- Email: [email protected]
Comparative review and efficacy of ablation techniques for the treatment of renal cell carcinoma
S204
Posters and Exhibits
lower extremity revascularization procedures (including angioplasty, stenting, stent-grafting and atherectomy) over a 36 month period. Of these, a subset of 24 patients with critical limb ischemia (CLI) had DSA angiograms that were postprocessed and analyzed for changes in infrageniculate perfusion using a quantitative software system (i-Flow, Siemens Medical Systems). Time to peak perfusion (TTP), mean slope of perfusion increase (MSP) and area under the perfusion curve (AUC) were compared before and after intervention. These changes were then correlated with clinical outcome. A composite endpoint of (a) improved Rutherford level, (b) healed wound within target angiosome, (c) improved wound perfusion at time of operative debridement and/or (d) reduction in planned amputation level was used to assign clinical outcome for each revascularization as success/failure. Results: Technical success was 100%; clinical success was 75% (18/24). Mean changes in TTP, MSP and AUC for the study cohort were -16%, 350% and 494%, respectively. Patients with clinical success had significantly greater AUC than failures (672% vs. -16%, P ¼ 0.028); a trend toward greater MSP among patients with clinical success was also observed (449% vs. 84%, P ¼ 0.09). No significant changes in time to peak perfusion were seen between patients with clinical success or failure. Conclusion: In this preliminary study, quantitative angiographic increases in infrageniculate blood flow measured through area under the perfusion curve was associated with clinical success following percutaneous revascularization. Further assessment of this technique is warranted in a larger, prospective cohort.
Mechanical embolectomy using the Solitaire FR revascularization device for acute arterial ischemic stroke in a pediatric ventricular assist device patient: a case report
Posters and Exhibits
M. Gaballah1, E. Rhee2, R.W. Hurst3, B.A. Pukenas3, R.N. Ichord4, J. Rossano5, S. Fuller6, K.Y. Lin5, G. Krishnamurthy1, A. Cahill1; 1Diagnostic Radiology, Children0 s Hospital of Philadelphia, Philadelphia, PA; 2 Anesthesiology and Critical Care, Children0 s Hospital of Philadelphia, Philadelphia, PA; 3Diagnostic Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA; 4Neurology, Children0 s Hospital of Philadelphia, Philadelphia, PA; 5Cardiology, Children0 s Hospital of Philadelphia, Philadelphia, PA; 6Cardiothoracic Surgery, Children0 s Hospital of Philadelphia, Philadelphia, PA Purpose: To describe the first published report of the Solitaire FR revascularization device for mechanical embolectomy in a child with acute arterial ischemic stroke and contraindications to thrombolysis. Materials and Methods: Case History: A 9-yo male with a biventricular assist device for heart transplant rejection developed sudden decreased consciousness and weakness of the right face, arm, and leg. A CT head showed early hypoattenuation in the left MCA territory. A CTAshowed proximal and distal left MCA branch filling defects. The child was not a candidate for thrombolysis so mechanical embolectomy was performed.Technique: A 4x20 mm Solitaire FR revascularization device was positioned across the occlusion from the proximal M1 segment
JVIR
to its bifurcation. The device was deployed for 10 min twice, recaptured, and withdrawn from the patient with continuous aspiration through the guiding sheath. A small amount of clot was retrieved with minimal improvement on angiogram. A 4x15 mm Solitaire device was then deployed for 20 min and withdrawn with large clot retrieval. Angiogram showed complete recanalization of the occluded segment and restoration of antegrade blood flow without distal embolization. Results: Complete revascularization was achieved within 7 hrs of symptom onset, without complications. One month later, the child developed a repeat acute arterial ischemic stroke following diaphragm plication. A CTAshowed distal left MCA occlusion. The patient underwent repeat mechanical embolectomy with two deployments of the 4x20 mm Solitaire device and successful revascularization within 7 hrs of symptom onset. His neurologic exam improved significantly over the first 24 hrs, with residual mild right-sided weakness, improved mental status, and resolution of aphasia. The child underwent heart transplantation 10 days later. Two months post-transplant, he was ambulatory and communicating with mild diffuse weakness and mild language impairment. The child was discharged home after 1 month with continued outpatient rehabilitation. Conclusion: The Solitaire FR revascularization device can be successfully used for mechanical embolectomy in children with acute arterial ischemic stroke and contraindications to thrombolysis.
