- Email: [email protected]
Cross-sectional imaging of liver embolotherapy
JVIR
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Posters and Exhibits
S213
4. Heyde EC. Gastrointestinal bleeding in aortic stenosis. N Engl J Med 1958; 259:196. 5. John R, Kamdar F, Liao K, et al. Improved survival and decreasing incidence of adverse events with the HeartMate II left ventricular assist device as bridgeto-transplant therapy. Ann Thorac Surg 2008; 86:1227–1235.
Educational Exhibit
Abstract No. 478
Impact of interventional radiology interest group meetings on medical student interest in interventional radiology as a specialty E. Rotem1, S. Jen2, A. Chi3, R. Dunlap4; 1Evans, GA; 2 Medical College of Georgia, Augusta, GA; 3Denver, CO; 4 Augusta, GA Learning Objectives: With the recent addition of the DR/IR residency pathway, there is a need to determine interest among medical students and resources available to them in pursuing a career in IR. We would like to present our experience with an IR interest group (IRIG), elaborate on shadowing opportunities, our institution, and IR online resources, as well as SIR membership and its effect on selection of an IR residency. Background: We would like to present the data we collected with first and second year medical students receiving surveys at the first and last IRIG meetings of each academic year. Participants received questions regarding demographics, interest in various specialties, and degree and type of interest in IR. During the study period, shadowing opportunities in IR and an IR specific newsletter were available to medical students. Surveys were sorted into 2 groups: pre-IR exposure and post-IR exposure. The first meeting of the academic year was the pre-group, and the last meeting was the post-group. Clinical Findings/Procedure Details: In the pre-IR exposure group (n¼64), 39.1% (n¼25) were female; 19% (n¼12) were married; IR interest was 76.6% (n¼49); and 45% (n¼29) were members of SIR. In the post-IR exposure group (n¼41), 39% (n¼16) were female; 22% (n¼9) were married; IR interest was 73.2% (n¼30); and 68% (n¼28) were members of SIR. SIR membership increased from 45% (n¼29) to 68% (n¼28) (αo0.05). Interest in interventional oncology increased from 58% (n¼37) to 76% (n¼31) (αo0.05). Interest in acute care increased from 83% (n¼53) to 95% (n¼39) (αo0.05). Conclusions: We found an overall increase in IR interest among all clinicians, with SIR membership facilitating an increase in awareness and presence of IR medical student retention. Students with oncology and acute care specialty interests find IR more appealing to which interest groups can offer more resources for these parties. We hope that these results are able to shed further light on how to increase knowledge of IR so that students may foster strong foundations in the field during their medical education.
Safety, efficacy, and outcomes of transarterial chemo-infusion for hepatocellular carcinoma in patients with poor hepatic function O. Abdul-Rahim1, A. Gonzalez-Beicos1, G. Narayanan2, L. Feun1; 1University of Miami, Miami, FL; 2Hollywood, FL
Educational Exhibit
Abstract No. 480
Cross-sectional imaging of liver embolotherapy C. Kim1, J. Cruz1, S. Bashir1, D. Strain2, P. Brady1; 1Albert Einstein Medical Center, Philadelphia, PA; 2University of Kentucky, Lexington, KY Learning Objectives: 1. To review the radiographic appearance of variant hepatic artery anatomy as well as parasitized extrahepatic vasculature that commonly supply hepatocellular carcinoma. 2. To discuss the immediate postembolization appearance of the liver with respect to hepatic perfusion differences and Ethiodol staining as well as posttreatment complications including hepatic abscess formation, biloma, and vascular injury. 3. To recognize potential sources of non-target embolization, understand their radiographic appearance, and delineate subsequent management. Background: Liver embolotherapy is widely recognized as a powerful adjunct in the treatment of unresectable hepatocellular carcinoma. Multiphase CT and MRI are imaging modalities of choice in the pre-procedural planning and post-procedural surveillance of these patients. Therefore, recognizing critical anatomic variants, normal post-procedural
Posters and Exhibits
Abstract No. 479
