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ABSTRACT
Year : 2018  |  Volume : 2  |  Issue : 3  |  Page : 1-33

Abstracts


Date of Web Publication14-Aug-2018

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How to cite this article:
. Abstracts. Arab J Intervent Radiol 2018;2, Suppl S1:1-33

How to cite this URL:
. Abstracts. Arab J Intervent Radiol [serial online] 2018 [cited 2021 Feb 28];2, Suppl S1:1-33. Available from: https://www.arabjir.com/text.asp?2018/2/3/1/239001

OC101: Vacuum-Assisted Suction Thrombectomy for Salvage of Failing Arteriovenous and Hemodialysis Reliable Outflow Grafts

Osman Ahmed, Sreekumar Madasser, Patrick Tran, Derek Heussner, Jordan Tasse, Ulku Cenk Turba

Rush University Medical Center, Chicago, US.

E-mail: [email protected]

Background: The aim of the study was to determine the safety and feasibility of vacuum-assisted suction thrombectomy for restoring patency to thrombosed hemodialysis reliable outflow (HeRO) and conventional arteriovenous (AV) grafts. Methods: Between December 2016 and August 2017, 11 consecutive patients (6 males, average age 63, and range: 39–80 years) with thrombosed HeRO (n = 7) or AV (n = 5) grafts underwent percutaneous thrombectomy procedures using the Penumbra® CAT 8® or CAT D® (Alameda, CA, USA) suction thrombectomy catheter as the primary device to clear the venous outflow tract or limb before pulling the arterial plug with a compliant balloon. A total of 21 hemodialysis declot procedures using suction thrombectomy were documented and analyzed. Average procedure length and fluoroscopy time, length of thrombus cleared, blood loss, complications, and primary patency were recorded and compared to the same patient's previous thrombectomy procedures. Results: All procedures were technically successful (100%) at restoring graft patency; however, reocclusion within 5 days occurred in 4 (19.0%) cases. Three (14.3%) interventions required additional balloon maceration or sweep to clear the venous outflow following thrombectomy. Average thrombus length treated by suction thrombectomy measured 21.1 cm (range: 12–27 cm). Average blood loss was 162.6 mL (range: 50–250 mL). No procedure-related complications were recorded. The average procedure length and fluoroscopy time using suction thrombectomy were 74.7 and 14.2 min, respectively, compared with 82.0 and 14.0 min, respectively, in the previous thrombectomy procedures using standard methods (P > 0.05). Conclusion: Vacuum-assisted suction thrombectomy is a safe and feasible method for removing thrombus and restoring patency to thrombosed AV and HeRO grafts.

OC102: Multicenter European Experience in the Use of the Indigo Vacuum-Assisted Thrombectomy System in Acute Limb Ischemia

Abdulrahman Alvi, Bella Huasen1, Alexander Massmann2, Stephen D'Souza1, Theodosios Bisdas3

Queens Hospital, Romford, 1Royal Preston Hospital, Preston, UK, 2Saarland University Medical Center, Faculty of medicine, University of Saarland, Hamburg, Germany, 3St. Franziskus-Hospital, Munster, Germany.

E-mail: [email protected]

Background: Percutaneous thrombectomy in patients with acute critical limb ischemia (CLI) is a challenging task. Several devices have been approved for this indication, but their effectiveness remains a matter of debate. The aim of this study is to present the first European experience with the Indigo aspiration thrombectomy system. Methods: A retrospective case review of all patients treated with the Indigo system between January 2016 and May 2017 in four European centers was conducted. The inclusion criterion was acute (≤14 days) lower limb ischemia. No exclusion criteria were used. Primary outcome was defined as technical success with restoration of antegrade blood flow without the need for thrombolysis or alternative revascularization strategies. Secondary outcomes included in-hospital serious adverse events (myocardial infarction, stroke, or death), need for blood transfusion, and in-hospital re-intervention. Results: Sixty-five cases of acute CLI were included in this study with 12-month follow-up. Technical success was achieved in all cases and for each treated vessel segment. No blood transfusions were required. No perforations, dissection, or neurovascular damage were encountered. Median-in-hospital stay was 2 days. One patient died during in-hospital stay due to heart failure and one patient suffered a myocardial infarction; both cases deemed to be unrelated to the procedure. On follow-up, 30-day reocclusion rate was 4% (from underlying primary causes such as AF). In these cases, repeat thrombectomy with the Indigo device was successfully performed. No episodes of reocclusion were reported on 12-month follow-up. Conclusion: In our experience, the Indigo system with its versatile range of catheters provides an easy, safe, robust, and trackable thrombectomy system in acute CLI cases with the capability to extract thrombus down to the pedal arch and without recourse to thrombolysis.

OC103: Ultrasound-Guided Central Venous Access Application in the Neonatal and Early Pediatric Intensive Care Unit (Single-Center Experience in 1000 Patients)

Zeinab Aly Moussa Aly, Karim Abd El Tawab

Ain Shams University Hospital, Cairo, Egypt.

E-mail: [email protected]

Background: Central venous (CV) access is mandatory in pediatric and neonatal Intensive Care Unit (ICU) allowing resuscitation for intravascular fluid and various medication injections as well as a mean for hemodynamic monitoring. Jugular vein catheterization is the most common central vein accessed followed by the femoral which is despite being safer carries higher incidence of thromboembolic and infectious complications. The ultrasound guidance can both increase the success rate and decrease the procedure-related complications. Methods: From March 2014 to November 2017, ultrasound-guided CV line (CVL) was applied in 1016 patients in the Ain Shams University Hospitals' ICU (median age: 3 months [0–24] months), neonates 0–28 days (n = 423), and pediatrics below 24 months (n = 539). The sites of cannulation were the right internal jugular vein (IJV) in 65.3% of the patients, left IJV in 23.2%, right femoral vein in 7.9%, and left femoral in 3.5%. Interventional radiology residents on duty applied 3, 4, or 5F double lumen CV catheter according to patient's age and weight under local anesthesia. Under transverse view 10 MHz ultrasound transducer, Doppler was done to identify the vein from the adjacent artery whether carotid or femoral; after proper sterilization, the transducer center was placed over the center of the vein. Cannulation is then performed using classic Seldinger technique. Results: Cannulation was successful in 98.2% of cases. Right IJV was always attempted first followed by left IJV followed by either femoral with no preference. There was no significant difference in technical success between the two groups. Carotid puncture happened in nine cases, eight neonates, and one pediatric patient in whom the catheter was applied to the artery and developed a transient ischemic attack after antibiotic injection to the artery which resolved spontaneously. One case developed hemopneumothorax treated by chest tube application and also resolved. Conclusion: Ultrasound-guided CV line is rather safe and feasible compared with published series on blind technique with higher overall success and a lower rate of complications.

OC104: Fistula Access Site Hemostasis: a Sticky Solution to a Bloody Problem

M. R. Akhtar, A. Zaman, T. Fotheringham

The Royal London Hospital, Whitechapel, London, UK.

E-mail: [email protected]

Background: Histoacryl (glue) is well established as an agent for hemostasis for small subcutaneous lacerations and wounds in the emergency department. We translate this well-established technique into the interventional radiology world, using it for achieving hemostasis of hemodialysis arteriovenous fistula (AVF) access sites after percutaneous interventions. We audit the effectiveness, safety, and patient acceptability of this technique to conventional suturing closure methods. Methods: We carried out an audit of the use of skin adhesives (Histoacryl®) to close fistula access sites versus conventional surgical suturing in our large tertiary care center where there is a variety of different preferred techniques on wound closure. Thirty-nine procedures were performed on 33 patients who underwent percutaneous intervention of failing or thrombosed AVFs. In total, there were 39 access sites. Postprocedure hemostasis was achieved using Histoacryl® on 25 access sites, while surgical suturing was used for 14 access sites. Procedure details, including time to hemostasis, size of access sheath, dose and time of heparin administration, immediate complications, and patient self-reporting numeric pain intensity scale (0–10), were all recorded. Results: Histoacryl® group had a mean pain rating of 0.4 (standard deviation [SD] 0.7), and the suturing group had a mean pain rating of 2.6 (SD 0.7). Meantime to achieve hemostasis was 92 s in the Histoacryl® group (range: 20–601 s) and 198 s in the suture group (range: 58–361 s). No immediate complications were reported in either group. Conclusion: This audit has shown that Histoacryl® offers a fast, technically simple, device/suture-free, and painless technique for acquiring hemostasis after AVF intervention.

OC105: Sandwich Technique for Complex Aortoiliac Aortic Aneurysms

Samer Koussayer

King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.

E-mail: [email protected]

Background: Common iliac artery (CIA) aneurysm is commonly associated with abdominal aortic aneurysm in about 40% of patients. It is preferable to preserve the internal iliac artery (IIA) whenever feasible. Intentional occlusion of an IIA during endovascular aortic repair (EVAR) results in new-onset buttock claudication and erectile dysfunction in ~28% and 17% of patients, respectively, and bilateral internal iliac occlusion is associated with increased risk of pelvic ischemic complications. Buttock claudication symptoms may improve over time but persist in more than half of affected patients 1 year after EVAR and can have a significant negative effect on patient quality of life. Fortunately, the more serious and potentially life-threatening complications of colon ischemia, pelvic necrosis, and spinal cord injury are less common, affecting ~1% of patients. Methods: There are many endovascular techniques to preserve the IIA. The most common one is using iliac branch endoprosthesis. However, in emergency situation, sandwich technique using parallel graft can be done easily. Unfortunately, no sizing formula has been used to determine the size of the parallel graft. Using mathematically calculation, we came up with specific formula to help in the sizing of the chimneys and decrease Type III endoleak. Results: Area of CIA graft = Area of EIA + Area of IIA (πcc = π EE + π II ) = (CC = EE + II) (Radius of CIA: C radius of EIA: E radius of IIA: I). Also we have to add 4 mm the fabric thickness E = 10/2 = 5 mm I = 8/2 = 4 mm. So, CC = 25 + 16 = 41 C = 6.4 mm. CIA graft has to be 6.4x2 + 4= 16.8 mm CIA graft has to be 6.4 × 2 + 4 = 16.8 mm Conclusion: We feel this formula for sizing the chimneys for iliac aneurysms will decrease the Type 1b endoleak.

OC106: Management of the Left Subclavian Artery with Thoracic Endovascular Aortic Repair

Sid Ahmed Benaroussi, Mohamed Najib Bouayed

Department of Vascular and Endovascular Surgery, Hospital University Establishment, Oran, Algeria.

E-mail: [email protected]

Background: The thoracic endovascular aortic repair (TEVAR) for aortic aneurysm and dissection has shown it superiority to open surgery. In 26%–40% of patients, the proximal sealing zone beyond the left subclavian artery (LSA) had inadequate length that led to LSA coverage. The practice guidelines in this situation to decide about the revascularization are based on low-quality evidence, and there is limited literature that guides us to optimal revascularization techniques. The purpose of this study was to compare outcomes of LSA coverage during TEVAR without and with revascularization using different surgical techniques. Methods: We performed a single-center retrospective cohort study of 80 patients who underwent TEVAR from 2008 to 2017. The LSA was covered to obtain an adequate proximal landing zone, and a selective LSA revascularization by subclavian-carotid transposition and chimney technique was employed. Stroke, spinal cord ischemia, upper extremity ischemia, vertebrobasilar insufficiency, primary patency of revascularization, and nerve injury were compared. Results: The origin of the LSA was covered in 11/80 patients and revascularization in 10/80 patients. Median follow-up was 46 months in the covered group and 36 months in revascularized group. There were no major complications in LSA covered group and only some local complications in revascularized group; however, we observe some endoleak in patients treated by chimney technique who needed reintervention. Conclusion: The theoretical risks of the LSA coverage without revascularization are not constant. However, the revascularization is not free of complications and requires a trained team. The chimney technique had to be improved to get a good result and it also requires a randomized study.

OC107: Global Approaches to Type B Aortic Dissection: Our Experience

Leila Ahlam Bouziane, Bouayed Mohamed Nadjib

Vascular Surgery Department, University Hospital, Oran, Algeria.

E-mail: [email protected]

Background: We report our experience in the endovascular treatment of type B aortic dissection Methods: Over a period of 69 months, a total of 41 type B aortic dissections (12 acute, 8 subacute, and 21 chronic dissections) were treated with stent graft in 33 cases and multilayer stents (MLSs) in 8 cases. Our series included 40 patients (One patient was operated for a double location): 9 women and 31 men with an average age of 64.9 years (21–84 years). Results: We had 100% technical success. Hospital mortality occurred in one (1.4%) patient. Follow-up was available for 39 patients at a median time of 26.5 months (1–69 months). We had 12 (8% [5/39]) complications: endoleak type II in 2 cases, chimney endoleak in 2 other cases, and 1 case of retrograde dissection. The late mortality rate was 10.2% (4/39). Late computed tomography scans' control was satisfying for acute dissections treated in emergency with stent graft and localized dissections treated with MLS. Regarding the dissecting aneurysms, the false lumen was patent in the abdominal aorta in eight cases with dilatation of the celiac aorta in four cases. Conclusion: Endovascular treatment has remarkably improved the prognosis of type B aortic dissections; however, long-term monitoring is mandatory.

OC108: Abdominal Aortic Aneurysm Screening: A Systematic Review and Meta-Analysis of Efficacy and Cost

Andrew Ying, Eshan Affan1

Westmead Hospital, 1Royal Prince Alfred Hospital, Sydney, Australia.

E-mail: [email protected]

Background: Abdominal aortic aneurysms (AAAs) can cause significant mortality when ruptured but are often undiagnosed before this time. Population screening of high-risk individuals and early intervention may mitigate AAA-related mortality. Large trials have demonstrated a mortality benefit for AAA screening, but adoption is not ubiquitous. This study sought to systematically review and consolidate the most recent randomized trial evidence on AAA screening in men and its cost-effectiveness. Methods: Randomized trials and cost-effectiveness studies of AAA screening in men were identified from searching Medline, Embase, CENTRAL, and relevant citation lists. Data were extracted as hazard ratios or raw event rates. Meta-analysis was conducted using a random-effects, inverse variance weighted model for continuous variables and Mantel-Haenszel weighting for event data. Cost estimates of screening were adjusted for inflation and reported as $US/quality-adjusted life year (QALY). Results: Five studies were identified totaling 175,085 participants (age 64–83) with a mean of 10.6 years of follow-up (4.4–13.1). The AAA detection ranged from 3.3% to 7.7%. Screening significantly reduced all-cause mortality (hazard ratio: 0.97, 95% confidence interval [CI]: 0.96–0.99, P = 0.002), AAA-related mortality (0.65, 95% CI: 0.48–0.89, P = 0.008), and emergent AAA repair (RR: 0.64, 95% CI: 0.46–0.91, P = 0.02). The number needed to screen to prevent one AAA-related death per 10 years ranged from 209 to 769 individuals. Sixteen cost-effectiveness analyses found a mean 16,854 $/QALY (range 266–73,369). Conclusion: Wider implementation of population-based AAA screening programs in elderly men should be considered as it continues to demonstrate a significant and cost-effective reduction in all-cause mortality as well as AAA-related mortality.

OC109: Acute Respiratory Insufficiency in Patients with Acute Type B Aortic Dissection: An Indication for Urgent Intervention

Mohammad Raffat Jaber

Harbor UCLA Medical Center, Los Angeles, US.

E-mail: [email protected]

Background: In this series, we examine six patients whom presented with acute Stanford type B aortic dissection with malperfusion and associated acute pulmonary syndrome with pleural effusion and lung disease similar to adult respiratory distress syndrome. Current discussions encourage attempts to stabilize the patient for an interval of 7–14 days to enhance thoracic endovascular aortic repair (TEVAR) outcomes; however, pulmonary compromise signals the need for more urgent intervention. Methods: Case Series (reports of new indications for TEVAR). Results: All six patients otherwise have no known prior history of chronic lung disease. Two patients presented with lower extremity weakness. One patient presented with spinal ischemia and bilateral lower extremity weakness. The fourth patient presented with acute renal insufficiency. The fifth patient presented with chest and back pain, acute renal insufficiency, and lactic acidosis. One of the five patients required tube thoracostomy placement and intubation. The second patient responded well to noninvasive positive pressure, Bilevel Positive Airways Pressure airway ventilation (BIPAP), and diuresis. The third patient remained intubated until he expired 1-week postoperatively. The fourth patient developed acute pulmonary insufficiency before any operative interventions and died shortly after intubation. The fifth patient's respiratory status markedly improved after intervention. Four patients underwent uneventful TEVAR of their descending thoracic aortic dissections. Conclusion: Current discussions encourage attempts to stabilize the patient for an interval of 7–14 days to enhance TEVAR outcomes; however, pulmonary compromise signals the need for more urgent intervention.

OC110: Endovascular Treatment of a Large Iatrogenic Popliteal Arteriovenous Fistula

Andrew Ying, Nedal Katib, Mauro Vicaretti

Westmead Hospital, Sydney, Australia.

E-mail: [email protected]

Background: A 40-year-old male presented with progressive left lower limb pain on a background of left knee surgery some 20 years prior. Examination revealed a thrill and bruit in the left popliteal fossa and diagnostic angiography confirmed a large arteriovenous fistula (AVF). Methods: Over-the-wire Fog arty catheter was used to exclude flow through the AVF and image run-off vessels. The native popliteal artery measured 6.5 mm above and below the fistula and an 8 mm × 50 mm Gore Viabahn covered stent was used to exclude the AVF with good results. The patient was started on clopidogrel and therapeutic anticoagulation with warfarin postoperatively. Results: This case illustrates the endovascular repair of a large, chronic AVF in which open surgery would have been very challenging. The majority of data on long-term primary patency of popliteal covered stents results from aneurysm treatment and is estimated to be 69.4% at 5 years. Conclusion: Treatment of chronic AV fistulas using covered stents in the popliteal region is a viable alternative to open repair.

OC111: Long-Term Primary Patency Rate After Nitinol Self-Expandable Stents Implantation in Long Totally Occluded Femoropopliteal (TASC II C and D) Lesions (Retrospective Study)

Mahmoud Farouk Elmahdy

Cairo University, Cairo, Egypt.

E-mail: [email protected]

Background: Endovascular therapy for long femoropopliteal lesions using percutaneous transluminal balloon angioplasty or first-generation of peripheral stents was associated with unacceptable 1-year restenosis rates. However, with recent advances in equipment and techniques, a better primary patency rate is expected. Hence, this study was conducted to detect the long-term primary patency rate of nitinol self-expandable stents implanted in long totally occluded femoropopliteal lesions (TASC II type C and D) and determine the predictors of reocclusion or restenosis in the stented segments. Methods: The demographics, clinical, anatomical, and procedural data of 213 patients with 240 de novo totally occluded femoropopliteal (TASC II type C and D) lesions treated with nitinol self-expandable stents were retrospectively analyzed. Of these limbs; 159 (66.2%) presented with intermittent claudication, whereas 81 (33.8%) presented by critical limb ischemia. The mean time of follow-up was 36 ± 22.6 months (range: 6.3–106.2 months). Outcomes evaluated were primary patency rate and predictors of reocclusion or restenosis in the stented segments. Results: The mean age of the patients was 70.9 ± 9.3 years, with male gender 66.2%. Mean preprocedural ankle-brachial index was 0.45 ± 0.53. One hundred and seventy-five (73%) lesions were TASC II type C, whereas 65 (27%) were type D lesions. The mean length of the lesions was 17.9 ± 11.3 mm. Procedure-related complications occurred in 10 (4.1%) limbs. There was no periprocedural mortality. Reocclusion and restenosis were detected during follow-up in 45 and 30 limbs, respectively, and all were retreated by endovascular approach. None of the patients required major amputation. Primary patency rates were 81.4% ± 1.1%, 77.7% ± 1.9%, and 74.4% ± 2.8% at 12, 24, and 36 months, respectively. Male gender, severe calcification, and TASC II D lesion were independent predictors for reocclusion, while predictors of restenosis were DM, smoking, and TASC IID lesions. Conclusion: Treatment of long totally occluded femoropopliteal (TASC II C and D) lesions with nitinol self-expandable stents is safe and is associated with highly acceptable long-term primary patency rates.

OC201: Biliary Culture Analysis Obtained During Percutaneous Biliary Intervention: A Multicenter Analysis – Are we Treating Biliary Sepsis with the Correct Antibiotics?

Pavan Najran, Jon Bell

The Christie Hospital NHS Foundation Trust, Manchester, UK.

E-mail: [email protected]

Background: A multicenter retrospective analysis of the pathogens isolated from biliary cultures in patients treated with percutaneous transhepatic intervention. To assess of the pathogen profile and antibiotic sensitivity to decipher the most appropriate treatment regimen. Methods: All percutaneous transhepatic interventions performed over a 2-year period in three separate centers were reviewed retrospectively. Those where no biliary culture was obtained were excluded from the study. Analysis of the culture results including pathogens grown and antibiotic sensitivity was performed. Results: A total of 104 patients were included in the analysis, 58 from center 1, 13 from center 2, and 33 from center 3. No pathogens were grown in 15.3% of cultures (n = 16). Of those with positive cultures (n = 88), enterococci and Pseudomonas were the most common pathogens grown in 52.3% of cases (n = 46). Ciprofloxacin and vancomycin were equally the most sensitive antimicrobials demonstrating sensitivity in 27.3% (n = 24) of positive cultures. Gentamycin was the fifth most sensitive antimicrobial demonstrating sensitivity in 20.5% (n = 18). Conclusion: Over the three centers included in the analysis, there is no common antimicrobial administered before percutaneous biliary intervention. In center 1, gentamycin is administered prophylactically; this study has demonstrated that this is comparably ineffective with low sensitivity and high resistance requiring a change in protocol. Effective antibiotic prophylaxis requires knowledge of likely pathogens and procedure-specific infection risks. However, the choice of antimicrobial is dynamic given the ability of antibiotic resistance to eliminate historically effective regimens.

OC202: Mechanical Thrombectomy within 6 h after Symptom Onset in Ischemic Stroke

Afra Sultan Muesem Alfalahi, Ayman Atmaz Alsibaie, Ahmad Saadat, Hamda Ahmad Kamalboor

Rashid Hospital, Dubai, UAE.

