Scientific Session 27 Neurointervention

recurrent PE. 2 of 14 patients (14%) with MRJ follow-up demonstrated IYC thombosis. CONCLUSION The OTW Greenfield filter is an effective system with few difficulties encountered during deployment. Filter leg asymmetry occurs in a significant number of cases and is frequently related to a small AP diameter cava. Deployment over-the-wire appears to offer no benefit; the authors therefore recommend removal of the wire immediately prior to filter deployment to avoid possible entanglement. MRJ follow-up reveals an acceptable incidence of IYC thrombosis. 9:00 am The Influence of Caval Geometry on the Balance of IYC Filter Leg Distribution Kyung/ae Cho, MD, Ann Arbor, MI. Mary C. Proctor, MS. Eric C. Doelle, MD. Lazar]. Greenfield, MD

PURPOSE- Experimental models and clinical reviews demonstrate no significant association between filter leg distribution and filter efficacy, yet many radiologists intervene when the limbs do not appear to be evenly distributed. We assessed whether an abdominal CT scan could eliminate the need for intervention and determined why the plain film and CT impressions varied. MATERiALS AND MElliODS.· A convenience sample of cases with AP and lateral plain films and post-placement CT scans underwent blinded, retrospective review. The transverse and AP caval diameters (axial en and the distribution of the filter legs (CT and plain films) were determined. The ratio of the transverse to AP diameter was used to define the geometry of the lYe. The clinical impression based on plain films was compared to that from the CT scans and the level of agreement was determined. RESULTS: Thirty-eight cases were reviewed. The plain films and CT scans agreed in 14 (37%) of the cases while the CT scan modified the plain film impression in 12 (32%) of the cases. Those that were modified had a mean transverse to AP ratio of 1.398 compared to those that were not modified, 1.216 (p = 0.008). In these cases the appearance of uneven filter leg distribution on plain films is a distortion caused by the elliptical shape of the lYe. This suggests that a disproportionate number of filters thought to be unevenly distributed actually spanned the cava well. CONCLUSIONS: When theIYC is elliptical, the filter legs appear unevenly distributed on plain films. CT images demonstrate the actual distribution which is more balanced than on plain films. CT scans can be useful in eliminating up to one-third of unnecessary interventions.

9:15 am Non-Fluoroscopic Inferior Vena Cava (IYC) Filter Placement Using Real-Time Electromagnetic Catheter Tip Localization Technology and Previously Acquired CT Data

Stephen Barnett Solomon, MD, Baltimore, MD. Carolyn Anne MaGee. David Ellis Acker. Anthony Charles Venbrux, MD PURPOSE- To determine the feaSibility of IYC filter placement using electromagnetic catheter tip localization information superimposed on previously acquired threedimensional CT images. MATERIALS AND MElliODS: Spiral abdominal CT scan data (Siemens Somatom Plus Four, Iselin, NJ) of three swine were transferred to the Magellan Intrabody Navigation System (Biosense, Setauket, NY). A Magellan position sensor (1.5 mm diameter) was placed at the tip of the caval filter stabilizer ("pusher") used to deploy the VenaTech IYC filter (B. Braun, Evanston, IL). Real-time location of the sensor was detected by a weak external magnetic field. This position was then superimposed on a monitor displaying the previously acquired CT scan images. RESULTS: As the "pusher" advanced the filter through the deployment sheath into proper position, the movement was observed on the Magellan monitor displaying the three-dimensional CT images. Appropriate filter position with relation to the renal veins was determined nonfluoroscopically. Following deployment, contrast injection with fluoroscopic monitoring confirmed accurate filter positioning. CONCLUSION Non-fluoroscopic placement of IYC filters is feasible using catheter tip localization technology and previously acquired CT scan data.

Scientific Session 27 Neurointervention Moderator: Tony P. Smith, MD 8:00 am Effective Emergency Fibrinolytic Therapy by Superselective Ophthalmic Artery in 5 Cases of Central Retinal Venous Occlusion (C.R.V.O.) Jean-Noel Vallee, MD, Paris, France. Alfredo Casasco, MD • Emanuel Houdart, MD, Harish ]haveri, MD. Alain Gaudric, PhD. Jean Jacques Merland, PhD

PURPOSE: We have used urokinase perfusion intra arte-', rially in ophthalmic artery and we have shown dramatic improvement of visual acuity as well as retinal arterio venous transit time in few hours in CRVO where as there is no none alternative therapy available. MElliODS.· 5 patients presented a recent and severe oedematous form of CRVO with severe visual loss at onset, and/or marked prolonged retinal circulation time and/or CRVO in the second eye, and/or a previous episode in the same eye. The evaluation parameters were visual acuity, fundoscopic examination and fluorescein angiography to measure retinal arteriovenous transit time and were observed before and 24 hours after

