Vascular Interventions

ter (CCD=Circumference/ pi), which was compared with CCD of the rvc obtained immediately before in ~ jection. Coronal diameter was also recorded and used as the cavagram eq ui va lent. Results were ana lyzed using the student's t-tesc. RESULTS: Of 10 subjects,S were female, 4 were male, and in one case, the gender and age data was not recorded. Comparison of the da ta revealed no significant difference between the pre-injection CCD (20.5 mm SD = 4.5) and the CCD during injection (20.8 mm SO ~ 4.6)(p~0.89). Similarly, no significant difference was noted between coronal diameters before 08.9 mm SO ~ 5.0) and during (20.0 mm SO ~ 4.8) injection (p~0.66).

CONCLUSIONS: Because the lVC is a capacitance ves sel, power injection of contrast material during cavography results in no s ignificant change in caval d imensions.

Poster No. 293 Spermatic Venography in Infertile Men With Equivocal Scrotal Ultrasound Findings ML Martin, Vancouver, Canada . L.5. Machan PURPOSE To evalu ate the findings of spermatic venogra-

phy in men with duplex scrotal ullrasounds which are eqUivocal for varicocele. Many infertile men are denied further investigation and treatment if ultrasound is not defmitively positive for varicocele. Il1ATERJAlS AND METHODS, Between February 1998

and May 1999, 248 men with infertility and oligospermia were evaluated by duplex ultrasound of the scrotum. Ultrasound was performed in the standing position using an ATL 5000 ultrasound machine following 15 minutes of standing. Ullrasound was considered positive for varicocele if 3 veins >2mm in diameter were present in the pampiniform plexus and there was abnormal accentuation of venous flow with Valsalva ma neuver. The examina tion was negative if there were no dilated veins and no or normal accentuation of flow. AJi Olher examinalions were considered eqUivocal. Spermatic venography was offered to all men with equ ivocal scrOlal ultrasounds. RESULTS: Scrotal ultrasound was negative in 250/ 490 (51.0%) and positive in 128/ 490 (26. 1%) of eva luated hemiscrota. Equivocal ullrasound fUldings were present in 112/490 (22.9"10). 93/ 112 (83.()%) were evaluated with internal spermatic venography. Spermatic venography was positive in 76/93 (81.7%) of sonograprucally equivocal hemiscrota; 11 / 1503.3%) with only dilated veins and 65/78 (83.3%) with only abnormal venous enhancement. Successful embolization was performed in 98.6% (75/76) of cases at the time of venography.

ranted in infertile men when scrotal duplex ultrasound is eqUivocal.

Vascular Interventions Poster No. 294 Abciximab Affords Early and Sustained Reperfuslon by Reduced·Dose Reteplase in a Primate Model of Peripheral Vascular Disease M.T. Nakada, Malvern, PA • MA. Nedelman • EB. Barnatban • R.E. jordan. H.F Weisman BACKGROUND: Arterial reperfusion by dissolution of occlusive thrombi may best be achieved with combinations of anriplatelet and fibrinolytic agents. This study determined the efficacy of combined doses of abciximab and reteplase in a monkey model of severe peripheral arterial injury incorporating a stenosis of the femoral artery and an occlusive thrombus. METHODS AND RESULTS: Total femoral arterial occlu-

sion was induced with thrombin -treated autologous blood. All anima ls received aspirin and peri procedural heparin and blood flow was continuously measured fo r 120 minutes. Animals received reteplase alone or reteplase with abciximab. Animals receiving reteplase alo ne received [Wo 0.14 unit/ kg bolus doses 30 minutes apa rt (ana logous to the non~weight adjusted 10 unit plus 10 unit regimen in man). Othe r groups rece ived e ither 0.125, 0.25, 0.4 or 0.8 mg/kg abciximab 10 minutes prior to initiation of 0.07 unit/kg doses of reteplase at 15 minute intervals. Reteplase was administered until flow was restored or [Q a maximum cumulative dose of 0.28 unitlkg. In the saline group, reteplase alone facilitated reperfusion in all 4 animals that was fo llowed by cyclic reflow and reocclusion. Increasing doses of abciximab resulted in a trend toward: 1) increased tota l patency time; 2) decreased number of reteplase boluses needed to achieve reperfusion; 3) decrea sed time to reperfusion; 4) more animals remaining persistently patent after reperfusion. CONCLUSION: Although reteplase alone restored

blood flow, persistent reperfu sion was more rapidly achieved and sustained with a combination of abciximab and reteplase. Abciximab decreased the reteplase dose requirement and yielded rapid and sustained patency in this model of severe peripheral arterial inj ury .

Abciximab bolu1 ~

Total R!(!plase U/k \0

Time (0

t.

~perfu1ion

Complete

Min ISD)

GPllb/Jlla blockade {SDI

0.18 (D)

46 (91

·6 (\)

0/4

1/4

~aten~t

0.11\

0.11 (0.06)

50 (111

45 (9)

CONCLUSION Retrograde flow in the internal sper-

0.15

O.ll (0.01)

48 (111

51 (14)

114

matic vein is common even when duplex ulU'asound is not definitively positive. Spermatic venography is war-

DAD

0.16 (0.01)

16 (11)

85 (\)

4/4

0.80

0.14 (D)

11 (1)

81 (Il)

4/4

285

Poster No. 295

MATERlAlS AND MEmODS: Fifty-two women with a

bleeding as measured by the PBAC. This patient was later diagnosed with endometrial hyperplasia and therefore excluded from the study. The mean score for the remaining patients prior to embolization equaled 237 (median 206, range 64.0-563). The mean for the tree month score was 130 (median 102, range 19.0-411), which represented a statistically significant change (P<.OOl). Thirteen of these patients also completed PBAC six months after embolization with a mean score of ll6 (median 81.0, range 33.0-467). These results were found to be a significant change from baseline (P<.OJ)

mean age of 44.5 (36-54) underwent uterine artery embolization (UAE) for symptomatic fibroids. Uterine arteries were embolized to stasis of flow using 355-500 micron PYA panicles. Imaging included pelvic IvlRl before and MR angiography 3 months after the embolization. The study cohort consisted of 16 of the 52 patients in whom both the pre and post procedure pelvic MR were available.

In tvventy-five patients tested, no difference was observed bervveen baseline hemoglobin and hematocrit levels and those obtained at three and six months posttreatment (p<.40). In a subgroup of eleven patients with a low hemoglobin (Hgb<]2) and/or hematocrit (Hct<37), no change was detected after therapy (P<.]O). However, this subgroup analysis may be limited by the small sample size.

RESULTS: Embolization to complete stasis of flow was successful in 31/32 (97%) of the UAs in the study, and ]09/110 overall. Post procedure MR revealed normal enhancement of the myometrium and endometrium in all patients with recanalization of the main UAs in 28/32 (87.5%). All fibroids were avascular with no evide nce of enhancement with a mean volume reduction of 48% at 3 months. Otherwise, there were no changes in the morphologic features of the uterus as compared to the baseline MR.

CONCLUSIONS: OUf early experience suggests that

Recanalization of Uterine Arteries After Embolization for Symptomatic Leiomyomas: Evidence on MRA M.K. Razavi, Stanford, CA • j. Rhee • D. Y. Sze • S. T Kee • CP Semha • M.D. Dake PuRPOSE: To study the morphologic fate of the uterine arteries (UA), myometrium, endometrium, and the cervix after UA embolization using contrast enhanced

MRl and MRA.

CONCLUSION: UAs appear to recanalize by 3 months with no morphologic change in the myometrium, endometrium, or cervix. All fibroids reduced in size and were avascular. These findings may have implications in issues such as fertility post embolization.

PBAC are effective toois in measuring the improvement in heavy menstrual bleeding in patients treated with UFE. Conversely) we did not find the measurement of hemoglobin and hematocrit to be useful in assessing changes in menstrual bleeding as a result of UFE. Poster No. 297 The Schon Tunneled Dialysis Catheter: A Retrospective Analysis of Radiologic Placement, Infection Rates, and Catheter Function in the Chronic Setting R. Sawhney, San Francisco, CA • IF. Urban. S. Perini. CM. Sasso. S.D. Wall PURPOSE: To retrospectively evaluate the Schon tun-

Poster No. 296 Use of Menstrual Calendar To Assess Outcome In Women Undergoing Uterine Fibroid Embolization (UFE) IG. Zorn, Washington, DC· IB. Spies. A .R. Roth· I Kim· S.M. Walsh

neled dialysis catheter (Angiodynamics, Queensbury, NY) with specific attention to procedurally related complications, infection rates, and catheter function. l11ETHOD AND MATERIALS: A retrospective, non-randomized study of the Schon tunneled dialysis catheter was performed. All data was collected at a facUity providing chronic hemodialysis to enrolled patients.

PURPOSE: To evaluate changes in menstrual bleeding

using pictorial blood loss assessment charts (PBAC) and laboratory hemoglobin and hematocrit values of patients undergoing UFE. MATERIAlS AND METHODS.· Patients udergoing UFE completed PBAC prior to embolization and at three and six months post-embolization. Hemoglobin and hematocrit values were also obtained on day three of each of these menstrual periods. Statistical paired t-tests were used to analyze the pre and post-procedure results with .05 significance level. RESULTS: Twenty-nine patients completed pre-em-

286

bolization and three month follow-up PBAC. One patient experienced as significant increase in menstrual

RESULTS: 40 Schon tunneled dialysis catheters were

placed by interventional radiologists in 35 patients over a two year period. Procedural success was achieved in all patients. There was 1 major placement bleeding complication which reqUired prolonged compression and the minor cautery in the operating room. There were 5 minor placement complications: 4 cases of minor oozing controlled in all 4 with limited compression and desmopressin acetate administration and 1 case of catheter kinking which was treated with tunnel revision. The mean blood flow rate immediately following catheter placement was 314.08 ml/min. The total number of catheter days was 45.~J (mean 117 days, range 15)-413 days). Episodes of poor blood flow

rate which required catheter manipulation/interventional treatment occurred at a rate of .088 per 100 ca thete r days with a mean occurrence at 43 days. No ca theters were removed for poor flow. Catheter removal for bacteremia occurred at a rate of .09 per 100 ca theter days with a mean occurrence at 45 days. The likelihood of freedom from infection using KaplanMeier survival analysis was 97% at 30 days, 84% at 90 days, and 76% at 180 days . CONCLUSIONS, Radiologic placement of the Schon tunneled dialysis ca theter can be accomplished safely with a high rate of technical success. Adequate catheter function and low infection rates can be achieved and maintained in the majority of patients.

Poster No. 298 How Cost-effective Is Endovascular Repair of Abdominal Aortic Aneurysm (AAA) in Patients Unfit for Conventional Surgical Repair: An Approach Using Modelling Techniques S.M. Thomas, SbeJJield, United Kingdom' N. w: Calvert. PA. Gm·nes • j.A . Michaels PURPOSE: Unfit patients with AAA may d ie of comor-

bid conditions and not aneurysm rupture, so e ndovascular treatment may not be justifjed, particularly when the mortality of endovascular repair approaches 20% (RETA data). Using modelling techniques we estimated the cost-effectiveness of endovascular repair in unfit patknts. MATERIALS Ai'vV MEmODS: The main model was con-

structed using a Markov decision tree for 70yr old men with aneurysms <6cm in diameter. The model simulated probabilities and costs to estimate cost-effectiveness of a strategy of best medical treatment against treating suitable cases with endovascular repair. RESULTS: Using a 20 year time horizon, the likely benefits of treating suitable cases with endovascular repajr of AAA were 3.09 life Years Gained (lYG) v's 2.14 1YG for best medical treatment. The additiona l costs of endovascular repair were estimated as £6,421 ($10,611). The marginal cost effectiveness ratio for endovascular repair was £6,717 ($ 11,100) per LYG. Uncertainty within the model was assessed using sensitivity analysis. Cost effectiveness was most sensitive to changes in aneurysm rupture probability, patient age, and degree of patient fitness. CONCLUSION The benefit of treating su itable cases with endovascular repair in unfit patients resulted in a margina l cost per LYG estimated as £6,717 ($11 ,100). In older patients, those with smaller aneurysms and the least 'fit' EVAR was least cost effective. In younger, fj ner patients, particularly those 'fit' but unsuitable for OR (e.g. because of a hostile abdomen) EVAR was most cost effective. Decision analysis is a valuable technique to assess cost-effectiveness of recently introduced treatments in vascular disease.

Poster No. 299 Subintimal Angioplasty of Occluded Calf Vessels: Initial Experience F.D. Hammer, Brussels, Belgium. H . Vraux • P.P. Goffette • R. Verbelst • P. Matburin PURPOSE: Evaluate the success rate and primalY pa-

tency rate of Percutaneous Intentional Exrraluminal Recana li sations (PIER) of infra-popliteal occlusions. MA7F.RJALS AND METHODS.. PIER has been initially described by A. Bolia and can be applied to infra-popl iteal vessels. Since December 97, we have treated 36 limbs (30 patients): 7 femoro-poplitea l or poplitea l occlusions extending into one or more ca lf vessels, and 29 occluded tibia l or peroneal arteries. The c1iJ.1ica l status was a Lerriche-Fontaine stage lIB in 1 case, stage III in 6 cases and stage IV in 29 cases. Twenty patients were diabetic (66.7%). Occlusion lengths ranged from 3 to 35 em (mean . 16.2 em) RESULTS: The immediate technica l success rate was

75%. Comp lications (8.3%): 1 pseudo-aneurysm at the puncture site required su rgery, and 2 dista l ernbolisations managed by thromboaspiration. The primary hemodynamic patency for successful procedures, eva luated by color Doppler scanning, was 87.3-77-61.6% at 3-6-13 months respectively. Even after late reocc1usion half of the patients are in a stable clinical situation that allows medical treatment. During a I -year follow-up the limb salvage was 83.3 % and the mortality rate 13.3%. CONCLUSIONS: PIER can be an alternative to distal bypass su rgelY in cases of su rg ica l contra-indications, poor skin conditions or insu fficient venous material. Long occlusions of calf vessels, even if calcified, can be [rea ted successfully with this method. The major limitation is the quality of the distal reperfused vessel. Clinical results are encouraging at least after 1 year of follow-up.

Poster No. 300 3D US Assistance for Obtaining Portal Vein Access During TIPS Procedures: 1 Year Experience S.C Rose, San Diego, CA • D.H. Pretorius • TR. NeLmn • TB. Kinney. T. V. Huynh. A.C. Roberts, et al PURPOSE: To describe the 3D US technique, to evalu-

ate the usefulness of information provided by 3D US, and to determine whether 3D US impacted the number of passes reqUired to obtain useful portal vein (PV) access, fluoroscopy time, or procedural time for creation of TIPS shunts. METHODS AND MATERIALS: Intermittent 3D US volume

acquisitions were obtained during creation of TIPS procedures in 20 patients. Specific useful information provided by 3D US was tabu lated. The number of passes required to achieve useful portal vein access, flu oroscopy time , and total procedure time was recorded,

287

and the results ..ptrn'm~·rr,vpllv compared to 25 patients who did not have 3D US. RESULTS: 3D US documented that the operator's opin-

ion of which hepatic vein had been selected was incorrect in 9 patients detected unfavorable PV anatomy which required modification of equipment or technique in 7 patients (35%), permitted estimation of the trajectory required to access the targeted PV in all patients (100%), assisted in selecting the optimal point along the hepatic vein for origination of the needle pass in 11 patients (55%), allowed avoidance of a large hepatocellular carcinoma in one patient (5%), and confirmed that access into the main portal vein was intrahepatic in 4 patients Comparing results of the 3D US group to the historic control group, the mean number of needle passes was 4.6 and 10.4 respectively (p=O.OOOl), the mean fluoroscopy time was 41.6 and 61.8 minutes respectively (p=0.004), and the mean total procedure time was 215 and 248 minu tes respectively (p=OW). CONCLUSION. 3D US provided imaging information

which detected technical errors and altered anatomy, and provided positional and directional information to significantly imp rove needle pass efficiency and minimize fluoroscopy time, and possibly lessen total procedure time.

