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Calcium arterial stimulation venous sampling for preoperative localization of occult insulinomas
S164
Educational Exhibit
Posters and Exhibits
Abstract No. 384
Venous thromboembolism: a comprehensive review J.P. Montgomery1, P.S. Kang2; 1Radiology, University Hospitals Case Medical Center, Cleveland, OH; 2 Radiology, Louis Stokes Veterans Affairs Medical Center, Cleveland, OH Learning Objectives: After viewing this exhibit, the audience will be able to: - Identify risk factors and clinical presentations of venous thromboembolic disease (VTE) - Understand current interventional radiology (IR) treatment of acute deep vein thrombosis (DVT) and pulmonary embolism (PE) o Mechanical and pharmacologic catheter based thrombolysis o Alternative devices including ultrasound assisted thrombolysis o Aspiration thrombectomy - Understand the role of angioplasty/ stenting to correct underlying anatomic predisposition - Understand the role of continued medical therapy - Understand the role of IVC filters Background: The spectrum of VTE encompasses both DVT and PE. This serious disease entity often results in hospitalization and may even result in death. VTE often recurs and may result in long-term complications including post-thrombotic syndrome and chronic thromboembolic pulmonary hypertension. Identification of risk factors including anatomic predisposition is paramount to achieving optimal therapy. Appropriate treatment of VTE is a critical step in preventing complications that are a major determinant of patient quality of life. Clinical Findings/Procedure Details: This exhibit will review risk factors, clinical presentations and complications of VTE. IR treatment methods of VTE are discussed including mechanical and pharmacologic catheter based thrombolysis utilizing case examples from our institution. Alternative therapeutic methods, including ultrasound assisted thrombolysis and aspiration thrombectomy, are also examined. The role of angioplasty/ stenting in cases of anatomic predisposition to VTE is highlighted with specific case examples. The role of continued medical therapy and IVC filters is also reviewed. Conclusion and/or Teaching Points: This exhibit aims to be a general but thorough review of the complex clinical disease of VTE and current strategies in therapy. This exhibit will engage the viewer in a review of VTE risk factors and clinical presentations. IR provides highly effective therapy with mechanical and pharmacologic thrombolysis. Optimal therapy of VTE is necessary not only to decrease the immediate morbidity and mortality but also to prevent recurrence and complications that significantly decrease patient quality of life.
Posters and Exhibits
Abstract No. 385 Clinical correlation between hepatic vein opacification and hepatopulmonary shunt fraction for 90Y evaluation N. Pinjaroen1,2, J. Kaufman2, K.J. Kolbeck2, K. Farsad2, L. Watson2; 1Radiology, Chulalongkorn University, Bangkok, Thailand; 2Interventional Radiology, Dotter Institute, Oregon Health and Science University, Portland, OR
’
JVIR
Purpose: Hepatopulmonary shunt (HPS) fraction Z20% is one of the occasional criteria preventing 90Y therapy. This study aimed to identify if there is clinical correlation between hepatic vein (HV) opacification and HPS during initial evaluation for 90Y therapy. Materials and Methods: We collected 90Y candidates from 2004 to 2011. Patient’s underlying disease, imaging, arteriograms, and HPS calculations were retrospectively reviewed. If the HV was opacified during visceral arteriogram, the time between contrast injection and HV visualization was recorded. Statistical analysis with unpaired t-test compared the time of HV visualization in patients with and without an elevated HPS fraction. Results: Total of 151 initial 90Y work up studies in 149 patients were included. The diagnoses included 75 HCC, 53 neuroendocrine tumor metastases, 14 colorectal metastases, 3 cholangiocarcinoma and 4 other metastases. Imaging revealed multifocal disease(n¼117, 77%), bilobar disease(102, 68%) and macrovascular invasion (41, 27%). Macrovascular invasions included 4 HV and IVC, 2 HV and portal vein (PV), 1 IVC, 11 main PV, 1 right main PV, 16 right PV branch, 2 left main PV and 4 left PV branch. Mean maximum tumor diameter was 6.9⫾3.6 cm. Twenty-nine patients (19%) did not complete Y90 therapy; due to (18) high HPS, (5) unfavorable vascular anatomy, (2) declining liver function, (1) gastric uptake, (1) extrahepatic tumor, (1) poor tumor localization and (1) misdiagnosis. HV opacification was noted in 15 studies. Nine out of 15 studies showed HPS fraction Z20%. PPV and NPV of HV opacification as a predictor of high HPS fraction were 60% and 94%. Average time until visualized HV in patients whom HPS fraction Z20% and o20% were 4.2 and 8.6 sec (p¼ 0.3). The difference of mean times between two group was 4.4 sec (95% CI - 0.4-8.3). Conclusion: The results demonstrated that visualization of the HV during initial arteriogram alone may not be sufficient to predict high HPS. We found that HV opacifications were seen on arteriograms earlier in the patients with high HPS (Z20%) than the patients with shunt o20%. However, the time difference in HV visualization between the two groups was not statistically significant due to the small sample size.
