- Email: [email protected]
Endovascular management of gonadal artery hemorrhage
JVIR
’
Posters and Exhibits
S275
continues to draw interest. At our institution, a quality assurance study was created to measure and to compare individual faculty and staff radiation dose levels during interventional radiology procedures with real-time feedback and extrapolation to patient doses. Learning objectives are to determine causes of increased radiation exposure, to identify exposure mitigation maneuvers and good practices, and to quantify the impact of these findings. Background: Physicians performing fluoroscopic procedures in an angiography unit were evaluated with a dose aware monitoring system to determine amounts of radiation exposure. Practice techniques proven to reduce radiation exposure were implemented to measure their impact. A machine specialist was present to observe and critique each case, and a radiology physicist was consulted to examine the angiography unit to determine the state of the room. Examination of the angiography unit and its settings presented additional methods of reducing radiation exposure, and changes were made accordingly. Clinical Findings/Procedure Details: Implementation of techniques, such as altering frame rates and fields of view, proven to reduce radiation exposure was successful. Unidentified, significant causes of increased radiation exposure, including default settings and incorrect configurations, were corrected. Digital magnification and “Fluoroscopy Save” functions on the angiography unit also reduced exposure. Prior to intervention, the average deep dose per physician was 596.6 mrem. Post intervention, the average deep dose was 127 mrem (p o 0.05). Average values of lens dose equivalents, skin dose equivalents, and extremity dose all decreased (p o 0.05) post intervention. Conclusions: Good practice techniques and use of a dose aware monitoring system were helpful in identifying and decreasing sources of radiation exposure for physicians and patients. This study was instrumental in increasing compliance, precaution, and use of safety measures by faculty and staff to reduce prolonged and unnecessary radiation exposure.
Educational Exhibit
safe invasive procedures. In the past, SIR has published a Standard of Practice guideline document that addresses this topic to assist interventionalists in their decisions. Clinical Findings/Procedure Details: 1. Review of coagulation and platelet activation pathways with diagrams. 2. Review of traditional and newer anticoagulation and antiplatelet medications and their mechanisms of action. 3. Present relevant labs and the recommended lab parameters for various common procedures. 4. Discuss corrective and reversal agents and their mechanisms of actions. Conclusions: Given the invasive nature of IR procedures and the complex hemostatic status of patients who present for procedures, it is important that the IR physician have an understanding of the numerous short and long term anticoagulation and antiplatelet agents, which are being used in both inpatient and outpatient settings. This exhibit will review the hematologic management of patients undergoing minimally invasive procedures who are currently being treated with traditional and newer anticoagulant and antiplatelet agents, their mechanisms of action, and the bleeding risks. References 1. Patel IJ, Davidson JC, Nikolic B, et al. Standards of Practice Committee, with Cardiovascular and Interventional Radiological Society of Europe (CIRSE) Endorsement. Consensus guidelines for periprocedural management of coagulation status and hemostasis risk in percutaneous image-guided interventions. J Vasc Interv Radiol 2012; 23:727–736. 2. Patel IJ, Davidson JC, Nikolic B, et al. Standards of Practice Committee, with Cardiovascular and Interventional Radiological Society of Europe (CIRSE) Endorsement; Standards of Practice Committee of the Society of Interventional Radiology. Addendum of newer anticoagulants to the SIR consensus guideline. J Vasc Interv Radiol 2013; 24:641–645.
Educational Exhibit
Abstract No. 629
Endovascular management of gonadal artery hemorrhage C. Young, M. Smetts, N. Arastu, R. Frimpong, R. Ristagno, A. Makramalla; University of Cincinnati Medical Center, Cincinnati, OH
Abstract No. 628
Periprocedural management of common and new anticoagulation and antiplatelet therapies for the interventional radiologist B. Cohen1, E. Roth2, D. Buck1; 1Allegheny Health Network, Pittsburgh, PA; 2Irving Radiological Associates, Irving, TX
Posters and Exhibits
Learning Objectives: 1. Discuss the coagulation and platelet activation pathways. 2. Discuss the new anticoagulation and antiplatelet agents, their mechanisms of action, and the associated monitoring labs. 3. Present recommended anticoagulation and antiplatelet medication management of patients based on the bleeding risks of common procedures. 4. Discuss corrective agents and measures. Background: In recent years, there has been an increase in the use of new anticoagulation and antiplatelet medications, each of which alters specific parts of the coagulation/platelet pathways. Given the rise in number and variety of procedures done in IR, management of these anticoagulation and antiplatelet agents has become vital in order to perform
Learning Objectives: 1) Discuss the epidemiology and mechanism of gonadal artery hemorrhage. 2) Review pertinent anatomical and imaging considerations. 3) Highlight techniques and principles for endovascular management of gonadal artery hemorrhage. 4) Discuss follow up care, postembolization imaging, and potential complications. Background: Gonadal artery injury is rarely encountered in clinical practice. Gonadal artery hemorrhage is most frequently seen in the setting of iatrogenic injury, blunt or penetrating trauma. In addition, ovarian artery hemorrhage has been reported due to spontaneous rupture of aneurysms during the puerperal period. Historically, these patients were managed surgically; however recent case reports have demonstrated the feasibility of endovascular treatment. Endovascular management of the gonadal artery hemorrhage is technically challenging due to anatomical considerations, particularly in postoperative patients. Clinical Findings/Procedure Details: This exhibit includes four cases of gonadal artery hemorrhage of differing etiologies. The discussion includes evaluation of the preprocedure imaging as well as a discussion of the technique involved in each case.
