- Email: [email protected]
Bland embolization versus radioembolization for treatment of multifocal hepatocellular carcinoma
S158
Posters and Exhibits
was 6.4 mSv/h (SD 3.8). Assuming invariable presence, the mean TEDE was 0.25 mSv (SD 0.15). When adjusted to a whole-liver absorbed dose of 60 Gy, the mean dose rate in the air at 1 m immediately after treatment was 30.9 mSv/h (SD 13.2), corresponding to a mean TEDE of 1.19 mSv (SD 0.51). None of the corrected dose rates, at any time, measured from either frontal or lateral position, would have led to a TEDE above 5 mSv. Conclusion: TEDE of patients treated with 166Ho-RE aimed at a 60 Gy whole-liver absorbed dose, will not exceed the NRC limit (3) of 5 mSv to another individual: not even when discharged immediately after treatment. Patients are to be provided with written instructions as to keep the exposure to other individuals as low as reasonably achievable. References 1. Smits MLJ, et al., Lancet Oncol 2012;13:1025-34. 2. NRC, Regulatory Guide 8.39, April 1997. 3. NRC, NRC-10 CFR 35.75.
Educational Exhibit
Abstract No. 368
Portal vein interventions
Posters and Exhibits
A. Sattar, S. Astani, S. Schwartz, S. Sturza, D. McVinnie, T.M. Getzen, D.L. Croteau, L.M. Vance; Radiology, Henry Ford Hospital, Detroit Learning Objectives: To discuss various portal venous interventions offered by interventional radiology including their indications, contraindications, clinical utility, expected outcome, and common complications. Background: Different portal vein interventions include portal vein stent (PVS), portal vein embolizaion (PVE), transjugular intrahepatic portosystemic shunt (TIPS), and direct intrahepatic portocaval shunt (DIPS). Clinical Findings/Procedure Details: Portal Vein Stent (PVS): Performed in the setting of portal venous stenosis or occlusion that commonly occurs in neoplastic conditions or post liver transplantation. Liver abscess has been reported as a post procedural complication. Portal Vein Embolization (PVE): Performed in preoperative treatment of major hepatic resection in patient when the future liver remnant is too small. PVE complications are rare but include transient hemobilia, infection, need for reembolization, portal vein thrombosis, and portal hypertension. Portal Vein Thrombolysis (PVT): PVT is the preferred treatment for acute intravascular thrombosis. Percutaneous portal vein clot lysis can be initiated in a few minutes providing almost immediate clot dissolution without the need for surgical intervention. Transjugular Intrahepatic Portosystemic Shunt (TIPS): Indications for TIPS procedure include recurrent or refractory variceal bleeding, Budd Chiari syndrome, hepatic hydrothorax, hepatorenal syndrome, and intractable ascites. Complications include but are not limited to hepatic encephalopathy, heart failure. There is improved survival of patients with refractory ascites when treated with TIPS. Direct Intrahepatic Portocaval Shunt (DIPS): Indications are similar to TIPS procedure for decompression of portal venous system. DIPS procedure includes direct puncture from the IVC through the caudate lobe to the main portal vein. The safety and effectiveness is increased by eliminating blind PV puncture and hepatic vein stenosis which is the most common cause of chronic TIPS failure. Conclusion and/or Teaching Points: Knowledge of portal vein interventions including their indication, clinical utility
’
JVIR
and expected outcome is critical for clinicians to improve patient care.
Abstract No. 369 Impact of a novel web-based quality-reporting tool (QatchAll) embedded into the workflow in vascular and interventional radiology A. Prabhakar1, T.K. Alkasab2, H. Harvey2, G.M. Salazar1, S. Ganguli1, G. Walker1, S.P. Kalva1, R.W. Liu1, Z. Irani1, S. Wicky1, G.R. Oliveira1, R. Oklu1; 1Vascular Imaging and Intervention, Massachusetts General Hospital, Harvard Medical School, Boston, MA; 2Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA Purpose: The purpose of this study was to determine the feasibility and the impact of using QatchAll to identify the frequency and type of technical issues reported in the Division of Vascular Imaging and Intervention at our institution. Materials and Methods: To assess, document and improve the technical quality of imaging studies and image guided interventions, our department has developed a novel information technology system called QatchAll embedded into our current workflow to report and track technical issues. The QatchAll database was reviewed August 2011 to September 2012 time period for technical issues reported by radiologists in the Division of Vascular Imaging and Intervention. The frequency and the types of quality issues reported were examined. As a measure of improvement in the quality of care achieved through the use of QatchAll, the frequency of quality issues over the time period of the study was also assessed. Results: 130 quality events were reported using the QatchAll interface integrated into the hospital Picture Archiving and Communication System (PACS) by 13 Vascular and Interventional Radiologists. 16% of the reports involved CT, 49% US, 16% MR, and 19% Procedures. During the study period, the average number of quality issues raised by the radiologists per month decreased in the second half of the study period (7.6 events) as compared to the first half (13 events). As a result of such reporting, there was increased frequency of communication between technologists and the radiologists, immediate correction of errors and a significant decrease in the number of call-backs for repeat examinations. Conclusion: Monitoring and improving quality in interventional radiology is greatly assisted by the QatchAll reporting tool embedded into the daily workflow. Utilizing QatchAll allows for better communication between technologists and radiologists with overall improvement in the quality of imaging studies.
