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Intervention IQ - Spreading the News of IR

CIRSE 2012 - LisbonMonday, September 17, 2012

C RSECardiovascular and Interventional Radiological Society of Europe

Don’t miss the Party of the Year!

Don’t miss this year’s most interactive session!

The Film Interpretation Panel has alwaysbeen one of CIRSE’s most popular sessions,and this year, we’re giving all congress delegates an even better opportunity to getinvolved, with our all-new “last man standing” format!

All participants will receive a limited-editioncap – make sure you get yours!

Turn to page 3 for more details.

Put your skills to thetest and find out howgood you really are!

Join us today at 15:30 in Auditorium 1!

Film InterpretationQuiz

live versions of well-known modern songsand standards in their own inimitable style,oiling the wheels of collegiality!

You can choose to join us for the dinner andparty, or if you prefer to have dinner else-where in the city, the party only. There areonly a few tickets left for this sought-afterevent – ask at the Hotel, Tours & Social Eventscounter to the right of the entrance hall tosecure your place.

Reward yourself for all your hard work atthis year’s CIRSE, and join us for the CIRSEParty tomorrow evening! After an intenseand hectic congress, the Party offers achance to catch up with your colleagues inmore informal surroundings – this year, inthe elegant surroundings of Pátio da Galé,one of Lisbon’s finest establishments.

Dinner will be served in the impressive Sala dos Riscos, and afterwards, the Germanband Fresh Music Live will entertain you with

so lution to their discomfort. Luckily, the rangeof treatment options offered by IR can providethem with the relief they seek.

The latest issue of Intervention IQ explores IR’sgrowing role in managing venous disorders.The traditional solutions to varicose veins, suchas surgical vein stripping, as often consideredtoo invasive by patients, or too expensive forinsurers. Newer ablation or foam-based methodsavoid the long recovery times and expense ofmore invasive therapies, and many patients arechoosing to pay privately for these options.

This issue also examines the vital role of IR intreating DVT, as well as the pioneering workbeing done on developing prosthetic valves.All of these issues are examined from both aclinical and an economic perspective, withinterviews with patients, clinicians and healtheconomists.

The latest edition was sent to 45,000 readers, areadership which mostly comprises non-radio -logists. To find out more, please see the compli-mentary copy in your congress bag, or visit theNext Publishing Intervention IQ Lounge to pickup one of our previous issues.

Some snippets from the current issue of IQ:

Voting With Their Wallets“It’s not just about cosmetics: quite a numberof patients are actually quite symptomatic –probably about 70-75% will have some degreeof symptoms.”- Dr. Kieran McBride, Scottish Vein Centre

Venous Disorders: widespread and costly“In 2006, the healthcare costs just for varicoseveins of the legs amounted to € 808 million inGermany“ - Robert Koch Institute Report 2009

Economy Class Syndrome “DVT can have serious consequences: venousthromboembolism is the third biggest cause ofcardiovascular mortality after stroke and heartattack.” - Dr. Gerard O’Sullivan, University College

Hospital Galway

Venous disorders affect a huge cross-section ofthe population – up to 90% of the adult popu-lation, according to some studies. While fatalitiesare relatively rare, restricted blood flow or de -fective venous valves can result in a markedlyreduced quality of life, and many patients arelooking for an effective, minimally invasive

See you there!

Join us for the CIRSE 2012 Party!Tuesday, September 18, 20:00

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Pedal Angioplasty 3

The general loss of taboos seems to also havereached the holy fields of interventional radiol-ogy. However, this is not without positive as -pects: infrapopliteal interventions and even pe -dal angioplasty were once so-called “forbiddenterritories”, but have now become a new play-ing field for enthusiastic and innovative inter-ventionists – and have proved to be of clear be ne fit to patients with critical limb ischaemia(CLI).

With the development of infrainguinal angio-plasty, a variety of new techniques and deviceshave been developed, which in recent years,have also found their way below the ankle.Consequently, so-called “pedal angioplasty” hasbeen established and is going now to conquerthe last territories of human vessels for interventional radiology.

Several studies have already underlined themeaning of below-the-ankle strategies. Regar -ding the pathophysiological mechanisms, the“angiosome model” has gained high accept-ance: based on the classic angiosome models ofTaylor and Attinger et al., some more recent stu -dies have also shown the value of an angiosomeconcept for the treatment of pedal arteries, andthere is increasing evidence that the angiosomeconcept is clinically useful in planning treat-ment for both infrapopliteal and pedal arteries.

According to this model, the foot is dividedinto six angiosomes: three angiosomes arisefrom the posterior tibial artery and supply theplantar side of the toe, web space of the toes,plantar foot and the inside of the heel. Onearises from the anterior tibial artery and sup-plies the dorsal side of the toe and dorsal foot;and two angiosomes arise from the peroneal

arteries and supply the lateral ankle and theoutside of the heel.

In a recent study, Iida et al. demonstrated thatachieving direct flow by angioplasty of themost appropriate vessel based on the angio-some model is clinically important for amputation-free survival.

Currently, lesions are generally approachedwith a system consisting of hydrophilic .014-inch guidewires, supported by low-profileballoon catheter in various lengths, specificallydesigned for below-the-knee (BTK) and below-the-ankle interventions. Local injectionthrough the balloon catheter can also be usedto confirm the correct intraluminal positionbefore inflation. Inflation times of between 60and 180 seconds are recommended, with apressure rate between 7 and 10 atm. The bal-loon size for foot vessels and plantar arch isusually 2-3 mm.

Regarding the newest techniques, the classicantegrade approach is being increasingly re -placed by alternative techniques. Technically,with the decreasing size of catheters and bal-loons, it gets more and more feasible to utiliseeven small access sites, such as the pedal arter-ies. Using micro-puncture equipment, access ofpedal arteries (and/or an antegrade-retrogradeaccess) can be achieved, resulting in a pedal-plantar loop, or subintimal flossing, as first de -scribed as the SAFARI technique by Spinosa.More recently, such pedal-plantar loop tech-niques have also been described, with a guide -wire loop from the anterior tibial artery to theposterior tibial artery created through thepedal arch to improve technical success.

Pedal Angioplasty: Breaking the Taboos Pedal angioplastySpecial SessionMonday, September 17, 10:00-11:00Auditorium 8

Don't miss it !

Further development of more distal angio-plasty techniques (such as subintimal tracking,pro ximal and distal to the pedal-plantar arch,transcollateral angioplasty and direct digitalretrograde puncture) have also been described,as well as retrograde transdorsal to plantar andtransplantar to dorsal techniques using pedalarteries. Indications for such procedures arisewhen there is no proximal stump for an ante-grade recanalisation, or when dissections orperforations appear.

In conclusion, when starting with the pre-evaluation and patient selection, foot vesselsshould nowadays be included, and should beexamined and imaged coincidentally, as thepatency of plantar arch vessels provides essential blood flow to both the forefoot andthe calcaneal region. Beyond a primary therapyof foot vessels, treatment of below-the-kneevessels becomes effective only when the outflow conditions are optimised.

Discussing modern concepts of endovasculartreatment below the knee, de novo lesions inpedal arteries should therefore be consideredin a global therapy concept in patients withcritical limb ischaemia (CLI), Rutherford cate-gory 4-6, on the basis of non-healing gangreneand/or ulcerations of the foot associated with acritically low level of oxygen tension (TcPO2).

Access from pedal arteries, including theirrevascularisation, might also be used in casesin which it is necessary to use a retrogradeapproach coming from the plantar arch to treatthe anterior or posterior tibial artery as the tar-get vessel when antegrade crossing becomesimpossible.

Thomas Rand (EBIR)

Prof. Thomas Rand is an interventional radio -logist and Head of Radiology at Hietzing GeneralHospital, Vienna. He graduated from the Univer -sity of Vienna, specialising first in osteoradiology,and later in interventional radiology. He complet-ed his professorial thesis in 2000 on the diagnosisof rheumatological illnesses. Prof. Rand completedfellowships at New York University and theUniversity of California, San Diego. He has beenauthor or co-author on over 100 peer-reviewedarticles and 10 books. He is a member of numer-ous scientific societies, and is much involved withresearch and education.

Thomas RandGeneral Hospital HietzingVienna, Austria

References:1. Clinical results of below-the knee intervention using pedal-

plantar loop technique for the revascularization of foot arteries.Manzi M, Fusaro M, Ceccacci T, et al. J Cardiovasc Surg (Torino).2009;50(3):331-7.

2. Pedal-plantar loop technique for a challenging below-the-kneechronic total occlusion: a novel approach to percutaneousrevascularization in critical lower limb ischemia. Fusaro M, DallaPaola L, Biondi-Zoccai G. J Invasive Cardiol. 2007; 19(2):E34-7.

3. Retrograde posterior tibial artery access for below-the-kneepercutaneous revascularization by means of sheathlessapproach and double wire technique. Fusaro M, Dalla Paola L,Biondi-Zoccai GG. Minerva Cardioangiol. 2006; 54(6):773-7.

4. Plantar to dorsalis pedis artery subintimal angioplasty in a pa -tient with critical foot ischemia: a novel technique in the arma-mentarium of the peripheral interventionist. Fusaro M, DallaPaola L, Brigato C, et al. J Cardiovasc Med. 2007; 8(11):977-80.

5. Subintimal arterial flossing with antegrade-retrograde interven-tion (SAFARI) for subintimal recanalization to treat chronic criti-cal limb ischemia. Spinosa DJ, Harthun NL, Bissonette EA, et al. J Vasc Interv Radiol. 2005 Jan;16(1):37-44.

6. Long-term results of direct and indirect endovascular revascu-larization based on the angiosome concept in patients with cri -tical limb ischemia presenting with isolated below-the-knee le -sions. Iida O, Soga Y, Hirano K et al. J Vasc Surg 2012;55:363-70? ???The Film Interpretation Quiz has always been one of CIRSE’s

most popular sessions, and this year, the audience will be given an even greater opportunity to get involved, thanks to our all-new,“last man standing” format.

The Quiz Master will present the audience with two possible answersto each case – those choosing incorrectly will be eliminated andmust sit down, while those who get the answer right will continue to the next case. The last few contestants left standing will be invited onstage for an exciting head-to-head finale!

Put your skills to the test and find out how good you really are!

Be part of this year’s most interactive session and win free registration to CIRSE 2013 in Barcelona!

Join us for the Film Interpretation Quiz!

Cardiovascular and Interventional Radiological Society of Europe

ECIO 2013

June 19-22Budapest | Hungary

www.ecio.org

Fourth European Conference on Interventional Oncology

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TACE is the current standard of care for patientswith intermediate-stage hepatocellular carcino-ma (HCC) and relatively preserved liver function.In a meta-analysis of randomised controll ed trials comparing conventional TACE regimens –including the administration of an anticancer-in-oil emulsion followed by embolic agents –versus best supportive care, TACE was shown toimprove overall survival from 16 to 20 months[1]. Various strategies to improve outcomes forthis patient group have become the subject ofmuch ongoing clinical research. The use ofdrug-eluting beads (DEBs), in particular, hasbeen shown to significantly diminish theamount of chemotherapy that reaches the sys-temic circulation compared with conventionalTACE regimens, thus increasing the local con-centration of the drug and the anti-tumoural efficacy [1, 2].