Educational Exhibit
Abstract No. 386
Calcium arterial stimulation venous sampling for preoperative localization of occult insulinomas S. Gadani, S. Huang, M.J. Wallace, R. Avritscher, B.C. Odisio; MD Anderson Cancer Center, Houston, TX Learning Objectives: (1) To review the clinical features, diagnosis, and treatment of insulinomas, (2) to discuss the indications and advantages of intra-arterial calcium-stimulated venous sampling (ASVS) vs. portal venous sampling and imaging for preoperative diagnosis of occult insulinomas, (3) to discuss the physiologic rationale of ASVS, technique, and result interpretation. Background: Insulinomas cause symptomatic hypoglycemia and are the most common islet cell tumors. Surgical resection is curative. Preoperative localization of an insulinoma is a prerequisite of successful surgical resection. Cross-sectional imaging modalities unreliably detect insulinomas less than 2 cm in size. ASVS is a highly sensitive test for localizing such occult insulinomas. Administration of calcium gluconate into the arterial supply of normal beta cells causes insulin release. The insulin surge from beta cells of an insulinoma is much greater allowing for tumor localization based on site of arterial injection. In the setting of
JVIR
’
Posters and Exhibits
S165
multifocal pancreatic lesions, ASVS can also be used to identify the region that is hormonally most active prior to the resection. Clinical Findings/Procedure Details: ASVS is performed in a fasting state. Arteries supplying the pancreas are selected and calcium gluconate is injected. Blood samples are obtained from hepatic veins simultaneously with each injection and evaluated for insulin levels. Location of the insulinoma is determined based on increase in the hepatic venous insulin levels corresponding to the pancreatic arterial territory stimulated. We will discuss the diagnostic algorithm, illustrate the ASVS technique in detail, and interpret the test results. We will also explain the physiologic rationale of the test, angiographic findings of insulinoma and potential use of cone beam CT scan in optimizing localization and identification. Conclusion and/or Teaching Points: ASVS is the most accurate method to localize occult insulinomas preoperatively. Familiarity with this technique has the potential to improve clinical outcomes after surgical resection.
Abstract No. 387 Importance of early closure of the marginal venous system in Klippel-Trenauny and CLOVES syndromes: anatomical and technical considerations A.P. Lillis1,2, R. Shaikh1, G. Chaudry1, A.I. Alomari1; 1 Radiology, Boston Children’s Hospital, Boston, MA; 2 Radiology, Brigham and Women’s Hospital, Boston, MA Purpose: To describe i.various configurations of the marginal venous system (MVS) in Klippel-Trenauny (KTS) and CLOVES syndromes, ii.the importance of early intervention and iii.report technical considerations. Materials and Methods: Patients with KTS and CLOVES underwent venous mapping using direct and diversion venographyfollowed by embolization of anomalous veins. Results: In KTS, a persistent sciatic vein was the most consistent and largest part of the MVS. Networks of veins, multiple perforators and communicators were common. In CLOVES, the leg marginal veins communicated with a truncal vein draining into the axillary/subclavian vein. Embolization and endovenous laser caudal to the communication with the iliac veins were performed. Use of ‘‘stopper wire/needle,’’ coil scaffolding or anchoring techniques, pull-back glue, Amplatzer obstructive device, and various combinations were utilized. Prior to implementing this approach, several patients had pulmonary embolism (1 fatality). Conclusion: The marginal venous systems in KTS and CLOVES syndromes should be mapped and closed early in life.
