ePOSTER WALL

Mechanical Thrombectomy In Lebanon , Challenges And Success

1Anis Nassif

1Lebanese American University

Background(s):

The Comprehensive Stroke center was established in february 2017 at the Lebanese American University in Beirut Lebanon as the only stroke center in the country . It offers all aspects of neurointerventional treatments .Despite all the challenges our country and medical system are facing , we managed to perform over 250 mechanical thrombectomies with over 80 % TICI 2c/ 3  recanalizations and successful mrs scores at 90 days . We would like to share our data and experience as well our financial difficulties in overcoming our many daily challenges in Lebanon

Material(s) and Method(s):

Retrospective analysis of all mechanical thrombectomy patients and their outcome and return to performing daily life activities and mrs scores .

About 80 % with ADAPT aspiration technique using the Penumbra aspiration system.10% with stentrievers using TREVO and Embotrap 10% with combined aspiration and stentrievers

Result(s):

In our center , we have predominantly partnered with Penumbra using the Ace 68 and Jet  aspiration catheters to obtain about 80 % successful recanalization after first or second pass to successfully treat LVO in the carotid or M1 segment as well as about 20 % tandem lesions . We found no difference in outcome with aspiration or stentrievers or combined approach in obtaining TICI 2c or 3 recanalization on first / second pass .

Conclusion(s):

Despite all the challenges our country Lebanon is facing , we managed to open a comprehensive stroke center and successfully treat patients with LVO and devastating NIHSS scores of greater than 12 with an 80% recanalization success rate . We are trying our best to educate the community and the country on stroke prevention and treatment modalities available in our state of the art comprehensive stroke center .

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Visualization Of The Brain Functional Activity Using Infrared Camera. What Can Bring Body Infrared Scanning To Endovascular And Interventional Radiology?

1Tigran Ghevondyan

Background(s):

Mankind is permanently working on and developing new devices for studying the brain, for assessing the cognitive and psycho-emotional state of a person. Currently, to study the functional activity of the brain, devices are used which combine the concepts of PET / CT, fMRT, fNIRS. These methods use X-rays, powerful magnetic fields, infrared rays, and visible light rays. For diagnostic and treatment, pdrticularly of brain pathology these methods are successfully combining with recently appeared methods of endovascular and interventional radiology.

The purpose of this study was to try to use a heat infrared chamber to visualize the processes of functional activity of the human brain. Several types of infrared cameras were used in our studies, among which the FLIR thermal camera in the CATS62Pro cell phone became the main research hardware. More than 900 thermal images of the head, face, hands, feet and about 80 thermal video recordings of the mentioned body parts are filmed with thermal camera. A comparative analysis of images and video recordings showed a significant advantage of the method of thermal video recordings for studying the functional activity of the brain.

Material(s) and Method(s):

Almost 800 photographs and video recordings of the head, face, limbs of more than 70 people of both sexes, different nationalities and different races were subjected to a multilateral study. Some participants had to be filmed multiple times, which was based on the requirements for the development of different sides of the method. The age of the participants ranged between 2 years and 86 years. Among studied persons one has suffered from left hand dysfunction. Video recordings of the heads of six men aged 32-85 formed the basis of this study. All six men were united by one sign – the absence of hair on their heads or the fact that they shaved their head hair. In men, non-contact imaging of five parts of the head was made: parietal, frontal, occipital, right and left temporal. Five static frames were cut from each video recordings, respectively, the 1st, 6th, 11th, 16th and 21st seconds. The arrangement of these static images in a row and their comparative evaluation made it possible to carry out a more detailed assessment of brain activity. During filming, the men sat in a chair and looked at a dimly neutrally painted wall from a distance of about two meters. Filming was carried out in a moderately lit room, at a temperature of 20 degrees Celsius.

Result(s):

Based on the analysis of thermal records, the following results were obtained. Video recordings of the head with a thermal imager make it possible to obtain information of a qualitatively new level compared to thermal photographs and, therefore, video recordings should become the basic method for studying the functional activity of the brain using thermography.

The thermal camera detects and registers the occurrence, presence, movement, extinguishing of warm foci and fields that correspond to functionally active areas of the grey matter of brain.

The functional activity of the brain is observed in all five parts of the head: parietal, frontal, occipital, in both temporal regions. In the simple sitting test used in this study, brain activity is more pronounced in the parietal and occipital parts of the head, which can be explained by the work of the sensorimotor zones of the anterior and posterior central gyri of both hemispheres of the brain, and the cerebellum, to maintain body position.

The movement speed of the active zones on the surface of the head is very high, however, they are completely captured and recorded by the thermal camera due to the high frame rate in infrared video mode (30 frames per second).

A direct interconnection was observed between functional activity of brain right hemisphere and left hand functional acquired restriction.

A relatively long video recording made it possible to detect an unexpected phenomenon that was remained undetected in thermal photographs [8]. We are talking about “flashes” of infrared radiation, which have different distribution over the area and different intensity. Flashes illuminate the entire or almost the entire head of the subject.

It was found that the frequency of outbreaks varies in different men: from one to five outbreaks in 30 seconds. Preliminary data indicate a possible connection or relationship between the frequency of outbreaks, on the one hand, and the general state of the body, brain functional activity, on the other hand.

Conclusion(s):

Now, the method has three disadvantages. 1) The impossibility of recording radiation from the cortex of the lower and inner parts of the brain, including the hippocampus and amygdala. 2) Low quality of thermal images of the head in persons with thick hair on the head, especially in women. 3) The need to have at own disposal five of the same type of thermal imaging cameras, since in some studies of the brain it may be necessary to synchronize video recording of brain activity in all five of the above-mentioned sections of the head at the same time.

However, along with its shortcomings, the method has broad prospects for being applied due to its advantages. The advantages are: no contact with the body of the subject during recording or video filming, high spatial, temporal, temperature resolution of the thermal camera, relative cheapness, absolute absence of influence of the thermal camera on the body, high autonomy from external power sources. Thermal video recording, along with direct or transcutaneous corticography, allows to get a picture of the “thought construction” in the brain even before these thoughts are realized by a person. And in comparison with the method of corticography, which is excessively traumatic and fraught with complications, thermal video recording has an important advantage, which gives a live, direct picture on-line. In addition, in the case of corticography, obtaining a picture is mediated through the transformation of electrical impulses into a color picture, through image reconstruction programs. Already today, the use of thermal video recording of the head is able to independently solve a number of problems in the areas of clinical resuscitation, neurosurgery, neurology, psychiatry, psychophysiology, for the early detection of autism in children, in the field of lie detection, in assessing the condition of astronauts in spaceships and stations. Undoubtedly, with all its limitations, the presented method of thermal videography is a valuable addition to the well-known widely used radiological methods for studying the brain, body. New era is beginning for cooperation and common work thermal imaging methods and methods and devices of endovascular and interventional radiology.

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Predictors Of Good Clinical Outcome After Thrombectomy For Distal Medium Vessel Occlusions

1Adrien Guenego,1Boris Lubicz, 1Boris Lubicz

1Erasme Hospital

Background(s):

Good clinical outcome predictors have been emphasized in mechanical thrombectomy (MT) for acute ischemic stroke (AIS) with large vessel occlusion (LVO). MT for distal, medium vessel occlusions (DMVO) is still debated. We sought to assess the factors associated with clinical outcome after MT for DMVO.

Material(s) and Method(s):

We retrospectively analyzed the data of consecutive patients who underwent MT for a primary DMVO in one large academic center and aimed to identify the baseline clinical, imaging and MT factors associated with good clinical outcome (defined as modified Rankin scale [mRS] of 0-2) at 3 months.

Result(s):

Between January 2018 and January 2021, 61 patients underwent a MT for an AIS with a primary DMVO.

Overall, good clinical outcome was achieved in 56% (34/61) of our patients. In multivariate analysis, we identified higher age (ODDS ratio 0.89 [0.83-0.96], p=0.003), puncture to recanalization time (ODDS ratio 0.97 [0.93-0.99], p=0.033), and baseline core volume (ODDS ratio 0.84 [0.75-0.94], p=0.003) as negative predictors of good clinical outcome, while final complete (or near-) recanalization (mTICI 2c-3) was a predictor of good outcome (ODDS ratio 14.19 [1.99-101.4], p=0.008).

Conclusion(s):

An older age, a longer puncture to recanalization time and a higher baseline core volume were strongly associated with poor clinical outcomes, while successful recanalization (mTICI 2c-3) was associated with better outcomes after MT for DMVO.

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The Anch’Or Harpoon Technique With A Manually Expandable Stentretriever (Tigertriever 13)

1Adrien Guenego,1Boris Lubicz, 1Boris Lubicz

1Erasme Hospital

Background(s):

Stent or balloon anchor technique has been emphasized in obtaining distal purchase to allow straightening of catheter loops, stabilize microcatheters in giant aneurysms or to access distal tortuous anatomy in thrombectomy.

Material(s) and Method(s):

Because of tortuosity and length, it is sometimes impossible to even reach a potential target with a microcatheter in thrombectomy, precluding the distal unsheathing of classical auto-expandable stentretrievers to perform the anchor technique.

Result(s):

We therefor developed the so called Anch’Or Harpoon Technique using a manually expandable stentretriever, the Tigertriever 13 (Rapid Medical, Yoqneam, Israel), in which the stentretriever is advanced outside of the microcatheter while remaining closed: either in case of tortuosity, where the Tigertriever 13 is opened distally to the microcatheter to establish a stable anchor prior to advancing the guiding and intermediate catheters as well as the microcatheter (anchor technique), either in case of length issue in distal occlusions where the Tigertriever 13 and its distal tip are used to cross the clot, then opened through the clot and retrieved (harpoon technique) to obtain a complete recanalization.

Conclusion(s):

The anchor and the harpoon technique seem feasible with a new generation of manually expandable stentretrievers.

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The Effect Of Uterine Artery Embolization On Fertility And Pregnancy : A Single Center Experience

1Abeer Faisal Aldhawi,2Maithaa Mohammed Alharfi, 3Maithaa Mohammed Alharfi, 3Abdullah Dhafer Alshehri, 1Fares Ali  Garad, 3Fares Ali  Garad, 3Ahmed Owaidh  Almutairi, 3Ehab Wahbah, 3Hatim Saad Alobaidi

1King Fahd Medical City, 2King Khalid Hospital, 3Prince Sultan Military Medical City

Background(s):

Uterine artery embolization is effective management for symptomatic uterine fibroids and postpartum haemorrhage. Several studies are evaluating the effects of the UAE on late pregnancies.  However, the effects on fertility are still uncertain. Uterine artery embolization has been studied as an alternative to myomectomy and hysterectomy, it has become both appropriate and famous, as a nonsurgical option used to treat these as a treatment for symptomatic uterine fibroids. The current study aims to assess the outcome of pregnancy rates following UAE in women seeking pregnancy.

Material(s) and Method(s):

A retrospective cohort study was carried out in Prince sultan military medical city among 221 married women aged 15-55 years. The questionnaire contains the socio-demographic profile of the participants, the reason for embolization, the pre and post embolization situation of the patient including previous pregnancies and their complications, contraception use, etc. The collected data were statistically analyzed using SPSS version 21. Chi-square tests and Logistic regression models were used. Associations were considered statistically significant at a P-value < 0.05.

Result(s):

The most common reason for embolization among the 51 patients is fibroids in 27 (52.90%) and PPH in 18 (35.20%) patients . The mean age of those 51 patients was 39+6.1 (range: 23 – 52) years.

A positive correlation was observed between those trying to conceive after the embolization and those who successfully conceived (p-value < 0.001), with 26 (51%) conceiving and 25 (49%) patients not conceiving. The age of women that conceived (32+4.6) versus those that did not (38.3+4.6) was significantly different, (p-value < 0.00001). It took less than one year to conceive for most of the subjects who successfully conceived. 99%(24patient ) conceived naturally, while one patient required assisted conception. Of those who conceived, (48%) had complications, while (52%) did not.60% of them had mischarged in previously failed pregnancies after the procedure while 30 % had bleeding in a different trimester. 10 % had placenta previa.

Conclusion(s):

Our results demonstrated that most of the women successfully conceived within less than one year. Among them, primarily women conceived naturally, and less than half of the patients had complications after conceived.

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Low Acute Hospital Resource Burden With Mechanical Thrombectomy Of Deep Vein Thrombosis In The Us-Based Clout Registry

1Abdullah A. Shaikh

1Allegheny Health Network

Background(s):

Endovascular treatment options for deep vein thrombosis (DVT) are evolving and include mechanical thrombectomy and catheter-directed thrombolysis (CDT). Mechanical thrombectomy may be beneficial over CDT as it does not necessitate thrombolytics and has the potential to significantly reduce intensive care unit (ICU) monitoring and hospital resource burden. The real-world ClotTriever outcomes (CLOUT) registry is currently evaluating patient outcomes following treatment of lower extremity DVT in the United States. The goal of this sub-analysis is to assess the acute hospital resource burden associated with DVT treatment using the ClotTriever System (Inari Medical, Irvine, CA).

Material(s) and Method(s):

The prospective, multi-center CLOUT registry assesses the safety and effectiveness of the ClotTriever System for the treatment of proximal lower extremity DVT with no restrictions on thrombus chronicity. Patients with unilateral or bilateral DVT, prior history or treatment of DVT, provoked or unprovoked DVT, high bleeding risk, cancer, or pregnancy were included. The primary effectiveness endpoint is complete or near-complete (≥75%) thrombus removal as determined by core laboratory-adjudicated Marder scores. Per protocol, various resource measures were collected during index hospitalization and through 30 days.

Result(s):

Of the first 250 patients enrolled in the CLOUT registry, median age was 62 years, 53% were male, 23% had prior history of DVT, and 40% were at a high bleeding risk with thrombolytics. Almost all procedures were performed in a single session (99.6%) with a median of 4 device passes and a median thrombectomy time of 28 minutes. No patients required adjunctive thrombolytics. Adjuvant venoplasty was used in 73% and stents were placed in 47% of cases. Median blood loss was 50 mL. Complete or near-complete thrombus removal was achieved in 85% of limbs, including 51% with complete thrombus removal. Post-thrombectomy ICU stay was needed in 6 patients and the median post-thrombectomy hospital stay was 1 day. Through hospital discharge, the reintervention rate was 0.4%. Through 30 days, the hospital readmission rate was 7.6%, of which 3.1% were procedure-related.

Conclusion(s):

Interim results from the US-based CLOUT registry demonstrate that mechanical thrombectomy with the ClotTriever System can be performed in a single session and is associated with short thrombectomy times, no need for thrombolytics, low blood loss, minimal ICU usage, and low hospital readmission rate. Further, these results indicate that the ClotTriever System is effective at removing thrombus while imparting low acute burden on hospital resources. Enrollment to 500 patients and two-year follow-up are ongoing.

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Thoracoabdominal Aortic Aneurysms Secondary To Aortic Dissection: Fenestrated Endovascular Aortic Aneurysm Repair (Fevar)

1Javairiah Fatima

1Medstar Health

Background(s):

Thoracoabdominal aortic aneurysms (TAAA) secondary to complex aortic dissections are a challenging pathology to treat, with significant morbidity and mortality associated with open repair even in patients deemed to be good risk. Herein we present a physician modified endograft used for total endovascular repair of a complex TAAA.

Material(s) and Method(s):

A 55 year old patient with history of Type A Dissection, ascending aortic replacement s/p arch debranching (innominate, and left common carotid artery), carotid-subclavian bypass and an antegrade thoracic endovascular stent graft placement (TEVAR) presented with an enlarging TAAA. A Cook Alpha thoracic endovascular device was modified back table to create a stent graft with 5 fenestrations customized to the patient’s anatomy and implanted.

Result(s):

Patient underwent a 5 vessel fenestrated endovascular stent graft repair of his aortic aneurysm in a staged fashion. Initial stage included implantation of the modified alpha device with bridging stents into celiac axis, superior mesenteric artery, 2 left renal arteries and one right renal artery.  Patient was discharged on POD 3 and then brought back as an outpatient in a month to embolize three sets of lumbar arteries and complete expansion of the iliac stent in the dissected right common iliac artery, completing the repair. Patient did very well with excellent integrity of repair on postoperative CT scan and no endoleak.

Conclusion(s):

Physician modified endovascular repair of complex thoracoabdominal aortic repairs is feasible and provides a durable repair for patients who otherwise may be unfit for open surgery.

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Safety And Efficacy Of Midline And Peripherally Inserted Central Catheter For Intravenous Therapy: A Randomized Controlled Trial

1AHMED BENTRIDI,1Patrick Gilbert, 1Patrick Gilbert, 1AHMED BENTRIDI, 1Vincent Oliva, 1Vincent Oliva, 1LOUIS BOUCHARD, 1CHOUNARD A, 1BERNIER C,

1CHUM

Background(s):

To test the hypothesis that Midlines are non-inferior to PICC for intravenous therapy that does not require a central catheter.

Material(s) and Method(s):

Vascular Plug insertion and bProspective randomized open-label clinical trial, in which Midlines are compared to PICCs in adults who required peripheral intravenous therapy of 1-4 weeks. With a noninferiority margin of 10%, 510 patients need to be enrolled in this study. Patients eligible for Midline according to recommendations of the Infusion Nurses Society (2016) were included. Vesicant intravenous therapy was excluded. Patients were followed until one week after venous access removal.  The primary efficacy outcome was the percentage of patients who completed their treatment without limitation due to catheter dysfunction.

Result(s):

This interim analysis includes the first 72 patients enrolled (45 men, 27 women; average age: 52,6 years) since August 2018, 35 randomized to the Midline group and 37 to the PICC group.  One catheter was removed prematurely in both groups (P=0,78). Catheter dysfunction, mostly incapacity to draw blood, was observed in 6/35 (21%) patients in the Midline group versus 1/36 (2,8%) patients in the PICCs group (p=0,01). There were 3/35 (8,5%) device-related adverse events in midline group and no adverse event in PICCs (p=0,46), There was one unrelated death in the PICC group and no major device-related event in both groups

Conclusion(s):

Comparison of primary efficacy outcomes with available data is not yet conclusive. However, given the greater catheter dysfunction rate with Midlines, these catheters should not replace PICC in patients with difficult venipuncture and who require blood samplings.

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Esophago-Pleural Fistula Closure With Vascular Plug And Bone Cement Injection Resulting From Chronic Pulmonary Koch’S

1Dr Maniah Rajput,1Dr Mukesh Kalla, 1Dr Mukesh Kalla, 1Dr Pankaj Shrimal

1SR kalla Hospital

Background(s):

Esophagorespiratory fistula (ERF) is an uncommon condition. Benign ERF is rare and may be due to Koch’s disease, trauma or infection. However, there have been few reports describing benign ERF and its treatments. Here we report a case of nonmalignant esophagopleural fistula successfully treated by vascular plug after complete filling of fistulous tract by bone cement and plug by NBCA.

Material(s) and Method(s):

Vascular Plug insertion and bone cement injection was considered as the first treatment due to the large chronic fistulous tract and. Bone Cement injection given by 12 Fr long sheath and through ICDT insertion site. A 24-mm diameter vascular plug (LifeTech, USA) was deployed under direct fluoroscopic vision

Result(s):

A repeat endoscopic and radiologic study demonstrated no extravasations. The patient remained asymptomatic at the subsequent follow-up 6 months after the Plug Deployment.

Conclusion(s):

Vascular plug alone can not stay at its place due to epithelization of the fistulous tract and dislodges from its site as in our case.

The pleural / Pulmonary site needs to close fully and permanently by any mean and primary pathology needs to treat vigorously.