Despite the continuous progress in techniquesand protocols [3], TACE has some inherent limi-tations [4]. TACE exerts therapeutic effects onlyin the treated territory; thus, tumour foci un -de tected – and therefore not targeted – at thetime of the procedure may progress. Moreover,by interrupting blood flow to the tumour, TACEinduces necrosis at the tumour site, but may cre -ate conditions that permit or encourage angio-genesis. Surrogate markers of tissue hypo xiathat increase after TACE include hypoxia-in du -cible factor 1 alpha and both plasma and hepa -tic vascular endothelial growth factor (VEGF) [4].

The combination of DEB-TACE and anti-angio-genic therapy represents a potentially powerfulapproach, based on mechanisms that are theo-retically synergistic. DEB-TACE has been shownto be safe and effective, with significantly re -duced systemic drug exposure compared toconventional TACE. Sorafenib, a multi-kinaseinhibitor with anti angiogenic and antiprolifera-tive properties, has demonstrated efficacy andsafety in patients with advanced HCC. Thus,treatment with sorafenib might curtail thepost-TACE rise in VEGF-mediated signalling andat the same time target any tumour foci distantfrom the site of TACE [5].

In a prospective, single-centre phase II studyconducted at the Johns Hopkins UniversitySchool of Medicine, safety and response of acombined protocol involving sorafenib 400 mgtwice per day and DEB-TACE were assessed in

35 patients [6]. Although most patients experi-enced at least one grade 3 to 4 toxicity, mosttoxicities were minor (grade 1 to 2, 83% vs.grade 3 to 4, 17%), and preliminary efficacydata were promising.

The Phase II randomised, double-blind, placebo-controlled SPACE study (Sorafenib or Placebo inCombination with DEB-TACE for Intermediate-Stage HCC) is the first global trial on the use ofTACE in the treatment of HCC [7]. The objectiveof the study was to evaluate the efficacy andsafety of sorafenib in combination with DEB-TACE in patients with intermediate-stage HCC.The study was conducted at 85 sites acrossEurope, North America, and the Asia-Pacific re -gion. Patients were eligible if they had asymp-tomatic, unresectable, multinodular tumourswithout vascular invasion or extrahepaticspread; Child-Pugh A liver functional status;and ECOG performance status 0. Patients wererandomised to receive sorafenib 400 mg bid ormatching placebo continuously (1 cycle = 4 weeks) until progression. All patients receivedDEB-TACE (150 mg doxorubicin) 3-7 days afterfirst dose of study drug, and then on day 1 (± 4 days) of cycles 3, 7, and 13, and every 6 cycles thereafter. Patients allowed optionalDEB-TACE sessions between cycles 7 and 13and cycles 13 and 19, if deemed necessary bythe investigator. The primary endpoint wastime to progression (TTP) according to modi-fied RECIST criteria by central independentreview (predefined alpha = 0.15). Secondaryendpoints were overall survival, time to vascu-lar invasion or extrahepatic spread, time tountreatable progression, and safety [7].

Of 452 patients screened, 307 were random -ised to sorafenib (n=154) or placebo (n = 153).The hazard ratio (HR) for TTP was 0.797 (95% CI,0.588, 1.080; p = 0.072). Median TTP (50th per-centile) was 169 days/166 days in the sorafeniband placebo groups, respectively; TTP at the25th and 75th percentiles (pre-planned) was112 days/88 days and 285 days/224 days in thesorafenib and placebo groups, respectively.There were no unexpected safety findings.Median treatment duration in the sorafeniband placebo groups was 4.8 and 6.3 months,respectively, and median daily dose of studydrug was 566 mg and 791 mg, respectively [7].Table 1 shows a summary of the efficacy data.

The SPACE study met its primary endpoint ofimproving TTP when sorafenib was added to aregimen of DEB-TACE, compared with DEB-TACE alone. The combination was well tolerat-ed and no new safety findings that would pre-clude use of the combination were observed.Nevertheless, the encouraging efficacy signalrequires confirmation with data from ongoingPhase III trials. In fact, several questions remainas we attempt to improve treatment outcomein HCC patients. The pathophysiologic com-plexity of HCC, balanced with a goal of provid-ing effective tumour therapy with preservationof organ function, makes optimal treatmentchoice a clinical challenge. An understandingof exactly which features of HCC and patienthealth may predict the clinical outcome ofcombination regimens is essential for prescrib-ing individualised, evidence-based therapeuticstrategies.

In summary, because of the efficacy and safetyof DEB-TACE in the treatment of HCC, there isgreat interest in its potential use in combina-tion with systemically-active drugs with anti-angiogenic properties. A growing body of clini-cal evidence suggests that the combination ofDEB-TACE and sorafenib may be safe and effec-tive, supporting the further clinical investiga-tion of this emerging combination regimen.

TACE and Anti-Angiogenic Therapy Synergies between loco-regional and systemic approaches in cancer managementSpecial SessionMonday, September 17, 08:30-09:30Room 3A

Don't miss it !

References: 1. Lencioni R. Loco-regional treatment of hepatocellular carcinoma.

Hepatology 2010;52:762-773.2. Lammer J, Malagari K, Vogl T et al. Prospective randomised

study of doxorubicin-eluting-bead embolization in the treat-ment of hepatocellular carcinoma: results of the PRECISION Vstudy. Cardiovasc Intervent Radiol 2010;33:41-52.

3. Lencioni R, de Baere T, Burrel M, et al. Transcatheter treatmentof hepatocellular carcinoma with doxorubicin-loaded DC Bead(DEBDOX): technical recommendations. Cardiovasc InterventRadiol 2012 [Epub ahead of print].

4. Lencioni R. Management of hepatocellular carcinoma withtransarterial chemoembolization in the era of systemic targetedtherapy. Crit Rev Oncol Hematol 2012 [Epub ahead of print].

5. Lencioni R, Crocetti L. Loco-regional treatment of hepatocellular carcinoma. Radiology 2012;262:43-58.

6. Pawlik TM, Reyes DK, Cosgrove D, Kamel IR, Bhagat N,Geschwind J. Phase II trial of sorafenib combined with concur-rent transarterial chemoembolization with drug-eluting beadsfor hepatocellular carcinoma. J Clin Oncol 2012;29:3960-3967.

7. Lencioni R, Llovet JM, Han G, et al. Sorafenib or placebo in com-bination with transarterial chemoembolization (TACE) withdoxorubicin-eluting beads (DEBDOX) for intermediate-stagehepatocellular carcinoma (HCC): Phase II, randomized, double-blind SPACE trial. J Clin Oncol 2012;30 (suppl 4; abstr LBA154).

newsIR TACE and Angiogenesis

Cardiovascular and Interventional Radiological Society of Europe C RSE

5congress

Prof. Riccardo Lencioni is an internationally re -cognised interventional oncology pioneer basedat the University School of Medicine, Pisa. Prof.Lencioni is known for his hugely influential pio-neering work in RFA of liver and lung tumours,combined use of TACE and RFA, and for havingbeen the Principal Investigator of a number oflarge, multicentre, international trials on thetreatment of HCC. He is a member of CIRSE’sExecutive Committee, the Programme CommitteeChairman for ECIO, and a founding member ofthe International Liver Cancer Association. Along -side his many publications, he has served on theeditorial board of CVIR, Investigative Radiology,European Radiology, and Journal of Hepatology.

Riccardo Lencioni (EBIR)Cisanello University Hospital Pisa, Italy

Riccardo Lencioni (EBIR)

Table 1: Phase II randomised, double-blind, placebo-controlled SPACE study (Sorafenib orPlacebo in Combination with DEB-TACE for Intermediate-Stage HCC). The combination of DEB-TACE and sorafenib improved time to progression (primary endpoint) and time to vascular invasion or extrahepatic spread compared to DEB-TACE alone (P = 0.072 and P = 0.076,respectively; predefined alpha = 0.15) [7].

Assessment* TTP OS§ Time to VI/EHS§ TTUP

HR 0.797 0.898 0.621 1.586

95% CI 0.588, 1.080 0.606, 1.330 0.321, 1.200 1.200, 2.096

P value (1-sided)† 0.072 0.295 0.076 0.999

TTP, time to progression; OS, overall survival; VI, vascular invasion; EHS, extrahepatic spread; TTUP, timeto untreatable progression; HR, hazard ratio; CI, confidence interval.* ITT population (all randomised patients); † predefined alpha = 0.15; § median was not reached in eithergroup.

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7UAE for AdenomyosisIRnewscongress

UAE for adenomyosis Uterine artery embolizationSpecial SessionMonday, September 17, 08:30-09:30Auditorium 8

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Paul Lohle

Adenomyosis is a benign invasion of endo -metrium into the myometrium that results in adiffusely enlarged uterus that microscopicallyexhibits ectopic non-neoplastic endometrialglands and stroma surrounded by the hyper-trophic and hyperplastic myometrium (Fig. 1).

The clinical diagnosis is challenging, as the pre-senting symptoms overlap with common uter-ine disorders such as fibroids of the uterus.Adenomyosis is often underdiagnosed and isresponsible for symptoms such as (and particu-larly) heavy menstrual bleeding and pain, withor without bulk-related symptoms and fertilityissues in premenopausal women. The reportedoccurrence of adenomyosis varies significantly.The prevalence of adenomyosis in tissues ob -tained from hysterectomy is reported between8.8% and 31%. With broad criteria for the diag-nosis of adenomyosis, a prevalence as high as70% in women aged between 40 and 50 is sug-gested. Of women with clinical manifestationsof adenomyosis, about one-fifth are under 40,but the vast majority are between 40 and 50 years.

Magnetic resonance imaging (MRI) is particu-larly useful both in doubtful transvaginal ultra-sound (TVUS) cases and in providing a com-plete evaluation of the disease with its panora -mic views. With T2-weighted images and con-trast enhanced T1-weighted MRI, the thicknessof the junction zone can reliably be measured;a thickness over 12 mm is considered diagnos-tic for adenomyosis. The presence of foci ofhigh signal intensity within the myometriumconstitutes an additional, but not a mandatorycriterion. MRI is a reliable modality for diagnos-ing adenomyosis, with a sensitivity varying inthe literature between 78% and 88% a speci-ficity of 67-100%. MRI can categorise adeno-myosis as focal or diffuse and can be repeatedin time to evaluate the effect of treatment.

Three different groups of uterine adenomyosisare easily identified with MRI: 1) pure adeno-myosis, 2) adenomyosis with fibroid predomi-nance and 3) uterine fibroids with adenomyosispredominance (Fig. 2). Adenomyosis may be

subdivided in diffuse or focal. Focal adeno-myosis is also known as adenomyoma. Frompersonal experience, maybe around 80% ofthese women have adenomyosis mixed withfibroids, 15% pure diffuse adenomyosis and 5%pure focal adenomyosis (adenomyoma).

Medical treatment of adenomyosis ranges fromlocal treatment with the release of medicationsby an intrauterine device (IUD) to systemicallyadministered treatment.

IUD-released progestogens are used to reduceheavy menstrual bleedings in women withadenomyosis. Medications available for syste -mic administration include gonadotropin-re -leasing hormone (GnRH) agonists. Excision orenucleation is usually the preferred surgicalapproach for focal adenomyosis, but the typeof treatment is heavily dependent on the typeof lesion and the extent of myometrial involve-ment. Hysterectomy is usually indicated as adefinitive treatment. Rates of complicationafter hysterectomy range between 1.5% and29.3%. Recovery time is reported to range bet -ween 6 and 8 weeks, and health care-relatedexpenses and lost time at work render hyste -rectomy an option associated with high costs.

