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Year : 2017  |  Volume : 1  |  Issue : 3  |  Page : 1-18


Date of Web Publication18-Apr-2017

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How to cite this article:
. Abstract. Arab J Intervent Radiol 2017;1:1-18

How to cite this URL:
. Abstract. Arab J Intervent Radiol [serial online] 2017 [cited 2019 Feb 17];1:1-18. Available from: http://www.arabjir.com/text.asp?2017/1/3/1/204689

OC 1.1:

Endovascular Treatment for Acute Mesenteric Ischaemia

Khalid Omar Bashaeb, Marawan El Farargy, George Antoniou

Pennine Acute Hospitals NHS Trust, Pennine Acute Hospitals NHS Trust, Manchester, United Kingdom.

E-mail: kobashaeb@hotmail.com

Background: Acute mesenteric ischemia (AMI) is associated with a significant morbidity and mortality. Endovascular techniques have emerged as a viable alternative treatment option to conventional surgery. We performed a systematic review of the literature and meta-analysis of reported outcomes. Methods: Our review conformed to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards with the protocol registered in PROSPERO (CRD42016035667). We searched electronic information sources (MEDLINE, EMBASE, CINAHL, CENTRAL) and bibliographic lists of relevant articles to identify studies reporting outcomes of endovascular treatment for AMI of embolic or thrombotic aetiology. We defined 30-day or in-hospital mortality and bowel resection as the primary outcome measures. We used the Newcastle-Ottawa scale to assess the methodological quality of observational studies. We calculated combined overall effect sizes using random effects models; results are reported as the odds ratio (OR) and 95% confidence interval (CI). Results: We identified 19 observational studies reporting on a total of 3362 patients undergoing endovascular treatment for AMI. The pooled estimate of peri-interventional mortality was 0.245 (95% CI 0.197–0.299), that of the requirement for bowel resection 0.326 (95% CI 0.229–0.439), and the pooled estimate for acute kidney injury was 0.132 (95% CI 0.082–0.204). Eight studies reported comparative outcomes of endovascular versus surgical treatment for AMI (endovascular group, 3187 patients; surgical group, 4998 patients). Endovascular therapy was associated with a significantly lower risk of 30-day mortality (odds ratio 0.45, 95% CI 0.30–0.67, P 1⁄40.0001), bowel resection (OR 0.45, 95% CI 0.34–0.59, P < 0.00001) and acute renal failure (OR 0.58, 95% CI 0.49–0.68, P < 0.00001). No differences were identified in septic complications or the development of short bowel syndrome. Conclusions: Endovascular therapy confers improved outcomes compared to conventional surgery, reduced mortality, risk of bowel resection and acute renal failure. An endovascular-first approach should be considered in patients presenting with AMI.

OC 1.2

(Second place oral presentation prize winner): Embolization of Genicular Arteries for Chronic Hemarthrosis Post Knee Prosthesis

Olivier D'archambeau, Elisa Luyckx, Thijs Van Der Zijden, Maurits Voormolen, Maurits Voormolen

University Hospital Antwerp, Antwerp, Belgium.

E-mail: olivier.darchambeau@uza.be

Background: Post-operative hemarthrosis after knee prosthesis can be invalidating due to painful swelling of the knee and diminished mobility. We describe the technique and clinical results of endovascular embolisation of genicular arteries. Methods: From 01.2007 until 12.2016, 31 patients were treated (17 m, 14 w) with a mean age of 67 y (range 48-90). A total of 38 embolisation procedures were performed (31-1, 5-2 and 1-3), 26 right and 12 left sided. The mean time from surgery to symptoms was 24, 4 months (range 1-64) and embolisation was 27,4 months (range 1-70). Surgery type was total knee prosthesis (TKP) in 29 patients, unicondylar prosthesis in 2. The technical approach was ipsilateral in 33 procedures and contralateral in 5. All embolisations were performed using 4F diagnostic catheters, 2.7F microcatheters and microspheres (range: 100-500 μ). The technical endpoint was subtotal devascularisation in order to avoid ischemic complications. Clinical endpoint was symptomatic improvement. Results: Technical success was achieved 100%. In all cases, the superior lateral and medial genicular arteries could be embolised. In 12/38 procedures (32%), one or both inferior genicular arteries could not be catheterised due to the superposition of the TKP. Symptomatic improvement was achieved in 26/31 patiënts (84%). Post-procedural pain was noted in all patiënts, resolving inside 24 hrs in most. Two complications occurred, one low grade infection and one aseptic necrosis. Conclusions: Endovascular embolisation of genicular arteries is safe and efficient for the treatment of chronic hemarthrosis post knee prosthesis placement. Clinical improvement is seen in most patients. Complications are rare.

OC 1.3:

Radiation and Contrast Reduction Strategies in Endovascular Aneurysm Repair Procedures

Khalid Omar Bashaeb, Andy Mayes

The Pennine Acute Hospitals NHS Trust, Manchester, United Kingdom.

E-mail: kobashaeb@hotmail.com

Background: The aim was to maximise reduction of radiation dose and intravenous contrast use in patients undergoing Endovascular Aneurysm Repair (EVAR) using current hybrid theatre technology. Methods: A combined retrospective and prospective study of patients undergoing EVAR using current technologies was performed. We developed and implemented dose reduction strategies (DRS) with three study groups, a. Pre-Hybrid, b. Post-hybrid installation pre-DRS implementation and, c. Post hybrid installation with DRS implementation. The pre-hybrid group was performed using a C-arm image intensifier (OEC 9900, GE) and post hybrid installation using a Discovery IGS 740 (GE Healthcare). DRS included use of fusion imaging, fluoroscopy frame rate reduction, extra low dose protocols, digital zoom and image collimation. All standard bifurcated endografts were included. Dose Area Product (DAP), procedure time, screening time and total intravenous contrast media used for each patient was recorded. Results: The mean DAP pre-hybrid was 41.67 Gycm2, which increased to 63.24 Gycm2 post-hybrid installation. This reduced to 36.57 Gycm2 after DRS implementation (43% reduction) despite an 8% increase in screening time in the post-DRS group (1218 secs vs 1118 secs). The contrast volume reduced from a mean of 80 ml of higher strength Niopam370 (Bracco, UK) intravenous contrast media pre-hybrid to 70.35 ml of lower strength Niopam300 (Bracco, UK) post-hybrid pre-DRS and to 54.19 ml after DRS implementation, an overall reduction of 32%. Conclusions: Current technologies alone may not result in radiation dose reduction. Developing DRS leads to significant reduction in DAP and contrast media volume. The benefit is reduction in radiation dose to patients and operators and contrast use reduction in patients.

OC 1.4:

Different Techniques of Carotido-Cavernous Fistula Embolization: Single Center Experience

Farouk Hassan

Faculty of Medicine, Cairo University, Cairo, Giza, Egypt.

E-mail: faroukkeden@yahoo.com

Background: Different techniques of carotido-cavernous fistula (CCF) endovascular embolization were described in the literature. This study reports, validates and compares these techniques in our series of 34 cases, aiming to standardize the most effective and safest approach. Methods: A retrospective analysis of all patients that underwent endovascular embolization of either direct or indirect CCF between 2011 and 2016 at a tertiary care center was performed. The technical and clinical results of different techniques were analyzed. Results: Among our 34 patients, 29 had direct CCF (DCCF) and 5 had indirect CCF (ICCF). Among the 29 DCCFs, 1 was caused by intracavernous aneurysmal rupture which was coiled, 1 was caused by spontaneous rupture of a carotid dissection which was treated by carotid occlusion and 27 were caused by direct head trauma. Among these 27 cases, 3 were treated by occlusion of the fistula using detachable balloon, 13 were treated by cavernous sinus occlusion either from arterial or venous approaches using coils or coils and onyx and 11 were treated by carotid occlusion using coils and/or detachable balloons ± histoacryl glue. Among the 5 ICCFs, 3 were treated by cavernous sinus occlusion, and 2 slow flow cases were conservatively managed. No procedure related complications. Recurrence occurred in 2 cases which were successfully treated in a second session. Conclusions: CCF can be effectively and safely treated by different endovascular approaches taking into consideration some technical points.

OC 1.5

(Third place oral presentation prize winner): Endovascular Coil Embolization of Ruptured and Unruptured Intracranial Aneurysms: Review of a 13-year Single Center Experience

Mustafa Belal Hafeez Chaudhry, Tanveer Ul Haq, Syed Naseer Ahmed, Waseem Akhtar Mirza, Waseem Akhtar Mirza, Syed Ather Enam

The Aga Khan University, Karachi, Pakistan.

E-mail: belal.ibnehafeez@gmail.com

Background: To report our experience with the endovascular coil embolization (ECE) of ruptured and unruptured intracranial aneurysms (ICA) during the past 13 years at tertiary care University hospital. Methods: A retrospective study was performed at Radiology Department, The Aga Khan University between April 2003 to April 2016. All patients with ICA undergoing ECE were included. They were divided in groups of conventional technique (CT) and remodeling technique (RT) based on technique of ECE. Chi square was used to determine if there was a significant association between procedure technique and success. Results: In total, 189 patients (95 men and 94 women) underwent ECE, of these, 156 (82.5%) patients presented with ruptured ICA and 33 (17.5%) patients with unruptured ICA. 50 (32%) patients presented with Grade II subarachnoid hemorrhage (SAH) based on the Hunt and Hess scale, followed by 41 (26.3%) with Grade III SAH. 33% ICA were located in ACommArtery, followed by 17% in internal carotid artery. Mean age was 46.5 years (Range: 10-78 years). 92 (48.5%) patients had wide neck ICA. In total, 164 (86%) patients were embolised with CT and 25 (14%) patients with RT. Overall, 170 (90%) patients (46% women and 45% men) underwent successful embolization (greater than 95% occlusion of the dome without any coil prolapsing into the parent vessel). No significant difference in procedural success rate in either group [CT vs. RT: 146 (89%) vs. 24 (96%); P < 0.4769]. Complications occurred in 41 (22%) patients; 9.5% had major complications with bad outcome; 12.5% had minor complications with good clinical outcome. Infarction was commonest complication (12%). Total 9 (4.7%) patients died including 4 (2.1%) expiries secondary to procedure related complications. 155 (82%) patients had good clinical outcome with Modified Rankin Scores of 0-2. Conclusions: ECE of ICA is a safe and effective technique with a small associated risk of permanent morbidity-mortality. In correctly selected patients employed technique gives good procedural success. Risk of further bleeding is small with vast majority of patients achieving independent recovery.

OC 1.6:

Carotid Angioplasty and Stenting: A Single Center Experience

Farouk Hassan

Faculty of Medicine, Cairo University, Cairo, Giza, Egypt.

E-mail: faroukkeden@yahoo.com

Background: Carotid artery stenting is an alternative to endarterectomy in treatment of carotid artery stenosis. Comparative studies have shown different results regarding the outcome of both techniques. Methods: A retrospective analysis of all patients that underwent carotid artery stenting between 2011 and 2016 at a tertiary care center was performed. Periprocedural and delayed, minor and major complications rates as well as the rate of restenosis over the follow up period were analyzed. Results: A total of 74 patients who underwent 76 procedures of carotid artery stenting were included for analysis. Average age of patients was 65 ± 9 years, with 45 male (60.8%). Symptomatic stenosis was seen in 54 cases (71%) and asymptomatic stenosis was seen in 22 cases (29%). Filter protection device was used in 66 cases (86.8%) and 10 cases (13.2%) were done without protective device. Prestent dilatation was performed in 12 cases (15.8%). Poststent dilatation was performed in 74 cases (97.4%). Minor complications occurred in 3 cases (4%) in the form of 1 case of intraprocedural transient ischemic attack, one case of minimal dissection and one case of retroperitoneal hematoma. No major complications occurred. Two cases (2.3%) of insignificant restenosis were encountered. Conclusions: Carotid artery stenting is an effective and relatively safe alternative to carotid endarterectomy. Further studies assessing the value of embolic protective devices and the best type of stent should be conducted.

OC 2.1:

Cervical Discs and Ozonucleolysis

Umair Rashid, A. Hameed

Punjab Institute of Neuro Sciences, Lahore, Pakistan.