Poster No. 301 The Safety and Efficacy of Reteplase for Thrombolysis BA. Wolf, Allentown, PA • f W Jaffe • fA. Newcomb • DI Shaff PURPOSE: To evaluate the safety and efficacy of

Reteplase (Centocor) fo r d ialysis graft, catheter, deep venous, and peripheral arterial thrombolysis. ME7HODS: Reteplase 5 units in 125cc9 NaCI was admi nistered for occluded dialysis grafts and catheters. The infusion time for the dialysis grafts was 30-45 minutes and one hour for the catheters. Pharmacomechanical technique was utilized for the dialysis grafts. For deep venous thrombosis, Reteplase one unit per hour was administered for 22 and for peripheral arterial occlusion, one unit per hour for 4 hours then 0.5 units per hour for 16 hours, A heparin bolus of 1500 units was given during dialysis thrombolysis, and a heparin infusion of 500 units per hour was administered during venous and arterial thrombolysis.

288

RESULTS: Prom 8/6/99 to 10/18/99, 22 patients received 34 administrations of Reteplase. Sixteen dialysis grafts received 24 administrations. Five catheters received 8 administrations. One deep venous thrombosis and one peripheral arterial occlusion had one administration each. There was one patient with both a dialysis graft and a catheter who received "C; 'lC;~I"")CC

Con different occasions). The maximum number of administrations was three in three patients. Thrombus was successfully cleared in all cases. No evidence of hemorrhage was noted , and no blood transfusions were required. No other untoward effects were reported by the patients. Post catheter removal time to hemostasis averaged 18 minutes for the dialysis grafts. CONG1.USIOIV: In this small group of patients, .. ---t"-~­ is efficacious and resulted in no complications,

Poster No. 302 Bleeding Associated With Intrathrombus Infusions of rt-PA For Peripheral Arterial and Venous Occlusions TO. McNamara, Los Angeles, CA • II. Chen • Cj. Temmins • B. Quinn PURPOSE: The recent unavailability of urokinase has

prompted a marked increase in the use of rt-PA for periphera l arterial and venous occlusions. This has provided an opportunity to observe the effect of different doses of rt-PA, duration of infusion, and concurrent anticoagulation on clot dissolution and bleeding complications. This report concentrates on the correlation between these factors and bleeding complications. METHOD/MATERIALS: From December 1998 through April 12, 1999, a total of 24 patients were treated with continuous intrathrombus infusions of rt-PA. Dosages ranged from 2 to 8 mglhr. Infusion durations ranged were concurrently antifrom 8 to 60 hours. Ten coagulated. Major bleeding was defmed as the requirement for transfusion, a 5 gm or greater drop in Hb, the need for surgical intervention, a hematoma greater than 15 em in diameter or the necessity to terminate the procedure. Minor bleeding was defined as a puncture site hematoma of 5 to 15 cm diameter, a llb drop of 3 to 5 gm, and distant site bleeding. RESULTS: Major bleeding occurred in 8 (33%), all of whom were also anticoagulated (100%). Minor bleeding occurred in 12 (50%), 1 of whom was anticoagulated. Three patients developed spontaneous subcutaneous hematomas at sites dista!)t from the entry site, each of them was anticoagulated, One patient bled from a site of balloon angioplasty in the SFA. This was severe and reqUired transfusion, There was a positive correlation between both higher doses and longer durations of infusions and the incidence and severity of bleeding complications. CONCLUSIONS: The use of rt-PA for percutaneous intrathrombus infusions of peripheral arterial and venous occlusions has been associated with a higher than previously reported incidence of bleeding This was particularly true if the patient was concurrently anticoagulated.

Poster No. 303 Incidence of Endoleaks in the Medium-Term Follow Up of Vascular Abdominal Aortic Aneurysm Repair: Experience in 76 Cases C. Mansueto, Verona, Italy . A. Scum · A. Adami · E. Ga/vagni • M. D'Ono/no • C. Procacci

PURPOSE: To eva luate the efftcacy of endovascular repair in the treatment of abdominal aortic aneurysm. ME7HODS AND MATERIALS, Between April 1994 and

May 1999, 76 patients underwent exclusion of abdominal aortic aneurys mal sac by placing different types of endoprosthesis: 8176 endoprosthesis were straight (i.e., aorta-aortic), while 6S!76 were bifurcated. RESULTS; The placement of the encto prosthesis suc-

ceeded in all cases, but in 8/76 palie nts a type 2 eodoleak manifested irrunediately after the procedure. The mortality rate in the following 30 days was O. During the follow up period (mean, ] 2 mths), type 2 endoleak was confirmed in the 8 pa tients, with no further dilation. In 2 cases a reduction of the aneurysmal sac was noticed. A type 1 endoleak was demonstrated in further 6 patient, 4 of whom had a stra ight endopresthesis placement. All of them underwent a new intervention: 5/6 had surgery, and 1/6 received a new e ndovascuJar repair.

8.5% by com puter analysis. The mean surface area of unopposed stent due to insufficie nt wall contact was 6.3% angiograp hically and 7.4% by computer analysis. The correlation between the b ifu rcat ion angle , degree of stenosis and stent-wall appos itio n was statistically ins ignificanr. CONCLUSION: Carotid stent-wall ap position is incom-

plete in the cadaver mode l. Arteriography te nds to unde restimate the stent-wall apposition , however, the degree is statistically insignificant. The ex tern al carotid arrery accounts for approximate ly 50% of the unopposed stent-wall surface.

Poster No. 305 Interventional RadiolOgic Management of Subcutaneous Chest Port Infections B. Funaki, Chicago, !L • A.N. Funaki • G.x. Zaleski · IA. LeeI· IN. Lorenz · ID. Rosenblum PURPOSE: To eval uate interventional radiologiC man-

agement of subcutaneous chest port infections. MATERIALS AND ME7HODS. Twenty·two patients (J 1

OBJECTIVE: To evaluate the ste m-wall apposition of self-expanding stents in the cadaver carotid artery by arteriography and specimen ana lysis.

men; 11 women; age 25-72 years, mea n 47 years) with infected chest pOllS were referred to our interventionai radiology sectio n for management. All patienrs had staphylococcal au reus bacteremia lmresponsive TO broad spectmm antibiotics with no clear source of infection other than indwelling access devices. Chest ports had been in place 3-549 days (mean 127.4 days) . At the time of device removal , 8 patients had local signs of infection consisting of erythema and tenderness at the port site and 14 pa tients had catheter~related septicemia wi th no local signs o f infection . Fourtee n patients were u·(.'a ted as outpatients and 8 were admiued with sepsis. All devices were removed via cUl-down and submitted for bacterial culture. In patients with suspected pocket infections, wounds were packed with iodoform gauze and allowed to hea l by secondary intention. In patients with catheter-related septicemia , the subcutaneous pockets were irrigated with dilute betadine and closed primarily with i.ntermpted sutures. All patients received a course of broad spectrum antibiotics and close follow-up.

METHODS A ND MATERIALS.· A total of 20 cadaver carotid arteries were harvested and initi al arteriogra m performed to eva luate degree of stenosis and angle of carotid bifurcation. Self-expanding 8 to 10 mm stainless-sleel stenls coated with indelible ink were deployed in the proximal iOlernal carotid arlery (lCA) ac ross the bifurcation. The stent-wall apposition was calculated from 1) orthogonal views from th e pos tstent arteriogram and 2) computer analysis of the ink distribution o n the arterial surface.

RESulTS: Device cultures were positive fo r sta phylococ~ ca l aureus in 100% (8/8) of patients with suspected pocket infections and in 71% 00/ 14) of patients with catheter-related septicemia. AJI patients who undelwent port removal resolved bacteremia within 1- 2 days with no Significant differences between patients with poSitive or negative device culrure s. All wound pockets healed well and no patients subseq uently developed cellulitis or abscesses. Cosmetic results were subjectively beuer in patients who underwent primary wound closure.

RESULTS: The mean percent of unopposed stenl sur-

CONCLUSION· Interventional radiologic management of

fa ce was 13.8% by angiogra phic criteria and 15.9% by compute rized spec imen analysis (P
chest port infectio ns is safe and effective. In patients w ith catheter-related septicemia who exhibit no local signs of wound infection, primary pocket closure after device removal is safe and well tolera ted .

CONaUSJON In our experience, type 2 endoleak is an early postoperative complication of endovascular abdominal aortic aneul}'sm, and it does not resolve spontaneously, even when sustained by small collatemls. Treatment is genemlly not neeck..'d, but only a watchful monitoring. Type 1 endoleak is more common in the straight endoprosthesis placement and requires surgical repair.

Poster No. 304 Carotid Artery Stent Wall Apposition: Cadaver Study K.D. Murphy, Syracuse, NY . A . V. Patel

289

Poster No. 306 Selectlve Uterine Artery Embolization for Symptomatic Fibroids: An Experience in China G. Teng, Nanjing, China . W. Tan · j. Guo . W Fang. S. He PURPOSE· To evaluate the safety and efficacy of uterine

artery embolization (UAE) for control of symptoms caused by uterine fibroids. MATERIALS AND METHODS, Bilateral UAE was per-

formed in 185 Chinese women with symptomatic uterine fibroids from May 1997 to June 1999. Polyvinyl alcohol particles (250--400 microns in diameter), silk thread or gelfoam was used in all patients,and fo llow-up of women with fibroid-related symptoms and US. RESULTS: Bilateral UAE was successful in 183 of 185 patients. All patients with symptoms of menorrhagia and/or pelvic/pressu re reported significant improvement. The average reduction of fibroid vol ume was over 50010 at 6 months in 153 patients who were observed for 6 months. Six patients became pregnant including one ectopic pregnancy. Pelvic pain was found in most patients, but fever and vomiting only in less 20% of all cases post-UAE. There were no severe complications encountered in this series. CONCLUSION: UAE appears to be safe and effective in

the patients with uterine fibroids, even in the patients who expect to become pregnant subsequently after the procedure. Poster No. 307 Coil Embolization of Patent Inferior Mesenteric Artery After Stent-Graft Repair of Abdominal Aortic Aneurysms M. Schoder, Vienna, Austria. T Hoelzenbein • M. Cejna • K. Hittmair • 1. Zaunbauer. j. Lammer

PURPOSE: To determine the relevance of a patent in-

ferio r mesenteric artery (IMA) fo r a successful endovascular repair of abdominal aortic aneurysm (AAA) and to eva lu ate the role of lMA embolization in these cases. MATERIALS AND METHODS: 127 patients with endovas-

290

cular AAA-repair had pre- and postoperative comrast enhanced computed tomography angiography (CTA). A patent l.~ prior to endovascular AAA-repair was identified in 24 patients. Preoperative embolization of the IMA was performed in 2/ 24 patients. CTA examination one week after stent-graft implantation showed an endoleak by retrograde perfusion of the IJ\1A in 12122 patients. In 7/ 12 patients this endoleak disappeared spontaneously within 3 month. A persistent endoleak was fou nd in 5/12 patients. Follow-up CTA examination revealed an unchanged aneurysmal sac diameter in 3/ 5, an increased diameter in 215 patients. In the 5 patients with a persistent lMA endoleak the lMA was embolized using a rnicrocatheter placed via the arc of Riolan.

RESULTS: A patent IMA was the reason for a persistent endoleak in 5 (23%) out of 22 patients. Corresponding to a primary failure rate of 4% of all endovascular AAArepairs. The systolic pressure within the aneurysmal sac ranged from 90 to 110 mm mercury. Embolization of the IMA was technically successful and sealed the endoleak in all patient,>. During a 12 month follow-up, the diameter of the aneurysmal sac decreased by 5mm in 1 patient and was unchanged in 2 patients. In 2 patients with a follow up less than 6 month the sac diameter remained unchanged, too. CONCLUSION: Because of a high incidence of primary endoleaks caused by a patent !MA, a preoperative embolization seems to be recommendable. Postoperative embolization is technically more demanding but an effective treatment of persistend endoleaks. Poster No. 308 Nightly Home Hemodialysis (NHHD), Improvement in Quality of Ufe R.S. Lockridge, Lynchburg, VA • D.H. Golwynjr PURPOSE: To report the initial experience in eleven pa-

tients undergoing Nightly Home Hemodjalysis. .MATERIALS AND METHODS: This is a retrospective re-

view of data collected during training and initiation of NHHD. Blood access was obtained using the Bard dual lumen dialysis catheter (Bard Access Systems, Salt Lake City, or an Ash split dialysis catheter (Medcomp, Harleysville, PA) via the right internal jugular vein. All patiems dialyzed using the Fresenius 2008H machine (Fresenius Medical Care, Germany) 4-9 hours/night for ~6 nights/week. Quality of life was assessed using the CHOICE Health Experience Questionnaire (CHEQ). Additional parameters such as hosp italization rates, BP, creatinine, albumin, phosphate binder usage and erythropoietin dosage were recorded.

un

RESULTS: All patients had a two- to threefold increase of weekly KtIV as measured by the formula of Basile and Francesco (2.3 x urea reduction ratio - 0.284). There were two episodes of septicemia and three exit site infections giving a catheter infection rate of 1.16/ 1000 total catheter days.

Preliminary data from the CHEQ (quality of life assessment questionnaire) shows marked improvement in physical functioning, pa in index, vitality, emotional, social functioning, health perceptions and physical role. Blooo pressure control was improved in most patients with fewer antihypertensive drugs. Cre-atinine and phosphorous levels were reduced. Erythropoietin dosages have been decreased. Hospitalization rates have also decreased. CONCLUSION: NHHD is a viable alternative to tradi-

tional three day per week in-center dialysis. Quality of life and BP control appear to be Significantly improved. Decreased medication requirements and hospitalization rates are additional potential benefits.

Poster No. 309 Small Intestinal Submucosa Covered Stents for TIPS, an Experimental Sttldy O.D. Ocbs, Portland, OR . j. Rosch · B.T Uchida · D. Pavcnik • FS. Keller· H. Timmernu:ms PURPOSE: To assess a new biogenic material , small irF testinal submucosa (SIS), for covering transjugular intrahepatic portosystemic shunt (TIPS) stents. SIS is known to function as a scaffo lding matrix in other applications such as arterial bypass grahs and tendon or liga ment repair. It has a pluripotential nature, allowing for remodel ing of arterial gra fts to include a three-layer wall with endothelium and vaso-vasorum. MATERIALS AND METHODS· Eight juvenile swine had

TIPS created with SIS covered Z stents and were followed venographically at two week intervals. The animals were sacrificed at the end of twelve weeks, or when the shunts became occluded. The stents and su rround ing parenchyma were harvested and gross and microscopic eva luation was done. RESULTS: Three shunts remained open; one until incidental animal death at seven weeks from a GI bleed and two to the end of the study at twelve weeks. The other five shunts were occluded at follow-up studies done between two and ten weeks, with a median duration to occlusion of 6 weeks. Gross and histologic examinations showed fibroblastic pseudointimal hyperplaSia moderately to significa ntly narrow ing the lumen in all animals. Bile duct in growth with bile stain was see n in fo ur shunts. This was severe in three animals and mild in one. Bile stained specimens contained either acute o r Iamillated thrombus. CONCLUSION: Small intestinal submu cosa is not effective in preventing two significant causes of TIPS failure in sw ine. The failure to prevent pseudointimal hyperplasia and bile duct ingrowth may be a direct result of the pluripo tential nature of the material.

