity, the halo type is recognized as a prominent rim around the cavity and the gross-enlargement type is an increase in the overall tumor size compared with the previous study. Follow-up MRI studies are performed to evaluate the effectiveness of ablation, and to reveal any possible complications after ablative therapies. Usually, baseline examination is obtained within the first week of the procedure primarily to detect complications or gross residual tumor that requires new intervention, and for follow-up comparison. Subsequent follow-up images are usually performed every three months for one year, and every six months thereafter. One disadvantage of contrast-enhanced MRI is the incapability to distinguish viable cells from reactive granulation tissue [6, 17] . Functional imaging, including diffusion MR imaging and apparent diffusion coefficient (ADC) mapping, has the ability to provide unique insight about molecular water distribution within a tumor, and therefore indicate the degree of tumor viability at the cellular level. Also, the ability of ADC to predict therapy outcome has been shown in many clinical studies. Several authors have reported that tumors with low pretreatment ADC values show a better response to various therapies than those with high ADC [18] [19] [20] [21] . However, location and size of the lesion potentially influence S141 CIRSE 2012 SS/FC/HL/HTS/CM without lipiodol. RE is performed with either resin or glass-based Y-90 particles, where the particles especially resin-based RE have an embolizing co-effect. Clinically, patients treated by means of TACE contrast-enhanced CT as the standard imaging technique is typically performed. MRI or more recently CEUS often complement CT in evaluating the therapeutic response [4] . Post-therapeutic imaging of TACE should be adjusted to the TACE technique. Whenever lipiodol is used a subsequent non-contrast CT scan documents filling of lesion and aids reembolization. Lesions completely filled with lipiodol are hard to assess by contrast-enhanced techniques. If not lipiodol is used, the non-contrast CT may be skipped and contrast-enhanced CT or MRI may be performed. Response shall include tumour enhancement looking for active residual or recurrent tumour [4, 5] .

Post-therapeutic imaging of RE typically includes a contrastenhanced CT of the chest and abdomen with the option to match images with additional PET looking for both, extra hepatic disease and hepatic response. Furthermore, MRI of the upper abdomen tailored to the liver is included for specific evaluation of treated tumours. Response shall include size criteria, signal changes, tumour enhancement and in addition FDG uptake [5] .

It is good clinical practice obtaining a baseline scan following TACE or RE treatment and to see the patient in regular intervals such as in intervals of 3 months depending on the technique and tumour type as an out patient basis together with tumour markers such as AFP or CEA [6] . Post-treatment imaging is imperative to evaluate response to therapy by assessing for residual or recurrent disease, revising prognosis, and guiding future therapy. There is increasing evidence that traditional size-based criteria for assessing response including contrast enhancement may mislead decision making in patients treated by TACE or RE [7] . When RECIST was compared to EASL criteria, which include tumour necrosis/viable tumour burden, RECIST missed all complete responses and underestimated the extent of partial tumour response because of tissue necrosis, wrongly assessing the therapeutic efficacy of locoregional therapies in a series of 55 patients with HCC. Response evaluation should incorporate the reduction in viable tumour burden as recognized by non-enhanced areas on dynamic imaging studies [3] . Dynamic contrast-enhanced imaging mainly bb CT for TACE and CT+MR for RE play a critical role in assessing tumour response [8, 9] .

Several new applications assessing tumour response have been proposed. These suggestions include diffusion weighted imaging (DWI), apparent diffusion coefficient (ADC), dynamic contrast-enhanced imaging with perfusion techniques, spectroscopy, and image subtraction of dynamic contrast-enhanced imaging from non-contrast imaging. These innovative imaging techniques can provide potential additional criteria to assess tumour response in addition to the accepted yet often limited WHO, RECIST, and EASL criteria, which are based on decrease of tumour size and lesion enhancement, respectively [10] [11] [12] [13] [14] [15] [16] . The ultimate endpoint in cancer research is overall survival. Nonetheless, other potential surrogate endpoints, such as response rate and time to progression, are currently used. Measurement of response rate in liver tumours has become a controversial issue. A modification of the current RECIST criteria called modified RECIST (mRECIST) has been proposed [17] . Recently, Shim and colleagues published a study comparing different assessment strategies in 332 patients with HCC who underwent serial chemoembolization. All measurable target lesions of 1 cm or larger in diameter were uni-and bidimensionally measured both at baseline and during follow-up. Intermodel agreement among the guidelines of the WHO, RECIST, EASL, and mRECIST were examined. The most reliable 16. Goldberg, S.N., G.S. Gazelle, and P.R. Mueller, Thermal ablation therapy for focal malignancy: a unified approach to underlying principles, techniques, and diagnostic imaging guidance. AJR Am J Roentgenol, 2000. 174 (2) 

Imaging after liver chemo/radioembolization

Radiology, Klinikum Karlsruhe, Karlsruhe, Germany.

1. To describe the state-of-the art imaging techniques after liver chemo/radioembolization and response criteria 2. To discuss the optimal timing of imaging in relation to therapy and follow-up strategies 3. To learn about future imaging potential and developments State-of-the art imaging techniques after liver chemo/radioembolization and response criteria Great improvements have been made to achieve local tumour control of primary liver malignancies and liver metastases. For hepatocellular carcinoma (HCC), transarterial chemoembolisation (TACE) and tumour ablation techniques have been established. For colorectal cancer as the most frequent tumour metastasizing to the liver, surgery is still the standard technique in localised disease, although percutaneous ablation has gained considerable acceptance. Radioembolisation (RE) is a newer technique with growing experience and more comparable data becoming available [1] . Contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI) are considered the modalities of choice to evaluate treatment response [1] . More recently, contrast-enhanced ultrasound (CEUS) has been proposed as well [2] . Imaging assessment of response in oncology was typically based on size criteria provided by the World Health Organization (WHO) and Response Evaluation Criteria In Solid Tumours (RECIST). However, size criteria are not ideally suited for assessing TACE or RE [1, 3] . The European Association for the Study of the Liver (EASL) proposed a system including tumour enhancement. In order to understand the limitations of size criteria alone we need to remember the therapy mechanisms. TACE techniques may include lipiodol mixed with a drug w/wo subsequent arterial embolization, bland microembolization, or the use of drug-eluted beads S142 C RSE CIRSE Abstract Book

Service de Radiologie, Hôpital Necker, Paris, France.

1. To describe the state-of-the art imaging techniques after renal ablation and response criteria 2. To discuss the optimal timing of imaging in relation to therapy and follow-up strategies 3. To learn about future imaging potential and developments No abstract available.

Imaging after lung cancer ablation L. Crocetti; Department of Hepatology, Liver Transplants, and Infectious Diseases, Pisa University School of Medicine Cisanello Hospital, Division of Diagnostic Imaging and Intervention, Pisa, Italy.

1. To describe the state-of-the art imaging techniques after lung cancer ablation and response criteria 2. To discuss the optimal timing of imaging in relation to therapy and follow-up strategies 3. To learn about future imaging potential and developments No abstract available.

What is the future of simulation?

Department of Radiology, St. James's University Hospital, Leeds, United Kingdom.

1. To assess the present situation and review the literature 2. To determine possible advantages and to depict drawbacks 3. To show future trends and developments To start to gaze into the future of simulation we need to have some understanding of the past, the present, the political landscape and the potential future applications. Simulation has been present for many years in many forms of training for individuals and teams. Within health services we will all have been exposed to it in some form or other. I have early recollections of taking blood and inserting intravenous cannulae on fellow medical students. These were simulations intended to provide prior experience before experimenting on patients. I am relieved that it was not considered necessary to learn about proctoscopy! Teams are also expected to undergo simulation training, an obvious example is a fire drill where everyone leaves the building and assembles, usually in the cold, at their muster point outside the building. The basis of a simulation can be seen to be an emulation of a real task or event allowing those participating to learn what is required in a safe controlled environment. It is self-evident that the content of the simulation should relate closely to the required learning objective. Consider again cannulation: in contemporary practice, medical students are spared and a training simulator is used. What is the aim of this simulation? We must be clear that this is intended to allow the demonstration of model was selected on the basis of the correlation with survival prediction. The study revealed that both mRECIST and EASL guidelines were independent predictors of overall survival (p<0.001 for both). These two approaches consider tumour enhancement and more accurately helped predict long-term survival in HCC patients treated with TACE [18] .

Simulation can incorporate far more than simple procedure training and extend to whole team behaviour. What is critical is that those involved in developing educational curricula consider where and how simulation can be integrated into training in order to fulfill specific functions. Simulation should target areas which are critical to safety, uncommon but important and also allow learning from adverse events to prevent repetition. Examples which are worth everyone considering are simulated reporting sessions incorporating important themes. Such a scenario would allow doctors to be observed in their interactions with other staff, their communication ability, how they organize and prioritise work. Many such scenarios could be envisaged. Similarly, it is easy to arrange simulations to improve teamwork following the safer surgery checklist sign out by identifying cases which would benefit from a debrief. Other simulations which would be useful might look at how we organize our workload and prioritise cases and how we interact with other members of the team and those requesting procedures. In my opinion a doctor able to decide whether a case needs doing and is appropriate is infinitely more valuable than one who accepts every referral. In future, it is our duty to make sure that we encourage the integration of meaningful simulation into training whether it is situational or procedural.

Robotics: potential major IR role or an expensive research tool?

Institute of Applied Medical Engineering, RWTH Aachen University & University Hospital Aachen, Aachen, Germany.

Learning Objectives 1. To describe rationale and advantages of robotics 2. To review the current literature 3. To analyse the potential role of this technique in patient management Introduction Robotics in medicine is an evolving field with an enormous potential for beneficial applications, in order to improve diagnostics and therapy. There are quite a number of projects in service robotics, which are dedicated to health care and may contribute to home care in future scenarios of "ambient assisted living". Other projects underline that robotics may play a role in physiotherapy and musculoskeletal rehabilitation. Besides these activities, there are two areas in the medical field, where robotic components are part of innovative treatment concepts, which may have the potential to be included into new clinical standards: minimal-invasive surgery and radiotherapy. It is very probable that these trends will have a stimulating effect on robotic applications in interventional radiology. Robotics in radiotherapy A linear particle accelerator is mounted on a robotic arm to improve accuracy of radiotherapy by improved dynamic adjustment of the radiation beam to the target (CyberKnife™, Accuracy [1] ). Targeted radiotherapy can be further supported by robot-assisted automatic patient alignment. A patient table, connected to a robot arm, is designed to increase accuracy of positioning during radiotherapy (robotic couch [2] ). Movement compensation of moving targets (due to patient movement or breathing) is a matter of research. An additional option of a robotic couch is robot-assisted patient transfer between different imaging modalities for trauma patients or patients with limited mobility.

In the surgical disciplines there is another field of advanced research in medical robotics. Several concepts are close to clinical implementation. The main purpose is to improve the performance of minimally invasive surgery [3] , especially in laparoscopic and endoscopic instrumentation. Examples of robot tasks are automatic adjustment of endoscope and light source [4] , robotic retaining and support correct aseptic technique and not the ability to access a vein and certainly not a difficult vein in a collapsed patient in an emergency. Does simulation work? If we reconsider fire drills the purpose is to teach us to recognize the need to move away from the fire to a place of safety. Ask yourself if you have ever ignored a fire bell? If the answer is yes, a potentially life-saving simulation has failed. Were you sure it was a test and not a real alarm? Did the drill tell you what you should do if you were in the middle of a procedure with a sick patient? Did you rehearse it? If the answer is no then the simulation chosen is ineffective for your needs! This begs the question: "does simulation need to be more realistic to be effective?" Once again the answer is no; simulation needs to be tailored to the learning needs of those undergoing the training. Continuing with the fire drill analogy, we do not need to have smoke and flames to learn how to behave in a real fire, we just need to know that we should retreat and move patients away from the fire. Aircrew may need smoke to practice evacuation of a smoke filled cabin before an inevitable conflagration. Firemen need to practice working in smoke-filled environments whilst fighting the fire and rescuing endangered lives. Thus, it is clear that within a context of "fire safety training" different levels of sophistication are required for different purposes. Interventional radiologists should consider how to decide whether to move a patient to a place of safety in mid procedure or whether it is safer to stay in place. Has the simulation taught you this? If not it has failed! Simulation training in medicine is not new and many simulators and simulations are available ranging from simple role play to learn to prioritise tasks to complex team training exercises involving entire operating theatres and theatre teams. We are all familiar with procedure simulators which are generally expensive and task specific such as those used in laparoscopic surgery. These often involve a combination of augmented reality with the "operator" using realistic tools and a simulated environment. Simulation in interventional radiology (IR) training has tended to be equated with the use of interventional simulators developed for angiographic procedures such as angioplasty and stenting. Let us consider these before proceeding with the wider picture. We need to ask the questions: · Are they fit for purpose? To answer this we need to be certain of the purpose for which they are to be used. It is suggested that they can be used not only for basic training but also to rehearse the most difficult cases in patientspecific anatomy. · Are they effective training aids? The evidence to date is not compelling. Whether they are effective again depends on the purpose for which they are being used and their context within an educational curriculum. There has been a tendency to adapt teaching to fit around the simulator rather than using simulation to help deliver a formal training curriculum. In my opinion these sophisticated and expensive devices do have a role but not as wide ranging as some would claim. There is no doubt that the steps of a procedure can be learned and rehearsed. In addition, some basic catheter skills can be acquired but the feel is not the same as in vivo and fine catheter manipulation is ineffective. Additionally, critical steps such as vascular access are not included. It should also be noted that simulators are not a panacea and that much of the value comes from the interaction with the trainer rather than simple repetition of procedures. Using simulators without expert feedback is likely to lead to adoption of poor practices. What should we be aiming for? There is no doubt that it is desirable to incorporate simulation into training and assessment. Patients, the public and regulators demand it. All wish to be reassured that those performing procedures on them are appropriately trained and simulation can help with this. However, a realistic and holistic approach to simulation is needed with a recognition of the limitations. Technical simulators do have a role to play but their use would be greatly enhanced if used as an element of global skill development.

Abstract Book fenestrated stent grafts. The findings were that, in comparison to conventional treatment, the robotic procedure is significantly faster, requires less catheter movements, and yields higher performance scores [16] . In a single case study, the Sensei system was applied clinically for AAA endovascular repair [17] . In a recent study, Riga et al. state that robotically steerable endovascular catheters offer improved manoeuvrability at the catheter tip, enhanced positional control and "off-the-wall" centerline navigation in a remote-control fashion [18] .

The introduction of imaging systems for interventional radiology or minimal-invasive surgery based on industry robotics is probably the most visible recent development (Artis zeego, Siemens Healthcare, Forchheim, Germany). The system consists of a standard flat panel detector and an x-ray tube mounted on a robot suspended C-arm.

While the system allows standard projection imaging the industrial robot's high placement accuracy is used to perform CT-grade large volume cross-sectional imaging scans by specific rotational patterns of the C-arm. 3-D imaging enables, for instance, pre-and post-interventional scans for TACE within the IR suite. The robot offers versatile, reproducible and fast movements of the C-arm, which is especially beneficial in an interdisciplinary OR environment (e.g. for neurosurgical and orthopedic interventions). However, there are only few publications, which evaluate the practical value of the system. One report is on the clipping of an aneurysm [19] . Intraoperative flat panel detector CT and 3D rotational angiography images were acquired, fused and sent to a neuronavigation system to provide intraoperative image guidance. Our team examined the combination of a robot arm-based flat panel detector with electromagnetic tracking for CT-guided spine interventions in phantom and animal model experiments [20] . Feasibility of this combination could be demonstrated for interventions such as facet joint punctures and intervertebral disc punctures. Robotics in IR: the future Is there a potential major IR role of robotics or is it just an expensive research tool? My prediction is that robotics will not stay merely a "research tool". I see robotics as an indispensable component of imaging devices, IR image guidance, navigation and instrumentation in the future. We will have robotically moved imaging devices with increased versatility and precision. For instance, in x-ray image guidance of interventions it is conceivable to move x-ray tube and flat panel detector separately, both robotically suspended, which obviates the need of a C-arm and allows more degrees of freedom. In non-vascular interventions, robotically assisted guidance of instruments to the target lesion will be implemented in clinical routine. In vascular interventions, robotics will provide improved manoeuvrability and enhanced positional control of catheters. In laparoscopic vascular procedures, the benefits of robotics are increased flexibility by robotic-wristed instrumentation and precision suturing. General advantages for all applications are the ability of motion scaling of hand movements and the reduction of radiation by remote control. However, in order to reach this level of clinical implementation, there is still a way to go. Current research tasks are the optimization of interoperability and workflow integration of robotic components, and the improvement of haptic feedback for the operator. functions and automation of suction function. In addition, there are precision tasks through narrow working channels like suturing or stapling of (micro-)anastomoses. The daVinci™ system (Intuitive Surgical) is a robotic surgical system, controlled by a surgeon from a console. Originally developed for heart and coronary bypass surgery, it is now clinically established in urologic surgery, mainly for minimal-invasive removal of the prostate gland. However, it gains increasing acceptance in other surgical disciplines, like gynecology, abdominal and pediatric surgery. There are also applications in the cardiovascular field like mitral valve repair. In a clinical pilot study, the creation of a robotically assisted aortofemoral anastomosis was examined [5] . The following advantages of robotics are pointed out: increased precision in suturing of anastomoses, increased flexibility of the robotic-wristed instruments, and the ability of motion scaling of hand movements. An alternative approach to establish a robotic surgical system is the DLR MiroSurge project [6] . Similar to the daVinci™ it includes an operator console, which was recently improved by a tactile and kinesthetic feedback of robotic instrumentation [7] .

In interventional radiology (IR) currently two major fields of application of robotics are perceivable: (a) robotics as a guidance modality for instruments (needles, catheters) in percutaneous interventions and (b) robotics as a component of imaging devices. The main goals of robotics in interventional radiology are to increase accuracy of the procedure, to optimize procedure time and to reduce radiation doses to patient and interventionalist. This is achieved, for instance, by utilization of planning scans or preoperative imaging data, which serve as reference data for high accuracy actuators of the robotic component. An additional aspect is the possibility to manipulate the interventional device by remote control from outside the interventional room. For instance, percutaneous pedicle screw implantation may represent substantial radiation exposure risk to patients and surgeons. Lieberman et al. [8] could demonstrate a 36% reduction in procedure time and a tremendous (97.8%) reduction in fluoroscopy time with robotically assisted remote control implantation.

There is nearly a decade of research in robotic components for percutaneous non-vascular interventions [9] . A robotic guidance system, dedicated for percutaneous placement of interventional instruments, can be used for CT-or fluoroscopy-guided interventions. Clinical trials were conducted testing the device for spinal nerve blocks and CT-based puncture of pulmonary nodules [3, 10] . A more recent concept is the so-called Light-Weight Robot LWR III (DLR/ KUKA, Augsburg, Germany). A prototype setting was tested in a feasibility study of a robotic flat detector CT-guided navigation system for needle placement [11] . The Innomotion system (Innomedic, Herxheim, Germany) was designed to be fully compatible with a magnetic resonance imaging environment by utilizing solely pneumatic robotic components. The robot can be used to place a needle holder at the skin entry level, according to a plan defined on preprocedurally acquired CT or MR imaging. Various phantom-based experiments and a limited clinical study have been carried out [12] . In a recent study, the Innomotion system was investigated in exvivo experiments for transapical aortic valve replacement under MRI guidance [13] .

In a recent meta-analysis of robotics in vascular interventions, 15 of 17 references dealt with laparoscopic procedures for AAA repair, aortic dissection treatment and endoleak repair [14] . To date, there is only limited experience with endovascular robotic applications to maneuver catheters. A robotic remote navigation system (Hansen Medical, Mountain View, California) was clinically tested for cardiac radiofrequency ablation in 40 patients with atrial fibrillation and flutter [15] . The study suggests the feasibility of remote control of the robotic catheter for mapping and ablation. The same system was tested in a phantom setting for cannulation of branches in 

How does fusion imaging help IR?

Interventional Oncology Department, General Hospital of Busto Arsizio, Busto Arsizio, Italy.

Learning Objectives 1. To present the properties of fusion imaging 2. To describe how the techniques can be applied 3. To show tips and tricks in clinical application In the last years, thermal ablation with radiofrequency, microwaves, cryotherapy, laser, etc. has been validated as an effective treatment for several different kinds of tumors in different body regions. Thermal ablation is actually considered a curative treatment for hepatocellular carcinoma with results comparable to resection and also as effective local treatment for liver metastases unresponsive to chemotherapy, either as potential alternative to surgical resection or as the only possible curative local treatment for unresectable metastases. More recently, thermal ablation has been successfully used for local control of other abdominal (renal carcinomas, non-functioning adrenal tumors, abdominal sarcomas, etc.) and extra-abdominal malignancies, e.g. lung primary or secondary cancers and bone tumors. An essential prerequisite for the correct use and the success of percutaneous ablation therapies is the availability of precise, reliable imaging techniques for careful pre-procedure planning, accurate intraprocedure targeting and elaborate post-procedure monitoring and assessing of the results achieved.

Nowadays several different imaging modalities can be used for the detection and characterisation of malignancies, each one with his peculiar advantage and disadvantage. In diagnostic radiology are well known the great improvement that derived from the ability to combine the advantages of anatomical imaging -such as computed tomography (CT)-with the advantages of functional imaging -such as positron emission tomography (PET). Ultrasound (US) is the most widely diffused imaging technique for guiding percutaneous procedures, as it allows for real time visualization of the needle insertion and monitoring of the procedure, and does not require ionizing radiation. Moreover, US guidance overcomes some of the limitations of other imaging modalities such as CT or magnetic resonance (MRI) that enable visualization of only transverse sections and often the visualization of the tumor only during the arterial and/or portal-venous phase of the dynamic study. However, there is a clinically relevant number of liver malignancies that are not sufficiently visible at US, and can be visualized only with contrast-enhanced CT or MRI. Successful ablation treatments guided with CT or MRI have been reported. However, compared to US, either CT or MRI suffer from some limitations. The major limitations of CT are the limited or absent real-time capability (so that many procedures are actually blind manoeuvres with subsequent confirmation), the very frequent need for the administration of contrast agents to visualize focal tumor targets due to the insufficient contrast resolution of baseline scans, and the use of ionizing radiation with relevant dose to both the patient and the operators.

With MRI the risk of radiation is lacking, the use of contrast agents to visualize targets is rarely mandatory, ablation devices can be placed along freely selected imaging planes and using almost realtime sequences. However, the high cost and limited availability of MRI machines, the need for magnetic ablation devices and the complex procedural environment greatly restrict the use of MRI for the S146 C RSE CIRSE Abstract Book

Nanotechnology: how will it help IR?

University of British Columbia Hospital/Radiology, Vancouver, BC, Canada.

Learning Objectives 1. To show the principles of nanotechnology 2. To discuss clinical applications 3. To present work in progress Nanotechnology deals with developing materials, or devices, with at least one dimension sized from 1 to 100 nanometres. Nanoparticles have properties that are not present in larger molecules such as strength, conductivity, and melting point. Nanoparticles have large surface area-to-volume ratios and often multiple functional groups, which allow conjugation to diagnostic and therapeutic agents. The small size allows design of particles that can cross anatomic and physiologic barriers. In radiology nanotechnology promises to improve both diagnosis and treatment in a multitude of diseases. Multifunctional nanoparticles offer promise for molecular and functional imaging. Nanoparticle-based contrast agents have been developed for all imaging modalities and allow advanced tumor imaging, including imaging of angioneogenesis or macrophage function. In vascular intervention, plaque specific imaging promises to better direct therapies for vulnerable plaque rather than crude treatment of stenosis, and nanoparticle drug formulations allow localized drug delivery for prevention of thrombosis or restenosis, or even for clot lysis. Advantages in interventional oncology include improved drug targeting such as with magnetic nanoparticles or to optimize loco-regional therapies, such as temperature sensitive drug release. In addition, even with improved molecular targeting, there are many instances where the site specific catheter or needle access further enhances the advantages.

Steering committee member, Cook Medical Advisory Board member, Boston Scientific

Diagnostic and Interventional Radiology, University of Pisa, Pisa, Italy.

Learning Objectives 1. To learn the role of recent MR and CT techniques 2. To review the differential diagnosis of atypical lesions 3. To review the role for liver biopsy Diagnosis of hepatocellular carcinoma (HCC) is actually demanded to imaging examinations, in combination with clinical and laboratory findings. The recent availability of different imaging modalities has improved the investigation of the processes that take place during the carcinogenetic pathway towards dysplasia and full malignancy, represented by the alteration of lesion vascular supply (progressive capillarization of the sinusoids and increasing number of muscularized unpaired arterioles); and to the progressive histological changes (loss of biliary polarization of the hepatocytes and derangement of the microscopic secretory structure) [1] . Imaging cirrhotic patients still remains a challenging issue, especially when a differential diagnosis between pre-neoplastic hepatocellular lesions, such as dysplastic nodules (DNs), and early neoplastic lesions is requested. If ultrasound (US) examination still represents the first guidance of ablations. The combination of two or more imaging techniques (the so-called "fusion imaging") has been applied in recent years to percutaneous procedures to overcome the limitations of a single imaging modality and combine the advantages of different imaging modalities. The development of systems for real-time image fusion of US and CT or MRI allow to precisely targeting also focal lesions undetectable with US. In our centre we have pioneered this kind of system since 2003, initially using for co-registration tiny metallic fiducial markers applied to the skin and subsequently external markers (xiphoid sternum and umbilicus) to get a first gross registration, and then internal markers to perform a fine tuning. The system, nowadays employed in several interventional centres throughout the world, is highly automated, can be used directly in the US interventional room and does not require relevant additional costs. Up to now more than 1,000 (mostly hepatic) malignant tumors have been treated at our institution using fusion imaging with radiofrequency, microwaves or laser ablation. Extremely interesting are the cases of tumors completely undetectable on US, targeted using the "virtual needle" provided by the fusion system and totally "blindly" for US. In this particularly challenging group, correct targeting was achieved in as many as 211 of the 230 (91.7%) liver tumors enrolled. Additional technical refinements, like automatic registration and microsensors positioned inside the cannula of radiofrequency electrodes or microwaves antennas, will likely further improve the results achievable and increase the diffusion of fusion imaging as guidance modality for interventional procedures.

because of the risk of portal hypertension and liver dysfunction. Percutaneous transhepatic angioplasty is the method of choice if the transstenotic gradient is above 3-5 mm Hg. Stenoses are usually located extrahepatically near the anastomoses. Technical success of angioplasty is 69-74%, however restenoses may develop in up to 50% of patients. In case of residual stenosis or recurrent stenosis implantation of self-expanding stents is recommended. In patients with portal venous thrombosis thrombus aspiration and lysis may be performed prior to angioplasty. Hepatic venous outflow stenoses occur in 1-6% of transplants, depending on the type of graft and of anastomosis. In living donor liver transplants hepatic venous stenoses are typically due to rapid hypertrophy causing vessel twisting and compression. Transjugular or transhepatic access is used to pass stenoses. In adult patients stenting seems to improve long term results, whereas in in pediatric patients repeated balloon angioplasty is probably the better option until grafts are of adult size. Technical success is 83-100%, however restenoses occur in 20-60% of cases. Clinical success is seen in 70-100%, major complications are rare. Hepatic artery stenoses develop in 4-11% of adult transplants. Angioplasty with stenting improves technical results; however, in tortuous vessels ballooning is the better option. Technical success is 80-100%, restenoses occur in up to 25%. Treatment is also recommended in asymptomatic patients, because up to 65% of them will become symptomatic and more than two thirds will develop biliary complications in the long term. 

Interventional management of biliary complications

Dept. of Radiology, Kings College Hospital, London, United Kingdom.

1. To review the most common biliary complications in liver transplantation 2. Which techniques can be used? 3. To review treatment options for benign stenosis and fistulae Liver transplantation is the accepted treatment of patients with irreversible liver cell failure, some metabolic disorders and a selected group of patients with hepatocellular carcinoma. Over the last twenty years, major transplant centres have reported improving patient survival, even though during this period they have developed more complex surgical techniques, including split liver, auxiliary and live-related transplantation. Coupled with this has a been an extension of the donor pool and the use of more marginal grafts and non-heart beating donors. This successful outcome has been diagnostic approach in the follow-up of cirrhotic patients, nowadays the diagnosis of nodules' nature is demanded to cross imaging modalities such as contrast-enhanced multidetector computed tomography (CT) or contrast-enhanced magnetic resonance (MR). According to international guidelines, non-invasive diagnosis of hepatocellular carcinoma (HCC) in liver cirrhosis relies upon the detection of early enhancement during the arterial phase of dynamic vascular study at both imaging modalities (CT and MR), associated with nodular wash out on the late phase [2] . In contrast, regenerative nodules and DNs usually fail to exhibit specific features at dynamic vascular study. In these last years, MR has revealed as the leading imaging tool in allowing a tissue characterization, thanks to its intrinsic capability to demonstrate pathologic changes taking place during the carcinogenetic processes. The introduction of ultrafast sequences and the development of hepatocyte-targeted compounds, such as Gd-EOB-DTPA, have allowed a simultaneous and sophisticated investigation of nodular vascular supply and of metabolic alterations of hepatocyte function, enlarging the horizons of MR applications within cirrhosis [3] . Particularly, since in nodules smaller than 2 cm, the lack of the typical post-contrast enhancement at vascular dynamic study is a frequent finding, such compounds can help obtaining a reliable diagnosis of the early stage of nodular malignant transformation, in which significant metabolic changes are already present without an evident arterial supply. Introduction

Popliteal entrapment syndrome (PAES) is a rare condition. However, it is the most common cause of surgically correctable lower limb vascular insufficiency among young adults who do not have a background of atherosclerosis. It is therefore important that radiologists understand the spectrum of this syndrome, the clinical presentation, and how best to utilize imaging to diagnose this condition. There are two distinct subtypes of PAES that have been identified, i.e. (1) anatomic and (2) functional. In anatomical PAES, an embryological basis of the entrapment can be identified. The normal popliteal artery runs between the two heads of the gastrocnemius muscle, in an oblique direction from medial to lateral, superficial to the popliteus muscle. This relationship between the artery and the muscles is disturbed in anatomic PAES. A useful classification is that of Love-Wheelan, modified by Rich and Collins, where 4 types of anatomic PAES are described (Table 1) . In functional PAES, the anatomy of the popliteal fossa is normal, and yet the patient is symptomatic and there is evidence of compression of the popliteal artery during leg movements. This has been included as a sixth subtype in the above classification.

The typical patient is that of a young healthy adult man, often athletic, in his 20s to 40s. The primary symptom is foot and calf claudication. Other symptoms include parasthesia, blanching or cramps. Typically, the pain occurs with walking rather than with running. The symptoms can often be bilateral. Patients can present with ischaemia, although this is rare. At clinical examination, the distal lower limb pulse should be examined in the neutral position, and with the foot plantar flexed or dorsiflexed. The pulses may be decreased or disappear on flexion.

Resting ankle brachial index (ABI) is usually normal, but ankle pressures will decrease on exercise. Imaging Catheter angiography has been the traditional imaging modality utilized for the diagnosis of PAES. However, with the advent of crosssectional imaging, Doppler ultrasound, MRI and CT have also been reported to be useful non-invasive methods for the diagnosis of this entity. Doppler ultrasound is an excellent screening tool for PAES, as it is relatively inexpensive, widely available and quick to perform. The popliteal artery should be patent for ultrasound to be useful. With plantar flexion, the peak systolic velocity in the distal popliteal artery and its branches could demonstrate decreased peak systolic flow. However, false-positive diagnoses may occur due to arterial compression below the trifurcation, to changes in relationship between muscle and artery at the ankle during provocation, and to signal loss due to probe displacement. Doppler ultrasound is also not able to image the soft tissue detail required to assess the anatomic relationship of the popliteal artery. The role of ultrasound is therefore dependent on appropriate patient selection, improvements in immunosuppression, intensive care management and the prompt recognition and treatment of all complications. Diagnostic and interventional radiology have been core specialties in achieving the targets of improved patient and graft survival and the goal of normal liver function. In paediatric recipients this target is to maintain normal liver function and optimal quality of life through the periods of infancy, childhood, adolescence and into adult life. The impact of live-related liver transplantation has further intensified the demand for the perfect outcome. Understanding of the mechanisms and pathogenesis of biliary complications in conjunction with percutaneous and endoscopic biliary techniques have been pivotal in prolonging graft survival. Improvement and consistency of surgical technique have reduced the more common biliary complications but the newer techniques present differing diagnostic and interventional challenges, particularly in paediatric recipients. A number of biliary complications are recognised which include biliary strictures, an acquired cholangiopathy of which there are a number of differing causative factors, roux loop obstruction, leaks at the level of the bile duct anastomosis or cut surface in reduced grafts. However, the clinical presentation may solely be of biochemical evidence of cholestatic liver function which commonly occurs posttransplantation and where there is a wide differential diagnosis. These include sepsis, acute or chronic rejection, strictures which may be anastomotic or non-anastomotic, roux loop obstruction, inadequate immunosuppression, drug hepatotoxicity, ischaemic graft injury which may precede or follow implanting of the donor graft, small for size syndrome or recurrent disease particularly in recipients transplanted for hepatitis C infection and primary sclerosing cholangitis. The clinical question for imaging is therefore to assess whether a correctable biliary cause be diagnosed in a patient with graft dysfunction and biliary features on biopsy or a recipient with progressive cholestasis without a medical cause. If so, the next question is to establish whether this biliary pathology is treatable by intervention. The paradigm of investigation is firstly with ultrasound Doppler and MDCT to establish if bile duct dilatation is present. At this stage it is important to recognise that unlike the native liver, bile duct dilatation may not occur even in the presence of a tight anastomotic stricture both with an end to end bile duct anastomosis or hepatico-jejunostomy. The second step is to establish whether there is any vascular cause, particularly hepatic artery occlusion or stenosis as causative factors and whether these require treatment by radiological intervention. MRC has allowed further interrogation of the biliary anatomy to determine whether a stricture is present at anastomotic or non-anastomotic level and if non-anastomotic whether it is part of a more diffuse cholangiopathy. There still remains a requirement for invasive diagnostic techniques of percutaneous and endoscopic cholangiography in patients where there is a high index of suspicion of a stricture and both the ultrasound and MRC have been normal or non-contributory. The principles of management, once a mechanical anastomotic cause has been diagnosed, is based on a trial of dilatation and stenting, correction of any arterial cause and optimisation of immunosuppression. Revisionary bile duct reconstruction or as last resort retransplantation remains therapeutic options. This presentation will review the algorithm for the diagnosis of these biliary complications, discuss the technical aspects of the interventional techniques and summarise their outcome. 

Imaging for the diagnosis of thoracic outlet syndrome

Department of Radiology / Division of Cardiovascular and Interventional Radiology, Medical University Vienna, Vienna, Austria.

1. To learn about the clinical importance and different clinical characteristics of thoracic outlet syndrome 2. To review the current imaging modalities for outlet syndrome 3. To learn how to diagnosis thoracic outlet syndrome Introduction The thoracic outlet syndrome (TOS) is a dynamically induced neurovascular syndrome caused by compression of the subclavian vessels and the brachial plexus within the thoracic outlet area. Consequently, three different distinct types of TOS are differentiated including neurogenic, venous and arterial. Out of these three causes, the neurogen type -caused by compression of the brachial plexus -is the most common one (in about 95%), and the arterial one is the rarest one (1%). The thoracic outlet includes three different spaces and is bordered from the cervical spine, the mediastinum and the pectoralis minor muscle. Main reasons for compression -especially during elevation of the arm -are posttraumatic conditions or anatomical variants including a cervical rib, aberrant scalene muscle anatomy or an elongated transversal process of the cervical vertebral body 7. Other reasons include abnormalities of the scalene muscles.

Given the fact that most of the TOS are due to dynamic compression of the brachial plexus neurological symptoms such as pain, paresthesia, weakness and cold intolerance are the most common clinical manifestation of TOS. Additional symptoms -in case of vascular TOS -include thrombosis of the subclavian vein, distal embolization, and/or digital ischemia. Due to the dynamic character of TOS, symptoms appear mostly only under provocation (mainly arm elevation), and usually disappear in rest. Thus, examination of patients suspected to suffer from TOS should always include examination at rest and under provocation, since fixed symptoms at rest will be present only in cases of long lasting TOS with secondary changes (aneurysms, thrombosis, occlusions).

Although the general diagnosis of TOS is made clinically, further imaging is needed to differentiate the different types of TOS, to detect the cause of TOS, and to plan the appropriate treatment. Different imaging modalities, including conventional X-Ray, ultrasound, CT-angiography, MR angiography, MR imaging, and digital subtraction angiography have been used in this regard. Conventional X-Ray (chest and neck region) can help to detect anatomical, bony reasons for TOs including cervical rib, elongated transversal process of the vertebral body C7, or posttraumatic exostoses or other posttraumatic changes. Rarely, bony tumors causing TOS can be diagnosed by X-Ray. However, in case of clear clinical signs of TOS, a negative or normal X-Ray does not exclude the diagnosis of TOS, since even soft tissue abnormalities can cause TOS, which were limited to screening of PAES or other pathology. The utilization of MRI for the diagnosis of PAES has been reported in a few studies. MRI avoids radiation exposure to the patient and the pitfalls associated with iodinated contrast medium. The soft tissue anatomy of the popliteal fossa is exquisitely demonstrated by MRI. MRI with MR angiography (MRA) has been shown to be an effective tool in the diagnosis of PAES. Dynamic MRA with the foot in forced plantar flexion has been described. However, patients will find it difficult to maintain sustained contraction during the entire period of scanning. Recently, several publications have described the utility of dynamic CT angiography (CTA) in the diagnosis of PAES. In this technique, the patient is scanned twice using a single bolus of iodinated contrast medium, with a 5 second delay between the two scans. The first scan is performed with the patient's feet in neutral position and the second scan with the feet in active plantar flexion. With the latest multidetector CT equipment, scan times have been significantly shortened. In our experience, the patient is on the CT couch for about 10 to 15 minutes for the entire scan. The images are then reviewed on a dedicated workstation where in addition to the axial scans, the images are reconstructed using multiplanar reconstruction, maximum intensity projection and volume rendering techniques. Dynamic CTA is able to visualise both the popliteal artery as well as the surrounding musculature and its variants. The advantages of dynamic CTA are that in addition to being non-invasive, it can be rapidly and reliably performed, and is easily reproducible. It is also less expensive and more readily available compared to MRI. Catheter angiography is therefore now less commonly performed for the diagnosis of PAES. It can clearly demonstrate abnormalities of the popliteal artery and images can be acquired during provocation. However, in view of its invasive nature, it is best reserved for situations where non-invasive imaging is unable to exclude PAES.

Although PAES is a rare condition, delayed diagnosis may potentially be limb threatening. There are now several non-invasive imaging techniques that can aid in the diagnosis of this condition, and radiologists should be familiar with them. Table 1 -Classification of PAES Type 1 -Medial head of gastrocnemius muscle is normal; popliteal artery is deviated medially and has an aberrant course Type 2 -Medial head of gastrocnemius muscle is located laterally; popliteal artery has normal course Type 3 -An abnormal slip of mature skeletal muscle, fibrous band, or additional tendinous band arising from migrating mesenchyme destined to become the medial head of gastrocnemius muscle Type 4 -Popliteal artery is located deep in the popliteal fossa, entrapped by the popliteus muscle or a fibrous band Type 5 -Popliteal vein is also entrapped with any type of popliteal artery Type 6 -Popliteal artery is normally positioned and entrapped by a normally positioned often hypertrophied gastrocnemius muscle (functional entrapment) S150 C RSE

Abstract Book MR with MR angiography seems to be the appropriate diagnostic algorithm in patients with clinical diagnosis of TOS. Conventional DSA has no place on this field, since in most of the patients no endovascular treatment will be performed. In this presentation, the complex anatomical situation at the thoracic outlet will be reviewed, as well as the classificationof TOS according to the leading symptoms. Additionally, an overview about currently used imaging modalities and their advantages and disadvantages will be provided. Finally, some recommendation for imaging algorithms and clinical imaging protocols will be provided and discussed.

Clinical and imaging assessment of chronic mesenteric ischaemia

Radiologie Interventionnelle, CHC Liège, Hopital Erasme Bruxelles, Liège, Belgium.

1. To learn about the clinical importance and different clinical characteristics of chronic mesenteric ischaemia 2. To review the current imaging modalities for chronic ischaemia 3. To learn when to use which imaging technique -evidence and pitfalls 1. To learn about the clinical importance and different clinical characteristics of chronic mesenteric ischaemia: Diagnosis occurs usually over 60 years of age. Most common cause results in atherosclerosis (98%) and caeliac artery (CA) or superior mesenteric artery (SAM) subocclusion process involving the proximal segment. Other etiologies are local or aortic wall dissection, aneurysmic aortic deformations including mesenteric vessels, median arcuate ligament syndrome, fibromuscular dysplasia, vasculitic syndromes, connective tissues disorder, coral-reef sclerosis, juvenile arteriosclerosis, etc. There are no specific enteral function laboratory parameter tests to confirm or rule out the existence of mesenteric ischemia. Clinical examination is more often normal with occasionally abdominal bruit contributing to delayed diagnosis. Usual clinical presentation: -old women (>60 y.o.) with ratio men/women 1:3, -classic triad of postprandial abdominal pain (26%) or anytime abdominal pain (34%), weight loss (23%) and food avoidance (50-70%).

-Sometimes it could result in an ischemic gastropathy (14%): nausea and vomiting (7%), fullness, epigastric pain, weight loss, gastric ulcers, ischemic colitis (8%), lower abdominal pain and diarrhea (7%) with gastrointestinal bleeding (3%). Usually, clinical and literature consider at least 2 of the 3 major mesenteric arteries must be involved to generate symptomatology. However, the SMA is often the bigger artery. The assumption that an individual SMA subocclusion is without symptoms in each case is not justified and must be correlated with owner anatomy. We could distinguish 4 stages to CMI as defined by Fontaine: I: Symptom-free not detected at conventional X-Ray. Ultrasound, mainly duplex ultrasound, plays an important role in the evaluation of vascular TOS, since it allows for real time demonstration of changes of flow velocities under rest and during provocation maneuver (elevation of the arm). The combination of B-mode ultrasonography with color-coded duplex ultrasound allows for combined assessment of hemodynamic changes as well as of secondary changes due to TOS like aneurysms or deviations of the vessels from normal course. Compared to other imaging modalities, examination of the patient in upright position is possible by means of ultrasound and duplex ultrasound, which reproduces the position at clinical examination. Additionally, no contrast material or radiation is needed. However, reports about the successful demonstration of neurogen TOS by means of ultrasound are lacking. Thus, the application of this technique seems to be limited to the vascular types of TOS. The great advantage of using CT and CT angiography for the diagnosis of TOS is the combination of high spatial resolution and the ability to demonstrate both the bony structures and the impact on vascular structures (compression, aneurysms, dislocations, occlusions). The high spatial resolution allows for reconstructions in different orientations and of 3D reconstructions which can be helpful in planning of surgical treatment in case of causing bony structures. Additionally, distal complications such as distal embolisms can be visualized by means of CT angiography due to the high spatial resolution. Even the CT angiography can and should be performed in rest as well as in provocation; however, two complete CT angiograms are required leading to doubled dose of contrast material and of radiation exposure as well. Furthermore, the evaluation of the cervical plexus and of the soft tissue structures by means of CT is limited, whereas CT is especially helpful for the further diagnosis of patients with vascular TOS. MR and MR angiography provides best visualization of soft tissue structures and the plexus compared to the other imaging modalities. Even at MR, examination in rest and under provocation is possible; however, even at MR two complete MR angiograms are required leading to prolonged examination time and doubled contrast dose. Using blood-pool contrast materials, both acquisitions (rest, provocation) can be performed during and after on single dose injection of contrast. Disadvantage of MR is the limited visualization of anatomical reasons (bony causes) of TOS and the limited spatial resolution of the distal arteries of the hand. However, despite these limitations, MR and MR angiography, including even T1-weighted sequences in the sagittal plane for anatomical overview should be part of any diagnostic workflow in case of clinically diagnosed TOS. Diagnostic angiography (DSA) has nowadays no place in the diagnostic algorithm of patients suffering from TOS, since the causes of the TOS cannot be detected or clarified by means of DSA, and the vascular situation can be visualized at equivalent confidence using CT or MR angiography. Diagnostic approaches to TOS As mentioned, the clinical diagnosis of TOS is made based on clinical examination at rest and during provocation. However, given the different types, localizations, and reasons for TOS, additional morphological information is needed for exact diagnosis and appropriate treatment. Although a number of different imaging modalities are available and in clinical use for that regard, none out of them can be used alone. None of these methods can answer all questions or can provide all needed information, whereas a combination of at least two modalities should be recommended. For the demonstration or the exclusion of bony causes of TOS, X-Ray or CT should be used, and for the soft-tissue component, MR should be added. If the vascular information should be better assessed by means of CT angiography or MR angiography is not proved yet. Taken into account the radiation exposure as important issue and the need for two acquisitions (rest and provocation), MR angiography seems to be favorable. Thus, a combination of X-Ray (or CT) and S151 CIRSE 2012 SS/FC/HL/HTS/CM of all).

-Nonfasting people down their PSV high limits generating false positive.

-Young and thin patient often have high PSV value during inspiration but must be normal during expiration phase. MRA: -It is the best sliced imaging for diabetics or severe atherosclerosis people.

-It is an inappropriated imaging to determine IMA stenosis.

-Overestimating stenosis grade is useful and has to be known.

-Stent and metallic artefacts can generate measurement errors for stenosis grade or empty area signal inside normal artery.

-Differentiation between local dissection and stenosis could be difficult and require axial imaging.

The arterial calcifications may result in overestimation of the degree of stenosis.

Service de Radiologie Cardiovasculaire, Hôpital Européen Georges Pompidou, Paris, France.

1. To describe the background, rationale and technique of non-contrast MRA 2. To describe the pros and cons of the method 3. To discuss the future of contrast-enhanced versus non-enhanced MRA Magnetic resonance angiography (MRA) is an established non-invasive modality to assess the aorta and its branches. MRA using gadolinium contrast infusion remains the mainstay and reference for magnetic resonance arterial imaging. However, new acquisition sequences not requiring contrast injection have been proposed and are now readily available. Ease of use, lower exam duration and cost, no adverse effects have been put forward as arguments in favor of these techniques. We will review technical advantages and caveats of non-contrast MRA sequences as well as currently available validation data and illustrate potential clinical applications. II: Intermittent abdominal pain (postprandial) III: Abdominal pain when resting IV: Ischemic necrosis These stages could be used to determine a therapeutic approach.

First-line imaging: Duplex ultrasound: Accuracy to identify significant stenosis approaches 90%. The examination is usually achieved fasting to avoid digestive gas, full stomach and arterial bypass. We can determine diagnosis of SMA or CA stenosis more than 50% for peak systolic value (PSV) ≥2m/sec. and for more than 75% for PSV ≥3m/sec. The diastolic value has also a great interest to confirm or rule out stenosis and some authors describe end diastolic value (EDV) ≥0.5 m/ sec. or peak diastolic value (PDV) >0.7 m/sec. as significant stenosis. Endoscopic ultrasound: Difficult to use in daily practice. The sensibility and specificity are the same as transabdominal duplex ultrasound which is easier to use as first-line and daily. Second-line imaging: CTA and 3D Gd-MRA: Highly reproducible, sensitive and specific non-invasive imaging tools. Sensitivity and accuracy are lightly higher for CTA than MRA. They can easily be used for diagnosis confirmation and pretreatment evaluation of the SMA and CA. Interobserver agreement for grading proximal splanchnic stenosis was 0.9 for CA and 0.92 for SMA and 0.48 for IMA. The True-FISP is superior for visualizing IMA instead of Gd-MRA but inferior than CTA. Accessibility for CTA is easier and short-time consuming than MRA. CTA is more specific and sensitive for small arteries, like IMA. Collateral arteries are better defined with CTA than MRA due to spatial resolution. Although new MR's modalities and sequences appear, the completion of CTA's examination is faster and achieved in a brief inspiration. Given the kind of population (atherosclerotic, old, multi-factors of comorbidity), the speed of the review is a factor in fewer artifacts for technically studying both, globally, with the same accuracy and specificity.

Nowadays, DSA is often only used for therapeutic. However, DSA is useful for ambiguous cases. It is a dynamic imaging, which can differentiate induced stenosis and functional stenosis. During the realisation of the DSA, we can determine if the stenosis is still present during inspiration, apnea or expiration time. For equivocal cases, a measure of translesional gradients can be achieved. The sensitivity and specificity are elevated but there are higher risks and comorbidity factors than other previous modalities.

Duplex ultrasound: If possible: Only fasting This modality is used for screening (first-line) and determine if stenosis is higher than 50% (PSV and PDV). CTA and MRA: Usually, it is used for confirmation of stenosis and grading. It can determine anatomical variability and pretreatment evaluation. It is also very useful -for these kinds of patients -to determine whether the femoral and iliac route are safe. DSA: It is useful for ambiguous or equivocal cases, for dynamic enhanced-imaging or direct measurement. Evidence/pitfalls: Duplex: -Patients with thyrotoxicosis have hyperdynamic circulation. PSV is often over than 3m/sec. fasting. The measurement of diastolic velocities is normal with better sensitivity and specificity than PSV, excluding stenosis. -Difficulties of examination due to obesity and disgestive gas (20% 

Paclitaxel-coated balloon angioplasty versus plain balloon dilatation for the treatment of failing dialysis access: a prospective randomized controlled trial K.N. Katsanos, P.M. Kitrou, S. Spiliopoulos, A. Diamantopoulos, D. Karnabatidis, D. Siablis; Department of Radiology, University Hospital of Patras, Patras, Greece.

Purpose: Τo report the final 1-year results of a prospective randomized trial investigating angioplasty with paclitaxel-coated balloons (PCB) versus plain balloon angioplasty (PBA) for the treatment of failing native arteriovenous fistulae (AVF) or prosthetic arteriovenous grafts (AVG).