E-mail: [email protected]

Background: Acute stroke consequence results on a heavy burden over affected society members ranging from physical disability, health-care resources, and financial support required. The aim of the study is to assess the clinical outcome postmechanical thrombectomy with or without intravenous (IV) or intraarterial tissue-plasminogen activator (t-PA) for the treatment of acute stroke. Methods: During a 3-year period at single center in Dubai, UAE, a total of 40 patients who could be treated within 6 h after the onset of symptoms of acute ischemic stroke to receive either medical therapy (including IV or intraarterial alteplase when eligible) and endovascular therapy with a stent retriever (thrombectomy group) or medical therapy alone (IV t-PA) (control group). All patients had confirmed proximal anterior circulation occlusion and the absence of a large infarct on neuroimaging. The primary outcome was the severity of clinical disability at 72 h and at the time of discharge, as measured by the National Institutes of Health Stroke Scale score and modified Rankin scale. Results: Thrombectomy reduced the severity of disability over the range of the National Institutes of Health Stroke Scale score and modified Rankin scale. Conclusion: Among patients with anterior circulation stroke who could be treated within 6 h after symptom onset, stent retriever thrombectomy reduced the severity of poststroke disability and increased the rate of functional independence.

OC203: Endovascular Management of Complex Wide-Neck Intracranial Aneurysms: Rashid Hospital Experience of the Current Day Armamentarium at Our Hands!

Yasir Jamil Khattak, Ayman Al Sibaie

Rashid Hospital, Dubai, UAE.

E-mail: [email protected]

Background: Subarachnoid hemorrhage due to ruptured cerebral aneurysm is a disastrous event accounting for approximately 5%–15% of all stroke cases and has a mortality rate of 20%–40%. There has been a radical change in the management of intracranial aneurysms during the past decade. Endovascular approach is now considered as the management of first-choice over surgical means; however, it has its limitations with respect to wide-neck aneurysms. We present the results of our experiences of using assisted techniques for wide-neck aneurysms, with an emphasis on potential applications, technical aspects, and associated complications. Methods: A retrospective review was performed to identify all cases from 2010 to 2017 performed at our institution in which assisted techniques of aneurysm embolization were employed. Demographic data including age, gender, vascular risk factors, and comorbidities were collected. Angiographic data were collected regarding the location, size, and shape of the aneurysms and whether they were ruptured or unruptured. Angiographic occlusion results were evaluated and classified according to the Raymond-Roy Scale. Data regarding devices used were evaluated in relation to the aneurysm. Results: A total of 133 aneurysms in 119 subjects were embolized at our institution from 2010 till 2017 with 67 wide-neck aneurysms having a mean aspect ratio (maximum width of dome/width of neck) of 2.07. Eighty-one percent of patients presented with subarachnoid hemorrhage. Assisted techniques were employed in 63% of the cases. Eighty-seven percent of the wide-neck aneurysms were located in anterior circulation, while 13% belonged to posterior circulation. Complete occlusion (Raymond-Roy Occlusion Class 1) was achieved in 85% of cases. Conclusion: The data from Rashid hospital add to the growing evidence that assisted techniques are safe, effective, and necessary when embolizing wide-neck intracranial aneurysms. Further rigorous clinical evaluation of all techniques and devices is required to precisely assess their safety and efficacy in the management of wide-neck aneurysms.

OC204: Treatment of Iatrogenic Peripheral Pseudoaneurysms

Saurabh Anant Joshi, Vivek Ukirde, Ashank Bansal, Ajit Patil, Abhijit Soni, Maunil Bhuta

Lokmanya Tilak Municipal Medical College, Mumbai, India.

E-mail: [email protected]

Background: Pseudoaneurysms are known complications of few invasive procedures, puncture site aneurysm after angiography, postjoint replacement surgery, etc. They are amenable to less invasive endovascular management, compared to open surgical approach. We present a series of 14 cases of pseudoaneurysms treated in our institute. Methods: Fourteen iatrogenic pseudoaneurysms were referred to our department in the past 2 years. Ten were postangiography arising from common or superficial femoral artery, two were postjoint replacement surgery, one in popliteal and femoral artery each, and 2 were involving brachial arteries, in dialysis patients in which artery was punctured in place of fistula vein. After initial ultrasonographic evaluation, sonography-guided compression was attempted in all. Four responded and 10 patients needed endovascular intervention. In one patient, pseudoaneurysm was arising from a branch of profunda femoris artery which was embolized using glue and coils. In remaining nine patients, the rent was in a major artery. In seven patients, balloon was kept in artery across the neck of pseudoaneurysm to occlude the flow in the pseudoaneurysm and percutaneous thrombin was injected. In one patient, complete thrombosis was not achieved by this treatment. In remaining two patients and in one who did not respond to percutaneous thrombin, a stent graft was deployed across the rent in the artery to close off the pseudoaneurysm. Results: All 14 patients were successfully treated, 4 by ultrasonography-guided compression and 10 by endovascular intervention. Balloon occlusion with percutaneous thrombin was done in seven patients and was adequate for six patients. Embolization with glue and coils was done in one patient in which the pseudoaneurysm was from a small branch. Three patients needed placement of stent graft. Conclusion: Interventional radiology offers various methods to successfully treat iatrogenic pseudoaneurysms in completely noninvasive or minimally invasive ways.

OC205: Planning for Yttrium-90 Selective Internal Radiation Therapy: A Primer

Omar Bashir, Mohammed Arabi, Shahbaz Qazi, Yousof Al Zahrani, Muhammad Almoaiqel, Refaat Salman

King Abdulaziz Medical City, Riyadh, Saudi Arabia.

E-mail: [email protected]

Background: Hepatocellular carcinoma (HCC) is one of the leading causes of cancer deaths worldwide. Yttirium-90 selective internal radiation therapy (Y-90 SIRT) has emerged as an effective treatment option for patients with intermediate and advanced HCC. The procedure involves delivery of glass or resin particles loaded with Y-90 into hepatic arteries supplying HCC. While a high radiation dose is delivered to the hepatic tumor, the adjacent hepatic parenchyma which is supplied preferentially by the portal vein is spared. Methods: In this educational presentation, we aim to simplify the otherwise complex multistep process undertaken before Y-90 SIRT. Results: While the SIRT procedure is based on a simple concept, it requires accurate and safe delivery of highly toxic doses of radiation into the tumor. Without proper planning, there is a high risk of undertreating HCC as well as causing significant complications from nontarget radiation injury. Based on our experience with Y90-SIRT, we present illustrated cases to give readers an overview of steps involved before SIRT. These include appropriate patient selection, careful angiographic mapping of the tumor, lung-shunt detection, and dose calculation. Conclusion: SIRT planning is a complex multistep process that requires a multidisciplinary approach to patient care, meticulous mapping angiography, and dose calculation to get the best results when treating HCCs.

OC206: Percutaneous Radiologic Gastrojejunostomy: Feasibility and Safety of a Modified Chiba-Needle Puncture Technique

Yasir Mohammed Nouri, Youngjong Cho, Ji Hoon Shin, Jong Woo Kim, Jin-Hyoung Kim, Heung-Kyu Ko

ASAN Medical Center, University of Ulsan, Seoul, South Korea.

E-mail: [email protected]

Background: The aim of the study was to evaluate the feasibility, safety, and effectiveness of percutaneous radiologic gastrojejunostomy (PRGJ) using a modified Chiba-needle puncture technique with a single gastropexy in the same puncture tract. Methods: A total of 57 PRGJ procedures using the one anchor technique were attempted in 55 consecutive patients between January 2008 and January 2017. The stomach was punctured using a 21-gauge Chiba-needle. A single anchor was used, and gastrojejunostomy tube placement was performed through the same tract of the anchor. The technical success, time length of the procedure, complications occurring within the next 30 days, and procedure-related mortality were evaluated by means of reviewing the imaging studies and patient medical records. Results: All 57 PRGJ procedures were successfully performed. The average procedure time was 16 min and 28 s. There were no procedure-related major complications. Only eight patients had pneumoperitoneum (14%) which was a minor complication and resolved spontaneously without further problems. There was no evidence of gastroesophageal reflux or aspiration aggravation in any study patient during the follow-up period. The procedure-related mortality was zero. Conclusion: PRJG using the modified Chiba-needle puncture technique with the use of a single gastropexy in the same puncture tract was demonstrated to be feasible, safe, and effective.

OC207: Iatrogenic Renal Vascular Injuries, Angiographic Findings, and Embolization

Ahmed Sayed Awad, Amr Nassef

Kasr Alainy Cairo University, Cairo, Egypt.

E-mail: [email protected]

Background: Renal vascular injuries mostly result from interventional urologic procedures such as percutaneous biopsy and nephrostomy. Serious hemorrhagic complications associated with percutaneous urologic procedures occur in 2.3%–15% of the patients endangering patients' life. Conventional surgical treatment including partial and total nephrectomy carries great morbidity and results in a remarkable renal parenchymal loss. With the development of transcatheter endovascular interventional procedures, microcatheters and embolizing materials precise localization and superselective catheterization of the arterial bleeder followed by embolization gives a minimally invasive treatment option which is able to control bleeding with minimal parenchymal loss and complication compared to surgery. Methods: This work included 64 patients (50 males and 14 females) between the ages of 3 and 60 years (mean age 37 years) with suspected renal vascular injury after renal intervention. They were underwent angiography and percutaneous transcatheter arterial embolization using coils and glue. Results: The source of bleeding was identified and embolized in 56 (87.5%) of patients (pseudoaneurysm = 34, pseudoaneurysm with arteriovenous fistula = 14, arteriovenous fistula alone = 4, and extravasation = 4). Bleeding stopped in 54 of the 56 patients (96.4%). In two patients (3.6%), recurrent bleeding occurred. Re-angiography and assessment were done and insertion of another coil was needed in one patient, whereas in the second one, glue was administrated. None of the patients underwent embolization required further surgical intervention. No significant immediate or delayed complications related to angiography or embolization was recorded. Conclusion: The endovascular embolization is an effective therapeutic technique in iatrogenic renal vascular injuries.

OC208: An Audit of a Major Trauma Center's Use of Splenic Embolization in Blunt Splenic Trauma: Are we Matching National Practice?

Eamon Lagha, Mohamad Hamady

St Mary's Hospital, Imperial College Healthcare Trust, London, UK.

E-mail: [email protected]

Background: The spleen is one of the most commonly injured organs associated with blunt abdominal trauma. Traditionally, the management of blunt splenic injury has involved either splenectomy or conservative management. Advances in interventional radiology (IR) have seen embolization, and subsequent splenic salvage becomes an attractive alternative to traditional management; however, the appropriate selection of patients remains varied worldwide. Since the introduction of regional trauma networks, there has been a transition toward increased utilization of splenic artery embolization. This audit compared St. Mary's Hospital's experience of splenic artery embolization with national practice. Methods: A retrospective analysis of major trauma patients with splenic injuries admitted to St. Mary's Hospital, from April 2012 to February 2015, were drawn from the prospectively collated TARN database. Data collected included demographics, injury severity, treatments, and outcomes in terms of mortality and length of stay. The management categories were grouped into IR, surgical, and conservative management and the data were compared against national practice. Results: Sixty-one blunt splenic injuries were treated at St. Mary's Hospital between April 2012 and February 2015; 13.1% were treated by Interventional Radiology VS 7.6% by IR in the rest of England and Wales (P = 0.14); Mortality rate for Interventional Radiology was 0% VS 6% for rest of England and Wales. Conclusion: This audit demonstrated that IR at St. Mary's Hospital performed better than the rest of England and Wales in the management of blunt splenic trauma. A higher proportion of splenic injuries were managed by IR at St. Mary's Hospital compared with the rest of England and Wales. Mortality rates and length of stay for IR were lower at St. Mary's hospital compared to the rest of England and Wales.

OC209: Direct Percutaneous Puncture and Embolization of Visceral Pseudoaneurysm: Safety and Clinical Efficacy

K. Sunil Kumar, R. Jagadeesh, Mahesh, K. N. Nagabhushan, D. Nageshwar Reddy, G. V. Rao

Asian Institute of Gastroenterology, Hyderabad, India.

E-mail: [email protected]

Background: The aim of the study was to assess the safety and clinical efficacy of direct percutaneous puncture and embolization in the treatment of visceral pseudoaneurysm. Methods: Retrospective analysis of all patients undergoing direct percutaneous puncture of pseudoaneurysm and embolization between January 2012 and January 2017 was done. The study included 26 patients (19 male and 7 female) with a mean age of 36 years (range: 10–71 years). Indications for direct percutaneous embolization were difficult catheterization of feeding artery, previous embolization of proximal artery, and the inability to identify feeding artery on angiography. Patients' demography, details of endovascular procedure, complications, and clinical outcome were evaluated. Patients were followed up for the recurrence of pseudoaneurysm (mean follow-up was 12 months). Results: Etiologies were pancreatitis in 20 patients, trauma in 2 patients, iatrogenic in 2 patients, and incidentally detected in 2 patients. Twenty-three patients had difficult catheterization, two patients had prior embolization of feeding artery, and in one patient, feeding artery was not identifiable on angiography. N-butyl cyanoacrylate (NBCA) with lipiodol was used in 23 (88.4%) patients, coil was used in 1 (3.8%) patient, and both coil and NBCA were used in 2 (7.7%) patients. Embolization of pseudoaneurysm was successful in all cases. No procedure-related complications were seen. Follow-up showed no recurrence of pseudoaneurysm. Self-limiting splenic infarct was seen in six patients. Self-limiting abdominal pain was seen in all patients with NBCA embolization. One patient developed liver infarct and subsequent liver abscess requiring percutaneous drainage. Conclusion: Direct percutaneous puncture and embolization are safe and effective in the treatment of visceral pseudoaneurysms and can be considered as alternative in patients with failed endovascular approach.

OC210: Endovascular Management of Transplant Kidney Vascular Complications: Experience from a Single Institution

Surya Nandan Prasad, Surya Nandan Prasad, Vivek Singh1, Rajendra Vishnu Phadke1

SRMS Institute of Medical Sciences, Bareilly, 1Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.

E-mail: [email protected]

Background: Vascular complications, especially transplant renal artery stenosis, are among the most common causes of graft dysfunction. Other vascular complications are renal vessel thrombosis, pseudoaneurysm, postbiopsy active renal bleed, and intraparenchymal arteriovenous fistula formation. Endovascular interventions are the first-line treatment in these cases with excellent immediate and long-term results. Methods: A retrospective analysis of postrenal transplant patients (from 2010 to 2013) was done who were referred to our department for evaluation and endovascular management of vascular complications. They were evaluated first with Doppler and then with magnetic resonance angiography, if needed. Finally, conventional angiography was done with intent to confirm the diagnosis and treat the patients with angioplasty, stenting, or embolization in the same sitting, if required. Follow-up was done with serial blood pressure measurements, serum creatinine estimation, and Doppler, first in immediate postprocedure period, then at 3- and 6-month intervals. Results: A total of 10 patients were included in the study with a mean age of 40.6 years. Five of them had transplant renal artery stenosis, one intraparenchymal pseudoaneurysm, one upper polar arteriovenous fistula, one atherosclerotic right common iliac artery stenosis, and two presented with active contrast extravasations from upper pole arteries. Patients with renal artery stenosis were treated with stenting across the stenosis. Intrarenal pseudoaneurysm, arteriovenous fistula, and active contrast extravasations were treated with coil and/or glue embolization. Postprocedure follow-up showed immediate and long-term improvement in blood pressure control, decreased serum creatinine level, and cessation of hematuria. Conclusion: Vascular complications in renal transplant patients are an important cause of graft dysfunction and perioperative morbidity. They can be treated effectively with endovascular interventions with excellent immediate and long-term results.

OC211: Significance of Distal Embolization of the Right Gastroepiploic Artery in Bariatric Gastric Embolization

Sherif Hegab

Alexandria University, Alexandria, Egypt.

E-mail: [email protected]

Background: Embolization of the arteries supplying the gastric fundus results in decrease in Ghrelin production with secondary decease in appetite. Methods: Four patients with morbid obesity ranging from 35 to 45 body mass index had left gastric embolization. Right gastroepiploic artery embolization was done in three of them, one simultaneous with left gastric embolization in one session and the other two patients in second separate session. Two milliliters of microspheres 300–500 U was used for left gastric embolization and 1–1.5 ml for the right gastroepiploic artery. Results: Significant decrease in hunger pain in the four patients is noted in the first 2 weeks. After 2 weeks, the hunger pain differs in the four patients. Two patients with left gastric artery embolization only lost satiety after 3–4 weeks from embolization. Second session of embolization showed the persistence of left gastric artery occlusion, while the gastroepiploic artery showed relative increase in its perfusion of the gastric fundus. Distal right gastroepiploic artery embolization was performed for these two patients in the second separate session. Satiety is resumed with persistent hunger score 3 out of 10 scales for 3 months. The percentage of body weight loss in 3-month follow-up ranged from 8% to 12% where better results are noted in the two patients with two sessions embolization. Conclusion: Bariatric gastric embolization gives better results with embolization of both left gastric and right gastroepiploic arteries and better in two separate sessions without adding any significant morbidity.

OC301: Short-Term Outcome of Prostate Artery Embolization for Begin Prostatic Hyperplasia at Prince Sultan Military Medical City, Riyadh

Alrashidi, I. Ibrahim Awadh, Fares Garad, Faisal Alahmari, Sultan Alammari, Abdulaziz Almat'hami, Hatim Alobaidi

Prince Sultan Military Medical City, Riyadh, Saudi Arabia.

E-mail: [email protected]

Background: Prostatic artery embolization (PAE) is emerging minimally invasive treatment for begin prostatic hyperplasia (BPH). Till now, it carries some cons and some pros as the variable options of BPH management. We report our short-term outcome for this procedure. Methods: From our early experience in applying PAE as one of the treatment options for BPH in selected cases started from October 2015 to October 2017. We review the patient presentation, preoperative prostate size, symptoms score, uroflow finding, patient welling, and patient comorbidities. Patients included in the study after full explanation of all BPH management options. We recommend it to the patients with multiple comorbidities and have a high anesthetic risk. Then, we showed the follow-up excluding missed follow-up patients and analysis of these results. Results: We had 17 patients with a mean age of 74.6 years. Patients with multiple comorbidities found in 15 of them and ten patients have high anesthetic risks (American Society of Anesthesiologists score 3). Five patients requested this management for fertility issue and worried about the retrograde ejaculation. All patients have smooth postoperative without significant complications. During follow-up, one patient developed a prostatic abscess managed by transurethral drainage. Another two patients developed retention post embolization and trial catheter removal failed. One patient was managed by transurethral resection of the prostate and found to have large median lobe. The other one still on an indwelling catheter. Two patients need remobilization for regaining symptoms. Twelve (70.5%) patients have shown improvement in the International Prostatic Symptom Score by 5–10 points and decreased the prostate size by 10–47 g on follow-up ultrasound. The average flow rate increased to a range 9–14 ml/s. Conclusion: Prostatic artery embolization is safe and effective for selected cases and need to be tailored to the patient condition. Long-term follow up is recommended.

OC302: Single-Center Experience in Targeted Prostate Biopsy Using Multiparametric Magnetic Resonance Imaging-Transrectal Ultrasound Elastic Fusion Technique

Jennifer Farah, Abbas Chamsuddin, Emilie Fayad, Raja Ashou

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

E-mail: [email protected]

Background: Targeted prostate biopsy is challenging because no single currently established imaging modality is both accurate for prostate cancer diagnosis and cost-effective for real-time procedure guidance. A system that fuses real-time transrectal ultrasound (US) images with previously acquired magnetic resonance imaging (MRI) images for prostate biopsy guidance is presented here. Multiparametric MRI-transrectal US (mpMRI-TRUS) fusion targeted biopsy of the prostate gland, a relatively newly performed technique, has shown the potential to gradually replace random TR US-guided prostate biopsy. Targeting suspicious lesions described on MRI has resulted in an increased detection of clinically significant cancer, decreased detection of low-risk cancer, and potential improvement in patient outcome. Methods: A total of 34 patients underwent mp-MRI; 25 performed at our center and 9 at other centers. Of all the 34 patients, 19 patients were classified by mp-MRI as having Prostate Imaging Reporting and Data System (PIRADS) 4/5, 10 patients as PIRADS 3, and 5 patients as PIRADS 2. All these patients underwent targeted and nontargeted registered mpMRI-TRUS elastic fusion biopsy between the end of January and December 2017. All patients had negative recent urine culture and underwent bowel preparation and received antibiotic coverage. Anticoagulation and antiplatelet therapy, when applicable, were withheld prior to biopsy. Elastic image fusion and organ-based tracking technique were used. It enabled freehand, three-dimensional TR biopsy mapping and accurate tracking of the prostate, compensating for patient- and probe-induced mobility. Results: Sixteen patients had positive biopsies for prostate cancer; positive results of targeted biopsies were found in 14 patients having PIRADS 4/5 (14 out of 19). Of these patients, three also had positive specimens from nontargeted areas; positive results were found in two patients in nontargeted areas. One of these was classified as PIRADS 4 and the other as PIRADS 3. These results show that 79% of patients classified by mp-MRI as PIRADS 4/5 and 10% of patients classified as PIRADS 3 had positive biopsies for prostate cancer. No reported complications, uncontrolled bleeding, or sepsis were noted in all biopsied patients. Conclusion: MpMRI-TRUS fusion biopsy is a safe and accurate method for targeted biopsy of prostate lesions. Despite the modest number of patients, our preliminary results are comparable to the published international numbers, showing a good correlation between the mp-MRI PIRADS classification and the pathological results of mpMRI-TRUS fusion biopsies.

OC303: Radial Access Oncological Intervention: A Single-Center Experience

Pavan Najran, Jon Bell

The Christie Hospital NHS Foundation Trust, Manchester, UK.

