Andreas Gruentzig Lecture Sunday, 14:30-16:00 Coronary Imaging Now and Future Perspective Room a 47 Y/O Male with ACS

congress newsR Andreas Gruentzig CIRSE 2008 - Copenhagen Lecture Sunday, September 14, 2008

Honouring the German radiologist Andreas Gruentzig, who first successfully developed angioplasty for expanding lumens of narrowed arteries, CIRSE's yearly Gruentzig Lecture has been given by some of the most outstanding personalities in the field of Interventional Radiology. Over the years these exceptional lectures have become one of the highlights of our meeting's scientific programme.

This year's Gruentzig Lecture will be given by Professor Christoph Becker, associate professor and section chief at the Munich University Hospital, who will speak about non-invasive cardiovascular imaging emerging into clinical applications.

We invite all of you to attend the Grunetzig Lecture which will take place today after the CIRSE meets PAIRS session at 14:30 in Room A.

Don't miss it ! Andreas Gruentzig Lecture Sunday, 14:30-16:00 Coronary imaging now and future perspective Room A 47 y/o male with ACS

Christoph R. Becker Coronary artery disease as detected by Associate Professor and Section Chief coronary CT angiography at Munich University Hospital, Germany Meanwhile there are more than 41 studies per- and 80 kV, the datasets originating from the CIRSE 2008 Gruentzig Lecturer formed with more than 2,500 patients compar- two detectors allow for spectroscopy-like visu- ing multi-detector-row CT with coronary alisation of atherosclerotic lesions. Apart from angiography for the detection of coronary morphology, PET/CT with F18-FDG may deliver Introduction artery stenoses. According to these papers, a new insights into the inflammatory activity of It is fairly well known that coronary heart dis- sensitivity and specificity of 96% and 76% has plaques, e.g. in the carotid arteries (7). ease is one of the leading causes of mortality, been reported, respectively (2). But more than Fig.1: Lipidrich (vulnerable) plaque in the left morbidity and death in developed countries. only displaying the contrast-filled lumen like in A second development pathway is rotating C- anterior descending coronary artery as detected Increasing efforts have been made in screening cardiac catheter, CTA as a cross sectional arm CT. The combination of catheter interven- by coronary computed tomography (arrow left). and diagnosing coronary artery disease with modality also has the ability to display the tion and CT will provide a variety of new appli- Three weeks later the patient experienced a different imaging modalities, such as catheter coronary artery wall. Coronary atherosclerotic cations for invasive cardiology, such as aortic- myocardial infarction caused by a culprit lesion at angiograph, ultrasound and MRI. For a long changes may appear as calcified, non-calcified root catheter directed coronary CT angiogra- the same location (arrow right). time the electron beam CT was the only CT or mixed plaques. In a recently published study phy (8) or time resolved 3D imaging of left atri- modality capable of imaging the coronary Leber et al. reported that non calcified lesions um and pulmonary veins (9). 40 y/o male with STEMI arteries without any motion artifacts. Multi- were predominantly found in patients with detector-row CT has advanced rapidly in the acute myocardial infarction, whereas calcified References: last decade and 64-detector-row and dual- lesions were found more often in patients with 1. Taylor AJ, Bindeman J, Feuerstein I, Cao F, Brazaitis M, O'Malley PG. Coronary calcium independently predicts incident prema- source CT scanners are now state of the art chronic stable angina (3). In patients with an ture coronary heart disease over measured cardiovascular risk scanners for robust imaging of the coronary acute coronary syndrome a non calcified lesion factors: mean three-year outcomes in the Prospective Army Coronary Calcium (PACC) project. J Am Coll Cardiol arteries, myocardium and valves with high in the coronary artery may correspond to an 2005;46:807-14. quality in terms of morphology and even func- intra-coronary thrombus (4). 2. Janne d'Othee B, Siebert U, Cury R, Jadvar H, Dunn EJ, Hoffmann U. A systematic review on diagnostic accuracy of CT- tion. based detection of significant coronary artery disease. Eur J Studies comparing intravascular ultrasound as Radiol 2007. 3. Leber AW, Knez A, White CW, et al. Composition of coronary Screening for coronary atherosclerosis and the gold standard for plaque imaging with CT atherosclerotic plaques in patients with acute myocardial cardiovascular risk assessment have shown a good correlation between the infarction and stable angina pectoris determined by contrast- Fig.2: Thrombus formation in a patient with enhanced multislice computed tomography. Am J Cardiol Coronary calcium screening is a surrogate echogeneity and CT density of coronary ather- 2003;91:714-8. myocardial infarction in the left anterior descend- marker for coronary atherosclerosis and has osclerotic lesions (5). The sensitivity and speci- 4. Becker CR, Knez A, Ohnesorge B, Schoepf UJ, Reiser MF. ing coronary artery as seen by computed tomog- Imaging of noncalcified coronary plaques using helical CT with been measured by electron beam CT for more ficity for CT to detect calcified and non-calci- retrospective ECG gating. AJR Am J Roentgenol 2000;175:423-4. raphy (left) and coronary angiography (right). than a decade now. As electron-beam CT is a fied coronary atherosclerosis is between 78 and 5. Schroeder S, Kopp AF, Baumbach A, et al. Noninvasive detection of coronary lesions by multislice computed tomography: rather expensive modality, the quality adjusted 94%, respectively (6). results of the New Age pilot trial. Catheter Cardiovasc Interv 8. Kumar A, Bis KG, Shetty A, et al. Aortic root catheter-directed life year saved (QALY) was $37,633 (1). Further 2001;53:352-8. coronary CT angiography in swine: coronary enhancement with 6. Achenbach S, Moselewski F, Ropers D, et al. Detection of calci- minimum volume of iodinated contrast material. AJR Am J studies are currently being conducted to prove Future application of cardiac CT fied and noncalcified coronary atherosclerotic plaque by con- Roentgenol 2007;188:W415-22. the hypothesis that the assessment of coronary Dual-source CT offers another potentially trast-enhanced, submillimeter multidetector spiral computed 9. Al-Ahmad A, Wigstrom L, Sandner-Porkristl D, et al. Time- tomography: a segment-based comparison with intravascular resolved three-dimensional imaging of the left atrium and pul- calcium by multi-detector-row CT is superior to promising features in characterising atheroscle- ultrasound. Circulation 2004;109:14-7. monary veins in the interventional suite--a comparison 7. Rudd JH, Warburton EA, Fryer TD, et al. Imaging atherosclerotic between multisweep gated rotational three-dimensional recon- the assessment of conventional risk factors to rotic coronary plaques. If the two X-ray tubes plaque inflammation with [18F]-fluorodeoxyglucose positron structed fluoroscopy and multislice computed tomography. estimate the risk of cardiovascular events in the operate at different energy levels, e.g., 140 kV emission tomography. Circulation 2002;105:2708-11. Heart Rhythm 2008;5:513-9. future.

Cardiovascular and Interventional Radiological Society of Europe C RSE congress CIRSE meets PAIRS 3 newsIR

CIRSE: 4,280 Members strong and growing!

CIRSE Goes Global Group Members - Europe CIRSE Membership

CIRSE has been growing at an outstanding Following a global strategic plan, CIRSE BSIR – British Society of Interventional 4500 4.280 rate over the past years. Group Membership offers very favourable conditions to all Radiology, www.bsir.org 4000 has significantly contributed to this devel- those national IR societies bringing in their Bulgarian Society of Invasive Radiology 3500 opment, enabling national societies to join entire membership. This has allowed many CSIR – Czech Society of Interventional CIRSE in their entirety at preferential condi- societies to join forces with CIRSE which is Radiology, www.csir.cz 3000

tions. becoming a global network of DeGIR – German Society of Interventional 2500 2,340 Interventional Radiology ranging from Radiology, www.degir.de 1,918 Brazil all the way to China. DFIR – Danish Society of Interventional 2000 Radiology, www.dfir.dk 1500 1,452

CIRSE Group Members Finnish Society of Interventional Radiology 1000 Hellenic Society of Interventional Radiology www.helrad.org 500 ILSIR – Israeli Society of Interventional 0 20052006 2007 2008/09 Radiology NGIR – Dutch Society of Interventional Radiology, www.ngir.nl CIRSE Corporate Members ÖGIR – Austrian Society of Interventional Radiology, www.oegir.at CIRSE gratefully thanks its Corporate PLTR – Polish Society of Interventional Radiology, www.polradiologia.org Members for their support through- RSIOR - Russian Society of Interventional out the year. OncoRadiology Abbott Vascular Edwards SERVEI - Spanish Society of Vascular and Angiodynamics ev3 Interventional Radiology, www.servei.org Angiotech Gore SSCVIR - Swiss Society of Cardiovascular and B. Braun Lombard Medical Interventional Radiology Boston Scientific Medtronic TGRD – Cardiovascular and Interventional BioSphere Medical Optimed Society of Turkey Biotronik Schering Cardinal Health Sirtex Group Members - Overseas Celonova St. Jude Medical Cook Medical Straub Medical CSIR – Chinese Society of Interventional Cordis Terumo Radiology Datascope Corresponding and Full Members 2,576 ESIR – Egyptian Society of Interventional Radiology, www.esir.org.eg Corporate Members 24 ISVIR – Indian Society of Vascular and Applicants (Members in progress) 1,680 Interventional Radiology, www.isvir.in PAIRS – Pan Arab Interventional Radiology TOTAL 4,280 Society SoBRICE – Brazilian Society of Interventional Radiology and Endovascular Surgery, www.sobrice.org.br

