Innovation at Work

congRress news CIRSE 2012 - Lisbon Saturday, September 15, 2012

Michael J. Lee CIRSE President InnovatIon at Work ...

Welcome to CIRSE 2012, a congress

Robert Morgan dedicated to excellence in IR! This is Scientific Programme neatly encapsulated by our slogan Committee Chairman “Innovation, Education, Inter vention.” Innovation is the key build - ing block of the discipline, which from its earliest days has been cha rac teri sed by inspired new ap proaches to treating acute and chronic diseases. Paulo Almeida Local Host Committee Chairman

The birth of IR Excellence and Innovation Continuing the Legacy of Innovation

1963 was an important year for radiology, due Dotter and like-minded radiologists continued In recognition of the continuing importance of As can be seen by the growing list of topics to a speech made at the first Czechoslovak Ra - to explore the possibilities of angioplasty, and innovative approaches to IR, Prof. Rolf Günther covered at every CIRSE meeting, innovation is diologic Congress by a certain Charles Dotter. to overcome the clinical obstacles presented. has established an Award for Excellence and still going strong, and has broadened the disci - The meeting, held at Karlovy Vary, was a large Doctors such as Melvin Judkins, Josef Rösch, Innovation, which will be presented at today’s pline to cover all manner of interventions, from international event, and the many delegates Stanley Baum, Sidney Wallace and Caesare Award Ceremony (see page 3) . This year, the the original vascular interventions, to encom - present listened in awe as Dotter explained his Gianturco, and many others besides, were all to award goes to Dr. Amman Bolia and Prof. pass stroke, trauma, kidney and musculoskele - vision of the future of radiology: “The angio - bring their own innovative ideas to the table. Jim Reekers, for their work in developing tal interventions, all the way to the most fast- graphic catheter can be more than a tool for subintimal angioplasty. moving field of all: oncology. passive means for diagnostic observation; Dr. Judkins was the one who would make the used with imagination, it can become an angioplasty truly minimally invasive, as he de - Subintimal angioplasty came into being in Innovation continues to be the bread-and-but - important surgical instrument.” vised and perfected the transfemoral approach, January 1987, following Dr. Bolia’s unintention - ter of every good IR, and this can express itself which was to largely replace the surgical cut- al recanalisation of a long popliteal occlusion in small ways – most usually, in the off-label His words turned out to be more than wishful downs of the brachial artery which had been through a dissection channel, while simultane - use of devices. While often having excellent thinking, and in January of the following year, used for early interventions. Dr. Rösch and ously in Amsterdam, the same approach was be - outcomes for patients in very dire situations, Dotter had the opportunity to try his theory. Dr. Baum in Los Angeles were to apply the ing developed independently by Jim Reekers. this practice is not without risks, and IRs can 82-year-old Laura Shaw presented with a non- ideas behind angioplasty to GI and biliary disor - According to Dr. Bolia, “the greatest discovery learn more about how to minimise complica - healing ulcer and gangrenous toes. The recom - ders, while Anders Lunderquist in Sweden was in relation to the technique was the ‘loop’, for it tions and protect themselves from legal action mendation to amputate the foot was flatly re - exploring the use of IR in pancreatic tumours. was with the help of the loop, with which one by attending today’s Medico-legal issues and IR fused, and her surgeon figured if she was refus - could not only extend the dissection through Session in Auditorium 2. ing surgery, Dotter might as well have a look at New applications were continually being consi - the length of a long occlusion, but also make a her. The reason for the injury was established dered, and new devices were designed. Many re-entry distally into a patent lumen. Therefore, Every year at CIRSE, we showcase the latest to be an ideal lesion on which to perform per - IRs adapted existing catheters and guidewires the real innovation was the discovery of the advances. Some of these prove to be major cutaneous angioplasty, and she agreed to try it. themselves, but some more well-known IRs, such loop.” advances, such as irreversible electroporation; Within minutes of the procedure, her foot was as Charles Dotter, entered into partnership with others are small improvements, or alternatives warm, blood flowed easily, her pain disappear - companies like Cook Medical. Others, such as For over 25 years, the technique has been that expand the indications to include previ - ed within a week, and the ulcer soon healed. Kurt Amplatz, were eventually to set up their own re fined and perfected with the help of hydro - ously disqualified sub-sections of patients. But She died 3 years later of an unrelated heart companies to produce their tailor-made devices. philic and ‘J’ wires, to the point that TASC D all innovations, large and small, help drive for - complaint, with both feet still intact. lesions previously thought to be the domain of ward not only IR, but patient care as a whole. Gaining public acceptance bypass surgery can now be dealt with using Growing as a specialty subintimal angioplasty. It has also been used in The continued need for innovation is best But from the public’s perspective, the arrival of many other occlusions, such as flush superficial explained by the great pioneer, Dr. Josef Rösch: This new therapy built on the previous innova - a Swiss cardiologist, Andreas Grüntzig, was artery occlusions (SFA), long tibial occlusions, “Present day interventionalists have a more tions that had led to diagnostic angiography, what really brought interventional radiological reconstitution of bifurcations and trifurcations defined clinical practice, with numerous estab - notably the pioneering work of Sven Seldinger. procedures into the open. Grüntzig had adapt - and iliac occlusions, and has led to many spin- lished techniques, tools and devices to select He was the first to crack the conundrum of how ed Dotter’s techniques, and had developed the off inventions. from. Despite this, interventionalists should to safely and successfully introduce a catheter first balloon catheter capable of dilating peri - always be thinking about potential improve - into a blood vessel – a puzzle that radiologists pheral arteries. In February 1978, the Lancet The technique has a steep learning curve, and ments in present procedures or developing had worked on since 1940. In 1952, a flash of published the impressive results from his first many find it difficult to perform. Prof. Reekers new techniques. An innovative, creative mind inspiration urged Seldinger to try a new arrange - five balloon cases, and the medical world suggests that further innovation may hold the must be an integral part of every ment of the tried and failed needle-catheter- responded with unprecedented warmth. His key: “To overcome this hurdle, we have now interventionalist.” guidewire combination: needle-wire-remove high profile and technical developments added developed a device for subintimal recanalisa - needle-catheter. This deceptively simple break - momentum to the progress of interventional tion with some engineers in Delft, which will through was to revolutionise radiology. procedures. make this technique available for all IRs”.

Cardiovascular and Interventional Radiological Society of Europe C RSE coIngRress opening Ceremony and awards 3 news

opening Ceremony and awards – 14:30, auditorium 1

Welcome to CIrSE 2012, the largest Ir con - Gold Medal Excellence and Innovation Pedro Burmester | Piano gress of the year! once again, we have made every effort to put together a broad scientif - Peter Mueller ic programme, covering the whole spectrum Boston, MA/US of Ir, and featuring some of the world’s most inspiring researchers and lecturers.

But we also strive to honour those who have served the discipline well over their careers, and who have made staggering contributions to the field of interventional radiology. Amman Bolia Jim Reekers Join us today at 14:30 in Auditorium 1 for our Laudation: Andy Adam Opening Ceremony and Awards, with enter - tainment provided by the internationally Peter Mueller completed his medical training at The R.W. Günther Award for Excellence and In no - Internationally acclaimed pianist Pedro Burmester renowned piano soloist, Pedro Burmester. the University of Cincinnati, Ohio, USA, and his vation in IR celebrates one of the key aspects of studied with the great Helena Sá e Costa, grad - residency in radiology at Massachusetts Gene ral interventional radiology – that of innovation. It is uating from the Conservatory of Porto in 1981 Hospital, Department of Radiology, Boston, USA. privately funded by the R.W. Günther Foundation. with astonishing full marks. Later, he moved to Welcome Address In 1978 he started his interventional career in the United States, attending master-classes of the GI radiology section of Massachusetts This award was presented for the first time at the legendary pianists Vladimir Ashkenazy, Jörg Michael J. Lee, CIRSE President General Hospital, joining a team that was to last year’s Annual Meeting, and will this year be Demus, Karl Engel and Tatiana Nikolayeva. Paulo Almeida, CIRSE 2012 Local Host Committee develop a number of non-vascular radiology awarded to Dr. Amman Bolia and Prof. Jim Chairman procedures which are now considered routine, Reekers for their ground-breaking work in While still very young, he won awards in seve ral Robert Morgan, CIRSE 2012 Scientific Programme such as percutaneous biopsy, abscess drainage, subintimal angioplasty, a novel technique dis - competitions, including the Prix Moreira de Sá, Committee Chairman cholecystostomy, gastrostomy, biliary drainage, covered in 1988, which has also been referred second prize at the International Piano benign biliary drainage and percutaneous to as “temporary percutaneous bypass” (see Competition Vianna da Motta, and the jury ablation of liver and renal tumours. page 1). This technique was initially met with prize at the Van Cliburn Competition in the CVIR Editor’s Medal Award scepticism, and its acceptance required much United States. Prof. Mueller’s primary clinical and research in te - hard work on behalf of Dr. Bolia, Prof. Reekers Due to a continued increase in qualifying rests are in biliary intervention, abscess drain age and other admirers of the technique. However, He began his professional career at the tender articles, reader interest and author submissions , and percutaneous ablation of malignant tu mours it is now accepted as a useful procedure, and is age of ten, and since then he has performed the editorial board have decided to honour of the liver and kidney. Over the years, Prof. the standard technique for long occlusive le - over 1,000 solo concerts, as well as accompany - three author groups for their outstanding Mueller has been intimately involved with novel sions of the SFA and in critical limb ischaemia ing orchestras and various chamber music contributions to CVIR. techniques such as the Brown-Mueller T-Tack for (TASC D lesions). The technique is also applicable ensembles in Portugal and abroad. use in percutaneous gastrostomy and percutane - in long tibial occlusions, reconstitution of the Safety Profile of Sequential transcatheter ous gastro-jejunostomy and the Dawson-Mueller bifurcations and trifurcations and iliac occlusions. His discography includes the works of J.S. Bach, Chemoembolization with DC Bead™: results drainage catheter for fluid drain ages. He has pub - Anecdotally, subintimal angioplasty has been Schumann, Schubert, Beethoven and Chopin, a of 237 Hepatocellular Carcinoma (HCC) lished well over 300 ar tic les, se veral books and applied in subclavian, brachial, renal, profunda duo disc with Mário Laginha, and various re cor - Patients editorships, and given over 15 “nam ed” lectures and superior mesenteric artery occlusions. dings with the Metropolitan Orchestra of Lisbon. Katerina Malagari, Mary Pomoni, on interventional ra diology. He has served on Themistoklis N. Spyridopoulos, the editorial boards of many radiology journals, This technique has a steep learning curve, but He currently works as a professor at the Hippokratis Moschouris and Alexis Kelekis, et al. including Radio logy, The American Jour nal of a high success rate when performed correctly, School of Music and Performing Arts in Porto CardioVascular and Interventional Radiology, Roentgenology, Clinical Radiology and CVIR. and has played an important rate in improving (his hometown), at the University of Aveiro and 2011, Volume 34, Number 4, Pages 774-785 limb salvage rates. at the Professional School of Music of Espinho.

Superiority of transcutaneous oxygen tension Measurements in Predicting Limb Distinguished Fellow Distinguished Fellow Distinguished Fellow Salvage after Below-the-knee angioplasty: a Prospective trial in Diabetic Patients With Götz richter Małgorzata Szczerbo- kenneth thomson Critical Limb Ischemia trojanowska Ulf Redlich, Yan Y. Xiong, Maciej Pech, Jörg Tautenhahn and Zuhir Halloul, et al. CardioVascular and Interventional Radiology, 2011, Volume 34, Number 2, Pages 271-279

renal artery Embolization Combined With radiofrequency ablation in a Porcine kidney Model: Effect of Small and narrowly Calibra t ed Microparticles as Embolization Laudation: Johannes Lammer Laudation: José Ignacio Bilbao Laudation: Michael J. Lee Material on Coagulation Diameter, volume, and Shape A native of Stuttgart, Germany, Goetz Richter Małgorzata Szczerbo-Trojanowska has worked Ken Thomson is Professor and Director of Radio - C. M. Sommer, N. Kortes, S. Zelzer, F. U. Arnegger, went to medical school in Freiburg, completing at the Department of Vascular and Inter ven tio nal logy at the Alfred Hospital, Melbourne, where he U. Stampfl, N. Bellemann, T. Gehrig, F. Nickel, his residency in both general pathology and Radiology, Medical University Lublin since 1972, has worked since 2000. He started his radio logy H. G. Kenngott and C. Mogler, et al. radiology. In 1988, he joined the Department but during her training in interventional radio - training in Perth, Western Australia and finished CardioVascular and Interventional Radiology of Radiology at Heidelberg University, where logy, visited a number of renowned centres ab - in Christchurch, New Zealand, before becoming 2011, Volume 34, Number 1, Pages 156-165 he became a professor in 1998, and served as road. In 1985 she was promoted to associate a Teaching Fellow at UBC, Vancouver, Canada in vice-chairman of the Department of Diagnostic professor, followed by a full professorship in 1974. There he studied chest radiology, before Radiology from 1993-2008. Since 2009, he has 1993. Since 1995 she has been Head of the taking up cardiovascular angiography and in - headed the Department of Diagnostic and Department of Interventional Radiology at the terventional radiology in Rochester, New York. Interventional Radiology at the Klinikum Medical University in Lublin, and since 1999, has Stuttgart. He has written 207 publications, also been Chairman of the Department of During his stay in North America, he developed 1 book edition and 51 book chapters. Radiology. a long-term working relationship with Bill Cook and Cook Australia. In 1977 he returned to Prof. Richter has pioneered numerous proce - Prof. Szczerbo-Trojanowska is an active member Australia, and in 1979, founded the Interven tio nal dures, introducing capillary embolisation in of numerous Polish and international medical Radiology Society of Australasia (IRSA). In 1981, renal tumours (1984), placing the first iliac stent societies, with a string of awards to her name, he accepted the position of Head of Inter ven tio - in man (1987), the first renal stent in man (1988), as well have having presided over many con - nal Radiology at the Royal Melbourne Hospital. and the first TIPSS in man (1988). Prof. Richter gresses and societies, including the ECR 2010. also performed the first EVAR in Europe at She has published over 200 papers in scientific Prof. Thomson successfully investigated several Heidelberg University in 1993. From 1990-1995, journals, as well as serving as an editorial board devices with first-in-human experience. He has he conducted the Clinical Embosphere Pilot member for many radiological and medical published over 120 articles and is one of the Study on UFE in Germany. Prof. Richter con - journals, CVIR among them. She is committed editors of Image Guided Intervention. He has tinues to be extremely active in both clinical to education and was involved in setting up given lectures on every continent, often per - and academic IR, focusing above all on vascular and hosting the first ESIR courses in Eastern forming live demonstration procedures. He has stenting and recanalisation techniques. Europe. Her main fields of interest are vascular been deeply involved with many societies, interventions: embolisation, carotid stenting notably RANZCR, the Asia-Pacific Society of and aortic aneurysm stent grafting. Cardiovascular and Interventional Radiology and the Asian Oceanian Society of Radiology.