E-mail: [email protected]

Background: Intra-arterial therapy is the foundation of interventional oncology encompassing a number of procedures including tumor embolization, liver-directed therapies (transarterial chemoembolization [TACE], selective internal radiotherapy [SIRT], and bland liver embolization), and oncological complication such as tumor hemorrhage. Traditional femoral access vascular intervention has been the foundation of these procedures; however, femoral punctures can result in a number of complications which limit patient mobility postprocedure. Radial access vascular intervention improves mobility postprocedure and reduces hospital stay. In addition, in the case of pelvic embolization, targets increase success rates and access to targets. We described our experience of radial access interventional oncology. Methods: We have performed over twenty cases of radial access vascular oncological procedures including Y90 treatment, bland liver embolization, TACE, drug-eluting bead (DEB)-TACE, and pelvic tumor embolization. Results: We have had no acute complications at the site of puncture or peripheral limb ischemia. We have had two procedure failures due to inability to cannulate the coeliac axis. However, in both of these cases, a second attempt via femoral approach was performed which also failed. One patient experienced radial artery spasm which we relived with local glyceryl trinitrate infiltration and intravenous sedation administration. Conclusion: Radial access vascular intervention is an innovative method of delivering intra-arterial therapy. In the oncology setting, it allows improved patient turnaround and reduced hospital stay. Successful hemostasis is also improved due to the relatively peripheral location of the target vessel and adjacent bone to allow adequate compression. We have experienced no significant complications and reduction in hospital stay. In addition, there has been excellent patient feedback focusing on the improved patient mobility postprocedure.

OC304: Combined Transarterial Chemoembolization and Percutaneous Ablation: A Single-Center Experience

Ibrahim Abulaziz Alghamdi, Zia Zergham, Mohammed Haytham Mawardi, Salah Saleh Kary, Majed Ahmed Ashour

King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia.

E-mail: [email protected]

Background: Hepatocellular carcinoma (HCC) is a significant health concern in the Middle-East countries. Various management options are implemented to increase the survival rate in liver cancer patients with variable success rates. In this study, we aimed to evaluate the impact of combined transarterial chemoembolization (TACE) and percutaneous thermal ablation with either radiofrequency ablation (RFA) or microwave ablation (MWA) on the survival rate of patients with 2–5 cm HCC managed at King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia. Methods: We retrospectively evaluated 17 patients; 12 males (70%) and five females (30%), with a median age of 74 years. Ten patients (59%) had Child–Pugh A score, while seven (31%) had Child–Pugh B score. The HCC sizes ranged from 2 to 5 cm on the widest dimension. Six lesions (35%) were treated with lipiodol-TACE and 11 lesions (65%) were managed with drug-eluting bead-TACE. RFA was used in ablating 13 lesions (76%) and four lesions (24%) were treated with MWA. We followed those patients by computed tomography/magnetic resonance imaging for local recurrence in 3, 6, 12, and 24 months. The survival rate was assessed in 6, 12, and 24 months. Results: After successful combined TACE and imaging-guided percutaneous ablation, no recurrence was noted over 3 and 6 months. However, the recurrence rate was 28% and 50% at 12 and 24 months, respectively. Hundred percent survival rate was accomplished in 6 and 12 months, while we achieved 86% in 24 months, which is similar to a large-scale meta-analysis. However, seven patients have been lost during follow-up. Conclusion: A meta-analysis of combined TACE and percutaneous ablation demonstrates the superiority of this method for decreasing local recurrence and increasing survival rate in patients with HCC measuring 3–5 cm. Our experience supports the recommendations of using combined embolic and ablative therapy in this group of patients.

OC305: Correlation between 30-Day Mortality and Albumin-Bilirubin and Platelet-Albumin-Bilirubin Score Grades Following Transarterial Embolization for Ruptured Hepatocellular Carcinoma: A Retrospective Single-Center Study

Omar Bashir, Mohammad Arabi, Refaat Salman, Shahbaz Qazi, Abdulrahman Alvi, Yousof Al Zahrani

King Abdulaziz Medical City, Riyadh, Saudi Arabia.

E-mail: [email protected]

Background: Although uncommon, hepatocellular carcinoma (HCC) presenting as acute rupture has a mortality rate reported to be high as 25%–75%. Management strategies include conservative treatment, surgical resection, as well as transarterial embolization (TAE). TAE can be an effective option to achieve hemodynamic stability in the acute phase though the overall 30-day mortality remains high. The recently developed Albumin-Bilirubin (ALBI) and Platelet-Albumin-Bilirubin (PALBI) grades have been shown to be accurate indicators of hepatic reserve in HCC patients. The purpose of our retrospective study was to assess the technical success and 30-day mortality of bland TAE for ruptured HCC. We also sought to correlate ALBI and PALBI grades with 30-day mortality rate. Methods: Data from electronic medical records and Radiology reporting system for all TAE procedures for patients diagnosed with ruptured HCC between 2012 and 2017 were retrospectively reviewed. We analyzed demographics, medical history, laboratory findings, and corresponding ALBI and PALBI grades, imaging findings, technical details, and clinical outcome. Results: A total of 24 TAE procedures were performed on 22 patients (16 males and 6 females) presenting with ruptured HCC between 2012 and 2017. Mean age at first presentation was 69.4 years (range: 24–103 years). Majority of the cases presented with abdominal pain and/or distention (n = 22) and were diagnosed on computed tomography (n = 21). Seven patients had solitary lesion, whereas 15 patients had either two (n = 2) or more (n = 13) lesions. Of the 22 patients, 20 patients had liver cirrhosis and 15 patients were known to have a diagnosis of HCC prior to rupture. The mean ruptured lesion size was 8.9 cm (range: 2.6–22 cm). Baseline ALBI grade at presentation was 2 (n = 10) and 3 (n = 13), while PALBI grade was calculated at 1 (n = 22) and 2 (n = 1). Gelfoam was the embolic agent in 12 (50%) and polyvinyl alcohol in 10 (42%) cases. Active contrast extravasation was noted in only 6 (25%) TAE procedures. All cases were technically successful (defined as satisfactory occlusion of artery feeding the ruptured tumor). Clinical success (defined as stabilization of hemoglobin levels 48 h post-TAE without need for re-intervention) was achieved in all but two interventions (one patient died within 48 h postintervention and another required a repeat embolization on the next day). 30-day mortality rate (27%) was calculated for 22 interventions (one patient lost to follow-up after being discharged on day 6). There was no correlation between 30-day mortality and ALBI grade (P = 0.8), PALBI grade (P = 1), and largest ruptured lesion diameter (P = 0.7). Conclusion: Despite technically successful TAE for ruptured HCC, there is a high 30-day mortality. There was no correlation between 30-day mortality and ALBI and PALBI grades in our study.

OC306: Hematoma or Contrast Extravasation Posthepatic Tumor Ablation: Does It Require Intervention?

Almamoon I. Justaniah, Quang Nguyen1, Ammar Sarwar1, Muneeb Ahmed

King Abdullah Medical City, Makkah, Saudi Arabia, 1Beth Israel Deaconess Medical Center, Boston, US.

E-mail: [email protected]

Background: This study aimed to determine the incidence and management of clinically significant bleeding after radiofrequency ablation (RFA) of hepatic tumors and to evaluate the need for angiographic intervention in patients with active contrast extravasation on immediate postablation imaging. Methods: In this Institutional Review Board-approved, Health Insurance Portability and Accountability Act-compliant study, computed tomography (CT) and clinical data were retrospectively reviewed of consecutive patients (March 2006–September 2014) who underwent percutaneous image-guided ablation of hepatic tumors. Patients were evaluated for the need of care escalation and angiographic intervention for ablation-related bleeding within 30 days of the procedure. Results: A total of 339 patients (422 tumors) treated with percutaneous ablation were included. One hundred and nineteen patients required hospitalization following ablation with 74 (62.1%) and 10 (8.4%) patients having a perihepatic hematoma and active contrast extravasation/bleeding, respectively, on postablation imaging. Nine out of 119 patients (7.6%) required escalation of care to an Intensive Care Unit (ICU). The average hospital stay of patients with a perihepatic hematoma, bleeding, or lack of thereof on immediate postablation imaging was 2.5, 1.6, and 2 days, respectively (P = 0.47 and 0.28). Furthermore, 6/339 patients (1.7%) required angiography due to clinically significant bleeding with 1/339 (0.3%) death postprocedure (from progressive hypotension requiring ICU admission, angiographic intervention, and subsequent emergent laparotomy on postprocedure day 1 for delayed hemorrhage and disseminated intravascular coagulation). In comparison with a lack of hematoma, the presence of a perihepatic hematoma or active contrast extravasation on immediate postablation imaging did not increase the need for angiographic intervention for bleeding compared to patients without perihepatic hematoma on immediate imaging (P = 0.14 and 0.13, respectively). Conclusion: Perihepatic hematoma and/or active contrast extravasation seen on immediate contrast-enhanced CT after hepatic tumor ablation does not necessitate escalation of care, increased hospital stay, or angiographic intervention and can be managed conservatively. Specifically, postablation contrast extravasation does not equate to unstable bleeding and need for immediate angiography.

OC307: Combined Treatment, Transarterial Embolization, and Microwave Ablation in Patients with Hepatocellular Carcinoma

Mohamed Zaitoun

Zagazig University Hospitals, Zagazig, Egypt.

E-mail: [email protected]

Background: This study aimed to compare the feasibility and benefit of combined therapy (transarterial embolization [TACE] + microwave ablation [MWA]) versus TACE or MWA alone in the treatment of hepatocellular carcinoma (HCC) >3 and <5 cm. Methods: During 3 years, 150 consecutive patients with HCC >3 and <5 cm were divided into three groups: Group 1: fifty HCC patients who underwent TACE, Group 2: fifty HCC patients who underwent MWA, and Group 3: fifty HCC patients who received combined therapy with TACE followed by MWA after 1 month. The mean age was 57 years, 94 (62.7%) patients were males. Follow-up with triphasic computed tomography (CT) was performed after 1 month and then every 3 months for 1 year. Results: After 1 month, complete response was detected in 27 cases (54%) in Group 1, 22 cases (44%) in Group 2, and 50 cases (100%) in Group 3; partial response in 8 cases (16%) in Group 1 and 5 cases (10%) in Group 2; and progressive disease in 15 cases (30%) in Group 1 and 23 cases (46%) in Group 2. Recurrence rate after 1 year was 38 cases (72%) in Group 1, 40 cases (80%) in Group 2, and 9 cases (18%) in Group 3. Disease-free survival rate at 12 months was 12 cases (24%) in Group 1, 10 cases (20%) in Group 2, and 41 cases (82%) in Group 3. Conclusion: Combined therapy (TACE + MWA) in HCC >3 cm and <5 cm is better than TACE or MWA alone concerning the recurrence rate and disease-free survival rate.

OC308: The Impact of Implementation of Electronic Medical Record on the Practice

Khalid Othman, Omar Bashir, Mohammed Arabi

National Guard Health Affairs, Riyadh, Saudi Arabia.

E-mail: [email protected]

Background: The use of information technology (IT) had measurable impact on many aspects of the practice of medicine and radiology. The introduction of electronic medical records (EMRs) has improved work efficiency by standardization of data collection and protocols, reducing the chances for medical errors, and facilitated long-term data maintenance. Implementation of EMR in interventional radiology represents a unique challenge, where both clinical and radiology information has to be integrated. Methods: This poster discusses the impact of introducing a new EMR system on workflow in vascular interventional radiology (VIR) and briefly discusses the preparation for launching EMR system, obstacles, advantages, and disadvantages based on an electronic survey of employees in the VIR unit at King Abdulaziz Medical City and King Abdullah Specialized Children Hospital. Results: Launching the EMR system was preceded by 6-month period of a hospital-wide training, introducing the new EMR system to all health-care providers and associates. During this period, all hospital units were equipped with new computers, IPads, and special printers compatible with the new system. Integration of the Radiology Information System and new EMR was carefully conducted and monitored by the radiology IT team and new pre- and post-procedure order sets for every VIR procedure were uploaded to the system. Intensive training of staff and “super users” was done in preparation for the actual launch of the system. On-call clinical and IT teams along with hotlines were available on the day of “Go Live” for troubleshooting. The electronic survey of the VIR team on the use of EMR had a 66% response rate. Nearly 75.6% of the surveyed staff felt that the EMR system met their needs. Almost 69.7% considered EMR system as an easy-to-use system, with 84.8% preferring EMR to the use of paper record. About 63.3% of the surveyed staff agreed that the EMR system reduces the preprocedural preparation time. Nearly 51.7% of the responders did not think that the EMR system reduces the duration of patient stay in holding area after the procedure. Majority of the responders (62%) considered that the EMR system reduces the risk of medical errors when compared with paper records. Conclusion: The EMR system has the capability of significantly changing the workflow in VIR department. Our survey results indicate that the majority of users felt that the EMR system is easy to use and it met their needs.

OC309: Comparative Effectiveness of Percutaneous Ethanol Injection Therapy and Parathyroidectomy in the Treatment of Secondary and Tertiary Hyperparathyroidism

Nakarin Inmutto, Tanop Srisuwan, Thanate Kattipatanapong, Prach Pochan

Chiang Mai University, Chiang Mai, Thailand.

E-mail: [email protected]

Background: Secondary and tertiary hyperparathyroidism is a common complication of chronic renal failure. Percutaneous ethanol injection therapy (PEIT) appears to be able to control appropriate parathyroid function alternatively to surgery. Methods: The records of 91 patients with chronic renal failure with secondary or tertiary hyperparathyroidism between January 2006 and July 2015 were reviewed retrospectively. Fifty-five patients underwent PEIT, while 36 patients underwent parathyroidectomy. Effectiveness and complication were compared between the two groups. Results: Parathyroid hormone level (PTH) after treatment <160 pg/mL was used to indicate successfulness of the treatment. The PEIT group showed lesser effectiveness than surgery group; 1.8% versus 61.1%, P = 0.000, odds ratio (OR) = 0.012 and 95% confidence interval (CI) = 0.001–0.970. There was no complication in the PEIT group. Symptomatic hypocalcemia was found to be 11.1% in the surgery group; P = 0.011, OR = 0.889, and 95% CI = 0.792–0.998. Conclusion: The efficacy of PEIT in the treatment of secondary and tertiary hyperparathyroidism was much lower than that of parathyroidectomy.

OC310: Percutaneous Image-Guided Peritoneal Dialysis Catheter Insertion: Retrospective Review of 58 Patients

Mohammad Arabi, Sultan Alammari, Shahbaz Qazi, Omar Bashir, Refaat Salman, Yousof Alzahrani

King Abdulaziz Medical City, Riyadh, Saudi Arabia.

E-mail: [email protected]

Background: This study aimed to retrospectively evaluate the short-term outcomes of image-guided percutaneous peritoneal dialysis (PD) catheter insertion. Methods: From August 2015 to October 2017, a total of 58 consecutive patients (29 males), with a mean age of 47.7 years (15–96 years), underwent percutaneous PD catheter insertion. Peritoneal catheter was the initial method of dialysis in 48 patients (83%), while 9 (17%) patients were on regular hemodialysis and 1 patient had a history of PD through a surgically placed catheter. Dwelling time was defined as the time from insertion to the last clinical follow-up or catheter removal. Procedure- and catheter-related complications were recorded. Results: Catheter insertion was successful in 57 patients (98%). One procedure was initially aborted after inferior epigastric artery injury that resulted in pseudoaneurysm requiring thrombin injection. This patient underwent uneventful catheter insertion on the other side few days later, rendering the overall technical success of 100%. Another patient had procedure-related peritonitis 48 h following the initial insertion and was treated by antibiotics and catheter exchange. Dialysis was successfully initiated in 55 patients (94%) and failed in the remaining 3 patients due to persistent blockage from previous PD-related adhesions (n = 1), large seminal vesicle cysts occupying the pelvis (Zinner syndrome) (n = 1), and one patient remained on hemodialysis. During a mean dwelling time of 299 days (21–819 days), dialysis remains ongoing in 32 patients (55%). A total of 23 catheters were removed during the mean time of 170 days (12–699 days) as follows: postrenal transplant (n = 9), patient's preference for hemodialysis (n = 4), peritonitis (n = 5), need for high-rate hemodialysis (n = 1), pleuroperitoneal connection (n = 1), leak (n = 1), wound infection (n = 1), and persistent blockage (n = 1). Catheter dysfunction due to blockage or tip migration occurred in 13% (8/58), with subsequent relapsing peritonitis necessitating catheter removal in five patients despite repeated manipulation and exchange. Two patients (2/8) had successful manipulation using a stiff wire with ongoing dialysis and one patient died from other comorbidities. Catheter-related peritonitis occurred in 26% (15/58) of patients, which was managed by antibiotics in 9 cases with ongoing dialysis at last follow-up and catheter removal in 5 patients. One catheter was complicated by the overlying skin necrosis due to excessive weight loss after insertion, which was managed by skin closure with sutures. One patient had tiny small bowel perforation during wire manipulation of malpositioned catheter, which was treated with antibiotics with no consequences. Two patients died during the follow-up time due to worsening comorbidities. Conclusion: Percutaneous image-guided placement of PD catheter is an effective minimally invasive technique. Proper catheter maintenance is essential to prevent catheter dysfunction and peritonitis, which represent the most frequent complications.

OC311: Difficulties and Challenging Cases in Radiological Intervention Management of Postcholecystectomy Biliary Injury and Posthepaticojejunostomy Complications: More Than 20 Years' Experience from Tertiary Care Centers

Abd El-Salam Abd El-Aziz Abd El-Aziz, Iyad M. Subei1, Hany Mohamed Abdel-Hakim Saif

Faculty of Medicine, Assiut University, Assiut, Egypt, 1Dr. Erfan and Bagedo General Hospital, Jeddah, Saudi Arabia.

E-mail: [email protected]

Background: In the late 1980s after the first successful laparoscopic cholecystectomy in Europe, this minimally invasive surgery rapidly became the accepted technique for the treatment of gallbladder disease in the United States of America. The rapid acceptance of this new technique by the medical profession and the public was related to the obvious advantages of reduced cost, decreased hospital length of stay, and increased patients' satisfaction (Nezam H Afdhal et al., 2017). Common bile duct (CBD) injuries are the most serious and feared complications of laparoscopic cholecystectomy since they cause substantial morbidity and increased hospital stay and increasingly often are the subject of legal disputes (Chir Ital., 2007). Recommendation, according to the last update as well known in the literatures, for the management of complications of cholecystectomy in biliary duct injuries should always be approached by an experienced multidisciplinary team consisting of surgeons, interventional gastroenterologists, and interventional radiologists. Methods: Patients presented at any time with different types of postcholecystectomy biliary injury and posthepaticojejunostomy complications were subjected to intervention radiological procedures with and/or without endoscopic-radiologic rendezvous. Results: We succeeded to manage 840 cases of postcholecystectomy biliary injury (783 cases) and posthepaticojejunostomy complications (57 cases) by percutaneous transhepatic biliary access, throughout more than 20 years starting in October 1995 when we had established the 1st intervention unit in upper Egypt, at Assiut University Hospital, and lately in other institutional centers in the Kingdom of Saudi Arabia. Conclusion: Biliary injuries or complications, following cholecystectomy or postcholecystectomy, usually can be treated within tertiary referral hepatobiliary multidisciplinary center, and major surgery can be avoided and performed only in selective conditions.

OC312: Percutaneous Endoscopic Gastrostomy Large-Bore Tube Application without the Use of Endoscope: Single-Center Experience on 86 Neurologically Compromised Patients

Rana Tarek Mohamed Khafagy, Karim Abd El-Tawab

Ain Shams University Hospital, Cairo, Egypt.

E-mail: [email protected]

Background: Despite being an established method of enteral feeding, percutaneous fluoroscopic-guided small-bore push gastrostomy tubes are more prone to tube occlusion and dislodgement. This study describes an adapted alternative of nonendoscopic technique to apply large-bore mushroom-head gastrostomy tubes originally designed to be applied endoscopically. Methods: Between January 2015 and November 2017, 86 gastrostomy tubes were placed in 86 neurologically compromised patients. 24F mushroom-head tubes were used. The stomach was filled with air via nasogastric tube through which a Dormia basket or a large Snare was introduced. A 16G Angiocath was advanced through a skin puncture into the Dormia basket at the gastric body level through which bifid guidewire was extracted by the Dormia basket or the snare. The gastrostomy tube was bound to the wire and pulled under fluoroscopic guidance. Technical success and procedural complications were assessed and regular follow-up was done to ensure tube function and monitor complications. Results: A 100% technical success was achieved defined as successful positioning of the stent, bypassing the leakage. Distal migration occurred twice in the same patient with balloon repositioning. Persistence of the leakage after stent removal took place in four patients (all were referred late 20 days plus postsurgery), three of which had re-surgery and one patient who had residual tubular cutaneous-anastomosis fistula had track coiling with cessation of leakage. Conclusion: Fluoroscopic-guided esophageal stenting might be effective in bypassing anastomotic leakages following bariatric surgeries; however, it should be considered as soon as significant leakage is diagnosed and should be considered before re-surgery. Placement of the stents was feasible without major procedure-related complications.

OC313: Role of Computed Tomography-Guided Percutaneous Celiac Plexus Neurolysis in Relieving Pain Due to Abdominal Malignancy

Hesham Mohamed Atef Soliman, Elsayed Elmekawy Elsayed1, Mohamed Shawky Elwarraky, Tarek Fawzy Abd Ella1

National Liver Institute-Menoufia University, Shebin El-kom, 1Faculty of medicine-Menoufia University, Shebin El-kom, Egypt.

E-mail: [email protected]

Background: Cancer-related pain remains a common problem in oncologic practice and has major influence on patient's comfort, tolerance of therapies, and probably survival This study aims to assess the efficacy of Computed tomography (CT)-guided celiac plexus neurolysis (CPN) to relieve pain in patients with advanced abdominal cancer. Methods: CT-guided CPN through anterior technique was done for 20 adult patients (their ages ranges between 30 and 70 years) suffering from abdominal cancer pain using ethanol (90%) as a neurolytic agent. To assess the degree of pain relief, the visual analog score (VAS) was used to assess the degree of pain; immediately after injection, 1 week, 1 month, and 3 months' post-CPN procedure. Results: Marked decrease of the pain intensity in all the patients was noted as a sharp fall of the VAS score immediately after injection of the neurolytic agent and more pronounced in the 1st day post-CPN with the relatively stationary course for 3 months. The VAS score base line was 9.1 ± 0.85. One day after CPN, pain severity decreased markedly to 1.3 ± 0.71, 1 week later, the decrease in pain severity almost maintained at the same level 1.7 ± 0.89, 1 month after CPN, the decrease in pain severity also maintained at the same level 1.9 ± 0.79 and 3 months after CPN pain severity still decreased significantly to 2.3 ± 1.02. The decline in the severity of pain at its average before and at different sequences after CPN recorded high significant statistical difference P < 0.001. Conclusion: CT-guided CPN is an effective and safe method for relieving severe pain due to abdominal cancer.