Don't miss it ! CIRSE meets PAIRS The Pan Arab Interventional Radiology Sunday, 14:30 - 16:00, Room A Society (PAIRS) - A brief profile

for the formation of our society. The need for PAIRS extended an invitation to Prof. Lammer eases that are common in the region, novel Aghiad Al-Kutoubi clearly defining the role of the interventional and the officers of CIRSE to attend its second methods of treatment for universal conditions Founding member and first president of PAIRS radiologist, cross fertilization of the various scientific meeting in Jordan. In the spirit of con- and regulatory issues facing the practice of IR. approaches, and promotion of the specialty tinuing and strengthening the collaboration were the driving forces behind the discussions between the two societies, members of PAIRS Hydatid disease is endemic in large parts of the that started in 1998 and culminated in the for- were offered the opportunity to benefit from Middle East as well as parts of Eastern Europe. mation of an interim board in 2004. group membership of CIRSE. This is testimony Percutaneous treatment represents one of the to the forward thinking of the leadership of most efficient methods of dealing with this The official launching of PAIRS took place in CIRSE in their efforts to encourage international menacing condition. Dr. Maurice Haddad who January 2006 at Arab Health in Dubai were the collaboration in the field of IR. Furthermore has published extensively on the subject will first scientific meeting was organised with the PAIRS was subsequently invited by current present his experience. participation of international faculty from CIRSE President Prof. Jim Reekers to take part in Spanning from the Atlantic Ocean in the West Europe and North America. The first AGM was CIRSE 2008 under the successful format of the Male impotence secondary to venous incompe- to the Arabian Gulf in the East, the Arab World also attended by nearly 75 interventionalists "CIRSE meets…" sessions. tence is probably largely under-diagnosed and shares a common language and heritage. mainly from the Middle East with some repre- presents a challenge in management. Dr. Hazem Cultural links with Europe developed in both sentation from the North African Arabic coun- PAIRS' third scientific meeting took place in Habboub will present his experience in treating this directions throughout the centuries. tries. A proposed bylaw was presented and Cairo in February 2008 maintaining the high condition using the new embolic material Onyx. adopted and the first governing board com- caliber of contributions from the invited facul- The influence of modern European medicine posed of a president, a vice president, a secre- ty. The presentations by members of PAIRS also Regulatory issues relating to the practice of IR may represents the different schools, particularly tary, a treasurer and five members was elected. reflected their increasing experience. be approached in different ways depending on the French in the North African countries and Discussions had already started with SIR to the legal framework of the respective country. Dr. the English in the Middle East. Consequently The future direction of the society was dis- build a collaborative initiative particularly in Adel Ahmad will present the Kuwaiti model of different practice patterns developed and cussed and preliminary plans for the following regulatory & training issues. We hope that this introducing regulations to safeguard the specialty merged in varied combinations. years were developed by the Executive collaboration will also help to enhance the and ensure the highest standard of healthcare. Committee. It was decided that one of the work of our society. Initiatives to expand the These regulations may be applicable and adapt- The need for a professional society to provide a most pressing issues was linking with the membership of PAIRS across the Arab World are able to other countries. forum for interventionalists in the Arab World major sister societies to benefit from their being formulated and put into effect under the became clear as the specialty was expanding, experience and expertise. At CIRSE 2006 in guidance of the new Board and current PAIRS The collaboration between our young society facing some of the challenges and difficulties Rome I had the chance to meet with then President Dr. Hazem Habboub. and CIRSE is of great importance for the devel- that are being experienced by colleagues all CIRSE President Prof. Johannes Lammer to dis- opment of IR across our region and will hope- over the world. Some of the unique features of cuss how the successful collaborative initiative At "CIRSE meets PAIRS" in Copenhagen three fully continue to grow. I think that through practice in the Arab countries, including health model that CIRSE had started with other inter- members of our society will present topics that CIRSE Group Membership and the CIRSE meets care provision, regulatory issues, availability of national societies could be an appropriate plat- were chosen to reflect the different aspects of PAIRS session we have made important steps resources and education formed the platform form for future links between PAIRS and CIRSE. IR practice in the Arab World; treatment of dis- in this direction.

Cardiovascular and Interventional Radiological Society of Europe C RSE congress Interventional Radiology and Vascular Surgery 5 newsIR Don't miss it ! Management of peripheral vascular disease I Foundation Course Vascular Surgery and Interventional Radiology - Sunday, 10:00-11:00, Room A Time for integrated fellowships and eventually a merger

Torben V. Schroeder Professor of Vascular Surgery, University of Copenhagen Consultant Vascular Surgeon, Rigshospitalet, Copenhagen, Denmark

Vascular Surgery has changed markedly over rial PTA, EVAR, venous procedures, including A survey has shown patients' awareness of From a vascular surgical perspective I see only the last decade for a number of reasons, most dialysis fistula interventions. Another 20% were Interventional Radiology to be lower that one sensible solution for the future, which is an importantly the developments in endovascular "the classical non-vascular interventional radio- that of virtually any other specialty in medi- increasingly closer collaboration, eventually techniques. Physicians and patients want the logical" procedures, such as embolisations cine. Furthermore it has been aired that leading to a merger between the two special- best results using the most recent technology. (tumour, uterus, GI-bleeding, etc.) and manag- there is an insufficient number of interven- ties (12). The first step is an integrated fellow- Patients are particularly attracted to the least ing liver diseases with percutaneous transhep- tional radiologist to deliver treatment, partic- ships - vascular surgeons need to develop pro- invasive methods. Although the long-term atic choleangiography (PTC) or transjugular ularly on an acute basis (4). ficiencies in endovascular techniques and inter- durability of many of these minimally invasive intrahepatic portosystemic shunt (TIPS). The ventional radiologist need to develop full procedures seems somewhat inferior to that of remaining 20% were nephro- or urererostomias · Thirdly, the increasing number of patients responsibility for the longitudinal care of the open surgery, the attraction lies in the lower or suprapubic bladder catherisations. These needing endovascular procedures consti- patients they treat (6). The current organisation perioperative morbidity and mortality (1). urologic procedures were unevenly distributed tutes an economic incentive for other physi- will not survive. Moreover, recurrences may still be handled throughout the country, as most were per- cians who have catheter skills, for instance with endovascular techniques. The lower M&M formed by the urologists themselves or by radi- cardiologists or vascular surgeons, who no In the future the majority of vascular specialists has enabled management of patients other- ologists under ultrasound guidance. Thus, leav- longer accept that Vascular Surgery and should be able to perform basic operations, as wise considered unfit for surgery, though in ing out the urological procedures, the distribu- Interventional Radiology should continue to well as endovascular procedures, whereas only direct comparison the benefit of endovascular tion was close to 75% vascular and 25% non- be complementary and instead do the a more limited number of vascular specialist repair may in fact be more convincing in the vascular. endovascular procedures themselves. In will be responsible for the complicated open fittest patients (1). Today at least a third of vas- some institutions there may even be con- and the advanced endovascular procedures, cular surgical patients are primarily managed The peace is threatened frontations between interventional radiolo- respectively. The less attractive alternative is endovascularly after clinical assessment includ- However, as volume - relative as well as gists, cardiologists and vascular surgeons that vascular surgeons somehow achieve the ing non-invasive imaging. In single centres the absolute - of endovascular practice has over who should perform percutaneous non- necessary technical skills and do the proce- number is even higher - and the proportion is increased over the years, this peaceful scenario cardiac peripheral vascular interventions. dures themselves - like the cardiologists did still increasing. of two specialties being complementary is years ago. threatened. Some vascular surgeons participated in the The endovascular evolution evolution of Interventional Radiology, others An argument from interventional radiologists Although many vascular surgeons have been · Firstly, vascular surgeons find it increasingly have taken up catheter-based procedures against merging with Vascular Surgery is that personally involved in the endovascular revolu- problematic that other skilled craftsmen themselves. Cardiologists have also wanted this would make interventional radiologist tion, most have been spectators, referring their treat 30-50% of their patients, just because to take part in the blooming catheter-based move away from their mother specialty radiolo- patients to catheter skilled radiologists. The the vascular surgeon has not mastered that "peripheral arterial industry". This has led to gy. However this has already happened in vascular surgeon has the patients, while the technique. Had it been a new open surgical several headings like "Who is trawling our many countries for Vascular Surgery which has interventional radiologist masters a technique, technique, the surgeons would have attend- waters", "Turf wars and silos" and "The battle moved away from surgery. And in many of the which under certain circumstances is the pref- ed meetings and visited skilled colleagues to for peripheral interventions" (11,12). countries where it has not happened, the vas- erence of the patient and the attending physi- learn the technique and would then have Between 1997 and 2002, procedure volume cular surgeons are fighting for individuality. cian. These patients will undergo minimally added it to their existing surgical practice (2). in percutaneous peripheral arterial interven- invasive procedures in most instances outside However, endovascular skills are not that tions grew at faster rates among cardiolo- Another argument against a merger is related of the department of Vascular Surgery, i.e. in easily acquired. Moreover, did it only concern gists, vascular surgeons and other physicians to the substantial technological development. the department of radiology, and under the 5-10% of patients - which was the case 10 than it did among radiologists. As a result, This has broadened Interventional Radiology responsibility of the interventional radiologist. years ago - it would seem reasonable, but the radiologists' share of this market from merely being a vascular subspecialty to These two, the interventional radiologist and today the number is much higher with fig- declined during the interval, although the treating multiple pathologies of many other the vascular surgeon, have planned the ures still increasing while the number of absolute numbers increased. The vascular organ systems. Again, in comparison Vascular endovascular treatment together, but except patients treated with open surgery is declin- surgeons' relative share increased the most, Surgery involves a number of patients not con- for the endovascular handling itself patients ing. This situation may be tolerated by the but in 2002 still only by 10%. Cardiologists sidered suitable for endovascular management remain under Vascular Surgery service and are elderly generation of vascular surgeons, but were responsible for more that one third of or who need no intervention at all. not seen by interventional radiologists, neither not by the next generation. Recently UK sur- the procedures (11). References: before nor after the treatment. This organisa- veys have clearly identified a wish among 1. Brown LC, Greenhalgh RM, Howell S et al. Patient fitness and tion seems prevalent in most Scandinavian and vascular trainees to make endovascular train- · Finally, with the increasing numbers the tra- survival after abdominal aortic aneurysm repair in patients from the UK EVAR trials.Br J Surg. 2007 Jun;94(6):709-16. many European countries with Vascular ing mandatory (3). Moreover it seems that ditional separation of vascular surgeon and 2. Reed AB. Advanced training in vascular surgery: how does it Surgery and Interventional Radiology collabo- most interventional radiologist would not interventional radiologist may be criticised need to change? Sem Vasc Surg 2006;19:191-3 3. Richards T, Jones K, Vascular surgical training. Future of vascular rating closely and being complementary. mind training vascular surgical trainees. In for inefficient patient care, management and surgical training: the trainees' views 2008;90:96-103 the UK a joint training pathway in Vascular training. 4. Hamilton G, Shearmann C. Vascular surgical training. Invited commentary. Ann R Coll Surg Engl 2008;90:95-96 Interventional Radiology has also undergone Surgery and Interventional Radiology has 5. Krysa J, Downes M, Taylor P. Should vascular surgeons be substantial changes since initially being a vas- been proposed and a curriculum developed The future trained in endovascular techniques? An observational study. Ann R Coll Surg Eng 2008;90:95-103 cular subspecialty. Today Interventional aiming at creating vascular specialists You may well ask whether Interventional 6. Messina LM, Schneider DB, Chuter TAM et al. Integrated feloow- Radiology has the application for the diagnosis trained to provide vascular service utilising Radiology can survive and flourish as a tech- ship in vascular surgery and interventianal radiology. Ann Surg 2002;236:408-15 and treatment of multiple pathologies of many open as well as endovascular techniques (4). nology-based nonclinical specialty (7,9). And 7. Katzen BT. Interventional Radiology: transformation into a clini- other organs than the vessels and interacts In the United States they have been imple- similarly you may ask whether Vascular Surgery cal discipline. JACR 2005; :725-31 8. Baerlocher MO, Asch MR, Hayeems E et al. The clinical interven- with many specialties. Based on a national sur- mented in a number of centres (5,6) can continue in isolation without taking part in tional radiologist: results of a national survey by the Canadian vey in Denmark covering all interventional radi- the minimally invasive surgical treatment of up Interventional Radiology association. Can Assoc Radiol J 2006:57:218-23 ological activity in 2007 performed by the · Secondly, a number of papers have to one half of their patients. Moreover, the 9. Brunner MC. Clinical IR: Its now or never. JACR 2004; : 449-51 Danish Society for Interventional Radiology addressed the fact that interventional radiol- above listed problems may seriously hamper 10. Choudhri AF, Carr TM. Who's trawling our waters? JACR 2007; :538-9 (DFIR) (Courtesy of Marc Hansen and John ogists have limited clinical responsibilities the recruitment of the next generation of vas- 11. Levin DC, Rao VM, Parker L et al. The changing roles of radiologists, cardiologists, and vascular surgons in percutaneous Grønvall), a total of 5,300 procedures were per- and that this should be changed (7-9). It has cular physicians. peripheral arterial interventions during a recent five-year inter- formed (close to 1,000 per 1 Mio. inhabitants). also been suggested that Interventional val.J Am Coll Radiol 2005;2:39-42 12. Green RM, Waldmann D for the center for vascular disease. Five- Of these, 60% were "classical" vascular, i.e. arte- Radiology is suffering an image problem (7). years results of a merger between vascular surgeons and interventional radiologists in a university medical center. JVS 2003;38:213-9

