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Abstract No. 311: Deployment performance and retrievability of the Cook Celect inferior vena cava filter: A single institution experience
Abstract No. 309 Radioembolization of advanced hepatocellular carcinoma using 90Y-resin microspheres: Mid-term results in a single institute experience L. Carpanese1, G. Pizzi1, R. Sciuto2, G.E. Vallati1, S. Rea2, A. Annovazzi2, L. Romano2, M. Crecco1, C.L. Maini2; 1Diagnostic Imaging and Interventional Radiology, IFO Regina Elena Cancer Institute, Rome, Italy; 2 Department of Nuclear Medicine, IFO Regina Elena Cancer Institute, Rome, Italy. Purpose: To evaluate the efficacy and effectiveness of a group of patients (pts) with multinodular and unresectable hepatocellular carcinoma (HCC) who underwent 90Y Radioembolization at midterm follow-up. Materials and Methods: 75 pts with unilobar and bilobar HCC were treated. 42% of pts had previous treatments. Lobar, segmental or superselective treatments were performed according with the tumor sites, hepatic function, and vascular dynamics. None of them had liver replacement ⬎50%. Overall response rate, recurrence and survival rate were evaluated. Follow-ups were performed at three-month intervals. Assessment of response rate was based on multiphasic CT evaluation basing on EASL classification modification of WHO criteria. Results: Median follow-up was 18 months (range: 3-40). 73 pts were evaluable: 58 were Child-Pugh Class A, 15 Class B. The median activity of SIR-Spheres delivered was 1.60 GBq. 21 pts had unilobar or main portal vein thrombosis (29%). Survival rate was compared with risk groups (P⬍0.0001) (median rate of survival: 14 months for Child Class A pts and 8 for Class B pts). Best Response rate was of 93% (68pts), while Objective Response Rate was of 78% (57 pts) comparing with BCLC and Clip Score, 41 pts (56%) showed partial response and recurrence rate. 7 pts underwent re-treatment with SIRT, while 15 underwent re-treatment with other techniques (Drug delivery embolisation, or RFA) obtaining good control of disease. No procedure complications related were shown. In seven pts, improving of portal vein thrombosis was revealed (33%) but no PVT progression was showed in all series.Two patients were downstaged to OLT and patologic specimens showed conplete lesion necrosis. Conclusion: Radioembolization is a safe and effective treatment in pts with advanced multifocal HCC and in portal vein thrombosis.
Transrectal abscess drainage in children A.R. Popescu1, S.K. Kim1, C.K. Rigsby1, D.H. Rothstein2, J. Donaldson1; 1Medical Imaging, Children’s Memorial Hospital, Chicago, IL; 2Pediatric Surgery, Children’s Memorial Hospital, Chicago, IL. Purpose: To retrospectively evaluate the effectiveness and safety of transrectal(TR) drainage of deep pelvic abscess in children using a combination of ultrasound(US) and fluoroscopic guidance. Both transgluteal(TG) and TR approaches are accepted techniques but vascular complications, catheter related pain and the need for CT-guidance make the TG approach less desirable in the pediatric population. Materials and Methods: Medical records of all patients with deep pelvic abscess drained via TR approach from
Results: 30 TR drainage procedures were attempted in 29 patients ages 1 to 16 years(mean 10.1 yrs). Drainage was successful in 28/29 patients(96%). One patient required additional placement of TR catheter to drain a second pelvic collection. TR drainage failed in one patient (3%) and CT-guided transabdominal drainage of the pelvic abscess was necessary. Average catheter duration was 5 days. No patients required surgical intervention for residual pelvic fluid collection. No patients complained of catheter related pain/discomfort. Conclusion: TR drainage has a very high technical success rate and low incidence of complications. Transabdominal US provides excellent visualization and guidance for TR approach. The TR technique avoids potential complications of TG access and the need for CT-guidance with its additional radiation exposure. Despite the stigma of performing drainage using this approach, it is very well tolerated by children of all ages. This approach should become the preferred method for children with deep pelvic fluid collections requiring percutaneous drainage Abstract No. 311 Deployment performance and retrievability of the Cook Celect inferior vena cava filter: A single institution experience A. Menard1, A. Common2, D. Marcuzzi2, V. Prabhudesai2; 1Queen’s University, Kingston, ON, Canada; 2University of Toronto, Toronto, ON, Canada. Purpose: To compare the performance and retrievability of the Cook Celect inferior vena cava filter when deployed from an internal jugular vein approach vs a common femoral vein approach. Materials and Methods: The study was conducted in a large tertiary referral center. We performed a retrospective review of the Cook Celect filter insertions and retrievals. We searched the diagnostic imaging reporting databse for all Cook Celect IVC filter insertions and removals from May 2004 to May 2009. The resulting group was separated into two groups based on insertion venous approach: internal jugular and common femoral veins. Three interventional radiologists reviewed the post insertion and pre removal venograms simultaneously and established consensus. The degree of filter tilt was measured in absolute degrees, and was also classified into three qualitative categories: negligible, minor, major. Rates of failure of removal were also measured for both approaches.
