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Abstract No. 347 EE: Cost effective renal artery infusion system for targeted renal therapy
cm3/min vs. 1.2 cm3/min, P ⫽ NS). Iceballs formed at similar rates when multiple probes were used (1.5 cm3/min) compared to the use of single probes (1.3 cm3/min, P ⫽ NS). Iceballs within exophytic tumors formed at the same rate as parenchymal tumors (P ⫽NS). Mean tumor size was 2.0 cm (range, 0.8 - 3.5 cm). No difference in iceball growth was seen within tumors ⬍ 2 cm diameter compared to tumors ⬎ 2 cm diameter (P ⫽ NS). Conclusion: Iceball volume increases at a linear rate during the first cycle of active freezing during renal cryoablation. Neither technical factors (probe size, use of multiple probes) nor anatomic factors (size and location of tumors)were significant determinants of iceball growth velocity.
Abstract No. 345 EE Initial experience of a collaborative fibroid center T. Wilkin1, M. Wilson1, S. Piereson1,2; 1Premier Radiology, Borgess Medical Center, Kalamazoo, MI; 2Obstetrics and Gynecology, Borgess Medical Center, Kalamazoo, MI. Learning Objectives: To present the initial experience from the first six months of operation of a collaborative fibroid center. Background: Uterine artery embolization (UAE) is gaining more acceptance as a treatment option for symptomatic fibroids within the gynecology community. In order to ensure that our patients are provided with the entire spectrum of treatment options, and as a reflection of the mutual respect and forward thinking of our practices, interventional radiology and gynecology have formed a collaborative fibroid center. Each patient is seen by both specialists in a single office visit, which entails a history and directed physical exam, review of imaging and laboratory findings, discussion of fibroid therapies, and a formal recommendation of which particular treatment option(s) would likely have the greatest benefit. The patient is encouraged and empowered to participate in the selection of her therapy. Data relevant to the practice of interventional radiology obtained from the first six months of the fibroid center, and contrasted to data from the previous calendar year, are presented below. Clinical Findings/Procedure Details: Number of patient encounters were calculated over six month intervals, including the year prior to and six months following the opening of the fibroid center. Total consults, UAE (completed procedures), and pelvic MRI were determined for each time interval. From March to September 2008, there were 24 consults, 11 UAE and 50 MRI. September 2008 through March 2009 had 27 consults, 11 UAE and 67 MRI. Upon opening of the fibroid center in March 2009, 83 consults, 17 UAE and 120 MRI were generated over the first six months. The data demonstrate an increase across all variables correlating with the opening of the fibroid center. As compared to the prior six months, total consults increased 207%, UAE (completed procedures) increased by 54%, and pelvic MRI had 79% growth. Patient feedback has been very positive, and new referral patterns have been generated. Conclusion and/or Teaching Points: Formation of a collaborative fibroid center has resulted in significant benefit to both interventional and diagnostic radiology. Continued growth is anticipated based on positive response from our patients and referring providers. S130
Abstract No. 346 Pre Yttrium-90 internal radioembolization shunt study for metastatic liver tumor: Is it essential? R.S. Williams1,2, E. McIntosh1,2, J. Montilla-Soler3, D.M. Schuster3, B. Barron3, H.S. Kim1,2; 1Division of Interventional Radiology and Image Guided Medicine, Emory University School of Medicine, Atlanta, GA; 2Radiology, Emory University School of Medicine, Atlanta, GA; 3 Division of Nuclear Medicine and Molecular Imaging, Emory University School of Medicine, Atlanta, GA. Purpose: To assess the utility of pre Yttrium-90 (resin based) internal radioembolization hepatopulmonary shunt studies for metastatic liver tumors. Materials and Methods: Consecutive patients with metastatic liver tumors who received 99m Tc MAA between 2003 and 2009. Patients with HCC were excluded. The shunt study was performed via trans-arterial delivery of the 99mTc MAA to the proper hepatic artery. Shunted lung activity was obtained by planar or SPECT scintigraphy. Median values with 95% confidence interval were assessed. Lung doses were calculated utilizing: Lung Dose ⫽ Activity*SF*50/lung mass (assumed 1kg). Results: 82 patients with metastatic disease were included in the study, 20(24.3%) patients with neuroendocrine, 19(23.2%) patients with colon, and 13(15.9%) patients with melanoma. The rest included breast, esophageal, pancreatic, adenocarcinoma, sarcoma, cholangiocarcinoma and unknown primaries. Each patient was infused with 99mTc MAA with radioactivity between 3-4 mCi (Median: 3.56 mCi) with a median hepatopulmonary shunt fraction of 6.88%. 