UAEIn 1995, Ravina published the first report ofwomen treated by uterine artery embolisation(UAE) for symptomatic uterine fibroids. UAE hasemerged as an effective therapy in the treat-ment of uterine fibroids. The clinical successrate of UAE for uterine fibroids with respect tosymptomatic improvement of associated men-orrhagia and pelvic pain ranges from 85-95%to 80-90%. Based on the similarity of symptomscaused by uterine fibroids and adenomyosis andthe positive results after UAE for fibroids, thisinterventional procedure has been investigatedas a possible option to treat adenomyo sis. Suc -cessful infarction of symptomatic fib roids withUAE may also be achievable in women sufferingfrom focal or diffuse adenomyosis with or with-out fibroids. Although the first results of UAEfor adenomyosis were disappointing, later stu -dies showed substantial clinical improvement

in the majority of treated women with adeno-myosis. Similar to UAE in fibroids, the targetedembolisation with occlusion of uterine arteryvessel branches with em bolic material willinduce cessation of arterial blood flow to theadenomatous tissue. Inten tional infarction willeventually result in complete or partial elimina-tion of adenomyotic foci and subsequentlyrelief of symptoms.

The UAE catheterisation technique for sympto-matic adenomyosis is no different from thetechnique for symptomatic fibroids. Embolisa -tion is performed by using a particulate embol-ic agent. The currently available data do notseem to indicate a preferred embolic agent foruse in women with symptomatic adenomyosis.Although in part based on speculation, deeppenetration with the embolic agent seems tobe needed for optimal infarction of areas withadenomyosis. Calibrated microspheres are ableto selectively occlude the tiny arterial branchesof the adenomatous tissue deep in the uterinestroma and thus create adequate tissue infarction. (Fig. 3).

Results of UAE in adenomyosis There are no randomised controlled trials as ses -sing the efficacy of UAE compared with surge ryor other treatment options as a treatment foradenomyosis. A complete and detailed meta-ana lysis on UAE for the treatment of adenomyo -sis is published including 15 studies with a to talof 511 patients, published between 1999 and2010 [1]. Clinical improvement of bleeding,pain, and bulk-related symptoms were report-ed by three quarters of included women. Themedian follow-up was 26.9 months.

ConclusionDuring the last decade, the UAE technique hasundergone several refinements and extendedits application beyond the embolisation of fib -roids. Now, also patients with pure adenomyo -sis or adenomyosis with fibroids, are potentialcandidates for UAE. Clinical and symptomaticimprovements have been reported by manystudies regarding UAE for adenomyosis. Short-term outcomes for pure adenomyosis and

adenomyosis with fibroids range from 83% to93%. In the long term, patients report signifi-cant im provement in 65% of pure adenomyosisand in 82% of adenomyosis with fibroids. UAEhas mini mal side effects, is cost-effective andpreserves fertility. Therefore, UAE is an attractivetreatment option, and a valuable alternative tohysterectomy.

References:1. Popovic et al. J Vasc Interv Radiol 2011; 22:901-9.

Fig. 1: Sagittal T2-weighted MRI of diffuse (a) and focal (b) adenomyosis.

Fig. 3: UAE in a woman with pure adenomyosis.(a) Frontal angiogram with contrast injection ofboth uterine arteries demonstrating the vasculari-sation of adenomyosis with deep penetrating pa -rallel arterioles. (b) Frontal angiogram after UAEwith the proper embolisation end-point. (c) Sagittal contrast enhanced T1 weighted MRI ofpure adenomyosis before UAE. (d) Sagittal con-trast enhanced T1 weighted MRI 3 months afterUAE demonstrating complete in farction of pureadenomyosis with uterine volume reduction.

Fig. 2: Different types of adenomyosis with or without fibroids.(a) diffuse pure adenomyosis. (b) focal pure adenomyosis (adenomyoma). (c) diffuse adenomyosis dominance with fibroids. (d) diffuse adenomyosis with fibroid dominance.

Dr. Paul Lohle is an IR at St. Elisabeth Ziekenhuisin Tilburg, the Netherlands. He is a recognised ex pert in the field of UAE, and has performedmany well-regarded studies into its use in treatinguterine fibroids and adenomyosis. His other areasof professional interest include vertebroplasty,and he was a co-author of the well-known VERTOS II trial. He obtained his Ph.D. for his thesison The Pathogenesis of Cystic Brain Tumours,and has published in many (inter)national peer-reviewed journals and books, while also acting asa reviewer for CVIR and JVIR.

Paul LohleSt. Elisabeth ZiekenhuisTilburg, Netherlands

a b c d

Be sure to pick up yourMembers’ Goodies!

As always, we have a small token of appreciation for all our members – a selection of limited-edition CIRSE-brandedgoodies to make your life a little bit easier.

Come along to the Society Booth on Tuesdayand choose any two of the following:· iPhone 4 or 4S case· Laptop sleeves 13” or 15”· USB Sticks 8GB· T-Shirts

Stocks are limited, so be sure to get there early for first pick!

References:1. Tessari L, Cavezzi A, Frullini A. Preliminary experience with a

new sclerosing foam in the treatment of varicose veins.Dermatol Surg 2001;27:58-60.

2. Yakes WF. Extremity venous malformations diagnosis and management. Seminars in interventional radiology1994;11:332-339.

3. Berenguer B, Burrows PE, Zurakowski D et al. Sclerotherapy ofcraniofacial venous malformations: complications and results.Plast Reconstr Surg 1999;104:1-11.

4. Yamaki T, Nozaki M, Sasaki K. Color duplex-guided sclerotherapyfor the treatment of venous malformations. Dermatol Surg2000;26:323-328.

5. Mimura H, Fujiwara H, Hiraki T, et al. Polidocanol sclerotherapyfor painful venous malformations: evaluation of safety and efficacy in pain relief. Eur Radiol 2009;19:2474-2480.

6. Choi YH, Han MH, O-Ki K et al. Craniofacial cavernous venousmalformations: percutaneous sclerotherapy with use ofethanolamine oleate. J Vasc Interv Radiol. 2002;13:475-482.

7. Cabrera J, Cabrera J Jr., Garcia-Olmedo MA et al. Treatment ofvenous malformations with sclerosant in microfoam form. ArchDermatol 2003;139:1409-1416.

8. Goyal M, Causer PA, Armstrong D. Venous vascular malforma-tions in pediatric patients: comparison of results of alcohol sclerotherapy with proposed MR imaging classification.Radiology 2002;223:639-644.

46 months [5]. 26 (90%) of 29 patients experi-enced an improvement in pain after sclero-therapy. Among the 24 patients for whom pain scores were measurable, a reduction inpain intensity of 50% or more was achieved in16 (67%). Predictors of a good response usingunivariate analysis were small size (less than orequal to 10 cm), a well-defined margin, andgood stasis of sclerosant during sclerotherapy.

In conclusion, recent studies show good resultsin 60-90% of patients undergoing sclerotherapyfor VM. Predictors of a good response to sclero -therapy are small size and well-defined margins.A better understanding of the risks and benefitsof sclerotherapy is still needed to ensure thebest patient outcomes while minimising complications.

Low-flow vascular malformations: what you need to know

Sclerotherapy is a mainstay in the treatment oflow-flow vascular malformations. This presenta-tion focuses on sclerotherapy for venous mal-formations (VMs). Indications for sclerotherapyof VMs include symptoms such as pain,swelling, haemorrhage, or dysfunction of adja-cent organs. Ethanol and detergent sclerosants– for example polidocanol, sodium tetradecylsulfate (STS), and ethanolamine oleate (EO) –are amongst the sclerosants used to treat VMs,but their availability in different countries isdependent upon local regulatory authorities.Absolute ethanol is the strongest sclerosant,3% STS and 5% EO have more moderateeffects, and 3% polidocanol is weaker still.Sclerosants act by causing endothelial damage,resulting in thrombosis of the VM lumen.

To increase the volume and effect of detergentsclerosants, they may be mixed with gas toform a foam, for example polidocanol or STSmay be mixed with sterile air or CO2. The use offoam has the advantages of an increased activesurface area, greater adhesion, longer durationof action, and vasospasm induced by foaminjection. Hence, enhanced efficacy can beachieved with lower volumes and lower con-centrations of sclerosant, leading to improvedoutcomes in large VMs compared with liquidsclerotherapy. In the Tessari method, sclerosingfoam is generated using a three-way stopcockand two disposable plastic syringes [1]. Onesyringe contains the liquid sclerosing solutionand the other contains gas. The liquid-to-airratio varies from 1:4 to 1:5. Foam is then gener-ated by pumping the contents backwards andforwards between the syringes during 20 pas-sages. In our institution, 3% polidocanol ismixed with CO2 at a liquid to air ratio of 1:4.Less than 5 mL of foam is used per injection foradults with an interval of 5 minutes betweeninjections.

The severity of pain on injection of ethanolduring sclerotherapy warrants general anaes-thesia. However, detergent sclerosants onlycause mild to moderate pain on injection andtherefore patients can tolerate with intra-venous analgesics. Direct puncture of a VM isusually performed with a fine needle underultrasound guidance, and blood is aspirated toconfirm that tip of the needle is within thelumen. Con trast medium is injected to observethe volume, shape, and blood flow of the VMand draining vein under fluoroscopy or digitalsubtraction angiography (DSA). If rapid outflowis observed, a tourniquet or manual compres-sion is used to control the blood flow. Thensclero sant is injected under DSA. Several punc-tures may be needed to fill the lumen of multi-locular lesions. If the VM lies within a limb, acompression garment can be applied to reducethe volume of thrombosed lumens after sclero -therapy, with the exception of the forearmwhere a compartment syndrome can develop(Volkmann contracture).

Several studies have quantified the improve-ment in patient outcomes after sclerotherapyalong with adverse events and side effects.Yakes reported symptom resolution in 90% of36 patients with extremity VMs after ethanolsclerotherapy [2]. A complication rate of 10%was observed in over 600 procedures, whichincluded blisters, skin necrosis, muscle con -tracture, nerve injury, cellulitis, deep venousthrombosis, pulmonary embolism, and cardio -pulmonary collapse. Berenguer and colleagueshave reported similarly positive outcomes ofethanol or STS sclerotherapy in 40 patientswith craniofacial VMs: 75% of interventionswere rated as curative or markedly improvingsymptoms [3]. In this series there were 20 cases(50%) of blistering, 11 cases (28%) of haemo-globinuria, 5 cases (13%) of deep ulceration, 3 cases (7.5%) of nerve injury and 3 cases (7.5%)of infection. Good results after polidocanol andEO sclerotherapy have also been reported with - out serious complications [4-6]. Cabrera andcolleagues reported good results using polido-canol foam sclerotherapy for 50 patients, inclu -ding those with Klippel-Trenaunay syndrome

[7]. Sclerotherapy was beneficial in 46 patients(92%): complete resolution of pain was achiev edin 25 of the 39 pa tients who presented withpain, and pain was reduced in the remaining14. No major adverse events were reported,although there were 4 cases (8%) of transientskin pigmentation, 3 cases (6%) of skin necrosis,1 case (2%) of interdigital necrosis, and 1 case(2%) of temporary weakness of the digit.

