congressR news CIRSE 2016 – Barcelona Monday, September 12, 2016

Interventional Oncology: the fourth pillar of care In recent years, the evidence supporting image-guided cancer therapies has grown, as have the range of treatments and applications available. Interventional oncology is increasingly being recognised as a key pillar of cancer care, alongside medical oncology, surgery and radiation oncology. While the annual ECIO meeting offers a dedicated educational forum, the field’s importance is such that it continues to be a key part of the CIRSE meeting. © [email protected]

Don’t miss it ! Radioembolisation Radioembolisation Evidence on the Rise Fundamental Course Monday, September 12 08:30-09:30 Helen Hemblade, CIRSE Office Room 112

While radioembolisation has been an available the two arms of the study [1]. Furthermore, the Committee headed by radioembolisation Today’s Fundamental Course treatment option for several years, new data European Society for Medical Oncology (ESMO) expert Prof. José Ignacio Bilbao, on the use of Radioembolisation on treating patients with metastatic colorectal included radioembolisation with Y-90 resin radioembolisation with SIR-Spheres for 08:30-09:30, Room 112 cancer (mCRC) and microspheres in its 2014 guidelines for patients tumours. The registry has now enrolled over (HCC) is now demonstrating a clearer picture of with liver-limited metastases failing the avail- 200 patients in medical centres with exper- Moderators: C.A. Binkert (Winterthur/CH), J. Ricke its clinical effectiveness. Past studies, providing able chemotherapeutic options, citing that it tise in this procedure and currently extends (Magdeburg/DE) the basis of knowledge on the use of radio- can prolong the time to tumour progression across six European countries. As CIRT moves embolisation with Y-90 resin microspheres to forward, even more countries are being lined Dose calculation for IRs treat mCRC, have indicated that radioemboli- Recently, a pilot randomised trial, SIRTACE, up for inclusion in this important data collec- E.G. Santos Martín (Pittsburgh, PA/US) sation has a role in chemotherapy-refractory suggested that radioembolisation could act tion project. This extensive research project mCRC but also delays liver progression and as an alternative to TACE for patients with un- aims to provide robust data to support the use Embolisation principles: preparation for possibly improves overall survival when added resectable HCC because a single session of of IR and its cutting-edge therapies, and help radioembolisation to first-line chemotherapy regimens. SIRT with Y-90 resin microspheres had a similar identify the patients that radioembolisation R.J. Lewandowski (Chicago, IL/US) impact on objective response rate and quality can benefit. The 2015 SIRFLOX trial greatly enhanced of life as multiple sessions of TACE [2]. Patient care: outpatient setup, special know ledge of the use of radioembolisation Furthermore, through its collaboration with precautions with Y-90 resin microspheres (SIR-Spheres) in With this wealth of evidence comes the chal- the European Institute of Biomedical Imaging W.S. Rilling (Milwaukee, WI/US) combination with first-line chemotherapy for lenge of how radioembolisation can be optimal- Research (EIBIR) and involvement in the patients with liver-dominant mCRC. In SIRFLOX, ly integrated into oncologic treatment plans. Horizon 2020 funding programme, the CIRSE Overview of recent trials patients were recruited with non-resectable Research Network encourages interventional- J.I. Bilbao (Pamplona/ES) liver-only or liver-dominant mCRC with no CIRSE revs up IO research ists to come forward with their research project previous chemotherapy for advanced disease. ideas. After screening, 530 patients were randomised Over the past few years, CIRSE has established to receive mFOLFOX chemotherapy (± beva- its European-wide research efforts with the A packed programme cizumab) or mFOLFOX chemotherapy (± beva- creation of two oncology registries. The recent- cizumab) and a single session of SIRT with Y-90 ly launched CIREL registry will pros pectively Alongside its research efforts, CIRSE is inten- resin microspheres. The primary endpoint observe the administration of irinotecan- sifying its educational initiatives in cancer was progression-free survival (PFS) at any eluting microspheres, a newly CE-approved therapy, working closely with practition- site, and there was no significant difference transcatheter chemoemboli sation (TACE) ers from different disciplines and industry. between the groups (median PFS 10.7 months system for treating patients with colorectal ad- Interventional oncology is therefore one of the and 10.2 months in the SIRT group and non- enocarcinoma with liver-only or liver-dominant core themes of this year’s congress. This morn- SIRT group, respectively). However, and quite metastatic disease. CIREL will be collecting data ing, four speakers in the Fundamental Course References: importantly, assessment of PFS in the liver over an initial period of three years following on radioembolisation will cover dosimetry, 1. Gibbs P, Heinemann V, Sharma NK, et al. SIRFLOX: Randomized with a com peting risks analysis showed that enrolment of the first patient, planned before preparation, special precautions and an over- phase III trial comparing first-line mFOLFOX6 ± bevacizumab (bev) versus mFOLFOX6 + selective internal radiation therapy patients whose treatment included SIRT had the end of 2016. view of recent trials on radioembolisation. (SIRT) ± bev in patients (pts) with metastatic colorectal a 7.9-month improvement in PFS in the liver Further relevant sessions coming up include cancer (mCRC). J Clin Oncol 2015; 33 (suppl.): A3502

from 12.6 to 20.5 months and a 31% reduced In 2014, the first-ever CIRSE Registry for SIR- Free Paper, Expert Round Table and a range of 2. Kolligs FT, Bilbao JI, Jakobs T, et al. Pilot randomized trial of risk of the tumours in their liver progressing. Spheres Therapy (CIRT) was launched under Hands-on Workshop interventional oncologic selective internal radiation therapy vs. chemoembolization in unresectable hepatocellular carcinoma. Similar liver resection rates were observed in the direction of an interdisciplinary Steering techniques. Liver Int 2015; 35: 1715-21

Cardiovascular and Interventional Radiological Society of Europe C RSE 2 / X-Session Monday, September 12, 2016 2016 is CVIR’s "Year of Innovation"

NEW cover design NEW monthly issues NEW and improved manuscript management system NEW simplified guidelines for authors NEW awards and competitions during CIRSE 2016 NEW impact factor – 2.144

Submit your manuscript now: www.editorialmanager.com/cvir

Vol 39 | no 9 | Sept 2016

Special Edition / CIRSE 2015 – Lisbon I 3 congressR Neurointerventions news

Don’t miss it ! Paradigm shift: acute ischaemic stroke Neurointerventions: stroke therapy Hot Topic Symposium Monday, September 12, 15:15-16:00 Helen Hemblade, CIRSE Office Auditorium 1

Thought-provoking new studies in endo- in the recently published two-year CRISP stroke network that brings as many suitable who exactly is eligible to perform endovas- vascular treatment and advances in imaging study (CT perfusion to predict response to patients with large vessel occlusions to stroke cular neurological procedures thus comes into for acute ischaemic stroke have subsequently Recanalization in Ischemic Stroke Project) centres as fast as possible, while patients who play: general interventional radiologists with led to fervent discussion about the role of of 102 ischaemic stroke patients in the USA need intravenous thrombolysis can be treated specific training, or only neuro-interventional the interventionalist in stroke therapy. Prior who had endovascular therapy, research- in regional stroke units. radio logists? For the general interventional to this past year, clinical studies had provided ers found that when CT perfusion imaging is radio logist, it has been doubted whether these neutral or even negative results on endo- performed, large areas of brain tissue can be The importance of imaging skills are transferable for treatment on an organ vascular treatment of acute ischaemic stroke. safely salvaged up to 18 hours after stroke as unique as the brain. And as such, endovas- However, recent results from several studies symptoms begin. According to this study, The current approach to patient selection for cular treatment requires very careful patient have proved otherwise. During this year’s Hot there was no significant association between mechanical stroke reperfusion therapies is selection. Topic Symposium – moderated by Prof. Tommy time to treatment and good outcomes when based on the time from stroke symptom onset Andersson and Prof. Klaus Hausegger – Prof. the CT per fusion imaging showed salvageable and imaging-derived existence of a major On the subject of eligibility, Dr. Brouwer Heinrich Mattle, Prof. Tobias Engelhorn and brain tissue. vessel occlusion such as the ICA, BA or the laments how it is often forgotten that endo- Dr. Patrick Brouwer will discuss current treat- proximal MCA. Prof. Engelhorn believes this vascular treatments are highly specialised and ment strategies, new evidence and the role of Current status approach to be reasonable in the first six hours moreover, that knowledge of the end-organ, the IR in acute ischaemic stroke therapy. after stroke onset when substantial salvage- technical skills and experience are necessary to In most countries, health authorities have able tissue probably exists in the majority of ensure a safe treatment. This is especially true The turning point approved the use of tissue plasminogen patients. However, this neglects the variable in the case of intra-arterial ischaemic stroke activator (tPA) for up to 4.5 hours. In the USA, collateral physiology that exists between treatment, which can be considered an opera- In 2014, the Amsterdam-based MR CLEAN the FDA has approved use for up to 3 hours individual patients and probably plays a critical tive procedure, and therefore needs a specialist trial demonstrated that patients who were after stroke onset. However, despite proven role beyond this time window. Besides the to perform the therapy, in comparison to IV treated with IA intervention within six hours clinical efficiency, at least 50% of IV-treated neurological deficit, brain imaging is of major thrombolysis where a nurse can administer the of symptom onset, in addition to usual care, stroke patients remain disabled or die. Clear importance. He argues that brain CT imaging treatment once the stroke specialist has set the had an increase in functional independence in evidence has accrued showing that urgent – ideally multimodal MRI using perfusion and indication for IV treatment. He cautions that daily life at three months without an increase recanalisation is crucial in patients with diffusion imaging and various types of cerebral practitioners who are unskilled and unaware in mortality, according to the modified Rankin ischaemic stroke caused by an occluded major angiography – should be available non-stop for are not only a serious threat to the patient but scale. Intra-arterial treatment consisted of arte- intracranial artery. However, early recanalisa- stroke patients. Prof. Engelhorn furthermore also to the future of the technique itself. rial catheterisation with a microcatheter and tion after IV treatment is seen in less than hinted to alternative approaches employing delivery of a thrombolytic agent, mechanical 10% patients with an occlusion of the internal ASPECT score and absolute lesion volumes of The thrilling discussion will continue in the Hot thrombectomy or both. carotid artery terminus, and the prognosis the core infarct and the surrounding region of Topic Symposium today – don’t miss out! without revascularisation is generally poor for hypo-perfusion as promising developments The exciting data from MR CLEAN and four such patients. Prof. Mattle notes that tPA is not that still require further validation. More neurointervention sessions at CIRSE other successful 2015 studies (ESCAPE, effective enough to dissolve large clots and, for 2016 REVASCAT, SWIFT PRIME and EXTEND IA) were patients with large vessel occlusions, mechani- What is the next step? pooled to set up the HERMES collaboration. cal thrombectomy after tPA, or mechanical Basic acute ischaemic stroke intervention This meta-analysis showed that for every 100 thrombectomy alone, is superior to intravenous Aside from the re-organisation of stroke Fundamental Course patients with a large-vessel anterior-circulation thrombolysis. On top of winning extra time, management across healthcare systems, this Tuesday, September 13, 08:30-09:30 ischaemic stroke treated with endovascular this is why intra-arterial treatment is regarded is the burning question among not only those Room 115 thrombectomy, 38 will have a less disabled as a potentially important component of the practising neurointerventions but also general outcome than with best medical management treatment. He outlines however, that he does interventionalists. Referencing the MR CLEAN How to improve acute stroke management: alone, and 20 more will achieve functional not believe mechanical throm bectomy could trial, Dr. Brouwer points out that the positive present and future independence, irrespective of geographical or be performed in all stroke victims and that patient outcome is a mere reflection of the Special Session patient characteristics. Results also suggested patients with occlusions distal to large vessels fact that these practitioners were trained to Tuesday, September 13, 10:00-11:00 a strong trend towards endovascular treat- will likely always be the target patients for in- perform thrombectomy as part of their normal Room 117 ment being beneficial for up to even eight travenous thrombolysis. Prof. Mattle suggests professional neurointerventional workload. hours from symptom onset. Furthermore, that the big challenge now is to organise a The potentially more important question of