POSTER SESSIONS
Abstract No. 310
2001-09/2009 were reviewed. Drainage procedures were performed transrectally through a sheath with Seldinger technique using transabdominal US and fluoroscopy for guidance, transrectal US and fluoroscopy. 10-12 Fr catheters were inserted, irrigated daily and left in place until output was ⬍25mL/day and fevers were resolved. Clinical follow-up and complications including catheter-related pain/discomfort were noted.
Results: There were 91 successful filter insertions; 64 from a common femoral vein approach and 27 from an internal jugular vein approach. Filter tilt was statistically more likely to be tilted when inserted from and internal jugular vein approach (8.00 degrees) than from a common femoral vein approach (5.05 degrees) (Student’s t-test p⫽0.003). Filter tilt was more likely to be negligible with a common femoral vein approach (75%) than with an internal jugular vein approach (51.9%). An internal jugular vein approach had a higher rate of minor (33.3%) and major tilt (14.8%) when S117
compared to a common femoral vein approach (21.9% and 3.1% respectively). The difference in qualitative tilt was statistically significant (Fischer exact test p⫽0.036). Retrieval was attempted in 25 cases, with two retrieval failures. There was no significant change in retrieval rate between the two groups. Conclusion: Insertion of a Cook Celect IVC filter from an internal jugular vein approach is more likely to result in significant tilt, which may reduce the likelihood of filter removal. The internal jugular vein approach should therefore be avoided and reserved for impossible/contraindicated femoral vein approaches. Abstract No. 312 Endovascular management of Budd Chiari syndromeKEM experience K.R. Rathod1, H. Deshmukh1, S. Bhatia2, B. Popat1, A. Shukla2, G. Avhad1; 1Vascular and Interventional Radiology, KEM Hospital, Mumbai, India; 2Gastroenterology, KEM Hospital, Mumbai, India. Purpose: To evaluate various non-surgical treatment (Endovascular Management) options in patients with BuddChiari syndrome refractory to medical management. Materials and Methods: Forty two consecutive cases of Budd-Chiari syndrome (BCS) were prospectively evaluated. All patients with refractory ascites/ haematemesis or deteriorating liver function, depending on morphology of inferior vena cava (IVC) and/or hepatic vein (HV) obstruction, triaged for radiological intervention, in addition to anticoagulation therapy. Follow-up was done with clinical assessment and colour doppler and DIPSS gram/inferior vena cava gram whenever feasible. Results: Radiological intervention was technically successful in 42/42. IVC stenting was done in 18, transjugular direct intrahepatic portosystemic shunt (DIPS) in 15, HV stenting in 8, combined IVC-HV stenting in one. One patient with occluded HV stent underwent subsequently TIPS. Complications encountered in follow-up: Grade I hepatic encephalopathy in two patients, resolved with medical management. Post procedure peritoneal hematoma was seen in one patient which resolved in ten days with medical management. Conclusion: The endovascular treatment options offered to the patients with Budd Chiari syndrome were primarily determined by the pattern of venous anatomy. Radiological interventions proved to be highly effective in management of Budd Chiari syndrome. Spectrum of Procedures Sr. No. TreatmentOptions 1 IVC stenting 2 TIPS 3 Hepatic vein stenting 4 IVC ⫹ Hepatic vein stent Total
No.ofPatients 18 15 08 01 42
Abstract No. 313 Impact of changing “IR Order” to “IR Consult” at a level I tertiary care hospital M. Recker, C. Meade, P. Harrod-Kim, D. Mittleider, T. Dykes, J.P. Gerding, S. Amberson, C. Baker; Maine Medical Center, Portland, ME. S118