Abstract No. 388
H. Dalsania, D.P. Jones; Mid South Imaging and Therapeutics, Memphis, TN Purpose: Percutaneous renal mass cryoablation is generally performed utilizing CT guidance. Electromagnetic navigation devices offer the potential advantage of reduced number of instrument adjustments and thus less imaging. The aim of our
Abstract No. 389 Evaluation of the safety and short-term clinical outcomes in the treatment of uterine fibroids with MR-guided focused ultrasound J.K. West, A. Park, J. Stone, K. Rea, D.L. Cage, W.E. Saad, S.S. Sabri, A.H. Matsumoto; Radiology and Medical Imaging, Division of Angiography and Interventional Radiology, University of Virginia Health System, Charlottesville, VA Purpose: This study was performed to evaluate the safety and clinical efficacy of treatment of symptomatic uterine fibroids using magnetic resonance-guided focused ultrasound therapy (MRgFUS). Materials and Methods: The study was approved by our IRB and data was collected prospectively on a nonrandomized basis. Baseline, 1 week, and 1 month clinical history and physical exam were performed, and pre- and post-procedural MRI’s were reviewed. Symptom Severity Scores (SSS) and Uterine Fibroid Symptom and Health-Related Quality of Life Surveys (UFSQOL) were obtained at baseline and 6 months. Inclusion criteria were pre-menopausal women over 18 years of age who were family complete with enhancing, device-accessible, symptomatic fibroids. Patients were excluded for excessive uterine fibroid size, pedunculation or significant calcification/heterogeneity of fibroids, overlying abdominal wall scar, or location inaccessible to the device. Treatment of 1-3 fibroids over 1-2 sessions was performed on the Insightec (Dallas, TX) ExAblate MRgFUS system per manufacturer instructions. Results: 18 women (mean age 43; range 27-52) completed MRgFUS with 14/18 (77.8%) receiving 2 MRgFUS sessions. Mean baseline SSS and UFS-QOL scores were 29.3 (max ¼ 40) and 123.6 (max ¼ 175), respectively. The mean fibroid volume pretreatment was 244 ml (range 28-554 ml). The mean and range of %-nonperfused volume of fibroids post-MRgFUS was 57.8%
Posters and Exhibits
Retrospective comparison of CT-guided ablation procedures with and without Veran ig4 guidance system
study was to determine whether the Veran ig4 Delivery System reduces procedure time and/or radiation dose during CT-guided percutaneous renal cryoablation of solid renal tumors. Materials and Methods: Retrospective analysis of 50 cases of renal cryoablation were performed at our institution. Cases were divided between those with Veran ig4 guidance those without. Procedure times were recorded from the CT images beginning with the time of the first scan to the time of the final scan. Total procedure radiation dose was recorded from the total dose length product (DLP). Patient ages ranged from 34-87 years with renal masses ranging in size from 0.9 cm up to 4 cm. Results: Our findings showed a mean procedure time of 82.25 minutes and a DLP of 3955.86 with the Veran ig4 guidance system. The procedures without the guidance system showed a mean procedure time of 82.07 minutes and a DLP of 3101.96. The procedure times were not statistically siginificant. Conclusion: Usage of the Veran ig4 guidance system is an evolutionary idea in improving renal cryoablation procedures. Although our findings did not show a statistical significance in procedure times, we believe this may be attributed to the learning curve associated with the guidance system. Furthermore, procedure times may be slightly increased with the Veran ig4 guidance system due to treatment of larger and more difficult lesions. We believe our findings warrant further investigation into using this novel technique for renal cryoablation.