This was a non-inferiority hypothesis trial registered in clinicaltrials.gov (NCT01174472). Enrollment criteria included clinical signs of failing dialysis access with angiographic documentation of a significant venous stenotic lesion in patients with AVF or AVG circuits. From March to December 2010, 40 patients were randomized to undergo either PCB dilatation (n=20; paclitaxel-coated balloon) or standard PBA (n=20; high-pressure balloon >20Atm) of a stenosed venous outflow lesion. Regular angiographic follow-up was scheduled bimonthly. Primary endpoint was set at primary patency of the treated lesion (defined as angiographic visualization of a patent lesion with <50% angiographic restenosis and no need for any interim repeat procedures). Results: Baseline and procedural variables were comparably distributed between both groups. Additional post-dilation with a highpressure balloon was necessary in 11/20 (55%) of the PCB-treated cases. There were no major or minor complications in either group. At 1 year, cumulative target lesion primary patency was significantly higher after PCB application (35% in PCB group versus 5% in PBA group, p<0.001; respective HR (95%CI) = 0.27 (0.13-0.58)). Numberneeded-to-treat to obtain one improved patient was single-digit (NNT=3.3, 95%CI=1.9-14.3). Conclusion: PCB angioplasty significantly improves patency after angioplasty of venous stenoses of failing vascular accesses used for dialysis. Disclosure: Dr. K. Katsanos discloses that he holds a proctorship agreement with INVATEC-MEDTRONIC.

H. Goessmann 

The Ash Split translumbar catheters for dialysis: a solution for patients in dialytic emergency

Radiology, Clinica de Marly, Bogota, Colombia.

Purpose: The loss of venous access is the main cause of morbidity in chronic renal failure patients on hemodialysis. We present our experience with the Ash Split catheter placed via translumbar in the ICV in patients without other venous access and in dialytic emergency. Material and Methods: Over a period of 10 years we had inserted 218 catheters in 201 patients (124 women) with average age of 45 years. By femoral access we advanced a pigtail to the ICV to the level of L2. Using the pigtail as target with patient in prone position, we punctured the ICV and advanced a guidewire; after making the subcutaneous tunnel, we advanced the catheter to the right atrium. The patient could be taken immediately to dialysis. All catheters were placed with fluoroscopy and general anesthesia. 

Prostatic arterial embolization: criteria to predict treatment outcome Purpose: To show that septal-perforator artery embolization is feasible, safe and successful in HOCM.

In HOCM, interventricular septum hypertrophy cause obstruction of flow through the left ventricular (LV) outflow tract with clinical consequences. When medical treatment is not enough, septum ablation with alcohol is indicated. We report seven patients in whom alcohol ablation was not possible because evidence of septal perforator-artery/left ventricle fistulae that were embolized. All septal-perforator arteries were embolized with 300-μ microspheres (Bead-Block®) using protection occlusion balloon. Then 1.5-4mm diameter controlled deployment microcoils (mean 3, range 2-5) were released after balloon retrieval. Procedures were performed in a cardiac catheterization suite, by a multidisciplinary team: cardiologists (hemodynamist, ultrasonographer), interventional radiologist, anesthesiologist. Definitions: Technical success is final transaortic gradient below 10mmHg. Clinical success is technical success without complications before hospital discharge.

Results: Technical and clinical success was achieved in 6 of 7 cases (one case reduced the gradient > 50% not reaching values < 10 mmHg). All patients referred post procedure pain, but less than with alcohol ablation. No non-target embolization was evidenced. One patient presented transient A-V block during microsphere embolization without clinical consequences as he was under atrio-ventricular pacemaker. There were no clinical complications during the hospitalization period (1.3 days mean time). Conclusion: Septal-perforator coronary artery embolization with microspheres and microcoils is feasible, safe and successful for patients in whom alcohol ablation is not possible. Patients with fistulization in the septal coronary arteries could benefit from this novel technique. Further studies may be needed.

The trouble with right-sided varicoceles: should MR venography be routinely performed prior to embolisation? MRV showed the testicular vein origin in 4 (4/6, 67%). A repeat procedure was performed in these four patients and successful embolisation was achieved in 2 out of those 4 repeat procedures (50%). Out of the 2 patients that MRV failed to define the origin of the testicular vein, 1 had surgery and 1 was managed conservatively. Conclusion: Identification and selective catheterisation of the testicular vein is the principal technical limitation for right-sided varicocele embolisation. In our small case series, our technical success rates improved from 11% to 50% with pre-procedural MRV. This suggests that pre-procedural MRV would be a useful strategy for rightsided varicocele embolisation, and should be considered even prior to initial attempt.

Persistent or recurrent varicocele after failed varicocelectomy: outcome in patients treated by percutaneous transcatheter embolization J. Kim Purpose: Many patients are not suitable for conventional revascularization and therefore alternative therapeutic strategies are necessary to avoid limb amputation. No pharmacologic treatment has S158 C RSE CIRSE Abstract Book altered the natural history of critical ischemia of the leg. Sphingosine-1-Phosphate (S1P) and vascular endothelial growth factor (VEGF) could have synergistic effects on creating more stable neovascularization in an ischemic hind leg animal model. Material and Methods: Hind-limb ischemia was induced in 40 rabbits. Divided equally into four groups, they received different intramuscular injections in the ipsilateral limb weekly: S1P solution (10); VEGF, (10) S1P+VEGF, (10) ; and serum albumin (control group), 10. Nuclear medicine flow (NMF) studies, corneal exam, and angiogram of the hind limbs were performed at 4 (N=5) and 8 (N=5) weeks for each group. After euthanasia, both hind limbs were examined immunohistopathologically. End-points were comparative clinical, morphological, histological, and perfusion-related changes.

Results: Angiogram analysis revealed no difference among the studied groups (p >.05). The corneal exam did not show corneal neovascularization. NMF studies showed the VEGF had a positive effect on both occluded and non-occluded limbs. The VEGF+S1P group had tagged red blood cell study with higher ratios between the occluded versus non-occluded limbs at 4 and 8 weeks (p <.05).

The S1P-only/VEGF-only treated legs and S1P+VEGF groups showed immunohistochemistry and muscle vessel counting with higher number of vessels when compared with the control group at 4 weeks. Conclusion: S1P+VEGF stimulates angiogenesis and reduces the hemodynamic deficit up to 8 weeks of follow-up. The combination of S1P+VEGF may have clinical application in limb ischemia. Purpose: To compare the complete occlusion or recanalization after embolization using hydrogel-coated coils and fibered coils in two arterial territories after 7 days, 1 month and 4 months. Material and Methods: Twelve sheep had one internal iliac and one renal artery randomly embolized using hydrocoils or fibered coils. Renal arteries were embolized using detachable 0.018 coils and internal iliacs using pushable 0.035 coils to achieve complete occlusion. All animals had control angiography performed at 7 days, 1 month and 4 months to assess recanalization before being sacrificed at 4 months. Tissue samples were embedded in resin, sectioned and stained with methylene and toluidine blue. Recanalization and inflammation were evaluated at pathology. Results: After 7 days, no difference in terms of recanalization was found between both products. At one month, 100% of the arteries embolized with hydrocoils were occluded angiographically versus 50% of those embolized with fibered coils (p=0.004). At 4 months, 80% of the arteries embolized with hydrocoils were occluded versus 25% of those embolized with fibered coils (p=0.01). Recanalization at angiography was always confirmed at pathology. The percentage of thrombus was significantly reduced after embolization with hydrocoils (36%) compared with fibered coils (77% (p<0.001). 

Effects of uterine artery embolization on histopathology and microvascular density in endometrium of guinea pig with uterine leiomyoma

Interventional Radiology, The 1 st Affiliated Hospital of Sun Yatsen University, Guangzhou, China.

Purpose: To investigate the effects of uterine artery embolization (UAE) on histopathology and microvessel density in endometrium of guinea pig with uterine leiomyoma. Material and Methods: Oestrostilben and progestin were used to induce uterine leiomyoma in Guinea pigs. Open surgery was performed in all guinea pigs for uterine leiomyoma verification. The guinea pigs with uterine leiomyoma were allocated randomly into three groups: control, UAE and pseudo-UAE group. In UAE group, guinea pigs were reallocated randomly into three subgroups: A1, A2 and A3 whose uteri were taken out on the 7 th -15 th , 16 th -30 th and 31 st -45 th day after UAE, respectively. The uteri were taken out at 16-30 days after pseudo-UAE in pseudo-UAE group and three weeks after open surgery in control group. Microvessel density (MVD) in basal lamina of endometrium was measured and histopathology of endometrium was observed and scored.

The grade of pathological injury in A1 was higher than that of A2 (p<0.001) and control group (p<0.001). There were no differences in grades of pathological injury between A2 and A3 (p=0.142), control and pseudo-UAE group (p=0.567), control group and A2 (p=0.116), A3 (p=0.782). The MVD in A1 was the lower than that in A2 (p=0.005) which was lower than that in A3 (p=0.021). There were no differences in MVD between A3 and control group (p=0.322), control group and pseudo-UAE group (p=0.412). Conclusion: Endometrium after UAE suffers from a transient ischemic injury with decrease in MVD and can recover with MVD increasing and reaching normal level in guinea pig with uterine leiomyoma. Purpose: Resorbable microspheres (MS) for embolization must have a sufficiently quick time of resorption to provide a functional recanalization and to avoid chronic vascular remodeling. We synthesized and evaluated rapidly resorbable MS. Material and Methods: Synthetic hydrogel MS were made of an adjustable hydrolyzable crosslinker and an acrylic monomer by suspension polymerization. MS were incubated in phosphate buffer at 37°C under agitation and mass loss was followed until total resorption. In vitro cytotoxicity was assessed on HUVEC and L929 fibroblast cell culture. In vivo biocompatibility and in vivo resorption were assessed by subcutaneous implantation in rabbits. MS were used for pig renal artery embolization, and compared with gelatin sponge particles. Recanalization of vascular trees was controlled by angiography at 1W. Results: Microspheres were successfully synthesized. Time of resorption varies from 1 day to 7 days according to the nature of the crosslinker. Molecular weight of the degradation products were S159

Free Papers below 50kDa (threshold for renal clearance). MS and their degradation products were non-toxic in both cell cultures. 90% of the material disappeared at D2 in rabbit skin and provoked only a mild inflammatory reaction. The space occupied by the material was rapidly replaced by fibrin and colonized by cells. Pig renal arteries were successfully embolized with MS. In angiograms MS embolization resulted in distal occlusion, whereas gelatin sponge occluded proximal arteries. Recanalization and infarct rate at 1W was different from gelatin sponge particles because of their different level of occlusion. Conclusion: Embolization with MS of a short resorption time resulted in recanalization of embolized arteries before 1W.

To evaluate multimodality visibility of embolization particles in Angiography, CT and MRI. In Part I of this work, Angiography and CT visibility were analyzed.

As an evolution of currently available embolization particles (Embozene®, CeloNova BioSciences, USA), those particles were modified. Additional embedding of X-ray and MRI materials should result in good visibility on Angiography, CT and MRI. Three different prototypes with different loads of X-ray and MRI materials (Intensity A, B and C) were compared with controls (commercially available Embozene®). Particle sizes with diameters of 100±25μm and 700±100μm were tested. Livers and kidneys were embolized with particles suspended in normal saline without any iodinated contrast material. Subjective particle visibility was evaluated in Angiography during particle injection applying a 3-point scale (0-definitely not visible; 1-probably visible; 3-definitely visible). Objective particle visibility was analyzed in CT applying absolute signal measurements (Hounsfield Units (HU)). Purpose: We aimed to evaluate the impact of using three-dimensional rotational angiography (3DRA) and intracranial guiding catheters on improving the procedure of angioplasty and stenting for intracranial atherosclerosis.

In this prospective single-center study, primary endpoint was the impact of using 3DRA on pre-intervention assessment, studied by comparing the diagnostic value of DSA and 3DRA. Findings of the stenotic lesion as shown on four standard views of DSA were compared with those in the best projection of 3DRA. Accuracy of DSA in diagnosing significant vascular morphology that led to alteration of management was compared with that of 3DRA. Secondary endpoint was the impact of using intracranial guiding catheters on the procedure. Results: In 169 patients, 181 DSA and 3DRA on 181 vessels were performed, and 79 (43.6%) of DSA were found to be of satisfactory quality as a pre-intervention assessment tool comparable to that of 3DRA. Sensitivity of DSA alone in diagnosing arterial fenestration, a contraindication for stenting, was 33.3%, specificity 98%. Extracranial (Guider) and intracranial (Neuron) guiding catheters were used in 61 and 24 patients, respectively. Intracranial catheters were significantly more successful in eliminating reverse curves in access path, 87.5% (7/ 8) Our novel data suggest that there may be a low embolic burden during CAS and that DWI lesions may be the result of later embolisation. This may be from disruption of atherosclerotic plaques within the aortic arch or from thrombus build up and stent embolisation. Reverse flow may be more effective than filters at preventing brain injury.

Preinterventional cerebral blood volume (CBV) mapping predicts final infarct volume in patients with acute cerebral artery occlusion (MCA or ICA) and endovascular recanalization Purpose: To evaluate the predictability of the final infarct volume in patients with acute occlusion of the middle cerebral artery (MCA) or the distal internal carotid artery (ICA) and successful endovascular recanalization by measuring cerebral blood volume (CBV) using flat panel detector computed tomography (FPDCT). Material and Methods: 19 patients with acute unilateral occlusion of the MCA or distal ACI without demarcated infarction, proven by CT at admission, and successful (TICI 2b or 3) endovascular thrombectomy were included. Cerebral blood volume maps (Axiom Artis zeeGo using syngo Neuro PBV IR, Siemens, Erlangen, Germany) were acquired from each patient immediately before endovascular thrombectomy. 24 hours after recanalization, each patient received multislice CT to visualize final infarct volume. On the coloured CBV maps, ROI were manually placed in the areas of decreased CBV to quantify CBV. Furthermore, the areas of decreased CBV were compared to the final infarct volume proven by CT the next day. Results: In 14 of 19 patients, areas of distinct CBV decrease (less than 12 ml/ 100g) corresponded to final infarct volume. In 5 patients, areas of decreased CBV overestimated final extension of ischemia probably due to inappropriate timing of data acquisition. Conclusion: CBV mapping using FPDCT is a promising tool to predict areas of irrecoverable brain parenchyma in acute thrombembolic stroke. Further validation is necessary before routine use for decision making for interventional thrombectomy. Disclosure: There is a scientific cooperation between the Institute of Neuroradiology Frankfurt and Siemens.

CT angiography-guided multivessel embolization in hemoptysis: does it reduce recurrence rates?

S.S. Joshi, J.K. Rai, S. Pene, P. Mehta, M.P. Cherian; Radiology, Kovai Medical Center and Hospital, Coimbatore, India. Purpose: To evaluate the efficacy of CT angiography-guided multivessel embolization in hemoptysis in reducing recurrence rates. Material and Methods: This retrospective and prospective study was conducted at Kovai medical center and hospital from August 2007 to December 2010. All patients with recurrent or massive hemoptysis referred for bronchial artery embolization underwent contrast-enhanced 64-slice multidetector CT of the thorax extending from base of the neck to upper abdomen. The etiology (aspergilloma, tumour, pulmonary sequestration) was noted whenever feasible during the study. All cases were followed up for period of 1 month for recurrence. Results: A total of 83 patients, 65 males and 18 females, underwent both CT angiography and DSA. Of the 83 patients, 80 patients had at least one abnormal bronchial artery. 83 abnormal co-existent nonbronchial systemic arteries were seen. 3 patients had hemoptysis of pulmonary artery origin. A total of 211 arteries, 128 bronchial (78 on the right and 50 on the left) and 83 non-bronchial were evaluated using both CT and DSA. On DSA additional 12 non-bronchial arteries were found. A total of 83 abnormal non-bronchial arteries in 45 patients were embolized. A total of 12 arteries were not seen on MDCT of which 4 were from the thyrocervical trunk, 2 from lateral thoracic, 3 from internal mammary artery, 2 from intercostal artery and 1 from the subclavian artery. No recurrences were seen in our study in the first month of embolization. Conclusion: MDCT helps in increasing technical success and reducing recurrence rates.

Is ECG gating for motion artifact reduction in CT angiography of the ascending aorta still required in times of high-pitch scanning? Purpose: To assess if the ultrafast high-pitch technique for CT angiography can be used without ECG gating for the diagnosis of diseases of the thoracic aorta without deterioration of the diagnostic accuracy. Material and Methods: Sixty consecutive patients referred for CT angiography of the thoracic aorta for different indications (aneurysm of the ascending aorta, Type A dissection, aortic coarctation, previous surgery of ascending aorta or aortic arch) were prospectively included. After randomization, they underwent CT angiographies with ECG-gating or using the high-pitch mode. For evaluation, motion artifacts and image quality were assessed in a blinded fashion by two independent radiologists at different predefined anatomic regions. Additionally, CNR and SNR were measured at the same anatomical levels. Finally, radiation dose was registered and compared between the two groups. Results: One patient was excluded due to technical reasons; thus, 59 patients (f:m=26:33) with a mean age of 68 years (range, 32 -92y) were included in the analysis (30 with ECG gating, 29 without). There were no significant differences in the radiation dose between the two examination techniques, although the mean DLP was lower in the non-gated group (602 versus 660mGy*cm, respectively (p=0.08)). Even in the image quality, no significant differences were found (p=0.12). However, the intra-arterial CNR values were significantly higher in most of the anatomical regions in the non-gated group (p=0.0003 -0.008, respectively). Conclusion: Diseases of the thoracic aorta can be diagnosed without ECG gating using an high-pitch scanning technique with similar image quality but higher contrast-to-noise ratios compared with ECG-gated CT angiographies.

Free Papers Purpose: The purpose of this study is to compare the tumor volume in a VX2 rabbit model as calculated by semi-automatic tumor segmentation from C-arm cone-beam CT (CBCT) and multi-detector CT (MDCT) images with the actual tumor volume. Material and Methods: 20 VX2 tumors in 20 adult male New Zealand rabbits (1 tumor per rabbit) were imaged with CBCT (using an intra-arterial contrast medium injection) and MDCT (using intravenous contrast injection). All tumor volumes were measured using a semi-automatic 3D volumetric segmentation software. The software uses a region-growing method employing non-Euclidean radial basis functions. After imaging, the tumors were excised for pathologic volume measurement. The imaging-based tumor volume measurements were compared with the pathologic volumes using linear regression, with Pearson test, and correlated with Bland-Altman analysis. Results: Average tumor volumes were3.53cm3±1.57 [1.36-7.20] on pathology examination: 3.80cm3±1.58 [1.32-7.26 ] on CBCT; and 3.90cm3±1.59 [1.76-7 .53] on MDCT (p<0.001). A strong correlation between pathology and CBCT and also with MDCT volumes was observed (Pearson correlation=0.993; and 0.996, p < 0.001, for CBCT and MDCT, respectively). The Bland-Altman analysis showed that MDCT scans tended to overestimate tumor volume, and there was a stronger agreement between CBCT and pathology tumor volume than with MDCT, possibly due to the intra-arterial contrast injection.

The tumor volume as measured by the semi-automatic tumor segmentation software showed a strong correlation with the "real volume" measured on pathology. Use of the segmentation software on CBCT and MDCT can be a useful tool for volumetric hepatic tumor assessment.

Oncologic intervention 1

Irreversible electroporation of lung metastases: initial experience J. Joskin, T. de Baère , L. Tselikas, G. Farouil, A. Hameg, F. Deschamps; Image Guided Therapy, Institut Gustave Roussy, Villejuif, France.

Purpose: Because recurrence rate of lung RFA has been reported higher when tumors are in contact with large vessels, we used Irreversible Electroporation (IRE) used to treat such located lung metastases and report herein our initial experience. Material and Methods: Seven male patients aged 37 to 74 years were treated for a single lung metastasis in contact with vessels 4 mm or larger. The metastases measured 15.1±3.7 mm [9] [10] [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] [21] abutting a pulmonary vessel 4 to 9 mm in diameter or the aorta (n=1). Primary tumors were colorectal (n=4), renal (n=2), or pancreatic. Two electrodes were inserted in 5 patients and 3 electrodes in 2 patients. Under general anesthesia and short pulses of current 1900 to 3000 volts/cm were delivered using a dedicated generator (Nanoknife®, Angiodynamics, Latham, NY).

Results: Treatment was well tolerated in all patients. We drained 3 pneumothoraxes. Immediate post ablation imaging showed a zone of alveolar condensation around the treated tumor. CT obtained on day 1 or 2 demonstrated an opacity with a maximum diameter 60% larger than the tumor. CT performed at 3 months demonstrated a decrease by 57% of the diameter of the ablation zone when compared with initial tumor size. This decrease was 25% at 1 month. After a median follow-up of 77 days, no tumor demonstrated local recurrence at CT (n=7) or at PET-CT (n=4). Conclusion: IRE is well tolerated and induces a rapid decrease in size of the treated tumor when compared with thermal ablative therapies. Encouraging initial results warrant further investigations.

Computed tomography hepatic arteriography has a hepatic falciform artery detection rate that is much higher than that of DSA and 99mTc-MAA SPECT/CT: implications for planning Y-90 radioembolization?

M.C. Burgmans 1 10.0 [7.7-10.9] and similar without or with PVO (9.3 [7.4-11.4] vs. 10.2 [7.7-11.8] ; p=0.826). Survival diminished with increasing symptomatic disease (ECOG 0 vs. 1 vs. 2: 10.8 [6.5-11.9] vs. 10.0 [7.7-11.8] vs. 6.6 [5.5-20.8] ; p=0.926) and without or with EHD (10.2 [8.2-11.7] vs. 7.4 [4.3-13. 

The efficacy of radiofrequency thermal ablation and cyberknife radiation therapy to treat colorectal liver metastases: data from a matched pair analysis (n=8) were treated with radiofrequency, microwaves or cryotherapy. We prospectively recorded feasibility, limitations, contraindications and complications of HFJV during PTT. We also estimated 3-D displacement of target organs under HFJV in 10 patients by repeating measures of target position on CT images during needle placement. Results: HFJV was used in 41 patients (80%). In 5 patients (10%) target lesions were right beneath the diaphragm, invisible on ultrasound during HFJV, and only visible in deep inspiration during conventional ventilation. In 5 patients (10%), severe COPD contraindicated HFJV. 18 patients (35%) showed complications to PTT according to SIR Classification System for Complications (10 type A, 2 type B, 1 type C, 4 type D, 1 type E), but none associated with HFJV. Hypercapnia during HFJV was never observed. Maximal range of target displacement during respiratory cycle was <1mm in x and y axis, and <5mm in z axis. 

S. Sun, F. Youness, S. Laroia, L. Song; Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, United States of America.

Purpose: Liver regional therapies can be beneficial in reducing morbidity and mortality in patients with metastatic neuroendocrine tumors (mNETs). We compared clinical outcomes of patients treated with transarterial bland embolization (TABE)/ chemoembolization (TACE) or selective internal radiation therapy (SIRT) with SIR-Spheres at our institution over the past ten years. Conclusion: There appears to be no significant difference in TTP in patients treated with SIRT compared with patients treated with TABE or TACE in this cohort; however, there may be a trend towards a longer time to disease progression in patients treated with chemoembolization compared with the other two modalities. Patients tend to have a prolonged survival after all three regional therapies.

Purpose: The challenge of avoiding collateral/branch vessel loss associated with covered stent applications has led to the evolution of flow-modulator stents. Currently, there are limited data on their use in the peripheral circulation. We discuss our preliminary experience using the Multilayered Aneurysm Repair System® (MARS) (Cardiatis) for across/below-knee popliteal endovascular aneurysm repair (PEVAR). Material and Methods: 6 PEVARs (4 unilateral, 2 sequential bilate-ral) using the MARS were undertaken between June and August 2011. Radiological assessments (week 1+6 monthly post-procedure using Doppler ultrasonography and biplanar knee radio graphs (additional contrast studies as necessary) sought evidence of aneurysm exclusion, graft patency and preservation of branches and run-off vessels. Clinical outcome was assessed including these parameters. Results: 5 males (mean age 76, range 62-86 years) with 6 popliteal artery aneurysms (PAAs; diameter 22-41mm, median 35mm: one with bilateral PAAs) underwent PEVAR, with extension into the below-knee PA. All patients but one were maintained on dual antiplatelet therapy. Technical success was achieved in each case. We observed 1 "endoleak" and 1 symptomatic (critically ischemic) stent occlusion requiring thrombectomy within 7 days, with re-occlusion. Two further symptomatic stent occlusions were identified within a 6-week follow-up period, totalling 3 occlusions out of 6 devices deployed. Patients with occluded devices are being managed conservatively, the others remain under surveillance. Conclusion: No firm conclusion can be reached on the efficacy of trans/infrageniculate PEVAR using MARS due to the inherent limitations of this small series. We must consider the risk/implications of early thrombosis in flow-modulator stents as with earlier generation stent-grafts. Larger, prospective trials +/-scope for alternative anticoagulant therapy should be considered to enable accurate evaluation of this device in PEVAR. Disclosure: Presenter for Gore.

Purpose: To evaluate the patency of balloon-expandable covered stents for the endovascular management instent stenosis in previously placed bare-stents in visceral arteries in patients with chronic mesenteric ischemia or renal stenosis who had previously had a positive clinical response to bare-stent placement. Material and Methods: Retrospective audit of patients undergoing covered stent (0.035-inch platform, V-12, Atrium) placement for the management of instent stenosis in visceral arteries was performed (01/2006-12/2011 ). Patency per artery was determined by imaging follow-up. Interval patency of the covered stents was compared with the interval patency of the bare-stents prior to placement of the covered stents (interval patency of the artery was compared prior to and after covered stent placement). Results: 32 visceral arteries in 25 patients (mean age: 68 years, range: 36-82) had instent stenosis in previously placed bare-stents. Arteries included 19 renal, 9 superior mesenteric, 2 celiac trunks and 2 inferior mesenteric arteries. Technical success and complication rates for placement of balloon-expandable covered stents were 100% and 0%, respectively. Mean covered-stent diameters was 5.5 (range: 5-7mm) . The mean bare-stent interval patency prior to covered-stent placement was 20.8 months (range: 2.9-96.0 months). The primary unassisted patency for covered-stent placement at 6, 9, 12 and 24 months was 94%+/-6, 94%+/-7, 94%+/-8, & 83%+/-11, respectively. The interval patency of the previously placed bare-stents versus the subsequently placed covered-stents at 6, 9, 12 & 24 months were 93%+/-4, 68%+/-6, 55%+/-7, & 25%+/-7 versus 94%+/-6, 94%+/-7, 94%+/-8, & 83%+/-11, respectively (P<0.001). Conclusion: Balloon-expandable covered stents are effective for the management of instent stenosis of bare-stents in visceral arteries. Disclosure: Dr. Saad is a consultant and grant recipient for Atrium. Purpose: The activation of sympathetic nerves in the development of essential hypertension has been largely demonstrated. The catheter-based renal denervation was investigated in patients with essential hypertension treated with at least three antihypertensive drugs, resistant to medical therapy (blood pressure > 160/90mmHg). The aim of the study was to assess efficacy and safety of percutaneous treatment with Ardian system at 12-month follow-up. Material and Methods: Between 2010 and 2011, 18 Patients with essential hypertension, treated with at least three antihypertensive drugs, non-responders to medications, underwent catheter-based denervation of both renal arteries. Angio-CT, Eco-color-Doppler S168 C RSE CIRSE Abstract Book with resistive index of both renal arteries, glomerular filtration rate and Holter pressure were evaluated before the procedure. Follow-up was scheduled at 1, 3, 6, and 12 months after the procedure. Blood pressure lowering effectiveness was evaluated by Student's t test. Results: In the treated patients, baseline office blood pressure was 171/102 mmHg (SD 34/21), mean 4-7 antihypertensive medications; glomerular filtration rate was 92.6mil/min/1.73m2 (SD 15) . Office blood pressure after the procedure was reduced by -21/-11 mmHg; -28/-10 mmHg; -29/-13 mmHg; -33/-12 mmHg at 1, 3, 6 and 12 months, respectively. In 13 Patients, medical therapy was reduced in both number and drugs dosage. Five patients obtained a blood pressure reduction without changing their medical therapy. No intra/periprocedural complications were observed. Conclusion: Catheter-based renal denervation is an innovative, fast and safe procedure. The clinical and procedural efficacy has been demonstrated by the achievement of significant blood pressure reduction without significant complications. Larger prospective randomised studies are needed to validate this technique.

To report the results of radiofrequency-based renal denervation (RD) with the Symplicity® Medtronic catheter in a prospective series of 10 consecutive patients with essential resistant hypertension (RH) 

Technical and clinical outcome of transjugular intrahepatic portosystemic stent: shunt bare metal stents versus polytetrafluoroethylene-covered stent grafts B.A. Radeleff, C.M. Sommer, N. Bellemann, T. Gockner, N. Kortes, U. Stampfl, H.U Only one patient had progressive increase in alkaline phosphatase, the rest of the laboratory findings was normal. This patient had no symptoms, regarding his disease. In case number 14, the stent was placed directly on a benign stricture of the bile duct without prior repair. (without hepaticojejunostomy). Results: After the procedures (biodegradable stent placement), the postoperative follow-up was unremarkable, without complications or technical difficulties.

C RSE

No strictures because of the stents or its degradation were seen. Only one patient presented elevation of the alkaline phosphatase. All the patients are asymptomatic to date. The real patency of the stenosis will depend on the long-term follow-up. This new technique could replace the balloon dilatation for the treatment of hepaticojejunostomy strictures and biliary strictures. Conclusion: Biodegradable stent is a feasible and safe alternative in the treatment of biliary strictures. Future RCT are mandatory to demonstrate the utility of biodegradable stents for the treatment of partial strictures located on the bile duct. Studies with long-term follow-up are needed.

Analysis For BRTO+No TIPS, the PCD, CSL, and AUC increased by 7%-1311% (+383%), 4%-2142% (+603%), and 4%-2119% (+622%), respectively. The four patients with BRTO+No TIPS had a GRS flow rate of 260, 928, 1108, and 1583ml/min. One patient had minimal increase in flow by Q-DSA (4-7%) and also demonstrated the lowest flow in the GRS (260ml/min). The remainder had an increase in liver perfusion Q-DSA parameters >85%. For BRTO+TIPS, the PCD, CSL, and AUC changed by -9%-+106% (+64%), +2%-+412% (+201%), and -19%-+404% Purpose: The objective of the study was to determine the practicability of cement augmentation using a balloon catheter via individual approaches taking into consideration the course of the fracture of the sacrum.

In 30 patients with severe osteoporosis a sacral fracture was detected by CT and MRT. In order to achieve a cement distribution longitudinally in relation to the fracture, the balloon catheter was inserted into the sacrum via a hollow needle either from caudal to cranial, from dorsal to ventral or from lateral transiliac to medial. The balloon catheter was then inflated and deflated 1-3 times along the fracture in the respective direction, and the hollow space created was then filled with PMMA cement. A conventional radiograph and a control CT were then performed. Pain intensity was determined pre-intervention, on the 2nd day postintervention and 6 and 12 months post-intervention, using a VAS. Results: The balloon sacroplasty was performed successfully in all patients. The radiographic and CT control showed sufficient cement distribution in the sacrum along the course of the fracture, whereby leakage could be ruled out. According to the VAS, the mean value for pain was 8.8 pre-intervention, there was a significant reduction in pain on the 2nd postoperative day, with an average value of 2.7 (p<0.001), which was stable at 2.5 after 6 months and 2.3 after 12 months. Conclusion: Approaches that take into account the course of the sacral fracture enable reliable cement augmentation. This makes balloon sacroplasty an effective treatment for significant pain reduction that has few complications.

Thermal influence on normal bone by radiofrequency ablation: an experimental study in rabbit . After the working cannula was inserted, a coil-shaped peek implant was placed within the vertebral body over a nitinol guidewire; cement was then injected under fluoroscopic control. Implant is designed with holes into the internal part to allow cement injection inside thus reducing leakages. 2-dimensional reconstruction CT was performed before and after the procedure to evaluate implant correct positioning and to detect any cement leakages. Visual analog scale (VAS), Oswestry questionnaire (ODQ) and analgesic drugs were evaluated before and after procedure. Results: Procedure was completed in all patients without complications. VAS and ODQ significantly improved (p<0.0005) from average of 9.4±1.1 to 1.0±1.0 and 84.1±7.6% to 4.1±3.3%, respectively. In 3/43 vertebrae (6,9%) a discal PMMA leakage was detected, in 6 (13,9%) a minimal paravertebral leakage occurred. 24 patients (60%) suspended any pain medication after treatment; in 15 patients (37,5%) pain was controlled by non-steroidal analgesic drugs. 1 patient (2,5%) underwent surgical decompression for disease progression. Conclusion: In painful metastases with involvement of the vertebral wall, peek implant-assisted vertebroplasty can achieve pain relief and leakage risk reduction.

Image-guided percutaneous cryoablation of Morton's neuroma J. Garnon, G. Tsoumakidou, X. Buy, I. Enescu, A. Gangi; Non vascular Interventional Radiology, University Hospital of Strasbourg, Strasbourg, France.

Purpose: To describe the technique of percutaneous cryoablation of Morton's neuroma, to evaluate the efficiency of the technique to treat forefoot pain secondary to Morton's neuroma, and to evaluate the safeness of the technique. Material and Methods: Between February 2009 and December 2011, ten neuromas in eight patients were treated using percutane-ous cryoablation. All patients suffered from mechanical forefoot pain when walking, with failure of conservative therapies. All procedures were performed on an outpatient basis, under local anesthesia, using a two-centimeter active tip cryoprobe. Image guidance included combined CT-fluoroscopy or MRI. The cryoprobe was inserted between the metatarsal heads through a small skin incision in the corresponding interdigital space. Cryoablation was performed for 5 minutes at maximum power. Proper covering of the neuroma by the ice ball was controlled with CT or MRI. Patient's evaluation was conducted one month after the procedure and then every six months. Evaluation consisted in assessment of pain and complication.

Results: Mean follow-up was 9.3 months (min:1, max:30). Improvement of pain was noted in 70% of cases at one-month follow-up (n=10) and in 85% at six-month follow-up (n=7). Complete improvement of pain was noted in 70% of cases at six-month followup. Transient oedema and forefoot pain after the procedure were noted in all cases. Complications included one local infection and one persistent local painful oedema. Conclusion: Image-guided percutaneous cryoablation seems to be a safe and effective technique to treat painful Morton's neuroma. Disclosure: Professor Afshin Gangi and Doctor Xavier Buy are consultants for Galil Medical.

Percutaneous osteosynthesis plus cementoplasty decreases the risk of pathological fracture of the proximal femur compared with cementoplasty alone Purpose: There is a risk of pathological fracture for osteolytic metastasis of the proximal femur, especially when cortical involvement is larger than 30 mm. Cementoplasty results in a high rate of fracture. Percutaneous osteosynthesis plus cementoplasty (POC) has recently been developed. The purpose of this study was to assess whether it decreases the risk of femoral fracture compared with cementoplasty alone (C). Material and Methods: Between February 2010 and December 2011, POC were performed for metastasis of the proximal femur with a cortical involvement >30 mm in patients not candidates for surgical stabilization. POC were performed by an interventional radiologist using a C-arm in an angio-suite. Three cannulated-screws (diameter of 8 mm) were inserted in an inverted triangle configuration in the femoral neck through three skin incisions of <1 cm. Then cement was injected around the screws using 11-gauge needles. We compared the rate of fracture in this population with our previous series of similar patients treated with C from June 2003 to January 2010. Results: Seven patients underwent POC (median follow-up =476 days) and 11 patients underwent C (median follow-up =731 days, p=0.06). The median survival at 1 year was 50% after POC and 45.5% after C (p=0.56). No fracture occurred after POC while the rate of fracture at 1 year was 85.5% after C (p=0.0056). Conclusion: Our initial experience with POC provides impressive results, which require further evaluation in patients with impending pathological fracture of the proximal femur and maybe in other location of bone metastases.

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Non-surgical management of pediatric liver trauma: a 5-year retrospective study R. Inchingolo, A. Ljutikov, P. Kane, J.B. Karani; Radiology, Kings College Hospital, London, United Kingdom. Purpose: Non-operative management with accurate CT evaluation and embolisation is now an accepted paradigm of treatment for liver trauma in the adults. This study was designed to determine the applicability of non-operative management in a pediatric population.

A retrospective observational study of 37 children (mean age 10.5 yrs) with hepatic trauma (28 blunt, 9 penetrating) admitted to a trauma referral center over a 5-year period. All patients were evaluated with CT and scored with an Association for the Surgery of Trauma (AAST) score. Their inpatient information was reviewed for demographics, associated injuries, modes of management, efficacy and complications of management, and outcome. Statistical analysis was performed using the GraphPad Prism software.

Results: There were 7 contusions, 2 grade-I, 2 grade-II, 9 grade-III and 17 grade-IV liver lacerations. Only two patients (grade-IV, penetrating) underwent surgery because of the presence of bowel perforation. The remaining had nonsurgical treatment: 3 cases (grade-IV) had primary angiography due to CT evidence of active bleeding and, in 2 of these, embolization was performed. Seven patients (2 grade-III, 5 grade-IV) had angiography during the follow-up for evidence of a complicating pseudoaneurysm and embolisation was performed in 6 of them. Embolisation was successful in all the children; one minor complication occurred (cholecystitis). ERCP +stenting was performed in 2 cases for a bile leak. All 37 children had a positive outcome. Conclusion: Our study demonstrates that non-operative management of hepatic trauma is applicable to children and may have a higher success rate than in adults.

Patterns of persistence in treated pulmonary arteriovenous malformations (PAVMs) 

Recanalization only 12 (52) 40 (75) Reperfusion only 3 (13) 5 (9) Recanalization+Reperfusion 8 (35) 8 (15) Incomplete Primary Treatment * 6 8 (15) *all also merited categorization in above groups Conclusion: Recanalization is the most common pattern of PAVM persistence and responds best to retreatment. Reperfusion by multiple adjacent pulmonary arteries is less common and much more difficult to successfully retreat.

Percutaneous transhepatic pancreatic islet cell autotransplantation as an adjunct to total pancreatectomy for chronic pancreatitis: a modified approach M. Guimaraes, C. Ledezma, C. Schonholz, C. Hannegan, M.B. Anderson, J.B. Selby Jr.; Interventional Radiology, Medical University of South Carolina, Charleston, SC, United States of America.

Purpose: In selected patients with chronic pancreatitis (CP), total pancreatectomy (TP) may be effective for the treatment of intractable pain. Further, the ensuing brittle or labile insulin-dependent diabetes mellitus has been shown to be ameliorated with intra-operative islet cell autotransplantation (I-IAT). In contrast to the I-IAT method, our modified approach is performed through a percutaneous transhepatic approach in the immediate postoperative period. We describe our experience at our institution using this modified approach. Purpose: To analyze in an experimental animal model the effect of 4 different levels of stents-graft oversizing on non-atherosclerotic aortas such as those found in young individuals who undergo stentgraft repair for traumatic aortic injuries. Material and Methods: Twenty-five pigs were randomized into 5 groups: 1 control (without stent-graft) and 4 oversizing groups (A: 10%-19%, B: 20%-29%, C: 30%-39%, and D: 40%). Biomechanical tests were performed 4 weeks after endoprosthesis deployment. The fragments were submitted to a histological and an immunohistochemistry analysis.

The results of the detachment test were similar in the 4 groups. The second test: maximum shear strength, maximum stress, and maximum tension supported by the aortic wall had a negative and linear correlation with oversizing. Strain, which reflects the elastic properties of the aortic wall, was very similar in all 4 groups, but a great difference was found when compared with the control group (p,0.0001). Histological and immunohistochemistry analysis supported that the aortic wall has a significant loss of elastic fibers and an important disarrange of its structure with the increase of stent-graft oversizing.

The biomechanical studies show a loss in aortic wall resistance with increase in oversizing, while the elasticity of the aortic wall undergoes significant change regardless of oversizing used. The histopathological examinations confirmed the breakdown in the structure of the aortic wall.

Restrictive bare stent preventing stent graft-induced distal redissection: clinical feasibility .033) and reduce the secondary intervention (3.9% vs. 9.3%, p=0.040). As to the aortic remodeling after TEVAR, the placement of RBS could significantly expand the true lumen at the level of descending aorta with narrowest true lumen and at the level of distal end of stent-graft.

The mismatch between the diameter of distal stentgraft and that of the compressed true lumen seems to make the predominant contribution to the occurrence of SIDR. Restrictive bare stent, as an adjunctive technique to TEVAR, could reduce the incidence of SIDR. According to the early-to mid-term observation, RBS could improve the morphologic remodeling of the dissected aorta at certain levels.

Free Papers effective solution for cell transplantation. Material and Methods: Fifty rats with proved hepatic cirrhosis were divided randomly into five groups. The following four groups, G1. G2. G3, and G4 were transplanted with allogeneic hepatocyte suspension (2ml, cell number: 2 × 106) through hepatic artery, portal vein, splenic artery, and caudal vein, respectively. The control group (G5) did not undergo any intervention. Liver function tests were performed in all groups before and after transplantation. Pathologic evaluation was performed to liver specimens after animals were sacrificed.

Results: Allogeneic hepatocyte transplantation in all different ways could improve liver functions and also reduce hepatic cell degeneration and necrosis in varying degrees. However, no significant improvement of liver fibrosis was demonstrated, though significant alterations in the reconstruction of the liver pseudo-lobule were seen. The splenic artery group (G3 group) had a lower mortality rate within three days after transplantation. Within a short term, the liver function could be improved significantly after transplantation in the G3 group; also, hepatocyte degeneration and necrosis could be inhibited effectively. Conclusion: Among all hepatocyte transplantation approaches for the hepatic cirrhosis models of rats, the intra-splenic artery transplantation had a lower mortality and was more effective in improving liver functions and reducing hepatic degeneration and necrosis.

In vivo evaluation of sunitinib-loaded DC Beads Purpose: To study the pharmacokinetics and potential toxicity of sunitinib eluting beads in an animal model. Material and Methods: Healthy New-Zealand white rabbits were used. 8 animals received 0.2ml of DC Beads loaded with 6mg of sunitinb intra-arterially in the hepatic artery (group 1) and 4 animals received 6mg of sunitinib administered orally (group 2). In group 1, animals were sacrificed 6 hours (n=4) and 24 hours (n=4) after embolization. In group 2, animals were sacrificed 6 hours (n=2) and 24 hours (n=2) after oral administration of sunitinib. Liver enzymes were measured at 0, 6 and 24 hours in both groups. Plasmatic sunitinib concentration was measured by LC MS/MS tandem mass spectroscopy at 0, 1, 2, 3, 4, 5, 6 and 24 hours. Following sacrifice, the livers were harvested and sunitinib concentration in liver tissue was assessed by LC MS/MS tandem mass spectroscopy. Results: After embolization we observed an expected elevation of AST and ALT. Serial plasmatic measurements after embolization showed a very low sunitinib concentration (<50ng/ml 

Four devices to turn introducer sheaths were developed and evaluated Purpose: To evaluate the size and shape of the ablation zone of three commercially available microwave ablation systems.

We performed 76 Microwave ablations in ex vivo bovine liver with three ablation systems: a water-cooled system with a maximum power of 180W (System A), a water-cooled system with the option for simultaneous use of 3 antennas with a maximum power of 45W each (System B) and a non-cooled, automatically frequency-modulated system with a maximum power of 32W (System C). 16 ablations were performed according to the manufacturer's recommendations (A: 180W/6min, B: 45W/10min, C: 32W/15min) and 60 ablations with reduced power or time. Volume, sphericity (b/a-Index) and mean transverse diameter of the ablation zone were compared using analysis of variance (ANOVA) and Tukey-Kramer HSD. Results: Ablation under manufacturer's recommendations: largest ablation volume, largest diameter and largest b/a-Index with system B with three antennas (mean volume=76.5cm³, mean diameter=50.6mm, mean b/a-Index=0.88; p<0.001). No significant difference in volume between system A (mean=57.5cm³) and C (mean=55.9cm³); however, significant larger diameter (A: mean=43.4mm, C: mean=40.9mm; p=0.023) and b/a-Index (A: mean=0.74, C=0.64; p<0.001) with system A. Smallest ablation zone with system B with use of one antenna (mean volume=17.1cm³, mean diameter=26.8mm, mean b/a-Index=0.58; p<0.01). With reduced ablation time (5 min) and use of one antenna significant largest ablation zone, b/a-Index and diameter with system A (mean volume=52.4cm³, mean diameter=42.3mm, mean b/a-Index=0.76; p<0.005).

Conclusion: Under manufacturer's recommendations largest and most spherical ablation zone with System B with simultaneous use of 3 antennas. No significant difference in volume between system A and C; however significant larger diameter and sphericity with system A.

Hydrogel-coated coils versus fibered coils in an animal model of peripheral embolization: mechanism of occlusion in a shortterm study Purpose: pREset is a new device for mechanical thrombectomy with an optimized cell design for thrombus removal in acute cerebral vessel occlusion. Data regarding the clinical use of this device are sparse and our purpose was to evaluate the safety and efficacy in daily practice. Material and Methods: Retrospective data analysis started from August 2011. Angiographic images and reports were evaluated to assess the ability to access target vessels and recanalization rates. Thrombolysis in cerebral infarction (TICI) scores IIb and III were considered successful recanalization. Device-related complications were recorded. We screened CT and MRI studies for haemorrhage defining symptomatic haemorrhages according to the ECASS III criteria. Results: We identified 80 consecutive patients and excluded two with incomplete data. Overall 86 of 90 occluded vessel segments were recanalized (96%). In three cases (3.8%) pREset failed to access target lesions and treatment strategy was changed. pREset alone was used in 56 patients (71%) reopening 61 of 63 vessels (97%) with a median of one passage (1) (2) (3) (4) (5) (6) (7) (8) . In 19 patients a multimodal approach with a variety of tools was necessary. The mean number of passages with 2-5 different stent-trievers increased to 4 (2) (3) (4) (5) (6) (7) . Additional angioplasty, stenting and aspiration manoeuvres were performed in 15 patients. Device-related vessel injuries did not occur. Five new vessel occlusions were attributable to thrombus displacement during retraction (6.4%). Hemorrhages were seen in 20 (25.6%) followup examinations with 6 (7.7%) symptomatic bleedings.

Purpose: The use of pipeline embolization device (PED) to treat intracranial aneurysms has been found potentially promising in several preliminary studies. We aim to evaluate the mid-term clinical and angiographic outcome. Material and Methods: In this prospective multi-center study involving 143 consecutive patients and 178 aneurysms that were followed clinically and angiographically up to 3 years; unruptured saccular or fusiform aneurysms, or recurrent treated aneurysms were included. Study endpoints included death, major stroke, all other complications, complete aneurysm occlusion rate, outcome of patients presenting with cranial nerve palsy before PED, occlusion or stenosis of parent artery, and occlusion of covered side branches. Results: There were 5 cases of peri-procedure death or major stroke (5/143, 3.5%), including 2 cases of post-PED rupture. There was 1 major intracerebral bleeding at 11 months, and no more major stroke afterwards. Nine minor complications were noted. Nine of 13 patients presenting with cranial nerve palsy completely recovered from the symptoms within a median duration of 3.5 months from treatment. Complete aneurysm occlusion rate was 84.5% at 18 months. On angiographic follow-up at 18 months, there was no parent artery occlusion; parent artery stenosis (>50%) occurred in 1 of 178 cases (0.5%), and occlusion of covered side branch occurred in 2 of 142 cases (1.4%). Conclusion: Endovascular PED is reasonably safe and effective for intracranial aneurysms with high procedure success rates, resulting in complete aneurysm occlusion and recovery from cranial nerve palsy. Treatment outcomes could probably be further improved with measures to prevent delayed rupture.

Purpose: To assess the effects of advancing age on the tolerance and clinical outcomes following radioembolization. 18.4 [12.8-22.8]) or advanced stage (10.3 [7.4-13.1] vs. 9.7 [7.5-11.7] ), respectively. Radioembolization was equally well tolerated in both cohorts. Changes from baseline in total bilirubin (grade ≥3) at 3 months were observed in 4.3% and 6.9% of older and younger cohorts, respectively (p=0.432). Conclusion: For eligible patients, radioembolization appears to be as well tolerated and effective for the elderly as it is for the young. Age alone should not be a discriminating factor for patients with HCC being considered for radioembolization.

3D ultrasound-guided microwave ablation of hepatocellular carcinoma Purpose: Microwave (MWA)-induced thermal ablation of hepatocellular carcinoma has rapidly evolved over the past decade. MWA permits large, uniform burn volumes through synergistic placement of multiple probes and is not affected by heat sink. We have developed a 3DUS system to ensure proper placement of ablation probes within the tumour to obtain optimum results. Material and Methods: Our system consists of a handheld device and software to segment the lesions with minimum user interaction. The 3D scanner incorporates mechanical translation and tilt sector sweeping of any conventional 2D US probe to acquire larger volumetric images of both the antennae and the target lesions. Results: Eight lesions ranging from 1.0-6.0 cm were successfully ablated using the system. Depending on the characteristics of the tumours, probes were inserted under 3DUS images and concurrent CT-scans were at different stages to confirm accurate placement. Using software, probes and tumours were segmented and their relative location were compared to the intended values extracted from CT images. Using the 3DUS the probes were directed towards the desired location in real-time and maintain their relative distance to each other. Assessment for probe was enhanced within our 3DUS system, as oblique scanning of the 3D US and segmented images enabled visualization of multiple probes in a single plane. Conclusion: A handheld, compound motion 3D US system capable of wide FOV imaging, with needle and tumour segmentation for intra-procedural guidance is developed and demonstrated for MW-ablation of HCC tumours. This provides a reliable, affordable and non-ionizing alternative to CT probe guidance. Purpose: To evaluate the safety, efficacy and midterm result of endovascular stent-graft placement for ureteroarterial fistulas (UAFs). Material and Methods: Stent-graft placements for repair of 10 UAFs were performed (4 males, mean age 74.9 ± 9.9 years). Long-term ureteral stenting was performed in 9 patients (90%), pelvic surgery was in 7 (70%) and pelvic radiation in 4 (40%). Gross hematuria was present in all patients (100%). Clinical diagnosis was based on cystoscopy or CT scans for urinary tract hemorrhage.