Purpose: To determine if transarterial chemo-infusion (TACI) of cisplatin or carboplatin can be safely performed in patients with hepatocellular carcinoma (HCC) and total bilirubin ≥ 2 mg/dL. Secondary endpoints include evaluation of tumor response to treatment and overall survival (OS). Materials: IRB approved retrospective review of 36 patients with HCC who underwent TACI with cisplatin or carboplatin at a tertiary care hospital from February 2012 through April 2015. Patients were grouped based on their pre-treatment total bilirubin level (TB): group 1 with TB o 2mg/dL (n¼15); group 2 with TB 2-3 mg/dL (n¼14); and group 3 with TB 4 3 mg/dL (n¼7). Cross-sectional imaging performed before and after chemo-infusion was reviewed using RECIST or mRECIST criteria to evaluate response. OS was estimated from the date of the first session of TACI to the date of death or last followup available in the medical record system. A total of 53 sessions of TACI were performed in all patients. All patients were not candidates for other therapies (e.g. TACE or Y90) at the time of treatment for various reasons such as hyperbilirubinemia, portal vein thrombus, or multiple prior radioembolizations. Average age was 60.6 years. There were 29 male and 7 female patients. Cisplatin was used in 39 sessions and carboplatin in 14 sessions of TACI. Results: The average increase in total bilirubin for groups 1, 2, and 3 were 0.4, 0.6, and 1.2 mg/dL, respectively (p¼0.1). There were two major complications in group 1 including one death due to multiorgan failure. Of the 49 procedures where pre- and post-treatment (within 3 months) imaging was available, stable disease was seen in 36, partial response in 4, and progressive disease in 9. Probability of survival at 1 year was 47%, 23%, and 28% for groups 1, 2, and 3, respectively. Conclusions: Transarterial chemo-infusion with cisplatin or carboplatin did not significantly increase total bilirubin levels in patients with pre-treatment TB ≥ 2 mg/dL suggesting it is a safe alternative for patients with HCC who are not candidates for conventional therapies due to advanced liver failure.
S214
Posters and Exhibits
findings, and evolving complications are vital to complete patient care. Clinical Findings/Procedure Details: This educational exhibit will focus on critical cross-sectional imaging findings in the preand post-procedural patient undergoing chemotherapeutic, bland, or radioembolization. Appropriate angiographic correlates will be provided for the following: Anatomic Variants a. Replaced and accessory vasculature Extrahepatic Collaterals a. Inferior phrenic arising from renal a. b. SMA colic branch c. Right internal mammary a. Post-Embolization Findings a. Differential perfusion b. Ethiodol staining c. Hepatic abscess d. Biloma e. Vascular injury (dissection) Non-target Embolization and Management a. Accessory left gastric a. – ulcerative gastritis b. Cystic a. – emphysematous cholecystitis c. Falciform a. Conclusions: Understanding the spectrum of radiographic findings inherent to liver embolotherapy is paramount in establishing safe and effective longitudinal patient management.
’
JVIR
leaving the hollow silicone models of vasculature, capable of being used under fluoroscopy. Larger diameter vessels such as the aorta and associated branch vessels were printed for use in training, without requiring casting in silicone. The angiographic models were then used by trainees as a cost effective and easily adaptable tool for improving angiography skills and procedures. Conclusions: A 3D printed angiographic model provides a safe and cost effective means to develop endovascular skills as well as practice and plan procedures without the downsides of radiation patient morbidity. This standardized, distributable 3D model could be used to compare resident abilities across years or institutions. Patient-specific 3D printed angiographic models can also be used for pre-procedural planning with the ability to plan, map and practice such procedures as angioplasty, coil deployment, stent placement, filter placement, or endovascular graft positioning. References
References 1. Aram J. Lee, Antoinette S. Gomes, David M. Liu, Stephen T. Kee, Christopher T. Loh, Justin P. McWilliams. The Road Less Traveled: Importance of the Lesser Branches of the Celiac Axis in Liver Embolotherapy. RadioGraphics 2012; 32(4):1121–1132. 2. Clark TWI. Complications of Hepatic Chemoembolization. Seminars in Interventional Radiology 2006; 23(2):119–125. 3. Hyo-Cheol Kim, Jin Wook Chung, Whal Lee, Hwan Jun Jae, and Jae Hyung Park. Recognizing Extrahepatic Collateral Vessels That Supply Hepatocellular Carcinoma to Avoid Complications of Transcatheter Arterial Chemoembolization. RadioGraphics 2005; 25(suppl 1):S25–S39. 3. Ingraham CR, Johnson GE, Nair AV, Padia SA. Nontarget Embolization Complicating Transarterial Chemoembolization in a Patient with Hepatocellular Carcinoma. Seminars in Interventional Radiology 2011; 28(2): 202–206.