Educational Exhibit Abstract No. 473
’
Abstract No. 474
Comparative review and efficacy of ablation techniques for the treatment of renal cell carcinoma S.P. Zivin1, M. Ginsburg2, J.T. Bui1, R.C. Gaba1, J. Minocha1; 1Radiology, University of Illinois at Chicago (UIC), Chicago, IL; 2Radiology, University of Chicago, Chicago, IL Learning Objectives: 1. To detail the percutaneous ablation techniques for renal cell carcinoma (RCC), including the benefits and contraindications of each modality2. To critically review the scientific literature regarding the efficacy and complications associated with the different ablative technologies in RCC Background: As imaging has improved, RCCs have been detected at an earlier stage with smaller average sizes. Additionally, preservation of renal function has become increasingly important. Percutaneous ablation of RCC a well-described, clinically acceptable treatment option. However, what is not clearly delineated is which ablation techniques are best for different clinical scenarios. The goal of this exhibit is to review the most commonly performed percutaneous renal ablation interventions for treatment of RCC, with a critical review of the literature. Clinical Findings/Procedure Details: For each of the following procedures, we will include indications, brief technical factors, advantages/disadvantages, contraindications, and a critcal review of the scientific literature regarding outcomes and efficacy. Each procedure will be illustrated with case examples from the authors’ institution. 1. Radiofrequency ablation. 2. Cryoablation. 3. Microwave ablation. 4. Irreversible electroporation (IRE).
JVIR
’
Posters and Exhibits
S205
Conclusion and/or Teaching Points: Percutaneous ablation of RCCs has become a standard treatment option in select clinical scenarios. The roles of each ablation technology are still evolving. Often, it is based upon availability and local expertise. This exhibit presents an up-to-date critical review of the scientific literature of each ablation technique, with focus upon comparison studies, and detailing the advantages of each approach.
Abstract No. 475 Impact of a novel balloon occlusion technique on fluoroscopy time and radiation dose during Y90 radioembolization Black1, A.K. Jones2, A. Mahvash1, B.C. Odisio1, R. Avritscher1, J. Ensor, Jr.3, R. Murthy1, J.R. Steele, Jr.1; 1 Interventional Radiology, UT MD Anderson, Houston, TX; 2Imaging Physics, UT MD Anderson, Houston, TX; 3 Biostatistics, UT MD Anderson, Houston, TX
Abstract No. 476 Optional inferior vena cava filters in neurosurgery patients: retrieval rates and clinical outcomes J. Minocha, L.C. Casadaban, A. Parvinian, L. Landers, M. Knuttinen, R.C. Gaba, J.T. Bui; Radiology, University of Illinois, Chicago, IL
Educational Exhibit
Abstract No. 477
An overview of ultrasound-guided transnodal lymphangiography with percutaneous thoracic duct embolization Bansal S.T. Kee, J. McWilliams, E.W. Lee; Division of Interventional Radiology, Department of Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA Learning Objectives: We will use an illustrative approach to review the pathophysiology of chylothorax and the treatment of chylothorax using transnodal lymphangiography and percutaneous thoracic duct embolization (TDE). Background: Chylothorax is a major complication associated with thoracic surgery and penetrating trauma. Leakage of chyle into the pleural space can result in metabolic, immunologic, and infectious complications with a mortality rate of up to 50%. Traditional treatment involves surgical ligation, which carries significant morbidity with limited rates of success. First described in 1998, TDE introduced a novel treatment option for thoracic duct injury that was further advanced with the
Posters and Exhibits
Purpose: To assess the impact of a novel balloon occlusion technique on time and dose metrics during Y90 radioembolization (Y90 RE) Materials and Methods: Prior to July 2011, Y90 RE was performed following standard coil embolization of all hepatoenteric collaterals. After July 2011, a technique was introduced whereby a temporary occlusion balloon was inflated in the common hepatic artery, resulting in hepatopedal flow in hepatoenteric collaterals, eliminating the need for coil embolization. A retrospective review of sequential patients who underwent Y90 RE before and after the introduction of the balloon occlusion technique was performed. Data were gathered from the radiology information system and the electronic medical record. Only patients with Michel’s classification type 1 anatomy were included. Results: 22 coil embolization patients and 21 balloon occlusion patients were included. The logarithms of the data were analyzed using two-tailed t-tests as the data followed log-normal distributions. The geometric means of fluoroscopy time (FT, 30.5 vs 13.9 min, -54%), dose area product (DAP, 735.0 vs 597.3 Gy-cm2, -19%), reference air kerma (Kar, 3,006 vs 2,397 mGy, -20%), and number of DSA runs (#DSA, 19.5 vs 18.0, -7.7%) all decreased in the balloon occlusion group versus the coil embolization group, however only the decrease in FT was statistically significant (FT: po0.0001; DAP: p¼0.261; Ka,r: p¼0.202; #DSA: p¼0.479). The lack of significance of the decreases in DAP and Kar was attributed to the much lower Kar rate in fluoroscopy compared to DSA (50-80x), and the fact that a similar number of angiograms are acquired regardless of the technique used. Conclusion: Use of a temporary occlusion balloon catheter versus coil embolization significantly decreased fluoroscopy time during Y90 RE. A larger sample size is necessary to determine if this technique results in reductions in DAP and Kar that are significant.