OC314: The Outcomes of Percutaneous Transhepatic Cholangiography for the Palliation of Malignant Jaundice in England Between 2001 and 2014

Nigel Trudgill, James Rees1, Felicity Evison2, Jemma Mytton2, Prashant Patel3, Kamarjit Singh Mangat4

Sandwell General Hospital, 1Liver Unit, Queen Elizabeth Hospital, Birmingham, 2Health Informatics Department, Queen Elizabeth Hospital, 3School of Cancer Sciences, University of Birmingham, Birmingham, UK, 4Department of Diagnostic Imaging, National University Hospital, Singapore, Singapore.

E-mail: [email protected]

Background: Relieving obstructive jaundice in patients with inoperable pancreatobiliary cancers improves quality of life and permits palliative chemotherapy. Percutaneous transhepatic cholangiography (PTC) with biliary drainage and/or biliary stenting and are commonly used to relieve obstructive jaundice in such patients, and we have examined outcomes of PTC in a national patient cohort. Methods: A retrospective cohort study of all patients undergoing PTC as part of palliative therapy of pancreatobiliary cancer in England between April 2001 and March 2014, identified from Hospital Episode Statistics. Multivariate logistic regression analysis was used to examine associations with mortality. Results: A total of 16,822 individuals undergoing PTC were analyzed (median age 72 [range 19–104], 50.3% males). About 58% had pancreatic and 30.1% had biliary tract cancer. In-hospital and 30-day mortality was 15.3 (95% confidence interval 14.7%–15.9%) and 23.1 (22.4%–23.8%), respectively. About 36% suffered a complication: sepsis (16.5%), stent blockage or displacement (6.4%), and acute kidney injury (4.7%). Thirty-day mortality was associated with increasing age (81+ odds ratio 2.68 [2.37–3.03], P < 0.001), comorbidity (Charlson score 20+, 3.10 [2.64–3.65], P < 0.001), and preexisting renal dysfunction (2.37 [2.12–2.65], P < 0.001), increasing deprivation (1.28 [1.13–1.44], P < 0.001), and cancer type other than pancreatic (unspecified biliary tract 1.28 [1.08–1.52], P = 0.004). Females had a better prognosis (0.91 [0.84–0.98], P = 0.011), as did those undergoing PTC in a “high-volume” provider (84–180 PTCs 0.68 [0.58–0.79], P < 0.001). Conclusion: In subjects undergoing PTC for the palliative relief of malignant jaundice, 30-day mortality is 23.1% and complications occur in 36%. Mortality is higher in older males, those with increasing comorbidity and when the procedure is carried out by operators performing low volumes of PTC.

OC315: Minimally Invasive Treatment of Benign Gallbladder Pathology in Nonsurgical Candidates: Cystic Duct Stenting

Mohammed Rashid Akhtar

The Royal London Hospital, Whitechapel, London, UK.

E-mail: [email protected]

Background: M. R. Akhtar, A. Zaman, T. Fotheringham; Acute cholecystitis in critically ill patients carries a high mortality rate. Patients who are unresponsive to medical management and unsuitable for immediate cholecystectomy require an interventional solution. Percutaneous cholecystostomy is an effective bridging therapy providing immediate symptom control until surgery. A subgroup of patients with severe comorbidities will never be suitable for surgery; these patients can become dependent on long-term external drainage to avert recurrent cholecystitis. Percutaneous cystic duct (cholecystoduodenal) stenting offers a solution to internalize these drains in both delayed surgical candidates and nonsurgical candidates. We present our series with a long-term follow-up demonstrating the benefits of this procedure. Methods: Eleven patients unfit for surgery in our institution underwent cystic duct stent insertion for the management of acute cholecystitis from July 2009 to April 2017. A two-stage procedure involved an initial percutaneous transhepatic cholecystostomy and a subsequent cystic duct stent insertion. An 8 Fr × 16 cm transplant ureteric stent was positioned with the proximal loop in the gallbladder and the distal loop in the duodenum. The cholecystostomy drain was removed at a later date after a check cholangiogram. Results: One patient presented with gallbladder perforation, seven patients with acute cholecystitis, one with gangrenous cholecystitis, and two patients with gallbladder empyema. Ten cases were successful at the first attempt. One case was unsuccessful (unfavorable cholecystostomy site for the second stage) second attempt not performed as the clinical team decided on a different management plan. The technical success rate was 91% and no immediate major complications. Conclusion: Cystic duct stenting has a high technical success rate with a low rate of complications. The good clinical outcome with no reintervention. This series has also demonstrated a wider indication of benign diseases for this procedure. Cystic duct stenting should be considered as a temporary and long-term option in critically ill-cholecystitis patients.

OC401: Removal of Embedded Tunneled Hemodialysis Catheters Using Endoluminal Balloon Dilatation: A Single-Center Experience

Shahbaz Ahmed Qazi, Abdul Aziz Harbi, Omar Bashir, Yousuf Al Zahrani, Mohammad Otaibi, Muhammad Arabi

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

E-mail: [email protected]

Background: Increasing frequency of tunneled hemodialysis catheter usage increases the burden for removal or exchange. A small proportion of dialysis catheter failed to be removed by conventional techniques. Methods: We retrospectively report a series of 12 cases in our institution between September 2015 and December 2017 who failed removal of tunneled dialysis catheters by conventional methods. The study cohort included 11 males and 1 female with mean age of 44 (12–90 years). The mean catheter dwelling time was 770 (153–1442 days). Reason for catheter removal included dysfunctional catheter (n = 5), line sepsis (n = 4), and switching to functioning fistula (n = 1). Catheter types included GlidePath Bard (n = 2), Vaxel Boston Scientific (n = 2), HemoStar Bard PV (n = 2), Palindrome Medtronic (n = 2), Equistream Bard (n = 1), Medcomp (n = 1), and unknown catheter. The insertion sites were internal jugular vein (n = 11) and femoral vein (n = 1). Nine cases were performed under local and 3 under general anesthesia. Single-lumen endoluminal balloon dilatation is done in eight cases and double-lumen dilatation in four cases. Low profile 0.018” or 0.014” balloons ranging from 5–8 mm were used. Results: All catheters were removed safely without any minor or major adverse events. In one case, the catheter was shredded completely but removed over the balloon with no complications. Conclusion: Minimally invasive endoluminal balloon dilatation of tunneled dialysis catheter is a safe and effective technique for removing embedded catheters.

OC402: Management of Arterial Injuries Related to Central Venous Access: A Single Institution Experience

Abdullah Ayesh Al-Mutairi, Mohammad Arabi, Abdulaziz Abdullah Alangari, Mohammad Mari Alamri, Abdulaziz Alharbi, Yousof Alzahrani

King Saud Bin Abdulaziz for Health Science University, Riyadh, Saudi Arabia.

E-mail: [email protected]

Background: Retrospectively identify the types of arterial injuries related to central venous access and management techniques with long-term outcomes. Methods: Between January 2007 and November 2017, a total of 20 patients (13 females) were included with a mean age of 63 (28–89 years) and mean body mass index of 25.75 (13.3–36.5). Venous access procedures included central venous catheter (CVC) placement, dialysis line insertion, or endovascular venous procedures. The study excluded patients who had arterial injuries related to arterial access, such as postarterial line placement, postangiography, or percutaneous coronary interventions. Results: Iatrogenic arterial injuries occurred after attempted venous access procedures into the common femoral vein (n = 18) and subclavian vein (n = 2). Injuries were related to CVC placement (n = 5), temporary dialysis catheter (n = 14), and inferior vena cava filter insertion (n = 1). Nine patients had transarterial venous catheter insertion complicated by active bleeding from pseudoaneurysm and arteriovenous fistula. Other injuries included isolated fistula (n = 3), isolated pseudoaneurysm (n = 4), isolated branch injury (n = 2), and intra-arterial insertion (n = 2). Endovascular management was done with stent-graft placement (n = 14), embolization of bleeding vessel (n = 2), thrombin injection for pseudoaneurysm (n = 2), or by compression/conservative management (n = 2). Technical success was achieved in 100%. One patient required repeat angiography and embolization of isolated branch following stent-graft placement to control bleeding fistula and pseudoaneurysm. Clinical success was achieved in all patients. Procedure-related complications included puncture site hematoma (n = 1), partially occlusive thrombus/spasm of the deep femoral artery after stent graft placement. Six patients (33%) died in <30 days after the procedure (3–20 days) from other comorbidities. Three additional patients (16%) died during the same admission of the procedure (38–114 days). In 7 out of 14 patients, who survived after stent-graft placement, there were no reported complaints related to possible stent stenosis or occlusion at mean follow-up time of 5 years (50 days–8.64 years). Conclusion: Despite technically successful endovascular management of arterial injuries related to venous access in critically ill patients, mortality rate remains high due to other comorbidities. Allowing for the small sample size, stent-graft placement for arterial injuries in this cohort of patients appears to be an effective option with high long-term patency rate.

OC403: Port a Cath Insertion by Interventional Radiologists Tips and Tricks

Amr Mahmoud Ahmed Abdelsamad, Yosra Abdelzaher Mohamed

Ain Shams University, Cairo, Egypt.

E-mail: [email protected]

Background: Modern chemotherapeutic management depends on repeated and safe access to the venous system for the delivery of drugs, fluids, and blood products and the periodic monitoring of the effects of treatment. Peripheral veins are rapidly destroyed by repeated venipuncture and by long-term chemotherapy. The long-term venous access devices (VADs) have helped to overcome the need for repeated peripheral or central venous puncture. One frequently employed type of venous access system is the Port-A-Cath system. The Port-A-Cath is a totally implantable VAD in which a conventional central venous catheter is attached to a subcutaneous injection port usually on the chest wall. The usage of ports for a wide variety of indications has also brought a wide spectrum of complications that are well documented in the existing literature. Methods: Two hundred and ninety patients were reviewed retrospectively in a 5 years' period (2011–2016) for the site of insertion, the type of the port the proper port function and the potential complications. Results: The results were in favor of low incidence of complications with some precautions (11.6%) as regard the insertion technique. Conclusion: Port a cath is an excellent auxiliary device for patients receiving regular chemotherapy conditioning that proper steps for insertion are followed

OC404: Effectiveness of Inferior Vena Cava Filter Departmental Follow-Up Form to Improve Filter Retrieval Rates: a Single-Center Experience

Esraa Arabi, Abeer Alkhathlan, Razan Alfaiz, Ghaida Almusallam, Yousof Alzahrani1, Mohammad Arabi1

King Saud Bin Abdulaziz University for Health Sciences, 1King Abdulaziz Medical City, Riyadh, Saudi Arabia.

E-mail: [email protected]

Background: Inferior vena cava (IVC) filter is a device inserted in patients who are prone to develop pulmonary embolism (PE) and deep venous thrombosis (DVT). PE and DVT are one of the most common medical conditions present in patients who have venous thromboembolism. Venous thromboembolism begins as DVT in the lower limbs which detaches and travels through IVC. The clot ends up as PE blocking the heart and lung circulation. One in 10,000 people are diagnosed with PE and increases to 5 in 1000 by the age of 80 annually. PE leads to hypopnea, chest pain, tachycardia, and in severe cases heart failure, loss of consciousness, and death. In the United States, 25%–40% of cases reported with sudden death. The first line of the treatment is anticoagulants and blood thinning medications. Some neurological and cardiovascular conditions limit the efficacy of anticoagulants. Therefore, IVC filters are used as second-line treatment. In 1973, the first filter was used to replace surgical interventions to prevent thrombosis. The IVC filter has a conical shape ending with hooks to anchor it to the IVC wall. An effective filter has easy placement and can trap all thrombi to prevent new or recurrent PE without migration or perforation of IVC. IVC filter is mainly indicated when anticoagulation therapy is not effective, as in patients with trauma, hemorrhage, and other cardiac problems. However, it cannot be used in severe uncorrectable coagulopathy, prothrombotic state, and active bacteremia. IVC filters are designed with different durability, permanent, and retrievable, according to the patients' conditions. Permanent filters were mainly used in the past until retrievable filters were approved by the Food and Drug Administration (FDA) in 2003. Although retrievable filters are designed to be removed, in some cases, they become permanent due to lack of patient's compliance or poor monitoring. In Wellington Hospital, out of 5000 patients with IVC filters only 12%–45% of filters were retrieved. No local studies, in Saudi Arabia, are available. Leaving the filter longer than necessary may lead to several complications. The longer the filters are left in the body, the greater the chances that migration and malposition will occur. This tilting, or malpositioning, can result, in less common cases, in filter fracture. Failed retrieval can also be caused by a trapped clot. When more than 25% of the filter is filled with a clot, it cannot be removed. Instead, the patient is given anticoagulants for the following 1–2 months, the filter removal attempt is then repeated. Other long-term complications include IVC perforation, IVC occlusion, and developing DVT. To prevent further long-term placement complications that counter-affect the main purpose of inserting filters, the FDA urged health institutions to maximize the retrieval rates. At King Abdulaziz Medical City, the Vascular and Interventional Radiology department established a departmental form in January 1, 2015, to improve retrieval rates of IVC filters. The purpose of the study to compare retrieval rates before and after implementing the form to access its effectiveness. Methods: This is a case–control retrospective study of all patients who had retrievable IVC filter insertion 2 years before and after implementation of a departmental follow-up from June 2015. The departmental follow-up form includes the following information: Patient's name, age, sex, and medical record number. It also contains most responsible physician badge number and pager. IVC filter date of insertion and removal, filter type, and implementing physician name are also included. Subjects were retrospectively analyzed based on age, gender, indication, type of filter, date of filter insertion, location of insertion, date of retrieval, dwelling time, and previous attempts of retrieval. Results: Between June 2013 and May 2017, a total of 307 filters were inserted in 183 males (59.61%) and 124 females (40.39%) with mean age of 59 (SD 17.24). Of these filters, 296 (96.42%) were placed in an infrarenal location and 11 (3.58%) were placed as suprarenal filters. The types of the filters were as follows: 167 Optease (54.40%), 33 Option Elite (10.75%), 78 Denali (25.41%), 2 Capturex (0.65%), and 27 Celect (8.79%). A total of 148 (48.21%) filters were inserted before establishing the follow-up form, and 159 (51.79%) were inserted after the form. A total of 53 (35.81%) of those filters inserted before the form were retrieved, while 61 filters (38.36%) of those inserted after the form were. The mean dwelling time of retrieved filters before the form was 32 days and 48 days for the 2 years after the form implementation, with a standard deviation of 49.42. This increase was explained by the use of filters with longer dwelling time. Filter retrieval was successful in 110 patients (96.49%) from the first attempt and four patients (3.51%) required more than one attempt Conclusion: The departmental follow-up of patients who undergo IVC filters results in improvement of the retrievability rates.

OC405: Pharmacomechanical Thrombolysis with Liberal Use of Stenting Reduced Postthrombotic Syndrome in Iliofemoral Deep Vein Thrombosis: Single-Center Experience

Owayed Al Shammeri, Ola Katheri, Ahmad Al-Ali

Habib Medical Group, Riyadh, Saudi Arabia.

E-mail: [email protected]

Background: Postthrombotic syndrome is common after deep vein thrombosis despite anticoagulant therapy. The symptoms range between leg heaviness and itching to venous ulcer and major disability. This syndrome is more likely to develop with more severe degree of deep vein thrombosis. Pharmacomechanical thrombolysis for treatment go deep vein thrombosis is act to rapidly remove thrombus and hence reduce the severity of deep vein thrombosis. Hence, it may reduce the incidence of postthrombotic syndrome. This study describes a single-center experience in the treatment of deep vein thrombosis to see whether pharmacomechanical thrombolysis for proximal iliofemoral deep vein thrombosis would reduce the incidence of postthrombotic syndrome compared to the historical data for patient receiving anticoagulation only. Methods: A retrospective data collection for patients underwent pharmacomechanical thrombolysis were performed for iliofemoral Deep vein thrombosis in a single center (Alrayyan Hospital, Riyadh). A demographic-, clinical-, procedural-, and postprocedural-related data were collected including 24-month incidence of postthrombotic syndrome were collected. A comparison of postthrombotic syndrome incidence for iliofemoral deep vein thrombosis using pharmacomechanical thrombolysis with liberal use of stenting compared to anticoagulation alone using historical data. Results: Fourteen patients underwent pharmacomechanical thrombolysis to treat iliofemoral deep vein thrombosis between May 2015 and July 2017. The average age is 39 years of age (22–67 years of age), eleven females and three males. Eight out of fourteen cases were identified to be May-Thurner syndrome either by computed tomography or intravascular ultrasound. Two patients were postpartum deep vein thrombosis. Eleven patients had left-sided iliofemoral deep vein thrombosis. All patient underwent 24 h thrombolysis, but two patients required 48 h thrombolysis as per a protocol for none of the patients developed major bleeding. Eleven patients underwent stenting, and ten patients had retrievable inferior vena cava filter, who are all retrieved within 1 month, except one retrieved after 6 months. Twelve patients were adherent to compression stocking with instructions of 8–12 h daily use for 2 years' duration. Among the 14-patient cohort, only one patient (7%) developed postthrombotic syndrome. The historical and contemporary incidence of postthrombotic Syndrome is 50% with the use of anticoagulation for all comers of deep vein thrombosis. Conclusion: This is a single-center experience of treatment of Iliofemoral deep thrombosis with liberal use of venous stenting. This study reports the incidence of postthrombotic syndrome is reduced markedly to 7% as compared to the use of anticoagulation alone in a contemprory data is 50%.

OC406: Variations in Sapheno-Popliteal Junction Anatomy

Neeraj Mehta, Pushpinder Singh Khera1, Pawan Kumar Garg1, Mahendra Lodha1

Dr S. N. Medical College, 1All India Institute of Medical Sciences, Jodhpur, India.

E-mail: [email protected]

Background: Varicose veins are also common in short saphenous vein territory which has most variable anatomy in lower extremity. Variations in the veins of the lower limb are very common. This may be due to the anomalous involvement of the main trunks of the veins or their tributaries alone. Detailed knowledge regarding the anatomical variations such as reduplication of vein and unusual course and termination of the vein is a prerequisite in the diagnosis and management of vascular diseases. Methods: Included in the study were 626 Limbs. They were referred to radiology department by physicians, surgeons, and orthopedicians for investigation of clinically detected superficial varicosities and suspected chronic venous disease. The examination includes history, clinical examination, and detailed duplex scanning of lower limb veins. Study data were based on the detailed examination and reporting of anatomic variation of termination of the short saphenous vein (SSV). Duplex scanning of lower limb veins was performed with the patient standing on low stool. Body weight was on placed on a contralateral limb which enabled examined side to be relaxed, slightly flexed, and externally rotated position. The popliteal fossa and calf venous system were evaluated with particular attention to termination of SSV. A real time B-mode zoom facility enabled optimal anatomic delineation of the SSV and Giacomini vein. The termination of SSV is variable and three patterns have been defined. Results: Following important observations was made: 410 out of 620 (65%) lower extremities shows the prevalence of Giacomini vein. In 45 out of 620 (7.2%) lower extremities, the SSV terminated into popliteal vein with further extension into thigh. In 171 out of 620 (27%) lower extremities, the SSV terminated into popliteal vein. Conclusion: A proper knowledge about the anatomy of the short saphenous vein and its communications with other veins and mode of termination of short saphenous vein is mandatory for a safe and successful intervention. The variant termination of the small saphenous vein may contribute to recurrent varicose veins in this territory; this aspect generally makes the subject of interest in the view of varicose vein operations.

OC407: Treatment of Incompetent Perforators in Recurrent Venous Insufficiency with Adhesive Embolization and Sclerotherapy

Krishna Prasad Bellam Premnath, Binu Joy1, Ajith Toms1, Teena Sleeba1

Queen's Hospital, London, UK, 1Rajagiri Hospital, Kochi, India.

E-mail: [email protected]

Background: Recurrent lower limb venous insufficiency is often a challenge in clinical practice and is most commonly due to incompetent perforators. Many of these patients do not have adequate symptom relief with compression and require some form of treatment for incompetent perforator interruption. The various treatment methods have been tried with different efficiencies. To evaluate the feasibility, efficiency, and safety of an outpatient combined cyanoacrylate adhesion–sodium tetradecyl sulfate sclerotherapy for the treatment of patients with symptoms of persistent or recurrent lower limb venous insufficiency secondary to incompetent perforators. Methods: Eighty-three limbs of 69 patients with symptoms of persistent or recurrent lower limb venous insufficiency secondary to incompetent perforators were treated with cyanoacrylate embolization of incompetent perforators and sclerotherapy of dilated collateral veins (surface branch varicose veins). Technical success, procedural pain, perforator occlusion, venous occlusion, clinical improvement, and ulcer healing were assessed. The follow-up was done 3- and 6-month postprocedure. Results: The procedure could be successfully performed in all patients. One hundred and ninety-one perforators were treated in total. Perforator and varicose veins occlusion rate was 100%. Deep venous extension of cyanoacrylate occurred in 4 (4.8%) patients, with no adverse clinical outcome. Venous clinical severity score improved from a baseline of 8.18 ± 3.60–4.30 ± 2.48 on 3-month follow-up and 2.42 ± 1.52 on 6-month follow-up (P < 0.0001). All ulcers showed complete healing within 3 months. Significant prolonged thrombophlebitis occurred in 38.5% of limbs. Conclusion: Combined cyanoacrylate adhesion and setrol sclerotherapy is technically easy, has a lot of advantages including being an outpatient procedure and highly efficacious but with a guarded safety profile.

OC408: Adhesive Embolization: Can it Replace Thermal Ablation for Truncal Varicosities?

Venkatesh Kasi Arunachalam, P. Santosh, R. Rahul, Elango, Jenny

KMCH, Coimbatore, India.

