Demonstration (Teaching) Poster

Demonstration (Teaching) Poster *

Demonstration Poster No. 370

CT-Guided Percutaneous Ethanol Induced Ablation,Open Surgery and Video-Laparoscopy in the Treatmentof SR-Adenomas.p Almeida, Dep.ofRadiology University Hospital Coimbra,Coimbra, Portugal • M. Pego • F C. Sousa • Fi. Oliveira •LA. Providencia • M. Ferreira

PURPOSE: Comparison of a group of 54 patients with HBPtreated by CT-guided percutaneous ethanol injection (PEl)started 1998, with two other groups, one of 50 patients treatedby open-surgery (OS) and a third of 37 patients treated byvideo-Iaparoscopy (VL), aU due to primaryhyperaldosteronism caused by functioning adrenal adenomasand certified by positive lab values.

MATERIALS AND METHODS: We describe the techniqueused for the CT-guided ethanol injection. The gender and theage distribution of the predominantly Caucasian patients weresimilar in the three groups.We analyzed and compared clinicalimprovement including HBP, lab values of plasmatic reninactivation (PRA) and of plasmatic concentration of aldosterone(PCA), reduction of drug intake and correlated age and time ofHBP diagnosis with the results achieved in each one of thetherapeutical methods.Complications and hospital stay aswell as costs were also compared.

TEACHING POINTS: Results were calculated using clinicalcontroi of lab values and HBP six months after the therapeuticprocedures (OS, VS, and PEI).In the group treated by PEl weachieved normal BP in 33 patients (61.1 %). In the remainingpatients we reduced the diary intake of anti-hypertensivedrugs in 16 and in 5 we didn't get any results.This means thatwe could obtain by this method good clinical results in anoverall of 49 of the 54 patients In the group treated by opensurgery (OS) we achieved cure in 32 patients (64%) and in thegroup treated by video-Iaparoscopy 23 patients (62%) areconsidered cured.The mean hospital stay for OS was 7 daysand for VL 4 days.Patients submitted to PEl can be releasedthe day after the procedure; this represents two days ofhospital stay. We kept initially for investigative purposespart of these patients 4 days in the hospital.

CONCLUSION: a) The therapeutic results between thesethree methods are not statistically significant and we mayconsider that cure was achieved in about 60% of the patientsof all groups.b) CT-guided ethanol injection might be a new,useful and simple method oftreatment for functioning adrenaladenomas; it is easy to accomplish, less invasive, reducessignificantly the costs and improves the life quality of thepatients.


The Non-Invasive Diagnosis of Traumatic Vasospasm.D.B. Wilhite, Tempie University, Philadelphia, PA, USA. PKelly • S. Kagan

PURPOSE: Color duplex ultrasonography (CDU) is aneffective tool in the evaluation of patients with penetratingextremity trauma. When used in conjunction with ankle brachialindices, CDU can replace angiography. CDU can accuratelydiagnose arterial and venous disruption, pseudoaneurysm,arteria l intimal injury and arteriovenous fistulae with asensitivity of 50 to 100% and a specificity of 97 % to 99 %.

Vasospasm is commonly seen in penetrating extremity trauma,and it is important to distinguish it from those injuries requiringintervention. A review of the literature yielded only 9 casesdescribing the utility of CDU in trauma-induced vasospasm.We report a case of traumatic large vessel vasospasmaccurately diagnosed by CDU.

MATERIALS AND METHODS: An 18 year old malepresented to the emergency room with a gunshot wound tothe left thigh. He was hemodynamically stable without anyclassic features of vascular injury; there were no neurologicdeficits and no orthopaedic injuries. The ankle brachial indexwas 0.3 on the affected limb and 0.7 in the contralaterallimb.A smali, nonexpanding hematoma was present at the site ofentry.CDU was performed by an experienced registeredvascular technologist and the B-mode images demonstrated amild stenosis of the superficial femoral artery. The peaksystolic velocity was 291 cm/sec and was also found to be250% higher at the area of narrowing compared to the normalappearing adjacent segments of the same vessel. A diagnosticarteriograrn confirmed these fmdings and excluded the presenceof an arterial injury. The ankle brachial indices returned tonormai within six (6) hours of injury and the patient wasdischarged the following day.

TEACHING POINTS: Trauma-induced vasospasm is rarelydescribed in the surgicalliterature. We report a case of arterialvasospasm caused by penetrating lower exu'emity traumaand accurately diagnosed by CDU. B-mode imaging effectivelydelineated the vessel anatomy, and flow velocity measurementsdemonstrated the compensatory physiologic changes in theaffected vessel. Trauma-induced vasospasm can be accuratelydiagnosed with non-invasive vascular imaging techniques.


Covered Metallic Stent Placement in the Treatment ofGastric OutłetObstruction and Postoperative Strictures.Y.-M. Han, Chonbuk National University Hospital, Chonju,Chonbuk, South Korea. K.Y. lin. GB. Chung • D.H.Yang

PURPOSE: To evaluate the effectiveness and long-term resultsof covered metallic stent placement in providing palliativecare for patients with inoperable malignant gastric outletobstruction and postoperative anastomotic malignantstrictures.

MATERlALS AND METHODS: Under fluoroscopic guidance,placement of self-expandable, covered stents was attemptedin 43 patients with inoperable or recurrent gastric cancer since2000, January. 28 with gastric outlet obstrllction were 18male and 10 female, age ranged from 47 to 87 years (mean: 66years). 15 with postoperative gastric anastomotic malignantstricture were 13 male and 2 female, age ranged from 39 to 82years (mean: 60 years). Ali patients had intolerance to oralalimentation and/or vorniting after ingestion. Success wasdefined both technically and clinically.

TEACHING POINTS: The placement of the stent wastechnically successful in all patients (100%). One patient'sstent was removed immediately after stent placement whichwas located in the stornach too much and another stent wasinserted successfully. After stent placement, 40 patients wereable to ingest at least liquids and had a markedly decreasedincidence of vomiting(clinical cussess: 93%). The follow-upduration in the 28 with gastric outlet obstrllction was I to 41weeks (mean: 13.6 weeks) which 21 patients died (1-28: 11.5weeks) and 7 patients lived (4-41: 19.9 weeks). The follow-

*new for 2003 meeting. Demonstration posters are intended to illustrate a theory Ol' educate the observer through illustrative caseexamples Ol' a compilation of the existing literature. SI27

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up duration in 15 with postoperative anastomotic malignantstricture was from 2 to 23 (mean: 11.1 weeks). The majorcomplication showed stent migration which was bowelobstruction in one patient and bawel perforation in one patient.

CONCLUSION: The covered metallic stent placementappears to be effective and valuable in the treatment of gastricoutlet obstruction and postoperative anastomotic malignantstrictures. The bowel obstruction and perforation must benotified to delayed complication after stent placement.


Pathologic Sequence or Embolie Materials on RabbitRenal Artery: PVA Versus Chitin/Chitosan Materials asa New Embollic Materials.B.K. Kwak, Chung-Ang University Hospital, Seoul, Korea.H.J. Shim • s.M. Han

PURPOSE: To evaluate the pathologic sequence ofPVA andchitin/chitosan materials on rabbit renal artery.

MATERIALS AND METHODS: Forty eight New Zealandwhite rabbits were classified into six groups. Polyvinyl alcohol(PVA) particles (150-250 mm) were used in group 1 (controIgroup), Chitin particles (150-250 mm) in group 2, Chitosanparticles (150-250 mm) in group 3, CJlitosan microspheres ingroup 4 (150-250 mm), group 5 (250-355 mm), group 6 (355500 mm), respectively. Rabbit right renal arteriography wasperformed using 4 F cobra catheter. Embolization wascontinued unril complete occlusion of the artery was achieved.Successful embolizations were achieved in all forty eightrabbi ts. One animaI was sacrified in each group on the 1st and3rd day, 1st, 2nd, 4th, 8th, 24th and 32nd weeks. Basichematologic and blood chelllistry were analysed and grossand microscopic pathologic findings were observed.

TEACHING POINTS: On gross pathologic examination, renalcontraction and discoloration were silllilar between chitinouscmaterials and PVA. Histologically chitosan microspheresgroups had a higher incidence of vasculitis, but a lower incidenceof recanalization and subintimal proliferation in comparisonwith PVA. Resorption was seen in PVA slowly after 8 weeks,and in chitosan lllicrospheres with a silllilar process in renalhilar arteries. Hematologic and blood chemistry showed nosignificant abnormal changes in each group.

CONCLUSION: Both PVA and chitin/chitosan embolicmaterials showed good embolization effect, but lessrecanalization in chitin/chitosan microsphere.


A Percutaneous-Endoscopic Biliogastric Anastomosis rorBiliary Obstruction. Case Report.BJ Lander, Centro Medico de Caracas. Unidad deHemodinamia, Caracas, Venezuela • M.I. Millan • R.Monserat • e. Gumina • A. Sanchez • J. Valeri, et al.