65(79.4%) patients had a shunt fraction of less than 10%, 1(19.5%) patients had a greater than 10% but less than 20% shunt fraction, and 1(1.2%) patient had a hepatopulmonary shunt fraction of greater than 20%. Median shunt fractions(SF) stratified for metastatic dx were: Adrenal 12.00%; Breast 8.1%; Unknown primary 8.0%; Pancreas 7.4%, Neuroendocrine 7.3%; Colon 7.2%; Adenocystic carcinoma of the parotid gland 6.9%; Esophageal 6.6%; Melanoma 6.0%; Rectal 5.6%, Anal 5.5%; Sarcoma 5.4%; Adenocarcinoma 5.3% Cholangiocarcinoma 5.3%; Lung 4.2%. The median Y-90 activity and median calculated pulmonary absorbed dose, per patient, for the initial lobar tx was 38.8 mCi & 5.13 Gy respectively. For those who received subsequent contralateral lobe treatment the median values were 31.0 mCi & 3.97 Gy. The overall cumulative activity and pulmonary absorbed dose were 3.32mCi & 6.15 Gy. There were no pulmonary embolism or peri-or postY-90 pneumonia. Conclusion: Our preliminary study demonstrates hepatopulmonary shunt above 20% is rare for metastatic non-HCC hepatic tumors. Cumulative absorbed pulmonary dose is well below life time maximum dose. Abstract No. 347 EE Cost effective renal artery infusion system for targeted renal therapy C. Wood, M.V. Beheshti, E. Erdem, W.C. Culp; University of Arkansas for Medical Science, Little Rock, AR. Learning Objectives: Contrast induced nephropathy and acute renal failure are leading causes of morbidity, mortality and result in enormous costs to society. Targeted renal therapy (TRT) is an emerging therapy where high dose fenoldopam is infused into the renal arteries after selective
catheterization. The delivery of therapeutic agents directly to the renal arteries has the advantage of providing a higher local effective dose than would be allowed by intravenous infusion while limiting adverse systemic effects due to renal first-pass elimination. A FDA-approved device, the Benephit PV Catheter Infusion System (AngioDynamics), is commercially available for TRT. This device utilizes a bifurcated infusion catheter which allows catheterization and infusion of bilateral renal arteries. The system is expensive and pre-supposes relatively normal anatomy. We have developed a bilateral renal infusion set that is cost favorable and allows atraumatic, selective renal artery catheterization with widely available off-the-shelf materials. Background: The system utilizes a 7-french 40 cm guide catheter (Cordis Inc.) through a standard 7-french vascular sheath. A double Tuohy Borst adapter is attached to the guide catheter with continuous infusion of heparinized saline. 3-french catheters (Cook Medical) using 0.025” guide wires were then steam shaped in a Cobra 2 configuration which can be used through the guide catheter to select the renal arteries. Clinical Findings/Procedure Details: This system is available at an estimated cost of $300, a substantial cost-savings in comparison with the commercially available alternative. The system offers the technical advantages of wire guided selective renal catheterization and is widely available. Conclusion and/or Teaching Points: Targeted renal therapy via renal artery infusion of vasodilators is an exciting therapy that is a topic of increasing interest among the nephrology and interventional radiology communities. The commercially available catheterization system is expensive and suffers technical shortcomings. The system can be fabricated from readily available components and can be used on difficult renal artery anatomy. The total cost is less than one-fifth of the cost of the commercially available alternative. Abstract No. 348 Expansive properties of NCBA/Lipiodol solution in coagulopathic blood R. Wray, J. Koizumi, K. Myojin, Y. Nagata, T. Hashimoto; Tokai University, Isehara, Japan.