E-mail: [email protected]

Background: Among the endovascular treatment, thermal ablation is one of the effective and acceptable methods of treatment. However, in a developing country like India, cost of the procedure is one of the main factors which determines the nature and type of the treatment. If a procedure can be done with one-fourth of the cost of thermal ablation for varicose veins with an equivalent result, it is beneficial to the patient. Methods: A prospective study is done to evaluate the occlusion and recanalization rate of cyanoacrylate embolization of trunk with foam sclerotherapy of varicosities and asses the cost benefits compared to the radiofrequency ablation of trunks with foam sclerotherapy of varicosities. Twenty patients in each group are randomly selected and underwent the procedure in the past 1 year. The patients are followed at least for 6 months (1 week, 1 month, 3 months, and 6 months), and the results are compared. Results: We are able to achieve technical success in 100% of patients. The occlusion rate for trunks is around 94% at 6 months for glue embolization compared to 94% for RF ablation at 6 months. There were no case with significant deep vein thrombosis in both groups. There is a significant improvement in venous clinical severity score with an ulcer healing rate more than 95% is noted in both groups. The cost of the Glue embolisation is cheap (at least one-fourth) compared to thermal ablation. Conclusion: Adhesive embolization and sclerotherapy is an affordable, cost-effective, and acceptable method of treatment for the varicose veins compared to the Thermal ablation.

OC409: Assessing Perceptions About Inclusion, Career Deterrents, and the Specialty of Interventional Radiology Among Medical Students and Female Trainees

Vishal Kumar, Yilun Koethe, Evan Lehrman, Maureen Kohi

University of California, San Francisco, US.

E-mail: [email protected]

Background: A diverse health-care workforce in radiology, as in other medical services, helps expand health-care access for diverse communities, including traditionally underserved populations. Radiology ranks 20th out of 20 of the largest medical specialties in terms of under-represented minorities (URM) in medicine representation (Chapman et al., 2014), and interventional radiology (IR) demonstrated the lowest levels of URM representation (West et al., 2017). In 2015, women comprised 47.6% of the US medical graduates, which translated into 26.7% female radiology and diagnostic radiology residents and fellows, and only 9.3% of IR female residents and fellows. The purpose of this study was to identify perceptions medical students and female IR trainees (residents and fellows) have regarding the field of IR, including issues of inclusion and occupational deterrents. Methods: Medical students, female residents, and female fellows were asked to complete an anonymous web-based survey to gauge understanding of and interest in IR, perceptions of diversity, and inclusion of underrepresented minorities and female physicians, and career deterrents when considering IR as a specialty. The survey responses used a 5-point Likert scale and were collected and stored using Google Forms cloud-based software. Data were examined using generalized mixed modeling assuming a binomial distribution and sandwich estimation with SAS and GLIMMIX. The study was IRB approved and HIPAA compliant. Results: A majority of medical students have negative or neutral perceptions when it pertains to issues of inclusivity of both female and minority physicians in IR. In addition, females perceived the length of training and male predominance within the specialty as deterrents to pursuing a career. Furthermore, female students were less likely to view IR as being inclusive of female physicians (all results statistically significant; P < 0.05). Regardless of gender, students expressed concerns over occupational radiation exposure, lack of direct patient care, and work-life balance. The majority of female resident and fellow respondents demonstrated that the presence of a female IR mentor influenced their decision to pursue a career in IR. Furthermore, mentorship was equally influential during medical school (46%) and residency (46%). While all female resident and fellow trainees believed that pursuing IR can fulfill potential career goals of direct patient care, high percentage of procedural work, and high salary, 38.5% did not believe that work-life balance can be achieved. Regarding lifestyle changes, many considered duration of training of 6–7 years (23.1%), extended daily work hours beyond training (38.5%), and call responsibilities in IR (46.2%) as deterrents in their pursuit of IR. Furthermore, despite existing data that pregnancy and fetal outcome among pregnant interventional radiologists matches that of the general population, nearly half (46.2%) were worried about occupational radiation exposure. About 38.5% of attendees did not consider IR to be inclusive of women, and equal number considered male predominance in the field of IR as a deterrent to their pursuit of IR. Conclusion: While limited by small sample size, our experience has identified critical perceptions medical students and female trainees have that may hinder women and URM from pursuing a career in the specialty. As our specialty looks to increase diversity and inclusion efforts, issues of diversity and inclusiveness, occupational radiation exposure, and career life balance should be discussed openly to promote recruitment and retention.

OC410: Reporting Early Results and Potential Impact of an Online Webinar-Based Interventional Radiology Elective

Vishal Kumar, Evan Lehrman, Maureen P. Kohi

University of California, San Francisco, US.

E-mail: [email protected]

Background: A review of the 2016–2017 American Association of Medical Colleges Total Enrollment by the United States of America (US) Medical School and Race/Ethnicity illustrates that medical student enrollment by race is not uniform across US medical schools. Previous studies have demonstrated a majority of medical students do not understand that radiologists perform interventional procedures, have a poor knowledge of IR, and are not interested in IR as a career. Interventional Radiology (IR) is now a new specialty and requires exposure and education at the medical student level. The purpose of this study was to evaluate the efficacy of a webinar-based IR elective for outreach to institutions without robust preclinical IR exposure. Methods: Between January and March of 2017, eight 50-min didactic sessions were broadcast, recorded, and distributed over the internet in the form of a webinar-based elective using GoToWebinar software (GoToWebinar, Boston, MA, USA). SIR Connect Portal and social media platforms Twitter, Facebook, and LinkedIn were used for promotion and advertising. Registrants and attendance were measured at each session, including the location of all registrants/attendants. This information was cross-referenced with a list of IR Interest Groups, the SIR directory, and the list of approved IR residency and fellowship programs. Student perceptions of IR careers were surveyed after the first session and after the final elective sessions. All statistical analyses used Fisher's exact test. Results: An average of 65 individuals (range 88–46) registered for the weekly elective sessions from 92 distinct institutions. Geographically, registration included 29 states and 9 countries. Eight Doctor of Osteopathy (DO) medical programs were included (9%). A weekly average of 39 male (65%) and 20 female (35%) students registered. Registrants included first (26%), second (36%), third (27%), and fourth (12%) year medical students. Additional registrants included radiology technologist and nursing students, as well as administrative staff. Out of 83 US institutions, 62% did not have their own Interventional Radiology Interest Group (IRIG) interest group, 57% did not have faculty listed in the SIR directory, and 74% did not have an integrated IR residency. Total attendance included 48 distinct institutions viewing five different countries, including 3 DO programs (6%). Weekly webinars averaged 30 attendants (range 10-56), with an average of 17 male (65%) and 20 female (35%) students. Of the total attendant institutions, 46% did not have their own IRIG interest group, 64% did not have faculty listed in the SIR directory, and 74% did not have an integrated IR residency. Conclusion: A webinar-based elective may serve as an effective method for increasing exposure to IR, especially for medical students at institutions and in regions without robust IR exposure.

OC411: In situ Arterialization of the Posterior Tibial Vein for Management of Critical Limb Ischemia Using Outback Re-Entry Catheter-Technical Report

Ibrahim Abulaziz Alghamdi, Zia Zergham, Donald John Bain, Hany Mohammed Hafez, Salah Saleh Kary, Majed Ahmed Ashour

King Faisal Specialist Hospital And Research Center, Jeddah, Saudi Arabia.

E-mail: [email protected]

Background: Critical limb ischemia (CLI) is considered a serious public health burden in the Gulf region especially with the high incidence of diabetes mellitus in this region. Several endovascular and open surgical methods are used to preclude amputations or mitigate the morbid consequences. Endovascular arterialization of the deep veins for improving the distal blood flow to the lower limb has recently been used in CLI patients. In this paper, we describe a new endovascular technique for in situ arterializations of the posterior tibial vein using Outback (Cordis) re-entry device. We discuss the patient selection criteria for arterialization of leg veins and discuss the outcome. Methods: We reviewed the demographic information, peripheral arterial disease risk factors, clinical history, treatment history, and images of the patient referred for consideration of arterialization of the leg veins. Images from PACS are used to describe the novel technique of lower limb venous arterialization. Results: A 52-year-old male patient, diabetic and heavy smoker, presented with a non-healing ulcer and rest pain in the right foot. He had a surgically amputated big toe. Imaging showed below knee occluded arteries with a patent dorsalis pedis and foot arteries. He was managed several times by endovascular methods with recanalization of the anterior tibial artery (AT). The AT was treated with a standard balloon, drug-coated balloons, short focal stent to maintain patency over 2 years. The patient presented with recurrent symptoms of CLI and occluded AT after almost every 3 months of intervention. A surgical femoral distal bypass was also done which occluded. The latest endovascular intervention was 5 months back with quick recurrence. His case was discussed in the multidisciplinary vascular meeting, and he was offered either surgical amputation or a trial of endovascular arterialization of the leg veins. The patient decided to go with the latter. The right common femoral artery was accessed in an antegrade fashion, and a 7-French sheath was inserted. First, the re-occluded AT artery was recanalized and treated with 3 mm standard balloon. The posterior tibial vein (PTV) was accessed under ultrasound guidance, and a simultaneous arteriogram and venogram were done for localization. From the femoral access, an Outback Re-Entry Catheter (Cordis) was inserted to the level of the Tibio-Peroneal trunk, and a needle was advanced successfully into the PTV to create an arteriovenous fistula. Angioplasty for the track was done followed by covering it with a stent graft. Balloon Valvotomy was done up to the hind foot. The final angiogram showed a fast flow of contrast to the foot. The patient was discharged with improved clinical symptoms. The patient was reviewed in 3 months with a healed ulcer, no rest pain and a clinically patent arterialized PTV. Conclusion: In situ arterialization of the deep veins using Outback Re-Entry Catheter (Cordis) is a new modified technique for endovascular management of end-stage CLI. It is technically feasible with good early clinical outcome in our patient.

P101: Hepatocellular Carcinoma Post-Transarterial Chemoembolization and Diffusion-Weighted Imaging: Therapy Outcome Prediction and Tumor Response Assessment

Hesham Abdelmonem Elsayed Temraz, Mohamed Mohame Houseni

National Liver Institute, Shebin Elkom, Egypt.

E-mail: [email protected]

Background: The current established therapeutic response criteria for hepatocellular carcinoma (HCC) postconventional transarterial chemoembolization (cTACE) is based on tumor enhancement. This can be difficult to quantify in some cases presented by benign conditions of enhancement and in tumor areas show heterogeneous pattern of enhancement. Furthermore, reliable response prediction before cTACE can help to identify patients with potential treatment benefit. Diffusion-weighted imaging (DWI) was investigated as an aiding tool for response assessment and outcome prediction. Methods: From February 2015 to February 2017, 60 patients/70 lesions with average lesions size 4.14 cm (range: 1.0–10 cm) diagnosed as HCC had performed DWI 2 weeks before and 3 weeks after cTACE. The b values used in the diffusion sequence were 50, 200, and 800 s/mm2. The corresponding apparent diffusion coefficient (ADC) maps were generated. The results were correlated with 3 months modified response evaluation criteria in solid tumors (mRECIST) objective response. Results: There was an absolute increase in ADC values in responding lesions compared to nonresponding lesions by mRECIST criteria (35.4% vs. 5.2%; P < 0.001). The increase in volumetric ADC values posttrans-arterial chemoembolization (TACE) to 1.65 × 103 mm2/s in at least >42% of the tumor volume correlates with objective response by mRECIST with a sensitivity of 90.4% and specificity of 80.1% (P = 0.001). The pretreatment ADC value above the threshold 1.31 × 103 mm2/s predicts tumor response by mRECIST with a sensitivity of 81% and specificity of 60%. Conclusion: ADC value differences before and after TACE may provide valuable information for lesions response post-TACE and may play a role in predicting the HCC response.

P102: Using Telemeeting Application Versus Face-To-Face Teaching in Afternoon Rounds in Radiology Residency in 2 Accredited Training Centers in Saudi Arabia

Basim Felemban, Amal Abdulaziz Salem1, Basmah Mohammad Allugmani1, Saja Samir Hafiz1, Noura Abdulaziz Alnajdi1, Sultan Albargi

Radiology Department, AlNoor Specialist Hospital, 1Faculty of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia.

E-mail: [email protected]

Background: Online lecture or what called “videoconferencing” is an innovative tool that could provide a high-quality learning experience, and it has the privilege of being, cost-effective, time-saving, and the possibility of being conducted over multiple remote sites, on a larger number of people. In this study, we aim to compare between online and face-to-face teaching in the means of effectiveness and satisfaction among radiology residents in tow centers of Saudi board. Methods: Two interventional Lectures held at two different radiology departments centers of Saudi board. One of the two lectures was face-to-face at one center and online at the other. The other lecture was conducted the other way. Hard copy tests containing seven questions about each topic were distributed among residents who attended the lectures. The residents were required to answer these seven questions before (pretest) and after (posttest) to assess the level of knowledge before and after the lectures about the provided topic. Four questions about the satisfaction of the residents regarding this experience were added to the posttest paper. Results: Twenty-six subjects were included in the study. Most of them (41%) at the third level of the residency program (R3). There is an increase in means of the total score of answers after the two lecture, but these changes are not statistically significant except in the face-to-face center at biliary pathologies lecture. Conclusion: The effectiveness of online teaching has been proved to be equal to face-to-face teaching, and even if it was not superior to it in the means of effectiveness, it still holds numerous advantages over it, which might be an indicator for the need of further research and development of online teaching to make it one of the most powerful teaching tools in the upcoming days.

P103: Anatomical Variation of the Prostate Artery in Computed Tomography Angiogram

Ibrahim Abulaziz Alghamdi, Randa Hussien Alyafeai, Junaid Islam, Majed Ahmed Ashour, Zia Zergham

King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia.

E-mail: [email protected]

Background: Understanding the prostate artery anatomy is the cornerstone in successful planning of prostatic artery embolization for benign prostatic hyperplasia. The purpose of our pager is to understand the variable normal Prostate Artery anatomy using computed tomogrpahy (CT) angiogram of our population. Methods: We retrospectively evaluated 100 internal iliac arteries' (IIA) thin collimated CT angiogram images, and three-dimensional reformats of 50 healthy kidney donor candidate, aged between 17 and 47 years old (median 27). In each IIA, we identified the origin of the prostate artery, obturator artery, superior vesical artery, and the middle rectal artery. Results: The prostate artery is seen in 97% of the examined IIAs. It most commonly originates from the common trunk of the internal pudendal artery (IPA) and inferior gluteal artery (IGA) (48%), followed by a direct origin from the IPA (43%). In only 4% of the PA seen originating from the obturator artery (OA) and 2% from other origins. Conclusion: CT angiogram is considered a helpful tool in understanding the different anatomic variations of the prostate artery. The common trunk of the IPA and IGA is the most common origin of the prostate artery, followed by the IPA. OA, superior vesical artery, or the main internal iliac artery form an uncommon variant origins.

P104: Understanding the Internal Iliac Artery Branching System Using Yamaki Classification

Ibrahim Abulaziz Alghamdi, Randa Hussien Alyafeai, Junaid Islam, Majed Ahemd Ashour, Zia Zergham

King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia.

E-mail: [email protected]

Background: Understanding the internal iliac artery (IIA) anatomy is paramount in interventional radiology daily practice with the paradigm shift toward endovascular management of various emergency and elective procedures in male pelvis. In 1998, Yamaki et al. established a modified classification system for the IIA anatomy based on the branching pattern of three major arteries: superior gluteal artery (SGA), inferior gluteal artery (IGA), and internal pedundal artery (IPA). Group A was found in 60%–80% of populations, Group B in 15%–30%, Group C in 5%–7%, and Group D in only 0.2%. The purpose of our study is to review the IIA branching anatomy in Arab population using the same classification system and compare it with the internationally published numbers. Methods: A total of 50 thin collimated computed tomography angiograms of healthy male kidney donors, aged between 17 and 47 years (median 27), were evaluated. A hundred pelvic halves were studied individually with and without three-dimensional reformats of the IIAs for the branching pattern applying Yamaki classification system. In Group A, the IGA and IPA make a common trunk (anterior division) while the SGA forms the posterior division. In Group B, the posterior division is formed by a common trunk between the SGA and IGA while the IPA forms the anterior division. The IIA trifurcates into those three major vessels in Yamaki Group C. Finally, in Group D, the SGA and IPA form a common trunk as the anterior division while the IGA forms the posterior division. Results: Among the evaluated 100 IIAs, Yamaki Group A was found in 79%, Group B in 14%, and Group C in 7%. Group D pattern was not observed in our sample. Conclusion: The IIA branching pattern in Arab population in our study is similar to the Yamaki classification system, where group A is the most common followed by Group B and Group C.

P105: 128-Slice Computed Tomography Evaluation of Takayasu Arteritis in South Punjab (Pakistan) Initial Experience at CPEIC, Multan

Maham Munir Awan, Mahe Munir Awan1, Aftab Akbar1

Chaudhary Pervaiz Elahi Institute of Cardiology, 1Nishter Medical University, Multan, Pakistan.

E-mail: [email protected]

Background: Takayasu arteritis (TA) alternatively known as a pulseless disease and aortic arch syndrome is an inflammatory and stenotic disease of medium- and large-sized arteries. Extensive research has revealed the prevalence of TA in Asia among teenagers and adults, resulting in consistent high blood pressure. In this study, selected patients with the prevalence of TA suspected on color Doppler ultrasound study were further evaluated with 128-slice computed tomography (CT) angiography. Methods: It is a prospective study consisting of 4012 patients who were referred to Radiology Department of Chaudhary Pervaiz Ellahi Institute of Cardiology, Multan (Pakistan) (which is a hub of vascular diseases), for 1 year. All patients underwent color Doppler ultrasound study for limb ischemia, renovascular hypertension, and carotid Doppler ultrasound for stroke-like symptoms, followed by CT angiography using 128-slice CT scan and low-osmolar contrast media. Maximum intensity projection, multiplanar reconstruction, and three-dimensional reconstruction of image data were done. Results: A total of 4012 patients were studied. Among them, six patients were diagnosed with the disease (TA) with a male:female ratio of 1:5. Conclusion: CT angiography is a very useful and reliable method of diagnosing TA, assessing disease activity, and a guide to treatment and follow-up.

P201: A Retrospective Comparative Study of Four Different Transarterial Regimens for Treatment of Hepatocellular Carcinoma

Abdulaziz Almat'Hami, Hatim Alobaidi1, Yousof Alzahrani2, Rebecca Zener, Daniele Wiseman, Amol Mujoomdar

Western University, Ontario, Canada, 1Parince Sultan Military Medical City, 2King Abdulaziz Medical City, Riyadh, Saudi Arabia.

E-mail: [email protected]

Background: Transarterial chemoembolization (TACE) is known to be a valid palliative measure in treating hepatocellular carcinoma (HCC). Indeed, it is considered as the first option in treating patients with unresectable multinodular HCC in the absence of portal vein thrombosis or invasion with preserved liver function. Furthermore, chemoembolization is also used as an adjuvant therapy to prevent tumor progression or to downstage the tumor to meet the transplantation criteria. Despite that, there is no standardized treatment regimen for chemoembolization. This single-center retrospective study aims to compare four different regimens of TACE for the treatment of unresectable HCC to assess tumor response, time to progression (TTP), and median survival. Methods: Ninety-eight TACE procedures on 88 patients with unresectable HCC (77 males and 11 females; mean age 68.4 years) performed between June 2007 and July 2014 were included. Four groups based on the regimen were compared. This includes 10 patients treated with I-131-lipiodol combined with cisplatin and doxorubicin (Group A), 15 patients treated with cisplatin and doxorubicin mixed with lipiodol (Group B), 53 patients treated with doxorubicin mixed with lipiodol (Group C), and 10 patients treated with doxorubicin-eluting beads (DEB-TACE) (Group D). The outcome measures reviewed were imaging response, TTP, technical success, and median survival. The tumor measurements were analyzed based on mRECIST criteria. Statistical analysis was performed using ANOVA and post hoc Tukey's test. Results: There is no statistically significant difference in the baseline tumor size among the study groups (P = 0.67): (Group A: mean 7.9 cm, median 6.3 cm; Group B: mean 6.1 cm, median 5.6 cm; Group C: mean 6.2 cm, median 5.7 cm; and Group D: mean 6.0 cm, median 4.7 cm). A complete response to the treatment was slightly higher in Groups B and C (15% and 13%, respectively) compared to Groups A and D (10%). The median TTP was shorter in Group A (4 months) compared to (6 months) Groups B, C, and D. There is no significant difference in median survival among the study groups (P = 0.96). Conclusion: Based on our review, there is no significant difference in imaging response, TTP, and survival between single agent TACE, dual agent TACE, radio-chemoembolization with dual agents, and DEB-TACE.

P202: Evaluation of Prostatic Lesions by Transrectal Ultrasound, Color Doppler, and the Histopathological Correlation

Gaurav Katyal, Babu Ram Goyal, Archana Mathur, Ravikumar Patel

Max Superspeciality Hospital, New Delhi, India.