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Interim Analysis Results Of A Prospective Monocentric Study On Totally Percutaneous Deep Foot Veins Arterialization

1Bruno Migliara

Background(s):

In the past decade, unfortunately, despite a continuous improvement of techniques and materials, for up to 20% of CLTI patients, revascularization is not possible or is not effective.1

For these patients, arterialization of the foot venous system could be considered an alternative treatment for limb salvage2-5.

The aim of this study is to evaluate the safety and effectiveness of our own standardized technique (Pioneer Peschiera Revascularization technique, PiPeR-technique) using an IVUS guided catheter, published on the EJVES 2018, in order to reduce major amputation in “no-option” CLTI patients6.

Material(s) and Method(s):

This study represents a prospective monocentric analysis on a continuous series of 18 “no-option” CLTI patients treated, from April 2019 to August 2021, in our department using the PiPeR technique6.

This study is conducted after the approval of the Verona-Rovigo Ethical Committee (n°6106, 30.01.2020) and all patients subscribed a specific consent.

The primary end-point is the limb salvage rate. The secondary end-points are: survival, amputation free-survival (AFS), wound healing. Furthermore, we analysed the quality of life of every patient during the healing process (Vascu Qol-6 Quest, Eq-5D-3L Quest and Eq-VAS Quest).

Result(s):

Eleven indWe performed 18 p-DVA in patients with “no-option” CLTI, 12 male and 6 female.  Median age is 74,4 years (60-87). Eleven patients in Rutherford 5 class (61,1%) and 7 in Rutherford 6 class (38,9%). Based on the WIfI classification: 16 (88,9%) in stage 4; 1 in stage 3 and 1 in stage 2. All these patients with a previous failed angioplasty of the tibial and foot arteries.Severe MAC-SAD is present in 15 patients (83,3%) and the median TcpO2 was 13,5 (8,53) mmHg. Procedural success rate is 100%. The median duration of the operation was 169,7 minutes (100-280). The median flow rate in the common plantar vein was 312,4 cm/sec (166-440).During the follow-up (median 502,7 day) we had 3 deaths (16,7%), not directly related to the arterialization. The limb salvage rate is 83,3%, because we had 3 major amputations; the AFS is 66,7%.

Despite a quite poor patency (38,9%), we obtained a good improvement of the TcpO2 from 13,7 (1-26) mmHg to 54,9 (31-84) and, also, the complete wound healing was obtained in 13 patients (72,2%), with a median time of 213,7 days (89-385).

Analysing our data, it’s possible to state that the patency of the p-DVA is mandatory during the first 6 months; after this period, probably due to the remodelling process of the arterialized veins and angiogenesis, if there is an occlusion of the p-DVA the TcpO2 remains high and the wound healing continues anyway.

Quality-of-life questionaries showed a tendence to the worsening during the first month and after a progressive improvement.

Conclusion(s):

Based on these interim analysis results of our registry, p-DVA, using the PiPeR-technique, seems to be safe and effective for “no-option” CLTI patients facing major amputation, with no mortality related to the intervention and an acceptable limb salvage rate and amputation free survival.

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Initial Oxford Experience Of The Inari Clottriever In Mechanical Venous Thrombectomy For Iliofemoral Deep Vein Thrombosis

1Ahmed Elzein Mohamed,1Emma Wilton, 1Emma Wilton, 1Andrew Wigham

1Oxford University Hospitals

Background(s):

The role of mechanical thrombectomy technology is increasing in the management of occlusive deep vein thrombosis (DVT). This paper describes the initial experience of eleven cases within a tertiary UK centre in the use of the ClotTriever device for mechanical venous thrombectomy.

Material(s) and Method(s):

A prospective database of all cases of venous thrombectomy with the ClotTriever device performed over a nine-month period was documented between 15/04/21 to 12/01/22 at a single tertiary UK hospital. Demographics, initial presentation and immediate procedural outcomes were recorded. Symptom improvement was assessed alongside follow-up vascular doppler ultrasound study at 24 hours, 2 weeks, 3 months and 6 months post-procedure. Clot clearance was assessed during the procedure with visual estimation of a contrast venogram and intravascular ultrasound. Technical success was defined as successful clot evacuation without the need for post-intervention thrombolysis or the use of additional thrombectomy devices. Re-occlusion rates at six months and subsequent need for re-intervention of the treated segment were also measured.

Result(s):

Eleven individual patients were treated with the Inari ClotTriever device (7 Male, 4 Female). Median age of 53 years (range 18-70 years). General anaesthesia was used in 55% (6 patients) and local anaesthesia for 45% (5 patients) of cases. Popliteal vein of the affected side was used for access in all cases. Median number of passes with the ClotTriever device was 5 (range 4-12). Complete clot evacuation ranged between 80-90%. Average number of iliac/femoral vein stents inserted 1.55 (0-4). Primary assisted patency 100%, with a 3-month primary patency rate of 82% (two requiring re-intervention within 3 months). No requirement for thrombolytic therapy or ICU admission. The 30-day mortality was zero. Re-occlusion rate at six months was zero..

Conclusion(s):

Initial experience suggests that the use of the ClotTriever device for mechanical venous thrombectomy in iliofemoral deep vein thrombosis is safe and effective. Follow up vascular ultrasound demonstrated good identification of the requirement for re-intervention. These cases contribute to the developing evidence base underlying venous thrombectomy and the increasing range of options for patients presenting with occlusive venous disease.

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Location, Location, Location! Is The Site Of Fistula Stenosis A Predictor For Primary And Secondary Patency?

1Michael Parker,1Baljeet Dhillon, 1Baljeet Dhillon, 1Tariq Ali

1Norfolk & Norwich University Hospital NHS Trust

Background(s):

There is a paucity of evidence to support the use of fistulaplasty to optimise and maintain vascular access at different lesion sites.

Material(s) and Method(s):

All patients undergoing fistulaplasty at a single-centre, tertiary vascular centre between 13/01/2015 and 21/09/2019 were included in the study. Baseline characteristics were recorded, and factors associated with Primary- and secondary patency rates were investigated.

Result(s):

206 patients (88male, 118 female) mean age 68(14) years underwent fistulaplasty. Prevalence of diabetes, ischaemic heart disease & antiplatelet usage were 33.3%, 21.4% and 69.9% respectively. The median number of fistulaplasties performed per access during the follow up period was 2[1-3].  65 fistulae were radiocephalic, 102 brachiocephalic, and 39 brachiobasilic transposition. 60 patients underwent a previous fistulaplasty before the study period, which we have termed recurrent stenosis (RS) and 146 were de novo stenoses (DNS). Stenosis location differed significantly between RS and DNS (p=0.03), with DNS primarily being anastomotic and RS prevailing in central and mixed locations. Younger fistulae were significantly more likely to have anastomotic stenoses than fistulae aged >1 year (p=0.001). These findings did not translate into statistically significant difference in primary patency, yet differences in SP were found by location of stenosis: Central 32[13-42] months, Fistula vein 20[12.5-35.5] and Mixed (n=33) 25 [13.5-37.5] months, Anastomotic 19[7-29.5], p=0.012.

Conclusion(s):

Fistula stenosis location is associated with the age and type of fistula. The failure of younger fistulas is usually secondary to anastomotic stenoses, and that these stenoses have a lower secondary patency than stenoses elsewhere. Provisional data suggests that central stenoses which primarily occur in older fistulae have better secondary patency following fistulaplasty than stenoses at other sites.

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Managing Abdominal Aortic Aneurysm, Open Surgery Versus Evar, A Retrospective Comparative Study

1Mohamed Rizk

1Faculty of medicine, Ain Shams university

Background(s):

Abdominal aortic aneurysm is a serious condition that can affect the life of the patient. It is treated when the size of the aneurysm reaches a cut value of 5.5 cm. dealing with AAA is either with open surgical repair which carries significant morbidity and mortality, or it can be done using a minimally invasive technique using an endograft (EVAR). This new technique is a demanding procedure, and these demands may not be met in all patients, noncompliance with these demands may lead to reintervention and increased risk of rupture

Material(s) and Method(s):

This were a retrospective study which included 61 patients from the period of December 2014 till December 2020. We included male or female patients presenting for elective repair of infrarenal abdominal aortic aneurysm (AAA) or having pain or leakage but not free rupture. According to the intervention method, patients were divided into two groups. Group (A): patients who underwent open surgical repair, group (B): patients who underwent endovascular aortic aneurysm repair (EVAR).

Result(s):

There was no significant difference between both groups as regard the demographic data except for age (P=0.0026). As regard the indication for intervention, there was no statistical difference (P=0.4881). there was a high statistical difference between both groups as regard the size of the aneurysm (P<0.0001). Patients in the surgical group have had general or combined general/ epidural, while patients in the EVAR group underwent the procedure using local or locoregional anesthesia. Intraoperative mortality in the surgical group was 4.65% versus non in the EVAR group. The operative time is significantly decreased in the EVAR group in relation to the surgical group (P< 0.0001). The postoperative mortality in the surgical group was 4.9% compared to 0% in the EVAR group (P=1.0000). The total hospital stay was found to be 8.9024 ± 1.9976 days in surgical group, while in the EVAR group it was 4.5 ± 0.9574 days with a P value of < 0.0001.

Conclusion(s):

Open surgical approach for managing AAA was associated with increased perioperative mortality and morbidity with increased hospital stay while EVAR was associated with less rates of perioperative morbidity and mortality but with increased rates of reintervention and late rupture, especially with non-adherence to the indications of use. Managing an AAA with either open surgical approach or EVAR must be tailored according to the patient’s comorbid condition and anatomical suitability.

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Primary Patency Rate With Paclitaxel Coated Balloon Angioplasty Versus Covered Stenting Of Failed Arteriovenous Grafts: A Retrospective Comparative Study

1Mohamed Rizk

1Faculty of medicine, Ain Shams university

Background(s):

To compare the technical success, primary patency of thrombosed prosthetic vascular access grafts of the upper limb after thrombectomy and dealing with the stenosis at the venous anastomotic site either with percutaneous angioplasty (PTA) with a Paclitaxel coated balloon or with stenting using a covered stent.

Material(s) and Method(s):

We reviewed the data of forty-seven (47) patients with thrombosed prosthetic vascular access PTFE grafts of the upper limb, who met our inclusion criteria from January 2014 till January 2021, patients underwent thrombectomy and intraoperative angiography. Patients were stratified into two groups according to how we dealt with venous anastomotic site. In group A, we used a Paclitaxel coated balloon, while in group B we used a covered stent.

Result(s):

The success rate was 100% (n=26), 100% (n=21) in both groups, in either the technical aspect or the clinical one (having dialysis from the access). There was no statistically significant difference between both groups as regard the descriptive data. Also, there was no statistical difference between both groups as regard the time since creation of the access (P = 0.9159). The primary patency of the procedure for group A at 3, 6, 12, 18, and 24 months was 88.46%, 73.08%, 61.54%, 53.85%, and 42.31% respectively, while in group B it was 90.48%, 80.95%, 66.67%, 57.14%, and 52.38% respectively.

Conclusion(s):

Using covered stent has a higher patency rate than using Paclitaxel-coated PTA balloon catheters for treating venous site anastomotic stenosis especially in midterm follow up periods, but still these results are statistically insignificant may be due to small number of study sample.

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Comparison Of Sonographic-Based Ti-Rads Classification And Cytological-Based Bethesda: 6-Month Experience In Somalia

1Ahmed Adam Osman

1Somali Turkish Education and Research Hospital

Background(s):

In this paper, we investigate thyroid nodules in Somalia using high-resolution ultrasonography over a 6-month period, and we compare the TRIADS and Bethesda thyroid reporting cytopathology systems

Material(s) and Method(s):

This was a prospective study including 59 patients. Between January 1, 2020, and June 1, 2020, patients referred to the Interventional Radiology Department of our hospital for fine-needle aspiration biopsy due to a thyroid nodule were analyzed.Adult patients older than 18 years were included in this prospectively planned study. Sonographic features of all nodules were recorded for TI-RADS scoring before biopsy, and TI-RADS scoring was performed by the radiologist. Accordingly, five features were sonographically evaluated (composition, echogenicity, shape, margin, and echogenic foci). Sonographic images were evaluated and recorded by a 4-year radiology assistant before biopsy. It was compared with the cytopathological Bethesda scoring.All analyses were performed using SPSS software version 22.0 (IBM SPSS Statistics Version 22.0, Armonk, NY: IBM Corp.)

Result(s):

Of the 59 patients included in the study, 16 (27.1%) were male and 43 (72.9%) were female. The mean age of the patients was 34.1 12.6 years (range, 19–60 years).Of the biopsied nodules, 31 (52.5%) were localized in the right lobe and 28 (47.5%) in the left lobe.The mean longest diameter of the nodules was 35.9 13.9 mm (range, 13-70 mm). The TI-RADS category was also significantly higher in those with larger nodule diameters (p = 0.026)

Conclusion(s):

According to the findings of our study, there is a moderate agreement between TI-RADS scoring and Bethesda. However, the rate of compliance was increasing in nodules classified as malignant nodules (TI-RADS 4).

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Laser Sheath Assisted Removal Of Inferior Vena Cava Filters With Long Dwelling Time

1Abdulmohsen Ahmed Alhussaini,1Abdullah Saed Alghamdi, 1Abdullah Saed Alghamdi, 1Mohammed Alzahrani, 1Mohammed Mubarak Alomaim, 2Mohammed Mubarak Alomaim

1King Saud bin Abdulziz University for Health and Sciences, 2King Abdulaziz Medical City

Background(s):

Laser Sheath Assisted Removal of Inferior Vena Cava Filters with Long Dwelling Time is a technique which utilizes laser-tipped sheaths. The laser light only penetrates vascular tissue causing the target tissues to disintegrate into particles. This approach reduces the amount of energy used during difficult retrieval procedures, allowing permanent filters to be removed in less fluoroscopic and procedural time.

Material(s) and Method(s):

A retrospective study of patients who underwent laser assisted IVC filter removal. A total of nine patients (5 males) with mean age of 33.9 years (19 – 57 years) had Optease filters (n=9), and one Recovery filter. Mean dwelling median was 19 months (7-70 month). One patient had filter related IVC occlusion and one had chronic occlusion of the right iliac veins. Both patients underwent balloon angioplasty after filter retrieval without stent placement.

Result(s):

Laser sheath assisted filter removal was technically successful in all patients. Average cumulative fluoroscopic exposure time was 55 minutes, and the total dose area product (DAP) average was 279196 mGyCm2. Following retrieval, five individuals developed minimal IVC stenosis which required balloon angioplasty in four patients, one patient had only minor extravasation and did not require treatment. There were no major complications. Follow up imaging showed recurrent IVC occlusion in the patient who presented initially with occlusion. Small filter fragments embedded in the wall at the original site were noted in patients who presented with venous occlusion. The remaining patients had no IVC abnormality on follow up imaging.

Conclusion(s):

Laser assisted filter removal of IVC filters long dwelling time is feasible and safe after failed retrieval with standard techniques.

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Percutaneous Access For Large Bore Aortic Devices:A Single Centre Experience Of A Preferential Approach

1Tania Guzman,1Isam Osman, 1Isam Osman, 1Zahra Alhaddad

1King Saud Medical City

Background(s):

Percutaneous access for endovascular abdominal (EVAR) and thoracic aortic interventions (TEVAR) may offer significant benefits to patients over open access. Safe arterial closure has been made possible by the increasing availability of novel closures devices. We report our experience with a preferential percutaneous approach and closure with a suture mediated closure device in a single centre.

Material(s) and Method(s):

Percutaneous access for endovascular abdominal (EVAR) and thoracic aortic interventions (TEVAR) may offer significant benefits to patients over open access. Safe arterial closure has been made possible by the increasing availability of novel closures devices. We report our experience with a preferential percutaneous approach and closure with a suture mediated closure device in a single centre.

Result(s):

Out of a total of 42 patients , 32 met the criteria and underwent percutaneous EVAR or TEVAR during the study period. 46% (15 out of 32 patients) were performed in an emergency setting. In total 41 femoral arteries were cannulated with a large bore introducer (average size 20 Fr, range 14 -25 Fr). Closure of the femoral artery with preloading technique was successful in 36 arteries(87%). A third device was required to achieve hemostasis in two further arteries achieving a primary success rate of 92% (38/41). In 8% (3/41) surgical intervention was required due to complications.In the first case an intimal dissection in a calcified artery caused arterial thrombosis.The remaining two bled :one with Marfanoid arteriopathy and in the second a resuscitative intra-aortic balloon without closure device preloading was used.

Conclusion(s):

Out of a total of 42 patients , 32 met the criteria and underwent percutaneous EVAR or TEVAR during the study period. 46% (15 out of 32 patients) were performed in an emergency setting. In total 41 femoral arteries were cannulated with a large bore introducer (average size 20 Fr, range 14 -25 Fr). Closure of the femoral artery with preloading technique was successful in 36 arteries(87%). A third device was required to achieve hemostasis in two further arteries achieving a primary success rate of 92% (38/41). In 8% (3/41) surgical intervention was required due to complications.In the first case an intimal dissection in a calcified artery caused arterial thrombosis.The remaining two bled :one with Marfanoid arteriopathy and in the second a resuscitative intra-aortic balloon without closure device preloading was used.

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Point Of View: Outcomes Of Percutaneous Peritoneal Dialysis Catheters Insertion By Interventional Radiologists

1Abdulaziz AlSharydah,1Shaima Abu alqasim, 1Shaima Abu alqasim, 1Mohammad Arabi

1Interventional Radiology section, Medical Imaging Department, NGHA

Background(s):

To assess the safety and long-term outcomes of percutaneous PD catheter insertion by interventional radiologists.

Material(s) and Method(s):

This retrospective study conducted between April 2015 till February 2021. A total of 131 patients (75 males) were enrolled in this study. The mean age was 50 ± 19.6-years with average BMI of 28 ± 7 kg/m2. The average dwelling time was 497.5± 462.3 days. Technical and clinical success were evaluated. Catheter related complications were classified into mechanical and non-mechanical categories including infectious complications. Indications for removal were analyzed.

Result(s):

Technical and clinical success were 100%. Forty-six patients were on PD at the last follow up with average dwelling time of 492 days. PD related complications were reported in 79/131 [60.3%] patients, including  Peritonitis [40.46%; 53/131], followed by Malposition/Migration [12.21%; 16/131], Tunnel/exit site infection [10.69%; 14/131], and dysfunction [12.21%; 16/131]. The incidence of peritonitis within 30 days post-insertion was 9.43%. The average interval between  insertion to migration is 100.5± 144.8 days (95% confidence interval [CI], 6.9 to 14.4). There was a trend for higher rate of malposition/migration in patients with higher BMI (P = 0.0561). Causes for PD catheters removal were: 1) Infection related [24.4%; 32/131]; 2) Renal transplant [16%; 21/131] [19%; 25/131]; 3) Mechanical complications [13.7%; 18/131]; 4) Patient’s preference [7.6%; 10/131]

Conclusion(s):

Clot buPercutaneous PD catheter placement by interventional radiologists pPercutaneous PD catheter placement by interventional radiologists provides acceptable long-term outcomes and complication rates that meet the recommended standards.

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Continuous Mechanical Aspiration Thrombectomy Performs Equally Well In Main Vs. Branch Pulmonary Emboli: A Subgroup Analysis Of The Extract-Pe Trial

1Suhail Dohad,2Michael Rosenberg, 3Michael Rosenberg, 4James M. Horowitz

1Smidt Heart Institute, Cedars-Sinai Medical Center, 2Department of Radiology, Rush University, 3Department of Radiology, University of Minnesota, 4Department of Radiology, NYU Grossman School of Medicine

Background(s):

The EXTRACT-PE trial evaluated safety and performance of the Indigo Aspiration System (Penumbra, Inc.) with an 8F system for the treatment of pulmonary embolism (PE) without use of thrombolytics. This subgroup analysis evaluates performance outcomes of patients with main pulmonary artery (PA) emboli versus discrete unilateral or bilateral PA emboli without main PA involvement.