Materials and Methods: 10 solutions of 0.5cc of Histoacryl Blue (NBCA) were prepared with increasing amounts of Lipiodol from ratios of 1:1 to 1:10, by increasing the amount of Lipiodol by 0.5cc for each solution. A standard volume of 1cc of each of these NCBA/Lipiodol solutions was injected into 3cc of blood. The formed clot was then extracted and placed in an empty 5cc syringe, and the volume of this clot was measured via its displacement of a known volume of normal saline. This method was completed in both coagulopathic blood of a know cirrhotic and control blood of a healthy volunteer. Results: The volumes recorded for the coagulopathic blood and control blood injected with NCBA/Lipiodol solution for
Conclusion: NBCA expands in blood to a significantly greater volume than that injected independent of the clotting process. To our knowledge this expansive property of NBCA has not yet been recorded. This attribute of NBCA makes it a desirable embolic agent in cases where patients have coagulopathy, such as cirrhotic patients needing transarterial chemoembolization or partial splenic embolization. Abstract No. 349 Cryoablation for lung metastasis of colorectal cancer: Outcome and prospective future Y. Yamauchi, M. Kawamura, S. Nakatsuka, Y. Izumi, H. Yashiro, N. Tsukada, M. Inoue, S. Kuribayashi, H. Nomori; Keio University School of Medicine, Tokyo, Japan. Purpose: Since pulmonary metastases from colorectal cancer are usually associated with multiple metastases, less invasive treatment like cryoablation seems to be preferable. Materials and Methods: From 2002 to 2007, percutaneous cryoablations for metastatic lung tumor from colorectal cancer were conducted on 24 patients (36-82, mean 62 years old; 17 male, 7 female) during 35 sessions for 65 metastatic lung tumors. Each procedure was percutaneously performed under local anesthesia. Coaxial needle insertion toward tumors was monitored with an MDCT scanner (Aquilion 4/16/64, Toshiba) which enables us to use multi-slice CT fluoroscopy. Cryoprobes were introduced into outer needles of the coaxial after removal of inner needles. Cryoablation was performed with triple freeze/thaw cycles using a cryoablation system (CRYO-care Cryosurgical Unit, 8ch). Rupture of cells, dehydration, blockage of microvasculature and apoptosis occur during triple FREEZE/ THAW cycles. At the end, the pathways of the probes were plugged with fibrin glue through the outer needle. There were follow-up examinations using CT scans 1 week, 1 month and 3 months later and thereafter at 3-monthly intervals. Results: The mean procedure time was 136 minutes (66-192 minutes). The procedures were well tolerated by all patients. Local control rate 2 year after treatment was 57%. 2-yearlocal-control-rate of the tumor ⬍⫽15mm was 77% and that of tumor ⬎15mm was 29% (p⫽0.0004 log-rank test). Overall survival rate was 92.3% 1 year after cryosurgery, and 63.7% after 2 years. Major complications were pneumothorax (19 sessions, 54%, chest tube required in 1 session), pleural effusion (21 sessions, 60%; no drainage case), and transient and self-limiting hemoptysis (13 sessions, 37%). There was no treatment-related death. Proximal and distal implantaion was not observed in these sessions.
POSTER SESSIONS
Purpose: NBCA is a commonly used, permanent and fast acting embolic agent that polymerizes rapidly in presence of blood. It shows expansive properties during polymerization making it an effective embolic agent for interventional procedures. In contrast to other embolic agents such as coils and gelfoam, NBCA does not require a coagulation reaction in the blood in order to embolize a target. This study investigates the expansive properties of N-Butyl Cyanoacrylate (NBCA) and how this is affected by coagulopathy.
the ratios of 1:1, 1:2, 1:3, 1:4, 1:5, 1:6, 1:7, 1:8, 1:9, 1:10 were 2.0, 2.2, 2.3, 1.9, 2.0, 1.1, 1.3, 1.3, 1.2, 1.0 and 2.3, 2.3, 2.0, 1.5, 2.0, 1.6, 0.6, 1.0 respectively. This increase in volume of the injected NCBA/Lipiodol solution was found to be statistically significant by paired t-test for both the coagulopathic blood and the control blood. The difference in the volume of the clots recorded for the coagulopathic blood as compared to the control blood was not statistically significant as determined by paired t-test.