E-mail: dr_umairch@yahoo.com

Background: We report our experience with ozonucleolysis between June 2005 to November 2016 with 4000 patients affected by pain cervical region (Bracehalga) due to disc herniation including of fibromylegia. Methods: All these cases treated by intradiscal, or paravertabral oxygen – ozone injections. Patients age between 20 to 70 years underwent percutenous ozoneuclealysis. The procedure done under the angiofioursocopy with full aspectic technique. The ozone generator, essential component placed close to the patients. Simple 23G needle to 22G spinal needle, (quincke type point) were used to inject ozone under fluoroscopy. No premedication or anesthesia were given and the procedures were performed at an outpatient facility with short hospital stay after the treatment. Results: Among 4000 patients 2000 patients were followed up for 5 months, 50% of the treated patients showed complete recovery with disappearance of symptoms. 25% of cases complaint of occasional episodes of pain neck and arms but no limitations of occupational activities –15% of the cases showed in sufficient improvement –5% cases no improvement and went for surgery 10% of the cases never turned up after the first visit. Most of these patient had no FDA surgical indication. The patients who failed to benefit from ozonucleolysis underwent surgery. In all these cases, the previous O2 O3 gas therapy had no negative effects on the surgical procedure. Conclusions: In our experience, Ozone Gas Therapy in treatment of cervical herniated disc has revolutionized the percutenous approach to nerve root disease making it safer cheaper and easier to repeat than treatments currently in use.

OC 2.2:

Microwave Ablation for Hepatocellular Carcinoma-Initial Experience at a Large Tertiary Care Center in Riyadh, Kingdom of Saudi Arabia

Turki M. Hamdi, Shahbaz Ahmed Qazi, Omar Bashir, Muhammad Arabi

King Abdul Aziz Medical City, National Guards Health Affairs Riyadh, Riyadh, Kingdom of Saudi Arabia.

E-mail: turkihamdi164@gmail.com

Background: This retrospective study aims to evaluate the outcome of microwave ablation (Emprint, Medtronics) for managing early stage hepatocellular carcinoma (HCC) at our institution. Methods: On retrospective review of our computerized database, 13 microwave ablation procedures for 11 patients were identified from December 2015 to December 2016. Patient demographics, serology, Child score, ECOG performance status, tumor characteristics and technical parameters were reviewed. All procedures were performed under conscious sedation or general anesthesia. Tumor response was assessed on follow-up cross-sectional imaging. Results: 11 patients (5 female and 6 male) with an age range of 37 years to 72 years with a mean age of 53 years were identified. Most patients demonstrated Child score A and were suffering from either hepatitis B or C. Mean diameter of the lesion was 2 cm. 4 treated lesions were sub-capsular in location whereas the others were parenchymal or centrally located. Most the procedures were performed under both ultrasound and CT guidance. We used a 13 gauge microwave antenna at 100 watts with a mean ablation of time duration of 2.8 minutes. Initial cross-sectional imaging follow-up was performed at a mean interval of 24 days. 8 patients showed complete response after the first session. 3 patients required additional procedures including repeat ablation as well as radiotherapy. One patient developed a small sympathetic pleural effusion after the procedure. No other complications were noted. Conclusions: Our initial results show microwave ablation an effective and safe therapeutic option in the management of early stage HCC.

OC 2.3:

To Determine the Health-related Quality of Life in Patients Undergoing Transarterial Chemoembolization for Hepatocellular Carcinoma

Nauman Al-Qamari, Hatem Adel, Syed Omair Adil, Amjad Sattar

Dow University of Health Sciences, Karachi, Pakistan

E-mail: naumanalqamari@gmail.com

Background: Liver cancer is third common cause of death worldwide. Hepatocellular carcinoma (HCC) is the most common liver cancer. Majority of cases are detected at advanced stage of disease. <50% patients are treated with transarterial chemoembolization (TACE), radiofrequency ablation (RFA) and percutaneous ethanol injection (PEI). TACE is considered as palliative treatment which increases the patients 3 years survival by 40% but it is associated with many significant complications including postembolization syndrome and chemotherapy related symptoms. Most of the physicians only focus on disease outcome, although patient's quality of life (QOL) has significant impact on disease outcome. To our knowledge, overall few studies has been conducted to see patient's QOL after TACE, but none in our region. Hence this was rational for our study. Methods: Before and after survey was conducted at Vascular Interventional Radiology (VIR) department of DUHS from Feb 2014 to Feb 2015. All patients who underwent TACE irrespective of age and gender with at least one follow up at or after 06 weeks were included. Patients who lost to follow up were excluded. SF 12 questionnaire was used to assess health-related quality of life before and after TACE. Patient demographics like age, gender, follow-up duration, bilirubin level, tumor size and Child Pugh score was calculated. All quantitative variables were presented in the form of median and interquartile range. Wilcoxon sign rank test was applied to see the difference before and after TACE. P value <0.05 was taken as significant. Results: Out of total 53 patients, female preponderance was found to be higher 42 (79.2%) than that of males 11 (20.8%). Majority of the patients were had hepatitis C 47 (88.7%) whereas hepatitis B infection was found in 6 (11.3%) patients. Majority of the patients were presented with child score B 34 (64.2%) followed by child score A 17 (32.1%) whereas only 2 (3.8%) patients were presented with child score C. Significant difference was observed in the physical and mental quality of life before and after TACE, i.e. 45.3 (42.2-47) vs. 46.2 (44.2-47.2), P value <0.001 and 52.3 (48.9-54) vs. 56.3 (53.4-58.9), P value <0.001 respectively. Conclusions: Significant improvement in physical and mental health related quality of life was observed in patients suffering from hepatocellular carcinoma undergoing TACE.

OC 2.4:

Five-year Experience of Percutaneous Cryoablation of Symptomatic Venous Vascular Malformations as Second-Line Therapeutic Option

Francois H. Cornelis, Francois Marin1, Christine Labreze1, Nicolas Grenier1

Tenon Hospital, Paris, 1Pellegrin Hospital, Bordeaux, France.

E-mail: francoiscornelis@hotmail.com

Background: To report the mid-term outcomes of percutaneous cryoablation (PCA) performed as second-line therapeutic option of venous vascular malformations (VVM). Methods: From 2011 to 2015, PCA was offered in 24 patients (mean age: 31 years, range: 12-64) as second-line treatment for recurrences of symptoms after sclerotherapy and when resection was not possible (due to lesion location or previous failure) or refused by the patient. Adverse effects were recorded, disease-free survival (DFS) and local tissue control (LTC) rates were calculated based on symptoms and volume evolution. Results: Mean follow-up was 18.7 months (6-48). Nine (37.5%, 9/24) adverse effects occurred but only three (12.5%, 3/24) were severe. Mean pain assessed by visual analogic scale (VAS) was 41.7 mm (0-80) before treatment and 20.3 mm (0-80) (P = 0.01) after. Mean volume decreased significantly after treatment from 22.4 cm3 (0.9-146) to 8.35 cm3 (0-81.3) (P < 0.001). Pain recurred in nine patients and size of one lesion increased. The DFS and LTC rates were 54% (95% CI: 22.94-77.27) and 93.33% (61.26-99.03) at 24 months, respectively. Only VVM volume >10 cm3 was associated with a higher risk of local recurrence (P = 0.05). Conclusions: PCA as second-line treatment appears to be safe and effective for local control of VVM according to mid-term results.

OC 2.5:

Bedside Intravascular Ultrasound-guided Inferior Vena Cava Filter Placement in Critically-Ill Patients

Mohammad Abusedera, Kyung Cho1, David Williams1

Sohag University, Sohag, Egypt, 1University of Michigan, Ann Arbor, Michigan, United States of America.

E-mail: malaa2@yahoo.com

Background: Pulmonary Embolism (PE) is a potentially life-threatening complication of critical illness. Prophylactic inferior vena cava filter (IVC) placement offers a protection rate of 99% against fatal PE. Methods: Bedside IVC filter insertion guided by IVUS in 37 consecutive critically-ill patients. All patients had clinical indications for IVC interruption; including prophylaxis in high risk patient in the absence of DVT or PE (n = 27). The other indication was that patients were suffering from PE and/or DVT with a contraindication to anticoagulation, or ineffective anticoagulation. Transportation to angio- suite was risky or not feasible. Results: 37 patients, 13 patients were female and 24 were male with age ranged from 18 to 80 years with an average age of 44 years old. The filters were placed correctly in 35 of 37 patients (95%). filter was inserted at iliac vein in 2 patients that were retrieved and IVC filter was inserted guided by Fluorsocopy via transgugular approach. Placement timing was 5 days at average for surgical ICU patient compared to 17 days for medical ICU patients. infrarenal IVC diameter was 21.8 mm. There were no filter-related complications such as migration penetration or Filter-related thrombosis. There was no recorded incident of PE after IVC filter deployment. Only one filter was retrieved 20 days after placement. Conclusions: Bedside IVUS guided IVC filter placement for critically ill patient in the intensive care unit is a radiation free, contrast free and it is not limited by patient's obesity or recent abdominal surgeries or orthopedic hardware which could be limiting factor for trans abdominal duplex Doppler guided technique.

OC 2.6

(First place oral presentation prize winner): Day Case Endovascular Aneurysm Repair – Our Experience after 250 Patients

Ahmed Kaabneh

James Cook University Hospital, Middlesbrough, United Kingdom.

E-mail: ahmedkaabneh@icloud.com

Background: With more than 1000 EVAR patients experience in our centre, the advancement of ultra-low profile EVAR devices and percutaneous access, discharging uncomplicated EVARs in less than 24 hours is becoming more common. Methods: Single centre retrospective analysis of prospectively gathered data on 250 consecutive elective day-case EVAR cases (dEVAR). Patients for dEVAR are selected following joint radiology, surgical and anaesthetic team meeting using UK day-case surgery and locally agreed guidance. Patients deemed suitable are put on a special dEVAR pathway to be admitted on day of surgery and discharged in less than 24 hours. Results: 220 patients were followed-up after dEVAR. 98% were successfully discharged in less than 24 hrs post-operatively. One patient (0.45%) with access vessel complications required additional procedures and had to be hospitalised for two days. One patients (0.45%) with non-cardiac chest pain was hospitalised for two days. Two patients (1%) failed to be discharged within 24 hours but no clear cause documented in the notes. None of the dEVAR patients had a re-admission to hospital within 30 days with no 30-day mortality. Cost comparison showed dEVAR led to reduced overall average cost when compared to standard EVAR from ≤13,705 (CI = ±685) to ≤ 9,330 (CI = ±735). Conclusions: dEVAR is not for every patient but can be performed safely under appropriate criteria. In this series morbidity was minimal with significant cost saving.


Interventional Radiology: Giving Cosmetic Medicine a Makeover

Samantha Huq, Erik Bee1

University of Connecticut School of Medicine, Farmington, 1St. Francis Hospital and Medical Center, Hartford, United States of America.

E-mail: shuq@uchc.edu

Background: The global cosmetic market has been on the rise with a recent surge in minimally invasive procedures. Cosmetic interventional radiology (IR) offers less risk, pain and recovery time. This translates into better care at lower cost when compared to traditional surgery. Medical care is evolving into a minimally invasive specialty which provides interventional radiologists the unique opportunity to take part in the rapidly growing cosmetic medicine marketplace. Methods: Comprehensive literature review was performed to identify the scope of IR within cosmetic medicine. Common cosmetic procedures performed by IR, techniques used and their effectiveness are investigated. Results: Varicose vein treatment, laser lipolysis and liposuction are frequently performed. Additional procedures such as botulinum toxin (Botox) injections, collagen fillers, arterio-venous malformation (AVM) sclerotherapy, laser skin resurfacing and hyperhidrosis treatment are also gaining popularity. Recent advances in endovenous techniques including endovenous laser therapy (EVLT), radiofrequency ablation and sclerotherapy have been revolutionary. EVLT has a 98% success rate and a long-term recurrence rate <7%, surpassing the results produced by traditional vein stripping. Laser lipolysis and liposuction are alternatives to invasive weight loss procedures. Lipolysis has gained popularity due to a study conducted by DiBernardo et al. (2009) where lipolysis was found to have significantly higher mean size shrinkage and skin tightening when compared to traditional liposuction. Conclusions: As radiology's most innovative branch, IR has a broad landscape; thus, it is at an advantageous position to expand into the emerging field of cosmetic medicine. Cosmetic IR offers equal value with no surgical scar, shorter recovery and lower morbidity when compared to open surgery. Advances developed by IR has dramatically changed medicine. In the near future, it will do the same for cosmetic medicine by creating both new and enhancing existing techniques through image guided approach in order to deliver optimal patient care.


Special Phantom for Ultrasound Interventional Training Construction, Advantages and Application

Musaad Taha Qurash, Amr Maged Elsaadany

HUKM, Kuala Lumpor, Malaysia.