ESIR 2016 Course

ESIR 2016 Clinical Procedure Training Mechanical Thrombectomy in Acute Ischaemic Stroke The Hague (NL), December 9-10

During this ESIR Clinical Procedure Training for experienced practitioners, focus will be placed on the logistics of stroke treatment, including available options, therapeutic windows, techniques and managing complications. Attendees will also have the opportunity to familiarise themselves with the most common thrombectomy devices during extensive hands-on workshops.

www.cirse.org/esir2016 C RSE foundation

Cardiovascular and Interventional Radiological Society of Europe C RSE Cardiovascular and Interventional Radiological Society of Europe

GEST 2017

EUROPE

Global Symposium and Technologies

May 31 – June 03 Florence, Italy

www.gest2017.eu

C RSE foundation I 5 congressR Embolisation news

Don’t miss it ! Musculoskeletal embolisation Can embolisation alter the course of chronic musculoskeletal Special Session Monday, September 12, 08:30-09:30 conditions? Room 117 Yuji Okuno

Osteoarthritis (OA) is the most common patients and have assessed long-term clinical and Lawrence (KL) grade. 33 out of 38 (88%) Yuji Okuno degenerative joint disease, and significantly results and safety profile. patients with KL grade 1-2 OA (early stage of Edogawa Hospital affects patients’ quality of life and results in OA) showed good clinical response, answering Tokyo, Japan direct and indirect costs ranging from 1-2.5% This treatment is based on the hypothesis that "very much improved" or "much improved" of the gross national product in Western in OA and other chronic painful conditions, on patient global impression of change countries. The most frequent site of OA is the abnormal neovessels have a central role in the questionnaires at four months after treatment. knee, with more than 40% of people older than start and continuation of inflammation and 16 out of 29 (55%) patients with KL grade 3 OA 70 diagnosed with knee OA. pain. Neovessels act as a pipeline of inflam- (moderate OA) showed good clinical response, matory cells, which in turn stimulate the but out of 8 patients with KL 4 grade (end stage There are currently no curative or effective development of new abnormal neovessels. OA), none showed good response. Patients disease-modifying treatments for OA. Current These abnormal neovessels are surrounded with marrow necrosis depicted on MRI Dr. Okuno is Director of the Musculoskeletal therapeutic options are essentially sympto- along their path by sensory nerve fibres that before treatment also showed poor results. Intervention Center at Edogawa Hospital in matic, usually temporary and often ineffective, are strongly suspected of being a major actor Thus, we suggest that these patients should Tokyo. He has published multiple works on with major joint replacement surgery in the start of pain and are stimulated by the not be eligible for TAME. musculoskeletal topics, particularly regarding the remaining the most radical treatment in abnormal increase of blood flow. subject of transcatheter arterial embolisation. end-stage OA. Joint replacement has a limited We continued clinical assessment up to 3-4 These have been featured in various journals, durability, carries the risk of complications (a The goal of TAME is not to achieve permanent years in 20 patients with KL 1-2 OA who were including the Journal of Vascular and significant driver of current high costs of OA) infarction, but to reduce the amount of treated between 2012-2013, and sustained , CardioVascular and and is not feasible in a considerable number abnormal neovessels and normalise the blood improvement was seen at final follow-up. Interventional Radiology, and the Journal of of patients due to comorbidities and elevated flow. The reduction of neovessels by TAME is On MRI follow-up of these 20 patients at 2 Shoulder and Elbow Surgery. perioperative risk. expected to reduce inflammation and also the years after TAME, none showed bone marrow stimulation of accompanying sensory nerves, necrosis, obvious cartilage loss compared to Several lines of evidence indicate that in- thus resulting in pain reduction in patients with baseline or aggressive degenerative changes. flammatory process plays a critical role in knee OA. Interestingly, MRI signs of synovitis improved the development of OA and is a vicious significantly at final follow-up compared to circle. Inflammatory mediators are released We used two types of embolic materials: baseline. by synovium and adipose tissue and cause imipenem/cilastatin sodium (IPM/CS) which cartilage loss and osteophytosis, which lead is a transient embolic agent, and calibrated We have applied the TAME procedure to to increased mechanical stress to surround- m icrospheres Embozene 75 μm. other chronic painful conditions, such as ing tissues and, in turn, cause further inflam- frozen shoulder and overuse injuries, in- mation [1]. IPM/CS is a crystalline compound, approved cluding tendinopathy and enthesopathy. So as an antibiotic, slightly soluble in water, and far, we have treated 98 cases of tendinopathy Angiogenesis is believed to contribute to the when suspended in contrast agent, forms and enthesopathy and 125 cases of muscu- origin of inflammation, and especially to its 10 to 70 μm particles that exert a transient loskeletal shoulder pain, including frozen continuance. Some researchers have demons- embolic effect [7]. Regarding Embozene 75 shoulder. We think that these conditions are References: 1. Goldring MB, Goldring SR. Osteoarthritis. Journal of cellular trated that pharmacological inhibition of μm microspheres, 0.15 ml of the solution good indications of TAME as well as knee physiology 2007; 213(3): 626-634 2. Ashraf S, Mapp PI, Walsh DA. Contributions of angiogenesis angiogenesis could lead to improvement of was diluted with 2 ml of contrast agent and osteoarthritis. to inflammation, joint damage, and pain in a rat model of inflammation and pain behaviour through an injected in 0.2 ml increments until blood flow osteoarthritis. Arthritis and rheumatism 2011; 63(9): 2700-2710 3. Mapp PI, Walsh DA. Mechanisms and targets of angiogenesis animal experimental model [2]. In addition, stagnated. According to our experience, this innovative and nerve growth in osteoarthritis. studies have shown that angiogenesis may interventional radiology pain treatment seems Nature reviews Rheumatology 2012; 8(7): 390-398 4. Okuno Y, Matsumura N, Oguro S. Transcatheter arterial contribute to chronic pain by enabling growth In our previous report of early experience [6], promising and offers a new effective option for embolization using imipenem/cilastatin sodium for of new unmyelinated sensory nerves along the TAME appears to be a feasible and effective pain control. Its efficacy and safety should be tendinopathy and enthesopathy refractory to nonsurgical management. JVIR 2013; 24(6): 787-792 neovessels [3]. In fact, histopathological studies pain treatment for patients with mild to studied in high quality, large scale trials with 5. Okuno Y, Oguro S, Iwamoto W, Miyamoto T, Ikegami H, have demonstrated the existence of abnormal moderate knee OA. The study included 14 control groups. Matsumura N. Short-term results of transcatheter arterial embolization for abnormal neovessels in patients with neovessels with accompanying nerve fibres patients with mild to moderate OA, resistant adhesive capsulitis: a pilot study. Journal of shoulder and in tissues from various painful conditions in- to conservative pain treatment, and found The TAME procedure remains more invasive elbow surgery / American Shoulder and Elbow Surgeons [et al.] 2014; 23(9): e199-206 cluding osteoarthritis. significant pain relief following embolisation, than other routinely used minimally invasive 6. Okuno Y, Korchi AM, Shinjo T, Kato S. Transcatheter arterial with validated Western Ontario and McMaster treatments for pain management, and should embolization as a treatment for medial knee pain in patients with mild to moderate osteoarthritis. Cardiovasc Intervent With the advent of new technology and skills Universities Arthritis Index (WOMAC) pain be performed by a trained interventional Radiol 2015; 38(2): 336-343 in the field of interventional radiology, emboli- scores decreasing from 12.2 ± 1.9 before radiologist. The limitations of our current 7. Woodhams R, Nishimaki H, Ogasawara G, Fujii K, Yamane T, Ishida K, Kashimi F, Matsunaga K, Takigawa M. Imipenem/ sation of small abnormal neovessels has be- treatment to 3.3 ± 2.1 at one month after studies include a limited number of patients cilastatin sodium (IPM/CS) as an embolic agent for come feasible, and appears to be a potential the procedure, 1.7 ± 2.2 at four months post- and no control group. To date, our work rep- transcatheter arterial embolisation: a preliminary clinical study of gastrointestinal bleeding from . target to treat chronic pain and inflammation embolisation. resents a solid proof of concept and a sound Springerplus 2013; 2: 344 in musculoskeletal conditions. basis for further studies. Between 2012 and March 2016, 75 patients We have previously reported the results of with knee OA were treated. No serious adverse transarterial embolotherapy in patients with event was noted. Minor complications, such as Changes of pain score after procedure refractory tendinopathy and enthesopathy [4], transient cutaneous colour change (only seen frozen shoulder [5] and mild to moderate knee in cases treated by Embozene) and moderate 17 osteoarthritis [6]. We named this embolisation subcutaneous haemorrhage at the puncture 16 treatment TAME (transcatheter arterial micro- site, were observed and resolved without any 15 embolisation), because it uses a small amount treatment. 14 13 of small-sized embolic particles. We have 12 continued to perform this treatment on more The severity of OA in these 75 patients was 11 classified according to radiographic Kellgren 10 9 8 Pain WOMAC 7 6 5 4 3 2 1 0 Pre 1 3 12 24 36

Time course (month)

Fig. 1: Angiography of normal and osteoarthritis knees pre- vs. post-embolisation Fig. 2: Trend of WOMAC Pain score in 20 patients with KL grade 1 or 2 knee OA treated with TAME In a normal knee without OA (a), a normal angiographic appearance of the left descending genicular A strong reduction of pain is shown in the first months after treatment, which is maintained at long-term artery is visible without neovessels. In a 61-year-old patient with knee OA (b), selective angiography of the follow-up till 36 months post-embolisation. descending genicular artery before embolisation shows abnormal neovessels (black arrow) adjacent to the medial condyle, which are eliminated after embolisation (c). MC=medial femoral condyle, LC=lateral femoral condyle

Cardiovascular and Interventional Radiological Society of Europe C RSE Film Interpretation Quiz

This light-hearted and interactive session has always been a CIRSE favourite! All delegates are invited to take part in this last-man-standing battle for supremacy – will you be crowned this year’s winner?