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Special Edition / CIRSE 2008 - Copenhagen congress Atherectomy 7 newsIR Don't miss it ! VR-HWS 5: Virtual Reality – carotids Can experience really make a difference to Hands-on Workshop Monday, 16:00-18:00, Simulator Gallery outcome for carotid artery stenting (CAS)? Carotid artery stenting (CAS) Special Session Wednesday, 8:30-9:30, Room B

(comparing CAS with CEA, not experienced ver- The six independent case series include Boltuch respective event rates were 4.6%, 2.2% and 2.1%. sus inexperienced operators), case series, reg- et al (2005) (8), superseding Ahmadi et al (2001) Whilst some of the improvement in outcomes Sumaira Macdonald (1) istries and post marketing surveillance studies. (9), Lin et al (December 2005) (10), replacing Lin between the pre-2000 and post-2000 cohorts Jonathan Smout (2) All have certain explicit limitations. et al (June 2005), McKevitt et al (2004) (11), may be ascribed to certain technological Gerry Stansby (2) Randomised trials tend to have polar opposite Roubin et al (2001) (12), Verzini et al (2006) (4) advances, (such dedicated carotid stents - (11), it attitudes to the experience of the operators per- and Setacci et al (2007) (13). There were is difficult to escape the conclusion that the (1) Vascular Radiology Department forming CAS. For example, physicians perform- improved results with time in 5 of 6 series, with experience of those centres submitting data to (2) Vascular Surgery Department ing CAS within CREST are carefully vetted. In the differences reaching statistical significance in this registry had an important influence on out- order to receive credentialing just to recruit into 4. Three of these papers aimed specifically to come, particularly as the adoption of protection Freeman Hospital, Newcastle upon Tyne the lead-in (non-randomised) phase, interven- evaluate the learning curve. devices post-2000 did not appear to lead to a Acute Hospitals Foundation Trust, UK tionists had to complete animal training, submit Ahmadi et al (2001) (9) (eventually superseded significant improvement in results. procedural and follow-up reports for peer review, by Boltuch et al 2005), evaluated three hundred Of the series and registries, there were four in the Education is when you read the fine print. attend a CAS operator's course and submit to a and twenty CAS procedures as four groups of pre 2000-2001 time frame (9,16,18,19) and four Experience is what you get if you don't. first-case observation by the device manufactur- eighty cases (although this predated technologi- in the post 2000-2001 time-frame (3, 13, 13, 16) Pete Seeger er's representatives. Following this, each inter- cal advances in CAS such as rapid exchange sys- with year-on-year outcome data. There were at ventionist was required to treat up to 20 lead-in tems and protection devices). There was a signifi- least trends to improved results with time (some The results of the EVA3S trial were disappointing patients using the only stent and protection cant reduction in the frequency of neurological were statistically significant) in both time periods. for many who have independently reviewed out- device approved for use within the trial (Acculink complications after the initial 80 interventions (p The available data support the perception that comes for CAS and felt that they were (and are) and Accunet; Abbott Vascular, Santa Clara, CA), = 0.03), but technical success was not apprecia- results for CAS have improved with time. It also not nearly as bleak as they were within this trial demonstrating excellent technique and results bly improved with increasing experience there- demonstrates that results can vary widely (1). As if then almost to add insult to injury, it before receiving approval to enrol patients into after. It was concluded that a relatively large between centres and studies. The influence of became clear that the authors of the paper, pub- the randomised phase. Before we accuse CREST number of interventions (i.e. 80) should be per- advances in technology on the overall reduction lished in the New England Journal of Medicine, of being overly proscriptive, it must be remem- formed to overcome the negative effects of the of the adverse event rate is difficult to extract considered that the experience of the interven- bered that over 40% of surgeon applicants initial learning phase. This paper showed tempo- from the influence of individual experience. tionist (whatever their background) did not influ- applying to join the ACAS trial were rejected on ral improvement in outcomes even when protec- Perhaps the most convincing data come from ence the outcome for patients in the CAS limb of the grounds of insufficient experience or subop- tion devices were not employed at any time- centres with "stable" i.e. non-evolving CAS tech- the trial. timal results (7). The "yin" to CREST's "yang" must point. nique. The consistent improvements in results For those who are unfamiliar with this trial, 527 surely be EVA3S. The trial protocol stated that Lin et al presented their results in two hundred even following the introduction of cerebral pro- patients were randomised to either surgery or interventionists had to have performed 12 CAS consecutive protected CAS procedures in 182 tection devices would support the contention CAS for symptomatic carotid stenosis (>60% by or 35 supraaortic stents (5 of which had to be patients in 2005. The results were analysed in that operator experience is a critical element in NASCET criteria). The recruiting centres were a CAS). However, when the trial started to recruit four sequential groups of 50 procedures. The 30- improved results. mixture of both academic and non-academic (in the year 2000), there were only around 4 cen- day stroke and death rate was 8% in the first centres totalling 20 and 10 respectively. No dif- tres in France with CAS experience and because cohort, 2% in the second and zero in cohorts 3