Purpose: Venous thromboembolism (VTE) in neurosurgery patients can be challenging to treat, especially because systemic anticoagulation is often contraindicated. The use of optional inferior vena cava (IVC) filters in this patient population has increased despite limited data for their use. The purpose of this study was to assess the retrieval rates and clinical outcomes in neurosurgery patients treated with optional IVC filters. Materials and Methods: In this single institution retrospective study, 192 consecutive neurosurgery patients (M:F ¼ 115:77, median age 60 years) treated with optional IVC filters between January 2011 and April 2013 were identified. Institutional IVC filter database review was used to identify demographic data (age, gender), clinical history (central nervous system pathology, malignancy), indication for IVC filtration (proven VTE or prophylaxis) and IVC filter type. Patients were followed until IVC filter removal or conversion into a permanent device. Results: 96% (n¼184) of optional IVC filters were placed for classic or extended indications (proven VTE) and 4% (n¼8) were placed prophylactically. Central nervous system pathologies included: intracranial hemorrhage (60%), intracranial lesion(s) (8%) and other (32%). Despite having a dedicated IVC filter clinic, only 19% (n¼36) had their filters retrieved. Older patient age (P¼0.018) and malignancy (P¼0.047) were statistically associated with keeping optional filters as permanent devices. Intracranial hemorrhage (P¼0.828), intracranial lesion(s) (P¼0.155) and filter type did not predict retrievability. Only older patient age was confirmed as significant in multivariate analysis (P¼0.023) while there was a trend toward significance with malignancy (P¼0.064). Conclusion: Retrieval of optional IVC filters in neurosurgery patients can be challenging. Older neurosurgery patients requiring IVC filters have a significantly lower likelihood of filter retrieval and may benefit from permanent devices to avoid excessive resource utilization and possible devicerelated complications. Additional studies are required to better understand the role of IVC filters in this patient population.
Posters and Exhibits
lower extremity revascularization procedures (including angioplasty, stenting, stent-grafting and atherectomy) over a 36 month period. Of these, a subset of 24 patients with critical limb ischemia (CLI) had DSA angiograms that were postprocessed and analyzed for changes in infrageniculate perfusion using a quantitative software system (i-Flow, Siemens Medical Systems). Time to peak perfusion (TTP), mean slope of perfusion increase (MSP) and area under the perfusion curve (AUC) were compared before and after intervention. These changes were then correlated with clinical outcome. A composite endpoint of (a) improved Rutherford level, (b) healed wound within target angiosome, (c) improved wound perfusion at time of operative debridement and/or (d) reduction in planned amputation level was used to assign clinical outcome for each revascularization as success/failure. Results: Technical success was 100%; clinical success was 75% (18/24). Mean changes in TTP, MSP and AUC for the study cohort were -16%, 350% and 494%, respectively. Patients with clinical success had significantly greater AUC than failures (672% vs. -16%, P ¼ 0.028); a trend toward greater MSP among patients with clinical success was also observed (449% vs. 84%, P ¼ 0.09). No significant changes in time to peak perfusion were seen between patients with clinical success or failure. Conclusion: In this preliminary study, quantitative angiographic increases in infrageniculate blood flow measured through area under the perfusion curve was associated with clinical success following percutaneous revascularization. Further assessment of this technique is warranted in a larger, prospective cohort.