Material(s) and Method(s):

The EXTRACT-PE trial was a prospective, single-arm, multicenter trial that enrolled 119 patients with acute submassive PE. Emboli location was collected at the time of enrollment; patients were then grouped based on whether emboli involved the main PA (with or without branch vessels) or not (branch vessels alone). CT obstruction was measured using the Qanaldi method (Core Lab). Procedural device time and changes in right ventricle to left ventricle (RV/LV) ratio and systolic PA pressure from before to after treatment with continuous mechanical aspiration thrombectomy  were compared between the groups.

Result(s):

Out of the 119 patients enrolled, 44 (37.0%) had emboli that involved the main PA and 75 (63.0%) branch emboli. No significant difference was observed between these groups for procedural device time, changes in RV/LV ratio or for systolic PA pressure from before to after treatment. Mean absolute reduction in clot burden was significant in both groups, main PA 3.6 (p = .03) and branch vessels 5.8 (p = .0004).

Conclusion(s):

The Indigo Aspiration System was effective at improving clinical outcomes for submassive PE patients regardless of emboli location. Clot burden was significantly reduced in both groups.

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Safety And Efficacy Of Percutaneous Cryoablation For The Treatment Of Uresectable Extra-Abdominal Desmoid Tumors Which Was Progressed On Chemtherapy

1Syed Faisal

1Tata Memorial Hospital

Background(s):

To determine the efficacy and safety of cryoablation in patients unresectable with desmoid tumors which was progressed on chemotherapy retrospectively at a single institution for the period of 1 year.

Material(s) and Method(s):

A retrospective, single-institution review identified 10 patients (age: 4-45) with extra-abdominal desmoid tumors who received CT-guided percutaneous cryoablation salvage treatment in total 14 sessions in the year 2021. Median maximal lesion diameter was 6 cm .Intent was palliative in all patients. Contrast-enhanced cross-sectional imaging was obtained before and after treatment in addition to routine clinical follow-up.

Result(s):

Technical success was achieved in all patients. The median follow-up was 5 months. Symptomatic improvement was demonstrated in 85 % of patients. At 3 months, the average change in viable volume was -75% and response by modified response evaluation criteria in solid tumors (mRECIST) was PR 70%, and SD 30% .No rapid postablation growth or track seeding was observed. No major procedure related complications were noted

Conclusion(s):

Cryoablation for desmoid tumors demonstrates a high degree of symptom improvement and local tumor control on early follow-up imaging with relatively low morbidity.

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The Use Of Ketamine/Midazolam Combination For Moderate Sedation In Vascular And Interventional Procedures: A Single Institution Experience

1Mohammad Arabi,1Abdullah Saed Alghamdi, 2Abdullah Saed Alghamdi, 1Mohammed Yousef Alzahrani, 1Mohammed Mubarak Alomaim, 1Mohammed Mubarak Alomaim, 1Khalid Othman

1King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, 2King Abdullah Specialized Children’s Hospital, Ministry of National Guard-Health Affairs

Background(s):

The use of ketamine in interventional radiology procedures remains historically unfavored due to the potential hallucination. Ketamine is known to induce dissociative anesthesia while maintaining airways and hemodynamics. The aim of this study is to assess the safety and effectiveness of moderate sedation using simultaneous administration of a mixture of ketamine and midazolam in interventional radiology procedures.

Material(s) and Method(s):

A retrospective cohort study was conducted of 74 consecutive patients (59.5% Females) who underwent a variety of vascular and interventional procedures in a tertiary care center. The mean age was 42.2 ± 16.6 (range, 13-80). Out of 74 patients, 15 had ASA score 1 (20.3%), 51 (68.9%) with score 2, and 8 (10.8%) with score 3.

Result(s):

Mean age of pThe mean dosage of ketamine was 33.9 ± 18.9 mg (range, 8-100). The mean dosage of midazolam was 1.6 (range, 0.2-5). Five patients required additional fentanyl for analgesia. The mean systolic Blood pressure (BP) at baseline was 127.3 ± 22.1, the mean systolic BP during the procedure was 143.1 ± 22.1, and the mean systolic BP during recovery was 133.1 ± 18.3. The mean diastolic BP at baseline was 71.2 ± 12.1, the mean diastolic BP during a procedure was 81.1 ± 12.9, and the mean diastolic BP during recovery was 74.8 ± 12.6. Aldrete score was recorded in 72 of the patients with a mean of 9.7 ± 0.5 (range, 7-10). The Mean lowest Ramsay score during the procedure was 1.9 ± 0.5 (range, 1-3) and the mean highest Ramsay score during the procedure was 2.7 ± 0.7 (range, 2-5). Side effects were observed in 5 patients, self-limiting hallucinations in 4 patients (5.4%), and vomiting in 1 patient (1.4%). No cardiovascular or respiratory complications were encountered

Conclusion(s):

The mixture of Ketamine and midazolam appears to be effective in providing adequate moderate sedation and analgesia during interventional procedures with a low rate of side effects.

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Comparison Study For Ivc Filter Retrieval Before And After Applying An Ivc Filter Retrieval Alert System (Ifras) A Single-Center Experience

1Hassan Ali Aljaziri

1Ministry of National Guard

Background(s):

The study evaluates the IVC Filter Retrieval Alert System (IFRAS) effectiveness in increasing the IVC filter retrieval rate.

Material(s) and Method(s):

The medical records of patients with advanced-stage (BCLC-C) HThe study represents an extension of a prior study done at the same institution in 2018 with a smaller sample size of 307 patients and a shorter duration of four years: two years before (2013 – 2015) and two years after (2015 – 2017) applying IFRAS. All patients who had IVC filters between January 2013 and December 2019 were reviewed retrospectively for the current study. Patients’ data are obtained from electronic medical records with a total sample of 756 patients. The sample consists of two categories. First, the filter retrieval rate, before launching IFRAS (between 2013 and 2015, for 312 patients). Second, the filter retrieval rate after launching IFRAS (between 2016 and 2019, for 435 patients). This study aims to evaluate the effectiveness of the alert system by comparing the retrieval rate before and after applying IFRAS. A dedicated administrative assistant documented patient data, insertion dates, and filter types. The assistant tracks patients actively and follows patients up with the referring physician or interventional radiologist through the Interventional Radiology (IR) clinic.

Result(s):

Mean age of patieThe study included 46-patients with a mean age of 65.3-years (SD=9.5 years). Child-Pugh (CP) A and B patients constituted 71.7% and 28.3% of the patients respectively. The mean size of The IVC filter retrieval rate before IFRAS establishment (2013-2015) was 38.3% (123/312) and climbed to 54.25% (236/435) with a P-value < 0.001. Before launching the IFRAS, the rate of patients with no follow-up was 45.17% (145/312), and it dropped to 41.15% (179/435).

Conclusion(s):

The study demonstrates a statistically significant difference in increasing IVC filter retrieval rate after launching the IFRAS.

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Safety And Efficacy Of 75 Microns Drug Eluting Embolic Used In Chemoembolization Of Advanced Stage Hepatocellular Carcinoma

1Khalid Mahmoud,2Husameddin El Khudari, 2Husameddin El Khudari, 1Ahmed Kamel Abdel Aal

1University of Texas at Houston, 2University of Alabama at Birmingham

Background(s):

According to the limited information in Computed tomography (CT)-guided percutaneous core needle biopsy (PCNB) of sub-centimeter pulmonary nodules with radiation burden to the patients and operator The aim of the study is to evaluate the effectiveness and safety of 75µm drug-eluting-embolic (DEE) in transarterial-chemoembolization (TACE) for patients with advanced Barcelona Clinic for Liver Cancer stage-C (BCLC-C) hepatocellular carcinoma (HCC).

Material(s) and Method(s):

The medical records of patients with advanced-stage (BCLC-C) HCC who had DEE-TACE using 75µm-DEEs loaded with Doxorubicin as their first treatment for unresectable HCC between November-2013 and March-2021 were retrospectively reviewed. Patients who had prior therapy for HCC were excluded. Tumor response and the toxicity profile were assessed.

Result(s):

Mean age of patieThe study included 46-patients with a mean age of 65.3-years (SD=9.5 years). Child-Pugh (CP) A and B patients constituted 71.7% and 28.3% of the patients respectively. The mean size of the index tumors was 5.34cm (SD=2.9cm), with 16 (34.8%) patients having central tumors around the porta-hepatis region. Portal vein (PV) invasion was seen in 9 (19.6%) patients. Twenty-one (45.6%) patients had a single hepatic lesion. At first imaging follow up, complete response, objective response and disease control was seen in 21.5%, 62% and 81% respectively. The median progression-free survival was 7.2-months. The overall-survival was 18.3-months (22.4-months for responders versus 8.7-months for non-responders, p= 0.002). The 6, 12 and 24-months survival were 61.9%, 34.76% and 13.02% respectively. Grade-3 and 4 clinical adverse events were seen in 8.8%, and grade-4 hepatobiliary injuries were seen in 2.2% of patients. There were no grade-5 adverse events reported.

Conclusion(s):

Although advanced-stage patients are usually offered systemic chemotherapy, TACE using 75µm-DEE is safe and efficacious and may be considered as an adjuvant or sole therapy.

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Technical Accuracy Of Percutaneous Needle Biopsy Of Sub-Centimeter Pulmonary Nodules Under Ct Fluoroscopy Guidance And Associated Procedural Complication

1Alireza Abrishami,2Yasaman Nasrollahpoor, 3Yasaman Nasrollahpoor, 2Pankaj Kafle, 2Mahsa Alborzi Avanaki, 4Mahsa Alborzi Avanaki

1Department of Radiology, Shahid Labbafinejad Hospital, Shahid Beheshti University of Medical Sciences, 2Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Tehran University of Medical Sciences, 3Shahid Beheshti University of Medical Sciences, 4Sirjan School of Medical Sciences

Background(s):

According to the limited information in Computed tomography (CT)-guided percutaneous core needle biopsy (PCNB) of sub-centimeter pulmonary nodules with radiation burden to the patients and operator for diagnosis of lung lesions as benign or malignant, we aimed to evaluate the accuracy rate of CT fluoroscopy-guided biopsy in these nodules.

Material(s) and Method(s):

A total of 156 cases with confirmed sub-centimeter pulmonary nodules were enrolled in this retrospective study from January 2019 to December 2021. Demographic data, past history of malignancy, nodules’ CT features and location, total dose length product (DLP), smart DLP, and associated complications were recorded; then, the relationship of all characteristics with certainty in pathology was assessed. Under CT fluoroscopy-guided, PCNB was performed through the nearest marker to the target lesion with the proper body position. Eventually, a control low dose lung CT scan was done to observe complications.

Result(s):

Mean age of patients was 56.7±12.3 years (range=22-82, female=97(62.2%). Mean nodule number was 4.6±5.6(range:1-15) and most patients had only one nodule (82;52.6%). Totally 124(79.5%) samples yielded a definite diagnosis [benign=84(53.8%), malignant=40(25.6%)], while 32(20.5%) cases showed non-diagnostic pathology. Based on the analyses, male gender (p<0.001), history of malignancy (p<0.001), zone of lesions [lower zone(66.7%) vs. non-lower zone(83.3%), p=0.03] and lesion size [lesions <6mm(48%) vs. ≥6mm(85.5%), p<0.001] were statistically associated with certainty in pathology. Regarding complications, patients with hemoptysis had greater nodule distance (31.7±15.5mm vs. 18.8±14.4, p=0.001) from the pleura(p=0.001). Smart DLP was about 32.5±37.2 mGy/cm.

Conclusion(s):

CT fluoroscopy-guided PCNB is a safe, effective, and precise method with minimal complication rates in pulmonary lesions of  ≥6mm to ≤10mm size due to uncertainty in pathologic assessment of nodules<6mm

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Vessel Preparation Using Atherectomy Or Intravascular Lithotripsy In Patients With Heavily Calcified Infrainguinal Arterial Disease; 1 Year Experience From A Tertiary Referral Centre

1Hashem Barakat,1Sanjay Patel, 1Hany Zayed

1Guy’s and St Thomas’ NHS Foundation Trust

Background(s):

Vessel preparation is important before definitive endovascular treatment of heavily calcified infrainguinal lesions in patients with Chronic Limb Threatening Ischaemia (CLTI). Our aim is to describe our approach and present our outcomes with different vessel preparation modalities: Intravascular lithotripsy (IVL) and Atherectomy.

Material(s) and Method(s):

This was a retrospective review of last years’ experience from a large tertiary referral centre in London, UK. Consecutive patients undergoing endovascular revascularisation for CLTI between January 2021 and January 2022 were screened. All those who underwent vessel preparation with plain balloon angioplasty (POBA), IVL or Atherectomy were included in this study. The main outcome measure was freedom from clinically driven target vessel revascularisation (TLR) at 3 and 6 months.

Result(s):

A total of 90 procedures on 84 patients are included. All patients presented with CLTI.

We compared the outcomes between the group undergoing POBA (44 limbs) and the group undergoing Atherectomy or IVL (46 limbs). The two groups were similar in most baseline characteristics, severity of presentation and anatomical staging of disease burden.

At 3 months, 11 patients from the POBA group required reinterventions, compared to 2 patients in the Atherecomy/IVL group (p=0.005). The trend was similar at 6 months; 15 patients in the POBA group required reintervention compared to 5 in the Atherectomy/IVL group (p=0.008).

Conclusion(s):

This study demonstrates favorable early outcomes when Atherectomy or IVL are used as vessel preparation techniques in patients with CLTI due to infrainguinal arterial disease.

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Percutaneous Cholecystostomy In Acute Complicated Versus Uncomplicated Cholecystitis; Is There A Difference In Outcomes? A Single Centre Experience

1Tariq Ali,2Karen Chan, 1Karen Chan, 2Zahra Al-Alwani, 1Amr Moussa, 1Amr Moussa

1Norfolk & Norwich University Hospital NHS Trust, 2University of Oxford

Background(s):

Percutaneous cholecystostomy (PC) is a minimally invasive image-guided placement of a drainage catheter in the gallbladder, particularly in patients who are considered high risk for definitive laparoscopic cholecystectomy (gold standard). There is a paucity of evidence comparing outcomes between complicated and uncomplicated cholecystitis in patients undergoing percutaneous cholecystostomies.

Material(s) and Method(s):

This is a double armed randomized prospective studAll patients undergoing PC at a single-centre, tertiary unit, between August 2016 and December 2020 were included in the study. 100 patients underwent primary PC as were considered unfit for surgery at the time of diagnosis. Baseline characteristics were recorded. Technical outcomes, complication rates, re-intervention and mortality rates were investigated.

Result(s):

100 patients (47 male, 53 female) mean age 71 (SD 11) years underwent PC. 47 patients were 80 years old or older. 34 of the cases were uncomplicated and 66 were complicated (emphysematous, perforation, gangrenous, biloma). Technical success rate was 100%. 15% subsequently underwent cholecystectomy. 12 patients had reintervention. 30-day mortality rate was 9%, and the 90-day mortality rate was 11%. After 6 months, 84 patients were alive of a total of 97 patients whose data were available.

The outcome in the form of 30-day, 90-day mortality, being alive after 6 months and reintervention are compared between complicated and uncomplicated cases using Chi squared test or Fisher’s exact test. There was no statistically significant difference in any of the compared outcomes (P = 0.135) between the two groups.

Cox proportional hazards model was used to study the factors affecting survival (30 days follow up). This included age, gender, reintervention rates, complicated cholecystitis, CRP, bilirubin levels, WCC and the presence of Acute Kidney Injury (AKI). Univariate and multivariable models are presented using the hazard ratio with the 95% Confidence interval.The only variable that showed statistically significant association with the risk of mortality was the presence of AKI on admission (as per modified RIFLE criteria). Patients who have AKI stage 2 or 3 had a higher hazard for mortality as compared to patients with no kidney disease. For patients with stage 2, HR=10.85 (95% CI: 1.33, 88.49), p-value = 0.026, and for patients with stage 3, HR=25.46 (95% CI: 2.40, 269.88), p-value =0.007. There was no statistically significant difference in hazard of mortality between complicated and uncomplicated cases, p-value = 0.094, or between patients less than 80 years old and those 80 or more, p-value = 0.117. The presence of gallbladder stones also showed no statistically significant association with the hazard of mortality, p-value=0.112.

Conclusion(s):

Our results demonstrate that PC is a safe and effective procedure in patients presenting with acute cholecystitis regardless of whether complicated or uncomplicated as no statistically significant difference was identified between the two groups. The results also highlight the importance of recognising and treating AKI, an independent risk factor affecting mortality.

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Preliminary Results Of Microwave Ablation Therapy In Parathyroid Adenomas

1Furkan Ertürk URFALI,2Sezgin ZEREN, 3Sezgin ZEREN, 1Güven Barış CANSU, 3Mustafa Cem ALGIN, 1Mustafa Cem ALGIN

1Furkan Ertürk URFALI,2Sezgin ZEREN, 3Sezgin ZEREN, 1Güven Barış CANSU, 3Mustafa Cem ALGIN, 1Mustafa Cem ALGIN

Background(s):

Although parathyroidectomy operations are effective treatments in patients with primary hyperparathyroidism, the use of local ablation treatments in this area has recently gained momentum due to post-procedure bleeding, hoarseness caused by nerve damage, and long recovery periods. We aimed to share the preliminary results of ultrasound-guided microwave ablation (MWA) and our experience about of the procedure.

Material(s) and Method(s):

Between March 2021 and February 2022, a total of 13 patients underwent US-guided microwave ablation therapy. MWA was applied to 2 patients because they could not get approval for general anesthesia and one patient had residual adenoma after the surgical procedure. Before the procedure, age, gender, blood parameters (calcium (Ca), parathyroid hormone(PTH)), localization of parathyroid adenoma, volume, shear-wave elastographic (SWE) values obtained from the archives. After the procedure, the control PTH was studied from the blood samples taken at the 2nd hour. Blood Ca level and USG evaluations were performed at the clinic controls of the patients at the 1st month after the procedure.

Result(s):

The mean age of the patients was 58.1 ± 9.2 (47-73). Of the patients, 4 (31%) were male and 9 (69%) were female. Of the parathyroid adenomas, 6 (46%) were on the right and 7 (54%) were on the left. The adenoma volume was measured as 1.41 ± 0.55 (0.38-2.77)cm3 and the SWE klioPascal (kPa) value was 4.77 ± 0.21 (4.51-5.12) before the procedure. Before the procedure, PTH was measured as 217.92 ± 157.37(125-713) ng/L, calcium 11.89 ±0.51 (11.3-13.2)mg/dL. No major or minor complications such as hoarseness or bleeding were observed in any of our patients after the MWA procedure. In the blood tests taken from the patients at the 2nd hour after the procedure, PTH levels of all patients were measured within the normal range. Post-procedure, adenoma volume was measured as 1.02 ±0.42 (0.22-1.63)cm3, PTH 20.69 ±7.86(10-34) ng/L and calcium 9.5 ±0.41(9-10.1) mg/dL. Parathyroid adenoma size decreased by 28% (p<0.001) on average after MWA. PTH levels decreased over 90% (p<0.001) and calcium levels decreased 20% (p<0.001).

Conclusion(s):

US-guided MWA is an effective treatment alternative to parathyroidectomy in the treatment of parathyroid adenoma, with its advantages such as being performed without general anesthesia and low complication risk. Our preliminary results showed that MWA treatment resulted in an effective improvement in blood PTH, Ca levels and adenoma size.