Cardiovascular and Interventional Radiological Society of Europe C RSE 4 off-label Use of Devices Saturday, September 15, 2012

Don't miss it ! Medico-legal issues and Ir Special Session off-label use of devices Saturday, September 15, 08:30-09:30 Interview with Tony Nicholson (EBIR) Auditorium 2

tony nicholson cedure on a patient. The stent graft malfunctions The early use of Wallstents in Superior Vena Ca - pre-procedural documentation and a discus - (EBIR) and cannot be released, resulting in either a val obstruction and the use of thrombin in iatro - sion with the departmental risk assessment Leeds General Infirmary, prolonged and far more complex procedure, or genic pseudoaneurysms are two innovative team. The patient and family should have a wit - Leeds, UK possibly open surgery. The patient does not do techniques that have helped many thousands nessed discussion and explanation of why the well. The family takes legal action. The family of patients. Both were and are used off-label. device is planned to be used off-label. If inno - lawyers ideally want to sue the company – after vation is necessary in the acute situation, the all, it is their device that has malfunctioned. The However, I have also had to advise in several details should be documented and later, if nec - company will naturally do all it can to defend medico-legal cases where the off-label use of essary, discussed with the patient, especially if itself and prevent that from happening. They thrombectomy devices to clear prosthetic and anything is to be left behind in the patient. All Dr. Tony Nicholson studied biochemistry, micro - quickly discover that the operator used a parti - native arteries has resulted in distal limb embo - practitioners should know what procedures biology and pharmacology before switching to cular type of stiff wire that they do not recom - lisation and amputation. Such cases are usually require off-label use. Thrombin for pseudoa - medicine. Following some registrar posts in medi - mend. It is a perfectly fine stiff wire and is the not defendable, especially if used off-label for neurysms is a good example. Documented cine and surgery, Dr. Nicholson studied radiology usual support wire used for many years by the the first time by the operator without inform - agreement with the hospital risk department at the University Hospital of Wales, and completed operator. The operator doesn’t realise that he ing the “team“ or more importantly, the for its use should be organised. his IR Fellowship in Cardiff and at the University has not been following the instructions for use patient. of California, San Diego. His broad scientific back - (IFU) of the stent graft as, like most of us, he/she Q: If an Ir does establish that a device is ground has made him an important voice for edu - has ignored the small print. It is then likely that Q: there is a long history of necessary expe - appropriate for an off-label application, cation and clinical evidence within IR. He is a for - the company will defend itself by blaming the rimentation in the field of Ir – is experimen - what steps should they or their mer President of the BSIR and former Dean and off-label insertion and release of the device. The tation an integral part of the discipline, or representative bodies take? Vice- President of the RCR, as well as having held lawyers will likely then look at the operator and now that a significant body of evidence has nume rous posts within CIRSE over the years. the hospital where the procedure was carried been gathered, should further experimenta - A: Documentation and discussion with colleag - out in order to get compensation for the family. tion be discouraged? ues. A technical report perhaps. Maybe a well- Dr. Richard McWilliams (EBIR) is an IR at the Royal Things can turn very nasty with not only the fa- organised single centre study. Ask to speak to Liverpool University Hospital, where he specialises mily’s lawyers, but also the company’s lawyers A: Experimentation remains an integral part of people in authority at the company to see if in vascular interventions and clinical practice. He aggressively questioning the operator. The the discipline and in an emergency situation, they will apply for its acceptance in this situa - has previously attended CIRSE as a speaker, mod - hospitals lawyers might also decide to protect spontaneous innovation without informed con - tion and make it an on-label function. However, erator and Hands-on Workshop instructor, and the hospital by heaping blame on the operator. sent is acceptable. However, if things go wrong, always remember that the successful use of a will be delivering this year’s lecture on the off- a full record of the events – what was done and device or technique on just a few occasions is label use of devices. Am I exaggerating and making a big deal over why – must be made immediately after the not a means of assessing the potential risks something that is unlikely to happen? As several case whilst everything is fresh in the mind. and complications. That will only come when a recent cases in Europe and other parts of the procedure has been done a thousand times! Unfortunately, Dr. nicholson will no longer world testify, this is not as unlikely as it may at In the elective situation, there must always be a For instance, the use of endoscopic biopsy for - be able to at tend CIrSE 2012, but his first sound. I don’t blame the company, but plan. If that plan includes the potential use of ceps has been advocated to get irretrievable esteemed colleague, Dr. richard McWilliams interventionists need to be aware of how they equipment and devices off-label, the plan must IVC filters out of the cava. It has been done suc - from Liverpool, will share his views and can protect themselves. be discussed with colleagues; the hospital risk cessfully, but has also been reported as having expertise on the off-label use of devices assessment team should be informed; and the potentially very bad complications. Do we know instead. Be sure to join us for an inspiring Q: What are the incentives for going off- patient and family must be informed. The com - the risk and benefit of trying this as op posed to session! label? What positive outcomes does it have? pany could be contacted and informed, but leaving the filter alone? We do not and proba - ultimately this will have no bearing on their bly never will, because it is likely that not all Q: How widely employed do you estimate A: Interventional radiologists have always been conduct if things do go wrong. All of the above complications will be reported. Only successes. off-label use of Ir devices to be? amazingly innovative and have invented many should be documented. The use of an aortic new devices and technologies. They have also cuff to fix a surgical dehiscence in the ascend - Q: Can device manufacturers themselves A: I believe that hardly a day goes by in any ho - used many devices for the benefit of patients ing aorta is the latest example of this in my play a role in best managing the legal/moral spital anywhere in the world where devices are in innovative ways. Innovative use of catheters, own department. grey area of off-label device use? not used off-label. This can vary from simple wires and other devices has got many a patient things like altering the shape of a wire, to the out of trouble. I remember many years ago Q: What advice would you give to young Irs A: I think it is time for CIRSE, as a representative use of a device for a purpose entirely different being called to a cardiac cath lab in a hospital who are looking to use devices experimen - body, to enter into discussion with companies than it was intended for. In many cases, the which did not have any IR. They had lost a tally – what steps should they take to ensure about the overly specific nature of their IFUs operator does not realise that the device is be - catheter in the right ventricle. There was minor (a) patient safety and (b) they are legally and to discuss the relationship between IR and ing used off-label, and the operator may have panic, and the cardiac surgeons were licking protected? the companies in this regard. After all, the com - been using it in a particular way or for a partic - their lips. They had no retrieval devices in the panies are happy to see results published and ular purpose for many years. All of this is fine cardiac cath lab, so using a standard support A: I think we should distinguish between the to sell their equipment on the back of such and much to the patient’s benefit, as long as wire doubled up and an 8 Fr right coronary word experimental and innovative. The place publications, but are very reluctant to update nothing goes wrong. However, if there is a catheter, I managed to retrieve the catheter. I for experimentation is in the laboratory or as and change their IFUs on this basis. Also when problem and the patient comes to harm, any recently attended the retirement party of that part of a properly constituted trial. We are talk - they do change their IFU, they often do so after subsequent legal action will be complicated by particular cardiologist, who typically had no ing about the innovative use of equipment and an adverse event and do not always advertise the off-label use. recollection of the incident! devices to achieve specific goals for the benefit the fact. There are multiple examples of that of the patient, and this is different. No patient happening, and it leaves the operating IR in a Q: What are the potential drawbacks and Q: What sort of outcomes have you had likes to be experimented on, especially when very bad position if something goes wrong and legal implications? using Ir devices off-label? they are sick. there has been a change in IFU of which he/she is unaware. The relationship between doctor A: Let us suppose an interventional radiologist A: There are many examples where off-label de - As stated above, I think elective innovation re - and company needs to be a two-way street is performing an endovascular stent graft pro - vice use has been to the advantage of pa tients. quires discussion as part of the team. It requir es and there needs to be trust.

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Special Edition / CIRSE 2012 - Lisbon coIngRress thrombectomy of Clotted Dialysis access 5 news

Don't miss it ! DHigalhy-siinst aecncseitsys fmocaunsaegde muletrnat sound thrombectomy of clotted dialysis accesses: glory and despair in Special Session Saturday, SOecptotebmerb 2e,r 1 105:0, 101-1:310:0-10 2:30 prosthetic grafts, despair and glory in autogenous fistulas ASaulda i3toF rium 6 Luc Turmel-Rodrigues (EBIR)

The answers to the most frequently asked History Luc turmel-rodrigues questions: Published clinical outcomes data suggest open (EBIR) · Thrombolytic drugs are not necessary when surgery confers comparable results to percuta - Clinique St-Gatien it comes to declot a dialysis fistula or graft. neous endovascular methods in thrombosed Tours, France Mechanical techniques are effective and prosthetic grafts, but frequently poorer and more rapid. often dismal results in forearm and upper arm · Fistula thrombectomy is usually a 1-2 hour native fistulas. The earliest publications on per - outpatient procedure and immediate cannu - cutaneous thrombectomy of dialysis accesses lation for dialysis is then feasible. go back to the mid '80s [12-13]. It was perform - Fig. 1: This thrombosed 4-year-old left transposed · Expensive thrombectomy devices are not ed predominantly on thrombosed prosthetic (as evidenced by the long surgical scar) radial fis - Dr. Turmel completed his fellowship in the Depart - necessary, basic manual aspiration works. grafts in tandem with prolonged urokinase or tula shows some aneurysmal formation in its can - ment of Cardiovascular Radiology of Paris Broussais · A thrombosed fistula or graft can be declot - streptokinase thrombolysis. nulation zone, which facilitates blind cannulation. Hospital under Prof. Gaux. He has published nu - ted up to 1 month after onset of thrombosis. me rous articles on dialysis fistula interventions in · There is always a tight underlying stenosis However thrombolytic therapy had a number major radiology and nephrology journals. He is when a native fistula clots. of shortcomings: ineffective in resistant throm - the main author of a textbook on “Diagnostic · Isolated thrombosis of a needling site bi, contraindicated in patients with recent sur - and Interventional Radiology of Dialysis Access”, aneurysm may not warrant intervention. gery, cerebral pathologies or severe hyperten - to be published in autumn 2012. He was a found - · Thrombosis within 1 month of access crea - sion. Dialysis needling points tended to ooze ing member of the French Society for Vascular Ac - tion surgery is rarely a reasonable indication incessantly. Pulse-spray thrombolysis appeared cess (1992) and of the European Vascular Access for percutaneous intervention. in 1989 to render infusion of thrombolytics Society (1999). He was the chairman of several shorter and offer a mechanical means of dis - international meetings held in Tours and Nice. Background rupting resistant and remnant thrombi [2]. It Percutaneous thrombectomy of thrombosed later became apparent that almost equivalent dialysis prosthetic grafts is usually relatively results could be obtained when saline was easy, but every experienced interventionist has used as a propellant instead of urokinase [3]. a story to tell regarding cases of native fistulas that took an inordinately long time to perform The realisation that results were due to the me - (more than 2 hours) and in the end failed. chanical effects of the spray rather than the pharmacologic effect of the thrombolytic agent All thrombectomy techniques may work in was the most crucial factor. However, concerns gore-tex grafts, given that the modest amount soon arose that thrombi dislodged by the sa - of thrombus (3.2 ml on average) [1], including line spray technique automatically ended up in Fig. 2: Through an antegrade cannulation of the Fig. 5: The 50 ml Vaclok syringe locked in residual thrombi after attempts at removal by the pulmonary circulation. These grew de spite thrombosed vein, a catheter is advanced over a aspiration mode fills up with a mixture of more or less effective devices or drugs, can be Scott Trerotola’s bold assertion in 1994 that the guidewire into the central veins and then gradually thrombi and fresh blood. simply pushed into the lungs, with very little average 3.2 mL of thrombi contained in any withdrawn as small boluses of iodinated contrast (but not zero) risk of severe complications. thrombosed gore-tex graft could be de - are slowly and gently injected. There are thrombi Pro sthetic grafts are thus easy to declot – this liberately pushed into the venous outflow by a seen in the arterialised vein segment from just above is their glory – but they are at high risk of Fogarty thrombectomy catheter without trig - the elbow, whilst the upper arm cephalic and basilic re thrombosis within 1 month of endovascular gerring any symptomatic pulmonary embolism veins are well opaficied and therefore remain patent. thrombectomy (20 to 68% of grafts depending [1]. However, the belief that iatrogenic emboli on the series) [2-10] – which is our despair... emanating from dislodged thrombi fragments were harmless soon proved erroneous, after In contrast, percutaneous recovery of throm - se veral anectodal reports of complications (some bosed native fistulas may be occasionally pun - fatal, like bronchospasm, respiratory failure, pa - ishingly long, and no amount of shortcuts or radoxical embolic cerebral infarct and systemic tricks can guarantee success. This may be our septic emboli) started emerging [14-16]. despair. However, once clinical success is achieved, the risk of early rethrombosis is low In Europe, the focus of percutaneous throm - and long-term cumulative patency rates are bectomy was mainly on thrombosed native high for years [11]. This is their glory. AVFs and, to a much lesser extent, grafts. The use of thromboaspiration as an adjunct therapy Autogenous fistula thrombectomy is thus a to urokinase thrombolysis was first published task that should certainly not be entrusted to in 1991 [17]. Thrombolysis was soon abandon ed the most junior member of a team, since a high as thromboaspiration alone was found to be Fig. 6: Having freed the more downstream seg - level of experience and astuteness in endovas - equally effective in clearing thrombi [4] ment of the vein of thrombi, contrast is seen to cular skills is mandatory, particularly for the (Figs. 1-11). Meanwhile, a number of expensive collect an outflow stenosis (arrow) which is the management of complications, which can be and innovative mechanical thrombecomy de - cause of the thrombosis. The task is now to aspi - serious when the AVF is branched onto the vices and gadgets came on the market world - rate the upstream thrombi near the anastomosis brachial artery (hand ischaemia). wide: Hydrolyser, Amplatz-Thrombectomy via the “arterial” introducer-sheath. device, Angiojet, Craggbrush, Arrow Trerotola Challenges in native fistulas percutaneous thrombectomy device, etc. [5-10]. Thrombectomy of native fistulas is subject to These devices thrived, despite the re-emergence variations in approach and technical difficulties on the scene of Urokinase thrombolysis in the depending on their configuration and anatomi - form of the ‘lyse and wait’ technique in 1997 cal particularities [11]. For instance, the arteria - [17]. In this technique, urokinase is injected Fig. 3: Through a retrograde puncture of the throm- lised vein diameter may be too small for access either blindly or under ultrasound guidance bosed vein, a catheter is advanced into the anas - by guidewire or catheter. It may be difficult to into the access just before the patient enters tomosis. Injection of contrast there shows a pa - reach the arteriovenous anastomosis because the interventional suite. After an hour or so of tent proximal artery perfusing its distal segment. the guidewire repeatedly strays into abundant lysis, the residual thrombi are effectively collaterals. It may be difficult to clinically locate pushed into the pulmonary circulation [18]. the underlying culprit (stenosis) as it can be anywhere between the anastomosis and cen - It was only in 2000 that a French series showed tral veins. The venous stenosis may be long or for the first time that autogenous accesses (in heterogeneous, and thus difficult to cross with this case predominantly forearm AVFs) could a guidewire. The clot burden may be substans - be treated by thromboaspiration with a high tial (30-50 mL). Aneurysms may be sizable in rate of success [11]. Other groups reported number and may harbour very adherent and around the same period that thrombosed AVFs mummified mural thrombi. The guidewire may could be percutaneously declotted by simply easily coil up in the aneurysmal sac, making it dilating the adjacent stenosis and allowing the Fig. 4: This picture shows two 8 Fr introducer- Fig. 7: This angiogram shows the aspiration challenging to catheterise the normal vein fur - thrombi to embolise into the pulmonary circu - sheaths after placement in opposite direction into ca theter in contact with thrombi near the anasto - ther upstream or downstream to it. The termi - lation, sometimes after disrupting them with a the thrombosed vein, with a venous ‘safety’ guide - mosis. The arterial ‘safety’ guidewire can be seen nal end of the radial artery may be equally rotating mini-pigtail catheter, a practice cer - w ire shown (arrow) coming directly off the skin across the anastomosis with its tip in the brachial thrombosed in forearm AVFs with end-to-end tainly unthinkable and unfeasible in aneurysmal puncture but alongside to the introducer sheath. or axillary artery. anastomoses, rendering thrombi disruption AVFs, which usually have a high thrombus especially challenging. volume [19-20]. continued on page 7 >>

Cardiovascular and Interventional Radiological Society of Europe C RSE

coIngRress taCE and radioembolisation / Dialysis access 7 news

Don't miss it ! Hepatocellular carcinoma: the spectrum taCE and radioembolisation: competitors or complementary? of interventions Special Session Thomas Helmberger (EBIR) Saturday, September 15, 11:30-12:30 Auditorium 8