Conclusion: From the outcome of cryosurgery for metastases from colorectal cancer, we found that percutanous cryoablation is a safe and feasible treatment option. But when the size of tumor is larger than 15mm in diameter, this treatment is not enough to control them radically, and we have to study more about the freezing kinetics to treat bigger tumors. S131
Abstract No. 345 EE Initial experience of a collaborative fibroid center T. Wilkin1, M. Wilson1, S. Piereson1,2; 1Premier Radiology, Borgess Medical Center, Kalamazoo, MI; 2Obstetrics and Gynecology, Borgess Medical Center, Kalamazoo, MI. Learning Objectives: To present the initial experience from the first six months of operation of a collaborative fibroid center. Background: Uterine artery embolization (UAE) is gaining more acceptance as a treatment option for symptomatic fibroids within the gynecology community. In order to ensure that our patients are provided with the entire spectrum of treatment options, and as a reflection of the mutual respect and forward thinking of our practices, interventional radiology and gynecology have formed a collaborative fibroid center. Each patient is seen by both specialists in a single office visit, which entails a history and directed physical exam, review of imaging and laboratory findings, discussion of fibroid therapies, and a formal recommendation of which particular treatment option(s) would likely have the greatest benefit. The patient is encouraged and empowered to participate in the selection of her therapy. Data relevant to the practice of interventional radiology obtained from the first six months of the fibroid center, and contrasted to data from the previous calendar year, are presented below. Clinical Findings/Procedure Details: Number of patient encounters were calculated over six month intervals, including the year prior to and six months following the opening of the fibroid center. Total consults, UAE (completed procedures), and pelvic MRI were determined for each time interval. From March to September 2008, there were 24 consults, 11 UAE and 50 MRI. September 2008 through March 2009 had 27 consults, 11 UAE and 67 MRI. Upon opening of the fibroid center in March 2009, 83 consults, 17 UAE and 120 MRI were generated over the first six months. The data demonstrate an increase across all variables correlating with the opening of the fibroid center. As compared to the prior six months, total consults increased 207%, UAE (completed procedures) increased by 54%, and pelvic MRI had 79% growth. Patient feedback has been very positive, and new referral patterns have been generated. Conclusion and/or Teaching Points: Formation of a collaborative fibroid center has resulted in significant benefit to both interventional and diagnostic radiology. Continued growth is anticipated based on positive response from our patients and referring providers. S130
Abstract No. 346 Pre Yttrium-90 internal radioembolization shunt study for metastatic liver tumor: Is it essential? R.S. Williams1,2, E. McIntosh1,2, J. Montilla-Soler3, D.M. Schuster3, B. Barron3, H.S. Kim1,2; 1Division of Interventional Radiology and Image Guided Medicine, Emory University School of Medicine, Atlanta, GA; 2Radiology, Emory University School of Medicine, Atlanta, GA; 3 Division of Nuclear Medicine and Molecular Imaging, Emory University School of Medicine, Atlanta, GA. Purpose: To assess the utility of pre Yttrium-90 (resin based) internal radioembolization hepatopulmonary shunt studies for metastatic liver tumors. Materials and Methods: Consecutive patients with metastatic liver tumors who received 99m Tc MAA between 2003 and 2009. Patients with HCC were excluded. The shunt study was performed via trans-arterial delivery of the 99mTc MAA to the proper hepatic artery. Shunted lung activity was obtained by planar or SPECT scintigraphy. Median values with 95% confidence interval were assessed. Lung doses were calculated utilizing: Lung Dose ⫽ Activity*SF*50/lung mass (assumed 1kg). Results: 82 patients with metastatic disease were included in the study, 20(24.3%) patients with neuroendocrine, 19(23.2%) patients with colon, and 13(15.9%) patients with melanoma. The rest included breast, esophageal, pancreatic, adenocarcinoma, sarcoma, cholangiocarcinoma and unknown primaries. Each patient was infused with 99mTc MAA with radioactivity between 3-4 mCi (Median: 3.56 mCi) with a median hepatopulmonary shunt fraction of 6.88%. 