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CTA findings and therapy for gastrointestinal (GI) bleeding: a pictorial review
JVIR
’
Posters and Exhibits
S147
approaches were utilized to reach the point of fistualization and treat with coils and ethanol. Sacrifice of the diseased transverse and sig-moid sinus was also utilized to treat the large dural AVF involving these segments. In the cavernous sinus only coil embolization was utilized. In those patients presenting the pulsatile tinnitus, it was absent at follow-up. Headaches also resolved. Except for one patient with a transient homonymous hemianopsia, no other complication occurred. Conclusion: Complex acquired dural AVF can be treated by endovascular means. With meticulous technique complications can be avoided. Long-term cures have been documented with retrograde approaches within the dural sinuses using ethanol, coils, and at times nBCA. By this venous approach complications can be vastly diminished.
Abstract No. 323 6 month dose-specific multi detector computed tomography response following unilobar Yttrium90 radioembolization for hepatocellular carcinoma J. Bailey, W. Lea, D.L. Transue, M. Tann, M.S. Johnson; Radiology, Indiana University School of Medicine, Indianapolis, IN
Educational Exhibit
Abstract No. 324
Beyond fibroids—obstetrical applications of uterine artery embolization S. Mehta, S. Faintuch, O.R. Brook; Department of Radiology, BIDMC, Boston, MA Learning Objectives: The purpose of this educational exhibit is to demonstrate and explore the role of uterine artery embolization (UAE) in obstetrical care including in the control of postpartum and postsurgical bleeding and treatment of uterine vascular malformations. We will also explore preoperative endovascular management of high-risk ectopic pregnancies and forms of gestational trophoblastic disease. Finally, the current data and understanding of UAE’s role in persevering fertility will be discussed. Background: UAE is an effective endovascular treatment and adjunct therapy for a wide range of obstetric and gynecological disorders that extends beyond symptomatic fibroid control, particularly in woman with a desire to preserve fertility. In order to successfully perform a uterine artery embolization, an in-depth understanding of the clinical situations and indications, as well as the many technical considerations of UAE, must be possessed by the interventional radiologist. Clinical Findings/Procedure Details: 1. Obstetrical clinical scenarios in which uterine artery embolization may be useful. 2. Pertinent pre-angiographic imaging findings on ultrasound, CT and MRI. 3. Uterine vascular anatomy and pathology (gestational trophoblastic disease, uterine vascular malformation, ectopic pregnancy) demonstrated through digital subtraction angiography. 4. Choice of embolization material: particles vs. gelfoam5. Pre-operative internal ileac arteries balloon placement vs. uterine artery embolization6. Fertility preservation after uterine artery embolization. Conclusion and/or Teaching Points: With appropriate knowledge of the clinical indications for which uterine artery embolization may be beneficial, and application of the appropriate techniques, a wide variety of obstetrical conditions can be successfully treated while preserving future fertility.
Educational Exhibit
Abstract No. 325
CTA findings and therapy for gastrointestinal (GI) bleeding: a pictorial review M. Cristescu, J. Thomas, J.W. Pinchot, P. Dalvie; Radiology, University of Wisconsin Hospital and Clinics, Madison, WI Learning Objectives: To review the spectrum of gastrointestinal (GI) bleed CT-angiography (CTA) imaging findings and describe how these findings influence treatment decisions. To review the indications and contraindications for CTAevaluation of GI bleeding. To illustrate how salient findings change management and therapeutic choice.