Goyal and colleagues have assessed the predic-tors of good response for ethanol sclerothera-py in 59 paediatric patients followed up from 1to 5 years [8]. Lesion size and patient symp-toms were assessed, with excellent or goodresults seen in 35 patients (59%). There was astrong association between their MR imagingclassification and the results of percutaneoussclerotherapy. An excellent response was seenin most small (less than or equal to 5 cm) well-defined VMs, and a poor result was seen inmost large (greater than 5 cm) infiltratinglesions. We have evaluated the predictors of agood response in pain relief after polidocanolsclerotherapy with a mean follow-up of

Vascular malformationsSpecial SessionMonday, September 17, 10:00-11:00Auditorium 2

Don't miss it !

Fig.1: Polidocanol foam sclerotheapy for a painful lower leg VM. (a) Fat-suppressed T2-weighted MRimage showing a varicose type VM. (b) Digital subtraction venogram obtained during injection of iodinated contrast medium via a direct puncture needle showing opacification of the VM. A tourniquetwas applied to the limb. (c) Digital subtraction venogram obtained during injection of sclerosing foamshowing negative contrast medium in the VM. (d) Pain disappeared and the VM shrunk 5 months aftersclerotherapy.

newsIR Vascular Malformations


9congress

Dr. Hidefumi Mimura has been a Professor of theDepartment of Diagnostic Radiology 2 atKawasaki Medical School/Kawasaki Hospital inOkayama, Japan, since 2011. He graduated fromOkayama University, where he completed his re -sidency in 1989 and became assistant and laterassociate professor. In the meantime, he served asvisiting assistant professor at University of Iowa(2005-2006). Dr. Mimura takes a professionalinterest in epidemiology, diagnosis and treat-ments of vascular malformations. He is a memberof the Japanese Society of Interventional Radio -logy (JSIR). Dr. Mimura has published 60 peer-reviewed papers.

Hidefumi MimuraKawasaki Hospital, Kawasaki Medical SchoolOkayama, Japan

Hidefumi Mimura

a c

b d

11Aortic Arch DiseaseIRnewscongress

Will there be a practical branched/fenestrated solution for aortic arch disease?

In the past decade, endoluminal repair ofdescending thoracic aortic pathologies havebecome common with proven advantages overopen surgery. However, endografts require anadequate zone of normal aorta as a proximallanding zone to seal. Pathologies involving theaortic arch (including aneurysmal degenera-tion, dissection and traumatic injury) often lackan adequate proximal sealing zone. To dealwith this, several endovascular techniques havebeen developed, including branch artery occlu-sion, debranching with extra-anatomical by pass,chimney techniques as well as fenestrated andbranched endografts. There are advanta gesand disadvantages to these techniques andtheir applicability varies with the proximallanding zone of the endograft (Fig. 1).

For any endograft procedure in the aortic arch,there are some general technical considera-tions. To facilitate successful and non-traumaticdevice delivery, sheaths are often hydrophiliccoated and may be pre-curved. Stiff guidewiresmay also be pre-curved and may either belooped in the ascending aorta or deployed intothe left ventricle to optimise support. Thehydrostatic pressures and left ventricular after-load effects are significant when deployingendografts in the aortic arch so techniquessuch as temporary cardiac arrest or rapid pacing may be considered.

Traditional Surgical Repair of Aortic Arch DiseaseSurgical repair of zone 0-2 aortic disease usual-ly requires cardiopulmonary bypass and deephypothermic circulatory arrest. 30-day mortali-ty is quoted from 0-16.5% and stroke 2-18%.These results provide an important baselinewhen comparing new and less invasiveendovascular techniques.

High volume centres report superb results withopen surgical repair. Patel et al. reviewed their17-year experience of open arch reconstruction,involving 721 patients. They reported a 30-daymortality rate of 5% and stroke rate of 4.7%.There were no reported cases of paraplegia.The results were durable with an actuarial 10 years survival of 65%.

For patients with very proximal ascending aor-tic and aortic valve pathologies, hybrid proce-dures utilising an elephant trunk endograftwith extra-anatomical bypass and endograftextension can be utilised. The endograft can bedelivered antegrade or retrograde. The retro-grade extension may be performed at the sametime as the primary procedure or as a can bedone as a second stage repair.

Branch Artery OcclusionThere has been a change in the approach toleft subclavian artery revascularisation whencoverage of the artery ostium is necessary dur-ing thoracic endografting. Rather than routinepre-procedural left subclavian artery revascula -risation for all cases, a selective approach is recommended with pre-procedural revasculari-sation reserved for higher risk patients.

Patients who are considered high risk for para-plegia may have prophylactic cerebrospinalfluid drainage but other cases can undergopost-procedural drainage only in the event of aparaparesis or paraplegia.

DebranchingSeveral debranching surgical techniques haveevolved. For Zone 1 debranching, the proximalgraft anastomosis is usually end to side onto theascending aorta with a partial occlusion clamp.Bifurcated limbs may be anastomosed onto theinnominate and left common carotid arteries(which are ligated proximally). Alternatively, a

single limb is anastomosed onto the innominateartery with a carotid-carotid bypass (Fig. 2).

The results of debranching techniques havebeen reported in several series, each involvingbetween 25 and 45 cases. Vallejo et al. reporteda 30-day mortality of 23.7%, a 13.1% incidenceof stroke and 2.7% incidence of paraplegia. Ye etal. reported a hybrid approach to type A dissec-tion with commercial endografts and de branch -ing. They reported technical success in 97.8% ofcases and a 30-day mortality of 6.7%. 32 of the45 cases had complete true lumen thrombosis!

Chimney GraftsIn the absence of fenestrated and branched de -vices, the proximal sealing zone can be ex tend edby the use of chimney grafts into branch arte ries.Gehringhoff et al. reported their use of chimneygrafts in aortic arch pathology. They used chim-neys in the left subclavian and common carotidarteries in 9 patients and reported a technicalsuccess rate of 88.9% (one proximal type I en do -leak requiring surgical conversion), and a 30-daymortality in 1 patient (11%). Over a mean followup of 15 months, all chimney grafts were patent.

Fenestrated and Branched EndograftsThe earliest fenestrated grafts used in the aorticarch involved a single scallop with debranchingand extra-anatomical arterial bypass. Subse-quently, customised grafts using a combinationof scallops and fenestrations have been used. Thefenestrations may have a pre-loaded cathe terand wire to facilitate covered stenting of thebranch. To date, only a small number of these ca -ses have been performed with customised grafts.

The complexity and stroke risk of branchedendografts in the aortic arch probably increaseswith each additional branch. One strategy is tolimit the stent graft to a single side branch anduse extra-anatomical arterial bypass. For zone 0coverage, Cook Medical has developed a bifur-cated graft delivered the innominate or rightcommon carotid arteries (Fig. 3). A graft exten-sion (e.g. Cook Zenith TX2) through the archand into the descending thoracic aorta canthen be delivered from the groin. This tech-nique avoids a sternotomy and aortic clamping.

Subsequently Cook has developed internal/external branch grafts for the aortic arch (Fig. 4).These devices allow branch grafting of multiplearch vessels. The internal branches allow treat-ment of non-aneurysmal aortic pathologies.None of these devices from Cook are availablecommercially as yet and less than 50 branchgraft cases have been performed worldwide todate.

Other companies such as Medtronic and Gorehave branch graft prototypes in development(Fig. 5).

Indications for Prophylactic Carotid toSubclavian Artery Bypass

· Risk factors for posterior circulation strokeincluding dominant left vertebral artery

· High paraplegic risk (extensive aortic coverage, previous aortic surgery)

· Existing or planned internal mammary arterycoronary bypass graft

Dr. Andrew Holden is Director of InterventionalRadiology at Auckland City Hospital and Asso -ciate Professor of Radiology at the University ofAuckland. He is also lead Radiologist for theAuckland Hospital organ transplant programmeand Co-Director of the Auckland EndovascularService. Dr. Holden is a committee member ofIRSA (Interventional Society of Australasia) andARGANZ (Abdominal Radiology Society ofAustralia and New Zealand) and is an examinerfor the RANZCR. Dr. Holden is the author of over50 articles in peer-reviewed journals and theauthor of three book chapters. He is currentlyPrin cipal Investigator in 15 trials, including many“first-in-man” interventional radiology device trials.

Andrew Holden Auckland City Hospital Auckland, New Zealand

Andrew Holden

Thoracic and thoracoabdominal aortaSpecial SessionMonday, September 17, 10:00-11:00Auditorium 6

Don't miss it !

Fig. 1: Ishimaru Classificaton of the ProximalLanding Zone of an Endograft in the Aortic Arch:· Zone 0 involves the ascending aorta and

requires coverage of all arch arteries includingthe innominate artery.

· Zone 1 involves the anterior aortic arch andrequires coverage of the left common carotidand subclavian arteries.

· Zone 2 involves the posterior aortic arch andre quires coverage of the left subclavian arteryonly.

· Zones 3/4 involves the aorta distal to the leftsubclavian artery.

a

a

b

Fig. 2: Traumatic Aortic Injury treated byComplete Arch Debranching and Endografting.(a) Two level injury to the aortic arch with traumato the anterior (arrowheads) and posterior (arrows)aortic arch. (b) CT after full debranching of theaortic arch and endografting.

b

Fig. 5: Prototype of Medtronic Thoracic Branch Stent Graft System.

Fig. 3: Bifurcated Graft Developed by CookMedical for Zone 0 Aortic Disease.(a) Bifurcated graft delivered via the innominateartery with the graft body deployed in zone 0 ofthe aortic arch. (b) A graft extension has beendelivered from the groin and deployed throughthe arch and into the descending thoracic aorta.

a

0

b

Fig. 4: Cook Medical Internal/External Branch Graftfor the Aortic Arch.(a) Bench view of Internal/ External Branch Graft.(b) CT after deployment in a patient with branchgrafts in the innominate and left common carotidarteries (Images courtesy of Dr T Chuter).

References:1. Ishimaru S. Endografting of the aortic arch. J Endovasc Ther

2004; 11(Suppl II):II-62-II-71.2. Patel HJ et al. Open arch reconstruction in the endovascular

era: Analysis of 721 patients over 17 years. J Thorac CardiovascSurg 2011;141:1417-23.

3. Vallejo N et al. Hybrid repair of thoracic aortic lesions for zone 0and 1 in high-risk patients. J Vasc Surg 2012;55:318-25.

4. Ye C et al. Endovascular stent-graft treatment for Stanford typeA aortic dissection. Eur J Vasc Endovasc Surg. 2011;42(6):787-94.

5. Gehringhoff B et al. Use of chimney grafts in aortic archpathologies involving the supra-aortic branches. J EndovascTher. 2011;18(5):650-5.

6. Chuter T, Schneider D. Endovascular Repair of the Aortic Arch.Perspec Vasc Surg Endovasc Ther 2007;19:188-192.


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Fig.1: 63 y/o male, non-small cell lung cancerinvading mediastinum.CT prior to treatment: Mediastinal lymph nodemetastases (*) causing SVC stenosis (arrow).Symptoms: Respiratory distress and superior venacava syndromes.

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newsIR Embolisation of Lung Cancer


13congress

Patients with primary lung cancer who haverecurrence after standard therapy, includingradiotherapy, systemic chemotherapy and sur-gery, are usually not indicated for any kind oftreatment. The best supportive care is usuallythe only treatment offered to them. But recentimprovement of interventional radiology tech-niques makes it possible to access these lesionstransarterially. We have been trying to managelung cancer patients with clinical symptoms bytargeting the lesions which threaten patients’lives or impair patients’ quality of life.