ference in outcome was seen in centres that it therefore took a very long time to recruit, the and 4. This paper would suggest a learning curve References: enrolled <21, 21-40 or >40 patients. When com- rules may have relaxed. Certainly, the final paper of 50 procedures with continued improvement 1. Mas JL, Chatellier G, Beyssen B, Branchereau A, Moulin T, Becquemin JP et al (EVA-3S Investigators). Endarterectomy versus stenting in paring the enrolling physician's experience, no states "centres fulfilling all requirements except despite the use of protection devices from the patients with symptomatic severe carotid stenosis. N Engl J Med. statistical difference was seen between those those with regard to the interventional physician start of data collection (10). 2006 Oct 19;355(16):1660-1671. 2. Mas JL. Author reply. N Engl J Med 2007;356:305. with 'experience' of >50 procedures, those with could join….stenting procedures had to be per- Verzini et al evaluated 627 CAS procedures per- 3. Ahmadi R, Willfort A, Lang W, Schillinger M, Alt E, Gschwandtner ME, less than 50 procedures experience, and those formed under supervision…). It appears that it formed with cerebral protection and dedicated Haumer M, Maca T, Ehringer H, Minar E. Carotid artery stenting: effect of learning curve and intermediate-term morphological outcome. J still being proctored after training (major adverse was perfectly feasible for an interventionist to carotid stents between 2001 and 2006 (4). When Endovasc Ther. 2001 Dec;8(6):539-546. event - MAE rates 12.2%, 11.0% and 7.1% respec- perform their first ever CAS procedure within this comparing the results of the first 3 years (n=195 4. Verzini F, Cao P, De Rango P, Parlani G, Maselli A, Romano L, Norgiolini L, Giordano G. Appropriateness of learning curve for carotid artery tively). trial, with guidance from a proctor who had CAS procedures) with the second three years stenting: an analysis of periprocedural complications. J Vasc Surg. This would appear to be counterintuitive and a done as little as 5 CAS procedures. Furthermore, (n=432 CAS procedures) the 30-day major stroke 2006 Dec;44(6):1205-1211. 5. Cowan JA Jr, Dimick JB, Thompson BG, Stanley JC, Upchurch GR Jr. cynic would argue that it is the first ever demon- most interventionists would consider experience and death rate decreased from 3.1% to 0.9% Surgeon volume as an indicator of outcomes after carotid endarterectomy: an effect independent of specialty practice and stration of a reverse learning curve. Of course the in supra-aortic stenting (utilising very different (P = .047), and the 30-day any stroke and death hospital volume. J Am Coll Surg. 2002 Dec;195(6):814-821. trial was never powered to come to a statistically technologies and techniques from CAS) to be rate decreased from 8.2% to 2.7% (P = .005). The 6. Holt PJ, Poloniecki JD, Loftus IM, Thompson MM. The relationship between hospital case volume and outcome from carotid endartec- meaningful conclusion with respect to "learning irrelevant when considering CAS expertise. authors concluded that the results highlighted tomy in England from 2000 to 2005. Eur J Vasc Endovasc Surg. 2007 curve" and there is a not insubstantial risk of a Unfortunately, neither the CREST or the EVA3S the importance "of an appropriate learning curve Dec;34(6):646-654. 7. Moore WS, Young B, Baker WH, et al. Surgical results: a justification of Type II error on the grounds of relatively small recruitment structure allows a realistic analysis of that involves a caseload larger than that general- the surgeon selection process for the ACAS trial: the ACAS investiga- numbers. In reality, 85% of those performing CAS the experience-outcome relationship. ly accepted for credentialing". tors. J Vasc Surg 1996;23:323-328. 8. Boltuch J, Sabeti S, Amighi J, Dick P, Mlekusch W, Schlager O, Ahmadi within EVA3S had performed less than 50 proce- Regarding registries, data submission is on a vol- The largest of the independent CAS registries is A, Minar E, Schillinger M. Procedure-related complications and early dures in total (2) and many operators would con- untary basis and it is human nature not to proffer the 'Global Carotid Artery Stent Registry'. The first neurological adverse events of unprotected and protected carotid stenting: temporal trends in a consecutive patient series. Journal of sider that this represents intervention on the cases with bad outcomes. Furthermore, most report from this registry was published in 2000 Endovasc Ther. 2005 Oct;12(5):538-547. steep part of the learning curve for CAS (3,4). registry data outcomes are self-audited, a notori- and demonstrated a non-significant reduction in 9. Ahmadi R, Willfort A, Lang W, Schillinger M, Alt E, Gschwandtner ME, Haumer M, Maca T, Ehringer H, Minar E. Carotid artery stenting: effect With regards the relationship between through- ously unreliable activity. Post-marketing studies stroke and death between 1997-1999 (14). This of learning curve and intermediate-term morphological outcome. J put and outcome (and by logical extension, intend to demonstrate safety in a real-world set- time period largely predated any important tech- Endovasc Ther. 2001 Dec;8(6):539-546. 10. Lin PH, Bush RL, Peden EK, Zhou W, Guerrero M, Henao EA, Kougias P, experience and outcome) for carotid endarterec- ting and are becoming common as a "Condition nical advances. Data on 12,392 cases from 53 Mohiuddin I, Lumsden AB Carotid artery stenting with neuroprotec- tomy (CEA), level-I and supporting evidence from of Approval" by bodies such as the FDA. centres were included in the 2003 update of this tion: assessing the learning curve and treatment outcome. Am J Surg. 2005 Dec;190(6):850-857. Europe and the United States indicates a linear However, most of these are formulated to evalu- registry (15). The paper graphically demonstrated 11. McKevitt FM, Macdonald S, Venables GS, Cleveland TJ, Gaines PA. relationship (5, 6). The relationship between ate particular stent/protection device combina- a steep learning curve for protected CAS. Stoke Complications following carotid angioplasty and carotid stenting in patients with symptomatic carotid artery disease. Cerebrovasc Dis. throughput and outcome for carotid stenting is tions and participation in these studies is and death rates for centres that had performed 2004;17(1):28-34. Epub 2003 Oct 3. 12. Roubin GS, New G, Iyer SS, Vitek JJ, Al-Mubarak N, Liu MW et al. less clear. However, as a highly technically com- inevitably influenced by industry keen to show 20-50 procedures were 4.04% compared with Immediate and late clinical outcomes of carotid artery stenting in plex procedure, it is likely that such a relationship the products in a good light. Undoubtedly, expe- 1.56% for those that had performed over 500. It patients with symptomatic and asymptomatic carotid artery stenosis: a 5-year prospective analysis. Circulation. 2001 Jan 30;103(4):532- exists. It certainly does in many other procedures. rienced interventionists would be preferentially is difficult from these data to set a figure on case 537. Exploring the relationship between experience invited to participate. number required for competency (presumably 13. Setacci C, Chisci E, de Donato G, Setacci F, Sirignano P, Galzerano G. Carotid artery stenting in a single center: are six years of experience and outcome or volume and outcome for CAS is Perhaps the most effective way of scrutinising somewhere between 50 and 500!) enough to achieve the standard of care? Eur J Vasc Endovasc Surg. a complicated matter. The technique has evolved the relationship between experience and out- The German Arbeitsgemeinschaft Leitende 2007 Dec;34(6):655-662. Epub 2007 Sep 20. 14. Wholey MH, Wholey M, Mathias K, Roubin GS, Diethrich EB, Henry M, rapidly since its inception in the mid nineties; come is to evaluate outcomes in single centres Kardiologische Krankenhausärzte (ALKK) includ- Bailey S, Bergeron P, Dorros G, Eles G, Gaines P, Gomez CR, Gray B, notable developments include dedicated carotid over time, after technical advances have been ed the results from 1,888 patients treated in 28 Guimaraens J, Higashida R, Ho DS, Katzen B, Kambara A, Kumar V, Laborde JC, Leon M, Lim M, Londero H, Mesa J, Musacchio A, Myla S, stents, fine guidewire and rapid exchange tech- made and to cross-reference this against year on hospitals over nine years (16). Analysis of these Ramee S, Rodriquez A, Rosenfield K, Sakai N, Shawl F, Sievert H, nology, low profile systems and cerebral protec- year outcome data where possible from inde- data confirmed a progressive reduction in stroke Teitelbaum G, Theron JG, Vaclav P, Vozzi C, Yadav JS, Yoshimura SI. Global experience in cervical carotid artery stent placement. tion devices. These technical refinements have pendent multicenter CAS registries (for example rates from 1996 to 2004 (6.3% to 1.9% respec- Catheter Cardiovasc Interv. 2000 Jun;50(2):160-167. occurred on a background of increasing practical the Wholey registry). tively, p=0.02). Major confounding variables in 15. Wholey MH, Al-Mubarek N, Wholey MH. Updated review of the global carotid artery stent registry. Catheter Cardiovasc Interv. 2003 and evidential experience. It is therefore difficult Our group recently performed a systematic this registry are the linear increase in the use of Oct;60(2):259-266. to extract the influence of technical advance review, evaluating 773 papers on carotid stenting cerebral protection devices from 1996-2004 and 16. Zahn R, Roth E, Ischinger T, Mark B, Hochadel M, Zeymer U, Haerten K, Hauptmann KE, von Leitner ER, Schramm A, Kasper W, Senges J. from the influence of individual experience on by using the primary search terms "carotid the proportional increase in asymptomatic Carotid artery stenting in clinical practice results from the Carotid outcome. artery", "stent" or "angioplasty", in conjunction patients treated. Artery Stenting (CAS)-registry of the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausarzte (ALKK). Z Kardiol. 2005 Furthermore, although there are superficially with the terms "volume", "outcome", "learning The Pro-CAS registry, another sizeable German Mar;94(3):163-172. many sources of data (and hundreds of thou- curve", "experience" and "randomised controlled registry, reported the combined rate of perma- 17. Theiss W, Hermanek P, Mathias K, Ahmadi R, Heuser L, Hoffmann FJ, Kerner R, Leisch F, Sievert H, von Sommoggy S; German Societies of sands of carotid stents performed around the trial". Twenty had data on >100 patients suitable nent neurological deficit and death in three Angiology and Radiology. Pro-CAS: a prospective registry of carotid angioplasty and stenting. Stroke. 2004 Sep;35(9):2134-2139. world) much of the available data are opaque to for the analysis of experience and outcome. cohorts; 735 patients treated before technical 18. Vitek JJ, Roubin GS, Al-Mubarek N, New G, Iyer SS. AJNR Am J public scrutiny. Redundant publication (duplicate Where duplicate publications or data sets com- advances in October 2000, 923 patients under- Neuroradiol. 2000 Oct;21(9):1736-1743. Carotid artery stenting: technical considerations. data/updated reports from the same operators), prised updates from ongoing series, the latest going unprotected CAS (after technical 19. Roubin GS, New G, Iyer SS, Vitek JJ, Al-Mubarak N, Liu MW Yadav J, self audit, voluntary data submission (to reg- publication was utilised. For the purposes of this advances) between October 2000 and 2003 and Gomez C, Kuntz RE.Immediate and late clinical outcomes of carotid artery stenting in patients with symptomatic and asymptomatic istries) etc. all serve to diminish data quality. The article we will focus on six sizeable series and 1609 concurrent patients undergoing protected carotid artery stenosis: a 5-year prospective analysis. Circulation. best available data comes from randomised trials four independent registries. CAS between October 2000 and 2003 (17). The 2001 Jan 30;103(4):532-537.

Cardiovascular and Interventional Radiological Society of Europe C RSE ES R .org THE DATABASE FOR INTERVENTIONALISTS CIRSE's latest e-learning tool now online!

1,900 online presentations Free for 24 hours - 7 days a week CIRSE members Free of charge for CIRSE Members

As part of its efforts Result to offer a complete Browse through all articles range of learning or the 5 interventional categories possibilities to inter- · Vascular · Embolization ventionists, CIRSE · Non Vascular · Oncology has launched a new · Clinical Practice online learning tool; and search the ever-growing database of expert material by keyword, author, topic www.esir.org. The or event. comprehensive data- View slide shows with audio support right away on your screen without any download base contains more hassle. than 1,900 titles, including high quali- Favorite ty streaming videos · Complete range of learning possibilities You would like to have interesting articles at from the CIRSE 2006 · Comprehensive database your disposal every time you log in? Simply click on ‘add to my favorites‘ button and 2007 congress- with over 1,900 titles including at the respective item and create your personal preference list. es, all recent CIRSE · Videos The option ‘contact the author’ enables you to pass your questions and comments to the abstracts and EPOS · Abstracts submitter of the paper and thus directly interact with the expert. posters, slide materi- · EPOS posters al of the CIRSE 2006 · Slide shows Profile and 2007 congress · Material from previous congresses The area ‘My profile’ leads to a very useful presentations and (CIRSE, ET, ECIO) and ESIR courses page with the entire range of offers available ESIR course material · View online or download for later use to CIRSE members at a glance. You can · book ESIR courses · register for the CIRSE congress · view and print congress/course relate documents · make hotel reservations · edit your personal data, etc.