Pick up complimentary flags at the door and use them to cast your vote in the multiple choice questions. The Quizmasters will present the audience with three possible answers to each case – those choosing incorrectly are out of the game! The last few contestants left standing will be invited onstage for an exciting head-to-head finale.

Those eliminated at the very beginning will get a second chance to put their skills to the test!

Can you beat our Quizmasters? And more importantly – can you beat your friends and colleagues? Find out how good you really are!

Join us today at 14:30 in Auditorium 1!

Quizmasters: Ian McCafferty (Birmingham/UK) Anthony Watkinson (Exeter/UK)

Special Edition / CIRSE 2016 – Barcelona I 7 congressR Vascular news

Don’t miss it ! Alternative arterial access Direct SFA Access Special Session Monday, September 12, 10:00-11:00 Florian Wolf Room 112

Ensuring a safe and stable arterial access is important feature for a direct antegrade access (statistically not significant); however, the rate Florian Wolf the absolute prerequisite for every arterial of the superficial femoral artery is the use of of haematoma was greater and the access time Medical University of Vienna intervention. For decades, the common femoral ultrasound guidance, which should be easy to was higher. Vienna, Austria artery was almost the only arterial access point achieve, since, in most interventional radio- used by interventional radiologists. Nearly logy suites, an ultrasound machine is available. In most cases, a 6 Fr. sheath is sufficient, but, every vessel in the can be reached With ultrasound, an optimal puncture site is in rare cases, 8 Fr. or even larger sheaths may from this common access site. chosen, and, under ultrasound guidance, local be necessary. The occlusion of the access anaesthesia is applied. The ultrasound-guided site can be performed using a closure device To reach the contralateral leg vessels, a cross- vessel puncture is performed using a 19 G like StarClose Proglide, Exoseal [5], or even over access is the preferred method, since it open needle, and only the anterior vessel wall Angioseal if the lumen of the vessel is large is also easy to achieve in obese patients, and should be punctured in order to avoid a wall enough. But even manual compression is safe. Assoc. Prof. Dr. Florian Wolf is Vice-Director of the C-arm is away from the puncture site, haematoma or a bleeding. The wire can also be In a recent study, there was no significant the Division of Cardiovascular and Interventional which enables easy and low-radiation work. advanced without any fluoroscopy, since there relationship between the sheath side and the Radiology at the University of Vienna, where he Nevertheless, there are some disadvantages to is no deep femoral artery, and the wire will rate of complications, particularly the rate of completed his medical education in 2000. He using a cross-over access: automatically glide into the peripheral super- pseudoaneurysms [2]. later became a certified radiologist in 2008 and ficial femoral artery. subsequently a holder of the EBIR certification. 1. The sheath cross-over must be done via the Direct access of the superficial femoral artery He is the co-founder of the educational platform aortic bifurcation, which can be difficult in Alternatively, a micropuncture set can be used, is a safe alternative to a cross-over access or an Vienna Heart which focuses on teaching post- steep bifurcations or in patients with heavy which was investigated in a recent study [1]. antegrade common femoral artery access, and graduates about cardiac imaging. As well as calcifications. That study showed that the rate of pseudo- should be part of every interventional radio- authoring or co-authoring over 40 publications, 2. Instruments with long shafts and long wires aneurysm was lower using a micropuncture set logist’s portfolio. Dr. Wolf is on the editorial board of the European must be used, which makes the inter vention Radiology journal. An active member of CIRSE, he more complex for the physician and his/ served on CIRSE’s Clinical Practice App Task Force her assistants, and also leads to a longer and was previously on the ESIRonline Editorial intervention time, and, as a consequence, a Board. higher radiation dose for the patient and the physician and his/her team. 3. The pushability, but especially the steer- ability, of the instruments might be not sufficient. Especially in complex inter- ventions, for example, with long-standing subintimal recanalisation of the SFA, an excellent pushability and an exact steering of the wire is crucial for successful pro- cedures. Lower-leg vessel recanalisations can be done using an antegrade access

almost exclusively – using a cross-over References: access in these patients is successful only in 1. Gutzeit A, Schoch E, Reischauer C, Hergan K, Jenelten R, Binkert CA. Comparison of a 21G micropuncture needle and rare cases. a regular 19G access needle for antegrade arterial access into the superficial femoral artery. Cardiovasc Intervent Radiol 2014; 37: 343-347 Moreover, in more and more patients, an 2. Gutzeit A, van Schie B, Schoch E, Hergan K, Graf N, Binkert arterial access using the contralateral common CA. Feasibility and safety of vascular closure devices in an antegrade approach to either the common femoral artery or femoral artery is not possible for various the superficial femoral artery. reasons, such as obesity, a short time period Cardiovasc Intervent Radiol 2012; 35:1036-1040 3. Kweon M, Bhamidipaty V, Holden A, Hill AA. Antegrade between groin surgery and the interven- superficial femoral artery versus common femoral artery punctures for infrainguinal occlusive disease. tional procedure, infection, and other reasons. J Vasc Interv Radiol 2012; 23: 1160-1164 Different alternative access routes are available, 4. Gutzeit A, Graf N, Schoch E, Sautter T, Jenelten R, Binkert CA. Ultrasound-guided antegrade femoral access: comparison including popliteal or pedal retrograde access, between the common femoral artery and the superficial transbrachial or trans-radial access, or a hybrid femoral artery. Eur Radiol 2011; 21: 1323-1328 5. Rimon U, Khaitovich B, Yakubovich D, Bensaid P, Golan G, intervention using a surgical cut-down. All Silverberg D. The Use of ExoSeal Vascular Closure Device for these techniques should also be part of the Direct Antegrade Superficial Femoral Artery Puncture Site portfolio of an experienced interventional Hemostasis. Cardiovasc Intervent Radiol 2015; 38: 560-564 radiologist; however, they also have some Fig. 1: 78-year-old obese female patient with Fig. 2: 65-year-old male patient, history of aortic disadvantages and cannot be used in all PADO IV and ulcerations in the left foot due to an stent graft implantation with a surgical cut-down patients. occlusion of the distal superficial femoral artery in the right groin three days before. CT control and the popliteal artery as well as high grade and clinical examination showed a high-grade Using the superficial femoral artery as an stenosis of the posterior and anterior tibial artery. stenosis of the right stent graft leg. PTA and self- alternative access site is technically relatively A puncture of the common femoral artery is not expanding stent implantation is performed using easy, and different studies have shown low possible due to the obesity of the patient. For that a direct access of the right SFA in order to avoid complications rates compared to the standard reason the SFA is punctured and a 6 Fr. sheath is the puncture of the right common femoral artery common femoral artery access [1-4]. The most inserted. after surgical cut-down.

ESIR 2016 Course

European School of Interventional Radiology

Clinical Procedure Training Critical Limb Ischaemia Amsterdam (NL), October 21-22

Limited places left: register today! www.cirse.org/esir2016

Cardiovascular and Interventional Radiological Society of Europe C RSE 8 Non-vascular: new Expert Cases Discussions Sunday, September 11, 2016

Don’t miss it ! Enteral feeding – gastrostomy, gastrojejunostomy, jejunostomy Per-oral image-guided gastrostomy Expert Case Discussion Hans-Ulrich Laasch Monday, September 12, 10:00-11:00 Room 115

Hans-Ulrich Laasch Traditional radiologically inserted gastrostomy The Christie NHS (RIG), which involves direct percutaneous Foundation Trust insertion of a feeding tube through the skin Manchester, UK into the stomach, is a widely established procedure [1], although there are significant variations in technique [2]. To reduce the risk of displacement, fixation of the stomach (gastropexy) is usually applied. Tubes need to have their retaining mechanism reduced to a size that allows percutaneous insertion and Since 2005, Dr. Hans-Ulrich Laasch has been most operators will use tubes with a retaining Head of Interventional Radiology at the Christie balloon. These are high-maintenance and need NHS Foundation Trust in Manchester, UK. regular replacement with the consequent cost Fig. 1: Two types of traction-removable retaining (1b) Corflo, Corpak He led the British multidisciplinary Registry of and often considerable patient discomfort. bumpers; (1a) MicKey, Vygon/Kimberly-Clark Oesophageal Stenting and is a faculty member of the British Society of Interventional Radiology However, conventional bumper-retained PEG (BSIR) and the Society of GI Intervention. tubes (Fig. 1) can be readily placed under Dr. Laasch plays an active role in education, and fluoroscopic guidance without using an is a technical advisor for the National Institute endoscope. In contrast to balloon-retained of Clinical Excellence (NICE). He has a particular tubes, PEG tubes do not require the weekly interest in hepatobiliary intervention, GI stents, water-exchange of the balloon and may easily nutritional support and sedation. remain in situ for one to two years. Their inner lumen is larger, as there is no need for the inflation channel of the balloon and their insertion does not require gastropexy. Trials have shown bumper tubes to be superior to References: 1. Given MF, Hanson JJ, Lee MJ. Interventional radiology balloon or loop-retained tubes [3, 4]. techniques for provision of enteral feeding. Cardiovasc Intervent Radiol 2005; 28(6): 692-703 2. Lowe AS, Laasch HU, Stephenson S, Butterfield C, Goodwin In our institution the technique has been M, Kay CL, et al. Multicentre survey of radiologically inserted termed PIG, reflecting the hybrid nature of gastrostomy feeding tube (RIG) in the UK. Clin Radiol 2012; 67(9): 843-54 PEG and RIG; however, it was first described Fig. 2: Endoscopic view of a push-PEG bumper. 3. Yip D, Vanasco M, Funaki B. Complication rates and as "the antegrade technique" by Towbin et patency of radiologically guided mushroom gastrostomy, balloon gastrostomy, and gastrojejunostomy: a review of al. in 1988 [5]. As the tube passes through and out of the mouth. A "push-PEG" is then 250 procedures. Cardiovasc Intervent Radiol 2004; 27(1): 3-8 mouth and oesophagus, antibiotic prophylaxis advanced antegradely down the oesophagus 4. Funaki B, Zaleski GX, Lorenz J, Menocci PB, Funaki AN, Rosenblum JD, et al. Radiologic gastrostomy placement: (e.g. 1.2g Co-Amoxiclav) needs to be given, into the stomach out of the skin. The external pigtail- versus mushroom-retained catheters. as for endoscopic PEG, and there is a small tube is cut to size and connectors attached. AJR Am J Roentgenol 2000; 175(2): 375-9 5. Towbin RB, Ball WS, Jr., Bissett GS, 3rd. Percutaneous risk of seeding of active surface tumour into The internal bumper provides excellent fixation gastrostomy and percutaneous gastrojejunostomy in children: the stoma [6]. Except for oro-pharyngeal and and is maintenance free (Fig. 2). The success antegrade approach. Radiology 1988; 168(2): 473-6 6. Cruz I, Mamel JJ, Brady PG, Cass-Garcia M. Incidence of oesophageal cancer treated with curative rate of this technique exceeds 90%, including abdominal wall complicating PEG tube placement intent, PIG is arguably preferable to RIG. After cases where endoscopy is contraindicated or in untreated head and neck cancer. Gastrointest Endosc 2005; 62(5): 708-11; quiz 52, 53 gastric inflation and percutaneous puncture, a not possible [7]. PIG is an extremely successful 7. Laasch HU, Wilbraham L, Bullen K, Marriott A, Lawrance JA, Johnson RJ, et al. Gastrostomy insertion: comparing the catheter and guidewire are manipulated from technique for placement of a feeding tube, but options – PEG, RIG or PIG? Clin Radiol 2003; 58(5): 398-405 the stomach retrogradely up the oesophagus is generally underused.