E-mail: [email protected]

Background: Prostate cancer is the most common malignancy in men in the United States, with approximately 192,280 cases diagnosed yearly. Globally too, prostate cancer happens to be the second-most common cancer among males, with annual incidence reaching up to 679,060 cases. The diagnosis and treatment of prostate cancer are very challenging. The current methods of screening for prostate cancer include measuring serum prostate-specific antigen levels (PSA), digital rectal examinations (DREs), and transrectal ultrasound (TRUS). A color Doppler ultrasound, because of its ability to effectively visualize vascular changes, provides a better diagnostic as well as prognostic value. Prostate cancer, in common with many other tumors, shows increased angiogenesis, resulting in increased microvessel density. Increased color Doppler blood flow tends to indicate more aggressive tumors with higher Gleason grades as well as a higher risk of recurrence. Due to the benefits of a color Doppler test, it is gaining popularity as a diagnostic modality for differentiating between various prostatic lesions with a reported benefit over the conventionally used TRUS approach. Methods: The study was carried out on a total of 40 male patients, aged 50–80 years, with serum PSA levels of 4–10 ng/ml in the absence of urinary tract infections, acute urinary retention, acute prostatitis, or recent catheterization and having a hard, enlarged nodular prostate on DRE. The project was approved by the institutional ethics committee. Informed consent was obtained from all the participants. All suspected patients attending the surgical outpatient/inpatient of our institution who fulfilled the inclusion criteria were examined in the left lateral decubitus, knee–chest position, and were subjected to DRE. TRUS with a color Doppler for the detection of prostatic lesion using G. E. LOGIQ 5 PRO ultrasound color Doppler machine (with a TRUS probe [6–10 MHz]). Later, a TRUS-guided biopsy was performed using an 18G biopsy gun to confirm the radiological diagnosis. Results: Data were analyzed using Statistical Package for the Social Sciences (SPSS) version 21.0 (IBM, New York, USA). A Chi-square test and a “t-” test of independent samples were used to compare the data. P < 0.05 indicated a significant association. Diagnostic efficacy was expressed in terms of sensitivity, specificity, positive predictive value, negative predictive value (NPV), and accuracy. The age of patients ranged from 51 to 77 years. The mean age of patients was 63.80 ± 6.76 years. A majority of the patients were <65 years of age (65%); on DRE, a total of 17 (42.5%) patients had induration while 23 (57.5%) had nodular lesions. PSA values ranged from 5.8 to 9.8 ng/ml. Exactly half of the patients had PSA <8 ng/ml; histopathologically, 13 (32.5%) cases were malignant. On TRUS evaluation, a total of 10 (25%) cases were malignant. TRUS findings combined with color Doppler vascularity findings diagnosed malignancy in 15 (37.5%) cases. Conclusion: The findings of the present study showed that TRUS with color Doppler flowmetry can play an important role in the detection of prostate malignancy, with high sensitivity as well as specificity. The high NPV, as observed in the present study, could avoid unnecessary diagnostic invasive intervention. In the present study, TRUS diagnosis established 30 (75%) cases as benign and 10 (25%) cases as malignant, showing the rate of cancer detection to be close to that diagnosed through histopathology. Among different TRUS characteristics, irregular shape, heterogeneous echotexture, loss of differentiation between the peripheral and internal zones, increased mean prostate weight, and capsular invasion were found to be significantly associated with malignancy.

P301: Challenges in Carotid Artery Stenting

Sibasankar Dalai, Rv Narayana, Rajesh Pati

Sevenhills Hospital, Vizag, India.

E-mail: [email protected]

Background: Carotid artery disease is a significant cause of acute ischemic stroke and transient ischemic stroke. Significant carotid artery diseases are treated by carotid endarterectomy (CEA) or carotid artery stenting (CAS). Methods: We are presenting some challenging situations where patients with significant carotid artery diseases are not suitable/willing for surgery (CEA) and the anatomy too is challenging for CAS. Also presenting some seemingly straight looking CAS but pose serious intraprocedural challenges. Results: We could deal with the challenging situations with innovation and persistence. Conclusion: Understanding the nature of the carotid plaque is of paramount importance in doing a successful CAS. Imaging of the entire access is a must to carry out a successful CAS in most situations.

P302: Assessing Readiness for Acute Stroke Mechanical Thrombectomy Service

Essam Hashem, Karim Abdeltawab, Merhan Nasr, Hesham Mansour

Ain Shams University, Cairo, Egypt.

E-mail: [email protected]

Background: Stroke is a leading cause of mortality and serious long-term disability. Recently published trials prove the superiority of endovascular mechanical thrombectomy (EMT) over best medical therapy, for selected patients with acute ischemic stroke. There is almost consensus that for optimum outcomes, onset-to-groin puncture time should be <6 h. The aim of our work is to assess our readiness to implement EMT, by evaluating aspects of delay in dealing with such time-critical group of patients. Methods: A prospective random sample of 20 patients presenting to our emergency department with acute stroke was selected. Total elapsed time from symptoms onset until release of emergency radiology report was measured and analyzed into five subcategories: from symptoms onset until decision to seek medical care (termed “awareness”); trip from home to hospital (“ambulance”); time spent in emergency room until arrival to radiology (“ER”); waiting time in radiology reception (“wait”); time until emergency radiology report release (“report”). Results: 2/20 (10%) were wake-up strokes, the other 18 cases had median time from onset to radiological diagnosis by CT, of 4:59:00. Previously described delay intervals are summarized in ascending order in this table. Median time (hours) (“ambulance” 02:17:30; “awareness”01:07:30; “ER”-00:55:00; “report”00:23:00; “wait”00:19:00; total-05:02:00). Conclusion: Assuming the interventionist reaches the hospital within 1 h, half of thrombectomy candidates can be started within the 6-h interval. There is an urgent need for mass media campaigns raising awareness regarding early manifestations of stroke. Emergency physicians should be educated about EMT, as most of them only knew about medical thrombolysis, whose window is only 4.5 h. Such unawareness can lead to slow management of patients presented beyond 4.5 h. A porter must be dedicated only for the transport of acute stroke patients. Radiology reception staff should be educated about the emergent nature of acute stroke-related scans and prioritize accordingly.

P401: Efficacy of Computer-Aided Detection of Thyroid Nodule in Reduction of Unnecessary Fine Needle Aspiration Cytologies Along with Role of Radiofrequency Ablation in Thyroid Nodule Treatment

Muhammad Fiaz

Superior University, Lahore, Pakistan.

E-mail: [email protected]

Background: AmCAD is a window-based computer-aided detection (CAD) device intended to assist the medical professionals for categorization of thyroid nodules through ultrasound. CAD is an objective way to determine which thyroid nodules need to have fine needle aspiration cytology (FNAC) and helping to reduce FNAC frequency in the thyroid. It saves workload, and there is no interobserver variation. Nodular thyroid disease is very frequent in clinical practice in Pakistan and worldwide. It is associated with increased risk of thyroid cancer and hyperfunction. In this paper, we propose a novel method for CAD of thyroid nodules in ultrasound (US) images followed by treatment if possible by Radiofrequency ablation (RFA). This novel method was experimentally evaluated using US images acquired from 24 patients. The results show that the proposed method achieves more accurate delineation of the thyroid nodules in the US images and faster convergence than other relevant methods. Methods: The purpose of this article is to introduce application and utilization of the CAD system in thyroid ultrasonography. After getting clear images of thyroid nodule along with longitudinal and traverse measurements, four parameters are calculated and displayed by the computer system automatically, which include microcalcifications, hypoechoic lesion, heterogeneity, and indistinct margin. Results: The results are displayed automatically with pointers in the semilunar figures. The necessity of FNAC dependents on the size and numbers of positive findings along with percentage risk of malignancy. Conclusion: This CAD system is objective, reproducible, and easy to use. It can be easy to determine the necessity for FNAC, but what we must keep in mind is that this method can reduce the necessity of FNAC, not replace FNAC for the diagnosis of thyroid cancer. RFA of thyroid nodule is minimally invasive very good tool as mode of treatment.

P402: Reduce Confusion! Using Combined Contrast Ultrasound and Fusion Technique During Radiofrequency Ablation of Liver Space-occupying Lesions

Asif Abalal Momin, Shenaz A Momin1

Prince Aly Khan Hospital, 1B. Y. L. Nair Hospital, Mumbai, India.

E-mail: [email protected]

Background: Purpose of this prospective study conducted in small oncology hospital is to highlight using either contrast-enhanced ultrasound (CEUS) with or without computed tomography (CT) fusion imaging to treat liver lesions well seen on positron emission tomography (PET)/CT or magnetic resonance imaging (MRI), but inconspicuous on ultrasound during radiofrequency and alcohol ablation of liver space-occupying lesions. Methods: Nine consecutive liver lesions; of size ranging from 1.2 to 4.7 cm; four metastatic and five primary HCC were subjected for US-guided radiofrequency or alcohol ablation earlier detected on either PET/CT or MRI. Using additional tools of CEUS or fusion imaging the pre, intra, and immediate post-RFA response was correctly judged; later confirmed on CT or PET study. In two cases, additional alcohol ablation was used to avoid heat sink effect due to main portal vein proximity and difficult RFA approach. Results: Except in two cases, all other lesions were considered as completely ablated based on pre- and post-CEUS enhancement pattern conducted before the patient was allowed to go home. One metastatic lesion showed definite peripheral enhancement and was reablated in additional sitting within next 2 h. In other case, CEUS showed minimal doubtful enhancement which on follow-up PET imaging was reported as post-RFA inflammatory response showing reducing standardized uptake values on repeat PET with absent enhancement on CEUS after 3 months. Conclusion: US guidance is at times handicapped by lack of confident identification of a lesion during ablation or by deciding the end-point of ablation merely on B-mode US due to difficulty in carrying out of immediate postablation PET/CT. This confusion can be minimized using real-time contrast US and fusion imaging to achieve the end-point.

P403: Pictorial Review of Biliary and Enteric Stents: What a Radiologist Needs to Know

Pavan Najran, Jon Bell

The Christie Hospital NHS Foundation Trust, Manchester, UK.

E-mail: [email protected]

Background: Enteric and biliary stents are important to recognize, however, these are commonly ignored and considered nonpathological in diagnostic imaging. Careful examination of the device is required to recognise common complications. Inexperience in the imaging appearances of such stents contributes to misinterpretation Methods: A pictorial review of biliary and enteric stents demonstrating how careful examination of such devices is essential to recognize and manage common complications. Results: We present a comprehensive pictorial review of metallic, biodegradable stents in a wide range of modalities. We discuss Imaging appearances of common complications of such stents including occlusion, migration, and fracture. Conclusion: A sound knowledge of the imaging appearances of enteric and biliary stents is essential to recognize common complications such as stent fracture and occlusion. Diagnostic radiologist needs to be aware of imaging appearance of a wide variety of stents in various modalities to facilitate prompt management when complications arise.

P404: Fluoroscopic-Guided Self-Expandable Retrievable Esophageal Stent Application in Management of Postbariatric Surgery Anastomotic Leaks

Background: Anastomotic leakage is a major complication of bariatric surgeries that can lead to high mortality and morbidity. Depending on the clinical presentation, management options include conservative management with or without external drainage, stenting, or surgical reintervention which carries relatively high morbidity and mortality rates. Methods: Self-expanding silicon stents were inserted under fluoroscopic guidance in 9 patients with radiologically diagnosed anastomotic leakage, 7 of them postbariatric gastric bypass operation and 2 patient after laparoscopic sleeve. Patients were referred for stenting between 7 and 26 days (mean 14 days) after surgery. Balloon repositioning was needed twice in one patient distal migration. The stent was left for 8 weeks in all patients. The patients were following a strictly fluid diet to avoid stent migration. Stents were removed endoscopically. The 9 patients were followed till removal of the stents. Results: A 100% technical success was achieved defined as successful positioning of the stent bypassing the leakage. Distal migration occurred twice in the same patient with balloon repositioning. Persistence of the leakage after stent removal took place in 4 patients (all were referred late 20 days plus postsurgery), 3 of which had resurgery and 1 patient who had residual tubular cutaneous-anastomosis fistula had track coiling with cessation of leakage. Conclusion: Fluoroscopic-guided esophageal stenting might be effective in bypassing anastomotic leakages following bariatric surgeries; however, it should be considered as soon as significant leakage is diagnosed and should be considered before repeat surgery. Placement of the stents was feasible without major procedure-related complications.

P405: Real-Time Elastography-Guided Prostate Biopsy Improves Cancer Detection Following Transrectal Ultrasound Biopsy: A Prospective Study of 392 Patients

Chaffa Aimeur, Mohamed Abdelmadjid Habba, Mounir Tabouche, Amine Habouchi, Radia Ait Chalal, Boudjema Mansouri

Bab El Oued Universitary Hospital, Algiers, Algeria.

E-mail: [email protected]

Background: Prostate cancer, the most common malignancy and the second leading cause of cancer-related death in men, is not only a major medical problem but also a significant public health issue because it may cause significant economic burden. Methods: Our study includes 392 men suspected of having prostate cancer on the basis of clinical and biochemical evaluation who underwent whole prostate analysis by real-time elastography (RTE) with identification of suspicious areas (hard areas) which are biopsied (2 cores by lesion) followed by 12 core systematic biopsy. We analyzed respectively the cancer detection rate of RTE and systematic biopsy. Results: Mean age of patients was 68.32 years (range 39–85) and mean prostate-specific antigen level was 12.73 (range 0.86–100). Cancer was found in 208 of 392 patients (53.06%). The rate of high-grade tumors (Gleason 8 and 9) was 19.71% (41 cases). RTE detected cancer in 71 patients (34.13%) and systematic biopsy detected it in 49 (23.55%). Positive cancer cores were found in RTE-targeted cores in 83 of 142 cases (58.45%) and in systematic cores in 511 of 4704 (10.86%). The cancer detection rate per core was 5.38-fold greater for targeted than for systematic biopsy. Comparison of B-mode US and RTE diagnostic accuracy in the detection of tumours located in the peripheral zone of the prostate gland showed a significant difference. Conclusion: RTE is an interesting complement to grayscale US to direct prostate biopsies; it reached a higher accuracy than B-mode ultrasound in the evaluation of the peripheral zone of prostate and in the selection of appropriate biopsy sites.

P406: Management of Complex Hilar Obstruction in Interventional Radiology Room: Experience of a University Hospital Center

Chaffa, Mohammed Abdelmadjid Habba, Mounir Tabouche, Amine Habouchi, Radia Ait Chalal, Boudjema Mansouri

Bab El Oued Universitary Hospital, Algiers, Algeria.

E-mail: [email protected]

Background: Palliation of patients with complex malignant hilar obstruction by self-expansive metallic stents insertion poses particular difficulties. Our study assessed the technical success, clinicobiological success, and complications (short- and medium-term) of percutaneous biliary drainage of malignant hilar biliary obstruction using self-expanding metallic stents. Methods: This is a retrospective single-center study.That included 27 patients with malignant hilar obstruction (Bismuth II, III, and IV) between January 2016 and September 2017. One or more self-expansive metallic stents were inserted across the stricture after failure to endoscopic drainage. Patients were evaluated 1, 3, and 6 months after stent placement. Clinicobiological data, imaging, and interventional radiology procedure were studied. Results: Successful stent insertion was achieved in 25 of 27 (92.6%) patients. Complete resolution of jaundice was achieved in 23 of 25 (92%) patients. In 2 of 27 (7.4%) cases, stent placement failure occurred. Early complications included cholangitis in 2 of 27 (7.4%) patients and stent occlusion in 1 of 25 (4%). Late stent occlusion occurred in 5 of 25 (20%) patients. Median stent patency was 183 days. Median patient survival was 204 days. Conclusion: Percutaneous biliary drainage with self-expansive metallic stents is safe, feasible, and achieves adequate drainage in the majority of patients with nonresectable complex tumors of the hepatic hilum.

P501: Below the Knee Angioplasty in Diabetic Patients: Predictors of Major Adverse Clinical Outcome

Mohamed Ali Kashkoush, Ahmed Abdelhamid Taha1, Ahmed Sayed Mostafa1

National Institute of Diabetes and Endocrinology, 1Faculty of Medicine Cairo University, Cairo, Egypt.

E-mail: [email protected]

Background: The aim of the study was to determine the predictors of clinical outcome following percutaneous transluminal angioplasty (PTA) in diabetic patients with below-knee atherosclerotic lesions causing critical limb ischemia (CLI). Methods: Over 1 year, 67 patients underwent below-knee PTA. All of these patients were CLI patients (patients either manifested by rest pain or tissue loss). The composite end point of interest was major adverse clinical outcome (MACO) of the treated limb at follow-up which was defined as clinical failure, need for subsequent endovascular, or surgical revascularization or amputation. Freedom from MACO was assessed using Kaplan–Meier curves. Results: Successful limb salvage was seen in 88% with CLI. Complete wound healing was achieved in 76% of cases with a mean time to healing of 10.7 months. Significant predictors of MACO were technical failure (P = 0.002) and occlusive lesions (P =e 0.019). We reported a percentage of 76.1% freedom of MACO. Conclusion: Below-knee PTA is a feasible therapeutic option in this diabetic population. Technical failure and occlusive lesions may be predictors of adverse outcome.

P502: Acute Upper Extremity Deep Vein Thrombosis: Effectiveness of Superior Vena Cava Filter

Sohiel Mohamed Ayman, Mohamed Fakhry1, Mohamed Nagib2

Ain Shams university, Cairo, 1El Amria General Hospital, 2Military Academy, Alexandria, Egypt.

E-mail: [email protected]

Background: With the advent of central lines, pacemakers, and defibrillators upper extremity, deep venous thrombosis (DVT) is increasingly common. An upper extremity DVT has about 5%–10% chance of becoming a pulmonary embolism (PE). Catheter-related thrombi result in PE more frequently than primary upper extremity DVT. Several reports of fatal PE due to upper extremity DVT had been documented. Langhan and Greenfield demonstrated in 1985 that superior vena cava (SVC) filters could safely be deployed in dogs. To date, a total of 127 cases are documented in literature. Methods: Forty-two patients with acute upper extremity DVT and anticoagulation therapy from January 1, 2014, to June 30, 2015. Four patients underwent percutaneous placement of SVC filter for prevention against PE. Follow-up chest radiographs were used to detect filter migration, dislodgment, and fracture. Pulmonary pressure after filter insertion was recorded. Patients were followed up clinically for evidence of SVC syndrome and PE Results: No complications such as filter migration, dislodgment, and fracture occurred (median follow-up 12 weeks). No patients developed clinical evidence of PE or SVC syndrome (median follow-up 15 weeks). Conclusion: Percutaneous filter placement in SVC is a safe and effective method in the prevention of symptomatic PE due to acute upper extremity DVT.

P503: Use of the Transbrachial Approach with Regular Radial Sheath as an Alternative Method in the Management of Aortoiliac Occlusive Arterial Diseases

Sohiel Mohamed Ayman, Mohamed Fakhry1, Mohamed Nagib2

Ain Shams University, Cairo, 1El Amria General Hospital, 2Military Academy, Alexandria, Egypt.

E-mail: [email protected]

Background: The best way to manage peripheral artery disease remains an unresolved issue. In recent years, endovascular therapy (EVT) has made remarkable advances, resulting in better outcomes in a variety of settings. Aortoiliac bifurcation lesions present various difficulties in treatment, and the therapeutic method remains controversial. In addition, while some reports have examined EVT outcomes in aortoiliac bifurcation lesions, there are few analyzing the influence of lesion morphology and stent configuration. Methods: Seven patients admitted to Shaq Almandine and El Amria hospitals; during the period July 1, 2016–April 30, 2017 with chronic bilateral lower limb ischemia (aortoiliac occlusive disease). After clinical evaluation, Doppler and CT angiogram transbrachial approach had been chosen using regular radial sheath. Follow-up after 1 day, 1 week, and 3 months Results: Five male patients and 2 females, with a mean age of 62.2 years underwent left transbrachial approach using 6 Fr. radial sheath. Follow-up revealed patent stents in all patients after 3-month period using Duplex study Conclusion: Radial sheath is a safe, unique, and cheap method for transbrachial approach, more friendly for arch manipulation and does not affect the pushability during the procedure

P504: Subarachnoid Hemorrhage in Young Adults in the KSA

Shaymaa Al-Umran, Faisal Alabbas, Hosam Al-Jehani

King Fahad Hospital of University, Khobar, Saudi Arabia.

E-mail: [email protected]

Background: The aim of this study is to review a series of aneurysms occurring in young adults all of which presented with subarachnoid hemorrhage (SAH). Methods: This was a retrospective review of prospectively collected data from January 2014 to 2017. Any patient with an aneurysmal SAH was included in the study. We excluded nonaneurysmal SAH and fusiform aneurysms. Parameters of location, size, complexity and mode of therapy, and clinical course were reviewed. Chi-square contingency analysis was used with significance below 0.05. Results: A total of 96 patients harboring 114 aneurysms were reviewed. A total of 30 patients harboring 36 aneurysms were aged between 18 and 36 years (31.5%). Two out of three were anterior circulation and one out of three were posterior circulation aneurysms. 60% were male and 40% were female, and 50% of males died due to SAH compared to 25% of females. Nine patients suffered a rebleed (30%) and six of those died. Twenty out of 27 patients developed vasospasm and 3 died early due to a rebleed. Fifteen out of 27 patients were coiled, and no significant difference in outcome was observed whether with coiling or clipping. Conclusion: Microsurgical or endovascular obliteration of the aneurysms produced equal results in the young adults presenting with SAH. Maintaining aggressive medical/international normalized ratio therapy during vasospasm is a key to preserving good outcome. Rebleed is a key factor in poor outcome and death. This group of SAH patients deserves further study in terms of their genetic influences which might alter the recommendation for longitudinal follow-up for each patient and the screening of their families.

P505: Bare Metal Stent for Central Venous stenosis/occlusion in Hemodialysis Patients: 5-year follow up study

Hyung Jin Shim, Dong Erk Goo1, Seung Boo Yang1, Yong Jae Kim1

Chung-Ang University Hospital, 1Soonchunhyang University Hospital, Seoul, South Korea.

E-mail: [email protected]

Background: The aim of this study is to analysis the effectiveness with patency rate of percutaneous bare metal stent for central venous stenosis/occlusion in patients who are undergoing hemodialysis. Methods: Totally 1016 central venous interventional procedures were performed in 891 patients during recent 10-year period. Four hundred and twenty-five subclavian (occlusion: 97, stenosis: 328) and 591 innominate (occlusion: 156, stenosis: 435) venous steno-occlusions were enrolled in this study. The follow-up period was 2 weeks–77 months (mean: 14.8 months). Technical success, complications, and long-term patency were evaluated as well as the statistic difference between the location of steno-occlusions, the existence of diabetes mellitus, and the history of central catheter. Results: Stents were implanted in 294 patients in 1016 procedures. All but one of the procedures was technically successful (99.7%). The one patient with an unsuccessful procedure was due to incomplete stent expansion. Two stent migrations were occurred as major complication without other. The primary patency rate for 6, 12, 24, and 36 months was 44%, 18%, 5%, and 2%, respectively (mean: 7.9 months). Repeat interventions, including additional balloon angioplasty and stent placement, were required in 172 patients (average: 2.54). There was no statistic difference except the history of central catheter (P = 0.0128). The secondary patency rate for 6, 12, 24, 36, 48, and 60 months was 80%, 67%, 42%, 37%, 30%, and 20%, respectively. Conclusion: Percutaneous central venous stent implantation in hemodialysis patients is useful in patients with suboptimal angioplasty and it was safe and effective to restore the hemodialysis function. However, repeat interventions are usually required to prolong the stent patency.