Abstract No. 370 Bland embolization versus radioembolization for treatment of multifocal hepatocellular carcinoma E.M. Vikingstad, P. Suhocki, B.I. Engstrom, D. Semmel, W.M. Pabon-Ramos, T.A. Gebhard, D.R. Sopko, C.Y. Kim; Vascular and Interventional Radiology, Duke University Medical Center, Durham, NC Purpose: To compare overall survival rates after treatment of multifocal hepatocellular carcinoma (HCC) with bland versus radioembolization.
JVIR
’
Posters and Exhibits
S159
Materials and Methods: Review of our procedural database revealed 44 patients treated with radioembolization for HCC between 9/2007 and 2/2012. From 9/05 to 2/2009, 84 patients were treated with bland embolization for HCC. Patients with unifocal disease, portal vein thrombosis, extrahepatic disease, or Okuda stage III disease were excluded from subsequent analysis. The final study population consisted of 29 patients who underwent bland embolization (24 males, mean age 63 years) and 29 patients who underwent radioembolization (20 males, mean age 69 years). Clinical records were retrospectively reviewed. Survival rates were estimated using the Kaplan-Meier method and compared using the log rank test. Results: A total of 31 bland embolization procedures were performed in 29 patients. Thirty-seven radioembolization procedures were performed in 29 patients. The 6 and 12 month survival rates for patients undergoing bland embolization were 86% and 71% respectively, compared to 83% and 60% for patients undergoing radioembolization (p¼0.057). Analysis of Okuda staging revealed that 31% of patients undergoing bland embolization were stage I compared to 86% of patients undergoing radioembolization (po0.01). Conclusion: In this retrospective study, bland embolization and radioembolization demonstrated comparable overall survival rates for patients with multifocal HCC and without portal vein thrombus. However, the patients treated with bland embolization in this study had a higher Okuda disease stage than those treated with radioembolization.
Educational Exhibit
Abstract No. 371
Streamlining a vascular referral service line through the use of a portable vascular laboratory J. Cannell, M. Montgomery; Texas AandM HSC - Scott and White Memorial Hospital, Temple, TX
Educational Exhibit
Abstract No. 372
Intraoperative major trauma embolization: initial experience and TIPS for success in establish a hemorrhage control team D.A. Valenti1, T. Razek2, V. Demers1, S. Kaduri1, A. Bessissow1, R.W. Lindsay1, C. Torres1, T. Cabrera1, L.N. Boucher1; 1Radiology, McGill University, Montreal, QC, Canada; 2Surgery, McGill University, Montreal, QC, Canada Learning Objectives: To outline basic selection criteria for intra-operative vs IR suite embolization. To review some pitfalls and roadblocks to success. Discuss keys for prompt response time and short procedural times. Background: A subset of severe poly-trauma patients are too unstable to be successfully imaged by CT and transferred to the IR suite. These patients require urgent transfer to the OR for stabilization and support. Nonetheless, some of these patients can benefit from embolization intra-operatively, as certain pelvic and parenchymal organ hemorrhage may be easier to control angiographically than surgically. Clinical Findings/Procedure Details: Basic materials required required for intra-operative angiography will be outlined as well as strategies to reduce response and procedure time. Conclusion and/or Teaching Points: Intra-operative angiographic hemorrhage control has become an essential part of our Trauma team. It is especially useful in those patients with such massive hemorrhage and severe hemodynamic instability that transfer to an OR setting is required just to maintain a minimum blood pressure. High clinical success rates are achievable despite challenging technical conditions.