S276
Posters and Exhibits
In particular, we will discuss different strategies for successful and stable access to tortuous gonadal arteries. We will also discuss various embolic materials (including cyanoacrylate, coils, and particles) along with considerations for choice of embolic agent. We also demonstrate management of gonadal arteriovenous fistulae as well as tumor related hemorrhage. Conclusions: Gonadal artery hemorrhage is a rare but potentially life-threatening clinical entity. Proper evaluation by preprocedure imaging, technical considerations, and embolic agent choice are key for successful and safe endovascular management of gonadal artery hemorrhage. References 1. Sheikh A, et al. Testicular Artery Hemorrhage after Inguinal Hernia Repair. J Vasc Interv Radiol 2014; 25:805–808. 2. Ingram M, et al. Testicular Artery Embolization for the Treatment of LifeThreatening Hemorrhage Postorchidectomy. Cardiovasc Intervent Radiol 2009; 32:381–384. 3. Niederhauser B, et al. Testicular Artery Embolization for the Treatment of Iatrogenic Hemorrhage: Report of Two Cases. J Vasc Interv Radiol 2011; 22:1347–1348. 4. Wakimoto S, et al. Spontaneous post-partum rupture of an ovarian artery aneurysm: A case report of successful embolization and a review of the published work. J Obstet Gynaecol Res 2015; 41:456–459. 5. Kwon J. Percutaneous Transarterial Embolization of Spontaneously Ruptured Ovarian Artery Aneurysm Using N-Butyl Cyanoacrylate. Iran J Radiol 2014; 11:e13371. 6. Sakaguchi I, et al. Embolization for post-partum rupture of ovarian artery aneurysm: Case report and review. J Obstet Gynaecol Res 2015; 41:623–662.
Educational Exhibit
Abstract No. 630
Normal postablative changes vs. residual/ recurrent tumor: how to tell them apart on imaging?
Posters and Exhibits
K. Patel1, M Le2, B. Achakzai, M.D.3, V. Paidpally2, M. Jaber4, S. Danier5, K. Shah1, M. Harvill6, J. Critchfield7, W Saad8; 1Wayne State University, Detroit, MI; 2Detroit Medical Center/Wayne State University, Detroit, MI; 3Henry Ford Hospital, Detroit, MI; 4 Dearborn Heights, MI; 5Grosse Pointe Shores, MI; 6 Harper University Hospital, Detroit, MI; 7Troy, MI; 8 University of Michigan, Ann Arbor, Michigan Learning Objectives: In this exhibit, we review sequential changes that occur on computed tomography (CT) and magnetic resonance (MR) imaging after percutaneous thermal ablation of renal tumors. We identify postablation findings of residual or recurrent tumor. We discuss appropriate time interval for follow up CT or MR imaging. Background: Kidney cancer is the twelfth most common cancer in the world with 338,000 new cases diagnosed in 2012. Percutaneous thermal ablation has played an important role in management of small renal tumors and has emerged as an effective, minimally invasive nephron-sparing treatment option. Postablation CT and MR imaging play an important part in evaluation of the ablation zone, surveillance of residual or recurrent tumor, and identification of procedure related complications. The appearance of the ablation zone can vary depending on tumor size, location and composition and interventional radiologists who perform this procedure should be able to recognize typical CT and MR imaging findings to prevent confusion with other pathologic processes.
’
JVIR
Clinical Findings/Procedure Details: We describe CT and MR imaging appearances and sequential changes of renal tumors after successful thermal ablative treatment. We depict CT and MR imaging features of normal postablative vs. residual/recurrent tumor. We highlight appropriate time interval for follow up CT or MR imaging. Conclusions: Percutaneous thermal ablation has emerged as an effective treatment method for eradication of small renal tumors. As more patients undergo renal thermal ablation procedures, accurate assessment of ablated tumors at postprocedural imaging in essential for evaluating the adequacy of treatment and guiding further management. Thorough knowledge of the postablative imaging findings is necessary to provide optimal patient care.