Posters and Exhibits
Purpose: To determine individual lesion dose-specific multi detector computed tomography (MDCT) response 6 months following unilobar radioembolization (Y90) for hepatocellular carcinoma (HCC). Materials and Methods: Immediate-post-Y90 MDCT images of patients who underwent unilobar Y90 for HCC between February 2011 and July 2012 and had 6 month follow up MDCT scans were evaluated. Individual tumors within the treated volumes were measured using WHO, RECIST, mRECIST, and 3D EASL criteria. Y90 activity on corresponding immediatepost-Y90 PET images was measured, converted into dose maps using voxel based S value MIRD methodology, and individual lesion dose was calculated using both mean lesion and voxel threshold dose schemes. 6 month follow up triple phase MDCT imaging was evaluated using the same measurement criteria and each lesion was labeled as complete response (CR), partial response (PR), stable disease (SD), or progressive disease (PD). Results: 34 patients with 71 HCC lesions underwent unilobar Y90 therapy with acceptable post procedural PET/CT. 29 patients with 61 lesions were included. Exclusions were lesion(s) smaller than 1 cm in diameter (2) and infiltrative lesion(s) without well-defined borders (8). 61 included lesions with an average follow up of 222 days (SD 61.7 days) received a mean dose of 206 Gy (SD 172 Gy) with minimum and maximum lesion doses of 30 and 1091 Gy. We observed a significant dose-reponse relationship for volume, mRECIST and 3D EASL measurements (all p values o0.05). mRECIST: CR can be achieved with 70% and 90% probabilities when at least 45%, (32%), [20%] and 100%, (75%), [51%] of voxels in lesions receive 150 Gy, (200 Gy), [250 Gy], respectively. 3D EASL: CR will be achieved with 70% and 90% probability when 31% (25%) and 77% (65%) of lesion voxels receive 175 Gy (200 Gy) respectively. The fractional response improved sharply beyond 150 Gy. Conclusion: Unilobar radioembolization PR and CR are achievable with increasing lesion dose. 3D EASL and mRECIST suggest lower doses are necessary to achieve 90%
likelihood of CR when compared to RECIST, WHO, and volume measurements. 3D EASL suggests 90% CR is achievable when 75% of a lesion receives 175 Gy.
S148
Posters and Exhibits
Background: Gastrointestinal bleeding remains a common and life-threatening medical emergency, particularly in the at-risk patient on anticoagulant medication, with bleeding diathesis, or with liver disease. At many centers, the management of occult gastrointestinal bleeding often requires on-call interventional radiologist involvement in bleed localization. The interventionalist must be able to expediently review imaging findings, most commonly using CTA, to decide whether to pursue intervention. Clinical Findings/Procedure Details: From our database and from a review of literature, we will present: 1. The spectrum of CTAfindings found in patients with gastrointestinal bleeding. 2. The limitations of CT imaging and appropriate uses of radionuclide imaging or angiogaphy. 3. Therapeutic considerations as they relate to salient CT findings. Conclusion and/or Teaching Points: After reviewing this exhibit, the interventional radiologist should be capable of: 1). Understanding the spectrum of pertinent CTAfindings in the bleeding patient. 2). Understand the limitations of CT in diagnosing acute bleeds. 3). Appreciate when angiography or radionuclide imaging should be pursued. 4). Discuss cases where CT imaging findings have altered management plans or therapy choice.
Abstract No. 326 Endovascular intervention for the management of pancreatitis-related bleeding: a retrospective analysis of thirty patients at a single institution
Posters and Exhibits
J. Kim1, J. Shin2, H. Yoon2, G. Ko2, D. Gwon2, K. Sung2; 1 Radiology, Ajou University Hospital, Suwon, Republic of Korea; 2Radiology, Asan Medical Center, Seoul, Republic of Korea Purpose: The aim of this study was to assess the outcome of endovascular intervention for the management of pancreatitisrelated hemorrhage. Materials and Methods: From January 2000 to July 2012, thirty patients underwent endovascular intervention for the management of pancreatitis-related hemorrhage. The underlying etiology of the disease, the clinical symptoms and laboratory findings, abnormalities seen on computed tomography, and details regarding the endovascular procedures were assessed, as were the outcome of each procedure and procedure-related complications. Results: A total of 33 endovascular procedures were performed in 37 visceral arteries. The splenic artery (n¼15, 40.5%) was the most commonly treated artery, and pseudoaneurysm was the most commonly detected abnormality on digital subtraction angiography (n¼29, 78.4%).Transcatheter embolization was performed in all but two patients in whom stentgrafts were placed in order to exclude splenic artery pseudoaneurysms. Embolization was performed using coils (n¼18) and/ or N-butyl cyanoacrylate (n¼16). Successful hemostasis was achieved during 30 procedures (90.9%) on the initial attempt. Splenic infarction was demonstrated on follow-up CT in nine patients and, while seven patients experienced clinical success, two patients required additional hospitalization. Among the successfully treated patients, none had recurrent bleeding during a mean follow-up duration of 28.5 months. Conclusion: Transcatheter embolization is effective for managing pancreatitis-related bleeding and has a low risk of complications.
