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 Table of Contents  
Year : 2019  |  Volume : 3  |  Issue : 3  |  Page : 1-44


Date of Web Publication25-Feb-2019

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2542-7075.252895

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How to cite this article:
. Abstracts. Arab J Intervent Radiol 2019;3, Suppl S1:1-44

How to cite this URL:
. Abstracts. Arab J Intervent Radiol [serial online] 2019 [cited 2021 Feb 28];3, Suppl S1:1-44. Available from: https://www.arabjir.com/text.asp?2019/3/3/1/252895

  OC1.1: Is it Trivial That Interventional Radiologists Comply with Radiation Protection Practices? Maybe Not! Top

Mostafa Abdelrahman

Jordan University of Science and Technology, Irbid, Jordan. E-mail: [email protected]

Background: Radiologists are at higher risk of adverse health effects due to their occupational radiation exposure; therefore, applying protection techniques is imperative. Studies on radiologists’ compliance in this regard are scarce. We aimed to assess compliance with radiation safety practices among radiologists. Method(s): Questionnaires were distributed to radiologists in tertiary hospitals. The questionnaire was designed to assess compliance in three domains: using personal protective devices, using exposure-reduction techniques during fluoroscopic exposures, and using personal dose-monitoring devices. Descriptive analysis of the compliance was performed. Result(s): Sixty-two radiologists were included in the analysis. Use of leaded aprons and thyroid shields was commonplace, whereas only 3.2% ever use leaded eyeglasses. About half of the radiologists always considered reducing the time of exposure and avoided exposure by the primary beam, and the other half did that sometimes. Most of the radiologists (66.1%) always complied with reducing the number of unnecessary exposures, and the rest only complied sometimes. Most of the radiologists (93.5%) always used single personal dose-monitoring devices, most commonly at the neck level over the collar. There was no difference in compliance between different sexes, position descriptions, hospital types, hospital sizes, or years of experience. Conclusion(s): Future compliance improvement strategies for radiologists should focus on use of thyroid shields and leaded eyeglasses and use of exposure-reduction techniques during fluoroscopic operations.

  OC1.2: Mechanochemical Endovenous Ablation, Mechanochemical Ablation: A Novel Endo-venous Technique without Tumescent Anesthesia and Comparable Results for Treatment of Varicose Veins Top

Amol Madanlal Lahoti, Vivek Kisan Ukirde, Saurabh Anant Joshi

LTMMC and LTMGH, Sion Hospital, Mumbai, Maharashtra, India. E-mail: [email protected]

Background: Minimally invasive endo-venous techniques have revolutionized the treatment and outcome of insufficient truncal veins and are associated with an good outcome. The use of thermal energy (EVLT- endo-venous laser therapy) requires the instillation of tumescent anesthesia around the vein. Mechanochemical endovenous ablation (MOCA) combines mechanical endothelial damage, using a rotating wire/ prongs, with simultaneous infusion of a liquid foam sclerosant. Studies using MOCA™ in both great and small saphenous veins showed good anatomical and clinical results with fast and equivalent post-operative outcome and recovery. Method(s): Mechanochemical endovenous ablation versus radiofrequency ablation in the treatment of primary great and small saphenous vein insufficiency is a single center study in which total of 30 patients (40 limbs) randomized (1:1) to MOCA™ and EVLT are studied. Patients with primary great and small saphenous vein varicosity and /or incompetence, are studied. The primary endpoint is anatomic success, defined as occlusion of the treated veins objectified with duplex ultrasonography at 3 months of follow-up. Post-procedural pain, initial technical success, clinical success, complications and the duration of the procedure and patient satisfaction were studied and compared. Both groups evaluated on an intention-to-treat principle. Result(s): The clinical (sign and symptoms) and radiological (on doppler ultrasound) outcome of both MOCA and EVLT are almost comparable. The peri-procedural pain is significantly less in the MOCA. There is no need of multiple needle injections to inject tumescent anesthesia in MOCA, so it is easy to perform MOCA. Patient satisfaction was better in MOCA. Varicosities associated and connected with GSV and SSV also got sclerosed through sclerosant injected into GSV and SSV. Conclusion(s): Significantly decreased peri-procedural pain and ease of the MOCA therapy in the treatment of varicose veins can make it treatment of choice in the treatment of varicose veins over EVLT as per our study.

  OC1.3: Does Left Ovarian Vein Reflux Cause a Pseudo-Nutcracker Effect Creating Meso-Aortic Narrowing of the Left Renal Vein? Top

David Beckett, Judy Holdstock, Angela White, Tim Fernandez-Hart, Mark Whiteley

The Whiteley Clinics, London, UK. E-mail: [email protected]

Background: Trans-abdominal and trans-vaginal ultrasounds are performed for pelvic venous reflux. Patients are scanned at diagnosis and at 6-8 weeks following Pelvic Vein Embolization. Our aim was: 1) Identify the proximal extent of Left Ovarian Vein (LOV) reflux. 2) Evaluate the left renal vein (LRV) and identify or exclude Nutcracker phenomenon as a cause of LOV reflux. 3) Compare changes in appearance or calibre of the LRV following PVE. Method(s): 24 female patients underwent embolisation between September 2016 and April 2017. Scanning was performed with patients erect and 30 degree. Diameters of the hilar and mesoaortic segments were recorded. Proximal versus distal LOV reflux prior to PVE was noted. 3 patients were excluded. Result(s): (1) Group 1: 11 patients with LOV reflux had pre PVE hilar to mesoaortic diameter ratios with a mean of 5.0 and post PVE diameter ratios with a mean 2.0 (p=0.001). (2) Group 2: 10 patients, 8 without LOV reflux and 2 with LOV reflux distally had pre PVE ratios with a mean of 2.1 and post PVE with a mean ratio of 2.0 (p=0.799). 5 patients in Group 1 had hilar to mesoaortic diameter ratios >5 prior to PVE with suspicion of Nutcracker. These 5 included both patients with PCS who experienced complete symptomatic resolution post PVE. Post PVE all patients in Group 1 had normal diameter ratios with none showing abnormal ratios. Conclusion(s): Nutcracker phenomenon has been suggested as a cause of LOV reflux, secondary to obstructive flow due to compression of the left renal vein between the Aorta and superior mesenteric artery. In this study, LOV reflux appeared to cause a siphon effect, with LRV drainage preferentially following the LOV reflux path. This results in physiological narrowing of the mesoaortic LRV – we have called this “pseudo-nutcracker” phenomenon. This effect is relieved following successful embolization of the LOV.

  OC1.4: Evaluation of Clustered Micro Calcifications, Initially Graded as Likely Malignant On Baseline Mammography, with Stereotactic Biopsy: A Rad-Path Correlation Top

Hafsa Shahwaiz Babar, Anis Ur Rehman, Imran Khalid Niazi

Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan. E-mail: [email protected]

Background: Stereotactic guided breast biopsy is an invincible tool to sample abnormalities visible only on mammography with subtle or occult ultrasound findings. Common mammographic abnormalities which require stereotactic core biopsy include calcifications, architectural distortion and satellite lesions. Use of stereotactic large-core needle breast biopsy is increasing with advancement in techniques for adequate localization of lesions. A study was performed to look for frequency of benignancy or malignancy of microcalfications and architectural distortions in patients initially falling in malignant category of BIRADS on baseline mammograms when compared with histopathology after stereotactic biopsy. Method(s): Patient presenting in OPD clinic who underwent stereotactic biopsies for labeled malignant on mammograms from May 2015 to May 2018 were included in retrospective study. Age, technique used, baseline mammogram and histopathology were reviewed. Result(s): A total of 91 patients underwent stereotactic biopsy. Age range varied between 28 to 81 years. Stereotactic biopsies were taken using a standard 14-gauge core needle with long throw of 22 mm excursion. None of the biopsy was inconclusive. In comparison with baseline mammograms and histopathology 40% of the clusters of micro calcification which were initially labeled as malignant turned out to be malignant on histopathology as well whereas 60% were reported as benign breast parenchyma. Conclusion(s): Agreement between the diagnostic accuracy of micro calcifications on mammogram and histopathology of same lesions after stereotactic biopsy was comparable to international figures with probability of being benign surpassing malignant on routine screening.

  OC1.5: Radial Access Intervention: Application in Complex Oncological Procedures Top

Srujana Ganti, Damian Mullan, Jon Bell, Pavan Najran

The Christie Hospital, Manchester, UK. E-mail: [email protected]

Background: Radial access for vascular intervention has been a firmly established as a default access route in our institution and is now routinely used for complex oncological procedures. We present our experience as Europe’s largest single site cancer center, share tips to deal with potential complications and tricks that would facilitate a safer, technically easier procedure. Method(s): Over the last 3 years, we have performed over 60 interventional oncological procedures ranging from intra-hepatic treatments including trans-arterial chemoembolization (TACE), selective internal radiation therapy (SIRT), pelvic intervention including fibroid and prostate embolization as well as acute vascular treatments. Result(s): Our procedural outcomes have demonstrated that radial access is a safe, viable access route with reduced morbidity and improved patient experience. Potential complications would include radial artery spasm for which a combination of Glyceryl Trinatrate (GTN), Heprin and Verapamil work well. Reduced torquability when accessing distant treatment sites can be overcome by using appropriate types and lengths of catheters. Further challenges such as limb ischemia and procedural failure will be discussed with specific clinical cases. Repeat radial artery punctures and poor haemostats can result in radial artery occlusion, we have devised a deflation protocol to reduce the incidence of this. Conclusion(s): Radial access is safe and technically feasible in complex oncological intervention. Once user familiarity is established, it can be safely used for a range of procedures ranging from diagnostic angiograms to complex and acute vascular treatments.

  OC1.6: Transcatheter Arterial Chemoembolization Combined with Percutaneous Injection of Ethnol for Treatment of Hepatocellularcarcinoma: In Comparison to Transcatheter Arterial Chemoemboliztion Treated Hepatic Cellular Carcinoma Top

Alishbah Ziad, Atif Iqbal Rana, Haider Ali, Zahid Amin Khan, Adnan Arif

Shifa International Hospital, Islamabad, Pakistan. E-mail: [email protected]

Background: Hepatic cellular carcinoma (HCC) is one f the leading cause of death. The objective of study is to see the better treatment option by comparing treatment outcome of two groups, one group given combination therapy of TACE and TEI and other treated by TACE alone. Method(s): A total of 60 patients (51 men and 9 women; age ranging from 48- 80 years) with histopathologically proven HCC were consecutively enrolled from 2016 to 2017 from data base of shifa international hospital. Thirty patient with combination of TACE with PEI (the combo group) and thirty with TACE alone (the control group). Treatment response based on size and enhancement pattern of the lesion were evaluated on serial CT. Result(s): 36% patient from combination group show full response, 43% partial response and 20% worsened response. 13% patient from TACE only treated group showed full response, 56% partial response and 30% worsened response. Conclusion(s): The study shows that the response of hepatocellular carcinoma (HCC) to combination of trans catheter arterial chemoembolization (TACE) and percutaneous ethanol injection (PEI) is better in comparison to those treated with trans catheter arterial chemoembolization (TACE) alone.

  OC1.7: Conventional Transarterial Chemoembolization in Single Hepatocellular Carcinoma Less than 5 Cm, Outcome and Overall Survival, Single Center Study Top

Mohamed Zaitoun, Hossam Kenawy

Zagazig University Hospitals, Zagazig, Egypt. E-mail: [email protected]

Background: Transarterial chemoembolization (TACE) can be the treatment of choice in patients with single hepatocellular carcinoma (HCC) who aren’t candidates for liver transplantation (LT), local ablation or hepatic resection (HR). Our aim is to determine the efficacy and monitor clinical outcomes in patients with single HCC ≤ 5 cm treated with conventional TACE (cTACE). Method(s): From January 2015 till October 2018, 100 consecutive patients with single HCC ≤ 5 cm underwent cTACE as a first line of treatment. Mean age was 59 years, 56 (56%) were males. Follow up with triphasic CT and AFP was done after 1 month then every 3 months for 3 years. We determined the predictive factors for complete response (CR) and overall survival (OS). Result(s): Seventy-two patients (72%) showed complete response and 28 patients (28%) showed partial response. Superselective TACE and tumor size (< 4 cm) were significant predictor factors for CR (p value < 0.05). The 1- and 3-year overall survival (OS) rates were 90.2% and 70.6% respectively. Complete response (CR) and child class (a) were significant predictive factors for overall survival (OS). Conclusion(s): TACE is an effective treatment in patients with single HCC ≤ 5 cm who aren’t candidate for curative therapy. Super selectivity of TACE and tumor size (< 4 cm) are the predictive factors for complete response (CR). Child class (a) and CR are the predictive factors for overall survival (OS).

  OC1.8: Outcome of Retinoblastoma after Intra-Arterial Chemotherapy Top

Hossein Ghanaati, Kavous Firouznia1, Fariba Ghasemi2

Medical Imaging Center, 1Advanced Diagnostic and Interventional Radiology Research Center, Imam Khomeini Hospital, 2Farabi Hospital, Tehran, Iran. E-mail: [email protected]

Background: In this presentation we aim to report our results for intra-ophthalmic artery chemotherapy (IAC) in the treatment of refractory and advanced retinoblastoma. Method(s): Patients who had failed to previous treatments and six naive patients with advanced retinoblastoma were included in our study. The patients received 1-2 treatments of IAC given 4-8 weeks apart. Complete response was defined as regressed tumor and complete disappearance of seeding clinically. Partial response was defined as partial regression of the tumor with live parts of the tumor and/or lessening of seeds, but not completes disappearance of them clinically. Result(s): A total of 24 eyes of 24 patients were treated with IAC during the study period. The mean age at the time of IAC was 38.9 months (14-120 months), and the mean follow-up was 16.8 months (3-36 months) after IAC. Tumor control was achieved in 14 eyes (58.3%). Type 3 (combined fleshy and calcified remnants) was the most common type of regression (37.5%). Complications included vitreous hemorrhage in nine eyes (37.5%), arterial occlusion in two (8.3%), cyclitic membrane possibly secondary to ischemia and tractional retinal detachment in one patient (4.2%), chorioretinal atrophy in three (12.5%) patients, and neovascular glaucoma in one eye (4.2%). In eight (33.3%) patients, no complication happened. Globe salvage was achieved in 62.5% of the cases. The success rate for naive patients was 84%. Sixty-seven percent of the cases received transpupillary thermotherapy and cryotherapy before IAC. Conclusion(s): Intra-ophthalmic artery melphalan is an effective treatment for advanced cases of retinoblastoma, with a reasonable level of success. In the short follow up period of this study, it appears that the primary cases showed better results in the control of tumor.

  OC1.9: Our Experience in Percutaneous Ablative Treatment of Renal T1a E T1b Lesions: Results from 90 Patients Treated with Microwave Ablation, Radiofrequency Ablation and Cryoablation Top

Santucci Domiziana, Faiella Eliodoro, Pacella Giuseppina, Grasso Rosario Francesco, Beomonte Zobel Bruno

Campus Bio-medico University, Rome, Italy. E-mail: [email protected]

Background: To evaluate efficacy and safety of ablation procedures for the treatment of kidney lesions <7 cm. Method(s): 90 patients with single T1a and T1b lesions of the kidney, susceptible to ablative procedure, were retrospectively analyzed: 30 treated with radiofrequency (RFA), 30 with cryoablation (CRA) and 30 with microwave (MWA). All lesions have been biopticed. Complications rate, local control in terms of disease free survival (DFS) and renal function, and survival in terms of cancer specific survival (CSS) and overall survival (OS), were evaluated. Result(s): Mean age of patients was 68.8 years (29-94 years); mean tumor size was 26.51 mm (6-102 mm). Eighty-two lesions (91%) were T1a and 8 (9%) T1b. In 19 cases artificial dissection was performed. The treatment was effective in 96% of cases, with peri-procedural complications in 6 patients (5 hemorrhages and 1 hydro-ureteronephrosis). Seven patients (7.78%) reported a recurrence of disease (9 T1a and 1 T1b) (p> 0.05) in a mean time of 3 months: 4 underwent MWA, 2 RFA and 1 CRA (p <0.05). One case of renal failure in mono-kidney patient was observed. The only significant predictor of DFS in the multivariate analysis, was the histotype, with a higher recurrence rate in RCC (p <0.05). Overall, 9 (10%) patients died for other causes. Conclusion(s): The safety and efficacy in short and long-term control of the three procedures are comparable. However, long-term surveillance is required, especially after MWA. Patient selection, based on tumor characteristics (size and location), and patient comorbidities remain crucial.

  OC1.10: Clinical Efficacy and Economic Impact of an Augmented Reality Navigation System: Experience On 498 Percutaneous Computed Tomogaphy-Guided Pulmonary Biopsies Top

Faiella Eliodoro, Santucci Domiziana, Pacella Giuseppina, Grasso Rosario Francesco, Beomonte Zobel Bruno

Campus Bio-medico University, Rome, Italy. E-mail: [email protected]

Background: To validate the reality navigation system SIRIO performance on CT-guided percutaneous pulmonary biopsy (PLB). Complications rate and histological sample quality were evaluated, in relation to lesion size and location. The economic impact was analyzed by comparing device and patient management costs and refunds by national healthcare system. Method(s): 496 patients over 18 years with lung nodules suspected of malignancy and non-diagnostic bronchoscopy or inadequate us-guided biopsy, were included. Patients with an affected coagultive profile or performance status were excluded. Maximum lesion diameter (ID), distance between lesion and pleural surface (DPS), distance traveled by the needle (DTP), procedure timing (PT) and validity of histological sample were evaluated. Costs for the consumptive material, procedure, CT and histocytopathologic analysis of the sample were analyzed, considering surgical day-hospital and PAC (comprehensive outpatient performance) as two different repayment options. Result(s): Histopathological diagnosis was obtained in 96.2%. LD mean was 20.7 mm, DPS 12.4 mm, DTP 7.9 mm and PT 29.5 minutes. The thoracic radiation dose was 51.2±49.1 mGy-cm. Procedural complications were reported in 156 cases, with 23 (4.6%) major complications. In these cases, DTP was significantly higher. About economical analysis, 44 PLB/month for 4 years, considering day-hospital, and 33 PLB/month for 2 years, considering PAC, are needed to get a complete depreciation. Conclusion(s): SIRIO is a useful tool for improving success rate and diagnostic accuracy with a significant reduction of complications and pt. Economic analysis is also positive, not considering its possible use for tumor ablation, with much higher refunds.

  OC1.11: Carotid Stenting by Proximal Protection, Aspiration Flow Reversal and Distal Anchoring using Double Mesh Stent: An Ideal Technique for Unstable Plaques Top

P. K. Mohammed Rafeeque1,2

1Meitra Hospital, Kozhikode, 2MES Medical College Hospital, Perinthalmanna, Kerala, India. E-mail: [email protected]

Background: Carotid artery stenting (CAS) with distal protection/ Endarterectomy are established novel procedures. A modified technique of carotid stenting was found to further minimise the procedural and post procedural embolic events and has superior ease, efficacy and safety profile compared to existing techniques. Method(s): Dedicated plaque characterisation and diffusion imaging of brain was done on the previous day by 3T MRI. Stenting was done under local anesthesia, temporary pacing, radial arterial line and via femoral access as routine. 9 F balloon guide catheter was placed just proximal to the stenosis and connected to the aspiration pump. The forward flow in CCA was arrested by balloon inflation and flow reversal in ICA was achieved by continous aspiration using pump, during each step – Initial wire passage, pre dilatation, negotiation of stent and during deployment. A double mesh stent was used, the distal end of which was positioned distally in landing and slowly deployed. Aspirated material was sent for histopathology study. Diffusion MRI of brain was done the next day. Result(s): There were no neurological events during or post procedure. No incidence of intimal injury which may happen with filter especially in cases of ICA tortuosity. Excellent stent apposition and total absence of plaque intrusion through struts due to additional mesh was worth noting. An OCT can demonstrate this excellently. Not a single diffusion restricting lesion in MRI next day. Conclusion(s): Proximal protection with ICA flow reversal during each step and use of double mesh stent with distal anchoring can potentially nullify embolic events associated with CAS. This technique holds high promise to be the procedure of choice in CAS especially with unstable plaques.

  OC2.1: Endovascular Treatment in Acute Basilar Artery Occlusion “Experience in Indian Patients” Top

Pokhraj Prakashchandra Suthar, Hemen I. Vithlani, Kamaldeep Chawla

Sterling Hospital, Vadodara, Gujarat, India. E-mail: [email protected]

Background: To assess the efficacy and feasibility of endovascular treatment in acute basilar artery occlusion. Method(s): Total 90 patients who underwent treatment with low-dose intraarterial alteplase combined with mechanical clot disruption for basilar artery occlusion were studied over period of ten years. All patients undergone either cerebral CT/MR with cerebral angiography followed by intraarterial treatment. We did not use intravenous route in all patients. After diagnosis of an occlusion on diagnostic angiography, an end-hole microcatheter over a microguide wire was advanced through 6-f guide catheter into occlusion site. The microcatheter tip was placed into the thrombus, and then a 20 mg bolus of alteplase was manually infused over 3 to 5 minutes. Mechanical clot disruption by multiple passes of the microwire with microcather through the clot was done after 20 mg bolus of alteplase. Followed by withdrawal of the microwire from the microcatheter, an additional 10 mg was manually infused for 3 to 5 minutes through microcatheter at the site of the remaining thrombus. Mechanical clot disruption using microcatheter and microwire was performed in remaining thrombus. Patients in whom distal migration of thrombus into posterior cerebral artery was additionally infused the 10 mg of alteplase through microcatheter. Percutaneous angioplasty or/and stent insertion performed in patients who were not achieved the complete recanalization. Recanalization status was classified according to the thrombolysis in cerebral ischemia (TICI) scale and recanalization was defined as TICI grades II or III. Variable parameters like age, sex, time to treatment, alteplase dose, duration of the procedure, recanalization, and symptomatic hemorrhages were analyzed. Clinical outcome measures were assessed on admision and at discharge of national institutes of health stroke scale (NIHSS) score, at 3 months after treatment modified rankin score (mRS). Result(s): 90 patients with acute basilar artery occlusion (32 women, 58 men) with a median age of 69 years (range, 44 -85 years). The median NIHSS score was 14.4 (range, 2-33) on admission and median time from symptom onset to intraarterial alteplase therapy was 320 minutes (range, 160-820 minute). The median intraarterial alteplase treatment duration was 20 minute (range, 10-25) and the alteplase dose was 20- 50 mg (median, 35 mg). Of these patients, sixteen patients were performed the additional injection of alteplase due to distal migration of thrombus into the posterior cerebral artery. Five patients were the severe stenosis of basilar artery after alteplase infusion and mechanical clot disruption with microcatheter and microwire. Of these patients, three patients were performed the stent placement after angioplasty and two patients were performed the angioplasty. Recanalization (TICI grade II or III) was achieved in 85 patients (94.44%). TICI grade III was occurred in 43 patients (47.78%) include, and TICI grade II was achieved in 42 patients (46.67%). Five patients (5.55%) was failed the recanalization of posterior circulation. Of these failed treatment patients, three patients had a massive thrombus into the vertebrobasilar artery, one was stopped the treatment due to procedure-related subarachnoid hemorrhage, and one had a diffuse and long segmental stenosis of basilar artery. There was symptomatic hemorrhage in four patients. Two patients were occurred the procedure-related hemorrhage. Eight patients (8.89%) died within one-week after procedure. At discharge, the median NIHSS score was 7.2 (range, 0-27). The NIHSS score of 55 patients was improved. In 30 patients, the NIHSS score was increased. At the 3-month follow-up, the functional outcome was favorable (MRS, 0-2) in 50 (55.56%) of the 90 patients. Unfavorable (MRS, 3-6) in 40 (44.44%) patients. Conclusion(s): We concluded from the study that low-dose intraarterial thrombolytics with mechanical clot disruption is feasible, safe and effective treatment for the acute basilar artery occlusion. A high rate of recanalization, high rate of survival rate and good functional outcome can be achieved.

  OC2.2: Finding Predominant Vessels Supplying Presurgical Embolization of Nasopharyngeal Angiofibroma Top

Shahzad Bhatti1,2

1Sir Ganga Ram Hospital, FJ Medical University, 1Lahore General Hospital, 2Sir Ganga Ram Hospital, Lahore, Pakistan. E-mail: [email protected]

Background: 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. Study is done to find the predominant arteral feeder during pre surgical embolization of Juvenile Nasopharyngeal angiofibroma (JFA) in order to reduce blood loss and intra operative time during surgery. Method(s): Four vessels angiography (DSA) 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 12-18 years males from January 2014 to December 2017. All patients underwent surgery with in 24 hours. Result(s): Out of 150 patients Internal maxillary artery was supplying 111 patients, 30 were supplied by accessary meningeal artery and 09 were supplied by ascending pharyngeal artery. Presurgical embolization with Spongostone proved significant reduction in intra operative blood loss and reduced surgical resection time. Conclusion(s): Internal maxillary artery proved to be the major feeder supplying JNFA. Presurgical embolization appears to be the treatment of choice prominently reducing intra operative blood loss, minimizing the need of blood transfusion with short intra operative time resulting in quick and better surgery.

  OC2.3: Cookie Cutter Technique for Percutaneous Direct Puncture Glue Embolization of High-Flow Craniofacial Arteriovenous Malformations Top

Saima Ahmad, Umair Rashid Chaudhry

Lahore General Hospital, Lahore, Pakistan. E-mail: [email protected]

Background: Direct puncture embolization with glue is an effective technique for pre-operative devascularisation of craniofacial arteriovenous malformations. Venous outflow and arterial inflow of the lesion need to be limited during injection of embolic material. Manual compression is the standard procedure for flow reduction, but when an AVM has multiple channels of venous drainage, achieving successful blockage of blood is technically difficult. This study demonstrates the use of a circumferential cookie cutter ring to reduce flow, with better results compared to manual compression. Method(s): This is a retrospective study of ten patients, over a period of two years, with craniofacial arteriovenous malformations who were treated with direct percutaneous injection of glue. Pre-embolization angiography was performed to see arterial feeders and venous draining veins. Adjunctive manoeuvres were used during embolization, including external compression of venous pouch with circular cookie cutter rings of different sizes varying based on lesion size. Glue cast was localized within and around the margins of circular cookie cutter ring without any distal migration. Result(s): No neurological complications secondary to the embolization procedure were observed. The arteriovenous shunts were successfully occluded in all cases. There was partial occlusion in two cases. Total occlusion achieved in five cases when embolization was followed by surgery. Only one case required a second session to achieve total occlusion. Post embolization, there was minimal residual flow in one patient, who declined further treatment due to mitigation of symptoms. The shape of glue cast was changed in two cases after removal of cookie cutter when low concentrated glue was used. No skin necrosis was seen post embolization. Conclusion(s): Percutaneous direct puncture embolization with glue saves time and is a safer method for superficial craniofacial AVMs with prominent venous pouch when external compression was applied with circumferential cookie cutters to reduce venous outflow.

  OC2.4: Posterior Fossa Arteriovenous Malformations: Endovascular Management Challenges Top

Hany Eldawoody, Mohamed Mostafa Aziz1, Wasem Aziz2

Prince Mohamed Bin Abdelaziz Hospital, Riyadh, Saudi Arabia, 1Department of Neurosurgery, Ainshams University, Cairo, 2Department of Neurosurgery, Alexandria University, Alexandria, Egypt. E-mail: [email protected]

Background: Posterior fossa arteriovenous malformations (AVMs) are complex neurovascular lesions, relatively infrequent and difficultly is encountered not uncommonly during their treatment. Although they represent less than 15% of all AVMs, studies showed that they have more aggressive natural history. The authors present their initial experience with multimodality management of 20 posterior fossa AVMs, with an emphasis on endovascular treatment in Egypt. Method(s): From January 2012 to august 2015; twenty patients with posterior fossa AVMs treated with endovascular techniques, radiosurgery and/or surgery were analyzed. Result(s): Out of the twenty cases; 15 cases were treated with onyx embolisation through 27 sessions, one case with glue NBCA. Out of these cases 3 were embolised over 90%, the rest of cases were partially embolised and referred for complementary treatment with surgery or gama knife. The most frequent difficulties encountered during endovascular treatment were catheter navigation in the tortuousity of SCA (2 territories), AICA (2 territories), PICA (1 territory). Identification of onyx flow to the vein in the working angle (3 cases), extravasation of onyx (2 cases). The average occlusion rate of the AVM embolised after an average 1.8 (range 1-7) procedure per case was 52.66%. The average size of AVM embolised was 2.6 cm in maximum diameter. 4 cases (20%) complicated by cerebellar tremors and ataxia 2 of them were transitory and 2 were permanent, one case died from pulmonary embolism. Pod2 and two cases with hemihypothesia, one was permanent. Conclusion(s): Considering our early experience, onyx embolisation to posterior fossa AVMs is feasible and can lead considerable obliteration rate when the AVM has single feeder, although the consideration of deep supply to the cerebellar nuclei and brain stem perforators is of utmost importance to diminish the possible untowarded consequences.

  OC2.5: Treatment of Femoropopliteal Arterial Disease in Critical Limb Ischemia with Drug Eluting Stents: A Real World Experience Top

Peter Drescher, John F. Kispert, Phillip Zalog

Advocate Aurora Medical Group, Milwaukee, Wisconson, USA. E-mail: [email protected]

Background: Drug eluting technology has revolutionized pad treatment. Drug eluting stents (DES) promise superior patency and clinical outcome based on recent randomized trials. The role of DES in patients with critical limb ischemia (CLI) is unknown, since cli is excluded from many DES trials. We report our experience in cli patients undergoing DES treatment of the femoro-popliteal artery (DES-fpa) in a real-world experience. Method(s): Cli patients, undergoing DES-FPA in single institution were followed prospectively over a two-year period with angiography, color duplex ultrasound (CDUS) and clinical evaluation. Outcome measures were primary patency (PP) of the treated lesion, target limb re-intervention (TLR). Secondary outcome was amputation (A) and major complications. Analysis of patient characteristics, lesion morphology including calcification, requirement of additional treatments and comparison to randomized des trials was performed. Result(s): 36 patients with CLI (mean age: 73), underwent des-FPA. Follow-up period ranged between 1-36 months with a mean of 13.7 months. Most patients were Rutherford 5 class. The lesion morphology was: length 128 mm (range 60-280 mm), moderate or severe calcification in 78%, TASC ii d lesion 47% and TASC II a lesions only 15%. Additional interventions were performed in 88% of all patients: 76% tibial, 12% aorto-iliac intervention. PP at 12 months was 67% with an average of 10.4 months. Mortality in the observation period was 26% (average: 3 mo). Excluding these patients, the pp was 82% with average patency of 15.7 months (4 - 30 months). TLR was 42% mostly tibial artery reintervention. Six patients (17%) underwent a, two of those major. Two major complications occurred (6%). Conclusion(s): Des- FPA in CLI patients demonstrate promising intermediate term results with primary patency of 67% and 82% when excluding unrelated early deaths, exceeding comparative results in this challenging patient population.

