Educational Exhibit Traditional Posters and E-Posters Chosen By

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Educational Exhibit Traditional Posters and e-Posters Chosen by the Annual Scientific Meeting Committee In advance of the upcoming annual meeting of the Society of Interventional Radiology in Seattle, the program committee wishes to highlight the scientific abstracts that will be presented. Abstracts were chosen using blinded review. Authors are congratulated for their contributions.

Baljendra Kapoor, MD, FSIR Chair, 2020 Annual Meeting Scientific Program

Traditional Posters

Abstract No. 734 by interventional radiology (IR) with PTA, stent placement across the celiac axis, SMA and IMA. Recurrent stenosis necessitated use of Diagnosis and endovascular techniques used in the a drug-eluting balloon in one patient. We present 3 cases of brachial treatment of chronic mesenteric ischemia artery access, 1 of radial artery access, 3 with CFA access and 1 cases of S Raza1, E Gandras2, J Weinstein2, C Greben2, M Farooq2 AVG access. These cases highlight the different angiographic appearances of CMI, technical challenges and mesenteric vessel imaging 1Northwell Health, North Shore University Hospital, Manhasset, characteristics favoring upper versus lower extremity arterial access. NY, 2North Shore University Hospital-Manhasset, Manhasset, NY

CONCLUSION AND/OR TEACHING POINTS: CMI is an important clinical LEARNING OBJECTIVES: 1. Pictorial, case-based discussion of chronic entity with IR playing a critical role in patient management and treat- mesenteric ischemia (CMI) including a review of the clinical presen- ment. Understanding the imaging findings, complications and tech- tation, criteria for intervention and key imaging findings. 2. Discuss nical aspects of treating CMI will help guide effective treatment and revascularization techniques and devices including stents, percuta- clinical success. neous angioplasty (PTA), drug-eluting balloons and how to measure and analyze endoluminal pressures. 3. Anatomical and patient considerations when determining if upper versus lower extremity arte- Abstract No. 735 rial access is appropriate. Arterial access sites reviewed include radial artery, brachial artery, common femoral artery and upper extremity “Putting the best foot forward”: utilization of dorsalis arteriovenous graft. pedis artery access for geniculate artery embolization

1 2 3 4 BACKGROUND: CMI most commonly results from occlusive atheroscle- J Meshekow , O Furusato Hunt , P Gerard , S McCabe , S rotic disease involving the proximal ostia of at least two of the three Maddineni5, G Rozenblit6 major mesenteric arteries: celiac axis, superior mesenteric artery 1Westchester Medical Center / New York Medical College, Beacon, (SMA), and inferior mesenteric artery (IMA). Other less common NY, 2Westchester Medical Center, Hartsdale, NY, 3New York Medical causes of CMI include compression by tumor, dissection and fibro- College- Westchester Medical Center, Valhalla, NY, 4Westchester muscular dysplasia. Typical clinical symptoms include postprandial Medical Center, Katonah, NY, 5Westchester Medical Center, abdominal pain, weight loss and aversion to food. Diagnosis can be Chappaqua, NY, 6Westchester Medical Center, Eastchester, NY made by CT angiography, conventional angiography, MRA or duplex LEARNING OBJECTIVES: 1. Provide a current overview of the therapeu- ultrasound. Endovascular treatment consists of revascularization with tic role of geniculate artery embolization in the treatment of osteo- angioplasty and stent placement with literature supporting high long- arthritic knee pain. 2. Demonstrate the utility of dorsalis pedis artery term patency rates and low morbidity. access for unfavorable geniculate artery anatomy encountered with CLINICAL FINDINGS/PROCEDURE DETAILS: We present 8 selected antegrade femoral artery access. cases of CMI secondary to multivessel atherosclerotic disease treated

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, 2020. *An underline under an author’s name designates the abstract presenter. ©SIR, 2020

SIR 2020 Annual Scientific Meeting | 1 2 | Traditional Posters SIR 2020 Annual Scientific Meeting

BACKGROUND: Osteoarthritis is the most prevalent degenerative perspective, the procedure is not as widely performed as one would joint disease and causes chronic disability in older adults. The patho- imagine. Understanding urologic work up including questionnaires, physiology is thought to consist of chronic inflammatory synovitis urodynamic flow studies and PVRs can help an interventional radiolo- with associated upregulation of angiogenesis promoting cytokines, gist distinguish good candidates from bad. To evaluate for candidacy, which ultimately leads to cartilage and bone destruction. Additionally, an interventional radiologist must thoroughly understand lower uri- recruitment of unmyelinated sensory nerves in these areas may con- nary tract symptoms (LUTS) in the setting of BPH/O as these guide tribute to regional pain. It has been postulated that embolization of management from conservative treatment to surgery. Maintaining a these abnormal neovessels disrupts inflammatory and pain-mediating relationship with the urologists remains important; however, an inter- pathways, thereby relieving symptoms. Geniculate artery embolization ventional radiologist who is capable of producing and interpreting has been demonstrated to be an effective treatment for mild to moder- urologic tests allows greater opportunity to find appropriate candi- ate osteoarthritis refractory to conservative treatment. Improvement dates. This exhibit highlights the urologic workup required to evaluate in knee pain and function has been shown up to 4 years after treatment patients appropriately as well as elucidates the ease of interpreting without significant complications. Traditionally, access for geniculate studies to find suitable candidates for PAE. artery embolization is achieved in antegrade fashion by means of the CONCLUSION AND/OR TEACHING POINTS: 1. Lower urinary tract symp- ipsilateral or contralateral femoral artery. However, normal variations toms (LUTS) can occur in the setting of BPH/O and guide manage- in geniculate artery anatomy (hairpin orientation of geniculate artery ment. 2. Worsened LUTS after conservative management gives rise to branches arising from the popliteal) may prohibit cannulation of the the need for further work up. 3. Further work up includes the Interna- target vessel from above. We present such a case as well as our experi- tional Prostate Symptom Score (IPSS), International Index of Erectile ence in providing successful treatment by means of retrograde access Function (IIEF) Questionnaire and Sexual Health Inventory For Men via the dorsalis pedis artery. (SHIM). 4. Pending on the IPSS Score, patient may or may not be a can- CLINICAL FINDINGS/PROCEDURE DETAILS: A. General Overview of didate for PAE. 5. Other urologic testing includes Urinalysis, PSA level, Traditional Geniculate Artery Embolization Techniques B. Overview postvoid residual test (PVR), DRE and Urodynamic testing (Qmax). 6. of Transpedal Access: i. Patient Selection. ii. Preprocedure workup iii. Understanding/interpreting the urologic work up gives an interven- Equipment and Devices iv. Access and Technique v. Pre- and Postpro- tional radiologist appropriate tools to evaluate for PAE. cedural “Dorsalis Pedis Cocktail” vi. Arterial Closure vii. Postprocedural care and follow-up. Abstract No. 737 CONCLUSION AND/OR TEACHING POINTS: For geniculate artery embolization, retrograde accesses via the dorsalis pedis artery is an effec- Hemorrhoidal artery embolization: a new frontier in tive salvage technique for patients with unfavorable geniculate artery hemorrhoid disease management anatomy. T Garg1, L Cusumano2, L Stevens3, M Naveed4 1Seth GS Medical College & KEM Hospital, Mumbai, Abstract No. 736 Maharashtra, 2UCLA Medical Center, Los Angeles, CA, 3The University of Texas at Austin Dell Medical School, Austin, An overview of interpreting urologic testing for prostate TX, 4Einstein Medical Center, Philadelphia, PA artery embolization candidacy LEARNING OBJECTIVES: 1. To learn about the clinical features, diag- 1 1 1 1 1 S Patel , M Swikehardt , H Brent , D Cohen-Addad , S Fahrtash , I nostic evaluation and treatment modalities available for hemorrhoids. 1 1 Provancha , W Kwon 2. To review the arterial anatomy of the superior rectal artery and its 1SUNY Downstate Medical Center, Brooklyn, NY anatomical variants 3. To learn about the procedure of hemorrhoidal artery embolization. LEARNING OBJECTIVES: 1. Overview of urologic testing in the setting of BPH/O. 2. Interpreting urologic testing. 3. Implications of urologic BACKGROUND: Hemorrhoidal disease affects 5% to 40% of people testing for PAE candidacy. 4. Pearls and pitfalls for Prostate artery around the world and is the most common anorectal disease. The embolization (PAE) candidacy. pathophysiology underlying development of hemorrhoids is poorly understood. However, it is hypothesized that hemorrhoids result from BACKGROUND: Understanding urologic work up in an interventional the breakdown of anal cushions; specialized vessel-rich submucosal radiologist’s perspective is imperative to appropriately evaluate can- tissue of the anus which assist in maintaining continence of fecal mate- didates for prostate artery embolization. Without the appropriate rial. Treatment of hemorrhoidal disease is performed by various meth- knowledge, interventional radiologists will risk having technical dif- ods: conservative treatment, nonsurgical, minimally invasive therapies, ficulty and complications during the procedure as well as potentially and surgical treatment. More recently, the “emborrhoid technique” has miss opportunities to treat patients who are appropriate candidates. been developed as a minimally invasive method to treat hemorrhoidal

CLINICAL FINDINGS/PROCEDURE DETAILS: PAE has been in the fore- disease with the embolization of the terminal branches of the superior front of recent interventional radiology (IR) advancements for the rectal artery via coil occlusion. past decade. However, because of limited knowledge of the procedure from an IR perspective and negative connotation from an urologists SIR 2020 Annual Scientific Meeting Traditional Posters | 3

CLINICAL FINDINGS/PROCEDURE DETAILS: Patients presenting with were originating from the petrosal branch of the MMA. 4: Superficial hemorrhoids undergo a proctologic examination and the severity of temporal artery and the MMA had a common trunk, instead of the symptoms is assessed using the French bleeding score for bleeding MMA originating from the internal maxillary artery. intensity, Goligher prolapse score for the degree of internal hemor- CONCLUSION AND/OR TEACHING POINTS: The MMA originates from the rhoid prolapse and visual analog scale (VAS) for pain and quality of IMA and the first intracranial branch is a posterior branch, called the life. Preprocedural imaging with CT angiography is used for vascular petrous branch. Embolization of the MMA is performed distal to the mapping and identification of potential contraindications to emboliza- origin of this branch because it supplies the facial and greater super- tion. The procedure is performed under local anesthesia via a femoral ficial petrosal nerves. Another feared complication with the petrous artery approach. The inferior mesenteric artery is cannulated with a branch is communication with the internal carotid artery (ICA). It is 4-Fr catheter and then a digital subtraction angiography followed by a important to be able recognize variant anatomy of the MMA and when cone-beam CT is done to identify all the superior rectal artery branches embolization of the MMA is unsafe. The most feared complications are supply of the corpus cavernous recti. The individual branches are then communication with the eye or the ICA. Thus, any anteriorly oriented catheterized and embolized using 2- to 3-mm diameter microcoils. branches toward the orbit must be scrutinized heavily and emboliza- CONCLUSION AND/OR TEACHING POINTS: The “emborrhoid technique” tion past the origin of the petrosal branch is recommended. is well-tolerated, can be performed in the outpatient setting and does not involve direct trauma to the treated region. It can potentially be used as a first-line treatment for younger active patients who would Abstract No. 739 prefer a minimally invasive method rather than direct anorectal Role of interventional radiology in the multidisciplinary manipulation. algorithmic management of acquired uterine enhanced myometrial vascularity Abstract No. 738 N Shah1, J Lappen1, M Al-Natour1, J Davidson1, R Paspulati1, K Herrmann1, S Tavri1 Middle meningeal artery anatomical variants and their 1 impact on embolization for chronic subdural hematomas University Hospitals Cleveland Medical Center, Cleveland, OH A Desai1, P Brady2, B McCabe3, M Ferra2, B Natarajan4, P Kim5, D LEARNING OBJECTIVES: 1. Discuss the etiology, pathophysiology, and Nguyen6 clinical presentation of acquired uterine enhanced myometrial vascularity (EMV). 2. Describe the role of Doppler ultrasound (US), dynamic 1Einstein Health Care Network, Philadelphia, PA, 2Albert Einstein magnetic resonance angiography (MRA) and catheter angiography Medical Center, Philadelphia, PA, 3Einstein Medical Center, Philadelphia, PA, 4N/A, Villanova, PA, 5Einstein Medical Center in the management of acquired uterine EMV. 3. Propose a multidisci- Philadelphia, Philadelphia, PA, 6Albert Einstein Medical Center– plinary algorithm for the management of acquired uterine EMV.

Philadelphia, Philadelphia, PA BACKGROUND: Delayed postpartum bleeding due to acquired uterine EMV is uncommon but possibly underreported and unrecognized. LEARNING OBJECTIVES: 1. Recognize anatomical variants of the middle The clinical presentation of acquired uterine EMV varies from insidi- meningeal artery (MMA) 2. Identify variant arterial anastomosis and ous bleeding to catastrophic hemorrhage. Arteriovenous malforma- supply of the MMA 3. Recognize when anatomical variants preclude tion/fistula (AVM/AVF), retained products of conception (RPOC), and embolization of the MMA. placental invasion abnormalities collectively form the differential for BACKGROUND: Chronic subdural hematoma (cSDH) is a disease of the acquired uterine EMV. Differentiating between these etiologies can elderly due to generalized cerebral atrophy and increased venous fra- be difficult. With the utilization of dynamic MRA, distinctions can be gility. The formation and growth of cSDH starts with separation of the made between these pathologies. Thus, the utilization of an algorith- dural border cell layer. Repeated bleeding of this outer membrane of mic approach is necessary to evaluate acquired uterine EMV. dura mater is a major cause of the evolution of cSDH. Embolization of CLINICAL FINDINGS/PROCEDURE DETAILS: Through a multicenter case the MMA is performed to inhibit blood reflux into pathologic structures review, this educational exhibit will outline an algorithmic approach receiving blood through the meningeal arteries, controlling bleeding to distinguishing between AVM, AVF, RPOC, and placental implanta- from the cSDH and enhancing spontaneous resorption of the hema- tion abnormalities. The utility of Doppler US in the diagnosis of EMV toma. As this procedure becomes increasingly adopted, it is important will be reviewed. We will present techniques of performing magnetic for interventional radiologists to be aware of the anatomical variants of resonance imaging (MRI) with dynamic time resolved angiography, the MMA and when embolization is unsafe. how to interpret the study, and its indications. With the review of mul- CLINICAL FINDINGS/PROCEDURE DETAILS: Cases: 1: An anteriorly tiple patient cases of uterine EMV, Doppler US, MRI/MRA, and cath- directed branch was identified and determined to be supplying a por- eter angiography findings will be correlated. Finally, we will present tion of the retina. Embolization was abandoned after this branch could treatment options (conservative therapy, uterine artery embolization, not be safely crossed. 2: Anatomical variant in which the MMA was and surgical options) to consider in a multidisciplinary management originating distally from the sphenopalatine artery 3: Anatomical vari- algorithm. ant of the MMA in which posterior branches supplying the meninges 4 | Traditional Posters SIR 2020 Annual Scientific Meeting

CONCLUSION AND/OR TEACHING POINTS: Interventional radiologists Abstract No. 741 must play a key role in the multidisciplinary management of delayed Basket thrombectomy: a novel use of distal protection postpartum bleeding. Utilization of dynamic MRA can overcome the wires in arterial thromboembolism limitations of Doppler US to potentially minimize overuse of catheter angiography and uterine artery embolization to ultimately provide T Sheu1, S Park2, J Swischuk1 definitive treatment. 1OSF Saint Francis Medical Center, Peoria, IL, 2University of Illinois College of Medicine, Peoria, IL

Abstract No. 740 LEARNING OBJECTIVES: 1. Present a novel technique: basket thrombectomy for arterial thromboembolic disease using distal protection wires. The role of minor nontraumatic lower extremity 2. Describe the technical aspects of the technique. 3. Present case- amputation in critical limb ischemia and diabetes based clinical applications. 4. Outline the advantages and limitations mellitus: when is the right time? of the procedure. 5. Review the available literature on this technique. D Braga1, J Marion1, O Adenikinju1, R Beasley1, A Zybulewski1, B BACKGROUND: Arterial thromboembolism is a common manifestation Olivieri1 of atherosclerotic disease that can lead to ischemic injury. In some 1Mount Sinai Medical Center, Miami, FL instances, thrombus that is resistant to more traditional methods of removal may be encountered that can lead to prolonged or unsuccess- LEARNING OBJECTIVES: 1. Review the epidemiology of nontraumatic ful endovascular treatments. Basket distal protection wires (DPWs) lower extremity amputation (NLEA) 2. Define minor NLEA and its role may serve as an alternative method of mechanical thrombectomy. Ini- in the management of critical limb ischemia (CLI) 3. Illustrate the types tially designed to trap distal emboli during endovascular procedures, of NLEA 4. Explore relevant tibial and pedal revascularization targets DPWs’ can be an alternate method of retrieving thrombi within ste- necessary to achieve optimal results from each type of NLEA 5. Pro- notic and occluded vessels when other methods such as catheter-divide an evidence-based NLEA decision-making algorithm essential for rected thrombolysis, atherectomy, rheolytic catheters, and suction interventional radiologists treating CLI patients from the perspective thrombectomy are unsuccessful or undesirable. of podiatric limb salvage specialists. CLINICAL FINDINGS/PROCEDURE DETAILS: We present five cases of BACKGROUND: Despite recent advances in endovascular therapy and an patients with acute ischemia of various vascular beds who underwent overall decline in the number of total performed NLEA, NLEA remains DPW basket thrombectomy after failing other conventional methods. an essential definitive reconstructive treatment option in CLI patients. In each case, a long guiding catheter with a removable side-arm valve A complex decision-making process is undertaken to determine the attached was used serving as a long sheath. The DPW was deployed most appropriate NLEA for each patient. Interventional radiology distal to the lesion and then pulled back carefully. After contrast confir- education about this area of CLI therapy is essential to providing the mation of the thrombus within the device, the DPW was retracted into best comprehensive care for our patients. In addition, knowledge of the guiding catheter and removed. Prior to complete withdrawal of the surgical approaches to the various types of NLEA and the complex DPW from the guiding catheter, the side-arm sheath was removed to interplay between revascularization and minor NLEA facilitates partic- facilitate removal of bulky thrombus. This technique was repeated until ipation in the multidisciplinary care these patients need. distal reperfusion and reduction in thrombus burden were adequately CLINICAL FINDINGS/PROCEDURE DETAILS: We will provide a pictorial achieved. Patients tolerated the procedure well without complica- primer on the types of NLEA and their surgical approaches. We will tions. Basket thrombectomy can be particularly beneficial when small illustrate the relevant vascular anatomy needed for surgical healing amounts of flow-limiting thrombus are present that have proven to be after minor NLEA via diagrams and case examples. We will provide resistant to other methods of mechanical removal. an algorithm to guide the endovascular physician on correct patient CONCLUSION AND/OR TEACHING POINTS: Basket thrombectomy, a selection for revascularization versus NLEA. Last, we will familiarize modified application of DPWs, demonstrates potential as an effective the reader with adjunctive tools now in use by the podiatric or vascular intervention for arterial thromboembolism. surgeon in the decision-making process to perform NLEA.

CONCLUSION AND/OR TEACHING POINTS: Knowledge of the types of NLEA is essential for the management of patients with CLI to not only Abstract No. 742 increase postprocedural limb salvage outcomes, but also to enhance Renal artery thrombosis: an overview of diagnosis and inter-specialty interaction in the multidisciplinary care needed for interventional management these patients. A thorough understanding of the key technical and clinical factors that play into the NLEA decision-making process allows L Betz1, N Kolicaj1, S Sturza1, J Fallucca1, S Schwartz1, T Getzen1 the endovascular physician to tailor their endovascular approach to 1Henry Ford Hospital, Detroit, MI promote NLEA healing success. LEARNING OBJECTIVES: After reviewing this educational exhibit, radiologists and trainees will have current knowledge about the following aspects of renal artery thrombosis: (1) etiology and clinical SIR 2020 Annual Scientific Meeting Traditional Posters | 5

presentation, (2) literature review of treatment options, and (3) Illus- intervention, an IR physician’s background and skill set can be extrap- trative cases of catheter-directed renal artery thrombolysis from our olated to stoke intervention. institution. CLINICAL FINDINGS/PROCEDURE DETAILS: The initial offerings for throm- BACKGROUND: Acute renal artery occlusion is a rare condition that can bectomy were the Merci clot retrieval system, a corkscrew-like device lead to devastating outcomes without prompt diagnosis and inter- that mechanically removes clot from vessels and the original Penumbra vention. The prevalence of renal artery thrombosis is estimated at aspiration system, a multicomponent device using a suction catheter 0.02/1000 of Emergency Department admissions. The most import- to aspirate and extract thrombus. The next generation of endovascular ant risk factor is atrial fibrillation although many patients have no devices focused on stent retriever systems; retrievable stent-like devices identifiable cause of embolic disease. Delays in diagnosis can result deployed across the thrombus that both retrieve clot and also promote in irreversible loss of renal function. The goals of treatment are to pre- restoration of blood flow by providing radial force to open occluded ves- serve renal function and prevent hypertension. These include systemic sels. The three currently FDA approved stent retriever devices are the anticoagulation, surgical embolectomy, catheter-directed thromboly- Stryker Trevo, Covidien Solitaire and Cerenovus Embotrap II systems. sis, and intraarterial pharmomechanical thrombectomy. Penumbra recently released its newest version of a stent retriever, the 3D Revascularization Device, which ensnares the clot in a self-expand- CLINICAL FINDINGS/PROCEDURE DETAILS: We summarize the clini- able stent allowing for easier suction and removal of the clot. cal manifestations of renal artery thrombosis and present a series of patients treated with catheter-directed thrombolysis from our insti- CONCLUSION AND/OR TEACHING POINTS: Although large academic tution. Renal artery thrombosis often presents with vague symptoms hospitals have dedicated neurointerventionalists, smaller community that can delay diagnosis. Patients may have acute or constant abdom- hospitals do not always have that luxury, and general interventional inal or flank pain, fever, nausea, and/or vomiting. Lactate dehydroge- radiologists are being called upon to perform more endovascular pro- nase (LDH) can be elevated, which is sensitive although not specific cedures for acute ischemic stroke management. Our poster will review for renal infarction. Contrast-enhanced CT can provide a roadmap of and explore the mechanisms and specific usages for the currently renal arterial anatomy, extent of thrombosis, and the presence of renal available devices. infarction. No formal treatment recommendations have been defined to date. Anticoagulation with or without thrombolysis is the prevailing standard. Although prompt treatment is desirable, thrombolysis has Abstract No. 744 been shown to improve renal function even after prolonged occlusion. Are we there yet? Routes to drug delivery in CONCLUSION AND/OR TEACHING POINTS: Early diagnosis of renal artery interventional radiology thrombosis is critical to prevent irreversible loss of renal function. Anti- A Kilgore1, L Jamal1, T Parnall1, I Altun1, K Zurcher1, S Naidu1, G coagulation with or without catheter-directed thrombolysis are con- Knuttinen1, I Patel1, J Kriegshauser1, S Alzubaidi1, H Albadawi1, R sidered standard treatment and may improve renal function even after Oklu1 prolonged occlusion. 1Mayo Clinic Arizona, Phoenix, AZ

Abstract No. 743 LEARNING OBJECTIVES: (1) To recognize clinical applications of current drug delivery technology, (2) understand the current landscape Stroke intervention for the general interventional of endovascular drug delivery within interventional radiology, (3) radiologist: a pictorial review of the current devices determine the most appropriate treatment options based on current guidelines D Portal1, D Eisman1, A Ramjit1, B Lei1, A Mahmud1, J Scheiner1 BACKGROUND: The rising rate of peripheral artery disease in USA (8 1Staten Island University Hospital Northwell Health, Staten Island, million people annually) commands attention; critical limb claudication NY represents high morbidity. Although we have become more adept at

LEARNING OBJECTIVES: We present a pictorial and technical review revascularization of the lesion, preventing restenosis has proven diffi- highlighting commonly used devices for endovascular treatment of cult. If we are able to deliver target drugs endovascular route to prevent acute ischemic strokes. Specific attention is given to what the general the inflammatory cycle leading to restenosis, our patient outcomes will interventional radiologist needs to know in the community hospital improve and along with the value of care provided. Currently, several setting. technologies exist to prevent restenosis, such as brachytherapy, rotational atherectomy, covered stents, drug-eluting stents (DES) and BACKGROUND: As the window for endovascular intervention expands, drug-covered balloons (DCB). DES and DCB are preferred when tri- with some trials demonstrating that intervention is beneficial up to 24 aled versus alternate modalities. The main drugs currently are pacli- hours from last known normal, the number of interventional radiology taxel and -limus drugs. As of August 2019, the FDA has issued updated (IR) consults for intracranial thrombectomy continues to increase. guidelines on paclitaxel stents usage. Developing newer stent materi- Although in large academic centers there are dedicated neurointer- als, using polymers, iron, and magnesium alloys have been considered ventionalists, in many community hospitals general interventional as alternative dissolvable stent materials. Also, the efficacy of these radiologists are relied upon for endovascular management of acute drugs has been optimized through excipients and polymers. strokes. Although traditionally there may be limited exposure to stroke 6 | Traditional Posters SIR 2020 Annual Scientific Meeting

CLINICAL FINDINGS/PROCEDURE DETAILS: The mechanism of action Abstract No. 746 of several drug delivery technologies, as well as diagrams explaining each technique, will be detailed on the poster. Ongoing trials regard- Creation of a biomedical engineering education ing the novel therapies for restenosis treatment and prevention will curriculum: the innovation track be highlighted. We will conclude by addressing the role interventional A Dabrowiecki1, K Cowdrick2, J Ackerman1, J Rains2, J Stubbs2, J radiologists have in the treatment and comparing it to more invasive Newsome1, Z Bercu1 surgical measures. 1Emory University School of Medicine, Atlanta, GA, 2Wallace H. CONCLUSION AND/OR TEACHING POINTS: Drug delivery to targeted Coulter Department of Biomedical Engineering, Atlanta, GA locations with consistent results are in need and being investigated. LEARNING OBJECTIVES: • Describe how our institution developed a The drug needs to be long-lasting and provide a slow sustained release, device design curriculum for interventional radiology (IR) residents. balancing focal impacts versus systemic side effects. Future studies • Provide guidance for other programs to create a similar initiative. will continue to focus on the basic sciences necessary to develop drugs • Provide insight into how the biomedical engineering community that will fulfill these aims. approaches innovation in IR.

BACKGROUND: Innovation is an extremely hot topic in the IR commu- Abstract No. 745 nity, and over the past 2 years, we created a curriculum to better facilitate our residents’ education in this dynamic and evolving specialty. Percutaneous arteriovenous fistula creation: clinical Combined with other educational efforts, this culminated in the cre- considerations and preparing for your first case ation of a formal 12- to 24-month track sanctioned by the Graduate A Lionberg1, J Jeffries1, J Fergus1, L Dalag1, O Ahmed1, R Navuluri1 Medical Education office to incorporate not only IR, but all residency 1University of Chicago Medicine, Chicago, IL specialties to enhance their biomedical innovation education and endeavors. LEARNING OBJECTIVES: 1. Understand the staff and technologist training necessary prior to performing percutaneous arteriovenous fistula CLINICAL FINDINGS/PROCEDURE DETAILS: Herein, we present a detailed (pAVF) creation. 2. Review the anatomic criteria for candidacy in the description of the steps we took creating this track in conjunction with two pAVF systems currently approved for use in the US. 3. Learn the our biomedical engineering colleagues from a local, nationally ranked requisite knowledge and relevant discussion points in preparation for biomedical engineering (BME) department. The curriculum comprises seeing pAVF consults. 4. Recognize the interventional radiology (IR) both free and low-cost resources to support the device design educa- follow-up responsibilities after successful pAVF creation. tion of the participants. Most importantly, there is active engagement with BME undergraduate and graduate students enriching the experi- BACKGROUND: With increasing utilization, there is growing evidence ence of residents by providing insight into the process, vernacular, and that minimally invasive percutaneous arteriovenous fistula creation problem-solving approaches employed by engineering innovators. may represent the most significant innovation in hemodialysis access One of the most practical and beloved components occurs when the since the Brescia-Cimino fistula was first introduced over 50 years ago. residents are the clinical sponsors of a capstone design project with Cited benefits of pAVF include increased anatomic sites for creation, the BME students to address an unmet clinical need observed in their reduced disfigurement, fewer interventions required and lower failure own practice. Together, engineers and residents ideate, design, and rates compared to surgically created fistulas. prototype an actual medical device in a single semester, providing a

CLINICAL FINDINGS/PROCEDURE DETAILS: This educational exhibit strong foundation for residents to generate intellectual property and describes the preparation and logistical hurdles that warrant consid- continue further product development. Ultimately, our goal is to form eration prior to offering pAVF creation to patients. The merits of pAVF a new generation of physicians well trained in all aspects of the device as a first line treatment are explained such that the learner will be able design process in order to improve the translation of IR device innova- to communicate effectively with potential referring nephrologists. tions to the bedside. Required staff training is discussed, including dialysis center technolo- CONCLUSION AND/OR TEACHING POINTS: Creating a biomedical gists and vascular sonographers, as this requires a coordinated effort “innovation” curriculum in collaboration with local BME colleagues is between interventional radiologists, nephrologists, and the device feasible, mutually beneficial, and fosters deeper collaboration with vendor. Many potential pAVF candidates will be concurrently evalu- physicians, particularly interventional radiologists. ated for traditional surgical fistula creation, so it is also important to learn how to effectively counsel the patient on the benefits, risks and alternatives to pAVF so that he or she may make an informed decision. Finally, patient follow-up should be arranged to ensure adequate maturation of the newly created fistula before hemodialysis is initiated.

CONCLUSION AND/OR TEACHING POINTS: The emergence of percutaneous arteriovenous fistula creation represents an innovation that is true to the legacy of IR. Recognition of the clinical care and advanced preparation needed for the procedure is vital to its success. SIR 2020 Annual Scientific Meeting Traditional Posters | 7

Abstract No. 747 Abstract No. 748

Resident education outside of the interventional Ultrasound guided Angio-Seal deployment for antegrade radiology suite: experiences with a comprehensive puncture curriculum in an academic interventional radiology H Jaffer1, S Mafeld2, T Chan3 residency 1University of Toronto, Toronto, ON, 2JDMI, Toronto General 1 2 2 2 2 D DePietro , S Trerotola , S Reddy , J Redmond , S Shamimi-Noori Hospital, Toronto, ON, 3N/A, Liverpool, United Kingdom 1Hospital of the University of Pennsylvania, Philadelphia, LEARNING OBJECTIVES: To discuss complications of antegrade Angio- PA, 2Perelman School of Medicine at the University of Pennsylvania, Seal deployment. To identify clinical and anatomic scenarios in which Philadelphia, PA ultrasound-guided deployment would be advantageous. To demon- LEARNING OBJECTIVES: To present our institutional experience with strate our institutional technique of Angio-Seal deployment under a comprehensive curriculum including didactic lectures, case-based ultrasound-guidance for antegrade puncture hemostasis. conferences, peer-led education, and protected morning rounds that BACKGROUND: Angio-Seal (Terumo Medical Corporation, Somerset, is an integral part of daily interventional radiology (IR) resident edu- NJ) deployment in antegrade access of the common femoral artery is cation. Potential benefits, implementation strategies, and lessons currently an off-label use of the device and has been associated with a learned will be discussed. complication rate of up to 9%. Complications include bleeding, hema- BACKGROUND: The implementation of the IR residency, and its goal toma, pseudoaneurysm, occlusion of the femoral artery and pain. of producing well-rounded and clinically oriented physicians, neces- Antegrade deployment entails risk of technical failure from intravascu- sitates a multifaceted approach to resident education. While technical lar plug deployment, or snaring of the anchor in the profunda femoris skills are largely taught within the IR suite, an expanded daily curricu- artery or calcified plaque. Ultrasound-guided Angio-Seal deployment lum, including protected time for resident education, creates a culture offers direct visualization of the sheath and intraluminal deployment of learning that allows for the effective training of successful future of the bioabsorbable co-polymer anchor to allow for precise and safe interventional radiologists. This exhibit will demonstrate a number of deployment, minimizing the aforementioned complications. In this experiences that have been integrated into an academic institutions educational poster, we present clinical and anatomic situations in daily workflow to provide such an environment and create a well- which ultrasound-guided deployment would be advantageous, and a rounded residency education. detailed account of our institutional technique for this procedure.

CLINICAL FINDINGS/PROCEDURE DETAILS: The following will be CLINICAL FINDINGS/PROCEDURE DETAILS: Clinical scenarios for ultra- reviewed in the form of a sample schedule, highlighting: 1) regularly sound-guided deployment: 1. Low common femoral artery puncture, occurring pre-rounds education, including a) bi-weekly case-based to avoid entrapment of the co-polymer anchor on the superficial fem- “chief” rounds, b) weekly didactic lecture, c) weekly multidisciplinary oral artery or profunda femoral artery. 2. Superficial femoral artery conferences. 2) Monthly occurring pre-rounds experiences, including puncture in obese patients 3. In heavily calcified vessels, to avoid resident-run morbidity and mortality conference, coding conference, snaring of the co-polymer anchor within posterior wall plaque. 4. In research meetings, and QA/QI conference. 3) Resident-led daily film patients who develop pseudoaneurysms during the intervention, to rounds, in which imaging from each case performed the day prior is avoid extraluminal deployment. 5. To ensure intraluminal deployment reviewed by the operating resident to highlight diagnostic findings, after primary failure of hemostasis. procedural techniques, and lessons learned. 4) Resident-led daily CONCLUSION AND/OR TEACHING POINTS: Ultrasound-guided Angio- board rounds, in which overnight consults are staffed and scheduled Seal deployment for antegrade common femoral or superficial femo- cases are presented, with presentations including medical history, pro- ral artery arteriotomy can be simply executed and provides significant cedural indications, prior imaging/procedures, and procedural plan. At advantages in ensuring proper deployment and minimizing complica- least one attending interventional radiologist is present for film and tions as described. board rounds to contribute to the educational discussion.

CONCLUSION AND/OR TEACHING POINTS: After reviewing this exhibit, the attendee will be familiar with numerous ways in which resident Abstract No. 749 education can be pursued outside the IR suite and ways in which Society of Interventional Radiology 2019 Periprocedural different educational strategies, including didactic, case-based, and Anticoagulation Guidelines: implementation of a web- peer-led education, can be used to build such a curriculum. based interactive clinical decision-making algorithm to efficiently optimize patient management J Youm1, S Hugdal1, R Burky1, H Morrison1, A Penn1, J Sung1, M Patel1 1Santa Clara Valley Medical Center, San Jose, CA

LEARNING OBJECTIVES: 1) To better understand the updated Soci- ety of Interventional Radiology (SIR) Consensus Guidelines for 8 | Traditional Posters SIR 2020 Annual Scientific Meeting

periprocedural anticoagulation and 2) to learn how to use a web-based CLINICAL FINDINGS/PROCEDURE DETAILS: In all the pictorial presenta- interface for generating patient-specific periprocedural anticoagula- tions of these procedures, the factor of time included in the imaging tion recommendations and the ability to perform both CT and fluoroscopy decreased procedural time and increased success rate. The 4D CT scanner brings bet- BACKGROUND: The SIR recently updated Consensus Guidelines for the ter quality imaging compared to DynaCT which is widely accepted for Periprocedural Management of Thrombotic and Bleeding Risk in Patients use during angiograms. Cross sectional imaging also adds the value of Undergoing Percutaneous Image-Guided Interventions. Prior recommen- three-dimensional visualization of the vital structures during TIPS and dations were relatively straightforward and primarily based on the risk of adrenal vein sampling. Additionally, three-dimensional road mapping bleeding by procedure. Updated guidelines are more patient-specific, as can be used during procedures that require complex access such as the recommendations now also depend on the patient’s thrombotic and TIPS. Finally, 4D Angio-CT allows the operator to perform dynamic CT bleeding risks, procedural bleeding risk, and the pharmacologic charac- during angiography for better evaluation of vascularity of tumors. teristics of the medication to be held or continued. Although more comprehensive, the thorough assessment of the three major risk profiles as CONCLUSION AND/OR TEACHING POINTS: 4D Angio-CT is a newer described above can be time-intensive. Also, the updated guidelines may imaging modality that can play a future role in improving interven- not be readily accessible to interventional radiologists, referring clinicians, tional procedures by enhancing the preprocedural and postprocedural and ancillary staff and providers who may desire streamlined access. assessments. We have presented seven examples of its usage in a Finally, as personalized medicine and shared decision making become modern IR setting. increasingly more important, patients may also desire more information regarding periprocedural anticoagulation management. Abstract No. 751 CLINICAL FINDINGS/PROCEDURE DETAILS: We developed a user-friendly interactive web-based software using open source tools and AJAX, Artificial interventional radiology: a primer on artificial presenting a series of hierarchical questions to assess thrombotic risk, intelligence for the interventional radiologist bleeding risk, and procedural bleeding risk. We concurrently developed G Wong1, T Patel1, F Grippi1, C Commander1, D Mauro1 web-based calculators for the CHAD2DS2-VASc Score and the HAS- 1 BLED Score that can be further used, when necessary, to aid assess- The University of North Carolina, Chapel Hill, NC ment of the thrombotic risk and bleeding risk, respectively. Additional LEARNING OBJECTIVES: This educational exhibit will provide a frame- hyperlinks to more detailed educational materials are also provided to work for understanding the basic concepts of artificial intelligence (AI) act as an educational tool for both radiologists and referring clinicians. and how they may be applied in the field of interventional radiology

CONCLUSION AND/OR TEACHING POINTS: A web-based tool, which has (IR). a user-friendly interface with built-in calculators, has been implemented BACKGROUND: The idea of AI is mystifying. An all-knowing computer to facilitate determination of specific periprocedural anticoagulation rec- that can make complicated decisions in a fraction of a second with ommendations based on the updated 2019 SIR Consensus Guidelines. superior accuracy is certainly intriguing, albeit not entirely realistic. AI has rapidly permeated the health care space. Radiology in particular Abstract No. 750 has benefited from AI tools over the past 20 years or more, and has seen explosive growth in interest over the last ten years. While IR is Advantages of four-dimensional angio-computed different in many ways than diagnostic radiology, AI tools could soon tomography in interventional radiology assist in decision making for patient care. Interventional oncology in particular may see great benefit in incorporation of AI tools that could H Basinger1, R Grammer1, K McCluskey1, N Rostambeigi2 help with lesion prognostication, creating multidisciplinary treatment 1West Virginia University, Morgantown, WV, 2West Virginia plans, predicting procedural risk and outcomes, planning procedural University/Washington University, Morgantown, WV/St. Louis, MO approach, improving postprocedural care, and much more. The creation of large data registries and analytics powered by AI tools could LEARNING OBJECTIVES: We aimed to highlight the benefits of four-di- assist in research at a large scale, which is needed for wider spread mensional (4D) Angio-computed tomography (CT) with exemplary acceptance of the innovative procedures that IR provides. For these critical interventional radiology (IR) procedures including transjugu- reasons, it is prudent for interventional radiologists to acquaint them- lar portosystemic shunt (TIPS), abdominal aortic aneurysm endoleak selves with the basics of AI as this field gains traction in healthcare. repair, prostate artery embolization, cervical mass embolization, adrenal vein sampling, and hepatic angiograms for pre-Y90 mapping or CLINICAL FINDINGS/PROCEDURE DETAILS: The following points regard- chemoembolization. ing AI will be explored: 1. What is AI? 2. How does AI work? 3. Current applications of AI. 4. A vision for the future of AI in IR. BACKGROUND: 4D Angio-CT is a new procedural modality that adds the parameter of time and combines CT with fluoroscopy. Visualization CONCLUSION AND/OR TEACHING POINTS: While many have heard of AI of structures of interest can be improved with 4D Angio-CT. Our insti- and its impacts on healthcare and radiology, this has rarely been in tution has implemented this technology and we describe herein our the context of IR. IR could benefit greatly from AI, and this primer will initial experience using this technology with complex interventional provide a starting point for those who wish to understand more about procedures. the intricacies of these technologies. SIR 2020 Annual Scientific Meeting Traditional Posters | 9

Abstract No. 752 LEARNING OBJECTIVES: Review the background and technique of four-dimensional (4D) flow magnetic resonance imaging (MRI) includ- Teaching an old dog new tricks: a review of the new and ing image acquisition, preprocessing, and visualization/quantification established uses of intravascular ultrasound of flow rates and patterns. Discuss the clinical applications of 4D flow B Contrella1, W Sherk2, A Zelickson1, L Wilkins1, D Sheeran1, A MRI in the context of cranial, chest, and abdominal imaging. Highlight Park3, M Khaja4 the emerging role 4D flow MRI will play in interventional radiology (IR).

1University of Virginia, Charlottesville, VA, 2University of Michigan BACKGROUND: Time-resolved 3D phase-contrast MRI with three-di- Hospital, Ann Arbor, MI, 3UVA Health System, Charlottesville, rectional flow encoding, also known as 4D flow MRI, is an emerging VA, 4University of Virginia Health System, Charlottesville, VA technique that is being increasingly used in hemodynamic assessment within the cranial, chest, and abdominal vasculature. By providing tem- LEARNING OBJECTIVES: 1. Describe the broad uses of IVUS in aortic, poral and spatial information of blood flow within a volumetric region peripheral arterial, and venous interventions. 2. Identify cases in which of interest, and by allowing for postacquisition quantification of vari- IVUS may be used in diagnosis and treatment of pathology. 3. Under- ous flow parameters such as total flow, shear wall stress, and pressure stand the potential of IVUS to continue to be used in an increasing vari- difference, 4D flow MRI allows for improved characterization of various ety of procedures and situations. pathologic vascular processes. Notable applications of this technique

BACKGROUND: Since its first use in percutaneous coronary interven- include determination of intracranial aneurysmal flow patterns, char- tion in the early 1990s, continuous innovation has promoted the use acterization of peripheral arterial disease, and the assessment of portal of intravascular ultrasound in a wide variety of clinical situations. Con- hypertension flow patterns in TIPS patients, along with stratification of currently, the increasing availability of intravascular ultrasound has their variceal bleeding risk. The utilization of information gained from allowed for use by more providers, in more treatment settings. IVUS 4D flow MRI may help to augment patient selection, complex proce- can be a valuable tool for interventionalists in more accurate diagno- dural planning, and assessment of treatment response, among other sis of aortic, arterial, and venous pathology and can assist in problem things, for various endovascular procedures. solving prior to or after treatment. CLINICAL FINDINGS/PROCEDURE DETAILS: Using illustrative diagrams

CLINICAL FINDINGS/PROCEDURE DETAILS: We present representative and institutional cases, we will provide an overview of the background cases to illustrate the broad uses of IVUS. In the aorta, IVUS is valuable and technique of 4D flow MRI. A review of seminal 4D flow MRI studies in confirming wire/catheter position in the true lumen of a dissection, and their outcomes will then be presented, with particular emphasis identifying dissection flap fenestrations, and locating vessel origins on studies pertinent to commonly performed minimally invasive pro- during TEVAR or EVAR. In the peripheral arteries, IVUS can be used cedures. We will conclude highlighting the ever-increasing role 4D flow to evaluate atheroma or thrombus, direct subintimal recanalization, or MRI will play in IR. evaluate wall apposition of a stent. In the venous system, IVUS can be CONCLUSION AND/OR TEACHING POINTS: 4D flow MRI is an emerging used diagnostically to evaluate external compression in May-Thurner technique that allows for the evaluation of complex blood flow in vari- Syndrome, Nutcracker Syndrome, or during provocative maneuvers ous vascular territories and quantification of various flow parameters. to diagnose thoracic outlet syndrome. Additionally, IVUS may also Improved understanding of altered hemodynamics in patients under- be used to direct intervention in inferior vena cava filter placement, going endovascular procedures may help enhance treatment and venous recanalization, or in identifying and disrupting fibrin sheaths assessment of response. during line exchange. IVUS may also be used, though less commonly, in biliary and lymphatic interventions. Abstract No. 754 CONCLUSION AND/OR TEACHING POINTS: IVUS can be used as an adjunct to angiography/fluoroscopy to improve treatment outcomes, Characterization of inflow and outflow channels of or in other cases such as IVC filter placement, can replace fluoroscopy endoleaks via computed tomographic angiography to allow procedures outside procedure rooms in select patient groups. As experience with and availability of IVUS continues to rise, the skills Q Yu1, S Sanampudi1, D Raissi1, M Ahmed1, M Winkler1 to effectively use IVUS in diagnosing and treating varying pathologies 1University of Kentucky, Lexington, KY are becoming increasingly valuable. LEARNING OBJECTIVES: 1. Recognize the application of imaging reconstruction in identifying extraluminal channels of thoracic aortic Abstract No. 753 aneurysm repair endoleaks 2. Understand our proposed scheme of extraluminal channels in addition to the standard classification of tho- Four-dimensional flow magnetic resonance imaging in racic aortic endoleaks interventional radiology BACKGROUND: Endoleak is a common complication after endovascu- 1 1 1 1 1 1 1 A Saini , I Altun , M Kuo , P Hoang , H Albadawi , I Patel , S Naidu , lar aneurysm repair. Most persistent endoleaks result from pressure 2 1 1 G Knuttinen , S Alzubaidi , R Oklu gradients between sites of blood ingressing into and egressing from 1Mayo Clinic Arizona, Phoenix, AZ, 2Mayo Clinic Arizona, Phoenix, AZ the sac through extraluminal channels. On top of the standard classification of endoleaks, we proposed a scheme that characterizes the 10 | Traditional Posters SIR 2020 Annual Scientific Meeting

persistent extraluminal channels of the thoracic aneurysm: Type 1) to sole vascular supply to the foot, supplying both the dorsalis pedis and fro flow only; Type 2) single outflow; Type 3) multiple outflow. artery and the plantar arch with associated diminutive anterior tibial Extraluminal channels were further subcategorized according to the and posterior tibial arteries. This anatomic variant cannot be detected following criteria: a) <10 mm in greatest dimension; b) >10 mm and on routine physical exam as DP and PT pulses are normal. With the aid <20 mm; c) >20 mm and/or increase (in between arterial and venous of meticulous preprocedure planning using CTA, free flap can still be phases) in volume within sac that exhibits opacification subsequent to done if PAM is present. contrast administration. In our study, three-dimensional image recon- CONCLUSION AND/OR TEACHING POINTS: For DIEP flaps, preoperative struction has been implemented to detect extraluminal channels when imaging, most often using CTA can help decrease complications and computed tomography is equivocal. surgical time by mapping out perforating vessels of the inferior epi- CLINICAL FINDINGS/PROCEDURE DETAILS: Case 1: Endoleak Type IIa gastric artery. Recognition of PAM is of utmost importance in avoiding (inferior mesenteric artery.). Channel Type 1a. Case 2: Endoleak Type postoperative devascularization complications of the donor leg with II with both a and b features. Channel Type 3c. Case 3: Endoleak Type fibular free flaps. II with channels from L4 lumbar arteries and the median sacral artery. Channel type 3c. Case 4: Endoleak Type IIIb. Channel Type 1c. Case 5: Endoleak with Type IIIa and IIc (accessory renal artery) features. Chan- Abstract No. 756 nel Type 3c. Case 6: Endoleak with both Type IIb and VI (venous flow) Emerging role and versatile use of contrast-enhanced features. Channel Type 2c. ultrasound in interventional radiology: a beginner’s guide CONCLUSION AND/OR TEACHING POINTS: 1. Imaging reconstruction S Raza1, J Pellerito2 is a powerful tool in identifying the extraluminal channels of aor- 1 tic endoleaks. 2.Our proposed scheme can vividly characterize the Northwell Health, North Shore University Hospital, Manhasset, 2 dynamic features of aortic endoleaks with persistent extraluminal NY, North Shore University Hospital, Northwell Health, Manhasset, NY channels. LEARNING OBJECTIVES: 1. Pictorial, case-based discussion of the versatile role of contrast-enhanced ultrasound (CEUS) in interventional Abstract No. 755 radiology (IR). 2. Use of CEUS in renal and hepatic biopsies. 3. Use of CEUS in the diagnosis and surveillance of Type I, II, and III endoleaks. 4. Deep inferior epigastric perforator and fibular free flap Use of CEUS in evaluating the patency of mesenteric stents. 5. Use of planning computed tomography: what to look for and CEUS in evaluating tumor vascularity after embolization. what to report BACKGROUND: CEUS is an evolving diagnostic alternative to con- C Cross1, R Hosein2, Z Cizman3, K Quencer4, C Kaufman2 trast-enhanced CT, MRI and invasive angiography in the setting of IR procedures and postprocedure surveillance. CEUS utilizes intrave- 1University of Utah School of Medicine, Salt Lake City, nously injected microbubble contrast (sulfur hexafluoride lipid-type A UT, 2University of Utah, Salt Lake City, UT, 3University of Utah, microspheres (Lumason, Bracco Diagnostics)) in imaging blood flow in N/A, 4N/A, Salt Lake City, UT organs and vessels, especially blood flow in microvasculature beyond LEARNING OBJECTIVES: 1-Review basics of deep inferior epigastric the resolution of standard imaging techniques. CEUS is incredibly use- perforator (DIEP) flaps and fibular free flap surgery 2-Review standard ful in patients who have limitations or contraindications to undergoing and variant anatomy of the inferior epigastric artery and lower extrem- contrast-enhanced CT or MRI. Common limitations to CT include radi- ity arteries. 3-Review literature showing utility of preoperative imaging ation, contrast allergy and acute renal injury and those to MRI include for DIEP and fibular free flaps. 4-Show examples of anatomic variants the patient having an MRI incompatible device. effecting surgical approach. CLINICAL FINDINGS/PROCEDURE DETAILS: We present 4 cases of suc- BACKGROUND: DIEP flaps are a newer alternative to transverse rectus cessful CEUS biopsy of renal (1 case) and hepatic (3 cases) lesions with abdominis myocutaneous (TRAM) flap for breast reconstruction and pathological correlation. 6 cases of endoleaks diagnosed on CEUS (2 have a lower incidence of abdominal wall complications. Fibular free cases of Type I, 3 cases of Type II, and 1 case of Type III) with CTA and flaps are used in mandibular or other bony reconstructions utilizing the invasive angiographic correlation. We will review key imaging findings peroneal artery and mid portion of the fibula for reconstruction. Pre- of 3 cases of CEUS in the evaluation of tumor vascularity after micro- operative computed tomography angiography (CTA) has been shown wave, chemoembolization and particle embolization. Finally, we will to be useful prior to both DIEP (1) and fibular free flaps (2). present 2 cases of CEUS in assessing superior mesenteric artery stent patency after treatment of chronic mesenteric ischemia. CLINICAL FINDINGS/PROCEDURE DETAILS: Knowing the position and number of perforators for the DIEP flap decreases both operative time CONCLUSION AND/OR TEACHING POINTS: CEUS is a quick, safe, non- and complications. With fibular free flaps, one dreaded donor site invasive imaging modality that does not utilize radiation, iodinated or complication is devascularization of the foot from unknowing sacrifice gadolinium contrast agents with multiple uses in IR. Understanding of the peroneal artery in the setting of peronea arteria magna (PAM). how to perform, interpret and use CEUS can significantly assist IR both This variant is present in approximately 5% of the population. With this in intraprocedural accuracy and postprocedural surveillance of various anatomic variant, the peroneal artery is the dominant and sometimes entities. SIR 2020 Annual Scientific Meeting Traditional Posters | 11

Abstract No. 757 LEARNING OBJECTIVES: To review the indications, technical approaches, and outcomes of percutaneous ablation techniques for Rods, balloons, jacks, and more: advanced the treatment of early-stage breast cancer and highlight its evolving musculoskeletal ablation techniques, safety measures, role in interventional oncology. and augmentation devices BACKGROUND: While thermal and cryoablation techniques have pri- N Kafity1, J Gemmete2 marily been well-studied for solid tumors in the liver, kidney, lung, 1University of Michigan, Ann Arbor, MI, 2University of Michigan and bone, evolving evidence is supportive of ablation as an effective Hospitals, Northville, MI minimally invasive curative treatment option for early-stage breast cancer. Conventional therapy for such tumors has generally consisted LEARNING OBJECTIVES: -Discuss important nerves to avoid during mus- of surgical intervention followed by radiation, hormonal therapy, or culoskeletal (MSK) ablations along with differences in radiofrequency adjuvant chemotherapy. Ablation offers a clinically effective, cost effi- (RF), cryo, and microwave (MWA) techniques for bone ablation. -Outline cient, and cosmetically acceptable treatment alternative. Recent work augmentation devices for post ablation stability (balloon kyphoplasty, has demonstrated the success of ablation in local tumor control for cementoplasty, percutaneous rod/screw/jack placement). -Discuss the early-stage breast cancer, while outperforming lumpectomy in terms use of preablation embolization to nullify the heat sink effect for hyper of obtaining tumor-free margins, which is among the most important vascular tumors along with techniques to protect structures such as bal- factors that influence outcomes. loons, hydro/pneumodissection, and thermocouples. CLINICAL FINDINGS/PROCEDURE DETAILS: This exhibit will include 1) BACKGROUND: Percutaneous ablation for bony lesions has been per- A review of contemporary treatment options for early-stage breast formed successfully since the early 1990s. Ablation is now considered cancer, 2) An introduction of thermal- and cryoablative technologies a first-line therapy for osteoid osteoma and is being used increasingly and novel developments, 3) Current applications of ablation in breast in other areas such as painful metastatic lesions and small primary cancer therapy and patient selection, 4) Ablation techniques with masses. As ablation techniques continue to improve, the possibilities emphasis on technical pearls and pitfalls, 5) Procedural indications, for treatment are rapidly expanding. This exhibit highlights advanced contraindications, and potential risks, and 6) Present literature, treat- treatment and safety techniques used for both large and dangerously ment outcomes and prognosis, and future directions. located lesions. CONCLUSION AND/OR TEACHING POINTS: After reviewing this exhibit, CLINICAL FINDINGS/PROCEDURE DETAILS: We present three cases, the viewer will gain a better understanding of the emerging applica- each highlighting an advanced technique for MSK ablation. Case 1: Post tions of ablation in the treatment of early-stage breast cancer includ- ablation screw fixation and pretreatment embolization Demonstrates ing its role in the treatment paradigm, technical pearls, current data, the use of pretreatment embolization, RF ablation, transiliac screw fix- and future directions. ation with cementoplasty in a 73-year-old patient with a painful metastatic renal cell carcinoma lesion in his left iliac wing. Case 2: SpineJack placement Demonstrates the use of RF ablation and bitranspedicular Abstract No. 759 SpineJack placement with cementoplasty in a 65-year-old patient with T12 and L1 compression fractures secondary to lymphoplasmacytic Improving target visualization for percutaneous needle lymphoma/Waldenstrom macroglobulinemia causing severe back biopsy in the modern era pain. Case 3: Balloon expansion within epidural space Demonstrates J Fergus1, L Dalag2, S Zangan3 the use of cryoablation with expansion of a balloon within the epidural 1University of Chicago, Chicago, IL, 2University of Chicago Medicine, space for spinal cord protection in a 10-year-old patient with a painful Chicago, IL, 3N/A, Elmhurst, IL C4 osteoid osteoma.

LEARNING OBJECTIVES: To discuss the roles of navigational tools and CONCLUSION AND/OR TEACHING POINTS: With advances in percutane- optical molecular imaging (OMI) in improving tissue yield for molecular ous ablation technology, safety measures, and postablation augmen- pathologic analysis in the age of precision medicine. tation devices, an increasing number of MSK lesions can be treated through minimally invasive means. BACKGROUND: Percutaneous needle biopsy (PNB) has traditionally been used to establish the nature of a tumor. With the recent paradigm shift in oncologic workup and management, identifying molecular and Abstract No. 758 genomic biomarkers in cancers not only helps establish a diagnosis, but now guides therapy. As early diagnosis of cancer continues to improve, Targeting early breast cancers with ablation therapies: the lesions targeted for biopsy are often smaller and less well-defined. opportunities and progress As a result, two promising strategies to improve tissue yield include M Makary1, J Bozer2, J Cerne2, L Cooke3, V Flanders4, J Dowell5 registration and tracking technologies and optical imaging. 1The Ohio State University Wexner Medical Center, Columbus, OH, 2The CLINICAL FINDINGS/PROCEDURE DETAILS: Registration and track- Ohio State University College of Medicine, Columbus, OH, 3Indiana ing technologies improve target visibility and localization by match- University School of Medicine, Indianapolis, IN, 4Northwest Radiology, ing reference and intraprocedural imaging datasets to create a Indianapolis, IN, 5Northwest Radiology, Carmel, IN 12 | Traditional Posters SIR 2020 Annual Scientific Meeting

working procedure dataset. For example, registering PET/CT images uneven awareness of interventional radiology procedures safety and with intraprocedural images has shown promise in improving tissue accuracy by the urologists. Percutaneous biopsy has the potential of yield. Tracking can be performed by radiologists using two techniques: circumventing preventable surgeries, particularly in patients at high electromagnetic and image-based tracking. Electromagnetic tracking surgical risk, confirm histologic success after ablation and supporting localizes an instrument using an electric current within a differential the selection of systemic therapy for metastatic RCC. magnetic field and does not rely on line-of-sight, whereas image- CONCLUSION AND/OR TEACHING POINTS: Nodules as small as 1.5 cm based tracking utilizes 3D rotational fluoroscopy or cone-beam CT to have been shown to be successfully biopsied under CT and Ultrasound create a 3D reference dataset to guide a device to its intended target guidance. The increasing use of percutaneous kidney mass biopsy can under fluoroscopy. OMI is a technique that visualizes and quantitatively prevent unnecessary surgical excisions, guide systemic therapy and measures biological and cellular process in vivo. OMI has the potential safely indicate ablative candidates, as reflected in the updated AUA to greatly improve image and spatial resolution and provide real time guidelines. Our exhibit has the additional purpose of informing the feedback. PET/CT guidance has been shown to improve spatial reso- current awareness level of most urologists professionals of the full lution when used to guide biopsy of 18-Fr FDG-avid lesions that were spectrum of the interventional radiologist role when managing an inci- not well visualized on other imaging modalities. Similarly, indocyanine dental renal mass. green, an FDA approved near-infrared fluorochrome, can provide an operator with real-time feedback allowing for real-time measurements of ICG fluorescence to confirm biopsy tip position. Abstract No. 761

CONCLUSION AND/OR TEACHING POINTS: Improving target visibility, Novel systemic agents in the battle against hepatocellular localization, spatial resolution, and providing real time feedback are carcinoma promising methods to improve tissue yield for PNB in the age of precision medicine. A Moiyadi1, A Ravilla2, H Dermendjian2, A Bhatt2, C Lam2, G Vatakencherry2 1Kaiser Permanente Los Angeles Medical Center, Los Angeles, Abstract No. 760 CA, 2Kaiser Permanente Los Angeles, Los Angeles, CA

To biopsy or ablate: a review of the evidence behind the LEARNING OBJECTIVES: 1) Review the major landmark trials regarding treatment algorithm of T1a renal mass novel HCC medical therapies and efficacies. 2) Overview of the risk fac- O Adenikinju1, S C. Durscki Vianna2, M Patel1, B Olivieri3, A tors for HCC and how they affect management in the era of precision Zybulewski4, R Beasley3 medicine. 3) Understand how these trials affect current management of HCC with regards to interventional therapies. 4) Provide a novel 1Mount Sinai Medical Center, Miami Beach, FL, 2Mount Sinai Medical framework for approaching HCC with treatment algorithms incorpo- Center, Miami, FL, 3N/A, Miami, FL, 4Icahn School of Medicine at rating the latest interventional and medical therapeutic options. Mount Sinai, New York, NY

BACKGROUND: Hepatocellular carcinoma (HCC) is the third leading LEARNING OBJECTIVES: 1. Guide the interventional radiologist through cause of cancer related death worldwide and its incidence continues the most common indications to biopsy a small renal mass when inci- to increase within the United States. Recent major randomized clinical dentally found. 2. Provide an algorithmic approach for patient selection trials have shown the efficacy of novel medications (tyrosine kinase and clinical decision making of when to biopsy and/or ablate based on inhibitors) in improving overall survival for patients with HCC. Compre- the current literature and data from the urological societies worldwide. hensive knowledge of the 1st and 2nd line medications and their major 3. Overview of biopsy techniques and available materials on for opti- side effects is critical to guiding patient management. Interventional mal histology sample collection described in the most current data. 4. radiology (IR) physicians must understand these medical options and A practical chart for the interventional radiologist of when to ablate, incorporate them into our treatment algorithms to improve survival of pre and post ablation control, post therapeutic histologic follow-up as our sickest HCC populations. well as initial diagnostic biopsy and work up. CLINICAL FINDINGS/PROCEDURE DETAILS: 1) Summary of the efficacy BACKGROUND: The American Urology Association (AUA) considers and side effects of the currently available systemic therapies for treat- nephron-sparing approaches as the gold standard of treatment of ment of HCC based on recent trials (SHARP, ASIA-PACIFIC, REFLECT, solid and complex cystic renal masses. However, they are not free of RESORCE, CheckMate, CELESTIAL, REACH). 2) Overview of the major surgical complications. With evolving minimally invasive options, the trials comparing 1st line medical therapy with currently offered inter- use of ablative therapies is on the rise. In this educational exhibit, we ventional therapies (SARAH, SIRVENIB, and SORAMIC) 3) Graphic will discuss the most current data on the role of biopsies and ablation detailing the general mechanism of action of tyrosine kinase inhibi- in order to avoid unnecessary nephrectomies in the setting of small tors. 4) Comprehensive flow chart to serve as a treatment algorithm to renal masses. guide patient management based on level of disease and goals of care. CLINICAL FINDINGS/PROCEDURE DETAILS: Through a comprehensive CONCLUSION AND/OR TEACHING POINTS: A firm understanding of the literature review it was found that there is a great disparity in the most major trials regarding the current available treatment options for HCC current European and American urological guidelines as well as a very is integral in order to provide comprehensive care. Furthermore, to SIR 2020 Annual Scientific Meeting Traditional Posters | 13

provide patients the appropriate guidance and treatment alternatives, LEARNING OBJECTIVES: To describe carotid artery blowouts and eluci- IR physician must gain knowledge of their associated risks and effi- date the role of endovascular treatments utilized for the management cacy. This expertise is critical for IR physicians to maintain pertinence of this condition. Recent evidence will be presented on outcomes from in an ever-evolving field. various interventions and sequelae posttreatment.

BACKGROUND: Carotid blowout syndrome (CBS) is a life-threatening Abstract No. 762 complication that can be seen in patients with history of head and neck malignancy, prior history of irradiation, flap necrosis, wound infections, The role of locoregional therapy in the treatment of liver- or after aggressive surgical management. Surgical management of dominant breast cancer metastatic disease carotid artery rupture has been replaced by stent-directed endovascular methods, which have supplanted traditional surgical open ligation M Makary1, J Cerne2, J Bozer2, L Cooke3, B Martinez4, J Dowell5 approaches due to a decreased risk of cerebrovascular accidents and 1 The Ohio State University Wexner Medical Center, Columbus, eventual mortality. OH, 2The Ohio State University College of Medicine, Columbus, OH, 3Indiana University School of Medicine, Indianapolis, IN, 4St. CLINICAL FINDINGS/PROCEDURE DETAILS: Two commonly utilized Vincent Health, Indianapolis, IN, 5St. Vincent Health, Carmel, IN techniques for management of CBS include endovascular occlusion and endovascular repair with covered stents with or without coil LEARNING OBJECTIVES: To review the utility of locoregional therapies embolization. The technical success rate is reported as high for these for breast cancer metastases to the liver as well as examine the current interventions although delayed hemorrhage, recurrent CBS, and dis- literature, treatment outcomes, and emerging treatment paradigms. ease progression to mortality are all relatively common complications

BACKGROUND: Metastatic liver lesions attributable to breast cancer result post procedure. We will review current evidence on various interven- in significant morbidity, with hepatic failure and subsequent death occur- tions including techniques, indications, outcomes and potential post- ring in 20% of patients. For unresectable lesions, locoregional therapies procedural complications. including TACE, TARE, TAE, and ablation, SBRT, hepatic arterial infusion CONCLUSION AND/OR TEACHING POINTS: CBS is a condition charac- chemotherapy, and systemic chemotherapy are the mainstay of treat- terized by high morbidity and mortality. Current endovascular inter- ment. Locoregional therapies have demonstrated improved overall sur- vention provides temporization for patients with CBS and should be vival while preserving the quality of life and minimizing toxicity in studies tailored to the clinical status and stability of the patient. to date, and appear to be a safe and effective adjuvant treatment for liver-dominant breast cancer metastases. Optimal outcomes are dependent upon proper patient selection and choice of treatment modality. Abstract No. 764

CLINICAL FINDINGS/PROCEDURE DETAILS: This educational exhibit will Stem cell delivery to the brain using magnetic resonance (1) present an overview of the pathophysiology and outcomes of met- imaging–guided focused ultrasound: a noninvasive astatic breast cancer, (2) review the current treatment paradigms for approach metastatic breast cancer, (3) review locoregional therapeutic options 1 2 1 (including TACE, TARE, TAE, and ablation) as well as other multidis- N Ahmed , D Gandhi , V Frenkel ciplinary treatments such as SBRT, hepatic arterial infusion chemo- 1University of Maryland School of Medicine, Baltimore, therapy, and systemic chemotherapy, (4) provide a case-based review MD, 2University of Maryland Medical Center, Baltimore, MD of locoregional therapies for dominant breast cancer metastases, (5) LEARNING OBJECTIVES: 1. Review indications and current delivery present best practices and evidence-based guidance for treatment techniques for neural stem cell (NSC) therapy. 2. Understand MRI- modality selection, (6) review the current treatment outcomes and guided focused ultrasound (MRgFUS) as a noninvasive modality for prognosis, and future therapies. delivering NSCs to the CNS and outline its advantages and challenges. CONCLUSION AND/OR TEACHING POINTS: After reviewing this exhibit, BACKGROUND: NSC therapy continues to make headway as an inter- the viewer will gain a better understanding of the role of locoregional ventional treatment strategy for acute traumatic, congenital, autoim- therapies in the management of metastatic breast cancer to the liver mune and chronic degenerative neurologic disease. NSCs are clinically including patient selection and management, current treatment out- versatile. Not only can they act as a potential nidus for improved neu- come data, and future therapies. rologic function in stroke patients, for example, they can also serve a multitude of other functions. Genetically modified NSCs can act as Abstract No. 763 therapeutic carriers of neurotrophic factors which can delay the progression of neurodegenerative disease. They can also be genetically Head and neck emergencies: management of carotid engineered for safely transforming prodrugs at the tumor site into artery blowout potent chemotherapeutics for the treatment of invasive glioblastoma. Maximizing the therapeutic potential of NSCs will require a delivery A Shetty1, K Shetty2, A Patel3, S Kim3 strategy that is efficacious, precise, and safe. 1University of Rochester School of Medicine, Rochester, NY, 2Boston University, Boston, MA, 3University of Rochester, Rochester, NY 14 | Traditional Posters SIR 2020 Annual Scientific Meeting

CLINICAL FINDINGS/PROCEDURE DETAILS: This educational exhibit up, clinical indications, patient selection and outcome measures is will explain the mechanisms by which MRgFUS can safely and revers- essential for adequate stroke treatment and patient care. ibly open the blood-brain barrier, allowing for enhanced transport of NSCs into the CNS. This technique avoids potential limitations such as invasiveness or imprecise targeting associated with other delivery Abstract No. 766 methods i.e., stereotactic injection, or intranasal delivery, respectively. Update on the multidisciplinary management of MRgFUS provides high specificity in targeting tissues with submillime- malignant biliary obstruction with critique of recent ter accuracy, minimizing damage to surrounding healthy tissues. literature CONCLUSION AND/OR TEACHING POINTS: The promise of NSC therapy R Bittman1, P Park1, G Peters1 is a call for interventional radiologists to become familiar with MRg- 1 FUS-mediated neural stem cell delivery, and to establish protocols Emory University School of Medicine, Atlanta, GA involving procedural techniques and tracking efficacy for patients over LEARNING OBJECTIVES: 1) Review the historical management of malig- time. nant biliary obstruction, emphasizing which clinical scenarios have favored percutaneous versus endoscopic drainage. 2) Analyze recent Abstract No. 765 literature which has complicated the discussion of how to best manage patients with malignant hilar obstructions. 3) Discuss manage- A practical review of stroke workup and updated ment strategies for these patients in light of conflicting evidence. 4) guidelines for endovascular therapy Describe ongoing trials designed to determine best practice in these cases. H Brent1, K Hewitt1, D Cohen-Addad2, A Efendizade1, Z Farooq3, D Bell1 BACKGROUND: The accepted standard first line treatment for biliary obstruction is endoscopic biliary drainage (EBD). After failed EBD, per- 1SUNY Downstate Medical Center, Brooklyn, NY, 2SUNY Downstate Medical Center, Brooklyn, NY, 3N/A, Brooklyn, NY cutaneous transhepatic biliary drainage (PTBD) is routinely employed. This paradigm works well for distal obstruction; however, in treatment LEARNING OBJECTIVES: Review the updated Society of Interventional of hilar obstruction, there is uncertainty regarding which is the best Radiology (SIR) guidelines on clinical practice of intraarterial stroke initial therapy. Although there is evidence suggesting that PTBD may revascularization. Discuss the diagnostic work up of acute ischemic be the best initial therapy, some recently published studies have chal- stroke using algorithm-based approach. Learn about patient selection lenged this notion. criteria and outcome measures related to endovascular stroke therapy. CLINICAL FINDINGS/PROCEDURE DETAILS: The first randomized con- BACKGROUND: Not long ago endovascular therapy for acute isch- trolled trial of PTBD versus EBD for resectable malignant hilar obstruc- emic stroke was a novel technique that was available in only the most tion was stopped early due to significantly higher mortality in the advanced institutions. Now, however, neurointerventional stroke PTBD group. management is available at both academic and community hospitals The observed mortality rate was much higher than is typically expected nationwide and cerebral revascularization has become commonplace. for PTBD, and could not be explained. A 2019 retrospective study of a With the recent publication of updated guidelines for clinical prac- national database reported that PTBD in this setting is associated with tice of intraarterial stroke management, it is crucial that interven- significantly increased postoperative morbidity and mortality. Fur- tional radiologists familiarize themselves with the diagnostic work-up, ther analysis of this study reveals that patients undergoing PTBD had patient selection, procedural planning, endovascular equipment and a significantly higher preoperative disease burden. Five other recent technique as well as outcome measures in order to provide adequate studies exploring risks of specific complications (including seeding patient care. metastasis) and all-cause mortality will be discussed. Common pitfalls CLINICAL FINDINGS/PROCEDURE DETAILS: We present a pictorial algo- surrounding this body of literature will be presented. rithm for radiologic workup and management of stroke. We focus on CONCLUSION AND/OR TEACHING POINTS: Some recent evidence sug- reviewing the pertinent aspects of acute stroke management essen- gests that PTBD is not an appropriate choice for initial management tial to interventional radiology and endovascular therapy. We review of malignant hilar obstruction; however, these studies do not account recent randomized controlled trials that have expanded the endovas- for selection bias or are otherwise flawed. Two randomized controlled cular therapy window and put an increased emphasis on defining the trials are ongoing. Interventional radiologists should continue to work core infarct volume. We discuss patient selection and outcome mea- alongside gastroenterologists and offer PTBD as a first-line interven- sures. Finally, we summarize with a stroke management algorithm tion, as appropriate, to patients with malignant hilar obstructions. scheme.

CONCLUSION AND/OR TEACHING POINTS: SIR has released updated guidelines with larger time intervals for treatment based on data from recent randomized controlled trials. Intra-arterial ischemic stroke revascularization has become standard of care across the United States and all over the world. Understanding the appropriate diagnostic work SIR 2020 Annual Scientific Meeting Traditional Posters | 15

Abstract No. 767 the Whitaker test. 3) Present a case-based pictorial essay to illustrate typical examples. Percutaneous antegrade retrograde urethral BACKGROUND: Advances in surgical techniques and immunosuppres- catheterization: complicated urethral catheter placement sive therapies in renal transplantation have improved both graft and K Chiang1, A Ray2 patient survival. Despite these improvements, vascular and nonvas- 1N/A, Greenville, NC, 2Brody School of Medicine at East Carolina cular complications remain a significant cause of morbidity for renal University, Greenville, NC transplant patients. Nonvascular complications such as obstruction, urine leak and peri-transplant fluid collections occur in up to 20% LEARNING OBJECTIVES: 1. Review indications for urethral catheteriza- of cases and can threaten graft viability. Ureteral obstruction is the tion 2. Define complex urethral catheterization 3. Discuss management most common urologic posttransplant complication, occurring in an of urethral trauma 4. Describe percutaneous antegrade retrograde estimated 2-10%. Ureteral ischemia causes the majority of early stric- urethral catheterization. tures with the distal ureteral anastomosis as the most common loca-

BACKGROUND: Acute urinary retention requires urgent bladder tion. While surgical revision has been the standard of care for ureteral decompression. Typically, retrograde urethral catheterization is ini- obstruction, percutaneous management is increasingly utilized in the tially attempted to manage urinary retention. However, in the setting management of these patients with high success and low complication of urethral injury or retrograde urethral catheterization failure, alter- rates. native approaches are considered. Often urologists are consulted to CLINICAL FINDINGS/PROCEDURE DETAILS: Nonvascular posttrans- manage these complications utilizing blind glide wire, suprapubic and/ plant complications will be reviewed with a focus on pathophysiology, or flexible cystoscopy techniques to relieve urinary retention. A rarely clinical presentation, workup, and percutaneous management of ure- reported alternative method performed by interventional radiologists teral stricture. Our treatment protocol including nephroureteral cath- is the percutaneous antegrade retrograde urethral catheterization eter placement, balloon dilation and serial up-sizing of the catheter, (PARUC) technique, used in the setting when traditional methods are nephrostomy placement to test the anastomosis and a Whitaker test unsuccessful. will be demonstrated with a case-based pictorial review. Successful

CLINICAL FINDINGS/PROCEDURE DETAILS: A retrospective analysis of and failed cases will be shown and continued postprotocol manage- six PARUC procedures performed by interventional radiologists at a ment and follow-up will be outlined. single institution from 2017-2019 were reviewed. This minimally inva- CONCLUSION AND/OR TEACHING POINTS: 1) Interventional radiologists sive technique begins with access into the urinary bladder and sub- play a vital role in the management of renal transplant complications. sequent antegrade passage of wire, catheter and sheath through the 2) Posttransplant ureteral obstruction is relatively common, and can penile urethra. Next, the urinary catheter is attached to the sheath affect graft survival if not corrected. 3) Percutaneous management of and guided through the urethra in a retrograde fashion. Interventional ureteral strictures in the transplant kidney is safe and effective and the radiologists successfully performed PARUC on six male patients rang- implementation of a structured protocol could result in avoidance of ing from 16 to 68 years old. Five patients (83%) failed urological cys- surgery in a high percentage of patients with a very low complication toscopic urethral catheterization. One patient (17%) did not undergo rate. cystoscopic urethral catheterization. Four patients (67%) had urethral injury secondary to pelvic fractures. Two patients (33%) had urethral strictures. The average fluoroscopy time was 11 minutes. No immediate Abstract No. 769 complication resulted from the percutaneous interventions. Urological applications of contrast-enhanced ultrasound CONCLUSION AND/OR TEACHING POINTS: PARUC is a minimally inva- interventions sive and rapid technique to assist urethral catherization in select cases. Patients with urethral trauma, failed urethral catheterization or existing V Kondray1, F Rahman2, A Hashmi3, S Dastmalcian4, L Walker4, N 5 suprapubic cystostomy are ideal candidates. Azar 1University Hospitals Cleveland Medical Center, Mayfield Heights, OH, 2Case Western Reserve University School of Medicine, Solon, Abstract No. 768 OH, 3N/A, Perrysburg, OH, 4University Hospitals Cleveland Medical Center, Cleveland, OH, 5University Hospitals Case Medical Center, Percutaneous management of ureteral strictures in Cleveland, OH patients with renal transplant: an institutional experience and pictorial review LEARNING OBJECTIVES: 1. Discuss ultrasound contrast agent (UCAs) properties. 2. Review uses in urologic procedures (diagnosis, biopsy, N Siesener1, J Cronan1, N Kokabi1, G Peters1 drainage, cryoablation). 3. Understand UCAs specific indications/ 1 Emory University School of Medicine, Atlanta, GA contraindications and patient selection. 4. Illustrate the advantages of CEUS in urologic applications. LEARNING OBJECTIVES: 1) Review the incidence and pathophysiology of ureteral obstruction in renal transplants. 2) Outline our institutional BACKGROUND: Ultrasound contrast has enhanced the diagnostic abil- protocol for managing benign ureteral strictures, including a review of ity and clinical utility of sonography in other organ systems. Within 16 | Traditional Posters SIR 2020 Annual Scientific Meeting

interventional radiology, ultrasound contrast has improved lesion rec- with the patient in the prone position. The pudendal canal is targeted ognition and anatomic characterization, allowing for more targeted by landmarks with tandem 22-G needles. Subsequently, steroids and and technically successful procedural interventions. While the use of analgesics are administered. Pain scales are obtained both pre and most traditional radiologic contrast agents is limited due to nephrotox- immediately post procedure. It is key to work closely with the ob/gyn icity, contrast-enhanced ultrasound is safe in these populations whose and urologists who are specialized in pelvic pain as the results help renal function is of particular concern. This characteristic is especially confirm or exclude their diagnosis. With this referral basis the practice useful in renal interventions. will grow rapidly.

CLINICAL FINDINGS/PROCEDURE DETAILS: Ultrasound contrast micro- CONCLUSION AND/OR TEACHING POINTS: Interventional radiologists bubbles are composed of gas molecules stabilized in a biocompatible play a key role in both the diagnosis and treatment of pudendal neu- shell. The biocompatible shell is metabolized in the liver, and the gas ralgia. Relief from nerve blocks is not only part of the diagnosis for is excreted through the lungs. Ultrasound contrast is advantageous in pudendal neuralgia but has been shown in the literature to provide genitourinary interventions by offering improved diagnostic power, long-term relief to a subset of patients. Patients who sustain tempo- dynamic enhancement imaging, lack of radiation, patient safety, por- rary relief may proceed to surgery or image-guided ablation. tability, and cost effectiveness. It is indicated in patients of large body habitus, radiosensitivity concerns, and with traditional contrast allergy. Few contraindications exist, but include cardiac shunts, pulmonary Abstract No. 771 hypertension, and ultrasound contrast sensitivity. CEUS may be used Palliative musculoskeletal pain management procedures in renal biopsy, renal or prostatic abscess drainage/ catheter place- in the pelvis ment, cryoablation, sinogram, and nephrostograms. T Sankhla1, P Chan2, Z Bercu2, J Prologo1, F Edalat3, J Newsome2, CONCLUSION AND/OR TEACHING POINTS: Ultrasound contrast is a safe N Kokabi1 and valuable tool in improving diagnostic yield and technical success 1 2 for urologic ultrasound-guided interventional procedures. Emory University School of Medicine, Atlanta, GA, Emory University School of Medicine, Decatur, GA, 3Emory University School of Medicine, Sandy Springs, GA Abstract No. 770 LEARNING OBJECTIVES: Emphasize the role of interventional radiolo- Block it: pudendal neuralgia and image-guided nerve gists in palliative pain control. Review interventional radiology treat- blocks ments for the management of musculoskeletal pain. Outline the application of these modalities for musculoskeletal pelvic pain through 1 2 3 A Luman , K Quencer , C Kaufman 5 example cases. 1University of Utah School of Medicine, Salt Lake City, UT, 2N/A, Salt BACKGROUND: While acute musculoskeletal pain can often be con- Lake City, UT, 3University of Utah, Salt Lake City, UT trolled adequately with short-term use of NSAIDs and opioid med-

LEARNING OBJECTIVES: Review etiologies of chronic pelvic pain. ications, the use of addictive opioid medications becomes more Review the diagnosis of pudendal neuralgia and clinical presentation. dangerous and less efficacious in cases of chronic pain when the Describe the technique for image-guided pudendal nerve blocks. Pro- source of the pain is poorly controlled. Particularly in patients with vide practice building suggestions. incurable advanced malignancies, with large tumor burden and/ or osseous metastases, interventional radiologists can significantly BACKGROUND: Chronic pelvic pain is diagnosed as pelvic pain lasting improve quality of life by employing an armamentarium of minimally greater than 6 months. There is a very broad differential that leads to invasive modalities to achieve improved pain control. difficulty reaching a diagnosis. The pudendal nerve is both a somatic sensory and motor nerve arising from S2-S4. Pudendal neuralgia is CLINICAL FINDINGS/PROCEDURE DETAILS: A variety of treatment defined by chronic pelvic pain due to entrapment of the pudendal modalities are used by interventional radiologists that can be very nerve. The entrapment of the pudendal nerve commonly occurs at useful in effective pain management in the palliative setting. While either the ischial spine or pudendal canal. The Nantes Criteria is vali- percutaneous thermal ablation is often employed with curative intent, dated for the diagnosis of pudendal neuralgia consisting if of 5 diag- palliative ablation can provide significant improvement in quality of nostic criteria: 1. Pain in anatomic area of the pudendal nerve. 2. Pain life, for example cryoneurolysis of the pudendal nerve in a patient with worse with sitting. 3. The pain does not cause awakening at night. 4. No inoperable nerve compression and femoral nerve ablation with radio sensory loss. 5. Relief of pain after a pudendal nerve block. Interven- frequency or cryoablation in a patient who was already immobile and tional radiologists play a key role in the diagnosis and management of suffering from debilitating femoral neuralgia. Nerve ablation with alco- these patients through image-guided nerve blocks. hol can also be highly effective, for example alcohol ablation of the hypogastric nerve for control of pelvic pain from a bulky tumor in a CLINICAL FINDINGS/PROCEDURE DETAILS: Procedure details and patient with a short life expectancy. In addition to neuropathic pain, images depicting how the procedure is performed will be included. bone pain from osseous metastases is also common in the palliative This will provide a step by step guide for those wanting to perform setting and very difficult to control. Cementoplasty in the sacrum or the procedure. Briefly, pudendal nerve blocks are performed in CT pelvis can be performed in conjunction with or independent of ablation SIR 2020 Annual Scientific Meeting Traditional Posters | 17 to provide significant pain relief. Each of these procedures will be out- Abstract No. 773 lined in detail with corresponding case example. Ultrasound fusion–guided musculoskeletal biopsy CONCLUSION AND/OR TEACHING POINTS: It is estimated that 50-64% of patients with cancer suffer from at least moderate pain. With a A Yaeger1, S Lundahl2, G Matcuk2, J Gross2, H Tchelepi2 wide array of tools available and some creative thinking, interventional 1Keck School of Medicine of the University of Southern California, radiologists are uniquely positioned to aid patients suffering from Los Angeles, California, Los Angeles, CA, 2Keck School of Medicine chronic and end-of-life musculoskeletal pelvic pain. of the University of Southern California, Los Angeles, California, Los Angeles, Los Angeles, CA

Abstract No. 772 LEARNING OBJECTIVES: Discuss the use of ultrasound fusion with cross-sectional imaging for difficult to characterize musculoskeletal Review of computed tomography–guided radiofrequency biopsies. ablation for sacroiliac joint pain BACKGROUND: Ultrasound fusion is an established technique which pairs A Ravilla1, A Moiyadi1, H Dermendjian1, M Gulati1, I Lekht1 real time B-scan ultrasound (US) with other forms of cross sectional imag- 1Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA ing including positron emission tomography–computed tomography (PET-CT), computed tomography (CT) and magnetic resonance imaging LEARNING OBJECTIVES: Review the epidemiology of sacroiliac (SI) joint (MRI) allowing interrogation of a target with real time volumetric data in pain. Describe the historical and physical exam findings associated order to help guide interventions that are difficult to see, are challenging with SI joint pain. Describe the efficacy of CT-guided radiofrequency to access safely or are difficult to characterize under more conventional ablation (RFA) for SI joint pain. Summarize the anatomical consider- methods. While percutaneous interventions have been described in the ations when performing a RFA for SI joint pain. Demonstrate cases of abdomen and pelvis, very few interventions have utilized this technique CT-guided RFA ablation of the SI joint. in the musculoskeletal system. Ultrasound fusion is a safe and novel tech-

BACKGROUND: Lower back pain is the second leading cause of disabil- nique for musculoskeletal interventions, specifically percutaneous biopsy. ity in the United States, costing $100-200 billion dollars in lost work- CLINICAL FINDINGS/PROCEDURE DETAILS: In this series, five patients days per year. Studies indicate that up to 15-30% of lower back pain were included in this cohort. In all cases, enough tissue was obtained can be attributed to the SI joint. SI joint pain can be caused by several in order to make a pathologic diagnosis. No biopsies needed to be etiologies, with degenerative joint disease and ligamentous instabil- repeated due to inadequate sample. There were no complications ity being the most common. While clinical history and physical exam in any of the reported cases. As ultrasound-guided biopsies have a techniques can increase suspicion of SI joint pain, radiologic diagnosis well-established safety profile, there is no increased risk of com- with fluoroscopic or CT-guided SI joint injection is the gold standard of plications using fusion biopsy techniques. In addition, the real time diagnosis. RFA of the nerves innervating the sacroiliac joint has been application of color and power Doppler is beneficial as compared to demonstrated to be efficacious in the treatment of lower back pain CT-guided biopsies in order to visualize vascularity in real time. Finally, arising from the SI joint. the patients in this study were not exposed to extra ionizing radiation

CLINICAL FINDINGS/PROCEDURE DETAILS: Overview of the current evi- as preexisting CT or PET-CT studies were used for the fusion data. dence behind RFA for SI joint pain. Summary and pictorial review of CONCLUSION AND/OR TEACHING POINTS: Ultrasound fusion percuta- the physical exam techniques to identify SI joint pain. Pictorial review neous intervention is a safe and precise method for tissue sampling. of the anatomy and variable innervation of the SI joint. Overview of Ultrasound fusion guided biopsy is an established technique for tissue other techniques for the management of SI joint pain including medical sampling in the abdomen and pelvis, but has not been widely adopted therapy, physical therapy and bracing, prolotherapy, neuroaugmenta- in the musculoskeletal system. In this series, all patients underwent tion, joint injections, and arthrodesis. Examples of radiographic images successful biopsy leading to a diagnosis without any complications. from CT-guided RFA ablations of the SI joint with a description of the Ultrasound-guided fusion is a novel technique for musculoskeletal procedural technique. interventions and should be considered if available.

CONCLUSION AND/OR TEACHING POINTS: Lower back pain is a complex condition with many possible etiologies including SI joint pain. While Abstract No. 774 evidence suggests that RFA can serve as a valuable tool for the treatment of SI joint pain, an understanding of the complex clinical eval- What interventional radiologists need to know about uation, variable anatomy, and procedural technique is necessary to nerve blocks: an anesthesiologist’s perspective identify the appropriate clinical scenario for this procedure and maxi- 1 1 mize its efficacy. J Huang , R Vazquez 1Massachusetts General Hospital, Boston, MA

LEARNING OBJECTIVES: To describe, illustrate, and potentially introduce interventional radiologists to various local/regional anesthesia options as well as cover scenarios in which these blocks could be helpful 18 | Traditional Posters SIR 2020 Annual Scientific Meeting

BACKGROUND: Regional anesthetic techniques are becoming plug. 3) Discussion of associated procedural complications and their increasingly utilized in non-OR anesthesia (NORA) sites, such as the management. 4) Follow-up recommendations and management con- interventional radiology (IR) suite, in an effort to decrease opioid siderations for postprocedural plug failure. administration and increase patient satisfaction. Up to 33% of patients CONCLUSION AND/OR TEACHING POINTS: Porcine-derived extracellular undergoing radiofrequency (RFA) and microwave (MWA) ablations matrix plugs may offer durable outcomes in treating enterocutaneous experience significant postprocedural pain as a sequelae of postabla- fistulae with low rates of complications. However, patient selection and tion syndrome. At our institution we have dedicated IR anesthesia who confirmation of favorable anatomy are critical, and appropriate selec- not only assist during the procedure but also perform preprocedural tion of an alternate fistula closure device on a case-by-case basis may regional anesthesia regularly. be required. Administration is easily reproducible across patients and CLINICAL FINDINGS/PROCEDURE DETAILS: I. Paravertebral block tar- in the appropriate setting, can be repeated successfully in the event gets the thoracic dermatomes as well the celiac plexus and is useful of failure. Follow-up entails not only proper wound care and man- for cases such as liver and renal ablations, transhepatic biliary drains, agement of complications, but also utilization of clinical expertise to as well as cryoablations of the chest wall and abdominal wall. II. Inter- optimize nutritional status and comorbid conditions to provide com- costal block targets the intercostal nerves and is useful for cases such prehensive care. as thoracic procedures, and upper abdominal wall procedures such as gastrostomy tubes III. Transversus abdominal plane (TAP) blocks target the abdominal wall nerves and can be used for placement of Abstract No. 776 drains in the abdominal wall such as gastrostomy tubes and biliary Management of inguinal lymphoceles using an intranodal tubes, as well as drains of the abdominal wall. IV. Erector spinae plane approach: indications, advantages, and limitations of an (ESP) block can provide analgesia of the posterior back and can be emerging technique used for nephrostomy tube placement V. Pectoralis and serratus plane (PECS) block provides analgesia to the upper chest and can be used as G Miller1, D Sheeran1, R Quadri1, J Kim2, A Ray3, A Park1 adjunct for port placements. 1University of Virginia, Charlottesville, VA, 2N/A, Suwon, Republic of Korea, 3Brody School of Medicine at East Carolina University, CONCLUSION AND/OR TEACHING POINTS: Regional anesthesia techniques have been immensely helpful to our practice and beneficial to Greenville, NC our patients and should be performed whenever feasible. LEARNING OBJECTIVES: 1. Review current diagnosis and treatment of inguinal lymphoceles including percutaneous drainage, chemical Abstract No. 775 sclerotherapy, and surgical options. 2. Highlight intranodal glue embolization including indications and technical details. 3. Discuss advan- A plug for porcine extracellular matrix enterocutaneous tages and limitations of intranodal glue embolization. fistula plugs: a primer on improving outcomes BACKGROUND: Inguinal lymphoceles are most commonly seen as com- J Sung1, K Lee2 plications following surgical and catheterization procedures. Initial treatment of postsurgical lymphoceles traditionally involves percuta- 1Weill Cornell Medical Center, New York, NY, 2Weill Cornell Medical neous drainage and chemical sclerotherapy with subsequent surgery College, New York, NY in failed cases. Intranodal glue embolization is an emerging technique

LEARNING OBJECTIVES: 1) Describe current minimally invasive thera- which provides interventionalists with a new tool to treat lymphoceles. pies and devices for treatment of enterocutaneous fistulae. 2) Provide The Learning Objectives of this exhibit are to highlight our institution’s institutional experience of strategies and outcomes using the porcine experience with intranodal lymphangiography and embolization for extracellular matrix fistula plug. 3) Discuss follow-up and multifaceted treatment of inguinal lymphoceles. approach for closure healing, and management of complications and CLINICAL FINDINGS/PROCEDURE DETAILS: The exhibit will use five plug failure. cases from our institution to demonstrate accurate diagnosis and

BACKGROUND: Enterocutaneous fistulae are a regularly encountered subsequent treatment of lymphoceles with intranodal glue. This tech- entity in inflammatory bowel disease and in the postsurgical setting nique appears to be safe based on available literature and serves as with high morbidity and mortality, with few effective treatments. The an effective adjunct treatment with chemical sclerosant therapy and enterocutaneous fistula plug is a minimally invasive modality with percutaneous drainage. In practice, a regional lymph node is punc- promising efficacy in early studies, for which various graft materials tured under ultrasound guidance, and lymphangiography performed and devices have been developed. Careful interventional planning and to demonstrate or refute communication with the lymphatic leak. Once comprehensive follow-up can positively affect therapeutic outcomes. identified, N-butyl cyanoacrylate embolization is performed. There are multiple important considerations during this procedure, such as CLINICAL FINDINGS/PROCEDURE DETAILS: This educational exhibit appropriate recognition of lymphatic drainage patterns, embolic dilu- will present the following: 1) Review of the natural history of disease, tion selection, and recognition of contraindications, such as a venolym- indications, and available minimally invasive interventions in the treat- phatic communication. ment of enterocutaneous fistulae. 2) Case-based demonstrations of highlighted concepts and pitfalls using the porcine extracellular matrix SIR 2020 Annual Scientific Meeting Traditional Posters | 19

CONCLUSION AND/OR TEACHING POINTS: Intranodal glue embolization Abstract No. 778 is a safe and effective tool available in the treatment of postsurgical lymphoceles, particularly in cases where percutaneous drainage or Retrograde access for thoracic duct embolization: a case- chemical sclerotherapy have failed. While future research is required based review to clarify the definitive role of intranodal glue embolization, this initial S Mohammad1, R Abboud2, L Delbono2, M Miller1, K Dickey1, T experience is promising. Downing1 1Wake Forest Baptist Medical Center, Winston Salem, NC, 2Wake Abstract No. 777 Forest School of Medicine, Winston Salem, NC

LEARNING OBJECTIVES: 1. To illustrate techniques for retrograde tho- Percutaneous image-guided cryoneurolysis: an overview racic duct access. 2. To present cases from our institution which high- of applications and technique light some of the variant lymphatic anatomy which can be encountered R Bittman1, J Prologo1 when using this approach. 3. To review postoperative considerations 1Emory University School of Medicine, Atlanta, GA and possible complications relating to thoracic duct embolization.

LEARNING OBJECTIVES: 1) Percutaneous image-guided cryoneurolysis BACKGROUND: Thoracic duct embolization has become a mainstay for is evolving as an effective treatment for a wide variety of pain syn- management of traumatic and nontraumatic chylous leaks which pre- dromes, including osteoarthritic knee pain, inguinodynia, peripheral viously would be managed through either diet modification or surgical neuropathy, headaches, and cancer-related pain. Objectives of this ligation of the thoracic duct. The standard method of pedal/inguinal presentation are to update the evidence and review the indications lymphangiography and transabdominal access of the cisterna chyli and techniques for each of these conditions. 2) The ability to target has been well-established in the literature. However, this approach is nervous structures deep within the body using advanced imaging not always possible and the risk of injury to intraabdominal structures, guidance and percutaneous techniques has given rise to research hemorrhage, and complications related to oil-based contrast use have involving non–pain-related applications for cryoneurolysis, including made retrograde thoracic duct access an appealing alternative. A obesity, sexual disorders, anxiety, and rhinitis. The evidence and tech- working understanding of the methods for retrograde thoracic duct niques of these expanded applications will be reviewed. access and possible anatomic variants which can be encountered is required to ensure successful access. BACKGROUND: The CDC and the US Department of Health and Human Services have prioritized the development and expansion of proce- CLINICAL FINDINGS/PROCEDURE DETAILS: We present 3 cases which dural alternatives to opioids, including cryoablation. As research and highlight approaches to successful retrograde thoracic duct access. clinical translation continue, new procedures, indications, reimburse- Cases presented include 1. A 12-year-old girl who presented with ment models, and evidence have emerged. This presentation seeks to spontaneous chylopericardium related to a congenital lymphatic mal- update Society of Interventional Radiology members in this space. formation. The terminal thoracic duct was percutaneously accessed at the junction of the left internal jugular and subclavian veins 2. A CLINICAL FINDINGS/PROCEDURE DETAILS: We present several case 44-year-old man status post coronary bypass which was complicated examples for pain and non–pain-related percutaneous image-guided by left chylothorax. The thoracic duct was accessed via a transvenous cryoneurolysis applications, followed by supporting evidence and approach from the left vertebral vein. 3. A 74-year-old man status post technical details. The cases include CT-guided genicular nerve cryoab- right upper lobe wedge resection complicated by right chylothorax. lation, cryoablation of the ilioinguinal and genitofemoral nerves for The thoracic duct was accessed via a transvenous approach from the management of inguinodynia, cryoablation of the greater occipital left subclavian vein. nerves, and several examples of direct nerve cryoablation for the management of painful metastatic disease. Beyond pain, we present CONCLUSION AND/OR TEACHING POINTS: Retrograde thoracic duct the latest evidence and techniques associated with percutaneous access is challenging, particularly due the variable position of the CT-guided cryovagotomy, cryoablation of the pudendal nerves for terminal thoracic duct. A deeper understanding of the techniques management of premature ejaculation, and ablation of the stellate used for its localization can help to ensure a higher rate of technical ganglion for PTSD. Updates regarding reimbursement models and success. practice management will be included within the case presentations.

CONCLUSION AND/OR TEACHING POINTS: Percutaneous image-guided Abstract No. 779 cryoneurolysis is a rapidly expanding technique, with ongoing research and clinical translation for both pain and non–pain-related indications. Thyroid radiofrequency ablation: a minimally invasive Amidst evolving reimbursement models, interventional radiologists alternative to surgery for symptomatic benign thyroid have a unique opportunity to embrace and accelerate this existing nodules momentum. J Matson1, J Barrera2, C Hoffman1, A Park1 1UVA Health System, Charlottesville, VA, 2University of South Carolina School of Medicine, Greenville, SC 20 | Traditional Posters SIR 2020 Annual Scientific Meeting

LEARNING OBJECTIVES: This exhibit aims to instruct viewers on how to BACKGROUND: SpineJack is an intravertebral implant characterized by perform thyroid RFA by reviewing the indications, contraindications, controlled craniocaudal expansion for the purpose of vertebral body relevant anatomy, equipment, key techniques, outcomes, potential height and coronal angulation restoration. It is combined with bone complications and their management. cement for treatment of vertebral compression fractures. SpineJack recently received 501(c) clearance from the FDA in September of 2018. BACKGROUND: While most benign thyroid nodules are asymptomatic Initial clinical studies suggest more efficient height and kyphosis cor- and require no treatment, indications for RFA include bulk symp- rection with SpineJack compared to standard vertebroplasty. toms (compression of adjacent structures) and cosmetic concerns for benign nonfunctioning nodules (BNFNs) and clinical hyperthyroidism CLINICAL FINDINGS/PROCEDURE DETAILS: Four patients were treated for autonomous functioning thyroid nodules (AFTNs). at our institution, 2 men and 2 women, with an age range of 63-75 years. Three patients had pathologic fractures related to multi- CLINICAL FINDINGS/PROCEDURE DETAILS: Thyroid RFA is an outpatient ple myeloma or lymphoma and 1 had an insufficiency fracture. Two procedure performed predominantly under local anesthesia, allowing patients received treatment of thoracic vertebra, T7 and T12, and for periodic assessment of laryngeal function via phonation. After 2 patients were treated for L1 fractures. Follow-up ranged from 3-7 perithyroidal lidocaine infiltration, the RF needle is directed into the months. All patients reported improvement in their symptoms with nodule using the transisthmic approach, from medial (isthmus) to the 3 reporting complete resolution of their pain. Increase in middle ver- lateral (nodule). The nodule is divided into conceptual ablating units tebral body height ranged from 1-20 mm. Both patients with lumbar which are smaller at the periphery of the nodule and in areas adjacent fractures experienced an increase in lordotic angle of 8-10 degrees. to critical structures such as the recurrent laryngeal and vagus nerves, One patient with thoracic fracture experienced increase in kyphotic trachea, esophagus, carotid artery and jugular vein. Initially, the elec- angle of 10 degrees. The other patient with a thoracic fracture did not trode tip is positioned in the deepest portion of the nodule and the have adequate imaging for angle evaluation. One patient had multiple moving shot technique is utilized to successfully treat each concep- subsequent fractures involving adjacent vertebra during the follow-up tual ablating unit under continuous ultrasound visualization. Treatment period; however, this patient also had multiple myeloma, confounding effect is progressive over time with reduction in nodule volume shown the results. to be 33-58% at 1 month and 51-85% at 6 months. Durability of RFA has been shown with mean volume reduction of 80% at 12 months, CONCLUSION AND/OR TEACHING POINTS: SpineJack is a promis- 84% at 24 and up to 95% at 60 months. RFA is effective in treatment ing treatment for thoracic and vertebral compression fractures and of AFTNs, improving abnormal thyroid function and often reducing resulted in consistent pain improvement and increase in vertebral required anti-thyroid drugs. Complications are rare but include voice body height and coronal angle in our initial patient cohort. change, pain, skin burn, tumor rupture, hematoma, and vomiting. Most complications are transient and resolve without intervention. Abstract No. 781 CONCLUSION AND/OR TEACHING POINTS: RFA is a safe and effective alternative to surgery for benign thyroid nodules demonstrating excel- Unvexing the Rex shunt: a review of surgical and lent, durable reduction in nodule volume, nodule-related symptoms, endovascular management of extrahepatic portal venous and cosmetic concerns with progressive reduction in nodule size over obstruction in pediatric patients time. Viewers will receive an up-to-date primer on thyroid RFA. E Speir1, P Vakil2, M Kohi3, M Heller4 1UCSF, San Francisco, CA, 2University of California, San Francisco, Abstract No. 780 San Francisco, CA, 3N/A, Tiburon, CA, 4University of California, San Francisco, N/A Initial experience with SpineJack for thoracic and lumbar vertebral compression fractures LEARNING OBJECTIVES: 1) Explore various causes and clinical manifestations of extrahepatic portal venous obstruction (EPVO) in pedi- 1 2 3 4 5 6 J Jia , J Sakioka , E Nguyen , A Ravilla , E Rosenthal , D Rex , M atric patients. 2) Detail the relevant surgical anatomy of mesoportal 7 8 Gulati , I Lekht (or Rex), splenorenal, and mesocaval shunts. 3) Understand the role 1Kaiser Permanente, Los angeles, CA, 2Kaiser Permanente, Los of interventional radiology (IR) in preprocedural shunt planning and Angeles, CA, 3Kaiser Permanente- Los Angeles Medical Center, management of shunt failure. Los Angeles, CA, 4Kaiser Permanente Los Angeles, Los Angeles, CA, 5N/A, Los Angeles, CA, 6Kaiser Permanente Medical Center, BACKGROUND: Extrahepatic portal vein obstruction (EPVO) occurs in Los Angeles, CA, 7Keck School of Medicine, Los Angeles, CA, 8N/A, pediatric patients secondary to a variety of intrauterine and neonatal Calabasas, CA causes including congenital portal vein atresia, prothrombotic states, and umbilical vein cannulation. EPVO results in prehepatic portal LEARNING OBJECTIVES: 1) To review the mechanism, procedural steps, hypertension leading to portal biliopathy, hypersplenism, and variceal and relevant literature regarding the recently available SpineJack hemorrhage. Surgical shunts, including mesoportal (or Rex), sple- system for vertebral compression fractures. 2) To present 4 cases of norenal, and mesocaval shunts, are the mainstay of therapy in these patients treated using SpineJack with special attention to symptom- patients. Although surgical shunts have a high rate of primary patency, atic relief and structural effects. SIR 2020 Annual Scientific Meeting Traditional Posters | 21

long-term shunt failure is a well-known complication. IR plays a crucial strategies. Finally, we will discuss future directions of radiation safety, role both in shunt planning as well as management of shunt failure. especially as the volume of cases in IR grows.