Poster No. 310 Transjugular Liver Biopsy Using the Shark Jaw Needle: Diagnostic Yield and Cost-Minimization B. Psooy, Halifax, Canada . R. Beecroft • D. Malalja/ian • T W Clark PURPOSE: Tra nsjugular liver biopsy is performed when coagulopathy or ascites preclude percuta neous liver biopsy. Existing single-use needle sys tems for tran sj ugular liver biopsy are expe nsive, whereas reusable needle systems are associa ted w ith a rate o f inadequate core specimens. We report o ur experie nce with the reusable shark jaw biopsy needle (Cook) including diagnost ic yield and direct cost of expendibles. METHODS: A cohort of 120 patients who underwent 122 transjugular liver biopsies over a 27 month period was reviewed. Coagulopathy was present in 94 patients

(77.0 %) and ascites in 58 patients (47.5%). A shark jaw needle (Cook), consisting of a re usable 16G needle with a modified cutting bevel, was used to obtain core speci mens through the right or middle hepatic veins. Pathologic records were reviewed for adequa cy of specimens, and medical reco rds for periprocedural and postprocedural complications. Direct cost of expendibles incorporated the biopsy needle, aspiration cannula, and associated devices (guidew ires, teflon catheter, sheath, introducer needle). RESULTS: Biopsies were technically s uccessful in 113/ 122 patients (92 .6%); diagnostic histologic cores were o btained in 111 / 113 (98.2%) of technically successful biopsies. The overall success rate was 91.0%. Complications included capsu lar penetration in 6 patients (4.9 %), cardiac arrhythmia in 2 (1.6%), and bleeding or hematoma at the puncture site in 8 (6.6 %). Tract embolization was performed in 3 of 6 cases of capsular penetratio n. No instances of subcapsular hemato ma , hemoperitoneum o r sepsis occurred. Founeen deaths occurred within 30 days , none of which were attributed to the biopsy procedure. Expendibles used for each procedure averaged $103 US, corresponding to a costper-successful biopsy of $113. CONCLUSION Transjugular liver biopsy performed with

the sha rk jaw needle has a diagnostic yield comparable to Single-use biopsy systems at a substantially lower

cost ($103 vs. $418). Complica tion rates are comparable or lower to those reported in other recent series.

Poster No. 311 TIPS Patency Using the Wallgraft Endoprosthesis: An Animal Model M. Stein, Sacramento, CA • B. Ruebner • j.M. Brock

PURPOSE': To examine the patency results and biocompatibility of the Wallgraft™ endoprosrhesis used in creating TIPS in pigs. MATERIALS AND METHODS, TIPS was crea ted in eight

healt hy pigs (mean weight 17.3±2.5 kg) using the Polyethylene Terephthalate (PET) covered Wa llgraft nt endoprosthesis (10 mm wide by 60 mm long). The stentgrafts we re dilated to 8 mm with an angioplasty ba lloon. The pigs were followed week ly with Doppler Ultrasound to verify patency. When considered occluded , the shunts were examined with tran sjugular portal venography. Following occlusion , the pigs were sac rified and the shunts were removed , cut with a mi cro tome and examined his to pathologically to look for poten ti al ca uses of occlusion and assess biocompatibility. Patency rates were calculated with life table ana lysis. RESULTS: TIPS was created s uccessfully in all an ima ls with good flow seen in all shunts at the comple tion of th e procedure. The mean patency was 3.0±1.2 weeks (range 2-5 weeks). All [he shu nts were oc-

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cluded at 5 weeks of fol lowup. TIPS cumulative patency was 50.0%±17.7% at 2 weeks, 12.5%±11.7% at 4 weeks and 0% at 5 weeks. Histopathologic analysis of the shunts demonstrated a moderate (0 severe lymphocytic reaction to the covered scent at the hepatic vein and portal ends as well as around the stent in the parenchymal tract. Inflammatory ce lls were seen on both sides of the PET cloth. Accelerated pseudoinrimal hyperplasia was also observed. The occlusions were thought to be related to the intense inflamma(Ory reactio n and poor biocompa tibility of the covered stent. CONCLUSION 11,e PET -covered Wallgrah'" endopros-

thesis resuhed in relatively poor patency rates in a pig model likely related (0 lymphocytic inflammation and poor biocompatibility. Poster No. 312 Treatment of AM With the Talent Stent-Graft Device. Phase n Low-risk USA Trial. Interim Report R. Ujlacke1; Charleston. SC • I Robison· lB. Selby PURPOSE: To present the first year results of phase I high-risk trial for the treatment of AAA using the Talent stent-graft device. MATERIAlS AND MEmODS' From April to December,

1997, 26 patients were enrolled in the trial. All patients were at high risk for conventional surgical aneurysm repair. There were 24 ma les and 2 females with a mean age o f 70 yrs. A bifurcated Talent stent-graft was used in all patients, under epidural anesthesia and sedation, and bilateral femoral cutdown was performed.The device was place under flu oroscopy and the patienrs were followed with CT scan at time of discharge, at 3 months, 6 months and 12 momhs. Technical success (TS) and clinical success (CS) were evaluated and recorded, as well as adverse events and complications. REWfLTS.- At implantation TS was 23/26 (88.5%), CS was 23/26 (88.5%), 1 endoleak, 2 convenions. At discharge TS was 22124 (91.7%), CS was 21124 (87.5%), 2 endoleaks (1 new), 1 death. At 3 months TS was 21123 (91.3%), CS was 17123 (73 .9'10), 2 endoleaks (1 new, 1 resolved), 3 deaths, 1 bowel ischemia. At 6 months TS was 18120 (90%), CS was 17120 (85%), 2 endoleaks (! new, 1 resolved), 2 deaths. At 12 months TS was 19/ 19 (100%), CS was 18/ 19 (94.7%), endoleaks resolved, 1 death. CONCLUSIONS: The Talent endovascular stent-graft

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proved to be a reliable device to treat patients at high risk for conventional surgical repair of l\.AA. The procedure related morbidity was minimal and the morta lity related to the procedure was very small. Seven patients died within the 12 months fo llow-up, consistent with the mortality encountered in that group of patients with multiple clinical problems.

Poster No. 313 Treatment of Abdominal Aortic Aneurysms (AAA) With Guidant-EVT Endograft: Correlation of AAA Size With Perigraft Flow Through 3 Year Follow-Up K.S. Cht"ang, Greenville, NC • H.D. Deaton. L.N. Keaton. W Bogey . D.M. Tripp. D. Brigham PURPOSE: Endovascu lar grafting is an alternative treatment for abdomina l aortic aneurysms (AM). Perigraft fl ow, defined as persistent circulation between the aortic wall and graft material, is a potential source of aneurysm growth and rupture. Our purpose is to correlate aneUiysm size vvith the incidence of perigraft flow with one type of endovascu lar graft repair of l\.Al\.. MEmODSIMATERIA1S' Over a 36 month period, 56 pa-

tients( 47 bifurcated, 7 aortoiliac, 2 tube endografts) were enrolled in Guidant-EVT Phase II and III clinical trials. 3 (5%) patients required inunecliate surgical conversion. 4 patients have expired or are lost to follow-up, but did not have perigraft flow at discharge. 13 recent patients, initially negative for perigraft flow, are pending next required intervaJ follow-up. CT and US are performed to evaluate aneurysm size and presence of perigraft flow. Maximum aneurysm diameter is measured by contrast enhanced 3mm collimation spiral cr at a consistent level. RESULTS.- Of 53 patients (95%) successfully implanted, 40 (75%) had no perigraft flow at discharge. Of 13 (25%) patients with perigraft flow, 7 resolved spontaneously by 12 months, 3 resolved with embolOtherapy and/or surgical intervention, and 3 are being observed without increase in AAA size. Of the 34 patients without perigraft flow, 23 (68%) patients have decreased AAA size and 11 (32%) have rema ined unchanged. No 1\.../\....4.. has increased in diameter over 4mm. CONCLUSIONS: There were no ruptures, delays in onset of perigraft flow, or significant increases in AAA size. More than two-thirds of the patients without perigraft flow have had decreasing AAA size. The long-term significance of patients with stable aneurysm size in [he abscence of detected perigraft flow remains in question. Longer term follow-up is needed.

Poster No. 314 Ultrasound-enhanced Peripheral Thrombolysis Using rt-PA. Preliminary Results With the EKOS Ultrasound Infusion System K.M. Sterling, Alexandria, VA • j. Link . D. Vonverk PURPOSE A feasibility study to evaluate a new multielement ultrasound drug delivery system to improve thrombolysis. MA'lERJALS AND METIIODS: Five patients were treated with the PT-] Ultrasound Infusion System (EKOS Corp, Bothell, WA) and rt-PA for thrombolysis of peripheral arterial occlusions (2 distal SFA, 2 popliteal, and 1 fempop graft) ranging in length from 3.5 to 40 em. The EKOS device is a two piece catheter consisting of: 1) a

6 F, 0.035" gUidewi re-compatible drug de livery sheath with a 10cm distal d rug infusion zone, and 2) an ultrasound core catheter with a 5cm d istal segment containing three ultrasound elements. The sheath drug infusion zone is placed via gu idewire into the occluding thrombus; the guidewire is then replaced with the ultrasound core catheter so as to position the ultrasound e lements with in the drug infu sion zone. Drug infusion is combined with low power (2.0 W) ultrasound radia tion . Combined drug and ultrasoun d therapy was applied for I to 1.9 hours (3 mg/hour) followed by 0 to 5.5 hours of drug-only infusion (1 mg/hr). The outcome (percent lysis) was estimated angiogr-aphically. RESULTS: Device technica l success was achieved in fou r pa tients. Of these , three had complete lysis «95%) approximately 4 hours (3.2S-5.5 hrs) after completion of the combined drug and ultrasound thera py. Three patients also were subsequently treated with adjunctive therapy (2 stent, I PTA). CONCLUSION: Preliminary resu lts with the EKOS ultra-

sound infus ion system suggest that complete lysis may be o btained using a relatively low dose of rt-PA. Since angiography was not performed until four hours after u ltrasound exposure, complete lysis may have occurred sooner. Fu ture studies will incorporate angiography at shorter time periods (Q more accura tely evaluate lysis time and drug requi rements. 0/. of Patients wI >95'1t Lysis 75'1.

Treatment Time (hrs)

rl-PA DOle (mg)

8.1

Poster No. 315 Treatment of AAA With the Talent Stent-Graft Device. Phase I High·Risk USA Trial. One Year Interim Report R. Uflacker, Charles/on, SC • I Robison · lB. Selby PURPOSE: To present the initial one month resu lts of

phase II low-risk trial for the treaLmenl o f AAA using the Talent stent-graft device. MA7ER1ALS AND METHODS, From July 1998 to January,

1999, 150 low risk patients were enrolled in the trial. All patients were considered to be at low risk fo r conventional su rgical aneurysm repair. 90% were males and 10% females with a mean age of 71 yrs. A bifurcated Talent slent-graft was used in all patients, under epidural anesthesia and sedation, and bilateral femoral cutdown was performed.The device was place under fluorosco py and the patients were followed with CT scan at time of discharge, al 3 months, and 6 months. Technical success (TS) an d clinica l success (CS) were evalua ted and recorded , as well as adverse events and complications.

RESULTS. At implantation TS was 86/95 (90.5%), CS was 86/95 (90.5%), 5 endoleaks, 2 conversions, 2 access difficulties, 1 ilia c artery rupture . At discha rge TS was 81/86 (94.2%), CS was 77/86 (89.5%), 5 endolea ks (3 new , 3 resolved), 1 death (stroke), 2 renal fun ction im-

pai rment. At 1 month TS was 58/6 2 (93.5%), CS was 57/62 (91.9%)' 4 endoleaks (2 new , 3 resolved) I renal function impairment (conLinued). CONCLUSIONS: The Talent endovascula r sren t-graft proved to be a reliable device to treat pat ie nts at low risk for conventiona l surgical repair of AAA. The procedure related morbidity was minimal and the mortality related to the procedure was very small. Only one patient died within the 1 month follow-up.

Poster No. 316 Protected Renal Artery Angloplasty and Stenting' A New Concept of Treatment. M. Henry, Essey Les Nancy, France · C. Klonaris • M. Amor • 1. Henry. E. Leborgne • B. Folliguet PURPOSE: Percu taneous angioplasry and sten ting of ath-

erosclerotic renal anery stenosis is cu rrently a well accepted revascul arization method. However, despite excellent immediate etec hnica l success, later resu hs demonstrate a deterioration in renal func tion in a considerable number of patients. Atheroembolism of the intraparenchyma l aJ1eries during the procedure is considered, among others, to be an important factor for this unfavorable outcome . Therefore, a novel te chnique, protected renal artery angioplasty and stenting could be a reasonable concept. We present o ur ea rly resu lts using this technique. MA7ER1A1S AND ME11fODS: Protected rena l angioplasty and stenting was used to treat 16 atherosclerotic renal artery stenoses (ostial, 8, bilateral, 4) in 12 pIS (M, 7, f, 5), Mean age . 68.1±8.5 y (49-87y). All P'S were hypenensive, 4 had moderate and 1 severe renal dysfunction. All had diffuse multilevel atherosclerotic disease. The technique consists of placing an 8 F gUiding catheter at the renal artery ostium. The lesion is then crossed with the PercuSurge Gua rdwireTM temporary occlusion balloonon-a-wire catheter and the protection b-alloon is inflated distal 1O the lesion. Predila tation and stenting of the lesion. Aspiration of the debriS with a monorail asp iration catheter. DeflaLion of the p rotecti on balloon . Ang iogra phic con trol. Blood pressure and creatinine level were followed thereafter and compared to baseline valu es.

RESULTS: lnunecliate technical success in all cases. Mean time of renal artery occlusion 262±126 sec (149-540 sec). Visible debris were seen in all pts and ana lyzed. Number of particles varied from 15 to 187 per procedure and diameter from 45 to 620611. No deterioration of renal fun ction was noticed in all pts including those with renal insufficiency. CONCLUSION: O ur preliminary results suggesl [hal protected renal artery angiopJasty and stenting wi th lhe PercuSurge device seems to be a safe and effective method in o rder to avoid atheroembo lic events during the procedu re . lndications for this technique should evaluated by larger and randomized studies.

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Poster No. 317 Impact of Graft Attachment Method on Endoleak Around Aortic Stent Grafts LD. Leigh, Boston, .MA • DJ. Rabkin· TG. Vrachliotis • D.P Brophy • E. V. Lang PURPOSE: To assess the effect of different graft attachment configura tions on aortic stent-grafl endoleak. MATERIAL AND METHODS: 20 mm diameter tube stent-

graft ske letons were made from Gianturco-Z-stents, honeycomb oitinol stents, and nitinol Z-stenrs with various length and widths of the individua l Z's and cells respective ly. Ste nts were covered on the outside with ironed Cooley-Verisoft woven polyester tube grafts or experimental materials such as Tecoflex , silastic, and Repel membrane. Since polyester leaks wirhout preclot-

(ing, it was made impermeable by means of Opsite covering. 'fwo methods of graft attachment were tested. For the standard attachment method, the graft was cut perpendicular to its long axis, and the straight cut edge was sutured to the end of the stent. For the contoured attachment method, the graft was afnxed to the skeleLOn and cut to match the zigzag configuratio n of the stent end. The assemblies were tested in a pulsatile flow circuit in vitro with an aortic simulation of 18 mm diameter. An interposed 60 mm lo ng gap simulated an aneurysm sac. Leakage was assessed by visual inspection and measureme nt of extravasated fluid. RESULTS: With the standard method, the graft materia l buckled inwa rds through the stent interstices permitting flow through the resulting crevices into the aneurysm sac. With decreasing width of the stent cells leakage decreased. The incidence of leak decreased with increasing length of the necks of the stent grafts exte nding beyond the aneurysm sac. With necks barely exceeding the length of the height o f the terminal zigzag of the stent skeleton , only the contou red attachment method was able to el iminate leakage. The contoured pattern resulted in an outward buckling of the graft material providing additional seal. CONCLUSIONS: Adopting the con toured attac hment method of graft materials to aonic stents minimizes o r eliminates leakage around stent-grafts in vitro. The gain is most pronounced when the aneurysm neck is short and when the cell width of the skeleton cannot be reduced.

