________~ 0-. _

Mortalily Based on MELD and Presence of Portal Venous DiseaseMELD PV No. of Mortalily Rale% (95% GI)

Disease Patients

Untangling Varicose Veins: An Algorithm for Treatment.M.G Tal, Yale University, New Haven, CT, USA·N. Denbow·A.Lorch 'E. Salik

1mo. 3mo. 6mo.$17 No 43 2.6(0,4.9) 7.9(0,16.7) 11.6(0.7,22.5)

Yes 14 15.4(0,35) 34.2 (6.6,61.6) 34.2 (6.6, 61.6)~16 No '37 42.7 (26.2,59.2) 46 (29.3.62.7) 46 (29.3,62.7)

Yes 15 46.1 (22.2,74) 55.6(29.7,61.5) 55.6 (29.7,81.5)

S45

Abstract No. 1242:39PM

MATERIALS AND METHODS: Since March 2003 160females have undergone evaluation for LE superficial venousreflux disease at our vein center. Consultation included adetailed medical history, a pertinent physical examination andperformance of a thorough LE venous duplex evaluation.Patients with symptoms ofPVCS and refluxing vulvar variceson venous duplex underwent gonadal venography. Ovarianvenous incompetence was treated with transcatheterembolization. Saphenous and nonsaphenous patterns ofsuperficial venous reflux were treated through a combinationof endovenous laser (DIOMED) and radiofrequency (VNUS)ablation, sclerotherapy, ambulatory phlebectomy and/orsuperficial vein excision (Trivex). All patients were followedup in clinic one week, one month and three to six months postprocedure(s).

RESULTS: Of 160 females patients evaluated for LEsuperficial venous reflux disease, 26 (16%) also presentedwith findings of PVCS. 24 of 26 underwent ovarianvenography, of which 22 (92%) were found to have ovarianvenous insufficiency (14 left, one right, and seven bilateral)for which transcatheter embolization was pelformed. Of the22 patients who underwent ovarian vein embolization, 14(63%) reported relief or significant reduction of pelvic and LEdiscomfort following embolization alone. Following furthercomprehensive treatment of remaining identifiable sources ofLE superficial venous reflux, 20 (91 %) of the 22 patients inthe PVCS subgroup subsequently reported satisfaction withtheir final outcome.

CONCLUSION: Complex patterns of superficial LEsaphenous and nonsaphenous venous insufficiency are oftenassociated with PVCS, which represents a challenging subgroupof patients. A comprehensive approach to diagnosis andtreatment play an important role in identifying all treatablesources of reflux, thus optimizing symptomatic relief.

Anatomical Orientation of the Bioprosthetic VenousValves: Does It Matter?D. Pavcnik, Dotter Interventional Institute, Portland, OR,USA'J. Kaufman-B. Uchida-L. Correa 'PS. Keller·J. Rosch

PURPOSE: Since 1999, we have been working on apercutaneous bioprosthetic bicuspid venous valve (BVV)consisting of small intestinal submucosa (SIS) attached to astainless steel square stent. To eliminate the occasional valvetilting the second generation BVV (SG BVV) has beendeveloped. The new valve is a sturdier, modified version of adevice invented several years ago. SG BVV solves the tiltingissue. The new valve has been in clinical trials since May2004. This study investigates short-term function of twodifferent anatomical orientations of the percutaneously placedSG BVV in the jugular vein (JV) in six female sheep.

MATERIALSAND METHODS: Twelve SG BVVs, consistingof SIS attached to a nitinol frame with radiopaque markers,were percutaneously placed under fluoroscopic control acrossthe natural valve (NV) into the IV above its union with thesubclavian vein. The valve opening of six implanted SG BVVswere anatomically oriented as crossed NVs and the other sixvalve openings were rotated 90 degree to the NY. The functionofSG BVVs was studied by immediate and six week venogramswith contrast medium injections distal and central to BVVs.The competency of SG BVV was tested additionally withcontrast medium injections into subclavian vein. The animalswere sacrificed at 6 week. Gross examinations were performed.

RESULTS: Desired anatomical valve orientation afterdeployment was seen in all 12 SG-BVVs. All valves exhibitedgood valve function on venograms immediately after

Abstract No. 122

Abstract No. 123

2:15PM

Sunday, April 3, 20052:15 PM - 4:00 PMModerator(s): Jan Namyslowski, MD

Wayne P Yakes, MD

Scientific Session 22Venous Insufficiency I VascularMalformations

2:27PM

MATERIALS AND METHODS: Over the last 2 years wetreated the varicose veins of 272 patients. All patients wereseen in clinic prior to the procedure where comprehensiveultrasound and physical examinations were performed and atreatment plan was formulated. Patients were followed afterthe procedure and additional treatment sessions wereperformed as needed. The treatment modality, outcome andcomplications were recorded. An algorithm that wouldoptimize patient outcome was constructed based on thisexperience.