According to several current, national and inter - Data on transvascular radioembolisation (RE; also thomas Helmberger a national guidelines for the treatment of HCC, the known as SIRT – selective intra-arterial radio- (EBIR) treatment algorithm is determined mainly by the embolisation therapy) in HCC have been avail - Klinikum Bogenhausen size and number of hepatic tumours and the pa - able now for more than 15 years, showing that Munich, Germany tient's performance conditions. Follow ing these similar results to local thermal ablative tech - guidelines, an estimated 20% of patients are can - niques could be achieved by super-selective RE. didates for a locally defined removal of the tu - However, in comparison to local ablation thera - mour(s) by ablative or resecting methods inclu - pies including TACE, the complexity of the RE ding liver transplantation, since tumour load is procedure in terms of radio-protection issues, limited and liver function largely preserved. handling, and costs may rank RE as not yet be - Prof. Thomas Helmberger is Head of the Institute ing the first choice in the treatment of locally for Diagnostic and Interventional Radiology at b However, the majority of the patients will pres - limited HCCs. the Klinikum Bogenhausen in Munich, Germany ent with an advanced tumour stage, hindering and a leading specialist in minimally invasive sufficient tumour control by minimally invasive Nevertheless, recent data are indicating that tumour therapies. A founding member of the or surgical treatment. In these cases, transarter - there could be an increasing role for RE com - German Society for IR (DeGIR), he is also an active ial techniques are mainly applied. Even though pared to TACE, due to less post-procedural CIRSE member, having acted as Co-Chairperson these techniques have been in use for more than abdominal pain, less frequency of post-ablative for last year’s CIRSE Congress in Munich. During 30 years, there is no general consensus on how syndrome [1, 2], reduced length of hospital this congress, his active co-operation with CIRSE’s transarterial chemoembolisation/embolisation stay [3], improved down-staging and increased publications department facilitated extensive (TACE, TAE) should be performed. In conse - median survival [4, 5]. In consequence, there press coverage of the event, as well as a hugely quence, substantial data exist on TACE, but also could be an extended role for RE in patients Fig. 1: 64-year-old male patient with history of successful Student Programme. quite a variety of technical regimens (e.g. em bo - not amenable to TACE (e.g. extended bilobar alcohol-induced liver cirrhosis and advanced lisation with Lipiodol only, Lipiodol + partic les, disease, multinodular disease, portal vein inva - multifocal, multinodular HCC (Child-Pugh A, BCLC · Recchia, F., et al., Chemoembolization of unresectable hepatocellu lar different particle sizes, lobar-, segmental-, tu - sion, previously failed TACE/TAE). stage C). CE-MRI (Gadoxetic acid hepatacytic carcinoma: Decreased toxicity with slow-release doxo rubicin elu ting mour-selective administration, etc.), blurring the phase) (a) prior to RE; (b) 3 months after RE (2,2 beads compared with lipiodol. Oncol Rep, 2012. 27(5): 1377-83. · Ray, C.E., Jr., et al., Interventional radiologic treatment of hepato - evidence on the therapeutic efficacy of TACE. Comparing TACE and RE, it seems that both ab - GBq, approx. ¾ of the dosage to the right, ¼ to cellular carcinoma-a cost analysis from the payer perspective. lative techniques might be complementary in the left liver lobe: partial response in terms of J Vasc Interv Radiol, 2012. 23(3): 306-14. · Radeleff, B.A., et al., [Transarterial ablation of hepatocellular car ci - Nevertheless, meta-analysis of TACE studies can targeting the same tumour stage according to reduced number of tumours, reduced perfusion, noma. Status and developments]. Radiologe, 2012. 52(1): 44-55. prove superiority over best supportive care in ad - different functional and performance stages of and secondary hypertrophy of the left liver lobe). · Perez-Rojas, E., Interventional radiology in oncology: clinical management of patients undergoing transarterial chemoemboliza - vanced HCC cases, and a 1-year survival rate of the liver and of the patient, respectively, due to tion for hepatic malignancies. Clin J Oncol Nurs, 2012. 16(1): 83-5. references: · Lencioni, R. and L. Crocetti, Local-regional treatment of hepato - 85-100% in smaller tumours (< 5 cm) and at least different modes of operation. There is still a lack 1. Salem R, et al. Gastroenterology. 2011;140:497-507. cellular carcinoma. Radiology, 2012. 262(1): 43-58. of up to 80% in larger or multiple tumours of of RCTs regarding the best technique(s) in deli - 2. Goin J, et al. World J Nucl Med. 2004;3:49-56. · Wiggermann, P., et al., Transarterial Chemoembolization of Child - A 3. Kooby DA, et al. J Vasc Interv Radiol. 2010; 21:224-30. hepatocellular carcinoma: drug-eluting bead TACE (DEB TACE) vs. TA - Child-Pugh A patients. In more ad vanced ca ses, vering TACE and RE, and the competing and 4. Iñarrairaegui M, et al. Int J Radiat Oncol Biol Phys. 2010;77:1441-8. CE with cisplatin/lipiodol (cTACE). Med Sci Monit, 2011. 17(4): 189-95. the liver function – characterised by the Child- complementary effects of the different compo - 5. Lewandowski, RJ, et al. Am J Transpl. 2009;9:1920-8 · Salem, R., et al., Radioembolization results in longer time-to-pro - gression and reduced toxicity compared with chemoembo - Pugh class (B or C), presence of ascites, and eleva - nents of each technique concerning embolisa - Further references: lization in patients with hepatocellular carcinoma. Gastroenter - t ed bilirubin (> 3 mg/L) – and the tumour – cha - tion (e.g. particle size) in both techniques, drug · Xie, F., et al., Comparison of transcatheter arterial chemoem - ology, 2011. 140(2): p. 497-507 e2. bolization and microsphere embolization for treatment of unre - · Sangro, B., et al., Survival after 90Y resin microsphere radio - racterised by number (≥ 3), size (≥ 5 cm), type of release in TACE (e.g. drug-eluting particles), lo - sectable hepatocellular carcinoma: a meta-analysis. J Cancer Res embolization of hepatocellular carcinoma across BCLC stages: spread (multinodular, diffuse, bilobar, extrahepat - cal radiation doses in RE (e.g. local/focal vs. glo - Clin Oncol, 2012. 138(3): 455-62. A European evaluation. Hepatology, 2011; 54: 868-878. · Sangro, B., M. Inarrairaegui, and J.I. Bilbao, Radioembolization for · Inarrairaegui, M., et al., Analysis of prognostic factors after yttri - ic, portal vein invasion), and elevated α- fetopro - bal), and optimal patient selection for TACE and hepatocellular carcinoma. J Hepatol, 2012. 56(2): 464-73. um-90 radioembolization of advanced hepatocellular carcinoma. tein (≥ 400 ng/mL) – are determining and limiting RE. Furthermore, deeper insight is needed into · Ritter, C.O., et al., Spontaneous liver rupture after treatment with Int J Radiat Oncol Biol Phys, 2010. 77(5): 1441-8. drug-eluting beads. Cardiovasc Intervent Radiol, 2012. 35(1): · Lewandowski, RJ., et al., A comparative analysis of transarterial the outcome in TACE procedures negatively. the potential use of new drugs and biologicals 198-202. downstaging for hepatocellular carcinoma: chemoembolization (e.g. sorafinib) in combination with TACE and RE. versus radioembolization. Am J Transplant 2009; 9: 1920-1928.

Thromboaspiration remains the main percuta - spasm associated with iatrogenic pulmonary references: >> 1. Trerotola S, Lund G, Scheel P et al. (1994) Thrombosed hemo - neous method of declotting thrombosed AVFs emboli. Antibiotic prophylaxis reduces the like - dialysis access grafts: percutaneous mechanical declotting with - in France, despite the emergence of other lihood of severe sepsis arising from septic em - out urokinase. Radiology 191:721-726. 2. Bookstein J, Fellmeth B, Roberts A et al. (1989) Pulsed-spray mechanical techniques worldwide. The Arrow- boli dislodged from infected mural thrombi or pharmacomechanical thrombolysis: preliminary results Trerotola device and the Angiojet are the breach in aseptic precautions. Am J Roentgenol 152:1097-1100. 3. Beathard G. (1996) Mechanical thrombolysis for the treatment of currently preferred devices in the US. thrombosed hemodialysis access grafts. Radiology 200:711-716. 4. Turmel-Rodrigues L, Sapoval M, Pengloan J et al. (1997) Manual thromboaspiration and dilation of thrombosed dialysis access: Contraindications to percutaneous mid-term results of a simple concept. J Vasc Interv Radiol 8:813- 824. thrombectomy 5. Overbosch E, Pattynama P, Aarts H et al. (1996) Occluded hemo - Temporary contraindications include fluid over - dialysis shunts: Dutch multicenter experience with the Hydrolyser catheter. Radiology 201:485-488. load and severe hyperkalemia > 6 mmol/L. 6. Trerotola S, Vesely T, Lund G et al. (1998) Treatment of throm - bosed hemodialysis access grafts: Arrow-Trerotola percutaneous thrombolytic device versus pulse-spray thrombolysis. Radiology Access infection (much more common in 206:403-414. prosthe tic grafts) is an absolute contraindication 7. Dolmatch B, Castaneda F, Mc Namara T et al. (1999) Synthetic dialysis shunts: thrombolysis with the Cragg thrombolytic brush to thrombectomy. An indurated tender skin catheter. Radiology 213:180-184. seg ment over a thrombosed AVF may indicate 8. Sofocleous C, Cooper S, Schur I et al. (1999) Retrospective com - parison of the Amplatz-Thrombectomy-Device with modified more an inflammatory process (thrombo - pulse-spray pharmacomechanical thrombolysis of the throm - phlebitis) rather than infection. Fig. 10: The completion angiogram of the venous bosed hemodialysis access grafts. Radiology 213:561-567. 9. Vesely T, Williams D, Weiss M et al. (1999) Comparison of the outflow is satisfactory after dilation. AngioJet rheolytic catheter to surgical thrombectomy for the Relative contraindications include accesses of treatment of thrombosed hemodialysis grafts. J Vasc Interv Radiol; 10:1195-1205. less than 1 month old, significant cutaneous ne - Fig. 8: This angiogram after additional aspiration 10. Barth K, Gosnell M, Palestrant A et al. (2000) Hydrodynamic crosis, AVFs which have never successfully been does not show evidence of residual thrombi. The thrombectomy system versus pulse-spray thrombolysis for thrombosed hemodialysis grafts: a multicenter prospective needled, AVFs which have recently undergone stenosis can now be dilated. randomized comparison. Radiology 217:678-6841- surgical revision (less than a month), the pres - 11. Turmel-Rodrigues L, Pengloan J, Rodrigue H et al (2000) Treat - ment of failed native arterio-venous fistulae for hemodialysis by ence of large aneurysms on the arterialised vein interventional radiology. Kidney Int 57:1124-1140. 12. Hunter D, Castaneda-Zuniga W, Coleman C et al. (1984) Failing (> 5cm in diameter), and a right-to-left shunt in arteriovenous dialysis fistulas: evaluation and treatment. the form of patent foramen ovale (a rare occur - Radiology152:631-635. 13. Zeit R, Cope C (1985) Failed hemodialysis shunts: one year of rence in adults). Severe respiratory failure is con - experience with aggressive treatment. Radiology154:353-356. sidered a relative contraindication to percuta - 14. Swan T, Smyth S, Ruffenach S et al. (1995) Pulmonary embolism following hemodialysis access thrombolysis/thrombectomy. J neous thrombectomy, due to the risk of pulmo - Vasc Interv Radiol 6:683-686. nary embolism, which can further com pound an 15. Owens C, Yaghmai B, Aletich V et al. (1998) Fatal paradoxic embolism during percutaneous thrombolysis of a hemodialysis already compromised respiratory reserve. graft. Am J Radiol 170:742-744. 16. Briefel G, Regan F, Petronis J (1999) Cerebral embolism after mechanical thrombolysis of a clotted hemodialysis access. A thrombosed fistula can be declotted up to Am J Kidney Dis 34,2:341-343. 1 month after onset of acute thrombosis. 17. Poulain F, Raynaud A, Bourquelot P et al. (1991) Local thrombol - ysis and thromboaspiration in the treatment of acutely throm - However, the fresher the clots, the easier the bosed arteriovenous hemodialysis fistulas. Cardiovasc Intervent thrombectomy is. Radiol 14:98-101. 18. Cynamon J, Lakritz P, Wahl S et al. (1997) Hemodialysis graft Fig. 11: Completion angiogram of the anastomosis declotting: description of the "Lyse and Wait" technique. J Vasc Heparin (on average 3000 IU per dose) and pro - however shows a remnant thrombotic plaque Interv Radiol 8:825-829. 19. Zaleski G, Funaki B, Kenney S et al. (1999) Angioplasty and bolus phylactic antibiotics (e.g. Cefazolin 1g) are ad - which should be left alone, given it is less likely to urokinase infusion for the restoration of function in thrombosed ministered intravenously before start of every Fig. 9: The stenosis is dilated with a 10 mm detach, em bolise downstream and cause early Brescia-Cimino dialysis fistulas. J Vasc Interv Radiol 10:129-136. 20. Schmitz-Rode T, Wildberger J, Hübner D et al. (2000) Recana li za - single procedure. Heparin inhibits broncho - Conquest® balloon at inflation pressure of 30 atm. access rethrombosis. tion of thrombosed dialysis access with use of a rotating mini- pigtail catheter: follow-up study. J Vasc Interv Radiol 11:721-7.

Cardiovascular and Interventional Radiological Society of Europe C RSE coIngRress Paediatric Ureteric Interventions 9 news

Don't miss it ! Paediatric Interventions Paediatric percutaneous nephrostomy and ureteric interventions Special Session Saturday, September 15, 10:00-11:00 Belarmino J. Gonçalves Room 3A

Urologic interventions are now performed in Belarmino J. Gonçalves the majority of centres by urologists. But some Portuguese Institute of specialised Interventional Radiology Units have Oncology (IPO) kept their skills over time. We have to remember Porto, Portugal that patients benefit from a multidisciplinary team, concerning both the complexity of the propos ed interventions and the ability to manage challenging cases. Angiographic skills al low the interventional radiologist to “deal” with the kid ney and the ureter as a vessel, Dr. Belarmino Gonçalves is an IR at Portugal’s performing such techniques safely and without foremost oncology institute, where he is the Angio - complications. For example, we can access the graphy Section Chief of the Department of Inter - non-dilated system easily and following a ventional Radiology. His department specialises, correct technique. Paediatric patients also have naturally, in oncologic interventions, as well as a diffe rent ap-proach according to the disease other hepato-biliary and musculoskeletal inter - condition. ventions, and haemodialysis access. Dr. Gonçalves and his colleagues have recently Percutaneous nephrostomy conducted a 4-year study into the use of The majority of nephrostomies are performed ePTFE/FEP-covered metallic stents in the treat - in a dilated kidney with significant degree of ment of biliary anastomotic stenosis and fistulae, obstruction, depending of the kidney function which he presented at this year’s SIR meeting in impairment or infection. In these cases, easy San Francisco. Dr. Gonçalves is a Member of the access is obtained using US-guided puncture Local Host Committee for this year’s CIRSE Annual through a distended calyx. But in some proble - Meeting. matic cases, such as the presence of a urinary Fig. 1: Percutaneous Nephrostomy: needle tract puncture of a non-dilated pelvicalyceal system. fistula (vesicovaginal, vesicorectal, uretrovagi - nal, ureteroenteric or ureterovaginal) or a low Malignant obstructions and benign chronic stric - references: 1. Barnacle AM et al. (2011) Paediatric Interventional Uroradiology. degree of obstruction, calyceal kidney punc - tures of the surgical ureteric anastomosis can Cardiovasc Intervent Radiol 34:227-240. ture may be challenging. In the available litera - be treated. Tight distal ureteric strictures can 2. Keeling AN, Lee MJ (2007) Crossing Ureteric Strictures: Microcatheters to the rescue when conventional methods fail. ture, the success rate ranges from 80-95%. be one of the most challenging to cross, even Cardiovasc Intervent Radiol 30:1234-1237. 3. Mandell VS, Mandell J, Gaisie G (1985) Pediatric urologic radio - Usually it can be initially made by US-guidance from above the obstruction (by nephrostomy logy. Intervention and endourology. Urol Clin North Am 12: with a tri-axial introducer kit (including a 22 G access). Sometimes special guidewires (0.014’’ 151-168. 4. Farrell TA, Hicks ME (1997) A review of radiologically guided Chiba-type needle, a 0.018’’ guidewire and 6 Fr or 0.016’’), low profile angioplasty balloon-ca - percutaneous nephrostomies in 303 patients. J Vasc Interv tri-axial catheter). In a second step, fluoro-guid - theters or microcatheters might be needed. Radiol 8:769-774. 5. Hogan MJ, Coley BD, Jayanthi VR et al (2001) Percutaneous ance with contrast agent injection in the After balloon ureteroplasty, a JJ stent can be in - nephrostomy in children and adolescents: outpatient calyceal system is useful to dilate and confirm serted to re-establish the normal urinary flow. management. Radiology 218:207-210. 6. Koral K, Saker MC, Morello FP et al (2003) Conventional versus correct needle position and to avoid multiple modified technique for percutaneous nephrostomy in new - punctures. An alternative technique is to inject For relapsing urinary stenosis and to avoid JJ borns and young infants. J Vasc Interv Radiol 14:113-116. 7. Stanley P, Bear JW, Reid BS (1983) Percutaneous nephrostomy air to distend the renal pelvis. A diuretic drug stent substitution, some studies report the use in infants and children. AJR Am J Roentgenol 141:473-477. may also be used to induce a transient calyceal of permanent metallic stents with good paten - 8. Patel U, Hussain FF (2004) Percutaneous nephrostomy of non - dilated renal collecting systems with fluoroscopic guidance: dilatation, but is usually not necessary. After Fig. 2: Percutaneous Nephrostomy: 0.018’’ guide wire cy rates. The main limitation of those studies is technique and results. Radiology 233:226-233. the insertion of a 6 or 8 Fr “pig-tail” catheter advanced through a dilated pelvicalyceal system. the short follow-up period. 9. Gupta S, Gulati M, Suri S (1998) Ultrasound-guided percuta - neous nephrostomy in non-dilated pelvicaliceal system. with the tip in the renal pelvis, the urinary flow J Clin Ultrasound 26:177-179. is diverted outside or from a fistulous tract. stenting may be useful to improve patient life A good US and fluoro-guided technique with 10. Barnacle AM, Roebuck DJ, Racadio JM (2010) Nephro-urology interventions in children. Tech Vasc Interv Radiol 13:229-237. quality or relieve pain, despite of the overall an appropriately high-quality material selection 11. Yavascan O, Aksu N, Erdogan H et al (2005) Percutaneous Some authors report the use of CT-guidance, survival potential benefit. In cases of haemorr - is always advised for urinary interventions, nephrostomy in children: diagnostic and therapeutic importance. Pediatr Nephrol 20:768-772. which might be useful to obese patients and hagic cystitis, ureteric encasement or non-func - espe cially for children. Angiographic vascular 12. Stanley P, Diament MJ (1986) Pediatric percutaneous nephros - when an ectopic kidney is present. Haemorr hage tional bladder (e.g. neurogenic or infiltrated), JJ and biliary interventional training might also tomy: experience with 50 patients. J Urol 135:1223-1226. 13. Irving HC, Arthur RJ, Thomas DF (1987) Percutaneous is the most frequent complication, but usually stent insertion is not usually useful and kidney be helpful to perform several techniques and nephrostomy in paediatrics. Clin Radiol 38:245-248. 14. Meir DB, Inoue M, Gur U et al (2004) Urinary diversion in is mild and self-limited. Catheter replacement function has no significant improvement. In without complications. The use of other stents children with pelvic tumors. J Pediatr Surg 39:1787-1790. is done every 3 months to avoid bacterial con - usual cases, stenosis or occlusion is surpassed than the JJ stent, such as metallic and/or cover - 15. Ghazali S, Barratt TM, Williams DI (1973) Childhood urolithiasis tamination and urinary tract infection. and a J catheter is placed. The ca the ter is nor - ed stents, requires further studies and a longer in Britain. Arch Dis Child 48:291-295. mally replaced every 3 or 4 months. In our follow-up, but may be applicable for selected Ureteral stenting long-term experience, a 6-month replacement cases. A multidisciplinary team of interven tio nal Besides the former indication, percutaneous increases the rate of urinary tract infection. radiologists, urologists and nephrologists as - nephrostomy may also be used for ureteric sures high technical success rates, low compli - stent placement. In malignant cases, ureteral cation rates and a reduction in costs.

