Scientific Session 21Embolization/Miscellaneous

Wednesday, April 10, 200212:30 PM - 2:00 PMModerator(s): Richard Shlansky-Goldberg, MD

Julian Struyven, MD

12:30PM Abstract No. 161

9 seronegative spondyloarthropathies, 8 psoriatic arthritis, Itensosynovitis and I vasculitis. Thirteen patients were lostto follow-up. The bn)y complications noted were 4 cases ofskin atrophy (prob'abIY under-reported). Thirty-fourprocedures achieved a c~plete response and 31 a partialresponse to the injections. Soft tissue swelling and pain wasreduced or eliminated in 58 and53 procedures, respectively.

CONCLUSION: Ultrasound guided tendon sheath injectionis a valuable therapeutic tool in children and providesinexpensi\(e, safe and effective treatment for numerousrheumatological diseases.

RESULTS: One hundred ultrasound guided tendon sheathinjections were performed on individual 83 patients. Meanpatient age was 7.8 years (1.0-17 .0 years). Diagnoses included29 pauciarticular JRA, 23 polyarticular JRA, 7 systemic JRA,

Ultrasound Guided Tendon Sheath Injections in Children.BL Connolly, Hospital/or Sick Children, Toronto, ON,Canada· S Daunt· R. Schneider' M1. Temple' 1. Amaral·PG. Chait

PURPOSE: Tendon sheath corticosteroid injection is becomingan increasingly common therapeutic approach in themanagement of pediatric rheumatic disease. The purpose ofthis study was to evaluate the safety and efficacy ofultrasoundguided tendon sheath injections in the treatment of pediatricrheumatological disorders.

MATERIALS AND METHODS: All ultrasound guided tendonsheath inj ections performed at our institution from June 1994to March 2001 were assessed. Procedural details, clinicalhistories, complications and outcomes were reviewed.Technique: The injections were performed under ultrasoundguidance (10 MHz linear probe). Needle localization andtriamcinolone hexacetonide administration were directlyvisualized in real-time.

Percutaneous Tboracic Duct Blockage for Treating HighOutput Chylothorax.C. Cope, Hospital a/the University a/Pennsylvania,Philadelphia, PA, USA

PURPOSE: To evaluate the efficacy of treating high outputchylothorax (CX) by percutaneous transabdominalembolization of the thoracic duct (TDE) or by needledisruption (ND) ofretroperitoneal lymph trunks, to providea safer alternative to open surgical thoracic duct (TD) ligation.

MATERIALS AND METHODS: Over a 4 year period, 41patients were referred for percutaneous treatment ofrefractoryhigh output spontaneous and post surgical CX. Followingpedal lymphography, retroperitoneal lymph ducts over 2mmin diameter were catheterized transabdominally for TDE withcoils, particles or glue through a 3F catheter; smalleruncatheterizable lymphatics were occluded by ND.

RESULTS: TDE (n=23) was performed in 20 pts; CX fluidoutput ceased in 13 pts after 4.1 days (mean) and fellsignificantly in 7. ND (n= 15) led to CX cure in 7 after 4.7days(mean). There was no procedural morbidity. Percutaneous Rxfailed or was not possible in II pts. Interventions for CXpartial response or NC failure included thoracotomy (n=8),pleurodesis (n=3), radiation- or chemo-Rx (n=3) with cure in13. There were 3 late non-procedural and one surgical deaths.

CONCLUSION: Percutaneous transabdominal occlusion oflymphatic trunks with complete or partial CX resolution waspossible in 73% ofattempts with no morbidity. This procedureshould be strongly recommended as alternative therapy beforeconsidering open chest TD ligation.

Transtracheal Access for Endobronchial Interventions.O.S Ozkan, UniverSity a/Texas Medical Branch atGalveston, Galveston, TX, USA· E.M Walser· D. Akinci •SA. Raza • MK. Kathuria

PURPOSE: To evaluate the safety and efficacy oftranstracheal access for endobronchial interventions.

