Traditional Educational Posters and 20 Educational e-Posters Chosen by SIR19 the Annual Scientific Meeting Committee In advance of the upcoming annual meeting of the Society of Interventional in Austin, Texas, the program committee wishes to highlight the traditional educational posters and educational exhibit e-posters that will be presented. The posters were chosen using blinded review. Authors are congratulated for their contributions. Nadine Abi-Jaoudeh, MD, FSIR Chair, 2019 Annual Meeting Scientific Program

NOTE ON ABSTRACTS ORDER Please note that abstracts Nos. 645 and 669 have been relocated to the Educational e-Poster section because of a late change in their presentation format from traditional poster to e-poster.

Traditional Educational Posters

Abstract No. 623 year, are present in pre-menopausal or pregnant women, cirrhosis, liver transplantation, or if the patient is symptomatic. All pseudoan- Case-based review of splenic artery aneurysms and eurysms are treated regardless of size as they carry a higher risk of pseudoaneurysms rupture than true aneurysms. Endovascular management has largely A Mohla1, R Gattu1, O Awan2, Y Awan1 replaced surgical options. 1St Agnes Medical Center, Baltimore, MD, 2University of Maryland Treatment options include stenting, to preserve blood flow, or embo- Medical Center, Baltimore, MD lization. Embolization agents include coils, particles, and Gelfoam. Readers will gain a better understanding on the technical aspects of LEARNING OBJECTIVES: The purpose of this educational exhibit is the procedure, the choice of complete embolization or stenting, as well to review the etiology, pathophysiology, clinical presentation, and as proximal versus distal interventions. Complications and regular fol- treatment options available for splenic artery aneurysms (SAA) and low-up requirements will also be discussed. pseudoaneurysms (SAP). We use a case-based analysis of a patient presenting with a splenic artery pseudoaneurysm rupture to demon- CONCLUSIONS: Splenic artery aneurysms and pseudoaneurysms are strate the typical workup, radiographic findings, and endovascular rare but potentially life-threatening conditions that require prompt treatment options available. recognition and treatment. Interventional radiologists play a crucial role in the diagnosis, treatment, and clinical management of patients BACKGROUND: Splenic artery aneurysms and pseudoaneurysms are presenting with SAAs and SAPs. rare, yet potentially life-threatening entities that can carry a mortal- ity rate of 75% when ruptured. SAPs are particularly uncommon with less than 200 cases described in the literature. Their presentation can Abstract No. 624 range from asymptomatic incidental findings to severe hemodynamic instability. Most SAPs occur due to acute or chronic pancreatitis; how- Diagnosis and endovascular techniques used in the repair ever, they are also seen secondary to blunt abdominal trauma, peptic of type I, II, and III endoleaks ulcer disease, and iatrogenic causes. S Raza1, D Putterman1, C Greben1, E Gandras1, S Raza1 CLINICAL FINDINGS/PROCEDURE DETAILS: Incidental SAAs < 2cm in 1North Shore University Hospital, Northwell Health, Manhasset, NY size do not require treatment and may be followed yearly. Treatment is indicated if aneurysms measure > 2cm, increase more than 0.5cm/ LEARNING OBJECTIVES: 1. Pictorial, case-based discussion of Type I, II and III endoleaks that were treated by interventional radiologists at our

SIR assumes no legal liability or responsibility for the completeness, accuracy and correctness of the information presented in the abstracts. Abstracts are published in the Annual Meeting Supplement to the Journal of Vascular and Interventional Radiology as submitted by the authors, except for minor stylistic adjustments to ensure consistency of format and adherence to Supplement style. Dosages, indications and methods of use for products that are referred to in the supplement by the authors may reflect their clinical experience or may be derived from the professional literature or other clinical sources. Because of the differences between in vitro and in vivo systems and between laboratory animal models and clinical data in humans, in vitro and animal data may not necessarily correlate with clinical results. Content current as of January 12, 2019. *An underline under an author’s name designates the abstract presenter. †N/A in the author affiliation area indicates that no affiliation was available at press time. In some abstracts, the authors’ names and affiliations are duplicated due to inconsistent affiliation listings by authors with the same affiliation. ©SIR, 2019

SIR 2019 Annual Scientific Meeting | 1 2 | Traditional Educational Posters SIR 2019 Annual Scientific Meeting

institution. 2. Discuss the clinical presentation, criteria for intervention, or webs of pulmonary vessels leading to chronic pulmonary hyperten- key imaging findings and specific repair techniques of each type of sion and right-sided heart failure. endoleak. CLINICAL FINDINGS/PROCEDURE DETAILS: -based pulmo- BACKGROUND: Endoleak, or persistent blood flow in the aneurysm nary remains the gold standard for defining the extent sac outside of the endograft, is a commonly encountered challenge of CTEPH and associated hemodynamic changes to right heart. Com- after aortic aneurysm repair. There are five types of endoleaks. Type I puted pulmonary angiogram (CTPA), ventilation/per- endoleaks result from failure of the stent graft to achieve a circumfer- fusion pulmonary (V/Q scan), dual-energy computed ential seal at the proximal (IA) or distal (IB) attachment sites. Type II tomography (DECT) and cardiac magnetic resonance imaging (MRI) endoleaks are the most common type and result from retrograde fill- provide non-invasive assessment of location, extent, and functional ing of the aneurysm sac from feeding vessels. Type III endoleaks result effects of pulmonary arterial stenosis, webs, and occlusion and help from endograft device defect including junctional leak or separation determine who would benefit from surgical or endovascular inter- of graft components. Type IV endoleaks result from graft porosity and vention. Pulmonary endarterectomy is the definitive curative therapy. Type V endoleaks refer to an enlarging aneurysm sac in the absence Some patients are poor surgical candidates due to underlying comor- of an identifiable endoleak. Interventional radiology plays a vital role bidities or distal thrombus location. Balloon pulmonary angioplasty in treating Type I, II and III endoleaks, whereas Type IV endoleaks are (BPA) has been shown to lower pulmonary vascular resistance and usually self limited and Type V endoleaks are treated with open surgi- improve right ventricular dysfunction in patients with inoperable or cal repair. refractory disease. Readers will be shown examples of BPA cases fol- lowed by a discussion of technical considerations and post-procedure CLINICAL FINDINGS/PROCEDURE DETAILS: We present five cases of evaluation. Type IA/IB endoleak, eight cases of Type II endoleak showcasing both common and uncommon arterial feeding vessels, and two cases of CONCLUSIONS: Imaging plays a crucial role in the management of Type III endoleak. Type I and III endoleaks are uncommon and treated CTEPH, from initial work-up to treatment referral and monitoring. Bal- emergently due to a high risk of aneurysm sac rupture. Type I endoleaks loon pulmonary angioplasty is an emerging and promising treatment were treated in various ways including coil or n-butyl cyanoacrylate and should be considered part of the interventional radiology domain. (n-BCA) embolization and graft extension. Type III endoleaks were treated with deployment of a new stent graft over the defective area. Type II endoleaks were treated via direct embolization of the aneurys- Abstract No. 626 mal sac and feeding vessel with microcoils, n-BCA and Avitene. Percutaneous atherectomy in peripheral arterial disease: CONCLUSIONS: Endoleaks are a frequently encountered complication current devices, indications, outcomes, and tips and tricks after aortic aneurysm repair, with interventional radiology playing a for a successful outcome critical role in patient management and treatment. Understanding R Norby1, D Sheeran2 the imaging findings, complications and technical aspects of treating 1 2 endoleaks will help guide effective treatment and clinical success. University of Virginia, Charlottesville, VA, University of Virginia Health System, Charlottesville, VA

Abstract No. 625 LEARNING OBJECTIVES: To review current types of atherectomy devices, their indications, outcomes, limitations, complications, and Interventional radiology in the management of chronic various techniques for optimal results. thromboembolic pulmonary hypertension BACKGROUND: Peripheral arterial disease (PAD) is associated with A Patel1, M Toliyat2, P Sutphin3, S Kalva2 significant morbidity and mortality, with increasing prevalence world- wide. Traditionally, endovascular revascularization in PAD has been 1University of Texas Southwestern, Dallas, TX, 2University of Texas performed with balloon angioplasty and/or stenting. Percutaneous Southwestern Medical Center, Dallas, TX, 3UT Southwestern Medical atherectomy offers interventionalists a minimally invasive option to Center, Dallas, TX remove atheroma and debulk both de novo and restenotic lesions. LEARNING OBJECTIVES: 1. Understand the critical role of various imag- CLINICAL FINDINGS/PROCEDURE DETAILS: There are multiple types ing modalities during the evaluation of chronic thromboembolic pul- of atherectomy devices, including directional, rotational, orbital, and monary hypertension (CTEPH). 2. Recognize indications to pursue laser; each having its own set of advantages and disadvantages. These pulmonary endarterectomy versus balloon pulmonary angioplasty. 3. devices have been shown to be safe and effective, although not with- Discuss post-procedure surveillance imaging. out limitations. There is increasing evidence supporting their use in BACKGROUND: Although pulmonary embolism (PE) is a significant complex lesions with severe calcification, atheroma, increased length, cause of morbidity and mortality, most patients have complete res- total occlusion, and/or in-stent restenosis. Atherectomy has been olution of thromboembolic disease. Despite this, a fraction of patients shown to increase the immediate technical success rate of revascular- retains thrombi that organize despite anticoagulation, causing stenosis ization procedures in PAD, with decreased residual stenosis, decreased SIR 2019 Annual Scientific Meeting Traditional Educational Posters | 3 dissection, and decreased need for stenting. Some disadvantages of Abstract No. 628 atherectomy are the risk of distal embolization, vessel perforation, and increased procedure time and cost. Current research is being per- Efficacy and safety of prostatic arterial embolization formed investigating the potential benefits of combining the use of versus alternative minimally invasive procedural therapies atherectomy devices with drug coated balloon angioplasty as part of for relief of lower urinary tract symptoms secondary to a no-stent strategy. benign prostatic hyperplasia

1 2 3 4 5 CONCLUSIONS: Percutaneous atherectomy devices are a safe and E Wajswol , V Chandra , M Shahid , J DeMeritt , P Shukla , 6 effective tool available in the treatment of PAD, particularly in com- A Kumar plex lesions or lesions where stenting is not desired. Recognition of 1Rutgers New Jersey Medical School, Hoboken, NJ, 2Rutgers their advantages and disadvantages, and leveraging them to optimally New Jersey Medical School, Belle Mead, NJ, 3N/A, N/A, 4HUMC, treat a given lesion, will allow an interventionalist to manage PAD more Saddle River, NJ, 5Rutgers–New Jersey Medical School, Newark, effectively. Future research will help further elucidate the best role for NJ, 6Rutgers New Jersey Medical School, New York, NY atherectomy devices in PAD. LEARNING OBJECTIVES: The learning objectives of this educational abstract are to inform the reader about the efficacy and safety of pros- Abstract No. 627 tatic arterial embolization (PAE) compared to other minimally invasive urologic surgical therapies. Bariatric embolization in the treatment of obesity: BACKGROUND: Benign prostatic hyperplasia (BPH) is a common pictorial review condition that affects many men as they age. BPH may cause both- A Saini1, I Breen1, P Hoang1, A Wallace1, C Czaplicki1, M Knuttinen1, ersome lower urinary tract symptoms (LUTS) such as frequency, S Naidu1, R Oklu1 urgency, straining, as well as nocturia that may significantly impact 1Mayo Clinic, Phoenix, AZ a patient’s quality of life. There exist a variety of both medical and surgical therapies that may be used to alleviate BPH symptomatol- LEARNING OBJECTIVES: 1. Review the role Ghrelin plays in stimulat- ogy. After conservative medical therapies fail to relieve LUTS, more ing hunger 2.Discuss the rationale for embolization of the left gastric invasive procedural therapies may be tried. Many urologic mini- artery (LGA) 3.Provide an overview of the results of pre-clinical and mally invasive surgical options exist for treating BPH; including but clinical studies examining embolization of the LGA 4.Discuss the future not limited to transurethral needle ablation (TUNA), transurethral role of interventional radiologists in the treatment of obesity microwave therapy (TUMT), prostatic urethral lift (Urolift), convec-

BACKGROUND: Obesity is a serious public health issue in the United tive radiofrequency water vapor thermal therapy (Rezum), laser States and contributes significantly to a multitude of diseases. Exist- photovaporization, and prostatic stents. Another recent minimally ing therapeutic strategies include lifestyle modifications, medications, invasive therapy that is becoming increasingly popular and has an and surgical treatments. However, surgical therapies are not without increasing amount of evidence is prostatic arterial embolization risk and can lead to severe complications. In recent years, minimally (PAE). invasive, catheter-directed embolization of the LGA has emerged as a CLINICAL FINDINGS/PROCEDURE DETAILS: The mechanism of action potential solution to the obesity epidemic. By embolizing the arterial of each therapy as well as diagrams explaining each therapy will be supply to the gastric fundus, ischemia of the gastric mucosa could lead detailed on the poster. Outcomes from trials of each therapy includ- to decreased Ghrelin production and weight loss. A number of pre-clin- ing International Prostate Symptom Score (IPSS), IPSS Quality of ical and clinical studies have examined the ideal embolic agent and Life (QoL), peak flow rate (Qmax), post-void residual (PVR), and efficacy of this procedure in modulating Ghrelin levels. Initial results International Index of Erectile Function (IIEF) will be compiled and have been promising but further prospective studies are needed to compared with the same outcomes from major trials of PAE. Rates determine the ideal embolization technique and patient population for of adverse events for each therapy classifed by the Clavien-Dindo this procedure. grading system will be included and compared to adverse events fol-

CLINICAL FINDINGS/PROCEDURE DETAILS: We will provide an overview lowing PAE. of the gastric artery embolization procedure with relevant diagrams. CONCLUSIONS: Many minimally invasive therapies exist for the treat- Pre-clinical and clinical studies will be analyzed with relevant patient ment of LUTS secondary to BPH. The main teaching points for this case data and outcomes. Ongoing trials will also be highlighted. We poster will be showcasing the variety of treatments, their mecha- will conclude by addressing the role interventional radiologists will nism of action, and comparing their relative efficacy (with specific play in obesity treatment in the future. endpoints such as IPSS, IPSS-QoL, Qmax, PVR, and IIEF) and safety

CONCLUSIONS: Embolization of the LGA has demonstrated efficacy in (adverse events classified by Clavien-Dindo system) to prostatic arte- reducing Ghrelin levels and promoting weight loss in pre-clinical and rial embolization. clinical studies. Further, prospective studies in larger patient cohorts are needed to validate these findings. Interventional radiologists will play a central role in the treatment and management of these patients. 4 | Traditional Educational Posters SIR 2019 Annual Scientific Meeting

Abstract No. 629 alcohol copolymer for the management of gastric bleeding. The cause of bleeding was due to either gastric tumor (4 cases) or Dieulafoy’s Getting out of sticky situations: techniques and versatile lesion (1 case), and all patients failed endoscopic management. Tech- applications of glue (n-BCA) in vascular and nonvascular nical success was achieved in all patients. All patients remained hemo- embolization dynamically stable post procedure, without evidence of recurrent A Khan1, P Novelli2, P Orons2 bleeding. No procedure related complications were observed with mean follow-up of 11.0 months. 30-day survival was 100%. 1University of Pittsburgh School of Medicine, Pittsburgh, PA, 2University of Pittsburgh Medical Center, Pittsburgh, PA CONCLUSIONS: In patients with gastric bleeding refractory to endo- scopic management, endovascular embolization with ethylene-vinyl LEARNING OBJECTIVES: This exhibit will use a case-based approach to alcohol copolymer is a safe and effective alternative. demonstrate the successful use of n-BCA in a variety of interventional radiology cases and aims to improve operator comfort with the use of glue through technical discussion of these procedures. Abstract No. 631

BACKGROUND: Glue is an infrequently utilized embolic agent in inter- Minimally invasive image-guided management of ventional radiology due to feared complications including catheter adenomyosis sticking and non-target occlusion. However, its properties allow for several unique advantages including improved embolization of small R Parikh1, S Hunt1, R Shlansky-Goldberg1 and tortuous vessels, quick administration, and effectiveness despite 1Department of Radiology, Hospital of the University of coagulopathy. Pennsylvania, Philadelphia, PA

CLINICAL FINDINGS/PROCEDURE DETAILS: A case-based illustration LEARNING OBJECTIVES: By the end of this exhibit, the participant of the diverse applications of glue will be provided. The caseload will should: 1. Be able to describe the clinical and imaging findings of ade- include vascular embolization of arterial bleeding, venous bleeding and nomyosis. 2. Understand the important parts of a focused history and arteriovenous malformation as well as nonvascular procedures includ- physical exam findings of adenomyosis, including the Health-Related ing biliary and ureteral embolization. The exhibit will discuss rationales Quality of Life and Uterine Fibroid Symptom assessment. 3. Understand for embolic agent use, procedural details, techniques of glue formula- the basic steps of uterine artery embolization (UAE) for treatment of tion and injection, as well as potential pitfalls and complications. adenomyosis and post-procedural management. 4. Understand the benefits, risks, and contraindications of UAE CONCLUSIONS: In a diverse embolization practice, glue (n-BCA) pro- vides unique qualities and advantages over other embolic agents. BACKGROUND: Adenomyosis is a benign process with ectopic prolifer- Through illustration of glue use in a broad variety of procedures, this ation of endometrial tissue within the myometrium and resultant uter- exhibit aims to increase utilization of glue in circumstances where use ine muscular hypertrophy. Presence of normal tissue in this abnormal of alternative agents may be inadequate. location makes treatment difficult. It is most common in women aged 40-50 years. Twenty-50% of hysterectomy specimen after failed UAE are found to have adenomyosis. Imaging features: US: Enlarged ellipti- Abstract No. 630 cal uterus with striations, poorly defined diffuse/focal hypoechoic areas, Liquid embolization of the left gastric artery myometrial cysts T2-weighted MRI: Enlargement of junctional zone to > 12 mm, hyperintense subendometrium, striations, myometrial cyst R Ogilvie1, D Patel1, N Kupfer1, S Soni1, T Ozga1, A Malamis1, C Molvar1 CLINICAL FINDINGS/PROCEDURE DETAILS: Common presentation of 1Loyola University Medical Center, Chicago, IL adenomyosis: bulk symptoms, dysmenorrhea, menometrorrhagia,

LEARNING OBJECTIVES: To demonstrate technical feasibility and out- dyspareunia, and fatigue. Some women may be asymptomatic. Con- comes of left gastric artery embolization using a liquid embolic sys- traindications: untreated pelvic infection, pregnancy, and gynecologic tem in patients with gastric hemorrhage who have failed endoscopic malignancy. Relative contraindications: contrast allergy, coagulopathy, intervention. and renal impairment. Work up: focused history, Health-Related Qual- ity of Life and Uterine Fibroid Symptom assessment, abdominopelvic BACKGROUND: Liquid embolic systems show promise in the manage- exam, and review of imaging. Thickened baseline junctional zone and ment of gastrointestinal bleeding due to their controllable adminis- low infarction rate may be predictive of treatment failure. High success tration, deeper vascular penetration than coil embolization, lack of rate of UAE in pure fibroid disease is reduced if adenomyosis is present, reliance on coagulation status, and lower risk of tissue infarction or particularly if pure adenomyosis present and especially if diffuse rather non-target embolization than particle or chemical agents.(1) To our than segmental disease. Technique: Uterine arteries distal to cervico- knowledge, no prior series are published demonstrating their safe or vaginal branches are accessed via radial/femoral approach. Different effective use in left gastric artery embolization. techniques with varying particle size have been used to embolize the

CLINICAL FINDINGS/PROCEDURE DETAILS: We present data from 5 uterine arteries to near stasis. cases of left gastric artery embolization performed with ethylene-vinyl SIR 2019 Annual Scientific Meeting Traditional Educational Posters | 5

CONCLUSIONS: Uterine artery embolization is a minimally invasive Abstract No. 633 image-guided therapy that has been shown to have promise in treat- ing adenomyosis. The use of prostate artery embolization for the treatment of refractory radiation-induced prostatitis

1 2 2 Abstract No. 632 M Roca , K Yamoah , N Parikh 1University of South Florida, Tampa, FL, 2Moffitt Center, Preoperative embolization of peripheral osseous renal Tampa, FL cell carcinoma metastases: case series and literature LEARNING OBJECTIVES: 1. Morbidity associated with radiation induced review chronic prostatitis. 2. Limited medical therapy options for radiation R Petek1, D Petrov2, K Cothron3 induced chronic prostatitis. 3. PAE as a novel treatment for refractory 1Lake Erie College of Osteopathic Medicine, Horseheads, NY, radiation induced chronic prostatitis. 2Allegheny General Hospital, Pittsburgh, PA, 3Allegheny Health BACKGROUND: Radiotherapy remains a mainstay of definitive therapy Network, Pittsburgh, PA for localized prostate cancer. The side effects of therapy are often

LEARNING OBJECTIVES: 1) Review renal cell carcinoma (RCC) metas- chronic, and challenging to adequately treat. Specifically, urinary tases and available treatment options. 2) Discuss current treatment symptoms associated with chronic prostatitis after radiation can cause options for peripheral osseous metastases. 3) Discuss role of pre-op- significant morbidity. Within the NIH categorization, this falls into Cat- erative transarterial embolization. 4) Discuss future studies for role of egory III, chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). interventional radiology in RCC metastasis treatment. Medical therapy is typically the treatment choice and includes the “three As” – antibiotics, anti-inflammatories, and alpha blockers. Anti- BACKGROUND: Renal cell carcinoma (RCC) accounts for 90-95% of biotics and anti-inflammatories are typically ineffective for long-term malignancies involving the kidney. Approximately one third of RCC control of symptoms. Alpha blockers have been shown to be effective metastases are to the appendicular and axial skeleton. As such, there as compared to placebo, however when they are effective, it is only in have been many treatments developed for osseous metastases, such about 50% of men. Therefore it is evident that CP/CPPS, particularly as molecular therapies targeting the vascular endothelial growth fac- related to radiation for PCa, represents a significant cause of morbidity. tors and mammalian target of rapamycin (mTOR) to treat and miti- gate the pathologic effects of the metastases such as pain, pathologic CLINICAL FINDINGS/PROCEDURE DETAILS: We report a series of four fractures, and hypercalcemia. However, surgical resection remains the patients with CP/CPPS following treatment with external beam radi- mainstay for treatment for individuals that develop skeletal metasta- ation therapy refractory to medical therapy who were treated with ses. As osseous RCC metastases are generally hypervascular in nature, Prostate Artery Embolization (PAE). All 4 patients had technically management of intraoperative blood loss can be difficult. Preoperative successful PAE without complications. Follow-up imaging with Pros- embolization may serve as an adjunct to improve bleeding complica- tate MRI at 12 wks detected an average 27% reduction in prostate vol- tions during surgery. ume. At 12 week follow-up, 2 out of the 4 patients reported an average improvement in I-PSS by 75%. The other 2 patients who did not report CLINICAL FINDINGS/PROCEDURE DETAILS: Preoperative transarterial I-PSS were no longer Foley catheter dependent at 12 weeks. Analysis embolization of RCC metastases has emerged as a minimally invasive of chronic prostatitis index is currently ongoing. intervention to mitigate the risks of perioperative bleeding. While there is controversy on the benefits of preoperative embolization, CONCLUSIONS: We evaluated an alternative approach for refractory there have been studies that show a potential benefit to pre-oper- radiotherapy induced prostatitis. We achieved overall improvement of ative embolization. This exhibit reviews the angiographic evaluation I-PSS and also eliminated Foley catheter dependence post-procedure. and transarterial embolization of peripheral skeletal RCC metastasis. Future studies should be conducted to evaluate the role of PAE in men Our exhibit includes imaging and periprocedural management that with medically refractory chronic prostatitis after radiation. demonstrates) CT and US evaluation of osseous RCC metastasis, 2) Patient Pre- 6-Week 12-Week Pre- 6-Week 12-Week digital subtraction angiographic findings and anatomy to be aware procedural Follow-up Follow-up procedural Follow-up Follow-up of during embolization, and 3) postembolization angiography of RCC Prostate Prostate Prostate I-PSS I-PSS I-PSS metastasis. Imaging modalities include CT, arterial angiography, and Volume Volume Volume (cc) (cc) (cc) digital subtraction angiography. 4) Post-operative follow-up includ- A 31.6 28.6 28 8 N/A N/A ing imaging when available. (off Foley catheter) CONCLUSIONS: Preoperative embolization of hypervascular RCC metastases may improve intraoperative blood loss and may serve to B 52 28 28 26 21 13 decrease the perioperative morbidity of such high risk surgery. C 65 53 54 4 0 0 D 78 N/A 52 26 N/A N/A (off Foley catheter) 6 | Traditional Educational Posters SIR 2019 Annual Scientific Meeting

Abstract No. 634 BACKGROUND: The introduction of vascular closure devices (VCDs) in the early 1990s offered an effective alternative to manual compression, Understanding surgical treatments for symptomatic the gold standard to achieve hemostasis following vascular access. VCDs benign prostatic hyperplasia: indications and outcomes have several advantages over manual compression including reduced compared to prostate artery embolization time to hemostasis, reduced time to ambulation, improved patient com- D Wang1, M Hsieh1, A Picel1 fort and improved workflow. Suture-based and non-suture-based VCDs are FDA-approved for use. Although VCD-associated complications are 1University of California San Diego, San Diego, CA uncommon, they can be life or limb-threatening when they occur. The

LEARNING OBJECTIVES: 1. Review the surgical options for the treatment range of reported complications includes infection, hematoma, of symptomatic BPH. 2. Learn the indications, outcomes, and complica- retroperitoneal hematoma, puncture site hemorrhage, puncture site ste- tions of the surgical techniques. 3. Compare surgical outcomes to PAE. nosis or occlusion, distal embolization, pseudoaneurysm development and arteriovenous fistula formation. Although some complications may BACKGROUND: BPH is a common cause of LUTS among the aging male require open surgery, the majority can be managed through an endo- population. Since its popularization in the 1950s, transurethral resection vascular approach. We describe safe and effective endovascular strate- of the prostate (TURP) has been extensively reviewed and currently gies to manage the majority of VCD complications. stands as the gold standard for surgical treatment. Although TURP is effective, there are multiple reported complications, including up to 65% CLINICAL FINDINGS/PROCEDURE DETAILS: This educational exhibit will incidence of ejaculatory disorders. Numerous minimally invasive surgical present a series of case examples that outline the array of endovascular techniques are proposed as alternative treatments to improve recovery treatment options available to address VCD complications. Numerous and lessen side-effects. As PAE emerges as another noninvasive treat- strategies have been utilized effectively depending on the complica- ment option, interventionalists must have a thorough understanding of tion, location within the vessel and the type of VCD deployed. Man- the treatment options to properly evaluate and counsel patients. agement examples include hemorrhage, occlusion with and without distal thrombosis, near-occlusion with and without distal embolization, CLINICAL FINDINGS/PROCEDURE DETAILS: TURP is commonly per- and pseudoaneurysm formation with and without a concomitant arte- formed for prostates <80-100 mL. Other transurethral treatments riovenous fistula. Clinical presentations range from acute and life or include photoselective vaporization of the prostate (PVP) and Holium limb threatening to chronic and gradual in onset. Treatment strategies laser enucleation (HoLEP). A wide variety of minimally invasive sur- include balloon occlusion, stent or endograft placement, thrombolysis, gical treatments are described, including prostatic urethral lift (PUL), atherectomy, and endovascular device retrieval. transurethral wave vapor thermoablative therapy, transurethral micro- wave therapy (TUMT), transurethral incision of the prostate (TUIP), CONCLUSIONS: VCDs offer many advantages over manual compres- and transurethral needle ablation (TUNA). Each technique varies in its sion, and their use has proliferated over time. Rarely, potentially severe degree of invasiveness, therapeutic benefits, and complications. For complications may develop from the use of VCDs. It is essential for the example, PUL is performed on prostates <80 mL with overall compli- interventional radiologist to be familiar with endovascular strategies to cation rate <10%, and TUIP is reserved for prostates <30 mL. Com- treat VCD complications. plications of retrograde ejaculation, sexual dysfunction, and urethral strictures influence the patient’s choice to pursue a particular surgi- Abstract No. 636 cal option. Early studies comparing surgical results to PAE suggest greater early volume improvement with TURP but similar symptomatic Metal 3D printing: emerging technologies for improvement with fewer adverse events after PAE. interventional radiology CONCLUSIONS: Multiple surgical treatment options are offered for M Kuo1, A Saini1, M Schwartz1, P Hoang1, S Naidu1, M Knuttinen1, S symptomatic BPH with differing indications, outcomes, and compli- Alzubaidi1, R Oklu1 cations. In order to best counsel patients regarding PAE, interven- 1Mayo Clinic, Phoenix, AZ tionalists must understand the spectrum of surgical options and their comparison to the outcomes and complications of PAE. LEARNING OBJECTIVES: 1. What is metal 3D printing 2. Segmentation and current and emerging metal 3D printing technologies 3. Next gen- eration point-of-care medical device manufacturing Abstract No. 635 BACKGROUND: Metal 3D printing offers the opportunity to create indi- Endovascular management of vascular closure device vidualized interventional materials (i.e., stents) at greater speed and complications lower expense compared to traditional methods of 3D printing. With metal 3D printing, milling, casting, and fabrication are bypassed, allow- M Moccia1, D Mittleider2 ing for microscopic accuracy of the desired object (1). Depending on 1Maine Medical Center, Portland, ME, 2Spectrum Vascular & the implant needed, metal 3D printing can be easily customized, includ- Interventional Physicians, Falmouth, ME ing intricate structures like porosity. Porosity mimics the structure of

LEARNING OBJECTIVES: To review endovascular techniques to manage bone, allowing natural structures to fuse more easily to the implant and vascular closure device complications. SIR 2019 Annual Scientific Meeting Traditional Educational Posters | 7

accelerating healing (2). The use of biocompatible metals, including high. 2. Variant radial artery anatomy is the second most common a titanium alloy, allows the immediate introduction of an implant (2). cause of access failure. It reduces technical success and increases the rate of RAS. 3. A high radial artery, tortuosity, and radial loops are the CLINICAL FINDINGS/PROCEDURE DETAILS: In this educational exhibit, most common anatomic variants. 4. Taking a stepwise approach may we will depict examples of metal 3D printing in interventional radiology help reduce rate of access failure. and highlight its advantages when compared to non-metal 3D printing. We will discuss precautions that are critical to ensure safety and prod- uct quality. We will demonstrate the process of developing 3D-printed Abstract No. 638 metals, from imaging, post-processing through printing. Finally, we will discuss the challenges of printing with metal versus other materials. Catheter-directed therapy for pulmonary embolism: where do we stand? CONCLUSIONS: Metal 3D printing presents numerous opportunities to improve patient care and quality of life, through highly individualized E Gayou1, M Makary1, K Natarajan2, J Dowell3 prosthetics and implants with biocompatible materials. The effec- 1Division of Vascular and Interventional Radiology, Department of tiveness and lower cost of 3D-printed metals contribute to the clear Radiology, Ohio State University, Columbus, OH, 2Department of importance of metal 3D printing in healthcare’s future. Radiology, St. Vincent Health, Indianapolis, IN, 3Northwest Radiology and Department of Radiology, St. Vincent Helath, Indianapolis, IN

Abstract No. 637 LEARNING OBJECTIVES: To provide an overview of catheter-directed therapy (CDT) techniques for the treatment of pulmonary embolism Transradial access: anatomic variants, the challenges they (PE), as well as an analysis of the current literature supporting its use. present, and how to overcome them BACKGROUND: In 2008, the US Surgeon General’s office issued a “Call 1 1 1 1 D Parhar , D Klass , D Liu , J Chung to Action” for the prevention of deep venous thromboembolism (DVT) 1University of British Columbia, Vancouver, BC and PE, citing the sequelae of venous thromboembolic disease as being primarily responsible for nearly 100,000 American deaths per LEARNING OBJECTIVES: 1. Review normal anatomy relevant to transra- year. Traditionally, systemic thrombolytics and anticoagulation were dial access 2. Describe the common variants in radial artery anatomy, the standard means of treatment. However, technological advances their incidence, and the technical challenges they pose 3. Describe in CDT have allowed for potentially safer and more efficacious treat- strategies to overcome these challenges as they pertain to non-coro- ments for acute PE. nary radiologic procedures CLINICAL FINDINGS/PROCEDURE DETAILS: 1) Review of the pathophys- BACKGROUND: Trans-radial access (TRA) was first used for coronary iology and current classification systems for PE, 2) technical overview interventions in 1989. Since then, it has been established that TRA of catheter based techniques for the treatment of PE, including con- markedly reduces the incidence of major complications compared to ventional CDT, mechanical and rheolytic thrombectomy, aspiration transfemoral access (TFA). However, one of the greatest limitations of and suction, and clot entrapment and retrieval, 3) analysis of the litera- TRA is a relatively high catherization failure rate, in the range of 1-5%, ture supporting the use of CDT for PE, including the ULTIMA, SEATTLE with anatomic variations presenting as the second most common II, PERFECT, and PEITHO trials, with comparisons made to traditional cause of failure. Recognition of the technical challenges that come with systemic therapies, and 4) current societal recommendations/guide- these anatomical variants is critical to the success of TRA. lines for the use of CDT for treatment of PE.

CLINICAL FINDINGS/PROCEDURE DETAILS: Puncture failure, radial CONCLUSIONS: After viewing this exhibit, the viewer will have a bet- artery tortuosity, and radial artery spasm (RAS) are among the most ter understanding of the technical aspects of CDT, the evidence sup- common reasons for catherization failure. Variant radial artery anat- porting its use, and the appropriate patient populations for whom this omy occurs at a rate of 9.1-22.8%, with a high-bifurcating/aberrant treatment is most effective. radial artery identified as the most common variant (5.1-8.3%), fol- lowed by tortuosity (3.8-5.6%), and radial loops third (0.8-2.0%). Overall, when a variant is present, technical success decreases sig- Abstract No. 639 nificantly from >98% to 93%. Moreover, the incidence of RAS also increases to 23.5% compared to approximately 1.5% in those without Drug repurposing of Protonix in hepatocellular carcinoma variants. Luckily, these variants can often be identified via pre-pro- therapy: targeting HSP70/APE1 dimerization cedural ultrasound or angiography. Through proper recognition and A Osifuye1, E Fayazzadeh2, C Brian3, G McLennan4, D Das2 a stepwise approach, the additional challenges presented by these 1University of Minnesota, Woodbury, MN, 2Cleveland Clinic, variants can easily be mitigated. Our aim is to describe each of the Cleveland, OH, 3Case Western University, Cleveland, OH, 4Cleveland common variants, provide pictorial examples, and discuss strategies Clinic, Chagrin Falls, OH specific to each variant to maximize success of TRA.

LEARNING OBJECTIVES: Heat shock protein 70 (HSP70) and Human CONCLUSIONS: 1. While TRA has lower incidence of major complica- apurinic/apyrimidinic endonuclease 1 (APE1) act in the base excision tions compared to TFA, catheterization failure rate remains relatively 8 | Traditional Educational Posters SIR 2019 Annual Scientific Meeting

repair pathway and is associated with poor Hepatocellular carcinoma to other organs-on-a-chip through microfluidic channels thus forming disease (HCC) prognosis although the molecular mechanisms are not a system-on-a-chip which can be used to comprehensively evaluate clearly known. HSP 70 and APE 1 association leads to increased endo- systemic response to a therapy such as TACE. LOACs can be loaded nuclease function, quicker DNA repair and resistance to cell death by with biopsied tumor tissue to test for drugs and locoregional therapy Doxorubicin. The purpose of this study is to use FDA approved ATPase safety and efficacy in treatment or clinical trial settings. In interven- inhibitor (Protonix) to dissociate HSP70/APE1 dimer thereby reducing tional radiology (IR), the design and integration of microscopic probes endonuclease function and enhancing efficiency of Doxorubicin. into LOAC could study the effects of IRE, cryoablation or RFA on tumor tissue, among many other applications. BACKGROUND: Rat hepatoma cell lines: N1S1 was used for co-immuno- precipitation assays. Liver tissue from rat HCC model and healthy age CLINICAL FINDINGS/PROCEDURE DETAILS: We will review the concept, matched controls were used to analyze HSP70 protein expression and fabrication, applications, and advantages of LOAC through pictures ATPase activity was measured using ATPase assay kit from Sigma. Pro- and diagrams. Then, we will describe how LOAC can be used in the tonix (Sigma) was used as ATPase inhibitor. Promega cell proliferation setting of clinical and investigational interventional radiology with assay kit was used to test cytotoxicity and viability of cancer cells. Total examples from key studies. Finally, we will discuss future applications cellular protein (50µg) was used for western blot analysis. Odyssey CLX of this technology and how it will impact the field of IR. was used to develop and analyze (densitometry) western blot data. CONCLUSIONS: LOAC is a novel bio-mimetic platform that has vari- CLINICAL FINDINGS/PROCEDURE DETAILS: APE1 co-immunoprecipi- ous applications in research and medicine. It will play an integral role tated with HSP 70 in N1S1 cells confirming their association in HCC. in drug and therapeutic development, research, and in personalized Rat HCC tissue samples that demonstrated increased HSP70 expres- medicine, among fields. sion (1.3 fold, p<0.05) compared to the healthy control samples also had increased ATPase activity by 2 fold (p<0.005). Inhibiting ATPase activity by Protonix increased sensitivity to Doxorubicin in cancer cells Abstract No. 641 resulting in more cell death. A combination of Doxorubicin and Proto- To sleep or not to sleep: sedation, analgesia, and local nix reduced cancer cell viability to 36% compared to the no treatment anesthesia for interventional radiologists group. Cell viability in presence of Doxorubicin was 77.27% and with protonix alone was 59%. Protonix reduced ATPase activity in cancer C Boyd1, S Calhoun2 cells by 1.6 fold (p<0.05) fold although it did not seem to significantly 1Morristown medical center, Overlook Medical Center, Morristown, affect protein level expression of HSP70 or APE1. NJ, 2Morristown Medical Center, Atlantic Health System, Long Valley, NJ CONCLUSIONS: Combination therapy of Protonix and Doxorubicin resulted in increased cancer cell death and may result in better HCC LEARNING OBJECTIVES: Review an interventional radiologist’s role in control. In vivo experiments are required to evaluate appropriate dos- pain control with and without the assistance of an anesthesiologist. age or side effects of combination therapy. BACKGROUND: The clinical role of the interventional radiologist is expanding, and knowledge of anesthetic and pain management strat- Abstract No. 640 egies is becoming crucial. During the initial patient consultation, the decision becomes paramount: Should I sedate this patient? Just use Liver-on-a-chip: applications in interventional radiology local anesthetics? Or should I consult an anesthesiologist? The pur- A Saini1, S Naidu1, M Knuttinen1, S Alzubaidi1, H Albadawi1, Z pose of this presentation is to review the anesthetic and pain manage- Zhang1, J Hu1, R Oklu1 ment options and discuss their indications with and without assistance from our anesthesia colleagues. 1Mayo Clinic, Phoenix, AZ CLINICAL FINDINGS/PROCEDURE DETAILS: The first topic discussed LEARNING OBJECTIVES: 1. Describe the concept of organ-on-a-chip, involves pre-procedural patient selection and risk/ benefit analysis how it’s fabricated, and its utility in research and medicine. 2.Summa- of different anesthetic plans. This includes defining the key differ- rize how liver-on-a-chip can be used to evaluate the safety and efficacy ences in different levels of sedation, and assessing patient risk fac- of drugs and therapies for liver diseases. 3.Discuss how liver-on-a-chip tors for obstruction (e.g., Mallimpati scores, STOPBANG criteria for can be used in interventional radiology to personalize therapy. obstructive sleep apnea) and global risk factors for cardiopulmonary

BACKGROUND: The liver-on-a-chip (LOAC) platform uses microfluidic risk like ASA physical status classifications, as well as the thought technology and tissue engineering to create “micro-livers” that can process for when the interventional radiologist should consult an mimic essential biological and physiological functions. By recreating anesthesiologist. The second section will discuss safe administra- highly specific biochemical and biophysical environments that mimic tion of intra-procedural anesthesia and pain control. This includes in vivo flow dynamics, mechanical or sheer forces, and microenviron- medication options and dosing (sedation and local anesthetics), ments, they offer significant advantages when compared to 2D or 3D effects of combined therapy versus single drug, nerve blocks and cell cultures and animal models in the assessment of the safety and effi- the monitoring requirements to ensure each patient’s intra-proce- cacy of various pharmaceuticals and therapies used for liver disease. dural safety. The final section of the presentation will review multi- LOAC can be made from a myriad of techniques and can be connected modal post-procedure pain control including opioid and non-opioid SIR 2019 Annual Scientific Meeting Traditional Educational Posters | 9 medication options. Post-procedural monitoring and reversal medi- Abstract No. 643 cations. Finally pain medication and anesthesia-related side effects and complications will be addressed. Technical strategies to prevent catheter associated thrombosis CONCLUSIONS: Radiologists must understand sedation, analgesia and local anesthesia as well as know their limitations while caring for A Wallace1, P Hoang2, D Fleck1, K Zurcher2, S Alzubaidi1, M 3 3 1 patients. It is important to understand the value of an anesthesia con- Knuttinen , S Naidu , R Oklu sultation and to master the evaluation of patient risk to maintain the 1Mayo Clinic, Phoenix, AZ, 2Mayo Clinic Arizona, Phoenix, AZ, 3Mayo best interest of the patient. Clinic Arizona, Scottsdale, AZ

LEARNING OBJECTIVES: 1) Describe the pathogenesis of thrombo- Abstract No. 642 sis and fibrin sheath formation at a catheter surface. 2) Describe the mechanisms of superhydrophilic surfaces, slippery liquid infused Applying materials science to prevent catheter fouling porous surfaces, and micropatterning and how these can be used in A Wallace1, D Fleck1, A Saini1, P Hoang2, M Knuttinen3, S Alzubaidi1, implanted devices. 3 1 S Naidu , R Oklu BACKGROUND: Indwelling and implanted devices are vital to 1Mayo Clinic, Phoenix, AZ, 2Mayo Clinic Arizona, Phoenix, AZ, 3Mayo modern medicine providing easy access to the vascular system, reliev- Clinic Arizona, Scottsdale, AZ ing obstructions, or altering blood flow. These devices, although made of relatively inert materials, are of limited design to combat the com- LEARNING OBJECTIVES: 1) Describe the basic steps to developing plex and dynamic environment of the body and can sometimes develop thrombus and infection on a catheter. 2)Describe the materials that complications, in particular thrombosis and occlusions, rendering the are used in a basic indwelling catheter and some of the design features device unusable and possibly causing more injury. The pathogenesis that prevent infection and thrombus. 3) Familiarize with advanced has been extensively studied and in doing so has created an expanding techniques that can be applied to a catheter design in order to prevent field of strategies to prevent thrombotic complications. Some of these adsorption, adhesion and fibrin crosslinking. exciting technologies include superhydrophilic materials, slippery liquid

BACKGROUND: Indwelling catheters are ubiquitous in modern medicine infused porous surfaces, and biomimicry inspired micropatterning. providing quick, simple, and safe access to the intravascular space. CLINICAL FINDINGS/PROCEDURE DETAILS: We will discuss the basic Catheters are made of a plastic polymer that is generally non-reactive. catheter material design and review how thrombus forms on the surface The surface of these catheters are dynamic having a complex interac- of catheters. Subsequently, we will discuss the concepts of superhydro- tion with molecules, proteins, cells, and pathogens. Thrombosis and philicity, slippery liquid infused porous surfaces, and micropatterning, infection within or around the catheter are complications of indwell- comparing and contrasting these techniques and reviewing the recent ing catheters with well studied pathogenesis. By studying and under- literature describing how these techniques have been used to prevent standing the basic principles of catheter associated infections and the complicated process of adsorption and adhesion that causes cath- thrombosis, various techniques for prevention have been developed eter associated thrombosis or fibrin sheath occlusions. We will also dis- and implemented to provide improved safety including antibacterial cuss the current limitations of these technologies and where further cuffs, subcutaneous tunneling, surface antibiotic and antithrombotic research is needed to make these techniques viable for clinical use. coatings, hydrophilic and zwitterionic materials, slippery surfaces, and micropatterning. CONCLUSIONS: Basic catheter design is made of a plastic polymer that, while generally inert, has a dynamic interaction at the surface with its CLINICAL FINDINGS/PROCEDURE DETAILS: We will discuss the two surroundings that develops over time. The surface characteristics of basic mechanisms of catheter fouling, infection and thrombosis, their catheters can be altered using a variety of strategies such as super- pathogenesis and epidemiological importance. We will then explore hydrophilicity, slippery liquid infused porous surfaces, and micropat- advanced strategies to prevent both infection and thrombosis address- terned surfaces to prevent thrombosis and fibrin sheath formation. ing catheter materials, catheter coatings using antibiotics and anti- thrombotics, hydrophilic and superhydrophilic materials, zwitterionic materials, slippery liquid infused porous surfaces, and micropatterning Abstract No. 644 techniques. For each of these methods we will review the current liter- ature and how these techniques have been applied to medical devices Expanding your skill set: create an arteriovenous fistula and how they might change clinical care. for dialysis access via endovascular approach

1 2 CONCLUSIONS: Catheters are generally safe and effective but compli- A Kalra-Lall , S Shuldiner cations can arise by infectious and thrombotic causes. Catheter design 1Case Western Reserve University, Cleveland, OH, 2Johns Hopkins can greatly influence the longevity and safety profile of a catheter and School of Medicine, Baltimore, MD understanding the mechanisms inherent in the design can improve LEARNING OBJECTIVES: Report on the development of a new cathe- overall patient care. ter system that allows for endovascular creation of an arteriovenous 10 | Traditional Educational Posters SIR 2019 Annual Scientific Meeting

fistula (endoAVF) as an alternative to traditional open surgery, along BACKGROUND: The structure and clinical content of the preliminary year with suggestions for patient selection. (internship) is being closely examined as the integrated IR residency becomes more popular. While a minority of categorical residency pro- BACKGROUND: The Fistula First Initiative set a goal that 65% of patients grams include a preliminary year, most applicants choose a surgical, should receive hemodialysis by native AVF based on reports of lower medical, or transitional internship. This exhibit is designed to aid medical complication rates and longer patency when compared to catheters students by examining the advantages of a surgical intern year and the and arteriovenous grafts. The challenge remains to create functional optimal characteristics of surgical programs for IR trainees. fistulas in patients with multiple co-morbidities and compromised vasculature restricting access circuit flow. Primary fistula failure rates CLINICAL FINDINGS/PROCEDURE DETAILS: Surgical training empha- are as high as 60% with mean maturation between 4 and 9 months; sizes typical, atypical, and post-operative anatomy and physiology. This re-intervention rates to maintain patency are high and many require aids in diagnostic interpretation and procedural execution. A surgical surgical revision or subsequent graft placement. intern learns the indications and treatment options for a diverse set of patients and pathologies; these management algorithms often directly CLINICAL FINDINGS/PROCEDURE DETAILS: The WavelinQ endoAVF sys- involve IR and parallel interventionalists’ decision-making process. Sur- tem (Becton, Dickinson Interventional) was designed to minimize ves- gical interns gain an understanding of comprehensive pre-, intra-, and sel trauma during fistula creation and provide a consistent vein-artery post-procedural care while developing advanced technical abilities in a anastomosis without surgical trauma. The procedure involves the use fast-paced and exciting environment. Trainees work closely with other of magnetic catheters inserted in an adjacent artery and vein. When specialties and with non-medical members of the care team. This unique aligned, the magnets hold the vessels together, and radiofrequency set of knowledge, skills, and experiences will ensure the future interven- energy creates a side-to-side anastomosis. Early proof of concept tionalist is well-equipped to be a critical member of the patient care demonstrated that an endoAVF could be created in 97% of cases with team. Trainees should choose programs most beneficial for careers in a mean time to fistula maturation of 58 days. A follow-up, prospective, IR by analyzing the operative/clinic experience and rotation schedule. multicenter trial provided similar technical success (98%), with 91% fis- Additionally, trainees should consider completing their preliminary and tula maturation by 3 months, and a primary patency rate of 69% at radiology training at one institution. The familiarity with hospital work- 12 months. Criteria for patient selection are evolving based on these flow is invaluable while the relationships formed improve communica- early clinical trials. Both pre-dialysis and dialysis patients are potential tion, multi-disciplinary collaboration, and patient-centered care as the candidates as well as those with previously failed surgical AVFs, which intern progresses in their training. can be treated if the target endoAVF site is distinct from the previous surgical location. Candidate requirements include the presence of per- CONCLUSIONS: A surgical preliminary year provides excellent training forator vein, target vein and artery > 2 mm in diameter, and distance for IR through diverse patient and pathology exposure, peri-proce- between artery and vein < 2 mm. dural and longitudinal care, and technical skill development. Trainees should identify those preliminary training programs ideal for their CONCLUSIONS: EndoAVF provides an innovative solution to AVF cre- future careers in IR. ation and management that avoids surgical trauma. The procedure is technically successful in 97-98% of cases and allows for fistula matura- tion >90% at 3 months. Abstract No. 647

Achieving clinical interventional radiology: how to Abstract No. 645 change the paradigm on your own terms

This abstract has been moved to the Educational e-Posters section D Covarrubias1, J Ho2, R Azzam2, G Covarrubias3 because its presentation format was changed from traditional educa- 1Kaiser Permanente West Los Angeles Medical Center, Los Angeles, tional poster to educational e-poster after the abstract numbering had CA, 2Kaiser Permanente West Los Angeles Medical Center, Los been finalized. Angeles, CA, 3Lakewood Regional Medical Center, Lakewood, CA

LEARNING OBJECTIVES: 1. To present a guide for practicing interventional Abstract No. 646 radiology (IR) physicians to create a clinical practice model 2. To present strategies and methods for the modulation of the level of clinical practice A medical student’s guide: the surgical preliminary year desired in order to ensure a smooth transition from more traditional prac- for prospective interventional radiology trainees tice models 3. To reveal attitudes and perceptions of referring physicians A Solomon1, M Tanaka2, R England3, A Arun1, R Dunlap3, T Walker2, from other specialties towards a more clinical IR practice via survey data B Holly1 BACKGROUND: IR has always been a clinical specialty at its core. Much 1Johns Hopkins Hospital, Baltimore, MD, 2Massachusetts General has been achieved in progressing away from a “procedure service” to Hospital, Boston, MA, 3Johns Hopkins Hospital, Baltimore, MD a true, stand-alone clinical specialty in recent years. However, there remains a significant heterogeneity to the actual practice of IR. This LEARNING OBJECTIVES: -Describe the advantages of a surgical prelim- variation is a natural consequence of the development of our specialty inary year for interventional radiology (IR) trainees -Identify optimal under the umbrella of diagnostic radiology. While the clinical model characteristics of surgical internships SIR 2019 Annual Scientific Meeting Traditional Educational Posters | 11

exists at many large or academic institutions, adapting this model to payment models for DR and IR studies. Finally, we discuss the special smaller practices can be challenging. We provide a model of how to intrinsic needs of interventional radiology as a , and navigate this process as well as modulate the degree of change over how these needs will shape future directions for the field to advance. time. Additionally, we present data gathered from our colleagues in CONCLUSIONS: A proper understanding of historical trends and current other specialties regarding their perceptions and opinions of IR before practice models in interventional radiology will help medical students, and after implementation of a clinical practice model. The hope is that residents, and radiologists understand and incorporate the ongoing this will facilitate the transition for other IR physician facing similar changes affecting our specialty. Knowledge of our current and future issues in influencing the way they practice our specialty. direction will help foster relationships with other medical specialties, and CLINICAL FINDINGS/PROCEDURE DETAILS: Positive experience for IR integrate the “new” interventional radiology into their medical practice. physicians to take control of their own practice model. Mutual benefit to referring physicians from other specialties as they partner with IR to provide care for mutual patients. Overall referring physicians were Abstract No. 649 enthusiastic and supportive of clinical model of IR practice Dorsal radial access in the anatomical snuffbox: a CONCLUSIONS: IR will continue its evolution towards the full clinical backhanded compliment to more traditional access routes specialty it deserves to be. It is the responsibility of IR physicians to J Champlin1, R Starke1, J Salsamendi1 champion this change, take control of their future, and transform their 1 practices into their ideal model. This can be achieved in many different University of Miami/Jackson Medical Center, Miami, FL ways and we hope that our experience will be useful to other IR phy- LEARNING OBJECTIVES: Review anatomical snuffbox access including sicians attempting to pursue this path. Referring physician attitudes relevant arterial anatomy, technical considerations, the utility of such appear to be shifting to welcome the new paradigm of clinical IR, access and it’s limitations. which is encouraging and necessary. BACKGROUND: Radial access is a gold standard for coronary interven- tion due to early mobilization, decreased complications and patient Abstract No. 648 preference, and has also become a popular alternative for interven- tional radiology (IR) interventions. Dorsal radial artery access in the Building tomorrow’s interventional radiology practice: anatomical snuffbox has been described for coronary interventions historical trends, current models, and future directions and more recently for IR interventions including TAE, TACE, TARE, vis- T Rashid1, E Esses1, C Lugo1, A Gaffar1, O Furusato Hunt1, W Gao1, P ceral embolization and stenting. Gerard1, S McCabe1, G Rozenblit1, S Maddineni1 CLINICAL FINDINGS/PROCEDURE DETAILS: The radial artery bifurcates 1Westchester Medical Center, Valhalla, NY into dorsal and superficial branches. The dorsal branch continues through the snuffbox and forms the deep palmar arch, whereas the LEARNING OBJECTIVES: 1. To investigate the historical trends that have superficial branch provides the main blood supply to the digital arter- helped shape past models of interventional radiology practices. 2. To ies. For snuffbox access, ulnopalmar circulation should be assessed discuss the special intrinsic needs of interventional radiology as a spe- and the hand clenched in ulnar flexion. Because the access site is distal cialty in the context of current practice models. 3. To explore the future to the conventional radial access site, longer catheters are needed. At directions of interventional radiology practices as the specialty evolves. case completion hemostasis can be achieved with manual pressure or BACKGROUND: In September 2012, the American Board of Medical radial band. There are multiple advantages and applications of snuff- Specialties (ABMS) separated interventional radiology (IR) from diag- box access. When puncturing the left radial artery, this access allows nostic radiology (DR), turning IR into an independent medical spe- one to lay the patient’s across their to perform the case cialty. This decision was telling of major changes that were underway from the right; useful for adhesive capsulitis, contractures and other in present radiology practice models, and supported major paradigm orthopedic limitations. Because access is distal to the radial artery shifts in the field of IR. Thus, it is imperative to educate trainees (med- bifurcation and superficial branch, lower neurovascular complications ical students, diagnostic and interventional radiology residents) about may be expected. Further, this access can be used when conventional historical and current radiology practice models. An understanding of radial access has resulted in spasm. Finally, snuffbox access allows the systems currently shaping DR and IR practices will help empower preservation of the radial artery for AVF creation or graft harvest prior trainees to further advance the IR specialty in the future. to CABG or MCA bypass. Limitations of snuffbox access include longer catheters needed, variant anatomy including an incomplete deep pal- CLINICAL FINDINGS/PROCEDURE DETAILS: We illustrate the historical mar arch and aberrant arteries arising from the snuffbox radial artery, trends and systems that interventional radiologists have utilized in the potential for dislodgement of nonadhesive wristband hemostatic early years of the specialty, alongside their DR colleagues. We explore devices and limited follow-up data. how these trends have helped shape current academic and private prac- tice models up to the present day. Examples of this include: current aca- CONCLUSIONS: Anatomical snuffbox access offers several potential demic and private practice models involving interventional radiology; advantages but requires an understanding of radial artery anatomy, intrinsic contractual stipulations for DR and IR practices including RVUs, unique technical considerations as well as the access site’s limitations. value added procedures and profit margins; CMS and insurance-based 12 | Traditional Educational Posters SIR 2019 Annual Scientific Meeting

Abstract No. 650 LEARNING OBJECTIVES: To present our institutional experience imple- menting an expanded clinical curriculum in the integrated interven- Emphasizing clinical aspects in interventional radiology tional radiology (IR) residency and identify helpful tips and potential training: methods of implementation obstacles for training programs during this transition period

1 1 1 G Rao , G Kroma , R Suri BACKGROUND: In 2012, the American Board of Medical Specialties 1University of Texas Health Science Center at San Antonio, San approved the American Board of Radiology proposal for a primary cer- Antonio, TX tificate in IR and diagnostic radiology. This led to a paradigm shift in the training of interventional radiologists with the goal of producing more LEARNING OBJECTIVES: How much clinical exposure should an inter- clinically skilled graduates. In 2016, fifteen medical students matched ventional radiology resident have during their residency training? into one of seven different integrated IR training programs and each year The closest comparison would be to a vascular surgery resident who the match has grown. As integrated IR programs have begun to imple- has clinical duties embedded in their curriculum. Designing the ideal ment their clinically centered curriculum across the nation, we present amount of exposure to the interventional radiology (IR) suite, diagnos- our institutional experience with this transition. We hope to underscore tic radiology, and clinical settings is to be evaluated in a systematic the benefits and challenges of an expanded clinical curriculum in a large method in order to create well rounded, clinically oriented interven- academic medical center and demonstrate the role of this curriculum tional radiologists. in preparing future interventionalists to become adept in the emerging

BACKGROUND: Understanding the importance of a good balance cost-effective and patient-centered healthcare system models. between time spent in the IR suite, IR outpatient clinic, and the inpatient CLINICAL FINDINGS/PROCEDURE DETAILS: To review the following: settings is paramount in making future interventional radiology clini- 1) the importance of increasing the clinical acumen of interventional cians ready for the increasing clinical demands. As a way of creating radiologists in order to optimize patient care, 2) published literature a method of implementation, it would be recommended to compare and workforce statistics describing current IR practices and emerging the interventional radiology residency training with vascular surgery trends, 3) the existing need for an expanded clinical curriculum in the residency training. Vascular surgery residents balance time spent in Integrated IR Residency training paradigm, 4) our institutional expe- the operating room, inpatient/ICUs, and clinic while the interventional rience implementing the expanded IR training curriculum, 5) advice radiology residents spend time in the reading room, IR suite, clinic and concerning challenges for IR programs in this new training model, and inpatient floors. ACGME has a set of requirements for vascular surgery 6) state of the current training transition period and a vision for the IR residents that encourage proficiency in all the domains of clinical com- practice models of the future. petency requiring the resident physician to assume personal respon- sibility for the care of individual patients. Recommendations from the CONCLUSIONS: After reviewing this exhibit, the viewer will become vascular surgery guidelines can be used to design a more clinically ori- familiar with the successful implementation and institutional experi- ented interventional radiology residency syllabus. ence of an expanded and clinically focused IR training paradigm at a large academic medical center. They will also appreciate the importance CLINICAL FINDINGS/PROCEDURE DETAILS: We present a comparison of producing clinically adept IR trainees as they confront the present study between a vascular surgery residency and an interventional trends in cost-effective and patient-centered healthcare markets. radiology residency and discuss the ideal balance of clinical duties with time spent in the IR reading room and IR suite. The structure of the time spent in the clinic is also discussed with emphasis on longitudinal Abstract No. 652 care of patients. For the novice trainee: principles of pre-procedural CONCLUSIONS: Though ACGME has a prescribed format for IR train- management in interventional radiology ing, interventional radiology residency programs vary and the need for standardization of clinical duties needs to be addressed. This exhibit will A Khan1, M Abad-Santos2, N Amesur3 summarize how vascular surgery training compares to interventional 1University of Pittsburgh School of Medicine, Pittsburgh, PA, radiology training and how to create a method of implementation of 2Harbor-UCLA Medical Center, Torrance, CA, 3University of clinical duties without compromising other aspects of IR training. Pittsburgh Medical Center, Pittsburgh, PA

LEARNING OBJECTIVES: This exhibit will review established guidelines Abstract No. 651 pertaining to pre-procedural management in interventional radiology (IR) and is geared towards medical students and junior residents. We Expanding the clinical curriculum in an integrated will provide discussion of various aspects of management in both vas- interventional radiology residency: institutional lessons cular and nonvascular procedures. learned and directions for the future BACKGROUND: Many medical students and junior diagnostic radiology C Raymond1, M Makary1, J Spain2, M Khayat3, C Raymond1 residents enter IR rotations without adequate knowledge of patient 1The Ohio State University Medical Center, Columbus, OH, management. The pre-procedure workup is a vital step in ensuring the 2Wexner Medical Center, The Ohio State University, Columbus, OH, safety of any particular interventional procedure, especially in reduc- 3University of Michigan, Ann Arbor, MI ing the risk of bleeding, infection, aspiration and contrast reactions. SIR 2019 Annual Scientific Meeting Traditional Educational Posters | 13

CLINICAL FINDINGS/PROCEDURE DETAILS: Presented are general the acceptance rate of matching into an integrated IR program for an aspects involved in the pre-procedure workup in IR including assess- eligible senior medical student is approximately 21.9%. The trend from ment of hemostasis and coagulation status, assessment of infection 2016 to 2018 shows that senior medical students can expect a very risk and recommended prophylaxis, pre-procedural management of competitive match in the coming 2019 residency match cycle. contrast allergies and contrast-induced nephropathy, relevant history and physical exam in the use of moderate sedation, and the minimiza- tion of aspiration risk Abstract No. 654

CONCLUSIONS: Appropriate pre-procedural evaluation is integral to a Immunotherapies for hepatocellular carcinoma: a primer patient-centered interventional radiology practice. A concise review of for the clinical interventional radiologist established practice guidelines is provided to highlight key factors in F Matsunaga1, D Bajor1, J Davidson1, S Tavri1 this process, and serves as a helpful reference to novice trainees enter- 1 ing interventional radiology. The information presented is pertinent to University Hospitals Cleveland Medical Center, Cleveland, OH a large scope of procedures in IR. LEARNING OBJECTIVES: 1) Review cancer immunosurveillance and tumor escape mechanisms. 2) Discuss the mechanisms, efficacy and Abstract No. 653 toxicities of novel immunotherapies for advanced hepatocellular car- cinoma (HCC). 3) Explore the possible synergistic effects of immuno- How competitive is matching into the interventional therapies and locoregional modalities. radiology residency: analysis of the 2017 and 2018 NRMP BACKGROUND: Interventional radiology is undergoing a paradigm shift match whereupon its practitioners are evolving into image-guided clinicians G Rao1, R Suri2, G Kroma3 who are now required to have a working knowledge of adjunct ther- apies in diseases such as advanced HCC. Sorafenib, a multi-kinase 1University of Texas Health Science Center at San Antonio, San inhibitor, is the only first-line systemic treatment for advanced HCC. Antonio, TX, 2University of Texas Health Sciences Center San Antonio, San Antonio, TX, 3University of Texas Health Science However, it has modest effects on overall outcome. Immunothera- Center, San Antonio, TX pies, namely immune checkpoint inhibitors, demonstrate promise in the treatment of HCC. These antibodies target immune pathways, ulti- LEARNING OBJECTIVES: 1. To examine outcomes of senior medical stu- mately restoring T-cell function and enhancing detection/destruction dents in the 2017 and 2018 ACGME integrated interventional radiology of HCC. Locoregional therapies induce systemic immune responses residency match. 2. To evaluate the expectations for the 2019 ACGME and thus hold potential for a therapeutic synergistic effect when com- integrated interventional residency match. 3. To discuss how the bined with immunotherapies. results of matching into integrated interventional radiology compared CLINICAL FINDINGS/PROCEDURE DETAILS: Results from phase 1/2 clin- to other specialties. ical trials of immune checkpoint inhibitors demonstrate efficacy and BACKGROUND: The National Residency Matching Program (NRMP) is safety profiles similar to or better than that of sorafenib (table) (1-4). a private, non-profit organization that provides an efficient means by Phase 3 clinical trials are currently under way. Tremelimumab com- which preferences of eligible applicants for U.S. residency positions bined with ablation yielded an objective response rate of 26% (5/19) are matched with the preferences of residency program directors. The in a small study (5). results of the match are charted and released every March in the Main CONCLUSIONS: Immune checkpoint inhibitors are a promising class Residency Match Data and Reports section of the NRMP. Data collected of drugs for the treatment of advanced HCC, with early data demon- from the 2017 and 2018 match were compared and demonstrate over- strating similar to better outcomes than sorafenib. It is imperative that all trends in how eligible senior medical students rank the integrated interventional radiologists understand their mechanisms, efficacy and interventional radiology pathway compared to other specialties. safety profiles as these could be combined with locoregional therapies CLINICAL FINDINGS/PROCEDURE DETAILS: 2018 NRMP match data to yield a synergistic therapeutic effect. shows 607 applicants applying for 133 interventional radiology (IR) posi- tions compared to 2017 NRMP data showing 563 applicants applying for Drug Mechanism Objective Disease Toxicities Response Control 124 IR positions. 2018 ACGME match data demonstrates approximately Nivolumab Anti-PD-1 42/214 138/214 Fatigue, pruritus, five applicants applying for every one IR position. The high ratio of appli- (20%) (64%) diarrhea, nausea cants to positions demonstrates continued strong interest in senior medi- Pembrolizumab Anti-PD-1 18/104 64/104 cal students applying to the integrated interventional radiology residency (17%) (62%) program. Comparatively, 1069 diagnostic radiology positions are available Tremelimumab Anti-CTLA-4 3/17 13/17 in the 2018 NRMP match. There are about eight diagnostic radiology posi- (18%) (76%) tions for every one integrated IR position in the 2018 match. Sorafenib Multi-kinase 7/299 129/299 Fatigue, alopecia, inhibitor (2%) (43%) hand-foot skin CONCLUSIONS: Continued high demand for integrated IR positions in reaction, rash, the 2018 match cycle among senior medical students demonstrates anorexia, diarrhea the need to increase the number of integrated IR positions. Overall, 14 | Traditional Educational Posters SIR 2019 Annual Scientific Meeting

Abstract No. 655 International Prostate Symptom Score (IPSS) to diagnose obstructive urinary pathology. 4. Illustrate common bladder reconstructions per- Interventional radiology management of iatrogenic formed for obstructive pathology. 5. Discuss the role of interventional complications of endoscopic procedures radiology (IR) in multidisciplinary care of urinary obstruction.