PURPOSE: We described a percutaneous endoscopictechnique to drain a biliary obstruction creating an anastomosisbetween the bile duct from segment II of the liver and thelesser curvature of the stornach.

MATERIALS AND METHODS: A 70-year-old man who hadundergone a laparoscopic cholecystectomy 5 monthpreviously, experienced recurrent cholangitis. Diagnosticcholangiography demonstrated complete obstruction of thecommon bile duct near the surgical clips.The surgical procedurewas contraindicated (A.S.A IV) and it was not possible tocross the obstruction either endoscopically or percutaneously.

After transhepatic catheterization of a segment n bile duct,the left lobe of the liver was perforated under fluoroscopicguidance with a 0.035-inch metallic guide wire until it madecontact with the lesser curvature of the stornach.Endoscopically the gastric wall was perforated with anesphinterotome in the point where the guidewire made theindentation. Anastomosis between the biliary tree and thestornach was maintained with a Wallstent graft 10 mm x 70mm.

TEACHING POINTS: The patient is alive at 6 month withoutjaundice or cholangitis.There was no demonstration of anydilatation of the biliary tree by an endoscopic cholangiographycontrol made through the stent at this time.

CONCLUSION: The percutaneous-endoscopic biliogastricanastomosis is an alternative method for tbe drainage of abiliary obstruction in patients where the surgical procedure iscontraindicated and interventional methods failed. Furtherinvestigation is required to evaluate long-term patency.


Error or Measurement in Digital Angiography.F.e. Lynch, The Penn State Milton S. Hershey MedicalCenter, Hershey, PA, USA

PURPOSE: Error of measurement is introduced in digitalangiography from a variety of sources including image I pixellllisalignment, magnification, penumbra, unsharpness and imagenoise. How these factors impact on object edge representation(and therefore on the accuracy of measuring an object) arediscussed in detail including pictorial explanations. Clinicallyrelavent examples of error in stenosis and size measurementaregiven.

MATERIALS AND METHODS: Error of measurementcalculations are performed using paramenters typical forcurrent digital angiography imaging equipmenŁ. Clinicallyrelavent examples including carotid stenosis measurement andsize measurement of arenal artery and iliac artery are given.

TEACHING POINTS: There is significant error ofmeasurement inherent to current digital angiographytechnology. The inherent error of measurement is significantenough that measuring with highly accurate devices (such ascalipers) makes linIe practical sense. The error of measurementcan be significantly reduced by imaging the target object andany calibration object with:• the smallest field of view (greatest magnification) that is

practical.• the objects in the same piane• the objects in the center of the field of view• the largest calibration object that is practical.• the imaging parameters with the best signal to noise.


Potential Fitfalls in Angiographic Diagnosis orHepatocellular Carcinoma: Review or 10-YearExperiences in 4,000 Patients.J. W Chung, Seoul National University Hospital, Seoul,Seoul, Korea. e.J. Yoon • rI. Kim. J.H. Park

PURPOSE: To elucidate potential fitfalls in angiographicdiagnosis of hepatocellular carcinoma

MATERIALS AND METHODS: During the past ten years,we have performed conventional catheter angiography forhepatocellular carcinoma in more than 4,000 patients andprospectively collected cases showing fitfalls in angiographicdiagnosis of hepatocellular carcinoma.

TEACHfNG POlNTS: The content of pitfalls were as follows:nontumorous arterio-portal shunt, difficult recognition ofhepatic artery variations, hidden foci under the gastric andspienic stain, failed segmentallocalization of tumors, total orpartial extrahepatic collateral supply at initial presentation orduring repeated chemoembolization, arterial hyperperfusiondue to portalor hepatic vein obstruction, hemodynamicchanges after TlPS, nonvisualization of tumor vascularitydue to collateral circulation or reversed f10w in celiac axisstenosis, insufficient amount of contrast media forangiography, forceful injection through the wedged catheter,overlapping lesions, accessory gastric arteries and gastricfundus stain, systemic hypervascularization of the lung viaright inferior phrenic artery, and direct communication betweenhepatic arteries and right inferior phrenic artery.

CONCLUSION: There are many different kinds of potentialpitfalls in angiographic diagnosis ofhepatocellular carcinoma.Recognition of these pitfalls may lead to its safe and effectivechemoembolization.


Establishing a Yttrium-90 Hepatic Embolization Programin a Private Practice Hospital; Lessons Learned.C. W Nut/ing, Good Samaritan Regional Medical Center,Phoenix, AZ, USA • B.F. Jones

PURPOSE: To describe the essential elements for theestablishment of a radioembolization program in a communityhospital.

MATERlALS AND METHODS: A review of the 70 yttrium90 embolization treatruents performed in a communityhospital over the last 18 months. This protocol was approvedby the local Institutional Review Board.

TEACHlNG POlNTS: 48 patients were treated. Eighteenpatients had prirnary hepatocellular and 30 patients metastaticliver cancer. There were 32/16 males/females and the mean agewas 55 (range 25-77). The common elements for establishmentof this service included the rapport with the referringphysicians, a website since 25 % were self-referred, approvalby the Radiation Safety Committee, application to the NuclearRegulatory Commission for the addition ofyttrium-90 to thenuclear materials license, involvement of radiation oncologyand nuclear medicine departments, calculation of theappropriate dose, and safeguards utilized to insure the correctdose was applied to the patient. Management of the patientswhile they were adrnitted was performed by the InterventionalRadiology service.

CONCLUSlON: Establishing a radioembolization program ina community hospital is feasible and rewarding. A teamapproach is necessary including nuclear mecicine, radiationoocology, medical oncology and interventional radiology. Aphysician extender is imperative to the success ofthis program.


The Evolution of Percutaneous Interventions forKlatskin Thmors.M.A. Madayag, Illinois Masonic Medical Center, Chicago,lL, USA • s.A. Gueyikian

PURPOSE: Perihilar cholangiocarcinomas involving thebifurcation of the hepatic ducts are known as KJatskin tumor(Bismuth c1ass II, III, IV). Percutaneous TranshepaticCholangiogram (PTC) is proven to be a both a diagnostic andtherapeutic toGI in cases of Klatskin tu mors. The evolution intreatment of KJatskin tumor has progressed with advances in

technology. We sought to provide a brief overview of thechanges in treatment of this uncommon tumor.

MATERJALS AND METHODS: A review of Iiterature and areview of 21 cases Klatskin tumor treated over a 22 yearexperience of a single interventional Radiologist at a singleinstitution was performed. The evolution of intervention isdiscussed and demonstrated with each new technologyapplied.

TEA CHlNG POlNTS: The evolution from drainage cathetersto plastic stents and finally to mesh stents is demonstrated inpictorial form.

CONCLUSION: Changes in treatment of Klatskin tumors byminimally invasive means have come about to reducecomplications and improve both survival and quality of life.


"Hidden" Hepatic Artery Pseudoaneurysms: AvoidingFalse Negative Imaging Studies.c.M. McClain m, Vanderbilt University Medical Center,Nashvilie. TN. USA. S. G. Meranze • PR. Bream. Jr. • C.Carr • M.J. Mazer. C. W Pinson

PURPOSE: While suspected on clinical findings, the diagnosisof an hepatic artery pseudoaneurysm (HAP) is usuallyconfmned by imaging studies. We preseot an illustrative casewhere a surgical drain obscured an HAP, and led to falsenegative CT and angiography.

MATERlALS AND METHODS: NH is a 65yr old female awho underwent partial hepatectomy for treatment ofa sarcomainvolving the liver and inferior vena cava. 15 days post-op,she was admitted with increasing Jachon-Pratt (J-P) drainoutput, which was bloody in nature. A CT demonstratedintra-peritoneal hemorrhage and an arteriogram was performedto evaluate the cause. No extravasation or HAP was identified.She was re-explored and the hematoma was evacuated withno bleeding site identified. The J-P was removed and newdraills were placed. Because ofcontinued hemorrhage, a repeatCT was performed. This suggested an HAP arising from aright hepatic artery branch. It was noted that it was adjacentto the original J-P drain insertion path. Arteriography wasperformed, demonstrating an HAP arising from a right hepaticartery branch. This was embolized using microcathetertechniques and rnicro-coils, effectively occluding the HAP.

CONCLUSlON: HAP is a known complication of malignancyand penetrating injuries, either traumatic or iatrogenic. Whilethe diagnosis is suggested clinically, it is often confirmed byimaging such as ultrasound, arteriography or contrast enhancedCT. If due to iatrogenic injury such as biliary drainage, theimaging can be falsely interpreted as negative if the drainobscures or tamponades the pseudoaneursysm. This limitationcan be overcome by obtaining the arteriograrn with the catheterin place and then repeating the arteriogram with it removed. Inthis particular patient, a surgically placed J-P drain obscuredthe pseudoaneurysm, leading to a falsely negative arteriogram.Once the J-P was removed, the aneurysm became apparentand was successfully treated with endovascular techniques.