Educational Exhibit
Abstract No. 481
Novel creation of an angiographic training model for trainees from 3D printed patient data
Posters and Exhibits
L. Eisenmenger, H. Ghandehari, M. Jensen, E. Huo; University of Utah, Salt Lake City, UT Learning Objectives: Discuss the utility of simulations in trainee education Learn about the use of 3D printing in the field of Interventional Radiology Demonstrate the production and utility of an angiographic training aid from 3D printed patient data to improve education and decrease risk to patients Materials: Current resident training in endovascular techniques takes place within the fluoroscopy suite during clinical cases, potentially increasing patient and staff radiation exposure in addition to potentially negatively impacting patient outcomes. 3D printing has emerged as a way to create cost effective, real-world objects from electronic data. A 3D physical training model from real world CT data can be used without fluoroscopy as an angiographic equivalent to improve trainee education and reduce risk to patients. The model can also be used under fluoroscopy to test skills without risking harm to a patient. Clinical Findings/Procedure Details: Patient CTA data was edited to remove all non-vascular data. Following conversion to a 3D surface rendering, polygon count was reduced and the resulting vascular model was printed on a standard fused-filament printer but with dissolvable filament. Models of small diameter vasculature were cast in silicone. The printed material was then dissolved,
1. Schubert C, van Langeveld MC, Donoso LA. Innovations in 3D printing: a 3D overview from optics to organs. The British journal of ophthalmology 2014; 98(2):159–161. 2. Lipson H. New world of 3-D printing offers “completely new ways of thinking”: Q&A with author, engineer, and 3-D printing expert Hod Lipson. IEEE pulse 2013; 4(6):12–14. 3. Ventola CL. Medical Applications for 3D Printing: Current and Projected Uses. P & T:a peer-reviewed journal for formulary management 2014; 39 (10):704–711. 4. Nacca N, Holliday J, Ko PY. Randomized trial of a novel ACLS teaching tool: does it improve student performance? The western journal of emergency medicine 2014; 15(7):913–918.
Abstract No. 482 Added value of physician extenders in an inpatient academic hospital: a retrospective review of E & M codes R. Hardman1, G. Noda2, L. Jenkins3, J. Jorgensen2, R. O’Hara1; 1University of Utah/Huntsman Cancer Center, Salt Lake City, UT; 2University of Utah, Salt Lake City, UT; 3 University of Utah/Huntman Cancer Hospital, Salt Lake City, UT Purpose: To quantify the added value of physician extenders impact on billing and documentation in an academic center. Materials: Our single center academic institution interventional radiology section added a dedicated physician extender to help in clinical rounds and inpatient management in fiscal year November 2015. We reviewed the trends in evaluation and management (E&M) CPT (Current procedural terminology) codes from fiscal year September 2013 to September 2016, including level of CPT charge. Results: The average number of E&M codes after adding a dedicated physician extender was 221.4 ± 49.7 per month. This number increased from an average of 135.2 ± 40.7 per month in the proceeding year prior to the addition of a physician extender (p¼0.002). Additionally, there was a shift in the level of E&M inpatient visits, from lower complexity level 1 and level 2 visits to more level 2, 3, and 4 visits. See figure 1. Conclusions: As interventional radiology increases its clinical involvement, physician extenders can impact the level of service and billing for interventional radiology decision making. Quantifiable increases in CPT E&M codes and level of service were seen in our single institution. Such increases in
’
Posters and Exhibits
S213
4. Heyde EC. Gastrointestinal bleeding in aortic stenosis. N Engl J Med 1958; 259:196. 5. John R, Kamdar F, Liao K, et al. Improved survival and decreasing incidence of adverse events with the HeartMate II left ventricular assist device as bridgeto-transplant therapy. Ann Thorac Surg 2008; 86:1227–1235.