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The Secondary Patency After Patch Venoplasty Vs Balloon Venoplasty In Management Of Neointimal Hyperplasia Of The Venous Anastomosis Of Thrombosed Arterio-Venous Grafts For Hemodialysis

1Yasser magdy Hamed elsayed,1Abdel Rahman mohamed ahmed, 1Abdel Rahman mohamed ahmed, 1Mohamed ismail Mohamed

1Ain Shams University

Background(s):

To compare the secondary patency after patch venoplasty and balloon venoplasty in management of neointimal hyperplasia of the venous anastomosis of arterio-venous graft for dialysis.

Material(s) and Method(s):

This is a double armed randomized prospective study that was carried out at Ain Shams University hospitals for 2 years. Twenty patients with thrombosed synthetic AV graft were enrolled in this study. The first group (10 patients) was treated with patch venoplasty and the second group (10 patients) with balloon venoplasty adjunctive after surgical thrombectomy.

Result(s):

Graft patency at 6 and 12-month follow up was 90%, 70% for the balloon angioplasty group vs 60% and 40% for the surgical patch venoplasty group (p-value: 0.3 and 0.37 respectively).

Conclusion(s):

In the present study, the outcome of balloon venoplasty was better than and patch venoplasty for thrombosed AV grafts. In addition to better graft patency, balloon venoplasty offers the advantage of shorter operative time, and lower morbidity. Further studies with large sample size and multicentric cooperation are required to confirm the present findings.

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Magnetic Compression Anastomosis After Living-Donor Related Liver Transplantation For Patients With A Disconnected Bile Duct: Preliminary Research

1Mahmut Kusbeci, 1 Halil Bozkaya, 1 Halil Bozkaya, 1 Egemen Öztürk, 1Kamil Doğan, 2Kamil Doğan, 2Galip Ersoz, 1Mustafa Parildar, 2Ilker Turan, 2Zeki Karasu

1Department of Radiology, Ege University Medical School, 2Department of Gastroenterology, Ege University Medical School

Background(s):

AdeThe purpose of this study is to present the use of the magnetic compression anastomosis (MCA) technique for the treatment of disconnected bile ducts following living-donor-related liver transplantation (LDLT) with the recently introduced through-the-scope magnet

Material(s) and Method(s):

The MCA technique was used in patients who had a disconnected bile duct and were unable to be treated with percutaneous or endoscopic procedures. Before the procedure, all patients had a percutaneous external biliary drainage catheter. By pushing a 5-Fr catheter over a guidewire, the magnet was percutaneously inserted into the proximal side of the obstruction. Endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic papillary sphincterotomy was performed concurrently. With a 5-Fr catheter and a guidewire, the sister magnet was carefully advanced to the opposite side of the obstruction. After confirming biliary recanalization, a guidewire was passed through the stricture, and the stricture was percutaneously dilated with a balloon-tipped catheter. During the first ERCP session, the stricture was dilated with an endoscopic balloon, two plastic stents were inserted, and the internal drainage catheter was removed. Stent exchange and multiple side-by-side stent placements were scheduled at three-month intervals for all patients.

Result(s):

Between April 2014 and November 2020, twelve LDLT patients with disconnected bile ducts (aged 36–65, six men) underwent the MCA technique. The magnet placement procedure resulted in biliary recanalization 13–42 days later. The procedure had a 90 percent success rate.

Conclusion(s):

OIn FEVAR the mode of visceral stent failures varies. Their complications and reinterventions are common and unpredictable, therefore a close surveillance must be contThe inclusion of a small number of patients and the lack of long-term data were the study’s limitations. The current case series, on the other hand, demonstrates that the MCA technique, which employs a small magnet with a 2.4-mm diameter, is effective and useful in LDLT patients with a disconnected bile duct. Furthermore, we believe that using this small magnet makes the MCA technique simpler and less complex than using magnets with larger diameters.

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Can You Predict The Unpredictable? Visceral Stent Reintervention In Fenestrated Endovascular Repair Of Juxta-Renal Aneurysms

1Enrico Mancuso,1Wissam Al-Jundi, 1Wissam Al-Jundi

1Norfolk & Norwich University Hospital

Background(s):

Adequate placement of visceral stents in FEVAR is key to achieve aortic aneurysm sealing, their failure can lead to significant complications and carry a considerable burden of reinterventions. The aim of this study is to identify pre-operative or intraprocedural predictors of visceral stents failure.

Material(s) and Method(s):

Retrospective review of consecutive 72 patients who underwent FEVAR in a single high volume centre over 9 years, between 2013 and 2021 . Outcomes of mortality, failure and reintervention of 217 visceral stents were collected, pre and post-operative imaging was reviewed.

Result(s):

The overall early mortalities at 30 days were 6 (8%) of these 3 (4%) were related to visceral stents failure. Intraprocedural complexity was documented in 11 (15%) cases and 3 (1.4%) fenestrations could not be stented. A significant early type 1c endoleak or acute visceral stent failure was identified in 8 (11%) patients, of these 7 (9.7%) had in-patient re-intervention within 30 days. At 1 year, 11 (15%) patients had  visceral stent reintervention, at 2 years it was 2 (2.8%) and at 3 years it was 2 (2.8%). One case had 2 re-interventions on the same visceral stent. To the dedicated review of the 2017 visceral stents, 20 (9.2%) needed re-intervention, of which 17 (7.8%) were renal stents. When comparing visceral stents with good outcome versus those that needed re-intervention, no significant difference was identified for aneurysm neck diameter (29 +/- 2.6 vs 30.5 +/- 6.4; p=0.49), diameter of target vessels (5.9 +/- 0.2 vs 5.55 +/- 0.5; p=0.34), stent oversize (15% +/- 0.02 vs 13% +/- 0.05; p=0.36) or length of coverage of the target vessels (18 +/- 0.88 vs 16.5 +/- 3.2; p=0.36).

Conclusion(s):

OIn FEVAR the mode of visceral stent failures varies. Their complications and reinterventions are common and unpredictable, therefore a close surveillance must be continued long term.

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Is Ischemia An Over Called Risk ? Empiric Particle Embolisation At Ileocecal Region In Patients With Positive Ct Bleeding Protocol But Negative Mesenteric Dsa – A Single Centre Experience

1Jehanzeb Shahid,1Tanveer ul Haq, 1Tanveer ul Haq, 1Junaid Iqbal

1Aga Khan University Hospital

Background(s):

GI bleed is one of the most commonly encountered emergencies of interventional radiology. Role of distal micro coil embolisation as compared to sole particle embolisation for lower GI bleeds is well established in literature as well as is recommended by various IR societies. Sole particle embolisation is less favoured due to risk of bowel ischemia. Catheter angiography and embolisation is usually preceded by diagnostic imaging (usually a CT bleeding protocol or RBC tag scan). One problem which IR some times encounter is diagnostic imaging test being positive for GI bleed but catheter angiography shows negative mesenteric DSA. This may occur partially due to the fact that arterial GI bleeds may some times by transient and may have already partially responded to medical treatment. But at the same time, just diagnostic DSA without intervention carries significant risk of re-bleed. The objective of our study is therefore to access the clinical outcomes of empiric particle embolisation at ileocecal area in patients with positive CT bleeding protocol and negative mesenteric angiography.

Material(s) and Method(s):

We retrospectively evaluated all of the patients from January 2016 to February 2022 who had positive bleeding protocol CT with focus of bleeding at ileocecal area. A total of 42 patients were identified. Out of those 42 patients, 26 patients had mesenteric angiogram positive for active bleeding and were therefore embolised using coil embolisation or a combination of coils and particles. 16 patients (n=16) were those with negative mesenteric angiogram for active bleeding and were our final sample size. Empiric embolisation of ileocecal area was performed in those patients using medium to large sized PVA particles (355-500 or 500-710 microns). The clinical outcome was identified on the basis of post embolisation rebleeding, clinical signs of bowel ischemia post embolisation and mean hospital stay post embolisation.

Result(s):

Out of 16 patients, re-bleeding was encountered in 3 patients with a mean time of re-bleed of 18 hours. One of the patient died of recurrent bleed and also developed multi organ failure later.  Non of the patients developed clinical signs of bowel ischemia or bowel infarct which was also assesed by LDH levels. Mean hospital stay post embolisation was 3.2 days. Embolisation procedural technical success rate was 100%.

Conclusion(s):

Our study concluded that empiric particle embolisation carries a lower actual risk of bowel ischemia in patients with positive CT bleeding protocol but negative mesenteric angiogram. Furthermore, it also reduces the risk of re-bleeds and impacts the mean hospital stay duration.

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Management Of Pediatric Congenital Porto-Systemic Shunt

1Ravi Gadahadh

Background(s):

To familiarise with the clinical features, presentation and management of Pediatric Congenital Porto-systemic Shunt (Abernathy Malformation)

Material(s) and Method(s):

Endovascular therapy is the mainstay treatment in the management of Congenital porto-systemic shunt .We will present cases showing the step and precautions to be undertaken prior to closure of a porto-systemic shunt..

Result(s):

We will present two contrasting cases highlighting the clinical and technical challenges in closing a porto-systemic shunt.

A simplified treatment algorithm will be presented to aid in management of such complex cases.

Conclusion(s):

Congenital porto-systemic shunts in pediatric age group have varied presentations.Treatment of this complex condition is paramount to prevent long term complications.

Safe closure of the shunt can be performed using an endo-vascular approach.

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Geniculate Artery Embolization For The Treatment Of Knee Pain Secondary To Osteoarthritis, A Prospective Pilot Study

1Ahmed Awad Bessar

1Zagazig University

Background(s):

To evaluate the efficacy of geniculate artery embolization (GAE) as a new method to alleviate intractable knee pain secondary to osteoarthritis (OA).

Material(s) and Method(s):

Twenty Egyptian female patients in their reproductive age (18–45 years) with a total of 30 symptomatic uterine fibroids measuring between 3 – 12cms in diameter underwent MR-HIFU treatment in the This is a clinical trial to assess role of GAE to treat OA related knee pain. In this perspective pilot study, twenty-three patients with moderate to severe knee pain and radiological findings of knee OA refractory to conventional medical treatment were enrolled. GAE was performed by antegrade femoral approach for the most painful knee by using 100 or 300-μm spherical particles. Assessment was performed at baseline and after GAE by 3 and 6 months. Radiological assessment was performed by magnetic resonant imaging and clinical assessment was performed by the Visual Analogue Scale (VAS) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC).

Result(s):

RSuccessful embolization of at least one geniculate artery was achieved in all patients (100%). Mean VAS was improved from 81 mm ± 16 at baseline to 33 mm ± 10 at 6-month follow-up (P <.01). Mean WOMAC score improved from 65 ± 10 at baseline to 26 ± 20 at 6-month follow up (P < .01). Transient skin discoloration occurred in two of 23 patients (8.7%). Four of 23 patients (17.4%) developed transient sensory paresthesia in the leg of the treated side.

Conclusion(s):

GAE is a safe and hoping new technique for treatment of OA related knee pain. Further comparative studies are needed to determine long-term effect of GAE in comparison to other methods of treatment.

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Magnetic Resonance-Guided High Intensity Focused Ultrasound Treatment of Uterine Fibroids; the First Egyptian Experience

2Mohamed Fawzi,1Eman Zaki Nossair, 1Eman Zaki Nossair, 2Mohamed Ali Bakry

1National Liver Institute, 2Faculty Of Medicine Cairo Unversity

Background(s):

Uterine fibroids are benign encapsulated uterine tumors disrupt the functions of the uterus causing many symptoms ranging from menorrhagia and dysmenorrhea to recurrent pregnancy loss, and infertility, and are the most common reason for hysterectomy in premenopausal women. Magnetic Resonance Imaging (MRI) guided High-intensity Focused Ultrasound (MR-HIFU) is a recent very low-pain to painless non-invasive procedure that has shown excellent therapeutic efficacy in treating uterine fibroids. Here we present the MRI findings of the first cohort of Egyptian women with uterine fibroids who underwent MR-HIFU.

Material(s) and Method(s):

Twenty Egyptian female patients in their reproductive age (18–45 years) with a total of 30 symptomatic uterine fibroids measuring between 3 – 12cms in diameter underwent MR-HIFU treatment in the National Hepatology and Tropical Medicine Research Institute, Cairo, Egypt over a period of 9 months (Feb 2021 – Dec 2021). Fibroid size, T1 and T2 signal intensities and Funaki type and non-perfused volume (NPV) of uterine fibroids were recorded pre- and/or post-treatment. The mean fibroid volume change after 6 months was also noted. Also symptom relief was recorded.

Result(s):

Remarkably, all thirty fibroids showed no less than 70% non perfused volume in the contrast enhanced MRI performed directly after the session. Follow-up showed significant relief in the primary symptoms mainly bleeding and significant improvement in HG level and also follow-up size reduction was measured and showed at least 30 % decrease in size.

Conclusion(s):

TOur institution is the first to introduce the ground breaking technology of MR-HIFU in Egypt. We have shown high efficacy of MR-HIFU in the treatment of uterine fibroids in Egyptian women. Our results have great potential of the wider use of this minimally invasive and effective treatment of uterine fibroids not just in Egypt but all the Middle East and Africa.

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Anatomy of Haemoptysis Intervention

1Mohammed Hasan Riyaz,1Alison Graham, 1Alison Graham, 1Ali Alsafi

1Imperial College Healthcare NHS Trust

Background(s):

Haemoptysis refers to bleeding originating from the lower respiratory tract, with the bronchial arteries representing the main source of haemorrhage, followed by the pulmonary arteries, and non-bronchial arterial circulation of the lung. A strong grasp of the anatomy of these arterial systems is required to correctly interpret angiographic studies, perform successful bronchial artery embolization (BAE), and minimise complications.

Material(s) and Method(s):

All patients treated with ER for CMI After preparation of suitable well-experienced iBetween January 2013 and January 2019, eleven patients (4 males and 7 females, mean age: 61.8 years) with dysfunctional 1We present multiple cases demonstrating the angiographic appearances of bronchial arteries, variant anatomy and non-bronchial systemic arterial supply to the lung using examples of BAE procedures performed at our centre.

Result(s):

MUO is most commonly caused by non-urological ca

The lungs benefit from a dual blood supply; the pulmonary arteries which provide around 99% of the arterial supply, and the bronchial arteries supplying the remaining 1%. The bronchial artery extends along the bronchi and subdivides to supply the numerous supporting structures of the lungs. The origin and supply of the bronchial arteries is variable; in most cases originating from the descending thoracic aorta and less frequently from other vascular territories including the subclavian artery, internal mammary artery, and inferior-phrenic artery… In 5-10% of known cases the intercosto-bronchial artery trunk can branch into the anterior spinal artery, highlighting the need for good angiopathic images and careful assessment of imaging to avoid serious complication during BAE.

In patients with chronic inflammatory lung disease, the inflammatory response can stimulate systemic and pulmonary shunting. The shunting occurs either as a result of dilatation of existing capillary anastomoses (bronchial to pulmonary artery), or neovascularity arising from non-bronchial systemic vessels giving rise to transpleural systemic to pulmonary shunts.

BAE is commonly performed to control moderate volume and massive haemoptysis. While immediate clinical success of BAE is high; recurrence of haemoptysis can occur usually secondary to incomplete embolization, recanalization of previously embolized arteries, and recruitment of new collaterals due to underlying disease progression.

Conclusion(s):

The Outback re-entry device can be safely and effectively used as a bail-out measure in patients whoThe interventional radiologist should be familiar with bronchial artery anatomy, anatomic variants and other systemic arterial supply that is commonly treated in patients presenting with haemoptysis.

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Percutaneous Nephrostomy Versus Ureteral Stenting In The Management Of Malignant Ureteral Obstruction: A Systematic Review

1Bilal Ibrahim,1Gowsikan Jeyakumar, 1Gowsikan Jeyakumar, 1Omar Kouli, 2Rami Hasan, Rami Hasan

1NHS Greater Glasgow and Clyde

Background(s):

Malignant ureteral obstruction (MUO) is caused by advanced urological or non-urological malignancy and is most commonly treated by either percutaneous nephrostomy (PCN) or ureteric stenting. MUO is seen to have globally poor prognosis, and, if not treated, can result in renal dysfunction, urosepsis or even death in patients regardless of intervention type.

No clear guidelines have been developed or are in use for deciding optimal management for urinary diversion with most authors believing this decision should be individualised under the care of a multidisciplinary team.

Material(s) and Method(s):

All patients treated with ER for CMI After preparation of suitable well-experienced iBetween January 2013 and January 2019, eleven patients (4 males and 7 females, mean age: 61.8 years) with dysfunctional 1340 studies were imported from PubMed, EMBASE and Scopus and studies were selected using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance. Following the removal of duplicate publications, a screening phase conducted by 2 independent authors resulted in 22 studies for data extraction.

Result(s):

MUO is most commonly caused by non-urological cancer and in most cases, is treated with PCN. PCN patients are more likely to have minor complications and ureteric stent patients are more likely to have major complications. Mortality rates and quality of life are globally poor regardless of intervention type and insufficient data is available to accurately assess cost-efficiency. Non-urological cancers have higher mortality and complications but improved quality of life in comparison to urological cancers. Further research is required to stratify these subgroups per intervention type

Conclusion(s):

The Outback re-entry device can be safely and effectively used as a bail-out measure in patients who fail conventional wiring techniques during endovasOverall, MUO has globally poor prognosis but is worse in the non-urological cancer cohort. PCN patients are more likely to have minor complications and less likely to have major complications with further research required to assess cost-efficiency.

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Laser Versus Mechanochemical Ablation In Treatment Of Primary Varicose Vein Of Lower Limb

Mohamed Abozeid Ahmed Abozeid

Background(s):

To compare EVLA with MOCA in the treatment of primary varicose vein of the lower limb

Material(s) and Method(s):

40 patients who had primary great saphenous varicose veins [VV] admitted at the Vascular Surgery Department, Al-Azhar University Hospital, New Damietta, Egypt. They randomized into two equal groups each one included 20 patients group [1] treated by EVLA and group [2] treated by MOCA.

Result(s):

The time of operation of studied patients ranged from 22 to 44 minutes, and there a statistically significant decrease in time of group 2 compared to group 1. [25.36±1.80 vs. 37.30±2.47 respectively]. Postoperative pain in studied patients ranged from 0 [no pain] to 7 [severe pain], there statistically significant decrease in pain of group 2 compared to group 1. As regard to induration, it was reported in 4 patients, representing 20% of group 1 [4] patients, were significant differences between groups 1 and 2 [20% vs. 0% respectively]. At the end of the sixth month postoperatively, as regard complete occlusion of the great saphenous vein [GSV] vein, there was statistically no significant difference between group 2 when compared to group 1 [92.5% vs. 95% respectively].

Conclusion(s):

Port removaMOCA was associated with better results on short-term follow-up

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Retrospective Review Of Factors Associated With Port Malfunction

1Jonathan Wakim,1Benjamin Frost, 1Benjamin Frost, 1Gregory J Nadolski, 1Terence P Gade, 1Terence P Gade, 1Stephen J. Hunt

1University of Pennsylvania

Background(s):

This study investigates the factors associated with port removal for malfunction in patients who underwent port removal at a high-volume tertiary academic center.

Material(s) and Method(s):

All A retrospective IRB-approved cohort of patients who underwent port removal from January 1999 to December 2019 were identified using a clinical quality improvement database and a search of radiology reports (Hi-IQ and Montage; n=5088). Manual review of the clinical record over a five-year period (2015-2019) was used to gather factors that might be associated with ports removed for malfunction (n=204) compared to those patients who went port removal for therapy completion (n=2930). Patients who had ports removed for indications other than malfunction or therapy completion (e.g., infection) were excluded from the current analysis.