  OC2.6: Modified Percutaneous Aspiration Injection Reaspiration and its Outcomes Top

Muhammad Awais, Aman Nawaz Khan, Ummara Siddique Umer, Seema Gul, Shahjehan Alam, Syed Ghaus Shah, Muhammad Asif, Ali Asghar Sahib, Hadia Abid, Abdullah Safi, Aliya Sharif

Rehman Medical Institute Peshawar, Charsadda, Pakistan. E-mail: [email protected]

Background: Modified Percutaneous Aspiration Injection Reaspiration (PAIR) procedure of hydated cyst has documented that its morbidity and mortality rates, hospitalization time, and recurrence rate are significantly less than those with surgery. Method(s): The study was performed in Radiology department of Rehman Medical Institute Peshawar. Twenty three patients who had undergone modified percutaneous PAIR procedure between January 2016 and August 2018 were selected for prospective study. In these cases twenty cases were of liver hydatid cysts, two were of spleen cysts and one case was of right posterior abdominal wall. In twenty cases pre procedure imaging work-up was performed by CT abdomen and in three cases by ultrasound abdomen. From every patient informed consent was taken and procedure outcomes and complication were explained to the patient. A consultant interventional radiologist performed procedure in twenty two cases by ultrasound guidance and in one case by CT guidance. Post procedure, patient was advised albendazole for two weeks. All patients were followed-up at 3, 6, 12, 24 months post procedure. Improvement in radiological imaging as well as in clinical symptoms assessed the procedure success and failure. Result(s): The age of our patients ranged between 10-75 years. Single, double and multiple hydatid cysts were seen in 69.56%, 21.7% and 8.6% respectively. On follow-up only 8.65% cases had mild right hypochondrium pain and only 4.35% cases had persistant liver hydatid cyst. No other procedure related complication noted. On serology, echinossus granulosus titre was negative in 3.4% cases. All patients were satisfied from modified PAIR procedure. Conclusion(s): Modified percutaneous PAIR procedure showed promising result with a success rate of almost 95.65%.

  OC2.7: Ultrasound Guided Management of Ectopic Pregnancy: Two Cases Presentation Medina, Saudi Arabia Top

Azza Usama Yosuph, Mazen Saud Alraddadi1, Gamal Mohamed Elaswally, Nisreen Fuad Khoja

Maternity and Children Hospital, 1King Fahd Hospital, Medina, Saudi Arabia. E-mail: [email protected]

Background: Cervical and cesarean section (CS) scar ectopic pregnancies are rare forms of ectopic pregnancies. They are one of the leading causes of maternal morbidity and mortality. Early detection and diagnosis of these entities are important for an early intervention to reduce its life-threatening complications. Medical or surgical management are depending mainly on fertility or life-saving conditions. Method(s): Two ladies were presented to the hospital with vaginal bleeding and cramping abdominal pain. Lab investigation and medical imaging confirm the diagnosis of 1st-trimester cervical and CS scar ectopic pregnancies for the first and second case respectively. Result(s): Both patients underwent an unsuccessful trial of systemic methotrexate therapy, followed by successful ultrasound-guided intra-amniotic injection of methotrexate, under standard precautions in the operative room with no immediate complications. Post-treatment period shows a progressive decline in the beta-HCG and evidence of gestational sac resolution in the follow-up imaging. Conclusion(s): As a minimally invasive procedure, ultrasound-guided intra-amniotic injection of methotrexate was our second line in managing and treating the ectopic pregnancy cases, it was safe and effective. Further evaluation with a larger sample is required to ensure its safety and efficiency.

  OC2.8: Angioembolization and Radiofrequency Ablation Assisted Vertibroplasy for Lytic Metastatic Tumour of Spine Top

Manish Rajput, Rakasi Naveen

TATA Memorial Hospital, Mumbai, Maharashtra, India. E-mail: [email protected]

Background: To determine the safety and efficacy of angioembolization and RFA assisted vertebroplasty (VP) on the basis of clinical outcome in pathological / insufficiency fracture of vertebra. The insufficiency fracture because of lytic metastasis secondary to primary malignancy, which is commenest malignancy of skeletal system. Method(s): Patient refered to ir department from 2008 to 2018 for malignant / pathological vertebral body fracture were assessed and distributed in two groups: (1) Multiple myeloma group. (2) Non myeloma group. For these two groups vertebroplasty assessment done and the other possibilities ruled out. Cocktail therapy was planned and given to only non myeloma group. Clinical effectiveness was assessed by cect spine and electronic medical record pre and post procedure. Pain score (VAS) were also documented pre and post procedure. Result(s): 31 patients were included in the study, which make 40 vp level. 6 patients were done angioembolization and rfa assisted vertebroplasty. 16 patients were done only rfa assisted vertebroplasty. 9 patients were done only vertebroplasty. All the cases were successfully treated without any morbidity and mortality. Pain score (VAS) reduced and increase in quality of life. Conclusion(s): Angioembolization and rfa assisted vertebroplasty is a safe and effective treatment option for metastatic lesion with soft tissue mass. Angioembolization decreases vascularity of soft mass and thermal cavity (RFA) allows controlled cement injection without posterior or disc leak.

  OC2.9: Combined Antegrade and Retrograde Approach in Iatrogenic Ureteral Injuries: The Rendezvous Technique Top

Pacella Giuseppina, Faiella Eliodoro, Santucci Domiziana, Grasso Rosario Francesco, Beomonte Zobel Bruno

Campus Bio-medico University, Rome, Italy. E-mail: [email protected]

Background: To evaluate feasibility and effectiveness of the rendezvous technique in case of complete iatrogenic ureteral injuries. Method(s): From 2012 to 2017, 21 patients were treated with the rendezvous technique for mono- or bilateral complete iatrogenic ureteral injuries. All the leak derived from the ureteral injury were previously assessed by CT-urography and antegrade pielography. The rendezvous technique was performed after a period from the main surgical intervention ranged from 8 to 67 days, by 2 interventional radiologists and urologic/gynecologic team, in order to re-establish the ureteral continuity. A nephrostomy was positioned for each side of the lesion and the procedure was completed with an anterograde and retrograde access. A double j stent was antegradely inserted and a nephrostomy tube was kept in place. No major complications were observed. A post-procedure CT-urography and a 30 days follow-up with contrast antegrade nephrostomography were performed. In absence of contrast leak, the nephrostomy tube was removed. At the time of stent removal the CT-urography was performed to confirm the restored integrity of the ureter. Result(s): The rendezvous technique was successful in all cases with resolution of the ureteral leak. All patients removed the nephrostomy tube after 30 days. After performing CT-urography the stent was removed permanently after 12 months. Three cases showed local post-treatment stenosis. Conclusion(s): The rendezvous technique is a safe and effective minimally invasive procedure that can be used to restore the continuity of the ureter avoiding open surgical.

  OC2.10: Computed Tomography Guided Pulmonary Nodule Microcoil Localization Top

Sultan R. Alharbi

King Saud University, Riyadh, Saudi Arabia. E-mail: [email protected]

Background: To evaluate the safety and effectiveness of CT guided micro coil localization of pulmonary nodule prior to video assisted thoracoscopy surgery (VATS). Method(s): From August 2015 to August 2018, 30 consecutive patients (17 men and 13 women; mean age, 56 years) underwent CT-guided micro coil localization of 42 pulmonary nodules (mean size, 7.3 mm; range, 4-18 mm). A 7 cm platinum micro coil was inserted into pulmonary nodules under CT guidance using a 21-gauge chiba needle. The technical details, surgical and pathologic findings associated with micro coil localizations were retrospectively evaluated. Result(s): All nodules were localized by CT guided micro coil with 100% technical success with mean time 13.4 minutes (range 8- 26 minutes). 6 patients developed Mild parenchyma lung hemorrhage along with needle tract and 7 patient developed mild pneumothorax all are asymptomatic and no intervention needed. 3 patients developed moderate pneumothorax for which needle aspiration was performed but not chest tube was inserted. No other complication occurred. All micro coils were identified during the surgery except one which was dislodged and attached to chest wall (41 out of 42 micro coils) 97.6 % clinical success and all nodule were surgically resected. Pathology revealed 28 metastatic pulmonary nodules, 1 primary adenocarcinoma-in-situ and 13 benign pulmonary nodules. Micro coils did not affect the histopathology examination. Conclusion(s): CT-guided micro coil localization is an effective and safe pre-operative localization procedure prior to VATS, enabling accurate resection and diagnosis of pulmonary nodules.

  OC2.11: Re-Establishing Patency of Occluded Metallic Biliary Stents by Endobiliary-Radiofrequency Ablation Technique Top

Shorav Bhatnagar, Alka Goyal1

QRG Central Hospital, 1AIIMS, New Delhi, India. E-mail: [email protected]

Background: Biliary drainage with the use of metallic biliary stents (MBS) is a well-accepted palliative therapy for patients with unresectable malignant hilar obstruction. These stents often lose their patency over a period of 6-9 months secondary to tumor ingrowth or overgrowth, epithelial hyperplasia. Occlusion caused by sludge deposition or clot or stone formation. Limited treatment options are available for such a condition. Endobiliary radiofrequency ablation (RFA) has been shown to be an effective modality in the treatment of malignant biliary obstruction Here we present our experience with endobiliary RFA technique for restoring the patency of occluded MBS. Method(s): Patients were taken with previously placed MBS for malignant aetiology, presented with rising serum bilirubin and signs of cholangitis secondary to occlusion of MBS. Percutaneous trans-hepatic biliary drainage was achieved in all cases. After negotiating guide-wire across the stent, biliary drainage was established. After treating cholangitis, endobiliary-RFA was performed. Post-procedure cholangiogram was performed to ascertain the patency. Periodic clinical follow-up was scheduled for 6-months or till their survival. Result(s): The patients were followed up clinically and with USG to a minimum of 6 months or till their survival. The presence of pneumobilia on USG along with normal LFT were considered as the signs of stent patency. All patients showed restoration of patency on cholangiography examination performed on the following day of RFA (restored diameter 6-8 mm). The mean duration of stent patency after the first session of RFA was 3.9 months (range 2-7 months) which was comparable to the primary patency of these stents (4.8 months). This extended period of stent patency ensured administration of additional cycles of chemotherapy in these patients coupled with objective improvement in the quality of life. Conclusion(s): Our experience suggests that endobiliary-RFA with balloon-sweep maneuver can be a safe and useful technique for re-establishing the patency of occluded MBS. Reopened stent with good short term patency offers medical oncologist a chance of administering additional chemotherapy which may improve patient’s survival.

  OC3.1: Road to Interventional Radiology: Introducing Interventional Radiology to the Global Community Top

Fabian Laage Gaupp, Ivan Rukundo1, Azza Naif1, Erick Mbuguje1, David Prologo2, Andrew Kesselman3, Douglas Silin, Frank Minja

Yale University, New Haven, 2Emory University, Atlanta, 3Cornell University, New York, USA, 1Muhimbili National Hospital, Dar es Salaam, Tanzania. E-mail: [email protected]

Background: According to the WHO four billion people around the world lack access to medical imaging, and even more lack access to Interventional Radiology (IR). We performed an assessment of the largest tertiary referral center and teaching hospital in Tanzania, a nation of over 50 million people. This demonstrated that there is currently not a single interventional radiologist in the entire nation, but all relevant imaging modalities, including Ultrasound, CT, and fluoroscopy, are available. Method(s): To address the acute shortage of IR in Tanzania, we started training Tanzanian Radiology residents in IR. Over the course of three years (2018-2021), 30 IR teams, each consisting of an IR faculty member, a nurse, and a technologist, travel to Tanzania in two-week blocks with the goal of training three Tanzanian residents per year to be fully competent in general IR and basic neurointerventional procedures. Result(s): During the initial two trips in October and November 2018, a total of 37 interventions were performed on 31 patients. Technical success was achieved in 30/31 initial procedures (97%). There were no major complications. Specifically, the following procedures were performed: 15 Core needle biopsies, 6 nephrostomy tube placements, 6 drain checks/internationazaions/exchanges, 4 biliary drain placements, 3 abscess drain placements, 2 cyst aspirations, and a cholecystostomy placement. All procedures were logged via Google forms and follow-up phone calls are performed at one and three months post-procedure. Preliminary follow-up data demonstrates that >90% of patients report no subsequent complications and are satisfied with the procedure and related care. Conclusion(s): This early experience demonstrates that IR practices can be established in the resource limited setting. There is potential for expansion of this program to other sites where IR can add great value, in many cases decreasing morbidity and improving patient satisfaction.

  OC3.2: Percutaneous Obliteration of Urinary Leakage after Partial Nephrectomy Using Coils and N-butyl-cyanoacrylate Top

Ji Hoon Shin, Yasir M. Nouri1, Hee Ho Chu

Asan Medical Center, Seoul, South Korea, 1King Fahad Hospital, Jeddah, Saudi Arabia. E-mail: [email protected]

Background: Urinary leakage is uniquely associated with partial nephrectomy (PN) and remains a challenging complication to treat. Recently, minimally invasive percutaneous approach to obliterate the urinary leakage after PN has been developed. Method(s): Data of 10 consecutive patients who underwent percutaneous obliteration of urinary leakage after PN using coil and NBCA were reviewed. A urinary fistulography was performed via the drainage catheter previously placed in the urinoma, and a pyelography was performed to locate the fistulous tract. If the fistulous tract was clearly visualized, super-selective embolization of the fistulous tract with coils and urinoma cavity sealing with NBCA were performed. In cases where the fistulous tract could not be clearly visualized, only urinoma cavity sealing was performed. Technical success was defined as complete occlusion of visualized urinary fistulous tract and followed urinoma cavity sealing. Clinical success was defined as control of current urinary leakage and either disappearance or decrease in size of the urinoma on follow-up computed tomography (CT). Result(s): In seven (70%) patients who showed obvious urinary fistulous tract, coil embolization of urinary fistulous tract and followed by sealing of urinoma cavity with NBCA was performed. Only sealing of urinoma cavity with NBCA was performed in three patients (30%) who could not visualize the distinct fistulous tract. All of the patients showed gradually decrease in size or complete disappearance of urinoma on follow-up CT without further symptom and sign of urinary leakage during the follow-up period (mean, 44.6 weeks; range, 11-117 weeks). Conclusion(s): Percutaneous obliteration of urinary leakage after PN using coils and NBCA is safe and effective. On the basis of the urinary fistulography, assessed by drainage catheter in the urinoma and pyelography, super-selective embolization of fistulous tract with coil and followed sealing of urinoma cavity with NBCA or only sealing of urinoma cavity offer complete occlusion of the urinary leakage.

  OC3.3: Combination of Preoperative Ultrasonographic Mapping and Radio-Guided Occult Lesion Localization in Patients with Locally Recurrent/Persistent Papillary Thyroid Cancer a Pilot Study Top

Amr Maged Elsaadany, Mohamed Alrowaily1

Sandwell and West Birmingham Hospital, Birmingham, UK, 2King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia. E-mail: [email protected]

Background: Better follow-up of patients with thyroid cancer and more sensitive detection leads to detection of recurrences in the neck. Our aim is to explore the feasibility of (ROLL) for radio-iodine negative cervical recurrences from thyroid cancer in patients with previously operated neck compartments to improve the surgical success and reduce the complication rates. Method(s): Pre and postoperative thyroglobulin levels and neck US were performed. The results of fine needle aspiration (FNA) cytopathology were available. In the morning of surgery, biopsy proven recurrent/persistent tumoral lesions were injected with Tc-99m labeled macro-aggregated albumin under US guidance. Thyroid bed exploration was carried out based on the location of lesions with the guidance of intra-operative gamma probe and neck map. The lesions showing high count rates were resected and labeled separately for histopathologic study and to ascertain removal of the radiolabeled lesions. Result(s): Total of 13 patients (8 females and 5 males) were included. Technical success rate was achieved in all patients with successful surgical removal of the lesions. All the lesions removed were positive on histopathologic assessment. Significant drop of the TG levels was achieved in all patients. Conclusion(s): The ROLL technique is feasible in patients with loco-regional recurrence particularly useful in patients already submitted to cervical dissections and/or with small lesions located in surgically difficult sites. It can therefore have clinical role in the management of cervical recurrences.

  OC3.4: Efficacy and Safety of Radiofrequency Ablation for Benign Thyroid Nodules: Initial Clinical Experience in Middle East Area Top

Kwang Hwi Lee, Hong Dae Kim, Eui Yong Jeon

Sheikh Khalifa Specialty Hospital, Ras Al Khamiah, UAE. E-mail: [email protected]

Background: Radiofrequency ablation (RFA) is a minimal invasive treatment modality for variable tumors of liver, kidney, bone etc. RFA has been also used to treat benign thyroid nodules to improve patient’s symptoms. However, thyroid RFA has been seldom introduced in middle east area. Method(s): A total 58 benign thyroid nodules in 45 patients (M:F= 8:37, mean age: 39 years ± 12.2) underwent ultrasound (US) guided percutaneous RFA using an internally cooled electrode. We investigated clinical symptom, cosmetic score (4-point scale), composition, thyroid volume. We assessed complications and volume reduction rate (VRR) in follow-up (median: 10 months). Result(s): Clinical manifestation was palpable mass (n= 10), discomfort (n=15), dysphagia (n= 16), voice change (n= 1), dyspnea (n=3). Cosmetic score were 3 (n= 25, cosmetic problem on swallowing only) and 4 (n= 20, readily detected cosmetic problem). Composition was predominantly cystic (n= 3), predominantly solid (n= 6), solid (n= 49). Mean initial thyroid volume was 18.13 ml ± 61.5 (range: 1.12 ~ 208.6). After RFA, mean thyroid volume was 6.07 ml ± 15.4 (0.16 ~ 75.3). Major complications were not detected. Perithyroid hemorrhage occurred during procedure in 3 patients, and it was spontaneously resolved in a month. All patients reported improvement of their symptoms after RFA. Mean VRR was 70.2% ± 25.7 (2.6 – 98.8). Conclusion(s): RFA is an effective and safe nonsurgical therapeutic method to manage benign thyroid nodules, and it can be widely spread in Middle East area.

  OC3.5: Hostile Necks Management: Saudi Experience with Heli-Fx Endoanchores Top

Samer Koussayer

King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia. E-mail: [email protected]

Background: Most neck challenges comes from short neck which is consider the main exclusion from standard EVAR treatment. ChEVAR and fEVAR are the most common solutions but it requires special skills and long waiting time for fEVAR. Also management of type 1 endoleak is the most challenging leak to deal with. The emerging technology with endoanchores brought reasonable solution to deal with short neck using standard EVAR and to treat type 1 endoleak. Method(s): We will review the endoanchores registry and our experience in Saudi in using endoanchores as prophylactic to prevent and as therapeutic to treat type 1 endoleak. Result(s): The result from endoanchores registry and our experience is very promising. Conclusion(s): Endoanchores can be used as prophylactic in challenge neck anatomy to prevent trype 1 endoleak and as therapeutic to treat type 1 endoleak.

  OC3.6: Endovascular Treatment of Visceral Arteries Pseudoaneurysms by Covered Stents Top

Mohammad Elhemeily, Charles Roux1, Marine Bravetti1, Wafik Turki1, Dan Toledano1, Marine Lataud1, Samia Boussouar1, Alban Redheuil1, Nour Dahbi1, Philippe Cluzel1

Ain Shams University, Cairo, Egypt, 1Département d’Imagerie Cardiovasculaire et de Radiologie Interventionnelle et Thoracique, Hôpital Universitaire La Pitié-Salpêtrière, Paris, France. E-mail: [email protected]

Background: Pseudoaneurysms of the visceral arteries are rare, but remain a therapeutic challenge given the high morbidity and mortality of the surgical treatment. We evaluated the value of their endovascular treatment by covered stents. Method(s): This is a retrospective, single-center study conducted from December 2015 to June 2018. All patients presenting with pseudoaneurysms of the visceral arteries (coeliac trunk, superior mesenteric and inferior mesenteric arteries and their branches) documented by cross sectional imaging were included. Endovascular treatement with covered stents was done. The pseudoaneurysm cause, site, size, distance from artery origin, the artery caliber, tortuosity, the angle between the artery ostium and the abdominal aorta, the duration of the procedure, the access site, the materials used, the technical success rate, the immediate and delayed complications at the first and last follow up were collected. Result(s): 21 interventions were performed on 19 patients. The majority were males with a median age of 60 years. The pseudoaneurysms were most commonly located in the hepatic arteries with liver transplantation being the most common etiology. Right femoral access was used in 9 patients and left brachial access was used in 10 patients. The median procedure time was 58 minutes. The technical success rate was 79% (15/19). Failure was due to artery dissection (3/19) or malcoaptation of the stent (1/19). The median duration before the first follow up was 45 days and 12 months before the last follow up. Complications encountered included perforation (1/19), endoleak (1/19), recurrence (1/19), partial (3/19) or complete (2/19) thrombosis. There was no procedure-related mortality. Conclusion(s): Endovascular treatment of visceral arteries pseudoaneurysms by covered stents is feasible, safe and effective. The brachial access is preferred in technically challenging cases due to certain anatomical factors such as increased artery tortuosity or increased distance from the artery origin.

  OC3.7: Modified Pressure Cooker Technique: An Effective Way to Control Ethylene Vinyl Alcohol Copolymer Reflux in Peripheral Arteriovenous Malformations Top

Virendersingh Kapoorsingh Sheorain, Manju Bharath Nr

Medanta The Medicity Hospital, Gurgaon, Haryana, India. E-mail: [email protected]

Background: Embolization of high flow pAVMs is a technical challenge. ethylene vinyl alcohol (EVOH) copolymer is a safe and effective liquid embolic agent routinely used in intracranial AVMs and its use is recently reported in peripheral AVMs as well. Most important technical challenge during ethylene vinyl alcohol (EVOH) copolymer injection is control of reflux. Modified Pressure Cooker Technique (mPCT) is a medthod to prevent reflux of EVOH which is well described in intracranial AVMs, however not reported in peripheral AVms. In Modified Pressure Cooker Technique a glus plug is created proximal to the devilary tip of detachable microcatheter in a unique way. We describe successful use of modified Pressure Cooker Technique (mPCT) in peripheral AVMs to control reflux and achieve adequate embolization. Method(s): Three patients with high flow peripheral AVMs were treated with ethylene vinyl alcohol (EVOH) copolymer (MENOX 18) embolization using modified Pressure Cooker Technique. We used Ultrasound guided Femoral access in all 3 cases. We used coaxial sytem using 7F 70 cm long Guiding sheath and intermediate catheter DAC 070. We used Combination of EVOH compatible detachable microcatheter (APOLLO 3 cm tip) and a non detachable microcatheter (Echelon 10) for nBCA glue plug creation needed for mPCT. We injected EVOH copolymer (Menox 18) via detachable APOLLO micro catheter and NBCA injection via the proximal catheter to create a glue plug to prevent EVOH copolymer reflux during injection of EVOH copolymer. Result(s): We achieved 100% Technical success: ethylene vinyl alcohol (EVOH) copolymer did not refluxed proximal to the glued segment of the detachable microcatheter and we had safe removal of detachable microcatheter post embolisation. Satisfactory embolization of the target nidus in all. No intra-operative complications. Conclusion(s): Use of modified Pressure Cooker Technique (mPCT)in peripheral AVMs is: (1) Safe and effective for ethylene vinyl alcohol (EVOH) copolymer injection. (2)Prevents reflux and allows forward progression of ethylene vinyl alcohol (EVOH) copolymer into nidus. (3) Can be applied in peripheral AVMs whenever ethylene vinyl alcohol (EVOH) copolymer is used as the embolic agent.

  OC3.8: Safety and Efficacy of Vascular Closure Devices in Antegrade Femoral Intervention: A Single Center Experience Top

Aeed Saad Alaklabi, Othman Zayed Alshehre, Juman Mohammed Alghamdi, Sulaiman Mohammad Alsharfan1, Mohamad Arabi, Abdulrahman Jan Alvi

King Abdulaziz Medical City, 1Security Forces Hospital, Riyadh, Saudi Arabia. E-mail: [email protected]

Background: The ability to safely achieve hemostasis is a key aspect of percutaneous vascular access. Vascular closure devices (VCDs) were designed to improve the safety of vascular closure; however this has been difficult to prove in recent studies. We present our experience with achieving hemostasis including assessing the safety and efficacy of VCDs. The aim of this study is to assess the technical success, complications and associated risk factors for achieving hemostasis in antegrade femoral punctures for infrainguinal interventions. Method(s): A retrospective review of all patients who underwent antegrade common femoral puncture for infrainguinal endovascular procedures between January 2016 and November 2018. Access site hemostasis was achieved either using VCD or manual compression (MC). Patient demographics, body mass index (BMI), previous ipsilateral groin punctures and surgeries, skin to vessel distance, common femoral artery (CFA) diameter, sheath size and complications were recorded. Result(s): A total of 175 antegrade femoral punctures were performed in 159 patients. Mean patient age was 65 years (21-102). Male:female ratio was 120:39 patients and mean BMI was 27.2 (16.24-43.79). Mean CFA diameter was 7.5 mm (3.5-12.7 mm) and mean skin to vessel distance (SVD) was 33.7 mm (9.6-20 mm). Sheath sizes utilized were 5 Fr (n=93), 6 Fr (n=66), 4 Fr (n=13), and 7 Fr (n=3). MC was used to achieve hemostasis in 46% (n=81) of patients. Angioseal was the most commonly used VCD in 43.6% (n=41), Exoseal 36% (n=34) and Proglide in 20% (n=19). Technical success in the VCD group was 92.5% (n=87). Six patients experienced complications (VCD=4; MC=2) including groin hematoma, pseudoaneurysm, distal thromboembolism and arterial perforation. Conclusion(s): In our experience, vascular closure devices are effective and safe in antegrade arterial procedure with limited number of complications. A larger study is required to compare vascular closure devices in antegrade punctures.

  OC3.9: To Determine Efficacy of Bilateral Inferior Petrosal Sinus Sampling in Differentiating Cushing Disease from Ectopic Cushing Syndrome Top

Muhammad Azeemuddin, Shahmeer Khan, Raza Sayani, Tanveer Ul Haq, Ayesha Shoukat1

Aga Khan University Hospital Karachi, 1Karachi Insitutute of Medical Sciences, Karachi, Pakistan. E-mail: [email protected]

Background: ACTH dependent cushing syndrome is further divided into cushing disease and ectopic cushing syndrome. Bilateral inferior petrosal sinus sampling (BIPSS) is a reliable tool in differentiating these two entities specially in cases where MRI findings are equivocal. Method(s): This is a retrospective study which includes all patients who underwent BIPSS at department of radiology AKUH with clinical diagnosis of ACTH dependent cushing syndrome. Histopathology correlation is considered gold standard. Result(s): In total 23 patients underwent bilateral inferior petrosal sinus sampling from 2006-2017, out of these 1 patient was excluded from the study on the basis of inadequate sampling 11 patients had no MRI or histopathology correlation. In the remaining 11 patients 8 were diagnosed as Cushing disease on BIPSS and proven to have pituitary adenoma on histopathology while 3 patients diagnosed with peripheral source of ACTH were diagnosed on histopathology to have bronchial carcinoid. Conclusion(s): In our study sensitivity of bilateral inferior petrosal sinus sampling was found to be 100 %. Although with advent of dynamic weighted MR imaging with pituitary protocol the utility of BIPSS has declined over time due to the invasive nature of the procedure however it is still a reliable test in cases where MRI findings are equivocal and inconclusive.

  OC3.10: Femoral-Popliteal versus Long Superficial Femoral Artery Stent Top

Maher Hamish, Terri-Ann Russell

Northampton General Hospital, Northampton, UK. E-mail: [email protected]

Background: The aim of this cohort study is to compare two modalities of treating long occlusion in the superficial femoral artery as a cause for critical leg ischemia; angioplasty with stenting vs a femoral-popliteal bypass and the rate of limb salvage and intervention needed to maintain patency. Method(s): We retrospectively obtained and reviewed data on all patients at the northampton general hospital with severe peripheral vascular disease who had long SFA stents during a 3 year interval commencing from April 1 2014 to march 31st 2017 and compared the patency and the need for a secondary intervention to a group of patients who had a femoral popliteal bypass during this same time period. All patients involved in this study were patients with severe peripheral vascular disease failing best medical management or presenting with evidence of critical limb ischaemia with evidence of tissue loss or rest pain. Best medical management entails patients being on a statin, an antiplatelet, having good control of hypertension and diabetes and smoking cessation advice. All patients had an arterial duplex assessment before and surveillance after an intervention to assess disease severity and patency respectively. Femoral-popliteal bypass procedure included patients who had either above or below knee bypass as well as patients who had a vein or a prosthetic used for the conduit. Primary patency was calculated from the time of the initial intervention until the time that there was occlusion. For patients who developed a significant stenosis and needed an intervention to maintain patency they were referred to as assisted primary patency and was calculated from the time of initial procedure to the time of occlusion. Result(s): Femoral-popliteal bypass of the 28 patients who had a femoral-popliteal bypass procedure, 22 were males and 6 females. The mean age of patients in this audit was 72.1 years. The youngest patient to have this procedure was 49 years old and the oldest being 92 years of age and almost half of this cohort (46.4%) were over the age of 75 years. Of the 28 patients that were operated on 2 died in hospital or within 30 days of having the operation, hence leaving only 26 patients in the surveillance population. All the patients who died were over the 78 years of age. 20 (86.95%) patients in this study had the long saphenous vein used for their bypass conduit while 3 (13.05%) patients had PTFE. Conclusion(s): Of a group of patients who share similar demographics the patency rate of femoral popliteal bypass was superior to that of long SFA stents 74% vs 56%. For both groups however, the need for a second intervention to maintain primary patency was similar at a rate of approximately 21%. The incidence of diabetes mellitus was significantly higher in the fem-pop group and appears to significantly affect graft patency and the need for another intervention, as 83% of patients with graft stenosis needing angioplasty were diabetic. Diabetes mellitus also seem to affect stent patency as 40% of patients who needed repeat angioplasty in the long SFA stent group had diabetes, however more significantly in the fem-pop population. There appears to be no obvious correlation between the type of blood thinner used and the maintenance of patency in the group with long SFA stents. Overall, 50% of patients with long SFA stents needed a second intervention to maintain primary patency while only 30% of patients who had fem-pop bypass needed another intervention to maintain patency of the conduit. It also apparent that majority of SFA occlusions in this audit occurred within the first 6 months of deployment.