RESULTS: The algorithm is based on physical exam andDoppler ultrasound findings in the initial visit. The first stepof the algorithm is to eliminate reflux at its highest point.After this is achieved, adjunctive treatment is pursued basedon the size and on the depth of the vessel to be treated. Forsuperficial varicosities with a tributary vein less than 4 mm indiameter sclerotherapy is perfonned. For superficial veinslarger then 5 mm, microphlebetomy is indicated. Forperforators and deeper veins of any size, ultrasound guidedsclerotherapy is performed. The preferred compound,concentration and mode of sclerotherapy is described.

CONCLUSION: An algorithm for treatment of varicose veinsis provided.l?e algorithm can serve as a guide in detenniningthe approprIate treatment modalities for varicose veinpatients.

PURPOSE: There are several options available for treatmentof varicose veins. These include laser and radiofrequencyablation, microphlebectomy, and liquid or foam sclerotherapy.We present an algorithm for the treatment of varicose veinsthat provides guidelines for the appropriate use of each ofthese modalities.

Pelvic Venous Congestion Syndrome and LowerExtremity Superficial Reflux Disease.C.M. Black, Intermountain Vein Center, Provo, UT, USA·J.Collins·D. Hatch 'D. Heaston' B. MClff' R. Nielsen ·R.Smilanich

PURPOSE: We report our experience in the care of womenwith lower extremity (LE) superficial venous reflux diseaseand concurrent symptoms of pelvic venous congestionsyndrome (PVCS).

Abstract No. 127

Percutaneous Sclerotherapy ofLymphatic Malformationswith Doxycycline.R.K. Mitri, Children S Hospital Boston, Harvard MedicalSchool, Boston, MA, USA ·A.Alomari-D.J. Lord·P.E. Burrows

PURPOSE: Low flow lymphatic malformations can beeffectively treated by percutaneous intralesional injection ofa variety of sclerosant drugs. This study aims to evaluate theefficacy of doxycycline in the treatment of lymphaticmalformations(LM).

MATERIALS AND METHODS: We reviewed the medicalrecords of all patients with lymphatic malformations whounderwent doxycycline sclerotherapy between Novemberl 51

1996 and September 1st 2004 at Children's Hospital Boston.Patient demographics, procedural data, and complication rateswere abstracted from the charts. In addition, surveys weresent to all study patients, to assess perceived improvementsin patients' symptoms and their satisfaction with the results.Any patients whose lesions were treated with sclerosant drugsother than doxycycline were excluded from further analysis.

RESULTS: Seventy-eight sclerotherapy procedures wereperformed on 58 patients in the study period. The median ageof the study population was 5.3 years with a range of 3months to 39 years. The location of the lesions treated wascervicofacial in 31 patients (67%), truncal in 9 patients (20%)and involving an extremity in 6 patients(l3%). Patients witha macrocystic LM demonstrated the greatest response totreatment while patients with a lymphaticovenous LMshowed the least response to treatment. The 16 (27%) patientswho required repeated treatment had an average of 2.9sessions. Preliminary survey results from the first 12 patientswho had a mean follow-up of 19 months, showed that 58% of

3:15PM

MATERIALS AND METHODS: Thirty-five patients withVMs referred for sclerotherapy were investigated. A T2­weighted volumetric acquisition was performed using a three­dimensional dOUble-echo steady state sequence (3D-DESS)followed by a perfusion study with a volumetric interpolatedbreath hold examination (VIBE) 1,2,5, and 10 minutes aftera bolus injection of 0.1 mmol/kg of gadolinium. Aftersegmentation of the source images, the total volume of theVM (non-enhanced volume) and its circulating portion(perfused volume) were evaluated. Baseline andpostsclerotherapy MR examinations were performed in 25patients (before, three and six months after sclerotherapy)whereas the remaining 10 patients had postsclerotherapyexaminations (3 months and 12 months),

RESULTS: Volumetric evaluation of the malformation wasobtained in all but two patients. In patients having baselineand postsclerotherapy studies, a total volume decrease ofmore than 50% was observed in 15 out of 25 patients, Atthree months postsclerotherapy, the volume of contrast uptakewas continuously increasing between 1 and 10 minutes,whereas in baseline and 12 months postsclerotherapy studies,the maximum enhancement was preferentially observedbetween 2 and 5 minutes. The mean ratio of perfused volumeversus total volume was measured at 98% before sclerotherapyand at 71 % 12 months postsclerotherapy. These findingswere consistent with the presence of perilesional inflammationafter the procedure and thrombosis of the circulating portionon long-term follow-up.

CONCLUSION: MR imaging of VMs with quantitativevolumetric evaluation combined with perfusion study is usefulto assess the efficacy of sclerotherapy. MR imaging follow­up after sclerotherapy should be performed 12 months afterthe procedure.