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Cardiovascular and Interventional Radiological Society of Europe C RSE 10 advertisement Saturday, September 15, 2012

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an Interview with Stacy Enxing Seng, President, Covidien vascular therapies

Q: What is Covidien vascular therapies’ ed community of out-of-the-box thinkers who leverage our technical expertise to provide the strategy for outperforming the market? are also practical problem solvers – all clearly market with a unique way to address hyper - motivated by the opportunity to have a pro - tension. A: As a global business, Covidien Vascular The - found and positive effect on patients’ lives. It’s rapies aspires to be the clear first choice for our impressive. And this is not just happening in We will continue to ensure that the products customers, employees, investors and business research & development and sales and market - and services we develop and provide are clini - partners by delivering breakthrough innova - ing – it’s what drives our entire organization. cally relevant and economically beneficial. Our tion in the treatment of vascular disease world - customers are under ever increasing pressure wide. We work hard every day to achieve this At Covidien, we offer a diverse yet complemen - to justify the procedures and products they goal by staying focused on the technologies tary range of technology solutions to treat vas - use, whether they are physicians in a small pri - and initiatives that our physician customers tell cular disease, including deep vein thrombosis, vate practice or hospitals in a large healthcare us are vital to achieving the best possible chronic venous insufficiency, dialysis access, system. Our responsibility is to make sure that outcomes for their patients. peripheral vascular disease and neurovascular Covidien products are economically valuable, disease. We are always looking to grow our while helping customers provide the highest Vascular Therapies is growing rapidly, and to leadership position in the businesses we are in standard of care. build on our momentum, we need to continue today, while laying the groundwork for tomor - embracing and investing in the collaborative row to lead in new and emerging areas, such as Q: What new products and technologies can relationships that we have with medical profes - hypertension and ischemic stroke treatment. we expect from Covidien in the next 12 to sionals around the world. By continuing to lis - 18 months? ten to the medical community and observing Q: What emerging market trends will be a them in action, we can deliver game-changing focus for Covidien in the coming years? A: Covidien recently launched the Viance™ products, supported by solid clinical evidence, Crossing Catheter and Enteer™ Re-entry that address unmet needs. By staying this A: We are particularly excited about the vascu - System, which offers a new way to treat chron - course, I strongly believe that we will trans- lar treatment of hypertension as a procedure ic total occlusions (CTOs) in peripheral arteries. f orm our business into the leading vascular that can be conducted by the interventional These innovative products will complement company worldwide. car dio logist, vascular surgeon and intervention al our peripheral vascular procedural support radiologist. To meet this widespread and grow - portfolio with tools that support the endovas - Q: What distinguishes Covidien in the highly ing public health need, we entered the hyper - cular treatment of peripheral arterial disease. competitive vascular market? tension market with the OneShot™ Renal De - ner vation System for the treatment of drug We are entering the CTO market for the first A: We not only have the right combination of resistant hypertension, a devastating condition time. Our new products take a unique ap - talent and technology at Covidien, we are also af fecting millions of people worldwide. As a proach, leveraging physician skill and finesse focused on common and often compassionate re cognized leader in radiofrequency ablation rather than the use of force or expensive goals. The result is an energized and empower - tech nology, we saw this as an opportunity to capital equipment.

Advertorial First Patient treated With tanDEM™: a new option For Drug-Elutable Microspheres

PD. Dr. Boris Radeleff, MD, EBIR First tanDEM™ patient University Hospital of Heidelberg, Germany This patient, a 48 year old male (175 cm, 78 kg) with HCC in segment VII due to chronic Introduction Hepatitis C was treated with TANDEM™. The CeloNova Biosciences recently launched patient’s case was discussed at the tumor board Embozene TANDEM™ Microspheres, which are on March 22, 2012 and had a baseline MRI on capable of loading Doxorubicin or Irinotecan April 4, 2012. up to 50 mg per ml microspheres. Embozene TANDEM™ Microspheres are commercially avail - Conclusion able in 2 ml or 3 ml syringes and in sizes of Our first experience with 100 µm TANDEM™ 40, 75 or 100 µm. Microspheres demonstrated: · The loading of the doxorubicin in our univer - After the CE mark was obtained, the first pa - sity pharmacy was easy and efficient. tient was treated with TANDEM™ particles by Fig. 1: MRI depiction of a 4,5 cm, hypervascular - · The application of the TANDEM™ Micro - Dr. Radeleff and his team at the University ized HCC nodule in the arterial phase using the spheres through a 2.8F microcatheter was the first histological tanDEM™ results: Hospi tal of Heidelberg, Germany. The Hepato - liver-specific contrast medium Primovist (Bayer effortless and similar with our previous expe - This histological slide shows TANDEM™ loaded cellular Carcinoma (HCC) patient was treated Vital, Germany). riences with the bland Embozene. with doxorubicin (red). The microspheres ade - with 100 µm TANDEM™ microspheres, loaded · No relevant post-embolization syndrome quately filled this small artery and show no sign with 150 mg Doxorubicin in 3 ml of particles. under standard IV medication (we observed of deformation. Observe the pseudo lobular pa - light fever and shivering, but no nausea or renchymal necrosis with intraparenchymal Patient preparation vomiting). bleeding adjacent to the embolization particles. Embozene TANDEM™ 100 µm microspheres (3 ml) · No adverse events pre or post intervention. were loaded with doxorubicin at the university’s pharmacy and immediately transferred to the an - The devascularization in the follow up MRI of the tanDEM™ Microspheres reference numbers: gio suite to treat the HCC patient. There, the do - patient after 14 days (figure 3) was exactly what Size 2ml Syringe 3ml Syringe xorubicin loaded microspheres were mix ed with we expected and gives us a good and safe feel - 40 ± 10 µm 10420-TS0 10430-TS0 8 ml of contrast agent, Imeron 300 (Bracco Altana ing for the planned TANDEM-TACE in the future. Pharma, Konstanz, Germany) before injection. 75 ± 15 µm 10720-TS0 10730-TS0 100 ± 25 µm 11020-TS0 11030-TS0 The pre-interventional patient management pro - cedure included an IV line, saline infusion, EKG, pulse oximetry and blood pressure monitoring. Fig. 2: After 14 days, in the follow-up MRI, we To order Embozene TANDEM™, please contact The following medications were administered: found a complete devascularized HCC nodule in your local CeloNova representative, or visit · 25 mg of Pethidine (pain management) the arterial and venous phase without vital tumor www.celonova.com · 20 mg Buscopan (spasmolytic) using the liver-specific contrast medium Primovist Embozene TANDEM™ is not currently available · 4 mg Ondansetron (antiemetic) (Bayer Vital, Germany). in the US.

Special Edition / CIRSE 2012 - Lisbon coIngRress Interventions in kidney transplant Complications 11 news

Don't miss it ! How to manage renal transplant angioplasty of transplant renal artery stenosis complications Special Session Jan Peregrin (EBIR) Saturday, September 15, 08:30-09:30 Auditorium 6

The incidence of transplanted kidney artery The technique of the procedure depends on Clinical results of TRAS angioplasty are report - Jan Peregrin stenosis (TRAS) is reported in the range of the technique of the transplantation. In the ed in several papers. The majority of these are (EBIR) 1-23% [1-5], and the number of positive graft arterial anastomosis of end-to-side type dedicated to hypertension treatment and the Institute for Clinical and dia gnoses increased with introduction of to the external iliac artery, the approach from authors generally agree on the fact that in Experimental Medicine (IKEM) duplex sono graphy, CT angiography [6] and the ipsilateral femoral artery is usually used some of the patients, the blood pressure Prague, Czech Republic MR angio graphy [7], as even asymptomatic pa - (Fig. 2), except in cases where the graft artery, de creases after successful PTA, but in almost tients are now diagnosed [8]. The wide range has very acute caudal angulation where a con - none of the cases is blood pressure normal of reported TRAS incidence is most likely influ - tralateral approach is necessary. In cases of without the medication. However, the results enced by non-standard definition of the end-to-end anastomosis to internal iliac artery, are difficult to compare due to non-standard haemodynamic significance of TRAS [9, 10]. a contralateral (“crossover”) approach is most methods of evaluation [20, 27]. Nevertheless, it Prof. Jan Peregrin is an IR at Prague’s Institute for Reported causes of TRAS are as follows: surgi - frequently used. A simple balloon dilatation is is necessary to remember that hypertension in Clinical and Experimental Medicine, where he has cal failure, graft type (higher TRAS incidence is usually employed as a primary measure, fol - patients with a kidney transplant increases the served as Head of the Department of Diagnostic reported in paediatric cadaverous kidney lowed by stent placement in the case of sub- risk of cardiovascular disease and plays a role in and Interventional Radiology since 1991. He held donors [11, 12], although not all authors con - optimal outcome or complication (occlusive chronic graft dysfunction progression [28]. the role of CIRSE President from 2009-2011, and is firm this situation [13]), immunological causes dissection) (Fig. 3). Some authors use primary currently a Trustee of the CIRSE Foundation, [9, 14], CMV infection [15, 16], and progression stenting, but there are no randomised data Despite the fact that hypertension remains the where he serves as Chairperson of the Advisory of the recipient atheromatous disease proxi - confirming the superiority of primary stenting most frequent indication to graft artery PTA, it Council. Prof. Peregrin has been a keen advocate mally to the graft artery anastomosis (Fig. 1) over plain balloon angioplasty with selective is repeatedly confirmed that successful angio - of IR both locally and internationally, and has [17]. It was repeated ly documented that stent placement [21, 22]. There are no reports plasty can favourably influence failing graft hosted many IR educational courses in Prague. He patients with TRAS have not only worse graft on the use of drug-eluting stents or protection function [9, 14-18]. Besides that, it was shown has written more than 170 scientific and educa - survival, but also overall survival rate [14, 18]. devices during TRAS angioplasty. that patients with untreated TRAS have poorer tional papers, and has served on the Editorial For many years, angioplasty (PTA) has been graft survival associated with poorer patient Board of CVIR, Česká Radiologie and Cor et Vasa. considered a method of choice in TRAS treat - Medication before and after angioplasty does survival as well [14]. In some papers, it is ment [9, 19, 20]. In the majority of cases, TRAS not differ from that for native kidney PTA (anti- reported that successful TRAS PTA can restore responds well to balloon dilatation (in recent aggregation using combination of Plavix and the kidney function even in the dialysed references: years more frequently combined with stent ASA before and after the procedure and patients with complete graft failure [18]. 1. Chandrasoma P, Aberle AM. Anastomotic line renal artery placement). Heparin 3000-5000 units during angioplasty). stenosis after transplantation. J Urol 1986;135(6): 1159-1162. 2. Lacombe M. Renal artery stenosis after renal transplantation. The amount of contrast medium used should Complications of graft artery PTRA are most Ann Vasc Surg 1988; 2(2): 155-160 3. Morris PJ, Yadav RV, Kincaid-Smith P, et al. Renal artery stenosis Diagnosis of TRAS is usually based on Doppler be as low as possible and the patient should be often “classic catheterisation” complications in renal transplantation. Med J Aust 1971; 1: 1255-1257. ultrasound examination and MR angiography, well hydrated to avoid contrast-induced (groin haematoma, bleeding, and false 4. Munda R, Alexander JW, Miller S, First MR, Fidler JP. Renal allo - graft artery stenosis. Am J Surg 1977; 134(3): 400-403. and rarely on CT angiography (contrast medium nephropathy (in patients with impaired graft aneurysm). Graft function impairment caused 5. Roberts JP, Ascher NL, Fryd DS, et al. Transplant renal artery load). Digital subtraction angiography remains function especially). by angioplasty is not frequent and usually stenosis. Transplantation 1989; 48(4):580-583. 6. Mell MW, Alfrey EJ, Rubin GD, Scandling JD, Jeffrey RB, Dafoe DC. the diagnostic gold standard, but it should be caused by contrast-induced nephropathy Use of spiral computed tomography in the diagnosis of trans - performed only when – in case of a positive The technical success rate of TRAS angioplasty rather than graft artery damage or distal embo - plant renal artery stenosis. Transplantation 1994; 57: 746-748. 7. Luk SH, Chan JH, Kwan TH, Tsui WC, Cheung YK, Yuen MK. Breath- result – immediate endovascular intervention is is reported as 70-90%, with a low complication lisation [20, 22, 26]; occlusive dissections re - hold 3D gadolinium-enhanced subtraction MRA in the detection planned. rate and a restenosis rate of 10-12% [20-26]. ported in the past are now solved by stent of transplant renal artery stenosis. Clin Radiol 1999; 54: 651-654. 8. Bruno S, Remuzzi G, Ruggenenti P. Transplant renal artery placement. stenosis. J Am Soc Nephrol 2004; 15(1): 134-141. 9. Audard V, Matignon M, Hemery F, et al. Risk factors and long- term outcome of transplant renal artery stenosis in adult recipi - ents after treatment by percutaneous transluminal angioplasty. a b ab Am J Transplant 2006; 6(1): 95-99. 10. Fervenza FC, Lafayette RA, Alfrey EJ, Petersen J. Renal artery ste - nosis in kidney transplantation. Am J Kidney Dis 1998; 31: 142-148. 11. Marques M, Prats D, Sánchez-Fructuoso A, et al. A. Incidence of renal artery stenosis in pediatric en bloc and adult single kidney transplants. Transplantation 2001; 71(1): 164-166. 12. Stanley P, Malekzadeh M, Diament MJ. Posttransplant renal artery stenosis: angiographic study in 32 children. Am J Roentgenol 1987; 148(3): 487-490. 13. Fauchald P, Vatne K, Paulsen D, et al: Long-term clinical results of percutaneous transluminal angioplasty in transplant renal cd artery stenosis. Nephrol Dial Transplant 1992; 7: 256-259. 14. Wong W, Fynn SP, Higgins RM, et al. Transplant renal artery stenosis in 77 patients-does it have an immunological cause? Transplantation 1996; 61(2): 215-219. 15. Pouria S, State OI, Wong W, Hendry BM. CMV infection is associated with transplant renal artery stenosis. QJM 1998; 91: 185-189. 16. Humar A, Uknis M, Papalois V, Gillingham K, Matas A. Is there an association between cytomegalovirus and renal artery stenosis in kidney transplant recipients? (abstr). Transplantation 2000; 69: S386. 17. Becker BN, Odorico JS, Becker YT, et al. Peripheral vascular dis - ease and renal transplant artery stenosis: a reappraisal of trans - plant renovascular disease. Clin Transplant. 1999; 13(4): 349-355. 18. Peregrin JH, Stříbrná J, Lácha J, Skibová J. Long-term follow-up Fig. 3: Stenosis of graft artery next to end-to-side of renal transplant patients with renal artery stenosis treated by anastomosis (a, b), with slow development of graft percutaneous angioplasty. Eur J Radiol.2008 Jun;66(3):512-8. 19. Henning BF, Kuchlbauer S, Böger CA, Obed A, Farkas S, Zülke C, function. The stenosis responded poorly to bal - Scherer MN, Walberer A, Banas M, Krüger B, Schlitt HJ, Banas B, Fig. 1a: Occlusion of common iliac artery proxi - Fig. 1b: After common iliac artery recanalisation loon dilatation (c). A balloon-expandable stent Krämer BK. Percutaneous transluminal angioplasty as first-line treatment of transplant renal artery stenosis. Clin Nephrol. 2009 mally to the graft artery origin (arrowheads) and restoration of flow to the graft, its function was placed into the stenosis and fully opened the May;71(5):543-9. resulting in graft function failure. returned to normal. graft artery (d). 20. Patel NH, Jindal RM, Wilkin T, et al. Renal arterial stenosis in renal allografts: Retrospective study of predisposing factors and outcome after percutaneous transluminal angioplasty. Radiology 2001; 219: 663-667. ab 21. Valpreda S, Messina M, Rabbia C. Stenting of transplant renal artery stenosis: outcome in a single center study. J Cardiovasc Surg (Torino). 2008 Oct;49(5):565-70. 22. Marini M, Fernandez-Rivera C, Cao I, Gulias D, Alonso A, Lopez- Muñiz A, Gonzalez-Martinez P. Treatment of transplant renal artery stenosis by percutaneous transluminal angioplasty and/or stenting: study in 63 patients in a single institution. Transplant Proc. 2011 Jul-Aug;43(6):2205-7. 23. Matalon TA, Thompson MJ, Patel SK, Brunner MC, Merkel FK, Jensik SC. Percutaneous transluminal angioplasty for transplant renal artery stenosis. J Vasc Interv Radiol 1992; 3:55-58. 24. Greenstein SM, Verstandig A, McLean GK, et al. Percutaneous transluminal angioplasty: the procedure of choice in the hyper - tensive renal allograft recipient with renal artery stenosis. Transplantation 1987; 43: 29-32. 25. Grossman RA, Dafoe DC, Shoenfeld RB, et al. Percutaneous transluminal angioplasty treatment of renal transplant artery stenosis. Transplantation 1982; 34: 339-343. 26. Benoit G, Hiesse C, Icard P, et al. Treatment of renal artery stenosis after renal transplantation. Transplant Proc 1987; 19(5): 3600-3601. 27. Rundback JH, Sacks D, Kent KC, et al. Guidelines for the report - ing of renal revascularization in clinical trials. J Vasc Intervent Radiol 2003;14:477-492. 28. Gray DW. Graft renal artery stenosis in the transplanted kidney. Transplant Rev 1994; 8: 15-21. 29. Beecroft JR, Rajan DK, Clark TW, Robinette M, Stavropoulos SW. Transplant renal artery stenosis: outcome after percutaneous Fig. 2: Stenosis of the graft artery next to the end-to-side anastomosis (a) resulting in hypertension and intervention. J Vasc Interv Radiol 2004; 15: 1407-1413. graft function impairment. Balloon angioplasty removed the stenosis (b), the hypertension was better 30. Opelz G, Döhler B: Improved long-term outcomes after renal transplantation associated with blood pressure control. Am J. controlled and the graft function improved. Transplant 2005; 19:181-192.