1 1 1 1 1 B Nowack , J Garrett , C Kisner , A Haritha , C Ahuja BACKGROUND: BPH is a highly prevalent condition affecting elderly 1Louisiana State University Health Sciences Center Shreveport, men. While considered a normal part of aging, BPH may become Shreveport, LA pathologic and precipitate bladder outlet obstruction and lower uri- nary tract symptoms (LUTS). Traditional therapies for BPH LUTS has LEARNING OBJECTIVES: Highlight the potential complications of been alpha-blockers and 5-alpha reductase inhibitors, and in severe endoscopic procedures. Discuss typical patient presentations and cases transurethral resection of the prostate (TURP) or prostatectomy multi-modality imaging findings. Demonstrate interventional radiol- is performed. ogy’s role in management with typical and uncommon techniques. Identify cases that require surgical intervention. CLINICAL FINDINGS/PROCEDURE DETAILS: With the advent of pros- tatic artery embolization as a minimally invasive alternative therapy to BACKGROUND: Thousands of diagnostic and therapeutic endoscopic TURP, IR clinicians are becoming increasingly involved in BPH therapy. procedures are performed each day in both outpatient and inpatient Understanding the IPSS symptom score and AUA/SUFU guidelines for settings by providers in multiple subspecialties. The volume of these uroflowmetry, postvoid residual, cystometric testing, pressure flow procedures combined with overall reported complication rates of study, leak point pressure measurement, electromyography, and video approximately 1% results in a high incidence of cases which may be urodynamic tests will become important to delineate from other reten- encountered in interventional radiology practice. These complications tion pathologies. Such knowledge is of increasing importance with the range from minor to life-threatening. An early diagnosis and character- introduction of the IR/DR training pathway, as IR residents reemerge ization followed by appropriate management is essential to minimize into clinical practice and assume more patient responsibility. morbidity and mortality. Many of these injuries, even when relatively severe, can be managed percutaneously, avoiding more invasive open CONCLUSIONS: Our exhibit will focus primarily on the clinical presenta- surgical intervention. tion of lower urinary tract obstruction, and a comprehensive review of IPSS questionnaire and AUA/SUFU urodynamic work up guidelines for CLINICAL FINDINGS/PROCEDURE DETAILS: This exhibit aims to illus- IR trainees involved in urinary system interventions. trate the gamut of complications arising from both diagnostic and therapeutic endoscopic procedures. Typical patient presentations for common and uncommon complications will be reviewed. The role of Abstract No. 657 multi-detector computed tomography and angiographic findings will be highlighted. A collection of patients seen in our academic tertiary The heart of all problems: imaging common care center provide the foundation for this educational review. complications associated with left-ventricular assist device CONCLUSIONS: A collection of patients seen in our academic tertiary care center provide the foundation for this educational review of iat- X Li1, S Partovi2, S Azeze3, A Dey4, V Kondray2, M Zacharias2, S Tavri2 rogenic complications of endoscopic procedures and the role of inter- 1Case Western Reserve University, Cleveland, OH, 2University ventional radiology in their management. Common and uncommon Hospitals Cleveland Medical Center, Cleveland, OH, 3N/A, Union complications and injuries. Typical patient presentations. Multi-modal- Beach, NJ, 4N/A, Cleveland, OH ity imaging findings. Interventional management techniques. Indica- LEARNING OBJECTIVES: The purpose of this educational poster is to tions for open surgical intervention. familiarize readers with the pathophysiology, clinical presentation, radiographic features and potential interventional treatment for Abstract No. 656 LVAD-associated complications.

BACKGROUND: Chronic heart failure (CHF) is a complex condition Interventional radiology clinician guide to urodynamic leading to significant morbidity and mortality. Advanced heart failure testing for bladder obstruction necessitates orthotopic heart transplantation. An estimated 2,200 V Kondray1, A Ray1, L Walker1, X Li2, G Kondray3, S Tavri1 patients received transplantation out of approximately 150,000 to 1University Hospitals Cleveland Medical Center, Cleveland, OH, 200,000 end-stage heart failure patients. Therefore, LVAD is increas- 2Case Western Reserve University, Cleveland Heights, OH, ingly being utilized for this patient population as a bridge-to-transplant 3Marymount Hospital, Garfield Hts., OH and as destination treatment. Although LVAD has shown a significant reduction in all-cause mortality in comparison to medical management LEARNING OBJECTIVES: 1. Understand urinary system and micturition alone, there are high rates of perioperative and long-term LVAD-asso- physiology. 2. Discuss benign prostatic hypertrophy (BPH) and lower ciated complications. urinary tract obstructive pathophysiology. 3. Review American Uro- logical Association (AUA)/ Society of Urodynamics and Female Uro- CLINICAL FINDINGS/PROCEDURE DETAILS: LVAD-associated com- genital Reconstruction (SUFU) urodynamic testing guidelines and plications can be divided into three categories: Device associated SIR 2019 Annual Scientific Meeting Traditional Educational Posters | 15

complications (infection, device thrombosis and thromboembolic audit was conducted revealing 83% of consultations were completed events), management associated complications (mainly bleeding) within twenty-four hours of the consult being placed. Approximately and altered hemodynamics associated complications (right heart fail- 99% of orders placed by IR clinicians were accurate requiring no addi- ure and aortic hemodynamic changes). Pathophysiologic alterations tional modifications. due to the “pulseless state” may lead to von Williebrand disease and CONCLUSIONS: Transitioning to an IR inpatient consult-based service angiodysplasia. A variety of vascular imaging modalities play a pivotal can lead to increased efficiency and improved patient safety. Mapping role in the diagnostic work-up of these complications. These modal- out the process, performing a pilot study, making changes as appropri- ities include ultrasound, CT / CTA, MRI / MRA and nuclear imaging ate, and maintaining frequent communication with the primary clinical (particularly PET-CT). Recently in a series of case reports endovascu- teams will increase the chance of a successful transition. lar approaches to treat these LVAD associated complications has been described and will be presented in this educational exhibit.

CONCLUSIONS: In the setting of advanced heart failure the LVAD device Abstract No. 659 is increasingly implanted as a bridge-to-transplant and as a destination Use of modified MMI to assess applicants for the option. Due to the increasing number of LVAD patients, the associated interventional radiology residency complications are more frequently encountered. Interventional radiol- ogists should be familiar with the vascular imaging appearance of S Narayan1, V Becerra1, D Collins1, C Stark1, L Keating2, K Mandato1, common complications using different modalities and should become A Herr2, G Siskin1 involved in endovascular treatment of these complications. 1Albany Medical Center, Albany, NY, 2Albany Medical Center, Slingerlands, NY

Abstract No. 658 LEARNING OBJECTIVES: To describe the Multiple Mini-Interview (MMI) process and its modified use in the interview process for an interven- Transitioning into a consult-based interventional tional radiology (IR) residency program. radiology service BACKGROUND: The MMI is a structured selection method designed to 1 2 2 3 A Blount , A Isaacson , C Burke , R Dixon assess non-cognitive attributes of applicants in the interview setting. 1UNC Hospital- Chapel Hill, Chapel Hill, NC, 2University of North This is done through the use of scenarios or questions that bring out the Carolina, Chapel Hill, NC, 3UNC Dept. of Radiology, Chapel Hill, NC attributes necessary for successful completion of a training program. By adding structure to interviews, the reliability and acceptability of LEARNING OBJECTIVES: To describe the transition from an order-based the process has been shown to increase. At least 40 medical schools interventional radiology (IR) inpatient service to a consult-based ser- in the United States are presently using the MMI format to interview vice and to delineate the benefits of such a conversion. applicants for medical school. With the IR residency in place, different

BACKGROUND: An “order-based” inpatient IR service, in which hos- ways to assess applicants are necessary to ensure appropriate selec- pital clinicians place procedure orders, can result in ordering errors, tion of students who will ultimately contribute positive to the field. decreasing workflow efficiency and threatening patient safety. After CLINICAL FINDINGS/PROCEDURE DETAILS: We have developed a a review of orders at our institution, we found approximately 70% of modified MMI protocol for use during IR residency interviews that procedure orders for inpatients were flawed, requiring cancellation or has been used to objectively assess applicants to our program. This correction, leading to the decision to convert to a consult-based inter- has the basis in the attributes believed to be necessary for success in ventional radiology service. IR, including empathy, motivation, professionalism, collegiality, work

CLINICAL FINDINGS/PROCEDURE DETAILS: A committee, composed ethic, and research participation. Applicants rotated through 8 timed of IR physicians, advanced practice providers, nurse managers, tech- stations. Four stations sought to assess the above characteristics using nologists, scheduling coordinators, and an operations manager was scenarios with focused follow-up questions (examples of which will be formed. A new consult-based process was developed, using LEAN and presented in the exhibit in more detail). The remaining four stations Six Sigma principles to map out the work flow, from the initial consult maintained a traditional interview format with 2 closed file interviews to the completion of the procedure. The steps of the process include: and 2 open file interviews, each of which focused on different aspects receiving the consult, reviewing the medical record, communicating of the applicant’s background. Applicants were scored at each station with the primary team, obtaining a patient history, performing a phys- and these scores were added together to arrive at a composite score ical exam, making written recommendations in the EMR, obtaining that was used to rank the applicants. A wrap-up session with all of the patient consent, and placing the correct procedural order. Using these interviews finalized the order. steps, a two-week pilot study was carried out with inpatients from two CONCLUSIONS: The Modified MMI system used at our institution for IR predetermined services. After one-week, the average time to complete residency interviews represents a structured approach to the difficult a consult (identified by the correct order being placed) was 20-40 task of resident selection. With the large number of qualified applicants minutes. An average of 15 consults were seen daily. The number of being seen throughout the country, utilizing this type of methodology orders that were incorrect or required modification dropped to nearly can help to ensure success for both IR applicants and IR programs. zero. After hospital wide implementation, a three month follow-up 16 | Traditional Educational Posters SIR 2019 Annual Scientific Meeting

Abstract No. 660 LEARNING OBJECTIVES: 1. To review the American College of Radiology (ACR) Liver Imaging Reporting and Data System (LI-RADS) version VIR QI: a case log archiving program embedded in a 2018 (v2018) criteria for reporting cross-sectional imaging findings in Picture Archiving and Communication System (PACS) patients at risk for hepatocellular carcinoma (HCC). 2. To pictorially E Clark1, J Gerding2, D Mittleider2, E Clark1 illustrate the spectrum of LI-RADS imaging observations using case- based examples from clinically acquired computed tomography (CT) 1University of New England College of Osteopathic Medicine, Portland, and magnetic resonance imaging (MRI) exams, with angiographic cor- ME, 2Spectrum Vascular & Interventional Physicians, Falmouth, ME relation. 3. To describe the clinical decision making implications of var-

LEARNING OBJECTIVES: To outline the capabilities of the VIR QI case ious LI-RADS categories as designated by the American Association log software in the MaineHealth PACS for the Study of Liver Diseases (AASLD) and National Comprehensive Cancer Network (NCCN) guidelines. BACKGROUND: Interventional radiology (IR) residencies must docu- ment cases in which a trainee is the primary operator across the spec- BACKGROUND: Developed in 2011, the ACR LI-RADS scheme is a com- trum of categories of procedures that are considered obligatory for IR prehensive classification system which standardizes radiological inter- resident education. An individual case may have components of mul- pretation for liver cross-sectional imaging in patients at risk for HCC. tiple categories of cases, and different trainees may be primary oper- Utilization of LI-RADS enables the interventional radiologist to use ator for different components of a single patient encounter. Existing specific descriptive terminology for consistent radiological reporting case log systems are reliant on excessive manual data entry. The VIR QI of liver abnormalities to meaningfully guide follow-up and/or treat- program was implemented in the MaineHealth PACS as a multi-func- ment. Current AASLD and NCCN practice guidelines have integrated tion application that captures highly detailed case log information to LI-RADS into their recommendations. As critical partners in image address the clinical need for better case log software in IR. interpretation and multidisciplinary care of HCC patients, it is essen- tial that interventional radiologists providing liver-directed therapy CLINICAL FINDINGS/PROCEDURE DETAILS: VIR QI is fully integrated understand and implement the LI-RADS system in day-to-day clinical into PACS. All Current Procedural Terminology (CPT) codes that are practice. tracked by ACGME for resident education (both mandatory, such as embolization codes 37441-4, and suggested, such as thrombol- CLINICAL FINDINGS/PROCEDURE DETAILS: In order to depict LI-RADS ysis code 37195) are available in a pull-down menu for each case within categories, this educational exhibit will define and pictorially illustrate PACS. Case types are organized by sequential pull-down menus, and the LI-RADS v2018 scheme using informative case examples derived each option is linked to a specific CPT code. When an IR resident opens from a single-institution HCC database. CT and/or MRI of various a case in PACS at MaineHealth, VIR QI is activated by a button on the LI-RADS categories-spanning benign entities to malignant masses-will toolbar. An individual patient encounter may satisfy multiple proce- be exemplified, with angiographic correlation. AASLD/NCCN treat- dure categories. A resident selects the case type(s) for which she was ment guidelines will be associated with each pictorial representation the primary operator. If a second resident is involved in a case, she for succinct clinical management review. utilizes the VIR QI button to select any component(s) for which she was CONCLUSIONS: LI-RADS provides contemporary descriptive verbiage the primary operator. The program archives the information on an indi- for liver abnormalities and represents essential knowledge for inter- vidual provider basis. At any point in time, a report can be generated ventional radiologists treating liver oncology patients. Viewers of this for an individual provider that can list every procedure type, quantity exhibit will have a working knowledge of the breadth of LI-RADS cate- that was logged, and individual patient information. gories, their imaging appearance, and their clinical consequences.

CONCLUSIONS: VIR QI can be a valuable software tool for IR residency programs as a case log system. It can distinguish each operator and Abstract No. 662 CPT code, and it can distinguish multiple primary operators for indi- vidual components of a single patient encounter. Program directors More than meets the eye: radiogenomics of liver can accurately quantify and track IR resident procedures with minimal manual data entry. A Saini1, I Breen1, Y Pershad1, M Kuo1, S Alzubaidi1, M Knuttinen1, S Naidu1, R Oklu1 1Mayo Clinic, Phoenix, AZ Abstract No. 661 LEARNING OBJECTIVES: 1. Describe the radiogenomics process includ- LI-RADS v2018: a pictorial primer for interventional ing preprocessing, radiogenomics analysis and modeling, and radiog- radiologists enomics associations. 2.Discuss the seminal studies on radiogenomics J Herren1, F Faraji1, J Kuwahara2, A Lipnik3, R Gaba4 in primary liver cancers including HCC and ICC, with a focus on meth- odologies, findings, and the prognostic and predictive abilities the 1University of Illinois at Chicago, Chicago, IL, 2University of Illinois models. 3. Understand the role of radiogenomics in interventional Hospital & Health Sciences, Chicago, IL, 3University of Illinois oncology and how information from radiogenomics models can be Hospital & Health Sciences System, Chicago, IL, 4University of used to guide locoregional treatments. Illinois Hospital, Chicago, IL SIR 2019 Annual Scientific Meeting Traditional Educational Posters | 17

BACKGROUND: Tumor biology is an important driver of prognosis and CONCLUSIONS: The results of pre-procedural printing are mostly sub- outcomes. Knowledge of gene expression patterns is necessary to jective, but resulted in greater operator confidence and understand- guide patient selection and treatment. Molecular profiling through tis- ing. In one case, the patient became a transplant candidate after the sue is invasive, does not capture the complete heterogeneity surgeons reviewed his model at transplant case conference, and had of a tumor, and only provides a single snapshot of a tumor in time. a life changing operation as a result. 3D printing from multi-modality Radiogenomics attempts to solve these issues by identifying quantita- models is the ultimate tool of understanding anatomy, and are a crucial tive and qualitative imaging traits on cross-sectional imaging and then part of patient care plan in these complex hepatobiliary cases. correlating these traits to gene expression profiles and clinicopath- ologic data. The resulting model can then be used to non-invasively and longitudinally provide prognostic and predictive information for Abstract No. 664 a given set of imaging traits and genomic expression data. The model Through the looking glass: the impact of augmented can then be refined through input of outcomes data. reality and mixed reality on image-guided procedures CLINICAL FINDINGS/PROCEDURE DETAILS: We will outline the radioge- M Schwenke1, J Greene2, M Singh3, S Braverman1 nomics process including: selection of imaging traits, analysis of gene 1 2 expression profiles, correlation of imaging traits and genetic informa- Santa Barbara Cottage Hospital, Santa Barbara, CA, University of 3 tion, and association of radiogenomic data with clinicopathologic data Colorado, Aurora, CO, Mount Sinai Hospital, New York, NY and outcomes. We will then review key studies on radiogenomics in LEARNING OBJECTIVES: Indirect or off-axis visualization (i.e., focusing liver cancers including HCC and ICC with a focus on the prognostic and on a screen instead of the procedural site) interferes with visual and predictive abilities of the models. Finally, we will describe the role of motor coordination. Augmented reality (AR) and mixed reality (MixR) radiogenomics in interventional oncology. can improve coordination through simultaneous in-line visualization of

CONCLUSIONS: Radiogenomics is an emerging field that attempts to both the procedural site and guiding images. Of the available inter- provide prognostic and predictive information through the correlation faces, optical see-through head mounted displays (OST-HMDs) offer of imaging features with genomic expression profiles and clinical data. the greatest flexibility and functionality. Interventional radiologists, with their expertise in image-guided biop- BACKGROUND: Indirect visualization (looking at a screen instead of the sies and cross-sectional imaging, in addition to an expanding arsenal of procedural site) during image-guided procedures impairs motor coor- locoregional therapies, will play a key role in the field of radiogenomics. dination. Augmented reality (AR) and mixed reality (MixR) procedural interfaces aim to alleviate this by simultaneous direct visualization of Abstract No. 663 the procedural site and guiding images. CLINICAL FINDINGS/PROCEDURE DETAILS: Video see-through AR 3D printing: understanding challenging hepatobiliary interfaces employ tablets to acquire and display images. The patient’s anatomy body, covered with several registration markers, is captured by the J Young1, R Klatte2, M Bayona Molano2 back-face camera of the tablet. Then, exam images are then super- imposed over the patient’s body on the tablet display. As the tablet is 1MetroHealth Hospital, Cleveland, OH, 2Cleveland Clinic, Cleveland, OH moved around the patient, this hybrid image adjusts spatial relation-

LEARNING OBJECTIVES: Understand the basic concept of building 3D ships to match the change in perspective. Fixed optical see-through models and printing them. Specifically, learn about how critical ana- interfaces, on the other hand, are attached to the imaging equipment tomic information from different imaging series/modalities can be allowing simultaneous co-registration of the patient and exam images. combined into one unified model. Additionally, see how multi-modality Hybrid images are displayed on a semi-transparent mirror outside the 3D models can assist in understanding complex anatomy, with some CT or MRI alleviating onerous aspects of closed bore MRI-guided pro- examples of 3D models that changed patient management. cedures. Optical see-through head mounted displays (OST-HMDs) are a wearable interface which also create dynamic hybrid image overlays BACKGROUND: This series demonstrates four unique cases of complex that adapt to the operator’s perspective. Unlike video see-through hepatobiliary anatomy in which interventions were greatly facilitated interfaces, OST-HMDs do not require marker placement. Additionally, by creating 3D models of their anatomy. While all 3D models facilitate OST-HMDs utilize touchless interfaces for manipulating virtual objects spatial understanding, the strength of these models specifically reside and controlling the user interface allowing the operator to remain ster- in the fact that they were constructed from a combination of multiple ile during the procedure. imaging series/phases/modalities. CONCLUSIONS: AR and MixR interfaces allow simultaneous in-line visu- CLINICAL FINDINGS/PROCEDURE DETAILS: With the aid of 3D modelling alization of the procedural site and guiding images which can improve software (Magics software, Materialise NV, Belgium), the most crucial visual and motor coordination. OST-HMDs offer the most flexible and information from each series was combined in accurate anatomic ori- functional approach for integrating AR and MixR into image-guided entation. These reconstructions were sent to GrabCAD Print software procedures. (Stratasys, MN) and were then printed on a Stratasys J750 or uPrint, with the final physical models evaluated by interventional radiologists and surgeons alike. 18 | Traditional Educational Posters SIR 2019 Annual Scientific Meeting

Abstract No. 665 guidance for central venous occlusion (CVO) treatment using pre-op CT/MR or cone-beam CT. Unique interventional radiology applications for a hybrid BACKGROUND: CVO patients present with symptoms (swelling) and computed tomography/angiography room or with malfunctional dialysis access. CVO can be chronic and usually K Nijhawan1, O Ahmed1 complex to treat due to venous tortuosity, stumps in different planes 1The University of Chicago, Chicago, IL in the mediastinum, and multiple collaterals. Pre-operative chest CT, MRI, or intra-procedural cone-beam CT can provide key 3D informa- LEARNING OBJECTIVES: Review imaging modality differences between tion that can be overlaid with the 2D . More specifically, 3D cone-beam CT and fan beam CT. Introduce the concept of a hybrid CT/ digital planning lines can provide guidance through the venous occlu- angiography room and its utility in interventional radiology (IR) pro- sion track where contrast based roadmapping for device navigation is cedures. Provide a pictorial review of unique cases performed at our not safe enough. This can also provide understanding of the adjacent institution using a hybrid CT/angiography room. structures and how to anticipate potential complications, leading to

BACKGROUND: Cone-beam CT (CBCT) with the use of a C-arm has safer and faster procedures, at lower radiation dose. become the most widely used configuration within the interventional CLINICAL FINDINGS/PROCEDURE DETAILS: A detailed description of suite for its ability to provide real time 3-D imaging in a single patient the procedural steps performed at our institution in the treatment of setup. However, traditional fan beam CT (FBCT) when compared to chronic and complex CVOs will be accompanied by pictorial examples CBCT provides images that are superior in quality, faster, and more of pre-operative image analysis and creation of models for 3D road- anatomically accurate, with a larger field of view. Hybrid CT/angiogra- mapping (Vessel ASSIST, GE Healthcare). Additionally, this will include phy rooms take advantage of these qualities by integrating volumetric case examples involving fusion of pre-operative chest CT/MRI. The CT fluoroscopy with FBCT. This combined system increases efficiency exhibit will also highlight technical details to prevent major compli- of common IR procedures, eliminates patient transfer between CT and cations in high risk procedures using conventional and the radiofre- fluoroscopy suites, and improves workflow by potentially reducing quency (RF) wire technique. time-to and time-of procedures. CONCLUSIONS: Advanced image guidance tools can be used to provide CLINICAL FINDINGS/PROCEDURE DETAILS: Hybrid CT/angiography accurate 3D roadmapping information during the recanalization of dif- was first introduced in Japan in 1992, yet very few institutions have ficult CVOs and potentially reduce procedure time as well as radiation implemented a combined suite due to high cost. However, demand exposure. for more challenging interventional procedures requiring high-con- trast resolution CT and/or precise real time CT-guided punctures has led to re-evaluation of a combined system. The use of the hybrid CT/ Abstract No. 667 angiography suite has been documented for procedures such as TACE, radiofrequency ablations, and kyphoplasty/vertebroplasty. In this A novel use of contrast-enhanced ultrasound in peripheral educational exhibit, we will present four unique cases of interventional arterial disease procedures performed in our institution’s hybrid CT/angiography suite. J Jia1, E Mastrolonardo2, M Soleman3, E Nguyen4, H Dermendjian5, Each case will emphasize the patient’s presenting history, describe the C Lam6, I Lekht7 workflow and technique of the interventional procedure performed, 1Kaiser Permanente, Los angeles, CA, 2Sidney Kimmel Medical review the relevant imaging, and highlight the utility of using a com- College, Philadelphia, PA, 3N/A, Laguna Niguel, CA, 4Kaiser bined CT/angiography system for a procedure traditionally performed Permanente Los Angeles, Los Angeles, CA, 5Kaiser LAMC, Studio using CBCT or requiring patient transfer to a dedicated CT room. City, CA, 6Kaiser Permanente Los Angeles Medical Center, 7 CONCLUSIONS: A hybrid CT/angiography room delivers real time CT Westminster, CA, N/A, Calabasas, CA images during radiologic interventions, as opposed to lower quality LEARNING OBJECTIVES: 1. Present a novel technique: contrast-en- “CT-like” images from CBCT. This allows interventional radiologists to hanced ultrasound (CEUS) assisted endovascular intervention for adjust and verify treatment success during and after procedures. peripheral arterial disease (PAD). 2. Discuss the technical aspects of the procedure. 3. Outline the benefits and limitations of CEUS. 4. Abstract No. 666 Review the available literature on this technique.

BACKGROUND: The prevalence of PAD is greater than 10% in patients 3D and image fusion during recanalization of chronic over 60 years of age. Accurate evaluation of disease severity is import- central venous occlusion ant when deciding to proceed with invasive treatment and in follow- R Yamada1, S Ghelman2, W Mimms2, M Guimaraes1 ing progression of disease. Contrast-enhanced ultrasound (CEUS) is a 1Medical University of South Carolina, Charleston, SC, 2GE noninvasive imaging technique that can be used to assess tissue per- Healthcare, Wauwatosa, WI fusion and can be a useful adjunct in management of PAD. We hypoth- esize that CEUS can be a useful adjunct in evaluating patients before LEARNING OBJECTIVES: Tips and tricks to facilitate creation and and after intervention for PAD. usage of three-dimensional (3D) models and digital planning lines as SIR 2019 Annual Scientific Meeting Traditional Educational Posters | 19

CLINICAL FINDINGS/PROCEDURE DETAILS: We present 4 cases of CLINICAL FINDINGS/PROCEDURE DETAILS: Highlighted cases include patients with Rutherford 4-6 peripheral vascular disease with super- transjugular biopsy of a cavoatrial junction IVC mass, using the ICE ficial femoral artery disease who underwent endovascular interven- catheter to visualize biopsy tract and margins of the lesion; transjug- tion. CEUS was used before and after these procedures to qualitatively ular renal biopsy performed through a renal vein with the ICE cathe- visualize perfusion in the affected leg using the patient’s contralateral ter in in the IVC for direct visualization of the biopsy tract. Procedure leg as a control. Two ml of lumason was injected via peripheral IV and was performed in a patient on dual antiplatelet therapy, in whom a the mid calf muscles were evaluated with CEUS side-by-side allowing percutaneous biopsy was deemed high risk for bleeding; TEVAR, for direct comparison immediately before the intervention. Following with use of the ICE catheter to assist with differentiating between a angioplasty, CEUS was used to evaluate change in blood flow in the complex mycotic aneurysm vs solid mass prior to placement of stent same location. Periprocedural CEUS demonstrated a number of ben- graft; transplant-pancreatic portal vein thrombectomy with the ICE efits: 1. Allowed for visualization of significant reduction in tissue per- catheter used to visualize the course of the vein and extent of throm- fusion in the symptomatic extremity compared to the asymptomatic bus; and with the ICE catheter used to determine the side. 2. Demonstrated visible increase in perfusion within the treated presence and extent of aortic wall invasion from a thymic mass, not extremity immediately following revascularization. CEUS is a nonin- clearly seen on CT. vasive technique that can be used as an adjunct in evaluation of the CONCLUSIONS: -Intracardiac offers advantages patients with PAD. It is safe as it does not require iodinated contrast or over rotational IVUS by pairing large FOV ultrasound technology with radiation. In the future, this technique may be useful in the outpatient a steerable, tip deflecting catheter. -Improved visualization with ICE setting and utilizing quantitative programs to accurately assess perfu- catheters allow for safer, more efficient procedure. sion and monitor progression of disease.

CONCLUSIONS: CEUS is a promising technique to evaluate tissue per- fusion in patients with symptomatic peripheral arterial disease that are Abstract No. 669 undergoing intervention. This abstract has been moved to the Educational e-Posters section because its presentation format was changed from traditional educa- Abstract No. 668 tional poster to educational e-poster after the abstracts numbering had been finalized. Intracardiac echocardiography (ICE) catheters, a versatile tool for improved visualization in interventional radiology: a review of unique applications Abstract No. 670 R Koppula1, A Struchen2, D Sheeran3, J Angle2 in interventional radiology 1 2 UVA Health System, Charlottesville, VA, University of Virginia, M Schwartz1, A Saini2, M Knuttinen2, S Alzubaidi2, S Naidu2, J Hu2, 3 Charlottesville, VA, University of Virginia Health System, H Albadawi2, R Oklu2 Charlottesville, VA 1Mayo Clinic School of Medicine, Scottsdale, AZ, 2Mayo Clinic, LEARNING OBJECTIVES: 1. Describe the function and technical specifi- Phoenix, AZ cations of intracardiac echocardiography (ICE) catheter technology. LEARNING OBJECTIVES: We aim to discuss the uses of intravascu- 2. In a case-based format, highlight uses of ICE catheters in unique lar ultrasound (IVUS) and applications to the field of interventional situations in interventional radiology. radiology. BACKGROUND: Intravascular ultrasound (IVUS) technology is used to BACKGROUND: Intravascular ultrasound originated in 1962 out of supplement fluoroscopy in various situations in interventional radiol- Japan through the application of ultrasonography onto an intrave- ogy (IR). Axial IVUS has been used extensively to better characterize nous probe (1). Since the creation of intravascular ultrasound, its lesions in PAD and venous disease. However, limitations of this tech- emergence has provided valuable positional and structural infor- nology include the lack of directionality and small field of view. Intrac- mation for interventional radiology. IVUS uses a catheter based ardiac echocardiography offers improved visualization with increased ultrasound apparatus to gather images within the blood vessels field of view, color doppler imaging, longitudinal imaging with rota- themselves rather than through conventional external assessment. tional beam steerability, and catheter-tip deflection. ICE catheters IVUS is able to generate cross-sectional images of the lumen in real have been used extensively in interventional cardiology. Within IR, time along with identifying potential pathologies within the blood their benefit has been proven in TIPS / DIPS creation and their usage vessel walls and adjacent structures (2). Moving the IVUS catheter in has also been described in EVAR and migrated IVC filter retrieval. In the blood vessel can provide detailed information about the length of this presentation, we describe additional situations in which the ICE vessels and the position of the probe in relation to anatomical land- catheter was used to perform procedures in a safer and more efficient marks. These properties make IVUS an appealing technology to use manner. in interventional radiology procedures. 20 | Traditional Educational Posters SIR 2019 Annual Scientific Meeting

CLINICAL FINDINGS/PROCEDURE DETAILS: Interventional radiology Shunt Afferent Efferent Features uses intravascular ultrasound in the treatment of patients to guide Paraumbilical left Paraumbilical L femoral vein Cruveilhier- catheters and assess pathology in minimally invasive procedures. (L) femoral vein Baumgarten IVUS is used clinically for measurement of vessels in the setting of syndrome atherosclerosis, transcaval liver , cardiac mass biopsies, and Infradiaphragmatic Right (R): R: ipsilateral R: SVC syndrome management of stent placements (3). The ability for IVUS to visu- L medial portal internal thoracic alize the vessel wall and surroundings make it useful for emergency vein and intercostal vein to superior vena L: L lateral imaging and can be used for interventional guidance. IVUS software cava (SVC) can store the images from a procedure and transfer the data into the portal vein L: L inferior phrenic Picture Archiving and Communications System (PACS). Interventional vein to inferior vena radiologists can better understand the vessel structure by looking at cava (IVC) or renal previous images of the vessel walls to identify and study the changes vein over time. Physicians are beginning to experiment with combining Mesenterico- Inferior L or R gonadal vein Prior abdominal contrast-enhanced ultrasound with intravascular ultrasound for identi- gonadal mesenteric surgery vein fying vulnerable plaques (4). Vertebrolumbar- Common iliac Azygos vein Budd-Chiari CONCLUSIONS: Intravascular ultrasound has numerous applications in azygos and lumbar syndrome interventional radiology procedures. Novel ways to implement exist- vein ing modalities can create opportunities for further imaging the human Transhepatic Intrahepatic IVC, coronary vein, Paraumbilical body and new procedures. portal vein vertebral plexus venous collaterals and hemiazygos vein Abstract No. 671 R posterior portal: R posterior IVC Subtype of IVC portal vein transhepatic Pictorial review of unusual spontaneous portosystemic Intrahepatic Portal/ Hepatic vein Mimics shunts encountered during TIPS placement and its clinical subcapsular hemangioma or vein aneurysm significance S Sanampudi1, A Roney1, M Winkler2, D Raissi3 1University of Kentucky College of Medicine, Lexington, KY, Abstract No. 672 2University of kentucky, Lexington, KY, 3University of Kentucky, Lexington, KY Quiescent interval single-shot magnetic resonance angiography: utility and techniques in peripheral artery LEARNING OBJECTIVES: The purpose of this study is to conduct a pic- disease torial review of some of the rarest spontaneous portosystemic shunts A Wallace1, K Zurcher2, D Fleck1, P Hoang2, M Knuttinen3, S (SPSS) encountered during transjugular intrahepatic portosystemic Alzubaidi1, S Naidu3, R Oklu1 shunt (TIPS) placement. We present 8 cases of SPSS using volume 1 2 3 visualizations, including augmented reality (AR) and 3D printings. Mayo Clinic, Phoenix, AZ, Mayo Clinic Arizona, Phoenix, AZ, Mayo Clinic Arizona, Scottsdale, AZ BACKGROUND: TIPS is performed in patients with portal hypertension to decompress portal hypertension side effects. Several types of por- LEARNING OBJECTIVES: 1) Familiarize with the technical acquisition and tosystemic shunts maybe visualized during the procedure. SPSS are cardiac gating of QISS and how it differs from other non-contrast MRA associated with hepatic encephalopathy (HE) and variceal bleeding. techniques. 2) Compare and contrast QISS with enhanced and non-en- Recognition of an SPSS is imperative for periprocedural planning. SPSS hanced MRA. 3) List limitations and artifacts that occur with QISS and may complicate TIPS procedures by exaggerating HE and increasing how this may inform when to use QISS. 4) List clinical indications for likelihood of acute TIPS failure. Also, in the presence of large SPSS, QISS and review some typical findings. portosystemic pressure gradients (PSPG) maybe an unreliable diag- BACKGROUND: Effective management of peripheral artery disease nostic tool of the degree of portal hypertension. (PAD) is predicated on accurately characterizing stenosis, a task often

CLINICAL FINDINGS/PROCEDURE DETAILS: There are 3 main types of performed by digital subtraction angiography, contrast-enhanced SPSS encountered: typical, ectopic, and atypical. We will focus on computed tomography (CTA) or contrast-enhanced magnetic reso- atypical SPSS that are described in the table below. nance angiography (MRA). These are of limited use in patients with contrast allergies or chronic kidney disease. Traditional non-con- CONCLUSIONS: An interventional radiologist must be familiar with trast MRA can be limited by long acquisition times, poor small vessel common and atypical SPSS variants on pre-procedural imaging. Large definition, and frequent non-diagnostic quality imaging. Quiescent SPSS can render PSPG unreliable and may induce acute TIPS failure if interval single-shot (QISS) MRA is a promising technique that signifi- not addressed. These variations can be easily learned and displayed cantly reduces scan times while providing a robust and accurate exam through 3D printing and AR. approaching the sensitivities and specificities of contrast-enhanced SIR 2019 Annual Scientific Meeting Traditional Educational Posters | 21

exams. Non-contrast exams do not run of the risks of contrast induced review the QISS MRA sequence and compare it to existing imaging nephropathy or nephrogenic systemic fibrosis seen with iodinated and techniques including DSA, CTA, CEMRA, and other NEMRA techniques gadolinium based agents. with a focus on diagnostic accuracy and image quality. Pictorial com- parisons of the various techniques will be presented. We conclude by CLINICAL FINDINGS/PROCEDURE DETAILS: We will compare and con- highlighting future applications of QISS and how QISS will affect inter- trast the QISS MRA technique and how acquisition differs from other ventional procedure planning. non-enhanced MRA techniques. Typical QISS MRA imaging in PAD and diabetes comparing the image appearance with other non-con- CONCLUSIONS: QISS MRA is a novel ECG-gated inflow-based NEMRA trast and contrast-enhanced exams will be presented. We will review technique that has demonstrated excellent image quality and diagnos- and present the recent literature regarding QISS PAD findings and tic accuracy for patients that have contraindications to contrast use. compare these results with other methods including flow sensitive dephasing and prepared steady state free precession. Finally we will present example cases where QISS was successfully used in clinical Abstract No. 674 care as well as address artifacts and limitations of QISS. Utility of quiescent interval single-shot noncontrast CONCLUSIONS: QISS MRA is an effective non-contrast method for magnetic resonance in inferior vena cava evaluating peripheral artery disease and may provide significant bene- interventions: pictorial review fits with reduced imaging time, robust quality, and accurate evaluation K Zurcher1, A Wallace1, D Fleck1, P Hoang1, M Knuttinen1, S of stenosis in complex settings. Alzubaidi1, S Naidu1, R Oklu1 1Mayo Clinic, Phoenix, AZ Abstract No. 673 LEARNING OBJECTIVES: -Develop a basic understanding of quiescent Quiescent-interval single-shot magnetic resonance interval single-shot (QISS) imaging -Examine current trends in use of angiography: a pictorial review QISS in interventional radiology. -Provide a pictorial review of QISS magnetic resonance venography (MRV) to assess the IVC -Describe 1 1 1 1 1 A Saini , A Wallace , H Albadawi , S Naidu , S Alzubaidi , M future potential uses of QISS MRV in interventional radiology (IR). Knuttinen1, A Panda1, R Oklu1 BACKGROUND: Non-contrast QISS MR angiography (MRA) has gained 1Mayo Clinic, Phoenix, AZ notice in the last several years for its potential in assessing peripheral LEARNING OBJECTIVES: 1. Outline existing non-enhanced MRA arterial disease. Benefits include providing an alternative imaging (NEMRA) techniques and their advantages/disadvantages in periph- modality for patients who cannot tolerate contrast agents (i.e., renal eral arterial disease (PAD) imaging. 2. Discuss the Quiescent-Inter- insufficiency) and eliminating the potential need for radiation in the val Single-Shot (QISS) sequence, its diagnostic accuracy, and image case of CTA. While QISS has initially been utilized primarily for arterial quality compared to CTA, contrast-enhanced MRA (CEMRA), DSA, disease, these benefits also apply to imaging of the venous system in and other NEMRA sequences in PAD. 3. Summarize the future appli- appropriate candidates. cations of QISS MRA in pulmonary, coronary, and intracranial arterial CLINICAL FINDINGS/PROCEDURE DETAILS: The use of QISS MRV in imaging. evaluation of the venous system is not well described. We present a BACKGROUND: In PAD, various imaging techniques including DSA, pictorial review including a case of QISS MRV utilized in pre-opera- CTA, and CEMRA exist to determine location and extent of disease, tive evaluation of an IVC-involving tumor in a patient who could not while helping to plan and guide interventions. Drawbacks to these receive iodinated contrast agents. Imaging of the IVC was technically techniques include radiation exposure, imaging artifacts, and impor- successful with resulting high quality diagnostic images and relatively tantly, the use of nephrotoxic contrast which is contraindicated in short acquisition time. This exhibit will also summarize the basic tech- patients who have pre-existing renal disease. Various NEMRA tech- nique and physics behind QISS, and review current literature on its use niques including time of flight (TOF), phase contrast, 3D FSE, and in arterial imaging. Additionally it will discuss potential further utility bSSFP exist to overcome these limitations. These existing NEMRA of QISS MRV in venous mapping, for example: pre-procedural assess- techniques are subject to signal loss, motion artifacts, and long scan ment of the IVC, determining DVT clot burden in central veins, or in times. QISS MRA is a novel ECG-gated inflow-based NEMRA tech- the lower extremity in cases in which ultrasound imaging is limited or nique that exhibits excellent diagnostic performance and image qual- not feasible. The benefits and accessibility of non-contrast imaging will ity, reduced artifacts, and short scan times versus existing NEMRA also be discussed. techniques and reference standards. With applications in peripheral, CONCLUSIONS: Successful imaging of the IVC in this case suggests that coronary, pulmonary, and intracranial arterial imaging, QISS MRA QISS MRV can be used in other scenarios in which accurate venous allows for fast, high quality diagnostic images in patients who have assessment is necessary in patients who cannot receive contrast contraindications to iodinated or gadolinium-based contrast. agents. Further research is needed to assess if there is potential utility CLINICAL FINDINGS/PROCEDURE DETAILS: We will present a pictorial of QISS MRV in the realm of IR. Potential uses include pre-procedural review of the NEMRA techniques used in PAD imaging. We will then imaging of central veins for various venous procedures. 22 | Traditional Educational Posters SIR 2019 Annual Scientific Meeting

Abstract No. 675 based on histotripsy. Collagenous tissues (bowel, bile ducts, blood vessels, and urothelium) are more resistant to damage by histotripsy Vasa vasorum development following endovascular than tumors and visceral organs. Because of this, RAST may be safer aneurysm repair: what the interventional radiologist to use in difficult locations than thermal ablation modalities such as needs to know RF, MW, and cryoablation. This exhibit will describe hepatic and renal H Torikai1, M Inoue1, M Hase1, N Ito1, S Nakatsuka1, M Jinzaki1 ablations performed safely in a normal porcine model in difficult ana- tomical locations. 1Department of Diagnostic Radiology, Keio University School of Medicine, Tokyo, Japan BACKGROUND: RAST is a high amplitude and low-duty cycle focused ultrasound method which destroys tissue at the cellular level with high LEARNING OBJECTIVES: To learn imaging findings and clinical signifi- precision. It is non-thermal and displays inherent sparing of collage- cance of hypertrophied vasa vasorum following endovascular aneu- nous structures with higher thresholds for cavitation, giving RAST a rysm repair (EVAR). “tissue-selective” property. In our lab, RAST has been used for renal

BACKGROUND: Vasa vasorum are known as the vessels associated with and hepatic ablation in 77 pigs, with many treatments performed arterial microcirculation. In recent studies, relationship between devel- safely within 1 cm of critical vulnerable structures. opment of vasa vasorum and both aneurysmal shrinkage and atypical CLINICAL FINDINGS/PROCEDURE DETAILS: Hepatic RAST ablation was type II endoleak after EVAR has been suggested. In this presenta- successful within 0.9 cm of the diaphragm (n=12). Procedures were tion, we review anatomy, imaging findings and clinical significance of performed during free breathing, with no major unintended injuries hypertrophied vasa vasorum following EVAR. noted. A 1.5 cm minor injury to the diaphragm was noted, though the

CLINICAL FINDINGS/PROCEDURE DETAILS: 1. Anatomy and Imaging collagenous architecture was maintained (n=1). In 11 pigs, RAST treat- findings Vasa vasorum of the aorta arise from the proximal area of ments were performed within 1 cm of the gallbladder. Gross pathology large arterial branches and circulate in the aortic wall. The outer third demonstrated minor injury to the gallbladder wall, but intact mucosa of the aortic wall derives its nutrition from the network of vasa vaso- (n=1). Findings also included intact bile ducts traversing ablation zones rum (1). Developed vasa vasorum following EVAR make a lot of anas- and large intact vessels at the periphery of ablations. Intentional tomoses around the surplus of the aortic wall. Due to hypertrophied targeting of the kidney in both the lower pole and centrally (n=15) vasa vasorum, aneurysmal wall is enhanced in the delayed phase of demonstrated sparing of the collecting system. At histopathology and computed tomography angiography (CTA). A network of hypertro- imaging, there were minor disruptions of the urothelium with no urine phied vasa vasorum can be demonstrated around the aneurysmal wall leaks. Renal ablation was also performed safely adjacent to bowel on digital subtraction angiography (DSA) and catheter-directed CTA. loops. On DSA from one aortic branch, some other aortic branches can be CONCLUSIONS: RAST shows promise for ablation adjacent to the dia- visualized through hypertrophied vasa vasorum (2,3). 2. Clinical sig- phragm, gallbladder, and bowel. Major vessels, bile ducts, and the cen- nificance A previous report has been suggested that aneurysm wall tral renal collecting system appear resistant to damage by histotripsy. enhancement due to hypertrophied vasa vasorum may be related to These findings could extend the indications for ablation and increase aneurysm shrinkage following EVAR (2). On the other hand, developed the safety of procedures if confirmed in humans. vasa vasorum could have been related to atypical type II endoleak and aneurysmal sac enlargement during long-term follow-up period after EVAR (3). Abstract No. 677

CONCLUSIONS: We learned anatomy and imaging findings of devel- Locoregional therapy, immunotherapy, and the abscopal oped vasa vasorum following EVAR. Interventional radiologists may effect: advances in the treatment of gastrointestinal need to consider hypertrophied vasa vasorum as a factor associated cancers with size change of the aneurysmal sac. A Saini1, A Wallace1, A Khurana1, M Kuo1, S Alzubaidi1, M Knuttinen1, S Naidu1, R Oklu1 Abstract No. 676 1Mayo Clinic, Phoenix, AZ

Ablation in tough spots: how robotically assisted sonic LEARNING OBJECTIVES: 1. Review various locoregional therapies in therapy (RAST) might help you interventional oncology and their efficacy in generating an immune E Knott1, K Longo1, J Swietlik1, Z Xu2, A Smolock3, F Lee4, T response against GI cancers. 2.Discuss the results and outcomes of Ziemlewicz1 studies examining combinations of locoregional therapies and immu- notherapies for GI cancers. 3.Discuss how the role of interventional 1University of Wisconsin, Madison, WI, 2University of Michigan, radiologists will evolve in the treatment of GI cancers with respect to Ann Arbor, MI, 3Thomas Jefferson University, Philadelphia, PA, new locoregional and systemic therapies. 4University of Wisconsin, Madison, WI

BACKGROUND: Locoregional therapies including RFA, microwave, LEARNING OBJECTIVES: Robotically assisted sonic therapy (RAST) is cryoablation, and irreversible electroporation are used in the treat- a non-invasive, non-thermal, and tissue-selective ablation modality ment for various malignancies. By releasing tumor associated antigens, SIR 2019 Annual Scientific Meeting Traditional Educational Posters | 23

these locoregional therapies have been shown to result in anti-cancer and ability to be loaded with various materials (drugs, antibiodies). immune responses and the abscopal effect. In recent years, advances We will select a few key studies that have elucidated the synergistic in immunotherapies including immune checkpoint inhibitors, adoptive effect between NPs and locoregional therapies and summarize their cell transfer, and vaccine-based therapies have demonstrated efficacy outcomes. Finally, we will discuss the role NPs will play in the future of for select patients across multiple cancer types. Several pre-clinical locoregional interventional oncology treatments. and clinical studies have examined the outcomes of combined locore- CONCLUSIONS: The use of nanoparticles to enhance the therapeutic gional and immunotherapy with promising results. efficacy of locoregional cancer treatments is an area of active research. CLINICAL FINDINGS/PROCEDURE DETAILS: We will review the various Interventional radiologists, with their armamentarium of locoregional locoregional therapies used for GI cancers in interventional oncology therapies, will play key roles in the research, adoption, and eventual and their efficacy in generating an immune response and an abscopal delivery of these nanoparticles to enhance canc effect. We will highlight seminal studies that investigate the combina- tion of locoregional therapies with various immunotherapies includ- ing anti-CTLA4, anti-PD-1, NK cell, and DC vaccine therapies, with a Abstract No. 679 focus on their safety, efficacy, and outcomes. Finally, we will discuss Percutaneous thermal ablation of pulmonary the evolving role interventional radiologists play in the treatment of GI malignancies cancers with respect to locoregional and systemic therapies. M Hoyer1, K Hong2 CONCLUSIONS: Interventional radiologists will continue to play a 1 central role in the treatment of various GI malignancies. Knowledge Johns Hopkins University School of Medicine, Baltimore, MD, 2 of advances in cancer immunotherapies and their synergy with new Johns Hopkins Hospital, Woodstock, MD locoregional therapies is essential. LEARNING OBJECTIVES: To provide an update on the various modalities of thermal ablation in the treatment of pulmonary malignancies, their Abstract No. 678 procedural techniques and complications, and patient follow-up. BACKGROUND: Percutaneous thermal ablation is the use of radiofre- Nanoparticles in interventional oncology: increasing quency (RF), microwave (MV), and cryoablation (CA) modalities for locoregional therapy efficacy the treatment of tumors. These modalities are becoming increasingly A Saini1, Y Pershad1, H Albadawi1, D Fleck1, S Naidu1, S Alzubaidi1, accepted for treatment of stage 1 and 2 non-small cell lung carcinoma M Knuttinen1, R Oklu1 (NSCLC), as well as select patients with stage 3a and 3b NSCLC or met- astatic disease to the lungs. In all cases, percutaneous thermal abla- 1Mayo Clinic, Phoenix, AZ tion is a reasonable alternative for surgically inoperable patients, or for LEARNING OBJECTIVES: 1. Review the compositions, various pay- those with residual or recurrent disease. As modalities become more loads, and delivery of nanoparticles (NPs) to tumors. 2.Discuss syn- numerous and complex, and as more inoperable tumors are referred ergy between NPs and various interventional locoregional therapies for ablation, the proper selection of patients and their optimal ablation 3.Describe how NPs will affect the future of interventional oncology procedure becomes more challenging. Our aim is to provide clarity to the field of lung tumor ablation and highlight the advantages and dis- BACKGROUND: Locoregional therapies in interventional oncology advantages of each treatment modality. including RFA, cryoablation and TACE/TARE have demonstrated effi- cacy for various tumor types. These modalities, however, have their CLINICAL FINDINGS/PROCEDURE DETAILS: RF is the most developed limitations including, but not limited to, tumor size, proximity to crit- and widely used ablation technique, creates reliable ablation zones, and ical structures, and collateral healthy tissue damage. NPs made from is synergistic with radiotherapy in the treatment of NSCLC. However, RF metals, lipids, and polymers offer solutions to the many drawbacks of energy may cause burns and interfere with implantable cardiac devices locoregional therapies. NPs take advantage of tumor vascularity and (ICDs). In contrast, MW ablation does not require a current to pass permeability which allow for precise delivery and distribution of NPs in through the body, decreasing the risk of burns and lowering post-pro- tumors. NPs can be loaded with drugs or antibodies to deliver targeted cedural pain. MW generators also achieve ablation temperatures more treatments. By allowing for increased and more uniform heat disper- quickly and with more applicators, allowing shorter treatment times and sion in thermal ablative therapies, NPs can enhance treatment efficacy. larger ablation volumes. However, this technique is more expensive, cre- In cryoablation, NPs can be used to selectively deliver immune-stimu- ates unpredictable ablation patterns, and interferes with ICDs. Finally, lating agents such as TNF-α, thereby avoiding systemic toxicity while CA does not interfere with ICDs, spares collagenous structures, and is also enhancing the native immune response to ablation and the absco- less painful. However, CA requires a cumbersome setup and yields a pal effect. In TARE, NPs can be loaded with reactive oxygen species poorly visualized ablation zone on post-procedural imaging. producing agents to enhance radiosensitivity. Finally, because NPs CONCLUSIONS: For most patients, RF ablation will be suitable with reli- can be visualized with diagnostic imaging, they can simultaneously be able results. For those with larger tumors, the increased temperature used to more precisely monitor treatment response. and volume of MW ablation may be more appropriate. In patients with CLINICAL FINDINGS/PROCEDURE DETAILS: We will provide a brief picto- ICDs or tumors in close proximity to vulnerable structures, CA is the rial overview of various NPs. Then, we will discuss their delivery, utility, treatment of choice. 24 | Traditional Educational Posters SIR 2019 Annual Scientific Meeting

Abstract No. 680 A comprehensive review with pictorials on current liquid biopsy tech- nology (rapid sequencing techniques), advantages, limitations and Step-by-step guide to liver tumor ablation assessment potential future applications will be presented. The five distinct test with open-source advanced imaging software kits with government approval are also reviewed.

1 2 3 4 5 T Nguyen , J McDevitt , S Rodriguez , S Kalva , P Sutphin BACKGROUND: Blood based biomarkers (liquid biopsy) are a rapidly 1The University of Texas Southwestern Medical Center, Dallas, TX, evolving technique utilizing laboratory analysis of circulating tumor 2UT Southwestern Medical Center, Baltimore, MD, 3University of cells (CTC), DNA and micro RNA (miRNA) found in simple blood Texas Southwestern Medical School Program, Dallas, TX, 4University draw. Considerable potential exists in initial cancer diagnosis as well of Texas Southwestern Medical Center, Dallas, TX, 5UT Southwestern as obtaining prognostic and theranostic information. Should the tech- Medical Center, Dallas, TX nique someday match information obtained with traditional tissue sampling its ability to supplant standard biopsy from a technical per- LEARNING OBJECTIVES: To provide a step-by-step guide to liver tumor spective becomes obvious. ablation assessment with registration, segmentation and radiographic ablation margin calculation with the open-source image analysis soft- CLINICAL FINDINGS/PROCEDURE DETAILS: Currently three main bio- ware 3D Slicer. markers can be analyzed through liquid biopsy. These include CTC, cir- culating tumor DNA (ct-DNA) and exosomes containing miRNA. CTC BACKGROUND: Thermal ablation including microwave ablation, radiof- theoretically represent a clone of the originating malignancy within the requency ablation, and cryoablation is used with both curative and blood pool and may offer a better sampling of disease heterogene- palliative intent for patients with primary and secondary liver malig- ity. ct-DNA as well as microRNA help solve sensitivity and specificity nancies. Several studies have demonstrated that the radiographic issues seen isolating CTC. Despite recent advances implementation tumor ablation margin is a key predictor of local tumor progression into clinical practice is difficult for several reasons. A major disadvan- and ablation failure. Intraprocedural characterization of the tumor tage is that circulating levels of the aforementioned biomarkers may ablation margin offers the advantage of identifying and subsequently compromise accuracy and reliability of the tests. Infrastructural chal- treating undertreated areas of the tumor. lenges also exist currently making costs and turnaround times of the CLINICAL FINDINGS/PROCEDURE DETAILS: In this educational exhibit, tests impractical. a step-by-step guide is provided for the assessment of tumor ablation CONCLUSIONS: Liquid biopsy is an evolving alternative to traditional margins with 3D Slicer. 3D Slicer is an open-source software package tissue sampling allowing cancer patients a potentially lower cost, publicly available at http://www.slicer.org. Diagnostic images demon- relatively painless, minimally invasive option to diagnose, stage and strating the target liver tumor to be ablated are compared with con- treat their disease. It has the potential not only to affect the role of the trast-enhanced images obtained immediately post ablation. DICOM interventional radiologist in cancer management in terms of diagno- images are loaded into 3D Slicer and image registration is performed sis by tissue sampling but also to help guide decision-making for liver using rigid, followed by non-rigid protocols to maximize alignment. directed therapies as more tumors are studied. After registration, the pre-ablation tumor and post-ablation zone are segmented from the pre- and post-ablation studies, respectively. The resulting pre- and post-ablation segments are then converted Abstract No. 682 to models for margin calculation. Subsequently, the model-to-model module is used to determine the distance or margin between the pre- Chemoembolization and radioembolization through the and post-ablation models. Finally, the distance distribution data is right inferior phrenic artery extracted and plotted as a histogram using a Python script. H Kim1, J Chung2 CONCLUSIONS: Tumor ablation margin is an important predictor of 1Seoul National University Hospital, Seoul-City, Seoul, 2Seoul ablation failure and local tumor progression. This exhibit provides a National University Hospital, Seoul, Republic of Korea step-by-step guide to assess liver tumor ablation margins with the open-source image analysis software 3D Slicer. LEARNING OBJECTIVES: The purpose of this exhibit is: (1) To review the anatomy of the inferior phrenic artery by using C-arm CT. (2) To review their suggestive findings on CT. (3) To learn how to trace tumor feeder Abstract No. 681 and origin of the inferior phrenic artery on MDCT. (4) To learn how to do safe chemoembolization and radioembolization through the infe- Liquid biopsy: current principles for the interventional rior phrenic artery. radiologist BACKGROUND: The right inferior phrenic artery is the most common 1 1 1 2 3 3 S Mahon , D Aggarwal , T Burr , T Ozga , C Molvar , P Amin extrahepatic collateral artery supplying hepatocellular carcinoma. 1Loyola University Medical Center, Maywood, IL, 2N/A, Riverside, IL, Chemoembolization and radioembolization through the inferior phrenic 3Loyola University Medical Center, Chicago, IL artery should be done to achieve complete response of the tumor.