Join Dr. Laasch and Dr. Sousa today at 10:00 to discuss similar cases and how they are best managed! To give you a taste of what to expect, take the quiz below...

Shown are single CT images from three different patients. All are presenting with slowly worsening abdominal pain. No clinical signs of peritonitis, no systemic sepsis, no peri-stomal leakage.

Questions:

1. Which 3 different complications are shown?

2. What is the appropriate management, assuming worsening symptoms?

3. Which one of the following additional symptoms will each patient describe?

a. Dyspnoea b. Vomiting c. Diarrhoea d. Increasing feeding pressures e. Gastro-oesophageal reflux

Join us today at 10:00 in Room 115 to debate the answers!

Special Edition / CIRSE 2016 – Barcelona I 9 congressR Non-vascular: new Expert Cases Discussions news

Don’t miss it ! Enteral feeding-gastrostomy, Percutaneous jejunostomy gastrojejunostomy, jejunostomy Expert Case Discussion Maria José Sousa Monday, September 12, 10:00-11:00 Room 115

Percutaneous jejunostomy is the "end of the Maria José Sousa line" option for providing enteral nutrition Portuguese Institute to patients suffering from gastrointestinal of Oncology malignancies associated with gastrointestinal Porto, Portugal obstruction or neurologic diseases with dysphagia.

Usually, before being referred for jejunostomy, there are first-line options, such as surgical approaches, oesophageal, gastric or duodenal stenting and endoscopic or radiologically Dr. Sousa is currently the Director of the inserted gastrostomy. Portuguese Institute of Oncology’s Interventional Radiology Service in Porto. She manages her team Nevertheless, some patients are directly Fig. 1a: CT image showing a jejunal loop close to Fig. 1b: Ultrasound images of jejunum. in the performance of a wide variety of minimally referred for radiological percutaneous the abdominal wall. invasive techniques, including biliary digestive jejunostomy. The most common request from interventions, renal vascular disease interventions, our nutritionists is to place large-bore feeding gynaecology and urology interventions, and non- tubes (16 Fr. or bigger), so that they can plan an vascular interventions. The service also takes part adequate nutritional intake. in multi-focused clinical trials, namely regarding radioembolisation of hepatic tumours with Y-90. We always perform the technique under US Dr. Sousa’s recent research as a co-investigator and fluoroscopic guidance with intravenous for “Gafchromic XR-QA2 film as a complementary and subcutaneous analgesia. dosimeter for hand-monitoring in CTF-guided ” was featured in the Journal of Applied The mobility of the small bowel, the difficulty Clinical Medical Physics. to identify the bowel loops and puncture and fixation of the jejunum wall to the anterior abdominal wall make the direct jejunostomy technique very challenging. Fig. 2a: Ultrasound guided puncture of jejunum, Fig. 2b: Deployment of a suture anchor, after To perform jejunostomy (mainly in cases of with visualisation of the needle. confirming intraluminal position of the needle. prior gastrectomy or impossibility of gaining access through the stomach to the jejunum), we may consider five main steps:

Step 1: Identify the target jejunal loop; CT can be used, but real-time ultrasound is our preferred guidance method for identification and guidance of puncture (Fig. 1a, 1b).

Step 2: Puncture the jejunal loop and get access to its lumen with a 17 gauge needle preloaded with a suture anchor. After con- firming the correct position of the needle with instillation of saline under ultrasound imaging or iodinated contrast medium for fluoroscopic visualisation, the suture anchor is placed. This step can be repeated placing another suture anchor for secure fixation of the lumen wall Fig. 3a: Puncture with an 18 G needle. (Fig. 2a and 2b).

Step 3: Puncture the jejunum wall with an Fig. 3b: Advance a super-stiff guidewire distally Fig. 4: Dilatation. 18 G needle, between the anchors, confirm for support. its position by distally advancing a 0.035" guidewire. A hydrophilic guidewire can also be useful. Progress distally with an angiographic catheter and exchange the guidewire for a super/ultra-stiff Amplatz wire (Fig. 3a and 3b).

Step 4: Dilate the tract to the desired size (consider 4 points above the feeding tube size if planning on placing a balloon type tube), we usually dilate until 20 or 22 Fr. by placing a peel-away sheath (Fig. 4).

Step 5: Through the peel-away sheath, place the 16 or 18 Fr. balloon retained tube (the most frequently used type). Confirm satisfactory placement by injection of contrast medium (Fig. 5a and 5b). Fig. 5a: 22 Fr. peel-away sheath in place.

Fig. 5b: 18 Fr. balloon retained feeding tube in place, injection of dilute contrast medium.

Cardiovascular and Interventional Radiological Society of Europe C RSE

I 11 congressR Clinical Management news

Don’t miss it ! How to handle the radiation risk How to identify high-risk procedures for patients Special Session Monday, September 12, 11:30-12:30 Graciano Paulo Room 115

Fluoroscopy-guided interventional procedures disease) and/or high weight (these patients are exposure history should be sent to the referring Graciano Paulo (FGIP) play an essential role in modern medi- at higher risk because their weight will require physician, and follow-up should be scheduled IPC-ESTeSC, Coimbra cine for diagnosing, treating and palliating higher fluoroscopy outputs). if clinically appropriate [5]. The interventionalist Health School numerous medical and surgical conditions, as should maintain contact with the patient and Coimbra, Portugal well as being an alternative to more invasive Patients that are expected and clinically the family when a tissue effect is expected [6]. procedures involving the known risks of general justified to undergo high-dose FGIPs should be anaesthesia and surgery, thus contributing to a adequately evaluated prior to the pro cedure, in The actions taken during the pre-, peri- and more efficient and improved patient experience order to characterise his/her exposure history, post-procedural phases of the FGIP are essential with better health care outcomes and quality clinical condition, skin damage and other to identify high-risk patients and to adapt the of life. relevant information, allowing the physician procedure to avoid high-dose exposure to the to prepare and adapt the best exposure con- patient. It is, however, very important to keep in Prof. Graciano Paulo is Vice-President of ESTeSC However, several literature references indicate ditions towards an optimised FGIP. One of mind that dose limits do not apply to individual Coimbra Health School (Portugal), where he that some FGIPs are performed by health the most important factors that increases a patients, as long as the FGIP are clinically is also coordinator, Professor and Chair of the professionals that do not make the best use of patient’s risk for adverse response is a previous justified and the benefits are higher than the Medical Imaging and Radiotherapy course. the equipment’s technological features, such as high dose from an earlier treatment [3]. risk. He was President of the European Federation a) not using the fluoroscopy timer correctly b) of Radiographers Societies from 2011-2014 not using the last image hold/save grab feature Peri-procedurally, it is of vital importance that Best practice demands a perfect symbiosis and is President of the Portuguese Society of and c) not setting the pulse rate correctly [1]. there is a good interaction between team between the medical physicist, the radio- Radiographers from 2001-2008. A great deal of his There is also a lack of education and training members. Teamwork depends on each team grapher and the interventionalist, prior, during written research is dedicated to radiation protec- in radiation protection amongst health pro- member being capable of undertaking their and after the FGIP. The varieties of fluoroscopy- tion for both patients and healthcare professionals. fessionals, and therefore a clear need to imple- role with professionalism and being able to guided procedures have different imaging Furthermore, Prof. Paulo is an external advisor of ment a life-long learning education programme identify when errors occur and how to recover requirements which need to be patient- and the CIRSE Radiation Protection Subcommittee. in radiation protection for all those health and correct these errors [4]. This can be done pathology-oriented. Patients’ pathology professionals involved in referring, prescribing in the following ways: a) anticipate the needs variability, sometimes under acute and critical and/or using ionising radiation [2]. of others; b) adjust to each other’s actions health conditions, introduces a stressful and to the changing environment; c) have a atmosphere amongst health professionals. This There is an evident lack of teamwork and common understanding about the whole FGIP needs to be controlled as a strategy to increase guidelines on how to plan, carry out and review pro cedure. procedural success. FGIPs, especially when delivering high doses to patients. In general, patients are not being Radiographers play an important role during Radiographers can and should contribute to the counselled about the radiation risks, prior, dur- the FGIP, not only by continuously monitoring harmonisation of radiation protection practice ing or after the FGIP and normally go home patient dose exposure, but also by choosing the amongst other health professionals carrying

