- Email: [email protected]
Adrenal gland imaging for hyperldosteronism: are imaging methods reliable?
S290
Posters and Exhibits
vessel by balloon catheters of appropriate size determined by MDCT or cone-beam CT. The procedure was discontinued when oxygen desaturation was 44% or hemo sputum occurred. We performed BPA in a staged fashion over multiple, separate procedures to maximize efficacy and reduce the risk of reperfusion pulmonary injury. Results: BPA procedure was performed 1-8 times (mean 3.7procedure). mPAP decreased to 14-56mg (mean 27.7mmHg) in all patients. In 10 patients, mPAP improve to under 30mmHg, which was reported to improve prognosis in patients with CTEPH. In 9 patients, the World Health Organization functional class classification improved from III to II. BPA was not defined clinically effective in 5 patients, because mPAP is over 30mmHg in spite of multiple BPA procedure. The duration from PEA to BPA in these four patients was 19-110 months (mean 70.2 months, p¼0.075). Conclusions: BPA for the treatment of the patients with CTEPH after PEA may be feasible and safe. BPA after PEA may be effective if the duration between PEA to BPA was short. Long term follow up is mandatory to confirm the effectiveness of this procedure. References 1. Sugiyama M, Fukuda T, Sanda Y, Morita Y, Higashi M, Ogo T, Tsuji A, Demachi J, Nakanishi N, Naito H. Organized thrombus in pulmonary arteries in patients with chronic thromboembolic pulmonary hypertension; imaging with cone beam computed tomography. Jpn J Radiol, (2014); published online EpubApr 24 (10.1007/s11604-014-0319-8). 2. Feinstein JA, Goldhaber SZ, Lock JE, Ferndandes SM, Landzberg MJ. Balloon pulmonary angioplasty for treatment of chronic thromboembolic pulmonary hypertension. Circulation 2001; 103:10–13.
Educational Exhibit
Abstract No. 664
Revisited diagnostic interventional endocrinology: IPSS, AVS, and ASVS
Posters and Exhibits
N. Yim, H. Kim, Y. Kang, H. Jung, J. Kim; Chonnam National University Hospital, Gwangju, Republic of Korea Learning Objectives: The objective of this exhibit is to present basic knowledge and practical tips about inferior petrosal sinus sampling (IPSS), arterial stimulation venous sampling (ASVS), and adrenal venous sampling (AVS). Background: Diagnostic interventional procedures, including IPSS, ASVS, and AVS has played a pivotal role in widening understanding about endocrinologic diseases better, in terms of functional and anatomical aspect. However, poor angiographic understanding about vasculature around deep seated endocrine organ, lack of knowledge for result interpretation, and lack of skill for venous sampling makes these procedures are overlooked, even by interventional radiologist. Clinical Findings/Procedure Details: 1) Physiologic, anatomical background for IPSS, ASVS, and AVS. 2) Technical tips and angiographic findings for accurate sampling and better procedure. 3) Interpretation of results, clinical application, and representative case presentation. Conclusions: In this educational poster, various important things related to IPSS, ASVS, and AVS will be provided. And representative cases from author’s institution also provided. And readers could deepen their understanding about venous sampling. The teaching points of this educational exhibit are: 1) To understand the anatomic and physiologic knowledge
’
JVIR
involved in IPSS, ASVS, and AVS. 2) To review technical tips that can help interventionist to do successful procedure with accurate results. 3) To know the way how to interpret result of each procedures.