  OC3.11: Superficial Facial High Flow Vascular Malformations Treated by Onyx Embolization: Is There a Need for Surgery after Percutaneous Occlusion Top

Mohamed Amine Habouchi, Abdelmadjid Habba, Mounir Tabouche, Chafa Aimeur, Sidahmed Faraoun, Boudjema Mansouri

University Hospital of Bab El Oued, Algiers, Algeria. E-mail: [email protected]

Background: Arteriovenous malformations (AVMs) and fistulas (AVFs) are rare vascular disorders, in which embolization is the first line treatment frequently associated to an adjunctive surgery for superficial and facial localizations. The aim of this study was to report our experience in embolization of high flow peripheral AVMs with onyx. Method(s): 5 women and 4 men were treated by percutaneous embolization with onyx, in our institute from January 2016 to June 2017 for superficial facial high flow vascular malformation. 3 patients were treated for acute bleeding and 6 patients for esthetic purpose. Patients were followed at 1, 3 and 12 months. Clinically symptoms, bleeding and esthetic improvement were assessed. Result(s): During this period we have embolized in our department 1 AVFs (Houdart type I) and 8 AVMs: 6 type ii and 2 type III (Houdart classification). Complete occlusion of the malformation in one session was achieved in 5 patients, and 1 patient needed a second session. 2 patients suffered from bruits which had totally disappeared immediately after embolization. Bleeding was controlled in all patients, and esthetic improvement was achieved at one month in 3 patients (labial AVM), and the 3 other at 3 months. None of our patients underwent surgery after embolization. No major complications were recorded. Conclusion(s): Onyx embolization for superficial facial high flow malformation is an effective and safe therapy, could be an option for first and only line treatment in non-complex lesions.

  OC3.12: Surfacer® Inside-Out® Access Catheter System: Setting Back the Clock for Dialysis Patients? Top

Asim Khwaja, Yasir Suliman1, Mohamed Almarzooqi, Iman Alshamsi, Moatasiem Bukhari1, Amin Eltahir, Emad Khater, Shahabaz Patil1

Sheikh Khalifa Medical City, 1Mafraq Hospital, Abu Dhabi, UAE. E-mail: [email protected]

Background: Central venous occlusion is a serious cause of patient morbidity in hemodialysis patients which limits formation of upper extremity vascular access. The Surfacer® Inside-Out® Access Catheter System (Merit Medical, USA) is a device that aims to restore access to right atrium through occluded central veins. We review the first five patients treated with Surfacer® in GCC. Method(s): All patients were approved by a multi-disciplinary team. Utilizing right femoral vein approach, a 10 French sheath was advanced to the occlusion in SVC or right innominate vein (RIV) under fluoroscopy. The Surfacer® Catheter was advanced through the occlusion and the needle guidewire was externalized in the right supraclavicular region. A peel-away sheath was pulled into the central venous system over the externalized guidewire as the Surfacer device was retracted. Next, a tunnelled hemodialysis catheter was placed through the peel-away sheath into the SVC. Result(s): Inclusion criteria were RIV or SVC occlusion with patent right femoral and iliac veins. Patients with active infection or bleeding diathesis were excluded. All patients had history of multiple failed AV accesses and failed attempts at endovascular recanalization of the occlusion using conventional techniques. All had RIV occlusion and one additionally had a left innominate vein and superior vena cava occlusion. Technical success rate was 100%. One patient had minor post-procedure bleeding at the catheter site that stopped after suturing. The tunnelled catheter was converted to a HeRO Graft® (Merit Medical, USA) in two patients, after 10 and 188 days. In the remaining patients, their original catheter remained functional 220 days post-procedure. Conclusion(s): The Surfacer® Inside-Out® Access Catheter System allows access into the right atrium through occluded central veins to facilitate creation of long term arteriovenous access or convert femoral to jugular access and maintain viability of secondary veins.

  OC3.13: Percutaneous Retrograde Access for Recanalization of Occluded Arteries in Thromboangiitis Obliterans (Buerger’s Disease) Top

Behlul Igus, Ali Fırat

Baskent University Istanbul Hospital, Istanbul, Turkey. E-mail: [email protected]

Background: Thromboangiitis obliterans (TAO) or Buerger’s disease is a non-atherosclerotic peripheral vascular disease, which affects mainly young male smokers before the age of 45, especially in low socioeconomic regions. The aim of the study was to evaluate the technical success of the percutaneous retrograde access procedure after failed antegrad recanalization in Thromboangiitis Obliterans (Buerger’s Disease) patients. Method(s): Thirteen consecutive patients (12 men, 1 women, mean age: 40.3 ± 5.6 years) and 14 arteries underwent retrograde puncture for recanalization with a diagnosis of TAO (Thromboangiitis Obliterans), between April 2015 and December 2018. After unsuccessful attempts using the antegrade approach, retrograde puncture were used under ultrasound and fluoroscopic guidance. Ipsilateral retrograde access was attempted in three patients with SFA (superficial femoral artery) in three patients with PTA (posterior tibial artery), in two patients with PEA (peroneal artery) and in five patients ATA (anterior tibial artery). The primary purpose of the study was to evaluate the technical success of the procedure in obtaining the ability to pass the wire across target artery and providing blood flow to the below the knee arteries. Result(s): Technical success was achieved 12 of 13 arteries (92.3%). In a patient who underwent PTA puncture, the retrograde approach failed because the guidewire could not be passed through the occlusive artery. There were no major complications in any of the cases. Conclusion(s): Endovascular treatment is a technically feasible and potentially effective treatment modality for Buerger’s disease. Retrograde interventions in TAO patients may improve technical success and clinical improvement, especially in cases where antegrade approach fails.

  C 3.14: Radiation Exposure During Varicocele Embolization: Does Access Site and Treated Side Matter? Top

Abdulaziz Khalid Alqubaisi, Ali S. Alsaadi, Mohammad Arabi

KSAUHS-NGHA, Riyadh, Saudi Arabia. E-mail: [email protected]

Background: This study aims to evaluate radiation exposure during varicocele embolization and correlate it with access site and embolized side. Method(s): This retrospective study included 39 patients who underwent varicocele embolization between Jan 2015 to Dec 2018. Embolization was done in all cases using a combination of coils and sclerosing agents in Sandwich technique. Bilateral embolization was done in 13 patients, while only the left side was embolized in 26 patients. Jugular vein access was used in 10 patients, while the brachial and basilic veins were used in 14 and 15 patients, respectively. Dose area product (DAP) and total fluoroscopy time were collected and correlated to the treated side and access. Statistical analysis was done on (StatPlus:mac, AnalystSoft Inc.,Version v6) using wilcoxon and kruskal-wallis tests. Result(s): The mean fluoroscopy time for left varicocele embolization was 26.76 minutes (8.23 minutes – 49.6 minutes), which was not statistically different (p=0.16) compared to bilateral embolization mean fluoroscopy time of 33.2 minutes (10.3 minutes – 58.83 minutes). There was no statistical difference (p=0.37) between the mean DAP for left varicocele embolization of 106239 mGy.cm² 12672–590429) compared to bilateral DAP of 107153 mGy.cm² (29593–257259). There was no significant difference (p= 0.22) between the mean DAP when using different vascular access (Brachial, DAP= 149416 mGy.cm²), (Jugular, DAP= 87569 mGy.cm²) (Basilic, DAP= 79179 mGy.cm²). However, the basilic vein access was correlated with significantly shorter mean fluoroscopy time of 22 minutes (8.97 minutes – 42.5 minutes) compared to brachial vein (32 minutes, 8.23 minutes – 58.83 minutes) and jugular vein (34 minutes, 8.3 minutes – 49.6 minutes) with a p-value of 0.0429. Conclusion(s): The choice of vascular access may help in reducing fluoroscopy time during varicocele embolization, without significant difference between left or bilateral embolization. This reduction in fluoroscopy time did not translate into significant difference in DAP, which indicates the need for stricter radiation precautions such as collimation and less angiographic exposures.

  OC3.15: Embolization of Procedures-Related Upper Gastrointestinal Bleeding: A Systemic Review Top

Yasir Mohammed Nouri, Ji Hoon Shin1, Jin Hyoung Kim1, Jong Woo Kim1

Ministry of Health, King Fahad General Hospital, Jeddah, Saudi Arabia, 1ASAN Medical Center, University of Ulsan, Seoul, South Korea. E-mail: [email protected]

Background: Procedure-related upper gastrointestinal bleeding considered as a rare cause of upper gastrointestinal bleeding (UGIB). In this presentation, we will review the most common procedures related UGIB with emphasis on endovascular role in diagnosis and treatment. Method(s): From 2001 to 2017 data, representative cases of procedure-related upper gastrointestinal bleeding were collected with their management details. Result(s): There are various categories of procedure-related upper gastrointestinal bleeding; Endoscopic mucosal resection / submucosal dissection, endoscopic ultrasound (EUS)-guided Intervention, percutaneous gastrostomy, and hepatobiliary procedures such as PTBD or ERCP. It presented as hematemesis, melena, or hemobilia which is associated with hepatobiliary intervention. In most cases the bleeding resolved spontaneously and, of those that did not, the majority responds to conservative management or endoscopy. Endovascular intervention was mainly embolization and stent graft insertion. Conclusion(s): In failed endoscopic treatment due to massive bleeding or in case of hemodynamically unstable patients or in hepatobiliary procedure related bleeding, endovascular intervention should be considered. Endovascular embolization represents the most viable treatment option regarding it is less invasive and not associated with complication of general anaesthesia.

  OC4.1: Duplex-Ultrasound Guided Percutaneous Management of Pseudoaneurysm of Branch of Visceral Artery Top

Manoj Kumar

King George’s Medical University, Lucknow, Uttar Pradesh, India. E-mail: [email protected]

Background: To describe the role of Duplex-Ultrasound Imaging (DUI) for diagnosis of pseudoaneurysm (PSA) of a branch of offending visceral artery (b-OVA) followed by DUI-guided percutaneous embolization. Method(s): 46 patients were referred to us for the management of intractable renal hematuria. 21 cases had PSA after nephrolithotomy. 12 cases had PSA after guided renal biopsies. 6 cases had PSA following road-traffic accident. 2 cases of the tuberous-sclerosis-complex developed PSA. 3 cases of arterio-venous and 2 cases of arterio-calyceal fistulae had been excluded from cohort. 6 cases of intractable vaginal/uterine haemorrhage. Among these, a unique complex case presented with post-hysterectomy and in subsequent course of management, surgical ligation of anterior division of both iliac arteries and 5 cases presented after cesarian surgery/dilatation and curettage, 4 cases of post-traumatic G.I. Bleed due developed PSA of b-hepatic artery, 10 cases of pancreatitis induced PSA from b-GDA and splenic arteries. 5 cases of G.I. bleed had bowel tumours were excluded by CTA. Total 61 PSA of b-OVA were included. DUI-guided-percutaneous-management (DPM) is a four-step process. Firstly, identification of PSA-sac of b-OVA. Secondarily, puncture of PSA-sac with 18 G puncture-needle under DUI. Subsequently, injection of gelfoam-slurry followed by NBCA-glue. Thrombosis of the PSA-sac was confirmed by absent flow on DUI during the procedure. Result(s): 60 PSA of b-OVA managed successfully and followed-up clinically, by DUI and CT-Angiography (if needed). A case of large sized (5x4 cm size) PSA of b-segmental-renal-artery developed pulmonary-thromboembolism and managed end-vascular coiling. Conclusion(s): DPM of PSA of b-OVA is safe, feasible and cost-effective modified embolisation management technique in a limited resources scenario.

  OC4.2: Initial Experience with the Covera Covered Stent for the Treatment of Dysfunctional or Thrombosed Arterio-Venous Grafts a Retrospective Analysis of 43 Patients Top

Michail Theofanis, Panagiotis Kitrou, Panagiotis Papadimatos, Spyros Papadoulas, Evangelos Papachristou, Konstantinos Katsanos, Dimitrios Karnabatidis

Department of Diagnostic and Interventional Radiology, Patras University Hospital, Patras, Greece. E-mail: [email protected]

Background: To retrospectively evaluate the safety and effectiveness of the Covera covered stent (CS) for the treatment of dysfunctional or thrombosed arterio-venous grafts (AVGs). Method(s): Within 21 months (February 2016 – November 2017), 61 patients underwent CS placement in our department for the treatments of their dysfunctional AVGs. Data were available for 43 patients, undergoing 43 procedures, using 43 devices. Mean follow-up was 214 days (20-524 days). Lesion characteristics were as follows: 33 cases with venous-graft anastomosis (VGA) stenosis, 7 cases of puncture zone stenosis, 12 cases of in stent-graft (SG) stenosis, 5 cases of psuedoaneurysm treatment. Twenty-six patients presented with thrombosis while 26/43 case were restenotic lesions. Primary outcome measure was target lesion primary patency (TLPP) at six months, while secondary outcome measures included factors influencing primary outcome. Result(s): Technical success was 100%. TLPP was 60.64% at six months (median TLPP 264 days). During the whole follow-up period 17 AVGs were thrombosed and 11 cases required a redo procedure. There was no significant difference in terms of TLPP when de novo lesions were compared with restenotic, in SG restenosis vs. non in-SG stenosis, patients presented or not with thrombosis, or whether lesion was placed in the puncture zone or in VGA. A significant difference was observed between cases presented with thrombosis after treatment vs. those that were not thrombosed (133 vs. 285 days respectively. p=0.007). Conclusion(s): Use of the Covera CS for AVG treatment is safe and effective in every case presented in this retrospective analysis.

  OC4.3: Endoluminal Stenting for Acute Obstructing Colonic Cancer Top

Balamurugan Rathinavelu, Shahabazali Patil, Shamsa Abdalla Alraeesi, Salem Nasser Al Harthi, Ateq Ali Al Messabi, H. Alzarooni, S. Alsheebani

Mafaraq Hospital, Abu Dhabi, UAE. E-mail: [email protected]

Background: Colorectal cancer is a common disease and up to 30% of colon cancers present as emergency. The elective surgery mortality rate is 3.5 to 5 % whereas emergency surgery, morbidity is 40% and mortality 15%. The objective of the study is to assess our colonic stenting experience and compare it with available International published data, advantage of colonic stenting in acute setting and improve treatment quality provided at our hospital. Method(s): Retrospective data collection using Cerner system from 2016 to Oct 2018. Inclusion criteria: Patients with left sided colonic adenocarcinoma coming to emergency department of our hospital with acute colonic obstruction. Patient records were analysed for demographic data, procedure indication, procedural details, outcome, screening time, hospital stay, complications. Result(s): Emergency admission with obstructing left sided colorectal cancer = 12; 5 underwent emergency diverting colostomy (Group 1) and 7 underwent colonic stenting (Group 2). Mean age was 66.5 and 60.5 respectively. There was no major complication in colostomy group, whereas 1 technical failure in stent group. Mean length of hospital stay was 13.5 days (colostomy group) and 1-3 days (stent group). Mean length of ICU stay was 2 days in group 1 whereas no ICU admission required in group 2 patients. Conclusion(s): Advantage of Colonic Stenting: (1) Combined procedure colonoscopy and IR. This gives reduced radiation dose due to reduced screening time. (2) Biopsy of the lesion can be performed at the same time. (3) Convert emergency to elective surgery. (4) Reduction of surgery related complications. (5) Reduced ICU and overall hospital stay. (6) Major surgery may be avoided for patients with end stage disease and unstable comorbid disease. (7) Better quality of life quality.

  OC4.4: Aspiration Thrombectomy for Acute Limb Ischemia: A Single Center Experience Top

Maria Antonella Ruffino, Maria Antonella Ruffino, Marco Fronda1, Andrea Discalzi, Andrea Mancini, Pierluigi Muratore, Denis Rossato, Dorico Righi, Paolo Fonio1

Department of Diagnostic Imaging and Radiotherapy, Vascular Radiology, A.O.U. Citta della Salute e della Scienza di Torino, 1Department of Surgical Sciences, Radiology Unit, University of Torino, Torino, Italy. E-mail: [email protected]

Background: Acute lower-extremity ischemia (ALI) is associated with high in-hospital amputation rates of 10%–30%, 1-year mortality rates of 15%–20%, and low amputation-free survival rates of 50%–65%. Although catheter-directed thrombolysis (CDT) is associated with a lower morbidity rate and is as effective as surgery for stage I and IIa ALI, it takes substantial time to be effective. The Indigo System (Penumbra, inc) is designed for aspiration thromboembolectomy available from 3 f to 8 f in size. The size-matched “separator” allows the catheter to be cleared of occlusive material without catheter removal from the area of thrombus. It has a pump-driven vacuum for consistent aspiration.r preliminary results of this device in the treatment of ali have been recently published. We want to report our single center experience with percutaneous aspiration thrombectomy (pat) as a first line treatment for acute lower limb ischemia (ALI). Method(s): Twenty-one patients who underwent pat for ali from March 2017 to June 2018 were included. The primary end-point was complete thrombus aspiration with return to patency of the target vessel. Adjunctive treatment for underlying stenosis or occlusion was not considered indicating technical failure, while the use of additional treatment for thrombus removal was considered as a technical failure. Result(s): The technical success was obtained in 18/21 patients (85.7%); 2 of the remaining 3 patients required additional treatment for thrombus removal and in 1 the pat failed to restored patency and the patient underwent open surgical treatment. No complications related to pad were reported. Conclusion(s): The technical success was obtained in 18/21 patients (85.7%); 2 of the remaining 3 patients required additional treatment for thrombus removal and in 1 the pat failed to restored patency and the patient underwent open surgical treatment. No complications related to pad were reported.

  OC4.5: Angiographic Anatomy of Prostatic Arteries in 168 Patients Undergoing Prostate Artery Embolization for Benign Prostatic Hyperplasia Top

Mohamed Shaker, Essam Hashem, Ahmed Okba, Karim Abd El Tawab

Ain Shams University, Cairo, Egypt. E-mail: [email protected]

Background: Prostatic artery embolization (PAE) has been established as a safe and effective treatment option for symptomatic benign prostatic hyperplasia. Thorough knowledge of detailed prostatic artery (PA) anatomy is essential to guarantee technical success and to avoid potential complications of non-target embolization. We aim to provide a pictorial review of PA and prevalence of each anatomical variant, in addition to important anatomical considerations, extracted from our case series. Method(s): We performed PAE on 168 consecutive patients until 2019. The most commonly used tools were 5-French cobra-head angiographic catheter and 2.7-French microcatheter. Images were analyzed by the operators. Result(s): In the 168 patients, 331 PAs were angiographically identified. Double arterial supply on the same side was noted in 9 patients (5%). In 10 patients (6%), only a unilateral PA was identified. No PA could be identified in 2 patients (1%). The frequencies of origins of PAs were found to be as follows: 133 (40%) from superior vesical artery (SVA), 97 (29%) from internal pudendal artery (IPA), 70 (21%) from obturator artery, 29 (9%) originated directly from anterior division of internal iliac artery and only 2 (<1%) originated from inferior gluteal artery. Contrast filling of contralateral PA main trunk was identified in 31 patients (18%). Penile anastomosis was identified with 28 PAs (8%) and rectal anastomosis was observed with 14 PAs (4%). Conclusion(s): PA has variable origins, even for both sides in the same patient. Knowledge of its detailed anatomy and anastomosis with nearby arteries is essential for safe and timely performance of PAE.

  OC4.6: Safety and Efficacy of Endovascular Revascularization of Single Patent Arch Artery in Patients with Takayasu Arteritis: Short Term Results Top

Priya Jagia, Niraj Pandey

All India Institute of Medical Sciences, New Delhi, India. E-mail: [email protected]

Background: Takayasu arteritis is a form of large vessel vasculitis commonly affecting the aorta and its major branches. Steno-occlusive lesions of all arch vessels can cause severe neurologic symptoms. There is paucity of literature regarding the role of endovascular revascularization in such cases. The present report describes immediate and short term follow-up results with plain balloon angioplasty of severely stenosed single patent arch arteries. Method(s): Angioplasty was performed in 5 consecutive patients with Takayasu arteritis (age, 22 – 50 years; mean, 31.0 ± 12.0416 years) with cerebrovascular symptoms caused by severe stenotic lesions of arch (ie, carotid, vertebral, brachiocephalic and 1st part of subclavian proximal to vertebral take-off) arteries. Result(s): Angioplasty was attempted in 8 stenotic lesions: vertebral (n=3), carotid (n=1), brachiocephalic (n=2) and 1st part of subclavian artery (n=2). Five lesions were discrete and three were diffuse. Balloon angioplasty was performed successfully in all patients. Improvement of luminal diameter from 1.625 mm ± 0.5825 mm to 4.75 mm ± 0.8452 mm (P < .0001), and the reduction in diameter of stenosis from 73.125% ± 14.1263% to 16.25% ± 8.3452% (P < .0001) was observed. No immediate procedure-related complication or significant neurologic deficits occurred. The presenting symptoms improved in all patients. On short term follow-up of upto 4 months, none of the patients had recurrence of neurologic symptoms. Conclusion(s): Plain balloon angioplasty of a sole patent arch artery in Takayasu arteritis is safe and effective, and provides excellent symptomatic relief in such patients.

  OC4.7: Glue Embolisation of Truncal Varicosities with Direct Puncture Technique: Is it a Threat to Thermal Ablation? A Prospective Study Top

Venkatesh Kasi Arunachalam, Rinoy Anand, Santosh Patil, Elango, Jenni

KMCH, Coimbatore, Tamil Nadu, India. E-mail: [email protected]

Background: Varicose veins is one of the most common disease presented to vascular clinic. Though there are many endovascular methods are available for the treatment of variocse veins, most of them are costly procedures. we need a treatment with lower cost and acceptable success rate, so that all group of people will be benefitted. With this background we did a study on glue embolisation of truncal varicosities. Aim of the Study: (1) To evaluate the success rate of adhesive embolisation using N Butyl 2 Cyanoacrylate. (2) To compare the occlusion rate with RFA. (3) To analyse the cost difference between both. Method(s): Study period: October 2017 to October 2018. Inclusion criteria: Incompetent SFJ wth reflux into GSV. Exclusion criteria – Deep vein thrombosis. Glue embolisation of great saphenous vein (GSV) is planned atleast for thirty patients. The great saphenous vein in thigh was punctered directly with 21 G needle atleast at 7 - 10 sites with a gap of 5 cms and 0.1-0.2 ml of glue is injected at each sites. After injection, compression is done with ultrasound probe for 45 seconds at that site. The injection is started from the caudal to cranial direction. The procedure is performed without perivenous tumescence. The patients are advised to come for follow up at one week, one month and six months intervals. The Patients will be evaluted for occlusion of GSV as well as complications associated with it. The results are compared with the results of RFA of varicose veins in our institute. Result(s): (1) Glue embolisation occlusion rate at 6 months: 93%. (2) Comparable to RFA at 6 months gap. (3) Decrease in the cost by >300%. Conclusion(s): The efficacy of glue embolisation of varicose veins done with direct puncture is similar to RFA at 6 months follow up and it can be done with decreased cost (<1/4th of RFA).

  OC4.8: Use of Glue in Varicocele Embolization: A Single Centre Experience and Literature Review Top

Mohamed Asadullah Al-Ajmi, Mahmood Al Hajriy, Said Al-Lamki

Royal Hospital, Muscat, Oman. E-mail: [email protected]

Background: The purpose of this study is to assess the patient’s outcome from symptomatic varicocele treated with two methods of embolization techniques one with coils combined with sodium tetradecyl sulphate (STS) and the other technique with N-butyl-2-cyanacrylate (Glue) in terms of immediate technical and clinical success, complications rates, procedure time, and assess any significance difference in the outcome between the 2 techniques. Method(s): A retrospective analysis of a consecutive series of varicocele embolization procedures performed between April 1st 2015 and July 22nd 2017 was undertaken. A total of 84 were included in our study, 41 using glue (48.8%, mean age of patients 31.98 years) and 43 using coils (51.2 %, mean age of patients 32.91 years). Demographic data, indications, complications and outcomes were compared. Result(s): A total of 32 procedures (38.1%) were motivated by infertility (glue = 15, coils + STS = 17), 33 (39.3%) by testicular pain (glue = 14, coils +STS = 19), and 19 (22.6%) by both (glue = 12, coils +STS = 7). Minor complications were observed in 2 cases (4.9%) in glue and in 5 cases after coil + STS embolization (11.6 %). Patients reported improvement in 65.9 % with glue sample, and 58.1% with coils + STS. Both agents showed similar success rates. The patients who were referred for testicular pain reported 89.5% improvement, while those patients referred for infertility reported 42.1 % improvement. Conclusion(s): Varicocele embolization is a safe and effective procedure. Embolization with glue gives a similar outcome compared with coils combined with STS.

  OC4.9: Early Portal Vein Thrombosis after Living Donor Liver Transplant: Interventional Radiology May be the Answer Top

Shahnawaz Bashir, Subash Gupta

Max Super Speciality Hospital, New Delhi, India. E-mail: [email protected]

Background: Incidence of PVT is close to 4% in adult LDLT due to technical difficulties in PV reconstructions, mainly related to a shorter vessel pedicle and limited vessel graft. Most cases of PVT occur early (1 month from transplant) and the clinical presentation is severe acute liver insufficiency or graft failure. When it occurs late (more than 4 weeks) recurrence of portal hypertension is a dominant feature. Without treatment PVT is associated with poor survival. Therapeutic options for PVT range from systemic anticoagulation to interventional radiological (IR) treatment, to surgical revision to retransplantation. The IR options presented in the literature include thrombolysis, portal vein angioplasty, stent placement and shunt occlusion if present. The IR approach may be via percutaneous transhepatic (PT), via transjugular intrahepatic portosystemic shunt (TIPS) creation or transplenic approach. Method(s): A total of 430 liver transplants were done at our institution between February 2017 and December 2018. Five cases of early PVT were referred to us for IR treatment. The diagnosis was initially made on colour Doppler ultrasound and findings confirmed on contrast CT. Portal vein access was taken by ultrasound guided direct percutaneous trans-hepatic approach in all but 1 case where percutaneous trans-splenic approach was taken. Urokinase (1 to 5 lac units) were used for thrombolysis, in 2 cases overnight urokinase infusion was used at 50,000 units/h. Balloon dilatation was done with a 6 mm diameter balloon. Portal flow steal by a large shunt was present in 2 cases which were closed by coils and covered stent respectively. Result(s): With IR treatment spontaneous portal vein flow was re-established in all but 1 patient [Table 2]. Long term follow up is available in 2 patients (7 and 9 months respectively) and they are doing well and shows excellent portal flow. The patient in whom spontaneous portal flow could not be established (s. no 3) was taken for surgical re-exploration after his liver enzymes increased remarkably next day. The surgical re-exploration revealed HAT in addition to PVT. There were areas of liver necrosis on gross inspection. Hepatic artery flow was re-establised after thrombectomy. However only sluggish portal flow could be re-established. This patient expired 2 days later due to multi-organ failure. One patient (s. no. 1) had undergone surgical re-exploration for concomitant HAT and PVT one day before IR treatment. Another patient (s. no. 5) had surgical re-exploration for HAT on POD 1 and had HAT recurrence on POD 6. Hepatic artery thrombolysis was done successfully. However this patient had intracranial bleed on POD 8 likely due to thrombolysis and died of liver insufficiency and progressive neurological deterioration on POD 38. Conclusion(s): Evidence-based evaluation outcomes of surgical and IR techniques to manage PVT is made difficult by its low incidence, which has heretofore prevented the publication of prospective comparative trials and limited the publication of large, retrospective series. However, IR therapies promise to avoid the risks of re-do operations in select post-surgical patients, besides providing a fair idea of anatomic causes such as venous redundancy, kinking, stenosis, anastomotic size mismatch and presence of shunts. IR management may be safe in early PVT and can often identify the anatomical cause of the PVT and corrective measures can be taken which might lead to long term improved results. However more studies with larger sample size are required to establish the safety and outcome of this approach. Our experience suggests that IR treatment is feasible and safe in early PVT in LDLT patients with good outcomes in cases where concomitant HAT is not present.

  OC4.10: Increasing Efficiency in the Interventional Radiology Division: Multiple Changes in Workflow from Patient Registration to Discharge Top

Umar Tariq, Jennifer Brent, Gordon Evans, Ashok Bhanushali, Tariq Rahman

Geisinger Medical Center, Danville, USA. E-mail: [email protected]

Background: We aim to present our experience with measures resulting in increased workflow efficiency in our clinical practice, and to evaluate the effect of these changes on the time elapsed at each stage of the workflow process and how it impact overall workflow efficiency. Method(s): We implemented a set of changes at each stage of the workflow process from patient registration, pre-operative workup, procedure, post-operative care, and discharge. Average time for completion of each stage of the process was determined before and after implementing the changes. Weekly case volume (WCV), weekly mean overtime hours (WMOH) and monthly percentage of first case on time (FCOT%) were compared before and after the intervention. Patient profiles including age, sex, and BMI where tracked to account for confounding variables. Student’s t-test was used to compare variables before and after intervention. F- test was used to compare variance before and after intervention. A p value of less than 0.05 was considered statistically significant. Result(s): No statistically significant difference was seen in the age, sex or BMI of patient population before and after intervention (p>0.05). There was a statistically significant 20% increase in WCV from 200 to 240, 45% decrease in WMOH from 10.8 hours to 4.9 hours and 25% increase in monthly FCOT% from 50% to 75% (p<0.01). Conclusion(s): Our workflow intervention resulted in better WCV, WMOH and FCOT%. Improved workflow efficiency is critical in the success of an interventional radiology department, and results in better patient care and overall patient satisfaction.