This case demonstrates the need to consider temporarilyremoving any adjacent drains or catheters in the region of aclinically suggested arterial injury in the presence ofnegativeimaging studies.

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Analysis oC Utilization Rates oC Interventional Servicesin a Hemodialysis Population.H.-c. Yoon, Kaiser Foundation Hospital, Honolulu, HI,USA - P Abcarian - l. T Watabe

PURPOSE: To evaluate the annua! utilization rates of IR andvascular surgery services and their pattems by a hemodialysispopulation in a single non-profit HMO.

MATERIALS AND METHODS: As part of an ongoing qualityassurance program for hemodialysis patients of a single HMO,all vascular access procedures are recorded by a centraldatabank. We reviewed these data for a 12 month period from7/1/01 to 6/30/02. Because vascular surgery and IR performall of the vascular access procedures within this HMO andthere is some overlap of procedures done by each group, weanalyzed the data for both groups.

TEACHING POINTS: The HMO serves approximately229,000 members. There were 231 hemodialysis patients whorequired at least one vascular access procedure during the 12month period: 84 patients underwent 1procedure; 65 patientsunderwent 2 procedures; 31 patients underwent 3 procedures;and 51 patient underwent 4 or more procedures. These last 51patients (22.1 %) underwent 299 of the 606 total procedures(49.3%). There were 254 procedures related to dialysiscatheters including 148 placement of tunnelled catheters,almost all of which were placed by IR. Among 204 lRprocedures related to dialysis access grafts and fistulae, therewere 23 fistulagrams and 7 venograms performed withoutany intervention; 69 cases of pharmacomechanicalthrombolysis almost always in combination with PTA; 103cases of graft or fistula PTA; and 2 cases of venous stenting.Among 161 surgical procedures, there were 3 grafts whichrequired excision, 8 revisions of AV fistulae, 12 revisions ofAV grafts, 5 AV graft thrombectomies, 1 AV graft PTAs, and132 new grafts or fistulae. Of the new grafts and fistulae, 59were AV fistulae and 73 were AV grafts.

CONCLUSION: Hemodialysis access-related proceduresimpose a large burden on IR and vascular surgery. However, itis a smali proportion of these patients who require most ofthe procedures. Further research is necessary into the factorscommon to this high-usage group of patients.


Cerebral Venous Thrombosis: Therapeutic Options.KD. Yalavarthi, University ofKansas Medical Center,Kansas City, KS, USA - MA. Brecheisen - PK Mygdal PL. lohnson - D.A. Eckard - TG. Raveill

PURPOSE: To detail the best approaches to managing cerebralvenous thrombosis.

MATERIALS AND METHODS: Deciding between directinterventional thrombolysis versus medical management canbe difficult. The pros and cons of each pathway and thespecific c1inical situations of when to use one method over theother will be discussed. The proper setup and technique forcatheter-directed thrombolysis of the cerebra! veins will bedetailed step-by-step. We will use multiple direct catheterthrombolysis cases from the University of Kansas MedicalCenter Neurointerventional Department, and current studiesand literature on cerebral venous thrombosis to arrive at theconclusions.


Splenic Embolization: Review oC Indications andTechniques.Ml. Kirsch, William Beaumont Hospital, Royal Oak, MI,USA - M Salari - Wl. Romano - R. Salem - S.K Wang M.A. Savin

PURPOSE: The immunologic function of the spleen has ledto concems regarding splenic embolization. Despite this, avariety of embolization procedures have been performed inthe splenic vascular territory. The purpose of this poster is toreview the spectrum of vascular embolotherapy involving thespleen.

MATERIALS AND METHODS: The exhibit will reviewembolization procedures involving the splenic vasculature andsplenic parenchyma. The vascular anatomy pertinent tosplenic interventions will be reviewed. Indications,contraindications, patient preparation, embolic agents andtechniques for treatment of hypersplenism, splenic arteryaneurysms, splenic trauma and portal hypertension relatedinterventions will be described.

TEACHING POINTS: A variety of embolization proceduresinvolving the splenic vascular territory can be carried outsafely and effectively with careful attention to indications,patient preparation and embolization technique.


Percutaneous Cholecystostomy in Children.Ml. TempIe, Hospitalfor Sick Children, Toronto, ON,Canada -P John -PG. Chait -EL Connolly -l.G.Amaral - 1.T Gerstle, et al.

PURPOSE: To describe experience with cholecystostomy inchildren.

MATERIALS AND METHODS: 6 percutaneouscholecystostomies were performed in 4 patients (3M, 1F; 917 y.o.; 13-51 kg). Inclications were acalculous cholecystitisin 5 and nonresponsive caJcu1us cho1ecystitis in l. 3 patientswere from lCU. Underlying conditions were AML (n=2),bone marrow transplant (n=1); ulcerative colitis with hepaticfibrosis (n= 1). 8 Fr. APD or Dawson Mueller drains wereplaced in all patients.

TEACHING POINTS: Ali procedures were successful.lnsertions were transhepatic (n=4) or transfunda! (n=2). Therewere no major complications. Microbiology results wereavailable on 3 patients. Enterbacter clocae (n=2) and E. coli(n=l) were found. All patients responded within 24 hours.The tubes were removed after 6 weeks in 5/6 cases. Deathoccurred in 2 patients. Deaths were unrelated tocholecystostomy. Causes of death were portal vein and hepaticartery thrombosis post right lobectomy (n=l) and massivevaricea! bleeding (n=I).

CONCLUSION: Percutaneous cholecystostomy can be safelyperformed in children. Gram negative cholecystitis was fouodin 3/3 patients cultured. High mortality rate (2/4 patients)reflects co-morbidity of patient population.


Percutaneous Treatment in Soft Tissue Hydatid Cysts.B. Gumus, Haeettepe University, Department ojRadiology,Ankara, Turkey • D. Akinei • O. Akhan • M. N. Ozmen • M.Koroglu • E. Erdogan

PURPOSE: The aim of this study is to demonstrate fourpatients with muscular echinococcosis and to evaluate theresults of percutaneous treatment in muscular hydatid disease.

MATERIALS AND METHODS: A 23-year-old woman(Patient l) with a type II hydatid cyst (45x39x23 mm) in theleft glureal region, a 12-year-old boy (Patient 2) with a type IIhydatid cyst (29x25x20 mm) in his left thigh, a 60 year-oldwoman (Patient 3) with 3 hydatid cysts, 2 type m and 1 typeI (1200,120 and 60 cc) in hel' left thigh and a 45 year-oldwoman (Patient 4) with a type m hydatid cyst (42x51x97mm) in hel' left thigh were catheterized with fluoroscopic andsonographic guidance. The total volume of cystic fluid wasaspirated and the cavity was irrigated with hypertonic saline.The catheter was kept in place for gravity drainage in threecases and the catheter was immediately withdrawn in patient1 after no contrast material dissemination was detected. Thecavity was also sclerosed with 95 % absolute alcohol in patient1 and 4. The catheter was kept in place for 6 days in patient2, lO days in patient 4. Patient 3 was catheterized for eachcysts and duration of drainage was 54, 12, I days respectively.The preprocedure work-up included sonographic, CT andMRI examinations. The foJJow up examinations includedsonographic and MRI examinations.

TEACHING POINTS: No residual cyst was detected inpatient 1 at one-year contro!. Two connected cysticcompartment 15x14x9 mm and 13x13x8 mm in diameter weredetected in third month control in patient 2. Two of the threecysts completely disappeared in patient 3 and 5% of theinitial volume in the largest cyst was detected at the sixthmonth contro!. A 33x27xl7 mm granulation tissue wasdetected at the first month controi of patient 4 .

CONCLUSION: Although surgery is stiJJ the conventionaltreatment modaJity in muscular echioococcosis, the necessityof wide surgical margins and general anesthesia are the majordisadvantages of this modality.The percutaneous approach isa new and effective treatment modaJity for muscular hydatiddisease. By the aid of furthel' studies , perhaps to take thisrnodality into consideration as a choice ot treatment will changethe c1inical course and approach in selected cases.


Percutaneous Drainage or Tuberculous andNontuberculous Retroperitoneal Abscess: Long TermFolJow-Up Results.D. Akinci, Haeettepe University, Radiology Department,Ankara, Sihhiye, Turkey • o. Kerimoglu • M.N. Ozmen •O. Akhan

PURPOSE: To evaluate the success and feasibility ofpercutaneous drainage of tuberculous and non-tuberculousretroperitoneal abscesses in long term foJJow-up.