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fibrinolysis therapy then with long term follow up at 7, 15, 30, 90, 180 days and 1 year. A transfemorally coaxially introduced Magic microcatheter was placed into the ophthalmic artery ostium, then 300 000 international units (IU) of Urokinase were infused by slow continuous electric pump in 40 minutes. Fibrinolysis was followed by heparinization for 4 to 6 weeks. The average delay in starting therapy was 0 to 3 days, except case no 5: 10 days. Follow up ranged from 1 to 12 months (mean 6 months). RESULTS: These 5 patients showed significant improvement in visual acuity in first 24 hours after the fibrinolytic therapy and in 4 of these 5 patients retinal arteriovenous circulation time improved markedly in 24 hours. These 5 patients exhibited complete normalization of the fundus within 2 to 4 weeks. No complication due to fibrinolytic therapy was observed. CONCLUSION These 5 patients improved by this minimal invasive fibrinolytic therapy presented common characteristics similar with pathologic entity already described by Brown (1993) and by Irjima Hiroyuki (1994). It could be an effective emergency treatment in selected patients subgroup of CRVO whereas at this time there is no emergency alternative therapy available.

8:15 am Ethanol Endovascular Management of Brain AVMs: Initial Results Wayne F. Yakes, MD, Englewood, CO PURPOSE: To determine the safety and efficacy of ethanol in the management of brain AVM as a preoperative measure, preradiosurgical adjunct, and as a primary mode of therapy. MATERIALS AND MElliODS: 28 patients, 15 males and 13 females (age range 5 years-62 years; mean age 45 years) underwent ethanol embolization to manage their brain AVMs (Grade II-Grade VI). Neuroleptic IV sedation was used in 26 patients, general anesthesia in 2 pediatric patients. Ethanol was the sole embolic agent to embolize a brain AVM. Follow-up evaluations included clinic visits, MR and arteriography.

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RESULTS: Vascular recanalization in neovascular recruitment phenomenon was not observed in any patient. In fact, progressive AVM thrombosis at follow-up arteriography was a constant feature. Of the 28 patients embolized, 4 underwent surgery to ultimately cure the lesion, 1 underwent radiosurgery, 1 patient had partial treatment of her AVM and was lost to follow-up, 4 patients' therapy is ongoing. Of the 22 patients who were definitively treated, 15 were cured of their AVM byembolization alone (53%). Of these 15 patients that were cured by ethanol endovascular therapy, 5 patients were Grade III and 9 patients were Grade IV and one Grade V. Four patients died of late subarachnoid hemorrhage. Transient complications occurred in 8 of 28 patients (28%)

and permanent complications occurred in 3 of 28 patients (10%). Of the 15 patients who were cured of their brain AVM by ethanol embolization alone, follow-up range included 6 mos-47 mos; mean 20 month followup). CONCLUSIONS: Progressive and permanent AVM occlusion is a common feature at follow-up. Arterial recanalization and neovascular recruitment never occurred. With aggressive Decadron therapy the transient complications related to swelling adjacent to the AVM are largely reversible. Of the 15 AVMs that were cured endovascularly, 5 were Grade III, 9 were Grade IV and 1 was Grade V. A 53% cure rate in these sizes and complexities of brain AVM is a significant step forward in the endovascular management of brain AVM. 8:30 am

Eradicative Facial Arterial Infusion Therapy for Tl T2 Lip Cancer Kazushi Kishi, MD, Houston, IX. Mashiro Matsunaka, MD. Morio Sato, MD. Tetsuo Sonomura, MD. Koji Vede, MD PURPOSE: To develop and evaluate a new eradicative facial arterial infusion therapy for Tl T2 lip cancer. MATERIALS AND MElliODS: Six patients with T1 T2 lip squamous cell carcinoma were entered present protocol after obtaining informed consent. Via a temporal skin incision a 4 French balloon catheter was inserted in external carotid artery. Tumor feeder was identified by indigo blue and the catheter was lodged to selectively infuse into the facial artery. Dosage for one cycle per 50 kg body weight was a combination of Mitomycin (: 10 mg on day 1,2 and Pepleomycin 5 mg on day 3-15, or solo Cisplatin 25 mg on day 1-5. Tumor disappearance was confirmed by biopsy. One to three cycles were carried out until histological disappearance of the tumor was confirmed. RESULTS: Complete tumor disappearance was obtained in all cases. All patients recovered beautiful lips within two months. No recurrence has been observed with mean follow-up term of 45.7 months (range, 1.0 to 10.9 years). No severe acute or late complication has been found. CONCLUSION This selective facial arterial chemoinfusion was thought to be a safe and effective radical treatment for Tl T2 lip cancer.