Educational Exhibit
Abstract No. 631
Anatomic variations of the right portal vein: prevalence, imaging features, and implications for successful transjugular intrahepatic portosystemic shunt creation S. Gunasekaran1, J. Bui1, R. Lokken2, C. Ray3, R. Gaba1; 1 University of Illinois Hospital, Chicago, IL; 2University of Illinois Chicago, Chicago, IL; 3University of Illinois Hospital and Health Sciences Center, Chicago, IL Learning Objectives: 1. To describe common anatomic branching patterns of the right portal vein. 2. To define the prevalence of right portal vein anatomic variations. 3. To recognize right portal vein anatomic variations on crosssectional imaging and wedged/direct portal venography during transjugular intrahepatic portosystemic shunt (TIPS) creation. 4. To describe potential procedural implications of right portal vein anatomic variations as they pertain to TIPS technical success. Background: For the past 25 years, TIPS has been utilized worldwide as a recognized treatment for portal hypertensive complications. Most commonly, TIPS creation involves transhepatic puncture of a right portal vein branch from a right hepatic vein approach. Though TIPS is commonly utilized in current clinical practice, transhepatic portal venous puncture may be technically demanding, requiring firm knowledge of the anatomy and spatial position of portal venous branch targets. Given the potential impact of venous anatomic variation on portal venous targeting, a better understanding of right portal vein anatomic variations can optimize TIPS technical success. Clinical Findings/Procedure Details: First, this exhibit will depict common right portal vein anatomic variations through illustrations and correlative images from pre-TIPS crosssectional imaging and intra-procedural wedged/direct portal venography during TIPS. Furthermore, this poster will review the relative frequency of right portal vein anatomic variations as encountered during TIPS creation at a single institution over the last 12 years (n4100), and also as described in current literature. Finally, this exhibit will discuss how right portal vein anatomic variations may facilitate or complicate portal venous puncture during TIPS, and what IRs should consider during portal venous targeting when facing less common variants. Conclusions: Portal venous anatomic variation-particularly involving the right portal vein-is a common occurrence. Given
’
Posters and Exhibits
S275
continues to draw interest. At our institution, a quality assurance study was created to measure and to compare individual faculty and staff radiation dose levels during interventional radiology procedures with real-time feedback and extrapolation to patient doses. Learning objectives are to determine causes of increased radiation exposure, to identify exposure mitigation maneuvers and good practices, and to quantify the impact of these findings. Background: Physicians performing fluoroscopic procedures in an angiography unit were evaluated with a dose aware monitoring system to determine amounts of radiation exposure. Practice techniques proven to reduce radiation exposure were implemented to measure their impact. A machine specialist was present to observe and critique each case, and a radiology physicist was consulted to examine the angiography unit to determine the state of the room. Examination of the angiography unit and its settings presented additional methods of reducing radiation exposure, and changes were made accordingly. Clinical Findings/Procedure Details: Implementation of techniques, such as altering frame rates and fields of view, proven to reduce radiation exposure was successful. Unidentified, significant causes of increased radiation exposure, including default settings and incorrect configurations, were corrected. Digital magnification and “Fluoroscopy Save” functions on the angiography unit also reduced exposure. Prior to intervention, the average deep dose per physician was 596.6 mrem. Post intervention, the average deep dose was 127 mrem (p o 0.05). Average values of lens dose equivalents, skin dose equivalents, and extremity dose all decreased (p o 0.05) post intervention. Conclusions: Good practice techniques and use of a dose aware monitoring system were helpful in identifying and decreasing sources of radiation exposure for physicians and patients. This study was instrumental in increasing compliance, precaution, and use of safety measures by faculty and staff to reduce prolonged and unnecessary radiation exposure.