To try out www.esir.org free of charge visit the CIRSE booth, the Internet Café or the EPOS area. www.esir.org is kindly supported by Cook Medical congress CIRSE Foundation 9 newsIR

The CIRSE Foundation - A Catalyst for Education

Johannes Lammer CIRSE Foundation Chairman

ESIR ESIR Course Venues 2007/2008

After my two year term as society president As you can see the Foundation has been very The European School of Interventional Lublin/Poland ended in 2007, I took on the great responsibili- active and the possibilities for additional activi- Radiology keeps expanding Budapest/Hungary ty of leading the CIRSE Foundation in the next ties are practically endless. I invite all of you to Heraklion/Greece two years. I am honoured to be given this great take advantage of the Foundation’s many edu- After its introduction in 2006 with the first two Villejuif/France opportunity to support the development of cational services and look forward to seeing courses on vascular interventions, further ESIR Brno/Czech Republic Interventional Radiology in Europe through the you at one of our meetings. courses were introduced in 2007 covering Plymouth/United Kingdom CIRSE Foundation’s many activities. more treatment methods in host cities all over Amsterdam/Netherlands Europe. Topics included radiofrequency tumour Strasbourg/France While the society supports interventional radi- The Structure of the CIRSE ablation, non-vascular upper GI interventions Winterthur/Switzerland ologists in issues concerning their daily prac- and basic as well as advanced vascular inter- Novi Sad/Serbia tice, the CIRSE Foundation must be a catalyst Foundation ventions. The response to the ESIR programme Valencia/Spain for education, making sure that Interventional has been overwhelming; young intervention- Prague/Czech Republic Radiology continues to be carried out by inno- ists from the individual host countries are keen Moscow/Russia vative and well trained physicians, as it has in The CIRSE Foundation is a non-profit organisa- to learn about interventional procedures and the past. To achieve this purpose and with the tion based in Switzerland. It is governed by the even colleagues from as far as Japan have support of our industry partners we base our Board of Trustees which is the ultimate authori- joined the courses. activities on the following four pillars: ty of the Foundation and is in charge of its overall governance and subordinated agencies. In 2008 there have been 5 ESIR courses and • Education grants: Every year the CIRSE 8 more will be held until the end of the year Foundation awards € 100,000 in grants to including 4 Institute Courses held at the Cordis young interventionists who wish to learn CIRSE Foundation Board of Cardiac & Vascular Institute (CCVI) in Hamburg new procedures in other hospitals. Thanks to Trustees Members: (DE) and at the Crossroads Institute in Diegem this programme numerous physicians have (BE). Due to the great success of the 2007 RFA been able to widen the range of their skills David J. Allison (UK) Chairman course in French language, another RFA course and disseminate new procedures in their Christoph L. Zollikofer (CH) Vice-Chairman was held in French in 2008. Additionally one hospitals. Rolf W. Günther (DE) course on Embolization Therapy will be held in The European School of Interventional Dimitris Kelekis (GR) Spanish in Valencia, Spain. Radiology (ESIR) is the educational arm of Andy Adam (UK) The ESIR course programme 2008 is kindly the Foundation, providing onsite education Johannes Lammer (AT) supported by educational grants from Cook, on a wide range of procedures at low cost. Cordis, Abbott, Boston, Celon, CeloNova, The two day courses include lectures of The CIRSE Advisory Council defines the ev3 and St. Jude Medical. European experts as well as case discussions strategic direction of the Foundation in in small groups. In 2008 we have increased keeping with the guidance provided by the the number of courses to 13. They will take Board of Trustees and is actively engaged in place in various European countries and the fund-raising and promotion of educa- include vascular and non-vascular topics as tional aims. well as “hands-on” courses in the learning centers of Abbott (Diegem) and Cordis Johannes Lammer (AT), Chairman (Hamburg). Up to now 470 physicians have taken the opportunity to attend the ESIR Vascular Division courses. In this context I would like to thank the local course organisers and the lecturers Stefan Müller-Hülsbeck (DE), Chairman for their work and enthusiasm. Christoph A. Binkert (CH), Online Education Board • Topic-related Special Focus Conferences Trevor John Cleveland (UK) every spring will support our main CIRSE Fabrizio Fanelli (IT), Online Education Board meeting in September. All of those who are Klaus A. Hausegger (AT) unable to come to the CIRSE Annual Meeting Jim Reekers (NL) or who want to get in-depth education on Marc Sapoval (FR) special topics will have the opportunity to Dimitrios Tsetis (GR) update their knowledge during these meet- Raman Uberoi (UK), Grants Review Board ings. After an excellent kick-off with the first European Conference on Interventional Oncology Division Oncology and the first European Conference on Embolotherapy ET ECIO 2008 attended by Riccardo Lencioni (IT), Chairman 1,200 delegates the Foundation will organise José Ignacio Bilbao (ES), Online Education Chairman an educational meeting every spring. In this Thierry de Baère (FR) context I would like to thank Tony Nicholson Adam Hatzidakis (GR) and Riccardo Lencioni for their superb Thomas K. Helmberger (DE) organisational work. In April 2009 the CIRSE Thomas J. Kröncke (DE) Foundation will organise a GEST Europe Jean-Pierre Pelage (FR) meeting together with the GEST founders. Phillipe Pereira (DE), Grants Review Board A second ECIO will be organized by the Tarun Sabharwal (UK), Online Education Board CIRSE Foundation in early 2010. • In addition to low the cost courses of the ESIR and the educational spring meetings mentioned above, the CIRSE Foundation offers interventional radiologists online education accessible through a new dedicated website. www.esir.org is a fantastic new tool comprising all material from recent CIRSE congresses and EPOS presentations.

Cardiovascular and Interventional Radiological Society of Europe C RSE congress Simulation 11 newsIR Don't miss it ! A closer look at Closure Devices Virtual Reality Workshop Sunday, 16:15-17:45, Room Closure Devices

Lars Lönn (1) Max Berry (2) Patrik Hidefjall (3)

(1) Endovascular Surgery and Interventional Radiology, Faculty of Health Sciences, Rigshospitalet, Copenhagen, Denmark, (2) Department of Radiology, Medical University of South Carolina, USA (3) Mentice AB, Goteborg, Sweden

Expanding roles for simulation technology

Today clinical practice does not offer the same best for certain anatomic regions and lesions is munity to do evaluation studies that validate yielded patient safety benefits as well as a safe opportunities as it used to for beginners to another skill learned via working on the simula- the functionality and metrics used in the simu- work environment for those who have the start training endovascular procedures through tor. A key benefit to the fluoroscopy functional- lators. This is a challenging task, as simulators opportunity to experience and learn from the traditional angiography, as non-invasive ity of a simulator is that the learner experiences constitute a moving target. However, without available technologies and expertise. Maybe modalities such as CT, MR and duplex ultra- no exposure to radiation. Simulation therefore validation of simulator behaviour and metrics regulations similar to the aviation simulation sound are increasingly used before a decision is equates to the safest "practice" field available simulators may not attain their full potential. model are needed in the health care sector in made to treat a patient. Alternatives such as for the operator and the patient. With validated data a much improved accept- order to reap the full benefits that simulation animal labs provide the opportunity to operate ance of simulators for other purposes such as has to offer. The use of simulators in certifica- on a living creature, but form other obstacles. With current advances in simulator develop- regular quality assurance, assessment and tion and credentialing is proposed to enhance Notwithstanding the ethical issues, animal ment there will be simulators that offer objec- training of experienced clinical staff can be patient safety by ensuring that medical profes- anatomies vary significantly from the human tive feedback in the form of an evaluation expected. Important issues may be to train sionals have been properly trained and tested. model, medication metabolism and reactions report afterwards as well as the immediate optimal imaging projections, to minimise radia- are drastically different and the costs of such response in case a mistake is made by the tion exposure and to train minimal use of con- In conclusion the incorporation of virtual reali- experience can be prohibitive. These circum- trainee. In this event there will be a tactile trast media. ty simulation in training is already here, despite stances challenge a facility's ability to train response to the operator which will be accom- lack of proven efficacy in randomised double- even the most basic endovascular skills in a panied by the appropriate hemodynamic Validated simulators may be used both in initial blind studies. In the future the adoption of this controlled environment. responses to mimic a realistic scenario. This certification of medical specialists and in regu- training might well be patient driven rather type of interaction makes simulators more real- lar testing for physicians to maintain their cre- than doctor driven. A structured training pro- A foreseeable increase in the incidence of istic for a wide range of users from the novice dentials. Also the medical device industry may gram, i.e. curriculum, must be developed in peripheral vascular disease and thus minimal to the expert. have to prove to regulatory authorities that order to merge cognitive and clinical skills with endovascular procedures translates into an their medical doctor customers have been cor- pure technical knowledge. increased need to train the next generation of Simulation allows an experienced practitioner rectly trained to ensure a safe and efficacious interventionalists. Endovascular simulator train- to train how to avoid and, if necessary, how to deployment of their clinical devices in a simu- In cooperation with the SIR, the CIRSE ing of basic skills answers this training need manage a complication during a procedure. lated clinical setting. Simulator Task Force led by Dr. Derek Gould and offers the ability to provide an introduction The associated training would more fully pre- from Liverpool has been doing continuous to endovascular procedures, including demon- pare the trainee for the rare occasions that do Today simulators have become widely accept- work in this field. Other important research stration of the selection and the subsequent occur in clinical practice after all. Simulators ed by medical educators and simulator centres groups include Professor Anthony Gallagher's, manipulation of different devices in a correct can ensure that a variety of complications have have been established at many teaching hospi- as well as Professors Nick Cheshire's from the sequence order for a specific procedure. been presented and a minimum threshold of tals. However, it is generally agreed that even Imperial College in London (the EVEREST competency met, regardless of the experience once simulator centres are established the team). A few Education and Simulation Centres As simulators offer several patient cases, level of the learner. services they provide are often underutilised in also exist within Scandinavia: Oslo, Norway, trainees learn how different device shapes and the existing medical curricula and hospital- Stockholm and Lund, Sweden. In Denmark, the sizes work within various anatomies. These In order to readily translate technological internal quality assurance routines. respective centre is located in Copenhagen; the exercises help to reduce the manipulation of progress in simulator design into a situation Centre of Clinical Education in Copenhagen led equipment required to selectively engage spe- where simulators are widely adopted and It should be recognised that Simulation Centre by Professor Charlotte Ringstedt. cific vasculature. Awareness and understanding accepted for their contribution to clinical prac- Training capabilities have demonstrated a cost of which C-arm projection angles will work tice, there is a need for the professional com- effectiveness of the teaching methods Patrik Hidefjall is a Mentice Employee. Lars Lönn employed. These methods and results have is a paid consultant for Mentice. Don't miss it ! Patient Awareness: Interventional Radiology: your alternative to surgery TODAY! Sun, Sept. 14, 12:30-14:00 Patient & Public event