Educational Exhibit
Abstract No. 478
Impact of interventional radiology interest group meetings on medical student interest in interventional radiology as a specialty E. Rotem1, S. Jen2, A. Chi3, R. Dunlap4; 1Evans, GA; 2 Medical College of Georgia, Augusta, GA; 3Denver, CO; 4 Augusta, GA Learning Objectives: With the recent addition of the DR/IR residency pathway, there is a need to determine interest among medical students and resources available to them in pursuing a career in IR. We would like to present our experience with an IR interest group (IRIG), elaborate on shadowing opportunities, our institution, and IR online resources, as well as SIR membership and its effect on selection of an IR residency. Background: We would like to present the data we collected with first and second year medical students receiving surveys at the first and last IRIG meetings of each academic year. Participants received questions regarding demographics, interest in various specialties, and degree and type of interest in IR. During the study period, shadowing opportunities in IR and an IR specific newsletter were available to medical students. Surveys were sorted into 2 groups: pre-IR exposure and post-IR exposure. The first meeting of the academic year was the pre-group, and the last meeting was the post-group. Clinical Findings/Procedure Details: In the pre-IR exposure group (n¼64), 39.1% (n¼25) were female; 19% (n¼12) were married; IR interest was 76.6% (n¼49); and 45% (n¼29) were members of SIR. In the post-IR exposure group (n¼41), 39% (n¼16) were female; 22% (n¼9) were married; IR interest was 73.2% (n¼30); and 68% (n¼28) were members of SIR. SIR membership increased from 45% (n¼29) to 68% (n¼28) (αo0.05). Interest in interventional oncology increased from 58% (n¼37) to 76% (n¼31) (αo0.05). Interest in acute care increased from 83% (n¼53) to 95% (n¼39) (αo0.05). Conclusions: We found an overall increase in IR interest among all clinicians, with SIR membership facilitating an increase in awareness and presence of IR medical student retention. Students with oncology and acute care specialty interests find IR more appealing to which interest groups can offer more resources for these parties. We hope that these results are able to shed further light on how to increase knowledge of IR so that students may foster strong foundations in the field during their medical education.
Safety, efficacy, and outcomes of transarterial chemo-infusion for hepatocellular carcinoma in patients with poor hepatic function O. Abdul-Rahim1, A. Gonzalez-Beicos1, G. Narayanan2, L. Feun1; 1University of Miami, Miami, FL; 2Hollywood, FL
Educational Exhibit
Abstract No. 480
Cross-sectional imaging of liver embolotherapy C. Kim1, J. Cruz1, S. Bashir1, D. Strain2, P. Brady1; 1Albert Einstein Medical Center, Philadelphia, PA; 2University of Kentucky, Lexington, KY Learning Objectives: 1. To review the radiographic appearance of variant hepatic artery anatomy as well as parasitized extrahepatic vasculature that commonly supply hepatocellular carcinoma. 2. To discuss the immediate postembolization appearance of the liver with respect to hepatic perfusion differences and Ethiodol staining as well as posttreatment complications including hepatic abscess formation, biloma, and vascular injury. 3. To recognize potential sources of non-target embolization, understand their radiographic appearance, and delineate subsequent management. Background: Liver embolotherapy is widely recognized as a powerful adjunct in the treatment of unresectable hepatocellular carcinoma. Multiphase CT and MRI are imaging modalities of choice in the pre-procedural planning and post-procedural surveillance of these patients. Therefore, recognizing critical anatomic variants, normal post-procedural
Posters and Exhibits
Abstract No. 479