PatientsMediastinal invasion or lymph node metastasescausing bronchial and/or airway stenosis aregood targets to treat via the transarterial ap -proach. Patients who could not be treated bystandard therapies for any reason (includingpoor general condition, allergic reaction toanticancer drugs, etc.) were also indicated. Atotal of 30 patients with mediastinal lesion whowere treated in our institution were evaluated.Mean age was 60 years old, and reduction intumour size was evaluated by RECIST criteria.The clinical efficacy was assessed by reductionof symptoms.

Treatment methodsThe specific techniques for the treatment oflung cancer were composed of microcatheters,diagnostic modalities and spherical embolicmaterial. The microcatheter provides safe andselective access from the peripheral arteries tothe mediastinal arteries, including bronchial,internal thoracic and inferior phrenic arteries.The angiography suites combined with CTscanner provided excellent images of theblood supply to the lesion during selectivearterial infusion of contrast material. This wasuseful in avoiding non-target embolisation ofhealthy organs or spinal circulation. A smalldose of anti-cancer drugs, including cisplatin,docetaxel, antracycline, fluorouracil or a combi-nation, were infused. Embolisation by sphericalembolic materials (HepaSphere, QuadraSphere)was performed after the infusion of drugs. Theendpoint of embolisation was elimination oftumour vasculature. After treatment, follow-upwith a CT examination was performed everymonth, and the same procedure was repeatedwhere necessary.

ResultsLung cancer was basically hypervascular. Nodu -lar lesions in the lung field were enhanced bybronchial arterial infusion CT in 90% of cases.The lesions infiltrating to the mediastinum

Embolisation of lung cancer: is there a role?

were usually fed by arterial circulation throughbronchial, intercostal, branches from subcla-vian artery and/or inferior phrenic arteries. Noserious complications (such as spinal cord em -bolisation or systemic embolisation) were ex -pe rienced. Detection of shunting from artery topulmonary vein was very important to avoidsystemic embolisation. Minor complicationswere mainly caused by the chemotherapeuticdrugs. The tumour reduction after 1 month wasCR;0%, PR;13%, SD;87%, PD;0%, however, morethan 10% tumour reduction was obtained in50% of patients. The clinical symptoms improv -ed in 14 out of 21 patients (67%). Reduction ofrespiratory distress or control of haemoptysiswas usually improved immediately after theprocedure. The obstructive pneumonia wasalso well controlled by decompression of thebronchial air-way caused by tumour reduction.

ConclusionTransarterial management of lung cancerpatients who had mediastianal invasion and/orlymph node metastases were well controlled inreduction of symptoms by the transarterialapproach. The treatment procedures were feasible in almost all patients. Adverse effectscaused by the procedure were negligible. Therole of interventional radiologists was tremen-dously effective, as they offered treatment toadvanced lung cancer patients who do nothave any other treatment options.

Ablation of lung cancerSpecial SessionMonday, September 17, 10:00-11:00Room 3A

Don't miss it !

Fig. 2: Right bronchial arteriogram.

Fig. 3: Good enhancement of the mediastinallymph node in bronchial arterial injection CT.

Fig. 4: Right internal thoracic arteriogram.

Fig. 5: Good enhancement of the mediastinal lymphnode in in ter nal thoracic arterial injection CT.Treatment: A total of 50 mg of CDDP and 500 mgof 5-FU was in-fused and 25mg of HepaSphere(100-150) was used to embolise both arteries.

Dr. Hori is Director of the Gate Tower Institute forImage-Guided Therapy, which he helped found in2002. He specialises in vascular interventions, in -cluding interventional oncology, UFE and treat-ment of vascular malformations. Since the clinicwas founded, over 7,000 cases of arterial chemo -embolisation have been performed, making it aleading centre in the region. Dr. Hori has participat -ed in the development of several interventionaldevices and materials, including Japan’s micro-catheter, the SAP-Microsphere, and peripheral de -vices for angiography. He serves as a medical spe-cialist as well as a director for the Japanese Socie -ty of Interventional Radiology and is Director forthe Japanese Society of Endovascular Intervention.

Shinichi HoriGate Tower Institute forImage Guided TherapyOsaka, Japan

Shinichi Hori

Fig. 6: CT in 3 months.Marked reduction of lymph node metastases andreopening of superior vena cava.Marked improvement of respiratory distress andsuperior vena cava syndrome.

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As a special service to members, CIRSE is offering a Members' Lounge at Lisbon 2012.

All CIRSE members are invited to take a rest, have some complimentary snacks and make use our wireless internet connection.

The entrance to our exclusive Members' Lounge is located on the first floor, opposite the Society Booth.

Members' Lounge

MR Meeting RoomsLC Learning CentresHoW Hands-on Workshops

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Future Meetings & Free Publications

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14 Advertisement Monday, September 17, 2012

Special Edition / CIRSE 2012 - Lisbon

Tuesday, 18 September

11.30 – 12.30Gore Learning CenterRefreshments will be served

Progression in the treatment of biliaryobstructionsModerator: P. Goffette, Brussels, Belgium

• GORE® VIABIL® Biliary Endoprosthesis: Clini cal results for malignant and benign biliary obstructionsF. Fanelli, Rome, Italy

• Tips and tricks using biliary stent for benignand malignant biliary obstructionsP. Almeida, Viseu, Portugal

W. L. GORE & ASSOCIATES, INC.Medical Products DivisionFlagstaff, Arizona 86004

800.528.8763 (US)00800.6334.4673 (EU)

goremedical.com

Gore Scientific Programme

Monday, 17 September

11.30 – 12.30Gore Learning CenterRefreshments will be served

Where and when is endoluminal bypass thetreatment of choice in peripheral artery disease? Interactive review and discussionof challenging casesModerator: C. Rabbia, Turin, Italy

• Long de novo SFA lesions case: Is there aconnection between stent graft oversizingand outcomes in long de novo SFA lesions?What does the 1-year VIPER data indicate? R. Pini, Turin, Italy

• In-stent restenosis case: Endoluminal bypassfor the treatment of SFA in-stent restenosis.What does the RELINE trial indicate?K. Deloose, Dendermonde, Belgium

• Complex popliteal aneurysm case L. Canaud, Montpellier, France

• Troubleshooting case: Other aneurysms D. Savio, Turin, Italy

• AV access case P. L. Riley, Birmingham, UK

14.30 – 15.30 Gore Learning CenterRefreshments will be served

Expanding TIPS indicationsModerators: D. Yu, London, UK; A. Krajina, Hradec Kralove, Czech Republic

• Is TIPS effective as bridge to liver transplant?G. Maleux, Leuven, Belgium

• Feasibility and efficacy of TIPS in childrenR. Aggazi, Bergamo, Italy

• Effect of TIPS on PVT in patients with cirrhosisA. Luca, Palermo, Italy

• Results GORE® VIATORR® TIPS Endoprosthesisto treat Budd Chairi SyndromeJ. C. García Pagán, Barcelona, Spain

Sunday, 16 September

8.00 – 8.20Gore Breakfast Symposium / Room 3A

Latest clinical evidence on stents versusstent grafts for SFA occlusive disease: What approach makes sense?Moderators: G. Krupski, Reinbek, Germany; E. Verhoeven, Nuremberg, Germany

• VIASTAR 1-year multicenter prospective randomized trial results: Does SFA endoluminalbypass really outperform stents for SFAocclusive disease and when do I use them?J. Lammer, Vienna, Austria


Learning by Sharing – Dealing with challenges in EVAR and TEVARModerator: B. Katzen, Miami, USA

• Hostile aortic necks: Approaches and techniques for best clinical outcomes withthe GORE® EXCLUDER® AAA Endoprosthesis featuring C3 Delivery SystemG. Robinson, Hull, UK

• Durability paired with innovation: Best treatment options for tortuous iliac arteriesN. Nyman, Stockholm, Sweden

• Emergency repair in the thoracic aorta:Logistic challenges and practical examplesM. Hamady, London, UK

• Acute Type B dissection: When and how totreat, personal experience and practicalexamplesJ. Brunkwall, Cologne, Germany


Latest innovation in peripheral stenting: Isthere still room for a new generation stentdesign? Updates and interactive review ofchallenging casesModerators: D. Scheinert, Leipzig, Germany

• Is there still room for a new stent design?F. Thavaut, Strasbourg, France

• Early clinical experience with the GORE® TIGRIS Vascular StentM. Piorkowski, Leipzig, Germany

• Interactive review of challenging cases: – M. Galli, Como, Italy– G. Krupski, Reinbek, Germany– N. J. Mosquera, Ourense, Spain

Products listed may not be available in all markets.GORE®, C3, EXCLUDER®, PROPATEN, TAG®, TIGRIS,VIABAHN®, VIABIL®, VIATORR®, and designs aretrademarks of W. L. Gore & Associates. © 2012 W. L. Gore & Associates GmbH AR3676-EU1 JULY 2012

Advertorial

15AdvertisementIRnewscongress


Advertorial Unmatched Data, Unsurpassed Patency and Superior TIPS Performance

The GORE® VIATORR® TIPS Endoprosthesis is an innovative solution for TIPS.

The Only FDA and CE Mark Approved Stent-Graft for TIPS

• Unsurpassed patency• Superior radial strength• Device flexibility• Brilliant visibility under fluoroscopy• Optimal configurations for TIPS applications

GORE® VIATORR® TIPS EndoprosthesisCompared to Bare Metal Stents

In a randomized prospective trial, Bureau, et al.,found the actuarial rates of primary patency inthe GORE® VIATORR® Device group and baremetal stent group were 76% and 36%, respec-tively, at 2 years (p = 0.001 – log-rank test)1.

In a retrospective analysis of cirrhotic patientswith refractory ascites, Maleux, et al., foundthat TIPS using the GORE® VIATORR® Deviceoffers better symptomatic control of the ascitesat one year follow-up and a better overall survival, compared to bare metal stents2.(Figure 1)

GORE® VIATORR® TIPS EndprosthesisCompared to Endoscopic Band Ligation(EBL)

In a randomized, controlled clinical trial withTIPS performed within 72 hours after diagnos-tic endoscopy and a 1-year follow up, resultsdemonstrated an 86% actuarial survival in theearly-TIPS group versus 61% in the pharma-cotherapy – EBL group (p < 0.001)3. The 1-yearactuarial probability of remaining free of failureto control bleeding and of variceal rebleedingwas significantly higher in the early-TIPS groupthan in the pharmacotherapy – EBL group (97%vs. 50%; absolute risk reduction, 47 percentagepoints; 95% confidence interval [CI], 25 to 69;number needed to treat, 2.1 patients; 95% CI,1.4 to 4.0).

The conclusion was that patients with cirrhosiswho were hospitalized for acute variceal bleed-ing and at high risk for treatment failure, theearly use of TIPS was associated with significantreduction in treatment failure and in mortality.