Cardiovascular and Interventional Radiological Society of Europe C RSE CHARITat Y RUN CIR SE 2012 Go an extra 2 miles for children with cancer!

CIRSE and Biocompatibles invite you to take part in the BtG Charity run and Football Cup on Saturday, September 15, at 19:00.

This light-hearted evening event will be in aid of the Österreichische kinder-krebs-Hilfe (austrian Childhood Cancer organisation) . Our football teams are all ready for kick-off, but there’s still plenty of room for cheerleaders, and last minute entrants to the Charity Run are most welcome!

A delicious buffet of snacks and drinks will be provided from 19:45 onwards, and shuttle buses will bring you from the congress centre to the sports arena, and from there to some central points in the city following the event.

anyone wishing to join the 3.2 km Charity run can sign up at the kuoni “Hotels, tours & Social Events“ Stand located in the entrance hall of the congress centre. Participants in the run are requested to donate a minimum of EUr 10 in aid of our chosen charity.

Be sure to join us for an evening of sport and socialising!

Saturday, September 15, at 19:00 at Belenenses Stadium (Estádio do Restelo, 1449-015 Lisbon) Shuttle buses leave from outside the Congress Centre Entrance at 18:40!

For more information please visit www.cirse.org or contact us at [email protected]

CIRSE supports compliance with ethical standards. Therefore, CIRSE emphasises that the present invitation is directed to participants of CIRSE 2012 and recommends that the participants who want to take part in the BTG Charity Run and/or Football Cup shall bear any and all costs in this context (including donations) themselves. Kindly note that participation in the BTG Charity Run and/or Football Cup is NOT included in the CIRSE 2012 registration fee! coIngRress treatment algorithms for acute Stroke 13 news

Don't miss it ! Basics of acute stroke management: Defining treatment algorithms for acute Stroke from diagnosis to treatment Special Session Ethem Murat Arsava Saturday, September 15, 10:00-11:00 Auditorium 2

Treatment algorithms in the acute stroke setting standard of care in patients presenting within 6 · Patients with acute ischaemic stroke present - Ethem Murat arsava are conventionally tailored according to time hours of symptom onset. Until now, no placebo- ing within 3 hours of symptom onset, but Department of Neurology, elapsed between symptom onset and hospital controlled trial has evaluated the use of intra- who have contraindications for systemic Faculty of Medicine admission. In patients presenting within 3 hours arterial rt-PA or mechanical clot retrieval devices thrombolysis might be considered for Hacettepe University, of symptom onset, systemic thrombolysis by in acute ischaemic stroke. How ever, the MERCI intra-arterial thrombolysis. Ankara, Turkey intravenous recombinant tissue plasmi nogen clot retriever®, the Penumbra system® and · The site of arterial occlusion is a key factor in TM activator (rt-PA) can be administered un less there Solitaire device have been ap proved by FDA as the decision algorithm for intra-arterial thro m - is a contraindication to the therapy. Intra venous devices for clot re mo val from cerebral blood ves - b olysis. This therapeutic option is consider ed rt-PA, which is currently the only ap prov ed treat - sels, based on their efficacy and safety in patients for patients with proximal arterial occlusions ment for acute ischaemic stroke, given at a dose with large vessel occlusions presenting within 8 and high clot burden, like internal ca ro tid ar - Dr. Ethem Arsava is Associate Professor of of 0.9 mg/kg (10% given as a bolus, remainder hours of symptom on set. Despite their approval tery, middle cerebral artery stem and basilar Neurology at Hacettepe University in Ankara. given over 1 hour, maximum dose 90 mg) within and widespread use, we still do not know artery occlusions. As there is currently no ran - Although he works primarily as a neurologist, he 3 hours of symptom onset has been shown to whether these devices, used alone or bridged to domised trial comparing the efficacy and has also spent time working in the Department of significantly improve functional outcome at 3 intravenous thrombolytics, improve patient out - safety of intravenous thrombolysis vs. intra- Radiology of the AA Martinos Center for Bio medi - months when compared to pla ce bo [1]. Meta- come or not. arterial thrombolysis, it is unknown whether cal Imaging in Massachusetts General Hospital, analysis of randomised trials of in tra venous rt-PA patients with proximal arterial occlu sions Boston, USA, and is intimately familiar with (NINDS, ECASS-I, ECASS-II, ATLANTIS) show an Intravenous rt-PA is the standard of care for all should be directly taken to the angiography neurological imaging. Dr. Arsava has been absolute increase of ~12% in the number of eligible ischaemic stroke patients presenting suite even if admitted within 3 hours of symp - author or co-author of 37 published papers, with patients achieving a modified Rankin Scale within 3 hours of symptom onset. The selection tom onset. However, bridging of intra-ven ous 341 citations. These papers have been published between 0 and 2 with intravenous rt-PA treat - of patients that should be treated by systemic and intra-arterial thrombolysis can always be in a wide range of journals, including Neurology, ment compared to placebo [1]. Syste mic throm - thrombolysis is clearly outlined in the current considered as an option in such patients. Stroke and Lancet Neurology. bolysis is still beneficial when administered acute ischaemic stroke management guidelines · Aside from arterial status, the presence of bet ween 3 to 4.5 hours after symptom onset [2]; [5]. On the other hand, selection of pa tients for sal vageable brain tissue is critical to attain however use of rt-PA in this time window awaits intra-arterial thrombolysis is a challenging ma xi mum benefit from intra-arterial throm - amount of brain tissue that has already approval from major medicinal agencies. pro cess. A number of clinical or imaging criteria bo lysis. The presence of clinical-diffusion un der gone irreversible damage might be a are currently used to guide clinicians to identify mismatch, diffusion-perfusion mismatch or criti cal factor in deciding to proceed on with Unfortunately, only less than 5% of patients with pa tients that could benefit from intra-arterial CBV-MTT mis match can be used to identify intra-arterial thrombolysis. ischaemic stroke can be treated with intra venous throm bolysis, though no level I evidence is pa tients with significant amount of ischae mic rt-PA in the real-world setting. Further more, present for the efficacy of this treatment in such penumbra that might be salvaged by re - effectiveness of intravenous thrombolysis is poor patients (Fig. 1): cana lisation and reperfusion. In addition, the references: 1. Hacke W, Donnan G, Fieschi C, Kaste M, von Kummer R, in patients with proximal arterial occlusions; Broderick JP, Brott T, Frankel M, Grotta JC, Haley EC Jr, rt-PA establishes recanalisation in less than 25% Kwiatkowski T, Levine SR, Lewandowski C, Lu M, Lyden P, Marler JR, Patel S, Tilley BC, Albers G, Bluhmki E, Wilhelm M, Hamilton of patients with internal carotid arte ry or middle S; ATLANTIS Trials Investigators; ECASS Trials Investi gators; NINDS rt-PA Study Group Investigators. Association of outcome cerebral artery occlusion [3]. Intra-arterial throm - with early stroke treatment: pooled analysis of ATLANTIS, bolysis is an attractive therapeutic option in such ECASS, and NINDS rt-PA stroke trials. Lancet. 2004 Mar 6;363(9411):768-74. patients. The only prospective randomised trial 2. Hacke W, Kaste M, Bluhmki E, Brozman M, Dávalos A, Guidetti that tested the efficacy and safety of intra-arterial D, Larrue V, Lees KR, Medeghri Z, Machnig T, Schneider D, von Kummer R, Wahlgren N, Toni D; ECASS Investigators. thrombolysis was the PROACT-II trial, which com - Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic pared intra-arterial prourokinase plus heparin stroke. N Engl J Med. 2008 Sep 25;359(13):1317-29. 3. Mori E, Yoneda Y, Tabuchi M, Yoshida T, Ohkawa S, Ohsumi Y, with heparin alone in ischaemic stroke patients Kitano K, Tsutsumi A, Yamadori A. Intravenous recombinant secondary to middle cerebral artery occlusion tissue plasminogen activator in acute carotid artery territory stroke. Neurology. 1992 May;42(5):976-82. admitted with in 6 hours of symptom onset [4]. 4. Furlan A, Higashida R, Wechsler L, Gent M, Rowley H, Kase C, 40% of patients in the prourokinase arm had a Pessin M, Ahuja A, Callahan F, Clark WM, Silver F, Rivera F. Intra- arterial prourokinase for acute ischemic stroke. The PROACT II modified Rankin scale of 0-2 at 3 months, while study: a randomized controlled trial. Prolyse in Acute Cerebral only 25% of the patients in the heparin-only arm Thromboembolism. JAMA. 1999 Dec 1;282(21):2003-11. 5. Adams H, Adams R, Del Zoppo G, Goldstein LB; Stroke Council had such a favourable outcome. Despite these of the American Heart Association; American Stroke Associa tion. results, the treatment was not approved by FDA Guidelines for the early management of patients with ischemic stroke: 2005 guidelines update a scientific statement from the and intra-arterial prourokinase did not become a Stroke Council of the American Heart Association/American Stroke Association. Stroke. 2005 Apr;36(4):916-23.

Electronic Poster awards 2012 - Congratulations to our Winners!

SCIEntIFIC PoStErS EDUCatIonaL PoStErS

Magna Cum Laude Certificate of Merit Magna Cum Laude Certificate of Merit Percutaneous in utero thoracoamniotic shunt Balloon coating with rapamycin using an Image-guidance for interventional oncology: Role of multidetector CT angiography in creation for congenital lung malformations: on-site coating device new tools in the angio-suite evaluation of acute gastrointestinal bleeding: a novel technique J. Schmeh l 1, I. Brau n2, J. Ruh r 1, M. Dobrat z1, A. Barah , T. de Baère, A. Hakimé, J. Joskin, a pictorial review S.B. Whit e 1, W.S. Rillin g1, M.B. Ame s2, R.S. Kuhlma n1, R. Bantleon 1, C.D. Clausse n1, B. Behnisc h2; L. Tselikas, A. Hameg, G. Farouil, F. Deschamps; R. Dattesi , R. Iezzi, M. Santoro, M.F. la Torre, T.R. Wigto n3, S.M. Tutto n1; 1Milwaukee, WI/US, 1Tübingen/DE, 2Hechingen/DE Villejuif/FR E.G.M. Antonuccio, A. Guerra, L. Bonomo; Rome/IT 2Portland, OR/US, 3Grafton, WI/US Fibroid embolization: long-term (mean 11yr) Cum Laude Endovascular treatment of in-stent occlusion: Cum Laude results MR neurography-guided injection procedures new technique for recanalization of long super - Radiofrequency ablation of benign non - M. Krokidis , H. Hamoda, L. Pepas, F. Tasker, for the diagnosis and treatment of pelvic pain ficial femoral artery occlusion (direct stent function ing thyroid nodules: 111 patients with P. Braude, Y. Khalaf, J.F. Reidy; London/UK syndromes puncture technique) 3-year follow-up J. Fritz, K. Wang, A.J. Flammang, A. Chhabra, L.M. Palena , B. Cesare, B. Domenico, A. Candeo, J.E. Shin , J.H. Baek, E.J. Ha, J.H. Lee, J.Y. Sung; Anatomical assessment of the origin of the right J.A. Carrino ; Baltimore, MD/US I. Alek, M. Manzi; Abano Terme/IT Seoul/KR inferior phrenic artery with the use of MDCT S. Kanasak i 1, A. Furukaw a2, T. Hiros e 1, Y. Hamanak a1, Alternative venous access: options in 3T-MR angiography evaluation of thoracic Ultra low-dose dual source CT angiography of S. Furu i 2, T. Sakamot o3; 1Kyoto/JP, 2Tokyo/JP, 3Otsu/JP challenging catheter-dependent patients outlet syndrome (TOS): assessment using the supraaortic arteries using 100 kV tube volt - R. Ramaswamy , A.R. Jani, A.C. Roberts, T.B. Kinney; bilateral synchronous venous contrast injection age, a high pitch and raw data-based iterative Dual recanalization technique for complex San Diego, CA/US D. Porett i 1, E. Lanz a 2, V. Pedicin i 1, G. Maur i 2, reconstruction: preliminary results tibioperoneal and femoropopliteal lesions in L.M. Sconfienz a2, F. Sardanell i 2; 1Rozzano/IT, D. Beitzke , R. Nolz, G. Edelhauser, D. Berzaczy, critical limb ischaemia 2Sandonato Milanese/IT C. Plank, F. Wolf, J. Lammer, C.M. Loewe; Vienna/AT Z. Ruzs a 1, B. Neme s1, F. Kut i 2, S. Kudrnov a1, K. Tót h 2, I. Konc z 2, Z. Bánságh i 1, B. Merkel y 1, K. Hütt l 1; Is IVC looking different? 1Budapest/HU, 2Kecskemet/HU L. Andrad e1, H. Correi a2, A. Gil-Agostinho 1, P.B. Soares 1, P. Donat o 1, F. Caseiro-Alve s 1; 1Coimbra/PT, 2Viseu/PT Long-term follow-up of radiofrequency ablation of renal tumours: a multicentre analysis with MR and endorectal US findings in benign minimum follow-up of 5 years prostatic hyperplasia before and after prostatic S. Roy-Choudhur y1, I. Pressne y2, A. Rekhi 1, J. Cast 3, artery embolization D.J. Breen 2; 1Birmingham/UK, 2Southampton/UK, T. Bilhim , J.M. Pisco, H. Rio Tinto, L. Fernandes, 3Cottingham/UK J.A. Pereira, M. Duarte, L.C. Pinheiro, A.G. Oliveira, J. O'Neill; Lisbon/PT

Cardiovascular and Interventional Radiological Society of Europe C RSE 14 advertisement Saturday, September 15, 2012

Advertorial Gore Scientific Programme

Sunday, 16 September Monday, 17 September Tuesday, 18 September

8.00 – 8.20 11.30 – 12.30 Gore Breakfast Symposium / room 3a Gore Learning Center 11.30 – 12.30 Refreshments will be served Gore Learning Center Latest clinical evidence on stents versus Refreshments will be served stent grafts for SFa occlusive disease: Where and when is endoluminal bypass the What approach makes sense? treatment of choice in peripheral artery Progression in the treatment of biliary Moderators: G. Krupski, Reinbek, Germany; disease? Interactive review and discussion obstructions E. Verhoeven, Nuremberg, Germany of challenging cases Moderator: P. Goffette, Brussels, Belgium Moderator: C. Rabbia, Turin, Italy • VIASTAR 1-year multicenter prospective • GORE® VIABIL® Biliary Endoprosthesis: randomized trial results: Does SFA endolumi - • Long de novo SFA lesions case: Is there a Clini cal results for malignant and benign nal bypass really outperform stents for SFA connection between stent graft oversizing biliary obstructions occlusive disease and when do I use them? and outcomes in long de novo SFA lesions? F. Fanelli, Rome, Italy J. Lammer, Vienna, Austria What does the 1-year VIPER data indicate? R. Pini, Turin, Italy • Tips and tricks using biliary stent for benign and malignant biliary obstructions 11.30 – 13.00 • In-stent restenosis case: Endoluminal bypass P. Almeida, Viseu, Portugal Gore Learning Center for the treatment of SFA in-stent restenosis. Refreshments will be served What does the RELINE trial indicate? K. Deloose, Dendermonde, Belgium Learning by Sharing – Dealing with challenges in Evar and tEvar • Complex popliteal aneurysm case Moderator: B. Katzen, Miami, USA L. Canaud, Montpellier, France

• Hostile aortic necks: Approaches and • Troubleshooting case: Other aneurysms techniques for best clinical outcomes with D. Savio, Turin, Italy the GORE® EXCLUDER® AAA Endoprosthesis featuring C3 Delivery System • AV access case G. Robinson, Hull, UK P. L. Riley, Birmingham, UK

• Durability paired with innovation: Best treatment options for tortuous iliac arteries 14.30 – 15.30 N. Nyman, Stockholm, Sweden Gore Learning Center Refreshments will be served • Emergency repair in the thoracic aorta: Logistic challenges and practical examples Expanding tIPS indications W. L. GorE & aSSoCIatES, InC. M. Hamady, London, UK Moderators: D. Yu, London, UK; A. Krajina, Medical Products Division Hradec Kralove, Czech Republic Flagstaff, Arizona 86004 • Acute Type B dissection: When and how to treat, personal experience and practical • Is TIPS effective as bridge to liver transplant? 800.528.8763 (US) examples G. Maleux, Leuven, Belgium 00800.6334.4673 (EU) J. Brunkwall, Cologne, Germany • Feasibility and efficacy of TIPS in children goremedical.com R. Aggazi, Bergamo, Italy 14.30 – 15.30 Gore Learning Center • Effect of TIPS on PVT in patients with Refreshments will be served cirrhosis Products listed may not be available in all markets. A. Luca, Palermo, Italy GORE®, C3, EXCLUDER®, TIGRIS, VIABIL®, VIA - Latest innovation in peripheral stenting: Is TORR®, and designs are trademarks of there still room for a new generation stent • Results GORE® VIATORR® TIPS W. L. Gore & Associates. design? Updates and interactive review of Endoprosthesis to treat Budd Chairi © 2012 W. L. Gore & Associates GmbH challenging cases Syndrome AR3674-EU1 JULY 2012 Moderators: D. Scheinert, Leipzig, Germany J. C. García Pagán, Barcelona, Spain

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

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

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

Special Edition / CIRSE 2012 - Lisbon coIngRress advertisement 15 news

Advertorial Unmatched Data, Unsurpassed Patency and Superior tIPS Performance

the GorE® vIatorr® tIPS Endoprosthesis is an innovative solution for tIPS.