Result(s):

Neither age (54.4 vs 54.2, p=0.8) nor gender [72% female vs 66% female, OR=0.75 (95%CI: 0.55-1.03), p=0.08] were different between the port malfunction and therapy completion cohorts. Only 3% (96/2930) of therapy completion patients had their ports removed in the inpatient setting, while 20% (40/204) of patients with port malfunction were removed as an inpatient. Metastatic cancer was more common in patients with port malfunction than therapy completion [55% vs 38%; OR=2 (95%CI: 1.3-3.3) p=0.003*]. Morbid obesity (BMI>35) was more common in patients with port malfunction than in patients who completed therapy [24% vs 16%; OR=1.73 (95%CI: 1-3) p=0.048*]. Interestingly, a lower percentage of patients who had their port removed for malfunction received chest wall radiation compared those who completed therapy [30% vs 20%; OR=0.5 (95%CI: 0.29-0.98) p=0.041*].

Conclusion(s):

Port removals due to malfunction are associated with patients having metastatic cancer and in patients with severe obesity. Ports removed for malfunction are more commonly removed in the inpatient setting compared to those removed for therapy completion. Understanding the factors correlating with port malfunction can inform discussions of procedural risk and help guide clinical management to avoid unnecessary complications and allow for early prevention measures.

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Outback Ltd Re-Entry Device For Endovascular Recanalization Of Central Venous Occlusions Associated With Failing Hemodialysis Access

1Jinoo Kim,1Je-Hwan Won, 1Je-Hwan Won

1Ajou University Hospital

Background(s):

To report our experience with the Outback LTD re-entry device for endovascular recanalization of central venous occlusions associated with dysfunctional arteriovenous fistulas.

Material(s) and Method(s):

All patients treated with ER for CMI After preparation of suitable well-experienced iBetween January 2013 and January 2019, eleven patients (4 males and 7 females, mean age: 61.8 years) with dysfunctional fistulas secondary to central venous occlusion underwent endovascular treatment using the Outback LTD re-entry device. Reasons for referral were increased venous pressure during hemodialysis (N = 5), arm swelling (N = 5), and graft thrombosis (N = 1). The mean age of the fistulas was 58.1 months, during which time nine patients had prior history of at least one salvage endovascular procedure. In all patients, the Outback LTD re-entry device was used as a bail-out measure after failed attempts to cross the occluded central vein using conventional wiring techniques. A retrospective review was performed to assess the clinical outcome of these patients.

Result(s):

Successful stenting was achieved in 9/12The site of occlusion was at the junction of the subclavian and innominate veins (N=9), in the right innominate vein (N=1), or in the subclavian vein (N=1). The re-entry device was introduced via the outflow vein of the arm (N=6), femoral vein (N=4), or internal jugular vein (N=1). Technical success was achieved in ten patients (90.9%), seven of whom required provisional placement of bare metallic stents. All ten patients underwent successful hemodialysis immediately after the procedure. Five patients with arm swelling were relieved of their symptoms. Excluding four patients who were lost for follow-up, the mean intervention-free period in the remaining six patients was 6.8 months, while the mean functional period of the fistula circuit after assisted procedures was 33.3 months. No complication related to the procedure was reported during this period.

Conclusion(s):

The Outback re-entry device can be safely and effectively used as a bail-out measure in patients who fail conventional wiring techniques during endovascular treatment of central venous occlusions.

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First Reported Series Of Iliocaval Stenting From Iraq, What Are The Earliest Lessons

1Hossein Ghanaati,2Omar Al Dahhan, 3Omar Al Dahhan, 4Halla Ghanem

1Tehran University of Medical Science, 2College of Medicine, University of Babylon, 3Fallujah Teaching Hospital, 4Imam Zain al Abideen Hospital

Background(s):

Endovascular revascularization (ER) for chronic mesIliocaval stenting is a demanding type of interventions that is missing totally in Iraq until recently, this is due to lack of sufficient experience from doctors Iliocaval stenting is a demanding type of interventions that is missing totally in Iraq until recently, this is due to lack of sufficient experience from doctors with related specialties i.e. the interventional radiologists and endovascular surgeons and also lack of suitable equipment in both the governmental and private sector of medical work.

Material(s) and Method(s):

All patients treated with ER for CMI After preparation of suitable well-experienced interventional radiologist partner and arrangement with two well-trained vascular surgeons and support from big private hospital, related equipment were prepared and scheduled interventions were issued for indicated cases on 2-3 months interval base.

Result(s):

Successful stenting was achieved in 9/12 patients (10/14 limbs)

Conclusion(s):

1.         Venous stenting procedures are very demanding surgeries that need precise equipment preparation that most of interventional radiologists are familiar with, and theoretical knowledge that most of vascular surgeons are familiar with, accordingly well-coordinated teamwork is always the best approach.

2.         Most of cases are due to history of provoked DVTs post operative or post trauma with lack of suitable DVT prophylaxis, also good number of chronic patients are lacking precise diagnosis of the nature of their deep venous problems, which both indicate defective overall venous management, not only interventional procedures, in Iraq.

3.         It is nice to say for any new medical project to start with easy cases, but this is difficult to achieve in reality, accordingly, we expected the most difficult cases management and we succeeded in management of most of them.

4.         Cost of the procedure was great obstacle, which prohibited many other patients from treatment.

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Factors Influencing Long Term Outcomes For Endovascular Revascularisation In Patients With Chronic Mesenteric Ischaemia

1Alaaeldin Ginawi, 1Ganesh Kuhan, 1James Kirk

1University Hospital of Derby and Burton NHS Foundation Trust

Background(s):

Endovascular revascularization (ER) for chronic mesenteric ischemia (CMI) has comparable outcomes with open revascularization, but it is associated with higher rates of restenosis and re-interventions.

Material(s) and Method(s):

All patients treated with ER for CMI between 2012 and 2020 were analysed. Twenty clinical, five anatomical, six procedure-related and seven outcome variables were collected. Kaplan-Meier survival analysis was carried out to identify variables influencing symptom recurrence, re-interventions and survival. Predictors were determined using a log-rank test and Cox regression analysis.

Result(s):

Thirty-seven patients were included with a mean age of 72.9 (range 50-90) years and 64.9% were women. Smokers were 51.4%, 94.6% patients had single-vessel treatment and 81.1% were treated with covered-stent. Median follow up was 59.7 (range 10.7-111.2) months. The 30-day-complications and mortality rates were 16.2% and 5.4% respectively. Symptoms recurred in 18.9% and 10.8% had re-interventions. Median survival was 86.4 (95% CI 29.0-143.8) months, median symptom free survival was 52.9 (95% CI 24.8-81.0) months and median intervention free survival was 86.4 (95% CI 26.4-146.4) months. Smoking was associated with recurrence of symptoms (p=0.028) and re interventions (p=0.033). Revascularisation using covered stents reduced re-interventions (p=0.002).

Conclusion(s):

The use of covered stent and cessation of smoking can improve the outcomes for ER in patients with CMI.

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Extra-Anatomic Internal-External Biliary Drainage Catheters To Manage Iatrogenic Common Hepatic Duct Injury

1Almamoon Justaniah,1Zergham Zia, 1Zergham Zia, 1Majed Ashour

1King Faisal Specialist Hospital & Research Center

Background(s):

IBile duct injuries during laparoscopic cholecystectomy are associated with increased mortality and morbidity. Management requires a multidisciplinary approach to decrease further complications and improve quality of life. We present a case of common hepatic duct (CHD) injury due to laparoscopic cholecystectomy managed by extra-anatomic internal-external biliary drainage catheters.

Material(s) and Method(s):

An 85-year-old male presented to an outside hospital with acute cholecystitis. A laparoscopic cholecystectomy was attempted and complicated by CHD injury. The surgery was converted to an open cholecystectomy however, the injury was not repaired. The patient was transferred to our institution to manage his biliary leak. A multidisciplinary team meeting was conducted with a consensus to proceed with drainage of biloma, percutaneous transhepatic cholangiogram (PTC) to assess the injury and percutaneous transhepatic biliary drains (PTBDs).

Result(s):

The patient was vitally stable with no leukocytosis or hyperbilirubinemia. Magnetic resonance imaging demonstrated a 4×5 cm collection at the porta hepatis and a right subhepatic collection measuring 5×7 cm. The intrahepatic bile ducts were nondilated. PTC under general anesthesia demonstrated CHD injury with contrast extravasation at the confluence, with involvement of the right and left main ducts. Bilateral PTBDs were advanced from the hepatic ducts to the duodenum through the porta hepatis collection and duodenal defect. Passing the catheters through the common bile duct (CBD) could not be achieved due to near complete separation of the CHD from the CBD. Drains were placed in the collections and removed after 2 weeks. The PTBDs were open to bag for one week, then capped with routine exchanges in the last 5 months.

Conclusion(s):

Interventional Radiology plays an important role in the management of bile duct injuries when patients are inoperable or when the defect is large.

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Case Of Delayed Diagnosis Of Pediatric Facial Venous Malformation With Satisfactory Result Post Sclerotherapy. A Case Report And Literature Review

1Abeer Faisal Aldhawi, 1Mohammed Hussain Almetlag, 1Saeed Bin Nihayah

1King Fahd Medical City

Background(s):

In 1982 Mulliken and Glowacki suggested a classification of vascular abnormalities based on endothelial properties into hemangioma and vascular malformations basis on clinical and histopathological features (1). Vascular malformations are always present at birth, whereas hemangiomas frequently appear within the first month of life and are not commonly discovered at birth. Furthermore, vascular malformations expand in proportion to the baby growth and never diminish on their own. (2). Congenital vascular malformation remains a complicated and perplexing diagnostic and clinical entity due to the vast diversification of clinical manifestations, site, unexpected clinical course, variable response to therapy, and a high chance of recurrence. Besides that, the lack of standard nomenclature makes differentiation difficult (3, 4). Venous malformations are the the most prevalent type of vascular abnormality in children and young adults that appear as solitary lesion 90 % with most prevalent n in the head and neck around 40 – 48 % (5-6-7).Besides slow growth, with time the venous malformation appears as low flow, sluggish development, localized or diffuse appearance, and compressible lesion (8). A multidisciplinary team must undertake a diagnostic and treatment plan (9). Diagnostic and interventional radiologists play an important part in a vascular anomaly team, they must be informed of the clinical history and findings to make the correct diagnosis and provide the appropriate treatment alternatives (10). Ultrasound scan is non-invasive, low-cost, and freely accessible, so it demonstrates that venous malformations are compressible, display mixture echotexture in comparison to adjoining subcutaneous tissue, and Doppler in addition to grey scale is important in distinguishing between low – and high flow malformations. (11).CT rule is restricted; it aids in the definition of bone involvement and phlebitis if present (12). T2-weighted or STAIR images in MRI provide a high signal intensity and best define the entire extent of the lesion and its relationship to neighbouring essential structures. Post gadolinium, will rise to enhance homogeneously or heterogeneously. (13). For a long time, surgical excision has been the preferred treatment strategy for congenital lymphatic and vascular malformations currently sclerotherapy is a preferred first-line treatment for venous malformation, it can reduce the size or eliminate the lesion (14). A variety of pharmaceuticals have been used to treat venous malformations,the most widely utilized agents are ethanol, bleomycin, and sodium tetracyclic sulfate (STS) (2). Sodium tetracyclic sulfate has been broadly utilized in the past for the sclerosis of oesophagal varices and varicose veins, and it is also being used more frequently in the therapy of vascular malformations, it has been observed to be effective in eliminating channels of VMs (15). Bleomycin is an anticancer agent; however, some recent attempts have been made to use it as a sclerosing agent in patients with congenital lymphatic malformations (16). Complications are rare included skin blistering, ulceration and nerve injury (17).We present the case of a 3 -year-old boy who had a lip and cheek venous malformation that delayed diagnosis and was effectively treated with sclerotherapy.

Material(s) and Method(s):

A male child, 3.5 years old baby, during infancy period the parents observed painless swelling at the right upper lip, upper gingival area, and right buccal areas accompanied with discolouration which increased with time and became noticeable with crying and fever. They went to primary care and were referred to a pediatric clinic because of the swelling and discolouration otherwise he is medically free and had no family history of vascularmalformation. The systemic examination was unremarkable, at that time his lesion was clinically diagnosed as a hemangioma. An ultrasound performed at the site of the local swelling revealed a 3.3 x 3 x 2.2 cm lesion mislabeled as hemangioma (Figure 1). The patient was seen by dermatologists, and an MRI revealed that the lesion extended from tthe lateral aspect of the right upper lip into the submucosal oral cavity; the ipsilateral orbital region was intact, and the lesion again was misdiagnosed as a hemangioma (Figure 2).At the age of two years and a half, the swelling and discolouration were still present with increase facial deformity associated with discomfort felling (Figure 3A) then the patient was evaluated by a multidisciplinary team consisting of a plastic surgeon, dermatologist, paediatrician, pediatric oncologist, and pediatric interventional radiologist.A pediatric interventional radiologist performed an ultrasound that revealed venous malformation and agreed to start sclerotherapy (Figure 4). After explaining the treatment plan to the patient’s parents and obtaining written consent, the patient had three sclerotherapy treatments under general anaesthesia and sterile technique. All sessions were carried out with the aid of ultrasonography and fluoroscopic guidance.During the first sclerotherapy session in November 2018, the right cheek and upper lip venous malformations were punctured at six different locations then perform a venogram.Sclerotherapy was administered via three catheters and 13 cc of 3 % sodium tetradecyl sulphate (Figure 5A). The second session took place in March 2019 and were using 2 ml of sodium tetradecyl sulphate foam and 1.5 cc (1.5 mg) of bleomycin (Figure 5b). The third session was held in August2019 with a total of 3 ml of 3 % sodium tetradecyl sulphate foam and 1 ml bleomycin (Figure5C), with the same three locations used in the first session.

Result(s):

The duration between sessions was not ideal, however, owing to a bed crisis and admission difficulties, the time between sessions was prolonged.The patient endured all the sessions with no acute or long-term complications. Both the swelling and symptoms are fade over time after sclerotherapy. The family and clinicians were satisfied with the results in both medical and cosmetic aspects . The last ultrasound obtained after the third session shows a considerable reduction in venous malformation (Figure 6)

Conclusion(s):

Sclerotherapy treatment was found to be an excellent option as a first-line treatment in terms ofsize reduction as well as safety profile. Follow-up ultrasound showed a significant reduction in size and with a minor remnant venousmalformation, the symptoms vanished totally, even with triggersThe diagnosis and differentiation of vascular malformations may overlap; this case highlightsthe importance of a multidisciplinary team in establishing an accurate diagnosis and selecting the best treatment strategy, as well as the importance of general radiologists being familiar with the various types of vascular malformations to minimize misinterpretation

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Use Of Distal Intracranial Catheters For Better Working View Of Cerebral Aneurysms Hidden By Parent Artery And/Or Its Branches: A Technical Note

1Ehab Mahmoud,1Chrsitoffer Nyberg, 1Chrsitoffer Nyberg, 1Borota Ljubisa

1Uppsala University Hospital ( Akademiska)

Background(s):

A good working view is critical for safe and successful endovascular treatment of cerebral aneurysms. In a few cases, endovascular treatment of cerebral aneurysms may be challenging because of difficulty in obtaining a proper working view.  In this report of 6 cases, we described the advantage of using a distal intracranial catheter (DIC) to achieve better visualization of cerebral aneurysms hidden by a parent artery and/or its branches.

Material(s) and Method(s):

Between September 2017 and January 2021, we treated 390 aneurysms with endovascular techniques. In six cases in which it was difficult to obtain a proper working view, the DIC was placed distally close to the aneurysm in order to remove the parent artery projection from the working view and obtain better visualization of the aneurysm. Clinical, procedural outcomes and complications were evaluated.

Result(s):

The position of the DIC was above the internal carotid artery (ICA) siphon in the six cases.  All aneurysms were successfully embolized. Raymond–Roy class 1 occlusion was achieved in all four unruptured aneurysms, while the result was class 2 in the two ruptured aneurysms. Placement of the DIC was atraumatic without dissections or significant catheter-induced vasospasm in all patients. Transient dysphasia was seen in two cases and transient aphasia in one.

Conclusion(s):

Using this technique, we have found it possible to better visualize the aneurysm sac and/or neck and thereby treat cases we otherwise would have consider untreatable.

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First-Pass Effect Predicts Clinical Outcome And Infarct Growth After Thrombectomy For Distal Medium Vessel Occlusions

1Adrien Guenego,1Boris Lubicz, 1Boris Lubicz

1Erasme

Background(s):

The First Pass Effect (FPE) in endovascular thrombectomy (EVT) has been associated with better clinical outcomes and lower stroke progression in large-vessel-occlusion but has not been evaluated in distal, medium vessel occlusions (DMVOs). We sought to assess the impact on clinical outcome and stroke progression of the modified FPE (defined as a single-pass successful [mTICI 2b/2c/3] revascularization) in patients who underwent EVT for a primary DMVO

Material(s) and Method(s):

We collected the data of consecutive patients who underwent EVT for a primary DMVO in one large academic center and compared the rate of good clinical outcome (modified Rankin Scale of 0-2 at 3 months) and stroke progression between patients who achieved mFPE to non-mFPE patients.

Result(s):

Between January 2018 and January 2021, we included 60 patients who underwent an EVT for an acute ischemic stroke (AIS) with a primary DMVO.

Overall, mFPE was achieved in 32% (19/60) of EVT. mFPE was associated with a significantly higher rate of good clinical outcome compared to non-mFPE patients (89% versus 46%, ODDS ratio = 16.04 [2.23-115.39], p=0.006 in multivariate analysis). Final stroke volume was lower among mFPE patients (6.9mL [4.7-13.6] versus 23mL [14.6-47], p=0.001) as-well-as stroke progression (6.8mL [4-12.1] versus 17.8mL [8.1-34.9], p=0.016).

mFPE was still associated with higher rates of good clinical outcome when compared to patients reaching an mTICI score ≥2b in more than one pass (89% versus 53%; ODDS ratio = 7.37 [1.43-38.08], p=0.017).

Conclusion(s):

ThmFPE is associated with better clinical outcomes and lower stroke progression in DMVO.

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Risk Factors for failure of Endovascular Aneurysm Repair with Acute Conversion to open Aortic Repair

1Waseem Wahood, 2Jacob McPhee,  2Brian Baigorri, 2Martin Radvany

1Dr.Kiran C. Patel College of Allopathic Medicine, 2Aventura Hospital & Medical Center

Background(s):

Patients with abdominal aortic aneurysms who undergo failure of endovascular aneurysm repair and conversion to open aortic repair (EVAR-c) have a higher 30-day mortality than those treated with open repair alone. The purpose of this study was to identify patients at risk for EVAR-c.

Material(s) and Method(s):

The National Surgical Quality Improvement Project Vascular-targeted database was queried from 2011 to 2019 for EVAR patients. Patient demographics were analyzed between EVAR and EVAR-c groups using chi-square and student t-tests. Multivariable logistic regression was conducted for risk factor assessment.

Result(s):

18,387 underwent EVAR and 146 underwent EVAR-c. There was no statistical difference in age (p=0.47), gender (p=0.32), race (p=0.75) or BMI (p=0.61). The average aneurysm diameter was 5.83 cm (SD=1.69) in the EVAR group, and 6.43 cm (SD=1.65) in the EVAR-c group (p<0.001). Aneurysm diameter (OR: 1.07 per 1 cm increase; 95% CI: 1.01 to 1.14; p<0.001), distal extension involving the common iliac (OR: 2.38, 95% CI: 1.43-3.98, p=0.001), and distal extension inferior to the common iliac (OR: 2.40; 95% CI: 1.24-4.63; p=0.009) were associated with higher odds of EVAR-c.

Conclusion(s):

This study suggests that aneurysm morphology plays a dominant and important role when predicting patients who are at risk for failure of endovascular therapy. These results may help guide patient selection for interventional radiologists.