Educational Exhibit
Abstract No. 665
Real-time MRI guided percutaneous sclerotherapy of low-flow venous malformations S. Partovi1, L. Vidal2, D. Nakamoto3, Z. Lu2, J. Buethe4, M. Coffey2, I. Patel5; 1University Hospitals Case Medical Center, Cleveland, OH; 2University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH; 3University Hospitals of Cleveland, Cleveland, OH; 4University Hospitals Case Western Medical Center, Cleveland, OH; 5University Hospitals, Case Medical Center, Cleveland, OH Learning Objectives: 1. To discuss appropriate patient preparation and positioning prior to real-time MRI guided percutaneous sclerotherapy 2. To become familiar with MRI sequence planning and sclerotherapy agents used for real-time MRI guided percutaneous sclerotherapy 3. To interpret MRI studies in the context of procedure planning of patients with low-flow venous malformations Background: 1. Low-flow venous malformations are congenital soft-tissue lesions that can be found throughout the body of adults and children; approximately 40% are in the head and neck. 2. Clinical symptoms are location-dependent and include pain, cosmetic defects, oral bleeding, focal thrombosis, muscle fibrosis, hemarthrosis, local compression effects, and cranial nerve palsy. 3. MRI guided sclerotherapy is an evolving and novel approach for low-flow venous malformation treatment. 4. MR imaging is used for pre-procedural visualization of lesions and surrounding anatomy as well as assessment of sclerosant delivery and needle placement during the procedure. 5. Sclerotherapy agents are delivered into the malformation to induce an endothelial inflammatory response leading to acute thrombosis and subsequent fibrosis. Clinical Findings/Procedure Details: Real-time MRI guided sclerotherapy treatment of low-flow venous malformations will be explained in a stepwise approach based on our own experience. We will share our institutional experience and demonstrate a variety of cases performed with this MR based interventional technique. Conclusions: 1. MRI protocol and interpretation for planning of the procedure 2. Patient preparation prior to procedure including the need for anesthesia or conscious sedation 3. Patient positioning in the MRI magnet for MRI guided treatment 4. Real-time MRI sequences for low-flow venous malformation identification, needle placement, and treatment success assessment using sclerosantGadolinium mixture injections
Abstract No. 666 Adrenal gland imaging for hyperldosteronism: are imaging methods reliable? A. Gasparetto1, P. Darvishi2, C. Freeman1, R. Norby3, J. Angle3; 1University of Virginia, Charlottesville, VA;
JVIR
’
Posters and Exhibits
S291
2
University of Virginia, charlottesville, VA; 3N/A, Charlottesville, VA
Transjugular Intrahepatic Portosystemic Shunts (TIPS): 9 (2 with concurrent transportal embolization of varices) TIPS revision: 2 Direct Intrahepatic Portosystemic Shunt (DIPS): 1 Total: 38 Mean follow up: 27 months (Range 2-108 months) Technical Success: 34/38 (3 failed PSE, 1 failed TIPS) Bleeding controlled: 32/34 (2 rebled within 1week) Recurrent bleeding: N¼22 Mean Bleeding Free Interval: All patients: 17 months (Range 5days– 60months) TIPS patients: 20 months (Range 3–60months) Percutaneous Embolization patients: 7 months (Range 5days36months) Adverse Events: -”Glue” pulmonary embolus post PTE - Bacteremia post PSE - Hemoperitoneum post TIPS Conclusions: TIPS provides the longest bleeding free interval but is not a feasible option in a lot of patients TIPS with concomitant embolization results in a longer bleeding free interval than TIPS alone Percutaneous embolization is successful in managing bleeding however has a high rebleeding rate In patients with a stoma, treatment other than TIPS commonly results in either early or delayed rebleeding in sites other than the stoma due to continued portal hypertension
Purpose: Cross-sectional imaging methods have been historically considered poor predictors of lateralization in patients suffering from primary hyperaldosteronism. However in certain clinical settings nodule size, imaging characteristics and demographics, particularly in patients ≤40 years, are considered good as predictors of lateralization. The purpose of this study is to investigate the ability of imaging methods to predict unilateral aldosterone hypersecretion on the basis of patient age and adrenal nodules size and imaging characteristics. Materials: Sevety-three consecutive patients who screened positive for primary aldosteronism (PA) were investigated retrospectively. Patient age, adrenal vein sampling (AVS) results, and imaging findings were compared to the diagnosis based on AVS and/or surgery. All patients had an adrenal protocol CT or MR. Results: Nine of 73 patients were excluded: 4 because of incomplete data and 5 with non-lateralization on AVS and bilateral nodules on imaging. Based on 59 CT and 5 MRI, 8 patients had no nodules, 56 had unilateral nodules, of which 7 had nodules o1cm and 49 had nodules ≥1cm. Imaging characterization among the 49 patients that displayed unilateral nodules ≥1 cm, 36 were adenomatous and 24 were adenomatous and fatty. AVS indicated lateralization in 35 (73.4%), 24 (66.7%) and 15 (62.5%) in patients with no nodule, nodule o1 cm, or nodules ≥1 cm, respectively. Ten patients were younger than 40 years old and among them 4 had unilateral fatty adenomatous nodules 41cm and two of them (50%) showed lateralization. Conclusions: Imaging methods cannot substitute for AVS, regardless the radiological findings or the age of the patient.