Educational Exhibit
safe invasive procedures. In the past, SIR has published a Standard of Practice guideline document that addresses this topic to assist interventionalists in their decisions. Clinical Findings/Procedure Details: 1. Review of coagulation and platelet activation pathways with diagrams. 2. Review of traditional and newer anticoagulation and antiplatelet medications and their mechanisms of action. 3. Present relevant labs and the recommended lab parameters for various common procedures. 4. Discuss corrective and reversal agents and their mechanisms of actions. Conclusions: Given the invasive nature of IR procedures and the complex hemostatic status of patients who present for procedures, it is important that the IR physician have an understanding of the numerous short and long term anticoagulation and antiplatelet agents, which are being used in both inpatient and outpatient settings. This exhibit will review the hematologic management of patients undergoing minimally invasive procedures who are currently being treated with traditional and newer anticoagulant and antiplatelet agents, their mechanisms of action, and the bleeding risks. References 1. Patel IJ, Davidson JC, Nikolic B, et al. Standards of Practice Committee, with Cardiovascular and Interventional Radiological Society of Europe (CIRSE) Endorsement. Consensus guidelines for periprocedural management of coagulation status and hemostasis risk in percutaneous image-guided interventions. J Vasc Interv Radiol 2012; 23:727–736. 2. Patel IJ, Davidson JC, Nikolic B, et al. Standards of Practice Committee, with Cardiovascular and Interventional Radiological Society of Europe (CIRSE) Endorsement; Standards of Practice Committee of the Society of Interventional Radiology. Addendum of newer anticoagulants to the SIR consensus guideline. J Vasc Interv Radiol 2013; 24:641–645.
Educational Exhibit
Abstract No. 629
Endovascular management of gonadal artery hemorrhage C. Young, M. Smetts, N. Arastu, R. Frimpong, R. Ristagno, A. Makramalla; University of Cincinnati Medical Center, Cincinnati, OH
Abstract No. 628
Periprocedural management of common and new anticoagulation and antiplatelet therapies for the interventional radiologist B. Cohen1, E. Roth2, D. Buck1; 1Allegheny Health Network, Pittsburgh, PA; 2Irving Radiological Associates, Irving, TX
Posters and Exhibits
Learning Objectives: 1. Discuss the coagulation and platelet activation pathways. 2. Discuss the new anticoagulation and antiplatelet agents, their mechanisms of action, and the associated monitoring labs. 3. Present recommended anticoagulation and antiplatelet medication management of patients based on the bleeding risks of common procedures. 4. Discuss corrective agents and measures. Background: In recent years, there has been an increase in the use of new anticoagulation and antiplatelet medications, each of which alters specific parts of the coagulation/platelet pathways. Given the rise in number and variety of procedures done in IR, management of these anticoagulation and antiplatelet agents has become vital in order to perform
Learning Objectives: 1) Discuss the epidemiology and mechanism of gonadal artery hemorrhage. 2) Review pertinent anatomical and imaging considerations. 3) Highlight techniques and principles for endovascular management of gonadal artery hemorrhage. 4) Discuss follow up care, postembolization imaging, and potential complications. Background: Gonadal artery injury is rarely encountered in clinical practice. Gonadal artery hemorrhage is most frequently seen in the setting of iatrogenic injury, blunt or penetrating trauma. In addition, ovarian artery hemorrhage has been reported due to spontaneous rupture of aneurysms during the puerperal period. Historically, these patients were managed surgically; however recent case reports have demonstrated the feasibility of endovascular treatment. Endovascular management of the gonadal artery hemorrhage is technically challenging due to anatomical considerations, particularly in postoperative patients. Clinical Findings/Procedure Details: This exhibit includes four cases of gonadal artery hemorrhage of differing etiologies. The discussion includes evaluation of the preprocedure imaging as well as a discussion of the technique involved in each case.
S276
Posters and Exhibits
In particular, we will discuss different strategies for successful and stable access to tortuous gonadal arteries. We will also discuss various embolic materials (including cyanoacrylate, coils, and particles) along with considerations for choice of embolic agent. We also demonstrate management of gonadal arteriovenous fistulae as well as tumor related hemorrhage. Conclusions: Gonadal artery hemorrhage is a rare but potentially life-threatening clinical entity. Proper evaluation by preprocedure imaging, technical considerations, and embolic agent choice are key for successful and safe endovascular management of gonadal artery hemorrhage. References 1. Sheikh A, et al. Testicular Artery Hemorrhage after Inguinal Hernia Repair. J Vasc Interv Radiol 2014; 25:805–808. 2. Ingram M, et al. Testicular Artery Embolization for the Treatment of LifeThreatening Hemorrhage Postorchidectomy. Cardiovasc Intervent Radiol 2009; 32:381–384. 3. Niederhauser B, et al. Testicular Artery Embolization for the Treatment of Iatrogenic Hemorrhage: Report of Two Cases. J Vasc Interv Radiol 2011; 22:1347–1348. 4. Wakimoto S, et al. Spontaneous post-partum rupture of an ovarian artery aneurysm: A case report of successful embolization and a review of the published work. J Obstet Gynaecol Res 2015; 41:456–459. 5. Kwon J. Percutaneous Transarterial Embolization of Spontaneously Ruptured Ovarian Artery Aneurysm Using N-Butyl Cyanoacrylate. Iran J Radiol 2014; 11:e13371. 6. Sakaguchi I, et al. Embolization for post-partum rupture of ovarian artery aneurysm: Case report and review. J Obstet Gynaecol Res 2015; 41:623–662.