CLINICAL FINDINGS/PROCEDURE DETAILS: After reviewing the surgical CONCLUSION AND/OR TEACHING POINTS: There are persistent limita- anatomy and indications for various surgical shunts, we will explain tions with current efforts to minimize radiation exposure. As IR grows the role of IR in preoperative planning. We will then highlight pertinent into a primary speciality, there will be a need for more attempts to imaging modalities and findings in the surveillance and identification innovatively solve this problem, either by focusing on reducing radi- of shunt dysfunction. Using a pictorial case review, we will then explore ation exposure within the room from equipment or by reducing the various endovascular techniques used in recanalization of these surgi- physical burden and risk of radiation exposure for IR personnel. cal shunts. Specifically, we will discuss the role of venoplasty, pharmacologic and mechanical thrombectomy as well as stenting via different percutaneous access routes, including transjugular, transhepatic, and Abstract No. 783 transsplenic approaches. We will conclude by reviewing primary-as- Addressing barriers to evaluation and management sisted patency rates and freedom-from-reintervention duration services at interventional radiology practices by utilizing among our patient cohort and in the literature. dictation-friendly templates CONCLUSION AND/OR TEACHING POINTS: Endovascular intervention H Shaikh1, L Ranzenberger1, A Patel1, J Murray1, M Abdulla2, J is a minimally invasive and effective approach to the management of Stenz3 failing surgical shunts pediatric patients with EPVO. Knowledge of rel- 1 evant shunt anatomy as well as recognition and skillful management Michigan State University/McLaren Health, Mount Clemens, 2 of shunt failure are vital for the practicing interventional radiologist. MI, Michigan State University College of Osteopathic Medicine, Detroit, MI, 3McLaren Macomb Hospital, Mount Clemens, MI

LEARNING OBJECTIVES: Describe the current barriers of evaluation and Abstract No. 782 management (E&M) code optimization at interventional radiology (IR) A huge weight on our shoulders: radiation safety in the departments. Highlight potential financial and communication bene- angio suite fits by integrating dictation-friendly templates. Explore ways to integrate E&M within radiology training programs. A Khurana1, A Kilgore1, I Breen1, A Wallace2, J Kriegshauser2, S Alzubaidi2, I Patel2, M Knuttinen3, S Naidu3, R Oklu2 BACKGROUND: Despite some institutions implementing clinically oriented approaches, IR departments continue to underutilize E&M ser- 1Mayo Clinic School of Medicine, Phoenix, AZ, 2Mayo Clinic Arizona, vice codes and fail to maximize RVUs. IR physicians routinely perform Phoenix, AZ, 3Mayo Clinic Arizona, Scottsdale, AZ evaluation and management services, but often fail to document and

LEARNING OBJECTIVES: 1) Review the radiation risk of various common bill for these services. Barriers to documentation include the lack of a procedures that interventional radiologists perform. 2) Understand standardized note template and limited exposure to billing practices the difficulties with minimizing radiation exposure, including physician. during training. The design and implementation of a standard con- 3) Highlight various innovations in radiation safety. sultation note template to be completed via dictation would enhance communication among providers while simultaneously optimizing BACKGROUND: Interventional radiologists heavily utilize fluoroscopy billing. Additionally, greater compliance with the 2019 CPT codes for and CT imaging to accurately perform their minimally invasive cath- interventional procedures could be achieved with the use of a standard eter-based procedures. Of all imaging procedures, fluoroscopically consultation note, thereby improving patient safety. guided interventional procedures deliver the highest radiation dose. There are many different versions of radiation protection that can CLINICAL FINDINGS/PROCEDURE DETAILS: Dictation-friendly consult be grouped into two groups: equipment-based radiation protection and progress note templates, applicable to both inpatient and outpa- and personal radiation protection. It is important for interventional tient settings, will be provided for on-service residents. Templates will radiology (IR) personnel to understand how each of these radiation include essential components (history, physical and medical decision safety interventions interacts with the radiation emitted from imaging making) to maximize billing and transparency. Another template fea- machines during procedures. ture to optimize documentation is a thorough presedation evaluation. Reference E&M codes and current modifiers for interventional pro- CLINICAL FINDINGS/PROCEDURE DETAILS: We will present an overview cedures will be made readily available. The implications of the Global of various strategies to minimize radiation exposure for personnel and Periods framework put forth by the CMS will be reviewed. E&M docu- patients while in an IR procedure. We will review the data on radiation mentation utilizing preexisting PACS infrastructure incentivizes usage exposure for commonly performed procedures for IR as well as dis- among radiologists while making information readily accessible to cuss current limitations with ensuring radiation safety, such as mus- referring providers. culoskeletal strain from personal equipment and proximity to imaging machines during the procedure. Then we will discuss data on new CONCLUSION AND/OR TEACHING POINTS: Standardized IR documenta- innovations in radiation safety to determine the efficacy of these new tion is an attainable high-value healthcare strategy for improving provider communication while capturing potential revenue in IR practices. 22 | Traditional Posters SIR 2020 Annual Scientific Meeting

We addressed potential barriers to documentation by designing a LEARNING OBJECTIVES: The Learning Objectives of this exhibit are to comprehensive template and reviewing fundamental billing practices. review the factors influencing room turnover time in interventional radiology (IR) and to identify the parameters that we have been using to improve room turnover time through an electronic system designed Abstract No. 784 to guide requests for inpatient transportation.

Development of a shared productivity and financial BACKGROUND: In most hospitals, increasing procedural volume and model for multidisciplinary care pressure to reduce length-of-stay are raising expectations for service in IR. However, variability in patient transportation time is almost always S Dybul1, M Back2, J Eklund2, B Gillespie1, K Kusnier1, G Seabrook3, a barrier towards optimizing efficiency. As a result, we developed an J Mayer1, W Rilling1, S Tutton3, P Patel1, P Rossi1, R Hieb1 interactive scheduling tool to make data-driven decisions regarding 1 2 Medical College of Wisconsin, Milwaukee, WI, Froedtert and the when to initiate transportation requests with the goal of reducing 3 Medical College of Wisconsin, Milwaukee, WI, Froedtert Memorial room turnover time and transportation delays. Data related to oper- Lutheran Hospital, Milwaukee, WI ational efficiency was collected over a 10-month period and included

LEARNING OBJECTIVES: Multidisciplinary approaches to patient care procedure type, inpatient location, transportation time, preparation have been shown to improve patient outcomes. Within our current time, and room turnover time. This data was collected from our elec- fee-for-service payment model, collaborative care is not incentivized tronic scheduling system which stores this information for all patients. for the majority of interventional radiology procedures, as only one Using this data, a computer-based tool was developed to guide the physician can bill for the majority of shared services. The Learning timing of transportation requests based on the inpatient location and Objective of this study is to demonstrate that shared billing can allow the procedure being completed prior to patient arrival. reporting of productivity metrics and accurately capture shared work CLINICAL FINDINGS/PROCEDURE DETAILS: A total of 2,222 inpatient performed. procedures performed on patients from 27 different inpatient units

BACKGROUND: At our institution, we developed a model within our were performed during the study period. The mean transportation professional billing system to address concerns with shared proce- time from all units was 42 minutes (range, 23-103 minutes), and the dures. Our coding staff apply “dummy modifiers” to the shared CPT mean room turnover time was 44 minutes. Using this data, an inter- codes. These modifiers have two purposes: to allow work relative value active tool that calculates the optimal time to send for a patient prior units (wRVUs) to be captured and divided equally between the two to completion of a given case was developed. By inputting several of servicing providers for purposes of reporting physician productivity, the variables listed above, this tool predicts when to call for the next and to allow for revenue to be identified and shared easily. patient so that their arrival time closely corresponds to the room-ready time. CLINICAL FINDINGS/PROCEDURE DETAILS: In fiscal year 2019, 152 procedures (diagnostic and interventional) not eligible for a co-surgeon CONCLUSION AND/OR TEACHING POINTS: It is feasible to develop a (-62) modifier were performed in a collaborative nature between the computer-based tool to help determine when to initiate a transpor- divisions of Vascular/Interventional Radiology and Vascular and Endo- tation request for an inpatient requiring an IR procedure. This tool can vascular Surgery. The “dummy modifier” was used for these cases. The maximize efficiency by decreasing room turnover time. Implementa- total wRVU collection for these procedures was 1753.2. Previously, all tion of this tool into current workflow can lead to further optimization of these wRVUs would be attributed to a single division. With use of of the tool itself and patient throughput in a busy IR practice. our modifiers, each division was able to collect 876.6 wRVU from these shared procedures. Abstract No. 786 CONCLUSION AND/OR TEACHING POINTS: Strong interdisciplinary relationships are important for the survival of our specialty. To discourage Factors influencing successful implementation of a joint internal competition and promote collaborative care, it is important to internal medicine–interventional radiology bedside develop a model that can support the allocation of wRVUs and reve- procedure service at a large tertiary academic center nue amongst the physicians involved. With our model, each division A Zhou1, C Herzke1, K Hong1 can accurately capture the shared work performed. 1Johns Hopkins Hospital, Baltimore, MD

LEARNING OBJECTIVES: Describe the development of a novel bedside Abstract No. 785 procedure service jointly managed by the Department of Medicine (DOM) and the Division of Interventional Radiology (IR) at a large Development of an interactive scheduling tool to increase academic center. Identify key aspects of the business proposal which throughput in a high-volume interventional radiology aided in obtaining funding to promote adoption and successful imple- practice mentation of similar services at other hospital systems. A Chockalingam1, C Stark1, R Brooks1, M Fickes1, L Keating1, A Herr1, G Siskin1 BACKGROUND: In 2015, multiple paracentesis-related sentinel events prompted examination of our DOM’s existing Central Procedure Ser- 1Albany Medical Center, Albany, NY vice (CPS). Root cause analysis highlighted insufficient training and SIR 2020 Annual Scientific Meeting Traditional Posters | 23

major structural limitations within the CPS contributing to unsafe prac- CMS made several adjustments to address the concerns of potentially tice. To improve patient outcomes, DOM and IR leadership proposed affected physicians, including IR. Among the adjustments made, CMS and implemented the Joint IM-IR CPS in 2016. Since implementation, decided to only consolidate outpatient visit levels 2 through 4, with a this joint service has resulted in higher-than-predicted case volume, no distinct level 5 visit maintained at an increased RVU to reflect man- major complications, and overall positive cost-benefit at our institution. agement of particularly complex patients. Physicians will now also be allowed to justify billing levels based on either the current standard CLINICAL FINDINGS/PROCEDURE DETAILS: The Joint IM-IR CPS intro- of documentation, time spent with a patient or the extent of medical duced the following major structural changes: expanded full-time pro- decision making. Finally, CMS created an add-on code to modify level cedural staff trained by IR; centralized scheduling and image storage 2 through 4 visits when extended time is spent with a patient. These through existing IR structures; and dedicated IR suite for back-up and changes, finalized November 1, 2018, are scheduled to take effect in overflow coverage. Persuasive safety benefits delineated in the busi- 2021. ness proposal included: enhanced house-staff training in all departments through IR, decreased complications (defined by MHACS), and CONCLUSION AND/OR TEACHING POINTS: The finalized 2019 changes increased provider and patient satisfaction (measured by HCAHPS to E&M CPT codes are designed to streamline documentation and and internal surveys). Valued financial benefits included: decreased billing and maintain fair reimbursement for outpatient management length-of-stay and decreased legal claims (estimated with histori- of complex and time-consuming patients. Taking effect in 2021, these cal cost data). To secure funding, the service’s financial viability was changes will greatly impact the financial viability of the IR outpatient demonstrated via comprehensive calculation of immediate labor clinic. and nonlabor costs, as well as a five-year budget plan accounting for variables over time such as high up-front costs, inflation, staff adjust- CPT Code Changes for IR E&M Billing ments, and increasing procedure demand. Visit Level, New 2018 RVUs Proposed 2019 RVUs Finalized 2021 RVUs 1 0.48 0.48 0.48 CONCLUSION AND/OR TEACHING POINTS: Collaboration between IR and DOM can greatly improve outcomes and productivity of hospital 2 0.93 1.90 1.76 bedside procedure services. Clear presentation of the benefits and 3 1.42 1.90 1.76 financial requirements, both immediate and future, are key for obtain- 4 2.43 1.90 1.76 ing institutional approval and funding for such services. 5 3.17 1.90 3.17 Visit Level, Established Abstract No. 787 1 0.18 0.18 0.18 2 0.48 1.22 1.18 Outpatient reimbursement and the interventional 3 0.97 1.22 1.18 radiology clinic: a review of the finalized 2019 CMS 4 1.50 1.22 1.18 evaluation and management CPT code changes 5 2.11 1.22 2.11 A Moore1, S Nguyen1, N Lafitte1, W Terrell1, M Mulatre1, R Trojan1

1 Integris Baptist Medical Center, Oklahoma City, OK Abstract No. 788

LEARNING OBJECTIVES: To review both the proposed and finalized Structured reporting in interventional radiology 2019 changes to the Current Procedural Terminology (CPT) codes for evaluation and management (E&M) services as described by the Cen- A Saini1, P Hoang1, I Altun1, A Sill1, J Kriegshauser1, I Patel1, ter for Medicare & Medicaid Services (CMS) in relation to the field of M Knuttinen2, S Alzubaidi1, S Naidu2, R Oklu1 interventional radiology (IR). 1Mayo Clinic Arizona, Phoenix, AZ, 2Mayo Clinic Arizona,

BACKGROUND: As IR continues to grow as an independent specialty, it is Scottsdale, AZ paramount that physicians maintain an understanding and awareness LEARNING OBJECTIVES: Provide an overview of structured reporting, of CMS outpatient visit reimbursement changes. E&M codes—which its utility in data integration, and the pressing need for specialty-wide categorize outpatient encounters as “new patient” (CPT 99201-99205, adoption within interventional radiology (IR). Review the benefits of Levels 1-5) or “established patient” (CPT 99211-99215, Levels 1-5)—rep- utilizing structured reporting including practice quality improvement, resent increasing complexity of care with correspondingly increased facilitation of patient registry data collection, and administrative/med- Relative Value Units (RVUs). Significant changes to this reimbursement icolegal considerations. Discuss recent analyses that support struc- paradigm were proposed, discussed and finalized by CMS in 2019. tured reporting in IR.

CLINICAL FINDINGS/PROCEDURE DETAILS: Potential revisions to CMS BACKGROUND: Procedural and postprocedural reporting in IR has the reimbursement for outpatient E&M coding for 2019 were published on potential to provide a wealth of quality and outcomes data that is July 27, 2018. Initially, CMS proposed consolidating visit levels 2 through necessary to substantiate the value of the specialty to various stake- 5 for both new and established patients—effectively averaging their holders. Current reporting practices lack the structure and uniformity RVU values—in order to simplify and streamline billing and documen- needed to easily extract and utilize this data for the advancement of tation. Due to feedback received during the interim proposal period, 24 | Traditional Posters SIR 2020 Annual Scientific Meeting

the field. Further structuring of generated reports through the stan- prolonged clinic encounters. To estimate the potential financial impact dardization of language and style used, data collected, and adherence of these changes, we analyzed IR outpatient E&M billing data for CPT to professional society guidelines will allow for the seamless collection codes 99201-99205 and 99211-99215. There were a total of 135,444 and dissemination of safety, efficacy and quality improvement data RVUs billed by IR to CMS in 2017. When scaled to match the finalized that can further the field. Structured reporting in IR can facilitate data 2019 and proposed 2020 RVU changes, these are projected to increase entry into clinical research registries, providing objective data needed to 142,842 and 166,627 RVUs (a 5.2% and 23% increase), respectively. to determine the safety, efficacy, and outcomes of procedures. It may CONCLUSION AND/OR TEACHING POINTS: The proposed 2020 changes also help to provide performance and quality metrics data, improve to E&M CPT coding, which would take effect in 2021, could result in an communication among stakeholders, and simplify billing procedures. up to 23% increase in revenue from outpatient IR clinic visits. These Recent analyses on the utility of structured versus free reporting have changes should further establish the financial viability of IR in the out- shown that it facilitates compliance with reporting requirements, patient clinic setting. reporting and coding efficiency, and satisfaction among radiologists and referring physicians. Interventional Radiology E&M CPT Codes

CLINICAL FINDINGS/PROCEDURE DETAILS: Through the use of illus- Outpatient Visit Level 2017 RVUs 2019 RVUs Proposed CPT Code 2020 RVUs trative diagrams, the value of structured reporting will be elucidated. Recent studies examining the benefits of structured versus free report- 99201 Level 1 (new) 0.48 0.48 N/A ing will be reviewed. Examples of structured reports will be illustrated. 99202 Level 2 (new) 0.93 1.76 0.93 99203 Level 3 (new) 1.42 1.76 1.60 CONCLUSION AND/OR TEACHING POINTS: Structured reporting can 99204 Level 4 (new) 2.43 1.76 2.60 seamlessly provide the outcomes-based data needed to further demonstrate the value of IR. They can also facilitate coding for reim- 99205 Level 5 (new) 3.17 3.17 3.50 bursement and reduce subjectivity of the reports. 99211 Level 1 (established) 0.18 0.18 0.18 99212 Level 2 0.48 1.18 0.70 99213 Level 3 0.97 1.18 1.30 Abstract No. 789 99214 Level 4 1.50 1.18 1.92 The changing financial landscape of interventional 99215 Level 5 2.11 2.11 2.80 radiology clinic: implications of the proposed 2020 CMS evaluation and management CPT code changes Abstract No. 790 S Nguyen1, A Moore1, W Terrell1, N Lafitte1, M Mulatre1, R Trojan1 The impact of advanced directives on the informed 1Integris Baptist Medical Center, Oklahoma City, OK consent process LEARNING OBJECTIVES: To review the proposed 2020 changes to the A Sayegh1, S Narayan1, N Doro1, L Keating1, C Stark1, A Herr1, G Current Procedural Terminology (CPT) codes for evaluation & man- Siskin1 agement (E&M) services as described by the Centers for Medicare 1 & Medicaid Services (CMS). We then evaluate the potential financial Albany Medical Center, Albany, NY impact of these changes on the field of interventional radiology (IR). LEARNING OBJECTIVES: To review the advanced directives that are

BACKGROUND: The establishment of financially viable outpatient clin- available to help guide care in the event that a patient is unable or ics is imperative for the growth of IR as a clinical specialty. To achieve incapable of making treatment-related decisions for themselves and this goal, IR physicians must be aware of potential reimbursement discuss how these advanced directives impact the informed consent changes for outpatient clinic visits as reflected in CMS E&M CPT codes. process occurring before an interventional radiology (IR) procedure.

These codes categorize outpatient encounters as “new patient” (CPT BACKGROUND: In an effort to maintain control over their individual 99201-99205, Levels 1-5) or “established patient” (CPT 99211-99215, healthcare, patients are often turning to advanced directives to clarify Levels 1-5). Modified in 2019 to take effect in 2021, the Relative Value their wishes in the event that their ability to make decisions is com- Units (RVUs) for levels 2 through 4 are slated to be merged with an promised. As part of the informed consent process, providers must be optional modifier for extended visits. Additionally, there will still be a aware of any advanced directives that have been put into place prior distinct level 5 for complex patient encounters. Newly proposed 2020 to that encounter. For example, living wills and documents assigning revisions to these E&M CPT codes were published by CMS on August other individuals as a power of attorney or health care proxy impact 14, 2019, for open consideration prior to finalization. the informed consent process by outlining who is empowered to make

CLINICAL FINDINGS/PROCEDURE DETAILS: The new CMS proposals decisions and what procedures may be appropriate in the context of seek to reinstate distinct RVU reimbursements for the five patient end-of-life care. encounter levels. Visit level would be determined by medical decision CLINICAL FINDINGS/PROCEDURE DETAILS: It has been our recent expe- making or time, rather than the history and exam. CPT code 99201 rience in the context of our IR practice, that an increasing number of would now be utilized for clinic visits by established patients without patients have advanced directives in place. Reviewing appropriately physician contact. A new service code, 99XXX, would be available for SIR 2020 Annual Scientific Meeting Traditional Posters | 25

completed and signed paperwork, such as a MOLST form, is the with subsequent respiratory failure, and encephalopathy precluding first step in carrying out the wishes of a patient. Once that is done, extubation. Recommendations include proposed actions to prevent the treatment plan can be reviewed with the patient or appropriate future similar problems, which in these cases included delaying an individuals to ensure compliance with the documents. This includes a elective TIPS in the setting of bacteremia and delaying extubation in discussion with a patient with a DNR in place regarding the degree patients with altered preprocedure mental status. to which procedural sedation or general anesthesia is appropriate or CONCLUSION AND/OR TEACHING POINTS: The SBAR format provides how complex a procedure should be in such a patient. This exhibit will a framework to move M&M discussions beyond individual and tech- define the advanced directives available to patients and then review nical factors to potentially more impactful systems improvement how the informed consent process and the performance of procedures opportunities. are potentially impacted by these directives.

CONCLUSION AND/OR TEACHING POINTS: The informed consent process prior to an interventional procedure is greatly impacted by the Abstract No. 792 presence of one or more advanced directives. Prior to obtaining con- Utilizing time-driven activity-based costing in sent, all patients must be asked about advanced directives and if pres- interventional radiology ent, the wishes that are outlined in those documents must be honored to the extent that is possible. This requires an understanding of these C Price1, A Pillai2, D Lamus3, M Reddick4 documents by all IR providers, which may be facilitated by this exhibit. 1University of Texas Southwestern Medical Center, Dallas, TX, 2University of Texas Health Science Center, Dallas, TX, 3University of Texas Southwestern Medical School Program, Abstract No. 791 Dallas, TX, 4N/A, Coppell, TX

SBAR: a proposal to improve the quality of morbidity and LEARNING OBJECTIVES: •To introduce the concept of TDABC and mortality discussions in interventional radiology value-based health care •To understand the methodology for cre- S Cheng1, D Hovsepian2, G Hwang3 ating a process map for interventional radiology (IR) workflow •To demonstrate an example of TDABC as applied to an IR workflow •To 1Stanford University, Stanford, CA, 2Stanford University, Palo Alto, conceptualize and analyze benchmarking for measuring operational CA, 3Stanford University Medical Center, Stanford, CA efficiencies and cost for common IR procedures.

LEARNING OBJECTIVES: Describe the Situation, Background, Assess- BACKGROUND: Time-Driven Activity-Based Costing (TDABC) is a key ment, and Recommendation (SBAR) format to standardize and component of value-based health care used to analyze costs of var- improve the quality of morbidity and mortality (M&M) discussions in ious processes. A detailed process map must be generated includ- interventional radiology (IR). ing all resources, direct and indirect, involved at each step. Costs are

BACKGROUND: There is immense potential in learning from medical assigned to each resource on a per-minute basis then multiplied by the errors, complications, and unanticipated outcomes at a M&M confer- required time. The result is an invaluable tool to compare processes, ence, provided that the focus is on improvement opportunities and not identify areas of waste or modifiable drivers of cost, and reduce total culpability. Technical details tend to dominate discussions; to redirect cost of a patient encounter. the focus to improvement opportunities, we propose the SBAR format. CLINICAL FINDINGS/PROCEDURE DETAILS: The vital step of TDABC We use as examples, two unanticipated deaths within 30 days after analysis is generating a thorough process map by observing the pro- transjugular intrahepatic portosystemic shunt (TIPS). cess in action, interviewing personnel, and verifying the process map

CLINICAL FINDINGS/PROCEDURE DETAILS: SITUATION is the statement with all active contributors including nurses, technologists, faculty, of problem. One patient died of sepsis 3 days after TIPS for refrac- residents, schedulers, and patients. Each step is assigned a time-based tory ascites; the second patient died of aspiration 3 days after TIPS cost association based on direct and indirect costs. For example, total for severe hydrothorax. BACKGROUND includes pertinent patient his- operational cost for an angiography suite is $539/hour. Based on an tory, such as patient workup and known risk factors. The first patient average angiography procedure of 38 minutes, this step is assigned had alcoholic cirrhosis with recurrent ascites. TIPS was postponed for a cost of $341.37. To maintain a comprehensive view of healthcare 8 days due to positive blood cultures. The second patient had alco- costs, this procedure must be repeated for each step in the process holic cirrhosis and had a previously failed attempt at TIPS due to small map as the above is a small percentage of the total cost of the patient hepatic veins. ASSESSMENT is a root cause analysis, typically pre- encounter. Upon completion of multiple iterations, the 50th percentile sented as a fishbone diagram of patient, provider/team, environment, cost of each step can be used to establish an institutional benchmark. policy, and equipment factors, including before, during, and after pro- Comparison of variations in efficiency centered around the institu- cedure. REVIEW OF LITERATURE should include a search on potential tional benchmark will identify weak links and establish accountability root causes and, if available, similar cases within the institution. We to enhance the value of services provided. looked at both uncomplicated patients with matched risk factors and CONCLUSION AND/OR TEACHING POINTS: TDABC has yet to become other patients with the same causes of death in our TIPS patient data- regular practice in IR. However, value-based health care is critical for base. Common causes of death after TIPS included sepsis, aspiration the future of IR and workflow mapping is essential to achieve this. In 26 | Traditional Posters SIR 2020 Annual Scientific Meeting

IR, TDABC and benchmarking practice can be instrumental in under- Abstract No. 794 standing efficiency, managing costs, and justifying reimbursement by employing the power of step-wise cost comparison. Hepatic venous interventions after orthotopic liver transplant

1 2 1 3 Abstract No. 793 M Brown , C Molvar , A Roth , J Kus 1Loyola University Medical Center, Maywood, IL, 2N/A, Chicago, Portal vein recanalization with transjugular intrahepatic IL, 3N/A, Lockport, IL portosystemic shunt: a new hope for patients with LEARNING OBJECTIVES: 1. Describe the surgical options for venous cirrhosis and portal venous thrombosis anastomosis in orthotopic liver transplant (OLT) 2. Understand the E Speir1, P Vakil2, E Lehrman1, K Kolli1, M Heller3 technical challenges they pose for hepatic venous interventions 3. 1UCSF, San Francisco, CA, 2N/A, Chicago, IL, 3University of Delineate strategies to recognize and overcome these challenges in California, San Francisco, N/A the posttransplant population.

LEARNING OBJECTIVES: 1) Review the prevalence, pathogenesis, and BACKGROUND: Hepatic venous interventions in patients after OLT consequences of PVT in patients with cirrhosis. 2) Describe the role of include transvascular pressure measurements, biopsy, and stent place- anticoagulation in the management of PVT and following PVR-TIPS. 3) ment. This visual display will describe the common OLT venous anas- Highlight various techniques used in PVR-TIPS using a pictorial case tomoses and address the challenges they pose to the interventionist. review. 4) Discuss clinical outcomes of patients undergoing PVR-TIPS CLINICAL FINDINGS/PROCEDURE DETAILS: Surgical techniques used to including patency rates, complications, and implications for possible reconstruct the hepatovenous system have evolved resulting in improved liver transplant. OLT outcomes. The conventional (bicaval) method removes the recipi-

BACKGROUND: Portal vein thrombosis (PVT) has a reported prevalence ent retrohepatic inferior vena cava (IVC) along with the liver, requiring of 10-25% in patients with cirrhosis. Although traditionally regarded as IVC cross-clamping. Many surgeons have adopted an approach in which a hypocoagulable state, cirrhosis has been shown to increase throm- the recipient IVC is left intact, anastomosing the recipient’s venous cuff botic potential as demonstrated by recent clinical and in vitro stud- of hepatic veins to the donor’s suprahepatic IVC in a “piggyback” fash- ies. Decreased portal velocities from splanchnic dilatation along with ion. More recently, transplant centers use a cavo-caval approach in which increased resistance caused by intrahepatic fibrosis further predispose the donor suprahepatic IVC is anastomosed directly to the recipient IVC patients to PVT. In addition to increasing risk of variceal bleeding and in a side-to-side fashion. The piggyback and cavo-caval methods avoid intestinal infarction, PVT is associated with increased perioperative IVC cross-clamping, therefore maintaining perfusion and limiting hemo- morbidity and mortality in patients undergoing liver transplant and is dynamic instability. Post-OLT vascular interventions are difficult given an independent risk factor for increased 1-year posttransplant mortal- anatomy often does not mimic that of a native liver. This is especially ity. However, by providing a patent portal vein and thereby enabling an true in OLT recipients with cavo-caval anastomosis as the intervention- end-to-end anastomosis, PVR-TIPS can improve transplant candidacy ist must navigate the mentioned side-to-side anastomosis of the IVC. In and peri-transplant morbidity and mortality in patients with PVT. this patient population, a femoral approach is an alternative method to achieve successful hepatic venous interventions. CLINICAL FINDINGS/PROCEDURE DETAILS: We will review three cases of PVR-TIPS performed at our institution for patients with cirrhosis CONCLUSION AND/OR TEACHING POINTS: Post-OLT hepatic venous and portal vein thrombosis in a variety of clinical contexts. The cases interventions are challenging given altered anatomy. Our aim is to will highlight various techniques for portal vein recanalization, includ- describe the common venous anastomoses with the aid of pictorial ing transhepatic and transsplenic access, as well as techniques for examples, discuss problems they pose in hepatic venous interventions, mechanical and pharmacologic thrombectomy. Peri-procedural care and offer strategies to maximize success. will be reviewed with a focus on the role of anticoagulation and management of potential complications. We will then detail patency rates Abstract No. 795 among our full patient cohort and compare these rates to larger case series reported in the literature. Percutaneous management of post liver transplantation

CONCLUSION AND/OR TEACHING POINTS: PVR-TIPS is a safe and effec- complications tive intervention that reduces complications of PVT in patients with F Razjouyan1, G Peters1 cirrhosis, especially in those undergoing liver transplant. 1Emory University, Atlanta, GA

LEARNING OBJECTIVES: To review common complications of liver transplantation. To show interventional techniques used to treat vascular and nonvascular complications of liver transplant.

BACKGROUND: Liver transplantation is an accepted treatment option for acute and chronic liver disease. However, it remains a complex SIR 2020 Annual Scientific Meeting Traditional Posters | 27

procedure with complications that may limit long-term success of the Endovascular modes of treatment are attractive due to the minimally procedure. Posttransplant complications can occur immediately or invasive nature and the complexity/morbidity of repeat surgery. Clear remotely. The most common and clinically important complications understanding of the transplant vascular anatomy is critical for suc- include arterial and venous stenosis/thrombosis, fluid collections, cessful endovascular management. Treatment methods may involve biliary complications, and graft rejection. Knowledge of common thrombectomy, angioplasty, stent placement and embolization based postoperative complications with early and accurate diagnosis and on the pathology and anatomy. Approach to the transplant vascula- prompt, appropriate intervention are essential for optimal outcomes. ture may be from contralateral or ipsilateral CFA access. Cases and The minimally invasive nature and lower morbidity associated with treatments from a single large volume transplant center are reviewed interventional radiology procedures make them preferable to surgery. to provide the reader a better understanding of this complex subject. Percutaneous management is increasingly utilized in the management CONCLUSION AND/OR TEACHING POINTS: Interventional Radiologist of these patients with high success and low complication rates, often plays an important role in the management of vascular complications obviating the need for surgery. following pancreas transplant. Clear understanding about the trans- CLINICAL FINDINGS/PROCEDURE DETAILS: We will show a series of plant vascular anatomy and review of current literature is important to cases demonstrating the gamut of posttransplant complications. We manage this complex set of patients. This education exhibit is aimed will describe the clinical presentation, show classic imaging appear- at increasing the awareness and knowledge about the anatomy and ances and illustrate interventional techniques used to successfully pathology of the transplant pancreas. manage these complications. The following will be presented: Non- vascular complications: postoperative hematoma and abscess; biliary complications: biliary anastomotic leak and anastomotic stenosis; vas- Abstract No. 797 cular complications: hepatic artery thrombosis, hepatic artery/portal Capturing crusty catheters: advanced techniques for the vein/IVC stenosis and splenic steal. Traditional and “piggyback” trans- removal of ports with prolonged dwell times plant configurations will be shown and both duct-duct and choledochojejunal biliary anastomotic complications will be demonstrated. B Dubois1, J Mahn1, M Cline1, B Pomerantz1, S Kazanjian1

1 CONCLUSION AND/OR TEACHING POINTS: Liver transplant is a life-sav- University of Michigan, Ann Arbor, MI ing operation. Complications can result in graft failure/loss and poor LEARNING OBJECTIVES: To describe the different advanced techniques patient outcomes. The early identification and minimally invasive used at a tertiary institution and in the literature for the removal of percutaneous treatment of many of these complications results in ports with prolonged dwell times. improved graft and patient survival, often precluding the need for re-transplantation. BACKGROUND: Ports make up a significant share of the over 5 million long-term central venous access devices placed each year in the United States. Port-associated long-term complications include infection Abstract No. 796 (estimated at a rate of 0.21 per 1000 port-days), venous stenosis (risk proportional to dwell time), venous thrombosis (up to 59% of ports), Vascular complications of pancreas transplantation: role and fracture with distal embolization (up to 3%). With the increasing of interventional radiologist number of port placements there has been a corresponding rise in the S Sharma1, S Young2, J Wong1 number of devices with prolonged dwell times (typically patients lost to follow-up). These ‘forgotten’ ports pose an unnecessary ongoing 1University of Minnesota, Minneapolis, MN, 2University of Minnesota, long-term risk to the patient and should be removed when possible. Edina, MN There is a significant subset of patients with densely adherent cathe- LEARNING OBJECTIVES: Understand the arterial anatomy of pancreas ters that require advanced techniques. transplant. Review the role of endovascular management of vascular CLINICAL FINDINGS/PROCEDURE DETAILS: Six individual techniques are complications of pancreas transplant. employed at this tertiary institution during challenging port removals: BACKGROUND: Diabetes mellitus is a common disease and pancreas 1. Peel-away sheath: forward pressure on a peel-away sheath over the transplant offers a definitive cure. Despite the evolution of surgical catheter dissects proximal adhesions. 2. Balloon-aided grip: balloon is technique over the decades, vascular complications are common. inflated in the distal port catheter to more evenly distribute the pull These complications may be graft or life threatening and timely inter- force over the adherent portions of the catheter. 3. Radial stretching: a vention is important. There has been a shift towards initial endovascu- balloon is repeatedly inflated/deflated along the catheter using circum- lar management before surgery in the management of these vascular ferential radial force to disrupt the fibrin sheath. 4. Loop snare: snaring complications. of catheter via femoral access. 5. Flossing: femoral-to-port through- and-through access is obtained and catheter/wire are simultaneous CLINICAL FINDINGS/PROCEDURE DETAILS: Vascular complications removed combining pull and traction forces. 6. Catheter sandwich: via following pancreas transplant include venous thrombosis, arterial through-and-through access two sheaths are advanced toward each thrombosis and stenosis, arteriovenous fistula, arteriourinary fistula, other from opposing accesses until they converge, dissecting the fibrin pseudoaneurysm. Clinical presentation may dictate an endoscopy, sheath. CT/ MR angiogram, tagged RBC scan may suggest the diagnosis. 28 | Traditional Posters SIR 2020 Annual Scientific Meeting

CONCLUSION AND/OR TEACHING POINTS: ‘Forgotten’ ports with pro- Abstract No. 799 longed dwell times can be associated with dense fibrotic adhesions making them a challenge to remove, often resulting in aborted Extracorporeal membranous oxygenation in patients with attempts. By employing the described techniques in a step-wise fash- acute pulmonary embolism undergoing catheter-directed ion (from least to most invasive) our tertiary institution has removed therapy: lessons learned the vast majority of challenging ports with low associated morbidity. M Clark1, A Banathy2, M Khaja3, E Downs1, A Sharma1, N Teman1, D Sheeran1, J Angle2, Z Haskal2 Abstract No. 798 1University of Virginia, Charlottesville, VA, 2N/A, Charlottesville, VA, 3University of Virginia Health System, Charlottesville, VA Interventional management of uncommon portal LEARNING OBJECTIVES: (1) Physiology and predictive factors of hypertensive complications peri-procedural cardiopulmonary decompensation. (2) Advantages of O Furusato Hunt1, A Gold2, J Meshekow3, S Maddineni4, G preemptive vascular access to expedite extracorporeal membranous Rozenblit5, S McCabe6 oxygenation (ECMO) in the event of cardiopulmonary collapse. (3) 1Westchester Medical Center, Hartsdale, NY, 2Westchester Medical Identify unique features and challenges of performing CDT in a patient Center, Valhalla, NY, 3N/A, Beacon, NY, 4N/A, Chappaqua, NY, 5N/A, on ECMO. Eastchester, NY, 6N/A, Katonah, NY BACKGROUND: Acute high-risk PE requires hemodynamic and respira-

LEARNING OBJECTIVES: 1. Provide an overview of the etiologies and tory support, anticoagulation, and reperfusion; the approach to each clinical manifestations of portal hypertension (PH). 2. Discuss the per- is determined by a PERT, which in our institution includes cardiac sur- cutaneous management of less common manifestations of PH using a gery, critical care, interventional radiology (IR), and vascular medicine. case-based approach. The role of IR is to determine if and when CDT, in the form of either lysis or embolectomy, are indicated. High-risk PE patients are partic- BACKGROUND: Clinical complications of cirrhotic PH include ascites/ ularly vulnerable to cardiopulmonary collapse during reperfusion due hepatic hydrothorax, variceal hemorrhage, and encephalopathy. Mini- to multiple factors including the hemodynamic effects of large shifts mally invasive image-guided management of PH complications is safe, in thrombus burden and release of vasoactive substances. ECMO is effective, and widely utilized when medical and/or endoscopic therapy emerging as a means of hemodynamic stabilization in high-risk PE, fails. Decompressive portosystemic shunts and retrograde obliteration thus its role is addressed by the PERT for every patient. ECMO has sig- of gastric varices are commonly employed techniques. Using a case- nificant risk and associated treatment challenges therefore it is imper- based approach, we will illustrate the interventional management of ative that all members are familiar with ECMO’s effects unique to their several less-commonly encountered PH clinical scenarios: arteriopor- discipline. tal fistula, medically refractory hepatic encephalopathy due to spontaneous portosystemic shunt, and umbilical variceal hemorrhage. CLINICAL FINDINGS/PROCEDURE DETAILS: CDT in patients deemed susceptible to cardiopulmonary collapse by the PERT are performed CLINICAL FINDINGS/PROCEDURE DETAILS: A 78-year-old woman with (1) ECMO team on standby, (2) placement of arterial and venous with autoimmune hepatitis and cirrhosis presented with shortness of access sheaths at the start of CDT for expeditious ECMO initiation in breath secondary to hepatic hydrothorax. CT revealed nonocclusive case of code event, or (3) preprocedure initiation of ECMO. Case exam- portomesenteric thrombosis and a large left lobe arterioportal fistula. ples highlighting the advantages and challenges of performing CDT After percutaneous embolization of the fistula there was complete with ECMO as well as the risks of starting ECMO emergently during and sustained symptomatic improvement, resolution of the porto- or immediately after CDT. Challenges on ECMO will be presented, mesenteric thrombosis and no further hydrothorax reaccumulation. including (1) negative right atrial pressures that increase the risk of air A 57-year-old man with NASH cirrhosis presented with intermittent entering the ECMO system, (2) PA pressures may be of limited clinical Westhaven grade 2-3 medically refractory hepatic encephalopathy value in determining the end point of CDT, and (3) mechanical disad- (HE). CT revealed a large spontaneous splenorenal shunt. The patient vantages of suction embolectomy with ECMO cannulas in place. underwent percutaneous transhepatic shunt embolization with rapid symptomatic improvement. The patient was maintained on medical CONCLUSION AND/OR TEACHING POINTS: Interventional radiologists therapy and remained free of HE for 18 months, when mild HE symp- must be comfortable in analyzing the risk of cardiopulmonary collapse toms recurred. A 58-year-old man with EtOH cirrhosis required multi- during CDT and assist PERT in determining if a patient will need ECMO ple hospital admissions for bleeding due to ruptured umbilical varices. intra or peri-procedurally. Additionally, interventional radiologists Percutaneous modified plug-assisted retrograde transvenous sclero- must be familiar with the challenges ECMO presents during CDT. sant foam obliteration (PARTO) of the umbilical varix resulted in cessation of bleeding without recurrence.

CONCLUSION AND/OR TEACHING POINTS: Interventional techniques are safe and effective treatment options for selected patients with medically refractory complications of PH. SIR 2020 Annual Scientific Meeting Traditional Posters | 29

Abstract No. 800 Abstract No. 801

Novel suture-mediated technique for torque-assistance Superior vena cava syndrome on call: unusual emergent during AngioVac thrombectomy of tricuspid and right manifestations of central venous obstructions atrial masses R Murphy1, M Kolber1, A Pillai2, D Lamus3 1 2 1 3 1 B Laughlin , C Grilli , A GRAIF , U Nwosu , D Leung 1UT Southwestern Medical Center, Dallas, TX, 2University of Texas 1Christiana Care Health System, Newark, DE, 2Christiana Care, Health Science Center, Dallas, TX, 3University of Texas Southwestern Newark, DE, 3N/A, Newark, DE Medical School Program, Dallas, TX

LEARNING OBJECTIVES: To describe a novel technique for directing the LEARNING OBJECTIVES: The Learning Objectives of this educational AngioVac cannula during right atrial thrombectomy. exhibit are to review unusual emergent manifestations of acute superior vena cava (SVC) syndrome. We present case-based examples of BACKGROUND: The AngioVac device is a vacuum-assisted aspiration patients presenting with complications related to acute SVC obstruc- cannula which has been used in the treatment of iliocaval, right atrial, tion that necessitate urgent or immediate recanalization. and pulmonary arterial thrombosis. 1 Two access points are made for extracorporeal veno-venous bypass, with the outflow line connected BACKGROUND: Acute SVC obstruction due to intrinsic or extrinsic to a centrifugal pump and filter. As the blood is circulated, the can- etiology can be a life-threatening emergency requiring urgent reca- nula is advanced to the clot or tumor until it comes into contact and is nalization. Clinical presentation can include laryngeal edema and aspirated into the cannula. Particulate matter is retained by the filter hemodynamic compromise due to poor preload, refractory obstruc- and the blood is returned through the inflow line. The 22-French can- tive shock in the setting of dialysis access dysfunction, abnormal nula expands to 48 French at the tip when deployed, and is available in systemic venous drainage pathways to pulmonary venous collateral- straight and 20 degree angled tips, which have limited mobility within ization (right-to-left shunt) resulting in acute stroke, and acute cerebral the right atrium and can make contacting small masses, such as tricus- edema with pseudophleblitic pattern resulting in depressed mental pid vegetations, difficult. Prior solutions to this have been described status and coma. in which the AngioVac is used in tandem with balloons or snares to CLINICAL FINDINGS/PROCEDURE DETAILS: Endovascular therapies for draw the cannula tip toward the mass. 2 Our Learning Objectives are SVC obstruction include percutaneous transluminal balloon angio- to describe a novel technique, which involves tethering the cannula tip plasty, SVC stenting, and thrombolysis performed alone or in com- with a suture to facilitate easy torquing of the cannula by simultane- bination. Readers will gain a better understanding on the clinical ously retracting the suture while advancing and rotating the cannula. assessment of unusual presentations of central venous occlusion,

CLINICAL FINDINGS/PROCEDURE DETAILS: In this poster, we describe technical aspects of the endovenous interventions available, indica- five cases of right atrial/valvular mass retrieval; including three tricus- tions for determining the most appropriate intervention, and identify- pid vegectomies, one right atrial angiosarcoma, and one right atrial ing complications necessitating emergent treatment. thrombus. Our presentation will be an image-rich display using images CONCLUSION AND/OR TEACHING POINTS: SVC obstruction is a poten- from transesophageal echocardiography before and after the proce- tially life-threatening condition that requires prompt recognition and dure, intraoperative fluoroscopy, and photography of the device setup treatment. Interventional radiologists play a crucial role in the diagno- and filtrate from the procedures. All of our cases achieved technical sis, clinical assessment, and endovascular intervention of patients pre- success with mass retrieval using this novel technique. senting with symptomatic thrombotic superior vena cava obstruction.

CONCLUSION AND/OR TEACHING POINTS: Based on a limited number of cases, the novel suture-mediated technique appears to be effective for providing directional guidance of the aspiration cannula during AngioVac-assisted right atrial thrombectomy. To our knowledge, this technique has not been previously reported, and may have the potential to safely improve the technical success of endovascular right atrial mass retrieval. 30 | e-Posters SIR 2020 Annual Scientific Meeting

ePosters

Abstract No. 802 Abstract No. 803

Aortic fenestration in management of acute mesenteric Causes of type II endoleak in abdominal aortic stents: ischemia from aortic dissection retrospective case review O Furusato Hunt1, A Gold2, S McCabe3, J Meshekow4, G Rozenblit5, D Aboubechara1, N Pigg1, B Baigorri1, R Fourzali1 6 S Maddineni 1Aventura Hospital & Medical Center, Miami, FL 1Westchester Medical Center, Hartsdale, NY, 2Westchester Medical Center, Valhalla, NY, 3N/A, Katonah, NY, 4Westchester Medical LEARNING OBJECTIVES: Understand the pathophysiology behind type Center / New York Medical College, Beacon, NY, 5N/A, Eastchester, II endoleak and the potential variant anatomy, which may contribute NY, 6N/A, Chappaqua, NY to endoleak.

BACKGROUND: Abdominal aortic aneurysm (AAA) refers to dilatation LEARNING OBJECTIVES: 1. Review the pathophysiology, incidence, risk of the abdominal aorta measuring 3.0 cm or greater in diameter. Males factors, and presentation of acute aortic dissection. 2. Understand the are at a higher risk for AAA; other major risk factors include age (65 role of aortic fenestration in management of acute mesenteric isch- years or older) and a history of smoking. One-time screening ultraso- emia from aortic dissection. nography is currently recommended for men ages 65-75 with a history BACKGROUND: Aortic dissection (AD) is classified by the Stanford of smoking. Management of AAA is dictated by the extent and rate of and DeBakey systems with the former most commonly used. Propa- aortic dilatation. For AAA measuring 5.5 cm or greater in diameter, gation of ADs may result in compression of the true lumen from the elective open or endovascular repair are advised. Although, endovas- false lumen, intimal flap extension into the origins of aortic branches, cular management is preferred due to the decreased periprocedural and/or branches originating from the false lumen. Mesenteric ischemia morbidity. Ruptured aortic aneurysm has a high associated mortality has been reported in approximately 5% of Type B AD with mortality and requires emergent repair. Reported rates of rupture were esti- rate of 36-90%. It is generally diagnosed on the basis of high clinical mated at 10% per year for AAAs 5.5 to 6.9 cm and 33% per year for suspicion in combination with labs such as rising lactate levels and AAAs 7 cm or greater. The infrarenal abdominal aorta is particularly imaging with CT angiography. Mortality from open surgical treatment susceptible to aneurysmal dilatation, which is thought to be related to for ADs complicated by mesenteric ischemia has been reported to be decreased wall elastin. After successful treatment of AAA, post stent 50-80%. Therefore, endovascular approaches, often stenting, have complications include stent endoleak, which are subdivided into 4 been demonstrated to be a safe alternative. However, in the absence groups based on the etiology of the endoleak. For the Learning Objec- of emergent stenting availability, fenestration of the intimal flap has tives of this study, we will focus on type II endoleaks and the variant been shown to be an effective means to restore visceral blood flow. anatomy and causes resulting in type II endoleaks. Using seven case based scenarios, we will illustrate the role of aortic CLINICAL FINDINGS/PROCEDURE DETAILS: After performing a ret- fenestration in management of acute mesenteric schemia from AD. rospective search through our image reporting software, positive CLINICAL FINDINGS/PROCEDURE DETAILS: Seven patients underwent queries for type II endoleak are obtained over a 2-year period at our technically successful aortic fenestration using gallstone retrieval bas- institutions. The vascular anatomy is described and the culprit vessel ket and needle fenestration with serial balloon dilation. Either bilateral contributing to type II endoleak is identified. The prevalence of each femoral artery or femoral/brachial artery approaches were utilized. In source contributing to type II endoleak is reported including variant three of these patients, tearing of the intimal flap in the caudal direc- anatomy. tion was performed using the guidewire. One patient who under- CONCLUSION AND/OR TEACHING POINTS: Endovascular aneurysm went tearing of the flap was complicated by occlusion of the bilateral repair remains the mainstay of AAA management. However, endoleaks iliac arteries, which were subsequently treated with kissing stents to are a particular concern with endovascular management. Understand- restore blood flow. Clinical course, follow-up, and pre/post procedural ing the possible culprits contributing to possible type II endoleak is cross sectional imaging that demonstrates the perfusion changes in crucial to minimize complication rates by appropriate preventative both the true and false lumens will be presented. measures. This educational exhibit demonstrates the prevalence of CONCLUSION AND/OR TEACHING POINTS: In selected patients with variant causes of type II endoleak at our institutions as well as mea- acute aortic dissection complicated by mesenteric ischemia, aortic sures for salvage. fenestration can be a safe and effective means of restoring blood flow to the visceral abdominal organs. SIR 2020 Annual Scientific Meeting e-Posters | 31

Abstract No. 804 LEARNING OBJECTIVES: 1) To educate medical students on the pathophysiology of thoracic and abdominal aortic aneurysms. 2) To demon- Comparison of aneurysm coiling occlusion rates by strate the approach of endovascular aneurysm repair (EVAR), its embolization technique indications, preprocedure, procedure and clinical follow-up. 3) To dis- D Harper1, H Cuellar2 tinguish the benefits of EVAR versus open repair of aortic aneurysms. 1University of Arkansas for Medical Sciences, Little Rock, AR, 2LSU BACKGROUND: What is EVAR? Placement of an endograft, a fab- Health Sciences Center, Shreveport, LA ric-covered self-expanding stent, to treat AAA and other vascular pathology. Endograft attaches to relatively healthy tissues proximal LEARNING OBJECTIVES: In this educational presentation we will review and distal to aneurysm, serving as a new wall and protecting aneu- the incidence and impact of subarachnoid hemorrhage and ruptured rysm from perfusion and thus rupture. Aortic aneurysm: Infrarenal cerebral aneurysms, define the two main types of cerebral aneurysms, aorta if diameter measures ≥3cm and thoracic aorta if vessel >50% of provide a comparison between intravascular embolization versus neu- the normal expected size. 30-50% of AAA patients die prior to being rosurgical clipping, describe and compare three coiling embolization able to undergo treatment. Atherosclerotic changes initiate remodel- techniques used to occlude cerebral saccular aneurysms using retro- ing in the adventitia. Strongest risk factor is smoking. Differing etiolo- spective chart review data from LSUHSC Shreveport to provide exam- gies between ascending and descending thoracic aneurysms due to ples of the effectiveness of each approach, apply the Raymond-Roy different embryologic origin (neural crest cells for ascending, paraxial Aneurysm Occlusion Classification system to categorize the success of mesoderm for descending). Landmark Trials UKSAT 2002 ADAM 2002 embolization and compare it with the Kamran Grading Schema. Finally, DREAM 2004 EVAR 1 and 2 2005 ACE 2009 PIVOTAL 2009 OVER we will provide a brief discussion and overview to summarize these 2012 show that EVAR has lower peri-operative mortality and nearly topics. similar survival and rate of aneurysm rupture compared to open repair.

BACKGROUND: The worldwide incidence of subarachnoid hemorrhage Access-related complications in 4.4% of patients, with a relative risk of (SAH) is estimated to be 9 per 100,000 per year, with significant 0.47, 95% CI 0.28-0.78 compared to open femoral access. Significant morbidity and mortality. In up to 85% of cases, the cause of SAH is a decrease in ruptured AAA deaths since the introduction of endovascu- ruptured cerebral aneurysm. The severe disability and death resulting lar repair. DREAM, EVAR 1, and OVER trials: lower perioperative mor- from ruptured intracranial aneurysms highlights the significance for bidity and mortality compared to open surgical repair preventative aneurysm obliteration. Initially, neurosurgical clipping of CLINICAL FINDINGS/PROCEDURE DETAILS: Procedure: CTA to assess aneurysms was the only available option for treatment and became proximal and distal landing zones 15-20% oversizing aortic diameter the standard of care. Endovascular embolization has developed as a ensures coverage and radial force to prevent stent migration. Per- successful alternative to this, involving multiple techniques, and we cutaneous access obtained at the femoral head level using Proglide provide a review of those techniques and related topics here. Addition- Suture-mediated closure system adequately heparinize to maintain ally, we include examples from a retrospective review of 121 patients ACT>250 exchange existing guidewire for stiff working wire complete treated for intracranial saccular aneurysms done at LSUHSC Shreve- deployment of aortic main body graft port to describe the effectiveness of three specific coiling embolization techniques used. CONCLUSION AND/OR TEACHING POINTS: Understanding stent grafts and collateral anatomy is key to successful EVAR Endoanchors and CLINICAL FINDINGS/PROCEDURE DETAILS: A total of 238 saccular cuffs can help achieve seal Clinical follow-up for endoleak development aneurysm procedures were done between January 2010 and Decem- ber 2014 at LSUHSC Shreveport using simple coiling, balloon assisted coiling, or stent assisted coiling techniques. These were evaluated for Abstract No. 806 immediate occlusion rates based on technique. Of these, 115 patients completed sufficient follow-up and were evaluated for long-term Not going with the flow: extracranial uses of flow- occlusion rates for each technique. diverting stents

1 2 2 2 2 CONCLUSION AND/OR TEACHING POINTS: There was little difference in J Hernandez , J Huang , Z Irani , P Sutphin , S Kalva the immediate postoperative occlusion rates achieved by each coiling 1Loma Linda University, Loma Linda, CA, 2Massachusetts General method, but stent assisted coiling had better occlusion rates at 1-year Hospital, Boston, MA follow-up. LEARNING OBJECTIVES: Educational exhibit on possible use cases of flow-diverting stents in treatment of extracranial aneurysms. Abstract No. 805 BACKGROUND: Flow-diverting stents are often used in the treatment of intracranial aneurysms. These stents are designed to reduce flow Do interventional radiologists ever EVAR? A trainee’s velocity in the aneurysm sac while simultaneously promoting throm- guide to aortic interventions bosis and maintaining flow in the artery. Use of flow-diverting stents E Jacobson1, H Szeto2 could be a useful tool in the treatment extracranial aneurysms by like- 1NYIT-COM, Old Westbury, NY, 2N/A, Newark, DE wise reducing flow velocity within the aneurysm, promoting thrombosis and maintaining flow in the artery. 32 | e-Posters SIR 2020 Annual Scientific Meeting

CLINICAL FINDINGS/PROCEDURE DETAILS: Three case presentations Abstract No. 808 on use of flow-diverting stents in treatment of extracranial aneurysms (splenic aneurysm, hepatic aneurysm, and renal aneurysm). Sprung an endoleak: spectrum of procedural interventions to repair aortic endoleaks CONCLUSION AND/OR TEACHING POINTS: Flow-diverting stents can be a useful tool in the treatment of extracranial aneurysms. W Johnson1, D Allen2 1Tufts Medical Center, Boston, MA, 2N/A, Newton, MA

Abstract No. 807 LEARNING OBJECTIVES: -Type 1 endoleak repair techniques: bare-metal stents, endoanchors, or extension cuffs. Type 2 endoleak repair tech- Pictorial review of methods to preserve the internal iliac niques: translumbar or transcaval embolization of the aneurysm sac arteries in endovascular abdominal aortic aneurysm or IMA embolization via the SMA. Type 3 endoleak repair techniques: repair relining the compromised graft with a new aortic stent graft and prox- H Coffey1, K Tan2 imal extension cuff.

1University Health Network, University of Toronto, Toronto, BACKGROUND: An endovascular approach is the preferred method to ON, 2Toronto General Hospital, Toronto, ON treating amenable infrarenal aortic aneurysms. At the author’s home institution, the interventional radiology team plays an active role with LEARNING OBJECTIVES: Review complications of IIA interruption in the vascular surgeons in performing interventions to repair endoleaks, EVAR. Present treatment options to preserve the IIA. Review consid- for which there are multiple approaches. erations and potential complications of the management possibilities. CLINICAL FINDINGS/PROCEDURE DETAILS: Type 1 endoleaks occur BACKGROUND: EVAR may require IIA exclusion and graft extension into when there is inadequate seal at the proximal or distal landing zone. the EIA in the setting of an inadequate CIA landing zone. However, lit- This can result in expansion of the excluded aneurysm sac and be erature reviews report ischemic complications in nearly 25% of these repaired utilizing endoanchors, bare-metal stents, or extension cuffs. patients. A total of 17% to 25% report impotence and 55% describe but- Endoanchors mimic a hand-sewn anastomosis; they are deployed tock claudication. Serious complications including buttock necrosis, intraluminally through the endograft material affixing the graft to the colon ischemia and spinal cord ischemia can occur in 1% to 3% of cases. adjacent arterial wall. Alternatively, balloon expandable bare-metal Bilateral IIA interruption should be avoided. Preserving the IIA comes stents or covered extension cuffs may be deployed to achieve better with high technical success and low complication rates. We will present wall apposition at the proximal or distal seal zone. Type 2 endoleaks several options for preserving the IIA with the aid of cases performed occur when there is retrograde flow from collateral branches supply- at our institution. ing the excluded aneurysm sac. The excluded aneurysm sac can be

CLINICAL FINDINGS/PROCEDURE DETAILS: Iliac Branch Device: Several accessed via translumbar or transcaval approach and then be injected IBD designs are available. Technical success and patency rates are high with Gelfoam, coils, or glue. If the excluded aneurysm sac is being sup- while the endoleak rate is low. Patient selection for suitable anatomy plied by the IMA, the IMA can be accessed via the SMA through the is integral to success. EIA tortuosity can kink the IIA origin once the Arc of Riolan or Marginal Artery of Drummond and embolized. Type 3 IBD is deployed. Additionally, extension of the IIA stent graft into a endoleaks occur when there is leakage between different components divisional artery may be needed when there is inadequate IIA sealing of the stent graft. These can be repaired by relining the compromised length. Sandwich technique The ST is an endovascular option in which graft with a new aortic stent graft or proximal extension cuff. the main body endograft is deployed and the IIA is cannulated via a CONCLUSION AND/OR TEACHING POINTS: Endovascular abdominal aor- brachial or contralateral approach. A covered stent graft is inserted in tic aneurysm repair is the favored method to treat infrarenal abdominal the IIA and deployed concurrently with the ipsilateral EIA stent graft to aortic aneurysms. Interpretation and intervention for postprocedural preserve flow. Hybrid approach Following distal landing of the endo- endoleaks is a common domain for interventional radiologists and graft to the EIA, an EIA-IIA bypass surgery is performed. While this familiarity with the different repair techniques is crucial to achieve option has excellent patency, it is technically demanding due to the optimal clinical results. anatomic location, particularly in obese patients. A second option is to bridge a graft limb into the IIA via brachial approach and then perform a femorofemoral bypass. Although the hybrid options are effective, Abstract No. 809 the minimally invasive advantage of EVAR is reduced. Visceral artery pseudoaneurysm formation in the setting CONCLUSION AND/OR TEACHING POINTS: IIA interruption has ischemic of acute pancreatitis: an interventional radiologist’s guide complications in up to 25% of patients. Options to preserve the IIA are for selecting endovascular treatment techniques on the available which are technically successful and low risk. Patient anat- basis of lesion location and morphology omy is critical to select suitable patients and therapeutic options. C Abraham1, A Klobuka1, P Kiproff1, J Potts1, D Buck1, K Cothron1, A Shaikh1, B Goodman1, A Dunn1 1Allegheny Health Network, Pittsburgh, PA SIR 2020 Annual Scientific Meeting e-Posters | 33

LEARNING OBJECTIVES: Identify key imaging features of abdominal of lesion, however, remains technically challenging to treat. Lesions visceral pseudoaneurysms (PSA) in the setting of acute pancreatitis. located at or near a luminal branching point pose unique obstacles Describe the locations, morphology, and possible complications asso- owing to variations in bifurcation configurations, initial lesion burden, ciated with PSA formation within the pancreatic arterial vasculature. morphology, bifurcation angle, and diameter discrepancies between Discuss the endovascular treatment approaches to abdominal visceral main and side branches; additionally, access to the branches must be PSA based on location and imaging findings. preserved for future interventions. Consequently, there are no one- size-fits-all solutions. Rather, tailored and meticulous procedural plan- BACKGROUND: Visceral artery PSA are most frequently caused by ning is necessary to achieve the desired results of intervention. inflammation (usually pancreatitis), iatrogenic (surgery), and trauma. Formation of visceral artery PSA is a common complication of pan- CLINICAL FINDINGS/PROCEDURE DETAILS: In this exhibit, we describe creatitis, occurring in up to 10% of patients with chronic pancreatitis. types of bifurcation lesions in several contexts including those in the PSA formation most commonly involves the pancreaticoduodenal vascular and biliary systems. Next, we illustrate lesion characteristic– and gastroduodenal arteries. The hepatic and splenic arteries may based approaches to intervention including procedures using a single be involved but to a lesser degree. Complications of PSA formation branch stent, kissing double stents, Y-triple stents, a stent-within-stent include life threatening arterial hemorrhage with associated mortal- technique (Cullote), and balloon-within-stent techniques. Further- ity reported to be as high as 7.8% in patients with acute pancreatitis. more, we introduce and showcase an innovative “train-track” tech- Endovascular embolization of visceral PSA in the setting acute pancre- nique that simplifies the Y-stenting technique and will be new to many atitis is preferred as the first-line modality over surgical intervention proceduralists. Finally, we discuss potential complications that may for treatment. arise and present proper precautionary measures and management.

CLINICAL FINDINGS/PROCEDURE DETAILS: A retrospective review from CONCLUSION AND/OR TEACHING POINTS: Bifurcation lesions are one July 2018 to June 2019 identified 12 patients with acute PSA involving of the most complex problems encountered by interventional radiol- the mesenteric vasculature. All of these patients underwent CT-angi- ogists. To date, there is no standardized treatment approach. Thus, ography at our institution. Further evaluation and treatment by cath- while knowledge of existing techniques is essential, innovative solu- eter-directed angiography was performed utilizing a femoral or radial tions are also frequently required to adequately treat the branches. arterial approach. Endovascular treatments consisted of a combination of several agents including covered-stents, coils, Gelfoam, and/ or particles. Immediate clinical and technical success was documented Abstract No. 811 and subsequent post discharge follow-up clinical evaluation and imag- A breath of fresh air: techniques, benefits, and challenges ing was reviewed. of percutaneous balloon pulmonary angioplasty in CONCLUSION AND/OR TEACHING POINTS: Preprocedural imaging, pro- treatment of chronic thromboembolic pulmonary cedural planning and PSA characterization are essential when man- hypertension aging patients with pancreatitis-induced arterial PSA. The choice of M Juan1, G Heresi Davila1, I Haddadin1 endovascular approach and treatment technique is highly dependent 1 on PSA location and morphology which has a direct impact on clinical Cleveland Clinic, Cleveland, OH and technical success. Operator familiarity with these lesion-specific LEARNING OBJECTIVES: 1) Describe the vascular lesions underlying variables as well as the proper selection of treatment option is there- chronic thromboembolic pulmonary hypertension (CTEPH) and the fore essential for all interventional radiologists. complexities associated with treating such lesions both surgically and minimally invasively; 2) highlight the importance of patient selection Abstract No. 810 and preprocedural evaluation by a multidisciplinary team to achieve optimized treatment benefits; 3) explain the techniques of percutane- A “fork in the road” moment: challenges in treating ous balloon pulmonary angioplasty (BPA) combined with the use of bifurcation lesions adjunctive intraprocedural imaging modalities; and 4) discuss appropriate management of potential procedural challenges. M Juan1, R Gurajala1, K Karuppasamy1 BACKGROUND: With progressive refinement of minimally invasive 1Cleveland Clinic, Cleveland, OH techniques, interventional radiologists now participate in the care LEARNING OBJECTIVES: 1) Describe bifurcation lesions in several con- of patients across an increasing number of disease entities. One of texts and highlight the unique technical challenges involved in treating these include the treatment of CTEPH. This potentially fatal condi- such lesions; 2) showcase an assortment of interventional techniques tion is traditionally treated by pulmonary endarterectomy. However, for treating bifurcation lesions; 3) introduce an innovative technique, 37% of patients are inoperable and 5-35% experience persistent or new to many proceduralists; and 4) discuss appropriate management recurrent pulmonary hypertension despite surgery. Thus, alternative of potential procedural challenges. treatment options are being explored to address this unmet medical need. Emerging evidence are now available to support the safety and BACKGROUND: Interventional radiologists, as adept operators of nee- efficacy of BPA. Still, the unique technique challenges of the procedure dles, wires, and catheters, are now able to offer treatments for more currently restrict its offering at certain expert centers. diseases than ever, reaching almost every part of the body. One type 34 | e-Posters SIR 2020 Annual Scientific Meeting

CLINICAL FINDINGS/PROCEDURE DETAILS: In this exhibit, we describe Abstract No. 813 the nature and characteristics of the vascular lesions rendering CTEPH a intricate condition to treat for surgeons and interventionalists. Next, Biodegradable stents: when, why, and what is next? we highlight the importance of a multidisciplinary approach to risk I Altun1, L Jamal1, K Zurcher1, M Kuo1, G Knuttinen1, J Kriegshauser1, stratification and preprocedural planning to achieve the desired out- S Naidu1, I Patel1, S Alzubaidi1, H Albadawi1, R Oklu1 comes of intervention. Furthermore, we showcase the techniques 1Mayo Clinic, Phoenix, AZ of BPA combined with the use of adjunctive intraprocedural imaging modalities including intravascular ultrasound, optical coherence LEARNING OBJECTIVES: 1. Identify stent classifications, their clinical tomography, and cone-beam CT based on our institutional experience. use, and their potential complications. 2. Define the properties of bio- Finally, we discuss potential complications that may arise and present degradable stents. 3. Discuss the possible application of biodegrad- proper precautionary measures and management. able stents in the interventional radiology (IR) practice.

CONCLUSION AND/OR TEACHING POINTS: BPA is increasingly inves- BACKGROUND: Clinicians have been using a variety of stents for decades tigated as a minimally invasive intervention in select patient popula- now. Despite the revolutionary change stents have introduced into the tions. Future prospective studies are required to further delineate the treatment of arterial diseases, restenosis continues to be a significant clinical role of this emerging therapeutic option. and frequent cause of treatment failure. The advancements in material science, has led to the emergence of many new types of stents that aim to avoid restenosis. For example, biodegradable stents are made Abstract No. 812 of polymeric or metallic material that degrades with time, and possibly elute drugs in the body. The mechanical properties, degradation rate, Below-ankle endovascular interventions for critical limb biocompatibility, and pharmacological properties of biodegradable ischemia: anatomy, techniques, and pitfalls stents highlights them as an idealistic alternative from currently used S Golden1, B Holly1, M Meuse2, M Lessne2 stents. Biodegradable stents have been used in biliary injury, intesti- 1Johns Hopkins, Baltimore, MD, 2Vascular and Interventional nal stricture, ureteral obstruction, esophageal stenosis and mostly in Specialists of Charlotte Radiology, Charlotte, NC coronary artery diseases. In IR, some cases might require the usage of stents. Potential candidates for biodegradable stent usage are cases LEARNING OBJECTIVES: Review typical and variant arterial anatomy of such as transjugular intrahepatic portosystemic shunt, arteriovenous the ankle and foot with focus on the angiosome and angiographisome malformations, peripheral arterial diseases and aneurysms. based interventions. Review tools and techniques of intrapedal interventions, including the role of pedal loop reconstruction, with case CLINICAL FINDINGS/PROCEDURE DETAILS: We will review the different illustrations. types of stents. We will discuss clinical indications and the most common reasons for treatment failure. We will present the efficacy and BACKGROUND: Critical limb ischemia (CLI) affects three to six million mechanical properties of biodegradable stents. We will also explore Americans, approximately two-thirds of whom will undergo ampu- the potential future applications of biodegradable stents in IR and lim- tation within four years of diagnosis. Adequate arterial flow to the itations of current stent applications. wound is essential for wound healing in these patients. Previous studies have confirmed the benefit of intact pedal circulation to maximize CONCLUSION AND/OR TEACHING POINTS: Biodegradable stents show wound healing. Interventional radiologists are assuming a larger role remarkable results in coronary diseases, but its mechanical properties, in the care of patients with CLI. Understanding of intrapedal arterial benefits, and limitations need to be recognized and addressed before anatomy and variants is critical to guiding below-ankle endovascular investigating new potential applications. revascularizations.

CLINICAL FINDINGS/PROCEDURE DETAILS: Written and pictorial Abstract No. 814 descriptions of vascular anatomy of the ankle and foot will be provided. Examples of common anatomic arterial variants will be described and Lower extremity angioplasty: getting a leg up on vascular illustrated. Pedal arch classification systems and their association pathology with likelihood of wound healing will be discussed. Case examples of A Sadeghi1, D Tran2, T Yablonsky1, W Vanlandingham2 advanced endovascular interventions in the foot and ankle, including 1Morristown Medical Center, Morristown, NJ, 2University of clinical scenarios, angiographic images, and commonly used tools will Oklahoma Health Sciences Center, Oklahoma City, OK be presented.

LEARNING OBJECTIVES: Review lower extremity anatomy and pathol- CONCLUSION AND/OR TEACHING POINTS: Interventional radiologists ogy. Describe postprocedural complications and imaging findings have a growing role in the treatment of PAD and CLI. An understanding after vascular intervention and determine appropriate indications for of the relevant anatomy, devices, and procedures is critical to employ- take-back to the angiography suite. ing these emerging techniques and potentially obviating the need for amputation in patients with critical limb ischemia. BACKGROUND: Interventional radiologists are the pioneers of peripheral vascular disease treatment, but in today’s world interventional SIR 2020 Annual Scientific Meeting e-Posters | 35

radiology (IR) may be losing ground. The following interesting cases Temporary embolization is done in cases of postpartum hemorrhage, reaffirm IR’s role in lower extremity intervention. traumatic pelvic fracture, and bleeding due to gastric or duodenal ulcers. Permanent embolic agents are divided into nonabsorbable CLINICAL FINDINGS/PROCEDURE DETAILS: Lower extremity angio- microparticles, coils, detachable plugs and balloons, and liquid scle- plasty and stent placement can be complicated by postprocedural rosants and polymers. Our presentation discusses each separately thrombosis and in-stent restenosis. These present at different stages with special emphasis on their characteristics, preparations, different after intervention and require different approach to treatment. One shapes and sizes available in the market, mechanism of action, indica- patient undergoes mechanical thrombectomy following ureteroar- tions, and complications. terial fistula repair. In another case, recurrent restenosis may require more aggressive intervention involving angioplasty with a cutting bal- CONCLUSION AND/OR TEACHING POINTS: Each embolic agent has loon and restenting. In a third case, shower emboli thrown from the unique characteristics which make it desirable in certain clinical sit- femoral artery during colonic arteriovenous malformation emboliza- uations and less useful in others. Knowledge about the properties of tion may be treated with aspiration embolectomy. Finally, nontarget each embolic agent and their preparation is required to ensure safe, embolization can be remedied using a snare device. effective embolization and avoid potential complications.

CONCLUSION AND/OR TEACHING POINTS: Successful vascular intervention relies on the radiologist’s knowledge of the vascular anatomy as Abstract No. 816 it is presented in the angiographic suite. The interventional radiologist must be familiar with common postprocedure complications and A strategy for embolic agent inventory in an era of cost address them accordingly. Integrating this knowledge with the pathol- containment ogy allows the interventional radiologist to deliver treatment in the R Patel1, F Khan1, C Stark1, L Keating1, A Herr1, G Siskin1 best interest of the patient. 1Albany Medical Center, Albany, NY

Abstract No. 815 LEARNING OBJECTIVES: The Learning Objectives of this exhibit are to review the factors contributing to the growing cost of care taking place A primer on embolic agents used in vascular within interventional radiology (IR) departments, to discuss strategies interventional radiology for cost-driven inventory decisions using embolic agents as an example, and to identify potential areas within the supply chain for interven- T Garg1, L Stevens2, S Pan3 tional radiology engagement in the hospital setting. 1Seth GS Medical College & KEM Hospital, Mumbai, BACKGROUND: Today, hospital expenses are growing to the point that Maharashtra, 2The University of Texas at Austin Dell Medical School, Austin, TX, 3N/A, Austin, TX they are becoming unsustainable. While there are several strategies that hospitals are taking to control this growth, it is clear that supply LEARNING OBJECTIVES: 1. To review the history and development of costs are one of the largest drivers of cost. As a supply-intensive spe- embolic agents 2. To review the basic classification of embolic agents cialty, IR is becoming increasingly identified as one location in the hos- 3. To review the types of temporary and permanent embolic agents, pital responsible for these supply-related expenses. their characteristics, uses, and limitations. 4. To review the basic algo- CLINICAL FINDINGS/PROCEDURE DETAILS: With growth in IR-related rithm for selection of embolic agents supply costs growing, interventional radiologists must take on some of BACKGROUND: The purposeful endovascular occlusion of a vessel the responsibility of controlling this growth within their respective divi- is termed “therapeutic embolization.” There are multiple types of sions and practices. Using embolic agents as one area where growth embolic agents that may be used, ranging from permanent to tem- is often noted, this exhibit will model a strategy for cost containment porary occlusion of an artery, vein or lymphatics. The first use of this incorporating common indications for treatment, available embolic therapy dates back to 1964, at that time, Gelfoam, a biologic substance agents, and supply costs. Items discussed will include participation in composed of purified skin gelatin- was employed to treat a cavern- group-purchasing organizations, consignment arrangements, storage ous carotid fistula. Soon after, the first transcatheter use of an embolic availability, honest case mix assessments, and personal preferences, agent, the autologous blood clot, was used to control an upper GI all of which must be explored when defining an institution-specific bleed. Since then, many agents have been developed for a variety of strategy for embolic supplies. clinical practice. CONCLUSION AND/OR TEACHING POINTS: In an era of growing aware- CLINICAL FINDINGS/PROCEDURE DETAILS: Embolization agents are ness of supply costs within IR departments, interventional radiologists classified on the basis of their physical state (solid vs. liquid), mech- have a responsibility to become engaged in the strategies required anism of action (mechanical vs. chemical), and origin (autologous vs. to lower the cost of the care they deliver. The information included in biosynthetic or synthetic); however, in clinical practice, they are classi- this exhibit will provide interventional radiologists with the knowledge fied into two categories; temporary and permanent as it relates to the base required to be an important contributor to these discussions. duration of occlusion. Commonly used temporary embolic agents are Gelfoam, collagen, and thrombin. Of these, Gelfoam is the most commonly employed for its easy preparation as compared to other agents. 36 | e-Posters SIR 2020 Annual Scientific Meeting

Abstract No. 817 LEARNING OBJECTIVES: To review a standardized imaging and guidance workflow developed for PAE by four academic institutions. To Adrenal artery embolization review available imaging tools to ensure technical success while reduc- J Miller1, Z Thwing2, B Baigorri3 ing patient/operator radiation exposure. 1HCA: Aventura Hospital, Hollywood, FL, 2Aventura Hospital and BACKGROUND: Prostate artery embolization (PAE) clinical benefits and Medical Center, Aventura, FL, 3N/A, Coconut Grove, FL cost effectiveness have been demonstrated in many reports. Recent publications have provided guidance on how to simplify pelvic vascu- LEARNING OBJECTIVES: 1. Adrenal gland hemorrhage is rare and sel- lar anatomy assessment and maximize treatment delivery, but limited dom requires treatment. 2. A thorough understanding of adrenal guidelines exist regarding imaging workflow. PAE remains technically arterial anatomy is required before pursuing endovascular therapy. 3. challenging, with variable imaging techniques being used based on Choice of embolic agent is dependent on etiology 4. Extra-adrenal fac- operator’s experience, typically resulting in long procedure time and tors determine prognosis. high radiation dose.

BACKGROUND: Adrenal hemorrhage is uncommon, increasingly diag- CLINICAL FINDINGS/PROCEDURE DETAILS: Standardized imaging pro- nosed, and rarely requires intervention. Knowledge of adrenal arterial tocol used by four expert sites performing 250 PAEs/year on average anatomy, management strategies, and optimal embolization tech- is provided. Key acquisitions to accurately understand patient vascu- niques is paramount. The adrenals are supplied by the superior, mid- lar anatomy, and tools available to interventional radiologists to plan, dle, and inferior adrenal arteries, which arise from the inferior phrenic guide and assess the embolization are detailed. (1) Proximal CBCT artery, aorta, and renal arteries, respectively. Variant anatomy from the from Internal Iliac Artery 5s spin, 2-3cc/s, 6-8s delay CBCT analysis, celiac axis, intercostal arteries, and spinal artery may occur. There are careful review of prostatic arteries and nontarget vessels. Semi-auto- about 50 perforating capsular arteries, which may result in massive matic segmentation of vascular tree and prostatic arteries. (2) Vascu- hemorrhage in the setting of trauma. This rich vascular supply allows lar guidance under fluoroscopy augmented with 3D overlay of vascular for embolization with a low risk for adrenal infarction or insufficiency. tree and prostatic arteries, digital zoom. (3 ) Distal super-selective Adrenal hemorrhage is most commonly caused by blunt abdominal CBCT of prostatic arteries 5s spin, 0.2-1cc/s, 8-10s delay CBCT analysis trauma and neoplasm. Traumatic adrenal hemorrhage is relatively to confirm gland blush and absence of nontarget branches and high- uncommon in contrast with other abdominal organ injuries due to flow anastomosis. (4) Embolization: PErFecTED Technique Subtracted the protective perirenal fat of the retroperitoneal space. Intractable fluoroscopy with intermediate DSAs. (5) Post embolization DSA pros hypotension is the only strong predictor of the need for embolization and cons of main variants are discussed, and best practices shared. in trauma patients. The mechanism for hemorrhage is shearing of Important concepts are illustrated with images acquired at one of our intracapsular arteries and increased venous pressure from abdominal institutions (IGS5/7 angiography suite equipped with Vessel ASSIST, compression. Pheochromocytoma and lung metastasis are the most GE Healthcare, Chicago, IL). common tumors to cause adrenal gland hemorrhage. The mechanism is increased intracapsular pressure from tumor growth. Iatrogenic CONCLUSION AND/OR TEACHING POINTS: A standardized PAE imaging trauma and adrenal artery aneurysm rupture are exceedingly rare. and guidance workflow helps new interventional radiology physicians to plan and perform safely this challenging procedure. Imaging CLINICAL FINDINGS/PROCEDURE DETAILS: A 72-year-old man with workflow using CBCT and 3D roadmap is key in ensuring technical back pain, hypotension, and adrenal hemorrhage from ruptured mid- and clinical success while minimizing patient and operator radiation dle adrenal artery aneurysm with lumbar branch. Treated with coil exposure. embolization.

CONCLUSION AND/OR TEACHING POINTS: 1. Adrenal gland hemorrhage Abstract No. 819 is rare and rarely requires treatment 2. Must examine arterial anatomy before embolization 3. Choice of embolic agent is dependent on etiol- Angiographic classification of the prostate artery: an ogy 4. Extra-adrenal factors determine prognosis interventionalist’s guide to prostate artery origins J Miller1, T Garg2, L Stevens3, B Baigorri4 Abstract No. 818 1HCA: Aventura Hospital, Hollywood, FL, 2Seth GS Medical College & KEM Hospital, Mumbai, Maharashtra, 3N/A, Austin, TX, 4N/A, Advanced image guidance for prostatic artery Coconut Grove, FL embolization: a multicenter technical note LEARNING OBJECTIVES: Review basic prostate vascular anatomy. Learn F Carnevale1, A Moreira2, A Assis3, A Rocha4, V Vidal5, T McClure6, C Nutting7 about the anatomical angiographic classification categorizing origins of prostatic arteries. Identify some less common arterial variants and 1University of Sao Paulo, Sao Paolo, Brazil, 2N/A, Sao Paulo, their clinical implications Brazil, 3University of Sao Paulo, Sao Paulo, SP, 4Hospital Das Clinicas, Sao Paulo, SP, 5Hospital Timone, N/A, 6Weill Cornell BACKGROUND: Benign prostatic hyperplasia (BPH) affects >50% of Medicine, New York, NY, 7N/A, Lone Tree, CO men over 50 and >90% of men over 70 years of age. It is the most SIR 2020 Annual Scientific Meeting e-Posters | 37

common benign neoplasm in men, and in 2000 accounted for 4.5 CLINICAL FINDINGS/PROCEDURE DETAILS: We present a case-based million physician visits and a direct cost of 1.1 billion dollars. Prostate pictorial review of different applications for Balloon occlusion embo- artery embolization (PAE) has emerged as a safe and effective therapy lization, including radiologic and clinical workup, and common cathe- for lower urinary tract symptoms secondary to BPH. Perhaps the most ters and techniques. challenging aspect of PAE is the proper identification of relevant pelvic CONCLUSION AND/OR TEACHING POINTS: 1) Balloon occlusion embo- arterial anatomy which is necessary to prevent increased procedure lization can conceivably increase concentration of targeted embolic time, undesirable radiation exposure to the patient and medical team, and reduce nontarget embolization. 2) Understanding the mechanics and to prevent nontarget embolization. Recognition of variant anat- of balloon occlusion embolization techniques are important for appro- omy is therefore of utmost importance. priate treatment and planning. 3) Balloon occlusion embolization per- CLINICAL FINDINGS/PROCEDURE DETAILS: Diagram demonstrating formed by interventional radiologists as a safe and effective treatment anterior/lateral and posterior/lateral branches supplying the central for many organ systems and disease processes. and peripheral gland. A diagram and CTA images illustrating most common origins of the prostatic artery/arteries. Labeled angiogram demonstrating a common variant with relevant pelvic arterial anatomy. Abstract No. 821

CONCLUSION AND/OR TEACHING POINTS: The prostate is supplied Bariatric artery embolization for management of obesity by anterior/lateral and posterior/lateral branches, which supply the T Garg1, V Danda2, J Miller3, A Shrigiriwar1, C Weiss4 transition zone and peripheral zone, respectively. Both branches are 1 embolized to prevent revascularization. The prostatic artery may arise Seth GS Medical College & KEM Hospital, Mumbai, 2 3 from the anterior division of the internal iliac artery in a common trunk Maharashtra, Thomas Jefferson University, Philadelphia, PA, HCA: 4 with or distal to the superior vesical artery (44%), from the internal Aventura Hospital, Hollywood, FL, Johns Hopkins Hospital, Baltimore, MD pudendal artery (31%), the obturator artery (19%), as well as less common origins (6%). Less common origins include an accessory internal LEARNING OBJECTIVES: 1. To review the gut hormone balance in energy pudendal artery origin, from an internal iliac trifurcation, from the pos- homeostasis. 2. To learn about the mechanisms behind bariatric artery terior division of the internal iliac artery or from the inferior epigastric embolization (BAE) for weight loss. 3. To learn about the technical artery. The prostatic artery may anastomose with the bladder, rectum, details of the BAE procedure. 4. Review existing evidence for the use penis, or seminal vesicles, as well as contralateral prostate branches. of BAE in the management of obesity. Ipsilateral anastomosis with capsular and urethral branches from separate posterolateral and anteromedial branches may also occur. BACKGROUND: Obesity, defined as having a body mass index (BMI) ≥ 30 kg/m2, is one of the most prevalent public health issues of the twen- ty-first century. In patients with morbid obesity or those with obesi- Abstract No. 820 ty-related comorbidities, bariatric surgery is considered the treatment of choice. However, bariatric surgery is relatively underutilized due to Balloon occlusion embolization: technique of the future? its risk of major complications and controversial cost-effectiveness. M Cellini1, B Williams2, A Isaacson3 Therefore, there is a demand for less invasive therapies that could also potentially target earlier stages of obesity. BAE is a minimally inva- 1University of North Carolina, Durham, NC, 2N/A, Charleston, sive procedure in which the gastric fundus is transarterially embolized SC, 3UNC Department of Radiology, Chapel Hill, NC through the left gastric artery (LGA) and, to a lesser extent, the gas-

LEARNING OBJECTIVES: After reviewing this exhibit, the reader will 1) troepiploic artery (GEA). The prevailing hypothesis behind the weight- learn the indications for Balloon occlusion embolization, 2) understand loss efficacy of BAE is attributed to the observed postprocedural the mechanism behind Balloon occlusion embolization, 3) learn about reduction in ghrelin, an appetite-stimulating hormone. the different balloon occlusion catheters, and 4) understand the dif- CLINICAL FINDINGS/PROCEDURE DETAILS: 1. Diagnostic angiography ference between high pressure and low pressure balloon occlusion with a femoral or radial artery access. 2. Catheter advanced until it embolization. reaches the aorta and then further advanced to select the celiac axis.

BACKGROUND: Embolic agents are traditionally delivered through an 3. Celiac axis angiography performed to delineate the anatomy of the end-hole catheter and are passively carried downstream with blood celiac trunk. 4. Microcatheter directed into the LGA which supplies the flow. Distribution of these embolic agents can be conceivably changed majority of the gastric fundus. 5. Selective embolization of LGA using by altering the local blood pressure within vessels. Catheters with 300-500 um Embospheres. 6. Postembolization angiography per- occlusion balloons are designed to locally affect blood pressure and formed to confirm occlusion of fundal vasculature. mechanically prevent retrograde blood flow and nontarget emboliza- CONCLUSION AND/OR TEACHING POINTS: Early preclinical and clinical tion. This technique is commonly used with hepatic tumor embolization data suggest that targeted embolization of the arterial supply to the and prostatic artery embolization; however, many other applications gastric fundus may provide a safe and effective approach to weight are also practical, including spleen and arteriovenous malformations, loss in the obese patient by inducing changes in the levels of gut hor- to name a few. mones involved in energy homeostasis. Additional studies are needed to further explore BAE’s safety profile and confirm its efficacy. 38 | e-Posters SIR 2020 Annual Scientific Meeting

Abstract No. 822 LEARNING OBJECTIVES: 1) Highlight the role of bariatric embolization in the treatment of obesity, 2) assess effectiveness, feasibility, and safety Bariatric embolization: interventional radiologists’ role in of bariatric embolization, and 3) evaluate the efficacy, postprocedure obesity treatment complications, clinical outcome and quality of life of these patients.

1 1 1 1 1 2 I Altun , A Khurana , L Jamal , T Parnall , G Knuttinen , I Patel , S BACKGROUND: Obesity is the leading causes of morbidity, mortality, 1 1 Naidu , R Oklu and healthcare system expenditure in the US. Nearly two-thirds of 1Mayo Clinic, Phoenix, AZ, 2Mayo Clinic, Phoenix, AZ Americans are overweight, obese, or morbidly obese. For severely obese patients, when lifestyle modification and medical treatments LEARNING OBJECTIVES: 1. Review the technique, management, indi- are inadequate, invasive therapeutic interventions become essential. cations, and complications for bariatric embolization. 2. Understand Surgery is the traditional treatment option, but it is associated with the mechanism of bariatric embolization. 3. Weigh the benefits of this high complication rates, morbidity and mortality. Bariatric emboliza- procedure compared to standard treatments. tion is a minimally invasive, transcatheter procedure that was recently

BACKGROUND: Obesity is a chronic health problem associated with introduced. In this educational exhibit, we review the current evidence significant morbidity, mortality, and socioeconomic burden. Cur- regarding bariatric embolization as a new therapeutic method to fight rently, clinical management is challenged by the existence of multiple against obesity. treatment options, the broad spectrum of clinical presentations, and CLINICAL FINDINGS/PROCEDURE DETAILS: The fundus of the stomach comorbidities. Bariatric embolization recently emerged as a minimally is the leading site for the release of ghrelin, an appetite-stimulating invasive interventional technique that targets the embolization of arte- hormone. Bariatric embolization involves access through the femo- rial supply for gastric fundus. Through embolizing the arterial supply ral or radial arteries and embolization of the left gastric artery, which of the gastric fundus ghrelin will be suppressed. Ghrelin is an appetite comprises the main fundal arterial supply and, if needed the distal left stimulant, and is associated with weight gain. Researchers focused gastroepiploic artery. A growing number of studies have evaluated the on ghrelin and noted that in obese patients ghrelin was dysregulated. safety and efficacy of BAE, which show an average 8% to 10% weight They hypothesized that there would be an increase in weight loss loss with no major complications and incidences of minor complica- postoperative bariatric surgery corresponding to a decrease in ghrelin tions including abdominal pain and superficial gastric ulcers. levels. Through embolizing the arterial supply of the gastric fundus, ghrelin levels will be suppressed as desired. Therefore, the bariatric CONCLUSION AND/OR TEACHING POINTS: Bariatric embolization is embolization procedure offers much more than just a simple transar- feasible, well-tolerated and effective for the treatment of obesity. In terial embolization; it also targets the hormonal and metabolic system. small studies, weight loss after the procedure is statistically significant. Bariatric embolization is becoming more popular, gaining more inter- Additional studies in a larger population with randomized designs and est from patients that cannot undergo major surgery or who are unre- longer-term follow-up are needed. sponsive to pharmacological treatments and lifestyle modifications.

CLINICAL FINDINGS/PROCEDURE DETAILS: This exhibit will present Abstract No. 824 a comprehensive overview of the bariatric embolization procedure including indications, techniques, and complications. We will explore, Bland embolization of prostate leiomyoma its current and future role in obesity management. We will also discuss J Isacson1, J Kuban1, R Sheth1, S Sabir1, C Roland1 the hormonal and metabolic changes postoperative embolization, 1The University of Texas MD Anderson Cancer Center, Houston, TX such as trending ghrelin levels, hemoglobin A1c, and cholesterol.

LEARNING OBJECTIVES: Prostate leiomyoma is a rare benign tumor CONCLUSION AND/OR TEACHING POINTS: This review describes bariatric embolization and its position compared to current standard obesity which can cause bulk symptoms similar to uterine fibroids. Bland treatments. Engagement of interventional radiologists in the treat- embolization has been successfully performed at our institution with ment of obesity is vital because it could potentially decrease the need durable symptomatic relief. for more invasive surgeries and the associated complications. BACKGROUND: Prostate leiomyoma is a rare benign tumor with less than 100 reported cases. Although most commonly discovered inci- dentally on pathology after prostate resection or biopsy, they occa- Abstract No. 823 sionally grow large and cause bulk symptoms similar to uterine fibroids. Bariatric embolization: state of the art Although complete resection offers an excellent long-term prognosis, location creates difficulty and risk with surgery. We present two cases 1 1 1 1 O Shafaat , N Hafezi Nejad , S Manupipatpong , J Tunacao , V of giant prostate leiomyoma safely and effectively treated with bland 2 1 1 Danda , T Dunklin , C Weiss embolization with sustainable therapeutic success. 1Johns Hopkins University School of Medicine, Baltimore, CLINICAL FINDINGS/PROCEDURE DETAILS: Case one is a 58-year-old MD, 2Thomas Jefferson University, Philadelphia, PA man who presented with a 4-year history of urinary frequency, nocturia, weak stream, incomplete emptying, and thinner caliber of his SIR 2020 Annual Scientific Meeting e-Posters | 39

stools, found to be related to a 14-cm prostate leiomyoma. His symp- size of PA increased from 14 to 12 mm after the procedure. No patient tom severity was classified as severe (28) when calculated with the experienced a recurrence. International Prostate Symptom Score (IPSS) score. Embolization was CONCLUSION AND/OR TEACHING POINTS: TAE is an effective alternative performed with improvement of all symptoms at follow-up. Repeat treatment for patients with PRH of BA. For patients with intrapulmo- embolization 4 weeks later resulted in resolution of all symptoms. His nary BAA, coil packing via PA becomes necessary. current IPSS score of 4 correlates with mild severity of symptoms. Case two is a 67-year-old man who presented with a palpable abdominal mass, bowel and bladder urgency, incomplete voiding, dysuria, and Abstract No. 826 four to five episodes of nocturia; found to have a 16 cm prostate leiomyoma. Bland embolization was performed with decreased size of the Clinical presentation and management of ruptured mass to 12 cm, improvement in urgency, and resolution of other urinary epiploic artery aneurysms symptoms. Repeat embolization was performed 10 months later with R D’Ortenzio1, L Leite2, S Ho3 further clinical improvement. After 2.5 years, he presented with mild 1 2 recurrent symptoms. A third embolization approximately 4 years after University of British Columbia, Vancouver, BC, University of British 3 his initial treatment resulted in complete resolution of all symptoms. Columbia, Vancouver, BC, Vancouver General Hospital, Vancouver, BC IPSS scores are not available.

LEARNING OBJECTIVES: We present a case of ruptured epiploic artery CONCLUSION AND/OR TEACHING POINTS: Bland embolization can be utilized in the management of symptomatic prostate leiomyoma to aneurysm (EAA), a rare subset of splanchnic artery aneurysms (SAAs) achieve durable symptomatic relief. successfully treated by transarterial embolization (TAE). The goal of this educational exhibit is to provide an anatomy review and discuss the clinical presentation, management options and potential compli- Abstract No. 825 cations of SAAs with a focus on procedural techniques.

Bronchial-pulmonary arterial fistula by transcatheter BACKGROUND: SAAs are a rare entity, with documented incidence of embolization 0.01-2% in the general population. SAA are potentially life threatening if ruptured, with mortality rates described as high as 25% with- 1 2 2 O Ikeda , Y Tamura , S Inoue out prompt intervention. EAA is a subset of SAA with unknown true 1Faculty of Life Sciences, Kumamoto University, Kumamoto-Shi, incidence. English literature describing EAA is limited to a few case Kumamoto, 2Faculty of Life Sciences, Kumamoto University, reports. The definitive treatment of unruptured or ruptured SAA is still Kumamoto, Kumamoto matter of debate, with both surgical and endovascular approaches being reported as effective. LEARNING OBJECTIVES: Evaluate the efficacy and safety of transcatheter embolization (TAE) of bronchial-pulmonary arterial fistula with CLINICAL FINDINGS/PROCEDURE DETAILS: A 71-year-old woman pres- primary racemose hemangioma (PRH). ents to the emergency department with sudden onset left upper quadrant pain and postural hypotension. A computed tomography BACKGROUND: PRH arteriography showed enlarged and convoluted angiography (CTA) demonstrated hemoperitoneum, with a 3.2 cm bronchial arteries (BAs), often forming a fistula with a pulmonary saccular aneurysm originating from an irregular and beaded left epip- artery (PA). Accordingly, transcatheter BA embolization (BAE) is loic artery. The aneurysm was also directly visualized by transabdom- predominant as the front-line treatment. Furthermore, transcatheter inal ultrasound. The patient was successfully treated with TAE using a arterial fistula embolization via the PA (PAE) is being adopted as one combination of detachable coils and N-butyl cyanoacrylate (NBCA). treatment option. The patient was discharged home 10 days postintervention. A litera- CLINICAL FINDINGS/PROCEDURE DETAILS: 6 patients (3 men, 3 women, ture review was conducted, and we summarized five case reports of mean age 60) with PRH of the BA were treated. Mean follow-up was ruptured epiploic arteries treated with interventional radiology proce- 35 months (range, 2-120 months). All patients showed enlarged and dures. The predominant clinical presentation is upper abdominal pain convoluted BA, and shunts between the BA and PA on CT and/or and hypotension. Management options include TAE, parent artery selective BA angiography, and they had no clinical history of bron- embolization or percutaneous thrombin injection. chopulmonary inflammation. Two patients had hemoptysis, and one CONCLUSION AND/OR TEACHING POINTS: EAA are an extremely rare had mediastinal hematoma due to ruptured BA aneurysms (BAAs). but potentially life-threatening subset of SAA that should be consid- Two patients detected by CT, and 4 with mediastinal and intrapulmo- ered as a differential diagnosis in patients that present with abdominal nary BAA were admitted. The mean number of nutrient BA was 2.6 pain and hemoperitoneum. Our case demonstrated that EAA rupture (range, 1-6 arteries). All feeding arteries were embolized using metal- may be reliably diagnosed with CTA and successfully treated by tran- lic coils and/or N-butyl-2-cyanoacrylate. Coil packing via the PA was sarterial embolization. performed in 2 of 4 patients with intrapulmonary BAA. The technical success rate was 100% and there were no severe complications. Mean 40 | e-Posters SIR 2020 Annual Scientific Meeting

Abstract No. 827 BACKGROUND: Coronary to bronchial artery communication is a known but infrequently encountered congenital anatomic variant, which is Current and emerging bioengineered embolic agents angiographically present in 0.08 per 1000 patients. Hemoptysis from M Kuo1, L Jamal1, I Altun1, A Wallace1, S Alzubaidi1, J Kriegshauser1, these variant pathways is rare in the literature and overall incidence is S Naidu1, I Patel1, M Knuttinen2, H Albadawi2, R Oklu1 not known. However, a common factor among known reports is the presence of an inflammatory process predisposing these patients to 1Mayo Clinic Arizona, Phoenix, AZ, 2Mayo Clinic Arizona, vessel rupture and bleeding including vasculitis, tuberculosis, or recur- Scottsdale, AZ rent pulmonary infections.