Educational Exhibit
Posters and Exhibits
Abstract No. 384
Venous thromboembolism: a comprehensive review J.P. Montgomery1, P.S. Kang2; 1Radiology, University Hospitals Case Medical Center, Cleveland, OH; 2 Radiology, Louis Stokes Veterans Affairs Medical Center, Cleveland, OH Learning Objectives: After viewing this exhibit, the audience will be able to: - Identify risk factors and clinical presentations of venous thromboembolic disease (VTE) - Understand current interventional radiology (IR) treatment of acute deep vein thrombosis (DVT) and pulmonary embolism (PE) o Mechanical and pharmacologic catheter based thrombolysis o Alternative devices including ultrasound assisted thrombolysis o Aspiration thrombectomy - Understand the role of angioplasty/ stenting to correct underlying anatomic predisposition - Understand the role of continued medical therapy - Understand the role of IVC filters Background: The spectrum of VTE encompasses both DVT and PE. This serious disease entity often results in hospitalization and may even result in death. VTE often recurs and may result in long-term complications including post-thrombotic syndrome and chronic thromboembolic pulmonary hypertension. Identification of risk factors including anatomic predisposition is paramount to achieving optimal therapy. Appropriate treatment of VTE is a critical step in preventing complications that are a major determinant of patient quality of life. Clinical Findings/Procedure Details: This exhibit will review risk factors, clinical presentations and complications of VTE. IR treatment methods of VTE are discussed including mechanical and pharmacologic catheter based thrombolysis utilizing case examples from our institution. Alternative therapeutic methods, including ultrasound assisted thrombolysis and aspiration thrombectomy, are also examined. The role of angioplasty/ stenting in cases of anatomic predisposition to VTE is highlighted with specific case examples. The role of continued medical therapy and IVC filters is also reviewed. Conclusion and/or Teaching Points: This exhibit aims to be a general but thorough review of the complex clinical disease of VTE and current strategies in therapy. This exhibit will engage the viewer in a review of VTE risk factors and clinical presentations. IR provides highly effective therapy with mechanical and pharmacologic thrombolysis. Optimal therapy of VTE is necessary not only to decrease the immediate morbidity and mortality but also to prevent recurrence and complications that significantly decrease patient quality of life.
Posters and Exhibits
Abstract No. 385 Clinical correlation between hepatic vein opacification and hepatopulmonary shunt fraction for 90Y evaluation N. Pinjaroen1,2, J. Kaufman2, K.J. Kolbeck2, K. Farsad2, L. Watson2; 1Radiology, Chulalongkorn University, Bangkok, Thailand; 2Interventional Radiology, Dotter Institute, Oregon Health and Science University, Portland, OR
’
JVIR
Purpose: Hepatopulmonary shunt (HPS) fraction Z20% is one of the occasional criteria preventing 90Y therapy. This study aimed to identify if there is clinical correlation between hepatic vein (HV) opacification and HPS during initial evaluation for 90Y therapy. Materials and Methods: We collected 90Y candidates from 2004 to 2011. Patient’s underlying disease, imaging, arteriograms, and HPS calculations were retrospectively reviewed. If the HV was opacified during visceral arteriogram, the time between contrast injection and HV visualization was recorded. Statistical analysis with unpaired t-test compared the time of HV visualization in patients with and without an elevated HPS fraction. Results: Total of 151 initial 90Y work up studies in 149 patients were included. The diagnoses included 75 HCC, 53 neuroendocrine tumor metastases, 14 colorectal metastases, 3 cholangiocarcinoma and 4 other metastases. Imaging revealed multifocal disease(n¼117, 77%), bilobar disease(102, 68%) and macrovascular invasion (41, 27%). Macrovascular invasions included 4 HV and IVC, 2 HV and portal vein (PV), 1 IVC, 11 main PV, 1 right main PV, 16 right PV branch, 2 left main PV and 4 left PV branch. Mean maximum tumor diameter was 6.9⫾3.6 cm. Twenty-nine patients (19%) did not complete Y90 therapy; due to (18) high HPS, (5) unfavorable vascular anatomy, (2) declining liver function, (1) gastric uptake, (1) extrahepatic tumor, (1) poor tumor localization and (1) misdiagnosis. HV opacification was noted in 15 studies. Nine out of 15 studies showed HPS fraction Z20%. PPV and NPV of HV opacification as a predictor of high HPS fraction were 60% and 94%. Average time until visualized HV in patients whom HPS fraction Z20% and o20% were 4.2 and 8.6 sec (p¼ 0.3). The difference of mean times between two group was 4.4 sec (95% CI - 0.4-8.3). Conclusion: The results demonstrated that visualization of the HV during initial arteriogram alone may not be sufficient to predict high HPS. We found that HV opacifications were seen on arteriograms earlier in the patients with high HPS (Z20%) than the patients with shunt o20%. However, the time difference in HV visualization between the two groups was not statistically significant due to the small sample size.