Abstract No. 126

Abstract No. 125

Ethanol Sclerotherapy of Soft Tissue VenousMalformation: Follow-Up with 3D Volumetric MR andPerfusion Study.J. Dubois, University ofMontreal, Montreal, QC, Canada·V.Khoury·R. Mansour-c. Lapierre·F. Rypens'G Soulez

PURPOSE: To evaluate the efficacy of ethanol sclerotherapyin soft tissue venous malformations (VMs) by volumetricquantification and perfusion study with MR imaging.

--:~ .....r,~", ~--~ --

3:03PM

2:51PM

MATERIALS AND METHODS: 32 patients had 63procedures for VMs in 18 months. An ultrasound-guideddirect-stick approach was used. The sclerosant was 3% sodiumtetradecylsulfate (STS). The sclerosant to air ratio was 1:3.STS was constituted into foam using 3 cc of air in a 3 ccsyringe and 1cc of STS in a 1 cc syringe and a 3-way stopcock.Clinical follow-up was monitored via telephone, physicalexam, ultrasound, or MR!. A questionnaire was sent to patientsfor their assessment of the treatment. Patient symptomswere graded on a 0 to 10 scale (no symptoms to intensesymptoms). Complications, recurrence of symptoms, andchange in size of malformation were also evaluated.

RESULTS: Pain, swelling, lesion size, and clinical impressionimproved during the first week and long-term follow-up. Thefoam texture enabled control of sclerosant, directing it to non­dependent areas of the lesion. Liquid sclerosant wasoccasionally used to also reach the dependent areas of thelesion. Foam was easily seen on fluoroscopy and ultrasound.There were fewer extravasation events and much wider spreadwith foam than with liquid. Overall, 87.3% of proceduresresulted in decreased size of the malformation while 68.3%showed 50-100% ablation of abnormal vessels.

CONCLUSION: Foam may have a greater sclerosing effecton vessels than liquid. Air within the foam gives excellentcontrol in a non-dependent direction and permits a much widerspread into very small abnormal vessels. Foam is seen withboth ultrasound and fluoroscopy, allowing precise bi-modalimaging. Foam may also have fewer adverse effects wheninadvertently leaked into normal vessels. This may be due tobubbles being easily carried away by more rapidly flowingblood in normal vessels while adhering to vessel walls instagnant flow. Also, while appearing more effective, foam isless painful than liquid.

Foam Sclerotherapy of Venous Malformations.C.D. Stanley, University of Minnesota, Minneapolis, MN,USA 'K.J. Kowalik·J. Kittur·D. W Hunter

PURPOSE: Direct-puncture sclerotherapy is an effective,less­invasive treatment for venous malformations (VMs), thansurgery and results in less bleeding, tissue destruction, andnerve and cosmetic injuries. Recurrence of treated VMs arecommon and multiple treatments may be required. Little hasbeen published on using foam sclerotherapy for vascularmalformations.

implantation and prior to sacrifice at six weeks. The 6 SGBVVs with anatomical orientation as NVs were found to besimilar in size or only slightly shorter than after placement. Awide anatomical variety of the cusp sizes were observed in allsix SG BVV with 90-degree anatomical orientation.

CONCLUSION: Our results indicate that SG BVV anatomicalorientation at deployment is important and should be thesame as orientation of the NY. Valve orientation might play animportant role in long term SG BVV function.

846

Scientific Session 23Dialysis Access

Radiation Dosage in Patients Undergoing RadiologicInterventions for Hemodialysis Access Complications.J.P. Eaton, Tripier Army Medical Center; Tripier AMC, HI,USA'L. Manlolo·H.C. Yoon

Treatment of Venous Malformations with a TissueEngineering Approach.C.J. Smithers, Children's Hospital, Boston, MA, USA ·A.M.Vogel'H.P. Kozekawich ·D.O. Fauza ·P.E. Burrows ·S.S.Fishman

547

Abstract No. 1308:12AM

radiation absorbed dose (in Gy-cm2) was recorded for eachprocedure. Factors which might affect radiation dose werealso recorded, including: physician performing the intervention,complexity and number of procedural interventions, procedureduration, and fluoroscopy time. Multivariate regression wasperformed to determine which factors were correlated withradiation dose.

RESULTS: A total of 209 patients underwent 466 radiologicinterventions during the study period. Patients underwent anaverage of2.2 ± 1.5 procedures. Average procedure time was52.9 ± 20.7 minutes with an associated fluoroscopy time of4.4 ± 3.8 minutes and an average radiation dose of 15.8 ± 23.8Gy-cm2

. The average cumulative patient dose over the 24month interval was 34.6 ± 45.8 Gy-cm 2. Multivariateregression demonstrated that only the complexity of theprocedure and the amount of fluoroscopy required during theprocedure are significant covariates of patient radiationexposure. Among the four interventional radiologists who didall of the procedures, there was no significant difference intheir procedural or fluoroscopy times. The only significantdifference in patient exposure was noted between the tworadiologists with the highest (19.3 ± 32.1 Gy-cm2) and lowest(12.4 ± 12.6 Gy-cm2) average patient exposure values (p­value 0.02), although there was no significant difference in theaverage fluoroscopy times between these same two radiologists(4.6 ± 4.3 minutes vs 4.8 ± 3.8 minutes).