LEARNING OBJECTIVES: 1. Review current uses for bioengineered CLINICAL FINDINGS/PROCEDURE DETAILS: A 20-year-old male with a embolics. 2. Evaluate current embolic agents and their efficacy and history of cystic fibrosis and 14 prior bronchial artery embolizations limitations. 3. Discuss emerging bioengineered embolics and the role and left lower lobectomy presented with massive hemoptysis eventu- of interventional radiologists in spearheading the use of these new ally leading to pulseless electrical activity requiring cardiopulmonary materials resuscitation. The patient was found to have an aberrant communi-

BACKGROUND: Interventional radiologists routinely perform endovas- cation of the bilateral upper lobe bronchial arteries with the left atrial cular embolization, a minimally invasive technique used to occlude branch of the left circumflex coronary artery. Given the anatomic lim- blood flow for a variety of medical conditions, including blocking a itations of the patient, the left atrial branch was intentionally embo- tumor’s blood supply or filling an aneurysm. A vast array of occlu- lized to achieve life-preserving hemostasis. Following the procedure, sive agents are clinically available, including coil, embolic particles, the patient went into multifocal atrial tachycardia, which eventually balloons, and gels. In the last few years, new embolic agents, such as spontaneously converted to normal sinus rhythm. Unfortunately, due the shear-thinning biomaterial GEM, are being developed to overcome to prolonged hypoxia leading to hypoxic-ischemic encephalopathy, some limitations presented by coils, such as artifacts left on imaging, the patient expired several days later. time, and inefficacy in treating coagulopathic patients. CONCLUSION AND/OR TEACHING POINTS: Coronary to bronchial artery

CLINICAL FINDINGS/PROCEDURE DETAILS: In this educational poster, communication is a known but infrequently encountered congenital we will review embolic agents in clinical practice. We will also pres- anatomic variant. It is important for the interventional radiologist to ent the most recent preclinical studies using these emerging bioen- be aware of these variants especially in patients with longstanding gineered embolics, and depict diagrams demonstrating their current inflammatory changes of the lungs. These aberrant branches typically utility in practice. Finally, we will conclude by explaining the expanding arise from the left circumflex coronary artery and in some cases prox- role of interventional radiologists in endovascular embolization due to imal embolization of the second order circumflex branches may be these new biomaterials. performed without dire effects. Unfortunately, due to comorbidities, patients who develop this condition tend to have poor outcomes. CONCLUSION AND/OR TEACHING POINTS: Bioengineering embolics is a constantly changing field. Understanding the current technologies available will elucidate the role these novel materials will play in endo- Abstract No. 829 vascular embolization. These emerging biomaterials will improve the treatment of patients by mitigating risks commonly associated with Endovascular interventions in the external carotid current embolic agents. circulation A Mahmud1, A Ramjit2, D Eisman2, D Portal3, B Lei2, T Nawrocki4, J 5 6 Abstract No. 828 Chen , E Landau 1Staten Island University Hospital-Northwell Health, New York, Embolization of the left atrial coronary artery in cystic NY, 2Staten Island University Hospital, Staten Island, NY, 3Staten fibrosis for control of massive hemoptysis due to coronary Island University Hospital Northwell Health, Staten Island, to bronchial artery communication NY, 4Staten Island University Hospital Northwell Health, Staten island, NY, 5Northwell Health Staten Island University Hospital, A Yaeger1, S Chau2, S Lundahl3, S Schroff2, J Vairavamurthy4, M Brooklyn, NY, 6N/A, Brooklyn, NY Katz5 1Keck School of Medicine of the University of Southern California, LEARNING OBJECTIVES: Following review of head and neck vascu- Los Angeles, California., Los Angeles, CA, 2N/A, South Pasadena, lar anatomy including normal variants, this study aims to enumerate CA, 3University of Southern California/LAC+USC Medical Center some of the techniques that interventionists can employ in treating Pro, Los Angeles, CA, 4Johns Hopkins Hospital, South Pasadena, diseases of the external carotid circulation. These include refractory CA, 5N/A, Los Angeles, CA epistaxis, facial trauma, iatrogenic complications, as well as head and neck neoplasms. LEARNING OBJECTIVES: Discuss anatomic variants of bronchial artery to coronary artery communication and the role of embolization in BACKGROUND: Despite playing an essential role in angiography, gen- these complex cases. eral interventionists are often under-utilized in managing diseases of the external carotid circulation. For example, in the setting of refractory SIR 2020 Annual Scientific Meeting e-Posters | 41

epistaxis, or trauma that is unresponsive to conservative measures, inferior phrenic artery in high risk patients who have recent history of interventionists can rapidly embolize injured vessels. With regard to surgery. Understanding the angiographic anatomy following surgery, head and neck tumors, tumor embolization can act as a precursor to technical considerations and choice of embolic agent are very import- surgical resection, or as a form of palliation in unresectable disease. ant for safe and successful endovascular treatment of iatrogenic inju- In rare cases, iatrogenic complications involving the external carotid ries to the inferior phrenic artery. vasculature may also necessitate endovascular intervention.

CLINICAL FINDINGS/PROCEDURE DETAILS: A brief review of the anat- Abstract No. 831 omy and interventional procedures used to treat each of these disease entities will follow with cases performed at our institution. Associated Geniculate artery embolization anatomy, normal variants, risks and potential pitfalls will be discussed. Radiological and picto- and procedural considerations rial correlates will be provided to elucidate the clinical success of such K Zacharias1, O Ahmed1 interventions. 1University of Chicago, Chicago, IL CONCLUSION AND/OR TEACHING POINTS: General interventional radiologists are well-equipped to intervene for diseases within the external LEARNING OBJECTIVES: Transcatheter arterial embolization of the carotid circulation. In our experience, with knowledge of the regional small arteries which supply the knees is a relatively new modality for anatomy and careful angiographic technique, such interventions can the treatment of mild to moderate osteoarthritis. This exhibit aims to greatly improve clinical outcomes for patients. review the normal arterial anatomy of the knee, discuss normal variations, and highlight procedural considerations for selection of arterial embolization targets. Abstract No. 830 BACKGROUND: Osteoarthritis is increasingly being viewed as a com- Endovascular management of iatrogenic injury to the plex and multifaceted inflammatory process. Angiogenesis is thought inferior phrenic artery to represent a significant contribution to this inflammatory process, and embolization of arteries supplying osteoarthritic knees has yielded R Frimpong1, J Andrews1, S Thompson1 positive results in reducing patient pain and increasing function. Tar- 1Mayo Clinic, Rochester, MN gets for arterial embolization can be selected through a combination of localization of pain to regions of specific arterial supply and selective LEARNING OBJECTIVES: 1. Review the angiographic anatomy of the angiography of these regions. inferior phrenic artery 2. Discuss angiographic findings of iatrogenic injury to the inferior phrenic artery. 3. Highlight different techniques CLINICAL FINDINGS/PROCEDURE DETAILS: The normal arterial network for endovascular management of inferior phrenic artery injuries. surrounding the knee joint consists of the superior patellar artery (SPA), descending genicular artery (DGA), lateral superior genicular artery BACKGROUND: Injuries to the inferior phrenic artery are not commonly (LSGA), medial superior genicular artery (MSGA), median genicular encountered in clinical practice. Surgeries involving the distribution artery (MGA), medial inferior genicular artery (MIGA), lateral inferior of the inferior phrenic artery such as hepatectomy and splenectomy genicular artery (LIGA), and anterior tibial recurrent artery (ATRA). can lead to injuries to the artery. Endovascular management of inferior The DGA is present in almost all patients, the MSGA is present in lit- phrenic artery injury can be technically challenging especially in post- tle over half of patients, and the remaining arteries are variably pres- operative patients due to distortion of the anatomy. Surgical manage- ent in roughly 70-90% of patients. These arteries supply predictable ment of iatrogenic injury to the inferior phrenic artery after procedures regions of tissue, which this exhibit will demonstrate schematically. such as Whipple carries an increased risk of morbidity and mortality. These regions (“angiosomes”) can be correlated with patient pain and Endovascular management offers less invasive option for treating iat- selected for angiography and, if neovasculature is present, microem- rogenic injury to the inferior phrenic artery. bolization. Reduction in neovasculature and reduction in patient pain CLINICAL FINDINGS/PROCEDURE DETAILS: The exhibit involves 5 cases can both be used as endpoints to indicate procedural success. of iatrogenic injuries to the inferior phrenic artery. The discussion CONCLUSION AND/OR TEACHING POINTS: Arterial supply of the knee is involves the etiology of the inferior phrenic artery injuries. We will relatively consistent across patient populations with the exception of discuss the angiographic anatomy and pattern of iatrogenic injures the MSGA which is present in only roughly half of patients. However, involving the inferior phrenic artery. In particular, we will highlight these arteries supply highly predictable regions of tissue and, there- on the strategies for catheterizing and obtaining stable access to the fore, targeted microembolization therapy can be achieved through a inferior phrenic artery which is often distorted after surgery. Emboliza- combination of localization of patient tenderness and selective angi- tion techniques and type of embolization material used for successful ography to confirm contributory arteries. treatment of inferior phrenic artery injuries will also be discussed.

CONCLUSION AND/OR TEACHING POINTS: Injuries to the inferior phrenic artery can be life threatening and can occur during surgeries such as Abstract No. 832 Whipple, splenectomy and hepatectomy. Endovascular treatment is Geniculate artery embolization for the treatment of mild an excellent option for safe management of iatrogenic injuries to the to moderate osteoarthritis: an overview 42 | e-Posters SIR 2020 Annual Scientific Meeting

A Sheu1, A Picel1 patient’s quality of life. There are both nonpharmacological and 1Stanford Medicine, Stanford, CA pharmacological therapies, such as exercising, weight loss, NSAIDS, topical capsaicin, and duloxetine. In more severe or drug-resistant LEARNING OBJECTIVES: 1. Understand the pathophysiology of knee cases, intraarticular glucocorticoid injection and surgery can be used osteoarthritis (OA). 2. Learn patient selection for geniculate artery as treatment options. Recently geniculate artery embolization has embolization (GAE). 3. Review GAE technique and published results. emerged as an alternative procedure for patients with knee osteoarthritis. This technique targets the increased vascularity of synovium. BACKGROUND: Chronic knee pain from OA is a common cause of dis- Despite promising results that show pain reduction and improvement ability, affecting 10% to 15% of 60-year-old men and women. Treat- in the quality of life, further independent randomized controlled stud- ment options vary depending on the severity of disease. Treatment ies are needed to demonstrate efficacy. starts with conservative management and percutaneous joint injection. Arthroscopy and total knee arthroplasty are surgical treatments CLINICAL FINDINGS/PROCEDURE DETAILS: Discuss current treatment for moderate to severe OA that has not responded to other treatments. strategies for knee osteoarthritis. Provide an overview of geniculate GAE is a novel technique for the treatment of refractory OA in patients artery embolization including indications, limitations, and potential who have not responded to conservative treatments and wish to avoid risks; pictorial review of cases will be provided. We will discuss how to surgery. optimize the technique of geniculate artery embolization.

CLINICAL FINDINGS/PROCEDURE DETAILS: The chronic inflammation CONCLUSION AND/OR TEACHING POINTS: Geniculate artery emboliza- in OA degrades cartilage, weakens subchondral bone, and results in tion is a minimally invasive solution for patients with knee osteoarthri- abnormal angiogenesis. Previously, the GAE procedure was utilized tis. Further research is needed to assess the efficacy and safety of this to manage hemarthrosis by treating the hypervascular synovium. It technique. was discovered that GAE can be applied to OA by targeting abnormal angiogenesis in the region of knee pain as indicated by the patient and demonstrated on MRI. Prospective cohort studies report the results of Abstract No. 834 GAE in patients with persistent pain despite conservative treatment. In a group of 72 patients, Okuno et al. demonstrated 86.3% clinical suc- Geniculate artery embolization: what we know and where cess at 6 months and 79.8% at 3 years. There was a decreased need for we’re headed conservative treatments, reduction of angiographic hypervascularity, S Shamah1, D Bamshad2, J Okun3 and improved MRI findings. Embolization has been performed with 1New York Medical College, Valhalla, NY, 2N/A, Valhalla, NY, 3N/A, imipenem/cilastin sodium and calibrated microparticles with no major Bergenfield, NJ adverse events reported. LEARNING OBJECTIVES: To complete a comprehensive literature review CONCLUSION AND/OR TEACHING POINTS: GAE is a promising technique of all articles published that discuss geniculate artery embolization for the treatment of mild to moderate OA in patients who have failed (GAE). To describe gaps in current research, what future studies are medical management. The procedure targets neoangiogenesis in the warranted, and hypothesize other possible applications. region of pain and improves synovitis with few reported procedure related complications. BACKGROUND: GAE is a novel, minimally invasive technique, with new applications still being understood. The earliest applications for geniculate artery embolization have been for hemarthrosis, specifically Abstract No. 833 status post knee replacement. More recently, geniculate artery embolization has been discussed in the setting of osteoarthritis. Because Geniculate artery embolization: next frontier for pain angiogenesis occurs in the setting of chronic inflammation, newly management? formed blood vessels grow into cartilage, synovium, and adjacent I Altun1, L Jamal1, A Sill1, K Zurcher1, S Naidu1, J Kriegshauser1, G bone and stimulate the growth of new sensory nerve fibers as well. The Knuttinen1, I Patel1, S Alzubaidi1, R Oklu1 goal is to decrease the size of inflammatory tissue around the knee, 1Mayo Clinic Arizona, Phoenix, AZ resulting in improvement of pain, stiffness and difficulty performing daily activities from OA. LEARNING OBJECTIVES: 1) Review the traditional approaches to pain CLINICAL FINDINGS/PROCEDURE DETAILS: Recurrent hemarthrosis management in patients with knee osteoarthritis. 2) Describe the following total knee arthroplasty (TKA) is a rare complication with rationale, procedure through case illustrations, and outcomes of genic- an incidence reported up to 1.6% or less. Case series reports of tech- ulate artery embolization. 3) Discuss the future direction of emboliza- nical success of GAE for hemarthrosis s/p knee arthroplasty include tion regarding pain relief in patients with osteoarthritis. Waldenberger et al. (2012), Weidner et al. (2015), Guevara et al. (2016), BACKGROUND: Osteoarthritis is the most common arthritis; it pres- Kolber et al. (2017), and van Baardewijk et al. (2018). These studies ents as joint pain, stiffness, and poses functional limitations. Despite reported technical success of 99%-100% and clinical success of 60%- numerous therapies to treat osteoarthritis there is no universal treat- 92%. Okuno et al. (n = 95) found cumulative clinical success rates at 6 ment modality that is applicable to all types of osteoarthritis cases. months and 3 years after GAE for osteoarthritis were 86.3 and 79.8%, The primary goal ion treatment is to relieve pain and increase the respectively. There is a current clinical trial on-going at the University SIR 2020 Annual Scientific Meeting e-Posters | 43 of North Carolina, Chapel Hill. The primary aims of the trial are to deter- Abstract No. 836 mine if GAE will reduce pain and disability (resulting from pain, stiffness and difficulty performing daily activities) caused by knee OA. First Introduction to prostate artery embolization: practical results of the study (demographics, adverse events) were released in points for interventional radiology residents August 2019, with subsequent data still pending. In our exhibit, these A Ramjit1, J Chen1, B Lei1, D Portal1, A Mahmud1, D Eisman1, E studies will be further discussed and analyzed. Other applications for Landau1, C Giordano1, N Ahmad1 GAE will be explored as well. 1Northwell Health Staten Island University Hospital, Staten Island, CONCLUSION AND/OR TEACHING POINTS: While performing GAE for NY hemarthrosis has been established with positive outcomes, GAE for LEARNING OBJECTIVES: Understand normal pelvic vascular anatomy. osteoarthritis is a relatively new concept with scant data. Review techniques for prostate artery embolization (PAE). Recognize the clinical course for benign prostate hyperplasia before and after Abstract No. 835 PAE.

BACKGROUND: Benign prostatic hyperplasia (BPH) is the proliferation How to approach and treat vascular malformations: of endothelium of the prostate transition zone. By age 50, approxi- a pictorial case based review for the interventional mately 50% of men will have symptoms of bladder outlet obstruction radiologist which degrades their quality of life. Prostate artery embolization (PAE) M Shahid1, O Gantz2, P Shukla3, A Kumar4 is an endovascular alternative to medical management and transure- 1Rutgers New Jersey Medical School, Princeton Junction, thral resection of the prostate for symptomatic BPH. NJ, 2Rutgers New Jersey Medical School, Newark, NJ 07103, CLINICAL FINDINGS/PROCEDURE DETAILS: A Barbeau test is performed NJ, 3Rutgers–New Jersey Medical School, Newark, NJ, 4Rutgers on the left wrist to confirm reconstitution of the superficial and deep New Jersey Medical School, New York, NY palmar arches via the ulnar artery. A diagnostic catheter is advanced

LEARNING OBJECTIVES: 1. To review classification, clinical presentation, into the common iliac artery. Digital subtraction angiography demon- evaluation and management of arteriovenous malformations (AVMs) strates the common, external and internal iliac arteries and their 2. Provide a case based pictorial review of different percutaneous branches. The prostatic artery has a variable origin, but most com- sclerotherapy and embolization techniques for different types of AVM monly arises from the internal pudendal artery. Once the presumed (high flow and low flow). prostatic artery is identified with subselective angiography, cone- beam CT confirms the prostatic arterial supply by demonstrating BACKGROUND: Vascular malformations (VMs) are best managed in a contrast enhancement of prostate parenchyma. Embolization micro- multidisciplinary fashion. interventional radiologists play a key role in spheres can then be deployed. The process is repeated on the con- treatment with embolization and staged sclerotherapy. tralateral side to complete embolization to the entire prostate gland.

CLINICAL FINDINGS/PROCEDURE DETAILS: This exhibit will provide a After procedure, a radial compression artery device is placed over the case based review of evaluation and treatment of different types of arteriotomy for approximately 45 minutes. Clinical parameters such as VMs. Case examples will describe selection of agents for embolization postvoid residual (PVR) and peak urinary flow rate (Qmax) also show and sclerotherapy of both low-flow and high-flow AVMs. Potential significant improvement at one month. PAE’s major advantage is the complications, expected outcomes, and appropriate clinical follow-up short duration and recovery following the procedure. Approximately will also be discussed. half of patients maintain or improve sexual function post PAE.

CONCLUSION AND/OR TEACHING POINTS: interventional radiologist CONCLUSION AND/OR TEACHING POINTS: PAE is a minimally invasive treat Vascular Malformations in a plethora of locations, with transcath- technique that is an alternative to TURP or subtotal prostatectomy in eter embolization and percutaneous sclerotherapy. An understanding patients with BPH. The interventional radiologist has several tools to of clinical features, anatomy and flow characteristics of VMs is essen- ensure the best possible outcomes, such as cone-beam CT to success- tial for interventional radiologists. fully identify the correct vascular bed and radial access to minimize immediate recovery. Trainees should familiarize themselves with both the technical details of PAE as well as the expected clinical course. 44 | e-Posters SIR 2020 Annual Scientific Meeting

Abstract No. 837 Abstract No. 838

Interventional radiology management of hemorrhage Next-generation embolization coils: is there a perfect following cyst: gastrostomy in the setting of complicated solution? pancreatitis I Altun1, L Jamal1, K Zurcher1, M Kuo1, I Patel1, G Knuttinen1, J J McCool1, H Bindner1, J Lee2, D McCleaf1, P Amin1, M Borge1, C Kriegshauser1, S Alzubaidi1, S Naidu1, R Oklu1 1 1 Molvar , A Malamis 1Mayo Clinic, Phoenix, AZ 1Loyola University Medical Center, Maywood, IL, 2Loyola University LEARNING OBJECTIVES: 1) Overview of the currently used endovas- Chicago Stritch SOM, Maywood, IL cular coils; pictorial case examples will demonstrate the use of these LEARNING OBJECTIVES: Review the classification and management coils. 2) Outline the efficacy of various coils used today and their cost. of complicated pancreatitis with a focus on peripancreatic fluid col- 3) Next generation emerging technologies will be discussed. 4) Dis- lections. Discuss the techniques of endoscopic cyst-gastrostomy for cuss bioactive, biodegradable and bioengineered coils as well as novel drainage of peripancreatic collections and consider risk factors and preclinical coils in interventional radiology. management options for postprocedural hemorrhage. Highlight our BACKGROUND: Prospective studies have shown that endovascular coil recent institutional experience with the endovascular management of embolization has significantly better outcomes than open surgical hemorrhage following cyst-gastrostomy. approaches. However, coil packing density, recanalization rate, and BACKGROUND: Acute pancreatitis is frequently complicated by the size of the neck are critical elements for successful treatment. To-date development of peripancreatic fluid collections which may be further rebleeding following coil embolization is a major problem especially in classified based on chronicity and the presence or absence of necro- coagulopathic patients. Some solutions include platinum coils coated sis. When these collections are well encapsulated and symptomatic, with a polymers designed to enhance clot organization and decrease they are often drained via endoscopic cyst-gastrostomy. Hemorrhagic recanalization. Hydrogel coils have also been developed to increase complications have been reported in 3% to 20% of cases and emboli- packing density leading to lower retreatment rates. Emerging embolic zation is occasionally required to achieve hemostasis). agents such as those that are bioengineered will also be reviewed.

CLINICAL FINDINGS/PROCEDURE DETAILS: Cyst-gastrostomy involves CLINICAL FINDINGS/PROCEDURE DETAILS: Hydrogel coils have a plat- transgastric drainage of a walled off collection via endoscopic creation inum core which is covered by hydrogel polymer that expands upon of a channel through the gastric wall directly into the collection. Dou- contact with the blood, therefore, increasing the filling volume within ble pigtail plastic and/or lumen-apposing metallic stents are typically vessels. Other bioactive coils that are covered with polyglycolic acid placed across the channel to facilitate drainage. Immediate bleeding (PGA), polyglycolic/polylactic acid (PGLA) trigger immune responses can occur from direct injury to a coursing vessel or pseudoaneurysm; and lead to organization around coils. We will compare and discuss however, delayed bleeding may also arise due to stent migration or bare platinum coils and new generation coils such as hydrogel and bio- injury related to cavity decompression. Some studies suggest higher active coils. Finally, we will discuss the role of novel clinical and preclin- rates of bleeding associated with metallic stent placement and necrotic ical coils in the future of embolization. collections undergoing necrosectomy. From May 2017 to June 2019, six CONCLUSION AND/OR TEACHING POINTS: Embolization via coils is patients were referred to our department with hemorrhage following widely used and considered the standard of treatment. However, new cyst-gastrostomy. Angiography in four patients showed a focal abnor- generation coils are on the rise and are being researched in hopes of mality within a celiac axis and/or SMA branch which was treated with improving success rates of treatment. However, well designed pro- targeted coil embolization. One patient was treated with prophylactic spective studies in larger patient populations are needed to validate embolization of the left gastric artery after a normal angiogram and their effectiveness. one patient underwent no intervention after a normal angiogram. Hemostasis was achieved in all cases.

CONCLUSION AND/OR TEACHING POINTS: Endoscopic treatment of Abstract No. 839 complicated pancreatitis is effective but is associated with a risk of Pictorial review of branching patterns of inferior hemorrhage. Interventional radiology plays an important role in the pancreaticoduodenal artery diagnosis and management of these hemorrhagic complications. S Sanampudi1, M Issa1, Q Yu1, M Winkler2, D Raissi1 1University of Kentucky, Lexington, KY, 2N/A, Lexington, KY

LEARNING OBJECTIVES: The Learning Objectives of this study are to conduct a pictorial review of different branching patterns of inferior pancreaticoduodenal artery (IPDA) encountered in patients with replaced right hepatic artery (RHA). The replaced RHA can arise from superior mesenteric artery (SMA), left gastric artery, common hepatic SIR 2020 Annual Scientific Meeting e-Posters | 45

artery, or the aorta. We present four different patterns of branching of (TURP), has a fairly high complication rate, with 18% of patients experi- IPDA using 3-dimensional volume visualization and augmented reality. encing sexual dysfunction and incontinence after surgery.

BACKGROUND: Transcatheter arterial embolization is first line treatment CLINICAL FINDINGS/PROCEDURE DETAILS: We will present an overview in patients with upper gastrointestinal (GI) bleeding who have failed of the procedure in a pictorial review. We will review initial data com- endoscopic therapies. Gastric and duodenal ulcers are most common paring PAE as a viable treatment for current standard treatment for causes of nonvariceal upper GI bleeding. Frequently embolized vessels BPH, namely pharmacologic intervention and TERP. We will measure during GI bleed include gastroduodenal artery, hepatic artery, and left the trends of performing this procedure over time amongst IR physi- gastric artery. Occasionally, smaller less common vessels need to be cians in different practice settings as it is becoming a standard plan embolized in the setting of GI bleed including IPDA. This is complicated of care for IR physicians with BPH patients. We will present various in the setting of anatomic variations, notably replaced RHA (most PAE cases from our institutions, discussing initial outcomes and results common mesenteric artery variant). Knowledge of the variations in during follow-up. Finally, we will reiterate the SIR’s most recent stance branching patterns of IPDA in patients with replaced RHA allows for on the procedure and comment on future directions of PAE. proper identification and control of bleeding source while preventing CONCLUSION AND/OR TEACHING POINTS: PAE, with more clinical test- complications of mesenteric ischemia. ing, can become the treatment of choice for BPH. Because of the nov- CLINICAL FINDINGS/PROCEDURE DETAILS: There are several anatomic elty of the procedure, guidelines for patient exclusion still need to be variants of IPDA branching, we will focus on the four patterns reported developed. in literature in patients with replaced/accessory RHA: type A, anterior and posterior IPDA arise from SMA through a common origin; type B, posterior IPDA arises from replaced RHA, anterior IPDA arises from Abstract No. 841 SMA; type C, IPDA arises from replaced RHA; and type D. posterior Prostate artery embolization: a review of anatomy, IPDA arises from replaced RHA, anterior IPDA arises from middle colic angiography and cone-beam computed tomography artery. imaging techniques CONCLUSION AND/OR TEACHING POINTS: Interventional radiologists P Massa1, E Hohlastos2, R Salem3, S Mouli4 and surgeons must be familiar with different branching patterns of 1 2 IPDA during treatment of upper GI bleeding and pancreaticoduo- Northwestern University, Chicago, IL, N/A, Chicago, 3 4 denectomy for tumors and liver transplants, respectively. These vari- IL, Northwestern Memorial Hospital, Chicago, IL, Northwestern ants can be easily learned and displayed through three-dimensional University Feinberg School of Medicine, Chicago, IL volume visualization and augmented reality. LEARNING OBJECTIVES: Review the complex pelvic anatomy and variants that must be understood to perform prostate artery emboliza- Abstract No. 840 tion. How to optimize intraprocedural imaging including cone-beam CT (CBCT), digital subtraction angiography (DSA), and use of embo- Prostate artery embolization lization guidance software to maximize therapeutic effect and avoid nontarget embolization. A Khurana1, I Breen1, A Sill2, S Naidu2, S Alzubaidi2, J Kriegshauser2, R Oklu2 BACKGROUND: Prostate artery embolization has developed as an alternative to surgical therapies for lower urinary tract symptoms related 1Mayo Clinic School of Medicine, Phoenix, AZ, 2Mayo Clinic Arizona, to benign prostatic hypertrophy. While in certain ways the procedure Phoenix, AZ is analogous to uterine artery embolization, prostate arteries are often LEARNING OBJECTIVES: 1. To highlight the recent updates in PAE as variable in origin, small, and in older patients with more atherosclerosis a new procedure in interventional radiology (IR). 2. Demonstrate the which dramatically increases the complexity of the case. Additionally, trends of performing the procedure in various practice settings. 3. nontarget embolization can be devastating in the pelvis. Understand- Review current Society of Interventional Radiology (SIR) stances on ing the anatomy and optimizing imaging is crucial for successful the procedure and future directions to ensure PAE becomes a stan- treatments. dard in IR clinical practice. CLINICAL FINDINGS/PROCEDURE DETAILS: Review of the salient anat- BACKGROUND: BPH is a common condition in older men in which the omy and clinically significant variants. Review of methods for opti- prostate enlarges, causing constriction of the urethra. This can lead mizing imaging during the procedure including the use of CBCT with to discomfort in urination, incomplete bladder emptying, nocturia, embolization guidance software to increase confidence in achieving dysuria, and urinary tract infections from bladder outlet obstruction, a complete embolization and managing significant collateral vessels. all collectively known as lower urinary tract symptoms (LUTS). Current Data from over 100 cases will be reviewed, including 40 with pelvic medical and surgical treatments of BPH pose many complications for CBCTs and 20 with embolization guidance. Data demonstrates a statis- patients. Medical treatment by alpha-1 antagonists can cause impo- tically significant increase in the number of prostatic arteries identified tence, gynecomastia, and orthostatic hypertension. The current gold and treated with use of embolization guidance software (preguidance standard for surgical intervention, transurethral resection of prostate 46 | e-Posters SIR 2020 Annual Scientific Meeting

2.0 vessels treated per PAE versus post-guidance 2.6 vessels treated Abstract No. 843 per PAE, p-value 0.01). The answer to pelvic pain is only a few coils away: the CONCLUSION AND/OR TEACHING POINTS: Prostate artery embolization, use of uterine artery embolization in the treatment of when performed correctly, can be a safe and effective alternative to adenomyosis surgical options for treatment of lower urinary tract symptoms in men with benign prostatic hypertrophy. Successful treatments rely on a N Pigg1, D Aboubechara2, R Fourzali3 deep understanding of pelvic arterial anatomy which can be enhanced 1Aventura Hospital & Medical Center, Aventura, FL, 2Aventura with optimized imaging and through the use of CBCT and embolization Hospital, Elk Grove, CA, 3N/A, Miami, FL guidance software. LEARNING OBJECTIVES: 1. To define the clinical applications of uterine artery embolization (UAE) in the treatment of adenomyosis. 2. To Abstract No. 842 identify indications for UAE: key clinical and anatomical patient selection criteria. 3. To discuss pre and post procedure considerations and Taking advantage of innovations in embolization plug describe the steps of the procedure. 4. To summarize the advantages technology and disadvantages of UAE and the current success rates in treating D Gewolb1, E Jacobson1, M Fickes1, C Stark1, L Keating1, A Herr1, G adenomyosis. 1 Siskin BACKGROUND: Adenomyosis is a benign uterine condition in which 1Albany Medical Center, Albany, NY there is proliferation of endometrial tissue into the myometrium of the uterus. The condition can cause debilitating menorrhagia, dysmenor- LEARNING OBJECTIVES: To review the evolution of plug technology rhea and bulk symptoms within some patients. For years the definitive and the role that plugs play in contemporary embolization procedures. treatment for these patients was hysterectomy but recently inter-

BACKGROUND: The origin of vascular plugs can be traced to 1997 with ventional radiologists have been using UAE in an attempt to treat the the introduction of the Amplatz Septal Occluder developed for the symptoms in these patients. The key to this therapy is to reduce the treatment of atrial septal defects. In 2003, this device was modified for blood flow to the uterus by embolizing the bilateral uterine arteries peripheral embolization and became known as the Amplatzer Vascular and thus reduce proliferation and increase necrosis of the implanted Plug. Since that time, several new embolization plugs have been devel- endometrial tissue. The studies have had mixed results; however, a oped, each with unique features and potential applications. Plugs are majority have shown relief of symptoms in a majority of patients and becoming increasingly popular given the degree of control they permit can provide long-term relief. during deployment and their space-occupying nature which facilitates CLINICAL FINDINGS/PROCEDURE DETAILS: This educational poster will occlusion. use several UAE cases to illustrate the interventional radiology (IR)

CLINICAL FINDINGS/PROCEDURE DETAILS: This educational exhibit approach to assessing when adenomyosis is suitable for IR treatment. will review the history of embolization plugs, focusing on the devel- This includes patient evaluation including diagnosis, demographics, opment of this technology and progressing through its evolution in symptoms, radiographic characteristics, patient selection, and pre and recent years. In addition, the clinical indications best served by the use post procedure considerations and response to therapy. 1. Initial imag- of plugs, the technical details associated with the use of plugs, and the ing 2. Planning approach 3. Accessing the uterine artery 4. Emboliza- procedural and economic rationale needed to optimize plug selection tion techniques 5. Post embolization imaging and follow-up will be reviewed. Finally, new innovations in plug technology will be CONCLUSION AND/OR TEACHING POINTS: Although surgery was the introduced. standard for treatment of adenomyosis for many years, UAE is becom-

CONCLUSION AND/OR TEACHING POINTS: Plugs represent an evolving more widely used and is providing beneficial results for patients ing category of embolic materials with a recent acceleration of new without the complications and stress that can come with surgery. Cur- product development. This new technology has enhanced the role rently, the rates of treatment success range anywhere from 50% to that plugs play in the treatment of an expanding array of indications. 75%. Long-term studies are still coming out, but UAE could provide a This exhibit will help interventional radiologists gain an appreciation viable treatment option for patients seeking to avoid surgery and gain for the features of the newest plug technology by helping them gain symptomatic relief. an understanding of how different features of embolic plugs have evolved over time. In addition, the cost and technical considerations discussed in this exhibit will assist interventional radiologists with plug Abstract No. 844 selection, taking into account how they differ from coils and how their The bleeding intercostal artery: a comprehensive review use impacts total procedure cost. J Lopera1, A Garza-Berlanga2 1UT Health Science Center in San Antonio, San Antonio, TX, 2N/A, San Antonio, TX SIR 2020 Annual Scientific Meeting e-Posters | 47

LEARNING OBJECTIVES: The review the mechanisms of traumatic and selective RAE is the preferred treatment for acute hemorrhage. Angio- iatrogenic injuries of the intercostal arteries. To understand the rele- graphic findings may vary significantly depending on its association vant anatomy of the intercostal arteries for interventional radiology with tuberous sclerosis complex, unique vascular character, lipid con- procedures. To review the different embolization techniques that can tent, and exophytic pattern. A variety of embolics have been used be used in the treatment of intercostal artery injuries. successfully at our institution including microspheres, coils, and ethanol:Ethiodol emulsions. Therefore, we present unique cases of RAE to BACKGROUND: Intercostal arteries are relatively common areas of acquaint the participant with a broad range of possible presentations. accidental injuries after major chest trauma and different invasive procedures. Active bleeding from IA injuries can lead to devastating CONCLUSION AND/OR TEACHING POINTS: RAE is associated with lower complications including massive hemothorax, chest and abdominal mortality rates than nephrectomy in the treatment of renal AMLs and is wall hematomas and could be life threatening. Embolization of IA inju- the preferred therapy for acute hemorrhage. In addition to prophylac- ries is highly effective but due to the extensive collateral flow, addi- tic treatment indications, interventional radiologists should be familiar tional embolization techniques may be required. with its epidemiology, presentation, imaging findings, and approach to rapid RAE should it arise in their institution. CLINICAL FINDINGS/PROCEDURE DETAILS: Relevant anatomy of the IA. Blunt chest trauma and IA injuries: imaging and treatment. IA injury during thoracentesis and biopsies. Complex IA injuries: advanced Abstract No. 846 embolization techniques. Transcaval approach for embolization of type II endoleaks CONCLUSION AND/OR TEACHING POINTS: IA injuries can occur after blunt and penetrating injuries of the chest and are relatively common H Brent1, D Cohen-Addad2, A Efendizade3, S Patel4, S Fahrtash5, W iatrogenic injuries. Embolization techniques are highly effective but Kwon6 can be very challenging given the size and tortuosity of the arteries 1SUNY Downstate Medical Center, Brooklyn, NY, 21987, Brooklyn, and the extensive collateral circulation. NY, 3N/A, Ferndale, MI, 4SUNY Downstate, New York, NY, 5N/A, Brooklyn, NY, 6N/A, New York, NY

Abstract No. 845 LEARNING OBJECTIVES: Review the types of abdominal aortic aneurysm (AAA) endoleaks and current therapies. Discuss the different The current state of management and treatment approaches for type II endoleak repair using images and illustrations. indications for renal angiomyolipomas Learn the indication and technique of transcaval endoleak embolization

1 1 1 1 1 R Raymond , M Novack , M Ezell , B Bordlee , J Caridi BACKGROUND: AAA is a life-threatening condition as rupture is usu- 1Tulane University School of Medicine, New Orleans, LA ally fatal. Endovascular abdominal aortic aneurysm repair (EVAR) is now standard of care for most patients with high success rates and LEARNING OBJECTIVES: 1. Describe the epidemiology, clinical presen- lower morbidity compared to open surgery. An endoleak is an EVAR tation, and clinical course of renal angiomyolipomas (AMLs). 2. Spec- complication and indicates persistent blood flow into an aneurysm sac ify the differences between sporadic and tuberous sclerosis complex after endoluminal graft placement. In this review we focus on type (TSC) renal AMLs. 3. Understand the role of imaging features and clini- II endoleaks, which are the most common and arise from collateral cal context in the prophylactic management strategy of renal AMLs. 4. arterial backflow commonly from the mesenteric and lumbar arter- Discuss the current state of renal AML treatment modalities and out- ies. Treatment by embolization of collaterals can be difficult and thus comes as well as share our experiences with a variety of cases treated techniques to embolize the aneurysm sac itself with CT-guided percu- at our institution. taneous approach have started to increase in popularity. However, in

BACKGROUND: Renal AMLs are benign rare neoplasms composed of cases where the aneurysm sac is located in a position that is difficult to smooth-muscle-like cells, adipocyte-like cells, and epithelioid cells. access with standard percutaneous or transarterial technique, a tran- Renal AMLs may be sporadic or associated with TSC. Due to irregular scaval approach provides an alternative with reduced risk of inadver- angiogenic aspects of the tumor, up to 30% to 40% of renal AMLs may tent abdominal organ injury. The transcaval approach offers an option present with life-threatening hemorrhage requiring emergent embo- when cases arise that were previously thought to be inoperable. lization. Although prophylactic embolization has shown to be a safe CLINICAL FINDINGS/PROCEDURE DETAILS: In this exhibit, we use a cus- and efficacious treatment option, indications still remain controversial tom-made cartoon diagram as well as radiographic images to demon- with imaging features, mass effect, and symptoms playing an import- strate the different approaches for endoleak embolization including ant role. the novel transcaval embolization technique. We discuss the appropri-

CLINICAL FINDINGS/PROCEDURE DETAILS: Multiple treatment options ate clinical indications, limitations and potential complications for each are available for renal AMLs, depending on the presenting size and of the established endoleak embolization techniques. Using a table to severity of symptoms. Partial or radical nephrectomy, renal artery summarize, we compare and contrast the pros and cons for each tech- embolization (RAE), and percutaneous ablation are potential treat- nique given the pertinent clinical scenario. ment options for non–life-threatening presentations, although 48 | e-Posters SIR 2020 Annual Scientific Meeting

CONCLUSION AND/OR TEACHING POINTS: Transcaval embolization is Abstract No. 848 an innovative approach to treatment of endoleaks, which provides an alternative and potentially less invasive means for treatment in a par- Unusual cases of gastrointestinal bleed and its ticular subset of patients. endovascular management: a pictorial review

1 2 3 4 Pros Cons R Agarwal , A Parihar , A Chandra , A Dangi 1 2 Transarterial Minimally invasive Need a large enough feeding Chandan Hospital, Lucknow, India, KGMU, Lucknow, Uttar Pradesh, 3 4 vessel to catheterize KGMU, Lucknow, Uttar Pradesh, KGMU, Lucknow, Uttar Pradesh Can specifically target and treat feeding vessel LEARNING OBJECTIVES: Many times the cause of bleed is not usual the Transcutaneous Useful for poor transarterial Need a direct path esophageal and gastric varices in patients with liver parenchymal dis- access (small feeder, etc.) Risk of organ injury ease. Importance of good doppler interpretation and CT imaging in a Transcaval Useful in cases with Risk of retroperitoneal rare cause of portal hypertension is insurmountable. What not to miss poor transarterial and bleeding on CT angiography so that our life is not made miserable by recurrent transcutaneous access bleed- post operative portal vein aneurysm.

BACKGROUND: Gastrointestinal bleed is a regular thing and most of the Abstract No. 847 times upper and lower GI scopies suffice in making the diagnosis and also taking care of the management. However, there are times when Traumatic splenic injury management: current imaging their result is negative and the patient keeps on bleeding while CT and intervention guidelines angio also fails to add on. Here we will be presenting a case series of M Diamond1, S O’Horo1 rare causes of Gastrointestinal Bleed and how interventional radiology (IR) makes a huge difference in not only diagnosing them but also in 1Boston Medical Center, Boston, MA their management. We hereby present five cases of Gastrointestinal

LEARNING OBJECTIVES: 1. Discuss the updated 2018 American Asso- bleed which were difficult to diagnose and how endovascular manage- ciation for the Surgery of Trauma Organ Injury Scale of the spleen. 2. ment and out-of-the-box thinking made life easy and patients happy. Discuss imaging of the spleen during blunt abdominal trauma. 3. Review CLINICAL FINDINGS/PROCEDURE DETAILS: Case 1: Duodenal varices as the current indications and contraindications for splenic artery angiog- cause of massive upper GI bleed with transsplenic catheter glue embo- raphy and embolization. 4. Discuss the methods of splenic artery embolization of the varices. Case 2: Post Whipple portal vein aneurysm with lization. 5. Review the complications of splenic artery embolization. massive bleed from the drain. Managing the same via percutaneous

BACKGROUND: The spleen is most common organ to be injured in blunt portal vein graft. Case 3: Unusual case of spontaneous splenic AVF abdominal trauma. Current literature on imaging in blunt abdominal who presented with variceal bleed. Case 4: Spontaneous cystic artery trauma, identification and classification of splenic injury, indications, aneurysm as a rare cause of hemobilia. Case 5: Posttraumatic arterio- contraindications, methods, and complications for endovascular portal fistula presenting as a recurrent cause of upper GI bleed. splenic artery intervention will be reviewed with case examples. CONCLUSION AND/OR TEACHING POINTS: In the absence of trans

CLINICAL FINDINGS/PROCEDURE DETAILS: 1. Updated AAST Organ hepatic route trans splenic route can easily be taken. Always look care- Injury Scale of the Spleen includes contained vascular injuries. 2. Imag- fully for portal veins as they can also be potential and curable cause of ing of the spleen in arterial and portal venous phases is recommended upper GI bleed. Importance of teaching the emergency care physicians to identify contained vascular injuries. 3. Indications for splenic artery the role of IR in GI bleed for better outcome. embolization include vascular injuries, moderate hemoperitoneum, and AAST grade IV and V splenic injury. Hemodynamic instability is Abstract No. 849 major contraindication for endovascular intervention. 4. A proximal or distal splenic artery embolization can be performed based on the Utility and technique of renal artery embolization prior angiographic findings. The dorsal pancreatic artery should be iden- to microwave ablation in patients with T1b renal cell tified prior to embolization for use as a landmark. 5. Typical embolic carcinoma agents used in trauma include coils, Gelform and vascular plugs. 6. 1 1 1 2 2 2 Complications include splenic abscess, rupture, septicemia, splenic O Shoaib , N Voutsinas , D Morris , M Ranade , V Bishay , R Patel , 2 2 2 2 vein thrombosis, and pancreatitis. E Kim , F Nowakowski , R Lookstein , A Fischman 1Icahn School of Medicine at Mount Sinai, New York, NY, 2Mount CONCLUSION AND/OR TEACHING POINTS: 1. Review the updated 2018 Sinai Health System, New York, NY American Association for the Surgery of Trauma Organ Injury Scale of the spleen. 2. Discuss imaging of the spleen during blunt abdomi- LEARNING OBJECTIVES: 1. Describe the indications for percutaneous nal trauma. 3. Review the current indications and contraindications for RCC ablation. 2. Describe the complications of percutaneous RCC abla- splenic artery angiography and embolization. 4. Discuss the common tion. 3. Describe the technique and rationale for selective RAE prior to methods of splenic artery embolization for trauma. 5. Review the com- ablation in T1b RCC. plications of splenic artery embolization. SIR 2020 Annual Scientific Meeting e-Posters | 49

BACKGROUND: RAE has been used for many years in the treatment efficacy of Onyx is well established in the treatment of intracranial vas- of both benign and malignant renal tumors and has been proven to cular anomalies. The purpose of this study is to illustrate and support be safe and effective. Ablation of renal lesions can be associated with the use of Onyx in treating extracranial high and low-flow vascular hemorrhagic complications. Particularly for larger lesions, it may be anomalies advantageous to perform embolization in preparation for ablation in CLINICAL FINDINGS/PROCEDURE DETAILS: Patients were initially an effort to decrease the rates of hemorrhagic complications and to assessed at a combined outpatient clinic involving both a vascular improve ablation efficiency by decreasing the “heat sink” effect. surgeon and an interventional radiologist. Cases were discussed in a CLINICAL FINDINGS/PROCEDURE DETAILS: 3 exemplary cases of selec- multidisciplinary team setting. Access to the nidus was performed via tive RAE embolization and ablation for T1b RCC will be presented. a combination of transarterial/transvenous and direct puncture routes Embolization in all patients was performed using 100 micron Emboz- using Onyx 34 with or without Onyx 18. Locations of vascular malfor- ene and 5 cc of lipiodol. In 1 patient, a subcapsular branch vessel mation: thigh (n = 2), supraclavicular fossa (n = 1), upper limb (n = 3), supplying tumor was additionally embolized utilizing two 2 × 4-mm calf (n = 2) and feet (n = 2). No of high-flow: 3; No of low-flow: 7. Patient interlocking coils. Embolization was performed until stasis of flow was satisfaction survey (questionnaire) was carried out at 3, 6, 18 months achieved and adequate tumor staining. Two patients had follow-up follow-up in 9 patients and 3 month follow-up in one patient. multiphase contrast-enhanced CT available for review. Mean lesion CONCLUSION AND/OR TEACHING POINTS: Treatment of peripheral vas- size was 4.9 cm (4.2-6.2 cm). No adverse events were noted up to 30 cular anomalies with Onyx results in a significant improvement in qual- days. Case A: Ablation done at 65 W with a single probe for 10 min- ity of life for patients at our center. The ease of handling and control of utes in 2 locations. Patient was disease free at 7 month follow-up con- Onyx, together with its permanent embolic potency and established trast-enhanced CT. Case B: Ablation done at 65 W with three probes safety profile makes it a desirable embolic material when treating for 10 minutes, followed by 95 W with a single probe for 5 minutes. peripheral vascular anomalies. Patient was disease free at 13 month follow-up contrast-enhanced CT. Case C: Ablation done at 90 W with a single probe for 5 minutes in 3 locations. Patient was lost to follow-up. Abstract No. 851

CONCLUSION AND/OR TEACHING POINTS: Combination selective RAE When fibroids strike back: minimizing pain and nausea can be safely performed prior to percutaneous ablation. There is little after uterine fibroid embolization published literature on selective RAE prior to ablation in T1b RCC, and larger scale studies on this topic are needed to prove the efficacy of K Dorsch1, M Scheidt1, S Vincent-Sheldon1, S White1, A Fairchild1 combination selective RAE and ablation and familiarity with this tech- 1Medical College of Wisconsin, Milwaukee, WI nique will be necessary moving forward in an effort to identify possible advantages of this promising treatment paradigm. LEARNING OBJECTIVES: 1. To review management strategies for pain and nausea in patients undergoing uterine fibroid embolization (UFE). 2. To review of the mechanism of action and evidence behind each Abstract No. 850 strategy.

Utility of ethylene vinyl alcohol (Onyx) in the treatment of BACKGROUND: UFE is a well-established minimally invasive, nonsurgi- peripheral vascular anomalies: a pictorial review cal option to treat uterine fibroids. Adequate control of post procedure pain and nausea remains particularly challenging. Opioids are the 1 2 P Tirukonda , T Tang mainstay of treatment for acute postprocedure pain; however, they 1Changi General Hospital, Singapore, Singapore, 2Singapore General are incompletely effective and have significant associated side effects. Hospital, Singapore, MP Utilization of non-narcotic pain strategies pre, peri, and post opera- tively can help reduce the overall need for narcotics and shorten hos- LEARNING OBJECTIVES: To illustrate the use of Onyx, an ethylene-vinyl pital length of stay. alcohol copolymer liquid embolic agent in the treatment of peripheral vascular anomalies. Correlation with technical, clinical success, opera- CLINICAL FINDINGS/PROCEDURE DETAILS: A review was conducted of tor and patient satisfaction. randomized control trials and case control studies focusing on strategies to reduce post UFE pain and/or nausea published between Jan BACKGROUND: High-flow arteriovenous and low-flow venous mal- 2000 and Sept 2019. Management strategies include epidurals, supe- formations are classified as congenital vascular anomalies by the rior hypogastric plexus block, intraarterial lidocaine administration, International Society for the Study of Vascular Anomalies (ISSVA). utilization of heat packs, and non-narcotic pain cocktail including IV The morphology of these anomalies can be variable. Treatment of acetaminophen, ketorolac, dexamethasone, and ondansetron. Nar- these anomalies can be challenging and requires a multidisciplinary cotic pain regimen including choice of narcotic and route of adminis- approach. Minimally invasive therapy has become the cornerstone in tration is explored. Anti-emetic regimens including drug choices, route the management of these anomalies. One of the most important proof administration, and timing is reviewed. A comparison of femoral and cedural principles in successful treatment is the permanent oblitera- radial access site as it relates to post procedure pain is summarized. tion of the nidus using embolic materials. Ethylene vinyl alcohol (Onyx, Medtronic) is a radiopaque, injectable embolic fluid. The safety and 50 | e-Posters SIR 2020 Annual Scientific Meeting

CONCLUSION AND/OR TEACHING POINTS: Control of pain and nau- Abstract No. 853 sea following UFE is achievable when a multimodality approach is employed. Although there is a wide variance in practice patterns, Bariatric left gastric artery embolization: an overview of having a detailed understanding of available medications and adjunct mechanism, technique, and reported literature procedures will assist interventional radiologists in optimizing pain C Liu1, Q Yu2, D Raissi2 control. 1University of Chicago, Lexington, KY, 2University of Kentucky, Lexington, KY Abstract No. 852 LEARNING OBJECTIVES: 1. Understand the mechanism of action and methodology of bariatric LGAE. 2. Review the preliminary clinical stud- Three-dimensional printed models: preprocedural ies of bariatric LGAE. planning for interventional radiology L Jamal1, J Mayer1, I Altun1, M Knuttinen1, S Naidu1, H Albadawi1, S BACKGROUND: Left-gastric artery embolization (LGAE) has been Alzubaidi1, J Kriegshauser1, I Patel1, R Oklu1 investigated for weight-loss purposes as a minimally invasive procedure. Through percutaneous vascular access, the left gastric artery 1Mayo Clinic Arizona, Phoenix, AZ that supplies the ghrelin-producing cells in the gastric fundus is embo-

LEARNING OBJECTIVES: 1. Understand the concept of creating 3D mod- lized with microspheres. Blood flow restriction in this area reduces els and printing them 2. Learn how they are being used in planning ghrelin secretion, achieving hunger suppression and weight-loss. In complex procedures 3. Future directions of 3D printing in clinical set- this study, our goal is to describe the mechanism of action, provide tings. 4. Educational benefits of 3D printing models for the medical a technical illustration, and review the preliminary clinical studies of staff. bariatric LGAE.

BACKGROUND: Currently, most 3D printed models (3DPMs) are gen- CLINICAL FINDINGS/PROCEDURE DETAILS: We conducted a search on erated from single imaging datasets (CT or MRI) through a process PubMed for studies published up to April 2019. Six studies with 57 known as segmentation. Generated 3D models have been used in patients of 38 studies were selected. Overall, postprocedural weight planning, guiding, and in speeding development of new transcatheter loss demonstrated an upward trend at 1-month, 3-month, 6-month, technologies. Thus, the emergence of this new tool is challenging how and study endpoints (P = 0.283, 0.116, 0.064, and 0.045, respectively). we previously imaged, planed, and carried out cardiovascular inter- By 6-month, the mean weight loss was 9.8 kg, which increased to 11.5 ventions. Interventional catheterization procedures, such as atrial sep- kg at or greater than 1 year. The excess weight loss also decreased in tal device closure, angioplasty of pulmonary venous baffle, and device the first 6 months after bariatric embolization: 8.6, 12.4, and 14.0 kg closure of a mitral valve leaflet perforation have been using 3DPMs at 1-month, 3-month, and 6-month respectively. No severely debilitat- for further guidance and accuracy. Also, 3DPMs have applications in ing complication was reported. Gastric ulcers occurred in 13 patients congenital heart disease, coronary artery disease, and in surgical and (22.8%). Two patients developed postprocedural pancreatitis (3.5%). catheter-based structural disease. However, these complications were short-lived and controlled with simple medications such as proton-pump inhibition. The maximal ghrelin CLINICAL FINDINGS/PROCEDURE DETAILS: In this educational exhibit, decreased 24 pg/mL from the baseline on average. The mean serum we will depict examples of left atrial appendages 3D models and ghrelin at 6-month postprocedural was 365.9 pg/mL, decreased from highlight the advantages for using it for device sizing. We will explore 453.9 pg/mL at baseline (P = 0.173). No significant difference in leptin the different cases in which 3D models have guided interventionists levels was found before and after bariatric embolization (P = 0.554). in procedures. We will also present the current process being used to generate 3D models. Finally, we will discuss the limitations, and future CONCLUSION AND/OR TEACHING POINTS: LGAE is safe and feasible directions of 3D printing for cardiovascular intervention. intervention in achieving weight-loss in patients who have failed conservative management and are high risk surgical candidates. Serum CONCLUSION AND/OR TEACHING POINTS: Interventional procedures are ghrelin level in the clinical setting is not as reliable in predicting weight- highly dependent on the quality of current imaging techniques and loss. Future research can focus on maximizing selective reduction of recently on their ability to produce 3D models. Through these 3D mod- ghrelin-producing cells while avoiding complications such as gastric els interventional radiologist and cardiologist have been able to better ulcers. predict device sizes, catheter placement, and assess the overall risk of a procedure. 3D models also have impacted medicinal education in numerous ways. The development of accurate 3DPMs is slowly shifting Abstract No. 854 clinical practice to focus more on preprocedural approaches that minimizes mis-sizing devices, and misplacement of catheters. Basics of wire technology: a primer for radiology trainees M Patel1, O Adenikinju1, S C. Durscki Vianna1, H Reynolds1, B Money2, R Beasley1, A Zybulewski1, B Olivieri1 1Mount Sinai Medical Center, Miami Beach, FL, 2Nova Southeastern University College of Osteopathic Medicine, Fort Lauderdale, FL SIR 2020 Annual Scientific Meeting e-Posters | 51

LEARNING OBJECTIVES: (1) Discuss the basic design and function of a is pioneered with the same technology as urologic lithotripsy and uses guidewire, (2) How core components of a guidewire influence vascu- sonic pressure waves to interact with soft tissues and high-density cal- lar intervention. (3) Discuss pearls and pitfalls through case examples cium in the intimal and media layers of the vessel wall. IVL fractures from our institution calcification while maintaining the integrity of the elastic components in the vessel wall through the use of a subnominal balloon, further BACKGROUND: There are six key components of a guidewire: core lowering the risk of complications. In comparison to atherectomy, IVL diameter, core material, core taper, tip design, coils and covers, and does not require the use of distal embolic protection due to its plaque coating. Components of guidewires affect their attributes such as tor- modifying technology and has a lower risk for vessel wall perforation. quability, support, flexibility, durability, and tip penetrance. In turn, a thorough understanding of these wire-specific attributes affects the CLINICAL FINDINGS/PROCEDURE DETAILS: Our assessment of intravas- operator’s tailored approach during intervention and can ultimately cular lithotripsy will 1) review the design and function of IVL, 2) discuss determine the technical success of a procedure, whether it be cath- the clinical safety, effectiveness, and complication rates of IVL versus eterizing an acutely angled prostate artery or crossing a pedal loop other common treatment options, 3) guide the reader on treatment chronic total occlusion. Here, we provide a primer on everything from modality selection for IVL, atherectomy, and balloon angioplasty the basics to the latest cutting-edge technological advancements in through case-based examples from our institution, and 4) compare the rapidly evolving field of guidewire design. the cost and efficacy of IVL as opposed to orbital, rotations, directional, and laser atherectomy. CLINICAL FINDINGS/PROCEDURE DETAILS: Our primer will 1) review the elements of a guidewire support chart, 2) discuss the significance of CONCLUSION AND/OR TEACHING POINTS: IVL has shown to be a prom- shaping the tip of a wire before navigating a lesion, 3) illustrate the ising tool for treating heavily calcified PAD for the endovascular spe- components of a guidewire involved in successfully cannulating an cialist. Constant advances in PAD therapies can expand the repertoire acutely angled or tortuous vessel, 4) illustrate how understanding of the CLI fighter. Here we educate and equip the operator on how to the components of a guidewire assist an operator in crossing a vas- navigate the peripheral space with modern lithotripsy. cular lesion through case examples, 5) provide an escalation process for guidewire failure while crossing an occlusion, 6) review common device-specific guidewires, and 7) provide an overview of guidewire Abstract No. 856 complications. The reader will also be equipped with a diagram of Detecting occult insulinoma by interventional radiology– common guidewires, their key attributes, and case examples of when guided selective arterial calcium stimulation test to apply them to augment their outcomes. G Petersen1, Z Berman1, J Minocha1 CONCLUSION AND/OR TEACHING POINTS: Knowledge of guidewire 1 design and corresponding wire characteristics is essential in order University of California, San Diego, San Diego, CA to maximize chances of procedural technical success and minimize LEARNING OBJECTIVES: Educate providers that the selective arterial complications. Our educational poster provides a core foundation on calcium stimulation test effectively locates occult insulinoma. the basics of guidewire construction and explores the latest advancements in technological wire design. BACKGROUND: The selective arterial calcium stimulation test (SACST) is an interventional radiology (IR)–guided diagnostic test for locating occult insulinoma. Dysplastic beta cells respond to calcium by secret- Abstract No. 855 ing insulin, while normal beta cells do not. By stimulating vascular territories of the pancreas with calcium and sampling venous insulin levels, Cracking calcium with big waves: a review of intravascular the location of dysplasia can be found. lithotripsy CLINICAL FINDINGS/PROCEDURE DETAILS: Our patient is a 49-year-old 1 1 1 1 H Reynolds , M Patel , O Adenikinju , S C. Durscki Vianna , A woman with a multiyear history of fasting hypoglycemia. Inpatient Zybulewski1, R Beasley1, B Olivieri1 fasting trial indicated the presence of insulin, although C-peptide was 1Mount Sinai Medical Center, Miami Beach, FL lower than expected for insulinoma. Sulfonylurea and insulin Ab testing were negative, IGF1/2 and ACTH were within normal limits. Dotatate- LEARNING OBJECTIVES: (1) Provide a role for intravascular lithotripsy PET/CT demonstrated avidity in the pancreatic tail, but EUS biopsy (IVL) in the treatment of peripheral artery disease (PAD). (2) Compare of a suspect tail region in the tail showed normal pancreatic and lym- the clinical outcomes and complication rates of IVL versus other com- phoid tissue. With conflicting PET and histologic results, and fasting mon treatments. (3) Use case examples from our institution to com- labs not fully excluding exogenous insulin use, she underwent SACST. pare IVL to other common treatment options for calcified PAD The right femoral vein was accessed and a 5-Fr Simmons 1 catheter BACKGROUND: Treatment of complex calcified PAD is a challenging was placed in the right hepatic vein for sampling measurements. The task that frequently includes the use of percutaneous transluminal right femoral artery was accessed and a 5-Fr SOS catheter was nav- angioplasty, stenting, and atherectomy. Collectively, these techniques igated to the celiac trunk. A Progreat microcatheter was sequentially mainly target intimal plaque without modification of remaining subad- advanced to the distal splenic (DSA), proximal splenic (PSA), proper ventitial plaque and come with an increased risk of dissection, perfora- hepatic (PHA, negative control) and gastroduodenal arteries (GDA) tion, restenosis, and distal embolization. Intravascular lithotripsy (IVL) before relocating to the proximal superior mesenteric artery (SMA). 52 | e-Posters SIR 2020 Annual Scientific Meeting

For each artery, calcium gluconate (0.025 mEq/kg) was administered CONCLUSION AND/OR TEACHING POINTS: Interventional radiologists with venous sampling immediately and every 30 seconds for 2.5 min- should be familiar with the diagnostic criteria of PSAs as well as com- utes followed by a 5-minute washout. mon treatment options. Based on the location and PSA characteristics, percutaneous thrombin injection is a safe and effective procedure CONCLUSION AND/OR TEACHING POINTS: Stimulation of the DSA for a variety PSAs that should in every interventional radiologist’s resulted in a 100% increase in venous insulin levels, the threshold for armamentarium. a positive test. The PSA, GDA, SMA, and PHA saw 30%, 30%, 80%, and 0% increases respectively. This outcome is most consistent with an insulinoma in the tail of the pancreas supplied by the DSA and SMA Abstract No. 858 (which appeared to supply the tail on angiography). The patient is scheduled for distal pancreatectomy. SACST is a simple and useful IR Pancreas-related hemorrhage: review of diagnostic procedure to establish the presence and location of insulinoma prior evaluation, clinical management, and contemporary to surgery. endovascular techniques M Makary1, R Patel2, A Da Silva1, B Cureton1, J Dowell3 Abstract No. 857 1The Ohio State University Wexner Medical Center, Columbus, OH, 2Chicago Medical School, Chicago, IL, 3Northwest Radiology, How thick is your neck? Treatment of peripheral and Carmel, IN visceral pseudoaneurysms with percutaneous thrombin injections LEARNING OBJECTIVES: To review the pathophysiology, clinical and diagnostic imaging evaluation, and interventional approaches for pan- 1 1 1 B Logiurato , C Barnett , N Lamparello creas-related hemorrhage, as well as examine the current literature, 1New York Presbyterian Hospital/ Weill Cornell Medical Center, New treatment outcomes, and future therapies. York, NY BACKGROUND: Pancreas-related hemorrhage is a life-threatening

LEARNING OBJECTIVES: -Define pseudoaneurysms (PSAs) and their condition that can occur secondary to a variety of etiologies. Key pathophysiology. Detail the diagnostic criteria for PSA across differ- considerations include sequelae of chronic pancreatitis, postsurgical ent imaging modalities. Provide an approach for risk stratification and hemorrhage such as in the setting of Whipple, and posttraumatic vas- deciding when to treat. Describe the different interventional radiology cular injury. While the initial presentation can be forthright such as a (IR) treatment options and risks. Provide case-based learning using hemorrhage in a pancreatic pseudocyst in the setting of pancreatitis, four interesting cases of PSA treated by IR. or a splenic artery pseudoaneurysm in the setting of trauma, unique presentations such as hemosuccus pancreaticus with obscure hemobi- BACKGROUND: PSA are a fairly common entity encountered by the lia or post-Whipple injury with elusive hemorrhage from a GDA stump. interventional radiologist. Given their potentially devastating compli- While endoscopy and cross-sectional imaging can be helpful, the cations, interventional radiologists should be adept at the diagnosis source of pancreas-related hemorrhage is not always readily identi- and different treatment of PSA. fied, and a high clinical suspicion and prior procedural planning is war- CLINICAL FINDINGS/PROCEDURE DETAILS: PSAs are a contained rup- ranted for optimal outcomes in these high acuity patients. ture through an arterial wall defect created by trauma, infection/ CLINICAL FINDINGS/PROCEDURE DETAILS: This educational exhibit inflammation, or iatrogenic procedures. While catheter angiography will (1) present an overview of pancreas-related hemorrhage while is the gold-standard diagnosis, duplex ultrasound (US), MRI, and CT reviewing relevant clinical presentations and anatomic considerations, can also aid in the diagnosis. US is inexpensive, portable, and non- (2) provide a case-based review of key etiologies of pancreas-related invasive, carrying a 94% sensitivity for diagnosis of PSA. Diagnosis hemorrhage (chronic pancreatitis, post-Whipple hemorrhage, post- is made through a combination of the clinical scenario and imaging traumatic vascular injury, and hemosuccus pancreaticus), (3) review findings, demonstrating a cystic structure with a classic “yin-yang the clinical management of pancreas-related hemorrhage including sign.” IR alternatives to surgical treatment of PSA include manual com- medical, interventional, and surgical techniques for treatment, (4) pression, percutaneous thrombin injection, endovascular coiling and present current endovascular techniques and technical pearls, (5) endovascular stent placement. Depending on the size, location and review the procedural indications, contraindications, and potential imaging characteristics of the PSA, image-guided thrombin injection risks, and (6) review the present literature, treatment outcomes and represents a quick, safe and effective treatment for PSA. If the PSA prognosis, and future therapies. is well visualized on imaging and a thin neck is present, the operator can slowly inject thrombin to achieve thrombosis with a 90% success CONCLUSION AND/OR TEACHING POINTS: After reviewing this exhibit, rate. Similarly, endoluminal techniques have also proven to be a safe the viewer will gain a better understanding of the management of pan- and effective way to treat visceral and wide-necked aneurysms not creas-related hemorrhage including the initial clinical diagnosis and amenable to percutaneous thrombin injection. Here we will review 4 management, endovascular techniques and technical pearls, as well as interesting cases (with images) of femoral, axillary, hepatic, and vis- current treatment outcome data and future therapies. ceral PSAs treated successful with percutaneous thrombin injection. SIR 2020 Annual Scientific Meeting e-Posters | 53

Abstract No. 859 approaches with well-known techniques including conventional fibri- nolytic infusion, ultrasound-enhanced lytic infusion, rheolytic throm- The role of interventional radiology in the management of bectomy, and aspiration thrombectomy. (3) Discuss pearls and pitfalls abnormal placentation of the different devices in a clinical presentation based discussion.

1 1 1 1 S Han , X Marko , S Kazanjian , W Sherk BACKGROUND: ALI is associated with high rates of morbidity and mor- 1University of Michigan Hospital, Ann Arbor, MI tality. Historically, catheter-directed thrombolysis has proven effective as standard of care in patients with early stage ALI. However, in prac- LEARNING OBJECTIVES: To describe the pathophysiology and diagno- tice the optimal endovascular therapy for ALI varies on a case-by-case sis of placenta accreta spectrum. To describe the management and basis, often depending on etiology, chronicity, clinical staging, ana- role of interventional radiology (IR) for hemorrhage in placenta accreta tomic location, and patient-specific factors. spectrum. To describe the techniques of intraaortic balloon occlusion, iliac artery balloon occlusion, and uterine artery embolization. To pro- CLINICAL FINDINGS/PROCEDURE DETAILS: Here we provide a case vide an overview of the evidence for the techniques in managing hem- based description of techniques, guiding the reader through pre orrhage in placenta accreta spectrum. procedural planning, device selection, outcomes, follow-up and retrospective analysis of special situations (Bypass and native artery BACKGROUND: Placenta accreta spectrum is a broad term that encom- simultaneous occlusion, CLI with bypass occlusion extending to the passes placenta accreta, placenta increta, and placenta percreta. infrapopliteal vessels.) It is imperative for interventional radiologists There has been increasing prevalence between 1 in 2510 and 1 in 4017 treating ALI to not only be well-versed in strengths and weaknesses of in prior observational studies and as high as 1 in 272 in women with a all available treatment options, but also to be able to delineate specific birth-related hospital discharge diagnosis. The management of hem- algorithmic endovascular approaches for ALI patient subclasses. orrhage in placenta accreta spectrum requires a multidisciplinary team and case-by-case approach to appropriately manage these patients. CONCLUSION AND/OR TEACHING POINTS: We provide an analyti- The role of IR in the management of placenta accreta spectrum has cal patient centered discussion to guide interventional radiologists been described in the prepartum, intrapartum, and postpartum set- through successful decision making in the treatment of complex pre- tings, primarily for the prevention or treatment of hemorrhage. sentations in ALI by (1) Describing the clinical presentation as well as the pertinent comorbidities on different ALI endovascular devices CLINICAL FINDINGS/PROCEDURE DETAILS: The literature was reviewed currently on the market; (2) comparing and contrasting mechanisms for the current evidence and management of placenta accreta spec- of action, benefits, and potential complications for each available ther- trum relating to IR. The techniques described are intraaortic balloon apy; (3) exploring procedural-associated costs of each technique; and occlusion, iliac artery occlusion, and uterine artery embolization. Dia- (4) discussing pearls and pitfalls for increasing device effectiveness grams and case examples will accompany each procedure to provide through case examples. the details of the procedures, as well as to describe the timing of when the procedures are utilized. A discussion of the current literature will accompany each procedure. Abstract No. 861

CONCLUSION AND/OR TEACHING POINTS: As hemorrhage in the setting Evidence-based algorithm for the endovascular of placenta accreta spectrum becomes more common, it is important management of pulmonary embolism based on current for the interventional radiologist to know how to perform the proce- literature and guidelines dural techniques, as well as to know the current evidence of these 1 1 2 3 4 procedures. E Narasimhan , P Li , S Nonas , B Zakhary , B Maughan , R Schenning1, K Farsad1, J Kaufman1, R Al-Hakim1 1Charles T. Dotter Department of Interventional Radiology, Oregon Abstract No. 860 Health & Science University, Portland, OR, 2Division of Pulmonary and Critical Care Medicine, Oregon Health & Science University, ALI meets CLI: unusual solutions for complex arterial Portland, OR, 3Division of Pulmonary and Critical Care Medicine, occlusions from a Vascular Center of Excellence Oregon Health & Science University, Portland, OR, 4Department S C. Durscki Vianna1, O Adenikinju2, C Ducaud3, H Reynolds1, B of Emergency Medicine, Oregon Health & Science University, Olivieri4, T Yates4, A Zybulewski5 Portland, OR

1 2 Mount Sinai Medical Center, Miami, FL, Mount Sinai Medical LEARNING OBJECTIVES: • Analyze current literature on pulmonary 3 4 Center, Miami Beach, FL, N/A, Palmetto Bay, FL, N/A, Miami, embolism (PE) management. • Understand various PE management 5 FL, Icahn School of Medicine at Mount Sinai, New York, NY options. • Identify issues for further research on PE management. • Eval- uate future evidence-based guidelines for PE. • Apply guidelines to shape LEARNING OBJECTIVES: (1) Review the clinical presentations and pathophysiology of acute limb ischemia (ALI) including the coexis- clinical practice. tence with chronic peripheral artery disease. (2) Explore teaching BACKGROUND: PE is a common diagnosis in clinical practice, which points through a retrospective case based analysis of nonconventional is treated by evolving data to support clinical decision-making. This 54 | e-Posters SIR 2020 Annual Scientific Meeting

educational exhibit will review current PE management literature, before returning through the reinfusion catheter. We describe a single including clinical and imaging evaluation prior to intervention and center’s experience using the AngioVac device. treatment options beyond systemic anticoagulation. CLINICAL FINDINGS/PROCEDURE DETAILS: We present 37 cases using CLINICAL FINDINGS/PROCEDURE DETAILS: This educational exhibit will the AngioVac between 2013 and 2019 at our institution. Demograph- begin by outlining mortality risks and outcomes of PE treated with ics, indications, procedural details and outcomes were retrospectively systemic anticoagulation (SA), including reviewing the ELOPE trial analyzed. Of the 37 cases 21 were for RA thrombus, 4 for IVC thrombus, which suggests a high occurrence of post-PE syndrome, defined by 3 for IVC to common iliac vein thrombus, 1 for left subclavian artery the American Thoracic Society as: exercise intolerance, dyspnea and thrombus, 4 for IVC to common femoral vein thrombus, 1 IVC to popli- reduced quality of life for 3 months following effective treatment. teal vein thrombus, 1 IVC to renal vein thrombus, and 1 Right atrium to The imaging/clinical evaluation of patients presenting with PE will be left atrial thrombus across a patent foramen ovale. 33 cases were des- reviewed, including methods for detecting RV strain by CT and serum ignated as successful/partially successful, and 4 were unsuccessful. In biomarkers as well as risk stratification scoring systems. We will then the cases of failure, 1 was a chronic thrombus, 2 due to large size, and review current literature and evidence based guidelines for manage- 1 due to location. Review of indications over time have demonstrated ment of PE with systemic thrombolysis, catheter based thrombus that removal of right atrial thrombus/vegetation has increased over removal, and surgical embolectomy. Data will be synthesized to rec- time with 8 cases between 2013-2017, 9 cases in 2018 and 5 cases so ommend clinical evaluations and treatments, including stratification far in 2019. from the 2014 European Society of Cardiology guidelines and treat- CONCLUSION AND/OR TEACHING POINTS: The AngioVac aspiration ment options based on risk stratification. We will then integrate the thrombectomy device is safe alternative to traditional pharmacome- literature and guidelines into an evidence based algorithmic treatment chanical techniques. It has evolved to play an integral role in the man- approach to evaluate and manage PE. agement of infective endocarditis refractory to medical management. CONCLUSION AND/OR TEACHING POINTS: -Patients presenting with signs/symptoms of PE should be initially evaluated and risk stratified -Initial evaluation should include H&P, CBC, CMP, EKG, and CTA Abstract No. 863 to confirm PE with RV/LV ratio -The core of initial management is SA The tissue is the issue: transplant artery thrombosis at diagnosis while further evaluation is underway -Treatment options for PE include SA, thrombolysis, catheter-assisted thrombus removal, A Khurana1, A Kilgore1, I Breen1, P Hoang1, M Knuttinen1, S mechanical/surgical thrombectomy and IVC filter placement -Our evi- Alzubaidi1, H Albadawi1, J Kriegshauser2, S Naidu3, I Patel4, R Oklu1 dence-based algorithm for PE evaluation and management is useful 1Mayo Clinic Arizona, Phoenix, AZ, 2Mayo Clinic Scottsdale, Phoenix, for clinical reference. AZ, 3Mayo Clinic Arizona, Scottsdale, AZ, 4Mayo Clinic–Arizona, Phoenix, AZ

Abstract No. 862 LEARNING OBJECTIVES: (1) Develop a basic understanding of transplant artery complications through case illustrations. (2) Examine cur- Single-center experience with the AngioVac device rent trends in treatment modalities. (3) Apply knowledge to decide A Heilala1, L Kabbani2, S Schwartz2 which treatment is best for the patient, and envision future directions for therapy within interventional radiology. 1Henry Ford Hospital, Royal Oak, MI, 2Henry Ford Hospital, Detroit, MI BACKGROUND: Transplant artery thrombosis is a major complication of solid organ transplants. Torsion, kinks, and angulation in the vessel can LEARNING OBJECTIVES: Indications for AngioVac. Describe steps of occur shortly after transplantation. Narrowing and stenosis of trans- AngioVac procedure. Results of single-center use of AngioVac Device. plant arteries cause blood flow to become turbulent and coagulable,

BACKGROUND: The AngioVac (AngioDynamics) is FDA approved as increasing the possibility of thrombosis within the artery. This compli- a venous drainage cannula during extacorporal bypass to remove cation is commonly studied in the context of liver and kidney trans- undesirable intravascular material. It has been used for removal of plantation. Hepatic artery thrombosis (HAT) causes the majority of iliocaval and central venous thrombus, atrial thrombus/tumors, valve allograft loss in liver transplant patients. Thrombosis in renal transplan- vegetation, and rarely pulmonary emboli. Other means of mechani- tation can be caused by a multitude of factors similar to HAT, with the cal thrombectomy and pharmacomechanical thrombolysis have been addition of external compression due to placement in the iliac fossa. the standard of care. The AngioVac is an alternative for large volume CLINICAL FINDINGS/PROCEDURE DETAILS: When developing treatment thrombectomy treated in a shorter timeframe. For right heart valve plans personalized to the anatomy of the patient, we must choose the vegetation, AngioVac is an alternative to valve replacement for acute highest efficacy imaging modality. We plan to present examples where infective endocarditis. It is option for septic endocarditis refractory to CTA and Doppler ultrasound usage must be considered carefully. medical management. The AngioVac system consists of a 22-Fr large- Assessing the potential for endovascular techniques suggest that suc- bore suction cannula, a veno-venous bypass circuit and reinfusion cess is dependent on timing. Usage of PTA, without or without stent cannula. Blood is bypassed through a filter, trapping thrombus/debris placement will be contrasted versus thrombectomy versus intraarterial SIR 2020 Annual Scientific Meeting e-Posters | 55 thrombolysis (IAT) with tissue plasminogen activator (tPA) or uroki- Abstract No. 865 nase. This exhibit will also review basic techniques for the aforementioned techniques and review the current literature that supports its Developing an orthotopic pancreatic adenocarcinoma use. Additionally, the exhibit will discuss the use of catheter-directed model in Lewis rats to study novel locoregional and thrombolysis for venous complications of renal transplantation. combinatorial therapies

1 2 3 2 4 5 CONCLUSION AND/OR TEACHING POINTS: Transplant artery thrombosis A Gabr , Y Jahangiri , B Uchida , K Yamada , J Li , O Taratula , O 5 2 is a leading cause of allograft failure. Early attempts at revasculariza- Taratula , K Farsad tion maximize the probability of graft survival. The development of 1Oregon Health & Science University–Tanta University, Portland, new thrombolytic agents and catheter tools will hopefully improve out- OR, 2Oregon Health and Science University, Portland, OR, 3OHSU comes in the endovascular treatment of transplant arterial thrombosis. Dotter Interventional Institute, Portland, OR, 4Oregon Health & Science University, Portland, OR, 5Oregon State University, Portland, OR Abstract No. 864 LEARNING OBJECTIVES: -To review the cell culture and tumor implan- Chemotherapy in interventional radiology: how much tation protocol for an orthotopic pancreatic ductal adenocarcinoma should we know? model in Lewis rats with histological characteristics of human pancreatic adenocarcinoma -To describe a reproducible technique for rat tail I Altun1, L Jamal1, A Saini1, M Kuo1, S Alzubaidi1, G Knuttinen1, S artery access ideal for repeated angiography and transarterial inter- Naidu1, R Oklu1 vention in survival studies -To illustrate an imaging protocol using US 1 Mayo Clinic, Phoenix, AZ and MRI to monitor rat pancreatic tumor implants.

LEARNING OBJECTIVES: 1. To discuss basic principles of chemotherapy BACKGROUND: The DSL-6A/C1 pancreatic adenocarcinoma cell line has and types of chemotherapeutics 2. To review the commonly used che- been successfully used to study pancreatic cancer in immuno-compe- motherapeutics in interventional radiology (IR) practice 3. To discuss tent Lewis rats. Orthotopic pancreatic implants of these cells produce the efficacy and safety of the regional administration of chemothera- locally invasive, moderate to well-differentiated pancreatic ductal peutics. 4. To present preclinical studies addressing reducing the toxic adenocarcinoma tumors mimicking those seen in humans. Although side effects of chemotherapy drugs. tumor propagation and implantation protocols have been described with variable outcomes, lack of robust available methodology is a chal- BACKGROUND: There are several types of chemotherapeutic drugs, such as alkylating agents, antimetabolites, topoisomerase inhibitors. lenge to reproduce the model. We provide a detailed protocol from Each drug has its own mechanism of action and effect on patients. cell culture to therapeutic testing suited for studying locoregional Despite the well-known severe adverse effects chemotherapeutics therapies. impose on patients, these drugs continue to be used. Many novel CLINICAL FINDINGS/PROCEDURE DETAILS: DSL-6A/C1 cells are propa- approaches have emerged in efforts to decrease its adverse effects. gated to 3 × 108, harvested and centrifuged. The cell pellet is resus- Approaches such as regional application of chemotherapeutics aim to pended in a nutrient gel matrix and injected subcutaneously into the reduce systemic exposure. This approach creates the opportunity for flank of 100-g donor Lewis rats to develop tumors. After 3 weeks, interventional radiologists to examine the practicality and applicability palpable tumors (10-15 mm) are excised and minced into 2-3 mm of new locoregional approaches. fragments for implantation into the pancreatic tail of recipient 300-g Lewis rats. Via a 1 cm left paramedian abdominal incision, the spleen CLINICAL FINDINGS/PROCEDURE DETAILS: An interventional radiologist should be acquainted with the basic principles and types of che- and pancreatic tail are exposed and fragments (2-3) are implanted in motherapeutic drugs, specifically those commonly used in IR. Our a small parenchymal pocket created using a needle and covered by a aim is to review chemotherapeutic agents used with locoregional gelatin sponge pledget. Tumor growth is followed with US at 2-week administration and in the emerging field of immunotherapy. We will intervals, and MRI at 4-week intervals. Arterial access through the rat also present preclinical studies aimed at reducing toxic side effects of tail artery is used for selective angiography and locoregional delivery chemotherapy. of therapeutic agents.

CONCLUSION AND/OR TEACHING POINTS: An immunocompetent Lewis CONCLUSION AND/OR TEACHING POINTS: Locoregional application of chemotherapeutics offers concentrated and direct delivery of agents rat orthotopic pancreatic adenocarcinoma model is described for to the tumor region. Interventionalists will greatly benefit from famil- developing innovative therapies for pancreatic cancer. This survival iarizing themselves with this topic, so that when they approach cancer model is suitable for transarterial intervention and follow-up. cases they could bring forth novel techniques improving the efficacy of treatment. 56 | e-Posters SIR 2020 Annual Scientific Meeting

Abstract No. 866 BACKGROUND: Synthetic biology is an emerging interdisciplinary branch of biology and engineering that designs and constructs arti- Ovarian venous sampling for hyperandrogenism: what the ficial biological systems. Though still in its infancy, synthetic biology interventional radiologist needs to know is already being used in the bioprocessing of pharmaceuticals like the S Uppal1, A Li2 antibiotic cephalexin and the type II diabetes treatment sitagliptin. Two specific applications of synthetic biology are currently being investi- 1University of Radiology–RWJ, Holmdel, NJ, 2University Radiology gated for use by interventional radiologists: locoregional vector and Group, Livingston, NJ designer cell delivery. Both can be delivered using percutaneous, tran-

LEARNING OBJECTIVES: Practical approach for interventional radiolo- sarterial, or retrograde balloon-occluded transvenous approaches. gists to confidently field hyperandrogenism consultations. Understand CLINICAL FINDINGS/PROCEDURE DETAILS: Oncolytic viruses and vec- causes for falsely elevated testosterone levels. Understand ovarian tors carrying synthetic biology payloads (e.g., gene editing platforms and adrenal venous anatomy to perform the selective venous sam- like CRISPR/Cas9) can be delivered into a specific organ or tumor. This pling procedure. Understand how to interpret the laboratory results of increases the efficiency of the treatment as compared to systemic the ovarian/adrenal venous sampling. delivery, as it reduces the amount of vector needed for the treatment.

BACKGROUND: Women with clinical features of hyperandrogenism, It also helps prevent off target effects such as immune activation which such as amenorrhea, hirsutism, cystic acne, balding, aggressive can occur more frequently during systemic delivery as compared to behavior, increased libido and virilization are often evaluated by endo- locoregional. Designer cells are synthetic cells that can perform log- crinologists. Most cases of hyperandrogenism are caused by polycys- ical functions such as cellular responses to environmental conditions tic ovarian syndrome. Very elevated serum testosterone can be due and/or specific antigens. These cells are capable of both sensing and to adrenal or ovarian tumors. Hyperandrogenism with very elevated altering the tumor microenvironment as well as binding to tumor-spe- serum testosterone can warrant a consultation for venous sampling of cific antigens and inducing tumor lysis. They can be designed to be the ovaries and/or adrenal glands to localization of suspected tumor. immunologically invisible by placing them inside a porous gel capsule. Ovarian and adrenal venous sampling should occur only after verifica- Alternatively, they can be created by first harvesting T-cells from the tion of clinical findings, laboratory testing, and nonlocalizing diagnos- patient, altering them in vitro, and then reintroducing them into the tic imaging exams. patient (as in the case of chimeric antigen receptor adoptive T-cell transfer). CLINICAL FINDINGS/PROCEDURE DETAILS: Discussion will include comprehensive algorithm for evaluation of hyperandrogenism. An empha- CONCLUSION AND/OR TEACHING POINTS: Synthetic biology is a rap- sis will be placed on physiological causes and causes of falsely positive idly developing field with tremendous potential to treat a variety of elevated testosterone. Adrenal and ovarian imaging will be briefly diseases including cancer. Interventional radiologists are well posi- reviewed. Technique and protocol for ovarian venous and adrenal tioned to deliver synthetic biology-derived therapies as locoregional venous sampling will be reviewed. approaches can improve both the efficiency and safety of delivery as compared to systemic approaches. CONCLUSION AND/OR TEACHING POINTS: A protocol for performing and interpreting ovarian and adrenal venous sampling is imperative to determine the source of hyperandrogenism when occult by diagnostic Abstract No. 868 imaging. Interventional radiologists needs to confidently understand and verify the endocrine preprocedural workup to avoid unnecessary Radiosensitizers for glioblastoma multiforme in an era of interventions. evolving interventional approaches S Manupipatpong1, A Pasciak2, C Weiss3 Abstract No. 867 1Johns Hopkins University School of Medicine, Baltimore, MD, 2Johns Hopkins University School of Medicine, Laurel, Percutaneous and endovascular delivery of synthetic MD, 3N/A, Baltimore, MD biology-derived therapies: translating bioengineering to LEARNING OBJECTIVES: To better understand radiosensitizer research the clinic for the treatment of glioblastoma multiforme (GBM) in light of new M Schwenke1, J Greene1, S Braverman2, M Singh1 advances in intraarterial therapy with which it can be used, such as 1Santa Barbara Cottage Hospital, Santa Barbara, CA, 2N/A, Santa Y-90 endovascular radiosurgery (presented at RSNA 2019). Barbara, CA BACKGROUND: The most common and aggressive CNS cancer, GBM

LEARNING OBJECTIVES: To learn what synthetic biology is and how it has a median survival time of 15 months. Its indeterminate tumor mar- is currently being utilized. To understand the specific applications of gins, proximity to critical structures, and tumor stem cells lending synthetic biology for interventional radiology that are currently being resistance to radiotherapy (RT) prevent its control with conventional researched. surgical resection and RT. Advances in catheter-based GBM therapy may offer a new avenue for radiosensitizer use. SIR 2020 Annual Scientific Meeting e-Posters | 57

CLINICAL FINDINGS/PROCEDURE DETAILS: Myriad pathways can be tar- opportunities for potentiating the therapeutic effect and improving geted for GBM radiosensitization. PARP and Wee1 inhibitors (i) have clinical outcomes. progressed to clinical testing, with an ongoing phase I/IIa PARPi Olapa- CLINICAL FINDINGS/PROCEDURE DETAILS: Endovascular treatment rib trial and a phase 0 Wee1i trial demonstrating favorable tumor pen- approaches allow for selective drug delivery and limit systemic side etration and drug safety profile. Perhaps as exciting are approaches effects. The advent of pressure-driven delivery systems further pro- still in their preclinical stages, including telomeric G4 stabilization, vides improved intratumoral drug delivery and may overcome estab- ATM, PI3K/Akt/mTOR, DNA-PK, and STAT3 inhibition, and, more lished barriers to drug delivery including elevated tumor hydrostatic broadly, autophagy modulation. G4-ligand RHPS4 works by blocking and interstitial fluid pressure. Tumor embolization with TACE induces telomeric replication and have been effective in radioresistant GBM ischemia which may be lethal or sublethal. Tumor cells surviving isch- cell lines. ATM, DNA-PK, STAT3 and PI3K/Akt/mTOR are essential to emia activate the metabolic stress response and rely on molecular DNA damage repair (i.e., RT-induced dsDNA breaks) and have shown dependencies which may be targeted to potentiate cell death and limit efficacy in vitro and in vivo. Autophagy targeting has been evaluated recurrence. Similarly, TARE produces lethal and sublethal radiation clinically with chloroquine, but other agents, such as the CUSP9 drugs, effects within the tumor which alters the tumor microenvironment. were recently investigated in vitro as well, although not yet in conjunc- Recent data suggest that these therapies may potentiate the endoge- tion with RT. Historically, a challenge leading to radiosensitizer failure nous immune response, which may improve both local and metastatic in vivo has been lack of blood-brain barrier (BBB) penetration, but a tumor response. recent development in NIR—namely, MRI-guided intraarterial immunotherapy following osmotic BBB opening—may open the door for CONCLUSION AND/OR TEACHING POINTS: At the conclusion of this the use of radiosensitizers without inherent BBB-penetrating abilities. presentation, the attendee will have an understanding of the biologic Further, delivery during intracranial access in Y-90 ER may offer syn- mechanisms behind current endovascular locoregional therapies for ergistic antitumor effects. HCC and the opportunities to further leverage their unique attributes to overcome existing limitations in current therapies. This will be of CONCLUSION AND/OR TEACHING POINTS: In light of new GBM treat- benefit to both clinicians and scientists as research in these areas con- ments in interventional radiology, radiosensitizers, despite most cur- tinues to expand. rently being in the preclinical stages, may be a promising option for boosting efficacy in a disease that has been resistant to effective treatment thus far. Abstract No. 870

Nano-micro-robotics in interventional radiology: fantasy? Abstract No. 869 J Garcia1, T Jarvis1, J Verhey1, A Kilgore1, D Scott1, H Albadawi1, G The biologic mechanisms of endovascular locoregional Knuttinen1, S Naidu2, S Alzubaidi1, J Kriegshauser1, I Patel1, R Oklu1 therapies for the treatment of hepatocellular carcinoma 1Mayo Clinic Arizona, Phoenix, AZ, 2Mayo Clinic Arizona, Scottsdale, R Kiefer1, J Benjamin2, N Perkons3, D Ackerman4, S Hunt5, G AZ Nadolski6, M Soulen7, T Gade2 LEARNING OBJECTIVES: The Learning Objective of this educational 1University of Pennsylvania, Glen Mills, PA, 2Hospital of the abstract is to explore the state of therapeutic applications of nano- University of Pennsylvania, Philadelphia, PA, 3University technology and their potential use in interventional radiology. In of Pennsylvania, Philadelphia, PA, 4PIGI Lab, Philadelphia, particular, the emerging field of soft-robotics will be introduced and PA, 5N/A, Philadelphia, PA, 6N/A, Wynnewood, PA, 7University of examples illustrated. Pennsylvania, Lafayette Hill, PA BACKGROUND: Nanorobotics are defined as devices that range in size LEARNING OBJECTIVES: The objectives of this presentation will be to from 0.1 to 10 micrometers that can perform tasks at nanoscale dimen- discuss the biologic mechanisms of endovascular locoregional ther- sions. Recent advances in biomaterials and nanotechnology along with apies for hepatocellular carcinoma (HCC) including the mechanisms a universal push for precision medicine have reinspired the idea nano- of cytotoxicity induced by transarterial embolization (TACE) and tran- robotic agents capable of detecting disease states and subsequently sarterial radioembolization (TARE). Additionally, the unique abilities of initiating the appropriate programmed therapies. A new field named endovascular locoregional therapies to overcome traditional barriers theranostics is focused on cultivating materials for these agents, in oncologic therapy will be discussed. including liposomes, polymers, and metal-based particles. Proposed applications tend to focus on targeted drug delivery and manipula- BACKGROUND: Hepatocellular carcinoma remains a leading cause of tion of cellular structures. The use of nanorobotic agents holds great cancer mortality worldwide. For many patients, locoregional thera- potential for improving upon existing technologies employed by pies are the standard of care and can provide a complete treatment interventional radiologists to diagnose and treat vascular disease and response in the early posttreatment period. However, many of these administer ablative cancer therapies. patients suffer from local tumor recurrence. Understanding the biologic mechanisms that lead to cell death, and cell survival, provides CLINICAL FINDINGS/PROCEDURE DETAILS: In this educational exhibit we will review the use of therapeutic magnetic carriers in the delivery 58 | e-Posters SIR 2020 Annual Scientific Meeting

of chemotherapeutic agents by way of magnetic resonance naviga- view. It will focus on the followings: 1. Reactive versus prophylactic gas- tion in the treatment of cancer. Additionally, we will discuss the use trostomy tube placement. 2. Potential technical difficulties of PEG. 3. of magnetically actuated nanorobots supplied with tissue plasmino- Potential technical advantages of PRG. 4. Brief review of the literature gen activator in treating thromboembolic disease. We will discuss the CONCLUSION AND/OR TEACHING POINTS: Although there is no consen- potential use of nanorobots in providing real time diagnostic data that sus on the right timing of placement of gastrostomy tube, it is still a can be used to inform appropriate therapies. Finally, we will discuss viable option for enteral feeding of patients with advanced head, neck the current limitations of these technologies and the further work that and esophagus cancer. With using of various imaging guidance modal- needs to be done to ensure their safety and reliability. ities and meticulous technique, PRG is an effective procedure with high CONCLUSION AND/OR TEACHING POINTS: The clinical applications of technical success rate and should considered as a first option in those nanorobotics hold the potential to become the foundation for preci- patients. sion medicine, bringing the diagnosis and treatment of common diseases into a level of efficacy unprecedented in medicine and surgery. The successful translation of current nanotechnologies into clinically Abstract No. 872 useful modalities faces many challenges ranging from toxicity to the Targeted therapy and companion diagnosis: the standardization of multidisciplinary nanorobotic research for compar- perfect marriage? An examination of theranostics in ative analysis. interventional radiology D Scott1, A Kilgore1, J Verhey1, J Garcia1, J Kriegshauser2, S Abstract No. 871 Alzubaidi2, I Patel2, S Naidu3, M Knuttinen3, H Albadawi3, R Oklu2

1 2 Percutaneous gastrostomy placement in advanced Mayo Clinic Alix School of Medicine, Phoenix, AZ, Mayo Clinic 3 head, neck, and esophagus cancer: when and why the Arizona, Phoenix, AZ, Mayo Clinic Arizona, Scottsdale, AZ radiologic technique? LEARNING OBJECTIVES: (1) Understand theranostics as an emerging A Khankan1, M Abdulhaq1, A Alayoub2, M Al-Khammash3, A field of medicine; (2) recognize the capabilities of diagnostic and ther- Kenawi1 apeutic synergism; (3) envision future directions and novel applications within interventional radiology (IR). 1King Abdulaziz Medical City, Jeddah, Makkah, 2Alfaisal University 3 Faculty of Medicine, Riyadh, Riyadh, Al-Hada Hospital for Armed BACKGROUND: Theranostics is a form of therapy that combines diag- Forces, Taif, Makkah nosis and treatment. This allows enhanced efficacy, improved patient outcomes, and more manageable adverse events. Theranostic com- LEARNING OBJECTIVES: 1. To discuss the rationale of percutaneous pounds can be selected to selectively target and accumulate in a target gastrostomy placement in advanced head, neck and esophagus can- organ, and through imaging modalities such as ultrasound, MRI, CT, or cer. 2.To demonstrate the technical advantages of percutaneous radio- nuclear medicine modalities, specific biological targets can be identi- logic gastrostomy (PRG) technique in those selected patients based fied and the companion treatment for a particular disease process can on our institution experience. be chosen specifically to the patient. As medicine begins to move away BACKGROUND: Patients with advanced head, neck and esophagus from the one size fits all approach for treatment, theranostics offers us cancer are often at risk for malnutrition which is determined by tumor the ability to act on our prerogative of patient-centered care. Precision localization, nutritional state prior to therapy, symptoms severity and medicine has gained popularity with our patients as they seek efficient type of oncologic treatment. Various international practice guidelines and effective care. Both private practice and in-patient medicine can have recommended placement of percutaneous gastrostomy tube appreciate the financial value of focusing on a theranostic paradigm. to maintain an adequate nutritional status, reduce dehydration and The application of nanoscience proposes to add synergism to diag- hospitalizations, and avoid treatment breaks. However, there is con- nosing and therapy we provide, suggesting we can improve patient siderable lack of consensus on the justification and right timing of outcomes by uniting diagnosis, drug delivery, and treatment response gastrostomy placement and commencing of enteral feeding. A percu- monitoring. taneous gastrostomy tube can be placed either endoscopically (PEG) CLINICAL FINDINGS/PROCEDURE DETAILS: Multiple widely used ther- or radiologically (PRG). However, it may be technically difficult or even anostic procedures with diagrams explaining the indications for impossible to use PEG technique in those patients with obstructing their use, mechanism of action, and reasons a theranostic approach cancer, comorbidities related to multimodal treatment approach or improves patient outcomes for these patients will be detailed on the other comorbidities. In such patients, the technique of PRG will pro- poster. Recently published studies will be highlighted. We will con- vide more reliable and safe approach to the stomach lumen because clude by exploring how interventional radiologists, in particular, can of using different imaging modalities for guidance and fine devices in benefit from a theranostic approach. spite of radiation exposure issue. CONCLUSION AND/OR TEACHING POINTS: Interventional radiologists CLINICAL FINDINGS/PROCEDURE DETAILS: The poster will provide an are experts at creating novel solutions to existing problems. IR has overview on percutaneous gastrostomy in from the technical point of the knowledge base and patient population to effectively implement SIR 2020 Annual Scientific Meeting e-Posters | 59

a paradigm that focuses on providing optimal treatment for the right LEARNING OBJECTIVES: To learn about the current state of knowledge patient, at the right time, with the right doses, providing a more focal on the genetic basis of peripheral artery disease (PAD), to learn about pharmacotherapy in the realm of theranostics. genetic advances relating to the treatment of PAD and to learn about the future application of PAD genetics in diagnosis and treatment

Abstract No. 873 BACKGROUND: PAD is an atherosclerotic vascular disease that affects blood vessels other than those of the coronary circulation. PAD affects The pursuit of translational research: microcomputed more than 200 million people worldwide, and approximately 10 mil- tomography lion individuals in the United States. Several acquired risk factors for PAD have been identified, such as dyslipidemia, diabetes mellitus, I Altun1, H Albadawi1, Z Zhang1, S Alzubaidi1, G Knuttinen1, I Patel1, and hypertension. However, there are genetic factors which act inde- R Oklu1 pendently of these risk factors and increase the risk of developing 1 Mayo Clinic Arizona, Phoenix, AZ PAD. In this poster, we will discuss the known genetic basis for the development of PAD, to better understand the challenges in disease LEARNING OBJECTIVES: 1. To describe the role of microcomputed tomography (micro-CT) in translational research; technique and pro- management. tocols will be illustrated through case examples. 2. To develop a deeper CLINICAL FINDINGS/PROCEDURE DETAILS: PAD has a multifactorial understanding of potential use of micro-CT scanner in the research of inheritance whose pathological impact is due to a combination of interventional radiology; examples such as GI Bleeding will be demon- genetic and environmental factors. Historically, genetic analysis of strated using micro-CT scanner. PAD has been done with the help of case-control and linkage studies. Unfortunately, both methods have limitations when providing insight BACKGROUND: Translational research is shaping the future of medicine by adapting novel techniques into investigative research tools. into the molecular mechanisms behind PAD. Advances in genome- micro-CT provides researchers unique, nondestructive, analytical, and wide association studies (GWAS) are done where single nucleotide three-dimensional investigation of samples. In addition to electronic polymorphisms (SNPs) are genotyped across the genome. This has devices, variety of materials, biological samples, in vivo scanning of allowed us to identify SNPs by comparing the frequency between an experimental animal such as mice, rat, small rabbit are also possi- cases and controls. Currently, about 30 replicated associations have ble with micro-CT scanner. Reconstruction of scanned samples allows been identified for PAD with the help of GWAS. The poster will focus conversion of raw images into three-dimensional images that can also on advances in gene-by-environment interactions, epigenetic factors, be used for 3D modeling and 3D printing. and acquired mitochondrial genetic alterations relating to PAD.

CONCLUSION AND/OR TEACHING POINTS: Identifying genes associated CLINICAL FINDINGS/PROCEDURE DETAILS: We will provide the role of micro-CT scanner in translational research. In our translational with PAD can help us develop screening tests for possible early disease research laboratory, we have broad experience to scan biomaterials, identification and management by identifying patients with genetic in vivo animals, ex vivo tissue samples, and 3D models. We will illus- susceptibility beyond the known risk factors and optimize medical trate micro-CT derived three-dimensional images of various samples therapy. By informing our practicing clinicians on the implications of from animal models of hemorrhage and oncology. We will also review its genetic component, we hope to increase their awareness of when various scanning protocols for samples and present challenges of this to consider the genetic component of PAD, ultimately leading to a imaging technique. Emphasis will be on protocols and technique espe- decrease in morbidity, mortality, and health care costs associated with cially when using IV contrast. PAD.