LEARNING OBJECTIVES: As precision medicine evolves, liquid biopsy CLINICAL FINDINGS/PROCEDURE DETAILS: 1) Vascular anatomy of infe- serves as an alternative to traditional tissue sampling in cancer therapy. rior phrenic artery with emphasis on tumor blush, pulmonary shunt, SIR 2019 Annual Scientific Meeting Traditional Educational Posters | 25

and adrenal gland. 2) Right inferior phrenic artery on MDCT and C-arm control with ablation and intra-arterial therapies, and palliative thera- CT: suggestive findings and tracing tumor feeders 3) Superselection pies with fluid drainages, pain control, and gastrostomy. of tumor feeders : how far a microcatheter should be advanced. 4) Special considerations: protection of normal branch, bland emboliza- tion, and Shepherd’s hook technique. 5) Radioembolization through Abstract No. 684 the inferior phrenic artery: what we should be aware of. Interventional localization of oncology lesions for CONCLUSIONS: With thorough knowledge of the inferior phrenic minimally invasive surgical resection artery, chemoembolization and radioembolization through the infe- A Jon1, A Kubiak2, P Kisza3 rior phrenic artery is safe and effective in patients with hepatocellular 1 2 carcinoma Rutgers-New Jersey Medical School, Newark, NJ, Rutgers NJMS, Newark, NJ, 3Rutgers, The State University of New Jersey/New Jersey Medical School, South Orange, NJ Abstract No. 683 LEARNING OBJECTIVES: This exhibit will review and illustrate possible Gastrointestinal stromal tumor: role of interventional indications for interventional radiology (IR) localization of lesions prior radiology in the treatment and management of localized to surgical procedures. Optimal procedure techniques employed in the and metastatic disease IR suite for precise localization of lesions will be emphasized. Emerging areas of procedure application will be reviewed. A Wallace1, A Saini1, D Fleck1, P Hoang2, K Zurcher2, J Kriegshauser3 BACKGROUND: Needle localization of breast masses under imaging guidance for diagnostic and therapeutic purposes has been long 1Mayo Clinic, Phoenix, AZ, 2Mayo Clinic Arizona, Phoenix, AZ, 3Mayo established in . Interventional localization of lesions in Clinic Scottsdale, Phoenix, AZ other parts of the body can facilitate excisional biopsy and definitive LEARNING OBJECTIVES: 1) Describe the role of surgical and medical treatment in adherence with minimally invasive therapy principles. therapies including tyrosine kinase inhibitors in the treatment of gas- CLINICAL FINDINGS/PROCEDURE DETAILS: Image-guided localization trointestinal stromal tumors (GIST). 2) Describe the role of interven- of breast and lung lesions prior to surgery has been extensively utilized tional radiology (IR) in the treatment and management of localized in clinical practice in last 30 years. We will demonstrate our institution’s and metastatic GIST. 3) Review the various techniques used in the IR experience with IR localization of oncological abdominal, thoracic and treatment and management of GIST with examples. musculoskeletal lesions prior to diagnostic and therapeutic surgery, BACKGROUND: GISTs are the most common mesenchymal tumor of the especially in clinically and diagnostically challenging cases. Besides gastrointestinal (GI) tract, most often presenting in the stomach, with presentation of the cases, we will review current literature regarding excellent prognosis if completely resected. On imaging they present as pre-surgical lesion localization. well circumscribed hyperenhancing submucosal masses often extend- CONCLUSIONS: IR assisted localization of lesions prior to surgical ing exophytically from the GI tract. GISTs are highly vascular tumors diagnosis and therapy can be used in multiple abdominal, thoracic, that can bleed extensively and nearly always express a growth factor musculoskeletal and other pathologies. These techniques contribute receptor with tyrosine kinase activity. While many GISTs can be treated effectively to pre-operative planning especially in challenging cases. surgically or with tyrosine kinase inhibitors when in the bowel, others This approach allows for increased accuracy and decreased procedure with metastatic lesions to the liver or elsewhere provide various oppor- related morbidity. A variety of image guidance modalities and localiza- tunities for therapies offered by IR. tion techniques are available for application. CLINICAL FINDINGS/PROCEDURE DETAILS: We will review the origins of GISTs as well as the conventional approach to management with these tumors including surgical excision and tyrosine kinase inhibitors. Abstract No. 685 IR’s role in improving treatment of the primary tumor and metastases Techniques and tips for ultrasound-guided administration including pre-surgical embolization for bleeding control, portal vein of hydrogel (SpaceOAR) to reduce rectal toxicity during embolization for treatment of liver metastasis, intraoperative and per- radiation therapy of prostate cancer cutaneous ablation, and intra-arterial therapies including bland embo- lization, transarterial chemoembolization, and Y90 radioembolization C Stuart1, T Morgan2, B Hershatter2, Z Bercu1, J Martin3, R will be reviewed. IR’s role in palliative therapies including paracentesis/ Ermentrout1 thoracentesis, percutaneous gastrostomy and transesophageal gas- 1Emory University Department of Interventional Radiology, Atlanta, trostomy, as well as nerve blockade for pain control will be discussed. GA, 2Emory University Department of Radiation Oncology, Atlanta, Examples of these interventions will be presented. GA, 3Duke University Department of Interventional Radiology, Durham, NC CONCLUSIONS: GISTs are common in the GI tract with typical imaging features and often effective surgical and medical therapies. IR offers LEARNING OBJECTIVES: 1. Introduce perirectal spacing using min- a wide variety of therapy options across different phases of manage- imally invasive administration of SpaceOAR hydrogel to reduce rec- ment including pre-operative embolization for bleeding control, tumor tal dose during prostate cancer radiation therapy. 2. Describe patient 26 | Traditional Educational Posters SIR 2019 Annual Scientific Meeting

selection criteria to maximize procedure efficacy. 3. Review sono- endovascular techniques, and external beam therapies. HDBRT is an graphic anatomy, procedural technique, and tips relevant to Spa- emerging minimally invasive therapy which has been demonstrated ceOAR administration. to have specific advantages for treating HCC tumors with challeng- ing characteristics such as large tumor size, close proximity to large BACKGROUND: External-beam radiation therapy (RT) or brachyther- vessels and sensitive structures, large shunting to other organs, and apy (BT) are commonly utilized in the treatment of localized prostate inability to access all of a tumor’s feeding vessels. cancer. While intensity modulated radiation therapy and BT tech- niques have allowed for more conformal treatments, rectal toxic- CLINICAL FINDINGS/PROCEDURE DETAILS: This educational exhibit will ity remains a concern. SpaceOAR has shown a significant benefit in review the etiology, epidemiology, and pathophysiology of HCC; clinical reducing rectal dose, toxicity, and decline in bowel quality of life after indications to suggest HDRBT when other therapies are contraindicated; RT. Although efficacious, SpaceOAR administration has not previously and technical considerations based on HCC tumor characteristics. It will been described in the interventional radiology (IR) literature. also review current literature and provide case examples from Charite Hospital, Berlin, to demonstrate optimal use of HDBRT. CLINICAL FINDINGS/PROCEDURE DETAILS: Patients are placed in dor- sal lithotomy position with sterile perineal preparation after an anti- CONCLUSIONS: HDRBT is an emerging therapy for the treatment of biotic, benzodiazepine, and fleets enema are given. A transrectal HCC. As its use becomes more wide-spread, it will be increasingly vital ultrasound probe is placed in the rectum. Small gauge needle delivery for interventional radiologists to understand this therapy, with a spe- of 1% lidocaine in the subcutaneous perineum is performed. The nee- cial focus on appropriate patient selection and optimal technique. dle is advanced 1-2 cm anterior to the probe for delivery of 5-10cc of 1% lidocaine at the prostatic capsule. Prostatic markers can be placed as needed. The 18G, 15cm, SpaceOar needle is advanced at a 30-40° Abstract No. 687 incident angle through the perineal rectrourethralis muscle into the Use of 4D/angio-CT for Y90/radioembolization treatment perirectal fat. The fat plane between the prostate and rectum can be planning and administration expanded with a small amount of saline infusion. Care should be taken not to inject the rectal wall. The two syringe SpaceOar delivery system D Jilani1, T Tullius2, S Zangan2 is assembled with the addition 0.5 mL water-soluble contrast added to 1University of Chicago Hospitals, Chicago, IL, 2University of Chicago, the accelerator syringe. The 10mL SpaceOar system is deployed over Chicago, IL 10 seconds. CT is performed to confirm location and obtain images for treatment planning. LEARNING OBJECTIVES: Explore the potential clinical benefits and future directions of utilizing 4D/Angio-CT during transarterial radioembolization. CONCLUSIONS: Perirectal hydrogel (SpaceOAR) administration is a minimally invasive, well tolerated, image-guided rectal preserving BACKGROUND: Increasing technological advances have altered the procedure performed prior to radiation therapy for prostate cancer. landscape of treatment planning and administration of cancer therapy, Although not previously described in the IR literature, interventional- even more apparent in the field of interventional oncology. The advent ists are well positioned to offer this procedure to patients in coordina- of 4D/angio-computed tomography (Infinix-I 4DCT, Canon) has the tion with radiation oncology colleagues. potential to have a profound impact on tumor localization during treat- ment planning administration by allowing for real time tumor location. As of now little to no research exists in regards to utilization of 4D CT Abstract No. 686 and Y90/radioembolization.

The emerging role of high-dose-rate brachytherapy in the CLINICAL FINDINGS/PROCEDURE DETAILS: During both the treatment management of hepatocellular carcinoma planning and administration stages the use of 4D/angio-CT (Infinix-I 4DCT, Canon) can better delineate real time anatomic and functional 1 2 J Stringam , F Collettini information. After cannulation of the feeding hepatic artery implemen- 1MD Anderson Cancer Center, University of Houston, Houston, TX, tation of 4D computed tomography can help ensure proper localiza- 2Charité Universitätsmedizin Berlin, Berlin, Germany tion as well as provide detailed vascular anatomical information on both pre and post-contrast images. Images acquired from 4D CT can LEARNING OBJECTIVES: Review etiology and epidemiology of hepa- then be superimposed on fluoroscopic images to provide a 3D image tocellular carcinoma (HCC). Review the literature regarding current display “roadmap.” The ability to quickly shift between CT and angio- methods of treatment including medical management, surgical man- graphic imaging allows for the systems to be used in tandem. The use agement, percutaneous interventions, endovascular interventions, of 4D/Angio-CT enhances the ability to delineate hepatic and tumor and external beam radiation therapies. Review current literature anatomy and pick up on subtle variations of vascular anatomy that regarding high-dose-rate brachytherapy (HDRBT) for the treatment increase the risk of non-target embolization. Further, tandem use can of HCC. Describe and discuss optimal HDRBT technique with regards provide near instantaneous feedback to confirm post-procedural out- to tumor characteristics. comes. The use of 4D/Angio-CT allows for true CT imaging prior to, BACKGROUND: HCC is currently treated with multiple approaches during, and after Y90 radioembolization. including medical and surgical management, percutaneous techniques, SIR 2019 Annual Scientific Meeting Traditional Educational Posters | 27

CONCLUSIONS: Technological advances, specifically the advent of 4D/ Abstract No. 689 angio-CT (Infinix-I 4DCT, Canon), allows for improved anatomical visu- alization and localization during treatment planning and administra- CODE STROKE! An overview of interventional tion of Y90 radioembolization. Its implementation has the capability to radiologists’ increasingly dynamic role improve workflow for the interventionalist and quite possibly reduce A Moiyadi1, K Kansagra2, J Kang3, N Sangha1, L Feng1, C Lam4, G costs and procedural time. Future directives should include analyzing Vatakencherry5 patient safety and efficacy as well as radiation dose when compared 1Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, with conventional Y90. 2Kaiser Permanente Los Angeles Medical Center, Glendale, CA, 3Kaiser Permanente Los Angeles Medical Center, Fullerton, CA, Abstract No. 688 4Kaiser Permanente Los Angeles Medical Center, Westminster, CA, 5Kaiser Los Angeles medical center, Los Angeles, CA Acute stroke management in the new reality: what it LEARNING OBJECTIVES: 1) Review the major landmark trials regard- means for an interventional radiologist ing TPA administration and thrombectomy in the setting of acute R Ahuja1, M Ferra1, A Syal1, B Natarajan1, T Matalon1, P Brady1 ischemic stroke. 2) Understand how these trials affect current 1Einstein Medical Center, Philadelphia, PA acute stroke management and hospital protocols 3) Update on the current tools and equipment available to neurointerventionalists LEARNING OBJECTIVES: 1. Break down and summarize the information when performing thrombectomy. 4) Overview of standard treat- to understand the current trends in practice of acute stroke man- ment algorithms for management of complications status post agement post DAWN and DEFUSE 3 trails for interventional radiolo- thrombectomy. gists who provide acute stroke care. 2. Understanding stroke severity BACKGROUND: Major randomized multi-center clinical trials have illus- index and National Institute of Health Stroke Scale (NIHSS) with trated the benefit of catheter-directed thrombectomy in the setting associated imaging characteristics on different modalities including of acute stroke. It is crucial for interventional radiology (IR) physicians CT/MR Perfusion. to understand and incorporate the results of these trials to practice BACKGROUND: Before DAWN and DEFUSE 3 trials, there was evidence proper stroke management. Furthermore, comprehensive knowledge suggesting that benefit of thrombectomy rapidly decays over time of the management during and after thrombectomy is important to and may no longer exist beyond 7.3 hours from stroke onset. We are in ensure patient safety throughout treatment. a brand-new era of acute stroke care led by 3 significant advances: 1. CLINICAL FINDINGS/PROCEDURE DETAILS: The exhibit will summarize Expansion of time window for interventional treatment,2.New reperfu- the major findings from landmark trials regarding the administration of sion therapies and devices,3. Better understanding of the role of basic tPA (NINDS, ECASS, and WAKE-UP), thrombectomy at 0-6 hours (MR and advanced neuroimaging. The current reality of management of acute CLEAN, EXTEND IA, REVASCAT, ESCAP, SWIFT PRIME), and throm- ischemic stroke has recently dramatically changed with the publication of bectomy at 6-16/24 hours (DAWN, DEFUSE 3). A comprehensive flow DAWN & DEFUSE trials. There is evidence that patients presenting within chart will be provided to guide decision making and give interventional 6 to 24 hours who will do well after mechanical thrombectomy (MT) can radiologists a better understanding of proper stroke protocol based be identified by delineating the core and using a clinical penumbra. on the aforementioned trials. We will review the standard equipment CLINICAL FINDINGS/PROCEDURE DETAILS: Time appears to be less crit- (sheaths, catheters, and microsystems) used by neurointerventional- ical to the outcome of patients, who present with significant penumbra ists, as well as various techniques employed to aid with vessel can- and small core, when treated with MT with time limit now extended to nulation. Finally, a treatment algorithm will outline management of a 24 hours. The number of patients who meet the core/penumbra mis- post-thrombectomy patient and be illustrated through example case match gradually decreases with time (<15% by 24 hours). The window scenarios. for IV tPA has not changed (excluding contraindications). Collateral CONCLUSIONS: A firm understanding of the major trials regarding the vessels are the driving force behind the timing of presentation of the treatment of stroke is necessary to understand the role of IR in the stroke patients and corresponding severity of symptoms. The stroke acute setting and to aid in development of hospital code stroke pro- parameters and how they impact stroke care will be discussed in detail tocols. Keeping up to date on the latest tools and equipment avail- in this exhibit. able to interventionalists is also imperative. Finally, it is crucial for IR CONCLUSIONS: Endovascular thrombectomy and medical therapy for physicians to understand the management and complications status acute ischemic stroke in patients with large vessel occlusion, benefits post thrombectomy to ensure safety and provide the best long-term selected patients who present up to 16-24 hours after last seen well. outcomes. Patients have less morbidity at 90 days, when treated with MT and medical therapy, rather than standard care alone. MT performed in this now extended time window demonstrates similar rates of TICI (Thrombolysis in Cerebral Infarction) 2B-3 reperfusion to earlier time window studies. 28 | Traditional Educational Posters SIR 2019 Annual Scientific Meeting

Abstract No. 690 know the techniques for fragmenting gallstones with flexible endo- scopes using EHL To know the possible complications from percuta- Inadvertent bowel traversal: risk factors, diagnosis, and neous gallstone removal management of a potential complication of image-guided BACKGROUND: Percutaneous gallstone removal (cholecystolithotomy) drain placement is minimally invasive and, unlike other nonsurgical alternatives, can be M Weintraub1, C Kaufman1, K Quencer2 used to remove any type, size, and number of stones in patients with 1University of Utah, Salt Lake City, UT, 2N/A, New Haven, CT both acute and chronic cholecystitis. For the last 30 years, we have been performing percutaneous gallstone removal as an alternative to LEARNING OBJECTIVES: 1. Identify and diagnose inadvertent bowel surgical cholecystectomy in high-risk patients with symptomatic gall- transversal (IBT) after drain placement 2. Understand management of bladder disease. IBT with drain placement CLINICAL FINDINGS/PROCEDURE DETAILS: 1. Indications and con- BACKGROUND: Image-guided drain placement into intra-abdominal traindications for percutaneous gallstone removal. 2. Percutaneous fluid collections is a commonly performed procedure. One potential cholecystostomy: transhepatic vs transperitoneal, fundus vs body. 3. complication is IBT. We present 5 cases of IBT, discuss risk factors, Tract dilation: coaxial dilator vs nephrostomy balloon. 4. Percutaneous diagnosis, management and outcomes. gallstone removal technique according to type, size, and number of

CLINICAL FINDINGS/PROCEDURE DETAILS: Case 1: 21 y/o M s/p distal stones. 5. Techniques for fragmenting gallstones with flexible endo- pancreatectomy with 7 cm fluid-filled collection underwent US-guided scopes using EHL. 6. Presence of cystic duct stone or CBD stone. 7. drain placement. Malposition was suspected given high output, wors- Post-operative care, tract evaluation and tube removal. 8. Clinical out- ening pain, and white count. CT showed the drain within jejunum. The comes. 9. Complications. drain was removed after 7 weeks with uneventful recovery. Case 2: 41 CONCLUSIONS: We present percutaneous gallstone removal technique y/o M with necrotizing pancreatitis and a 9 cm air/fluid pancreatic head according to type, size, and number of stones, the techniques for frag- pseudocyst. One day after drain placement, the patient had massive menting gallstones with flexible endoscopes using EHL and the possi- upper GI bleed requiring angiogram. A pullback injection of the drain ble complications. showed duodenal traversal. The drain was downsized and removed 25 days later. Repeat endoscopy showed healing at the site of IBT. Case 3: 41 y/o M with ruptured appendicitis and 8 cm pelvic fluid collection under- Abstract No. 692 went US-guided drain placement. CT 6 days later for bowel obstruction showed the drain traversing terminal ileum. This was confirmed during Interventional techniques for colorectal-vaginal fistula ileocecectomy. Case 4: 54 y/o F s/p sleeve gastrectomy with a 3 cm management: pictorial review air/fluid collection between the duodenum and pancreatic head with A Saini1, Y Pershad1, M Kuo1, H Albadawi1, M Knuttinen1, S Naidu1, S US-guided drain placement. CT for high volume bilious output from the Alzubaidi1, R Oklu1 drain showed the drain in duodenum. An NJ tube was placed. The patient 1Mayo Clinic, Phoenix, AZ was discharged with plan for serial downsizing and subsequent removal.

Case 5: 54 y/o F with cholangiocarcinoma who underwent US-guided LEARNING OBJECTIVES: -Describe the etiology and imaging-based percutaneous cholecystostomy tube for cholecystitis. Feculent material diagnosis of colorectal-vaginal fistulas -Discuss various interven- was draining around the catheter. CT and pull-back fluoroscopy injec- tional techniques for fistula treatment including fistula plugs and tion confirmed IBT. A new site cholecystostomy tube was placed and the AMPLATZER device -Review the short and long-term outcomes with existing tube downsized and removed 3 months after placement. these techniques and compare their outcomes to those of surgical procedures. CONCLUSIONS: IBT can be a complication of image-guided drain place- ment. High output and lack of clinical improvement may lead to the BACKGROUND: Colorectal-vaginal fistulas can result in distressing diagnosis. IBT can be confirmed by CT, fluoroscopy and/or endoscopy. symptoms including passage of feces/flatus through the vagina, infec- Downsizing the drain and allowing time for tract formation is the rec- tions, and vaginitis. Their etiology can include obstetrical complica- ommended management. tions, malignancy, trauma, infection, radiation-effects, or post-surgical causes. Diagnosis can be achieved through barium enema, vaginog- raphy, CT, and MRI, among other modalities. Management is often Abstract No. 691 surgical and the technique depends on the fistula location. In recent years, numerous percutaneous interventional techniques including fis- Percutaneous gallstone removal: technical considerations tula plugs and AMPLATZER occluder device have been used with good and update outcomes in patients not amenable to surgery. B Glaenzer1, D Picus1, S Kim1 CLINICAL FINDINGS/PROCEDURE DETAILS: We will briefly review the 1 Washington University School of Medicine, St. Louis, MO symptoms, etiologies and diagnosis of colorectal-vaginal fistulas on

LEARNING OBJECTIVES: To know the percutaneous gallstone removal CT and MRI. Then, we will provide an overview of surgical approaches steps and technique according to type, size, and number of stones to by fistula location. Finally, we will review the literature on various SIR 2019 Annual Scientific Meeting Traditional Educational Posters | 29 interventional techniques used to treat these fistulas including plugs, Abstract No. 694 AMPLATZER, and other novel devices, with a focus on their short and long-term outcomes. We will also review the relevant associated pro- Techniques used to prevent complications and cedures. We conclude by describing the role interventional radiolo- perform challenging cases when placing percutaneous gists will play in the future of fistula treatment. gastrostomy tubes

1 1 CONCLUSIONS: There are many causes of colorectal-vaginal fistulas N Hewlett , O Abdul-Rahim and they can cause distressing symptoms. In recent years, various 1University of South Alabama, Mobile, AL interventional techniques have been described to treat these fistulas LEARNING OBJECTIVES: This poster will review different techniques with good outcomes. Further investigations into fistula management used to mitigate safety concerns and problem solve for technically will continue to broaden the role of the interventional radiologist. challenging percutaneous gastrostomy tube placement.

BACKGROUND: Optimizing nutritional support for healing in critically Abstract No. 693 ill patients and quality of life in chronically ill patients is best achieved through enteral feeding. Patients who will require long-term access Percutaneous transesophageal gastrostomy tube for enteral feeding require gastrostomy tube placement. These tubes placement: indications and technical approach were originally placed surgically, but percutaneous endoscopic place- J Martissa1, J Stewart2, J Martissa1 ment became the favored technique. Fluoroscopic guidance was first 1University of North Carolina Medical Center, Chapel Hill, NC, used in 1981 for placement and since that time many techniques have 2University of North Carolina Medical Center, Durham, NC been developed in attempts to minimize complications and perform technically difficult cases. LEARNING OBJECTIVES: Upon review of this exhibit the learner will 1) Understand the indications for percutaneous transesophageal CLINICAL FINDINGS/PROCEDURE DETAILS: Traditional percutaneous gastrostomy (PTEG) tube placement, 2) Understand the intraproce- radiological gastrostomy is performed by passing a nasogastric tube dural steps for technically successful placement, and 3) Understand and insufflating the stomach prior to fluoroscopically guided puncture. post-procedural care following placement. When this is not possible options include: nasogastric intubation with a guide wire and subsequent coaxial placement of the nasogastric tube, BACKGROUND: Percutaneous gastrostomy tube placement is a well-es- direct fluoroscopically guided puncture of a physiologic gastric air bub- tablished minimally invasive image-guided procedure used for nutri- ble or air bubble created with effervescent sodium bicarbonate. CT and tion or gastric venting. However, in some patients, direct gastric access ultrasound may also be utilized to guide direct stomach puncture. Gas- is either not desirable or not technically feasible. PTEG tube placement tropexy of the stomach with T-fasteners is controversial with proponents is commonly performed in Asia; however, it is not widely performed in for and against this technique citing many technical and safety advan- the United States and thus many healthcare providers are not familiar tages. The most common gastrostomy insertion techniques are place- with this procedure. ment through a peel away sheath via the Seldinger technique, coaxial

CLINICAL FINDINGS/PROCEDURE DETAILS: PTEG tube placement is placement over an angioplasty balloon, and a per-oral technique. Many appropriate for select patients. Percutaneous access to the stomach techniques have been utilized to minimize complications including using is not desirable in patients with peritoneal carcinomatosis, stomach ultrasound to localize the liver margin, barium administration to delin- wall involvement by cancer, or ascites. Traditional percutaneous gas- eate the colon. In technically challenging cases, transhepatic, infracolic trostomy tube placement can also be technically infeasible secondary and intercostal routes can all be utilized for safe placement. to anatomic limitations. PTEG tube placement avoids the requirement CONCLUSIONS: Multiple techniques to mitigate safety concerns and for direct access to the stomach, which can be problematic in these technical challenges have been developed for percutaneous gastros- patients. The procedure can be performed with moderate sedation tomy placement. This has become a viable option for primary place- under ultrasound and fluoroscopic guidance, using equipment avail- ment and placement of gastrostomy tubes when traditional routes are able in any well-stocked angiography suite. Percutaneous access to not feasible. the esophagus is gained by puncturing a balloon within the esoph- agus, with a wire advanced into the balloon and eventually into the stomach. The Seldinger technique is then utilized to place a pigtail Abstract No. 695 drainage catheter terminating in the stomach. Following the proce- dure, patients are able to eat, speak, and swallow normally. A suction Use of extracellular matrix for enterocutaneous fistula device is usually required to facilitate adequate gastric drainage for the closure, a novel approach: a single-institution experience indication of gastric venting following the procedure. J Marlow1, D Zuckerman2

CONCLUSIONS: Percutaneous transesophageal gastrostomy tube 1Mallinckrodt Institute of Radiology- Washington University of St. placement is an effective minimally invasive procedure for patients Louis, St. Louis, MO, 2Washington University, St. Louis, MO who are not candidates for traditional percutaneous gastrostomy tube LEARNING OBJECTIVES: Use of extracellular matrix slurry for tract placement. embolization to facilitate closure of chronic enterocutaneous fistulas. 30 | Traditional Educational Posters SIR 2019 Annual Scientific Meeting

BACKGROUND: Enterocutaneous fistulas (ECF) are a spectrum of CONCLUSIONS: The combined treatment of articular radiofrequency medically complex disorders that often require a multidisciplinary (42 ° C for 6 min) and articular grafting of mesenchymal cells previ- treatment plan including parenteral nutrition, wound care, and often ously taken from the subcutaneous adipose tissue and separated by a surgical management. ECFs also often carry significant morbidity and special MyStem mono-use system shows a clear clinical resolution of quality of life issues. MicroMatrix (ACell, Inc©) is a porcine-derived uri- the arthritic pain symptomatology allowing 100% of the population to nary bladder matrix which facilitates tissue regeneration (1,2). Applica- study the return to normal daily activities previously compromised in tion of this matrix is for draining and complex wounds (1). Studies have the clinical follow-up to 1 year from treatment. demonstrated the effectiveness of this matrix for ECF closure (2). We present 5 patients with 6 ECF who underwent fistula tract emboliza- tion using this matrix slurry at our institution. Abstract No. 697

CLINICAL FINDINGS/PROCEDURE DETAILS: 5 patients (4 men, 1 woman) Left stellate ganglion block: calming the cardiac electrical with ECF were treated at a single, tertiary academic medical center. storm Median age was 50 (24-64). The most common underlying diagnosis M Makary1, A Rajan1, J Dowell2, V Flanders3, B Martinez4 was Crohn’s disease with 3 patients having small bowel-cutaneous fis- 1 2 tulas. The average number of treatments per patient was 3.8 (1-6). The The Ohio State University Medical Center, Columbus, OH, The Ohio 3 dose of the urinary bladder matrix ranged from 500-1000mg mixed with State University, Powell, OH, Northwest Radiology, Indianapolis, IN, 4 3-20mL of contrast to form a slurry. Tract embolization was performed St. Vincent Health, Indianapolis, IN via an angiographic catheter positioned in the fistula during fluoroscopy. LEARNING OBJECTIVES: To review the technical details and applica-

CONCLUSIONS: Average follow-up was 333 days. All 5 patients toler- tions of the left stellate ganglion block (LSGB) procedure and high- ated the fistula tract embolization well with no immediate complica- light its promising role in the management of the cardiac electrical tions. Of the 6 ECF, 3 showed improvement including 2 with reduced storm. output and 1 with complete closure. Given the significant morbidity BACKGROUND: Cardiac electrical storm is defined by recurrent epi- of ECF and the complexity of management, fistula tract embolization sodes of ventricular tachycardia or ventricular fibrillation within a with extracellular matrix may be a useful non-operative approach in 24-hour window. The pathogenesis of electrical storm is a combina- the treatment of ECF. tion of the presence of structural heart disease alongside a triggering event like arrhythmia or electrolyte abnormality. While treatment for Abstract No. 696 this high-mortality condition typically centers around repetitions of ACLS and electrical defibrillation, sympathetic blockade with LSGB Mesenchymal stem cell injection for joint cartilage has shown promise as an effective adjunct therapy. LSGB has fur- regeneration: 1-year single-center experience ther demonstrated reduced electrical defibrillation requirements and post-procedure symptom recurrence. F Vecchietti1, F Fasoli2 CLINICAL FINDINGS/PROCEDURE DETAILS: This exhibit will include: 1. A 1Ospedale CTO–Roma, Italy, 2Department of Radiology and review of cardiac electrical storm and its current management paradigm, Interventional Radiology, S. Eugenio Hospital–Rome, Italy, Roma, AK 2. Relevant neck anatomy of the cervical sympathetic ganglia, 3. Indi-

LEARNING OBJECTIVES: The aim of this work is to illustrate the ther- cations and contraindications for performing LSGB, 4. Commonly used apeutic possibilities in the radiological interventional field offered by LSGB techniques and review of the literature, 5. Recommended peri-pro- the minimally invasive techniques derived from one year single-center cedural management, 6. Potential complications and adverse side effects, experience of the use of my stem system . and 7. Other current and future applications of the LSGB procedure.

BACKGROUND: The progressive aging of the world population leads to CONCLUSIONS: This exhibit will provide the viewer with a better under- an increase in osteo-degenerative diseases such as osteoarthritis; the standing of the cardiac electrical storm, optimal utility of LSGB and techniques of regeneration of articular cartilage assume, to date, a role current literature, procedural interventional techniques, peri-proce- of primary interest in medical practice. Stem cells including various stem dural patient management, and promising future applications of this cells and pluripotent stem cells are now used in tissue engineering. innovative intervention.

CLINICAL FINDINGS/PROCEDURE DETAILS: The study population con- sists of 100 patients, selected on the basis of clinical and radiological Abstract No. 698 positivity (MRI and confirmed RX) to multi-segment arthroplasty joint degenerative pathologies (shoulder, hip, knee). Each patient selected, Visual algorithm for use of sclerotherapy agents in the with written informed consent, underwent local anesthesia, combined treatment of venous malformations radiofrequency joint treatment (42 ° C for 6 min) and joint grafting under M Hoque1, A Isaacson1, C Burke1, J Stewart2 ultrasound guidance and fluoroscopic confirmation of mesenchymal 1 2 cells previously taken from the subcutaneous adipose tissue and sepa- University of North Carolina, Chapel Hill, NC, University of North rated through the appropriate MyStem single-use system. Carolina Medical Center, Durham, NC SIR 2019 Annual Scientific Meeting Traditional Educational Posters | 31

LEARNING OBJECTIVES: Upon review of this exhibit, the learner will 1) CLINICAL FINDINGS/PROCEDURE DETAILS: In July 2018, CMS published Understand factors relevant to the selection of appropriate sclerother- proposed revisions to reimbursement for 2019. Among them, CMS pro- apy agents for the treatment of venous malformations through review poses changes to RVU structure for outpatient E&M coding by con- of a visual algorithm, and 2) Understand adjunct techniques that can densing the RVUs for levels 2-5 into a single value. This will effectively be combined with sclerotherapy to increase effectiveness. average the RVUs for these levels in an attempt to simplify billing and streamline documentation. As a result, specialties which tend to bill BACKGROUND: Percutaneous sclerotherapy is a mainstay of treatment at lower encounter levels will see an average increase in RVU gener- of vascular malformations as part of a multidisciplinary approach to ation from outpatient visits and, conversely, specialties which bill at their management. A number of sclerotherapy agents have been higher levels will see a decrease in reimbursement. CMS has provided utilized and each have unique characteristics that may influence the estimates of specialty impacts under the proposed coding changes, choice of sclerosant for a particular lesion. Adjunct techniques such as with interventional radiology estimated at “minimal change to overall endovenous laser therapy or embolization may be used to increase the payment.” In order to confirm this estimate, we utilized outpatient E&M effectiveness of sclerotherapy. A visual algorithm based on available billing data available from CMS for 2017. The RVUs generated by IR for literature designed to aid in the selection of sclerotherapy agent and CPT codes 99201-99205 and 99211-99215 were analyzed, which show adjunct techniques is presented. generation of 135,444 RVUs billed to CMS. When scaled to match the CLINICAL FINDINGS/PROCEDURE DETAILS: Multiple agents are com- proposed RVU changes for 2019, this total increased 142,802 RVUs, monly used for the percutaneous treatment of venous malformations. representing a 5.2% increase. The characteristics of the lesion to be treated should be consid- CONCLUSIONS: The proposed changes to E&M CPT coding for 2019 ered when making the selection of sclerosant. For example, alcohol may result in potential gains of up to 5.2% in outpatient IR clinic is extremely effective but can cause serious complications, and so reimbursement. These changes—and their financial implications— lesions in close proximity to nerves and skin may be best treated with should help to further establish the financial viability of outpatient a different agent. Several adjunct techniques are commonly utilized in IR clinics. order to facilitate effective sclerotherapy. Endovenous laser ablation is often utilized when several components of a venous malformation Actual vs. Scaled RVUs Generated by Interventional Radiologists from communicate with a single draining vein. Embolization using devices Outpatient E&M CPT Codes (coils, plugs) or liquid agents (glue, Onyx) can be used in the setting of Actual Scaled 2017 RVUs using proposed brisk drainage to facilitate sclerotherapy. 2017 RVUs 2019 CPT code changes Level 1 visits 873 873 CONCLUSIONS: The choice of sclerotherapy agent for the treatment of a venous malformation is important for achieving clinical success and Level 2 visits 8699 20,282 avoiding complications. Characteristics of the lesion to be treated can Level 3 visits 49,781 63,824 help to guide selection of the sclerotherapy agent. Level 4 visits 60,932 48,884 Level 5 visits 15,159 8939 Abstract No. 699 Total RVUs 135,444 142,802

Financial implications of the proposed 2019 CPT code changes for outpatient Evaluation & Management Abstract No. 700 services: a perspective for interventional radiology How MIPPS will impact interventional radiology A Moore1, M Mulatre1, W Terrell1, N Reyes1, M Hyatt1, R Trojan1 S Rehman1, M Hallisey1 1INTEGRIS Baptist Medical Center, Oklahoma City, OK 1Hartford Hospital, Hartford, CT LEARNING OBJECTIVES: To review proposed changes to the 2019 LEARNING OBJECTIVES: Review current interventional radiology Current Procedural Terminology (CPT) codes for Evaluation & Man- Re-imbursement model. Define MIPPS. MACRA- Quality metrics. How agement (E&M) services—as described by the Center for Medicare MIPPS will change interventional radiology practices. & Medicaid Services (CMS)—and to evaluate the potential financial impact of these changes on the field of interventional radiology (IR). BACKGROUND: Background on traditional reimbursement model used in interventional radiology (IR). Define MIPPS MIPPS vs APMS MACRA- BACKGROUND: With recent trends in IR toward establishing outpatient quality indicators in IR. What IR physicians need to know about clinics, it is important to remain current on outpatient CMS reimburse- MACRA. How MIPPS will impact IR reimbursements. ment. CMS reimburses outpatient visits through E&M codes, which categorize outpatient encounters as ‘New Patient’ (CPT 99201-99205) CLINICAL FINDINGS/PROCEDURE DETAILS: IR physician reimbursements or ‘Established Patient’ (CPT 99211-99215). Representing a spectrum in future will be directly linked to the quality of care provided under of patient and care complexity, the increasing level of an outpatient MIPPS. Reimbursements will be directly tied to the quality indicators encounter (from 1-5) corresponds with increasing Relative Value Units defined by MACRA. It is imperative for IR Physicians to know these qual- (RVUs). ity indicators in order to stay competitive in the hospital setting. 32 | Traditional Educational Posters SIR 2019 Annual Scientific Meeting

CONCLUSIONS: Moving forward, MIPPS will likely be the major reim- Outpatient CMS E&M CPT Code Utilization in Interventional Radiology, bursement model in the healthcare setting. This will aim to shift a focus 2009 to 2017 from “fee for service” model to “quality of care.” 2009 2010 2011 2012 2013 2014 2015 2016 2017

Level 1 MIPPS Performance Categories 1246 1664 1550 1469 1863 2253 2286 2874 3053 E&M visits Quality Level 2 5165 6876 7603 7944 9078 10,565 10,469 13,771 14,427 Resource use or cost E&M visits

Clinical practice improvement activities Level 3 12,491 15,414 15,844 19,113 23,509 25,704 32,258 40,330 46,385 Advancing care information E&M visits Level 4 7137 10,322 10,147 10,809 14,956 18,662 23,705 32,109 35,157 E&M visits Abstract No. 701 Level 5 861 2814 2817 2987 3060 3768 4502 5793 5879 E&M visits

Interventional radiology, Evaluation & Management Yearly 26,900 37,090 37,961 42,322 52,466 60,952 73,220 94,877 104,901 coding, and the outpatient clinic: a 9-year perspective totals from Centers for Medicare & Medicaid Services billing data Abstract No. 702 A Moore1, M Mulatre1, N Reyes1, W Terrell1, M Hyatt1, R Trojan1 1INTEGRIS Baptist Medical Center, Oklahoma City, OK Using human psychology to reduce equipment waste and decrease inventory costs LEARNING OBJECTIVES: To evaluate the growth of interventional radiology in the outpatient clinic setting by reviewing available Cen- A Demmert1, K Hong2 ter for Medicare & Medicaid Services (CMS) billing data for outpatient 1Johns Hopkins, Baltimore, MD, 2Johns Hopkins Hospital, Evaluation & Management (E&M) Current Procedural Terminology Woodstock, MD (CPT) codes between 2009-2017. LEARNING OBJECTIVES: To our efforts to decrease waste through moti- BACKGROUND: With increasing interest in establishing and develop- vating physicians to prioritize using supplies prior to expiration. ing interventional radiology clinics, it is important to understand the primary means for financial reimbursement in the outpatient setting. BACKGROUND: Inventory management is a complex process, and expir- Current Procedural Terminology (CPT) codes—as determined by the ing equipment is a common source of waste in many departments. As Centers for Medicare & Medicaid Services (CMS)—guide reimburse- an example, our inpatient interventional radiology center deals with ment from both CMS and private insurers. Specifically, outpatient visits roughly $30,000 of soon to expire supplies every month ranging from are categorized as ‘New Patient’ (CPT 99201-99205) or ‘Established wires and catheters to saline and medications. Patient’ (CPT 99211-99215). Each of these categories has 5 levels of CLINICAL FINDINGS/PROCEDURE DETAILS: In an attempt to reduce patient encounters, with increasing complexity from Level 1 to Level 5. waste from expired equipment, a multidisciplinary team was convened Yearly utilization data of these E&M CPT codes are published by CMS consisting of inventory management, nursing leads, technologists, for review. and physicians. A system was implemented to incentivize the appro-

CLINICAL FINDINGS/PROCEDURE DETAILS: Review of outpatient E&M priate use of soon-to-expire equipment, consisting of monthly tally- CPT code billing shows that there were 26,900 total outpatient encoun- ing and collection of this equipment on a display cart. Residents and ters billed to CMS from outpatient interventional radiology clinics in fellows were awarded $5 coffee gift cards for the appropriate use of 2009. This increases every year between 2009 and 2017—as demon- soon-to-expire supplies. Over the 13 month trial period, we identified strated in Table 1—with a total of 104,901 total outpatient encounters $422,732.65 of soon-to-expire supplies. Of those, only $284,518.00 billed in 2017. This represents a 290% increase over a 9-year span, mir- expired with the remainder successfully used for patient care. A total roring the anecdotal growth and importance of outpatient interven- of $2,355 in gift cards were awarded over that period, for a total sav- tional radiology clinics to modern practice. ings of $135,859.65 or $9,704.27 per month. Prior to the implemen- tation of this program an average of $29,511 per month was wasted, CONCLUSIONS: The importance of an outpatient clinic to the growth reduced to $20,322.71 per month. a modern interventional radiology practice is becoming standard dogma. The adoption of interventional radiology clinics is demon- CONCLUSIONS: Through incentivizing our physician trainees and tech- strated empirically through E&M CPT billing data, which shows a nologists, we were able to reduce the amount of wasted, expired sup- 290% increase in outpatient visits billed to CMS by interventional plies by almost 50%. This resulted in a total savings of $135,859.65 over radiologists between 2009 and 2017. As the primary means of reim- our 13 month post-implementation period. bursement for these outpatient visits, the utilization of E&M billing codes by interventional radiologists is paramount for continued growth and success. SIR 2019 Annual Scientific Meeting Traditional Educational Posters | 33

Abstract No. 703 LEARNING OBJECTIVES: 1. Review the wide spectrum of commonly recruited portosystemic collaterals in portal hypertension 2. Identify To new heights: interventional radiology outreach to its multimodality appearance on ultrasound, computed tomography, underserved regions via aircraft-delivered mobile health and magnetic resonance imaging. 3. Describe different intervention units aimed to decrease portal venous pressure or mitigate the sequelae of R England1, F Laage-Gaupp2, D Mollura3, A Kesselman4 portal hypertension, including TIPS/DIPS, Denver shunt and BRTO/ CARTO/PARTO. 1Johns Hopkins Hospital, Baltimore, MD, 2Yale New Haven Hospital, New Haven, CT, 3RAD-AID International, Chevy Chase, MD, BACKGROUND: Portal hypertension is defined by an increment in portal 4Stanford University Medical Center, Menlo Park, CA vein pressures, at least 5mmHg above the inferior vena cava. This is caused by resistance to portal blood flow, most commonly in the liver LEARNING OBJECTIVES: - Discuss interventional radiology (IR) in (e.g., cirrhosis) but can be also prehepatic (e.g., portal vein thrombo- developing countries - Examine the hybrid airship as delivery vehicle sis) or posthepatic (e.g., Budd-Chiari syndrome). Chronic liver disease, - Outline the mobile IR unit: specifications and capabilities - Evaluate increased resistance is caused by structural and dynamic changes. The patient and location optimization: Geographic Information Systems structure is distorted by fibrosis and nodules formation. The dynamic (GIS) - Assess sustainability and limitations changes include an increase in splanchnic blood flow due to local

BACKGROUND: Half the world’s population lacks radiology technology, release of vasodilators in the setting of liver dysfunction. This result in directly impacting health outcomes. IR services have the potential to the formation of collateral between portal venous blood vessels to the reduce morbidity, mortality, and costs over traditional treatment options. systemic circulation. The collateral variety is anatomically and physi- Mobile health is a valuable resource for underserved areas, however ologically interesting. More interestingly is integrating the anatomical 1 billion people in the world are burdened with lack of transportation and physiological knowledge to understand the mechanism, purpose, infrastructure. New hybrid airship technologies provide the capability to and indication of different intervention. deploy mobile units to these regions for delivery of sustainable IR services. CLINICAL FINDINGS/PROCEDURE DETAILS: This exhibit presents the

CLINICAL FINDINGS/PROCEDURE DETAILS: Mobile IR units were wide variety of portosystemic collateral throughout different modal- designed to be loaded in and deployed from the first medical hybrid ities including computed tomography, sonographic and magnetic res- airship, capable of efficiently transporting 20 tons of equipment over onance imaging. Followed by an overview of different techniques to 1500 miles and landing on unprepared surfaces (grass, dirt, snow, water, relieve portal venous hypertension. Including TIPS and BRTO/CARTO/ etc.). Units are 9’ wide by 18’ long by 9’ tall and can house both fluo- PARTO. Emphasizing the tradeoff of each. The indication and side roscopic and ultrasound (US) imaging modalities with supply storage. effects. Summaries by an algorithm describing proper patient selec- Target patient populations focus on oncology and infectious disease, tion according to types of collateral and clinical presentation (MELD to provide procedures including: - Venous access - US- and fluoroscop- score, esophageal/gastric varices, ascites, encephalopathy and so on). ic-guided biopsy - Aspiration and drainage - Endovascular embolization CONCLUSIONS: Insight of the variety of portosystemic collaterals, their and ablation Underserved regions and target locations are identified presentation throughout different modalities and understanding their using quantitative GIS data, integrating population density, health out- drainage mechanism is essential. In conjugation with clinical setting, comes, infrastructure, and local topography. Sustainability of each unit it allows us to choose different interventional procedures, including is achieved by resupply and location transfer via hybrid airship, however TIPS, BRTO or even both. limitations may include ability to continually staff the unit with person- nel, which is often on a volunteer basis with scheduling constraints. Abstract No. 705 CONCLUSIONS: The world’s first medical hybrid airship has been devel- oped to enable mobile IR units to deploy in locations that were previ- Beyond your standard TIPS: complex portal venous ously inaccessible to traditional mobile health vehicles. These units are interventions designed to be versatile and provide underserved patient populations access to a variety of IR services, sustainable via airship resupply and Q Yu1, S Sanampudi1, G Gabriel2, D Raissi2 location transfer. Careful logistical planning is required for optimal 1University of Kentucky College of Medicine, Lexington, KY, utilization. 2University of Kentucky, Lexington, KY

LEARNING OBJECTIVES: 1.Review the theory and methodology behind Abstract No. 704 portal venous decompressive therapy. 2.Pictorial review of atypical and extreme portal venous system intervention scenarios A pictorial overview of numerous portosystemic collateral and related therapeutic interventions BACKGROUND: Trans-jugular intrahepatic portosystemic shunt (TIPS) is a well validated procedure in the management of variceal hemorrhage 1 1 1 1 2 D Cohen-Addad , H Brent , S Patel , S Fahrtash , H Liu and ascites secondary to portal hypertension. In our institution, TIPS 1SUNY Downstate Medical Center, Brooklyn, NY, 2SUNY Downstate revisions, recanalizations, and additional portal venous interventions Medical Center, Brooklyn, NY are performed routinely to maximize its therapeutic value in complex cases and extreme clinical scenarios with limited therapeutic options. 34 | Traditional Educational Posters SIR 2019 Annual Scientific Meeting

CLINICAL FINDINGS/PROCEDURE DETAILS: We will review multiple chal- of resected hepatocellular carcinoma, developed portal vein occlusion lenging portal hypertension scenarios managed with non-standard TIPS with cavernous malformation resulting in refractory ascites. DEPS was and uncommon portal venous system procedures. Highlights of some created from SMV to IVC. The portosystemic gradient improved from 12 cases are listed below: Case 1-2: Trans-splenic TIPS access for patients to 5 mmHg. The patient returned 1 month later due to persistent ascites with thrombosed portal and splenic veins. Case 3: Acute TIPS thrombo- and underwent shunt dilation without complications. sis in a patient with large spontaneous portosystemic shunt identified CONCLUSIONS: Procedural complication of DEPS can include intraper- as competing mesenterico-renal shunt via the left gonadal vein. Throm- itoneal hemorrhage from the direct puncture from the IVC to the por- bectomy Coil embolization of the competing shunt was performed. Case tal collateral vein. Thus, careful pre-DEPS imaging and IVUS guidance 4: Sustained ascites and varices recalcitrant to TIPS revision and reca- are critical. DEPS may also require revisions due to shunt dysfunction, nalization of the splenic and portal vein. Superior mesenteric, splenic indicated by a rise in the hepatic venous portal gradient to >12 mmHg and inferior mesenteric venous stents placed to allow for optimal hepa- or a recurrence of the complications of portal hypertension. DEPS dys- topetal flow into the TIPS stent. Case 5: Patient presenting with acute function may arise from shunt occlusion/stenosis. Regular imaging fol- liver failure 3 weeks post liver transplant, found to have complete acute low-up to evaluate DEPS patency is essential. Dysfunction may also be portal vein thrombosis managed with IVUS-guided TIPS placement and due to competing collateral veins. These should be embolized to force AngioJet pharmacomechanical Thrombectomy. Case 6: Recurrent lower portal flow primarily to DEPS to ensure its patency. GI bleed from rectal varices secondary to portal hypertension managed with inferior mesenteric vein Onyx embolization. After IMV emboliza- tion, newly developed bleeding esophageal varices managed with left Abstract No. 707 portal vein TIPS due to occluded right portal vein. Endovascular techniques in management of hepatic CONCLUSIONS: 1. Theory and methodology behind portal venous encephalopathy: confusion to clarity decompressive therapy. 2. Beyond standard TIPS, unique portal venous system interventions for unusual challenging clinical situations. R Varma1, E Bready2, N Mani3, S Saddekni4, M Devane5, A Gunn4, A Abdel Aal4 1University of Alabama Birmingham, Vestavia Hills, AL, 2University Abstract No. 706 of Alabama Birmingham, Gardendale, AL, 3Mallinckrodt Institute of Radiology, Chesterfield, MO, 4University of Alabama Birmingham, Direct extrahepatic portosystemic shunt: a new Birmingham, AL, 5Greenville Health System, Simpsonville, SC alternative to TIPS S Lee1, E Lee1, S Saab2, J McWilliams1, S Kee1 LEARNING OBJECTIVES: To review the incidence, pathophysiology, classification and factors associated with the development of Hepatic 1Division of Interventional Radiology, Department of Radiology, Encephalopathy (HE). To review spontaneous and post TIPS portosys- UCLA Medical Center, Los Angeles, CA, 2Division of Hepatology, temic shunt vascular anatomy. To review various endovascular tech- Department of Medicine, Pfleger Liver Institute, UCLA Medical niques in management of refractory HE secondary to spontaneous Center, Los Angeles, CA portosystemic shunts and following TIPS creation.

LEARNING OBJECTIVES: - Describe the indications for direct extrahe- BACKGROUND: HE is a neuropsychiatric syndrome secondary to por- patic portosystemic shunt (DEPS). - Understand the DEPS vasculature tosystemic shunting and has an incidence of up to 70% in cirrhotic anatomy. - List potential DEPS complications. patients with almost 5%-35% of new or worsened HE post successful

BACKGROUND: TIPS has been used for over 20 years to treat the com- TIPS creation. Although HE is well controlled with medical manage- plications of portal hypertension. In cases of inaccessible portal vein, ment, almost 3%-7% of these cases are refractory to medical manage- however, an alternate means of decompressing the portal system is ment. This exhibit describes the various endovascular techniques used needed. We present two cases of creating a direct extrahepatic por- for management of refractory hepatic encephalopathy secondary to tosystemic shunt (DEPS) with: 1) a mesocaval approach, described in spontaneous portosystemic shunts and post TIPS creation. one other clinical report to date, 2) a novel approach using a peri-gas- CLINICAL FINDINGS/PROCEDURE DETAILS: -Relevant vascular anat- tric collateral vein. omy: •Portal venography, pre and post TIPS. •Spontaneous portosys-

CLINICAL FINDINGS/PROCEDURE DETAILS: 1) A 46-year-old female with temic shunts -Endovascular techniques for management of refractory Budd-Chiari syndrome, presented with complete portal vein thrombosis HE: •TIPS Reduction: Parallel stent graft, controlled reduction, suture and signs of portal hypertension. Using intravascular ultrasound and flu- constrained stent graft. •TIPS occlusion: Amplatzer/coils •Transvenous oroscopic guidance, DEPS was created from the patient’s enlarged left retrograde portosystemic shunt occlusion: plug assisted, coil assisted, gastric vein to the IVC. The portosystemic gradient improved from 19 to balloon assisted 4 mmHg. In the following 2 years, however, patient developed recurrent CONCLUSIONS: 1. Prevention (i.e., careful patient selection for elec- DEPS stenoses, requiring 7 shunt revisions as well as IVC venoplasty, tive creation of portosystemic shunt creation) still remains the key. 2. due to Budd-Chiari–related thromboses. She eventually received a liver Identify the potential treatable cause like spontaneous shunts lead- transplant. We are continuing to treat her with further venoplasties ing to refractory HE. 3. Portosystemic shunt reduction/occlusion for for post-transplant IVC stenoses. 2) A 75-year-old male, with history SIR 2019 Annual Scientific Meeting Traditional Educational Posters | 35

refractory HE in patients with high MELD score have guarded out- LEARNING OBJECTIVES: 1. Review the indication and methodology comes. 4. Spontaneous portosystemic shunt occlusion and TIPS behind parallel transjugular intrahepatic portosystemic shunt 2. A brief reduction/occlusion can lead to improvement of refractory encepha- literature review of transjugular intrahepatic portosystemic shunt lopathy but can exaggerate portal hypertension. BACKGROUND: Transjugular intrahepatic portosystemic shunt (TIPS) is a well validated procedure in the management of variceal bleeding and Abstract No. 708 ascites secondary to portal hypertension. However, in certain clinical situations, variceal bleeding and ascites prove difficult to manage with Intravascular ultrasound (IVUS) TIPS: anatomy, pitfalls, one primary Viatorr stent despite shunt patency at its maximum diam- and lessons learned eter and subsequent revisions. In these recalcitrant cases, a second parallel TIPS (PS) also known as a “double-barrel TIPS” may be the S Rambhia1, R Ramaswamy1, S Kim1 only solution. Here we present a short case series of 3 patients with 1 Washington University School of Medicine, St. Louis, MO portal hypertension and PS using only Viatorr stents for the primary and the parallel stents. The goal is to discuss the indications, method- LEARNING OBJECTIVES: 1. To review anatomical considerations from IVUS point of view as it pertains to hepatic and portal vein relation- ology, technical challenges and a review of literature behind PS. ship, needle angle and needle positioning 2. To correlate IVUS images CLINICAL FINDINGS/PROCEDURE DETAILS: TIPS patency was evalu- and cross-sectional images (CT and MRI) 3. To discuss potential factors ated using venography before PS procedures. Doppler US was used to that can complicate/confound IVUS imaging such as hepatic tumor or assess subsequent shunt patency during follow-ups. Case 1: Alcoholic hepatic steatosis. 4. To show troubleshoot cases using IVUS TIPS such cirrhosis with hematochezia, jaundice, type-1 isolated gastric varices, as PV thrombosis, small PV, hepatic tumors, parallel TIPS, etc. 5. To and lower GI bleeding, despite TIPS placement 4 months earlier. TIPS know lessons learned from IVUS TIPS. patency and adequate flow were demonstrated. PS was performed and further reduced the portosystemic gradient (PSG). At 6-month BACKGROUND: The addition of intravascular ultrasound (IVUS) to con- ventional TIPS has been discussed in the literature in recent years as a follow-up, ascites had resolved; both stents remained patent. Case 2: means of providing additional imaging guidance for what once was a Hematemesis, esophageal varices, and acute blood loss anemia due procedure done primarily with fluoroscopy alone. Various parameters to cirrhosis from alpha-1 antitrypsin deficiency. The primary TIPS was such as decreased procedural time, radiation dosage, and number of recanalized using sharp recanalization and balloon angioplasty. PS was needle passes have been used to compare conventional TIPS (cTIPS) placed from right hepatic vein to the left portal vein. PSG and direct with IVUS TIPS (iTIPS). And while iTIPS has the potential to improve portal pressure were reduced. Two-week, 2-month, and 6-month fol- patient outcomes as opposed to cTIPS, a learning curve still exists with low-ups showed PS patency. Case 3: Readmission 5 days following becoming facile with iTIPS implementation. In this educational exhibit, TIPS for decompensated NASH cirrhosis with recurrent variceal bleed- we review important procedural considerations that operators should ing. Primary shunt patency was not sufficient for symptomatic control. be aware of as they relate to iTIPS. PS was placed from right hepatic vein to left portal vein. Six-month follow-up revealed patency in TIPS, PS, and the main portal vein. CLINICAL FINDINGS/PROCEDURE DETAILS: 1. IVUS machine setup, probe placement and anatomical orientation of intraprocedural images. 2. CONCLUSIONS: 1. Indications and methodology of PS. 2. How we man- Anatomical considerations from IVUS point of view as it pertains to age complex cases with PS. 3. Literature review. hepatic and portal vein relationship, needle angle and needle position- ing. 3. Correlation IVUS images and cross-sectional images (CT and Abstract No. 710 MRI). 4. Factors that can confound IVUS imaging such as underlying hepatic tumor or hepatic steatosis. 5. Troubleshoot cases using IVUS Brachial plexus blocks for anesthetic management TIPS such as PV thrombosis, small PV, hepatic tumors, parallel TIPS, in upper extremity dialysis arteriovenous fistula etc. 6. Lessons learned from IVUS TIPS angiography and angioplasty

CONCLUSIONS: We present a guide for operators for navigating IVUS P Lourenco1, D Valenti1, L Boucher2, T Cabrera3, K Muchantef3, A augmented TIPS (iTIPS) as far as anatomical review, procedural con- Bessissow4, N Martinez5, J Perez2, B Moosavi6 siderations, and potential confounding/complicating factors to be 1McGill University, Montreal, QC, 2McGill University Health Centre, aware of with IVUS TIPS. Montreal, QC, 3N/A, Montreal, PQ, 4N/A, BROSSARD, PQ, 5University of Chile, Santiago, Chile, 6BIDMC, Boston, MA

Abstract No. 709 LEARNING OBJECTIVES: 1. To review neuroanatomy relevant to upper extremity. 2. To review brachial plexus blocks and applications to Parallel TIPS shunts with VIATORR stents: case series and upper extremity arteriovenous fistula (AVF) angiogram and angio- review of the literature plasty. 3. To review evidence of brachial plexus blocks and regional Q Yu1, M Nisiewicz1, S Krohmer2, D Raissi2 anesthesia as a substitute to conscious sedation in the management 1University of Kentucky College of Medicine, Lexington, KY, of AVF angioplasty. 2University of Kentucky, Lexington, KY 36 | Traditional Educational Posters SIR 2019 Annual Scientific Meeting

BACKGROUND: Upper extremity dialysis AVF angiography and angio- stenting performed in 30 patients will be presented; with average age plasty are common radiological interventions in the evaluation of of 52 years (17-81 years) with an average follow-up of 508 days (0-2111 patients with problematic AVFs. Angioplasty is frequently the most days). This will include a discussion of technical factors affecting stent painful step, and related pain can often result in incomplete angioplasty patency including length of stent overlap, total stented length, stent balloon inflation and suboptimal angiographic and clinical improvement, size, and stent positioning. requiring repeat intervention in the future. Pain management in AVF CONCLUSIONS: Endovascular iliocaval reconstruction is a routinely angioplasty commonly consists of a combination of local anesthesia and performed procedure with favorable outcomes and patency rates in conscious sedation, and is accompanied with the risk of CNS depression patients with iliocaval obstruction. Technical considerations, including and may be contra-indicated in some patients. In addition, conscious stent positioning, stent diameter, and stented length should be taken sedation provides inadequate pain control in other patients. into account when planning iliocaval reconstruction. CLINICAL FINDINGS/PROCEDURE DETAILS: The techniques for inter-sca- lene, supra-clavicular, infra-clavicular and axillary brachial plexus blocks will be reviewed, as well as the site-specific areas of anesthetic Abstract No. 712 effect. Inter-scalene and supra-clavicular approaches are most indi- Transsplenic portal venous access: pictorial review and cated for brachiocephalic AVFs, whereas supra-clavicular, infra-clavic- institutional experience ular and axillary approaches are most suited for radiocephalic fistulas. M Still1, G Kumar2, M Kolber3 CONCLUSIONS: 1. Brachial plexus blocks are a safe and effective alterna- 1 2 tive to conscious sedation in the treatment of AVF stenoses. 2. Brachial UT Southwestern Interventional Radiology, Dallas, TX, University plexus blocks are easy to perform in the hospital and out-patient setting, of Texas Health Science Center at San Antonio, San Antonio, TX, 3 and can achieve adequate anesthesia in the upper extremity, minimizing Mount Sinai Hospital, The Icahn School of Medicine, New York, NY or even negating the need for conscious sedation and anesthetic sup- LEARNING OBJECTIVES: Our goal is to review trans-splenic portal port. 3. Different brachial plexus techniques can be employed effectively venous access (TSPV) using case examples as well as to review cur- depending on the location of the upper extremity AVF. rent literature on technique. We will review relevant ultrasound and fluoroscopic anatomy, indications, access and closure techniques, and Abstract No. 711 potential complications. BACKGROUND: Methods of portal venous access include transjugu- Endovascular iliocaval reconstruction: techniques, lar-intrahepatic and percutaneous transhepatic approaches have been outcomes, and gaps in knowledge studied and verified for portal access in creation of TIPS. However, cer- S McCann1, T Huber1, A Uflacker1 tain clinical scenarios such as portal vein thrombosis (PVT) have an increased TIPS technical failure rate. Patients with large or infiltrative 1University of Virginia, Charlottesville, VA hepatic malignancy are predisposed to difficult transhepatic portal