with no information about the dose received optimal exposure parameters and equipment out FGIP, ensuring that everyone understands References: and the possibility of skin injuries. FGIP should manipulation to achieve the adequate image that radiation protection is the responsibility of 1. Pike S. Technical Principles for Diagnostic Fluoroscopic Procedures. Image Wisely 2014 be always performed considering a three quality for the clinical task at the lowest dose each individual, and behaves accordingly. 2. European Commission. Radiation Protection no 175: dimensional action approach: pre-procedural, for patients and staff. Guidelines on Radiation Protection Education and Training of Medical Professionals in the European Union. 1st ed. peri-procedural and post-procedural actions. Clearly, the best team will use fluoroscopy Luxembourg: Publication Office of the European Union 2014 By using this approach and specific metho- The post-procedural phase is important, minimally. The dose management and 3. Wagner LK, McNeese MD, Marx M V, Siegel EL. Severe skin reactions from interventional fluoroscopy: case report and dological actions, it’s possible to reduce the mainly if the procedure has delivered a high radiation protection training should there- review of the literature. Radiology 1999; 213(3):773–6 potential risks of FGIPs. cumulative dose (>1 Gy). There should be fore be an integral and essential component 4. Baker DP, Salas E, King H, Battles J, Barach P. The role of teamwork in the professional education of physicians: current established guidance on how to give informa- of any training. Furthermore, knowledge status and assessment recommendations. During the pre-procedural phase, it is of crucial tion to the patient regarding the symptoms about high-risk procedures for patients more Jt Comm J Qual Patient Saf 2005 Apr; 31(4): 185–202 5. Steele JR, Jones AK, Ninan EP. Establishing an Interventional importance to identify high-risk patients, of deterministic effects of radiation, providing susceptible to ionising radiation is crucial to Radiology Patient Radiation Safety Program. such as those with some systemic disease (for additional information and answering ques- minimise the radiation effects, while maxi- Radiographics 2012; 32: 277–88 6. Balter S, Miller DL. Patient skin reactions from interventional example, diabetes mellitus or connective tissue tions. Written information about the procedure mising the benefits of FGIP to the patient. fluoroscopy procedures. Am J Roentgenol 2014; 202(4): 335–42

Today’s 16:15-17:15 17:30-18:30 Featured Papers FP 2206 Abdominal aorta FP 2304 Thoracic aorta FP 2306 Oncology: beyond the liver Room 133 Room 117 Room 133 Monocentric evaluation of home-made versus Endovascular management of chronic Endovascular denervation of the celiac or will be presented in the Free Paper sessions, standard renal fenestrations in endovascular symptomatic aortic dissection (CSAD) with the hypogastric arteries for management of taking place from 16:15-17:15 and from aortic repair for juxtarenal aortic aneurysms streamliner multilayer flow modulator (SMFM): refractory abdominal cancer pain 17:30-18:30 C. Caradu, J. Morin, D. Midy, E. Ducasse; 12-month outcomes from the global registry B. Damascelli1, V. Tichà1, G. Patelli2, Bordeaux/FR S. Sultan1, E.P. Kavanagh1, F. Stefanov1, D. Miotti3, A. Prino4, S. Pasqua4, A. D’Alessio5; M. Sultan1, A. Elhelali1, V. Lundon1, V. Costache2, 1Milan/IT, 2Alzano Lombardo/IT, 3Pavia/IT, FP 2207 Gynaecological intervention E.B. Diethrich3, N. Hynes1; 4Novara/IT, 5Osio Sotto/IT Room 134 1Galway/IE, 2Sibiu/RO, 3Phoenix, AZ/US Why gynecologists do not perceive any conflict FP 2307 Radiation protection with IR over uterine fibroid treatments FP 2305 Embolisation 1 Room 134 E.J. Keller, M. Crowley-Matoka, J.D. Collins, Room 114 Real-time patient and staff dose moni- H.B. Chrisman, M.P. Milad, R.L. Vogelzang; Usefulness of conebeam computed tomo- toring in IR practice Chicago, IL/US graphy and automatic vessel detection soft- A.M.H. Sailer, L. Paulis, L. Vergoossen, ware in emergency transarterial embolization R. de Graaf, G.W. Schurink, C. van der Leij, A.M. Ierardi1, P. Torcia2, U.G. Rossi2, E. Duka1, M.W. de Haan, W.H. van Zwam, M. Das, M. Cariati2, G. Carrafiello1; 1Varese/IT, 2Milan/IT J.E. Wildberger, C.R. Jeukens; Maastricht/NL

Cardiovascular and Interventional Radiological Society of Europe C RSE Special Edition / CIRSE 2016 – Barcelona I 13 congressR Aortic news

Don’t miss it ! Thoracic cases Visceral ischaemia in a complex case of aortic dissection Expert Case Discussion Monday, September 12, 14:30-15:30 Tilo Kölbel, Beatrice Fiorucci Auditorium 2

In the Expert Case Discussion session this thoracoabdominal false lumen aneurysm with final result, with unimpeded flow to the SMA Tilo Kölbel afternoon, my fellow presenters and I will a maximum of 52 mm in diameter. The major and without evidence of on/off phenomenon University Heart Center discuss a selection of issues that arise during entry tear of the dissection was at the level of (Fig. 6). Hamburg, Germany thoracic cases. My presentation will cover the LSA and a smaller entry tear was visible at visceral ischaemia in a complex case of aortic the level of the CT. A StarClose closure device was used to close dissection and the positive results after a the right CFA 6 Fr. access site. The left CFA 5 Fr. stenting procedure and b-TEVAR were per- Neither signs nor symptoms of other ischaemic access site was closed with 15 minutes of man- formed. compli cations were evident at physical ual compression. A compression dressing was examination and blood tests. then applied at both groins for 10 hours. The patient, a 61-year-old male, was admitted to a peripheral hospital for abdominal pain In order to treat the bowel ischaemia, the The abdominal symptoms (abdominal pain Since 2009, Prof. Kölbel has been a Senior and the acute onset of bloody diarrhoea. patient underwent selective angiography with and bloody diarrhoea) completely disappeared Consultant for the vascular medicine department The patient, whose previous medical history the aim to revascularise the SMA in case of after the stenting procedure. and is the Head of the German Aortic Center, a revealed hypertension, had been treated in malperfusion. part of the University Medical Center Hamburg- 2001 with surgical replacement of the aortic In order to treat the false lumen aneurysm Eppendorf. He is a Professor of Vascular Surgery arch for the treatment of an acute type A The procedure was performed in a hybrid and to expand the true lumen, the patient at the University of Hamburg since 2011 and a dissection. After this procedure, he under- operating room under general anaesthesia underwent left carotid-subclavian bypass and reviewer for numerous journals. went a regular clinical and imaging follow- and full systemic heparinisation with 100 iU/kg branched thoracic endovascular aneurysm up at another hospital for a residual type B heparin-natrium. Percutaneous access at the repair (b-TEVAR) with candy plug implanta- dissection. level of the right mid-common femoral artery tion in the days following the visceral stenting (CFA) was used. procedure. Based on the clinical findings and on the previous medical history, an ischaemic True lumen angiography confirmed the Post-operative CTA was performed two weeks colitis was suspected and therefore CTA was presence of an entry tear at the level of the after the stenting procedure and showed performed, which showed a residual type B celiac trunk. In addition, reduced perfusion patency of the treated SMA (Fig. 7). The false aortic dissection after previous arch replace- of the left renal artery, which originated from lumen was thrombosed proximal to the level ment, extending from the left subclavian artery the false lumen, was evident compared to the of the candy plug, with good position of the (LSA), which was also dissected at the origin to contralateral side (Fig. 3). Angiography in a thoracic branched graft and evidence of a small His co-author, Dr. Fiorucci, works in the Vascular the left common iliac artery. Thus, the patient lateral projection showed a dissection in the type 1A endoleak, which was treated conser- Surgery department at the University of Perugia was transferred to our institution for further proximal AMS, with an on/off phenomenon vatively. in Italy. investigations and treatment. and interruption of the flow inside the vessel (Fig. 4). Percutaneous puncture of the left CFA The post-operative course was uneventful, CTA evaluation was performed using a dedi- was then performed to access the false lumen. except for a post-implantation syndrome with cated TeraRecon Aquarius workstation. False lumen angiography showed a rapid filling fever following the b-TEVAR procedure, not Occlusion of the inferior mesenteric artery of the celiac trunk and of the left renal artery associated to any significant laboratory find- (IMA ) and high-grade stenosis of the superior from the false lumen (Fig. 5). ing. The patient was discharged 14 days after mesenteric artery (SMA ) were evident. A the last procedure and CTA control has been dissection flap was visible at the level of SMA, The SMA was then catheterised from the true scheduled at 6 months. causing a significant flow reduction in the lumen, using a Cobra catheter and a hydro- vessel (Fig. 1). The celiac trunk (CT) and the philic guidewire, which was exchanged for left renal artery rose from the false lumen, an Amplatz guidewire. A 45 cm 6 Fr. Flexor while the right renal artery originated from introducer sheath was then advanced to the the compressed true lumen. The right iliac origin of the vessel. The tight stenosis was ab axis originated from the true lumen, while the treated with the implantation of a 10/40 mm left common iliac artery was dissected to the ev3 Protégé stent and post-dilated with a 8/20 Fig. 1: Pre-operative CTA in an axial (a) and bifurcation (Fig. 2). In addition, CTA showed a mm balloon. Angiography showed a good sagittal (b) projection showing a dissection flap at the origin of the SMA, causing a severe flow reduction in the vessel.

Fig. 2: Pre-operative 3D re- Fig. 3: True lumen angiography, show- Fig. 4: True lumen angio- Fig. 5: False lumen angiography. Fig. 7: Post-operative CTA, showing Fig. 7: Post-operative CTA, construction showing the type ing an entry tear at the level of the CT. graphy in a lateral pro- The CT and the left renal artery patency of the treated SMA. showing patency of the B dissection. False lumen (red) Right renal artery branches from the true jection (RAO 64°). The branch from the false lumen. treated SMA. extends from the left sub- lumen. SMA is dissected at the clavian to the left iliac bifur- origin with significant flow cation. The left renal artery impairment. and the celiac trunk originate from the false lumen, while the right renal artery branches from the true lumen (blue). The SMA is dissected at the origin with a significant flow reduction.