12:30 12:50 13:15 WELCOME Using Interventional Radiology - Introduction to Breakout Sessions 2. PVD

Poul Erik Andersen New Scientific Advances and Insights Poul Erik Andersen • John Grønvall 2008 Local Host John Grønvall 2008 Local Host Local Host Committee Member Jim A. Reekers Local Host Committee Member • Previous PVD Patient CIRSE President 13:20 - 14:00 13:00 BREAKOUT SESSIONS 3. Oncology 12:40 Interventional Radiology - • Dennis Tønner Nielsen The History of Interventional Local Host Committee Member A Look Ahead • Previous Interventional Oncology Patient Radiology 1. UFE Lars Lönn • Poul Erik Andersen Poul Erik Andersen Local Host Committee Member 2008 Local Host 2008 Local Host • Previous UFE Patient

Cardiovascular and Interventional Radiological Society of Europe C RSE congress Photo Contest 13 newsIR Don't forget ! Don't forget to cast your vote for the best CIRSE 2008 Photo Exhibition Photo Exhibition + Contest picture vis-à-vis the Abbott Lounge next to the main auditorium entrance.

In our many years in radiology we have had To share this passion with all our colleagues, We hope that you will enjoy this interesting the chance to attend numerous congresses, CIRSE has organised the first CIRSE Photo new feature of the congress an look forward getting to know colleagues from around the Exhibition featuring photographs created by to the Photo Exhibition and Contest becom- world. In these encounters we have noticed its members and congress delegates. The ing a regular feature of the CIRSE meeting ! that many of us share a hobby: photogra- exhibition is located vis-à-vis the Abbott phy. To us this shows that some people were Lounge at the main auditorium foyer and can Jim Reekers simply born to be imagers. be visited throughout the congress. To vote James Spies for your favourite picture, please use the computer next to the exhibition. The winner will be announced at the Foundation Party. Holland by Jim Reekers

A sunny danish coast by Frank Meijer [not titled] by Iftikahr Ahmad [not titled] by Levent Oguzkurt Cappadocia at dawn by Peter Nye

Chimney rock in Cappadocia, Turkey, by Erol Akgül Sami by Linda Scott Freefall on the hill by Josh Burrill GEST 2007 by Petr Duras

La vie en rose by Rick Shoenfeld The Lincoln Memorial at sunset by James Spies Long Lake at the south coast of the Black Sea Vascular Surgery by Wojciech Cwikiel by Kairgeldy Aikimbaev

Red sea fan at Balicasag by Pierre Thoorens Silverton Mountain, Colorado by Dennis Griffin The outsider by Andrew Jones The holy Tibetian Mountains by Winnie Chan

Lake Louise, Alberta, Canada by Kirsteen Burton Myself entering the water by Milan Totev Sunrise at the Floe Lake, Rockwall, Kottenay Cow with a view by David M. Kasper National Park, BC, Canada by Jan Namyslowsky

Cardiovascular and Interventional Radiological Society of Europe C RSE 14 DVT and Pulmonary Embolism Sunday, September 14, 2008

Don't miss it ! IVC filters Special Session Sunday, 10:00-11:00, Room B Deep vein thrombosis and pulmonary embolism: diagnostic and therapeutic pathways

Patrick Haage Professor and Chairman, Department of Diagnostic and Interventional Radiology Region West, HELIOS University Hospital, Wuppertal, Germany

Various strategies in the diagnostic process for with low pre-test probability of disease. In "PE After confirmation of PE, heparin anticoagula- suspected deep vein thrombosis (DVT) and likely"cases an imaging study should follow. tion must be administered to patients. For pulmonary embolism (PE) have been devel- Angiography has long been recognised to be patients requiring treatment beyond heparin oped and introduced, including clinical pre-test the most exact modality with a sensitivity and anticoagulation due to massive PE causing cir- probability assessment, D-Dimer testing, ultra- specificity of 95% and 100%, respectively. Thus culatory collapse, systemic thrombolytic thera- sound imaging and CT and MR pulmonary it is deemed to be the reference standard that py is advisable if there are no absolute con- angiography (CTA, MRA). PE should be all other techniques have to be measured traindications. assumed in every patient with inexplicable dys- against. pnea, tachypnea or acute chest pain; its ade- Unfortunately the rate of lysis-associated major quate diagnosis often relies on imaging tech- Advantages include the option of inducing a haemorrhage and intra-cerebral haemorrhage niques. local fibrinolysis-therapy via the angiographic is in the order of 20% and 3-5% of patients, catheter already in place. However, angiogra- respectively. Catheter-directed percutaneous DVT itself is a potentially life threatening disor- phy is not possible in up to 20% of patients and therapy employing combinations of mechani- der particularly due to the associated risks of due to its associated invasiveness, morbidity cal thrombus "rotating pigtail" fragmentation, pulmonary embolism, renal failure and phleg- and sporadic mortality it is nowadays being aspiration and intra-thrombus lysis is a credible masia cerulea dolens. Chronic venous hyper- employed less frequently and replaced by alternative. Advantages include fast hemody- Fig.1: Diagnostic algorithm in case of "likely" DVT tension resulting in the "postphlebitic syn- multi-detector CT and recently MRA, both of namic shock relief, in part by offering the lytic should include clinical probability, drome" as a consequence of DVT has been esti- which are faster, less invasive, less operator- drug a greater surface area for lysis after D-Dimer and ultrasound mated to affect 500,000 individuals in the dependent and are associated with a smaller mechanical fragmentation. United States alone. Thus, timely diagnosis and number of complications. Besides, the experi- treatment are essential measures to provide ence in properly executing, evaluating and In conclusion, any patient with clinically sus- adequate care for the patient. This postulation interpreting a pulmonary angiogram is gradu- pected PE must be risk stratified, in an ideal is substantiated by the fact that the organiza- ally decreasing in the younger generation of setting with a criteria-validated clinical decision tion of a venous thrombus proceeds much radiologists. pathway. Following the assessment of pre-test faster than that of an arterial thrombus, there- probability, D-Dimer assays quite reliably by aggravating successful treatment strategies. Looking at CT, another advantage is its wide- exclude PE in low risk groups. In 2008 CTA is Subsequent pulmonary embolism is a fre- spread availability. However, adequate visuali- the preferred initial imaging modality in the quently observed cause of patient morbidity zation of the pulmonary vascular tree cannot majority of cases. and mortality. Particularly patients with iliac be achieved with a standard CT scan of the and inferior caval vein thrombosis are at seri- thorax; it requires dedicated imaging proce- Anticoagulation with low-molecular-weight ous risk for pulmonary embolism and long- dures and protocols which may be combined heparin is considered the treatment of choice term clinical consequences of post-thrombotic with a CT phlebography of the IVC, iliac veins in DVT and stable PE patients. In unstable PE syndrome. and the lower extremity to depict potential patients systemic thrombolysis and alternative- peripheral thrombi (Fig.2,3). Using CTA as the ly catheter directed thrombolysis, especially in Approximately 50% of patients with central initial imaging modality has proven to be cost case of contraindications to thrombolysis, can Fig.2: MIP-CT image accurately depicts multiple deep vein thrombosis have pulmonary perfu- effective. Also, CTA can disclose alternative or be advocated. massive pulmonary emboli sion defects characteristic of pulmonary additional diagnoses. A patient suspected of References: embolism. Thus patients with symptoms con- having PE may happen to have pneumonia, a 1. Eggers H, Proksa R. Multiprocessor system for real-time convo- sistent with DVT should in the beginning pneumothorax, an aortic dissection or a lution interpolation reconstruction. Proc Int Soc Magn Reson Med 1999;95 receive a determination of pre-test probability tumour, which can be diagnosed by CTA. 2. Garg K, Welsh CH, Feyerabend AJ, et al. Pulmonary embolism: using an established prediction model (Table MRA does offer advantages over spiral CT, diagnosis with spiral CT and ventilation-perfusion scanning: correlation with pulmonary angiographic results or clinical out- 1). After determination of the clinical pre-test because it does not involve ionizing radiation come. Radiology 1998; 208:201 - 208 probability, a D-Dimer test should be per- and makes use of smaller amounts of gadolini- 3. Fiumara K, Kucher N, Fanikos J, Goldhaber SZ. Predictors of major hemorrhage following fibrinolysis for acute pulmonary formed if the pre-test score is >1 (Figure 1). A um chelates which have an even better safety embolism. Am J Cardiol 2006;97:127-129 positive D-Dimer test entails an ultrasound profile than iodinated contrast agents. 4. Goldhaber SZ. Pulmonary embolism. Lancet 2004; 363:1295- 305 examination followed by treatment in case of 5. Haage P, Bücker A, Krüger S, Adam G, Glowinski A, Schäffter T, thrombosis. Over the last few years many of the limitations Weiß S, van Vaals JJ, Günther RW. Radial k-scanning for real- time MR imaging of central and peripheral pulmonary vascula- of earlier MR techniques were dealt with. High ture. Röfo Fortschr Geb Röntgenstr Neuen Bildgeb Verfahr Appropriate anticoagulation therapy is consid- signal-to-noise ratios and high contrast 2000;172:203-206 6. Horlander KT, Mannino DM, Leeper KV. Pulmonary embolism ered the standard DVT treatment. Interventions between flowing blood and pulmonary filling mortality in the United States, 1979-1998. An analysis using multiple-cause mortality data. Arch Intern Med 2003;163:1711- like thrombolysis and IVC filter placement are defects can now be depicted with the develop- 1717 reserved for few individual indications, espe- ment of contrast-enhanced MRA in a single 7. Kearon C, Kahn KR, Agnelli G, Goldhaber SZ, Raskob GE, Comerota AJ. Antithrombotic therapy for venous thromboem- cially since there are no randomised data con- breath-hold, during "first-pass" imaging with bolic disease: American College of Chest Physicians evidence- firming the benefit of invasive procedures. The Gadolinium-containing contrast media. The key based clinical practice guidelines (8th Edition). Chest 2008;133:454S-545S application of low-molecular-weight heparin as aspects that restrict magnetic resonance 8. Kirchin MA, Pirovano G, Venetianer C, Spinazzi A. Safety assess- Fig.3: Corresponding CT phlebography in the treatment of choice nowadays permits outpa- angiography application are non-diagnostic ment of gadobenate dimeglumine (MultiHance): extended clin- same patient as Fig. 2 ical experience from phase I studies to post-marketing surveil- tient managing of most DVT patients. The dura- quality of images and alterations that avert a lance. J Magn Reson Imaging 2001;14:281-294 demonstrating a long segment right-sided tion of anticoagulation therapy depends on patient from entering a magnetic field, which 9. Kluge A, Mueller C, Strunk J, Lange U, Bachmann G. Experience femoral vein thrombus in 207 combined MRI examinations for acute pulmonary whether the primary episode was idiopathic or together are in the order of 15%. These difficul- embolism and deep vein thrombosis. AJR Am J Roentgenol secondary to a temporary risk factor (e.g. sur- ties are a weakness of MRA, particularly when 2006;186:1686-96 10. Musset D, Rosso J, Petitpretz P, Girard P, Hanny P, Simonneau G, gery, trauma, malignancy). An international compared with spiral CT. Labrune M, Duroux P. Acute pulmonary embolism. Diagnostic normalised ratio (INR) of 2 to 3 should be the value of digital angiography. Radiology 1988;166:455-459 11. Oudkerk M, van Beek EJ, Wielopolski P, van Ooijen PM, target. Furthermore, the necessity to eliminate the Brouwers-Kuyper EM, Bongaerts AH, Berghout A. Comparison need for breath-holding for the detection of of contrast-enhanced magnetic resonance angiography and conventional pulmonary angiography for the diagnosis of pul- Clinically, requirements of an acceptable PE pulmonary emboli in dyspneic patients is monary embolism: a prospective study. Lancet 2002;359:1643- assessment are that it is feasible in most beyond question for any imaging modality. 1647 12. van Beek EJ, Reekers JA, Batchelor DA, Brandjes DP, Buller HR. patients and leads to the proper diagnosis and Improved gradient performance, ultrafast Feasibility, safety and clinical utility of angiography in patients with suspected pulmonary embolism. Eur Radiol 1996;6:415- consecutively the appropriate therapy. To this reconstruction capabilities and software tools 419. regard, evidence just as in DVT supports the for "on-the-fly" interactive MR scanning now 13. van Erkel AR, van Rossum AB, Bloem JL, et al. Spiral CT angiography for suspected pulmonary embolism: a cost-effectiveness use of a clinical prediction rule for establishing offer the potential for real-time MR imaging analysis. Radiology 1996; 201:29 - 36 pre-test probability of PE (Table 2). Combining with satisfactory contrast and spatial resolution 14. Weber OM, Eggers H, Spiegel MA, Scheidegger MB, Proksa R, Boesiger P. Real-time interactive magnetic resonance imaging a D-Dimer assay with a clinical prediction rule for pulmonary MRA, which albeit will have to with multiple coils for the assessment of left ventricular func- cuts down the need for further imaging studies prove its ability to challenge the current exami- tion. J Magn Reson Imaging 1999;10: 826-832 15. Wells PS. Advances in the diagnosis of venous thromboem- in appropriately selected patients, i.e. patients nation of choice: multi-slice CT. bolism. J Thromb Thrombolysis. 2006;21:31-40.