CONCLUSION AND/OR TEACHING POINTS: Micro-CT is nondestructive imaging modality for obtaining high-resolution images of biological Abstract No. 875 and nonbiological samples. This exhibit seeks to educate interventional radiologist on the role of micro-CT imaging in translational research. Arm pain in patients with arteriovenous fistulas: diagnosing complications and determining interventions J Fleecs1, J Buckley2, B Wible3 Abstract No. 874 1University of Missouri–Kansas City, Kansas City, MO, 2University What we know about the genetic link of peripheral of Missouri Kansas City, Kansas City, MO, 3University of Missouri arterial disease: a primer for #CLIfighters and Kansas City; Saint Luke’s Hospital of Kansas City, Kansas City, MO interventional radiologists LEARNING OBJECTIVES: The Learning Objectives of this exhibit are to 1. T Garg1, E Perez2 Review complications of arteriovenous fistulas (AVFs). 2. Demonstrate 1Seth GS Medical College & KEM Hospital, Mumbai, key diagnostic clinical and imaging features of common complications, Maharashtra, 2University of Minnesota, Earl E. Bakken Medical including ischemic steal syndrome, central venous stenosis, and AVF Devices Center, Minneapolis, MN thrombosis. 3. Identify indications for treatment and explore relevant 60 | e-Posters SIR 2020 Annual Scientific Meeting

procedural techniques, outcomes, and potential complications of currently available data shows potential benefits for endoAVF com- interventions. pare to SAVF, in terms of patency, life to maturation, number of maintenance interventions and respectively lower cost. As these tools may BACKGROUND: Arteriovenous fistula creation is considered the gold become more prevalent, awareness of these tools is essential for the standard for vascular access in patients requiring long-term hemodial- interventionalists. ysis. Arm pain is a relatively common complaint of patients with AVFs, which commonly arises in the setting of three key complications: ischemic steal syndrome, central venous stenosis, and thrombosis. This Abstract No. 877 exhibit will discuss the workup of arm pain in patients with AVFs, the clinical and exam findings that may suggest a diagnosis prior to fis- Overview of Food and Drug Administration–approved tulogram, as well as the appropriate treatment intervention for each. endovascular techniques for creating arteriovenous fistulas for hemodialysis access CLINICAL FINDINGS/PROCEDURE DETAILS: The clinical and radiologic findings of ischemic steal syndrome, central venous stenosis, and AVF D Yoakum1, D Tabriz2 thrombosis will be discussed as well as the appropriate treatment 1Rush Medical College, Chicago, IL, 2Rush University Medical Center, intervention for each. Chicago, IL

CONCLUSION AND/OR TEACHING POINTS: There are three common LEARNING OBJECTIVES: • Describe the patient selection, relevant anat- complications of AVFs that can present with arm pain. The ability to omy, and technique for percutaneous creation of arteriovenous fistulas differentiate the potential etiologies of arm pain aids in guiding optimal (pAVF) for hemodialysis • Compare two techniques approved in the treatment. U.S. for pAVF creation • Discuss the rationale for using noninvasive versus invasive creation of pAVF.

Abstract No. 876 BACKGROUND: Over 85% of patients with end stage renal disease (ESRD) in the U.S. use hemodialysis for life support.¹ Successful hemo- Endovascular arteriovenous fistula: an emerging dialysis depends on having a reliable source for vascular access. Access technology is achieved surgically by creating a biological arteriovenous fistula D Cohen-Addad1, H Brent2, R Morgan3 (AVF), implanting a prosthetic arteriovenous graft, or implementing a central venous catheter. Since 2003, the use of AVF for renal replace- 1SUNY Downstate Medical Center, Brooklyn, NY, 2SUNY Downstate ment therapy among ESRD patients in the U.S. has increased from Medical Center, Brooklyn, NY, 3St. George’s Hospital, London, England 32% to 62.8%. Although surgical AVF is the preferred therapy, it often fails due to vessel stenosis, thrombosis, and lack of maturity. In the last LEARNING OBJECTIVES: Review the forearm vascular anatomy allowing two years, the FDA has approved two devices that have demonstrated the endovascular creation of fistulas. Describe the current techniques. improved outcomes by creating AVFs percutaneously: (i) WavelinQ Discuss the strengths and weaknesses of the endovascular approaches EndoAVF System and (ii) Ellipsys Vascular Access System. versus the surgical approaches. CLINICAL FINDINGS/PROCEDURE DETAILS: The WavelinQ EndoAVF BACKGROUND: Since its development 50 years ago surgical arterio- System offers both a 6 french (Fr) and 4 Fr catheter model that uses venous fistula (SAVF), revolutionized the life of millions of patients an antiparallel dual-catheter approach to create a side-to-side fistula dependent on dialysis. It currently remains the gold standard as the between the ulnar artery and vein. Under fluoroscopy guidance, the most effective access for hemodialysis in terms of morbidity and vessels are positioned with magnetized catheters and punctured with mortality. Despite its success, complication remains, including long radiofrequency current to create the anastomosis. The Ellipsys Vascu- maturation time, patency rates, and the need to re-intervene. SAVF lar Access System exhibits a 6 Fr single-catheter model to construct commonly fail due to intimal hyperplasia resulting in stenosis. This is a side-to-side anastomosis between the perforating branch of the often attributed to vessel manipulation during anastomosis creation. median antecubital vein and radial artery. Under fluoroscopy guidance, a needle enters the median antecubital vein and continues ret- CLINICAL FINDINGS/PROCEDURE DETAILS: Innovative noninvasive tools rograde to penetrate the radial artery in the desired location. Using a allow an endovascular creation of arteriovenous fistulas (endoAVF). sheath and catheter, the Ellipsys device is inserted to the junction site This approach minimizes vessels manipulation and primary results where it clenches the vessels together and applies thermal energy and show promising outcomes with good hemodialysis stability, low re-in- pressure to create a tissue-fused elliptical-shaped anastomosis. tervention, and failure rates. Two devices are currently available, Ever- linQ by TVA Medical and EllipsysR by Avenu Medical. We review both CONCLUSION AND/OR TEACHING POINTS: The WavelinQ EndoAVF Sys- device technical aspects. The anatomy allowing their creation. Patient tem and the Ellypsis Vascular Access System offer an innovative per- selection criteria. Trial results. Complications. Comparison between cutaneous method for AVF creation in patients who require long-term endoAVF and SAVF success rate and cost. Finally, we discuss the vascular access for hemodialysis. future potential of EndoAVF

CONCLUSION AND/OR TEACHING POINTS: EndoAVF is an innovative approach with promising results in a subtype of patients. The SIR 2020 Annual Scientific Meeting e-Posters | 61

Abstract No. 878 LEARNING OBJECTIVES: The Society of Interventional Radiology (SIR) has a standing mission to promote D&I within its membership. A cur- Percutaneous arteriovenous fistula creation: a riculum was developed to guide understanding of principles underly- comprehensive “how-to” guide ing D&I, particularly relevant to interventional radiology (IR) practice, A Salei1, H El Khudari2, R Varma3, A Kamel Abdel Aal4, A Gunn5 including status of D&I in IR, discussion of diverse groups and their strengths, microaggressions, workplace hostility, and the role of SIR in 1UAB Hospital, Birmingham, AL, 2N/A, Birmingham, AL, 3University increasing workforce and patient D&I. A key purpose is to demonstrate of Alabama at Birmingham, Vestavia Hills, AL, 4N/A, Hoover, how embracing a culture of D&I will stimulate innovation and growth AL, 5University of Alabama At Birmingham, Birmingham, AL within the IR field.

LEARNING OBJECTIVES: 1. Percutaneous dialysis arteriovenous fistula BACKGROUND: The United States represents a rapidly shifting envi- (endoAVF) creation is a novel, minimally invasive technique to create ronment of diverse populations and underrepresented minorities are permanent hemodialysis access 2. EndoAVF creation by interventional already “overrepresented” within our current healthcare patient pop- radiology is associated with quicker maturation, lower costs, and fewer ulation. While diversity leads to improved patient care and enhances complications 3. EndoAVF expands anatomic options for dialysis AVF creativity and medical innovation. Unfortunately, IR is one of the least creation by offering additional sites for creation 4. EndoAVF avoids the diverse medical specialties, thus affecting workforce recruitment and scarring and disfigurement seen with surgically created access patient care.

BACKGROUND: Chronic kidney disease (CKD) is a significant source CLINICAL FINDINGS/PROCEDURE DETAILS: Interrelated modules were of morbidity and mortality in the United States. Many patients with developed that will serve as a framework for an SIR-specific D&I cur- CKD require long-term hemodialysis access. The arterio-venous fistula riculum. Modules introduce terminology for SIR members (e.g., uncon- (AVF) is the preferred access when hemodialysis is needed; however, scious bias and microaggressions), put diversity into the context of IR, many patients are not optimal surgical candidates while others may and provide concrete examples of how members can foster inclusion experience long wait times for a surgical referral. The development of through their interactions with colleagues, trainees, and patients. The percutaneous, image-guided AVF creation (endoAVF) can alleviate modules describe the mechanisms linking root causes and ultimate some of these problems; although, the procedure is not yet widely manifestations of certain malignant behaviors limiting D&I in IR and available. The Learning Objective of this exhibit is to provide interven- discuss methods of mitigation and amelioration. tional radiologists with a comprehensive review of endoAVF creation. CONCLUSION AND/OR TEACHING POINTS: To overcome barriers to diver- CLINICAL FINDINGS/PROCEDURE DETAILS: 1. Overview of hemodialysis sity, a culture of change must be adopted. Recruiting and maintaining access, including limitations of current options 2. Pictorial review of a representative body of diverse workforce to provide harmonious pertinent vascular anatomy 3. Discussion of the concept of endoAVF patient care as well as expanding inclusive research efforts to better creation 4. Preprocedural assessment of patients, including sono- understand the needs of diverse populations are both paramount to graphic evaluation and mapping 5. Pictorial review illustrating the the growth of IR practice. Establishing IR as a vanguard for D&I will available devices and the technical aspects of the endoAVF procedure embolden the specialty to face the challenges of modern patient care. 6. Review procedural complications and strategies to improve safety profile 7. Discuss postprocedural follow-up including pictorial review of sonographic maturation criteria and interventional strategies to assist Abstract No. 880 maturation and cannulation 8. Overview of current evidence-based literature on endoAVF creation. A different look at moderate sedation for the interventional radiologist: what anesthesia has to say CONCLUSION AND/OR TEACHING POINTS: endoAVF is an emerging image-guided procedure that can improve the availability and safety O Adenikinju1, S C. Durscki Vianna2, M Patel1, H Reynolds3, A of hemodialysis access for patients with CKD Zybulewski4, R Beasley2, B Olivieri2 1Mount Sinai Medical Center, Miami Beach, FL, 2N/A, Miami, FL, 3Mount Sinai Medical Center, Miami, FL, 4Icahn School of Abstract No. 879 Medicine at Mount Sinai, New York, NY

A curriculum for fostering diversity and inclusion within LEARNING OBJECTIVES: (1) Outline the essential components of the the Society of Interventional Radiology anesthesia plan vital for the interventional radiologist (from preoperative evaluation (ASA, PMH, physical exam) to postoperative care). (2) K McNamara1, c heiberger2, M Hamilton3, S Warhadpande4, P Rochon5, G Salazar6 Formulate criteria for anesthesia consultation. (3) Outline the medication profiles for operative analgesia and sedation based on case types 1Stanford University School of Medicine, Stanford, CA, 2University and common patient comorbidities to enhance procedural safety and of South Dakota Sanford School of Medicine, Sioux Falls, comfort. (4) Expand the interventional radiologist’s toolbox of anxio- SD, 3Zucker School of Medicine at Hofstra/Northwell, Hempstead, lytics, as taught by an anesthesiologist. (5) Detail operator limitations NY, 4University of Pittsburgh, Pittsburgh, PA, 5University of in interventional radiology when administering anesthesia. (6) Explore Colorado, Denver, CO, 6MGH, Chestnut Hill, MA the cutting edge of ‘balanced anesthesia’ for the interventionalist. 62 | e-Posters SIR 2020 Annual Scientific Meeting

BACKGROUND: Interventional radiologists tend to perform procedures the learner needs to acquire the required cognitive knowledge about on patients with significant comorbidities who are unable to undergo the procedure. Standard learning via textbooks and online media. surgical operation. Thus, it is vital that the interventional radiologist See: The learner should then see how the procedure is performed by has a strong knowledge base on the pharmacological principles and his instructor. During this step, we suggest constant interaction with consequences of perioperative analgesia and sedation. This multidis- the learner by asking questions particularly focusing what he/she has ciplinary exhibit provides a stepwise approach to the most commonly learned about the procedure. Provide immediate feedback. Practice, used sedatives and alternatives encouraged by our anesthesia col- Prove and Do: incorporating 3 steps into one, this is where simulation leagues to incorporate into our practice. comes to the fore. First, we suggest the use of learner-directed exercises where learners verbalize to their mentors a step by step approach CLINICAL FINDINGS/PROCEDURE DETAILS: Successful interventions to performing a procedure. Second, we recommend the learners prac- require effective and safe sedation, analgesia, and amnesia while main- tice a procedure in simulation, first with supervision and then without, taining hemodynamic stability, airway protection with spontaneous followed by test simulations proctored by their mentors. The final step ventilation, and patient cooperation and comfort. Based on our assess- is when the learner performs the procedure on a patient, initially under ment, if difficulty achieving these pillars is suspected, anesthesia con- direct supervision and real-time feedback. Maintain: practice is key to sultation and general anesthesia should be considered. This exhibit will skill maintenance (1) educate the reader on commonly used pharmacologic agents for conscious sedation/analgesia, such as fentanyl, Versed, Precedex, and CONCLUSION AND/OR TEACHING POINTS: A standard for simulation ketamine; (2) outline the limits of sedation for nonanesthesiologists as training will enhance IR residency training and serve as an essential detailed by the ASA Task Force and ACGME; (3) provide a table of pos- assessment tool of procedural skills competency sible hypnotic–analgesia combinations based on patient comorbidities and case type, including when general anesthesia should be sought; and (4) inform the reader on contraindications, adverse events, and Abstract No. 882 available reversal agents. Always use protection: a pictorial guide to protective CONCLUSION AND/OR TEACHING POINTS: Mastering the pillars of mod- radiation equipment in interventional radiology erate sedation is vital for effective, efficient, and safe periprocedural J Moon1, M Abad-Santos1, S Park1 care. Interventional radiologists can broaden our current lexicon of 1 pharmacological sedation with the help of the perspective of an anes- Harbor-UCLA Medical Center, Torrance, CA thesiologist provided here. LEARNING OBJECTIVES: 1. Provide education for interventional radiology (IR) personnel (including medical students, residents, fellows, Abstract No. 881 nurses, technicians, and other providers who work in the angiography suite) regarding available protective radiation equipment that should A new paradigm for procedural skills training in be used. 2. Provide a pictorial guide for proper utilization of equipment interventional radiology and common pitfalls. 3. Review basic radiation safety principles and how they can be applied to minimize occupational radiation exposure. G Gabriel1, R Jayavarapu2, M Winkler2, D Raissi1 BACKGROUND: Increasing prevalence of image-guided procedures has 1University of Kentucky, Lexington, KY, 2N/A, Lexington, KY led to increased awareness of the risks associated with medical radi- LEARNING OBJECTIVES: To describe a new paradigm for procedural ation. While reducing patient dose is imperative, it is also important skills training in interventional radiology (IR) to reduce occupational exposure of the interventional radiologists and others who work within the angiography suite. There are many bodies, BACKGROUND: The traditional “see one, do one, teach one” appren- including The United States Nuclear Regulatory Commission (NRC) ticeship model of training was never ideal. In our era of mature sim- and the International Commission on Radiological Protection (ICRP), ulation technologies, it is no longer acceptable. However, there not that engage in an iterative process to better understand these risks. yet standardization of simulation training across IR training programs. More recently, studies have examined the relationships between occu- Traditional one-year IR fellowship programs sunset at the end of this pational exposure to cataract formation and cancer incidence, such as academic year. The new independent IR residency programs start on brain tumors. It is necessary for all those who work within the inter- July 1, 2020, complementing the recently implemented integrated IR ventional suite to minimize occupational radiation exposure by utilizing residency programs. It is a perfect time to establish a standard for sim- both radiation safety equipment and proper technique. ulation training in IR CLINICAL FINDINGS/PROCEDURE DETAILS: Images of various radi- CLINICAL FINDINGS/PROCEDURE DETAILS: Sawyer et.al published a ation protection equipment, such as safety goggles, aprons (one- paper in 2015 describing an evidence-based six-step pedagogical piece and multipiece), thyroid shields, radiation caps, table drapes, framework for procedural skill training: Learn, See, Practice, Prove, Do, shields (mobile, mounted, adjustable), and disposable radiation pro- and Maintain. Implementing their proposed framework may be chal- tective drapes will be appropriately displayed and their effectiveness lenging to any procedure-based specialty. We suggest that a modified reviewed. Additional measures to reduce occupational exposure will practical version of their framework be adopted, standardized and be reviewed. These principles include minimizing exposure time, applied to simulation teaching in IR. Learn: this is the first step where SIR 2020 Annual Scientific Meeting e-Posters | 63

increasing distance from radiation source, and maximizing the use of obesity become more popular compared to traditional surgery, but shielding, such as the use of radiation protective equipment. long-term adverse effects are not clearly understood. Bariatric embolization is a new and well-tolerated minimally invasive procedure that CONCLUSION AND/OR TEACHING POINTS: A variety of radiation protec- show promising results. More studies with larger population of patients tive equipment is available to the IR team to minimize excessive occu- are needed to establish the efficacy and long-term adverse effects. pational exposure when utilized as part of basic radiation safety. The information presented will be important to members of the IR team at all levels of training. Abstract No. 884

Radiation Protective Equipment Dose Reduction (%) Application of art in patient education on the transjugular Radiation Cap 3.3 intrahepatic portosystemic shunt procedure Safety Goggles Variable depending on position, up to 95 0.5 mm Lead Apron 90 A Anoushiravani1, R Schenning1, J Kaufman1, K Farsad1, Y Thyroid Shield 50 Jahangiri1 Mounted Ceiling Shield 90 1Oregon Health and Science University, Portland, OR Disposable Radiation Safety Drape 65 LEARNING OBJECTIVES: To apply hand-drawn graphical artwork for patient education on complex procedures such as Transjugular Intra- Abstract No. 883 hepatic Portosystemic Shunt (TIPS) creation.

An overview of minimally invasive treatment options to BACKGROUND: Application of the arts in medicine can enhance patient treat obesity communication, stimulate shared human experience and help enrich a deeper sympathy and understanding between physician and patient. 1 1 1 O Shafaat , N Hafezi Nejad , C Weiss Descriptive artwork can be especially effective during the consulta- 1Johns Hopkins University School of Medicine, Baltimore, MD tion and consent process for complex procedures, such as TIPS creation, to improve patient understanding. Patient engagement in their LEARNING OBJECTIVES: 1) Highlight the role of available minimally health care can directly impact their satisfaction and perceptions of invasive procedures in the treatment of obesity, 2) assess effective- the health care environment. ness, feasibility, and safety of all available minimally invasive procedures, and 3) evaluate the efficacy, postprocedure complications, CLINICAL FINDINGS/PROCEDURE DETAILS: Detailed illustrations of the clinical outcomes of these patients. steps involved during the TIPS procedure were hand drawn by a skilled illustrator familiar with anatomic rendering. These included anatomic BACKGROUND: Obesity is a significant cause of morbidity, mortality, relationships in the liver, the location of the shunt and the devices used and cost expenditures to the healthcare system in the US. Surgical in the procedure. An educational pamphlet with an accompanying treatments are still conventional when exercise, diet, and medications explanation complete with preprocedural and postprocedural care fail to treat obese and severely obese patients. Minimally invasive pro- was prepared. The artwork was added to the pamphlet to enhance cedures have an increasing role in the treatment of obesity as they patient visualization and understanding of procedural details in order are better tolerated. In this educational abstract, we will review min- to facilitate provider interactions during the consultation and consent imally invasive therapeutic options for severely obese patients such process. as cryoablation of the vagus nerve, as well as endoscopic treatments such as intragastric balloons, endoscopic sleeve gastroplasty, endo- CONCLUSION AND/OR TEACHING POINTS: Application of art to describe scopic aspiration therapies, gastrointestinal bypass sleeves, and bar- complex medical procedures can improve patient understanding and iatric embolization. may be effective in ultimately enhancing the physician-patient relationship and patient satisfaction. CLINICAL FINDINGS/PROCEDURE DETAILS: Percutaneous CT-guided cryoablation of the vagus nerve is performed by using a cryoablation probe in the posterior vagal trunk as it transitions to the posterolateral esophagus. This method was recently introduced and the pilot study showed feasibility and tolerance of the treatment in class I and II obese patients. Besides, there are new generations of endoscopically placed intragastric devices, such as the duodenal jejunal bypass sleeve, as well as ingestible intragastric balloons. Multiple independent studies have evaluated the use of bariatric embolization in obese patients and showed a favorable efficacy. Research to further optimize the efficacy and safety of the procedure is in progress.

CONCLUSION AND/OR TEACHING POINTS: CT-guided cryovagotomy is a new modality in the pilot stage and it should be done in other trials with higher patient population. Endoscopic treatment options to treat 64 | e-Posters SIR 2020 Annual Scientific Meeting

Abstract No. 885 Table 1

Applications of three-dimensional printing in Techniques and Applications of 3D printing in Interventional Radiology Technique Advantages Disadvantages Applications in IR interventional radiology • Low cost Solid organs, tumor • Rough finish with vascular supply, 1 2 1 1 1 1 Material Extrusion • Easily accessible hollowed vascular K Wattamwar , A Johri , J Cynamon , S Lee , A Brook , N Wake anatomy, trainee/patient • Low resolution education, surgical 1Albert Einstein College of Medicine, Montefiore Medical Center, Material selectively • Wide material selection planning deposited via nozzle 2 • Difficult support New York, NY, Penn State College of Medicine, Milton S Hershey • Heat resistant and removal Medical Center, Hershey, PA strong Sheet Lamination • Low cost • Slow build rate Not applicable, not typically used in LEARNING OBJECTIVES: medicine This presentation will distill the three-dimen- Sheets of material bonded • Large build volume • Design limitations sional (3D) printing process and identify applications in interventional Direct energy deposition • Fast build rate • Materials limited to Custom devices with metals gross detail, e.x. radiology (IR). Seven major printing techniques and workflow required Materials melted and fused • Fully dense parts catheter/sheath to create patient-specific models from DICOM data will be explained. while depositing • Low resolution • Less waste Considerations for generating hollowed, tissue-mimicking, and 3D • Rough finish printed vascular models will be addressed. Finally, a discussion of IR Powder Bed Fusion • High resolution • High cost Custom devices with fine detail, e.x. IVC applications will follow, referencing billable CPT codes and including Powder bed selectively • Strong output • Material limitations filter, stent fused by thermal energy an exhibition of various physical printed models. • No need for support • Slow build rate system BACKGROUND: 3D printing, also known as rapid prototyping or addi- tive manufacturing, has many purposes in medicine today, including Binder Jetting • Mult-colored prints • High initial cost Solid organs with internal structures (if presurgical planning, intraoperative guidance, and education for train- Powder materials joined by • Low material cost • Rough finish model is bi- ees and patients. In order to generate patient-specific models, CT or selectively depositing valved/split), tumor liquid bonding agent with vascular supply, • Fast build rate • Fragile output gross and fine vascular MR image data must first be segmented and converted to virtual 3D anatomy, trainee/patient models which represent the anatomy of interest. Common digital file education, surgical planning formats required for 3D printing include STL, OBJ, and VRML. There Material Jetting • Smooth finish • Slow printing Solid transparent organs with colored internal are seven major printing techniques, each of which affords unique Material droplets • Mult-material and • High cost structures, tumor with selectively deposited multi-colored prints vascular supply, gross applications in IR as delineated in Table 1. and fine vascular anatomy, hollowed • Biocompatible materials vascular models, CLINICAL FINDINGS/PROCEDURE DETAILS: 3D printing confers advan- trainee/patient • Large build volumes education, surgical tages in interventional oncology, such as discerning the geometry of planning, intraoperative guidance a complex tumor ablation or in detailing the arterial supply of hepa- • High resolution tocellular carcinoma for chemoembolization. A model can motivate Vat Polymerization • Smooth finish • Single material prints Solid organs, tumor with vascular supply, the approach toward a complex filter retrieval by demonstrating the Liquid photopolymer • High resolution • Small build volume gross and fine vascular anatomy, hollowed selectively cured by light- exact locations of the device’s components in an intuitive way. It can activated polymerization vascular models, • Transparent • Difficult support trainee/patient help avoid hepatic arterial injury in TIPS and transvenous liver biopsy. removal education, surgical • Fast build rate planning, intraoperative It can offer insight into window selection for complex CT-guided biop- guidance sies and drainages. It facilitates in vascular intervention by delineating • Biocompatible material the course of tortuous or variant anatomy. Applications for IR training are manifold as well, from demonstrating various percutaneous and vascular access techniques to illustrating normal and variant anatomy. Abstract No. 886

CONCLUSION AND/OR TEACHING POINTS: 3D printing enhances under- Building interventional radiology procedural skills standing of spatial anatomic relationships via haptic and visual feed- curriculum in Houston, Texas, USA, and Rabat, Morocco back. Printing workflow includes image acquisition, segmentation, 1 1 1 1 2 computer-aided-design modeling and printing. There are seven print- J Stringam , W Borror , N Cardenas , J Kuban , R Zvavanjanja ing techniques which offer unique applications in IR, including proce- 1The University of Texas MD Anderson Cancer Center, Houston, dural planning, intraoperative guidance and education. TX, 2The University of Texas, Houston, TX

LEARNING OBJECTIVES: Review literature in regard to current most effective procedural skills training methods. Describe the teaching methodology developed through a transatlantic partnership between radiology training programs in Houston, Texas, USA, and Rabat, Morocco. Detail optimal construction methods for low cost tissue simulation training phantoms. Present evaluation metrics used to assess the effectiveness of the program. SIR 2020 Annual Scientific Meeting e-Posters | 65

BACKGROUND: The recent development of integrated interventional of thrombolytics via standard pigtail catheters or specially designed radiology training programs has presented the opportunity for an catheters such as the Unifuse catheter (Angiodynamics). The EKOS early emphasis on hands-on skills training. Both in the United States device (BTG) uses small ultrasound transducers at the tip of the cathe- and abroad, multiple potential barriers to optimal training exist. Key ter to facilitate the entry of thrombolytic into the clot. Multiple devices amongst these include the cost of materials, lack of curriculum, and are available for vacuum assisted thrombectomy, including the Pen- lack of assessment methods. Noting these barriers, training programs umbra Indigo system. The Aspirex (Straub) and CLEANER (Argon) in Houston, Texas and Rabat, Morocco worked through a collaborative thrombectomy devices use high speed rotational components to effort to develop assessment methods that quickly identify a trainee’s remove clot. The most recent addition, the Inari FlowTriever Retrieval/ skill level and areas of weakness, and created curriculum designed to Aspiration System is a device that removes clot through both aspira- address and improve these areas. They also designed low cost tissue tion and mechanical force. The AngioJet thrombectomy device (BS), simulation phantoms that can be easily customized to represent spe- still commonly used despite recent black box warning, performs rhe- cific tissues to be used with this curriculum. By working with a large olytic thrombectomy by creating a low-pressure environment around variety of residents, the team was able to develop adaptable curricu- the catheter in order to facilitate thrombolysis and aspiration. lum to address a great diversity of skill levels and learning styles. CONCLUSION AND/OR TEACHING POINTS: As interventional radiolo- CLINICAL FINDINGS/PROCEDURE DETAILS: This educational exhibit will gists continue to increase their role in the management of complex PE present review of current leading procedural skills teaching methods; cases, it is paramount that we are familiar and comfortable with the a description of the methods developed in the collaboration between myriad options currently available. Our poster will review and explore radiology training programs in Houston, Texas, and Rabat, Morocco; the mechanisms and specific usages for the currently available devices. recipes for the creation of customizable, low cost tissue simulation phantoms that can be easily constructed in minimal resource settings; and results of procedural skills assessments administered pre- and Abstract No. 888 post-workshop implementation. Cystic fibrosis: frequent flyers with unique interventional CONCLUSION AND/OR TEACHING POINTS: Through a collaborative radiology needs effort, the transatlantic partnership between radiology training pro- J Howe1, D Mauro2, K Anton3 grams in Houston, Texas, and Rabat, Morocco, developed adaptable 1 2 and effective hands-on, procedural skills curriculum and training tools University of North Carolina, Chapel Hill, NC, The University of 3 for residents. North Carolina, Chapel Hill, NC, N/A, Chapel Hill, NC

LEARNING OBJECTIVES: (1) To discuss the unique needs of the cystic Abstract No. 887 fibrosis (CF) patient population pertinent to interventional radiology (IR). (2) To highlight the various image-guided procedures and their Catheter-directed therapy for acute pulmonary embolism: associated challenges as they relate to the CF patient population. a pictorial review BACKGROUND: CF is an autosomal recessive disorder caused by cystic D Portal1, D Eisman1, T Nawrocki1, J Chen1, E Landau1 fibrosis transmembrane conductance regulator (CFTR) gene muta- tions. Abnormal CFTR protein results in exocrine dysfunction affect- 1Staten Island University Hospital Northwell Health, Staten Island, ing the lungs, liver, pancreas and small bowel. Being one of the most NY common genetic disorders in the white population, CF patients often LEARNING OBJECTIVES: We present a pictorial and technical review require multiple IR procedures to treat disease complications. highlighting the importance and utility of image-guided catheter-di- CLINICAL FINDINGS/PROCEDURE DETAILS: As CF causes multiorgan rected therapies (CDT) for treatment of acute pulmonary embolism dysfunction, minimally invasive image-guided interventions are critical (PE), through exploring current techniques and devices available for to the clinical care of this patient population. Interventions include (1) CDT. pleural drains (2) percutaneous biopsy/aspiration (3) bronchial artery BACKGROUND: Over the past two decades the standard of care for embolization (4) enteric tubes (5) transjugular intrahepatic portosys- treatment of acute massive and submassive PE has shifted from systemic shunts (TIPS) and (6) central venous access. Given the chronic- temic IV thrombolytic therapy to now include multiple CDT options. ity of disease and repetitive interventions, CF patients present unique Importantly, CDT expanded treatment options for patients where sys- challenges to the interventional radiologist including (1) anomalous/ temic thrombolysis is contraindicated for various reasons, including aberrant bronchial arterial supply during repeat embolization and (2) recent surgery, recent stroke or active bleeding. CDT, with its proven peripheral and central venous catheter choice, location, and subse- decrease in morbidity and mortality has ushered interventional radiol- quent complications. We will present a pictorial review of interesting ogy to the forefront of PE management. procedural findings in the CF population and techniques to help overcome their challenges. CLINICAL FINDINGS/PROCEDURE DETAILS: CDT can be divided into two broad categories: thrombolysis and thrombectomy. Tradi- CONCLUSION AND/OR TEACHING POINTS: (1) Complications associated tional catheter-directed thrombolysis involves local administration with multiorgan dysfunction in CF creates complex diagnostic and 66 | e-Posters SIR 2020 Annual Scientific Meeting management challenges for the interventional radiologist. (2) A thor- Abstract No. 890 ough understanding of the unique clinical and procedural needs in the CF population is required to provide high level patient care throughout Development of a simulation-based procedural IR practices. curriculum for image-guided procedures E Smith1, G Smith2, L Bergman1, A Amer1, A Jacobs1, H El Khudari1, 1 1 1 Abstract No. 889 C Burgan , A Gunn , J Zarzour 1University of Alabama At Birmingham, Birmingham, AL, 2University Developing high-fidelity, multi-learning objectives of Alabama at Birmingham School of Medicine, Birmingham, AL hepatobiliary simulation for interventional radiology LEARNING OBJECTIVES: 1. Understand the role of simulation in current trainees using a novel three-dimensional segmentation medical education. 2. Learn the ways in which simulation can be uti- and printing technique lized in image-guided procedure instruction. 3. Outline the structure of A Solomon1, R England1, R Stewart2, J Siewerdsen2, R Liddell1 the procedural simulation curriculum being implemented at our insti- 1Johns Hopkins School of Medicine, Baltimore, MD, 2Johns Hopkins tution. 4. Discuss the first procedural simulation session and subjective University, Baltimore, MD feedback from instructors and learners. 5. Review future plans and potentials for growth. LEARNING OBJECTIVES: •Review the role of simulation training in interventional radiology (IR). •Develop a high-fidelity, cost-effective BACKGROUND: Simulation training permits learners to practice a proce- hepatobiliary simulator for IR trainees. •Provide a model for assessing dure in a safe, controlled environment before treating actual patients. simulator validity and efficacy. Procedural simulation has been shown to improve skills during such image-guided procedures as lumbar punctures, thoracenteses, and BACKGROUND: A major challenge facing medical education is providing central venous catheter placement when combined with deliberate hands-on experience while improving patient safety and outcomes. As practice. Despite this, there is a relative lack of standardized training the traditional apprentice model loses traction, simulation-based train- modules to assist educators who wish to begin or expand a simulation ing is a tool that provides interactive, procedure-based learning in a program for image-guided procedures. safe and reproducible environment. As with other medical specialties, simulation is becoming increasingly utilized in IR training. 3D-printed CLINICAL FINDINGS/PROCEDURE DETAILS: Quarterly simulation ses- anatomic models have been used for patient education, presurgical sions in the School of Medicine Simulation Center are being held to planning, and, to a limited extent, simulation training. Designing a mul- teach core procedures in coordination with resident rotation sched- tipurpose, high-fidelity hepatobiliary model may fill a gap for IR train- ules. These sessions are primarily radiology faculty led with residents ees wishing to gain hands-on experience. also undergoing simulation teaching training in order to allow more flexible “resident run” teaching sessions, if additional simulation expe- CLINICAL FINDINGS/PROCEDURE DETAILS: D2P (3D Systems, Rock Hill, rience is requested by any residents. The residents filled out a survey SC) and Meshmixer (Autodesk Research, New York, NY) software was to rate their confidence with paracentesis, thoracentesis, and central used to segment CT and MRCP images and create a custom stereo- line placement before and after the simulation lab instruction (n = 11). lithographic file. A Connex Object 260 (Stratasys, Eden Prairie, MN) The mean confidence level increased from 3.18 to 4.27 (P = 0.018) for printer was used with materials selected based on durability, water- paracentesis, 2.82 to 3.91 (P = 0.05) for thoracentesis, and 3.72 to 4.45 proofness, realism, and imaging characteristics. Total printing cost was (P = 0.19) for central line placement. $700. By incorporating liquid-filled systemic venous, portal venous, and biliary anatomy in addition to focal hepatic lesions, this model CONCLUSION AND/OR TEACHING POINTS: The initial simulation session enables reproducible simulation of endovascular and percutaneous has been held with initial data suggesting overall increased confidence procedures including 1. Percutaneous biliary drain placement and level among residents. Feedback from the instructors and learners will exchange 2. Cholecystostomy and cholangioscopy 3. Transjugular and be outlined with focus on future adjustments and plans for inclusion of direct intrahepatic portosystemic shunt 4. Transjugular liver biopsy 5. a wider variety of image-guided procedures, including abscess drain- Ultrasound and CT-guided biopsy. Trainee pre- and post-simulation age and percutaneous biopsies. Data collection will continue through- assessments and surveys were created to assess content and con- out additional simulation sessions with the hopes of future publication. struct validity. Task-specific checklist evaluations were designed to establish model effectiveness and trainee competency.

CONCLUSION AND/OR TEACHING POINTS: •Simulation training is a valuable and safe tool for IR trainees. •Multipurpose hepatobiliary simulators can be created using 3D printing with careful materials selection. •Model effectiveness and validity can be assessed through trainee and evaluator assessments. SIR 2020 Annual Scientific Meeting e-Posters | 67

Abstract No. 891 Supplies for CreationSupplies of Models For Creation of Models Model Type Supplies DIY hands-on workshop for interventional radiology - Knox gelatin powder symposiums - Corn starch L Stevens1, S Pan2 1The University of Texas at Austin Dell Medical School, Austin, - Metamucil 2 TX, Austin Radiological Association, Austin, TX Ballistics gelatin - Peeled green grapes, blueberries, olives

LEARNING OBJECTIVES: To create models replicating fundamental - Food coloring; blue, black and red interventional radiology (IR) procedures for medical student practice - Suction canisters (any size) both with and without the use of ultrasound. - Syringe BACKGROUND: IR has become an increasingly popular and competi- - PVC white composite board (2" thickness) tive field amongst medical students. Despite this growing enthusiasm, development of simple, inexpensive, do-it-yourself (DIY) models rep- - Silastic tubing licating fundamental IR procedures for medical student practice are - Drill and multiple size drill bits lacking. Instructional articles for the creation of phantoms used in ultrasound (US)-guided practice have been described. However, rec- - Flat top stainless streel screws (#6 x 5/8th oval Flow Model ipes for ballistics gelatin are not standardized and are often limited to head) one procedure. In addition, student practice is restricted by the avail- - Silicon sealant ability and type of ultrasound equipment. This exhibit describes how to create models for application and practice at a cost effective price. - Box cutter Included are ballistics gelatin molds with application of the Seldinger - Wire cutter wire technique, US-guided biopsy, homemade flow models, and drain - Foam pool noodle; any color stitch/knot tying- all using common household products and hospital items (see table). - 1' PVC pipe

CLINICAL FINDINGS/PROCEDURE DETAILS: Ballistics gelatin: Air free - Saw phantoms can be created using gelatin powder, food dye, IV extension - Drill tubing, and echogenic materials (e.g., corn starch, Metamucil, blue- Drain Stich/Knot berries, grapes, and olives). Flow models: Using PVC white compos- Tying - Plexiglass (1 ft x 2 ft; cut to size) ite board, box and wire cutters, silastic tubing, silicon sealant, flat top - Zip ties screws and a drill, a vascular system can be replicated whereby students directly observe intravascular interventions they are perform- - IV extension tubing ing. Drain stitch/knot tying: These fundamental skills can be practiced - Silicon pot holder using a foam pool noodle, silicon potholder, plexiglass, IV extension tubing, PVC pipe, zip ties, and wool yarn. Specific details are discussed in exhibit. Abstract No. 892 CONCLUSION AND/OR TEACHING POINTS: The development of a DIY, hands-on workshop is imperative to the success of a medical student Do more than hold pressure: the interventional IR symposium. The practical knowledge of how to replicate funda- radiologist’s guide to hemorrhagic shock mental procedures using inexpensive and easily accessible items will 1 2 3 4 5 impact the future of IR by fostering interest and enhancing medical N Dullet , S Mathevosian , R Ahuja , K Kansagra , M Patel , G Woodhead6, H McGregor1, C Hennemeyer7 students’ skills through hands-on manipulations. 1University of Arizona, Tucson, AZ, 2UCLA David Geffen School of Medicine, Los Angeles, CA, 3Albert Einstein Medical Center, Philadelphia, PA, 4Kaiser Permanente, Glendale, CA, 5University of Arizona–Banner Medical Center, Tucson, AZ, 6N/A, N/A, 7University of Arizona, N/A

LEARNING OBJECTIVES: Define hemorrhagic shock including causes and physiologic response to hemorrhage. Provide an overview of management principles of hemorrhagic shock in the pre-hospital, early-hospital, and late-hospital periods. Review the types of blood/ transfusion products, and each of their uses. Provide an overview of mass transfusion protocol. 68 | e-Posters SIR 2020 Annual Scientific Meeting

BACKGROUND: As the role of interventional radiology (IR) in the treat- hypoxemia. The Centers for Medicare and Medicaid Services (CMS) ment and management of trauma grows, IR physicians need to be conditions of participation requires that the anesthesia services pro- increasingly familiar with the management of hemorrhage. This neces- vided by any physician in the hospital be organized and directed by sity is reflected in critical care training requirements of the integrated an anesthesiologist. The ASA has recognized capnography as a criti- IR/DR resident curriculum. Having a fundamental knowledge of the pro- cal component in patient monitoring during moderate sedation and is gression of hemorrhagic shock, blood/transfusion products, and mass supported by several cost-benefit analyses. transfusion protocols is essential for the interventional radiologist. CLINICAL FINDINGS/PROCEDURE DETAILS: There are two types of CLINICAL FINDINGS/PROCEDURE DETAILS: We will provide an overview hypoventilation detected by capnography. Bradypneic (type 1) of hemorrhagic shock, including classifications of hemorrhagic shock, hypoventilation occurs with oversedation with opioids. It is charac- physiologic changes with a comparison table with other forms of terized by a decreased respiratory rate, high EtCO2 and increased shock. We will then provide an overview of mass transfusion protocol waveform amplitude. Hypopneic (type 2) hypoventilation with sed-

(MTP) and related trials. Contents and indications of different blood/ ative hypnotic drugs. It occurs with low tidal volumes, lower ETCO2 transfusion products (e.g., pRBCs, platelets, FFP, cryoprecipitate, PCC) and decreased waveform amplitude. Detecting these changes during will be reviewed in a table format. This will include a discussion about procedural sedation should alert the physician to assess for airway complications/adverse reactions that may occur with transfusions and obstruction, provide supplemental oxygen, reduce dosing or cease MTP, including but not limited to electrolyte imbalances, transfusion drug administration, and consider reversal agents if appropriate. reactions, and transfusion related acute lung injury (TRALI). We will CONCLUSION AND/OR TEACHING POINTS: End-tidal capnometry moni- review the pre-hospital, early-hospital, and mid-late hospital man- toring should be used to complement pulse oximetry during all proce- agement of hemorrhagic shock, including methods of resuscitation, dures requiring sedation and should be considered a standard of care. and labs of importance. Lastly, a discussion about the interventional Physicians must familiarize themselves with this simple monitoring radiologist’s role in the management of hemorrhagic shock, including tool and incorporate it into their practice. opportunities and indications for intervention, will be included.

CONCLUSION AND/OR TEACHING POINTS: Interventional radiologists play an active role in the management of unstable patients in hem- Abstract No. 894 orrhagic shock. In cases of trauma or massive hemoptysis, patients Establishing an online educational teaching file on may present to the IR suite in unstable conditions. With a knowledge Instagram for an academic pediatric interventional of basic principles of hemorrhagic shock and transfusion products, radiology department: proof of concept interventional radiologists are better equipped to manage unstable patients in the IR suite. V Wadhwa1, D Tassel2, S Jorgensen2, K Wong3 1University of Arkansas for Medical Sciences, Little Rock, AR, 2Phoenix Children’s Hospital, Phoenix, AZ, 3University of Abstract No. 893 Arkansas for Medical Sciences & Arkansas Children’s Hospital, Little Rock, AR End-tidal capnography: a lifesaving modality in interventional radiology LEARNING OBJECTIVES: To describe a proof of concept of establishing S Kanaparthi1, R Moodey2 an educational teaching file on Instagram for an academic pediatric interventional radiology (IR) department. To describe tips and tricks to 1University of South Florida Morsani College of Medicine, Tampa, help other academic IR departments to establish a social media pres- FL, 2University of Florida, Jacksonville, FL ence on Instagram.

LEARNING OBJECTIVES: Review the importance of end-tidal capnom- BACKGROUND: Instagram is photo and video-sharing social networking etry which is the graphic measurement of carbon dioxide (CO ) during 2 service owned by Facebook Inc, which has over 800 million monthly expiration. It is a vital tool to monitor patients receiving conscious active users. An Instagram user’s account’s posts can be shared pub- sedations as it provides real-time information on ventilation, perfusion licly or with preapproved followers. For an image rich clinical specialty and body metabolism. such as IR, Instagram is a powerful social media platform for education.

BACKGROUND: Interventional radiologists are performing many pro- CLINICAL FINDINGS/PROCEDURE DETAILS: Academic IR departments cedures which require conscious sedation. Fentanyl and versed are usually have educational teaching files in their archives. These consist usually used for sedation and are administered by nurses under the of teaching cases which may be reviewed by future trainees. However, supervision of the physician performing the radiological procedure. most PACS archives are difficult to access and expensive to maintain, These sedative agents can cause airway obstruction, hypoventila- and most trainees may not utilize them because of the effort involved. tion, apnea and hypoxemia. Monitoring vital signs with pulse oxime- Instagram provides a free and easy way to upload IR case images with try cannot assess ventilation adequately leading to cardiopulmonary annotations and descriptions. The average attention span of adults has complications. Capnography is necessary for early detection of respi- vastly decreased, which has led to a push in education to get people ratory distress. Several studies have demonstrated that the addition the information that they need to know in a way they can remember. of capnography during procedural sedation reduces the incidence of SIR 2020 Annual Scientific Meeting e-Posters | 69

Short Instagram vignettes fit perfectly into this new generation. Train- CONCLUSION AND/OR TEACHING POINTS: Both low- and high-fidelity ees can spend just few minutes reviewing an Instagram post and then simulation are important tools in the development of an effective IR delve deeper into the pathology by whichever method they learn curriculum in low-resource countries. A 1-2 week IR simulation curric- best. Among the social media platforms currently available, Instagram ulum with proficiency benchmarks has been developed and imple- focuses on images making it the best choice for an image rich spe- mented at international sites. cialty such as IR and as such has the least amount of distractions for its users. In this exhibit, we will describe our experience with establishing an Instagram teaching files for an academic pediatric IR department, Abstract No. 896 which has gained over 42,000 followers in just 3 years. Tips and tricks Expanding early interventional radiology education for undertaking and sustaining such an endeavor are also discussed. beyond the anatomy block and the promising role of CONCLUSION AND/OR TEACHING POINTS: Academic interventional extracurricular learning modalities radiology departments can adopt the described strategies to develop I Breen1, G Knuttinen2, S Naidu3, R Oklu4, S Alzubaidi5, I Patel6, J a social media presence on Instagram and create a free, open-access Kriegshauser7 (if wanted) and image-rich teaching files which trainees will actually 1 2 utilize and benefit from. Mayo Clinic School of Medicine, Irvine, CA, Mayo Clinic, PHOENIX, AZ, 3Mayo Clinic Arizona, Scottsdale, AZ, 4Mayo Clinic Arizona, Phoenix, AZ, 5Mayo Clinic, Phoenix, AZ, 6Mayo Clinic - Arizona, Abstract No. 895 Phoenix, AZ, 7Mayo Clinic Scottsdale, Phoenix, AZ

Establishment of a simulation curriculum for LEARNING OBJECTIVES: We emphasize the importance of partnering interventional radiology training in developing countries the development of preclinical interventional radiology (IR) education curricula with extracurricular IR educational enrichment opportunities. R England1, A Kesselman2 BACKGROUND: With the recent addition of IR as a primary specialty in 1Johns Hopkins Hospital, Baltimore, MD, 2N/A, New York, NY medicine, there is now also an impetus to integrate IR education early

LEARNING OBJECTIVES: Explore the state of interventional radiology (IR) into the medical school classroom. The majority of existing models training in developing countries. Highlight the use of high- and low-fidel- describe integration of IR curriculum into the anatomy block of med- ity simulation in IR training: • IR-physician led didactics • Low-fidelity ical school; however, challenges in this model call for exploration of simulation modules • High-fidelity simulation modules • Simulation sym- supplementary educational modalities. posium Considerations for evaluating proficiency and competency. CLINICAL FINDINGS/PROCEDURE DETAILS: We have implemented and

BACKGROUND: In low- and middle-income countries, access to life-sav- previously reported on a model of preclinical IR education which was ing IR treatment is limited. One comprehensive and sustainable solu- integrated into the first year anatomy block. However, we report on tion for establishing IR services in these countries is the initiation of challenges encountered in this educational model, including time con- local training programs. Given resource limitations in these develop- straints, premature exposure to challenging clinical topics, and lack of ing regions, simulators provide an opportunity for radiologists to gain longitudinal learning. While preclinical IR education in anatomy offers hands-on procedural experience in a risk-free environment. Low-fi- a meaningful introduction to IR, we propose that IR be vertically inte- delity, model-based simulators have the advantage of being simple grated into medical school curricula, throughout basic science and and affordable, while high-fidelity, computer-based simulators offer a clinical blocks, using appropriate clinical correlates. In addition, with more sophisticated, realistic training experience. the rapidly evolving and growing specialty of IR, the opportunity to learn about IR through regional symposia, national conferences, and CLINICAL FINDINGS/PROCEDURE DETAILS: An IR simulation curriculum other extracurricular learning experiences is a robust way to sustain was developed and implemented in Vietnam, Tanzania and Kenya, student interest in IR, provide a platform for students to explore indi- with the primary goal of familiarizing trainees with devices and tech- vidualized interests (e.g., particular subspecialty), to learn about ongo- niques used in nonvascular and endovascular procedures, prior to per- ing research, and to network with and learn from experts in the field. forming them on patients. 1-2 week site visits were performed, which included IR physician-led didactics, low- and high-fidelity simulation CONCLUSION AND/OR TEACHING POINTS: We discussed the current instruction, and a concluding symposium. Low-fidelity simulators state of preclinical IR education and the recent focus on integrating included: • Biopsy • Drainage catheter placement/exchange • IVC filter IR education into anatomy block. We suggest that vertical integration placement/removal • Vascular access. High-fidelity simulator modules of IR education into the entirety of preclinical and clinical years will included: • Introductory cases: TACE (guided), IVC filter placement • address the challenges that arise out of an anatomy-course specific Beginner cases: UAE, vascular trauma • Intermediate cases: prostate curriculum. We also discuss the vital role of supplementing formal IR artery embolization (PAE), iliac/SFA intervention • Advanced cases: curricula with meaningful extracurricular activities. Early exposure to TACE (advanced), PAE (advanced). Procedural competency and pro- IR is paramount in order to promote understanding of the specialty, ficiency will be determined with assessment of procedural time, fluo- invigorate student interest, and improve visibility of the scope of IR roscopy time, contrast utilization, and off-target embolization through practice. computer simulation measurements. 70 | e-Posters SIR 2020 Annual Scientific Meeting

Abstract No. 897 BACKGROUND: The IR community has an undeniably strong Twitter presence. Last year, the Society of Interventional Radiology’s (SIR’s) Giant hemangiomas: when to treat and how to do it 2019 national conference in Austin, Texas, achieved the rank of num- H Rana1, C Wiggins1, P Patten1, O Abdul-Rahim1, Z Hussain1 ber one spot for most-tweeted-about conference in the world. There have been official hash-tags published by SIR. Interventional radiol- 1University of South Alabama, Mobile, AL ogists are sharing educational cases and participating in important

LEARNING OBJECTIVES: To review and discuss case presentation, compli- discussions that contribute to shaping the academic IR community. cations, imaging characteristics, and management of giant hemangiomas. Since Twitter is a prime meeting place for the IR community and allows images and videos to be uploaded, it is an excellent way to share cases. BACKGROUND: Giant hemangiomas, coined “giant” once they are However, precautions must be taken when uploading cases to Twitter greater than 5cm, are a unique entity of liver hemangiomas that are where the privacy of patients is not compromised. Creating a HIPAA usually asymptomatic. Typically, these lesions are discovered inci- compliant protocol and guidelines for uploading IR cases to Twitter will dentally during imaging for unrelated pathologies. Due to the lack of be valuable to anyone who wants to share their cases. symptoms, delayed treatment can sometimes lead to catastrophic complications, such as rupture or the Kasabach-Merritt syndrome, a CLINICAL FINDINGS/PROCEDURE DETAILS: Guidelines and a protocol rare coagulopathy associated with these giant variants. The manage- for uploading cases to Twitter will be informed by reviewing HIPAA ment of giant hemangioma and its current indications are controversial guidelines and applying them to the format of IR cases on Twitter. and there has been no official consensus. Surgical resection and tran- Expert opinion from those who have been successful at uploading IR sarterial embolization (TAE) by interventional radiology are currently cases to Twitter, and input from hospital marketing and public relations the most common treatment options. officials will also be utilized.

CLINICAL FINDINGS/PROCEDURE DETAILS: In this educational exhibit, CONCLUSION AND/OR TEACHING POINTS: A protocol and guidelines we discuss patient presentation, complications, multimodal imaging created for the purpose of allowing interventional radiologists to con- findings and management of giant hemangiomas with illustrations fidently and safely upload their cases to Twitter and share them with from our institution. Management of giant hemangioma varies from the thriving IR community on Twitter. treating symptomatic patients only with surgical resection, TAE or a combination of both TAE and surgery, to routinely treating all lesions Abstract No. 899 based on a size cut-off.

CONCLUSION AND/OR TEACHING POINTS: Giant hemangiomas are a Interventional radiology abroad: success, challenges, and well-known entity of benign liver masses. When untreated they may future endeavors in central Vietnam contribute to decreased quality of life, due to chronic pain, and in T Pham1, D Sella2, A Kesselman3, J McKinney1 rare cases catastrophic events such as rupture or Kasabach-Merritt 1Mayo Clinic, Jacksonville, FL, 2Mayo Clinic Florida, Jacksonville, syndrome. Understanding patient presentation, feared complica- FL, 3N/A, New York, NY tions, imaging characteristics and treatment options are crucial to providing quality care for patients. Although the ideal treatment for LEARNING OBJECTIVES: The Learning Objectives of this exhibit are giant hemangiomas is still controversial, current research trends indi- to (1) share global experiences from the most recent interventional cate treatment of only symptomatic giant hemangiomas with either radiology (IR) outreach in Central Vietnam, (2) illustrate challenges surgical resection or TAE. TAE has been shown to be a safe and effec- related to political, social, economic, and cultural differences in global tive alternative to surgical resection, allowing interventional radiolo- healthcare, and (3) discuss strategies for future endeavors. gists to play an integral role in the diagnosis and treatment of giant BACKGROUND: There are approximately 100 practicing interventional- hemangiomas. ists in the country of Vietnam, most located in the North (Hanoi) and South (HCMC). In Central Vietnam, this number equals to less than 10. Abstract No. 898 Of those practicing in the country, only one is female. Currently, there is one medical school and one radiology residency training hospital in How to safely and easily share interventional radiology the Central region. Radiology readiness assessment in 2018 demon- cases to Twitter strated no interest in IR among current trainees (5-10 per year). In a joint collaboration between Mayo Clinic Jacksonville Radiology and B Hamade1, R Cobb1, M Edelstein1, R Patel1, C Hanrahan1, N Montecalvo1, J Holten1, I Leopold1, D Pryluck1, G Cohen1 RAD-AID International, IR outreach in this area of disparity started in 2014, with expansion in 2019, at two main sites in Da Nang and Hue 1Temple University Hospital, Philadelphia, PA City. Our goal is to provide further education and onsite training to

LEARNING OBJECTIVES: Create a protocol and provide guidance for current interventionalists, increase exposure, promote departmental interventional radiologists to confidently upload and share cases with support, and stimulate interest in IR among current trainees in the the interventional radiology (IR) community via the social media plat- hopes of building growth and sustainability for IR in Central Vietnam. form Twitter in a HIPAA-compliant manner. CLINICAL FINDINGS/PROCEDURE DETAILS: Outreach in June 2019 consisted of 2 interventionalists, 1 IR nurse, 1 IR technologist, and 1 IR SIR 2020 Annual Scientific Meeting e-Posters | 71 resident spanning 1 week at Da Nang General Hospital and Hue Uni- Abstract No. 901 versity Hospital with itinerary incorporating 2 symposiums, lectures, nonvascular procedures (PTBD, stents, and US guided biopsies/drain- Mentorship, sponsorship, and coaching: key faculty and age), and IR nursing/technologist education. The exhibit will discuss resident development concepts and a guide for successful our onsite assessment, challenges faced during execution of planned implementation in interventional radiology outreach, lessons learned on global healthcare, and small but signifi- I Siddiqui1, S Kalantarova1, R Jindal1, J Minkin1, M Tembelis2, J cant advancement made toward building sustainability. Hoffmann3

CONCLUSION AND/OR TEACHING POINTS: Bridging healthcare dispar- 1NYU Winthrop Hospital, Mineola, NY, 2Stony Brook School of ity and building sustainability for IR in nondeveloped countries is of Medicine, Stony Brook, NY, 3NYU Winthrop Hospital, Garden City, utmost importance. Cultural and social differences can be challenging, NY but not an impenetrable barrier. Continued assessment of current out- LEARNING OBJECTIVES: 1. Define similarities and differences between reach and its limitations is essential in constructing and implementing mentorship, sponsorship, and coaching. 2. Highlight the use of these forthcoming global healthcare initiatives. concepts in medicine, and more specifically in interventional radiology (IR). 3. Inspire the reader to reflect on current faculty and resident Abstract No. 900 development programs at her/his institution and work with colleagues to strengthen the experience. Lumbar and neck back pain, an occupational hazard for BACKGROUND: While mentorship, sponsorship, and coaching are used interventionalists: a review on preventative methods and interchangeable by some people, they are three very different con- healthy habits cepts and approaches to professional development. An understanding D Cohen-Addad1, H Brent2, S Patel3, Z Farooq4, S Fahrtash4 of the key differences between mentorship, coaching, and sponsor- 1Suny Downstate Medical Center, Brooklyn, NY, 2SUNY Downstate ship will allow administrators, leaders, faculty, and trainees to work Medical Center, Brooklyn, NY, 3SUNY Downstate, New York, together to more effectively design and implement faculty and resi- NY, 4N/A, Brooklyn, NY dent development programming at their institutions.

LEARNING OBJECTIVES: Review the prevalence and known occu- CLINICAL FINDINGS/PROCEDURE DETAILS: Define mentorship, coach- pational risks associated with neck and lower back pain. Describe a ing, and sponsorship. Review similarities and differences between variety of preventative methods. Learn healthy habits assisting in the these employee development concepts. Highlight the use of these prevention of lower back pain. three approaches in the business world, medicine, and specifically in IR. Detail how each of these may be used in unique situations, depending BACKGROUND: Interventionalists perform multiple interventions per day, on the needs of the trainee. Review the current status of mentorship, interventions that sometimes last hours, often in awkward body position coaching, and sponsorship programs in IR training. Provide a guide for with heavy personal protective garments. The repetitive nature of this use of these professional development tools within IR training. Sug- physical stress can be a risk factor for back injuries. Once injuries occur gest unique uses and/or combinations of these tools to maximize IR it is often long-lasting with disability and cost, ranging from decreasing resident and faculty development. the amount of intervention to even switching to diagnostic radiology (IR). The occupational risk of radiation is well established; however, little CONCLUSION AND/OR TEACHING POINTS: Mentorship, sponsorship, and is described about the occupational musculoskeletal hazard and about coaching are crucial components in the professional development of preventive mechanisms. As anything prevention is often more effective a physician. Successful implementation involves personal relationship than restoration. that relies upon clear expectations, effective communication, com- mitment, core skills, mutual chemistry and longitudinal assessment of CLINICAL FINDINGS/PROCEDURE DETAILS: We review the prevalence career goals. Department financial and/or time support of these con- and risk factors of the neck and lower back pain in the intervention- cepts are integral to successful implementation and utilization. alists community. We describe healthy habits from the ergonomic arrangement of the IR suites, position of the screen, equipment reach, table height, and more. Variety of available personal protective gar- Abstract No. 902 ments and their respective pro and cons. Last, we focus on a variety of preventative physical exercise that can be performed daily. Moderate sedation for patients with left ventricular assist devices in interventional radiology procedures: pearls CONCLUSION AND/OR TEACHING POINTS: The physical demand for IR and pitfalls results in increased prevalence of neck and back pain, this is not benign 1 2 2 2 2 as it can lead to disabilities on the operator. Awareness of this occupa- S Singhal , H Chengazi , K Chughtai , A Cantos , S Virdee , D 2 tional hazard and more importantly knowledge on a variety of good Butani habits and preventive methods are essential for the longevity of an 1George Washington University School of Medicine and Health interventionalist career. Sciences, Washington, DC, 2University of Rochester Medical Center, Department of Imaging Sciences, Rochester, NY 72 | e-Posters SIR 2020 Annual Scientific Meeting

LEARNING OBJECTIVES: •Understand left ventricular assist device BACKGROUND: True collaboration allows for experts in different fields (LVAD) physiology. •Understand how to monitor LVAD patients to come together and work as a team to achieve a common goal. undergoing interventional radiology (IR) procedures. •Be familiar with Interventional radiologists are uniquely positioned to play a role in resuscitation techniques in LVAD patients. a variety of collaboration opportunities that exist between different specialties. Previous studies have shown that multidisciplinary coor- BACKGROUND: Continuous flow cardiac assist devices are growing dination of patient care has been associated with improved quality of in popularity and significantly improve survival and overall quality care and decreased hospital stays. Multidisciplinary collaborations are of life in patients with chronic heart failure. Consequently, the num- also important to promote collegiality between interventional radiolo- ber of patients with LVADs presenting for IR procedures continues to gists and other departments, and demonstrate the added value that increase. Therefore, it is imperative for IR physicians to be familiar with interventional radiologists provide. Performing multidisciplinary, col- LVAD physiology. The aim of this exhibit is to discuss the important laborative procedures alongside other specialists is one way in which physiologic ramifications of LVADs, focusing on procedure selection, interventional radiologists can use their unique skillset to positively anticoagulation, intraprocedural cardiopulmonary monitoring, and impact patient care and foster relationships with other departments. resuscitation. CLINICAL FINDINGS/PROCEDURE DETAILS: We present a case-based CLINICAL FINDINGS/PROCEDURE DETAILS: As conventional sphygmo- pictorial review of collaborative procedures including ureteroarterial manometers rely on pulsatile blood flow for monitoring, the continu- fistula repair with urology, internal iliac artery balloon placement for ous flow pattern of LVADs create a challenge for intraprocedural blood high-risk placenta previa patients with obstetrics, and percutaneous/ pressure monitoring. For intraoperative monitoring, many authors con- endoscopic rendezvous biliary access with gastrointestinal medicine. tinue to support the use of noninvasive blood pressure cuffs despite A description of the technique for each collaborative procedure will be the nonpulsatile flow. These devices range from standard cuffs, to included, as well as radiologic and clinical workup and relevant risks slow inflating or doppler measurement. In settings of labile pressure or and complications. when more accuracy is required, intraarterial lines may be necessary. Additionally, though LVAD patients are at increased risk of bleeding CONCLUSION AND/OR TEACHING POINTS: (1) The skillset of interven- compilations, they require long-term maintenance anticoagulation to tional radiologists is useful in a variety of collaborative joint proce- prevent pump thrombosis. In this exhibit, we will discuss anticoagula- dures with other specialists for the treatment of numerous disease tion considerations and procedure modifications to minimize bleeding processes. (2) Joint procedures with other specialties can result in in LVAD patient procedures. If resuscitation is required, LVAD specific improved patient care. (3) Multidisciplinary collaborations can pro- considerations must be taken. These include addressing power and mote interdepartmental collegiality and demonstrate the value of col- thrombosis issues, alternative tests for tissue perfusion, and utilizing laboration with interventional radiology. waveform capnography to monitor chest compression quality.

CONCLUSION AND/OR TEACHING POINTS: •LVAD physiology alters Abstract No. 904 hemodynamics, posing unique challenges in perioperative care. •Care must be given to managing anticoagulation, intraoperative monitor- Over-leaded: the efficacy of advanced barrier protection ing during moderate sedation, and procedure modifications. •Multiple K Segars1, B Ashley2 blood pressure monitoring modalities are available, ranging from inva- 1 2 sive to noninvasive. •We advocate for having an LVAD team present in Medical University of South Carolina, Charleston, SC, MUSC, the room for both major and minor procedures. Charleston, SC

LEARNING OBJECTIVES: (1) To understand the available options for Abstract No. 903 advanced barrier protection. (2) To explain the benefits and shortcom- ing of both leaded caps and hand protection. (3) To review the basics Multidisciplinary procedures in interventional radiology: of radiation safety. improved patient care through interdepartmental BACKGROUND: Leaded aprons and eye wear are mainstays of radiation collaboration safety. Partially due to concerns regarding the carcinogenic effects M Cellini1, B Williams2, A Isaacson3, J Du Pisanie4, J Stewart5 of occupational radiation exposure, advanced barrier protection has become increasingly popular. Specifically, companies have introduced 1University of North Carolina, Durham, NC, 2N/A, Charleston, radiation shielding for the head and hands. SC, 3UNC Department of Radiology, Chapel Hill, NC, 4UNC School of 5 Medicine, Chapel Hill, NC, N/A, Durham, NC CLINICAL FINDINGS/PROCEDURE DETAILS: Leaded surgical caps consist of a barium bismuth composite designed to minimize radiation LEARNING OBJECTIVES: After reviewing this exhibit, the reader will to the brain. Attenuation of these caps has been reported as high as (1) learn how interventional radiologists can collaborate with other 85.4%. However, a more recent study found that caps provide minimal departments to perform a wide variety of joint procedures, (2) review protection of the brain given the angle of exposure. Scatter radiation specific case-based examples of collaborative procedures, and (3) being the largest source of dose during a procedure, the cap provides understand the benefits of collaboration with respect to improving minimal protection. Leaded gloves as well as lead-free (bismuth) pro- patient care. tective gloves are available to reduce shatter radiation exposure to the SIR 2020 Annual Scientific Meeting e-Posters | 73

hands. Another recent addition to the market is a cream containing bis- patient’s quality of life. In an already demanding residency where train- muth which may provide levels of radiation attenuation similar those of ees are expected to learn all of diagnostic radiology, clinical medicine, bismuth surgical gloves. Currently no products are available intended and interventional procedures, further investigation into optimal meth- to be worn beneath the primary beam. Many available products have a ods of incorporating palliative care into IR training is recommended. black box warning against do so, as the dramatic increase in secondary scatter radiation may increase the dose to the operator. Abstract No. 906 CONCLUSION AND/OR TEACHING POINTS: Adherence to radiation safety is an important part of any practice, and this includes pro- Palliative pain management: a growing niche for the tecting oneself with the best available equipment. Concerns regard- interventional radiologist ing occupational radiation exposure may continue to encourage the S Tesfalidet1, K Schramm1 emergence of advanced barrier protection. Interventional radiologists 1 must remain knowledgable about these products and their possible University of Colorado, Aurora, CO benefits. Operators can always reduce radiation dose by using a com- LEARNING OBJECTIVES: (1) Physicians are seeking alternative pain bination of personal protective equipment, appropriately positioning management strategies in response to increased FDA regulation to the themselves away from the source of radiation, and minimizing fluo- opioid epidemic. (2) Interventional radiologists can provide directed roscopy time. analgesia through novel applications of their existing skill set.

BACKGROUND: Traditional pharmacologic management of pain con- Abstract No. 905 ditions is now challenging because of the reaction to opioid over prescription and resulting abuse. FDA crackdown on prescribing con- Palliative care: what is interventional radiology’s role? trolled substances for pain conditions has led providers to seek alter- M Shnayder1, W Sherk2 native pain therapies for their patients. The interventional radiologist’s use of image-guided, minimally invasive, targeted procedures can be 1University of Michigan, Ann Arbor, MI, 2University of Michigan applied to novel settings that previously were relegated to pharmaco- Hospital, Ann Arbor, MI logic management. LEARNING OBJECTIVES: 1. Understand the interventional radiologist’s CLINICAL FINDINGS/PROCEDURE DETAILS: This presentation will high- role in the palliative care team using case-based examples. 2. Highlight light novel pain management procedures that can be performed using the importance of palliative care training within interventional radiol- skills common to interventional radiologists. Through a pictorial essay, ogy (IR) and ways to incorporate training into the IR curriculum. the following techniques of interventional pain management will be BACKGROUND: Unlike hospice care which focuses on end-of-life com- demonstrated: (1) intercostal nerve block and ablation for abdominal fort, palliative care aims to improve the quality of life of patients and cutaneous nerve entrapment syndrome; (2) geniculate nerve block families dealing with life-threatening illness. Historically, interventional for knee pain; (3) anterior and middle scalene chemodenervation for radiologists have functioned as proceduralists, separate from the pal- thoracic outlet syndrome; (4) stellate ganglion block for post herpetic liative care team. With an ever-growing emphasis on clinical training neuralgia and pruritus; (5) celiac plexus block for visceral pain syn- within IR and peri-procedural management, the integral role of IR drome; (6) hypogastric and ganglion impar blocks for pelvic pain syn- within palliative care becomes more apparent. Interventional radiolo- dromes; and (7) lumbar sympathetic neurolysis for lower extremity gists are frequently involved in every stage of management for pallia- complex regional pain syndrome. tive care patients. Despite significant overlap, little attention has been CONCLUSION AND/OR TEACHING POINTS: The interventional radiolo- given to palliative care training for IR trainees. gist’s skill set is well adapted for treating a variety of pain conditions. CLINICAL FINDINGS/PROCEDURE DETAILS: Using a case-based format, Percutaneous pain management procedures are safe and effective IR’s role in palliative care will be emphasized. Specifically, IR’s role in primary, complementary, and/or alternative treatment options – par- diagnosis, therapeutic and palliative treatment, pain management, ticularly when traditional and multidisciplinary approaches to pain psychosocial support, and goals of care discussions will be described. management fail or lead to unwanted systemic effects. This essay A list of therapeutic and palliative IR procedures will also be presented. highlights procedures that can easily be added to the practicing phy- There are multiple ways to incorporate palliative care into IR training. sician’s armamentarium. Some examples include seminars, rotations with a palliative care service, fellowship training, or online modules. The pros and cons of these methods will be discussed.

CONCLUSION AND/OR TEACHING POINTS: There is a gap in palliative care training for IR physicians. Crucial palliative care skills that interventional radiologists require include how to: conduct end-of-life discussions, provide psychosocial and spiritual support for patients, offer bereavement support for families, assess and manage pain, provide procedural recommendations, and determine strategies to optimize 74 | e-Posters SIR 2020 Annual Scientific Meeting

Abstract No. 907 Abstract No. 908

Pedal lymphangiography for postoperative lower Peripheral arterial disease: from amputation to limb extremity lymphatic injury: a pictorial technical review salvage, decades of innovation with companion cases R Ahuja1, T Garg2, N Dullet3, S Mathevosian4, D Nguyen1, B A Moreland1, B Holly2, J Buethe3 Natarajan1, M Ferra1 1Johns Hopkins Hospital, Baltimore, MD, 2N/A, N/A, 3N/A, Towson, MD 1Albert Einstein Medical Center, Philadelphia, PA, 2Seth GS Medical College & KEM Hospital, Mumbai, Maharashtra, 3University of LEARNING OBJECTIVES: To understand the following aspects of pedal Arizona, Tucson, AZ, 4UCLA David Geffen School of Medicine, Los lymphangiography for patients with lower extremity lymphatic injury: Angeles, CA • Clinical applications and patient selection • Equipment/supplies • Detailed procedural techniques • Postprocedure care. LEARNING OBJECTIVES: To review the various diagnostic modalities commonly utilized in evaluating patients with clinically symptomatic BACKGROUND: The most common contemporary indication for lymph- PAD. To discuss the benefits and limitations of these examinations angiography is in the diagnosis and treatment of thoracic or abdom- with their angiographic correlates. To identify key imaging findings, inal lymphatic injuries. Ultrasound-guided intranodal approach has pearls and pitfalls inherent to the interpretation of these examinations. now become the preferred method in many practices. Pedal access To describe the various minimally invasive techniques available in the is much less commonly performed because it is time consuming and treatment of PAD. technically challenging, and thus training opportunities in the technique are limited. Despite the shift towards intranodal access, the BACKGROUND: PAD remains a highly prevalent debilitating disor- pedal approach remains pertinent in patients with inguinal, pelvic, or der affecting patients with known atherosclerotic disease, history of lower extremity lymphatic injuries not well characterized on intranodal extensive cigarette smoking, and/or diabetes. Presentations vary from lymphangiography or cross-sectional imaging. clinically silent disease to severe restriction of daily activity with the ultimate risk of a threatened limb. Specifically, claudication, rest pain, CLINICAL FINDINGS/PROCEDURE DETAILS: To be illustrated with photo- impotence, and poor wound healing are some of the more common graphic and fluoroscopic images of companion cases: 1) lower extrem- reasons for patients to seek treatment. Since the existence of percuta- ity lymphatic leak status post inguinal lymph node dissection; 2) lower neous endovascular work pioneered by Dotter and Judkins, both diag- extremity lymphatic leak following a saphenous vein harvest. • Using nostic and interventional radiologists have redefined, innovated, and a 25G needle, methylene blue and lidocaine are injected intradermally expanded upon the diagnosis and treatment of PAD. Exploring current into the web spaces of the first to third toe interspaces of the affected utility of imaging modalities in the diagnosis of PAD and a brief adjunc- lower extremity. • After 15-30 minutes, a transverse incision is made tive description of current and novel endovascular therapies that will into the subcutaneous tissue of the dorsum of the foot, taking care to provide the framework for radiologists to actively participate in the avoid the lymphatic channels, which are opacified with dye. • A target multidisciplinary care of PAD patients. lymphatic channel is dissected and isolated using a 3-0 silk thread. • The lymphatic channel is accessed with a 30G lymphangiography nee- CLINICAL FINDINGS/PROCEDURE DETAILS: Exhibit will discuss the var- dle and lipiodol is injected manually or using a lymphangiogram pump ious noninvasive diagnostic modalities in patients who are being con- device at a rate of 0.5 cc/min. • Intermittent fluoroscopy is used to sidered for medical, endovascular, or surgical therapy. Additionally, a monitor lipiodol progression and to identify the site of leak/obstruc- discussion of current and novel endovascular therapies with a brief tion. • The cut-down site is closed, and the patient is placed on non– review of the current literature regarding the efficacy of balloon angio- weight-bearing restrictions for the affected lower extremity for 5 days. plasty, pharmacomechanical treatment, atherectomy, stenting, and endovascular laser therapy will be explored. CONCLUSION AND/OR TEACHING POINTS: • Pedal lymphangiography remains a relevant procedure in the evaluation and treatment of CONCLUSION AND/OR TEACHING POINTS: DR and interventional radiol- patients with inguinal, pelvic, and lower extremity lymphatic leaks ogy continue to play a pivotal role in the multidisciplinary management not well characterized via intranodal approach or on cross-sectional of PAD. By reviewing the underlying disease pathophysiology, recog- studies. nizing the strengths and limitations of available radiologic examinations, and understanding the array of minimally invasive interventions available today, radiologists will remain at the forefront of patient care with respect to this debilitating but wholly treatable disease.

Abstract No. 909

Pictorial and clinical review of rare serious complications of uterine artery embolization and associated risk factors J Herren1, M Niemeyer2, C Florido3 1UI At Chicago, Chicago, IL, 2N/A, Chicago, IL, 3N/A, Watseka, IL SIR 2020 Annual Scientific Meeting e-Posters | 75

LEARNING OBJECTIVES: (1) Recognize the clinical presentation and LEARNING OBJECTIVES: To examine The Essentials of Bedside Ultra- imaging features of less common but serious complications associated sound-Guided Procedures outlined in the Point of Care Ultrasound with uterine artery embolization (UAE). (2) Identify the potential risk manual designed for rapid diagnostic evaluation and bedside proce- factors of each complication for incorporation into the preprocedural dures in critically ill patients clinical assessment. (3) Understand the appropriate management of BACKGROUND: Ultrasound is a noninvasive imaging modality which each complication, which often warrant expeditious intervention. is rapid, incredibly accurate, and widely available. Through a collab- BACKGROUND: Uterine fibroids are the most common tumor in women orative effort with interventional radiology (IR) trainees across the of reproductive age. In some studies, the estimated cumulative inci- country, the Society of Interventional Radiology RFS members have dence by age 50 is as high as 70% to 80%. While the majority of created a Point of Care Ultrasound manual designed for rapid diag- fibroids remain asymptomatic, many women experience disruptive nostic evaluation and bedside procedures. This consolidated guide symptoms, usually menorrhagia and pelvic pressure, for which they contains multiple ultrasound examinations performed at bedside with seek treatment. Hysterectomy today remains the most common sur- emphasis on indications, contraindications, step-by-step instructions gical treatment, but minimally invasive uterine fibroid embolization on how each exam is performed, and actionable findings with sugges- (UFE) has become a well-established, safe and effective alternative to tive management. surgery. UAE was first performed to treat leiomyoma in 1995 based on CLINICAL FINDINGS/PROCEDURE DETAILS: The clinical importance of its previous use in the setting of pelvic trauma and postpartum hem- ultrasound cannot be overlooked given its availability and noninvasive orrhage, indications for which UAE is still often performed. Recovery nature. The creation of a Point of Care Ultrasound manual is an invalu- time, postprocedural pain, and complications are all significantly lower able tool in the search for rapid clinical diagnoses for more focused after UFE compared to surgery. However, it is essential to recognize care and better patient outcomes. An example includes a focused the potential for post procedure morbidity, and understand the appro- cardiac ultrasound designed to evaluate cardiac function, pericardial priate management in these patients. effusion and volume status with actionable findings such as identifying CLINICAL FINDINGS/PROCEDURE DETAILS: Pyomyoma, uterine necro- a pericardial effusion and preventing its progression to tamponade. A sis, fibroid expulsion, radial artery thrombosis, and anorgasmia are transthoracic ultrasound can also provide an evaluation of portions of uncommon but serious complications that can occur after UAE. Uti- the aorta in patients whom you suspect aortic dissection. The man- lizing real case examples, the clinical presentation and salient imaging ual extends beyond the cardiovascular system and includes bedside findings will be highlighted for each complication. Through a review of ultrasounds to evaluate the pulmonary, neurologic, GI/GU, and mus- the literature, risk factors will be described. Intraprocedural strategies culoskeletal systems. to mitigate risk will then be discussed. Lastly, the appropriate clinical CONCLUSION AND/OR TEACHING POINTS: Given the increasing amount management will be presented. of diagnostic studies ordered with the same number of limited CONCLUSION AND/OR TEACHING POINTS: Pyomyoma, uterine necrosis, resources, the ability to provide real-time diagnostic solutions and per- fibroid expulsion, radial artery thrombosis, and anorgasmia are rare form procedures at bedside has been elevated by the accessibility of but serious complications following UAE, and need to be promptly rec- the Point of Care Ultrasound manual. This abstract will emphasize the ognized and managed due to their associated morbidity and potential myriad diagnostic evaluations that can be performed by the IR trainee mortality. This cased based exhibit aims to educate practicing inter- at bedside to evaluate multiple organ systems and disease states. This ventional radiologists and interventional radiology trainees on the clin- abstract will also highlight multiple ultrasound-guided procedures ical presentation, imaging appearance, risk factors, and management which can be performed at bedside for critically ill patients by the IR for rarely encountered but potentially serious complications after UAE, trainee to rapidly improve patient care and management. with the goal of improving patient outcomes.

Abstract No. 911 Abstract No. 910 Preventing physician burnout in interventional radiology: Point-of-care ultrasound: the essentials of bedside scope of the problem and keys to success ultrasound-guided procedures S Kalantarova1, L Tsikitas2, L Madsen2, M Surovitsky2, V Karimi3, J D Nguyen1, S Mathevosian2, R Ahuja3, N Dullet4, A Desai5, P Kim6, Hoffmann4 7 3 K Kansagra , M Ferra 1NYU Winthrop Hospital, Valhalla, NY, 2NYU Winthrop Hospital, 1Albert Einstein Medical Center - Philadelphia, Philadelphia, Mineola, NY, 3Stony Brook School of Medicine, Stony Brook, PA, 2UCLA David Geffen School of Medicine, Los Angeles, NY, 4NYU Winthrop Hospital, Garden City, NY CA, 3Albert Einstein Medical Center, Philadelphia, PA, 4University of LEARNING OBJECTIVES: Viewers of this exhibit should be able to iden- Arizona, Tucson, AZ, 5Einstein Health Care Network, Philadelphia, PA, 6Einstein Medical Center Philadelphia, Philadelphia, PA, 7Kaiser tify burnout, particularly as it relates to interventional radiology (IR) Permanente, Glendale, CA and its risk factors. By the end of this presentation, learners will review tips and suggestions identified by the ACR, other societies, and the relevant literature to avoid burnout. 76 | e-Posters SIR 2020 Annual Scientific Meeting

BACKGROUND: Physician burnout is a topic that recently has been include transferring a patient to the ED, requesting admission to a receiving a substantial amount of attention. The burnout epidemic has medicine observation service or an ICU, or “calling a code.” All staff the potential to affect all medical specialties, including IR. Physician should have some knowledge of these steps and how to carry them burnout has been associated with lower patient satisfaction rates, out their respective tasks. Finally, cases complicated by rigors should higher rates of medical error, higher physician and staff turnover, be tracked, reported, and reviewed in a morbidity conference format substance abuse, and suicide. Thus, an understanding of burnout, its or quality improvement project setting. causes, ways to avoid it altogether, and interventions to manage burn- CONCLUSION AND/OR TEACHING POINTS: Due to the high prevalence of out are of great importance to interventional radiologists and trainees. rigors after routine IR procedures, a systematic framework should be CLINICAL FINDINGS/PROCEDURE DETAILS: 1. Define burnout in the adopted at high volume institutions to assist in clinical care. Specific medical profession. 2. Discuss how burnout pertains to radiologists, steps that should be undertaken include reviewing infectious disease and interventional radiologists in particular. 3. Review relevant data, epidemiology, allocating resources for medical therapy, and the train- specific to burnout in IR. 4. Highlight risk factors for physician burnout ing of clinical staff on triage to higher levels of care. and methods to avoid and address those risks. 5. Define and discuss burnout in medical trainees such as medical students, residents and fellows and how to specifically address these groups. Abstract No. 913

CONCLUSION AND/OR TEACHING POINTS: Although physician burnout Revamping with ROTEM: case-based review of is quite common, it currently remains a somewhat taboo and con- applications in interventional radiology troversial topic. However, as burnout can have substantial negative S Shah1, C Nagel2, A Kesselman3 impact on physicians, staff, and patients, it is crucial for interventional 1 2 radiologists and trainees to have a strong understanding of burnout, Weill Cornell - New York Presbyterian, New York, NY, New York 3 how to avoid it, and best ways to address when it occurs. Medical College, Valhalla, NY, N/A, New York, NY

LEARNING OBJECTIVES: To review the concepts of the ROTEM (rota- Abstract No. 912 tional thromboelastography) test and its application to interventional radiology (IR) practice.

Proposals for quality improvement of managing rigors in BACKGROUND: In complex IR patients (e.g., those with coagulopathy interventional radiology and/or cirrhosis), the routine lab tests may not accurately reflect the J Albright1, A Jo2, B Pomerantz3 true bleeding risk and transfusion requirements related to various procedures. ROTEM plays an important role in analyzing the underlying 1University of Michigan, Ann Arbor, MI, 2N/A, Ann Arbor, MI, 3N/A, defects in coagulopathy and allows for goal-directed therapy prior N/A to low to high risk procedures. In this review we present a few case LEARNING OBJECTIVES: Review key specific points in interventional examples of applications of a rapid ROTEM test just prior to few IR radiology (IR) care of postoperative patients with rigors. Highlight procedures. Furthermore, there is a quick turnaround time with this pearls and pitfalls in training staff and residents in appropriate deci- test, 15-20 mins, compared with traditional coagulation lab test, which sion making. is around 45-60 mins.

BACKGROUND: Rigors is among one of the most common complica- CLINICAL FINDINGS/PROCEDURE DETAILS: The exhibit will discuss tions after routine IR procedures, particularly PTC and PCN exchanges. basics to ROTEM performance and interpretation, consideration/chal- Often suspected as a precursor to sepsis, rigors is a major cause of lenges faced during implementation and case-based review. Cases: (1) patient morbidity and challenging decision making for clinicians. Stan- liver biopsy in a pediatric patient with elevated international normal- dardizing management will improve clinical care, particularly at institu- ized ratio (INR), (2) paracentesis in a cirrhotic patient with low plate- tions with trainees and residents. The individual details of clinical care lets, and (3) TIPS in a cirrhotic patient with elevated INR. are mundane and often well known, but review and simplification are CONCLUSION AND/OR TEACHING POINTS: Familiarity and proper patient essential for high acuity situations. selection in the use of ROTEM has the potential for improved assess- CLINICAL FINDINGS/PROCEDURE DETAILS: The spectrum of clinical ment of patient’s bleeding risks and transfusion requirement prior to management of a patient with rigors can range from administration IR procedures. of Demerol and continued observation to emergent ICU transfer and escalation of care, and the appropriate course of action is often more obvious in retrospect. In addition to allocating resources allowing for Abstract No. 914 nursing care, provider assessment, and basic medical therapy there Review of arteriovenous hemodialysis access for trainees a few key systemic measures that may assist in seamless IR postprocedure care. Preoperative and escalation-of-care antibiotic regimens A Hopp1, K Zurcher1, S Alzubaidi1, J Kriegshauser1, G Knuttinen1, S should be reviewed on an institutional level, often with the help of ID Naidu1, R Oklu1, I Patel1 consulting physicians who have knowledge of local strains and resis- 1Mayo Clinic Arizona, Phoenix, AZ tance. It is important to review appropriate levels of triage that may SIR 2020 Annual Scientific Meeting e-Posters | 77

LEARNING OBJECTIVES: •Know the current options for hemodialysis hands-on training with their Tanzanian counterparts. This program will (HD) access •Understand upper extremity vascular anatomy •Know last for three years, with ten trips per year. We follow a two-week-on, the most common arteriovenous (AV) fistula configurations •Review two-week-off system, giving local IR trainees time to assemble patient physical examination findings useful for diagnosing pathologies lists and teaching goals between trips. Our onboarding process is bro- ken into a series of checklist items to be completed at various times BACKGROUND: •Request for diagnosing HD AV access site flow issue is prior to departure, starting six months prior to departure. These frequently encountered in interventional radiology. •Operative notes checklist items include vaccinations/medications, insurance, visas, are helpful but understanding upper extremity vascular anatomy and mobile phones, and travel registries. We coordinate these tasks via knowing the common types of AV fistula are essential. •Don’t forget two-month, one-month, and two-week preparation calls. When vol- physical examination findings clues! unteers return home, they submit subjective reports which we compile CLINICAL FINDINGS/PROCEDURE DETAILS: •Three types of hemo- and pass onto the next team. dialysis options and their pros and cons °Central venous catheters CLINICAL FINDINGS/PROCEDURE DETAILS: From October 2018 through °Arteriovenous fistula °Arteriovenous graft •Vascular anatomy of September 2019, 10 teams comprised a total of 41 volunteers traveled upper extremity °Arterial (proximal to distal) ♦Subclavian → Axillary to Tanzania for two weeks each. These volunteers have come from a → Brachial → Radial + Ulnar °Venous (peripheral to central) ♦Basilic + variety of institutions across the United States and Canada. There have Brachial + Cephalic → Axillary → Subclavian •3 most common types been no major travel complications, injuries, or other medical issues of AV fistula, in the order of surgical intervention recommended by in this time. In addition, we have been able to implement incremen- the National Kidney Foundation, and their pros and cons °Radioce- tal improvements to the onboarding process with each consecutive phalic °Brachiocephalic °Brachiobasilic with transposition •Physical group. examination findings are clues to pathology °Chest wall collateral, arm swelling → Central venous stenosis °Pale hands → Steal syndrome CONCLUSION AND/OR TEACHING POINTS: There is an urgent need to °High pitched bruit, discontinuous bruit, systolic only bruit, thrill other improve global access to IR. We have successfully implemented a than at the arterial anastomosis → Local stenosis °Water hammer pulse global IR outreach program in a short period of time, and we are eager → Pre-stenosis °Diminished pulse → Post-stenosis to share our streamlined process in order to help other programs get similar initiatives off the ground. CONCLUSION AND/OR TEACHING POINTS: •There are 3 types of HD venous access options: Central venous catheter, arteriovenous fistula, and arteriovenous graft. The arteriovenous graft is the preferred Abstract No. 916 option due to lowest mortality and complication rate. •Upper extremity vascular anatomy is essential for understanding AV access. •The The “core” interventional radiologist: a review of 3 most common configurations of AV fistula are radiocephalic, bra- modifiable risk factors and a practical visual guide of core chiocephalic, and brachiobasilic with transposition. •Normal arteriove- exercises for the prevention of neck and back pain nous fistulas should have easily compressible pulse, low-pitched bruit A Gold1, E Regenbaum2, O Furusato Hunt3, P Gerard1, S McCabe4, throughout, and palpable thrill at the arterial anastomosis only. S Maddineni5, G Rozenblit6, J Meshekow7 1Westchester Medical Center, Valhalla, NY, 2Texas Health Sports Abstract No. 915 Medicine, Fort Worth, TX, 3Westchester Medical Center, Hartsdale, NY, 4N/A, Katonah, NY, 5N/A, Chappaqua, NY, 6N/A, Eastchester, Streamlining the process of global interventional NY, 7Westchester Medical Center–New York Medical College, radiology outreach Beacon, NY

1 1 1 A Gonchigar , F Laage Gaupp , F Minja LEARNING OBJECTIVES: 1. Review the occupational hazards encoun- 1Yale School of Medicine, New Haven, CT tered by the interventional radiologist related to spinal health and back pain. 2. Review the impact of occupational back and neck pain on the LEARNING OBJECTIVES: Global outreach projects are increasingly pop- interventional radiologist. 3. Explore potential benefits of increased ular within the world of interventional radiology (IR). However, there core muscle strength for prevention of back pain. 4. Provide a practical are numerous challenges faced by teams that attempt to start IR ini- visual guide for a simple preventative exercise routine that can easily tiatives within the developing world, including vaccinations, prophy- be implemented. lactic medications, visas, and insurance. We started the first IR training program in Tanzania in 2018 and have successfully completed 10 BACKGROUND: Interventional radiologists encounter unique occupa- two-week trips over the course of the first year. We have significantly tional hazards that result in a much greater prevalence of low back streamlined team onboarding and program management. We believe pain (LBP) as compared to the general population. This increased that our model can serve as a template for other programs aiming to risk of LBP is associated with performing long procedures while establish their own global outreach initiatives. standing with heavy personal radiation protection equipment, and often times, awkward positioning. Much attention has been given to BACKGROUND: Our Tanzanian IR initiative involves teams of IR attend- proper ergonomics and behavioral modification for the prevention ings, technologists, and nurses from the United States conducting of LBP in the interventional radiologist; however, prevention in the 78 | e-Posters SIR 2020 Annual Scientific Meeting

form of exercise or core strength is a relatively underexplored and of common IR procedures/techniques, post procedure care and com- underemphasized topic. mon call responsibilities.

CLINICAL FINDINGS/PROCEDURE DETAILS: 1. Common environmental CONCLUSION AND/OR TEACHING POINTS: This guide is intended to be risk factors for the development of back pain include repetitive motion read prior to the rotation to give an overview of the workings of the patterns, insufficient recovery time, prolonged standing, heavy shield- department. Additionally, it should be used during the rotation as a ing garments, and awkward body postures. 2. Decreased core stability concise, yet thorough, reference to answer most of the day-to-day and neuromuscular control are modifiable biophysical risk factors for questions that arise. This will allow the student/resident to spend less the development of back pain. 3. There is modest evidence to support time getting comfortable in the rotation and to focus more on every- exercise interventions for the prevention and treatment of back pain. thing IR has to offer. 4. Stretching and regular exercise to increase core strength and endurance, with a focus on neuromuscular control and progressive loading, should be incorporated into routine clinical practice; the key muscles in Abstract No. 918 focus being the back-extensor and abdominal muscles, with additional The interventional radiology resident’s guide to consideration given to hip strengthening. 5. A visual reference guide to managing call: distractions, disasters, downtimes, and for improving muscular strength and endurance. discussions CONCLUSION AND/OR TEACHING POINTS: Neck and back pain are com- A Farag1, G Vatakencherry2, G Gabriel3, D Raissi3, B Pressman4, S mon preventable occupational hazards experienced by interventional Hawkins3 radiologists. Risk factors for development of back pain are modifiable 1 2 and should be considered for prevention in routine clinical practice. University of Kentucky Healthcare, Lexington, KY, N/A, Los Angeles, CA, 3University of Kentucky, Lexington, KY, 4N/A, Lexington, KY Abstract No. 917 LEARNING OBJECTIVES: 1. Recall strategies to minimize the impact of The complete interventional radiology rotation guide: a distractions and disasters. 2. Execute a plan when the typical services primer for fellows, residents, and medical students are not offered or there is a system malfunction. 3. Effectively communicate with referring residents and attendings. 4. Master the 3 steps to 1 1 1 1 1 1 D Portal , A Ramjit , D Eisman , J Chen , B Lei , A Mahmud , T interdisciplinary success: availability, affability, ability. Nawrocki1, N Ahmad1 BACKGROUND: Interventional radiology (IR) residents experience 1Staten Island University Hospital Northwell Health, Staten Island, a myriad of daunting tasks and complications during overnight call. NY Knowledge of common distractions and emergencies that hap-

LEARNING OBJECTIVES: This educational exhibit will highlight our com- pen overnight and how to effectively handle these issues is pivotal. prehensive guide for interventional radiology (IR) resident and med- An IR resident is expected to handle their patient list, staff consults ical student rotations. This guide outlines the steps for a majority of efficiently, perform minor procedures, and read/advise on diagnostic interventional procedures. It also serves to familiarize the reader with studies related to procedures. The decisions made during the night can the commonly used tools and devices such as catheters, wires and the have a profound impact on patient outcomes. This exhibit aims to pro- numerous machines used for IR procedures. vide an “on-call” guide to common overnight issues and how to deal with complicated cases that may arise. BACKGROUND: IR has become a very popular rotation among medical students and radiology residents and in turn, many more students/ CLINICAL FINDINGS/PROCEDURE DETAILS: Problems can manifest in residents are rotating through IR to gain experience in this unique field anything from multiple emergency cases at once to fluoro room mal- of medicine. However, the same factors that make IR such an exciting function. Distractions occur from phone calls, environment, inappro- field today - treatment of the entire spectrum of patients and diseases, priate ED consults, outside imaging being inadequate and resident/ engagement of broad medical knowledge and technical skills, modern attending discrepancies. Common pitfalls include improper documen- technologies and tools, constant innovation and evolution of the field tation, not calling the attending when help is needed, not communicat- itself - can make preparing for an IR rotation a daunting and intimidat- ing with referring teams, and not performing solo procedures on time. ing task. Often it can take weeks just to become oriented to the general The way consulting teams view the resident and the IR department workflow of a department, let alone to learn the nuances of each work- plays a significant role in patient care. Regardless of your ability, refer- day, from important lab values to watch for to choosing appropriate ring providers view availability and affability in higher regards. Patient catheters, and everything in between. care can be streamlined significantly using this interdisciplinary tactic. On-call procedures vary depending on institutional guidelines; how- CLINICAL FINDINGS/PROCEDURE DETAILS: Our guide reviews the ever, a resident’s ability to perform simple tasks and willingness to call commonly used catheters and guidewires at our hospital, as well as help if needed are other crucial “on-call” skills that must be mastered. pictures of the machinery, button/pedal functions, consent forms as well as screenshots for commonly used EMR functions. Much of the CONCLUSION AND/OR TEACHING POINTS: Overnight call for an IR res- information is universally applicable, including physical exam and ident can be a grueling and daunting task. Having a plan ready for patient care, appropriate lab work, basics of anesthesia, explanations SIR 2020 Annual Scientific Meeting e-Posters | 79 disasters, distraction, and complicated situations is crucial for effective Abstract No. 920 patient care and efficient coverage. The role of the interventional radiologist in post lung transplant patients Abstract No. 919 A Arne1, K Anand2, J Rabang1, A Nikravan1, S Tokman1, R Scott1, S 1 The radiology resident guide to effective travel Cornejo 1Creighton University-Arizona Health Education Alliance, Phoenix, A Farag1, K Kansagra2, B Patel3, H Hasham4, A Eweka5, G AZ, 2UTHSCSA, San Antonio, TX Vatakencherry6, A Niekamp7

1University of Kentucky, Lexington, KY, 2Kaiser Permanente, LEARNING OBJECTIVES: Examine the therapeutic approaches provided Glendale, CA, 3N/A, Long Island City, NY, 4N/A, Portland, OR, 5N/A, by interventional radiologists in lung transplant patients and review Mineola, NY, 6N/A, Los Angeles, CA, 7N/A, Houston, TX associated clinical context distinct to this patient population.

LEARNING OBJECTIVES: 1. Understand why traveling economically is BACKGROUND: Lung transplantation is a lifesaving procedure for crucial to building a professional career. 2. Understand the importance patients with end stage lung disease. Lung transplant recipients com- of travel points and sky-miles. What are they? How are they obtained? monly face pulmonary and extrapulmonary complications that require How to use them? 3. Learn to enjoy travel while not “killing the bank.” a multidisciplinary approach. Interventional radiologists and the pro- 4. Learn how to optimize searches for national conferences and trainee cedures they perform are integral in the longitudinal care of these travel scholarships. patients. Although some of these procedures may be routine practice, the clinical context in which they are performed is unique to the lung BACKGROUND: Medicine continues to be a career of increasing com- transplant population and deserves special consideration. In this edu- petitiveness with interventional radiology currently the most com- cational exhibit, we review interventional radiology (IR) procedures petitive. It is becoming more crucial for trainees to take advantage of commonly performed in lung transplant patients and the associated networking opportunities at national conventions and resident/fellow clinical considerations unique to this patient population. society meetings. Leadership roles are often contingent on a trainee’s level of engagement during these events. Costs associated with travel CLINICAL FINDINGS/PROCEDURE DETAILS: Some of the procedures may seem prohibitive at times. This exhibit aims to elucidate how to that IR performs to diagnose and treat transplant recipients include travel freely with SkyMiles and travel points, and how to streamline angiography, angioplasty, stenting, balloon dilation, kyphoplasty, searching for conference related scholarships. vertebroplasty, thoracentesis, thrombectomy/thrombolysis, thoracic duct embolization, lung nodule biopsy, fiducial marker placement, CLINICAL FINDINGS/PROCEDURE DETAILS: Very few professionals as well as insertion of ports, hemodialysis/plasmapheresis catheters, know to effectively use SkyMiles and travel points to obtain free or feeding tubes, chest tubes, peripherally inserted central catheters, and cheap airline/hotel accommodations and access to their respective inferior vena cava filters. We hope to explain the importance of these lounges. How these are obtained and used effectively can have a pro- procedures in lung transplant patients in depth during short oral pre- found impact on using the travel techniques discussed. These points sentations and visual aids. can be obtained by several methods other than conventional spend are easier to obtain than traditionally known. We will discuss expert CONCLUSION AND/OR TEACHING POINTS: Interventional radiologists travel tips and tricks, along with common travel mistakes, from resi- provide a wide range of procedures that are diagnostic and therapeu- dents and fellows who have used these techniques during interview tic for lung transplant recipients. Informing the medical community of and conference travel. Effective travel not only reduces the overall cost these procedures may improve patient outcomes and satisfaction. of a trip but can reduce stress, improve efficiency and allow for a continued productivity. When to schedule a flight, and how to deal with flight cancellations/deviations are critical while navigating interview Abstract No. 921 season and balancing work/conference life. Streamlining productivity The utility of an interventional radiology trainee as a during travel using lounges and workspaces allows for a near normal member of the intensive care unit team work environment. N Dullet1, S Mathevosian2, R Ahuja3, D Nguyen4, K Kansagra5, M CONCLUSION AND/OR TEACHING POINTS: Involvement with national Ferra3 radiology groups and attendance at radiology conferences has 1University of Arizona, Tucson, AZ, 2UCLA David Geffen School become essential for our competitive specialty. Understanding how to of Medicine, Los Angeles, CA, 3Albert Einstein Medical Center, travel effectively will allow the average medical student, resident, or Philadelphia, PA, 4Albert Einstein Medical Center - Philadelphia, fellow to attend these important events. Philadelphia, PA, 5Kaiser Permanente, Glendale, CA

LEARNING OBJECTIVES: 1. Provide an overview of the Intensive Care Unit (ICU) rounding experience with attention to important clinical patient parameters, including labs, ABGs, vital signs, and ventilator settings among others. 2. Describe the utility of the interventional 80 | e-Posters SIR 2020 Annual Scientific Meeting

radiology (IR) resident during ICU rounds including image interpreta- discussion through a dedicated committee and literature, akin to other tion, bedside ultrasound evaluation and preprocedural management. medical foundations. There is a clear need for this organized platform. 3.Elaborate on the applications of point of care ultrasound (POCUS) CLINICAL FINDINGS/PROCEDURE DETAILS: The importance of ethics in for timely assessment and diagnosis. IR will be introduced through allusion to the specialty’s historical roots BACKGROUND: The IR physician/trainee plays an essential role in the and basis of image-guided, minimally invasive treatments. Principles care of increasingly ill patients. Knowledge of basic critical care princi- of ethics will be defined and be paired with real case examples. Bul- ples is essential in the preoperative, intraoperative, and postoperative leted are five action items we advocate implementing, 1. Expand the periods. As a result, IR residency and fellowship training has evolved to current Ethics Committee scope of SIR, by adding a working structure include ICU training. The role of the IR/ESIR resident in the ICU team that regularly defines our ethical mission, based and expanded from is variable across training programs, with roles ranging from being an the existing Code of Ethics. 2. Expand topics beyond societal rules to observer to serving as a team senior. Radiology residents can aid in include ethics in practice, research, education, and societal member- image interpretation/ordering, POCUS, and performing procedures. ship. 3. Institute a medium (e.g., SIR Connect), to allow for free dis- course to involve all IR community members who wish to participate. CLINICAL FINDINGS/PROCEDURE DETAILS: We will review labs and clin- 4. Establish projects and generate publications with supportive opin- ical data points that are important to focus on during ICU pre-round- ion and data that aid in establishing a strong ethical opinion. 5. Learn ing. We will review common applications of POCUS as they pertain from other specialties that have established ethics sections (e.g., ACEP, to ICU rounds, including but not limited to volume status and respi- AMA Journal of Ethics, bioethicists, and institutional ethicists). ratory exams. This will include a discussion about common bedside POCUS procedures. We will discuss the goals an IR trainee should have CONCLUSION AND/OR TEACHING POINTS: - It is imperative to establish a for their ICU rotation, such as gaining an understanding of ventilator structured framework for the ethics of clinical IR. - Current discussion settings and their application in different settings, vasopressors, and of ethics in IR has been inadequate. - A brief introduction to ethics and management of septic and hemorrhagic shock. The details for each action items provide us with a tangible agenda. of these will be deferred to alternate posters. We will elaborate on the team approach in critical care medicine with a case example demonstrating IR’s role in the treatment plan. Abstract No. 923

CONCLUSION AND/OR TEACHING POINTS: IR physicians are taking a Understanding practices and gaps in multidisciplinary larger role in the care of critically ill patients and need to understand hepatocellular carcinoma care within the community basic critical care concepts. To that extent, the ICU/Critical Care rota- oncology setting in the United States tion requirement was established. The IR resident can play a key role in P Philip1, L Boehmer2, L Lucas2, C Mangir2 the ICU team by helping with image interpretation, ordering appropri- 1 ate imaging, POCUS, and procedures. Karmanos Cancer Institute, Wayne State University, Detroit, MI, 2Association of Community Cancer Centers, Rockville, MD

Abstract No. 922 LEARNING OBJECTIVES: HCC incidence continues to rise and presents a myriad of complex challenges involving multiple disciplines to To heal or pioneer? Structured ethics culture in screen, diagnose, and provide personalized therapy. The study aimed interventional radiology, a call to action to understand how multidisciplinary cancer programs were structured to manage HCC patient care and to identify challenges and practices 1 2 3 R Abboud , S Mohammad , K Dickey for management of patients with HCC, a cancer less commonly seen in 1Wake Forest School of Medicine, Winston Salem, NC, 2Wake Forest community care settings. Baptist Medical Center, Winston Salem, NC, 3Wake Forest School of BACKGROUND: The Association of Community Cancer Centers (ACCC) Medicine–Radiology, Winston Salem, NC developed a needs assessment to identify factors associated with LEARNING OBJECTIVES: 1) To address the need for a foundational eth- delivery and coordination of care for HCC patients in community ics doctrine in interventional radiology (IR) through discrete action settings. The survey was deployed electronically in July 2018 to mul- items, 2) To introduce basic concepts of ethics as they relate to IR, 3) tidisciplinary providers, representing 17 oncology professions. Of the To initiate a dialogue and environment for disseminating ethical topics responses (n = 31), 69% identified their care setting as a “nonteaching within the Society of Interventional Radiology (SIR) and the greater IR community hospital, freestanding cancer center, private practice or community. other.”