E-mail: mosad_taha@yahoo.com

Background: Training on patients causes more pain, complication, cost and time with possible technical problem e.g. non-targeted organ biopsy. Alternatives. Simulation provide safe training more adherent to ethical issues. This poster show a simple low cost gelatin phantom for training with easy construction and many advantages. Methods: Using gelatine with special formula adjusted to obtain echogenicty similar to human tissue with minimized needle pass artifact. New technique for biopsy phantom is demostrated with many advantages in controlling target echogenicity and posterior shadow to simulate any suggested target. Results: The produced phantom is extremely helpful to the IR trainners who need to avoid patient harm and increase skills of puncture and targeting for biopsy. It also have the advantages of low cost and avilable ingradients with construction step by step demonstration. Conclusions: Safe low cost IR training is feasible by this special formula simulating human echogenicity with reduced needle pass artifact.


Evaluation of the Causes of Erectile Dysfunction in Patients Undergoing Invasive Penile Doppler Sonography: A Study of Adult Pakistani Population

Usman Khanzada, Sohail Ahmed Khan, Kamran Masood Khan, Hatem Adil, Munawar Hussain

Dow Institute of Radiology, Karachi, Pakistan.

E-mail: khanzada1@hotmail.com

Background: In patients with erectile dysfunction it is important to differentiate psychogenic from organic causes. Color Doppler sonography of penis is a relatively inexpensive and partially invasive tool for this purpose. This study was conducted to evaluate the causes of erectile dysfuction in the adult population of Pakistan, who underwent penile doppler sonography. Methods: This retrospective cross sectional study was conducted at the Dow Institute of Radiology, Dow University of Health Sciences, Karachi, Pakistan. All consecutive patients presenting with the complaints of erectile dysfunction and undergoing penile doppler sonography from July, 2014 till June, 2016 were included in this study (n = 97). The examination was performed by a radiologist with more than five years experience in small parts ultrasonography. All examinations were performed on GE Voluson S6 and GE Logiq P5 with a high frequency probe. Following baseline scans, intracavernosal injection of 20 μg of prostaglandin E1 was given close to the base of penis. Peak systolic velocity and end diastolic velocity were measured in each cavernosal artery at the interval of 5 minutes. Patients with a peak systolic velocity of less than 25 cm/sec were considered to have arterial insufficiency. A greater than 5 cm/sec end diastolic velocity was used to describe venous incompetence. Erection grading of penis at the interval of ten minutes was done by erection hardness grading score. Results: Out of 97 patients (mean age 37.09 ± 11.59 years; range 19-69); 50 (51.5%) patients had normal penile Doppler sonographic findings, 24 (24.7%) had arterial insufficiency, 15 (15.5%) had venous leak, while 8 (8.2%) patients had arterial insufficiency with venous leak. Conclusions: Penile doppler sonography is a useful tool for evaluation of causes of erectile dysfunction. The majority of studied Pakistani individuals demonstrated no organic cause, thus conforming to the high prevalence of psychogenic etiology.


Awareness Regarding Radiation Protection Among Residents and Technologist Working in Vascular Interventional Radiology Department: A Multicenter Study from Pakistan

Syed Amir Raza, Kamran masood, Munawar Hussain

Dow Institute of Radiology, Karachi, Pakistan.

E-mail: amir.zaidi@duhs.edu

Background: To determine the level of knowledge regarding radiation protection among residents and technologist working in vascular interventional radiology department. Methods: A survey was conducted regarding radiation protection from March 2016 to November 2016 at tertiary care hospitals of Karachi, Pakistan. A structured questionnaire was distributed to 65 participants. The questionnaire was divided into 2 sections. In the first section, demographic information of the participants was included. In the second section, 6 questions regarding radiation protection were included. Results: Out of total 65 participants, males were predominantly higher 51 (78%) as compared to females 14 (22%) [Median age 37 (28-42)]. Majority of the participants 43 (66%) were residents while 22 (34%) were technologists. Awareness for evaluation of personal dosimeter data and radiation protection tool was found to be higher 55 (85%) followed by disease caused by radiation damaged 48 (74%), tissue most susceptible to injury from ionizing radiation 40 (62%), knowledge about dose optimization 34 (52%), standard about radiations 29 (45%) while only 14 (22%) were susceptible to radiation damage. Conclusions: The findings of our study have showed considerably low knowledge in our studied participants. In particular, technologist working in VIR department should be trained through regular educational seminar.


Artificial Ascites a Problem-solving Technique in Primary Hepatic Tumor Radiofrequency Ablation

Haytham Mohamed Nasser

Ain Shams University, Cairo, Egypt.

E-mail: Hmnh1980@gmail.com

Background: Primary liver malignancies are not uncommon especially in Egypt due the high prevalence of virus B and C. Treatment options include surgical option (transplantation, hepatectomy) and less invasive option (RF, microwave, TACE and TARE). RF is a very good treatment option which is equivalent to hepatectomy yet less invasive in patient with lesions less than 3 cm (Barcelona Clinic Liver Cancer, 2016). RF is avoided when the lesion is near bowel or in the liver dome hidden by the lung. Artificial ascites is considered as valuable problem solving technique for these limitations. Methods: Before ablation of 21 peripherally located hepatic tumors near adjacent bowel, intra peritoneal infusion of adequate amount glucose 5% using 18 G needle aiming for adequate tumor bowel separation to avoid thermal injury of gastrointestinal tract. Results: Technical success with was done adequate separation in more than ninety percent of the patient with safe tumor ablation. One patient with failure of separation which was likely attributed to peritoneal adhesion subsequent to previous surgery. No serious complication. None of the patient required post operative diuretics. Conclusions: Production of artificial ascites is a safe technique with no major technical complication nor post operative thermal bowel injury or adhesions. It is safe effective technique to feasible delivery of radiofrequency ablation of hepatic tumor near gastrointestinal tract avoiding major surgery in lesion less that 3 cm (hepatectomy).


Value of Rectal Spacing in Cancer Prostate Management Plan

Haytham Mohamed Nasser

Ain Shams University, Cairo, Egypt.

E-mail: Hmnh1980@gmail.com

Background: Prostate cancer is third most common malignancy (National Cancer Institute, 2016). In 2013, there were an estimated 2,850,139 men living with prostate cancer in united states (National Cancer Institute, 2016). Treatment options include surgical option (total prostatectomy) and less invasive radiotherapy option (three dimensional conformal radiotherapy 3D CRT and intensity modulated radiotherapy IMRT). Radiotherapy is an effective treatment option which is equivalent to prostatectomy yet less invasive (National Comprehensive Cancer Network, 2016). Rectal toxicity is one of the most limiting factors for radiotherapy because of rectal tolerance dose. Rectal spacing is considered as valuable problem solving technique for these limitations. Methods: Before the radiotherapy planning of 12 patients, rectal spacing was done by hydrogel using 18 G needle aiming for adequate rectal separation targeting 10-20 mm to avoid radiation rectal injury. Results: Technical success with adequate rectal separation was done in all patients. No serious complications. None of the patient required post procedural care. Radiation dose was delivered with decreased rectal manifestation and toxicity. Conclusions: Injection of rectal spacer is a safe technique with neither major technical complication nor post operative radiation gastrointestinal injury (rectal toxicity). It is a safe effective technique to deliver higher required radiation dose compared to convention radiation dose for better control cancer prostate avoiding major surgery (prostatectopmy) with reduced risk of rectal toxicity.


Flouroscopy-guided Percutaneous Hydrodissection for Radiofrequency Ablation of Hepatic Malignancies Involving the Liver Capsule: Evaluation of Technical Success and Safety

Maham Jehangir, Atif Rana, Sadaf Irshad

Shifa International Hospital, Islamabad, Pakistan.

E-mail: maham.61@hotmail.com

Background: Radiofrequency ablation is a widely recognized procedure for local control of unresectable primary or metastatic cancer of the liver. Hydrodissection under ultrasound guidance has emerged as a common technique to protect adjacent tissues from RFA related thermal damage. This study was undertaken to evaluate the technical success and safety of fluoroscopy-guided percutaneous hydrodissection for hepatic malignancies abutting the liver capsule. Methods: A total of 60 patients were treated with ultrasound-guided percutaneous RFA from January 2011 to July 2016 at our institute. Fluoroscopy guided percutaneous hydrodissection was performed in 15 patients (6 males, 9 females; age range, 42-84 years; mean age, 60.9+/- 9.9 years) with 15 hepatic nodules. All these tumors were closely apposed to the liver capsule in the right lobe. An 18 G single wall needle was used to access the peritoneal space and hydrodissection was performed with 5% dextrose in water displacing liver capsule at least 5 mm away from the diaphragm. Two RFA systems with multilined expandable electrodes were used for ablation. The technical success, safety of technique including the early and delayed complications were analyzed. Results: The primary technical success rate of percutaneous fluoroscopy guided hydrodissection was 100% (15/15). The mean volume of solution infused for hydrodissection was 736.1 ± 335.9 mL (range, 200-1500 mL). No major complication related to hydrodissection occurred during the procedure and on 6 weeks follow up CT scan. There were two minor complications (n = 2, 13%). Conclusions: Fluoroscopy guided percutaneous hydrodissection is a safe and effective technique prior to radiofrequency ablation of hepatic malignancies abutting the liver capsule.


Tumor Cell Needle Tract Seeding and Intracardiac Migration Following Percutaneous Image Guided Fiducial Seeds Implantation: A Two Rare Complications

Yousof Al Zahrani, Mohammed Arabi, Azzam Khankan, Saif Al Thagafi, Mohammed Al Moaiqel

King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia.

E-mail: yousof1403@hotmail.com

Background: Fiducial markers are useful for stereotactic body radiotherapy for treatment of malignant tumors. Here, we report two cases of rare complications following percutaneous fiducial markers placement. Methods: First case, a 51-year-old male with high grade metastatic neuroendocrine tumour of the liver who underwent ultrasound guided placement of four fiducial markers in the right hepatic lobe tumour. Second case, a 41-year-old lady with rectal adenocarcinoma and pulmonary metastasis who underwent CT guidance fiducial markers placement in four metastatic lung lesions. Results: First case developed tumor cell seeding along the needle tract of the fiducial marker placement procedure. This was detected on follow up cross sectional imaging. Second case developed intracardiac migration of one of the fiducial markers into the left ventricle during the procedure. The patient continues to be totally asymptomtic on follow up after one and half month after the procedure. The migrated fiducial marker has not changed its location in the left ventricle as well. Conclusions: Although rare, tumour cell tract seeding and intracardiac migration following percutaneous fiducial markers placement are potential complications and should be taken in consideration.


Comparison of Efficacy of Transarterial Chemoembolization and Radiofrequency Ablation For Treating Solitary Hepatocellular Carcinoma in Patients with Hepatitis B or C

Junaid Iqbal, Sadia Rashid

Dow University of Health Sciences, Karachi, Pakistan.

E-mail: junaid2008@gmail.com

Background: Hepatocellular carcinoma (HCC) is a common cancer and ranks second amongst all causes of cancer deaths world wide. Its incidence is increasing day by day in many countries specially in Pakistan due to high prevalence of hepatitis B and C which is known risk factor for HCC. Methods: This is a retrospective study conducted from January 2015 to December 2015, in which total 148 patients were enrolled with mean age of 56.7 years out of which 84 were men and 64 were women. 102 patients were HCV positive and 46 patients were HBV positive. All patients had solitary HCC (<4 cm). Out of 148 patients, 68 underwent RFA (45.9%) and 80 patients underwent TACE (54.1%). The response of treatment was assessed at 6 weeks follow up by quadriphasic CT scan. Patients were followed up to 2 years for overall survival. Results: A total of 148 patients with solitary HCC were enrolled [RFA 68 (45.9%) and TACE 80 (54.1%)]. At 6 weeks of follow-up, complete response was found higher in RFA group patients which was 67.6%, as compared to patients who had TACE which was 45%. Progressive disease and partial response in TACE was 17.5% and 30% respectively (P value 0.031) which is higher than RFA. At 1 year follow-up, out of total 148 patients, signficnatly higher mortality was observed in TACE (17.5%) as compared to RFA (2.9%) (P value 0.004). Among these 132 alive patients, follow-up at 2 year showed insignificantly higher mortality in TACE (18.2%) as compared to RFA (9.1%) (P value 0.128). Conclusions: RFA is considered as first line of treatment for solitary HCC whereas TACE can be taken as alternative treatment when RFA is not possible.