  OC4.11: Association of Concomitant Disease in the Profunda and Femoro-Popliteal Veins to Cumulative Patency and Re-Intervention Rates Following Ilio-Femoral Venous Stenting of Limbs with Postthrombotic Occlusion Top

Leslie Fiengo, Adam Gwozdz1, Prakash Saha1, Lawrence Stephenson1, Leonardo Jones1, Nicholas Jackson1, Justinas Silickas1, Taha Kahn1, Soundrie Padayachee1, Alberto Smith1, Stephen Black1

Department of Vascular, London, 1Academic Department of Vascular Surgery, School of Cardiovascular Medicine and Science, St Thomas’ Hospital, King’s College London, London, UK. E-mail: [email protected]

Background: Ilio-femoral stent patency is inferior in post-thrombotic disease compared with non-thrombotic venous obstruction. The aim of this study was to examine whether decreased inflow to the stent, caused by intraluminal obstructive disease, was associated with greater risk of re-intervention and inferior long-term patency outcomes. Method(s): Consecutive patients (2012-2017) receiving a nitinol venous stent for post-thrombotic disease were included for analysis. Pre-operative ultrasound was used to identify femoral vein (FV), profunda vein (PV), and/or popliteal vein (POPV) intraluminal scarring and/or residual thrombosis, and categorised into one of 3 groups: absence of disease; disease in a single inflow vessel; or disease in more than one inflow vessel. Stent patency was assessed using duplex ultrasonography post-intervention, and re-interventions performed when there was a reduction in stent diameter of >50% or occlusion. Result(s): Of 164 patients treated, cumulative patency was 89% (median follow-up 2.4 yrs; range 46-308 wks). However, 70/164 (43%) patients required re-intervention to maintain patency (median number of re-interventions 2; range 1-6). The respective disease state of inflow vessels are shown in Table 1. Cumulative patency and re-intervention rates were significantly worse in patients with more than one diseased inflow vessel (P=0.47, P=0.004, respectively). Disease in the FV+PV+POPV was associated with a higher risk of re-intervention (16/25 (64%); HR 2.76; P=0.009, 95% CI [1.29, 5.92]), and was a strong predictor of cumulative patency loss compared with patients that had no inflow vessel disease (18/25 (72%) HR 17.26; P=0.009, 95% CI (2.02, 147.07). Conclusion(s): Maintaining stent patency in post-thrombotic limbs is influenced by the quality of inflow vessels. Patients with intraluminal scarring and/or residual thrombosis in the FV+PV+POPV should be counselled on their increased risk of patency loss.

  P101: Relative Atherosclerotic Sparing of the External Iliac Artery: Possibility of a Less Vasculopathic Arterial Graft Target Top

Pooya Torkian, Taraneh Faghihi, Reza Talaie1

Shahid Beheshti University of Medical Sciences, Tehran, Iran, 1Minnesota Hospital, Minnesota, USA. E-mail: [email protected]

Background: Calcified plaque build-up can increase the risk of subsequent vascular complications in pelvic solid organ transplantation and vascular bypass procedures. The purpose of this study was to assess the degree of atherosclerotic calcification in pelvic vessels. Method(s): We retrospectively reviewed the unenhanced computed tomography scans of 197 patients from August 2016 to March 2018. Using calcium-scoring software, we examined the distribution map of calcified plaques, focusing on four different arterial segments—the abdominal aorta, the common iliac artery (CIA), the EIA, and the common femoral artery (CFA)—to determine which one showed the least mural calcification. Result(s): A total of 197 patients (118 men, 79 women) with a mean age of 61.19 ± 10.8 years were included in our study. The right EIA segment had the lowest average calcification score (18.2± 92.1), including 180 cases (91.4%) of zero calcification, followed by 178 cases (90.4%) of zero calcification in the left EIA. When adjustments were made for age, gender, smoking status, diabetes, hypertension and hyperlipidemia, the Odds ratio (OR) of the left EIA for reaching a higher calcium score level was 1.19 (P=0.44, not significant) times greater than the reference group (right EIA). The ratio was markedly higher in the abdominal aorta segment (OR=146.7.4, P<0.001), followed by the right CIA (OR=42.5, P<0.001), the left CIA (OR=27.3, P<0.001), the right CFA (OR=3.96, P<0.001), and the left CFA (OR=3.51, P<0.001). Conclusion(s): The study demonstrates a significantly less calcific plaque burden in EIA compared to the adjacent arterial bed.

  P102: Hail Medical Students’ Knowledge About Imaging Modalities, Risks and Protection in Radiology Top

Meshael Alreshidi, Dalal Alshubrmi, Fayez Alreshidi, Khaled Soliman1, Ibrahim Alrashidi1

University of Hail, Hail, 1Prince Sultan Military Medical City, Riyadh, Saudi Arabia. E-mail: [email protected]

Background: Safety in radiology become a very important patient and occupational safety issue with this constant increase in the use of diagnostic radiology in modern evidence-based medicine. The objective of this study was evaluation of the knowledge of Hail University medical students about safety measures in radiology to ensure they have the essential knowledge to protect themselves and their patients. Method(s): In this cross-sectional study, an anonymous electronic questionnaire was sent to 174 randomly selected students. The questionnaire contained 38 questions. The respondents’ answers to these questions were used to classify them according to their demographic characteristics, and evaluate their knowledge about common imaging modalities, radiation risks, and safety measures. The data were analyzed using SPSS version 22 software. Result(s): Seventy-five (51.7%) of 145 respondents were female and 70 (48.3%) were male. Fifty-five respondents (37.9%) were in year 4, 38 (26.2%) were in year 5, and 52 (35.9%) were in year 6. The mean score for knowledge about common imaging modalities was 4.10 ± 2.030 out of 10, that for knowledge about the risks of radiation was 3.17 ± 1.954 (range 0–8) out of 13, and that for knowledge about radiation protection measures was low at 0.79 ± 0.922 (range 0–4) out of 8. Overall, there was improvement in knowledge about imaging modalities and the risks of radiation as the number of clinical years increased (P<0.01), but it was still unsatisfactory. Conclusion(s): The study showed there is very limited knowledge about radiation risks and safety measures among clinical years medical students which highlights the need for an urgent action taken by medical schools to improve their students’ knowledge about these topics.

  P103: Awareness of Interventional Radiology Among Clinical-Years Medical Students and Medical Interns at University of Hail Top

Rahaf Abdalaziz Odah Albaqawi, Meshael Alreshidi, Dalal Alshubrami, Halah Alrasheedi, Fayez Alreshidi1, Ibrahim Alrashidi2

College of Medicine, Hail University, 1Family Medicine Department, College of Medicine, Hail University, Hail, 2Department of Radiology, Prince Sultan Military Medical City, Riyadh, Saudi Arabia. E-mail: [email protected]

Background: One of the most important challenges facing the evolution of modern interventional radiology is the lack of awareness among medical students about it. Objectives: This study aimed to determine the knowledge, perception, and views of University of hail clinical-year medical students and medical interns regarding various topics of interventional radiology. Method(s): In this cross-sectional study, validated anonymous electronic questionnaire was sent to all clinical years students and medical interns. All the participants were informed about the study aim and objectives and an informed consent was obtained. Result(s): Two hundred responses were received. The majority of participants (45%) were agreed that their knowledge and information in interventional radiology is poor. The minority (17%) of the participants are interested to consider a career in diagnostic radiology or in interventional radiology. On the other hand, the most common reported reason of not considering radiology as a career was the inadequate and enough knowledge about it (27.5%). The majority of participants (72.5%) have not exposed to interventional radiology. Only (36.5%) of participants are interested in doing a 2-week interventional radiology elective during their internship year. Conclusion(s): This study demonstrate that the majority of the under-graduates and interns are lacking for basic knowledge of interventional radiology. About one-third of respondents are interested in doing their elective in interventional radiology, on the other hand, more than the half of participants are not interested or not sure yet.

  P201: Non-Target Lung Embolization During Portal Vein Embolization Due to Unrecognized Intrahepatic Porto-Systemic Venous Fistula Top

Sultan R. Alharbi

King Saud University, Riyadh, Saudi Arabia. E-mail: [email protected]

Background: To review literature of this rare complication and rare vascular malformation. To reinforce the value of pre-procedural conventional portogram for vascular abnormality even if contrast enhanced CT or MRI were normal. Preoperative portal vein embolization is standard procedure done to enhance the size of the future remnant liver. It is simple and relatively safe procedure with low complication rate. The non-target embolization complication is very rare and if it happened it usually involve the future remnant liver portal vein branches. Non- target lung embolization during portal vein embolization is not reported in the available English literature. Intrahepatic porto systemic vascular malformation is rare in non-cirrhotic liver. Result(s): A 60 -year- old male patient with metastatic colonic cancer to the liver is referred for interventional radiology for preoperative right portal vein embolization. He underwent contrast enhanced CT and MRI which show the right hepatic metastasis and normal patent portal vein system with standard anatomy. Ipsilateral portal vein approach was utilized after portogram, right portal vein embolization was done using amplatzer plug followed by glue. During glue injection, small amount the glue was seen flowing into the heart and bilateral lungs through a retrospectively seen an intrahepatic portosystemic venous fistula. Patient remained clinically stable. After four-week patient underwent right hepatectomy and had uneventful post-operative course. Conclusion(s): although an intrahepatic porto systemic venous fistula is rare in non-cirrhotic liver carful evaluation of portal vein especially conventional portogram is mandatory before portal vein embolization to avoid non- target embolization.

  P202: Sentinel Node and Occult Lesion Localization in Non-Palpable Breast Carcinoma: Will it be Standard Procedure Top

Menatallah Shaher Ahmed Tawfik

Al Zahra Sharjah Hospital, Sharjah, UAE. E-mail: [email protected]

Background: SNOLL (combined ROLL-Radioguided Occult Lesion Localization and SLN-Sentinel Lymph Node mapping) in one seesion is the new proposed standard technique used for non palpable invasise breast carcinomas, it overcomes difficult technicalities encountered with WGL (Wire Guided Localization) with wire migration being the most common encountered. Also, it doubled the benefits of both accurate radioactive localization and excision by gamma held camera intra-operative and Sentinel lymph node mapping for infiltrated malignant lymph nodes with much less time consuming in one imaging guided injection intervention procedure either US or mammography or MRi guided, 0.2 ml 99m TC MAA and 0.2 ml 99m TC nanocolloid intra-tumoral and peri-areolar respectively. Method(s): Review study paper for the most recent published papers about SNOLL and it’s efficency as a standard procedure for non palpable breast carcinoma Localization and Sentinel lymph nodes mapping. Result(s): All 8 most recent studies about SNOLL was in favour of this new technique, only one study reported that WGL and ROLL alone are comparable. Not any study was against the procedure. The comparative tools used in these studies are many yet most important used are; negative margins, re-operate rate, operation time, voulme and excised specimen weight, successful excision and SLN mapping. Conclusion(s): SNOLL proved it is accurate, simple, safe, reliable technique, it improves negative margins in many studies and recommended to be the standard procedure.

  P203: Selective Treatments Including Trans-arterial Chemoembolization in Hepatocellular Carcinoma Patients Combined with Segmental or Subsegmental Portal Vein Tumor Thrombosis, 1 Year Survival Top

Mohamed Zaitoun, Saeed Bakry Elsayed

Zagazig University Hospitals, Zagazig, Egypt. E-mail: [email protected]

Background: To determine efficacy and safety of selective TACE in patients with hepatocellular carcinoma (HCC) and segmental and subsegmental portal vein tumor thrombosis (PVTT). Method(s): During 12 months, 20 consecutive child a patients with single HCC and segmental or subsegmental PVTT were treated selectively with conventional TACE (lipiodol+adriamycin) using a microcatheter. Mean age was 58 years, 12 (60%) were males. Abdominal ultrasound was done after 1 week to detect ascites. Liver functions was done after 1 week to detect any change then after 1 month then every 3 months for 1 year. Follow up with triphasic CT was performed after 1 month then every 3 months for 1 year. Result(s): After 1 week, decompensated ascites was noted in only one patient (5%). After 1 month, complete response was detected in 15 cases (75%), partial response in 5 cases (25%). One case (5%) died during the follow up. Overall survival rates at 12 months was 95%. Conclusion(s): Selective TACE is effective and safe in HCC patients with segmental or subsegmental pvtt with excellent survival rate at 12 months.

  P204: Bland Embolization in Hepatocellular Carcinoma Patients with Borderline Liver Functions, 1 Year Survival Rate Top

Mohamed Zaitoun, Saeed Bakry Elsayed

Zagazig University Hospitals, Zagazig, Egypt. E-mail: [email protected]

Background: To determine efficacy and monitor safety of bland embolization in patients with hepatocellular carcinoma (HCC) and high bilirubin level. Method(s): From January 2017 to June 2018, 25 consecutive HCC patients who were Child-Pugh class b with high bilirubin level (> 2 mg/dl and < 4 mg/dl) and no ascites and no signs of extrahepatic disease were treated selectively with bland embolization (PVA 150-250 µm for HCC < 5 cm and 255-350 µm > 5 cm) using a microcatheter. Mean age was 55 years, 16 (64%) were males. Abdominal ultrasound was done after 1 week to detect ascites. Liver functions was done after 1 week to detect any change then after 1 month then every 3 months for 1 year. Follow up with triphasic CT was performed after 1 month then every 3 months for 1 year. Result(s): After 1 week, decompensated ascites was noted in two patients (8%). After 1 month, complete response was detected in 15 cases (60%), partial response in 10 cases (40%). Three cases (12%) died during the follow up. Overall survival rates at 12 months was 88%. Conclusion(s): Bland embolization is effective and safe in Child-Pugh class b patients with HCC with high survival rate at 12 months.

  P205: Combined Trans-arterial Embolization and Microwave Ablation for the Treatment of >3 cm Liver Metastases Top

Faiella Eliodoro, Santucci Domiziana, Pacella Giuseppina, Grasso Rosario Francesco, Beomonte Zobel Bruno

Campus Bio-medico University, Rome, Italy. E-mail: [email protected]

Background: Evaluate efficacy and safety of a combined therapy for liver metastases treatment >3 cm, using a two-step single session combined approach of transarterial embolization (TAE) followed by percutaneous microwave ablation (MWA) for curative intent. Method(s): Between January 2015 and December 2017, 24 technically unresectable liver metastases >3 cm were selected for the combined treatment. The percentile variation in ablated tissue volume with respect to a stand-alone thermal coagulation therapy (δv) was calculated. The final ablation volume (VE-T) was compared with the initial nodule volume (VN) and the expected ablation volume of stand-alone MWA (VT). Technical success was defined as complete target devascularization at the immediate post-procedural CT. One, 3, 6 and 12 months post-procedure follow-up was performed and major and minor complications were reported. Result(s): Tumor dimension ranged from 32 to 73 mm. Full technical success was achieved in all treated tumors. The final ablation volumes were in the range 50-450 cm3 with short-axis diameter of the ablation zone ranged between 12 and 48 mm. The mean δv increment in final ablation volume with respect to stand-alone MWA was 196% (range: 25 cm3 – 210 cm3) (p<0.05). The VE-t mean was 4 times the VN mean, while the VT mean was about twice the VN mean. No recurrence and only one major complication were observed. Conclusion(s): Our results provide preliminary evidence of efficacy, obtaining a larger necrotic area, and safety, for the low complication rate, of a combined two-step single-session TAE-MWA treatment of unresectable hepatic metastasis >3 cm.

  P206: Assessment of Arterial Supply and Response to Trans Arterial Therapy of Caudate Lobe Hepatocellular Carcinoma: A Retrospective Single Institution Study Top

Emad Samhan Alrasheed, Mohammad Arabi

King Abdulaziz Medical City, Riyadh, Saudi Arabia. E-mail: [email protected]

Background: To retrospectively study the angiographic supply of HCC located in caudate lobe and evaluate the response rate after trans arterial chemo embolization or trans arterial radio embolization. Method(s): A total of 12 patients (M:F=10:2) with mean age of 65 with caudate lobe HCC. Nine patients (75%) had solitary lesion and 3 patients (25%) had 2 lesions. Patients were treated with TACE (n= 5) and TARE (n= 7) Response rates was assessed on follow up imaging using mRECIST. Result(s): Tumor supply to caudate lobe HCC was from the right hepatic artery in 54.5% (n= 6), left hepatic artery 36.4% (n= 4) and left hepatic/right inferior phrenic arteries in 9.1 % (n= 1). Complete lesion response was achieved in 75% (n=9), one of which had liver transplant. Disease recurrence at 14 and 6 months follow up in 16.6%. One patient has no follow up. Conclusion(s): Trans arterial therapy of caudate lobe HCC is effective in treatment and down staging HCC. Careful angiographic evaluation of arterial is essential to improve outcomes.

  P207: Uterine Artery Embolization and Methotrexate Infusion as Sole Management for Cesarean Scar and Cervical Ectopic Pregnancies: A Single-Center Experience Top

Ali Hassan Elmokadem, Rihame M. Abdel-Wahab, Ahmed A. El-Zayadi, Mohamed M Elrakhawy

Mansoura University, Mansoura, Egypt. E-mail: [email protected]

Background: The incidence of cesarean scar pregnancy (CSP) and cervical pregnancy (CP) increased significantly in recent years. The related heamorrhage can be lethal and often needs hysterectomy. This study aims to assess the technical and clinical results of uterine artery embolization (UAE) combined with intra-arterial methotrexate (MTX) infusion for CSP and CP. Method(s): A retrospective study was conducted for eleven patients (age range from 25-40 year, mean; 31.8 y) with CSP (7/11) and CP (4/11). The diagnosis was confirmed by elevated b-hCG levels (mean 31.245 mlU/mL) with sonography and/or magnetic resonance imaging. They were treated with UAE using particulate embolic material. In all patients, the infusion of MTX (50 mg/m2) was performed before UAE. Follow-up periods after UAE ranged between 6 to 24 months included weekly sonography and b-hCG level assessment. Result(s): In ten patients, UAE controlled active vaginal bleeding and reduced post- procedural b-hCG levels significantly by the second week. One patient presented with persistent elevated b-hCG level and vaginal rebleeding. The rebleeding was successfully controlled by second UAE procedure. The ectopic pregnancies were resolved and uterus was preserved in all patients. No major complications were detected. Normal menses resumed within 2 months after UAE. Two patients had subsequent natural successful intrauterine pregnancies. Conclusion(s): UAE combined with intra-arterial MTX infusion resulted in resolution of ectopic pregnancies with control of hemorrhage and without hysterectomy in this small group of patients.

  P301: Computed Tomography Guided Drainage of Postsleeve Gastrectomy Leak Collection Top

Sultan R. Alharbi

King Saud University, Riyadh, Saudi Arabia. E-mail: [email protected]

Background: Sleeve gastrectomy is now very popular bariatric surgery. post sleeve gastrectomy leak is challenging complication to treat. conservative management is preferred over operative one. drainage of the leak collection with endoluminal stenting is essential component of conservative management. CT guided percutaneous drainage is alternative to surgical and endoscopy drainage. no standards approach for post sleeve gastric leak is established. Method(s): Retrospective review of all post sleeve gastrectomy leak collection CT guided percutaneous drainage from February 2011- September 2018 done in our institution. our institution is well known center of excellent for post sleeve gastrectomy leak management. Result(s): 53 patients underwent CT guided percutaneous drainage for post sleeve gastrectomy leak collection (23 females and 30 males; average 33.8 range 18-65). All procedures were done using CT guidance and Seldinger technique. Drains size range from 10-14 Fr. Technical and clinical success was 100 %. 1 patient had bleeding complication that was treated by embolization. 10 patients need drain change or adjustment. No patient underwent surgery for collection management. indwelling drain time average of 70 days. All patient underwent endoluminal stent placement. Conclusion(s): CT guided percutaneous drainage of post sleeve gastrectomy leak is safe and effective treatment.

  P302: Ultrasound Guided Trans-Gluteal Approach for Percutaneous Collection Drainage: Why, Who and How? Top

Amr Maged Elsaadany, Bandar Safar1, Samy Alashwal1, Shaqran Binkhamis1, Mohamed Farouk Badran1, Fida Alaeddin1

Sandwell and West Birmingham Hospital, Birmingham, UK, 1King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia. E-mail: [email protected]

Background: Percutaneous abscess drainage is the standard of care in the absence of indications for immediate surgery. Variety of disorders can produce fluid collections in the lower abdomen and pelvis. These pelvic collections can be drained in several approaches with the trans-gluteal approach being useful and effective. Advantage of the ultrasonographic approach include less time in the CT-imaging area, less procedural time, less radiation exposure, and ability to avoid blood vessel puncture by real-time color Doppler during catheter placement. Disadvantages include poor sonographic penetration in the deep pelvic tissues of even an average-sized adult. Method(s): We elected to overcome the necessity of CT-guidance for drainage of pelvic collections by using trans-gluteal sonographic guidance. Curved-3-5 MHz transducer is used to scan the pelvis with the patient in prone position from para-sacral regions. The coccyx was palpated as a landmark, and the puncture site should be caudal and close to this landmark to avoid damage to the neuro-vascular bundle. Oblique-sagittal or axial imaging through the area of the greater sciatic foramen is used to guide the needle into the collection. Drainage can be performed by using the Seldinger or trocar technique under local and conscious sedation. The catheter removed once the output diminished to <20 ml/day for 48-72 hours. Result(s): We elected to overcome the necessity of CT-guidance for drainage of pelvic collections by using trans-gluteal sonographic guidance. Curved-3-5 MHz transducer is used to scan the pelvis with the patient in prone position from para-sacral regions. The coccyx was palpated as a landmark, and the puncture site should be caudal and close to this landmark to avoid damage to the neuro-vascular bundle. Oblique-sagittal or axial imaging through the area of the greater sciatic foramen is used to guide the needle into the collection. Drainage can be performed by using the Seldinger or trocar technique under local and conscious sedation. The catheter removed once the output diminished to <20 ml/day for 48-72 hours. Conclusion(s): Ultrasonographic-guided trans-gluteal abscess drainage is an alternative route for pelvic collections. This procedure is safe and effective for moderate/large fluid collections in non-obese patients and eliminates the need for using valuable CT time to perform these procedures.

  P303: Transrectal Ultrasound Guided Drainage of Deep Pelvic Abscess in Females Top

Eman Ahmed Hamed, Karim Ahmed Abd Eltawab

Ain Shams University Hospitals, Tanta, Egypt. E-mail: [email protected]

Background: Percutaneous drainage is a standard treatment for patients with pelvic abscess. However deep abscess might be challenging for percutaneous root especially small volume collections which are relatively commoner in females in child bearing period being prone to a number of etiologies, commonest of which are postsurgical complications, pelvic inflammatory disease and complicated inflammatory bowel disease. Transrectal guidance allows drainage of the inaccessible deeply seated pelvic collections due to close proximity to the collection. We favor aspiration over drainage catheter insertion to avoid fistulation and patient inconvenience. To assess the technical and clinical success or the transrectal ultrasound guided drainage of deep pelvic abscess in females. Method(s): From January 2015 to October 2018; 34 female patients were presented to Ain Shams University Interventional Radiology Unit for deep pelvic abscess drainage. A 14 G 25 cm needle was introduced through adapter over a the endocavitary probe. Complete aspiration was always tried with irrigation with normotonic saline till aspirate clearance. Local injection of broad spectrum antibiotic was injected before removal of the needle. Result(s): Technical success defined as ability to completely aspirate the abscess was achieved in 30 patient (88%). In 3 patients abscess could not be aspirated completely due to relatively large volume, and 1 patient due to markedly thick abscess content necessitating surgical drainage. Clinical success defined as no recurrence within the first 3 months was 86%. 4 cases had recurrence with procedure redo. 1 had second recurrence and referred for posterior colpotomy. No major complications were seen, minor self-limiting anal pain was noted in most of the cases and managed conservatively, minor self limiting rectal bleeding occurred in 3 cases. Conclusion(s): Transrectal US guided aspiration of deep pelvic abscess in females shows relatively high rates success with low rates of complications and should be tried before surgical drainage.

  P304: Percutaneous Image-Guided Gastrostomy Insertion with and without Gastropexy: A Single Tertiary Care Center Experience in Saudi Arabia Top

Shaima Ahmed Abdulrahman, Yousof Alzahrani, Hana Alfaleh, Fawziah Alorfi, Ali Rajeh, Nehal Alghamdi, Mohammed Aljarie, Mohammad Arabi

King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia. E-mail: [email protected]

Background: Gastropexy is used by many interventional radiologists during percutaneous image-guided gastrostomy insertion. This study compares major and minor complication rates of gastrostomy insertion with and without gastropexy at our center. Method(s): This is a retrospective observational study including adult patients who underwent image-guided gastrostomy insertion at our center from January 1st, 2015 to November 30th, 2018. The sample was divided into patients who had gastrostomy insertion with gastropexy and those without. Major and minor complication rates were assessed based on the Society of Interventional Radiology guidelines and compared using Chi-square. Result(s): A total of 830 patients [512 males (61.8%); 318 females (38.2%)] were included. Gastropexy was performed for 428 (51.6%) patients [1 anchor, 41 patients (9.6%); 2 anchors, 268 patients (62.7%); 3 anchors, 118 patients (27.5%); and 4 anchors, 1 patient (0.2%)]. The remaining 402 patients (48.4%) had no gastropexy. Technical success was achieved in 100% with and without gastropexy. A total of 143 complications occurred; 6 major and 137 minor. For those who had major complications, 2 were from gastropexy group. No significant difference was found in major (0.47% vs 1%, P=0.37), or minor complication rate (18.7% vs 14.2%, P=0.08) between gastropexy and no gastropexy groups, respectively. Furthermore, there was no significant difference when studying complication rates in relation to the number of anchors used (P= 0.32 for major complications, P= 0.57 for minor complications). Conclusion(s): No significant difference in major or minor complication rates was found between patients who underwent gastrostomy insertion with gastropexy versus without gastropexy. Furthermore, no significant difference in complications was found in relation to the number of anchors used.

  P305: Percutaneous Management of Post Liver Transplant Biliary (strictures) Complications in Pediatric Patients: A Single Center Experience Top

Bader A. Alahaideb, Bander O. Safar, Sulaiman M. Alsharfan, Abdulmajeed R. Alhazzani1, Amr M. Alsaadany, Hamad S. Alsuhaibani

King Faisal Specialist Hospital and Research Center, 2King Saud Medical City, Riyadh, Saudi Arabia. E-mail: [email protected]

Background: The outcome of percutaneous management (PM) of post liver transplant biliary strictures (PLTBs) in pediatric age group. Method(s): Between august 2011 and December 2017, a total of 19 pediatric patients with (PLTBS) had pm. All patients presented with clinical and biochemical evidence of biliary obstruction. Biliary dilatation by imaging studies was seen in 17 patients. Protocol of three balloon dilatation sessions, at 4-6 weeks interval, is followed. Review of type of biliary anastomosis, status of the hepatic artery, outcome of the percutaneous management was carried out. Result(s): Out of the19 patients underwent pm for post-LT biliary strictures, 16 were successful with resolution of the clinical picture of biliary obstruction. One of the patients who failed PM was re-transplanted due to graft failure secondary to hepatic artery occlusion. The other two were surgically revised. The average number of dilatation sessions is 4.4 (2-9). The median age at first pm is 2.9 years (1-10). 13 patients were male and 6 were female.16 post living donor and 3 post cadaveric liver transplant. One patient has duct-to-duct anastomosis and the remaining has hepatico-jejunostomy. The median time from LT to first pm was 9.4 months (1-26). No complications were encountered. Conclusion(s): Pm of post liver transplant biliary strictures is safe and has very high success rate and surgery should be reserved for patients who have failed PM.

  P306: Ultrasound Guided Needle Lavage in Supraspinatus Calcifying Tendinopathy Top

Pokhraj Prakashchandra Suthar, Hemen I. Vithlani, Chirag Patel1

Sterling Hospitals, 1Parul Institute of Medical Sciences and Research Parul Sevashram Hospital, Vadodara, Gujarat, India. E-mail: [email protected]

Background: Calcifying tendinopathy of shoulder (CFT) is caused by deposition of hydroxyapatite crystal inside rotator cuff tendons. It most commonly affect supraspinatus, infraspinatus and subscapularis tendon. The calcifying tendinpathy is treated with percutaneous needle lavage under ultrasound guidance. Study was conducted to evaluate the role of ultrasound guided treatment in the supraspinatus calcifying tendinopathy. Method(s): This is a retrospective study which included 30 patients with chronic shoulder pain who had calcifying tendinopathy.30 patients were underwent 50 percutaneous lavage between June 2017 to June 2018. Patients were followed up at 10 weeks. If symptoms persisted and calcification persistent on x ray and/or ultrasound; reintervention was performed. Result(s): 1 mm decreased in calcification width between shoulder x-rays performed before and after treatment, was associated with decrease in need of re-intervention probability by 20 %. Increased probability of re-interventionism is associated with well-defined acoustic shadow on ultrasound. Conclusion(s): Significant differences were found in calcification thickness/width, opacity change and type of acoustic shadow of supraspinatus calcifying tendinopathy after the intervention.