Poster No. 318 Value of Intecnailliac Artery Balloon Occlusion in Treatment of Life-TItreatening Obstetrical Hemorrhage M.K. Razavi, Stanford, CA • E. Hansch • D. Y Sze • c.p Semba • M.D. Dake PURPOSE In the setting of uncontrollable postpartum

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hemorrhage, rapid uterine artery (UA) embolization can be a life saving technique that avoids hysterectomy. We evaluated the utility of internal iliac artery baHoon-oc-

elusion to allow time for UA catheterization and complete emboliza tion. MA7El1lALS AND MET7iODS.· Ten women ages 18-41

undelWent temporary balloon occlusion of the ante rior divisions o f internal iliac aneries bilaterally to control postpartum hemorrhage. Through the lumen of the balloon catheters, the UAs were then selected and embolized in 8 of the 10 patients using microcatheters. Temporary balloon occlusion was sufficient to cease all bleeding in the other 2 patients. Specific diagnoses included cervical pregnancy (1), uterine atony (5), placenta previa andlor accreta (4). RESULTS: Complete embolization could not be achieved

in time in one patient requiring hys terectomy. Embolization tluough the coaxial system was successful in 7 with complete control of hemorrhage. Temporary balloon occl usion was sufficient in the remaining 2 pa tients. One patient developed fever which was trea ted with antibiotics. Mean blood loss 'was 3300 ml (J80~4000 mI). In the 8 patients that required embolization, bilateral temporary balloon occlusion controlled the bleeding for a mean duration of 13 minutes. CONCLUSION Use of internal iliac artery balloon occlusion allows timely control o f bleeding permitting ca the(erizarion and comp lete embo li zation of uterine arteries.

Poster No. 319 Angioplasty for Infrageniculac Arteries: A '-year Experience A.A. Khan, Washington, DC· Rj. Gray. B.M. Smith · A .M . Shaikh · T. Sasaki. D.K. Lurie, et at PURPOSE: To report the outcomes of a retrospective analysis of infragenicular PTA's.

MA7E'RIALS AND MEmODs.· The medical records and

angiograrns of 186 patients who undelWent infra genicular PTA from '92 to '99 were reviewed. Sufficient data was available for 121 extremities treated in 114(48 male, 66 female) patients with average age=64.J(34-86) years. Risk faclors included diabetes in 81 patients, HTN in 79, ESRD in 35, and smoking in 34. Chronic ischemia catego ries were 3(n=10), 4(n=38), or 5(n=73)' Of these, 48 patients had non healing ulcers and 25 had gangrene. 45 had concurrent (7 PTA,S lysis, 3 bypass) and/or previous (J9 PTA, 30 bypass) inflow procedures above the popliteal artery. 55 popliteal, 170 tibial, and 3 dorsalis pedis arteries were dilated. Average ste nosis was 80(55-100)% and average lengt h was 1.6(0.2- 7.0) em. 7 had a planned T.MA or toe amputation with the PTA. Procedure success was defined to require anatomic success (straight-line flow to ankle in at least one tibial with <30% residua l stenos is) and clinical success (improvement by 2 categories for chron ic ischem ia category 5 and by 1 for categories 3 and 4). Hemodynamic suc-

cess was defined as either an increase in abi <0.2 or a palpable pedal pulse. Continued clinical and hemodynamic patency was used to construct life tables that were analyzed using the Kaplan-Meier survival analysis method. Cox proportional hazards model was used to evaluate variables (ESRD, diabetes, HTN, smoking, ischemia category, gangrene , and straight-line flow) likely to affect outcomes.

symptoms only after a total hip replacement. Tissue loss score increased from .6±.9 to 1.5±1.3 (p=.08). Walking distance improved an average of 200 yards. Walking and mobility scores improved from 3.5±1.8 to 1.7±1.7 (p<.03), and from 4.5±2.6 to 6.7±2.7 (p<.05), respectively. Work and self-care scores did not change significantly. Pain severity score improved from 7.4±2.5 to 4.6±3.2 (p<.02).

RESULTS: Procedure success was 70.2 %. Primary patency was 64.5%(n= 57) at 6 months, 55.0 %(n=25) at 1 year and 45 .7%(n=10) at 2 years. Patients with ESRD were 3 times more likely to fail (p
CONCLUSIONS: Aortic bifurcation reconstruction in patients with extensive and complex aorto-iliac disease is effective in providing lasting symptom relief. Durable hemodynamiC benefits can be expected in addition to improved quality of life at mid-term followup.

WIlHDRAWN

Complications included 4 distal emboli, 1 PTA-site thrombosis, 2 puncture site injuries and 1 contrast ATN. CONCLUSION Infragenicular PTA is safe and the majority benefit for at least 1 year; however, ESRD patients are 3 times less likely to benefit and more likely to require amputation.

Poster No. 320 Delayed Assessment of Hemodynamic and Quality-of-Life Measures Following Aortic Bifurcation Stent-Reconstruction Cj. Heaney, Iowa City, IA • Mj. Sharafuddin • S. Sun • K.A. Yousef. ].B. Corson PURPOSE: Delayed clinical efficacy of aortic bifurcation stent-reconstruction has not been studied. We evaluated the mid-term clinical efficacy and quality of life following aorto-iliac bifurcation reconstruction. METHODS: Between 5/1998 and 9/ 1999, 20 patients with complex arterial occlusive disease underwent aorto-iliac reconstruction (claudication: 15, ulceration: 5). Aorto bi-iliac reconstruction was performed in 13 patients, and aorto-mono-iliac in 7. Fontaine scale, ankle arm indices (AAl), and tissue loss were assessed from the clinical record. Telephone interviews were also conducted to assess subjective quality-of-life based on mobility, self care, work activities, pain and anxiety scores (1 to 10). One patient who developed an incapacitating CVA, and three patients lost to followup could not be interviewed. RESULTS: Pressure gradient decreased from 50±23 to 1.2±3.3 mmHg following stenting (p<.OOO5)' Number of stents used was 2.4±1.0 per limb (stented length: 73±40 em per limb). AAI improved from 0.54±0.24 to 0.78±0.2 (p<.005), at mean followup of 5 months (range 1-14). On telephone interview (Mean followup : 7.5±5 months), 12 of 15 patients reported significant sustained symptoms relief of at least one Fontaine-grade (p<.Ol). One patient reported no difference, and another one described symptom progression (both had extensive infrainguinal PVD). One patient reported resolution of

Poster No. 321 Poster No. 322

Transplant Renal Artery Stenosis - Results of Angioplasty and Stenting Dj. Alcorn, Glasgow, United Kingdom • ]. Moss • S. Rodger • T Collidge PURPOSE: To assess the technical and clinical outcomes following pta and/ or stenting of transplant renal artery stenosis (TRAS). MATERIALS AND METHODS: During a 68 month period 21 hypertensive allograft recipients underwent attempted percutaneous treatment of haemodynamically signficant TRAs. Indications for treatment - Isolated hypertension 6 cases, associated allograft dysfuction 6 cases, allograft dysfunction related to introduction of ACE Inhibitor 7 cases. RESULTS: Technical success 95% - Primary PTA 19 patients; PTA and Stenting 1 patient. Restenosis occurred in 8 (40%) patients requiring further PTA (4), Stenting (3) and medical management (1). 7 (35%) patients suffered 8 major complications including 1 acute allograft loss due to stent thrombosis. 5 (25%) patients retuned to dialysis during follow-up period. Clinical follow-up showed a Significant (p < 0.01) fall in systolic and diastolic blood pressure at 1 month and at a mean of 30 months follOWing procedure . There was an immediate reduction in antihypertensive medication but this was not maintained. CONCLUSION The apparent benefits of PTA and Stenting of TRAS in blood pressure control must be weighed against the high complication profile and the need for the gradual reintroduction of antihypertenSive medication.

Poster No. 323 Fatal Complication of Percutaneously Inserted Central Catheter: Extent of Tip Movement S.H. Smyth, Tucson, AZ • ].M. Zaetta PURPOSE: A patient with a total artificial heart had an acute cardiac arrest and death occurring 7 days after bedside placement of a percutaneously inserted central

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catheter (PICC). At autopsy the cause of death was found to be due to [he PICC (tricuspid valve was wedged shut by the ca theter tip). This initiated a snldy to evaluate the movement of the PIce tip secondary to arm position. MATElUA1S AND MEIHODS· During PICC placements in 70 patients a gu idewire was utilized to measure the skin to SVC/right atrial junction distance w ith the arm abducted at 45-90 degrees. Movement o f the tip was determined by placing the arm £11 the patient's side and measuring the difference in the two positions.

RESULTS: Movement of the arm from the abducted position to the patient's side caused movement of the tip from the sve toward the right atrium an average of 20.6 mm, (range of 0 to 63.8 rum), if placed via the basilic vein. If placed via the cephalic vein the same movement of the arm resulted in movement of the tip from the sve toward the right atriu m an average of 12.5 m.m (range of -13.5 to 35.9 mm). CONCLUSION Changes in arm position can result in significant PICe tip movement. Determining the extent of movement of the tip is critical in patients with rightsided artificial valves.

Poster No. 324 Embolization for Haemoptysis: A 6 Year Review P Y. Goh, Singapore, Singapore - MB. Lin - N. Teo DE Wong PURPOSE: To review ou r method of arterial emboliza-

tion for ha ernoptysis. MATERIAL AND METHODS· 159 angiograms were performed for 130 cases o f massive or moderate haemoptysis. The follow-up period ranged fro m 1 month [0 5 years. Most were due to tube rcu lous bron ch iectasis 09.5%) and malignancy 02.8%). Other causes were diffuse pulmonary haemorrhage, Middle Lobe Syndrome, absent right pulmonary artery, sequestrated lung and lobar pneumonia . Vascular access was obtained via the femoral route but 2 cases required a brachial app roach after attempts to cannu late abnorma l branches of the subclavian artery from the groin were unsuccessfu l. A concerted effort was made in all cases to selectively ca nnulate the intercostal , subclavia n and infe rior phrenic arteries, in addition to the bronchial arteries. All abnormal vessels fou nd we re embolised using PYA particles (at least 350-500 micrometers in size) alone or in combinatio n with gelfoam. If necessa ry, a microcatheter coaxial system was used without hesitation. RESULTS: Bronchial artery hypertrophy was found in 82% of cases; 34.4% of wh ich had systemic contribu-

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ti on. O nly 6.4% had abnormal systemic vessels with normal bronchial arteries and these were mainly nonTB in origin . No angiographic abnormalities were found in 11 .5%. 30010 of our malignant cases were angiographically normal compared to only 4.8% of those due to TB. Satisfactory control of haemoptysis was achieved in

the majority of cases and no further intervention was requ ired. 13% required repeat sessions; o f which 52% needed a single repeat, 24% reqUired 2 and 24% required 3. Cases requiring su rgica l intervention were rare. No major complicatio ns were encountered. CONCLUSION: Embolization is an effect ive mode of treatment for moderate to mass ive haemoptysis. The majority of our cases were due to TB. Approximately one third had systemic contributions, indicating that a concerted search for abnormal system ic vessels is mandatory.

Poster No. 325 Spontaneous Retroperitoneal Hemorrhage With Hemodynamic Collapse, Management by Transcathter Selective Arterial Embolization Kj. Andresen, Iowa City, 1A • Mj. Sharajuddin • S. Sun - M.s. Stecker . K.A. Yousej- L.A. Wibbenmeyer PURPOSE: Spontaneous retroperitoneal hemorrhage

(SRH) with hemodynamic collapse is associated with high monality. Current trea tment options are mostly limited to supportive care or su rgical packing. We describe ou r experie nce with the management of active SRH using selective transcatheter embol ization. MATERIAlS AND METHODS, Between November 1997 and August 1999, 5 consecutive patients underwent angiographic evaluation of SRH complicated by hemodynamiC collapse. All patients were on anticoagulation therapy. All had a c r study demonstrating signs of active localized bleeding (iliopsoas, 3, rectus sheath , 2), foUowed by angiography and subsequent transc:atheter embolization.

RESULTS: Nonselective exp loratory aortography identified active bleeding in all patients, although lhe findings were often subtle. Selective angiography of the supplying artery(ies) confirmed and characterized the bleeding in all cases. Where appropriate, careful select ive angiography of known collateral pathways was also performed. Supply to bleed was via one or two lumbar arter ies in all 3 psoas hematomas. In abdominal wa ll hematomas, supply was from the inferior epigastriC arte ry in 2 patients, with additional supply from the deep circumflex iliac artery in 1. Mu hiple sma ll bleeders in the territory of the feeding vessel occurred in 3 patients, with secondary collateral supply from a second vessel in 2 patients. In all cases, bleeding location on angiography correlated closely with CT. Microcoil embolization successfully con trolled extravasation in all patients. In o ne patient, a second adjunctive embolizatio n cession was needed. Stabilization of hemodynamic parameters and marked decrease in transfusion requirements occu rred in aU patients. Four of the five patients survived the immediate post-procedure interval. CONCLUSIONS: In SRH with associated hemodynamiC collapse, and signs of active loca lized bleeding on cr, transcatheter selective embolization may be a viable life-saVing option. This new indication should be further eva lualed.

Poster No. 326 Arterial Embolotherapy for Upper GastroIntestinal Hemorrhage: Outcome Assessment V.L. Oliva, Montreal, Canada. R. Aina • E. Therasse • P. Perreault • M. P. Dufresne • C. Souiez

PURPOSE: To assess the safety and efficacy of arterial embolotherapy for treating upper gastro-intestinal hemorrhage and identify factors influencing fe-bleeding and mortality.

MATERIALS AND ME71iODS, Seventy-five patients underwent arterial embolization for acute upper gastro-intestinal hemorrhage (UGIH) from various causes: 47 gastric or duodenal ulcers, 10 iatrogenic injuries, 8 tumors, 6 inflammatOlY cond itions and 4 others. Th e embolic agents used were coils, PVA particles, geLfoam and glue.

RESULTS: The technical success was 98.7%. Primary control of bleeding was ac h.ieved in 57 (76%) patients. Clinical success rose to 82.5% after re peat embolization in 5 add it iona l patients. Complications were: self-resolving duooenal ischemia (2), hepatic infarct (1) and inguinal hematoma 0). The peri-procedural mortality (mostly from underlying illness) was 33.3% at 30 days and 57.3% after a mean follow-up of 34.5 months. There was no late re-bleeding. Factors influencing ea rly re-bleeding were, a) coagulopathy (Odds Rali=19.46, p
CONClUSION Arterial embolotherapy for UGIH is sa fe, effective and durable. Coagulation disorders should be corrected and the use o f coils alone shou ld be discouraged to obtain higher clinica l success.