LEARNING OBJECTIVES: 1) Review the causes of iliocaval stenosis or venous access due to limited options for needle trajectory and the risk occlusion. 2) Describe endovascular methods used in iliocaval recon- of malignant seeding. In addition, transhepatic access related bleed- struction. 3) To highlight critical procedural steps and technical consid- ing may carry increased consequences when compared to splenic erations. 4) Discuss factors affecting stent patency rates. hematomas. Trans-splenic portal venous access has been used as an alternative method for portal venous catheterization. Historical risks of BACKGROUND: Iliocaval stenosis or occlusion can be caused by trans-splenic access have more recently been mitigated by real-time extrinsic compression due to malignancy or anatomic variants (e.g., ultrasound guidance and smaller sheath size. Trans-splenic approach May-Thurner), congenital venous atresia, neonatal umbilical catheter also provides additional benefits in particular clinical scenarios. For complication, or deep venous thrombosis (DVT). Endovascular treat- example, chronic liver failure leads to complications such as variceal ment of iliocaval obstruction with angioplasty and stenting with or hemorrhage, PVT, and/or coexisting ascites. without catheter-directed thrombolysis has been shown to provide a safe and effective method for reestablishing and maintaining venous CLINICAL FINDINGS/PROCEDURE DETAILS: In this educational exhibit, outflow. Multiple variations in iliocaval stenting can be found in the lit- we will review six separate cases of TSPV used in the creation of TIPS, erature, however limited treatment guidelines exist and few compari- variceal embolization, and portal venous recanalization with stenting sons have been made of stenting techniques. This exhibit will discuss to meet our objectives. All cases were successful. Splenic tracts formed key technical aspects of iliocaval reconstruction and their effects on by varying sheath sizes and tract closures were performed with plugs, stent patency rates. coils, and/or gel foam. Portal vein recanalization was confirmed patent on follow-up imaging in 5 patients. Management of complications such CLINICAL FINDINGS/PROCEDURE DETAILS: This educational exhibit will as splenic hematoma, pseudoaneurysm, and splenic arterial injury will illustrate multiple stent configurations used in iliocaval reconstruction. be demonstrated and discussed. Procedural steps along with technical considerations will be high- lighted. Reported clinical outcomes, stent patency rates and com- CONCLUSIONS: Left-sided access via trans-splenic approach can plications will be summarized. Lastly, a small case series of iliocaval circumvent a thrombosed portal vein, and simplify the approach, SIR 2019 Annual Scientific Meeting Traditional Educational Posters | 37 cannulation, and embolization of these vessels. By the end, the reader Abstract No. 714 will have the necessary knowledge to provide additional, safe routes to difficult portal venous access. Peripheral application of large-volume glue embolization: descriptive tutorial of techniques, pearls, and pitfalls

1 2 3 4 Abstract No. 713 S Cesar Durscki Vianna , O Adenikinju , M Patel , V Bishay , M Ranade5, A Fischman6, B Olivieri2, T Yates7, M Syed8, F 9 5 Neurophysiologic monitoring techniques to predict Nowakowski , R Lookstein and prevent nerve injury during treatment of vascular 1Mount Sinai Medical Center, MIAMI, FL, 2Mount Sinai Medical malformations: an update Center, Miami Beach, FL, 3Mount Sinai Medical Center, Coral Gables, FL, 4Icahn School of Medicine at Mount Sinai Hospital, New C Bailey1, N Ghodasara1, R England1, C Weiss2, S Mitchell3, E Ritzl1 York, NY, 5Mount Sinai Hospital, New York, NY, 6Icahn School of 1Johns Hopkins Hospital, Baltimore, MD, 2The Johns Hopkins Medicine at Mount Sinai, New York, NY, 7N/A, Miami, FL, 8Mount University School of Medicine, Baltimore, MD, 3Johns Hopkins, Sinai Roosevelt Hospital Center, New York, NY, 9Mount Sinai Medical Baltimore, MD Center, New York, NY

LEARNING OBJECTIVES: (1) Defining vascular malformations – low and LEARNING OBJECTIVES: 1) Review the chemical properties of n-bu- high flow (2) Interventional treatments (3) Nerve damage – peripheral tyl-2-cyanoacrylate (nBCA) glue and its applications 2) Explore the and central a. Preventative techniques (4) Neurophysiological monitor- on-label and off-label use and possible complications associated with ing techniques during embolization and sclerotherapy a. Overview of the application of large quantities of nBCA liquid embolic therapy 3) the goals of neurophysiological monitoring (SSEP, MEP, EEG, Speech Guide the reader through our method for selecting eligible cases, as and motor mapping, Nerve conduction studies) (5) Neurophysiologi- well as determining the benefits and potential complications of the use cal / Pharmacological mapping techniques using examples from our of large volumes of this liquid embolic agent 4) Discuss pearls + pitfalls institution a. Provocative testing for the central nervous system b. of large-volume nBCA glue embolization in the peripheral circulation Provocative testing for the peripheral nervous system through case examples

BACKGROUND: Vascular malformations (VMF) are abnormal clusters of BACKGROUND: The nBCA liquid embolic system (Trufill, Cordis) is vessels that can occur in any part of the body. The two main categories currently indicated for the treatment of cerebral arteriovenous mal- of VMFs are low-flow malformations which include venous, lymphatic, formations. The use of liquid embolic agents (LEAs) in peripheral and capillary malformations and high flow malformations which interventions is expanding due its lack of dependance on an intact include arteriovenous malformations and fistulas. Minimally invasive coagulation cascade as well as its ability to perform rapid, cast-like interventional radiology procedures such as sclerotherapy and embo- complete embolization. Many cases have been reported describing the lization are the mainstays of treatment for these complex vascular off-label use of small volumes (<1cc) of nBCA glue mixture for emboli- lesions. However, minimally invasive, sclerotherapy and embolization zation of small peripheral vessels. However the use of large volumes of carry a risk of regional nerve damage that can lead to irreversible neu- glue (>1cc) in the embolization of large vascular lesions in the peripheral rologic deficits. circulation is not well described in the literature. Large-volume periph- eral glue embolization can be extremely useful in achieving complete, CLINICAL FINDINGS/PROCEDURE DETAILS: Estimated incidence of rapid embolization in cases that would normally require large amounts nerve damage during embolosclerotherapy is 8.6%. Neurophysiologic of traditional embolic agents, potentially resulting in decreased proce- monitoring techniques have been developed to help prevent and pre- dural cost, and reduction in procedural and fluoroscopy time. However, dict neurologic injuries during embolization and sclerotherapy. This the use of large volumes of nBCA glue requires knowledge and skill to exhibit will discuss nerve injury that can result from VMF treatment achieve controlled, effective embolization while minimizing the risk of and the techniques utilized to predict and prevent these injuries using potentially disastrous complications. examples from our institution. Techniques currently used include somatosensory evoked potentials (SSEPs), motor evoked potentials CLINICAL FINDINGS/PROCEDURE DETAILS: The technical aspects of (MEPs), electroencephalography (EEG), speech and motor mapping, large-volume peripheral nBCA glue embolization will be discussed in nerve conduction studies as well as provocative testing with Amital a case-based format. The advantages and disadvantages of large-vol- and lidocaine. ume nBCA glue embolization compared to other embolic agents will be discussed. Techniques to minimize non-target embolization while CONCLUSIONS: Vascular malformations often require sclerotherapy increasing embolization effectiveness will be described. or embolization for treatment; however, regional nerve damage can occur depending on chosen technique and location. As such, it is CONCLUSIONS: The use of large volumes of nBCA glue to achieve rapid important to employ the latest nerve monitoring techniques in order complete embolization of large vascular volumes will be described to prevent such injuries. through case-based examples. 38 | Traditional Educational Posters SIR 2019 Annual Scientific Meeting

Abstract No. 715 LEARNING OBJECTIVES: We describe automated pipelines for alerting the interventional radiology (IR) research group that a patient in an Endovascular retrieval and management of fractured IR research database has visited the institution, and auto-populating inferior vena cava filters and fragments many data fields directly from the electronic health record (EHR) to the W Klejch1, O Ahmed2 IR research database. This process vastly reduces the need for manual chart review, and optimizes the process of capturing follow-up data. 1University of Chicago, Chicago, IL, 2University of Chicago, Northbrook, IL BACKGROUND: We have developed REDcap database entitled Venous InTerventionAL (VITAL) containing manually entered, longitudinal, LEARNING OBJECTIVES: Prevalence, risk factors, and clinical presenta- clinical and imaging data for all venous IR patients seen at our institu- tions of inferior vena cava (IVC) filter fragmentation. Pre-procedural tion (n=687). An institutional research group has developed software approach to fragment retrieval including pre-imaging considerations, architecture which regularly pulls comprehensive patient data from vascular access, catheter and snare selection, as well as coordination our EHR, Epic (Verona, WI), into a research-compliant MySQL data- with electrophysiology and surgical teams. Technical feasibility and base. Our team has developed a script that connects the institutional approach to retrieval based on anatomic location, particularly intrapul- EHR database to REDcap, to streamline the process of updating VITAL monary and intracardiac fragment locations. Complications related to with new follow-up information. fragment retrieval and post-procedural management. Consideration for abandoning a filter fragment and associated complications. CLINICAL FINDINGS/PROCEDURE DETAILS: Our data pipeline automat- ically notifies us if a patient within our research database has been BACKGROUND: Since the recommendation by the FDA that IVC filters seen anywhere in our institution for follow-up, describes the date and should be removed once the risk of pulmonary embolism has subsided nature (e.g., clinic visit, laboratory, imaging) of the follow-up, and gath- there has been increased interest in the utilization of removable filters. ers structured and unstructured data from the follow-up. The script While filter related complications such as device migration and long- automatically sends structured data (e.g., dates of new imaging pro- term thrombosis are reduced by timely retrieval, certain complications cedures, accession numbers) into the appropriate data forms in VITAL. such as complex retrieval and filter fragmentation are increasingly The pipeline sends unstructured data (e.g., clinic notes, text reports encountered in clinical practice secondary to prolonged implantation. from telephone encounters) into a queue on a secure web application. The reported prevalence of filter fracture is varied between 2-38%, A data curator may subsequently access the newly identified follow-up likely secondary to the type of filter placed and suboptimal follow-up. encounter(s) notes using the web application, and manually enter data Despite being a common complication, there is a relative paucity of lit- from the notes into appropriate forms in VITAL. erature addressing the approach to filter fragment retrieval and man- agement. Potential locations of filter fracture and migration include the CONCLUSIONS: We have automated the flow of large amounts of struc- IVC wall, renal vein, spine, abdomen, aorta, pulmonary artery, and right tured follow-up data from an EMR into our custom research data- heart. Special consideration is needed for intracardiac and intrapulmo- base. We have also automated the identification of patients who have nary retrieval. Life threatening complications such as tachyarrhythmia, returned for follow-up anywhere within our institution, which allows perforation, and cardiac tamponade have also been reported. for targeted data capture, and the maintenance of an up-to-date research database. CLINICAL FINDINGS/PROCEDURE DETAILS: Pre-procedure imaging con- siderations; coordination with electrophysiology and surgical teams; technical approach for forceps and snare retrieval as well as laser abla- Abstract No. 717 tion; recommendations for abandoning a fragment; and post-proce- dural imaging and follow-up. Diagnosis and management of iatrogenic central venous hemorrhage CONCLUSIONS: IVC fracture, fragmentation, and embolization are com- mon complications. Pre-procedural imaging and technical approach D Suttle1, T Huber1, A Park2, P Norton1, K Hagspiel3 are critical for successful retrieval. Special considerations for intrac- 1University of Virginia, Charlottesville, VA, 2UVA Health System, ardiac retrieval is necessary to reduce life threatening complications Charlottesville, VA, 3N/A, Charlottesville, VA

LEARNING OBJECTIVES: To understand common as well as uncommon Abstract No. 716 but potentially life-threatening causes of iatrogenic central venous hemorrhage.-To understand the anatomic boundaries and fluoro- Automated and integrated electronic updating of a scopic correlates of potential locations of central venous hemorrhage. longitudinal interventional radiology research database To understand the clinical implications of central venous hemorrhage A Souffrant1, T Mabud1, V Arendt1, D Cohn1, R Shah2, L Hofmann3 depending on location. To understand management options for cen- tral venous hemorrhage. 1Stanford University School of Medicine, Stanford, CA, 2VA Palo Alto Health Care System, Palo Alto, CA, 3Stanford University Medical BACKGROUND: Iatrogenic central venous hemorrhage is rare, but Center, Stanford, CA potentially life-threatening depending on the location of injury. Due to SIR 2019 Annual Scientific Meeting Traditional Educational Posters | 39

the frequency of either direct cannulation or crossing with guidewires, room main desk are paged to be on standby for initiation of ECMO. Our interventional radiologists should be aware of the fluoroscopic and institution has a set a goal of 90 minutes from time of alert to initiation angiographic appearance of venous injury and extravasation because of cannulation for location benchmarking. As part of the PERT quality most injuries are amenable to immediate endovascular or image- assessment, we are monitoring ECMO use and outcomes as well. This guided intervention. exhibit will describe this process and present a template for institu- tions that wish to implement a similar alert. CLINICAL FINDINGS/PROCEDURE DETAILS: Delineation of central venous anatomy by venogram is paramount to determining presence CONCLUSIONS: Massive PE patients can decompensate quickly. Early of central venous injury. Compartmentalizing the central veins, from utilization of ECMO can improve patient outcomes. This exhibit pres- axillary to vena cava, as well as knowledge of causes of injury can ents a template for the triage process, communication structure, and direct the interventional radiologist to predict possible complications necessary teams involved in implementing IR ECMO alert to support beyond the insult to the vein. PE treatment.

CONCLUSIONS: Fatal outcomes from iatrogenic central venous injury are rare and possibly underreported. Understanding venographic Abstract No. 719 anatomy and discerning the possible locations of hemorrhage from pericardial, mediastinal, intrathoracic, and axillary can direct the From diagnosis to recanalization: a review of portal vein interventional radiologist to timely, targeted, and possibly life-saving thrombosis and its management intervention. J Yun1, D Szaflarski2, S Koneru3, N Georgiou4, M Hon2, J Hoffmann5 1Stony Brook School of Medicine, Mineola, NY, 2Winthrop University Abstract No. 718 Hospital, Mineola, NY, 3NYU Winthrop Hospital, Mineola, NY, 4Winthrop-University Hospital, Mineola, NY, 5NYU Winthrop Establishing the interventional radiology extracorporeal Hospital, Garden City, NY membranous oxygenation alert: enhancing survival during catheter-directed therapy of massive pulmonary LEARNING OBJECTIVES: 1. Review common and uncommon causes of embolism Portal Vein Thrombosis (PVT) and its imaging appearance on all diag- nostic radiology modalities. 2. Detail the PVT management guidelines, 1 1 1 T Huber , A Sharma , Z Haskal including the role of interventional radiology. 3. Describe ongoing 1University of Virginia, Charlottesville, VA questions regarding PVT management in unique scenarios.

LEARNING OBJECTIVES: Understand the rationale for establishing an BACKGROUND: PVT refers to thrombus anywhere in the main portal interventional radiology (IR) extracorporeal membranous oxygen- vein and/or intrahepatic portal vein branches. PVT can occur in the ation (ECMO) alert at institutions offering pulmonary embolism treat- setting of cirrhosis or malignancy; however, a substantial number of ment. Define the stakeholders and processes necessary to establish cases are seen in patients with no liver disease. This exhibit reviews the an IR ECMO alert. Describe a proposed algorithm for triaging patients prevalence, diagnosis, and treatment of PVT, to educate interventional with massive pulmonary embolism (PE) who may require ECMO. radiologists and trainees so that they can be active participants in the care of these patients. BACKGROUND: Patients with massive PE can decompensate rapidly during catheter-directed therapy (CDT). Pre-activation of the ECMO CLINICAL FINDINGS/PROCEDURE DETAILS: This exhibit reviews PVT team can prove lifesaving. To lessen potential intra-procedural mortal- causes and prevalence in children and adults and details PVT cate- ity we created a hospital-wide interdisciplinary IR ECMO alert to expe- gories: acute in non-cirrhotic population, chronic (extrahepatic portal dite the initiation of ECMO during CDT. This exhibit presents a template venous obstruction), and PVT in cirrhotic patients. Key concepts in the for the creation of an IR ECMO alert, including stakeholders, workflow, diagnosis of PVT are described, including history, physical exam, labo- and benchmarks for outcomes. ratory, endoscopy, and imaging findings. The role of imaging in diagno- sis and treatment is reviewed, including US, CT, MRI, and angiography. CLINICAL FINDINGS/PROCEDURE DETAILS: Pulmonary embolism A case-based review highlights diagnosis and management options/ response team quality improvement sessions affirmed the IR pro- interventions (supported by relevant literature review), and includes posed need for a standby ECMO alert process. A triage mechanism topics such as systemic anticoagulation, thrombolysis (intra-arterial for “ECMO friendly” CDT in sites including the hybrid OR, the cardiac via superior mesenteric artery, transhepatic or transjugular PV punc- catheterization lab, as well as in the IR department was discussed. We ture, trans-splenic access), thrombectomy, transjugular intrahepatic created a set of standardized hospital protocols and hierarchical com- portosystemic shunt (TIPS), shunt surgery, and liver transplant. Finally, munication strategies over multiple stakeholder meetings. Through a discussion of managing unique scenarios and ongoing questions will this process, a new alert was created, modeled after aortic or stroke include portal cholangiopathy and PVT in hepatocellular carcinoma, alerts. After determining that ECMO may be required during cathe- duration of systemic anticoagulation, and role of prophylactic antico- ter-directed therapy, a separate page is sent that alerts the cardio- agulation in preventing PVT in high risk patients. thoracic surgeon, perfusionist team, anesthesiologists, and operating 40 | Traditional Educational Posters SIR 2019 Annual Scientific Meeting

CONCLUSIONS: Knowledge of PVT diagnosis and treatment is criti- Abstract No. 721 cal for interventional radiologists to have maximal, timely impact on patient care and help provide optimal patient outcomes. Mechanical thrombectomy for massive pulmonary embolism

1 1 1 1 1 Abstract No. 720 P Massa , D Knapp , A Martynov , S Schwartz , J Fallucca 1Henry Ford Hospital, Detroit, MI Initial experience with the ClotTriever Device: tips and tricks for large-volume central venous thrombectomy LEARNING OBJECTIVES: Indications and contraindications for interven- tions on massive pulmonary embolism as employed by the Pulmonary 1 2 3 3 3 3 J Kochiyil , D Rubin , J Santoscoy , R Beasley , T Yates , B Olivieri Embolism Response Team (PERT) at our institution. Decision making 1Mount Sinai Medical Center, Miami Beach, FL, 2Nova Southeastern and patient selection for mechanical thrombectomy versus thrombol- University, Fort Lauderdale, FL, 3Mount Sinai Medical Center, Miami ysis for massive pulmonary embolism (PE). Technique for performing Beach, FL mechanical thrombectomy within the pulmonary arteries. Large-cali- ber venotomy closure techniques. LEARNING OBJECTIVES: To present our initial experience with the new Inari ClotTriever System in a series of patients with acute, subacute, BACKGROUND: Interventional radiology serves as an integral member and even chronic iliofemoral deep venous thrombosis (DVT). To illus- of a well-functioning PERT offering minimally invasive techniques to trate the ex vivo and intraprocedural appearance of various compo- treat massive pulmonary embolism. Pulmonary arterial thromboly- nents of this new device. To educate on pearls and potential pitfalls in sis has become a standard of care for massive pulmonary embolism patient selection for this device. To describe pre- and intraprocedural however not all patients are good candidates for thrombolytic therapy. tips and tricks for successful removal of thrombus using the ClotTriever Pulmonary artery mechanical thrombectomy allows for a different through case-based examples. modality to treat patients with contraindications to thrombolytics as well as offer an immediate flow improving treatment to patients with BACKGROUND: The benefits of thrombus removal for iliofemoral DVT extensive clot burden and significant right heart strain. have been explored. As our understanding of the complex spectrum of thromboembolic disease grows, new devices are being developed CLINICAL FINDINGS/PROCEDURE DETAILS: Image-driven step-by-step to address the growing need of the interventionalists to remove the guide for performing mechanical thrombectomy within the pulmonary most thrombus possible in an efficient, effective, and safe manner. arteries including techniques to access the pulmonary arteries, per- Recently, the ClotTriever System (Inari Medical Inc. Irvine, CA, USA.) forming the pulmonary angiogram, wire selection, and placement of thrombectomy system was specifically developed to remove exten- guide catheter. Discussion of peri-procedural considerations includ- sive volumes of thrombus in large vessels without thrombolytics and ing patient selection and preparation, femoral versus jugular access, without the need for veno-venous bypass. However, clinical out- sheath choice, and closure techniques for the required large-caliber comes and techniques for procedural success have yet to be widely venotomy. described. CONCLUSIONS: To recognize massive PE patients that would bene-

CLINICAL FINDINGS/PROCEDURE DETAILS: This report presents our fit from mechanical thrombectomy versus thrombolysis. Develop an initial procedural outcomes of the ClotTriever System in a series understanding of how to perform mechanical thrombectomy of mas- of patients with iliofemoral DVT who underwent successful endo- sive PE to add it to the learners armamentarium for future interventions. vascular thrombus removal without complications. A 28-30 day follow-up demonstrated near complete resolution of symptoms and no recurrence of thrombosis. The ClotTriever is an FDA 510(k) Abstract No. 722 cleared over-the-wire catheter-based mechanical thrombectomy Pulmonary embolism thrombolysis in the setting of brain system indicated for the removal of large venous thrombus from imaging findings: to lyse or not to lyse blood vessels ranging in size from 6 mm to 16 mm. The device is useful in mechanically clearing not just extensive acute thrombus, R Bou Said1, A Rohana1, K Natarajan2, J Cooke2, B Martinez2, but also suspected subacute and even chronic thrombus. Over the V Flanders3, J Dowell3 course of our experience with the device, tips and tricks for effec- 1Texas Tech University Health Sciences Center El Paso, El Paso, TX, tive device usage and improved patient selection factors have been 2St. Vincent Health, Indianapolis, IN, 3St. Vincent Health; Northwest identified. Radiology, Indianapolis, IN

CONCLUSIONS: In our experience with the ClotTriever device, a sub- LEARNING OBJECTIVES: 1. Discuss different treatment options for stantial reduction in clot burden and near complete patency can be patients with pulmonary embolism (PE) and concurrent intracranial achieved even in suspected subacute and chronic venous thrombosis abnormalities. 2. Divide intracranial findings into absolute contraindi- in a method unlike that of any other device. cation for thrombolysis, relative contraindication, and not a contrain- dication. 3. Present example cases from our institution and discuss the estimated relative risk of bleeding in different brain tumors. SIR 2019 Annual Scientific Meeting Traditional Educational Posters | 41

BACKGROUND: Patients with brain tumors have among the highest CLINICAL FINDINGS/PROCEDURE DETAILS: 1. Discuss the imaging char- incidence of venothrombotic events (VTE), estimated at 3.5% (1), acteristics of submassive and massive PE. 2. Discuss the imaging find- as compared to other cancer types. This risk increases dramatically ings in various intracranial pathologies: Primary tumors, metastasis as in the perioperative period for brain masses; 23.8% in metastatic well as hemorrhagic and embolic stroke. 3. Present the risks of throm- brain disease and 21.4% in high grade glioma patients (1). PE in these bolysis associated with the various intracranial findings. 4. Discuss patients carries a great morbidity and mortality risk. It also poses the the indications/contraindications for thrombolysis based upon brain clinical dilemma for treatment options by weighing the relative risk imaging findings. 5. Present relevant cases from our institution; imag- of bleeding versus hemodynamic instability from PE. Risk of bleed- ing findings, treatment and clinical outcome. ing also varies with the histology of intracranial tumors, from < 1% CONCLUSIONS: Pulmonary embolism in the settings of an abnormal to 29.2% in mixed oligodendroglioma/astrocytoma to 50% in meta- brain imaging finding is a frequent clinical scenario and may be asso- static (2). Although many imaging findings were initially ciated with grave consequences. Knowledge of the indications and considered to be absolute contraindication for thrombolysis, recent contraindications associated with each finding will help guide clini- case reports and case series suggest thrombolysis may be safe in cians and interventionalists in a multidisciplinary treatment approach select patients. to avoid severe side effects and complications. 42 | Educational e-Posters SIR 2019 Annual Scientific Meeting

Educational e-Posters

Abstract No. 645 Abstract No. 669

This abstract has been moved from the Traditional Educational Post- This abstract has been moved from the Traditional Educational Posters ers section because its prese ntation format was changed to an edu- section because its format was changed to an e-poster. The change cational e-poster. The change was made after the abstract numbering was made after the numbering of abstracts had finalized. had been finalized. Intravascular ultrasound and venous thrombosis: a pictorial New players in chronic vascular access for hemodialysis: essay percutaneous creation of arteriovenous fistulas B Lee1, R Winokur2, A Malhotra2 1 2 1 1 J Jeffries , T Tullius , L Dalag , R Navuluri 1New York-Presbyterian/Weill Cornell Medical Center, New York, NY, 1The University of Chicago, Chicago, IL, 2University of Chicago, 2Weill Cornell Medicine, New York, NY Chicago, IL LEARNING OBJECTIVES: To review intravascular ultrasound findings asso- LEARNING OBJECTIVES: 1. Introduce a novel approach to chronic ciated with venous thromboembolic disease, associated venous patholo- vascular access in patients undergoing hemodialysis 2. Describe the gies, and treatment-related findings through a pictorial essay format. procedural steps of two similar but slightly different devices using pic- BACKGROUND: Intravascular ultrasound (IVUS), when used in conjunc- torial models and captions 3. Discuss recent FDA approval and how tion with planar venography, increases sensitivity in the detection of this approach compares to the currently recommended method for common venous pathologies such as venous webs or external compres- chronic vascular access creation using the latest literature sion, which can be difficult to detect or missed entirely when evaluated BACKGROUND: End stage renal disease (ESRD) is increasingly prevalent with planar venography alone. As such, IVUS has become a standard worldwide and particularly in the US, ultimately requiring either renal component of venous assessment for the diagnosis and treatment of transplant or dialysis. Nearly half a million people in North America venous thrombosis for patients who may be candidates for catheter-di- alone underwent hemodialysis (HD) in 2015. HD requires safe and reli- rected therapies and interventions. Despite this, while IVUS findings in able vascular access. Surgically created arteriovenous fistulas (sAVF) regards to coronary artery disease has been well-described in the liter- in the upper limb are the current recommendation, however this has ature, there is a notable absence of a compendium regarding standard its limitations and drawbacks. Recently a novel approach for chronic IVUS findings associated with venous thromboembolic disease. access has been approved by the FDA, and early studies show it com- CLINICAL FINDINGS/PROCEDURE DETAILS: This presentation illustrates pares favorably to sAVF in time to maturation, patency, and procedural the characteristic IVUS findings associated with venous thromboem- costs: percutaneously created arteriovenous fistulas, or endovascular bolic disease, covering the range of appearances associated with acute AVFs (endoAVF). venous thrombus, chronic post-thrombotic changes, and extrinsic CLINICAL FINDINGS/PROCEDURE DETAILS: This exhibit will describe the compressive etiologies such as May-Thurner anatomy, as well as the two devices recently approved by the FDA that allow creation of endo- IVUS characteristics of associated treatment-related findings including AVF, namely the WavelinQ system (Bard USA) and the Ellipsys vascu- stents and vena cava filters. Context and comparison is provided with lar access system (Avenu Medical USA), and provide a simple step by each IVUS finding with correlative planar venography findings. step narrative of the procedures themselves. Pictorial models will be CONCLUSIONS: IVUS is an increasingly important tool in the diagnosis used to demonstrate the relevant anatomy and procedural details for and treatment of venous thromboembolic disease in conjunction with each device. In addition, the exhibit will discuss early studies compar- standard venography. As a result, it is essential for the interventionalist ing endoAVF with sAVF. Lastly, a brief discussion of the opportunity looking to treat this disease to be familiar with the IVUS findings of this technology provides to expand the scope of care interventionalists venous thromboembolic disease, therapies, and their correlative find- can offer patients with ESRD. ings on planar venography. CONCLUSIONS: The newly FDA approved WavelinQ and Ellipsys sys- tems allow percutaneous creation of arteriovenous fistulas. They demonstrate safety, efficacy, and opportunity for another valuable Abstract No. 723 service to provide patients with ESRD. Bloody connections: review and treatment of aortic fistulizations O Deochand1, M Prasad2, T Yablonsky3, S Calhoun4 1Atlantic Health- Morristown Medical Center, Morristown, NJ, 2Morristown Medical Center, N/A, 3Morristown Medical Center, Morristown, NJ, 4Morristown Medical Center, Atlantic Health System, Long Valley, NJ SIR 2019 Annual Scientific Meeting Educational e-Posters | 43

LEARNING OBJECTIVES: Understand the clinical features, demograph- of trauma, can be iatrogenic from surgery/procedures, or can arise as ics, and pathophysiology of aortic fistulas. Mastery of the imaging complications of inflammatory conditions such as pancreatitis. Ability characteristics of selected fistulas through provided examples, with to treat pseudoaneurysms is a requirement of interventional radiology; emphasis on the importance of contrast phased CT scan and cor- however, the subset of uncommon pseudoaneurysms may require relation with angiography. Provide the learner with additional imag- innovative techniques for successful treatment. ing examples of special topics, specifically post procedure/surgery. CLINICAL FINDINGS/PROCEDURE DETAILS: The exhibit will describe Understand the management options and outcomes. causes and presentations of common and uncommon pseudoaneu- BACKGROUND: Aortic fistulizations are abnormal communications rysms, as well as standard and innovative techniques for pseudoan- between the aorta and various adjacent structures. The pathophysi- eurysm treatment. Indications for surgery versus percutaneous and ology of aortic fistulas can be divided into whether they are primary endovascular embolization will also be reviewed based upon current (such as from infection or radiation therapy) or more commonly sec- literature. The exhibit will describe techniques beyond conventional ondary causes (status post aortic repair). The most classic case is embolization methods, such as balloon occlusion, direct liquid embolic that of aortoenteric fistula (AEF), where the patient may complain of injection of a mesenteric pseudoaneurysm, and direct thrombin injec- epistaxis or hematochezia. CT scan imaging may show perienteric fat tion of a gluteal pseudoaneurysm. We will also describe conventional stranding, with bowel closely adherent to aorta that contains locules of methods for treating pseudoaneurysms in uncommon locations air. Prognosis is grave, with mortality approaching 85%. including phrenic, bronchial, and lumbar arteries. We will review our experience and the literature for outcomes including technical and CLINICAL FINDINGS/PROCEDURE DETAILS: This educational exhibit clinical success, recurrence rate, mortality, and morbidity. will provide the reader with diagnostic and post-treatment imaging of aortic fistulas. Not only providing detailed evaluation of AEFs, cases CONCLUSIONS: Interventional radiology plays a pivotal role in provid- of imaging diagnosed aorto-coronary artery, aorto-caval, and aor- ing prompt and minimally invasive definitive treatment for common to-subphrenic collection fistulas collected from our institution will be and uncommon pseudoaneurysms. The interventional radiologist presented. Special topics in secondary causes, including imaging case must possess the skill set to treat common and uncommon pseudoan- of aortic fistula status post EVAR and ilio-ureteral fistula status post eurysms, which may require exploration of unconventional techniques ureteral stent insertion. Management options and outcomes for these when surgery is not an option. patients will be discussed, including imaging example of AEF repair with omentoplasty. Abstract No. 725 CONCLUSIONS: Recognition of the important diagnostic imaging find- ings and treatment options are critical to the morbidity and prognosis Endovascular management of iliac artery aneurysms of patients with aortic fistulizations. D Kirkpatrick1, C Busch1, H Hasham1, A Thors1, K Hance1, A Alli1 1University of Kansas Medical Center, Kansas City, KS Abstract No. 724 LEARNING OBJECTIVES: The purpose of this educational exhibit is to Conventional and innovative techniques for treatment of present interventional radiologists, fellows, residents and allied health pseudoaneurysms professionals about the prevalence, classification, management, and complications of iliac artery aneurysms. M Jarmakani1, L Shreve2, E Mendoza3, H Javan4, T Geisbush5, A Song6, P KIm7, K Nelson8, J Katrivesis9, D Fernando10, N Abi-Jaoudeh11 BACKGROUND: Iliac artery aneurysms (IAA) are present in 20% of patients with abdominal aortic aneurysms (AAA) and a solitary finding in 0.03% 1Department of Radiological Sciences, Orange, CA, 2University of California Irvine, Irvine, CA, 3University of California, Irvine, Long of the general population. IAA are usually asymptomatic, and incidentally Beach, CA, 4University of California Irvine, Orange, CA, 5Chicago found on imaging studies performed for other reasons. Rupture can be Medical School, San Diego, CA, 6Howard University College of seen in 38%, with an associated mortality of up to 58%. Several classifica- Medicine, Fulton, MD, 7Rosalind Franklin University, Culver City, tion systems have been proposed, which guide the approach to therapy. CA, 8University of California Irvine, North Tustin, CA, 9Georgetown Endovascular management is the preferred treatment, with low mortality University Hospital, Washington, DC, 10UC Irvine, Buena Park, CA, rates and similar complication rates to AAA repair. 11University of California Irvine, Orange, CA CLINICAL FINDINGS/PROCEDURE DETAILS: We present a pictorial review

LEARNING OBJECTIVES: Briefly describe causes of uncommon pseu- of IAA disease, accompanied by four cases demonstrating the treat- doaneurysms. Briefly describe unconventional presentations of ment of a solitary internal iliac artery aneurysm, an aortoiliac aneurysm pseudoaneurysms. Discuss conventional techniques for treating pseu- treated with an aortic endograft and branched iliac endoprosthesis, a doaneurysms. Discuss innovative treatment techniques of uncommon previously treated IAA complicated by type II endoleak, and bilateral pseudoaneurysms. Discuss success and limiting factors to treatment. internal iliac artery aneurysms treated with bilateral bifurcated endo- prostheses. Detailed diagrams of a common IAA classification scheme BACKGROUND: Pseudoaneurysms are frequently encountered in clini- and the associated endovascular management will be provided. cal practice but can have unconventional presentations and can arise in uncommon locations. Pseudoaneurysms can present as sequelae 44 | Educational e-Posters SIR 2019 Annual Scientific Meeting

CONCLUSIONS: Iliac artery aneurysms, particularly when seen in com- BACKGROUND: Type II endoleaks are the most common endoleak sub- bination with abdominal aortic aneurysms, are a clinical entity many type occurring in approximately 10-25% of patients who have under- interventionists will encounter in their clinical practice. Familiarity with gone abdominal aortic endovascular aneurysm repair (EVAR). This these treatment approaches and complications will help insure suc- endoleak subtype occurs due to retrograde flow from either single or cessful treatment and minimization of morbidity. multiple collateral vessels that feed into the aneurysm sac, which can be highly challenging to treat from a technical and outcome perspec- tive. Despite the technical challenges, endovascular techniques are the Abstract No. 726 preferred treatment method and demonstrate less morbidity and mor- tality than surgical and conservative management. Review of interventional radiologic techniques as an adjunct to TEVAR CLINICAL FINDINGS/PROCEDURE DETAILS: This educational exhibit will: (1) present an overview of Type II endoleaks while reviewing relevant S Bansal1, V Kotha2, E Herget3, J Appoo4, A Gregory1 anatomy and physiology, (2) provide a case-based review of imaging 1 2 University of Calgary, Calgary, Alberta, Foothills Medical Centre, findings in various modalities (CTA, MRA, and Duplex Sonography), (3) 3 4 Calgary, AB, N/A, Calgary, AB, University of Calgary, Calgary, AB review the clinical management of Type II endoleaks including medical, interventional, and surgical techniques for repair, (4) present current LEARNING OBJECTIVES: Review the indications, procedural details, and potential complications of interventional radiology procedures including: endovascular techniques and technical pearls, (5) review the proce- -Chimney Graft -Petticoat -Percutaneous embolization of Type 2 endoleak dural indications, contraindications, and potential risks, and (6) review -Endovascular embolization of Type 1A endoleak -Coil assisted TEVAR the present literature, treatment outcomes and prognosis, and future -Stentless TEVAR -Use of endostapler for Type 1A endoleak -Endovascu- therapies. lar techniques for coarctation and patent ductus arteriosus repair CONCLUSIONS: After reviewing this exhibit, the viewer will gain a better understanding of the management of type 2 endoleaks including the BACKGROUND: TEVAR is now increasingly used for thoracic aortic aneurysm and dissection repair. As outcomes from TEVAR improve proper utility of endovascular techniques, technical pearls and treat- and experience with post-operative imaging increases, interventional ment outcomes, as well as current data and future therapies. radiologic techniques are gaining popularity in managing endoleaks and persistent false lumen perfusion. In addition, endovascular Abstract No. 728 adjuncts to primary TEVAR has increased operative success rate. At our institution, interventional radiology is an integral component of the Atherectomy in the management of lower extremity multidisciplinary thoracic aortic program and all thoracic aortic sur- peripheral arterial disease: case-based review of currently geries are planned and executed in a multidisciplinary fashion. available technology CLINICAL FINDINGS/PROCEDURE DETAILS: Techniques include: chim- M Shahid1, P Shukla1, V Chandra2, O Jamil3, A Kumar4 ney (parallel) graft, PETTICOAT, percutaneous embolization of Type 2 1Rutgers–New Jersey Medical School, Newark, NJ, 2Rutgers New endoleak, endovascular embolization of Type 1A endoleak, coil assisted Jersey Medical School, Belle Mead, NJ, 3Rutgers New Jersey TEVAR, stentless TEVAR, use of endostapler for Type 1A endoleak and Medical School, Newark, NJ, 4Rutgers New Jersey Medical School, endovascular techniques for coarctation and patent ductus arteriosus New York, NY repair. LEARNING OBJECTIVES: 1. To review current indications and outcomes CONCLUSIONS: This poster is intended to provide a comprehensive for atherectomy in femoro-popliteal and infrapopliteal arterial lesions. review of various interventional techniques that are used as adjuncts 2. Provide a case based pictorial review of different atherectomy tech- to TEVAR and how interventional radiology plays an integral role in nology available in the US multidisciplinary aortic disease management. BACKGROUND: Atherectomy, the removal of plaque from diseased ves- sels, has continued to emerge as a major therapy in the management Abstract No. 727 of peripheral arterial disease (PAD). Instead of damaging the native vessel by pushing aside plaque with a balloon or stent, the plaque is Type II endoleaks: review of imaging evaluation and removed. More recently, Use of atherectomy has been described for contemporary treatment strategies treating both calcified and non-calcified lesions as part of “vessel P Dubé1, M Makary1, J Cooke2, J Dowell3 prep” prior to drug coated balloon use .Over the past several years, 1The Ohio State University Medical Center, Columbus, OH, 2St Vincent’s several atherectomy devices have been introduced in the US market Hospital, Carmel, IN, 3The Ohio State University, Powell, OH for treatment of femoro-popliteal or small-vessel tibio-peroneal dis- ease. These include rotational, directional, photoablative/laser and LEARNING OBJECTIVES: To review diagnostic imaging evaluation, clin- orbital atherectomy. ical management, and interventional techniques of Type II endoleaks, CLINICAL FINDINGS/PROCEDURE DETAILS: This exhibit will provide a as well as examine the current literature, treatment outcomes, and case based review of the different atherectomy devices available future therapies. SIR 2019 Annual Scientific Meeting Educational e-Posters | 45 in the US. Existing literature including guidelines and appropriate Abstract No. 730 use of atherectomy devices will be reviewed. Cases demonstrating the use photoablative, rotational, directional, and orbital atherec- Aberrant anatomy in uterine artery embolization: tomy will be presented. Technical device specific factors will be parasitized omental artery and other variant vascular discussed. supply to the fibroid uterus

1 2 3 4 CONCLUSIONS: Atherectomy plays an increasingly significant role in R Hasan , S Mittal , K Anton , C Gonsalves the endovascular treatment of lower extremity peripheral arterial dis- 1Drexel University College of Medicine/Hahnemann University ease. With a plethora of devices now available in the US, an under- Hospital, Philadelphia, PA, 2Winthrop-University Hospital, Mineola, standing of device functionality and appropriate use is essential for the NY, 3University of North Carolina, Chapel Hill, NC, 4Thomas interventional radiologists treating PAD. Jefferson University Hospital, Philadelphia, PA

LEARNING OBJECTIVES: Display a pictorial review of variant uterine Abstract No. 729 arterial anatomy potentially leading to incomplete fibroid emboliza- tion if not detected. Provide a case-based review of parasitized uterine Tips and tricks for pedal loop chronic total occlusions supply from omental artery branches. Detail procedural techniques to better define the anatomy in patients with aberrant arterial supply to O Adenikinju1, E Atri2, S Cesar Durscki Vianna1, R Beasley1, B Olivieri1, T Yates1 the fibroid uterus 1Mount Sinai Medical Center, Miami Beach, FL, 2Herbert BACKGROUND: Uterine fibroids are the most common benign neo- Wertheim College of Medicine, Florida International University, plasms of the female reproductive tract, causing menstrual distur- Hollywood, FL bances and bulk-symptoms including pain, bloating, urinary frequency, and constipation. Uterine artery embolization (UAE) is utilized as first- LEARNING OBJECTIVES: 1) Review vascular anatomy below knee and line therapy for symptomatic fibroids or as adjunct therapy prior to below ankle (BTK & BTA) and its relation to the angiographosome con- surgical myomectomy/hysterectomy. Recognition of common and cept (wound-related revascularization) 2) Critical limb ischemia (CLI) uncommon variant arterial anatomy is imperative to providing opti- pathophysiology leading to chronic total occlusion 3) Explore tech- mal treatment as unrecognized variants frequently lead to incomplete niques for access, crossing and delivering therapy 4) Guide the reader embolization and diminished clinical outcomes. on wire and device selection based on access and plaque morphology 5) Develop an algorithm for BTK and BTA disease; the latter being the CLINICAL FINDINGS/PROCEDURE DETAILS: We provide a pictorial, case- frontier and most challenging area of CLI 6) Discuss pearls & pitfalls based review of less commonly reported variant arterial anatomy through case examples obtained during uterine artery embolization of the fibroid uterus. Mul- tiple examples of interesting variant anatomy including omental, round BACKGROUND: Around 18 million Americans are affected by peripheral ligament, inferior mesenteric, and anomalous ovarian artery supply to artery disease (PAD). The end-stage variety of PAD, CLI, results in a the fibroid uterus are shown. We provide procedural tips to improve high proportion of lower extremity amputations. Up to 40% of patients identification of this aberrant vasculature in order to prevent incom- with symptomatic PAD have chronic total occlusions (CTO). Arterial plete fibroid embolization. A review of the literature is presented. revascularization is an important component in the management of CLI, and may provide pain relief, promote wound healing and limb CONCLUSIONS: A detailed understanding of common and uncom- salvage when appropriate wound management strategies are also mon variant uterine arterial anatomy is crucial to maximize treatment employed. Vascular specialists must have an understanding of vessel response and minimize potential complications in UAE. Small techni- course and variation, the strengths and weaknesses of available treat- cal/procedural tips can help detect aberrant anatomy in UAE. ment options, and be able to delineate an algorithmic endovascular approach for BTA CTO patients. Abstract No. 731 CLINICAL FINDINGS/PROCEDURE DETAILS: Our algorithm guides vas- cular specialists in the management of CTOs in pedal loop reconstruc- Bullet points: a case-based review of close range gunshot tions by: 1) Reviewing rationale for different BTK/BTA endovascular wounds resulting in various post-traumatic fistula devices 2) comparing and contrasting mechanisms of action, benefits, formations and potential complications for each available therapy 3) Discussing D Foote1, B Black1, A Goud1, A Suzuki-Han2 pearls and pitfalls for increasing procedure efficacy through case 1Harbor UCLA Medical Center, Torrance, CA, 2Harbor UCLA Medical examples. Center, Redondo Beach, CA CONCLUSIONS: Tibiopedal occlusions represent a final frontier for man- LEARNING OBJECTIVES: The purpose of this exhibit is: 1. To explain the agement of CLI. Our algorithm will help vascular specialists to effec- unique mechanisms of injury in gunshot wounds using our experience tively manage this complex disease. at a level 1 trauma center. 2. To discuss methods to rapidly identify injury patterns, complications injury and discuss the role of interventional 46 | Educational e-Posters SIR 2019 Annual Scientific Meeting

radiology. 3. To review optimal imaging protocols for gunshot wounds year. We will use these cases to illustrate different embolization tech- in the emergency setting. 4. To review case examples illustrating gun- niques, pitfalls, and complications. Using angiographic images, we will shot wounds, management and long-term sequelae. define the anatomy of the chest wall. Complications include non-tar- get embolization, stroke and refractory bleeding. BACKGROUND: Gunshot wounds are a significant health and safety issue in the united states with a gun homicide rate over 25 times higher CONCLUSIONS: Rarely patients with chest wall hematomas will fail than any other high income country. In 2015 there were 36,252 firearm conservative management and require aggressive management with deaths and 84,997 gunshot wound victims in the united states with embolization. An understanding of anatomy and potential complica- an estimated average cost of $734.6 million per year in hospitaliza- tions is critical in successful management of these cases. tions. This cost is even higher, nearing $48 billion, if total lifetime costs are included, factoring in additional medical and work-loss costs . At our level 1 trauma center we have seen between 315 and 372 gunshot Abstract No. 733 injuries per year with a wide variety of presentations. In our experi- Geniculate artery anatomy and the role of embolization in ence close range gunshot wounds often result in various fistulas which patients with osteoarthritis can be managed with minimally invasive techniques which are often a cheaper alternative with less morbidity. N Shah1, D Dinh1, Y Epelboym1

1 CLINICAL FINDINGS/PROCEDURE DETAILS: Using 20 cases we will illus- Boston Medical Center, Boston University School of Medicine, trate imaging findings in gunshot wounds, management and long-term Boston, MA sequelae. Cases include gunshot wound to the with aortocaval LEARNING OBJECTIVES: 1. Review synovial angiogenesis in osteoar- fistula; left subclavian arteriovenous fistula managed with coil embo- thritis (OA) 2. Review geniculate artery anatomy 3. Role of geniculate lization; gunshot through the liver managed with embolization; liver artery embolization (GAE) for OA 4. Review literature for clinical out- wound with post-traumatic cutaneous biliary fistula, requiring bile comes of GAE for OA flow diversion; MRI image of gunshot wounds with typical artifacts; and angiograms of shock arteries in multiple cases. BACKGROUND: Osteoarthritis (OA) is the leading cause of chronic pain in older patients (1). In part, the severity of knee OA pain is associ- CONCLUSIONS: Gunshot wounds are a significant public health issue. ated with synovitis severity (2). Pathology of synovium in OA patients Interventional radiology physicians play an important role in treating reveals a thickened lining layer, inflammatory infiltration, and increased these injuries. Understanding the different mechanisms of injury can vascularity (3). Angiogenesis promotes additional hyperplasia and help a radiologist identify critical injuries and guide management. inflammation leading to joint destruction, accompanied by sensory nerve growth contributing to OA pain (4,5). Recent literature suggests Abstract No. 732 that transarterial embolization of the geniculate arteries (GAE) can improve pain symptoms in patients with mild to moderate knee OA Chest wall hematomas: an overview of anatomy, (1,5). Symptomatic relief may be due to reduced synovitis, reduced approach, and complications periarticular innervation and nociception, and maintaining integrity of the joint (5). To perform GAE, it is vital to have a detailed under- 1 1 1 1 1 1 G Zhu , Z Cizman , R Hardman , R O’Hara , K Marashi , G Fine , standing of the geniculate artery anatomy. The popliteal artery gives K Quencer1, C Kaufman1 rise to five geniculate arteries; medial superior, lateral superior, middle, 1University of Utah, Salt Lake City, UT medial inferior, and lateral inferior geniculate arteries.

LEARNING OBJECTIVES: After viewing this exhibit, the reader will be CLINICAL FINDINGS/PROCEDURE DETAILS: Multiple studies on GAE for able to: 1) Understand the anatomy of the chest wall blood supply. 2) OA have been performed, predominantly internationally. The largest Understand interventional radiology’s role in management of chest prospective study to date was performed in Japan with 72 patients wall hematomas and the approach. 3) Recognize the potential compli- embolized with Imipenem/Cilastatin sodium or 75-μm spherical cations with chest wall angiography and embolization. embolic in areas of synovial hypervascularity and palpable pain. That study revealed abnormal genicular neovascularity in all cases. Mean BACKGROUND: Chest wall hematomas often result from iatrogenic WOMAC pain scores significantly decreased from baseline up to 24 injury or trauma; however, spontaneous and non-traumatic causes months after embolization. Clinical success rates at 6 months and 3 have been reported. Often hematomas can be managed conserva- years were 86.3% and 79.8%, respectively. Two-year post procedure tively, however, hematomas can be life threatening. Embolization can knee MRI showed significant reduction in synovitis, without osteone- play an integral role in the patient management. An understanding of crosis or aggressive progression of OA. the anatomy, approach, and potential complications is therefore cru- cial when these scenarios arise. CONCLUSIONS: Geniculate artery angiogenesis and sensory nerves growth is thought to be a major contributing factor for pain in OA. CLINICAL FINDINGS/PROCEDURE DETAILS: Following a review of the Several recent studies show transcatheter arterial embolization of the pertinent arterial anatomy of the chest wall, we present a total of six geniculate arteries to significantly improve pain symptoms and quality cases of chest wall hematomas, with both traumatic and non-trau- of life in patients with mild to moderate knee OA. matic etiologies (respectively two and four) at our institution the past SIR 2019 Annual Scientific Meeting Educational e-Posters | 47

Abstract No. 734 3. To review pertinent scientific literature underlying major decision points in managing splenic trauma. 4. To discuss some of the pre- and Interventional management of post-operative partial post-procedure complications underlying the interventional manage- nephrectomy complications ment of splenic trauma.

1 1 1 1 1 T Rashid , C Lugo , E Esses , A Gaffar , O Furusato Hunt , BACKGROUND: The is the second most commonly injured 1 1 1 S McCabe , G Rozenblit , S Maddineni abdominal organ. Many splenic injuries require intervention for hemo- 1Westchester Medical Center, Valhalla, NY dynamic instability or continued failed non-operative management. Interventional radiology plays an ever-evolving role in multidisciplinary LEARNING OBJECTIVES: 1. To discuss the rationale for partial nephrec- management of splenic trauma and can spare patients the associated tomy as a treatment option for suitable cases of renal cell carcinoma. morbidity and mortality risks involved in surgical exploration, espe- 2. To discuss different post-operative complications after partial cially in light of other organ system injuries. Having an understanding nephrectomy. 3. To discuss different interventional management of the indications and contraindications for intervention, patterns of options for post-operative complications after partial nephrectomy. injury that would help delineate intervention as defined by the AAST

BACKGROUND: Partial nephrectomy, or nephron-sparing surgery, is spleen injury scale, and principles of interventional management can the standard of care surgical treatment for T1a renal cell carcinoma help ensure proper management of the patient. and favored over radical nephrectomy for T1b renal cell carcinoma CLINICAL FINDINGS/PROCEDURE DETAILS: We illustrate the American for better renal functional preservation leading to improved survival Association for the Surgery of Trauma (AAST) classification system for advantages. This procedure is not without significant post-operative different patterns of splenic trauma using a case-based approach. We risk. Thus, the management of post-operative complications after further perform a review of current scientific literature that helps influ- partial nephrectomy requires a multidisciplinary team of urologists, ence the major decision points between operative, non-operative, and medical oncologists, and interventional radiologists. Understanding interventional management. Finally, we describe some of the pre- and the different post-operative complications that can arise after par- post-procedure complications associated with interventional manage- tial nephrectomy, including different decision points between medi- ment of splenic trauma. cal, interventional, and surgical management, can help ensure proper management of the patient and prevent morbidity and mortality. CONCLUSIONS: With a proper understanding the current AAST grading system and scientific literature underlying the management of splenic CLINICAL FINDINGS/PROCEDURE DETAILS: Using a case-based trauma, the interventional radiologist can help devise appropriate approach, we discuss the rationale for partial nephrectomy as a proce- management plans on a per patient basis and communicate them with dure in appropriately staged renal cell carcinoma over radical nephrec- the multidisciplinary team to help prevent morbidity and mortality. tomy. We utilize the scientific literature to discuss the many reported post-operative complications that can arise after partial nephrectomy, and utilize pertinent clinical and imaging features that can help delin- Abstract No. 736 eate between them. Finally, we discuss the different interventional management options of post-operative complications after partial Optimizing pain control with superior hypogastric nerve nephrectomy. block during uterine fibroid embolization

1 1 1 1 1 1 CONCLUSIONS: Partial nephrectomy is a safe and efficacious pro- R Ahuja , M Naveed , A Desai , M Callaghan , A Syal , B Natarajan , 1 1 cedure in patients with appropriately staged renal cell carcinoma to M Ferra , D Decotiis help preserve nephron function, thus conferring improved survival 1Einstein Medical Center, Philadelphia, PA advantages. This procedure is not without the potential for significant LEARNING OBJECTIVES: Post procedural pain is one of the most com- post-operative complication. The interventional radiologist can help mon side effects of uterine artery embolization (UAE) for fibroid treat- devise appropriate management plans and communicate them with ment which limits its widespread use as an alternative to hysterectomy. the multidisciplinary team to help prevent long-term morbidity and Providing adequate periprocedural pain relief remains a continuing mortality. challenge. With newer techniques and devices, Superior hypogastric nerve block (SHNB) is a great adjunct technique for decreasing pain Abstract No. 735 postembolization without adding additional major risk.

BACKGROUND: UAE is an excellent viable alternative to surgery, with Management principles of splenic trauma equal patient satisfaction, shorter hospital stays, and faster return T Rashid1, C Lugo1, C Shilagani1, E Esses1, A Gaffar1, O Furusato to work; however, post procedural pain remains a hurdle for its more 1 1 1 1 1 Hunt , W Gao , S McCabe , G Rozenblit , S Maddineni widespread use. Post embolization pain usually peaks 6-8 hours after 1Westchester Medical Center, Valhalla, NY UAE, which is usually severe and is primarily a result of tissue ischemia. Pain is often managed with intravenous opioids, which necessitates LEARNING OBJECTIVES: 1. To review the AAST spleen injury scale. 2. To hospital admission. SHNB during UAE can reduce the need for narcot- discuss the principles of interventional management of splenic trauma. ic-based pain control and eventually decrease the overall hospital stay. 48 | Educational e-Posters SIR 2019 Annual Scientific Meeting

CLINICAL FINDINGS/PROCEDURE DETAILS: The superior hypogastric CONCLUSIONS: Pain management strategies for UFE begin in the ini- plexus (SHP) is a retroperitoneal structure located bilaterally at the tial patient consultation. Aggressive pain control before, during, and level of the lower 1/3 of the 5th lumbar vertebral body and upper 1/3 of after UFE has a dramatic effect on pain related to postembolization the first sacral vertebral body at the sacral promontory and in proxim- syndrome. In particular, superior hypogastric nerve block is recog- ity to the bifurcation of the common iliac vessels. After femoral access, nized as a major contributor to minimizing postembolization syn- a catheter is advanced into the contralateral common iliac artery. Next, drome pain. If used effectively, women can be safely and confidently 21g Chiba needle is advanced into the SHP via an anterior infraumbili- discharged on the day of the procedure with little risk for readmission cal approach using the arterial catheter as a fluoroscopic landmark to for pain control. target the vertebral body below. A small amount of contrast is infused to exclude intravascular placement of the tip. A long acting local anes- thetic is then injected for SHNB. Abstract No. 738

CONCLUSIONS: Improvement in periprocedural pain is one of the keys Preoperative embolization of spinal metastasis of renal to the widespread adoption of UAE as a first-line therapy in the treat- cell carcinoma: a review of the literature and current ment of symptomatic fibroids. SHNB significantly lessens pain after practices UAE. It can significantly reduce the need for pain-related narcotics R Petek1, D Petrov2, B Goodman2 after UAE without exposing the patient to increased major risk more. 1 SHNB makes the recovery period more comfortable for the patient Lake Erie College of Osteopathic Medicine, Horseheads, NY, 2 and allows for same day discharge making UFE more cost-effective Allegheny General Hospital, Pittsburgh, PA and accessible. LEARNING OBJECTIVES: 1) Review renal cell carcinoma (RCC) metas- tases and available treatment options. 2) Discuss current treatment Abstract No. 737 options for vertebral metastases. 3) Discuss role of preoperative tran- sarterial embolization. 4) Discuss future studies for role of interven- Pain management strategies for uterine fibroid tional radiology in RCC metastasis treatment. embolization BACKGROUND: As overall survival from cancer increases, the inci- C Commander1, D Mauro1, C Burke1, J Stewart1 dence of spinal metastasis has also continued to increase. As symp- tomatic Renal cell carcinoma (RCC) metastases to the spine increase 1University of North Carolina, Chapel Hill, NC in prevalence, there has been an increase in directed treatments for

LEARNING OBJECTIVES: After reviewing this exhibit, the reader will 1) spinal metastases, such as molecular therapies targeting the vascu- learn the various causes of pain associated with uterine fibroid embo- lar endothelial growth factors and mammalian target of rapamycin lization, 2) understand postembolization syndrome, and 3) learn pain (mTOR) to treat and mitigate the pathologic effects of spinal metas- management techniques used for uterine fibroid embolization. tases such as spinal cord compression and hypercalcemia, both which often predict poor outcomes. Surgical resection remains as a BACKGROUND: Uterine fibroid embolization (UFE) is a safe and effec- mainstay for locoregional control of RCC spinal metastasis, which can tive treatment for women with symptomatic uterine fibroids. Pain often be complicated by perioperative blood loss due to the hyper- associated with the procedure is often cited as a reason women pursue vascular nature of RCC tumors. Endovascular embolization of these (or are advised to seek) alternative treatment for their fibroids such as lesions improves intraoperative blood loss, and may improve surgical myomectomy or hysterectomy. Diligent pain management strategies outcomes. employed before, during, and after the procedure can be extremely effective at minimizing post-UFE pain. In this exhibit, we review cur- CLINICAL FINDINGS/PROCEDURE DETAILS: Preoperative transarterial rent techniques and therapies for optimizing UFE-related pain and embolization of RCC metastases has emerged as a minimally inva- postembolization syndrome secondary to UFE. sive intervention to mitigate the risk of preoperative bleeding. While there is controversy on the benefits of preoperative embolization, CLINICAL FINDINGS/PROCEDURE DETAILS: A variety of techniques can most studies have looked at intraoperative blood loss as the primary be used to minimize pain associated with UFE. Pre-procedure consulta- outcome. This exhibit reviews the angiographic evaluation and tran- tion with the patient is useful for providing reasonable expectations of sarterial embolization of spinal RCC metastasis. Our exhibit includes her expected post-procedure experience. Pre-procedure administra- an imaging review of: 1) RCC spinal metastasis, 2) Important arterial tion of an antiemetic, a narcotic, and a long-acting anti-inflammatory anatomy to be aware of during embolization, and 3) postembolization are often used to preempt post-procedure pain. The use of tumescent angiography of RCC metastasis. Imaging modalities include CT, arterial anesthesia around the femoral access site has also been proposed. In angiography, and digital subtraction angiography. addition to standard moderate sedation regimens, intraprocedural pain control methods include superior hypogastric nerve block and CONCLUSIONS: Preoperative embolization of hypervascular spinal intraarterial lidocaine administration. Aggressive post-procedure RCC metastases may reduce intraoperative blood loss and is emerg- treatment with narcotics, non-steroidal anti-inflammatory drugs, and ing as an adjunct therapy aimed at improving metastatic morbidity in antiemetics are essential for managing pain associated with postem- patients with advanced RCC. bolization syndrome. SIR 2019 Annual Scientific Meeting Educational e-Posters | 49

Abstract No. 739 LEARNING OBJECTIVES: Increase awareness of SACE as a safe and feasible pre-EVAR procedure with aim to reduce risk of postop spinal Renal artery embolization for severe nephrotic syndrome: ischemia. Increase knowledge of vital preprocedural steps to maximize anatomical, procedural, and pictorial review of the role success such as: 1)Stopping anti-hypertensive medications 3 days prior for interventional radiology in non-surgical nephrectomy to procedure. 2)Obtaining CTA for planning of target vessel emboliza- M Hoque1, B Harris2, J Stewart1, D Mauro1, K Anton1 tion likely to be covered during EVAR. 3)Performing SACE on inpatient basis to monitor neurologic sequelae. 1University of North Carolina, Chapel Hill, NC, 2Temple University, Philadelphia, PA BACKGROUND: Segmental artery coil embolization (SACE) for arte- riogenic spinal cord collateral precondition before thoracoabdominal LEARNING OBJECTIVES: Detail a multidisciplinary approach to patient aortic aneurysm (TAAA) repair (EVAR) has been recently described selection for renal artery embolization (RAE), medical nephrectomy, (1,2) and adopted at our institution. We share our early experience of or surgical nephrectomy. Better define the role of interventional radiol- SACE in four cases occurring between Mar 1 and Sept 30, 2018 prior ogy in the treatment of patients with severe nephrotic syndrome. Pro- to elective staged EVAR. All patients had preoperative CTA. Anti-hy- vide a pictorial review of anatomic and technical considerations in RAE pertensive held 3 days prior to procedure. Patients were admitted to for nephrotic syndrome monitor neurologic sequelae and place a spinal drain if needed.