1. Norton ID, Andrews JC, Kamath PS. Management of ectopic varices. Hepatology 1998; 28:1154–1158. 2. Helmy A, Al Kahtani K, Al Fadda M. Updates in the pathogenesis, diagnosis and management of ectopic varices. Hepatol Int 2008; 2:322–334. 3. Kinkhabwala M, Mousavi A, Iyer S, Adamsons R. Bleeding ileal varicosity demonstrated by transhepatic portography. AJR Am J Roentgenol 1977; 129:514–516. 4. Tripathi D, Helmy A, Macbeth K, Balata S, Lui HF, Stanley HA, et al. Ten years’ follow-up of 472 patients following transjugular intrahepatic portosystemic stent-shunt insertion at a single centre. Eur J Gastroenterol Hepatol 2004; 16:9–18. 5. Smith-Laing G, Scott J, Long RG, Sherlock S. Role of percutaneous transhepatic obliteration of varices in the management of bleeding from gastroesophageal varices. Gastroenterology 1981; 80:1031–1036.
Educational Exhibit
Educational Exhibit
Abstract No. 667
References
Abstract No. 668
The role of interventional radiology in venous blood sampling revisited
K. Khalidi1, K. Sniderman2; 1University of Toronto, Toronto, ON; 2Toronto General Hospital/University Health Network, Toronto, ON
J. Tisnado1, M. Amendola1, J. Tisnado2, M. Sydnor2, D. Komorowski2, M. Pasyk1; 1Virginia Commonwealth University, Richmond, VA; 2Richmond, VA
Learning Objectives: To report our institution’s experience with the endovascular management of bleeding ectopic varices (BEV) over a 10 year period Review sites of ectopic varices Review endovascular procedures for management of BEV Background: Ectopic varices are large pressurized portosystemic venous collaterals that occur anywhere in the abdomen except in the gastroesophageal region. They account for up to 5% of all variceal bleeding. Hemorrhage associated with these varices can be massive with a high mortality rate. There are multiple imageguided approaches to management of BEV. They include direct percutaneous access to varices, antegrade & retrograde sclerotherapy &/or embolotherapy, & portosystemic shunts. Clinical Findings/Procedure Details: Retrospective review at our institution (2005-2015). All patients who underwent endovascular management for BEV RESULTS: # of Patients: 20 Sex:12 M, 8 F Bleeding Ectopic Site: 17 Stomal Varices (8 Colostomy, 8 Ileostomy, 1 Ileal conduit) 2 Rectal, 1 Small Bowel I.R Therapies: Percutaneous Peristomal Embolization (PSE): 9 Percutaneous Transhepatic Embolization (PTE): 17
Learning Objectives: Venous blood sampling (VBS) was a “routine” procedure to localize endocrine tumors before “noninvasive” imaging. Lately the need of VBS decreased. With newer CT scanners, small tumors (o5 mm) are found. Young IRs do not learn VBS procedures. Some physicians are unaware of these “obsolete” but important IR procedures. Therefore, VBS must be “resuscitated” and “revisited.” Background: The VBS procedures reviewed are: inferior petrosal sinus VBS and sinography, cavernous sinous VBS and sinography, VBS and venography of neck, chest and mediastinal veins, percutaneous catheterization of the portal vein for VBS, adrenal gland VBS and venography, right hepatic vein VBS during arterial stimulation with CAþþ, gonadal VBS and venography, and renal vein and IVC VBS. Results: Radiologists, IRs, and clinicians alike must be aware of the role of VBS and venography in evaluating patients with clinical and laboratory evidence suggesting an endocrine tumor (s) in whom, a complete workup, including “noninvasive” imaging, is nondiagnostic.