MATERIALS AND METHODS: A retrospective analysis ofpercutaneous drainage of 63 retroperitonea1 abscesses including12 tuberculous psoas abscesses, was performed in 59 patients(38 men, 21 women, mean age:26 years) in whom at least oneyear foUow-up data were available. 61 retroperitonealabscesses; 6 in renal parenchym, 12 in pararenal area, 8 innephrectomy space and 37 in iliopsoas muscle were drainedby catheterization and 2 abscesses were drained by simpleaspiration only. In addition to catheterization all patients

underwent systemic antibiotic treatment according to theircultured microorganism.

TEACHING POINTS: The overall cure rate of percutaneousdrainage of retroperitoneal abscess was 89% (56/63). Therecurrence rate was 7% (5/63), 3 of which were cured byrecatheterization and 2 by surgical drainage. Catheterizationtime was between 2 days and 2 months (mean:14.3 day).Neither major complications nor mortality related to techniquewere observed.

CONCLUSION: Percutaneous drainage of both tuberculousand nontuberculous retroperitoneal abscess provides effectiveand permanent treatment mostly in aU cases.


Radioembolization or Hepatic Tumors: Comparison ory -90 Agents.D.M. Coldwell, Fox Chase Caneer Center, Philadelphia, PA,USA

PURPOSE: To evaluate the safety and methods used toradioemboJize primary and metastatic tumors through thecomparison of the ftrst patients on whom the two radioembolicagents were utilized.

MATERIALS AND METHODS: A review of the first twelvepatients who had the treatment of hepatic tumors withyttrium-90 containing ceramic based spheres which wereembolized in the hepatic arteries was compared with the firsttwelve patients on whom were utilized the resin based Y-90spheres. The procedurai complications, misadministrations,and results of the two cohorts of patients was compared.

TEA CHING PO INTS: The demographics of each group weresimilar: the mean age was 62 (for TheraSpheres) and 63 (forSirSpheres). Each group had 7 men and 5 women. The tumortypes treated were 3 HCC and 9 CRC mets for TS and 4 HCCand 8 CRC mets for SS. There was a single misadministrationfor TS and none for SS. The follow-up CT scans demonstrateda propensity for the treatment of the posterior lobes for TSand more well distributed treatment for SS. The postprocedural toxicity was virtually nil for TS but the typicalpost-embolization syndrorne of nausea, vomiting, pain, andfever was seen in aJJ SS patients. Both groups had significantlethargy develop within 7-10 days following the treatment.

CONCLUSION: The long term outcome of radioembolizationfor hepatic tumors has not yet been determined. Lengtheningof survival has not yet been demonstrated but there is promiseutilizing this method. Both agents available are effective buteach has its drawbacks and advantages. Furthel' study ofoutcomes will deterrnine the efficacy of this type oftreatment.


The Role or MRA and CTA in Vascular Anomalies.O. Konez, The Cleveland Clinie Foundation, Cleveland,OH, USA. P Burrows • S. Contraetor

PURPOSE: To demonstrate the role of Magnetic ResonanceAngiography (MRA) and Computed TomographicAngiography (CTA) in the pre- and post-procedural evaluationofVascular Anomalies.

MATERIALS AND METHODS: Various vascular anomalieswere evaluated with either MRA Ol' CTA in addition to standardcross-sectional imaging (MRl Ol' CT) for the initial diagnosisOl' follow-up to treatment in patients who were referred toour Vascular Anomalies CJinic. The MRA consisted ofmultiphasic post-Gadolinium scanning and the time-of-flight S131

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(TOF) technique using a 1.5 Tesla MR scanner (MagnetomSymphony, Siemens), while the CTA consisted of themultiphasic post-contrast technique using a state-of-the-artmulti-detector CTscanner (Somatom, Sentation 16, Siemens).The imaging findings of both the MRA and CTA werecompared with the digital subtraction angiography in patientswho underwent either sclerotherapy or embolizationprocedures.

TEACHlNG POINTS: Both MRA and CTA have played animportant role in the evaluation ofthe vascular architecture ofvascular anomalies. MRI/MRA allowed the accurateassessment of the nature and extent of the anomalous tissue,whereas CT/CTA has the advantage of quick imaging withhigh-resolution.

CONCLUSION: MRA/CTA should be added to crosssectional imaging protocols (MRI ar CT) for a more detailedimaging work-up. MRA and CTA can replace conventionalangiography during initial diagnosis, follow-up and also whiletailoring interventional therapy for vascular anomalies. Furtherresearch studies to establish ideal imaging protocols areindicated.


IR Assisted ERCP in Patients Post-Gastric and BiliaryDiversion Surgery with Biliary Tract Obstruction.A.Q. Giap, Kaiser Permanente, Anaheim, CA, USA. P.J.Mowji • S.L. Gert/er

PURPOSE: Endoscopic retrograde cholangiopancreatography(ERCP) in patients with gastric and biliary diversion surgeryis more difficult due to anatomical changes. The difficultiesinclude entrance to the afferent loop and selective cannulationof the bile duct. The overall success rate by ERCP is reportedin the range of 30-80% with average around 60%. Therendezvous technique has been used successfully to localizethe afferent loop in difficult cases. The procedure combinespercutaneous transhepatic cholangiography with insertion ofa guidewire through the ampulla by the Invasive Radiologist(IR) to help select the afferent loop and assist in difficuIt bileduct cannulation during endoscopy

MATERIALS AND METHODS: We are reporting three casesof biliary tract obstruction from our medical center that fai ledinitial ERCPs.l. A 19 year-old female post hepaticojejunostomy withcholedocholithiasis and recurrent cholangitis after transectedbile duct at laparoscopic cholecystectomy.2. A 69 year-old female post Bilroth II and significantcardiopulmonary comorbidities with recurrent biliarypancreatitis from choledocholithiasis.3. A 26 year-old female with recurrent biliary cholic andobstruction three years post hepaticojejunostomy and silasticbiliary stent placement following transsected bile duct atlaparoscopic cholecystectomy.

TEACHING POINTS: Using the rendezvous techniques wewere able to successfully resolve the biliary obstruction andobviate the need for surgical intervention in these patients.l. CBD stone extraction for first case.2. Sphincterotomy and CBD stone/sludge extraction on secondcase.3. Extraction of proximal migrated silastic biliary stent, biliarysludge/stone extraction and biliary enteric anastamosis dilationon the third case.

CONCLUSION: The rendezvous technique is useful inpatients with a history of gastric ar biliary diversion whenERCP is unsuccessfuI. The IR assisted approach improvesthe ability of ERCP to offer non-surgical therapy to thesechallenging biliary cases.


Spectrum of Complications Encountered inInterventional Radiology at a County Hospital and LevelOne Trauma Center.M.S. Curvelo, Nassau University Medical Center; EastMeadow, NY, USA. R. Baxi • C. Mathur

PURPOSE: The purpose of our presentation is to review andillustrate the range of both conunon and unusual complicationsencountered in the interventional radiology practice of aCounty Hospital and Level One Trauma Center with a trainingprogram with residents and fellows.

MATERlALS AND METHODS: The authors retrospectivelyreview illustrative cases of encountered complications in aCounty Hospi tal and Level One Trauma Center over a periodof approximately 10 years. Interventional Radiologistsemployed Conventional Angiography, Digital SubtractionAngiography, Computerized Tomography, Ultrasound andNuclear Medicine studies, when available, in the evaluationand management of the patients. Several cases are selectedand presented to illusttate the spectrum of complications. Areview ofthe current literature was made and compared to ourexperience.

TEACHING POINTS: The adverse events encountered in thepractice of interventional radiology can be categorized inpuncture site problems, vascular and technical complicationsrelated to broken catheters, or wire related. Cases of arteriovenous fistulas, pseudo aneurysm formation and Angiosealcausing femoral artery occlusion are given as puncture siteinjuries. Cases of acute arterial occlusion, pulmonary arteryand subclavian artery injuries, aortic and femoral arterydissections are example of vascular complications related tocatheters and wires. Cases of retrieval of broken catheters orglide wires, are examples of "non-vascular" catheter or wirerelated events. Furthermore undesired coil embolization andmisplaced filters are shown as technical related injuries.

CONCLUSION: In conclusion, the spectrum ofcomplicationsencountered in the interventional radiology practice of aCounty Hospital and Level One Trauma center with residentand fellows is wideo It is imperative for the interventionalradiologist to be familiar wi th them in order to recognizeproblems eady and, if possible, correct potentially lifethreatening injuries.


Use of Guiding Catheters for Visceral ArteriaIEmbolization.K.N. Vinaya, Yale University School ojMedicine, NewHaven, CT, USA. J. Pollak • M. Tal

PURPOSE: Embolotherapy of visceral artery branches istypically performed using a selective catheter, frequently witha coaxial microcatheter. Subselective microcatheter positioningcan be difficult due to limited contrast delivery for adequatevessel opacification and limited ability to reach across largervessels to engage their branches. This study assesses the valueof guiding catheters for visceral artery embolization.