BACKGROUND: Querying the literature on ethics of clinical IR yields CLINICAL FINDINGS/PROCEDURE DETAILS: 61% of respondents indi- minimal resources. As IR develops into a more clinical specialty, the cated their cancer programs do not have a specialized hepatobiliary lack of citable discussion around IR ethics begs the question -- why has multidisciplinary team. Among those who have hepatobiliary multidis- this foundational topic evaded our formal awareness and assessment? ciplinary teams the composition and degree of specialization varied. Here, we aim to initiate the dialogue of “Ethics in IR” through an intro- 85% of respondents that do not have a specialized hepatobiliary team duction of basic ethical concepts and how they relate to IR. We hope indicated that HCC patients are managed in consultation with a gen- that following this review, the SIR will consider leading this imperative eral tumor board. 52% of respondents indicated their cancer program SIR 2020 Annual Scientific Meeting e-Posters | 81 discussed participation in clinical trials with all HCC patients, and 55% Abstract No. 925 of cancer programs conducted HCC clinical trials. 52% indicated their cancer program had a formal pathway that outlines adherence to the Managing expectations: how to navigate moral, ethical, NCCN guidelines for HCC management, 5% were in the process of and legal boundaries in the era of social media developing and 43% were not in the process of developing such a path- A Shrigiriwar1, T Garg2, V Garg3 way. Of respondents that reported barriers their cancer program faces 1Seth GS Medical College and KEM Hospital, Mumbai, (n = 13) 31% indicated lack of psychosocial services, lack of screening Maharashtra, 2Seth GS Medical College & KEM Hospital, Mumbai, and no/limited access to clinical trials. 23% responded delayed treat- Maharashtra, 3Dr. DY Patil University School of Dentistry, Mumbai, ment and 15% responded delayed diagnosis as challenges. Maharashtra CONCLUSION AND/OR TEACHING POINTS: The survey reviewed mul- LEARNING OBJECTIVES: 1. To learn about the legal and ethical aspects tidisciplinary care delivery for HCC patient populations and revealed associated with social media in interventional radiology (IR). 3. Learn unique protocols and associated challenges within primarily commu- about various ways to navigate through the legal and ethical issues. nity-based settings.

BACKGROUND: Social media platforms such as Twitter are one of the major sources used by IR physicians for networking and sharing novel Abstract No. 924 procedural techniques used for treating individual patients. With ongoing technological advancements, it is time for us to be cognizant Urological alternatives to prostate artery embolization: about our professional commitments and preserve patient trust and what an interventionalist should know strengthen our doctor-patient relationships. With more and more phy- J Farah1, S Mehta2 sicians actively engaging in social media, it is imperative for physicians 1Saint George’s University, Jacksonville, FL, 2N/A, Newton, MA to know about various guidelines governing health care in social media and avoid potential lawsuits. These laws governing health care in social LEARNING OBJECTIVES: The objective of this educational abstract is to media fall under the Health Insurance Portability and Accountability summarize and illuminate the different choices of procedures to treat Act (HIPPA). HIPAA was formed to set national standards for confi- benign prostatic hyperplasia from a urological perspective. The goal dentiality, security, and transmissibility of personal health information of this abstract is to educate interventional radiologists who are inter- (PHI). PHI is any information that can be used to identify an individual. ested in starting a Prostate artery embolization (PAE) practice to the Currently, HIPAA allows social media posts of content which have been urological alternatives that exist. de-identified. However, potential legal consequences are still possible

BACKGROUND: BPH is a benign enlargement of prostatic tissue and a if the detailed patient interaction is described even if the material has problem in over 80% of men. As men age, the incidence and severity been de-identified. of BPH increases. TURP has been the gold standard for surgical treat- CLINICAL FINDINGS/PROCEDURE DETAILS: In 2013, the American Col- ment, but alternatives such as prostatic urethral lift, photoselective lege of Physicians (ACP) and the Federation of State Medical Boards vaporization, laser enucleation and plasma vaporization exist as treat- (FSMB) came up with guidelines on Online Medical Professionalism ment options. PAE is an emerging treatment option for many patients and gave the following considerations 1. Physicians should maintain with promising results. An interventional radiologist treating patients separate professional and social spheres. 2. Documentation about for BPH must be familiar with the urological alternatives in order to patient care communications should be included in the patient’s medi- best evaluate and educate patients. cal record. 3. Self-auditing must be done. They stated that these guide-

CLINICAL FINDINGS/PROCEDURE DETAILS: The indications, contrain- lines should be a starting point, and, modifications will be needed as the dications, preprocedure workup, post procedure recovery and clini- technology advances. According to the US Copyright Law and Photo- cal outcomes will be discussed for a variety of urological procedures, graphs, physicians who take medical pictures of patients or specimens including TURP, UroLift, HOLEP, REZUM, Greenlight, TUNA, Aquabla- (unless such images are mandated explicitly by their employment. tion, and Prostiva. CONCLUSION AND/OR TEACHING POINTS: Create awareness about

CONCLUSION AND/OR TEACHING POINTS: Interventional radiologists various laws and guidelines governing healthcare in social media and performing prostate artery embolization should be familiar with the focus on their relevance to interventional Radiologists. urological alternatives. Readers will learn about the variety of urological options and how they compare to prostatic artery embolization. Abstract No. 926

Tools and terminology for cost studies in interventional radiology A Amalou1, H Amalou2, S Xu3, H Celik4, B Turkbey3, B Wood1 1National Institutes of Health Clinical Center, Bethesda, MD, 2N/A, Bethesda, MD, 3National Institutes of Health, Bethesda, MD, 4NIH, Bethesda, MD 82 | e-Posters SIR 2020 Annual Scientific Meeting

LEARNING OBJECTIVES: To define and learn basic terminology and tools BACKGROUND: MACRA transitions traditional fee-for-service to a value used to describe whether and how interventional radiology (IR) proce- based payment system. The two payment options under MACRA dures, technology, or approaches are cost-effective or not. To better are Merit-Based Incentive Payment System (MIPS) and the Alterna- understand the ways of measuring and reporting cost metrics from a tive Payment Model (APMs). Participation in MIPS involves financial macro-economic, public health, hospital, or practice perspective. incentives and penalties based on a single scoring system based on quality, advancing care information/EHR meaningful use, and clinical BACKGROUND: Cost studies in IR may be most commonly performed practice improvement activities. While most providers are expected by regulators or administrators trying to assess effectiveness or value to participate in MIPS initially, advanced APMs are the eventual target of a procedure or technology or coded intervention across a certain under MACRA with a The Centers for Medicare & Medicaid Services population, often to measure impact, benefit or overall cost. (CMS) goal of 85% of U.S. healthcare expenditures processed through CLINICAL FINDINGS/PROCEDURE DETAILS: Costs can be defined and APMs by 2022. MACRA included modest positive payment updates in compared in terms of direct costs of procedures or indirect costs of the Medicare Physician Fee Schedule but leaves a six-year gap from overhead (hospital, departmental, or administrative costs). Allocated 2020 through 2025. While some major health systems were able to costs may also reflect overall hospital costs. Actual costs to a practice take advantage of the five percent incentive payments of converting or a hospital may not reflect the overall value or cost effectiveness of to APMs, CMS acknowledges that Advanced APMs are not available to a procedure, approach or technology. Cost effectiveness attempts to all physicians. measure the value of a procedure or approach in terms of the ratio of CLINICAL FINDINGS/PROCEDURE DETAILS: On May 8, 2019, the AMA dollars to impact, often across a population or demographic. Reim- testified before a public hearing called by the U.S. Senate Commit- bursement approaches cost analysis from the other direction. Reim- tee on Finance to examine “MACRA and the Road Ahead.” The AMA bursement patterns vary widely, according to geography, insurance submitted a written statement setting forth its testimony and asking coverage, and often even on a hospital to hospital basis. In basic terms, Congress to extend the advanced APM incentive payments for an CPT codes may be split into technical or professional supervision or additional six years. The Society of interventional radiology supported interpretations components, and procedural reimbursements may be this letter. split into subunits or lumped into one global all-inclusive code that even covers postprocedural imaging. Also confounding the simple CONCLUSION AND/OR TEACHING POINTS: This educational poster will study of cost is that CPT codes (with RVUs) may be added to a diag- go over steps that interventional radiologists should be aware of for nostic code to yield a DRG code which has an actual dollar value and is working under MIPS, including justification for standardized reporting also somewhat “global,” in that it may cover all services throughout an and the IR Registry. Additionally, we will discuss the challenges that inpatient admission. Outpatient versus inpatient reimbursement often APM options present for interventional radiologists who interact with varies widely. Attempts to define standardized metrics with which to a significant number of clinical services. Finally, we will discuss the compare procedures across a population include quality adjusted life framework for the AMA, ACR, and SIR positions on MACRA. years (QALYs), cost-effectiveness ratios, cost per patient, and cost per diagnosis. Abstract No. 928 CONCLUSION AND/OR TEACHING POINTS: It is thus not easy to track, metric, or measure absolute cost nor cost effectiveness on a stan- Building an artificial intelligence platform in dardized scale, and the models may be easily skewed by underlying interventional radiology or interventional oncology assumptions. H Amalou1, H Celik2, N Varble3, A Amalou2, S Xu2, S Harmon4, T Sanford4, G Brown4, D Xu5, Z Xu5, H Roth5, R Suh1, S Raman1, P Abstract No. 927 Pinto4, B Turkbey4, B Wood4 1UCLA, Los Angeles, CA, 2NIH, Bethesda, MD, 3Philips, Bethesda, Why are the American Medical Association, American MD, 4NIH NCI, Bethesda, MD, 5NVIDIA, Bethesda, MD College of Radiology, and Society of Interventional Radiology bracing for MACRA in 2020? What the LEARNING OBJECTIVES: To understand the basic terminology and lan- interventional radiologist should know guage of deep learning (DL), machine learning (NL), texture analysis, radiomics, and artificial intelligence (AI) in imaging and image-guided 1 1 1 1 1 A Kolarich , S Golden , B Holly , K Hong , A Menard interventions. To define the nuts and bolts required to set up data anal- 1Johns Hopkins Hospital, Baltimore, MD ysis workflow and infra-structure to enable image labeling, data flow, and building of AI models in an academic interventional radiology (IR) LEARNING OBJECTIVES: 1. Understand the historic framework for setting. MACRA implementation. 2. Understand the payment paths available to providers under the Medicare Access and CHIP Reauthorization Act BACKGROUND: Multimodality data science tools may help better use (MACRA). 3. Physician payment freezes and advanced payment mod- imaging to characterize cancer or predict outcomes. AI and deep els (APM’s), 2020 to 2025. 4. American Medical Association (AMA), learning have tremendous potential for prediction of cancer outcomes American College of Radiology (ACR), and Society of Interventional (prognosis and selection for specific therapies) via the computerized Radiology (SIR) positions on MACRA. interrogation of imaging, pathology, and molecular data. However, SIR 2020 Annual Scientific Meeting e-Posters | 83

there is currently a lack of well-defined uses of AI in interventional of postoperative lymphoceles and complex leaks: embolization, sclero- radiology or clinical oncology. Many cancers have specific imaging therapy and thoracic duct interruption. phenotypes that may generally indicative of prognosis; however, a CLINICAL FINDINGS/PROCEDURE DETAILS: Treatment of postoperative validated methodology for predictive algorithms or classification does lymphoceles and other complications vary depending on the injury. not yet exist for most cancers. Predictive models will require specific Conventional lymphangiography or dynamic contrast-enhanced MR expertise, computational resources, and pooled clinical data such as lymphangiography can be used. With conventional lymphangiogra- imaging, genomics, and tissue. Multidisciplinary, multi-institutional phy, three main methods are utilized: pedal, nodal and transhepatic. team science will be required to better meet challenges in IR. An Transcatheter sclerotherapy has a high success rate, with the usage understanding of the basic language and terminology of AI will help of ethanol, bleomycin, iodine, and doxycycline. The choice of sclerotic radiologists and interventional radiologists better adapt to this rapidly agent is often the user preference. For more complex cases such as emerging field using rapidly evolving tools to become dynamic part- high output lymphorrhea, if the source of leakage is from the abdomen, ners in the ongoing data science revolution in medicine. such as lumbar or para-aortic lymphatic structures, pedal or nodal CLINICAL FINDINGS/PROCEDURE DETAILS: AI tools may be developed ultrasound-guided lymphangiography is best suited. Noninvasive to better characterize, diagnose, triage and treat cancer, or predict imaging is an option, such as MR or SPECT/CT. The educational exhibit outcomes with imaging surrogate biomarkers. Imaging AI may assist will review case-by-case postoperative complication, relevant imag- with organ, vessel, or tumor segmentation, registration, or treatment ing, and type of intervention/agent used for definitive management. planning, which may facilitate assessment or IR procedures. The lan- CONCLUSION AND/OR TEACHING POINTS: After review of the exhibit, guage and tools required to annotate, label, process, and store images the reader should have an increased familiarity and knowledge of the must be coupled to tools, computing power and expertise with which various lymphangiography studies, current interventional procedures/ to build and deploy AI models. Crowd sourcing, transfer learning, and agents, technique, and post procedural management practices. registries may facilitate an integrated approach.

CONCLUSION AND/OR TEACHING POINTS: A basic understanding of AI language will enable IR’s to sit at the table instead of be on the menu Abstract No. 930 in the AI revolution. Thoracic duct embolization in management of plastic bronchitis in adults with no congenital heart disease Abstract No. 929 R Frimpong1, E Bendel1

1 The role of the interventional radiologist in management Mayo Clinic, Rochester, MN of lymphatic complications in the abdomen: a pictorial LEARNING OBJECTIVES: 1. Review the clinical manifestations of plastic and case review bronchitis and diseases associated with the condition. 2. Explain the S Kim1, A Patel2, A Shetty3, Z Nuffer4, A Sharma5 role of abnormal lymphatic drainage in the pathophysiology of plastic bronchitis. 3. Discuss preprocedure lymphangiography findings in 1University of Rochester-Strong Memorial Hospital, Rochester, patients with plastic bronchitis. 4. Explain the techniques for thoracic NY, 2University of Rochester, Rochester, NY, 3University of Rochester School of Medicine, Rochester, NY, 4The University of Texas MD duct embolization in patients with plastic bronchitis. 5. Discuss the Anderson Cancer Center, Houston, TX, 5Strong Memorial Hospital, clinical outcome in patients with plastic bronchitis following thoracic Rochester, NY duct embolization.

BACKGROUND: Plastic bronchitis is a rare condition where patients LEARNING OBJECTIVES: 1. Review common radiographic findings of expectorate bronchial casts. Exact etiology is unknown but conditions surgical lymphatic complications. 2. Brief overview of the different that cause abnormal lymphatic drainage have been linked with plastic modalities for lymphangiography and agents used for intervention, bronchitis. Current studies on plastic bronchitis have been on children including embolization, sclerotherapy and thoracic duct interruption. who have had corrective surgery for congenital heart disease. Adults 3. Case-based review of successful treatment of common post pro- without congenital heart disease who develop plastic bronchitis have cedural complications including leaks and high output lymphorrhea. significant comorbidities from the condition. Lymphangiography 4. Management of patients in the immediate postprocedural period. and thoracic duct embolization provides has the potential to provide BACKGROUND: Postoperative lymphoceles and lymphatic leaks usu- symptomatic relief for patients with plastic bronchitis. ally occur in surgical procedures that are in close approximation to the CLINICAL FINDINGS/PROCEDURE DETAILS: This exhibit discusses lymphatic ducts and lymph nodes. Examples include prostatectomy 4 adults with no history of congenital heart disease who presented and renal transplant. Chylothorax can occur if there is injury to the tho- with plastic bronchitis. The clinical diagnosis including image find- racic duct. Conventional lymphangiography and dynamic contrast-en- ings of plastic bronchitis will be discussed. The technique and find- hanced MR lymphangiography are available for evaluation. Generally ings of lymphangiography will be discussed. Technical consideration for low output lymphorrhea conservative management is adequate. and embolization of abnormal lymphatics will also be highlighted. Three main interventional techniques are employed for management The exhibit will discuss complications arising from thoracic duct 84 | e-Posters SIR 2020 Annual Scientific Meeting

embolization. Finally, clinical outcome following embolization of abnor- undergo initial screening CTs for diagnosis, targeted contrast-en- mal lymphatics in all 4 patients with plastic bronchitis will be discussed. hanced ultrasound may be helpful in the detection and monitoring of splenic PSA before and after embolization. CONCLUSION AND/OR TEACHING POINTS: Plastic bronchitis is a rare condition with unknown etiology but related to conditions that impair the normal flow of lymph. Current literature on plastic bronchitis has Abstract No. 932 been mostly on children with corrective surgery for congenital heart disease. Lymphangiography with thoracic duct embolization has the Hidden in plain sight! Iatrogenic arteriovenous fistulas: potential to treat adults with plastic bronchitis. a case series of angiographic findings and clinical presentations Abstract No. 931 D McCleaf1, J McCool1, C Molvar1, R Garcia-Roca1, J Olivieri1, M Borge1 Feasibility of using contrast-enhanced ultrasound for 1Loyola University Medical Center, Maywood, IL the evaluation of pseudoaneurysm after splenic artery embolization for splenic trauma LEARNING OBJECTIVES: Recognize that arteriovenous fistulas are infre- quent, yet serious complications of surgical procedures with distinc- 1 1 2 R Flato , H Tchelepi , J Vairavamurthy tive angiographic findings. The provided case series will demonstrate 1Keck School of Medicine of the University of Southern California, a variety of arteriovenous fistulas that interventionists may encounter Los Angeles, CA, 2Keck School of Medicine of the University of as well as the relevant clinical presentation. Southern California, South Pasadena, CA BACKGROUND: Iatrogenic arteriovenous fistulas are rare complications LEARNING OBJECTIVES: Evaluate the role of contrast-enhanced ultra- of surgical procedures involving sharp disruption of an artery and adja- sound for the evaluation of pseudoaneurysm after splenic artery cent vein. The disruption allows the high pressure arterial system to embolization for trauma. preferentially decompress into the low pressure venous system. This event may go under appreciated during the operation and well into BACKGROUND: The spleen is the most commonly injured intraabdom- the postoperative recovery. Common sequelae include abdominal inal organ in blunt trauma, and splenic artery embolization is often bruit, back pain, congestive heart failure, lower extremity edema, skin performed for therapy. After undergoing embolization for splenic changes, hematuria, and renal failure. trauma, patients are monitored for continued vascular manifestations of splenic injury, including hemorrhage and pseudoaneurysm (PSA) CLINICAL FINDINGS/PROCEDURE DETAILS: Case 1: A 76-year-old man formation. Computed tomography angiography (CTA) is the most with a surgical history of prior L4-L5 discectomy presenting with common imaging modality employed for detecting PSA after splenic worsening congestive heart failure due to aortocaval fistula. Case trauma. However, contrast-enhanced ultrasound (CEUS) may be help- 2: A 65-year-old man with a history of multiple bowel surgeries pre- ful in the detection of PSA while avoiding the ionizing radiation asso- senting with an abdominal bruit due to arteriovenous fistula between ciated with CTA. the inferior mesenteric artery and vena cava. Case 3: A 38-year-old woman presenting with severe postoperative hemorrhage following a CLINICAL FINDINGS/PROCEDURE DETAILS: A database of all CEUS pre- hysterectomy due to pseudoaneurysm and arteriovenous fistula from formed from 2015 to 2019 was reviewed to identify patients under- the right superior rectal artery to the common femoral vein. Case 4: going CEUS following embolization for splenic trauma. Many of these A 70-year-old man with a history of multiple bypass procedures pre- CEUS cases were performed with Ultrasound CT Fusion to more senting with worsening lower extremity claudication symptoms due to accurately identify the area(s) of concern. The Fusion was performed a left common femoral artery to common femoral vein fistula. Case 5: with the initial trauma CT obtained at the time of presentation to the A 35-year-old man with a history of pancreatic transplant complicated emergency department. Patient demographics, initial imaging, hospi- by pancreatitis and lymphoma presenting with both GI bleed and tal course, and follow-up imaging results were reviewed. Four patients worsening heart failure due to high-grade intratransplant aortocaval were identified that underwent CEUS for evaluation of PSA after prox- fistula. imal splenic artery embolization for splenic injury seen on initial CT obtained in the emergency department for trauma. Patient age ranged CONCLUSION AND/OR TEACHING POINTS: Interventionalists should be from 14 to 37 years (average age 23, three male, one female). Of the alert to the clinical and angiographic signs of arteriovenous fistula which four patients, three also had follow-up CTA. In one case, both the CTA often go unsuspected in patients with a history of surgical instrumentation. and CEUS were negative for PSA; in one case, both the CTA and CEUS showed a possible PSA; and in one case, the CTA showed a possible PSA while the CEUS was negative for PSA. In the final case, only a follow-up CEUS was obtained, which was negative for PSA. In all cases, the patient was discharged without further dedicated splenic imaging or intervention.

CONCLUSION AND/OR TEACHING POINTS: Splenic PSA is a common vascular injury seen after intraabdominal trauma. Though most patients SIR 2020 Annual Scientific Meeting e-Posters | 85

Abstract No. 933 2. Demonstrate key diagnostic clinical and imaging features of these diseases. 3. Identify indications for treatment and the role of interven- Mechanical circulatory support devices: what the tional radiology. 4. Explore appropriate treatment options for each interventional radiologist needs to know disease.

1 2 3 4 5 A Patel , A Brahmbhatt , A Shetty , K Chughtai , A Sharma BACKGROUND: Lower extremity arterial disease caused by atheroscle- 1University of Rochester, Rochester, NY, 2University of Rochester, rosis is a common pathology encountered and treated by interven- Rutherford, NJ, 3University of Rochester School of Medicine, tional radiologists. Though atherosclerosis is certainly prevalent, there Rochester, NY, 4University of Rochester Medical Center, Rochester, are also multiple nonatherosclerotic causes of lower extremity arterial NY, 5Strong Memorial Hospital, Rochester, NY disease that can be a significant cause of morbidity, including Buerger disease, popliteal entrapment syndrome, cystic adventitial disease, LEARNING OBJECTIVES: 1. Review common mechanical circulatory and ergotism. Although these diseases can share similar features of support devices (MCS), indications and implementations. 2. Review clinical presentation with atherosclerotic disease, they each have spe- expected and unexpected hemodynamic changes including venous cific ideal treatments, thus making it imperative to differentiate these and arterial doppler ultrasound waveforms. 3. Discuss important con- etiologies of lower extremity arterial disease. siderations prior to intervention on patients with mechanical support devices. CLINICAL FINDINGS/PROCEDURE DETAILS: The clinical and imaging findings of Buerger disease, popliteal entrapment syndrome, cystic BACKGROUND: The number of patients on MCS such as ventricular adventitial disease, and ergotism will be presented and discussed in assist devices, extracorporeal membrane oxygenation, intraaortic bal- this exhibit, in addition to the recommended treatment options for loon pumps, and total artificial hearts are increasing. In addition to rou- each and how these diseases differ from the typical findings of ath- tine procedures, complications secondary to these devices can result erosclerotic disease. in varied pathology requiring intervention. As a result, interventional radiologists should be familiar with MCS and exercise increased cau- CONCLUSION AND/OR TEACHING POINTS: Nonatherosclerotic etiologies tion when treating these patients. of lower extremity arterial disease are important to correctly identify in order for patients to receive appropriate interventions. CLINICAL FINDINGS/PROCEDURE DETAILS: There are many different types of MCS, which cause unique hemodynamic alterations. This exhibit will review extracorporeal membranous oxygenation, intraaor- Abstract No. 935 tic balloon pump, left ventricular assist device, and the total artificial heart. In addition to the conventional uses and alternate implemen- Optimizing your pelvic congestion imaging protocol tations will also be presented e.g., trans septal ECMO cannula used to A Griffith1, E Naatz1, K Quencer1, M Rezvani2, A Kennedy3, C decompress the left ventricle. These devices result in loss of normal Kaufman3 doppler ultrasound findings including flow reversal, lack of waveforms, 1N/A, Salt Lake City, UT, 2University of Utah, Salt Lake City, and changing vascular compliance. These changes can complicate UT, 3University of Utah, Salt Lake City, UT interventional procedures. This exhibit will review the major MCS devices in current use. The indications, approaches, and the expected LEARNING OBJECTIVES: 1. Review the clinical presentation of pelvic hemodynamic change will be examined. Important preprocedural con- congestions syndrome 2. Outline imaging protocols for pelvic conges- siderations, pearls, and pitfalls related to each of the devices will be tions (ultrasound and MRI) 3. Review imaging findings of pelvic venous explored. insufficiency on ultrasound, MRI, CT and venography 4. Discuss associated imaging findings including May-Thurner and Nutcracker CONCLUSION AND/OR TEACHING POINTS: The use and variety of mechanical support devices is rapidly growing. An understanding of Syndrome the expected changes in arterial pulsatility, venous waveforms, flow BACKGROUND: Chronic pelvic pain (CPP) is defined as pelvic pain directions, and hemodynamic shifts can help interventionalists better lasting for greater than 6 months duration. This accounts for approx- plan procedures and avoid potentially catastrophic complications. imately 40% of gynecology visits. CPP can be caused by many different etiologies leading to difficulty in diagnosis. Pelvic congestion syndrome (PCS) is due to venous insufficiency of the gonadal and Abstract No. 934 pelvic veins causing dilated tortuous parametrial veins. Approximately Nonatherosclerotic lower extremity arterial disease 4% to 6% of women with CPP have PCS. The diagnosis of PCS requires both imaging and clinical findings. Once diagnosed treatment can be 1 2 3 J Fleecs , J Buckley , B Wible pursued such as gonadal vein embolization. 1University of Missouri - Kansas City, Kansas City, MO, 2University CLINICAL FINDINGS/PROCEDURE DETAILS: Ultrasound, and MRI are of Missouri Kansas City, Kansas City, MO, 3University of Missouri most often used to aid in the diagnosis of PCS. CT can be informa- Kansas City; Saint Luke’s Hospital of Kansas City, Kansas City, MO tive but is not often the primary imaging modality given the radiation

LEARNING OBJECTIVES: The Learning Objectives of this exhibit are to 1. and young patient population. However, a CT is often done for other Review nonatherosclerotic causes of lower extremity arterial disease. reasons and may be used to aid in the diagnosis of PCS. Ultrasound is 86 | e-Posters SIR 2020 Annual Scientific Meeting

often first line imaging for pelvic pain. The ultrasound imaging protocol anastomotic or in-stent stenosis) and response to therapeutic inter- and findings will be reviewed with image examples. MRI is very useful ventions (e.g., angioplasty or stent placement). for the diagnosis of PCS as well as evaluating other associated findings CONCLUSION AND/OR TEACHING POINTS: Angiographic imaging is such as May-Thurner or Nutcracker. MRI may also reveal other underly- frequently used for guidance and assessment of vascular interven- ing conditions which could account for the patient’s pain such as ade- tions. The newly developed 2D qDSA and 4D-DSA techniques can nomyosis, fibroids, or endometriosis. Optimal MRI imaging protocol make many of these procedures safer and more effective. Addition- and findings will be reviewed with image examples. Finally, venogra- ally, quantitative angiography will facilitate more robust outcomes in phy is the “gold standard” for imaging pelvic venous insufficiency. We research. Ultimately, these techniques may represent a new gold-stan- will review imaging and associated findings on venography. dard in IR practice. CONCLUSION AND/OR TEACHING POINTS: Chronic pelvic pain is a large problem women of reproductive age accounting for almost half of appointments for OB/GYNs. Proper imaging technique is crucial to Abstract No. 937 aid in the diagnosis of pelvic congestion syndrome. Once diagnosed Reducing intravenous iodinated contrast dose in these patients can proceed with treatment options such as gonadal abdominopelvic computed tomography angiography vein embolization. using dual energy: experiences from a quality improvement project Abstract No. 936 L Dalag1, J Fergus2, G Mendez2, P Patel3

1 2 Quantitative angiography: a new era in guiding vascular University of Chicago Medicine, Chicago, IL, University of Chicago, 3 procedures Chicago, IL, N/A, Rolling Meadows, IL G Schefelker1, S Periyasamy2, C Hoffman1, M Speidel1, P Laeseke1 LEARNING OBJECTIVES: 1. Demonstrate the technical feasibility of utilizing reduced intravenous doses of iodinated contrast using dual 1University of Wisconsin Madison, Madison, WI, 2University of energy computed tomography (DE-CT) in providing angiographic and Wisconsin School of Medicine and Public Health, Madison, WI abdominopelvic images of diagnostic quality. 2. Investigate the safety LEARNING OBJECTIVES: •Describe methods for quantifying blood flow and clinical benefit of using reduced contrast dose in DE-CT in patients and velocity on angiography •Demonstrate feasibility and accuracy with renal insufficiency. 3. Compare radiation dose and image noise in of performing quantitative angiography •Describe current and future patients receiving dual energy CT angiography (CTA) compared with clinical applications for quantitative angiography. traditional single energy CTA of the abdomen and pelvis.

BACKGROUND: Angiographic imaging is an important component BACKGROUND: While the reported incidence of contrast-induced of many interventional radiology (IR) clinical procedures including nephropathy (CIN) is less than 3% in patients with normal renal func- embolizations, angioplasties and stent placements. Many of these tion, the incidence rises dramatically up to 40% in patients with chronic procedures aim to increase or decrease perfusion effects in tissue kidney disease (CKD). Recent pioneering phantom and animal studies by regulating blood flow, but are limited by subjective assessment on DE-CT have demonstrated the technical feasibility of remarkably of angiographic changes. Modern equipment, computing power and reducing iodinated contrast dose, up to 50% reduction, without sig- imaging technology allow objective quantification of flow. This quan- nificant increase in radiation dose or image noise. Many patients who titative angiographic approach can be used to standardize procedural receive CTA have preexisting CKD secondary to vascular and medi- endpoints. cal comorbidities. Utilizing DE-CT techniques in CTA imaging has the potential to meaningfully reduce morbidity related to CIN, which is CLINICAL FINDINGS/PROCEDURE DETAILS: Quantitative 2D digital sub- associated with worsened clinical outcomes such as dialysis, long-term traction angiography (qDSA) is a newly developed imaging technique renal insufficiency, and overall mortality. which extracts blood velocities from time-resolved DSA sequences. It uses the time attenuation curves from DSA to perform blood velocim- CLINICAL FINDINGS/PROCEDURE DETAILS: This exhibit will review the etry in the target vasculature. 4D-DSA is a similar technique that allows fundamental physics of DE-CT and discuss the alternative imaging for characterization of arterial blood flow through reconstruction of approaches that have traditionally been considered to address the time attenuation curves from 3D volumetric scans. These quantitative risk of CIN in patients with renal insufficiency. This exhibit will draw angiography techniques have a variety of applications. Intra-proce- from experiences related to our institution’s recent quality improve- dural quantitative angiography is particularly significant for character- ment project on DE-CTA, which entailed a modest reduction of con- izing endpoints in embolizations where subjective assessments have trast dose using dual energy in select patients with comparison single been shown to have poor correlation with tumoral perfusion changes. energy CTA as an initial proof of concept. We will present comparative The ability to calculate the blood flow in near-real time allows the quantitative and pictorial data on aortic attenuation, radiation dose interventional radiologist to objectively assess perfusion, and may (CTDIvol), SNR, and CNR of reduced contrast DE-CTA imaging used in improve the safety and efficacy of the procedure. Quantitative angi- clinical practice in comparison with traditional CTA. ography may also be used for evaluating pathologic flow states (e.g., SIR 2020 Annual Scientific Meeting e-Posters | 87

CONCLUSION AND/OR TEACHING POINTS: Viewers of this exhibit will Abstract No. 939 gain a precise understanding of the essential physics related to DE-CT and its potential role in reducing CIN in patients with preexisting renal Cryoablation of sarcomatous lesions near the ureter: insufficiency. pearls and pitfalls G Landinez1, D Ljuboja2, S Yevich3 Abstract No. 938 1The University of Texas MD Anderson Cancer Center, Houston, TX, 2Harvard Medical School, Boston, MA, 3Department of Bowel displacement in percutaneous ablation: a review Radiology, Division of Vascular & Interventional Radiology, Houston, of current techniques and a new wire displacement TX technique LEARNING OBJECTIVES: To report the use of cryoablation as an adjunc- N Zhang1, S Schmidt1, A Pillai1, D Zhang1 tive technique in the treatment of retroperitoneal sarcomas (RPS) for 1UT Southwestern Medical Center, Dallas, TX locoregional cure. To describe challenges arising from the proximity of retroperitoneal sarcomas to vital structures in the retroperitoneum, LEARNING OBJECTIVES: 1. Overview of existing bowel displacement specifically as it refers to the ureter. To outline techniques available to methods used in percutaneous ablation. 2. Report of a new bowel dis- lessen the morbidity of cryoablation near vital structures. placement method using a wire during a renal tumor ablation case. BACKGROUND: Retroperitoneal sarcomas include a diverse group of BACKGROUND: Percutaneous ablation (radiofrequency, microwave, tumors with controversial treatment algorithms. Complete resection or cryoablation) is a minimally invasive treatment option with high with negative margins remains the gold standard for localized disease. reported technical success rates for solid renal tumors. Although com- Cryoablation represents a promising option in nonresectable sar- plication rates are relatively low, injury to adjacent structures remains comas. Ureteral stricture is a known complication during ablation of a potential adverse event. Inadequate separation between adjacent tumors within 1 cm from the ureter with an incidence rate of up to 25%. organs and the target lesion may lead to premature termination of a Understanding the pearls and pitfalls of RPS cryoablation near import- case. In particular, bowel within 1-3 cm of the target lesion is generally ant structures is important in managing this disease process considered a contraindication and displacement of bowel is standard of care. Current methods of bowel displacement include hydrodissec- CLINICAL FINDINGS/PROCEDURE DETAILS: An important initial tion (hydrodisplacement), gas insufflation, balloon interpolation, and approach to define the boundaries between tumor and surrounding electrode torqueing. This exhibit will provide pictorial and case-based vital structure was meticulous image-guided hydrodissection. Atten- examples of current accepted methods. In addition, we will demon- tion was paid to placing the needle in the most-dependent space, strate a case using a Rosen wire after hydrodissection failed to yield where a hydro-plane could be attained successfully. In most cases, this adequate bowel displacement. proved effective at separating the ureter, and near-by nerves from the targeted lesion. In one case, the ureter was not amenable to mobiliza- CLINICAL FINDINGS/PROCEDURE DETAILS: The patient is a 37-year- tion. To preserve the ureter and avoid the potential for a stricture, we old woman with an enlarging 2.6 cm partially cystic right renal tumor decided to place a wire within the involved ureter. This was done per- referred to interventional radiology for radiofrequency ablation. Pre- cutaneously, in an antegrade fashion and under fluoroscopic guidance procedural CT imaging demonstrated colon within 2 cm of the target. to aid visualization of the ureter. Additionally, percutaneous placement Hydrodissection was attempted with 1000 cc of D5W instilled into of a nephroureteral stent within the involved ureter was used as a pre- the perinephric tissue. CT images demonstrated very little change in ventative adjunctive technique, in case ureteral stenosis ensued. position of the bowel in question. A Rosen wire was then percutaneously placed along the track. CT images showed the colon had been CONCLUSION AND/OR TEACHING POINTS: Cryoablation allows for mon- displaced to >3 cm away. An angioplasty balloon was then inflated in itoring of the ice margins with relationship to surrounding vital struc- this location to ensure a firm barrier between the bowel and lesion, as tures, making it an attractive candidate for nonsurgical treatment. In wire displacement alone is not currently an accepted method of bowel cases where nearby structures surround or involve the tumor, hydrodisplacement. The ablation was successful. No adverse outcomes were dissection should be considered as a means to mobilize adjacent reported. organs. Additionally, wire placement within the ureter and prophylactic nephroureteral placement are useful adjunctive techniques. CONCLUSION AND/OR TEACHING POINTS: Several safe techniques for displacement of critical nonrenal structures during percutaneous ablation of renal tumors exist. In addition to the established bowel displacement techniques, we demonstrated a novel technique using a stiff wire placed percutaneously to manipulate the colon and achieve adequate displacement. 88 | e-Posters SIR 2020 Annual Scientific Meeting

Abstract No. 940 LEARNING OBJECTIVES: This educational exhibit aims to review the relevant anatomy and imaging findings related to the Sciatic nerve. Ice ice, maybe?! Percutaneous image-guided cryoablation Different clinical case presentations will be provided. Technical consid- indications, approaches, and outcomes: a 2020 update erations such as sedation method will also be provided. After reading M Le1, I Siddiqui2, L Tsikitas1, M Tembelis3, J Hoffmann4 this education exhibit, the reader will have increased knowledge and comfort about cryoablation near the sciatic nerve. 1NYU Winthrop Hospital, Mineola, NY, 2N/A, Mineola, NY, 3N/A, Stony Brook, NY, 4NYU Winthrop Hospital, Garden City, NY BACKGROUND: The anatomy of the sciatic nerve will be discussed. Since the sciatic nerve has such a large distribution of motor and sensory LEARNING OBJECTIVES: 1. Review the indications, preprocedure it is an extremely important structure to consider when performing work-up, procedural techniques, adjunctive techniques, and postpro- cryoablation. Although nerve injury is relatively rare with cryoablation, cedural management (including complications) of image-guided per- in this scenario if injured it can have devastating consequences. Gener- cutaneous cryoablation. 2. Highlight scenarios in which cryoablation ally, nerve injury occurs at temperatures below 10°C. would be particularly advantageous or disadvantageous when compared to other types of ablation. 3. Detail the use of cryoablation as a CLINICAL FINDINGS/PROCEDURE DETAILS: Consideration for this proce- primary cancer treatment modality as well as a palliative care option. dure must be performed in the context of a multidisciplinary team. Dis- 4. Share practice-building recommendations. cussion with the medical oncologist, surgeon, and radiation oncologist should be had prior to performing the procedure. For this exhibit, mul- BACKGROUND: Image-guided cryoablation can be used to treat a tiple cases of tumors near the sciatic nerve will be shown. Treatment variety of tumors, both for curative intent and/or palliation of pain. of tumors utilizing U/S, CT and MRI guidance will be shown. Technical Given that an array of tumor types and locations can be treated and considerations such as general anesthesia with EMG monitoring ver- that multiple ablative options exist, it is important for interventional sus moderate sedation with active patient response will be discussed. radiologists to have an in-depth understanding of the strengths and Technical challenges and considerations will also be discussed for each weaknesses of ablative technologies. Further, a working knowledge of the cases along with review of the current relevant literature. of adjunctive techniques will help to maximize procedural success. Understanding relevant data and how to incorporate this into practice CONCLUSION AND/OR TEACHING POINTS: Tumors near a major nerve building strategies will help interventional radiologists to implement such as the sciatic nerve can cause distress for even the most expe- cryoablation into their clinical practice. rienced interventional radiologists. After reading this educational exhibit, we hope that the reader will be more comfortable perform- CLINICAL FINDINGS/PROCEDURE DETAILS: Cryoablation review/intro- ing a minimally invasive curative treatment for patients who have duction: • Physics • Pathophysiology • Types of probes • Compare exhausted all other options. devices currently on the market, including relevant literature review. Advantages/disadvantages of cryoablation in various organs and tumor locations. Percutaneous cryoablation steps: • Involvement in Abstract No. 942 tumor board • Clinic visit • Determining the best procedural approach • Adjunctive techniques (hydrodissection, carbodissection, balloon Intraprocedural confirmation of tumor ablation using angioplasty interposition, preablation embolization, etc.) • Post proce- contrast-enhanced ultrasound dure clinic and imaging follow-up • Detailed review of organ-specific A Salei1, B McCafferty2, B Snead3, V Daruwalla4, R Varma5, M approaches, protocols, and outcomes, including kidney, lung, liver, soft Robbin6, A Gunn7 tissue tumors, prostate, and nerve. Keys to developing a successful 1UAB Hospital, Birmingham, AL, 2N/A, Birmingham, AL, 3N/A, program: • Tumor board presence • Outreach • Awareness of misper- Homewood, AL, 4DMC/Wayne State University, Detroit, ceptions about ablation • Highlight outcomes • Follow-up • Future MI, 5University of Alabama at Birmingham, Vestavia Hills, needs/directions. AL, 6University of Alabama at Birmingham, Birmingham, 7 CONCLUSION AND/OR TEACHING POINTS: An understanding of the indi- AL, University of Alabama At Birmingham, Birmingham, AL cations, approaches, and outcomes of image-guided percutaneous LEARNING OBJECTIVES: 1. Intra-procedural assessment of tumor abla- cryoablation in a variety of tumor types and locations is integral to tion could improve technical and oncologic outcomes. 2. Contrast-en- successful implementation and practice building. hanced US (CEUS) is sensitive for the detection of liver and kidney tumors, can be performed rapidly, and lacks the potential renal toxicity Abstract No. 941 of iodinated contrast. 3. CEUS can be a powerful tool in guiding percutaneous renal and liver ablations that has the ability to detect residual Image-guided cryoablation of pelvic tumors near the disease intraprocedurally, thereby leading to a more complete ablation sciatic nerve BACKGROUND: Percutaneous ablation of primary liver and kidney O Zuberi1, B Key2, S Yevich3 cancers has similar outcomes to traditional surgery in appropriately 1MD Anderson, Houston, TX, 2Medical College of Wisconsin, selected patients. Adequate coverage of the tumor with margins Milwaukee, WI, 3University of Texas, Houston, TX is crucial for clinical success but is often first assessed on follow-up imaging. Many methods can be used to assess the ablation zone SIR 2020 Annual Scientific Meeting e-Posters | 89

intraprocedurally. For this purpose, CEUS is rapid, noninvasive, sen- a 1 cm pseudoaneurysm adjacent to the biliary drain in the peripheral sitive, and non-nephrotoxic. Yet, CEUS is unfamiliar to many interven- right hepatic lobe. Angiography demonstrated chronic occlusion of tional radiologists. Therefore, the purpose of this exhibit is to highlight the right hepatic artery and intrahepatic collaterals supplying the right the ability of CEUS to be used intraprocedurally to evaluate the abla- IHAP. Transarterial and percutaneous embolization attempts were tion zone. unsuccessful. Surgery consultation deemed him a poor candidate for right hepatectomy. MWA was subsequently performed with two CLINICAL FINDINGS/PROCEDURE DETAILS: 1. Overview of imaging guid- Neuwave PR 15 XT microwave antennae bracketing the IHAP for a 10 ance during ablation, including advantages and drawbacks of both CT minute cycle at 65 Watts. CTA 14 days after MWA showed successful and US. 2. Description of the physics and physiology underlying CEUS, ablation of the IHAP. He has not experienced further bleeding to date including current clinical uses. 3. Review the imaging appearance of with 8 weeks’ follow-up and completed a 6 week course of antibiotics. renal cell carcinoma and its primary differential diagnoses on CT, MRI, US and CEUS. 4. Review the imaging appearance of hepatocellular CONCLUSION AND/OR TEACHING POINTS: MWA is a feasible treatment carcinoma and its primary differential diagnoses on CT, MRI, US and option in patients with IHAP that are not amenable to transarterial or CEUS. 5. Literature review of using CEUS during image-guided abla- percutaneous embolization. tions to detect residual tumor intraprocedurally. 6. Pictorial review from our institution of using CEUS during renal and liver ablations to guide treatment and detect residual tumor intraprocedurally, including Abstract No. 944 tips and tricks for image optimization. Percutaneous image-guided ablation of pulmonary CONCLUSION AND/OR TEACHING POINTS: CEUS is effective at identi- malignancies: indications, techniques, follow-up imaging, fying residual liver and kidney tumors during image-guided ablations and future directions which can improve clinical outcomes A Sill1, D Alzate2, K Zurcher1, S Naidu3, S Alzubaidi3, G Knuttinen3, R Oklu3 Abstract No. 943 1Mayo Clinic Arizona, Phoenix, AZ, 2University of Arizona College of Medicine Phoenix, Del Mar, CA, 3Mayo Clinic, Phoenix, AZ Microwave ablation for treatment of an intrahepatic artery pseudoaneurysm LEARNING OBJECTIVES: Discuss indications and contraindications for percutaneous lung tumor ablation. Compare ablation techniques. 1 1 1 1 1 K Kinsman , B Welch , T Atwell , N Neidert , C Fleming , C Describe expected post-ablation imaging findings. Discuss trends in 1 Reisenauer lung tumor ablation utilization and technology. Case illustrations will 1Mayo Clinic, Rochester, MN be used to highlight the objectives.

LEARNING OBJECTIVES: This exhibit will review a case utilizing micro- BACKGROUND: Percutaneous image-guided ablation has proven effi- wave ablation (MWA) to achieve hemostasis for an intrahepatic arterial cacious and safe in the treatment of primary and secondary pulmonary pseudoaneurysm (IHAP) with limited conventional treatment options. malignancies, but the exact role of this treatment modality remains The exhibit will also review the literature regarding thermal ablation for ill-defined. Surgical resection is the primary treatment of choice for controlling hemorrhage. patients with resectable disease; however, only 20% of patients meet criteria for surgical resection at the time of diagnosis. Percutaneous BACKGROUND: IHAP is a rare but serious complication most commonly ablation has emerged as an important treatment option for patients related to iatrogenic trauma. The first line treatment option is transar- with other solid organ malignancies but has not gained widespread terial embolization with a clinical success rate of approximately 88%1. adoption for treatment of pulmonary malignancies. MWA is a novel treatment alternative that can provide hemostasis in a less selective manner. There are few case reports describing MWA to CLINICAL FINDINGS/PROCEDURE DETAILS: Indications include curative achieve hemostasis. One case series showed successful MWA in 7 post or palliative ablation of medically inoperable primary or metastatic pul- biopsy hemorrhage cases, 2 cases were hepatic hemorrhage2. MWA monary tumors, preferably in a peripheral location. The most common was successful in the treatment of 3 cases of intraoperative hepatic technique is cryoablation, followed by radiofrequency ablation (RFA) tumor hemorrhage3. We could not find any case reports detailing the and microwave ablation (MWA). A triple-freeze cryoablation protocol use of MWA for IHAP. is used, which differs from the double-freeze protocol used in the liver and kidney. Imaging guidance is most commonly performed with CT, CLINICAL FINDINGS/PROCEDURE DETAILS: The case at our institution but ultrasound can be considered in certain juxtapleural tumors. Up involved a 55-year-old man, whom required a roux-en-y hepaticoje- to one week post-ablation, CT may show intralesional bubbles and junostomy in 2016 after iatrogenic injury to the right hepatic artery ground-glass opacities (GGO) encompassing the lesion, represent- and biliary tree during a cholecystectomy. He developed a stricture ing the ablation zone. For six months, CT should reveal progressively at the hepaticojejunostomy managed with a percutaneous biliary decreasing size of the ablation zone with an unchanged or smaller drain placed in 2016. After accidental retraction of the drain in 2019, non-enhancing primary tumor. PET-CT at 3-6 months post-ablation he developed recurrent intermittent bleeding through and around can evaluate for any metabolic activity to suggest recurrence. Despite the drain. Computed tomography angiography (CTA) demonstrated being cost efficient and providing promising results (e.g., 80-90% 90 | e-Posters SIR 2020 Annual Scientific Meeting of RFA procedures achieving complete ablation), there has been no Abstract No. 946 increase in ablation procedures since 2012, per CMS data. Protective adjunctive maneuvers in thermal ablation: a CONCLUSION AND/OR TEACHING POINTS: Percutaneous lung tumor visual how-to guide ablation is an effective, cost-efficient therapy that should be a component in the multimodal treatment of patients with medically inoperable J Huang1, A Thabet1, K Yamada1, R Arellano1, P Mueller1, R Uppot1 primary or metastatic pulmonary malignancies. 1Massachusetts General Hospital, Boston, MA

LEARNING OBJECTIVES: The Learning Objectives of this abstract are Abstract No. 945 to review various percutaneous protective maneuvers used to reduce nontarget ablation such as hydrodissection, pneumodissection, artifi- Please cook in safety: protective techniques to overcome cial ascites, balloon interposition and go in depth on how we perform challenges of treating renal lesions with thermal ablation these maneuvers including planning, technique, and equipment. The N Pigg1, Y Yang2, B Baigorri3, R Fourzali4 aim is that the reader will be able to reference this presentation and perform these maneuvers on their own. 1Aventura Hospital & Medical Center, Aventura, FL, 2N/A, North Miami Beach, FL, 3N/A, Coconut Grove, FL, 4N/A, Miami, FL BACKGROUND: Thermal ablation techniques are considered an effective locoregional therapy for hepatocellular carcinoma and renal cell LEARNING OBJECTIVES: 1. To identify indications for renal thermal abla- carcinoma with greater than 90% technical success rates and com- tion: key clinical and anatomical patient selection criteria 2. To discuss plication rates lower than 11%. The most frequently used ablative preprocedure planning considerations 3. To highlight protective ther- techniques here are microwave ablation and cryoablation. However, mal ablation barrier techniques for renal lesion localization: landmarks, thermal injuries to adjacent structures can be severe and care should contrast, hydrodissection, gas insufflation, balloon interposition, and be made to prevent nontarget tissue injury. There exists a multitude pyeloperfusion. of percutaneous protective techniques with the most extensively

BACKGROUND: Thermal ablation has been employed in the treatment techniques utilized here being hydrodissection, pneumodissection, of renal lesions since the 1990s. It is based on the idea of employing and balloon interposition. Hydrodissection is a technique often used thermal energy in the form of radiofrequency ablation, microwave to separate anatomic structures for the purpose of safely performing ablation and cryoablation in order to kill tumor cells and cause necro- image-guided procedures. Techniques include installation of fluid or sis. However, the technique is not without risks and side effects such CO2 into various fascial planes to incite separation of tissues allowing as damage to nearby organs and muscular structures, such as the for access to deeper structures or to prevent damage to adjacent crit- renal collecting system, ureters, and even the diaphragm. To prevent ical organs during ablation. neighboring tissue damage, there are several preventive techniques CLINICAL FINDINGS/PROCEDURE DETAILS: 1. Hydrodissection/artificial that have been employed. Some of these include hydrodissection, gas ascites. 2. Pneumodissection. 3. Balloon interposition. 4. Gelfoam. 5. insufflation, balloon interposition, and pyeloperfusion. By employing Torque. these techniques the targeted lesions can be treated, while minimizing risk of harming normal functional tissue. CONCLUSION AND/OR TEACHING POINTS: Prevention of iatrogenic thermal injuries is of paramount importance and this can be achieved CLINICAL FINDINGS/PROCEDURE DETAILS: This educational poster will through protective techniques. There are many ways to perform these use four thermal ablation cases to illustrate the interventional radiol- techniques as well as many others not mentioned in this guide. We ogy (IR) approach to assessing when a renal cell carcinoma lesion is hope that the information provided within this exhibit will allow indi- suitable for IR treatment. A general overview of patient presentation, viduals and practices with little or no experience to perform these pro- key clinical history, and initial relevant lab and imaging results will be cedures with guidance cultivated through thousands of cases. discussed. Then, the presentation will focus on CT images to highlight lesion characterization, protective techniques, ablation options, as well as postprocedural follow-up. Abstract No. 947

CONCLUSION AND/OR TEACHING POINTS: Ablation is becoming more Renal nephrometry scoring for patient selection prior to widely used and is providing beneficial results for patients without the percutaneous ablation of renal cell carcinoma complications that can come with surgery, including significantly less blood loss, a shorter duration of surgery, fewer postoperative com- V Macha1, A Salei2, B McCafferty3, B Snead4, V Daruwalla5, R plications and shorter hospital stay. There are multiple ablation tech- Varma6, A Gunn7, H El Khudari3 niques available and each have similar rates of successful treatment, 1UAB School of Medicine, Birmingham, AL, 2UAB Hospital, recurrence, and complications. As we move forward with further use Birmingham, AL, 3N/A, Birmingham, AL, 4N/A, Homewood, of thermal ablation for the treatment of renal lesions protective tech- AL, 5Dmc/Wayne State University, Detroit, MI, 6University of niques can help optimize lesion targeting and reduce complications. Alabama at Birmingham, Vestavia Hills, AL, 7University of Alabama At Birmingham, Birmingham, AL SIR 2020 Annual Scientific Meeting e-Posters | 91

LEARNING OBJECTIVES: 1. Renal nephrometry scoring was originally CLINICAL FINDINGS/PROCEDURE DETAILS: Optimal candidates will developed to aid in patient selection prior to partial nephrectomy. 2. have lesions < 5 cm. Thermal ablation has been the most widely stud- Interventional radiologists have attempted to use existing nephrom- ied. The risk of hypertensive crisis during adrenal ablation is not limited etry scoring systems to evaluate patients prior to image-guided abla- to pheochromocytoma, therefore premedication with an α-adren- tion of renal cell carcinoma. 3. Ablation-specific nephrometry scores ergic inhibitor is recommended as it has been shown to significantly have been developed but are not yet widely validated. decrease intraprocedural systolic blood pressure. Additional procedural considerations include having an anesthesiologist with experi- BACKGROUND: Percutaneous ablation of small renal cancers has similar ence in managing catecholamine-induced complications, establishing technical and oncologic outcomes as partial nephrectomy with fewer an arterial line, and alerting the anesthesiologist prior to manipulation complications. Patient selection and recognition of potential hazards of the probe or applying thermal energy. Postprocedural management are critical to the safety profile of percutaneous renal tumor ablation. of medications can be complex, requires multidisciplinary cooperation, To assist in this arena, interventional radiologists have attempted to and varies by the type of adrenal mass being ablated. The outcomes use existing renal nephrometry scores, such R.E.N.A.L and PADUA, in for ablation of functional adenomas have yielded promising results and order to risk stratify patients. However, these existing scores are nei- have even shown to be noninferior to laparoscopic adrenalectomy for ther widely employed amongst interventional radiologists nor consis- aldosteronomas. Furthermore, the ablation group had shorter opera- tently correlated with outcomes in renal tumor ablation. Due to this, tions with less blood loss, less postprocedural pain, and shorter hospi- ablation-specific scores, including ABLATE, M(C)2, and P-RAC, have tal stays. The outcomes for pheochromocytoma and ACC are limited, been developed. The purpose of this exhibit is to review and compare thus adrenal ablation should be limited to patients who are not surgical these scoring systems. candidates or refuse surgery. CLINICAL FINDINGS/PROCEDURE DETAILS: 1. Overview of epidemi- CONCLUSION AND/OR TEACHING POINTS: Management of adrenal ology and treatment guidelines for renal cell carcinoma 2. Detail the lesions with percutaneous ablation can be challenging. Emerging data R.E.N.A.L nephrometry score, including how to calculate and its valid- highlights the importance of procedural preparation and patient selec- ity in percutaneous renal ablation 3. Detail the PADUA score, including tion. Additionally, adrenal ablation is comparable or better than sur- how to calculate and its validity in percutaneous renal ablation 4. Detail gery in select patients. the ABLATE algorithm, including a description of its individual components and its recommendations 5. Detail the M(C)2 score, including its calculation and validity in percutaneous renal ablation 6. Detail Abstract No. 949 the P-RAC score, including its calculation and validity in percutaneous renal ablation Thermal ablation in the treatment approach for treatment of oligometastatic non–small cell lung cancer CONCLUSION AND/OR TEACHING POINTS: Familiarity with the advantages and disadvantages of the various renal nephrometry scoring M Dendy Case1, J Uhlig2, S Gettinger3, J Blasberg3, D Boffa3, K systems aids the interventional radiologist in patient selection prior to Kim3 percutaneous renal ablation. 106492, Wallingford, CT, 2University Medical Center Goettingen, Goettingen, Germany, 3Yale School of Medicine, New Haven, CT

Abstract No. 948 LEARNING OBJECTIVES: To outline the treatment strategy for patients with oligometastatic NSCLC, with specific focus on local therapies Technical considerations of adrenal ablation including thermal ablation, surgery, and SBRT. B Manchec1, Y Koethe2, C Pena3, B Schiro3, R Gandhi3 BACKGROUND: Most patients diagnosed with non–small cell lung can- 1Advent Health, Orlando, FL, 2Miami Cardiac and Vascular Institute, cer (NSCLC) present with advanced disease. To date, multidisciplinary Miami, FL, 3Miami Cardiac & Vascular Institute, Miami Cancer treatment strategy utilization of local thermal ablation in Stage 3 and Institute, Miami, FL 4 oligometastatic NSCLC patients need further investigations. This study aims to review the treatment strategies for stage 3 and 4 oli- LEARNING OBJECTIVES: This poster will review the indications and gometastatic NSCLC, with specific emphasis on utilization, integration contraindications for percutaneous adrenal ablation, procedural plan- and sequence of local thermal ablations. ning, technical considerations, postprocedural care, and expected outcomes. CLINICAL FINDINGS/PROCEDURE DETAILS: A brief overview of the established standard of care in this patient population will be dis- BACKGROUND: Most adrenal lesions can be diagnosed with clinical his- cussed. A review and meta-analysis of the published data on the tory, biochemical evaluation, and diagnostic imaging. Current guide- available systemic chemotherapies, radiation therapies, surgical man- lines recommend surgical removal of several adrenal lesions, including agement, immunotherapies and localized interventional oncology pheochromocytomas, adrenocortical carcinomas (ACC), unilateral treatments will be presented with emphasis placed on interventional functional adenomas, and nonfunctional adenomas ≥ 4 cm. As more oncology treatments. Research supporting the multidisciplinary inte- studies are published on adrenal ablations, procedural details have gration and sequencing of thermal ablation treatments in this patient been refined. population will be outlined. This study will provide an overview of the 92 | e-Posters SIR 2020 Annual Scientific Meeting

opportunities for treating advanced stage NSCLC patients with local of ablation techniques and their role as an alternative to surgery are thermal ablation therapies (including radiofrequency ablation, micro- critical for the interventional approach to thyroid nodules. wave ablation, cryoablation) in the setting of oligoprogression and oli- gometastasis. The study will outline the optimal sequencing of local treatments, in relation to other treatment modalities. Abstract No. 951

CONCLUSION AND/OR TEACHING POINTS: Defining and understanding Transchondral access for irreversible electroporation of roles and sequencing of local thermal ablation in patients with stage 3 hepatocellular carcinoma: case report and 4 oligometastatic NSCLC patients could greatly enhance patient M Elboraey1, Z Devcic2, B Toskich3 outcomes. This meta-analysis will outline the most optimal treatment 1 2 paradigm and how it relates to interventional ablation techniques for Mayo Clinic - Florida, Jacksonville, FL, Mayo Clinic, Jacksonville, 3 treating patients with oligometastatic NSCLC. FL, N/A, Jacksonville, FL

Stage IV NSCLC- Approach in Treating Oligometastatic Disease LEARNING OBJECTIVES: 1. To understand the limitations of irreversible 1. Classified as Oligometastatic Disease Burden electroporation (IRE) as an ablative modality for hepatocellular car-

2. All Sites Treatable With Definitive Local Therapy cinoma (HCC). 2. Review the suggested technique to overcome the limitations of IRE. 3. Mediastinal Staging

N0, N1 N2, N3 BACKGROUND: According to the Barcelona Clinic Liver Cancer (BCLC) Local Therapy with Surgery, SBRT or Thermal Lesion Specific Cytoreduction with Surgery, staging system, stage (0) and stage (A) of HCC are eligible for cura- Ablation +/- Chemotherapy SBRT or Thermal Ablation + Chemotherapy tive treatments such as thermal ablation. Close proximity to challenging sites such as bile ducts and the hepatic hilum can be an anatomic Abstract No. 950 limitation for some ablative modalities. IRE is a nonthermal ablation modality that has been shown to preserve the extracellular matrix and Thyroid nodules: ablation techniques is theoretically less likely to damage critical structures such as bile ducts. IRE probes must be placed in parallel, which can limit its use I Altun1, T Parnall2, M Kuo2, V Mehta2, J Kriegshauser2, S Alzubaidi2, and substantially increase procedure time. In this exhibit, we describe S Naidu2, M Knuttinen2, I Patel2, H Albadawi2, R Oklu2 the use of bone biopsy sheaths “Bonopty kit” for transchondral access 1 2 Mayo Clinic, Phoenix, AZ, Mayo Clinic Arizona, Phoenix, AZ to facilitate placement of parallel probes in challenging situations.

LEARNING OBJECTIVES: 1. Review treatment options for thyroid nod- CLINICAL FINDINGS/PROCEDURE DETAILS: A 79-year-old patient, with ules 2. Define the mechanism, efficacy, side effects, and advantages of a prior history of prior radiation segmentectomy for HCC 2 years ago, thyroid nodule ablation techniques in interventional radiology 3. Dis- presents with a new 1.5 cm lesion which involved the main right bile cuss future aspects of thyroid nodule ablation and advanced image- duct bifurcation. Angiography demonstrated an inadequate micro- guided modalities. vascular conduit, watershed arterial supply, and nontarget preferen- tial flow which precluded ablative radioembolization. The lesion was BACKGROUND: Thyroid nodules are common tumors that can be easily treated with percutaneous ethanol injection (PEI), but it was refrac- detected on ultrasound. Though most thyroid nodules are benign and tory. The lesion was subsequently embolized with lipiodol to improve do not require treatment, those that are concerning for malignancy visibility for IRE. A safe window was identified that would not trans- or become symptomatic due to compression of the airway, must be gress adjacent ducts, the portal vein, or hepatic artery form a ventral addressed. The standard for the management of thyroid nodules is approach. An initial attempt at probe placement was unsuccessful due surgical excision or thyroid lobectomy. Although thyroid surgery is a to the costal cartilage impeding parallel placement. A plane was cho- well-established procedure, it requires general anesthesia and carries sen where two probes were placed in between cartilage and two were risk of damage to the parathyroid glands, injury to the recurrent laryn- placed through it using the bone biopsy sheaths “Bonopty kit.” IRE geal nerve, and potential airway compromise due to postoperative was performed without any complications. Liver MRI at three months bleeding. For patients are not surgical candidates, minimally invasive demonstrated mRECIST of complete response and no damage to bile ablation has emerged as a safe and effective alternative option. ducts. In the exhibit, we will show the procedural images from this case. CLINICAL FINDINGS/PROCEDURE DETAILS: Radiofrequency, micro- CONCLUSION AND/OR TEACHING POINTS: The Bonopty kit can be uti- wave, laser ablation, and high intensity focused ultrasound (HIFU) are lized to drill through bone/cartilage and permit placement of parallel image-guided thermal ablation techniques available for thyroid nod- probes for ablation. ules. In this report we will present the procedure description, indication, efficacy, side effects, and pitfalls of each procedure. In addition, we will discuss advanced image-guided modalities, such as contrast-enhanced ultrasound and virtual navigation with fusion imaging.

CONCLUSION AND/OR TEACHING POINTS: Image-guided minimally invasive ablation techniques offer safe and effective alternative treatment options for benign thyroid nodules. Understanding the advancements SIR 2020 Annual Scientific Meeting e-Posters | 93

Abstract No. 952 – Ultrasound-guided PTHC and cholecystostomy using contrast. 5. Therapeutic – Postsurgical drain placement for fluid collection. 6. Current methods of liver biopsy: a pictorial review Therapeutic - Sinograms during and after catheter placement to better A Patel1, S Kim2, A Shetty3 characterize fluid collection, relation to surrounding structure, catheter location and response to therapy. 1University of Rochester, Rochester, NY, 2University of Rochester- Strong Memorial Hospital, Rochester, NY, 3University of Rochester BACKGROUND: With increasing dependence on advanced cross-sec- School of Medicine, Rochester, NY tional imaging, contrast-enhanced ultrasound (CEUS) has yet to catch on despite its recent approval by the FDA. CEUS has a plethora of LEARNING OBJECTIVES: 1. Review the current indications, methods, applications including its ability to aid in characterizing lesions by eval- risks, and benefits of the various methods of liver biopsies including uation of their dynamic enhancement pattern, improve tissue biopsy percutaneous ultrasound-guided liver biopsies, fluoroscopic guided by increasing lesion detectability, and help guide targeting the viable liver biopsies, transjugular liver biopsies and percutaneous CT-guided tissue in heterogeneous lesions. Emerging applications including cho- liver biopsies. 2. Discuss the important considerations with each lecystostomy, percutaneous transhepatic cholangiogram (PTHC) and method including indications, preprocedure, periprocedure, and post- management of post hepatobiliary surgical complications like biliary procedure patient management. leaks and fluid collection are also available. The aim of the exhibit is to

BACKGROUND: The liver is one of the most commonly biopsied organs. discuss CEUS and its role in diagnostic and therapeutic applications in Biopsy plays a crucial role in the management of a myriad of diseases hepatobiliary work with focus on its more novel applications. ranging from cirrhosis, hepatic steatosis, hepatocellular carcinoma, CLINICAL FINDINGS/PROCEDURE DETAILS: A review of our institution’s metastatic disease, transplant rejection, and so on. There are multiple use of CEUS will be provided. A pictorial demonstration with numerous different techniques that can be employed to obtain biopsy samples. cases demonstrating CEUS ability to provide the dynamic enhance- Being comfortable with these different methods can be a helpful tool ment pattern of lesions, improve lesion detectability, perform PTHC, in the repertoire of the interventional radiologist. and help assess for post ablation complications will be provided.

CLINICAL FINDINGS/PROCEDURE DETAILS: There are several com- CONCLUSION AND/OR TEACHING POINTS: CEUS is a powerful imag- monly used techniques that can be employed for liver biopsies. These ing modality, which in the appropriate setting, has many diagnostic methods include transjugular liver biopsies, percutaneous ultra- and therapeutic applications in hepatobiliary work including char- sound-guided liver biopsies, percutaneous fluoroscopic guided liver acterizing, targeting, and treating focal lesions. In addition, its lower biopsies and CT-guided percutaneous liver biopsies. These methods cost, availability, portable access, and lack of ionizing radiation make offer different approaches to tackle a similar problem; moreover, they it a favorable option in evaluation and treatment postoperative fluid each pose different risks and benefits This educational exhibit will collections. highlight the equipment, procedural steps, benefits and risks/pitfalls of commonly used biopsy methods. We will also explore key considerations in patient and method selection, as well as preprocedure, Abstract No. 954 periprocedure, and postprocedure considerations. Lung biopsy success rates: tips and tricks CONCLUSION AND/OR TEACHING POINTS: Liver biopsies are a commonplace procedure performed in interventional radiology departments H Bindner1, S Haque1, T Ozga2 across the country. Understanding the different approaches to liver 1Loyola University Medical Center, Maywood, IL, 2Loyola-Gottlieb biopsies are critical to the interventional radiologist, as each method Memorial Hospital, Melrose Park, IL offers different avenues in tackling the same clinical problem. LEARNING OBJECTIVES: Computed tomography guided percutaneous lung biopsy is the gold standard for evaluation of suspicious pulmonary Abstract No. 953 nodules. However, the use of this technique is not always successful in obtaining an adequate sample for analysis and can result in complica- Diagnostic and therapeutic application of contrast- tions, with pneumothorax the most common complication reported. enhanced ultrasound in management of hepatobiliary As precision medicine evolves, better biopsy techniques can result in pathologies, an update higher success rates with low number of complications. A comprehen- H Rajeswaran1, A Rahnemai-Azar2, A Hashmi3, N Azar4 sive review with pictorials of lung biopsy techniques, advantages and limitations will be presented. 1Case Western, Cleveland, OH, 2University hospitals, Case Western Reserve University, Cleveland, OH, 3N/A, Perrysburg, BACKGROUND: CT-guided percutaneous methods were first used to OH, 4University Hospitals Case Medical Center, Cleveland, OH obtain lung biopsy samples decades ago. However, advances in cancer treatment such as new genomic focused therapy, have broadened LEARNING OBJECTIVES: 1. Review indication for application of con- the need for adequate core lung biopsy samples obtained through CT trast agents 2. Diagnostic - image-guided tissue sampling: improve guidance. Therefore, it is critical that there are methods developed detectability, lesion selection and targeting viable tissue in heteroge- which allow for both sample adequacy and have few complications. nous lesions. 3. Therapeutic – ablation of liver lesions. 4. Therapeutic 94 | e-Posters SIR 2020 Annual Scientific Meeting

CLINICAL FINDINGS/PROCEDURE DETAILS: Lung biopsies are a routine hemodynamic monitoring. If bleeding after solid organ biopsy does procedure at Loyola-Gottlieb with over 130 core biopsies performed develop, management strategies include supportive care with resus- over the last three years. In comparison to reported complication rates, citation and transfusion. Any coagulopathy should be immediately biopsies performed at Loyola-Gottlieb have a low complication rate corrected. Angiography can be performed to evaluate the source of which require subsequent intervention (<6%) and have a relatively high bleeding and embolize the culprit vessel. Cases of acute and delayed adequate biopsy sample rate (>95%). To obtain these high sample ade- bleeding complications from percutaneous biopsy of liver, spleen, kid- quacy and low complication rates, a stringent standardized approach ney, lung, mesenteric mass, and pelvic mass are discussed. is employed which emphasizes a few core principles. These principles CONCLUSION AND/OR TEACHING POINTS: Major bleeding complications include the judicious use of preprocedure CT imaging to plan the best from percutaneous biopsy can have catastrophic outcomes. Interven- biopsy approach and the use of preprocedure PET imaging to ensure tionalists performing biopsy should be aware of new guidelines in placement of the biopsy needle within an area of active tumor. At the preprocedural screening, periprocedural planning and technique to time of the procedure, several methods are regularly employed to minimize bleeding risk. If bleeding o [Editor’s note: unfinished sen- minimize unneeded lung injury. These methods include administering tence as submitted] sedation prior to obtaining a scout image to reduce respiratory motion, and always entering the pleura at 90 degrees to reduce the effect of sheer. A Biosentry plug is routinely placed following the obtainment Abstract No. 956 of the biopsy sample to reduce the complications of hemorrhage and pneumothorax. Protractor-assistance to reduce readjustment, time, and radiation dose in cross-sectional procedures: a pictorial CONCLUSION AND/OR TEACHING POINTS: Complications of lung biopsy review and description of technique can be minimized with standardization of lung biopsy techniques. J Jia1, E Nguyen2, A Ravilla3, J Sakioka4, M Taon5, E Rosenthal6, D Rex7, M Gulati8, I Lekht9 Abstract No. 955 1Kaiser Permanente, Los angeles, CA, 2Kaiser Permanente- Los 3 Major bleeding after percutaneous solid organ biopsy: Angeles Medical Center, Los Angeles, CA, Kaiser Permanente Los Angeles, Los Angeles, CA, 4Kaiser Permanente, Los Angeles, prevention and management CA, 5Kaiser Permanente Los Angeles, Glendale, CA, 6N/A, Los M Adam1, A Ushinsky1, S Kim1 Angeles, CA, 7Kaiser Permanente Medical Center, Los Angeles, 8 9 1Mallinckrodt Institute of Radiology, Washington University School CA, Keck School of Medicine, Los Angeles, CA, N/A, Calabasas, CA of Medicine, St. Louis, MO LEARNING OBJECTIVES: 1) To review the technique of protractor-as-

LEARNING OBJECTIVES: 1. Present select cases of bleeding as a com- sisted needle placement for CT-guided procedures 2) To provide plication of percutaneous biopsy related bleeding. 2. Discuss appro- didactic examples including its use in lung biopsies, ablation probe priate management and potential interventions to control iatrogenic placement, and sacroiliac joint injections hemorrhage. 3. Identify risk factors and approaches to prevention of BACKGROUND: There is widespread use of CT-guidance for numerous postprocedural bleeding. interventional procedures. Most commonly, these procedures are per-

BACKGROUND: Major bleeding, defined as requiring transfusion or formed in a trial and error fashion with repeated CT scans performed other intervention, is a risk of percutaneous solid organ biopsy. The to adjust a needle to desired position. We suggest a method using pro- rate of major bleeding ranges from 0.1 to 6.6 % depending on the organ tractor-assistance for precise initial needle placement to minimize the biopsied. Splenic biopsy has been shown to have the highest rate of number of readjustments, procedure time, and radiation dose. major bleeding, up to 8.3 %. A variety of interventions are available to CLINICAL FINDINGS/PROCEDURE DETAILS: Following a scout CT, a line address major bleeding, including angiography and embolization. We is drawn tangential to the intended entrance site, τ, directly onto the present an overview of the prevention and management of percutane- digital CT images. The intended trajectory of the needle is then drawn, ous biopsy related major bleeding and the angle between the two lines is measured, θ. The distance of

CLINICAL FINDINGS/PROCEDURE DETAILS: The prevention of biopsy the intended trajectory is also noted, Δ. An electronic protractor inside hemorrhage involves preprocedural evaluation. Patients should be a sterile ultrasound probe cover is then held tangential to the skin sur- evaluated based on multidisciplinary guidelines for procedural can- face, along τ, and the needle directed toward the lesion at an angle didacy. New guidelines discuss anticoagulation, coagulopathy and of 180-θ and advanced Δ. Using this method at our institution, nee- hematology lab goals prior to biopsy. For renal biopsy, institution spe- dle placements are nearly always performed in one attempt. We have cific blood pressure goals may be considered. Procedural planning and used this method in the gamut of CT-guided procedures, including technique reduces hemorrhage risk. The biopsy approach should be intrathoracic and intraabdominal biopsies, ablation probe placement, evaluated to avoid large vessels. The smallest possible biopsy device and sacroiliac joint injections. which still yields acceptable cores should be used. Some practitioners CONCLUSION AND/OR TEACHING POINTS: Protractor-assisted CT embolize the biopsy tract with Gelfoam or a blood patch. Postproce- guidance is a promising and simple method to improve efficiency of dure management includes the application of pressure to the site and CT-guided procedures. SIR 2020 Annual Scientific Meeting e-Posters | 95

Abstract No. 957 (HCC). (3) Using Lipiodol for tumor enhancement during HCC embolization. (4) Understanding stereotactic body radiotherapy (SBRT) in The rebirth of biopsy of hepatocellular carcinoma as a treatment of HCC. (5) Highlighting dosimetric Impact of Lipiodol in necessity in the era of targeted therapy SBRT.

1 1 2 3 A Khankan , M Abdulhaq , M Al-Khammash , A Alayoub , A BACKGROUND: Past uses of lipiodol have elucidated new potential util- 1 Kenawi ity with an increase in use for HCC transarterial embolization. With the 1King Abdulaziz Medical City, Jeddah, Makkah, 2Al-Hada Hospital advances in SBRT, aiding radiation oncologists with residual lipiodol for Armed Forces, Taif, Makkah, 3Alfaisal University Faculty of dye within an HCC lesion increases dosimetry impact allowing for bet- Medicine, Riyadh, Riyadh ter outcomes.

LEARNING OBJECTIVES: 1. To overview the molecular profiling of hepa- CLINICAL FINDINGS/PROCEDURE DETAILS: Hepatocellular carcinoma is tocellular carcinoma (HCC) and in selection and directing the targeted one of the most common tumors worldwide with a relatively high mor- therapies. 2.To highlight to expanded indications, expectations and tality rate. Due to the insensitivity of HCC to radio/chemotherapy, sur- potential future role biopsy in HCC management in addition to its gical treatments have often been the mainstay of treatment; however, impact on interventional radiology practice. because of tumor location and extent of the disease limiting functional reserve, surgical resection is not favorable for most patients. With new BACKGROUND: Most of current international guidelines for manage- technological advances, transarterial embolization has become an ment of HCC mandate the utility of imaging not histologic investiga- accepted means to treat HCC. Prior use of lipiodol in lymphangiogra- tions in the diagnostic setting except in selected situations. HCC is a phy as a contrast agent elucidated the potential use as a chemoem- unique highly heterogenous at genetic, immunologic and molecular bolization agent, particularly in the setting of HCC. The stark dying of levels. Several HCC subtypes have been characterized with distinct HCC lesions with lipiodol has significantly aided radiation oncologists molecularly and histologically patterns and prognostic impacts. Var- in locating tumors during SBRT of which has advanced independently ious systemic and targeted therapies with understanding the molec- with increased interest in liver tumor radiotherapy. With the ability to ular biology of HCC have evolved the management of HCC in the last clearly visualize HCC lesions, dosimetry values have increased allowing decades and have increased the need for tissue biopsy for tissue bio- more overall efficiency and a relative efficacious result of less radia- markers, molecular analysis and specific histopathologic subtyping. tion to otherwise healthy tissue. This exhibit will highlight the history Such a need for biopsy in HCC management becomes a necessity due of lipiodol briefly as well as explain the reasons lipiodol is useful in the to the potential implications in patient prognostication and proper setting of HCC treated with SBRT after TAE/TACE. selection for effective therapies. CONCLUSION AND/OR TEACHING POINTS: (1) Lipiodol is made from CLINICAL FINDINGS/PROCEDURE DETAILS: The poster will provide infor- poppy seed oil, is radio-opaque and can be used in conjunction with mation the role of biopsy in HCC patients focusing on the followings: - embolic agents. (2) TACE/TAE has become an accepted management Current limitations of imaging and misclassification between HCC and of nonresectable hepatocellular tumors. (3) SBRT in addition to TACE/ other intrahepatic malignancies. - Morphologic variants and molecular TAE, has allowed a more definitive means to treatment of HCCs. (4) subtypes of HCC relevant to the targeted therapy. -Current limitations. Residual Lipiodol as a surrogate fiducial for image guidance in SBRT is - Expanded indications and expectations. - Future directions. feasible and efficient. (5) Dosimetric values are highly impacted when

CONCLUSION AND/OR TEACHING POINTS: Recent molecular classifi- tumors are enhanced with Lipiodol. cation and development of targeted therapy for HCC have renewed the interest in tissue biopsy for the diagnosis, management and prognostication of HCC. Interventional radiologists must be aware of the Abstract No. 959 expanded indications, tissue yield, and expectations related to biopsy Overcoming limitations in the treatment of locally in order to adapt to the new changes, alleviate the possible challenges, advanced pancreatic cancer with transarterial and continue their efficient role in patient care. microprofusion utilizing a novel dual balloon catheter B Manchec1, R Gandhi2 Abstract No. 958 1Advent Health, Orlando, FL, 2Miami Cardiac & Vascular Institute, Guiding stereotactic body radiotherapy with Lipiodol Miami Cancer Institute, Miami, FL enhancement during chemo and bland embolization of LEARNING OBJECTIVES: This poster will review the current challenges hepatocellular carcinoma of treating locally advanced pancreatic cancer (LAPC), introduce tran- S Patel1, M Swikehardt1, H Brent1, I Provancha1, S Fahrtash1, W sarterial microperfusion utilizing a novel dual balloon catheter (Ren- Kwon1 ovoCath), and present early results of patients with LAPC who were treated with intraarterial (IA) Gemcitabine. 1SUNY Downstate Medical Center, Brooklyn, NY BACKGROUND: Pancreatic cancer is the 3rd leading cause of cancer LEARNING OBJECTIVES: (1) History of Lipiodol and its uses. (2) Under- mortality, with a median overall survival of only 9-12 weeks. There standing bland and chemo-embolization of hepatocellular carcinoma has been little improvement in mortality despite advancements in 96 | e-Posters SIR 2020 Annual Scientific Meeting

detection and treatment. LAPC includes patients with unresectable infiltration, previous treatment, and peripheral local recurrence. tumors who have not developed distant metastasis. Traditionally, Numerous EHC vessels have been documented including phrenic, these patients have been treated with intravenous (IV) gemcitabine; intercostal, gastric, omental and lumbar arteries. Although some ves- however, effectiveness is limited by tumor hypovascularity and a sels may be visible on CT/MRI, due to the origin variability vigilant angi- dense tumor matrix. ography is essential. If an EHC vessel is suspected, additional selective angiography of possible branches based on tumor location and/ CLINICAL FINDINGS/PROCEDURE DETAILS: The RenovoCath (RC-120) is or suspected origin may be required for complete evaluation. Addi- a dual balloon catheter designed to overcome the limitations of drug tionally, if there is a focal defect in the periphery of known tumor on penetration secondary to tumor hypovascularity. After advancing hepatic angiography, EHC should be suspect. Additionally, knowledge the catheter into the hepatic or superior mesenteric artery, the bal- of EHC location and intervention is required prior to treatment in order loons are inflated at the proximal and distal edge of the tumor border. to avoid potentially catastrophic nontarget embolization such as spinal Gemcitabine is then infused by power injection between the balloons cord infarct. causing an IA pressure high enough to diffuse the drug into the adjacent tumor. In total, 43 patients have been treated with IA gemcitabine CONCLUSION AND/OR TEACHING POINTS: A significant portion of HCC using the RC-120 catheter. The initial RRI (safety) study included 20 demonstrate EHC vessels, complicating treatment with TACE. Under- patients that received dose escalated gemcitabine, and the following standing the clinical scenarios, CT/MRI findings, and angiographic RR2 (registry) study included 25 patients that received full dose (1000 findings of EHC is essential for adequate treatment and to prevent mg/m2) twice monthly treatments (2 patients rolled over). The average nontarget embolization. Interventional radiologists should understand number of treatments was 4 (range, 1-14). 30% of patients completed how to treat these vessels for successful TACE. the intended 4 cycles of IA therapy. The median survival of the cohort was 12.4 months. Patients who received prior chemoradiation and had ≥3 IA gemcitabine treatments (n = 10) had a 2-year survival of 68.6% Abstract No. 961 and a median survival of 27.8 months. The improved results in this sub- Prostate artery chemoembolization: past, present, and group is believed to be secondary to radiation-induced reduction in future directions microvascular washout. J Greene1, M Schwenke1, S Braverman2, M Singh1 CONCLUSION AND/OR TEACHING POINTS: IA gemcitabine using the 1 2 RC-120 catheter to increase drug diffusion demonstrates encouraging Santa Barbara Cottage Hospital, Santa Barbara, CA, N/A, Santa early results in treating LAPC, especially in patients who received prior Barbara, CA chemoradiation. LEARNING OBJECTIVES: To review and describe past and current methods of prostate chemoembolization (PACE), and to identify develop- Abstract No. 960 ing future directions of therapy. BACKGROUND: Prostate artery embolization (PAE) has been shown to Parasitic hepatocellular carcinoma: tumors gone rogue be effective in mitigating symptoms and complications associated with B Oliver1, M Cline1 prostate cancer (PCa) such as hematuria and lower urinary tract symptoms (LUTS). PAE is generally not pursued in patients who have been 1University of Michigan, Ann Arbor, MI found to have PCa as localized disease is approached with curative

LEARNING OBJECTIVES: -Recognize when to suspect extrahepatic treatment modalities such as prostatectomy, external beam radiother- collateral (EHC) arterial supply of hepatocellular carcinoma (HCC) apy, and brachytherapy. Recent data suggests PAE is not completely including patient characteristics, tumor location and imaging findings effective at eradicating all tumor cells. PACE has been shown in early -Understand the anatomy which lead to parasitic HCC including the data to be effective therapy and may be considered in the future for most common EHC vessels and identification of these vessels on imag- PCa patients who refuse or discontinue a curative treatment regimen. ing -Understand treatment implications for parasitic HCC focusing on Future directions that have been discussed include prostate artery angiographic findings, technical factors, possible complications, and selective internal radiation (SIRT). findings on follow-up imaging. CLINICAL FINDINGS/PROCEDURE DETAILS: Patients who are planning

BACKGROUND: HCC carries a high mortality rate with the number of to undergo PACE are started on an acid suppression medication, cases expected to increase. In patients who are not candidates for nonsteroidal anti-inflammatory medication, and antibiotic prior to ablation or surgery, transarterial chemoembolization (TACE) is the the procedure. The patient is positioned, prepped and draped in the standard of care. Up to 27% of HCC may demonstrate parasitic vessel usual fashion. Once access has been obtained, nitroglycerin is injected recruitment. Therefore, it is essential to be able to recognize parasitic into the prostatic arteries. Angiograms are performed to determine HCC, not only for successful treatment, but also to avoid serious treat- the anatomy of the prostatic vessels. Cone-beam CT may be per- ment complications. formed at this time to further elucidate variant anatomy. Nontargeted embolization is prevented by coil embolization of collateral vessels to CLINICAL FINDINGS/PROCEDURE DETAILS: The tumor characteristics the bladder, rectum, or penis, as necessary. A solution off docetaxel which increase the likelihood of EHC vessels supplying HCC include and 150- to 300-µm Embospheres are injected until stasis of flow is larger size, peripheral location, exophytic growth, extrahepatic SIR 2020 Annual Scientific Meeting e-Posters | 97 obtained bilaterally. Biochemical success, failure and recurrence are Abstract No. 963 tracked with prostate specific antigen (PSA) levels. Checkpoint inhibitor therapy: a new tool for CONCLUSION AND/OR TEACHING POINTS: PAE should be considered in interventional oncologists managing LUTS and complications related to PCa. Early data demonstrate PACE to be a safe and effective alternative treatment modality A Lee1, N Fidelman2 for patients with localized tumor and an effective method for man- 1UCSF, South San Francisco, CA, 2University of California San aging complications in patients with advanced disease. SIRT may be Francisco, San Francisco, CA considered as a potential treatment modality for PCa in the future. LEARNING OBJECTIVES: - To develop a basic understanding of the science behind checkpoint inhibitor therapy. - To understand cur- Abstract No. 962 rent research directions for checkpoint inhibitor applications, and the potential applications of this technology to interventional oncology. Allies during end-of-life care: interventional radiology BACKGROUND: Checkpoint inhibitor therapy, along with other immu- and management of malignant pleural effusions notherapies, has undergone rapid evolution in last few years, with now J Jeffries1, M Gayed1, L Dalag1, J Li2, R Navuluri1 thousands of clinical trials involving these new agents in progress. The 1The University of Chicago Medicine, Chicago, IL, 2The University of 2018 Nobel Prize in Medicine was awarded to two scientists who were Chicago Pritzker School of Medicine, Chicago, IL instrumental in pioneering the field of immuno-oncology, Drs. Tasuku Honjo and James Allison. LEARNING OBJECTIVES: 1. Review the epidemiology, pathophysiology, clinical presentation, and diagnosis of malignant pleural effusions 2. CLINICAL FINDINGS/PROCEDURE DETAILS: Checkpoint inhibitors: Compare and contrast available therapeutic options including repeat Normally, the immune system is balanced between stimulation and thoracentesis, chemical pleurodesis, and indwelling pleural catheter repression. Immune “checkpoints” exist as a part of this balance which placement with an emphasis on current evidence based guidelines 3. helps regulate the immune system, giving the immune system self-tol- Illustrate the basic techniques of thoracentesis and indwelling pleural erance and preventing the immune system from killing the host. Cur- catheter placement through schematics and case based examples rent FDA-approved checkpoint inhibitors target one of three types of receptors, PD-1, PD-L1, and CTLA-4, all involved in T cell inhibition. BACKGROUND: Malignant and paramalignant pleural effusion (MPE) Checkpoint Inhibitor Therapy and interventional radiology (IR): Inter- is the accumulation of fluid within the pleural space in the setting of ventional radiologists have begun examining the possible synergies tumor either directly involving the space itself or from distant tumor between checkpoint inhibitors and IR treatments for cancers. These effects that indirectly cause fluid leakage and/or accumulation. MPEs include combinations of Y90 and checkpoint inhibitor therapy as well cause over 125,000 hospital admissions per year in the U.S. and are as ablation and checkpoint inhibitor therapy. estimated to result in up to $5 billion per year in inpatient charges. These often represent advanced or incurable disease with the average CONCLUSION AND/OR TEACHING POINTS: Checkpoint inhibitor ther- survival after diagnosis estimated between 3-12 months. This makes apy an amazing new advance in the treatment of cancers. Our under- the role of management often palliative with the goal of symptomatic standing of this area continues to grow by leaps and bounds. While relief through removal of fluid and possibly prevention of re-accumu- the technology is not perfect, there are amazing opportunities for lation. The therapeutic options available offer an opportunity to dras- interventional radiologists utilize this new technology to augment our tically improve the quality of life for patients who often face chronic procedures. and/or terminal illness.

CLINICAL FINDINGS/PROCEDURE DETAILS: This exhibit will describe the Abstract No. 964 epidemiology of MPEs including the yearly incidence and substantial economic burden to the health care system. It will also include discus- Immunotherapeutics and intratumoral delivery: a growing sion of the pathophysiology, clinical presentation, and diagnosis. The field for interventional radiology involvement emphasis of the exhibit will compare and contrast the available thera- A Lee1, M Kohi2 peutic options and how interventional radiologists and other providers 1UCSF, South San Francisco, CA, 2N/A, Tiburon, CA can utilize the most current evidence, including consensus guidelines from the American Thoracic Society, Society of Thoracic Surgeons, LEARNING OBJECTIVES: - To provide a brief overview of intratumoral and the Society of Thoracic Radiology, to guide management on a injection history, current applications, technique, and potential prob- case-by-case basis. The basic techniques of thoracentesis and indwell- lems - To provide an overview of immunotherapeutic agents that are ing catheter placement will be illustrated through schematics and case currently being tested via intratumoral delivery examples. BACKGROUND: While the intratumoral delivery of therapeutic agents CONCLUSION AND/OR TEACHING POINTS: By correctly managing malig- has been described in various forms for long periods of time, the actual nant effusions, providers can significantly improve quality of life in applications of the procedure were limited due to the types of oncol- often terminally ill patients. ogy agents available at the time, namely chemotherapy agents. Due to concerns with toxicity and injection control, direct injection of tumor 98 | e-Posters SIR 2020 Annual Scientific Meeting

with chemotherapy had limited uses. Intratumoral approaches were team. Under sterile procedure and imaging guidance, injections are still technically utilized for other types of oncology treatments, such typically performed with division of the provided dose into 3-4 frac- as thermal ablation or ethanol ablation where the lesions were directly tions and distributed in a radial fashion throughout the lesion. Distrib- accessed. The interest in intratumoral approaches has slowly regained uting the agent throughout different regions of a tumor may be more popularity over the last few years as the types of agents available for effective at stimulating an immune response because tumors are het- intratumoral therapy has increased, namely immunotherapeutics. erogenous with variability in neoantigens and preexisting immune cell infiltrates. Postprocedural and interval disease response monitoring is CLINICAL FINDINGS/PROCEDURE DETAILS: Intratumoral injection. at the discretion of the oncology team. There are descriptions of intratumoral injection with immunomodu- latory agents as early as the late 19th century, where pro-inflamma- CONCLUSION AND/OR TEACHING POINTS: Interventional radiologists tory bacterial extracts were injected into lesions. The current interest can serve an important role in the oncologic management of patients in intratumoral therapy was rekindled in the last few years primarily in with advanced disease through intratumoral injections. Success- the area of melanoma treatment. A few factors made melanoma an ful delivery of intratumoral injections can be made possible through ideal disease for intratumoral therapy - lesions are often superficial proper pretreatment diagnostic workup and coordination with the and easy to inject, even without image guidance. In addition, the suc- referring oncologists. cess of checkpoint inhibitor therapy (namely CTLA-4 and PD-1 inhibitors) in the setting of melanoma also spurred interest in whether direct Table 1 System Laboratory Value delivery of the agents to the tumor. Hematological CONCLUSION AND/OR TEACHING POINTS: Intratumoral injection is a rel- Solid Tumor Absolute neutrophil count > 1,500/mcl atively simple and overall safe way to delivery oncology agents directly Subjects Lymphoma into the tumor. With recent advances in oncology agents, there has > 1,000/mcl Subjects been renewed interest in intratumoral approaches, particularly in over- Solid Tumor Platelets > 100,000/mcl coming the dangerous systemic effects of immunotherapeutics. This Subjects is an exciting new area for oncology, and an opportunity for interven- Lymphoma > 75,000/mcl tional radiologists to bring our skills to the table in the treatment of Subjects Solid Tumor these patients. Hemoglobin > 9 g/dL or > 5.6 mmol/L Subjects Lymphoma > 8 g/dL or > 5.0 mmol/L Abstract No. 965 Subjects Renal Intratumoral injections: what the interventional Serum Creatinine or < 1.5 X ULN or Creatinine Clearance radiologist should know a > 60 mL/min for subject (CrCl) (Measured or calculated) or with creatinine levels > 1.5 V Gioioso1, R Gindi-Kolker1, M Ingham1, S Reis1 Glomerular Filtration Rate (GFR) X ULN in place of CrCl 1 Columbia University Irving Medical Center, New York, NY Hepatic Total bilirubin (serum) < 1.5 X ULN or LEARNING OBJECTIVES: The learning objectives of this educational Direct bilirubin < ULN for exhibit are to exemplify the role of the interventional radiologist in subjects with total bilirubin intratumoral injections, describe the pretreatment workup and meth- levels > 1.5 X ULN odology for injections, as well as to identify potential associated AST (SGOT) and ALT (SGPT) < 2.5 X ULN impediments or complications. Coagulation International Normalized Ratio < 1.5 X ULN BACKGROUND: Patients with advanced solid or soft tissue malignancies (INR) or Prothrombin Time (PT) Activated Partial Thromboplastin often have exhausted multiple lines of chemotherapy, radiation, and/ < 1.5 X ULN or surgical management. Intra-tumoral injections, using STING (stimu- Time (APTT) a lation of interferon genes) or oncolytic virus therapy, either alone or in Creatinine clearance should be calculated per institutional standard combination with immunotherapy antibodies, may provide a potential benefit to cancer patients through their ability to stimulate an immune response opposing their malignancy. Abstract No. 966

CLINICAL FINDINGS/PROCEDURE DETAILS: Lesions are selected for intratumoral injection at the direction of the referring oncologist, but On systemic therapies of hepatocellular carcinoma may be left to the discretion of the interventional radiologist. Lesions T Wolfe1, F Dayyani1, D Fernando1, K Nelson1, J Katrivesis1, N Abi- must be readily and repeatedly accessible, either by ultrasound or CT Jaoudeh1 scan. Potential target lesions are biopsied and pathology results are 1University of California Irvine, Orange, CA reviewed to confirm presence of malignancy prior to initiation of treatment. Treatment eligibility must be within predetermined parameters LEARNING OBJECTIVES: (1) Provide an overview of current systemic (Table 1). The dose to be administered is provided by the oncology therapies for management of advanced hepatocellular carcinoma SIR 2020 Annual Scientific Meeting e-Posters | 99

(HCC). (2) Review ongoing trials for the treatment of HCC. (3) High- CLINICAL FINDINGS/PROCEDURE DETAILS: Ultrasound Fusion software light potential of interventional radiology (IR) collaborations. co-registers a previously obtained MRI, PET or CT scan with real-time ultrasound, which improves the accuracy needed to locate poorly BACKGROUND: Currently, the only treatment of advanced HCC per soci- visualized lesions on ultrasound and provides the operator more etal guidelines is systemic therapy. Until recently, the sole approved confidence while performing the biopsy. In this exhibit the strength systemic treatment led to only 2.7 months overall survival benefit. of fusion technology including indications, diagnostic applications, However, since 2017, several other options have become available and added characterization value. Several additional specific applications more trials are underway. such pediatric, renal failure, oncology and electromagnetic needle CLINICAL FINDINGS/PROCEDURE DETAILS: Since 2017, several systemic tracking will be reviewed. therapeutic options for the treatment of advanced HCC have come to CONCLUSION AND/OR TEACHING POINTS: With recent advances in the market and additional options are being studied. Moreover, some AI, the fusion technology will soon gain popularity in the healthcare. systemic options are being studied at earlier stage of the disease, in Despite initial steep learning curve, this technology provides examin- combination with locoregional and even curative therapies. The sys- ers ample clinical opportunities, such as helping to better characterize temic options can be divided into two classes namely molecular tar- specific lesions with providing additional information. Furthermore, geted therapies, such as multikinase inhibitors, and immunotherapies this technology will help to minimize the radiation and/or cost from which modulate the immune system by several mechanisms including other axial imaging guided procedures such as CT scan and MRI. checkpoint inhibitors, oncolytic viruses and chimeric antigen receptor-T cells (CAR-T cells). Targeted therapies include sorafenib, lenvatinib, cabozantinib, and regorafenib, which have gained approval along Abstract No. 968 with several others currently being explored. Among immunotherapies, checkpoint inhibitors are currently the most studied, although Primer on medical therapies for hepatocellular carcinoma: checkmate 459, testing nivolumab, did not meet its endpoint. A com- keeping pace with rapidly growing landscape plete review of various therapies, their mechanisms of action, results C Chao1, L Garcia Paredes2 of clinical trials, and upcoming trials will be addressed. IR has a role 1 2 in potentiating these therapies through targeted administration and University of Maryland, Cerritos, CA, University of Puerto Rico combination local with systemic therapy. School of Medicine, San Juan, PR

CONCLUSION AND/OR TEACHING POINTS: Systemic therapies for HCC LEARNING OBJECTIVES: Discover and understand the medical thera- have significantly expanded in the past 2 years and several new ther- pies available to treat HCC, which have recently dramatically expanded, apies are being studied. Knowledge of these new therapies, as well as including the trial results, adverse effects, difference between medica- upcoming therapeutic options, is essential for interventional radiolo- tions and literature on combination with locoregional therapy. gists, due to the potential role for IR in combination therapies. BACKGROUND: Therapies by interventional radiology have dominated the treatment of HCC since few patients qualify for liver transplant or Abstract No. 967 resection. Until 2007, there was no effective medical therapy for HCC. Even after sorafenib’s approval in 2007, there was still a dearth of med- Practical uses of fusion and contrast-enhanced ultrasound ical therapies for HCC. However, in the last few years there has been in interventional radiology: do you really need computed an exponential acceleration of medical therapies for HCC. Although tomography? the medical therapies can be broadly grouped into 3 classes: multireceptor tyrosine kinases inhibitors, immunotherapies and monoclonal 1 2 3 4 A Rahnemai-Azar , H Rajeswaran , A Hashmi , N Azar antibodies, there are significant differences between the medications 1University hospitals, Case western Reserve University, even in the same class. Cleveland, OH, 2Case Western, Cleveland, OH, 3N/A, Perrysburg, CLINICAL FINDINGS/PROCEDURE DETAILS: The Exhibit will comprehen- OH, 4University Hospitals Case Medical Center, Cleveland, OH sively review the medical therapies available to treat HCC including LEARNING OBJECTIVES: To review limitations and disadvantages of multireceptor tyrosine kinase inhibitors (sorafenib, regorafenib, lenva- CT scan/MRI. To review limitations of ultrasound. Describe ultrasound tinib and cabozantinib); monoclonal antibodies such as ramucirumab fusion. Modalities, steps for fusion. Types of registrations, artificial which target vascular endothelial growth factor (VEGF); and immuno- intelligence (AI). Clinical applications: improved visualization, localiza- therapies (nivolumab, atezolizumab, pembrolizumab). Comparison of tion, and characterization. Specific scenarios. the trial data will be made include results such as overall survival and time to progression of disease as well as adverse effects. In addition, BACKGROUND: CT-guided interventions are radiation exposure to literature on combination therapies will be reviewed. Results of com- patients, as well as physicians. Economic analyses demonstrated bination of medical therapies will be reported such as pembrolizumab CT-guided interventions are 1.89 times more expensive per than ultra- and lenvatinib as well as atezolizumab and bevacizumab. Moreover, sound. CT-guided equipment is also four times as expensive when results on combination of medical therapy with locoregional therapy compared to ultrasound. Yet, ultrasound also have limitation, it is oper- will be covered including the TACTICS trial (which showed a benefit ator dependent and some lesions are poorly visualized with US. from combining chemoembolization and sorafenib). Finally, important 100 | e-Posters SIR 2020 Annual Scientific Meeting limitations of the trials are reviewed such as exclusions and patients Abstract No. 970 which had received other therapies. Straight to the point: preoperative, direct percutaneous CONCLUSION AND/OR TEACHING POINTS: To be an effective Interven- intralesional embolization of spinal tumors tional Oncologist treating HCC, a good grasp of medical therapies, their benefits, adverse effects and limitations is required since these G Mitchell1, D Hillman1, H Marin2 medical therapies are being proffered as adjunctive and/or combina- 1Henry Ford Hospital, Detroit, MI, 2Hospital Of University of tion therapies. Pennsylvania, Philadelphia, PA

LEARNING OBJECTIVES: Review the practice of preoperative emboli- Abstract No. 969 zation of hyper vascular spinal tumors. Discuss the technique of direct embolization of spinal tumors, via percutaneous access to the lesion. Pulmonary arterial fiducial insertion for CyberKnife Cases reviewed will include preoperative treatment of an aggres- stereotactic radiosurgery: a novel technique sive hemangioma, and a renal cell carcinoma metastasis, using liquid J Moideen1, I Subbanna2, V Bhargavi3, M Rajasekharan3 embolics, with discussion of surgical outcome.