The procedure was successfully performed in all ten cases. Angiography revealed fistula, aneurysm or encasement of the artery in four cases (40%). In six cases (60%) angiography revealed no abnormality; fistula site was considered as the crossing point of urinary tract and artery. The fistulas were located at common iliac artery in five cases (50%), external iliac artery in four (40%) and abdominal aorta in one (10%) case. Stent-grafts were placed to sufficiently cover the lesions. Nine procedures were performed with a tubular stent-graft and one with bifurcated aorto-iliac stent-graft. 

Single-center experience in using a new OCT-guided recanalization device for the SFA 

Endovascular treatment of the bent popliteal artery segments in patients with critical limb ischemia: 12-month results after implantation of a helical nitinol stent with increased radial force and flexibility Purpose: Pelvic congestion syndrome is a common health problem, a challenging diagnosis and a doubtful entity. We evaluate the clinical signs and symptoms, the radiology signs and the long-term clinical outcome of transcatheter treatment. On the other hand, we will try to settle a classification in function of the physiopathology and presence of leakage points.

The study population includes more than 300 consecutive patients referred to our Angio lab from 2008 to 2012. All of them had lower abdominal pain and pelvic varicosities were found on retrograde ovarian vein venography. Aetiology was primarian in most of them and physiopathology was established in all of them. Different embolization materials were employed during this period. We analyzed the clinical signs and symptoms, the clinical overall outcome with a median follow-up of more than 24 months and the leak points if detected. Results: Technical success rate was 97 %. Immediate complications were noted in 6 patients. Clinical follow-up reveals a total relief of symptoms in 71% and variable in 19%. We settled an accurate diagnosis and therapeutic algorithm based on our 25-year experience working in this field. The most common physiopathology is primary ovarian vein or/and internal iliac vein tributary reflux alone (40%) or with left renal vein compression (36%). Conclusion: Congestive pelvic syndrome is a challenging but relevant diagnosis in which transcatheter treatment is a safe and feasible technique leading to complete relief of symptoms in more than 70% of our patients. Understanding physiopathology is mandatory to adequately treat with embolization and/or stenting.

Rheolytic thrombectomy for deep vein thrombosis: interim report of a prospective multi-center registry . 85% had a history of deep venous thrombosis. 55% of subjects were diagnosed with May-Thurner syndrome (79% Female). 47 procedures were performed in the left, 5 in the right and 7 in both lower extremities. In 25 patients the vena cava inferior was partially stented. The average number of stents used in a procedure was 2.4 (median2). At 1 year primary patency was 82%. Assisted primary and secondary patency rates were 97% and 94%. Re-thrombosis occurred in 19% of the procedures. Bleeding complication occurred in 12% of procedures. Relief or significant improvement of symptoms of chronic venous occlusive disease was achieved in 82%. Conclusion: Endovenous recanalisation by angioplasty and stenting of long-term occluded ilio-femoral vein segments is a safe and effective treatment option with good midterm results. The majority of reocclusions can be adequately treated by a secondary procedure.

Free Papers study. All patients were taking a minimum of 3 antihypertensive medications including a diuretic at baseline (average 5 medications). Results: Bilateral denervation was performed by delivering an average of 5.5 ultrasound emissions in each subject (average heating time 4.3 minutes per subject). Sedatives and analgesics were administered during the intervention and the treatment was well tolerated by all patients. Both office and home blood pressure measurements showed an immediate, significant, and sustained decrease. At three months, results from the first 11 cases were comparable to published data on radiofrequency renal denervation with a statistically significant average reduction in office and home blood pressure of -32/-16 mm Hg and 16/9 mm Hg, respectively. In accordance with the protocol, the dose of antihypertensive medications had to be reduced in 3 patients. Conclusion: Endovascular ultrasound renal denervation appears to be a safe and effective treatment for resistant hypertension. Sixmonth results from the REDUCE first-in-man study will be presented. Disclosure: Member of the Medical advisory Board of Record

Superselective particle embolization enhances efficacy of radiofrequency ablation: effects of particle size and sequence of action Purpose: To evaluate the effects of particle size and course of action of superselective bland transcatheter arterial embolization (bland-TAE) on the efficacy of radiofrequency ablation (RFA). Material and Methods: Twenty pigs were divided into 5 groups: Group Ia, 40μm bland-TAE prior to RFA; Group Ib, 40μm bland-TAE after RFA; Group IIa, 250μm bland-TAE prior to RFA; Group IIb, 250μm bland-TAE after RFA and Group III, RFA alone. This experiment was performed using a combined CT and angiography system. A microcatheter was inserted superselectively into a peripheral hepatic arterial branch and intra-arterial enhanced CT was performed. Then, a RF-electrode was placed inside the enhanced area under CT guidance. A total of 40 treatments was performed. Treated zones were measured for size on contrast-enhanced CTs on day 1 and day 28. Animals were euthanized and the treated zones were examined pathologically.

Results: There were no complications during procedures and follow-up. The short-axis diameter of the ablation zone in Group Ia (3.19±0.39cm) Purpose: To improve the overall quality of vascular radiology services at a large teaching hospital by surveying and understanding the experience of patients and to develop an interventional radiology-specific patient experience survey applicable to all procedurebased day case radiology units.

A patient experience survey, covering a broad range of quality measures was designed specific to a large vascular radiology day unit, after wide consultation with vascular healthcare governance, nursing and patient liaison services. 100 patients were surveyed. Tabulated responses for all questions were reviewed and recommendations made for quality improvements. Results: Overall, the majority of patients had a very good or excellent experience with regard to all questions within the survey. Any 'poor' or 'average' responses were investigated to try to determine the root cause of their experience. Most of these related to the waiting time from referral to treatment. Other negative responses were received concerning the communication of information. Positive feedback, such as by a letter of recommendation from patients, were encouraged and used to boost staff morale and improve staff engagement in organisational changes necessary to further improve organisational efficiency. Conclusion: Patient experience surveys provide invaluable user feedback on the quality of services offered. This information is a powerful means by which change can be effected, to focus on specific deficiencies or to improve the overall efficiency of an interventional service as well as to reduce waste. The proposed Sheffield APEX survey is offered as a template to others wishing to improve the quality of their interventional radiology service. Purpose: Expose the intrarterial thrombolisis experience of our centre as part of an organized network dealing with stroke treatment in the Catalan population. Material and Methods: For the past six years, a joining effort has been made in Catalunya to begin step-by-step the availability of urgent stroke treatment covering all the population of somewhat more than 7 million people. Among the main Catalonian hospitals, 13 centres around the country were selected to harbour stroke units, with specialized neurologists and to administer intravenous fibrinolytic treatment as part of a network connected with the main central tertiary hospitals. After three years, the basis for intra-arterial treatments was considered to be set, since not only these 13 centres were active, but also patient urgent transportation from a central system and other facilities, as teleconference. From these, three "nodes" were determined to perform intra-arterial thrombolysis and combine two or three main central hospitals. 

Prospective evaluation of the optimal duration of bed rest after vascular interventions using 3-French sheath introducer systems: a preliminary report Purpose: The aim of this single-center, prospective study was to determine the optimal duration of bed rest after vascular interventions (IR) via the femoral artery using 3-French sheath introducer systems. Material and Methods: Patient eligibility criteria included clinical necessity for angiography, no coagulopathy or anticoagulant therapy, no hypersensitivity to contrast medium, age >20 years, and written informed consent. The sheath was inserted via the femoral artery using Seldinger's method. To determine the optimal duration of bed rest, bed rest length was reduced as follows: The first group (level 1) received 3 hours of bed rest after IR. If no bleeding or hematomas were observed in this group, the next group (level 2) . No significant difference was identified between non-patent, unilateral and bilateral recanalisation of the uterine arteries for percentage dominant fibroid infarction or dominant fibroid volume reduction. The presence of bilaterally or unilaterally patent uterine arteries was not associated with inferior clinical outcomes (symptom score or UFS-QOL scores) at 6 months. There is no statistically significant association between the presence of ovarian artery collaterals and uterine artery patency.

The high rates of uterine artery patency challenge the current paradigm that non-spherical PVA is a permanent embolic agent and that permanent uterine artery occlusion is necessary to optimally treat uterine fibroids. Despite high rates of uterine artery recanalisation in this cohort, satisfactory fibroid infarction rates and UFS-QOL scores were achieved.

Ten-year outcome of percutaneous radiofrequency ablation of hepatocellular carcinoma: does local tumor progression affect survival?

H. Rhim 

Volumetric changes after 90Y-radioembolization for hepatocellular carcinoma (HCC): an option to portal vein embolization before liver surgery? Purpose: Modifications of liver volume after 90Y-radioembolization have been described as case report in the literature, but the incidence and quantitative extent of increase of liver volume after this therapy are unknown.

We performed a retrospective study on patients treated with 90Y-microspheres for HCC on cirrhosis. Main inclusion criteria were treatment of one liver lobe, no prior liver surgery and CT scans allowing volumetric assessment. We measured treated (TrV), tumoral (TuV) and contralateral (CV) liver volumes. We calculated the whole liver volume (WLV=TrV+CV) and the fraction of functional remnant liver volume (FFRLV) after a virtual hepatectomy (CV/WLV-TuV 

We postulate an expectant approach with newer endovascular devices, with intervention sooner than previously described medically managed cases, but not in immediate peri-trauma period, thus allowing time to stabilize patient and treat other potentially life-threatening injuries. We have been successful in more than 30 patients in the last five years. We propose this strategy to manage this heretofore-desperate situation. Conclusion: Delayed endovascular repair of ATRTA is a safe and effective treatment strategy allowing optimization of timing for intervention and thus improving patient outcomes.

A new concept of stent: the multilayer flow modulator stent. Purpose: To describe our experience with a novel bioabsorbable biliary stent in the percutaneous treatment of benign biliary strictures. Material and Methods: A novel bioabsorbable polydioxanone biliary stent (Ella-DV biliary stent, ELLA-CS, Czech Republic) was deployed in 8 patients with increased level of bilirubin due to a postsurgical biliary stricture. This stent is made of polydioxanone, a material that allow to obtain a high radial force, but that is reabsorbed by the body within 6 months. All patients had benign stricture that was not treatable by endoscopy and had previously undergone multiple (2 to 5) unsuccessful attempt of standard bilioplasty. All patients were followed with US and serum level of bilirubin at 3 months. 3 patients had an additional follow-up at 6 months.

The procedure was successfully performed in all patients and immediate restoration of the normal caliber of the biliary duct was obtained. In all patients serum level of bilirubin returned to normal values after the procedure. No immediate or late complications occurred and no patients had recurrence of the initial stricture (mean follow-up of 4.2 months, range 3-11 months). At the 3-month follow-up the stent was still visible and patent in all patients. No stent was visible in the 3 patients with 6-month follow-up. Conclusion: Percutaneous bioabsorbable biliary stent placement seems to be feasible and effective in the treatment of benign biliary strictures in patients not suitable for endoscopic treatment and in which standard bilioplasty has failed. 

Effectiveness of holmium laser lithotripsy for complicated biliary calculi

Interventional Radiology, Emory University Hospital, Atlanta, GA, United States of America.

Purpose: Holmium laser lithotripsy revolutionized the management of urolithiasis and is being used increasingly in the treatment of biliary calculi. In this study, we report our experience using holmium laser lithotripsy in treating biliary calculi that failed management with percutaneous transhepatic cholangiography (PTC), endoscopic retrograde cholangiopancreatography (ERCP), or both. Material and Methods: This a retrospective study involving 14 patients over an 8-year period (12/2003 to 12/2011 ) who underwent percutaneous holmium laser lithotripsy in order to treat complicated biliary calculi refractory to therapy with ERCP or PTC. Using a multidisciplinary approach holmium laser lithotripsy was performed through existing PTC or T-tube tracts. Stone clearance was evaluated intraprocedurally and postprocedurally through follow-up imaging. Results: Stone burden ranged from 1.7 cm to 9 cm. Patients had predominantly common duct stones, but a few intrahepatic stones were treated. All but one of the patients was able to be treated completely with one procedure. There were no major perioperative complications. Conclusion: Percutaneous endoscopic holmium laser lithotripsy is effective in treating biliary calculi refractory to ERCP or PTC. Most patients can be treated completely with a single procedure. The overall success and low morbidity of this procedure suggest that it should be considered prior to surgery in the treatment of biliary stones refractory to other minimally invasive treatment.

Electronic Posters drainage (PTBD), Iridium-192 intraluminal brachytherapy (BT); metal biliary stenting and external-beam radiotherapy (EBRT) plus systemic chemotherapy (ChT). All patients underwent BT and biliary stenting; this was the only treatment in 14 (group A), and was combined with EBRT in 11 patients (group B), and with EBRT and ChT in 7 (group C). Mean and median survival, complication rate and duration of hospital stay were calculated for each group. Results: The association of BT+EBRT+ChT and stenting (group C) obtained the best median survival (15 months) and 1 yr survival (71.42%) followed by group B patients (14 months and 63.63%, respectively). The combined BT+EBRT with total dose of 54-60 Gy, with or without ChT, followed by metal stent positioning, had significantly higher median survival rate (14 months) than BT alone (7 months).

The multimodal approach with BT+EBRT, with or without addition of Cht, improves survival in unresectable hilar CLCA and should be considered as a suitable alternative to palliative surgery.

Percutaneous biliary stone removal using flushing technique followed by balloon sphincteroplasty and fragmentation of stones used by stone basket in patients with failed endoscopic extraction Purpose: To evaluate the efficacy of percutaneous stone removal through the PTBD route using contrast-saline mixture flushing after sphincteroplasty and fragmentation of stones used by stone basket in patients who have failed endoscopic removal. Material and Methods: Percutaneous stone removal was performed in 48 patients with bile duct stones who have failed endoscopic extraction. In two patients, CBD stones were recurrent and removal was retried. All subjects underwent PTBD for securing biliary route. Thereafter, an 8F sheath was inserted into the biliary tree through the PTBD route and sphincteroplasty was performed. Stone basket was used to capture and fragment the stones and contrastsaline mixture was injected via the sheath to push the fragmented stones into the duodenum. Follow-up cholangiogram was performed 2-3 days later to evaluate residual stones. The technical success rates were classified the cases into success, partially removed or failure with an analysis of any complications. Results: The technical success rate was achieved in 43 of 50 cases (86%). In 6 patients, stones were partially removed. One patient had large stones and stone removal was failed. In 32 cases (64%), stone removal was achieved in the first attempt. Transient hyperbilirubinemia was developed in 3 cases and serum amylase was elevated in 4 patients. But these patients did not need any treatment. Conclusion: Percutaneous biliary stone removal using flushing technique by balloon sphincteroplasty and fragmentation of stones used by stone basket is a safe and effective procedure that can be used in patients which have failed endoscopic biliary stone extraction.

Comparative analysis of symptomatic non-parasitic benign liver cysts percutaneous treatment with ethanol and 20% NaCl solution (49-97)). The median ASA grade is 3. Patient notes were reviewed, in addition to computerised data on radiology, haematology, biochemistry and microbiology. The procedure was deemed clinically successful if there was a reduction in at least two of the following: fever, pain, white cell count, and or CRP within 72 hours of the procedure. Clinical Findings/Procedure: In 98% (n=24) of cases, PC was performed for acute cholecystitis. The median time between diagnosis and PC was 2 days. All cases were technically successful. The procedure was clinically successful in 61% (n=14) of patients, clinically unsuccessful in 9 and unknown in 2. The clinically unsuccessful cases had significantly worse pre-procedural physical status, with median ASA grade=4 (p<0.05). Bile cultures were positive in n=11 (44%). In 27% of positive bile culture results, patients' antibiotics were not changed based on sensitivities; of these, 66.6% were clinically unsuccessful. The mean hospital stay was 18 days (6-83days). 10 patients had subsequent cholecystectomy. The mean time between cholecystostomy and surgical intervention was 100 days . Four patients had PC as a definitive treatment at a mean follow-up of 4 years. There were no serious complications. 30-day mortality rates were 12%. Conclusion: This work highlights the importance of sending bile for culture and altering patients' antibiotics based on sensitivities in order to maximise clinical success. In our experience PC is used as a temporising measure. (16.2% MSFT 19.2% BSIR) were less than the national data which are likely due to the experience of the operator (100% consultant MSFT). There is a high 30-day mortality in PTCs for benign disease (14% MSFT, 15.6% BSIR), PTC should be considered at last resort in this group. The malignant disease 1-year survival is poor in both groups (10% MSFT 20% BSIR) this is most likely due to the palliative nature of the procedure and the aggressive malignant disease, symptom relief being the main aim. Conclusion: In a district general hospital, PTC with biliary drainage and stenting remains a valuable and safe interventional procedure for symptomatic relief of biliary obstruction in patients with malignant lesions. Caution should be observed in patients with benign disease as there is an associated mortality both locally and nationally.

Learning objectives: To describe the use of a new flexible endoscope for different percutaneous transhepatic biliary interventions. Background: Access to biliary tree for intervention is generally obtained by retrograde endoscopy. However, in several situations this approach is not feasible, such as in case of anatomic or surgical variation. In these cases percutaneous approach with fluoroscopicguided procedures has been proven to be a valuable alternative. The recent development of flexible and small caliber endoscopes that can be introduced percutaneously offers today the possibility of direct visualization even during percutaneous procedures. Clinical Findings/Procedure: PolyScope (Lumenis Surgical) is a novel flexible 8F endoscope with a 1.2-mm working and irrigation channel that is equipped with a patented disposable catheter system that isolates the fiber optic preventing its contact with the patient. The PolyScope can be introduced percutaneously after administration of local anesthesia, and can be used in combination with fluoroscopy to guide several types of procedures, such as laser lithotripsy, biopsy of the biliary system and biliary recanalization. Moreover, the use of a disposable catheter minimizes the costs related to the sterilization. Conclusion: PolyScope is a novel flexible endoscope that can be used for direct visualization during percutaneous biliary interventions and that can be of great value in the management of several complex situations.

We evaluated the correlation between diagnostic ultrasound (US) of breast lesions and fine needle aspiration cytology (FNAC). Then we evaluated the correlation between cytology and histology (I) of these lesions underwent surgery.

In 2011 we performed 1589 ultrasound breast, and identified 213 suspicious lesions to be subjected to FNAC, which was performed with pathologist on site, and extem-poraneous analysis of the sample to assess their appropriateness. We classified the lesions into 5 classes ultrasound (U) according to the criteria defined dall'Echografic BIRADS Lexicon. The results of cytology were classified into 5 classes (C) according to the guidelines of F.O.N.Ca.M. We then evaluated the correlation between diagnostic US and FNAC and I. Results: The distribution of lesions in 5 U classes was: U2 57, 55U3, 36U4 and 65U5. The diagnostic concordance between U. and FNAC was 97.1%, with a sensitivity of 98%, specificity 93%, negative and positive predictive value of 94.9% and 97.3% and diagnostic accuracy of 96.6%. The 98 patients with lesions C4-C5 were subjected to surgery and the histology confirmed high-grade malignancy of lesions with a concordance of 99.7%. Conclusion: Having achieved high diagnostic concordance between U and FNAC, then between FNAC and histology, we can say that the FNAC, less invasive and traumatic for the patient than needle biopsy percutaneous (CB) may be still a valid method if done with pathologist on-site to assess the adequacy of the sample taken.

Purpose: To develop a new method for percutaneous vertebral body fusion as a minimally invasive alternative treatment for instability of the vertebral column due to spondylolisthesis, facet joint damage, or vertebral body fractures which so far are treated by major open surgery. Material and Methods: Using the transpedicular access an 11G straight cannula with a mandril is inserted into the vertebral body under fluoroscopy control. A metallic flexible superelastic rod with a diameter of 2.0 mm and a length of 4.0 cm, and being shaped in a curved fashion, and having a sharp tip is loaded in a straightened fashion into the previously positioned cannula. The curve of the rod is orientated downwards. When the rod is hammered with a pusher from the straight cannula into the vertebral body it describes a route corresponding to its preshaped curve downwards, changing direction within the upper vertebra, and then penetrates the disk space and enters the lower vertebral body. Several rods can be implanted in a single segment to achieve a complete fixation. Experiments have been performed with pig and human cadaver spinal columns to evaluate the biomechanical properties of this new type of vertebral fusion. 

Preoperative embolization of spinal tumors: an analysis of factors influencing intraoperative blood loss C. Chen, J. Long; Department of Radiology, Peking University People's Hospital, Beijing, China.

Purpose: Preoperative embolization has been introduced into primary and metastatic spinal tumors surgery to reduce extensive hemorrhage and facilitate surgical resection. The purpose of this retrospective study was to evaluate the safety of spinal tumor preoperative embolization and the factors that may influence intraoperative blood loss. Material and Methods: A retrospective analysis of 91 spinal tumor preoperative embolization procedures was performed. Multiple factors were evaluated with respect to intraoperative blood loss, including sex, initial or recurrence tumor, embolic particle size, surgical approach, tumor involving area, and tumor pathology. Results: No major complication occurred in all 91 cases. Evaluation of these cases demonstrated that secondary procedures were associated with increased intraoperative blood loss (P = 0.044) relative to first operations in the cervical, thoracic, and lumbar tumors. No other factors were found to be statistically significant predictors of intraoperative blood loss. Conclusion: Preoperative embolization of spinal tumors appears to be a safe procedure, and may decrease the intraoperative blood loss volumes. In cervical, thoracic, and lumbar tumors, further research is needed to define whether prophylactic embolization of 2~3 section of the intercostal artery/lumbar artery beyond the levels affected by tumors could decrease the intraoperative bleeding in patients who need repeated surgery. For sacrococcygeal tumors, the effectiveness of preoperative sacral artery embolization is unclear. For all spine tumors, complete embolization is particularly important; however, using smaller embolic particles may not provide added benefit. Purpose: To determine the safety and effectiveness of a vertebral augmentation device for treatment of spinal compression fracture that creates channels in the vertebral body to allow targeted polymethylmethacrylate (PMMA) bone cement flow. Material and Methods: 19 vertebral compression fractures in 11 patients (9 women, age: 79 plus/minus 11 years, mean collapse: 39%) were prospectively treated at a single site with the Blazer Vertebral Augmentation System (Benvenue Medical, Inc., Santa Clara, CA) between July 2011 and February 2012. This system offers targeted circular channel creation via a unipedicular technique and controlled bone cement delivery. Main study outcomes were pain severity using a visual analogue scale, radiographically identified events including bone cement leak and adjacent or subsequent fracture, and clinical events including reoperation and revision at the index level. The follow-up period for all post-treatment assessments was 7 days. Results: Clinical utility of the Blazer Augmentation System was excellent. Curvilinear vertebral channels were created in each vertebra and targeted cement delivery through the bone channels was easily achieved (2 plus/minus 1cc per level). Mean back pain severity scores decreased from 7.2 at pre-treatment to 0.2 at follow-up (p<0.001). No clinical adverse events were reported. Conclusion: The early experience with the Blazer Vertebral Augmentation System suggests that this device may have clinical utility in the treatment of vertebral compression fracture. The bone channels produced by the device allow targeted cement delivery from endplate to endplate, with potentially superior interdigitation compared to balloon-assisted systems. Purpose: Treating cancer patients with pelvic insufficiency or pathologic fractures can be challenging. These fractures are the result of extensive prior pelvic radiation or lytic metastatic lesions. Surgical options are highly invasive resulting in prolonged hospitalization.

Here, we will present our experience with stabilization of pelvic fractures via image-guided percutaneous screw fixation and subsequent instillation of polymethyl methacrylate (PMMA). Material and Methods: Five consecutive patients presented with insufficiency or pathologic pelvic fractures. These patients were seen in orthopedic or interventional radiology clinic for percutaneous pelvic stabilization. Using CT and fluoroscopic guidance, together an interventional radiologist and an orthopedic surgeon percutaneously threaded stabilization screws across the pelvic fractures and PMMA was injected to aid in hardware stabilization. Results: All five patients had successful percutaneous placement of large bore stabilization screws for fracture fixation. In contrast to open surgical fixation, we had no need for general anesthesia, no significant blood loss (<50 mL), and no cardiovascular complications. In follow-up, all patients reported marked improvement in pain scores, reduced narcotic usage and increased mobility. All patients were eligible for discharge home the day of the procedure. Conclusion: Sacroplasty and osteoplasty have been shown to relieve pain; however, the structural integrity of the underlying bone after cement augmentation is not significantly improved. Similarly, surgical screw fixation rarely incorporates PMMA installation due to anatomic limitations and concern for cement leakage. Image guidance allows the opportunity to combine these complimentary methods. Therefore, we believe that this hybrid screw and cement augmentation afford more structural support allowing for better long-term results.

Purpose: Cryoablation of spine lesions and CO 2 protection of the spinal cord have been successfully reported under multidetector CT plus fluoroscopy guidance. At present, the feasibility of spine cryoablation under C-arm CT is unknown. A spine cryoablation pilot study under C-arm CT guidance and CO 2 protection of the spinal cord is reported. Material and Methods: C-arm CT-guided percutaneous cryoablation was performed in two domestic female swines (five lumbar vertebral bodies). A 1.7-mm cryoprobe was inserted by transpedicular route through 10 G vertebroplasty needles. Thermosensor insertion and CO 2 injection were provided with an 18 G needle inserted at the anterior portion of the spine canal to control temperature and to protect the spinal cord, respectively. Different freeze-thaw-freeze cycles were delivered for each vertebra. Spine MRI was obtained from the first animal. Results: C-arm CT provided good visualization of spine canal CO 2 distribution, as well as the needles inside vertebrae. The first animal survived for it designated time of 6 days after ablation of L1 and L2 vertebral levels; the lowest temperatures recorded at spine canal were 10 o C at L1 and 8 o C at L2; no significant symptoms were reported. The second animal died one hour after the procedure; the lowest temperatures recorded at spine canal were 9.9 o C at L6; 10.2 o C at L5 and 18.2 o C at L4. Cryoablation areas were well correlated with MRI and pathology. Conclusion: C-arm CT allows good quality images to guide porcine spine percutaneous cryoablation as well as good visualization of CO 2 lumbar epidural injection in order to protect the spinal cord.

Role of radiofrequency ablation for recurrent fibromatosis T.P. Dharia, S. Kulkarni, N.S. Shetty, G.D. Sangani, A.M. Polnaya, M. Thakur, A. Puri, A. Gulia, C. Pramesh; Interventional Radiology, Tata Memorial Hospital, Mumbai, India.

Purpose: Fibromatosis, benign neoplasm has a propensity to invade locally and to recur after surgical resection. Observation, hormonal therapy, anti-inflammatory drugs and radiation are the current modes of therapy. Radiofrequency ablation has been recently reported in the treatment. We report our early experience of RFA. Material and Methods: Twelve patients underwent 24 sessions of percutaneous RFA in our institution. History of surgical intervention and refractory to chemotherapy was there. Pre-procedure evaluation was done using contrast-enhanced MRI (CEMRI). Under US or CT guidance, multitinged electrodes were used. Response evaluation was done using CEMRI in 11 patients and diffusion-weighted MRI (DWMRI) in 3 patients using RECIST criteria. Quality of life was objectively evaluated using the EORTC QLQ C30 version 1.0. Range of movements' was documented in those cases involving the joints. Pain score was assessed using visual analog scale. Statistical significance was evaluated using paired t-test. Results: Significant improvement in the mean pain score was noted post-procedure from 7.5 to 2 (p< 0.05). Overall quality of life improved from a mean of 62.3 to 13.6 (p < 0.05). Significant increase in range of movements of the joints from a mean of 21 degrees to 80 degrees (p< 0.05). One patient developed foot drop (0/5 power) after the first session and a patient had liquefaction of the mass. Conclusion: Our preliminary results suggest that RFA is a safe and effective treatment option for recurrent fibromatosis. Significant improvement in the pain scores, joint mobility and overall quality of life was reported by all patients at follow up.

Percutaneous vertebroplasty in Modic changes S. Masala, M. Chiocchi, A. Bindi, A. Taglieri, G. Simonetti; Diagnostic Imaging, Interventional Radiology, Molecular Imaging and Radiation Therapy, Policlinico Tor Vergata, Rome, Italy.

Purpose: To evaluate the efficacy of percutaneous vertebroplasty (PVT) in patients with chronic low back pain (LBP) associated with vertebral endplates Modic changes, not responding to conservative therapy and to intradiscal corticosteroid injection (IDIC). Material and Methods: A retrospective study was conducted in 43 patients with severe LBP associated with Modic change (mean age: 77 years; range: 91-39) treated between January 2006 and December 2007 by PVT compared with 55 patients who continued conservative therapy. None was responsive to analgesic therapy (FANS), to IDIC and to any sort of physiotherapic treatment. A quantitative measure of pain perception before the procedure was performed in all patients using a visual analogic scale (VAS). Diagnosis was made by a spine plain X-ray and subsequently MRI examination. PVT was performed by injection bone cement polymethylmethacrylate (PMMA). Follow-up was performed by imaging and clinical evaluations at 12, 24 and 36 months after the procedure by assessing visual analogue scale (VAS) testing of pain. Results: We observed a significant reduction of pain at 12, 24 and 36 months after the procedure in patients with Modic changes treated with PVT; in the same period, a significant worsening of pain in patients untreated was observed. A statistical significant difference of VAS values was observed between the two groups of patients.

Our results demonstrate that PVT is an effective tools in pain reduction in patients with vertebral endplate Modic changes not responding to conservative therapy and to intradiscal corticosteroid injection (IDIC).

Comparison between radiofrequency targeted vertebral augmentation, balloon kyphoplasty and vertebroplasty using high viscosity cement in treatment of vertebral compression fractures

Radiology, University of California at San Diego, San Diego, CA, United States of America.

Purpose: Both vertebroplasty and balloon kyphoplasty have been described for treatment of vertebral compression fractures. This study compares the incidences and patterns of cement leakage in cases treated with high-viscosity cement vertebroplasty (HVC-VP), standard balloon kyphoplasty (BKP) and a novel procedure, radiofrequency targeted vertebral augmentation (RF-TVA) that allows targeted delivery of radiofrequency activated (high-viscosity) cement after creating multiple channels using a midline osteotome. Material and Methods: Retrospective analysis of postoperative radiographs of patients treated with the three techniques was analyzed for the incidence and location of cement leakage. 112 consecutive patients with 159 treated levels were included. There were 66 levels in HVC-VP, 46 levels in BKP, and 47 levels in RF-TVA groups treated.

In the HVC-VP group, 33 leakages were reported (17 discal, 11 venous, 4 paravertebral and 1 epidural). In the BKP group, 31 S208 C RSE CIRSE Abstract Book leakages were reported (15 discal, 11 venous, 3 paravertebral and 2 epidural) . In the RF-TVA group, a total of 16 leakages were reported (8 discal, 5 venous, 3 paravertebral and non-epidural) . Conclusion: These findings show that cement augmentation using RF-TVA technique may provide approximately 50% reduction in leakage rate when compared to conventional VP using high viscosity cement and standard BKP. This may be related to the combination of controlled delivery of radiofrequency activated (high viscosity) cement at a fixed low rate of injection into site-specific channels created using a navigational osteotome. RFK allows uni-pedicular access and remotely controlled cement delivery to decrease procedural invasiveness and physician radiation exposure, respectively. Purpose: To investigate the safety and efficacy of ultrasonographyguided botulinum toxin A (BTX-A) injections into submandibular glands for children with excessive drooling. Material and Methods: Between January 2006 and January 2011 all children who underwent ultrasonography-guided BTX-A injections for excessive drooling were included in this retrospective study. Total number of 39 injection procedures were performed in 20 patients (ages ranged from 3 to 16 years ). Efficacy of the injections was evaluated at 4th-12th weeks after the injection. Severity of drooling was assessed before and after the procedure using the teacher drooling scale. Only the submandibular glands were injec-ted for each procedure. Dose of BTX-A was adapted for each child according to personal body weight. Results: Technical success rate was 100%. Procedures were performed under iv sedation and local anesthesia in 19 patients and with local anesthesia in 1 patient. No procedure-related major or minor complication was detected. The dose administered into the submandibular glands ranged from 15 to 25 U/gland. No child had severe or life-threatening events due to botulinum toxin treatment. One family reported intermittent problems with swallowing due to viscous saliva. After consecutive sessions clinical success was achieved at 16 patients (80%) at the end of the 12 weeks. Time to effect ranged from 5 to 30 days (mean 15 ); length of effect ranged from 8 weeks to 24 weeks. Conclusion: An injection of BTX-A into submandibular glands under US guidance significantly improves subjective measures of drooling and reduces the impact of the child's drooling on families.

Safety considerations about transforaminal injections: is CT guiding the best choice? 1 Learning objectives: To present the advanced technique used in our institution in order to avoid neurologic complications during fluoroscopic-guided transforaminal injections. To list several technical considerations used to be able to visualise any vascular structure.

To discuss potential advantages compared to CT guidance. Background: Transforaminal injections are routinely performed since the last decade with a high level of efficacy on discoradicular conflicts. Neurologic complications are very rare but serious, thus controversy about the indications recently rose up and safety considerations became of major importance. Clinical Findings/Procedure: During the last year, 43 transforaminal injections were performed under fluoroscopic guidance following a dedicated technique and material. All patients were treated using an interventional neuro-vascular room with a flat panel detector (SIEMENS, Axiom Artis). A dedicated blunt-tipped non-traumatic device was placed within the target foramen under intermittent fluoroscopic guidance. Every corticosteroid injection was preceded by a test injection of contrast media using a high-resolution real-time digital AP subtracted road-map fluoroscopic sequence, in order to detect any vascular opacification. Only when no vascular flow pattern was detectable, the corticosteroid suspension was injected through a microbore tube. Concerning efficacy of the procedures, results were the same as recently published studies, 75% of patients experienced good and excellent results. Conclusion: Several vascular opacifications were depicted on the high quality test injection image series, thus proving the ability of this technique to demonstrate a potentially dangerous situation before corticosteroid injection. Concerning efficacy of the procedures, results were the same as recently published studies, 75% of patients experienced good and excellent results.

Learning objectives: To review the principles of safe sedation and analgesia in the interventional radiology lab when prescribed by interventional radiologists. To review the pharmacology of commonly used sedative, analgesics and reversal agents, and to discuss various implementations that may be made to help ensure safe sedation and analgesia practice. Background: Interventional radiologists commonly prescribe sedation and analgesia for patients whilst performing procedures. Safe practices and working in a team environment is paramount in delivering optimal patient care. Clinical Findings/Procedure: Knowledge of the pharmacology of sedatives, analgesics and reversal agents is mandatory. Adequate staff training and ongoing education is vital. Pre-procedural patient assessment and check lists should be performed to gauge risk and supportive requirements. Interventional radiologists should take up the leadership role in safe sedation and analgesia prescription. Conclusion: To ensure safe sedation and analgesia practice within the IR lab, numerous steps should be undertaken to deliver safe and adequate sedation and analgesia.

Paradigm shift in interventional radiology: from the lab to the clinic. Are we there yet

Vascular and Interventional Radiology, University of Texas Health Sciences Center San Antonio, San Antonio, TX, United States of America.

Learning objectives: To highlight the changing face of interventional radiology as a field more akin to clinical medicine, evidenced by the paradigm shift to outpatient clinics and longitudinal patient follow-up. Background: The field of interventional radiology has morphed several times over the last few decades. Though innovations and technical finesse still define IR, the move from a technical-based specialty to a patient-oriented focus has now started defining IR. Clinical Findings/Procedure: 1. Explore outpatient clinic models in academic and private settings: (a) dominantly oncologic, (b) mixed bag (oncologic and hepatobiliary) and (c) all inclusive. 2. Highlight clinic structure issues---dedicated space and support staff versus hybrid. 3. Explore issues involved with a viable clinical practice---billing/ coding (E&M codes), self-referral. 4. Understand outpatient guidelines delineated by SIR and CIRSE. 5. Evidence-based review of the clinical model in interventional radiology. Conclusion: Interventional radiology has metamorphosed into a dominantly clinical specialty over the last few decades, most evident by the recent impetus on outpatient clinics and longitudinal follow up. This exhibit intends to highlight the issues involved with this paradigm shift.

Use of fusion imaging techniques in interventional radiology

Radiology, Erasmus MC, Rotterdam, Netherlands.

Learning objectives: To provide the reader with an overview of fusion imaging techniques used in interventional radiology. · To understand the indications, advantages and disadvantages of fusion imaging. · To review the requisites to increase its usability. Background: In needle-guided interventions (NGIs), correct and accurate imaging is of importance for lesion targeting and complication reduction. US is the most frequently used modality because of its availability and real-time imaging capabilities. However, visualisation of targets can be problematic and switching to CT or other (additional) modalities may be needed. Fusion imaging is experimented with to combine these modalities and provide both speed and visibility. Clinical Findings/Procedure: Literature on fusion imaging so far shows promising results, but the technique is only scarcely used in clinical practice. Fusion between US and CT or US and MR images is most reported on. Experiments up till now state targeting with a reported inaccuracy of only several millimetres. However, patient movement such as respiratory motion and tissue distortion by US probe compression interfere with accuracy. In procedures, e.g. radiofrequency ablation (RFA), where safety margins are strict, inaccuracies pose a serious problem. Conclusion: Fusion imaging is a promising technique for interventional radiology because of its enhancement of target visibility over conventional US guidance; however, gross patient movement remains challenging. Therefore, more research is needed to validate the feasibility of fusion imaging with emphasis on motion correction algorithms.

To assess the efficacy of fluoroscopy-guided wire manipulation in patients with malfunctioning peritoneal dialysis (PD) catheter. Material and Methods: From January 2001 to April 2011, 74 fluoroscopy-guided wire manipulation was performed in 54 patients (mean age, 52.8±2.10 years; range, 12~79 years) at our institution. Exclusion criteria for the examination was that the manipulations were performed to the PD catheters (n=6) undergoing manipulation in the past 30 days. Immediate success, long-term success and complications were retrospectively reviewed. Immediate success was defined as immediate restoration of PD catheter function after manipulation and long-term success was defined as maintained normal PD catheter function at least 30 days after the manipulation.

The primary causes of catheter malfunction were omental wrapping with adhesions in 43/68 cases (63.2%), and catheter displacements in the remaining 25/68 (36.8%) cases. There were no procedure-related major complications. Immediate success of manipulation was 74% (50/68) and long-term success was 47% (32/68). Secondary new PD catheters were reinserted in 23 cases of failed 36 cases, and remaining 13 cases were transferred to hemodialysis. Conclusion: Fluoroscopy-guided wire manipulation in patients with malfunctioning PD catheter is a safe procedure. The technique is a simple, inexpensive, and effective way of prolonging PD catheter function.

Transhepatic central venous catheters for long-term hemodialysis . Using the vertical ultrasound-guided method, subcutaneous catheter course's angle was very acute (range 20°-45°), puncture of the carotid artery occurred in 4 (0,8%) patients, malfunction due to fibrosis pinching the catheter occurred in 6 (1,1%) patients. Using the lateral ultrasound-guided method, subcutaneous catheter course's angle was little acute (range 45°-85°), puncture of the carotid artery occurred in 1 (0,2%) patients, malfunction due to fibrosis pinching the catheter occurred in no patients (0%).

The lateral ultrasound-guided technique for percutaneous internal jugular venous cannulation for permanent central venous access compared to the vertical one is better in terms of periprocedural and postprocedural complication rate.

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The role of ultrasound in haemodialysis fistula patients: a pictorial review Learning objectives: · Review the anatomy underlying arteriovenous haemodialysis fistulae (AVF). · Describe the process of pre-operative ultrasound vascular mapping. · Review the ultrasound appearances of a normally functioning AVF. · Review the ultrasound appearances of common complications of haemodialysis fistulae. Background: Increasing numbers of people worldwide are developing end stage renal failure requiring haemodialysis. AVF are the preferred form of vascular access for long-term haemodialysis. These patients often have multiple co-morbidities and frequently have numerous fistulae created in their lifetimes. Dialysis access procedures and complications are a major cause of morbidity for these patients. Optimising creation and management of haemodialysis AV fistulae is therefore crucial. Clinical Findings/Procedure: Pre-operative ultrasound vascular mapping is performed using spectral and colour Doppler ultrasound. Upper limb (and sometimes lower limb) arteries and veins are assessed for calibre, quality and blood flow to allow recommendation of the most appropriate site for AVF formation. After AVF creation, problems with maturation and post-operative complications are relatively common. In skilled hands, colour Doppler ultrasound provides a quick, cheap and non-invasive method of AVF assessment and can guide the choice of endovascular or surgical salvage procedure. Conclusion: Pre-operative ultrasound vascular mapping and postoperative ultrasound AVF assessment can improve maturation rates, reduce the incidence of post-operative complications, and rapidly and non-invasively identify complications when they do occur. Ultrasound assessment is also useful in planning intervention, be it radiological or surgical. Background: Progressive venous occlusion in patients dependent on long-term central venous access for total parenteral nutrition, hemodialysis access, and chemotherapy is an expected and often unavoidable outcome. Once standard access sites are occluded, alternative routes of venous access must be established in a systematic approach, so as to preserve future access options and minimize associated complications. Clinical Findings/Procedure: The main objective is to review standard central venous access techniques and focus on alternative access options in progressive venous occlusion including: translumbar and transhepatic caval access, transthoracic access into the azygous system, upper extremity venous access, and the common femoral or greater saphenous vein approaches. Recanalization of central venous occlusions will also be addressed. Utilizing case examples, specific techniques will be reviewed to provide a detailed understanding of alternative access options. Conclusion: In the setting of progressive venous occlusion, establishing alternative methods of venous access in catheter-dependent patients is a necessary step in the maintenance of life-sustaining treatments and therapies. A firm understanding of venous anatomy and technical options is critical to procedure success in these challenging cases.

Pull-back venographic and gross findings of tunneled cuffed hemodialysis catheters removed in asymptomatic hemodialysis patients Learning objectives: The number of tunneled cuffed catheter (TCC) in hemodialysis (HD) patients is increasing; however, there are few data about natural history of TCC removed in asymptomatic HD patients. The purpose of this study is to evaluate pull-back venographic and gross findings of removed TCCs. Background: One-hundred and twenty-four TCCs were removed between March 2009 and August 2011. Pull-back venography was performed and we recognized the presence of fibrin sheath around the catheter, filling defects suspicious of thrombus and stenotic lesions. Removed TCCs were cut at 1 and 2 cm from the tip and intracatheter fibrin and thrombi were grossly investigated. Clinical Findings/Procedure: Mean age of the patients was 57.1±14.6 years and 75 patients (60.5%) were man. Patients with DM accounted 62.1% (n=77). A total of 57 (46.0%) of 124 cases had abnormal venographic findings such as fibrin sheath (34.7%), thrombus (11.3%) and stenosis (2.4%). Intra-catheter fibrin and thrombus was detected in 73 (58.9%) catheters by gross evaluation of cut lumen. Overall, ninety-five (76.6%) out of 124 patients had catheter-related complications on the inside or outside of the catheter. Conclusion: This study shows that a considerable number of asymptomatic HD patients have catheter-related problems. Therefore, we suggest that the reduction of the number of dwelling TCCs is thought to be more important than the adequate management to prevent complications.

Purpose: For hypersplenism, portal hypertension, or hematologic disorders, etc., partial splenic embolism (PSE) is often performed.

To prevent severe complications such as abscess formation, around 30% of normally vascularized splenic mass should be preserved to keep the normal immune function and the normal direction of blood flow through the splenic circulation. However, the estimation of splenic infarction during PSE is often difficult. According to Murray's law, flow rate is in accordance with the vessel diameter (D) to the third power and the exponent varies from 2.33 to 3.0 depending on whether the flow is turbulent (2.33) or laminar (3.0). Thus, we compared splenic infarction rates (SIR) based on D2.33 and D3 of splenic arteriography with manual volumetry on postcontrast CT one week after PSE.

In twenty-five patients (42-73, mean 59.6 y/o) with hypersplenism, PSE was performed using n-butyl cyanoacrylate. On splenic arteriography each intrasplenic branch diameter (D) was measured. The SIR-D2.33 were calculated as the addition of the embolized D2.33 divided by the sums of total D2.33 and SIR-D3 as the addition of the embolized D3 divided by the sums of total D3. Both SIRs were compared with actual SIR-CT. Results: SIR-D2.33 (68.1±15.0%) and SIR-D3 (71.4±16.9%) did not show any significant difference from SIR-CT (71.1±12.2%), and significantly (p<0.05) good correlations (r=0.49, r=0.49, correspondingly) with SIR-CT. Conclusion: SIR can be estimated using Murray's law based on splenic arteriography before PSE.

Role of enhanced CT in assessing the source of arterial hemorrhage in patients with pelvic fracture. Comparison with angiography Purpose: To evaluate the diagnosis of enhanced CT; E-CT in identifying the source of arterial hemorrhage in patients with pelvic fracture. Material and Methods: The patient population included 15 patients with pelvic fracture who underwent E-CT and angiography between January 2004 and August 2008. The analysis of E-CT involved the presence and site of extravasation, hematoma and fluid collection. We defined these three findings as bleeding. Five distinct regions of the pelvis identified as potential sites of hemorrhage were divided on the basis of anatomical landmarks. The regions were the upper pelvic region, the gluteal region, the pelvic sidewalls, the presacral space, the small pelvic region. Finally, we investigated concordance between the extravasation, hematoma and fluid collection of E-CT and angiographic findings. Results: Extravasation was identified in 10/15 (66.7%) patients with 15 sites. 7/15 (46.7%) sites of extravasation were corresponding with angiographic findings. Hematoma was identified 15/15 (100%) patients with 36 sites. 16/36 (44.4%) sites of hematoma were corresponding with angiographic findings. Fluid collection was identified 8/15 (53.3%) patients with 11 sites. 4/11 (36.4%) sites were corresponding with angiographic findings. As for five divided regions, the highest concordance region between E-CT and angiography was the upper pelvic region in 10/12 (83.3%). The next were the presacral space in 4/7 (57.1%) and the pelvic sidewalls in 11/23 (47.8%). The lower concordance region was the small pelvic lesion in 2/9 (22.2%) and the gluteal region in 1/11 (9.1%).

We evaluated the diagnosis of E-CT in identifying the source of arterial hemorrhage in patients with pelvic fracture. The upper pelvic region is the highest concordance region between the findings of E-CT and angiography, and the lower concordance regions were the small pelvic region and the gluteal region.

C RSE CIRSE Abstract Book -liver transplant patients (2 males and 2 females of 37-to 61-yearold) developing splenic artery steal syndrome had SAE performed. Three of them had history of end-staged liver cirrhosis and one had hepatocellular carcinoma, requiring liver transplantation. Splenic artery steal syndrome was suspected by deranged liver function and either absent hepatic artery flow on Doppler US or attenuated hepatic artery on contrast CT scan. Digital subtraction angiogram (DSA) and SAE were performed on day 1 to day 6 of post-operative period. Metallic coils (7-18 coils of size 5-10mm) were used for embolization. Results: Immediate post-embolization DSA showed increased flow to the hepatic artery of the liver graft. Follow-up imaging showed either restored hepatic artery flow on ultrasound or patent and normal-sized hepatic artery on CT scan in 3 out of the 4 patients. The hepatic artery remained attenuated on CT scan in one patient. All patients had improved liver function shortly after embolization. Extent of splenic infarction was also evaluated. Two patients had 22-29% volume of splenic infarct with more distal embolization, while the other two had <7% volume of splenic infarct with more proximal embolization. Conclusion: SAE offered promising imaging and clinical outcomes for patients developing splenic artery steal syndrome shortly after liver transplantation. More proximal SAE was preferred to reduce the extent of splenic infarction.

Purpose: Hereditary hemorrhagic telangiectasia (HHT), known as Osler-Weber-Rendu syndrome is autosomal dominant inheritance disease. The pathophysiology involves disorders in growth and migration of endothelial cells, which leads to telangiectasias and arterio-venous malformation formation. The most common symp-tom is recurrent epistaxis (80-90%). Advanced disease can result in extensive bleedings. Due to the rarity of the disease and availability of only symptomatic treatment, there are no guidelines for effective therapy. The purpose of the study is to evaluate effectiveness and safety of endovascular embolisation in epistaxis in patients with HHT. Material and Methods: Retrospectively, we evaluated 15 patients with severe epistaxis suffering from HHT, who have been treated using intravascular technique. In all cases, embolisation was suggested when nasal packing and cauterisation were not effective. Branches of external carotid artery were selectively embolised using microcatheters. Embospheres 500-700μm were used as embolising material. Results: Immediate bleeding control was achieved in 13 patients. In 2 patients due to ethmoidal arteries involvement, embolisation was not completed. There were no severe complications after embolisation. Ten patients suffered from facial pain up to 4 days after the treatment. Three patients reported facial paraesthesia, which resolved after up to 5 days from the procedure. In 27-month follow-up, recurrent epistaxis occurred in 6 patients between 3 and 24 months after treatment, but bleedings were less frequent and less severe. Conclusion: Embolisation reduces the frequency, severity and duration of nasal bleeding in patients with HHT, improving patients' quality of life. It is safe procedure although it cannot provide a longterm cure in most cases.