BACKGROUND: Nephrotic syndrome is caused by a number of medi- CLINICAL FINDINGS/PROCEDURE DETAILS: Case 1: 79-year-old M with cal conditions and pharmaceuticals. This condition is characterized by Crawford type 2 TAAA measuring 7.5 cm had 1-vessel SACE using 3-4 heavy proteinuria leading to peripheral edema, hyperlipidemia, and mm microcoils. Discharged on PPD#1. 4 wks later EVAR with spinal hypoalbuminemia. Systemic complications include venous thrombotic drain placement was done. Discharged on POD#4. No neurologic events, bacterial infections, accelerated atherosclerosis, and renal fail- sequelae on clinic visit 31 days (d) later. Case 2: 71-year-old M with his- ure. Uncontrolled severe nephrotic syndrome, refractory to medical tory of type B dissection post TEVAR in 2011, presents with expan- management, can lead to significant morbidity and mortality. Fail- sion of aneurysm. 2-vessel SACE done using 3-4 mm microcoils. 6d ing conservative management, these patients require some form of later, first stage endovascular repair with spinal drain was performed, nephrectomy or renal ablation. Surgical nephrectomy results in higher and 27d later second stage 2-vessel branch repair completed. Second morbidity and longer hospital stays. Minimally invasive alternatives to postop course complicated by transient renal injury needing tempo- this approach include RAE or medical nephrectomy, the latter of which rary dialysis. Discharged in POD#25. No neurologic sequelae. Case 3: is frequently clinically unsuccessful. 65-year-old M with history of CKD, PAD, HTN and type 4 TAAA. 6-ves-

CLINICAL FINDINGS/PROCEDURE DETAILS: We will provide a case-based sel SACE using 3-5 mm microcoils done with uneventful discharge on review of renal artery embolization for severe nephrotic syndrome in PPD#1. 15d later 4-vessel EVAR with spinal drain done with hospital a 67-year old female who failed a trial of medical nephrectomy using discharge on POD#7. No neurologic sequelae on clinic visit 45d later. high-dose NSAIDs. Discussion will include relevant imaging, anatomic Case 4: 79-year-old M with type 3 TAAA measuring 6.3 cm. 4-vessel considerations, as well as important procedural decisions; including SACE done using 2-4 mm microcoils. Discharge on PPD#1. Pending choice of unilateral vs bilateral ablation, single setting vs. staged, and custom EVAR. No neurologic sequelae. preferred embolization agents. A detailed review of the literature will CONCLUSIONS: SACE before EVAR appears safe in our early experi- also be provided. ence of minimizing risk of spinal cord ischemia.

CONCLUSIONS: Uncontrollable nephrotic syndrome causes significant debilitation in this patient population. Morbidity and mortality from Abstract No. 741 bilateral surgical nephrectomy has been reported as high as 87% and 11.7%, respectively. Medical nephrectomy using a short course of The origins of hemoptysis: ectopic bronchial artery high-dose indomethacin has been reported, however frequently is anatomy unsuccessful. Renal artery embolization using variable embolization agents can be a successful, minimally invasive treatment option for E Joiner1, R Hardman1, R O’Hara2, C Kaufman1, Z Cizman1, 1 1 this patient population. Future studies may help define optimization of K Quencer , K Marashi embolization agents for improved clinical success. 1University of Utah, Salt Lake City, UT, 2University of Utah/ Huntsman Cancer Center, Salt Lake City, UT

Abstract No. 740 LEARNING OBJECTIVES: -Review terminology regarding anatomy of the bronchial arteries. -Review possible anomalous origins of ectopic Segmental artery coil embolization for arteriogenic bronchial arteries with case examples. -Review importance of aware- preconditioning of the spinal cord network before ness of possible ectopic bronchial arteries in the setting of bronchial thoracoabdominal aortic aneurysm repair: an early artery embolization for massive hemoptysis. experience BACKGROUND: The bronchial arteries typically originate from the prox- A Sidhu1, T Chan1, A Jaberi1, G Annamalai1, K Tan1 imal descending thoracic aorta and are described as orthotopic when 1University Health Network, University of Toronto, Toronto, ON they originate between the superior endplate of T5 and the inferior 50 | Educational e-Posters SIR 2019 Annual Scientific Meeting

endplate of T6. Bronchial arteries originating elsewhere are described 22-gauge 15cm needle is advanced under direct fluoroscopic guidance as ectopic. Rates of at least one ectopic bronchial artery have been targeting the superior hypogastric nerve plexus, located midline just described in the literature as ranging from 8-56% of patients (1-4). anterior to the vertebral bodies at the level of L5-S1 intervertebral disc Possible anomalous origins include the aortic arch, distal descending space. Confirmation of needle placement with dilute contrast and aspi- thoracic aorta, subclavian artery, brachiocephalic artery, thyrocervical ration is used to ensure needle tip is extravascular, with a classic fan- trunk, internal mammary artery, intercostal artery, phrenic or gastric shaped appearance of the contrast. Next, 20 mL of bupivacaine HCl arteries and coronary arteries (1,2). Awareness of potential anomalous 0.25% is injected at this location. Fluoroscopic imaging is then used to origins of the bronchial arteries is particularly important in the setting confirm the solution was confined to the prevertebral region along the of massive hemoptysis for localizing the source of bleeding during expected nerve bundle. angiography for possible embolization. CONCLUSIONS: The addition of SHNB provides improved pain control CLINICAL FINDINGS/PROCEDURE DETAILS: A case review of 11 ecto- for UAE. By adding approximately 8-10 minutes of procedure time, pic origins of bronchial arteries in patients who underwent bronchial patients have improved pain control and decreases the amount of opi- artery angiography will be presented. Ectopic bronchial artery origins oids needed for pain control. This technique also allows UAE to be per- presented include the internal mammary, thyrocervical, brachioce- formed in an outpatient setting. When performing this procedure it is phalic, phrenic, gastric, and intercostal arteries. important to confirm proper placement of the needle, as intravascular administration of bupivacaine can lead to cardiac arrest. CONCLUSIONS: -Bronchial arteries may arise from an orthotopic or ectopic location. -Possible ectopic origins of bronchial arteries include the aortic arch, distal descending thoracic aorta, subclavian Abstract No. 743 artery, brachiocephalic artery, thyrocervical trunk, internal mam- mary artery, intercostal artery, phrenic or gastric arteries, or coro- Uterine fibroid embolization cost analysis nary arteries. -Awareness of possible ectopic origins of the bronchial W Bremer1, A Valeshabad2, C Ray3 arteries is key during bronchial artery embolization for massive 1 hemoptysis when the bronchial arteries are not found in the normal University of Illinois-Chicago Medical Center, Chicago, IL, 2 3 orthotopic location. University of Illinois-Chicago, Chicago, IL, University of Illinois Hospital and Health Sciences Center, Chicago, IL

Abstract No. 742 LEARNING OBJECTIVES: 1) Establish the burden uterine fibroids place on society. 2) Discuss the various methods of cost analysis in the med- The role of a superior hypogastric nerve block in uterine ical literature. 3) Analyze the cost-effectiveness of the various uterine artery embolization sparing treatment options for uterine fibroids. J Foster1, S Lone2, R Pyne3 BACKGROUND: Uterine fibroids are a common occurrence in pre- menopausal women, with an incidence by age 50 of up to 80% in 1Rochester Regional Health, Rochester, NY, 2Rochester General black women and 70% in white women. This results in an estimated Hospital, Rochester, NY, 3Rochester General Hospital, Pittsford, NY direct cost of $4.1-9.4 billion USD per year with an additional cost

LEARNING OBJECTIVES: The objective of this abstract is to discuss the of 1.5-17.1 billion USD per in lost work hours. Although hysterectomy role of a superior hypogastric nerve block (SHNB) in uterine artery is a definitive solution for women with uterine fibroids, alternative embolization (UAE). We will review the anatomy and pathophysi- therapies exist for women wishing to preserve fertility or avoid sur- ology of this procedure. We will also discuss the technique used to gery. Cost analysis in the medical literature is generally underutilized, perform this procedure during a UAE with tips to improve success. particularly in North America, and can assist in guiding management Lastly, we will discuss the benefits of performing this procedure for of uterine fibroids. your patients. CLINICAL FINDINGS/PROCEDURE DETAILS: Uterine sparing less-inva-

BACKGROUND: UAE is an effective treatment for symptomatic fibroids sive options include uterine artery embolization (UAE), uterine artery with Level A data recognized by the American College of Gynecology. occlusion (UAO), myomectomy, and Magnetic Resonance-guided This treatment is an alternative to hysterectomy as it has a shorter hos- Focused Ultrasound Surgery (MRgFUS). Studies determining the pital stay, faster return to work and equal patient satisfaction. Unfor- overall economic burden and indirect costs of uterine fibroids are dis- tunately, post-procedural pain remains an obstacle for its widespread cussed. Multiple studies assessing monetary costs, lost productivity, use. SHNB was found to be an excellent addition to this procedure to and outcomes associated with uterine sparing treatment options were control post-procedural pain and decrease opioid use. By adding this reviewed to help guide decision making in the treatment of uterine technique, UAE can be performed as an outpatient procedure with the fibroids. proper pain regimen as demonstrated in studies. CONCLUSIONS: 1) UFE trends towards higher costs, however this is not

CLINICAL FINDINGS/PROCEDURE DETAILS: During the UAE, after the statistically significant. 2) Quality adjusted life years (QALY) between aortic bifurcation is identified by placement of catheter and wire, the the varying treatments does not differ. 3) Lost productivity makes overlying skin near the umbilicus is numbed with lidocaine. Next, a uterine fibroid embolization more cost effective. SIR 2019 Annual Scientific Meeting Educational e-Posters | 51

Abstract No. 744 LEARNING OBJECTIVES: After reviewing this exhibit, the reader should understand the classification and pathophysiology of endoleaks after 2D perfusion angiography: an overview of technique and endovascular aneurysm repair (EVAR) and describe the benefits of 4D application in critical limb ischemia angio CT in their diagnosis and treatment.

1 2 2 3 4 3 A Alvi , Z Asseri , A Bin Habjar , M Arabi , O Bashir , S Qazi , R BACKGROUND: Seventy-five percent of abdominal aortic aneurysms 3 5 4 Salman , Y Al Zahrani , M Almoaiqel today are treated with endovascular aneurysm repair (EVAR) rather 1King AbdulAziz Medical City, Riyadh, Riyadh, 2King AbdulAziz than open repair. Persistent endoleak is the most common indication Medical City, NGHA, Riyadh, Riyadh, 3King Abdulaziz Medical City, for reintervention post-EVAR, up to 44% of which are classified as type Riyadh, Saudi Arabia, 4King Abdulaziz Medical City, Riyadh, Riyadh, II. Traditionally, patients will undergo CT angiography for endoleak sur- 5Western Ontario University, London, ON veillance. It is only after an intervenable source is targeted on conven- tional CT that the patient is brought to the angiography suite for further LEARNING OBJECTIVES: To demonstrate the utility of 2D Perfusion workup and management, which may entail transarterial, translumbar Angiography (2D-PA) in Critical Limb Ischemia (CLI). Technical consid- and/or transcaval embolizations. The most common is the transarterial erations and analysis of data obtained will be illustrated with reference approach. We have recently made use of a combined CT-fluoroscopy to recent literature and cases performed in our institute. suite for the contemporaneous diagnosis and treatment of endoleaks. BACKGROUND: CLI is a combination of both decreased inflow to the foot CLINICAL FINDINGS/PROCEDURE DETAILS: This exhibit will review the (macrocirculation) and volume flow through the capillary bed (micro- different types of endoleak and address our early experience using circulation) resulting in diminished oxygen concentration in the tissues. a combined CT-fluoroscopic suite in four separate cases. The advan- The goal of endovascular therapy in CLI is to recanalize the vessels to the tages of this technology will be highlighted. Two cases included suc- foot, obtain better tissue perfusion, and to accelerate wound healing. cessful coil embolization of suspected type II endoleak arising from the 2D-PA is a new imaging algorithm to measure volume flow in the whole inferior mesenteric artery. The other two cases demonstrate the confi- foot both in the macrocirculation and microcirculation utilizing data dent diagnosis of a type IB endoleak and type III endoleak. Images will from plain old digital subtraction angiography. Although this technique be provided from each case showing the corresponding CTA, angiog- requires additional software acquisition, it does not incur additional raphy and 4D angio CT images. radiation exposure or contrast dose. 2D-PA helps determine whether further revascularization of more outflow vessels is required to achieve CONCLUSIONS: Our early experience with a combined CT-fluoroscopy optimal inflow thus providing an objective end point for the procedure. suite has improved our ability in real time to more accurately diagnose, classify and treat endoleaks. CLINICAL FINDINGS/PROCEDURE DETAILS: 2D-PA is based on standard digital angiography at frame rate of three images per second followed by automatic reconstruction with post processing software on a dedi- Abstract No. 746 cated workstation. Care must be taken to fully immobilize the foot and to standardize parameters prior to 2D-PA. Perfusion analysis is based Management of critical limb ischemia: contemporary on calculating the change in density per pixel over time with images methods, emerging novel approaches, and a review of the being acquired before and after revascularization. Reconstructed literature images are evaluated for arrival time, time-to-peak, area under the N Cornish1, S Mustafa2, M Hoy3, A Birney4, D Igonkin5, D Sarkar6 curve (AUC) and mean transit time (MTT). A region of interest is cho- 1 2 sen by the operator to create a time-density curve. Change in maximal Maimonides Medical Center, Staten Island, NY, Maimonides 3 peak density and change in AUC best illustrate differences in pre and Medical Center, Brooklyn, NY, The George Washington University School of Medicine and Health Sciences, Washington, DC, 4Mount post procedural perfusion. Sinai Hospital, New York, NY, 5James J. Peters VA Medical Center, CONCLUSIONS: 2D-PA is a useful tool in critical limb ischemia evalu- N/A, 6Maimonides Medical Center, New York, NY ation and treatment. It aids in selection of patients who may benefit LEARNING OBJECTIVES: Review the definition and pathophysiology of from endovascular intervention based on functional imaging of the critical limb ischemia (CLI) along the spectrum of peripheral artery dis- microcirculation. Objective measurements of microvascular perfusion ease (PAD). Discuss the contemporary treatment options available for during and following endovascular procedures can help determine CLI and imaging modalities. Discuss the newer alternative approaches both the end point and outcome of revascularization. for treating CLI with a review of the literature to determine their effi- cacy. Propose a treatment algorithm based on current literature. Abstract No. 745 BACKGROUND: CLI is the most dangerous stage of PAD caused by tis- sue hypoxia injury and lack of blood supply, including distal extremity Early experience using a combined computed ischemia, ulcers, or gangrene. The prevalence of PAD in the general tomography–fluoroscopy suite in treatment of suspected population is 3-10% and 11.2% of patients with PAD deteriorate to CLI endoleaks with sac enlargement each year. Patients with CLI have high amputation (10-40%) and mor- J Groene1, S Zangan1, T Tullius1, B Funaki1 tality rates (20% within the first 6 months) with a high risk of cardio- 1University of Chicago, Chicago, IL vascular events. 52 | Educational e-Posters SIR 2019 Annual Scientific Meeting

CLINICAL FINDINGS/PROCEDURE DETAILS: There is no clear preferred damage. 2.Perioperative diagnosis of hypertensive urgency and strategy between endovascular and open surgical revascularization emergency is critical in deciding to proceed with a procedure. 3.Inter- for the treatment of CLI as determined by the BASIL trial. Typically, ventional radiologists should be aware of special considerations (e.g endovascular therapy is the first line treatment due to low procedural catecholamine excess, pregnancy, aortic dissection) that can be asso- risk . Current endovascular treatment options include PTA, atherec- ciated with hypertensive crises and their targeted medical therapies. tomy, or intravascular thrombolysis. Balloon angioplasty and stent- CONCLUSIONS: Interventional radiologists should: 1.Understand the ing form the backbone of endovascular techniques. Drug-eluting and need to effectively diagnose hypertensive crises and provide quick drug-coated balloons offer low rates of repeat revascularization and and effective treatment as a critical component of physician com- the SIROCCO trial will be reviewed. However, certain patients may petency and patient safety. 2.Know treatments of hypertension and require open surgical revascularization. Other novel therapies to be hypertensive crises and determine how to navigate a procedure for a discussed include below the knee angiosome-directed angioplasty, hypertensive patient and when to consult a specialist. 3.Know pathol- hybrid surgical techniques such as iliac stenting and common femo- ogies associated with hypertensive crises relevant for interventional ral endarterectomy, lower extremity bypass grafting, and bone mar- radiology procedures. row mononuclear cell transplantation for therapeutic angiogenesis. In addition transpedal access and subintimal re-entry will be reviewed. A summary of upcoming clinical trials such as the BEST-CLI Trial and Abstract No. 748 BASIL-2 trial. A proposed treatment strategy will be provided based on the current literature. Off-label use of closure devices: Maverick or Bailout?

1 1 2 3 4 5 CONCLUSIONS: Endovascular and surgical treatments for CLI and T Chan , A Sidhu , S Mafeld , A Jaberi , G Annamalai , K Tan should not be viewed as competing therapies but rather complemen- 1University Health Network, University of Toronto, Toronto, ON, tary techniques. Despite the confusion endovascular techniques are 2JDMI, Toronto General Hospital, Toronto, ON, 3University of almost always first line a several newer therapies are emerging. Toronto, University Health Network, Toronto, ON, 4Mount Sinai Hospital and University Health Network, Toronto, ON, 5Toronto General Hospital, Toronto, ON Abstract No. 747 LEARNING OBJECTIVES: Improve awareness and knowledge of off-la- Managing hypertension: what the interventional bel techniques associated with vascular closure devices. Increase radiologist needs to know knowledge of how off-label use of vascular closure devices can bail F Rahman1, R Blonsky2, A Kalra-Lall3, C Martin4 interventional radiologists out of difficult situations. Develop deeper understanding of the potential benefits and pitfalls of these techniques. 1Case Western Reserve University School of Medicine, Cleveland, OH, 2Marshfield Health System, Marshfield, WI,3 Case Western BACKGROUND: The use of vascular closure devices (VCD) has increased Reserve University, Cleveland, OH, 4Cleveland Clinic, Cleveland, OH significantly over the past decade. While closure devices are useful, the use of these devices can be limited by indications within the instruc- LEARNING OBJECTIVES: The purpose of this exhibit is: 1. To describe tions for use (IFU). Off label use outside the IFU of these devices can the immediate management of hypertensive urgencies and emergen- be controversial but are more common than anticipated. There are cies, highlighting management and decision-making for interventional numerous techniques described in case reports published in peer radiology procedures. 2. To review the mechanisms of action of antihy- review journals and presentations in interventional radiology confer- pertensive medications and indications for their use. ences. The purpose of this educational poster is to summarize off label

BACKGROUND: The new Guideline for the Prevention, Detection, Eval- use of the commonly used closure devices described in the published uation, and Management of High Blood Pressure in Adults issued by literature. The off-label use of VCD can be broadly summarized into the ACC and AHA in partnership with 9 other professional associations three main groups: 1) Planned closure of vessels not within the IFU of published in 2017 addressed the evaluation and treatment of hyperten- the vascular closure device. 2) Treatment of inadvertent puncture of sive urgency and emergency. Additionally, an analysis by Muntner et al. arteries with the vascular closure devices. 3) Off-label use of VCD for found that with the new guidelines, the prevalence of hypertension will nonvascular structures. rise to approximately 46% of US adults. With the magnitude of patients CLINICAL FINDINGS/PROCEDURE DETAILS: We identified 15 articles with a diagnosis of hypertension, the knowledge of how to identify and within the published literature describing the various off-label use of manage hypertensive crises will be of utmost importance to the inter- VCDs. In our institution, we have a series of examples of off-label use ventional radiologist. We will discuss an approach highlighting the rec- of VCDs which we will illustrate in the poster including the use of Pro- ognition and immediate interventions for this ever-growing problem. Glide Perclose for 12Fr axillary artery access, Angio-Seal and Exoseal

CLINICAL FINDINGS/PROCEDURE DETAILS: 1.Hypertensive urgency is in brachial access, double Angio-Seal technique for large access, Pro- defined as systolic blood pressure of ≥180 mmHg and/or diastolic blood Glide Perclose and Angio-Seal combined for large access and Exoseal pressure of ≥120 mmHg after checking at least twice and hyperten- for SFAs. The poster will describe in detail the indication, alternative, sive emergency as hypertensive urgency with evidence of end-organ benefits and potential pitfalls of each technique. SIR 2019 Annual Scientific Meeting Educational e-Posters | 53

CONCLUSIONS: These techniques are usually used in complex or bail- Abstract No. 750 out scenarios where the alternative involves extensive surgery. While we are not advocating routine use of these techniques, being aware Resuscitative endovascular balloon occlusion of the aorta of these techniques will add to the armamentarium when faced with A Saini1, K Zurcher1, P Hoang1, A Wallace1, S Alzubaidi1, a challenging case. M Knuttinen1, S Naidu1, R Oklu1 1Mayo Clinic, Phoenix, AZ Abstract No. 749 LEARNING OBJECTIVES: 1.Discuss the indications for REBOA, tech- nique, management, and complications 2.Summarize the high-grade Percutaneous management of rectal bleeding: the evidence, consensus statements and controversies surrounding “emborrhoid” procedure and retrograde transvenous REBOA 3.Describe the role interventional radiologists will play in the obliteration of varices future of REBOA research. A Abunimer1, P Nadendla2, S Patel2, N Kokabi2, G Peters2 BACKGROUND: REBOA involves the placement of an endovascular 1Virginia Tech Carilion School of Medicine, Roanoke, VA, 2Emory balloon in the aorta to control non-compressible torso hemorrhage University, Atlanta, GA in emergency medicine or trauma. It’s indicated for life-threatening

LEARNING OBJECTIVES: 1. Review the pathophysiology of hemor- hemorrhagic shock in patients with intra-abdominal, retroperitoneal, rhoids and rectal varices as etiologies for rectal bleeding. 2. Under- pelvic, or lower extremity hemorrhage and is used primarily as a tem- stand the application of emerging therapies in the treatment of rectal porizing measure prior to definitive management. It is less invasive and bleeding. more quickly applied when compared to resuscitative thoracotomy, which often times is not possible in a pre-hospital, trauma setting. BACKGROUND: Rectal bleeding is a common clinical problem with Studies examining the efficacy and outcomes of patients undergoing diverse etiologies. The most common anorectal condition causing REBOA have demonstrated mixed results, however high grade evi- rectal bleeding is hemorrhoids, resulting from distortion of vascularity dence suggests there is no survival benefit when compared to tho- and connective tissue of the anal cushions. Treatment is symptomatic racotomy. Furthermore, the procedure is not without complications and typically minimally invasive, but 10% of patients require surgery including dissection, thromboemboli, limb/organ ischemia, and death. which can be associated with significant complications. Rectal varices However, in trauma cases where no alternative exists, REBOA offers a are dilatations of submucosal veins from portal hypertension, rarely fast and effective temporizing solution. causing life-threatening hemorrhage. Variceal management ranges from supportive care to endoscopy, Transjugular Intrahepatic Porto- CLINICAL FINDINGS/PROCEDURE DETAILS: We will provide an overview systemic Shunt (TIPS) and even surgery. Up to 1/3 of cirrhotic patients of REBOA, its indications, technique, management and complications have both conditions. Emborrhoid and retrograde transvenous obliter- in a pre-hospital, trauma setting. We will discuss issues related to com- ation (RTO) have shown excellent short-term outcomes for the man- mon femoral artery cannulation and how interventional radiologists agement of hemorrhoids and rectal varices, respectively. can play a role in developing solutions to this rate limiting step. We will review the most relevant, well-designed studies examining outcomes CLINICAL FINDINGS/PROCEDURE DETAILS: This exhibit reviews the liter- and survival of REBOA patients. Finally, we will summarize areas for ature and details the indications, applications, and crossover between future research with respect to indications, complications, and optimal the Emborrhoid technique and RTO. Both procedures will be illustrated patient population. via case presentation. Emborrhoid employs embolization of the termi- nal branches of the superior rectal arteries using standard equipment, CONCLUSIONS: REBOA is a quick, non-invasive solution for non-com- embolics, and familiar techniques. RTO has gained popularity in treat- pressible torso hemorrhage in trauma and emergency medicine. ing gastric and stomal varices in patients with portal hypertension. The Ongoing research should elucidate the optimal indications and patient treatment of rectal varices is a novel application of this increasingly population for this life saving technique. utilized procedure.

CONCLUSIONS: Emborrhoid is a new use of embolization in treating Abstract No. 751 rectal bleeding caused by hemorrhoids. Existing data show hemor- rhoid size reduction, decreased flow, no significant immediate compli- Tangled: a pictorial review of ultrasound and angiography cations, and excellent patient satisfaction. RTO is emerging as a viable of postpartum hemorrhage caused by uterine option to treat rectal varices. These treatments may be used sequen- arteriovenous malformations and subinvolution of the tially with Emborrhoid in order to decrease arterial inflow to stabi- placenta lize critically ill patients before TIPS/RTO. Interventional radiologist D Hillman1, G Mitchell1, B Craig1, J Fallucca1 engagement in these new service lines is an opportunity to employ 1Henry Ford Hospital, Detroit, MI existing skill sets, possibly decreasing the need for surgery and its associated complications. LEARNING OBJECTIVES: Review the current standard of care for angiography and uterine artery embolization (UAE) in the setting of 54 | Educational e-Posters SIR 2019 Annual Scientific Meeting

postpartum hemorrhage (PPH). Review the ultrasound and angio- CLINICAL FINDINGS/PROCEDURE DETAILS: A 35-year-old woman with graphic diagnostic features and treatment of uterine arteriovenous no past medical history and a social history of long-term daily can- malformations (AVM) in the setting of PPH. Compare the ultrasound nabis use presented to the ER with severe right lower extremity pain and angiography features and treatment of cases of subinvolution of and cyanosis of her right lower leg. Imaging revealed a right superficial the placenta (SIP) to that of uterine AVM. femoral artery occlusion. The patient failed catheter-directed throm- bolysis and an emergent infragenicular femoropopliteal bypass was BACKGROUND: PPH can occur in up to 6% of deliveries and is a major performed. Extensive rheumatologic and hematologic evaluation was cause of maternal mortality. UAE is preferred for PPH after failure of negative and the concluded causation was chronic cannabis use. Four conservative treatment, as UAE can be performed in an emergent years later, the patient presented with severe left upper extremity pain. manner and can be repeated if necessary. UAE is effective for multiple CTA and conventional angiography confirmed thrombotic occlusion of types of PPH, and 24 hours after delivery AVMs are the most com- the left subclavian artery. The patient underwent embolectomy and mon type to require UAE. Subinvolution of the placenta (SIP) as an limb perfusion was restored. etiology for PPH is a relatively underrecognized in both diagnostic and interventional radiology. SIP describes a persistence of large placental CONCLUSIONS: This case demonstrates two distinct acute ischemic vessels within the myometrium greater than 24 hours after delivery. events secondary to cannabis arteritis and illustrates the importance We present a pictorial review of ultrasound and angiographic cases to of recognizing cannabis use as a cause of vasculopathy in young adults illustrate the differences between uterine AVM and SIP. without any other identifiable risk factors. Both appropriate and timely treatment of acute ischemia and lifestyle modification are necessary to CLINICAL FINDINGS/PROCEDURE DETAILS: The appearance of uterine prevent long-term complications and morbidity. AVM and SIP in the setting of PPH can be nearly identical on ultrasound with both showing enlarged myometrial vessels with low-resistance on Doppler. However, uterine vessel angiography can clearly diagnose a Abstract No. 753 uterine AVM with tortuous and hypertrophied uterine vessels and an early draining vein. We present several cases of PPH with uterine AVM Immuno-oncology: a new dimension to interventional diagnosed on ultrasound that were confirmed with angiography and oncology embolized successfully. We contrast those cases to patients with PPH A Lee1, I Moreno2, P Dong3 and features that were consistent with AVM on ultrasound, whom had 1 2 no evidence of AVM on angiography, thus suggestive of SIP. Despite UC Davis Medical Center, Sacramento, CA, Saint Louis University, 3 the lack of AVM found on angiography, these cases were embolized via St. Louis, MO, N/A, Sacramento, CA gelatin foam with successful hemostasis of the PPH. LEARNING OBJECTIVES: –Immuno-oncology is a young and rapidly

CONCLUSIONS: PPH is a significant factor of maternal mortality and developing area in oncology that holds enormous potential for revo- can be successfully treated with UAE. Uterine AVM and SIP can have lutionizing the standard of care in cancer therapy –The field of Immu- nearly identical features on ultrasound but can be distinguished during no-oncology is broad, with different immunotherapies harnessing angiography however, the lack of an AVM on angiography should not different mechanisms, reflecting the complexity of the interactions preclude embolization. between the immune system and cancer –Interventional radiology has an opportunity to play a large role in the development of this new field and change the landscape of cancer care Abstract No. 752 BACKGROUND: Traditionally, the majority of solid tumors are treated Cannabis arteritis: a rare cause of acute limb ischemia with a variety of surgery, chemotherapy, and radiotherapy. However, overall survival and prognosis of these cancers remains poor. The 1 1 1 1 1 D Tew , K Siddall , I Azar , O Enrizo , L Dubensky immune system was long hypothesized to play a role in protecting the 1Aventura Hospital and Medical Center, Aventura, FL body against cancer – there is now data that demonstrates the key role the immune system plays in eliminating early tumor cells through LEARNING OBJECTIVES: Review the differential diagnosis of acute limb “immune surveillance,” but eventually tumors develop mechanisms to ischemia in young women. Describe the clinical presentations of can- help evade destruction by the immune system. The “modern era” in nabis arteritis. Illustrate the management of vascular side effects from immuno-oncology began in 2011 with ipilimumab, a checkpoint inhibi- daily cannabis use. tor that targeted the CTLA-4 receptor in patients with advanced mel- BACKGROUND: Cannabis is the most consumed psychoactive drug anoma. Since then, around 30 IO therapies have been approved by by young adults. Marijuana consumption in the general population the FDA, and several thousand more are in various stages of clinical is increasing as a result of decriminalization and legalization for both trials and development. This discussion will focus on FDA-approved IO medicinal and recreational use. The chronic neurologic, psychologic therapies, though numerous other IO therapies are in various stages and pulmonary side effects of cannabis use are well described; how- of development, which include but are not limited to NK cell therapy, ever, vascular complications are less common. The clinical presentation oncolytic viruses, neoantigens, new antibody targets, and regulatory of cannabis arteritis varies and includes venous thrombosis, atheroma- T cell therapies. tous arterial disease or peripheral vascular disease. The condition is rare with less than 100 cases reported over the past 50 years. SIR 2019 Annual Scientific Meeting Educational e-Posters | 55

CLINICAL FINDINGS/PROCEDURE DETAILS: Immune checkpoint inhib- CONCLUSIONS: Few tools are available for interventionalist to narrow itors; chimeric antigen receptors and adoptive cell transfer; weak- the diameter of vessels. The management of DASS and high flow fis- nesses, drawbacks, and adverse effects; interventional radiology and tula has predominantly been performed surgically and is challenging immuno-oncology from an interventional radiology perspective. MILLER offer a minimally invasive approach with desired hemodynamic changes. In this exhibit, CONCLUSIONS: Immuno-oncology is an exciting new domain in oncol- we review the pathophysiology and diagnostic imaging of DASS and ogy that has brought a powerful new class of medications to the table. high-flow fistula. We also briefly review open surgical approaches and Understanding how these new treatments can be used, and what sort specifically focus on the MILLER procedure. of combinations are the most effective for patients, will be an area of active research for several years to come. Interventional radiology now has a unique opportunity to help develop these new treatments Abstract No. 756 to their full potential. 3D printing technologies: the value and potential of 3D models in interventional radiology training, procedural Abstract No. 754 — WITHDRAWN planning, and patient education M Makary1, B Sugar2, A Chafitz2, A Rajan1, J Dowell3 Abstract No. 755 1The Ohio State University Medical Center, Columbus, OH, 2Ohio State University Medical Center, N/A, 3The Ohio State University, Minimally invasive limited ligation endoluminal-assisted Powell, OH revision (MILLER): a successful minimally invasive technique for DASS and high-flow arteriovenous fistula LEARNING OBJECTIVES: To review the impact of 3D printed models in interventional radiology education and to discuss its emerging signifi- 1 1 1 1 1 D Cohen-Addad , S Patel , H Brent , S Fahrtash , W Kwon cance and potential for vascular intervention. 1State University of New York Downstate Medical Center, BACKGROUND: Since the development of stereolithography, 3D print- Brooklyn, NY ing has begun to gain popularity within various medical fields. Using

LEARNING OBJECTIVES: 1. Review the pathophysiology of arteriove- imaging specific to the individual patient, 3D models have aided in sur- nous fistula leading to dialysis-associated steal syndrome (DASS) and gical/procedural planning in a variety of fields including oromaxillary/ high flow fistula. 2. Review briefly existing alternate open surgical ther- craniofacial surgery, cardiovascular medicine, urology and many more. apy 3. Guide the viewer through the indication, technical steps, tips With the improvement of the intrinsic characteristics of 3D printed and potential complications of the MILLER procedure. models, its utility has the potential to also aid in interventional radiol- ogy education and procedures. Because patient specific 3D anatomic BACKGROUND: DASS is relatively uncommon. When mildly symptom- models require image acquisition (i.e., CT), it is crucial that interven- atic it can be observed, however, when severe it can be debilitating tional radiologists become familiar with the technology as its utility and even lead ulceration and threatened limb ischemia. High flow gains relevance in the scope of radiology. (>2L/min) can lead to cardiac overload failure, elevated venous pres- sure, post-dialysis bleeding and accelerated access growth. Open sur- CLINICAL FINDINGS/PROCEDURE DETAILS: 1. Introduce various 3D gical procedures have been the backbone of intervention for DASS printing technologies, 2. Review the current utility of 3D printing in and high flow fistula. Most interventional radiology interventions are various medical fields (cardiology, orthopedic surgery, etc.), 3. High- useful to expend (angioplasty/stents), to remove (thrombectomy), light the applications of 3D printing in interventional radiology and block (embolization )or even dissolve (thrombolysis) vascular prob- the processes necessary to create 3D models from the interventional lems, however, there is no many options when narrowing is desired. radiologist’s perspective, 4. Discuss the use of 3D printing in proce- MILLER procedure offers a minimally invasive intervention that may be dural planning and intervention rehearsal education, 5. Examine the a reasonable first-line therapy to produces the desired hemodynamic use of 3D models in patient education, 6. Compare the use of 3D changes by creating a precise stenosis. We introduce the MILLER tech- printing in interventional radiology resident education to conventional nique in this exhibit. cadaver lab in medical school anatomy and surgical residency training paradigms, and 7. Present the challenges and limitations of 3D printing CLINICAL FINDINGS/PROCEDURE DETAILS: 1.A pictorial review of the (financial, regulatory, legal, etc.). anatomy, pathophysiology, and diagnostic imaging DASS and high flow fistula. 2.Brief Pictorial overview of existing alternate open surgi- CONCLUSIONS: After reviewing this exhibit, the viewer will become cal therapy including: Distal Revascularization-Interval Ligation (DRIL); familiar with the variety of printing technologies available and the 3D Revascularization Using Distal Inflow (RUDI); Proximalization of Arte- printing process, understand the current utility and benefits of suc- rial Inflow (PAI) and Open Surgical Banding and Plication. 3.Graphics cessful implementation in patient education as well as in procedural and radiographic guide to MILLER technique, as well as a review of planning and rehearsal, and have a greater appreciation for its poten- indication, patient selection, and potential complication tial impact and challenges in vascular intervention. 56 | Educational e-Posters SIR 2019 Annual Scientific Meeting

Abstract No. 757 devastating complications may be mitigated through swift deci- sion-making. The response to the complications presented in this An interventional radiologist’s guide to buying a educational exhibit can be broadly categorized into those requiring protective apron immediate re-intervention, those better addressed by urgent surgical G Rao1, R Suri2, G Kroma3 consultation, and complications where prompt medical management is most appropriate. 1University of Texas Health Science Center at San Antonio, San Antonio, TX, 2University of Texas Health Sciences Center San BACKGROUND: Complications are an unavoidable aspect of any proce- Antonio, San Antonio, TX, 3University of Texas Health Science dure-based specialty. While complications are inevitable, their severity Center, San Antonio, TX is quite variable. The actions undertaken in the critical period of time immediately following the realization of a complication may mean the LEARNING OBJECTIVES: 1.) To review different styles of protective difference between a minor event and a major catastrophe. aprons. 2.) To provide guidance on what to consider when investing in radiation safety. CLINICAL FINDINGS/PROCEDURE DETAILS: A sample of the clinical sce- narios where rapid re-intervention may be an appropriate and effec- BACKGROUND: Interventional radiologists have a variety of choices tive remedy include: 1) complex filter retrievals with caval wall injury to consider when it comes to protecting against radiation exposure. and interventional techniques used to quickly temporize intraperito- The protective apron has been the cornerstone of radiation safety for neal hemorrhage; 2) use of a cobra catheter to aspirate a large-volume those exposed to daily radiation. Protective aprons can range from air embolus occurring during central venous access; 3) interventional one-piece to multi-piece and can vary in weight. Aprons can also be maneuvers to address stent mal-position and -deployment 4) use of backless, zero-gravity, and be made of light weight lead equivalent a Fogarty to contain bleeding and preserve aeration when massive material. Interventional radiologists need to consider budget, radiation hemoptysis is encountered during lung biopsy and intubation is not type, distance from radiation exposure, frequency of use, and available immediately available; and 5) use of a pre-procedure ready bag with materials when deciding on the right protective apron. covered stents for containment of ruptured vessel from SVC/IVC to

CLINICAL FINDINGS/PROCEDURE DETAILS: Aprons play an important iliac artery. Complications more appropriately addressed by immediate role in the protection of interventional radiologists and helps miti- surgical consultation will include clinical scenarios such as extravascu- gate radiation exposure. Understanding the variety of options on the larally placed central venous catheters. Examples of the importance market is key to investing in the most appropriate protective apron. A of prompt medical management in averting catastrophic complica- side-by-side comparison of the different styles of protective aprons tions include the use of coagulation reversal agents during episodes from a variety of manufacturers will make the physician aware of the of uncontrolled bleeding and antibiotic coverage for procedure related considerations needed in radiation safety. This exhibit will compare the genitourinary and biliary sepsis. variety of options on the market and demonstrate trade-offs between CONCLUSIONS: Complications are inevitable. Adequate pre-procedural different styles of apron. planning and preparation are a critical first step in addressing compli-

CONCLUSIONS: Advances in material technology have driven growth cations with poise rather than panic, and preventing misfortune from in the protective apron market. The interventional radiology physi- spiraling into disaster. cian should be familiar with different styles of aprons and learn about the changes occurring in the radiation safety market. The literature is lacking in studies evaluating the variety of ways physicians can pro- Abstract No. 759 tect against radiation exposure with the use of protective aprons. Clinical aspects of hemodialysis: what every This exhibit seeks to educate interventional radiologists on how best interventional radiologist must know to evaluate radiation safety when it comes to choosing a protective apron. N Frantz1, A Agrawal1, T Hostetter1, S Tavri1 1University Hospitals Cleveland Medical Center, Cleveland, OH

Abstract No. 758 LEARNING OBJECTIVES: 1. Overview of clinical hemodialysis (HD) with review of a Nephrologist’s approach to dialysis. 2. Describe a hemo- Avoiding the catastrophic complication: how adequate dialysis unit, know basic physiologic parameters and laboratory val- pre-procedural planning and preparation can prevent ues, and understand typical terminology in a hemodialysis report. misfortune from spiraling into disaster 3. Review relevant National Kidney Foundation Kidney Disease Out- D Biederman1, T Schlachter2 comes Quality Initiative (KDOQI) guidelines, and how they relate to HD access monitoring, surveillance, and management. 4. Discuss clinical 1Albert Einstein Medical Center, Philadelphia, PA, 2Yale University, assessment for dysfunctional HD access prior to intervention. Southport, CT

BACKGROUND: Hemodialysis access circuits (catheters, arteriovenous LEARNING OBJECTIVES: This educational exhibit will present multi- grafts and fistulae) are exceedingly common, and require intervention ple different clinical scenarios arising from common interventional to maintain and restore circuit patency. With the growing clinical role radiology procedures and describe situations in which potentially SIR 2019 Annual Scientific Meeting Educational e-Posters | 57

of interventional radiology and new training pathways, the goal of Coaching can be applied in interventional radiology at all phases of this exhibit is to educate interventional radiologists about the clinical learning. According to lessons from the surgical literature, the radiol- aspects of hemodialysis before and after intervention. ogy resident, interventional radiology fellow, and intervnetional radiology attending can all benefit from coaching to improve their CLINICAL FINDINGS/PROCEDURE DETAILS: We will discuss the prac- procedural skills. The use of simulation devices can be an important tical approach utilized by Nephrologists in performing hemodialy- tool for learners during coaching. sis. Exhibit will emphasize variables which can affect urea clearance (Kt/V), and quantitative dialysis measurements such as blood access CONCLUSIONS: Coaching is an emerging educational concept in the flow rate (Qa), venous/arterial access pressures, and access recircula- surgical literature that is fundamentally different than traditional tion (AR). Pertinent laboratory values such as electrolyte disturbances methods of teaching procedural skills. Interventional radiologists will also be reviewed with recommendations for correction. Discuss should familiarize themselves with this educational technique in order KDOQI guidelines for HD access circuits as relevant to interventional to improve learning environments and increase technical skills. radiology and clinical evaluation of HD access prior to intervention.

CONCLUSIONS: Poorly functioning HD access circuits require interven- Abstract No. 761 tional radiology to restore patency. A better understanding of clinical approach to hemodialysis used by Nephrologists is essential for the Curriculum development for image-guided procedures new generation of interventional radiologists. based on fresh-frozen cadaver Y Karrar1, B Coombs2, T Brady3, P Maurer4, N DiSomma5 Abstract No. 760 1OSF Saint Francis Medical Center, Peoria, IL, 2University of Illinois College of Medicine at Peoria, Washington, IL, 3OSF St. Francis, Coaching: an educational technique to improve Peoria, IL, 4N/A, Morton, IL, 5N/A, Peoria, IL competency and procedural skills in interventional radiology LEARNING OBJECTIVES: Basic and advanced curricula based on frozen cadaver models were developed at the UICOMP in conjunction with 1 2 1 3 4 5 E Smith , A Patel , K Arif , R Varma , A Abdel Aal , J Hoffmann , JUMP simulation to train medical students, radiology residents and 1 A Gunn fellows in image-guided interventions. 1University of Alabama at Birmingham, Birmingham, AL, 2N/A, BACKGROUND: Medical students and radiology residents typically Homewood, AL, 3University of Alabama at Birmingham, Vestavia do not get hands-on experience in image-guided procedures before Hills, AL, 4University of Alabama Birmingham, Birmingham, AL, 5NYU Winthrop Hospital, Garden City, NY performing them on patients under supervision during interven- tional radiology (IR) rotations. This produces a steep learning curve LEARNING OBJECTIVES: Understand the definition of coaching as it to understand and apply the principles of ultrasound and fluoroscopy. applies to medical education and how it differs from traditional teach- Understanding the tools of the trade like different biopsy needles, ing methods. Explain how coaching can improve both procedural and micropuncture sets, drainage catheters, guidewires and vascular cath- non-procedural skills in interventional radiology. Provide practical eters is sometimes challenging during a single rotation through the IR guidance to educators for the implementation of coaching strategies department. in their own practices. CLINICAL FINDINGS/PROCEDURE DETAILS: UICOMP and JUMP sim- BACKGROUND: Coaching, as opposed to teaching, is an emerging con- ulation lab-provided fresh-frozen cadavers are initially scanned with cept in medical education. Coaching requires a different approach CT and US to determine existing pathology. A C-arm and ultrasound to education because it encourages the learner to develop indepen- equipment are used for image guidance. The curriculum is divided into dence, problem-solving skills, and confidence. basic and advanced categories. Additionally, a pulsatile model that includes mechanically perfusing the cadaver was attempted to allow CLINICAL FINDINGS/PROCEDURE DETAILS: Basic principles of coaching basic training in vascular access, diagnostic angiogram and more in medical education rely on instilling confidence and problem-solv- advanced endovascular intervention. Initial pre and post survey was ing skills in the learner to promote independent practice. The first done for a pilot group of R1 and R2 radiology residents with positive stage of coaching is to strategize with the learner, where the over- outcomes not only in improving the technique, but also with increased all plan is reviewed, common mistakes are explained, and goals are confidence that translated to better participation in cases during IR defined. The second stage of coaching is practice, where the learner rotations and increased understanding of patient management. Addi- performs the task with support from the coach. The coach should tionally, it improved the residents’ interpretive skills of diagnostic stud- encourage autonomy. The third stage of coaching is the debrief, ies like arterial and venous duplex, CTA and MRA. where the initial goals of the procedure are reviewed and the learner is given an opportunity for self-critique. Coaching has been shown CONCLUSIONS: Simulation based training has been shown to improve to be an effective educational tool in the surgical literature. Even the efficiency and accuracy of interventionist. Development of cadav- though coaching has relevance to procedural aspects of interven- er-based hands-on training for medical students and residents at tional radiology, it is not well-known among most interventionalists. UICOMP has shown similar positive results. Continuing to advance the 58 | Educational e-Posters SIR 2019 Annual Scientific Meeting

curriculum to incorporate it into core rotations during the diagnostic palliative care training module developed included discussion of the radiology residency will be of benefit to the department, the hospital scope of practice in palliative care, and an overview of palliative IR pro- and most important to patients. cedures. Clinical skills included building rapport, assessing a patient’s goals of care, risk/benefit discussions involved in informed consent, Basic Advanced and case presentations to illustrate how patient prognosis informs Ultrasound Diagnostic procedural management. The module included a framework to under- 1. Random liver biopsy 1. Angiogram of aortoiliac vessels, stand patient suffering, and effective communication skills for eliciting arch vessels, mesenteric and renal 2. Random renal biopsy patient goals of care. A palliative care reading list, formal online com- arteries 3. Thoracentesis munication curriculum, and subcertification in Hospice/Palliative Care 2. US-guided access of popliteal Medicine were proposed for trainees interested in pursuing additional 4. Paracentesis artery, dorsalis pedis artery, training. 5. Venous or arterial access posterior tibial artery and radial artery 6. Central lines, tunneled lines, ports, CONCLUSIONS: Interventional procedures are already an import- PICC 3. Inferior venacavogram ant component of palliative care. With the expanding role of IR and 4. Angiogram of pulmonary arteries increasing clinical focus of IR education it is essential that trainees Fluoroscopic Interventional develop clinical and communication skills necessary to manage the specific needs of the palliative care population. 1. Diagnostic angiogram (aortoiliac, 1. Arterial angioplasty and stenting lower extremities) 2. Embolization (particle, coil, plug, 2. Chest tube placement gel foam, glue) Abstract No. 763 3. Drain placement 3. IVC filter placement or retrieval 4. Lumbar puncture 4. TIPS creation Development of automated case logging for early 5. Joint aspiration or 5. PCN or NU tube specialization in interventional radiology residency (shoulder, hip, wrist, elbow) 6. Percutaneous cholecystostomy training programs 7. Percutaneous transhepatic A Ramjit1, J Chen1, C Giordano1, D Geller1, E Landau1, J Scheiner1, cholangiogram and biliary drain D Sarkany1, N Ahmad1 placement 1Northwell Health Staten Island University Hospital, Staten Island, 8. Vertebroplasty or kyphoplasty NY 9. Gastrostomy tube placement LEARNING OBJECTIVES: Understand the ACGME procedural experi- ence requirements for early specialization in interventional radiology Abstract No. 762 (ESIR) residents. Review existing methods of case logging. Explore an alternative system for resident procedural experience logging.

Developing clinical skills for palliative interventional BACKGROUND: Residency training is an essential pathway to transform radiology: beyond bedside manner medical students into independent practitioners. To better prepare E Rinzler1, N Arastu2, G Wade3, A Makramalla1 interventional radiologists for direct patient care over a broad range of clinical experiences, the ACGME instituted a two year fellowship model 1University of Cincinnati, Cincinnati, OH, 2University of Cincinnati to replace the existing one year fellowship pathway. To balance the Medical Center, Cincinnati, OH, 3Eastern Virginia Medical School, length of training with improved clinical experience, the ACGME imple- Norfolk, VA mented multiple training pathways that did not lengthen the older, res- LEARNING OBJECTIVES: Assess and develop trainee knowledge of pal- idency and fellowship model. ESIR provides a pathway for residents in liative interventional radiology, with an emphasis on clinical decision diagnostic radiology residency programs to complete training in inter- making and patient communication skills. ventional radiology within 6 years. Residents in ESIR programs must complete 500 cases that fall within specific CPT codes defined by the BACKGROUND: Palliative care is therapy focused on symptomatic relief ACGME. These cases are performed by the resident over 12 months and improving patients’ quality of life. Although often equated with of dedicated IR rotations during the diagnostic radiology residency. hospice and end-of-life, palliative care is not solely utilized in the set- When an ESIR program certifies a resident’s case log, they become ting of terminal diagnoses. We surveyed radiology and interventional eligible for a 1 year fellowship following residency. radiology (IR) trainees from our academic, tertiary care program to assess their knowledge and comfort level managing palliative care CLINICAL FINDINGS/PROCEDURE DETAILS: To create an automated patients. Then, in conjunction with members of our institution’s pallia- residency logging system, our institution’s project manager pulled a tive care team, we developed a module to address their training needs. single resident’s dictations from a completed IR rotation. Each indi- vidual dictation (defined by an accession number) was categorized by CLINICAL FINDINGS/PROCEDURE DETAILS: The primary areas identi- the resident and IR attending physician. This information was used by fied for trainee education included patient communication and med- the project manager to generate a case log website that categorized ical decision making within the context of palliative care goals. The SIR 2019 Annual Scientific Meeting Educational e-Posters | 59

Sample Data from PowerScribe 360 Resident Exam Desc Exam CPT SRC ESIR Category Details Amit Ramjit SC SP SEL CATH PULM ART BI 36014 syngoRIS Thrombolysis or thrombectomy (arterial or Catheter-directed PE thrombolysis venous) Amit Ramjit SP CHOLECYSOSTOMY SISC 47490 syngoRIS Primary GI intervention (PTBD, Cholecystostomy tube placement cholecystostomy, gastrostomy)

procedures based on the ACGME provided guidelines. To build the CLINICAL FINDINGS/PROCEDURE DETAILS: This educational exhibit software that would classify dictations into a categorized table of reviews concepts of radiation safety in the IR suite, including patient, cases for ESIR, a manual review of dictations was performed. A single operator, and staff safety. We discuss key radiation safety terms, resident’s dictations (Amit Ramjit, MD) were pulled from PowerScribe including Kerma, Air kerma, and Scatter Radiation, and then describe 360. The individual accession numbers were manually classified into critical information about radiation dose, including absorbed dose, the ESIR case log categories as defined by the ACGME by the resident equivalent dose, effect dose, and entrance skin dose. Technologic and IR attending physician. We determined which CPT codes used at developments that have led to improved radiation safety in the IR suite our institution that were unique to each of the ESIR case log catego- are detailed, including automatic exposure control, shaping filters, ries. With this information, the software could then be built to tabulate electronic image magnification, and protective equipment. We then cases for each user in PowerScribe. review how radiation exposure is measured, report current limitations for patients and IR staff members, and discuss the various effects of CONCLUSIONS: Case logging is an integral part of procedural based radiation exposure. A review of the evolution of radiation safety cul- residencies. ESIR residents have unique challenges under this model ture in IR is included. Finally, we describe key points of how to further because they must meet both diagnostic and interventional require- improve the radiation safety culture, with focus on implementing a ments during their residency. An automated system that classifies and radiation safety time-out at the start of each procedure. appropriately tallies cases for residents minimizes errors, prevents delays in reporting and seamlessly accommodate multiple number of CONCLUSIONS: A thorough understanding of radiation safety in the IR residents. Our logging system is an example how ESIR programs can suite is critical for physicians to have maximal positive impact on safety meet logging requirements and have real time data on their resident’s for patients, physicians and staff. Incorporating a radiation-safety progress. component into the time-out process may benefit and strengthen the radiation safety culture in a department.

Abstract No. 764 Abstract No. 765 Embracing a culture of radiation safety in the interventional radiology suite: keys to success and Integration of interventional radiology during the first development of the radiation safety time-out year of medical school S Kalantarova1, D Szaflarski2, E Margono3, D Gregorius1, I Breen1, J Kriegshauser1, A Silva1, S Naidu1, S Alzubaidi1, J Hoffmann4 M Knuttinen1, A Saini1, R Oklu1 1NYU Winthrop Hospital, Mineola, NY, 2Winthrop University 1Mayo Clinic, Phoenix, AZ Hospital, Mineola, NY, 3N/A, Mineola, NY, 4NYU Winthrop Hospital, Garden City, NY LEARNING OBJECTIVES: We discuss a model of interventional radiol- ogy (IR) integration into the anatomy block during the first year of LEARNING OBJECTIVES: 1. Radiation safety is a key concept that can medical school. We emphasize the importance of early exposure to IR have major impact on interventional radiology (IR) patients, physicians, during medical school, both in educating students about and inspiring and staff members. 2. IR attendings, trainees, and staff members must interest in the specialty. understand how to maximize radiation safety device incorporation in BACKGROUND: With the recent addition of IR as a primary specialty the IR suite. 3. Implementation of a Radiation Safety Time-Out before in medicine, there is now also an impetus to integrate IR education starting a procedure can help to embrace and strengthen the culture into the medical school classroom. We discuss a proposed model for of radiation safety in IR. integrating IR teaching into the anatomy block during the first year of BACKGROUND: Knowledge of key radiation safety principles is essen- medical school. tial for maintaining a safe environment in the interventional radiology CLINICAL FINDINGS/PROCEDURE DETAILS: First year anatomy block suite. Maximizing safety during procedures involves understanding integrated the IR education through didactic lectures spanning a vari- these concepts, as well as being committed to incorporating core con- ety of topics that corresponded to the respective anatomy lessons. cepts of radiation safety into the procedural time-out process to fully Daily lectures covered both diagnostic and interventional radiology embrace a radiation safety culture. clinical correlates, with duration of 30 minutes-1 hour. Some examples 60 | Educational e-Posters SIR 2019 Annual Scientific Meeting of IR topics covered in lectures included TIPS procedure, palliative Abstract No. 767 percutaneous nerve blocks, and fundamentals of embolizations. An IR faculty was also present daily during didactic lectures and gross Parental leave: history, current practices, and future anatomy laboratory to answer 1:1 questions about radiology topics, IR trends in radiology services, and an overview of IR practice. During a survey conducted A Mittal1, J Moon2, I Breen3, Y Zhu4 following the end of the block, approximately 50% students reported 1Meharry Medical College, Nashville, TN, 2Albany Medical College, that they gained understanding of the clinical practice of IR. Albany, NY, 3Mayo Clinic School of Medicine, Irvine, CA, 4N/A, Chicago, IL CONCLUSIONS: We demonstrated a model that integrated IR educa- LEARNING OBJECTIVES: (1) To provide a literature review of policies tion during anatomy in the first year of medical school. Many students and practices regarding parental leave in the context of radiology. reported gains in learning about IR, but continued evidence-based (2) To educate trainees and clinicians on radiology-specific obstacles research is needed to identify optimal methods for IR education in and challenges to implementing a successful parental leave model. (3) medical school. Early exposure to IR can promote understanding of To clearly expound on the necessity for further development in the the specialty, invigorate student interest, and improve visibility of this accommodation of child-rearing physicians. continually evolving field.

BACKGROUND: Increasing awareness about parental (maternity) leave is the first step to bringing about positive change for new parents Abstract No. 766 working in the field of radiology. Currently, this issue is also seen as a potential burden of entry for women in radiology. Therefore, we would Interventional radiology art like to review historical and current policies, along with future trends, J Benites1, B Hamade2 in order to highlight this issue and amplify discussions about this topic. 1Cooper Medical School, Camden, NJ, 2Temple University Hospital, CLINICAL FINDINGS/PROCEDURE DETAILS: Below is a list of the policies Philadelphia, PA and position statements currently in place, which will be expounded upon

LEARNING OBJECTIVES: Create a website with artistic original hand further. Currently, the federal Family Medical Leave Act (FMLA) of 1993 drawn downloadable interventional radiology procedure animations allows employees to take as much as 12 weeks of job-protected unpaid so that academic presenters may have access to utilize the artwork leave for the birth of a child or to bond with a newly adopted child. In July for their own presentations with the purpose of spreading knowledge of 2017, the Society of Interventional Radiology, in conjunction with the about interventional radiology capabilities. Women in IR section, issued the following position statement. At mini- mum, they recommended adhering to the FMLA allowances. They also BACKGROUND: We believe that there is a place for enriching educa- support maternity leave of no less than 6 weeks for vaginal delivery and tion about interventional radiology procedures through art. Our goal no less than 8 weeks with the maintenance of benefits and 100% of pay. is to help spread knowledge of interventional radiology procedures Lastly, the American Association for Women Radiologists conducted between interventional radiologists, other hospital/outpatient medi- a series of surveys in the 1980s regarding pregnancy and maternity cal services, and within medical schools through downloadable hand leave policies. They developed a comprehensive maternity policy that drawn artistic animations for individuals to use within their own pre- included: planned pregnancy, preconception, antenatal guidance for sentations. All with the vision of supporting a community ethos of fluoroscopy and angiography, prenatal sick leave, efforts to complete collegiality that will ultimately have a positive downstream impact on normal duties during prenatal period, maternity leave, call requirements, patient care. adoption leave, paternity leave, family leave, and insurance.