Abstract No. 164

Abstract No. 163

1:03PM

LeVeen Expandable-Hook Radiofrequency Electrode:Experience in Treatment of Liver Malignancy.D. Lu, University a/California, Los Angeles, CA, USA·SS Raman· P Limanond • D. Aziz • P Chen

PURPOSE: To evaluate our short-term experience with theLeVeen expandable-hook needle (Radiotherapeutics Corp.)for image-guided RF ablation (RFA) of liver malignancy.

MA TERJALS AND METHODS: RF ablations were performedusing the LeVeen needle for 72 liver tumors in 40 patients at

12:52 PM

MATERIALS AND METHODS: Over the past 2 years, wehave performed 8 transtracheal procedures on 5 patients,withmalignant bronchial obstructions (n=4) and one patient with apost-lobectomy bronchopleural fistula. With fluoroscopicguidance, sheaths (6-10 F) were placed through the anteriorwall of the trachea below the vocal cords after ultrasound wasused to verify needle placement below the isthmus of thethyroid gland. All procedures were completed successfullyusing intravenous conscious sedation and endotrachealinjections of2% lidocaine. The wires and catheters were coatedwith viscous lidocaine to prevent cough reflex. Nobronchoscopic guidance was utilized and no patients wereintubated. The introducer sheaths used during the procedurewere removed at the end of the procedure and gentle manualpressure was applied for 10 minutes.

RESULTS: The main cause of patient discomfort was coughreflex induced by the wires and catheters. This could be takenunder control with the appropriate use of liquid and viscouslidocaine. Two patients complained ofear ache and one patientcomplained ofsore throat for 24 hours after the procedure butthere were no significant complications from the transtrachealaccess, which was performed on one patient four times in 3months to successfully occlude a large bronchopleural fistula.Post procedure CT scans and X-rays showed minimalsubcutaneous emphysema in the neck of all patients and onepatient had mild but asymptomatic pneumomediastinum.

CONCLUSION: Percutaneous transtracheal access to thebronchi is safe in patients with relatively good pulmonaryreserve and facilitates endobronchial interventions withoutthe use ofintubation or general anesthesia. In our experience,asymptomatic subcutaneous emphysema orpneumomediastinum is common after these procedures butsignificant complications are rarely encountered.

Abstract No. 16212:41 PM

S56

Comparative Study of PVA Particles, Embospheres andGelSpheres in a Rabbit Renal Artery EmbolizationModel.D. Redd, Emory University Hospital, Atlanta, GA, USA· H.Chaouk· G. Shengelaia • L. Latini· D. Goupil· L. Poole­Warren

our institution (36 HCC, 31 colon, 2 breast, 2 sarcomas, 1hepatoblastoma). Choice of needle was determined by tumortype, size, location, and geometry. 15, 30, 23, and 4 lesionswere treated using the 2, 3, 3.5, and 4 cm arrays respectively.Overlapping positions were performed per lesion to aim for a5-10 mm margin beyond tumor. Tract ablation was alwaysperformed. 21 lesions were treated by intra-operativesonographic guidance, and 51 percutaneously (44 by US, and7 by CT). Lesion size ranged between 0.8 cm to 7.5 cm (mean2.3 cm). Available clinical and radiological fOllOW-Up werereviewed. 45 lesions had baseline post-ablation CT/MRIwithin 2 weeks, and post ablation RF defect size were used tocalculate extent of margin ablation. Follow-up time rangedfrom I to 24 months (mean 5.8 months). Lesions were allowedre-treatment within 6 months, beyond which evident tumorwas defined as local recurrence.

RESULTS: Mean ablated margin beyond tumor was 0.8 cmfor those lesions with contrast-enhanced CT/MRJ within 2weeks of ablation. Only 2 lesions required dual treatmentsessions. Within follow-up period, successful ablation wasachieved in 61 tumor nodules (85%). There were 11 incompleteablations or local tumor recurrences (15%). There was onehemorrhage requiring transfusion, but no other majorcomplications.