  P307: Egyptian Females in Interventional Radiology Field: A Different Experience at Ain Shams University Hospital Top

Rana Tarek Mohamed Khafagy

Ain Shams University, Cairo, Egypt. E-mail: [email protected]

Background: Though the prevalence of female radiologists has increased in the past few decades, many countries still suffers from shortage of females in the IR field. This study discusses survey findings about the prevalence of female IRs in Egypt and describes the female IRs’ special experience at Ain Shams University Hospital in Cairo. Method(s): Telephone surveys were conducted with the head of IR departments in the largest 19 medical institutes in Egypt to determine the no. of females and the work system in their departments. Another survey was conducted with female radiology residents and fellows at Ain Shams University hospital in random fashion. The survey involved questions about marital and parental status, experiences in training and the reasons for joining this field. Result(s): .9 % (6 out of 101) of IR consultants,11.7% (10 out of 85) of IR fellows and 34.4% (21 out 61) of IR residents, in the surveyed 19 institutes representing Egypt, were females. 25.2% (24 out of 95) of IR consultants,28.2 % (24 out of 85) of IR fellows and 39.3 % (24 out of 61) of IR residents in Egypt were counted at Ain Shams University hospital where females make up 54 % (13 out of 24) of the IR residents and 25% (6 out of 24) of the IR fellows with no counted female IR consultants.30 surveys were completed with female radiologists at Ain Shams University hospital revealing an increase in their share in the IR field due to many reasons. Conclusion(s): Though the fact that many countries suffers from shortage of females in the IR field, the IR unit at Ain Shams University Hospitals is starting to show a different experience on the residents and fellows’ level and consequently on the consultant’s level in the near future.

  P308: Computed Tomography-Guided Biopsy in Vertebral Osteomyelitis Top

Jingyu Zhou, Kiyon Naser-Tavakolian, Michael Clifton, Isael Perez, Valmore Suprenant

Stony Brook University Hospital, Stony Brook, USA. E-mail: [email protected]

Background: Patients with suspected vertebral osteomyelitis routinely undergo a biopsy procedure early in their admission. Our goal is to assess the utility of surgical pathology and other clinical factors in guiding treatment of vertebral osteomyelitis. Method(s): This was an IRB-approved retrospective review of CT-guided core biopsies for suspected vertebral osteomyelitis. 67 patients met our inclusion criteria. A chart review was performed for the following clinical factors to determine their impact on antibiotic regimen changes: microbiological cultures, presence of paravertebral abscess/phlegmon, fever, elevated erythrocyte sedimentation rate (ESR), elevated C-reactive protein, and an elevated white blood cell count. Results were analyzed using SPSS (version 25, IBM), p-values were obtained using a Chi-squared test. Result(s): Of the 69 biopsied cases of vertebral osteomyelitis, 26 cases (38%) yielded positive cultures. Among the group of positive cultures, 16 (62%) of the biopsies contributed new information, isolating either a new or different organism. In the cases with positive cultures, 15 (58%) had changes in their empiric antibiotics (p < 0.001). A change in empiric antibiotic coverage was seen in 3 patients with negative biopsy cultures. 24 patients had a paravertebral abscess or phlegmon described in the pre-biopsy MRI. In this subset of patients with paravertebral abscesses or phlegmon, a positive biopsy culture was seen in 16 (66%) patients (p < 0.001). 10 patients who had positive cultures did not have a paravertebral abscess or phlegmonous changes. In addition, no significant association was noted with changes in antibiotic regimen in the presence of a fever, leukocytosis, elevated ESR or CRP. Conclusion(s): Although CT-guided vertebral core biopsies are relatively low yield, they often provide results that are clinically relevant for proper treatment. Positive culture results contribute pertinent information and aid in identifying the most efficacious antibiotic(s) for clinicians to formulate a successful treatment plan.

  P401: Splenic Artery Embolization: When and How to Do It? Top

Amit Kumar Verma, Stephen Edward Ryan, Ashish Gupta, Adnan Hadziomerovic, Karl Smyth, Rima Aina, Pasteur Rasuli

The Ottawa Hospital, University of Ottawa, Ottawa, Canada. E-mail: [email protected]

Background: Splenic artery embolization is an interventional treatment used to stop active bleeding in blunt splenic trauma. It is also commonly used as a prophylactic measure adjuvant to other treatments in various clinical situations to promote splenic salvage and non-operative management. The aim of this presentation is to give an overview of rationale to indications, patient selection and procedural technicalities in splenic artery embolization. Method(s): A thorough literature review was done on splenic artery embolization in blunt splenic trauma as well as non-traumatic conditions. The content was reviewed for various indications, the rationale for patient selection and use of this treatment as prophylactic or adjuvant measures to medical treatment along with its long-term effect in non-operative management. Experience of our institutional practice for this novel treatment was also added. Result(s): Blunt splenic trauma American Association for the Surgery of Trauma Grade (AAST) IV-V, is amongst most common indications for splenic artery embolization. Patient selection in AAST Grade III splenic injury is variable depending on associated findings (hemoperitoneum, active contrast blush, Pseudoaneurysm, fistula etc.), treating interventionist and trauma unit. Other indications include portal hypertension, Idiopathic thrombocytopenic purpura, Hypersplenism, thalassemia and splenic artery aneurysm with the risk of rupture. Partial versus total embolization, proximal versus distal embolization and choice of embolizing agents is variable amongst the treating interventionist depending on the indication and aim of embolization. Splenic infarction with secondary infection/abscess and non-targeted embolization are amongst the more severe, though less common complications. Conclusion(s): Splenic artery embolization is a procedure to enhance the success rate of organ salvage and non-operative management of blunt splenic trauma (AAST Grade III and above). It is also a good adjuvant measure to improve the hepatic function and variceal bleeding in portal hypertension as well as improve blood counts in various cytopenic conditions.

  P402: Comparative Study between Conventional Surgery and Radiofrequency Ablation in Treatment of Varicose Vein Top

Mohamed Ismail, Moustafa Aborahma

Ain Shams University, Cairo, Egypt. E-mail: [email protected]

Background: Varicose veins are a very common problem all over the world. Surgery has been the gold standard treatment for many years, however now other less invasive options are available and sometimes more efficient. Method(s): This observational retrospective study included 41 patients with varicose vein recruited from general surgery department and vascular surgery unit at Ain Shams Hospitals and in Nasser Institute for Research and Treatment. Result(s): Operative time was significantly less in CS compared to RFA. One, six and twelve months post intervention follow up using clinical examination and duplex imaging were used to asses outcome and detect complications and recurrence rate. No major complications were detected after both techniques; however minor post operative complications like paresthesia and ecchymosis were significantly less after RFA. Post operative pain, duration of analgesia use and time needed to return to normal activity were also significantly less in RFA group than CS group. Recanalization of GSV was not detected after radiofrequency maneuver nor CS. This study proved that radiofrequency ablation technique is a safe and efficient in treating varicose veins however long-term results and cost effectiveness need further evaluation. Conclusion(s): Conventional surgery has been used for a long time for treatment of varicose veins with variable degrees of minor to major complications. Duplex guided radiofrequency ablation is an efficient and a safe modality in the treatment of great saphenous vein varicosities. Of most importance is an adequate Duplex scan to identify accessory channels and double superficial systems.

  P403: Angiographic Findings and Outcomes of Bronchial Artery Embolization for Hemoptysis Due to Tuberculosis Top

Orkun Sarioglu, Ahmet Ergin Capar, Melike Yuksel Yavuz1, Umit Belet

Department of Radiology, University of Health Sciences, Tepecik Educational and Research Hospital, 1Department of Chest Diseases, İzmir Dr. Suat Seren Chest Diseases and Surgery Training and Research Hospital, Izmir, Turkey. E-mail: [email protected]

Background: Hemoptysis is a common, important and sometimes life-threatening symptom. The causes of hemoptysis vary significantly between the developed and non-developed countries. In non-developed countries, tuberculosis remains the most frequent cause of massive hemoptysis. Management of hemoptysis include conservative treatment, surgery and bronchial artery embolization (BAE). Since Remy et al. first described BAE for the management of hemoptysis, several studies have declared the efficacy of BAE in tuberculosis patients. The aim of this study was to evaluate angiographic findings during BAE in tuberculosis patients and to compare them with non-tuberculosis patients. Method(s): Patients who underwent BAE between August 2015 and July 2018 in a single interventional radiology department with hemoptysis refractory to medical and bronchoscopic treatment were reviewed. A total of 89 patients (66 male and 23 female; mean age 52.71 ± 15.37) were incorporated in the study. Patients were divided into two groups: tuberculosis group (n = 36) and non-tuberculosis group (16 malignancy, 22 bronchiectasis, 6 pulmonary infection, 4 chronic obstructive pulmonary disease, 4 idiopathic, 1 pulmonary arteriovenous malformation; n = 53). Angiography and embolization procedure were performed by a 5-year, 10-year, and 20-year experienced interventional radiologists with a classical method. Angiographic findings were classified as tortuosity, hypertrophy, hypervascularity, aneurysm, bronchopulmonary shunt, extravasation, and normal bronchial artery. Chi square test was used to compare angiographic findings between tuberculosis and non-tuberculosis patient group. Result(s): The most common angiographic findings in tuberculosis patients were tortuosity (%97.2) as well as hypervascularity (%97.2). Extravasation was seen in only one patient (%2.7). Bronchopulmonary shunt was found significantly higher in tuberculosis patients compared to non-tuberculosis group (p = 0.002). None of the groups showed statistically significant difference in respect to recurrence (p = 0.436). Conclusion(s): BAE is a useful and effective treatment method of hemoptysis in tuberculosis. Bronchopulmonary shunt was seemed to be significantly higher in tuberculosis patients.

  P404: Outcomes of Type II Endoleak Treatment using High Volume Ethylene Vinyl Alcohol Copolymer (ONYX®) Top

Umar Tariq, Brandon Nuckles, Fatima Memon1, Ravi Kagali11, Vinod Maller2, Tariq Rahman, Evan Ryer, Luis L. Nadal

Geisinger Medical Center, Danville, 1Wayne State University/ Detroit Medical Center, Detroit, 2University of Tennessee Health Science Center, Memphis, USA. E-mail: [email protected]

Background: We aim to report our experience with Onyx®, (ethylene vinyl alcohol copolymer) for embolization of type 2 endoleak (T2E) after endovascular repair of abdominal aortic aneurysms (EVAR). Method(s): Endoleak repairs using Onyx performed from 2010 to 2016, as part of clinical management were retrospectively reviewed. Technical success (TS) was defined as absence of fluoroscopic evidence of endoleak at the termination of procedure. Clinical failure (CF) was defined as increase in sac diameter greater than 5 mm or increase in sac volume greater than 10% on follow-up computed tomography angiography (CTA), at least 3 months post-procedure or more. Absence of CF was deemed clinical success (CS). Student’s t-test was used for statistical analysis. A p value of less than 0.05 was defined to be statistically significant. Result(s): A total of 13 patients (mean age 77 years, 12 males and 1 female) underwent persistent T2E repair following EVAR at our institution in a duration of 6 years. Mean interval between EVAR and endoleak repair was 40.7 months. Translumbar access was used in all patients. The mean volume of Onyx used per treatment was 13.4 mL. Additional targeted coil embolization of a feeding inferior mesenteric artery was performed in one patient. TS and CS was achieved in all patients; none of the patients had CF. Mean pre-treatment diameter and volume were 73 mm and 340 cc respectively. Mean post-treatment diameter and volume were 71 mm and 320 cc respectively. There was a trend towards decreased diameter and improved volume post-treatment, however it did not reach statistical significance (p = 0.11). There were no major postprocedural complications. Conclusion(s): Our study presents the clinical outcome of the use of Onyx as the main treatment modality on patients with T2E after EVAR. Onyx with or without coils is safe and effective in treatment of T2E after EVAR.

  P405: Endovascular Management of Traumatic Thoracic Aorta Injury Top

Ziadi Jalel, Chatti Sana, Derbel Bilel, Melek Ben Mrad, Faker Ghedira, Raouf Denguir

La Rabta Hospital, Tunis, Tunisia. E-mail: [email protected]

Background: Acute traumatic rupture of the descending thoracic aorta is a life-threatening situation. Endovascular technique offers a minimal invasive alternative compared to open surgical repair, thereby reducing morbidity and mortality. The aim of this study is to evaluate the early outcomes of patients undergoing thoracic endovascular aortic repair for blunt aortic isthmus injury. Method(s): Between January 2009 and October 2018, 52 patients with acute traumatic rupture of the descending thoracic aorta were treated with a stent-graft. Preoperative workup included body computed tomography scan for all patients. The endovascular management was selected because of associated polytrauma. The injuries were classified into categories (grades I-IV) based on severity: intimal tear, intramural hematoma, pseudo aneurysm, or rupture. Result(s): Ninety-two percent (23/2) of patients were male with mean age of 38.4 (range 16-78) years. Thoracic stent grafts were implanted within a median of 5 days following injury (range 01-15 days). Seventy-two percent of aortic injuries were grade III. Mean injury severity score was 29 (range 16-61). The left subclavian artery was completely covered in70% of patients. One patients underwent staged procedure: left carotid artery and subclavian artery revascularization then endograft procedure; due to a retrograde dissection involving the origin of the left carotid artery. The median procedure time was 50 minutes, and median hospital stay was 8.9 days. There was 100% successful device delivery and deployment. The postoperative course was uneventful, especially no upper limb ischemia or neurologic complication. No procedure-related deaths have occurred and no cardiac or peripheral vascular complications were observed within the 12 months (range 6-16 months) follow-up. Computed tomography at one month showed in one patient a complete coverage of the left carotid artery by the stent graft without any clinical consequence, and in one patient endoleak type 3. Conclusion(s): Thoracic endovascular aortic repair in treatment of blunt thoracic aortic injuries showed a good early outcome. It is considered the new gold standard treatment. Dealing with young patient represents the big challenge.

  P406: Vena Cava Filter Deployment Prior to Percutaneous Endovenous Therapy for Proximal Lower Limb Deep Venous Thrombosis: Should we Routinely Practice? Top

Mohamed Ismail, Ahmed Khairy1

Ain Shams University, 1Benha University, Cairo, Egypt. E-mail: [email protected]

Background: Anticoagulant therapy remains the prevalent treatment for venous thromboembolism (VTE). In the new era of percutaneous endovenous intervention, there is a progressive raise in the use of percutaneous endoluminal clot dissolution techniques as catheter directed thrombolysis (CDT) and mechanical aspiration thrombectomy (MAT) devices due to its established shortterm benefits. Prophylactic Deployment of inferior vena cava (IVC) filter during percutaneous endovenous therapy for lower extremities deep venous thrombosis (DVT) is still debatable issue. Method(s): Percutaneous endoluminal clot dissolution using either CDT or MAT for proximal lower extremity DVT was performed on 64 limbs in 58 patients of 148 patients diagnosed with proximal acute / subacute DVT in vascular surgery department of study hospitals. IVC filter was deployed in 31 patients prior or during the procedure. Result(s): From 58 patients were treated for proximal DVT with clot debulking procedures, IVC filter was prophylactically deployed in 30 patients (51.7%). Trapped thrombus in the deployed filters as revealed on venocavography was observed in 8/30 (26.7%) filters deployed prophylactically with overall rate of thrombus embolization during percutaneous endovenous thrombus dissolution techniques was 11/58 patients (18.9%). Conclusion(s): Catheter directed thrombolysis could be done safely and effectively without routine prophylactic IVC filter placement in treating acute DVT. Selective filter placement may be considered in patients undergoing mechanical thrombectomy or patients with more proximal thrombus pattern with multiple risk factors.

  P407: Preoperative Embolization of Renal cell Carcinoma Femoral Mets with Pathological Fracture: Case Series Top

Aliya Sharif, Aman Nawaz Khan, Ummara Siddique Umer, Shahjehan Alam, Syed Ghulam Ghaus, Seema Gul, Hadia Abid, Abdullah Safi, Kalsoom Nawab

Rehman Medical Institute Peshawar, Peshawar, Pakistan. E-mail: [email protected]

Background: Renal cell carcinoma (RCC) accounts for 3% of all cancers, with peak incidence between 60 and 70 years of age. RCC is very aggressive tumour and almost 20-30% of patients have metastatic disease at time of presentation. Most common metastasis in RCC occurs to lung, followed by bone, lymph nodes, liver, adrenal gland and brain. Skeletal metastasis may present with pain, impending fractures, nerve compressions, hyperkalemia and even pathological fracture which may require surgical interventions. As RCC is normally a hypervascular tumor, seen in 65%–75% of patients that bleed profusely even after a simple biopsy. We present here two cases of Renal cell carcinoma metastasized to femur with pathological fracturs and were pre-operatively embolized and then underwent operation fixation with minimal blood loss. Method(s): Angiography and embolization was done using state of art, digital substraction angiography unit (Siemens artis zee floor mounted), under local anesthesia by a single interventional radiologist with experience of more than 10 years. Transfemoral route was used in both cases. Access was gained through 5-6 Fr cathether and combination of gelfoam particles and tornado coils were used for embolization. No immediate post operative complications observed. Result(s): At our institution, embolization of femoral metastasis showed high technical success and reduced intraoperative blood loss. Conclusion(s): At our institution, embolization of femoral metastasis showed high technical success and reduced intraoperative blood loss, in keeping with published series from across the world. Preoperative embolization of hypervascular tumour /metastases should be considered to decrease intraoperative blood loss.

  P408: Femoropopliteal Angioplasty: Short and Mid-Term Results: Results of a Cohort of 270 Cases Top

Ben Mrad Melek, Ziadi Jalel1,2, Gdira Faker1,2, Miri Rim1,2, Kalfat Taoufik1,2, Denguir Raouef1,2

Departement of Cardiovascular, La Rabta Hospital of Tunis, 1Faculty of Medicine, Tunis, 2University Tunis, El Manar, Tunis, Tunisia. E-mail: [email protected]

Background: Percutaneous endovascular therapy is becoming a primary option for managing femoropopliteal occlusive disease. The purpose of this study was to evaluate the mid-term results of endovascular treatment of femoropopliteal arterial disease and to identify predictor factors for success. Method(s): Records and observations of patients having had a femoropolitteal angioplasty procedure between January 2012 and January 2018 were studied. Inclusion criteria – Femoropopliteal angioplasty performed for stenosing and / or occlusive atheromatous lesions. Exclusion criteria: (1) Associated supra-crural surgery. (2) Aneurysmal pathology. (3) Absence of angiographic exploration. Result(s): Femoropopliteal percutaneous transluminal angioplasty was performed on 270 consecutive limbs (265 patients). The average age of our patients was 62.2 In our study, 87.6% of patients had critical limb ischemia. Lesions were classified as Trans-Atlantic Inter-Society Consensus (TASC) A (43%), B (43%), C (7%), and D (7%). Femoropopliteal interventions included simple balloon angioplasty in 117 cases (43.2%), and use of at least one stent for the the remaining 153 cases (56.8%). Technical success was achieved in 98.7% of patients. We recorded three deaths and a major morbidity rate was 15%. The actuarial primary patency at 12 and 36 months was 65.4% and 40.2%, respectively. The actuarial primary limb preservation rate was 94.4 % at 12 months. Comparison between simple balloon angioplasty and the use of primary stenting show no difference in patency (P = 0.832) and limb salvage (P = 0.67). Negative predictors of primary patency determined by univariate analysis included popliteal location (P < 0.001) and TASC D (P < 0.001). However, diabetes mellitus (P = 0.001) and poor run off (P < 0.001) were the principal predictive factors of limb loss. Conclusion(s): Femoropopliteal angioplasty can be performed with a low morbidity and mortality. Intermediate primary patency is directly related to TASC classification and popliteal localization. Primary stenting dosen’t improve permeability and limb salvage.

  P409: Percutaneous Revascularization Aq4 as a Feasible Option for Complex Aortoiliac Occlusive Disease with Fair 1-Year Outcome Top

Ahmed Khairy Allam, Atef Abd Elghany Salem, Ahmed Kamal Gabr1

Benha University, Benha, 1Ain Shams University, Cairo, Egypt. E-mail: [email protected]

Background: Aortoiliac arterial occlusive disease (AIOD) is one of the commonest patterns of systemic atherosclerosis with a spectrum of chronic symptoms from intermittent claudication to critical limb ischemia, which is a common therapeutic challenge. A meaningful shift has evolved in treating symptomatic AIOD from open to endovascular repair, which are becoming an attractive treatment option even in complex lesions, especially in patients with considerable risk. The aim of this study was to assess the feasibility, that is, technical success rates, primary patency, and safety outcome for Trans-Atlantic Inter-Society Consensus (TASC) D lesions treated endovascularly with analysis of outcome of stent graft versus bare metal stent in patients with advanced Leriche syndrome. Method(s): A prospective case series study: over 30 months, our case study was conducted on 22 patients with TASC D lesion morphology undergoing treatment for symptomatic chronic AIOD at the Vascular Unit, General Surgery Department, Benha University Hospitals, Vascular Surgery Department, Nile Insurance Hospital and Vascular Surgery Department, Security Forces Hospital and Al-Noor Specialist Hospital, Makkah, Saudi Arabia. The patients were enrolled from April 2015 until October 2016 with a 12-month follow-up period from the last patient enrolled. SPSS, version AQ8 20.0 for Windows was used for statistical analysis. Result(s): Our study had a technical success rate of 95.5% in crossing TASC D lesion with immediate angiographic success (91%). The 12-month primary patency rate was 85% for TASC D lesions with a target lesion revascularization of 15%. Stent grafts had a higher 1-year patency rate (91.7%) versus bare metal stent (75%). The total procedure-related complications rate was 18.1% and 30 days procedure-related mortality was 4.7%. Conclusion(s): Our study shows that technical success of endovascular therapy for TASC D lesions was 95.5% with a 1-year primary patency of 85% and a complication rate of 22.7% in TASC D lesions. Utilizing more than one access with antegrade crossing the lesion through brachial access was paramount for technical success. Long-term follow-up is mandatory to support the durability of the procedure.

  P410: Extra-Hepatic Collateral Supply to Hepatocellular Carcinoma: What a Radiologist Should Know Top

Shivanand Gamanagatti, Shalimar, Shashi Paul, Abhishek Arora, Arunkumar Gupta

All India Institute of Medical Sciences, New Delhi, India. E-mail: [email protected]

Background: Trans-arterial Chemo-embolization (TACE) is the most widely used palliative treatment for intermediate stage HCC. Presence of arterial supply of HCC other than the normal supply from hepatic artery, is termed extrahepatic collateral supply (ECS). If ECS is present, TACE must be done through ECS also, for achieving complete tumor response. Method(s): (1) To know the prevalence, sources and significance of extracapsular collateral supply (ECS) in hepatocellular carcinoma (HCC). (2) To understand the signs suggesting ECS before, during and after TACE. Result(s): At initial presentation, prevalence of ECS is 10-15%, however it increases as the number of TACE sessions increases. Common sources of ECS include inferior phrenic, omental, cystic, adrenal, intercostal, internal mammary, renal, superior mesenteric and gastroduodenal arteries. Suspect ECS in large subcapsular tumors with exophytic growth, adjacent organ invasion, hypertrophied extrahepatic collaterals and marginal recurrence abutting the liver capsule after TACE or local ablation. During TACE, no or incomplete tumor blush on selective hepatic arterial run, or defect in lipiodol deposition in the mass suggest ECS. Search for ECS is mandatory if follow up imaging shows peripheral defect in lipiodol deposition or enhancing residual component of primary mass. An alternative treatment should be undertaken if TACE through ECS fails. Conclusion(s): ECS is common in HCC at initial presentation and increases with repeated TACE sessions. For achieving complete tumor response, active search for signs of ECS should be done before, during and after TACE.

  P411: Crush Stent Technique: A New Approach for Occluded Iliac Stent Top

Ben Mrad Melek, Ben Hammamia Mohamed1, Miri Rim1, Gdira Faker1, Denguir Raouef1

Departement of Cardiovascular, La Rabta Hospital of Tunis, 1Faculty of Medecine, University of Tunis El Manar, Tunis, Tunisia. E-mail: [email protected]

Background: Iliac stent thrombosis is problematic. Surgery is often indicated because endovascular recanalization of the occluded stent is difficult. Some interventional cardiologists described a new technique to manage occlusion of coronary stent, the “Crush stent technique” consist on subintimal recanalization and swatting of the “old stent”. The aim of this report was to demonstrate the feasibility and safety of this technique also for iliac artery. Method(s): A 55 years old woman was admitted in our department for a critical lower limb ischemia due to thrombosis of left common iliac stent implanted 2 years earlier for claudication. The ankle-brachial index was 0.5. Our initial strategy was to cross intraluminally the occlusion and to use a drug-eluting balloon. However, we failed to achieve an intraluminally stent recanalization, so we performed a subintimal recanalization of the occluded stent. The wire crossed the occlusion completely outside stent through the subintimal space. Firstly, we performed a balloon angioplasty, a 7 mm balloon was inflated at eight ATM pressure and contributed in crushing of the thrombosed stent. Therefore, we deployed an 8 x 80 mm Wall-Stent (Boston Scientific), covering all the common and external iliac artery. Result(s): Final angiography was satisfactory showing a patent iliac conduit with a total flattering of the old stent. Post operative course was favorable with symptomatic relieve, the left ankle-brachial index was improved to 0.85 and duplex ultrasound showed patency of the wall stent at 1 and 6 months. There was no hemodynamic disturbance particularly at the site of the subintimal crush. Conclusion(s): Crush stent technique is not only feasible for coronary stent thrombosis but can also be performed for peripheral arterial stent thrombosis especially when intraluminally stent recanalization cannot be achieved. In our knowledge, it is the first report in the literature of a “crushed stent” technique for a thrombosed iliac stent.

  P412: Uterine Artery Embolization for the Symptomatic Adenomyosis: Short-Term Follow up using Uterine Fibroid Symptom Quality of Life Questionnaire Top

Ibrahim Alrashidi, Faisal Alahmari1, Hayat Matouk Alharthy1, Abdulaziz Almat’hami1, Abdulwaheed Alruhaimi1, Abdulrahman Alkhalifa1, Fares Garad1

Prince Sultan Military Hospital, 1Ministry of Health, King Fahad General Hospital, Riyadh, Saudi Arabia. E-mail: [email protected]

Background: The purpose of this study was to assess clinical outcomes 3 months after uterine artery embolization (UAE) in the treatment of symptomatic adenomyosis. Method(s): in this prospective cohort study, at Prince Sultan Military Medical City recruited patients with symptomatic adenomyosis for UAE. The 3 months’ post-intervention outcomes were health-related quality of life (HRQOL), symptom severity scores (SSS). Result(s): Eighteen patients with adenomyosis have more than 12 mm thickening of the junctional zone based on MRI imaging (11 with Fibroids are excluded) were treated with UAE between January 2012- April 2018. The 3 months’ questionnaire was interviewed in 7 patients. The median age of 47 (28-55). The main clinical presentation was abnormal uterine bleeding and Dysmenorrhea. The median duration of symptom is 24 (12-84) months. A 71.4 % of patients received hormonal therapy prior to intervention. The median hemoglobin pre and post-intervention 11.5 and 12.6 respectively. A 28.6 % of patients received blood transfusion pre-UAE. No patient underwent a secondary hysterectomy during the follow-up period. The HRQOL and SSS scores as measured by UFS-QOL at 3 months after UAE showed The score for distress level has been significantly reduced (Z value= -2.366, p value=0.018) from baseline 4.6 (3.6-5) to after 3 months 2.25 (1-3.37). As well as, the score of symptoms level has been significantly reduced Z value= -2.366, p value=0.018) from baseline 4 (3.6-5) to after 3 months 1.6 (1-3.58). Conclusion(s): After 3 months of follow-up, UAE improved the distress and symptom of the selected patients with adenomyosis, however larger number of patients and longer duration of follow-up is recommended to support the UAE for the management symptomatic adenomyosis.

  P413: Balloon Occlusion of Internal Iliac Arteries in Management of Morbidly Adherent Placenta: Initial Experience at Our Centre Top

Ummara Siddique, Aman Nawaz Khan, Shahjehan Alam, Syed Ghulam Ghaus, Seema Gul

Rehman Medical Institute, Peshawar, Pakistan. E-mail: [email protected]

Background: Abnormal placentation is a potential cause of maternal morbidity and mortality from massive postpartum bleeding. Interventional radiology has impressive role in management of various obstetrical emergencies. Pelvic arterial embolization has added a new dimension in the management of obstetric hemorrhage. Method(s): This is a retrospective study conducted at radiology and gynecology departments of Rehman Medical Institute Peshawar. We retrospectively studied eleven cases over a period of two years from May 2015 to May 2017 and patients were diagnosed of having morbidly adherent placenta during antenatal period either by ultrasound or magnetic resonance imaging (MRI). The mean gestational age at presentation was 36 weeks. All patients were in age group of 30-36 yrs with mean age of +33.37 yrs. All were multiparous with a mean parity of +4-5. Previous Cesarean Section delivery was the major independent risk factor in most of the cases. About 60% cases were diagnosed during antenatal checkup and in most of the cases the placenta were type IV Placenta previa. Patients were divided into two groups. 5 patients were managed by conventional treatment (conventional group). In 6 cases, interventional radiologist was involved for trans-catheter arterial balloon occlusion balloon occlusion (study group). The internal iliac balloons were inserted pre-operatively and arterial occlusion was done just after the delivery and in one case additional uterine artery embolization was done post-operatively. In Conventional treatment, no prophylactic temporary balloon occlusion was done and patients were treated by either removal of placenta and oversewing of the placental bed or caesarean hysterectomy. One patient presented postoperatively with placenta in situ and septicemia. Result(s): The results of the two groups were compared taking different variables into account. In comparing the operating time the mean operating time in conventional group was +2.37 hr and that in interventional group was +1.25 hr with a total increase of approx.1.12 hr, which is quiet significant. The average blood loss was 962 ml more in conventional group (mean 2037 ml vs 1075 ml) and consequently increased transfusion of blood (mean+6.5 packs vs. 2.25 packs i.e 4.25 packs more). In our comparative study platelets and fresh frozen plasma (FFP) was exclusively needed in conventional group. Mean stay in intensive care unit (ICU) was more in conventional group with a mean of 2.7 days as compared to 1 day in interventional group. In 2 cases there was per-operative injury to surrounding structures attributed to difficult obstetric emergency and excessive blood loss. In one case the patient had ureteric injury and in other case there was bladder injury. In interventional group, not even a single case of damage to surrounding structure was noted, which can be partly attributed to less stress of the surgeon due to comparatively better hemodynamic stability of patient and partly due to clear field of the surgeon. Conclusion(s): We conclude that use of per-operative arterial occlusive balloons for managing morbidly adherent placenta at our center showed good initial results with decreased patient morbidity.