Special Edition / CIRSE 2008 - Copenhagen congress Interventional Oncology 15 newsIR

Table 1: Clinical model for predicting pre-test probability of deep-vein thrombosis (DVT) Table 2: Clinical model for predicting pre-test probability of pulmonary embolism (PE)

Clinical Feature Score Clinical Feature Score Active cancer (treatment ongoing, administered within previous 6 mo or palliative) 1 Previous pulmonary embolism or deep venous thrombosis 1.5 Paralysis, paresis or recent plaster immobilization of the lower extremities 1 Heart rate >100 beats per minute 1.5 Recently bedridden > 3 d or major surgery within previous 12 wk requiring general or Recent surgery or immobilization 1.5 1 regional anaesthesia Clinical signs of deep venous thrombosis 3 Collateral superficial veins (nonvaricose) 1 Alternative diagnosis less likely than pulmonary embolism 3 Localized tenderness along the distribution of the deep venous system 1 Hemoptysis 1 Swelling of entire leg 1 Cancer 1 Calf swelling > 3 cm larger than asymptomatic side(measured 10 cm below tibial tuberosity) 1 Pitting edema confined to the symptomatic leg 1 A score of >4 indicates that the probability of PE is "likely". A score of 4 and less indicates that the Previously documented DVT 1 probability is "unlikely." Alternative diagnosis at least as likely as DVT -2

A score of 2 or higher indicates that the probability of DVT is "likely". A score of less than 2 indicates that the probability is "unlikely."

Don't miss it ! Interventional oncology in renal cancer Special Session Tuesday, 8:30-9:30, Room C

Interventional Oncology: Imaging is the key

David J. Breen Clinical Director of Radiology Southampton University Hospitals, UK

As radiologists, first and foremost, many of us Therefore an ability to accurately confirm nent of the training schedule so as to allow References: 1. Goldberg SN. et al. Image-guided tumour ablation: standardiza- know that imaging has become the de facto tumour eradication is essential to the practice more time for the development of technical tion of terminology and reporting criteria. JVIR. (2005) 16:765 currency of modern medicine. Few patients, of interventional oncology. Non-enhancement skills. The understanding and ability to manipu- 2. Choi H et al. Correlation of computed tomography and positron emission tomography in patients with metastatic gastrointesti- certainly from the surgical-interventional end at post-procedural imaging is the current late imaging - the currency of cancer interven- nal stromal tumor treated at a single institution with imatinib of the spectrum, can be usefully discussed arbiter of treatment success, but can be limited tions - has never been more important to the IR mesylate: proposal of new computed tomography response criteria. J.Clin.Onc.(2007) 25::1753 without concurrent review of their radiology. It by contrast, spatial and temporal resolution. and we must not compromise on this aspect of is our ability to understand and manipulate this Besides this in situ treatments invoke collateral our training or practice. currency which places both diagnostic and changes, such as post-ablation marginal hyper- interventional radiology at the centre of patient aemia and subtended perfusional changes fol- care. Nowhere is this more evident than in the lowing embolization. Accurate post-procedural arena of interventional oncology. imaging will be essential to interventional oncology and was in fact the underlying theme At the recent ECIO meeting in Florence, and in of the recent ECIO meeting, linking both keeping with the tradition of interventional embolic and ablation approaches together. meetings, we heard about no end of new Whilst non-enhancement is useful, better char- embolic agents and ablation devices. The acterisation following ablation or embolization underlying theme however was the role of awaits major developments in functional imag- imaging in a new era of non-extirpative treating where for example we know that FDG-avid- ments for cancer. As cancers get smaller at the ity poorly, if at all, defines treatment success in time of reliable detection and characterisation, areas such as hepatocellular and renal cancer it becomes less necessary to invoke major and for the present spatial resolution remains resections - for example, the right hepatectomy limited. for the solitary 2cm liver metastasis. In such cir- Fig.1: Late arterial phase CT of a large carcinoid Fig.2a: A 42mm right renal tumour demonstrates cumstances outcomes from chemotherapy 5-year outcome data remains the gold stan- tumour following 'Bead Block' embolization. brisk enhancement in the late arterial phase. (and in particular newer biologic agents), dard for cancer therapies, but given the current Equivocal areas of enhancement noted deep embolization and ablation are jockeying for rapid evolution of drugs and devices we must within the embolized tumour (arrow). Whilst the position against the morbidity of conventional look to scrupulous intermediate term imaging effects are dramatic, a more clearly defined resection. These interventions are however to confirm the 'surgical' adequacy of many method of reporting treatment outcome will have inherently non-extirpative, i.e. the treated can- oncological interventions now being carried to be sought. cer is not removed. Whilst the surgeon looks to out. In reporting these critical imaging studies the pathologist for the single negative resec- we must look to a common radiologic lan- tion margin, we must judge success against guage which defines treatment outcomes. contrast-enhanced or increasingly functional Various groups have sought to standardise the imaging in all three dimensions. It is interesting language used in reporting the post-procedur- to note that whilst resection margins are usual- al imaging resulting from these treatments ly adequate in, say, hemihepatectomy, they are (1,2). This will be an important step forward if often less than adequate following metastatec- those undertaking such procedures are to con- tomy. In other words the more tailored resec- vince oncological and surgical colleagues that tion is a problem for all of us and particularly these interventions are anything other than tin- when absolute confirmation of complete abla- kering with the overall tumour biology. tion is sought. The unifying theme here is the critical interpre- With newer embolic agents we are all seeing tation of post-procedural imaging following in dramatic areas of apparent devascularisation, in situ cancer therapies. Imaging - and its inter- multifocal hepatocellular carcinoma for exam- pretation - is a critical component of Fig.2b: Following RF ablation there are small lin- Fig.2c: A repeat cryoablation was performed. The ple, but what does it mean (Fig.1)? Similarly 'Interventional Radiology' and remains one of ear areas of equivocal enhancement within the tumour now shows clear progressive involution at with ablation devices we must be able to con- our key skills, placing us at the centre of the treated tumour mass (arrow). How should this be 6 month follow-up. vince both clinical colleagues and patients alike discussion of clinical case management. In the reported? Does this need re-treatment? that the tumour has been effectively destroyed rush to train more IRs there has, in recent years, with adequate global margins (Fig.2a-c). been pressure to reduce the diagnostic compo-

Cardiovascular and Interventional Radiological Society of Europe C RSE 16 Film Interpretation Panel Sunday, September 14, 2008

Film Interpretation Panel Join us to witness the fight of Team Odin versus Team Thor tomorrow at 3pm in Room A. For those of you who like to get a head start we have put together this year's cases.