CONCLUSION: The LeYeen expandable-hook radiofrequencyelectrode needle is safe and effective for ablation of livermalignancy.

PURPOSE: The purpose of this study was to evaluate theendovascular response and histological characteristics ofpolyvinyl alcohol (PYA) particles, trisacryl (TA)(Embosphere® microspheres) and PYA hydrogel (HG)calibrated microspheres (GelSphere™ Embolic Agent) in arabbit renal artery embolization model.

MATERIALS AND METHODS: Thirty 4-5 kg New Zealandwhite rabbits underwent selective left renal arterycatheterization with embolization to complete stasis and weredivided into three groups. Twenty two rabbits were embolizedusing HG calibrated microspheres (300-500 !lm), 5 using TAcalibrated microspheres (300-500 !J.m) and 3 using PYAparticles (150-250 !lm). Follow-up angiography wasperformed at up to 7 days (n= 18) prior to necropsy with thecontrol and treated kidneys analyzed histologically.

RESULTS: Angiographic occlusion of the left renal arterywas achieved acutely in all animals. Mean injection volumefor renal artery occlusion was 0.40 ml (PYA), 0.62 ml (TA)and 0.40 ml (HG). Mean injection time was 164 seconds(PYA), 222 seconds (TA), and 244 seconds (HG). Promptproximal renal artery stasis occurred during PYA infusion.Patchy parenchymal staining developed during infusion ofeither calibrated microspheres which lead to progressive renalartery occlusion. Follow-up angiography showedrecanalization in all animals treated with PYA particles, andno recanalization in either calibrated microsphere groups. Severediffuse necrosis, mild to severe subcapsular inflammation andfibrosis, and occasional tubular and vascular mineralizationwas observed in all groups. Aggregation of PYA particlesresulted in proximal occlusion oflarge vessels. Minimal vesseldiameter occluded in the TA group (280 !lm) and HG groups S57

Abstract 0.166

Abstract No. 167

1:25PM

1:36PM

A Technique for Cutting a Coil at Any Length.A. Laurent, H6pital Lariboisiere - Paris, France· L.Domas· R. Chapol • X. Zhi • Z. Miao • L. Feng

PURPOSE: It is common to have to deliver successivelyseveral coils to obtain a sufficient filling of an aneurysm. Bycomparison with usual coils having a fixed length, a coil whichcould be cut at any length would offer the possibility to adaptthe length of delivered coil to the volume to occlude. Wetested if it was possible to cut electrolytically a corrodablemetallic coil at its emergence ofa catheter.

MATERIALS AND METHODS: Prototype coils have been

(290 !lm) were comparable. In both calibrated microspheresgroups, distal vascular occlusion was achieved with as few asone particle and proximal aggregation was not observed.

CONCLUSION: Renal artery embolization using GelSphere™Embolic Agent and Embosphere® microspheres resulted inpermanent vascular occlusion at 7 days with similarhistOlogical results. GelSphere™ and Embosphere®microspheres are both compressible particles which are easilydelivered through a microcatheter.

In Vitro Stability of Tris-Acryl Gelatin Microspheres ina Multipharmaceutical Chemoembolization Solution.D.S. Ball, St. Luke's Hospital, Bethlehem PA, USA· R.CHeckman· S. W Olenick· H.L. Folander

PURPOSE: To evaluate the in-vitro stability of tris-acrylgelatin microspheres (TAGM) in a multipharmaceuticalchemoembolization solution as a preliminary step to usage inhepatic chemoembolization.

MATERIALS AND METHODS: Half cc aliquots of 100-300micron and 300-500 micron TAGM were suspended in (a)1cc Ethiodol, (b) Icc normal saline,or (c) a standardchemoembolization solution of Cisplatinum 100mg.,Doxorubricin 50 mg., Mitomycin-C 10 mg., Ethiodol3 cc andIodixanol 320 5 cc. Each mixture with spheres was incubatedat 37°F for 24 hours and was then examined visually withinits glass test tube and using li·ght microscopy.The samplesincubated in Ethiodol alone required centrifugation to separatethem from the solution.