Poster No. 327 Does the Geometry of Transjugular Intrahepatic Portosystemlc Shunts Predict the Likelihood of Subsequent Shunt Dysfunction? LI Perry, Boston, MA • P Amatulle • D.P. Brophy · EV Lang PURPOSE To evaluate whether the geometry of tran-

sjugular intrahepatic portosystemic shu nts (TIPS) affects the likelihood of subsequent need for shunt revis io n.

requiring revision vs those not requiring reviS ion. The average angle of curva ture of the sten t(s), the average angle of the stent with the hepatiC vein, and the average distance of the stent end from the hepatiC vein origin were 116 degress, 175 degrees and 14mm respectively, for those requiring revisio n. For those not requ iring reviSion, measurements were 113 degrees, 175 degrees, and 13mm , respectively. CONCLUSIONS: Based on the final anteroposterior TIPS angiogram alone, one cannot predict the likelihood of shunt dysfunction requ iri ng revision.

Poster No. 328 Creation of Radiopaque Thrombi for In Vivo Experiments D.B. Broum, St. Louis, MO • CB. Claiberman • A . W Alien . H. Singh . F.C Lynch . PN. Waybill PURPOSE: A number of percutaneous thrombectomy devices are undergoing investigation for treatment of patients with venous thromboembolism. Use of radiopaque thrombus to monitor thrombus delivery and assess thrombectomy has been p reviously reported. The purpose of this project was to quantitatively test the effect of mixing different ratios of blood and contrast in order to faciJitate maximal thrombus formation and radiopacity.

MATERIALS AND ME71iODS, Varying rati os of blood and contrast were mixed in the follOWing fash io n: 2 cc blood: 8 cc contrasl (ratio = 0.25), 4 cc blood: 6 cc conlrast (ratio = 0.67), 6 cc blood: 4 cc contrast (ratio = 1.5), 8 cc blood: 2 cc contrast (ratio = 4). Contrast was added at day 0, 3, or 6. Each samp le received one of 2 ionic contrast agent,> to opacify the clots. At day 14, thrombus mass and opacity was determined. RESULTS: Three blood: contrast combinations produced

maximal thrombus and radiopacity. These were sodium iothalamale 30% with a ratio o f 4 with contrast added on day 0, and sod ium iothalama le 600iO with a ratio o f 1.5 with contrast added on day 3 o r 6. CONCLUSION When forming radiopaque thrombi, sig-

nificant differences can resu lt from the ratio of blood to contrast used. Contrast rype can also affect radiopacity and mass formed . Using optimal ratios of blood!contrast should maximize device evaluation with minimal wasting of valuable resources such as test sl.Jbjects, physician lime, and equi pment.

MATERIALS AND ME71iODS· We retrospectively assessed anteropos terior digital angiograms taken at the end of 61 TIPS procedures fo r a) degree of ste nt angulation, b) angu lation of th e end of the stent with th e hepatic vein, an d c) distance of the stent end from the hep atic vei n o r ig in (inferior vena cava). Reintervention was pe rfo rmed if recurrence of clinical symptoms and/or findings on so nograph ic followup suggested s hunt dysfunction .

Comparing Cavography With Ultrasound in Measurement of Caval Biometry OR. Kaura, Calgary, Canada . C.B. So • IC SaUken • R.R. Gray

RESULTS; Of the 61 TIPS procedures performed over a

PURPOSE Inaccurate assessment of inferior vena caval

three-year period, 27 required revis ion at 1 day to 13 months post procedure. There were no Significant differences in the parameters described above for patients

biometry prior to rvc filter insertion can result in inappropriate filter choice, particularly when the cava l diame ter exceeds 28 mm, when on ly a bird's nest filter

Poster No. 329

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should be deployed. Once a filter is inse rted, the rve adopts a circular configuration. Measurement of a single frontal plane (cavography) could be inaccurate as the lye can adopt varying geometry and orientation in vivo. The study was designed to determine if the diameter obtained by cavography using a single frontal plane, correlated with the diameter obtained by ultrasound using transverse and antero-posterior planes. MFIHODS: Prior to TVC filter inse rtion, 46 patients were examined with ultrasound. Infrarenal TVC measurements were made; transverse (usTD) and antero-posterior dimensions (usAPO) were recorded. The patient then proceeded to cavography (prior to filter insertion) and a magnification corrected measurement of the transverse diameter (cTD) was made from the cavagram. The dimensio ns obtained from ultrasou nd were then used to calculate an average circular diameter (ACO) with the equation ACD=O.5 (usTD +usAPD) . The ACD was then compared transverse diameter obtained by cavography. Results were analyzed using the Student's t-test.

RESULTS.' Of 46 subjects, 23 were male and 23 were female. Mean age was 70 years with a range from 23 to 87 yea rs. Comparison of the mean ACD (15.5 mrn 5D=3.3) with mean cTD (17.2 mm 50=3.0) demonstrated a significa nt difference (p=O.0004). CONQUSIONS: Single plane measurement of caval diameter from cavography differs significantly from ultrasound measurement in two planes. The dimensions obtained by ultrasound more closely approximate the diameter of the cava once it is distended to a circle and consequently, ultrasound may be more useful than cavography to determine caval diameter prior to fLlter insertion.

Poster No. 330 Temporary Vena Cava Occlusion to Control Aortic Blood Flow for Precise Deployment of Endovascular Stent-Graft: Efficacy of Coaxial Double-Balloon Catheter T lshiguchi, Nagoya, Japan . N. Nishikimi • T Ohta • S. Arahata • 5. !toh • T lshigaki

PURPOSE: Temporary o cclusion of the inferior vena cava (TVC) and the superior vena cava (SYe) originally using two baBoon catheters has been shown to be effec~ tive in reducing aortic blood flow for precise deployment of stem-grafts . This study is to eva lu ate the effjcacy of a coax ial double-balloon catheter designed for vena caval occlusion during aortic stent-graft placemem. MATERiALS AND ME7HODS.. A coaxial double-balloon

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catheter was designed for temporarily occluding the TVC and the sve to control aortic blood flow during deployment of aortic stem-grafts. The catheter has two latex balloons with platinum markers mounted on a 6-F s haft. The distance between the ba lloons is 10 cm and each balloon is ind ependendy inflated with carbon dioxide. In patients with thoracic and abdominal aortic aneurysms, the balloon catheter was introduced via the

femoral vein over a stiff guidewire to the vena cava, and the balloons were inflated just before deployment of the self-expandable stent-grafts. RESULTS: TemlXlrary vena caval occlusion resulted in

immed iate, reversi ble and reprodUcible decreases of the mean aortic blood pressure and aortic blood flow. In the consecutive 26 cases of endovascular stent-grafting for 15 abdominal and 11 thordcic aortic aneurysms, vena caval occlusion was used in 11 patients, 5 patients with the original method using two balloon catheters and 6 patients using the double-balloon cathe te r. Toand-fro movement of the stent-grafts was negligible and the downstream shift of stent-grafts during deployment was 0.6 ± 1.2 mm w ith vena ca val occlusion, which was significantly sma ller than in 11 other patients with drug-indu ced systemic hypotension 03.7 ± 18.2 mm). The double-balloon catheter was much more easily placed at the appropriate position and the balloons showed no movement toward the right atrium. There were no complications. CONCLUSION Temporary vena caval occlusion is technically feaSible, safe and effective for accurate placement of aortic scent-grafts. Coaxial doub le -baUoon catheter was as effective as the original two-catheter method for precise deployment of stent-grafts and was much easier to use.

Poster No. 331 Perclose Device for Femoral Arterial Closure After Stent Graft Placement S.F Quinn, Eugene, OR • ]. Kim . C T McGlade PURPOSE: This report describes the early clinical expe-

rience using the Perclose device for arterial closure after placement of a transluminally placed endovascular graft, (TPEG). MATERiALS AND ME7HODS.· Ten patients had TPEG de-

vices placed for iliac aneurysms (n=2), abdominal aortic aneurysms Cn=7) or thoracic aortic transection (n=1). The devices were either tubular (n==3) or bifurcated (n=7) for a total of 17 femoral arterial sites. The devices were introduced through 14 French (18 French 0.0.) (n=9), 16 French (20 French O.D.) (n=2) or 12 French (1 4 French O .D.) (n=6). After the arrerial puncture was performed, o ne (n;; ; ; lO) or two (n'""7) PercJose device was placed. Of the 24 Perclose devices placed, either 8 French (n=3) or 10 French (n::;21) were used. After Perclose deployment, the arteriotomies were to dilated to the appropriate sizes for the deployment sheaths. All patients were anticoagulated during the procedure. After TPEG deployment, hemostasis was achieved by the Perclose sutures that were in place. RESULTS: All 17 femoral sites were closed without im -

mediate femoral or lower extremity complications. Nine of the ten (90010) patients ambulated within 4--6 hours. Eight of the patients were discharged within 24 hours of the procedure. Two patients had iliac occlusions within

2 months of the TPEG placements. Neither patient had femoral arterial occlusions at surgical exploration. No long term follow-up is available. CONCLUSION The Perclose device , when placed prior to al1erial dilatation, can be used to achieve hemostasis

for TPEG procedures. The long term effect on the femoral arteries is uncertain.

Poster No. 332 Treatment of Arterial Lesions With the WallgraftTM Endoprosthesis M. Stein, Sacramento, CA • K.M. Helms· 1M. Brock · we Pevec • D.P. Link PURPOSE: To evaluate the safety and efficacy of the treatment of arterial lesions with the Wallgraft™ endoprosthesis. MATERIALS AND METHODS: Eleven patiems (seven women, four men, mean age 55.5±lB.3 years) have undergone placement of the Wallgraft'", PET (Polyethyl· ene terephthalate) covered stent, for treatment of pseudoaneurysms in the infrarenal aorta, internal carotid, com mo n iliac, external iliac and subclavian arteries, an arteriovenous fistula (AVF) from the superficial femoral artery to the superficial femoral vein and five iliac atherosclerotic stenoses. The AVF was caused by penetrating trauma. Three of the patients with occlusive lesions had claudication and two had limb-threatening ischemia. All stents were introduced using a 10F vascular sheath through the femoral approach. Patients were followed prospectively with symptomatic review, physical examination, Doppler ultrasound and arteriography if needed. The mean follow up period was 14.1±7.4 months (range 4--28 months).

RESULTS: Technical success of Wallgraft™ deployment was 1000/0 with resolution of all the lesions treated. One patient with a pseudoaneurysm in the right subclavian artery at the confluence of the vertebral and internal mammary arteries required additional coil embolization of a peri-stentgraft pseudoaneurysm via a direct percutaneous needle approach. The patient with the AVF reqUired embolization of a venous pseudoaneurysm. One patient cloned her graft at 30 days and had successful mechanical thrombectomy and revision with a Wallstent. No deaths occurred at 30 days. One patient developed a small groin pseudoanewysm that was successfully compressed with ultrasound assistance. At 28 monrhs of follow up, the cumulative rates of primary patency, secondary patency and survival were 47.7±16.6%, 90.0±9.5% and BO.8±12.3% respectively. Four of five patients with severe intra graft stenoses were successfully revised with Wallstents and dilatation to restore patency. CONCLUSION: Our data suggests that the Wa ligraft"fM

endoprosthesis is a safe device for the treatment of arterial lesions. Primary patency rates are relatively low, which may limit the indications for this device.

Poster No. 333 Transcatheter Revascularlzation for Chronic Mesenteric Ischemia SR. Parikh, Seattle, WA • K.H johansen . IE. Block PURPOSE· To determine efficacy, durability and safety of stents and PTA for symptomatic stenosis or occlusions of superior mesenteric al1et)' (SMA) and celiac artery (CA). Chronic mesenreric ischemia (CMI) causes morbitity characterized by post prandial pain and weight loss due to inanition. Beca use these patients are generally elderly, and subject w systemic atherosderosis, mortality and morbidilY rates for operative visceral reconstruction may be high. MEmODS: We evaluated 16 patients (12 F, 4 M, range 19 to 87 yrs., with mean of 62) with clinical, ultrasound and angiographic co nfirmation of CMI managed between 1995-1999 at a University affiliated conununity teaching hospitaL Study endpOints included patient mortality and recurrent sym ptoms of CM L Vessels with PTA included proximal SMA (n=4), mid SMA (n=3) and distal SMA (n=1), proximal CA (n=3)' Vessels stented included proximal SMA (n=9), proximal CA (n=6).

RESULTS: Clinical follow up was complete in all 16 patients at a mean of 1B.5 months. 4 patients died during follow up period. 2 deaths were related to recurrent CMI and CAD and 2 others related to CAD alone. Of the 3 patients with recurrent sympwms of CMI, 2 died from CMI and CAD, and 1 underwent PTA with resolution of CMt Other 10 patients remain asymptomatic. All patients had early relief of pain and noted weight gain post procedure. No patient required operative intervention for treatment of CM!. Recurrent symptoms were seen in patients with angioplasty and mid to distal SMA lesions (19%), 9 patients had vascular disease in other beds: renals, iliacs aorta and subclavian. Complications: 2 small hematomas, 1 asymptomatic pseudoaneurysm, 1 sma ll stroke, 1 SMA and iliac dissection requiring treatment. CONCLUSIONS: Presence of CMI is a marker for accelerated systemic atheroscle rosis in other vascu lar beds. Mortality in these patients is related to associated CAD and recurreD[ CM!. Transbrachial stenting of SMA and CA is a safe, durable and reliable technique. The results of stenting appear to be more durable for proximal visceral artery lesions.

Poster No. 334 Percutaneous Atherectomy With the Endomyocardial Bioptome M. Bulvas, Prague, Czech RepubliC • R. Urbanova • R. Klezlava • 1. Vitkava PURPOSE: The aim of the study was to test atherectomy with the endomyocardial bioptome as treatment of excentric or polypoid arterial stenoses. MATERIALS AND METHODS· We used the endomyocardial bioptome to extract stenOSing tissue of 27 short,

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markedly asymmetrical or polypoid arterial narrowings of the lower limbs in 23 patients. Extraction of excentrically stenosing tissue was undertaken by access from the common femoral artery. Ipsilateral approach was used in all cases. The extracted tissues were examined by histopathology. RESULTS: Twenty-four asymmetrical primary stenoses were reduced to or below 30 % by endomyocardial bioptome extraction. The mean bioprome reduction o f 27 primary stenoses was from 81.9 % to 14.4 %, p
~

based extraction is an effective and simple method for the treatment of short, primary stenoses with a high degree of excentricity . Poster No. 335 Endoleak Following Endovascular Aortic Aneurysm Repair

D.O. Kessel, Leeds, United Kingdom . I. Robertson· Dj. Scott. D.C Berridge. P j. Kent· Ej. Taylor PURPOSE: To assess outcomes of stent grafting in care-

fully selected patients.

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MATERIALS AND METIlODS.. A prospective study of 23 consecutive patients haVing e ndovascu lar aneurysm repair. All patients had proximal necks at least lOmm long (range 12-50mm) and no larger than 250101 in diameter. The proximal grafts were oversized 10-20%. Large lumbar trunks and patent inferior mesenteric arteries were embolized prior to stent grafting. All patie nts had stent grafts deployed in the angiography suite via bilateral femoral arteriotomies. Additional distal extension cuffs were used to treat aneul)'smal iliac arteries. Primary procedura l success was gauged on completion angiography and pre-discharge CT. Patients were followed up with dual phase spiral CT at 1,3,6, 12,18 and 24 months. Aneurysm size and the presence of endoleaks was recorded.