Keywords: Intra-arterial occlusive balloons, morbidly adherent placenta, placenta accreta, placenta increta, placenta percreta

  P414: Aspiration Thrombectomy for Acute Deep Vein Thrombosis of the Left Lower Extremity of a Child after Cardiac Radiofrequency Ablation Top

Maria Antonella Ruffino, Maria Antonella Ruffino, Marco Fronda1, Andrea Discalzi, Pierluigi Muratore, Dorico Righi, Paolo Fonio1

Department of Diagnostic Imaging and Radiotherapy, Vascular Radiology, A.O.U. Citta della Salute e della Scienza di Torino, 1Department of Surgical Sciences, Radiology Unit, University of Torino, Torino, Italy. E-mail: [email protected]

Background: Deep vein thrombosis (DVT) of the lower extremity is rare in children and most of them or history of CVC placement. The therapy includes anticoagulation, systemic thrombolysis and, in rare cases, thrombectomy. Systemic thrombolysis with TPA has been used to treat patients who do not respond to anticoagulation and those with extensive DVT. Thrombo-aspiration with penumbra/Indigo System is a safe and effective treatment for adult patient with ALI, PE, and AVF thrombosis. We report of the case of an adolescent with DVT in the left lower extremity who underwent thrombo-aspiration with Indigo System. Method(s): A 14-year-old boy, with previous RFA for wolff-parkinson-white syndrome, with DVT of left popliteal, superficial, common femoral, and iliac veins not responding to anticoagulation underwent thrombo-aspiration with indigo system. After US-guided puncture of the popliteal vein, the dilator (3f) of a micropuncture set kit was positioned. An 0.018 guidewire was advanced along the venous axis, and the dilator was changed for an 8f sheath. Before starting the aspiration, a removable caval filter was positioned. Venography after the aspiration revealed partial recanalization of the left venous axis. Locoregional thrombolysis was performed with 0.6 mg of TPA. There were not complications during any phase of treatment. Anticoagulant therapy was administered. Result(s): One week after the procedure, the swelling of the left lower extremity had resolved completely. Caval filter was removed three months later. Duplex us at 1, 3 and 6 months confirmed recanalization of popliteal, common femoral and iliac veins and only residual thrombosis of the superficial femoral vein. The patient had no symptoms. Conclusion(s): DVT mechanical aspiration can be safe and effective to treat acute DVT of the lower extremity in older children and adolescents. Thrombo-aspiration before thrombolysis helps to decrease the thrombus burden, improve outflow for effective thrombolysis, and reduce the dose of thrombolytic required.

  P415: Parastomal Bleeding Embolization Technique Top

Sultan R. Alharbi

King Saud University, Riyadh, Saudi Arabia. E-mail: [email protected]

Background: In this poster presentation we describe and illustrate parastomal bleeding embolization technique in two cases. one case we did direct percutaneous and other case we use trans-hepatic approach. in this poster we also explain why we use direct percutaneous or trans-hepatic approach. Both cases were technically and clinically successful without complication. Method(s): N/A. Result(s): N/A. Conclusion(s): N/A.

  P416: Tips and Tricks in Chimney-Graft Technique Endovascular Repair: Steps for Successful Outcome Top

Samer Koussayer

King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia. E-mail: [email protected]

Background: ChEVAR becoming very popular option to treat juxtarenal AAA in emergency or urgent situation. The technique is very diverse and this result in conflict data about the outcome and the rate of type 1 endoleak. Method(s): In this presentation i will review the steps and tricks in ChEVAR deployment for best outcome and review literature comparing ChEVAR with FEVAR. Result(s): Chevar has very good outcome with very low rate of type 1 endoleake if carried out in standard technique. These results are very comparable with FEVAR. Conclusion(s): Chevar is an alternative technique to treat juxtarenal AAA especially in emergency situation and it carry very low rate of type 1 endoleak if deployed correctly.

  P417: The Effect of Partial Ѕplenic Arterial Embolization in the Control of Hypersplenism Top

Mohamed Haroun Hassan Ibrahim, Ѕhrief Hamed Mοѕtafa Abοgamra

Ain-Shams University Hospitals, Cairo, Egypt. E-mail: [email protected]

Background: The uѕe οf splenic artery embolization iѕ uѕed fοr the intentional infarctiοn οf ѕplenic tiѕѕueѕ tο reduce their cοnѕumptive activity. Method(s): Fifteen patients with hyperѕpleniѕm due to chronic liver disease were included. This was a prospective study that included patients with thrombocytopenia (platelet count <70.000) who referred from the Tropical Department to the Interventional Radiology Unit for partial splenic arterial embolization. Partial splenic arterial embolization was performed to reduce the hyperfunction of the spleen in patient with hypersplenism. Result(s): The mean age of the selected patients was about 48 years old. The most common cause of hypersplenism is chronic liver disease due to HCV infection in 12 patients (80%), bilharzial disease in 2 patients (13%) and mixed HCV and bilharzial infection in 1 patient (7%). The most frequent risk factors were past history of blood transfusion in 7 patients (47%), past history of surgery in 5 patients (33%), and past history of parentral antibilharzial treatment in 3 patients (20%). Bleeding tendency was found in 15 patients (100%), while abdominal pain was found in 12 patients (80%). As regard other symptoms, lower limb swelling and abdominal enlargement were noticed in 30% and 20% of patients respectively, anemic manifestations and recurrent infection were noticed in 53% and 47% of patients respectively. Post embolization syndrome was the most common complication and occurred in all patients (100%). Newly developed aѕciteѕ occurred in 2 patients (13%). Ѕplenic abscess was developed in 2 patients (13%). No other complications had been reported. Conclusion(s): Partial splenic arterial embolization is an effective method for the treatment of thrombocytopenia resulting from hypersplenism in patients with liver cirrhosis; however, the procedure is associated with complications, and hence must be performed only if clearly indicated and by an expert person.

  P418: My Escape Through Chimney Top

Yasir Khattak, Ayman Al Sibaie

Rashid Hospital, Dubai, UAE. E-mail: [email protected]

Background: Open Repair (OR) remains the “gold standard” for treatment of AAAs and Juxtarenal Aneurysms (JAAA), although there is an increased morbidity and mortality rate, longer operating time, and higher need for transfusions. Endovascular repair (EVAR) offers an alternative as it obviates the need for extensive surgical dissection. Fenestrated EVAR (f-EVAR) devices are used in JAAA to overcome the insufficient neck length resulting in inadequate sealing of standard endografts. Chimney-graft technique EVAR (Ch-EVAR) has been employed to preserve the visceral aortic branches, deploying a stent parallel to the aortic endograft allowing the sealing in a healthier aortic zone. A recent review of the Ch-EVAR showed promising results in terms of morbidity, mortality, and durability at 6 and 12 months follow-up. Method(s): We present a unique case of a juxtarenal AAA (J-IAAA) with contained leak in the presence of an indwelling aortic stent with disintegration and kinkage of stent successfully treated with Ch-EVAR. Result(s): Patient was successfully treated with EVAR and bilateral renal artery chimney-grafts (Ch-EVAR). Conclusion(s): Ch-EVAR shows is valid and viable treatment as well as bail out option for challenging cases of JAAA, where a custom-made device is either not available or not amenable to deployment due to difficult access.

  P419: High Flow Arterio-Venous Fistula Closure with Amplatzer Vascular Plug in with High Cardiac Output Failure Patient with CKD Top

Amol Madanlal Lahoti, Vivek Ukirde, Saurabh Anant Joshi, Ashank Bansal, Arvind Borde

LTMMC and LTMGH, Sion Hospital, Mumbai, Maharashtra, India. E-mail: [email protected]

Background: The Amplatzer Vascular Plug (AVP) is a cylindrical plug made of self-expanding nitinol wire mesh with precise delivery control, which can be used for a variety of vascular pathologies. An AVP is an ideal vascular occlusion device particularly in high-flow vessels, where there is high risk of migration and systemic embolization with traditional occlusion devices. Method(s): 20 year old,young male, recently diagnosed chronic kidney diesase presented with palpitation, breathlessness and chest pain. We present a case where through tranfemoral approach, An amplatzer vascular plug is deployed at the site of a –v fistula with precise delivery and complete occlusion of the fistula. Result(s): Succesful closure of high flow a-v fistula causing high flow cardiac output failure in a chronic kidney disease patient resulting in improved signs and symptoms with maintained distal circulation. Conclusion(s): Vascular occlusion of hemodialysis fistulas using an Amplatzer vascular plug has recently been described only by interventional vascular radiologists. This as a better option than surgical ligation or coils with reduced hospital stay and associted morbidity.

  P420: Long Life Efficient Permcath Fibrin Sheath Angioplasty Top

Raafat Shalabi, Mahmoud Maamoun

Davita Health Care Center, Jeddah, Saudi Arabia. E-mail: [email protected]

Background: Fibrin sheath formation around long-term haemodialysis catheter is a common cause of failed dialysis access. The sheath begins as a thrombus containing some fibrin in the first few days and transforms to a cellular-collagen tissue after 1 week. Upon catheter removal, the sheath tends to remain in the vein instead of attaching to the catheter. Method(s): The topic discuss 2 years experiences of dealing with 150 permcath insertion and exchange at Vascular access center in Davita care dialysis center, Jeddah, Saudi Arabia. Treatment options include pharmacological and mechanical methods. Pharmacological therapy involves instillation of urokinase (5,000 units or above) or tissue plasminogen activator (2.5 mg in 50 mls normal saline over 3 hours) to lyse the thrombus. Mechanical treatment includes catheter exchange, fibrin sheath disruption using guide wire and angioplasty balloon, before the permcath. Removal, 0.035 Guide wire was passed through the arterial red line of the catheter. The Catheter is freed from the cuff adhesion and pulled out till the tip to be kept at the vein inlet. Angiogram to be done. Result(s): a fibrin sheath was present,in 50 patients with malfunctioning permcath. angioplasty was performed using an 8×4 or 10×4 balloon along the entire length of the fibrin sheath. A completion venogram was performed to document disruption of the fibrin sheath. Conclusion(s): The result of our study is, disruption of fibrin sheath in malfunctioning permcath can keep using the same side of vein insertion specially for patient with poor chances of AVF creation avoiding central venous stenosis and preserving efficient hemodialysis access.

  P421: Uterine Artery Embolization to Control of Life Threatening Unusual Secondary Postpartum Haemorrhage Top

Mohamed Hamdna Allah El Ghobashy, Mohamed El Sharkawy1

Interventional Radiology Unit, Faculty of Medicine, Cairo University, 1Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt. E-mail: [email protected]

Background: Secondary post partum haemorrhage is a rare post natal complication yet with significant morbidity and mortality. Method(s): We present a 21 yr old female primigravida suffered from severe secondary post partum haemorrhage after cesarean section by five weeks presented to emergency department with significant haemoglobin drop, ultrasound revealed increased myometrial vascularity with intrauterine echogenic material, further contrast enhanced CT study revealed hypertrophied left uterine artery with suspected arteriovenous malformation Endovascular uterine artery angiography and embolization was done followed by elective hysterscopy and curretage. Result(s): Successful control of vaginal bleeding with stable haemoglobin level, no need for transfusion Histopathological examination of the curretage specimen revealed infracted afenomatous polyp. Conclusion(s): Uterine artery embolization is safe and feasible for primary control of secondary post paryim haemorrhage even in cases with retained placental products and endometrial polyps.

  P422: Prophylactic Antibiotic for Portacath Insertion, is there any Benefit? Top

Shahabazali Patil, Shamsa Abdalla Alraeesi, Balamurugan Rathinavelu

Mafaraq Hospital, Abu Dhabi, UAE. E-mail: [email protected]

Background: Prophylactic antibiotics for portacath insertion is a controversial topic and is mainly indicated in immunocompromised patients requiring the same procedure. The aim of the study is to review patients at our hospital who underwent portacath insertion with prophylactic antibiotic cover and compare them with patients who had the same procedure without antibiotic cover. We reviewed the rate of catheter-related infections (CRIs) in these two groups. Method(s): This is a retrospective study and was done by analysing the medical records, clinic letter and procedural notes using Cerner system. CRIs were defined as a patient treated with antibiotics for port site induration, positive blood cultures, or suspicion of infection that led to port removal within 30 days of placement. We reviewed the data of patients who underwent portacath insertion between March 2018 until Dec 2018. Result(s): A total of 31 Portacath insertions were done at our institution during the above mentioned period. A total of 21 patients had no antibiotic cover for the portacath insertions and 10 patients had prophylactic antibiotic cover. There were 18 male and 13 female patients. Mean age= 48 (18-70). 28 patients had right sided portacath insertion. Three patients had left sided portacath insertion. No immediate procedural or delayed complication were seen in either cohort. Conclusion(s): Our study did not show any benefit of giving prophylactic antibiotics prior to insertion of portacath.

  P423: Drug Coated Balloons in Hemodialysis Access Circuits: A Meta-Analysis and Systematic Review Top

Eshan Tahrir Affan, Hamid Hajian

Westmead Hospital, Sydney, Australia. E-mail: [email protected]

Background: Hemodialysis access stenoses are a major source of morbidity and cost for renal dialysis populations. With endovascular techniques a single access can be maintained for a longer period, although this often requires multiple balloon angioplasties (BA) with adjuncts such as high pressure or cutting balloons to treat areas of neointimal hyperplasia in the access circuit. Drug coated balloons (DCB) have been used to decrease recurrence of stenoses although the evidence is not yet definitive. This study sought to collate data from trials to assess 6 and 12 month target lesion revascularization as a measure of DCB efficacy compared to BA. Method(s): Embase, Medline and the Cochrane Central Registry were searched for randomised controlled trials evaluating DCB against BA for arteriovenous fistulas and grafts, central venous stenoses were excluded. The outcome was the need for revascularization due to index lesion restenosis within 6 and 12 months or access thrombosis. A random effects meta-analysis with generic inverse variance weighting was used to generate summary statistics for these outcomes. Result(s): 69 abstracts were identified from which seven studies were included for meta-analysis, totaling 707 access stenoses. All studies utilised paclitaxel coated balloons as intervention. At 6 months DCB showed a non-significant trend towards reduced restenosis (RR 0.74, 95% CI: 0.49 to 1.11, p=0.14). The 12 month results also showed no significant difference between DCB and BA (RR 0.91, 95% CI: 0.67 to 1.23, p=0.53). Conclusion(s): Although there was a reasonable amount of heterogeneity, the results presented show that routine use of DCB in hemodialysis access circuits should be reconsidered until further studies show subgroups that may benefit. It is possible that the continued hemodynamic disturbance in the fistula circuit does not allow for the same patency effects of paclitaxel seen in the peripheral arterial circulation.

  P424: Below Knee Angioplasty in Diabetic Patients: Predictors of Major Adverse Clinical Outcomes Top

Mohamed Ali Kashkoush

National Institute of Diabetes and Endocrinology, Cairo, Egypt. E-mail: [email protected]

Background: To determine predictors of clinical outcome following percutaneous transluminal angioplasty (PTA) in diabetic patients with below knee atherosclerotic lesions causing critical limb ischemia (CLI). Method(s): Over one year, 67 patients (CLI 100%) underwent below knee PTA. The composite end point of interest was major adverse clinical outcomes (MACO) of the treated limb at follow up which was defined as clinical failure, need for subsequent endovascular or surgical revascularization or amputation. Actuarial freedom from MACO was assessed using Kaplan-Meier curves. Result(s): 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 value 0.002) and occlusive lesions (p value 0.019). We reported a percentage of 76.1% freedom of MACO. Conclusion(s): Below knee PTA is a feasible therapeutic option in this diabetic population. Technical failure and occlusive lesions may be predictors of adverse outcome.

  P425: Non-Operative Management of Hepatic Parenchymal and Vascular Injuries: A Departmental Review Top

Muhammad Sami Alam, Raza Sayani

Agha Khan University, Karachi, Pakistan. E-mail: [email protected]

Background: Life threatening conditions like gastrointestinal bleeding is a medical emergency which require an intervention to control the bleeding. Conventionally, surgical method was opt to manage such patients but high mortality and morbidity rates of 10%-20% convinced the health care workers to switch to some relatively safer and less invasive method to manage hemorrhagic conditions. Advent of non-operative management i.e. arterial embolization for blunt hepatic injuries in around late 20th century emerged as an operative intervention in controlling bleeding. Arterial embolization is becoming a standard first-line treatment option for the management of hemodynamically unstable patients with acute arterial bleeding from all sources. Minimally invasive percutaneous technique offers treatment for arterial lesions that were previously considered inoperable or deemed to require extensive surgical dissection and/or reconstruction, associated with high morbidity and mortality. Mortality increases substantially if emergency surgery is required for aneurysm rupture. Interventional radiology techniques are being used increasingly to treat pseudo aneurysms, and in most centers, they are the first line of treatment. The success of interventional radiology treatment is dependent on high quality cross sectional pre-procedural imaging and adequately trained vascular interventional radiologists. Interventional radiology has proven to be highly suited to this type of condition, thanks to reduced invasiveness, high success rate and lower risk of complications. Method(s): A retrospective review of cases of hepatic arterial angioembolization performed in our department during 8-year period was performed. Sixty vascular angiographies were performed in 56 patients (45 males and 11 females, age range 12-66 years) who were referred with hemorrhagic hepatic and vascular emergencies to Aga Khan University hospital’s angiography suite from December 2007 to December 2015. Data on clinical indication, technique, site and type of bleeding lesions was obtained from a retrospective review of medical records. Success rate, clinical outcome and complications of the procedure were analyzed. Result(s): Fifty six patients underwent angioembolization in our department during this period. Most of them had computerized axial tomographic (CT) scan followed by HA. Active extravasation and pseudoaneurysm formation was seen in most with a few showing arteriovenous malformation, tumoral blush or laceration. Conclusion(s): Hepatic arterial angio embolization is a safe, effective and lifesaving therapeutic tool for managing liver parenchymal and related vascular emergencies in hemodynamically stable patients.

  P427: Efficacy of Conventional Venography in Therapeutic Planning of Budd Chiari Patients Top

Ashank Bansal, Vivek Ukirde, Saurabh Joshi, Arvind Borde, Akshay Gursale, Sagar Bhalerao

Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra, India. E-mail: [email protected]

Background:  Budd-Chiari syndrome More Details is a heterogeneous group of disorders characterized by hepatic venous outflow obstruction that involves one or more draining hepatic veins or IVC. Clinical manifestations in many cases are nonspecific, and imaging may be critical for early diagnosis of venous obstruction and accurate assessment of the extent of disease. If Budd-Chiari syndrome is not treated promptly and appropriately, the outcome may be dismal. Comprehensive imaging evaluations, in combination with pathologic analyses and clinical testing, are essential for determining the severity of disease, stratifying risk, selecting the appropriate therapy, and objectively assessing the response. The main goal of treatment is to alleviate hepatic congestion, thereby improving hepatocyte function and allowing resolution of portal hypertension. Various medical, endovascular, and surgical treatment options are available. Percutaneous and endovascular procedures, when performed in properly selected patients, may be more effective than medical treatment methods for preserving liver function and arresting disease progression in the long term. Objective: Evaluate efficacy of conventional venography in therapeutic planning and follow up of patients with Budd Chiari. Method(s): Sample size: Total of 65 patients were sequentially evaluated and followed up. Inclusion criteria – Patients with chronic liver disease and suspected to have hepatic venous outflow obstruction on MR venography of abdomen or on ultrasound porto-splenic Doppler. Exclusion criteria – Patients with a known liver disease (infective), inflammatory, CLD with good visualization of all 3 hepatic veins and IVC on imaging. Patients were evaluated with suspicious findings of Budd Chiari on colour Doppler and MR venogram. Further regular workup was done with PT/INR and HIV, HBsAg and HCV and posted for conventional venography with jugular puncture. Pigtail catheter run was taken of IVC and catheterization of the hepatic veins/collateral was attempted using 4 Fr head hunter or 4 Fr Cobra. Percutaneous puncture of hepatic vein/large collateral was also done using 22G Chiba needle. Result(s): Out of the 65 patients for whom conventional venography was done, 34 patients had evidence of lesions with the intra or infrahepatic portion of IVC causing IVC short or long segment narrowing with collaterals, 46 patients had lesions in left hepatic veins, 35 in middle hepatic vein and 33 in right hepatic vein. Only 70 % correlation could be found between MR venography of abdomen and conventional IVC gram studies. A decision for appropriate therapeutic management on basis of findings on conventional venography was then taken after discussion with gastro-enterology department. Patients were then regularly followed up every month clinically and using USG doppler. Conclusion(s): Conventional venography is a better imaging modality than Mr venography and doppler for evaluation and further planning of patients with Budd Chiari syndrome helping in decision making and follow-up.

  P428: Drug Eluting Balloon Angioplasty Versus Bare-Metal Stent in Treating Chronic Total Occlusion of Femoro-Popliteal Arterial Segment; a Review of One-Year Outcome of 90 Patients with TASC C and D Lesion Top

Ahmed Khairy Allam, Mohamed Ismail1

Benha University, Benha, 1Ain Shams University, Cairo, Egypt. E-mail: [email protected]

Background: Bare metal stent (BMS) scaffolding of superficial femoral artery occlusive lesions has been associated with high rates of late clinical failure. Maintaining the patency of recanalized arterial segments was the main issue behind the concept of leave nothing behind to be evolved and balloon angioplasty becomes preferred option for endovascular therapy. Drug eluting balloons (DEBs) have shown to be effective alternative to BMS for patients with de novo complex superficial femoral occlusive disease. Purpose: To compare the outcome of DEB versus BMS in treating complex chronic total occlusion (CTO) of superficial femoral and proximal popliteal artery in patients with disabling claudication and critical limb ischemia regarding technical success, primary patency, clinically driven target lesion revascularization (cd-TLR), and limb salvage rate. Method(s): 90 patients (110 limbs) were complaining of disabling and critical limb ischemia due to complex femoro-popliteal occlusive lesions were randomly allocated into two groups according to the intervention method performed. Group (A); 48 patients (57 limbs) were submitted for treatment with paclitaxel DEB and Group (B); 42 patients (53 limbs) submitted for treatment with BMS. Follow-up period was for 1, 6 and 12. Result(s): BMS seems to have lower patency and higher cd-TLR rates compared to patients who received Paclitaxel DCBs but not statistically significant. The primary patency rates were 100%, 96%, 86.2%at 1, 6, 12 months respectively in DEB group, Vs 100%, 89.8%, 77.6% at 1, 6, 12 months respectively in BMS group. TLR rates were 2%, 7.8% at 6, 12 months respectively in DEB group Vs 6.1%, 14.2% at 6, 12 months respectively in BMS group. Conclusion(s): Percutaneous therapy for TASC C and D femoro-popliteal lesion using DEB or BMS are both safe and effective with one-year high patency rate. Paclitaxel DEBs seem to have a promising important role in prevention of restenosis and recurrence of peripheral arterial occlusive disease. However, stents are still playing important bailout role in the treatment of residual stenosis and dissection. Further follow-up is essential to obtain and document long-term outcome of percutaneous therapy for complex and long SFA lesions.

  P429: Ultrasound Guided Common Femoral Artery Access: A Meta-Analysis and Systematic Review Top

Eshan Tahrir Affan1,2

1Westmead Hospital, 2Nepean Hospital, Sydney, Australia. E-mail: [email protected]

Background: Common femoral artery vascular access is commonplace in all forms of interventional procedures including coronary, peripheral vascular and cerebrovascular. Ultrasound guided arterial access is not the standard of care as in central venous access. Current studies are not conclusive and there remains considerable variation in clinical practice. This meta-analysis aimed to determine the potential benefits of ultrasound guidance in preventing access complications and inefficiencies. Method(s): Embase, Medline and the Cochrane Central Registry were searched for randomised controlled trials evaluating ultrasound guided versus palpation or fluoroscopy assisted common femoral access for any interventional procedures. A random effects meta-analysis was used to evaluate haematoma or pseudoaneurysm formation as well as number of attempts required for access. Result(s): 228 abstracts were identified from which six studies were included for meta-analysis, totaling 2492 participants. Ultrasound use was associated with a significant reduction in haematomas and pseudoaneurysms (RR 0.42, 95% CI: 0.24 to 0.72, p<0.002) as well as puncture attempts with 0.63 less needle passes required on average (95% CI: -1.18 to -0.08, p=0.03). Conclusion(s): The routine use of ultrasound guided common femoral artery access significantly reduces bleeding complications and the number of attempts required for successful access. This should be recommended as a standard procedure. Routine use would likely overcome the learning curve to facilitate uncomplicated access in more difficult cases.

  P430: Uterine Artery Embolisation for Giant Fibroids: Does Size Matter? Top

Neeral Patel, Dermot Mallon, Alison Amoah, Ailing Fagan, Mohamad Hamady

Imperial College Healthcare NHS Trust, London, UK. E-mail: [email protected]

Background: Studies have suggested UAE in the case of giant fibroids (defined as fibroids ≥10 cm) increases post-procedural risk levels in comparison with smaller fibroids. The aim of this study is to determine the suitability of UAE in cases of giant fibroids and to assess the procedural outcomes and complications. Method(s): Retrospective data was collected for UAEs conducted over a five-year period at a tertiary centre. Patients with pre- and post-procedure MRI studies as well as giant fibroids were included. Alterations in the volume of the uterus and size of the dominant giant fibroid were calculated pre- and post-UAE. Post-UAE complications and surgical interventions were also documented. Patient satisfaction was assessed using the 40-point uterine fibroid symptom quality of life (UFS-QoL) questionnaire. Result(s): Between 2013-2018, 281 female patients underwent UAE. Of these, 24 (8.5%) patients were found to have giant fibroids (mean age 50.8±3.8 years; range: 40-55). The mean pre-UAE uterine volume was 1511.6±517.9 CC, while mean post-UAE uterine volume was 961.4±483.6 CC (p<0.05). The mean giant fibroid size pre-UAE was 13.5±2.6 cm, and post-UAE was 10.3±3.6 cm (p<0.05). 92% of fibroids were effectively devascularised. 16.7% of patients experienced post-UAE pelvic infection. 18.2% patients underwent further surgical intervention. Conclusion(s): UAE is a safe and efficacious treatment option for giant fibroids. The percentage of patients developing post-UAE infection is perhaps higher than quoted average of 2%, given the greater burden of necrotic tissue after giant fibroid embolisation.

  P431: Type II Congenital Portosystemic Shunt: Consideration for Endovascular Closure Top

Shadi Saleem

Oklahoma University Health Scinces Center, Oklahoma City, USA. E-mail: [email protected]

Background: Congenital portosystemic shunts with preserved portal flow (type II) have variable anatomy and thus variable clinical manifestations and differing methods of treatment. Review of the literature shows shunts arising from a portal branch should be considered for endovascular closure as first-line treatment. Method(s): Following ultrasound-guided access via the right IJ, venography and portogram were performed via hand injection to look for additional abnormalities. The distal left portal vein of the shunt was coiled with 2 detachable Azur coils (3 mm x 2 cm, 4 mm x 5 cm). Result(s): Postembolization venogram showed successful closure. A total of 3.15cc of contrast was used with a total radiation dose of 127 mGy. Follow-up 2-week ultrasound showed no residual shunt. The patient’s hypoglycemia resolved and ammonia levels improved. Conclusion(s): While no specific guidelines exist regarding endovascular versus surgical treatment, the literature favors endovascular therapy as first-line treatment in type II shunts involving portal barnches. In the pediatric population, there is hesitation given the radiation exposure and use of contrast. However, endovascular intervention can be relatively safe with care to keep the radiation and contrast dose to a minimum.

  P432: Endovascular Management of Venous Complications Following Liver Transplantation Top

Mohammad Arabi, Omar Bashir, Refaat Salman, Shahbaz Qazi, Mohammad Almoaiqel

King Abdulaziz Medical City, Riyadh, Saudi Arabia. E-mail: [email protected]

Background: Venous complications following liver transplantations are rare but can lead to significant morbidity or graft loss. These complications may involve the portal vein, hepatic veins or the inferior vena cava. The underlying etiology could be related to thrombosis, anastomotic stenosis or vascular kink and may manifest early during the post-operative period or as a late complication. Method(s): This poster will illustrate and review. (1) The vascular anatomy of venous anastomosis in liver transplant. (2) The incidence of venous complications after liver transplant. (3) The role of endovascular management. (4) Presentation of illustrative cases.

  P433: An Audit of Ultrasound Surveillance Following Deployment of Arterial Stents in the Lower Limb Top

Yasser Al-Obudi, Muhammad Zamir

West Hertfordshire Hospitals NHS Trust, London, UK. E-mail: [email protected]

Background: There has been an increase in the number of stents deployed in the iliac, femoral and popliteal arteries following endovascular management of peripheral arterial disease. Excessive neointimal hyperplasia can lead to the development of in-stent stenoses following insertion and so most endovascular surgeons advocate the use of a formal stent surveillance program to identify clinically quiescent stenoses which can then undergo re-intervention to maintain stent patency. This audit aims to assess the number of patients who are undergoing stent surveillance as well as the timeframes related to the scans. Method(s): Retrospective audit of all patients who have had deployment of iliac, femoral and popliteal stents in the past five years and documentation of commencement onto the stent surveillance programme. A 100% enrolment was set as the standard. Result(s): Lower limb arterial stents were deployed in 106 patients. The average age was 71 years with an overwhelming male predominance (75%). Approximately half of the stents were inserted for category two and three patients (Rutherford classification for peripheral arterial disease) whilst 34% were inserted for category four and five patients. Only 69% of patients had been enrolled onto the stent surveillance programme with a median time of 85 days for the initial post-procedural duplex. Conclusion(s): A formal, consistent stent surveillance programme is essential to identify subclinical in-stent stenoses. Early recognition allows for speedy re-intervention in those patients who are deemed clinically appropriate ultimately leading to stent patency. Enrolment onto stent surveillance programmes should be managed by a dedicated member of the team with regular auditing.