Educational Exhibit
Abstract No. 386
Calcium arterial stimulation venous sampling for preoperative localization of occult insulinomas S. Gadani, S. Huang, M.J. Wallace, R. Avritscher, B.C. Odisio; MD Anderson Cancer Center, Houston, TX Learning Objectives: (1) To review the clinical features, diagnosis, and treatment of insulinomas, (2) to discuss the indications and advantages of intra-arterial calcium-stimulated venous sampling (ASVS) vs. portal venous sampling and imaging for preoperative diagnosis of occult insulinomas, (3) to discuss the physiologic rationale of ASVS, technique, and result interpretation. Background: Insulinomas cause symptomatic hypoglycemia and are the most common islet cell tumors. Surgical resection is curative. Preoperative localization of an insulinoma is a prerequisite of successful surgical resection. Cross-sectional imaging modalities unreliably detect insulinomas less than 2 cm in size. ASVS is a highly sensitive test for localizing such occult insulinomas. Administration of calcium gluconate into the arterial supply of normal beta cells causes insulin release. The insulin surge from beta cells of an insulinoma is much greater allowing for tumor localization based on site of arterial injection. In the setting of
JVIR
’
Posters and Exhibits
S165
multifocal pancreatic lesions, ASVS can also be used to identify the region that is hormonally most active prior to the resection. Clinical Findings/Procedure Details: ASVS is performed in a fasting state. Arteries supplying the pancreas are selected and calcium gluconate is injected. Blood samples are obtained from hepatic veins simultaneously with each injection and evaluated for insulin levels. Location of the insulinoma is determined based on increase in the hepatic venous insulin levels corresponding to the pancreatic arterial territory stimulated. We will discuss the diagnostic algorithm, illustrate the ASVS technique in detail, and interpret the test results. We will also explain the physiologic rationale of the test, angiographic findings of insulinoma and potential use of cone beam CT scan in optimizing localization and identification. Conclusion and/or Teaching Points: ASVS is the most accurate method to localize occult insulinomas preoperatively. Familiarity with this technique has the potential to improve clinical outcomes after surgical resection.
Abstract No. 387 Importance of early closure of the marginal venous system in Klippel-Trenauny and CLOVES syndromes: anatomical and technical considerations A.P. Lillis1,2, R. Shaikh1, G. Chaudry1, A.I. Alomari1; 1 Radiology, Boston Children’s Hospital, Boston, MA; 2 Radiology, Brigham and Women’s Hospital, Boston, MA Purpose: To describe i.various configurations of the marginal venous system (MVS) in Klippel-Trenauny (KTS) and CLOVES syndromes, ii.the importance of early intervention and iii.report technical considerations. Materials and Methods: Patients with KTS and CLOVES underwent venous mapping using direct and diversion venographyfollowed by embolization of anomalous veins. Results: In KTS, a persistent sciatic vein was the most consistent and largest part of the MVS. Networks of veins, multiple perforators and communicators were common. In CLOVES, the leg marginal veins communicated with a truncal vein draining into the axillary/subclavian vein. Embolization and endovenous laser caudal to the communication with the iliac veins were performed. Use of ‘‘stopper wire/needle,’’ coil scaffolding or anchoring techniques, pull-back glue, Amplatzer obstructive device, and various combinations were utilized. Prior to implementing this approach, several patients had pulmonary embolism (1 fatality). Conclusion: The marginal venous systems in KTS and CLOVES syndromes should be mapped and closed early in life.