RESULTS: All grafts were deployed successfully with no type I endoleaks. There were no major procedure related problems. At completion 1 patient had transgraft leak through a presumed defect in the graft fabric at the flow divider and 1 patient had a type II leak via iliolumbar vessels. 1 patient died w ithin 30 days following surgery for rectal carcinoma. 3 (14%) patients developed delayed type II endoleaks Cat 3 and 6 months) through patent lumbar arteries, none of these had been t.h.rought to require preoperative embolization. Subsequent embolization was attempted in 3 patients and was successful in 2. All grafts remain patent at follow up ranging from 1 month to 27 months with no type I leaks. Aneu rysm size decreased in most patients with aneurysm exclusion but changed lime in patients with extensive mural thsombus. Aneurysm diameter increased or did not change in the patients with endoleaks. CONCLUSION: High technical success rates are achieved if patients are carefu lly selected. Type I endoleaks are avoidable if stem grafts are appropriately chosen . Type II lumbar endoleaks are an important ca use of concern, they are difficult to treat and may lead to aneurysm expansion. The role of preoperative embolization of branch arteries remains uncertain.

Poster No. 336 Is Radiologic Screening Necessary to Follow TIPS in Patients Treated for Refractory Ascites? L.D. Bub, Denver, CO • J.D. Durham· R. Shrestha • D.A. Kumpe .}. Krysl • G.T Everson PURPOSE: To determine if a plasma renin activity (PRA)

can be used to predict inadequate portal decompression in patients following TIPS pro<..:edures performed for treatment of refra ctory ascites. MA7ERLAJ.5 AND METHODS. Twenty-eight patients with end-stage liver disease (mean Child-Pugh 11.3) and refractory ascites were enlisted in a Clinical Research Center study to investigate hormonal and biochemical responses to TIPS. Patients were assessed at baseline, three weeks, and lruee months. Portography was per~ formed at each follow-up evaluation. Using a Fisher's Exact Test, the PRA that predicted a portosystemic gradient (PSG) of < 12 mmHg with greater than 80010 sensitivity was determined.

RESULTS: TIPS was performed successfully in 27/28 pati ents (%%). Thirty-day mortality fo!1owing TIPS was 4/28 (14%). Seventeen of 28 patients C61 %) responded clinically to TIPS with diuretic co ntrolled or absent ascites without paracentesis. AJI patients clinically responsive to TIPS had a PSG less than 14 mmHg; five of six non-responders had PSG· 17 mmH g at Lhree weeks. Twenty-two of 28 patients (79%) underwent three-week follow-up, and 16 of 28 (57%) underwent three-month follow-up. Baseline, three-week, and truee-momh mean PSG and PRA were 18.7 mmHg and 13.6 mg/Uhr, 10.3

mrnHg and 5.1mg/Uhr, and 13.1 mmHg and 3.8mglUhr. At three weeks, a PRA < 4.0 mglUhr predicted a PSG < 12 mmHg with a sensitivity of 83% and specificity of 75% (p < 0.03). At wee months, this relationship was not found to be significant. CONCLUSION: In many patients undergoing TIPS for re~ ffactory ascites, a dramatic clin ical respo nse to TIPS predicts ad equa te portal decompressio n. Screening for shu nt pate ncy is unnecessary in this gro up . When clinical ambiguity exists, a PRA is both sensi tive and specific at pred icting inadequate porra l decompressio n at three weeks, obviating rhe need for rad io log ica l screening.

WITHDRAWN

Poster No. 337 Poster No. 338

Vena Caval Filter Placclnent: Technical Success and Immediate Complications: Variations Between Interventlonal Radiologist and Vascular Surgeon Operators HK. Pal1ickel; Pontiac, Ml • M.A. Savin · S. Sadiq • Y.A. A/beer . R.E. Olson PURPOSE: Evaluate the technica l success and immediate complications of ve na caval fiher (VCF) placement by interventiona l radiologists (IRs) and vascular surgeons (VSs). MATERIALS AND METHODS.· The med ica l record and radiographs of ]48 consecutive patients who underwent VCF placement between December ] 995 and February ] 999 (n=] 48) at a sin gle hospital were retrospectively reviewed. Technical success and in hospital complicatio n data was assessed. RESULTS.· 142 records were comp lete. Of these, 114 fil ters were p laced by IRs and 28 by VSs. Patient de mographics were s imilar in the IR and VS groups.Inferio r vena cavagrams were obtai ned prior to all IR placemenls bU( in o nl y 25% of VS p lacements (p<.OOOl). Filter misplacemen t occu rred in ]2 (43%) o f the VS placements and in on ly ] (0 .9010) of the IR placeme nts (p<.OOOl). No ne of the VS misplaceme nts were recognized at [he time of placement. Of the VS mi splacements, 3 (1] %) were placed in iliac veins and 9 (32%) were placed above the rena l veins. Major comp lica ti ons occu rred in 2 (7%) of the VS p lacements and none o f the IR place ments (p<.048). Both complicatons were in patients with filter misplacement in iliac ve ins (retroperitoneal hematoma requ iring transfusion and pulmonary emb olus likely from exis ting unprotected deep ve in thro mbosis in contralateral extremity). CONCLUSION IRs placed VCF with greater technical

success and fewer immediate complications than VSs. This may be altributed lO IRs hav ing greater familiarity with image gUided procedures and adhering to procedure related imaging protocols.

Poster No. 339 Histological Response of the Aorta and Clinical Results After Endovascu1ar Treatment of' Abdominal Aortic Aneurysms With a Self· Expandable Nitinol ePTFE Stent·Graft F. W Cartes-Zumelzu, ZUrich, Switzerland · I Lammer • M. Cejna • S. Thurnher • T Holzenbein • H. Plenk PURPOSE: To better understand the biological effect of endoluminal therapy with a nitin ol e-PTFE cove red stentgr.aft o n the aorta and to eva lu ate the clinical outcome of Aortic Abdom inal Aneurysm (AAA) repair with this new device. A1ATER1A1 AND METHODS: We treated 12 ovine aortas with the nitino l framed and e-PTFE covered ste ntgrafts. After 4 weeks and 3 month implants were retri eved and histopathologically eva luated. The dinical trial included the endovascular th erapy of AAAs with the sa me GoreM-Prograft bifurcated device in 30 patients with a median age of 72 y (59y-86y). Aneurysm diameter ranged from 44mm-88mm (median 55mm). The median fo llow-up period is 13 month. Histopathologica l exam ination revea led neointimal growth o f 24 % through the stentgraft but in co mpl ete coverage of the ste ntgra ft after 4 and 12 wee ks. Loca lized loss of cell nuclei in the elasLic layer beneath the stent was seen indicating cellular necrosis due to pressure aga inst the aortic wall. In the clinica l pilot study the primary success rate was 87%. Four leaks were detected. We had 3 major and 3 minor complications. No conversion to su rgery or dea th occurred. RESULTS:

CONCLUSION: Histopathological examina tions in the ovine aorta showed no evide nce of disruption of the media tha t could lead to progressive dilatation of the stented aortic necks. Nevertheless furthe r studies are necessary to determine the biohistological response to stentgraft therapy, especially in diseased aortic tissue. In th e clin ica l pi lot study the endovascular therapy of AAAs was a n e ffective and safe approach of treatment

but further longterm st udies are needed to determine its rea l lo ngterm efficacy. Poster No. 340 Complications Associated With Use of rt-PA Versus Retavase During TIU'omoolysis of Peripheral Arteries and Veins TO. McNamara, Los Angeles, CA • K. T. Aban • B. Qu inn . R. Hung BACKGROUND: The unavai lability of urokinase h as re-

su lted in increased use of rt-PA and retavase. The safery and efficacy profile of these agents is not well established for peripheral vascular use. PURPOSE· Establish the incidence of comp lications relative to dose, duration of infUSion, type o f drug, type of condUit, and whether or not the patie nt is concurrently anticoagul ated .

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MA1ERIAlS AND METHODS: Retrospective review of results

in 40 patients treated with rt-PA and 43 patients treated with retavase over a 10 month period at a single institution.

ful atherectomy, four puncture site haematomas, o ne case of distal embolization and one case where the stent became snared in the atherectomy device

RESULTS: Bleeding .requiring transfusion was noted in

CONCLUSIONS· Directional atherectomy is useful in the

25% of the patients receiving rt-PA and 3% of those receiving retavase. Predisposing factors were dosage, associated anticoagulation, and duration of infusion.

treatment of NIH associated with stents or prosthetic grafts. lne best results are obtained in patients detected at surveillance rather than those occluded at presentation.

DISCUSSION Early experience suggests that It-PA is

more like ly to be associated with bleeding during peripheral thrombolytic infusions than retavase. This difference was most marked in patients receiving concom itant anticoagulation. Poster No. 341 Directional Atherectomy in the Treatment of Neointimal Hyperplasia Associated With Arterial Grafts and Stents: Immediate and Medium Term Results MB. Matson, London, United Kingdom. RA. Morgan. S.M. Thomas • TJ1.t/. Buckenham • A .M. Belli PURPOSE: To assess the efficacy and safety of atherec-

tomy in the treatment of anastomotic stenoses due to neointimal hyperplasia (NIH) in prosthetic anerial bypass grafts and endovascular stents. Restenosis at the anastomoses of prosthetic anerial bypass grafts and of endovascular stems is most commonly due to NIH and may lead to late occlusion. The results of balloon angioplasty are disappointing. The results are presented of 36 atherectomy procedures in 31 patients with mean follow up of 22 months. MATERIAL> AND ME7HODS.. Two groups of patients were treated. Group 1 comprised patients presenting with acute limb ischaemia and an occluded graft or stent. These patients required thrombolysis or mechanical thrombectomy before atherectomy. Group 2 comprised patients with stenoses detected at surveillance by duplex. The Simpson and Pullback atherectomy catheters and the Redha-cut device were used. Technical success was defined as <3()O/o residual stenosis. Pollow-up was with regular duplex scanning. RESULTS: In group 1, thirteen atherectomies were per-

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formed at twelve sites (one aorto-common femoral graft and eleven f~moro-popliteaI). Seven of the twelve grafts (58%) occluded after a mean period of 242 days (5-613). The remaining five grafts remain patent (primary patency 42% after a mean period of 19 months). In group 2, 23 athereClOmies were performed at 20 sites in 19 grafts/ stems (five iliac stents, five aorto-femoral grafts and 9 femora·popliteal grafts). One graft occluded after 511 days. Nine grafts and fOUI stents remain patent after a Single treatment (primary patency 68010 after mean period of 24 months), three grafts and one stent are patent after repeat atherectomy (primaI)' assisted patency of 89% after a mean period of 24 months) and one required surgical revision for restenosis. Complications encountered were one postoperative death following unsuccess-

Poster No. 342 Percutaneous Endoluminal Treatment of Iliac Occlusions M. Henry, Essey Les Nancy, France • M . A mor • I. Henry. C. K/onaris • B. Mentre • K. Tzvetanov PURPOSE: To evaluate the long-term results of percuta-

neous recanalization techniques for iliac artery occlusion. MATERiAlS AND ME7HODS: Percutaneous recanalization was attempted in 155 patients (142 males, mean age, 56.9+1·10.6, range . 33 to 80) with 173 iliac artery occlusions, utilizing pharmacological thrombolysis in 38, excimer laser in 10, mechanical thrombectomy in 19, balloon angioplasty alone in=23, and angioplasty plus srenL placement in 132 cases. Lesions located in the common iliac artery in 106 cases and in the externa l iliac in 67 cases. RESULTS: The primary recanalization rate was 90%

(155/ 173) regardless of location (CIA 90'10 EIA 90'10,), Ie· sion length «60mm, 98%, <60mm, 86%, p=ns), and age of thrombus (<3 months, 99%, <3 months, 80%,p=ns). Complications included 6 (3.4%) cases of distal embol ism treated by thromboaspiration (n=4) or Fogarty balloon embolectomy (n=2). Nine (5.2%) early thromboses were treated surgically. Primary (PI) and secondary (PII) pa· tency rates were calculated at 8 years for all cases (intention to treat) and for recanalized lesions only using life table analysis. Overall, PI was 61%, and PH was 77%. PI for lesions
sions represents a true alternative to vascular surgery and a fust-line treatmem option. Shorter occlusions have more favorJ.ble outcome. Although not statistically significant stents have a tendency to improve long-term results and are recommended for routine use in chronic iliac occlusions. Poster No. 343 Percutaneous Recanalization of Chronic Iliac Occlusions HF. Odink, Heer/en, The Netherlands • E. Bollen • TT Greven • I. De Ploeg . S. Rozeman • R. \Ve/ten, et a/

PURPOSE In a prospective study of 192 iliac PTA's, 49 patients with a chronic iliac occlusion (26%) were found, who were treated by percutaneous recanalization.

METHOD: Pre-PTA all patients were classified folloWing the Rutherford classification. Recanalization was done by a fetro o r an antegrade approach. In most procedures a stent was placed. A recanalization was classified as a technical success if the angiographic lumen was more than 70010 and if the pressure gradient had disappeared. A direct cl inical success was defined if 24 hrs after post-PTA a raise was found in the ABI at rest of more than 0.10. Follow-up was done by duplex scanning and treadmill testing. For follow-up the Rutherford/ Becker classification was used with a scale from -3 lip to +3. The procedure was a clinical success if there was a categorial improvement of at least +1. RESULTS, Men = 33 and women = 16 (mean age = 60.2 years ± 10.1) with a total of 51 iliac occlusio ns. Mean length of the occlusion = 6.3 cm ± 3.3. A successful recanalization was done in 44 procedures (86%) by a retrograde (n=31) or by an antegrade approach in 8 procedures by a cross-over technique and in 5 procedures by a brachial approach (0=13). Seven arteries could not be recanalized. After PTA and stent placement the ElA ruptured in two patients and in another patient an embolism of the CFA was found. These tluee patients were operated. The total technical failure rate was 10. Nine technical failures were found in the first group of 34 procedures. During the last 17 reca nalizations o ne technical failure was seen. The major complication rate was 10% (n=5). The technical success rate was 80% (n=41). Stent placement was done in 39 arteries. In [wo procedures no stent was pJaced due to the good angiographic result and (he disappearance of the p ressure gradient. CONCLUSION Percutaneous recanalization of chronic

iliac occlusions showed a learning curve with a technical success rate of 800k and a l()OJo complication rate. The primary patency rate of the procedure wiJI be presented. Poster No. 344 Clinical Experience With Stent Placement for Mesenteric Ischemia Rj. Schmall, Ann Arbor, MI · JI Gemmete • D.M. Williams. D. Narasimham • SN. Kazanjian

PURPOSE· To describe our experience with stent placement for mesenteric ischemia. MATERIALS AND ME1HODS.· From February 1996 to October 1999, 20 patients (9 males, 11 females), age 42 to 86 years (mean 66) underwent stent p lacement for mesenteric ischemia. 8 patients with aortic dissection complicated by ischemic compromise of the liver o r bowel (2 celiac, 7 superior mesenteric as1ery), 10 patients with 11 stenoses (4 celiac, 7 superi or mesenteric artery), and 2 patients with 4 atherosclerotic occlusions were treated. Follow-up was obtained cl in ically in all patients and angiographically in 2 patients.