Educational Exhibit
’
JVIR
Abstract No. 327
Technique of placement of peritoneal dialysis catheter using fluoroscopy and ultrasound guidance A.K. Abdel Aal, S. Saddekni, N. Ertel, E. Underwood, R. Oser, M.F. Hamed; Radiology, University of Alabama at Birmingham, Birmingham, AL Learning Objectives: The objective of this educational exhibit is to: 1. Discuss the indications and contraindications of peritoneal dialysis (PD) catheter placement in the new era of urgent-start PD. 2. Review the pre-procedure patient preparation. 3. Demonstrate a minimally invasive technique for placement of PD catheters. 4. Highlight the importance of the use of ultrasound (including gray-scale and color Doppler ultrasound) as well as fluoroscopy to guide safe placement of PD catheter and minimize complications. 5. Describe the essential methods of catheter care after placement.6. Highlight complications and how to avoid and how to manage them. Background: PD catheters can be placed by interventional radiologists and this approach may offer scheduling efficiencies, is cost-effective and is a minimally-invasive approach to PD catheter placement. In the USA, changes in the dialysis reimbursement structure by the Centers of Medicare and Medicaid Services is expected to result in increasing use of PD, a less costly dialysis modality, which offers the patient the opportunity to receive dialysis in the home setting, have more independence for travel and work schedules, and preserves vascular access for future dialysis options. Therefore, placement of PD catheters by interventional radiologists may be increasingly requested by nephrology practices, as recent publications have demonstrated the favorable impact of Interventional Radiology PD catheter placement capabilities on PD practices. Clinical Findings/Procedure Details: The authors submit this proposed technique with detailed description of the steps for placement of PD catheters using ultrasound and fluoroscopic guidance by interventional radiologists. We will support our description of the technique with images from our institutional archive. Conclusion and/or Teaching Points: After viewing this exhibit, the viewer will be familiar with the advantages of using ultrasound and fluoroscopic guidance for placement of PD catheters. Performing this technique by interventional radiologists may allow for expeditious placement of permanent PD catheters in the late-referred patient with end-stage renal disease, thus facilitating urgent-start PD, and avoiding the need for temporary vascular access catheters.
Abstract No. 328 Initial clinical experience with percutaneous irreversible electroporation of renal tumors A. Ahmad1, M. Morgan2, S.P. Reis1, C.K. Trimmer1,2, J. Cadeddu2,1; 1International Radiology, UT Southwestern Medical Center, Dallas, TX; 2UROLOGY, UT Southwestern Medical Center, Dallas, TX Purpose: The purpose of this study was to retrospectively evaluate initial IRE experience in order to assess the feasibility, safety, effectiveness and radiographic outcomes of renal tumor ablation by IRE.
’
Posters and Exhibits
S147
approaches were utilized to reach the point of fistualization and treat with coils and ethanol. Sacrifice of the diseased transverse and sig-moid sinus was also utilized to treat the large dural AVF involving these segments. In the cavernous sinus only coil embolization was utilized. In those patients presenting the pulsatile tinnitus, it was absent at follow-up. Headaches also resolved. Except for one patient with a transient homonymous hemianopsia, no other complication occurred. Conclusion: Complex acquired dural AVF can be treated by endovascular means. With meticulous technique complications can be avoided. Long-term cures have been documented with retrograde approaches within the dural sinuses using ethanol, coils, and at times nBCA. By this venous approach complications can be vastly diminished.
Abstract No. 323 6 month dose-specific multi detector computed tomography response following unilobar Yttrium90 radioembolization for hepatocellular carcinoma J. Bailey, W. Lea, D.L. Transue, M. Tann, M.S. Johnson; Radiology, Indiana University School of Medicine, Indianapolis, IN
Educational Exhibit
Abstract No. 324
Beyond fibroids—obstetrical applications of uterine artery embolization S. Mehta, S. Faintuch, O.R. Brook; Department of Radiology, BIDMC, Boston, MA Learning Objectives: The purpose of this educational exhibit is to demonstrate and explore the role of uterine artery embolization (UAE) in obstetrical care including in the control of postpartum and postsurgical bleeding and treatment of uterine vascular malformations. We will also explore preoperative endovascular management of high-risk ectopic pregnancies and forms of gestational trophoblastic disease. Finally, the current data and understanding of UAE’s role in persevering fertility will be discussed. Background: UAE is an effective endovascular treatment and adjunct therapy for a wide range of obstetric and gynecological disorders that extends beyond symptomatic fibroid control, particularly in woman with a desire to preserve fertility. In order to successfully perform a uterine artery embolization, an in-depth understanding of the clinical situations and indications, as well as the many technical considerations of UAE, must be possessed by the interventional radiologist. Clinical Findings/Procedure Details: 1. Obstetrical clinical scenarios in which uterine artery embolization may be useful. 2. Pertinent pre-angiographic imaging findings on ultrasound, CT and MRI. 3. Uterine vascular anatomy and pathology (gestational trophoblastic disease, uterine vascular malformation, ectopic pregnancy) demonstrated through digital subtraction angiography. 4. Choice of embolization material: particles vs. gelfoam5. Pre-operative internal ileac arteries balloon placement vs. uterine artery embolization6. Fertility preservation after uterine artery embolization. Conclusion and/or Teaching Points: With appropriate knowledge of the clinical indications for which uterine artery embolization may be beneficial, and application of the appropriate techniques, a wide variety of obstetrical conditions can be successfully treated while preserving future fertility.