Thinking outside the pelvic box: an atlas of unusual prostatic arterial supply for prostatic artery embolization Learning objectives: To describe unusual anatomical variants in prostatic arterial supply using CTA and DSA. To describe some technical aspects for selective prostatic artery embolization in different anatomic variants. Background: Prostatic artery supply is complex and there are a lot of anatomic variations. The most common prostatic artery origins are: internal pudendal artery, superior vesical artery, common gluteal-pudendal trunk and obturator artery. Although these anatomy accounts for more than a half of cases, there are some important variations. Origins from prostate-rectal trunk, inferior gluteal, superior gluteal and accessory pudendal artery should not be forgotten. Rare variations are sometimes observed and we should be ready to think on other possibilities. Clinical Findings/Procedure: CTA is used to study prostatic artery supply before prostatic artery embolization. We describe and offer a pictorial CTA and DSA atlas of unusual and rare prostatic artery origins, such as prostate-rectal trunk, epigastric from external iliac artery, epigastric from internal iliac artery, accessory internal pudendal artery, obturator from inferior gluteal artery and directly from inferior or superior gluteal. Conclusion: Prostatic anatomy is very variable. Before any prostatic artery embolization is crucial to evaluate prostatic vascular anatomy with CTA to avoid surprises. In these cases, data from DSA should be compared with CTA to confirm different origins.

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MR and endorectal US findings in benign prostatic hyperplasia before and after prostatic artery embolization Learning objectives: In this review, we provide a pictorial demonstration of the variety of arterial injuries to both the great vessels and the other vessels within the thorax and the diversity of their endovascular management. We also discuss some pitfalls in diagnosis and treatment. Background: Multiple arterial structures reside within the thorax. Both the great vessels (the aorta and its branches and the pulmonary arteries) and the other vessels within the chest such as the internal thoracic artery, intercostal vessels, and the radicular arteries can be subject to injury post-trauma and during surgery or intervention. Clinical Findings/Procedure: In this review, we cover the imaging findings and management in cases of:

arteries and subclavian artery.

Management using stent grafts, coils, covered stents and other embolic agents are discussed.

The advent of multi-detector computed tomography (MDCT) and CT angiography has enabled accurate identification and localisation of arterial injury within the chest which has proven invaluable in planning and guiding endovascular intervention.

Endovascular management of these injuries in our centre is considered the first line, life-saving management in the vast majority of cases. Learning objectives: To describe the relevance of periprocedural identification of active bleeding due to the presence of the artery "corona mortis" (translated as "crown of death") and its transcatheter embolization, in pelvic trauma. Background: About 2% of patients with pelvic fractures presents arterial haemorrhage for which mortality, if untreated, is very high. The angiography and transcatheter embolization are associated with a significant reduction in morbidity, mortality, and blood transfusions. It is important that the interventional radiologists be familiar with the typical sites of pelvic bleeding as well as the potential anatomic variations of the origins and courses of bleeding arteries. A common variant artery, susceptible to traumatic injury, is the artery also known as "corona mortis" or aberrant obturator artery, originating from the external iliac artery or its branches. It has an incidence of 13 -36% of the subjects. Clinical Findings/Procedure: 39 patients with pelvic fractures, associated with active bleeding and hemodynamic instability, underwent to urgent angiography. 10 patients showed the artery "corona mortis": 7 patients underwent endovascular embolization, via inferior epigastric artery, for the persistence of active bleeding in the obturatory region, even after the internal iliac artery branch embolization. Conclusion: The artery "corona mortis" is a common vascular variant and a potential cause of life-threatening bleeding in pelvic trauma. The presence of active bleeding from this vessel must always be sought, by the angiography of the external iliac artery, before and after the embolization of the hypogastric branches.

Interventional Learning objectives: This educational exhibit reviews our institution's experience in the management and treatment of hereditary hemorrhagic telangiectasia (HHT). We seek to familiarize the audience with HHT and the interventional radiology techniques used to treat sequelae of this disease. Background: HHT is a genetic disorder of small blood vessels affecting about 1 in 5000 people leading to vascular malformations, aneurysms, vascular shunts, and hemorrhage involving various organ systems including the brain, nose, liver, lungs, and bowel. These patients often go unrecognized as most are initially asymptomatic. Others may only present with epistaxis or oral telangiectasias. Serious complications such as vascular rupture, stroke, and brain abscess are an ever present risk for HHT patients. Interventional radiologists play a crucial role in the treatment of brain and lung vascular malformations helping to reduce the risk of stroke, paradoxical emboli, and venous to arterial shunting. Clinical Findings/Procedure: UCSD is one of nine HHT centers

C RSE CIRSE Abstract Book in the United States for the management of HHT patients. In this exhibit, we review the genetics, clinical manifestations, histopathology, workup, diagnostic criteria, and radiographic presentation of HHT. The role of interventional radiology in treating brain and lung vascular malformation is discussed along with potential complications and imaging follow up. We also provide a comprehensive pictorial review of cases accrued at our institution related to HHT treatment. Conclusion: Clinicians and interventional radiologists must recognize HHT patients and any affected family members, due to their potentially life-threatening indolent condition. By sharing our experience, we demonstrate our repertoire of diagnostic and therapeutic options for the treatment of HHT.

Role of endovascular treatment of pelvic fractures hemorrhage in emergency setting F. Piacentino, G. Carrafiello, M. Mangini, F. Fontana, A.M. Ierardi, C. Floridi, L.N. Cardim, C. Pellegrino, G. De Marchi, C. Fugazzola; Radiology, University of Insubria, Varese, Italy.

Learning objectives: To evaluate the role of endovascular treatment in controlling active bleeding, false aneurysms or vessel occlusions in polytrauma patients with pelvic vascular injuries with or without associated pelvic fractures. Background: From March 2009 to April 2010, 36 patients (25 men -11 women) with major pelvic trauma associated with high-flow hemorrhage were referred to our emergency department. All patients underwent CT examination. Vascular injuries were in 11 cases of superior gluteal artery, 5 of lateral sacral artery, 7 of internal pudendal artery, 2 of lumbar artery, 4 of common femoral artery, 1 of external iliac artery, 1 of inferior gluteal artery, 2 of obturator artery and 3 cases of the hypogastric artery. In 34 cases embolization was performed using steel coils, in 2 cases bleeding was treated using a stentgraft. Multiple small distal bleeding sites were embolized with Gelfoam suspension. Clinical Findings/Procedure: The technical success rate was 100% documented at post-procedural angiography; no complications occurred during the procedures. Clinical efficacy was 100%; in fact, none of the patients had to undergo a new arteriography for hemorrhage recurrence. From all, 34 patients had a stabilization of vital parameters. Two patients deceased. Conclusion: In our study, percutaneous control of pelvic hemorrhages showed a valuable therapeutic option: transarterial embolization is a rapid, safe, effective and minimally invasive technique, features that make it very useful in this setting, where the clinical course and prognosis are related to the achievement of hemodynamic stability. Learning objectives: To discuss the main clinical parameters of disease severity in benign prostatic hyperplasia, to explain the preembolization workup and techniques on how to perform prostatic arterial embolization, and to explain the clinical follow-up after the procedure. Background: Benign prostatic hyperplasia has a high prevalence rate in men older than 50 years and is a condition often associated with lower urinary tract symptoms. The most frequent symptoms are decreased urinary stream, higher urinary frequency and urinary urgency. Prostatic artery embolization has been described as a useful interventional treatment for this condition with promising results. Clinical Findings/Procedure: Our patient evaluation includes: clinical history and examination, severity of low urinary tract symptoms with IPSS, quality of life (QoL), erectile/sexual function, uroflowmetry, digital examination, transrectal ultrasound and PSA. A CTA is performed in patients within the inclusion criteria to assess vascular anatomy. We selectively catheterize the prostatic artery and embolize. The end points are near stasis in prostatic vessels and obliteration of prostatic artery supply observed in the control angiogram. Follow-up of clinical parameters is performed at one, three and six months, one and two years. Conclusion: Prostatic artery embolization is a challenging and safe procedure to treat benign prostatic hyperplasia. Clinical evaluation and CTA are essential as pre-embolization workup. Follow-up plays an important role in these patients to understand technical and clinical outcomes.

Bronchial migration of pulmonary arterial coils Embolization of two pulmonary artery aneurysms was performed in a patient of 47-year-old with Hughes-Stovin syndrome who suffered haemoptysis. The procedure was complicated by migration of various coils into an adjacent bronchus and required surgical treatment twelve months later.

A case of lung cancer in need of transcatheter embolization of multiple pulmonary arteriovenous malformations and unilateral pulmonary artery occlusion test before resection Y. Tomozawa, S. Ohta, A. Sonoda, N. Kono, H. Otani, S. Watanabe, N. Nitta, M. Takahashi, K. Murata; Radiology, Shiga University of Medical Science, Otsu, Japan.

We performed transcatheter microcoil embolization of multiple pulmonary arteriovenous malformations in a patient combined with lung cancer. Because of the severe reduction of the cardiopulmonary function, unilateral pulmonary artery occlusion test was also needed before the resection of lung cancer.

Purpose: To assess the relationship between number of feeders in type 2 endoleaks after endovascular abdominal aortic repair (EVAR) and change in aneurysm diameter. Material and Methods: Contrast-enhanced CT was performed 1 week after EVAR to evaluate thrombosis in 85 aneurysm patients. Feeders involved in type 2 endoleaks were evaluated; and three groups were categorized according to the number of feeders: no feeder group (39 patients), defined as no involved vessels and endoleaks; single feeder (14 patients); and multiple feeder groups (32 patients). The change in aneurysm diameter in each group was compared at 1, 2, and 3 years after EVAR. Results: Increase in aneurysm diameter (≥3 mm) was observed in 3 patients each in the single and multiple feeder groups. Decrease in aneurysm diameter (≥3 mm) was observed in 26 and 13 patients in the no and multiple feeder groups, respectively. Mean changes in aneurysm diameter at every year were −6.4, −7.6, and −14.1 mm in the no feeder group; +0.1, +1.2, and +2.7 mm in the single feeder group; and −3.2, −4.6, and −1.3 mm in the multiple feeder group. The single and multiple feeder groups exhibited significantly larger aneurysm diameter than the no feeder group at each observation year. The multiple feeder group displayed significant decreases in diameters than the single feeder group. Conclusion: Regardless of the number of feeders, the presence of a feeder was the only predictive factor of aneurysm expansion.

Aortic remodeling after thoracic endovascular aneurysm repair for chronic type B aortic dissection: comparative study of entry closure vs. complete false lumen exclusion K. Uotani, T. Taniguchi, N. Kusunoki, H. Tomimatsu, Y. Yokota, N. Katayama, A. Kawasaki, G. Okubo, T. Suga, N. Mori, Y. Nishimoto, S. Noma; Radiology, Tenri Hospital, Tenri, Japan.

Purpose: To evaluate aortic morphologic change after thoracic endovascular aneurysm repair (TEVAR) for chronic type B aortic dissection. Material and Methods: Twenty-five patients with non-complicated chronic type B aortic dissection underwent TEVAR. Thirteen patients who had type B dissection with patent false lumen underwent entry closure (group A). Ten patients who had thrombosed false lumen with enlarged ulcer-like projection and 2 patients who underwent surgical visceral de-branch underwent false lumen exclusion by TEVAR (group B). Degree of false lumen thrombosis, aortic size, and

C RSE CIRSE Abstract Book diameter of true lumen was evaluated on follow-up CT. Results: False lumen was partially thrombosed in group A, while complete false lumen thrombosis was achieved in all patients of group B. During a mean follow-up period of 552 days, a mean aortic diameter enlarged from 51.8 to 55.1mm in group A, whereas that of group B decreased from 47.7 to 40.8mm (p<0.05). A mean true lumen diameter significantly increased from 15.6 to 25.1mm in group A (p<0.01). Aortic enlargement was observed in 7 patients (54%) of group A and 1 patient (8%) of group B, and additional TEVAR (n=1) and surgical aneurysm repair (n=2) was needed for 3 patients of group A. False lumen recanalization due to intimal flap injury at the edge of stentgraft was observed in 4 patients of group A as a late complication (21.5±4.7 months after TEVAR). No major adverse events concerning TEVAR were observed in both groups. Conclusion: Complete false lumen exclusion may contribute to better aortic remodeling than entry closure for chronic type B dissection.

C-arm rotational CT angiography in the endovascular treatment of complex aneurysms Purpose: Fenestrated and/or branched stentgrafts for endovascular treatment of juxtarenal and thoraco-abdominal aneurysms require meticulous planning based on CT angiography (CTA) and workstations. Successful deployment relies on predicting the positions of the fenestrations or branches in relation to target vessels, which requires extensive experience and becomes extremely difficult when the vessel anatomy is tortuous.

A new imaging technology has developed recently involving C-arm rotational CTA whereby intra-operative images gathered by the rotating C-arm can be converted to CTA images in all formats. In addition, these images can be fused with pre-existing multi-detector CTA images in "real time" in the operating theatre enabling the vessel anatomy to be outlined whilst deploying complex stentgrafts. This is made possible either by fusing fluoroscopic images and pre-procedure multi-slice CTA images of landmarks such as the vertebral bodies, or by performing a contrast-enhanced C-arm rotational CTA and fusing the acquired image with the existing vessel anatomy. In both situations images can be used as a 3D roadmap, guiding deployment of branched stentgrafts and subsequent vessel cannulation. Results: Preliminary experience using this technology in 10 patients with complex FEVAR/TEVAR has been associated with a reduction in the volume of iodinated contrast medium used and a lower radiation dose. Conclusion: Intra-operative C-arm rotational CTA provides highquality "real-time" 3D roadmapping, allowing accurate orientation of the stentgraft and assisting in vessel cannulation with subsequent reduction in the dose of contrast and radiation exposure.

Additionally, completion C-arm CTA helps in determining whether further interventions are necessary, and obviates the need for discharge multi-slice CTA. Disclosure: Jowad Raja and Krassi Ivancev are consultants for Cook.

Long-term efficacy of endovascular treatment of isolated iliac artery aneurysms P. Cerini, R. Fossaceca, G. Guzzardi, E. Malatesta, I. Di Gesu', C. Stanca, M. De Bonis, A. Carriero; Diagnostic and Interventional Radiology, "Maggiore della Carità" Hospital "A. Avogadro" University, Novara, Italy.

Purpose: To evaluate the effectiveness of endovascular treatment of isolated iliac artery aneurysms. Material and Methods: From May 2005 to December 2010, 32 patients (31 males and one female, mean age 73 +/-12 years) with a total of 40 IIAA underwent endovascular treatment in our institution. We evaluated technical success, primary patency, early and late complications and overall mortality. Results: At a median follow-up period of 36 months, we achieved a technical success of 100%, primary patency of 95% and secondary patency of 100% (thrombolisis in 2 pts), with complete exclusion of the aneurysm in 84.6% of cases. In 12.8% of cases there was a reduction in volume of the aneurysm sac with a type II endoleak incidence of 12.8%. The overall survival at 1, 2, 3, and 6 years was 96.8%, 84.2%, 66.6%, 64%, respectively. Conclusion: Our study documents the effectiveness of endovascular treatment of isolated iliac artery aneurysms, which has become the first line treatment in our institute. This finding is coherent with the most recent literature data and confirms the safety and longterm patency of stent-graft placement.

The influence of iliac limb engagement on secondary intervention following endovascular aneurysm repair Purpose: Optimum utilisation of iliac vessels in endovascular aneurysm repair (EVAR) remains undefined. This study analysed whether secondary iliac intervention is influenced by the proportion of iliac vessel utilised at primary procedure. Material and Methods: Retrospective interrogation of an EVAR database identified a control group of patients over 6 months (Jan-Aug 2010) and a patient cohort in whom secondary iliac intervention had been performed (2004) (2005) (2006) (2007) (2008) (2009) (2010) (2011) . Patient demographics and operative details were comparable. Iliac vessels were optimally profiled on CT-angiogram using Leonardo work station and had mid-luminal lengths measured from aortic bifurcation to distal iliac stent and iliac bifurcation. The proportion of iliac artery covered by the stent was compared between the groups; (Mann-Whitney U: p<0.05).

The control group (n=42) had no significant differences between vessels receiving ipsilateral and contralateral limbs. None required iliac intervention over one follow-up. The secondary iliac re-intervention group (n=20) required 14 contralateral and 7 ipsilateral limb extensions at mean 22.1 months post-EVAR. There was significantly less proportionate utilisation in those iliacs requiring re-intervention compared to the opposite side despite no significant difference in iliac length (p<0.001 and p=0.944, respectively).

Comparing data between the iliac re-intervention group and the control group, iliac length was shorter (48.9 vs. 59.7mm; p<0.015), stent engagement was less (28.0 vs. 43.0mm; p<0.001) and proportionate iliac utilisation was reduced (53.7% vs. 72.8%; p<0.001). Conclusion: Proportionate utilisation of the iliac artery by graft limb is important, potentially influencing secondary iliac intervention. This appears more important than simply graft length. Maximal

Learning objectives: To describe the technical solutions and atypical treatments done in 12 years of experience with endovascular abdominal aortic aneurysm repair (EVAR). Background: EVAR treatment generally consists of deployment of a bifurcated stent-graft or aorto-uniiliac stent-graft; however, in selected cases atypical treatment or solutions can be adopted to obtain an optimal result. Clinical Findings/Procedure: In our experience of 374 EVAR done in 20 cases technical variations and alternative solutions were adopted. These are the options used: deployment of one or two bare or covered stent in one or both renal arteries or superior mesenteric artery in cases of hostile infrarenal neck (Chimney technique) in 13 cases; deployment of a single or double straight stent-graft in case of focal aneurysm or pseudoaneurysm in 4 cases; bilateral deployment only of iliac extensions in case of distal aneurysm in 1 case; "Sandwich technique" with deployment of covered stent in the hypogastric artery to exclude iliac aneurysm and preserve patency of the hypogastric artery in 1 case; "kilt technique" in case of hostile infrarenal neck in 1 case; "hybrid treatment" done with deployment of main stent-graft body and deployment of covered stent as contralateral limb through an axillary access in case of external iliac artery occlusion in 1 case. Conclusion: After 12 years of experience with EVAR an alternative series of treatments and solutions have developed with the goal to achieve an optimal result also in unusual or complex situations. However, these atypical treatments sometimes are very difficult and results are not always guaranteed and complications can be observed.

A pictorial essay demonstrating the use and potential complications of snorkels, periscopes and back- Learning objectives: (1) Identify the angiographic and CT appearance of the various methods of managing aortic branches. (2) Describe the technique for the creation of snorkels, periscopes, and back-table endograft fenestrations. (3) Demonstrate advantages and limitations of these various methods of aortic branch vessel preservation.

Background: The availability of the shelf solutions for dealing with branch vessel preservation in the face of complex aortic aneurysms is still limited to clinical studies and few high-volume centers.

Patients with no open surgical alternatives may be considered for back-table fenestrated or parallel branch grafts. These solutions, including the "snorkel" (or "chimney") technique, can be utilized when faced with anatomic variations or complex aneurysmal necks. The literature to date has shown positive results as compared to the current standard and the use of these techniques continues to grow. However, there remains a paucity of literature in describing and demonstrating the use of side branch endovascular access via these methods. Clinical Findings/Procedure: We have collected cases which demonstrate the use of snorkeling, periscoping, and back-table fenestrations to access various branch vessels during endovascular repair of aortic aneurysms. The images demonstrate how these techniques allow for stent placement to the branch vessels when dealing with difficult access configurations or unique anatomy of target branch vessels. Additionally, we will review the unique pre-planning that is required for these cases and potential complications which include endoleaks and stent migration. Conclusion: There is a current unmet clinical need in available, feasible options for accessing branch vessels during endograft repair of complex aortic aneurysms. These cases provide pictorial examples of how the snorkel and periscope techniques and back-table fenestrations can be used to overcome this obstacle, while maintaining patency of the branch vessels. Close follow up is crucial for identifying potential stent branch stenosis, endoleaks, or stent migration.

Electronic Posters diagnosis by ultrasound in high-risk pregnancies helps to identify cases for follow-up and advance multidisciplinary planning of cesarean section. The object of interventional radiological adjunctive support is to reduce haemorrhage and allow appropriate surgery, which imply a low maternal and fetal morbidity as well as maintained fertility. Clinical Findings/Procedure: Based on the current literature we provide an overview of various management options available for placenta percreta, including the uterus-preserving treatment modalities: leaving placenta in situ and local resection. The emphasis will be on the role of interventional radiology in a multidisciplinary team, both for the elective and acute setting. An overview of complications associated with the different management modalities will also be provided. Conclusion: Interventional radiology can provide extensive benefits into the multidisciplinary patient care of placenta percreta pregnancies. However, different complications are to be considered depending on the chosen management modality.

Non-fibroid uterine artery embolization Learning objectives: To show the usefulness of uterine artery embolization (UAE) in obstetric and gynecologic pathology, excluding fibroid embolization. Background: UAE is a procedure well established in fibroid management. It is also an effective and safe procedure in other diseases causing heavy vaginal bleeding. Non-fibroid UAE can be divided into three main groups according to our experience: -obstetric: placenta accreta, postpartum uterine atony, ectopic pregnancy; -vascular: arterio-venous malformation; -systemic: hemorrhagic diatheses. Clinical Findings/Procedure: Following femoral arterial access, the contralateral iliac artery is selected, and the anterior division of the internal iliac artery is catheterized. Whenever is possible, the diagnostic catheter is further advanced to the uterine artery, which is then embolized using PVA microspheres between 500 and 900 μm. In some cases, a microcatheter is needed to prevent spasm in the uterine artery. The procedure is then repeated on the ipsilateral uterine artery. In our experience, bleeding cessation was achieved in all cases, preventing hysterectomy. Further uterine dilation and curettage was necessary to treat ectopic pregnancy or placenta accreta. Conclusion: UAE is a safe and effective procedure in obstetric and gynecologic diseases other than uterine leiomyoma.

Magnetic resonance (MR) findings before and after uterine artery embolization (UAE) for uterine leiomyomas and adenomyosis J.A. Pereira, H. Rio Tinto, L. Fernandes, M. Duarte, T. Bilhim, J.M. Pisco; Interventional Radiology, Saint Louis Hospital, Lisbon, Portugal.

Learning objectives: To review the MR imaging features of uterine leiomyomas and adenomyosis before and after UAE. To identify preand post-treatment MR imaging features that may be associated with clinical outcome after UAE. Background: UAE is an increasingly performed, minimally invasive alternative to hysterectomy or myomectomy for women with symptomatic uterine fibroids. Clinical failure after UAE for leiomyomas in 6 cases gelatine sponge. Results: The embolization has been effective in 50 cases; in 2 cases of PPH, hysterectomy occurred anyway. We did not have ischemic or embolic, early or late complications.

The full potential of arterial catheterization is being explored for obstetrical conditions such as ectopic pregnancies, abnormalities of the placenta and PPH. Early diagnosis allows for prophylactic, presurgical embolization or placement of catheters or balloons, thus enabling rapid treatment of hemorrhage, should it arise. These cases represent true emergencies; with rapid intervention, the significant morbidity and mortality associated with PPH can become a thing of past.

Imaging diagnosis and transcatheter embolization of acquired uterine vascular malformations A. Picel, S. Koo, A.C. Roberts; Radiology, University of California San Diego, San Diego, CA, United States of America.

Learning objectives: 1. To understand the imaging diagnosis and differences between acquired and congenital uterine arteriovenous malformations.

2. To review the traditional treatment options and the technique of transcatheter arterial embolization. Background: Uterine vascular malformations may present as unexplained vaginal bleeding that can be life-threatening. Acquired vascular malformations are distinct from congenital lesions and may be better classified as arteriovenous fistulas. Transcatheter embolization presents a minimally invasive treatment option that may preserve fertility. Clinical Findings/Procedure: Patients with acquired arteriovenous fistulas often present after uterine trauma or intervention. Imaging diagnosis is important as intervention may worsen bleeding. Color Doppler ultrasound demonstrates a mosaic pattern of turbulent flow with high velocities and low resistive index within hypoechoic spaces. Traditional therapy consists of hysterectomy or ligation of uterine arteries; however, transcatheter arterial embolization provides a less invasive treatment option that has demonstrated success with minimal complications in several case series. Embolic material is commonly administered to provide occlusion. Fertility is usually maintained because of the development of collateral vasculature. Conclusion: 1. Appropriate imaging diagnosis of acquired uterine malformations is important, as surgical intervention may worsen or precipitate life-threatening hemorrhage. 2. Transcatheter arterial embolization offers several advantages over traditional surgical hysterectomy; including a lower risk of complications, fertility preservation, and shorter hospitalization.

Purpose: To assess the feasibility and diagnostic performance of a non-enhanced MR angiography sequence (syngo NATIVE SPACE, Siemens) to detect and quantify lower limb peripheral arterial disease (PAD) with gadolinium-enhanced MR angiography (CE-MRA) as the reference standard. Material and Methods: 51 patients known to have lower limbs arteriopathy were included in this prospective study. We performed in every patient NATIVE sequence and CE-MRA on a 1.5T system. We evaluated exam duration, image quality, and location, number and severity of lesions. Results: Examination duration was longer for NATIVE (mean of 39.6 minutes vs. 10 minutes for CE-MRA). Image quality was significantly better in CE-MRA, with 92% of images listed as good to excellent for CE-MRA and 53% for NATIVE. Sensitivity, specificity, negative predictive value (NPV) and accuracy of NATIVE were, respectively, 75%, 95%, 89% and 88% for all mixed levels, 52%, 97%, 88% and 87% for aorto-iliac level, 87%, 99%, 95%, and 92% for femoro-popliteal level,

C RSE CIRSE Abstract Book intervals using Wilcoxon signed-rank test.

Results: The diameters of three arteries did not significantly change after embolization. The median Vmax of PHA, GDA, and Rt. GEA before embolization were 72.0 cm/sec (range 34. 6-114.7), 52.7 (39.7-102) , and 51. 1 (33.5-69) , respectively. The values 1-2 days after embolization were 44. 6 (22.4-73.4), 55.9 (20.6-84.9) , and 24.2 (9.6-72.3), respectively. Those values 5-7 days after embolization were 51.1 (21.1-111.2) , 57.1 (13.2-111) and 21.7 (7.7-78.2) , respectively. Compared to pre-embolization state, significant decrease in Vmax was observed in 1-2 and 5-7 days after embolization in PHA and Rt.GEA. Conclusion: The Vmax of collateral blood flow to the liver and stomach, from the superior mesenteric artery to PHA and the Rt. GEA via the GDA respectively, continuously decreased in 1-2 and 5-7 days after the embolization. The waiting time longer than 7 days may be necessary for sufficient recovery to pre-embolization state. 20 were under anticoagulation therapy (95%), 8 had both anticoagulation/antiagregant agents (38%) and one patient suffering from severe coagulation disorders. The majority (58%) of hematomas involved the rectus sheath. The bleeding arteries were identified at CT in 13 patients (62%). Active bleeding (extravasation) was seen in 11 patients (55%). The inferior epigastric artery was the site of bleeding and TCE in 13 patients (52%). In 90%, TCE was done with gelfoam and/or coils. Angiographic cessation of bleeding with embolization was achieved in all patients. Complications in 3%. All-cause mortality at 30 days was 35%. Reintroduction of anticoagulant was done in 86%. Conclusion: Drug-induced spontaneous extraperitoneal hematomas are associated with a high mortality rate even the bleeding controlled. TCE is a safe and effective technique in managing patients under anticoagulants.

The significance of right gastric artery anomaly in transarterial hepatic regional therapy S. Sun, S. Laroia, F. Youness, L. Song; Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, United States of America.

Purpose: To access the incidence and clinical significance of right gastric artery (RGA) arising from left hepatic artery (LHA) deep in the porta hepatis region during transarterial hepatic regional therapy. Material and Methods: Medical records and arteriograms of 560 patients with HCC or hepatic metastases treated either with transarterial bland embolization, TACE, or with radioembolization at our institution from 2003 to 2011 were reviewed and analyzed. The CE-MRA (11 atherosclerotic, 3 dysplastic) with 4 significant RAS. Sensitivity, specificity, PPV and NPV of NE-MRA were, respectively, 100%, 100%, 100% and 100% for reader 1, and 100%, 98,2%, 87,5% and 100% for reader 2. Overestimation of the stenosis grade occurred in two cases for the reader 2 (<50% vs. normal in one case, ≥50% vs. <50% in the other case). Conclusion: NE-MRA has become a viable alternative to CE-MRA for the study of the renal arteries. In case of significant stenosis, given the risk of overestimation, the use of CE-MRA is still indicated.

Variant hepatic arterial anatomy on angiography in 2111 patients A. Polikarpov, P. Tarazov, J. Suvorova, A. Kozlov; Angio/Interventional Radiology, Russian Scientific Center of Radiology and Surgical Technologies, St. Petersburg, Russian Federation.

Purpose: To study hepatic arterial variants using digital subtraction angiography in a large series of patients. Material and Methods: Hepatic arteriograms of 2111 patients were analyzed according to Hiatt et al. (1994) classification. Results: Six types of arterial anatomy were identified: Type 1.

Typical: the common hepatic artery (CHA) arose from the celiac artery, divided on the gastroduodenal artery (GDA) and the proper hepatic artery (PHA) with the left (LHA) and right (RHA) hepatic arteries = 66.1%. Type 2. Aberrant (replaced or accessory) LHA from the left gastric artery (LGA) = 9.9%. Type 3. Aberrant RHA from the superior mesenteric artery (SMA) = 9.8%. Type 4. Aberrant LHA from

LGA with aberrant RHA from SMA = 3.8%. Type 5. CHA from SMA = 1.7%. Type 6. In 184 (8.7%) remaining cases, 61 other variants were found and divided on 5 groups. Thirty-five variants of the hepatic artery have never been described. Conclusion: Typical arterial anatomy of the liver takes place in about 2/3 patients, while different variants are presented in the remaining 1/3. Knowledge of these variants is important for abdominal surgeons and interventional radiologists.

There are unforeseen consequences that can occur after surgery. A 47-year-old man who developed atypical chest pain after a type A dissection repair. Imaging revealed aortitis and rupture of the aorta into the sternotomy wound.

Primary aorto-esophageal fistula as a complication of an aneurysm of the thoracic aorta dissected A. Ranalli We present a rare case of aorto-esophageal fistula in a patient with aneurysm of the thoracic aorta dissection presented in the emergency department for gastrointestinal hemorrhage. Few cases have been reported in literature. It remains predominantly a postmortem diagnosis.

Endovascular and surgical management of the palatine epithelioid hemangioendothelioma M.S. Olshanskiy 1 , N.G. Korotkih 2 , I.V. Stepanov 2 , V.V. Evteev 3 ; 1 Angiography and Endovascular Surgery, Voronezh Regional Clinical Hospital #1, Voronezh, Russian Federation, 2 Cranio-maxillofacial surgery, Voronezh State Medical Academy, Voronezh, Russian Federation, 3 Radiology, Voronezh Regional Clinical Hospital #1, Voronezh, Russian Federation.

Since 1978 till 2010, approximately 37 cases of rare tumor epithelioid hemangioendothelioma, located in oral cavity, were published in English literature. The case of this tumor affecting hard palatine is unique. A 55-year-old male patient was admitted in cranio-maxillofacial department with the complaints for mass in oral cavity, discomfort during eating, speech roughness and bleeding from ulcerated tumor. Considering a vascular origin of a neoplasm evaluated by ultrasound, CT and angiography it was decided to apply a selective embolotherapy as a fist line therapy. After successful bilateral selective embolization of feeding arteries arising from both external maxillary arteries, this tumor was surgically removed without any sufficient blood loss. In immediate postoperative period, the speech restored and there was no discomfort during eating. The patient was discharged in satisfactory condition on 5 days after this two-line management. The follow-up time consists of 20 months.

Virtual histology-intravascular ultrasound as a diagnostic alternative for morphological characterization of carotid plaque: comparison with histology and high-resolution magnetic resonance findings M. Chiocchi, R. Gandini, M. Stefanini, D. Morosetti, A. Chiaravalloti, G. Loreni, G. Simonetti; Diagnostic Imaging and Interventional Radiology, IRCCS Policlinico di Tor Vergata, Rome, Italy.

Learning objectives: The primary target was to validate VH-IVUS as a diagnostic tool for plaque characterization through in vivo characterization of carotid artery plaques by correlation to ex vivo histological specimen. The secondary target was to compare in vivo VH-IVUS with HR-MR imaging. Background: Stroke is the third most common death cause and one of the most common causes of long-term disability in the western world. Carotid plaque morphology is, more than the stenosis degree, the main predictor of cerebro-vascular accidents. Highresolution magnetic resonance imaging demonstrated to be the most sensitive and specific diagnostic tool for in vivo morphological characterization of atheromatous carotid artery plaques, strongly in agreement with histology. VH-IVUS may be a valid diagnostic alternative for the in vivo morphological characterization of carotid artery plaques. Clinical Findings/Procedure: Forty-two images were used for correlation between VH-IVUS and histology. Quantitative analysis of different plaque components revealed a good concordance (0.80) between the two methods (95% CI 0.69 to 0.92). We revealed a strong correlation between data obtained from VH-IVUS evaluation with HR-MR and histological examination. Assessment of necrotic plaque components, however, had non-optimal results using VH-IVUS.

Electronic Posters was similar. Primary patency was not significantly different between the two groups (I: 68%, II: 79%, NS), but assisted primary (I: 73%, II: 89%, NS) and secondary patency (I: 71%, II: 89%, NS) tended to be greater in group II, because of fewer early thrombotic failures. Some 5-mm grafts were used in group I only and with these excluded, the patency differences were minimal, suggesting no benefit to heparin-bonding for grafts > 6 mm. Patencies in both groups were similar to those reported for above-knee ePTFE bypass. Conclusion: Heparin bonding does not improve patency in Viabahn-assisted subintimal recanalization (VASIR) compared to standard Viabahn stent-grafts, making it difficult to justify the added expense, but maintaining patency in a failing graft to allow timely salvage intervention may be an important benefit, particularly in smaller diameter grafts. Patient selection may be a more important predictor of success than heparin bonding.

Sealing antegrade femoral artery puncture sites with a novel bioabsorbable vascular closure device. An analysis of success rates, adverse events and patient satisfaction Purpose: Fast and sufficient vessel leakage sealing after antegrade inguinal arterial access for endovascular intervention is crucial to avoid access site complications and to increase patients' comfort. For a new entirely extravascularly deployed bioabsorbable plugbased vascular closing device (VCD) its feasibility, safety, and pain during implantation was examined. Material and Methods: 59 consecutive patients underwent a peripheral endovascular procedure (PEP) with an antegrade femoral puncture. 42 (73.7%) patients had at least one PEP with common manual compression (MC) in their medical history. The new VCD was used to seal the puncture sites in all cases despite severe calcification. A sonographic check-up of the puncture site was conducted after one day and puncture site bleedings were assessed. After at least one week, the patients were interviewed via telephone for the occurrence of hematomas, signs of infection and satisfaction with the procedure. The pain level was evaluated using visual analogue scales. Results: Use of the new VCD was technically successful in 98.3%. Adverse events occurred in 4 cases (6.8%), but none of them needed further surgical treatment. All patients had no (93.0%) or low (pain level ≤2; 7.0%) pain due to the use of the VCD. In the follow-up no signs of infection were observed at the puncture sites. All 42 patients who had at least one PEP with MC preferred the sealing via the new VCD.

The use of the tested new VCD was reliable and safe in sealing antegrade puncture sites. Also, the patient satisfaction was excellent.

Anastomotic line renal artery stenosis after transplantation

Renal artery stenosis after renal transplantation

Renal artery stenosis in renal transplantation

Renal allograft artery stenosis

Transplant renal artery stenosis

Use of spiral computed tomography in the diagnosis of transplant renal artery stenosis

Breathhold 3D gadolinium-enhanced subtraction MRA in the detection of transplant renal artery stenosis

Transplant renal artery stenosis

Risk factors and longterm outcome of transplant renal artery stenosis in adult recipients after treatment by percutaneous transluminal angioplasty

Renal artery stenosis in kidney transplantation

Incidence of renal artery stenosis in pediatric en bloc and adult single kidney transplants

Posttransplant renal artery stenosis: angiographic study in 32 children

Long-term clinical results of percutaneous transluminal angioplasty in transplant renal artery stenosis

Transplant renal artery stenosis in 77 patients-does it have an immunological cause?

CMV infection is associated with transplant renal artery stenosis

Is there an association between cytomegalovirus and renal artery stenosis in kidney transplant recipients? (abstr)

Peripheral vascular disease and renal transplant artery stenosis: a reappraisal of transplant renovascular disease

Protocol biopsy: what is the rationale and what is the evidence

Course and relevance of arteriovenous fistulas after renal transplant biopsies

Percutaneous renal biopsy

Asymptomatic large extracapsular renal pseudoaneurysm following kidney transplant biopsy

Surgical management of renal artery aneurysm

Biopsy related hemorrhage of renal allograft treated by percutaneous superselective renal artery embolization

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Superselective arterial embolisation with a liquid polyvinyl alcohol copolymer in patients with acute gastrointestinal haemorrhage

Embolization as treatment of choice for bleeding peptic ulcers in high-risk patients

Transcatheter embolization in management of hemorrhage from duodenal ulcer: long-term results and complications

Transcatheter arterial embolization of acute upper gastrointestinal tract bleeding with N-butyl-2-cyanoacrylate

Estimation of usefulness of N-butyl-2-cyanoacrylatelipiodol mixture in transcatheter arterial embolization for urgent control of life-threatening massive bleeding from gastric or duodenal ulcer

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Therapeutic decision-making in endoscopically unmanageable nonvariceal upper gastrointestinal hemorrhage

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Outcome of 'Kissing Stents' for aortoiliac atherosclerotic disease, including the effect on the non-diseased contralateral iliac limb

Aortic bifurcation reconstruction: use of the Memotherm selfexpanding nitinol stent for stenoses and occlusions

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Whistle while you work: an analysis of NHS foundation trust policies

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Endovascular repair of aortic aneurysm in patients physically ineligible for open repair

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Open Versus Endovascular Repair (OVER) Veterans Affairs Cooperative Study Group. Outcomes following endovascular vs open repair of abdominal aortic aneurysm: a randomized trial

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The long term results of the UK EVAR trials: the sting in the tail

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Direct medical costs of acute pancreatitis hospitalizations in the United States

The burden of gastrointestinal and liver diseases

Practice guidelines in acute pancreatitis

Timing and impact of infections in acute pancreatitis

Organ failure and infection of pancreatic necrosis as determinants of mortality in patients with acute pancreatitis

Acute pancreatitis

Management of acute pancreatitis: from surgery to interventional intensive care

Update on acute pancreatitis: ultrasound, computed tomography, and magnetic resonance imaging features

Computed tomography and magnetic resonance imaging in the assessment of acute pancreatitis

Nonenhanced magnetic resonance imaging of mild acute pancreatitis

Pancreatic fluid collections prior to intervention: evaluation with MR imaging compared with CT and US

A pancreatic ductal leak should be sought to direct treatment in patients with acute pancreatitis

A clinically based classification system for acute pancreatitis

Systematic review and meta-analysis of antibiotic prophylaxis in severe acute pancreatitis

A conservative and minimally approach to necrotizing pancreatitis improves outcome

Draining sterile fluid collections in acute pancreatitis? Primum non nocere! Surg Endosc

Endovascular Management of of vascular complications in pancreatic transplants

Multirow CT in the follow-up of pancreas transplantation

Evaluation of vascular complications of pancreas transplantation with high specialresolution contrast-enhanced MR angiography

Venous thrombosis and occlusion after pancreas transplantation: Evaluation with breath-hold gadolinium-enhanced three-dimensional MR imaging

Pancreas transplant outcomes for United States (US) and non-US cases as reported to the United Network for Organ Sharing (UNOS) and the International Pancreas Transplant Registry (IPTR) as of

Successful PTA and stenting for acute iliac arterial injury following pancreas transplantation

Treatment of external iliac artery dissection with endovascular stent placement in a patient with simultaneous pancreas and kidney transplantation

Embolization of a mesenteric arteriovenous fistula following pancreatic allograft: The steal effect

Percutaneous embolization of a high-flow pancreatic transplant arteriovenous fistula

Transarterial and transvenous embolotherapy of arteriovenous fistulas in the transplanted pancreas

Pseudoaneurysm of the superior mesenteric artery after pancreas transplantation treated by endovascular stenting

Successful endovascular treatment for gastroduodenal artery pseudoaneurysm with an arteriovenous fistula after pancreas transplantation

Lower gastrointestinal hemorrhage from an arterioenteric fistula in a pancreatorenal transplant patient

Endovascular management of acute enteric bleeding from pancreas transplant

Transcatheter thrombolysis of thrombosed hepatic arteries in liver transplant recipients: predictors of definitive endoluminal success and the role of preoperative thrombolysis

Management of Hepatic Artery Steno-Occlusive Complications After Liver Transplantation

Endovascular treatment of hepatic artery thrombosis following liver transplantation

Erectile dysfunction: a disease marker for cardiovascular disease

Physiology of Penile Erection and Pathophysiology of Erectile Dysfunction

Targeting vascular structure for the treatment of sexual dysfunction

Cardiovascular disease, metabolic syndrome and erectile dysfunction

Endothelial dysfunction and erectile dysfunction in the aging man

Microvascular arterial bypass surgery: long-term outcomes using validated instruments

Clinical management guidelines for obstetrician-gynecologists

Transcatheter arterial embolization for control of massive puerperal hemorrhage after bilateral surgical hypogastric artery ligation

Obstetric hemorrhage: prophylactic and emergency arterial catheterization and embolotherapy

Life threatening primary post-partum hemorrhage: treatment with emergency selective arterial embolisation

Percutaneous embolization in the management of intractable vaginal bleeding

Is selective embolization of uterine arteries a safe alternative to hysterectomy in patients with postpartum hemorrhage?

Management of life-threatening post-partum hemorrhage: indications and technique of arterial embolisation

Arterial priapism: diagnosis, treatment and long-term followup

Traumatic laceration of intracavernosal arteries: the pathophysiology of nonischemic, high flow priapism

Treatment of "high flow" priapism with superselective transcatheter embolization: a useful alternative to surgery

Treatment of high flow priapism with superselective catheter embolization in 27 patients: a multicenter study

Recurrent varices after surgery (REVAS), a consensus document

Embolization treatment of recurrent varices of pelvic origin

Varicose veins arising from the pelvis due to ovarian vein incompetence

The Pelvic Congestion Syndrome

Ovarian vein embolisation for the treatment of pelvic congestion syndrome: long-term technical and clinical results

Report: pelvic pain syndrome -treatment of a case by ovarian vein embolization

Pelvic congestion syndrome (pelvic venous incompetence): Impact of ovarian and internal iliac vein embolotherapy on menstrual cycle and chronic pelvic pain

Embolotherapy for pelvic congestion syndrome: Long term results

Pelvic venous incompetence: reflux patterns and treatment results

Pelvic vein reflux in female patients with varicose veins: comparison of incidence between a specialist private vein clinic and the vascular department of a National Health Service District General Hospital

Pelvic vein embolisation in the management of varicose veins

Uterus and bladder necrosis after uterine artery embolisation for postpartum haemorrhage

Hemorrhage in obstetrics and gynecology

Serious primary post-partum hemorrhage, arterial embolization and future fertility: a retrospective study of 46 cases

Fertility and pregnancy following pelvic arterialembolisation for postpartum haemorrhage

Evaluation and treatment of lower urinary tract symptoms in older men

Complications of Transurethral Resection of the Prostate (TURP)-Incidence, Management, and Prevention

High power diode laser vaporization of the prostate: preliminary results for benign prostatic hyperplasia

Benign prostatic hyperplasia: transcatheter arterial embolization as potential treatment -preliminary study in pigs

The effect of transarterial prostate embolization in hormone-induced benign prostatic hyperplasia in dogs:a pilot study

Treatment of Palpable Varicocele in Infertile Men: A Meta-analysis to Define the Best Technique

Percutaneous embolization of a left-sided varicocele in a patient with a duplicated inferior vena cava

Retrograde embolization and causes of failure in the primary treatment of varicocele

Male varicocele: transcatherer foam scelotheraphy with sodium tetradecyl sulfate-outcome in 244 patients

Evaluation and management of the persistent recurrent varicocoele

Selective Spermatic Venogrpahy and Variococele Embilization in Men with Circumaortic Left Renal Veins

Persistent or recurrent varicocoele after failed varicocoelectomy: Outcome in patients treated using percutaneous transcatheter embolization

Anatomic varants of the spermatic vein: importance for percutaneous sclerotherapy of idiopathic varicocele

Digital subtraction angiography-guided percutaneous transcatheter foam sclerotherapy of varicocele: A novel tracking technique

Comparison of recurrent varicocele anatomy following surgery and percutaneous balloon occlusion

Post-surgical recurrent varicocoele: efficacy of internal spermatic venography and steelcoil embolization

Presistent and recurrent postsurgical variococeles: venographic anatomy and treatment with N-butyl cyanoacrylate embilization

Congenital anomalies of the inferior vena cava and left renal vein: evaluation with spiral CT

Detailed anatomy of the internal spermatic vein and the ovarian vein. Human cadaver study and operative spermatic venography: clinical aspects

Difficulties in the treatment of symptomatic varicocele using percutaneous embolization: the circumaortic renal vein

Spectrum of congenital anomalies of the inferior vena cava: cross sectional imaging findings

References 1. AbouZahr C. Global burden of maternal death and disability

Clinical management guidelines for obstetrician-gynecologists

Transcatheter arterial embolization for control of massive puerperal hemorrhage after bilateral surgical hypogastric artery ligation

Obstetric hemorrhage: prophylactic and emergency arterial catheterization and embolotherapy

Life threatening primary post-partum hemorrhage: treatment with emergency selective arterial embolisation

Percutaneous embolization in the management of intractable vaginal bleeding

Is selective embolization of uterine arteries a safe alternative to hysterectomy in patients with postpartum hemorrhage?

Management of life-threatening post-partum hemorrhage: indications and technique of arterial embolisation

Uterus and bladder necrosis after uterine artery embolisation for postpartum haemorrhage

Hemorrhage in obstetrics and gynecology

Serious primary post-partum hemorrhage, arterial embolization and future fertility: a retrospective study of 46 cases

Fertility and pregnancy following pelvic arterialembolisation for postpartum haemorrhage

Intersociety consensus for the management of peripheral arterial disease (TASC II)

Angiographic Patency and Clinical Outcome After Balloon-Angioplasty for Extensive Infrapopliteal Arterial Disease

Vascular involvement in diabetic subjects with ischemic foot ulcer: a new morphologic categorization of disease severity

Long-term outcomes after angioplasty of isolated, belowthe-knee arteries in diabetic patients with critical limb ischemia

Subintimal angioplasty as the first-choice revascularization technique for infrainguinal arterial occlusions in patients with critical limb ischemia

Carotid stents: unleashed, unproven

Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis

30 day results from the SPACE trial of stentprotected angioplasty versus carotid endarterectomy in symptomatic patients: a randomized non-inferiority trial

International Carotid Stenting Study Investigators. Carotid artery stenting versus carotid endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): an interim analysis of a randomized controlled trial

New ischaemic brain lesions on MRI after stenting or endarterectomy for symptomatic carotid stenosis: a substudy of the International Carotid Stenting Study (ICSS)

Chiu D et al for the CREST Investigators. Safety of stenting and endarterectomy by symptomatic status in the carotid revascularization endarterectomy versus stenting trial (CREST)

Gaines PA on behalf of the CAVATAS Investigators. Long term risk of carotid restenosis in patients randomly assigned to endovascular treatment or endarterectomy in the Carotid and Vertebral Artery and Transluminal angioplasty Study (CAVATAS)

Stent Protected Angioplasty versus Carotid Endarterectomy for symptomatic stenosis: two year results of the SPACE Study

Filter-protected versus unprotected carotid artery stenting: a randomised trial

Transcervical carotid stenting with flow reversal is a safe technique for high-risk patients older than 70 years

Randomised controlled trials comparing endarterectomy and endovascular treatment for carotid artery stenosis: A Cochrane Review

A systematic review and meta-analysis of randomised trials of carotid endarterectomy vs stenting

Carotid artery stenting versus carotid endarterectomy: a comprehensive meta-analysis for short and ling-term outcomes

Short term and intermediate term comparison of endarterectomy versus stenting for carotid artery stenosis: systematic review and metaanalysis of randomised controlled trials

Carotid artery stenting vs carotid endarterectomy: meta-analysis and diversity-adjusted trial sequential analysis of randomised trials

Intra-arterial infusion of anticancer drugs: theoretic aspects of drug delivery and review of responses

Pharmacologic rationale for regional drug delivery

Clinical pharmacology of hepatic arterial chemotherapy

Pharmacokinetic advantage of intra-arterial hepatic oxaliplatin administration: comparative results with cisplatin using a rabbit VX2 tumor model

A phase I and pharmacokinetic study of gemcitabine given by 24-h hepatic arterial infusion

The blood supply of neoplasms in the liver

Loco-regional treatment of hepatocellular carcinoma

Panel of Experts in HCC-Design Clinical Trials. Design and endpoints of clinical trials in hepatocellular carcinoma

Management of hepatocellular carcinoma: an update

Clinical Practice Guidelines: Management of hepatocellular carcinoma. European Association for the Study of the Liver and the European Organization for Research and Treatment of Cancer

Loco-regional treatment of hepatocellular carcinoma

The effect of pelvic MR imaging on the diagnosis and treatment of women with presumed symptomatic uterine fibroids

Resolution of hydronephrosis after uterine artery embolization for fibroids

Uterine artery embolization for leiomyomata: factors associated with successful symptomatic and imaging outcome

Long-term Outcome of Uterine Artery Embolization of Leiomyomas

Uterine artery embolization for treatment of leiomyomata: long-term outcomes from the FIBROID Registry

Is a large fibroid a highrisk factor for uterine artery embolization?