Posters and Exhibits
Endovascular management of bleeding ectopic varices: a retrospective review
Posters and Exhibits
vessel by balloon catheters of appropriate size determined by MDCT or cone-beam CT. The procedure was discontinued when oxygen desaturation was 44% or hemo sputum occurred. We performed BPA in a staged fashion over multiple, separate procedures to maximize efficacy and reduce the risk of reperfusion pulmonary injury. Results: BPA procedure was performed 1-8 times (mean 3.7procedure). mPAP decreased to 14-56mg (mean 27.7mmHg) in all patients. In 10 patients, mPAP improve to under 30mmHg, which was reported to improve prognosis in patients with CTEPH. In 9 patients, the World Health Organization functional class classification improved from III to II. BPA was not defined clinically effective in 5 patients, because mPAP is over 30mmHg in spite of multiple BPA procedure. The duration from PEA to BPA in these four patients was 19-110 months (mean 70.2 months, p¼0.075). Conclusions: BPA for the treatment of the patients with CTEPH after PEA may be feasible and safe. BPA after PEA may be effective if the duration between PEA to BPA was short. Long term follow up is mandatory to confirm the effectiveness of this procedure. References 1. Sugiyama M, Fukuda T, Sanda Y, Morita Y, Higashi M, Ogo T, Tsuji A, Demachi J, Nakanishi N, Naito H. Organized thrombus in pulmonary arteries in patients with chronic thromboembolic pulmonary hypertension; imaging with cone beam computed tomography. Jpn J Radiol, (2014); published online EpubApr 24 (10.1007/s11604-014-0319-8). 2. Feinstein JA, Goldhaber SZ, Lock JE, Ferndandes SM, Landzberg MJ. Balloon pulmonary angioplasty for treatment of chronic thromboembolic pulmonary hypertension. Circulation 2001; 103:10–13.
Educational Exhibit
Abstract No. 664
Revisited diagnostic interventional endocrinology: IPSS, AVS, and ASVS
Posters and Exhibits
N. Yim, H. Kim, Y. Kang, H. Jung, J. Kim; Chonnam National University Hospital, Gwangju, Republic of Korea Learning Objectives: The objective of this exhibit is to present basic knowledge and practical tips about inferior petrosal sinus sampling (IPSS), arterial stimulation venous sampling (ASVS), and adrenal venous sampling (AVS). Background: Diagnostic interventional procedures, including IPSS, ASVS, and AVS has played a pivotal role in widening understanding about endocrinologic diseases better, in terms of functional and anatomical aspect. However, poor angiographic understanding about vasculature around deep seated endocrine organ, lack of knowledge for result interpretation, and lack of skill for venous sampling makes these procedures are overlooked, even by interventional radiologist. Clinical Findings/Procedure Details: 1) Physiologic, anatomical background for IPSS, ASVS, and AVS. 2) Technical tips and angiographic findings for accurate sampling and better procedure. 3) Interpretation of results, clinical application, and representative case presentation. Conclusions: In this educational poster, various important things related to IPSS, ASVS, and AVS will be provided. And representative cases from author’s institution also provided. And readers could deepen their understanding about venous sampling. The teaching points of this educational exhibit are: 1) To understand the anatomic and physiologic knowledge
’
JVIR
involved in IPSS, ASVS, and AVS. 2) To review technical tips that can help interventionist to do successful procedure with accurate results. 3) To know the way how to interpret result of each procedures.