RESULTS: Technical Sllccess was achieved in 18 of 20

patie nts. 4 atherosclerotic occlusions in 2 patients prevenred stent placement. A brachia l artery hematoma requi ring surgical evacuation was the only procedure related compJication. Two patients died within 30 days following treatment related to compl ications from their dissection. Two patients who initia lly presented with bowel infarction from their dissection underwent partial small bowel resection after stent placement. One patient had a partial small bowel resection 6 months after stent placement for a bowel infarction related to chronic mesenteric ischemia. Another patient suffered a sp in al cord infarct from the dissection with lower extremity weakness whic h subsequenlly showed improvement over time. Clinically, all parienl'i but [WO reported relief of their symptoms, at a mean follow-up of 22 months (range 1 month to 43 months). Angiographic follow-up in 2 patients at 3 months and 16 months showed 1000/0 primary patency. CONCLUSIONS: Stent placement for treatment of mesen ~

teric ischemia has a high technical and clini cal success rate. Technical success is greater in patients with bra nch vessel compromise from aortic dissection and atherosclerotic stenosis. Complete vessel occlusion from atherosclerosis may limit success. Poster No. 345 Initial Results and Mid-Term Patency Rates of Hemobahn™ Stent·graft Placement for the Treatment of Femoro.Popllteal Occlusions TJahnke, Kiel, Gerrnany • J. Brossmann • G. Voshage • C Humann· S. Mueller-Huelsbeck • I Grimm, et al

PURPOSE- To evaluate the safety and effectiveness of "intention-to-treat" stent-graft placement using the HEMOBAHNTM self-expanding endoprosthesis in patients with femoropopliteal occlusive d isease MATERIAL AND ME1HODS, The HEMOBAHN'" endoprostheSiS, a self-expanding nitinol stent with an inner lining of ultra-thin polytetrafluoroethylene (ePTFE), was used in patients presenting with primary occlusions of the superficial femoral artery (SFA). Up to date 18 patients, 5 female and 13 male were treated. Mean length of the lesions was 8,7 ± 4,7 cm. Follow-up eva luations with assessment of Rutherford clinical stage, colo rcoded duplex sooography (CCDS) and MR-imaging were carried out at discharge as well as I, 3, 6, and 12 month after implantation. RESULTS: Initial technical success was ach ieved in all

patients and scent-graft placement induced an initial improvement of the mean clinical stage from category 3 to 1. The mean value of treatmenl success according to the SCVJR classification was +1 ,8 (±0,9). So far 9/ 18 patients have been fo llowed up for at least 6 months. Cn o ne case thrombosis of the graft occured within 14 days. Despite the absence of in-stent stenoses [Wo patients exper ienced reocclusions before 6-months due to stenoses of the superficial femo ral artery proxima l

303

or dislal lO the graft. Three patient" showed moderate intimal hyperplasia inside the slcnl-graft ostium as early as 1 month , but only one patient developed a reocclusion (at 4 months). A late failure at 8 months in another patient again was due to atherosclerotic lesions proximal and distal to the stent graft without compromised stental lumen. CONCLUSION: Endovascular placement of the HEMO-

BAH:-J™ stent-graft for treatment of femoropopliteal occlusions shows promising initial results. However at 6 months follow-up the reocclusion rate was 55%. Reocclusions were primarily due to high -grade stenoses of the SFA proximal or distal to the stentgraft, thus we conclude that "intention-to-treat" stemgraft placement into the femoro-popliteal level should be preferably performed for single lesions of the SPA without impaired blood-flow in proximal or distal arterial segments.

Poster No. 346 Prevalence of Uterine to Ovarian Artery Anastomoses In Patients With Symptomatic Uterine Leiomyomas: To Embolize or Not to Embolize

lvl.K. Razavi, Stanford, CA • D.Y Sze • S. Slonim • S. T Kee • c.p Semba • M.D. Dake PURPOSE: To determine the prevalence of angiographi-

cally visible natural anastamoses between the uterine and ovarian arteries in patients treated intra-arterially for symptomatic fibroids. MATERIALS AND METHODS.. Fifty-two women with a mean age of 44.5 (36-54) underwent uterine artery embolization (UAE) for symptomatic fibroids. All patients had pre and post embolization abdominal, pelvic, and selective uterine arteriograms using automated contrast injection . Uterine arteries were embolized using 355-500 micron PYA particles.

Poster No. 347 Long~Term

Results of Retrograde Transvenous Obliteration for vastric Varices and/or Hepatic Encephalopatby

T Fukuda, Kobe, Japan. S. Hirota· S. Matsumoto· K. Sugimoto • K. Sugimura • M. Sako

PURPO.5E: To evaluate the long-term results and to assess the relapse-free survival and prognostic factors of retrograde transvenous obliteration (RTO) for gastriC varices (GV) and/or hepatic encephalopathy . MATERIALS AND METHODS: Between De cembe r

1994 and September 1999, 44 patients underwent RTO . The subjects consisted of 36 patients with GV, two with hepatiC encephalopathy and six with both . Thirty-two patients have been consecutively followed up with gastrointestinal endoscopy for more than one year. The hepatic function reserve was estimated according to the Child-Pugh classification. Development of the portosystemic collateral circu lation was assessed as grade 1 to 5 according to the size and number of collateral veins. The relationship be tween aggravation of esophageal varices (EV) and improvement in hepatiC function reserve after RTO on the one hand, and the grading of collateral veins on the others was analyzed. The re lapse-free survival and the prognostic factors after RTO were also assessed. RESULTS: GV disappeared in 30 of the 32 patients, and

hepatiC encephalopathy improved completely in all of them. Improvement in hepatic function reserve was observed in 20 of the 32 patients 3 months after RTO, in 16 patients 6 months after RTO, but in only 8 patients 1 year after RTO. Aggravation of EV was seen in 6 patients (four patients with high -grade collateral veins). A relapse-free survival rate was 94.9% one year after RTO, and 91.4% three years after RTO. Hepatocellular carcinoma was a complication in 24 patients during the follow-up period, and 8 patients died of it.

RESULTS: On abdominal aortograms, angiographically

visible ovarian to uterine artery anastomoses were identified in 5 of the 52 patients (9.6%). Selective ovarian arteriograms were performed in 2 of the 5, with embolization in one. The latter patient who was post-menopausal with .severe menorrhagia requiring transfusions underwent embolization prior to hysterectomy. Clearly identifiable uterine to extra-uterine anastomoses were seen on selective pre-embolization uterine arteriograms of 9 other patients (17%). UAE did not change the appearance of the ovarian arteries on the abdominal aonograms. The procedures were clinically successful in 46 patients (88%), including all with identified anastomoses. CONCLU.510N· Presence of visible ovarian to uterine ar-

304

tery connections docs not appear to change the short~ term clinical outcome of UAE. 'Ihesc anastomoses, however, may impact the management of patients with severe menorrhagia, or increase the risk of ovarian failure.

CONCLUSION 1) Improvement in hepatic function re -

serve was seen in 63 % of the cases, and aggravation of EV in 16%. The grade of collateral veins was related to the improvement in hepatic function and aggravation of EV. 2) The most important prognostiC factor was concomitant presence of hepatocellular carcinoma.

Poster No. 348 Transjugular Intrahepatic Porto-Systemic Stent Shunt (TIPSS) AfterOrthotopic liver Transplantation (OLT).

PP. Goffette, Brussels, Belgium • PP. Laterre • IP Lerut PURPOSE: To evaluate the technical feasability and

clinical outcome of TIPSS in liver transplanted patients with recurrent portal hypertension. MATERTAL: Among a 5-year period, 8 liver trans-

planted patients undervent TfFSS because of recurrent

a llograft viral C (n='5) and B (n=1) disease, secondary bilialY ci rrhosis du e to ch ronic re jection (n =1) and ve n o-occlu~ i ve disease (n=1). Ind ica ti o ns fo r porta l decompression we re refractory asdtis (n =5), untra ctable hydrothorax (n=l). recurrent variceal bleeding (n=1) and to reduce portal hypertenSion before surgical biliary repair (n=1). Delay between OLT and TIPSS ranged from 2 to 61 months (mean 22). Following CHILD-PUGH class., patients were B (n"'5) and C (n=3). Fi ve pat. presented a late ro-latera l cavo-caval Piggy-back ana stomosis and three a classical Piggyback anastomosis.Procedures were performed by transjugula r(7) or combined tran she pati c and transfemoral approaches(1) and by us ing Pa lmaz( n=6)or Wall stent(n =2).

thrombus and retrograde passage of 3 and 4 french endho le calheters into thro mbosed calf ve ins for injection o f rt-PA. A maximum daily dose of 50 mg and a maximum cu mu lative dose of 200 mg of rt-PA was permitted per affected ex trem ity. Plasma fibrinogen levels were monitored during thrombo lytiC therapy. Concurrent systemiC anticoagul ation is ini tiated with heparin and maintained on wa rfarin for 6 mon ths. Venograms were pe rformed daily during thrombolytic the rapy and 1 to 2 months following discharge. At 6 monLhs, cl inical and dup lex ultrasound eXamination is performed to evalua te for venous insuffi ciency.Ventila tion-perfus io n lung sca ns were perform ed prior to and aft er completi on of thrombolytiC th erapy in seven patients to assess embolic risks.

RESULTS: TIPSS procedures succeeded in all patients, with a mean porto-systemic gradient reduction o f 59%. Acute angle between receiver's IVC and d onor's hepatic veins rendered the access (0 the hepatiC vein difficult in four pat.. Ascitis disappeared in all but one patients. No recurreOl bleeding was observed. Six patients had a worsen encepha lopathy managed by dietetary restricLion. Durin g the F-up, 4 pat. died, 1. 5, 4, 5 and 32 months after TIPSS. Causes of death were respectively pancrea titis (n=1) and end-stage li ve r failu re (n =3). One patient was retrans planted 16 months after TIPSS. Three pat. are alive (F. up 20, 21 and 38 mo.) awaiting fo r retra nsplantatio n for 2; bil iary surgery was uneventfull in one. In three of fiv e cycios porine trea ted pa ti ents, dose had (0 be redu ced drastica ll y due to severe nephrotoxicity.

RESULTS: Complete (>95%) and exte ns ive 05-95%)

CONCLUSiON TIPSS may be extended to liver transplant recipients in case of decompensated recurrent allograft cirrhosis, especia ll y when retransplantation or redo-biliary surgery are sched ul ed; cyclosporinemia must be fo ll owed ca refu lly follOwing TIPSS in orde r to avoid severe sid e effects,

thrombolYSiS was acheived in 11 extremities and pa rtial lysis (50-75%) in the remain ing case, Total It-PA doses ranged from 50 to 200 mg with an average d ose of 104mg. Plasma fibrinogen levels remained over 150 mgldL except in one patient (10%), and no serious bleed ing compli cations occurred. Ventilation perfusion scans indi cated asymptomatic emboli occurred in about one third of patients. CONCLUSiONS: Single da ily intraclot injection of rt-PA appears to be an effecti ve trea tment for acu te DVT

w hen combined w ith standard anticoagu lation. Cos t of rt-PA in this regimen compares favorab ly with urokinase doses reponed in the literature.While no significant bleeding o r e mbolic complicatio ns were encountered, a larger study is needed to define these risks more precisely.

Poster No. 350 CO 2 Guided Arterial Intervention D.O. Kessel, Leeds, United Kingdom - 1. Robertson L. Denton • S. Simpson

Poster No. 349

PURPOSE: To determine the utility of CO 2 angiography

Technique and Outcomes of Single Daily lntraclot Injections of Recombinant Tissue Plasminogen Activator in Treatment of Acute Deep Venous Thrombosis of the Lower Extremity R. Chang, Bethesda, MD • TH. Shawker • CD. Chen • R.O. Cannon, 11i - Dj. Mayo - M.K Horne, III

fo r endovascular p rocedures in patients at risk o f contrast induced nephroxicity.

PURPOSE: To eva lu ate safety and effi cacy of recombi-

nant ti ss ue plas minogen activator (rt-PA) in treatment of acute deep vein thrombosis (DVT) when administered once da ily as an intraclot injection thro ugh pulse sp ray and end ho le catheters. MATERIALS AND METHODS: Ten patients with acu te

deep ve in thrombosis (12 affected legs) were trea ted by d irect intraciOl injection of recombinant tissue plasminogen activator (rt-PA) once a day in th e angiographic suite . Catheterization of ipsilateral femora l or popliteal veins permitted introduction of pu lse spray ca thete rs to treat popliteal, femoml, iliac, and caval

MATERiALS AND METHODS: 26 patients with renal im -

pairment or history o f adverse reaction LO iodine containing contras t underwent a va riety of endovascu lar procedures (tabl e 1) us ing hand injected CO 2 angiography as the primary imag ing modality. All studi es we re performed on a dedicated angiograp hy uni t (Siemens Multistar TOP) with software for minimum opacification image summation. Procedure times, contrast vo lumes and recorded X-ray dosage we re noted.

RESULTS: All the procedures were co mpleted Sll ccessfu lly. Additional angiography with gadolinium or conven tiona l iodinated contrast was performed in 9 patients for comparative p urposes. CO 2 alone would have been su fficient in 22 patients. CO 2 was unsuccessful in a single patient undergoing lumbar artery em bolization, the lumbar arteries cou ld no t be imaged due to

3D5

the buoyancy of the CO 2 and conventi onal contrast was used throughout. Volumes of iodinated contrast were sigruficandy redu ced compared to conventional practice (ta ble 1). Procedural times and x ray dose were comparable with conventio nal angiography. CONCLUSION CO, angiography can be safely used as an ahe rnative to iodinated co ntrast to gUide the majority of endovascula r procedures. Procedure times and radiation doses are not significantly increased . Additi onal conventional contrast is sometimes required but the volume is significantly reduced.

Pro(~dure

Peripheral angioplalty I stenling Renal angioplasty I stenting

Numbu 01 PalienU

Hean Y(llumt (II C(lntrasl I ml (range) Jl (o...t5)

S (G-20 gadolinium)

Aortic stenl grahing

)0 la-laO)

Embolization

25

(O- I ~O)

Poster No. 351 Square Stent Based Large Vessel Occ1uder D. Pavcnik, Portland, OR • B.T Uchida· H.A. Timmermans • K. Yamacado • FS. Keller • j. Rosch, et at PURPOSE: In vitrO and in vivo experimental evaluation of a Square stent based vascu lar occlusion device for large vessels. MATERIAL AND MEmOD5.· Square slent occluders (SSO) were constructed from squa re stainless steel ste nts covered by porcine small intestine submucosa (SIS). SSOs with proximal barbs were delivered thro ugh a guiding cathe ter. The SSOs with proximal and distal barbs were fro nt loaded and delivered coaxially. A pusher with a retention mechanism at its end was used for deployment. In vitro testing for competency of the SSO was done using a flow model with pressure measurement. In a experimental pilot study in 3 swi ne 5 SSOs were placed su bsequently inlo the abdomin al aorta (n=2), common iliac (n""'1) and pulmonary artery (n""'2), Angiography was performed before and after placement of each SSO . Animals were fo llowed at 2 months by angiography, then sacrificed for gross and histologic eval uation.

306

RESULTS: In vitro SSOs with four barbs were easily collapsed and front loaded into guiding catheters (6 F for 5mm occcluder 10 10 F for 40 rnm occluder). A 20·rnm SSO adapted to tubular structu res from 10 to 15 nun in diameter forming a polygon with a range from 18.5 to 17-rrun in length respectively. In the flow model, SSOs endured pressure increases up to 300 rrun Hg. In vivo the SSOs self-expanded and self-adapted to the vessel without migration in aU cases. The locking pusher allowed precise SSO placement and enabled its barbs to engage the vessel wa ll and preventing dislodgement by blood flow. Complete arterial occlusion occurred within

10-20 minutes and arteries remained occluded to the time of sacrifice in all cases. After two months , histolog ic evalu ation revealed SIS replaced by host tissue and remodeled with variable fibrocytes, fibroblasts and some inilammatory cells. Complete endothelialization was seen on both sides of the SSO. CONCLUSION· The SIS large vessel occluder has proved effective and reliable for acute and chronic occlusion in a high flow model and in experimental animals.