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Outcomes of Resuscitative Endovascular Balloon Occlusion of the Aorta Compared to Resuscitative Thoracotomy in Non-Cardiac Arrest Patients: A Review of the National Trauma Database

1Waseem Wahood,1Harmandip Singh, 1Jacqueline Mirza, 1Aaiz Hussain, 1Stephen Ely, 2Michael Renda

1Dr. Kiran C. Patel College of Allopathic Medicine, 2Kendall Regional Medical Center

Introduction(s):

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is a minimally invasive technique used to control noncompressible torso hemorrhage (NCTH) in patients experiencing profound shock. REBOA primarily serves as a temporary course of action to bridge patients into a surgical intervention. Traditionally, the common approach to life-threatening hemorrhage has involved resuscitative thoracotomy (RT) with aortic cross-clamping. Our study compares REBOA with RT by evaluating peri- and post-procedural outcomes in patients whom have not lost vital signs nor sustained cardiac arrest.

Material(s) and Method(s):

The American College of Surgeons Trauma Quality Improvement Program (ACS TQIP) was utilized to extract procedure data in 2017. Patients who underwent REBOA (n = 83) were compared with patients who underwent RT (n = 114). Cox proportional hazard analysis was conducted comparing survival in the ICU between the two procedures. Kaplan-Meier curve was created to depict survival time. Multivariable logistic regression was conducted to compare complications between the two procedural techniques. Patients in cardiac arrest prior to arrival were excluded.

Result(s):

.Those who underwent REBOA had higher proportion of acute kidney injury complications compared to RT [8 (9.64%) vs. 1 (0.88%); p=0.004] as well as pulmonary embolism [5 (6.02%) vs. 0 (0.00%); p=0.008]. However, multivariable cox proportional hazard analysis indicated that inpatient mortality was less likely in the REBOA cohort compared to RT (HR: 0.49, p=0.049). REBOA patients had a higher average survival time in the ICU compared to RT patients (41.4 vs. 14.9 days, respectively; p=0.021). REBOA was found to have higher odds of acute kidney injury compared to RT (OR: 11.52; p<0.023).

Conclusion(s):

Patients who underwent REBOA had a higher rate of survival in the ICU as compared with RT. However, REBOA was associated with more postprocedural complications compared to RT. We recommend further research on the efficacy and safety of REBOA.

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Hysterectomy Versus Uterine Artery Embolization for Fibroid Treatment: A National Clinical and Financial Comparison

1Waseem Wahood,1Sarah Raines, 1Lexi Frankel, 1Iliza Minaya

1Kiran C. Patel College of Allopathic Medicine

Introduction(s):

Uterine fibroids are benign tumors originating from the myometrium consisting of smooth muscle. Each year, 200,000 hysterectomies are performed for the treatment of uterine fibroids. Uterine artery embolization (UAE) is another well-documented treatment for uterine fibroids that is minimally invasive with rapid recovery times. Herein, we aimed to assess the outcomes of hysterectomy versus UAE for the treatment of uterine fibroids using a national database.

Material(s) and Method(s):

The National Inpatient Sample (NIS) was queried for admissions involving patients with fibroids from 2012 to 2019. Admissions were divided into groups 1) those who receive UAE, and 2) those who received hysterectomy. Trend in proportion of utilization of UAE was conducted using Cochran-Armitage test. Multivariable logistic regression was conducted to assess patient profile between the two groups as well as non-routine discharge (Transfer to Short-term Hospital, Transfer to Skilled Nursing Facility or Intermediate Care Facility, Home Health Care, Against Medical Advice). These results are depicted as odds ratios (ORs) and 95% confidence intervals (CIs). Negative binomial regression was used to assess risk factors associated with total charge (in 2020 dollars) and total length of stay (LOS). These results are depicted as beta-coefficients (coef.) that are interpreted as percents.

Result(s):

823,245 admissions involved intervention for fibroids; 812,070 (98.64%) underwent hysterectomy and 11,175 (1.36%) underwent UAE. There was an increase in the trend of utilization of UAE by an average of 0.07% per year (95% CI: 0.055 to 0.100; p<0.001). Compared to White patients, UAEs were more likely utilized by Black patients (OR: 2.19; p<0.001) and those of other races (OR: 1.50; p<0.001). Hispanic patients had similar odds of receiving UAEs over hysterectomies compared to White patients (OR: 1.04; p=0.61). Those who underwent UAEs had higher odds of non-routine discharge (OR: 1.48; p=0.001) compared to those who underwent hysterectomies. Those who underwent UAE had a higher total charge by 28.1% (p<0.001) and similar LOS (coef.: 3.90%; p=0.15) compared to those who received hysterectomies.

Conclusion(s):

Uterine artery embolization is a rapidly growing treatment for symptomatic uterine fibroids. Its use has resulted in similar length of stays and increased total charge and odds of non routine discharge as compared to hysterectomy. UAE utilization is higher in Black patients, suggesting an area for further investigation.

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Role of Vascular Endothelial Growth Factor in Arteriovenous Malformation Associated Seizures

1Wessam Fathi Mohammed Mustafa,1.2Ibrahim El-Menshawy

1Mansoura University Hospital, 2Mansoura University Hospital

Background(s):

This study was designed to evaluate the role of vascular endothelial growth factor in AVM associated seizures

Material(s) and Method(s):

A case-control study conducted on 40 patients subdivided into 3 groups on Mansoura university hospital

The patients subdivided into three groups:

  • 10 patients: AVM with seizures.
  • 16 patients: AVM without seizures.
  • 14 patients (control): patient without AVM.

Plasma samples were collected from 40 patients to detect the basal level of VEGF. The serum samples were immediately centrifuged and frozen at -80 C, VEGF were measured by commercially available ELISA (double-antibody sandwich enzyme linked Immunosorbent Assay) kits (Human vascular endothelial cell growth factor ELISA Kit, SUNRED Biological Technology)

Data were fed to the computer and analyzed using IBM SPSS software package version 22.0.Significance of the obtained results was judged at the 0.05 level.

Result(s):

There was statistically significant higher mean of VEGF among AVM cases in comparison to control group, also the VEGF mean value was statistically significant higher among epileptic cases than cases without epilepsy

Conclusion(s):

Our results confirmed the role of VEGF in both AVM and epilepsy and it may be used in future as a reliable and valid predictor. Regarding the debate of the role of VEGF in epilepsy, whether if it’s a neuroprotective or it’s epileptogenic, our study tilting the balance heavily in favour of the epileptogenic effect of VEGF. This study not only gives a hope for using VEGF as a predictor tool in AVM and epilepsy but also VEGF may have a role in future treatment.

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Transvenous Embolization (Tve) of Brain Arteriovenous Malformations (Bavms): Up to Date Meta-Analysis

1Mohamed Deinwar,1Hossam Elfeki, 1Ashraf Ezz Eldin, 1Basem Awad

1Mansoura University Hospital

Introduction(s):

We conducted an up-to-date meta-analysis to assess the rate of success and complication of the TVE to conclude its efficacy and safety.

Material(s) and Method(s):

Literature was searched for relevant and potentially relevant studies from 1982 through February 2021. Studies that met our eligibility criteria and reported the main outcomes (endovascular occlusion and complication rates) were included.

Result(s):

Seven studies were finally selected. In total, 154 patients were reviewed with detailed BAVMs characteristics and endovascular TVE techniques. The weighted mean rate of immediate endovascular total occlusion, overall technical complication, and overall good functional outcome (mRs< 2) were 93% (95%CI=89.1-96.9%, I2=0%, P 0.487), 10.5% (95%CI=4.3-16.6%, I2=30.8%, P 0.193), and 90.9% (95%CI=85.3-96.6%, I2=26.6%, P 0.241) consecutively.

Conclusion(s):

The results of TVE for BAVMs showed it is generally safe and effective in certain selected patients. However, the complementary role of TAE to TVE as a definitive endovascular treatment for BAVMs cannot be separated. More studies concerning this role need to be conducted.

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Interventional Radiology in Hemoptysis Secondary to Congenital Heart Disease: Beyond the Bronchial Arteries

1Vimal Chacko Mondy,1Anoop A

1SCTIMST

Objectve(s):

Hemoptysis is a rare but potentially lethal complication in patients with congenital heart disease (CHD). Hemoptysis in the setting of CHD can arise from a distinct set of causes which are seldom seen outside this cohort. The aims and objectives of this study were to:

1.         To evaluate the various CHD which present with hemoptysis and identify the underlying source of hemoptysis

2.         To study the role of interventional radiology in management of hemoptysis in patients with CHD

Material(s) and Method(s):

This was a retrospective single-center study. Consecutive patients with CHD (n=42) who presented with hemoptysis were included in the study. The clinical details were obtained from hospital records and pre-procedural and interventional imaging from PACS. The underlying CHD and the source of hemoptysis were evaluated as well as management of these patients including interventional radiology procedures.

Result(s):

The most common source of hemoptysis were major aortopulmonary collaterals (n=17; 30%) in patients with Tetrology of Fallot and Ventricular septal defect with pulmonary atresia. The most common interventional procedure done was embolization of major aortopulmonary collaterals (n=16; 40%). The other procedures included embolization of pulmonary AVMs (n=2; 5%) and anomalous systemic arterial supply (n=4; 9%). Minor hemoptysis was managed conservatively (n=10; 24%) and some required surgical correction of the underlying cardiac condition (n=10; 24%).

Conclusion(s):

Hemoptysis in the setting of CHD can occur from numerous different sources which are distinct from those seen in the general population. Endovascular management plays a pivotal role in the acute setting for control of hemoptysis as well as in preparing the patient for definitive surgery.

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Endovascular approach to a Failing Arteriovenous Hemodialysis Fistula: What Interventional Radiologists need to know

1Vimal Chacko Mondy,1Anoop A

1SCTIMST

Introduction(s):

End-stage renal disease (ESRD) is increasing incidence with many patients requiring renal replacement therapy (RRT).  Limitation of donor availability and high economic cost preclude the procedure in many patients. Hemodialysis is the most commonly done RRT and is usually done by creating an arteriovenous fistula (AVF) which can be either native or graft AVF. There are many associated complications with AVF requiring surgery or intervention requiring surveillance for early identification and appropriate treatment.

Material(s) and Method(s):

The various causes of hemodialysis AVF failure and its clinical presentations. The role of ultrasound in the surveillance of AVFs The different endovascular treatment options for failing arteriovenous fistula with representative examples.

Result(s):

Stenosis in the AVF circuit is the most common cause of failing fistula, and the treatment of choice is balloon angioplasty. The various endovascular therapeutic options in other complications include thrombolysis or mechanical thrombectomy, venoplasty for thrombotic occlusions, angioplasty for central venous stenosis, stenting for failed angioplasty, or rapid recurrence of stenosis embolization of early draining veins if it is the cause for non-maturation of AVF or secondary failure. Distal hypoperfusion ischemia syndrome due to arterial stenosis is treated by balloon angioplasty to improve distal flow.

Conclusion(s):

As the number of AVFs created for hemodialysis increases, knowledge of its hemodynamics, associated complications, and interventional radiology techniques for its management are essential for an interventional radiologist.

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Resuscitative Endovascular Balloon Occlusion of the Aorta (Reboa): A Minimally Invasive approach to Control Acute Torso Hemorrhage

1Talal Mourad,2Usman Mahay

1University of Illinois College of Medicine Peoria, 2University Hospitals Birmingham NHS Foundation Trust

Objective(s):

1. Provide a review of resuscitative endovascular balloon occlusion of the aorta (REBOA) and explore its utility in controlling non-compressible hemorrhage below the diaphragm. 2. Discuss the clinical indications for REBOA as well as contraindications and recognized complications. 3. Outline steps for REBOA placement with helpful illustrations.

Material(s) and Method(s):

REBOA is an intervention that can control life-threatening hemorrhage below the diaphragm for patients in hemorrhagic shock unresponsive to resuscitation. It is a temporary measure intended to sustain perfusion to the heart and brain until definitive hemorrhage control can be obtained. It has gained popularity as a minimally invasive alternative to resuscitative thoracotomy (RT) with aortic cross-clamping, which has been the standard in controlling non-compressible torso hemorrhage. However, careful clinical evaluation is warranted prior to REBOA placement. Only patients meeting appropriate criteria are candidates for therapy. This criteria, as well as contraindications and complications from REBOA use will be discussed in detail.

Result(s):

Vascular access is usually obtained through the common femoral artery with a 7 French sheath and a balloon is directed either to Zone 1 (between the left subclavian and celiac arteries) or Zone 3 (between the caudal renal artery and aortic bifurcation) of the aorta. While Zone 1 occlusion is indicated for confirmed hemorrhage arising below the diaphragm, Zone 3 occlusion is reserved for patients in hemorrhagic shock with evidence of a pelvic fracture. Once the appropriate balloon location is confirmed on imaging, the balloon is inflated to tamponade the vessel. Monitoring for loss of the contralateral femoral pulse indicates sufficient balloon inflation. The patient may then be transferred for definitive surgical or endovascular hemorrhage control.

Conclusion(s):

REBOA is a recognized safe and efficacious intervention for rapid, non-invasive control of non-compressible hemorrhage in an emergency setting. It has been shown to be a faster method to aortic occlusion compared with RT after obtaining arterial access. Ongoing research should elucidate further clinical indications and outcomes regarding its use.

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A Pictorial Review of Segmental Arterial Mediolysis: An Interventional Radiology Perspective of Image Findings and Treatment

1Tae Yang Kim,1Tariq Ali

1Norfolk & Norwich University Hospital

Background(s):

Since the first description of segmental arterial mediolysis (SAM) in 1976 by Slavin and Gonzales-Vitale, cases have been reported in the literature in increasing numbers and there is a growing awareness of this pathologic entity. Although the gold standard for diagnosis is histopathological, SAM is increasingly being described based on radiological appearances as the majority of suspected SAM cases do not go on to have a biopsy or surgical resection. There does not currently exist a consensus of non-histopathological diagnostic criteria for SAM, however many have adopted those described by Kalva et al in which imaging criteria include the presence of dissection, fusiform aneurysm, occlusion, beaded appearance, or wall thickening of the mesenteric or renal arteries, with the absence of associated contiguous aortic dissection or atherosclerosis; in the majority of studies the presence of dissection and aneurysm were the most common imaging findings and the diagnostic likelihood is increased when these are found in multiplicity rather than in isolation. The diagnosis of SAM is suspected where alternative pathologies are excluded or less likely, including congenital connective tissue disorders, collagen vascular disorders, inflammatory arteritis and fibromuscular dysplasia (FMD). There is particular debate in distinguishing SAM from FMD and whether or not they are truly distinct disease entities.

Material(s) and Method(s):

Cases of suspected SAM based on radiological findings were compiled at a single institution (NNUH) over a period of 7 consecutive years (2015 – 2021). All cases were reviewed by 3 interventional radiologists and representative cases were selected for presentation.

Result(s):

Eight cases of suspected SAM were selected in total. Four cases were detected following an acute presentation with symptoms including abdominal pain, vomiting, and signs of hypovolaemic shock associated with a low haemoglobin level. Four cases were detected incidentally on imaging performed to detect other pathologies, including CT colonography for change in bowel habit, US urinary tract for non-visible haematuria, and CT angiograms to detect abdominal aortic aneurysms (AAA) as part of the UK National AAA Screening Programme. Affected vessels included branches of the coeliac artery, superior mesenteric artery and renal arteries, as well as iliac arteries. Pathologies included ruptured aneurysms, fusiform aneurysms, thrombosed aneurysms, beaded appearances due to multiple aneurysms and stenoses, and dissections. Endovascular treatment was by embolisation in all cases, predominantly with the use of coils. All cases of embolisation were successful.

Conclusion(s):

SAM can manifest itself acutely following a ruptured aneurysm, where it is a potentially life-threatening condition. SAM can also be detected incidentally with the increasing use of imaging for various clinical scenarios. SAM predominantly affects the mesenteric arteries, but is not limited to these vessels. Our case series are in concordance with the majority of other studies on SAM, whereby the most common imaging findings are the presence of aneurysms and dissections. Endovascular treatment with embolisation plays an important role in the management of SAM.

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Percutaneous Thoracic Duct Embolization for Chylous Leak. A Informative Guide for Technologist and Nurses

1Sooraj Suresh Rahila,1Fouad Nawaf Ahmad Hammad, 1Hammad Rashid R M Al Hamar, 1Dr. Ali R.Barah

Background(s):

Imaging findings on Lymphangiogram and CT. Discussing the management of Chylous Leak. Highlights the technique and principles for embolization

Material(s) and Method(s):

Chylous leaks, such as chylothorax and chylopericardium, are uncommon effusions resulting from the leakage of intestinal lymphatic fluid from the thoracic duct (TD). The cause can be either traumatic or nontraumatic. The Treatment is traditionally consisted surgery. This can occur anywhere along the pathway of chyle that begins in the intestinal lymphatic ducts and continue through the cisterna chyli and into the TD. Thoracic duct embolization (TDE) has become a viable treatment alternative due to it high success rate and minimal complications.

Result(s):

PTDE is a minimally invasive image-guided intervention by using sclerosant agents . TDE has better outcomes than conservative management. Percutaneous lymphangiography technique by USG is used to directly access the hilum of an inguinal lymph node with a 24G LP needle is used for injecting an oil-based contrast agent at a rate of 1 to 2 mL per 5 minutes up to 6 mL, which should achieve appropriate opacification of the abdominal and pelvic lymphatics.

When the target duct is confirmed, a 22G chiba needle is used for transabdominal access under fluoroscopy. A stiff 0.018 guidewire is used to access the duct, a 2.4 or 3Fr 65cm microcatheter is used to advanced over the wire into the TD, after which the guidewire may be removed contrast is then injected to define the source of the leak and TD anatomy. The TD is then embolized with a sclerosant agents.

Conclusion(s):

TDE is an important alternative treatment to patients with traumatic and nontraumatic chylous leaks with no associated mortality, minimal morbidity, and a high success rate.

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Effectiveness and Safety of Intracrani Alangioplasty without Stenting as first Therapuetic option for Symptomatic Intracranial Stenosis

1Shorog Althubait, 1Hamada A. Salam, 1Hani Lababidi, 1Sultan Alqahtani

1Saudi German Hospital, Riyad

Background(s):

Atherosclerotic intracranial arterial stenosis (ICAS) is one of the most common causes of stroke worldwide, associated with a high risk of recurrent stroke in spite of the presence of many therapeutic options, knowing that the current ASA guidelines (2021) recommend that medical therapy (anti-thrombotic, risk factors control, lifestyle modifications) is the first and main option for treatment of symptomatic ICAS (stroke or TIA patient) even if recurrent, while interventional therapy (angioplasty with or without stenting) still questionable.

To evaluate the outcome, safety, and effectiveness of intracranial balloon angioplasty without stenting as first option for symptomatic intracranial stenosis compared to aggressive medical therapy and intracranial stenting

Material(s) and Method(s):

Forty-five patients with symptomatic ICAS were enrolled and equally randomized in this study, where fifteen patients(medical group) underwent medical treatment(antiplatelets therapy+control risk factors+life style modification), fifteen patients (angioplasty group) underwent angioplasty without stenting using (drug-eluting ballon) and fifteen patients(stenting group) underwent angioplasty with stenting.