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

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

GorE® vIatorr® tIPS Endoprosthesis Compared to Bare Metal Stents

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

In a retrospective analysis of cirrhotic patients with refractory ascites, Maleux, et al., found that TIPS using the GORE® VIATORR® Device Reprinted with permission from Elsevier, A216. offers better symptomatic control of the ascites at one year follow-up and a better overall survival, compared to bare metal stents 2. age transplant-free survival at 12, 24 and Considering these results, the role of GORE® (Figure 1) 36 months of follow-up was 63.1%, 49% and VIATORR® TIPS Endoprosthesis in the manage - 38.1% for patients allocated in the BMS-TIPS ment of portal hypertension should be consid - GorE® vIatorr® tIPS Endprosthesis group and 52.5%, 35.2% and 28.7% for patients ered. The improvement of TIPS patency by Compared to Endoscopic Band Ligation allocated to large volume paracentesis (LVP), using ePTFE-covered stents is maintained over (EBL) respectively. (Figure 2) time with a decreased risk of hepatic ence pha - lopathy and a decreased risk of death. Further - In a randomized, controlled clinical trial with Health Economic Benefits more, data demonstrate the clinical advantage TIPS performed within 72 hours after diagnos - of GORE® VIATORR® TIPS Endoprosthesis in tic endoscopy and a 1-year follow up, results Bureau et al. reported that TIPS with bare metal treatment of patients with variceal bleeding demonstrated an 86% actuarial survival in the stents has been less cost effective than other and refractory ascites. Finally, GORE® VIATORR® early-TIPS group versus 61% in the pharma - procedures. This is mainly owing to the moni - TIPS Endoprosthesis has demonstrated a de - cotherapy – EBL group ( p < 0.001) 3. The 1-year toring and the revisions required to maintain crease in associated patientcare costs. Consid - actuarial probability of remaining free of failure shunt patency. It has been shown that the use ering these results, the role of GORE® VIATORR® to control bleeding and of variceal rebleeding of covered stents could result in cost reduction TIPS Endoprosthesis in the management of was significantly higher in the early-TIPS group because of decreased clinical relapses and portal hypertension should be considered. than in the pharmacotherapy – EBL group (97% decreased need for shunt revisions 1. vs. 50%; absolute risk reduction, 47 percentage points; 95% confidence interval [CI], 25 to 69; TIPS is a safe intervention that reduces the reference: 1. Bureau C, Pagan JCG, Layrargues GP, et al. Patency of stents cov - number needed to treat, 2.1 patients; 95% CI, need for LVP. Careful calibration allows satisfac - ered with polytetrafluoroethylene in patients treated by trans - 1.4 to 4.0). tory relief of ascites with a low incidence of HE. jugular intrahepatic portosystemic shunts: long term results of a Adapted with permission from Acta Gastroenterologica Belgica randomized multicentre study. Liver International 2007; It has been demonstrated that extremely low 27(6):742-747. The conclusion was that patients with cirrhosis complication rates and exceptionally high 2. Maleux G, Perez-Gutierrez NA, Evrard S, et al. Covered stents are better than uncovered stents for transjugular intrahepatic porto - who were hospitalized for acute variceal bleed - patency rates can be achieved with the use of systemic shunts in cirrhotic patients with refractory ascites: a ing and at high risk for treatment failure, the GORE® VIATORR® TIPS Endoprosthesis. In the retrospective cohort study. Acta Gastro-Enterologica Belgica 2010;73(3):336-341. early use of TIPS was associated with significant United Kingdom, health economic data fa - 3. García-Pagán JC, Caca K, Bureau K, et al; Early TIPS Transjugular reduction in treatment failure and in mortality. voured TIPS with a cost of £500 per month of Intrahepatic Portosystemic Shunt) Cooperative Study Group. Early use of TIPS in patients with cirrhosis and variceal bleeding. pa tient follow-up for TIPS and £3,500 per New England Journal of Medicine 2010;362(25):2370-2379. tIPS Compared to Large volume month of patient follow-up for paracentesis. 4. Salerno F, Cammà C, Enea M, Rössle M, Wong F. Transjugular intrahepatic portosystemic shunt for refractory ascites: a meta- Paracentesis (LvP) Careful patient selection for this procedure has analysis of individual patient data. Gastroenterology 2007; de mon strated significant health economic 133(3):825-834. InDICatIonS For USE UnDEr CE Mark: The GORE® VIATORR® 5. Pither C, Bryant TJ, Stedman B, et al. TIPS for refractory acsites: a TIPS Endoprosthesis is indicated for use in the treatment of portal Although randomized comparisons of the benefit in favour of a dedicated TIPS single centre experience with covered stents. Abstract presented hypertension and its complications such as: variceal bleeding refrac - GORE® VIATORR® Device vs. LVP are in progress, endoprosthesis 5. at The Liver Meeting® – The 60th Annual Meeting of The tory to, or intolerant of, conventional therapies, inaccessible varices, American Association for the Study of Liver Diseases (AASLD); gastropathy, refractory ascites, and/or hepatic hydrothorax. Refer to data from bare metal stents provide evidence October 30-November 3, 2009; Boston, MA. Hepatology at goremedical.com for a complete description of all contraindica - of the effectiveness of the TIPS procedure com - Conclusion 2009;50(4)Supplement: 465A. Abstract 339. tions, warnings, precautions and adverse events. InDICatIonS For USE In tHE US: The GORE® VIATORR® TIPS pared to continued LVP in ascites patients. In a Endoprosthesis is indicated for use in the and revision treatment of meta-analysis of individual patient data, it was A large body of published data demonstrate nu - portal hypertension and its complications such as variceal bleeding, gastropathy, refractory ascites, and / or hepatic hydrothorax. reported that bare metal stent – TIPS signifi - merous clinical advantages of GORE® VIATORR® cantly improves transplant-free survival of cir - TIPS Endoprosthesis in treatment of patients W. L. Gore & Associates, Inc. • Flagstaff, AZ 86004 • goremedical.com rhotic patients with refractory ascites 4. The cu - with refractory ascites and variceal bleeding. Products listed may not be available in all markets. mulative probability of developing the first Furthermore, GORE® VIATORR® TIPS Endo pro - GORE®, VIATORR®, and designs are trademarks of W. L. Gore & Associates. episode of hepatic encephalopathy (HE) was sthesis may be associated with decreased pa - © 2012 W. L. Gore & Associates, Inc. AR1414-EN2 JULY 2012 similar between the groups (p = .19). The aver - tient-care costs compared to other therapies.

Cardiovascular and Interventional Radiological Society of Europe C RSE ES IR 2013

European School of Interventional Radiology

CIrSE and the CIrSE Foundation are dedicated to providing tailor-made educational opportunities for interventionists at all levels. 2013 will be no diﬀerent!

Stroke Intervention April 12-13, 2013 Klagenfurt/AT Embolisation April 19-20, 2013 Odense/DK Peripheral arteries & Lower Extremities April 26-27, 2013 Amsterdam/NL

GESt Europe 2013 Global Embolisation Symposium and technologies Europe’s premier embolotherapy meeting May 1-4, 2013 Prague/CZ www.gest2013.eu Biopsies & Drainage Procedures May 24-25, 2013 Ankara/TR Musculoskeletal Interventions June 7-8, 2013 Frankfurt/DE ECIo 2013 European Conference on Interventional oncology Join us for the fourth ECIO – now an annual event! June 19-22, 2013 Budapest/HU www.ecio.org Lung Interventions: Embolisation & ablation July 5-6, 2013 Frankfurt/DE abdominal & thoracic aortic Stent Graft October 18-19, 2013 Rome/IT tumour ablation November 8-9, 2013 Lausanne/CH

For more information on upcoming ESIR courses, please refer to www.cirse.org

All courses are suitable for preparation for EBIR (European Board of Interventional Radiology) EB IR

C RSE Cardiovascular and Interventional Radiological Society of Europe coIngRress Update on Stroke revascularisation results 17 news

Don't miss it ! acute stroke treatment Update on stroke revacularisation results Special Session Saturday, September 15, 11:30-12:30 Tommy Andersson Room 3A

Acute ischaemic stroke is a devastating disease tommy andersson Merci X-series Trevo Pro-4 and today’s third leading cause of death in the Karolinska University Hospital western world, responsible for 10-12% of the Stockholm, Sweden overall mortality. Protecting the brain by mainly pharmacological means from the consequen ces of ischaemia has been the focus for research and development for a long time, but as it has never worked in human trials, the interest has expanded towards revascularisation strategies. Reperfusion of the parts of the brain that suffer Dr. Tommy Andersson is Head of Neurointer ven - from ischaemia by recanalisation of the occlud - tions and the Director for Education in Neuro - ed artery is today the most effective therapy for vascu lar Treatment at Karolinska University acute stroke patients. By restoring blood flow Solitaire FR Capture Hospit al, Stockholm. He also serves as shared to the threatened tissue before progress to in - director for the Section of Neurointervention and farction, reperfusion therapies reduce the final Angiography at KERIC (Karolinska Experimental infarct size and enable better clinical outcome. Research and Imaging Centre). Dr. Andersson Such revascularisation can be achieved phar - graduated from Karolinska Institute Medical macologically with thrombolytic drugs admin - School and completed his fellowship in Vascular istered intravenously or intra-arterially, or Neurosurgery and Interventional Neuroradiology mechanically by intra-arterial thrombectomy. at Toronto Western Hospital. He is board-certified in Neurosurgery and Neuroradiology, has author - Pharmacological thrombolysis ed over 50 publications and book chapters, and Intravenous (i.v.) thrombolysis with alteplase has served as referee for several international (recombinant tissue plasminogen activator – journals. rt-PA) has proven to be efficient and safe in se - Fig. 1: Thromboemboli removed with the original X5 Merci device and with various “stent-trievers”. These veral randomised control studies. Initially the are all CE-marked and commercially available in Europe today. positive effect of the treatment was shown to be significant within 3 hours of stroke onset but patients excluded from intravenous treatment, spective, randomised studies for mechanical an improved outcome for the many patients more recently the window has been extended e.g. presenting > 4.5 hours after ictus or with thrombectomy with the purpose of studying that may otherwise die or become severely in - to 4.5 hours. But despite being clinically efficient an unclear time of onset? Could it also offer safety and effectiveness, e.g. THRACE (Trial and jured by the terrible blow of an ischaemic stroke. in large series, > 50% of the patients treated something for non-responders in whom the Cost Effectiveness Evaluation of Intra-arterial intravenously remain disabled or die. Such un - intravenous infusion does not or may not work; Thrombectomy in Acute ischaemic Stroke) in favourable outcomes are more likely in pa tients we know that patients with NIHSS ≥ 12, which France, and in the Netherlands MR CLEAN (mul - with severe neurological deficits, higher age and is indicative of a large vessel occlusion, espe - ticenter randomized clinical trial of endovascu - Suggested reading: 1. Andersson T, Kuntze Söderqvist Å, Söderman M, et al; Mecha ni - persistent arterial occlusion. So, if the treat ment cially if the length of the thrombus is > 8 mm, lar treatment for acute ischemic stroke in The cal thrombectomy as the primary treatment for acute basilar cannot achieve revascularisation, the chances are unlikely to respond to i.v. treatment. There Netherlands). IMS III, performed in the USA, artery occlusion: experience from 5 years of practice. J Neuro intervent Surg. 2012:Mar 20 (Epub ahead of print). of a good clinical outcome become less and it are no randomised controlled studies for mech - Canada, Australia and the European Union, 2. del Zoppo GJ, Higashida RT, Furlan AJ, et al; PROACT: a phase II has been shown that partial or complete reca - anical thrombectomy, but the technique has studies a combination of i.v. and i.a. therapies randomized trial of recombinant pro-urokinase by direct arterial delivery in acute middle cerebral artery stroke. PROACT Investi - nalisation by i.v. rt-PA is especially un likely in been evaluated in two prospective, non-ran - compared with conventional i.v. thrombolysis. gators. Prolyse in Acute Cerebral Thromboembolism. Stroke. proximal large vessel occlusions, only achieved domised trials: the MERCI-trial and the Multi- The i.a. therapy includes thrombectomy with 1998;29:4-11. 3. Dávalos A, Mendes Pereira V, Chapot R, et al; Retrospective mul - in 10% of occluded internal carotid arteries and MERCI trial. Both these studies included pa tients the Merci-device, as well as augmented i.a. ticenter study of Solitaire TM FR for revascularization in the in 25% of occluded proximal middle cerebral with large vessel occlusions in which me chanical sono-thrombolysis with the EKOS ultrasound/ treatment of acute ischemic stroke. Stroke. Submitted. 4. Fischer U, Arnold M, Nedeltchev K et al; NIHSS score and arterio - ar teries (MCA). Many stroke patients do suffer thrombectomy could be started within 8 hours micro-infusion system. On April 19 this year, it graphic findings in acute ischemic stroke. Stroke. 2005;36:2121-25. from large vessel occlusions and the conse - after symptom onset. MERCI-trial patients were was announced that the National Institute of 5. Furlan A, Higashida RT, Wechsler L, et al; Intra-arterial prouroki - nase for acute ischemic stroke. The PROACT II study: a random - quence is that the numbers needed to treat for rt-PA ineligible, whereas the Multi-MERCI trial Neurological Disorders and Stroke decided that ized controlled trial. Prolyse in Acute Cerebral Thrombo embo - death and dependence become high and in - also included patients that had been unsuc - the enrolment should be put on hold based on lism. JAMA. 1999;282:2003-11. 6. Global burden of stroke; http://www.who.int crease with time; < 90 min = 4; 90 min-3 hours cessfully treated with i.v. rt-PA. These trials recommendations from the Data and Safety 7. Hacke W, Kaste M, Bluhmki E, et al; Thrombolysis with alteplase =7; and 3-4.5 hours = 14. In summary, it could showed higher recanalisation rates compared Monitoring Board. The decision was taken be - 3 to 4.5 h after acute ischemic stroke. N Engl J Med. 2008; 359:1317-29. be stated that i.v. thrombolysis is a proven with control patients from the PROACT II study, cause of futility, as there were no differences in 8. IMS II Trial Investigators: The Interventional Management of Stroke (IMS) II Study. Stroke. 2007;38:2127-35. therapy that should be executed on all eligible a reasonably good percentage of independent clinical outcome between the two patient 9. IMS III: www.ims3.org patients, but we need additional therapies for patients at 90 days’ follow-up, but a higher groups in the study. The subject follow-up will 10. Lees KR, Bluhmki E, von Kummer R, et al; Time to treatment with intravenous alteplase and outcome in stroke: an updated non-eligible patients and for non-responders. mortality rate as compared to actively treated continue and there were no significant safety pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials. patients in PROACT II. concerns. We will have to wait to see the details Lancet. 2010;375:1695-703. 11. Mr Clean: www.trialregister.nl Could then intra-arterial thrombolysis with of the study and the basis for this decision. 12. Ogawa A, Mori E, Minematsu K, et al; Randomized trial of intra - rt-PA or various kinases be such an additional The Penumbra Pivotal Stroke Trial and the arterial infusion of urokinase within 6 hours of middle cerebral artery stroke: the middle cerebral artery embolism local fibrino - therapy? Three randomised trials, PROACT I, Penumbra Post trial evaluated a thrombus aspi - In conclusion, mechanical thrombectomy lytic intervention trial (MELT) Japan. Stroke. 2007;38:2633-9. PROACT II and MELT, have studied the efficacy ration technique. Both studies revealed a very seems to be safe and efficient, offering the 13. Penumbra Pivotal Stroke Trial Investigators; The penumbra piv - otal stroke trial: safety and effectiveness of a new generation of in MCA occlusions with the infusion starting high rate of recanalisation, but the percentage possibility for good patient outcome. mechanical devices for clot removal in intracranial large vessel within 6 hours of symptom onset. Treated pa - of independent patients at 90 days were rela - occlusive disease. Stroke. 2009;40:2761-8. 14. Riedel CH, Zimmermann P, Jensen-Kondering U et al; The im port- tients had higher recanalisation rates and bet - tively low in the Pivotal trial, with a high mor - Summary and future ance of size: successful recanalization by intravenous throm bo - ter 90-day outcomes than the control groups, tality rate comparable to that in Multi-MERCI. Ischaemic stroke is a common disease in the lysis in acute anterior stroke depends on thrombus length. Stroke. 2011;42:1775-7. but a higher occurrence of symptomatic intra - The 90-day outcome was markedly improved in industrialised world that mostly affects older 15. Rosamond W, Flegal K, Furie K, et al; Heart disease and stroke cranial haemorrhage. The combination of i.v. the Post trial, with a decreased mortality also. people. With an ageing population, a steady statistics: 2008 update-a report from the American Heart Asso - ciation Statistics Committee and Stroke Statistics Sub com mittee. and i.a. thrombolysis has actually been investi - increase of stroke patients can probably be ex - Circulation. 2008;117:e25-146. gated in the IMS I and IMS II studies. The pa - More recently, so-called “stent-trievers” have pected. For these patients, we need safe and 16. Roth C Papanagiotou P, Behnke S, et al; Stent-assisted mechani - cal recanalization for treatment of acute intracerebral artery tients received i.v. rt-PA followed by the same been widely used and they are today the first efficient treatment options. Today, revasculari - occlusions. Stroke. 2010;41:2559-67. drug additionally administered intra-arterially. choice for many neurointerventionalists. One sation with intravenous thrombolysis and/or 17. Saver JL; Time is brain – quantified. Stroke. 2006;37:263-6. 18. Smith WS; Safety of mechanical thrombectomy and intravenous Treated patients in both studies had signifi - such “stent-triever”, the Solitaire TM FR revas - mechanical thrombectomy offers an excellent tissue plasminogen activator in acute ischemic stroke. Results of the multi Mechanical Embolus Removal in Cerebral Ischemia cantly better outcomes than placebo-treated cularisation device, was used in six experienced treatment option, and can be used in combina - (MERCI) trial, part I. AJNR Am J Neuroradiol. 2006;27:1177-1182. patients in a large rt-PA stroke trial and a simi - European centres where retrospective data was tion with other treatment strategies. 19. Smith WS, Sung G, Starkman S, et al; Safety and efficacy of mechanical embolectomy in acute ischemic stroke: results of lar rate of symptomatic ICH compared with collected for 141 patients. This study showed the MERCI trial. Stroke. 2005;36:1432-1438. actively treated patients from that same trial. 86% revascularisation success, 6% symptomatic We also need proper recruitment and standard - 20. Tarr R, Hsu D, Kulcsar Z et al; The POST trial: initial post-market experience of the Penumbra system: revascularization of large So, after looking at i.a thrombolysis as an add- intracranial haemorrhages, and good outcome, ised training for an increasing number of neu - vessel occlusion in acute ischemic stroke in the United States on treatment, it seems that it may offer addi - i.e. independence, in 55% of the treated pa tients. rointerventionalists in the near future. For this and Europe. J Neurointerv Surg. 2010;2:341-4. 21. The IMS Study Investigators Combined intravenous and intra- tional benefit, but the results and outcomes are Similar results with that same device were pre - reason, the UEMS (Union Européenne des arterial recanalization for acute ischemic stroke: the Interven - not strikingly improved, perhaps because i.a. sented at the International Stroke Conference Médecins Spécialistes) has in 2011 established tional Management of Stroke Study. Stroke. 2004;35:904-11. 22. THRACE: http://clinicaltrials.gov/ct2/show/NCT01062698 pharmacological therapy takes time, and time in New Orleans, USA in February 2012. In the guidelines for training to achieve “Certification 23. Wahlgren N, Ahmed N, Dávalos A, et al; Thrombolysis with alte - is exactly what is missing for an acute stroke Solitaire TM arm of the SWIFT trial (SOLITAIRE™ of particular qualification” in interventional plase for acute ischaemic stroke in the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST): an patient. With the Intention for Throm bec to my) success - neuroradiology, as well as a system for accredi - observational study. Lancet. 2007;369:275-82. ful recanalisation was achieved in 61%, symp - tation of the training programmes at various 24. Wahlgren N, Ahmed N, Dávalos A, et al; Thrombolysis with alteplase 3-4.5 h after acute ischaemic stroke (SITS-ISTR): an Mechanical thrombectomy tomatic intracranial haemorrhage appeared in hospitals and institutions. observational study. Lancet. 2008;372:1303-09. If we need to be fast and efficient, yet safe, is 2%, and 58% of the patients presented with a 25. Wardlaw JM, Murray V, Berge E, et al; Thrombolysis for acute ischaemic stroke. Cochrane Database of Syst Rev. 2009;7(4). mechanical thrombectomy the treatment we good neurological outcome at 90-day follow-up. The combination of new and better tools, both 26. Wolpert SM, Bruckmann H, Greenlee R, et al; Neuroradiologic are looking for? Could it be an alternative for pharmacological and mechanical, and a standard - evaluation of patients with acute stroke treated with recombi - nant tissue plasminogen activator. The rt-PA Acute Stroke Study There are also several on-going national pro - ised training of operators, can hopefully lead to Group. AJNR. 1993;14:3-13.