Complete Ablation Rate of Percutaneous Radiofrequency Ablation of Hepatocellular Carcinoma in Favorable and Unfavorable Locations: Using Real Time Ultrasound Guidance and Expandable Electrode Needle

Nakarin Inmutto, Chinnu Kaoworakarn

Chiang Mai University, Chiang Mai, Thailand.

E-mail: ninmuttomd@gmail.com

Background: To evaluate the success rate of percutaneous radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC) by using real time ultrasound guidance and expandable electrode. Methods: A retrospective study reviewed of CT and MRI findings from August 2015 to October 2016 of 91 HCCs. The patient's data, RFA data, location of the HCC, complication after procedure and imaging success rate of complete ablation were analyzed. The size of tumor range 0.5-4.5 cm. We performed RFA by using real time ultrasound guidance and expandable electrode needle (LeVeen, Boston scientific cooperation, USA) with stepwise method and double ablation method to reduce ablation time and more ablative area. The unfavorable locations of tumor (exophytic appearance, near capsule, near gallbladder, near bowel, near vessels) were performed without artificial ascites. Results: Complete ablation was obtained in 91.2% (73/91) of all HCCs. The complete ablation rate in favorable location was 100% (12/12), while the complete ablation rate in unfavorable location was 89.9% (71/79). Only one complication was found in 91 sessions of all HCCs. Conclusions: Using expandable electrode catheter combined with real time ultrasound guidance help ablates tumor in high risk locations with high success rate, low complication and fast operation time.


(Second place poster presentation prize winner): Endovascular Armamentarium for the Management of Wide-Neck Intracranial Aneurysms: Rashid Hospital Experience

Yasir Jamil Khattak, Ayman Al Sibaie, Muhammad Anwar Saeed, Ahmad Abdelmuhdi

Rashid Hospital, Dubai, United Arab Emirates

E-mail: dryasirjamil@gmail.com

Background: Endovascular therapy (EVT) is considered to be the first line treatment for aneurysm however this treatment option has its limitations in cases of wide necked aneurysm (WNA). These include high risk of coil protrusion in the parent vessel and early recanalization in case of bifurcation aneurysms. These limitations prompted the development of more complex endovascular techniques. In the present short review, we give introduction of these techniques and devices and provide case examples performed in Rashid hospital Dubai. Methods: Balloon Remodeling: This technique is probably the more frequently used in the treatment of WNBAs. Balloon is temporarily inflated in front of the aneurysm neck followed by coil packing and deflation before permanent coil deployment to evaluate possible migration. In more than 30 cases of ruptured and unruptured WNA's dealt at Rashid hospital, the remodeling technique was shown to be safe and potentially improved anatomical results. Stent Assisted Coiling: A stent can be deployed across the aneurysm neck in the parent vessel and coiling performed with catheter progressed through the stent struts. Y Stenting: When the aneurysm is centered at bifurcation, a Y stenting technique can be used. Although the chances of morbidity are higher in this technique, we did not encounter any complications in our patient series at Rashid Hospital except occasional spasm in parent vessel. Woven Endobridge Device: WEB is an intrasaccular flow disrupter having a braided nitinol mesh. The mesh structure of the WEB provides a stentlike apposition to the aneurysm wall. Flow Diverters: Flow diverters are low-porosity stents designed to reduce hemodynamic exchange between the aneurysm and the parent artery, which promotes thrombosis and neointimal overgrowth over the aneurysm neck. Flow-diverter treatment is associated with high efficacy, but with safety that is inferior to standard coiling. pCONus: The pCONus is a stent-like endovascular implant featuring a distal end that opens like a blossoming flower with its four petals resting on the inside of the aneurysm along the neck. The petals support the deployment of coils inside the aneurysm. Other Devices: Pulse Rider device self expandable implants and Luna device are few other techniques employed in the coiling of wide neck aneurysms. Results: Provided in the form of pictures case examples. Conclusions: The management of a patient with a wide necked cerebral aneurysm is complex, however the continuous development of new neuro endovascular techniques and materials nowadays offer a significantly wider range of therapeutic possibilities in cases of aneurysms with unfavorable size and configurations which have traditionally been treated surgically.


Endovascular Management of Intracranial Dissecting Aneurysms: Single Center Experience

Farouk Hassan

Faculty of Medicine, Cairo University, Cairo, Giza, Egypt.

E-mail: faroukkeden@yahoo.com

Background: Management of intracranial dissecting aneurysms is controversial and technically challenging. The aim of this study is to evaluate the efficacy and safety of different endovascular management strategies. Methods: A retrospective analysis of all patients that underwent endovascular treatment of either ruptured or unruptured intracranial dissecting aneurysms, between 2011 and 2016, at a tertiary care center was performed. The technical and clinical results of different techniques were analyzed. Results: Among our 24 patients, 14 patients had ruptured aneurysms and 10 cases had unruptured aneurysms. Parent vessel occlusion was performed in 12 cases, and artery preserving technique was successfully performed in 8 cases. Two cases showed spontaneous thrombosis of their aneurysms before treatment and 2 cases rebled and died before treatment. Among the 8 cases treated by artery preserving technique, 2 cases were treated by coils, 2 cases by stent-assisted coiling, 2 cases by flow diverter stent, 1 case by balloon assisted coiling and 1 case by 2 braided stents. No procedure related complications. Recurrence occurred in 1 case which is not treated yet. Conclusions: Endovascular approach offers many effective and safe strategies for the management of the intracranial dissecting aneurysms. The involved artery and the collateral circulation should be taken into consideration during decision making.


Sub Arachnoid Hemorrhage: Update in Endovascular Treatment of Intracerebral Aneurysms

Shahzad Karim Bhatti, Umair Rashid

Lahore General Hospital, Lahore, Pakistan.

E-mail: shahzadkbhatti@gmail.com

Background: Sub arachnoid hemorrhage (SAH) is mostly the result of ruptured aneurysms. There are two types of aneurysms, secular and fusiform. Coiling is most prevalent endovascular treatment of sacular aneurysms. Challenge comes for wide neck sacular and fusiform aneurysms. Objective is to assess the latest endovascular treatment of wide necked sacular and especially of fusiform aneurysms. Methods: 178 patients were coiled between Jan 2015 to Nov 2016 in Department of interventional neuroradiology, Lahore General Hospital, Lahore. Patients were of both genders with age ranging from 22-65 yrs. Among them eight had wide neck or fusiform shape, which are difficult to coil by conventional coiling. Results: Out of 178 patients 170 were coiled with conventional coiling. Other eight had either wide neck or are of fusiform in shape. Flow diverters are latest mode of treatment for such aneurysms. Eight flow diverters were deployed five on fusiform and three on wide necked aneurysms. These are nickel cobalt soft stents especially designed for intra cerebral use. Wide necked aneurysms also had partial coiling for further reinforcement. All patients were successfully treated with no complications. Conclusions: Endovascular coiling is better option for treatment of both anterior and posterior circulation aneurysms with less morbidity and mortality. Flow diverters have added another option for endovascular treatment of wide necked and fusiform aneurysms.


Local Experience with a New Retrievable Device for Stroke Thrombectomy in a Tertiary Academic Center

Mohammed Almekhlafi, Dareen Alshaer, Abdulelah Alturkistani, Abeer Khoja, O. Ayub

King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia.

E-mail: malmekhlafi@kau.edu.sa

Background: Intravenous tPA has limitations in treating patients with large vessel occlusion stroke. The use of intra-arterial catheter for mechanical removal of thrombus was approved by FDA in 2004 for using MERCI Retriever. Then retrievable stents were introduced with two randomized trials showing their superiority over the MERCI device. Stents development continued with introduction of other devices including the ERIC device which is believed to have some advantages over the first generation retrievable stents. However, local published experience with the device is lacking. Methods: During a 2-year period at academic center in Jeddah, we conducted a retrospective study of all patients who were treated within 6 hours after the onset of symptoms of acute ischemic stroke and were treated with the ERIC device. All patients had confirmed proximal anterior circulation occlusion and a favorable ASPECT score on neuroimaging. Results: Nine stroke patients were enrolled in this retrospective study. The median age was 60.5 years and the median NIHSS score on admission was 19. Six patients had middle cerebral artery occlusions while one patient had terminal carotid occlusion, one basilar occlusion, and one anterior cerebral artery occlusion. Distal access catheterization was done in all but one patient. Balloon guide catheters were not used. The rate of successful angiographic reperfusion (TICI 2b or 3) with the ERIC device was 67% (six patients) while 22% (two patients) had TICI 2a score due to distal non-target embolization noted on the final angiograms. The 24 h and 7 days median NIHSS were 14 and 9, respectively. The median modified Rankin Scale on discharge was 3 and two (22%) died. One patient had symptomatic hemorrhagic transformation of the infarct. Conclusions: The ERIC device was successfully deployed in all cases and achieved reperfusion in the majority of cases with large vessel acute ischemic stroke.


Role of Trans-Catheter Prostatic Artery Embolization in Management of Benign Prostatic Hyperplasia

Momtaz Thabet Allam Mohammad, Abd Al Kariem Hassan Abd Allah, Moustafa Hashem Mahmoud Othman, Hany Mohammed Abd El Hakeem Seif, Hany Mohammed Abd El Hakeem Seif

Faculty of Medicine, Assuit, Egypt.

E-mail: mthabetallam@yahoo.com

Background: To evaluate the efficacy and safety of prostatic artery embolization as a line of treatment for benign prostatic hyperplasia in patient with moderate to severe lower urinary tract symptoms (LUTS) secondary to BPH after failure of medical treatment. Methods: Twenty patients included in this study and their ages ranged from 43-93 years (mean 68.3 y). All patients complained of moderate to severe LUTS secondary to benign prostatic enlargement. All patients underwent prostatic artery embolization (unilateral n = 5 and bilateral n = 15). The embolizing material used is PVA ranged from (45-250). Patients were followed up using international prostate symptom score (IPSS), prostate volume, quality of life (QOL) and peak flow rate (Qmax). Results: Nineteen patients show IPSS reduction by 0.0-86% (mean 73.68% +/- 16.8), prostate volume reduction by 14.6-41.5% (mean 26.16% +/- 7.8), QOL improvement by 0.0-100% (mean 81.3% +/- 24.34) and Qmax improvement by 36.1-80.5% (mean 62.6% +/- 14.29) after one and three months follow up. Clinical improvement was +/- 95%. One patient shows clinical failure after successful bilateral prostatic artery embolization. No deaths. Minor complications as hematuria and blood in stool occurred in 10% (2 cases) and were self-limited. Conclusions: Prostatic artery embolization is safe and effective line of treatment for patients with moderate to severe LUTS secondary to benign prostatic enlargement after failure of medical treatment. It has low morbidity, good short-term symptomatic control associated with prostate volume reduction and quality of life improvement.


Ultrasound Guided Percutaneous Biopsy of Omentum: A Safest Technique to Detect the Causes of Omental Thickening

Junaid Iqbal, Sadia Rashid

Dow University of Health Sciences, Karachi, Pakistan.

E-mail: junaid2008@gmail.com

Background: The objective of our study was to determine the diagnostic value and safety of ultrasound guided percutaneous biopsy of omental thickening. Methods: We prospectively analyzed 60 patients who underwent USG-guided omental biopsies in our institute from January 2016 to July 2016. Results: Total 60 patients were included in our study. There were 40 (66.7%) female and 20 (33.3%) male patients. There were total 36 (60%) malignant cases, 20 (33.3%) chronic inflammation suggestive of TB while 4 (6.7%) were chronic peritoneal infection. Out of 36 malignant cases, majority 24 (66.7%) had ovarian cancer, 8 (22.2%) had endometrium cancer and 4 (11.1%) had large bowel cancer. Repeat biopsies were performed only in 4 (6.7%) cases. Conclusions: Ultrasound-guided percutaneous biopsy of omentum is less expensive, safe and effective method with a high diagnostic accuracy.


(First place poster presentation prize winner): Role of Interventional Radiology in Removing Unwanted and Misplaced Medical Devices

Omar Bashir, Aesam Duligan, Refaat Salam, Mohammad Arabi, Mohammad Arabi, Mohamed Almoaiqel

King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia.

E-mail: drobashir@gmail.com

A large variety of medical devices are implanted by various specialties. Standard techniques are often successful in removing these implants. Occasionally, these devices are misplaced, lost or embedded in such a way that they require removal using unconventional methods. Interventional radiology techniques permit practitioners to remove these unwanted or misplaced devices in a safe and minimally invasive manner. We present case vignettes highlighting our experience and techniques in dealing with such scenarios. Presented cases include removal of bile ducts stents placed initially with ERCP, “lost” intravascular guidewires, removal of oesophageal stents, removal of needle fragments from soft tissues and removal of embolized catheter fragment from pulmonary circulation. Failure to retrieve misplaced or unwanted medical devices using standard methods is not an uncommon occurrence in hospital practice. Interventional Radiology offers safe and minimally invasive solution in such scenarios.