Result(s):

The angioplasty group had a better clinical and radiological outcome with NIHSS below or equal (6) at 12 months follow up post-procedure in (100%) of the patients in the angioplasty group, in comparison to (80%) of the patients in both medical group and stenting group. also, a better functional outcome with MRS score (0:1) at 12 months follow-up post-procedure in (93,3%) of the patients in the angioplasty group, in comparison to (66,7%) in the medical group and (80%) in stenting group. Brain imaging (CT or MRI) show ( no significant new insult )at 12 months follow up post-procedure in the angioplasty group in (100 %) of the patients, while( 80%) of the patients in both medical and stenting groups show (no significant new insult), in addition to, cerebrovascular imaging(CTA or MRA) show (no significant restenosis) at 12 months follow up post procedure in angioplasty group in (100%) of the patients in comparison to (80%) in the medical group and (80%) in stenting group, recurrent ischemic events occurred in (0%) of angioplasty group, with (20%) of medical group and (13,3%) of stenting group.

Conclusion(s):

At the end of this study, we can conclude that intracranial balloon angioplasty using drug-eluting ballon is superior for both medical therapy and intracranial stenting

and safe as the first option for treatment of symptomatic intracranial stenosis further randomized control trials are required since it will change the current practice paradigm.

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Endolymphatic Thoracic Duct Stent-Graft Placement for Persistent Right Sided Chylothorax Post Fontan Procedure. A Case Report

3Sultan Mana Mania Alamri,1,2Mohammad Farouq Badran

1King Fahad Medical City, 2King Faisal Specialist Hospital & Research Center, 3King Faisal Medical City

Introduction(s):

Chylothorax can cause serious hypovolemia, electrolyte imbalances, starvation, and immunological compromise in a short period. High venous pressure and obstructed thoracic duct drainage can impact post-Fontan lymphatic circulation. Instead of embolizing or disturbing the thoracic duct, a thoracic duct stent-graft reconstruction may be considered to eliminate the site of leak while maintaining the normal physiologic lymphatic drainage channel.

Material(s) and Method(s):

A 5-year-old male patient, has a history of congenital heart disease with double inlet left single ventricle, pulmonary atresia, ventricular septal defect, underwent ductus arterisus stenting and Glenn procedure with left pulmonary artery stenosis during the first year of his life.

Recently the patient underwent an extra-cardiac fontan procedure which was complicated by persistent right sided pleural effusion. A chest tube was placed during the surgery.,the right-sided pleural effusion showed a high drain output of about more than 500 cc / 24 hours which was confirmed by fluid analysis to a chylothorax. The patient has conservative therapy with low fat diet however it failed, The patient was brought to the radiology department for an enhanced US lymphatic scan and Dynamic MR lymphangiogram. showed left internal jugular vein immediate contrast flow confirming the patency of the thoracic duct.The patient was booked by the interventional radiology service for lymphangiography and possible thoracic duct intervention.

Result(s):

The procedure was performed under general anesthesia in a supine position. Lipiodol was injected showed a small amount of contrast agent leaking from the right side.

The patient was monitored for 10 days, with no improvement of the right-sided effusion.

The patient was brought to the interventional radiology department for thoracic duct intervention. Via The left brachial vein and direct cisterna chyli access, . Lymphangiogram and Cone-beam CT  with 3 D reformat was obtained confirming no evinced of leak. However, there were multiple abnormal plexiform small ducts at the level of T8 and cistern chyli  . A 5-mm, 10-cm VIABAHN endoprosthesis was deployed within the thoracic duct, excluding the plexiform lymphatic channels. Post stenting lymphangiogram showed patent stent with brisk flow and total resolution of the previously seen plexiform lymphatic channels.

Conclusion(s):

For the treatment of chylothorax, thoracic duct stent-graft reconstruction may be a technically successful and safe alternative to thoracic duct embolization, disruption, and surgical ligation, while also potentially preserving anterograde flow in the central lymphatics. More investigation and follow-up are required.

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Tips and Tricks for Advanced Aortic Repair (Fevar/Bevar)

1Salar Samimi

1Richmond Medical

Background(s):

The purpose of this proposed 15-minute oral presentation is to provide tips and tricks for advanced Endovascular Aneurysm Repair (EVAR) of aortic disease. Technical success of these complex thoraco-abdominal aortic repairs is often strictly dependent on a specific technical road map. The purpose of this talk is to present the most critical points each operator must keep in mind in order to increase the probability of technical success, divided into four separate categories: Imaging, Sizing, Anatomical contra indications not discussed in the IFU, and Device Design & Deployment.

Material(s) and Method(s):

Tips and Tricks for FEVAR/BEVAR/IBD EVAR will be presented with the help of procedural images, and animations, to firmly illustrate each point clearly and concisely.

Result(s):

Where available, procedural and follow up imaging of patients for which these strategies was used will be presented.

Conclusion(s):

The purpose of this proposed oral lecture is to familiarize the operator of the topics and tactics which he/she will need to bear in mind in order to increase technical success. The lecture is based on the assertion that each procedure has its own unique road map for success, and hence with consideration of these points, the probability for technical success can be significantly increased.

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Ultrasound-Guided Angioplasty of Peripheral Arteriovenous Fistula Stenosis in Hemodialysis Patients

1Mohamed Redha Saker,1Sebti Draouat

1Chu Benbadis

Introduction(s):

Native arteriovenous fistula (AVF) is the vascular access of choice for chronic hemodialysis patients because of its longevity and low rate of complications which are dominated by stenosis. Ultrasound-guided angioplasty of peripheral AVF stenosis in hemodialysis patients constitutes a minimally invasive percutaneous endovascular therapeutic alternative intended to restore a vascular caliber satisfactory for the correct functioning of the AVF.

Material(s) and Method(s):

Our study is prospective for evaluation of a series of 24 patients with end-stage chronic renal failure, hemodialysis and who present with stenosis of the AVF drainage vein, treated in the interventional radiology department of the Benbadis hospital in Constantine, over a period of 23 months from December 2019 to October 2021. The patients included had a significant stenosis ≥ 50% compared to the adjacent segment considered normal associated with a low flow of the AVF. All the patients in our study underwent

Doppler ultrasound exploration of the AVF before and after ultrasound-guided angioplasty. We performed 36 angioplasties in 24 patients without fluoroscopic guidance or contrast product and analyzes were performed using Microsoft Excel software.

Result(s):

A total of 36 angioplasties performed in 24 included patients, aged on average 51.08 ± 14.25 years with a slight female predominance and a sex ratio of 0.85. Risk and comorbid factors are dominated by hypertension (95.8%), diabetes (20.8%) and tobacco (25%). The age of AVF varies between 1 and 7 years, 100% of native AVF (n=24), 50% of fistulas are proximal (n=12) and the other half are distal, 50% are radiocephalic, 41.7% brachiorocephalic (n=10) and 8.3% brachiobasilic (n=2), 75% of patients (n=18) presented a low flow of the AVF and 62.5 % (n=15) of prolonged bleeding time. 45.8% of the stenosis were juxta-anastomotic, 41.7% post-anastomotic and 20.8% of the cephalic arch. In 58.3% the catheterization was retrograde. We used very high pressure (40 atm) expansion balloons in 50%. All angioplasties are performed with 100% technical success. Percentage increase in caliber is 115.13 ± 40.88% and that of increase in AVF flow rate is 156.13 ± 77.28%. The percentage of minor complications that occurred during the 36 angioplasties was 5.55% (n=2) represented by partial vein thrombosis and a small parietal hematoma. The average time required for an ultrasound guided angioplasty is 40 minutes.

Conclusion(s):

Exclusive ultrasound guidance angioplasty of peripheral AVF stenosis is a feasible, effective and safe technique, allowing vital venous capital to be preserved for hemodialysis patients while hoping for definitive treatment of IRCT by renal transplantation.

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Distal Transradial Artery access for Neuroangiography and Neurointerventions

1,2Roger Barranco Pons, 1Oscar Chirife 1Victor Cuba

1Hospital de Bellvitge, 2Neurospinal Hospital

Introduction(s):

The distal transradial approach (dTRA) is progressively gaining more clinical use in the fields of cardiology and other vascular interventions, as it offers a few advantages compared to the conventional radial approach (TRA). These include lower rates of vascular occlusion which permits preservation of the proximal radial artery for future procedures in the event of a distal occlusion.

Aim: To share the experience in the use of dTRA for neurointerventions, showing its advantages, pitfalls as well as sharing our optimized puncture and hemostatic ultrarapid compression protocols to improve the use of this vascular access.

Material(s) and Method(s):

A retrospective analysis of our experience of diagnostic and interventional procedures performed via dTRA using an optimized protocol for puncture and post puncture compression of the dTRA was performed.

The rate of complications (hematoma and arterial dissection at puncture site) femoral crossover and assessment of post-procedural stenosis/occlusion with the ultrarapid compression protocol were also assessed.

Result(s):

From March 2019 to July 2020 a total of 100 distal radial procedures were carried out and 53 diagnostic angiograms (53%) and 47 interventional procedures (47%) were included in the analysis. We achieved a 96% technical success, with a femoral crossover requirement in 3 cases (3%), and one conventional TRA crossover due to puncture failure. Of the patients, 3 presented puncture site hematomas (3%) with no intervention required, 61 patients (61%) underwent the ultrarapid hemostasis protocol in association with a hemostatic pad. Ultrasound follow-up was performed in 20 patients (20%) at 1–2 months with 1 case of occlusion (5%) and 2 of radial stenosis (10%). In all 3 cases, proximal radial artery remained patent.

Conclusion(s):

The dTRA is a safe and feasible access route for angiography and neurointerventions. Using vasodilators pre-puncture, we attained a variable increase in the vascular diameter facilitating puncture and reducing the risk of occlusion and vascular spasm.

A rapid deflation protocol for post-puncture hemostasis does not significantly increase the hematoma rate.

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Transradial Versus Transfemoral Access for Acute Stroke Endovascular Thrombectomy

1,2Roger Barranco Pons, 1Oscar Chirife 1Victor Cuba

1Hospital de Bellvitge, 2Neurospinal Hospital

Introduction(s):

To compare clinical outcomes and safety of transradial (TRA) versus transfemoral access (TFA) for endovascular mechanical thrombectomy in acute stroke patients.

Material(s) and Method(s):

Retrospective analysis of 832 consecutive patients with acute stroke undergoing interventional thrombectomy using TRA (n = 64) or TFA (n = 768).

Result(s):

Direct TFA failures occurred in 36 patients, 18 of which underwent crossover TFA to TRA, while direct TRA fail- ures occurred in 2 patients having both crossovers to TFA. Successful catheterization was achieved in 96.8% (62/64) and 95.3% (732/768) of patients undergoing direct TRA and direct TFA, respectively, without significant differences. The median (IQR) catheterization time was 10 (8–16) min in the direct TRA group and 15 (10–20) in the direct TFA group (P < 0.001). This difference was also significant in the subgroup of anterior circulation strokes and in patients younger and older than 80 years of age. The majority of procedures yielded thrombolysis in cerebral infarction grade 2b/2c/3 revascularization in patients undergoing direct TRA (88.5%) and direct TFA (90.8%), without statistically significant differences. The median (IQR) puncture to recanalization time was 37 (24–58) min for the direct TRA group and 42 (28–70) min for the direct TFA group. Significant differences in access site complications, symptomatic ICH, and mRS score 0–2 at 90 days between both TRA and TFA accesses were not found.

Conclusion(s):

TRA is not inferior to TFA in the probability of catheterization, times of catheterization and revascularization, and other clinical outcomes for mechanical thrombectomy in acute stroke.

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The Comparison of Diagnostic Efficacy between fine Needle Aspiration and Core Needle Biopsy to Determine a First-Line Diagnostic Method for Thyroid Nodules

1Kwang Hwi Lee,1Jiyeong Lee

1Sheikh Khalifa Specialty Hospital

Objective(s):

Fine needle aspiration (FNA) has been applied for thyroid nodules, as a first-line diagnostic method for several decades. Core needle biopsy (CNB) has been suggested as a supplementary diagnostic tool for thyroid nodules recently. The purpose of this study is to compare diagnostic efficacy between FNA and CNB, and to evaluate diagnostic value of CNB as a first-line diagnostic method.

Material(s) and Method(s):

From 2015 to 2021, 60 patients underwent FNA (M:F= 17:43, mean age: 43 years) and 253 patients underwent CNB (M:F= 54:199, mean age: 48.2 years) were enrolled. Pathologic evaluation was classified using same categories in both methods, based on Bethesda classification: I: non-diagnostic, II: benign, III: indeterminate, IV: follicular neoplasm, V: suspected malignancy and VI: malignancy.

Result(s):

The pathologic results of FNA vs CNB were 21.6% vs 3.6% in category I, 44.3% vs 42.2% in category II, 14.8% vs 9.2% in category III, 2.3% vs 27.8% in category IV, 10.2% vs 6% in category V and 6.8% vs 11.2% in category VI (p< 0.05). Inconclusive rate of FNA vs CNB was 36.4% vs 12.8% (p< 0.001). Malignant rate of FNA vs CNB was 4.1% vs 0.5% in category I, 5.4% vs 1.2% in category II, 15.2% vs 7.8% in category III, 0% vs 17% in category IV, 100% vs 95% in category V and 100% vs 100% in category VI (p> 0.05).

Conclusion(s):

CNB was superior to FNA reducing inconclusive rate for thyroid nodules. CNB can be applied as an alternative first-line diagnostic method for thyroid nodules.

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Dural Arteriovenous Fistulas: A Systematic Approach; Diagnosis, Classification, and Endovascular Treatment.

1Skander Sammoud

1National institute of Neurology Mongi Ben Hamida

Objective(s):

Intracranial dural arteriovenous fistulas (DAVFs) are rare lesions accounting for 10-15% of intracranial arteriovenous malformations. They involve an anomalous shunt between meningeal arteries, intracranial (venous sinuses and/or cortical veins), or medullary veins. The DAVFs are usually acquired, implying previous aggression of the dura mater. Thus, they are associated with dural sinus thrombosis, previous craniotomy, and trauma. However, they are idiopathic in most instances and have no evident cause. Their clinical presentation is variable, with symptoms depending on their location and venous drainage pattern. However, lesions with cortical venous drainage have the highest risk of causing the most significant morbidity and mortality. High clinical suspicion alongside noninvasive cross-sectional imaging techniques such as computed tomography (CT) and magnetic resonance imaging (MRI) help establish the diagnosis. Digital subtraction angiography (DSA) is the gold standard for diagnosis and accurate classification, permitting the evaluation of the feeding vessels, cortical venous drainage, and venous ectasia. Accordingly, a prompt diagnosis and precise classification of these lesions are essential. Endovascular treatment is nowadays the primary therapeutic modality for DAVFs. The access route can be divided into transarterial, transvenous, and combined approaches based on angioarchitecture, venous drainage model, and location. Surgical resection and stereotactic radiosurgery may be considered in some cases. A personalized case-by-case approach accomplishes a high grade of complete treatment with a low complication rate. This review highlights the epidemiology, clinical presentation, classification, and endovascular treatment of patients with intracranial DAVFs.

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Prostate Artery Embolization: An Initial Experience in Shifa International Hospital

1Zahid Amin Khan,1Maria Rauf

1Shifa International Hospital

Objective(s):

The study aims to report our very early experience with prostate artery embolization in patients with benign prostatic hypertrophy (BPH) in Shifa International Hospital setting.

Material(s) and Method(s):

This retrospective study was approved by the Institutional Ethical Review Board, and informed consent was obtained from all the patients. This single-center study was conducted on 7 patients with prostate volumes ranging from 39–100 g. Prostate volume, uroflowmetry and the International Prostate Symptom Score (IPSS) were used to assess clinical and functional outcomes. Five patients with lower urinary tract symptoms due to benign prostatic hyperplasia. Among seven of them, two patients had indwelling penile catheters due to BPH. Follow-up was obtained at 3 months. Bilateral prostatic arterial embolisation was performed in 5 cases and unilateral embolization in 2 cases. One patient who presented with an indwelling catheter had persistent symptoms despite shrinkage of his prostate and was later found to have had a preexisting urethral stricture not initially diagnosed. No major complications were seen in any patient. One patient had a resistant UTI which responded to a change of antibiotics following his urine C&S reports.

Result(s):

Patients with a mean age of 67.5 years underwent prostate artery embolization. It was successful in all the cases. Bilateral embolization was performed in 7 patients and unilateral approach in 2 patients. Clinical improvement was characterized by a mean prostate volume reduction of 53 % and marked improvement in their IPSS score. All preexisting medications were no longer in use.

Conclusion(s):

The initial experience with prostate embolization has been very rewarding and it is a great alternative treatment for BPH. It is a very safe and effective procedure but requires advanced endovascular skills and appropriate patient selection. It is especially indicated in patients in whom the prostate volume is more than 80 cc to avoid open prostatectomy, in those in whom antiplatelets therapy cannot be stopped due to significant co-existing cardiac issues, those unfit for general anesthesia or in younger men who are sexually active.

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Type of Chronic Arterial Occlusive Disease among the Adult Population attending a Tertiary Hospital in Bangladesh

1Mahbubur Rahma

1Green Life Hospital

Objective(s):

To identify histopathological pattern  of Chronic Arterial Occlusive Disease among adult population in Bangladesh.

Material(s) and Method(s):

The present observational study was carried out in the department of vascular surgery at Bangabandhu Sheikh Mujib Medical University,Dhaka for a period of one year. Only the admitted patients at BSMMU was considered for the study. Informed written consent was taken from the patients. After surgery tissue were send for histopathological examination and report was collected. Data was collected well informed data collection sheet.

Result(s):

The study shows most common histopathological pattern of Chronic arterial occlusive disease were atherosclerotic plaque (82.8%) then fibrous (75.9%) , thrombus (75.9%), chronic inflammation cells (72.4%) and acute inflammation cells (13.7%).

Conclusion(s):

This study shows common histopathological pattern were atherosclerotic plaque, then fibrous, chronic inflammation cells, thrombus  and acute inflammation cells in chronic arterial occlusive disease.So mass media and other related with medical profession should give some important knowledge to the population about the disease.

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Women in IR in Sub-Saharan Africa: Carving our Niche in a Male Dominated Specialty

1Ofonime Nkechinyere Ukweh,2Latifa Rajab, 3Sarah Khoncarly, 4Judy Gichoya 5Murray Asch

1Muhimbili University of Health and Allied Sciences, 2Muhimbili National Hospital, 3Department of Radiology, MetroHealth Medical Centre/Case Western Reserve University, 4Department of Radiology and Imaging Sciences, Emory University School of Medicine, 5Lakeridge Health

Introduction(s):

Women in interventional radiology (WIR) represent a growing minority in a historically male-dominated specialty. The number of WIR continues to rise with the support of professional associations. Sub-Saharan Africa (SSA) not only suffers from a lack of formal IR training programs but also suffers from a scarcity of female interventional radiologists with young professional associations without the capacity for WIR outreach. This study aims to highlight the gender gap and the potential reasons for the lack of WIR in SSA, with recommendations of how to engage more WIRs in Africa.

Material(s) and Method(s):

A prospective evaluation was conducted using an online survey that examined physician age, nationality, training type, experience, involvement, and barriers faced by female interventional radiologists in Africa. The survey, devised by the authors, consisted of 10 questions and was sent electronically to all identifiable female interventional radiologists in sub-Saharan Africa. Areas of suggestion for improving upon these barriers were also discussed along with the development of the African Women in IR Team,  that would identify and work with any interested and or prospective women in sub-Saharan Africa who would need help in resource finding and support to accomplish their goals. Responses were collected in October 2021 and analyzed.

Result(s):

A total of 6 WIR from four countries in SSA responded to the survey: 1 IR attending and 5 trainees. 83.3% of respondents were between the ages 30-40 and all respondents came from diagnostic radiology backgrounds, who subsequently entered a two-year IR fellowship program. 50% of respondents considered opportunities equal between female and male IRs, while 33.3% reported experiencing gender bias and were asked to give a brief description. Examples included being bullied by male colleagues, male colleagues given preferential treatment during training, and women being discouraged from pursuing IR and left out of interesting learning opportunities because they are “too young to be in IR” or that “women should not be exposed to radiation”. These implicit biases present as an invisible barrier that make it difficult for WIR to receive admitting privileges in certain facilities.