MATERIALS AND METHODS: 30 viseeral embolizationsover 30 months were performed in 23 patients using a guidingeatheter system. After seleetion of the main aortie branehvessel, the initial eatheter was exehanged for a 6 Freneh orlarger shaped guiding eatheter and coaxial4 or 5 Freneh eatheter.The inner eatheter was used for subbraneh eannulation usingeonventional size seleetive wires. When needed, a 3 Frenehmierocatheter was also used for subselection of smaller vessels.

TEACHING POINTS: Embolotherapy was sueeessful in 29of30 proeedures performed in 15 men and 8 women, ages 16to 82 years. A 4 or 5 Freneh eatheter was loeated in a thirdorder braneh vessel or higher in 16 instances. A 3 Frenehmieroeatheter was used in 14 instances. In al! eases the abilityto injeet larger volumes of eontrast helped visualize thevaseular anatomy for sueeessful embolization. Indieationsineluded tumors (17), bleecting (12) and aneurysms (I). Thevessels embolized were hepatie artery branehes (7), splenieartery (3), left gastrie artery (1), gastroduodenal artery O),superior mesenterie artery branehes (2) and renal arterybranehes (6). In one instance, the guiding eatheter system wasused to retrieve a migrated eoil and then successfuUy eompletethe embolization without loosing position. A guiding eatheterwas not helpful in one proeedure due to a diffieult angle ofsubbraneh vessel origin.

CONCLUSION: A guicting eatheter provides excellent supportwithin a main viseeral artery for eoaxial manipulations with a4 or 5 Freneh eatheter or mieroeatheter. This permits easiersubseleetive eannulation and emboJization.


VertebraI Augmentation with Kyphoplasty andVertebroplasty: lndieations, Teehnique andComplications.RL Cirillo,Jr., Wake Forest University Baptist MedicalCenter, Winston-Salem, NC, USA • J.D. Regan • S.P. Loehr• HP. Clark • J. Lioyd • E. Marnell .

PURPOSE: To describe our experience in the emerging roje ofkyphopJasty and vertebropJasty for painfuJ vertebraJ bodyfraetures.

MATERlALS AND METHODS: We retrospeetiveJy reviewedour experienee with both kyphoplasty and vertebropJasty.We will deseribe the fundamental principles of vertebraiaugmentation, the different instrumentation systems as wellas radiologie principles.

TEACHING POINTS: Osteopenic vertebrai eompressionfraetures may eause severe pain and spinal deforrnities. Thisean adversely affeet the quality of life, physieal funetion,mentaJ health and survivaJ of patients that are afflieted bythese fraetures. Both kyphoplasty and vertebroplasty involvethe pereutaneous pJaeement of a needle(s) usually through atranspedieuJar approaeh with the injeetion ofpolymethyJmethaeryJate into the vertebrai body.KyphopJasty invoJves the additional insertion of balloontamps to eJevate the vertebraI eompression fraeture.

This seientific exhibit will illustrate the similarities anddifferenees involved in kyphoplasty and vertebropJasty. Itwill deseribe the eritieal steps needed to ensure safe eompJetionof vertebral augmentation and deseribe the variety of techniquesavailable and diseuss the potential eomplieations involvedwith these procedures. It will also diseuss the development ofan interventional radiology praetiee invoJved withvertebroplasty or kyphoplasty.


Relationship between the Portal Vein and the BiJe Duetlmplieation for Transjugular lntrahepatic PortosystemicShunt.KH Lee, University ofYonsei College ofMedicine, Seoul,South Korea. K B. Sung • H K Yoon • G. Y. Ko • D. Y. Lee

PURPOSE: To evaluate the relationship between the portalvein (PV) and bile duet using eoronal and axial MR imagingand to assess whether biliary tree ean be used as landmark forportaj vein aeeess.

MATERIALS AND METHODS: From March 2000 toSeptember 2002, TIPS was performed in 60 patients. Amongthem, 57 patients whose TIPS traet was ereated from theright hepatie vein to either the right PV or the PV bifureationwere included. MR images using true fast imaging with steadystate preeession (true-FISP) studies for evaluating anatomierelationship between PV and bile duet were obtained fromtwo hundred patients suspeeted of hepatie tumor or biliarydisease.

TEACHING POINTS: Duringthe TIPS proeedure, bile duetwas visualized on tractogram of eight out of fifty seven (14%), and eholangiogram eould be obtained from these eightpatients. Moreover, using bile duet as the landmark, the rightPV in three patients and PV at bifurcation leveJ in five patientswere sueeessfully aeeess. On MR irnages, PV bifurcation wasloeated posteromedially to bile duet in 179 cases (89.5%),posteriorly in 13 (6.5%) and medially in 8 (4%) at hepatiehilar level while the right PV was loeated posteroinferiorly toright bile duet in 80 eases (40%), posteriorly in 70 (35%). Inremaining patients (n=50, 25%), bile duet erossed at themidpoint or distal one-third of the right PV

CONCLUSION: Thorough understanding of anatomierelationship between PV and bije duet at the liver hilum isusefuJ in performing TIPS.


lnterventional Management oC Reetus SheathHematomas.J. W Ho, SUNY Upstate Medical University, Syracuse, NY,USA • P. Speller • KD. Murphy .0.1. Kwon • F.J.Mangiacapra • R. Wolfson

PURPOSE: Reetus Sheath Hematomas (RSH) may oeeurspontaneously, secondary to trauma, or as a eomplieation ofantieoagulation. Most are typiealJy sejf limited and improvewith eorreetion of coagulopathy or as tamponade oeeurs. AsmalI group of patients continue to bJeed and may requiremore aggressive intervention. Surgical intervention may addsignifieant morbidity to these patients. We report ourexperienee in managing four patients with RSH utilizingeatheter direeted embolization.

MATERIALS AND METHODS: Between 2001 and 2002 fourpatients with RSH that failed conservative therapy andremained unstabJe were treated with embolization. Theembolization was aehieved with two separate methods. Threewere treated with a eombination of gelfoam and mieroeoilswhiJe the fourth was treated with thrombin and mieroeoils.

TEACHING POINTS: Evaluation of potential bleeding soureesineJude superior and inferior epigastrie arteries. In all fourpatients post-emboJization evaluation of these vesseJsdemonstrate eessation of aetive extravastion. Followingtherapy these patients were more hemodynamieaJly stabJe.

CONCLUSION: Catheter direeted embolization is a safe andeffective treatment for patients with RSH and fai! eonservativetherapy.

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TunneIed PICC Lines: A SimpIe and Effective SoIutionfor Patients with Difficult Venous Access.J. W Ho, SUNY Upstate Medical University, Syracuse, Nr,USA. D. Biskup • KD. Murphy .0.1. Kwon • F.J.Mangiacapra • B. Estes

PURPOSE: Evaluation of central venous access utilizingtunneled 3Fr through 7Fr catheters which are typicallyperipherally placed.

MATERIALS AND METHODS: Between 1996 and 2002, 75tunneled central venous cathers (3-7Fr PICC) were placed in58 patients. These tunneled catheters were placed withultrasound and fluoroscopic guidance in the interventionalsuite. The patients received moderate conscious sedation orgeneral anesthesia during the procedure. The indications forCYC placement and removal, veins accessed, complicationsfrom the procedure and longevity of the CV Iines were examinedin this study.

TEACHING POINTS: During the six year period 75 centralvenous catheters (CVC) were placed by InterventionalRadiology. The procedure was successful for all patients. Themajority (59%) of patients who received these tunneled CYCwere either patients with end stage renat disease and armgrafts/fistulas or infants with smalI peripheraI veins. Eightypercent (60175) were placed in the right side, tunneling alongthe right chest wall. The mean dwell time of these catheterswas 24 line days. Sixty one percent (46175) were removedbecause treatment was completed. No procedure relatedcomplications was observed.

CONCLUSION: Tunneled central venous catheters are safeand effective solutions for patients with c1ifficult peripheralvenous access.


BIunt Dissection Versus Excision for TuIUleIed CatheterRemoval.J. W Ho, SUNY Upstate Medical University, Syracuse, Nr,USA. M. C. Rainisch • F.J. Mangiacapra • KD. Murphy •0.1. Kwon • R. Wolfson

PURPOSE: As the use of tunneled central venous cathetersincrease, interventionalists nol only place more but are alsocalled upon to remove them more often. Traditionally, bluntdissection with traction on the catheter has been the methodused at our institution to remove these lines. This study seeksto evaluate local incision over the polyester cuff (cutdown) asa method of tunneled catheter removal.