8:45 am Endovascular Stents for the Treatment of Traumatic Jugular Vein Injuries Robert Kyu Won Ryu, MD, Denver, CO. Shaun P. McManimon, MD. Terry Lin, MD • Bahri Bilir, MD. David A. Kumpe, MD

PURPOSE: To investigate the role of endovascular stents in the treatment of traumatic jugular vein occlusions and intracranial hypertension.

CONCLUSION This technique for treatment of obstruction of the nasolacrimal system is simple and safe, and may obviate the use of more invasive procedure.

MATERIALS AND METHODS: Over a 15 month period, five patients were diagnosed with acute post-traumatic bilateral (n = 3) and unilateral (n = 2) jugular vein occlusions. Four patients had sustained blunt head injury and one had been strangled. All injuries were diagnosed on carotid arteriography. The indication for jugular vein stenting was refractory intracranial hypertension. Follow-up imaging was obtained on two patients with a mean interval of 4.5 months (range: 1-8 months). Patients were maintained on heparin and converted to coumadin.

9:15 am

RESULTS: Jugular vein occlusions were successfully stented in four of five (80%) patients. After stent deployment, intracranial pressure decreased an average of 9.5 mmHg (range: 0-28). Both patients with follow-up imaging have widely patent stents. One patient is neurologically normal. One patient remains hemiparetic secondary to an unassociated stroke. Two patients died within one week of traumatic brain injury. CONCLUSIONS: Endoluminal stents can effectively relieve jugular vein occlusions. Improved venous outflow after stenting may help relieve intracranial hypertension.

9:00 am Nonsurgical Placement of Nasolacrimal Stents: Our Experience Juan Maria PulidO-Duque, MD, Las Palmas, Canary Islands, Spain. Maria Dolores Pardo, MD. Elias G6m:::, MD. Ricardo Reyes, PhD. Jose Martin Carreira, PhD. Manuel Maynar, PhD PURPOSE: To present our experience in the treatment of nasolacrimal occlusion inserting polyurethane stents. MATERIALS AND METHODS: Ninety three polyurethane stents were placed under fluoroscopic guidance in 79 consecutive patients with epiphora due to total or partial obstructions of the nasolacrimal system. The set designed by Song was used in all patients. The procedure was performed introducing a guide-wire through the superior punctum into the canaliculus and advancing it acroSE the obstructions into the inferior meatus of the nasal cavity. After pulling out the guidewire, the stent is advanced retrograde and released into the sac and the lacrimonasal duct. The average time of the procedure was 20 minutes (range 6-90). RESULTS: The technical success rate was 100%. Complete resolution of epiphora was accomplished in 83 eyes and partial resolution in 8, two patients did not improve. No major complications ocurred. After a mean of 180 days follow-up 75 out 93 stents were patent (80%) in the control dacryocystography.

Percutaneous Vertebroplasty for Spine Stabilization and Pain Control John Dean Barr, MD, Hershey, PA. Michelle Sniveley Barr, MD. ThomasJames Lemley, PA-C. Richard Michael McCann, R1R(CV) PURPOSE: Pain relief and spinal stabilization were assessed following treatment of vertebral compression fractures by percutaneous vertebroplasty (PV). MATERIALS AND METHODS: 35 vertebrae in 21 patients were treated. 16 patients with 28 vertebrae had symptomatic, osteoporotic fractures and had failed medical therapy. 5 patients with 7 vertebrae had metastatic disease. Prevention of vertebral collapse with spinal cord or nerve injury was desired and these patients were poor surgical candidates. Using CT and fluoroscopic guidance, 11-15 gauge needles were advanced into the vertebrae using transpedicular approaches. Polymethylmethacrylate cement mixed with barium sulfate and tungsten powder to increase radiopacity was injected into the vertebrae. RESULTS: Among the 16 patients treated for osteoporotic fractures, 8 had complete or marked pain relief, 6 moderate relief and 2 no significant change. Only one of the 5 patients with malignancies had significant pain relief. No further vertebral compression occurred in these patients and spinal canal compromise was prevented in 4 patients. One patient required open resection for an aggressive tumor. One patient developed a transient radicular neuritis. No other complications occurred. CONCLUSIONS: PV provided significant pain relief in a high percentage of patients with osteoporotic fractures. PV produced spinal stabilization in patients with malignancies, but rarely proVided significant pain relief.

Thursday, March 5, 1998 1:00 pm-2:30 pm Scientific Session 28 Hepatobiliary/Abdominal Intervention Moderator: David J. Eschelman, MD

1:00 pm The Biliary Manometric Perfusion Test-Long Term Predictive Value of Success After Treatment of Benign Bile Duct Injuries: 10 Year Experience Scott Jeffrey Savader, MD, Baltimore, MD. Gunnar Bendix Lund, MD. Anthony Charles Venbrux, MD. Carol Angela Prescott, RN. Sally Elizabeth Mitchell, MD

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