Purpose: To examine the impact of moving away from the “order-based” IR procedural system to an IR Consultation Service. Materials and Methods: All IR Procedure orders in the computer-based order entry system were eliminated and replaced with an “IR Consult”. We performed a retrospective analysis of the IR consults requested, IR procedures performed and outpatient office volumes. Comparisons were made of procedure volumes and inpatient consults before and after implementation of the “IR Consult” (Kruskal-Wallis test or t-test). Surveys were performed of the participating 6 interventional radiologists and physician’s assistant to examine the impact of the consultation service on their daily hours. Survey was also performed of the radiology residents to determine its impact on resident IR education. Results: After establishment of “IR Consult request”, there was a significant increase in the number of IR inpatient consults performed (p⬍0.0001). There was a slight decrease in IR procedural volume in comparison to two previous years (p⫽0.0035). There was a significant increase in outpatient office volume due to initial inpatient consults performed (p⫽0.015). The daily work hours of the interventional radiologists and PA did not change significantly (p⬎0.05). There were significant changes with IR Resident education: 1) Increased frequency of pre-procedural patient evaluation (65% vs 15%, p⬍0.05) 2) Increased frequency of post-procedural follow-up (75% vs 10%, p⬍0.05) 3) 90% of residents felt the Consult Service “enhanced their IR training”. Conclusion: Changing to a Consult service from a traditional Order-based service has increased the number of inpatient consults, outpatient office visits and enhanced resident education without significant changes in work hours as well as enhanced our image in the hospital. Changing from IR Order to IR Consult Variable “IR Order” Inpatient Consults 1/1.5 per month IR Procedure Volume 187/173 Office Visits 110 per month Resident pre-Procedure Eval 15% Resident post-Procedure Follow-up 10%
“IR Consult” 9 per month 147 125 per month 65% 75%
p Value ⬍0.0001 0.0035 0.015 ⬍0.05 ⬍0.05
Abstract No. 314 Transarterial hepatic chemoembolization in patients who have previously undergone TIPS J.R. Reinherz, A. Stangl, R. Lookstein, F. Nowakowski, E. Kim, J.L. Weintraub; Mount Sinai Medical Center, New York City, NY. Purpose: Patients who have undergone TIPS for portal hypertension are not considered ideal candidates for treatment of hepatocellular carcinoma (HCC) with TACE. There is concern that TACE will lead to hepatic function deterioration in patients who have diversion of portal blood flow via a TIPS. The objective of this retrospective review is to evaluate the safety of performing TACE in patients with TIPS through use of the Model for End-Stage Liver Disease (MELD) scoring system both pre and post TACE. Materials and Methods: A retrospective review of the radiology information system was conducted to identify all patients with TIPS who had undergone TACE procedures from 2004 through 2008. 9 patients (9/9 males; age range, 50.3 - 73.1y; median age, 56.1y) were identified and had undergone a total of 16 TACE procedures. Prior to TACE, all patients had pre-procedure labs to allow for calculation of the pre-procedure MELD score. Patency of TIPS at the
Transrectal abscess drainage in children A.R. Popescu1, S.K. Kim1, C.K. Rigsby1, D.H. Rothstein2, J. Donaldson1; 1Medical Imaging, Children’s Memorial Hospital, Chicago, IL; 2Pediatric Surgery, Children’s Memorial Hospital, Chicago, IL. Purpose: To retrospectively evaluate the effectiveness and safety of transrectal(TR) drainage of deep pelvic abscess in children using a combination of ultrasound(US) and fluoroscopic guidance. Both transgluteal(TG) and TR approaches are accepted techniques but vascular complications, catheter related pain and the need for CT-guidance make the TG approach less desirable in the pediatric population. Materials and Methods: Medical records of all patients with deep pelvic abscess drained via TR approach from
Results: 30 TR drainage procedures were attempted in 29 patients ages 1 to 16 years(mean 10.1 yrs). Drainage was successful in 28/29 patients(96%). One patient required additional placement of TR catheter to drain a second pelvic collection. TR drainage failed in one patient (3%) and CT-guided transabdominal drainage of the pelvic abscess was necessary. Average catheter duration was 5 days. No patients required surgical intervention for residual pelvic fluid collection. No patients complained of catheter related pain/discomfort. Conclusion: TR drainage has a very high technical success rate and low incidence of complications. Transabdominal US provides excellent visualization and guidance for TR approach. The TR technique avoids potential complications of TG access and the need for