Educational Exhibit
Abstract No. 630
Normal postablative changes vs. residual/ recurrent tumor: how to tell them apart on imaging?
Posters and Exhibits
K. Patel1, M Le2, B. Achakzai, M.D.3, V. Paidpally2, M. Jaber4, S. Danier5, K. Shah1, M. Harvill6, J. Critchfield7, W Saad8; 1Wayne State University, Detroit, MI; 2Detroit Medical Center/Wayne State University, Detroit, MI; 3Henry Ford Hospital, Detroit, MI; 4 Dearborn Heights, MI; 5Grosse Pointe Shores, MI; 6 Harper University Hospital, Detroit, MI; 7Troy, MI; 8 University of Michigan, Ann Arbor, Michigan Learning Objectives: In this exhibit, we review sequential changes that occur on computed tomography (CT) and magnetic resonance (MR) imaging after percutaneous thermal ablation of renal tumors. We identify postablation findings of residual or recurrent tumor. We discuss appropriate time interval for follow up CT or MR imaging. Background: Kidney cancer is the twelfth most common cancer in the world with 338,000 new cases diagnosed in 2012. Percutaneous thermal ablation has played an important role in management of small renal tumors and has emerged as an effective, minimally invasive nephron-sparing treatment option. Postablation CT and MR imaging play an important part in evaluation of the ablation zone, surveillance of residual or recurrent tumor, and identification of procedure related complications. The appearance of the ablation zone can vary depending on tumor size, location and composition and interventional radiologists who perform this procedure should be able to recognize typical CT and MR imaging findings to prevent confusion with other pathologic processes.
’
JVIR
Clinical Findings/Procedure Details: We describe CT and MR imaging appearances and sequential changes of renal tumors after successful thermal ablative treatment. We depict CT and MR imaging features of normal postablative vs. residual/recurrent tumor. We highlight appropriate time interval for follow up CT or MR imaging. Conclusions: Percutaneous thermal ablation has emerged as an effective treatment method for eradication of small renal tumors. As more patients undergo renal thermal ablation procedures, accurate assessment of ablated tumors at postprocedural imaging in essential for evaluating the adequacy of treatment and guiding further management. Thorough knowledge of the postablative imaging findings is necessary to provide optimal patient care.
Educational Exhibit
Abstract No. 631
Anatomic variations of the right portal vein: prevalence, imaging features, and implications for successful transjugular intrahepatic portosystemic shunt creation S. Gunasekaran1, J. Bui1, R. Lokken2, C. Ray3, R. Gaba1; 1 University of Illinois Hospital, Chicago, IL; 2University of Illinois Chicago, Chicago, IL; 3University of Illinois Hospital and Health Sciences Center, Chicago, IL Learning Objectives: 1. To describe common anatomic branching patterns of the right portal vein. 2. To define the prevalence of right portal vein anatomic variations. 3. To recognize right portal vein anatomic variations on crosssectional imaging and wedged/direct portal venography during transjugular intrahepatic portosystemic shunt (TIPS) creation. 4. To describe potential procedural implications of right portal vein anatomic variations as they pertain to TIPS technical success. Background: For the past 25 years, TIPS has been utilized worldwide as a recognized treatment for portal hypertensive complications. Most commonly, TIPS creation involves transhepatic puncture of a right portal vein branch from a right hepatic vein approach. Though TIPS is commonly utilized in current clinical practice, transhepatic portal venous puncture may be technically demanding, requiring firm knowledge of the anatomy and spatial position of portal venous branch targets. Given the potential impact of venous anatomic variation on portal venous targeting, a better understanding of right portal vein anatomic variations can optimize TIPS technical success. Clinical Findings/Procedure Details: First, this exhibit will depict common right portal vein anatomic variations through illustrations and correlative images from pre-TIPS crosssectional imaging and intra-procedural wedged/direct portal venography during TIPS. Furthermore, this poster will review the relative frequency of right portal vein anatomic variations as encountered during TIPS creation at a single institution over the last 12 years (n4100), and also as described in current literature. Finally, this exhibit will discuss how right portal vein anatomic variations may facilitate or complicate portal venous puncture during TIPS, and what IRs should consider during portal venous targeting when facing less common variants. Conclusions: Portal venous anatomic variation-particularly involving the right portal vein-is a common occurrence. Given