Educational Exhibit
Abstract No. 665
Real-time MRI guided percutaneous sclerotherapy of low-flow venous malformations S. Partovi1, L. Vidal2, D. Nakamoto3, Z. Lu2, J. Buethe4, M. Coffey2, I. Patel5; 1University Hospitals Case Medical Center, Cleveland, OH; 2University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH; 3University Hospitals of Cleveland, Cleveland, OH; 4University Hospitals Case Western Medical Center, Cleveland, OH; 5University Hospitals, Case Medical Center, Cleveland, OH Learning Objectives: 1. To discuss appropriate patient preparation and positioning prior to real-time MRI guided percutaneous sclerotherapy 2. To become familiar with MRI sequence planning and sclerotherapy agents used for real-time MRI guided percutaneous sclerotherapy 3. To interpret MRI studies in the context of procedure planning of patients with low-flow venous malformations Background: 1. Low-flow venous malformations are congenital soft-tissue lesions that can be found throughout the body of adults and children; approximately 40% are in the head and neck. 2. Clinical symptoms are location-dependent and include pain, cosmetic defects, oral bleeding, focal thrombosis, muscle fibrosis, hemarthrosis, local compression effects, and cranial nerve palsy. 3. MRI guided sclerotherapy is an evolving and novel approach for low-flow venous malformation treatment. 4. MR imaging is used for pre-procedural visualization of lesions and surrounding anatomy as well as assessment of sclerosant delivery and needle placement during the procedure. 5. Sclerotherapy agents are delivered into the malformation to induce an endothelial inflammatory response leading to acute thrombosis and subsequent fibrosis. Clinical Findings/Procedure Details: Real-time MRI guided sclerotherapy treatment of low-flow venous malformations will be explained in a stepwise approach based on our own experience. We will share our institutional experience and demonstrate a variety of cases performed with this MR based interventional technique. Conclusions: 1. MRI protocol and interpretation for planning of the procedure 2. Patient preparation prior to procedure including the need for anesthesia or conscious sedation 3. Patient positioning in the MRI magnet for MRI guided treatment 4. Real-time MRI sequences for low-flow venous malformation identification, needle placement, and treatment success assessment using sclerosantGadolinium mixture injections
Abstract No. 666 Adrenal gland imaging for hyperldosteronism: are imaging methods reliable? A. Gasparetto1, P. Darvishi2, C. Freeman1, R. Norby3, J. Angle3; 1University of Virginia, Charlottesville, VA;
JVIR
’
Posters and Exhibits
S291
2
University of Virginia, charlottesville, VA; 3N/A, Charlottesville, VA
Transjugular Intrahepatic Portosystemic Shunts (TIPS): 9 (2 with concurrent transportal embolization of varices) TIPS revision: 2 Direct Intrahepatic Portosystemic Shunt (DIPS): 1 Total: 38 Mean follow up: 27 months (Range 2-108 months) Technical Success: 34/38 (3 failed PSE, 1 failed TIPS) Bleeding controlled: 32/34 (2 rebled within 1week) Recurrent bleeding: N¼22 Mean Bleeding Free Interval: All patients: 17 months (Range 5days– 60months) TIPS patients: 20 months (Range 3–60months) Percutaneous Embolization patients: 7 months (Range 5days36months) Adverse Events: -”Glue” pulmonary embolus post PTE - Bacteremia post PSE - Hemoperitoneum post TIPS Conclusions: TIPS provides the longest bleeding free interval but is not a feasible option in a lot of patients TIPS with concomitant embolization results in a longer bleeding free interval than TIPS alone Percutaneous embolization is successful in managing bleeding however has a high rebleeding rate In patients with a stoma, treatment other than TIPS commonly results in either early or delayed rebleeding in sites other than the stoma due to continued portal hypertension
Purpose: Cross-sectional imaging methods have been historically considered poor predictors of lateralization in patients suffering from primary hyperaldosteronism. However in certain clinical settings nodule size, imaging characteristics and demographics, particularly in patients ≤40 years, are considered good as predictors of lateralization. The purpose of this study is to investigate the ability of imaging methods to predict unilateral aldosterone hypersecretion on the basis of patient age and adrenal nodules size and imaging characteristics. Materials: Sevety-three consecutive patients who screened positive for primary aldosteronism (PA) were investigated retrospectively. Patient age, adrenal vein sampling (AVS) results, and imaging findings were compared to the diagnosis based on AVS and/or surgery. All patients had an adrenal protocol CT or MR. Results: Nine of 73 patients were excluded: 4 because of incomplete data and 5 with non-lateralization on AVS and bilateral nodules on imaging. Based on 59 CT and 5 MRI, 8 patients had no nodules, 56 had unilateral nodules, of which 7 had nodules o1cm and 49 had nodules ≥1cm. Imaging characterization among the 49 patients that displayed unilateral nodules ≥1 cm, 36 were adenomatous and 24 were adenomatous and fatty. AVS indicated lateralization in 35 (73.4%), 24 (66.7%) and 15 (62.5%) in patients with no nodule, nodule o1 cm, or nodules ≥1 cm, respectively. Ten patients were younger than 40 years old and among them 4 had unilateral fatty adenomatous nodules 41cm and two of them (50%) showed lateralization. Conclusions: Imaging methods cannot substitute for AVS, regardless the radiological findings or the age of the patient.