CLINICAL FINDINGS/PROCEDURE DETAILS: The website was created, CONCLUSIONS: The policies, recommendations, and position state- “www.interventionalradiologyart.com,” where academic presenters ments can be further discussed and potentially updated. We would can visit to view and download animations of hand drawn interven- also like to highlight current challenges and the need for additional tional radiology procedures to use within their own presentations. standardized policies on parental leave in radiology. There is currently a sample of animations that will continually be updated with new procedures. The aim is to start with common proce- dures, and add additional procedures that reflect the ongoing interests Abstract No. 768 of the Society of Interventional Radiology community. Percutaneous computed tomography–guided CONCLUSIONS: An interventional radiology art website was published cryoablation of the bilateral pudendal nerves for the with downloadable procedure animations. Downloads and feedback palliation of intractable pain related to pelvic neoplasms will be monitored and content will be continually updated for use as an educational tool. A Mittal1, D Hsu2, Z Bercu2, J Newsome2, E Friedberg3, G Peters4, J Prologo5 1Meharry Medical College, Nashville, TN, 2Emory University School of Medicine, Atlanta, GA, 3N/A, Mountain Lakes, NJ, 4Emory University, Atlanta, GA, 5Emory University School of Medicine, Division of Interventional Radiology and Image Guided Medicine, Atlanta, GA SIR 2019 Annual Scientific Meeting Educational e-Posters | 61

Table 1 Age/Sex Primary Lesion Presenting Symptoms Post-procedure Course Measures Taken Before IR Consultation 54/F Rectal mass, primary rectal small cell Admitted to inpatient service for Discharged 2 days after procedure Narcotic and non-narcotic neuroendocrine tumor intractable, burning, sharp pelvic with significantly improved pain adjustments, radiation and rectal pain not responding to medical regimen 51/F Rectosigmoid mass, primary colon Admitted to inpatient service for Discharged to hospice 2 days after Narcotic and non-narcotic cancer intractable, 9/10 pelvic and rectal procedure. Discharge pain level adjustments pain not responding to medical recorded as 2/10 regimen 47/F Anal cancer, squamous cell primary Admitted to inpatient service for Discharged day of procedure with Narcotic and non-narcotic intractable, 10/10 pain related to a significantly improved pain adjustments, radiation perineal anal-cutaneous fistula 73/F Vaginal carcinoma, squamous cell Admitted to inpatient service with Discharged day after procedure with Narcotic and non-narcotic primary unmanageable, intractable pelvic and no signs of distress or pain. Patient adjustments vaginal pain refractory to medical reported pain as resolved regimen 78/F Bladder cancer, undifferentiated Admitted to inpatient service with Discharged day of procedure with Narcotic and non-narcotic urothelial cell origin intractable, 10/10 pelvic pain related resolved symptoms adjustments to bladder mass 63/F Bladder cancer, urothelial carcinoma Admitted to inpatient service Pain controlled following procedure. Narcotic and non-narcotic primary with multiple problems, including Remained hospitalized for 10 days adjustments, radiation obstructive uropathy and pain for multiple medical problems

LEARNING OBJECTIVES: The purpose of this report is to examine the with intractable pelvic pain related to neoplasm. All patients reported safety and efficacy of percutaneous CT-guided cryoablation of bilat- subjective pain improvement and there were no procedure-related eral pudendal nerves as palliation for intractable pain related to pelvic complications. Patient cohort details can be found in Table 1. It is also neoplasms. important to note that while this subjective description appears prom- ising, it lacks objective pre-and post-procedure pain quantification and BACKGROUND: Percutaneous image-guided cryoneurolysis is evolving the sample size is small. as a novel treatment option for patients with nerve related disorders. This study details the application of percutaneous, bilateral, CT-guided cryoablation of the pudendal nerves in the setting of intractable pain Abstract No. 769 secondary to pelvic neoplasm. Proof of principle use of virtual and augmented reality CLINICAL FINDINGS/PROCEDURE DETAILS: This retrospective review through the HoloLens OpenSight software for training was approved by the local Institutional Review Board. Six patients common femoral artery vascular access (100% female; mean age, 61 years; age range 47-78 years) over 2 years were referred to the interventional radiology department for manage- M Weintraub1, G Fine1, A Eastaway1, A Cogman2, K Marashi3, ment of intractable pain secondary to pelvic neoplastic masses. Each E Quigley3 patient underwent CT-guided cryoablation of the bilateral pudendal 1University of Utah, Salt Lake City, UT, 2N/A, Tulsa, OK, 3N/A, Salt nerves. For purposes of this report, the electronic medical record Lake City, UT was reviewed for pertinent history and pre-procedure workup docu- mentation, procedural details, and post-procedure course – including LEARNING OBJECTIVES: 1. Demonstrate the use of virtual reality/aug- potential adverse sequelae related to the procedure and documen- mented reality (VR/AR) through the Microsoft HoloLens and Open- tation of potential impact of the procedure on the patient’s present- Sight software to create a training environment for image-guided ing pain. Brief description about the procedure: Patients treated with procedures 2. Appreciate the utility of a VR/AR simulator in assist- CT-guided cryoablation of the pudendal nerve for neoplastic condi- ing with access to challenging anatomy and decreasing the risk of tions are placed prone on the CT table and scout axial non-contrast complication images of the obtained – on which the pudendal canal is identi- BACKGROUND: Common femoral artery (CFA) access under ultrasound fied. A cryoablation probe is advanced to the site and two freeze-thaw guidance is commonly performed to gain vascular access in interven- cycles, typically 8 minutes and 4 minutes, respectively, are completed. tional procedures. Complications of CFA puncture include bleeding, During the procedure, the patient is kept comfortable with moderate dissection, thrombosis, pseudoaneurysm, and arteriovenous fistula. sedation medication. Proper training for CFA access is essential for minimizing complica-

CONCLUSIONS: Technical success in percutaneous CT-guided cryoab- tions. A VR/AR environment is a unique tool to prepare operators for lation of bilateral pudendal nerves was achieved in all six patients performing minimally invasive procedures. 62 | Educational e-Posters SIR 2019 Annual Scientific Meeting

CLINICAL FINDINGS/PROCEDURE DETAILS: The training model is cre- consideration is the side and bottom shielding. In fluoroscopic pro- ated from anonymized volumetic CTA images of the hip, arteries, veins, cedures, operators are not looking at the patient during procedures, muscles, and nerves on a Siemens (Berlin, Germany) scanner. DICOM and as a result the positioning of the operator’s head can have large images are segmented using Materialise software (Mimics and 3Mat- implications on the radiation dose to the eye. Scatter from the side can ics, Materialise, Leuven, Belgium). The 3D virtual object is imported easily reach the lens unless barrier protection is in place. In addition, into VR and AR applications. The patient-specific multicolor, multima- scatter striking the operator’s head can scatter through the skull and terial model is 3D printed on a variety of FDM, PolyJet, and SLA print- reach the lens of the eye. ers, using an array of materials to replicate soft tissue and vascular CONCLUSIONS: Recent data support a lower dose limit for the lens, with structures. The OpenSight software (Novarad Corporation, Salt Lake stochastic impact of even low dose radiation exposure. Intervention- City, UT) is used to overlay the patient’s anatomy, based on the virtual alists should be aware of available equipment to protect their vision. model, onto the 3D printed simulator, using the HoloLens Augmented Studies found that wrap around style and angled frames with side Reality Platform (Microsoft Corporation, Redmond, WA). Trainees shielding performed the best. In addition to eyewear, barrier shielding wearing the HoloLens goggles are able to see a holographic real-time and geometry are encouraged to reduce the operator dose resulting image as they physically gain access on the 3D-printed virtual model, from scatter radiation. enabling successful navigation of potentially challenging anatomy.

CONCLUSIONS: The HoloLens and OpenSight software enables trainees to practice CFA access on 3D virtual patient-specific models while they Abstract No. 771 are guided in real time by a holographic image of the patient’s anat- Target obscured by intervening bowel? An effective omy. By practicing obtaining CFA access before a procedure is actually technique to aid in computed tomography–guided performed, trainees can be better prepared in the clinical setting. This abdominal and pelvic intervention software may be particularly useful in cases of complex anatomy and potentially more complicated steps of interventional procedures. K Marchak (Groesch)1, K Schramm2, M Gipson3 1University of Colorado Dept of Radiology, Denver, CO, 2University of Colorado, Denver, CO, 3Radiology Imaging Associates, Denver, CO Abstract No. 770 LEARNING OBJECTIVES: To highlight an adjunctive biopsy and drainage Protecting our vision to heal: considerations for radiation technique for target obscured lesions utilizing equipment commonly safety eyewear available in the interventional radiology suite. B Ashley1, D Mauro2, R Dixon3, C Commander4 BACKGROUND: CT-guided biopsy or drainage is one of the most com- 1UNC Hospitals, Chapel Hill, NC, 2Mount Sinai, New York, NY, 3UNC mon procedures in interventional radiology. Approaching the target Dept. of Radiology, Chapel Hill, NC, 4University of North Carolina, from a percutaneous approach requires creating and traversing a Chapel Hill, NC path without disrupting critical structures, commonly referred to as a “window.” One major limitation for an appropriate window within the LEARNING OBJECTIVES: 1. Briefly review key concepts of radiation abdomen and pelvis is intervening viscera. In an increasingly obese safety: stochastic and deterministic effects. 2. Understand the import- American population, target to skin distance can also be longer than ant considerations for selecting protective eyewear 3. Present the lim- readily available needles. Previous devices have been described to itations of protective eyewear help mitigate these dilemmas but they require purchase of materials BACKGROUND: Traditionally, cataract formation secondary to radiation and/or sterile processing following use. Such devices include a man- to the eye has been considered a deterministic effect. Recent data ufactured abdominal compression apparatus, an F-spoon with a slit, suggest the effect may in fact be stochastic, with any dose increas- and custom 3D-printed paddles. All of these devices require either ing the risk of cataract formation. Reflecting this trend, the Interna- preoperative purchase, custom manufacturing, and/or repeat steril- tional Commission on Radiological Protection (ICRP) has adopted a ization procedures. We propose a simple, readily available solution to new occupational eye dose limit from 150 to 20 mSv. Given that clinical this common procedural dilemma that does not require preoperative practice exposes operators to doses that could exceed the new limit, purchase or sterilization of a specific device. interventionalists should have knowledge of radiation safety regarding CLINICAL FINDINGS/PROCEDURE DETAILS: Three patients with need the eye. This abstract will provide a review of current literature regard- for CT-guided procedures are included (two biopsies, one drain place- ing evaluation and selection of protective eyewear. ment). In these patients, pre-procedural CT scan demonstrated bowel CLINICAL FINDINGS/PROCEDURE DETAILS: Similar to protective aprons, obscuring a conventional percutaneous approach. For these cases, a glasses are measured in mm of lead thickness. While the most effec- modified sterile saline bowl was created using a scalpel and sterile scis- tive glasses provide 0.75mm Pb equivalence from direct exposure, sors to remove a portion of the floor of the bowl. The custom modified there are additional considerations beyond the lens. Protective glasses sterile saline bowl was attached to the patients and used as a paddle to come in many shapes and styles, and studies have performed phan- compress the bowel out of the anticipated procedural tract. Following tom testing to determine which provide the best protection. The indi- confirmation of successful clearance of the field on follow-up imag- vidual fit of the glasses can be important; however, the most important ing, the modified sterile bowl was secured to the patients to provide SIR 2019 Annual Scientific Meeting Educational e-Posters | 63 compression and used for successful biopsy/ aspiration through the Abstract No. 773 modified floor of the bowl. Upper gastrointestinal endoscopy: what every CONCLUSIONS: CT-guided abdominal and pelvic interventions are interventional radiologist must know often complicated by intervening bowel. By firmly securing a custom modified bowl for needle placement, this dilemma is solved using N Frantz1, V Kondray1, Z Smith1, B Glessing2, C Sutter1, S Tavri1 readily available supplies. 1University Hospitals Cleveland Medical Center, Cleveland, OH, 2University Hospitals Ahuja Medical Center, Beachwood, OH

Abstract No. 772 LEARNING OBJECTIVES: 1. Review basic principles of upper gastrointes- tinal (GI) endoscopy and focus on contraindications and limitations. 2. Through the virtual looking glass: how virtual reality will Illustrate endoscopic classification of gastro-esophageal varices and change the face of interventional radiology education ulcers, and principles of endoscopic treatment. 3. Describe common M Makary1, A Chafitz2, B Sugar2, A Rajan1, I Vargas3, J Dowell4 endoscopic balloon tamponade devices used for management of life-threatening hemorrhage. 4. Brief overview of interventional radiol- 1The Ohio State University Medical Center, Columbus, OH, 2Ohio ogy (IR) procedures in the setting of endoscopic failure of bleeding State University Medical Center, N/A, 3Eli Lilly, Indianapolis, IN, 4The control. Ohio State University, Powell, OH

BACKGROUND: Management of upper GI bleeding is a complex LEARNING OBJECTIVES: To explain virtual reality (VR) and how VR multi-disciplinary undertaking that usually starts with GI Endoscopy. technologies can impact interventional radiology (IR) trainee educa- With increasing multi-disciplinary collaboration and clinical training tion as well as pre-procedural planning. in IR, it is important for interventional radiologists to understand the BACKGROUND: VR refers to a computer-generated simulated environ- basics of upper GI endoscopy. This exhibit aims to provide an overview ment separate from the user’s interactive physical reality. Augmented of upper GI endoscopy that every IR must know. reality (AR) refers to a subset of VR where virtual images are overlayed CLINICAL FINDINGS/PROCEDURE DETAILS: We will discuss the approach over the physical world. VR and AR technologies have tremendous utilized by Gastroenterologists in performing endoscopy. This exhibit versatility in their medical applications ranging from laparoscopy train- will emphasize contraindications and limitations for performing endos- ing to treatment of psychiatric conditions. These technologies are ripe copy, provide an image-rich endoscopic classification of gastroduode- for IR, particularly for trainee simulation education as well as pre-pro- nal ulcers (Forrest) and varices with associated clinical implications, cedural planning and training. While the current master-apprentice and basic prognostic scoring systems commonly used when eval- model of training has many disadvantages including patient exposure uating a patient prior to endoscopy such as Rockall, Blatchford, and to risk, longer times in the IR suite, and lack of standardization in case AIMS65 scores. Illustrate the different types of balloon devices and load, VR technologies can serve to mitigate these weaknesses and their function in the management of catastrophic hemorrhage. Finally, improve both the trainee’s and patient’s experience. provide brief overview of IR procedures used in the setting of failed CLINICAL FINDINGS/PROCEDURE DETAILS: 1) Review the history of endoscopic interventions. VR and AR, and the current commercially available technologies, 2) CONCLUSIONS: Upper GI bleeding commonly requires IR therapy Describe the role of VR simulation in training paradigms and proce- if endoscopic treatment is unsuccessful or not feasible. For better dural planning/training, 3) Evaluate existing VR simulators used in patient care and with increasing multi-disciplinary efforts in training other disciplines (General Surgery, Vascular Surgery, and Gastroenter- the new generation of IRs, a better understanding of upper GI endos- ology), 3) Describe VR applications in IR demonstrating examples in copy is imperative for the future. prostatic artery embolization (PAE), transarterial chemoembolization (TACE), biliary interventions, endovascular abdominal aortic aneu- rysm (AAA) repair, acute stroke management, and others, 4) Evaluate Abstract No. 774 the benefits of VR simulation to improve trainee didactics, procedural planning and technical success, and patient care outcomes, 5) Review When regular contrast just won’t do . . . get CO2! the current literature as well as future applications and research direc- M Sighary1, S Patel1, S Fahrtash1, M Swikehardt1, A Sajanmalliath1, tions, and 6) Describe the barriers preventing widespread adoption R Leonardo1 and practical solutions. 1State University of New York, Downstate Medical Center, New York, CONCLUSIONS: After reviewing this exhibit, the viewer will gain a NY deeper understanding of the advantages of IR simulation training over the traditional master-apprentice model, recognize the currently avail- LEARNING OBJECTIVES: 1. Identify scenarios in which carbon dioxide able VR technologies and their applications, and learn about the role (CO2) should be utilized as a for angiography. 2.Review of VR in improving IR education, procedural planning, and patient care of basic physiology of intravascular CO2 and how we can utilize it to outcomes. our advantage. 3.Recognize and manage possible complications asso-

ciated with intravascular CO2 administration. 64 | Educational e-Posters SIR 2019 Annual Scientific Meeting

BACKGROUND: CO2 has been utilized as a contrast agent since the issues, (4) gender parity improves work-place dynamics for both gen- 1950s. With the recent advent of smaller and more user-friendly ders, and (5) it is fair and ethical to ensure women feel equal oppor- devices, it has become increasingly practical to use CO2 in clinical tunity in all areas of potential interest. Many interventional radiologists practice. There are a variety of situations in which it is favorable to recognize the need for gender parity in their workforce and understand use CO2 as a contrast agent, including in the setting of a contrast the need to actively recruit women into IR. This exhibit will review the allergy, renal failure not on dialysis and for visualization of the portal current status of female interventional radiologists, the reasons why venous system. With an understanding of the physiology of intra- gender parity is important, and what current literature suggests will vascular CO2 and imaging physics, one is able to generate clinically impact change. useful fluoroscopic images. Though complications related to CO2 CLINICAL FINDINGS/PROCEDURE DETAILS: A review of gender demo- angiography are rare, it is important to recognize and know how to graphics of trainees, faculty, and leaders as depicted on websites of treat them. the 78 integrated IR residency programs, and from the ACIR will be

CLINICAL FINDINGS/PROCEDURE DETAILS: CO2 is an excellent alterna- presented along-side select Association of American Medical College tive when traditional contrast media is contraindicated. It is relatively Demographic Data for comparison. This will be followed by explana- safe and easy to use. One can utilize a basic understanding of its phys- tions for why gender parity is important, historical deterrents, and iology in order to generate excellent images. It is prudent to recognize what can be done to actively recruit and support female candidates in the rare but potentially life threatening complications and know how hope of increasing the number of women in IR. to respond instantly CONCLUSIONS: Given the accumulating interest in medical subspecial-

CONCLUSIONS: CO2 as a negative contrast medium in angiogra- ties gender-parity and the disparity common to interventional radiol- phy has been used since the 1950s. It was first used in diagnos- ogy, awareness of the current status of women in the field is important ing pericardial effusions and its low risk profile has led to research for guiding program development. The large programmatic changes of in discerning its ability to be used in many vascular interventions. late make it especially timely to deepen understandings of the impor- Iodinated contrast has long been the gold standard in angiography tance and impact of gender diversity, how the field currently compares for vascular interventions, but also carries the risk of hypersensitiv- to others, and how parity might be achieved. ity reactions as well nephrotoxicity. Contrast induced nephropathy can be detrimental to patients with CKD or renal transplants. Most Abstract No. 776 interventional radiology procedures can be done with CO2 angiog- raphy with minimal risks to patients. CO as a media for visualiz- 2 Wound care: why isn’t it part of your interventional ing vessels and doing various interventional procedures should be radiology practice? recognized by clinicians for its practicality and low risk profile. We 1 1 1 2 3 will review multiple clinical settings in which CO2 is preferred over W Terrill , D Petrov , K Cothron , M Barton , G Edry traditional iodinated contrast. 1Allegheny Health Network, Pittsburgh, PA, 2Jackson Memorial Hospital/University of Miami, Miami, FL, 3Rocky Vista University, Centinneal, CO Abstract No. 775 LEARNING OBJECTIVES: 1. Define wound care and outline the practice Women of interventional radiology: where we are of wound care physicians. 2. Describe the epidemiology and patho- C Piper1, C Kaufman2, N Tabori3, M Johnson4, M Ranade5 genesis of chronic wounds. 3. Discuss the relevant intersection of inter- ventional radiology and wound care. 1Yale New Haven Hospital, New Haven, CT, 2University of Utah, Salt Lake City, UT, 3MedStar Washington Hospital Center, Baltimore, MD, BACKGROUND: As the United States population ages, the already high 4Yale University School of Medicine, New Haven, CT, 5Mount Sinai cost of chronic wounds on Medicare is projected to increase. Recent lit- Hospital, New York, NY erature confirms the positive impact that wound care physicians have on treating chronic wounds, which has led to an increased demand for LEARNING OBJECTIVES: The goal of this exhibit is to familiarize inter- providers competent in wound care. Many of these wounds originate ventional radiologists with the contemporary status of female physi- from vascular or venous complications; interventional radiologists aid- cians in interventional radiology (IR), to increase awareness of gender ing in the care of these patients have the unique opportunity to pro- parity importance and to encourage initiatives aimed at increasing vide comprehensive wound care and expand the scope of their clinical female representation. practice. BACKGROUND: Historically, IR has been one of the most gender-un- CLINICAL FINDINGS/PROCEDURE DETAILS: This exhibit will illustrate the balanced subspecialties. Interest in gender disparity within IR has intersection of wound care and interventional radiology by defining increased dramatically in the recent years, as has awareness of the and outlining the following: 1. The epidemiology of chronic wounds reasons why gender-parity is important: (1) mixed-gender teams pro- 2. The skills and knowledge base required of a wound care physician duce better work, (2) nearly 50% of medical students are now female, including surgical debridement. 3. The role of vascular and venous (3) female physicians tend to better address female-related medical SIR 2019 Annual Scientific Meeting Educational e-Posters | 65

interventions in the chronic wound population. Peer reviewed journal aspect of hospital finance as well as faculty and resident medical edu- articles will be utilized to provide data on the aforementioned topics. cation. It is no longer simply a virtuous goal.

CONCLUSIONS: Chronic wounds present an increasingly common problem, for which the best outcomes are achieved with a multidisci- Abstract No. 778 plinary approach, including wound care physicians and interventional radiologists. Wound care offers a unique way for interventionists to SIR Grassroots Leadership Program: growing role of expand their clinical practice by incorporating the fundamental skills advocacy in establishing interventional radiology– of wound care. inclusive medicine O Kutsenko1, D Huynh2, J Huang3, R Peng4, C Molloy5 Abstract No. 777 1SUNY Upstate Hospital, Syracuse, NY, 2SIR, Fairfax, VA, 3Pennsylvania Hospital, University of Pennsylvania, Philadelphia, Historical development and increasing importance of PA, 4Albert Einstein College of Medicine, Montefiore Medical Center, patient satisfaction surveys Bronx, NY, 5Kaiser Permanente, Los Angeles, CA

1 1 1 1 D Cohen-Addad , K Hewitt , A Efendizade , D Reede LEARNING OBJECTIVES: 1. Review the foundation history of interven- 1SUNY Downstate Medical Center, Brooklyn, NY tional radiology (IR) as an independent specialty. 2. Describe the roles of SIRPAC and SIR Government Affairs and Advocacy Committees in LEARNING OBJECTIVES: Review the history of quality and safety in establishing relationships with legislative bodies. 3. Provide IR physi- healthcare Discuss the Hospital Consumer Assessment of Healthcare cians and trainees with information about Grassroots Leadership Pro- Providers and Systems (HCAHPS) survey, its relationship with the Val- gram, its current agenda, and possibilities of participation. 4. Emphasize ue-Based Purchasing program, and its increasing importance to hospi- current debates that impact reimbursement, scope of practice, medical tals and physicians. Learn the relevance of patient satisfaction surveys malpractice reform, GME residency positions, and patient access to IR to interventional radiology and provide potential options to improve services. scores BACKGROUND: IR has seen a transformation in recent years, transition- BACKGROUND: US healthcare is currently aiming to reduce its cost ing from a subspecialty of diagnostic radiology (DR) into a primary while improving the quality of care. As a result, many programs were medical specialty in 2012, implementing IR/DR pathway in 2014, and developed providing incentives based on quality. Among many quality recently being named the most competitive specialty of 2018 NRMP measures, there is an increasing role in patients’ satisfaction surveys residency match. With independence comes growing responsibilities .Such as the Hospital Consumer Assessment of Healthcare Providers as we develop our identity. One of the areas that remains the least and Systems (HCAHPS) by the Centers for Medicare & Medicaid Ser- developed is our political action committee (PAC) which on a daily vices (CMS).As part of the increasing focus on trainee’s education in basis engages legislators to fight for our privilege to practice. The SIR regards to patient safety and quality improvement (Section VI of the Grassroots program brings IR physicians and trainees to Capitol Hill ACGME).We elaborate on the history of health care quality measures to educate lawmakers about IR and its pivotal role in patient care and with a specific focus on patients’ satisfaction surveys. healthcare economics.

CLINICAL FINDINGS/PROCEDURE DETAILS: Historical review includes CLINICAL FINDINGS/PROCEDURE DETAILS: The SIR Grassroots Lead- the life stories of Semmelweis and Ernest Codman, the Foundation ership Program allows IR physicians and trainees the opportunity to of the American College of Surgery, The Joint Commission, the Don- educate legislators about the policy issues that directly impact inter- abedian Model, Press Ganey Survey, the Leapfrog Group, the Agency ventional radiologists. The program takes place over two days at the of Health Care Research and Quality (AHRQ), and HCAHPS. Key his- SIRPAC headquarters in Washington, D.C. Participants attend “boot torical moments in the health financing system including the diag- camp” to gain understanding of the current issues and then meet nosis related program (DRG) and the Value-based program (VBP). with lawmakers at Capitol Hill to engage in the political discourse. This We describe the HCAHPS survey; methodology, sampling criteria, dialog not only educates authorities but also gives physicians under- and composition. Scoring mechanism including different weighting standing of the importance of advocacy. factors, achievement, improvement, consistency, and overall scores. Specifically, HCHAPS financial linkage to reimbursement via the VBP. CONCLUSIONS: IR is seeing amazing changes and is constantly evolving Finally, we focus on its specific relevance to the interventional radiol- in terms of education, scope, and innovation. With newfound indepen- ogy departments including confounding factors and potential ways to dence we must also be cognizant of the non-clinical aspects of medi- improve survey results. cine to aid our field in its growth. The Grassroots Leadership Program is an excellent introduction to political advocacy and IR’s increasing CONCLUSIONS: 2% withholding of VPB is estimated to represent an presence in medicine and healthcare system. overall $1.9 billion (in 2018) of total CMS healthcare funding. Patient satisfaction composes 25% of the hospital total performance score. Learning how to improve patient satisfaction is now an important 66 | Educational e-Posters SIR 2019 Annual Scientific Meeting

Abstract No. 779 including May-Thurner syndrome (MTS), in patients presenting with CS and the importance of pelvic MRV. 3.Discuss the endovenous inter- Carbon dioxide angiography and venography: a pictorial ventions and outcomes for patients with CS and MTS. review and clinical applications BACKGROUND: CS can account for up to 40% of ischemic and A Fang1, A Adovor1 are defined as strokes not readily attributable to cardioembolism, large 1Saint Louis University Vascular and Interventional Radiology, St. vessel atherosclerosis or small vessel disease, despite extensive vas- Louis, MO cular, cardiac, and serologic evaluation. Potential etiologies include patent foramen ovale (PFO) in the setting of paroxysmal atrial fibril- LEARNING OBJECTIVES: 1. Review of carbon dioxide as a safe and use- lation, aortic arch plaque, thrombophilias, autoimmune or inflamma- ful contrast agent including the properties, methods of delivery and tory disorders, and May-Thurner syndrome (MTS). Determination of principles of successful imaging. 2. Advantages and disadvantages of underlying etiology is essential to guiding intervention and preventing using carbon dioxide as a contrast agent in interventional radiology recurrence, therefore a thorough diagnostic workup is essential. For 3. Pictorial review of different clinical applications of carbon dioxide patients with CS, workup to determine etiology includes CT or MRI contrast agent using case examples. of the brain, imaging of the extra/intracranial large vessels, cardiac

BACKGROUND: Carbon dioxide is a colorless, odorless gas that is safe evaluation with TTE/TEE, prolonged cardiac monitoring, and hema- and a useful contrast agent for vascular imaging. Advantages of using tologic testing. Several recent series highlight the importance of MRV carbon dioxide as a contrast agent include lack or renal toxicity and in assessing for a pelvic source of emboli in patients with CS and PFO, anaphylactic response. Carbon dioxide can be used in patients with particularly in the setting of pelvic DVT and MTS. Between 10-30% of renal failure and contrast allergy. Carbon dioxide can be injected patients presenting with CS and PFO have been determined to have a through smaller diameter micro-catheters and unlimited volumes can MTS variant and endovenous interventions including angioplasty and be used safely. The disadvantages of using carbon dioxide include stenting have resulted in excellent outcomes for these patients. absolute contraindication in thoracic aortography, coronary arteriog- CLINICAL FINDINGS/PROCEDURE DETAILS: We will review CS, its etiolo- raphy and cerebral arteriography. Carbon dioxide angiography should gies and workup. Then, we summarize recent series that highlight the be performed with caution in patients with pulmonary hypertension prevalence of MTS or pelvic vein pathology in patients presenting with and COPD. CS and PFO. The importance of pelvic MRV with respect to diagnosis

CLINICAL FINDINGS/PROCEDURE DETAILS: Pictorial review of the indi- and interventional planning will be discussed. Finally, we review endo- cations and clinical applications of carbon dioxide angiography and venous treatments for these patients and their outcomes. venography will be presented. We will present a variety of cases where CONCLUSIONS: CS is an ischemic stroke with of undetermined etiology. carbon dioxide is used as a contrast agent in patients with renal failure Pelvic vein pathology including DVT and MTS in the setting of PFO or contraindication to iodinated contrast agent. Cases include carbon is more prevalent than expected. Endovenous interventions result in dioxide lower extremity angiography/venography and interventions, excellent outcomes for these patients. carbon dioxide agent for fistulogram/declot procedure and interven- tion, carbon dioxide for biliary intervention, carbon dioxide cavog- raphy for Inferior vena cava filter placement, carbon dioxide wedge Abstract No. 781 hepatic venogram for Transjugular Intrahepatic Portosystemic Shunt (TIPS) procedure and Transjugular liver biopsy (TJLB). CT and MR findings of vasculitis involving the aorta and mesenteric vasculature CONCLUSIONS: Carbon dioxide is a safe and useful contrast agent that can be used in patients in patient with contrast allergy or renal G Wong1, T Patel1, D Mauro1, L Burke1, C Burke1 insufficiency for all angiography and venography procedure and inter- 1University of North Carolina Hospitals, Chapel Hill, NC ventions except thoracic aortography, coronary arteriography and cerebral arteriography. LEARNING OBJECTIVES: Pictorial review of the essential CT and MR findings as well as clinical manifestations of immune-mediated vascu- litis involving the aorta and mesenteric vasculature. Abstract No. 780 BACKGROUND: Vasculitis refers to general vessel wall inflammation, Cryptogenic strokes and the value of magnetic resonance which can either be due to immune-mediated causes or direct invasion venography by organisms. Immune-mediated vasculitis can further be divided into large vessel, medium vessel, and small vessel involvement. Despite the 1 1 1 1 1 1 A Saini , S Alzubaidi , S Naidu , M Knuttinen , H Albadawi , J Hu , relatively rare occurrence, as experts in vascular imaging, interven- 1 R Oklu tional radiologists must be able to identify and categorize vasculitis 1Mayo Clinic, Phoenix, AZ detected on cross-sectional imaging. While there is a vast amount of overlap in imaging findings, laboratory findings, and clinical presenta- LEARNING OBJECTIVES: 1.Define cryptogenic stroke (CS), potential eti- tions, with knowledge of all three, a specific focused differential diag- ologies, and the workup for patients presenting with CS. 2.Summarize nosis can be provided. recent literature regarding the prevalence of pelvic vein pathology, SIR 2019 Annual Scientific Meeting Educational e-Posters | 67

CLINICAL FINDINGS/PROCEDURE DETAILS: Imaging findings on CT Abstract No. 783 and MRI and differentiating laboratory values and clinical features of the following large, medium, and variable vessel vasculitides will be Imaging characteristics of hereditary hemorrhagic explored: 1) Takayasu Arteritis 2) Giant Cell Arteritis 3) Polyarteritis telangiectasia: a lesson in incomplete penetrance Nodosa 4) Kawasaki Disease 5) Behcet’s Disease 6) Cogan’s Syndrome J Cao1, M Anderson2, P Sutphin2, G Kumar3 CONCLUSIONS: Differentiating specific types of vasculitis is difficult 1University of Texas Southwestern Medical Center, Dallas, TX, 2UT as there are many common features. With in depth knowledge of the Southwestern Medical Center, Dallas, TX, 3University of Texas Health imaging characteristics and clinical manifestations of the different vas- Science Center at San Antonio, San Antonio, TX culitides, radiologists can help to establish a specific diagnosis. LEARNING OBJECTIVES: Identify the common imaging findings of hereditary hemorrhagic telangiectasia (HHT) Discuss the variation in Abstract No. 782 imaging findings that may be encountered in HHT patients with vary- ing degrees of organ involvement Discuss the relevant imaging find- techniques in deep vein thrombosis ings to clinical outcome as well as findings relevant to endovascular evaluation embolization therapy

1 1 1 1 1 1 P Hoang , A Saini , S Naidu , H Albadawi , M Knuttinen , S Alzubaidi , BACKGROUND: Hereditary hemorrhagic telangiectasia (HHT) is an auto- R Oklu1 somal dominant disorder of vascular development that with varying rates 1Mayo Clinic, Phoenix, AZ of penetrance. HHT classically presents in adolescence with epistaxis, gastrointestinal bleeding, anemia, and mucosal telangiectasia. Commonly LEARNING OBJECTIVES: The purpose of this education exhibit is to: 1. encountered radiologic findings of HHT include pulmonary (50%), hepatic Detail the most commonly used elastography techniques for evalua- (30%), and cerebral (10%) arteriovenous malformations (AVM) for which tion of thrombus. 2. Evaluate the current experimental and clinical evi- endovascular occlusion is the preferred method of treatment. As AVMs dence of elastography techniques for aging DVT. enlarge over time there is an increased risk of complications such as

BACKGROUND: DVT is a significant medical problem with an inci- hemoptysis, gastrointestinal bleeding, intrapulmonary shunting resulting dence of 1 in 1000 adults and greatly reduces quality of life through in cardiac dysfunction, stroke, and cerebral spread of infection. post-thrombotic syndrome. With continually emerging endovascular CLINICAL FINDINGS/PROCEDURE DETAILS: Cross-sectional contrast-en- catheter techniques to treat venous clots, improved imaging tech- hanced CT studies were reviewed for patients diagnosed clinically with niques is desirable to accurately determine clot age. Treatment choice HHT. Each case was accessed for classic pulmonary, hepatic, or cere- for DVT and prognosis can be influenced by the age of the clot. The bral AVM findings and graded based on severity of organ involvement. current gold standard for assessment of DVT is venous duplex ultra- A secondary survey was performed for additional less commonly sonography, combining color flow Doppler imaging with compression encountered disease manifestations and their relevance to clinical ultrasonography. No conventional modality, including ultrasound, outlook, symptoms, or management. Further assessment was made magnetic resonance imaging, or computed tomography, can directly of imaging findings which would or did go on to affect attempted AVM provide information about tissue rigidity, a characteristic associated endovascular occlusion with clot age. Since clot age clearly influences the treatment approach and prognosis for patients, measuring this quantity is extremely clin- CONCLUSIONS: HHT as most commonly encountered by radiologists ically desirable. As thrombus ages, its mechanical properties also is through contrast-enhanced cross-sectional imaging. The cases pre- change; therefore, thrombus stiffness should be a surrogate marker sented as encountered by our institution conveys the wide array of for the chronicity of a thrombus. organ systems that are involved in this disease process as well as the varying degrees of penetrance leading to a clinically diverse level of CLINICAL FINDINGS/PROCEDURE DETAILS: First, we will explain the disease severity. As most patients will obtain at least one CT angio- rationale behind frequently used elastography techniques. This review gram for workup of HHT and likely subsequent imaging to follow dis- will collate and evaluate experimental and clinical evidence on these ease progression which provides valuable insight for interventional imaging systems and deformation techniques for indirect elastic- radiologists in procedural planning including anatomic variations, size ity measurement. There will be a focus on US and MRI elastography of arterial feeding vessels, and sites of disease involvement. techniques in the assessment of thrombus aging. Strain elastography and shear wave elastography are the most common techniques to age thrombus. These elastography techniques can distinguish between Abstract No. 784 acute and chronic clots by characterizing tissue stiffness. Imaging of acute aortic syndromes: a primer for residents CONCLUSIONS: Accurate estimate of the stage and maturity of DVT is 1 1 2 1 1 3 4 useful in determining proper therapeutic management. When clot age R Ahn , P Sutphin , S Saboo , H Early , A Bass , K Menon , J Birch , 1 1 1 1 1 cannot be determined with ultrasound duplex analysis, elastography H Park , E Hyatt , A Palumbo , S Abbara , S Kalva techniques may offer a helpful adjunct. This can provide useful infor- 1UT Southwestern Medical Center, Dallas, TX, 2University of mation to the interventional radiologist evaluating the patient for more Texas San Antonio, Dallas, TX, 3Stanford University, Dallas, TX, invasive thrombus treatments. 4Massachusetts General Hospital, Boston, MA 68 | Educational e-Posters SIR 2019 Annual Scientific Meeting

LEARNING OBJECTIVES: 1. Rapid and accurate diagnosis of acute aortic and “replaced” to identify MAVs. Over 300 MAV were identified. The syndromes is critical to limit morbidity and mortality. 2. Critical vas- following list represents the 9 rarest variants encountered: gastro- cular findings can be subtle and difficult to identify. This exhibit will splenic trunk and hepatomesenteric trunk; celiacomesenteric trunk illustrate the spectrum of imaging findings in acute aortic syndromes and left gastric artery (LGA) from aorta; replaced common hepatic from subtle to grossly abnormal findings. 3. Viewers will understand artery (CHA) from SMA with accessory LHA from LGA; arc of Buhler; the imaging characteristics and major subtypes of acute aortic syn- splenic artery from SMA with gastrohepatic trunk; shared origin of left dromes. Classification and grading of these findings will also be pre- renal artery and IMA with dorsal pancreaticoduodenal arcade (DPA) sented. 4. Institutional experience with added value of spectral (dual from celiac, RHA originates from posterior pancreaticoduodenal energy) CT imaging will also be presented. arcade. LHA arises from LGA; accessory mesenteric artery arises from aorta, accessory RHA arises directly from celiac axis; gastroduodenal BACKGROUND: Interventional radiologists must be experts at inter- artery arises from the aorta, accessory LHA from gastrosplenic trunk. preting vascular imaging studies as they are used frequently for the Replaced RHA arises from SMA; RHA originates from the celiac axis. diagnosis of acute aortic syndromes and are used for planning inter- DPA from RHA. ventional treatments. Critical vascular findings may be subtle and are seen infrequently in clinical practice. Delayed diagnosis can lead to cat- CONCLUSIONS: Foreknowledge of obscure MAVs can guide pre-pro- astrophic complications. cedural planning and prevent potential complications. With the uti- lization of AR and 3D volume rendering, trainees and experienced CLINICAL FINDINGS/PROCEDURE DETAILS: Diagnostic approach to operators can easily become more familiar with unusual mesenteric acute aortic syndromes, including CT protocols, post-processing and vascular anatomy. the application of spectral imaging (dual-energy/detector based spec- tral CT) will be discussed. Diseases entities including traumatic aortic injuries, acute aortic syndromes (penetrating aortic ulcers, intramural Abstract No. 786 hematomas, aortic dissection), aortic aneurysms (rupture, impending rupture, mycotic aneurysms), thrombus (aortic, great vessels, mesen- Non-atherosclerotic peripheral arterial disease of the teric) and aortoenteric fistulas will be presented. lower extremities

CONCLUSIONS: Viewers of this presentation will have an understanding T Patel1, G Wong1, D Mauro1, H Yu1, L Burke1 of the imaging findings associated with acute aortic syndromes, recom- 1University of North Carolina Hospitals, Chapel Hill, NC mended CT protocols and our institutional experience with spectral CT. LEARNING OBJECTIVES: The purpose of this exhibit is to: 1. Briefly review peripheral arterial disease (PAD) and discuss selected non-ath- Abstract No. 785 erosclerotic conditions that can cause PAD in the lower extremities. 2. Provide examples of key clinical features and imaging findings to help Mesenteric artery variants from Appalachia make a diagnosis in the patient with non-atherosclerotic PAD. 3. Dis- S Sanampudi1, M Issa2, M Winkler3, D Raissi2 cuss various treatment options that are available for these conditions, including potential endovascular treatments for non-atherosclerotic 1University of Kentucky College of Medicine, Lexington, KY, 2University of Kentucky, Lexington, KY, 3University of kentucky, PAD.

Lexington, KY BACKGROUND: Peripheral arterial disease is an extremely common condition, most commonly due to atherosclerotic disease. However, LEARNING OBJECTIVES: The purpose of this study is to conduct a there are numerous other etiologies that can lead to lower extremity pictorial review of the nine rarest mesenteric artery variants (MAV) pain and PAD symptoms. Specific disease processes to be aware of encountered at a single tertiary center over the last 10 years. These include popliteal entrapment syndrome, cystic adventitial disease, iliac MAV will be presented via 3D reconstruction of Computed Tomo- artery endofibrosis, fibromuscular dysplasia, and vasculitides such as graphic Angiography (CTA) images and on-site smartphone based giant cell arteritis, Takayasu’s arteritis, and Buerger’s disease. augmented reality (AR).

CLINICAL FINDINGS/PROCEDURE DETAILS: A pictorial review of the var- BACKGROUND: Identification of variants involving the celiac, superior ious causes of non-atherosclerotic PAD will be presented with a dis- mesenteric artery (SMA), inferior mesenteric artery (IMA), and their cussion of key clinical information that can help narrow the differential. branches is critical in pre-procedural planning. While replaced/acces- Imaging finding on angiography, CT, MRI, and/or ultrasound associ- sory right hepatic artery (RHA) and left hepatic artery (LHA) are rather ated with the selected conditions will be included. Additionally, man- common variants, less frequently described variants are encountered agement of these conditions will also be reviewed, including the role of with more frequency with the increase use of CTA. There is great value endovascular treatment options for these patients. in improving our ability to identify these variants peri-procedurally with potential treatment related implications. CONCLUSIONS: PAD is most commonly secondary to atherosclerotic disease; however, there are numerous other causes of PAD. Inter- CLINICAL FINDINGS/PROCEDURE DETAILS: A retrospective search ventional radiologists who may be seeing these patients in clinic and of the radiology information system was performed using search performing angiograms or reading imaging studies on these patients terms: “aberrant artery,” “anomalous artery,” “variant,” “accessory” SIR 2019 Annual Scientific Meeting Educational e-Posters | 69

should be familiar with these conditions and how to diagnose them. LEARNING OBJECTIVES: To review the evidence behind non-surgical These conditions should be considered in younger patients that don’t approaches to stage 1 and 2 non-small cell lung carcinoma (NSCLC), have typical risk factors for atherosclerotic disease or findings on his- including radiofrequency ablation (RFA) and stereotactic body radia- tory and physical exam suggestive of one of these disorders. tion therapy (SBRT).

BACKGROUND: Surgery is the preferred treatment modality for stage 1 Abstract No. 787 and 2 NSCLC. In non-surgical patients, acceptable alternatives include RFA and SBRT. While there is no well-defined treatment algorithm, Interventional oncology and adrenal tumors current recommendations from the American College of Chest Physi- cians and the Society of Thoracic Surgeons favor the use of SBRT due H Narayanan1, M Osman2, A Chun3, A Venbrux2, S Sarin4, D Scher5 to an abundance of supporting long-term data. Current data to sup- 1 2 George Washington University Hospital, Arlington, VA, George port RFA is limited to retrospective studies and trials that lack direct 3 Washington University Hospital, Washington, DC, George comparison to SBRT. In this exhibit, our aim is to assess the available 4 Washington Hospital, Washington, DC, George Washington evidence evaluating RFA and SBRT in the treatment of stage 1 and 2 University, Washington, DC, 5George Washington University, NSCLC in non-surgical candidates. Baltimore, MD CLINICAL FINDINGS/PROCEDURE DETAILS: Three studies have directly LEARNING OBJECTIVES: Percutaneous ablative and embolic techniques compared RFA and SBRT in the treatment of lung cancer. A 2015 study for the treatment of various adrenal tumors offers unique challenges to retrospectively compared RFA and SBRT in 95 Japanese patients. the interventional radiologist. The objective of our educational poster The investigators found similar rates of 3-year local progression (RFA: will be to give the practicing interventional radiologist/interventional 9.6%, SBRT: 7.0%), overall survival (86.5%, 79.6%), and major compli- oncologist an updated review of current adrenal tumor interventions cation (10.4%, 8.5%). A 2016 pooled analysis examined 31 studies on and to highlight the technical aspects involved. Understanding the SBRT comprising 2767 patients and 13 studies on RFA comprising 328 appropriate indications, techniques, peri-procedure imaging, as well patients. There were significantly lower rates of local tumor control as post- procedure management of these patients is paramount to following RFA compared to SBRT at 1, 2, 3, and 5 years (77% vs. 97%, maximizing safety and success rates. 48% vs. 92%, 55% vs. 88%, and 42% vs. 86%). However, overall survival

BACKGROUND: Adrenal tumors consist of a wide variety of patholo- was similar between the two modalities. A 2018 analysis of the National gies; including primary adrenal neoplasms and metastases. Due to the Cancer Database examined 4,454 patients treated with SBRT and 335 unique physiology of the adrenal glands, adrenal ablation/embolization treated with RFA. This study found that patients treated with RFA has important risks to consider. An understanding of the surrounding experienced significantly more comorbidities. However, similar overall anatomy as well as the arterial supply of the adrenal glands is crucial to survival rates were seen following RFA compared with SBRT at 1, 3, and performing successful procedures. Our educational poster will discuss 5 years (89.3% vs. 85.5%, 52.7% vs. 54.3%, 27.1% vs. 31.9%). pertinent anatomy as well as anatomical variants to consider. CONCLUSIONS: In limited analysis, RFA may be as effective as SBRT

CLINICAL FINDINGS/PROCEDURE DETAILS: Percutaneous ablative tech- in the treatment of NSCLC, with a potentially similar safety profile. niques that have been applied for the treatment of adrenal tumors However, until the field of interventional radiology pushes for large, include percutaneous radiofrequency ablation, cryoablation, micro- multicenter, randomized controlled trials, RFA will continue to be con- wave, and chemical ablation. Adrenal artery embolization can also be sidered third-line treatment for stage 1 and 2 NSCLC. employed as an adjunctive therapy for highly vascular or unresect- able adrenal tumors for palliation. Our educational poster will provide Abstract No. 789 examples from our institution of these various techniques.

CONCLUSIONS: Our educational poster aims to review current proce- Renal ablation cost analysis dures being employed for the treatment of adrenal tumors and present W Bremer1, A Valeshabad2, C Ray3 our institutional experience with percutaneous embolization and abla- 1University of Illinois-Chicago Medical Center, Chicago, IL, tion. Additionally, we will discuss the clinical management and proce- 2University of Illinois-Chicago, Chicago, IL, 3University of Illinois dural aspects of these cases, including pertinent anatomy as well as Hospital and Health Sciences Center, Chicago, IL potential pitfalls and complications.

LEARNING OBJECTIVES: 1) Establish the role of cost analysis in the med- ical literature, including the metrics used to determine cost effective- Abstract No. 788 ness. 2) Discuss the frequency of small renal masses in the general population and the methods of management. 3) Review the cost effec- Radiofrequency ablation vs. stereotactic body radiation tiveness of renal ablation versus surgical and nonsurgical options in therapy in non-surgical candidates with lung cancer management of small renal masses. M Hoyer1, K Hong2 BACKGROUND: Over 60% of renal cell carcinomas (RCCs) are being dis- 1 Johns Hopkins University School of Medicine, Baltimore, MD, covered incidentally during radiologic imaging, leading to a rise in RCC 2Johns Hopkins Hospital, Woodstock, MD incidence. Small renal masses account for the majority of RCC diagnoses, 70 | Educational e-Posters SIR 2019 Annual Scientific Meeting

however, have an overall favorable prognosis, with many RCC patients selective nature of cavitation caused by histotripsy holds promise for dying from unrelated causes. Treatment paradigms have shifted from pancreatic tumors where preservation of underlying architecture is radical nephrectomy to nephron sparing options such as nephron spar- paramount to preventing complications. RAST may offer a less inva- ing surgery (NSS) and ablation due to lower rates of mortality and sive treatment method for uterine fibroids. chronic kidney disease. Cost analysis can assist in determining the most CONCLUSIONS: RAST combines the focused ultrasound treatment cost effective option and where limited resources are best directed. modality of histotripsy with robotic micropositioners to perform CLINICAL FINDINGS/PROCEDURE DETAILS: A Pubmed search of “renal non-invasive, non-thermal ablations. RAST has been safely applied to ablation cost” was performed and articles over the last 10 years were porcine liver, kidney, and fat with promising results. Potential future chosen for review. A review of cost studies using different outcomes applications for RAST include pancreatic tumors and uterine fibroids. was performed including cost studies comparing ablation to NSS and studies comparing ablation to biopsy/surveillance. The methods of cost analysis and the results of these studies are discussed. Abstract No. 791

CONCLUSIONS: 1) For those undergoing treatment, ablation is almost Technology selection for percutaneous ablation of renal always less costly than other forms of treatment. 2) Active surveillance cell carcinoma comes with its own costs, however active surveillance with ablation N Doro1, R Miller1, A Sayegh1, C Stark1, L Keating1, K Mandato1, therapy reserved for advancement of disease might be preferred. 3) A Herr1, G Siskin1 Biopsy is probably not cost-effective. 1Albany Medical Center, Albany, NY

Abstract No. 790 LEARNING OBJECTIVES: To review the technique, outcomes, and potential complications of the ablative technologies utilized for the Robotically assisted sonic therapy (RAST): current percutaneous treatment of renal cell carcinoma. developments in a large porcine model and potential BACKGROUND: Renal cell carcinoma is known to be amenable to per- applications cutaneous ablation for definitive treatment. With the introduction of K Longo1, J Swietlik2, E Knott1, A Smolock3, T Ziemlewicz4, F Lee5 new ablative technology in recent years, interventional radiologists are faced with deciding which technology to use in a particular patient. 1University of Wisconsin, Madison, WI, 2University of Wisconsin, 3 MADISON, WI, University of Pennsylvania, Philadelphia, PA, CLINICAL FINDINGS/PROCEDURE DETAILS: Radiofrequency, microwave, 4University of Wisconsin Hospital and Clinics, Madison, WI, and cryoablation are the tools available for the percutaneous treat- 5University of Wisconsin, Madison, WI ment of renal cell caricnoma. In addition, embolization can be used in select cases for palliative treatment. As new technology is introduced, LEARNING OBJECTIVES: Robotically assisted sonic therapy (RAST) is the research used for evaluation must be reviewed. Understanding a non-thermal focused ultrasound therapy utilizing histotripsy and is the technology, the tumor and patient-based selection criteria, the currently being developed as a non-invasive ablation modality. The reported outcomes, and potential risks will help interventional radiol- goal of this exhibit is to describe the developments achieved with this ogists determine the most appropriate device for an individual patient technology to date including ablation of porcine liver, kidney, and fat and the specific tumor being targeted for treatment. and to discuss the potential for future applications with RAST.

CONCLUSIONS: The ablative technologies available for use in the treat- BACKGROUND: RAST uses the mechanism of histotripsy to destroy ment of renal cell carcinoma are highly effective strategies for minimally tissue at the cellular level by pressure-induced acoustic cavitation. invasive treatment of these lesions. Physicians offering this treatment to Histotripsy has been well studied in small animal models. When his- their patients must have an understanding of patient-based, lesion-based, totripsy is combined with motorized micropositioners to allow treat- and technology-based criteria used to select the most appropriate device ment of a defined volume, it is termed RAST. In order to determine the for each patient. This educational exhibit will help define these criteria to applicability of use for human tumors, we have applied RAST to the optimize treatment selection for patients with renal cell carcinoma. liver, kidney, and subcutaneous fat in a large porcine model.

CLINICAL FINDINGS/PROCEDURE DETAILS: We have performed RAST in 87 porcine models to date. In liver and renal models, RAST has been Abstract No. 792 safely used to create 2.5-3 cm ablation spheres. Pathologic analysis demonstrates a sharply demarcated acellular tissue homogenate with Thermal protection for image-guided percutaneous a thin transition to normal adjacent tissue. A recurrent finding was that ablation: review of classic techniques and introduction to densely collagenous structures such as bile ducts, blood vessels, and new methods the urinary collecting system are more resistant to cavitation induced T Bochnakova1, R Arellano1, K Yamada1, R Uppot1, T Bochnakova1 tissue damage due to higher mechanical strength. Finally, RAST has 1Massachusetts General Hospital, Boston, MA very recently been applied to subcutaneous fat with promising results that are currently under evaluation. Potential future applications LEARNING OBJECTIVES: To review challenges of percutaneous ablation for RAST include pancreatic tumors and uterine fibroids. The tissue including potential complications of thermal injury. To describe classic SIR 2019 Annual Scientific Meeting Educational e-Posters | 71

techniques of thermal protection including hydrodissection, CO2 pneu- of this emerging field. In the future, liquid biopsies will further influ- modissection, balloon interposition, artificial pleural effusion or pneu- ence interventional oncology through improved patient and treatment mothorax through case examples. To introduce gel foam absorbable selection, and by enhanced monitoring of treatment response. powder as an alternative method of thermal protection without the CLINICAL FINDINGS/PROCEDURE DETAILS: We will explain the con- limitations of other thermal protective techniques. cept and process of liquid biopsy, and outline key studies that have BACKGROUND: Thermal protective techniques are often used to sepa- demonstrated its utility in cancer diagnostics, prognostics, and ther- rate anatomic structures for the purpose of safely performing image- apeutics. We will describe how advances in the field of liquid biopsy guided ablations. These techniques are performed to prevent thermal will influence and affect interventional oncologists; case reviews will injury to healthy surrounding structures and to minimize heat/cold be included. Finally, we will provide an overview of future applications dissipation within the body. Each substance used for separation has of liquid biopsy in interventional oncology. unique properties that can be taken advantage of to maximize success CONCLUSIONS: Liquid biopsy involves the isolation and subsequent of ablation based on anatomical location and surrounding structures. analysis of a tumors genetic material from any biological fluid in an CLINICAL FINDINGS/PROCEDURE DETAILS: Description of the most attempt to provide diagnostic, prognostic, and predictive information. common thermal protective methods including the benefits and lim- It non-invasively and longitudinally provides information on tumor itations of each technique based on anatomical locations: hydrodis- heterogeneity and mutation status, helping to personalize and tailor section, CO2 pneumodissection, balloon interposition; artificial pleural image-guided locoregional treatments. effusion or pneumothorax; pyeloperfusion; Gelfoam absorbable gela- tin powder. Abstract No. 794 CONCLUSIONS: Thermal protective techniques have allowed ablation, a potentially curative treatment option, to be performed for lesions that Expected and unexpected complications of percutaneous otherwise cannot be targeted safely. The technical considerations, lung biopsy: a comprehensive pictorial review of a basic benefits and limitations of the most common methods are described but essential procedure to adequately select the optimal approach based on lesion location. N Cornish1, M Hoy2, S Mustafa3, A Birney4, D Igonkin5, D Sarkar6 Gelfoam absorbable gelatin powder is a new option in the toolbox of 1 2 thermal protective techniques without some of the limitations encoun- Maimonides Medical Center, Staten Island, NY, The George tered with other methods. Washington University School of Medicine and Health Sciences, Washington, DC, 3Maimonides Medical Center, Brooklyn, NY, 4Mount Sinai Hospital, New York, NY, 5James J. Peters VA Medical Abstract No. 793 Center, N/A, 6Maimonides Medical Center, New York, NY

Emerging liquid biopsy technologies and interventional LEARNING OBJECTIVES: Reduce complications following percutaneous oncology lung biopsy by providing a review of the common/uncommon poten- tial complications. Discuss risk factors associated with the develop- 1 1 1 1 1 1 A Saini , Y Pershad , H Albadawi , S Naidu , M Knuttinen , M Kuo , ment of complications. Provide technical considerations to prevent 1 R Oklu complications and an algorithm for postprocedural management of 1Mayo Clinic, Phoenix, AZ complications based on institutional data.

LEARNING OBJECTIVES: 1.Describe the concept of liquid biopsy includ- BACKGROUND: Percutaneous biopsy is a minimally invasive tool to ing isolation, enrichment, and analysis of circulating tumor cells (CTC) aid in the clinical diagnosis of thoracic lesions that is very safe when and circulating tumor DNA (ctDNA). 2.Explain the role of liquid biopsy performed by appropriately trained and experienced physicians. Com- in cancer diagnostics, prognostics, and therapeutics. 3.Discuss the role pared with other percutaneous biopsy procedures, lung biopsy carries liquid biopsies will play in interventional oncology. 4.Present clinical a higher risk of potential complications, including death. Pneumotho- cases and demonstrate the value of liquid biopsies rax and pulmonary hemorrhage are the most common complications, however, air embolism and tumor seeding of the pleura and chest wall BACKGROUND: A liquid biopsy is a sample of any biological fluid, most are uncommon complications that we have experienced. Institutional often peripheral blood, that contains CTCs and ctDNA that has been protocols for the performance of lung biopsy and management of shed from a tumor. Enrichment and analysis of genetic material from complications should be in place. Recognizing associated risk factors CTC’s and ctDNA can non-invasively and longitudinally provide insight with careful attention to preprocedural planning and technique and into a tumors heterogeneity and genetic composition, while also pro- postprocedural care can help prevent or minimize complications. viding diagnostic, prognostic, and therapeutic information. For exam- ple, levels of ctDNA have been correlated with disease burden and CLINICAL FINDINGS/PROCEDURE DETAILS: We present an institutional chemotherapy response in colorectal cancer, and rises in ctDNA have review of potential complications for patients undergoing percuta- been able to predict recurrence six months before radiological imag- neous lung biopsy with corresponding imaging correlation. Prepro- ing. Interventional radiologists, with their expertise in tissue biopsy, cedural risk factors and risk stratification are discussed. We discuss armamentarium of locoregional therapies, and their ability to selec- the role of diagnostic imaging and procedural techniques that place tively catheterize vessels, will play an integral role in the development the patient at risk for a higher rate of complications and when it is 72 | Educational e-Posters SIR 2019 Annual Scientific Meeting

imperative to consider alternatives to the percutaneous route includ- CONCLUSIONS: Pleural blood patching and rapid needle-out with roll- ing bronchoscopic or surgical biopsy. Techniques that reduce the risk over are two low cost techniques for reducing the incidence of pneu- of complications and our institutional protocol for management of mothorax. On site cytopathologic evaluation increases diagnostic complications are discussed. accuracy, particularly for lesions <2 cm. The vast majority of clinically significant pneumothoraces are detected within 2 hours. CONCLUSIONS: Prevention/management of complications follow- ing percutaneous lung biopsy is best achieved by recognizing risk factors, implementing techniques that minimize complications, and Abstract No. 796 using an institutional protocol to manage complications. The impor- tance of safe percutaneous biopsy has been heightened with the Periprocedural carcinoid symptom management advancement of interventional oncology as it is seen as a means of and prevention for patients with neuroendocrine collaborating with medical and surgical oncologists and a referral liver metastasis undergoing TACE: a referral center base for patients. institutional perspective M Makary1, A Olfat2, E Elliott1, J Dowell3 Abstract No. 795 1The Ohio State University Medical Center, Columbus, OH, 2N/A, San Mateo, CA, 3The Ohio State University, Powell, OH Percutaneous needle biopsy of the lung in 2018: a review of evidence-based best practices LEARNING OBJECTIVES: To present a large tertiary referral center expe- rience with periprocedural prevention and management of carcinoid 1 1 2 A Maybury , Y Epelboym , S O’Horo syndrome in patients with neuroendocrine metastases to the liver 1Boston Medical Center, Boston, MA, 2Boston Medical Center, undergoing transarterial chemoembolization (TACE). Hingham, MA BACKGROUND: Neuroendocrine tumors (NETs) are a heterogenous LEARNING OBJECTIVES: Percutaneous needle biopsy of the lung is a group of rare hormone-producing neoplasms that are the most com- commonly performed procedure with considerable practice variation. mon cause of carcinoid syndrome. Carcinoid syndrome is caused by The goal of this review is to summarize evidence-based best practices the secretion of vasoactive substances causing flushing, fluctuations for the interventional radiologist. in blood pressure, diarrhea, and bronchospasm. Patients with NET metastases to the liver have a higher propensity to experience car- BACKGROUND: A comprehensive literature review was performed to cinoid symptoms during TACE due to the release of vasoactive and evaluate articles pertaining to lung biopsy in PubMed, EMBASE, and hormonal factors. Optimal periprocedural management guidelines to Web of Science. Filters were applied for English-language articles pub- manage and prevent labile carcinoid symptoms has not been estab- lished in clinical journals since 1998. Results were sorted into guide- lished. In this exhibit, we present our decade-long institutional experi- lines, reviews, and original research. Other articles were added upon ence as a NET referral center with the periprocedural management for review of references. control and prevention of carcinoid effects in NET patients undergoing CLINICAL FINDINGS/PROCEDURE DETAILS: Topics addressed in this locoregional therapy with both conventional and drug-eluting bead poster include techniques and devices for reducing pneumotho- TACE. rax rates, the utility of on-site cytopathology for select cases, and CLINICAL FINDINGS/PROCEDURE DETAILS: This exhibit will present: 1. A evidence-based practices for post biopsy care. Several device review of the pathophysiology of NETs and associated carcinoid dis- administered tract embolization trials report significantly reduced ease, 2. Summary of current management paradigms and published pneumothorax and chest tube rates, however, wide adoption of locoregional therapy data, 3. Outline of our institutional protocol for such devices may pose significant financial costs. Pleural blood the periprocedural management and prevention of carcinoid symp- patching, a low-cost alternative, has been shown to be non-infe- toms in patients undergoing both conventional and drug-eluting bead rior, with reported risk reductions of 32-33%, and 36-75%, respec- TACE, 4. Summary of our institutional outcomes over the past decade tively. Tsuo et al. show improved diagnostic accuracy from 93.3% and learned insights, 5. Description of treatment challenges and pearls to 97.1% with on-site cytopathology. Subgroup analysis showed for establishing local periperocedural management guidelines, and greatest benefit for lesions <2 cm in size. Regarding post-biopsy 6. Review of the current literature with a focus on future research care, O’neil et al. report a 38% reduction in pneumothorax and 73% directions. fewer chest tubes with a mean needle out rollover time of 9.5 sec- onds. With similar methods, Kim et al. reported a 62% reduction in CONCLUSIONS: After reviewing this exhibit, the viewer will become chest tubes and 46% reduction in delayed pneumothorax. Time to familiar with the challenges of management and prevention of car- detect clinically significant delayed pneumothorax ranged from 4 cinoid symptoms in NET patients with liver metastases undergoing to 120 hours across studies, with the vast majority presenting within locoregional therapy, gain a deeper understanding of the current lit- 2 hours. Brown et al. prospectively demonstrated safe post biopsy erature, learn insights from a decade-long experience of a large NET management in a 315 patient series based upon an initial and 2 hour referral center, and gain pearls for developing local interdisciplinary radiograph. guidelines to provide optimal care and outcomes. SIR 2019 Annual Scientific Meeting Educational e-Posters | 73

Abstract No. 797 progression and liver failure). Previously only large tumors were thought to be at risk for spontaneous rupture, however, all HCC tumors Celiac and splanchnic plexus neurolysis: dos and don’ts are at now believed to be at risk including small tumors with an aggres- A Justaniah1, D Waggas2 sive behavior. The symptoms of ruptured HCC are related to the posi- tion of the tumor and range from asymptomatic to hemoperitoneum 1King Abdullah Medical City, Makkah, Saudi Arabia, 2Fakeeh College with peritonitis and hemodynamic instability. for Medical Sciences, Jeddah, Saudi Arabia CLINICAL FINDINGS/PROCEDURE DETAILS: propriate management LEARNING OBJECTIVES: To be able to: -Understand the history of celiac remains a subject of debate. Available options include conservative plexus neurolysis -Identify the celiac plexus on CT/MRI -Recognize the treatment, surgical hemostasis, transarterial embolization (TAE), and pain pathway -Evaluate patients for the appropriateness of such a pro- emergency staged liver resection. The prognosis is poor with conser- cedure -Manage palliative patients with pain due to advanced visceral vative treatment and surgical hemostasis. TAE is an effective means of neoplasm -Perform the procedure obtaining hemostasis and should be considered as a first line options.