Percutaneous Management of Benign Biliary Enteric Anastomotic Strictures after Iatrogenic Bile Duct Injuries

Mustafa Belal Hafeez Chaudhry, Nauman Alqamari1, Raza Sayani, Rana Shoaib Hamid2, Rana Shoaib Hamid

The Aga Khan University, 1Dow Institute of Radiology, Karachi, Pakistan, 2Sultan Qaboos University Hospital, Muscat, Oman.

E-mail: belal.ibnehafeez@gmail.com

Background: To assess the technical success, complications and reintervention rate of percutaneous transhepatic balloon dilatation (PTBD) of biliary enteric anastomotic strictures (BES). Methods: A retrospective review of patients who underwent PTBD for benign resistant BES, were previously treated for iatrogenic bile duct injuries, from December 2004 to January 2016 was performed. Diagnostic transhepatic cholangiogram was performed to assess level of obstruction. Strictures were dilated using 8-12 mm diameter balloons followed by placement of 8-10 Fr internal-external drainage catheters, which're removed after 3-5 days post-PTBD cholangiogram. Follow up by clinical assessment, liver function tests and ultrasound was done. Fischer exact test was used to determine if there was a significant association between PTBD sessions and recurrent strictures. Results: In total, 37 patients underwent PTBD including 10 (27%) males and 27 (73%) females. Mean age was 41.3 yrs.(range 23-70 yrs.). Out of these, 29 (78.4%) were treated with choledochojejunostomy and 8 (21.6%) with hepaticojejunostomy. 100% success was achieved in all the PTBD sessions. 19 (51.3%) patients were treated with a single PTBD session. Mean follow-up time was 36 months (Range 1–75 months). 2 (5.4%) patients were lost to follow up after first session of PTBD. 18 (48.7%) patients needed reintervention, out of these, 11 (29.7%) were symptom free after second session on 3 year follow up, 3 (8.1%) were symptom free after the third session of PTBD. No significant difference in risk of recurrent strictures after 1st and 2nd PTBD sessions [18 (48.7%) vs. 7 (39%); P < 0.5716]. In 4 (10.9%) patients, the symptoms persisted and the stricture recurred even after third session and were treated by placing metallic stent. In total, 3 (8.1%) patients got complicated with the stone formation; in 2 (5.4%) patients it was successfully removed percutaneously and in 1 (2.7%) percutaneous attempt failed followed by surgical removal. Conclusions: PTBD is a safe and useful treatment option for BES for long-term symptoms free time-period. However, there is no significant difference in developing recurrent BES after PTBD sessions. Few patients with resistant strictures might require stent placement.


Articular Cartilage Protection with Temperature Monitoring During Percutaneous Tumor Thermal Ablation: Novel Technique

Salem Bauones1,2, Julien Garnon2, Georgia Tsoumakidou2, Roberto L Cazzato2, Afshin Gangi2

1King Fahd Medical City, Riyadh, Saudi Arabia, 2University Hospitals of Strasbourg, Strasbourg, France.

E-mail: sa.bauones@gmail.com

Background: Objective: To review our initial experience in acetabular cartilage protection from thermal injury with temperature monitoring during percutaneous image-guided tumor thermal ablation. Methods: Between June 2015 and May 2016, three consecutive oncologic patients (mean age 58 years; range 48-67 years) with acetabular bone metastasis underwent percutaneous image-guided thermal ablation procedures along with hip joint cartilage thermal monitoring. Owing to the close proximity of the metastatic lesion to the acetabular articular cartilage, a thermocouple was placed under CT and fluoroscopic guidance, immediately near to the acetabular roof and next to the ablation zone in order to measure the reached local temperature near to the cartilage. Stand-alone thermal ablation (n = 1) and Combined thermal ablation with cementoplasty (n = 2) had been performed to optimize local palliation or disease control. Follow-up was undertaken every few weeks. Clinical and radiological outcomes at follow-up were assessed. Results: Three acetabular metastases were treated with thermal ablation and temperature monitoring of the acetabular articular cartilage during the ablation procedure. Mean size of lesions was 1.6 cm (range 1.5-2 cm). Technical success was achieved in all cases (100%), without complications. No hip cartilage damage on MRI. Good palliation and local disease control in two cases. One case showed local recurrence and distant progression of his metastatic disease after 27 weeks of follow-up. Conclusions: Temperature monitoring of the articular cartilage during percutaneous image-guided thermal ablation appears technically feasible with good short-term efficacy in this complex patient subset. Further studies are warranted to confirm these promising initial results.


The Efficiency of Tanshepatic Biliary Decompression in Patients with Failed Endoscopic Therapy

Elie Lteif, Abbas Chamsuddin, Raja Ashou

University of Balamand, Saint George University Medical Center, Beirut, Lebanon.

E-mail: achamsuddin@beirutclis.com

Background: To evaluate the efficiency, indications, outcome, complications and safety of Percutaneous Transhepatic Biliary Decompression (PTBD) in patients with benign and malignant biliary obstruction and failed endoscopic therapy. We report a single-center experience of percutaneous biliary drainage in patients with biliary obstruction salvaged with PTBD at St. Georges Hospital University Medical Center (SGHUMC). Methods: This study was approved by our institutional review board. Over a period of 18 months (January 2015-June 2016), Endoscopic Retrograde Cholangiopancreatography (ERCP) was performed on 44 patients with biliary obstruction. Of these, 39 patients had malignant obstruction, and 4 patients had benign stone-related obstruction. Failure to properly intubate the ampulla and decompress the biliary tree through the retrograde endoscopic approach by experienced gastroenterologists occurred in 14 patients. These 14 patients were then referred for PTBD. Insertion of biliary drains was performed under fluoroscopic, ultrasound or CT scan guidance by interventional radiologists using Acustik sets and biliary drainage catheters ranging from 10-22 French calibers. Results: Drainage and decompression of the biliary system was successful in all 14 patients. 12 patients had malignant obstruction, 1 patient had occluded pre-placed metallic stent by debris and pus and one patient had a stenotic bilioenteric anastomosis with inadequate history of previous surgery prior to ERCP. Rendez-vous technique was used in 2 patients for eventual placement of metallic stents. Clinical improvement evidenced with dropping bilirubin levels, resolving jaundice and sepsis-related symptoms were seen in all patients. Two-step external drainage with later conversion to internal metallic-stent drainage was performed in 2 patients. Single-step internal-external drainage was performed in 12 patients. No major complications were reported. Minor complications included fever, self-limiting intra-catheter bleed, skin infection, transitional catheter blockage and partial catheter dislodgment. Conclusions: PTBD remains an efficient method in the treatment of biliary obstruction in patients with failed retrograde endoscopic therapy. Our small series shows that PTBD remains the final resort in patients with failed endoscopic therapy in addition to its proven role as an initial approach for biliary decompression.


To Compare the Efficacy and Complications of 16 Gauge and 18 Gauge Trucut Biopsy Needle in Ultrasound Guided Percutaneous Liver Biopsies

Sadia Rashid, Junaid Iqbal

Dow University of Health Sciences, Karachi, Pakistan.

E-mail: dr_sadiarashid@yahoo.com

Background: Ultrasound guided percutaneous liver biopsy is the gold standard for characterization of liver lesions and determination of diffuse liver disease and liver fibrosis. It is an easy but invasive method which sometimes may cause severe complications. Methods: This is a prospective study conducted from January 2016 to December 2016. A total of 426 patients were included in the study, out of which 244 (57.3%) were males while 182 (42.7%) were females. Mean age of the patients was 54.62 ± 13.25 years. 202 (47.41%) patients underwent liver biopsy by 16 gauge trucut biopsy needle while 224 (52.58%) patients had biopsies using 18 gauge needle. Results: Overall, mild pain was found in 86 (20.2%) patients, severe pain in 36 (8.5%) patients, vasovagal in 13 (3.1%) patients, local hematoma in 12 (2.8%), severe hemorrhage in 3 (0.7%), pneumothorax in 2 (0.5%) patients while 20 (4.7%) samples were inadequate. Comparison of complications in both groups showed that except inadequate specimen and severe pain, insignificant association of complications was observed in both group. Number of inadequate specimen was significantly higher in patients who underwent biopsy by 18 gauge trucut needle as compared to the patients who underwent biopsy by 16 gauge needle (P value 0.001). Severe pain was significantly higher in patients who underwent biopsy by 16 gauge needle as compared to 18 gauge needle (P value 0.016). Conclusions: Ultrasound guided percutaneous liver biopsy using either 16 or 18 gauge trucut needle is safe and effective method to characterize liver lesions with very low rate of complications. However 16 gauge needle should be preferred as the inadequacy of specimen in our study was higher for 18 gauge needle.


Percutaneous Cryoablation of Symptomatic Abdominal Wall Endometriosis: Mid-Term Outcomes and Comparison with Surgery Alone in a Single Institution

Francois H. Cornelis, Julie Maillot1, Jean Luc Brun1, Nicolas Grenier1

Tenon Hospital, Paris, 1Pellegrin Hospital, Bordeaux, France.

E-mail: francoiscornelis@hotmail.com

Background: To compare the outcomes of percutaneous image-guided cryoablation of symptomatic abdominal wall endometriosis (AWE) versus surgery alone. Methods: From 2004 to 2016, cryoablation or surgery alone was performed for AWE in a single institution in 7 (mean age: 36.1 y) and 13 (mean age: 31.9 y) patients, respectively. Fifteen lesions were treated by cryoablation (mean size: 2.3 cm; range 0.5-7 cm) and 16 by surgery (2.5 cm; 1.1-3.4 cm). Tolerance, efficacy and patient and procedural characteristics were compared. Results: Median follow-up was 22.5 (range: 6-42) months after cryoablation and 54 (14-149) after surgery. The median procedure and hospitalization durations were 41.5 minutes (24-66) and 0.8 days (0-1) after cryoablation, and 73.5 minutes (35-160) and 2.8 days (1-12 days) after surgery (both P = 0.01). Fifteen patients had general and 5 had local anesthesia (3 cryoablations and 2 surgery). Three patients (23.1%) had severe complications and 9 esthetic sequels (69.2%) after surgery, none after cryoablation (P = 0.05). The median 12 and 24-month symptom free-survival rates were 100% and 66.7% [95%CI: 5.4; 94.5] after cryoablation and 92% [55.3; 98.9] after surgery at both time points (P = 0.45). Conclusions: Cryoablation presents similar effectiveness to surgery alone for local control of AWE while reducing hospitalization duration and complications.


Efficacy of Trans-arterial Chemoembolization in Combination with Percutaneous Ethanol Injection for Hepatocellular Carcinoma

Muhammad Shozab Ahmed, Atif Rana, Maham Jehangir

Shifa International Hospital, Islamabad, Pakistan.

E-mail: muhammedshozab@gmail.com

Background: To evaluate combined efficacy of trans-arterial chemoembolization (TACE) using drug eluting beads, Hepasphere (Merit medical, USA), with percutaneous ethanol injection (PEI) for hepatocellular carcinoma (HCC) a retrospective review was conducted. Methods: During January 2015 to January 2017, 34 patients with hepatocellular carcinoma underwent combined therapies (TACE + PEI). Out of these two patient's were excluded because lipid was used.The tumour response at 3 months, 6 months, 12 months and 24 months was evaluated using a pre-defined criterion. Results: Most of the tumours were located in right lobe. The tumour size ranged from 1-10 cm with mean size of 4.2 cm. The average amount of alcohol used was 12 ml. The tumour response rates in the combined TACE + PEI showed more than 90% reduction in arterialisation at 3 and 6 months' follow-up in 16 (50%) patients, while at 12 months' follow-up this response decreased to 13 (40%) tumours. 6 (18%), patients showed approximately 60-90% reduction of arterialization, while only in 2 (0.06%) patients no response was observed and in one patient disease progression was observed at three months followup. Conclusions: In terms of the effect on the tumour response, combined TACE + PEI therapy was an effective in controlling the disease process.


Response of Intra-Arterial Chemoembolization Using Hepaspheres in Hepatocellular Carcinoma – Our Initial Experience

Sadia Sajid, Atid Rana, Shams Barki, Najam Ul Hassan, Najam Ul Hassan

Shifa International Hospital, Islamabad, Pakistan.