CT-guidance with its additional radiation exposure. Despite the stigma of performing drainage using this approach, it is very well tolerated by children of all ages. This approach should become the preferred method for children with deep pelvic fluid collections requiring percutaneous drainage Abstract No. 311 Deployment performance and retrievability of the Cook Celect inferior vena cava filter: A single institution experience A. Menard1, A. Common2, D. Marcuzzi2, V. Prabhudesai2; 1Queen’s University, Kingston, ON, Canada; 2University of Toronto, Toronto, ON, Canada. Purpose: To compare the performance and retrievability of the Cook Celect inferior vena cava filter when deployed from an internal jugular vein approach vs a common femoral vein approach. Materials and Methods: The study was conducted in a large tertiary referral center. We performed a retrospective review of the Cook Celect filter insertions and retrievals. We searched the diagnostic imaging reporting databse for all Cook Celect IVC filter insertions and removals from May 2004 to May 2009. The resulting group was separated into two groups based on insertion venous approach: internal jugular and common femoral veins. Three interventional radiologists reviewed the post insertion and pre removal venograms simultaneously and established consensus. The degree of filter tilt was measured in absolute degrees, and was also classified into three qualitative categories: negligible, minor, major. Rates of failure of removal were also measured for both approaches.
POSTER SESSIONS
Abstract No. 310
2001-09/2009 were reviewed. Drainage procedures were performed transrectally through a sheath with Seldinger technique using transabdominal US and fluoroscopy for guidance, transrectal US and fluoroscopy. 10-12 Fr catheters were inserted, irrigated daily and left in place until output was ⬍25mL/day and fevers were resolved. Clinical follow-up and complications including catheter-related pain/discomfort were noted.
Results: There were 91 successful filter insertions; 64 from a common femoral vein approach and 27 from an internal jugular vein approach. Filter tilt was statistically more likely to be tilted when inserted from and internal jugular vein approach (8.00 degrees) than from a common femoral vein approach (5.05 degrees) (Student’s t-test p⫽0.003). Filter tilt was more likely to be negligible with a common femoral vein approach (75%) than with an internal jugular vein approach (51.9%). An internal jugular vein approach had a higher rate of minor (33.3%) and major tilt (14.8%) when S117
compared to a common femoral vein approach (21.9% and 3.1% respectively). The difference in qualitative tilt was statistically significant (Fischer exact test p⫽0.036). Retrieval was attempted in 25 cases, with two retrieval failures. There was no significant change in retrieval rate between the two groups. Conclusion: Insertion of a Cook Celect IVC filter from an internal jugular vein approach is more likely to result in significant tilt, which may reduce the likelihood of filter removal. The internal jugular vein approach should therefore be avoided and reserved for impossible/contraindicated femoral vein approaches. Abstract No. 312 Endovascular management of Budd Chiari syndromeKEM experience K.R. Rathod1, H. Deshmukh1, S. Bhatia2, B. Popat1, A. Shukla2, G. Avhad1; 1Vascular and Interventional Radiology, KEM Hospital, Mumbai, India; 2Gastroenterology, KEM Hospital, Mumbai, India. Purpose: To evaluate various non-surgical treatment (Endovascular Management) options in patients with BuddChiari syndrome refractory to medical management. Materials and Methods: Forty two consecutive cases of Budd-Chiari syndrome (BCS) were prospectively evaluated. All patients with refractory ascites/ haematemesis or deteriorating liver function, depending on morphology of inferior vena cava (IVC) and/or hepatic vein (HV) obstruction, triaged for radiological intervention, in addition to anticoagulation therapy. Follow-up was done with clinical assessment and colour doppler and DIPSS gram/inferior vena cava gram whenever feasible. Results: Radiological intervention was technically successful in 42/42. IVC stenting was done in 18, transjugular direct intrahepatic portosystemic shunt (DIPS) in 15, HV stenting in 