1Healthcare Global, Bangalore, Ak, 2HCG Hospitals, Bangalore, BACKGROUND: Preoperative embolization of both primary and meta- India, Bangalore, Ca, 3HCG Hospitals, Bangalore, India, Bangalore, static spinal lesions is performed to reduce intraoperative blood loss. Karnataka Typically, embolization of these lesions is accomplished via a transarterial approach. However, some tumors may prove difficult to treat, LEARNING OBJECTIVES: Internal gold Fiducials are markers necessary due to unfavorable anatomy or size, or elevated risk. Percutaneous, for treatment planning and tracking the movements of target lesions direct intratumoral injection of embolic material has been described as during CyberKnife stereotactic radiosurgery. Percutaneous image- a possible safe and effective technique, which may be an appropriate guided fiducial insertion is standard technique for CyberKnife. Occa- alterative in some cases to the transarterial approach. sionally percutaneous placement can be contraindicated, hence we considered the possibility of transarterial insertion of fiducials. CLINICAL FINDINGS/PROCEDURE DETAILS: We will review the indications and current techniques for preoperative embolization of spinal BACKGROUND: We had three cases of transarterial fiducial placement tumors. The option for percutaneous, direct intratumoral embolization at our center. First case was of an adenocarcinoma of lung, planned will be discussed. Cases highlighted will include an aggressive heman- for SBRT. He developed significant nonresolving pneumothorax after gioma, and a metastatic renal cell carcinoma; both managed with per- Biopsy. Second case was with adenocarcinoma of right lung, planned cutaneous embolization using liquid embolic material. for SBRT. He had the fear of pneumothorax encountered during prior biopsy. Third case was with carcinoma endometrium, with metastatic CONCLUSION AND/OR TEACHING POINTS: Preoperative transarterial lung lesion for SBRT. He had significant chemotherapy induced throm- embolization of hypervascular spinal lesions is a typical method for bocytopenia and altered bleeding parameters. The possibility of tran- reducing surgical bleeding risk. Percutaneous, direct intratumoral sarterial fiducial placement was considered in these cases. embolization using liquid materials, may be a safe and effective option in select lesions. CLINICAL FINDINGS/PROCEDURE DETAILS: Under local anesthesia and transfemoral venous approach, the pulmonary artery was accessed. Angiogram was performed, and lobar arteries supplying the lesion Abstract No. 971 were selectively catheterized. The segmental arteries supplying the lesion were super-selectively catheterized and gold fiducials of size The rise of T1 renal cell carcinoma: technical aspects of 8 × 0.5 mm were deployed in the vicinity of the lesion. No minor or current treatment options major clinical complications seen. One fiducial in a patient migrated R Raymond1, M Novack1, M Ezell1, B Bordlee1, J Caridi1 post deployment. Post procedure CT scans confirmed the position of 1Tulane University School of Medicine, New Orleans, LA fiducials and patients further underwent successful CyberKnife SBRT.

LEARNING OBJECTIVES: 1. Discuss of the evolution of T1 RCC treatments CONCLUSION AND/OR TEACHING POINTS: Intra-arterial Fiducial placement is an effective alternative procedure in patients with contrain- and the importance of having an open inter-disciplinary discussion for dications to percutaneous fiducial placement. It is a relatively safe unique cases at every institution. 2. Review the latest literature and procedure with no risk of pneumothorax, hemothorax, or hematoma. recommendations for percutaneous ablation, embolization, surgical However, there is a risk of fiducial migration into peripheral arteries interventions, and combined approaches for T1 RCC. 3. Describe the during the procedure. safety and efficacy associated with each approach. 4. Identify anatomical considerations, correct technique, and indications for each approach while exposing the attendee to a variety of cases successfully performed at our institution.

BACKGROUND: RCC is a slow growing malignant renal neoplasm that classically presents as a palpable flank mass with hematuria, fever, and weight loss. The gold standard treatment for T1 RCC is partial SIR 2020 Annual Scientific Meeting e-Posters | 101

nephrectomy; however, RAE and percutaneous ablation have demon- did not correlate with increased OS in this study. An institutional review strated robust therapeutic outcomes in recent years, both anecdotally of a 1000 patients was performed which included predominantly BCLC and in large studies. With the rapid rise in CT-imaging rates, incidental C patients. Investigators reported improved overall survivability (25 findings of T1 RCC continues to rise making minimally invasive tech- months vs. 20 months) after Y90 for intermediate stage disease com- niques an attractive option for patients. pared to reported EASL-EORTC guidelines.

CLINICAL FINDINGS/PROCEDURE DETAILS: Understanding the advan- CONCLUSION AND/OR TEACHING POINTS: Recent studies suggested tages and limitations of the available treatment options allows the that Y90 has an increased TTP and improved overall survival compared potential to cure patients with the same efficacy as surgical excision. to TACE, suggesting a primary role in the management of intermediate Preoperative embolization has also been shown to decrease blood HCC. Additional randomized controlled studies are needed to establish loss, lower transfusion rates, and decrease overall mortality during a guideline for the treatment of patients with intermediate HCC. nephrectomies. RAE with an ethanol-Ethiodol emulsion allows penetration of the smallest vessels in the neoplasm with the added advantage of Ethiodol being a contrast agent, facilitating follow-up CT Abstract No. 973 imaging and percutaneous ablation. Proper probe size and placement A pictorial review of the imaging findings post-Y90 with or without hydrodissection is necessary to avoid damaging sur- radioembolization therapy: what radiologists should rounding structures. Sharing the technical aspects of our experience know with these modalities will aid others in navigating through a variety of anatomical predicaments. P Vakil1, E Speir1, R Lokken1, N Fidelman2, M Heller3

1 CONCLUSION AND/OR TEACHING POINTS: Selective RAE and/or percu- University of California, San Francisco, San Francisco, 2 taneous ablation are rapidly growing widely accepted modalities for CA, University of California San Francisco, San Francisco, 3 the treatment of T1 RCC with outcomes similar to surgical excision but CA, University of California, San Francisco, N/A with much less morbidity. Maintaining an open discussion of potential LEARNING OBJECTIVES: To (1) review the different techniques of treatment options between specialties will provide the patient with the Yttrium-90 (Y90) radioembolization (including segmentectomy and best outcome and experience. radiation lobectomy) and their impact on posttherapy imaging, (2) recognize the timing and prevalence of benign findings and complica- Abstract No. 972 tions post Y90 therapy on angiographic, cross-sectional, and nuclear medicine imaging, (3) review imaging criteria for assessing treatment Update on locoregional management of hepatocellular response, and (4) highlight emerging modalities used in response carcinoma: transarterial embolization versus Y90 assessment. S Calamita1, M Wang2, E Hoffer1 BACKGROUND: The tumoricidal properties of Y90 radioembolization stem from local radiation, as opposed to chemo-cytotoxic and/or isch- 1Dartmouth-Hitchcock Medical Center, Lebanon, NH, 2Dartmouth emic effects seen in transarterial chemotherapy or bland embolization. Hitchcock Medical Center, Lebanon, NH As a result, there is a delay before therapeutic effects manifest on fol-

LEARNING OBJECTIVES: TACE and Y90 are locoregional therapies rec- low-up cross-sectional CT and MR imaging. In addition, radiation-in- ommended for management of intermediate HCC. Indications based duced increases in blood flow could be confused for residual disease. on the Barcelona Clinic Liver Cancer (BCLC) Staging system and tech- We performed a literature review followed by a retrospective chart nical aspects of the procedures will be discussed. The most recent review of our institution’s Y90 database between 2011-2019 to provide literature will be reviewed to assess outcomes data to determine if evi- examples highlighting key teaching points. dence exists to recommend Y90 over TACE. CLINICAL FINDINGS/PROCEDURE DETAILS: Findings such as capsular

BACKGROUND: Hepatocellular carcinoma (HCC) is the most common retraction are unique to radiation segmentectomy and not seen in primary liver cancer and is now the third leading cause of cancer deaths other forms of intraarterial therapy. Common benign findings such as worldwide. Although liver transplantation and resection are curative peritumoral ring enhancement, can occur at 1-month follow-up and treatments, the majority of patients are not surgical candidates. As a could be mistaken for residual disease. Tumor viability measures such result, transarterial therapy has become a mainstay in the treatment as residual enhancement are more sensitive and earlier predictors of of tumors classified as Barcelona Clinic Liver Cancer (BCLC) stage B tumor response than decrease in size, which can take 4 to 6 months (4+ lesions, lesions > 3 cm, good performance status, Child-Pugh A-B). after treatment. Moreover, changes in tumor microcirculation and The most common treatments are currently TACE and Y90. However, increases in molecular diffusion may precede tumor morphological the 2018 American Association for the Study of Liver Disease does not changes after Y90. These changes can be quantified using intravoxel have specific guidelines on treatment recommendations. incoherent motion DWI and have been shown to be useful in measuring tumor response to Y90 and predicting prognosis. CLINICAL FINDINGS/PROCEDURE DETAILS: A single-center randomized control trial of primarily BCLC A patients found a significantly CONCLUSION AND/OR TEACHING POINTS: Posttreatment imaging after increased time to progression (TTP) in Y90 patients compared to radioembolization therapy introduces a unique collection of imaging TACE patients (>26 months compared to 6.8 months). Increased TTP findings not seen in other forms of intraarterial therapy. Familiarity 102 | e-Posters SIR 2020 Annual Scientific Meeting with these is vital for patient management and avoiding misinterpre- Abstract No. 975 tation that could lead to unnecessary additional therapies or delay in pursuing other treatment options. Dosimetry for radioembolization: a trainee’s guide D Szaflarski1, J Young2, A Ghandour1, A Algharras3, A Gill1, A Kalra- Lall4 Abstract No. 974 1Cleveland Clinic, Cleveland, OH, 21988, Parma, OH, 3N/A, Montreal, Considerations for post Y90 radioembolization dosimetry QC, 4N/A, Cleveland, OH based on imaging modality LEARNING OBJECTIVES: Review radiopharmaceutical properties of G Gadodia1, K Karuppasamy2, V Reddannagari1, R Gurajala3 Yttrium-90 and describe the properties of two common radiotracer 1Cleveland Clinic Foundation, Cleveland, OH, 2N/A, Westlake, carriers on the market, glass (TheraSphere ) and resin (SIR-Sphere). OH, 3Cleveland Clinic Corp, Beachwood, OH Understand the different models used for dose calculations, including body surface area (BSA), partition model and multipartition model. LEARNING OBJECTIVES: The objective of this exhibit is to review the Demonstration of measurements made in the 3D lab to obtain volumes methodology, clinical utility, and limitations of the various imaging for partitioned dose calculations. Describe advanced applications used modalities available for post-Y90 radioembolization dosimetry. in radioembolization planning and treatment, including embolization

BACKGROUND: While the use of Y90 microspheres for treatment of guidance tools, vasculature mapping software, multiple selective dos- hepatic neoplasms has been around for many years, there is still no ing and dose splitting. highly accurate methodology to measure patient dosimetry, making BACKGROUND: Radioembolization has proven its role in the treatment it difficult to establish fundamental dose-response relationships for and management of primary and metastatic hepatic tumors. More treatment efficacy and hepatic toxicity. Current standards for Y90 institutions are performing radioembolization and trainees need to dosimetry utilize general formulas which take into account the vol- understand the principles behind treatment planning and dose calcu- umes of the lesions and the liver. New workflows allow for dosimetry lations to safely perform these procedures in practice. Dosimetry has based on the various post Y90 imaging modalities, each of which has become more advanced with utilization of SPECT/CT for planning, and their own methodology, merits, and limitations. advanced software applications allowing for more selective treatment

CLINICAL FINDINGS/PROCEDURE DETAILS: SPECT/CT utilizes com- and maximization of tumor dose delivery with minimization of radia- bined bremsstrahlung and CT anatomic imaging. This is often the most tion to normal liver. More patients are presenting with complex tumors widely available modality. However, due to the poor bremsstrahlung and complicated treatment histories which require advanced treat- activity of Y90 particles, and poor soft tissue resolution of CT, clinical ment paradigms including multiple selective dosing and dose splitting. utility is limited to evaluation of extrahepatic deposition, as the poor Thus, it is important to become familiar with all treatment strategies tumor to background distinction does not allow for accurate dosimetry for radioembolization as a trainee, in order to offer our patients the calculations. Coincidence imaging in PET/CT allows for much higher best possible outcome. spatial resolution of the microsphere deposition, and thus more accu- CLINICAL FINDINGS/PROCEDURE DETAILS: Radioembolization first rate dosimetry calculations. This modality continues to become more begins with hepatic angiography and technetium 99m-MAA injection. widely available but is still generally less so than SPECT. Finally, the It is important to know the common arterial variants and which arteries poor soft tissue resolution of CT again limits evaluation of tumor ver- pose a risk of nontarget embolization. Understanding how to obtain sus healthy liver. The combination of coincidence imaging and superior 3D volumes and interpret your own angiography and scintigraphy soft tissue resolution afforded by PET/MR allows for better contouring images, particularly SPECT/CT is crucial in developing a radioembo- and tumor versus liver evaluation. Accuracy of attenuation correction lization practice. Knowing limitations of radioembolization and when is a potential limitation to accurate MR based dosimetry, though with modifications need to be made is equally as important. recent upgrades this may be comparable to CT. Still, its use is mostly limited by its cost, low availability, and scan time. CONCLUSION AND/OR TEACHING POINTS: It is important for the trainee to be familiar with radioembolization dosimetry and advancements in CONCLUSION AND/OR TEACHING POINTS: The current post Y90 imaging software applications for optimal treatment outcomes with minimal modalities have different data acquisition approaches and limitations adverse effects in practice. which could affect image quality and accurate dosimetry. As attenuation correction and availability continues to improve, PET/MR may evolve as the gold standard due to better assessment of the tumor Abstract No. 976 and background. Effectively using radiation dosimetry software to evaluate radioembolization treatment C Chao1, L Garcia Paredes2 1University of Maryland, Cerritos, CA, 2University of Puerto Rico School of Medicine, San Juan, PR SIR 2020 Annual Scientific Meeting e-Posters | 103

LEARNING OBJECTIVES: To demonstrate the purpose and value of radi- chemoembolization (TACE) or sorafenib, respectively. Though TACE is ation dosimetry software and how to effectively use the tools to review the gold standard for intermediate stage HCC (BCLB B), growing evi- radioembolization therapies and, potentially, plan future treatments. dence supports patient treatment through transarterial radioembolization (TARE) with Yttrium-90 microspheres. Recently, there has been BACKGROUND: As radioembolization is being increasingly used to treat a surge in innovative designs in particle design specifically in bioengi- liver cancer, analysis of radiation dose to the tumor (tumor dose) and neering. Potential value of biodegradable particles, point-of-care syn- radiation dose to nontumor liver parenchyma are becoming increas- thesis, and 3D printing technologies for Y90 therapy will be discussed. ingly important. Studies are suggesting a minimum tumor dose necessary to achieve tumor necrosis. In addition, studies are also evaluating CLINICAL FINDINGS/PROCEDURE DETAILS: Ranging from 20 to 60 um toxicity to nontumor liver parenchyma and looking at maximum radia- in diameter, Y90 microspheres are made of glass (TheraSpheres) or tion doses. Recognizing the value of radiation dosimetry, there is now biodegradable resin (SIR-Spheres). Compared to the 2500 Bq activity a European directive on basic safety standards mandating dosim- per glass microsphere, resin microspheres have 60 Bq of activity per etry-based treatment planning for radiopharmaceutical therapies. sphere. As a result, more resin microspheres are required for the same In the United States, the FDA has approved the radiation dosimetry dose of glass microspheres, potentially increasing its embolic effects. software of several vendors for retrospective use. In addition, the FDA Weighing the benefits of higher radiation to ablate the tumor versus has approved one vendor’s software for retrospective use as well as lower radiation to surrounding parenchyma is necessary to choose pretreatment dosimetry planning. With wider availability of radiation which microsphere to use. Next generation particle designs may allow dosimetry software, interventional radiologists should become famil- real-time visualization, biocompatibility, greater control in the amount iar with the software and how to effectively utilize the tools to evaluate of radiation that can be packed into beads, and more versatility with their radioembolization treatment and, potentially, how to plan future combination treatments. treatments. CONCLUSION AND/OR TEACHING POINTS: There has been little innova- CLINICAL FINDINGS/PROCEDURE DETAILS: The exhibit reviews radi- tion over the past decade on Y90 particle design. Understanding the ation dosimetry including the recent literature showing the value of benefits/risks of various Y90 materials coupled with patient and tumor dosimetry in treatment planning and posttreatment evaluation. The characteristics will allow the provider to choose the optimal therapy. software from the different vendors will be reviewed. The common Newer particle designs have the potential to leverage immunotherapy steps in using the software including registration, contouring, interpo- with ablation for best outcomes. lation, segmentation and dosimetry analysis will be detailed. Common issues in using the software such as data preparation and fusion will be reviewed. More sophisticated analysis including multicompartment Abstract No. 978 analysis will also be discussed. Finally, how the software can be used to Transcarotid artery revascularization: why, how, and evaluate MAA imaging versus PET/CT imaging will be covered. results—what every interventional radiologist should CONCLUSION AND/OR TEACHING POINTS: With the arrival of radiation know dosimetry software, interventional radiologists can quantitatively C Cross1, S Weber2, C Griffin3, K Quencer4 evaluate their radioembolization therapies and, potentially, plan future 1 treatments more effectively. University of Utah School of Medicine, Salt Lake City, UT, 2University of Utah, Farmington, UT, 3University of Utah, Salt Lake City, UT, 4N/A, Salt Lake City, UT Abstract No. 977 LEARNING OBJECTIVES: (1) Understand drawbacks to and poten- Y90 particles: can design improve outcome? tial complications of established carotid revascularization methods (carotid endarterectomy-CEA and transfemoral carotid stenting). (2) 1 1 1 2 1 1 M Kuo , L Jamal , I Altun , H Albadawi , S Naidu , S Alzubaidi , G Review how TCAR is performed and how it mitigates stroke risk with- 1 1 3 1 Knuttinen , J Kriegshauser , I Patel , R Oklu out distal embolic protection. (3) Review results of recently published 1Mayo Clinic Arizona, Phoenix, AZ, 2Mayo Clinic Arizona, Scottsdale, studies. AZ, 3Mayo Clinic Arizona, Phoenix, AZ BACKGROUND: Stoke is a leading cause of death and disability. Carotid LEARNING OBJECTIVES: 1. Pictorial review of Yttrium-90 (Y90) radi- atherosclerotic stenosis is a major risk factor for ischemic stroke. Inter- oembolization technique for locoregional tumor control, specifically vention may be performed based on clinical status, surgical risk, symp- hepatocellular carcinoma to highlight issues related to failure. 2. Dis- toms, plaque morphology and percent stenosis. Traditional methods cuss current and emerging designs of Y90 particles. 3. Evaluate the of carotid revascularization are CEA, which has a 0.5% to 3% periop- efficacy of different Y90 microsphere designs, such as glass and resin erative mortality rate and a 1.5% to 4.8% rate of stoke. Additional risks material and emerging technologies. include cranial nerve injury. Transfemoral carotid stenting has a 2% to 9% 30 day risk of stroke and death even with the use of embolic pro- BACKGROUND: Hepatocellular carcinoma (HCC) is the most common tection devices. TCAR is an emerging procedure which has performed primary malignancy of the liver and a leading cause of cancer-re- well compared to transfemoral stenting and CEA with low 30-day lated deaths worldwide. Patients with unresectable tumors undergo stoke rate (1.4%), low death rate (0.9%) even in high risk patients. locoregional treatment or systemic agents, such as transarterial 104 | e-Posters SIR 2020 Annual Scientific Meeting

TCAR is an emerging procedure which has performed well compared we evaluate for sacroiliac (SI) joint dysfunction and treat with SI joint to transfemoral stenting and CEA. interventions using CT guidance. Last, if patient continues to have pain we re-evaluate and possibly start over. CLINICAL FINDINGS/PROCEDURE DETAILS: Cut-down to the carotid just above the clavicle is performed. U suture is placed for subsequent CONCLUSION AND/OR TEACHING POINTS: As an interventional radiolo- hemostasis. Micropuncture technique to access the common carotid gist we can play a key role in the diagnosis and treatment of back pain. artery is done followed by placement of a proprietary sheath. Femoral However, the treating interventional radiologist needs to know how to vein access is obtained and flow reversal through the filtered tubing is clinically evaluate low back pain and have a structured algorithm for performed. Stent is placed and sheath removed using the U suture to its evaluation and management to successfully provide the best care obtain hemostasis. Flow reversal time is typically 10 minutes compared to patients. to typical CEA clamp time of 30 minutes.

CONCLUSION AND/OR TEACHING POINTS: TCAR is a hybrid procedure Abstract No. 980 for carotid revascularization using a small cut-down to the common carotid and subsequent stent placement using flow reversal with Distal radial access in neuroangiography promising results. Interventional radiologists should be aware of this D Bageac1, D Goldman2, C Kellner2, R De Leacy3 procedure as an alternative to transfemoral stenting and CEA. 1University of Connecticut, Long Island City, NY, 2Icahn School of Medicine at Mount Sinai, New York, NY, 3Ichan School of Medicine Abstract No. 979 at Mount Sinai, New York, NY

A practical approach to clinical evaluation, management, LEARNING OBJECTIVES: 1. Understand the technique and advantages and treatment of back pain for the interventional offered by distal transradial access (dTRA) in neuroangiography. radiologist BACKGROUND: Evidence is growing that transradial access in angio- K Kansagra1, M Taon1, D Rex2, E Rosenthal2, I Lekht1 graphic procedures leads to lower complication rates and similar efficacy to the traditional femoral approach among experienced pro- 1Kaiser Permanente Los Angeles Medical Center, Los Angeles, ceduralists. Access at the distal radial artery, located beyond the ori- Ca, 2Kaiser Permanente Los Angeles Medical Center, Los Angeles, gin of the superficial palmar branch on the dorsum of the hand, offers CA further benefit due to the superficial course of the artery, the presence LEARNING OBJECTIVES: 1. Understand the common etiologies of back of carpal bone deep to the puncture site leading to ease of compres- pain and how they can be evaluated 2. Have a practical approach to sion, more comfortable patient positioning, and preserved antegrade back pain and how it can be implemented when evaluating a patient flow through the superficial palmar branch in the event of occlusion at seen in interventional radiology clinic. 3. Review the role of the inter- the puncture site. Beyond these general benefits, dTRA offers unique ventional radiologist in treating back pain advantages during neuroangiography, particularly in the event that intraoperative angiography in desired. By allowing the hand to rest in BACKGROUND: Back pain is a common ailment, often causing signifi- a natural palm-down position, the patient can be oriented face down cant disability. It is estimated back pain affects up to 80% of individuals or laterally, which could render access to the wrist impossible but may at one point. In the United States, 12% to 15% of visits to health care be necessary depending on the operative approach required by the providers annually are related to low back pain. Therefore, it’s integral surgeon. We will describe the technique and consideration involved in that interventional radiologists involved with treating back pain under- dTRA for neuroangiography, and well and 2 cases in which dTRA was stand the common etiologies and have a practical approach to a com- employed intraoperatively. mon chief complaint. CLINICAL FINDINGS/PROCEDURE DETAILS: 1. Technique of achieving CLINICAL FINDINGS/PROCEDURE DETAILS: This educational exhibit access and closure are described. 2. Results from 70 cases of neuro- builds on the concept that pain can be divided into radicular pain angiography utilizing dTRA are described with 2 year follow-up data. and somatic pain. It is key to identify the exact etiology of the back 3. Cause of dTRA failure did not differ significantly from causes of pain as the potential treatment varies for each cause. In evaluation proximal TRA failure. 4. No access site complications were recorded. 5. of patients, we utilize a stepwise approach that outlines the role of dTRA was utilized in 2 intraoperative cases in which proximal TRA and image-guided procedures as not only therapeutic but also diagnostic. femoral access were deemed cumbersome or impossible. In this algorithm we begin by asking if the patient’s pain can be related to radicular symptoms. If so, we opt for an epidural steroid injection. CONCLUSION AND/OR TEACHING POINTS: dTRA offers unique benefits If the patient fails treatment or symptoms are not related to radicular over proximal transradial access in neuroangiography, with similar etiologies, we entertain the possibility of facet dysfunction and treat rates of failure and complications. with a medial branch/dorsal ramus intervention. Next is spinal stenosis References: 1. Snelling BM, Sur S, Shah SS, et al Transradial cere- which is treated with an epidural steroid injection. If the patient contin- bral angiography: techniques and outcomes J Neurointervent Surg ues to have pain, we then evaluate for discogenic pain which is diag- 2018;10:874-881. 2. Brunet M, Chen SH, Sur S, et al Distal transradial nosed with a possible discogram and treated with an epidural steroid injection. If the patient continues to have symptoms despite all this, SIR 2020 Annual Scientific Meeting e-Posters | 105

access in the anatomical snuffbox for diagnostic cerebral angiography. LEARNING OBJECTIVES: 1. Understand middle meningeal artery embo- J Neurointervent Surg 2019;11:710-713. lization (MMAE) procedure 2. Therapeutic effect of MMAE on subdural hematomas (SDH) 3. Discuss the imaging technique and advantages of Spectral CT in MMAE follow-up Abstract No. 981 BACKGROUND: Chronic subdural hematoma is a common condition Embolization of chronic subdural hemorrhage: a case related to a cycle of chronic inflammation and angiogenesis. Emboli- series and review of the literature zation of the middle meningeal artery (MMA) is performed to devas- cularize the subdural membranes sufficiently to enhance resorption of D Petrov1, D Miller2, R Cerejo2, B Goodman3, C Li2 the hematoma. This procedure is an effective alternative to surgery 1 2 Allegheny General Hospital, Pittsburgh, PA, Allegheny Health for treatment of SDH. Due to its success, the procedure has become 3 Network, Pittsburgh, PA, N/A, Pittsburgh, PA more widespread. As this procedure becomes increasingly utilized, it is crucial for interventional radiologists to be aware of the important LEARNING OBJECTIVES: (1) Review chronic subdural hemorrhage (cSDH) pathophysiology and epidemiology. (2) Discuss current treat- imaging follow-up. MMA embolization may result in an increase in den- ment options for chronic subdural hemorrhage. (3) Discuss role of sity on the post embolization CT. The Spectral CT scanner’s dual-layer transcatheter embolization of the middle meningeal artery in cases detector enables synthesis of data over energy ranges creating image of cSDH. (4) Discuss future studies for role of interventional radiology results. This allows for differentiation between materials based on the (IR) and neurosurgery in cSDH. density of the structure and effective atomic size using information from the high and low energies from the dual layer. Therefore, Spec- BACKGROUND: Chronic subdural hemorrhage (cSDH) is a challenging tral CT scanners enable image analysis to differentiate between brain pathology due to high recurrence rates of 2% to 37%. Embolization parenchyma, hemorrhage, and iodine. The ability to reliably identify of the middle meningeal artery (MMA) has emerged as a minimally hemorrhage immediately after therapy allows for appropriate patient invasive intervention utilized as an adjunct or alternative to surgical management. approaches in the setting of cSDH. This exhibit reviews the angiographic evaluation and transarterial embolization of the middle menin- CLINICAL FINDINGS/PROCEDURE DETAILS: MMA embolization is per- geal artery in patients suffering from cSDH refractory to conservative formed at our institution in an inpatient setting, with over 20 patients treatment with medical therapy. As there is limited research on cSDH having received this procedure. Angiography of the common carotid and limited knowledge regarding indications and approach to treat- artery (CCA) and external carotid artery is performed on the affected ment in the IR literature, we present this exhibit with an aim to edu- side. The MMA is selected via a microcatheter and microwire and cate the IR community practicing neuroendovascular therapies on the embolization is performed. Spectral CT is acquired in all patients within subject. 24 hours of the procedure. Spectral CT definitively demonstrates that the high density material present post MMAE is secondary to contrast CLINICAL FINDINGS/PROCEDURE DETAILS: Our exhibit includes imag- staining and not acute hemorrhage. ing that demonstrates: (1) chronic subdural hemorrhage staging using CT and MRI, (2) arterial anatomy to be aware of during embolization, CONCLUSION AND/OR TEACHING POINTS: Spectral CT can accurately and (3) post-embolization angiography and clinical follow-up. Imaging differentiate between intraparenchymal hemorrhage and iodinated modalities include CT, MRI, arterial angiography, and digital subtrac- contrast material. This distinction is important in immediate postpro- tion angiography. cedure care of patients after MMAE. Spectral CT affects decision-making regarding monitoring and prognostication. CONCLUSION AND/OR TEACHING POINTS: MMA embolization may present a less invasive alternative to surgery for cSDH. With an aging population and increasing use of systemic anticoagulation amongst Abstract No. 983 the general US population, cSDH incidence may increase in the next decade. Thus, it is beneficial to understand the anatomic consider- Inferior petrosal sinus sampling for Cushing’s syndrome: ations to take for preprocedural embolization of these lesions. what the interventional radiologist needs to know H Patel1, A Lu2, F Kang3, A Li4 Abstract No. 982 1Rutgers Robert Wood Johnson Medical School, Lawrenceville, NJ, 2Rutgers Robert Wood Johnson Medical School, Piscataway, Importance of dual-layer detector spectral computed NJ, 3Rutgers Robert Wood Johnson Medical School, Somerset, tomography in evaluation of post-middle meningeal NJ, 4University Radiology Group, Livingston, NJ artery embolization patients LEARNING OBJECTIVES: 1. Overview of Cushing’s syndrome (CS) and its B McCabe1, M Naveed1, A Desai2, A Syal3, B Natarajan4, P Brady5 diagnosis. 2. Role of inferior petrosal sinus (IPS) sampling in diagnos- 1Einstein Medical Center, Philadelphia, PA, 2Einstein Health Care ing Cushing’s disease. 3. IPS sampling technique/protocol. 3 Network, Philadelphia, PA, Einstein Hospital, Philadelphia, BACKGROUND: CS is a constellation of signs/symptoms resulting from 4 5 PA, N/A, Villanova, PA, Albert Einstein Medical Center, chronic hypercortisolism, which may due to exogenous or endoge- Philadelphia, PA nous sources. Endogenous sources are classified as ACTH-dependent 106 | e-Posters SIR 2020 Annual Scientific Meeting

(pituitary tumor or ectopic ACTH-producing tumor) or ACTH-in- treat the conditions affecting the joint compartments and soft tissue dependent (adrenal adenoma producing cortisol). H&P, imaging, around the temporomandibular joint. (2) Interventional sialography and biochemical workup is performed, to prove ACTH-dependent and management: Used to detect salivary stones, strictures and there- CS. Interventional radiology may be consulted for IPS sampling for after remove the stones or open the duct through catheter-based patients with ACTH-dependent CS with a pituitary microadenoma ≤6 procedures. (3) Embolization: It is used for vascular tumors and mal- mm, to potentially diagnose Cushing’s Disease (CD). If CD is diagnosed, formations affecting the maxillofacial region and epistaxis. The vas- patient proceeds to surgery. cular anomalies include hemangioma, arteriovenous malformations, venous malformations, and lymphatic malformations. (4) Dacrocysto- CLINICAL FINDINGS/PROCEDURE DETAILS: Under fluoroscopy, both gram and interventions: Used to see the course of lacrimal duct and femoral veins are accessed and microcatheters are directed to the ori- manage complications like stones and strictures using interventional fices of the left and right IPS. Diagnostic venography follows. 60% of techniques. patients have symmetric pituitary venous drainage and most of the venous outflow from each side of the pituitary drains into the ipsi- CONCLUSION AND/OR TEACHING POINTS: Maxillofacial IR is currently in lateral IPS. Variant IPS anatomy is amenable to sampling provided its infancy and undergoing rapid development, it has already expanded the IJV demonstrates a connection with the IPS. 2 Baseline samples to make a lot of surgical procedures obsolete and will continue to so as of ACTH, cortisol, and prolactin, are collected from the right femoral more and more techniques are developed. sheath (peripheral sample) and both IPSs (central samples). CRH is then administered at 1 ug/kg, up to 100ug. Post-CRH sampling from the periphery and both IPSs is obtained at 3, 5, and 10 min. Simultane- Abstract No. 985 ous IPS sampling is imperative to avoid error due to temporal variation Middle meningeal artery embolization for chronic in ACTH secretion and to account for lateralization in blood flow from subdural hematomas the anterior pituitary as it drains into the petrosal sinuses. A positive test for CD is indicated by a pre-CRH central/peripheral ACTH >2, or K Man1, M Prasad1, J Shim1, S Calhoun1, T Yablonsky1 post-CRH ratio >3(up to 96% sensitivity). Specificity approaches 100%. 1Morristown Medical Center, Morristown, NJ The patient should be monitored for signs of cerebral ischemia, which warrants prompt procedure termination. LEARNING OBJECTIVES: 1. Review the etiologies and disease course of subdural hematoma (SDH). 2. Review the diagnostic imaging charac- CONCLUSION AND/OR TEACHING POINTS: IPS sampling is the gold stan- teristics of SDH at various stages of acuity/chronicity. 3. Review the dard in diagnosing CD in ACTH-dependent CS with equivocal non- indications, contraindications, and clinical considerations for middle invasive workup. With an understanding of the evaluation of CS, the meningeal artery (MMA) embolization in the setting of chronic SDH. interventional radiologist can be a partner in this complex diagnosis. 4. Describe the procedure and technical considerations for MMA embolization. 5. Describe clinical and imaging follow-up after MMA Abstract No. 984 embolization.

BACKGROUND: Chronic SDH is a common neurological disease process Maxillofacial interventional radiology among elderly populations with high recurrence rates, ranging from T Garg1, V Garg2, A Shrigiriwar1 2% to 37% in the literature. Complications of chronic SDH can range widely, from chronic headaches to seizures or focal neurological defi- 1Seth GS Medical College & KEM Hospital, Mumbai, cits. The pathophysiology of the disease is thought to be related to Maharashtra, 2Dr. DY Patil University School of Dentistry, Mumbai, Maharashtra an initial mechanical injury that weakens the dura-arachnoid interface and induces an inflammatory reaction involving neoangiogenesis of LEARNING OBJECTIVES: (1) To learn about applications of interven- fragile blood vessels and fibrinolysis preventing clot formation, leading tional radiology (IR) in the maxillofacial region. (2) To learn about the to recurrent/continued hemorrhage. A chronic SDH is contained within different percutaneous and transarterial IR procedures performed by a dural outer membrane, which is fed via meningeal arteries. Emboli- maxillofacial and interventional neuroradiologist. zation of the MMA is thought to control the ongoing hemorrhage in the SDH membrane and allow for resolution of the hematoma. BACKGROUND: Maxillofacial IR is one of the most progressing areas of radiology where imaging techniques are used to perform procedures CLINICAL FINDINGS/PROCEDURE DETAILS: This educational exhibit will that previously were managed via dangerous, disfiguring, long surger- review the disease course and imaging characteristics of SDH. We dis- ies which lead to a large number of postoperative complications. The cuss methods of angiography, microcatheterization, and embolization development in this field started along with interventional neuroradiol- of the MMA as a treatment option for chronic SDH. We present a case ogy as they frequent manage disease in the neck area and there has series of patients treated with MMA embolization at our institution. been a rapid increase in the number of procedures which can now be CONCLUSION AND/OR TEACHING POINTS: Middle meningeal artery performed by minimally invasive techniques. embolization is a minimally invasive treatment option that can break CLINICAL FINDINGS/PROCEDURE DETAILS: The procedures which are the cycle of chronic SDH and improve patient quality of life. currently being performed in the maxillofacial region are (1) Temporo- mandibular joint arthroscopy and arthrography: Used to visualize and SIR 2020 Annual Scientific Meeting e-Posters | 107

Abstract No. 986 LEARNING OBJECTIVES: • Review the current standard of care for angiography and preoperative embolization for a hypervascular head and Preoperative embolization of intracranial meningiomas: neck tumors. • Review endovascular embolization techniques and an endovascular case series and literature review embolic material of hypervascular head and neck tumors. • Discuss the E Yannone1, D Petrov2, C Li1, R Williamson3 practice of direct tumor embolization of head and neck tumor, highlighting a case of an unusual, hypervascular nasal tumor successfully 1Allegheny Health Network, Pittsburgh, PA, 2Allegheny General embolized by direct puncture via transnasal approach. Hospital, Pittsburgh, PA, 3Allegheny Health Network, Pittsbugh, PA BACKGROUND: Surgical resection of hypervascular head and neck LEARNING OBJECTIVES: (1) Review intracranial meningiomas and dis- tumors carries a significant risk of intraoperative bleeding correlated cuss the role of preoperative transarterial embolization. (2) Examine with tumor size and vascularity. Preoperative embolization of these three cases of preoperative meningioma embolization to discuss cra- hypervascular tumors has been shown to decrease intraoperative nial arterial anatomy, meningioma characteristics, embolization tech- bleeding as well as decrease patient morbidity, mortality and length of niques, and embolic agents used. (3) Review the surgical outcomes hospital stay. However, variability in tumor location, size and feeding and 6-month follow-up of each patient. (4) Review available literature arteries lends a wide scope of the route of tumor access and embolic to evaluate techniques and embolic agents most often utilized. choices. While endovascular techniques are most common, recent

BACKGROUND: Intracranial meningiomas are vascular tumors that literature has demonstrated that liquid embolic agents administered may require surgical resection, particularly in clinically symptomatic by direct puncture technique can be utilized either in conjunction with patients. Preoperative transarterial embolization has been shown to endovascular embolization or used alone when the risk of nontarget decrease intraoperative blood loss and time in surgery. Preoperative embolization is too great for endovascular embolization. embolization may also lower postoperative complication rates for CLINICAL FINDINGS/PROCEDURE DETAILS: We discuss preoperative tumors in challenging locations. Successful embolizations have been embolization of hypervascular head and neck tumor with DSA cor- performed in various locations and arterial supplies, but there has relates as well as a review of endovascular technique including embolic been some controversy reported over the benefits of different embolic and catheter section. Further discussion regarding direct tumor embo- agents. Much of the literature consists of case reports or single-insti- lization of hypervascular head and neck tumor where endovascular tution studies, limiting standardized recommendations regarding pre- embolization is at high risk for nontarget embolization. We highlight operative embolization. a case of a hypervascular lobular capillary hemangioma within the

CLINICAL FINDINGS/PROCEDURE DETAILS: Our exhibit will review nasal cavity managed by direct tumor embolization via a transnasal the angiographic evaluation and transarterial embolization of three approach with a liquid embolic agent. intracranial meningioma cases. The exhibit includes imaging that CONCLUSION AND/OR TEACHING POINTS: Preoperative embolization of demonstrate: Location of intracranial meningiomas, important arterial hypervascular head and neck tumor is an effective method to decrease anatomy, embolic agents used, and post-embolization angiography of the rate of bleeding during surgical resection. Hypervascular head and the tumors. Imaging modalities include CT, MRI, and arterial angiog- neck tumors at high risk for nontarget embolization can be effectively raphy. Each case will discuss reported surgical blood loss, length of embolized by direct tumor embolization with a liquid embolic. surgery, and complications encountered by the 6-month follow-up. A literature review will provide an overall understanding of the size and location of meningiomas most often embolized, embolic agents used, Abstract No. 988 and success rates. Digital boot camp: grading intracranial collaterals CONCLUSION AND/OR TEACHING POINTS: Meningioma embolization has been shown to improve outcomes during surgical resection. Lack A Efendizade1, D Cohen-Addad2, K Hewitt1, H Brent1, Z Farooq3, D 1 of randomized control trials limits recommendations regarding which Bell tumors to select and which embolic agents are most effective. Under- 1SUNY Downstate Medical Center, Brooklyn, NY, 2SUNY Downstate standing the various techniques and agents used is important for neu- Medical Center, Brooklyn, NY, 3N/A, Brooklyn, NY rointerventionalists who may be looking to incorporate this procedure LEARNING OBJECTIVES: Review concepts of collateral vessel forma- into their practice. tion, and its relevance to patient selection for thrombectomy of intracranial large vessel occlusion. Describe a web-based application that Abstract No. 987 teaches trainees to grade collateral status on a spectrum using intracranial CT angiography. Learn how to apply the findings on intracranial Victory smells like garlic: a practical and pictorial review CTA for appropriate patient selection for thrombectomy in acute isch- of endovascular and direct tumor embolization of emic stroke (AIS). hypervascular head and neck tumors BACKGROUND: In a typical stroke algorithm, an initial noncontrast D Hillman1, P Williams1, G Mitchell1, H Marin1 head CT is performed to exclude intracranial hemorrhage (in addi- 1Henry Ford Hospital, Detroit, MI tion to other exclusionary criteria) such that an IV thrombolytic agent can be administered. With more recent advances in understanding 108 | e-Posters SIR 2020 Annual Scientific Meeting

of emergent large vessel occlusion (LVO), several trials (MR CLEAN, family has realistic outcome expectations after intervention. Cannulating ESCAPE, EXTEND-IA, REVASCAT, and DAWN) have heralded the era a diseased type III aortic arch, which is prevalent in patients of advanced of thrombectomy for LVO. The most recent DAWN trial has shown that age, is usually the most challenging aspect of the procedure. Appropriate a subset of patients are viable candidates for thrombectomy up to 24 catheter and sheath selection and avoidance of balloon occlusion make hours after last known well. The ability to identify this “subset” then carotid access easier. The next typical pitfall is diseased and tortuous becomes of crucial importance. The ultimate question in patient selec- carotid siphon. For this reason, having a lower threshold for stent-treiver tion is whether the symptomatology matches the core infarct size and utilization may contribute to reduced procedural complications and faster location seen on imaging. procedure times. Often, larger aspiration catheters are more difficult to be safely advanced into the brain and can have complications of dissection or CLINICAL FINDINGS/PROCEDURE DETAILS: Cerebral collateral circu- carotid-cavernous fistula which we will present. lation refers to vascular structures which compensate for loss of or impaired blood flow in the normal distribution. It is the presence of CONCLUSION AND/OR TEACHING POINTS: EVS therapy can be safely these collaterals which allow the stroke team to determine the volume and effectively performed in nonagenarian stroke patients provided of Penumbra (hypoperfused, though viable tissue), and it is the very patients are carefully selected and proper technique is used. same compensatory vascular supply that that correlates with imaging findings on perfusion mapping. Fundamentally, if the stroke symptoms do not correlate with core infarct size, there is potential for functional Abstract No. 990 recovery post-revascularization. Ditch digging: the art of drains CONCLUSION AND/OR TEACHING POINTS: Several collateral grad- J Huang1, A Thabet1, R Uppot1, K Yamada1, R Arellano1, P Mueller1 ing systems have been proposed, based both on DSA and CTA. We 1 describe a web-based application that entrains the user to accurately Massachusetts General Hospital, Boston, MA grade collateral vascular supply to a region of compromised blood LEARNING OBJECTIVES: The Learning Objective of this presentation is flow in the setting of AIS using CTA source images, for the purpose of to serve as a resource to aid individuals in the care and management patient selection. Using this tool, trainees learn the spectrum of col- of complex drainages built upon over 45 years of experience at a high lateralization in cerebrovascular blood supply, which is an important volume center. predictor of post-stroke outcome. BACKGROUND: Drain placements and management remains a staple of many, if not all, interventional radiology practices. Although life pre- Abstract No. 989 serving, drains are rarely considered desirable and patients often look forward to their removal. There are many methods and criteria that Endovascular stroke therapy in nonagenarians: selection people follow before removing a drain usually surrounding low output, and pitfalls collapsed cavity, and lack of systemic symptoms. However, there are J Springer1, A Desai1, B McCabe1, R Ahuja1, P Brady1 situations where these general criteria may not apply such as the case when the drain is in a particularly tenuous position such as the mediasti- 1Albert Einstein Medical Center, Philadelphia, PA num, when there is the presence of a fistula, when the collection involves LEARNING OBJECTIVES: 1. Correctly select advanced age (>90) stroke proteolytic enzymes, and when the collection recurs despite satisfying patients for endovascular thrombectomy 2. Learn to recognize and traditional removal criteria. We the authors would like to present our overcome the pitfalls of endovascular treatment in nonagenarians management methods cultivated over 45 years of experience.

BACKGROUND: Early endovascular stroke (EVS) treatment for large CLINICAL FINDINGS/PROCEDURE DETAILS: “Complex” drainage scenar- vessel occlusions was controversial in patients over 80 years of age ios: I. Pancreatic necrosis Size/Type: >14 Fr, as large as possible. Multi- due to the concern that risks of intervention may outweigh benefits. purpose or Thal drain. Maintenance: 2 week interval CT and drain check Over the last 3 years at our institution no age cut off has been used Removal criteria: Normal CT, clear drainage, no pockets II. Mediastinal for EVS treatment. This has resulted in successful EVS treatment of Size/Type: Smaller sized drain, usually 8-12 Fr Dawson Mueller Main- many nonagenarians. Appropriate patient selection is critical in order tenance: 2 week interval CT and drain check Removal criteria: Normal to improve patient outcomes. Factors such as anatomic variation and CT, drainage <20cc/day, no pockets, no fistula III. Fistulous Connection patient comorbidities can become pitfalls in this patient population Size/Type: Small catheter usually 8-12 Fr Dawson Mueller, needs to be even for the most experienced interventionalist. away from the fistula Maintenance: 2 week interval CT and drain check Removal criteria: No obstruction, no foreign body, patient eating and CLINICAL FINDINGS/PROCEDURE DETAILS: Rather than age, patient evacuating normally. IV. Recurrent abscess Size/Type: Typically at least premodified Rankin score (>2) is the most important clinical component a 14-Fr MP Maintenance: 2 week interval CT and drain check Removal in selection of stroke patients for EVS therapy. We have observed that criteria: No fistula, no collection, drainage under 20cc/day. elderly patients are often able to tolerate ischemia better than younger patients due to multiple factors, including collateral perfusion pathways CONCLUSION AND/OR TEACHING POINTS: Drain care and management from chronic hypoperfusion and cerebral atrophy, permitting for edema can and often represents the ultimate in longitudinal care where all the without shift or herniation. Conversely, recovery of functional status is also skills of the individual will be utilized to treat the patient. It is not a glorious delayed in this age group, and therefore it is imperative that the patient’s or attractive proposition but one that requires patience and empathy. SIR 2020 Annual Scientific Meeting e-Posters | 109

Abstract No. 991 disposable endoscopes - Illustrate technical success and complications of PBE. Examine the cost and logistical benefits of disposable Biliary intervention: beyond the basics versus reusable endoscopes.

1 2 1 2 A Sadeghi , D Tran , S Calhoun , W Vanlandingham BACKGROUND: PBE remains a rare procedure in interventional radiol- 1Morristown Medical Center, Morristown, NJ, 2University of ogy (IR), providing direct visualization of the biliary system for diag- Oklahoma Health Sciences Center, Oklahoma City, OK nosis and treatment. PBE has been shown to be safe and effective, and favored especially in patients with altered anatomy prohibiting a LEARNING OBJECTIVES: Discuss clinical presentations and indications peroral approach. Traditionally, reusable endoscopes have been uti- in patients requiring biliary intervention. Review biliary tree anatomy lized for PBE, but come with the disadvantages of high upfront capital and common anatomic variants using CT, MR, US, and fluoroscopy. costs and logistical barriers such as sterilization and repair. Recently, Apply knowledge using case examples. the development of disposable, single-use endoscopes may allow IR

BACKGROUND: Interventional radiology (IR) is often consulted to aid practices to bypass these financial and logistical hurdles. in management of hepatobiliary disease and postoperative complica- CLINICAL FINDINGS/PROCEDURE DETAILS: Both reusable (Olympus tions. Providing minimally invasive, high impact solutions is the cor- URF-2) and disposable (Boston Scientific LithoVue, Verathon GlideS- nerstone of IR. The purpose of this educational exhibit is to present cope BFlex) digital endoscopes will be reviewed, including comparative complex hepatobiliary cases requiring IR, and to correlate imaging discussion on device metrics, PBE technical success, and complica- with clinical findings. tions, with examples shown. Cost analysis of disposable, single-use

CLINICAL FINDINGS/PROCEDURE DETAILS: Patients requiring biliary endoscopes versus reusable endoscopes for PBE on a cost-per-case intervention can be generally divided into those with mass obstruc- basis will be illustrated, demonstrating significant cost savings for sin- tion, those requiring bridging until definitive management, or both. gle-use endoscopes (BFlex: $295/case; LithoVue: $1500/case) over The clinical history is important because these patients often pres- reusable endoscopes (URF-2: $4934/case). Economic constraints for ent with similar symptoms: jaundice, elevated liver and pancreatic reusable endoscope use are primarily due to low procedure frequency, enzymes, and sometimes cholangitis. Cholangiocarcinoma and pan- fixed capital costs, and variable repair expenses. Additional logisti- creatic adenocarcinoma are major contributors to biliary obstruction, cal considerations for reusable endoscopic systems include complex especially since they arise from ductal cells themselves. The prognosis monitor towers, sterilization requirements, and turnaround time. is poor, likely related to degree of vascular invasion and distant metas- CONCLUSION AND/OR TEACHING POINTS: Disposable, single-use endo- tasis at presentation. A patient with obstructive jaundice from a large scopes may provide a safe and effective alternative to disposable pancreatic adenocarcinoma benefits from a biliary drain. In a differ- endoscopes for patients undergoing PBE. By avoiding high capital ent scenario, the same patient who undergoes surgery and devel- costs and several logistical barriers, these single-use endoscopes may ops abdominal pain from biliary leak benefits from a stent to reduce allow incorporation of PBE procedures into IR practices that are oth- symptoms until operative management. Likewise, a patient post erwise unattainable. esophagectomy and radiation with new duodenal stricture benefits from an internal-external drain and stent placement. Lastly, patients with extensive choledocholithiasis, hemorrhagic and perforated chole- Abstract No. 993 cystitis, and bilomas among others also greatly benefit from a variety of biliary interventions. External biliary drainage through the gallbladder for ascending cholangitis: when failure is not an option CONCLUSION AND/OR TEACHING POINTS: The population requiring biliary intervention ranges from benign to malignant in etiology. A careful A Podlaski1,2, I Dahan1,2, I Chiong1,2 review of biliary and vascular anatomy, proficiency with multimodal 1MetroHealth Medical Center, Cleveland, OH, 2 Case Western imaging, and knowledge of the biliary pathology itself allows the inter- Reserve University, N/A ventional radiologist to provide high impact case with as low risk as LEARNING OBJECTIVES: Discuss indications for access to the biliary possible. system using a percutaneous transcholecystic approach. Describe the need for biliary decompression in cases of ascending cholangitis. Abstract No. 992 Detail an alternative method of biliary access and decompression in a patient with ascending cholangitis and severe liver dysfunction. Disposable endoscopes: incorporating percutaneous BACKGROUND: Percutaneous transcholecystic access to the biliary sys- biliary endoscopy into interventional radiology practice tem is a technique that may be utilized for indications such as placement by avoiding high capital costs and logistical barriers of a common bile duct (CBD) stent, removal of CBD stones, and failed R England1, H Singh1, K Hong1 percutaneous transhepatic cholangiography. However, this technique 1Johns Hopkins Hospital, Baltimore, MD can also be used for decompression in critically ill patients. Placement of a transhepatic biliary drainage catheter can be traumatic, especially LEARNING OBJECTIVES: Review the indications and advantages of per- in a coagulopathic patient. Despite being a potentially lifesaving pro- cutaneous biliary endoscopy (PBE). Recognize various reusable and cedure, this can be very high risk. Severe ascending cholangitis has a 110 | e-Posters SIR 2020 Annual Scientific Meeting

mortality rate approaching 100% with conservative therapy alone. A of benign anastomotic strictures developing at the choledochojejunal transperitoneal approach to gallbladder canalization with subsequent anastomosis after definitive surgical repair. transcholecystic access provides an alternative route for biliary drain- CONCLUSION AND/OR TEACHING POINTS: Imaging and percutaneous age in patients with ascending cholangitis and significant bleeding risk. interventions performed by interventional radiologists are critical CLINICAL FINDINGS/PROCEDURE DETAILS: A 68-year-old man with an in the multidisciplinary management of complicated patients with existing common bile duct stent presented with ascending cholangi- adverse outcomes after cholecystectomy. tis which progressed to septic shock. Imaging revealed obstruction of the CBD at the site of the stent. The interventional radiology (IR) team was consulted and placed a percutaneous cholecystostomy tube at Abstract No. 995 the bedside by way of a transperitoneal approach. Later, IR was again Percutaneous biliary endoscopy: a comprehensive consulted for percutaneous transhepatic cholangiography and biliary education program for developing skills in interventional drain placement. The patient was noted to be coagulopathic. A Glide- radiology endoscopy wire was inserted through the existing cholecystostomy tube and into the gallbladder. The cholecystostomy tube was removed and a Beren- R England1, H Singh1, A Solomon1, O Kutsenko2, R Srinivasa3, J stein catheter was advanced over the wire. The wire and catheter were Chick4, K Hong1 then advanced through the cystic duct into the intrahepatic bile ducts, 1Johns Hopkins Hospital, Baltimore, MD, 2SUNY Upstate University at which point they were exchanged for an 8-Fr biliary drain. Hospital, Syracuse, NY, 3Ronald Reagan UCLA Medical Center, Los Angeles, CA, 4University of Washington, Seattle, WA CONCLUSION AND/OR TEACHING POINTS: Access to the intrahepatic biliary system via a transcholecystic approach is a feasible and effec- LEARNING OBJECTIVES: - Recognize indications of percutaneous bil- tive technique for biliary decompression in the critically ill patient with iary endoscopy (PBE). Review PBE procedure techniques. Illustrate ascending cholangitis. available low-fidelity and high-fidelity endoscopy simulation options.

BACKGROUND: PBE is an emerging technique in interventional radiol- Abstract No. 994 ogy (IR), providing direct visualization of the biliary system for diagnosis and treatment. PBE has been shown to be safe and effective, More than just a bile duct injury: managing complex and favored especially in patients with altered anatomy prohibiting a hepatobiliary injuries after cholecystectomy peroral approach. More readily available IR education and simulation V Zavaletta1, G Peters1 training for PBE is required to address the increased prevalence of this procedure. 1Emory University, Atlanta, GA CLINICAL FINDINGS/PROCEDURE DETAILS: The indications, patient LEARNING OBJECTIVES: (1) To illustrate through case presentation the preparation, procedure setup, equipment selection, endoscopic tech- importance of image-guided procedures in the evaluation and man- nique, and outcomes for PBE will be reviewed, highlighting select agement of adverse outcomes related to cholecystectomy. (2) To raise comprehensive publications and online video tutorial. An inexpen- awareness of the optimal imaging evaluation in patients with vascu- sive, low-fidelity model for practicing hands-on endoscopy has been lar and biliary injuries after cholecystectomy. (3) Outline an approach developed, allowing for endoscopic visualization, manipulation, and to the multidisciplinary management of hepatobiliary injuries after instrumentation. Techniques for simulation assembly and use will be cholecystectomy. provided. For more advanced training, a patient-modeled, 3D-printed

BACKGROUND: Image-guided procedures are paramount in the man- liver simulator was created to allow for percutaneous, transhepatic agement of adverse surgical outcomes related to cholecystectomy. access to a representative biliary system, including cystic and ductal Although a majority of patients will require re-operation, the imaging components. Case examples will be reviewed. expertise and percutaneous skill set of the interventional radiologist CONCLUSION AND/OR TEACHING POINTS: Percutaneous biliary endos- are important in defining the problem and temporizing the patient copy is a growing procedure for advanced IR practices. Development during the interval between the initial operation and definitive surgical of a comprehensive curriculum for developing skills in this procedure is repair. essential. Both low- and high-fidelity simulation models allow for grad-

CLINICAL FINDINGS/PROCEDURE DETAILS: We present a case series uated hands-on training for PBE. illustrating the types of injuries encountered, optimal imaging evaluation of these injuries and a variety of percutaneous techniques used to Abstract No. 996 successfully manage adverse outcomes of cholecystectomy as a part of a multidisciplinary team. Complications presented include hepatic Percutaneous transhepatic cholangioscopic lithotripsy for artery clipping/occlusion leading to right hepatectomy with hepatico- removal of common bile duct stones jejunostomy, bile duct injury requiring biliary drainage and repair with Roux-en-Y anastomosis, cystic duct stump leak, and choledocholithi- M Boumezrag1, E Cohen1 asis. We will also show examples of percutaneous treatments in cases 1Medstar Georgetown University Hospital, Washington, DC SIR 2020 Annual Scientific Meeting e-Posters | 111

LEARNING OBJECTIVES: This exhibit will use a case-based approach to provide GB decompression, biliary drainage and cholangiography. In (1) demonstrate the successful use of percutaneous transhepatic chol- patients who underwent previous surgery or who have intolerance or angioscopic lithotripsy (PTCSL) in a patient with a common bile duct anxiety for endoscopy, in cases of having difficulties to perform PTBD, (CBD) stone and (2) review the applications, instruments, and tech- or in patients who have previously undergone percutaneous chole- niques of PTCSL. cystostomy, percutaneous transcholecystic interventions can be performed as an alternative route. BACKGROUND: In patients with aberrant anatomy, ERCP can be technically challenging and often results in failure to access the biliary CLINICAL FINDINGS/PROCEDURE DETAILS: Cystic duct (CD) cannulation system. For these situations, a percutaneous approach can be used is necessary to perform various trancholecystic interventions. For the to achieve similar outcomes. PTCSL involves two procedures. The first successful cystic duct cannulation perform a GB puncture in the long is to make a tract between the skin and the bile duct by percutaneous axis direction of the GB, keep catheter drainage for 3 days or more to transhepatic biliary. The second involves dilatating the tract in order to reduce inflammation of the biliary tree, insert a 8-Fr sheath into the GB pass a cholangioscope followed by lithotripsy to allow fragmentation for the back support, and use guide wires with various sizes and tips. and removal of the CBD stones. Through cystic duct cannulation, various interventional procedures such as CBD stone removal, biopsy, biliary dilation, biliary stent place- CLINICAL FINDINGS/PROCEDURE DETAILS: A 76-year-old woman pre- ment, and GI intervention can be performed. sented to the ED with persistent abdominal pain, elevated LFTs, and a dilated CBD. Several unsuccessful ERCPs were attempted to place CONCLUSION AND/OR TEACHING POINTS: Percutaneous transcholecys- a CBD stent. A percutaneous biliary drain was placed, and the patient tic interventions seems to be safe, technically feasible and clinically underwent a surgical attempt at cholecystectomy. Surgery was ham- effective procedures. Percutaneous transcholecystic approach can be pered by severe inflammatory changes; the surgeon reported that she used as an alternative route for the patient who could not use peroral had to limit her procedure due to these changes. She was then referred or transhepatic route. back to interventional radiology (IR) for removal of her biliary drain. Contrast injection into the drain demonstrated a large retained stone in the CBD. Furthermore, undiagnosed intestinal malrotation was sus- Abstract No. 998 pected after contrast in the small bowel did not cross the midline. A CT Playing nice with endoscopists: a case review of joint was ordered and confirmed this as well as heterotaxy syndrome with interventional–gastrointestinal procedures left isomerism thus explaining inability to identify/locate the papilla on ERCP. After discussion with all members of the care team, a deci- P Mody1, S Calhoun2 sion was made to attempt internalization of the drain and schedule 1Morristown Medical Center, Springfield, NJ, 2N/A, Long Valley, NJ the patient for a rendezvous procedure with the GI service if the stone could not be removed during the IR procedure. She subsequently LEARNING OBJECTIVES: (1) Provide case-based overview of interven- underwent successful percutaneous transhepatic cholangioscopic tions performed in conjunction with gastroenterology. (2) Review clin- lithotripsy by IR through the existing access. An external drain was left ical approach to planning joint interventions, as well as technique and and capped with subsequent removal after an asymptomatic capping possible complications. trial. BACKGROUND: Interventional radiology (IR) performs a wide range of

CONCLUSION AND/OR TEACHING POINTS: PTCSL offers an additional image-guided hepatobiliary and gastrointestinal procedures. There is option for management of biliary calculi, especially for patients with some overlap with procedures performed by gastroenterologists, who aberrant anatomy. This case demonstrates findings of intestinal malro- utilize an endoscopic approach. In patients with complicated pathol- tation on conventional fluoroscopy. ogy or anatomy, a combined approach may be beneficial in overcoming technical difficulties that may be encountered with a unidirectional approach. Abstract No. 997 CLINICAL FINDINGS/PROCEDURE DETAILS: This presentation will review Pictorial review of percutaneous transcholecystic complex interventions performed in conjunction with urology and interventions gastroenterology via a case-based approach. These include “rendezvous” techniques for management of complicated biliary and gastro- 1 2 J Yun , G Jung intestinal pathology, including choledocholithiasis, biliary strictures, 1Kosin University Gospel Hospital, Busan, Republic of Korea, 2Kosin and strictures of the bowel. A brief overview of the procedures will be Medical Center, Pusan, Republic of Korea given, including indications, technique, and possible complications. All cases and images are obtained via database search at our institution. LEARNING OBJECTIVES: The Learning Objectives of this review are to illustrate the various transcholecystic interventions and to discuss the CONCLUSION AND/OR TEACHING POINTS: Patients with complicated clinical significance, technical aspects and complications of this alter- hepatobiliary pathology may benefit from joint procedures between IR native access to the biliary tree. and other specialties. Multidisciplinary evaluation and communication are vital for optimal patient care. BACKGROUND: Percutaneous cholecystostomy is a well-established procedure for management of acute cholecystitis. It has been used to 112 | e-Posters SIR 2020 Annual Scientific Meeting

Abstract No. 999 BACKGROUND: Percutaneous transhepatic biliary drainage (PTBD) procedure can be used to relieve biliary obstruction. In cases of biliary Shot through the duct: treating traumatic biliary injury injury, PTBD can be used for biliary diversion as a treatment or bridge J Fu1, M Abad-Santos1, B Black1, A Suzuki-Han1 to surgery. PTBD of nondilated biliary systems can be challenging due to difficult visualization/identification. While endoscopic retrograde 1Harbor-UCLA Medical Center, Torrance, CA cholangiopancreatography (ERCP) is a valid alternative, it may not be

LEARNING OBJECTIVES: This exhibit will review established guide- a feasible option in certain cases such as hepaticojejunostomy. This lines and management of bile duct injuries in interventional radiology. educational exhibit intends to provide tips and tricks to such cases. Case-based reviews of patients presenting with typical and atypical CLINICAL FINDINGS/PROCEDURE DETAILS: Background will be pro- traumatic biliary injury (including biliary-vascular fistulas, biliary-cu- vided. Relevant tips for clinical evaluation and follow-up will be out- taneous fistulas and biliary transection) will demonstrate the acute lined. Detailed technique will be explained. Different approaches will be clinical presentation, typical workup, radiographic findings, and inter- demonstrated with advantages and disadvantages of each approach. ventional treatment options. Challenging cases will be shown. Teaching points will be emphasized.

BACKGROUND: Accidental trauma accounts for up to 5% of the total Tips and tricks will be provided. Literature review will be performed. number of biliary injuries, and of these patients, 80% to 90% are victims CONCLUSION AND/OR TEACHING POINTS: Learning different techniques of penetrating traumas from stab or gunshot wounds. A high degree and approaches to access nondilated biliary systems may potentially of suspicion for biliary injury should be maintained when a patient is improve the technical success rate of the interventionalist, and subse- found to have traumatic injury to the liver. Up to 50% of patients with quently, the clinical outcome. bile in the peritoneum at surgery do not show symptoms. In the case of extrahepatic bile duct injury, up to 20% of injuries are not detected during exploratory laparotomy. Delayed complications of biliary injury Abstract No. 1001 and biliary leakage can lead to sepsis. Understanding the standard procedural steps for interventional or noninterventional therapy is vital Transjugular insertion of biliary stent: an uncommon in ensuring appropriate management. procedure for a common dilemma

1 1 1 1 CLINICAL FINDINGS/PROCEDURE DETAILS: Early detection of biliary A Mohla , D De Cotiis , R Amin , J Chern injury can help to reduce morbidity and mortality. Technetium-99m 1Cooper University Hospital, Camden, NJ HIDA cholescintigraphy, ultrasound, and CT evaluation are valuable LEARNING OBJECTIVES: The learning objectives of this education diagnostic tests in establishing the presence of biliary injury. For defin- exhibit is to review the pathophysiology, presentation, and treatment itive diagnosis, percutaneous transhepatic cholangiography (PTC) and options for malignant biliary obstruction. We use a case-based, picto- ERCP remain the gold standard. Bilomas are the most common pre- rial review of an alternative technique utilizing a transjugular approach sentation of biliary injury secondary to hepatic ischemic necrosis and for biliary stent placement (TIBS) for those patients unable to undergo are managed with placement of drainage catheters. Traumatic gall- traditional transhepatic approach and who have failed endoscopic bladder injuries are rare, but critically ill patients can benefit from cho- stent placement. lecystostomy tube placement and ultimately cholecystectomy. Minor bile duct injuries (including many intrahepatic ductal injuries) are usu- BACKGROUND: Biliary obstruction is a debilitating complication that ally treated with biliary diversion. Hemobilia may be the first indication affects nearly 70% of patients with pancreatic adenocarcinoma or for the presence of an arterial or venous fistula; depending on severity, other biliary malignancies. Decompression alleviates patients’ pain this may be treated with embolization. and discomfort and is associated with improved outcomes in those undergoing surgical resection. Traditional means of stent placement is CONCLUSION AND/OR TEACHING POINTS: Exposure to the spectrum of endoscopically or with PTC/PBD if endoscopic placement fails. How- biliary injuries will aid in understanding the role of the interventional ever, these patients often present with co-morbidities, chiefly coagu- radiologist in the setting of trauma. lopathy or massive ascites, which preclude transhepatic intervention. Transjugular insertion of biliary stent (TIBS) is one solution that is safe Abstract No. 1000 and feasible but is rarely considered in today’s clinical practice.

CLINICAL FINDINGS/PROCEDURE DETAILS: We present a case of a 64 Tips to access nondilated bile ducts year-old man with advanced pancreatic cancer who presented with A Justaniah1, A Azzouz2 biliary obstruction after failure of an endoscopically placed stent. 1King Abdullah Medical City, Makkah, Saudi Arabia, 2King Abdullah Patient was unable to undergo transhepatic repair due to large vol- Medical City, Makkah, None ume ascites and persistent coagulopathy. A transjugular approach was undertaken utilizing a TIPS set for placement of a self-expand- LEARNING OBJECTIVES: To be able to understand the anatomy of the ing SMART stent, balloon deployed VBX stent, and cholangioplasty. bile ducts; identify nondilated bile ducts on US/CT/MRI/Fluoro; recog- Postoperatively, patient’s hyperbilirubinemia and septicemia improved nize the most common injuries and surgeries; perform the procedure; with continued stent patency. Readers of this exhibit will learn prepro- and manage these patients completely or as a bridge to surgery. cedure TIBS planning, anatomical considerations, technical aspects, SIR 2020 Annual Scientific Meeting e-Posters | 113 stent choice, and imaging landmarks. Complications, common pitfalls, Abstract No. 1003 and postoperative care will also be discussed in this exhibit. Abbvie PEG-J Tube placement with Duopa pump by CONCLUSION AND/OR TEACHING POINTS: Interventional radiologists interventional radiology for treatment of Parkinson’s play a crucial role in the treatment of malignant biliary obstruction in disease: a single-institution experience of 15 cases patients unsuitable or refractory to endoscopic techniques. Transjugu- lar biliary catheterization offers a safe, effective, and technically viable J Wells1, G Malyutin2, M Meek3, L Wyerick2, M Lotia2, T Virmani2 approach for stent placement or revision in patients with contraindica- 1University of Arkansas For Medical Sciences, Little Rock, tions to transhepatic drainage. AR, 2University of Arkansas for Medical Sciences, Little Rock, AR, 3N/A, Little Rock, AR

Abstract No. 1002 LEARNING OBJECTIVES: We describe our experience with the placement of the uniquely designed AbbVie PEG-J tube for Duopa adminis- It is not okay to pass gas: the impact of patient’s tration in the treatment of Parkinson’s disease. biopsy side—decubitus position on the occurrence of BACKGROUND: Retrospective chart review was performed of 15 complications during lung biopsy patients with Parkinson’s disease that had placement of an AbbVie G Kroma1, S Jen2, A Joseph2, G Rao3, A Chesley1 PEG-J tube by interventional radiology between 2016 and 2019. There 1University of Texas Health Science Center, San Antonio, TX, 2N/A, were 4 female and 11 male patients with a mean age of 64 (21-75). San Antonio, TX, 3University of Texas Health Science Center at San Unified Parkinson Disease Rating Scale (UPDRS) scores were docu- Antonio, San Antonio, TX mented before and after procedure in 10 patients. Patient reported symptom control at follow-up. Follow-up results after placement was LEARNING OBJECTIVES: 1. Explaining the pathophysiology of the air-re- measured at one month and one year. Complications and repeat pro- lated lung biopsy complications. 2. Listing the advantages of posi- cedures were recorded. tioning the patient with the biopsy side decubitus during lung biopsy procedure. CLINICAL FINDINGS/PROCEDURE DETAILS: Disease control was achieved in 13 patients as defined by maintaining or decreasing their BACKGROUND: Percutaneous lung biopsy is frequently required in tho- UPDRS score after the procedure and patient reporting overall satis- racic oncology practice however; it has high complication rate with faction with treatment at one month. Thirteen patients reported sat- pneumothorax rate of 15% to 45% according to prior studies. Systemic isfaction with tube and reduced symptoms. The average decrease air embolism (SAE) is another rare but potentially fatal complication. in UPDRS pre and post procedure in 10 patients was 4.2 points with Several studies have evaluated different means of reducing compli- only one patient’s score going up. At one month, two patients’ J tubes cations after percutaneous lung biopsies. This exhibit delineates the were replaced-one clogged and one dislodged. There was one pro- impact of patient’s biopsy side-decubitus position on the occurrence cedural related complication with a t-tack site infection treated with of complications during lung biopsy procedures. oral antibiotics. At one year, four patient’s J tubes had to be replaced.

CLINICAL FINDINGS/PROCEDURE DETAILS: Conflicting data exists in the One patient twice required the entire GJ system to be replaced due to literature about the influence of patient’s position on the pneumotho- incidental dislodgement. rax rate but only four studies, to our knowledge, evaluated the effect CONCLUSION AND/OR TEACHING POINTS: AbbVie PEG-J tube place- of directly performing the lung biopsy using a biopsy-side-down tech- ment for Duopa infusion improved or maintained motor fluctuation nique. Three of these studies demonstrated significant reduction of symptoms in 13 of 15 patients. One patient had worsening UPDRS the pneumothorax rate (between 61% and 69% rate reduction) using scores at one month and one patient lost to follow-up. Dislodgement this technique. Intra-pleural pressure is normally negative (less than was the most frequent cause for repeat intervention. In our experience, atmospheric pressure) because of inward lung and outward chest wall this is related to tube design which requires 4 pieces clicked together recoil. Consequently, and during lung biopsy, the air may enter the tho- to join the pull G and the J portion. racic cavity and result in pneumothorax or SAE. Placing the biopsy side down will counterpart this atmospheric-plural pressure gradient and theoretically reduces the biopsy complications. The occurrence of sys- Abstract No. 1004 temic air embolism is also reduces as biopsy side down position places the lesion below the level of the left atrium, increases the venous pres- Complications of percutaneous gastrostomy tube sure, and consequently decreases the chance of aspirating air should placement: recognition and tips for avoiding trouble the tip of the needle inadvertently placed in a pulmonary vein. P Park1, G Peters2, R Bittman1 CONCLUSION AND/OR TEACHING POINTS: Biopsy side decubitus posi- 1Emory University School of Medicine, Atlanta, GA, 2Emory tion during lung biopsy procedures reduces the incidence of air-related University, Atlanta, GA complications including pneumothorax and systemic air embolism. LEARNING OBJECTIVES: Through case presentation: 1. Illustrate early Additional potential advantage is a gravity-protection of the contra- and late complications of percutaneous gastrostomy tube placement lateral lung in patient with severe hemoptysis complicating the biopsy. 114 | e-Posters SIR 2020 Annual Scientific Meeting

2. Outline the importance of preprocedure work-up 3. Discuss strate- CLINICAL FINDINGS/PROCEDURE DETAILS: The CoapTech device con- gies to improve outcomes. sists of a gastric catheter with a balloon enclosing a magnetic bar at its distal end and an external, handheld magnet. The gastric catheter is BACKGROUND: Imaged-guided percutaneous gastrostomy tube place- passed orally into the stomach. The external magnet is used to maneu- ment is a routinely performed procedure to provide enteral nutrition ver the balloon to the desired location. When the external magnet is to patients with inadequate oral intake or for venting with impaired coupled to the magnet in the gastric tube balloon, the gastric tube bal- gastric motility. It can be performed either antegrade or retrograde. loon will be in place in the stomach pushing it flush against the inter- This common procedure can result in major complications in 1.4% to nal abdominal wall. The balloon is then filled with 30 mL of methylene 5.9% and minor complications in 7% to 45% as defined by the Society blue. This allows for complete US visualization from skin-to-stomach, of Interventional Radiology standards. The frequency of complications facilitating safe percutaneous puncture into the stomach and guide- makes it important to recognize pitfalls and know how to successfully wire-assisted placement of the gastrostomy tube. manage complications. CONCLUSION AND/OR TEACHING POINTS: Percutaneous ultrasound CLINICAL FINDINGS/PROCEDURE DETAILS: We present cases to illus- gastrostomy placement promises many benefits. Real-time visualiza- trate various complications that can occur during and after gastros- tion with US allows for identification of critical structures at the time tomy tube placement. Cases include loss of wire access after tract of puncture. The stomach must approximate the abdominal wall for dilation, tube placement outside the stomach, infection at the insertion the magnets to coapt, reducing the risk that interspersed colon will or T-fastener sites, peri-stomal leakage, vascular injury with hemor- be inadvertently punctured. PUG can be performed at bedside for rhage, accidental dislodgement, retention balloon rupture due to flush- patients too unstable to leave the ICU. Clinicians with various training ing into balloon port by nursing staff, tube malposition or migration backgrounds could perform this procedure. Additionally, because PUG causing gastric outlet obstruction and massive pneumoperitoneum. does not necessitate use of fluoroscopy, it may free up the IR suite Tips to avoid complications are given for each case. Thorough prepro- for other IR procedures allowing more patients to receive IR care in a cedure assessment and cross sectional imaging review, adequate dis- timely fashion. While the advent of PUG is promising, necessary clinical tention of the stomach, gastric puncture in lateral projection and use trials in humans are now underway. of cone-beam CT with placement of modified catheters for difficult windows are a few strategies that will be demonstrated.

CONCLUSION AND/OR TEACHING POINTS: Percutaneous gastrostomy Abstract No. 1006 tube placement can result in serious morbidity and mortality. The Gastrointestinal stenting by interventional radiology: we interventional radiologist must appreciate the potential complications still have a crucial role of the procedure, utilize meticulous technique to minimize risks and recognize and manage complications when they occur. J Lopera1, A Garza-Berlanga2 1UT Health Science Center in San Antonio, San Antonio, TX, 2N/A, San Antonio, TX Abstract No. 1005

LEARNING OBJECTIVES: To review the fluoroscopic techniques avail- Feeding the future: the promise of the percutaneous able for gastrointestinal (GI) stenting. To illustrate cases of GI stenting ultrasound gastrostomy done by interventional radiology (IR) after endoscopy has failed. To N Azimov1, C Kraus1, A Lichliter1, N Dhiman1, S Brejt1, J Susman1, J emphasize that placement of GI stenting provides many times better Weintraub1, S Reis1 palliation that enteral tubes.

1 Columbia University Irving Medical Center, New York, NY BACKGROUND: Gastrointestinal metallic stent placement was developed by IR but is rarely done by us anymore as endoscopic techniques LEARNING OBJECTIVES: The aims of this abstract are to 1) Describe took over this practice. On some occasions after endoscopic tech- percutaneous ultrasound gastrostomy and the CoapTech device. 2) niques have failed, we are mainly consulted to place decompression Discuss the potential significant benefits of percutaneous ultrasound tubes. Given our special skills with wires and catheters, we can suc- gastrostomy. cessfully perform GI stenting even in those cases that endoscopists BACKGROUND: Percutaneous fluoroscopic gastrostomy placement is have failed. one of the most common methods for placement of a gastrostomy CLINICAL FINDINGS/PROCEDURE DETAILS: Complex esophageal steno- tube in interventional radiology (IR). A new method for placement of a sis and fistulas: stenting techniques for IR. Gastroduodenal stenting in gastrostomy tube called percutaneous ultrasound gastrostomy (PUG) malignant gastric outlet obstruction. Colonic stent placement under recently received FDA clearance. PUG uses the CoapTech device along fluoroscopy. with ultrasound (US) in order to reduce the complexities associated with other methods of placement of a gastrostomy tube, ideally allow- CONCLUSION AND/OR TEACHING POINTS: GI stenting is preferable for ing patients to undergo gastrostomy insertion in a safe and timely palliation for malignant stenosis of the GI tract and it is a better alterna- manner by a wide range of clinicians. tive than placement of decompression and feeding tubes. GI stenting done by IR under fluoroscopy is an invaluable service that we can still provide, especially in those cases that endoscopy has failed. SIR 2020 Annual Scientific Meeting e-Posters | 115

Abstract No. 1007 LEARNING OBJECTIVES: 1. Outline difficulties in converting gastrostomy tubes (G-tubes) to gastrojejunostomy (GJ) tubes based on mechanical Interventions for enterocutaneous fistula in inflammatory and anatomic factors 2. Outline techniques to convert gastrostomy to bowel disease GJ tubes, including a novel technique utilizing the same gastric entry T Parnall1, I Altun1, M Kuo1, A Sill1, S Alzubaidi1, S Naidu1, G point. 1 2 3 4 1 Knuttinen , H Albadawi , I Patel , J Kriegshauser , R Oklu BACKGROUND: Although G tubes placed by endoscopists and inter- 1Mayo Clinic Arizona, Phoenix, AZ, 2Mayo Clinic Arizona, Scottsdale, ventional radiologists are functionally equivalent and have similar AZ, 3Mayo Clinic - Arizona, Phoenix, AZ, 4Mayo Clinic Scottsdale, complications rates, technical aspects of tube placement and related Phoenix, AZ gastric entry angles are quite different. PEG tubes are typically directed toward the gastric inlet whereas percutaneous G tubes are LEARNING OBJECTIVES: 1. Review the pathophysiology of enterocuta- typically directed toward the pylorus. The angle of the subcutaneous neous (EC) fistulas in patients with inflammatory bowel disease 2. Dis- track into the stomach becomes significant when conversion from G cuss the role of interventional radiology (IR) in the use of bioadhesives tube to GJ tube is desired. Despite suboptimal biomechanics, most and extracellular matrix (ECM) material for closure of EC fistulas. 3. interventional radiologists will attempt conversion of PEG tubes to GJ Provide case based illustrations to support the use of bioadhesives and tubes. When the subcutaneous track of the existing G tube is directed ECM material in the interventional setting. towards the lower esophageal sphincter, accessing the duodenum can

BACKGROUND: Inflammatory bowel disease (IBD) is a chronic inflam- be challenging and may require advanced techniques. GJ tubes suc- matory process of the small and large intestine. A rare but significant cessfully placed via this route are often under significant tension and complication is the development of spontaneous EC fistula due to the at high risk for recurrent recoiling into the stomach. transmural chronic inflammatory process of the bowel wall. Migration CLINICAL FINDINGS/PROCEDURE DETAILS: We will review various tech- of myofibroblasts allows epithelization of a tract between the intes- niques of G tube placement and successful GJ tube conversion. Partic- tine and other organs or the skin allowing leakage of bowel contents ular attention will be paid to the challenges involved with converting and can lead to nutritional deficiency. The standard treatment is sur- PEG tubes to GJ tubes. A novel method for creating a new pylorus-di- gical resection of the involved bowel, which can lead to complica- rected subcutaneous track into the stomach using “pop-the-balloon” tions including anastomotic leak, subsequent obstruction, and fistula technique will be showcased. This procedure is performed entirely recurrence. IR has been utilized in curettage of fistula tracts and more through the existing gastrostomy and does not require any new gas- recently injection of materials into the fistula tracts to stimulate clo- trostomy defect nor nasogastric tube placement. Cases will be shown sure. Debridement disrupts the epithelial layer along the tract which illustrating the mechanical advantage of GJ tubes placed by this maintains patency of the tract. Bioadhesives such as fibrin glue, prod- technique. ucts of bovine serum, and synthetic materials bridge the sides of the tract ultimately resulting in obliteration. CONCLUSION AND/OR TEACHING POINTS: Percutaneous G tube placement is a widely accepted method of enteral nutrition performed by CLINICAL FINDINGS/PROCEDURE DETAILS: We will review the efficacy multiple specialties. GJ tube conversion failure and/or recurrent gas- of bioadhesives and ECM materials in closure of EC fistulas associated tric recoiling is related to the technique of initial G tube placement. with IBD. We will also compare IR techniques with surgical closure with The pop-the-balloon technique is a tool allowing interventional radiol- respect to success rates, complication rates, and risk of recurrence. ogists to correct the angle of the subcutaneous track into the stomach, Finally, we will discuss future innovations currently being examined. thereby gaining mechanical advantage over GJ tubes converted from

CONCLUSION AND/OR TEACHING POINTS: The spontaneous devel- PEG tubes. opment of EC fistulas is a relevant complication in patients with IBD. There is a role for IR in the treatment of these fistulas and may represent an alternative to surgery in certain settings. Use of interventional Abstract No. 1009 techniques has the potential to reduce complication risks and optimize PTEG/J: how we do it success of fistula tract closure in patients with IBD who may be at higher risk of surgical complications. C Branach1, W Sherk1, J Shields2, M Sanogo2 1University of Michigan Hospital, Ann Arbor, MI, 2University of Michigan, Ann Arbor, MI Abstract No. 1008 LEARNING OBJECTIVES: -PTEG/J placement is an effective and viable Preventing recurrent gastric recoil of gastrojejunostomy minimally invasive alternative compared to standard PEG/J placement tubes by creating a new, pylorus-directed subcutaneous in patients with contraindications to typical enteral access needing track using the pop-the-balloon technique long-term tube feeding. -Patients amendable to PTEG/J placement A Levey1, P Park1, M Loya2, G Peters3, N Resnick4 include, but are not limited to, patients with ascites, overlying prom- inent gastroepiploic vessels, previous gastric resection, or those with- 1Emory University School of Medicine, Atlanta, GA, 2Emory out a good anatomical window for placement. -The PTEG technique University Hospital, Atlanta, GA, 3Emory University, Atlanta, GA, 4N/A, Atlanta, GA 116 | e-Posters SIR 2020 Annual Scientific Meeting

involves accessing the cervical esophagus and placing a feeding tube Symptom Score (IPSS) questionnaire is completed by patients to grade utilizing both sonographic and fluoroscopic techniques. the severity of 7 symptoms from 0 to 5. A total score of 0-7 is mild, 8-19 is moderate, and 20-35 describes severe disease. An additional ques- BACKGROUND: Percutaneous gastrostomy placement is the traditional tion evaluates overall quality-of-life (QoL) related to LUTS. Original method for patients needing long-term enteral feeding. However, not studies recommend therapy for IPSS≥18 and QoL≥3. Noninvasive uro- all patients can undergo this procedure, including those with gastric dynamic testing is performed to assess functional measures such as cancer, partial or total gastrectomy, transverse colonic/liver interposi- maximum urine flow rate (Qmax) and postvoid residual volume (PVR). tion, or severe ascites. PTEG placement was first developed in Japan Qmax >12 mL/sec suggests that there may be an alternative nonob- for patients with malignant obstruction, and its application and indica- structive cause for LUTS, and invasive urodynamic testing is recom- tions within clinical practice continue to expand. mended in these cases. PVR volume ≥ 300 mL is often used to indicate CLINICAL FINDINGS/PROCEDURE DETAILS: A rupture free balloon retention. A digital rectal examination and serum prostate-specific catheter is advanced into the upper esophagus above the level of the antigen should be checked before intervention to exclude malignancy. thoracic inlet and filled with contrast. From a left neck approach, ultra- Biopsy is recommended in concerning cases. Imaging with CT, MR, or sound is utilized to visualize the balloon which is punctured with an transrectal ultrasound may be used to assess prostate volume. Pros- 18-gauge needle. The purpose of the balloon is to allow “pseudo-in- tate volume >40 mL is recommended for treatment. sufflation” of the esophagus and preventing puncture of any critical CONCLUSION AND/OR TEACHING POINTS: Detailed understanding of structures within the neck. Successful puncture is confirmed, and a the preprocedure clinical evaluation for patients with LUTS is essential guidewire is advanced through the needle with the tip in the balloon. for interventional radiologists to ensure appropriate patient selection The balloon and guidewire are advanced together into the stomach. and optimize outcomes after PAE. The balloon is then removed over the guidewire in the stomach. A 16-Fr dilator and 18-Fr peel-away sheath are inserted over the wire and the tract is dilated. A 15-Fr feeding tube is inserted over the wire through Abstract No. 1011 the external sheath. Tube position is confirmed with contrast injection. The external sheath is removed and the tube is secured to the neck with Interventional treatment for iatrogenic urine leakage a Statlock mechanism. The feeding tube is ready for use immediately. from the urinary tract

CONCLUSION AND/OR TEACHING POINTS: In select patients, percuta- T Seo1, M Song2, W Yang3 neous transesophageal gastrostomy tube placement is an effective 1Korea University, Guro Hospital, Seoul, Republic of Korea, 2Korea alternative to percutaneous gastrostomy tube placement. University Guro Hospital, Seoul, Republic of Korea, 3Korea University Guro Hospital, Seoul, Republic of Korea

Abstract No. 1010 LEARNING OBJECTIVES: Readers can apply these procedures in situation of uncontrolled urine leakage after iatrogenic injury. Various inter- Clinical evaluation of patients undergoing prostatic artery ventional procedure was applied for urine leakage which was difficult embolization to treat by simple procedure. S Cheng1, A Picel2 BACKGROUND: Urine leakage is benign condition, but it degrades qual- 1Stanford University, Stanford, CA, 2N/A, San Francisco, CA ity of life, and the suffering is unbearable. We experienced 3 cases of uncontrolled urine leakage from kidney, ureteropelvic junction and LEARNING OBJECTIVES: (1) Understand the components of a detailed urinary bladder, respectively. These cases were managed with various patient evaluation before prostatic artery embolization (PAE) for procedures based on percutaneous nephrostomy (PCN). benign prostatic hyperplasia (BPH). (2) Review the indications for PAE based on preprocedure symptom scores, urinary function, and pros- CLINICAL FINDINGS/PROCEDURE DETAILS: Case 1. History: laparoscopic tate size. calyceal diverticulectomy and stone removal in upper pole of the left kidney. Problem: perirenal and perisplenic urinoma. Treatment: percu- BACKGROUND: PAE is a minimally invasive treatment option for taneous drainage, double-J ureteral stent (DJUS) and sclerotherapy patients with symptomatic BPH. Several conditions may lead to both- of calyceal diverticulum with N-butyl cyanoacrylate. Case 2. History: ersome lower urinary tract symptoms (LUTS). PAE is successful in lateral fixation of vertebral bodies due to tuberculous spondylitis. patients with LUTS due to benign prostatic enlargement and bladder Problem: urinoma by iatrogenic rupture of ureteropelvic junction. outlet obstruction. Detailed preprocedure evaluation is necessary to Treatment: placement of the new DJUS by Rendez-Vous technique of exclude other conditions that may cause LUTS, such as malignancy, cystoscopically inserted DJUS and percutaneously inserted catheter in infection, urethral stricture, detrusor under or over activity, stones, urinoma. Case 3. History: hysterectomy and radiation therapy for cer- and neurogenic bladder. A complete clinical evaluation is necessary to vix cancer, spontaneous rupture of urinary bladder with extension to select patients most likely to benefit from PAE. proximal thigh, disarticulation of hip joint. Problem: no wound healing

CLINICAL FINDINGS/PROCEDURE DETAILS: Clinical evaluation con- of incision site due to continuous urine leakage. Treatment: PCN and sists of a complete medical history and physical exam with review of occlusion of the both ureters with ureteral occlusion stents. medications and prior urologic treatments. The International Prostate SIR 2020 Annual Scientific Meeting e-Posters | 117

CONCLUSION AND/OR TEACHING POINTS: Appropriate procedures Abstract No. 1013 based on PCN would be helpful to manage uncontrollable urine leakage from urinary tract. Neobladder salvage with an alternative pathway for urinary drainage

1 2 2 Abstract No. 1012 G Wade , Z Wenker , D Vu 1University of Cincinnati, Cincinnati, OH, 2University of Cincinnati Interventional radiology treatment for ureterosciatic Medical Center, Cincinnati, OH hernia: percutaneous catheter and guidewire-assisted LEARNING OBJECTIVES: Highlight additional techniques and benefits reduction for urinary drainage beyond nephrostomy and nephroureteral stenting W Le1, H Bai2, V Nguyen3, G Soares3 in young active patients with complicated anatomy. 1Brown University, Providence, RI, 2Department of Diagnostic BACKGROUND: An otherwise healthy 29-year-old woman presented Imaging, Providence, RI, 3N/A, Barrington, RI to interventional radiology (IR)service with past medical history of

LEARNING OBJECTIVES: To illustrate the incidence and traditional bladder exstrophy causing reflux and ESRD, neobladder with Mitro- management of ureterosciatic hernia and describe an interventional fanoff creation, and transplanted kidney in the right lower quadrant. radiology (IR) treatment approach via percutaneous catheter and Transplant procedure was complicated by ureteral stricture requiring wire-assisted reduction nephrostomy placement with salvage procedure attempted by using the native right ureter as a conduit to the neobladder, but ureteral stric- BACKGROUND: Ureterosciatic hernia is the rarest form of sciatic hernia ture recurred. Urine output from the transplant kidney had been man- with less than thirty reports published worldwide. While clinical pre- aged by IR placed nephrostomy tube for approximately 2 years after sentation varies depending on etiological factors, general symptoms several failed attempts to traverse the transplant and native ureters. from the cases reported include local swelling as well as pressure and flank pain in the pelvic region. Traditional surgical management has CLINICAL FINDINGS/PROCEDURE DETAILS: Initially, percutaneous involved excision of the hernia with reimplantation of the remaining access was obtained under CT guidance with a 21-G 15 cm needle from ureter, reduction of ureter length, and transabdominal/transgluteal the left lower abdomen into the distended neobladder with needle tip hernia reduction plus ureter fixation. More recently, treatment options terminating in a compound calyx in closest proximity to the neoblad- include isolated laparoscopy, robot-assisted laparoscopy, and even der wall. A 0.018-inch guidewire was then coiled in the transplant kid- transvaginal manual reduction. Finally, reports regarding IR treatment ney collecting system. Patient was transferred to the fluoroscopy suite involve percutaneous catheter and guidewire-assisted reduction. where new percutaneous access was obtained through an upper pole calyx and a 7-Fr sheath was placed into the collecting system. Through CLINICAL FINDINGS/PROCEDURE DETAILS: This presentation highlights the sheath a one-step snare device was used to grasp the 0.018-inch the case of an 85-year-old woman with no history of stone disease, guidewire from the lower pole neobladder access site and pulled hematuria, or recurrent urinary tract infection who presents to the through the upper pole sheath creating a through and through flossed emergency department with left lower quadrant and flank pain for access. A 5-Fr Neff catheter was then placed over the guidewire and one week. Severe hydronephrosis of the left kidney was found second- into the neobladder followed by placement of an Amplatz 0.035-inch ary to herniation of the left ureter into the greater sciatic foramen as guidewire. The 5-Fr catheter was exchanged for a capped 8-Fr Skater demonstrated on CT. After gaining access to the collecting system, a drainage catheter after serial dilation. Patient followed up after one percutaneous catheter and wire were placed antegrade, and the ureter week for upsizing of the drainage catheter to 10-Fr without complica- was reduced from the sciatic hernia with subsequent placement of a tion. After 8 weeks, the external-internal catheter was converted to a percutaneous nephroureterostomy catheter (PCNU). Postprocedure 14-F internal stent that will be exchanged via snare technique through saw no significant complications and patient was discharged the next the Mitrofanoff. day. One month later, the PCNU was converted to a double J internal ureteral stent with routine maintenance and exchanges performed by CONCLUSION AND/OR TEACHING POINTS: This new technique was urology. successfully performed to allow an otherwise healthy and functional young female patient to achieve a more normal and active lifestyle CONCLUSION AND/OR TEACHING POINTS: Percutaneous catheter and without the burdens of a urinary drainage bag. guidewire-assisted reduction of ureterosciatic hernia is an effective, minimally invasive treatment option that is not limited to just elderly patients or poor surgical candidates. 118 | e-Posters SIR 2020 Annual Scientific Meeting

Abstract No. 1014 Indications of emergent PCNs (total 41 PCN tracts) Urinary tract obstruction + UTI/sepsis 25 (60%) Usefulness of emergency percutaneous nephrostomy tubes for subsequent definitive procedures Urinary tract obstruction + AKI 16 (40%) Urinary tract obstruction + UTI/sepsis + AKI 4 A Salaskar1, P Mufarrij2, D Scher2, A Venbrux2, S Sarin2

1George Washington University Hospital, Washington, DC & Amita Usability of emergent PCN tracts Saint Francis Hospital, Chicago, IL, 2George Washington University Hospital, Washington, DC Usable 10 (24%) Partially usable 1 (3%) LEARNING OBJECTIVES: To evaluate the usability of emergently placed Unusable 30 (73%) percutaneous nephrostomy (PCN) tracts for subsequent definitive treatments such as percutaneous nephrolithotomy (PCNL) or percutaneous antegrade ureteroscopy (PAU). The reasons for unusability of emergent PCN tracts (30) Indirect or poor access to target stone 43.3% BACKGROUND: PCN placement for emergent renal drainage is a life- Direct placement into the renal pelvis 36.7% saving treatment when urinary tract obstruction (UTO) is associated with infection/sepsis or acute kidney injury (AKI). After resolution of Placement into proximal ureter 3.33% sepsis or AKI, urologists frequently perform PCNL or PAU to relieve the Placement into renal infundibulum 3.33% obstruction. The existing PCN tract can serve as an access for future Placement into adjacent calyx 3.33% PCNL or PAU, if optimally placed. Unable to pass guidewire into renal pelvis 3.33%

CLINICAL FINDINGS/PROCEDURE DETAILS: Method: A multi-institu- Encrustation prohibiting manipulation of PCN tract 3.33% tional retrospective review was performed over 4 years to identify Dislodgement from the kidney 3.33% patients who underwent PCNL/PAU and who also had prior emergent PCN tube placement. The demographic, perioperative data, stone Number of staged procedures required during definitive treatment to free status and complications were recorded. The existing PCN tracts achieve stone free status, stratified by usability of PCN tracts were classified as “usable” if subsequent PCNL/PAU was performed Usable PCN tracts (n = 10) Single stage: 8 (80%) by dilating the existing PCN tract; “partially usable” if the existing PCN Two stage: 2 (20%) tract was dilated and used, but an additional tract was also created Partially usable PCN tracts (n = 1) Single stage: 1 (100%) to complete the PCNL/PAU; “unusable” if existing PCN tracts were Single stage: 15 (50%) deemed unsuitable for dilation, and a new tract was created to complete PCNL/PAU. Results: 36 patients with 41 emergently placed PCNs Unusable PCN tracts (n = 30) Two stage: 13 (43%) subsequently had PCNL/PAU treatment. Of the emergent PCN tracts, Three stage: 2 (7%) 10 (25%) were usable; 1 (2%) were “partially usable,” and 30 (73%) were “unusable.” The PCN tracts were deemed unusable because of rea- Complications using Clavien Dindo 9 (25%) sons shown in the table. In 80% of patients with “usable” PCN tracts, a system (n = 9 patients) stone free status was achieved in a single stage. Eight of 9 complica- Grade 1 + 2 1 (11%) transfusion tions, including two “grade 3b” complications, occurred after PCNL in related patients who had unusable PCN tracts. Grade 2 6 (66%) transfusion related CONCLUSION AND/OR TEACHING POINTS: Our results indicate that the Grade 3b 2 (22%) UTO and AVF emergently placed PCN tracts can optimally drain the kidney, but they frequently are suboptimal for subsequent PCNL/PAU. When emergent PCN tracts are “usable,” a stone-free status is high likely to be achieved Abstract No. 1015 in a single stage procedure without any complications. Given the role, an interventional radiologist plays in obtaining emergent percutane- Revival of an old technique: fallopian tube recanalization ous access, definitive procedures should be taken into account while offers patients a minimally invasive, cost-effective, and planning an emergent PCN. well-tolerated alternative option for fertility therapy c heiberger1, N Nezami1, K Hong2 1Johns Hopkins School of Medicine, Baltimore, MD, 2Johns Hopkins School of Medicine, Ellicott City, MD

LEARNING OBJECTIVES: This educational exhibit will discuss interventional radiology (IR) guided fallopian tube recanalization (FTR) in comparison to popular contemporary infertility managements protocols, namely assisted reproductive technologies (ART) such as invitro fertilization (IVF). The technical feasibility, outcomes (e.g., fertility rates, SIR 2020 Annual Scientific Meeting e-Posters | 119

complications), financial costs, and patient perception of each treat- used techniques and a review of the literature, (5) potential complica- ment option will be reviewed. tions and adverse side effects, and (6) Additional current and future applications of nerve blocks. BACKGROUND: Women’s health is a new frontier in IR due in part to the growing demand for minimally invasive procedures such as uterine CONCLUSION AND/OR TEACHING POINTS: This exhibit will provide the artery embolization (UAE) for leiomyomas and adenomyosis, which viewer with a better understanding of the various nerve blocks offered may preserve or restore fertility for patients desiring further child- by IR, procedural techniques and variations in anatomy, optimal utility birth. FTR, another IR-guided procedure, directly targets patient infer- of nerve blocks and current literature, and future applications of pain tility. The advent of IVF and other ARTs witnessed a rapid decline in management offered by IR. the number of patients receiving FTR, despite being a financially and energy expensive process. Abstract No. 1017 CLINICAL FINDINGS/PROCEDURE DETAILS: We reviewed the literature regarding both FTR and ART. The reported mean pregnancy rates fol- Burn your pain away: review the use of heat base thermal lowing each therapy were similar: IVF, 36.3% (all ages and infertility ablation for osteoid osteomas causes), and FTR, 27% (all ages). Additionally, a series of FTR cases N Pigg1, J Miller2, B Baigorri3, R Fourzali4 successfully performed within the past year at Johns Hopkins Depart- 1 2 ment of Interventional Radiology was reviewed and demonstrated the Aventura Hospital & Medical Center, Aventura, FL, HCA: Aventura 3 4 procedures modern technical feasibility and tolerability. Hospital, Hollywood, FL, N/A, Coconut Grove, FL, N/A, Miami, FL

CONCLUSION AND/OR TEACHING POINTS: FTR remains an efficacious, LEARNING OBJECTIVES: 1. To define the clinical applications of thermal cost-effective, and well tolerated alternative to invitro fertilization that ablation in the treatment of osteoid osteomas 2. To identify indications can be performed in a clinical setting. It should be promoted as an for thermal ablation: key clinical and anatomical patient selection cri- IR-driven minimally invasive option for infertility management before teria 3. To discuss pre and post procedure considerations and describe more expensive and patient demanding therapies. the steps of the procedure 4. To summarize advantages and disadvantages of microwave ablation, RFA and cryoablation

Abstract No. 1016 BACKGROUND: Osteoid osteoma (OO) is a benign bone tumor that is common in ages 10 to 30 and affects long bones. The tumor comprises A pictorial essay of nerve blocks for pain control in 2% to 3% of all bone tumors and 10 to 20% of benign bone tumors. OO interventional radiology usually presents with pain that can be debilitating in some patients. The standard for treatment used to be surgical, but over the last decade 1 2 S Jaisinghani , R Pyne several ablation techniques have been used to treat OO, including 1Rochester Regional Health, Webster, NY, 2Rochester Regional cryoablation, microwave ablation (MWA) and radio frequency ablation Health, Rochester, NY (RFA) (3). The key to these therapies is the destruction of the nidus to ensure a permanent cure. To date there have only been small scale LEARNING OBJECTIVES: To review the technical details and appli- studies but the results have been positive. cations of various nerve blocks offered by interventional radiology (IR) including brachial plexus blocks for dialysis arteriovenous fistula CLINICAL FINDINGS/PROCEDURE DETAILS: This educational poster (AVF) management, superior hypogastric plexus in the setting of will use several thermal ablation cases to illustrate the interventional chronic pelvic pain, Celiac ganglion block for pancreatic cancer, facet radiology (IR) approach to assessing when an osteoid osteoma is block injections, and highlight their role in the peri-procedural patient suitable for IR treatment. This includes patient evaluation including management. diagnosis, demographics, locations and size of lesions, radiographic characteristics of different lesions, patient selection, and pre and post BACKGROUND: The clinical role of the interventional radiologist is procedure considerations and response to therapy. 1. Initial imaging. 2. expanding as the scope of the procedures that we perform contin- Planning approach. 3. Accessing the lesion. 4. Ablation of the lesion. 5. ues to grow. As such, knowledge of pain management strategies has Post ablation imaging and follow-up imaging. become crucial. Pain management in more involved procedures such as uterine artery embolization or angioplasty of a AVF commonly CONCLUSION AND/OR TEACHING POINTS: Although surgery was the consists of a combination of local anesthesia and conscious sedation standard for treatment of OO for many years, ablation is becoming with fentanyl and midazolam, which can often be insufficient and lead more widely used and is providing beneficial results for patients with- to post procedural pain, longer hospital stays, and increased depen- out the complications and stress that can come with surgery. While dency on opioids. Also, it is common for patients to be undertreated there are multiple ablation techniques available, MWA may have with conscious sedation due to their vitals and other contraindications. a higher efficiency over other modalities due to its ability to rapidly overcome the high impedance in sclerotic bone lesions. All three tech- CLINICAL FINDINGS/PROCEDURE DETAILS: This exhibit will include (1) niques has also been shown to have similar rates of successful treat- a review of current peri-procedural pain interventions offered by IR, ment, (rates of recurrence and complications). Thermal OO ablation (2) relevant nerve anatomy and aberrant courses, (3) indications and may prove a valuable skill for the future interventionalist. contraindications to peri-procedural pain management, (4) commonly 120 | e-Posters SIR 2020 Annual Scientific Meeting

Abstract No. 1018 LEARNING OBJECTIVES: Master ultrasound anatomy and necessary landmarks through institutional examples of each of the major joints. Fluoroscopic versus computed tomography–guided Review imaging examples and technical overview of the most com- sacroplasty: if, how, and when? mon musculoskeletal (MSK) procedures, including steroid injection, R Dolan1, M Loya1, J Newsome2, Z Bercu3, W O’Connell4, N Kokabi4, MRI arthrogram, arthrocentesis, and barbotage in the treatment of A Chary5 calcific tendinosis. Discussion of the procedural indications, clinical outcomes, and role of interventional radiologists in this field tradition- 1Emory University, Atlanta, GA, 2N/A, Decatur, GA, 3Emory ally dominated by musculoskeletal radiologists. University School of Medicine, Decatur, GA, 4Emory University 5 School of Medicine, Atlanta, GA, Premier Radiology, Brookhaven, BACKGROUND: In small hospitals/rural areas across the United States, GA MSK radiologists who perform joint procedures can be rare to find. Even in a large hospital system, MSK imagers may stray away from LEARNING OBJECTIVES: 1. Summarize previous published studies procedural work and focus their time on diagnostic imaging studies. regarding efficacy of sacroplasty. 2. Highlight fluoroscopically guided In these scenarios, both young patients with sports injuries and aging and computed tomography (CT)–guided sacroplasty techniques. 3. patients with chronic joint pain may seek the aid of interventional Describe differences in techniques for insufficiency fractures versus radiologists to provide symptom relief and/or aid in their diagnosis. metastatic disease. 4. Proposing a management algorithm of patients with bony sacral pain. CLINICAL FINDINGS/PROCEDURE DETAILS: Initial evaluation of the joint of clinical concern includes understanding which shaped US probe is BACKGROUND: Sacral fractures are notoriously painful and debilitating appropriate. Examples include the hockey stick probe for the wrist in and often occur when bone is already weakened by neoplastic lesions first extensor tendon sheath injections, a linear probe for the elbow (pathologic fractures) or another cause such as osteoporosis or radia- in radiocapitellar joint injections, and a curved probe for the hip in tion therapy, termed sacral insufficiency fractures (SIFs). SIFs typically iliopsoas tendon sheath injections. Choosing between a 22G 3.5- or occur in elderly patients (often with many medical comorbidities) and a 5-inch spinal needle is dependent upon patient body habitus, while are typically treated with nonsurgical management. Image-guided a larger gauge needle may be needed for joint aspirations. My insti- cement augmentation of the sacrum, or sacroplasty, has become a tutional review demonstrates a variety of injectable mixture prepara- viable alternative to nonsurgical management. Previous studies have tions. For steroid injections, the composition of the quantity and ratio demonstrated over 50% reduction in pain immediately following the of Kenolog to ropivacaine varies, depending on joint size and pain procedure with sustained pain relief years following the procedure. history. For ultrasound-guided arthrograms, the mixture is often less CLINICAL FINDINGS/PROCEDURE DETAILS: Sacroplasty can be per- than 0.1 mL of gadolinium with 10 mL of sterile saline. Percutaneous formed under fluoroscopic or CT guidance. Selection is often based on needle lavage and aspiration, known as barbotage, can provide dra- operator preference, although there are advantages and limitations to matic symptomatic relief to those suffering from debilitating calcific each approach. Fluoroscopic guidance allows for efficient localization, tendinosis. but visualization of the cortices during needle positioning can prove CONCLUSION AND/OR TEACHING POINTS: As interventionalists, our challenging and there is a risk of cement leakage in the sacral foram- procedural scope is ever expanding and one must be prepared to ina. CT provides superior spatial resolution, allowing for more accurate serve any patient community. Understanding the most common mus- needle placement in complex fractures and avoidance of surrounding culoskeletal procedures can be a valuable tool and service in caring for neurovascular structures, but cement injection cannot be monitored these patients. in real time. The details of each technique will be thoroughly outlined.