RESULTS: TAGM of both size ranges in Ethiodol appearedto dissolve into a cloudy solution, however after centrifugationthe particles were separated from the Ethiodol as a layer ongross examination and were intact at microscopy. TAGM insal ine had no gross degradation and were intact at microscopy.TAGM in the multipharmaceutical contrast and Ethiodolsolution were unable to be grossly seen in solution due to thedeep red color of Doxorubricin; they were not distorted byswelling or crenation at microscopy but absorbed the redcolor. The number of spheres per high powered field wassimilar in each solution.

CONCLUSION: TAGM of 100-300 microns and 300-500microns were grossly and microscopically stable at normalbody temperature for 24 hours when incubated with saline,Ethiodol or a multipharmaceuticaJ chemotherapy solution withEthiodol and Iodixanol. TAMG may be suitable as a substitutefor PYA particles for hepatic chemoembolization if in-vivoanimal tests can be performed to confirm similar persistenceofocclusion and effective chemotherapy distribution in targetlesions.

Abstract o. 1651:14PM

CONCLUSION: The most striking scrotal ultrasound findingafter varicocele embolization is decreased Valsalva accentuationof blood flow within the pampiniform plexus. Pampiniform

Scrotal Ultrasound Findings after VaricoceleEmbolization.L.S. Machan, University ofBritish Columbia, Vancouver,BC, Canada· M. Martin· V. Chow· M.K. Nigro

PURPOSE: To assess the scrotal ultrasound findings at 3month followup in men who have been treated by varicoceleembolization.

MATERJALSAND METHODS: 99 males aged 12 -74 (mean32.9) had varicocele embolization with coils and tetradecylsulfate (n=78); coils and glue (n= II); coils, tetradecyl sulfateand glue (n=I); or glue alone (n=9). Indications were infertility(n=74), symptoms (n=17) or adolescent varicocele (n=8).Scrotal sonography was performed in both quiet respirationand with Valsalva manoevre with gray scale ultrasound andcolor flow duplex with the patient upright after 15 minutes ofstanding pre - treatment (n=99), and 3 months post ­embolization (n=62 to date). Scrotal ultrasound was considereddefmately positive ifthere were 3 pampiniform plexus veinsgreater tban 2 mm diameter and abnormal Valsalva accentuationof flow on color duplex.

RESULTS: Mean maximal post Valsalva pampiniform veindiameter pre -treatment was 2.66 mm (range 1.7 - 6.7) andValsalva accentuation ofblood flow on duplex exam was gradedas marked (n=38), moderate (n=57), mild (n=I), normal (n=3),or none (n=O). At post - treatment ultrasound 2 men (3.2%)had persistent varicoceles (pampiniform vein diameters 3.1and 5.4 mm respectively, both with marked flow enhancement).Of 60 adequately treated varicoceles mean maximal venousdiameter was 1.40 (range 0 - 3.7) and flow accentuation wasgraded as marked (n=O), moderate (n=O), mild (n=5), normal(n=53), or none (n=2). 28 / 60 (46.7%) had veins ~ 2 romdiameter. No post - embolization hydroceles or venousthrombus were seen.

prepared with superelastic nitino] wires (NiTi) and withstainless steel (SS). The wire diameter sized .05 mm, the coilsdiameter .32 mm. The coils were pushed through amicrocatheter and various coil lengths (ranging from I to 50cm) were set in contact either with artificial plasma (Hankssolution, 37°C, pH 7) and submitted to a 2 rnA current for 20minutes at maximum (in vitro test) or with blood in rabbit'sinfrarenal aorta and submitted to a 2rnA current (in vivo test).69 trials have been done with NiTi coils (38 in vitro, 31 invivo), 12 with SS coils (in vitro only).