P506: Successful Implementation of Electrocardiographic-Guided Peripherally Inserted Central Catheter Placement by a Nurse-Lead Peripherally Inserted Central Catheter Placement Team

Aabid Tharayil Mohammed

King Abdullah Medical City, Makkah, Saudi Arabia.

E-mail: [email protected]

Background: The use of electrocardiographic guidance has been shown to be safe and effective for the placement of peripherally inserted central catheters (PICCs). The goal of this study was to evaluate the Sherlock 3CG tip confirmation system (TCS) in the placement of PICCs (using chest radiographs as the golden standard) and then to successfully implement use of the Sherlock to reduce the utilization of chest radiographs for PICC positioning at our institution. Methods: From January to June 2017, we analyzed the positions of PICCs placed with the Sherlock 3CG TCS. A chest radiograph performed after each PICC placement was interpreted by four independent observers . A catheter tip located within the superior vena cava (SVC) or cavoatrial junction was considered successful placement of PICC. The study comprised a total of 130 PICC placements. Exclusion criteria included atrial fibrillation, atrial flutter, or atrial dysrhythmias. Fifty-one PICC placements were included in the first phase of trial. PICC training in Phase 1 included 1-h training by the company Rep. 1 h online course. Hands-on training for tip confirmation was not mandatory to start the PICC insertion. Seventy-nine PICC placements were comprised Phase 2 of the trial. This time the hands-on training was made mandatory. Results: Results of Phase 1 were not satisfactory, with 82% of PICCs placed in the SVC or cavoatrial junction. Results of Phase 2 were considered satisfactory, with 96% of PICC placements into the SVC or cavoatrial junction. Conclusion: The Sherlock 3CG TCS is an effective device for guiding PICC placement to the SVC or cavoatrial Junction. Sufficient educational training is important to achieve a successful transition from radiographic confirmation to usage of the Sherlock 3CG TCS. This device will generally eliminate the need for radiographic confirmation of PICC placement in our patient population, except for patients with atrial fibrillation, atrial flutter, or atrioventricular junctional arrhythmic patients.

P507: Incidence of Finding Abdominal Aortic Aneurysm in Abdominal Computed Tomography Scan and its Implication on its Prevalence in Saudi Arabia

Faris Alomran, Husain Aljawad, Mohammed Alshehri1, Jaffar Alshahri, Mohammed Owais Alzwadi1, Saad Algarni

King Faisal Specialist Hospital and Research Center, 1Alfaisal University, Riyadh, Saudi Arabia.

E-mail: [email protected]

Background: In Saudi Arabia, the number of thoracic and abdominal aortic aneurysms (AAAs) treated does not exceed 200/year. For a population of over 30 million, this number is far below international standards. The lack of studies on incidence of AAA in the gulf has left many questioning whether AAA is massively underdiagnosed or whether the prevalence is inferior to international standards. We designed a study to estimate the prevalence of AAA in our region. Methods: This was a retrospective review of all abdominal computer technologies (CTs) done from January 1, 2011, to December 31, 2016, in our hospital. We included all male patients at age 65–75 years in whom a CT was done for reasons other than diagnosing and managing aortic aneurysms. All external aortic diameters of 3 cm or more were considered positive for AAA. Results: The total number of reviewed CTs was 2032. The mean age was 69.8 ± 3.1 years and the mean aortic size was 1.9 ± 0.3 cm. There were 2026 cases (99.7%) with sizes <3 cm and the mean age was 69.8 ± 3.1 years. There were six cases (0.3%) with sizes ≥3 cm and the mean age was 72.3 ± 3.1 years. The only statistically significant factor for AAA was age, 69.8 versus 72.3 ± 3.1 years (P = 0.0433). Conclusion: Based on our data, the number of AAA in our population is inferior to most international screening programs. This low incidence could explain the far inferior number of diagnosed AAA in our population, and there are a number of scientific theories to support this result. However, these data are from a tertiary referral center, and many risk factors for AAA were not available. A pilot screening program in the nonhospital population would provide more robust evidence on the need of an AAA screening program.

P508: Endovascular Treatment of Aneurysms of the Popliteal Artery

Sekkal Abderrahmane Riad, Bouayed Mohamed Nadjib

EHU, Oran, Algeria.

E-mail: [email protected]

Background: Arterial aneurysms of the lower limbs account globally 16% of arterial aneurysms, 70% of which are located in the popliteal arteries. Their prevalence is at 1% increasing with age. It usually falls within the context of an arteriomegaly rather than an atheromatous disease. Once the diagnosis is made and the indication retained, the patients had to be treated to prevent the complications caused by this type of lesions. This poster illustrates some cases of popliteal aneurysms treated with endovascular technique successfully in our department. Methods: We performed a single-center retrospective cohort study of 11 patients who underwent stenting of the popliteal artery for aneurysmal diseases of lower limbs between January 2010 and October 2017. Clinical improvement, permeability, stent thrombosis, intra-stent stenosis, and stent fracture were evaluated. Results: Eleven patients were treated for aneurysmal lesions of the popliteal artery, including 2 false aneurysms and 9 aneurysms. All our patients evolved well postoperatively. Clinical improvement was observed in all patients: no fracture or stent disconnection with aneurysms, without endoleak. One patient presented stent thrombosis after 2 years of follow-up. Conclusion: it seems reasonable to think that endovascular repair should be considered, case by case, as an alternative for open repair of popliteal artery's aneurysms. The technical improvements of covered endoprostheses and prospective studies gathering multiple observations will allow in future to affirm the interest of this treatment.

P509: Aortic False Aneurysm Endovascular Treatment on Behcet's Disease in four Cases

Sekkal Abderrahmane Riad, Bouayed Mohamed Nadjib

EHU, Oran, Algeria.

E-mail: [email protected]

Background: Behcet's disease is a systemic vasculitis of unknown origin. The vascular or angio-Behcet's manifestations interest all vessels. Venous involvement is frequent (30%) manifested as venous thrombosis. Arterial involvement is rare but severe (3%–5%) presenting as aneurysm and false aneurysm and may affect all vessels. The purpose of this poster is to show our experience in the endovascular treatment of false aortic aneurysms on Behcet's disease. Methods: We operated four patients who had false aneurysms of the thoracic and abdominal aorta that we treated according to their locations using endograft or Multi-layer Flow-modulating Stents (MFM). All our patients have been put under adequate medical treatment. Clinical improvements, permeability, stent thrombosis, and exclusion of false aneurysm were evaluated. Results: Our patients were treated endovascularly, two benefited from the placement of a covered endoprosthesis excluding the false aneurysm immediately after the control in per procedure, for the other ones, a multilayer stent was used and this seen the absence of landing zone compared to the digestive arteries, and the results were marked by the total exclusion of false aneurysms after 18 months of follow-up. After a 3-year follow-up, the stents are permeable with no false aneurysms at the impaction zones. Conclusion: For the Behcet's disease, the endovascular methods represent a good alternative to the classical surgical attitude and thus open up new therapeutic perspectives framed of course by a corticoid and immunosuppressive treatment.

P510: Selective Vesical Artery Embolization in Management of Lower Urinary Tract Hemorrhage on Top of Locally Advanced Urinary Bladder Tumors

Essam Hashem, Karim Abdeltawab

Ain Shams University Hospitals, Cairo, Egypt.

E-mail: [email protected]

Background: Causes of lower urinary tract hemorrhage are diverse. Locally advanced urinary bladder (UB) tumors are among the important causes, especially postirradiation therapy. If not properly managed, it may lead to serious morbidity and mortality. Vesical artery embolization may be a safe and effective minimally invasive method for bleeding control. Methods: In the period between January 2015 and November 2017 at Ain Shams University Hospitals, 12 patients (mean age of 68 years), with known locally advanced UB malignancy presenting with gross hematuria, underwent transarterial embolization after failure to achieve hemostasis using conservative measures. Clinical success was defined as stabilization of vital data of the patient and obviation of conventional invasive surgical management. Permanent embolization particles (300–500 μ) were used as the embolic agent of choice in all cases. Results: Bleeding was angiographically identified in two patients. In the other ten patients, no definite bleeders could be identified, and thus, empirical bilateral vesical artery embolization was performed. Clinical success was achieved in nine patients (75%), and this included the two patients with angiographically identified bleeding source. Surgical management was required in the remaining three patients, due to postembolization rebleeding. No significant periprocedural complications were encountered. Conclusion: In our limited sample size, transcatheter embolization is shown to be a safe and effective treatment option in management of gross hematuria due to locally advanced UB malignancy. Angiographic identification of the bleeding source is thought to yield higher clinical success rates. We recommend undertaking further studies with larger sample size to consolidate our results as well as stratification by tumor type and whether bleeding source is identified or not. This stratification process may improve patient selection criteria for the procedure.

P511: Incidence and Percutaneous Management of Arterial Emboli Occurring During Hemodialysis Graft Recanalization

Dong Erk Goo, Yong Jae Kim

Soonchunhyang University Hospital, Seoul, South Korea.

E-mail: [email protected]

Background: Embolization of clot fragments in the feeding artery is a possible complication of percutaneous declotting procedure in hemodialysis graft patients. We describe the incidence and management of accidental arterial emboli during dialysis graft declotting procedures. Methods: Between August 1997 and August 2012, 2484 patients (961 males; 1523 females) with thrombotic occlusions of hemodialysis grafts were treated with several percutaneous techniques. Percutaneous transluminal angioplasty was performed at the stenotic lesion after thrombolysis procedure. We analyzed the incidence of arterial emboli according to the method of thrombolysis and the location of the dialysis graft by Chi-square test. Results: Arterial emboli were documented by angiography in 83 cases (3.3%) of patients. Sixty-one cases of embolization involved the brachial artery or its branches, 14 involved the ulnar artery, and 8 involved the radial artery. Two patients complained of finger pain, but it immediately subsided. The numbers and incidence of arterial emboli according to the thrombolysis method are given. Arterial emboli were retrieved by occlusion balloon/fogarty balloon (45), guiding catheter-assisted aspiration (15), observation without intervention (16), sheath assisted aspiration (2), back-bleeding technique (3), and others (2). Subsequent fistulograms obtained in 26 patients and demonstrated arterial stenosis in 2 patients. Follow-up fistulogram demonstrated complete resolution of the observation emboli in three of four patients. Conclusion: Arterial emboli are seldom occurrence during percutaneous dialysis graft thrombectomy procedure, and the majority can be easily retrieved by percutaneous techniques. Clinical observation also appears to be indicated in asymptomatic patients.

P512: Extent Intravenous Thoracoabdominal Aortic Aneurysms: A Systematic Review

Benazi Ahmed, Bouayed Mohamed Nadjib

EHU, Oran, Algeria.

E-mail: [email protected]

Background: We compare the patency and complication rates of endovascular procedures with the outcome of open surgery for thoracoabdominal aneurism extend intravenous (IV). Methods: A systematic search of published studies PubMed reporting treatment of thoracoabdominal aneurism extend IV was performed. Results: Extent IV thoracoabdominal aortic aneurysm open repair is considered relatively safer. Improvements in the surgical technique have helped to greatly reduce death and complications at experienced centers. The development of totally endovascular repair with branched graft devices has provided a solution for patients who were previously judged inoperable. Conclusion: The possibility to choose between different options of treatment (surgical and/or endovascular) along with the experience of the center surely makes the differences on outcomes.

P513: Superiority of Intrasac Ethylene Vinyl Alcohol Copolymer Liquid Embolic (Onyx®) Embolization Compared with Other Embolization Agents and Techniques for the Treatment of Type II Endoleaks Following Endovascular Stent-Graft Treatment of Abdominal Aortic Aneurysms

Hatim Alobaidi, Stewart Kribs1

Prince Sultan Military Medical city, Riyadh, Saudi Arabia, 1London Health Science Centre, Ontario, Canada.

E-mail: [email protected]

Purpose: The aim of the study was to review our experience with the efficacy of ethylene vinyl alcohol copolymer liquid embolic (Onyx®) injected directed into the aneurysm sac compared with other embolic agents and techniques for the treatment of persisting type II endoleaks (after endovascular repair for abdominal aortic aneurysms [EVAR]). Methods: All patients treated at our center between April 2005 and July 2015 who underwent an embolization procedure for a persistent type II endoleak after EVAR were retrospectively reviewed. Patients were divided into three groups depending on the embolic agent used and the technique of embolization. Group 1 underwent embolization with Onyx® injected directly into the aneurysm sac, using either a transarterial or a direct sac puncture technique. Group 2 underwent embolization with agents other than Onyx®, including cyanoacrylate, also injected directly into the aneurysm sac. Group 3 included patients treated by any other embolization technique or agent. Successful treatment was defined as resolution of the endoleak on a follow-up computed tomography and <5 mm aneurysm sac expansion. Results: Thirty-nine patients underwent 56 embolization procedures. The number of patients and embolization procedures for the three groups was as follows: Group 1: 13 and 14; Group 2: 10 and11; Group 3: 21 and 31. The availability of postprocedure follow-up for the three groups was as follows: Group 1, 11/14 (79%); Group 2, 11/11 (100%); and Group 3, 26/31 (84%). Procedural success for the three groups was as follows: Group 1, 36%; Group 2, 18%; and Group 3, 23%. The success of Onyx embolization for patients in Group 1 who had only a single endoleak was 4 of 8 (50%). There was one major complication in Group 3 which was lower extremity weakness secondary to spinal infarction following embolization of a lumbar artery supplying the endoleak using polyvinyl alcohol particles. Conclusion: The success of embolization for persistent type II endoleaks following endovascular stent grafting for abdominal aortic aneurysms is limited with all embolization agents and techniques. However, Onyx® embolization injected directly into the aneurysm sac had the greatest success, especially if only one endoleak is present.

P514: Presurgical Embolization of Nasopharyngeal Angiofibroma: Finding Predominant Arterial Feeder

Shahzad Karim Bhatti, Umair Rashid

Lahore General Hospital, Lahore, Pakistan.

E-mail: [email protected]

Background: Juvenile nasopharyngeal angiofibroma (JNA) Nasopharyngeal angiofibroma is a benign fibrovascular tumor affecting young adolescent boys, originating from the posterolateral wall of the nasal cavity. The young patients mostly present with chronic epistaxis, nasal obstruction, rhinorrhea, conductive hearing, and diplopia. The aim of the study is done to find the predominant arterial feeder during presurgical embolization of juvenile nasopharyngeal angiofibroma to reduce blood loss and intraoperative time during surgery. Methods: Four-vessel angiography (digital-subtraction angiography) was done in all patients including internal and external carotid angiography with superselective angiography of vessel-supplying tumor. Presurgical embolization of 150 patients done with spongostone in angiography suit of Neuroradiology Department, Lahore General Hospital, Lahore, Pakistan, with age ranging from 12 to 18-year males from January 2012 to June 2016. All patients underwent surgery within 24 h. Results: Out of 150 patients, internal maxillary artery was supplying 111 patients, 30 were supplied by accessary meningeal artery, and 9 were supplied by ascending pharyngeal artery. Presurgical embolization with spongostone proved significant reduction in intraoperative blood loss and reduced surgical resection time. Conclusion: Internal maxillary artery proved to be the major feeder supplying JNA. Presurgical embolization appears to be the treatment of choice prominently reducing intraoperative blood loss and minimizing the need of blood transfusion with short intraoperative time, resulting in quick and better surgery.

P515: Outcomes of Elective Percutaneous Peripheral Revascularization in Outpatients: 10-Year Single Center Experience

Sonaz Malekzadeh, Tanina Rolf, Francesco Doenz, Christophe Constantin1, Anne-Marie Jouannic, Salah-Dine Qanadli

CHUV, Lausanne, 1Sion Hospital, Sion, Switzerland.

E-mail: [email protected]

Background: The aging population, along with increased cardiovascular risk factors, has led to an increase in vascular diseases incidence, and subsequently, the need for therapeutic procedures. Today, percutaneous transluminal angioplasty (PTA) and stenting are considered the first-line treatment for a variety of procedures for patients with disabling peripheral arterial disease (PAD). The aim of this study is to evaluate the safety and feasibility of peripheral percutaneous endovascular procedures in a large group of outpatients suffering from PAD. Methods: We evaluated all elective patients who underwent peripheral balloon angioplasty (PTA) or stenting for PAD of the lower extremities as “out-patient admission protocol” (OPAP) from January 2005 to December 2015. By protocol, patients were expected to be discharged 4 h after the procedure. Clinical profile, procedure details, and technical success were reviewed. Complications, conversion rate, readmission rate, and long-term follow-up were evaluated. Results: Four hundred and forty-nine consecutive patients with a mean age of 66 ± 10.1 years (280 men and 169 women) were evaluated. Four hundred and seventeen patients (93%) suffered from claudication. Femoral access was obtained in 96% (6-French sheath in 87%) of patients. PTA alone was performed in 18% and PTA/stents in 82%. Technical success was 98.6%. Over the 8 observed failures, 4 patients had a second successful procedure. Closure devices were used in 52.4% procedures. All patients received heparin during the procedure and were discharged with dual antiplatelet therapy. Conversion and readmission rates were 2% and 0.6%, respectively. Complication rate was 3.6% (minor and major 2.8% and 0.8%, respectively). No correlation was found between complications and closure device usage. Restenosis rate was 24.5% during the long-term follow-up (mean 44 months). Conclusion: As designed, The OPAP was feasible, safe, and effective with very low conversion and complications rates. These results strongly support a larger use of such approaches as routine practice.

P516: Stenting Angulated Aortic Aneurysm Neck Before Endovascular Aortic Repair: A Case Report

Mohamed Omar Elfarok, Karim Abdeltawab

General Organization of Teaching Hospitals and Institutes, Cairo, Egypt.

E-mail: [email protected]

Background: Increasing number of patients with angulated abdominal aortic aneurysm (AAA) neck are being treated with endovascular aneurysm repair (EVAR). Moreover, more patients with unsuitable or high-risk anatomy defined in the instructions for use for endografts are being referred to centers with high volume. In this case report, we discuss specific problems that can be encountered during preoperative planning in relation to periprocedural stent graft deployment in patients with angulated AAA necks and offer potential solutions for these problems. The aorta can angulate in several directions (dimensions) simultaneously. Two neck angles are evaluated in the preoperative evaluation. Suprarenal neck angulation refers to an angle measured between the long axis of the immediate suprarenal aorta and the infrarenal aorta. The second angle is aortic neck angulation which measured between the long axis of the infrarenal neck and the long axis of the AAA. Case Report: An 81-year-old male presented to his general practitioner with chronic lower back pain., and pulsatile abdominal mass, patient referred to vascular clinic and a diagnosis of AAA was made, risk factors include diabetes, hypertension and dysliaedemia, CT scan was done which showed 65 mm AAA infrarenal by 15 mm with a severely angled aortic neck. The alpha angle was 89° and the Betal angle was 90°. We planned to deploy self expandable nitinol aortic stent E-XL at the angled neck before the Device to remodel the proximal aorta and then to deploy the device from bilateral femoral cutdowns. We have found that both angles have decreased by 15%, patient was discharged 3 days later with no endoleak. Conclusion: The use of self-expandable E-XL stent in severely angulated necks before EVAR may offer an advantage in lowering the aortic angle to around 15% less and decrease the secondary interventions in these cases.

P517: Endovascular Management of a Pulmonary Artery Aneurysm

Noha Husain Guzaiz, Ahmed Fouad Azhari, Muath Abdulmohsen Alahmadi, Mohammed Mahmood Raslan, Ahmed Elsakhawy, Almamoon Ibrahim Justaniah

King Abdullah Medical City, Makkah, Saudi Arabia.

E-mail: [email protected]

Background: Pulmonary artery aneurysms are a rare. They constitute <1% of thoracic aneurysms with a prevalence of 1 in 14,000 individuals. Studies have shown associations with pulmonary hypertension and infection. Given its rarity, management of such cases is still controversial. Our aim is to present a minimally invasive technique using endovascular coiling. Case Report: We report a case of a 38-year-old female with a known history of chronic pulmonary embolism and bilateral pulmonary artery aneurysms. She presented with massive hemoptysis. Computed tomography (CT) angiography chest revealed multiple pulmonary aneurysms. A dominant 1.7 cm saccular aneurysm was noted in the right superior pulmonary artery with communication to the adjacent bronchus. Results: We performed a pulmonary arteriography that confirmed the CT findings. Coil embolization was performed to the dominant aneurysm, preserving the flow to the distal branches. The patient was discharged with no further episodes of hemoptysis up to 90 days. Complete thrombosis of the aneurysm was noted in the 60-day follow-up CT. Conclusion: Endovascular management can be considered as a minimally invasive alternative to surgical intervention for the management of pulmonary artery aneurysms.

P518: Experience with Bronchial Artery Embolization for Haemoptysis in Patients with Aspergilloma

Krishna Prasad Bellam Premnath, Binu Joy1, Vijaykumar Akondi Raghavendra1

Queen'S Hospital, London, UK, 1Rajagiri Hospital, Kochi, India.

E-mail: [email protected]

Background: The aim of the study was to describe our experience with bronchial artery embolization for massive or persistent hemoptysis in patients with aspergilloma. Methods: This is a retrospective study where patients with aspergilloma presenting with massive or persistent hemoptysis who were treated over the past 18 months with bronchial artery embolization and followed up in our hospital were reviewed for history, procedure details, complications, and recurrence from the case records. Results: Number of patients treated in the 18-month period was 16. Fifteen patients had aspergillomas in cavities of tuberculous sequel, and one in a necrobiotic rheumatoid nodule. Fourteen patients had massive hemoptysis and two had mild but persistent hemoptysis. All patients underwent CT angiography before embolization for bronchial/other systemic culprit artery mapping. All patients had successful attempts of bronchial artery embolization. Polyvinyl alcohol particles were used in 6 and gelfoam slurry was used in 8 patients. One patient had recurrence after 4 h of embolization and was reembolized; gelfoam was the agent used in this case. Three cases had recurrence within 6 months. All other cases had no recurrence of hemoptysis, and the longest recurrence-free period recorded was 16 months. Three patients were cured of aspergilloma after embolization. None of the patients had any complications related to embolization. Conclusion: Aspergillomas can cause recurrence of hemoptysis even after successful satisfactory embolization. Embolization may have a role in disappearance of aspergilloma as has been demonstrated in three of our cases and has never before reported or discussed in literature.