Uterine artery embolization in patients with a large fibroid burden: long-term clinical and MR follow-up. Cardiovascular and interventional radiology

Patient care and uterine artery embolization for leiomyomata

Uterine artery embolization for pedunculated subserosal fibroids

Safety and effectiveness of uterine artery embolization in patients with pedunculated fibroids

Limited efficacy of uterine artery embolization for cervical leiomyomas

Long-term results of uterine artery embolization for symptomatic adenomyosis

Midterm clinical and first reproductive results of a randomized controlled trial comparing uterine fibroid embolization and myomectomy

Leiomyosarcoma in a series of hysterectomies performed for presumed uterine leiomyomas. American journal of obstetrics and gynecology

Smooth muscle tumors of uncertain malignant potential and leiomyosarcomas of the uterus: MR findings

Uterine-Artery Embolization versus Surgery for Symptomatic Uterine Fibroids

Uterine Artery Embolization in the Treatment of symptomatic Uterine Fibroids (EMMY Trial): Periprocedural Results and Complications

Uterine Fibroids: Uterine Artery Embolization versus Abdominal Hysterectomy for Treatment -a Prospective Randomized, and Controlled Clinical Trial

Midterm Clinical and First Reproductive Results of a Randomized Controlled Trial Comparing Uterine Fibroid Embolization and Myomectomy

Uterine Artery Embolization versus Myomectomy: Impact on Quality of Life-Results of the FUME (Fibroids of the Uterus: Myomectomy versus Embolization) Trial. Cardiovasc Intervent Radiol

Uterine artery embolization for symptomatic uterine fibroids

Uterine artery embolization versus surgery in the treatment of symptomatic fibroids: a systematic review and metaanalysis

Randomised comparison of uterine artery embolisation (UAE) with surgical treatment in patients with symptomatic uterine fibroids (REST trial): 5-year results

Uterine artery embolization vs hysterectomy in the treatment of symptomatic uterine fibroids: 5-year outcome from the randomized EMMY trial

Long-term results after balloon angioplasty of the crural artery

Critical Limb Ischemia: Endovascular Strategies for Limb Salvage

Meta-analysis of infrapopliteal angioplasty for chronic critical limb ischemia

The role of infrapopliteal angioplasty

S91 CIRSE 2012 SS/FC/HL/HTS/CM

Vascular complications associated with spontaneous aortic dissection

Fenestration revisited. A safe and effective procedure for descending aortic dissection

Percutaneous interventions for treating ischemic complications of aortic dissection

Outcomes of stent-graft treatment of false lumen in aortic dissection

Endovascular Stent-Graft Placement for the Treatment of Acute Aortic Dissection

Nonsurgical Reconstruction of Thoracic Aortic Dissection by Stent-Graft Placement

Endovascular Repair of Contained Rupture of the Thoracic Aorta

Expert Consensus Document on the Treatment of Descending Thoracic Aortic Disease Using Endovascular Stent-Grafts

True-lumen collapse in aortic dissection. Part II. Evaluation of treatment methods in phantoms with pulsatile flow

Randomized Comparison of Strategies for Type B Aortic Dissection: The Investigation of STEnt Grafts in Aortic Dissection (INSTEAD)

Provisional Extension to Induce Complete Attachment After Stent-Graft Placement in Type B Aortic Dissection: The PETTICOAT Concept

Prospective multicenter clinical trial (STABLE) on the endovascular treatment of complicated type B aortic dissection using a composite device design

Volume changes in aortic true and false lumen after the "PETTICOAT" procedure for type B aortic dissection

Combined Proximal Endografting With Distal Bare-Metal Stenting for Management of Aortic Dissection

Treatment of Stanford Type B aortic dissection with stent-grafts: preliminary results

Treatment of acute aortic type B dissection with stent grafts

Update on outcomes of acute Type B aortic dissection

A prospective study of medically treated acute type B aortic dissection

Growth rate of aortic diameter in patients with type B Aortic Dissection during the chronic phase

Long-term predictors of descending aorta aneurysmal change in patients with aortic dissection

Comparison of endovascular aneurysm repair with open repair in patients with abdominal aortic aneurysm (EVAR trial 1), 30-day operative mortality results: randomised controlled trial

A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms

Fenestrated Stent Grafting for Short-necked and Juxtarenal Abdominal Aortic Aneurysm: An 8-year Single-centre Experience

Fenestrated Endovascular Grafting: The French Multicenter Experience

Mid-term results of endovascular aneurysm repair with branched and fenestrated endografts

Endovascular repair of thoracoabdominal aneurysms

Present and future of branched stent grafts in thoraco-abdominal aortic aneurysm repair: a single-centre experience

Endovascular repair of thoracoabdominal aortic aneurysms

Endografting of the aortic arch

Hybrid repair of thoracic aortic lesions for zone 0 and 1 in high-risk patients

Endovascular Repair of the Aortic Arch

Endoluminal Repair of a Thoracic Arch Aneurysm using a Scallop-Edged Stent-Graft

Emergency debranching and stent grafting for complex aortic arch injury

The Aortic Arch and Ascending Aorta: Are They Within the Endovascular Realm?

Results with a selective revascularization strategy for left subclavian artery coverage during thoracic endovascular aortic repair

Open arch reconstruction in the endovascular era: Analysis of 721 patients over 17 years

Endovascular stent-graft treatment for Stanford type A aortic dissection

Use of chimney grafts in aortic arch pathologies involving the supra-aortic branches

Global cancer statistics

Associazione Italiana Registri Tumorali

Harrison's principles of internal medicine

Estimates of the cancer incidence and mortality in Europe in

United States Cancer Statistics: 1999-2007 Incidence and Mortality Web-based Report

Polmone. In: Sabiston DCJ. Trattatto di Chirurgia. Le basi biologiche della moderna pratica chirurgia

Race and sex differences in the receipt of timely and appropriate lung cancer treatment

The quality of life after chemotherapy in advanced non-small cell lung cancer patients

Radiofrequency ablation of lung tumors

Caring for the dying patient with lung cancer

Ten-year survey of lung cancer treatment and survival in hospitals in the United States: a national cancer data base report

Randomized trials of radiotherapy in stage IIIa and IIIb non small cell lung cancer: a meta-analysis

Percutaneous radiofrequency thermal ablation in the management of lung tumours: presentation of clinical experience on a series of 35 patients

Clinical applications of radio-frequency tumor ablation in the thorax

Image-guided radiofrequency tumour ablation: challenges and opportunities -part I

Percutaneous treatment of low flow vascular malformations

Serum ethanol levels in children and adults after ethanol embolization or sclerotherapy for vascular anomalies

Reversible cardiac arrest after polidocanol sclerotherapy of peripheral venous malformation

Preliminary experience with a new sclerosing foam in the treatment of varicose veins

Extremity venous malformations diagnosis and management

Sclerotherapy of craniofacial venous malformations: complications and results

Color duplex-guided sclerotherapy for the treatment of venous malformations

Polidocanol sclerotherapy for painful venous malformations: evaluation of safety and efficacy in pain relief

Craniofacial cavernous venous malformations: percutaneous sclerotherapy with use of ethanolamine oleate

Treatment of venous malformations with sclerosant in microfoam form

Advanced management of venous malformation with ethanol sclerotherapy: mid-term results

Predictors of response to percutaneous ethanol sclerotherapy (PES) in patients with venous malformations: analysis of patient self-assessment and imaging

Venous vascular malformations in pediatric patients: comparison of results of alcohol sclerotherapy with proposed MR imaging classification

The resuscitation and stabilization of major multiple trauma patients in a trauma center environment

Time factors associated with CT scan usage in trauma patients

New Aspects in the emergency room management of critically injured patients: A multi-slice CT-oriented care algorithm

Emergency Room Management of Patients With Blunt Major Trauma: Evaluation of the Multislice Computed Tomography Protocol Exemplified by an Urban Trauma Center. The Journal of Trauma Injury infection and Critical care

Improving CT scan capabilities with a new trauma workflow concept: Simulation of hospital logistics using different CT scanner scenarios

Selective use of Computed Tomography Compared With Routine Whole Body Imaging in Patients with Blunt Trauma

Is the use of pan-computed tomography for blunt trauma justified? A prospective evaluation

Relative Threshold of Detection of active Arterial Bleeding

Multidetector CT. Detection of Active Hemorrhage in Patients with Blunt Abdominal Trauma

Imaging of chest trauma: Radiological patterns of injury and diagnostic algorithms

Imaging Evaluation of Penetrating Neck Injuries

Arteriography in the management of hemorrhage from pelvic fractures

Eastern Association for the Surgery of Trauma practice management guidelines for hemorrhage in pelvic fracture-update and systematic review

Quality Improvement Guidelines for Endovascular Treatment of Traumatic Hemorrhage

Predictors of mortality following severe pelvic ring fracture: results of a population-based study

The effect of pelvic fracture on mortality after trauma: an analysis of 63,000 trauma patients

Predictors for the selection of patients for abdominal CT after blunt trauma: a proposal for a diagnostic algorithm

CT of blunt abdominal and pelvic vascular injury

Evaluation and Management of the Trauma Patient for the Interventional Radiologist

Drug-eluting and bare mitinol stents for treatment of atherosclerotic lesions in the superficial femoral artery: long-term results from the SIROCCO trial

First clinical trial of nitinol self-expanding everolimus-eluting stent implantation for peripheral arterial occlusive disease

Paclitaxel inhibits arterial smooth muscle cell proliferation and migration in bitro and in vivo using local drug delivery

Polymer-free paclitaxel-coated Zilver PTX stents-evaluation of pharmacokinetics and comparative safety in porcine arteries

Paclitaxel-eluting stents show superiority to balloon angioplasty and bare metal stents in femoropopliteal disease: 12-month Zilver PTX randomized study results

Nitinol stents with polymer-free paclitaxel coating for lesions in the superficial femoral artery above the knee: 12-month safety and effectiveness results from the Zilver PTX single arm clinical study

Outback catheter for femoropopliteal occlusions: immediate and longterm results

Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II)

Limitations of percutaneous transluminal angioplasty and stenting for the treatment of disease of the superficial femoral and popliteal arteries

Pathobiology of restenosis after angioplasty

Balloon angioplasty versus implantation of nitinol stents in the superficial femoral artery

Simpson catheter for percutaneous transluminal removal of atheroma

Transluminal atherectomy for occlusive peripheral vascular disease

Percutaneous peripheral atherectomy: angiographic and clinical follow-up of 60 patients

Transluminal atherectomy for occlusive peripheral vascular disease

Peripheral directional atherectomy: 4-year experience

Directional atherectomy versus balloon angioplasty in segmental gemoropopliteal artery disease: Twoyear follow-up with color-flow duplex scanning

New reperfusion devices: the Kensey catheter, the atherolytic reperfusion wire device, and the transluminal extraction catheter

Infrainguinal atherectomy using the transluminal endarterectomy catheter: patency rates and clinical success for 144 procedures

Current status of atherectomy for peripheral arterial occlusive disease

The collaborative rotablator atherectomy group. Peripheral atherectomy with the rotablator: a multicentre report

Percutaneous peripheral atherectomy of femoropopliteal stenoses using a new-generation device: six-month results from a single-centre experience

Long-term results after directional atherectomy of femoro-popliteal lesions

Initial clinical experience with percutaneous atherectomy in the infragenicular arteries

Midterm results after atherectomy-assisted angioplasty of below-knee arteries with use of the Silverhawk device

Two-year results after directional atherectomy of infrapopliteal arteries with the SilverHawk device

Midterm outcomes from the TALON registry: Treating Peripherals with SilverHawk Outcomes Collection

Novel treatment of patients with lower extremity ischemia: use of percutaneous atherectomy in 579 lesions

Plaque excision with the Silverhawk catheter: Early results in patients with claudication or critical limb ischemia

Incidence and clinical significance of distal embolization during percutaneous interventions involving the superficial femoral artery

Midterm patency following atherectomy for infrainguinal occlusive disease: a word of caution

Distal embolic protection during femoropopliteal atherectomy

Becker Young Investigator Award: Intraarterial Adenovirus for Metastatic Gastrointestinal Cancer: Activity, Radiographic Response, and Survival

Clinical Trial Results with Oncolytic Virotherapy: A Century of Promise, A Decade of Progress

References 1. Viducich RA, Blanda MP, Gerson LW. Posterior epistaxis: clinical features and acute complications

Endovascular treatment of epistaxis

Effect of internal maxillary arterial occlusion on nasal blood flow in swine

Therapeutic percutaneous embolization in intractable epistaxis

Angiographic embolization for the treatment of epistaxis: a review of 108 cases

Angiographic embolization for epistaxis: a review of 114 cases

Superselective embolisation for intractable idiopathic epistaxis

Arterial embolization in the management of posterior epistaxis

Selective embolization in the treatment of intractable epistaxis

Assessment of safety and efficacy of arterial embolisation in the management of intractable epistaxis

Superselective angiographic embolization for intractable epistaxis

Idiopathic intractable epistaxis: endovascular therapy

Anastomoses in recurrent epistaxis

Endovascular treatment of epistaxis: indications, management, and outcome

Endovascular treatment of epistaxis: indications, management, and outcome

Absorbable metal stent implantation for treatment below the knee critical limb ischemia: 6-month analysis

Angioplasty or primary stenting for infrapopliteal lesions: results of a prospective randomized trial

Below knee bare nitinol stent placement in highrisk patients with critical limb ischemia is still durable after 24 months of follow-up

Infrapopliteal percutaneous transluminal angioplasty versus bypass surgery as first-line strategies in critical leg ischemia. A propensity score analysis

Meta-analysis of infrapopliteal angioplasty for chronic critical ischemia

Inhibition of Restenosis in Femoropopliteal Arteries: Paclitaxel-Coated Versus Uncoated Ballon: Femoral Paclitaxel Randomized Pilot Trial

Local Delivery of Paclitaxel to Inhibit Restenosis during Angioplasty of the Leg

Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial: Analysis of amputation free and overall survival by treatment received

The Pacifier Trial. A Randomized Multicenter Trial Evaluating Prevention of Restenosis with Paclitaxel-Coated PTA Balloon Catheters in Stenosis or Occlusion of Femoropopliteal Arteries: First Report

Human studies of angiogenic gene therapy

Therapeutic angiogenesis for cardiovascular disease: biological context, challenges, prospects

Gene therapy in the treatment of peripheral vascular disease

An update on therapeutic angiogenesis for peripheral vascular disease

Meta-analysis of randomized, controlled clinical trials in angiogenesis: gene and cell therapy in peripheral arterial disease

Gene and stem cell therapy in peripheral arterial occlusive disease

A comparison of thrombolytic therapy with operative revascularization in the initial treatment of acute peripheral ischaemia

Results of a prospective randomized trial evaluating surgery versus thrombolysis for ischemia of the lower extremity: the STILE trial

Thrombolysis or peripheral arterial surgery: phase I results. TOPAS Investigators

A comparison of recombinant urokinase with vascular surgery as initial treatment for acute arterial occlusion of the legs. Thrombolysis or Peripheral Arterial Surgery (TOPAS) Investigators

Assessment of peripheral intraarterial thrombolysis versus surgical revascularization in acute lowerlimb ischemia: a review of limb-salvage and mortality statistics

Recommendations for radioembolization of hepatic malignancies using yttrium-90 microsphere brachytherapy: a consensus panel report from the Radioembolization Brachytherapy Oncology Consortium

Design and endpoints of clinical trials in hepatocellular carcinoma

Current strategy for staging and treatment: the BCLC update and future prospects

Management of hepatocellular carcinoma: an update

National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology. Hepatobiliary guidelines

Hepatocellular carcinoma: ESMO clinical recommendations for diagnosis, treatment and follow-up

Transarterial therapies for hepatocellular carcinoma

Radioembolization using 90Y-resin microspheres for patients with advanced hepatocellular carcinoma

Yttrium-90 microspheres for the treatment of hepatocellular carcinoma

Short-term follow-up of radioembolization with yttrium-90 microspheres before liver transplantation: new perspectives in advanced hepatocellular carcinoma

Radioembolization using 90Y resin microspheres in patients with hepatocellular carcinoma and portal vein thrombosis

Safety and efficacy of 90Y radiotherapy for hepatocellular carcinoma with and without portal vein thrombosis

A comparative analysis of transarterial downstaging for hepatocellular carcinoma: chemoembolization versus radioembolization

Therapeutic equivalence in survival for hepatic arterial chemoembolization and yttrium 90 microsphere treatments in unresectable hepatocellular carcinoma: a two-cohort study

Radioembolization for hepatocellular carcinoma using Yttrium-90 microspheres: a comprehensive report of long-term outcomes

Bioresorbable stents: the next revolution

Biodegradable stents -where are we in 2009

Endothelial progenitor cell capture stents: will this technology find its niche in contemporary practice?

Coronary bioabsorbable magnesium stent: 15-month intravascular ultrasound and optical coherence tomography findings

Anti-angiogenic drugs and resorbable microspheres: what is the promise? Abstract book CIRSE 2011 Munich

Development and Preliminary Testing of a Translational Model of Hepatocellular Carcinoma for MR Imaging and Interventional Oncologic Investigations

Portal-mesenteric venous thrombosis. In Image-guided interventions

Imaging and radiological interventions of portal vein thrombosis

Transcatheter thrombolytic therapy for acute mesenteric and portal vein thrombosis

Treatment options for hepatobiliary and pancreatic cancer

Chemoembolization of intrahepatic cholangiocarcinoma with cisplatinum, doxorubicin, mitomycin-C, ethiodol, and polyvinyl alcohol: A 2-center study

Treatment of unresectable cholangiocarcinoma with gemcitabine-based transcathether arterial chemoembolization (TACE): a single-institution experience

Transcatheter arterial chemoembolization or chemoinfusion for unresectable intrahepatic cholangiocarcinoma: clinical efficacy and factors influencing outcomes

Initial experience from a combination of systemic and regional chemotherapy in the treatment of patients with nonresectable cholangiocellular carcinoma of the liver

Transarterial chemoembolization (TACE) for inoperable intrahepatic cholangiocarcinoma

Chemoembolization (TACE) of unresectable intrahepatic cholangiocarcinoma with slow-release doxorubicin-eluting beads: preliminary results

Transcatheter arterial chemoembolization in unresectable cholangiocarcinoma: initial experience in a single institution

Treatment of unresectable cholangiocarcinoma using yttrium-90 microspheres: results from a pilot study

Yttrium-90 radiotherapy for unresectable intrahepatic cholangiocarcinoma: a preliminary assessment of this novel treatment option

Locoregional intra-arterial therapies for unresectable intrahepatic cholangiocarcinoma

Long-term results of balloonoccluded retrograde transvenous obliteration for the treatment of gastric varices and hepatic encephalopathy

Interventional Radiologic Treatment for Idiopathic Portal Hypertension

Downgrading" of gastric varices with multiple collateral veins in balloon-occluded retrograde transvenous obliteration

Balloonoccluded retrograde transvenous obliteration for portal hypertension, Radiation Medicine

Outflow patterns of gastrointestinal shunts and collateral veins from gastric varices: Radiologic variations and relevance to balloon-occluded retrograde transvenous obliteration, CVIR

Current surgical treatment for bile duct cancer

Varying appearances of cholangiocarcinoma: radiologic-pathologic correlation

Plastic or metal stents for malignant stricture of the common bile duct? Results of a randomized prospective study

Unresectable hilar cholangiocarcinoma: multimodality approach with percutaneous treatment associated with radiotherapy and chemotherapy

Malignant biliary duct obstruction: long-term experience with Gianturco stents and combined-modality radiation therapy

Brachytherapy and percutaneous stenting in the treatment of cholangiocarcinoma: a prospective randomised study

Phase II study of systemic gemcitabine chemotherapy for advanced unresectable hepatobiliary carcinomas

Recurrent benign biliary strictures: management with selfexpanding metallic stents

Malignant biliary obstruction: histologic findings after treatment with self-expandable stents

New ePTFE/FEP-covered stent in the palliative treatment of malignant biliary obstruction

Radiologic spectrum of cholangiocarcinoma: Emphasis on unusual manifestations and differential diagnoses

Therapy for biliary stenoses and occlusions with use of three different metallic stents: single-center experience

Metallic stents in malignant biliary obstruction: prospective long-term clinical results

Common bile duct obstruction due to malignancy: treatment with plastic versus metal stents

Metallic stents in malignant biliary obstruction: results of multicenter European study of 240 patients

Percutaneous transhepatic placement of biliary endoprostheses: results in 100 consecutive patients

Treatment of malignant biliary obstruction with polyurethane covered Wallstents

New ePTFE/FEP-covered stent in the palliative treatment of malignant biliary obstruction

Malignant biliary obstruction: treatment with ePTFE / FEP-covered endoprotheses-initial technical and clinical experience in a multicenter trial

ePTFE/FEP-covered metallic stents for palliation of malignant biliary disease: can tumor ingrowth be prevented?

Management of malignant biliary obstruction: Technical and clinical results using an expanded polytetrafluoroethylene fluorinated ethylene propylene (ePTFE/FEP)-covered metallic stent after 6-year experience

Malignant biliary obstruction: clinical and histopathologic correlation after treatment with self-expanding metal prostheses

Malignant biliary duct obstruction: long-term experience with Gianturco stents and combinedmodality radiation therapy

Thermal Ablation in Biological Tissue Using Tubular Electrode

Effects of the Geometry of a Tubular Electrode on the Temperature Distribution in Biological Tissue

A Tubular Electrode for Radiofrequency Ablation Therapy

Finite Element Modeling of Cholangiocarcinoma Radiofrequency Ablation

Heat Transfer to Blood Vessels (abstract)

Creation of large thermal lesions in liver using saline-enhanced RF ablation

Dielectric Properties of Tissues

New insights on cholangiocarcinoma

Cholangiocarcinoma: Update and future perspectives

Radiofrequency tumor ablation: principles and techniques

Hepatic bipolar radio-frequency ablation between separated multiprong electrodes

Hepatic radiofrequency ablation with internally cooled probes: effect of coolant temperature on lesion size

Natural history of hepatocellular carcinoma and prognosis in relation to treatment: study of 850 patients

Minimally invasive treatment of malignant hepatic tumors: at the threshold of a major breakthrough

Minimally invasive image-guided therapies for hepatocellular carcinoma

Magnetic resonance imaging features of focal liver lesions after intervention

Hepatocellular carcinoma: diagnosis and treatment

Assessment of tumor response on MR imaging after locoregional therapy

New guidelines to evaluate the response to treatment in solid tumors. European Organization for Research and Treatment of Cancer, National Cancer Institute of the United States, National Cancer Institute of Canada

Hepatocellular carcinoma: evaluation of therapeutic response to interventional procedures

Comparison of CT findings with resected specimens after chemoembolization with iodized oil for hepatocellular carcinoma

Clinical management of hepatocellular carcinoma. Conclusions of the Barcelona-2000 EASL conference. European Association for the Study of the Liver

Pre-, peri-, and posttreatment imaging of liver lesions

Image-guided tumor ablation: proposal for standardization of terms and reporting criteria

Local-Regional Treatment of Hepatocellular Carcinoma

Small hepatocellular carcinoma in cirrhosis: randomized comparison of radio-frequency thermal ablation versus percutaneous ethanol injection

Imaging appearances following thermal ablation

Post-treatment imaging of liver tumours. Cancer Imaging

Assessment of the therapeutic response of hepatocellular carcinoma treated with transcatheter arterial chemoembolization: comparison of contrast-enhanced sonography and 3-phase computed tomography

Evaluation of tumor response after locoregional therapies in hepatocellular carcinoma: are response evaluation criteria in solid tumors reliable? Cancer

Imaging features of hepatocellular carcinoma after transcatheter arterial chemoembolization and radiofrequency ablation

Imaging response in the primary index lesion and clinical outcomes following transarterial locoregional therapy for hepatocellular carcinoma

Alpha-fetoprotein response after locoregional therapy for hepatocellular carcinoma: oncologic marker of radiologic response, progression, and survival

Peri-intraprocedural imaging: US, CT, and MRI

Computed tomography perfusion in evaluating the therapeutic effect of transarterial chemoembolization for hepatocellular carcinoma

Radiologic findings following Y90 radioembolization for primary liver malignancies

Assessment of tumor response on MR imaging after locoregional therapy

Functional MR imaging as a new paradigm for image guidance

Tumor response after yttrium-90 radioembolization for hepatocellular carcinoma: comparison of diffusionweighted functional MR imaging with anatomic MR imaging

Role of diffusion-weighted imaging in evaluating therapeutic efficacy after transcatheter arterial chemoembolization for hepatocellular carcinoma

Diffusion-weighted MR imaging for determination of hepatocellular carcinoma response to yttrium-90 radioembolization

Functional MRI evaluation of tumor response in patients with neuroendocrine hepatic metastasis treated with transcatheter arterial chemoembolization

Hepatocellular carcinoma: assessment of response to transarterial chemoembolization with image subtraction

Modified RECIST (mRECIST) assessment for hepatocellular carcinoma

Which response criteria best help predict survival of patients with hepatocellular carcinoma following chemoembolization? A validation study of old and new models

Motion Tracking for Minimally Invasive Robotic Surgery

Robotically assisted aortofemoral bypass grafting: lessons learned from our initial experience

DLR MiroSurge -A Versatile System for Research in Endoscopic Telesurgery

The sigma.7 haptic interface for MiroSurge: A new bi-manual surgical console

Assessment of Pedicle Screw Placement Accuracy, Procedure Time, and Radiation Exposure Using a Miniature Robotic Guidance System

Robotically assisted interventions: clinical trial for spinal blocks

Robotically assisted lung biopsy under CT fluoroscopy: lung cancer screening and phantom study

Development of a robotic FD-CT-guided navigation system for needle placement-preliminary accuracy tests

MRI-guided procedures in various regions of the body using a robotic assistance system in a closed-bore scanner: preliminary clinical experience and limitations

Pneumatic actuated robotic assistant system for aortic valve replacement under MRI guidance

Clinical applications of robotic technology in vascular and endovascular surgery

Atrial fibrillation ablation using a robotic catheter remote control system: initial human experience and long-term follow-up results

The role of robotic endovascular catheters in fenestrated stent grafting

Robotassisted antegrade in-situ fenestrated stent grafting

Roboticallysteerable catheters and their role in the visceral aortic segment

Fusion of Intraoperative Three-Dimensional Rotational Angiography and Flat-Panel Detector Computed Tomography for Cerebrovascular Neuronavigation

Technologies for guidance of radiofrequency ablation in the multimodality interventional suite of the future

Virtual sonographic radiofrequency ablation of hepatocellular carcinoma visualized on CT but not on conventional sonography

Electromagnetic navigation system for CT-guided biopsy of small lesions

Targeting liver lesions for radiofrequency ablation: an experimental feasibility study using a CT-US fusion imaging system

Clinical utility of realtime fusion guidance for biopsy and ablation

Microwave ablation assisted by a real-time virtual navigation system for hepatocellular carcinoma undetectable by conventional ultrasonography

Clinical evaluation of spatial accuracy of a fusion imaging technique combining previously acquired computed tomography and real-time ultrasound for imaging of liver metastases

Biliary and reticuloendothelial impairment in hepaatocarcinogenesis: the diagnostic role of tissue specific MR contrast media

Management of Hepatocellular Carcinoma: An Update

Characterization of Cirrhotic Nodules with Gadoxetic Acid Enhanced magnetic Resonance Imaging: The Efficacy of Hepatocyte Phase

Popliteal artery entrapment syndrome

Popliteal vascular entrapment: its increasing interest

Colour Doppler USG imaging in the diagnosis of popliteal artery entrapment syndrome

Diagnosis of popliteal artery entrapment syndrome: the role of duplex scanning

MR imaging and MR angiography in popliteal entrapment syndrome

Between a rock and a hard place: clinical and imaging features of vascular compression syndromes

Evaluation of MR angiographic technique in the assessment of thoracic outlet syndrome

In 88 patients (73.9%) there was PV reduction after PAE (group A; mean follow-up 7 months), while in the remaining 31 patients (26.1%) PV did not reduce after PAE (group B

Results: Mean baseline parameters (age/prostate volume/PSA/IPSS/ QoL/Qmax/post-void residual volume-PVR) group A: 66 years/88 mL/6.5 ng/mL/24/4.2/8.9 mL/s/110.2 mL

Conclusion: PV did not reduce after PAE in 26% of patients and was more likely to occur after unilateral PAE. PVR improved more in patients with PV reduction and poor clinical outcome was more frequent in patients without PV reduction. Disclosure: Cook Medical stenosis, before the surgical/endovascular procedure, 24-h after and at 1-month follow-up. After treatment, evaluation was done at five standard levels (CCA, proximal stent, mid stent, distal stent, ICA)

At 1 month follow-up CCA PSV post-CAS and CCA PSV post-TEA were 60

Results: 79 (7.4%, n=79/1066) transplants underwent 89 PCN procedures. 67 (75%, n=67/89) underwent nephroureteral stent (NUS) placement and 12 (25%, n=12/89) were simple PCN. Procedurerelated complications in early vs

0% (n=2/66) p>0.05. Catheter-related complications in early PCN vs. late PCN were 13%, (n=3/23) and 11% (n=7/66) p>0.05. GS at 12, 36, and 48 months after PCN placement for early PCN vs. late PCN was 86% ±7, 81 ±8, and 81 ±10 vs. 93% ±3, 75 ±8, and 66 ±9

Early PCN does not pose additional risk to the graft; however, it is a poor prognostic indicator for long-term graft survival. Disclosure: W. Saad is a grant recipient from Siemens, and consultant to Siemens, Boston Scientific, Meditech. He is also a paid speaker for Atrium

P-105, P-106

1409.6, 3103.2, P-156

P-191, P-255, P-257

1403.6, 1409.2, P-145, P-349

P-191, P-192, P-255, P-257

1803.1, P-46, P-77, P-94, P-183, P-189, P-245

1408.2, 1408.5, 1409.1, P-292, P-293, P-295

Du Mesnil de Rochemont

3007.3, 3008.6, P-66

1803.1, P-94, P-245

1403.6, 1409.2, P-145, P-349

P-74, P-93, P-114, P-368

3202.3, P-25, P-35, P-236, P-237

103.1, P-118

L. 1803.1, P-46, P-94

A. 1403.6, 1409.2, P-145, P-349

P-74, P-114, P-172

2504.1, P-271

P-1, P-72, P-92, P-261, P-284

P-105, P-106

sion [12,13]. In addition, the amount of brain tissue that has already undergone irreversible damage might be a critical factor in deciding to proceed on with intra-arterial thrombolysis [14]. This report presents 2 patients with tracheo-innominate artery fistula who were successfully treated by an endovascular procedure using stent-grafts. Patients were a 30-year-old man treated with the transfemoral approach and a 69-year-old man treated via the right common carotid artery.

C RSE CIRSE Abstract Book

J.J. Gemmete 1 , M. Gao 2 Purpose: To compare the effectiveness of the percutaneous injection of Onyx with traditional particulate embolic agents in reducing estimated blood loss (EBL) and the number of packed red blood cells (PRBCs) used intraoperatively during surgical resection of a JNA. Material and Methods: 46 consecutive resections since 1995 for which preoperative embolization was either particulate (n=39) or Onyx (n=7), and for which age at operation, date of operation, length of hospital stay, Fisch grade of tumor, resection approach, EBL during resection, and fluids during resection were available.

The mean EBL for the Onyx group was 658.6±858.7 mL and for the particulate group 1348.6±932.2 mL (one-tailed student's t-test p=0.043). The mean units of PRBCs used in the Onyx group was 0.29±0.76 units (p=0.003) and for the particulate cohort 1.56±2.01 units. The relationship between embolization type, EBL and embolization type, PRBCs remained significant in the subset of patients with Fisch grade=III (Onyx n=4, particulate n=18, EBL p=0.001 and PBRCs p=0.045), and other Fisch categories did not have enough patients for statistical analysis. The relationship between embolization type and EBL remained significant after correcting for age at operation (p=0.033). The proportion of resections for which an endoscopic approach was used was significantly higher in the Onyx group than in the particulate group (71.4% and 20.5%; p=0.009), and this was also significant in the subset of patients with Fisch grade=III (p=0.040). Conclusion: Percutaneous injection of Onyx prior to surgical resection of a JNA reduces intraoperative EBL and the number of PBRC units used intraoperatively when compared with particulate material. Disclosure: J.J. Gemmete is a paid consultant for Covidian the maker of Onyx.

Clinical outcome after prostatic artery embolization: unilateral versus bilateral embolization T. Bilhim 1 (Group B) . Pain was measured (0 -10) during PAE, after 4-8 hours and the week following PAE. Complication rates were compared. The outcome of PAE was evaluated by IPSS, QoL and IIEF measurements, prostate volume reduction, PSA, Qmax and PVR measurements at 3 and 6 months. Results: Patients lost to follow-up: 3 (Group A); 5 (Group B). Mean PVA volume used: 0.33cc in Group A; 0.4cc in Group B. Mean pain scores during embolization: 3.2 (group A); 2.9 (group B); after embolization, mean pain scores: 0.1 (group A) and 0 (group B). There were no statistically significant differences in the minor complication rates, with no major complications. Mean IPSS/QoL reduction: 8.9/1.9 (Group A); 10.4/2.1 (Group B); mean prostate volume reduction: 19% (Group A); 18% (Group B). Poor clinical outcome: 18.9% (Group A); 8.6% (Group B). Conclusion: No significant differences were noted in pain severity or complication rates after PAE for BPH using 100 μm or 200 μm PVA particles. The clinical outcome at 3 and 6 months seems to be slightly better with 200 μm PVA particles. Disclosure: Cook Medical S175

Free Papers Free Paper Session EVAR, TEVAR and aortic intervention 2203.1 CO2 digital subtraction angiography to reduce the incidence of contrast-related nephropathy associated with complex endovascular aortic aneurysm repair E.W. Johnston, L.M. Morgan-Rowe, D. Simring, J. Hague, J. Raja, J. Cross, O. Agu, T. Richards, P. Harris, K. Ivancev; University College Hospital, Multidisciplinary Endovascular Team, London, United Kingdom.Purpose: Fenestrated and branched EVAR procedures involve multiple DSA runs and are associated with a significant incidence of contrast-induced nephropathy. We describe the use of CO2 as the primary contrast agent in patients undergoing complex EVAR. The aim of this study is to determine whether this policy is effective in reducing the incidence of post-operative renal dysfunction. Material and Methods: Two consecutive cohorts of patients undergoing fenestrated and branched EVAR were compared. 41 procedures were completed with iodinated contrast media (group 1) and 27 utilised CO2 as the primary contrast agent (group 2). Endpoint assessed was renal impairment, defined as an increase in creatinine of >25%. Purpose: Identification of CT parameters as predictors for the development of type II endoleak (EL) after endoluminal stent-graft repair (ESGR). Material and Methods: 130 patients with abdominal aortic aneurysms (AAA) were treated with ESGR between 2004 and 2011. After reviewing postoperative CT angiographies, patients were stratified into non-endoleak (NELG, n=80) and endoleak groups (ELG, n=50).

The following parameters were evaluated by preoperative CT angiography: diameter and area of the perfused lumen in AAA, maximal thickness of the thrombus, number and diameter of perfused lumbar arteries (LA) and the inferior mesenteric artery (IMA). Statistical analysis comprised a complex analysis, whereas a p-value <0.05 was considered statistically significant. Results: There were no differences in diameter (ELG 43.4±12.7 mm; NELG 40.0±10.4 mm, p=0 .524), area of the perfused lumen of the AAA (ELG 14.1±9.9 cm²; NELG 11.1±7.0 cm², p=0.405), and maximal thickness of the thrombus (ELG 14.6±11.3 mm; NELG 18.3±13.1 mm, p=0.589) . In contrast, the number (ELG 3.8±1.4; NELG 2.8±1. 6, p=0 .004) and diameter (ELG 2.4±0.4 mm, 2.1±0.4 mm NELG p=0 .008) of the LA within the AAA were associated with the development of an EL. The involvement of AMI in the AAA (92.0% ELG; NELG 71.3%) and diameter of the AMI (ELG 3.8±0.9 mm; NELG 3.3±0.7 mm) were significant in the univariate (p=0.005; p=0.004), but not in the multivariate analysis (p=0.609; p=0.264).

The diameter and number of perfused LA within the AAA were the most important predictive factors in the development of EL, whereas involvement and diameter of the AMI did not play an important role in the multivariate analysis.

The ADSORB trial: acute dissection treatment with stent graft or best medical therapy Purpose: The Penumbra Coil 400TM (PC 400) is a new generation of inherently softer platinum embolic coils with a larger diameter than conventional coils. This system is expected to use fewer coils, reduce embolization procedure time, and achieve higher packing density. The goal of this study was to evaluate its performance in small to large aneurysms, and when appropriate, with adjunct devices including flow diverters.

This was a retrospective case-review of consecutive cases treated by the PC400 since September 2010 in Europe. Follow-ups were performed in accordance with each center's standard procedures.Results: Forty-one aneurysms were treated in 39 patients at 16 centers, including 6 ruptured and 35 unruptured aneurysms. Aneurysms were predominantly located in the ICA (65%) and MCA/ACA (24%). Approximately 50% of cases were treated using adjunct devices; stents, balloons or flow diverters. Mean size was 13.5mm. An average of 4.6 coils was used per aneurysm to 32.6% packing density. No peri-procedural rupture or thromboembolic complications occurred. Conclusion: These data show treatment with the PC 400 can result in favorable occlusion rates with high packing densities, a substantial reduction in number of coils and procedure time compared with conventional coils, and an acceptable safety profile. Due to coil softness, clinical practice in some centers has evolved from using conventional coils to the PC400 in the treatment of small to large/ giant aneurysms. The larger microcatheter can pass Solitaire and Neuroform struts or be jailed with flow diverters. More experience is warranted to confirm these results.

Free Papers Free Paper Session Oncologic intervention 3

Impact of prior procedures on overall survival following radioembolization in patients with unresectable hepatocellular carcinoma (HCC) S188 C RSE

The present work in progress reports the first experience with a new thrombectomy tool in 7 centers: Aperio®, Acandis Pforzheim / Germany. Material and Methods: The Aperio® thrombectomy device was used in the treatment of acute ischemic stroke by interventional neuroradiologists in 8 different hospitals: using a microcatheter, the device was placed and deployed at the site of vessel occlusion. Subsequently, the device and consecutively the thrombus was removed by applying aspiration. Results: In all cases (n=68), the target vessel was reached. Revascularization-rate (TICI 2/3) after the first attempt was 32%. Finally, in 85% recanalisation was successful (TICI 2/3); 12% remained occluded (TICI 0). Preparation, visibility under fluoroscopy, and handling of the device and the supplied microcatheter were described as good or very good by the users in ca. 80-90%. Device-related clinically significant adverse events were rare (3%). The first, very limited clinical results were promising: 7/11 patients rendered a modified Rankin Scale ≤ 2 at discharge. Conclusion: Aperio® seems a promising tool for thrombectomy: preparation/handling was felt to be easy, a high rate of recanalization was achieved and the use appeared safe. 

Comparing outcomes of magnetic resonance-guided focused ultrasound surgery and uterine artery embolization for uterine fibroids -short-term and mid-term results V. Fröling, K. Meckelburg, C. Scheurig-Muenkler, N.F. Schreiter, M.H. Maurer, B. Hamm, T.J. Kroencke; Radiology, Charité, Berlin, Germany.Purpose: To compare the short-and mid-term improvement in Symptom Severity (SS) and Health-Related Quality of Life (HRQoL) and re-intervention rate after Uterine Artery Embolization (UAE) and Magnetic Resonance-guided Focused Ultrasound Surgery (MRgFUS) for uterine fibroids. Material and Methods: Eighty women (mean age: 38.1; range: 27.7-55.3 years) with symptomatic fibroids who underwent MRgFUS or UAE at our department between 2002 and 2009 were subdivided into a short-term (n=72) and a mid-term (n=60) follow-up group. Uterine Fibroid Symptom and Quality of Life (UFS-QOL) questionnaire including SS and HRQoL was assessed before, at short-term (2.5-7.5 months; mean 5) and mid-term follow-up (7.6-24 months, mean: 15.6) after UAE and MRgFUS. Results: Re-intervention rate after UAE in short-term follow-up was significantly lower than after MRgFUS (P< 0.001) and nearly reached significance in mid-term follow-up (P=0.063). SS and HRQoL in shortterm follow-up after UAE was significantly better than after MRgFUS (P=0.020; P=0.025). Conclusion: UAE for symptomatic uterine fibroids has a significantly lower re-intervention rate and is superior to MRgFUS regarding symptom control and improvement in HRQL at short-term followup. At mid-term follow-up, the need for a second intervention did not differ significantly but showed a tendency to do so, while symptoms and HRQL were comparable in treatment responders.

Endovascular repair of ruptured abdominal aortic aneurysm: technical and team training in an immersive, virtual reality environment N. Rudarakanchana 1 3 Interventional Radiology, Imperial College, London, United Kingdom.Purpose: This study evaluates a fully immersive simulated angio suite for training and assessment of technical endovascular and human factor skills. Material and Methods: Two virtual reality (VIST-C, Mentice) simulators were integrated into a simulated angio suite (ORCAMP, Orzone). Ten different teams, led by expert (n=5) or trainee (n=5) interventional radiologists, performed a simulated ruptured endovascular aortic aneurysm repair (rEVAR) within a 45-minute session. Time to achieve proximal control, as well as total procedure and fluoroscopy times were recorded as measures of performance. Participants (n=23) completed post-procedure questionnaires evaluating facevalidity, technical and human factor aspects on a Likert scale from 1(not at all) to 5 (very much). Results: Experts were significantly faster than trainees in achieving proximal control (median 352 vs. 501s, p=0.047) and took 1749s (IQR 1540 to complete the procedure, whilst no trainee was able to complete within the allotted time (p=0.005). Total fluoroscopy times were significantly lower in the expert group (782 vs. 1086s, p=0.016). Realism of the simulated angio suite was scored highly by all team members (median 4/5, . Participants found the immersive environment useful for acquiring technical skills (4/5, 3.5-5) , teamwork (5/5, 4-5) and communication skills (4/5, 4-5) .Conclusion: This is the first study to evaluate a fully immersive simulated angio suite and assess performance of teams during rEVAR. Technical performance measures differ between experts and trainees. Questionnaire responses appear to validate the model in terms of realism and potential use to acquire technical and human factor skills. This environment provides novel opportunities for training and assessment of endovascular skills.

Clinical Findings/Procedure: 1. Review of risk factors, clinical symptoms and imaging features for central venous disease. 2. Review of the multiple endovascular techniques for recanalization (wire recanalization, subintimal recanalization and re-entry, intraluminal recanalization) and patency maintenance (angioplasty, bare metal stents and covered stents). 3. Evidence-based analysis of treatment options (angioplasty, bare metal stents and covered stents), and their associated variable patency due to recurrent restenosis. 4. Discussion of emerging treatment options (drug eluting stents, cutting balloons, cryoplasty and brachytherapy). 5. Review of approaches to prevention and management. Conclusion: Current endovascular treatment options for central venous disease include angioplasty, bare metal stents and covered stents, each of them being associated with variable patency due to recurrent restenosis requiring repeat interventions. An evidencebased analysis of available literature is essential to assess the efficacy of these emerging treatment options and develop standardized approaches to prevention and management. PTA is recommended first per DOQI guidelines, with bare stents only having an equivalent role to PTA. Stentgrafts have an evolving role and need to be assessed better.

A. Ianniello Purpose: To evaluate the effectiveness of endovascular treatment of pelvic arterio-venous vascular malformations (AVMs), considering the different techniques, approaches and embolizing agents. Material and Methods: Between January 2008 and December 2011, 7 patients (4 women and 3 men, age 21-50, mean 39 years) suffering from pelvic AVMs were treated. According to the location and the different morphologies of the nidus, in 4 patients, we adopted a trans arterial approach using cyanoacrylate and lipiodol as sclerosing agent (in 1 patient also ethanol), in 2 patients a percutaneous approach under angiographic control using ethanol while in one case we closed first the efferent veins (with coils and Amplatzer Vascular Plug) and then the arterial inflow using cyanoacrylate and lipiodol. Results: In 5 patients we obtained a reduction of pain and size of the AVMs. In 2 patients we have no clinical improvement; in one case we were unable to reach the nidus of the malformation because of the improper release of coils (by another centre), while the other patient presented the most extensive pelvic AVMs, not responsive despite 3 different embolizing sessions. Conclusion: Treatment of pelvic AVMs represents a challenge in the challenge. Endovascular treatment represents, due to the widespread availability of techniques and materials, the first therapeutic choice in pelvic AVMs that must be faced in specialized centers requiring experience and knowledge of this problem by operators.

Risk factors of liver complications related to extrahepatic artery embolization for massive hemorrhage after pancreatobiliary surgery K. Shibuya 1 Purpose: To evaluate the risk factors of major hepatic complications related to hepatic arterial embolization (HAE) for massive bleeding after pancreatic and biliary surgery. Material and Methods: Between March 2006 and October 2011, 20 patients (18 men, 2 women; mean age 72) who had undergone HAE to proper and/or common hepatic artery for massive hemorrhage after pancreatobiliary surgery were enrolled in this retrospective study. Major complications (hepatic failure and infarction) were detailed according to pretreatment shock index (SI), portal vein stenosis, and arterial collateral pathways. Results: Bleeding sites were located in the gastroduodenal artery stump (n = 12), proper and/or common hepatic artery (n = 6), and right hepatic artery (n = 2). Hemodynamic stability was achieved in all cases after HAE. Rebleeding occurred in five patients, and successfully controlled by repeat embolization. Two patients died of multiple organ failure despite successful HAE. Major hepatic complications arose in five (25.0%) patients; hepatic failure and infarction were observed in four (20.0%) and two (10.0%) patients, respectively. The incidence of major hepatic complications was significantly associated with pretreatment SI of more than 1.0 (p = 0.014, Fisher exact test). Conclusion: HAE can be performed safely in most patients and successfully control massive bleeding after pancreatobiliary surgery.Major hepatic complications were more likely to occur in patients with hemodynamic instability. Hepatic artery preserving techniques should be considered in these patients.

This study aimed to investigate the diagnostic value of DMSA and MAG 3 scanning in the follow-up of patients with abdominal aortic aneurysm (AAA) treated with fenestrated and chimney stent grafts specifically evaluating renal function. Background: The neck of a juxtarenal aneurysm is often too short for stable haemostatic stent-graft implantation. Fenestrations (holes) in the stent-graft permit implantation at a more favorable level by providing a route for flow to the renal arteries. The aorta around the renal and visceral arteries is too dilated for haemostatic contact with the wall of the stent-graft. There is a gap, which must be bridged by a branch of the stent-graft. Balloon-expanded covered stents run transaxially from fenestrations to the branch arteries (renal or visceral). The role of the chimney technique in the management of complex abdominal aortic aneurysms is still unclear. However, long-term endograft durability, proximal fixation and renal function remain a significant concern. Clinical Findings/Procedure: A total of 19 patients (14 males and 5 females, mean age: 75 years) with AAA undergoing fenestrated/ chimney stent grafts were prospectively studied from August 2010 to September 2011. Pre-and post-fenestration DMSA and MAG 3 data were evaluated. The primary-assisted patency of renal artery stents was 100% at a median follow-up of 12.5 months (range, 2 days-77.4 months). Conclusion: Adjunctive renal artery stenting during endovascular AAA repair using the "encroachment" and "chimney" techniques is safe and effective. Short-and medium-term primary patency rates are excellent, but careful follow-up is needed to determine the durability of these techniques.

R. Gandini, M. Chiocchi, D. Morosetti, A. Chiaravalloti, G. Loreni, G. Simonetti; Diagnostic Imaging and Interventional Radiology, IRCCS Policlinico di Tor Vergata, Rome, Italy.Learning objectives: To investigate the feasibility and efficacy of trans-caval endoleak embolization (TCEE) of type I and II endoleaks occurring after endovascular abdominal aortic aneurysm repair (EVAR). Background: Notably, when an EVAR is successful, as defined as complete sealing at the attachment sites, blood flow into the aneurysm sac can still occur. The reperfusion is usually due to the patency of several collateral branches, such as from the inferior mesenteric artery (IMA), the superior mesenteric artery, the sacral artery and the lumbar arteries, or to the incomplete sealing off of the graft to the native vascular system. This condition is known as type I or type II endoleak. Clinical Findings/Procedure: TCEE was technically successful in all patients (100%). Intrasac pressure dropped from a mean of 63. to a mean of 7.8 ± 2.3 mmHg (range: [5] [6] [7] [8] [9] [10] [11] [12] . Mean time of fluoroscopy was 15.4 ± 4.1 minutes (range: [10] [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] [21] [22] . During a mean 9.9 ± 4.5-month (range: [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] [16] [17] [18] follow-up period, no aneurysm-related deaths, further increases in aneurysm sac diameter or endoleak recurrences were observed. Conclusion: TCEE of type I and II endoleaks associated with aneurysm sac enlargement is a safe, effective and feasible procedure. This technique does not require high operational skills and can be performed by all endovascular specialists without the need of CT guidance.

Two cases of tracheo-innominate artery fistula successfully treated by endovascular stent-graft repair H. Sato Two patients with infrarenal AAA treated with trivascular ovation endoprosthesis. In both it was the collapse of the grafts. The absence of metallic stents as a support of the prosthesis has determined incomplete deployment, resulting in complexity of the procedure.

Acute endovascular management of aortobronchial, aortocaval and aortoenteric fistulas I.J. Walton 1 Aortobronchial, aortoenteric and aortocaval fistulas are uncommon, but catastrophic complications, occurring primarily or after aortic reconstruction. Conventional surgical management is associated with high mortality and morbidity. We report three cases of major aortic fistulous complications managed with endovascular techniques.