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Special Edition / CIRSE 2016 – Barcelona I 15 congressR Aortic news

Don’t miss it ! Thoraco-abdominal aortic disease Technical challenges in endovascular TAAA procedures Lecture Session Monday, September 12, 16:15-17:15 Stéphan Haulon, Jason Wilkins and Mark R. Tyrrell Auditorium 2

Thoracoabdominal aneurysms (T-AAA) are requirement to preserve organ blood flow device planning, design and manufacture Stéphan Haulon aortic aneurysms that involve the thoracic and function. The latter is achieved by the than conventional EVAR. Deployment is more University Hospital and abdominal segments of the aorta and provision of custom-made branches for exten- technically demanding and takes longer of Lille (CHRU) the visceral branches. The total endovascular sion into the visceral vessel ostia – branched to complete due to a greater contrast and Lille, France repair of thoraco-abdominal aortic aneurysms endo vascular aneurysm repair (BEVAR). Total radiation burden. BEVAR also requires ad- remains a technique in evolution. endovascular repair of a true aortic aneurysm ditional sites for arterial access (particularly using a branched device was first described in sub clavian/axillary/brachial) and has more Although the first successful open repair 2001 [9]. potential for type III endoleaks because of the was reported 56 years ago [1], the risk of large number of overlapping components. In open treatment remains substantial. In the In common with all varieties of EVAR, the short, this is a technique that places unusual pre-endovascular era, Crawford’s considerable technique relies on adequate proximal and demands on both the operating/anaesthetic Prof. Stéphan Haulon graduated from medical experience showed that operative mortality distal aortic or iliac sealing zones. Similar to team and the patient. While it is hoped that school at the Paris VI University in 1994. He then risk and the risk of paraplegia relates to most, it requires the intravascular assembly of these demands will prove less arduous than started a general and vascular surgery residency aneurysm extent, leading to the "Crawford several overlapping components, with blood- conventional open T-AAA repair, the risks at the Lille University Hospital (CHRU de Lille) classification" [2]. This classification (now tight sealing at each overlap. As with the use remain appreciable. This is all the more acutely prior to a vascular surgery fellowship in Lille and slightly modified [3]) still forms the foundation of fenestrated devices used to proximalise evident because, in most authors’ experience, Cleveland. In 2006 he was appointed Professor in underpinning the technical approach and risk the proximal aortic sealing zone in juxta-renal the patient group is even less physiologically Vascular Surgery. He is currently head of the Aortic assessment of TAAA repair. Even in the "lowest AAA (fenestrated EVAR – FEVAR), it requires resilient (and often older) than patients Centre at the CHRU Lille. His main interest is in risk" subgroup (Crawford type IV T-AAA), the the cannulation of visceral target vessels, and presenting with AAA in general, and the "turn- aortic surgery and especially in the endovascular physiological demands of open surgical repair extensions from the main device into each of down rate" is consequently high. treatment of complex aortic aneurysms such as still place considerable stresses on patients. these using covered bridging stents. Again, thoraco-abdominal and arch aneurysms, and These demands are likely to be beyond the there is a requirement for haemostatic seal Device design requires high-quality, arterial dissections. reserve of many, and the recovery time in between the extension stent and the main de- phase contrast-enhanced CT imaging and survivors is long. vice, and also between the extension stent and access to software capable of 3D image Dr. Jason Wilkins is the clinical lead for the IR each target vessel. manipulation. This facilitates the measurement department at King’s College Hospital (UK) and Limited by the simple tubes or bifurcated grafts of true cross-sectional aortic and target vessel Dr. Mark Tyrrell is a consultant vascular surgeon at that constituted the first generations of devices In the case of FEVAR, much of the proximal landing zone diameters, and of the relative true Guy’s and St Thomas’ Hospital (UK). available for endovascular aneurysm repair seal is provided by apposition of the main longitudinal and rotational distances between (EVAR), initial attempts to extend the benefits device against the wall of the non-diseased target vessels based on vessel centre-lines. of EVAR to patients with T-AAA took the form visceral-bearing aorta, with secondary sealing of "hybrid solutions", where the visceral vessels between the (balloon-expandable) extension Successful deployment and aneurysm were debranched and reperfused using extra- stents and the device (by internal flaring), and e xclusion require adequate proximal and distal References: 1. Etheredge SN, Yee J. Smith JV, Schonberger S., Goldman anatomical routes, to be followed by variants between the extension stents and the target aortic and target vessel sealing zones. Each MJ. Successful resection of large aneurysm of the upper of standard EVAR. Although initial reports were vessels. In contrast, in the case of BEVAR, the of these has to be of sufficient length and abdominal aorta and replacement with homograft. Surgery 1955; 38: 1071-1081 greeted with enthusiasm [4, 5, 6], good results proximal sealing zone lies proximal to the straightness. For durable patency, the target 2. Crawford ES, Crawford JL, and Safi HJ. Thoracoabdominal have not been universal [7, 8] and the approach visceral- bearing aortic segment and there is vessels have to be of a minimum diameter aortic aneurysms: Preoperative and intraoperative factors determining immediate and long-term results of operations in does not exploit all of the potential advantages no visceral vessel level apposition between (5 mm). Target vessel cannulation may be 605 patients. J Vasc Surg 1986; 3:389-404 of a "pure" endovascular approach. This unmet the main device and the (aneurysmal) aortic problematic, but the limitations concerning 3. Estrera AL, MD, Miller CC, Huynh TT, Porat E, Safi HJ, MD. Neurologic Outcome After Thoracic and Thoracoabdominal need, together with a rapid technological wall. In this case, the branches are an integral relative target vessel origin proximity are less Aortic Aneurysm Repair. Ann Thorac Surg 2001; 72:1225-31 advance, has encouraged the development part of the main device (and their origins are of a problem than is the case with FEVAR. 4. Watanabe Y, Ishimaru S, Kawaguchi S, et al., Successful endografting with simultaneous visceral artery bypass of more ambitious endovascular solutions to therefore inherently haemostatic), with the The manipulation and passage of the main grafting for severely calcified thoracoabdominal aortic extend the principles and potential benefits of seal being required within the branch and BEVAR device (and also TEVAR/EVAR devices aneurysm. J Vasc Surg 2002, 35: 397–399 5. S.A. Black, J.H. Wolfe, M. Clark, M. Hamady, N.J. Cheshire and EVAR to the challenging T-AAA patient group. then within the target vessel. In practice, some proximally and distally), and then the relatively M.P. Jenkins, Complex thoracoabdominal aortic aneurysms: aneurysm anatomies require combined FEVAR/ long covered bridging stents, demands Endovascular exclusion with visceral revascularization. J Vasc Surg 2006; 43: 1081–108 The ultimate therapeutic goal in the treatment BEVAR solutions and in many instances either operative techniques, wires, catheters, imaging 6. M. Gawenda, M. Aleksic, J. Heckenkamp, V. Reichert, A. of T-AAA is the same as that in the endo- solution could be applied – as evidenced by (and anatomy) to achieve reasonably straight Gossman and J. Brunkwall, Hybrid-procedures for the treatment of thoracoabdominal aortic aneurysms and vascular treatment of any aortic aneurysm – the approaches of Chuter (BEVAR only) [10] and routes from the access vessels, through the dissections. Eur J Vasc Endovasc Surg 2007; 33 (1):71–77 the exclusion of the aneurysm wall from arterial Bicknell (FEVAR only) [11]. device branches and on to the target vessel 7. Chiesa R, Tshomba Y, Melissano G, et.al., Hybrid approach to thoracoabdominal aortic aneurysm in patients with prior blood pressure, thereby eliminating the risk ostia and sealing zones. Aortic tortuosity at the aortic surgery. J Vasc Surg 2007; 45: 1128-113 of aortic rupture, while preserving distal per- It is self-evident that patient, aneurysm ana- visceral bearing segment may preclude the use 8. Resch T, Greenberg RK, Lyden S, Clair D, Krajewski L, Kashyap V,et al. Combined staged procedures for the treatment of fusion. In the special case of the endovascular tomy and surgical team selection is paramount. of currently available devices. thoracoabdominal aneurysms. J Endovasc Ther 2006; 13: 481-9 management of T-AAA, there is the additional BEVAR requires considerably more complex

Posters on Stage Selected posters and their presenting authors will take centre stage in these sessions. The posters will be displayed and navigated on terminals which are specifically designed for poster discussions in small groups. Come and meet authors of top-rated posters in an informal and open setting, join in lively debates and ask questions!

Today at 13:30-14:15 in the Poster Area Posters on Stage – Non-vascular interventions Moderators: K.A. Hausegger (Klagenfurt/AT), O.M. van Delden (Amsterdam/NL)

The below-listed posters will be discussed:

P-225 Pancreatic duct percutaneous image-guided drainage: what for and how? M. Mizandari (Tbilisi/GE) P-207 Monitoring thermal-induced changes of liver stiffness by real-time point shear wave elastography (pSWE) in ex-vivo bovine liver tissue F. Calcagni (Pisa/IT) P-30 Local biliary temperature and bile duct damage in catheter radiofrequency of ex vivo porcine liver W. Lu (Beijing/CN) P-423 of benign thyroid nodules: a prospective multicenter study S.L. Jung (Seoul/KR) P-76 Percutaneous CT-guided sympathicolysis with radiofrequency for the treatment of palmar hyperhidrosis J.M. Madrid (Pamplona/ES)

Cardiovascular and Interventional Radiological Society of Europe C RSE 16 Advertisement Monday, September 12, 2016

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• In a randomized, controlled clinical trial 1. García-Pagán JC, Caca K, Bureau K, et al; Early TIPS (Transjugular observed in the RCT, supporting its use in with TIPS performed within 72 hours after Intrahepatic Portosystemic Shunt) Cooperative Study Group. clinical practice." 2 Early use of TIPS in patients with cirrhosis and variceal bleeding. diagnostic endoscopy and a 1-year follow New England Journal of Medicine 2010;362(25):2370-2379. up, results demonstrated an 86% actuarial • The consensus in portal hypertension known survival in the early-TIPS group versus 61% in as the Baveno VI Guidelines reports: "An early the pharmacotherapy – EBL group (p < 0.001). Actuarial Probability of the Primary Compo- TIPS with PTFE-covered stents within 72 h Reference:

Figure 1. site Endpoint / According to Treatment Group (ideally <24 h) must be considered in patients 1. García-Pagán JC, Caca K, Bureau K, et al; Early TIPS (Transjugular bleeding from EV, GOV1 and GOV2 at high risk Intrahepatic Portosystemic Shunt) Cooperative Study Group. Early use of TIPS in patients with cirrhosis and variceal bleeding. The 1-year actuarial probability of remai- of treatment failure (e.g. Child-Pugh class C New England Journal of Medicine 2010;362(25):2370-2379. ning free of failure to control bleeding and <14 points or Child-Pugh class B with active 2. Garcia-Pagán JC, Di Pascoli M, Caca K, et al. Use of early-TIPS for high-risk variceal bleeding. Results of a post-RCT surveillance of variceal rebleeding was significantly bleeding) after initial pharmacological and study. Journal of Hepatology 2013;58(1):45-50. higher in the early-TIPS group than in the endoscopic therapy (1b;A). Criteria for high 3. de Franchis R; Baveno VI Faculty. Expanding consensus in portal 3 hypertension: report of the Baveno VI Consensus Workshop: pharma cotherapy – EBL group (97% vs. 50%). risk patients should be refined." stratifying risk and individualizing care for portal hypertension. Figure 2. Journal of Hepatology 2015;63(3):743-752.