  P434: Hepatic Artery Stenosis in Liver Transplant Recipient’s Angioplasty and Stenting a Single Center Experience Top

Shahbaz Ahmed Qazi, Muhammad Al Moiqel, Omar Bashir, Muhammad Arabi, Muhammad Saeed

King Abdul Aziz Medical City National Guards Health Affairs, Riyadh, Saudi Arabia. E-mail: [email protected]

Background: Significant hepatic artery stenosis after liver transplantation can lead to thrombosis with associated high morbidity and mortality. The aim of our study is to evaluate our technical success rate, clinical outcomes and complications. Method(s): It’s a retrospective study in 13 patients who underwent liver transplantation between 2010 and 2018. Recipients demographics, type of liver transplant, clinical presentations methods of diagnosing hepatic artery stenosis, types of anastomosis, approached for intervention, hepatic artery stenosis grading, primary angioplasty and in some cases assisted stenting were evaluated. All patients were assessed after intervention by clinical outcomes, Doppler examination. Result(s): Out of 13 patients, 5 patients after angioplasty were assisted by stenting, 11 patients have good flow (84%), in 1 patient no change in flow and 1 have poor flow,1 patient complicated by non flow limiting dissection, 1 underwent for surgical redo, 10 patients are still alive. Conclusion(s): Our results suggest hepatic artery angioplasty and stenting in liver recipients are minimally and safe procedures good alternative option to open surgeries.

  P435: Varicocele Embolization after Surgical Failure Top

Essam Hashem, Karim Abd El Tawab, Mohamed Shaker

Ain Shams University, Cairo, Egypt. E-mail: [email protected]

Background: Varicocele is a common condition affecting up to 15 % of young adult males. It is associated with chronic scrotal pain and it can found in up to 81 % of infertile males. Surgery is the classic treatment for varicocele, however failure rates may reach up to 15 %. We aim to describe post-surgical angiographic patterns and assess both safety and efficacy of embolization for treatment of varicocele after surgical failure (residual or recurrent). Method(s): Inclusion criteria were symptomatic varicocele (pain or infertility) diagnosed by scrotal ultrasonography, presenting more than 3 months after previous surgical treatment. All patients underwent endovascular transcatheter retrograde varicocele embolization, under local anesthesia via right femoral vein or right internal jugular vein. We had no restrictions regarding embolization method/material. Peri-operative complications; procedure time; radiation dose; pre/post-embolization (3 months): pain score, scrotal ultrasonography and semen analysis were recorded. Result(s): Ten consecutive patients were recruited. Seven suffered from chronic scrotal pain and four from infertility; eight patients had left varicocele and only two patients had bilateral varicoceles. Eight procedures were done via femoral approach and two were jugular. In nine procedures n-butyl cyanoacrylate was used and only one procedure was done using sodium tetradecyl sulphate 3 % foam. No serious perioperative complications were encountered; only one patient developed hydrocele one week after operation that subsided with conservative management. Pain score, scrotal ultrasonography and semen analysis significantly improved in nine patients. Angiographic patterns of post-surgical varicoceles are described through original images. Conclusion(s): Varicocele embolization after surgical failure is safe and effective, however larger sample size is needed to consolidate the conclusion.

  P436: Pelvic Vein Embolisation of Gonadal and Internal Iliac Veins Can be Performed Safely and with Good Technical Results in an Ambulatory Vein Clinic, Under Local Anaesthetic Alone: Results from Two Years’ Experience Top

David Beckett, Elund Davis, Tim Fernandez-Hart, Sophia Bishop, Chlyinde Lewis-Shiell, Previn Diwakar, Mark Whiteley

The Whiteley Clinics, London, UK. E-mail: [email protected]

Background: Pelvic vein embolisation is increasing in venous practice for the treatment of conditions associated with pelvic venous reflux. In July 2014, we introduced a local anaesthetic “walk-in walk-out” pelvic vein embolisation service situated in a vein clinic, remote from a hospital. Method(s): Prospective audit of all patients undergoing pelvic vein embolisation for pelvic venous reflux. All patients had serum urea and electrolytes tested before procedure. A combination of coil embolisation and sclerosant were used in all patients. We noted (1) complications during or post-procedure (2) successful abolition of pelvic venous reflux on transvaginal duplex scanning (3) number of veins (territories) treated and number of coils used. Result(s): In 24 months, 121 patients underwent pelvic vein embolisation. Three males were excluded as transvaginal duplex scanning was impossible and six females excluded due to lack of complete data. None of these nine had any complications. Of 112 females analysed, mean age 45 years (24-71), 104 were for leg varicies, 48 vulval varicies and 20 for pelvic congestion syndrome (some had more than one indication). There were no deaths/serious complications at 30 days. Two procedures were abandoned, one completed subsequently and one was technically successful on review. One more had transient bradycardia and one had a coil removed by snare during the procedure. The mean number of venous territories treated was 2.9 and a mean of 3.3 coils was used per territory. Conclusion(s): Pelvic vein embolisation under local anaesthetic is safe and technically effective in a remote out-patient facility outside of a hospital.

  P437: Interventional Radiology Awareness Among Final-Year Medical Students in Riyadh: 5 University-Based Cross-Sectional Study Top

Abdullah Bader Abohimed

National Guard Health Affairs, Riyadh, Saudi Arabia. E-mail: [email protected]

Background: Interventional Radiology was born in 1964 thanks to the efforts of Charles Dotter. Today, Interventional radiology is an ever-expanding field of medicine that incorporates a wide array of minimally-invasive, image-guided procedures with both diagnostic and therapeutic properties. However, there exists a glaring ambiguity about the role of the Interventional Radiologist. This, in part, is due to the overlap between Interventional radiology and other specialties for procedures and administrative tasks. The confusion that this creates may sway medical students away from the field of Interventional radiology and could directly impact both recruitment of young exciting prospects, and the shortage of Interventional radiology practitioners. There is little to suggest from the medical literature about the knowledge of Interventional radiology among final-year medical students. However, there are a handful of studies, all of which conclude that the majority of final-year students lack even the basic knowledge of Interventional Radiology. Method(s): We will be running a cross-sectional, self-administered questionnaire at 5 university-based medical schools in the Riyadh region targeting all final-year medical students. 285 potential participants have been recognized. Result(s): Results will be analyzed soon. Conclusion(s): We believe that IR will become a force to reckon with in the near future. The minimally-invasive nature of IR procedures has proven to be a safe alternative to conventional surgery. We feel with this study we can advance IR knowledge amongst pre-graduate medical students and ultimately enhance IR recruitment, especially in the Gulf region.

  P438: The Utility of Two-Dimensional Perfusion Angiography in Critical Limb Ischemia: A Single Center Experience Top

Abdulrahman Alvi, Zahra Assiri, Asma Bin Habjar, Muhammad Al Moaqil

King Abdul Aziz Medical City, Riyadh, Saudi Arabia. E-mail: [email protected]

Background: CLI is a combination of both decreased inflow to the foot (macrocirculation) and volume flow through the capillary bed (microcirculation) resulting in diminished oxygen concentration in the tissues. The goal of endovascular therapy in CLI is to recanalise the vessels to the foot, obtain better tissue perfusion, and to accelerate wound healing. 2D-PA is a new imaging algorithm to measure volume flow in the whole foot both in the macrocirculation and microcirculation utilizing data from plain old digital subtraction angiography. Method(s): A retrospective single-center study review of 21 patients from February, 2017 to August 2018 (mean age 84±42 years; 17 men, 8 women) with CLI who underwent lower limb digital subtraction angiography (DSA) A standardized contrast administration protocol was applied during DSA using a 2D perfusion–enabled image intensifier. Representative hindfoot and forefoot regions of interest were analyzed, and representative numeric density values [time to peak (TTP), mean transit time (MTT) and area under the (time-density) curve (AUC)] were calculated using 2D perfusion–enabled angiographic software to assess foot perfusion. Result(s): The numeric density values (mean change in TTP (0.75 s), MTT (0.85 s) and AUC (1835.53)) were compared before and after angioplasty and by level of treatment and these parameters were correlated with disease severity (Fontaine Classification (III=8; IV=16). Conclusion(s): In our initial experience, 2D-PA is a useful tool in critical limb ischemia evaluation and treatment by providing objective measurements of microvascular perfusion during and following endovascular procedures. This helps determining both the end point and outcome of revacularisation.

  P439: Sharp Recanalization of Chronic Venous Occlusions Utilizing Outback Re-Entry Device Top

Ali Alsaadi, Mohammad Arabi, Omar Bashir, Shahbaz Ahmed Qazi, Mohammed Al Moaiqel

King Adulaziz Medical City, Ministry of National Guard, Riyadh, Saudi Arabia. E-mail: [email protected]

Background: Chronic total venous occlusion of superior or inferior vena cava is increasingly encountered in daily practice. Several endovascular techniques including thrombolysis, percutaneous transluminal angioplasty (PTA), bare and covered metallic stents have been implemented to restore venous patency. Patients who fail standard recanalization techniques may require sharp recanalization procedures to reconstruct the chronically occluded segments. Several tools have been used to cross the occluded segments such as TIPS needles, trans septal needle, direct trans mediastinal needle puncture and radiofrequency wire. The use of re-entry devices in crossing chronic venous occlusions is seldom reported in the literature. Method(s): This educational poster will present few illustrative cases of the use of Outback re-entry device in recanalization of chronically occluded IVC and SVC with discussion of technical considerations. Result(s): This educational poster will present few illustrative cases of the use of Outback re-entry device in recanalization of chronically occluded IVC and SVC with discussion of technical considerations. Conclusion(s): Sharp recanalization of chronic venous occlusions utilizing Outback re-entry device is a safe and reliable way to cross the central occlusion with good success rate.

  P440: Unusual Cases of Gastrointestinal Hemorrhage Managed in Interventional Radiology Top

Sultan R. Alharbi

King Saud University, Riyadh, Saudi Arabia. E-mail: [email protected]

Background: in this poster we report and illustrate 2 cases of very rare GI bleeding. one upper GI bleeding due to Esophago-mediastinal fistula secondary to mediastinal TB complicated by Mediastinal bronchial artery aneurysms which is treated by coils embolization. second case of lower GI bleeding due to secondary arterio-enteric fistula post Aorto-bi-femoral graft presented with life threating bleeding managed by endovascular stenting by covered stent.

  P441: HERO® Graft Placement: Getting Rid of the Catheter in Patients with Central Stenosis Top

Yasir Suliman, Asim Khwaja1, Mohamed Al Marzooqi1, Hefsa Alshamsi2, Moatasiem Bukhari, Amin Eltahir3, Emad Khater4, Shahabaz Patil4

Departments of Surgery and 4Radiology, Mafraq Hospital, 4Department of Radiology, Mafraq Hospital, Departments of 1Radiology, 2Medicine and 3Surgery, Sheikh Khalifa Medical City, Abu Dhabi, UAE. E-mail: [email protected]

Background: Central venous stenosis and occlusion are a major cause of vascular access dysfunction and failure. The HeRO® Graft provides access for patients with central venous occlusion who are catheter-dependent or have failing fistulae or grafts by providing reliable venous outflow directly into the right atrium [Figure 1c and d]. Moreover, when combined with the use of early cannulation grafts it has the advantage of immediate access directly after the procedure. We reviewed our experience using the strategy of combining the use of HeRO graft with early cannulation graft. Method(s): Patients with suspected central venous occlusion or stenosis who are catheter-dependent or have failing fistulae or grafts were discussed in multi-disciplinary meetings. Only patients with central venous stenosis or occlusion confirmed by CT or conventional venogram were included [Figure 1a and b]. Patients with active infection, brachial artery diameter less than 3 mm, hypercoagulable state and ejection fraction less than 20 were excluded. Result(s): Five hemodialysis patients with history of multiple failed arteriovenous access and confirmed central venous occlusion were recruited. All patients underwent successful placement of HeRO graft in combination with early cannulation graft [Figure 1c and d]. All grafts were accessed within 48 hours. Median follow up was 219 days (range 32 -240 days). No adverse events were noted during the follow up period. HeRO graft thrombosis occurred in three patients, requiring re-intervention using percutaneous thrombectomy, primary patency 40%. All five grafts remain patent and functional, secondary patency 100%. Conclusion(s): HeRO® graft placement can provide vascular access in hemodialysis patients with central venous occlusion who would otherwise remain catheter dependent. Combining the use of early cannulation graft with HeRO graft placement can further reduce catheter dependence and does not appear to impact HeRO graft secondary patency.

  P442: Drug-Coated Balloon use in Dysfunctional Arterio-Venous Access Treatment the Effect of Consecutive Treatments in Target Lesion Primary Patency Top

Michail Theofanis, Ioannis Spyridonidis, Panagiotis Kitrou, Panagiotis Papadimatos, Konstantinos Katsanos, Dimitrios Karnabatidis

Department of Diagnostic and Interventional Radiology, Patras University Hospital, Patras, Greece. E-mail: [email protected]

Background: This was a retrospective longitudinal analysis investigating the safety and effectiveness of consecutive treatments with the Lutonix Drug-Coated Balloons (DCB) in dysfunctional arteriovenous access; both fistulae (AVF) and grafts (AVG). Method(s): From January 2015 to December 2017 (3 years), 339 Lutonix DCB were used in 257 procedures of 165 patients with a dysfunctional AVF or AVG. Of these patients, 33 had ≥2 procedures, adequate data and were included in the analysis. In these patients, 112 procedures were performed (22 treated twice, 4 patients 3 times, 7 patients 4 times, 2 patients 5 times and 3 patients 6 times) using 133 devices. Mean lesion follow-up was 247 days (min. 20 days – max. 908 days). Mean balloon diameter was 8.13 mm (3-12 mm) and length 63.16 mm (40-150 mm). Primary outcome measure safety, defined as freedom from any serious adverse event(s) involving the AV access circuit through 30 days for all procedures and target lesion primary patency (TLPP). Secondary outcome measures included investigation of independent factors that may influence outcomes. Result(s): Safety was reached in all cases (112/112 procedures, 100%). Median TLPP was 227 days for the first intervention and 280 days for the second consecutive intervention [p=0.37; Hazard ratio: 1.271 (CI: 0.75-2.16)]. Conclusion(s): Consecutive use of the Lutonix DCB for the treatment of dysfunctional dialysis access was safe. There was no significant difference in TLPP between the 1st and 2nd procedure, although a numerical improvement was observed. Results suggest consistency in TLPP regardless of the aging arterio-venous access.

  P443: The Use of Supera Stents in Maintaining Dysfunctional Dialysis Arterioveonus Fistulas: A Single Center Experience Top

Aeed Saad Alaklabi, Hasan Alshehri1, Ali Rajeh, Omar Bashir, Refat Salman, Mohamad Arabi

King Abdulaziz Medical City, 1Prince Sultan Military Medical City, Riyadh, Saudi Arabia. E-mail: [email protected]

Background: Dialysis access failure is a major cause of mortality and morbidity among dialysis patients. Preservation of access is critical to maintaining hemodialysis, avoiding uremia, and managing the complications of kidney failure. The usual IR approach to thrombosed or stenosed arteriovenous fistula (AVF) is a combination of thrombectomy and balloon angioplasty of the underlying lesion. Stents and stent grafts appear to be an ideal method to treat thrombosis or neointimal hyperplastic stenosis. These safe endovascular device stents improving blood flow through the fistula or graft as they oppose elastic recoil and subsequent thrombosis. Stent placement is minimally invasive procedure, performed by IR doctors utilizing ultrasound and fluoroscopic guidance with rare complication and less stay in the hospital. The main indications of these procedure are early recurrent thrombosis, recoil stenosis and pseudoaneurysm of AVF. Method(s): This is a retrospective study of 11 consecutive patients (6 females) with mean age of 56 years, who underwent Supera stent placement for salvage of dialysis AVF between December 2016 to July 2018. Nine patients had brachiocephalic fistula and 2 patients had brachiobasilic fistula. Patients presented with fistula thrombosis (n=8) and dysfunction (n=3). Lesions were distributed along the venous outflow including the cephalic arch (n=5) and juxta-anastomotic needling segment (n=6). Evaluated outcomes included technical success, primary stent and circuit patency. Other outcomes were time to re-intervention and secondary patency. Result(s): Technical success was (100%). One stent stretched into the access sheath and was successfully removed through the puncture site, and a new stent was successfully deployed. Three patients required additional stent grafts at other sites during the index procedure. No major complications. Fistula function was restored in all patients with no additional interventions for a mean time of 242 days (50-734 days). Seven patients required re-intervention at mean time of 131 days (50-262 days). Reasons for re-interventions included inflow stenosis (n=5), outflow stenosis (n=1) and in-stent stenosis (n=1). Seven fistulas remain patent at mean follow up time of 484 days (136-734 days). Conclusion(s): Supera stent placement in AVF stenosis refractory to balloon angioplasty is technically feasible and may be effective in maintaining fistula function. Further evaluation of this technique requires larger randomized studies.

  P444: Angioplasty of Forearm Arteries: A New Approach to Manage Dialysis-Associated Steal Syndrome Top

Rim Miri, Melek Ben Mrad, Yassine Khadhar, Mohamed Ben Hamamia, Faker Ghedira, Raouf Denguir

Department of Cardiovascular Surgery, Faculty of Medicine of Tunis, La Rabta Hospital, Tunis El Manar University, Tunis, Tunisia. E-mail: [email protected]

Background: The steal syndrome is an ischemia of the hand, secondary to a decrease of its peripheral perfusion, due to the confection of a vascular access for hemodialysis, usually an arterio-venous fistula of the upper limbs. This syndrome is due to a local hemodynamic change and to the diversion of the distal arterial blood to the venous system. Its origin might be either hemodynamic, arterial or venous. The affection of the distal fore-arm arteries might be an etiology, yet neglected. This rare affection is rare but potentially disabling might be revealed by pain following an effort or even at rest and it might also be revealed by an ulcer, necrosis or gangrene. In the litterature and also in the daily practise, the treatment of this syndrome is usually a surgical treatment and it consists in decreasing the blood flow through the arteriovenous shunt or in enhancing the distal perfusion circumventing the arteriovenous fistula. There is only few data in the litterature concerning the endovascular treatment of arterial lesions of the fore-arm symptomatic of steal syndrome with arteriovenous fistula in patients suffering of chronic renal failure. The aim of our study is to evaluate the feasibility, the security and the results of the angioplasty of fore-arm arteries in the management of dialysis -associated steal syndrome. Method(s): We herein describe four cases of male patients with terminal chronic renal failure at the stage of hemodialysis via an arteriovenous fistula of the upper limbs. All patients were symptomatic of steal syndrome. Dupplex ultrasound and CT angiography were the examinations for the diagnosis of arteritis of the forearm. Result(s): All the patients underwent endovascular therapy. We proceeded with an angioplasty of the different lesions of the forearm arteries. The immediate postoperative course was marked by the presence of distal pulses and less ischemic pain. Long term out come was marked by healing of the amputation site,pain disappearing and functional arteriovenous fistula. Conclusion(s): The treatment methods that the vascular surgeon has are various and the endovascular treatment seems to become the treatment of choice. This procedure is simple, secure with an interesting good rate of limb salvage. It allows to treat the ischemia, preserve the vascular access and avoid the surgical intervention in patients with heavy medical history.

  P445: Endovascular Interventions in Obstetric Emergencies: A Game changer Top

Shivanand Gamanagatti, Mohit Gambhir, Vatsala Dodwal, Neena Malhotra, J. B. Sharma, Aunkumar Gupta

All India Institute of Medical Sciences, New Delhi, India. E-mail: [email protected]

Background: To evaluate role of endovascular IR procedures in obstetric emergencies. Method(s): In this ethically approved study a total of 33 patients presenting with obstetric emergencies were recruited during the period September 2017 to October 2018 after taking informed consent. The clinical success and complications were evaluated. Result(s): The spectrum of obstetric emergencies encountered were uterine arteriovenous malformations in 13 (40%) patients, retained products of conception or retained adherent placenta in 8 (24%), placenta accreta in 8 (24%), retained products of conception with secondary arteriovenous malformations in 3 (9%) patients, and pseudoaneurysm in 1 (3%) patient. A total of 28 uterine artery embolizations (repeat procedure required in 3 patients) were performed with clinical success in all the patients. Prophylactic intraoperative balloon occlusion of bilateral internal iliac arteries was done in 8 patients with suspected placenta accreta. Of these 3 patients (37.5%) had focal placenta accreta which separated after delivery of baby whereas the remaining 5 (62.5%) patients underwent hysterectomy with mean intraoperative blood loss of 3.31 (0.8- 6.8) litres and relative ease of hysterectomy for surgeons. There were no major complications, however minor complications were seen in 10 (30%) patients. These included periprocedural pain in 3 (9%) patients, post embolization syndrome in 5 (15%) patients and puncture site hematoma in 2 (6%) patients. All these resolved on conservative management. Conclusion(s): Interventional radiological procedures are helpful in obstetric emergencies with significant clinical success rate and low complication rate.

  P446: Mechanical Thromboaspiration of Acute Thrombosis of Dialysis Arteriovenous Fistulae and Grafts using the Penumbra Indigo System: Preliminary Results from a Single Center Experience Top

Maria Antonella Ruffino, Maria Antonella Ruffino, Marco Fronda1, Andrea Discalzi, Andrea Mancini, Pierluigi Muratore, Denis Rossato, Dorico Righi, Paolo Fonio1

Department of Diagnostic Imaging and Radiotherapy, Vascular Radiology, A.O.U. Citta della Salute e della Scienza di Torino, 1Department of Surgical Sciences, Radiology Unit, University of Torino, Torino, Italy. E-mail: [email protected]

Background: Thrombosis of vascular accesses is most often due to venous anastomotic outflow stenosis or obstruction. Many percutaneous mechanical devices have been developed to eliminate the clot. Their clinical success rates are usually between 71% and 100%, with low incidence of serious complications. The indigo mechanical thrombectomy system (Penumbra, inc) consists of vacuum-assisted thrombectomy, which enables continuous thrombus aspiration. Preliminary results with this device in treatment of thrombosed vascular access have been recently reported in literature. We want to report the preliminary results of our early experience with Indigo System CAT8, and the new cat d, in the treatment of acute thrombosed av f and avg. Method(s): Between November 2017 and July 2018, 5 patients with acutely thrombosed dialysis fistulae were treated. All procedures were performed within 48 hours of the occurrence of thrombosis. Patients (average age, 71 y; age range, 57–86 y; 3 men and 2 women) were treated with the indigo system. Result(s): Technical success was 80% (4 of 5 patients). Clinical success was 80% (4 of 5 patients); 1 patient had a thrombosed dialysis fistula 24 hours after declotting. No technical or device-related complications were reported. Adjunctive procedures included PTA (60%) and stent graft deployment (40%; 2 of 5 patients). Mean FU was 163 days (range 59–301). Primary patency at one-month was 80%. One patient had a second aspiration for recurrent thrombosis of the fistula at 37 days from the first procedure, leading to a 3-month primary patency of 60% and a secondary patency of 80%. Conclusion(s): Our preliminary experience confirms the safety and the efficacy of mechanical thrombo-aspiration with indigo system in the treatment of thrombosed dialysis AVF and/or AVG. Our results in terms of clinical success and patency at 3-month are in line with what reported by vascular guidelines.

  P447: Feasibility, Safety, and Effectiveness of Endovascular Stent-graft Placement for Emergency Repair of Acute Descending Thoracic and Abdominal Aorta Top

Priya Jagia, Amrinder Malhi

AIIMS Hospital, New Delhi, India. E-mail: [email protected]

Background: The traditional treatment for most patients with diseases of the descending thoracic aorta and abdominal aorta were surgical intervention with graft interposition. Now the trend is shifting towards the minimally invasive procedures especially towards the endovascular procedures. Several clinical studies have shown high success rates of emergency repair of acute thoracic and abdominal aortic disease by endovascular stent grafting. Compared with elective endovascular repair of thoracic aortic lesions, emergency stent-grafting is more demanding in several respects. Because many emergency procedures must be performed outside regular hospital hours, a team of radiologists, vascular surgeons, anesthesiologists, operating room nurses, and radiographers who can quickly set up the imaging, surgical, and interventional equipment should be on call around the clock. Method(s): We analyzed departmental database of endovascular stent graft patients from 2016 to 2018 in the department of Cardiovascular Radiology and endovascular intervention, All India Institute of Medical Sciences, New Delhi, India. We found total of 37 cases of endovascular stent graft deployment, out of which 32 were male and 5 were female. Out of these 37 cases, 10 were traumatic pseudoaneurysms, 2 were infective in etiology (one was of thoraco-lumbar tubercular spondylitis with pre and para vertebral abdominal and lower DTA pseudoaneurysm and another was upper DTA infective pseudoaneurysm). Eleven stent grafts were deployed in the emergency, out of which 10 were for traumatic pseudoaneurysms and 1 was for symptomatic infra renal abdominal aortic aneurysm. One case had a previous stent graft placement done for type B aortic dissection which now presented with DTA aneurysm and dissection at distal end of prior stent graft. In another postsurgical case, type B aortic dissection occurred following ascending aortic repair with arch vessel repair surgically. In total 27 patients had presented with back pain on presentation which was relieved after stent graft placement. Eleven patients were of type B aortic dissection. Result(s): Primary technical success rate (good entry sealing, absence of type I leak) was seen in 36/37 (97.29%) patients. In-hospital mortality was 0%. None of the patients had any spinal cord injury or paraplegia. At 6 months followup, none of the patient needed reintervention and clinical success was achieved in all but one patient who continued to have mild back pain. During follow-up, none of the patients died due to stentgraft-related complications. Conclusion(s): Emergency repair of acute descending thoracic aortic disease and abdominal aortic disease with stent-graft placement offers a promising alternative to open-chest surgery, especially in patients who are hemodynamically unstable and at high surgical risk.

  P448: Safety and Efficacy of Covered Endovascular Reconstruction of the Aortic Bifurcation Technique for Complex Aortoiliac Occlusive Disease: A Single Center Experience Top

Maria Antonella Ruffino, Maria Antonella Ruffino, Marco Fronda1, Andrea Discalzi, Andrea Mancini1, Pierluigi Muratore, Denis Rossato, Dorico Righi, Paolo Fonio1

Department of Diagnostic Imaging and Radiotherapy, Vascular Radiology, A.O.U. Citta della Salute e della Scienza di Torino, 1Department of Surgical Sciences, Radiology Unit, University of Torino, Torino, Italy. E-mail: [email protected]

Background: Endovascular intervention with kissing stenting (KS) is the first-line treatment for complex aortoiliac occlusive disease (AIOD) and it is related to less morbidity and a shorter hospital stay compared with open surgery. Unfortunately, recent study reported a primary patency of KS at 2-year follow-up of 79%. The geometry of the KS configuration was previously identified as a risk factor for restenosis and thrombosis. To achieve better long-term patency in 2013, a new technique named the covered endovascular reconstruction of the aortic bifurcation (CERAB) technique was introduced. The results at 1-year FU reported a primary and secondary patency rates of 87% and 95%, respectively. Three-year FU confirmed the good outcome of the CERAB technique for extensive AIOD with a primary, primary assisted, and secondary patency rates of 82%, 87%, and 97%, respectively. We want to report our single center experience with CERAB for the treatment of extensive AIOD. Method(s): Between February 2018 and July 2018, 9 patients (1 female) where diagnosed with intermittent claudication (7) and critical limb ischemia (2) and treated with CERAB technique. Lesion morphology was evaluated by CT angiography. All lesions were 7 TASC d and 2 TASC c lesions. Follow-up consisted of clinical assessment and duplex ultrasound at one and three months follow up. Patency rates and clinically driven target lesion revascularization were calculated. Result(s): Technical success was obtained in all the procedures (100%). Primary patency at three months was 100%. No complications were reported. There was no 30-day mortality. Median hospital stay was 1 days. Conclusion(s): The CERAB technique appears to be a safe and feasible alternative to open surgical reconstruction of the aortic bifurcation in complex occlusive disease. Our results are in line with what reported by latest studies in literature.

  P449: Clinical Outcomes in Patients with Preprocedural Hepatofugal Portal Venous Flow Undergoing Partial Splenic Artery Embolization for Hypersplenism Top

Mohamed Zaitoun, Riham Dessouky, Mohammed Basha

Zagazig University Hospitals, Zagazig, Egypt. E-mail: [email protected]

Background: Several previous studies suggested that hepatofugal flow should be considered as a contraindication to partial SAE. In this study we aimed at evaluation of the clinical outcomes of partial splenic artery embolization (SAE) in patients with post cirrhotic hypersplenism and preprocedural hepatofugal portal venous flow. Method(s): From January 2017 to October 2018, 40 patients with hypersplenism and hepatofugal portal venous flow underwent partial SAE. We considered 40 patients with hypersplenism and hepatopedal portal venous flow who are age-, gender- and Child Pugh classification matched case controls undergoing SAE for hypersplenism during the same period (control group). Perioperative and clinical outcomes after 1 year of follow up were compared between the two groups. Result(s): No significant differences were detected in the age, sex and laboratory investigations between the two groups (p ≥ 0.350). Mortality rate was zero in both groups. No significant difference were found regarding the postoperative complications between the two groups (p ≥ 0.250). Regarding the long-term clinical, laboratory and radiological outcomes, no significant differences were noticed between the two groups (p ≥ 0.3). Conclusion(s): Partial SAE in post cirrhotic hypersplenism patients with hepatofugal portal venous flow can be performed safely without significant complications and shouldn’t be considered as a contraindication for partial SAE in well selected patients with child’s a cirrhosis.