Transcatheter arterial embolization of the spleen in swines: comparison between two types of embolic materials with different occlusion times A. Ikoma, T. Sonomura, N. Kawai, H. Minamiguchi, M. Nakai, H. Sanda, K. Nakata, M. Sato; Radiology, Wakayama Medical University, Wakayama, Japan.Purpose: To compare the occlusion times of the splenic artery and the degree of spleen injury by transcatheter arterial embolization (TAE) using new gelatin sponge (RMG) with a short occlusion time and original gelatin sponge (GS) with a long occlusion time. Material and Methods: Eighteen healthy young swines were divided into two groups of nine according to the embolic material: RMG and GS. RMG was prepared by freeze-drying and heating to a temperature of 130°C for cross-linkage. The splenic arteries of swines were completely occluded using RMG and GS particles (2mm in diameter). Splenic arteriographies were performed before TAE, immediately after TAE, 30 minutes, 60 minutes, 120 minutes, and 3 days after TAE. The spleens were removed 3 days after TAE. The spleens were cut into 1-cm thick sections and the necrosis rates were calculated. Results: In the RMG group, the splenic arteries were partially recanalized 30 minutes after TAE, and were completely recanalized 60 minutes after TAE in all swines. In the GS group, the splenic arteries remained occluded for at least 3 days after TAE in all swines. The mean necrosis rates of the spleens were 4.75% in the RMG group and 58.57% in the GS group. The necrosis rate of the RMG group was significantly lower than that of the GS group. Conclusion: RMG has an occlusion time of less than 60 minutes, and gives less damage to the splenic tissue. Therefore, RMG can be a new temporary embolic material.Purpose: Doxorubicin-loaded microbubbles can be shattered into nanoshards within tumor vasculature for non-invasive selective delivery of drug to HCC. Previous experiments demonstrated tumoricidal dox concentrations at 14 days at a dose of 0.8mg/kg. In this study, escalating doses of dox microbubbles were administered for two 3-week cycles. Material and Methods: Morris3924a hepatomas were implanted in the left lobe of ACI rats. Dox-microbubbles were injected IV at doses of 0.8 mg dox/kg, 1.6 mg/kg, and 4 mg/kg and the tumors insonated for 20 minutes at an MI of 0.42. Serum drug concentration was measured 5 minutes after injection. Tumor size and CBC were measured at baseline, 12+/-1 day, and day 21, at which time a second cycle of therapy was administered at the same dose. Rats were killed on day 42 and tissues analyzed for dox concentration and histologic response.Results: Serum dox levels at the three doses were 0.4 +/-0.3 mcg/ml, 0.8 +/-0.7 mcg/ml, and 3.2 +/-1.7 mcg/ml. There was no significant change in hemoglobin or platelet counts. Most rats developed a leukocytosis. After cycle 1, tumor size (cm +/-SD) at day 0, 12 and 21 were: 0.8mg/kg 0.9 +/-0.1, 1.5 +/-0.1, 2.0 +/-0.4; 1.6 mg/kg 1.0 +/-0.4, 1.8 +/-0.4, 2.4 +/-0.1; 4.0 mg/kg 1.1 +/-0.1, 1.7 +/-0.1, 2.5 +/-0.1. Conclusion: Dox-loaded US microbubbes at doses up to 4mg dox/ kg were tolerated without significant hematologic toxicity. Growth inhibition was not seen after one cycle; results following the second cycle and necropsy will be reported.

Magnetic particle imaging: first real-time visualization of instruments for cardiovascular intervention J. Haegele 1 3 Institute of Medical Engineering, University of Luebeck, Lübeck, Germany.Purpose: Magnetic particle imaging (MPI) is a new radiation-free tomographic imaging method measuring the spatial distribution of superparamagnetic iron oxide nanoparticles (SPIOs). MPI allows fast and detailed image acquisition with high sensitivity; thus, guidance of cardiovascular interventions seems to be a promising application. We evaluated the feasibility and different methods of instrument visualization. Material and Methods: Two identical balloon catheters (Abbot Vascular, Fox plus PTA-catheter) were filled either with diluted Resovist (Bayer Pharma AG, 25 mmol(Fe)/l) or with sodium chloride. They were inserted into the lumen of a vessel phantom, which was filled oppositional to the balloon catheters with either diluted Resovist or sodium chloride. Additionally, the application of a bolus of pure Resovist (500 mmol(Fe)/l) through the Resovist-labeled balloon catheter was recorded. All images were acquired using a preclinical MPI-demonstrator (Philips Research, Hamburg). Results: All images were acquired using a field of view (FOV) of 36x 36 x 20 mm3. Using MPI, image acquisition with high temporal (21.54 ms) and spatial resolution (<3 mm) was possible. No motion artifacts occurred while imaging instrument movement through the FOV, inflation and deflation of the balloons and bolus administration in real time. Conclusion: Visualization of labeled and unlabeled instruments for cardiovascular interventions is feasible in real-time without motion artifacts. Furthermore, monitoring of the administration of a SPIO-based tracer is possible as well. Evaluation of different labeling approaches, especially for small instruments, and the guidance of those in contrasted vessels is necessary and currently under investigation. Disclosure: J.R., B.G. and J.Bo. are employees of Philips Technologies GmbH. All authors cooperate within the project "Magnetic Particle Imaging Technologie" ("MAPIT"), supported within the budget of the german Federal Ministry of Education and Research.

To study the anti-tumoral effect of sunitinib-eluting beads in the rabbit VX2 tumor model. Material and Methods: VX2 tumor was implanted in the liver of New Zealand white rabbits. Seven animals received 0.2ml of DC beads loaded with 6mg of sunitinib (group 1), 6 animals received 0.2ml of DC beads (group 2) and 6 animals received NaCl 0.9% intraarterially in the left hepatic artery. One animal in each group was killed at 24 hours and the others were left to survive. Liver enzyme was measured daily. In group 1 plasmatic sunitinib concentration was measured daily by LC MS/MS tandem mass spectroscopy. At day 15 all living animals were killed. After killing, or premature killing, the livers were harvested for determination of the VEGF receptor tyrosine kinase activity by western blot and histopathological examination. Results: In group 1, no animal died during follow-up. In groups 2 and 3, respectively, 2 and 3 animals died during follow-up. In group 1, plasmatic sunitinib level remained under therapeutic concentration during the whole experiment. There was an evident lack of phosphorylation of the RTK in group 1 and there was an augmentation of the RTK phosphorylation in group 2 at 24 Purpose: To compare the degree of uterus damage in swine caused by embolization of both uterine arteries using gelatin sponge particles (GSPs) and N-butyl cyanoacrylate (NBCA) mixtures. Material and Methods: NBCA was mixed with iodized oil (Lp) so that it could be monitored under fluoroscopy. Fifteen swine were divided into three groups of five according to the embolic material: group A (GSPs), group B (NBCA/Lp=1/1) and group C (NBCA/Lp=1/7). Both uterine arteries of swine were completely occluded with GSPs and NBCA mixtures. The uteri were removed 3 days after embolization in all three groups, and radiographies of the removed specimens were performed in groups B and C to confirm distribution of NBCA mixtures. The necrosis rates of the uteri were calculated using 1-cm grids, and the uteri were evaluated histologically. Results: Radiographies showed NBCA mixtures in the proximal portions of the uterine arteries in group B, and in the proximal and distal portions of the arteries in group C. The mean necrosis rates of the uteri were 4.9% in group A, 1.3% in group B and 41.4% in group C. The mean necrosis rate of group C was significantly higher than those of groups A and B. Histologic examination showed karyolysis and hemorrhage in the necrotic portions. Conclusion: NBCA mixture (NBCA/Lp=1/7) gives more damage to the uteri compared to GSPs and NBCA mixture (NBCA/Lp=1/1). Therefore, a dilute NBCA mixture should be avoided in uterine artery embolization because of a significant threat of uterus damage.

Microwave ablation of the liver with a 1.8-mm diameter 2.45-GHz applicator: ablation zones achieved and CT features of maturation of the ablation zone P.A. Patel, I. Wilson, B. Stedman, N. Hacking, D.J. Breen; Department of Radiology, Southampton University Hospitals NHS Trust, Southampton, United Kingdom.Purpose: There is little data on ablation zone (AZ) maturation and size achieved with new 2.45-GHz microwave ablation probes of 1.8 mm diameter. This dosimetry study was performed to characterise the relationship between treatment duration (TD), extent of ablation zone and CT appearances of the maturing AZ in an ex-vivo bovine liver model. Material and Methods: Multiple (28) ablations were performed in 4 ex-vivo bovine livers at 180W for durations between 0.5 and 8 minutes. AZ size was assessed by gross examination. CT scans were performed every minute for 10 minutes after each ablation in two of the livers to visually assess maturation of the AZ and measure the area of out-gassing. Results: Nonlinear regression analysis demonstrates a logarithmic relationship between TD and AZ longitudinal and transverse diameters is demonstrated (R2=0.86 and 0.90). There is a relative plateau in AZ size beyond approximately 6 minutes TD. The CTs demonstrate initially coarse gas bubbles within the region of the ablation site that become finer and more peripheral with time. The area demarcated by the outer edge of the bubbles correlates closely with the AZ size. The AZ is best visualised at 4-6 minutes post-ablation. Conclusion: Our data demonstrate increasing AZ size with TD, trending towards a plateau in the dose response curve at approximately 6 minutes. This suggests there is little AZ size to be gained in ablating beyond this time. Our data also suggest that the optimal time to image for assessment of the AZ achieved is 4-6 minutes post-ablation. Disclosure: Microsulis supported the project with a free probe and materials. Data collection and analysis was independent of any commercial influence.

Balloon coating with rapamycin using an on-site coating device J. Schmehl Purpose: The efficacy of drug-eluting balloons (DEB) has already been shown in clinical trials. The drug predominantly used is paclitaxel due to its lipophilic properties and the rapid onset of action.Limitations of the substance used and also the excipients exist. Aim of the investigation was to evaluate the feasibility and efficacy of a balloon coating with a rapamycin solution.

The balloon coating with rapamycin was conducted with an on-site coating machine (Translumina GmbH). Concentrations ranged from 2% to 4%. Measurements regarding the amount of substance released to the vessel wall were carried out on explanted porcine coronary arteries using UV/VIS spectroscopy. The inflation time varied between 30 sec and 120 sec. The biological effect of the coating was evaluated in a porcine peripheral overstretch and stent implantation model using quantitative angiographic analysis.

The mean amount of rapamycin applied to the balloon surface was 558μg for the 2% solution and 1440μg in case of the 4% solution. An amount of 95μg up to 193μg was found to be released into the vessel wall, respectively. The quantitative measurements of the angiographic examinations 4 weeks after treatment showed a reduction of diameter stenosis from 20.6±17.4% in the control group to 11.6±5.5% in the DEB group. Conclusion: A balloon coating with rapamycin omitting an excipient is possible using a dose-adjustable coating machine. Further investigations regarding a sufficient effect of the released amount of drug in-vivo are necessary. Disclosure: Translumina GmbH (Hechingen, Germany) provided devices used in this study.

C RSE Purpose: Thrombin inhibits the VE-cadherin of the vascular endothelical cell, and increases endothelial permeability in a rapid and reversible way. The purpose of this study was to evaluate transmission of cisplatin to blood and tissue in transarterial infusion with thrombin. Material and Methods: VX2 tumor cell suspension was injected to 10 Japanese white rabbits' right thighs. A nodular VX2 tumor 3 cm in diameter was produced after 14 days following implantation. Ten rabbits were randomly divided into 2 groups of 5 rabbits each, thrombin group and control group. A microcatheter was inserted into the right femoral artery. In thrombin group, thrombin (300UI), cisplatin (3mg), lipiodol (0.3ml) and iopamidol (0.3ml) suspension was infused into the right femoral artery. In control group, cisplatin, lipiodol and iopamidol suspension was infused. Platinum concentrations in plasma were measured in 5 and 10 minutes after administration. Using tumor specimens that were excised 30 min after infusion, platinum concentrations were measured.

The platinum concentrations in plasma in 5 and 10 minutes after administration were 0.59±0.28μg/ml and 0.70±0.078μg/ml for the thrombin group, respectively, and 2.7±1.2μg/ml and 2.2±0.58μg/ ml for the control group, respectively. At both 5 and 10 min after infusion, the platinum concentrations in plasma for the thrombin group were significantly lower than that for the control group. The platinum concentration in tumor tissue was 4.1±1.8 μg/wet g for the thrombin group and 1.0±1.2μg/wet g for the control group. The platinum concentration in tumor tissue for the thrombin group was significantly higher than that for the control group. Conclusion: Transarterial infusion with thrombin may have pharmacological advantages.

In vivo distribution of different sizes of bland and drug-loaded microspheres in a pig liver model Purpose: Various sizes of calibrated microspheres can be used for embolization and chemoembolization procedures. We compared two sizes of bland and doxorubicin-loaded microspheres in a model of hepatic artery embolization in pig to verify that small microspheres achieve (1) a more distal and (2) (2) at 120 days after the procedure. Videotape was used to measure the time for coil delivery and for complete vessel thrombosis. Patency of the renal arteries was evaluated by angiogram and pathology exams at each endpoint. Histopathology evaluated vessel recanalization, levels of inflammatory markers [Eotaxin, Interferon, Transforming Growth Factor (TGF), Interleukin-1-beta (Il-1)], coil stability, and grade of renal parenchymal necrosis. The contralateral kidney (not embolized) was used for control. Results: The Nester coil had the fastest embolization time while the Azur coil had the slowest. There was no statistically significant difference in the time for vessel thrombosis between the Nester and Interlock coils, but both were faster than the Azur coils.

The Azur coils had the lowest renal artery recanalization rate at 120 days, however had the longer delivery and vessel occlusion times. The Nestor coils and the Interlock had no significant difference in the inflammatory response or in recanalization and both had similar delivery and vessel occlusion times.

Novel MR-safe guidewire with passive iron-platinum alloy nanoparticles for cardiovascular interventional MRI 45-150μm was detected on T2WI. At histologic analysis, SCM was found at uterine myometrium or endometrium but PVA was found at the perimyometrium. Inverse relationship was seen between the SCM size and the size of the lumen filled by this embolic agent. Conclusion: Calibrated SPIO-loaded chitosan microcapsules permit more segmental arterial occlusion than do PVA particles, and have great potential as a new embolic material since it travels into blood vessels more distally. The level of arterial occlusion was correlated with the size of the microcapsule size. MR imaging studies can be used to evaluate treatment response after embolization as this material can also be detected on T2-weighted MR imaging.

Endovascular glue embolisation in a rare case of aberrant right subclavian artery esophageal fistula S. Kulkarni, T.P. Dharia, N.S. Shetty, M. Thakur, A.M. Polnaya, G. Sanghani; Interventional Radiology, Tata Memorial Centre, Mumbai, India.Aberrant right subclavian artery esophageal fistula is a rare cause of massive hematemesis with fatal outcome. We report a case of upper-third esophageal malignancy eroding into the aberrant vessel that was salvaged from this devastating complication by endovascular glue embolisation.

Gastric leak after sleeve gastrectomy: IR can give the answer M. Corona, C. Zini, A. Bruni, A. Cannavale, F. Fanelli, F.M. Salvatori; Interventional Radiology Unit, Department of Radiological Sciences, Sapienza -University of Rome, Rome, Italy.

To evaluate a possible non-surgical approach to gastric leak (GL) post-laparoscopic sleeve gastrectomy (LSG). Material and Methods: From July 2004 to December 2010, 16 patients (3 males, 13 females; mean age 43±7years) were treated for GL post-LSG by our team. All patients had a radiograph with contrast medium (Gastrographin) and computed tomography (CT) examination that confirmed contrast swallow. Basing on radiographic findings we divided patients into "drainable" or "non-drainable". Results: Twelve patients (75%) were drainage eligible. In 7 patients (58%) drainage was a valid stand-alone procedure; the other 5 patients (42%) required a covered stent placement due to non-complete resolution of GL. A covered stent was implanted in 1 patient (6%) with a posterior gastric leak non-eligible for percutaneous drainage or surgical approach. After 1009,8±456,7 days of followup, 1 patient (6%) died from cardiovascular event and 2 patients (12%) needed a bilio-pancreatic-digestive bypass (BPD-BP) due to no reduction of their BMI. The other 12 (75%) patients are in a good to optimum state of health and they present significant reduction of their BMI.

We are confident about the viability of non-surgical approach to GL post-LSG.

Transcatheter embolization of acute gastrointestinal bleeding: results in 475 patients A. Kvashin, S. Atamanov, A. Melnik, A. Bykov, A. Pomkin, M. Shirkin; Interventional cardio-angiology department, Irkutsk Regional Hospital, Irkutsk, Russian Federation.Purpose: To evaluate the efficacy and safety of endovascular treatment in patients with endoscopically unmanageable acute gastrointestinal bleeding. Material and Methods: We retrospectively studied the outcomes of 475 (mean age 59.5 years old; 28% female) patients who underwent endovascular approach for acute GI, performed between 1974 and 2011 years. Clinical data, angiography signs of the GI, long-term results, recurrent hemorrhage, complications were recorded. We met a row direct signs of the GI: extravasation of contrast medium-23% (112/475), amputation of the bleeding vessel-9%, regional artery spasm-40%, aneurysm of the celiac trunk-0.8% (4/475). The indirect signs included the regional hypervascularization and periarterial diffusion. We controlled GI using three ways: superselective vasopressor's infusion, combination between temporary embolization peripheral branches by albumin human microaggregates with vasopressors infusion and superselective embolization by nonabsorbable particles. First and second methods were performed in 169 (35.5%) cases. we used superselective embolization by nonabsorbable particles (PVA 500-700; metal coils; gelatin sponge) in 306 cases. Results: In groups where we used a vasopressor's infusion and combination method the recurrent rate was 24.8%. Left gastric artery embolization by non-absorbable particles has shown 21.8% (67/306) recurrence rate. Embolization of the gastro-duodenal artery demonstrated good results, recurrent rate in this group was 10%. There was no major complication in all cases. Conclusion: Endovascular embolization is a safe and effective procedure in the management of GI bleeding. Endovascular method significantly reduces mortality in acute GI bleeding provided we continue our efforts to optimize embolization technique. . Major complications were observed in 5 (5.6%) patients (gastrointestinal perforation) and minor complications in 9 patients (10%). The average interval from onset was 35.77 months (7-197 months) and was statistically significant when considered site of onset (BO vs UL; BO vs LL: p=0.003, p=0.006, respectively). After RIG placement the average follow-up was 11.92 months (1-23months) . 32 patients died during the follow-up. The average time between RIG and death was negatively correlated with the ALSFRS-r (p=0.024).

No difference was observed considering BMI, FVC or sex differences. Conclusion: RIG is an feasible, safety and effective enteral nutritional assistance in MND patients. The enteral nutrition necessity varies according to initial presentation symptoms. The ALSFRS-r score at RIG placement correlates with survival time.

C RSE Learning objectives: To summarize the main indications for percutaneous gastrostomy (PG) in oncologic patients, to review the main advantages of PG placement procedure using ultrasound and fluoroscopy, and to recognize possible complications and how to avoid them. Background: Radiologic PG has become an accepted method of enteric access for patients requiring long-term nutritional support, especially in oncologic practice due to malignant lesions of the oropharynx, hypopharynx or esophagus. In contrast with the endoscopic procedure, the percutaneous approach can be considered a fast alternative for the patient. Expertise with the technique must always be achieved to avoid complications. Clinical Findings/Procedure: A review of the gastrostomy procedure will be presented, as well the main advantages of the percutaneous technique. US evaluation and fluoro-guided steps to perform it are shown and the clinical outcome is also reported. Conclusion: Radiologic PG is generally a very safe procedure. Nevertheless, it is important that radiologists be familiar with the correct technique and aware of the short-term and long-term possible complications of PG. The percutaneous approach may be quicker and more comfortable for the patient than the endoscopic method. Clinical outcome is generally good and complications are rare. Learning objectives: The objectives were to carry out a 5-year audit of primary percutaneous RIG insertion, to identify all cause morbidity and mortality at 30 days, to highlight significant complications directly attributable to RIG placement, and to illustrate our departments' response to the findings. Background: RIG placement is a common interventional procedure. While a standardised approach to placement existed in our institution, we decided to audit our primary RIG placements to identify possible improvements that could be made in this approach. Clinical Findings/Procedure: Extensive picture archiving and communication system (PACS), electronic patient record (EPR) and patient chart reviews were undertaken. 540 RIG tube placements were attempted in the period December 2006 to December 2011. 241 were primary attempts and 13 of these attempts were technically unsuccessful (n=228). Within 30 days, 42 tubes (18.4%) were replaced. Intraperitonealfree air leaks were identified in 20 patients (8.7%), 1 patient (0.4%) had a rectus sheath haematoma, 1 tube (0.4%) was placed in the splenic flexure and 1 T Tack was placed transhepatically. A single patient with an air leak required placement of extra T Tacks, none of the other patients required treatment. Minor complications were identified in 37 patients (16.2%) . All cause 30-day mortality was 4.8% (11 patients) . None of the deaths were directly attributable to RIG placement. Conclusion: In general, RIG placement is a safe procedure. We continue to give NG dilute barium 12 hours prior to procedure to outline the colon. We have also started performing routine preprocedure ultrasound to ensure that the left lobe of the liver is not enlarged. Learning objectives: The objectives were to explain anatomical background of celiac artery compression syndrome, to learn how to assess the imaging modalities used in the diagnosis of this syndrome, and to discuss significance for endovascular interventions and potential clinical manifestation. Background: The celiac artery compression is not uncommon entity. With extensive use of CT angiography it could be seen in significant group of patients and it could also be found in up to onethird of autopsy studies, but only few patients manifest typical clinical signs represented usually by postprandial pain and weight loss and definitive pathophysiological mechanism is still unclear. Clinical Findings/Procedure: Celiac artery compression is caused by fibers of median arcuate ligament connecting diaphragmatic crura. It could be visualized with conventional or CT (poss. MR) angiography. The lateral (sagittal) view is crucial and the compression has a typical focal hooked appearance narrowing of the proximal celiac artery. This narrowing could be highly influenced by respiratory movements and it typically increases during expiration. In groups of symptomatic patients the surgical therapy could be considered, but the indication criteria remains controversial. Conclusion: Although celiac artery compression is not uncommon entity and could be found in significant number of CT angiography studies, majority of patients has no symptoms and findings must be correlated with clinical signs. Besides potential clinical symptoms it could be source of difficulties for endovascular procedures involving catheterization of celiac artery and thus the basic knowledge of this entity could prevent potential complications. Learning objectives: To show our experience with Kimberly Clark's Introducer Kit to facilitate placement of enteral feeding tubes.

Background: Kimberly Clark´s Introducer Kit for placement of enteral feeding tubes under fluoroscopic guidance has been used at our institution in 42 patients since January 2010. The kit includes four pre-loaded t-fasteners with resorbable suture and locking suture lock, a serial dilator with peel-away sheath, J-tip guidewire and over-the-wire stoma measuring device. Clinical Findings/Procedure: Under fluoroscopic guidance and after gastric insufflations, local anaesthesia is injected in the abdominal wall below the left costal margin at the point where the stomach should be punctured. Then three T-fasteners are inserted forming a triangle to ensure gastric wall apposition to the abdominal wall, minimizing gastric content leakage. The stomach is punctured in the middle of the triangle, and a guidewire is coiled in the fundus. The tract is dilated using the serial dilator with peel-away sheath. The enteral feeding tube is inserted through the peel-away sheath, and it is secured inflating a balloon. Conclusion: Kimberly Clark´s Introducer Kit includes all the tools to facilitate primary placement of enteral feeding tubes. In our experience, the main advantages of this kit are the safety of the t-fasteners and the ease of use of the serial dilator with peel-away sheath,

Electronic Posters which ensures tract dilation in one step, minimizing over-the-wire interchange of different dilators and resulting in a faster and safer procedure.

Percutaneous thrombin injection of a visceral artery pseudoaneurysm originating from the right gastric artery E. Gbeddy Visceral arterial aneurysms are a rare but potentially life-threatening entity. Standard treatment is surgical repair, though the interventionalist may be needed for assistance in complicated cases. We present a case in which a right gastric artery pseudoaneurysm percutaneously injected thrombin.

Direct angiographic visualisation of hemosuccus pancreaticus with multiple pseudoaneurysms: a rare angiographic demonstration A percutaneously drained postoperative fluid collection secondary to surgery for a pancreatic insulinoma matured into a high volume pancreatic fistula. The cutaneous access to the fistula was used to establish internal drainage into the stomach creating a fistulogastrostomy. Purpose: The internet is widely used by patients to source healthcare-related information. We sought to analyse the quality of information available on the internet about uterine artery embolization (UAE).

We searched the three major search engines for "uterine artery embolization"; and compiled the top 50 results from each. After excluding repeated sites, scientific articles and links to documents, the remaining 50 sites were assessed using the LIDA instrument that scores sites across the domains of accessibility, usability and reliability. The Fleisch reading ease score (FRES) was calculated for each of the sites. Finally, we checked the country of origin and the presence of certification by the Health On the Net Foundation (HONcode) and their effect on LIDA and FRES scores.

The following mean scores were obtained: accessibility, 48/60 (80%); usability, 42/54 (77%); reliability, 20/51 (39%); total LIDA, 110/165 (67%) and FRES, 42. Nine sites had HONcode certification and this was associated with significantly higher p value. Conclusion: In general, sites are well designed and easy to use. However, many score poorly on the reliability of their information; either being produced in a non-evidence-based way or lacking currency. It is important that patients are guided to reputable, location-specific sources of information online; especially as prominent search engine rank does not guarantee reliability of information. Disclosure: A paper with the same abstract has just been accepted for publication in the CVIR journal. 

C RSE CIRSE Abstract Book long-term improvement in symptoms and would recommend the procedure to a friend. The improvement is more pronounced in the first 2-6 years after the procedure.

Uterine artery embolization in the treatment of obstetric hemorrhages: our experience A. Ranalli, S. Bruni, C. Marcato, E. Epifani, P. Larini, C. Rossi; U. O. Radiologia, sez. Radiologia Interventistica, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy.Purpose: To evaluate clinical effectiveness and safety of uterine artery embolization in the treatment of postpartum hemorrhage and for a prophylactic purpose in the case of severe obstetric hemorrhage. Material and Methods: 70 women underwent superselective embolization of uterine arteries between April 2002 and November 2011. In 57 patients emergency embolization was performed for therapeutic purposes. In other 13 cases the embolization was carried out for a prophylactic purpose. The procedure was performed through transfemoral artery catheterization and selective catheterization of bilateral uterine arteries mainly using Gelfoam and only in some particular case coils.

The percentage of success against the resolution of the bleeding was 94.7% in cases of therapeutic treatment. In 92.3% of cases of prophylactic embolization this procedure has prevented the occurrence of serious bleeding. Complications were rare and easily treatable. The results of follow-up have confirmed that, in most cases, the technique not only allows the preservation of the integrity of the reproductive system of women but also preserves fertility and, in particular, this has been shown by 5 cases of pregnancies that occurred after the procedure.

The high clinical effectiveness rate, low complication rate, and, in particular, the possibility of preserving reproductive function make the arterial embolization the method of choice for control severe postpartum hemorrhage conservatively intractable. This procedure also represents a new opportunity of treatment not only of postpartum bleeding but also with a prophylactic purpose to prevent a severe hemorrhage which could endanger woman's health.

Embolization for emergency management of postpartum hemorrhage Purpose: Hemorrhage is a major cause of postpartum morbidity and mortality; conservative measures continue to be the first line of defense, but once these measures fail, the options in the past have been few. Many patients routinely underwent bilateral hypogastric or uterine artery ligation. If refractory bleeding continued, the hysterectomy was needed. The treatment algorithm has changed over the years with the emergence of transcatheter embolization, which is quickly becoming the modality of choice to control and prevent pelvic hemorrhage.

We treated 52 patients for massive PPH with embolization technique by catheterizing and occluding selectively uterine arteries with embolic material. Furthermore, we also tried to manage PPH prophylactically in patient at high risk for severe bleeding such ectopic pregnancy or abnormalities of placenta. Clinical success was defined as obviation of hysterectomy. The embolization materials used were in 44 cases polyvinyl alcohol particles (PVA) and

Uterine artery embolization for symptomatic adenomyosis: has been attributed to the presence of undiagnosed adenomyosis, frequently due to the absence of screening MR imaging. More so, fibroid ischemia after UAE is a known predictive factor of clinical success. Clinical Findings/Procedure: A pictorial review describing the preand post-embolization MR features of uterine leiomyomas and adenomyosis. The major pulse sequences, protocols and relevant findings will be discussed. Before UAE, angio-MR sequences may help plan the procedure and the T2-weighted images allow a confident diagnosis of adenomyosis (low myometrial signal intensity, diffuse or focal thickening of the junctional zone, high-signal-intensity foci corresponding to myometrial cysts, poor definition of the endomyometrial junction, and poor definition of lesion borders). MR allows accurate evaluation of the leiomyomas before and after UAE (number, location, volume). Post-treatment analysis of fibroid ischemia on gadolinium-enhanced T1-weighted images is related to treatment outcome and should be assessed. Conclusion: MR imaging is a useful tool for interventional radiologists performing UAE. Knowledge of the major pulse sequences and imaging findings before and after UAE is paramount. MR imaging may help differentiate uterine leiomyomas and adenomyosis. Quantitative assessment of signal intensity and morphologic changes before and after UAE may help predict clinical outcome.

How Learning objectives: To describe the usual pelvic arterial anatomy and its variants.To review the key aspects of this endovascular treatment.To discuss the impact of the different vascular imaging findings in the safety and the technical success of this angiographic-based treatment as an outpatient technique. Background: Uterine fibroid embolization (UFE) is a uterus sparing and highly effective technique. Recovery period is short and serious complications are rare. UFE can be performed as an outpatient procedure, the control of post-embolization symptoms being the main challenge in this setting. Clinical Findings/Procedure: We retrospectively review the clinical and imaging findings of all the patients that underwent UFE at our institution, from 2006 to 2011. Uterine fibroid embolization was performed under local anesthesia with polyvinyl alcohol particles (PVA). Patients were given acid-suppressing drugs, nonsteroidal anti-inflammatory, anti-histaminic drugs and laxatives twice on the day before and once in the morning of UFE. Pain score, rated from 0 to 10, was evaluated, using a numeric pain scale. Four to eight hours after the embolization all patients received tramadol 100mg i.v. and metoclopramide 25 mg i.v. The outcome of UFE was evaluated at 6 months by pelvic magnetic resonance, clinical observations and questionnaires. Conclusion: With the understanding of uterine artery anatomy, their variants and appropriated medication started on the day before, the UFE procedure can be performed, safely, as an outpatient procedure.

Electronic Posters and 82%, 87%, 87% and 85% for sub-popliteal level. If we only consider Leriche and Fontaine stage II patients, NATIVE results were slightly better. Conclusion: Unenhanced MR angiography in our study showed a good NPV, which suggests its utility as first step test to screen PAD, especially in patients at risk of nephrogenic systemic fibrosis (NFS). (22.2%) , celiac to common hepatic artery aneurysm in one (11.1%), splenic artery aneurysm in one (11.1%), celiac artery dissection in two (22.2%) . Of these, one pancreaticoduodenal artery aneurysm and one celiac artery aneurysm ruptured and subsequent transcatheter arterial embolization were performed successfully. In one patient with ruptured splenic artery aneurysm, embolization was unsuccessful and converted to open surgery.

In patients with MALCS, associated vascular abnormalities should be noted. Possible mechanisms include poststenotic dilatation, repeat compression and decompression to the celiac artery, and increased flow in the collaterals.

Non-enhanced MR angiography of the renal arteries: comparison with contrast-enhanced MR angiography 

Anatomical assessment of the origin of the right inferior phrenic artery with the use of MDCT Purpose: In a case with hepatocellular carcinomas (HCC), right inferior phrenic artery (RIFA) most frequently gives collateral blood supply to tumors; therefore, knowledge of anatomical variation of RIFA is essential for chemoembolization (TACE) through those collateral arteries. Purpose is to investigate variation of RIFA, as well as, potential of MDCT to demonstrate them. Material and Methods: 309 cases underwent contrast-enhanced MDCT between April 2011 and January 2012 were enrolled. Thinsection (0.5-1mm) MPR and axial images were used for assessment. Origin of RIFA was investigated whether it was from one of the major branches of abdominal aorta or directly from abdominal aorta. Direct origin at the aorta was further examined whether it was from right-side, center or left-side of aorta at level above celiac artery (CA), around CA, between CA and superior mesenteric artery (SMA), around SMA or below SMA. Whether RIFA arose as a common trunk with left IFA (LIFA) was also recorded. Results: Origin of RIFA was confirmed in 303 of 309 cases from MDCT data. RIFA arose as a common trunk with LIFA in 29%. RIFAs arose from one of aortic branches in 51.8% mostly from CA, and directly from aorta in 48.2% most frequently from right-side at level between CA and SMA, followed by left-side at level above CA. In addition, rare variations were observed.

The origin of RIFA is quite variable and its knowledge will help in catheterization of RIFA when necessary. Since it is demonstrated on MDCT in most cases, thin-slice MDCT should be performed prior to TACE if available.

Unenhanced 3D turbo spin echo MR angiography of lower limbs in peripheral arterial disease: a comparative study with gadolinium-enhanced MR angiography Learning objectives: The purpose of this paper is to illustrate, through the formula of the "pictorial essay", the main imaging features of vascular malformations (VaM) of the pelvis. Background: VaM are subdivided into 2 groups on the basis of their vascular components and flow characteristics: low-flow VaM (venous malformations: VM, lymphatic malformations: LM, etc.) and high-flow VaM (arteriovenous malformations: AVM, etc.). Although VaM could occur at any anatomical region, pelvic localization is rare. Ultrasonography is the first imaging modality used in the suspicion of a VaM. Magnetic resonance (MR) and/or computed tomography (CT) are second level imaging modalities, essential to assess the extent of the lesions, the involvement of adjacent organs and to confirm the suspected of VaM. Angiography and phlebography complete the pre-operative planning in VaM (respectively, for high and low flow lesions). Clinical Findings/Procedure: VM especially interest the perineum, in particular genitals and less commonly the rectum. Their identification is relatively easy using T2-weighted fat-sat sequences in MR. At MR, LM typically show septate fluid collections (macrocystic forms) or a clear hyperintense area at T2-weighted fat-sat sequences with enhancement of the septa (in microcystic form). AVMs consist of a group of arteries and veins of varying sizes connected by tortuous, dilated and dysplastic vessels forming the "nidus" of the lesion: CT angiography and MR-angiography differentiate this group of highflow vascular anomalies from the remaining VaM. Conclusion: MR and CT are able to identify and typify the various forms of VaM, so to refer the patient to the more appropriate treatment (endovascular or surgical).

A. Barah Learning objectives: To present the principle, the benefits, the drawbacks and some clinical evaluation of new image-guidance tools for oncologic interventional procedure under ultrasound or fluoroscopy guidance in the angio-suite. Background: Despite the development of sophisticated guidance with CT, MR or PET, today most of the interventional oncology procedures are still performed in an angio-suite where US and fluoroscopy remain the most accessible imaging modalities for guidance. New tools dedicated to optimization of target visualization and optimization of catheter or needle path became available in the past few years. Their goal is to improve speed and accuracy in oncologic interventional procedures including US or fluoro-guided percutaneous puncture and vascular navigation. Clinical Findings/Procedure: We will describe principle of electromagnetic navigation of needles with US, image fusion (CT+US, 3D cone beam+PET/MRI, 3D angio+CT/MRI), computer-assisted vascular navigation with automatic tumor feeders recognition and real time 3D roadmap, computer-assisted needle placement in bone tumors with the help of fluoroscopy enriched with previously characteristics of RGA anomaly were recorded and complications resulted from non-targeted therapy were analyzed. Results: Among the 560 patients, there were 21 patients (3.75%) who had anatomic anomaly of RGA that arise from LHA deep in the porta hepatis region. The anomaly RGA mimics the branches of LHA in 13 patients (61.9%). Angiographic findings are capable in differentiating the RGA from LHA in caliber, course, branching pattern and final location of its distal branches in all 13 patients. Of them, three patient's RGA were unrecognized and received chemoembolotherapy accidentally. Of the three patients, two patients developed chemical gastritis and ulceration requiring surgical intervention. The other patient was managed medically and experienced sustained gastritis for three years. Conclusion: Recognition of RGA anomaly is imperative during transarterial hepatic regional therapy, especially when the targeting lesions are in the left hepatic lobe. The RGA is angiographically differentiable. Failure to recognize the RGA anomaly may result in significant morbidity in patients who underwent transarterial hepatic regional therapy.

Carotid intima media thickness as a reflection of global atherosclerotic disease: correlation with whole body magnetic resonance angiography in patients with peripheral arterial disease J. Purpose: Carotid intima media thickness (cIMT) has been suggested as a surrogate marker for atheroma burden within the body, and as a technique for assessing response to treatments. Our study compared cIMT with total atheroma burden as measured by whole body magnetic resonance angiography (WB-MRA). As atherosclerosis is a bodywide disease analysis of a multiple arterial segments by WB-MRA was used to calculate a score reflecting atheroma burden. Material and Methods: 50 patients with symptomatic peripheral arterial disease were enrolled for the study over a 6-month period. All participants underwent both carotid ultrasound and WB-MRA on 2 occasions at 6-month intervals. Calculating the total body atheroma score involved contrast-enhanced MRI of the arterial tree and standardised analysis of multiple segments for extent of stenosis. The total score calculated by summing scores of all segments. The normalised value was calculated by dividing this by the number of assessable segments. Results were analysed with Stata statistical analysis software.

The atherosclerotic burden in the assessed population was high with a mean TBA score of 34.6 s.d 13.7 (minimum possible score 0, maximum possible score 155). In the studied population the mean cIMT was 0.97mm s.d. 0.282 (right) and 0.99 s.d. 0.331 (left) with high correlation between the two (correlation co-efficient 0.581; p<0.001) cIMT thickness did not correlate with WB-CEMRA total body atheroma score (correlation co-efficient 0.28 (p=0.078) (right) and 0.27 (p= 0.091) (left)). Conclusion: cIMT was not found to accurately predict total atheroma burden as measured by WB-MRA.

C RSE CIRSE Abstract Book donors is mandatory. MDCT has replaced conventional imaging for preoperative evaluation of these patients. New scanners have brought isotropic CT imaging to clinical routine significantly improving vascular imaging and provide analysis of large anatomical volumes with better spatial and temporal resolution of images and shorter acquisition time. MDCT has become a valuable minimally invasive tool for visualization of normal vascular anatomy, its variants and pathological conditions, potentially predicting contraindications to renal donation. Clinical Findings/Procedure: The purpose of this presentation is to describe the most important information for the surgeon in the preoperative evaluation of living laparoscopic donors, focusing on the renal arterial and venous anatomy with principal variants, abnormalities of the renal parenchyma and collecting system, renal calculi and other pathological renal and extra-renal conditions. Conclusion: MDCT is a minimally invasive and accurate technique for preoperative evaluation of potential living renal donors. MDCT provides a comprehensive depiction of renal arterial, venous, and urinary tract anomalies, which provides critical information for planning laparoscopic nephrectomy.

Congenital and acquired anomalies of the thoracic aorta: the value of computed tomography angiography

Serviço de Imagiologia Geral, Hospital de Santa Maria, Lisbon, Portugal.Learning objectives: To assess the value of computed tomography (CT) angiography in the diagnosis and evaluation of thoracic aortic abnormalities (both congenital and acquired). Background: Thoracic aortic anomalies encompass a large group of entities, with different pathophysiological mechanisms, clinical features and therapeutical implications. These abnormalities can be divided into congenital and acquired. Congenital anomalies can be further subdivided into abnormalities of the aortic arch (arteria lusoria, right aortic arch, double aortic arch) and aortic coarctation. Thoracic aorta can also be affected by various acquired diseases, including penetrating atherosclerotic ulcers, intramural hematomas, dissection, aneurysms (degenerative, mycotic) and pseudoaneurysms. Clinical Findings/Procedure: The authors evaluated thoracic CT-angiographies performed at our institution between January 2010 and December 2011. All of the above-mentioned anomalies were found, allowing to select the cases that enable illustration of the proposed findings, with complementary review of etiology, clinical features and therapeutical approach. Conclusion: CT-angiography is the imaging modality of choice in the suspicion of thoracic aortic anomalies, allowing proper diagnosis and characterization, as well as appropriate therapeutical orientation (medical vs. classical surgery vs. endovascular repair), precluding the need for further investigation.

Magnetic resonance imaging of pancreas allografts J.K. West 1 Learning objectives: (1) To review the normal anatomy and different types of allografts, including systemic bladder drainage (SBD) and porto-enteric drainage (PED) types.(2) To review the MR appearance of the most common complications acquired 3D-volume. We will present numerous didactic examples in order to illustrate advantages and drawbacks of the systems. We will integrate in the poster the results of 4 scientific studies recently published or in press which will help the reader to further quantify benefit of such navigation systems, and understand the medical population and clinical scenario more prone to benefit from such advanced technologies. Conclusion: This poster will help IRs to understand how, for whom (patient and physician), and when computer-assisted navigation can enhance quality of treatment.

Role of multidetector CT angiography in evaluation of acute gastrointestinal bleeding: a pictorial reviewDepartment of Bioimaging and Radiological Sciences,Institute of Radiology, "A. Gemelli" Hospital -Catholic University, Rome, Italy.Learning objectives: To learn multidetector CT (MDCT) angiography scanning technique for the evaluation of acute gastrointestinal (GI) bleeding, to identify MDCT angiographic findings in acute GI bleeding, and to explain pitfalls in image interpretation that may delay accurate diagnosis of GI bleeding. Background: Acute GI bleeding is a common major medical emergency causing significant morbidity and mortality. Accurate and early diagnosis of the bleeding source is crucial because a condition of hemodynamic instability can lead to death. New MDCT scanners have brought isotropic CT imaging to clinical routine significantly improving vascular imaging and provide analysis of large anatomical volumes with better spatial and temporal resolution of images and shorter acquisition time. As matter of fact, MDCT angiography has become a rapid and non-invasive tool for fast and accurate detection and localization of acute GI bleeding. Clinical Findings/Procedure: The purpose of this presentation is to illustrate MDCT angiography acquisition protocol and to describe images findings for the diagnosis of acute GI bleeding. We also discuss potential pitfalls related to image interpretation and MDCT angiographic findings of acute GI bleeding. Conclusion: MDCT angiography is an available, non-invasive and accurate technique for detection or exclusion of acute GI bleeding.MDCT angiography also provides additional information essential to directing and planning therapeutic angiographic procedures in order to obtain faster selective catheterization of bleeding vessels, thereby facilitating embolization. Learning objectives: This work reviews the latest developments in the field of interventional MR imaging. Special emphasis is given on the pulse sequences used for the real-time monitoring of the device positioning. The factors that influence the accuracy and duration of the different MR-guided procedures are addressed. The ability of MRI to image the tissue thermal changes during the thermal ablation procedures is pointed out. Background: MR has been successfully used to guide different interventional radiology procedures. The possibilities for realtime monitoring, multi-planar and thermal imaging, the high contrast resolution and the absence of radiation exposure are superb features. Clinical Findings/Procedure: Dedicated software and hardware components have been developed to meet the requirements of interventional radiology procedures. Magnet and system designs (cylindrical superconducting high-field large-bore systems), as well as instrumentation material fabrication (low-artifact materials) have been refined to meet the demands of the different procedures. Titanium needles are adequately visualized with acceptable artifact on 1.5 T field strength. Regarding pulse sequences, BEAT IRT and TRUFI are used for instrument real-time positioning, while T2 BLADE is used for reduction of the needle artifact and confirmation of the precise tip location. MR-thermometry can monitor the tissue temperature changes during the percutaneous thermal ablation procedures.

The continuous advances in the magnet systems and the pulse sequences used as well as the instrumentation refinement have made MR-IR a clinical reality.

Lower limb ischaemia due to occlusion of a persistent sciatic artery aneurysm Persistent sciatic artery is a rare congenital anomaly, prone to degenerative atherosclerosis or aneurysmal degeneration. We report the case of an 81-year-old man with lower limb ischaemia due to complete occlusion of a right persistent sciatic artery aneurysm.

Two cases of huge aortic aneurysms of young adults with tuberous sclerosis complex T. Ichikawa, J. Koizumi, C. Ito, N. Nakamura, K. Myojin, T. Hara, T. Sekiguchi, Y. Imai; Radiology, University Hospital, Isehara, Japan.Two rare cases of aneurysms in young adults with tuberous sclerosis complex (TSC) were reported. One was an aortic arch aneurysm and another was a recurrent abdominal aortic aneurysm. Vascular involvement in TSC is caused by heterozygous mutations in TSC2.following pancreas transplantation.(3) To review appropriate scan protocols for the evaluation of pancreatic allografts at 1.5 T and 3 T.(4) To review the relative value of different contrast-enhanced MRA (CE MRA) and non-contrast MRA techniques in the assessment of pancreas allografts, including ultrafast time-resolved techniques. Background: · Pancreas transplantation: clinical indications. · Role of imaging in patients with allograft dysfunction. · Sequence selection, parallel imaging techniques. · Time-resolved versus non-time resolved CE MRA protocols. · Extracellular versus blood pool contrast media. · Artifacts, pitfalls, and ways to minimize these. Clinical Findings/Procedure: · To review arterial anatomy of allografts. · To review venous anatomy of allografts. · To review exocrine drainage anatomy of allografts. · To review MRI/MRA appearance of i. normal pancreas allografts (SBD and PED), ii. arterial complications, iii. venous complications, and iv. acute/chronic rejection. · To discuss relative value of imaging at 3 T versus 1.5 T. Conclusion: MRI is useful for the diagnosis of clinically relevant vascular complications in pancreatic allografts. This educational exhibit reviews the MRI/MRA appearance of normal pancreas allografts as well as its most common complications. Learning objectives: To review the literature for the presentation, epidemiology, etiology, diagnosis, and prognosis of Moyamoya disease. We also review the key imaging features of Moyamoya disease and discuss new neuroradiologic methods that may be useful to better characterize the disease. Background: Moyamoya disease is a chronic progressive cerebrovascular disease characterized by stenosis or occlusion of the Circle of Willis arteries with prominent arterial collateral circulation. Those collateral vessels are small, weak and prone to hemorrhage, aneurysm and thrombosis. The etiology is unknown, and was originally considered exclusive to East Asia. Moyamoya disease is increasingly diagnosed throughout the world but remains an under recognized cause of ischemic and hemorrhagic strokes in Western countries. There is no known cure, and existing treatment options are controversial. Clinical Findings/Procedure: Noninvasive and conventional angiographic studies are gold standard for diagnosis and should demonstrate stenosis or occlusion of the Circle of Willis vessels. Imaging has been concentrated primarily on diagnosing of Moyamoya. Although these applications are important, they ultimately fail to quantify the effects of the condition on cerebral hemodynamics. New imagiologic methods may provide valuable information to address this issue. Conclusion: Although Moyamoya disease is rare, the prompt diagnosis and appropriate management is crucial in improving the longterm prognoses of patients. Future advances may provide a single imaging tool that can fully characterize the disease process at one sitting.

C RSE CIRSE Purpose: Carotid artery stenting (CAS) is becoming an alternative to carotid endarterectomy(CEA). However, restenosis is a postoperative issue, with a reported frequency of 2.27% to 8%. The differences in stent design appear to affect the incidence of stenosis, and the antiplatelet agent cilostazol (CLZ) has also been reported to inhibit restenosis. The objective was to investigate the frequency of restenosis and the effect of Ciostazole in preventing such restenosis after CAS using the Carotid Wallstent (CWS). Material and Methods: Between May 2010 and December 2011, 64 lesions in 62 consecutive patients of CAS using the CWS were performed, and all patients were followed clinically (3.0 to 16.6 months; mean 8.2) and assessed by ultrasonography, 3D-CTA or angiography at three and six months postoperatively. Restenosis was defined as > 50% stenosis, The incidences of restenosis and differences in the incidence of restenosis by the difference in type of antiplatelet agent between the CLZ group (n=31; aspirin 100 mg and CLZ 200 mg) and the non-CLZ group (n=33; aspirin 100 mg and clopidogrel 75 mg (n=30) or ticlopidine 100 to 200 mg (n=3) were retrospectively investigated. Two antiplatelet agents were given starting one week preoperatively until at least three months postoperatively. Results: Restenosis occurred in 6 of the 62 cases (9.7%), but all cases were asymptomatic lesions. All five cases of restenosis were in the non-CLZ group, with no cases of restenosis in the CLZ group; the difference was significant (P=0.0126).

The restenosis rate after CAS using CWS was 9.7%. CLZ significantly prevented restenosis after CAS.

C RSE

Randomized control study of the intravascular ultrasound vs. angiography for the evaluation and treatment of carotid artery stenoses M. Chiocchi, R. Gandini, M. Stefanini, D. Morosetti, A. Chiaravalloti, G. Loreni, G. Simonetti; Diagnostic Imaging and Interventional Radiology, IRCCS Policlinico di Tor Vergata, Rome, Italy.Learning objectives: Primary endpoint was to evaluate the realtime ability of IVUS to identify any technical difficulties or complications during stenting and improve outcomes and patency rates. Background: Intravascular ultrasound (IVUS) and virtual histology, IVUS (VH-IVUS), provide high resolution on vessel imaging in order to plan and perform endovascular procedures. This technique has been extensively validated in the coronary arteries; however, also in the carotid arteries many studies proved a high diagnostic accuracy. Clinical Findings/Procedure: No periprocedural or late complications were observed. No statistical significance was experienced in long-term stent patency between the two groups. Mean length of procedural time in IVUS-assisted procedures resulted 7 minutes longer than non-IVUS-assisted procedures. Virtual histology-IVUS evaluation of plaque morphology led to a different stent choice in three patients. In one case, the IVUS assessment revealed the suboptimal stent deployment, solved by angioplasty; in one patient, VH-IVUS detected plaque protrusion through stent cells, immediately treated by manual aspiration. Conclusion: IVUS and virtual histology-IVUS have proven to be effective for real-time evaluation of CAS, allowing the operator to add additional maneuvers in order to improve outcomes and patency rate.