The conclusion was "in patients with INDICATIONS FOR USE UNDER CE MARK: The GORE VIATORR® TIPS Endoprosthesis is indicated for use in the treatment of Child-Pugh class C disease or class B disease portal hypertension and its complications such as: variceal with active bleeding who were admitted bleeding refractory to, or intolerant of, conventional therapies, inaccessible varices, gastropathy, refractory ascites, and/or hepatic for acute variceal bleeding, the early use hydrothorax. Refer to Instructions for Use at goremedical.com of TIPS with an e-PTFE-covered stent was Figure 2 for a complete description of all contraindications, warnings, precautions and adverse events. associated with significant reductions in the Licensed with permission from the Massachusetts Medical Society. failure to control bleeding, in rebleeding, and 1. García-Pagán JC, Caca K, Bureau K, et al; Early TIPS (Transjugular Products listed may not be available in all markets. in mortality, with no increase in the risk of Intrahepatic Portosystemic Shunt) Cooperative Study Group. GORE®, VIATORR®, and designs are trademarks of hepatic encephalopathy". 1 Early use of TIPS in patients with cirrhosis and variceal bleeding. W. L. Gore & Associates. New England Journal of Medicine 2010;362(25):2370-2379. © 2016 W. L. Gore & Associates GmbH AV3127-EN1 JUNE 2016

Special Edition / CIRSE 2016 – Barcelona I 17 congressR Vascular news

Don’t miss it ! The patient’s perspective in PAD Shared decision-making in PAD Special Session Tuesday, September 13, 08:30-09:30 Dirk Ubbink Room 112

Why SDM? disease, the treatment options and the pros To date, SDM is still poorly implemented in Dirk T. Ubbink Nowadays, shared decision-making (SDM) is and cons of these options. On the other side, vascular surgery [8]. One of the reasons for this Academic Medical Center, considered an essential part of high-quality professionals should make sure they are in- is that the attitude of the professionals involved University of Amsterdam healthcare [1]. The reasons for this are ethical, formed about the patients’ values, goals and in caring for patients with PAD has not yet Amsterdam, Netherlands legal and societal. Ethically, this relates to the preferences. Obviously, the doctor is expert changed from a paternalistic or advisory role adage "primum nil nocere", dating from the in the medical realm, but the patient is expert to a situation in which expertise is exchanged time of Hippocrates. Legally, there is now an in terms of his or her own values, wishes and between care provider and patient to reach obligation to adequately inform the patient preferences. Unfortunately, the present situa- a treatment decision together. This process as a pre-requisite for true, informed consent. tion is that the patient’s expertise is often left may be supported by facilitating tools, such as And societally, people are becoming better unattended. This contradicts the definition of patient decision aids and option grids [2]. informed about medical possibilities through evidence-based medicine, which states that Dr. Ubbink completed his Ph.D. in Surgery and the internet and social media, leading to a our clinical expertise should be guided by the Decision aids are online tools for patients Vascular Surgery at Maastricht University in 1992. shift towards more self-management of their best available evidence as well as the patients’ and their partner or relatives that provide He is currently the principal investigator for the disorder, as well as a growing awareness situation and preference [6]. information about the disorder, the treat- Department of Surgery at the Academic Medical among patient advocacy groups and medical ment options, their pros and cons (based on Center of the University of Amsterdam and has societies to emphasise the need for better The application of SDM in clinical practice was existing evidence and guidelines) and some held various positions there since 1993, including patient involvement. boosted by the publication of the Salzburg questions for the patients to help them decide Head of the Vascular Diagnostic Laboratory, statement in 2011, in which an international on their preference. The development and Director for Evidence-Based practice and Program In the vascular surgical realm, the intended group of scientists, clinicians, journalists and content of such decision aids is generated Leader and Staff Advisor in the Department benefit of an intervention may be accom- journal editors designed and edited a mani- according to the International Patient Decision of Quality Assurance and Process Innovation. panied by direct harm or complications from festo to draw attention to the importance of Aid Standards instrument (IPDASi) [9]. For His interests include evidence-based practice, the intervention itself. Thus, care professionals the role of the patient when caring for his or the Netherlands, we have nearly completed communication of evidence to the patient, shared and patients have to weigh the possible her health and disease [7]. This has helped to the development of decision aids for various decision-making and patient-oriented surgical benefits against the possible harms of the position patients at the centre of healthcare [1]. vascular surgical disorders, i.e. PAD, carotid research. procedures [2]. For patients suffering from artery stenosis, abdominal aneurysm and peripheral arterial disease (PAD), several treat- How to apply SDM varicosis. Screenshots of the decision aid for ment options exist, including medication, Elwyn et al. have proposed a step-by-step PAD patients are shown in Figure 2. supervised exercise, interventional radiology approach to make sure SDM takes place and vascular surgery. The extent to which during the doctor-patient encounter in which Option grids are one-page summaries of these options differ in terms of their effects the treatment decision is to be made [4]. This answers to the questions patients frequently References: 1. Stiggelbout AM, Van der Weijden T, De Wit MP, et al. Shared on patient-relevant outcomes like walking approach is illustrated in Figure 1 below. ask. These answers are given for each of the decision making: really putting patients at the centre of distance, limb salvage, quality of life or disease treatment options. This tool can be used during healthcare. BMJ 2012; 344, e256 2. Ubbink DT, Hageman MG, Legemate DA. Shared Decision- progression is not such that it leads to a clear- the doctor-patient encounter to guide the Making in Surgery. Surg Technol Int 2015; 26:31-6 cut choice for every patient. Hence, the treat- conversation towards exploring the patient’s 3. Charles C, Gafni A, Whelan T. Shared decision-making in the medical encounter: what does it mean? (or it takes at least two ment choice cannot be made only on available preferences. An example of an option grid to tango). Soc Sci Med 1997; 44(5), 681-692 evidence as to the superiority of one treatment for carotid artery stenosis can be found on 4. Elwyn G, Frosch D, Thomson R. et al. Shared decision making: a model for clinical practice. over another. Each treatment option has its www.optiongrid.org. We are also developing J Gen Intern Med 2012; 27(10), 1361-1367 5. Elwyn G, Edwards A, Kinnersley P, Grol R. Shared decision own benefits and harms. Therefore, the patient Fig. 1: The four-step process of shared decision- such option grids for the vascular disorders making and the concept of equipoise: the competences of may, and should be, involved in the decision- making during the consultation. mentioned above. The second screenshot in involving patients in healthcare choices. Br J Gen Pract 2000; 50(460), 892-899 making process. Figure 2 is part of the option grid for PAD. 6. Sackett D. Evidence-based medicine: what it is and what it isn’t. BMJ 1996; 13;312(7023): 71-2 7. Salzburg Global Statement. Salzburg statement on shared What is SDM? The first step is to indicate that there is a treat- Effects of SDM decision making. BMJ 2011; 342, d1745 SDM can be summarised as preference- ment decision to be made together. Secondly, The improvement in quality and safety of care 8. Santema TB, Stubenrouch FE, Koelemay MJ, et al. Shared Decision Making in Vascular Surgery: An Exploratory Study. sensitive care, in which the values and pre- the doctor explains the possible treatment through SDM is supported by publications in Eur J Vasc Endovasc Surg 2016; 51(4): 587-93 ferences of the patient should be an essential options, each with their benefits and harms. leading medical journals in terms of better 9. Elwyn G, O’Connor AM, Bennett C, et al. Assessing the quality of decision support technologies using the International and integrated part of the eventual treatment Thirdly, the patient is explicitly invited to ex- patient participation [10], satisfaction [11] and Patient Decision Aid Standards instrument (IPDASi). choice [3, 4]. It should be considered as a press their preference regarding these options compliance [12]. Furthermore, this approach PLoS One 2009; 4(3):e4705 10. Montori VM, Brito JP, Murad MH. The optimal practice of principle that potentially applies to all care and possible outcomes. Finally, this preference may reduce surgical overtreatment [13] and evidence-based medicine: incorporating patient preferences in delivery to individual patients rather than is incorporated in the final decision regarding costs as well [14]. practice guidelines. JAMA 2013; 18;310(23): 2503-4 11. Mulley AG, Trimble C, Elwyn G. Stop the silent misdiagnosis: being subordinate to the level of evidence the treatment choice. SDM does not necessarily patients’ preferences matter. BMJ 2012; 345, e6572 available or to the presence or absence of mean the patient must contribute to the treat- PAD patients in particular are facing diagnostic 12. Stacey D, Legare F, Col NF, et al. Decision aids for people facing health treatment or screening decisions. equipoise [5]. ment decision-making process but should at or treatment decisions in various stages of their Cochrane Database Syst Rev. 1, 2014; CD001431 least be invited to express their preference and disease for which several options exist. Hence, 13. Knops AM, Legemate D , Goossens A, Bossuyt PM, Ubbink DT. Decision aids for patients facing a surgical treatment decision: SDM relies on clear, bi-directional communi- the extent to which they want to be involved in these moments are excellent opportunities to a systematic review and meta-analysis. cation between healthcare professional and choosing the best treatment option. So it is the involve them in the decision-making process. Ann Surg 2013; 257(5), 860-866 Oshima Lee E, Emanuel EJ. Shared decision making to improve patient. On one side, patients are to be in- process in the first place rather than the final This is likely to improve the quality of care we care and reduce costs. N Engl J Med 2013; 368(1), 6-8 formed about available evidence as to their choice that should be shared. can offer to our PAD patients.

Fig. 2: Screenshots from a decision aid for PAD. The left panel shows information about the decision aid, the right panel some preference-eliciting questions.