Purpose: To determine if transarterial chemo-infusion (TACI) of cisplatin or carboplatin can be safely performed in patients with hepatocellular carcinoma (HCC) and total bilirubin ≥ 2 mg/dL. Secondary endpoints include evaluation of tumor response to treatment and overall survival (OS). Materials: IRB approved retrospective review of 36 patients with HCC who underwent TACI with cisplatin or carboplatin at a tertiary care hospital from February 2012 through April 2015. Patients were grouped based on their pre-treatment total bilirubin level (TB): group 1 with TB o 2mg/dL (n¼15); group 2 with TB 2-3 mg/dL (n¼14); and group 3 with TB 4 3 mg/dL (n¼7). Cross-sectional imaging performed before and after chemo-infusion was reviewed using RECIST or mRECIST criteria to evaluate response. OS was estimated from the date of the first session of TACI to the date of death or last followup available in the medical record system. A total of 53 sessions of TACI were performed in all patients. All patients were not candidates for other therapies (e.g. TACE or Y90) at the time of treatment for various reasons such as hyperbilirubinemia, portal vein thrombus, or multiple prior radioembolizations. Average age was 60.6 years. There were 29 male and 7 female patients. Cisplatin was used in 39 sessions and carboplatin in 14 sessions of TACI. Results: The average increase in total bilirubin for groups 1, 2, and 3 were 0.4, 0.6, and 1.2 mg/dL, respectively (p¼0.1). There were two major complications in group 1 including one death due to multiorgan failure. Of the 49 procedures where pre- and post-treatment (within 3 months) imaging was available, stable disease was seen in 36, partial response in 4, and progressive disease in 9. Probability of survival at 1 year was 47%, 23%, and 28% for groups 1, 2, and 3, respectively. Conclusions: Transarterial chemo-infusion with cisplatin or carboplatin did not significantly increase total bilirubin levels in patients with pre-treatment TB ≥ 2 mg/dL suggesting it is a safe alternative for patients with HCC who are not candidates for conventional therapies due to advanced liver failure.
S214
Posters and Exhibits
findings, and evolving complications are vital to complete patient care. Clinical Findings/Procedure Details: This educational exhibit will focus on critical cross-sectional imaging findings in the preand post-procedural patient undergoing chemotherapeutic, bland, or radioembolization. Appropriate angiographic correlates will be provided for the following: Anatomic Variants a. Replaced and accessory vasculature Extrahepatic Collaterals a. Inferior phrenic arising from renal a. b. SMA colic branch c. Right internal mammary a. Post-Embolization Findings a. Differential perfusion b. Ethiodol staining c. Hepatic abscess d. Biloma e. Vascular injury (dissection) Non-target Embolization and Management a. Accessory left gastric a. – ulcerative gastritis b. Cystic a. – emphysematous cholecystitis c. Falciform a. Conclusions: Understanding the spectrum of radiographic findings inherent to liver embolotherapy is paramount in establishing safe and effective longitudinal patient management.
’
JVIR
leaving the hollow silicone models of vasculature, capable of being used under fluoroscopy. Larger diameter vessels such as the aorta and associated branch vessels were printed for use in training, without requiring casting in silicone. The angiographic models were then used by trainees as a cost effective and easily adaptable tool for improving angiography skills and procedures. Conclusions: A 3D printed angiographic model provides a safe and cost effective means to develop endovascular skills as well as practice and plan procedures without the downsides of radiation patient morbidity. This standardized, distributable 3D model could be used to compare resident abilities across years or institutions. Patient-specific 3D printed angiographic models can also be used for pre-procedural planning with the ability to plan, map and practice such procedures as angioplasty, coil deployment, stent placement, filter placement, or endovascular graft positioning. References
References 1. Aram J. Lee, Antoinette S. Gomes, David M. Liu, Stephen T. Kee, Christopher T. Loh, Justin P. McWilliams. The Road Less Traveled: Importance of the Lesser Branches of the Celiac Axis in Liver Embolotherapy. RadioGraphics 2012; 32(4):1121–1132. 2. Clark TWI. Complications of Hepatic Chemoembolization. Seminars in Interventional Radiology 2006; 23(2):119–125. 3. Hyo-Cheol Kim, Jin Wook Chung, Whal Lee, Hwan Jun Jae, and Jae Hyung Park. Recognizing Extrahepatic Collateral Vessels That Supply Hepatocellular Carcinoma to Avoid Complications of Transcatheter Arterial Chemoembolization. RadioGraphics 2005; 25(suppl 1):S25–S39. 3. Ingraham CR, Johnson GE, Nair AV, Padia SA. Nontarget Embolization Complicating Transarterial Chemoembolization in a Patient with Hepatocellular Carcinoma. Seminars in Interventional Radiology 2011; 28(2): 202–206.