Worsening of cognitive abilities after carotid endarterectomy and carotid artery stenting M.G. Stanisic Learning objectives: Atherosclerosis of carotid arteries, in many cases asymptomatic, not only increases the risk of severe central nervous system complication like transient ischaemic episodes (TIAs) and strokes but also decreases the quality of cognition. The aim of this study was to compare the effect on cognitive functions of carotid endarterectomy (CEA) and carotid artery stenting (CAS) for asymptomatic carotid artery stenosis. Background: A prospective study was conducted among 32 asymptomatic patients with no neurological deficits, who were admitted for the treatment of carotid artery stenosis. 20 patients consented to participate in the study. 12 were classified for CEA and 8 for CAS. CAS and CEA were performed by vascular surgeons and endovascular specialist with high level of expertise. Before analyzing cognitive functions, quick test of intelligence (Wechsler Adult Intelligence Scale Test) was performed. 8 patients were excluded due to low intelligence quotient. Among the rest of the study group (12 patients: 6 women, 6 men) cognitive functions were evaluated by the Benton visual retention test (BVRT). The measurement was performed 12-24 hours before and 12-14 weeks after revascularization. Statistical analysis of numeric results of BVRT was performed with the use of chi2 test. Clinical Findings/Procedure: Among analyzed patients, 9 (4 women, 5 men) presented worse results in BVRT after revascularization (p<0,05). 1 patient presented better and 2 patients had the same Definitive endovascular treatment of dural AVFs requires obliteration of the site of the fistula: either the diseased dural sinus or the pial vein. We report two cases of dural AVFs that were successfully occluded by embolization with Azur detachable coils.re-sults after treatment. There was no statistically significant difference between those who underwent CAS and CEA. Conclusion: CAS and CEA equally reduce cognitive functions. It can be explained by asymptomatic psycho-organic brain damage due to atherosclerosis itself and embolisation during interventions.

Vulnerable carotid artery plaque imaging L. Saba Learning objectives: This exhibit will have the following sections:(1) classification of plaque type in US-CT-MR, (2) elements associated with the plaque instability: type of plaque, thrombus, intraplaque haemorrhages, fissured fibrous caps and ulcerations. (3) CT, MR and US imaging findings with histological comparison of carotid vulnerable plaque. (4) Limits and potentialities of MR, CT and UC. (5) Algorithm for the automated plaque analysis. (6) Presentation of relevant cases. Background: The vulnerable plaque identifies an atherosclerotic plaque characterized by the presence of a large necrotic lipid core covered by a thin or disrupted fibrous cap with an high tendency to rupture. In this exhibit our purpose is to describe the physiopathology of vulnerable plaque and to review CT, MR and US imaging findings of carotid vulnerable plaque with histological correlation. Clinical Findings/Procedure: In this exhibit the following findings will be presented: intima-media thickness and carotid artery wall thickness, different types of plaque according to the imaging techniques, plaque's complications (fissured fibrous cap, ulcerations, thrombus, and intraplaque haemorrhages). In several cases histological correlation will be presented.

The composition of the plaque of carotid artery as well as its morphology is associated with different levels of risk for the development of cerebrovascular ischemic events. CT, MRA and US allow to identify and characterize those features of plaque vulnerability allowing to identify the correct therapeutical approach.Purpose: To evaluate the safety and effectiveness of MR-guided percutaneous cryoablation of small renal tumors using 17-gauge ultrathin cryoneedles. Material and Methods: Eleven patients (mean age 66.9 years, range 46-80 years) with small renal tumor underwent MR-guided percutaneous cryoablation. A single renal tumor less than 4 cm in diameter was included in this study. Patients received only local anesthesia at puncture site of the skin. Under 0.3-T open MRI guidance, 17-gauge cryoneedles were advanced into the renal tumor. Ablation was performed by 2 freeze-thaw cycles with MRI monitoring of iceball formation. Patients were hospitalized overnight for observation. Follow-up imaging with contrast-enhanced CT and physical examinations were evaluated.

The maximum tumor diameter ranged from 15 to 32 mm (mean, 24.0 mm). The number of cryoneedles ranged from 1 to 5 (mean, 3.0). All procedures were technically successful and MRI could clearly depict cryoneedles and iceball. There was no procedure-related complication or mortality. Mean follow-up period was 10.3 weeks (range, 1-21 weeks). To date 1 patient treated with a single cryoneedle has had evidence of persistent tumor on followup contrast-enhanced CT at 2 weeks and required re-treatment. In other 10 patients treated with multiple cryoneedles, no evidence of recurrence or new tumor development was observed on follow-up contrast-enhanced CT. Conclusion: MR-guided percutaneous cryoablation using 17-gauge cryoneedles was safe and effective for the treatment of small renal tumors. Simultaneous use of multiple cryoneedles helps compensate for the smaller iceball formation of thin cryoneedle.

Focal ablation with robotic high-intensity focused ultrasound for prostate cancer treatment

Interventional Radiology, Samara Oncology Centre, Samara, Russian Federation.

We explored the effectiveness of focal ablation with robotic high-intensity focused ultrasound (rHIFU) treatment for prostate cancer, hormone-resistant prostate cancer (HRPC) and failure after external beam radiotherapy (EBRT). Purpose: To assess the enhancement of lung tumors within 2 years after cryoablation, and to evaluate the necessity of contrast material. Material and Methods: CT images of 49 patients treated with cryoablation for 70 tumors from 2003 to 2010, who underwent followup at least 1 year and evaluated with contrast-enhanced CT at least once, were reviewed retrospectively. Patients generally had a follow-up CT 1 day after the procedure, then 1 week, 1 month, and the at 3-month intervals. All patients underwent 2-phase dynamic contrast-enhanced CT on 1 week. Results: Marginal enhancement was seen on day 1 in 33% (6/18) of cryoablated-zone, and disappeared within 3 months after the procedure. Internal enhancement was seen in 4% (3/70) at 1 week, and disappeared within 1 month. Enhancement was also seen at 6 months or later in 13% (9/70) corresponding to local progression, but did not contribute to earlier detection. On the images at 1 week, a dense and thick rim with (18/31) or without (13/31) enhancement was seen at the periphery of cryoablated-zone which consists of GGO in 44% (31/70), while the remaining 56% (39/70) showed a clearly margined consolidation almost without enhancement. Neither of the findings added value for the evaluation of local progression. Conclusion: Enhancement after cryoablation is variable and our preliminary results suggest that contrast material is not necessary itself for early detection of local progression.

Cryoablation Purpose: To report our initial experience with CT-guided fine cryoprobes for percutaneous cryoablation therapy (PCT) in patients with primary and secondary lung tumors. Material and Methods: Thirty-two consecutive patients (24 men and 8 women) with 34 inoperable lung tumors (12 primary and 22 metastases), mean size 2,7 cm (1 -8 cm) underwent CT-guided fine cryoprobes PCT sessions. The following parameters were evaluated: the number of procedures completed; the number of ablated masses; the rate of overall morbidity and mortality (based on common terminology criteria for adverse events; CTCAE); the results of follow-up CT images. Results: All the procedures were well tolerated. No intra-procedural deaths occurred. No major complications were observed. Morbidity consisted of 21% pneumothorax and 3% cases asymptomatic small pulmonary hemorrhage, respectively, all of CTCAE grade 1. On 6-month CT follow-up scans, complete lack of enhancement was achieved in 91% of treated lesions (p<.000) and technical success tumor maximum size was revealed in 92% cases (p<.000). Low density of entire lesion, central necrosis and mass solid appearance were observed in 62%, 21% and 17%, respectively, of cryoablated tumors. Conclusion: Our preliminary experience confirms that PCT is a feasible and safe technique for the treatment of primary and secondary lung tumors. Our preliminary data also suggest that fine cryoprobe PCT reduces the rate of morbidity and mortality among the patient population. Future well-designed clinical trials with larger patient populations are necessary to further investigate the longterm results and prognostic factors.

Electronic Posters the intended treatment position an angiography and an angiography-based C-arm CT (XperCT™, Philips Healthcare) of the upper abdomen were acquired. Angiographies and XperCT™ were performed from 48 microcatheter positions followed by MAA injections and MAA-SPECT/CT. MAA-SPECT/CT served as the reference standard to determine the accuracy of hepatic arteriography and C-arm CT for the detection of extrahepatic arterial flow. Results: MAA-SPECT/CT revealed extrahepatic depositions in 5 patients (17%). Hepatic arteriography was true negative in 22 (73%), false negative in 5 (17%), and unclear in 3 patients (10%). C-arm CT was true positive in 3 (10%), true negative in 24 (80%), false positive in 1 (3%), and false negative in 2 patients (7%). The specificity and the NPV of hepatic arteriography for the detection of extrahepatic flow were 88% and 81%, respectively. For C-arm CT the sensitivity, specificity, PPV, NPV, and accuracy for the detection of extrahepatic flow were 60%, 96%, 75%, 92%, and 90%, respectively. Conclusion: By detection of extrahepatic flow invisible on conventional angiography, C-arm CT offers additional information when assessing radioembolization patients for extrahepatic flow. Through more accurate detection of extrahepatic flow C-arm CT may optimize the workflow when preparing patients for radioembolization. Disclosure: I am an instructor for the use of TheraSphere (Nordion) radioembolization particels.

Transarterial hepatic chemoperfusion of uveal melanoma metastases: survival and response to treatment 

Technique effectiveness of microwave thermal ablation of hepatic tumors: the series grows, the results do not change , and size of the tumor were analyzed. EASL recommendations and modified RECIST criteria were used for response evaluation of HCC nodules. Partial response and disease progression were considered together as incomplete response. New nodule appearance within 6 months from therapy was considered as early progression disease (ePD). Results: In univariate analysis, there was a statistically significant difference in complete response between central versus superficial tumors (P=0.049), among tumors with pseudocapsule versus incomplete pseudocapsule and without pseudocapsule (P=0.0001), and between tumors with rich versus poor vascularisation (P=0.0016). Every increase of 1 mm in diameter reduces to 5% the probability of complete response. In multivariate analysis, presence of pseudocapsule (vs incomplete or absent) was the only factor significantly associated with response (OR=20.5; 95% confidence interval 1.65-255.7; P=0.0189). Incomplete response was significantly associated with ePD (OR=0.09; 95% confidential interval 0.01-0.78; P=0.0292). Conclusion: CT/MR pattern before TAE is correlated with the treatment response, and should be considered for a proper selection of the patients.

Induction of hypertrophy of the left hepatic lobe by unilateral right-sided radioembolization using 90y-labelled resin microspheres in patients with right-sided secondary malignant liver tumors 

Microwave ablation versus radiofrequency ablation for small liver malignancies: rates of technical success No nontarget embolisation was seen. Most patients were discharged within 24 hours post-procedure. One patient developed an abscess in the embolised liver segment, which was resected at surgery. Less periportal inflammation was observed at surgery compared to previous experience with alternative embolic agents, facilitating efficient dissection. Conclusion: Our PVE technique offers an effective procedure with minimal risk of nontarget embolisation. The achievement of excellent FLR hypertrophy levels enables safe and efficient major liver resections. Future progress will be consequent upon elucidation of mechanisms involved in the hypertrophy response induced by PVE.

Complications of radiofrequency ablation therapy We did not encounter any procedure-related death in our experience. Minor complications were in the form of pain (5.8%), fever (2.2%), and infection (1.8%). 11 of the 16 patients who had post-procedure pain had undergone RFA for aggressive musculoskeletal fibromatosis. Conclusion: RFA is associated with a small percentage of complications, but with adequate precautions is a safe option for non-surgical candidates. Knowledge of procedure-related complications helps in planning the strategy of treatment, early detection and adequate treatment of any adverse events.

Lung thermal ablation (RFA-microwaves) using a real-time needle guidance software combining cone-beam computed tomography and fluoroscopy Learning objectives: To describe two different approaches for portal vein embolization as a preoperative technique before major hepatic resection, and to review the technical challenges and the relationship with complications when the embolization material used. Background: Portal vein embolization is currently used to induce liver hypertrophy preoperatively in patients with indication for major hepatic resection. The technique can be performed using the contralateral and ipsilateral approaches. It depends not only on each team experience but also on the embolization material used. The contralateral approach is the most commonly used but has a major risk of injuring the remnant liver and compromising the resection. Using the ipsilateral approach, complications will only affect the liver that will be resected and do not compromise surgery. Clinical Findings/Procedure: Anatomical and technical challenges, as well as procedure details for both contralateral and ipsilateral approaches on portal vein embolization. Patient criteria for portal vein embolization, possible complications. Description of embolization materials used, such as particles, coils and glue.(3 males and 3 females, mean age 66), with 6 inoperable pancreatic adenocarcinomas (mean tumor diameter 32 cm) were treated with percutaneous microwave ablation in our Radiology Department. All procedures were performed with a percutaneous approach using a single antenna in 5 cases and 2 antennas in the remaining case. Feasibility was defined as a correct antenna deployment into the lesions. Safety was evaluated according to recorded complication immediately after procedure and during the follow-up. Complications were classified according to CTCAE classification in 5 grades of severity. Follow-up was performed with CT scan after 1, 3, and when possible, 6 and 12 months following the ablation procedure.Results: Feasibility was 100% since in all cases antenna were correctly deployed into the tumor. No intra-procedural or immediate post-procedural complication occurred. Four delayed complications were registered in four patients (2 grade 1 complications, 1 grade 3 and 1 grade 4 complication). To date all patients are alive with a mean survival period of 9 months after the treatment.

The results registered in our preliminary experience can be considered encouraging. Further studies with a larger number of patients are needed to assess the effectiveness of percutaneous microwave ablation in the treatment of pancreatic cancer. All were treated at 2 institutions and gave their prior informed consent. They were randomized on a continuous basis into group 1 that did (n=275) or group 2 that did not (n=95) receive iv steroids before TACE. Hypersensitivity reactions occurred in 16 group 1-(5.8%) and 9 group 2 patients (9.5%). In group 1 the median number of procedures, the mean cisplatin dose per TACE session, and the median total cisplatin dose were 3.1 (range [1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] , 55 mg (range 20-80 mg), and 182 mg (range 20-892 mg), in group 2 these values were 3.3 (range 3-10), 56 mg (range 30-78 mg), and 178 mg (range 100-520 mg). The difference between the 2 groups was not statistically significant. However, significantly more patients who did not receive pre-TACE steroid treatment manifested hypersensitivity reactions that elicited serious symptoms (88.9% vs. 37.5%, p<0.027). Conclusion: While the pre-TACE iv administration of steroids failed to prevent hypersensitivity reactions completely, it lessened their severity in patients with HCC.

C RSE We report the first IRE ablation of an HCC lesion surrounding a TIPS stent-graft. After a failed TACE procedure due to arteriovenous shunts, we performed the first ablation of an HCC surrounding a TIPS stent-graft using the non-thermal IRE technology.

Endovascular treatment of pulmonary artery stenosis: a case report

Diagnostic and Interventional Radiology, AC.O. San Filippo Neri, Rome, Italy.A 47-year-old woman complaining of cough and respiratory distress was diagnosed with biopsy-proven malignancy of the right lung. Ce-MDCT revealed tight narrowing of the right branch of pulmonary artery. A stent deployment was achieved with sudden relief of symptoms.

Treatment of We describe the case of 3 hepatic metastasis of primitive neuroectodermal tumor of the small bowel successfully treated with singlestep balloon-occluded percutaneous radio-frequency thermal ablation (RFA) plus transcatheter arterial chemoembolization (TACE) with a good result according to RECIST criteria.

Case of unusual ischemic cholecystitis after TACE: involvement of isolated arteries An 80-year-old female was diagnosed ischemic cholecystitis after TACE, although embolization was performed distal side of cystic artery. In detailed imagery analysis, well-developed isolated arteries acting as collateral of cystic artery was seen at the surface of the liver.Conclusion: Contralateral and ipsilateral approaches are technically possible for portal vein embolization. Different materials can also be used depending on each team experience. Teams have to bear in mind possible complications associated with each specific approach.

Microwave ablation of juxta-cardiac hepatoma: EKG artefact arising from water-pump vibrations U. Pua, K.M. Gummalla; Diagnostic Radiology, Tan Tock Seng Hospital, Singapore, Singapore.Vibration artefacts generated from the water-pump of an internally cooled microwave probe can mimic broad complex tachycardia on EKG monitor during juxta-cardiac tumor ablation. Normal pulse oximetry waveform allows recognition of this artefact and provides an alternative for intra-procedure cardiac monitoring.

Yttrium-90 radioembolization for metastatic liver pheochromocytoma A metastatic liver pheochromocytoma refractory to chemotherapy was treated with yttrium-90 radioembolization. Discussion will center around treatment options, as well as pre-and post-procedure care in this high-risk patient population.

Celiac Transarterial radioembolization is widely used in the treatment of unresectable liver tumors. Celiac axis occlusion can be the limiting factor in selective catheterization of the hepatic artery. We showed a successful approach to radioembolization after celiac axis stent placement.

A short-term result of a patient with pancreatic cancer treated with high-intensity focused ultrasound: a case report Purpose: Popliteal artery entrapment syndrome (PAES) can be a difficult diagnosis to make and the collaboration of clinical history and imaging findings is important. We assess the prevalence of functional PAES over an 18-month period and describe the diagnostic imaging protocol utilised in our tertiary vascular referral centre. Material and Methods: 21 patients were investigated for suspected PAES over an 18-month period. There were 18 males and 3 females. The mean age was 31 years. All patients underwent a duplex ultrasound, arteriography and MRI.Results: There was no evidence of abnormal popliteal fossa anatomy on MRI in any patient. Duplex US and angiographic appearances performed at rest were normal in all patients. Stress imaging with active plantar/dorsi flexion elicited significant arterial compression or occlusion in 11 patients (53%) on duplex and 9 patients (43%) on angiography. These findings are in keeping with functional PAES. Conclusion: Functional entrapment may be more prevalent than previously thought. As PAES symptoms usually arise on exertion, provocation manoeuvres should be incorporated as routine practice during imaging studies. Robust clinical and imaging algorithms are essential in the diagnosis of PAES. We describe the case of two patients with HCC not responding to "Milan criteria" for hepatic transplantation. They were treated with BO-RFA plus TACE with DC-BEAD as a neoadjuvant bridge treatment for understaging HCC, making transplantation possible.

Bronchial carcinoid: an alternative to surgery C. Arena, E. Guidi, A. Cicorelli, A. Lunardi, E. Bozzi, R. Cioni, C. Bartolozzi; Diagnostic and Interventional Radiology, University of Pisa, Pisa, Italy.We present a new non-invasive combined treatment of recurrent bronchial carcinoid. Superselective arterial embolization with embosphere of the lesion was followed by endoscopic laser surgery within 24 hours. Successful lesion excision was obtained, without significant intraoperative blood loss.

Is it possible to obtain an efficacy treatment of hypervascular bone metastases?E. Guidi, C. Arena, A. Cicorelli, A. Lunardi, E. Bozzi, R. Cioni, C. Bartolozzi; Diagnostic and Interventional Radiology, University of Pisa, Pisa, Italy.We describe two cases of hypervascular bone metastases from primary thyroid cancer (papillary/follicular) that were treated with superselective arterial embolization followed by radiofrequency ablation. Excellent pain control and lesion necrosis at imaging were observed during follow up.

Massive liver destruction followed by a biloma formation after radiofrequency ablation for multiple HCC Purpose: Our purpose is to evaluate the clinical outcomes and safety of radiofrequency (RF) ablation of benign nonfunctioning thyroid nodules followed-up for longer than 3 years. Material and Methods: This is a retrospective study. And this study was conducted in a single thyroid center. We evaluated 126 benign nonfunctioning thyroid nodules of 111 patients. RF ablation was performed using the Cool-Tip RF system and an internally cooled electrode. Nodule volume, cosmetic and symptom scores were evaluated before treatment and during follow-up. And complications and factors related to efficacy were evaluated. Results: The mean number of RF sessions was 2.2 ± 1.4, and the mean follow-up duration was 49.4 ± 13.6 months. Thyroid nodule volume decreased significantly from 9.8 ± 8.5mL to 0.9 ± 3.3mL (P < .001) with a mean volume reduction of 93.4 ± 11.7%. The cosmetic (P < .001) and symptom scores (P < .001) improved significantly. Factors related to efficacy were initial solidity and volume. Marginal regrowth was observed in seven nodules. The overall complication rate was 3.6% (4/111). All patients with complications recovered without sequelae and there were no delayed complications. Conclusion: RF ablation is effective in shrinking thyroid nodules as well as in controlling nodule-related problems after 3 years without life-threatening complications or sequelae. These findings indicate that RF ablation is an effective and safe nonsurgical treatment modality for benign nonfunctioning thyroid nodules.

Tryptase as a biomarker for predicting response to transarterial chemoembolization in hepatocellular carcinoma V. Goffredo Purpose: To reveal the effects of elasticity of a bead on the occlusion of a blood vessel by computer simulation. Material and Methods: A moving-particle semi-implicit method was used to simulate blood flow and the motion of a bead. It was assumed that a bead was flowed into a tapered blood vessel having a straight daughter branch. A diameter of the blood vessel where an injected bead stopped was assessed as the occluded vessel diameter, and a deformation ratio of the bead was evaluated. Bead elasticity and blood flow conditions were parametrically varied so as to investigate their effects on the occluded vessel diameter. The range of Young's modulus used was from 1kPa to 60kPa, which includes the elasticity of commercially available beads.

The diameter of blood vessel where the vessel was occluded and the deformation ratio of a bead was significantly affected by the elasticity of a bead. Softer beads passed downstream through the blood vessel by squeezing itself. Stiffening of beads resulted in occlusion of the blood vessel. In effect, highly stiff beads stopped at the portion where the blood vessel diameter was equivalent to the bead size. It was also found that the velocity of blood flow affected the occluding position of the blood vessel. Faster blood flow generates higher blood pressure, which pushed beads into more distal side. Conclusion: Bead elasticity and flow conditions have significant impacts on occluding position of blood vessel, addressing a necessity of taking account of them when choosing a bead size in transcatheter embolization. Results: Twelve patients were included (7 males, mean age 7 years). Lesion location included larynx, pharynx, tonsillar fossae and soft palate. All patients were treated with 3% STS injected trans-orally and/or percutaneously under direct visual, ultrasound and/or fluoroscopic guidance. Trans-oral injection was performed via a rigid bronchoscopic approach. An average of 3 treatments per patient was required (range 1-9). In 4 (33.3%) patients a single treatment provided symptomatic relief. For those patients requiring multiple treatments (n=8), a mean of 4 treatments was required over an average period of 28 months. 83% of patients (10/12) responded well to was used to access the congenital lung malformation (CPAM in two patients and chylothorax in one patient) after fetal anesthesia was administered via intra-muscular injection. A wire was coiled into the cyst/effusion and exchange was made for a pediatric transplant double J ureteral stent through a peel-away sheath, which was deployed with the proximal portion residing in the amniotic cavity. Results: All patients had successful placement of percutaneous drainage catheters and successful decompression of the lung malformation, allowing lung re-expansion, resolution of hydrops and prolongation of pregnancy. The first two babies were born at 30 weeks gestation and are alive and well today. The third fetus is now at 27-week gestation. Conclusion: Seldinger percutaneous approach to draining congenital lung malformations is feasible when these malformations cause pulmonary hypoplasia and fetal hydrops. A multi-disciplinary team of MFM-IR is optimal for proper patient selection and management. Criteria for enrollment in the study were as follows: (1) having a predominantly solid nodule (solid portion greater than 50%); (2) reporting pressure symptoms or cosmetic problems; (3) cytologic confirmation of benignancy at US-guided fine needle aspiration (FNA); (4) serum thyroid hormone and thyrotropin (TSH) levels within normal limits; and (5) refusal of or ineligibility for surgery. Thyroid functions, nodule volumes, and clinical concerns were evaluated before RF ablation at 6-month and last follow-up after RF ablation.

The mean follow-up duration was 43.7±30.7 months (range, 7-92 months). The mean nodule volume was 9.7 ml (0.9-57.6 ml) before the procedure, and was significantly decreased at last follow-up (P < .001) with mean volume reduction rate of 87.2%. The mean symptom score (P = .003) and cosmetic grade (P = .003) were also significantly decreased at last follow-up. The TSH, fT4, and T3 levels were not significantly changed at last follow-up (P > .05), and remained normal in all cases. There were no major complications such as voice change during the procedure and follow-up periods. Conclusion: RF ablation of benign thyroid nodules does not affect thyroid functions in patients with previous lobectomy. RF ablation is the procedure of choice to preserve thyroid functions for these selected patients.

C RSE CIRSE Abstract Book along the arterial tree. A drop of 15-30 mmHg between adjacent segments should raise the suspicion of PAOD in the segment superior to the abnormal reading. Tissue ischemia is associated with an absolute ankle pressure of 35 mmHg or less in nondiabetic patients. The toe brachial index may be utilized in patients with noncompressible vessels. The EST significantly improves test sensitivity for detection of PAOD in patients with claudication. The normal extremity Doppler waveform is high-resistance and triphasic with reversal of flow in early diastole. A low-resistance monophasic waveform is a nonspecific indicator of a proximal stenosis. Conclusion: 1. Noninvasive vascular studies identify patients with lifestyle-limiting PAOD who may benefit from medical and surgical treatment.2. These are well-tolerated studies that are easily performed and provide important quantitative physiologic information regarding the degree and level of PAOD for treatment planning.

The multiple applications of the Amplatzer vascular plug in interventional radiology Clinical Findings/Procedure: The AVP was initially designed to allow the occlusion of peripheral veins and arteries. In our department we have used the Amplatzer vascular plug in a large variety of vascular and non-vascular cases.

The AVP is a simple and cost-effective device, which allows precise occlusion of targeted vessels in various vascular and non-vascular territories in selected cases, this device provides precise delivery and secure positioning with fast procedure times that result in low radiation exposure for physician and patient.

How Learning objectives: To review the anatomy of the male internal pudendal artery (IPA), its collaterals and anatomic variations, and to describe technical aspects and outcome of embolization of the male IPA in the treatment of high-flow priapism (HFP). Background: HFP is a pathologically persisting erection of the penis not associated with sexual stimulation. It is caused by unregulated blood flow in an arteriolacunar fistula between one of the terminal branches of the IPA and lacunar spaces of the corpora cavernosa. Conservative management may resolve up to two thirds of the cases; however, early interventional radiology management is treatment. Complete resolution was achieved in 4 cases (33%) with a significant reduction in size in a further 6 cases (50%). Two patients reported recurrent symptoms despite treatment. There were no significant complications within this cohort. In particular, no patients suffered airway compromise during treatment. Conclusion: STS sclerotherapy offers a highly effective and safe treatment option when managing children with venous malformations of the upper airway. Carefully planned treatment protocols allow reliable symptom control without airway compromise.

Male pelvic arteries revisited: an anatomical-radiological pictorial assay Learning objectives: To review the radiological anatomy of the male internal iliac artery (IIA) using angio-CT and digital subtraction angiography (DSA). Background: Embolization of pelvic arteries is performed in a vast number of clinical settings and a growing interest has been noted in prostatic artery embolization (PAE) for benign prostatic hyperplasia (BPH). In order to avoid untargeted ischemic complications after selective pelvic arterial embolization, knowledge of the radiological anatomy of the IIA is essential. Clinical Findings/Procedure: Pictorial review of over 200 male pelvic sides evaluated with angio-CT and DSA before embolization for various reasons. IIA have been classified by Yamaki in 4 groups according to the pattern of bifurcation of their main collateral branches (the superior gluteal, the inferior gluteal and the internal pudendal arteries). Another large artery that may be found in the pelvis is the obturator artery that arises from the IIA in 2/3 of cases and from the epigastric artery in the remaining 1/3. One important anatomical variant is the accessory pudendal artery that may be found in up to 20% of pelvic sides. In this educational presentation we will review the anatomical and radiological features of the main collateral vessels of the IIA, also focusing on smaller vessels as the prostatic, vesical and rectal arteries.

The most frequent pattern of IIA bifurcation is the type A, followed by types B and C. After being familiarized with the larger IIA collaterals, identification of smaller vessels (prostatic, vesical or rectal arteries) becomes easier.

A. Picel 

Antiplatelet agents: specific agents and their role in interventional radiology

Radiology, University of Colorado, aurora, United States of America.Learning objectives: 1. To discuss the pharmacology, indications, contraindications, relative costs, and side effect profiles of the currently available antiplatelet agents frequently used during interventional radiology procedures. 2. To present the benefits and drawbacks associated with each of the antiplatelet agents. 3. To briefly present literature comparing various antiplatelet agents and their use in endovascular procedures. Background: Antiplatelet agents are commonly used during and after interventional radiologic procedures. Knowledge of these agents is vital for the practicing IR and will be discussed in this educational poster. Clinical Findings/Procedure: Pharmacology, indications and contraindications, relative costs, and side effect profiles of each of the commonly used agents in IR will be presented. In addition, trials comparing antiplatelet agents will also be presented.

At the completion of this poster, the reader will have a better understanding of the available antiplatelet agents used in IR and when one particular agent may prove advantageous over others.believed to provide a better outcome for high-flow fistulas. Clinical Findings/Procedure: The IPA arises from the anterior division of the internal iliac artery and gives rise to several collateral branches (muscular, inferior rectal, perineal-scrotal, bulbar and urethral arteries) and two terminal branches (cavernosal and dorsal artery of penis). The most common anatomic variation is the accessory pudendal artery, which may replace the dorsal artery of the penis. The fistula is usually unilateral and embolization should be performed in a highly selective position, to avoid ischemic complications and preserve the erectile function. The authors review the anatomical and radiological features of the IPA before and after selective embolization. Conclusion: Prolonged priapism has been shown to result in a worsening prognosis for erectile recovery. Successful embolization enables resolution of priapism within 24 hours of the procedure and preservation of the erectile function in most cases. Knowledge of the anatomy of the IPA is paramount for technical success.

Percutaneous management of ureteral stenosis in renal transplant patients

Radiology, Laiko Gen. Hosp. Athens, Athens, Greece.Learning objectives: To present percutaneous nephrostomy and ureteral stenting in the management of obstructive uropathy in renal transplant patients. Background: Ureteral stenosis is a non-rare complication postrenal transplantation. Percutaneous dilatation can be the first choice treatment. Clinical Findings/Procedure: 46 patients with ureteral strictures of the transplanted kidney were managed with percutaneous nephrostomy and ureteral stenting. 46 percutaneous nephrostomies were successfully performed. In 44 patients the placement of ureteral stent was attempted, successfully in 40 (90,9%). Four of these 40 patients were lost at follow-up. In 32/40 patients with ureteral stricture the stent was removed after a mean time of 12 months (range 8-19 months) and 24 (75%) of them did not develop any sign of recurrence at a mean follow-up of 44 months (range 11-80 months). In 4 patients the ureteral stent remains without any problem for a mean time 8,5 months. No major complication was noticed in the above 46 patients. Conclusion: Percutaneous antegrade ureteral stenting is a safe and effective method that contributes to the evasion of a major surgical intervention.

Clinical and imaging 5-step workup protocol of a suspected peripheral AVM 

The use of contrast-enhanced ultrasound in guiding vascular intervention when all else fails

Radiology, King's College Hospital, London, United Kingdom.We describe two fistulaplasty cases in patients allergic to radiological contrast media. These were performed under ultrasound guidance using microbubble ultrasound contrast agents. Both procedures were performed successfully with good quality imaging enabling confirmation of success and the exclusion of complications.

Grade 3 coronary artery rupture complicating a left coronary angioplasty in a case of acute myocardial infarction treated successfully with microcoil embolization We experimented one case of severe coronary perforation during angioplasty practised in acute myocardial infarction. We noticed collapse related with pericardial effusion. It was successfully treated with immediate pericardiocentesis, balloon inflation and then microcoil embolization of left marginal coronary artery.

Cerebral embolization after lymphangiography in a patient with chylothorax: case report

Radiology, Johns Hopkins School of Medicine, Baltimore, MD, United States of America.We describe diffuse cerebral hypoxia and consequent death as a result of oil contrast emboli to the brain and terminal organs in a patient underwent lymphangiography for chylothorax, with a history of Hodgkin's lymphoma treated with radiation therapy. A 61-year-old male on Coumadin for atrial fibrillation presented with severe epigastric pain and dysphagia found to have a paraesophageal hematoma from a bronchial artery pseudoaneurysm. Discussion will revolve around diagnosis, causes, and treatment of bronchial artery pseudoaneurysms.

Stent placement for pulmonary artery anastomotic stenosis soon after living-donor lobar lung transplantation Left pulmonary artery anastomotic stenosis was seen in a 64-yearold man soon after bilateral living-donor lobar lung transplantation. Pulmonary artery anastomotic stenosis was successfully treated with percutaneous transluminal angioplasty and metallic stent placement, using 6 x 18mm Palmaz Genesis.

A novel technique of retrieving a migrated oesophageal stent

Radiology, Raigmore Hospital, Inverness, United Kingdom.A 52-year old patient underwent oesophagogastrectomy for tumour developed anastomotic leak. A stent was placed which migrated into the thoracic cavity. Stent retrieved using a minimal-access technique by CT-guided access and then dilatation with PCNL sheath followed by snaring and retrieval.

Preclinical Purpose: To evaluate the efficacy of a new generation Amplatzer vascular plug micro (AVPM) delivered through a micro-catheter in a canine model under good laboratory practice (GLP) conditions. Material and Methods: The AVPM is a cylindrical self-expanding device with 2 lobes constructed from nitinol braid available in 3, 4, 5 and 6 mm diameters. Twenty-four arteries of 3 dogs were resolution of the pulmonary thrombo-embolism. Conclusion: Percutaneous thromboaspiration alone or with locoregional thrombolysis is a rapid, effective and safe procedure in critical patients with massive pulmonary thrombo-embolism.

Relevance of time-resolved contrast-enhanced MRA during 3-step angiography of the calf in comparison to DSA in patients with peripheral arterial occlusive disease IIb-IV 

The study was designed to assess safety and efficacy of the EXOSEAL™ vascular closure device (VCD) for antegrade puncture of the femoral artery. Material and Methods: In a prospective study from February 2011 to January 2012, 94 patients received a total of 101 procedures via an antegrade puncture of the femoral artery. An EXOSEAL™ VCD was used for closure in all cases. The technique of puncture, the time of manual compression and the use of compression bandage were documented. All patients were monitored by vascular ultrasound and color-coded duplex sonography of their femoral artery puncture site within 12 to 36 hours after angiography to check for major vascular complications. Furthermore, the patients' clinical status and medication were documented. Results: In 101 antegrade angiographic procedures the EXOSEAL™ VCD was applied successfully for closure of the femoral artery puncture site in 97 cases. The VCD could not be deployed in three cases due to malfunction of the EXOSEAL™ VCD itself and in one case due to kinking of the vascular sheath introducer. 12-36 hours after angiographic procedure vascular ultrasound showed no major complications at the femoral artery puncture site in 94 cases. Vascular complications were found in a total of seven cases with four cases of pseudoaneurysms and three cases of significant late bleeding, all not requiring surgery.

The EXOSEAL™ VCD is safely applicable for antegrade puncture, with an overall complication rate of 7% and no major events.

A.J. Lippert 1 Purpose: The objective of this study was to compare two mechanical rotational catheters (Rotarex and Pathway) with regard to their safety and effectiveness in the treatment of stenoses and occlusions of the femoropopliteal arteries. Material and Methods: 156 patients with femoropopliteal lesions were treated, 114 of them with the Rotarex catheter and 42 with the Pathway catheter. The pre-interventional Rutherford classification was on average 3.32 (2) (3) (4) (5) in the Rotarex group and 2.93 (2) (3) (4) (5) in the Pathway group. The mean lesion length was 13.9 (2-30) cm and 5.1 (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) cm, respectively (p<0.05). The ankle-brachial index (ABI) was determined pre-and postinterventionally and after 12 months. (18 stents, 12 PTA) . Primary unassisted patency for IA versus proximal SA at 6, 12, 24 and 36 months was: 100%+/-0, 93%+/-6, 87%+/-9, and 73%+/-10 versus 93%+/-3, 90%+/-3, 87%+/-4, and 84%+/-5, respectively (P=0.01). Primary unassisted patency for proximal versus mid-distal arteries at 6, 12, and 24 months was: 94%+/-2, 91%+/-3, and 87%+/-4 versus 68%+/-9, 63%+/-11, and 50%+/-11, respectively (P<0.0001). Conclusion: Endovascular management of atherosclerotic stenoocclusive disease of innominate and subclavian arteries is more effective in proximal left subclavian arteries compared to innominate arteries and is more effective in proximal subclavian/innominate disease compared to mid-to-distal subclavian disease likely due to muscle and shoulder-girdle motion. Purpose: To evaluate the functional outcomes of endovascular management of symptomatic subclavian atherosclerotic stenoocclusive disease and compare primary balloon-angioplasty to primary stent placement. Material and Methods: Retrospective audit of patients undergoing primary endovascular management of subclavian steno-occlusive disease was performed (02/1997-08/2011) in two institutions. Cohort was divided into balloon-angioplasty group (PTA-group) and stent placement group (stent-group). Recurrence of symptoms warranted imaging confirmation of recurrent arterial disease. Patency was determined by clinical success with or without imaging followup (patency by clinical response). Results: 160 primary endovascular procedures were found. Technical success was 99% (n=158/160). Major complication rate was 3.8% (n=6/160). The overall intent-to-treat primary unassisted and primary-assisted patency of all subclavian endovascular procedures at 1, 4, 6 and 8 years were: 86%+/-3, 75%+/-5, 72%+/-6, and 72%+/-9 vs. 91%+/-3, 87%+/-4, 87%+/-5, and 83%+/-7, respectively. 35 (77% female: n=27/35) were in the PTA-group (mean age: 63, range: and 123 (67% female: n=83/123) were in the stent-group (mean age: 63, range: 39-85). Primary unassisted patency at 1, 3, 4 and 6 years for PTA-group vs. stent-group were: 85%+/-7, 85%+/-7, 85%+/-7, and 81%+/-9 vs. 87%+/-4, 75%+/-5, 73%+/-6, and 70%+/-8, respectively (P<0.001). Primary-assisted patency at 1, 3, 4 and 6 years for PTA-group vs. stent-group were: 97%+/-3, 93%+/-5, 93%+/-9, and 93%+/-6 vs. 91%+/-3, 88%+/-4, 86%+/-5, and 86%+/-6, respectively (P<0.001). Conclusion: Endovascular management of steno-occlusive atherosclerotic disease of the subclavian arteries is very effective in the long-term (>70% unassisted and >80% assisted primary patency at 8 years). Percutaneous transluminal angioplasty appears to have better long-term patency compared to primary stent placement.

C RSE

Effects of placement of a single stent with size discrepant vessels in an animal study H. Cho, M. Nango, Y. Sakai, E. Sohgawa, K. Kageyama, S. Hamamoto, A. Yamamoto, Y. Miki; Radiology, Osaka City University, Osaka, Japan.Purpose: To examine the differences in neointimal hyperplasia (NIH) area after placing a self-expanding (SE) stent with size discrepant vessels. Material and Methods: Subjects were 7 female beagles and target vessels were the abdominal aorta and right common iliac artery (CIA). A nitinol SE stent was placed so that it was normal-sized in the aorta and oversized in the CIA. Angiography was performed immediately after stent placement and again at 1 and 3 months, whereas stent diameter and NIH areas were measured using intravascular ultrasound. Animals were killed at 3 months and histopathological examination was performed. Furthermore, the chronic outward force (COF) of the same SE stent as what was used in this experiment was investigated with in vitro testing. Results: NIH area was seen on the iliac artery side of the stent at 1 month (5.1 ± 4.2 mm2), and at 3 months (7.8±2.5 mm2). NIH area was not seen on the aorta at any time. NIH area was significantly larger on the iliac side than on the aortic side time-dependently (at 3 months; p<0.005). In pathological examination, NIH thickness on the iliac side was also significantly greater than on the aortic side. The COF in the same size as aorta and iliac artery was 0.17 and 0.73 Newton respectively. Conclusion: When placing in a single stent with size discrepant vessels, NIH area was significantly increased at the oversized region. We need to note the difference to the NIH. Purpose: The purpose of the study was to evaluate the acute success and clinical impact of retrograde transpedal access for retrograde below-the-knee (BTK) chronic total occlusions (CTO).

The clinical and angiographic data of 40 consecutive patients with CLI treated by retrograde transpedal recanalisation between 2010 and 2011 were evaluated in a pilot study. We examined the one-month major adverse events (MAEs). Clinical success was defined as relief of resting pain, healing of ulceration or avoidance of amputation. After re-entry to the true lumen failed or the guidewire passage was unsuccessful during anterograde approach, the anterior tibial or posterior tibial artery was punctured under fluoroscopic guidance. Results: 36 (90%) of 40 procedures were finished successfully with a good angiographic result and flow; the failure rate was 10% (2 unsuccessful puncture, 1 failed reentry and 1 unsuccessful retrograde passage). Limb salvage at one month was 92.5%. Balloon angioplasty was performed in all successful interventions and provisional stenting was done in 17 patients (42.5%). One major and three minor vascular complications occurred (1 tibial artery occlusion and 1 spasm) in the investigated population (2.5 and 7.5%). The onemonth MAE in the investigated population was 10 (3 major amputations and one cardiac death). Conclusion: Failed antegrade attempts to recanalise CTO-s of BTK vessels can be salvaged using a retrograde transpedal access, with a low complication rate. This technique could be valuable for patients with critical limb ischemia due to femoropopliteal and infrapopliteal occlusions once larger studies with follow-up confirm safety and efficacy.The majority of subjects presented with hypertension (73.3%) followed by smoking (68.3%), history of PAD (63.3%), and hyperlipidemia (61.7%). About one-third of the subjects were diabetics, 56.7% were in Rutherford Class 3 and 26.7% in Class 2. Six months late lumen loss data will be available upon presentation. Conclusion: Preliminary outcome data suggest a reduction in late lumen loss in favour of the paclitaxel-releasing balloon versus the uncoated balloon in subjects with femoropopliteal lesions. Disclosure Research Grant BIOTRONIK.

Rheolytic thrombectomy for limb ischemia: interim report of a prospective multi-center registry

Interventional Radiology, Christiana Care Health, Newark, DE, United States of America.Purpose: To report registry data in which limb ischemia (LI) was treated with rheolytic thrombectomy. Material and Methods: A 2-phase ongoing voluntary registry of the MEDRAD Angiojet catheter used in the treatment of upper and lower extremity LI was examined. Electronic data capture case report forms were filled out by clinical site staff capturing patient LI history, procedural information including adjunctive treatments and adverse events. Phase 1 followed patients to a 3-month follow-up documenting symptomatic improvement. The ongoing phase 2 will follow patients through 12 months.Results: Of the current 710 treated vessels (307 patients), 89% showed significant occlusion at baseline, whereas final angiography showed only 7% remained significantly occluded (p<0.0001).In patients classified as acute, 90% were significantly occluded at baseline and only 5% were significantly occluded at final angiography (p<0.0001). In chronic patients, there were 86% significantly occluded at baseline and only 10% were significantly occluded at final angiography (p<0.0001). At 3-month follow-up, patients reported the following regarding their current condition: 73% reported their condition improved, 15% remained unchanged, and 12% worsened. Of the patients treated, there was an 8% bypass rate and only a 7% amputation rate. Conclusion: Angiojet rheolytic thrombectomy used both with and without thrombolytic is an effective and safe treatment in both acute and chronic arterial limb ischemia. 

Revascularization in digital branches of the foot: new challenges for preserving foot functionality after pedal recanalization L.M. Palena, B. Cesare, B. Domenico, A. Candeo, I. Alek, M. Manzi; Interventional Radiology Unit, Policlinico Abano Terme, Abano Terme, Italy.Learning objectives: To illustrate the endovascular treatment of digital branches of the foot, in cases of diabetic patients with distal wounds on the toes, in order to avoid minor amputations. Background: Recanalization of the tibial vessel and foot arteries is a well-established treatment option for limb salvage in diabetic patients with critical limb ischemia (CLI) and foot lesions. The role of percutaneous transluminal angioplasty (PTA) is supported by recent data. In diabetic patients, foot salvage is possible today, but for a complete preservation of the foot functionality toe revascularization represents a new challenge to avoid amputations. This exhibit illustrates technical and anatomical aspects regarding recanalization of the digital branches of the foot, illustrating the indications through sample cases. Clinical Findings/Procedure: The purpose of this poster is to illustrate technical aspects and indications of digital artery recanalization after pedal recanalization through the presentation of cases of digital arteries revascularization. Conclusion: Recanalization of foot digital arteries is possible and in selected cases could be necessary to increase the blood flow in the distal wound on the toes, helping the ulcer to heal, thus avoiding minor amputation, or supporting surgical incision healing and thus maintaining foot functionality.

Electronic Posters recanalization and predilatation were carried out from tibial access and final angioplasty with or without stent placement was performed from the femoral access. The patients were followed for functional improvement and arterial patency. Antegrade access was performed from the common femoral artery and retrograde access was performed from the anterior tibial (in 12 limbs) and posterior tibial artery (in 10 limbs). Retrograde tibial approach resulted in final procedural success in 18 (82%) of patients. One patient had thrombosis of the accessed tibial artery which was successfully treated with anticoagulation alone. Conclusion: Retrograde tibial recanalization technique in infrainguinal complex arterial occlusion increases success rates of percutaneous recanalization in failed antegrade approach. This is a feasible endovascular option with minimal complication rates to avoid more invasive, time-consuming or costly procedures.

Percutaneous treatment of traumatic upper extremity arterial injuries: a single center experience G. Carrafiello, M. Mangini, F. Fontana, A.M. Ierardi, F. Piacentino, C. Pellegrino, C. Fugazzola; Radiology, University of Insubria, Varese, Italy.Learning objectives: To assess the feasibility and effectiveness of emergency percutaneous treatment for traumatic injuries to upper extremity arteries. Background: Between January 2000 and December 2007, we observed 11 patients (mean age 49.9 years) with traumatic (11 cases) injuries of upper extremity arteries (3 pseudoaneurysms, 4 occlusions (probably due to dissection in 3 cases and to a mural hematoma in 1 case), 3 transections; one lesion involving axillary artery (6 cases), subclavian artery (3) and brachial artery (2). Pseudoaneurysms and transections were treated with stent-graft (6), dissections and mural hematoma were treated with bare stent (2) or angioplasty (PTA) (3). Follow-up (mean 45.1, range 12-81) was performed with color Doppler ultrasound (CDU) at 1, 3, 6 and 12 months during the first year and then yearly. Clinical Findings/Procedure: Immediate technical success was obtained in all cases. No major complications occurred. One incomplete thrombosis of radial artery recanalized after 1 month with systemic medical therapy. During a mean follow-up of 45.1 months, 1 stent-graft occlusion occurred and it was treated with intra-arterial pharmacological thrombolysis (urokinase 60.000 UI/hour for 12 hours). Overall primary clinical patency rate was 95.2% and secondary success rate 100%. Conclusion: Percutaneous treatment is a feasible and safe tool for injuries of upper extremity arteries because it can provide a fast and definitive exclusion of bleeding or a resolution of acute ischemia. This approach, thanks to its low invasiveness, can be proposed as first-line treatment in patients with lesions of upper extremity arteries.

Successful endovascular treatment for rare arterioureteral fistula H. Tanaka Arterioureteral fistula is rare life-threatening condition and emergent treatment is required. We present 2 cases of massive bleeding arterioureteral fistula and successful stent graft treatment. Angiographic findings are pseudoaneurysm and massive ureteral with time to flow restore after arms' adduction.

1. 3T magnet with quick volumetric sequence and bilateral synchronous venous injection allows the visualization of both veins and arteries with both abducted and adducted arms and short execution time.2. Synchronous bilateral contrast injection evaluates venous flow slowdown due to compression in both limbs simultaneously with a single injection during and after arms' abduction.3. This technique discrimination between arterial and venous obstruction and points out the site of compression, offering highvalue preoperative anatomical information.

Dynamic Learning objectives: MR protocol and sequences were used for the evaluation of vascular thoracic outlet syndrome. The objectives were to describe the normal anatomy of the thoracic outlet on axial, sagittal and reconstructed three-dimensional images, and to illustrate the findings of vascular thoracic outlet syndrome on dynamic MR. Background: Thoracic outlet vascular syndrome is produced by the compression of vascular structures in the interscalene triangle, costoclavicular space and retropectoralis minor space. The imaging diagnosis is based on dynamic angiography to evaluate the vascular structures. Dynamic MR angiography provides an excellent tool to evaluate the vascular findings, arterial and venous, localization and causes of the compression. Clinical Findings/Procedure: We present our experience in the vascular outlet syndrome with dynamic MR angiography. Pulse sequences, regional anatomy and relevant findings in arterial and vascular involvement are commented and illustrated. Conclusion: Dynamic MR angiography provides a correct arterial and venous map of the thoracic outlet and demonstrates the causes and localizations of the thoracic outlet syndrome. Learning objectives: To describe the technical aspects of retrograde tibial approach and balloon predilatation for recanalization of complex infrainguinal arterial occlusions and to determine its efficacy in minimizing failure rates. Background: Infrainguinal arterial occlusions can be difficult to treat by endovascular means especially in long segment occlusions and failure of the endovascular approach may result in amputation in patients with CLI. After failed revascularization attempt, 40% to 50% of patients will lose their leg within 6 months, and up to 20% will die. Few reports exist on intervention retrograde tibial approach for infrainguinal arterial occlusion. Five-year-old child developed tracheo-innominate fistula after tracheoplasty with a bovine pericardium for congenital tracheal stenosis treated successfully with stent graft implantation. It is a rare condition with a high mortality. Stent grafts are good option of treatment. Purpose: The aim of the present study was to determine the dose reduction to patients undergoing to electrophysiology procedures, after the introduction of an optimization program combined with a focused training program on radiation protection.