Educational Exhibit
Abstract No. 325
CTA findings and therapy for gastrointestinal (GI) bleeding: a pictorial review M. Cristescu, J. Thomas, J.W. Pinchot, P. Dalvie; Radiology, University of Wisconsin Hospital and Clinics, Madison, WI Learning Objectives: To review the spectrum of gastrointestinal (GI) bleed CT-angiography (CTA) imaging findings and describe how these findings influence treatment decisions. To review the indications and contraindications for CTAevaluation of GI bleeding. To illustrate how salient findings change management and therapeutic choice.
Posters and Exhibits
Purpose: To determine individual lesion dose-specific multi detector computed tomography (MDCT) response 6 months following unilobar radioembolization (Y90) for hepatocellular carcinoma (HCC). Materials and Methods: Immediate-post-Y90 MDCT images of patients who underwent unilobar Y90 for HCC between February 2011 and July 2012 and had 6 month follow up MDCT scans were evaluated. Individual tumors within the treated volumes were measured using WHO, RECIST, mRECIST, and 3D EASL criteria. Y90 activity on corresponding immediatepost-Y90 PET images was measured, converted into dose maps using voxel based S value MIRD methodology, and individual lesion dose was calculated using both mean lesion and voxel threshold dose schemes. 6 month follow up triple phase MDCT imaging was evaluated using the same measurement criteria and each lesion was labeled as complete response (CR), partial response (PR), stable disease (SD), or progressive disease (PD). Results: 34 patients with 71 HCC lesions underwent unilobar Y90 therapy with acceptable post procedural PET/CT. 29 patients with 61 lesions were included. Exclusions were lesion(s) smaller than 1 cm in diameter (2) and infiltrative lesion(s) without well-defined borders (8). 61 included lesions with an average follow up of 222 days (SD 61.7 days) received a mean dose of 206 Gy (SD 172 Gy) with minimum and maximum lesion doses of 30 and 1091 Gy. We observed a significant dose-reponse relationship for volume, mRECIST and 3D EASL measurements (all p values o0.05). mRECIST: CR can be achieved with 70% and 90% probabilities when at least 45%, (32%), [20%] and 100%, (75%), [51%] of voxels in lesions receive 150 Gy, (200 Gy), [250 Gy], respectively. 3D EASL: CR will be achieved with 70% and 90% probability when 31% (25%) and 77% (65%) of lesion voxels receive 175 Gy (200 Gy) respectively. The fractional response improved sharply beyond 150 Gy. Conclusion: Unilobar radioembolization PR and CR are achievable with increasing lesion dose. 3D EASL and mRECIST suggest lower doses are necessary to achieve 90%
likelihood of CR when compared to RECIST, WHO, and volume measurements. 3D EASL suggests 90% CR is achievable when 75% of a lesion receives 175 Gy.
S148
Posters and Exhibits
Background: Gastrointestinal bleeding remains a common and life-threatening medical emergency, particularly in the at-risk patient on anticoagulant medication, with bleeding diathesis, or with liver disease. At many centers, the management of occult gastrointestinal bleeding often requires on-call interventional radiologist involvement in bleed localization. The interventionalist must be able to expediently review imaging findings, most commonly using CTA, to decide whether to pursue intervention. Clinical Findings/Procedure Details: From our database and from a review of literature, we will present: 1. The spectrum of CTAfindings found in patients with gastrointestinal bleeding. 2. The limitations of CT imaging and appropriate uses of radionuclide imaging or angiogaphy. 3. Therapeutic considerations as they relate to salient CT findings. Conclusion and/or Teaching Points: After reviewing this exhibit, the interventional radiologist should be capable of: 1). Understanding the spectrum of pertinent CTAfindings in the bleeding patient. 2). Understand the limitations of CT in diagnosing acute bleeds. 3). Appreciate when angiography or radionuclide imaging should be pursued. 4). Discuss cases where CT imaging findings have altered management plans or therapy choice.