Abstract No. 388
H. Dalsania, D.P. Jones; Mid South Imaging and Therapeutics, Memphis, TN Purpose: Percutaneous renal mass cryoablation is generally performed utilizing CT guidance. Electromagnetic navigation devices offer the potential advantage of reduced number of instrument adjustments and thus less imaging. The aim of our
Abstract No. 389 Evaluation of the safety and short-term clinical outcomes in the treatment of uterine fibroids with MR-guided focused ultrasound J.K. West, A. Park, J. Stone, K. Rea, D.L. Cage, W.E. Saad, S.S. Sabri, A.H. Matsumoto; Radiology and Medical Imaging, Division of Angiography and Interventional Radiology, University of Virginia Health System, Charlottesville, VA Purpose: This study was performed to evaluate the safety and clinical efficacy of treatment of symptomatic uterine fibroids using magnetic resonance-guided focused ultrasound therapy (MRgFUS). Materials and Methods: The study was approved by our IRB and data was collected prospectively on a nonrandomized basis. Baseline, 1 week, and 1 month clinical history and physical exam were performed, and pre- and post-procedural MRI’s were reviewed. Symptom Severity Scores (SSS) and Uterine Fibroid Symptom and Health-Related Quality of Life Surveys (UFSQOL) were obtained at baseline and 6 months. Inclusion criteria were pre-menopausal women over 18 years of age who were family complete with enhancing, device-accessible, symptomatic fibroids. Patients were excluded for excessive uterine fibroid size, pedunculation or significant calcification/heterogeneity of fibroids, overlying abdominal wall scar, or location inaccessible to the device. Treatment of 1-3 fibroids over 1-2 sessions was performed on the Insightec (Dallas, TX) ExAblate MRgFUS system per manufacturer instructions. Results: 18 women (mean age 43; range 27-52) completed MRgFUS with 14/18 (77.8%) receiving 2 MRgFUS sessions. Mean baseline SSS and UFS-QOL scores were 29.3 (max ¼ 40) and 123.6 (max ¼ 175), respectively. The mean fibroid volume pretreatment was 244 ml (range 28-554 ml). The mean and range of %-nonperfused volume of fibroids post-MRgFUS was 57.8%
Posters and Exhibits
Retrospective comparison of CT-guided ablation procedures with and without Veran ig4 guidance system
study was to determine whether the Veran ig4 Delivery System reduces procedure time and/or radiation dose during CT-guided percutaneous renal cryoablation of solid renal tumors. Materials and Methods: Retrospective analysis of 50 cases of renal cryoablation were performed at our institution. Cases were divided between those with Veran ig4 guidance those without. Procedure times were recorded from the CT images beginning with the time of the first scan to the time of the final scan. Total procedure radiation dose was recorded from the total dose length product (DLP). Patient ages ranged from 34-87 years with renal masses ranging in size from 0.9 cm up to 4 cm. Results: Our findings showed a mean procedure time of 82.25 minutes and a DLP of 3955.86 with the Veran ig4 guidance system. The procedures without the guidance system showed a mean procedure time of 82.07 minutes and a DLP of 3101.96. The procedure times were not statistically siginificant. Conclusion: Usage of the Veran ig4 guidance system is an evolutionary idea in improving renal cryoablation procedures. Although our findings did not show a statistical significance in procedure times, we believe this may be attributed to the learning curve associated with the guidance system. Furthermore, procedure times may be slightly increased with the Veran ig4 guidance system due to treatment of larger and more difficult lesions. We believe our findings warrant further investigation into using this novel technique for renal cryoablation.