65(79.4%) patients had a shunt fraction of less than 10%, 1(19.5%) patients had a greater than 10% but less than 20% shunt fraction, and 1(1.2%) patient had a hepatopulmonary shunt fraction of greater than 20%. Median shunt fractions(SF) stratified for metastatic dx were: Adrenal 12.00%; Breast 8.1%; Unknown primary 8.0%; Pancreas 7.4%, Neuroendocrine 7.3%; Colon 7.2%; Adenocystic carcinoma of the parotid gland 6.9%; Esophageal 6.6%; Melanoma 6.0%; Rectal 5.6%, Anal 5.5%; Sarcoma 5.4%; Adenocarcinoma 5.3% Cholangiocarcinoma 5.3%; Lung 4.2%. The median Y-90 activity and median calculated pulmonary absorbed dose, per patient, for the initial lobar tx was 38.8 mCi & 5.13 Gy respectively. For those who received subsequent contralateral lobe treatment the median values were 31.0 mCi & 3.97 Gy. The overall cumulative activity and pulmonary absorbed dose were 3.32mCi & 6.15 Gy. There were no pulmonary embolism or peri-or postY-90 pneumonia. Conclusion: Our preliminary study demonstrates hepatopulmonary shunt above 20% is rare for metastatic non-HCC hepatic tumors. Cumulative absorbed pulmonary dose is well below life time maximum dose. Abstract No. 347 EE Cost effective renal artery infusion system for targeted renal therapy C. Wood, M.V. Beheshti, E. Erdem, W.C. Culp; University of Arkansas for Medical Science, Little Rock, AR. Learning Objectives: Contrast induced nephropathy and acute renal failure are leading causes of morbidity, mortality and result in enormous costs to society. Targeted renal therapy (TRT) is an emerging therapy where high dose fenoldopam is infused into the renal arteries after selective
catheterization. The delivery of therapeutic agents directly to the renal arteries has the advantage of providing a higher local effective dose than would be allowed by intravenous infusion while limiting adverse systemic effects due to renal first-pass elimination. A FDA-approved device, the Benephit PV Catheter Infusion System (AngioDynamics), is commercially available for TRT. This device utilizes a bifurcated infusion catheter which allows catheterization and infusion of bilateral renal arteries. The system is expensive and pre-supposes relatively normal anatomy. We have developed a bilateral renal infusion set that is cost favorable and allows atraumatic, selective renal artery catheterization with widely available off-the-shelf materials. Background: The system utilizes a 7-french 40 cm guide catheter (Cordis Inc.) through a standard 7-french vascular sheath. A double Tuohy Borst adapter is attached to the guide catheter with continuous infusion of heparinized saline. 3-french catheters (Cook Medical) using 0.025” guide wires were then steam shaped in a Cobra 2 configuration which can be used through the guide catheter to select the renal arteries. Clinical Findings/Procedure Details: This system is available at an estimated cost of $300, a substantial cost-savings in comparison with the commercially available alternative. The system offers the technical advantages of wire guided selective renal catheterization and is widely available. Conclusion and/or Teaching Points: Targeted renal therapy via renal artery infusion of vasodilators is an exciting therapy that is a topic of increasing interest among the nephrology and interventional radiology communities. The commercially available catheterization system is expensive and suffers technical shortcomings. The system can be fabricated from readily available components and can be used on difficult renal artery anatomy. The total cost is less than one-fifth of the cost of the commercially available alternative. Abstract No. 348 Expansive properties of NCBA/Lipiodol solution in coagulopathic blood R. Wray, J. Koizumi, K. Myojin, Y. Nagata, T. Hashimoto; Tokai University, Isehara, Japan.