Educational Exhibit
Abstract No. 373
Splenic artery embolization as treatment for splenic artery steal syndrome after liver transplantation D.V. Strain1, P. Brady1, T. Matalon1, M. Horrow1, J. Ortiz2, A. Parsikia2; 1Radiology, Albert Einstein Medical Center, Philadelphia, PA; 2Transplant Surgery, Albert Einstein Medical Center, Philadelphia, PA Learning Objectives: Splenic artery steal syndrome is an underdiagnosed entity first described in 1991 and occurring in 3-8% of patients after orthotopic liver transplantation (OLTX). The purpose of this article is to describe five cases of splenic artery steal syndrome in a single institution. Background: An imaging search engine was used to search for liver transplant patients with a diagnosis of splenic artery steal syndrome. Further chart review to evaluate for what treatment was performed, and the post treatment changes.
Posters and Exhibits
Learning Objectives: 1)The reader will learn strategies to increase efficiency in the evaluation of vascular referrals through the use of electronic medical records and a portable vascular laboratory.2)Methods and strategies utilizing a portable vascular laboratory to improve patient care, reduce healthcare costs, and increase access to care in Interventional Radiology will be discussed. Background: Noninvasive vascular testing including Doppler ultrasound, segmental pressures, pulse volume recordings, and ankle brachial indices are regularly used for evaluation of peripheral vascular disease. Ultrasound is also used in evaluation of venous reflux and venous mapping. Testing can be used to screen, diagnose, and plan for vascular therapy. With the development of compact mobile noninvasive diagnostic devices, noninvasive testing has become portable. Portable vascular laboratories allow for rapid evaluation when patients are initially seen with primary care providers in office-based clinics. This technology has been utilized to increase referrals to Interventional Radiology. Clinical Findings/Procedure Details: This exhibit will demonstrate how to incorporate a portable vascular laboratory into an existing vascular service line. A practical guide will be proposed which can be used to prioritize referrals based on this portable testing and the information available in the electronic medical record. Strategies to improve communication with referring clinicians and optimize treatments will be presented. Also exhibited will be the possible benefits of improving efficiency including potential cost-reduction. Methods utilizing
portable devices to appropriately screen patients for referral to Interventional Radiology will be highlighted. Conclusion and/or Teaching Points: Through the use of a portable noninvasive vascular laboratory and a supporting EMR, vascular referrals can be more efficiently evaluated. The potential benefits of portability and increased efficiency include costreduction and increased patient volume to Interventional Radiology.
Posters and Exhibits
was 6.4 mSv/h (SD 3.8). Assuming invariable presence, the mean TEDE was 0.25 mSv (SD 0.15). When adjusted to a whole-liver absorbed dose of 60 Gy, the mean dose rate in the air at 1 m immediately after treatment was 30.9 mSv/h (SD 13.2), corresponding to a mean TEDE of 1.19 mSv (SD 0.51). None of the corrected dose rates, at any time, measured from either frontal or lateral position, would have led to a TEDE above 5 mSv. Conclusion: TEDE of patients treated with 166Ho-RE aimed at a 60 Gy whole-liver absorbed dose, will not exceed the NRC limit (3) of 5 mSv to another individual: not even when discharged immediately after treatment. Patients are to be provided with written instructions as to keep the exposure to other individuals as low as reasonably achievable. References 1. Smits MLJ, et al., Lancet Oncol 2012;13:1025-34. 2. NRC, Regulatory Guide 8.39, April 1997. 3. NRC, NRC-10 CFR 35.75.
Educational Exhibit
Abstract No. 368
Portal vein interventions
Posters and Exhibits
A. Sattar, S. Astani, S. Schwartz, S. Sturza, D. McVinnie, T.M. Getzen, D.L. Croteau, L.M. Vance; Radiology, Henry Ford Hospital, Detroit Learning Objectives: To discuss various portal venous interventions offered by interventional radiology including their indications, contraindications, clinical utility, expected outcome, and common complications. Background: Different portal vein interventions include portal vein stent (PVS), portal vein embolizaion (PVE), transjugular intrahepatic portosystemic shunt (TIPS), and direct intrahepatic portocaval shunt (DIPS). Clinical Findings/Procedure Details: Portal Vein Stent (PVS): Performed in the setting of portal venous stenosis or occlusion that commonly occurs in neoplastic conditions or post liver transplantation. Liver abscess has been reported as a post procedural complication. Portal Vein Embolization (PVE): Performed in preoperative treatment of major hepatic resection in patient when the future liver remnant is too small. PVE complications are rare but include transient hemobilia, infection, need for reembolization, portal vein thrombosis, and portal hypertension. Portal Vein Thrombolysis (PVT): PVT is the preferred treatment for acute intravascular thrombosis. Percutaneous portal vein clot lysis can be initiated in a few minutes providing almost immediate clot dissolution without the need for surgical intervention. Transjugular Intrahepatic Portosystemic Shunt (TIPS): Indications for TIPS procedure include recurrent or refractory variceal bleeding, Budd Chiari syndrome, hepatic hydrothorax, hepatorenal syndrome, and intractable ascites. Complications include but are not limited to hepatic encephalopathy, heart failure. There is improved survival of patients with refractory ascites when treated with TIPS. Direct Intrahepatic Portocaval Shunt (DIPS): Indications are similar to TIPS procedure for decompression of portal venous system. DIPS procedure includes direct puncture from the IVC through the caudate lobe to the main portal vein. The safety and effectiveness is increased by eliminating blind PV puncture and hepatic vein stenosis which is the most common cause of chronic TIPS failure. Conclusion and/or Teaching Points: Knowledge of portal vein interventions including their indication, clinical utility
’
JVIR
and expected outcome is critical for clinicians to improve patient care.