E-mail: dia.sajid.ds@gmail.com

Background: To retrospectively assess the response of intra-arterial chemoembolization using hepasheres in patients of hepatocellular carcinoma. Methods: Being tertiary care facility and largest liver transplant center in the country, our Center is a primary referral center for patients of hepatocellular carcinoma. From March 2014 to November 201, 38 patients (27 males and 12 females) with 43 hepatocellular carcinoma lesions fulfilled the criteria for intra-arterial chemoembolization and underwent the procedure. All the patients were evaluated with follow up dynamic CT and/or MRI six weeks after the procedure using modified response evaluation criteria in solid tumors (mRECIST). Results: Mean size of the lesions was 4.9 cm (range 1.1 to 10 cm). Child- Pugh score was A in 26 patients and B in 12 patients. Technical success rate of TACE was 100%. No major complications were documented. Complete response was observed in 13.9% of lesions whereas partial response in 65.1%of lesions, 13.9% of lesions remained stable and progressive disease was documented in 13.9% of lesions. Conclusions: Our initial experience shows, in patients of unresectable HCC, TACE using hepasheres is a safe option with good response.


Efficacy of Ultrasound Guided Foam Sclerotherapy in Treatment of Chronic Venous Ulcer and Controlling Ulcer Induced Pain: An Egyptian Experience

Ahmed Hassan El Sayed Mohamed Soliman, Ahmed Hassan Elsayed Mohamed Soliman, Haytham Mostafa1

Faculty of Medicine, Ain Shams University, Cairo, 1Ismailia Oncology Hospital, Ismailia, Egypt.

E-mail: hanan.mostafa@kasralainy.edu.eg

Background: Chronic venous ulcers forms about 75% of leg ulcers as severe sequel of chronic venous insufficiency and venous hypertension, associated with pain affecting patient's quality of life. Our objective is assessment of ultrasound guided foam sclerotherapy in treatment and control of pain of chronic venous ulcer. Methods: A prospective study is conducted on 60 patients with 65 ulcers to evaluate the efficacy of ultrasound guided foam sclerotherapy injection in management of chronic venous ulcers. Patient follow up is done regards ulcer healing. Numerical pain score after 72 hours, 1 week and on follow up visits. Duplex scans were done preprocedural and after 1st week, 3 months and 6 months. Results: A total of 65 legs were treated in 60 patients had the procedure done, age (30 to 70); 23 patients (38%) were CEAP 5, 42 patients (70%) were CEAP 6. Fifty ulcers (76%) healed after the 1st month follow up becoming 59 (90%) after 3 months then 62 (95%) at 6th month. No recurrence appeared after the first month, 6 appeared after 3 months (9%) and 9 recurred after six months follow up (13%). Numerical pain score showed 75% of patients' pain relief after 72 hrs, 100% relief after 1 week. Conclusions: Foam sclerotherapy shows significant efficacy in venous ulcer healing and reduction in ulcer induced pain in 72 hours reaching complete pain resolution after 1 week.


Case Reprot: Management of Cervical Ectopic Pregnancy with Uterine Artery Embolization

Nabih Diab, Chadi Diab, Younis Alazzawi, Mel Ghaleb

Texas Tech University Health Science Center, El Paso, Lubbock, Texas, United States of America.

E-mail: nabih.diab@ttuhsc.edu

Background: We present a rare case of cervical ectopic pregnancy managed by Interventional Radiology. A 44-year old female presented to the ER with complaints of dizziness, fatigue, non radiating left pelvic pain and 5 days of heavy vaginal bleeding with clots. The patient denied ongoing pregnancy, any prior similar episodes or any additional symptoms. Methods: The speculum exam showed large bulging hyper vascular cervix actively bleeding with clots. No purulent discharge was noted. The bladder was not palpable and non-tender. Otherwise, the physical exam was unremarkable. Beta-HCG levels were elevated (71964 mIU/ml). Sagittal transvaginal ultrasound of the uterus demonstrated an empty uterine cavity with intracervical normal appearing gestational sac containing a fetal pole (CRL of 1,65 cm), amnion and yolk sac. The patient was counseled for the available therapeutic options including surgical management versus a combination of medical and embolization and opted for the latter. In the IR-suite, the patient underwent a selective embolization of the uterine arteries with Gelfoam. Results: Post embolization, the patient's bleeding decreased significantly which manifested in significant improvement in the vital signs. The patient was started on a Methotrexate regimen. After 2 days, the patient's Beta-HCG dropped to 3,646 mIU/ml and she was discharged home. On her 1 month follow-up appointment, the patient denied any cramping, discharge or bleeding. Conclusions: In cases in which patients decide to avoid surgical options, Interventional Radiology offers alternatives approaches. This case report has demonstrated the efficacy of managing ectopic pregnancies by a combination of embolization and medical therapy.


Emergency Tranarterial Embolization of Ruptured Hepatocellular Carcinoma

Aya Essam Hanafy Ahmed, Karim Abd El Tawab

Ain Shams Hospitals, Cairo, Egypt.

E-mail: ayaessam894@gmail.com

Background: Spontaneous rupture of hepatocellular carcinoma (HCC) is relatively rare emergency condition carrying high rates of mortality. Patients usually present with hemodynamic instability and hemoperitoneum. Rate of post management success depends on various conditions most important of which is the patient's hemodynamic status upon presentation, proper diagnosis, liver function, and future liver remnant. The aim of our study was to assess the short term outcome bleeding arrest by angioembolization for cases with rupture HCC. Methods: From December 2014 till December 2016, five ruptured HCC cases diagnosed clinically and radiologically were referred to Ain Shams University Hospitals IR unit for emergency angioembolization. Full lab studies and imaging were taken. Hand cut Gel foam was the embolic agent used. Results: Technical success defined as catheterization of the HCC feeding vessel with cessation of tumoral blush on control angiogram was achieved in 100% of cases 3 cases were HCC from the left lobe and 2 from the right lobe. Clinical success defined as cessation of bleeding denoted by rise of HgB concentration on blood transfusion and achieving hemodynamic stability was achieved in 100% of cases within the first 3 days. 1 case died one week after the procedure from massive oesophageal varices bleeding. Another died during hospital admission from hepatic decompansation status affecting renal functions. 3 patients ar still under their regular follow up. Conclusions: Emergency transarterial angioembolization for ruptured HCC carries high technical and clinical success rates aiming at hemodynamic stability and bleeding cessation.


Testicular Infarction, a Complication of Preoperative Renal Embolization with Embospheres and Gelfoam: A Case Report

Husameddin M. El Khudari, Mani Razmjoo, Gregory Berberian

Saint Vincent Hospital, Worcester, United States of America.

E-mail: drhusameddin@gmail.com

Background: Renal artery embolization (RAE) has a wide range of indications including preoperative embolization of renal cell carcinomas and treatment of benign renal tumors for potential hemorrhagic complications. RAE is considered generally safe and effective, however it is not without potentially serious complications. We present a case of right testicular infarction following right renal embolization for a renal cancer using Embospheres and Gelfoam. Case Report: A 59-year-old male with large right renal cell carcinoma invading the renal vein, underwent preoperative right renal artery embolization using embospheres and gelfoam to decrease intraoperative hemorrhage and the need for post-operative transfusion. During the procedure a small uretral artery was seen arising from the distal right renal artery. Following the procedure the patient underwent right nephrectomy with minimal bleeding intraoperatively and estimated blood loss of less than 200 ml. On postoperative day 2, the patient developed right testicular pain and swelling. Physical examination showed mild right scrotal swelling and skin edema. Scrotal ultrasound showed heterogenous right testicle with decreased vascularity and absent arterial waveforms, although some venous waveforms were demonstrated. Small to moderate right hydrocele with debris. The patient was managed conservatively, with progressive improvement. On follow-up the patient reported resolution of the symptoms and scrotal ultrasound showed interval improvement in the right testicle vascularity with demonstration of both venous and arterial waveforms. Conclusions: Small renal arterial branches and connections are potential route for non-target embolization during renal artery embolization, leading to potentially serious complications including testicular infarction.


Endovascualr Embolization of Brain Arterio-Venous Malformations Using Extended Onyx Injection Technique

Waseem Aziz1,2

1Tawam Hospital, Al Ain, United Arab Emirates, 2Alexandria University, Alexandria, Egypt.

E-mail: wasemaziz@gmail.com

Background: To report our experience in the treatment of brain arteriovenous malformations using extended Onyx injection technique (ev3, Irvine, Calif). Methods: From November 2010 to Agust 2014, 22 patients with brain arteriovenous malformations were treated endovascularly. They were 9 men and 13 women with a mean age of 32 years. A total of 34 endovascular procedures were performed with Onyx as the sole embolic agent. Results: The course of endovascular treatment was completed in 18 patients. In 8 patients, an angiographic cure was achieved using embolization as the sole therapeutic technique. 6 patients underwent radiosurgical treatment after nidal size reduction <2 cm was accomplished by endovascular treatment. 4 cases underwent surgery after embolization. Further endovascular treatment was planned in 4 patients, Procedure-related transient neurologic deficits were observed in 1 patient, experienced mild transient hemiparesis resolved soon after treatment. There were no procedure related permanent morbidity or deaths. Conclusions: Onyx allows obtaining higher rates of anatomic cures compared with those obtained previously with other embolic agents in the treatment of brain arteriovenous malformations.


Percutaneous Direct Intrahepatic Porto Systemic Shunt in Chronic Budd Chiari: Techniques and Report of Four Cases

Mohammad Arabi, Essam Dulagian, Yousof Alzahrani, Shahbaz Qazi

King Abdulaziz Medical City, Riyadh, Saudi Arabia.

E-mail: marabi2004@hotmail.com

Background: To describe the techniques of percutaneous direct intrahepatic porto systemic shunt (DIPS) in chronic Budd Chiari syndrome and report the technical and clinical success in four patients. Methods: Between Aug 2015 and Dec 2016, four patients (2 males) with mean age of 40.7 years (23-65 years) presented with chronic Budd Chiari due to hypercoagulable state (n = 3). Patients presented with progressive liver failure (Child-Pugh score B7-B9) and refractory ascites (n = 4) with grade 3 esophageal varices (n = 1), medically treated hepatic encephalopathy. Patients had mean BCS-TIPSS score of 4.4 (3.3-6.2) with complete chronic occlusion of hepatic veins (n = 4) and IVC occlusion (n = 1). Two patients failed previous attempts of hepatic vein recanalization and IVC stenting, retrospectively. All patients underwent ultrasound and fluoroscopy guided percutaneous direct intrahepatic porto systemic shunt creation extending from the right portal vein to IVC. One patient had IVC recanalization along with shunt creation. Results: All procedures were technically successful with no procedure related complications. One patient required shunt revision 3 days later with portal stent extension due to shunt thrombosis. All shunts remain patent at mean follow up time of 205 days with resolution of ascites in 3 patients. One patient had decreased frequency of drainage due to associated nephrotic syndrome and hypo albuminemia. All patients required life-long anticoagulation with warfarin. Conclusions: Percutaneous direct intrahepatic porto systemic shunt creation in chronic Budd Chiari is technically feasible and safe with good short term outcomes.


Microwave Ablation of Hepatocellular Carcinoma Using a New Percutaneous Device and Results of Combination Therapy: Preliminary Results

Muhammad Fiaz, Ammara Saeed1

Superior University, 1Alrazi Hospital, Lahore, Pakistan.

E-mail: muhammad.fiaz@alrazihealthcare.com

Background: Thermal ablative techniques have gained increasing popularity as safe and effective options for patients with unresectable solid malignancies. Microwave ablation has emerged as a relatively new technique with the promise of larger and faster ablation areas without some of the limitations of radiofrequency thermal ablation. Methods: Under ultrasound and CT guidance 30 HCCs in 22 patients were treated through a percutaneous approach. The median diameter of lesions was 2.3 cm (range = 2.0-8.0 cm); 14 lesions had a diameter greater than 30 mm. We used a microwave generator (ECO for Microwave Ablation) connected to a 14- or 16-gauge coaxial antenna. Contrast-enhanced computed tomography scan was carried out one month after treatment, and then every three months to assess efficacy. Results: Complete ablation was achieved in 84.3% of the lesions after a mean of 1.03 percutaneous sessions. For small HCCs (diameter <3 cm) complete necrosis was obtained in 100%. Local tumor progressions were found in 3 treated lesions (15.1%) a median of 10.5 months after ablation. Minor complications occurred in 5.1% procedures. No deaths, or other major complications occurred. Conclusions: In our experience, the new device for microwave ablation proved to provide an effective and safe percutaneous ablative method, capable of producing large areas of necrosis. Combination therapy with microwave ablation followed by TACE is very good tool for large sized tumours.