TIPS Compared to Large VolumeParacentesis (LVP)

Although randomized comparisons of theGORE® VIATORR® Device vs. LVP are in progress,data from bare metal stents provide evidenceof the effectiveness of the TIPS procedure com-pared to continued LVP in ascites patients. In ameta-analysis of individual patient data, it wasreported that bare metal stent – TIPS signifi-cantly improves transplant-free survival of cir-rhotic patients with refractory ascites4. The cu -mulative probability of developing the firstepisode of hepatic encephalopathy (HE) wassimilar between the groups (p = .19). The aver-

Reference:1. Bureau C, Pagan JCG, Layrargues GP, et al. Patency of stents cov-

ered with polytetrafluoroethylene in patients treated by trans -jugular intrahepatic portosystemic shunts: long term results of arandomized multicentre study. Liver International 2007;27(6):742-747.

2. Maleux G, Perez-Gutierrez NA, Evrard S, et al. Covered stents arebetter than uncovered stents for transjugular intrahepatic porto -systemic shunts in cirrhotic patients with refractory ascites: a retrospective cohort study. Acta Gastro-Enterologica Belgica2010;73(3):336-341.

3. García-Pagán JC, Caca K, Bureau K, et al; Early TIPS TransjugularIntrahepatic Portosystemic Shunt) Cooperative Study Group.Early use of TIPS in patients with cirrhosis and variceal bleeding.New England Journal of Medicine 2010;362(25):2370-2379.

4. Salerno F, Cammà C, Enea M, Rössle M, Wong F. Transjugularintrahepatic portosystemic shunt for refractory ascites: a meta-analysis of individual patient data. Gastroenterology 2007;133(3):825-834.

5. Pither C, Bryant TJ, Stedman B, et al. TIPS for refractory acsites: asingle centre experience with covered stents. Abstract presentedat The Liver Meeting® – The 60th Annual Meeting of TheAmerican Association for the Study of Liver Diseases (AASLD);October 30-November 3, 2009; Boston, MA. Hepatology2009;50(4)Supplement: 465A. Abstract 339.

W. L. Gore & Associates, Inc. • Flagstaff, AZ 86004 • goremedical.com

Products listed may not be available in all markets. GORE®, VIATORR®, and designs are trademarks of W. L. Gore & Associates.© 2012 W. L. Gore & Associates, Inc. AR1414-EN2 JULY 2012

age transplant-free survival at 12, 24 and 36 months of follow-up was 63.1%, 49% and38.1% for patients allocated in the BMS-TIPSgroup and 52.5%, 35.2% and 28.7% for patientsallocated to large volume paracentesis (LVP),respectively. (Figure 2)

Health Economic Benefits

Bureau et al. reported that TIPS with bare metalstents has been less cost effective than otherprocedures. This is mainly owing to the moni-toring and the revisions required to maintainshunt patency. It has been shown that the useof covered stents could result in cost reductionbecause of decreased clinical relapses anddecreased need for shunt revisions1.

TIPS is a safe intervention that reduces theneed for LVP. Careful calibration allows satisfac-tory relief of ascites with a low incidence of HE.It has been demonstrated that extremely lowcomplication rates and exceptionally highpatency rates can be achieved with the use ofGORE® VIATORR® TIPS Endoprosthesis. In theUnited Kingdom, health economic data fa -voured TIPS with a cost of £500 per month ofpa tient follow-up for TIPS and £3,500 permonth of patient follow-up for paracentesis.Careful patient selection for this procedure hasde mon strated significant health economic benefit in favour of a dedicated TIPS endoprosthesis5.

Conclusion

A large body of published data demonstrate nu -merous clinical advantages of GORE® VIATORR®TIPS Endoprosthesis in treatment of patientswith refractory ascites and variceal bleeding.Furthermore, GORE® VIATORR® TIPS Endo pro -sthesis may be associated with decreased pa -tient-care costs compared to other therapies.

Considering these results, the role of GORE®VIATORR® TIPS Endoprosthesis in the manage-ment of portal hypertension should be consid-ered. The improvement of TIPS patency byusing ePTFE-covered stents is maintained overtime with a decreased risk of hepatic ence pha -lopathy and a decreased risk of death. Further -more, data demonstrate the clinical advantageof GORE® VIATORR® TIPS Endoprosthesis intreatment of patients with variceal bleedingand refractory ascites. Finally, GORE® VIATORR®TIPS Endoprosthesis has demonstrated a de -crease in associated patientcare costs. Consid -ering these results, the role of GORE® VIATORR®TIPS Endoprosthesis in the management ofportal hypertension should be considered.

INDICATIONS FOR USE UNDER CE MARK: The GORE® VIATORR®TIPS Endoprosthesis is indicated for use in the treatment of portalhypertension and its complications such as: variceal bleeding refrac-tory to, or intolerant of, conventional therapies, inaccessible varices,gastropathy, refractory ascites, and/or hepatic hydrothorax. Refer toat goremedical.com for a complete description of all contraindica-tions, warnings, precautions and adverse events.INDICATIONS FOR USE IN THE US: The GORE® VIATORR® TIPSEndoprosthesis is indicated for use in the and revision treatment ofportal hypertension and its complications such as variceal bleeding,gastropathy, refractory ascites, and / or hepatic hydrothorax.

Adapted with permission from Acta Gastroenterologica Belgica

Reprinted with permission from Elsevier, A216.


16 Splenic Trauma Embolisation Monday, September 17, 2012

Splenic trauma embolisation: from haemorrhage control to organ preservation?

TraumaSpecial SessionTuesday, September 18, 08:30-09:30Auditorium 6

Don't miss it !

Splenic trauma is a complex medical situationin which clinicians have to simultaneously facedifferent problems. The aim of medical manage -ment of splenic trauma is first to control haem-orrhage when the patient is actively bleeding,then to avoid unnecessary surgical or radiologi-cal procedure and to preserve splenic functionas much as possible [1].

A wide range of attitudes exist, from pure ob -servation (so called non-operative manage-ment, or NOM) [2] to urgent splenectomy bylaparotomy. In between these two opposingoptions, embolisation has emerged as a solu-tion to control bleeding and to maintain thespleen function as an adjunct to NOM. Despitenumerous theoretical advantages, embolisa-tion has not gained wide acceptance in manyinstitutions, for both logistical reasons and insome cases, lack of evidence [3]. Interestingly,despite important variations between centres,the most inclusive trauma centres using embo -lisation have a lower splenectomy rate, withsimilar costs to small hospitals [4]. In order toclarify the position of embolisation in this setting, we will focus on specific questions.

What is the best embolisation technique:proximal or distal?The technique of embolisation varies from onecentre to another [5]. Basically, proximal splenicembolisation consists of occluding the splenicartery proximally using coils or vascular plugs.A significant reduction of distal splenic arterialsystolic and diastolic pressure by a factor of 2 isobserved because of the persistence of collate ralbranches feeding the splenic hilum [6]. Distalembolisation consists in selective cathe terisa tion

of bleeding arterial branches as close to therupture as possible using coils of gel foam. Therate of splenic infarction is of course higher incase of distal splenic embolisation. De spite abetter knowledge of respective indications ofproximal and distal embolisation, controversiesstill exist and a large systematic review did notfind differences between the 2 groups in termof risk of splenic re-bleeding [7].

Head-to-head comparison or randomised trialscomparing these two techniques have not yetbeen done. The final aim should be definedeither on the bleeding control or on the risk ofre-bleeding. Our local policy depends on theangiographic results and on CT scoring of thesplenic trauma. A single active bleeding siterapidly accessible angiographically is embo lis eddistally with coils when possible, but a proxi-mal embolisation is always added. This is donebecause splenic lacerations carry a risk of re-bleeding from the bleeding vessels. Whenbleeding sites are numerous or if splenic fractures are extensive, we favour proximalembolisation in the splenic trunk.

Who is a good candidate for embolisation?Indications for embolisation have significantlyevolved over time. Initially, mainly patientswith pseudoaneurysms, or arterio-venous fistu-las were embolised, often after a certain delayafter the trauma and always in patients in a sta-ble haemodynamic condition. From these con-servative indications, the idea has emergedthat proximal embolisation could help spleenhealing as an adjunct to NOM [8]. The mainproblem was then to select patients at risk ofre-bleeding, and the literature has then fo -cused on the identification of risk factors. Pa -tients with high-grade lesions over grade 3(whether or not associated with parenchyma-tous blush) on contrast-enhanced CT werethen identified at high risk of re-bleeding [9].This also emphasises in those haemodynami-cally stable patients the absolute necessity ofobtaining a contrast-enhanced CT before treat-ment decision. Those series focused then onthe rate of secondary splenectomy or at leastof failure of re-bleeding. More recently, emboli-sation techniques have been used in unstablepatients with splenic trauma [10]. Embolisationhas many theoretical advantages in unstablepatients over damage control surgery, but it istoo early to have a definite opinion on thispoint.

Is splenic function altered by embolisation?The spleen is often considered the organ re -sponsible for immune response against pneu-mococcus and haemophilus. The rate of posi-tive immune response to these germs was similar in large group of embolised patients ascompared to the normal population [11]. Morerecently, despite a small number of patientsembolised, splenic embolisation was reportedto maintain a normal total T-lymphocytes, total

T lymphocytes helper and suppresser as well asC3, C4 and propoerdin concentrations as compared a normal population. In this study,pa tients who underwent a splenectomy had anincreased number of B lymphocytes and natu-ral killer cells [12]. Does this translate in clinicalconsequences? Another recent paper compar -ed the risk of infectious complications aftersple nectomy, NOM and embolisation. Compa-rison of patients in terms of trauma characte-ristics, treatment modality and haemodynamicstatus identified splenectomy as a significantfactor influencing the risk of infectious compli-cations, with an odds ratio of 9.62 (p < 0.001).In pa tients with severe grade of trauma (from 3to 5), splenectomy was the most significant factor increasing the risk of infectious compli-cation (adjusted odd ratio 16.67 p < 0.001). Inthis series, embolisation was not significantly associated with increased risk of infection [1].

In conclusion, an abundant literature is nowsupporting the benefit of proximal splenicembolisation in case of trauma. The main indi-cation remains high grade splenic trauma inpatients in stable haemodynamic conditions.New results open the gate for embolisation ofpatients in more severe haemodynamic conditions pending a proper selection.

Alban Denys is a Professor of Radiology and Headof the Interventional Radiology Unit at LausanneUniversity Hospital, Switzerland. Prof. Denys haswide experience in hepato-biliary, pancreatic anddigestive interventions, treating both acute andchronic conditions. Having obtained his medicalqualifications in Paris, France, he completed hisresidency in Montreal, Canada, where he laterworked as a visiting professor (1999). Prof. Denyswas awarded the RSNA Prix Cum Laude in 1990.

His co-author, Dr. Pierre Bize, is an interventionalradiologist at the same hospital. His special inter-ests include interventional oncology and trans-catheter embolisation, especially UFE and hepato-biliary interventions.

Alban Denys(EBIR)Lausanne University HospitalSwitzerland

References:1. Demetriades D, Scalea TM, Degiannis E, Barmparas G,

Konstantinidis A, Massahis J, et al. Blunt splenic trauma:splenectomy increases early infectious complications: a pro -spective multicenter study. The journal of trauma and acutecare surgery. 2012;72(1):229-34. Epub 2012/02/09.

2. Velmahos GC, Chan LS, Kamel E, Murray JA, Yassa N, Kahaku D,et al. Nonoperative management of splenic injuries: have wegone too far? Arch Surg. 2000;135(6):674-9; discussion 9-81.

3. Gomez D, Haas B, Al-Ali K, Monneuse O, Nathens AB, Ahmed N.Controversies in the management of splenic trauma. Injury.2012;43(1):55-61. Epub 2010/10/26.