Cardiovascular and Interventional Radiological Society of Europe C RSE Special Edition / CIRSE 2015 – Lisbon I 19 congressR Interventional Oncology news

Don’t miss it ! Treatment options for High-intensity focused ultrasound Special Session Tuesday, September 13, 08:30-09:30 Franco Orsi Room 117

Pancreatic cancer is one of the main "killers" The unique advantage of the HIFU technique focused ultrasound may offer the following Franco Orsi in oncology, with a very poor prognosis, both is mainly represented by the absence of the benefits: European Institute in patients amenable to resection (6% 5-year percutaneous approach for delivering the of Oncology survival rate, which has not substantially energy at the level of the tumour. • Shorter recovery time Milan, Italy improved in the last 40 years) and, of course, • Very high safety profile in more advanced-stage disease. The median In the last few years, HIFU has been proposed • More precise targeting of tumour and survival ranges from 4.5 months for stage IV as an option for palliative treatment of pan- metastases, resulting in lower risk for and 24.1 months for stage I. More than 50% creatic tumours in the advanced stage. complications of patients are diagnosed with an advanced Focused ultrasound has the potential to offer a • The procedure can be done repeatedly stage of pancreatic disease. Radiotherapy "non-invasive" ablative technique for palliation and chemotherapy are the primary common in patients with pancreatic cancer. Guided by However, not all patients will be suitable for Prof. Franco Orsi is the Medical Director of the therapies for unresectable pancreatic cancer, imaging (usually ultrasound, due to the feature focused ultrasound treatment because of Unit of Interventional Radiology at the European but they are both only palliative options, of providing real-time images), a high-intensity some possible technical limitations, such as Institute of Oncology and has been Professor limited to relieving symptoms, improving acoustic beam is focused to the target. This interposed bowel loops, blocking the pathway of Radiation Oncology at the Milan University quality of life and prolonging survival. beam heats and destroys the cancerous tissue of the beam. For that reason a pre-treatment since 2000. Prof. Orsi is a founding member and without damaging nearby tissues or structures. US simulation is mandatory to better define one of the Presidents of newly formed the Italian In recent years, there has been a further Multiple pre-clinical and non-randomised the technical feasibility of the HIFU treatment. European Society of Interventional Radiology. trend towards a progressive reduction in the clinical series have been published, reporting In order to reduce the risk of bile duct damage He is a CIRSE Fellow and has been involved in a invasiveness of local treatments, aiming to more than 3,500 patients already treated (when the tumour is located close to the main number of projects, including the Clinical Practice achieve the same result as standard options worldwide with HIFU therapy, with the aim bile duct or when it is already involved), a stent Manual. He was also a member of the former but with less morbidity and a better quality of assessing the safety and efficacy of this placement is mandatory a couple of weeks Rules Committee. of life. This has opened up new horizons procedure. Substantial tumour-related pain before the treatment. Because of the need towards minimally invasive techniques in reduction was achieved in most cases after for a very precise energy delivery, general several different fields of oncology, such as HIFU treatment and few significant side effects anaesthesia is required during USgHIFU, percu taneous treatment of liver and were observed. in order to better control the respiratory pancreatic cancer and in order to collect a tumours. Recently, following the experience movements of the abdominal organs during larger amount of clinical data for supporting its of other oncologic disciplines where they A recent review reported a better rate of pain the HIFU sonications. There is an increas- use in a daily practice, an international registry demonstrated high efficacy in achieving local palliation when HIFU is applied alone than ing interest in using HIFU for treating the should be activated very soon. control in several types of malignancies, some when in association with chemotherapy and/ studies focused on the application of minimally or radiotherapy. This is probably due to the invasive image-guided in pancreatic overlapping specific side effects from the cancer. Among the percutaneous minimally concurrent therapies. Moreover, some studies invasive thermal ablation techniques, radio- reported an increased effect on survival when frequency ablation (RFA), , laser chemotherapy is delivered in combination with ablation therapy (LA or LITT), microwave HIFU. The mechanical destruction of tumour ablation (MWA) and the newer IRE were tissue, rather than thermal, is advocated as investigated in pancreatic cancer as local per- the main cause of the increased stimulation cutaneous treatments and reported as feasible of the immune system which is reported by and locally effective but with a very low safety some authors and could be the reason behind profile, due to the high rate of complications a better survival rate, even in the advanced caused by needle insertion. In this scenario, stages. An increasing level of CD4, CD8, CD the advent of more and more precise and Helper and NK have been been reported in sophisticated imaging tools led in the ‘90s to a advanced pancreatic cancer patients treated resurgence of interest in an old "non-invasive" with USgHIFU. In our experience at the thermo-ablative technique, based on the use European Institute of Oncology, some patients of ultrasound energy. High-intensity focused with no other “standard” therapeutic options ultrasound (HIFU) is a highly precise medical underwent HIFU for pain palliation and the procedure, which employs externally delivered next follow-up revealed tumour shrinking ultrasound energy to burn and destroy the not only at the level of treatment, but also in tumour tissue located deep within the body, d istant metastases (Fig. 1). selectively and without harming overlying Fig. 1: After two ineffective lines of CHT, on September 2014 this patient underwent USgHIFU for pain and adjacent structures within the path of the As a potentially non-invasive technique palliation. Later images detected shrinkage both of the primary tumour and the metastatic retro- beam. that does not rely on ionising radiation, peritoneal lymph nodes. This patient is now disease free! Couldn’t make it to ECIO 2016?

Find out what you missed in the ECIO 2016 Review – a complimentary copy is to be found in your congress bag.

You can also find all presentations on www.esir.org!

Cardiovascular and Interventional Radiological Society of Europe C RSE Special Edition / CIRSE 2016 – Barcelona I 21 congressR Crossword / Society Lounges news

Crossword Puzzle 12 Helen Hemblade, CIRSE Office 3

4 5

Across 67

1. Canidae combustion in mCRC data (7) 8 4. Pressure damage (10) 6. Number of roads that make up La Rambla (4) 9 11. Anagram: buried notifiers (7,8) 13. Upgraded data on ruptured AAA (7) 14. Abnormal anastomosis (8) 16. 13% detected in RPP checks at CIRSE 2015 (9) 17. Alternative to anti-coagulants in PE prevention (3,7) 10

11

Down 12

2. Grid district (8) 13 3. The table of the knights of IR (5) 5. Anagram: raincoat aliens (14) 7. Aortic ...... haematoma (10) 8. Barcelona day of love and literacy (3,5) 14 9. Double element ultrasound (6) 10. Sedation (12) 15 12. Son of Zeus / meta-analysis of stroke data (6) 15. Flamenco guitar / little hat (5) 16

17

85 84 numbra s Members’ Lounge 88 81 86 83 90 89 87 82 80 As a special service to members, CIRSE is offering a Members’ Lounge at Barcelona 2016. 75 78 79 77 Auditorium 2 TG 74 All CIRSE members are invited to take a rest, have some 73 complimentary coffee and make use of our wireless 71 72 76 internet connection. Lunch will also be provided in this Poster Area Members‘ space. 49 44 43 Lounge R. 48 ard 45 42 The Members’ Lounge is located on the entrance level, next to Auditorium 2. 50 47 46 41 Lounge of the Europe- an Trainee 38 37 33 32 31 Forum 39 oston 30 36 cientific 40 29 Internet 34 35 ETF Lounge 52627 28 Area There will also be a new European Trainee Forum Lounge next door to the Members’ Lounge for IR residents to mingle and relax as well.

Residents and IRs-in-training will be able to network and enjoy complimentary coffee and wireless internet in this space, and lunch will be provided to enjoy here too!

Stop by throughout the congress and meet cology your

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r- colleagues!

Pain

Biliary enou

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A A Cardiovascular and Interventional Radiological Society of Europe

Have you downloaded the CIRSE Society app update?

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Install the CIRSE/IDEAS 2016 event and easily plan your personal Pain

programme! You can also... Oncology

· complete paperless session evaluations! Aortic

· browse the exhibition by product category Venous

· take part in e-voting sessions Biliary Arterial

· send questions to the moderators Bili Arterial

lairetrA ... and much more! INTE suoneV Barcelona, SpainyrailiB September 10-14 citroA 2016 Be sure to submit your session evaluations in time! ArterialINTERVEN Biliary Venous AorticOncology Pain Available for iOS and Android Neuro

INNOVATION | EDUCATION | INTERVENTION

Special Edition / CIRSE 2016 – Barcelona ECIO 2017 European Conference on Interventional Oncology April 23-26 Bilbao, Spain

www.ecio.org

ECIO 2017 – Charting the course of interventional oncology

LEADERS IN ONCOLOGIC INTERVENTIONS

Interventional oncology is evolving rapidly, 2017 programme will once again embrace Clinical involvement continually exploring new territories and this important theme, with several sessions making exciting progress. Keeping abreast examining different aspects of the disease: To encourage more IOs to get involved in of these changes can be a challenge, epidemiology, ESMO guidelines and available tumour boards and clinical management, but the annual European Conference on therapies; follow-up, quality and efficacy; ECIO 2017 will offer a number of useful ses- Interventional Oncology offers all oncology and the current evidence, including results of sions, including ones on tumour biology, how practitioners a comprehensive forum for the CLOCC and SIRFLOX trials, and discussions to get started in IO practice, general patient education and exchange. of what endpoints should be pursued. management, complication management and A special Multidisciplinary Tumour Board a morbidity and mortality conference. The upcoming congress will be held in Bilbao, will also explore CRC metastases beyond the Spain, and will once again cover a broad guidelines. And so much more… cross-section of clinical topics, ranging from well-established IO therapies, such as local An emphasis on evidence The conference will of course be exploring new ablation of HCC, to newer clinical areas, such as technologies and clinical applications, such immunotherapy and genomics. The Scientific This data-based analysis will be a common as intra-tumoural viral therapy, intra-arterial Programme Committee, under the leader- strand throughout the congress, with a number immunotherapy, and new drugs for advanced ship of Thomas Helmberger and Afshin Gangi, of sessions committed to presenting and HCC. Clinical fields such as breast, kidney, have already devised a diverse and stimulating even questioning the current guidelines and and MSK tumours will be thoroughly examined, programme. evidence, such as the Best IO papers of 2016, while special “how I do it” lectures will guide which will see authors of the most influential novices through liver, lung, kidney and bone Revisiting colorectal metastases clinical papers present their work and take interventions. questions. Another session will equip delegates Following the warm reception of the extended with concrete information on how they can focus on colorectal liver metastases in 2016, the support data acquisition within IR. Be sure to join us in Bilbao!

R C SE Cardiovascular and Interventional Radiological Society of Europe

IR Congress News is published as an additional source of information for all CIRSE 2016 Editors-in-Chief: C. Binkert, F. Fanelli participants. The articles and advertorials in this newspaper reflect the authors‘ opinion. Managing Editor: Ciara Madden, CIRSE Office CIRSE does not accept any responsibility regarding their content. Editorial Team: Michelle Weiss, Helen Hemblade If you have any questions about this publication, please contact us at [email protected]. Graphics/Artwork: LOOP. ENTERPRISES media / www.loop-enterprises.com

Cardiovascular and Interventional Radiological Society of Europe C RSE