Laser Sheath Assisted Removal of Optease Filters with Long Dwelling Time

Mohammad Arabi

King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia.

E-mail: marabi2004@hotmail.com

Background: To evaluate the feasibility and safety of laser sheath assisted removal of IVC filters with long dwelling times. Methods: Between December 2015 and December 2016, three patients underwent laser sheath assisted filter removal. All patients had prophylactic filter placement following trauma and prior to orthopedic surgery. Filters were infra renal Optease with mean dwelling time was 510 days (210-720 days). All patients had failed previous retrieval attempts using standard techniques, and were prescribed prophylactic anticoagulation therapy. Glidelight laser sheath was used (12 or 14 Fr) to disengage the filter from the IVC wall. The sheath was operated at 60 mjoule/mm with pulse repetition rate between 60-80 Hz. Two filters were removed via femoral access and one was removed from jugular access as the hook was embedded in the occluded right iliac vein. Results: Laser sheath assisted filter removal was technically successful in all patients. The mean fluoroscopy time was 55 minutes (4-118 minutes) and the mean total DAP was 101410 mGyCm2. Two patients had IVC stenosis following retrieval and responded adequately to balloon dilatation. No major complications were encountered. Patients were prescribed prophylactic enoxaparin for 10 days post procedure. Abdominal CT scan at 1 month was done in two patients, showed patent IVC with no stenosis or thrombosis. All patients discontinued the pre-procedure anticoagulation therapy. Conclusions: Laser sheath assisted filter removal of Optease filters with long dwelling time is feasible. Safety of this technique is yet to be proven in a larger patient cohort.


Peritoneal Decompression Devices: Introduction to IR Nurses

Khalid Othman, Mohammad Arabi, Azzam Khankan

King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia.

E-mail: othmankh@NGHA.MED.SA

This educational poster introduces peritoneal decompression devices to IR nurses and briefly discusses how to maintain them in patients with malignant ascites. Malignant ascites (MA) is the cancer-associated accumulation of fluids in the peritoneal cavity. The most gastrointestinal tract tumors that are frequently associated with MA include pancreatobiliary, gastric, esophageal and colorectal cancers. MA associates with significant morbidity and poor prognosis with median overall survival of 1-6 months. Symptomatic MA is a significant clinical challenge due to considerable reduction in the quality of life (QoL) with no generally accepted guidelines for the management of MA. The main goal of the peritoneal decompression is to palliate the symptoms of elevated intra-abdominal pressure (discomfort, dyspnea, nausea, and vomiting) and improve QoL. Paracentesis is indicated for symptomatic ascites which can be relieved by draining up to 5 L of fluid. Peritoneal decompression devices (PDDs) help in maximizing time spent out of hospital. They include external drainage catheter devices and peritoneovenous shunts. These devices are placed under strict aseptic techniques, imaging guidance and sometimes-moderate sedation on outpatient or one-day surgery basis at the interventional radiology suites. However, to date, none of these different devices has been subjected to evidence-based clinical trials.


Selective Salpingography and  Fallopian tube More Details Interventions: An Educational Poster

Alharbi Abdulaziz, Arabi Mohammed, Aldulaigan Essam, Alammri Sultan, Alammri Sultan

King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia.

E-mail: Deebk010@hotmail.com

Fallopian tube disease is a major cause of infertility. Hysterosalpinogram and selective salpingography may reveal the underlying pathology. Fallopian tubes recanalization or embolization may help improving the pregnancy rate in cases of tubes obstruction or hydrosalpinx, respectively. Fallopian Tube Recanalization: Obstruction of the uterine (proximal) segment of the fallopian tube can be seen in 10-20% of hysterosalpingograms and has a variety of underlying causes. Selective salpingography and fallopian tube recanalization may improve pregnancy rate by 15-60% within one year. Fallopian Tubes Embolization: Hydrosalpinx accounts for 10-30% of tubal pathologies in patients with secondary infertility, and it may affect the outcome of in vitro fertilization by reducing the probability of implantation and by increasing the risk of early pregnancy loss. While tubal embolization may not increase the rate of pregnancy, it may reduce the risk of abortion.


Ultrasound-guided Thrombin Injection for Management of Iatrogenic Pseudoaneurysm: A National Institutional Experience

Alharbi Abdulaziz, Guzaiz Noha, Qazi Shahbaz, Salman Refaat

King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia.

E-mail: Deebk010@hotmail.com

Background: Iatrogenic pseudoaneurysms (IPAs), are identified with increasing frequency in current clinical practice. Although small pseudoaneurysms (less than 1.0 cm in diameter) are usually asymptomatic, larger pseudoaneurysm can be painful and symptomatic require treatment. The aim of the study is to demonstrate our experience regarding the efficacy of ultrasound guided thrombin injection in the management of iatrogenic groin pseudoaneurym. Methods: From 2007 to 2016, 61 pseudoaneurysms were injected with thrombin under ultrasound guidance using 20 to 25G needles. A total of 36 men and 21 women underwent this procedure with mean age of 62.3 years. The aneurysms were developed due to either non-ultrasound guided femoral arterial puncture prior cardiac catheterization (54 cases) or ultrasound guided femoral arterial puncture for abdominal arterial interventions (3 cases). All of the pseudoaneurysms were in the groin, 48 from the common femoral artery, 6 from the superficial femoral artery and 3 from the external iliac artery. Thrombin was injected under US guidance until achieving complete thrombosis in all cases. Thrombin dose ranged from 100 to 5000 IU depending on the size of the pseudoaneurysm. Results: Complete thrombosis of the pesudoaneurysm was achieved in 54 cases with a single injection of thrombin. Two case required second injection of thrombin to achieve thrombosis and one case required stenting due to incomplete thrombosis. No complications related to thrombin have been encountered. Conclusions: Ultrasound-guided thrombin injection is effective and safe in the management of iatrogenic pseudoaneurysms.


Successful Endovascular Control of Acquired Uterine Arterio-Venous Malformations Using N-Butyl Cyanoacrylate and Polyvinyl Alcohol Particles

Shady Nabil Mashhour

Kasr Al Ainy, Cairo University, Cairo, Giza, Egypt.

E-mail: Shady.mashhour@gmail.com

Background: Uterine arteriovenous malformations are rare. However, they may present with life threatening bleeding. Traditionally hysterectomy is the mainstay therapy for these patients, however, increasing reports of successful control using endovascular techniques have recently surfaced using various embolic agents and techniques. Here we report two cases of acquired uterine arterio-venous malformations managed successfully using NBCA and PVA and their midterm follow up. Case Report: Two cases were refereed to our interventional radiology department diagnosed by Doppler US and MRI as having uterine AVMs. The first cases presented with menometrorrhagia and significant blood loss during menstruation which necessitated blood transfusion on two separate episodes and refused to undergo hysterectomy. The second case presented in a state of hemodynamic shock following an attack of bleeding and had failed surgery due to extensive pelvic adhesions. Using standard endovascular techniques both uterine arteries were catheterized; glue was injected into the dominant feeding side and PVA was injected in the contralateral side. Both patients returned to their normal menstrual cycle with good control of bleeding. Clinical and radiological follow up was maintained for 29 month and 14 month for the cases, respectively. Conclusions: Endovascular management is a viable alternative in the control of uterine arterio-venous malformations in patients not eligible for surgery.


Uterine Artery Embolisation for Post-partum Haemorrhage Associated with Placenta Accreta and AV Malformation: Case Report and Review of Literature

Mohamad S. Hamady

Imperial College, London, United Kingdom.

E-mail: m.hamady@imperial.ac.uk

Background: Post partum haemorrhage secondary to placenta accrete is a serious complication of childbirth. The current available treatment ranges from emergency hysterectomy to uterine artery embolisation. We describe a patient who presented with PPH in whom retained placenta accreta associated with vascular malformation was successfully treated with uterine artery embolisation together with review of literatures. Case Report: A 38-year old nulliparus presented with significant post partum haemorrhage of 3.6 Liters, intially controlled by packing. Five weeks post partum, the patient presented with recurrent unprovoked bleed. Ultrasound and Magnetic Resonance Angiography (MRA) were demonstrated retained placental tissue with dilated vessels and increased vascular flowconsistent with retained placenta accreta and vascular malformation. First session embolisation was performed using Embospheres particles 700-900 microns (Merit Medical Inc., USA). A second embolisation procedure was carried out via the left CFA using micro coils (Boston Scientific, Watertown, MA, USA) and gelfoam pledges until complete occlusion was achieved. Two months post-partum, the patient presented complaining of foul smelling vaginal discharge, due to necrotic placenta and received full course of antibiotics with dilatation and curettage. Follow-up US demonstrated no residual vascular malformation. Conclusions: Placenta accreta and uterine AVMs are recognised causes of uterine bleeding. Uterine artery embolization is an alternative treatment for uncontrolled postpartum haemorrhage and an effective treatment for acquired AVM's outside of pregnancy.


Staged Percutaneous Ultrasound Guided Bleomycin Sclerotherapy Could be a Promising First Line of Treatment for Orbital Lymphatic Malformations in Children

Omar Abdelaziz, Farouk Hassan, Rania Al Essawy, Karim Bakr

Cairo University Hospital Kasr Al-Ainy, Cairo University Hospital, Cairo, Giza, Egypt.

E-mail: ohamada@yahoo.com

Background: Orbital lymphatic malformations are benign vascular lesions that can be challenging to treat. Although a conservative approach is preferred in small lesion, larger ones may cause amblyopia if treatment is delayed. Surgical debulking is difficult with an associated risk of haemorrhage or collateral damage. We aim to evaluate the effectiveness and safety of ultrasonographic and fluoroscopic guided intra-lesional Bleomycin injection sclerotherapy in cases of orbital lymphatic malformations in children. Methods: In this prospective study, 4 children diagnosed with unilateral orbital lymphatic malformations (from June 2015-February 2016) were subjected to repeated percutaneous ultrasound and flouroscopic guided Bleomycin injections (2000-2500 iu each) after accurate assessment of extent, size and cystic architecture by Magnetic Resonance Imaging (MRI). All children presented with disfiguring proptosis with or without subconjunctival or eyelid extension of the lesion. MRI was repeated after 2 months of injection for radiological assessment. Results: An acceptable clinical improvement of proptosis as well as a diminution in more than 50% of the volume of the lesion by MRI and replacement of the bright signal by low signal ill defined area with the disappearance of cysts was achieved in all subjects after an average of 3 to 6 injections (2 months interval). Except for a transient painful oedema of the periorbital tissue for few days after injection, no major complications were noted. Follow up 8-15 months. Conclusions: Intralesional Bleomycin therapy could be a safe and effective first choice treatment for children with orbital lymphatic malformations.


Safety Assessment of Continuous Versus Discontinuous Warfarin Therapy in Cardiovascular Endovascular Procedures: Observations from a Meta-analysis

Nadia Hussain, Amira Ahmed

Al Ain University of Science and Technology, Al Ain, United Arab Emirates

E-mail: nadia.hussain@aau.ac.ae

Background: Endovascular procedures are commonly performed in patients with a history of anticoagulation treatment. Proper balance between reduction of thromboembolic events and the risk of bleeding is necessary to improve perioperative patient outcomes. Anticoagulation achieved with oral medication is not easily reversible, thus many patients are advised to discontinue warfarin and are given heparin before endovascular procedure. An alternative strategy, to perform endovascular procedures in patients without interruption of anticoagulation therapy, has been adopted. In our study we conducted a meta-analysis of complication rates and outcomes in patients undergoing endovascular procedures who receive continuous versus discontinuous warfarin therapy. Methods: Literature published between 2000 and 2015 was searched for reports of comparative studies of vascular procedures. Information on periprocedural complications and patient deaths less than 30 days after the procedure was extracted. A random effects model was used and odds ratios (ORs) were reported. An OR of less than 1 was considered to indicate lower risk of the outcome with discontinuous warfarin therapy. Meta-analysis was conducted by using meta-analysis software. Results: A total of 32 studies of 15,326 patients were included. For arterial procedures, there were no significant differences between the continuous versus discontinuous warfarin therapy groups in access site hematoma (OR, 0.59; 95% confidence interval [CI]: 0.33, 1.03; P =0.06), any bleeding complications (OR, 0.56; 95% CI: 0.30, 1.06; P =0.07), mortality (OR, 1.40; 95% CI: 0.37, 5.25; P =.62), intracranial hemorrhage (OR, 0.55; 95% CI: 0.03, 8.91; P =.68), ischemic stroke (OR, 0.85; 95% CI: 0.12, 5.84; P =.87), and major bleeding (OR, 0.56; 95% CI: 0.21, 1.51; P =.25). For venous procedures, uninterrupted warfarin was associated with lower odds of access site hematoma (OR, 0.70; 95% CI: 0.50, 0.99; P =.04), any bleeding complications (OR, 0.61; 95% CI: 0.48, 0.77; P <.01), ischemic stroke (OR, 0.21; 95% CI: 0.10, 0.45; P <.01), and major bleeding (OR, 0.64; 95% CI: 0.51, 0.80; P <.01). For arterial and venous procedures combined, uninterrupted warfarin was associated with lower odds of access site hematoma (OR, 0.68; 95% CI: 0.51, 0.91; P =.01), bleeding complications (OR, 0.59; 95% CI: 0.48, 0.74; P <.01), ischemic stroke (OR, 0.25; 95% CI: 0.12, 0.50; P <.01), and major bleeding (OR, 0.61; 95% CI: 0.49, 0.77; P <.01). Heterogeneity in most analyses was low, and confidence in the estimates was moderate. Conclusions: Continuous perioperative warfarin therapy is safe for patients undergoing arterial procedures, but discontinuous warfarin may be preferred for those undergoing venous procedures; no differences in outcome rates were found in the randomized controlled trials. Future studies are required to confirm these results.