Materials and Methods: 10 solutions of 0.5cc of Histoacryl Blue (NBCA) were prepared with increasing amounts of Lipiodol from ratios of 1:1 to 1:10, by increasing the amount of Lipiodol by 0.5cc for each solution. A standard volume of 1cc of each of these NCBA/Lipiodol solutions was injected into 3cc of blood. The formed clot was then extracted and placed in an empty 5cc syringe, and the volume of this clot was measured via its displacement of a known volume of normal saline. This method was completed in both coagulopathic blood of a know cirrhotic and control blood of a healthy volunteer. Results: The volumes recorded for the coagulopathic blood and control blood injected with NCBA/Lipiodol solution for
Conclusion: NBCA expands in blood to a significantly greater volume than that injected independent of the clotting process. To our knowledge this expansive property of NBCA has not yet been recorded. This attribute of NBCA makes it a desirable embolic agent in cases where patients have coagulopathy, such as cirrhotic patients needing transarterial chemoembolization or partial splenic embolization. Abstract No. 349 Cryoablation for lung metastasis of colorectal cancer: Outcome and prospective future Y. Yamauchi, M. Kawamura, S. Nakatsuka, Y. Izumi, H. Yashiro, N. Tsukada, M. Inoue, S. Kuribayashi, H. Nomori; Keio University School of Medicine, Tokyo, Japan. Purpose: Since pulmonary metastases from colorectal cancer are usually associated with multiple metastases, less invasive treatment like cryoablation seems to be preferable. Materials and Methods: From 2002 to 2007, percutaneous cryoablations for metastatic lung tumor from colorectal cancer were conducted on 24 patients (36-82, mean 62 years old; 17 male, 7 female) during 35 sessions for 65 metastatic lung tumors. Each procedure was percutaneously performed under local anesthesia. Coaxial needle insertion toward tumors was monitored with an MDCT scanner (Aquilion 4/16/64, Toshiba) which enables us to use multi-slice CT fluoroscopy. Cryoprobes were introduced into outer needles of the coaxial after removal of inner needles. Cryoablation was performed with triple freeze/thaw cycles using a cryoablation system (CRYO-care Cryosurgical Unit, 8ch). Rupture of cells, dehydration, blockage of microvasculature and apoptosis occur during triple FREEZE/ THAW cycles. At the end, the pathways of the probes were plugged with fibrin glue through the outer needle. There were follow-up examinations using CT scans 1 week, 1 month and 3 months later and thereafter at 3-monthly intervals. Results: The mean procedure time was 136 minutes (66-192 minutes). The procedures were well tolerated by all patients. Local control rate 2 year after treatment was 57%. 2-yearlocal-control-rate of the tumor ⬍⫽15mm was 77% and that of tumor ⬎15mm was 29% (p⫽0.0004 log-rank test). Overall survival rate was 92.3% 1 year after cryosurgery, and 63.7% after 2 years. Major complications were pneumothorax (19 sessions, 54%, chest tube required in 1 session), pleural effusion (21 sessions, 60%; no drainage case), and transient and self-limiting hemoptysis (13 sessions, 37%). There was no treatment-related death. Proximal and distal implantaion was not observed in these sessions.
POSTER SESSIONS
Purpose: NBCA is a commonly used, permanent and fast acting embolic agent that polymerizes rapidly in presence of blood. It shows expansive properties during polymerization making it an effective embolic agent for interventional procedures. In contrast to other embolic agents such as coils and gelfoam, NBCA does not require a coagulation reaction in the blood in order to embolize a target. This study investigates the expansive properties of N-Butyl Cyanoacrylate (NBCA) and how this is affected by coagulopathy.
the ratios of 1:1, 1:2, 1:3, 1:4, 1:5, 1:6, 1:7, 1:8, 1:9, 1:10 were 2.0, 2.2, 2.3, 1.9, 2.0, 1.1, 1.3, 1.3, 1.2, 1.0 and 2.3, 2.3, 2.0, 1.5, 2.0, 1.6, 0.6, 1.0 respectively. This increase in volume of the injected NCBA/Lipiodol solution was found to be statistically significant by paired t-test for both the coagulopathic blood and the control blood. The difference in the volume of the clots recorded for the coagulopathic blood as compared to the control blood was not statistically significant as determined by paired t-test.
Conclusion: From the outcome of cryosurgery for metastases from colorectal cancer, we found that percutanous cryoablation is a safe and feasible treatment option. But when the size of tumor is larger than 15mm in diameter, this treatment is not enough to control them radically, and we have to study more about the freezing kinetics to treat bigger tumors. S131