Educational Exhibit
Abstract No. 481
Novel creation of an angiographic training model for trainees from 3D printed patient data
Posters and Exhibits
L. Eisenmenger, H. Ghandehari, M. Jensen, E. Huo; University of Utah, Salt Lake City, UT Learning Objectives: Discuss the utility of simulations in trainee education Learn about the use of 3D printing in the field of Interventional Radiology Demonstrate the production and utility of an angiographic training aid from 3D printed patient data to improve education and decrease risk to patients Materials: Current resident training in endovascular techniques takes place within the fluoroscopy suite during clinical cases, potentially increasing patient and staff radiation exposure in addition to potentially negatively impacting patient outcomes. 3D printing has emerged as a way to create cost effective, real-world objects from electronic data. A 3D physical training model from real world CT data can be used without fluoroscopy as an angiographic equivalent to improve trainee education and reduce risk to patients. The model can also be used under fluoroscopy to test skills without risking harm to a patient. Clinical Findings/Procedure Details: Patient CTA data was edited to remove all non-vascular data. Following conversion to a 3D surface rendering, polygon count was reduced and the resulting vascular model was printed on a standard fused-filament printer but with dissolvable filament. Models of small diameter vasculature were cast in silicone. The printed material was then dissolved,
1. Schubert C, van Langeveld MC, Donoso LA. Innovations in 3D printing: a 3D overview from optics to organs. The British journal of ophthalmology 2014; 98(2):159–161. 2. Lipson H. New world of 3-D printing offers “completely new ways of thinking”: Q&A with author, engineer, and 3-D printing expert Hod Lipson. IEEE pulse 2013; 4(6):12–14. 3. Ventola CL. Medical Applications for 3D Printing: Current and Projected Uses. P & T:a peer-reviewed journal for formulary management 2014; 39 (10):704–711. 4. Nacca N, Holliday J, Ko PY. Randomized trial of a novel ACLS teaching tool: does it improve student performance? The western journal of emergency medicine 2014; 15(7):913–918.
Abstract No. 482 Added value of physician extenders in an inpatient academic hospital: a retrospective review of E & M codes R. Hardman1, G. Noda2, L. Jenkins3, J. Jorgensen2, R. O’Hara1; 1University of Utah/Huntsman Cancer Center, Salt Lake City, UT; 2University of Utah, Salt Lake City, UT; 3 University of Utah/Huntman Cancer Hospital, Salt Lake City, UT Purpose: To quantify the added value of physician extenders impact on billing and documentation in an academic center. Materials: Our single center academic institution interventional radiology section added a dedicated physician extender to help in clinical rounds and inpatient management in fiscal year November 2015. We reviewed the trends in evaluation and management (E&M) CPT (Current procedural terminology) codes from fiscal year September 2013 to September 2016, including level of CPT charge. Results: The average number of E&M codes after adding a dedicated physician extender was 221.4 ± 49.7 per month. This number increased from an average of 135.2 ± 40.7 per month in the proceeding year prior to the addition of a physician extender (p¼0.002). Additionally, there was a shift in the level of E&M inpatient visits, from lower complexity level 1 and level 2 visits to more level 2, 3, and 4 visits. See figure 1. Conclusions: As interventional radiology increases its clinical involvement, physician extenders can impact the level of service and billing for interventional radiology decision making. Quantifiable increases in CPT E&M codes and level of service were seen in our single institution. Such increases in