Single Centre Experience Using Ekos-Catheter-Directed Thrombolysis in the Management of Acute Sub-Massive Pulmonary Embolus

Charles Hall, Mohamad Hamady, Taranpal Bansal, William Oldfield1, Robert Thomas

Departments of Radiology and 1Medicine, Imperial College Healthcare NHS Trust, London, United Kingdom.

E-mail: charlie.hall@imperial.nhs.uk

Background: Acute pulmonary embolism (PE) results in approximately 150,000 deaths per year in the United States. Massive PE results in haemodynamic instability. Patients with a sub-massive PE have a large embolus burden with evidence of right ventricular dysfunction (RV/LV ratio >0.9) but are haemodynamically stable. A Lancet review estimates the 3-month mortality rate for sub-massive PE is 21%. The treatment for massive PE is systemic intravenous tissue plasminogen activator (tPA) therapy. A beneficial reduction in all-cause mortality in these patients is attenuated by the 3-5% risk of catastrophic intracerebral haemorrhage. For haemodynamically stable patients with sub-massive PE, the current standard of care is anticoagulation. Our institution presents three patients with acute sub-massive PE managed with EkoSonic (EKOS) acoustic pulse thrombolysis, a form of ultrasound-enhanced catheter-directed thrombolysis (UE-CDTR). This combines conventional catheter directed tPA thrombolysis with high-frequency ultrasound, which increases thrombus permeability via acoustic cavitation for increased tPa efficacy. Methods: Three patients with CT pulmonary angiography (CTPA) confirmed sub-massive PE with RV dysfunction and a positive biomarker of cardiac strain (BNP/Troponin) underwent EKOS. Under local anaesthetic and via common femoral vein approach, EKOS endovascular systems were placed in either one or both lower lobe pulmonary arteries. A tPA bolus followed by infusion (0.5 mg/hr tPA) was commenced according to protocol. Results: At 4 hours, all patients had a reduction in resting heart rate and a reciprocal improvement in oxygen requirements. Repeat CTPA at 24 hours following initiation of EKOS-directed thrombolysis demonstrated significantly decreased thrombus burden (up to 75%) and radiographic resolution of RV dysfunction with no episodes of major haemorrhage. Conclusions: Our institution has successfully employed EKOS-directed thrombolysis in three patients with sub-massive PE. All patients had clinical and radiological improvement with reduced inpatient stay compared to patients treated with anticoagulation alone.


Role of Interventional Radiology in Challenging Vascular Access for Pediatric Patients

Mohamed El Ghobashy, Mostafa Gad, Bibi nazaria, Hafez bazaraa

Faculty of Medicine, Cairo University, Cairo, Giza, Egypt.

E-mail: Mohamed.elghobashy@kasralainy.edu.eg

Background: The purpose of this study is to determine the technical and functional aspects concerning image guided peripherally inserted central catheter (PICC) and central venous catheters for challenging vascular access in pediatric patients. Methods: This prospective study done including 20 pediatric patients, 10 patients of them undergo peripheral inserted central catheters while, the other 10 patients undergo traditional CVCs using ultrasound and/or fluoroscopy guidance for different indications. Results: Venous access devices were successfully provided for 20 patients. There were 12 males (60%) and 8 females (40%) with a mean age of 4.91 years (range, 0-15 years). The right internal jugular vein was targeted for 6 cases (30%); 3 patients coming for BMT and 3 patients on regular hemodialysis. The left internal jugular vein was used for 3 cases (15%). The right subclavian vein was used in 1 case (5%) with end stage renal disease and the right internal mammary vein was used in 1 case (5%) on regular haemodialysis. The left femoral vein was used for 5 patients (25%) and the right femoral vein was used for 2 (10%) PICC lines with multisystem organ failure. Technical success in all patients. Conclusions: Image guided venous access success is considered as a feasible, safe and valuable option for central venous access in pediatric patients.


Carbon Dioxide as Alternative Contrast Agents for Diagnostic Angiography and Vascular Interventions

Mohammed Al-Toki, Jamal Abdulla

Department of Radiogy, Diakonie-Kliniken Kassel, Kassel, Germany.

E-mail: towki@hotmail.com

Background: To evaluate the role of CO2 contrast agent for diagnostic angiography and vascular interventions as an alternative to the iodinated contrast in the in patients with renal failure or severe allergic reaction. Carbon dioxide (CO2) was used as a contrast agent particularly in patients who were hypersensitive to iodinated contrast material or whose renal function was compromised since years. Recently with the availability of high-resolution DSA and a reliable gas delivery system CO2 angiography has become widely used to guide various vascular interventions, including angioplasty and stent placement. Materials and Methods: In 2016, 28 patients were examined with CO2 angiography in our department, about 20% of them underwent above Knee angioplasty. All of the patients had contraindication to use the iodinated contrast, critical renal function, previous sever reaction to iodinated contrast. Most of the angiography was done through transbrachial approach, selective CO2 angiography of the iliac, femoral and below knee arties were done. For the angioplasty in the iliac artery selective transbrachail angioplasty was performed, for the angioplasty in the femoral and below knee arteries ipsilateral antegrade approach was performed. The image summation techniques was used to improve the quality and accuracy of the angiography image. Results: 5000 unit heparin were given to all patients who underwent angioplasty, no heparin was given to the diagnostic angiography. The most important complication was pain experience during CO2 injection; to decrease the pain during the procedure we decrease the injection rate, increase the time between each injection. Conclusions: The use of CO2 contrast agent for diagnostic angiography and vascular interventions for the iliac, femoral and popliteal arteries in patients who have a contraindication to iodinated contrast materialseems to be safe, useful and effective alternative to the iodinated contrast. However, the use of CO2 below Knee is less effective.


The Role of the Interventional Radiology in the Management of the Thoracic Outlet Syndrome

Mohammed Al-Toki, Jamal Abdulla

Department of Radiology, Diakonie-Kliniken Kassel, Kassel, Germany.

E-mail: towki@hotmail.com

Background: To evaluate the role of interventional radiology for diagnosis and treatment of the Thoracic outlet syndrome (TOS). Introduction: Thoracic outlet syndrome (TOS) is a term used to describe a group of disorders that occur when blood vessels and/or nerves in the space between the lower neck and upper chest area (the thoracic outlet) are compressed. Symptoms include neck, shoulder, and arm pain, numbness in the fingers, or weakness, impaired circulation and discoloration of the extremities. Often symptoms are reproduced or worsened when the arm is positioned above the shoulder or extended. Diagnosis of thoracic outlet syndrome is suggested by the symptoms and physical findings and is supported by Electromyography (EMG) and/or radiological examinations. Materials and Methods: About 42 patients were examined in our department in 2016, 4 patients underwent venous thrombolysis and angioplasty before the surgary. Every patient had superior thorax aperture x-ray, and cervical spine x ray. Both median cubital veins were punctured and indirect arteriogram for the both subclavian arteries and venogram for both subclavian veins in normal position, in abduction and in hyperabduction position were done. The examinations were done in sitting position. The number of patients with subclavian artery occlusion is more than the patients who had subclavian vein occlusions. We treated 4 patients with venous occlusion and thrombosis with thrombolysis and angioplasty before the operation. Results: The number of patients with subclavian artery occlusion is more than the patients who had subclavian vein occlusions. We treated 4 patients with venous occlusion and thrombosis with thrombolysis and angioplasty before the operation. Conclusions: Interventional radiology confirms the diagnosis of the TOS, plays an important role in the treatment of their complications and could be an adjuvant therapy to improve the surgical result.


Emergency Embolization: Patient's Pathway from Phone Call Reporting to Bleeding Cessation: Single Center Experience

Marwa Hosni Bedair, Karim Abd El Tawab

Ain Shams University, Cairo, Egypt.

E-mail: dr.marwa.h.bedair@gmail.com

Background: Hemorrhage is a major yet preventable cause of death and long term disability varying from mild self-limiting to massive neccissitating angioembolization or surgery. The time from patient injury to hemorrhage cessation critically affects prognosis. We prospectively assessed the emergency protocol and transfer logistics for Emergency Embolization patients in Ain Shams University hospitals in 2016. Materials and Methods: 80 bleeding patients were presented from ER or inpatient wards with average haemoglobin concentrations 6 mg/dL. The protocol followed was reporting cases to IR residents through official IR emergency telephone who instantly reported to on call IR consultant. Patients were transferred by ambulance to the Angiosuite. Polytrauma patients did MDCT whole body and FAST US first. Emergency team did resuscitation via blood products and medical support during transfer. Vascular-sheath was applied by the residents till consultant arrival. Results: Average call to angiosuite time was 17 minutes. Average call to Consultant arrival was 73 minutes and call to procedure end was 106 minutes. 1ry cessation of bleeding was achieved in 79 cases, 1 patient with pph needed further hysterectomy. Rebleeding after 48 hours or more occurred in 6 patients 2 of which underwent embolization, 3 died and 1 underwent nephrectomy. Bowel ischaemia occurred in 1 patient with resection of gangrenous sigmoid loop 6 days postembolization. 10 patients died within the first week despite hemodynamic stabilization attributed to marked coagulopathy upon arrival. Conclusions: IR plays a major role in management of hemorrhage. Patients transfer time and hemodynamic status are the most important prognostic factors.


Custom-made Fenestrated Endograft for Patients with Type 1 Endoleak and Previous Endovascular Aneurysm Repairs: A Promising Endovascular Alternative Approach to Open Surgery

Muhammad Affan Zamir, Nich Burfitt, Colin Bicknell, Michael Jenkins, Richard Gibbs, Mohamad Hamady

Imperial College Healthcare NHS Trust, London, United Kingdom.

E-mail: affanzamir@nhs.net

Background: Endovascular management of type 1 endoleak in patients with pre-existing endovascular stent graft (EVAR) is quite challenging due to the anatomical limitations. Custom-made fenestrated stent grafts have been proposed to increase the proximal landing zone and thereby eliminate the endoleak. We present our experience in nine patients who have undergone FEVAR using a custom made AnacondaTM graft. The clinical and technical success rate as well as lessons will be discussed. Materials and Methods: Retrospective review of patients with type IA endoleaks who underwent FEVAR from 2010-2016. The technical success, vessel patency, reintervention, clinical and imaging follow-up were recorded. Results: Nine patients (eight male; mean 80 years, ASA grade ≥III) with type IA endoleaks/aneurysm enlargement were included. Five patients were treated with cuffs whilst four underwent complete re-alignment; 30 side branches were treated with success in 28 (93%). The overall technical success was 88%. Mean hospital stay was 6.8 days with no 30-day mortality. The reintervention rate was 22% related to endoleaks from renal fenestrations. There were no type I endoleaks following the procedures. Two patients died at 6 and 18 months from septicaemia and myocardial infarction respectively and one patient lost to follow-up who died from ruptured aortic aneurysm at 51 months. The remaining patients continue to be followed-up with stable aneurysm sac sizes. Conclusions: Custom-made fenestrated stent grafts to treat type 1 endoleak in patients with previous EVAR provide an alternative to open surgery in selected patients, especially in those with significant comorbidities.


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