MATERIALS AND METHODS: Prospective randomized trialbetween May, 2002 and October, 2002 involving 64 patientsand an eąuaI number of tunneled catheters. Patients refered toour department for tunneled catheter removal were randomizedinto either the blunt dissection group or cutdown group. Theindwelling time of the catheter, level of experience of theoperator (resident, fellow, attending), time reąuired for catheterremoval, complications (catheter fracture etc...), and whetherthere was conversion from one method to another wasrecorded.

TEACHING POINTS: 33 catheters were removed with bluntdissection and 28 removed with cutdown method. 3 catheterswere initially started with blunt dissection and eventuallyconverted to cutdown method. There were no catheterfractures in either group and the polyester cuffs wererecovered with all catheters. The blunt dissection catheterswere implanted an average of 83line c1ays while the cutdown

group dwelled for 181line days. The mean time for catheterremoval using blunt dissection was 7 minutes 38 secondswhile the mean time for cutdown technique was 9 m.inutes 5seconds. Differences in removal times were observed betweengroups of c1iffering experience.

CONCLUSION: Cutdown technique is a safe and effectivemeans of tunneled catheter removal and can be used to removeespecially tenacious catheters.


Management of Recurrent Ascites by the InterventionaIRadioIogist.S. K Wang, William Beaumont Hospital, Royal Oak, MI,USA. M.A. Savin • R. Salem • M.J. Kirsch • WP. Romano

PURPOSE: The interventional radiologist is frequentlyinvolved in the management of recurrent ascites. The treatmentis dependent on the type of ascites encountered as well asother cIinicaI factors. This exhibit will provide acomprehensive review of the treatment of recurrent ascitesby the interventional radiologist.

MATERIALS AND METHODS: We will review the pathologicbasis of recurrent ascites, indications for treatment, procedures,technical points and complications related to the variousprocedures, and expected outcomes. The procedures to bediscussed will include repeat paracentesis, TIPS, and theinsertion of tunneled catheters, peritoneal ports, andperitoneovenous shunts.

TEACHlNG POINTS: Management of patients with recurrentascites is well within the capability of aU interventionalracliologists. Familiarity with the fuli spectrum of image-guidedtreatment options and their indications is necessary for theappropriate management of the individual patient.


The Importance of Radiation Safety Education in theInterventional Procedures Suite.WP. Arnold, Dialysis Access Specialists Access Center,Timonium, MD, USA. H. F. Cotar • A. Bramnik • TF.Litchfield

PURPOSE: To assess radiation safety issues in dedicatedhemoclialysis vascular access centers where non-radiologistsare perforrning procedures, and to investigate the impact of anew radiation safety program on radiation safety knowlege.In adclition, the purpose of the project was also to reassurestaff that current radiation protection processes and policieswere effective.

MATERIALS AND METHODS: A needs assessment surveywas developed for use in 8 free-standing interventional accesscenters that reported the state regulations on radiation safety;the current and past dosimetry readings; the badging andshielding use as well as the machine placement and shieldingwithin the room. Primary safety points were lead-lined wallsalong with standard 0.5 mm aprons, thyroid collars, and ringbadges. Facility radiation surveys were performed twiceannually. Post-education testing was performed after thedevelopment and implementation of a fuli training programfor all medical staff.

TEACHING POINTS: Priar to the development of astandardized approach for radiation safety, the post-training/ implementation test scores ranged from 40-100 (mean of78)wi th a significant improvement of post-training test scores of78-100 (mean of 90). In addition, the facility survey scores



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2.1 ±0.61.S±0.3

2.6±0.31.9±0.4

Markers ol ovarian reserve posl UAE in 23 women with baseline FSH<1 OmIU/mLpreUAE 1 month post 3 months postS.?±O.S 9.0±1.1' 10.?±2.3t199.1 ±38.4 204.8±41.? 253.6 ± 60.5

FSH (mIU/mL)Eslradiol (pmoVL)Number ol anIrai folliclesRighl 3.5 ± 0.4Left 2.S±0.4'p <0.01, tP < 0.05 VS. preUAE

PURPOSE: The impact ofuterine artery embolization (UAE)on ovarian reserve was studied, to help refine the indicationsfor UAE.

MATERIALS AND METHODS: From January 2000 to June200 I, 48 premenopausal women with symptomatic uterinefibroids underwent UAE using 355-5OO~PVA particles. Priorto UAE, serum FSH and estradiol (E2) levels were determined;ultrasound assessed the volume of the fibroids, ovarian volume,antral follicle count, and ovarian blood flow. Ali tests weredone on day 3 of the menstrual cycle prior to UAE andrepeated on day 3 of the first and third cycles post UAE.

TEACHING POINTS: Twenty-three patients had baselineFSH <10 rnIU/mL and were included in the analysis. Meanage was 44.1±2.4 years. The volume of the largest myomawas 197±37 cm3 pre-UAE, and 130±25 cm3 and 91±18 cm3,

one and 3 months post-UAE. A significant decrease in thediameter of the largest myoma was seen 3 months post UAE(P<O.OI). There was a significant increase in serum FSH levelspost UAE. Increases of >1OrnIU/mL were encountered in 7women one month post-UAE, and in 9 women 3 monthspost-UAE. The highest level was 22.8 mIU/mL a month afterand 33.8 rnIU/mL 3 months after UAE. Changes in E2levels,ovarian volume, number of antraI follicles and ovarian bloodflow I and 3 months after UAE did not reach significance,however non-statistically significant trends were observed inincreasing E21eveJs and in a decreasing number ofantraI follicles.

CONCLUSION: We observed a trend to increased E2 levelsand decreased number of antraI follicles, along with astatistically significant increase in serum FSH levels post UAE.aur results suggest that UAE with 355-5OO~ PVA particlesmay decrease ovarian reserve in some patients.

Change in Ovarian Reserve after Uterine ArteryEmbolization for Leiomyomata.D.A. VaLenti, McGill University HeaLth Centre, MontreaL,QC, Canada • T. TuLandi • A. Sammollr • T.J. Child • L.Seti • CI. Torres, et al.

Intraarterial rTPA Thrombolysis for Ischemie Stroke:University of Colorado Experience June 1999 - September2002.J. Mao, University ojColorado Health Sciences Center,Denver, CO, USA • S. Johnson • D.A. Kumpe • D. Huddle• J. Durham • M.l. Ludkowski

PURPOSE: There is Limited pubLished data investigation of rtPA use in the treatment of acute stroke. This poster details asingle institution 's experience using intraarterial r-tPAthrombolysis for thromboembolic stroke from June 1999 toSeptember 2002.

MATERIALS AND METHODS: Thirteen patients presentingwith acute stroke between June 1999 and September 2002were reviewed retrospectively. Ten were outpatients presentingto the emergency room. Three were inpatients admitted forother diseases. AlI patients were examined by the stroke teamat time of presentation and evaluated with noncontrast CTscans of the brain. Five patients had early signs of stroke suchas swelling and loss of gray-white junction. Others were


after the dedicated implementation showed significantimprovement as well. The development and implementationof a dedicated safety system was c1early a significant trainingissue related to non-radiologist interventionaLists. Caseloadsduring the training period were 6.2 cases/day with an averagefluoro time· of 4.1 minutes for all procedures perfonned. Inaddition, testing dosimetry badges were placed at 43 cm, 56cm and 60 cm away from the primary beam, with no recordablereading of scatter radiation.

CONCLUSJON: A dedicated training program on radiationsafety principles and procedures along with local regulationswill significantly improve staff knowledge about radiationsafety, and its importance in the interventional sui te.Particularly in light of non-radiologists performing proceduresin freestanding centers, such an organized approach should bereplicated.

Percutaneous Therapy for Appendiceal Abscesses in thePediatrie Age Group.D.E. Lee, University ojRochester MedicaL Center,Rochester, NY. USA • B. ArsLan • DL WaLdman • G. T.Drugas • L. G. SahLer • N. C PateL, et al.

PURPOSE: To evaluate safety and effectiveness of imagingguided drainage ofabscesses due to perforated appendicitis inthe pediatric age group.

MATERJALS AND METHODS: We retrospectively reviewed31 patients within pediatric age group, who had percutaneousabscess c1rainage due to perforated appendicitis within thepast 4 years at our institution. Patient age varied between 1and 17 with a mean of 10.2. Eighteen patients were male, and13 were female. Ali patients had an initial ComputedTomography (CT) scan that demonstrated the collection(s).All procedures were performed within the next 24 hours ofdiagnosis. During the procedures ultrasound and fluoroscopywas used in 15, and CT was used in 16 cases for imagingguidance. Size of the catheters varied between 8F and 14 F.SampIes are sent for culture and sensitivity studies from allcollections. All patients were on broad spectrum antibiotics,pending culture results. Drainage tubes were removed afterthe amount of draining fluid decreased to less than 30 cc/day.