This study observed 11 patients undergoing implantable cardioverter defibrillators (ICD) and 34 patients undergoing different procedures of electrophysiology. The peak skin dose (PSD) was measured using radiochromic XR type RV2 films. The impact after introducing several optimization actions has been evaluated, comparing PSD with the Mann-Whitney test before and after optimization, for the two samples of patients Results: The procedure optimization lead to a statistically significant PSD reduction for both biventricular ICD ((2,94 vs 1,03 Gy, P<0,0001) and electrophysiology procedures (2,96 Gy vs 1,05 Gy, P=0,007). On patients with PSD greater than 3 Gy a follow-up was arranged, as recommended by ICRP report no. 85: no damage was reported for any patient. Conclusion: Poor basic knowledge on radiation protection and non-optimized exposure parameters were the mean causes for high patient dose before our program. It is relevant to point out that this study was commissioned by the Electrophysiology Lab. Several optimization actions combined with a focused training program on radiation protection brought significant results in reducing radiation dose to patients. extravasation at iliac artery. Peripheral stent graft treatment is an effective alternative method. We present a successful case of combined retrograde and antegrade subintimal recanalization of superficial, popliteal, tibioperoneal trunk and the peroneal arteries through an occluded dorsalis pedis artery, leading to the achievement of complete infrainguinal subintimal recanalization and foot wound healing.

Microcoil repair of a post-traumatic arteriovenous malformation of the hallux, in a high-performance: a case report Multilayer-flow-diverter stents have been successfully used to treat a variety of peripheral aneurysms, except popliteal. We describe a case of successful exclusion of a popliteal aneurysm using a flowdiverter stent, with infrapopliteal PTA, clinical/CT follow-up and 6 months percutaneous re-intervention. Percutaneous transgluteal embolisation of symptomatic IIA aneurysm was performed in prone position in 73-y/o male patient 6 years after open repair of ruptured CIA aneurysm utilizing microcoils and plugs with preserving of superior to inferior gluteal artery collateral.

Electronic Posters non-significantly higher vessel opacification (p=0.07) and reduced image noise (p= 0.381) in all segments resulting in non-significantly higher CNR (p=0.159) and SNR (p=0.152) values compared to the standard 120 kV protocol using filtered back projection. There was no difference in the subjective image quality and subjective image noise. DLP was significantly lower using 100 kV (90,6±7.9 vs. 228,3±38,3 mGy*cm; p<0.001).

The use of 100 kV tube voltage, a high pitch and raw data-based iterative reconstruction in DSCTA of the supraaortic arteries allows for radiation dose reduction of 60% without influencing diagnostic confidence.

Evaluation of the dose to skin of patients in interventional radiology using radiochromic film P. Chabrot, J. Guersen, F. Magnier, V. Chassin, M. Labattu, L. Cassagnes, L. Boyer; Radiologie B, CHU Clermont-Ferrand, Clermont-Ferrand, France.

To determine the interest of radiochromic films (RCF) to quantify and map dose issued to skin of patients in interventional radiology, and to compare those data with indicators given by facilities.Material and Methods: RCF were used for 75 procedures which can issue doses to skin likely to exceed the threshold of 3 Gy (threshold of determinist effect). Calibration of the films was conducted, with 2 qualities of X-ray beam (81 and 117 kVp), for Ka values from 10 cGy to 11 Gy. Following their reading, the images of the films were broken down in 3 colors (red, green and blue). Calibration curves were created for the red, green and blue colors. The total uncertainty of the measurement of the dose was calculated taking into account the experimental uncertainty and ionization chamber uncertainty. The calibration of TLDs was conducted for Ka values of 50, 100 and 200 cGy. Results: RCF indicated dose to skin that PKS and Ka could underestimate. During the study period, they have identified 12 patients for which the dose to skin exceeded 3 Gy (Ka issue from angio-suites was less than 3 Gy), justifying a particular medical follow-up (skin effect risk). The measures carried out with the TLDs validate the method used with films. Conclusion: The use of RCF allows measurement of the maximum dose received in the skin taking account of overlapping fields (+areal distribution), with results quickly obtained at the end of the procedure. The study confirms that the Ka should not be used to estimate dose to skin.

Six-year follow-up using patient dose diagnostic reference levels in interventional radiology as part of a national program Purpose: Radiation exposure to interventionalists is increasing. Current standard radiation protection devices are heavy and do not protect the head of the operator. The aim of this study is to evaluate the effectiveness and comfort of caps and thyroid collars (TC) made of a disposable, light-weight, lead-free material (XPF) for occupational radiation protection in a clinical setting. Material and Methods: Up to two interventional operators were randomized to wear XPF or standard 0.5mm lead-equivalent TC in 60 consecutive endovascular procedures requiring fluoroscopy. Simultaneously a XPF cap was worn by all operators. Patient and procedure data were registered and radiation doses measured using dosimeters placed outside and underneath the caps and TC. Wearing comfort was assessed at the end of each procedure on a visual analog scale (0-100, with 100 optimal). Results: Patient and procedure data did not differ between the XPF and standard protection group. The cumulative radiation dose measured outside the cap was 15700 μSv and outside the TC 21240 μSv. Measured radiation attenuation provided by XPF caps (n=70), XPF TC (n=40) and standard TC (n=38) Conclusion: Caps and thyroid collars made of XPF provide a lightweight, disposable option for effective personal radiation protection in an interventional setting. Disclosure: BloXR (Salt Lake City, UT) provided the XPF caps/thyroid collar and radiation detectors for study purposes.

Ultra low-dose dual source CT angiography of the supraaortic arteries using 100kV tube voltage, a high pitch and raw databased iterative reconstruction: preliminary results D. Beitzke, R. Nolz, G. Edelhauser, D. Berzaczy, C. Plank, F. Wolf, J. Lammer, C.M. Loewe; Department of Radiology / Division of Cardiovascular and Interventional Radiology, Medical University Vienna, Vienna, Austria.

To evaluate image quality, diagnostic confidence and radiation dose using 100kV tube voltage and second generation iterative image reconstruction for high pitch dual source CT angiography (DSCTA) of the supraaortic arteries in comparison to a 120kV standard protocol using filtered back projection. Material and Methods: DSCTA of the supraaortic arteries was performed in 20 patients randomly using either 100kV, 3.2 pitch and raw data-based iterative reconstruction or 120kV, 2.4 pitch and filtered back projection. Contrast-to-noise ratio (CNR) and signal-tonoise ratio (SNR) calculations were performed to objectively evaluate image quality in 7 vascular segments. For the evaluation of subjective image quality and subjective image noise a four-point scale was applied to 15 vascular segments in each patient by two readers. The dose-length-product (DLP) was used to compare the differences in radiation dose.

The use of 100 kV and iterative reconstruction showed S270 C RSE CIRSE Abstract Book different between the groups. Cement injection was more convenient using the screw-injector system. Conclusion: Using a dedicated screw-injector system and lead glove shielding reduce significantly radiation dose delivered to the radiologist hands during vertebroplasty.

Radiation dose reduction in the angiography and interventional radiology suite

Medical Imaging, Flinders Medical Centre, Adelaide, SA, Australia.Learning objectives: Learning objective included extensive literature review and a range of phantom studies to determine optimum radiation dose reduction strategies and possibility to significantly reduce everyday radiation dose. Background: It was found that the radiation dose equivalent of 55000 chest x-rays could be saved in one year by simple protocol variation when comparing CT scanning protocols in two similar Medical Imaging departments. This raised the question of how much radiation was used in the angiography and interventional radiology suite and would it be possible to save the equivalent of 55000 chest x-ray examinations? Clinical Findings/Procedure: Auditing baseline radiation dose levels showed that all examinations were within normal ranges. It was calculated that an overall dose reduction of 22 per cent over one year would save a dose equivalent of 55000 chest x-rays. Major reductions in procedural radiation dose were immediately achieved following introduction of dose reduction strategies. An average of 90 per cent dose savings has been achieved for all interventional procedures. Even lengthy procedures such as TIPS that require up to 60 minutes of fluoroscopy and hundreds of images are now performed at radiation dose levels in the low to mid-range scale of radiation dose for medical imaging examinations. Conclusion: Changes in protocol were introduced. All interventional procedures at Flinders Medical Centre are now performed at 10 per cent or less of previous norms. Low radiation doses are now used for what previously were considered dangerously high radiation dose procedures. Radiation doses for diagnostic angiography procedures have also been heavily reduced.

Unenhanced magnetic resonance angiography of renal arteries: 51 patients Purpose: To assess the feasibility and performance of a nonenhanced 3D balanced steady state free precession sequence (NATIVE) compared to gadolinium-enhanced magnetic resonance angiography (CE-MRA) as the reference standard to detect renal artery stenosis. Material and Methods: 51 patients with arterial hypertension, renal failure, or as part of an evaluation of peripheral arterial disease were included in this prospective study. NATIVE and CE-MRA were performed on 1.5 T system (Siemens). Signal quality and stenosis grade were assessed per segment for renal arteries, and for ostia of celiac trunk and superior mesenteric artery (SMA). We compared signal 

The registration and follow-up of patient dose values using a national database to set DRLs helped to reduce patient doses and to improve radiation safety awareness in the IR community and, at the same time, to fulfill the national and European patient protection regulations.

Percutaneous fluoroscopy-guided vertebroplasty: prospective randomised study of the radiation exposure to the operator comparing two different cement injection systems, with and without lead glove shielding G. Tsoumakidou, S. Loos, X. Buy, J. Garnon, N. Claus, A. Gangi; Non-Vascular IR, University Hospital of Strasbourg, Strasbourg, France.Purpose: To compare the radiation exposure of the radiologist using a Luer-lock syringe, a dedicated screw-injector system, and lead protective gloves. Material and Methods: Percutaneous vertebroplasty was performed in 46 patients (109 levels) under fluoroscopic guidance by three experienced interventional radiologists. Patients were randomly separated into three groups. Cement injection was performed in group A (14 patients) using a Luer-lock syringe, in group B (16 patients) a dedicated screw-syringe with a connection tube and in group C (16 patients) a dedicated screw-syringe and lead protective gloves. Parameters recorded were type of fracture, radiation dose to: right-left hand, under the apron of the radiologist and to the patient per vertebra and during injection, injection-time, complications-leaks and difficulty of injection.

The mean radiation dose on the right hand of the operator was: 174.11 and 48.22 μGy for groups A and B, respectively (p<0.0005), and on the left hand: 78.67 and 27.03 μGy (p=0.001). Radiation dose reduction was 72% and 65% for the right and left hand, respectively, using the screw-injection system. A non-significant difference was found for the doses calculated under the radiologist's apron and for the patient. Lead glove shielding resulted in a radiation dose reduction on the hands of 46%. The duration of the injection, volume of cement injected and number of leaks were not S271

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Nine-year single centre experience of radiofrequency ablation for renal tumours Purpose: To report the long-term efficacy of RFA use in treatment for renal tumours in terms of survival, complications and effect on renal function. Material and Methods: Retrospective analysis of 73 sessions of RFA in 60 patients was performed. The survivals were analysed using Kaplan Meier survival curves. The renal function (eGFR) was assessed before and after one month from the procedure. Results: The median patient age was 66. 53 patients had a single session, 5 patients had 2 sessions and 2 patients underwent 5 sessions. The mean size of renal mass treated was 3.1 cm with SD 1.4 (range 1-6cm). Ablation sizes ranged from 2 to 7cm with a mean of 5 cm. On 4-to 6-week follow-up, six patients had incomplete ablation. In 4 of these patients residual tumour was successfully re-ablated, in one patient repeat RFA was not performed and one case was opted for radiological surveillance. Four patients had recurrence on subsequent imaging after an initial good response. The survival measured 96.2%, 88.4%, 77.3%, 66.7%, 50%, and 36% at one, two, three, four, five and nine years, respectively. The median survival for the whole group was 58 months. Five sessions of RF ablation resulted in major procedural complication: 2 large peri-renal abscesses, one peri-renal haematoma and two cases of perforated colon that underwent laparotomy and defunctioning colostomy. Three sessions resulted in worsening of eGFR at one-month follow-up with a mean deterioration of 8.7. Conclusion: RFA for renal tumours has good long-term efficacy with few complications and no significant effect on the renal function. Purpose: To compare the survival in patients undergoing RFA for renal tumours with single vs. bilateral kidneys. Material and Methods: 60 patients with a renal tumor were treated with 73 sessions of RFA over a period of nine years. Out of 60 patients, 12 patients had a single kidney while 48 patients had bilateral kidneys. Survival was calculated and compared in both groups using Kaplan-Meier curves.

The parameters of both groups in terms of age, sex, size of lesion treated and size of ablation performed were comparable and not significantly different. The median survival time for patients in the single kidney group was 67 months vs. 49 months for patients with bilateral kidneys. Between 38 and 68 months, patients with a single kidney showed improved survival. Below 32 months and above 68 months, the proportion of bilateral kidney patients estimated to be alive was larger than the proportion of single kidney patients estimated to be alive. A log rank test was performed which showed a non-statistically significant p value (=0.9069 > 0.05) at a statistically significance level α=5%.

There was no significant difference in long-term survival between the two groups.quality of NATIVE and CE-MRA. Sensitivity, specificity, negative predictive value and accuracy were calculated. Results: 114 renal arteries, 51 celiac trunks and 51 SMA were evaluated. 20 significant stenosis were found on CE-MRA for renal arteries, 10 stenosis and 3 occlusions for celiac trunk, and 3 stenosis for SMA. At artery-by-artery analysis, sensitivity, specificity, accuracy and NPV of NATIVE in detecting stenosis were, respectively, 85%, 96%, 94% and 96% for renal arteries, 100%, 97%, 98% and 100% for celiac trunk, 100%, 100%, 100% and 100% for SMA. No significant difference for signal quality was found for the global exam and for the different segments evaluated, except for hilar and intrarenal branches that had better signal quality on NATIVE sequence.

The high NPV in our study suggests that nonenhanced NATIVE sequence can be achieved by first intention to eliminate RAS in patients at high risk of nephrogenic systemic fibrosis.

Renal artery aneurysms. First human treatment with the multilayer flow modulator stent 

Partial splenic artery embolization in HCV-related cirrhosis prior to pegylated interferon-based therapy 

Although several studies have reported that partial splenic embolization (PSE) is effective in hypersplenism, there are few studies in hepatitis C virus (HCV)-related cirrhosis prior to interferon (IFN)-based therapy. Therefore, we decided to evaluate preand post-PSE effect on various hematologic parameters before IFNbased therapy. Material and Methods: Partial splenic embolisation was performed in 9 patients with HCV-related cirrhosis who could not receive IFNbased therapy because of thrombocytopenia. Demographic, clinical and laboratory parameters (hematologic and liver function profile) pre-and post-PSE were recorded. Conclusion: Partial splenic embolization is an effective therapeutic modality for the treatment of thrombocytopenia; hypersplenism secondary to HCV-related cirrhosis and allowed safe use of peg-IFN-based therapy. It is a simple, rapid procedure that is easily performed under local anaesthesia; and it allows preservation of adequate splenic tissue to safeguard against overwhelming infection.

C RSE CIRSE Abstract Book no benefits were observed in the absence of significant SPG. Conclusion: Measuring translesional pressure gradient can be useful to guide endovascular treatment and predict clinical response to angioplasty of renal artery FMD stenosis.

Initial experience with embozene microspheres for prostatic artery embolization: Purpose: To assess technical and clinical outcomes on prostatic artery embolization for benign prostatic hyperplasia using embozene microspheres. Material and Methods: This is a prospective study from July to November 2011. It is a initial experience using embozene microspheres to perform prostatic artery embolization for benign prostatic hyperplasia. Nine patients aged 59-81 (mean 68 years) were treated with embozene microspheres (250 to 500m). Technical and clinical outcome were analyzed at three-month follow-up. Poor outcome after PAE considered when 1 criteria was met: international prostate symptom score (IPSS) ≥20 and/or reduction <25%; quality of life (QoL) ≥4 and/or reduction <1; peak urinary flow (Qmax) improvement <2.5 mL/s; additional treatments required.

The mean initial prostatic volume was 93 cc. In all these patients we observed a reduction in prostatic volume in three months. In three patients we met at least one criteria for poor clinical outcome. We observed clinical improvement in the remaining six patients at three months follow-up. Conclusion: Although the short follow-up period and the sample size, in one-third of cases we had poor clinical outcomes. The remaining patients had significant improvement.

Is endovascular treatment of visceral aneurysms a viable alternative to surgery?M. Bossalini, E. Epifani, A. Modoni, C. Bosi, A. Ranalli, S. Bruni, C. Marcato, P. Larini, C. Rossi; U. O. Radiologia, sez. Radiologia Interventistica, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy.Learning objectives: To verify the effectiveness of endovascular visceral aneurysms therapy, proposed as a viable alternative to open surgery. Background: 21 patients underwent percutaneous endovascular treatment for 23 visceral aneurysms: 9 splenic arteries, 6 renal arteries, 3 hepatic arteries, 2 superior mesenteric arteries, 2 pancreaticduodenal arteries and 1 celiac trunk. 18 aneurysms were asymptomatic; 3 patients had aspecific abdominal pain. Indications were due to a rapid growing lesion or aneurysms of 2.0 cm or more in diameter. Endovascular therapy consisted of coil embolization (78%) or stent-graft implant (22%). Clinical Findings/Procedure: Immediate technical success was achieved in 20 cases. Complication occurred only in one case due to distal embolization just after stent implantation in an hepatic artery; resolved after thrombolytic therapy. With a follow-up ranging from 4 months to 5 years, successful results, defined as effective placement of devices into the vessel or into the aneurysm, complete exclusion of the aneurysm from the flow and lack of flow through the aneurysm during follow-up, were obtained in all cases. There were no cases of acute or delayed organ failure. Conclusion: Visceral aneurysms are uncommon high-risk lesions. Guidelines for percutaneous endovascular therapy are not yet avail-

Super selective arterial embolization with absolute ethanol during micro-balloon occlusion for angiomyolipoma of the kidney Y. Kodama, Y. Sakurai, S. Tatsumoto; Radiology, Teine Keijinkai Hospital, Sapporo, Japan. Purpose: To evaluate the safety, feasibility and effectiveness of super-selective arterial embolization with absolute ethanol during micro-balloon occlusion for angiomyolipomas of the kidney. Material and Methods: From 2007 to 2012, eight angiomyolipomas of the kidney treated by super-selective arterial embolization with absolute ethanol during micro-balloon occlusion were enrolled this study. 4 patients had solitary lesions without tuberous sclerosis. A patient with tuberous sclerosis had multiple lesions and treated 4 lesions for three procedures. Age ranged from 25 to 59 years (median 34). Tumor volume was ranged from 58 to 475ml (median 171). Absolute ethanol was injected when 3.3F micro-balloon inserted to the tumor feeding artery sparing normal branches as distal as possible for nephron preserving policy. Technical success was defined whether feeding artery cannulation was successful or not. Technical success, complication, serum creatinine level change, associated renal infarcted volume, and tumor volume change after 1 year were assessed. Results: Amount of absolute ethanol was ranged from 3 to 10ml (median 7). All procedures were technically successful. No complication was occurred. Creatinine level change was -0.03 to 0.23mg/dL (median 0.11). Associated renal infarcted volume was 0-15ml (median 0). Tumor volume compared to that before procedure was 2-34% (median 19) in 6 lesions. Two lesions had not been followed one year. Conclusion: Super-selective arterial embolization with absolute ethanol during micro-balloon occlusion for angiomyolipomas of kidney is safe, feasible and effective treatment and minimizes the renal damage.

PressureWire assessment of fibromuscular dysplasia during renal artery angioplasty I. Fiorina, T. Cascella, N. Cionfoli, L.P. Moramarco, M. Torresi, P. Quaretti; Diagnostic and Interventional Radiology Department, Fondazione Policlinico S. Matteo, Pavia, Italy.Purpose: Fibromuscular dysplasia (FMD) is one of the most common causes of secondary hypertension but the lesions are often complex and difficult to quantify. We compared the imaging evaluation of the FMD stenosis with functional transtenotic gradient measured by PressureWire.

We performed a retrospective analysis of all consecutive patients with renal fibromuscular dysplasia underwent endovascular intervention between January 2008 and September 2011. The patients were 5 young women (43±13 years old) with poorly controlled hypertension. We studied the lesions with preoperative contrast-enhanced MRI and selective renal artery angiography, then we evaluated their hemodynamic significance through a 0.014" guidewire distally provided with a micropressure sensor (PressureWire, St Jude Medical), without any vasodilator injection. Therefore, we monitored the antihypertensive therapy and the blood pressure values before the discharge and at 1 month follow-up. 

C-arm CBCT image-guided transcatheter arterial embolization with n-butyl 2-cyanoacrylate for renal arteriovenous malformation

Radiology, Showa University Hospital, Tokyo, Japan.Learning objectives: We would like to introduce our method of C-arm CBCT image-guided transcatheter arterial embolization (TAE) with n-butyl 2-cyanoacrylate (NBCA) for renal arteriovenous malformation (AVM). Background: Using a C-arm angiography system with a flat-panel detector cone-beam CT (C-arm CBCT), three-dimensional (3D) image acquisition and real-time procedural evaluation can be performed in one room without having to move the patient. Clinical Findings/Procedure: C-arm CBCT image-guided TAE with NBCA for renal AVM was performed in 4 patients (1 man, 3 women, age range 25-63 years) with 5 renal AVM. Our method was as follows: percutaneous transfemoral catheterization using Seldinger's method was employed. Selection of main feeding artery into AVM that was made on a 1-mm slice C-arm CBCT showed AVM. We rotated 3D image to the best position where we could see the virtual main feeding artery. C-arm angle was synchronized with the 3D image to the best position. So we can select main feeding artery easily. Embolization into the nidus was performed alternatively with a mixture of NBCA and lipiodol. Successful embolization was achieved in 4 patients without procedural complications (success rate: 100%). Conclusion: C-arm CBCT image-guided TAE with NBCA for renal AVM is an efficient procedure.able. In our opinion visceral aneurysms of more than 2.0 cm in diameter localized outside the parenchyma or of increasing size need to be considered for treatment. The unfavorable prognosis in case of rupture suggests an aggressive attitude towards visceral aneurysms. The positive results obtained suggest that endovascular treatment of visceral aneurysms can represent a viable alternative to surgery. Learning objectives: The incidence, time of development, angiographic findings of renal artery lesion associated with Moyamoya disease. The distinction of intervention for renal artery stenosis associated with Moyamoya disease. Background: Moyamoya disease is an idiopathic cerebrovascular occlusive disease characterized by progressive stenosis or occlusion at circle of Willis and development of fine collaterals (Moyamoya vessels). It is known that renal artery stenosis can develop in some part of Moyamoya patients, but detailed clinical features are not clear. Clinical Findings/Procedure: We previously reported 7% incidence of renal artery stenosis by prospective study with renal angiography simultaneously performed with brain angiography for Moyamoya patients. But since then we have experienced the cases with newly developed renal artery stenosis and restenosis after cerebrovascular lesion had become stable. Therefore, it is estimated that the lifelong incidence of renal artery stenosis can be higher. It is very important to treat renovascular hypertension so as to avoid brain hemorrhage that is high risk for adult Moyamoya patients. Most of the stenosis is short and occurs at proximal part of renal artery. PTRA is effective but we have experienced the cases of resistant to balloon dilatation and restenosis after PTRA. Conclusion: It is important for Moyamoya patients to monitor with caution for the renovascular lesions even after the cerebrovascular lesion had become stable. PTRA is effective; however, it may be required supposing the possibility of bypass surgery or renal autotransplantation in future, because the majority of patients are young and there are cases of resistant to balloon dilatation and restenosis.

Selective embolization for recurrent high-flow renal arteriovenous fistula with aneurysmal change caused by selfstabbing in a hara-kiri suicide attempt 

Dissection of the celiac trunk as a rare complication following liver transplantation: description of a case and endovascular management We present the rare case of a dissection of the celiac trunk occurring 3 weeks after liver transplantation. The dissection led to a subtotal occlusion of the hepatic transplant artery. Endovascular rescue through stenting was achieved via a transbrachial approach.

Spontaneous adrenal haemorrhage without underlying adrenal abnormality In a patient with fibromuscular dysplasia, multiple fusiform and saccate aneurysms of both renal arteries were successfully treated by the implantation of a multilayer stent in the right main renal artery and embolisation of peripheral aneurysms.

Retrograde access for SMA stenting 

A successful coil packing of an aneurysm of the inferior pancreaticoduodenal artery (IPDA) achieved by balloon angioplasty and stent placement for severe stenosis of the superior mesenteric artery (SMA)A. Ikoma, M. Nakai, T. Sonomura, N. Kawai, H. Sanda, K. Nakata, H. Minamiguchi, M. Sato; Radiology, Wakayama Medical University, Wakayama, Japan.An aneurysm 20mm in diameter of the IPDA was successfully treated with coil packing, which was achieved by balloon angioplasty and stent placement for severe stenosis of the SMA using a pull-through technique from the celiac artery.

Stent-assisted coil embolization using a partial stent to treat a wide-necked aneurysm at the renal artery bifurcation O. Ikeda, Y. Nakasone, S. Inoue, K. Yokoyama, Y. Tamura, Y. Yamashita; Diagnostic Radiology, Kumamoto University Graduate School of Medical and Pharmaceutical Sciences, Kumamoto, Japan.We successfully used stent-assisted coil embolization and a partial stent to treat a 53-year-old woman with a wide-necked (20 mm) aneurysm at the renal artery bifurcation. The aneurysm was detected incidentally at CT for ureterolithiasis.

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Hepatic vein embolisation to increase future liver remnant volume prior to hepatic resection A.J. Wigham, J. Harris, A.M. Papadopoulou, A. Goode, N. Davies, D. Yu; Interventional Radiology, Royal Two patients with end-stage kidney disease on chronic haemodialysis and hypertension resistant to pharmacologic treatment underwent catheter-based renal denervation of both renal arteries. Angio-CT and Holter pressure were evaluated before the procedure. Follow-up was scheduled at 30 days after procedure.

Percutaneous oocyte retrieval complicated by obturator artery hemorrhage, managed by covered coronary stent

Radiology Department, Mater Misericordiae University Hospital, Dublin, Ireland.A young woman with subfertility underwent percutaneous oocyte retrieval. Post-procedure, she suffered from acute hemorrhagic shock and was transferred to IR. Emergency angiography revealed an obturator pseudoaneurysm and haemorrhage. A vessel preservation technique using a coronary covered stent was used. end-stage liver disease) and splenic volumes. Results: 18 patients were included. Mean nominal and percentage change in hepatic volume was +195cm3 +/-221 (range -60 to +766cc) and +12% +/-18 (range: -4 to +78%), respectively (p=0.0017). 39% (N=7/18) of patients had significant increase (>10% increase) in hepatic volume and none had significant decrease (>10% decrease). 72% (N=13/18) of patients had an increase in splenic volume after BRTO of which 6 were significant (>10% increase). There were no pre-BRTO predictors (MELD or splenic volumes or hepatic volumes) of significant hepatic volume increase. However, those with significant hepatic volume increase were more likely to have post-BRTO improved MELD and splenic growth (p=0.031 and p=0.044, respectively). Conclusion: Hepatic volumes increase significantly after BRTO with approximately 40% exhibiting increase hepatic volumes exceeding 10%. There are no predictors of increased hepatic volumes post-BRTO. However, significantly increased hepatic volumes (>10% growth) are associated with better and improved hepatic reserve.

Management of portal vein stenosis by interventional stent application B.A. Radeleff, U. Stampfl, C.M. Sommer, N. Bellemann, N. Kortes, H.U. Kauczor; Diagnostic and Interventional Radiology, University of Heidelberg, Heidelberg, Germany.Purpose: Over a time interval of 3 years 8 consecutive patients (6 males and 2 females with an age of 50.7±5.7 years) were referred to our department with a portal vein stenosis (diagnosis by CT/ MRI). The portal vein stenosis was due to a previous liver transplantation in 4 cases, in 3 cases due to a pancreas or cholangiocellular carcinoma and in 1 case it was caused postoperative after Whipple operation.

The access to the portal vein was achieved percutaneously by CT guidance or by TIPS procedure. In 7/8 patients, portal vein stenosis was treated technically successful by stent application (balloon expandable stent in 4 patients and selfexpandable stent in 3 patients). In 1 patient (2.5-year-old girl after liver transplantation) we performed a plain old balloon dilatation. Results: 2 patients showed (1 week and 1 year, respectively, after the stent application) an occlusion and stenosis, which were treated successfully by an additional balloon-expandable stent. We observed no minor or major complications. The 30-day mortality rate was 0%. Conclusion: Interventional portal stent application due to a stenosis is a safe and effective procedure to curatively treat portal vein stenosis with a high technical and clinical success. The choice of the optimal access path depends on previous surgical procedures of the liver, the liver function and the possible presentation of ascites.

Interventional thrombolysis of portal vein thrombosis using transjugular intrahepatic portosystemic-stent-shunt approach B.A. Radeleff, J. Krause, C.M. Sommer, N. Bellemann, N. Kortes, U. Stampfl, H.U. Kauczor; Diagnostic and Interventional Radiology, University of Heidelberg, Heidelberg, Germany.Purpose: To evaluate retrospectively our experiences with interventional thrombolysis of acute or subacute thrombosis of the portal vein (PV) using the transjugular intrahepatic portosystemic-stentshunt (TIPS) approach. Two patients with BRTO unmanageable gastric varices first underwent coil embolization of the outflow vessel beyond the gastric varices via the percutaneous transhepatic approach followed by the injection of sclerosing agent. One-year follow-up gastroendoscopy showed no recurrence of gastric varices. We present two cases of endoscopically unmanageable rectal varices that were treated by balloon-occluded antegrade transvenous sclerotherapy followed by microcoil embolization. Microcoil embolization caused less burden to the patient. Follow-up endoscopy confirmed eradication of the rectal varices. We present a 53-year-old man with portal hypertension who underwent cystectomy with urinary diversion for bladder carcinoma. 21 months later he presented gross haematuria due to ileal conduit varices. Transcatheter variceal embolization with cyanoacrylate glue and coils was successfully performed.

Benefits To describe the advantages, the technique and the effectiveness of the double approach, transhepatic and transjugular, in endovascular treatment of a steno-occlusion of the portal vein, non-transplantation related, compared to single intercostal access.

Successful balloon-occluded retrograde transvenous obliteration (BRTO) with cyanoacrylate under temporary portal venous occlusion for duodenal varices K. Sofue, Y. Arai, Y. Takeuchi, K. Shibamoto, T. Nakamura, N. Shiba; Diagnostic Radiology, National Cancer Center, Tokyo, Japan.Bleeding duodenal varices was successfully embolized by BRTO with cyanoacrylate under temporary portal venous occlusion of transhepatic balloon catheter. This is an alternative procedure when usual BRTO failed to achieve adequate accumulation of ethanolamine oleate due to unembolized afferent vessels.

Primary 

Interventional radiology management of post-partial nephrectomy complications 

Long-term results after prolonged ureteral stenting in cases of obstructive uropathy post-renal transplantation P. Pappas, P. Leonardou; Radiology, Laiko Gen. Hosp. Athens, Athens, Greece.Purpose: Renal transplantation is an effective treatment for endstage renal disease. Ureteral stenosis is the most frequent urologic complication. We report our long-term follow-up results concerning percutaneous treatment of ureteral obstruction after renal transplantation. Material and Methods: 35 patients with renal transplant obstructive uropathy were managed percutaneously. Nephrostomy was performed successfully in all 35 kidneys. Balloon dilatation and antegrade ureteral stenting was attempted, which was successful in 33 patients (94.2%). Success was defined as a reduction in hydronephrosis with subsequent drop in plasma urea and creatinine levels.No major complications were observed. The ureteral endoprosthesis remained in place for a long period of at least 12 months in all these patients. Results: After prolonged ureteral stenting (mean duration 15 months), the stent was removed in all patients, 30 (90.9%) of whom had no recurrence. Conclusion: Percutaneous prolonged ureteral stenting can replace open reconstructive surgery because they have a high success rate and they can also offer a definitive treatment with low morbidity.

Electronic Posters complication in the partial nephrectomy group that required primary ureteral repair and one complication in the cryoablation group that required embolization after treatment of an 8 cm lesion with a nephrometry score of 10X. Overall there was no difference in the nephrometry scores of each group and patient selection was primarily due to urologists' choice. Conclusion: Our data show that cryoablation is safe, and as effective compared to partial nephrectomy in a similar nephrometry score group of patients. Considering the less cost and less hospital stay it is probably underutilized. Clinical Findings/Procedure: Procedure includes posterior or posterolateral access below the twelfth rib. Renal hilum, vessels and renal parenchyma should be avoided. After local anesthesia under US-guidance 5 F pig tail catheter is inserted and cyst fluid is aspirated, with volume recording. 20 min after 95% ethanol instillation, in quantity of 30-50% of aspirated volume, alcohol is reaspirated and catheter is removed. In 2010 at our department a total of 15 pts was punctured with the intention of renal cyst sclerosation. In 11 pts sclerotherapy was successful. Cyst size was 6-12 cm. Average volume of instilled alcohol was 37% of the aspirated cyst volume. We had no major complications. 4 pts underwent only puncture and aspiration of cyst content because of bloody and thick cyst content, proximity to peripelvic structures, and severe pain. Technical success rate for sclerotherapy was 73%. Conclusion: US-guided percutaneous sclerotherapy of simple renal cysts is safe, quick, effective, inexpensive, and minimally invasive procedure. 

Utilization of "nephrometry score" to assess outcomes of percutaneous cryoablation versus partial nephrectomy in management of renal cancers Purpose: To evaluate outcomes percutaneous cryoablation and surgical partial nephrectomy utilizing predictive value of nephrometry score. Nephrometry score is a commonly used tool by urological practices to predict surgical outcomes. Material and Methods: All patients who underwent percutaneous cryoablation and partial nephrectomy during the past 2 years in our institution were reviewed. Their nephrometry scores were identified by measuring lesion diameter, distance from hilum, anatomical position, as well as presence or absence of exophytic component. All pre-procedure and post-procedure images were reviewed for scoring. Complication rates, hospital stay, procedure cost and recurrence rates were assessed. Results: 27 patients underwent cryoablation and 127 patients underwent partial nephrectomy. Median follow-up for partial nephrectomy group was 4.5 months and cryoablation was 13.3 months. There were no recurrences in the cryoablation group and 6 recurrences in the partial nephrectomy group. This was not statistically significant with a P value of 0.2. There was one major S282 C RSE While the patients with no fatigue (FSS<2.0) or mild/moderate fatigue (FSS 2.0-3.9) did not report significantly changed fatigue, the patients with severe fatigue (FSS≥4.0) experienced statistically significant drop of FSS scores, which in this subgroup was 1.21. Such variables as the patients' sex, age, duration of the disease or localization of vascular lesions did not influence the level of postprocedural improvement of fatigue. Conclusion: Our results confirm the findings of the previous studies that have found positive effect of endovascular treatment on chronic fatigue in multiple sclerosis patients. Despite all limitations of our study, an improved fatigue, especially severe one, appears to be an encouraging finding, warranting further studies in this area.

Clinical usefulness of thin slice CT to detect right adrenal vein for adrenal venous sampling S. Onozawa, H. Yamaguchi, H. Tajima, S. Murata, K. Nakazawa, T. Mine, T. Ueda, S. Kumita; 1 Radiology, Nippon Medical School, Tokyo, Japan.Purpose: To support adrenal venous sampling (AVS), thin-slice abdominal-enhanced CT (TECT) is performed to identify right adrenal vein. The purpose of this study is to assess the usefulness of TECT for AVS in comparison with angio-CT during AVS. 

Safety and effectiveness of the multifunctional vena cava filter system

Dept. Vascular Surgery, AZ St-Blasius, Dendermonde, Belgium.WITHDRAWN case, an endovenous laser was used to remove a particularly lodged filter. Finally, a hydrophilic wire was used to retract the filter into the sheath above. Results: All cases showed excellent angiographic results. All patients were discharged the following day with no immediate or medium term complications. Conclusion: IVC filter extraction can be a challenging task for the interventional radiologist with high rates of failure reported in the literature. We describe a novel method successfully used to retrieve IVC filters with long dwell times in three patients.

Adrenal venous samplings: usefulness of coaxial guidewire placement into the right adrenal vein for repeated samplings Purpose: Selectivity of adrenal vein catheter is essential before interpretation of adrenal venous sampling (AVS) which is the gold standard to identify lateralized, surgically curable source of primary aldosteronism. Many centers use repeated AVS protocols, before and after ACTH stimulation. The aim of this study is to evaluate guidewire insertion into the right adrenal vein catheter to maintain AVS selectivity (adrenal/peripheral cortisol ratio (Ca/Cp)) over time.Material and Methods: A 0.014 inch guidewire was inserted into the right adrenal vein to secure the 5 F catheter and facilitate blood drawing. Plasma cortisol levels from the left and right adrenal veins and from the left iliac vein were assessed in 110 consecutive patients undergoing bilateral simultaneous sets of AVS performed at -5 and 0 minutes before (basal), and +5, +10 and +15 minutes after (stimulated) intravenous bolus administration of 250 μg of ACTH. Ca/Cp ratio of ≥2 for basal and >10 for stimulated AVS were considered selective.Results: 36/110 (32.7%) right and 35/110 (31.8%) left sets of AVS were excluded because the first AVS was not selective or missing (3). 72/74 (97.3%) right and 72/75 (96,0%) left AVS that were selective in the first AVS were still selective in the last sampling. Complications from guidewire insertion were low, with only 2 (2.7%) cases demonstrating contrast media extravasation around the right adrenal vein during procedure. Conclusion: Guidewire insertion into the adrenal vein to stabilize the right adrenal vein catheter is a safe and effective method to maintain AVS selectivity over time.

Change in chronic fatigue severity after endovascular treatment for chronic cerebrospinal venous insufficiency in the Purpose: Attempts to recanalize chronic central venous occlusions with conventional endovascular techniques are often unsuccessful. Therefore, an alternative therapeutic strategy is necessary to treat symptomatic patients. Purpose: To evaluate the short-term results of endovascular venous recanalization for repositioning of implantable cardioverter defibrillator (ICD) in patients with venous stenosis or thrombosis after implantation of ICD. Material and Methods: Between September 2010 and October 2011, 7 patients (4 males, mean age 58 years) with ICD for the treatment of malignant ventricular arrhythmia or cardiac arrest, considered at high risk for sudden cardiac death, and who had subsequently developed venous stenosis or thrombosis, underwent endovascular venous recanalization and immediate replacement of a new ICD. The primary aim of the study was to evaluate the safety and efficacy of the procedure.

The procedure was successfully performed in all patients.No major periprocedural (bleeding, hematoma, thromboembolic events, cardiac perforation during the introduction of the electrode wires) or late complications (displacement of electrode wires or infection) occurred. Patients were hospitalized for a mean of 7 days.

The implantation of medical devices as ICD has significantly increased in recent years. However, the management of patients with ICD is complex especially in relation to infective and vascular complications, caused by these devices. Endovascular treatment with venous percutaneous angioplasty and ICD replacement can be considered a safe and effective therapeutic option, in the setting of a multidisciplinary experience team.

Small changes, big results: fighting the bug V. Rachapalli Purpose: Infection of peripherally inserted central catheters (PICC) is associated with increased patient morbidity and costs. We set a goal of significantly reducing infection and re-insertion rates at our institution. Purpose of the study was to evaluate the impact of simple practice changes on major outcomes like catheter-related infection and reinsertion rates. Material and Methods: Given that a vast majority of PICCs are placed by the radiology department at our institute, all catheter insertions were required to follow a specific procedural protocol, which included: higher puncture site, default use of single lumen catheters, change of skin disinfectant and staff education. Results: Of the 2336 lines inserted during the study period of 13 months, 1497 catheters were placed using the new protocol. The infection rate dropped from 3.3% to 1.4% (p<0.005) and the reinsertion rate dropped from 22% to 12.5% (p<0.001). The key components of the new protocol were: changing the insertion site to a higher location in the upper arm, regular use of a single lumen catheter unless there was a clinical requirement for a dual lumen catheter, use of 2% chlorhexidine (CHG) -70% isopropyl alcohol (IPA) to prepare skin and staff education. Previous insertion site location varied between inserters, double lumen PICCs were preferentially used, 0.5% CHG -70% IPA was used for skin disinfection. Conclusion: Reducing catheter-related sepsis, catheter occlusion and venous thrombosis are critical in a central venous access service. Simple measures, easily implemented, had a significant impact on reducing catheter-related infection, reducing re-insertion rates, and patient morbidity.

Electronic Posters there was no significant difference between the pure left adrenal and right adrenal. If adopting cortisol-corrected aldosterone ratio from high-side to low-side >4 as unilateral aldosterone excess, the results from common trunk and pure left adrenal differed in 3 cases (5%). Conclusion: Super-selective left AVS can avoid the blood dilution due to IPV and alter the final judgments in a few case. Because it can equalize the condition to right, we think it is preferable and recommend left AVS at before and after the IPV joining.

A Learning objectives: This exhibit familiarizes the audience with available IVC filters, their indications, and retrieval mechanisms. We also review usual and unusual complications of placement and retrieval. Background: Venous thromboembolic disease is a significant source of morbidity and mortality in the United States. With the advent of the Mobin-Uddin filter in 1967, patients refractory to or with contraindications to anticoagulation have been treated with IVC filters. Since retrievable filters were introduced in the 1990s, they have also been used prophylactically in high risk patients. Although filter effectiveness is subject to much debate, they are used with increasing frequency and complications both usual and unusual are also increasingly seen. Each filter type has advantages and disadvantages and the clinician and interventional radiologist must be familiar with the available types to optimize selection. Clinical Findings/Procedure: We provide a comprehensive pictorial review of available IVC filters and retrieval mechanisms with indications for placement and retrieval. In addition, we share our experience with filter complications including usual cases of filter migration, penetration through the IVC wall, thrombosis, fracture, and difficult retrievals along with unusual cases seen at our institution. We include cases of a self-extricating filter fragment through the cardiac wall, bowel and aortic penetration, unintentional aortic and lumbar vein placement, failure to open, and difficult endobronchial forceps retrieval with IVC perforation among others. Conclusion: It is important for both clinicians and radiologists to familiarize themselves with various IVC filters, their retrieval mechanisms, and their potential complications. IVC filter complications can range from the mundane to the truly outrageous.

Symptomatic pulmonary embolus during lower extremity deep venous thrombolysis: the role of IVC filters.

Department of Radiology and Medical Imaging, University of Virginia Health Systems, Charlottesville, VA, United States of America.

Adrenal venous sampling in the evaluation of primary hyperaldosteronism: a decade of experience at a single institution Purpose: To investigate the clinical impact of adrenal venous sampling (AVS) in the evaluation and management of primary hyperaldosteronism in the era of modern imaging. Material and Methods: We conducted a retrospective study of 98 (51 women) consecutive patients (average 51.1yo) with hyperaldosteronism who underwent adrenal venous sampling between 1999 and 2010. We evaluated imaging (CT or MRI) findings and AVS results to determine their rates of concordance and discordance. We defined discordance as AVS results that would imply different management than imaging alone would suggest. Relevant imaging findings were adrenal nodules and adrenal thickening. We also noted whether the finding was bilateral or unilateral and the laterality of unilateral lesions. We used a ratio of aldosterone/cortisol 

The diagnostic value of super-selective left adrenal venous sampling for primary aldosteronism The diagnostic radiologist should always aware the treating physician prior to surgical and interventional procedures. Familiarity with the imaging features of congenital and pathologic entities that can affect the IVC is the key to the correct diagnosis and management. 4. Images as well as interesting cases/variations elucidating various issues raised in above sections will be provided. Conclusion: This poster will provide a useful review on managing filters in complex cases and will update the reader, on techniques to deal with difficult filter retrievals. Manual compression to puncture site. Conclusion: Treatment methods for refluxing ovarian veins have included laparoscopic ligation and resection using a retroperitoneal approach. However, surgical options usually require patient admission and the risks of a general anaesthetic. Ovarian vein embolisation by way of transjugular approach seems to be a safe alternative which is carried out as a day case and is well tolerated by patients. Studies reporting the long-term efficacy of the procedure are still required.

Is IVC looking different? Learning objectives: The objectives were to review the embryogenesis of the inferior vena cava (IVC) and describe the most common variations in IVC anatomy, and to recognize the clinical and surgical implications in identifying these anomalies. Background: Due to complex embryological development of the IVC, a broad spectrum of congenital anomalies and pathologic conditions can occur in venous anatomy. Although most anomalies are asymptomatic and are encountered incidentally, it is essential to be aware of these variations and their imaging appearance in order to avoid diagnostic pitfalls. Imaging plays a crucial role in the diagnosis and management of diverse conditions that affect the IVC. Their correct identification is useful in the planning of vascular interventions and prevents their being mistaken for disease. Clinical Findings/Procedure: The exhibit will include a discussion about embryogenesis and a picture review of well-known anatomical variants of the inferior vena cava (IVC), such as duplicated IVC, left sided IVC, absent IVC, azygos continuation of IVC, absent infrarenal IVC, high bifurcation of the IVC, complete agenesis of IVC and megacava.

The knowledge and identification of congenital anomalies of the inferior vena cava has an important diagnostic value given the potential clinical and surgical implications they entail.

Electronic Posters

The patients' clinical evaluation before IVC filter placement is crucial to decide if the filter will be placed infra or eventually above the renal veins. We should consider anatomical and technical differences on placing the filter below or above the renal veins as well as its potential complications.

Hook, line and sinker: a difficult case of filter retrieval U. Salati, A. Hurley, R. Browne, W.C. Torreggiani; Radiology, Adelaide and Meath Hospitals Incorporating the National Childrens Hospital, Dublin, Ireland.A 39-year-old man underwent retrieval of IVC filter inserted 18 months previously. It was imbedded and eventually required triple access via both internal jugular veins and right femoral vein and a series of snares and wires for removal. In order to evaluate ACTH secretion from the very small lung tumor, we adopted retrograde pulmonary venous sampling via corresponding segmental pulmonary artery with occlusion balloon catheter. The blood showed high ACTH level and resected specimen revealed ACTH producing carcinoid.

Life-threatening brain edema caused by acute occlusion of superior vena cava (SVC) stent K. Sofue, Y. Arai, Y. Takeuchi, K. Shibamoto, T. Nakamura, N. Shiba; Diagnostic Radiology, National Cancer Center, Tokyo, Japan.We report a case of brain edema caused by acute occlusion of SVC stent. This complication potentially leads to complete venous shut down of SVC and life-threatening situation. Immediate diagnosis and countermeasures are indispensable to avoid possible irreversible brain injury.

Coil embolization assisted with a coil anchor through ultrasound-guided direct puncture of stomal varices A 67-year-old man with history of cirrhosis and ileostomy for operated ulcerative colitis had stomal bleeding. CT and ultrasound revealed bleeding from stomal varices. Coil embolization assisted with a coil anchor through ultrasound-guided direct puncture of the varices was successfully performed.

In patients with IVC thrombosis with or without filter, endovascular treatment provides high technical and clinical success rates with acceptable patency rates.

Vena cava filter (VCF) removable: a single center experience with a single "device" F.A. Vizzari, D. Laganà, G. Carrafiello, D. Lumia, G. Xhepa, G. De Marchi, M. Mangini, F. Fontana, C. Fugazzola; Radiology, University of Insubria, Varese, Italy.Learning objectives: To evaluate the safety of the removal of both short-and long-term VCF final removable type ALN. Background: From 2002 to 2010, 201 VCF of the type "final/removable" were placed percutaneously. In 109/201 patients, the VCF was placed with absolute indications, in 77/201 the VCF was been placed for relative indications and in 15/201 the VFC was placed for temporary filtration. Follow-up was performed with echo-color-Doppler and X-ray of the abdomen at 3 and 12 months, then annually. Indications for removal were: the absence of contraindications to anticoagulant therapy and pulmonary embolism, the patency of the venous iliac-caval axis. All the candidates of removal of VCF have performed a CT angiography. Clinical Findings/Procedure: The release with correct position of the VCF ("tilting" < 15 degrees) was achieved in all cases with technical success of 99,01%. In 2 (0,99%) cases it was verified a "tilting" >15 degrees. Hematomas occurred in only 8 jugular access site which resolved spontaneously. Were removed 26/201 VCF with a technical success 96.16% of the VCF. In 7/26 it was necessary to a double approach, right jugular and femoral access. The VCF was removed after placement at 6 months in 11 patients, at 12 months in 8 patients, at 24 months in 4 patients and at 36 months in 3 patients. There were no peri-procedural complications.

The removal procedure is more difficult than the positioning procedure. Technical success of the removal procedure is directly proportional to the "tilt" of the VFC. The filter still does not have the extremes of certain absolute removal. Learning objectives: To describe the indications for IVC filter placement above the renal veins and to review the procedure details of IVC filter insertion in this location and its clinical implications. Background: Most IVC filters are placed in the infra-renal inferior vena cava with the upper part of the filter placed just below the level of the lowest renal vein. However, supra-renal IVC filter placement can be performed in some clinical situations: IVC thrombus extending above the renal veins, renal vein thrombosis, previous IVC interruption, patent large ovarian vein, pulmonary emboli despite IVC filter, duplicated IVC and pregnancy. Clinical Findings/Procedure: IVC filters can be placed by either femoral or jugular approach. Before the IVC filter placement, a cavogram should be obtained to evaluate caval diameter and patency, as well as venous anomalies and extent of thrombus. This allows predicting the desired final position of the filter. Also, the location of renal veins should be assessed. Compared with infra-renal IVC, supra-renal is larger and shorter, more variable with cardiac dynamic and pressures. These differences contribute to the choice of the filter with some associated risks. The method of deployment depends on each filter. A final cavogram is performed to evaluate the position and stability of the filter.

C RSE A 23-year-old female was readmitted after kidney transplantation with graft dysfunction and repeated severe bleeding from rectal varicosis. CT scan showed aplastic infrarenal IVC. After stent recanalisation (bioresorbable, nitinol) of the IVC graft function normalized and no further bleedings occurred.

Retrieval of Optease filter using rigid forceps T.G. Van Ha, C. Straus, L. Kang, J. Lorenz, B.S. Funaki; Radiology, University of Chicago, Chicago, IL, United States of America.We present the use of rigid endobronchial forceps in three patients in the retrieval of Optease filters. The indwelling time ranged from 5.6 to 7.3 months and two patients had failed primary attempt. All three filters were successfully removed without complications.

Author Index

Please note that bold numbers indicate presenting authors and P-numbers stand for electronic poster presentations.