Cardiovascular and Interventional Radiological Society of Europe C RSE CIR SE 2012 Party

Tuesday, September 18, 20:00 Pátio da Galé, Lisbon

Held at the stunning location of the Pátio da Galé, the CIRSE 2012 Party will be the perfect opportunity to meet colleagues and friends on a late summer evening.

Dinner will be served in the impressive Sala dos Riscos. After dinner, the German band "Fresh Music Live" will entertain you with live versions of well-known modern songs and standards in their own inimitable style.

A great party is guaranteed!

You can choose to join us for the dinner and party or, if you prefer to have dinner elsewhere in the city, the party only.

Make sure to secure your tickets for the CIRSE 2012 Party! Please refer to the "Hotel, Tours & Social Events" counter at the congress centre.

Kindly note that the CIRSE Party is a seated dinner. Table or seat reservation is not possible. CIRSE supports compliance with ethical standards. Therefore, CIRSE emphasises that the present offer (made by KUONI Destination Management operated by Buzz Portugal DMC) is directed to participants of CIRSE 2012 and recommends that the participants who want to accept the present offer shall bear any and all costs in this context themselves. coIngRress Intervention IQ Magazine 19 news

Intervention IQ – Flying the Flag for Ir

We are proud of the IRs of this world: every RFA for Varicose Veins day, you provide patients with exemplary care and minimally invasive solutions to their prob - the treatment To begin with, a physician of any one of these Prof. Christoph a. Binkert lems. But do you get the recognition you de - specialties examines the patient. A duplex MD, MBA, Director of the serve? Do your procedures get the resources Radiofrequency (RF) ablation is one of the ultrasound is a vital part of the examination, in Institute of Radiology and they should? Are your patients given all the common ways to treat symptomatic varicose order to reliably diagnose and locate the in - Chairman of Diagnostic and options you make available to them? Do your veins by applying endovenous heat. sufficient varicose vein(s) causing the Interventional Radiology, colleagues know what you can offer? symptoms. Winterthur Kantonsspital, With the latest technology a catheter with an Switzerland A lack of awareness is still one of the main RF tip is inserted into the varicose vein and ad - RF therapy can be applied in most cases except obstacles surrounding IR, which can reduce the vanced to where the treatment should begin, wher varicose veins are very tortuous or the need for invasive procedures. To overcome which is typically at the groin level. The RF tip diseased vein segments are very short (less this, Intervention IQ has been established as a heats each segment to 120°C for 20 seconds, as than 10cm). In these circumstances surgical Patient’s point of view high-quality channel of communication to key the catheter is carefully pulled back segment therapy is more suitable. decision-makers in healthcare, providing a con - by segment. Ms. Sonja Budja, a patient of Prof. Binkert, tinuous flow of information which shows the the results shares her experience of how she found RF successes and potential of IR as a promising As it is heated the injured vein will close shut therapy a convenient and effective treatment alternative or adjunct to open surgery. Inter - and no longer be able to cause troublesome RF therapy of varicose veins is a safe and effec - for symptomatic varicose veins: vention IQ reaches over 45,000 readers per symptoms. tive procedure with success rates of 90% or issue, including hospital managers, department higher at two years. “The leg that was affected felt uncomfortably heads, doctors, health politicians, the medical In order to protect the surrounding healthy tis - heavy and the calf was discoloured and red. I industry and many more. By reaching these sue a large amount of local anaesthetic is in - Symptoms disappear typically within a few feared the development of an ulcer. groups, the goal is to facilitate patient access to jected around the vein (tumescent anaesthe - weeks and serious complications are extremely gentle, minimally invasive solutions. sia), this absorbs excess heat so burning is rare. The most likely problem is aching pain “I had already had a vein- stripping operation done avoided. and bruising for a few days. Some staining of on the other leg 20 years ago and I can remember Every issue is themed, and our latest issue, the treated vein can occur, although this dis - how the operation was quite invasive. I needed Venous Interventions, offers a succinct over view ablation methods compared coloration has no clinical impact. In rare cases, spinal anaesthesia and had to stay in hospital for of the venous disorders that IR can treat. As the nerve which runs alongside the vein can be three days. This time around, I looked for a less ever, a combination of IR interviews, patient RF and laser treatments have shown very simi - damaged by the heat. This sounds more dra - invasive treatment option that wouldn’t require testimonials, economic analysis and latest lar results. One advantage of RF is that the matic than it is, because typically the problem me to stay in hospital or have strong anaesthesia. research is used to show the role that IR can therapy is more standardised as the technique is only a sensory deficit around the ankle which and does play in treating these common requires the catheter to be pulled back seg - likely recovers over the following months. “The [endovenous RF therapy] I went on to have complaints. ment by segment every 20 seconds. Laser abla - Motor function is hardly ever impaired. six weeks ago was very tolerable. I could barely tion involves a continuous pull back during the feel the pinpricks of the needles. The atmosphere procedure: this will vary with each physician. Patient Satisfaction was relaxed and so the procedure went by very quickly. I was most impressed that I left home at Another advantage is that the RF therapy The vast majority of the treated patients are very 14:30 and returned at 17:30, able to walk without seems to give rise to less postprocedural pain pleased with the procedure. Patients like the any significant pain! and bruising when compared to bare tip laser fact that RF therapy is an outpatient treatment fibres. However, this advantage may be bal - with only local anaesthesia needed. They are “My recovery went very smoothly and I returned anced when covered laser fibre tips and also very happy and sometimes even surprised to my normal daily routine the next day. I was different wave lengths are used. that there is little or no recovery time, minimal able to run the household as normal, doing the or no pain and a good cosmetic outcome. cooking, cleaning and even the laundry. From the Interdisciplinary care day after that day I was able to go for walks for Unfortunately, RF and laser vein therapies are an hour or so at a time. Patients with symptomatic varicose veins are generally not reimbursed by insurance compa - examined at our interdisciplinary vascular cen - nies in many European countries. Therefore, “I am very happy with the result of the treatment. tre, in which IR, vascular surgery and angiology the treatment has to be paid for by the patient. The heaviness and most of the redness and dis - work together. Efforts to overcome the reimbursement issues coloration have disappeared and I am in no pain. are being made. The newer [IR] treatment is an improvement over the surgery which I had on the other leg. I would recommend this treatment to everyone.”

With very special thanks to Sonja Budja.

Superficial Veins Vein Ablation of the leg Catheter Vein Vein in Vein Heated Closes You can find a complimentary copy in your congress bag – if you’d like to read any of Great Saphenous our previous issues, you can pick them up at Vein the next Publishing Intervention IQ Lounge, here in the Congress Centre. Catheter entry Here’s an extract from the latest issue… point Varicose Vein

To find out more, visit Vein Ablation image reprinted with permission of Thorough follow-up is an essential part of clinical care: Prof. Binkert takes time to sit down with the the Society of Interventional Radiology patient in his office. www.intervention-iq.org © 2004-12, www.SIRweb.org. All rights reserved.

Cardiovascular and Interventional Radiological Society of Europe C RSE 20 advertisement Saturday, September 15, 2012

Advertorial new Product Launches

ATRIUM BAYER BOSTON SCIENTIFIC BOSTON SCIENTIFIC

V12 RX covered stent JETSTREAM Atherectomy System Innova™ Self-Expanding PROMUS Element™ Plus BTK Stent Bare-Metal Stent System

The V12 RX covered stent is the latest addition Bayer expands its portfolio of interventional pro - The Innova™ Self-Expanding Bare-Metal Stent The PROMUS Element™ Plus BTK Stent has to Atrium’s complete line of V12 balloon ex- ducts with the introduction of the JETSTREAM System is designed to treat peripheral vascular been approved with Below The Knee indication pandable PTFE covered stents. The new .014” Atherectomy System for restoring flow and pre - lesions in arteries above the knee, specifically and is aimed to provide physicians improved rapid exchange, low profile (5 and 6Fr intro - serving options in the treatment of peripheral the superficial femoral artery (SFA) and DES performance in treating patients with ducer sheath compatible), highly deliverable arterial disease (PAD) . proximal popliteal artery (PPA). Critical Limb Ischemia (CLI) or severe lower leg V12 RX stent platform is the ultimate solution This rotational atherectomy system offers a range claudication in infrapopliteal lesions. The for small vessel applications and tortuous of catheter sizes to treat both above (ATK) and The innovative design and stent architecture PROMUS Element Stent uses a proprietary PtCr anatomy. below the knee (BTK) peripheral arterial disease. used in the Innova Stent platform provide (platinum chromium) alloy designed specifi - Indicated for use in multiple lesion morpholo - excellent radial strength while remaining flexi - cally for stenting, which enables thinner struts V12 RX is a fully encapsulated customizable gies including calcium and thrombus, the ble and very fracture-resistant, which is critical and enhanced visibility. The innovative alloy balloon expandable PTFE covered stent. JETSTREAM technology features differential to sustaining patency in treated SFA and PPA and stent design offers a more conformable Atrium is the first and only company to provide cutt ing to remove lesion materials while pre - lesions. The Innova Stent System consists of a stent with less recoil and higher radial strength. you with a high quality covering technology serving the soft vessel walls. Nitinol, self-expanding bare-metal stent loaded It employs an advanced low-profile delivery that is engineered to optimize healing, reduce The JETSTREAM System also provides continu - on an advanced low-profile delivery system. system featuring a dual-layer balloon and Bi- restenosis, and prevent bleed through. Let ous active aspiration and a unique front-cutting Deployment accuracy is enhanced with a tri- Segment™ inner lumen catheter designed to Atrium, the world leader in balloon expandable head on all the family of catheters. The Navitus axial catheter shaft designed to provide added facilitate precise stent delivery across challeng - covered stents, and its superior V12 product catheter expandable blade technology enables support and placement accuracy as well as ing lesions. The everolimus drug and fluorinat - offering deliver the results you expect, where physicians to treat both the common and radiopaque markers to enhance ease of use. ed copolymer stent coating have been studied you need it and when you need it. To find out superficial femoral arteries with one device. The Innova Stent is 6F (2.0 mm) compatible in multiple randomized clinical trials and ‘real- more about Atrium’s V12 family and how it can Initially, the JETSTREAM System will be market - and is available in sizes from 5 mm to 8 mm in world’ registries in both Coronary and Peri phe - benefit your patients please visit us at ed to select countries through Bayer direct stent diameter and 20 mm to 200 mm in ral Artery Disease, demonstrating excellent www.atriummed.com or our Atrium booth 6 sales offices and local distributors. length. long-term safety and efficacy. The Promus during CIRSE. Element™ Plus BTK will be available in both Published by MEDRAD BV, Horsterweg 24, 6199 Over-The-Wire and Monorail ™ platform, and is AC Maastricht-Airport, The Netherlands. available with a reference vessel diameter of Phone 31 (0)43 3585600. Chamber of 2.25 mm to 4 mm and from 12 mm to 38 mm Commerce Maastricht 14045092 in length.