BACKGROUND: Currently, pain management represents a small pro- Particle embolization with embospheres or PVA stops the arterial sup- portion of daily interventional radiology practices. We would like to ply to the tumor itself and the microvascular tumor bed. TAE should not uncover the splanchnic/celiac plexus neurolysis technique to help preclude surgery in patients that can undergo resection or lobectomy other interventional radiologists help their patients. The technique was as this has improved survival rates. However, mortality is high in the introduced in 1914. The procedure is prescribed for palliative patients acute phase and patients may benefit from TAE first. A review of the presenting with intractable pain, nausea and vomiting due to aggres- current literature and cases treated at our institution will be provided. sive visceral neoplasms. The goal is to alleviate patients pain and mini- CONCLUSIONS: The present day interventional community is well- mize their narcotic requirements. equipped to manage HCC, however spontaneously ruptured HCC may

CLINICAL FINDINGS/PROCEDURE DETAILS: Background will be pro- present a dilemma. Interventional radiology has become an essential vided. Relevant tips for clinical evaluation and follow-up will be out- part of the multidisciplinary team managing acute rupture and any lined. Detailed technique will be explained. Different approaches will be lesion of spontaneously ruptured HCC should be considered for TAE as demonstrated with advantages and disadvantages of each approach. a first line treatment due to the high risk associated with surgery in the Cases of advanced visceral neoplasm will be shown. Teaching points acute phase. Surgery then should be considered in patients who can will be emphasized. Tips and tricks will be provided. Literature review undergo resection or lobectomy. will be performed.

CONCLUSIONS: Splanchnic/celiac plexus neurolysis ameliorates Abstract No. 799 patients pain and improves their quality of life by minimizing their nar- cotic requirements. CT guidance offers a more precise delivery of the Understanding the role of radiation oncology and their sclerosant with less complications. locoregional therapies S Tsymbalyuk1, B Tolaymat1, A Choksi1, S Ronson2, C Chao3 Abstract No. 798 1University of Maryland School of Medicine, Baltimore, MD, 2Radiation Oncology Affiliates of Maryland, Towson, MD,3 University Management of spontaneously ruptured hepatocellular of Maryland, Baltimore, MD carcinoma: a case-based review of diagnostic LEARNING OBJECTIVES: Understand the role of radiation oncology and characteristics and therapeutic interventions their therapies, including stereotactic body radiation therapy and pro- N Cornish1, S Mustafa2, M Hoy3, A Birney4, D Igonkin5, D Sarkar6 ton therapy. 1Maimonides Medical Center, Staten Island, NY, 2Maimonides BACKGROUND: Tumor Board is a multidisciplinary meeting to deter- Medical Center, Brooklyn, NY, 3The George Washington University mine the best management for a patient’s cancer. Radiation oncology School of Medicine and Health Sciences, Washington, DC, 4Mount plays an important role. Most radiologists are not familiar with the Sinai Hospital, New York, NY, 5James J. Peters VA Medical Center, details of the therapies that radiation oncology can offer. To converse N/A, 6Maimonides Medical Center, New York, NY effectively with radiation oncologists, interventional radiologists have

LEARNING OBJECTIVES: Discuss the incidence and imaging charac- to understand their therapies, the advantages of their therapies, their teristics of spontaneously ruptured hepatocellular carcinoma (HCC) limitations, requisites for their procedure and possible adverse events. with case based institutional examples. Review the available treatment Moreover, the literature and trials supporting their therapies need to options and their indications. Indicate the complications, survival, and be studied to weigh treatments by the different specialties. mortality based on treatment modality. CLINICAL FINDINGS/PROCEDURE DETAILS: The exhibit reviews com-

BACKGROUND: HCC is the fifth most common cancer in the world. mon therapies that radiation oncologists provide. Stereotactic body Spontaneous rupture is a rare complication seen in 3%-15% of cases. radiation therapy (SBRT) and proton therapy are reviewed including The exact mechanism is unknown, however it can be life-threatening their indications, contra-indications, limitations, requisites and pos- and is the third leading cause of HCC-related death (following tumor sible adverse events. The advantages of proton therapy over SBRT 74 | Educational e-Posters SIR 2019 Annual Scientific Meeting

will be examined. How outcomes of their therapies are assessed will LEARNING OBJECTIVES: 1) Describe the epidemiology and clinical pre- be discussed. The role that simulation scans, contour mapping, dose sentation of carotid webs. 2) Describe the pathophysiology and histo- fractionation and pencil beam scanning versus passive scatter proton pathology of carotid webs. 3) Describe the radiologic findings related therapy in limiting radiation doses will be detailed. Finally, a review of to carotid webs utilizing CTA and angiography. 4) Describe medical, the literature and trials supporting the therapies be examined. surgical and endovascular management of carotid webs.

CONCLUSIONS: Interventional radiologists must have a good under- BACKGROUND: Carotid webs are a rare and less well- known cause of standing of radiation oncology and the therapies that they provide to large vessel occlusion and embolic strokes. Only a few cases have been converse effectively at Tumor Board and to determine the best man- previously described in the literature, and optimal medical, surgical agement for a patient. and potentially endovascular management of carotid webs is not well established.

Abstract No. 800 CLINICAL FINDINGS/PROCEDURE DETAILS: A 35- year-old- female with no significant past medical history woke up with right sided weakness Update on liver transplant point system: what an and aphasia. Her non-contrast CT scan of the brain was negative for interventional radiologist needs to know any hemorrhage or early ischemic changes. She was not a candidate for intravenous thrombolysis as she presented outside the traditional time R Brader1, D Gerber2, P Hayashi2, D Mauro2 window. Her CTA showed a left M1 segment occlusion. CT-perfusion 1 2 UNC-Chapel Hill, Chapel Hill, NC, UNC Chapel Hill, Chapel Hill, NC showed no core infarct but a moderate sized penumbra. She underwent successful mechanical thrombectomy and made a complete recovery LEARNING OBJECTIVES: Understand liver transplant allocation policy and point assignment with focus on 2017 policy changes. Apply trans- during her hospital stay. Stroke etiology work-up was negative for atrial plant list status to the decision-making tree for treatment of hepato- fibrillation, intracardiac thrombus, hypercoagulable state or atheroscle- cellular carcinoma rotic disease. Her CTA and angiogram did show a carotid web on the left carotid bulb. On further investigation, she was found to have transient BACKGROUND: The various stages of hepatocellular carcinoma have ischemic attacks (TIAs) involving the left hemisphere in the past. As no several acceptable treatment options. Interventional radiologists play other stroke etiology was found, her carotid web was deemed to be the a major role in treating many of these patients. A patient’s priority sta- likely cause of her strokes and TIAs. She underwent successful endarter- tus on the transplant list can further influence treatment decisions. In ectomy of the left carotid artery and the entire web was excised. Pathol- 2017, the Organ Procurement and Transplantation Network (OPTN) ogy of the endarterectomy specimen showed fibrous intimal thickening modified their policy for liver transplant allocation, including adjusting of the arterial wall. The patient has not had any recurrent TIAs or Stroke exception points given to patients with hepatocellular carcinoma. since the surgery. Imaging in this exhibit will include: CT, CTA and digital subtraction angiography as well as histology slides from the case. CLINICAL FINDINGS/PROCEDURE DETAILS: The purpose of this educa- tional exhibit is to review the liver transplant MELD point system, with CONCLUSIONS: Although rare, carotid webs are a less known etiology focus on the 2017 updates, particularly the assignment of exception for acute embolic strokes. This entity should be understood by those points in patients with hepatocellular carcinoma, and review how this performing neurointerventional work as well as diagnosticians who can guide tumor board treatment decisions. may encounter it in their practice.

CONCLUSIONS: Multiple factors influence hepatocellular carcinoma treatment, including intrahepatic disease burden, extrahepatic dis- Abstract No. 802 ease burden, vascular invasion, underlying liver function, and trans- plant status. All factors must be taken into account in order to optimize Distal transradial access in the anatomical snuffbox for treatment decisions and patient outcomes. Updates to the 2017 OPTN diagnostic neuroangiography policy can affect the priority status of patients with hepatocellular car- 1 2 cinoma who are on the waiting list for liver transplantation. A thorough C Ritchie , R Tomalty understanding of the transplant point system is necessary for an inter- 1Mayo Clinic, Jacksonville, FL, 2Radiology of Huntsville P.C., ventional radiologist to actively and knowledgeably participate in mul- Huntsville, AL tidisciplinary tumor board decisions involving the ideal management LEARNING OBJECTIVES: Learn and Identify the anatomy of the distal of patients awaiting liver transplantation. radial artery Learn the appropriate location of appropriate access into the vessel Learn the appropriate material needed to perform angiog- Abstract No. 801 raphy from this site Understand the potential complication and mor- bidity associated with this type of access and it frequency Understand Carotid webs, a less well-known cause of embolic stroke: the post procedure care and follow required after this procedure an endovascular case presentation BACKGROUND: Radial artery (RA) access is a well-established modality D Petrov1, E Yannone1, R Cerejo1, B Goodman1 for vessel access through out multiple fields of image-guided intra- 1Allegheny Health Network, Pittsburgh, PA vascular medicine. Well describe in the cardiology literature is distal Transradial access in the anatomical snuffbox for coronary procedures SIR 2019 Annual Scientific Meeting Educational e-Posters | 75

as it has reduces the risk of occlusion in the RA located in the proximal interventional radiologists demonstrated a 700% to 800% greater to the wrist, a frequent finding in patients who develop a forearm RA exposure as compared with the neurointerventionalists; however, the occlusion due to puncture trauma or hemostasis trauma at the tra- neurointerventionalists’ occupational exposure limit was within the ditional radial puncture site. We demonstrate in this case the utility NRC monitoring requirement because the NRC requires an employer of distal RA access to make a neurological angiography (NA) without to provide an annual report of cumulative radiation dose to employee additional complexity, morbidity or time when compared to either tra- whose occupational exposure is > 1 mSv total effective dose equivalent. ditional femoral access for radial artery access. NRC also requires badge dosimeter monitoring of all adult employees that requires a dose equal to or greater than 10% of annual dose limit. CLINICAL FINDINGS/PROCEDURE DETAILS: A retrospective review was performed on a prospectively maintained database of 30 patients that CONCLUSIONS: Radiation safety is a critical concept for NI as proce- have undergoing anatomic snuff box access for neurologic angiog- dures such as cerebral angiography are above the threshold for moni- raphy (NA) and intervention between 2017 and 2018 at two separate toring occupational exposure limit set by the NRC. institutions among 3 operators. Anatomic snuff box access for diag- nostic neuro interventional procedures requiring a sheath size of 6 Fr Table 1 or less was used in all cases. There was a 100% success rate in both Occupational Exposure Dosage Requirement institutions with an equivalent 30-day morbidity outcomes, primary Lens 20 mSv/yr vessel patency when compared to traditional femoral artery access. Radiation worker 50 mSv/yr

CONCLUSIONS: Anatomic snuff box access for neuro interventional diag- Extremity, skin, organ dose 500 mSv/yr nostic is a safe and simple alternative to traditional transfemoral access. Acute exposure to threshold to cause cataract 2.5 Gy Annual dose rate limit for cataract formation 0.15 Gy/yr

Abstract No. 803 Public Exposure Dosage Requirement Infrequent 5 mSv/yr Radiation safety in cerebral angiography: NCRP Continuous 1 mSv/yr radiation guidelines and a retrospective occupational dose comparison between neurointerventionalists and Embryo or fetus via mother 5 mSv/yr interventional radiologists Embryo fetus (after declared pregnancy) 0.5 mSv/mo Controlled areas 50 mSv/yr A Goel1, Z Badar2, A Swarnkar3, H Masoud2 Uncontrolled areas 5 mSv/yr or 0.02 mSv/hr 1SUNY Upstate Medical University Program, Syracuse, NY, 2SUNY Genetically significant dose 0.25 mSv Upstate Medical Center, Syracuse, NY, 3N/A, Jamesville, NY Effective dose from background radiation in the 3 mSv/yr LEARNING OBJECTIVES: Radiation Safety plays a crucial role in Angi- United States ography. There has been concern regarding occupational dose to the lens of interventionalists. The data in the literature suggests absence Abstract No. 804 of a threshold dose, however, the latency period for radiation cataract formation is inversely related to the radiation dosage. Occupational Comprehensive review of stroke imaging and its role in radiation protection is a necessity in the practice of interventional and determining patient eligibility for endovascular therapy Neurointerventional procedures, such as cerebral angiography. This guideline is intended to offer a review of the NCRP guidelines for occu- S Shukla1, B Baigorri1, R Fourzali1, Y Serulle1 pational radiation safety 1Aventura Hospital and Medical Center, Aventura, FL

BACKGROUND: The development of cataracts is no longer be determin- LEARNING OBJECTIVES: 1. Review various imaging modalities and their istic, therefore, ICRP has lowered the threshold dose value for eyes from use in the management of acute stroke 2. Understand clinical and 150 to 20 mSv/year. The limit for extremities and the skin is 500 mSv/ imaging criteria used in determining patient eligibility for endovascu- year. Lead equivalent thickness of radiation protective eye wear is 0.75 lar intervention mm (98% attenuation). However, the actual lens dose is higher as expo- sure due to backscatter within the cranium. The new sport-wrap leaded BACKGROUND: There are approximately 140,000 deaths per year in the eye wear has a lower attenuation factor as their 45 degree angle is lower United States relating to stroke, accounting for one out of every twenty (4.5) as compared to the traditional leaded eye wear style (5.2). In the deaths. Moreover, with over 795,000 cases per year, cerebral infarc- United States, NCRP guidelines recommendations include an occupa- tion has become the leading cause of serious long-term disability. A tional limit of 50 mSv/ year and a lifetime limit of 10 mSv multiplied by comprehensive understanding of stroke imaging is essential for any the individual’s age in years. For pregnant women, after declaration of provider performing interpretation of acute cerebral ischemia and/or pregnancy, the embryo/fetus dose should not exceed 5 mSv/year. hemorrhage and evaluating patient’s eligibility for potential endovas- cular stroke therapy. CLINICAL FINDINGS/PROCEDURE DETAILS: A retrospective comparison was performed that included obtaining radiation dosage exposure CLINICAL FINDINGS/PROCEDURE DETAILS: Patient evaluation including for 2 neurointerventionalists and 4 interventional radiologists. The NIHSS, demographics, occlusion type, extent of infarct core, and time 76 | Educational e-Posters SIR 2019 Annual Scientific Meeting

window will be discussed. Stroke imaging using the modalities listed LEARNING OBJECTIVES: Review neoplastic processes that can mimic below will be reviewed. 1. Noncontrast CT 2; CT angiography 3; CT per- abscesses and review the possible complications from percutane- fusion imaging; 4. MRI: diffusion-weighted MRI and perfusion-weighted ous interventions or drainage procedures as well as how this affects MRI; 5. MRA; 6. digital subtraction angiography; and 7. sonography. patients’ care and prognosis.

CONCLUSIONS: Although an unenhanced CT is the study of choice BACKGROUND: A variety of neoplastic entities misdiagnosed as abdo- during initial evaluation, subsequent imaging may include CTA, CT menal and pelvic abscesses might lead to unnecessary interventions perfusion, MRI/MRA, MR perfusion, and US. These advanced imag- such as percutaneous aspiration or even drain placement. This might ing techniques are often employed in patient selection and treatment lead to complications and drain malfunction in addition to worsening planning. A thorough understanding of these modalities and correct prognosis and tumor spread. Identifying these situations and always interpretation is essential in the delivery of endovascular treatment. excluding the possibility of a neoplastic process is crucial to avoid Moreover, with recent DAWN and DEFUSE 3 trials expanding the such complications especially with infected tumors that might be potential treatment window, comfort with these advanced neuroim- misdiagnosed. aging modalities is paramount for the delivery of safe and effective CLINICAL FINDINGS/PROCEDURE DETAILS: We here present cases mis- endovascular care. diagnosed as abscesses and an intervention was performed. We will review how the patients presented including symptoms, signs and lab- Abstract No. 805 oratory data as well as imaging findings. We will also review the out- comes of interventions performed and the adverse effects. This review Endovascular techniques in stroke management will also cover how the diagnosis of cancer was made, the outcomes including pathological diagnosis and how to avoid such situations. S Shukla1, B Baigorri1, R Fourzali1, Y Serulle1 1Aventura Hospital and Medical Center, Aventura, FL CONCLUSIONS: It is crucial for interventional radiologists to recog- nize neoplastic processes to avoid unnecessary interventions and LEARNING OBJECTIVES: 1. Understand the evolution of endovascular drain placements that might lead to complications and suboptimal techniques in the treatment of acute ischemic stroke and clinical trials. management. 2. Compare mechanics of first generation versus second generation mechanical thrombectomy devices. 3. Review current techniques uti- lized in stroke treatment 4. Understand time-to-reperfusion and strat- Abstract No. 807 egy of treatment. The role of percutaneous mediastinal abscess drainage in BACKGROUND: There are 795,000 new cases and 140,000 deaths each conjunction with endoscopic esophageal stent placement year from stroke. Mechanical thrombectomy techniques have evolved for benign esophageal perforation-rupture: maximizing since the advent of endovascular therapy and is playing an increasing treatment strategies role in stroke management. A comprehensive understanding of the M Ali1, A Aly2, K Nandipati2, J Stavas3 different mechanical thrombectomy techniques and their evolution is necessary for providing appropriate patient care. 1Creighton University, Omaha, NE, 2Creighton University Medical Center, Omaha, NE, 3University of North Carolina, Chapel Hill, NC CLINICAL FINDINGS/PROCEDURE DETAILS: We will provide a compre- hensive review of the various endovascular techniques that have been LEARNING OBJECTIVES: -Review surgical and endoscopic manage- utilized in the treatment of acute ischemic stroke, including intraarte- ment of benign esophageal perforation. -Discuss the role of percuta- rial fibrinolysis, coil retrievers, aspiration devices, and stent retrievers. neous mediastinal abscess drainage by interventional radiology (IR). -Review complications of esophageal endoluminal stenting and per- CONCLUSIONS: Mechanical thrombectomy with stent-retrievers and/or cutaneous drainage. aspiration is the preferred technique in the endovascular management of acute ischemic stroke. With appropriate patient selection using advanced BACKGROUND: Benign esophageal perforation with mediastinitis is a imaging techniques, mechanical thrombectomy can be performed in rare condition but with reported high morbidity and mortality. Causes large vessel occlusions up to 24 hours following symptom onset. are Boerhaave’s, iatrogenic, swallowing foreign bodies, trauma and food impaction. IV antibiotics and surgical debridement has been the primary treatment. The use of self-expanding metallic and plas- Abstract No. 806 tic stents (SEMS/SEPS) has emerged as an alternative treatment for benign perforations to improve outcomes and avoid surgery. Mediasti- Problematic neoplasms that mimic abscesses: a review of nal abscess is a leading cause of mortality and morbidity after esoph- unintended interventions and drainage procedures and ageal rupture. Concomitant percutaneous drainage of the mediastinal how to avoid them abscess with SEMS/SEPS has been described as an alternative treat- A Makramalla1, J Moulton2 ment with comparable results to surgery. This review discusses current 1University of Cincinnati, Cincinnati, OH, 2University of Cincinnati treatment strategies, specifically the role of adjunctive percutaneous Medical Center, Cincinnati, OH drainage of mediastinal abscess and related fluid collections. SIR 2019 Annual Scientific Meeting Educational e-Posters | 77

CLINICAL FINDINGS/PROCEDURE DETAILS: Temporary endoscopic can place endoscope through a 10-12F sheath; if this is unsuccessful, SEMS/SEPS placement has emerged as a minimally invasive treatment assistance from GI colleagues using larger endoscopes may be neces- option for benign esophageal ruptures and leaks with lowered mortal- sary) f) If the above methods fail, only then consider PTC/intervention ity and morbidity rates reported. Covered stents seal the leak and offer The above protocol has allowed a safe and effective multi-disciplinary mucosal protection while healing takes place. Drawbacks include stent approach to these patients. migration, dysphagia, development of abscess and strictures. Reports CONCLUSIONS: The Hutson loop offers alternative access to the biliary have shown that drainage of pleural-mediastinal fluid collections per- system in patients with biliary-enteric anastomoses. This technique is formed in conjunction with stent placement aid healing. Percutaneous safe and allows IR to perform a wide range of options for biliary inter- perilesional drainage, particularly in the mediastinum, is often more ventions, including endoscopy. complex due to anatomy constraints. Various techniques have been described based on location and relationships with mediastinal struc- tures that allow safe drainage. Selection of a safe route and detailed Abstract No. 809 knowledge of mediastinal anatomy are important factors for success. A simple method of unclogging enteral feeding tubes: CONCLUSIONS: Endoscopic stenting has been shown to be an alter- even when traditional methods have failed native to surgery for the treatment of esophageal perforations. IR drainage of associated mediastinal abscess can aid the management A Levy1, S Kovacs1 of these perforations and improve overall success. 1Lenox Hill Hospital, New York, NY

LEARNING OBJECTIVES: 1) Review common techniques/devices for Abstract No. 808 clearing obstructed feeding tubes as well as their positives, nega- tives, and potential complications 2) Discuss an effective technique for Interventional radiologic management of biliary clearing enteral feeding tubes, as well as potential complications, in the complications following liver transplants in patients with context of a study in a small cohort Hutson loops BACKGROUND: Enteral feeding tubes are commonly placed to provide 1 1 1 1 1 E Russell , M Ravi , S Resnick , A Gabr , M Abecassis , patients with nutrition and hydration when they are unable to meet R Lewandowski1, R Salem1, A Riaz1 their daily caloric and hydration requirements by mouth. They may 1Northwestern University, Chicago, IL also be placed for patients with aspiration risk secondary to malig- nancy, neurological/mechanical dysphagia, as well as critical illness. LEARNING OBJECTIVES: To describe the subcutaneous jejunal access More than 245,000 patients per year require at least a temporary loop (Hutson loop) and its role in percutaneous trans-jejunal biliary feeding tube during a hospital stay in the US. It is estimated that up to interventions by interventional radiology (IR). Biliary interventions that 35% of enteral tubes become clogged. Interventional radiologists are can be performed through the Hutson loop will be discussed and avail- often consulted for enteral tube placement and unclogging/replace- able data will be summarized. ment. An effective method of clearing these tubes can circumvent the BACKGROUND: Patients with biliary-enteric anastomoses are at need for replacement, which saves patients from additional radiation increased risk for biliary complications (anastomotic leaks/strictures). and improved patient satisfaction. Reconstructed enteric anatomy (roux limb) renders peroral endos- CLINICAL FINDINGS/PROCEDURE DETAILS: The described technique copy difficult. To avoid inherent risks to the transplanted liver associ- comprises of a few simple steps. The first involves inserting an ated with repeat surgical interventions or percutaneous transhepatic 18-gauge needle or stiff catheter into the feeding tube, taking care not (PTC), a more convenient access to the biliary system to puncture the tube. The next step is to apply a Kelley clamp around was reported by Hutson et al. The Hutson loop is placed during cre- the feeding tube and needle, such that the tube is collapsed around ation of the biliary-enteric anastomosis (most often in liver transplant the patent needle. Next, attach a saline flush to the needle and inject patients with primary sclerosing cholangitis). The afferent limb of the gently to feel for resistance. Once resistance is felt, gradually increase Roux-en-Y is affixed to the anterior abdominal wall which provides a pressure until the resistance is relieved and saline flows through the target for percutaneous jejunal entry. opposite end of the tube. This allows for a significant amount of pres- CLINICAL FINDINGS/PROCEDURE DETAILS: Our current institutional pro- sure to be applied without allowing saline to reflux out of the tube. The tocol for biliary interventions in patients with Hutson loops includes: technique was successful in clearing clogged enteral tubes for small a) Fluoroscopic/sonographic identification of the Hutson loop with cohort of patients, most of which for whom other techniques were pre- percutaneous jejunal access b) Access of the jejunal loop towards the viously unsuccessful. hepaticojejunostomy (retrograde from the Hutson loop) c) Opacifica- CONCLUSIONS: 1) An effective method of clearing obstructed feed- tion of the biliary system (understanding donor biliary anatomy and ing tubes can circumvent the need for replacement, which decreases knowledge of multiple biliary-enteric anastomoses is important) d) radiation exposure and improved patient satisfaction. 2) Review com- Catheterization of the biliary-enteric anastomosis and intervention monly utilized techniques/devices for clearing feeding tubes 3) Dis- (plasty/stenting) as clinically indicated e) Endoscopy through the Hut- cuss positives, negatives, and potential complications of all methods son loop can help directly visualize the biliary-enteric anastomosis (IR 78 | Educational e-Posters SIR 2019 Annual Scientific Meeting

Abstract No. 810 LEARNING OBJECTIVES: 1. Discuss the properties of ultrasound con- trast agents (UCAs) 2. Review novel uses in hepatobiliary procedures Extracellular matrix enterocutaneous fistula plugs: (diagnosis, biopsy, drainage, microwave/radiofrequency ablation) 3. indications, deployment, and expected outcomes Understand the specific indications/contraindications of UCAs and T Smith1, L Jenkins1, C Kaufman1, K Marashi1, Z Cizman1, R O’Hara2, best patient selection. 4. Illustrate the powerful advantages of hepato- R Hardman1 biliary contrast-enhanced ultrasound in diagnostic and interventional applications. 1University of Utah, Salt Lake City, UT, 2University of Utah/ Huntsman Cancer Center, Salt Lake City, UT BACKGROUND: While ultrasound has several distinct advantages to CT and MRI scanning, it has traditionally been an imaging modality LEARNING OBJECTIVES: 1. Identify patients that would likely benefit without contrast, thereby limiting its diagnostic applications. With the from an extracellular matrix enterocutaneous fistula plug placement advent of ultrasound contrast, the diagnostic power and interventional 2. Discuss procedural details 3. Cover expected outcomes, potential uses of sonography have remarkably improved. In hepatobiliary appli- complications, and pitfalls cations CEUS has improved anatomic resolution and lesion distinction,

BACKGROUND: Enterocutaneous fistulas allow enteric contents to to allow for safer and more precise interventional approaches. infect sterile spaces, which can lead to delayed healing, skin inflam- CLINICAL FINDINGS/PROCEDURE DETAILS: The established and fre- mation, necrosis, and have a reported mortality of 10-30% (1-3). High quent use of ultrasound in hepatobiliary pathologies allowed for initial output fistulas can divert flow away from the gastrointestinal tract investigation of UCAs in the abdomen. Ultrasound contrast is a reus- causing malnutrition, dehydration, and electrolyte disturbances (1). able and safe agent to diagnose hepatic and biliary diseases, largely Management involves infection control, optimizing nutrition, and fis- due to its favorable metabolism in the liver and lungs. The advantage tula closure. Up to 30% of fistulas will heal spontaneously (4). In cases of ultrasound contrast agents in interventions is because of its real- that do not close spontaneously, surgery or interventional radiology time enhancement imaging, speed, lack of radiation, portability, and can play a role in management and tract closure. cost effectiveness. The use of contrast is indicated in patients with

CLINICAL FINDINGS/PROCEDURE DETAILS: Before attempting fistula radiosensitivity, large body habitus, isoechoic lesions, and traditional closure adjacent fluid collections and fluid within the fistula must be contrast allergies. The few contraindications to contrast-enhanced drained. Fluoroscopic evaluation of fistula anatomy should be done ultrasound include cardiac shunts, pulmonary hypertension, and to determine size, tract maturity, and areas of communication. Plug ultrasound contrast sensitivity. CEUS may be applied to and aug- Placement: 1. Select fistula plug (4 or 7 mm diameter, 18 cm long) 2. ment common hepatobiliary interventional procedures, including liver Gain access across the fistula 3. Irritate tract with a brush 4. Introduce mass biopsy, portal vein biopsy, mass ablation, cholecystostomy, and a sheath into the superficial fistula and flush with hydrogen peroxide 5. hepatic abscess drainage. Advance the deployment sheath over the wire into bowel 6. Insert plug CONCLUSIONS: Ultrasound contrast is a safe and powerful agent in into sheath 7. Deploy the plug, remove the sheath over the plug while improving pre-procedural diagnostic information and technical out- simultaneously hydrating the plug 8. Secure plug externally comes for hepatobiliary ultrasound-guided interventional procedures.

CONCLUSIONS: The ideal patient has a solitary tract that is 2-6 mm wide and between 2-18 cm long. If the opening to the tract is too wide, the plug could disintegrate from leaking GI fluids. A mature tract with low Abstract No. 812 output (<200mL/day) and a narrow opening into GI tract are favorable Percutaneous gastrostomy of the gastric remnant after characteristics for treatment with an extracellular matrix fistula plug. bariatric or metabolic surgery: why and how it is done High output fistulas, patients with a distal obstruction/stricture, tumor at the site, history of radiation at the site, surgical mesh at the site or M Ali1, A Aly2, D Wessling2, K Nandipati2, J Stavas3 persistent abscess are more likely to fail. The interventional radiologist 1Creighton University, Omaha, NE, 2Creighton University Medical should be familiar this device in the treatment of persistent enterocu- Center, Omaha, NE, 3University of North Carolina, Chapel Hill, NC taneous fistula. LEARNING OBJECTIVES: 1. Describe various bariatric/metabolic sur- geries and pertinent anatomy 2. Discuss indications for percutaneous Abstract No. 811 remnant gastrostomy following bariatric surgery 3. Review distinctive remnant access techniques and procedural complications Hepatobiliary contrast-enhanced ultrasound interventions: tried and true modality with improvement BACKGROUND: The worldwide number of bariatric/metabolic surgical over conventional gray-scale alternatives procedures has increased, with Roux-en-Y gastric bypass being one of the most commonly performed. Certain procedures result in the 1 2 1 1 1 3 V Kondray , C Kondray , J Curcio , L Walker , R Kessner , N Azar creation of a gastric remnant with limited endoscopic access. Compli- 1University Hospitals Cleveland Medical Center, Cleveland, OH, cations may arise in the excluded stomach or as result of the surgery 2MetroHealth Cleveland, Cleveland, OH, 3University Hospitals Case that require access to the remnant. Image-guided percutaneous gas- Medical Center, Cleveland, OH trostomy can be performed as an option to laparoscopy or laparotomy. SIR 2019 Annual Scientific Meeting Educational e-Posters | 79

CLINICAL FINDINGS/PROCEDURE DETAILS: Percutaneous image- to the other 2 muscle layers for ease of injection. Each of the 3 mus- guided gastrostomy in a surgically altered stomach presents technical cles at each of the 6 spots receives 8.3cc of the Botox mix. A repeat entry challenges. Access to the remnant is made difficult by its poste- non-contrast abdominal CT should be performed after 2-4 weeks and rior location relative to the spleen, pancreas, colon and ribs. In addition, prior to surgical repair to determine change in muscle length and thick- body habitus may change from weight loss altering the remnant posi- ness, as well as hernia reduction. tion. Two major post-surgery complications requiring urgent remnant CONCLUSIONS: Ultrasound-guided Botox injection is a safe, easy, and access are distention and malnutrition with rates of stoma ulceration effective method for improving the success rate of surgical hernia after undivided gastric bypass up to 15%. Multiple fluoroscopic and repair. Non-contrast CT scan should be performed before and after CT-guided techniques are available to access the excluded stomach Botox injection in the abdominal muscles, and prior to surgical repair, when nondistended and enveloped. Hydro-dissection methods assist in order to gauge the adequacy of the procedure. with obtaining a safe window for puncture whereas fine-needle inser- tion by transhepatic, transjejunal or trans-splenic allow air distention to provide a puncture target for gastropexy. Various complications are Abstract No. 814 known such as traction-related skin ischemia, gastrocutaneous fistula, tube leakage, gastric erosion, hemorrhage and peritonitis. This exhibit Percutaneous nephrostomy in nondilated systems: will describe the indications for remnant access, different approaches indications and techniques related to type of surgery and anatomy and complications. A Gupta1, R Arellano1 CONCLUSIONS: Percutaneous image-guided gastrostomy of the gas- 1Massachusetts General Hospital, Boston, MA tric remnant is an effective and safe method to manage bariatric/met- abolic surgical complications. LEARNING OBJECTIVES: To describe the indications, techniques, and challenges involved with percutaneous nephrostomy placement in nondilated urinary systems. Abstract No. 813 BACKGROUND: Percutaneous nephrostomy procedures have been Pre-procedural ultrasound-guided botulinum toxin A for performed for more than 60 years for the treatment of urinary primary surgical hernia repair obstruction. Techniques involving ultrasound and fluoroscopic guid- ance for placement of a nephrostomy catheter have been extensively 1 2 1 P Lang , J Martissa , A Isaacson described. While obstructive uropathy is the most common indication 1University of North Carolina, Chapel Hill, NC, 2UNC Health Care, for PCN, at times PCN are indicated in a non-dilated collecting system. N/A This is typically for urinary diversion, usually in the setting of bladder or ureteral leaks. The lack of distension often results in poor visualization LEARNING OBJECTIVES: Ultrasound-guided Botulinum toxin A (Botox) of the collecting system (both sonographically and fluoroscopically) injection for abdominal hernia reduction and abdominal muscle relax- and can make access to the collecting system challenging and cum- ation prior to surgical hernia repair. bersome. Urinary diversion in non-dilated collecting systems is used BACKGROUND: Open abdominal surgery is associated with a 20-35% in pre and post procedural settings. Pre-procedurally, nephrostomy chance for developing ventral hernia. Surgical repair of ventral hernias access may be requested prior to performing lithotripsy for uteropel- is difficult due to significant muscle tension and lateral traction. Even vic or ureteral stone management. Post-procedurally, access may be with successful repair, 24-43% of patients develop hernia recurrence. necessary for the management of ureteral injuries or urinary fistulas. Pre-surgical injection of Botox into the abdominal muscles has been More infrequently, patients suffering from intrinsic renal failure either demonstrated to be a safe, easy, and effective method for both ini- secondary to acute tubular necrosis or glomerulonephritis may need tial hernia reduction and muscle relaxation to facilitate surgical hernia urinary diversion in the setting of severely depressed renal function. repair. Pre-operative Botox injection in patients with ventral hernia has CLINICAL FINDINGS/PROCEDURE DETAILS: Here we describe the follow- also been shown to lead to reduced post-operative pain and opioid ing techniques for access into non-dilated collecting systems. I. General use, as well as low hernia recurrence rates, in patients undergoing sur- nephrostomy access steps in dilated systems. II. General nephrostomy gical repair. access steps in non-dilated systems including the following: A. Intrave- CLINICAL FINDINGS/PROCEDURE DETAILS: Patients with a ventral nous contrast opacification with or without volume loading B. Double abdominal hernia receive a non-contrast abdominal CT scan prior to Puncture technique with the use of gaseous contrast C. Retrograde Botox injection, which occurs 2-4 weeks prior to planned surgical her- contrast opacification D. Use of Contrast-enhanced ultrasound nia repair. 3 equidistant spots along the anterior axillary line are marked CONCLUSIONS: Percutaneous nephrostomy placement in nondilated and locally anesthetized on each side of the abdomen between the systems can be a technically challenging procedure that requires care- costal margin and the anterior superior iliac spine. 300 units of Botox ful planning, proper positioning, and diligent equipment selection. are diluted to 2 units/cc in 0.9% saline. Under ultrasound guidance, the Understanding and using the above techniques will allow an interven- transversus abdominis, internal oblique, and external oblique are iden- tional radiologist to obtain nephrostomy access reliably and efficiently tified at each spot. An 18-23G spinal needle is advanced first into the in nondilated systems. transversus abdominis at each spot, and then subsequently withdrawn 80 | Educational e-Posters SIR 2019 Annual Scientific Meeting

Abstract No. 815 LEARNING OBJECTIVES: 1. Understand the presentation and etiology of ureteroarterial fistulas. 2. Review the key imaging findings in diagnosis. Renal oncocytomatosis: diagnosis and percutaneous, 3. Identify treatment options. 4. Recognize potential complications of image-guided management of a rare clinical condition ureteroarterial fistula treatment.

1 2 3 4 5 R Esposito , J Gordetsky , M Coker , E Underwood , A Abdel Aal , BACKGROUND: Ureteroarterial fistulas are a rare and potentially life 2 2 2 M Lockhart , S Rais-Bahrami , A Gunn threatening occurrence. They present with hematuria, flank pain, or 1UABSOM, Birmingham, AL, 2University of Alabama at Birmingham, both. The bleeding is usually spontaneous but may begin in the con- Birmingham, AL, 3N/A, Vestavia, AL, 4N/A, Pelham, AL, 5University text of anticoagulation or urinary stent manipulation. The etiologies of Alabama Birmingham, Birmingham, AL are numerous but most frequently seen in the treatment of a pelvic malignancy. Diagnosis is dependent on imaging and treatment options LEARNING OBJECTIVES: 1) Understand the epidemiology, pathophysi- are dependent on the underlying source of the fistula. ology, imaging findings, and clinical presentation of patients with renal oncocytomatosis. 2) Discuss the risks and benefits of the therapeutic CLINICAL FINDINGS/PROCEDURE DETAILS: This exhibit will define ure- options that exist, including a description of percutaneous, image- teroarterial fistulas and describe the current therapeutic options in guided management the context of two case studies. One case is of a 76 year old male with a history of bladder cancer status post cystectomy and bilateral dou- BACKGROUND: Renal oncocytomatosis is a rare clinical condition ble J ureteral stent placement into ileal conduit, who presented with in which a patient has multiple, bilateral oncocytomas. Patients can pulsatile bleeding during ureteral stent removal. The second case is a experience pain and renal failure but these masses can be difficult to 57 year-old male with a history of rectal cancer status post resection, distinguish from renal cell carcinomas (RCCs) on imaging. The purpose colostomy, pelvic radiation, and bilateral double J stent placement, of this educational exhibit is to review the imaging and clinical features who presented with pulsatile bleeding into the bladder on cystos- of renal oncocytomatosis and to present the case of a renal oncocy- copy. An outline of potential challenges in diagnosis and treatment tomatosis patient managed by percutaneous cryoablation. will be presented as well as a step-by-step narrative of how these

CLINICAL FINDINGS/PROCEDURE DETAILS: 1) Oncocytomas are benign particular cases were handled. Diagnostic images will be displayed kidney lesions but ‘oncocytomatosis’ is when there are multiple, as well as before and after angiography that confirmed resolution of bilateral tumors in a single patient 2) Renal oncocytomatosis is a the cases. rare clinical condition with only a few case reports in the literature 3) CONCLUSIONS: Ureteroarterial fistula is a rare and often fatal pathol- Clinically, patients with renal oncocytomatosis may be quiescent for ogy. With a mortality rate of approximately 58%, rapid diagnosis and long periods of time with the lesions often being discovered inciden- treatment is essential to ensuring favorable outcomes. This poster tally. However, some patients can present with pain or renal failure. presentation will review the techniques for diagnosis and treatment 4) On ultrasound, oncocytomas appear as well-defined, isoechoic of ureteroarterial fistulas with an emphasis on recognizing risk factors or hypoechoic masses with a ‘spoke-wheel’ pattern of vessels 5) and procedural variables. On computed tomography, oncocytomas appear as well-defined, variably enhancing lesions that can mimic RCC 6) On magnetic res- onance imaging, oncocytomas appear as well-defined, enhancing Abstract No. 817 masses that cannot be reliably differentiate from RCC 7) On angi- ography, oncocytomas show a classic ‘spoke-wheel’ appearance 8) Acute abdominal interventions in the pregnant patient: Hematoxylin and eosin stains of oncocytomas show small nests of a case review tumor cells in a fibromyxoid background with uniform nuclei and P Mody1, T Yablonsky1 abundant eosinophilic cytoplasm 9) Case presentation from our 1 institution demonstrating the successful management of renal onco- Morristown Medical Center, Morristown, NJ cytomatosis with percutaneous cryoablation 10) Brief review of avail- LEARNING OBJECTIVES: 1. Identify diagnostic imaging features of acute able case reports of renal oncocytomatosis abdominal pathology in the pregnant patient. 2. Discuss relevant inter-

CONCLUSIONS: Renal oncocytomatosis is a rare clinical condition ventions and their potential complications. 3. Review special consider- which, when symptomatic, can be managed through minimally inva- ations and techniques regarding how to minimize radiation exposure sive, image-guided ablation. in the obstetric population.

BACKGROUND: The acutely ill obstetric patient is challenging, as the physician must be mindful of the well-being of two patients rather than Abstract No. 816 one. Surgical intervention can increase the risk for preterm labor, and Ureteroarterial fistulas: diagnosis and treatment efforts are made to avoid non-obstetric laparotomy unless absolutely necessary. Interventional radiology has therefore become key in the 1 2 2 3 A Abunimer , S Patel , Y Alazzawi , R Ermentrout management of acute abdominal pathology. A number of interven- 1Virginia Tech Carilion School of Medicine, Roanoke, VA, 2Emory tions can be performed utilizing various imaging modalities to treat University, Atlanta, GA, 3Emory University School of Medicine, or manage the acute illness until the patient is postpartum or stable Atlanta, GA enough for definitive therapy. SIR 2019 Annual Scientific Meeting Educational e-Posters | 81

CLINICAL FINDINGS/PROCEDURE DETAILS: Using a case-based Potentials and ankle nerve block. The minimum clinical follow-up was approach, this presentation will review common acute conditions 5 days (mean, 19 weeks; range, 1-52). All patients reported resolution in pregnancy, including obstructive uropathy, acute cholecystitis, of pre-procedure pain. During follow-up, none of the patients had complicated appendicitis, abnormal placentation, postpartum hem- any major complication. orrhage, and acute visceral trauma. Relevant interventions will be CONCLUSIONS: The use of real-time multi-planar CT guidance, naviga- discussed for each case, including nephrostomy placement, percu- tion software and orthopedic tools allowed for safe ablation of OO in taneous drainage, catheter-assisted cesarean section, pelvic angiog- challenging locations with resolution of pain related disability at short raphy & embolization, and visceral angiography & embolization. All follow-up. cases and images are obtained via database search at our institution. Finally, we will review techniques for limiting radiation exposure to the fetus. Abstract No. 819

CONCLUSIONS: Pregnant patients who are acutely ill can benefit from A how-to guide for interventional radiology management image-guided interventions, which can be diagnostic and therapeutic, of chronic pelvic pain and reduce the need for emergent non-obstetric laparotomy. Interven- tional radiologists should be familiar with these procedures in obstet- T Muso1, O Zuberi2, L Dinglasan2 ric patients, as they can decrease overall morbidity and mortality for 1University of Louisville Department of Radiology, Louisville, KY, these patients. 2University of Louisville, Louisville, KY

LEARNING OBJECTIVES: The goal of this educational exhibit is to pro- Abstract No. 818 vide a concise resource for the management of chronic pelvic pain from an interventional radiology perspective. Clinical manifestations Advanced guidance and access techniques for of pelvic pain correlated with nerve distributions and relevant anat- challenging osteoid osteoma ablations omy, strategies for management and procedure choice, key imaging D Shnayderman1, A Tadros1, S White1, E Weil1, S Dybul1, S Tutton1 findings, and procedural techniques will be discussed.

1Medical College of Wisconsin, Milwaukee, WI BACKGROUND: Chronic pelvic pain has a relative prevalence compa- rable to asthma (1), with estimates ranging from 5.7 to 26.6% (2) and LEARNING OBJECTIVES: To review advanced image guidance and tech- a total yearly national cost upwards of $2.8 billion (3). Interventional niques for the safe and effective ablation of osteoid osteomas (OO) in radiologists are well suited to diagnose and treat this common prob- atypical locations. lem in a minimally invasive manner using tools already in their arma-

BACKGROUND: OO are benign, invariably painful, osteoblastic mentarium, especially when more conservative measures have failed tumors. They are most frequently seen in the femur and tibia, which to provide relief. account for 50-60% of lesions. Radiofrequency ablation (RFA) is CLINICAL FINDINGS/PROCEDURE DETAILS: This exhibit reviews inter- a well-established minimally invasive treatment for these lesions. ventional management strategies for chronic pelvic pain. Common OO adjacent to joints and in small bones present unique technical etiologies that result in nerve sensitization, anatomic nerve distri- challenges, including fractures, chondromalacia, tendon disruption, butions, clinical manifestations of pelvic pain specific to each nerve neurovascular injury, and skin burns. Advanced imaging guidance distribution and symptom-guided management will be discussed. and access techniques have allowed treatment of OO in challeng- Specifically, we review the relevant imaging anatomy and symptom- ing locations affording greater accuracy and mitigating potential atology of the superior hypogastric plexus, ganglion impar, pudendal complications. nerves and ilioinguinal nerves, suggest a treatment approach algo-

CLINICAL FINDINGS/PROCEDURE DETAILS: The use of advanced rithm based on patient symptoms, provide a step-by-step guide to guidance and access techniques, including real-time multi-planar image-guided nerve blocks with illustrative examples on CT and US, reformats, navigation software, and orthopedic access tools were and review potential complications and aspects of post-procedure reviewed in small bone and juxta-articular OO in those undergoing care. RFA at our institution. Data presented will include lesion size, post CONCLUSIONS: Chronic pelvic pain is a common problem with a sig- procedure pain relief and complications. Atypical lesions were found nificant socioeconomic cost and often poor management resulting in in 8 patients (4 male); mean age, 24 years, (range 13-42). Lesion inadequate treatment response. After conservative measures fail to locations included lunate, medial humeral epicondyle, 3rd proximal provide relief, pelvic pain may be treated by interventional radiologists, phalanx of the foot, 1st metatarsal, 3rd metatarsal, proximal fibula who are well positioned to provide single-site, patient-centered care with close proximity to deep fibular nerve, iliac bone with extension with their spectrum of minimally invasive options using tools and tech- into the SI joint, and T12 pedicle with extension into the costoverte- niques already in their armamentarium. bral junction. Mean lesion size was 8.9 mm (range 5-13). CT guidance with multi-planar reformatting, orthopedic power drill, and, in several cases, needle guidance software were used. Adjunctive techniques included neurologic monitoring with EMG and Somatosensory Evoked 82 | Educational e-Posters SIR 2019 Annual Scientific Meeting

Abstract No. 820 LEARNING OBJECTIVES: To highlight the potential utility of CBCT nee- dle guidance in nonvascular procedures. To contrast and compare From no zone to the safe zone: tips for organ and tissue CBCT needle guidance with standard fluoro, CT & US guidance. To displacement with hydro- and pneumo-dissection when explain the technical aspects of CBCT needle guidance, including room performing percutaneous procedures with unfavorable set-up, procedure planning and patient positioning anatomy BACKGROUND: The use of Cone-Beam CT (CBCT) is now routine for A Aly1, M Ali2, C Eicher3, J Stavas4 certain vascular procedures, such as chemo-embolization. However, 1Creighton University Medical Center, Omaha, NE, 2Creighton the use CBCT and needle guidance software remains under-used in University, Omaha, NE, 3N/A, Elkhorn, NE, 4University of North many centers, due to perceived complexity, lack of familiarity with the Carolina, Chapel Hill, NC technical details and inadequate awareness of its potential.

LEARNING OBJECTIVES: Discuss procedures in which hydro- and pneu- CLINICAL FINDINGS/PROCEDURE DETAILS: Nonvascular procedures mo-dissection are feasible Review anatomic considerations, needles, such as percutaneous drainage, biopsies and tumor ablation often catheter types, solutions and balloon devices Describe different tech- involve complex 3-D anatomical relationships that may be difficult to niques of tissue displacement with case examples fully characterize and understand on 2D fluoroscopic and cross-sec- tional images. CBCT allows volumetric data acquisitions from which 3D BACKGROUND: Percutaneous imaging-guided procedures constitute target and needle path identification and evaluation can be performed. a substantial number of many interventional radiologists’ clinical This allows use of double-angle needle paths that would be challeng- practice. Needle access with imaging guidance is used frequently for ing in CT, trajectories can be close to sensitive vascular (or other) struc- biopsies, drainages and tumor ablation. The requirements for safely tures that are not visible on fluoroscopy and, planning is unaffected performing such procedures are a safe pathway for access to the tar- by gas and skin to target distance, which can hinder US visualization. get and a safe zone in the vicinity of the target, to eliminate collateral Procedure details: Patient and target positioning are important, with injury to adjacent structures. Hydro-dissection and pneumo-dissec- the target being centered in the field of view in the frontal and lateral tion are performed by injecting liquid materials or air in a controlled views. CBCT acquisition is often done before prepping and draping. manner to reposition vital structures away from the “danger zone” of The needle path planning is done while the team preps and drapes. the treatment area. This exhibit will review different techniques and Continuous or intermittent fluoroscopy of the needle during advance- materials used to safely perform a variety of percutaneous imag- ment is possible, including in relation to the 3D CBCT data. An addi- ing-guided procedures. tional CBCT can be done to confirm needle tip position if necessary.

CLINICAL FINDINGS/PROCEDURE DETAILS: Thermal ablations of cen- CONCLUSIONS: CBCT needle guidance is a valuable tool in complex or tral lung tumors place mediastinal structures at risk of injury. Similar higher risk nonvascular cases. There is a learning curve to the tech- situations occur during imaging-guided biopsy/drainage and ablation nique, but once it is mastered CBCT becomes straightforward, is quick procedures in the abdomen and pelvis where bowel loops, viscera and to perform and is highly effective. vascular structures are vulnerable to injury. Various fluids or air can be injected to displace adjacent or overlying structures to allow a safe window for access. Causing an artificial pneumothorax assists with Abstract No. 822 lung tumor ablation safety. Likewise, creating artificial ascites can shift mesenteric and pelvic structures and provide a safe entry space and Lymphangiography techniques and application margin of safety during the ablation itself. Volume and method of injec- D Hsu1, G Peters1 tions or balloon insertion varies on the procedure to be performed. 1Emory University School of Medicine, Atlanta, GA CONCLUSIONS: Hydro- and pneumo-dissection can assist with per- cutaneous imaging-guided procedures to make them successful and LEARNING OBJECTIVES: 1. To illustrate intranodal lymphangiogra- safe, where otherwise there would be an increased risk of complication phy and compare it to pedal lymphangiography 2. To review the or an exam unable to be performed. Multiple techniques are available indications, contraindications, risks, complications and outcomes of to effectively accomplish these challenging procedures. lymphangiography

BACKGROUND: The consists of a highly complex and variable network of lymphatic vessels that transport fats, proteins, and Abstract No. 821 T-lymphocytes throughout the body and empty into the venous sys- How and when to use cone-beam computed tomography tem. Lymphatic abnormalities may lead to chylous ascites, and needle guidance in nonvascular interventions or protein-losing enteropathy and are due to etiologies such as granu- lomatous infections, malignancy, or iatrogenic injuries. Lymphangiog- 1 2 2 3 3 A Shrivastava , J Toro , L Boucher , C Torres , T Cabrera , K raphy has gained popularity in recent years as a diagnostic modality 3 3 2 Muchantef , A Bessissow , D Valenti to identify lymphatic abnormalities for subsequent interventional pro- 1McGill University Health Centre, Montreal, QC, 2McGill University, cedures including thoracic duct embolization and less commonly, liver Montreal, QC, 3McGill University, Montreal, PQ lymphatic embolization. SIR 2019 Annual Scientific Meeting Educational e-Posters | 83

CLINICAL FINDINGS/PROCEDURE DETAILS: The anatomy of the lym- the thoracic duct. Contrast is injected through the sheath to opacity phatic system will be reviewed. We will describe the two main tech- the cisterna chyli and the optimal sheath positioning is confirmed. The niques for opacifying the cisterna chyli and thoracic duct: pedal wire is then subsequently removed. lymphangiography (PL) and intranodal lymphangiography (IL). PL is a CONCLUSIONS: Image-guided thoracic duct externalization is tech- technically challenging procedure requiring a cut down on dermal lym- nically feasible and safe technique to divert and decompress of the phatics visualized with the aid of lymphatic indicator dye, followed by central lymphatic system. It is a marked improvement compared to the direct catheter cannulation. Unlike PL, IL does not require a cut down, surgical cut-down of the thoracic duct that was previously described instead opacifying lymphatics via direct ultrasound-guided puncture in the surgical literature. of superficial inguinal lymph nodes with injection of oil-based con- trast. We will review the indications and contraindications of lymph- angiography and present cases to highlight significant lymphatic Abstract No. 824 anatomy. Risks including pulmonary oil embolization and systemic arterial embolization in the setting of a right to left cardiac shunt will Establishing the lateral decubitus cervical approach as be discussed. a viable technique for the intrathecal administration of nusinersen (Spinraza) in patients with spinal muscular CONCLUSIONS: While there are non-invasive imaging modalities for atrophy detecting lymphatic abnormalities, lymphangiography provides a real- time target for therapeutic percutaneous interventions. Knowledge of M Sheth1, M Edelstein2, D Niman2 the contraindications to the procedure and its associated risks are par- 1Temple University Hospital, Philadelphia, PA, 2Temple University amount to the safe performance of lymphangiography. Hospital, Philadelphia, PA

LEARNING OBJECTIVES: This educational exhibit aims to: 1) familiarize Abstract No. 823 the reader with the interventional radiologist’s role in the intrathecal administration of Nusinersen (Spinraza) in patients with spinal mus- Thoracic duct externalization: how we do it cular atrophy (SMA), 2) highlight common technical limitations to the D Kwon1, G Nadolski1, M Itkin1 traditional prone, posterior lumbar approach in this patient population, and 3) describe a lateral decubitus, cervical approach as an alternative 1Perelman School of Medicine at the University of Pennsylvania, technique for safe drug delivery in complex situations. Philadelphia, PA

BACKGROUND: SMA is an inherited neuromuscular disorder character- LEARNING OBJECTIVES: This educational exhibit aims to familiarize ized by progressive muscle weakness and atrophy, and consequently, interventional radiologists with percutaneous thoracic duct external- early infant mortality or severe disability. Nusinersen, an intrathecal ization technique. agent, has been shown to improve motor function in patients with SMA BACKGROUND: Historically, the surgical diversion of the thoracic duct and is the only FDA-approved drug for this condition. Factors including has been used to drain thoracic duct lymph in order to achieve immu- severe scoliosis, presence of surgical hardware, and motor deficits can nosuppression. However, it has fallen out of favor due to the invasive make the standard lumbar approach to intrathecal drug administration nature of the procedure and inconsistent outcomes, due anatomical infeasible or unsafe. As experts in anatomy and procedural adaptabil- variability of the lymphatic anatomy. Recently there has be a devel- ity, interventional radiologists are well suited to navigate such lim- opment of a new, minimally invasive and image-guided, lymphatic itations. In these cases, a cervical approach to CSF access with the intervention techniques that allow evaluation of the lymphatic anat- patient in a lateral decubitus position may be utilized for drug delivery. omy and catheterization of the thoracic duct. Here, we describe a CLINICAL FINDINGS/PROCEDURE DETAILS: In the traditional lumbar technique of deploying of the retrograde catheter in the thoracic duct, approach to intrathecal injection, the patient is placed in the prone through brachial vein, that allowed capturing of the lymphatic fluid at position and under bi-plane fluoroscopic-guidance, a 22 gauge nee- the level of cisterna chyli. We utilized this technique to divert the lymph dle is inserted through either the L2-L3 or L3-L4 interspinous space. in neonates with non-immune hydrops, thus reducing the lymphatic Needle placement is confirmed by CSF return and Nusinersen is slowly congestion and in patients with abnormal pulmonary lymphatic flow injected. In the cervical approach, the patient is placed in the lateral and poorly defined location of the chylous leak in order to temporary decubitus position and under bi-plane fluoroscopic guidance, a 25 occlude the thoracic duct as a test before permanent occlusion. gauge needle is inserted into the C1-C2 intraforaminal space, CSF CLINICAL FINDINGS/PROCEDURE DETAILS: A standard lymphangio- return is confirmed, and Nusinersen is injected. Example imaging of gram is performed with ultrasound-guided intranodal injection of each technique is provided, with special attention to unique anatomic ethiodized oil into an inguinal using a 25-gauge spinal and safety considerations for the cervical approach. needle. After the cisterna chyli is adequately opacified, it is accessed CONCLUSIONS: A lateral decubitus, cervical approach for intrathe- percutaneously and a wire is advanced into the subclavian vein and cal nusinersen injection is a dynamic, safe, and effective alternative captured by a snare that is advanced through the left brachial vein. for treating patients with SMA who have complex lumbar anatomic The wire is pulled out and externalized through the brachial vein. Next, restrictions and motor limitations. a 4-6F vascular sheath is advanced along this wire from the arm into 84 | Educational e-Posters SIR 2019 Annual Scientific Meeting

Abstract No. 825 LEARNING OBJECTIVES: Review the pathology and outcomes of chil- dren with spinal muscular atrophy (SMA). Learn the procedures avail- Percutaneous decompression for lumbar spinal stenosis able for intrathecal access. Understand the indications for choosing with neurogenic claudication: an initial experience more advanced techniques to deliver nusinersen.

1 2 N Arastu , E Paik BACKGROUND: Spinal muscular atrophy is an autosomal recessive 1University of Cincinnati Medical Center, Cincinnati, OH, 2The Christ disease affecting motor neurons and is the most common genetic Hospital, Cincinnati, OH cause of death in infants. Commonly administered by lumbar punc- ture in the clinic or with imaging guidance, this is the initial method of LEARNING OBJECTIVES: Briefly examine the mechanism of lumbar spi- administering nusinersen. Deformities and spinal instrumentation from nal stenosis and neurogenic claudication. Describe and illustrate the orthopedic surgeries are common in SMA patients, preventing tradi- function of the MILD (Vertos Medical, Aliso Viejo, CA) minimally inva- tional intrathecal access by lumbar puncture for nusinersen delivery. sive lumbar decompression device for treatment of neurogenic clau- Transforaminal lumbar sac access, ultrasound or fluoroscopy-guided dication symptoms due to lumbar spinal stenosis. Discuss follow-up cervical spine access, or subcutaneous catheter placement can be the care, pre/post decompression imaging, and potential complications. alternative approaches with failed/difficult lumbar access. Given the

BACKGROUND: Neurogenic lumbar claudication as a result of lumbar potential benefit of nusinersen, exploring all methods to obtain intra- spinal stenosis (LSS) is a significant source of functional limitation and thecal access is essential for a pediatric interventional radiology (IR) pain in elderly patients. Ligamentum flavum thickening and hypertro- practice. phy accounts for a large degree of this canal narrowing. Percutane- CLINICAL FINDINGS/PROCEDURE DETAILS: We intend to review the ous lumbar decompression by ligamentum flavum debulking offers a technique, indications, complications, tips and tricks for each of these minimally invasive and clinically effective early treatment solution, as techniques and their relevance to an IR practice: ultrasound-guided an alternative to current therapy options such as temporary epidural lumbar puncture, fluoroscopy-guided lumbar puncture, ultra- steroid injections (ESI) or more invasive surgical decompression. Little sound-guided cervical puncture, fluoroscopy-guided cervical punc- information on this topic currently exists in the interventional radiol- ture (C1-C2), transforaminal delivery using cone-beam computed ogy (IR) literature, as we present one of the early cases of MILD mini- tomography, transosseous access via drill, subcutaneous intrathecal mally invasive lumbar decompression performed by IR since Medicare catheter system. approval in late 2016. CONCLUSIONS: Nusinersen administration for SMA is providing a novel CLINICAL FINDINGS/PROCEDURE DETAILS: MILD minimally invasive treatment for a previously untreatable condition and the number of lumbar decompression utilizes a sculptor device with an epiduro- patients requiring these procedures is expected to increase. Pediatric gram-guided percutaneous dorsal interlaminar approach to debulk interventional radiologists can provide the best approach for deliver- portions of the bony lamina and hypertrophic ligamentum flavum ing nusinersen by being aware of the options available to them. in selective fashion, without any resultant destabilization. Using a case-based method, we will provide a systematic discussion including patient preparation and follow-up care, and a step-by- Abstract No. 827 step “how to” procedural guide to performing minimally invasive percutaneous lumbar decompression with relevant correlate epi- Endovascular treatment of tracheo-innominate artery durography. Procedure-specific considerations such as technical fistula: case report and literature review with pooled difficulty and patient selection, as well as potential complications, cohort analysis will be addressed. T Taechariyakul1, Y Jahangiri2, W Nichols3, F Keller4

CONCLUSIONS: IR performed percutaneous minimally invasive lum- 1Oregon Health and Science University, Portland, OR, 2Charles T. bar decompression is a safe and effective early treatment option Dotter Department of Interventional Radiology, Oregon Health and for selected patients with central spinal stenosis suffering from neu- Science University, Portland, OR, 3Legacy Emanuel Medical Center, rogenic claudication symptoms. Appropriate patient selection and Portland, OR, 4Dotter Interventional Institute, Portland, OR understanding of procedure-specific techniques and relevant imaging LEARNING OBJECTIVES: To report a case of tracheo-innominate artery are critical to success. fistula (TIF) with successful endovascular treatment and pooled cohort analysis of the historical cases. Abstract No. 826 BACKGROUND: Tracheo-innominate artery fistula (TIF) is a rare yet fatal complication of tracheal structural diseases and palliative inter- An overview of techniques for intrathecal administration ventions such as long-term tracheostomy placement. TIF is primar- of nusinersen in children with spinal muscular atrophy ily treated surgically with the ligation of the innominate artery. More C Ortiz1, A Chau2, S Desai2, K Kukreja2 recently, endovascular techniques have shown promise in treating TIF. 1Baylor College of Medicine, Houston, TX, 2Texas Children’s Hospital, CLINICAL FINDINGS/PROCEDURE DETAILS: A 14-year-old boy with Houston, TX Gorham’s syndrome and long-term tracheostomy presented with an SIR 2019 Annual Scientific Meeting Educational e-Posters | 85

episode of massive hemoptysis. Arch aortogram revealed a pseudo- CLINICAL FINDINGS/PROCEDURE DETAILS: Pictorial review of twenty aneurysm of the innominate artery. An endovascular stent grafts was selected cases, including: LM and VM of the head and neck (i.e., placed in the innominate artery without complications sealing the fis- tongue, carotid sheath, retropharyngeal, submandibular and para- tula and excluding the right subclavian artery. No procedure-related pharyngeal spaces) resulting in severe airway compression, orbital LM complications were observed on follow-up, and the patient passed with proptosis, disfiguring facial LM (eyelid, lip, chin), intra-abdominal away 6 months later due to disease-related etiologies. A total of 226 LM with IVC compression, LM and VM of superficial tissues (chest wall, cases with TIF were reported in 122 publications, among whom 30 upper and lower extremities) and varicoceles. This exhibit will discuss cases were treated endovascularly, 106 were treated surgically, and the clinical symptoms and key imaging findings of each lesion, alterna- 90 were reported with no definitive treatment. The overall survival tive attempted treatments, procedural techniques and complications. rate was 40% in a mean follow-up time of 4±9 months. The patients’ Sclerosing agents used in these cases and reviewed in this exhibit mean age was 34±22 years, and 39% were females. The mean time include: ethanol, doxycycline, bleomycin, and sodium tetradecyl sul- interval between tracheostomy and hemorrhage was 1±2.6 years. fate. We will review the dose, mechanism, indications and complica- Among evaluated factors, a longer time interval between tracheos- tions of each sclerosant. tomy placement and fistula formation (HR:0.82, P=0.017) and cases CONCLUSIONS: Percutaneous sclerotherapy of low-flow VMF has after year 2000 (HR:0.58, P=0.003) were associated with signifi- proven to be an effective, minimally invasive technique in treating oth- cantly decreased hazards of post-intervention death. There was no erwise potentially fatal and disfiguring lesions. To achieve clinical suc- statistically significant association between treatment modality (per- cess, an understanding of imaging findings, procedural technique and cutaneous or surgery) and post-intervention hazard of death (HR: different sclerosing agents is necessary. 0.70, P=0.420) or rate of complications (33% versus 47%, respec- tively, P=0.178).