4. Hamlat CA, Arbabi S, Koepsell TD, Maier RV, Jurkovich GJ, RivaraFP. National variation in outcomes and costs for splenic injuryand the impact of trauma systems: a population-based cohortstudy. Annals of surgery. 2012;255(1):165-70. Epub 2011/12/14.

5. Madoff DC, Denys A, Wallace MJ, Murthy R, Gupta S, Pillsbury EP,et al. Splenic arterial interventions: anatomy, indications, techni -cal considerations, and potential complications. Radiogra phics :a review publication of the Radiological Society of NorthAmerica, Inc. 2005;25 Suppl 1:S191-211. Epub 2005/10/18.

6. Bessoud B, Denys A. Main splenic artery embolization usingcoils in blunt splenic injuries: effects on the intrasplenic bloodpressure. Eur Radiol. 2004;14(9):1718-9. Epub 2004/02/14.

7. Schnuriger B, Inaba K, Konstantinidis A, Lustenberger T, ChanLS, Demetriades D. Outcomes of proximal versus distal splenicartery embolization after trauma: a systematic review andmeta-analysis. J Trauma. 2011;70(1):252-60. Epub 2011/01/11.

8. Ekeh AP, Izu B, Ryan M, McCarthy MC. The impact of splenicartery embolization on the management of splenic trauma: an8-year review. Am J Surg. 2009;197(3):337-41. Epub 2009/02/28.

9. Bessoud B, Denys A, Calmes JM, Madoff D, Qanadli S, SchnyderP, et al. Nonoperative management of traumatic splenic in -juries: is there a role for proximal splenic artery embolization?AJR Am J Roentgenol. 2006;186(3):779-85. Epub 2006/02/25.

10. Bize PE, Duran R, Madoff DC, Golliet-Mercier N, Heim C, Pilleul F,et al. Embolization for multicompartmental bleeding in patientsin hemodynamically unstable condition: prognostic factors andoutcome. Journal of vascular and interventional radiology: JVIR.2012;23(6):751-60 e4. Epub 2012/04/17.

11. Bessoud B, Duchosal MA, Siegrist CA, Schlegel S, Doenz F,Calmes JM, et al. Proximal splenic artery embolization for bluntsplenic injury: clinical, immunologic, and ultrasound-Dopplerfollow-up. J Trauma. 2007;62(6):1481-6. Epub 2007/06/15.

12. Walusimbi MS, Dominguez KM, Sands JM, Markert RJ, McCarthyMC. Circulating cellular and humoral elements of immune func-tion following splenic arterial embolisation or splenectomy intrauma patients. Injury. 2012;43(2):180-3. Epub 2011/06/24.

Fig.1: 69-year-old patient referred in unstablehaemodynamic condition after an attempt of per-cutaneous drainage of a perisplenic collectionafter colectomy. (a) Coronal CT reformation show - ing active bleeding in the splenic hilum and peri -splenic hematoma after. (b) Splenic angio gramshows massive bleeding in the liver hilum as wellas multiple bleeding sites in the upper pole of thespleen. (c) Selective catheterisation of the rup-tured branch shows active bleeding and is subse-quently embolised using glue. (d) Angiogramafter proximal splenic artery embolisation usingcoils. One month later the spleen has regenerated,please note the glue in the ruptured artery fromthe hilum.

a

e

b

c

d

Alban Denys (EBIR) and Pierre Bize (EBIR)



New Product LaunchesAdvertorial

The V12 RX covered stent is the latest additionto Atrium’s complete line of V12 balloon ex-pandable PTFE covered stents. The new .014”rapid exchange, low profile (5 and 6Fr intro -ducer sheath compatible), highly deliverable V12 RX stent platform is the ultimate solutionfor small vessel applications and tortuousanatomy.

V12 RX is a fully encapsulated customizableballoon expandable PTFE covered stent. Atrium is the first and only company to provideyou with a high quality covering technologythat is engineered to optimize healing, reducerestenosis, and prevent bleed through. LetAtrium, the world leader in balloon expandablecovered stents, and its superior V12 productoffering deliver the results you expect, whereyou need it and when you need it. To find outmore about Atrium’s V12 family and how it canbenefit your patients please visit us atwww.atriummed.com or our Atrium booth 6during CIRSE.

V12 RX covered stent

The PROMUS Element™ Plus BTK Stent hasbeen approved with Below The Knee indicationand is aimed to provide physicians improvedDES performance in treating patients withCritical Limb Ischemia (CLI) or severe lower legclaudication in infrapopliteal lesions. The PROMUS Element Stent uses a proprietary PtCr(platinum chromium) alloy designed specifi -cally for stenting, which enables thinner strutsand enhanced visibility. The innovative alloyand stent design offers a more conformablestent with less recoil and higher radial strength.It employs an advanced low-profile deliverysystem featuring a dual-layer balloon and Bi-Segment™ inner lumen catheter designed tofacilitate precise stent delivery across challeng-ing lesions. The everolimus drug and fluorinat-ed copolymer stent coating have been studiedin multiple randomized clinical trials and ‘real-world’ registries in both Coronary and Peri phe -ral Artery Disease, demonstrating excellentlong-term safety and efficacy. The PromusElement™ Plus BTK will be available in bothOver-The-Wire and Monorail ™ platform, and isavailable with a reference vessel diameter of2.25 mm to 4 mm and from 12 mm to 38 mmin length.

Innova™ Self-Expanding Bare-Metal Stent System

The Innova™ Self-Expanding Bare-Metal StentSystem is designed to treat peripheral vascularlesions in arteries above the knee, specificallythe superficial femoral artery (SFA) and proximal popliteal artery (PPA).

The innovative design and stent architectureused in the Innova Stent platform provideexcellent radial strength while remaining flexi-ble and very fracture-resistant, which is criticalto sustaining patency in treated SFA and PPAlesions. The Innova Stent System consists of aNitinol, self-expanding bare-metal stent loadedon an advanced low-profile delivery system.Deployment accuracy is enhanced with a tri-axial catheter shaft designed to provide addedsupport and placement accuracy as well asradiopaque markers to enhance ease of use.The Innova Stent is 6F (2.0 mm) compatibleand is available in sizes from 5 mm to 8 mm instent diameter and 20 mm to 200 mm inlength.

The TruePath™ CTO Device, is designed to facili-tate the crossing of chronic total occlusionswithin the peripheral vasculature. The TruePath™CTO Device features a rotatingdiamond-coated tip designed to break throughoccluded peripheral arteries and facilitate theplacement of conventional guidewires. Theultra-low 0.018” (0.46 mm) profile is engineeredfor optimal crossing and once positioned; thedistal tip rotates at 13,000 rpm through calci-fied lesions and other fibrous blockages.

The ReOpen clinical study evaluated theTruePath™ CTO Device in 85 patients with peri -pheral artery lesions. Study results demonstrat -ed the device is safe and effective in facilitatingthe crossing of intraluminal CTOs following re -sistance or prior failed attempts with a conven-tional guidewire. In the study, technical successwas achieved in 80.0 percent of pa tients, whileimproved post-procedure blood flow was de -monstrated in 82.4 percent of patients. Safetywas demonstrated with a 98.8 percent freedomfrom clinical perforation at the time of procedure.

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¹ Benchtop testing performed against industrystandard products. Data on file.

BAYER

JETSTREAM Atherectomy System

Redefine access with a set engineered to makeevery aspect of your procedure go smoothly.

Cook Medical offers the widest assortment ofdrainage products available, designed to ac -cess, target and treat any drainage objective.The Aprima Access set redefines access withour long-established focus on patient comfortand procedural ease.

· The Transitionless-Tip™ design requires lessinsertion force than standard access sets1 andvirtually eliminates hang-ups during entry,which helps provide seamless access andreduce the risk of patient trauma.

· The entire shaft and distal tip – not just onesmall band – are radiopaque to maximize flu-oroscopic visibility during placement.

· The set includes an EchoTip® echogenic ac-cess needle for optimal ultrasound visibility, a Cope Mandril wire guide, and the hydro-philic-coated coaxial introducer sheath,which work to ge ther to ease every step ofthe placement process.

Aprima™ Access NonvascularIntroducer Set

Drill into hard bone easily with a ratchet-style needle.

Cook Medical’s versatile line of high-quality,ultrasharp, ergonomic Osteo-Site needlesallows clinicians to access, biopsy and infusebone in a variety of situations, ensuring thatany procedural need can be met.

Cook’s new Osteo-Site Ratchet needle isdesigned for situations in which hard bonepenetration is needed.

· A ratchet-style unidirectional drilling actionand unique spade-tip design allow hand-drilling into hard bone.

· Hand control allows smooth drilling whilereducing risk of incidental loss of pressure ordirection.

· The quiet drilling operation can help maintain patient comfort.

· The outer cannula is marked in 1 cm incre-ments to help guide drilling and gage depth.

Provide the right PICC for any treatment and every patient.

Cook Medical’s diverse array of venous accessproducts, from PICCs and ports to both acuteand long-term CVCs, is designed to make sureclinicians are never left without an answer fortheir patients.

Our new 3.0 and 6.0 Fr Turbo-Ject power-injectable PICCs continue our mission of providing the right device in any situation.

· A complete line of PICC options can ensurethat you always have the tool you need, from silicone and power-injectablepolyurethane options to catheters uniquelyimpregnated with the antibiotics minocy-cline and rifampin to help prevent CRBSIs.

· More sizes and configurations can increasetreatment options and help improvepatients’ lives every day.

· New 3.0 and 6.0 Fr power-injectable PICCsadd to an already diverse product selection.

CAUTION: The law restricts these devices to sale by or on the orderof a physician. Indications, contraindications, warnings and instruc-tions for use can be found in the product labeling supplied witheach device. Information for the use only in countries with applicable health authority product registrations

Bayer expands its portfolio of interventional pro -ducts with the introduction of the JETSTREAMAtherectomy System for restoring flow and pre-serving options in the treatment of peripheralarterial disease (PAD) .This rotational atherectomy system offers a rangeof catheter sizes to treat both above (ATK) andbelow the knee (BTK) peripheral arterial disease.Indicated for use in multiple lesion morpholo-gies including calcium and thrombus, the JETSTREAM technology features differential cut ting to remove lesion materials while pre-serving the soft vessel walls.The JETSTREAM System also provides continu-ous active aspiration and a unique front-cuttinghead on all the family of catheters. The Navituscatheter expandable blade technology enablesphysicians to treat both the common andsuperficial femoral arteries with one device.Initially, the JETSTREAM System will be market-ed to select countries through Bayer direct sales offices and local distributors.

Published by MEDRAD BV, Horsterweg 24, 6199AC Maastricht-Airport, The Netherlands. Phone 31 (0)43 3585600. Chamber ofCommerce Maastricht 14045092


18 Advertisement Monday, September 17, 2012

Advertorial New Product Launches

A different approach to CTO you can really feel.

Designed to ensure that the expert hand of thephysician is front and center, the Viance™ cross -ing catheter and the Enteer™ re-entry systemwork intuitively to provide effective treatments.

Viance™ Crossing Catheter – Finesse over ForceA precision instrument designed to quickly andsafely deliver a guidewire via the true lumen,the Viance™ crossing catheter puts the controlof crossing where it belongs: in your hands.Providing an effective frontline option forCTOs, the Viance™ catheter enables you to uti-lize a proactive technique to cross total occlu-sions via the true lumen.