Abstract No. 326 Endovascular intervention for the management of pancreatitis-related bleeding: a retrospective analysis of thirty patients at a single institution
Posters and Exhibits
J. Kim1, J. Shin2, H. Yoon2, G. Ko2, D. Gwon2, K. Sung2; 1 Radiology, Ajou University Hospital, Suwon, Republic of Korea; 2Radiology, Asan Medical Center, Seoul, Republic of Korea Purpose: The aim of this study was to assess the outcome of endovascular intervention for the management of pancreatitisrelated hemorrhage. Materials and Methods: From January 2000 to July 2012, thirty patients underwent endovascular intervention for the management of pancreatitis-related hemorrhage. The underlying etiology of the disease, the clinical symptoms and laboratory findings, abnormalities seen on computed tomography, and details regarding the endovascular procedures were assessed, as were the outcome of each procedure and procedure-related complications. Results: A total of 33 endovascular procedures were performed in 37 visceral arteries. The splenic artery (n¼15, 40.5%) was the most commonly treated artery, and pseudoaneurysm was the most commonly detected abnormality on digital subtraction angiography (n¼29, 78.4%).Transcatheter embolization was performed in all but two patients in whom stentgrafts were placed in order to exclude splenic artery pseudoaneurysms. Embolization was performed using coils (n¼18) and/ or N-butyl cyanoacrylate (n¼16). Successful hemostasis was achieved during 30 procedures (90.9%) on the initial attempt. Splenic infarction was demonstrated on follow-up CT in nine patients and, while seven patients experienced clinical success, two patients required additional hospitalization. Among the successfully treated patients, none had recurrent bleeding during a mean follow-up duration of 28.5 months. Conclusion: Transcatheter embolization is effective for managing pancreatitis-related bleeding and has a low risk of complications.
Educational Exhibit
’
JVIR
Abstract No. 327
Technique of placement of peritoneal dialysis catheter using fluoroscopy and ultrasound guidance A.K. Abdel Aal, S. Saddekni, N. Ertel, E. Underwood, R. Oser, M.F. Hamed; Radiology, University of Alabama at Birmingham, Birmingham, AL Learning Objectives: The objective of this educational exhibit is to: 1. Discuss the indications and contraindications of peritoneal dialysis (PD) catheter placement in the new era of urgent-start PD. 2. Review the pre-procedure patient preparation. 3. Demonstrate a minimally invasive technique for placement of PD catheters. 4. Highlight the importance of the use of ultrasound (including gray-scale and color Doppler ultrasound) as well as fluoroscopy to guide safe placement of PD catheter and minimize complications. 5. Describe the essential methods of catheter care after placement.6. Highlight complications and how to avoid and how to manage them. Background: PD catheters can be placed by interventional radiologists and this approach may offer scheduling efficiencies, is cost-effective and is a minimally-invasive approach to PD catheter placement. In the USA, changes in the dialysis reimbursement structure by the Centers of Medicare and Medicaid Services is expected to result in increasing use of PD, a less costly dialysis modality, which offers the patient the opportunity to receive dialysis in the home setting, have more independence for travel and work schedules, and preserves vascular access for future dialysis options. Therefore, placement of PD catheters by interventional radiologists may be increasingly requested by nephrology practices, as recent publications have demonstrated the favorable impact of Interventional Radiology PD catheter placement capabilities on PD practices. Clinical Findings/Procedure Details: The authors submit this proposed technique with detailed description of the steps for placement of PD catheters using ultrasound and fluoroscopic guidance by interventional radiologists. We will support our description of the technique with images from our institutional archive. Conclusion and/or Teaching Points: After viewing this exhibit, the viewer will be familiar with the advantages of using ultrasound and fluoroscopic guidance for placement of PD catheters. Performing this technique by interventional radiologists may allow for expeditious placement of permanent PD catheters in the late-referred patient with end-stage renal disease, thus facilitating urgent-start PD, and avoiding the need for temporary vascular access catheters.
Abstract No. 328 Initial clinical experience with percutaneous irreversible electroporation of renal tumors A. Ahmad1, M. Morgan2, S.P. Reis1, C.K. Trimmer1,2, J. Cadeddu2,1; 1International Radiology, UT Southwestern Medical Center, Dallas, TX; 2UROLOGY, UT Southwestern Medical Center, Dallas, TX Purpose: The purpose of this study was to retrospectively evaluate initial IRE experience in order to assess the feasibility, safety, effectiveness and radiographic outcomes of renal tumor ablation by IRE.