1. Norton ID, Andrews JC, Kamath PS. Management of ectopic varices. Hepatology 1998; 28:1154–1158. 2. Helmy A, Al Kahtani K, Al Fadda M. Updates in the pathogenesis, diagnosis and management of ectopic varices. Hepatol Int 2008; 2:322–334. 3. Kinkhabwala M, Mousavi A, Iyer S, Adamsons R. Bleeding ileal varicosity demonstrated by transhepatic portography. AJR Am J Roentgenol 1977; 129:514–516. 4. Tripathi D, Helmy A, Macbeth K, Balata S, Lui HF, Stanley HA, et al. Ten years’ follow-up of 472 patients following transjugular intrahepatic portosystemic stent-shunt insertion at a single centre. Eur J Gastroenterol Hepatol 2004; 16:9–18. 5. Smith-Laing G, Scott J, Long RG, Sherlock S. Role of percutaneous transhepatic obliteration of varices in the management of bleeding from gastroesophageal varices. Gastroenterology 1981; 80:1031–1036.
Educational Exhibit
Educational Exhibit
Abstract No. 667
References
Abstract No. 668
The role of interventional radiology in venous blood sampling revisited
K. Khalidi1, K. Sniderman2; 1University of Toronto, Toronto, ON; 2Toronto General Hospital/University Health Network, Toronto, ON
J. Tisnado1, M. Amendola1, J. Tisnado2, M. Sydnor2, D. Komorowski2, M. Pasyk1; 1Virginia Commonwealth University, Richmond, VA; 2Richmond, VA
Learning Objectives: To report our institution’s experience with the endovascular management of bleeding ectopic varices (BEV) over a 10 year period Review sites of ectopic varices Review endovascular procedures for management of BEV Background: Ectopic varices are large pressurized portosystemic venous collaterals that occur anywhere in the abdomen except in the gastroesophageal region. They account for up to 5% of all variceal bleeding. Hemorrhage associated with these varices can be massive with a high mortality rate. There are multiple imageguided approaches to management of BEV. They include direct percutaneous access to varices, antegrade & retrograde sclerotherapy &/or embolotherapy, & portosystemic shunts. Clinical Findings/Procedure Details: Retrospective review at our institution (2005-2015). All patients who underwent endovascular management for BEV RESULTS: # of Patients: 20 Sex:12 M, 8 F Bleeding Ectopic Site: 17 Stomal Varices (8 Colostomy, 8 Ileostomy, 1 Ileal conduit) 2 Rectal, 1 Small Bowel I.R Therapies: Percutaneous Peristomal Embolization (PSE): 9 Percutaneous Transhepatic Embolization (PTE): 17
Learning Objectives: Venous blood sampling (VBS) was a “routine” procedure to localize endocrine tumors before “noninvasive” imaging. Lately the need of VBS decreased. With newer CT scanners, small tumors (o5 mm) are found. Young IRs do not learn VBS procedures. Some physicians are unaware of these “obsolete” but important IR procedures. Therefore, VBS must be “resuscitated” and “revisited.” Background: The VBS procedures reviewed are: inferior petrosal sinus VBS and sinography, cavernous sinous VBS and sinography, VBS and venography of neck, chest and mediastinal veins, percutaneous catheterization of the portal vein for VBS, adrenal gland VBS and venography, right hepatic vein VBS during arterial stimulation with CAþþ, gonadal VBS and venography, and renal vein and IVC VBS. Results: Radiologists, IRs, and clinicians alike must be aware of the role of VBS and venography in evaluating patients with clinical and laboratory evidence suggesting an endocrine tumor (s) in whom, a complete workup, including “noninvasive” imaging, is nondiagnostic.
Posters and Exhibits
Endovascular management of bleeding ectopic varices: a retrospective review