TEACHING POINTS: No significant complications occurredduring the procedures. Patients were"discharged with thefollowing cri teria:I-afebrile for 24 hours without antipyretics,2-WBC < 9000 with normaI differential,3-abscesses resolved on follow up CT and c1rains removed,4-tolerating regular diet.All patients responded well to percutaneous c1rainage withbroad-spectrum antibiotics and discharged to home aftermeeting the above mentioned criteria. Twentyeight patientsreceived interval appendectomy (lA) within 6 to 8 weeksafter discharge. Two patient's farnilies declined the lA, andfollow-up was lost on one patient.

CONCLUSION: Percutaneous drainage ofappendiceal abscesswith imaging guidance in pediatric patients is a safe and effectivetreatment modaJity. lnterval appendectomy can be performedafter the patient is stabilized by percutaneous drainage andantibiotic therapy.

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norma!. The average amount of time elapsed betweenpresentation of symptoms and initiation of treatment was 3hours (range 1-4.5 hours). Average treatment time was 1.5hours (range 20min - 3.3 hours). Average total r-tPA used was17 mg (range 4 - 50mg). Four patients received systemicheparinization. Long term follow up, when appropriate, wasrecorded.

TEACHING POINTS: One patient presented with an isolateddistal ICA thrombus. Two patients had thrombus in the Al/A2 segments. Seven patients had thrombus in Ml1M2. Threepatients presented with extensive thrombus in the distal ICA+ M I + Al. Totallysis was achieved in nine patients (69%).Partiallysis was achieved in three patients (23%). No Iysiswas seen in one patient (7%). Six patients (46%) had clinicallysignificant neurologic improvements (post treatment NIHSS< 4). Two patients (15%) had petechial hemorrhages with noeffect on clinical outeome. Two patients had large parenchymalhemorrhages that resulted in poor clinical outcome. Overall,significant residual neurologic deficits were seen in four patients(31 %). Death occurred in three patients (23%) due toprogressive brain edema from evolving infarction.

I. Intraarterial thrombolysis with r-tPA in the setting of acutestroke appears promising.2. Significant clinical improvement was seen in 46% of ourstudy group.3. Favorable prognostic factors include younger patient age,early time to treatrnent, and location of clot.4. Significant intracranial hemorrhage occurred in aminorityof patients.


The Role of Arterial Interventions in Liver TransplantRecipients.WE.A. Saad, University ofRochester MedicaZ Center,Rochester, Nr, USA. DL Waldman • D.E..Lee • L.G.Sahler • N. C. PateZ • A. Bozorgzadeh, et al.

PURPOSE: To evaluate the effectiveness and safety ofarterialinterventions in hepatic transplant recipients, including hepaticartery (HA) PTA and/or thrombolysis and AVF embolizations.

MATERIALS AND METHODS: A retrospective chart reviewof transplant recipients, undergoing arterial interventions from8/91 to 10/02 (11 years and 2 months) was made. Of thosepatients there were 30 PTA attempts (27 patients) for HAstenosis, 3 HA emboJizations (3 patients) for hepato-portalfistulas, one HA pseudoaneurysm embolization and 5 attemptsat recanulating thrombosed hepatic arteries.

TEACHING POINTS: 1) Four attempts were unsuccessful(due to spasm and/or vessel tortuosi ty / kinks.) without anyadverse effects. Technical success was achieved in 22 allograftswith an intent to treat rate of 73.3 % (22130) and a technicalsuccess rate of angioplastied lesions of 84.6 % (22/26).Thecomplication rate was 15.4 % (4/26) including 2 (7.7%) withimmediate complications (HA dissection and mpture) and 2(7.7%) with delayed complications (HA thrombosis at 8 and16 days post PTA). Synergistic procedures (celiac tmnk PTAor stenting and splenic artery embolization) were performedin 3 of the successful PTAs to improve HA inflow. Ondividing the 30 attempts into 3 chronologic groups, the intentto treat rates, technical success rates & complication ratesrespectively were as follows:

A: 5/10(50%), 517(71.4%) & 217(28.6%).B: 7110(70%), 7/9(77.8%) & 2/9(22.2%).C: 10/1O(100%), 10/1O(100%) & 0/1 O(0%).

2) Ali 3 of the hepato-portal fistula coil embolizations as wellas the HA pseudoaneurysm coil embolization were successfulwithout evidence of parenchymal necrosis.3) Ali 5 attempts at recanulating thrombosed HAs failed.This included pharmacologic and mechanical thrombolysisand PTA.

CONCLUSION: PTA of HA stenosis after livertransplantation is a relatively safe procedure and demonstratesa learning curve. Selective embolization for hepato-portal AVFsis relatively safe with no evidence of hepatic parenchymalnecrosis. In our Iimited experience at recanulating thrombosedhepatic arteries, all attempts were unsuccessfu!.


Transhepatic Tesio Catheters: Tips,Tricks, Techniquesand Pitfalls.R.S. Florek, West Jefferson Medical Center, Marrero, U,USA. R.C. Batson • G. Rivera • T. Craig

PURPOSE: Long term dialysis is characterized by progressiveloss of suitable venous access sites. After exhausting peripheralaccess sites, direct Caval and Transhepatic-caval catheterplacements have been utilized. We report a group of patientswho were able to be maintained on dialysis using the Transhepatic caval access route.

MATERIALS AND METHODS: Patients were eligible forTranshepatic Tesio catheter placement after exhausting allother peripheraJ access sites. One patient required dialysisaccess for thirty days, while a de-novo arm shunt matured.Four others have been maintained for intermediate length oftime, two for several months and two for over a year. Onecatheter was successfully thombolysed to restore flow rate,and one was replaced when it extruded into the peritonealcavity. One catheter was removed for infection after eighteenmonths of use. Technique for placement and maintainance arediscussed.

TEA CHING POINTS: Ali patients were able to be maintainedwith adequate hemodialysis flow rates of 280-300 mJJrninusing the transhepatic route. Patient acceptance and ease ofdialysis are good throughout usage. With two cathetersfunctioning more that a year, the possibility of long termdialysis using the transhepatic route is considered.

CONCLUSION: Transhepatic Tesio catheter placement forhemodialysis access is a viable technique when the peripheralaccess sites are exhausted.


Percutaneous Peripheral Intra-Trabecular Osseoplasty.R.S. Florek, West Jefferson Medical Center, Marrero, U,USA • C. Sinwnson

PURPOSE: Osteoporotic long bone fracturues in bed riddenpatients are a source of pain for the patient and frustration forthe physician. Surgical options are usually Iimited due to thepatient 's general debilitated status. Effective palliation offracture site pain can be achieved by methacralate bone cementstabilization of the fracture.

MATERIALS AND METHODS: A 91-year-old woman hadsustained a complete, oblique fracture of the distal third tibia.She was bedridden and demented and the treatment optionswere limited. Surgical fixation, ORIF would have a lowprobability of success, and would have a high potential forinfection, given the state of incontinence. An Off-Iabel use ofPMMA Bone cement was discussed with the family to

stabilize the fracture site, and this option was consented foron a compassionate use indication. PMMAPolymethylmethacralate bone cement was injected directlyinto the fracture eleft using a standard 11 guage bone trocarunder fluoroscopic guidance using local and IV sedation. ThePMMA extended above and below the fracture, into the intratrabecular spaces,within the marrow space, similar topercutaneous Vertebroplasty procedures. No methacralateextended outside the cortical margin.

TEACHING POINTS: The patient's pain response at thefracture site resolved . The fracture site has been stable forover a year without evidence ofmovement. No callus formationhas formed as expected in this immobile, osteoporotic bone.A proposal to do additional patients beyond the singleepisodel compassionate use indication was submitted to thehospital's Investigational Review Board(IRB) forconsideration,and this was deferred pending additionalpublished experience.

CONCLUSION: Percutaneous Peripheral Intra-trabecularOsseoplasty (PlO) is a promising technique for stabilizationof long bone fractures in patients who may not be candidatesfor orthopedic surgery.


The Natural History of Thnneled Dialysis Catheters.A. Falk, Mount Sinai Medical Center, New York, NY, USA

PURPOSE: To track the natural history of tunneled dialysiscatheters and to document the presence of a fibrin sheathupon removal.

MATERIALS AND METHODS: From 7/1/01 through 10/11/02 all tunneled hemodialysis catheters that presented tointerventionaJ radiology for removal were entered into thestudy. Patient demographics, catheter dwell time, catheterlocation, and reason for removal were recorded. Catheterswere dissected from the tunnel and retractedjust distal to theinsertion site. Contrast venography was performed withimaging over the chest during injection through the proximal/red porto'during the valsalva maneuver. The presence of asheath was recorded. Catheters were then removed orexchanged.