Abstract No. 369 Impact of a novel web-based quality-reporting tool (QatchAll) embedded into the workflow in vascular and interventional radiology A. Prabhakar1, T.K. Alkasab2, H. Harvey2, G.M. Salazar1, S. Ganguli1, G. Walker1, S.P. Kalva1, R.W. Liu1, Z. Irani1, S. Wicky1, G.R. Oliveira1, R. Oklu1; 1Vascular Imaging and Intervention, Massachusetts General Hospital, Harvard Medical School, Boston, MA; 2Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA Purpose: The purpose of this study was to determine the feasibility and the impact of using QatchAll to identify the frequency and type of technical issues reported in the Division of Vascular Imaging and Intervention at our institution. Materials and Methods: To assess, document and improve the technical quality of imaging studies and image guided interventions, our department has developed a novel information technology system called QatchAll embedded into our current workflow to report and track technical issues. The QatchAll database was reviewed August 2011 to September 2012 time period for technical issues reported by radiologists in the Division of Vascular Imaging and Intervention. The frequency and the types of quality issues reported were examined. As a measure of improvement in the quality of care achieved through the use of QatchAll, the frequency of quality issues over the time period of the study was also assessed. Results: 130 quality events were reported using the QatchAll interface integrated into the hospital Picture Archiving and Communication System (PACS) by 13 Vascular and Interventional Radiologists. 16% of the reports involved CT, 49% US, 16% MR, and 19% Procedures. During the study period, the average number of quality issues raised by the radiologists per month decreased in the second half of the study period (7.6 events) as compared to the first half (13 events). As a result of such reporting, there was increased frequency of communication between technologists and the radiologists, immediate correction of errors and a significant decrease in the number of call-backs for repeat examinations. Conclusion: Monitoring and improving quality in interventional radiology is greatly assisted by the QatchAll reporting tool embedded into the daily workflow. Utilizing QatchAll allows for better communication between technologists and radiologists with overall improvement in the quality of imaging studies.
Abstract No. 370 Bland embolization versus radioembolization for treatment of multifocal hepatocellular carcinoma E.M. Vikingstad, P. Suhocki, B.I. Engstrom, D. Semmel, W.M. Pabon-Ramos, T.A. Gebhard, D.R. Sopko, C.Y. Kim; Vascular and Interventional Radiology, Duke University Medical Center, Durham, NC Purpose: To compare overall survival rates after treatment of multifocal hepatocellular carcinoma (HCC) with bland versus radioembolization.
JVIR
’
Posters and Exhibits
S159
Materials and Methods: Review of our procedural database revealed 44 patients treated with radioembolization for HCC between 9/2007 and 2/2012. From 9/05 to 2/2009, 84 patients were treated with bland embolization for HCC. Patients with unifocal disease, portal vein thrombosis, extrahepatic disease, or Okuda stage III disease were excluded from subsequent analysis. The final study population consisted of 29 patients who underwent bland embolization (24 males, mean age 63 years) and 29 patients who underwent radioembolization (20 males, mean age 69 years). Clinical records were retrospectively reviewed. Survival rates were estimated using the Kaplan-Meier method and compared using the log rank test. Results: A total of 31 bland embolization procedures were performed in 29 patients. Thirty-seven radioembolization procedures were performed in 29 patients. The 6 and 12 month survival rates for patients undergoing bland embolization were 86% and 71% respectively, compared to 83% and 60% for patients undergoing radioembolization (p¼0.057). Analysis of Okuda staging revealed that 31% of patients undergoing bland embolization were stage I compared to 86% of patients undergoing radioembolization (po0.01). Conclusion: In this retrospective study, bland embolization and radioembolization demonstrated comparable overall survival rates for patients with multifocal HCC and without portal vein thrombus. However, the patients treated with bland embolization in this study had a higher Okuda disease stage than those treated with radioembolization.