P519: Dialysis Catheter Placement: Is the Tip Correctly Positioned?

Yasir Khattak, Muhammad Anwar Saeed, Ayman Sibaie

Rashid Hospital, Dubai, UAE.

E-mail: [email protected]

Background: The “optimal” positioning of a permanent dialysis catheter tip has been long debated, with multiple conflicting recommendations. As with any other dialysis access, hydraulic performance is of paramount importance for tunneled catheters. This depends mainly on the catheter tip position. Thus, an agreement on the optimal catheter tip position is of significant importance. Methods: A retrospective review was performed to identify all patients requiring permanent dialysis access catheters from 2010 to 2017 at our institution. Demographic data including age and gender were collected. Data regarding access site, catheter type used, and tip location were also collected. Results: A total of 665 permanent catheters were placed in 595 patients. Multiple types of catheters including staggered tip and split tip were used. The tip location included distal superior vena cava, sinoatrial junction, distal right atrium, and inferior vena cava. Conclusion: Our data suggest that, among multiple variables including patient size, catheter length, type of catheter, and operator technique, tip location is the most important factor affecting catheter functionality and postprocedure complications. A standardized approach regarding tip positioning should be adopted to improve the catheter performance and prevent future complications.

P520: The Safety and Short-Term Efficacy of Bronchial Artery Embolization for Management of Massive Hemoptysis (Single Centre Experience)

Rana Tarek Mohamed Khafagy, Karim Abd El-Tawab

Ain Shams University Hospital, Cairo, Egypt.

E-mail: [email protected]

Background: Massive hemoptysis has been described as the expectoration of an amount of blood ranging from 100 mL to more than 1000 mL over a period of 24 h. It may result from various causes the most common of which among Egyptian practice is bronchiectasis followed by bronchogenic carcinoma. Methods: 23 patients (18 males and 5 females) were referred to IR Unit Ain Shams University Hospitals for the management of massive hemoptysis during the period from (January 2015 to November 2017). Median age was 59.5 years (range: 15–77 years). Causes were bronchiectasis in 14, bronchogenic Carcinoma in 5, tuberculosis in 2, and cystic fibrosis in 2 cases. Computed tomography chest was done for all patients. Right femoral vascular access using a 6F sheath was done, then selective probing of thoracic aortic side-branches was done using 4F Cobr catheter with selective bronchial angiography. Identifiable bleeders were embolized otherwise, empiric embolization of arteries supplying the diseased segment was done. Spherical particles 300–700 μm were used. 2.7F microcatheter was used for superselective embolization if the artery was smaller than the mother catheter. Results: In 13 (57%) of the patients, bleeder was detected. In 10 (43%) patients, no pathologic arteries were detected. Selected vessel stasis was achieved in all patients. During 1st month, bleeding totally stopped in the 13 patients with identifiable bleeders as well as 9 of the empiric embolization group. One patient with bronchogenic carcinoma developed massive hemoptysis 2 days after the embolization and was scheduled for urgent reevaluation angiography and embolization; however, patient died from disseminated intravascular coagulation and multisystem organ failure before the second procedure. No major complications occurred. Chest pain and mild postembolization syndrome took place in most of the patients. Conclusion: In this limited series, bronchial artery embolization is an effective option in management of severe hemoptysis with high hemostasis and low complication rates

P521: Role of Inferior Vena Cava Filter Insertion before Thrombolysis of Acute Iliofemoral Deep Venous Thrombosis

Mohamed Ismail, Amr Mahmoud

Ain Shams University, Cairo, Egypt.

E-mail: [email protected]

Background: The aim is to measure the need to inferior vena cava (IVC) filter insertion before catheter directed thrombolysis (CAT) and its effect on the morbidity and mortality. Methods: A prospective randomized cohort study. It took place at Ain Shams University hospitals between 2013 and 2016. Thirty cases with left lower limbs extensive iliofemoral deep venous thrombosis (DVT) (<14 days) were treated by CAT only with no role for pharmacomechanical procedures. First angiography after starting CATs was done after 24 h to do “lysis check” followed by another session if not completely resolved. IVC filter usage for 15 cases (high-risk group). They are retrievable type and are removed later on not immediately. IVC filter loading by emboli was divided into (small 1/3 the diameter) and (large >1/3). Follow-up was done at interval 3, 6, and 9 months by clinical assessment (CEAB classification) and duplex study to assess recanalization and valve incompetence. Results: Thirty cases were collected and divided into 15 without the use of IVC filter and 15 cases used it. Only three cases have large embolic load in IVC (>1/3) and these patients had positive risk factors (oral contraceptives, previous history of DVT, and extension of DVT to IVC). Twenty-eight cases had successful lysis, while two patients complicated and aborted (one had hemorrhagic ovarian cyst and the other had retroperitoneal hematoma). One case had major complication and needed reintervention due to thrombosed iliac stents and two cases had minor ones. Six cases with IVC filter failed to be retrieved. Two cases without IVC filter developed pulmonary embolism (PE). Conclusion: IVC insertion is not recommended for patient with extensive iliofemoral DVT who received thrombolysis except for those who have strong risk factors or previous history of PE.

P522: Ballooning of Inferior Vena Cava and Iliac Veins Is It Enough for Treating of Chronic Venous Insufficiency

Mohamed Ismail, Amr Mahmoud

Ain Shams University, Cairo, Egypt.

E-mail: [email protected]

Background: The aim of the study was to evaluate patency and improvement of symptoms of chronic venous insufficiency after ballooning of inferior vena cava (IVC) and iliac by high pressure balloons without stenting Methods: retrospective study of patients is manifested by chronic venous insufficiency physically active with extensive iliocaval obstruction or stenosis. We collected data from ten patients underwent ballooning of iliac veins and IVC by high pressure balloons (sequential gradual dilatation up to 18 mm balloon for 3 min each time) after passing the lesion by hydrophilic 0.035 wires combined with stiff wire 0.035 through ipsilateral antegrade popliteal access in five patients, femoral vein in thre patients, and through GSV in two patients ultrasound guided. Results: Two out of 10 patients need reintevention within 1 year, one of them developed extensive iliofemoral deep venous thrombosis, 8 of them their symptoms improved with 100% primary patency with follow-up venous duplex. Conclusion: although the typical recoil nature of venous disease, primary patency of balloon venoplasty has a preliminary good results with no consequences of possibility of stent occlusion.

P523: Role of Endovascular Management in Treatment of postphlebitic Iliocaval Obstruction Patients

Mohamed Ismail, Amr Mahmoud

Ain Shams University, Cairo, Egypt.

E-mail: [email protected]

Background: The aim of research is to evaluate our experience of endovascular management in treatment of postphlebitic iliocaval obstruction in Ain Shams University Hospitals. Methods: This is a prospective cohort study. Thirty patients (20 female/10 male) aged between 30 and 45 years old presented with lower limb iliofemoral deep venous thrombosis 6–12 months ago. They received treatment for at least 6 months in the form of anticoagulation and elastic stocking. They were complaining of unilateral lower limb swelling which did not improve with conservative management and secondary varicose veins. High pressure balloons 14, 16, and 18 were used in all cases. Twenty-four cases were stented. Seventeen were stented by Wallstent while 7 by venous stents. Results: Follow-up was done at 3, 6, 9, 12, 18, and 24 months using duplex; 6 cases failed due to failure to pass the wire (4 cases), venous perforation (2 cases); 20 of 24 patients who received stents were patent, while 4 were occluded (2 of them succeeded to recanalized by thrombolysis). Conclusion: Endovascular management has a role in the treatment of postphlebitic iliocaval obstruction patients and need strict follow-up.

P524: Uterine Artery Embolization in Postpartum Hemorrhage

Essam Tarek Essameldien Abdullah, Karim Ahmed Abdultawab

Ain Shams University Hospitals, Cairo, Egypt.

E-mail: [email protected]

Background: Postpartum uterine hemorrhage is one of the most important causes of maternal mortality worldwide and as well in Egypt. Causes are variable most important of which are uterine atony and birth canal lacerations. Uterine artery embolization is very effective if local measures failed to stop bleeding Methods: In the period between January 2015 and November 2017, 75 women (mean age 26 years) with postpartum hemorrhage underwent embolization in Ain Shams University Hospitals after failure to achieve hemostasis after conservative treatments. Clinical success was defined as stabilization of vital data of the patient and obviation of hysterectomy. Gel foam hand cut pledges were the embolic agent used. Results: Bleeder whether extravasation or pseudoaneurysm could be identified angiographically in 32 patients. In 43 patients, no definite bleeder could be identified, so bilateral uterine artery embolization was done empirically. Clinical success rate was 80% (60 patients including 31 patients with angiographically identified bleeder). Hysterectomy was needed in 15 patients after rebleeding post-UAE. No major procedural-related complications were recorded. Conclusion: Transcatheter arterial Embolization of the uterine artery is a feasible treatment option in the management of postpartum bleeding with low rates of complications. Angiographic identification of the bleeding source was associated with higher clinical success rates decreasing the need for hysterectomies.

P525: Transarterial Embolization of the Renal Arteries for Management of Iatrogenic Renal Vascular Injuries: Single Centre Experience

Essam Tarek Essameldien Abdullah, Karim Ahmed Abdultawab

Ain Shams University Hospitals, Cairo, Egypt.

E-mail: [email protected]

Background: Despite being considered minimally invasive, percutaneous nephro-urological interventions; percutaneous nephrolithotomy (PCNL), percutaneous nephrostomy (PCN), and renal biopsy can be associated with massive life-threatening hemorrhage. Surgical management in the form of partial and total nephrectomy is usually associated with marked comorbidity and massive renal parenchymal loss. This study aims to assess the technique and short-term hemostasis of transarterial renal artery embolization in iatrogenic vascular injuries. Methods: In the period between January 2015 and November 2017, 122 patients with suspected renal vascular trauma (100 post-PCNL, 19 postrenal biopsy, and 3 post-PCN) either presenting with hematuria (103 patients) or increasing perinephric hematoma by ultrasonography (19 patients) were referred to our institute for the possibility of embolization. Embolization was done with vascular coils, gelatine sponge particles, N butyl cyanoacrylate, or combination of those agents. Results: The bleeding artery could be identified and embolized in 115 patients; in patients with negative angiography, no further intervention was done. One hundred and nine patients showed clinical improvement in the form of stoppage of hematuria or stabilized vital data and stabilized size of hematoma. Rebleeding occurred in three patients (all embolized by gelatin sponge particles alone) who were treated by another session of embolization. None of the treated patients needed any further surgical treatment. No major complications occurred. Conclusion: In this limited series, transarterial renal artery embolization has shown to be an effective option in the management of iatrogenic renal vascular injuries with high hemostasis as well as low complication rates.

P526: Recognizing Arterial Supply Patterns to Hepatocellular Carcinoma for Optimal Transarterial Therapy: A Pictorial Review

Omar Bashir, Muhammad Arabi, Refaat Salman, Shahbaz Qazi, Abdurrahman Alvi, Yousof Al Zahrani

Kingabdulaziz Medical City, Riyadh, Saudi Arabia.

E-mail: [email protected]

Background: Transarterial therapies including transarterial bland embolization, transarterial chemoembolization TACE), and selective intraarterial radiation treatment (SIRT) are management options offered to select patients suffering from hepatocellular carcinoma (HCC). Most HCCs derive their blood supply from the hepatic artery. However, it is not uncommon for some HCCs to develop extrahepatic arterial supply from a variety of sources including inferior phrenic, internal mammary, and gastroduodenal arteries. Identification of these “parasitic” vessels helps in minimizing the chances of under treatment. In addition, recognition of flow dynamics of hepatic arterial and HCC supply permits operators in optimizing flow for delivery of Y-90 during SIRT. Methods: In this educational poster, we present a series of case vignettes demonstrating the value of recognizing hepatic arterial flow patterns for optimal delivery of transarterial therapy when treating HCC. Results: We aim to highlight imaging features of HCCs which may predict the presence and source of extrahepatic arterial supply. We also demonstrate angiographic techniques that help in optimal delivery of TACE and SIRT. Conclusion: Knowledge of hepatic arterial flow patterns and extrahepatic tumor supply can help in optimizing safe delivery of transarterial therapy for treating HCC.

P527: Acute Deep Vein Thrombosis with Duplication of Inferior Venecava

U. Gurunandan, Ambarish Satwik, V. S. Bedi, Sandeep Agarwal, Ajay Yaday, Dhruv Agarwal

Sir Ganga Ram Hospital, New Delhi, India.

E-mail: [email protected]

Background: Venous thromboembolism (VTE) is the third leading cause of cardiovascular mortality. In young patients, VTE is frequently associated with hereditary coagulation abnormalities, immunological disease, and neoplasia. The advent of computed tomography scan and venography has identified venacaval malformations as a new etiological factor. Duplication of inferior vena cava (IVC) is a rare finding in radiological studies. The incidence is about 0.2%–3%. Its symptomatic presentation is even rarer. We present a 43-year-old male with acute left lower limb deep vein thrombosis (DVT) with duplicated IVC. Case Report: Patient presented with acute pain in left lower limb and diffuse swelling since 6 h. Venous Doppler showed acute ileo-femoropopliteal DVT. There was no history of trauma or previous hospitalization or surgery. There was no evidence of pulmonary embolism. Patient underwent pharmacomechanical thrombolysis with IVC stent placement. Venography revealed duplicated left-sided IVC with stenotic segment which was stented. Results: Postoperative period was uneventful. Limb swelling had reduced in size. Patient was discharged on anticoagulants. Computed tomography scan at 1-month follow up showed patent stent. Conclusion: Duplicated IVC can be considered as one of those rare congenital causes that predisposes to VTE. Surgeons need to be aware of such anomalies of IVC and that they may influence decision-making in patients with an acute presentation of thromboembolic disease.

P528: Extracranial Carotid Artery Pseudoaneurysm in an Infant

U. Gurunandan, V. S. Bedi, Sandeep Agarwal, Ajay Yaday, Ambarish Satwik, Dhruv Agarwal

Sir Ganga Ram Hospital, New Delhi, India.

E-mail: [email protected]

Background: Cervical masses in infants are frequent during routine clinical practice. They are usually congenital or of infectious origin. Vascular abnormalities, such as extra cranial carotid aneurysms, are very uncommon. We report the case of a 10-month-old boy with a giant ruptured pseudoaneurysm of the left internal carotid artery (ICA). Case Report: A 10-month-old child presented to us with rapidly developing left neck swelling for 15 days. Patient had undergone fine-needle aspiration cytology 3 weeks back. Patient had skin breach with oozing of fluid mixed with blood. Computed tomography scan revealed a giant pseudoaneurysm from left ICA with occluded distal ICA. Results: Patient underwent surgical repair of the pseudoaneurysm. Postoperative period was uneventful with no neurological deficits. Conclusion: Carotid artery pseudoaneurysm is an uncommon pathology particularly in the padiatric population. It is mostly due to trauma or iatrogenic. For the treatment, endovascular and surgical options could be considered, each possibility having its precise indications. When possible, surgical management by resection and end-to-end anastomosis would be preferred.

P529: Penetrating Aortic Ulcer Presenting as Hematemesis

U. Gurunandan, Ambarish Satwik, V. S. Bedi, Sandeep Agarwal, Ajay Yaday, Apurva Srivastava

Sir Ganga Ram Hospital, New Delhi, India.

E-mail: [email protected]

Background: Aortoesophageal fistula (AEF) is a rare and life-threatening condition with fatal outcome if not identified and treated early. In more than half of the cases, aortic aneurysm rupture is the causative factor. There are only a few case reports of aortic ulcer presenting as hematemesis or hemoptysis in the literature. We are presenting a case of penetrating aortic ulcer with hematemesis. Methods: A 61-year-old male, smoker, hypertensive presented to the emergency with a history of syncope and hematemesis 4 days back. Physical examination showed blood pressure of 100/90 mmHg, heart rate of 110 bpm, and normal pulse in both legs. Patient was admitted in Intensive Care Unit and emergency computed tomography scan revealed descending thoracic aortic ulceration. Results: The patient underwent successful endovascular repair and was discharged after 8 days in a stable condition. Conclusion: AEF is a rare and dreaded cause of upper gastrointestinal hemorrhage. Many patients present with herald bleeding before the final exsanguination, which is critical to recognize as it allows window period for diagnostic and therapeutic maneuvers. In the present endovascular era, penetrating aortic ulcers can be safely treated with minimal procedure-related morbidity and mortality.

P530: Is Coverd Stent Graft Prone for Thrombosis: Case Report of Complication Faced on Follow-Up after Endovascular Management of Popliteal Artery Aneurysm

Vaibhav Lende, Vivekananda, Sravan Cps

Bhagwaan Mahaveer Jain Hospital, Bengaluru, India.

E-mail: [email protected]

Background: Popliteal artery aneurysms are the hallmark of peripheral aneurysms, accounting for 70%, and are commonly bilateral in 50%–75% of patients. The prevalence and incidence of popliteal artery aneurysms are not precisely known. The presence of a popliteal aneurysm is a marker of risk to limb and life because 33%–43% are associated with an abdominal aortic aneurysm. Ligation and bypass reconstruction has long been the “gold standard” for the treatment of popliteal aneurysms. Recently, endoluminal repair with a percutaneously delivered stent graft has become a valid alternative to open repair. We present a complication of coverd stent thrombosis in 3rd-month follow-up for a patient treated for popliteal artery aneurysm. Case Report: We present 60-year male patient presented with left forefoot rest pain of sudden onset with fore foot discoloration for 2 days. On examination, patient was having thrash foot with all toes of the left leg discolored and ischemic. All distal lower limbs pulses were palpable except left dorsalis pedis artery. Computed tomography angiogram of the lower limbs revealed bilateral popliteal artery aneurysms, Left 4.2 cm × 6 cm and right 2.1 cm × 4 cm. Since left was symptomatic, decision was taken to intervene for the left popliteal aneurysm first. Covered Stent graft deployed of 8 mm × 10 cm (fluency). Poststenting there was no endoleak. Procedure went uneventful. Patient presented at 3 month with stent occlusion and underwent catheter directed thrombolysis. Results: The first procedure of deployment of stent graft went uneventful with no endoleak and good sealing zone. Postthrombolysis patient put on anticoagulation and now till 8-month follow-up patient is doing well. Conclusion: Endovascular therapy is a safe modality of treatment although long-term data are not available. Furthermore, proper follow up of all the patient is very important.

P531: Refractory Chyloma Posttotal Thyroidectomy: How to Manage

Hassan Mosa Ali Alshehri, Mohammad Badran, Ali Rajeh, Amr Maged Elsaadany

King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.

E-mail: [email protected]

Background: Thyroidectomy and neck lymph node dissection are a common neck endocrine surgery. Chyle leak is a rare but troublesome complication of cervical surgeries. Case Report: This is a case report of a patient who suffered from left side chyle leak (chyloma) after total thyroidectomy and bilateral neck dissection. The patient was managed initially conservatively in the form of continuous collection drainage and oral intake cessation then sclerotherapy, and finally definite management was with thoracic duct embolization. Results: Technically and clinically successful embolization of thoracic duct leak. One week after thoracic duct embolization, the neck swelling disappeared, drain catheter removed, and resume regular diet. Conclusion: Thoracic duct embolization is effective, and less invasive than surgical options for the management of thoracic duct injury.

P532: Sclerotherapy of Varicose Veins: Is It Boon Or Curse!

Neeraj Mehta, Nitesh Manohar Gonnade1

Dr S. N Medical College, 1All India Institute of Medical Sciences, Jodhpur, India.

E-mail: [email protected]

Background: Ultrasound-guided foam sclerotherapy is a minimally invasive treatment option used for ablation of truncal and perforator reflux for chronic venous ulceration. Foam sclerotherapy is characterized by an overall high degree of safety, though special attention should be given to the embolic and thrombotic complications. Good technique, adequate imaging, general precautions, and compliance with post-treatment instructions may help avoid some of the adverse events and an appropriate early intervention may minimize possible sequelae. Methods: In this educational exhibit, we tried to highlight the basic steps of sclerotherapy, it's benefits and complications associated with it. Results: In this educational exhibit, we tried to highlight the basic steps of sclerotherapy, it's benefits and complications associated with it. Conclusion: Sclerotherapy of varicose veins guided by ultrasound is a procedure that offers many advantages: multiple indications, simple to be done, low cost, and minimally invasive.

P533: Broken Catheters: A Review of Surgical Management

A. Shaffeek, J. Ravikrishnan, M. C. Rajendran, M. H. Abdul Rasheed

Government Medical College, Trivandrum, India.

E-mail: [email protected]

Background: A large variety of diseases are nowadays diagnosed and treated with catheterization procedures. As the number of procedures increase, the number of catheter-related complications also increase. The catheter or guidewire can break during the procedure. Unintentionally, the catheter may get embolized to unwanted sites and chambers. In developing countries, the diagnostic and therapeutic catheters are reused to contain cost. This practice also increases the risk of breakage of the catheters. Methods: Government Medical College, Trivandrum, is a tertiary care center doing around 5000 angiograms per year, including coronary and peripheral angiograms. The hospital is a referral center for the other hospitals in the district. The department of cardiothoracic and vascular surgery provides surgical backup for these procedures. A review of records was done to assess the frequency of surgical management in catheter-related complications during November 2015 to October 2017. Results: The total number of angiograms was 9876 during the study period with total of five catheter-related complications that required surgery. Indications for surgery included broken catheter in popliteal artery (n=1), broken catheter in iliac artery (n=1), broken sheath in femoral artery (n-1), pericardial pigtail in pulmonary artery (n=1), guidewire in radial artery (n=1). The mean hospital stay was 10 days Conclusion: Even though rare, serious vascular complications do occur in diagnostic and therapeutic catheterization. Though snaring and retrieval is possible in many occasions, surgery has a definite role in case of failure of percutaneous methods. By timely surgical approach, all our patients had a good outcome.






 

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