TEACHING POINTS: 190 tunneled dialysis catheters wereremoved in 127 patients (67 male), ages 3-87 years (median53 years). 67 catheters were removed for infection, 62 forother working access, 44 for poor function (flow rates < 200mJImin), 4 were retracted, 3 for resolved ATN, 2 for SVCsyndrorne, 2 for cracked ports and 6 for unknown cause. 151were removed from the IJ vein (107 right, 441eft), 13 from thesubelavian vein (4 right, 9Ieft), 6 from the innominate vein (4right,2 left) 13 from the femoral vein (10 right, 3 left) and 7from other veins. 122 catheters were removed, and 68 wereexchanged over wires for new catheters (40 with PTA venousto disrupt the fibrin sheath). Data on catheter dwell time wasavailable for 170 catheters. Dwell time was 1-548 days (median67 days). 131 catheters were injected. 105 (80%) had fibrinsheaths, ofwhich 24 had thrombus identified along the cathetertract. 10 patients had known central venous ocelusion.

CONCLUSION: Approximately one third oftunneled dialysiscatheters are removed for infection, one-third for other workingaccess, and one-fourth for poor function. Catheters usuallyremain in patients for 2 months. Fibrin sheaths associatedwith hemodialysis catheters are very common, as is thrombusformation around the sheath. Central venous ocelusion canmimic the appearance of a fibrin sheath on contrastvenography.


Interventional Radiology of Transhepatic Islet CeIlTransplantation.Z. Neeman, NIH, Bethesda, MD, USA. BJ. Wood. R.Chang • M.G. "ysoki • B. Hirshberg • D.M. Harlan

PURPOSE: The technical details of ultrasound- andfluoroscopic-guided transhepatic islet celi transplantation aredesclibed. The pitfalls, problems, and potential complicationsof the procedure are detailed, as well as ways to avoid them.

MATERIALS AND METHODS: The NIH program hastransplanted islet allografts into six patients with long-standingand brittle type l diabetes. Each patient requires twotransplantation sessions 1 islet celi doses. Patients ranged inage from 39 to 63 years, were thin (average body mass index21.7 kg/m2), and had diabetes for 13 - 50 years. One majorinelusion criteria was hypoglycemia unawareness. Cadavericislet cells were processed by a large cell-processing unit. Whenadequate cells were obtained, the islet celi allografts wereinfused via the portal vein. Patients were treated withdaclizumab, sirolimus and tacrolimus to prevent rejection.Heparin was administered to counteract the thrombogenicislet preparation.

TEACHING RESULTS: Portal veins were accessed with a0.18 wire, and eventually a 4.1 Fr Kumpe catheter underalternating ultrasound and f!uoroscopic guidance with preprocedura I portal .venograms and portal venous pressuremonitoring at 5 minute intervals. Following the 45 to 60 minuteinfusion, the catheter is removed and the track embolizedwith gelfoam pledgets, taking care not to inject the vein withgelfoam. One portal vein thrombosis and one massiveintraperitoneal hemorrhage were seen. The team should beready to perform diagnostic angiography with hepatic arteryemboJization or thrombolysis via superior mesenteric arteryon short notice. Following transplantation, none hasexperienced any serious hypoglycemia events, and insulinindependence was achieved in 3/6 patients thus far.

CONCLUSION: Islet celi transplantation may soon becomea successful way to avoid insulin-dependence in type ldiabetics without the typical harmful irnrnunosuppressiveslike steroids or cyelosporine. Significant remaining hurdlesinelude limited islet supply, balancing hemostasis, and lifelong immunosuppressives. Interventional radiologists will beimportant p1ayers in the is1et celi transp1antation team, andshould be watchful of potential complications and ways toavoid them.


Hemodialysis Catheter Placement in Difficult Patientsby Dual Femoral and Supraclavicular Approach.WP. Arnold. Dialysis Access Specialists, 7imonium, MD,USA

PURPOSE: Even though catheter access for hemodialysis isthe least optima l mode as stated in the K-DOQI guidelines, itis nevertheless necessary and useful in a large percentage ofincident patients. As insertion sites deteriorate with use,subsequent catheter insertions may become difficult orimpossible. This presentation describes a technique used in adedicated access practice to achieve supra-elavicular catheteraccess in those patients deemed "unlikely to access" byultrasonic evaluation or catheter access failures by trial ofplacement at another facility.

MATERIALS AND METHODS: Abstract length restrictionsmake description of the technique impossible. Thispresentation will describe in detail a dialysis central S137

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catheterization technique using a combination femoral veinapproach to find veins extending into the supraclavicular arearrom the SVC and a 8 mm PTA balloon catheter as a target forsupraclavicular puncture in patients who have no appropriateveins by sonographic evaluation Ol' have had unsuccessfulattempts at dialysis catheter access in another facility. Thedual approach has allowed successful catheterization in themajority of attempts. It is appropriate and useful for bothdual lumen and split catheters.

TEACHING RESULTS: This technique has been successfullyused to insert catheters into patients who had been doomed tofemoral, trans-lumbar, Ol' trans-hepatic catheters in the pastOl' have been abandoned for lack of access. It has been used in20 patients with success in 17 (85%). The failures have beenrelated to complete occlusion of the SVC below the innominatevein contluence (2 patients) and both SVC and IVC occlusionin the other. Technically manipulation of a PTA ballooncatheter is easier than an intravascular snare, and the balloonprovides an ideal target for puncture to assist in micro wirepassage.

CONCLUSION: A dual approach to central venous accessfor dialysis catheter insertion will be described. It is safe andhas obviated the need for more invasive or risky catheteraccesses in the majority of patients with d.ifficult catheteraccess problems.


Hemostream: The True over the Wire Chronie DialysisCatheter.J.F. McGuckin, Jr., Philadelphia Vascular Institute,Philadelphia, PA, USA

PURPOSE: Evaluate the placement and performance of ahigh tlow rate chronic dialysis catheterinto the right atriumfrom either the right Ol' left side without a peel- away sheath.

MATERIALS AND METHODS: Eight sheep were studied inthe supine position. Sheep were accessed from both sides forcatheter placement. Access to the internal jugular vein wasobtained using US guidance with a Cook micropuncture set(Bloomington, IN). A Terumo 0.035 Glidewire (Somerset,NJ) was then placed through the introducer into the IVC. An18Fr Coons dilator was then placed over the wire with the tipat the right atrium. A delto-pectoral subcutaneous tunnel wasthen created using the Rex Medical (Radnor, PA) hollowtunneler exiting the neck access site. After removing the d.ilatorthe Glidewire was passed backward through the tunneler andthe external wire loop reduced. After the tunneler was removedfrom the tract the Coons dilator was placed over the wirethrough the tunnel and then removed. The l6Fr Hemo-Streamcatheter was then placed over- the- wire with the tip at theright atrium and then the wire and stiffener removed. Flowrates and mechanical hemolysis for the Hemo-Stream werealso tested separately.

TEACHING POINTS: Catheter placement from eitherapproach takes less than six minutes after jugular access isachieved. The placement is nearly bloodless at both the tracttunnel and neck access site secondary to graded dilalion andthe absence of the peel-away sheath. The catheter is veryresistant to kinking as well. The tlow rate was 17% higherthan a commercial catheter of si.rnilar length (495cc/min) whileachieving extremely low hemolysis (6% percent less then thecommercial catheter). The Hemo-Stream had a recirculationof 1.17% which surpassed the DOQI Guideline recirculationstandard of less than 5% .

CONCLUSION: Catheter placement of tunneled catheterscan be difficult secondary to bleeding, kinking,and possibleair embolism. The Hemo-Stream Over The Wire ChronicDialysis catheter allows for simple passage of the catheterthrough the tunnel without unnecessary over dilation, tunnelor access site bleeding, and reduces the risk for air embolism.This catheter also provides a high tlow rates, low recirculationand hemolysis with excellent long-term patency.


Contrast-Enhaneed MRA for the InterventionalRadiologist: What You Need To Know.T.H. Nguyen, UC Irvine Medical Center, Orange, CA, USA• F. Tsai

PURPOSE: To illustrate the basic concepts and value ofcontrast-enhanced MRA, as a potential substitute forconventional catheter-based diagnostic angiography, and todemonstrate how to perform this technique in current clinicalpractices.

MATERIALS AND METHODS: At least 50 contrast-enhancedMRA performed in our institution from 1997 to 2002, werereviewed and analyzed. These examinations were obtained ind.ifferent areas of the body, from head to toe, on a standard 1.5Tesla MR scanner with fast spoiled gradient echo, steppingtable, power injector, and bolus chasing capability, as theminimum requirement.

TEACHING POINTS: Although the technique has evolvedwith time and has become more sophisticated, the basicprinciples still remain. The fundamental pulse sequences havecontinuously improved with shorter TR and TE, fasteracquisition time, increased signal to noise ratio (SNR), andgreater spatial resolution. Seven important concepts will beexplained and illustrated in this poster, in a simplified manner,to allow familiarity with the technique, as weB as itsperformance and interpretation. Diagnostic limitations andpitfalls were also included.

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