RESULTS: The cutting time was not significantly differentfor NiTi coils and SS coils (NiTi I : 459 ± 44 sec; SS :506 ±III sec). (NS) ForNiTi coils, the electrosection was localizedonly at their emergence of the catheter, both in in vitro and invivo tests. The cutting time was a few shorter in vivo than invitro (p = .0026, Mann Whitney). The cutting time was notinfluenced by the immersed length ofthe coil (NS, Spearman).SS coils were fragmented in several pieces in vitro (maximum10 pieces). In vivo testing of these coils was judged notnecessary.

CONCLUSION: Compared with stainless steel coils whichare cut in several points, NiTi coils can be cut precisely attheir emergence out of the catheter. Thus NiTi coils can beproposed for electrolytical cutting at variable length. Anoptimization of the cutting time should be possible with anappropriate choice ofmetal nature, coil process, wire diameter,and current intensity.

Abstract No. 170

Abstract No. 169

3:26PM

Wednesday, April 10, 20023:15 PM - 4:45 PMModerator(s): Wayne F Yakes, MD

The Management of Internal Carotid Artery Ruptureswith Endovascular Grafts.S. Kubaska, Cleveland Clinic Foundation, Cleveland, OH,USA· R.K. Greenberg· D. Clair· G. Barber· R.M. Green• K. Ouriel

PURPOSE: To assess the utility ofthe Wallgrafts in the settingof internal carotid artery ruptures and pseudoaneurysms.

MATERJALSAND METHODS: Three patients presented withrupture and one patient presented with a pseudoaneurysm ofthe internal carotid artery. All were treated with a Wallgraftendoprosthesis using interventional or combined surgical andinterventional approaches. The charts, radiographs, and follow-

Endovascular Treatment of Atherosclerotic VertebralArtery Stenoses.M. C. Henry, Nancy, France· I. Henry· K. Tzvetanov • C.Klonaris • M. Hugel

PURPOSE: To evaluate the safety and efficacy ofpercutaneous interventional treatment (angioplasty/stenting)in patients with symptomatic vertebral artery stenosis.

MATERIALS AND METHODS: 23 procedures wereattempted in 22 patients by femoral approach using coronarytechniques. (M: 12, F: 10, mean age: 67.7 ± 6.9 years (57-80).Right: 6, left: 17. All patients had multivascular diseases(carotid stenosis: 18, renal stenosis: 2, peripheral vasculardisease: 8, coronary disease: 12). Indications for angioplastyincluded: diplopia (n=4), dizziness (n=22), TIA (n=3). Alllesions were ostial. Mean % stenosis 79.1 ± 7.4%: (70-95).Mean lesion length: 8.3 ± 2.4 mm (5-12). Mean arterial diameter4.6 ± 0.6 mm (4-6).

RESULTS: Technical success 21/23, there were 2 failures inpatients with very tortuous calcified arteries. The first 3patients were treated by angioplasty alone, the others withballoon expandable stents (Palmaz : n=9 and other coronarystents: n=9). Post stent drug regimen included a combinationof Aspirin with Ticlopidine or Clopidogrel for 30 days.Angiographic success, defined as ~ 20% residual stenosiswithout in hospital emergency surgery, stroke or death: 21/23 lesions. Post procedure arterial diameter: 2.2 ± 3.7 mm (4­6). Mean residual stenosis 2 ± 3.6%. Four patients developedrestenosis during follow-up (31.3 ± 26.2 months), amongthem, one total occlusion was treated medically and the 3stenoses were successfully treated with balloon angioplasty.

CONCLUSION: Endoluminal treatment of vertebral arterystenosis can be performed safely and effectively with a hightechnical success rate, a low complication rate and a durableclinical success in patients with symptomatic atheroscleroticvertebral artery stenosis.

venous diameter does decrease but abnormal venous dilationpersists in nearly half (46.7%) of patients.

3:15PM

Scientific Session 22Neurointerventions - EmbolizationlMiscellaneous

Abstract No. 1681:47PM

SS8