CONCLUSIONS: Percutaneous treatment of tracheo-innominate artery Abstract No. 829 fistulas with stent graft placement has equivalent survival benefit and Establishing an interventional radiology clinic in a complication rates as surgical interventions. Longer interval between community hospital setting tracheostomy placement and fistula formation is a predictor of higher survival after interventions. B Lei1, A Ramjit1, J Chen1, D Portal1, N Ahmad1 1Staten Island University Hospital Northwell Health, Staten Island, NY Abstract No. 828 LEARNING OBJECTIVES: Review the growing necessity and benefits of Treatment of pediatric low-flow vascular malformations clinical interventional radiology (IR) in the community hospital setting. with percutaneous sclerotherapy Identify challenges to and solutions for establishing an IR clinic in the S Raza1, C Sung2, D Siegel3, S Raza1 community.

1North Shore University Hospital, Northwell Health, Manhasset, BACKGROUND: The healthcare paradigm in which IR operates pre- NY, 2Long Island Jewish Medical Center, New Hyde, NY, 3Northwell dominantly from behind the scenes as a consulting inpatient service Health, New Hyde Park, NY is becoming increasingly outdated. In recent decades, rapid expansion of services that IR is capable of providing has substantiated the need LEARNING OBJECTIVES: Increase the participant’s understanding of for more comprehensive longitudinal relationships between patients percutaneous sclerotherapy in the treatment of low-flow vascular and interventionalists. Moreover, competition with other procedural malformations (VMF) in the pediatric population using a case-based specialties further incentivizes IR to increase its visibility within the pictorial review. This exhibit will showcase unique anatomic and clini- healthcare system and develop a platform for direct engagement with cal presentations of VMF treated by interventional radiologists at our patients and referring clinicians. institution. After reviewing these cases, the viewer will become famil- iar with the pathophysiology of VMF, clinical indications for sclero- CLINICAL FINDINGS/PROCEDURE DETAILS: Establishing an IR clinic therapy, procedural techniques, complications, and commonly used involves a set of practical requirements that is relevant for interven- sclerosants. tional radiology in the community hospital setting where elective procedures are taking greater hold. These requirements include an BACKGROUND: Interventional radiology commonly utilizes percutane- administrative framework for scheduling, medical documentation, ous sclerotherapy as a minimally invasive means of treating various and billing/evaluation management coding in addition to retaining symptomatic VMF. VMF are classified as either high or low-flow lesions, adequate physical space and support staff. A comprehensive busi- with the latter including venous (VM), lymphatic (LM), capillary and ness plan should also be devised to ensure clinical practice is gen- mixed malformations. These lesions can develop almost anywhere in erating revenue and should include marketing strategies to promote the body and can result in a wide variety of clinical symptoms, includ- awareness amongst patients and referring physicians. We will dis- ing airway compression, recurrent infection, neuromuscular impinge- cuss each of these challenges further as well as the approaches we ment, chronic pain and physical disfigurement. have taken in developing our clinical IR practice at Staten Island Uni- versity Hospital. 86 | Educational e-Posters SIR 2019 Annual Scientific Meeting

CONCLUSIONS: Setting a strong foundation for an interventional radiol- Table 1 ogy clinic is becoming increasingly important for safeguarding the Ultrasound-Guided Kyphoplasty (Lumbar) Percutaneous specialty’s economic durability and scope of practice in the commu- Kidney Biopsy Cryoablation nity hospital setting. However, it is also an enterprise in which many E/M service 99233 99233 92255 traditional radiologists may lack experience. We offer our approach Assessment Kidney Z94.0 L3 vertebral S32.030A RCC C64.2 to this unique challenge to show not only viable paths to a successful transplant body fx clinical IR practice in the community but also opportunities for creativ- Elevated R79.89 Uncontrolled E13.42 HTN I10.0 ity and leadership. creatinine DM with neuropathy Abstract No. 830 Procedure 50200, 76942 22514 50205 Global 0 day 10 day 90 day Evaluation and management services basics for today’s period interventional radiologists M Mulatre1, A Moore1, N Reyes1, W Terrell1, M Hyatt1, R Trojan1 Abstract No. 831 1INTEGRIS Baptist Medical Center, Oklahoma City, OK

LEARNING OBJECTIVES: Evaluation and management (E&M) coding is How to establish an interventional radiology inpatient a medical coding process used by health care providers in the U.S. to consultation service line for dummies be reimbursed by Medicare, Medicaid and private insurance. It is a con- G Kroma1, S Jen2, M Le3 fusing maze of words and numbers that many physicians know little 1University of Texas Health Science Center, San Antonio, TX, 2UT about. The purpose of this educational poster is to outline key portions Health San Antonio, San Antonio, TX, 3University of Texas, Health of the E&M coding system for today’s interventional radiologists. Science Center at San Antonio, San Antonio, TX

BACKGROUND: Documentation is the key to adequate and timely LEARNING OBJECTIVES: Establish interventional radiology (IR) as reimbursement. There are three key components when selecting the a primary service with a formal consultation service line. Create appropriate level of E&M services; history, examination, and medical a work flow algorithm with established team members that have decision making. To bill the highest code available for consultation defined roles. Establish order to billing pattern with assistance from services, there must be a comprehensive history and high complexity the billing and coding department. Use proper documentation in medical decision making. EMR to optimize billing and reimbursement.Establish inpatient con- CLINICAL FINDINGS/PROCEDURE DETAILS: The comprehensive history tinuity of care. includes chief complaint, an extended HPI, a complete review of sys- BACKGROUND: As interventional radiology continues to evolve as a tems and past, social and family history. High complexity must meet or primary care specialty, the importance of establishing defined roles exceed two of the following three categories; extensive management as clinicians has become even more crucial. Interventional radiologists options for diagnosis or treatment, extensive amount of data to be are both imaging experts and clinicians who are in an unique position reviewed and high risk of complications and/or morbidity or mortal- to provide comprehensive care through image-guided therapy. Estab- ity. Given that interventional radiology is a procedural specialty, one lishing a comprehensive clinical model of practice requires collabo- must be familiar with where the intended procedure falls under the rative efforts from hospital administration, the departmental coding global surgery period. Global surgery period includes all the necessary and billing team, IR providers, and referring physicians. With a formal services normally performed before, during, and after a procedure. service line, continuity of care is established through practicing both It applies in any setting, including an inpatient hospital, outpatient inpatient and outpatient follow-up. hospital, Ambulatory Surgical Center (ASC), and physician’s office. There are three types of global surgical packages based on the num- CLINICAL FINDINGS/PROCEDURE DETAILS: Algorithm with defined ber of post-operative days; 0-Day, 10-Day and 90-day post-operative work flow and roles of all team members. Template examples with Period. Many of the codes for interventional radiology procedures fall essential components to maximize billing. Referring opportunities and under the 0-day post-operative period in which post-operative vis- visibility within the hospital its beyond the day of the procedure are not included in the payment CONCLUSIONS: This exhibit illustrates a systemic team-based amount for the surgery and post-operative visits are separately bill- approach to IR revenue management. Engaging available resources able and payable. to include physicians, coding and billing, IT, and medical record sup- CONCLUSIONS: This succinct summary provides today’s interventional port teams will help to establish a comprehensive service that results radiologists the basics to approaching coding and documentation. in better patient care, an improved IR practice reputation, and mon- Armed with the information, interventional radiologists can begin to etary gains. make strides towards maximizing reimbursements. SIR 2019 Annual Scientific Meeting Educational e-Posters | 87

Abstract No. 832 BACKGROUND: To assess pericardial pathologies, cardiac ultrasound (echocardiography) is generally used because of its portability, acces- Leading the charge: how interventional radiology can sibility, and low cost. To percutaneously drain pericardial effusion, car- deliver on value-based care diologists often use an echocardiography probe to select an area in J Roebker1, S Chadalavada2,3 which to blindly advance an access needle; however, because of the presence of the lungs, rib cage, and postoperative blood products 1University of Cincinnati College of Medicine, Cincinnati, OH, 2University in the mediastinum, this technique provides limited views for proce- of Cincinnati Medical Center, Cincinnati, OH, 3 UC Health, N/A dure planning. The absence of a safe echocardiography window often

LEARNING OBJECTIVES: Describe current trends in reimbursement. Dis- results in referral for an open surgical pericardial window without cuss differences in incentives created by value- and production-based consulting a radiologist. Computed tomography (CT)-guided proce- systems. List ways interventional radiology (IR) can lead value-based care dures are standard practice in radiology departments; this provides an unrestricted view, allowing one to identify a safe trajectory for percu- BACKGROUND: The Centers for Medicare and Medicaid Services (CMS) taneous drainage, localize and characterize pericardial fluids, detect has been shifting outpatient services into bundled payments over the pericardial thickening and masses, identify epicardial fat pad and past several years in an effort to control rising healthcare costs. This is blood products, and detect lung/pleural abnormalities. CT can help accomplished through ambulatory payment classifications (APC), which to identify needle trajectories unavailable with echocardiography for are Healthcare Common Procedure Coding System (HCPCS)/Current cardiologist; but feasible for real-time ultrasound guidance by radiolo- Procedural Terminology (CPT) codes grouped together based on similar gists. Following drainage, CT helps to identify any un-drained/residual resource use. APCs are a measure of productivity and connected to the pockets. Pericardial drainage service by radiology in our hospital pro- relative value unit (RVU), which has traditionally undervalued IR by not vides cost savings and is preferred by the patients and surgeons. recognizing the intangible benefits IR brings to patient care. However, bun- dled payments shift incentives towards quality outcomes at a reduced cost CLINICAL FINDINGS/PROCEDURE DETAILS: We describe various meth- and are an opportunity to demonstrate IR’s value to the healthcare system. ods of percutaneous pericardial drainage. We highlight the advantages of real-time visualization of needle progress and show a proposed pro- CLINICAL FINDINGS/PROCEDURE DETAILS: The CMS hospital outpatient cedural room setup in radiology to streamline technical execution. We prospective payment system (OPPS) was reviewed in detail, including also discuss potential complications. the methodology of RVUs, HCPCS and CPT codes, and APCs. A dis- cussion of their interconnectedness and relevance to IR is given. As CONCLUSIONS: Combined CT-ultrasound setup in radiology proce- evidenced by the 2017 OPPS final rule, the CMS is increasing bundled dural rooms allow one to evaluate distribution of pericardial effusion payments and incentivizing providers to improve outcomes at a lower and drain the effusion using real-time needle visualization techniques. cost. IR performs several procedures that are more cost-effective than By embracing this service, radiologists would reduce the need for sur- surgical alternatives and is poised to be a leader under value-based gical procedures in these patients. reimbursement. Described is a strategy for IR to use APC and RVU data to increase value, how current procedures fit into value-based care, and Abstract No. 834 the significance of capturing the value created by future procedures.

CONCLUSIONS: The economic incentives created by reimbursement Lean Six Sigma: how lessons from industry can improve underlie a hospital’s decisions on how to allocate scarce resources; as interventional radiology workflow efficiency and patient such, it is critical for IR physicians and trainees to be aware of the current care delivery state and future trends. This understanding will improve communica- M Makary1, A Chafitz2, B Sugar2, I Vargas3, J Sarbinoff4, J Dowell5 tion with administrators, guide the formulation of metrics that align with 1The Ohio State University Medical Center, Columbus, OH, 2Ohio high-value care, and drive innovation. Bundled payments are an oppor- State University Medical Center, N/A, 3Eli Lilly, Indianapolis, IN, tunity for IR to be a healthcare leader, but only if we are prepared. 4Allergan, Austin, TX, 5The Ohio State University, Powell, OH

LEARNING OBJECTIVES: To review the Lean Six Sigma quality improve- Abstract No. 833 ment methodology and demonstrate its applications in interventional radiology (IR). Real-time image-guided percutaneous pericardial drainage: a minimally invasive way to achieving a BACKGROUND: Lean Six Sigma encompasses quality improvement substantial value proposition methods created by the car industry to achieve efficient production. Today, these methods are typically used in conjunction and have M Juan1, N Austin1, R Gurajala1, K Karuppasamy1 demonstrated useful applications in improving healthcare delivery. 1Cleveland Clinic, Cleveland, OH Lean Six Sigma uses a Define-Measure-Analyze-Improve-Control

LEARNING OBJECTIVES: To showcase percutaneous pericardial drain- (DMAIC) framework to identify measurable variables to quantify sys- age techniques, highlight the advantages of real-time imaging guid- tem problems or inefficiencies, and design interventions to combat ance, propose a blueprint of procedural room assembly, and discuss these inefficiencies. Potential targets of this framework include pre-, management of procedural complications. intra-, and post-procedural steps of IR procedures and patient care. 88 | Educational e-Posters SIR 2019 Annual Scientific Meeting

CLINICAL FINDINGS/PROCEDURE DETAILS: 1) Introduce the history and Abstract No. 836 original utility of Lean Six Sigma in industry, 2) Review the DMAIC framework and the function of each of its components, 3) Highlight Atypical spontaneous portosystemic shunts applications of Lean Six Sigma in improving healthcare delivery, 4) A Moreland1, B Holly1, M Lessne2, A Moreland1 Discuss successful implementation of this tool in the IR workflow 1Johns Hopkins Hospital, Baltimore, MD, 2Vascular & Interventional to improve low IVC filter retrieval rates, patient scheduling delays, Specialists of Charlotte Radiology, Charlotte, NC perceived long wait times of referring physicians for central venous access and PEG tubes, first case start time inefficiency, and excessive LEARNING OBJECTIVES: 1. Review various types and pathophysiology expenditure on overtime, and 5) Review potential future applications of atypical spontaneous portal-systemic shunts (SPSS) 2. Describe of Lean Six Sigma in IR and lessons for effective quality improvement clinical symptoms and treatment options for atypical SPSS projects. BACKGROUND: Portal hypertension is a frequent consequence of CONCLUSIONS: After reviewing this exhibit, the viewer will become cirrhosis, which gives rise to significant morbidity and mortality in familiar with the origins of the Lean Six Sigma methodologies, learn affected patients. SPSS are closely linked to complications of portal about successful implementation examples of the DMAIC framework hypertension such as hepatic encephalopathy and gastrointestinal applied to various inefficiencies in the IR workflow, and develop a bleeds. The pathophysiology driving the development of SPSS is deeper appreciation of the potential of this tool and its future applica- thought to originate with hepatofugal flow and a combination of dila- tions in improving IR care delivery. tion of pre-existing veins and neo-angiogenesis. SPSS are present in 60% of patients with portal hypertension: the most common types are splenorenal (46%) or paraumbilical (27%). Numerous rarer SPSS Abstract No. 835 pathways have been described in the literature. This abstract reviews various atypical SPSS, their symptoms and treatment through case Trolley problems in interventional radiology: when illustration and literature review. interventional radiologists must sacrifice healthy tissue for the greater good of the patient CLINICAL FINDINGS/PROCEDURE DETAILS: In this presentation we J Okun1, D Bamshad2, M Siddiqi1, S Gonzales1 review atypical SPSS, with a focus on the extrahepatic shunt types. Case examples will be provided of atypical SPSS, including umbil- 1Rutgers New Jersey Medical School, Newark, NJ, 2New York ical-common femoral vein shunt with compression of the sper- Medical College, Valhalla, NY matic cord leading to symptomatic varicocele, and portal-ovarian

LEARNING OBJECTIVES: To understand and appreciate the various vein shunt with associated bleeding small bowel varices. Treatment scenarios in which interventional radiologists must make the difficult options including atypical approaches for balloon retrograde trans- decision to sacrifice healthy tissue or cause long-term sequela for the venous obliteration (BRTO) and transportal venous obliteration will greater good of the patient. be illustrated.

BACKGROUND: The Trolley Problem is a famous thought experiment in CONCLUSIONS: SPSS correlate with increasing MELD score, hepatic field of ethics in which one must choose between harming one individ- encephalopathy, and bleeding, with shunts constituting independent ual in an effort to save many. (1) Interventional radiologists often face risk factors for death and transplantation. However, outcomes can be a similar dilemma when treating patients in which they must choose to improved through interventional radiology treatment options. Atypi- take on great risk of damaging healthy tissue or causing other sequela cal SPSS may be encountered and their recognition is essential to tar- in order to achieve the best possible outcome. get therapy and mitigate complications.

CLINICAL FINDINGS/PROCEDURE DETAILS: This exhibit will review the Spontaneous Extrahepatic Portosystemic Shunt Types most common clinical scenarios in which interventional radiologists Draining into SVC Spleno-coronary/pulmonary must make the difficult decision to take on great risk of potentially Spleno-azygous/phrenic damaging healthy tissue, or causing other negative downstream clin- Pancreaticoduodenal/hemiazygous ical effects, for the greater good of the patient. Among the clinical Draining into IVC Gastrorenal scenarios presented will include radioembolization, TACE, and TIPS Gastrocaval and their potential effects on liver function; embolization for trauma Gastro- or spleno-gonadal and gastrointestinal bleeding and the risk of sacrificing healthy tissue; Splenorenal contrast administration when there is great risk for kidney injury; and Spleno-adreno-renal Spleno-caval central line placement in patients with active blood infection. Transsplenic Mesenterico-gonadal, renal, caval CONCLUSIONS: It is crucial that interventional radiologists appreciate the procedural scenarios in which they may have to sacrifice healthy tissue, or cause other sequela, for the greater good of the patient. Giv- ing thought to the clinical reasoning and ramifications of these deci- sions before they arise will better allow us to make correct decisions when there is little time to act. SIR 2019 Annual Scientific Meeting Educational e-Posters | 89

Abstract No. 837 BACKGROUND: Secondary lymphedema currently has no cure, and is a major source of post oncologic therapy morbidity. Often impacting The implications of distal transradial access in the upper and lower extremities, there is significant long-term mor- interventional radiology bidity in cancer patients after undergoing radiation, chemotherapy, or B Carney1, J Khoury2, S Shah3 surgical interventions. Although surgery can provide symptom relief of impacted limbs along with improved quality of life, there remains 1Nassau University Medical Center, East Meadow, NY, 2NYIT College complications in management. of Osteopathic Medicine, Brooklyn, NY, 3N/A, Old Westbury, NY CLINICAL FINDINGS/PROCEDURE DETAILS: Lymphedema secondary to LEARNING OBJECTIVES: Describe the advantages and disadvantages oncologic therapy impacting the upper and lower extremities most of distal transradial access (dTRA) compared to traditional transradial frequently results from breast and gynecologic malignancies, respec- access (TRA) and transfemoral access (TFA). tively. Often times complete decongestive physiotherapy is a highly

BACKGROUND: Transradial access (TRA) has become a viable alternative effective treatment for both primary and secondary lymphedema. to transfemoral access (TFA) for 25 years. Achieving vascular access via Percutaneous catheter-based interventions have been used to pro- the radial artery has many advantages over femoral access, including vide symptomatic relief following diagnostic lymphoscintigraphy and decreased complications (retroperitoneal hematoma, pseudoaneurysm, venography. We will review cases from our institution of patients who AV fistula), decreased length of stay and overall improved patient com- developed secondary lymphedema, and the outcomes of patients fort and satisfaction. TRA, however, is not without complications; the treated with venoplasty/stent placement. most common being radial artery occlusion (RAO). Distal transradial CONCLUSIONS: Management of these patients involves a multidisciplinary access (dTRA), which entails accessing the radial artery distally within approach. MRI, venogram/lymphogram and nuclear scintigraphy play an the anatomical snuffbox on the dorsal aspect of the hand, has been important role in diagnosis and treatment of these patients. Future long- shown to decrease incidence of RAO and improve comfort for patients. term follow-up studies are important to ensure treated vessels are sus-

CLINICAL FINDINGS/PROCEDURE DETAILS: One study analyzed 1512 tainable and are resistant to developing recurrent thrombotic events. non-coronary interventions utilizing TRA and found 98.2% techni- cal success, 0.13% major complications (including pseudoaneurysm Abstract No. 839 and seizure) and 2.38% minor complications (including hematoma/ bleeding, RAO, arm pain, and radial artery spasm). Another study sug- The nuts and bolts of nutcracker syndrome gested RAO as a complication of coronary intervention can be as high as 10% with traditional TRA. A recent study assessing the benefits of D Holt1, S Strader2, T Brady1, M Daghfal1, R Bertino3 dTRA found zero incidence of RAO after use in 70 procedures. The 1University of Illinois/OSF St. Francis, Peoria, IL, 2Lincoln Memorial decreased incidence of RAO is due to maintenance of anterograde University-DeBusk College of Osteopathic Medicine, Madison, IN, flow through the superficial palmar arch, as the puncture site is distal 3Central Illinois Radiology Associates, Peoria, IL to the branch point of the superficial palmar arch at the proximal pol- LEARNING OBJECTIVES: 1) Understand the clinical presentation and licis brevis artery. The 1st digit is less likely to become ischemic due to pathophysiology of Nutcracker phenomenon. 2) Understand pertinent maintained flow through anastomosis with the superficial palmar arch. anatomy and identify common findings on ultrasound, CT, and venogra- CONCLUSIONS: dTRA has been proven to be a safe and effective tech- phy. 3) Discuss treatment options and appropriate clinical and imaging nique for percutaneous intervention and angiography. In addition to the follow-up. The above points will be illustrated with a case series of patients known benefits of radial access over femoral access, dTRA also decreases who were successfully treated with percutaneous stenting. Cases include, the risk of radial artery occlusion and further improves patient comfort. but are not limited to, three female pediatric patients, two with Nutcracker This technique can likely be used safely and effectively to improve patient Syndrome (NCS) and one with Posterior Nutcracker Syndrome (PNS). outcomes in certain interventional radiology procedures utilizing 4F to 6F BACKGROUND: Vague abdominal pain is a common presenting clini- sheaths/catheters. Further research on this topic is warranted. cal symptom and finding the cause can be challenging. The patient’s symptoms may lead to repeated office and emergency room visits, as Abstract No. 838 well as, frustration from the lack of diagnosis. NCS and PNS are clin- ically and radiographically similar syndromes, both resulting in renal Secondary lymphedema and percutaneous catheter- vein outflow obstruction, which can be overlooked. Delayed diagno- based interventions: pictorial review sis may be even more common in pediatric populations as nutcracker phenomenon is most commonly seen in adults. Currently, there are no A Kilgore1, M Schwartz1, A Khurana1, I Breen1, S Naidu1, M Knuttinen1, S Alzubaidi1, L Rotellini-Coltvet2, R Oklu1 well-established diagnostic or treatment criteria. 1Mayo Clinic, Phoenix, AZ, 2Mayo Clinic Hospital Arizona, Phoenix, AZ CLINICAL FINDINGS/PROCEDURE DETAILS: Nutcracker phenomenon is radiographically characterized by compression of the left renal vein LEARNING OBJECTIVES: To review the major cause of secondary between the aorta and superior mesenteric artery (NCS) or between lymphedema in the western world and the proposed role that inter- the aorta and the spine (PNS). If symptoms and appropriate imaging ventional radiology can play in its ongoing management. 90 | Educational e-Posters SIR 2019 Annual Scientific Meeting findings are present, the patient can be said to have NCS/PNS. NCS/ Abstract No. 841 PNS commonly presents in thin females between the ages of 20 and 40 years. Typically, the patient has left flank or abdominal pain with Cracking a tough nut: the interventionalist’s role in managing or without hematuria. Prevalence is unknown. Symptoms can mani- gonadal vein reflux in the setting of nutcracker syndrome fest or be exacerbated after weight loss or with exercise. Venography J Birch1, T Bochnakova1, G Martinez-Salazar2 may demonstrate enlarged tortuous hilar vessels with collateralization. 1Massachusetts General Hospital, Boston, MA, 2Massachusetts Ultrasound can be used as an effective screening tool with venography General Hospital, Boston, MA providing more definitive information. Treatment options include sur- gical or intravascular repair. LEARNING OBJECTIVES: 1. To illustrate the diagnostic features of Nut- cracker Syndrome, including the three forms of nutcracker syndrome, CONCLUSIONS: NCS/PNS can have high morbidity and should be included renocaval pressure gradients and the possible secondary finding in the differential for vague abdominal or flank pain. Investigation for nut- of gonadal vein reflux. 2. To recognize that patients with nutcracker cracker phenomenon with appropriate imaging can help make the diag- syndrome have pelvic varicosities and may present with symptoms of nosis, which can be effectively treated with percutaneous stenting. pelvic congestion syndrome. 3. To understand therapeutic options for patients with nutcracker syndrome, including treatment of associated Abstract No. 840 gonadal vein reflux, and complications of gonadal vein embolization

BACKGROUND: Nutcracker syndrome occurs in patient with nutcracker Two better than one: balloon and plug-assisted retrograde anatomy, where there is extrinsic mesoaortic compression of the left transvenous obliteration (B-PARTO) of gastric varices renal vein in the setting of clinical symptoms, which includes hematu- A Abdel Aal1, K Mahmoud1, H El Khudari1, N Aboueldahab1, ria, varicocele and abdominal or flank pain. Diagnostic imaging can be 2 3 1 R Varma , S Saddekni , A Gunn obtained with ultrasound, CT, MRI or conventional venography. Con- 1University of Alabama at Birmingham, Birmingham, AL, 2University ventional venography with renocaval pressure measurements confirm of Alabama at Birmingham, Vestavia Hills, AL, 3University of a true clinically significant compression. Left renal vein hypertension Alabama @ Birmingham, Birmingham, AL can result in pelvic varices and even symptoms suggestive of pelvic congestion syndrome. LEARNING OBJECTIVES: 1. To review the indications and contrain- dications of gastric variceal obliteration. 2. To discuss the existing CLINICAL FINDINGS/PROCEDURE DETAILS: Imaging findings and diag- venous obliteration techniques such as Balloon assisted retrograde nostic imaging features of gonadal vein reflux by Doppler ultra- transvenous obliteration of gastric varices (BRTO) and plug-assisted sound, CT, MR, and conventional venography will be presented. retrograde transvenous obliteration of gastric varices (PARTO). 3. To Treatment options of nutcracker syndrome will be discussed, demonstrate how to perform a technique that involves both the bal- including the Interventionalist’s role in left renal vein stenting loon and plug for obliteration of gastric varices (B-PARTO). 4. Outline or treatment of secondary pelvic varicosities with gonadal vein the outcomes of the different techniques. 5. Discuss the potential com- embolization. Single-institution case presentations and outcomes plications associated with the techniques. of patients with pelvic congestion in the setting of nutcracker syn- drome who underwent gonadal vein embolization by interventional BACKGROUND: Gastro-esophageal varices are a common complica- radiology will be presented. tion of portal hypertension. When the pharmacologic and endoscopic treatment are limited, interventional procedure may be the treatment CONCLUSIONS: Patients with clinically significant nutcracker syndrome indication. Transjugular intrahepatic portosystemic shunt (TIPS) have can present with pelvic congestion syndrome due to significant pelvic reliable clinical outcomes. Studies showed the effectiveness of both varicosities and gonadal vein reflux and may symptomatically benefit balloon occluded retrograde transvenous obliteration (BRTO) and from gonadal vein embolization. plug-assited retrograde transvenous obliteration (PARTO) of gastric varices. Balloon and plug-assisted retrograde transvenous obliteration (B-PARTO)of gastric varices is a relatively new technique used. Abstract No. 842

CLINICAL FINDINGS/PROCEDURE DETAILS: A 9 French balloon occlu- Intravascular ultrasound–guided transcaval endoleak sion sheath is placed in the distal end of the spleno-renal shunt, and embolization: how we do it the balloon is inflated. The sclerosant is then injected through the W Sherk1, R Pampati2, X Marko3, M Khaja2 sheath under fluoroscopic guidance while watching for leakage across 1 2 the balloon and overflow into the portal vein. When the delivery of University of Michigan Hospital, Ann Arbor, MI, University of Michigan, Ann Arbor, MI, 3MCVI Baptish Health South Floridia, the sclerosant is satisfactory, an Amplatz Vascular Plug is delivered Miami, FL through the sheath. The balloon is then deflated under fluoroscopy.

LEARNING OBJECTIVES: -Transcaval endoleak embolization is an alter- CONCLUSIONS: After viewing the poster, the reviewer will understand the technique and effectiveness of the standard procedures for scle- native to transarterial and translumbar approaches in the manage- rosing gastric varices which are BRTO and PARTO, and will learn how ment of type II endoleaks following endovascular aortic repair (EVAR) to combine both procedures into one. -Proper patient selection requires review of computed tomography SIR 2019 Annual Scientific Meeting Educational e-Posters | 91

angiography (CTA) to identify the relationship of the inferior vena cava LEARNING OBJECTIVES: Define the differentiating imaging features to the aneurysm sac, the size and location of the endoleak, and poten- of slow-flow vascular malformations. Emphasize the utility of mul- tial inflow and outflow arteries -Intraprocedure intravascular ultra- tisequence MRI in the pre-treatment planning. Describe in detail the sound (IVUS) can help identify the perfused portion of the aneurysm ultrasound and fluoroscopic-guided low-flow vascular malformation sac and guide the transcaval access in real-time sclerotherapy procedure. Discuss general and site-specific lesion and treatment-related complications. Outline the overall expected course BACKGROUND: Persistent type II endoleaks following EVAR are associ- and outcomes. ated with an increased incidence of adverse outcomes, but their man- agement may be difficult. The transcaval approach to type II endoleak BACKGROUND: The International Society for the Study of Vascular embolization has been described as a safe and effective alternative to Anomalies (ISSVA) splits vascular anomalies into two broad classes: established transarterial and translumbar techniques. With IVUS guid- vascular tumors and vascular malformations. Malformations are then ance, transcaval embolization can be considered in select patients. further divided into various subcategories based on the underlying histopathology of the lesion itself. For therapeutic considerations, CLINICAL FINDINGS/PROCEDURE DETAILS: For the procedure, two vascular malformations are generally classified into a low-flow and separate venous accesses are obtained for the transcaval needle high flow vascular malformations irrespective of the histologic type. and IVUS. The IVUS is positioned at the level of the aneurysm sac These lesions may warrant interventions when causing pain, mass and used to identify hypoechoic perfused portions relative to the effect, growth disturbance or cosmetic dissatisfaction. Sclerotherapy remaining echogenic thrombosed sac. A transseptal needle, such is one of the effective treatment options as an isolated approach or as BRK-1 (St. Jude; St. Paul, Minnesota), is advanced over guidewire as an intermediate step “downstaging” for surgical extirpation. The to the appropriate level. With IVUS and fluoroscopic guidance, the primary challenge that an interventionist encounters is the widely needle is directed toward the target within the aneurysm sac. Blood variable locations and trans-spatial extensions that these lesions fre- return may be noted when the inner stylet is removed. Contrast is quently have. injected through the needle to confirm position within the endoleak. Sac embolization is then performed similar to a direct translumbar CLINICAL FINDINGS/PROCEDURE DETAILS: We will review the typi- puncture technique. IVUS and/or venogram are performed to plan cal and differentiating imaging features of slow-flow Venous and closure of the transcaval tract with coils or plug as needed. Follow-up lymphatic malformations on grayscale and Doppler ultrasound, CTA is performed typically in one month to evaluate the sac size and and multi-sequence MRI including time-resolved MRA (TWIST). endoleak resolution. The commonly used sclerosant and a detailed description of image guide sclerotherapy will be described. Selected cases involving the CONCLUSIONS: In select patients, intravascular ultrasound-guided auricle, parotid gland, oral mucosa, peritoneal cavity, spinal canal, transcaval embolization is an alternative method to treat type II and the are discussed emphasizing the complica- endoleaks after EVAR. tions that we encountered and/or potential ones reported in the literature.

Abstract No. 843 CONCLUSIONS: These illustrative cases demonstrate the importance of accurate vascular malformation description based on a lesion’s ana- Low-flow vascular malformations, challenging locations tomic location in anticipation of site-specific complications. The points with site-specific treatment, and complications: a single- mentioned above are crucial for tailoring procedural planning, the mul- center experience tidisciplinary approach as well as informed consent in the care of such C Diab1, K El Salek1, S Aaron Ross2, C Moorthy1 patients. 1Texas Tech University Health Sciences Center, El Paso, TX, 2Texas Tech University Health Sciences Center, El paso, TX

Selected Postsclerotherapy Complications Case Sex Age Site Type of Sclerosant Sessions Site-Specific Complications General Imaging Lesion (n) Complications Modality

1 M 4Y L ear VM STS 2 none Ear blisters US, MRI 2 F 7Y R masticator compartment, lower lip, VM STS 1 none ARF + dialysis US, MRI and base of neck 3 M 22y Floor of the mouth, neck, chest wall, VM STS+AA 2 Oral mucosal bleeding, required None US, MRI and mediastinum ICU, and surgical repair 4 M 2y Intraabdominal LM None 1 Intraperitoneal contrast None US, MRI leakage 5 F 2y Lumbar paraspinal, retroperitoneal, VM STS+ AA 9 Nerve compression, extremity None US, MRI and epidural weakness 6 F 6y Right leg and foot (SQ, IM, IO) VM STS + AA 6 Skin ulceration, osteonecrosis Hemoglobinuria US, MRI 92 | Educational e-Posters SIR 2019 Annual Scientific Meeting

Abstract No. 844 LEARNING OBJECTIVES: 1. Understand the demographics and presen- tation of varicoceles. 2. Mastery of the anatomy and imaging charac- Portal vein embolization: the how, what, when, and why teristics related to varicoceles. 3. Gain an appreciation for the role of S Alzubaidi1, S Naidu2, G Knuttinen3, J Kriegshauser4, R Oklu1 embolization in the relief of the symptoms of varicoceles in males, and how the procedure is generally accomplished 4. Learner will be able to 1Mayo Clinic, Phoenix, AZ, 2Mayo Clinic Arizona, Scottsdale, AZ, confidently and intelligently discuss the use of varicocele embolization 3Mayo Clinic College of Medicine and Science (Phoenix, AZ, 4Mayo as a next step/alternative to failed surgical ligation/varicocelectomy. Clinic Scottsdale, Phoenix, AZ BACKGROUND: Varicoceles are caused by insufficiency or diminution of LEARNING OBJECTIVES: 1) To review the indications and contrain- the internal spermatic vein, with subsequent venous dilatation and dis- dications for Portal vein embolization (PVE); 2) To demonstrate the ruption of normal drainage into the IVC. Although common and many relevant anatomy and technical approaches, both Transsplenic and times asymptomatic, patients may seek medical attention to amelio- transhepatic various clinical scenarios through case presentations; 3) rate associated testicular pain, aesthetic appearances, infertility and To list the major complications that may occur with this technique to prevent testicular atrophy in the younger population. Interventional

BACKGROUND: PVE was first performed in a patient by Makuuchi in radiology has become paramount in the non-invasive management of 19841. PVE is accepted one approach prior to major hepatic resection varicoceles, with decreased morbidity and mortality when compared to induce hypertrophy of future live remnant (FLR)2. However, its tech- to surgery. nique has expanded to involve transsplenic approach to eliminate the CLINICAL FINDINGS/PROCEDURE DETAILS: This educational exhibit will risk of damage to the FLR, to avoid traversing the tumor in the ipsilat- review the clinical and imaging criteria for the diagnosis and potential eral lobe and also ipsilateral transhepatic access requires reverse cured treatment of varicoceles, via example cases from our institution. We catheters to access veins targeted for embolization. will discuss and provide imaging of the preprocedure, periprocedure

CLINICAL FINDINGS/PROCEDURE DETAILS: Through a case presen- and postprocedure in coil and/or sclerosant embolotherapy by inter- tation, various clinical scenarios will demonstrate the utility of PVE. ventional radiology. Preprocedural workup will be presented for each case in addition to CONCLUSIONS: Much in a similar fashion as “Pelvic Congestion Syn- a review of relevant Portal vein anatomy. PVE can be performed with drome” is a treatable cause of chronic pain in female patients, this proj- various embolization agents which will be highlighted. The various ect aims to present the role of interventional radiology to provide relief clinical presentations include 1) Transplenic PVE with metastatic col- of the ailments associated with varicoceles in male patients. orectal cancer of the right lobe requires extended right hepatectomy; 2) Transplenic PVE of the left hepatic lobe for cholangiocarcinoma involving the Lt. to avoid going through the right lobe (FLR); 3) tran- Abstract No. 846 shepatic PVE for HCC of the right lobe to induce Lt. lobe hypertrophy. These cases will highlight not only the technique used, but will also Complex inferior vena cava filter retrieval: the role of demonstrate the corresponding FLR value increase in a time-related preoperative imaging in planning advanced retrieval fashion. Complications that can result from performing PVE will also techniques and associated venous interventions be addressed, along with tips on how to avoid them. Furthermore, post W Johnson1, N Halin1, D Allen2 procedure management of each of these cases will be illustrated. 1Tufts Medical Center, Boston, MA, 2Tufts Medical Center, Newton, CONCLUSIONS: Our case by case illustration demonstrates the var- MA ious ways that PVE can be used prior to surgical resection to treat patients who have liver neoplasm from a variety of causes. Although LEARNING OBJECTIVES: 1. The role of preoperative imaging in proce- the transhepatic PVE technique is fairly straightforward, it is essential dural planning for IVC filter retrieval 2. Specific indications for use of to understand the potential benefits of transsplenic approach, relevant advanced techniques, such as laser sheath or endovascular forceps anatomy and preprocedural workup in order to reduce the risk of post 3. Associated venous interventions in cases of IVC thrombosis and procedure complications. iliofemoral venous stenosis

BACKGROUND: IVC Filter retrieval has become increasingly frequent since the introduction of a dedicated CPT code for IVC filter retrieval in Abstract No. 845 2012 and as the negative consequences of long-term IVC filter place- “The male-type pelvic congestion syndrome”: imaging ment have become better appreciated. While filter retrieval is often and embolization of spermatic varicoceles a straightforward procedure, it can be technically complex in cases where there are filter complications, such as filter migration, filter frac- 1 2 3 4 O Deochand , M Prasad , T Yablonsky , S Calhoun ture, IVC perforation and filter thrombosis. 1Atlantic Health- Morristown Medical Center, Morristown, NJ, CLINICAL FINDINGS/PROCEDURE DETAILS: A series of complex IVC fil- 2Morristown Medical Center, N/A, 3Morristown Medical Center, ter retrieval cases will be reviewed with associated pre-operative CTV Morristown, NJ, 4Morristown Medical Center, Atlantic Health of the abdomen and pelvis. Embedded IVC filter prongs, embedded or System, Long Valley, NJ angulated filter heads, and fractured IVC filters are easily demonstrated SIR 2019 Annual Scientific Meeting Educational e-Posters | 93

on CTV. In anticipated challenging cases, a larger than typical (12 a month was available for review. The mean tilt of these filters was 21 French or larger) right IJ approach sheath is inserted in preparation for degrees (±5.7). The filter struts were penetrating the IVC wall in one of advanced retrieval techniques. A loop snare technique is utilized for three patients. embedded filter hooks or engaging a filter without a hook. Rigid endo- CONCLUSIONS: The double wire-loop snare technique is a novel modi- vascular forceps are useful to retrieve fractured fragments and dissect fication to the previously described hangman technique. It is safe and the filter off the IVC wall. A laser sheath may be used to dissect filter effective technique for removing filters with embedded hooks. In our legs in cases where the endovascular forceps are insufficient. Laser experience, the technique achieved a 100% success rate without any sheath is our first choice in cases when a permanent filter was placed. associated complications despite significant filter tilt and extended If the CTV demonstrates caval or iliofemoral thrombosis or stenosis, dwell times. we recanalize the iliofemoral vessels via common femoral access and perform thrombectomy if needed. Following filter removal, we then angioplasty or stent the iliofemoral vessels to optimize flow. Abstract No. 848

CONCLUSIONS: While IVC filter retrieval is often straightforward, Adrenal vein sampling: technique and use complications such as fractured filter fragments, embedded filters and associated caval thrombus can add complexity to the proce- M Kuo1, A Saini1, S Alzubaidi1, M Knuttinen1, S Naidu1, H Albadawi1, dure. Preoperative CTV easily demonstrates these complications and R Oklu1 informs the need for advanced techniques and associated venous 1Mayo Clinic, Phoenix, AZ interventions. LEARNING OBJECTIVES: Review the technique and indications for adre- nal vein sampling and evaluation of results. Review procedural risks Abstract No. 847 and patient follow-up considerations. Multiple case illustrations will be included to depict anatomy, procedure and complications. Two loops are better than one: a modified hangman technique for the retrieval of inferior vena cava filters BACKGROUND: Adrenal vein sampling (AVS) remains the gold standard with embedded hooks for localizing aldosterone-secreting adenomas and differentiating adenomas from bilateral adrenal hyperplasia in patients with primary 1 2 3 4 5 E Mastria , K Kolli , R Kerlan , M Kohi , E Lehrman hyperaldosteronism (PA) (1). PA is caused by hypersecretion of aldo- 1University of California San Francisco, San Francisco, CA, 2UCSF, sterone, contributing to hypokalemia and hypertension (2). AVS draws San Francisco, CA, 3UCSF, kentfield, CA,4 University of California, blood from both adrenal veins and inferior vena cava (IVC), and then San Francisco, San Francisco, CA, 5UCSF, San Francsico, CA compares aldosterone and cortisol levels to evaluate adrenal hyperac- tivity (3). Risks, though rare, can include embolization, symptomatic LEARNING OBJECTIVES: The objective of this exhibit is to describe a groin hemorrhage, and adrenal hemorrhage. novel modification to the hangman technique of IVC filter retrieval: the double wire-loop snare technique. CLINICAL FINDINGS/PROCEDURE DETAILS: This educational poster will describe the pathophysiology of PA. We will explain the anatomy of BACKGROUND: A common reason for failure of IVC filter retrieval is an the adrenal veins and the technique of adrenal vein sampling, show- embedded retrieval hook that cannot be engaged with a conventional casing images from multiple cases at our institution and demonstrat- loop snare. The technique described in this educational exhibit com- ing the anatomical variations, results, treatment and follow-up in these bines the wire-loop snare and hangman techniques. patients. AVS can be difficult for inexperienced operators and tips for CLINICAL FINDINGS/PROCEDURE DETAILS: The double wire-loop snare successful performance of AVS will be discussed. technique can be employed when initial attempts with the conven- CONCLUSIONS: Adrenal vein sampling can be challenging to perform tional loop snare technique fails to engage the retrieval hook because and this presentation will improve the readers understanding of how to it is embedded in the caval wall. To perform the technique, a reverse perform this exam through case examples and discussion. curve catheter is used to pass a wire in the “hangman space” between the apex of the filter and the caval wall, inferior to the fibrous cap. The leading end of the wire is snared and pulled back through the sheath to Abstract No. 849 form a loop. A second loop is formed in a similar manner through the struts of the filter. This combination of loops allows the sheath to be Chronic venous insufficiency: clinical presentation, shuttled down onto the embedded hook. Application of traction to the imaging appearance, and current treatment options, “hangman” loop dissects the entrapped hook from the wall. The filter is including n-butyl cyanoacrylate ablation then collapsed using the sheath and the wire looped between the filter E Chow1, M Hendrix2 struts, and the filter is removed. The technique has been attempted in 1 2 five patients. Technical success in filter retrieval was 100%, and there VCU Health System, Richmond, VA, N/A, Richmond, VA were no associated complications. The median dwell time for the filters LEARNING OBJECTIVES: After reviewing this educational exhibit the was 427 days (range 28-2190). Median fluoroscopy time was 19.2 min audience will be able to: 1. Describe normal lower extremity venous (range 9.2-47.2). In three of five patients, a CT abdomen from within anatomy. 2. Recognize the clinical and ultrasound imaging appearance 94 | Educational e-Posters SIR 2019 Annual Scientific Meeting

of chronic venous insufficiency secondary to an incompetent great that failed to involute. This remnant is avalvulous in nature, therefore saphenous vein. 3. Understand the indications and contraindications causing severe venous reflux. Our vein practice has observed venous of great saphenous vein ablation. 4. Explore currently available treat- reflux in this lateral system leading to unique, debilitating symptoms ments, including conservative therapy, and thermal and radiofre- of nighttime cramping, charley horses and restless legs, primarily in quency ablation of the great saphenous vein. 5. Discuss the technique younger, middle-aged women. These symptoms are related to the of n-butyl cyanoacrylate (NBCA) adhesive ablation, with exploration unique pathophysiologic basis underlying the disease. of our institution’s experience and outcomes. 6. Discuss post-pro- CLINICAL FINDINGS/PROCEDURE DETAILS: Using retrospective data cedural care and follow-up for patients treated for lower extremity tracking, patients with dilated, refluxing lateral subdermic venous sys- venous insufficiency. tems on dedicated venous ultrasound were found to have the afore- BACKGROUND: Chronic venous insufficiency can be a debilitating mentioned nighttime symptoms. Of interest, these patients often lack disease leading to chronic lower extremity pain, skin pigmentation reflux in other truncal systems. Upon treatment with ultrasound-guided and ulceration. One of the principal causes of venous insufficiency is foam sclerotherapy (USGFS), patients experienced relief of their night- incompetence of the great saphenous vein. Interventional radiologists time symptoms within 24 to 48 hours. This case series demonstrates a are able to treat this condition with various minimally invasive tech- correlation of patients with lateral subdermal venous plexopathy who niques including: thermal and radiofrequency ablation, and recently had symptoms of restless leg, cramping and charley horse pain prior to NBCA adhesive ablation. receiving USGFS from 1/1/2015 through 12/31/2017.

CLINICAL FINDINGS/PROCEDURE DETAILS: This educational exhibit CONCLUSIONS: The avalvulous nature, coupled with the divergence in will discuss the pathophysiology, clinical presentation, and treatment mechanism of pathology, allows us to observe the lateral venous sys- options of lower extremity chronic venous insufficiency secondary to tem to become incompetent paradoxically at night while patients are incompetence of the great saphenous vein. Ultrasound techniques laying down. It is hypothesized that this pooling of superficial venous and imaging to indicate great saphenous vein incompetence will blood in the lateral calf and thigh manifests as irritation of the iliotib- be reviewed, in addition to a brief review of normal lower extremity ial band, ultimately causing restless legs and/or cramping and charley venous anatomy. Treatment options including thermal and radiofre- horses. Thus, we postulate the association between patients with lat- quency ablation will be discussed. Emphasis will be directed toward eral plexus reflux and debilitating nighttime symptoms. NBCA adhesive ablation, with exploration of our institution’s expe- rience with the procedure and addressing possible complications. Lastly, post-procedural care and patient follow-up recommendations Abstract No. 851 will be discussed. Parathyroid venous sampling for parathyroid adenoma CONCLUSIONS: Chronic venous insufficiency is a debilitating con- localization dition which interventional radiologists are uniquely able to treat. In P Hoang1, A Saini1, S Alzubaidi1, H Albadawi1, S Naidu1, this exhibit, we explore the clinical and imaging appearance of chronic M Knuttinen1, J Hu1, M Kuo1, R Oklu1 venous insufficiency and treatment options in the interventionalist’s 1 arsenal, with an emphasis on the new NBCA adhesive ablation, Mayo Clinic, Phoenix, AZ

LEARNING OBJECTIVES: 1. To review the etiologies, pathophysiology, Abstract No. 850 and clinical presentation of hyperparathyroidism. 2. To discuss the rational and technique of venous catheterization and sampling for pre- Lateral subdermic venous plexus reflux: a new paradigm operative localization of parathyroid adenomas. 3. To review the ana- of chronic venous insufficiency causing restless legs and/ tomic and technical considerations for selective parathyroid venous or nighttime cramping sampling; multiple case illustrations will be included. L Stevens1, R Pyne2 BACKGROUND: Hyperparathyroidism is a condition characterized by overactivity of the parathyroid glands. Surgical resection is the current 1University of Kansas School of Medicine, Kansas City, KS, single curative treatment for primary hyperparathyroidism. Selective 2Rochester General Hospital, Rochester, NY surgical resection is crucial to avoid the complication of hypoparathy- LEARNING OBJECTIVES: Characterize the prevalence and association roidism which would require lifelong medical supplementation. Non- of lateral subdermic venous plexus reflux in the development of night- invasive imaging modalities such as such as Technetium Sestamibi time symptoms of restless legs, cramping and charley horses. imaging with single photon emission computed tomography (SPECT) and 4D CT have a high success rate in localizing abnormal parathy- BACKGROUND: As the field of phlebology advances, venous insuffi- roid glands. The technique of selective parathyroid venous sampling ciency is more understood. However, the lateral subdermic venous (PVS) has been reported previously in the setting of treatment for system, a network of reticular veins at the lateral knee, remains poorly recurrent or persistent disease when noninvasive imaging is negative understood. Superficial venous reflux results from valvular incompe- or discordant. The interventional radiologist’s understanding of normal tence. In contrast, this lateral venous network has a variant physiology, and variant anatomy regarding the possible locations of parathyroid and thus a dissimilar pathophysiologic mechanism for disease. More- glands and their pattern of venous drainage is crucial to the success over, this lateral system is thought to be a persistent fetal remnant vein SIR 2019 Annual Scientific Meeting Educational e-Posters | 95

of invasive localization study. Selective thyroid venous catheterization technique for therapeutic endovascular portal vein interventions and and detection of a venous parathyroid hormone gradient allow for portal vein venography in non-coagulopathic patients for unfeasible localization of parathyroid adenoma. or failed trans-hepatic access. Although there is an increased risk of bleeding complications, the majority of these can be managed CLINICAL FINDINGS/PROCEDURE DETAILS: This educational exhibit conservatively. will explain the workup involved in patient with suspected primary hyperparathyroidism. This exhibit will review findings of parathyroid adenomas Sestimibi imaging and 4D CT for localization of adenomas. Abstract No. 853 Parathyroid venous sampling technique will be detailed. Selected cases of patients whose parathyroid adenomas have been successfully Superior vena cava syndrome resistant to previous localized at our institution will be reviewed and discussed. venoplasty treated with intravascular laser thrombectomy with intravascular ultrasound: case presentation and CONCLUSIONS: Although an uncommon procedure, it is important to literature review understand the technique and application of parathyroid venous sam- pling. The procedure is successful at localizing parathyroid adenomas R Petek1, D Petrov2, A Dunn3, A Shaikh2 pre-operatively, resulting in shorter operating room times and reduced 1Lake Erie College of Osteopathic Medicine, Erie, PA, 2Allegheny patient morbidity. General Hospital, Pittsburgh, PA, 3UPHS, Philadelphia, PA

LEARNING OBJECTIVES: 1) Review the causes and pathophysiology Abstract No. 852 of superior vena cava (SVC) syndrome 2) Discuss the clinical presen- tation and radiologic work up of SVC syndrome 3) Discuss the treat- Trans-splenic portal interventions: technique and ment options for SVC syndrome 4) Discuss the role of intravascular management of portal hypertension ultrasound (IVUS) and intravascular laser in treating recurrent SVC P Hoang1, A Saini1, M Knuttinen1, S Alzubaidi1, S Naidu1, syndrome H Albadawi1, R Oklu1 BACKGROUND: Superior vena cava (SVC) syndrome is a type IV tho- 1Mayo Clinic, Phoenix, AZ racic central venous obstruction that can result from chronic or acute disruption of flow through the SVC. SVC obstruction may be caused LEARNING OBJECTIVES: 1. To discuss rationale and technique of splenic by intrinsic or extrinsic limitations to normal laminar flow causing access for portal interventions. 2. To review the clinical indications symptomatic obstruction. Intrinsic mechanisms may include throm- and evaluate the risk factors for intraperitoneal bleeding during trans- bosis secondary to hypercoagulable state or due to the presence of splenic portal interventions. 3. Provide recommendations based on long-term indwelling intravascular devices. Extrinsic mechanisms of what we have learned with our trans-splenic access experience. Multi- obstruction may relate to extrinsic compression of the SVC by malig- ple case presentations will be included. nancies or other space occupying entities. As the pressure in the SVC BACKGROUND: Interventions involving the spleen are approached with rises, collateral drainage arises from other venous systems such as the caution due to the risks of hematoma and intraperitoneal bleeding. The azygous and internal mammary venous arcades. While collateraliza- percutaneous trans-hepatic approach has been the conventional way tion develops, high pressure in the SVC may cause facial and upper of portal venous access; however, this approach may not be success- extremity edema and erythema, dyspnea, and potentially cerebral ful if the patient has no patent or attenuated intrahepatic portal vein edema. branches. The trans-hepatic approach may also not be feasible due to CLINICAL FINDINGS/PROCEDURE DETAILS: Our exhibit includes images possible tumor seeding if malignancy is present. A percutaneous trans- that demonstrate: 1) Recurrent SVC stenosis and occlusion in a symp- splenic approach to portal vein access is a rare approach applied by cli- tomatic patient. 2) IVUS of thrombotic and stenotic SVC, and 3) review nicians. This technique is not suitable in patients with decompensated of laser thrombectomy for effective management of resistant stenosis cirrhosis and coagulation deficiencies due to increased risks of bleed- and thrombosis. Imaging modalities include CT, conventional venog- ing. However, in the subset of patients without coagulopathies, this raphy, digital subtraction angiography, and IVUS. 3) Demonstrate route of access can be useful in providing portal venous interventions severe SVC stenosis and occlusion in symptomatic patients. 4) Show when the trans-hepatic approach is not feasible or is unsuccessful. and delineate alternative venous pathways that develop in the set- CLINICAL FINDINGS/PROCEDURE DETAILS: This educational exhibit will ting of central venous occlusion. 5) Review venoplasty and stenting detail the trans-splenic access technique. Pictorial review of selected techniques for effective non-surgical treatment. Imaging modalities cases requiring the use of trans-splenic access for a variety of por- include CT venography, conventional venography, and digital subtrac- tal vein interventions will be included: portal vein embolization, portal tion angiography. vein recanalization, trans-splenic portal vein venography and emboli- CONCLUSIONS: Laser thrombectomy utilizing IVUS should be consid- zation of a varix, and TIPS. ered as an alternative therapy in the appropriate patient population CONCLUSIONS: Although an uncommon route of access, it is important with treatment resistant SVC syndrome. to understand the technique and possible applications of percutane- ous trans-splenic splenic vein access. This route is a safe and effective 96 | Educational e-Posters SIR 2019 Annual Scientific Meeting

Abstract No. 854 Abstract No. 855

Treatment options for IVC thrombosis in the setting of Use of intraprocedure echocardiography during nephrotic syndrome mechanical/aspiration thrombectomy for the endovascular treatment of acute pulmonary embolism A Rohana1, R Bou Said1, K Natarajan2, B Martinez2, V Flanders3, J Dowell3 and thrombus-in-transit 1 2 2 2 2 1Texas Tech University Health Science Center El Paso, El Paso, TX, J Buckley , K Cho , B Wible , N Saucier , J Borsa 2St. Vincent Health, Indianapolis, IN, 3St. Vincent Health; Northwest 1University of Missouri Kansas City, Kansas City, MO, 2Saint Luke’s Radiology, Indianapolis, IN Hospital Kansas City/ UMKC, Kansas City, MO

LEARNING OBJECTIVES: Discuss current indications for treatment as LEARNING OBJECTIVES: The purpose of this abstract is to demonstrate well as treatment options for IVC thrombosis in nephrotic syndrome: the use of transesophageal echocardiography (TEE) during the endo- Ultrasound-accelerated, catheter-directed thrombolysis (EKOS, vascular treatment of acute pulmonary embolism (PE) and throm- Bothell, WA;), Angiojet (Possis Medical, Minneapolis, MN), Aspiration bus-in-transit via mechanical/aspiration thrombectomy. Relevant thrombectomy using AngioVac (AngioDynamics, Albany, NY) and sur- basic TEE findings including cardiac anatomy, appearance of throm- gical thrombectomy. bus, and features of right heart dysfunction will also be reviewed.

BACKGROUND: Although venous thrombosis in the settings of nephrotic BACKGROUND: PE is a common and potentially life-threatening condi- syndrome is a rare entity; it carries high morbidity and mortality risk. tion which may be treated endovascularly via mechanical/aspiration Increased incidence of venous thrombosis in nephrotic syndrome is thrombectomy under certain clinical circumstances. Such procedures related to the increased urinary excretion of endogenous anticoag- require navigation through the right heart to successfully position ulant proteins and increased synthesis of prothrombotic factors. The catheters and/or mechanical devices within the pulmonary arteries. tools available to the interventionalist for IVC thrombosis have made Use of intraprocedure TEE may not only help guide navigation through these cases now potentially treatable by percutaneous methods. the right heart but may also be used to provide real-time evaluation of Understanding the treatment options and approach to patients with thrombus location/burden or assessment of changes in cardiac func- nephrotic syndrome-related IVC thrombosis as well as the indications tion during endovascular treatment of PE. and risks for treatment is paramount to guide a multi-disciplinary CLINICAL FINDINGS/PROCEDURE DETAILS: A 68-year-old male pre- team toward patient care. Given the grave risks associated with VTE sented with acute massive PE two days after major pelvic surgery. CTA in nephrotic syndrome, prompt diagnosis and treatment is warranted. demonstrated significant clot burden in the central pulmonary arteries Cases from our institution using various treatment techniques will also as well as a large thrombus-in-transit within the right atrium. Patient be presented. elected to proceed with treatment via mechanical large-bore aspira- CLINICAL FINDINGS/PROCEDURE DETAILS: Discuss the imaging charac- tion thrombectomy. Intraprocedure TEE showed thrombus within the teristics and findings of nephrotic syndrome-related IVC thrombosis. central pulmonary arteries as well as within the right atrium, extending Discuss indications and risks for medical, surgical as well as interven- through the tricuspid valve. Aspiration thrombectomy of central PE tional therapies for IVC thrombosis. Present and discuss available and the thrombus-in-transit was successfully performed under real- catheter-directed approaches to IVC thrombosis, including US-accel- time TEE guidance, which allowed for direct visualization of catheter erated thrombolysis, Angiojet thrombectomy, and AngioVac aspira- tip relative to thrombus and cardiac valve structures. Intraprocedure tion thrombectomy utilizing representative cases from our institution. improvements in right heart function were also observed by TEE. The Discuss patient follow-up including post procedural outpatient clinical patient was discharged home without complication two days later. care, medical management, and imaging follow-up after intervention Similar cases of aspiration thrombectomy with intraprocedure TEE as well as future directions. guidance have subsequently been performed at our institution.

CONCLUSIONS: Given the increased utilization of catheter-directed CONCLUSIONS: Intraprocedure echocardiography may be used during therapies for IVC thrombosis, an understanding of the therapeu- mechanical/aspiration thrombectomy for treatment of acute PE and tic options as well as risks and benefits for patients with nephrotic thrombus-in-transit in order to visualize cardiac structures, identify syndrome-related IVC thrombosis is important to determine those location of thrombus, and assess changes in cardiac function. that may best benefit from percutaneous intervention and guide the multi-disciplinary treatment team toward improved patient outcome.