CONCLUSION: Patients undergoing radiologic interventionsfor hemodialysis access complications receive considerablecumulative radiation. Techniques to minimize radiation doseshould always be utilized in these patients.

A Prospective Controlled Trial on Endovascular VersusSurgical Treatment of Stenosis in Forearm ArteriovenousFistulae.G. Mansueto, University of Verona, Verona, Italy'N.Tessitore 'D. Cenzi 'v. Bedogna 'A. Lupo'R. Pozzi Mucelli

PURPOSE: To compare PTA versus surgery in the treatmentof venous perianastomotic stenoses in forearm aIteriovenousfistulae (AVF).

MATERIALS AND METHODS: A prospective controlled trialwas performed in 62 forearm AVE 40 AYFs were treated byPTA and 22 by surgery. The two groups were comparable forsubject and AYF age, pre- and post-treatment Qa. Primaryand assisted primary patency were reviewed at 6, 12, 24, 36and 48 months. Endpoints for primary patency and assistedprimary patency were restenosis and technique failure(reintervention by another technique or access loss). In surgerythe two patencies corresponded, since restenosis was treatedby PTA.

RESULTS: Success rate at 6 months was 100% for surgeryand 98±29'0 for PTA assisted primary patency, while at 48months success rate was 50±14% for surgery and 64±12%for PTA. The primary patency was lower in PTA than insurgery (p=0.02) while assisted primary patencies weresimilar (p=0.22) at Kaplan Meyer analysis. At multivariateCox analysis PTA and surgery have a similar risk of techniquefailure (HR 0.5; 95% CI 0.2-1.5; p=0.23).

CONCLUSION: In our experience in forearmAVF the technicalsurvival was similar for the 2 techniques. Even if the restenosisrate after pre-emptive correction of perianastomotic stenosisis higher with PTA than surgery, PTA allows repeatintervention and primary assisted patency is better for PTA.

Abstract No. 128

Abstract No. 129

3:27PM

Monday, April 4, 20058:00 AM - 9:30 PMModerator(s): Brian Funa.ki, MD

Richard J. Gray, MD

PURPOSE: Sclerotherapy for vascular malformations is oftenlimited by luminal recanalization. This study examined whetheran injectable tissue-engineered construct could prevent thiscompl.ication in a rabbit model of venous sclerotherapy.

MATERIALS AND METHODS: Ethanol sclerotherapy of atemporarily occluded jugular vein segment was performed in46 rabbits, which were then divided in 3 groups. Group 1(n=16) had no further manipulations. In groups 11 (n= IS) andill (n= IS), 0.5mL collagen hydrogel was injected intraluminally,respectively devoid of and seeded with autologous fibroblasts.At 1, 4, and 20-24 weeks postoperatively, vein segmentswere examined for patency and resected for histologicevaluation. Statistical analysis was by Fisher's exact test.

RESULTS: All vein segments were occluded at I and 4 weeksin all groups, despite histologic evidence of progressiveendot'1elial ingrowth. However, at 20-24 weeks, angiographydemonstrated restoration of vessel patency in groups 1 (3/6)and (3/5), but not in group III (0/6; p=0.043), in whichhistology confirmed an obliterated lumen for all vessels.

CONCLUSION: An injectable, fibroblast-based engineeredconst,uct prevents mid- to long-term recanalization in aleporine model of vascular sclerotherapy. This noveltherapeutic approach may prevent recurrence of vascularmalfonnations following sclerotherapy, thus reducing the needfor repeated procedures and morbid operative resections.

patients report complete response to treatment, 34% reporteda partial response and 8% reported minimal or no response.The remainder of survey results are currently being compiled.The overall procedural complication was 2.6% with a meanfollow-up time of II months.

CONCLUSION: Percutaneous sclerotherapy usingdoxycycline represents a safe and effective treatment forlymphatic malformations. More follow-up is necessary toquantify long-term outcomes and assess the risks of lesionrecurrence.

8:00AM

PURPOSE: To determine cumulative radiation dose and thefactors which influence this dosage in patients undergoingradiologic interventions for hemodialysis access complications.

MATERIALS AND METHODS: The records of all patientsundergoing radiologic interventions for complicationsassociated with a failing or thrombosed arteriovenous fistulaor graft over a 24 month {Jeriod were analyzed. The measured