8, combined IVC-HV stenting in one. One patient with occluded HV stent underwent subsequently TIPS. Complications encountered in follow-up: Grade I hepatic encephalopathy in two patients, resolved with medical management. Post procedure peritoneal hematoma was seen in one patient which resolved in ten days with medical management. Conclusion: The endovascular treatment options offered to the patients with Budd Chiari syndrome were primarily determined by the pattern of venous anatomy. Radiological interventions proved to be highly effective in management of Budd Chiari syndrome. Spectrum of Procedures Sr. No. TreatmentOptions 1 IVC stenting 2 TIPS 3 Hepatic vein stenting 4 IVC ⫹ Hepatic vein stent Total
No.ofPatients 18 15 08 01 42
Abstract No. 313 Impact of changing “IR Order” to “IR Consult” at a level I tertiary care hospital M. Recker, C. Meade, P. Harrod-Kim, D. Mittleider, T. Dykes, J.P. Gerding, S. Amberson, C. Baker; Maine Medical Center, Portland, ME. S118
Purpose: To examine the impact of moving away from the “order-based” IR procedural system to an IR Consultation Service. Materials and Methods: All IR Procedure orders in the computer-based order entry system were eliminated and replaced with an “IR Consult”. We performed a retrospective analysis of the IR consults requested, IR procedures performed and outpatient office volumes. Comparisons were made of procedure volumes and inpatient consults before and after implementation of the “IR Consult” (Kruskal-Wallis test or t-test). Surveys were performed of the participating 6 interventional radiologists and physician’s assistant to examine the impact of the consultation service on their daily hours. Survey was also performed of the radiology residents to determine its impact on resident IR education. Results: After establishment of “IR Consult request”, there was a significant increase in the number of IR inpatient consults performed (p⬍0.0001). There was a slight decrease in IR procedural volume in comparison to two previous years (p⫽0.0035). There was a significant increase in outpatient office volume due to initial inpatient consults performed (p⫽0.015). The daily work hours of the interventional radiologists and PA did not change significantly (p⬎0.05). There were significant changes with IR Resident education: 1) Increased frequency of pre-procedural patient evaluation (65% vs 15%, p⬍0.05) 2) Increased frequency of post-procedural follow-up (75% vs 10%, p⬍0.05) 3) 90% of residents felt the Consult Service “enhanced their IR training”. Conclusion: Changing to a Consult service from a traditional Order-based service has increased the number of inpatient consults, outpatient office visits and enhanced resident education without significant changes in work hours as well as enhanced our image in the hospital. Changing from IR Order to IR Consult Variable “IR Order” Inpatient Consults 1/1.5 per month IR Procedure Volume 187/173 Office Visits 110 per month Resident pre-Procedure Eval 15% Resident post-Procedure Follow-up 10%
“IR Consult” 9 per month 147 125 per month 65% 75%
p Value ⬍0.0001 0.0035 0.015 ⬍0.05 ⬍0.05
Abstract No. 314 Transarterial hepatic chemoembolization in patients who have previously undergone TIPS J.R. Reinherz, A. Stangl, R. Lookstein, F. Nowakowski, E. Kim, J.L. Weintraub; Mount Sinai Medical Center, New York City, NY. Purpose: Patients who have undergone TIPS for portal hypertension are not considered ideal candidates for treatment of hepatocellular carcinoma (HCC) with TACE. There is concern that TACE will lead to hepatic function deterioration in patients who have diversion of portal blood flow via a TIPS. The objective of this retrospective review is to evaluate the safety of performing TACE in patients with TIPS through use of the Model for End-Stage Liver Disease (MELD) scoring system both pre and post TACE. Materials and Methods: A retrospective review of the radiology information system was conducted to identify all patients with TIPS who had undergone TACE procedures from 2004 through 2008. 9 patients (9/9 males; age range, 50.3 - 73.1y; median age, 56.1y) were identified and had undergone a total of 16 TACE procedures. Prior to TACE, all patients had pre-procedure labs to allow for calculation of the pre-procedure MELD score. Patency of TIPS at the