Case 1 Case 2

Pelvic Hemorrhage Chest pain

· 27 year old female · A 66 year old man was involved in a minor car accident while driving his car and · Previous cervical cancer treated by surgery and nodal resection wearing a seat belt. · One year after surgery severe vaginal bleeding > 2 l · He suffered no injury but felt a sharp chest pain and sought medical help in the emergency room of our hospital. · Chest X-ray revealed bilateral pleural effusion (not shown). · A contrast-enhanced CT scan was obtained.

Selected coronal reformat of arterial phase of CT

Describe the abnormalities and treatment options What is your diagnosis? Predisposing conditions? Treatment?

Special Edition / CIRSE 2008 - Copenhagen congress Film Interpretation Panel 17 newsIR Don't miss it ! Odin vs. Thor Film Interpretation Panel Monday, September 15, 15:00, Room A Monday, 15:00, Room A

Case 3 Case 4 Foot pain and ulceration Biopsy - yes or no? That is the question

· 22 year-old male of North African origin · 65 year old male · The symptomatic left leg always larger than the right · History of rectum cancer · Since 2 years hypertrophic violaceous plaques · One year after surgery suspicion of local lymph node metastatic disease · Last 2 months increasing pain in foot and ulceration

Biopsy yes or no? If yes, how? Left foot

STIR MR angio

Coaxial biopsy performed with and 18-gauge needle. Jet of blood DSA left foot through the coaxial needle after removal of the biopsy needle.

Biopsy performed What happened? What should you do? Diagnosis? Treatment options? Treatment?

Cardiovascular and Interventional Radiological Society of Europe C RSE 18 Advertisement Sunday, September 14, 2008

Gore Scientific Program at CIRSE Copenhagen, 13 - 16 September 2008

Meet the Expert Workshops - Monday, 15 September, 2008 | Sunday (TIPS, BILIARY) 14.30-15.30 Gore Learning Center (Room M1) 12.00-13.00 and 13:30 - 14:30 Monday (SFA) 13.30-14.30 The Role of GORE VIABAHN® Endoprosthesis - Tuesday (PAA) 13.30-14.30 Saturday, 13 September, 2008 | 12:00 - 14:00 Endoluminal SFA Bypass for Treating Complex Mini Advanced AAA Workshop SFA Lesions - A Critical Debate of Burning Gore Satellite Symposium - Participation on invitation only. Topics Room C

Sunday, 14 September, 2008 | 12.00-13.00 Moderators: Dr. R. Nymann, Uppsala, Sweden, Monday, 15 September, 2008 | 8.00-8.20 Discussing the Future of TIPS For the Treatment Dr. A. Rampoldi, Milan, Italy Long-Term Results of Total Endoluminal SFA of Portal Hypertension Bypass with the GORE VIABAHN® Dr. R. Chopra, Chicago, USA Endoprosthesis Moderator: Dr. F. Fanelli, Rome, Italy Dr. R. Kruse, Den Bosch, The Netherlands Moderator: Dr. E. Verhoeven, Groningen, Lessons Learned Using GORE VIATORR® TIPS Tuesday, 16 September, 2008 | 12.00-13.00 The Netherlands Endoprosthesis Endovascular Treatment of Popliteal Prof. P. Goffette, Brussels, Belgium Aneurysms: Tips and Tricks, Lessons Learned GORE VIABAHN® Endoprosthesis - An Endoluminal SFA Bypass and the Future Results of a Controlled Randomized Trial What do Long-Term Data Tell us About the Role of the Heparin Bioactive Surface Comparing GORE VIATORR® TIPS Use of GORE VIABAHN® Endoprosthesis for Dr. R. Chopra, Chicago, USA Endoprosthesis with Banding for Cirrhotic Endovascular PAA Treatment? Patients with Acute Variceal Bleeding. Dr. E. Verhoeven, Groningen, The Netherlands A New Controlled Randomized Trial to Current and Future TIPS Indications Compare GORE VIABAHN® Endoprosthesis with Dr. A. Luca, Palermo, Italy Indications, Contra-Indication, Lessons Learned Bare Nitinol Stents for Long SFA Lesions Using the GORE VIABAHN® Endoprosthesis for Prof. J. Lammer, Vienna, Austria Sunday, 14 September, 2008 | 13.30-14.30 Endovascular PAA Treatment Lessons Learned with the GORE VIABIL® Biliary Prof. M. Maynar, Las Palmas, Spain For Meet the Expert Workshop reservation Endoprosthesis to Treat Biliary Obstructions please visit the Gore booth at CIRSE. Case Review Session - The Role of GORE VIABIL® Biliary Gore Learning Center (Room M1) W. L. Gore & Associates, Inc. Endoprosthesis to Treat Malignant Flagstaff, AZ 86004 Biliary Obstructions Sunday-Tuesday, 14-16 September, 2008 00800.6334.4673 Prof. W. van Steenbergen, Leuven, Belgium Bring your own case and consult the experts at the Gore learning center! Meet with the experts For international contacts and additional Technical and Clinical Results Using GORE directly after the workshop to discuss your case product information, visit goremedical.com VIABIL® Biliary Endoprosthesis - A 6 Years and to get direct advice. You might win a scien- Experience tific voucher of 250 EUR. Please bring your case GORE, VIABAHN®, VIABIL®, VIATORR® and designs Dr. F. Fanelli, Rome, Italy on CD or memory stick. are trademarks of W. L. Gore & Associates. © 2008 W. L. Gore & Associates GmbH, AM1632-EU1, JULY 2008

Special Edition / CIRSE 2008 - Copenhagen congress The Alternative Guide to Denmark 19 newsIR

CIRSE Initiative for UFE Patient Information

The UFE dedicated website Similarly, the information available online in www.uterinefibroids.eu provides detailed the multiple European languages differs greatly information on fibroids, treatment options with excellent websites available in some lan- and UFE and is intended to make this highly guages, principally in English, and a total successful non-surgical procedure more absence of information in others. Whilst widely known among patients and referring enhancing traffic to existing websites through doctors in Europe. selected links, www.uterinefibroids.eu will first and foremost seek to provide information in As so often with medical treatments, and par- languages in which information on UFE is cur- ticularly with innovative treatment methods, rently lacking. their availability and practice varies widely across Europe. UFE is now an accepted alternative treatment to hysterectomy and myomecto- my in a good number of countries in which it is Should you be willing to contribute UFE related readily accessible to many patients. However, in content or links to existing websites in your other countries its status is yet to be deter- national language, please contact us at mined, with some countries offering no UFE [email protected]. www.uterinefibroids.eu treatment at all to date.

More stuff you should know about Denmark

Petra Mann Although historically linked to Denmark, Another Copenhagen classic are hot dogs with Danish Beer CIRSE Office Iceland and Norway, Greenland is ethnically røde pølser (red sausages), which are sold in lit- associated with North America, the majority of tle hand-pulled carts around the city. If you're Denmark is the European country with most Greenlanders being of Inuit origin. It is com- feeling a little frisky, go up to one and ask for a breweries per capita - around 60-70 in total, Greenland - the land where your drink mon knowledge that Inuit languages will have hot dog "med det hele", which will get you the many of which are located in Copenhagen and needs no ice cubes up to 20 words for different types of snow, but works for your street meat. offer guided tours followed by a tasting of the what is less known is that Western Greenlandic, establishment's products. Incidentally, this is Greenland is defined as a self-governing for example, has immensely long words which You will see that in terms of restaurants where I say good-bye to my male audience. Danish province (whatever that means) and is can sometimes express what other languages Copenhagen really leaves nothing to be mostly known for being, well, bloody cold - need entire sentences for. So when two desired. It offers a wide range of exquisite Until recently the Carlsberg brewery virtually with an average annual temperature of -11°C Greenlanders speak about last night's TV pro- establishments, 11 of which have been award- held a monopoly on the Danish beer marked, even the toughest nipple will stand to constant gramme, you might hear one of them say ed Michelin stars. The Noma Restaurant has during which it acquired many local breweries attention. Apart from cold, Greenland is also Aliikusersuillammassuaanerartassagaluarpaalli, recently even been awarded a second star, so if and shut them down in order to increase its immensely huge; it comprises roughly expressing his disagreement about the quali- you can get a reservation (for 2011, that is), do market shares. Angered by this development, a 2,000,000 km². Discounting 81%, which are ties of an entertainer. The most interesting fact go there! I must warn you though: upon receiv- consumer movement called Danske covered by the Greenland ice sheet (The name you should know about the Inuit culture, how- ing your check you might have to part with the Ølentusiaster ("Danish Beer Enthusiasts") was Iceland was probably already trademarked), ever, is that they kiss with their noses, so if you idea that both of your children will go to col- founded in an Odense pub in 1998. I daresay that still leaves 7km² for each of its 56,000 do go there you might want to reconsider that lege. that the founding fathers of this illustrious soci- inhabitants. I guess my point is that they must nose job. ety were as intoxicated as a sailor on leave, have really big back yards or a lot of golf cours- which explains the movement's great success. es or something. Danish Food Today the society boasts almost 11.000 mem- Or: When does love for herring become too bers, holds two beer festivals per year and has intense? achieved an outstanding revival of beer variety throughout Denmark, which of course explains As in the other Scandinavian countries, Danes why Copenhagen is one of Europe's most pop- eat a lot of meat. Frikadeller and karbonader ular conference destinations. are popular dishes of fried meatballs with gravy, and although eating marinated reindeer For more information go to www.ale.dk or con- sounds like something you would have to do sult the closest pub for an immediate sampling. on Fear Factor, it is actually worth a try.

Of course the Danes would not be a sea-faring nation if they did not also eat a fair share of fish on their smørrebrød. Marinated herring and smoked eel are some of the specialties and are a common sight at breakfast buffets. Although it was not a culinary experience I had hoped I would ever make, having fish for breakfast is not all that bad and most Danes will insist that it is the best hang-over cure (not that any of us would ever need such a thing).

IR Congress News is published as an additional source of information for all CIRSE 2008 participants. 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: Poul Erik Andersen, Afshin Gangi Managing Editor: Petra Mann, CIRSE Office Graphics/Artwork: LOOP. ENTERPRISES media

Cardiovascular and Interventional Radiological Society of Europe C RSE