CONCLUSION AND/OR TEACHING POINTS: 1. Strong literature and institutional evidence suggests that sacroplasty is a highly efficacious pro- Abstract No. 1020 cedure for treatment of debilitating sacral fractures. 2. Sacroplasty can be performed safely using fluoroscopic and CT guidance and should Adhesives in interventional radiology be considered an alternative to nonsurgical management. 3. Manage- L Jamal1, I Altun2, H Albadawi1, S Alzubaidi3, M Knuttinen4, S ment algorithm of working up patients with bony sacral pain to deter- Naidu4, I Patel5, T Jamal6, R Oklu7 mine eligibility (including Denis classification) and potential benefit 1Mayo Clinic, Scottsdale, AZ, 2Mayo Clinic, scottsdale, AZ, 3Mayo from sacroplasty. Clinic, Phoenix, AZ, 4Mayo Clinic Arizona, Scottsdale, AZ, 5Mayo Clinic - Arizona, Phoenix, AZ, 6Virginia Commonwealth, Richmond, VA, 7Mayo Clinic Arizona, Phoenix, AZ Abstract No. 1019 LEARNING OBJECTIVES: This exhibit provides a comprehensive review Tour de joints: overview of the most common ultrasound- of (1) the benefits and limitations of the materials used as adhesives, guided musculoskeletal procedures (2) how interventional radiologists could benefit and further use adhe- O Deochand1, H Su2, N Shah2 sives in their practice, and (3) current preclinical and clinical trials testing the efficacy and safety of novel adhesives. 1Atlantic Health- Morristown Medical Center, Morristown, NJ, 2Morristown Medical Center, Morristown, NJ SIR 2020 Annual Scientific Meeting e-Posters | 121

BACKGROUND: Adhesives are based on natural polymers, cross-linked approach. The anterior para-aortic approach is usually considered in via biochemical reactions, resulting in a more biocompatible alterna- patients with advanced disease who are unable to lie in the prone positive to synthetic glues. They are mainly composed of fibrin or colla- tion or variant or abnormal abdominal anatomy. The approach may gen, though researchers have recently shifted their attention to using be unilateral or bilateral. We describe both the approaches and the Gelatin and polysaccharide-based adhesives. Biological adhesives potential complications. mimic the final stages of blood clotting using a rich concentration of CONCLUSION AND/OR TEACHING POINTS: Celiac plexus block is an easy, fibrin as well as trapping coagulation products and inducing plate- safe and effective procedure in alleviating debilitating abdominal pain. let adhesion via the properties of collagen. Adhesives are available The technique brings out long-term pain control in such patients and commercially and have been used for a variety of surgeries, including reduce the demand and side effects of high dose opioids. neurosurgery, ophthalmic, and cardiovascular surgery. Recent studies show the employment of biological adhesives in the field of interventional radiology. Though surgeons generally treat wound closure Abstract No. 1022 issues, there are conditions that concern interventional radiologists such as the placement and removal of chest wall vascular ports. Newly Evaluating pain syndromes: a review of the interventional developed devices for wound closure that an interventionist could use radiologist’s diagnostic arsenal include Dermabond, Closure film, and Indermil. M Taon1, K Kansagra2, I Lekht3 CLINICAL FINDINGS/PROCEDURE DETAILS: The mechanism of action of 1Kaiser Permanente Los Angeles, Glendale, CA, 2Kaiser Permanente, each skin adhesive as well as diagrams explaining each treatment will Glendale, CA, 3N/A, Calabasas, CA be detailed on the poster. Clinical studies using these skin adhesives will be analyzed, focusing on safety, success rate, and cost efficacy. LEARNING OBJECTIVES: 1. Review key components of the medical history, Interventional radiologists have the opportunity to impact wound pain history, and physical exam in pain syndromes. 2. Review strengths healing cases through potentially decreasing the risk of infection, and weaknesses of radiography, computerized tomography, magnetic improving room turnover time, and minimizing the risk of needlestick resonance imaging (including MR neurography, MR angiography, and MR injuries. This poster will conclude by addressing the role interventional venography), myelography, electromyography, nerve conduction veloc- radiologists have in treatment through bypassing additional suturing ity, quantitative thermal sensory testing, somatosensory evoked poten- and aiming for minimally invasive care. tials, brainstem auditory evoked responses, discography, bone scans, and diagnostic injections in evaluating pain syndromes. 3. Review the role of CONCLUSION AND/OR TEACHING POINTS: Biological adhesives can the interventional radiologist in evaluating pain syndromes benefit interventional radiologists can be employed into their practice. Further studies are required in the assessment of the efficacy, and fea- BACKGROUND: According to the National Institute of Health, chronic sibility of using these devices. pain affects more Americans than diabetes, heart disease, and cancer combined. In 2011, the Institute of Medicine of the National Academies reported more than 100 million adults in the U.S. suffer from chronic Abstract No. 1021 pain. Interventional radiologists involved with pain management should be knowledgeable about the key components of a patient’s his- Celiac plexus block: why, where, and how tory and physical exam, as well as the diagnostic modalities available P Sharma1, R Sulaiman2, A Ghasemiesfe3, P Kochar1, E Rotem4, M to evaluate pain syndromes. Osman5 CLINICAL FINDINGS/PROCEDURE DETAILS: This educational exhibit 1Yale University–Bridgeport Hospital, Milford, CT, 2Bridgeport will review key aspects of the medical history, pain history, and phys- Hospital, Bridgeport, CT, 3N/A, Milford, CT, 4N/A, Westport, CT, 5Yale ical exam that should be evaluated in pain syndromes. A comprehen- New Haven Health-Bridgeport Hospital, Bridgeport, CT sive evaluation should include the time of onset, duration, associated symptoms, exacerbating or relieving factors, impact on a patient’s daily LEARNING OBJECTIVES: To review the indications, patient profile and activities and psychologic state, as well as an assessment of whether the complications of Celiac plexus block. To review the anatomy and varia- pain is neuropathic or nociceptive. There is an extensive arsenal avail- tions. To review the common techniques and workarounds. able to evaluate pain syndromes, including radiography, computerized BACKGROUND: Debilitating intractable abdominal pain is the most tomography, magnetic resonance imaging (including MR neurography, common indication for Celiac plexus block when there is failure of MR angiography, and MR venography), myelography, electromyog- treatment with high dose opioids. This includes pain in the setting of raphy (including single fiber electromyography and surface electro- malignant and benign neoplasms involving the organs innervated by myography), nerve conduction velocity, quantitative thermal sensory the Celiac plexus like the liver, gallbladder, stomach, pancreas, spleen, testing, somatosensory evoked potentials, brainstem auditory evoked both kidneys, the entire small bowel, and the first two-thirds of the responses, discography, bone scans, and diagnostic injection. large bowel. Departmental archives were reviewed along with compre- CONCLUSION AND/OR TEACHING POINTS: Understanding the diagnos- hensive review of literature. tic modalities available for evaluating pain syndromes can empower CLINICAL FINDINGS/PROCEDURE DETAILS: Most commonly used interventional radiologists to provide optimal patient care and pain approaches performed are the anterior or posterior paraaortic management. 122 | e-Posters SIR 2020 Annual Scientific Meeting

Abstract No. 1023 PNBCs requiring removal in the interventional suite. 3. Outline various techniques for the percutaneous removal of entrapped foreign bodies, Fallopian tube recanalization: a comprehensive pictorial particularly retained nonvascular catheters. review for a life-changing and life-creating procedure BACKGROUND: PNBCs are commonly used for the purpose of peri-op- S Mustafa1, D Igonkin2, D Sarkar3 erative pain management. They are generally well tolerated and pro- 1Maimonides Medical Center, Brooklyn, NY, 2James J. Peters VA vide effective pain control with less sedation, may facilitate earlier Medical Center, N/A, 3N/A, Jamaica, NY discharge, and improve patient satisfaction. One rare complication of PNBC placement is catheter entrapment. Entrapped catheters can be LEARNING OBJECTIVES: Discuss the epidemiology of infertility and successfully removed using a variety of techniques to avoid surgical the imaging required to diagnose a fallopian tube occlusion. Review removal. the indications for fallopian tube recanalization (FTR) and how to perform the procedure. Indicate the management and complications of CLINICAL FINDINGS/PROCEDURE DETAILS: We present two cases of patients who undergo fallopian tube recanalization. Provide a man- entrapped PNBCs in the right shoulder adjacent to the brachial plexus agement algorithm for patients with infertility. following orthopedic procedures that were successfully removed by interventional radiology (IR) using image guidance. After failed BACKGROUND: Infertility affects approximately 10% to 20% of couples attempts at catheter removal at the bedside, the anesthesiologist and is defined as the inability to conceive after 1 year of unprotected referred the patient to IR. First, a guidewire was placed through the intercourse. There are a variety of reasons for infertility, but nearly 65% catheter in an attempt to straighten the catheter. Then, the outer of cases are caused by female infertility, of which tubal infertility is the portion of a 6-Fr introducer system was advanced over the retained most common cause. Tubal infertility is adhesive or occlusive disease catheter in an attempt to sheath it. Finally, a Tuohy-Borst adapter was often due to a history of pelvic inflammatory disease or endometrio- placed on the hub of the 6-Fr dilator and hydro-dissection was per- sis and less commonly due to salpingitis isthmica nodosa. Historically, formed using normal saline to free the tip of the retained portion. The the only alternatives provided to these patients were laparoscopic sur- catheter was able to be removed using steady, gentle pressure in both gery, in vitro fertilization or hormonal stimulation, all of which are more cases with minimal pain. One of the patients had some mild residual costly physically, financially and emotionally. pain and paresthesia in the axilla that improved following physical

CLINICAL FINDINGS/PROCEDURE DETAILS: Hysterosalpingography therapy with near complete resolution of symptoms. (HSG) is a fluoroscopic examination that can evaluate the patency of CONCLUSION AND/OR TEACHING POINTS: Entrapped PNBCs are very fallopian tubes and reveal other uterine abnormalities to help in diag- rare, with few reported cases in the literature (2). However, the inter- nosing the underlying cause of infertility. If a proximal tubal occlusion ventional radiologist can apply his or her skill set to aid the patient and is the diagnosis, a fertility specialist will often refer the patient to an remove the catheter using image guidance and some creative thinking, interventional radiologist for fallopian tube recanalization as a treat- saving the patient from an open procedure that may have a greater risk ment option. We present an institutional review of cases of patients of complications. who underwent HSGs that were positive for tubal occlusion that warranted FTR. Patient risk factors and clinical history are discussed. A review of the current literature and cases treated at our institution will Abstract No. 1025 be provided. Image-guided peripheral nerve cryoneurolysis for pain CONCLUSION AND/OR TEACHING POINTS: Interventional radiologists relief in calciphylaxis are well-trained in utilizing guidewires and catheters under fluoroscopy for angiographic procedures. These are the same set of skills M Edquist1, E Azene1 necessary for performing fallopian tube recanalization to help treat 1Gundersen Health System, La Crosse, WI infertility in women who experience tubal occlusions. LEARNING OBJECTIVES: To spread awareness about a disease with a high mortality rate whose risk factors are common among interven- Abstract No. 1024 tional radiology patients, to add to the growing list of clinical applications for cryoneurolysis, and to present the first reported case of Image-guided retrieval of entrapped peripheral nerve peripheral nerve cryoneurolysis for pain relief in calciphylaxis. block catheters BACKGROUND: Calciphylaxis, properly termed calcific uremic arteri- 1 2 3 T Patel , G Wong , D Mauro olopathy (CUA), is a disfiguring, intensely painful systemic condition 1University of North Carolina Hospitals, Chapel Hill, NC, 2The with a high mortality rate (50%-80%). CUA affects 1% to 4% of patients University of North Carolina, Chapel Hill, NC, 3The University of with ESRD on dialysis. Clinically, CUA presents with exquisitely pain- North Carolina, Chapel Hill, NC ful, purpuric skin nodules or plaques that eventually form ulcers with black eschars. Lesions usually form in areas of high adiposity. Rarely, LEARNING OBJECTIVES: The Learning Objectives of this exhibit are to 1. lesions form on the digits or genitalia. Cryoneurolysis (CN) involves the Review the indications and possible complications of peripheral nerve freezing of nerves to treat neurally mediated conditions, most com- block catheter (PNBC) placement. 2. Present 2 cases of entrapped monly pain. CN has been used to treat pudendal neuralgia, phantom SIR 2020 Annual Scientific Meeting e-Posters | 123

limb pain syndrome, ilioinguinal neuralgia, and postthoracotomy pain illustrations including figures of techniques used for pain manage- syndrome, among several other painful conditions. ment and their indications, contraindications, alternatives and potential risks. We will also review the role of image guidance systems in CLINICAL FINDINGS/PROCEDURE DETAILS: A 48-year-old man with interventional pain management and translational preclinical studies ESRD on chronic hemodialysis, and atrial fibrillation on warfarin ther- for future techniques. apy presented with painful penile and toe lesions due to CUA. Intra- venous narcotics failed to control his intense pain. Bilateral CT-guided CONCLUSION AND/OR TEACHING POINTS: Pain management therapies pudendal and sciatic nerve cryoneurolysis was performed to avoid traditionally require a multidisciplinary approach and can present cer- below-knee amputation and total penectomy and to facilitate ther- tain risks. Interventional procedures have emerged as an alternative, apy and wound management. After the procedures, his pain markedly minimally invasive, and relatively safe approach for pain management. improved, and he no longer required IV narcotics. He was also able to Development of various advanced image guided technologies can participate fully in wound care and physical therapy. Despite distal leg provide a safer procedure environment for optimal patient care. weakness from sciatic nerve cryoneurolysis, his ambulation improved significantly because he was no longer limited by pain while walking. His clinical status steadily improved until his discharge home fifteen Abstract No. 1027 days after the procedures. Large hepatic hemangioma: educational review of CONCLUSION AND/OR TEACHING POINTS: Image-guided peripheral minimally invasive techniques nerve cryoneurolysis may be considered in the palliative manage- H Javan1, C Boyd1, J Cosman1, J Chin1, D Fernando1, K Nelson1, J ment of intractable pain caused by calciphylaxis (CUA). Interventional Katrivesis1, N Abi-Jaoudeh1 radiologists commonly care for patients at risk of developing CUA. 1 Interventional radiologists should be aware of this disease and the role University of California Irvine, Orange, CA they may have in its management. LEARNING OBJECTIVES: Review of interventional radiology techniques for large hepatic hemangioma (HH)

Abstract No. 1026 BACKGROUND: HH is the most common benign liver tumor. These lesions are mostly asymptomatic. Patients with symptomatic HH may Interventional approach to pain: clinical management, experience various symptoms from abdominal pain, fullness, fatigue, challenges, and future directions jaundice to disseminated intravascular coagulation and life-threat- I Altun1, T Parnall1, A Saini1, L Jamal1, S Alzubaidi1, S Naidu1, J ening bleeding due to rupture. Treatment options for symptomatic Kriegshauser1, I Patel1, G Knuttinen2, R Oklu1 patients include surgery, percutaneous interventions, and transarterial embolization. This educational exhibit will review percutaneous 1Mayo Clinic, Phoenix, AZ, 2Mayo Clinic, PHOENIX, AZ image-guided locoregional treatments for HH. LEARNING OBJECTIVES: Define current approaches to pain manage- CLINICAL FINDINGS/PROCEDURE DETAILS: The following treatment ment. Through a case pictorial review, efficacy of pain management methods for large HH will be discussed: (1) Transarterial embolization, procedures, the role of advanced image-guided modalities will be dis- (2) percutaneous microwave ablation and radiofrequency ablation, cussed. The role of nerve blocks and cryoablation techniques will be and (3) Percutaneous sclerotherapy, Discussion for each method will highlighted. include patient selection, technical aspects of the procedure, out- BACKGROUND: Pain management often requires an interdisciplinary comes and potential complications. approach. Interventional procedures are being increasingly utilized in CONCLUSION AND/OR TEACHING POINTS: Multiple treatment options pain management. Intercostal nerve block, spinal injection, and other for HH are available. However, the treatment of large HH is challeng- peripheral nerve injections are often chosen for noncancer induced ing because of its highly vascular nature. This educational exhibit will pain, while nerve ablation is generally preferred for severe cancer review all available treatment techniques and present a systematic related pain. Also, there are more sophisticated techniques such as spi- review of the literature. nal cord stimulation, which involves implanting electrodes in the epidural space, neuraxial infusion in which drugs infused into the epidural space, and deep brain stimulation. In addition to direct nerve intervention, there are interventional therapies to relieve pain via tumor ablation, embolization and vertebral augmentation. Interventional pain management is a minimally invasive and effective alternative treatment options that offer fewer side effects and risk than traditional methods. Progressive advancements in image-guided systems suggest these procedures may become more reliable in the near future.

CLINICAL FINDINGS/PROCEDURE DETAILS: This educational exhibit will provide the reader with various interventional pain management options that are currently available. We will present detailed case 124 | e-Posters SIR 2020 Annual Scientific Meeting

Abstract No. 1028 BACKGROUND: Traumatic lymphatic leak is a rare but potentially life-threatening complication. Postoperative lymphatic leak is the lead- Liver lymphatic embolization for the management of ing cause of traumatic lymphatic leak and can arise anywhere within protein-losing enteropathy in patients with congenital the lymphatic system. In this educational exhibit, we present lymphan- heart disease giogram findings and lymphatic intervention techniques according to M Arabi1, A Alsaadi1, M Alotaibi1, M Badran2 type of surgeries or procedures from neck to groin. 1King Abdulaziz Medical City, Riyadh, Saudi Arabia, 2King Faisal CLINICAL FINDINGS/PROCEDURE DETAILS: 1. Lymphangiogram findings Specialist Hospital and Research Center, Riyadh, Saudi Arabia according to type of surgeries including thoracic outlet decompression surgery, head and neck cancers, lung cancer, esophageal cancer, hepa- LEARNING OBJECTIVES: Discuss the prevalence and etiology of pro- tobiliary surgeries, urologic surgeries, gynecologic surgeries, groin tein losing enteropathy (PLE) in patients with congenital heart disease. procedures and lymph node dissection in groin. 2. To correlate clinical Role of liver lymphangiography to demonstrate leakage of liver lymph symptoms of lymphatic leak into surgical tube in neck, chylothorax, into the duodenum. Demonstrate the technique of liver lymphatic chylous ascites, chyluria, pelvic lymphocele, and groin lymphocele. 3. embolization. Present illustrative cases Different lymphatic intervention techniques: Transabdominal thoracic

BACKGROUND: PLE is characterized by severe loss of protein, primarily duct access, US-guided retrograde thoracic duct access in the left albumin, into the intestinal tract. In patients with congenital heart dis- neck, balloon occluded retrograde lymphangiogram and emboliza- ease and elevated central venous pressure, the mechanism of albumin tion, direct puncture of lymphatic channels, intranodal embolization loss is likely related to leakage of albumin-rich lymph into the duodenal according to location and type of surgeries or procedures. lumen through focal hepatoduodenal lymphatic channels. Liver lym- CONCLUSION AND/OR TEACHING POINTS: We present lymphangiogram phatic embolization may provide improvement of serum albumin lev- findings and lymphatic intervention technique according to type of els and reduce albumin transfusion requirements. surgeries or procedures from neck to groin.

CLINICAL FINDINGS/PROCEDURE DETAILS: Liver lymphangiography and lymphatic embolization is performed under general anesthesia Abstract No. 1030 with simultaneous upper GI endoscopy to document the lymphatic leak. Under ultrasound guidance, a 22-gauge Chiba needle is used to Lymphatic variant anatomy and the role of an target the periportal echogenic line surrounding the right portal vein. interventional radiologist: a pictorial review Opacification of the liver lymphatic vessels is confirmed by gentle injection water-soluble iodinated contrast. Then a mixture of contrast A Merritt1, S Haroon2, L Campos3 with methylene blue (9:1 mixture) is injected to confirm hepatoduode- 1Boston Medical Center, Cambridge, MA, 2Boston University Medical nal leak by endoscopy. The needle is then to be flushed D5 dextrose Center, Boston, MA, 3N/A, Cambridge, MA prior to embolization by injection of 1 to 2 mL of Glubran2 diluted with LEARNING OBJECTIVES: (1. Review basic lymphatic anatomy, (2) review lipiodol (1:6 mixture). The goal of the embolization is to deliver the glue Possible variant lymphatic anatomy, (3) basic procedural steps in distally close to the leakage site within the duodenum. identifying lymphatic (variant) anatomy, (4) troubleshooting the cis- CONCLUSION AND/OR TEACHING POINTS: Lymphatic leakage into the terna chyli, and (5) overview of techniques for gaining access and duodenum through the hepatoduodenal lymphatic system is a con- embolization. siderable cause for PLE for patient with congenital heart disease and BACKGROUND: Lymphatic leak, or lymphorrhea, can be a lethal com- elevated central venous pressure. Liver lymphatic embolization may plication from surgical intervention or trauma. The most common of improve the patient symptoms and reduce the need for frequent albu- these lymphorrhea complications is the Chylothorax. Because of the min transfusions. high volume and nutrient-rich lymphatic fluid transported through the easily damaged thoracic duct, these patients have a high mortality Abstract No. 1029 rate ranging between 25% and 50%. Understanding variant anatomy in these patients is arguably just as important as understanding “normal” Lymphangiogram findings and lymphatic intervention anatomy since somewhere between 40% and 60% of patients have a from neck to groin variant. With the knowledge, the interventional radiologist can play a M Adam1, S Kim1, C Guevara1, R Ramaswamy1 vital role in the treatment of high-output or unremitting chylothorax and be an effective alternative to surgical intervention. 1Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO CLINICAL FINDINGS/PROCEDURE DETAILS: This pictorial exhibit will demonstrate the ‘normal’ lymphatic anatomy and review variant LEARNING OBJECTIVES: 1. To review lymphangiogram findings (lym- anatomy that is crucial to know if performing lymphatic interven- phatic leak) according to type of surgeries or procedures. 2. To know tions. Cases from our institution and data from the literature will be different techniques to treat lymphatic leaks according to location and utilized to describe this anatomy and demonstrate the steps needed type of surgeries or procedures. to evaluate anatomy and troubleshoot difficult anatomy. The role of SIR 2020 Annual Scientific Meeting e-Posters | 125

the interventional radiologist in the life-threatening lymphatic leak/ yet easy to understand, discussion of clinical, radiographic evaluation chylothorax will be describe highlighting techniques for access and and technical information for clinical success. embolization.

CONCLUSION AND/OR TEACHING POINTS: Given the prevalence of vari- Abstract No. 1032 ant lymphatic anatomy, a thorough understanding of variant anatomy and how to determine this anatomy are essential tools for the inter- New and evolving role of interventional radiology for ventional radiologist. With this knowledge, an interventional radiolo- image-guided Nexplanon removal gist will be able to play a major role in the evaluation and treatment J Herzog1, L Walker2, D Nakamoto3 of critical conditions such as lymphorrhea (in particular chylothorax). 1 2 Teaching points: (1) classification of anatomy, (2) understanding of University Hospitals, Cleveland, OH, University Hospitals Cleveland 3 functional anatomy, (3) techniques for access, and (4) techniques for Medical Center, Cleveland, OH, University Hospitals of Cleveland, embolization. Cleveland, OH

LEARNING OBJECTIVES: To discuss interventional radiology’s (IR’s) Abstract No. 1031 evolving role in Nexplanon removal. - To describe the initial approach to implant visualization using ultrasound and/or radiography - Review Nerves, ganglion blocks, and steroid injections in the typical imaging appearances of the Nexplanon implant with ultra- interventional radiology: a tutorial for success sound and/or radiography and provide example images - To explain the most common abnormal migration sites of implants not visual- 1 1 A Freedman , A Freedman ized with conventional methods, and consider second-line options for 1Medical College Georgia/Augusta U. Medical Center, Augusta, SC localization. - Provide a detailed review of the most commonly utilized implant removal techniques, with a focus on the advantages, disad- LEARNING OBJECTIVES: Concise discussion of clinical findings, imag- vantages, and the equipment necessary for each. - Highlight possible ing, techniques and tips and pearls how steroid and local anesthetic complications of implant removal and how they can be avoided. injections are integrated into the interventional radiology (IR) practice, including but not limited to celiac, intercostal, superior hypogastric, BACKGROUND: BACKGROUND: The use of subdermal contraceptive arm inferior hypogastric, selective nerve root, and epidural, both lumbar implants has tripled in the United States from 2006 to 2013. The radi- and cervical steroid injections, facet and sacroiliac joint injections are opaque, matchstick-sized Nexplanon implant has been the only avail- performed. able since 2011, with nonradiopaque implants of similar used in prior years. Removal is commonly performed in the gynecologist’s office; BACKGROUND: The interventional radiologist, with imaging and tech- however, patients with nonpalpable implants should be referred to IR nical skills is ideally suited to evaluate patients with pain, assess imag- before blind attempts at removal which are associated with more coming and target treatments to reduce pain. For example, we can readily plications and longer removal time. reduce pain from radiculopathy, through epidural steroid injections and selective nerve root blocks, pelvic pain, especially post UFE pain, CLINICAL FINDINGS/PROCEDURE DETAILS: Ultrasonography is the with superior hypogastric ganglion blocks and treat pancreatic can- first-line modality for implant visualization given their echogenicity cer pain with celiac plexus blocks and ablation. Fluoroscopy, a readily and acoustic shadowing, and removal is often performed with US available tool enables us to diagnose and treat causes of back pain, guidance. Fluoroscopy can be utilized for implants placed after 2011, by palpating the spine, marking the skin site and pinpointing then and MRI can be done if fluoroscopy and US are unrevealing. The most injecting the specific facet joint, or sacroiliac joint causing pain. These common abnormal locations are the upper arm and the axillae; how- techniques are easy to incorporate into a busy IR practice and can ever, there are rare cases of endovascular migration. The standard effectively reduce pain. technique is to make a small incision and use a mosquito forceps for removal, but other techniques can be utilized. Nerve damage with CLINICAL FINDINGS/PROCEDURE DETAILS: To date, over 200 patients resultant neuropathy, paresthesias, and muscle paralysis are potential with back, pancreatic or pelvic pain have been treated by this author. complications and can often be avoided with proper technique and Most have experienced significant relief of their pain. Utilization of imaging guidance. good history, physical exam plus a review of pertinent imaging including CT, MRI as well as diagnostic fluoroscopic exam will usually detail CONCLUSION AND/OR TEACHING POINTS: This review will discuss the the source of the patient’s pain. Targeted steroid/local anesthetic steps in Nexplanon removal from typical and atypical anatomic loca- treatments have been used by pain specialists and interventional tions. We will describe the imaging appearance, explore varying tech- radiologists for years to relieve back pain, radiculopathy, abdominal niques, and discuss potential pitfalls of removal. and pelvic pain. A technical discussion and decision tree for back pain will be discussed, in addition to detailed concise diagrams and tips to achieve clinical success.

CONCLUSION AND/OR TEACHING POINTS: Interventional radiologists can enhance their practice and reduce back pancreatic cancer and pelvic pain in their patients. This exhibit will provide a comprehensive, 126 | e-Posters SIR 2020 Annual Scientific Meeting

Abstract No. 1033 LEARNING OBJECTIVES: 1. To describe the diagnostic imaging features of different adrenal gland pathologies. 2. To define the laboratory and Percutaneous image-guided drainage procedures clinical findings associated with various adrenal diseases. 3. To illus- approach and technique from head to toe trate interventional approaches to diagnosis and management of K Gala1, S Kulkarni2, N Shetty2, N Shetty1 adrenal lesions. 1Tata Memorial Hospital, Mumbai, Maharashtra, 2N/A, Mumbai, India BACKGROUND: An estimated 5% of abdominal imaging studies reveal adrenal “incidentalomas.” interventional radiologists utilize imaging LEARNING OBJECTIVES: Percutaneous image-guided Techniques is modalities and clinical features to discern benign versus malignant performed under ultrasound or CT guidance for drainage of collec- adrenal pathology, and employ interventional approaches-spanning tions in the treatment of patients with head and neck, cardio- thoracic, percutaneous biopsy, adrenal venous sampling, adrenal artery embo- abdominal or pelvic sepsis either in postoperative patients or onco- lization, and percutaneous adrenal ablation-to diagnose and manage logical patients having collection and thus avoiding the major surgery. adrenal gland lesions. As such, a thorough understanding of the diag- It can be simple aspiration if fluid is serous or insertion of pigtail if the nostic imaging and clinical features of adrenal gland pathology as well fluid is purulent or serosanguinous. In this abstract we will describe as the basic tenets of adrenal intervention is of critical importance for the techniques and approaches how to do, when to do and follow-up. interventional radiologists.

BACKGROUND: Various techniques are used in drainage of the collec- CLINICAL FINDINGS/PROCEDURE DETAILS: First, this exhibit will depict tion by ultrasound or CT guided depending on the position of the col- common adrenal gland pathologies through correlative cross-sec- lection. 1) In head and neck region- aspiration is better. 2) Subphrenic tional and angiographic imaging, with attention to diagnostic features collection—subcostal anterior. 3) Mediastinal—right paravertebral, of different adrenal gland pathologies. Furthermore, this poster will anterior. Predominantly it is used for postoperative setting in cases review the technical approaches and considerations for diagnostic of the esophageal leaks. 4) Cardiac—in the pericardial space. 5) Tho- adrenal procedures, including adrenal biopsy and adrenal vein sam- racic—in the pleural space (anterior, posterior, or lateral) for collection, pling. Finally, this exhibit will illustrate interventional procedures for pleural effusion or pneumothorax. If there is loculated effusion, it is the management of adrenal disease, including adrenal artery embo- better to inserted the pigtail with the Seldinger technique since the lization and percutaneous adrenal ablation, with a focus on technical wire can break the locules if they are thin. ICD is inserted in cases of methods and potential pitfalls and complications. large effusion. 6) In abdomen and pelvis—transhepatic, transgastric, gastrosplenic, left anterior pararenal, paravertebral, right anterior CONCLUSION AND/OR TEACHING POINTS: Adrenal gland masses are pararenal, transduodenal, transgluteal, transvaginal and transrectal. 7) a relatively common occurrence. A greater understanding of adrenal In gall bladder—it is called percutaneous cholecystectomy. Transhep- gland imaging and intervention will enhance the ability of IR operators atic versus transperitoneal 8) Urinary bladder—percutaneous supra- to provide accurate diagnostic assessment as well as effective and safe pubic cystostomy. therapeutic management for adrenal gland pathologies.

CLINICAL FINDINGS/PROCEDURE DETAILS: We use the Seldinger technique for all patients. However, sometimes we used direct puncture Abstract No. 1035 trocar-catheter combination. Open surgical drainage is now reserved for cases where percutaneous drainage fails to control sepsis, fails to Removal of chronic retained foreign bodies: a case report close fistulae, or is impossible due to the presence of interposed struc- and review of fistulograms tures such as bowel, major vessel or any other organ in the path. P Williams1, Y Albeer2

CONCLUSION AND/OR TEACHING POINTS: Percutaneous image-guided 1Henry Ford Health System, Detroit, MI, 2N/A, Bloomfield, MI drainage of collection is safe and effective technique for the treatment LEARNING OBJECTIVES: Multiple modalities can be utilized to delineate of patients with thoracic, abdominal or pelvic sepsis in postoperative and treat a fistulous tract associated with foreign bodies. Computed patients or oncological patients having collection and thus avoiding tomography (CT) and ultrasound can underestimate the extent of a major surgery. fistulous tract with a fistulogram illuminating the full extent. A fistulogram is an underutilized and described modality for assistance in Abstract No. 1034 foreign body removal.

BACKGROUND: A 60-year-old man sustained a puncture injury to the Radiologic imaging, diagnostic evaluation, and right buttock 30 years prior during a toboggan accident. At the time interventional management of adrenal masses: an update of the accident the wound was debrided and remained asymptomatic for interventional radiologists until a year before seeking care. The wound was treated unsuccessfully S Trivedi1, R Gaba2 with incision/drainage and antibiotics before a referral to general sur- 1Riverside University Health System, Diamond Bar, CA, 2University gery was placed who started their workup with a CT. The CT showed of Illinois at Chicago, Chicago, IL a fistulous tract extending from the skin in the upper posterior thigh to the gluteus maximus muscle. Ultrasound evaluation demonstrated SIR 2020 Annual Scientific Meeting e-Posters | 127 three echogenic structures within the region. Interventional radiology Abstract No. 1037 was consulted to localize the foreign bodies prior to surgical removal. Wound care: a primer for interventional radiologists CLINICAL FINDINGS/PROCEDURE DETAILS: The foreign bodies were not visible fluoroscopically. Limited ultrasound of the posterior thigh T Garg1, L Cusumano2, F Hao3, H Lee4, M Walsworth5, A Chen6 and gluteal region revealed multiple echogenic foreign bodies. The 1Seth GS Medical College & KEM Hospital, Mumbai, foreign bodies were bracketed with three localizing wires. The fis- Maharashtra, 2UCLA Medical Center, Los Angeles, CA, 3University tula skin opening was cannulated with 4-Fr. Dilator and a fistulogram of California- Los Angeles, Los Angeles, CA, 4West Los Angeles delineated the tract and the relation of the foreign bodies to the fistula Veterans Administration, Manhattan Beach, CA, 5West Los Angeles tract. The dilator was then advanced over glide guidewire deep into Veterans Administration, Santa Monica, CA, 6West Los Angeles the fistula. The patient was subsequently taken for surgical exploration Veterans Administration, Los Angeles, CA which yielded the foreign bodies. LEARNING OBJECTIVES: 1. To review the pathogenesis of wounds and CONCLUSION AND/OR TEACHING POINTS: Although foreign bodies have physiology of healing in Critical Limb Ischemia (CLI) patients 2. To been long evaluated using radiographs and ultrasound, a fistulogram is learn about medical optimization, wound debridement, offloading and not a highly used or documented tool for evaluation of fistulous tracts hyperbaric therapy 3. To review the different types of wound dress- in the setting of foreign bodies. It is an important modality because ings, their benefit, and negative effects treatment requires full excision of the tract. Ultrasound, despite its BACKGROUND: Peripheral vascular disease (PAD) is the third leading many advantages, has limitations with wooden foreign bodies less cause of cardiovascular morbidity and it affects over 20 million peo- than 2.5 mm not being able to be reliably detected. Radiographs, ple in the United States. Amputation prevention in PAD is achieved although great as a screening modality for foreign bodies, are not able through improved access for diagnosis, prompt revascularization and to detect radiolucent foreign bodies such as wood. multidisciplinary team involvement for optimal wound healing. Wound healing is a complex multifactorial process which consists of inflamma- Abstract No. 1036 tory, proliferative and remodeling phase. Smoking cessation, diabetes control, statin and cilostazol use and exercise program are import- When good catheters go bad: prevention, identification, ant for optimizing wound healing. Various developments in the past and management of malpositioned catheters, drains, decades like Intermittent Pneumatic Compression, Dehydrated Human tubes, and devices Amnion/ Chorion Membrane, Tissue Growth Factors and micro-RNA, and cell therapy are currently being explored and are likely to revolu- C Molloy1, S Ganguli1, R Uppot1, K Yamada1, P Mueller1, T Walker1 tionize wound care. 1Massachusetts General Hospital, Boston, MA CLINICAL FINDINGS/PROCEDURE DETAILS: Preparation of wound bed LEARNING OBJECTIVES: - Recognize malpositioned catheters, drains, with debridement is performed using at least of one the five primary tubes and devices - Review appropriate anatomic landmarks to pre- methods referred to as BEAMS (Biological, Enzymatic, Autolytic, Sur- vent malpositioning gical Sharp, and Conservative Sharp Debridements). Identification of

BACKGROUND: Patients throughout the world receive catheters and tissue viability during or prior to debridement utilizes two-dimensional drains for innumerable reasons including central venous access, perfusion angiography, methylene blue angiography, hyperspectral abscess drains, urinomas, seromas, etc. Occasionally, these devices are tissue oxygenation measurement and near-infrared fluorescent angi- found to be malpositioned, sometimes in dramatic fashion. ography. Wound dressing is then chosen to provide an optimal moist, warm and clean environment for wound healing. Commonly used CLINICAL FINDINGS/PROCEDURE DETAILS: This educational exhibit pro- dressings are autolytic, alginates and bacteria reducing dressing. Tis- vides numerous imaging examples of malpositioned catheters, drains, sue protection and offloading in patients with diabetes and foot ulcers tubes and devices. We discuss best practices to ensure appropriate by using total contact casts, removable cast walkers and custom foot- placement of specific types of catheters, tubes and drains to enable wear orthoses. Implementation of Hyperbaric oxygen therapy proto- interventionalists to optimally place catheters, tubes and drains. We col may be considered on an individual basis. also discuss management strategy to minimize patient harm when a malpositioned catheter, drain, tube or device is identified. CONCLUSION AND/OR TEACHING POINTS: Knowledge about wound care is important for endovascular physicians as it helps in preventing CONCLUSION AND/OR TEACHING POINTS: Catheters, drains, tubes amputation and maximizes the potential for limb salvage. and devices are critical in the medical care of innumerable patients throughout the world. It is critical that interventional radiologists understand safety steps to safely and accurately place these devices. In addition, interventional radiologists must be able to recognize malpositioned catheters, drains, tubes and devices and understand appropriate management strategy to provide optimal patient care when a malpositioned catheter, drain, tube or device is identified. 128 | e-Posters SIR 2020 Annual Scientific Meeting

Abstract No. 1038 Abstract No. 1039

Case-based review of computed tomography–guided Computed tomography–guided suboccipital puncture rupture of symptomatic lumbar facet synovial cysts with for intrathecal nusinersen (Spinraza) administration intra-articular steroid injection in patients with extensive postsurgical changes and A Saleem1, M Elshikh2, F Ahmad2, I Masood2, A Moshksar2, K Harrington rods Raghuram3 G Kuyumcu1, C Hennemeyer2, C Moffet1 1UTMB Galveston, Diagnostic Radiology, Galveston, TX, 2University 1University of Arizona, Tucson, AZ, 2University of Arizona, N/A of Texas Medical Branch at Galveston, Galveston, TX, 3N/A, Galveston, TX LEARNING OBJECTIVES: 1. Spinraza injection in adults with spinal muscular atrophy 2. Safe alternatives to lumbar puncture in patients LEARNING OBJECTIVES: To discuss the role of computed tomography with scoliosis, extensive postsurgical changes and Harrington rods 3. (CT)–guided rupture of lumbar facet synovial cysts (LFSCs) as a min- CT-guided suboccipital puncture 4. Safety considerations in suboccip- imally invasive option in the management of symptomatic patients. ital puncture To review the technical aspects of the procedure and potential challenges. To review the outcomes regarding effectiveness, imaging find- BACKGROUND: SMA results from loss of both copies of the SMN1 gene, ings, and complications. which is located on the long arm of chromosome 5 (5q). SMN gene encodes survival motor neuron (SMN), which is a protein necessary BACKGROUND: Lumbar synovial cysts are outpouchings that arise from for motor neuron survival. SMA is autosomal recessive disease with facet joint capsule and lined by synovial cells. LFSC can be an indepen- three well-described types. All types of SMA cause progressive muscle dent source of back pain and radiculopathy and most commonly found wasting resulting in respiratory difficulties and neuromuscular scoli- at L4 to L5. Initial treatment options include analgesic medications, osis. Severe scoliosis often requires posterior spinal fusion for better physical therapy, or epidural steroid injection. In refractory cases, sur- diaphragm function which unfortunately renders most patients poor gical resection is recommended. CT-guided rupture, however, is a min- candidates for LP. Nusinersen is a newly developed antisense oligo- imally invasive alternative to surgical resection and can eliminate the nucleotide drug that alters the splicing of SMN2 messenger RNA. The need for surgery in a subset of patients. SMN2 gene is similar to SMN1 and is usually present in patients with SMA. SMN protein encoded by native SMN2 is rapidly degraded and is CLINICAL FINDINGS/PROCEDURE DETAILS: The procedure is most commonly performed under CT-guidance with moderate sedation and not sufficient to prevent motor neuron loss in humans. In the presence patient in prone position. An initial low-dose CT scan is performed of nusinersen, the altered splicing of SMN2 leads durable protein prod- to identify a safe access site. The cyst can then be accessed either uct. The treatment course requires three loading every 2 weeks and a directly or indirectly depending on the size and location. Indirect rup- fourth dose, 1 month after the third loading dose. Maintenance treat- ture is performed by accessing the cyst through the parent facet joint. ment then requires an injection every fourth month. Due to extensive The cyst is first aspirated and then ruptured by forceful injection con- postsurgical changes and Harrington rods LP is challenging in these taining steroid, anesthetic, and diluted contrast. At our institution, we patient who require multiple punctures for treatment. typically use 1 to 2 mL of dexamethasone (10 mg/mL), 1 mL of 0.25% CLINICAL FINDINGS/PROCEDURE DETAILS: 1. After failure multiple bupivacaine, and 1 mL of Omnipaque 180 diluted in 2 to 4 mL of normal times under fluoroscopic LP 36-year-old man was transferred to CT. saline. Direct cyst rupture requires placement of the needle in the cyst 2. Whole-spine CT did not show any accessible window due to patient itself followed by forceful injection. Alternatively, fenestration can be positioning post and Harrington rods. 3. Suboccipital puncture was performed in which the cyst is accessed directly, contents aspirated performed 4. 5 patient with similar findings underwent 20 procedures. and then injected with steroids, anesthetic, and diluted contrast. This is then followed by back-and-forth needle motion to fenestrate the cyst CONCLUSION AND/OR TEACHING POINTS: 1. Suboccipital/cisternal wall. Successful rupture will demonstrate spread of into the epidural puncture can be an alternative injection route for Spinraza. 2. Patients space on postprocedure CT. with Harrington rods and extensive postsurgical changes may not have an window for LP under CT or fluoroscopy. 3. Given higher bene- CONCLUSION AND/OR TEACHING POINTS: LFSC can be an indepen- fit risk ratio it might be favorable to perform a suboccipital CT-guided dent source of back pain, radiculopathy, and neurogenic claudication. puncture in SMA patients. CT-guided rupture of the cyst with intraarticular steroid injection provides a minimally invasive treatment option with high technical success, early treatment response, and low complications. SIR 2020 Annual Scientific Meeting e-Posters | 129

Abstract No. 1040 Abstract No. 1041

Spinal biomechanics and use of implantable spinal Transforaminal lumbar puncture for intrathecal access: height restoration devices in the treatment of vertebral case series with literature review and comparison with compression fracture other techniques H Chengazi1, R Grinstead2, A Cantos3, D Butani4, S Virdee4 V Velayudhan1, S Patel2, A Efendizade3 1University of Rochester, Rochester, NY, 2Arnot Ogden Medical 1SUNY Downstate, Brooklyn, NY, 2SUNY Downstate, New York, Center, Elmira, NY, 3University of Rochester–Strong Memorial NY, 3SUNY Downstate Medical Center, Brooklyn, NY Hospital, Rochester, NY, 4N/A, Rochester, NY LEARNING OBJECTIVES: 1. Review of common techniques for intrathe- LEARNING OBJECTIVES: 1. Review the biomechanical principles behind cal access, with associated risks and benefits. 2. Description of trans- vertebral body height restoration 2. Review the appropriate patient foraminal approach for intrathecal access, with technical focus. 3. selection criteria for implantable device vertebral body augmentation Proposition of transforaminal lumbar puncture as a safe and effective 3. Understand the hardware, and procedural steps, that entail place- alternative to traditional lumbar and cervical puncture in patients with ment of an implantable height restoration device. challenging access and as a less invasive option compared to surgery.

BACKGROUND: Vertebral compression fracture (VCF) is a common BACKGROUND: Fluoroscopic-guided lumbar puncture (LP) is a pro- entity that results in significant morbidity including pain, limitation of cedure commonly performed by radiologists, which in some circum- physical function, loss of independence, depression, and other disease stances may be difficult or impossible using a traditional posterior related to long-term immobility. Height loss in VCF often results alters interspinous or interlaminar approach. Alternatives to LP include cer- the normal spinal curvature. This may limit the ability of intervertebral vical and cisternal punctures, placement of an Ommaya reservoir, and discs to withstand axial loading, predisposing to further VCF. Verte- lumbar laminectomy. More recently, however, there has been a move bral body height restoration has historically been attempted with bal- toward access of the thecal sac through a transforaminal approach in loon kyphoplasty, although this procedure has limitations including patients with challenging anatomy using computed tomography (CT) suboptimal optimal height restoration. Implantable height restoration and most recently described with fluoroscopy. devices have recently been introduced as a novel approach to height CLINICAL FINDINGS/PROCEDURE DETAILS: This exhibit outlines our restoration. Although still under clinical investigation, these devices approach and experience using transforaminal LP (TFLP) in patients may allow for greater control of height restoration and internal fixation with spinal muscular atrophy (SMA) with a 100% success rate. We dis- of vertebral body compression fractures. cuss its utility in other patients with difficult access and compare TFLP CLINICAL FINDINGS/PROCEDURE DETAILS: The preprocedural workup with other techniques to access the intrathecal space. of VCF, and for candidacy of implantable device placement will be CONCLUSION AND/OR TEACHING POINTS: Lumbar puncture is a com- discussed, including fracture etiology/morphology, important asso- monly performed procedure for a variety of indications that sometimes ciated findings and indications/contraindications. Relevant measure- requires image guidance. TFLP provides a safe and viable alternative in ments pertaining to patient selection and device deployment will be patients with contraindications to traditional LP, including those with reviewed. The procedure itself will be discussed in detail, including difficult access due to severe spinal deformity, extensive posterior anesthesia, positioning, imaging planes, approach, device deploy- spinal fusion and other reasons. In patients with scoliosis, placing the ment, time constraints and hardware removal. Postprocedure evalua- patient in the lateral decubitus position with the apex up allows for tion will be discussed, including pain assessment and neurologic exam the shortest needle path from the skin surface to the neural foramen in the immediate postprocedural period. and helps avoid organ puncture. Directing the needle into the posterior CONCLUSION AND/OR TEACHING POINTS: 1. Vertebral compression and inferior aspect of the neural foramen provides the route with the fracture is a significant contributor to morbidity in aging populations. least likelihood of neurovascular complications. Evidence discussed 2. Patient selection and preprocedural analysis is of critical importance in this report and that of others validates that this procedure can be in the evaluation of VCF. 3. Preservation of normal biomechanics may easily learned and performed with a high rate of success and low rate be an important determinant of outcomes after VCF. 4. Implantable of complications when using image guidance and following proper devices may improve height restoration and outcomes in patients with technique. VCF; however, this requires investigation. 130 | e-Posters SIR 2020 Annual Scientific Meeting

Abstract No. 1042 Abstract No. 1043

Endovascular management of vascular complications Techniques used to treat common pediatric after pediatric liver transplant gastrojejunostomy tube complications L Young1, R Posham2, D Goldman1, A Fischman3, V Bishay2, M P Rao1, A Brahmbhatt2, N Ohene-Baah3 Ranade4, F Nowakowski2, J Titano5, R Lookstein6, E Kim3, R Patel5 1University of Rochester School of Medicine and Dentistry, 1Icahn School of Medicine at Mount Sinai, New York, NY, 2N/A, Rochester, NY, 2University of Rochester, Rochester, NY, 3University New York, NY, 3Mount Sinai Health System, New York, NY, 4Medical of Rochester Medical Center, Rochester, NY College of Wisconsin and Affiliated Hospitals, N/A, 5Mount Sinai Medical Center, New York, NY, 6Icahn School of Medicine at Mount LEARNING OBJECTIVES: The aim of this exhibit is to illustrate several Sinai, New York, NY techniques used to treat common pediatric gastrojejunostomy tube complications and reduce procedure time. LEARNING OBJECTIVES: Understand types and prevalence of post- liver transplant vascular complications in pediatric patients. Describe BACKGROUND: Gastrojejunostomy (GJ) tube placement and replace- diagnostic and treatment methods that can be used by interventional ment is a common interventional radiology procedure in the pediatric radiology (IR) to manage these complications. population. Major complications after GJ tube placement occur in 5% to 9% of patients. Maintenance issues, however, are very common and BACKGROUND: Early arterial, portal venous, and venous outflow com- occur in over half of all patients. Most pediatric GJ tube interventions plications following pediatric liver transplant can lead to graft loss, require deep sedation or general anesthesia. This places these patients patient death, or need for re-transplantation. While vascular complica- at risk for adverse events, such as hypoxia. In addition, the stochastic tions occur in both adult and pediatric patients, some types are more effects of radiation are of particular concern in the pediatric popula- frequent in pediatric patients due to factors including differences in tion. Reducing procedure time and repeat procedures can mitigate the surgical technique and size discrepancy between the donor and the negative effects of radiation exposure and prolonged sedation. recipient patient. For example, hepatic artery thrombosis (HAT) is the most common early complication after pediatric liver transplant, with CLINICAL FINDINGS/PROCEDURE DETAILS: One technique for tube an incidence of 30% in children under one year, for which outcomes replacement is to utilize the indwelling GJ to maintain pyloric sphincter are dramatically improved with early intervention. While surgical tech- patency. A 4-Fr Kumpe catheter can be placed via the gastrostomy niques have evolved over time to help reduce these complications, into the gastric lumen. The catheter is then advanced alongside the IR can provide endovascular therapies to successfully treat many of existing GJ tube into the proximal small bowel. This technique can the vascular complications following liver transplantation in pediatric be used in cases where the existing GJ tube lumen is clogged. This patients. technique allows for rapid access into the small bowel and is especially useful in cases with complex gastro-enteric anatomy and obscuring CLINICAL FINDINGS/PROCEDURE DETAILS: Six cases of treated vascu- hardware. GJ tubes can prolapse into the gastric body, while the cath- lar complications in 5 transplant patients with an average age of 30.8 eter tip remains in the proximal small bowel. A balloon occlusion cath- months (12-69 mo) including hepatic vein torsion and stenosis, Budd- eter positioned within the antral-pyloric region can provide additional Chiari syndrome, IVC occlusion, acute portal vein stenosis, portal vein support and, in conjunction with a guidewire, can be utilized for loop thrombosis, hepatic artery thrombosis, and hepatic arterial stricture reduction. Gastric outlet obstruction can occur in pediatric patients -Etiology of liver transplant was biliary stricture and failed Kasai proce- with a small caliber pylorus even when using the smallest available size, dure in 4 cases and familial intrahepatic cholestasis in 1 case -Describe 14-Fr GJ tubes. In these cases, a modified 6- to 8-Fr enteral feeding the postsurgical vascular anatomy, clinical presentation and likely eti- tube (Medela) can be threaded through a 14-Fr gastrostomy tube. This ology of the complications in each case and how these may be unique reduced external diameter can eliminate gastric outlet obstruction and to a pediatric transplant population -Describe treatment methods reduce the risk of perforation and aspiration. employed including intravascular ultrasound, percutaneous transluminal angioplasty and stent placement. Outline several diagnostic and CONCLUSION AND/OR TEACHING POINTS: This exhibit highlights several treatment considerations (e.g., imaging technique, tools, radiation techniques that can be used to treat common GJ tube complications, dosage) for managing these patients while reducing procedure and sedation time.

CONCLUSION AND/OR TEACHING POINTS: IR can play a key role in the management of the breadth of vascular complications after liver trans- Abstract No. 1044 plant in pediatric patients. Three-dimensional printed pathology for patient education: a pictorial formula for interventional radiologists S Chadha1, P Shukla2, A Kumar3 1Rutgers New Jersey Medical School, Monmouth Jct, NJ, 2Rutgers– New Jersey Medical School, Newark, NJ, 3Rutgers New Jersey Medical School, New York, NY SIR 2020 Annual Scientific Meeting e-Posters | 131

LEARNING OBJECTIVES: 1. To separate relevant anatomy and pathology considered, and staffing models required to support efficient use of for 3D printing using a CT or MR DICOM file using the free open source expanded hours of coverage. software 3D Slicer. 2. To convert a DICOM file to an STL file for use in BACKGROUND: Most clinical services limit weekend care to urgent or a 3D printer. 3. To review the relevant costs and procedures related to emergent situations. However, providing access to nonemergent pro- operating a 3D printer for interventional radiology–related preproce- cedures on weekends may reduce length of hospital stay and unnec- dural education. essary admissions. We successfully implemented a new operational BACKGROUND: Commercially available and affordable 3D printing has model of providing nonurgent IR services to the inpatient and emer- been demonstrated in many medical research applications. Its clinical gency room patient population on evenings and weekends. use case has been elucidated in medical treatment and more recently, CLINICAL FINDINGS/PROCEDURE DETAILS: In this presentation, we patient education. Studies have shown that use of 3D printed models will review strategies to develop a proposal for expanded coverage, of patient anatomy and pathology in preprocedural visits can signifi- including what types of data can be used to demonstrate the need cantly increase patient understanding of their condition and satisfac- for increased IR coverage. We will further discuss different models of tion when compared to standard of care visits or generalized model implementation that can be considered, and staffing models required use. This use case has been demonstrated successfully for kidney to support efficient use of expanded hours of coverage. Finally, we tumors, lumbar disease, liver surgical procedures, prostate cancer, etc. will review data from our initial analysis following a 1-year period of The advent of open source software such as 3D slicer and affordable implementation, in which we demonstrated that use of routine week- 3D printers makes implementation of personalized patient models end procedural services allowed ~25% of patients to be discharged ear- for education in the preprocedural visit possible in many healthcare lier than anticipated, and resulted in progression of care in more than centers. 50% of patients. We will also review the positive impact that greater IR CLINICAL FINDINGS/PROCEDURE DETAILS: In order to pictorially depict access had with respect to specific patient types, such as those requir- the relevant procedures related to personalized 3D printing, screening hemodialysis access management. shots and images of software and the 3D printed product will be CONCLUSION AND/OR TEACHING POINTS: In conclusion, expanded used. The pictorial formula will walk through the procedures and tools availability of nonurgent IR inpatient services has the potential to offer employed using a case of chemoembolization of HCC and a case of PAE significant institutional value through reduced length-of-stay, facilitat- as examples. These procedures include the DICOM upload process in ing discharge from an emergency room and by enabling faster pro- 3D slicer, segmentation of selected anatomy and pathology (including gression of care. tumors, vessels, and organs), export to STL format, 3D printer settings, and the final product.

CONCLUSION AND/OR TEACHING POINTS: Open source software and Abstract No. 1046 affordability of 3D printers has made widespread adoption of 3D Interventional radiology: moving beyond Twitter printing in healthcare centers possible. Studies have shown increased patient understanding and satisfaction when personalized anatomical M Cellini1, D Homen2, A Isaacson3, J Stewart2 models are used in preprocedural visits. Viewers of this exhibit will 1University of North Carolina, Durham, NC, 2N/A, Durham, NC, 3UNC understand how to affordably create and adopt 3D prints of patient Department of Radiology, Chapel Hill, NC anatomy for preprocedural patient education. LEARNING OBJECTIVES: After reviewing this exhibit, the reader will (1) understand the different social media services available for physicians, Abstract No. 1045 (2) learn how to use each service to educate and bring awareness to the field of interventional radiology (IR), and (3) learn how to use these Expanded interventional radiology service to evening and platforms as a marketing tool. weekend coverage for routine nonurgent inpatient cases: lessons learned from successful implementation over a BACKGROUND: Social media platforms have completely transformed 3-year period the way physicians interact with their colleagues and patients. These platforms allow for many opportunities available to interventional T Fudim1, S Faintuch2, A Sarwar1, J Weinstein1, D Hallett1, M radiologists which can improve the way we practice and market our- Ahmed3 selves as physicians. A single social media post has the potential to 1Beth Israel Deaconess Medical Center, Boston, MA, 2Beth Israel reach millions of people instantly, yet many interventional radiolo- Deaconess Medical Center–Harvard Medical School, Boston, gists remain unaware of how to use these platforms to their benefit. 3 MA, Beth Israel Deaconess Medical Center/Harvard, Boston, MA Social media allows for an interventional radiologist to demonstrate their unique skillset and value offered to patients. With the recent shift LEARNING OBJECTIVES: Review strategies to develop a proposal for towards clinically focused IR practices, these platforms can help to expanded coverage, including what types of data can be used to bridge the doctor-patient divide. Furthermore, a large online presence demonstrate the need for increased interventional radiology (IR) allows for patients to see first-hand the personalities of their interven- coverage. Discuss different models of implementation that can be tional radiologists, which can aid in building trust. 132 | e-Posters SIR 2020 Annual Scientific Meeting

CLINICAL FINDINGS/PROCEDURE DETAILS: We present a review of many CONCLUSION AND/OR TEACHING POINTS: By providing an updated social media platforms, including Instagram, YouTube, and TikTok. For guide for NOAC management, the challenging and evolving land- each platform, we will include a description and how each platform can scape of anticoagulation can be navigated with clarity and confidence, provide a unique opportunity for medical education, marketing, and empowering interventionalists to deliver optimal patient care. awareness of interventional radiologists and/or their practices.

CONCLUSION AND/OR TEACHING POINTS: (1) The use of social media Abstract No. 1048 can allow for awareness and improve education in IR. (2) There are many social media platforms, beyond Twitter, that can be useful for Open your own wound care clinic: the key to success in interventional radiologists. (3) Using social media platforms is a way to critical limb ischemia market yourself and bridge the doctor-patient divide. O Adenikinju1, M Patel1, A Zybulewski2, R Beasley3, B Olivieri3 1Mount Sinai Medical Center, Miami Beach, FL, 2Icahn School of Abstract No. 1047 Medicine at Mount Sinai, New York, NY, 3N/A, Miami, FL

NOAC, no problem: a practical guide on novel oral LEARNING OBJECTIVES: Provide a primer on how interventional radiol- anticoagulant therapy for the interventional radiologist ogists can build their own in-office wound care clinic. Describe the benefits of providing in-office wound care to critical limb ischemia 1 2 3 1 1 D Reyes , B Money , R Ahuja , O Adenikinju , H Reynolds , A (CLI) patients. Identify clinic components and staff necessary to Zybulewski1, R Beasley1, B Olivieri1 provide simple wound care in the office. Compile a pictorial essay of 1Mount Sinai Medical Center, Miami Beach, FL, 2Dr. Kiran C. Patel essential supplies to effectively provide in office wound care. Explore College of Osteopathic Medicine, Fort Lauderdale, FL, 3Albert the financial benefits of providing in office wound care. Einstein Medical Center, Philadelphia, PA BACKGROUND: Complex lower extremity revascularization is only one LEARNING OBJECTIVES: (1) Illustrate the differences between FDA-ap- part of the battle to achieve wound healing in CLI patients: it is imper- proved novel oral anticoagulants (NOACs), including mechanism of ative that they also receive excellent wound care. While often thought action. (2) Identify patient selection factors that influence efficacy of as a surgical or podiatric skillset, many simple in-office wound and application of NOACs. (3) Demonstrate when to hold and resume care procedures can performed by and charged for by interventional NOACs during the periprocedural period. (4) Provide an updated radiology CLI specialists. As interventional radiologists emerge from NOAC guide for nonvalvular atrial fibrillation, venous thromboem- their training ready to fight the CLI epidemic via endovascular means, bolism (VTE) management, and interventional procedures that will it is imperative that they are also equipped with an understanding of empower the reader to approach NOAC management with safety and the essential components of and economic benefits of providing their confidence. own in-office wound care.

BACKGROUND: Since the approval of NOACs such as dabigatran CLINICAL FINDINGS/PROCEDURE DETAILS: This educational presenta- (Pradaxa), rivaroxaban (Xarelto), and apixaban (Eliquis), there have tion will help the reader 1) identify the key clinic components and staff been numerous trials and consensuses supporting their safety and necessary to provide simple in office wound care, 2) illustrate a pic- efficacy. Favorable properties including lack of routine laboratory test- torial essay of essential in office wound care supplies + their uses, 3) ing, fixed dosing, and noninferiority compared to traditional anticoag- provide key wound care training pearls from the perspective of wound ulants have led to a dramatic rise in their use across nearly all patient care and podiatric specialists through case examples, and 4) explore populations. Despite these advantages, NOACs present various the financial benefits of providing in-office wound care for CLI patients. periprocedural challenges with unreliable laboratory metrics to predict CONCLUSION AND/OR TEACHING POINTS: To compete in the increas- bleeding risk and until recently, lack of FDA-approved reversal agents. ingly popular field of CLI care, technical skill sets beyond revascu- CLINICAL FINDINGS/PROCEDURE DETAILS: We provide a comprehen- larization are becoming necessary. Adjuvant wound care is a vital sive reference guide for the interventionalist, which will (1) illustrate component in the fight for wound healing and can be provided by vital characteristics of NOACs for optimal periprocedural planning, interventional radiologists in their own office. This educational exhibit (2) describe indications for stopping and resuming NOACs based on equips the interventional radiologist with the tools needed to build and bleeding risk assessment and procedure type, building on the Soci- benefit economically from a successful wound care clinic. ety of Interventional Radiology Consensus Guidelines, (3) highlight specific NOAC applications in VTE prophylaxis and peripheral arterial disease, (4) outline indications and applications for FDA-approved Abstract No. 1049 NOAC reversal agents (idarucizumab [Praxbind] and andexanet alfa [Andexxa]), and (5) demonstrate an algorithm for individualized NOAC Physician practice earnings for hospital-based Y90 versus management based on patient characteristics and clinical context. office-based Y90 We summarize the information outlined with case-based examples to D Xu1, S Reis2 enhance comprehension. 1Columbia New York Presbyterian, New York, NY, 2Columbia University Irving Medical Center, Briarcliff Manor, NY SIR 2020 Annual Scientific Meeting e-Posters | 133

LEARNING OBJECTIVES: 1. To outline the Medicare fee differences for BACKGROUND: RPA aids in decreasing cycle time for key processes office-based versus hospital-based Y90. 2. To outline the average and can perform a repetitive task with 70% higher efficiency as com- costs of performing office-based versus hospital-based Y90. pared to an average employee. This model has been integrated into the healthcare infrastructure with estimated 35-65% cost reduction for BACKGROUND: Y90 has been safe and effective for the treatment of onshore operations and 10-30% for offshore operations. In the health certain hepatic malignancies. Standard protocol entails a planning care industry, cost savings are estimated ranging from 20-60% of angiography with Tc-99m MAA imaging and lung shunt fraction calcu- baseline FTE cost. lation prior to Y90 administration. Many centers are now beginning to perform SIRT in an outpatient office-based lab. However, both Medi- CLINICAL FINDINGS/PROCEDURE DETAILS: An RPA model was imple- care reimbursement fees and costs for the entire treatment are depen- mented at our institution to facilitate and complete RPA opportunity dent on the type and setting of where treatment occurs. assessments, implement proof of concept (POC) for three back-office functions, change management and operations support. This was CLINICAL FINDINGS/PROCEDURE DETAILS: 2019 Medicare National done in order to address a more efficient way of processing OHIP Payment Amounts was used. Hospital and office-based lab technical billing rejections. The initial billing rejections included a 14-step pro- and professional fees were queried. A standardized test case of left cess that was performed manually. The finance RPA BOT processed hepatic lobe malignancy treatment with embolization during mapping between 4000-6000 billing reconciliations/week and the HR BOT was used. The following procedures were queried: initial 2nd/3rd/ reviewed and processed 500 email inquiries/week. This RPA model is beyond selective catheterization, visceral/selective angiography, arte- expected to perform workload normally performed by 4 FTEs, thus rial embolization, SPECT/CT, radiopharmaceutical location of tumor, enabling hospital to process OHIP rejections faster. Other examples lung shunt assessment, treatment planning, simulation, dosimetry, of RPA in the health care industry include improvement in outpatient physics consultation, tumor embolization, pass through billing of SIR- billing process at MENA hospital (initial billing rejections: 30%-40%) Spheres, and limited PET/CT. Equipment costs included 5-Fr sheath, resulting in releasing 20 FTE’s; Hospital (anonymous) required an 0.038 wire, curved catheter, angled tip hydrophilic wire, a microcath- update of 50,000 backlogged records that were performed via an eter/microwire coaxial system, embolization coils, intravenous con- RPA in 1 minute per case, corresponding to 6 months work for a full trast, and SIR-Spheres. Utilization of a single plane fluoroscopy unit, a time employee. C-arm, a SPECT/CT, and a PET/CT were calculated based on average purchasing cost, a 10-year lifespan, and maintenance cost combined CONCLUSION AND/OR TEACHING POINTS: Benefits of RPA in healthcare, with the average national nursing and technologist cost for the respec- specially interventional radiology include patient scheduling, coding tive modalities. compliance, claims administration, clinical documentation, charge capture, increasing reimbursements, accounts receivable, patient self- CONCLUSION AND/OR TEACHING POINTS: For hospital-based treat- pay administration, improvement in bill efficiency, validating health ment, total professional revenue was $1761. The majority of the hos- plans (OHIP) and third-party insurance eligibility. pital reimbursed fees are allocated to technical fees, which was $41,119. However, near all of the costs associated with hospital based treatment may be allocated towards the technical component, being Abstract No. 1051 approximately $19,562. In an office-based lab, both the professional and technical components may be combined. As such, total revenue Slow your roll: tackling authority gradients in was $48,770. Approximate costs were $19,528. Approximate gross interventional radiology revenue was thus $29,242. J Huang1, F Fintelmann1, R Sheridan1, S Kalva1, J Hirsch1, P Sutphin1 1Massachusetts General Hospital, Boston, MA Abstract No. 1050 LEARNING OBJECTIVES: This presentation will explore the authority Robotics process automation: process efficiency in health gradient in interventional radiology (IR) and explain how it can jeop- care ardize patient care, and discuss steps that can be taken to reduce the gradient and improve communication. Z Badar1, G Kalboneh2, S Frosi Stella3, G Markose4, F Gastaldo5, S Nair6 BACKGROUND: The concept of the authority gradient was first described in the airline industry where it is referred to as cockpit gra- 1McMaster University, Hamilton, ON, 2Ernst & Young LLP, Burlington, ON, 3University of Toronto, Toronto, ON, 4N/A, Hamilton, dient. It describes how an imbalance in authority affects communica- ON, 5Hamilton General Hospital, Dundas, ON, 6N/A, Ancaster, ON tion in critical situations and may lead failure to recognize and avoid threats. Aviation studies demonstrated a 21% higher incident rate LEARNING OBJECTIVES: RPA is an innovative solution for automatic when working in a hierarchical environment directly owing to junior handling of processes with high volume repetition. It is a software that ranking individuals being unwilling to contest their seniors. Medicine, uses established control mechanisms to run repetitive, rule based pro- similarly, is a steep hierarchy and studies have documented the exis- cesses. Specifically, the role of RPA implementation at our institution tence of adverse outcomes associated with the authority gradient in (pre and post full time equivalent [FTE] savings and processing time) medicine. for OHIP (Ontario Health Insurance Plan) rejections will be discussed. 134 | e-Posters SIR 2020 Annual Scientific Meeting

CLINICAL FINDINGS/PROCEDURE DETAILS: The consequence of the interventional radiologists looking to engage their value analysis com- authority gradient is a breakdown in communication that limits the mittees and potentially become engaged in these activities. availability of critical information in the decision making process. CONCLUSION AND/OR TEACHING POINTS: Interventional radiologists Combating the authority gradient requires efforts at the institutional, should view value analysis committees as partners in providing them departmental and individual levels. The presentation will review the with cost-effective medical devices to provide care to their patients. authority gradient in specific IR scenarios. In addition, steps that can Opportunities exist for interventional radiologists to become a partic- be undertaken to reduce the steepness of the authority gradient and ipant on value analysis teams so that familiarity with the specialty is improve teamwork and improve communication will be reviewed. increased, enabling appropriate decision making when new devices -Training to educate about the authority gradient and potential effects are considered for purchase. on patient safety -Assess the authority gradient from the perspective of the most junior members of the team -Assertiveness training; encourage team members to speak up -Formalized communica- Abstract No. 1053 tions such as briefing and debriefing where the hierarchy is formally suspended. There’s an app for that: the value of enhancing an interventional radiology clinical service with a handheld CONCLUSION AND/OR TEACHING POINTS: Hierarchical institutions and app disciplines carry the associated burden of the authority gradient. The authority gradient can adversely affect patient care and outcomes. N Doro1, F Khan1, R Brooks1, C Stark1, L Keating1, A Herr1, G Siskin1 Fortunately, actions can be taken to reduce the steepness of the 1Albany Medical Center, Albany, NY authority gradient. LEARNING OBJECTIVES: The purpose of this educational exhibit is to review the clinical imperative for interventional radiologists to perform Abstract No. 1052 daily rounds as part of inpatient management, to review the coding and requirements for documentation for these services, and to high- The hospital value analysis committee: friend or foe? light the benefit of an app for handheld devices that facilitates organi- S Narayan1, D Gewolb1, R Patel1, C Stark1, L Keating1, A Herr1, G zation and charge capture for these services. Siskin1 BACKGROUND: As interventional radiology (IR) has evolved as an inde- 1Albany Medical Center, Albany, NY pendent specialty, the need for providing pre- and postprocedural patient care is growing in importance. With the advent of the IR resi- LEARNING OBJECTIVES: This exhibit will review the evolution and dency, it has now become a requirement for centers directly involved purpose of hospital value analysis committees and identify areas of with resident education to provide appropriate pre- and postproce- opportunity for interventional radiologists in a hospital’s supply chain dural care including inpatient rounds and outpatient office visits. operations.

CLINICAL FINDINGS/PROCEDURE DETAILS: Managing an inpatient IR BACKGROUND: Value analysis committees have been put into place at service is an important part of a clinical IR service. For any busy IR most hospitals to help control cost as the prices of medical and sur- practice, organizing the inpatient service can become quickly over- gical supplies continue to increase. These committees are meant to whelming. Keeping track of the patients being treated by IR, determin- establish a process for bringing new medical devices into the hospital. ing how often they need to be seen, appropriately documenting and By taking an unbiased look at the potential uses of a device and the coding these encounters, and becoming engaged in the outpatient fol- potential outcomes associated with use of a device balanced against low-up required after discharge can be challenging and requires ongo- the cost of a device, value analysis committees can help control cost ing attention. This is especially difficult when a practice covers multiple while at the same time ensuring that a hospital has appropriate devices hospitals. Our practice has developed algorithms for consultations and available to treat patients with a variety of conditions. many of the procedures that we perform that has provided structure CLINICAL FINDINGS/PROCEDURE DETAILS: Given the device-dependent to this process. This has been greatly facilitated by an app for hand- nature of interventional radiology, and the rapid pace which defines held devices (UnisonMD) that interfaces with our EMR, our practice the development of new devices relevant to this specialty, there are management systems, our hospital databases, and our regional health innumerable opportunities for interventional radiologists to interact exchanges. With the use of this app, we have become more consistent with their respective value analysis committees. In most cases, value with direct patient management protocols and better at capturing the analysis committees are seen as hurdles set up to prevent physicians charges associated with these encounters, leading to better care and from having the new or expensive devices available for their use. While enhanced revenue. this may be true in some instances, it is certainly possible for goals CONCLUSION AND/OR TEACHING POINTS: The utilization of a hand- to be aligned and for interventional radiologists to interact positively held app to help our providers manage inpatients before and after with value analysis committees to standardize inventory, control cost, procedures has resulted in significant improvements to our IR clinical and enable the introduction of new devices as they become available. practice. The benefits with organization, communication, and revenue This exhibit will discuss those opportunities and provide guidance for generation have been significant and have in turn led to actual and potential opportunities for growth and better patient care. SIR 2020 Annual Scientific Meeting e-Posters | 135

Abstract No. 1054 Abstract No. 1055

A secure texting platform for improving communication Are leaded caps effective at reducing radiation exposure between interventional radiologists and referring in the interventional radiology suite? physicians: a single-institution experience at a tertiary G Rao1, G Kroma2, R Suri3 academic medical center 1University of Texas Health Science Center at San Antonio, San 1 2 3 4 2 J Meshekow , A Gold , S McCabe , S Maddineni , P Gerard , G Antonio, TX, 2University of Texas Health Science Center, San 5 Rozenblit Antonio, TX, 3University Texas Health San Antonio, San Antonio, TX 1Westchester Medical Center–New York Medical College, Beacon, LEARNING OBJECTIVES: 1. To explore the literature on the effectiveness NY, 2Westchester Medical Center, Valhalla, NY, 3Westchester Medical of reducing radiation exposure through the use of leaded caps. 2. To Center, Katonah, NY, 4Westchester Medical Center, Chappaqua, NY, 5Westchester Medical Center, Eastchester, NY provide guidance on what to consider when evaluating a leaded cap.

BACKGROUND: Interventional radiologists need to understand the LEARNING OBJECTIVES: 1. To review the utilization of a secure literature on effective methods to reduce radiation exposure in the (encrypted) texting platform and demonstrate its utility for an inter- interventional radiology (IR) suite. Many advances in understanding ventional radiology (IR) section within an academic institution. 2. To radiation exposure have guided the development of effective thyroid demonstrate the integration process, outline the workflow, and illus- shields, leaded aprons, and more recently the use of leaded glasses. trate each of the core components of a secure texting application/ The literature on the use of leaded caps has yet to be explored as platform. extensively. BACKGROUND: Communication is an integral component of multidis- CLINICAL FINDINGS/PROCEDURE DETAILS: Leaded caps can be used as ciplinary patient care. A multitude of factors play a role in the mode an additional tool to mitigate radiation exposure to the interventional of communication between interventional radiologists and referring radiologist. A review of literature on leaded caps has shown mixed health care providers. Timely communication is more important than results with a few studies demonstrating that a .5 mm leaded cap to the method of information delivery. While traditional short message be highly effective at reducing scatter to the brain when compared to service (SMS) texting harbors potential breach of patient confidenti- only the use of a lead glass shield, while other studies having shown ality, secure encrypted messaging via a third party application (Tiger- radiation protective caps to have minimal clinical relevance. Under- Connect, San Francisco, CA), offers a safe and effective means of standing the various options and styles of leaded caps is vital to reduce communication between interventional radiologists and healthcare radiation to the brain. This exhibit will explore the literature on leaded providers. We sought to implement institution-wide secure texting to caps and investigate the variety of options that are available for use. facilitate information exchange between IR professionals (physicians, nurses, and staff) and ordering providers. Such communication can CONCLUSION AND/OR TEACHING POINTS: Innovations in radiation be implemented by using personal smartphones or any in-network safety are important to understand in order to reduce the risk of ioniz- computer. ing radiation to the IR physician. The interventional radiologist should be familiar with the literature on leaded caps and their effectiveness in CLINICAL FINDINGS/PROCEDURE DETAILS: A. Generalized Workflow reducing intracranial radiation exposure. This exhibit focuses on edu- Map B. Review of Secure Texting: i. Contact Information and Phone- cating interventional radiologists on radiation exposure to the brain book ii. Daytime IR Staff iii. On-call and Emergencies iv. Highlighted along with how best to evaluate various radiation safety options. Features: a. Image sharing b. Read receipts c. Typing awareness indicator v. Nursing Utilization vi. Faculty, Resident, and Housestaff Procedures C. Outline for utilization, instruction, and adoption of a Abstract No. 1056 secure texting platform as a means of communication between IR and providers. Discharge process standardization in the interventional radiology department: augmenting patient education to CONCLUSION AND/OR TEACHING POINTS: The utilization of a secure texting platform expedites information exchange and optimizes work- decrease future emergency department visits flow by streamlining communication, which inherently improves inter- S Maratto1, L Elsamaloty1, B Hammelman2 departmental quality of care, efficiency, and patient safety. In addition, 1Pennsylvania Hospital, Philadelphia, PA, 2N/A, Philadelphia, PA asynchronous communication is less disruptive to both IR and ordering providers. We offer strategies from our experience to create an LEARNING OBJECTIVES: To evaluate nursing satisfaction and emer- effective mode of communication between interventional radiologists gency department presentations as process and outcome metrics and healthcare providers. within an interventional radiology (IR) department after implementation of standardized, comprehensive, procedure specific discharge instructions.

BACKGROUND: The periprocedural phase of care offers many opportunities in process improvement. Regarding discharge processes particularly, emphasis on standardizing postprocedural education can lead 136 | e-Posters SIR 2020 Annual Scientific Meeting

to optimizations in patient centered care. Since the implementation of CLINICAL FINDINGS/PROCEDURE DETAILS: This exhibit will: 1. Review a new electronic medical record, IR at our institution has strived for evolving AI techniques including machine learning and deep learning. clinician driven discharge process uniformity to decrease variability of 2. Explore the use of convolutional neural networks in the radiological patient discharge education. After serial PDSA cycles we evaluated a classification and diagnosis of tumoral lesions amenable to IR thera- new discharge process with a nursing voice of customer survey, as well pies. 3. Describe the utility of machine learning techniques in optimiz- as by quantifying postprocedural emergency department visits. ing patient selection for IR interventions. 4. Discuss approaches for AI integration in the IR workflow to improve image guidance during CLINICAL FINDINGS/PROCEDURE DETAILS: I. Initial PDSA and pilot a. interventions. 5. Survey the role of artificial neural networks in predict- Nursing survey b. Nurses indicated two major themes for improve- ing responses to IR treatments. 6. Explore future directions as well as ment: specificity and clinician input c. New instructions for ten pro- challenges in the development and utilization of AI in IR. cedures added to the electronic medical record d. During repeat survey all nurses agreed that patients better understood their pro- CONCLUSION AND/OR TEACHING POINTS: After reviewing this exhibit, cedures II. Second PDSA and intervention a. Data query for patients the viewer will gain a deeper understanding of the role of AI in radiol- receiving percutaneous tubes with postoperative emergency visits b. ogy and the potential implications in the contemporary practice of IR. In 6 months, 91 tube procedures yielded 31 patients with emergency department visits post discharge c. Distribute wallet sized “tube/drain information cards” for patients describing what to look for after proce- Abstract No. 1058 dure and who to contact if new symptoms arise d. Recount number of Epic reports: arming the interventional radiology practice postprocedural emergency department visit. with large data CONCLUSION AND/OR TEACHING POINTS: In the IR department, the A Saini1, P Hoang1, I Altun1, T Parnall1, A Wallace1, G Knuttinen1, S dynamic workflow creates inherent variability in the daily processes Alzubaidi1, I Patel2, H Albadawi3, S Naidu4, R Oklu1 and patient experience. Using two PDSA cycles, we detailed this vari- 1 2 ability during discharge in a pilot driven by a nursing survey and will Mayo Clinic Arizona, Phoenix, AZ, Mayo Clinic–Arizona, Phoenix, 3 4 use postprocedural emergency department visits as outcome metrics AZ, Mayo Clinic, Scottsdale, AZ, Mayo Clinic Arizona, Scottsdale, AZ after distribution of tube information cards. Based on our work, we believe that improving our procedural discharge information can aug- LEARNING OBJECTIVES: Review the different types of Epic reports ment patient safety and decrease potentially wasteful presentations to including Application reports, reporting workbench, clarity reports the emergency department. and radar dashboard. Discuss the utility of these report types in the context of clinical research, quality improvement, and practice management. Highlight the role structured reporting can play in the cre- Abstract No. 1057 ation of these reports.

Emerging applications of artificial intelligence in BACKGROUND: Epic is a widely used electronic medical record (EMR) contemporary interventional radiology practice system with a multitude of capabilities. In addition to its role in doc- L Cooke1, E Von Ende2, M Makary2, J Dowell3 umenting patient care, Epic also allows for the extraction of large, complex sets of data relevant to patient care, clinical research, and an 1Indiana University School of Medicine, Indianapolis, IN, 2The Ohio organization’s operations through the generation of various reports. State University Wexner Medical Center, Columbus, OH, 3Northwest Specifically, data contained within Epic can be exported into vari- Radiology and St. Vincent Health, Indianapolis, IN ous databases and then analyzed to provide a report specific to an

LEARNING OBJECTIVES: To explore the opportunities and challenges end-user’s needs. Physicians can use “Epic Clarity” reports to pres- for artificial intelligence (AI) integration into interventional radiology ent or aggregate data across time—for example, a report including (IR) practice, and identify ways in which AI can be utilized to increase patients treated with a specific intervention in a given time frame can personalization of IR procedures as it relates to diagnosis and patient be generated to assess treatment outcomes or complication rates. selection. Furthermore, practice administrators can create “Reporting Work- bench” reports, which can be used to gain real-time information on BACKGROUND: The practice of IR has paved the way for minimally inva- practice operations, workflow efficiency, and operating costs, among sive therapies for a diverse array of patient conditions. The integration other things. Collectively, these reports and others can help stream- of machine and deep learning, capable of recording, analyzing, and line patient care, research, and daily operations. As with any computa- interpreting data as well as establishing correlations, may prove useful tional process, bad data input will lead to bad data output; therefore, in the interventional clinical management including optimizing treat- structured reporting will play an increasingly larger role in large data in ment strategies and patient selection for IR therapies. Expanding the interventional radiology (IR). AI technology into the modern IR practice to analyze clinical metrics and provide meaningful interpretations and predictions toward pro- CLINICAL FINDINGS/PROCEDURE DETAILS: We will provide an overview cedural approaches and outcomes has the potential to improve both of the 4 major report types in Epic including their creation, typical end- procedural throughput and patient outcomes. This exhibits aims to user, and capabilities. Through sample reports, the potential of Epic highlight the role of AI in IR practice and future efforts in its integration. SIR 2020 Annual Scientific Meeting e-Posters | 137 reports in IR will be elucidated. The importance of structured reporting Abstract No. 1060 in large data IR will be highlighted. An image-rich procedural review of transmesenteric CONCLUSION AND/OR TEACHING POINTS: Epic reports allow for the method of intrahepatic portosystemic shunt harvesting, analysis, and utilization of large datasets buried within the Epic EMR. By incorporating these reports into practice, IR stakeholders J Wu1, A Gaffar1, J Meshekow2, S McCabe1, S Maddineni1, G 1 can streamline patient care, research, and daily operations. Rozenblit 1Westchester Medical Center, Valhalla, NY, 2Westchester Medical Center–New York Medical College, Valhalla, NY Abstract No. 1059 LEARNING OBJECTIVES: (1) To review indications and provide an Patient safety and quality improvement 101: a guide for image-rich step-by-step approach of the transmesenteric method of interventional radiologists and trainees intrahepatic portosystemic shunt. (2) To provide an overview of the M Juliano1, V Cascio1, O Jawhar1, J Hoffmann2 transmesenteric method of intrahepatic portosystemic shunt including the benefits, complications, and relevant imaging findings. 1NYU Winthrop Hospital, Mineola, NY, 2NYU Winthrop Hospital, Garden City, NY BACKGROUND: Transjugular intrahepatic portosystemic shunt (TIPS) is an increasingly popular treatment option in patients with portal hyper- LEARNING OBJECTIVES: 1. Highlight key quality improvement concepts tension and associated sequela. The most critical step of the TIPS and strategies that are important to interventional radiologists and procedure involves access into the portal vein. Unfortunately, this is our patients. 2. Review why these concepts are important and how complicated by the potential for injury to nearby structures including successful implementation and utilization can improve patient satis- the bile duct, hepatic artery, and lungs. Conventional access is gained faction, safety, and overall workplace satisfaction. through the jugular venous approach; however, various anatomic and

BACKGROUND: Patient safety, performance improvement, and quality patient specific considerations can make obtaining access via this improvement projects and initiatives exist in every hospital. However, route exceedingly difficult. One alternative approach is the transmes- formal and longitudinal education about these topics has not been enteric method, which is only feasible with a synergistic relationship mandated in training programs until recently. Because of this, inter- between general surgery and interventional radiology. We provide an ventional radiologists and trainees may not be adequately exposed educational overview of cases performed at our institution utilizing the to these concepts, why they are important, and how best to utilize in transmesenteric method. day to day practice. This educational exhibit reviews key patient safety CLINICAL FINDINGS/PROCEDURE DETAILS: I. Anatomy of the portosys- and quality improvement concepts and provides recommendations for temic system. II. Pathophysiology of bleeding esophageal and gas- successful implementation. tric varices. III. Patient Selection. IV. Rationale for Transmesenteric as

CLINICAL FINDINGS/PROCEDURE DETAILS: Review the history of qual- opposed to conventional TIPS. V. Step-by-step procedural review for ity improvement and patient safety in medicine, with a focus on inter- performing Transmesenteric TIPS. VI. Clinical and Imaging findings. ventional radiology (IR). Detail numerous concepts and models will be VII. Post procedural imaging results. VIII. Complications and post treat- reviewed, including (but not limited to): the Donabedian model, the ment management. Deming model for continuous quality improvement, process maps, CONCLUSION AND/OR TEACHING POINTS: The transmesenteric method walking the Gemba, key driver diagram, Lean Six Sigma, and plan- for TIPS may be a good alternative in particularly challenging cases for do-study-act cycles. This will include relevant literature review, with which conventional transjugular approach cannot be performed. We IR-specific examples where appropriate. Finally, the exhibit will provide present a procedural review including technical considerations, ben- the reader with recommendations and suggestions for strengthening efits, and complications of a transmesenteric method of intrahepatic QI programs and involving additional staff and trainees in the process. portosystemic shunt.

CONCLUSION AND/OR TEACHING POINTS: Providing exceptional, high-quality care is important to interventional radiologists as physicians continue to navigate an increasingly complex, quality-drive Abstract No. 1061 health care system. Knowledge of key quality improvement and safety Hemorrhagic ectopic varices: evaluation and concepts and how to implement them in daily practice is essential for management long-term success. As interventional radiologists have an opportunity to demonstrate the quality and value of image-guided procedures, R Le1, M Agrait Bertran1, S Hagaman2, T Meyer1, J Matteo1, J Kee- they must do so using accepted and proven quality improvement Sampson1, S Bashir1 approaches. This can help to protect the specialty, advocate for IR 1UF Health Jacksonville, Jacksonville, FL, 2Lake Erie College of patients, and promote further growth in the future. Osteopathic Medicine–Bradenton, Bradenton, FL

LEARNING OBJECTIVES: 1. Recognize the relationship of variceal bleeding as a consequence of portal hypertension 2. Review ectopic variceal anatomy and its collateral pathways 3. Describe intervention strategies 138 | e-Posters SIR 2020 Annual Scientific Meeting

for hemorrhagic variceal bleeding, highlighting the balloon ante- Therapeutic planning and safe treatment depend upon identifying grade transvenous obliteration (BATO) technique 4. Outline technical their afferent and efferent supply and understanding their hemody- aspects, potential complications, and outcomes for patients undergo- namics. The purpose of this exhibit is to aid the interventional radiology ing the BATO procedure. trainee in distinguishing the varied and variant angiographic anatomy associated with gastric varices, as well as parallel collateral networks. BACKGROUND: Hemorrhagic varices are a sequalae of portal hypertension. Ectopic varices, located outside of the gastroesophageal portion CLINICAL FINDINGS/PROCEDURE DETAILS: 1) Angiographic venous of the digestive tract, represents 5% of all variceal bleeding, yet show a anatomy of the left upper quadrant a. Portal-venous tributaries i. Left 4x increased likelihood of bleeding compared with gastroesophageal gastric vein and its variants ii. Fundal drainage: Posterior gastric and varices and up to 40% mortality rate. These varices have variable anat- short gastric veins iii. Gastroepiploic vein: a source of ectopic varices b. omy, and an interventionist must quickly determine the optimal proce- Systemic veins i. Esophageal veins ii. Inferior phrenic vein c. Physiologic dure, of which there is no consensus in the literature. This exhibit’s goal shunts i. Portosystemic: Veins of Retzius ii. Interportal: Portocoronary is to help solidify the reader’s knowledge of the anatomy, pathophysi- anastomoses 2) Portosystemic shunts in portal hypertension a. Vari- ology, and management of rare, but deadly, types of variceal bleeding. ceal shunts: hepatofugal versus hepatopedal b. Nonvariceal shunts 3) Variceal complexes a. Afferent pathways b. Efferent pathways: i. SVC CLINICAL FINDINGS/PROCEDURE DETAILS: Varices arise as dilated col- versus IVC ii. Single versus combined efferents laterals when the porto-systemic gradient disappears. They can also occur via thrombosis or from select gastrointestinal surgeries. Radio- CONCLUSION AND/OR TEACHING POINTS: - Gastric varices are a part logic evaluation depends on location. It varies from doppler ultrasound of collateral-forming response which includes both variceal and non- to multiplanar portal venous computed tomography or magnetic reso- variceal collaterals - Afferent pathways vary according to the location nance imaging. Some varices, like rectal varices, may be evaluated and of the gastric varices on the stomach - Efferent pathways may receive potentially treated during colonoscopy. Intervention is patient-specific contribution from nonvariceal collaterals and may drain to a combina- and depends on his or her clinical status, comorbidities, and etiology tion of IVC, SVC, pulmonary, or brachiocephalic veins. of variceal bleeding. BATO can be used in patients with poor functional status as an adjunct for TIPS decompression. Transjugular portal venous or direct percutaneous portal venous access can be used to Abstract No. 1063 place a balloon occlusion catheter for a prolonged period and to inject Less punctures, safer transjugular intrahepatic sclerosant into a varix. Coils can be used after sclerosant to maintain portosystemic shunt: understanding and optimizing portal venous stasis. intracardiac echocardiography catheter use during CONCLUSION AND/OR TEACHING POINTS: Hemorrhagic ectopic varices transjugular intrahepatic portosystemic shunt can be a fatal consequence of portal hypertension, requiring a thor- C Molloy1, J Huang1, K Yamada1, S Kalva1, S Ganguli1, T Walker1 ough clinical and imaging evaluation prior to intervention. BATO is a 1 useful procedure that can quickly curtail bleeding for hemodynami- Massachusetts General Hospital, Boston, MA cally compromised patients. LEARNING OBJECTIVES: Understanding intracardiac echocardiography (ICE) catheter use during transjugular intrahepatic portosystemic Abstract No. 1062 shunt (TIPS). Orientation and landmarks of ICE catheter images. Strat- egies to optimize successful portal vein cannulization.