Mechanical embolectomy using the Solitaire FR revascularization device for acute arterial ischemic stroke in a pediatric ventricular assist device patient: a case report
Posters and Exhibits
M. Gaballah1, E. Rhee2, R.W. Hurst3, B.A. Pukenas3, R.N. Ichord4, J. Rossano5, S. Fuller6, K.Y. Lin5, G. Krishnamurthy1, A. Cahill1; 1Diagnostic Radiology, Children0 s Hospital of Philadelphia, Philadelphia, PA; 2 Anesthesiology and Critical Care, Children0 s Hospital of Philadelphia, Philadelphia, PA; 3Diagnostic Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA; 4Neurology, Children0 s Hospital of Philadelphia, Philadelphia, PA; 5Cardiology, Children0 s Hospital of Philadelphia, Philadelphia, PA; 6Cardiothoracic Surgery, Children0 s Hospital of Philadelphia, Philadelphia, PA Purpose: To describe the first published report of the Solitaire FR revascularization device for mechanical embolectomy in a child with acute arterial ischemic stroke and contraindications to thrombolysis. Materials and Methods: Case History: A 9-yo male with a biventricular assist device for heart transplant rejection developed sudden decreased consciousness and weakness of the right face, arm, and leg. A CT head showed early hypoattenuation in the left MCA territory. A CTAshowed proximal and distal left MCA branch filling defects. The child was not a candidate for thrombolysis so mechanical embolectomy was performed.Technique: A 4x20 mm Solitaire FR revascularization device was positioned across the occlusion from the proximal M1 segment
JVIR
to its bifurcation. The device was deployed for 10 min twice, recaptured, and withdrawn from the patient with continuous aspiration through the guiding sheath. A small amount of clot was retrieved with minimal improvement on angiogram. A 4x15 mm Solitaire device was then deployed for 20 min and withdrawn with large clot retrieval. Angiogram showed complete recanalization of the occluded segment and restoration of antegrade blood flow without distal embolization. Results: Complete revascularization was achieved within 7 hrs of symptom onset, without complications. One month later, the child developed a repeat acute arterial ischemic stroke following diaphragm plication. A CTAshowed distal left MCA occlusion. The patient underwent repeat mechanical embolectomy with two deployments of the 4x20 mm Solitaire device and successful revascularization within 7 hrs of symptom onset. His neurologic exam improved significantly over the first 24 hrs, with residual mild right-sided weakness, improved mental status, and resolution of aphasia. The child underwent heart transplantation 10 days later. Two months post-transplant, he was ambulatory and communicating with mild diffuse weakness and mild language impairment. The child was discharged home after 1 month with continued outpatient rehabilitation. Conclusion: The Solitaire FR revascularization device can be successfully used for mechanical embolectomy in children with acute arterial ischemic stroke and contraindications to thrombolysis.
Educational Exhibit Abstract No. 473
’
Abstract No. 474
Comparative review and efficacy of ablation techniques for the treatment of renal cell carcinoma S.P. Zivin1, M. Ginsburg2, J.T. Bui1, R.C. Gaba1, J. Minocha1; 1Radiology, University of Illinois at Chicago (UIC), Chicago, IL; 2Radiology, University of Chicago, Chicago, IL Learning Objectives: 1. To detail the percutaneous ablation techniques for renal cell carcinoma (RCC), including the benefits and contraindications of each modality2. To critically review the scientific literature regarding the efficacy and complications associated with the different ablative technologies in RCC Background: As imaging has improved, RCCs have been detected at an earlier stage with smaller average sizes. Additionally, preservation of renal function has become increasingly important. Percutaneous ablation of RCC a well-described, clinically acceptable treatment option. However, what is not clearly delineated is which ablation techniques are best for different clinical scenarios. The goal of this exhibit is to review the most commonly performed percutaneous renal ablation interventions for treatment of RCC, with a critical review of the literature. Clinical Findings/Procedure Details: For each of the following procedures, we will include indications, brief technical factors, advantages/disadvantages, contraindications, and a critcal review of the scientific literature regarding outcomes and efficacy. Each procedure will be illustrated with case examples from the authors’ institution. 1. Radiofrequency ablation. 2. Cryoablation. 3. Microwave ablation. 4. Irreversible electroporation (IRE).
JVIR
’
Posters and Exhibits
S205
Conclusion and/or Teaching Points: Percutaneous ablation of RCCs has become a standard treatment option in select clinical scenarios. The roles of each ablation technology are still evolving. Often, it is based upon availability and local expertise. This exhibit presents an up-to-date critical review of the scientific literature of each ablation technique, with focus upon comparison studies, and detailing the advantages of each approach.