BOSTON SCIENTIFIC COOK MEDICAL COOK MEDICAL COOK MEDICAL

TruePath™ CTO Device Osteo-Site® Ratchet Bone Biopsy Aprima™ Access Nonvascular Peripherally Inserted Central and Infusion Needle Introducer Set Venous Catheters

The TruePath™ CTO Device, is designed to facil - Drill into hard bone easily with a ratchet- redefine access with a set engineered to make Provide the right PICC for any treatment itate the crossing of chronic total occlusions style needle. every aspect of your procedure go smoothly. and every patient. within the peripheral vasculature. The TruePath™CTO Device features a rotating Cook Medical’s versatile line of high-quality, Cook Medical offers the widest assortment of Cook Medical’s diverse array of venous access diamond-coated tip designed to break through ultrasharp, ergonomic Osteo-Site needles drainage products available, designed to ac - products, from PICCs and ports to both acute occluded peripheral arteries and facilitate the allows clinicians to access, biopsy and infuse cess, target and treat any drainage objective. and long-term CVCs, is designed to make sure placement of conventional guidewires. The bone in a variety of situations, ensuring that The Aprima Access set redefines access with clinicians are never left without an answer for ultra-low 0.018” (0.46 mm) profile is engineered any procedural need can be met. our long-established focus on patient comfort their patients. for optimal crossing and once positioned; the and procedural ease. distal tip rotates at 13,000 rpm through calci - Cook’s new Osteo-Site Ratchet needle is Our new 3.0 and 6.0 Fr Turbo-Ject power- fied lesions and other fibrous blockages. designed for situations in which hard bone · The Transitionless-Tip™ design requires less injectable PICCs continue our mission of penetration is needed. insertion force than standard access sets 1 and providing the right device in any situation. The ReOpen clinical study evaluated the virtually eliminates hang-ups during entry, TruePath™ CTO Device in 85 patients with peri - · A ratchet-style unidirectional drilling action which helps provide seamless access and · A complete line of PICC options can ensure pheral artery lesions. Study results demonstrat - and unique spade-tip design allow hand- reduce the risk of patient trauma. that you always have the tool you need, ed the device is safe and effective in facilitating drilling into hard bone. · The entire shaft and distal tip – not just one from silicone and power-injectable the crossing of intraluminal CTOs following re - · Hand control allows smooth drilling while small band – are radiopaque to maximize flu - polyurethane options to catheters uniquely sistance or prior failed attempts with a conven - reducing risk of incidental loss of pressure or oroscopic visibility during placement. impregnated with the antibiotics minocy - tional guidewire. In the study, technical success direction. · The set includes an EchoTip® echogenic ac- cline and rifampin to help prevent CRBSIs. was achieved in 80.0 percent of pa tients, while · The quiet drilling operation can help cess needle for optimal ultrasound visibility, · More sizes and configurations can increase improved post-procedure blood flow was de - maintain patient comfort. a Cope Mandril wire guide, and the hydro- treatment options and help improve monstrated in 82.4 percent of patients. Safety · The outer cannula is marked in 1 cm incre - philic-coated coaxial introducer sheath, patients’ lives every day. was demonstrated with a 98.8 percent freedom ments to help guide drilling and gage depth. which work to ge ther to ease every step of · New 3.0 and 6.0 Fr power-injectable PICCs from clinical perforation at the time of procedure. the placement process. add to an already diverse product selection.

CAUTION: The law restricts these devices to sale by or on the order of a physician. Indications, contraindications, warnings and instruc - ¹ Benchtop testing performed against industry tions for use can be found in the product labeling supplied with each device. Information for the use only in countries with standard products. Data on file. applicable health authority product registrations

Special Edition / CIRSE 2012 - Lisbon coIngRress advertisement 21 news

Advertorial new Product Launches

CORDIS COVIDIEN COVIDIEN

POWERFLEX® Pro .035” PTA OneShot™ Renal Denervation Viance™ Crossing Catheter System Enteer™ Re-entry System

Cordis announces the launch of the POWERFLEX® Covidien, a global leader in vascular therapies a different approach to Cto you can Enteer™ re-entry System – Pro .035” PTA DILATATION CATHETER in Europe. and RF technology, is proud to announce the really feel. the power of intuitive control introduction of the OneShot™ renal denerva - The Enteer™ re-entry system, consisting of the POWERFLEX® Pro is a .035” PTA workhorse tion system. The OneShot system’s balloon ca - Designed to ensure that the expert hand of the catheter and guidewire, gives you intuitive con - solution that delivers advanced crossability and theter features a proprietary, continuous spiral physician is front and center, the Viance™ cross - trol to reliably target the true lumen from the remarkable versatility to treat routine, or electrode and integrated irrigation to optimize ing catheter and the Enteer™ re-entry system subintimal channel above or below the knee. challenging cases in the lower extremities. procedural speed, consistency, and ease-of-use. work intuitively to provide effective treatments. The system requires no capital equipment. It’s designed to be nothing less than a precise POWERFLEX® Pro was developed to meet phy - Quick. Consistent. Controlled. viance™ Crossing Catheter – extension of your own expert hand. sicians’ needs for a lower profile, puncture re - Finesse over Force sistant, PTA balloon, in a wide range of sizes. · Single-treatment rF ablation reduces pro - A precision instrument designed to quickly and This balloon catheter offers many features and cedure time: 2 minutes total ablation per safely deliver a guidewire via the true lumen, benefits to aid in patient treatment; including artery the Viance™ crossing catheter puts the control long lengths up to 220 mm to treat long le sions · Spiral electrode creates standardized, of crossing where it belongs: in your hands. in one uniform dilatation, short balloon shoul - reproducible ablation pattern: no need for Providing an effective frontline option for ders for accuracy and post-dilatation balloon - catheter repositioning or multiple ablations CTOs, the Viance™ catheter enables you to uti - ing, along with a rated burst pressure of up to per artery lize a proactive technique to cross total occlu - 18 atmospheres to treat calcified lesions. · Integrated irrigation cools and protects sions via the true lumen. surrounding tissue, reduces char formation, POWERFLEX® Pro demonstrates the company’s and increases depth of lesion commitment to deliver solutions for the treat - · Low pressure balloon ensures consistent ment of Peripheral Vascular Disease (PVD) and wall apposition and ablation pattern. is the most recent addition to CORDIS Lower Available in 5-7 mm diameters, allowing Extremity Solutions Portfolio. physicians to treat a wide range of vessels · Designed for delivery over a standard 0.14” guidewire to allow for ease-of-use with tools familiar to interventionalists

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

116091-001 (A) JUL/12 - Intl 116091-001 (A) JUL/12 - Intl

INSIGHTEC MERIT MEDICAL PHILIPS STERYLAB

ExAblate O.R. ONE Snare™ – Industry leading image quality MULTICORE® Endovascular Snare System at a fraction of the dose

Exablate o.r. is the new generation Mr Merit Medical is pleased to introduce the ONE Philips new generation of interventional X-ray MULtICorE® provides an optimised needle guided Focused Ultrasound therapy for Snare™ Endovascular Snare System , with a systems, the AlluraClarity family incorporates a visualization under ultrasound guided biopsy treating uterine fibroids, adenomyosis and single 90-degree angle loop for retrieval and set of techniques, programs, and practices that procedures. By the natural of its constituent bone metastases manipulation of IVC filters, coils, stents and ensure excellent image quality, while reducing material it functions at any angle of entry into other foreign bodies. The Nitinol and gold plat - radiation exposure to people in X-ray the body in relationship to the generation of Reduced treatment time, expanded patient po - ed tungsten loop construction provides excel - environments. sound waves by the ultrasound transducer. pulation and increased treatment durability are lent visibility and structural integrity. The core Thanks to its perfect smoothness, avoids any new features offered by InSightec's ExAblate wire provides flexibility and super elasticity to During interventions you can’t afford to make a risk of seeding of malignant cells along the O.R. This 3 rd generation system implements the accommodate tortuous vessel navigation. The trade-off between image quality and X-ray needle’s path from the patient’s body out. experience of thousands of treatments. It en - ONE Snare Endovascular Snare System includes dose. But what if you could significantly reduce Specimens provided through MULtICorE® are ables physicians to treat the targeted region in a snare, a snare catheter, a new peel-away in - X-ray dose with no impact on image quality particularly abundant and allow a quick, safe less time, streamlining workflow and improv - tro ducer tool designed to simplify snare de - and no change to your preferred way of and easy biopsy procedure, either performed ing the user and patient experience. Women ploy ment, and a torque device. Available in working? manually or through the most common imag - who could not previously be treated effective - 9 different kit configurations with 7 snare loop Now you can with Philips revolutionary new ing guiding systems, such as CT, US, MRI. ly, i.e. scars, bowels in beam path, and fibroids sizes ranging from 5mms to 35 mms to generation of interventional X-ray systems: the of varying sizes, can now also be treated. accommodate a broad range of vessel sizes. AlluraClarity family.

ExAblate is a non-invasive treatment with pro - The ONE Snare, along with the interlaced triple Please visit www.philips.com/alluraClarity ven quick recovery, safe symptom relief, and loop EN Snare® Endovascular System are two for more information. effective, durable results, that preserves the retrieval options designed to provide you with uterus and fertility. It also provides effective the accuracy and reliability needed to capture pain palliation of bone metastases, osteoid or manipulate any foreign object within the osteoma and other painful osseous conditions. vasculature. Not available in the US.

Cardiovascular and Interventional Radiological Society of Europe C RSE 22 advertisement Saturday, September 15, 2012

Advertorial new Product Launches Submit your manuscript STERYLAB VIDACARE to a global audience! PARAGON® Introducing the Coaxial Biopsy

CVIR is the official journal of: 00270 • ISSN 0174-1551 34(1) 1-220 (2011) Tray, an innovative and versatile Austrian Society of Interventional Radiology (ÖGIR) solution for your bone biopsies Brazilian Society of Interventional Radiology and Endovascular Surggery (SoBRICE) CardioVascular and Interventional Radiology British Society of Interventional Radiology (BSIR) The official journal of the Cardiovascular and Interventional Radiological Society of Europe

Chinese Society of Interventional Radiology (CSIR) vol 34 Sterylab, in the biopsy field for 40 years, thanks OnControl® Bone Access System is the first sig - no 4 august Czech Society of Interventional Radiolgy (CSIR) 2011 to innovative technologies and advanced engi - nificant advance in bone biopsy technology in CV R Danish Society of Interventional Radiology (DFIR) neering, presents ParaGon ®: 40 years. Clinicians now have the ability to ef - Dutch Society of Interventional Radiology (NGIR) fectively, safely and rapidly obtain superior Finnish Society of Interventional Radiology (FSIR) the nEW MILEStonE of Bone-Marrow Biopsy. bone biopsies. Vidacare® is introducing an ad - German Society of Interventional Radiology (DeGIR) di tion to the OnControl® Bone Access System, Indian Society of Vascular and Interventional Radiology (ISVIR) Main advantages: the Coaxial Biopsy Tray designed specifically for Interventional Radiology Section of the Polish Medical Society of Radiology (PLTR) multiple bone biopsies in the same location. Israeli Society of Interventional Radiology (ILSIR) · 100% success in retrieval of intact specimen Japanese Society of Interventional Radiology (JSIR) · No need for bone luxation · Rapid access for hard bone lesions with a Korean Society of Interventional Radiology (KSIR) · Easy and fast maneuvre uniquely designed power driven needle Russian Society of Interventional OncoRadiology (SIOR) Available online C RSE www. springerlink.com · One maneuver for bone marrow biopsy and technology Swiss Society of Cardiovascular and Springer aspiration · Precise access to the most difficult target Interventional Radiology (SSCVIR) · Bone marrow aspiration after biopsy lesions Cardiovascular and Interventional Society of Turkey (TGRD) · Minimally invasive, less pain: 11G can replace · Enables multiple bone biopsies in the same C standard 8G location To submit a manuscript, please visit: vIr'S IMP nEW · Exceptional core biopsy samples, quickly and http://mc.manuscriptcentral.com/cvr aCt FaCt View it at: consistently 2.0 or: http://www.sterylab.it/Marketing/Paragon/ · Versatile design provides options for your 93 specific needs

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

Card T h e io o f f i c i Va a l j o u scu r n a l o la f t h e r a C a r d i nd o v a s c In u l a r a te n d I n rve t e r v e nt n t i o n ion a l R a d al i o l o g Ra i c a l S di o c i e t y olo o f E u gy C r o p e V v o l 3 4 n o a 4 R ugust 2 0 1 1

It’s not too late ... sign up for the ESIr autumn Courses now!

ES Ir 20 12 Courses

European School of Interventional Radiology

CLI & Diabetic Disease radiologia Intervencionista no vascular Liver Interventions vienna (at), october 5-6, 2012 Bilbao (ES), 19-20 de octubre, 2012 Munich (DE), november 9-10, 2012 this course is designed for physicians at an interme- (course in Spanish language) this course is designed for physicians at an inter - diate level who wish to build on their existing expe - El curso tratará los siguientes temas: mediate level who wish to broaden their rience in the treatment of critical limb ischaemia. · Técnicas intervencionistas en los conductos knowledge of liver interventions. biliares, el tracto urinario y el tracto digestivo You will learn about: You will learn about: · El papel del ultrasonido en el tratamiento aconsejado · Diagnosis and treatment goals · Indications for various treatment options · Gestión de complicaciones · Endovascular devices and tools · Ablation techniques · Seguimiento del paciente · Access and interventions including recanalisation · Embolisation techniques including chemo- and · Protección de radiación pertinente techniques radio-embolisation · Specifics of diabetic foot management Este curso está diseñado para médicos de niveles 2-3 · Complications · Interdisciplinary teamwork and clinical care (intermedio) quienes desean mejorar sus conocimien - · Clinical results tos y capacidades en intervenciones no vasculares.

aortic & thoracic Stent Graft Biliary Percutaneous Interventions For the detailed programme rome (It), october 12-13, 2012 Prague (CZ), october 26-27, 2012 or further information, this course is designed for physicians at an in ter - this course is intended for physicians at basic and mediate and advanced level with existing expertise intermediate level who wish to offer percutaneous please visit www.cirse.org in aortic and thoracic stent grafts who wish to biliary interventions. or write to [email protected] broaden their horizons in the field. You will learn about: You will learn about: · Imaging techniques for diagnosis and work-up · Indications for treatment and patient selection · Practical techniques, including tips and tricks · The role of EVAR and other treatment options · Details and comparison of treatments for benign · Pre- and post-procedural imaging and malignant lesions · Device selection and techniques · Treatment evaluation · Possible complications and their management · Contra-indications and complications

Special Edition / CIRSE 2012 - Lisbon CIR SE 201 2 WiFi and Mobile App

at CIrSE 2012, we will once again offer a free Wireless Service to all delegates. this ensures that you can enjoy the many features of the CIrSE 2012 Mobile app all day long!

Get connected!

WiFi Log-in Details Username: cirse Password: cirse2012

The Wireless Service is available throughout the congress centre (with the exception of the Exhibition Halls Pavilion 1 and 2). It will disconnect after 30 minutes if not actively used.

CIrSE goes live!

Download the brand new CIrSE 2012 Mobile app and browse through numerous categories, including:

· congress programme and agenda · speakers · publications · exhibitors · floor plans · live news feeds · Lisbon city guide · and much more…

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The above services are kindly sponsored by Cook Medical be insp Ir ed...

The IRs of the Future

The future of any specialty depends on attract - positive feedback received, we are this year ing bright and enquiring minds to it ranks, and expanding the programme to include under - on those minds surpassing the existing scientific graduates from all over Europe, and offering data with their own innovations and research. introductory lectures in both English and Portuguese. For many medical students, their discovery of interventional radiology comes late in their The 2012 initiative has attracted over 300 re - careers. Radiology education has typically been gistered students from across Europe, and we presented in terms of diagnostics, and the warmly welcome them to our Annual Meeting! more hands-on, clinically-oriented students To ensure that the participants get the most often choose their field of specialisation with - out of the congress, we have recommended a out being fully aware of their options. Indeed, range of courses and sessions that are especial - many of CIRSE’s most active members started ly relevant for medical students, as well as doc - out as surgical registrars. tors just starting out in their careers.

Additionally, students are rarely given the op - The popularity of this initiative just goes to por tunity to experience a medical congress – show that medical students are eager to learn even with discounts, the costs can be prohibi - more about our specialty, and it underlines tive. How can medical trainees get a feel for the how important it is for the IR community to en viron ment, the devices, the research and the constructively interact with them before they ca reer options if they are only ever in the choose their career path. classroom? Welcome to CIRSE 2012! Providing support and inspiration We are delighted to welcome so many medical For the last two years, CIRSE has offered local students to our congress, and hope you will medical undergraduates the opportunity to find the sessions and the atmosphere informa - attend our congress free of charge. CIRSE gave tive and inspirational. Be sure to join us for the students the chance to see a new side of medi - in tro ductory lecture today (11:00 in Portu - cine, and they described the experience as guese; 13:00 in English), where experienced IRs being “exciting and entertaining,” “inspira - will explain the various procedures and career tional” and “an optimal concept”. Due to the op tions, before letting you explore the disci - pline for yourself.

Today’s student sessions:

Introducing Ir (in Portuguese language) 11:00-12:00, Auditorium 4

Introducing Ir (in English language) 11:00-12:00, Auditorium 4

Simulation training – Basics of angioplasty and stenting With kind cooperation from Mentice and Simbionix 16:30-17:30, Simulator Gallery

Essentials of Femoral artery access and Haemostasis: Proper techniques and Management of Complications 16:30-18:00, Cordis Cardiac & Vascular Institute Learning Centre

Full programme available on: · www.cirse.org/students · CIRSE 2012 App

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

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