Ins and outs of gastric varices: an angiographic review of BACKGROUND: TIPS is a commonly performed procedure to treat venous pathways refractory esophageal bleeding and/or recurrent ascites in patient R Kutcher1, D Alvarez Valero1, A Pavidapha1, H Malik1 with portal hypertension. Traditionally, TIPS was performed via fluoroscopic guidance which often required multiple punctures through 1University of Massachusetts Medical School, Worcester, MA cirrhotic liver to obtain access to the portal system. With the advent LEARNING OBJECTIVES: (1) Review normal portal-venous and systemic of ICE catheter operators may utilize internal planar ultrasound images venous anatomy of left upper quadrant, with attention to their relation to guide TIPS procedures. This exhibit provides guidance on how to to gastric varices. (2) Identify the angiographic appearance of vari- utilize and optimize ICE catheter use, orient users to ICE images, and ous portosystemic shunts, both physiologic and secondary to portal improve TIPS success rates with fewer punctures. hypertension, focusing on gastric varices as a subset of portosystemic CLINICAL FINDINGS/PROCEDURE DETAILS: Operators at our institution shunts. (3) Correlate angiographic findings with corresponding CT perform TIPS via traditional fluoroscopic techniques and with the use anatomy. (4) Illustrate the combination of afferent and efferent venous of ICE catheters. This exhibit reviews optimal ICE catheter techniques. pathways supplying and draining gastric varices. We also review labeled intraoperative ICE images to provide orienta- BACKGROUND: Gastric varices affect approximately 15% of patients tion for new users to better understand the anatomy and how to best with portal hypertension and are associated with a bleeding-related optimize transhepatic punctures during TIPS. mortality rate of 45%. Anatomically, gastric varices arise in a venous CONCLUSION AND/OR TEACHING POINTS: Interventionalists who per- network whose natural variability is compounded by its communica- form TIPS may benefit from understanding how to use ICE catheter tion with otherwise occult portosystemic collaterals and minor veins. SIR 2020 Annual Scientific Meeting e-Posters | 139

and interpret the real-time images obtained using ICE catheter to opti- LEARNING OBJECTIVES: (1) Describe the common technical variations mize the technical success of TIPS and minimize the number of tran- of retrograde transvenous obliteration procedures including bal- shepatic punctures. loon-assisted retrograde transvenous obliteration (BRTO), plug-assisted retrograde transvenous obliteration (PARTO), and coil-assisted retrograde transvenous obliteration (CARTO). (2) Highlight key pro- Abstract No. 1064 cedural steps and techniques used to maximize success. (3) Discuss intraprocedural complications and review management strategies. Parallel transjugular intrahepatic portosystemic shunt for the treatment of portal hypertension complications BACKGROUND: Retrograde transvenous obliteration is an increasingly common procedure used to treat bleeding or at risk gastric varices in G Kroma1, J Lopera2, F Nemeh1 patients with chronic liver disease and portal hypertension. There is an 1 2 University of Texas Health Science Center, San Antonio, TX, UT increasing body of literature regarding the safety and efficacy of this Health Science Center in San Antonio, San Antonio, TX technique. However, as an indirect result of this growing body of literature, there are also now multiple technical variations of this procedure, LEARNING OBJECTIVES: To evaluate the feasibility of a second parallel transjugular intrahepatic portosystemic shunt (TIPS) to reduce portal utilizing different combinations of sheaths, catheters, and embolics venous pressure and control the complications of portal hypertension. to achieve success. Procedural complications encountered in various RTO techniques may be associated with difficult anatomy, equipment BACKGROUND: Since the transjugular intrahepatic portosystemic shunt failure, or operator inexperience. This exhibit will review the technical (TIPS) was first introduced clinically in 1989, it has been an effective details of the three most common RTO techniques and their associ- and safe procedure for treating complications of portal hypertension. ated complications, and also provide tips for management in these However, the main drawback of TIPS procedure is the high rate of situations. shunt dysfunction. Several methods have been utilized in treating TIPS dysfunction, including balloon angioplasty, overlapping stent, and the CLINICAL FINDINGS/PROCEDURE DETAILS: This educational exhibit will creation of a parallel shunt (PS). PS is generally used as the last thera- illustrate different variations in the RTO technique including BRTO, peutic option. There is little data on clinical use of PS for the manage- PARTO and CARTO. Common procedural steps along with technical ment of TIPS dysfunction. The aim of this study is to investigate the considerations will be reviewed. Reported intraprocedural complica- safety and feasibility of PS in treating TIPS dysfunction. tions including frequency will be discussed such as nontarget embolization, and balloon and shunt rupture, along with case examples to CLINICAL FINDINGS/PROCEDURE DETAILS: Between March 2015 and highlight strategies for management of complications. July 2016, 5 patients (4 men and 1 woman) underwent Parallel Shunt placement for the management of TIPS dysfunction. The demographic CONCLUSION AND/OR TEACHING POINTS: RTO procedures are a com- data, operative data, postoperative recovery data, hemodynamic data, monly performed and effective group of procedures used in the treat- and complications were analyzed. The creation of PS was technically ment of symptomatic gastric varices. Knowledge and application of successful in all patients. The mean and standard deviation portosys- the available techniques and their potential complications is key to temic pressure gradient before and after the PS procedures was 13.8 maximizing technical and clinical success. ± 5.2 mm Hg (range, 7-21 mm Hg) and 7.4 ± 2.5 mm Hg (range, 3-9 mm Hg), respectively. The mean and standard deviation MELD score Abstract No. 1066 before and after PS procedures was 16.6 ± 4.8 (range, 15-24) and 16.8 ± 4.8 (range, 10-23), respectively. The duration of follow-up was 1 to 12 The road less traveled: portosystemic shunts of the months. Two patients had transient hepatic encephalopathy after the nongastrorenal variety creation of parallel TIPS. One patient died within a month of the proce- 1 2 3 4 5 dure due to renal failure. Four patients have their ascites resolved for K Ameyaw , J Huang , P Sutphin , Z Irani , S Smolinski-Zhao , S Kalva2 the duration of the documented follow-up. 1University of Chicago Pritzker School Medicine, Chicago, CONCLUSION AND/OR TEACHING POINTS: Parallel TIPS is an effective IL, 2Massachusetts General Hospital, Boston, MA, 3Massachusetts and safe approach for the treatment of TIPS dysfunction with no sig- General Hospital, Winchester, MA, 4N/A, Northampton, MA, 5N/A, nificant increase in the hepatic encephalopathy or significant impact Boston, MA on the MELD Score. LEARNING OBJECTIVES: To describe and illustrate nongastrorenal portosystemic shunts and their treatments. Abstract No. 1065 BACKGROUND: Portosystemic shunts are characterized by partial RTO uh-oh!: technical details and management of or complete diversion of portomesenteric blood into systemic veins intraprocedural complications during retrograde via congenital, acquired, or medically created shunts. Portosystemic transvenous obliteration of gastric varices shunts are routinely observed in patients with chronic liver disease and portal hypertension; however, their occurrence in individuals with S McCann1, A Banathy1, R Norby1, D Sheeran1 congenital or spontaneously acquired portosystemic shunts likely go 1University of Virginia, Charlottesville, VA under appreciated. Unfortunately, due to the vague symptomatology 140 | e-Posters SIR 2020 Annual Scientific Meeting

associated with the disease course (i.e., hepatic encephalopathy, a challenge in the placement of TIPS. It is necessary to characterize hyperammonemia) and variability in presentation patients may be mis- the vascular anatomy prior to performing TIPS and use interventional diagnosed with more common etiologies further delaying evaluation techniques to accurately target portal vein branches. Understanding with computed tomography angiography and appropriate treatment. the tools available for best visualization of the vascular anatomy of the We present here a short series of cases illustrating the presentation liver is critical for the success of the procedure. and treatment of nongastrorenal portal systemic shunts in patients.

CLINICAL FINDINGS/PROCEDURE DETAILS: 1. Left gastric to inferior Abstract No. 1068 vena cava shunt 2. Inferior mesenteric vein to gonadal vein 3. Inferior mesenteric vein to rectal vein 4. Hepatic vein to portal vein 5. Superior TIPS, DIPS, and other tricks: a review of portosystemic mesenteric vein to IVC 6. Gastric vein to pulmonary vein. collaterals and various interventions

1 2 CONCLUSION AND/OR TEACHING POINTS: Although uncommon, aware- S Jaisinghani , A Gupta ness of the presentations and management options of spontaneous 1Rochester Regional Health, Webster, NY, 2N/A, Pittsford, NY portal systemic shunts are necessary for patients in need of early radiologic evaluation and definitive endovascular interventions. LEARNING OBJECTIVES: 1. Review the pathophysiology of various portosystemic collaterals as a result from portal hypertension. 2. Describe various interventions used in decreasing portal venous pressure including Abstract No. 1067 transjugular intrahepatic portosystemic shunt (TIPS), direct intrahepatic portocaval shunt (DIPS), coil-assisted retrograde transvenous obliter- Transjugular intrahepatic portosystemic shunt procedure: ation (CARTO), balloon-occluded retrograde transvenous obliteration addressing anatomical variants (BRTO), plug-assisted retrograde transvenous obliteration (PARTO), T Parnall1, I Altun1, K Zurcher1, M Kuo1, J Kriegshauser1, M and Denver shunt. 3. Indications, contraindication, and complications of Knuttinen1, I Patel1, H Albadawi2, S Naidu2, S Alzubaidi1, R Oklu1 the above interventions. 4. Pictorial review of the above interventions.

1 2 Mayo Clinic Arizona, Phoenix, AZ, Mayo Clinic Arizona, Scottsdale, BACKGROUND: Portosystemic varices are a common complication AZ of portal hypertension. Portal hypertension is defined as a wedged hepatic venous pressure greater than 5 mm Hg above the free hepatic LEARNING OBJECTIVES: 1. Pictorial review of transjugular intrahepatic venous pressure, otherwise known as the hepatic venous pressure gra- portosystemic shunt (TIPS) procedure and anatomic considerations 2. dient (HVPG). When this gradient exceeds 12 mm Hg, variceal hemor- Describe the anatomic variations of the hepatic and portal vein rele- rhaging may occur. Causes can be anatomically divided into prehepatic vant for TIPS procedure. 3. Discuss interventional techniques of target- (e.g., portal vein thrombosis), hepatic (e.g., cirrhosis), and post-hepatic ing branches of the portal vein during TIPS placement, i.e., ICE imaging (e.g., Budd-Chiari syndrome). Depending on the precise location of the and fusion technologies. pathology, various portosystemic collaterals may develop to lower the BACKGROUND: Intrahepatic portosystemic shunt is a procedure that portal venous pressure. Integrating the anatomy and physiology of involves transhepatic puncture of a portal vein from a hepatic vein each varix allows the clinician to choose the appropriate intervention. branch and introduction of a shunt to connect the portal and the sys- CLINICAL FINDINGS/PROCEDURE DETAILS: 1. Provide an overview of the temic circulation. There are a number of anatomic variations of the anatomy and physiology and various portosystemic collaterals resulting portal vein that can be identified on CT or MRI scans, which should be from portal venous hypertension 2. Pictorial essay of various techniques considered when performing a TIPS procedure; these will be reviewed such as TIPS, DIPS, CARTO/BARTO, and combinations of techniques with case illustrations. Visualization aides such as ICE imaging, fusion 3. Use-cases of each intervention as well as their contraindications and technologies, IVUS, CT guidance, etc. will also be discussed and illus- complications 4. Patient selection based on current guidelines. trated through cases. Where available, sensitivity and specificity of each imaging modality in facilitating TIPS access will be discussed. CONCLUSION AND/OR TEACHING POINTS: A strong knowledge base of the anatomy and physiology of the various portosystemic collaterals as CLINICAL FINDINGS/PROCEDURE DETAILS: We will present descriptions well as knowing what options are available for intervention allows the cli- of the different branching patterns of the portal vein and discuss the nician to handle a wide variety of cases. Understanding the appropriate significance of those anatomic variants through case illustrations using indication and contraindication, and possible combinations of interven- a variety of imaging tools. We will discuss the implications of these tions, allows for increased efficacy and better patient outcomes. variations for an interventional radiologist during a TIPS procedure and the approach that can be taken for different anatomic variants. We will present cases from our institution in which variations of the Abstract No. 1069 portal vein anatomy were relevant during TIPS placement. Finally, we will discuss techniques to identify optimal portal vein branch targets Using intracardiac echocardiography during transjugular and their relationship with the hepatic veins. intrahepatic portosystemic shunt creation

CONCLUSION AND/OR TEACHING POINTS: Anatomic variations of the D Zipkin1, H Anbari1, M Sanogo1 portal venous system and the hepatic venous circulation can provide 1University of Michigan, Ann Arbor, MI SIR 2020 Annual Scientific Meeting e-Posters | 141

LEARNING OBJECTIVES: For individuals to gain a better understand- viability. While portal vein recanalization (PVR) with and without portal ing of why they should and how to use intracardiac echocardiography vein stenting has been described in adult liver transplant candidates, (ICE) during a transjugular intrahepatic portosystemic shunt creation a transsplenic approach in an adult liver transplant recipient has yet to procedure (TIPS). be reported. Furthermore, the combination of transsplenic portal vein stenting and extrahepatic portosystemic shunt embolization has not BACKGROUND: Intravascular ultrasound (IVUS) has been used in been described in the posttransplant population. medicine since the 1980s, mostly in cardiology; however, in recent decades, multiple uses for IVUS have been documented in interven- CLINICAL FINDINGS/PROCEDURE DETAILS: A 56-year-old white woman tional radiology (IR) including but not limited to evaluation of steno- with hepatocellular carcinoma underwent an orthotopic liver trans- sis, stent deployment, and deployment of IVC filters. Two common plantation. Follow-up liver ultrasound demonstrated abnormal hetero- types of IVUS catheters exist, the mechanical tipped catheter and geneous echotexture within the main portal vein consistent with main the phased array tipped catheter. There are different advantages and portal vein thrombosis. Percutaneous transluminal angioplasty of the disadvantages for these catheters but the more recently developed main portal vein with a 6 mm × 40 mm balloon was performed with phased array catheter produces US imaging similar to most handheld improved flow and significant residual stenosis/irregularity of the vein. US equipment including but not limited to color and Doppler imaging. Subsequent placement of a 10 mm × 40 mm self-expanding stent with post-dilation with an 8 mm balloon was performed. Persistent compet- CLINICAL FINDINGS/PROCEDURE DETAILS: Our educational exhibit itive flow was noted in the large splenorenal shunt. A 12-mm Amplatzer will demonstrate several cases of TIPS creation using a phased array plug was deployed into the shunt and additional embolization was per- IVUS (ICE) catheter. We will discuss our anecdotal advantages includ- formed with multiple 0.035 10-mm Nester coils. Post-interventional ing decreased number of punctures, decreased procedure time, and ultrasound demonstrated a widely patent portal venous system with decreased potential procedure related complications. We will discuss portal stent placement and appropriate blood flow velocities. the steps we take and how these have helped us gain access to the portal system on either the first or second puncture in most cases. CONCLUSION AND/OR TEACHING POINTS: We describe a technique for using transsplenic access in the setting of acute posttransplant PVT to CONCLUSION AND/OR TEACHING POINTS: IR has been at the forefront facilitate main portal vein stent recanalization and large portosystemic of developing minimally invasive techniques using imaging techniques shunt embolization for portal venous flow augmentation. to guide intervention. Intravascular ultrasound has been adopted for several procedures in IR, and recent advances in IVUS, including the phased array tipped catheter, have many potential uses including nee- Abstract No. 1071 dle localization during TIPS. Studies in many other body parts have shown that US-guided access helps to avoid complications. When cre- Liver transplant complications: what the interventional ating an intrahepatic shunt direct visualization is no different and will radiologist needs to know help to avoid unnecessary complications. We hope that our experi- A Joseph1, K Anand2, A Chesley3, K Roodhouse4, S Jen5, J Lopera6 ences will help others gain a better understanding of how to use IVUS 1 2 and ICE to create the safest TIPS procedure possible. UT Health San Antonio, San Antonio, TX, UTHSCSA, Phoenix, AZ, 3University of Texas Health Science Center, San Antonio, TX, 4N/A, San Antonio, TX, 5University of Texas Health Sciences– Abstract No. 1070 San Antonio, San Antonio, TX, 6UT Health Science Center in San Antonio, San Antonio, TX Endovascular transsplenic recanalization with angioplasty and stenting of an occluded main portal vein with LEARNING OBJECTIVES: After viewing the exhibit the reader will: 1. Rec- splenorenal shunt embolization in an adult liver ognize common complications encountered in the early postoperative transplant recipient liver transplant recipient including hepatic artery stenosis, bile duct stricture, biliary leaks and hepatic abscesses. 2. Understand posttrans- 1 2 3 M Brown , S Gueyikian , S Huffman plant arterial anatomy, when to angioplasty, when to stent, and when 1Aurora St. Luke’s Medical Center, Milwaukee, WI, 2N/A, Inverness, to defer. 3. Understand posttransplant biliary anatomy and biliary IL, 3N/A, Lake Bluff, IL intervention in complex biliary strictures and occluded biliary systems.

LEARNING OBJECTIVES: To present an adult liver transplant recipient BACKGROUND: Orthotopic liver transplant (OLT) remains the definitive with hepatic decompensation secondary to complete main portal treatment in patients with end stage liver disease. Surgical complica- vein thrombosis who underwent successful endovascular transsplenic tions in the immediate posttransplant period are common and can be revascularization with angioplasty and stenting with splenorenal shunt divided into vascular and biliary complications. The most common embolization vascular complications are hepatic artery stenosis (HAS), hepatic artery occlusion, hepatic artery pseudoaneurysm, portal vein throm- BACKGROUND: Portal vein thrombosis (PVT) is a known complication bosis or stenosis and inferior vena cava thrombosis or stenosis. The of cirrhosis, and PVT and portosystemic shunts have been associated most frequently encountered biliary complications are bile leaks, bili- with increased liver transplant operative time, morbidity, and mortal- ary strictures and bilomas/bile lakes. Lastly, other complications may ity. Surgical ligation of portosystemic shunts is an accepted method of include postsurgical fluid collections and infections. Interventional improving portal venous flow to prevent early PVT and improve graft 142 | e-Posters SIR 2020 Annual Scientific Meeting

radiology (IR) is uniquely positioned to provide assistance with endo- for a sizeable splenorenal shunt causing steal of flow through the graft, vascular and percutaneous management of the above complications, as well as porto-portal collateralization as a long-term complication particularly within the arterial and biliary systems. of portal stenosis in an 18-year old patient with a transplant in infancy.

CLINICAL FINDINGS/PROCEDURE DETAILS: Using a combination of CONCLUSION AND/OR TEACHING POINTS: This pictorial review will focus computed tomographic (CT), 3 dimensional reformatted CT, and dig- on the relevant vascular anatomy and potential vascular complications itally subtracted images, we aim to illustrate posttransplant anatomy following liver transplantation. We will discuss the imaging findings, and commonly encountered surgical complications of OLT and their review the angiographic appearance, as well as the endovascular management. We will present a series of cases from our institution treatment options. including HAS, acute hepatic artery occlusion, hepatic artery pseudoaneurysms, biliary strictures, biliary leaks, central biliary occlusion, portal vein stenosis, portal vein thrombosis and hepatic abscesses. Abstract No. 1073 Detailed presentation on stentable and nonstentable HAS lesions in Renal allograft loss and necrosis after failure to recognize addition to navigating through an occluded biliary tree via a rendez- persistent sciatic artery variant vous procedure. G Wade1, D Vu2, R Quillen3, Z Wenker2, A Makramalla3 CONCLUSION AND/OR TEACHING POINTS: OLT presents unique compli- 1 2 cations that IR is able to treat. Knowledge of these entities is critical in University of Cincinnati, Cincinnati, OH, University of Cincinnati 3 management of the post liver transplant patient. Medical Center, Cincinnati, OH, University of Cincinnati, Cincinnati, OH

Abstract No. 1072 LEARNING OBJECTIVES: Highlight the clinical importance of persistent sciatic artery (PSA), a rare variant anatomy and potential cause of Pictorial review of common and uncommon vascular complications in renal transplant patients. complications following liver transplantation BACKGROUND: Our report presents a 52-year-old man after deceased J Herzog1, L Walker2, M Al-Natour3 donor renal allograft for end stage renal disease secondary to diabetes. Postoperative course was complicated by delayed graft function. 1University Hospitals, Cleveland, OH, 2University Hospitals Cleveland Biopsy showed extensive necrosis of the renal parenchyma. Nuclear Medical Center, Cleveland, OH, 3N/A, Rocky River, OH medicine renal flow study showed absent flow to the transplant kidney

LEARNING OBJECTIVES: (1) Describe the surgical techniques for liver with decreased or absent flow in the right iliac system. transplantation with a focus on the vascular anastomotic reconstruc- CLINICAL FINDINGS/PROCEDURE DETAILS: Arteriogram revealed a pre- tions utilized. (2) Review the most common immediate and delayed viously unknown PSA and occlusion of the right external iliac artery, vascular complications associated with liver transplantation. (3) Dis- with thrombosis of the renal transplant artery. The variant PSA was cuss potential treatment options for common vascular complications. an extension of the right internal iliac, acting as the dominant vascular (4) Showcase uncommon vascular complications after transplant and supply to the right lower extremity. PSA is a rare congenital anom- discuss approaches to treatment. aly that results from persistence of an artery that normally regresses

BACKGROUND: Liver transplantation is the only definitive treatment during embryonic development. The incidence of PSA is estimated to for most patients with end-stage liver disease. Vascular complications be 0.025% to 0.04%. The patient developed Staphylococcus lugdun- of transplantation have a high degree of morbidity, and often result ensis bacteremia and explanted kidney had near total parenchymal in graft loss. Well known vascular complications include complete necrosis with inflammatory and necrotic changes of the perinephric occlusion or stenosis of the hepatic artery and vein, the inferior vena fat. cava, and the portal vein, a preponderance of which being amenable CONCLUSION AND/OR TEACHING POINTS: Failure to identify PSA can to endovascular interventions. However, less common complications lead to graft loss and serious complications. Cross sectional imaging can and do occur, presenting unique challenges to the interventional in renal transplant candidates could identify rare anatomical variants radiologist. or more commonly; advanced atherosclerotic disease and iliac artery

CLINICAL FINDINGS/PROCEDURE DETAILS: Using a number of different stenosis to avoid such complications. cases, we will showcase the imaging findings and treatment of common and uncommon vascular complications of liver transplantation. Duplex ultrasonography as well as cross-sectional imaging are used to Abstract No. 1074 diagnose these complications, with subsequent confirmatory angiog- Vascular and biliary variants in the liver transplantation: raphy performed before intervention. Hepatic artery occlusion/steno- related vascular complications and interventional sis accounts for a large portion of vascular complications and is treated management by angioplasty with or without stenting and thrombolysis for complete occlusion. Portal vein stenosis/thrombosis is treated similarly; F Grippi1, C Commander2, G Wong3 however, collateral veins can present unique challenges. Through the 1UNCH, Chapel Hill, NC, 2N/A, Chapel Hill, NC, 3The University of review of two uncommon cases, we describe an approach to treatment North Carolina, Chapel Hill, NC SIR 2020 Annual Scientific Meeting e-Posters | 143

LEARNING OBJECTIVES: to present a pictorial review of the most com- comprising a greater number of air embolism incidents. The endovas- mon preoperative vascular and biliary anatomical variants. Changes cular procedures complicated by air embolism can result in significant in the hepatic anatomy after surgery. Related vascular complications morbidity and mortality. after liver transplantation. Summarize the most common interventional CLINICAL FINDINGS/PROCEDURE DETAILS: This education exhibit will radiology (IR) procedures use for treatment. Review clinical outcomes. review pathophysiology, risk reduction techniques, clinical findings, BACKGROUND: Liver transplantation requires a multidisciplinary team- diagnostic tests and most importantly, management of air embo- work in which radiologists play a key role in identifying normal and lism. The pathophysiology and risk reduction techniques will first be abnormal anatomy for accurate surgical planning. Knowledge of the detailed. The educational exhibit will then illustrate the key clinical range of imaging modalities, current surgical techniques and related findings, diagnostic tests, and management strategies. This exhibit complications is vital to properly evaluate and treat the patient who will also review the data found in the literature regarding the incidence will and has undergone liver transplantation. Even though vascular of air embolism as well as effectiveness of therapies. Finally, selected complications following liver transplantation are rare, they are related cases of air embolism will be presented and their management dis- to a high incidence of failure and mortality, mostly due alterations in cussed. Imaging of air embolism will be presented in the exhibit. the blood flow of the transplanted liver. Advances in endovascular CONCLUSION AND/OR TEACHING POINTS: Air embolism is listed as a intervention have improved the success rate of liver transplantation. It “never event” by The National Quality Forum, highlighting the impor- is important for the interventional radiologist to understand the differ- tance of instituting effective preventative and management measures. ent types of liver transplantation and associated anatomical changes The exact consequence of air embolism depends on the rate and vol- for optimal interventional therapeutic strategies. Vascular complica- ume of air introduced into the vascular system. High clinical suspicious tions such as hepatic artery, hepatic vein, and portal vein stenosis/ and rapid intervention is critical for reducing morbidity and mortality. occlusion and portal hypertension are some of the most common vas- The interventional radiologist’s knowledge in preventative techniques, cular complication recently treated by IR with effective results. detection, and management is key in reducing patient morbidity and CLINICAL FINDINGS/PROCEDURE DETAILS: A case-based review of the mortality. most common vascular and biliary anatomic variations found on CT, MRI, and ultrasound. Common procedures performed for the management of vascular complications following liver transplant will be Abstract No. 1076 presented. Vascular interventions include procedures such as hepatic Case-based review of central line insertion–related vein, hepatic artery, or portal vein angioplasty or stenting and trans- complications and interventional radiology–based jugular liver biopsy, TIPS for recurrent portal hypertension and other. management strategies CONCLUSION AND/OR TEACHING POINTS: Interventional radiologists K El Salek1, G Williams2 play a central role in the diagnosis and treatment of many of the most 1 commonly encountered vascular complications after liver transplan- Texas Tech University Health Science Center, PLFSOM, El Paso, TX, 2 tation, showing great efficacy and survival rate, in part highly related Texas Tech University Health Science Center, PLFSOM, El Paso, TX to adequate preprocedural imaging evaluation of the hepatobiliary LEARNING OBJECTIVES: This educational exhibit aims at familiarizing anatomy. the audience with insertion related complications of large-bore central venous catheters with emphasis on timely identification and subse- Abstract No. 1075 quent interventional radiology (IR)–based management approaches. We will discuss immediate and delayed complications related to mis- Air embolism: a potential devastating outcome of a placement and structural complications. After reviewing this exhibit common procedure the audience should have a better understating of these complications and management approaches. P Hoang1, A Wallace2, K Zurcher2, D Fleck2, R Oklu3 BACKGROUND: Central line placement is common when treating crit- 1Mayo Clinic Arizona, Phoenix, AZ, 2N/A, Phoenix, AZ, 3Mayo Clinic, ically ill patients. Sonographic guidance for venipuncture does not Phoenix, AZ eliminate complications. We will perform a case-based review of cath- LEARNING OBJECTIVES: 1. To review the etiology and incidence of air eter related complications with emphasis on IR-based management embolism. 2. To discuss the prevention techniques, clinical findings, approaches. We categorize the complications as follows: 1- Arterial diagnostic tests, and clinical management of air embolism. placement 2- Extravascular placement 3- Structural complications.

BACKGROUND: Air emboli is a rare and preventable complication that CLINICAL FINDINGS/PROCEDURE DETAILS: I-Arterial Misplacement: can result in significant morbidity and mortality. Air embolism only Case 1: A 48-year-old man with placement of hemodialysis catheter in occurs when there is a connection between the air and a vascular the right subclavian artery successfully managed with balloon stent- structure. Iatrogenic procedures are the main cause of vascular air ing. We discuss different endovascular management techniques of embolism and can arise as a result of line placement, barotrauma, and arterial misplacement (balloon occlusion, Angio-Seal devices or stent surgical procedures. With increasing use of vascular access devices, grafts) and the different factors favoring one approach over the other. procedures performed within interventional radiology are now II-Extravascular Misplacement: Case 2: A 82-year-old woman with 144 | e-Posters SIR 2020 Annual Scientific Meeting

inadvertent placement of a left subclavian catheter into the medias- events still occur resulting in significant morbidity and mortality. tinum. Management approach of inadvertent extravascular placement Understanding common pitfalls related to aberrant positioning can of large-bore catheters is complex and usually involves a surgical con- help enable early detection and prevention. Recognition of the type of sultation. Careful evaluation for injury of great vessels and adjacent malpositioning allows for appropriate and successful management of mediastinal structures is critical. III-Structural post insertion compli- the resultant complications. cation: Case 3: Surgically placed subclavian port with pinch syndrome, transection and distal embolization managed via a gooseneck snare. Fractured catheters is a rare occurrence, more commonly seen in sur- Abstract No. 1078 gically placed subclavian catheters. We discuss retrieval approaches Computed tomography venography with dual contrast with gooseneck snare and important technical considerations. injection: a novel technique for vessel mapping CONCLUSION AND/OR TEACHING POINTS: Catheter insertion related V Ramakrishnan1, P Bream2, V Ramakrishnan1 complications have serious morbidity, early identification and treat- 1 2 ment is crucial with IR management becoming standard of care. University of North Carolina, Durham, NC, UNC Chapel Hill, Chapel Careful identification of compromised structures and spaces dictates Hill, NC management which is overviewed here. LEARNING OBJECTIVES: To describe a novel technique in accurate upper extremity vessel mapping in patients requiring HeRO graft or Abstract No. 1077 central venous catheter placement. BACKGROUND: The current modality used for evaluation of patients Central line twists and turns: recognizing pitfalls to avoid with suspected central venous occlusion is ultrasound with or without malpositioning and complications computed tomography (CT) or conventional venography. We describe W Behl1, A Park1, D Sheeran2, T Seo3, D Kinariwala2 a technique of CT venography that utilizes simultaneous bilateral injections and two individually timed passes to fully evaluate the inflow to 1UVA Health System, Charlottesville, VA, 2University of Virginia, the SVC. This method provides a map for future intervention and is Charlottesville, VA, 3Korea University, Guro Hospital, Seoul, Republic particularly useful when planning recanalization of the central veins in of Korea patients with SVC syndrome or need for hemodialysis access. LEARNING OBJECTIVES: Identify factors that lead to malpositioning, CLINICAL FINDINGS/PROCEDURE DETAILS: 1. Use at least 22 gauge nee- including variant venous anatomy, inadvertent arterial catheterization, dles in both arms. 2. Have patient positioned prone with arms above extravascular catheter positioning, and effects of collateral supply their heads. 3. Fill power injector with Omnipaque in both lumens of due to stenosis and/or occlusion. Review complications associated the Med Rec power injector. 4. Have the scan start at the same time as with central venous catheterization, including venous thrombosis the injection, 40 mL total in each IV at a rate of 3.0 mL/s. 5. Takes 15s to from indwelling catheters, tip placement in an inadequate vessel, and scan cranial to caudal within the desired window. 6. After adjusting for anatomic concerns leading to mechanical problems. Discuss trouble- scan time and injection time ~27s, start second scan caudal to cranial at shooting improperly functioning catheters, diagnosing malpositioning, 40 seconds (delayed phase). 7. MIPS Post processing is performed with and the management of complications. 20 × 3-mm and 5 × 3-mm pictures. BACKGROUND: With an ever-growing need for durable vascular access, CONCLUSION AND/OR TEACHING POINTS: We believe this protocol for central venous catheter (CVC) placement represents a substantial and CT venography can be used in any patient requiring accurate vessel progressively expanding service provided by interventional radiolo- mapping in lieu of bilateral upper extremity Doppler ultrasounds or gists. Despite the use of image guidance and advancements in tech- conventional venography. We aim to use this new procedure at our nique to facilitate safe and successful placement, CVC access is not institution in order to help with vessel mapping for vascular patients without risk. Complications from malpositioning can lead to significant who need to undergo the HeRO graft placement and for patients who morbidity and mortality. The objective of this educational review is need central venous catheter access in the setting of chronic venous to describe common reasons for incorrect CVC placement, as well as obstruction or poor vasculature. review ways to identify, correct, and prevent associated complications.

CLINICAL FINDINGS/PROCEDURE DETAILS: A review of aberrantly placed CVC was conducted and relevant cases were selected based Abstract No. 1079 on the presence of congenital abnormalities, inadvertent arterial punc- Single-incision chest port versus double incision chest ture, extravascular catheterization, and development of collaterals by port techniques: a single-center retrospective review of stenosis or occlusion. Factors leading to this catheter placement are outcomes reviewed, followed by appropriate diagnostic approach once identified, as well as complications and management of these malpositioned A Levy1, V Gendel2, S Kovacs3 CVCs. 1Lenox Hill Hospital, Northwell Health, New York, NY, 2Rutgers RWJMS, 3 CONCLUSION AND/OR TEACHING POINTS: Despite the widespread prev- Department of Radiology, New York, NY, N/A, Rivervale, NJ alence and improved safety profile of central venous access, adverse SIR 2020 Annual Scientific Meeting e-Posters | 145

LEARNING OBJECTIVES: (1) Present retrospective single-center data, CLINICAL FINDINGS/PROCEDURE DETAILS: This educational exhibit which compares single incision chest port infection rates versus the reviews details of corrective procedures for CHD, emphasizes postop- traditional double incision technique, over a 1-year period. (2) Review erative cardiovascular anatomy, and discusses technical considerations the steps of the single incision chest port placement technique for establishing central venous access under fluoroscopic guidance. Many of these patients lack conventional atria and will instead have BACKGROUND: Long-term venous access is essential for oncology systemic venous return diverted through conduits and baffles. Guide- patients who require frequent phlebotomy as well as chemotherapy wire advancement may be further complicated by stenosis or leakage infusions. The chest port has become paramount in these patients, of these systems. Case images will be presented to illustrate antici- particularly via the right internal jugular vein (IJV), due to its reduced pated intraprocedural findings. These will include patients who have short- and long-term complication rates. A single incision method has undergone the Fontan, Mustard, Jatene, or Rastelli procedures for been described that involves making a single incision for the chest anomalies such as tricuspid atresia, hypoplastic left heart, or transpo- port pocket and tunneling the micropuncture needle through the tract, sition of the great arteries. preferably to the IJV for access under ultrasound-guidance. The presence of a single incision, away from the venipuncture site is thought to CONCLUSION AND/OR TEACHING POINTS: Patients who receive cor- reduce the risk for infection. Patients also report satisfaction of more rective procedures for CHD have unique cardiovascular anatomy, and concealable incisions. establishing central venous access in these patients can be confus- ing without understanding resultant structures and complications. CLINICAL FINDINGS/PROCEDURE DETAILS: Retrospective data from Reviewing anatomical deviations and anticipated challenges in CHD July 2018 to September 2019 was evaluated. A total of 177 patients will better prepare interventionalists for the care of this unique cohort underwent successful chest port placements at our institution. Single of patients. incision (n = 35) and double incision (n = 142) chest port placements were assessed for differences in infection rates, fluoroscopy time, and cumulative skin dose. Factors such as double lumen (n = 19), versus Abstract No. 1081 single lumen ports (n = 158) and vessel accessed were also considered. Results show a higher infection rate with double incision chest port Using an EMR based intravenous access algorithm to placement. However, fluoroscopy and skin dose is decreased as com- improve line selection and patient care pared to the single incision technique. M Ferra1, P Kim2, A Syal3, P Bosniak4 CONCLUSION AND/OR TEACHING POINTS: (1) Single-incision chest port 1Albert Einstein Medical Center, Philadelphia, PA, 2Einstein placements reduce the risk of infection. (2) The single incision tech- Medical Center Philadelphia, Philadelphia, PA, 3Einstein Hospital, nique increases fluoroscopy time and may increase the total lifetime Philadelphia, PA, 4Einstein Medical Center, Philadelphia, PA radiation exposure to interventionalists who prefer this technique LEARNING OBJECTIVES: The aim of this abstract is to demonstrate the utility of an EMR based algorithm designed to assist ordering physi- Abstract No. 1080 cians in selecting the appropriate type of intravenous (IV) access for a given patient based on treatment duration, laboratory values, and Technical considerations for adult congenital heart clinical parameters in accordance with the MAGIC guidelines. disease: a review with case illustrations BACKGROUND: In today’s medical environment there are multiple IV 1 1 1 1 C Ju , A Gill , K Karuppasamy , C Martin lines and catheters, both peripheral and central, available to providers 1Cleveland Clinic, Cleveland, OH and patients for a variety of clinical indications, treatment durations, and disease states. Many providers outside of the interventional radiol- LEARNING OBJECTIVES: 1. Review cardiovascular anatomy in adult ogy (IR) field are not familiar with the indications and contraindications patients with congenital heart disease (CHD) using fluoroscopic and for these types of lines and therefore will order inappropriate forms of illustrated case images. 2. Discuss long-term sequelae for corrected IV access for their patients. In an effort to improve patient care and CHD and anticipated complications for procedures requiring central facilitate appropriate line orders, our institution is developing an EMR venous access. based tool which will provide a series of prompts based on the MAGIC

BACKGROUND: The success of cardiac procedures for CHD in the past guidelines to guide ordering physicians to the correct line choice. few decades is allowing a growing population of patients to survive CLINICAL FINDINGS/PROCEDURE DETAILS: Our institution has devel- comfortably into adulthood. As mortality rates in this cohort decrease, oped an EMR based algorithm to guide ordering physicians towards the utilization of the healthcare system for radiologic interventions the selection of an appropriate form of IV access for their patients. is expected to increase. Establishing central venous access remains Our IR department places a variety of IV lines, including midlines, PICC a cardinal skill that precedes numerous interventions performed by lines, central venous catheters, dialysis catheters, and tunneled cen- radiologists. However, there remains little guidance for basic proce- tral venous catheters. We have used the MAGIC guidelines to create dures performed on this growing population of patients whose venous an algorithm to facilitate the appropriate selection of IV access. EMR- anatomy deviates from the traditional paradigm. based prompts include treatment duration, creatinine level, type of 146 | e-Posters SIR 2020 Annual Scientific Meeting

medication to be administered, coagulation parameters, and patient with high rates of technical and clinical success. Interventional radiol- location (outpatient/inpatient/ER). ogists should understand selection of endovascular techniques based on preprocedure and intraprocedural imaging in addition to the impor- CONCLUSION AND/OR TEACHING POINTS: 1. To demonstrate how an tance of surveillance for restenosis in the longitudinal management of EMR based algorithm can facilitate the selection of appropriate forms these patients. of IV access for patients on an outpatient and inpatient basis. 2. To improve the education of non-IR ordering physicians regarding the inclusion and exclusion criteria for peripheral and central intravenous Abstract No. 1083 access. 3. To improve patient care by reducing orders for inappropriate/non-indicated forms of IV access. 4. To increase implementation Balloon pulmonary angioplasty as an evolving and awareness of the MAGIC and NKF KDOQI guidelines at an insti- management technique for chronic thromboembolic tutional level. pulmonary hypertension S Smolinski-Zhao1, K Rosenfield1, A Witkin1, J Rodriguez-Lopez1, S Abstract No. 1082 Kalva1 1Massachusetts General Hospital, Boston, MA An illustrative review of malignant venous obstruction and endovascular treatment techniques LEARNING OBJECTIVES: 1. Review diagnostic criteria and imaging findings of chronic thromboembolic pulmonary hypertension (CTEPH). 2. 1 1 1 1 1 A Banathy , L Wilkins , M Clark , B Contrella , D Sheeran , D Discuss the management options and outcomes for CTEPH. 3. Describe Williams2, M Khaja1 the technique and outcomes of balloon angioplasty of CTEPH. 1University of Virginia, Charlottesville, VA, 2University of Michigan BACKGROUND: CTEPH occurs as the sequelae of acute or recurrent Health System, Ann Arbor, MI pulmonary embolism, and results in significant patient morbidity and LEARNING OBJECTIVES: 1. Recognize the clinical presentations and mortality. Pulmonary endarterectomy has been the standard of care imaging features of malignant venous obstruction 2. Describe endo- but balloon pulmonary angioplasty (BPA) is an evolving management vascular treatment strategies for malignant venous obstruction 3. option, particularly for patients who are not surgical candidates. Understand the postprocedure management and possible complica- CLINICAL FINDINGS/PROCEDURE DETAILS: A description of the clinical tions of stenting malignant venous obstructions manifestations and diagnosis of CTEPH will be provided. Imaging find- BACKGROUND: Venous obstruction is an uncommon but morbid com- ings on computed tomographic angiography and fluoroscopic angi- plication of malignancy. Patients with SVC syndrome may have facial ography will be demonstrated. Management options will be reviewed, and upper extremity edema, headache, and stridor while iliocaval with an emphasis on the percutaneous interventional technique. obstruction typically presents with severe lower extremity edema. CONCLUSION AND/OR TEACHING POINTS: CTEPH is associated with Portal system involvement can cause new onset ascites in noncirrhotic poor clinical outcomes and a small percentage of patients remain with patients. Venography demonstrates stenosis and extensive venous clinically significant disease post endarterectomy. Balloon pulmonary collateralization. Partial or complete thrombosis may occur due to angioplasty is a promising, minimally invasive treatment technique. stenosis from extrinsic compression or direct tumor invasion. Endo- vascular treatment is becoming first line and can provide immediate symptomatic relief compared to chemoradiotherapy. The most com- Abstract No. 1084 mon complication of malignant venous stenting is in-stent restenosis due to tumor ingrowth or stent thrombosis with reported rates of 13% Hybrid surgical endovenectomy and iliac stenting for iliac to 41%. vein occlusion with poor infrainguinal flow

CLINICAL FINDINGS/PROCEDURE DETAILS: We present a pictorial case R Meek1, T Liem1, J Kaufman2, R Al-Hakim1 series (n = 5) to illustrate diagnostic and therapeutic endovascular 1Oregon Health & Science University, Portland, OR, 2Dotter interventions in malignant obstruction involving the SVC, IVC, brachio- Interventional Institute, Lake Oswego, OR cephalic veins, iliac veins, and portomesenteric system. Cases demonstrate use of intravascular ultrasound in treatment planning to assess LEARNING OBJECTIVES: (1) Understand the clinical indication for iliac for sites of external compression and intravascular thrombus, pulse- vein stenting. (2) Understand the importance of infrainguinal flow spray tPA and rheolytic thrombectomy, balloon angioplasty, and stent assessment prior to iliac vein stenting. (3) Understand the role for placement to improve flow in thrombosed veins. Technical success combined open operative and endovenous interventions in treating was defined as vessel recanalization and decreased flow in collateral post-thrombotic syndrome (PTS). vessels on completion venography. Cases with restenosis were suc- BACKGROUND: PTS is a known complication following deep venous cessfully treated with repeat angioplasty and stent relining. Technique thrombosis (DVT) that may cause significant long-term morbidity in and stent selection as well as anticoagulation will be discussed. up to 50% of patients. PTS presents with a wide clinical spectrum rang-

CONCLUSION AND/OR TEACHING POINTS: Interventional radiology ing from lower extremity edema, to debilitating venous claudication plays a key role in symptom palliation of malignant venous obstruction and ulceration. Although multifactorial, venous flow obstruction is a SIR 2020 Annual Scientific Meeting e-Posters | 147

major contributor to the development of PTS. Patients with moderate SVC by: a. Bland Thrombus b. Hepatocellular carcinoma c. Renal Cell to severe PTS and known iliac vein obstruction can undergo iliac vein carcinoma d. Adrenal Cortical carcinoma e. Budd-Chiari Syndrome f. stent placement with a high rate of clinical improvement. However, Review of Classification of Thoracic Central Venous Occlusion g. Pri- stent patency requires adequate inflow from the infrainguinal veins mary lung cancer h. Mediastinal tumors i. Leiomyosarcomas and leio- to prevent thrombus formation. Stenting of the common femoral vein myoma iv) Treatment of IVC and SVC stenosis and occlusion including may not provide adequate inflow in patients with extensive common indications and contraindications a. Stenting b. Venoplasty c. Balloon femoral vein disease burden. In select cases, hybrid endovenectomy assisted banding v) Pitfalls a. Pseudolipoma of the common femoral vein combined with iliac vein stent placement CONCLUSION AND/OR TEACHING POINTS: Understanding obstructive can be utilized as a treatment option. Three patients underwent hybrid pathology of the SVC and IVC is of important clinical significance for a surgical and endovenous iliofemoral reconstruction procedures at our radiologist. There are many different etiologies of vena cava obstruc- institution between 2013 and 2019. tion that can be confidently diagnosed with a combination of imaging CLINICAL FINDINGS/PROCEDURE DETAILS: All three patients had and clinical evaluation. IR plays a key role in the diagnosis and treat- chronic iliofemoral occlusion and presented with severe longstanding ment of these pathologies. Knowledge of the clinical presentations, symptoms of deep venous obstruction. Endovenectomy with patch classifications, and imaging features of vena cava obstruction is essen- vein angioplasty was performed in the common femoral veins, and tial in guiding management. all patients had stenting through the common and external iliac veins. All patients required catheter-directed thrombolysis within 30 days of hybrid iliofemoral reconstruction, and 1/3 patients subsequently Abstract No. 1086 underwent stent extension into the mid-common femoral vein. All Optimizing outcomes in superior vena cava obstruction patients noted significant improvements in quality of life following while avoiding the pitfalls hybrid iliofemoral reconstruction. After 30 days, no patients required additional intervention to last known follow-up. J Russell1, N Frantz2, L Walker2, J Davidson2, S Tavri2, M Al-Natour2

1 2 CONCLUSION AND/OR TEACHING POINTS: Hybrid endovenectomy and University of Toledo College of Medicine, Toledo, OH, University iliac vein stenting in patients with iliac occlusion and poor infrainguinal Hospitals Cleveland Medical Center, Cleveland, OH flow can successfully treat PTS. LEARNING OBJECTIVES: 1) To understand the different pathologies and clinical presentations of SVC obstruction. 2) Review of multimodality Abstract No. 1085 imaging findings of SVC obstruction. 3) Indications/contraindications of endovascular versus surgical treatment. 4) Understand endovascu- Imaging and treatment of inferior vena cava and superior lar treatment of SVC stenosis/obstruction, with emphasis on variations vena cava obstruction in technique and approach to angioplasty, stenting, and thrombolysis. 5) Review possible minor/major procedural complications, and what to 1 1 1 1 1 J Yeboa , H Malik , Y Kim , A Harman , A Goldstein be prepared for in the worst-case scenario. 1University of Massachusetts, Worcester, MA BACKGROUND: A variety pathologies can lead to SVC obstruction which

LEARNING OBJECTIVES: 1. A pictorial review of the conventional anat- is classified as either extrinsic compression or intraluminal obstruction. omy, variant anatomy, and pathological processes involving the infe- As an interventional radiologist, it is important to recognize present- rior vena cava (IVC) and superior vena cava (SVC). 2. Demonstrate ing symptoms and management as SVC obstruction can be complex, the utility of various imaging modalities (ultrasound, CT, MRI, and requiring a collaborative multidisciplinary approach in order to act in angiography) in the diagnosis of IVC and SVC pathology. 3. Illustrate the patients’ best interest. secondary tumoral invasion of the IVC and SVC (e.g., hepatocellular CLINICAL FINDINGS/PROCEDURE DETAILS: This exhibit will provide an carcinoma, renal cell carcinoma, adrenal cortical carcinoma, primary overview of the different pathologies of SVC stenosis and obstruction. lung malignancy, mediastinal masses). 4. Illustrate primary tumors of It will also illustrate multimodality imaging appearance of SVC steno- the IVC and SVC (e.g., leiomyosarcoma) 5. Demonstrate interventional sis and obstruction We will discuss indications and contraindications, treatments for IVC and SVC obstruction. 6. Review imaging pitfalls factors impacting approach/technique and proper disease grading. It such as pseudolipoma and pseudothrombosis. will talk about management from an endovascular approach (selection

BACKGROUND: IVC and SVC obstructive pathology is often encoun- of balloon, stent, etc.) as well as discuss the importance of multidisci- tered in clinical practice and often presents with SVC or IVC syndrome. plinary treatment and procedures offered by complimenting special- Diagnostic and interventional radiology (IR) play roles in the diagnosis ties. Finally, institutional case based minor (local infection) and major and treatment of these conditions. (SVC rupture, pericardial tamponade, etc.) complications will be analyzed. These include worst case scenarios; how to detect when some- CLINICAL FINDINGS/PROCEDURE DETAILS: Anatomic illustrations and thing is wrong and how to be prepared. clinical images with discussion: i) Standard IVC and SVC anatomy ii) Anatomic variants a. Left sided SVC b. Duplicated SVC c. Absent IVC d. CONCLUSION AND/OR TEACHING POINTS: A variety of pathologies can Duplicated IVC e. Retro-aortic and circumaortic left renal vein f. Azy- lead to acute and chronic SVC obstruction/stenosis. It is crucial to gous continuation of the IVC iii) Occlusion and stenosis of the IVC and recognize presenting clinical symptoms which allows for swift action. 148 | e-Posters SIR 2020 Annual Scientific Meeting

From there, proper imaging, diagnosis and management of the patient Abstract No. 1088 can follow. As interventional radiologists, it is crucial to have a diagnostic approach along with a multidisciplinary mindset to optimize patient Stent reconstruction of thoracic central venous outcomes and best avoid complications. obstruction: illustrative anatomic review, reporting standards, and technical guide

1 1 2 3 Abstract No. 1087 A Solomon , A Kolarich , M Lessne , B Holly 1Johns Hopkins School of Medicine, Baltimore, MD, 2Johns Hopkins Review of thoracic central vein obstruction, recanalization School of Medicine, Vascular and Interventional Specialists of techniques, and long-term outcomes Charlotte Radiology, Charlotte, NC, 3Johns Hopkins School of Medicine, N/A E Mendoza1, K Nelson1, J Cosman1, M Rupasinghe1, J Katrivesis1, D 1 1 Fernando , N Abi-Jaoudeh LEARNING OBJECTIVES: • Describe the relevant anatomy and evalu- 1University of California, Irvine, Orange, CA ation of patients with thoracic central venous obstruction (TCVO). • Demonstrate techniques for stent reconstruction of TCVO. LEARNING OBJECTIVES: 1. Understanding the pathophysiology of thoracic central vein obstruction (TCVO). 2. Defining the reporting stan- BACKGROUND: TCVO results from narrowing or occlusion of the cen- dards for TCVO. 3. Indications for treatment of TCVO. 4. Breakdown tral venous structures of the chest including the intrathoracic internal of recanalization techniques. 5. Review of the current data on TCVO. jugular (IJ) and subclavian (SC) veins, brachiocephalic veins (BC), and superior vena cava (SVC). Patients with TCVO can present with swell- BACKGROUND: TCVO is a morbid condition resulting in upper torso ing, pain, dyspnea, and/or neurologic changes with variable symptoms venous congestion and restricted options for central venous access. based on etiology and acuity of obstruction. Interventionalists treating Causes of TCVO include thoracic malignancies, anatomical variants, these challenging patients must understand the etiology, classifica- and long-term catheter use. Its true incidence is unknown though tion, and technical aspects of stent reconstruction in TCVO. reported between 10-40% in patients with indwelling catheters. Treat- ment has shifted from surgical to endovascular repair, which is well CLINICAL FINDINGS/PROCEDURE DETAILS: Pathologic and iatrogenic tolerated and offers significant decrease or resolution of symptoms mechanisms of obstruction can be categorized into 3 etiologies: and restoration of dialysis access. Current data is limited due to incon- compression, wall thickening, and endoluminal obstruction. TCVO sistent definitions of TCVO, techniques, and clinical endpoints. Recent is reported based on the anatomic pattern of obstruction: • Type guidelines were released to classify TCVO in a reproducible manner 1: one IJ or SC obstruction • Type 2: unilateral BC or ipsilateral IJ/SC and is the first step in achieving comprehensive data analysis. obstruction • Type 3: Bilateral BC obstruction with SVC flow • Type 4: SVC obstruction The degree of stenosis, type of flow, symptoms, CLINICAL FINDINGS/PROCEDURE DETAILS: Identifying the pattern of signs, and performance status should also be reported for patients TCVO can help guide procedural approach. Blunt recanalization is with TCVO. Treatment of TCVO depends on the location, cause and first attempted with a stiff glidewire and catheter support. Sharp and degree of obstruction. Restoring venous flow often requires complex radiofrequency (RF) recanalization consists of either a long endovas- endovascular stent reconstruction. This exhibit will focus on the tech- cular needle or RF wire and is reserved when blunt recanalization has nical details of stent reconstruction from preprocedural imaging to failed due to an increased risk of major complications. Use of cone- common pitfalls and complications. This will include a demonstration beam computed tomography to direct needle trajectory is recom- of complex access, appropriate triaxial support, and wires. Emphasis mended to avoid devastating vascular injury. Once the obstruction will be placed on indications for sharp or radiofrequency recanaliza- is crossed, serial angioplasty with or without stent placement is per- tion and the role of intravascular ultrasound. The relative advantages formed. The types of stents and postprocedural management have of available balloons and stents will be reviewed in addition to optimal yet to be standardized. Recent studies show covered stents maintain stent location and orientation. better patency over uncovered stents. Another study showed no significant difference of restenosis in patients who did and did not receive CONCLUSION AND/OR TEACHING POINTS: • Interventionalists play a anticoagulation in benign cases. critical role in the evaluation and management of patients with TCVO. • Stent reconstruction for TCVO is technically challenging but can be CONCLUSION AND/OR TEACHING POINTS: TCVO recanalization is safely and effectively performed to improve patient symptoms and well-tolerated with high success rates. Education on reporting guide- vascular access. lines is the first step towards unifying the data to discover the optimal procedural approach, postprocedural management, and long-term patency. Abstract No. 1089

Superior vena cava syndrome: diagnosis and management M Nannery1, L Campos2 1Boston University School of Medicine, Boston, MA, 2Boston Medical Center, Boston, MA SIR 2020 Annual Scientific Meeting e-Posters | 149

LEARNING OBJECTIVES: Through a case: 1. Recognize signs and symp- catheter, followed by angioplasty and stent placement. In cases refrac- toms of superior vena cava (SVC) syndrome 2. Identify possible eti- tory to traditional methods, the RF wire is a viable option. There are ologies of SVC syndrome 3. Recognize the radiographic findings of technical points that improve the safety and success when using this central venous stenosis 4. Identify risk factors for intravascular device advanced recanalization technique, and ensure avoidance of causing associated central venous stenosis 5. Discuss treatment options for pericardial tamponade. central venous stenosis. CLINICAL FINDINGS/PROCEDURE DETAILS: Venous access is obtained BACKGROUND: SVC syndrome is the constellation of signs and symp- at the internal jugular/upper extremity and groin, although often bilat- toms resulting from compression of the SVC. These include face, neck eral IJ/upper extremity access is required. Defining the stump of the and upper extremity swelling, dyspnea, distention of neck and chest occluded vessel is imperative, and many obliques may be acquired wall veins, dizziness and headaches. Cerebral and laryngeal edema using an angled catheters to define the occlusion. Once the length and can become severe, leading to confusion, dysphagia, and stridor. Less characteristics of the occlusion have been defined, the RF wire may be than one percent of cases are fatal. Patients with mild to moderate loaded through one catheter, while a snare is loaded via the adjacent. symptoms are candidates for CT or MRI venography, while patients We prefer to advance the RF wire from inferiorly to reduce the effect of with severe, life threatening symptoms should be sent directly to inter- the heart on the target (snare) Using short pulses, the RF wire should ventional radiology (IR) for catheter-based venography and potential be passed through the occlusion and into the snare. Once through and immediate intervention. The most common etiology is invading or through access is obtained, a long catheter is passed over the RF wire, externally compressing malignancy, followed by indwelling intravas- and used to exchange for a long stiff wire. The occlusion should be cular device–associated stenosis. conservatively predilated using balloon venoplasty. Covered stents should be used in the SVC. The covered stent is loaded on one end of CLINICAL FINDINGS/PROCEDURE DETAILS: We present a case of mod- the through and through wire while the final balloon is loaded from the erate SVC syndrome in a 62-year-old man with stage IV lung cancer other, simultaneously. Immediately following venoplasty, the balloon is and SVC stenosis related to an indwelling right subclavian port-a- deflated and retracted and the stent is advanced and deployed cath. Through a pictorial essay, we outline the preintervention vessel collateralization, our intervention with balloon venoplasty, and the CONCLUSION AND/OR TEACHING POINTS: In using this updated tech- postintervention forward blood flow. We discuss the relevance of SVC nique of simultaneously loading the stent and balloon, we have expe- obstruction above versus below the azygous vein. We outline the intra- rienced no cases of pericardial tamponade. RF wire recanalization is vascular device associated risk factors for central venous stenosis as an effective technique for CVO recanalization. Adherence to certain well as the current recommendations regarding treatment of central technical points will ensure avoidance of pericardial effusion and pro- venous stenosis. mote successful outcomes.

CONCLUSION AND/OR TEACHING POINTS: 1. SVC syndrome presents with face and upper extremity swelling, but can progress to dyspnea, Abstract No. 1091 cerebral and laryngeal edema, and death. Severe cases should go right to IR. 2. The most common etiology is malignancy, followed by indwell- Left brachiocephalic vein perforation with hemodialysis ing intravascular device associated stenosis. 4. More time, more cath- catheter migration: a novel treatment of transvenous eters, more infections, and more contact with endothelium increase balloon-assisted embolization with N-butyl cyanoacrylate the risk of venous stenosis. 5. Percutaneous transluminal venoplasty R Fujitsuna1, F Sugihara1, D Yasui1, M Tsukahara1, H Saito1, T Ueda1, remains the first line treatment. 6. More research is needed on stenting Y Miyagi2, S Kumita1 as primary intervention. 1Department of Radiology, Nippon Medical School, Tokyo, Japan, 2Department of Cardiovascular Surgery, Nippon Medical Abstract No. 1090 School, Tokyo, Japan

The radiofrequency revisited: a technical update on LEARNING OBJECTIVES: Review of the literature for iatrogenic left radiofrequency wire recanalization brachiocephalic vein (LBV) perforation with hemodialysis catheters. Learn how to perform a new endovascular treatment method-bal- 1 2 B Ashley , M Guimaraes loon-assisted embolization with N-butyl cyanoacrylate (NBCA). 1MUSC, Charleston, SC, 2Medical University of South Carolina, BACKGROUND: Iatrogenic LBV perforation is rare, but can cause mas- Charleston, SC sive bleeding with fatal consequences when caused by large-bore

LEARNING OBJECTIVES: 1. To provide a general overview in approach- hemodialysis catheters. There is a particularly high risk of venous per- ing CVO recanalization 2. To update the previously described tech- foration in cases of left internal jugular vein puncture because it forms nique using the radiofrequency (RF) wire. a perpendicular angle with the LBV. Simple catheter removal, surgical repair, and endovascular treatment with stent graft placement have BACKGROUND: Central venous occlusions are a known complication been reported; however, venous perforation treatment is still contro- of long-term indwelling central venous catheters. These patients may versial. We reviewed the literature regarding the treatment options suffer from debilitating upper extremity and facial swelling. Traditional methods of treating these occlusions involve crossing with a wire and 150 | e-Posters SIR 2020 Annual Scientific Meeting

and their advantages/disadvantages and presented our new endovas- portal hypertension. 2. Intrahepatic portal venous-hepatic venous cular treatment, discussing the procedure details and technical points. communication: These shunts are relatively uncommon and most cases occur in patients without cirrhosis. Symptomatic shunts can be CLINICAL FINDINGS/PROCEDURE DETAILS: A 44-year-old man under- managed conservatively (protein restriction, oral lactulose, nonab- went 12-French hemodialysis catheter placement in the left inter- sorbable antibiotics), surgically (portal vein ligation or hepatic lobec- nal jugular vein under ultrasound guidance for leukapheresis. Chest tomy) or via transcatheter embolization. Transcatheter embolization radiographs revealed a well-positioned catheter tip. The leukapheresis can be performed via the following three access routes: 1. Transileo- procedure was performed without problems. The following day, chest colic: Catheter is advanced into the portal venous system via ileocolic radiographs revealed migration of the catheter tip and CT scan showed vein through a small abdominal incision. 2. Transhepatic: Percutaneous mediastinal hematoma and emphysema; the catheter tip was located puncture of an intrahepatic portal venous branch under sonographic outside the LBV. Venous perforation with catheter migration was guidance. 3. Retrograde transcaval: Two catheters are advanced into diagnosed and endovascular treatment under general anesthesia was the portal venous system through the shunt vessel via bilateral trans- planned. A balloon catheter (12 mm × 40 mm) was inserted into the femoral venous access. One catheter advanced into the main por- perforation site via the left brachial vein. A microcatheter was inserted tal vein is used for portography while the other catheter is used for via the most distal hemodialysis catheter port and placed outside the embolization. vessel. Venography via the microcatheter showed extravasation into the mediastinum. We performed tract embolization using NBCA-Lip- CONCLUSION AND/OR TEACHING POINTS: High-flow intrahepatic porto- iodol mixture while inflating the balloon and subsequently removed systemic shunts can be a cause of hepatic encephalopathy in patients the hemodialysis catheter. Post-embolization venography showed no without cirrhosis. Transcatheter embolization is effective for the man- active contrast extravasation. There were no serious complications. agement of such shunts.

CONCLUSION AND/OR TEACHING POINTS: Although rare, iatrogenic LBV perforation should be recognized as a life-threatening complica- Abstract No. 1093 tion. Balloon-assisted embolization with NBCA is safe and effective for iatrogenic LBV perforation. Varicocele embolization: tips and tricks for success R Spouge1, K Jumaa2, G Annamalai3 Abstract No. 1092 1University of British Columbia, West Vancouver, BC, 2University of Toronto, Toronto, ON, 3N/A, Toronto, ON Transcatheter embolization of symptomatic intrahepatic portosystemic venous shunts LEARNING OBJECTIVES: 1. To review the preprocedural preparation which may be helpful but is often overlooked, including review of com- 1 2 2 3 M Afzaal , P Sharma , A Ghasemiesfe , A Saeed Bamashmos , R mon anatomical variants. 2. To examine commonly used equipment, Ali4 the reasons why they are used, and helpful alternatives to consider. 3. 1Yale New Haven Health Bridgeport Hospital, Bridgeport, CT, 2Yale To review common pitfalls and provide simple tips and tricks to ensure University–Bridgeport Hospital, Milford, CT, 3Yale University– procedural success. Bridgeport Hospital, Bridgeport, CT, 4Yale New Haven Hospital, New Haven, CT BACKGROUND: Varicoceles are a common cause of chronic pain and infertility. Percutaneous embolization has largely replaced surgical liga- LEARNING OBJECTIVES: 1. To familiarize interventional radiology tion in Canada due to the low-risk nature of the procedure, outpatient trainees with intrahepatic portosystemic venous shunt as a cause of setting, and quick recovery time. Embolization success rates range encephalopathy in noncirrhotic patients. 2. Angiographic findings and between 87% and 95%. Numerous protocols have been described embolization techniques for the management of intrahepatic porto- using different equipment and embolic agents, which vary between systemic venous shunts. institutions. This educational exhibit will review common protocols and methods and provide valuable tips and tricks that can improve success BACKGROUND: An intrahepatic portosystemic venous shunt is defined rates, particularly for new operators. as a communication between an intrahepatic portal vein and a systemic vein via an abnormal intrahepatic venous channel. Such shunts CLINICAL FINDINGS/PROCEDURE DETAILS: This exhibit will review com- are frequently seen in cirrhotics with portal hypertension but can ponents to a successful embolization: 1. Access: conventional jugular also occur in patients without cirrhosis (congenital, portal venous access versus femoral access. 2. Equipment: side-by-side comparison aneurysm rupture or trauma). Asymptomatic intrahepatic shunts are of commonly used catheters and wires, why operators use them, and discovered as incidental findings on imaging. Clinical manifestations alternatives to consider (for example, in cases of acute vessel take- depend on shunt flow; a high-flow shunt can cause encephalopathy off or crossing venous valves). 3. Anatomy and variants: knowledge and hypoglycemia. of common variants can prevent undue operator frustration; these include right gonadal vein emptying into the right renal vein, circumao- CLINICAL FINDINGS/PROCEDURE DETAILS: On angiography, following rtic renal veins, supernumerary renal and/or gonadal veins. 4. Embolic types of intrahepatic portosystemic shunts are seen: 1. Intrahepatic agents: Commonly used coils will be reviewed, how to size them, and portal venous-perihepatic venous communication: These shunts are the ideal landing zones. The use of liquid embolic agents will also be more common and are typically seen in patients with cirrhosis and SIR 2020 Annual Scientific Meeting e-Posters | 151 reviewed. 5. Salvage maneuvers: despite best efforts, complications Abstract No. 1095 can occur. Helpful tips will be demonstrated via cases (e.g., snaring a coil). Considerations for inferior vena cava filter placement: a review of caval anatomic variants and filter complications CONCLUSION AND/OR TEACHING POINTS: Varicocele embolization is a safe and effective procedure. Thorough understanding of the purpose K Zurcher1, R Shrestha2, A Sill1, A Wallace1, J Kriegshauser3, S 4 5 4 and justification each step and each piece of equipment can increase Alzubaidi , I Patel , R Oklu operator success and overall patient satisfaction. 1Mayo Clinic Arizona, Phoenix, AZ, 2Mayo Clinic Arizona, Scottsdale, AZ, 3Mayo Clinic Scottsdale, Phoenix, AZ, 4Mayo Clinic, Phoenix, AZ, 5Mayo Clinic, Phoenix, AZ Abstract No. 1094 LEARNING OBJECTIVES: Review indications and technique for inferior What is pelvic congestion syndrome? vena cava (IVC) filter placement. Develop an understanding of caval anatomic variants. Identify technical considerations of filter placement J Foster1, R Pyne2,3 in patients with variant caval anatomy through case illustrations. Sum- 1 2 Rochester Regional Health, Rochester, NY, Rochester General marize complications of IVC filter placement. Hospital, Pittsford, NY, 3 The Vein Institute, N/A BACKGROUND: IVC filter placement is a common and typically well tol- LEARNING OBJECTIVES: The objective of this abstract is to understand erated procedure. Indications range from inability to anticoagulate in pelvic congestion syndrome (PCS). We will review the epidemiology, the setting of deep vein thrombosis (DVT), failure of anticoagulation, diagnosis and examine the treatment of PCS. massive pulmonary embolism, prophylaxis, to iliocaval DVT. Filters

BACKGROUND: PCS is pelvic pain that is noncyclical and caused by pel- are traditionally placed in the infrarenal IVC, from an inferior jugular vic varicosities. Pelvic varicosities are the result of dysfunctional venous or femoral approach. A number of caval anatomic variants have been valves, retrograde blood flow, and/or venous engorgement. Some described. The presence of variant caval anatomy can alter a number causes of varicosities include environmental factors like pregnancy, of technical considerations during filter placement. which increase pelvic vein capacity by 60% and congenital anomalies CLINICAL FINDINGS/PROCEDURE DETAILS: Several known caval ana- like absent valves which occur in up to 15% of women. PCS commonly tomic variants present specific technical considerations for IVC filter occurs in multiparous, premenopausal women. The exact cause of pel- placement. Analyzing preprocedural imaging, as well as predeploy- vic pain from varicosities is unknown. Theories include activation of ment IVC venogram from the left common iliac vein, is vital in iden- pain receptors in the venous walls or release of neurotransmitters from tifying variant anatomy and avoiding associated complications. A dilated vein walls. Pelvic varicosities are the hallmark feature of PCS; duplicated IVC requires placement of two filters, or a single filter supe- however, they may be present in completely asymptomatic women. rior to the central confluence, in order to provide adequate protection

CLINICAL FINDINGS/PROCEDURE DETAILS: PCS is diagnosed by imaging from central embolization. Circumaortic or duplicated renal veins must showing vein incompetence and the appropriate clinical presentations. also be excluded. Failure to recognize this variant may result in unin- Each imaging modality has criteria for diagnosing vein incompetence. tentional suprarenal filter placement. Mega vena cava is described as Ultrasound criteria are pelvic veins ≥ 6 mm, slowed/reversed flow of an IVC >28 mm in diameter. Identification of this variant is necessary to ovarian veins, or associated polycystic ovaries. CT/MRI criteria is the avoid unintentional filter migration. Additionally, gonadal vein place- presence of at least four ipsilateral pelvic veins varying in caliber, with ment should be excluded. A brief summary of additional filter compli- one measuring > 4 mm or an ovarian vein > 8 mm. Catheter-directed cations, such as tilt, fracture, or nondeployment is also discussed. venography is best for evaluation; its criteria is an ovarian vein of > 10 CONCLUSION AND/OR TEACHING POINTS: IVC filter placement is a com- mm and congestion of the pelvic veins with retrograde filling. PCS is mon and well tolerated procedure; however, an understanding of caval treated medically or endovascularly. Medical management (hormones) variants is critical in avoiding unnecessary complications. Analysis of may provide symptomatic relief; rarely sustained. Endovascular treat- preprocedural imaging / predeployment venogram is vital in identi- ment involves the embolization of the ovarian veins, typically per- fying variants prior to placement. Interventional radiologists should formed after failed medical management. Multiple embolizing agents demonstrate proficiency in adapting filter choice, positioning, or num- can be used in the ovarian vein including sclerosants, glue, absorbable ber in these situations. gelatin sponge, coils, and/or vascular plugs.

CONCLUSION AND/OR TEACHING POINTS: PCS is a common cause of Abstract No. 1096 pelvic pain which is difficult to diagnose due to the long differential for pelvic pain. Patients with pelvic pain and image findings for Evolution of design modifications to the Greenfield vein incompetence typically respond to embolization of the ovarian inferior vena cava filter and their relevance to retrieval vein; with 60% to 100% reporting significant clinical improvement in 1 2 2 1 research studies. R England , M Lessne , R Sing , B Holly 1Johns Hopkins Hospital, Baltimore, MD, 2N/A, Charlotte, NC 152 | e-Posters SIR 2020 Annual Scientific Meeting

LEARNING OBJECTIVES: - How to recognize the various generations of Postprocedure complications include caval thrombosis, filter fracture, Greenfield inferior vena cava (IVC) filters - Complications of Greenfield and filter perforation. The Food and Drug Administration recommends IVC filters - Indications and techniques for removing different genera- removal of IVC filters when they are no longer indicated. Despite this, tions of Greenfield filters. a lot of centers still have low retrieval rates, some as low as 8.5%. At a county hospital, acquiring additional resources for clinical manage- BACKGROUND: Awareness of the potential risks of IVC filters has ment is often difficult. Residents and training programs must find ways increased recently, and many interventional radiologists have become to still deliver quality care within these limitations. filter experts while developing a sophisticated, advanced IVC filter retrieval practice. Such expertise requires both breadth and depth of CLINICAL FINDINGS/PROCEDURE DETAILS: Several measures were put knowledge regarding IVC filters and advanced removal techniques. into action by residents at a county institution to improve retrieval The Greenfield filters were a commonly placed permanent IVC filter; rates as a quality improvement project. Prior retrieval rate over a 1-year however, interventional innovations have made them accessible to period ranged from 25 to 39%. Proactive steps include prescheduling removal. As there have been several generations of Greenfield filters removal appointments at the time of filter placement, direct informa- produced over the years, being able to identify each type, their long- tion handouts given to the patients, and weekly follow-up communi- term complications, and strategies for removal specific to the genera- cation with referring providers and patients. Methods involving the tion are essential for an advanced IVC filter removal program. electronic medical record (EMR) include changes to consult notes, procedure dictation, and post procedure notes to include removal rec- CLINICAL FINDINGS/PROCEDURE DETAILS: Each of the 3 types of ommendations. One year following these changes, 44 IVC filter were Greenfield IVC filters—24-Fr stainless steel, 12-Fr titanium, and 12-Fr placed. 13 were appropriate for removal and 11/13 (85%) were removed stainless steel--will be reviewed with attention on radiographic recog- within 6 weeks. Patients who did not have their filters removed either nition. Complications of the Greenfield filters and their management had persisting indications, changes of goals of care, transfer of care to will be discussed with examples shown. When indicated, retrieval of other facilities, or expired. permanent IVC filters is challenging not only due to the lack of snare hook, but also because of extended in-situ duration and unique fil- CONCLUSION AND/OR TEACHING POINTS: This exhibit will go over ter generation design attributes. The original generation Greenfield resourceful ways for residents to tackle IVC filter retrieval from many was delivered through a 24-Fr sheath and contains a large “cap.” The aspects. These include empowering the patient, utilizing the EMR, and later generation titanium and stainless-steel Greenfield filters can be concise communication with referring providers. identified by a wavy strut design without a large cap. The titanium Greenfield filter is further differentiated by its exaggerated, reverse curve fixation anchors. Case examples of each filter generation with Abstract No. 1098 attention to proper removal techniques and equipment such as laser Inferior vena cava filter management in the setting sheaths will be reviewed. of infection: review of the literature and pathway to CONCLUSION AND/OR TEACHING POINTS: Permanent Greenfield IVC guidelines and recommendations filters are encountered in an advanced IVC filter practice. Removal, A Abramyan1, H McGregor1, C Hennemeyer2, M Patel3, G when indicated, can be performed safely in expert hands with detailed Woodhead3 knowledge of the disparate generations of Greenfield filters and 1 2 3 removal techniques specific to those generations. University of Arizona, Tucson, AZ, University of Arizona, N/A, N/A, N/A

Abstract No. 1097 LEARNING OBJECTIVES: 1. Present the existing FDA position statement on IVC filter placement in septic patients. 2. Provide an overview of the Improving inferior vena cava filter retrieval rates at a literature summarizing what is known about IVC filters as a nidus for county hospital: a resident quality improvement initiative infection, before and after antibiotic management 3. Propose a working set of guidelines about how to manage IVC filter placement and 1 1 1 M Abad-Santos , B Black , A Mlikotic retrieval in the setting of bacteremia and sepsis. 1Harbor-UCLA Medical Center, Torrance, CA BACKGROUND: Since the advent of optional/retrievable inferior vena

LEARNING OBJECTIVES: 1. Review the indications for inferior vena cava cava filters, interventional radiology physicians have managed IVC (IVC) filter placement. 2. Discuss the various obstacles to IVC filter filter removal, including establishing filter clinics. A common clinical removal that patients face from the experiences at a county hospital. challenge involves a request for filter placement or retrieval on inpa- 3. Demonstrate available strategies to develop a resident-run IVC filter tients who have or have recently had bacteremia or sepsis. The FDA retrieval clinic. advocates against the use of IVC filters in patients at risk of septic embolism. However, given the sparse research on this subject, at this BACKGROUND: IVC filter placement is an interventional radiology time there is no consensus guidelines or recommendations from the procedure that provides protection against pulmonary embolism in Society of Interventional Radiology about this topic. patients who are not candidates for medical anticoagulation. While these are effective in preventing pulmonary embolism, IVC filters CLINICAL FINDINGS/PROCEDURE DETAILS: Greenfield et al retrospec- are also associated with risks in the setting of prolonged dwell time. tively reviewed 175 patients diagnosed with sepsis at the time of IVC SIR 2020 Annual Scientific Meeting e-Posters | 153

filter implantation, of which 56 returned for routine late follow-up to IVC to calculate cortisol selectivity index (SI). Once adequacy of (mean 12.9 months). None of the filters were removed for any reason, sampling is been confirmed, lateralization index (LI) is calculated by and no reports of subsequent septic episodes were recorded. There comparing aldosterone/cortisol to each side. have been three reported cases of bacteremic patients with IVC filters CONCLUSION AND/OR TEACHING POINTS: AVS plays a key role in the who were successfully treated with IV antibiotics without subsequent workup of primary aldosteronism. Despite its difficulty, AVS can have septic episodes, followed up to 13, 33, and 42 months. In two of these high technical success rate by understanding anatomical variations of patients, IVC filter infection was demonstrated on PET/CT. In support adrenal veins. Strict protocol during the AVS can demonstrate optimal of these case reports, an earlier in vivo canine study demonstrated clinical follow-up. that infected thrombi in IVC filters were sterilized by IV antibiotic therapy, including the embolus, the filter, and caval wall. On the contrary, there have been two case reports of infected Gunther Tulip filters that Abstract No. 1100 necessitated retrieval, where IV antibiotic therapy failed. An overview of bilateral inferior petrosal sinus sampling CONCLUSION AND/OR TEACHING POINTS: Proposal/pathway toward guidelines: 1. Bacteremia is not an indication for filter removal. 2. I Masood1, F Ahmad1, M Elshikh1, A Saleem2, K Raghuram3 Known bacteremia is a relative contraindication for filter placement. 1University of Texas Medical Branch at Galveston, Galveston, 3. Following a course of antibiotics and/or negative cultures, IVC filter TX, 2UTMB Galveston, Diagnostic Radiology, Galveston, TX, 3N/A, placement is reasonable. Galveston, TX

LEARNING OBJECTIVES: To discuss the role of bilateral inferior petro- Abstract No. 1099 sal sinus sampling (BIPSS) in the diagnostic work-up of Cushing syndrome (CS) including indications, contraindications, and diagnostic A trainee’s guide to primary aldosteronism and adrenal criteria. To review the technical aspects of BIPSS, relevant anatomy, venous sampling and potential pitfalls. To discuss the efficacy and diagnostic perfor- F Kang1, H Patel2, A Li3 mance of BIPSS compared to biochemical tests and MRI.

1Rutgers Robert Wood Johnson Medical School, Somerset, BACKGROUND: Localization of the source of ACTH is critical for diag- NJ, 2Rutgers Robert Wood Johnson Medical School, Lawrenceville, nosis as well as management of patients with ACTH-dependent CS. NJ, 3University Radiology Group, Livingston, NJ Sources of ACTH include pituitary and ectopic ACTH-producing tumors. Localization of ACTH source can be challenging due to limited LEARNING OBJECTIVES: 1. Overview of aldosterone secretion pathway. sensitivity and specificity of various biochemical tests as well as pitu- 2. Work-up of suspected aldosteronism. 3. Role of adrenal venous sam- itary MRI. In such cases, BIPSS helps to differentiate Cushing disease pling (AVS) in the workup of aldosteronism. 4. Anatomy of the adrenal from CS due to ectopic ACTH-secreting tumors and is considered the venous drainage. 5. AVS technique/protocol. 6. Results interpretation. gold standard with a sensitivity of 88-100% and specificity of 67-100%. BACKGROUND: Hypertension affects more than 25% of the adult pop- CLINICAL FINDINGS/PROCEDURE DETAILS: Anterior pituitary venous ulation in the US. Primary aldosteronism is a common and treatable drainage is usually to the ipsilateral cavernous sinus, which then drains cause of secondary hypertension, affecting up to 15 % of all hyper- into the inferior petrosal sinus (IPS) and finally into the jugular vein. tension, and it is imperative to determine unilateral aldosterone pro- Venous sampling of bilateral IPS is recommended to avoid false-neg- ducing adenoma from bilateral idiopathic adrenal hyperplasia because ative results. Bilateral femoral venous accesses are established to unilateral disease can be treated with adrenalectomy. AVS is the gold catheterize each IPS. To confirm catheter positioning and venous standard assay to distinguish unilateral from bilateral adrenal sources drainage digital subtraction venography is performed before and after of autonomous aldosterone secretion. sampling. At our institution, synchronized blood samples are obtained CLINICAL FINDINGS/PROCEDURE DETAILS: At our institution, AVS is from bilateral IPS and peripheral IV (P) prior to CRH administration. At perform using the sequential technique, unless specified by the refer- time 0, a weight-based (1 mcg/kg) dose of CRH is administered and ring physician, and Cosyntropin stimulation is utilized. A 5- French samples are obtained at 1, 2, 10, 15, and 30 minutes. IPS/P ACTH ratios vascular sheath is placed in the right common femoral vein. Selection are calculated. A basal ratio >2 and peak stimulated ratio (post-CRH) and sampling of the right adrenal vein is done first. Selection and sam- >3 are indicative for pituitary source. Interpetrosal ACTH ratio ≥ 1.4 pling of the left adrenal vein is obtained second. Infrarenal inferior vena indicates lateralization of ACTH secretion with the highest side harbor- cava (IVC) sample is obtained last. Confirmation of vessel selection is ing the microadenoma. confirmed using hand injections. A specific protocol used during AVS CONCLUSION AND/OR TEACHING POINTS: CS requires multimodality will be discussed, which requires meticulous coordination and docu- diagnostic approach including biochemical tests, MRI, and BIPSS. mentation, including a seamless chain of communication between the BIPSS is highly accurate in distinguishing ectopic from pituitary ACTH physician performing the procedure and support staff responsible for production. BIPSS can be technically challenging and requires knowl- storing and labeling samples. Venous cortisol levels are used as pos- edge of pituitary venous drainage and its variations. itive controls to determine that sampling was adequately performed from the adrenal veins. Cortisol level in each adrenal vein is compared 154 | e-Posters SIR 2020 Annual Scientific Meeting

Abstract No. 1101 parathyroid surgery and negative or discordant imaging (neck ultrasound, Tc99m sestamibi scan, 4DCT of the neck/chest), SVS of the Chylous reflux syndrome: the role of the radiologist from neck is indicated for localization of the abnormal parathyroid tissue. diagnosis to treatment Distorted anatomy and scarring from prior surgery increases the risk of M Yamamoto1, H Kondo2, Z Ryusei1, A Suzuki1, M Ozawa1, T complications during repeat surgery, and SVS can guide the surgeon Sugawara1, S Hitomi1, J Toda1, H Oba1 to the site of abnormal tissue, to minimize the degree of exploration necessary, and therefore minimize risk and negative outcomes to the 1Teikyo University School of Medicine, Tokyo, Japan, 2N/A, N/A patient.

LEARNING OBJECTIVES: 1. To summarize normal lymphatic pathway CLINICAL FINDINGS/PROCEDURE DETAILS: SVS requires premapped and lymphatic pathway of CRS patients. 2. To summarize the physio- neck venous anatomy from diagnostic venogram. Following this, a logical mechanism of lymphogenesis and transport in CRS patients. 3. schematic and sequence of the sampling is created, discussed with To learn about the lymphatic pathways of CRS. 4. To discuss treatment support staff, and then performed. Single femoral venous access is for various symptoms of CRS. used to minimize collection error. Via the femoral vein, a 4- to 6-Fr cath-

BACKGROUND: Primary chylous reflux syndrome is rare. Rupture of eter is advanced to the central chest and neck veins. Central vessels dilated lymphatic vessels may result in chylous ascites, chylothorax, (SVC, IVC) serve as peripheral comparisons, to which superior/inferior or leakage of chyle through chylocutaneous fistulas in the lower limbs thyroidal, thymic, etc. veins are compared. Interventional radiologist or genitalia. However, the cause of lymph duct dilatation is unknown. collects venous blood (1-2 mL) from each site. Accurate sampling and Chyle may reflux through incompetent lymphatics, causing lymph- interpretation requires robust communication between the Interven- edema. Although surgical options for CRS have been mainly focused tional Radiologist and support staff. Our institution’s protocol and “call on thus far, here we will explain lymphatic embolization for CRS. back” system will be discussed. An increased PTH level of 1.5- to 2-fold over the peripheral sampling site is considered diagnostic. CLINICAL FINDINGS/PROCEDURE DETAILS: Related to CRS, this exhibit presents the following: 1. Brief description of lymphatic pathway related CONCLUSION AND/OR TEACHING POINTS: SVS in postoperative patients to CRS 2. Summary of technique of ILE (i) Puncture inguinal lymph with persistent or recurrent primary hyperparathyroidism is a valuable nodes under ultrasound guidance; (ii) Inject contrast medium via the diagnostic modality, reported to correctly predict the localization of puncture needles to pinpoint leakage site; (iii) If the leak is located the affected gland in upwards of 89% of cases. Thus, the interventional higher than the cisterna chyli, insert the catheter into the thoracic duct radiologist can be a valuable clinical partner in the diagnosis of this and then embolize the leak. If the leak is lower than the cisterna chyli, subset of hyperparathyroidism. embolize the lumbar lymphatic trunk. 3. Summary of technical implications of CRS In addition to embolization of the leak point, it is nec- Abstract No. 1103 essary to embolize the superior lymph duct to prevent back flow. 4. Presentation of cases experienced by us Portovenous interventions utilizing intravascular CONCLUSION AND/OR TEACHING POINTS: We illustrate a novel treat- ultrasound ment method for CRS. TDE or INE is useful as a treatment for CRS and S Aziz1, Z Bhatti2, C Guevara2 is also useful to explore the etiological mechanism. 1UTHealth McGovern Medical School, Pearland, TX, 2N/A, Houston, TX Abstract No. 1102 LEARNING OBJECTIVES: 1. Brief review of IVUS, with discussion of Parathyroid hormone selective venous sampling: what the equipment and technical aspects. 2. Review of cases utilizing IVUS in interventional radiologist needs to know various portovenous interventions. 3. Scenarios where imaging guidance via IVUS is specifically applicable and advantageous. 4. Disad- 1 2 3 H Patel , F Kang , A Li vantages of IVUS. 1Rutgers Robert Wood Johnson Medical School, Lawrenceville, BACKGROUND: Intravascular ultrasound (IVUS) can be used as an NJ, 2Rutgers Robert Wood Johnson Medical School, Somerset, adjunct modality to visualize the portovenous system, and has gar- NJ, 3University Radiology Group, Livingston, NJ nered increasing interest over the past few years to visualize and direct

LEARNING OBJECTIVES: 1. Overview of parathyroid-calcium homeosta- transvenous and intravenous hepatic interventions. It’s most high- sis. 2. Role of selective venous sampling (SVS) in the workup of per- lighted application has been in portal vein targeting during transjug- sistent/recurrent hyperparathyroidism. 3. Parathyroid SVS protocol ular intrahepatic portosystemic shunt (TIPS) placement, with recent and result interpretation. literature suggesting improvements in procedural metrics. However, there is a paucity of literature describing additional applications of BACKGROUND: Hyperparathyroidism is an excess of parathyroid hor- IVUS in portovenous interventions. This exhibit will discuss indications, mone (PTH) due to overactive parathyroid gland(s). Localization of applications with cases, current literature and our institutional experi- abnormal glands with noninvasive imaging modalities has a high ence of utilizing IVUS in various hepatobiliary interventions. success rate, and is followed by resection via surgical neck exploration. However, for patients with persistent or recurrent disease after SIR 2020 Annual Scientific Meeting e-Posters | 155

CLINICAL FINDINGS/PROCEDURE DETAILS: Cases utilizing IVUS for por- Abstract No. 1105 tovenous interventions are demonstrated, such as TIPS, direct intrahepatic portocaval shunt placement (DIPS), portal vein mechanical and Variant anatomy in adrenal vein sampling chemical thrombolysis, portal vein stent placement, mesenteric vein R Ruttiman1, B Holly1, M Lessne2 embolization and thrombolysis and transcaval liver biopsy. 1Johns Hopkins Hospital, Baltimore, MD, 2N/A, Charlotte, NC CONCLUSION AND/OR TEACHING POINTS: It is important to be familiar with the spectrum of IVUS applications as it is being increasingly used LEARNING OBJECTIVES: • Review the utility of adrenal vein sampling as an adjunct modality to visualize and direct various portovenous in diagnosis and localization of adrenal pathology in the setting of interventions. Although costly and requiring a steep learning curve, primary aldosteronism. • Highlight typical and variant vascular anat- IVUS has many unique advantages and can be useful for providing omy associated with adrenal vein sampling through schematic illustra- imaging guidance and directing interventions in cases where there is tions. • Underscore the importance of recognizing variant adrenal vein hepatic/portal vein thrombus, distorted and/or postsurgical anatomy, anatomy via computer tomographic, venographic and intraoperative mass effect from tumor, and in various additional clinical scenarios. depictions.

BACKGROUND: Primary aldosteronism is the most common cause of secondary hypertension, accounting for 5% to 10% of all subtypes of Abstract No. 1104 hypertension. Primary aldosteronism is due to either aldosterone-se- Treating superficial venous insufficiency: a primer for creting adenoma/unilateral adrenal hyperplasia versus bilateral adre- residents nal hyperplasia. The former is cured with surgical excision while the latter is medically managed. Differentiating between these entities 1 1 1 A Fladten , M Li , A Fairchild with laboratory testing and imaging alone may be cumbersome and 1Medical College of Wisconsin, Wauwatosa, WI misleading. Adrenal vein sampling allows for discrete diagnosis and lateralization of primary aldosteronism. Typical adrenal vein anatomy LEARNING OBJECTIVES: 1. Review lower extremity venous anatomy involves left adrenal vein drainage into the left renal vein and right and physiology. 2. Understand clinical presentation and noninvasive adrenal vein drainage directly into the inferior vena cava. And while imaging findings of venous insufficiency. 3. Present the spectrum of variant anatomy is uncommon, it does occur. As such, successful cath- FDA-approved treatments for superficial venous insufficiency. erization of adrenal veins during adrenal vein sampling can be tech-

BACKGROUND: Lower-extremity varicose veins are common, ranging in nically challenging, even in experienced hands. This review provides prevalence between 10% and 30% worldwide. Approximately 6% of the examples of variant adrenal vein anatomy via computer tomographic, population have advanced chronic venous disease with skin changes venographic and intraoperative depictions. and healed or active ulcers. Venous insufficiency is frequently associ- CLINICAL FINDINGS/PROCEDURE DETAILS: Schematic illustrations of ated with pain, edema, loss of working days, and deterioration of qual- typical and well described variant adrenal vein anatomy will be pro- ity of life. The work-up and treatment of patients with chronic venous vided. Through computer tomographic, venographic and intraoper- disease is often housed in free-standing clinics, away from main teach- ative depictions, multiple cases of variant adrenal vein anatomy will ing hospitals, and therefore may be less often encountered by trainees. be presented. Examples of cases that will be included: confluent right

CLINICAL FINDINGS/PROCEDURE DETAILS: We present a pictorial review adrenal vein and inferior accessory hepatic vein, retro-aortic renal vein of lower extremity venous insufficiency with emphasis on the superfi- with anomalous left adrenal vein, separate origin of left adrenal and cial system and approach to patient work-up. Normal and abnormal phrenic veins. Technical pearls and pitfalls of adrenal vein sampling will superficial venous anatomy and sonographic evaluation is reviewed. be discussed. Treatments presented include compression therapy, thermal and non- CONCLUSION AND/OR TEACHING POINTS: Adrenal vein sampling contin- thermal saphenous ablation techniques, phlebectomy, approach to ues to be the gold standard for differentiating primary aldosteronism. incompetent perforators, and sclerotherapy of incompetent veins. Knowledge of typical and variant adrenal vein anatomy is fundamental

CONCLUSION AND/OR TEACHING POINTS: Chronic venous insufficiency to successful selection of both adrenal veins. is a spectrum of disease that is frequently encountered in the population. Understanding the disease, patient work-up, and treatment options can allow interventional radiologists to impact the quality of Abstract No. 1106 life of many. A pictorial review of May-Thurner syndrome with case illustrations of endovascular repair in routine and acute settings J Jeffries1, A Lionberg1, J Li2, B Funaki3 1The University of Chicago Medicine, Chicago, IL, 2The University of Chicago Pritzker School of Medicine, Chicago, IL, 3The University of Chicago Medicine, Riverside, IL 156 | e-Posters SIR 2020 Annual Scientific Meeting

LEARNING OBJECTIVES: 1. Review the pathophysiology, clinical presen- CLINICAL FINDINGS/PROCEDURE DETAILS: The Inari Medical FlowTriever tation, and diagnosis of May-Thurner syndrome (MTS). 2. Discuss the is a large-bore endovascular suction thrombectomy device with management of MTS in both routine and acute settings using case- optional, self-expanding nitinol mesh disks that engage acute clot and based illustrations of both classic and atypical presentations. assist in aspiration. The Inari ClotTriever is an endovascular device that collects acute clot in a nitinol mesh bag and delivers it to a nitinol fun- BACKGROUND: MTS is a manifestation of chronic venous disease (CVD) nel for aspiration. Herein, we present six examples of both FDA-ap- that occurs when the right common iliac artery (CIA) compresses the proved and off-label use of the FlowTriever and ClotTriever systems left common iliac vein (CIV) on the fifth lumbar vertebra. Chronic com- to extract clot in cases of acute PE, iliocaval thrombosis, superior vena pression leads to fibrosis within the vein lumen and formation of spurs cava thrombosis, May-Thurner syndrome, portal vein thrombosis, and that can lead to partial or complete obstruction with or without deep IVC filter-associated thrombus. vein thrombosis (DVT) in the left iliofemoral vein. It affects an estimated 2-5% of the population and can cause significant morbidity in CONCLUSION AND/OR TEACHING POINTS: Anticoagulation is the main- affected patients. In addition to DVT and sequela of postthrombotic stay of treatment for patient with VTE. Fibrinolytics are commonly syndrome (PTS), rarely chronic CIV compression can lead to unique used in patients with more severe disease. Endovascular thrombec- injuries requiring emergent endovascular intervention. tomy, especially with new devices, may be employed to remove large volumes of thrombus from several vascular territories without the CLINICAL FINDINGS/PROCEDURE DETAILS: This exhibit will describe the addition of fibrinolytics. pathophysiology, methods of diagnosis, and clinical presentations of MTS with an emphasis on atypical presentations and the appropriate management in the acute setting. Case examples will illustrate angio- Abstract No. 1108 graphic findings and management of classic MTS as well as more atypical manifestations including rupture of the iliac vein predisposed by Lost art of pulmonary angiography in the new era of May-Thurner physiology. catheter-based pulmonary embolectomy

CONCLUSION AND/OR TEACHING POINTS: MTS is an often-overlooked H Mojibian1, J Cornman-Homonoff2, J Lee3, I Singh4, J Pollak5 disease that can cause significant morbidity in affected patients. 1Yale, New Haven, CT, 2Yale New Haven Hospital, New Haven, Rarely, it can lead to unexpected injuries requiring emergent endovas- CT, 3N/A, Guilford, CT, 4Yale University School of Medicine, New cular repair. Haven, CT, 5N/A, Woodbridge, CT

LEARNING OBJECTIVES: 1. Review catheter-based pulmonary angi- Abstract No. 1107 ography techniques including advanced techniques. 2. Review the principles of right heart invasive measurements. 3. Review right heart An illustrative review of endovascular treatment invasive measurement parameters and clinical interpretation of those techniques using the Inari Medical FlowTriever and parameters in the setting of acute pulmonary embolism. ClotTriever systems in venous thromboembolic disease BACKGROUND: Use of catheter-based pulmonary thrombectomy 1 2 2 3 K Wilson , B Majdalany , B Ross , M Khaja devices requires adequate knowledge of performing selective pul- 1University of Michigan, Ann Arbor, MI, 2Emory University, Atlanta, monary angiography. Younger interventional radiologists lack skills GA, 3University of Virginia Health System, Charlottesville, VA of pulmonary angiography and interpretation of right ventricle hemodynamic measurements can be challenging. This educational exhibit LEARNING OBJECTIVES: 1. Recognize the clinical presentation and address those issues. imaging features of venous thromboembolism (VTE) in various vascular beds. 2. Discuss endovascular treatment strategies for venous CLINICAL FINDINGS/PROCEDURE DETAILS: The exhibit will be divided thromboembolic disease including thrombolysis and thrombectomy. as follow: importance of pulmonary angiography and review of new 3. Highlight the use of new thrombectomy devices in several patient catheter-based embolectomy devices, essential tools, navigation to scenarios. the pulmonary artery, tips and tricks to selective pulmonary angiography, basic of hemodynamic pressure measurement, clinical inter- BACKGROUND: The incidence of VTE, including deep-vein thrombosis pretation of invasive measurements before and after treatment, and (DVT) and pulmonary embolism (PE), is estimated between 104-183 advanced techniques. per 100,000 person years. Complications of VTE include postthrombotic syndrome, chronic thromboembolic pulmonary hypertension, CONCLUSION AND/OR TEACHING POINTS: All interventional radiol- central venous occlusion, portomesenteric occlusion, and death. Most ogists who are interested in the treatment of pulmonary embolism patients with VTE are treated with systemic anticoagulation, and in need to make themselves familiar with angiographic techniques some cases, fibrinolytics. The addition of systemic or directed throm- as well of understanding the clinical importance of hemodynamic bolytic therapy increases the risk of a major bleeding event over the measurements. use of anticoagulation alone, and some patients have contraindications to both. As a result, there is a need for a method to reduce clot burden in patients suffering from VTE without exposing them to the risks of pharmacological thrombolysis. SIR 2020 Annual Scientific Meeting e-Posters | 157

Abstract No. 1109 Abstract No. 1110

Portal vein recanalization: review of anatomy, indications, Splenic and portal vein thrombosis: the interventional technique, and literature radiology perspective N Shah1, L Campos2 I Altun1, T Parnall1, M Kuo1, L Jamal1, G Knuttinen1, S Naidu1, I Patel1, 2 3 4 1 1Boston Medical Center, Boston, MA, 2N/A, Cambridge, MA H Albadawi , S Alzubaidi , J Kriegshauser , R Oklu 1Mayo Clinic - Arizona, Phoenix, AZ, 2Mayo Clinic, Scottsdale, LEARNING OBJECTIVES: Understand the anatomy of the portal venous AZ, 3Mayo Clinic, Phoenix, AZ, 4Mayo Clinic Scottsdale, Phoenix, AZ system and common variants. Review of the Yerdel grading system for portal vein thrombosis. Describe patient population with portal LEARNING OBJECTIVES: (1) Review the anatomy of splenic and portal vein thrombosis including cirrhotic, noncirrhotic, and pediatric. Explain vasculature and pathophysiology of splenic vein thrombosis (SVT) and conventional and novel technical approaches related to portal vein portal vein thrombosis (PVT). (2) Present clinical approaches to SVT recanalization. Review clinical outcomes and most recent published and PVT. (3) Discuss interventional procedures performed in patients literature. with SVT and PVT through case illustrations.

BACKGROUND: Portal vein thrombosis causes significant morbidity and BACKGROUND: SVT is a rare clinical condition that can result in left- mortality. Common portal vein (PV) division is of the main PV into left sided portal hypertension. The most common cause of SVT is pancre- and right branches, accounting for 65-80% of patients. Most common atitis and also occurs in patients with renal disease, coagulopathy, and variant is PV trifurcation. Clinical presentation for PV thrombosis (PVT) cancer. PVT is a more prevalent condition that is related to cirrhosis, is abdominal pain, ascites, bleeding, jaundice, or cholangitis. Patients coagulation abnormalities, and cancer. SVT can present as isolated with cirrhosis, or noncirrhotic patients with thrombophilic syndromes, upper GI bleeding or splenomegaly, while the clinical presentation of malignancy, myeloproliferative disorders, pregnancy, inflammation PVT depends on extent and onset of thrombus formation. With the and/or infection. Yerdel grading system is a classification system for improvements in imaging techniques, it is now less challenging to PVT depending on the percent occlusion of the PV and SMV. PVT is diagnose patients with SVT and PVT and although angiography is associated with increased intraoperative and postoperative morbidity the diagnostic test of choice, SVT and PVT can also be detected by and mortality, as well as, independent risk factor for increased one- CT and MR angiography. Depending on the severity, management of year mortality following liver transplantation. PVT includes anticoagulant therapy, locally administration of thrombolytic therapy, surgical thrombectomy, and TIPS. In addition to anti- CLINICAL FINDINGS/PROCEDURE DETAILS: Several approaches for por- coagulant therapy, splenectomy or splenic arterial embolization can tal vein recanalization (PVR) including TIPS, transsplenic, and transhe- be performed to address bleeding gastric varices or hypersplenism in patic. Thornburg et al. first described the portal vein recanalization patients with SVT. and transjugular intrahepatic portosystemic shunt placement with use of transsplenic approach. Establishing outflow with TIPS at the time CLINICAL FINDINGS/PROCEDURE DETAILS: We will provide an overview of PVR alleviates the venous stasis, primary causative factor for PV of SVT and PVT including clinical presentation, pathophysiology, and thrombosis. Habib et al. described portal vein recanalization to achieve angiographic anatomy with relevant diagrams. We will compare clin- transplant candidacy in patients with chronic portal vein thrombosis. If ical presentations and discuss interventional approaches to SVT and anterograde access is unable to be canalized, a transhepatic retrograde PVT. Finally, we will discuss minimally invasive procedures that can be approach can be considered. Patient with noncirrhotic portal vein utilized. thrombosis require different clinical and interventional considerations. CONCLUSION AND/OR TEACHING POINTS: A better understanding of In the pediatric population, chronic PV recanalization success rate was the clinical approach to patients with SVT and PVT is essential for an evaluated in pediatric patients with orthotopic liver transplantations. interventional radiologist. Interventional radiologist should know anat-

CONCLUSION AND/OR TEACHING POINTS: Learn and understand omy, imaging findings, and differences of SVT and PVT, as well as the the indications, techniques and clinical outcomes for portal vein interventional techniques that can be used in management. recanalization. 158 | e-Posters SIR 2020 Annual Scientific Meeting

Abstract No. 1111 Patients with right ventricle dysfunction, myocardial necrosis, and a high PE severity index score are high acuity and may benefit from ST and/or The role of catheter-directed therapy devices in CDT. Others are low acuity and likely best served with AC and monitor- pulmonary embolism ing; aggressive therapies are not routinely indicated. Catheter-directed A Khoo1, A Mills1, N Mani1, S Vedantham1, P Kavali1 thrombolysis with (e.g., EKOS) or without (e.g., Uni-Fuse and Cragg-Mc- Namara) ultrasound assistance is the most common CDT for submassive 1Mallinckrodt Institute of Radiology, St. Louis, MO PE and may reduce the risk of bleeding when compared to full dose ST.

LEARNING OBJECTIVES: Discuss treatment options for PE. Provide a In the ULTIMA and SEATTLE II studies, ultrasound-assisted thrombol- framework to triage patients and select appropriate therapy. Catego- ysis improved outcomes in PE and earned FDA clearance for this use. rize devices for catheter-directed therapy (CDT). Catheter-directed mechanical thrombectomy is traditionally used in massive PE; however, there is growing interest in applying it to high acu- BACKGROUND: Acute PE is a leading cause of cardiovascular mortality. ity submassive PE patients at risk of bleeding complications from cath- PE is stratified into low-risk, submassive, and massive based on car- eter-directed thrombolysis. Techniques include aspiration/suction (e.g., diovascular stability and right heart strain. The roles of anticoagulation FlowTriever, Penumbra Indigo, JETi, Aspirex, Greenfield, and AngioVac), (AC), systemic thrombolysis (ST), and CDT continue to emerge and fragmentation (e.g., Argon Cleaner, generic pigtail catheters), and rheo- merit review. lytic (e.g., AngioJet). The FlowTriever device improved RV function in the

CLINICAL FINDINGS/PROCEDURE DETAILS: Low-risk PE can be man- FLARE study for submassive PE and is the only thrombectomy device aged with AC alone. Massive PE has a mortality risk up to 65% and is currently FDA cleared for PE. treated aggressively with ST and/or CDT. Submassive PE has an inter- CONCLUSION AND/OR TEACHING POINTS: Carefully selected submas- mediate mortality risk and its optimal treatment is evolving. To identify sive and massive PE patients may benefit from CDT. Multiple CDT submassive PE patients at risk of decompensation who stand to benefit devices for thrombolysis and thrombectomy are available; two are from aggressive therapy, submassive PE is subdivided into two groups. FDA-cleared.