Educational Exhibit
Abstract No. 371
Streamlining a vascular referral service line through the use of a portable vascular laboratory J. Cannell, M. Montgomery; Texas AandM HSC - Scott and White Memorial Hospital, Temple, TX
Educational Exhibit
Abstract No. 372
Intraoperative major trauma embolization: initial experience and TIPS for success in establish a hemorrhage control team D.A. Valenti1, T. Razek2, V. Demers1, S. Kaduri1, A. Bessissow1, R.W. Lindsay1, C. Torres1, T. Cabrera1, L.N. Boucher1; 1Radiology, McGill University, Montreal, QC, Canada; 2Surgery, McGill University, Montreal, QC, Canada Learning Objectives: To outline basic selection criteria for intra-operative vs IR suite embolization. To review some pitfalls and roadblocks to success. Discuss keys for prompt response time and short procedural times. Background: A subset of severe poly-trauma patients are too unstable to be successfully imaged by CT and transferred to the IR suite. These patients require urgent transfer to the OR for stabilization and support. Nonetheless, some of these patients can benefit from embolization intra-operatively, as certain pelvic and parenchymal organ hemorrhage may be easier to control angiographically than surgically. Clinical Findings/Procedure Details: Basic materials required required for intra-operative angiography will be outlined as well as strategies to reduce response and procedure time. Conclusion and/or Teaching Points: Intra-operative angiographic hemorrhage control has become an essential part of our Trauma team. It is especially useful in those patients with such massive hemorrhage and severe hemodynamic instability that transfer to an OR setting is required just to maintain a minimum blood pressure. High clinical success rates are achievable despite challenging technical conditions.
Educational Exhibit
Abstract No. 373
Splenic artery embolization as treatment for splenic artery steal syndrome after liver transplantation D.V. Strain1, P. Brady1, T. Matalon1, M. Horrow1, J. Ortiz2, A. Parsikia2; 1Radiology, Albert Einstein Medical Center, Philadelphia, PA; 2Transplant Surgery, Albert Einstein Medical Center, Philadelphia, PA Learning Objectives: Splenic artery steal syndrome is an underdiagnosed entity first described in 1991 and occurring in 3-8% of patients after orthotopic liver transplantation (OLTX). The purpose of this article is to describe five cases of splenic artery steal syndrome in a single institution. Background: An imaging search engine was used to search for liver transplant patients with a diagnosis of splenic artery steal syndrome. Further chart review to evaluate for what treatment was performed, and the post treatment changes.
Posters and Exhibits
Learning Objectives: 1)The reader will learn strategies to increase efficiency in the evaluation of vascular referrals through the use of electronic medical records and a portable vascular laboratory.2)Methods and strategies utilizing a portable vascular laboratory to improve patient care, reduce healthcare costs, and increase access to care in Interventional Radiology will be discussed. Background: Noninvasive vascular testing including Doppler ultrasound, segmental pressures, pulse volume recordings, and ankle brachial indices are regularly used for evaluation of peripheral vascular disease. Ultrasound is also used in evaluation of venous reflux and venous mapping. Testing can be used to screen, diagnose, and plan for vascular therapy. With the development of compact mobile noninvasive diagnostic devices, noninvasive testing has become portable. Portable vascular laboratories allow for rapid evaluation when patients are initially seen with primary care providers in office-based clinics. This technology has been utilized to increase referrals to Interventional Radiology. Clinical Findings/Procedure Details: This exhibit will demonstrate how to incorporate a portable vascular laboratory into an existing vascular service line. A practical guide will be proposed which can be used to prioritize referrals based on this portable testing and the information available in the electronic medical record. Strategies to improve communication with referring clinicians and optimize treatments will be presented. Also exhibited will be the possible benefits of improving efficiency including potential cost-reduction. Methods utilizing
portable devices to appropriately screen patients for referral to Interventional Radiology will be highlighted. Conclusion and/or Teaching Points: Through the use of a portable noninvasive vascular laboratory and a supporting EMR, vascular referrals can be more efficiently evaluated. The potential benefits of portability and increased efficiency include costreduction and increased patient volume to Interventional Radiology.