Abstract No. 475 Impact of a novel balloon occlusion technique on fluoroscopy time and radiation dose during Y90 radioembolization Black1, A.K. Jones2, A. Mahvash1, B.C. Odisio1, R. Avritscher1, J. Ensor, Jr.3, R. Murthy1, J.R. Steele, Jr.1; 1 Interventional Radiology, UT MD Anderson, Houston, TX; 2Imaging Physics, UT MD Anderson, Houston, TX; 3 Biostatistics, UT MD Anderson, Houston, TX
Abstract No. 476 Optional inferior vena cava filters in neurosurgery patients: retrieval rates and clinical outcomes J. Minocha, L.C. Casadaban, A. Parvinian, L. Landers, M. Knuttinen, R.C. Gaba, J.T. Bui; Radiology, University of Illinois, Chicago, IL
Educational Exhibit
Abstract No. 477
An overview of ultrasound-guided transnodal lymphangiography with percutaneous thoracic duct embolization Bansal S.T. Kee, J. McWilliams, E.W. Lee; Division of Interventional Radiology, Department of Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA Learning Objectives: We will use an illustrative approach to review the pathophysiology of chylothorax and the treatment of chylothorax using transnodal lymphangiography and percutaneous thoracic duct embolization (TDE). Background: Chylothorax is a major complication associated with thoracic surgery and penetrating trauma. Leakage of chyle into the pleural space can result in metabolic, immunologic, and infectious complications with a mortality rate of up to 50%. Traditional treatment involves surgical ligation, which carries significant morbidity with limited rates of success. First described in 1998, TDE introduced a novel treatment option for thoracic duct injury that was further advanced with the
Posters and Exhibits
Purpose: To assess the impact of a novel balloon occlusion technique on time and dose metrics during Y90 radioembolization (Y90 RE) Materials and Methods: Prior to July 2011, Y90 RE was performed following standard coil embolization of all hepatoenteric collaterals. After July 2011, a technique was introduced whereby a temporary occlusion balloon was inflated in the common hepatic artery, resulting in hepatopedal flow in hepatoenteric collaterals, eliminating the need for coil embolization. A retrospective review of sequential patients who underwent Y90 RE before and after the introduction of the balloon occlusion technique was performed. Data were gathered from the radiology information system and the electronic medical record. Only patients with Michel’s classification type 1 anatomy were included. Results: 22 coil embolization patients and 21 balloon occlusion patients were included. The logarithms of the data were analyzed using two-tailed t-tests as the data followed log-normal distributions. The geometric means of fluoroscopy time (FT, 30.5 vs 13.9 min, -54%), dose area product (DAP, 735.0 vs 597.3 Gy-cm2, -19%), reference air kerma (Kar, 3,006 vs 2,397 mGy, -20%), and number of DSA runs (#DSA, 19.5 vs 18.0, -7.7%) all decreased in the balloon occlusion group versus the coil embolization group, however only the decrease in FT was statistically significant (FT: po0.0001; DAP: p¼0.261; Ka,r: p¼0.202; #DSA: p¼0.479). The lack of significance of the decreases in DAP and Kar was attributed to the much lower Kar rate in fluoroscopy compared to DSA (50-80x), and the fact that a similar number of angiograms are acquired regardless of the technique used. Conclusion: Use of a temporary occlusion balloon catheter versus coil embolization significantly decreased fluoroscopy time during Y90 RE. A larger sample size is necessary to determine if this technique results in reductions in DAP and Kar that are significant.
Purpose: Venous thromboembolism (VTE) in neurosurgery patients can be challenging to treat, especially because systemic anticoagulation is often contraindicated. The use of optional inferior vena cava (IVC) filters in this patient population has increased despite limited data for their use. The purpose of this study was to assess the retrieval rates and clinical outcomes in neurosurgery patients treated with optional IVC filters. Materials and Methods: In this single institution retrospective study, 192 consecutive neurosurgery patients (M:F ¼ 115:77, median age 60 years) treated with optional IVC filters between January 2011 and April 2013 were identified. Institutional IVC filter database review was used to identify demographic data (age, gender), clinical history (central nervous system pathology, malignancy), indication for IVC filtration (proven VTE or prophylaxis) and IVC filter type. Patients were followed until IVC filter removal or conversion into a permanent device. Results: 96% (n¼184) of optional IVC filters were placed for classic or extended indications (proven VTE) and 4% (n¼8) were placed prophylactically. Central nervous system pathologies included: intracranial hemorrhage (60%), intracranial lesion(s) (8%) and other (32%). Despite having a dedicated IVC filter clinic, only 19% (n¼36) had their filters retrieved. Older patient age (P¼0.018) and malignancy (P¼0.047) were statistically associated with keeping optional filters as permanent devices. Intracranial hemorrhage (P¼0.828), intracranial lesion(s) (P¼0.155) and filter type did not predict retrievability. Only older patient age was confirmed as significant in multivariate analysis (P¼0.023) while there was a trend toward significance with malignancy (P¼0.064). Conclusion: Retrieval of optional IVC filters in neurosurgery patients can be challenging. Older neurosurgery patients requiring IVC filters have a significantly lower likelihood of filter retrieval and may benefit from permanent devices to avoid excessive resource utilization and possible devicerelated complications. Additional studies are required to better understand the role of IVC filters in this patient population.