  P450: Endovascular Treatment of Arterial Injuries with Bentleys Begraft Stent-graft System: Preliminary Results Top

Maria Antonella Ruffino, Maria Antonella Ruffino, Marco Fronda1, Andrea Discalzi, Andrea Mancini, Pierluigi Muratore, Denis Rossato, Dorico Righi, Paolo Fonio

Department of Diagnostic Imaging and Radiotherapy, Vascular Radiology, A.O.U. Citta della Salute e della Scienza di Torino, 1Department of Surgical Sciences, Radiology Unit, University of Torino, Torino, Italy. E-mail: [email protected]

Background: Arterial injuries can occur in a vast array of arterial beds with substantial morbidity and mortality. Endovascular therapy (embolization/covered stent) provides a minimally invasive and effective alternative to surgery. In the last decade, new more flexible peripheral stent-grafts have been developed. Differently from coils, stent-grafts allow for the exclusion of the lesion/defect without the sacrifice of the target vessel avoiding ischemic complications. The aim of our study is to evaluate the efficacy and the safety of begraft peripheral stent-graft for endovascular treatment of arterial injuries. Method(s): Between June 2015 and May 2018, 56 patients (mean age 66.7±14.8 y, 34 males) underwent emergency begraft stentgraft implantation for 60 arterial injuries. Twenty-one (37.5%) of these patients were haemodynamically unstable. The primary endpoints of this study were technical and clinical success, rates of minor and major complications. The secondary endpoint was the patency of the device during the follow-up. Result(s): Active bleeding was observed in 28 (50%) patients, pseudoaneurysms in 9 (16%), FAV in 2 (3.6%), an enteric-iliac fistula in 1 (1.8%) and dissection in 16 (28.6%). In all patients, the respective lesion or defect was effectively excluded by covered stent. Clinical success was documented in 55/56 patients (98.2%). Major complications included death in one patients (1.8%, not procedure-related) and rebleeding in another (1.8%, due to the progression of acute pancreatitis). Minor complications were reported in two patients (3.6%). After a mean FU of 511±325 (range 2-1100) days, total person-time 50 years, all the implanted devices are patent, corresponding to a rate of no patency ≤2x10-2 events per person-years (EPPY). Conclusion(s): The implantation of begraft peripheral stent-graft for the treatment of arterial injuries is minimally invasive and effective, with acceptable patency rate at the mid-term follow up. Larger cohort studies and longer follow up are needed to confirm these preliminary results.

  P451: Uterine Artery Embolisation for Submucosal Fibroids: Efficacious and Safe? Top

Neeral Patel, Dermot Mallon, Alison Amoah, Aisling Fagan, Mohamad Hamady

Imperial College Healthcare NHS Trust, London, UK. E-mail: [email protected]

Background: Uterine artery embolisation (UAE) is an accepted treatment option for the majority of uterine fibroids. UAE in the case of submucosal fibroids is more contentious given the potential risk of expulsion of necrotic material. The aim of this study was to determine the suitability of UAE in cases where submucosal fibroids exist and to assess the procedural outcomes and complications. Method(s): Retrospective data was collected for UAEs conducted over a five-year period at a single tertiary centre. Patients with pre- and post-procedure MRI studies as well as submucosal fibroids were included. Alterations in the volume of the uterus and size of the dominant submucosal fibroid were calculated pre- and post-UAE. Post-UAE complications and surgical interventions were also documented. Patient satisfaction was assessed using the 40-point uterine fibroid symptom quality of life (UFS-QoL) questionnaire. Result(s): Between 2013-2018, 281 female patients underwent UAE. Of these, 26 (9.3%) patients were found to have submucosal fibroids (mean age 47.5±5.0 years; range: 35-56). The mean pre-UAE uterine volume was 986.5±565.1 CC, while mean post-UAE uterine volume was 666.9±542.0 CC (p<0.05). The mean dominant submucosal fibroid size pre-UAE was 5.3±2.5 cm, and post-UAE was 3.25±2.74 cm (p<0.05). 100% of fibroids were effectively devascularised. 7.7% of patients experienced post-UAE pelvic infection. 41.2% patients underwent further surgical intervention, while 58.8% were discharged from clinic. Conclusion(s): UAE is a safe and efficacious treatment option for submucosal fibroids, however a high percentage of patients may require adjunctive surgical intervention to augment therapeutic results.

  P452: Transarterial Genicular Artery Embolization as Treatment of Chronic Knee Pain in Patients with Osteoarthritis Top

Sergejs Pavlovics, Helmuts Kidikas, Janis Savlovskis, Yana Solskaya, Karlis Kupcs, Andris Veiss

Department of Interventional Radiology and Neuroradiology, Pauls Stradins Clinical University Hospital, Riga, Latvia. E-mail: [email protected]

Background: Osteoarthritis is a common cause of pain and disability. Symptoms are seen in an approximately 10 % of people over the age of 55 years. Mild to moderate knee osteoarthritis resistant to medication therapy, yet not severe enough to warrant joint replacement, represents a challenge in its management. Recent publications demonstrated that transcatheter arterial embolization for chronic painful conditions resulted in excellent pain relief. Our goal is to demonstrate the safety and efficacy of transcatheter arterial embolization for mild to moderate knee osteoarthritis that is resistant to conservative treatment. Method(s): We share our initial experience of four cases. Patients had moderate to severe medial knee pain (pain and total WOMAC* score) resistant to conservative therapy for at least 3 months. Patients were assessed by conventional radiography and MRI. Common femoral artery was punctured under local anaesthesia and percutaneous arterial access was obtained in an ipsilateral anterograde fashion. Abnormal neovessels were identified within soft tissue surrounding knee joint in all cases by arteriography. We used polyvinyl alcohol embolization particles 40-150 μm in two cases and 75 μm Embozene microspheres in other two cases. Embolic agent was infused until hemostasis in pathological neovessels was achieved. The patients were discharged on the same day. Result(s): The technical success rate was 100 %. No major adverse events were related to the procedures. Knee pain of treated patients significantly decreased 1 month after the procedure. Conclusion(s): Transcatheter arterial embolization for mild to moderate knee osteoarthritis refractory to traditional nonsurgical management was effective, minimally invasive and safe treatment option.

  P453: Transhepatic Permanent Dialysis Catheter Application: Single Center Experience in 300 Patients with End Stage Renal Disease Top

Ghada Samir Ibrahim, Karim Ahmed Abd El Tawab

Faculty of Medicine, Ain Shams University, Cairo, Egypt. E-mail: [email protected]

Background: For patients on hemodialysis; when the AV Fistulae or grafts are exhausted, patients need tunneled dialysis catheters applied through Jugular, subclavian or femoral veins. Permanent dialysis catheter in hepatic veins as an alternative is used when the other routes are thrombosed. This study describes the technique and primary success rate of application of permanent dialysis catheter in hepatic veins. Method(s): From January 2015 to October 2018, 296 patients with thrombosed classic routes were presented to our unit for Transhepatic permicath application. Procedure was done under local analgesia. The chosen hepatic vein (Right in 128 patients, middle in 110 and left in 58 patient) was accessed by a 16 G Angiocath under ultrasound guidance. Under fluoroscopic guidance, a hydrophilic guide wire was introduced through the angiocath in hepatic vein and secured upwards in Inferior Vena Cava and atrium in 234 patients or downwards in Inferior Vena Cava in 60 patients, a split catheter was applied over 2 wires upwards and downwards in 2 cases. Peel away sheath was advanced over the wire. Subcutaneous tunnel was formed and the catheter was inserted over the wire through the peel away sheath over the wire. Result(s): Technical success rate was 100%. Mild shoulder pain was noted in some patients and managed conservatively. 183 patients had 6 months patency rate.15 patients developed tunnel infection and thrombosis and had their catheters removed within the first 6 months.11 patients developed thrombosis within the first few dialysis sessions. 1 patient developed fatal hepatic subcapsular hematoma. Rest of the patients could not be followed up. Conclusion(s): Combined ultrasound and fluoroscopic guided transhepatic permanent dialysis catheter application offers a reliable option with good short and mid term patency rates for patients with exhausted classic venous access routes.

  P454: A Clinically Driven New Classification for Aortic Dissections Top

Sonaz Malekzadeh, D. Bodenmann, Antoine Topolsky, A. Nicolas, Jean-Aibert Collinot, Anne-Marie Jouannic, Prof. Salah-Dine Qanadli

Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland. E-mail: [email protected]

Background: To report a new classification for aortic dissections (AD), based on a modified Stanford classification, to consider the aortic arch as a separate entity and integrate patterns influencing treatment strategy notably malperfusion syndrome (MPS). The proposed classification was evaluated in a large population of ADs. Method(s): All patients with proven de novo acute AD who were admitted to our hospital from 2005 to 2017 were included in this study. All pre-therapy CT angiographies were reviewed and reclassified using the new classification based on three types and four subtypes: Type: A, dissection involving at least the ascending aorta; Type B, dissection involving exclusively the descending aorta; and type C, dissection involving the aortic arch with/without descending aorta. Subtype: 0; absence of MPS; 1, dynamic MPS; 2, static MPS; 3, static and dynamic MPS. Result(s): A total number of 228 consecutive patients were included in the study. According to the new classification, AD were distributed as 153 type A, 50 type B (38B0, 5B1, 6B2, 1B3) and 25 type C (18C0, 6C2, 1C3). The new type represented 11% of all ADs. MPS was present in 28% of type C. Treatment strategies in type C included endovascular interventions and surgery in 32% and 12%, respectively. Conclusion(s): The new classification is easy to use and feasible in a large group population. It should be helpful driving the decision making process and especially in integrating the latest development in trans-catheter therapies.

  P455: Pelvic Venous Reflux in Males with Varicose Veins and Recurrent Varicose Veins Top

David Beckett, Alaa Ismail1, Emma Dabbs, Judy Holdstock, Scott Dos Santos, Mark Whitele

The Whiteley Clinics, London, 1Royal Bournemouth Hospital, Bournemouth, UK. E-mail: [email protected]

Background: To report on a male cohort with pelvic vein reflux and associated primary and recurrent lower limb varicose veins. Method(s): Full lower limb duplex ultrasonography revealed significant pelvic contribution in eight males (3% of those presenting during the time period) presenting with bilateral lower limb varicose veins. Testicular and internal iliac veins were examined with either one or a combination of computed tomography, magnetic resonance venography, testicular, transabdominal or transrectal duplex ultrasonography. Subsequently, all patients received pelvic vein embolisation, prior to leg varicose vein treatment. Venography and Cross sectional Imaging depicts reflux from not only the internal iliacs but the testicular veins communicating avidly with the legs. Result(s): Pelvic vein reflux was found in 23 of the 32 truncal pelvic veins and these were treated by pelvic vein embolisation. Four patients have since completed their leg varicose vein treatment and four are undergoing leg varicose vein treatments currently. Conclusion(s): Pelvic vein reflux contributes towards lower limb venous insufficiency in 3% males with leg varicose veins. Despite the challenges, we suggest that pelvic vein reflux should probably be investigated and pelvic vein embolisation considered in such patients to reduce risks of recurrence.

  P456: Anatomical Abnormalities of the Pelvic Venous System and their Implications for Endovascular Management of Pelvic Venous Reflux Top

David Beckett, Alaa Ismail1, Scott Dos Santos, Emma Dabbs, Barrie Price, Mark Whiteley

The Whiteley Clinics, London, 1Royal Bournemouth Hospital, Bournemouth, UK. E-mail: [email protected]

Background: Pelvic venous reflux is often treated with pelvic vein embolisation; however, atypical pelvic venous anatomy may provide therapeutic challenges. Method(s): We retrospectively over 100 patient files and reported symptoms and diagnostic imaging. Patients in which aberrant anatomy had been demonstrated was reviewed. We discuss the basic techniques of Pelvic Vein Embolisation and highlight in a pictorial review the range of anatomical abnormalities demonstrated in the female pelvis. Result(s): Anatomical abnormalities demonstrated included internal iliac veins draining into the contralateral common iliac vein, duplicated inferior vena cava, reverse-angle renal veins with atypical left ovarian vein drainage and direct drainage of the internal iliac vein to the inferior vena cava. All patients were successfully treated with pelvic vein embolisation. Catheter choice and approach to treatment when facing anatomical variations are shown. Conclusion(s): Abnormal embryological development may cause variable pelvic venous anatomy. Knowledge of this will enable interventional radiologists to successfully treat such patients. This pictorial review demonstrates the most commonly encountered abnormalities and the challenges to interventional radiology in Pelvic Vein Embolisation.

  P457: The Efficacy and Safety of Radiofrequency Ablation As a Treatment Option for Benign Thyroid Nodules Top

Yasser Saleh Alduribi, Mohammed T. Alshammari

Security Forces Hospital Program, Riyadh, Saudi Arabia. E-mail: [email protected]

Background: The aim of this study is to measure the efficacy and safety of radiofrequency ablation (RFA) as a treatment option for benign thyroid nodules. Method(s): The study includes 56 pathologically proven benign thyroid nodules from 50 patients as Bethesda II by two timely separated fine needle aspiration (FNA). All nodules were treated with RFA between January 2016 and December 2018 by interventional radiologist. The volume and size of the nodules were determined before treatment utilizing ultrasound evaluation. The response was retrospectively assessed using the volume reduction ratio (VRR) by ultrasound examination at 6 months and 12 months post ablation procedure. Therapeutic success was defined as a >50% and 75% volume reduction at 6 months and 1 year, respectively. All minor and major complications were recorded. Result(s): The mean volume of nodule was 54.3 cm3 (42.6–291.5). The mean VRRs were 60.4±12.7% at 6 months and 81.4±11.8% at 1 year. Two patients (4%) had immediate voice changes and three patients (6%) had infection with sinus formation. Conclusion(s): Radiofrequency ablation is very effective in decreasing the size of the benign thyroid nodule.

  P458: Contrast-Enhanced Ultrasound in Vascular and Interventional Radiology: Current Status and Future Perspective Top

Mohammed Al-Natour, Dean Nakamoto, Nami Azar

University Hospitals Cleveland Medical Center/Case Wstern Reserve SOM, Cleveland, USA. E-mail: [email protected]

Background: Ultrasound (US) is the modality of choice for the workup of many vascular pathologies based on a plethora of advantages. However, US has inherent limitations including limited spatial resolution, and lower sensitivity to slow blood flow and vascular luminal irregularities. For evaluation of vascular pathology, angiography has long been considered the gold standard. Cross-sectional imaging techniques have gradually replaced angiography for the evaluation of many vascular beds, currently being regarded as the diagnostic imaging modality of choice for diagnosis of virtually almost every vascular disease leaving angiography mainly for treatment purposes. The introduction of microbubbles as ultrasonographic contrast agents has rendered contrast-enhanced ultrasound (CEUS) an evolving valuable complementary technique with markedly increased diagnostic accuracy for assessing both the macro- and microvascular anatomy of the vasculature. CEUS has a safety profile which is much favorable when compared to other contrast agents. Due to its superior spatial and temporal resolution, ability for prolonged scanning and dynamic and real-time imaging, it provides clinically significant additional information compared to the standard Duplex US. Method(s): In this communication, we discuss the currently available literature regarding vascular applications of CEUS, with special attention to the abdominal aorta, briefly elaborate on CEUS technique and present cases in order to illustrate the added value in the diagnosis and treatment of aortic pathologies. Result(s): CEUS enables imaging of adventitial vasa vasorum providing additional clinical utility since adventitial vasa vasorum has important implications in the pathogenesis of vascular diseases. The recent advances of CEUS along with ongoing development of drug-eluting contrast microbubbles has allowed improved targeted detection and real-time ultrasound guided therapy for aortic vasa vasorum inflammation and neovascularization in animal models. Conclusion(s): CEUS is uniquely suited to comprehensively assess and potentially treat vascular diseases in the future.

  P459: Inferior Vena Cava Filters: Retrospective Review of a Single Center Experience Top

Reema Alrasheed, Rifaat Salman, Naila A. Shaheen, Anita Immanuel1, Giamal Edin Gmati, Ghazy A. Bukhary

National Guard Health Affairs, 1East Suffolk and North Essex NHS Foundation Trust, Essex, UK. E-mail: [email protected]

Background: Venous thromboembolism is a preventable culprit of Pulmonary Embolism. PE remains a source of significant mortality and morbidity in Saudi Arabia, its exact incidence remains unknown, however, deaths due to VTE and PE range from 10-12% in inpatients. While most patients are managed by oral anticoagulants; many risk factors preclude their use and recurrent PE remains a major risk. IVC filters has been introduced since 1969, many filter types were developed since then which had better outcomes and less complications. In this review, we explored the indications, success and complications rate of IVC insertion in a large tertiary hospital in Saudi Arabia to compare it to the trends reported in the latest edition of Guidelines in the United States and Europe (CIRSE). Method(s): The medical charts of patients who had IVC insertion from 2011-2016 years were reviewed. Indications of insertion, outcomes, complications of IVC were collected. Categorial variables were summarized as proportion and percent. Continuous variables were summarized as mean and standard deviation. Data was analyzed using SAS. Result(s): Total of 411 patients were eligible based on the inclusion criteria. 61.07% males, 38.93% females. The main referring departments were Internal Medicine, Orthopedics, and Emergency Room 15.54% (n= 55), 13.84% (n= 49), 12.99% (n=13.84), respectively. Main indication for filter insertion in our sample was calculated based on the latest SIR guidelines. the most common indication of insertions was Absolute or relative contraindication to Oral anti coagulants 131 (37.86%) followed by PE or DVT and transient inability to anticoagulate in 65 (18.79%). 2.94% had history of thrombophilia and one patient (0.24) pregnant at the time of insertion and had thrombosis as a late complication. While 18.79% (n=65) of our patients did not have a clear indication documented to insert IVC filters. Thrombotic events were calculated in our sample and 52.94% (n=216) had only one thrombotic event. An increase of filters insertion was noted from 2011 (n=57) to 2016 (n=89). The institution has all filter types available most of the time, yet, Optease filters were inserted mostly (75.31%) followed by Denali (15.65%). 97.32% (n= 399) of filters were inserted infrarenally, while 2.20% were inserted suprarenally (n=9). In 0.49% (n=2) of our patients, IVC filter was inserted in the common iliac vein. We have lost long follow up due to different reasons in 55.42% (n=225) of our patients which is significant despite the follow up measures taken in our institution. Immediate complications did not occur in 83.90% (n=344). Most common immediate complication was tilting 13.66% (n=56). Mean duration of filter in situ was 91.91 days. No late complications occurred in 40.25% (n=163). Loss of follow up due to death and other causes occurred in 27.90% (n=113) and 21.48% (n=87), respectively. Most common late complication was Thrombosis 9.38% (n=38). Successful retrieval rates varied between years. IVC thrombus complicated retrieval in 1.97% of patients (n=8) and failure to retrieve due to other comorbidities and implications occurred in 1.48% (n=6). Conclusion(s): We have observed IVC Insertion problems similar to international reported figures. The rate of Insertion problems was 5-23% in the US, while it was 16.1% (n=66) in our sample. Filter movement was reported in 0-18% in the US, whereas it was 0.49% in ours (n=2). Retrieval was successful in 84.97% (n=153) of patients who followed up, 50.62%, compared to 34% in the US. IVC filter penetration occurred in 0.49% (n=2) of our patients which significantly lower than the range reported in US (0-41%) which could be due to loss of follow up in our sample. Compared to the International standard considered by our institution, our sample had similar thresholds. In summary, IVC filter placement in our institution had minimal complications and is similar. The rate of mortality was 0.24%.

P460: A Prospective Randomized Study Comparing the Use of Plain Percutaneous Transluminal Angioplasty Balloon Catheters for Primary Balloon Angioplasty versus Hydrostatic Dilatation to Prepare the Cephalic Vein Prior to Creation of Radio-Cephalic Arteriovenous for Dialysis

Mohamed Ismail, Mohamed Rizk

Ain Shams University, Cairo, Egypt. E-mail: [email protected]

Background: To compare the immediate technical success, maturation time, and the need for further balloon assisted maturation for radio-cephalic arteriovenous fistulas to render them ready for hemodialysis. Method(s): Fifty-seven (57) patients with ESRD in need for vascular access for whom a radio-cephalic arteriovenous fistula was of choice, with a cephalic vein ≤ 3 mm. They presented to us from the period of November 2014 till January 2017, were randomized into two groups. The cephalic vein was prepared in group (A) using hydrostatic dilatation prior to creation of the fistula, while in group (B) the vein was prepared using a PTA balloon catheter for primary balloon angioplasty prior to the creation of the fistula. Result(s): The technical success rate was 96.5%, 100% in both groups respectively. The reintervention rate was 35.7%, 7.1% in both groups respectively. The mean maturation time was 43 days, 32.1 days in both groups respectively. Conclusion(s): Using primary balloon dilatation during creation of a radiocephalic arteriovenous fistula leads to a decreased maturation time and less reintervention rate, but still these results are statistically insignificant may be due to small number of study sample.

  P461: Localized Aortic Primary Stenting for Focal Aortic Stenosis: Review of 9 Patients with Short-Term Outcome Top

Mohamed Ismail, Atef Abd Elhamed, Ramez Mounir, Ahmed Khairy1

Ain Shams University, 1Benha university, Cairo, Egypt. E-mail: [email protected]

Background: Focal infra-renal aortic stenosis that demands treatment is relatively infrequent condition. Short stenotic lesions may be amenable for endovascular treatment, while long lesions are traditionally treated withsurgical bypass grafting. Method(s): Nine consecutive patients were treated for infra-renal aortic stenotic lesions with primary focal aortic stenting between April 2014 and October 2015 in vascular unit, general surgery department, Benha University and vascular surgery department, Nile Insurance Hospital and vascular surgery department, Ain Shams University. Indications included disabling claudication (n?2), blue toe syndrome (n?4) or minor tissue loss (n?3). Result(s): This study had technical success 88.9% with clinical and hemodynamic success 100%. 6 months primary patency for focal aortic stents was 100% with complications rate 22.2%. Conclusion(s): Focal aortic stenotic lesions could be safely managed by endovascular therapy. Primary stenting is associated with improvement of clinical and hemodynamic outcome.

  P462: Urgent Embolization of Bilateral Middle Rectal Artery in the Management of Life-Threatening Hemorrhoid Bleeding in a Patient with Occlusion of the Inferior Mesenteric Artery Top

Wafa Boughanmi, Vania Tacher, Eva Jambon, Manuel Vitellius, Marjane Djabbari, Hicham Kobeiter

Henri Mondor Hospital, Créteil, France. E-mail: [email protected]

Background: Internal hemorrhoids rarely cause life-threating massive rectal bleeding and usually depend on the inflow of the superior rectal arteries. We report a case of an urgent emborrhoid technique by embolizing both middle rectal arteries in a patient presenting with a life-threatening rectal bleeding and an occluded inferior mesenteric artery on CT scan. Method(s): The procedure was performed with a right femoral arterial approach. Left internal iliac artery was cannulated with a 5 F long sheath (after cross- over). Angiographies then Cone Beam CT (CBCT) were performed showing a large anastomotic left middle rectal artery involved in the hemorrhoidal vascularazition. Superselective catheterization of left middle rectal artery was realized using a 2.8 F microcatheter. Then embolization using a packing of microcoils and some pledget of gelfoam to close the anastomotic shunts was performed. Right internal iliac artery was then catheterized. Angiography and CBCT showed a less anastomotic right middle rectal artery involvement in hemorrhoid vascularization but confirmed the origin of the bleeding with contrast within the rectum. Hence, only one microcoil was used and some gelfoam pledget. Result(s): Angiographies and CBCT confirmed the origin of the bleeding and showed satisfying final result with complete exclusion of internal hemorrhoids. Stabilization of vital signs was perceived during the procedure. A three weeks clinical and endoscopic follow-up showed no recurrence of the bleeding. Conclusion(s): Emborrhoid technique can be used in urgent treatment of massive hemorrhoid bleeding even when the access to the inferior mesenteric artery is not possible by embolizing middle rectal artery as it is the main blood supply of hemorrhoid in this case. CBCT helps identifying the main feeder arteries and guides the embolization.

  P501: Effectiveness of ACE68 and ACE64 Catheters in Anterior Circulation Large Vessel Occlusion: Promise Study Subgroup Analysis by Occlusion Location Top

Rosario Papa, Peter Schramm1, Pedro Navia2, Joaquin Zamorra Parra3, Alejandro Tomasello Weitz4, Werner Weber5, Jens Fiehler6, Patrik Michel7, Vitor Pereira8, Timo Krings8, Laurent Pierot9

A.O.U Policlinico, Messina, Italy, Acireale, Italy, 1Universitätsklinikum Schleswig-Holstein, Lübeck, 5Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, 6Universitätsklinikum Hamburg-Eppendorf, Hamburg, Geramny, 2Hospital Universitario Donostia, San Sebastian, 3Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, 4Vall d’Hebron Hospital, Barcelona, Spain, 7Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland, 8University of Toronto, Toronto, Canada, 9Hôpital Maison Blanche, Reims, France E-mail: [email protected]

Background: The PROMISE Study documented safety and efficacy of ACE68 and ACE64 Reperfusion Catheters in patients with acute ischemic stroke (AIS) from large vessel occlusion (LVO), treated with ADAPT (A Direct Aspiration First Pass Technique) as frontline treatment. This analysis examines the safety and efficacy by occlusion location. Method(s): PROMISE was a prospective, single-arm, multicenter study. Inclusion criteria were anterior circulation LVO within 6 hours of ictus; NIHSS ≥ 2; CT-ASPECTS ≥ 6; or MR-ASPECTS ≥ 5. Primary endpoints included successful angiographic revascularization (mTICI 2b-3), clinical independence (mRS 0-2) at 90 days. Secondary endpoints included safety events, functional improvement at 7-10 days. This subgroup analysis investigates these endpoints by occlusion location. Result(s): Across 20 European centers, 204 patients (median age 74 [IQR 65-80]) were enrolled. Primary occlusion locations were 21.1% (43/204) ICA/Carotid-T, 60.8% (124/204) M1, 18.1% (37/204) M2. Median baseline CT ASPECT score was 9 [IQR 8-10]. Median baseline NIHSS score was 16 [IQR 11-20]. Prior to procedure, 61.8% (126/204) patients had IV rtPA. Immediate post-procedural angiographic revascularization (mTICI 2b/3) rate was 93.1% (190/204), 90-day mRS 0-2 rate was 61.0% (122/200). Subgroup analysis by occlusion location: ICA/Carotid-T final revascularization (mTICI 2b/3) was 95.3% (41/43), 90-day mRS 0-2 was achieved in 64.3% (27/42); MCA M1 final revascularization was 92.7% (115/124) and 90-day mRS 0-2 rate was 57.0% (69/121); MCA M2 final revascularization was 91.9% (34/37) with 70.3% (26/37) having 90-day mRS 0-2. Safety rates were favorable (sICH=2.9%; ENT=1.5%); 90-day morbidity (mRS 3-5) was observed in 31.5% (63/200), and 90-day all cause-mortality was observed in 7.5% (15/200). Device and procedure-related SAEs at 30-days were reported in 2.0% (4/204) and 4.4% (9/204) of subjects, respectively. There was no significant difference in safety rates by treatment location. Conclusion(s): This subset analysis of the PROMISE study demonstrates the ACE68/64 Reperfusion Catheters are able to achieve high mTICI scores, with comparable safety profile and 3-month mRS in all studied locations for patients with LVO-AIS.


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OC1.1: Is it Tri...
OC1.2: Mechanoch...
OC1.3: Does Left...
OC1.4: Evaluatio...
OC1.5: Radial Ac...
OC1.6: Transcath...
OC1.7: Conventio...
OC1.8: Outcome o...
OC1.9: Our Exper...
OC1.10: Clinical...
OC1.11: Carotid ...
OC2.1: Endovascu...
OC2.2: Finding P...
OC2.3: Cookie Cu...
OC2.4: Posterior...
OC2.5: Treatment...
OC2.6: Modified ...
OC2.7: Ultrasoun...
OC2.8: Angioembo...
OC2.9: Combined ...
OC2.10: Computed...
OC2.11: Re-Estab...
OC3.1: Road to I...
OC3.2: Percutane...
OC3.3: Combinati...
OC3.4: Efficacy ...
OC3.5: Hostile N...
OC3.6: Endovascu...
OC3.7: Modified ...
OC3.8: Safety an...
OC3.9: To Determ...
OC3.10: Femoral-...
OC3.11: Superfic...
OC3.12: Surfacer...
OC3.13: Percutan...
C 3.14: Radiatio...
OC3.15: Emboliza...
OC4.1: Duplex-Ul...
OC4.2: Initial E...
OC4.3: Endolumin...
OC4.4: Aspiratio...
OC4.5: Angiograp...
OC4.6: Safety an...
OC4.7: Glue Embo...
OC4.8: Use of Gl...
OC4.9: Early Por...
OC4.10: Increasi...
OC4.11: Associat...
P101: Relative A...
P102: Hail Medic...
P103: Awareness ...
P201: Non-Target...
P202: Sentinel N...
P203: Selective ...
P204: Bland Embo...
P205: Combined T...
P206: Assessment...
P207: Uterine Ar...
P301: Computed T...
P302: Ultrasound...
P303: Transrecta...
P304: Percutaneo...
P305: Percutaneo...
P306: Ultrasound...
P307: Egyptian F...
P308: Computed T...
P401: Splenic Ar...
P402: Comparativ...
P403: Angiograph...
P404: Outcomes o...
P405: Endovascul...
P406: Vena Cava ...
P407: Preoperati...
P408: Femoropopl...
P409: Percutaneo...
P410: Extra-Hepa...
P411: Crush Sten...
P412: Uterine Ar...
P413: Balloon Oc...
P414: Aspiration...
P415: Parastomal...
P416: Tips and T...
P417: The Effect...
P418: My Escape ...
P419: High Flow ...
P420: Long Life ...
P421: Uterine Ar...
P422: Prophylact...
P423: Drug Coate...
P424: Below Knee...
P425: Non-Operat...
P427: Efficacy o...
P428: Drug Eluti...
P429: Ultrasound...
P430: Uterine Ar...
P431: Type II Co...
P432: Endovascul...
P433: An Audit o...
P434: Hepatic Ar...
P435: Varicocele...
P436: Pelvic Vei...
P437: Interventi...
P438: The Utilit...
P439: Sharp Reca...
P440: Unusual Ca...
P441: HERO&...
P442: Drug-Coate...
P443: The Use of...
P444: Angioplast...
P445: Endovascul...
P446: Mechanical...
P447: Feasibilit...
P448: Safety and...
P449: Clinical O...
P450: Endovascul...
P451: Uterine Ar...
P452: Transarter...
P453: Transhepat...
P454: A Clinical...
P455: Pelvic Ven...
P456: Anatomical...
P457: The Effica...
P458: Contrast-E...
P459: Inferior V...
P461: Localized ...
P462: Urgent Emb...
P501: Effectiven...

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