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POWERFLEX® Pro is a .035” PTA workhorse solution that delivers advanced crossability andremarkable versatility to treat routine, or challenging cases in the lower extremities.

POWERFLEX® Pro was developed to meet phy -sicians’ needs for a lower profile, puncture re -sistant, PTA balloon, in a wide range of sizes.This balloon catheter offers many features andbenefits to aid in patient treatment; includinglong lengths up to 220 mm to treat long le sionsin one uniform dilatation, short balloon shoul-ders for accuracy and post-dilatation balloon-ing, along with a rated burst pressure of up to18 atmospheres to treat calcified lesions.

POWERFLEX® Pro demonstrates the company’scommitment to deliver solutions for the treat-ment of Peripheral Vascular Disease (PVD) andis the most recent addition to CORDIS LowerExtremity Solutions Portfolio.

Covidien, a global leader in vascular therapiesand RF technology, is proud to announce theintroduction of the OneShot™ renal denerva-tion system. The OneShot system’s balloon ca -theter features a proprietary, continuous spiralelectrode and integrated irrigation to optimizeprocedural speed, consistency, and ease-of-use.

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· Single-treatment RF ablation reduces pro-cedure time: 2 minutes total ablation perartery

· Spiral electrode creates standardized,reproducible ablation pattern: no need forcatheter repositioning or multiple ablationsper artery

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· Low pressure balloon ensures consistentwall apposition and ablation pattern.Available in 5-7 mm diameters, allowingphysicians to treat a wide range of vessels

· Designed for delivery over a standard0.14” guidewire to allow for ease-of-usewith tools familiar to interventionalists

Visit us at booth 30 or our Learning Center forhands-on demonstrations.

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ExAblate O.R. is the new generation MRguided Focused Ultrasound therapy fortreating uterine fibroids, adenomyosis andbone metastases

Reduced treatment time, expanded patient po -pulation and increased treatment durability arenew features offered by InSightec's ExAblateO.R. This 3rd generation system implements theexperience of thousands of treatments. It en -ables physicians to treat the targeted region inless time, streamlining workflow and improvingthe user and patient experience. Women whocould not previously be treated effectively, i.e.scars, bowels in beam path, and fibroids ofvarying sizes, can now also be treated.

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Merit Medical is pleased to introduce the ONESnare™ Endovascular Snare System, with asingle 90-degree angle loop for retrieval andmanipulation of IVC filters, coils, stents andother foreign bodies. The Nitinol and gold plat-ed tungsten loop construction provides excel-lent visibility and structural integrity. The corewire provides flexibility and super elasticity toaccommodate tortuous vessel navigation. TheONE Snare Endovascular Snare System includesa snare, a snare catheter, a new peel-away in -tro ducer tool designed to simplify snare de -ploy ment, and a torque device. Available in 9 different kit configurations with 7 snare loopsizes ranging from 5mms to 35 mms to accommodate a broad range of vessel sizes.

The ONE Snare, along with the interlaced tripleloop EN Snare® Endovascular System are tworetrieval options designed to provide you withthe accuracy and reliability needed to captureor manipulate any foreign object within thevasculature.

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Philips new generation of interventional X-raysystems, the AlluraClarity family incorporates aset of techniques, programs, and practices thatensure excellent image quality, while reducingradiation exposure to people in X-ray environments.

During interventions you can’t afford to make atrade-off between image quality and X-raydose. But what if you could significantly reduceX-ray dose with no impact on image qualityand no change to your preferred way of working? Now you can with Philips revolutionary newgeneration of interventional X-ray systems: theAlluraClarity family.

Please visit www.philips.com/AlluraClarityfor more information.

PHILIPS

Industry leading image quality at a fraction of the dose

Enteer™ Re-entry System – The power of intuitive controlThe Enteer™ re-entry system, consisting of thecatheter and guidewire, gives you intuitive con -trol to reliably target the true lumen from thesubintimal channel above or below the knee.The system requires no capital equipment. It’sdesigned to be nothing less than a preciseextension of your own expert hand.

Not available in the US.

MULTICORE® provides an optimised needlevisualization under ultrasound guided biopsyprocedures. By the natural of its constituentmaterial it functions at any angle of entry intothe body in relationship to the generation ofsound waves by the ultrasound transducer.Thanks to its perfect smoothness, avoids anyrisk of seeding of malignant cells along theneedle’s path from the patient’s body out.Specimens provided through MULTICORE® areparticularly abundant and allow a quick, safeand easy biopsy procedure, either performedmanually or through the most common imag-ing guiding systems, such as CT, US, MRI.

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STERYLAB


New Product LaunchesAdvertorial

OnControl® Bone Access System is the first sig-nificant advance in bone biopsy technology in40 years. Clinicians now have the ability to ef -fectively, safely and rapidly obtain superiorbone biopsies. Vidacare® is introducing an ad -di tion to the OnControl® Bone Access System,the Coaxial Biopsy Tray designed specifically formultiple bone biopsies in the same location.

· Rapid access for hard bone lesions with auniquely designed power driven needletechnology

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Visit us at the 2012 CIRSE Conferencein Lisbon at Booth #61For information and supporting research,please visit www.vidacare.com.

PARAGON®

Sterylab, in the biopsy field for 40 years, thanksto innovative technologies and advanced engi-neering, presents PARAGON®:

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IR Congress News is published as an additional source of information for all CIRSE 2012participants. The articles and advertorials in this newspaper reflect the authors' opinion.CIRSE does not accept any responsibility regarding their content. If you have any questions about this publication, please contact us at [email protected].

Editors-in-Chief: Robert Morgan, Riccardo Lencioni Managing Editor: Ciara Madden, CIRSE OfficeGraphics/Artwork: LOOP. ENTERPRISES media / www.loop-enterprises.com

Today’s Featured Papers

FP 2201Bone, spine and soft tissue interventionVERTOS IV trial: a randomised controlledtrial of vertebroplasty for painful acuteosteoporotic vertebral fractures using aSHAM procedure as control groupC.E. Firanescu1, P.N.M. Lohle1, C.A. Klazen2, O.E. Elgersma3, M.C. Schoemaker1, A.J. Smeets1,R.J. Nijenhuis1, F.H. Jansen4, W.J. van Rooij1, J. de Vries1; 1Tilburg/NL, 2Enschede/NL,3Dordrecht/NL, 4Eindhoven/NLAuditorium 4

FP 2202 Embolotherapy 2Percutaneous transhepatic pancreatic isletcell autotransplantation as an adjunct tototal pancreatectomy for chronic pancreatitis: a modified approachM. Guimaraes, C. Ledezma, C. Schonholz, C. Hannegan, M.B. Anderson, J.B. Selby Jr.;Charleston, SC/USAuditorium 7

FP 2203EVAR, TEVAR and aortic interventionThe ADSORB trial: acute dissection treat-ment with stent graft or best medical therapyJ. Lammer 1, J.S. Brunkwall2, P.R. Taylor3, E.L. Verhoeven4, P. Kasprzak5; 1Vienna/AT,2Cologne/DE, 3London/UK, 4Nuremberg/DE,5Regensburg/DEAuditorium 2

FP 2204Experimental work in IR 2X-ray induced DNA double-strand breaks inchildren undergoing flat-panel CT duringcardiovascular interventionsM.A. Kuefner, M. Brand, C. Engert, M. Sommer, M. Glöckler, M. Uder; Erlangen/DERoom 1.15

will be presented in the Free Paper sessions, taking place from 16:45-17:45

CardioVascular and Interventional Radiology

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CVIR is the official journal of:

Austrian Society of Interventional Radiology (ÖGIR)Brazilian Society of Interventional Radiology and Endovascular Surggery (SoBRICE)British Society of Interventional Radiology (BSIR)Chinese Society of Interventional Radiology (CSIR)Czech Society of Interventional Radiolgy (CSIR)Danish Society of Interventional Radiology (DFIR)Dutch Society of Interventional Radiology (NGIR)Finnish Society of Interventional Radiology (FSIR)German Society of Interventional Radiology (DeGIR)Indian Society of Vascular and Interventional Radiology (ISVIR)Interventional Radiology Section of the Polish Medical Society of Radiology (PLTR)Israeli Society of Interventional Radiology (ILSIR)Japanese Society of Interventional Radiology (JSIR)Korean Society of Interventional Radiology (KSIR)Russian Society of Interventional OncoRadiology (SIOR)Swiss Society of Cardiovascular and Interventional Radiology (SSCVIR)Cardiovascular and Interventional Society of Turkey (TGRD)

To submit a manuscript, please visit: http://mc.manuscriptcentral.com/cvr

CardioVascular and Interventional Radiology

C RSE

v o l 3 4n o 4august2 0 1 1RCV

T h e o f f i c i a l j o u r n a l o f t h e C a r d i o v a s c u l a r a n d I n t e r v e n t i o n a l R a d i o l o g i c a l S o c i e t y o f E u r o p e

00270 • ISSN 0174-1551 34(1) 1-220 (2011)

Available onlinewww.springerlink.com

Springer

CVIR'S NEW IMPACT FACTOR:2.093

FP 2205Neuro and carotid interventionMid-term outcome of pipeline embolizationdevice for intracranial aneurysms: a prospec tive study in 143 patients with 178 aneurysmsS.C.-H. Yu, J.C.-K. Kwok, P.W. Cheng, K.Y. Chan, S.S. Lau, W.M. Lui, K.M. Leung, R. Lee, H.K.M.Cheng, Y.L. Cheung, C.M. Chan, G.K.C. Wong, J.W.-Y. Hui, Y.C. Wong, C.B. Tan, W.L. Poon, K.Y. Pang, A.K.S. Wong, K.H. Fung; Hong Kong/HKAuditorium 3

FP 2206Oncologic intervention 3Comparison of the survival and tolerabilityof radioembolization in elderly versusyounger patients with unresectable hepatocellular carcinoma (HCC)J.I. Bilbao1, R. Cianni2, L. Carpanese3, D. Gasparini4,F. Fiore5, K.E. Wilhelm6, P.M. Paprottka7, R. Golfieri8,B. Sangro1, M.L. Diaz1, G. Pizzi3, R. Salvatori2, E. Giampalma8, O. Geatti4, S. Ezzidin6, P. Bartenstein7, S. Lastoria5; 1Pamplona/ES,2Latina/IT, 3Rome/IT, 4Udine/IT, 5Naples/IT,6Bonn/DE, 7Munich/DE, 8Bologna/ITRoom 3.A

FP 2207Peripheral vascular disease intervention 2UK popliteal artery aneurysm stent graftstudyS.D. Goode, T.J. Cleveland, P.A. Gaines;Sheffield/UK; for the Popliteal Study InvestigatorsAuditorium 6

FP 2208Venous interventionRheolytic thrombectomy for deep veinthrombosis: interim report of a prospectivemulti-center registryM.J. Garcia; Newark, DE/UAuditorium 8

FP 2209Late breaking abstractsCarotid stenting with distal protection inhigh surgical risk patients: one-year resultsof the ASTI trialM. Bosiers1, K. Mathias2, R. Langhoff3, H. Mudra4, J. Diaz-Cartelle5, K.D. Dawkins5; 1Dendermonde/BE,2Dortmund/DE, 3Berlin/DE, 4Munich/DE, 5Natick,MA/USRoom 3.B

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