Poster No. 352 Endovascuar Stent-Grafts Placement for the Treatment of Aortic Dissection H. Nishimaki, Sagamihara, japan . Z.B. Lin· y. Isobe • H . Imai • K. Sohma • K. Obara, et al PURPOSE: To demonstrate the usefuln ess o f endovascular stent~graft s placement for [he treatment of aortic dissection. MATERIALS AND MEmODS, From April 1996 to AUgu st 1999, 16 patients (15 men, 1 woman) underwent endovascular stent-grafts placement over the entry tear of descending aorta of aortic dissection (Stanford A type 3, B type 13). The entry sites were noticed at proximal descending aorta (average 1Acm distally from orifice of left subclavia n artery) in 9 patienrs and at distal descending aorta in 7.

This procedure was performed on acute phase (average 4.7 days, range 1 - 8) in 3 patients: 2 with o rgan ischemia and 1 with retrograde Stanford A type. The stent-grafts were composed of modified 2-stents covered with woven polyester graft material and delivered through a catheter under fluoroscopic gUidance. RESULTS: Stent-grafts were placed successfully in all patients. Closure of enrry tears was observed immediately after procedure in 14 patients (87.5%). Because the entry site of oilier 2 patients were close to the o rifice of left su bclavian artery «O,5c m), we did TAE for the major perigraft leakage. Complete thrombosis o f the false lumen in thoracic aorta was achieved in 13 patients (81 0/0) and p artial thrombosis in 3. Paraplegia was not develo ped in all patients. CONCLUSIONS: This study suggests that endovascular scent-grafts placement for the treatment of aortic dissection is safe and effective method in selected patients.

Poster No. 353 Application of a New Nitinol Stent in Transjugular Intrahepatic Portosystemic Shunt: Short-Term Results j. Park, Seoul, South Korea. Cj. Yoon • j. W Chung . HE. Kim· HI Ie PURPOSE: To investigate the effectiveness of a new mesh-type nitinol stent in transjugular intrahepa tic porlosystemic shum (TIPS).

METHODS: TIPS procedure was performed in 22 pa-

RESULTS: In vitro at rest the valve was closed with a

tients (M:F=20:2, mean age 52.5 years) with a new nitinol stent, Niti-S (Tae Woong Medical, Korea) lOmm in diameter and 6--8cm long, for massive variceal bleeding (n = 20) or intractable ascites (n = 2). All patients were diagnosed as liver cirrhosis with positive viral markers of hepatitis B or C. Child's classification of the patients was A in 3 patients, B in 4, and C in 15. Nineteen patients were treated emergently. Follow-up evaluation was performed with duplex ultrasound and clinical assessment for 1 to 19 months (mean 6.5months).

pressure of 61 rrun Hg below the valve and 60 mm Hg above the valve. During injection of 100 ml of water the valve opened permitting fluid flow. After injection the valve inunediately closed and the pressure below the valve declined to 11 mm Hg with a range 6--16 mm Hg. Above valve pressure was unchanged. RecovelY time of venous pressure to resting level was 24-32 seconds. The valve remained closed vvith retrograde flow and endured pressures increased to 290 nun Hg. In all animal experiments, good valve function was observed. No pressure gradient was observed through the valves in supine position. A pressure gradient of 12-15 nun Hg developed immediately in an up right position with less pressure below the valves. All veins remained patent at two weeks and smooth incorporation of the SIS valves into the vein wall was observed. Histologic evaluation demonstrated early SIS remodeling with variable fibrocytes, fibroblasts and macrophages

RESULTS: The technical success rate for creation of TIPS was 100% (22/22). The mean portosystemic pressure gradient decreased significantly from 23.8 mmHg to 11 .2 mmHg. Variceal bleeding and/or ascites were controlled in all patients. Neither significant complication during procedure nor death within one month occurred. Encephalopathy developed or aggravated in four patients 08.2%), which was controlled with medical therapy. TIPS dysfunction due to acute thrombus in two weeks occurred in four patients 08.2%). The shunt was recanalized with endovascular approach. Primary and secondary patency rates were 80.6% and 100% at 6 months, 61.1% and 90.0% at 12 months (Kaplan-Meyer method) . During the follow-up period, four patients died of rebleeding (n=1), uremia (n=2), and peritonitis (n=l) respectively. CONCLUSION: A new mesh-type nitinol stent is effec-

tive and safe for TIPS procedure. A further study is mandatory for the evaluation of long-term effectiveness of this stent in TIPS .

Poster No. 354 Percutaneously Introduced Prosthetic Venous Valve, An Experimental Study D. Pavcnik, Ponland, OR • B. T Uchida. H.A . Timmermans • A1. LoriuO.-"C • FS. Kelle,' • j. Rosch PURPOSE: In vitro and in vivo experimental evaluation of a new, homemade, at1ificial, bicuspid, square-stenr venous valve was performed.

.MA7ER1ALS AND METHODS: Bicuspid valves were con-

structed from square stents covered by porcine small intestine submucosa (SIS). In vitro testing of the valves was done using in a flow model for competency with pressure measurement during prograde and retrograde flow. Calf venous pump input (lOOmi) was provided by a side arm to the flow model. In an acute experiment in three dogs valves with four barbs were placed into the IVC through an 8 F gUiding catheter. Function of the valves and their stability was studied in supine and upright position with injections of contrast medium and pressure measurement. For longer term testing, valves were placed into the IVCs and iliac veins of three young swine. Animals were followed at two weeks by venograms, then were sacrificed for gross and histologic evaluation.

CONCLUSION· SIS square valve is a promising one -way competent valve capable of sustaining high venous back pressure, while allowing forn'ard flow with minimal resistance

Poster No. 355 Effectiveness of Embolization in Cases of Hemoptysis Due to Pulmonary Tuberculosis: Comparlson of Chest Radiographic Study and Angiography Y. Kim, Wonju, South Korea. D. Kim. M. Lee •

1. Hong. ]. Park PURPOSE: To compare the effectiveness of emboliza-

tion in cases of hemoptysis due to pulmonary tubercu losis with the severity of lung parenchymal injury and the pattern of pleural infiltration SUBJECTS AND METHODS· The findings on chest radiographic studies and angiography were comparatively analyzed in 206 patients from Mar. 1992 to Dec . 1998. The findings on chest radiography or CT were classified as follows: Type I referes to simple pulmonary tubercu10sis(Thc): Type IT includes pulmonary Tbc complicated by bronchiectasis, or cavitation; Type TIT is either Type I or II accompanied by pleural infiltrates limited to the lung apex; Type IV is defined as Type III plus pleural infiltrated beyond the apex.

.lillgiographic findings were divided into the follOWing groups: Group I consists of abnormalities of only bronchial artery; Group II includes abnormalities in the bronchial artery and either internal mammalY artery or one of the intercostal arteries; Group'TTl is the conditions of Group I or II plus an abnormality of one of the branches of the subclavian artery; Group IV is abnarmlities in at least two branches of the sbubclavian artery or direct visualization of hypervascularity from sbuclavian artery. We studied the initial post-embolization hemostatic effect and the results of follow-up over 6 months.

307

RESULTS: A compa rison of rad iogra phic stud ies and bronchial angiography is seen in the table. We found that as the severity of pleural infi ltra tio n and associa ted compli cation increase, so did the severity of the ma nifesta tion of systemic collatera l a rteries other than bronchial artery increase. The initial success rate were as follows, Type I 96%; Type II 80%,Type III 70% and Type IV 56%. The longte rm effects are 8()O/o in type I, 75% in type II, 59% in Type III an d 48% in Type IV. CONCLUSION: Since the severely incresed circulation in systemic collateral arteries makes in is difficult to expect good hemostatic results after embolization in cases with extensive p leura l infiJtration as seen chest radiography and incases with assoc iated comp li cations o f pulmonary The, We recommend aggressive treatment after embolizatio n in such instances.

1!1' I ln=49)

IIln=45)

4n

14

In

II

15

II

15

Grade I

III

IlIln=4n)

13

IVln=12)

18 38

W

Poste r No. 356

The Use of Power Injection With Radiographlc Contrast Media Into Peripherally Inserted Central Catheters (PICC Lines)

c.E. Herzig, Los Angeles, CA • D.S. Harrell •

Ii. Di Fiori

• M J. Dawson

PURPOSE: Man y patients are now receiving PICC lines for primary veno us access. Higher flow rates are needed for faster cr scan protocols. The question often arises as to the maximum flow Idte at whic h you can safely inject a PICC line. This study was undertaken to determine the endurance PICC lines when power injected with iodinated contrast med ia. MATERlAI.S AND MI:.7HODS· Five commonJ y used brands

(Cook, Bard, Med i-tech , Braun , and Medcomp) of single lumen and double lu men PICC lines were power injected using a slandard Medrad Ma rk V injector simulating a cr scan injection. Contrast (Omnipaque 300) wac; injected at a flow rate 1 cc/sec and increased by 0.2 cdsec increments until catheter rupture. Actual flow rates and pressures (psi) were recorded after each injection. RESULTS; There was grea t variation in flow rates and pressures tolerated in different types of cathete rs, depending on the cath eter design and constmction. The PICC lines tolerated powe r injections qu ite well with all lines handling injections up to 2 cc/sec and 130 psi, wi th an average bursting flow rate between 2.3 - 3.0 cc/sec and 140 - 180 psi. The site of catheter ru pture was exdusively located at the most proximal portion of the catheter, immediately dislal to the external "hub". CONCLUSION The tested brands will tolerate power

308

injection of rad iographic contrast medi a at flow rates

accep table fo r IV cont rast en hanced CT. Factors believed to intlue nce flow rates include: the inner and outer diameter, tip des ign (end-hole or "groshong" tip) , Si ngle lumen or double lumen, and ma terials used (silicone or po lyu rethane). In the advent of cathete r rupture, the site of rupture was dete rmined to be the portion of the catheter ou t side of the patient and thus woul d not cause unnecessary trau ma to the patient. Perhaps fu ture designs of PIce lines could be manu factured so that the external "h ub" is the flow rate-limiti ng portion of the ca theter and thus prevent ruptu re of the catheter d uring power injection.

Poste r No. 357 MRI of Uterlne Fibroids After Uterlne Artery EmbolJzation T Katsumori, Shiga, Japan . K. Nakajima · M. Tokuhiro PURPOSE: To assess the therapeutic results of uterine artery embol ization (UAE) fo r symptomatic fibro ids on MRI w ith contrast administration (Gd-DTPA). MATERiALS AND MEmODS· Seventeen patients (age

range 37-52 yea rs, mean 44.7 years) w ith symptomatic fib ro ids unde rwent UAE w ith ge latin sponge particles of about 500-1000 ~m in d iameter. Dominant ribro ids were located in the submucosal area in 8 patients, in the intra -mu ral area in 7, and in the su bseroasa l area in 2. The n umber of fi broids ranged from 1 to 20 (mean 5.5) per patient, and the total number was 93 in all patients. The size of dominant fi b ro ids ranged from 2 to 14cm (mean 7.2cm). Plain and enh anced MRls were obtained befo re UAE and 1 week, 4 mo nths, and 1 year after UAE. RESULTS: In all patie nts, UAE was successfully pe rformed and no severe complications related to the procedu re occurred. Enhanced MRI obtained 1 week afte r UAE revealed that in the dominant fibro ids 1000h infarction rates in 14 pa tients and 70-90%1 infarction rates in the re main ing 3 we re achieved, wh ile the myometriu m was well enhanced in all patients. The same enhanced MRI revealed that of 93 fi broids, ] 00% infarction rates in 88 fibroids (95%) we re ac hieved. Enhanced MRI obtai ned 4 months after UAE revealed that the non-enhanced area in the dominant fibroid was markedly decreased in size, but the res id ual e nhanced area was increased in size in 3 patients, although all dominant fi bro ids were decreased in size in all patients, compared to MRI 1 week after UAE. Enhanced MRI obtained 4 months and 1 year after UAE revealed that the larger the non-en hanced area of the emboli zed fibroid was, the be tter the tu mor reduction was. The average tu mo r reduction rates were 57% at 4 months and 70"10 at 1 yea r aiter UAE. CONCLUSION MRI with contrast administration is a useful diagnostiC method because it ca n asse-,Ss the therapeu tic results of uterine fibro ids treated by UAE, including the nature of uterine fibroids as well as tu mor reduction.

Poster No. 358

Canalization of Completely Obstructed Veins in Budd-Chiari Syndrome With Squeezing Technique Y Chen, Cuangzhou, China. YH. Ii • Q.L. Zeng PURPOSE: To evaluate the effe<.:t5 and safety of endoluminal canalization for complete obstl1lcrion of hepatic

vein and inferior vena cava (lYe) in Budd-Chiari syndrome(BCS) with squeezing techenique. MATERIALS AND METHODS. There were 21 patients with Bes 03 male and 8 female, ]8-56 years,mean age 33 years). The complete obstruction were 10cared within hepatic veins (0=4), IVC (n=11), both of them (n=6). The catheters were inserted from femoral vein (0=14), jugular vein (n",,4), hepatic vein (n=9) to the obstructive position. Then the slide

guidewire or stiff guidewire was used to squeeze through the potential tracks or residual hole of obstructive segment monitoring under biplane fluoroscopy without puncture technique. After the catheter and guidewire were demonstrated to have passed through the occlusion to the other Side: PTA and stent implanting were performed. Echo Doppler was used as follow-up examination during the 4- to 36-months period after treatment. RESlRTS: ~'e successfully canalized all membranous (n::::]9) and segmental (n==8) venous obstruction, without procedure-related complications. Mental stents were implanted in hepatiC vein in 2 cases. Clinical and hemodynamic improvement occurred immediately after successful procedures. The average venous pressures decreased from 3.0 to 1.2KPa to 1.3 to O.4KPa and inner diameter of vein increased to I1jA,3.8mm. All patients were free of clinical sympLOms and signs after one month. None of symptoms and injury of liver function recurred in 21 cases during the follow-up period. CONCLUSION: It is believed that the potential tracks or residual hole exist in so-called completely obstructed hepatic vein or IVC in BCS. So the squeezing technique is effective and safe for these patients.

Poster No. 359 Use of the SF-12 Health Survey for General Health Status Assessment After Uterine Fibroid Embolization: Preliminary Findings I Kim, Washington, DC • lB. Spies. j. G. Zorn • A.R. Roth. SM. Walsh PURPOSE: To evaluate the effectiveness of the SF-]2

Health Survey in measuring and interpreting health status and outcomes after uterine fibroid embolization (UFE). MATERIALS AND METHODS: Patients were given the self-administered SF-12 Health Survey (Standard) prior to UFE and 3 months post-UFE. SF-12 uses lwO scales, a physical component summary scale (PCS) and a mental component summary scale (MCS), to provide a generic measure of a patient'S health status. Both PCS and MCS are scored using norm-based methods; a score of 50 is considered to be the mean (SD 10) in the general U.S. population. Therefore, a score greater than (or less than) 50 would indicate a person 's general health status to be better (or worse) than the general population. Changes in PCS and MCS scores between pre-UFE and 3-month post-UFE surveys were analyzed for statistical significance using a paired t-test.

RESlIL7S: Fifteen patients completed the SF-12 Health Survey both prior to UFE and at 3-month post-UFE. Mean PCS scores for pre-UFE and 3-month post-UFE surveys were 47 and 52.4, respectively. PCS scores, on average, increased by 5.38 (SD 7.35; median 3.94; range -5.37 to 24.3) after 3 months pOSl-UFE (p<0.05). Mean MCS scores for pre-UFE and 3-month post-UFE surveys were 43.2 and 52.2, respectively. MCS scores, on average, increased by 8.99 (SD 9.78; median 8.06. range -4.48 to 31.4) after 3 months pOSl-UFE (p
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