Conclusion(s):

Addressing and identifying issues of gender inequality in male-dominated specialties remains an important topic in SSA. It’s important to break down these barriers and promote and support our female trainees in the future.

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Endovascular Therapy for Dialysis Access-Associated Steal Syndrome (Dass)

1Owayed Al Shammeri,1Bilal Hayek, 1Asel Budaichieva, 1Abdullah Alwehbi

1Habib Medical Group

Background(s):

End Stage Renal Disease Patients with Arteriovenous Fistula (AVF) encounter many vascular risk related to reduced or increase arteriovenous fistula flow. Dialysis Access-Associated steal syndrome is one of devastating complication which may lead to limb loss. There are multiple vascular techniques to correct this complication. We present in this article two endovascular approaches with 12-month follow up. One by using stent graft covering two thirds of anastomosis of arteriovenous fistula generating artificial stenosis diverting more flow to the hand. The other approach is by using Supera stent jailing the arteriovenous fistula diverting more flow to the hand.

Material(s) and Method(s):

We studied the long-term outcome of two endovascular techniques to treat Dialysis Access-Associated steal syndrome (Stent graft or Supera self expandable nitinol inetrwoven wire stent).

Result(s):

12 month follow up showed functioning AV fistula with no clinical manifestation of Dialysis Access-Associated steal syndrome.

Conclusion(s):

We described two endovascular techniques to treat dialysis associated steal syndrome with durable long term ourtcome (12 month follow up). Endovascular innovation continues to save AV fistula to be more durable

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Segmental Yttrium-90 Radioembolization as an Initial Treatment for Solitary Unresectable HCC

1Natalie Rothenberger, 2,3Shakthi Kumaran Ramasamy,  2Thuong Van Ha, 2Steven Zangan, 2Osman Ahmed

1Geisinger Commonwealth School of Medicine, 2University of Chicago, 3Loyola University Medical Center

Background(s):

To evaluate the objective response rate (ORR), time to progression (TTP), and overall survival (OS) in patients with unresectable solitary HCC who were treated with 90Y glass microspheres infused at a segmental level.

Material(s) and Method(s):

Single institution retrospective study of 35 patients with unresectable HCC deemed not suitable for percutaneous ablation who underwent segmental transarterial radioembolization (TARE) treatment. Eligibility criteria included patients with solitary, unilobar, <5cm unresectable HCC lesions who underwent TARE as a primary treatment strategy between November 2012 and April 2020. Imaging follow-up was performed on each patient at 3, 6, and 12-months post-treatment. Local and overall tumor response was evaluated using mRECIST criteria and primary endpoints were ORR, TTP and OS. Adverse events (AEs) were graded for severity using the Common Terminology Criteria for Adverse Events (CTCAE) v.5.0. Kaplan-Meier analysis was used to evaluate OS.

Result(s):

Median tumor size was 3 cm (range: 1.0-4.8 cm) in the 35 patients studied, with 25.7% being Eastern Cooperative Oncology Group (ECOG) 0 and 62.9% ECOG 1. A majority of patients (88.5%, 31/35) were Barcelona Clinic Liver Cancer (BCLC) stage C, with one patient classified as BCLC-A and BCLC-0 each. For 34.2% (12/35), TARE functioned as a bridge to transplantation. Patients who received a transplant exhibited a median pathologic necrosis of 98% (IQR 7.5). At 12 months post-TARE, the combined ORR for local and overall mRECIST was 94.3% and 85.7%, respectively. All patients had a mean local TTP of 11.9 months (CI:2.7-21.0), and global TTP of 13.2 months (CI:6.4-20.0). Among the 14.3% (5/35) of patients who experienced AE’s following treatment, 80% were Grade 1, one patient experienced a Grade 4, and all events resolved within one month of treatment. Total OS at 1 year was 97.1%, whereas patients who underwent OLT had an OS of 100%.

Conclusion(s):

Segmental TARE was a safe and effective treatment for solitary unresectable HCC less than 5cm. When used as a bridge to transplant, near complete pathologic necrosis rates of treated lesions were observed on explant.

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Endovascular Management of Pulmonary Artery Aneurysm: Case Series

1Noor Badrawi,1Ayman Alsibaie

1Rashid Hospital and Trauma Center, Dubai Health Authority

Background(s):

Pulmonary artery aneurysm is an uncommon condition that can be congenital or acquired. Aneurysms are defined as localized dilatation of a blood vessel which involves part or all three layers of the vessel wall. The clinical appearance is often non-specific, thus early detection and appropriate management are critical for avoiding morbidity and death from the potentially fatal rupture and massive hemoptysis. In such conditions, endovascular therapies are becoming more common. We present a case series with our experience with endovascular management of pulmonary artery aneurysm including the clinical presentation, endovascular approach, and outcomes of four patients.

Material(s) and Method(s):

Case I: A 52 years old gentleman, known case of diabetes mellitus type II & ischemic heart disease, presented with a three days history of a productive cough with bloody streaks and fever.

He was found to have an abnormal chest radiograph that showed lung consolidations and cavitary lesions which was later diagnosed as pulmonary tuberculosis with a positive tuberculosis mycoplasma PCR test. Further imaging with a contrast-enhanced CT scan identified a large cavity with intra-cavitary small aneurysmal dilatation in the anterolateral aspect of the cavity at the upper lobe of the right lung. The presence of a pseudo-aneurysm arising from the anterior segmental branch of the right upper pulmonary artery was confirmed by a conventional angiography (DSA) of the upper branch of the right pulmonary artery and coils were used to selectively embolize the aneurysm’s feeding branch.

The patient tolerated the procedure and his symptoms subsided. The patient was started on anti-tuberculosis medications and later discharged with outpatient clinic follow-up.

Case II: A 50-year-old gentleman, known case of diabetes mellitus type II, presented with a one-week history of cough, shortness of breath, five episodes of hemoptysis associated with generalized body aches, and night sweats. The patient’s vitals revealed tachycardia (115 beats/min), and physical examination of the chest revealed reduced air entry in the right middle and lower chest. Laboratory investigations showed raised white blood cells, decreased hemoglobin, and raised inflammatory markers. Suspicion of tuberculosis was raised and results showed positive acid-fast bacilli & sputum & bronchoalveolar lavage (BAL) was positive for mycobacterium tuberculosis.

Contrast-enhanced CT scan of the chest showed a cavity with surrounding consolidation containing an enhancing round lesion representing an aneurysmal dilation at a branch of the pulmonary artery supplying the right lower lobe. Selective DSA at the right pulmonary artery demonstrated an aneurysmal dilatation at a posterior segmental branch of the right lower lobe. The feeding branch of the aneurysm was successfully embolized using coils. The procedure was well tolerated by the patient, who had an uncomplicated hospital stay.

Case III: A 45 years old Asian male, recently diagnosed with pulmonary tuberculosis and started on anti-tuberculosis medication, presented with a one-day history of multiple episodes of hemoptysis. He also complained of weight loss (30 Kg) and progressive abdominal distension in the past 7 months. On physical examination, he had tachypnea and tachycardia (110 beats/min) and had reduced air entry bilaterally mostly over the left side of the chest.

Contrast-enhanced CT scan of the chest revealed widespread multifocal consolidations in both lungs, tree in bud nodules, bronchiectasis, and a cavitary lesion at the posterior segment of the right upper lobe with an aneurysmal dilatation of a sub-segmental pulmonary artery branch. Conventional angiography of the right pulmonary artery confirmed the presence of the aneurysm at the posterior segmental arterial branch of the right upper lobe. The feeding branch of the aneurysm was embolized using coils.

Unfortunately, few days after the procedure, the patient’s clinical status deteriorated with hypotension and oxygen desaturation, and had to be intubated. Laboratory investigations revealed raised septic markers and the patient was escalated to intravenous antibiotics and inotropic support. The patient continued to deteriorate and passed away.

Case IV: A 45 years old gentleman presented with three months history of multiple episodes of hemoptysis increasing in amount. On physical examination, he had tachycardia and tachypnea requiring supportive high-flow nasal oxygen to maintain saturation.

Chest radiograph showed extensive bilateral lung consolidations. Contrast-enhanced CT scan revealed bilateral patchy lung consolidations with tree-in-bud nodules, bronchiectasis, and cavitary lesions, particularly over the apical segment of the right lower lobe. An additional finding of a pulmonary artery aneurysm at the posterior segment of the right lower lobe.

Conventional pulmonary angiography was performed and the feeding segmental branch of the aneurysm at the right lower lobe was selectively embolized using coils.

Unfortunately, two days after the procedure, the patient experienced fresh blood hemoptysis, became hypotensive with oxygen saturation & GCS drop requiring blood transfusion and intubation. The patient was kept on continuous monitoring in the intensive care unit and kept on intravenous antibiotics and inotropic support. However, the patient kept deteriorating and passed away.

Result(s):

All of the presented cases underwent endovascular treatment using coil embolization of the feeding vessel and have tolerated the procedure well with no complications within the first 24hrs. Unfortunately, half of our patients have clinically deteriorated and have passed away.

Conclusion(s):

Pulmonary artery aneurysm are rare and may be of congenital or acquired etiology. One of the most common causes is post-infection Rasmussen’s aneurysm formation secondary to pulmonary tuberculosis. Endovascular therapies aim to occlude these aneurysms and prevent life-threatening massive hemoptysis in case of rupture. The selection of the appropriate management depends on the clinical presentation and outcomes of these procedures tend to vary.

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The Relation of Collateral Status in Baseline Ct Cerebral Angiography to the Outcome of Acute Ischemic Stroke Management

1Nagy Salah Ismail,1Ahmed Abdel Alim, 1Farouk Hassan

1Kasr Aliany, Cairo University Hospitals

Background(s):

Stroke is the leading cause of disabling disease and mortality worldwide (1). Patients with suspected acute ischemic stroke should be rapidly evaluated clinically and radiologically to 1) confirm diagnosis, 2) exclude common stroke mimics, 3) identify contraindications to revascularization, 4) Site of vascular occlusion (2). Treatment decision (IV thrombolysis and/or mechanical revascularization) is based on the time window and imaging features: parenchymal lesion and arterial occlusion site (3). Multimodal CT includes NCCT and CTA of head and neck CT perfusion (CTP). Multimodal MRI includes various sequences, such as DWI, ADC, FLAIR, GRE, and perfusion-weighted imaging in addition to MRA of head and neck (4). NCCT help making a decision of acute management (5). CTA is used to determine the site of arterial occlusion and qual¬ity of the collateral flow, which is an important prognos¬tic factor for good outcome (6). CTA can display collateral supply at the level of Willis’ circle arteries and the retrograde filling of the cortical arteries by leptomeningeal junctions, the development of arterial collaterals lowers the speed of infarction growth and increases the chance of a good clinical outcome with timely recanalization (7).

Reperfusion therapy including intravenous (r-tPA) and mechanical thrombectomy (MT) are the only approved treatments for AIS.

The study aimed to evaluate the relation of collateral status in CTA to the clinical outcome of acute ischemic stroke management.

Material(s) and Method(s):

This was a prospective study carried out over the span of 2 years (January 2019 to December 2020) for evaluation of the impact of the collateral status in cerebral CTA on the clinical outcome of acute ischemic stroke management.

A total number of 51 patients: 30 males and 21 females. The age of the patients ranged from 34 to 80 years, and the mean was 55.4.  All patients were presented by symptoms of acute ischemic stroke and underwent CTA to assess vascular occlusion and the state of collateral circulation; some had different comorbities as discussed in (table 1)

Result(s):

The current prospective investigation was achieved during two years (January 2019 to December 2020) for patients with acute ischemic stroke who have done CTA of cerebral circulation for assessment of the collateral state. A total number of 51 participants: 30 males and 21 females. The age of the participants varied from 34 to 80 years (mean 55.4). Every participant was clinically evaluated, subjected to  NCCT followed by CT cerebral angiography to assess large vessel occlusion, state of collateral circulation according to Tan scale (0 –3): 0 (absent collaterals), 1 (collateral filling 0-50%), 2 (collateral filling >50 but <100%) and 3 for 100% collateral filling compared to opposite side.

Conclusion(s):

Good state of the cerebral collaterals in patients with acute ischemic stroke was associated with good clinical outcome, good reperfusion, lower rates of symptomatic ICH, mortality rate and stroke severity.

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Thrombolysis in Upper Limb Ischaemia

1Mohammed Khidir Tayfor

1Tayfor vascular & Stroke Centre

Introduction(s):

To highlight the effectiveness and excellent out come of trans catheter Thrombolysis in treatment of acute and sub acute upper limb Ischaemia

Material(s) and Method(s):

Thrombolysis is well known method to treat and to resolved clots. Here in our centre we have series of cases presented with acute and sub acute upper limb Ischaemia treated with transcatheter thrombolysis with excellent outcome and short hospital staying …In well equipped interventional suits , angiogram done first to localize the site of the clots, followed by fixation of the multi side holes catheter in the clots for infusion of the magic TPA

After that control angiogram performed to the the result.

Result(s):

All cases presented to our IR suit after clinical evaluation and then  treated with transcatheter  Thrombolysis we find that most of them showed total or near total lysis of the clots. No groin or systemic complications reported. Less than 24 hrs hospital admissions registered

Conclusion(s):

Transcatheter Thrombolysis as a treatment of upper limb Ischaemia is very effective method of treatment and better to be the first line of treatment before surgical embolectomy

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Telestroke and Artificial Intelligence Value in Regional Stroke Service

1,2Mohamed Elmahdy

1Faculty of Medicine Cairo University, 2King Hamad University Hospital

Introduction(s):

The decision of re-perfusion therapy in Acute Cerebrovascular stroke is One of the major advances in the time management for Stroke Telestroke and Artificial Intelligence in Stroke Imaging. 

In the eastern province in Saudi Arabia there are 2 comprehensive Stroke programs First one is public University Hospital and second is a private facility 6 Hospitals Group, 4 of them in the eastern Province serving 2.5 million population

Material(s) and Method(s):

We Included 129 Patients in Our Current facility offers 24/ 7 comprehensive stroke service  Equipped with two cathlabs and 6 neurologists in the Hub and the other Group Hospitals have one Hospital to two neurologists in the 4 eastern Province Branches

Result(s):

Now the Hospital is implementing the RAPID AI system as 1 Hub and 3 Spokes which provide a rapid Neurology and Radiology urgent consultation  for 129 patients as well as improve the reperfusion decision and time nevertheless Compensates for the low number of stroke physicians in the other Facility

Conclusion(s):

Telestroke and Artificial intelligence are cornerstones in the setup of regional stroke program

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Dural Sinus Stenting is more physiological in Treatment of Idiopathic Intracranial Hypertension

1,2Mohamed Elmahdy

1Faculty of Medicine Cairo University, 2King Hamad University Hospital

Introduction(s):

Idiopathic intracranial hypertension (IIH) is a disabling disease its prevalence of one per 100,000 predominant in women Its Pathophysiology is related to increased intracranial pressure. Symptoms classically consist of chronic headaches, papilledema, and visual impairment.  Traditional treatments involve decreasing Cerebrospinal pressure (CSF) though weight control, acetazolamide, CSF diversion, or optic nerve fenestration. However, all previous treatments didn’t target the cause of elevated CSF pressure rather than to relieve the pressure. Recently venous sinus stenting is targeting an important pathophysiologic mechanism which is symptomatic dural sinus stenosis, It provides more physiological management of Increased ICP and Improve symptoms as well as reduce unnecessary drug side effects.

Material(s) and Method(s):

6 patients with resistant IIH, 2 of them had hypoplasia of the contralateral side with significant stenosis of the main lateral sinus. Pressure gradient was measured across the stenosis and was found 80+ mmH2O using microcatheter, A Stent was placed across the stenotic area with measurement of pressure gradient across the stent which showed immediate improvement of the pressure gradient across the stent.

All Patients were medicated with dual antiplatelet therapy.

Result(s):

All patients had improvement of pressure gradient as well as their symptoms with reduction of papilledema on subsequent neuroophthalmological assessment, No Procedure related Complication.

Conclusion(s):

Dural Sinus Stenting is a safe effective procedure in the treatment of IIH where there is symptomatic dural sinus stenosis.

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Reference Value of Lower Limb Arteries in Saudi Population utilizing Ct Angiography

1,2Abdullah S. Mirza

1King Saud Medical City, 2King Saud University

Introduction(s):

CT angiography is a non-invasive diagnostic tool for vascular evaluation. It is a very useful tool for peripheral arterial disease diagnosis and planning the appropriate intervention. This study is to evaluate the pelvic and lower limb arterial diameter of a healthy Saudi population.

Material(s) and Method(s):

We conducted a retrospective study of all patients examined for a CT lower limb angiography between July 2015 and December 2021. Inclusion criteria include adult asymptomatic Saudi patients with normal lower limb arteries. Exclusion criteria include symptomatic patients with vascular insufficiency, atherosclerosis, dense vascular calcifications, poor imaging technique, or incomplete data. Most of the included patients underwent CT angiography for preoperative for a fibular flap, post-trauma, or for vascular malformation evaluation. the vascular diameter was obtained using automatic and semi-automatic software. Six arterial segments were measured at pre-defined locations for each patient: common iliac, external iliac, common femoral, proximal superficial femoral, distal superficial femoral, and popliteal arteries bilaterally.

Result(s):

One hundred and twelve patients were included in the study, with 76 /112male (68%), mean age 38.3 (range: 18-80). Average arterial diameter as following common iliac artery (9 mm), external iliac artery (7.5 mm), common femoral artery (7.3 mm), proximal superficial femoral artery (6.11mm), distal superficial femoral artery (5.3 mm), and popliteal artery (4.8 mm). No significant difference between the right and left limbs could be observed.

Conclusion(s):

We presented the reference values for different vascular pelvic and lower limb segments in a healthy Saudi population.

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Diagnostic Adequacy Rate of Cervical Lymph Node Fine Needle Aspiration: A Two-Years Study

1Mohammed Alsaleh

1King Fahad Specialist Hospital

Background(s):

To assess the diagnostic adequacy, failure, and repetition rates of the cervical lymph nodes fine needle aspiration sampling, as well as the different factors affecting its diagnostic yield at King Fahad Specialist Hospital in Dammam, Saudi Arabia.

Material(s) and Method(s):

This is a single center retrospective study that was evaluating all included patients who underwent fine needle aspiration (FNA) for the diagnosis of cervical lymphadenopathy at King Fahad Specialist Hospital at Dammam in the period between June 2018 to June 2020. The data is collected from Picture Archiving Communication System (PACS), and electronic patient file and record (Medicaplus software). Approval for the study has been obtained from The Ethical Committee of King Fahad Specialist Hospital, Dammam, Saudi Arabia. SPSS was used to analyze the data.

Result(s):

The study included 98 patients; 64.3% of our patients were females, and 38.8% were younger than 40 years old. The most common size of the needle used was 22G (79.6%). The diagnostic accuracy rate was 77.6%. 22.4% were inconclusive necessitating a repeat sampling. The use of 22G needle appears to increase the likelihood of inconclusive sample when compared to 25G needle, however this difference did not appear to be statistically significant. History of prior thyroid cancer appears to significantly correlate with the rate of malignant FNA (P-value 0.014).

Conclusion(s):

Ultrasound guided FNA appears to be accurate in the diagnosis of cervical lymphadenopathy with an accuracy rate of 77.6% with approximately 22.4% of the study cohort requiring a repeat sample which were all benign on repeat sampling. History of prior thyroid cancer appears to significantly correlate with the rate of malignant FNA. The rate of of inconclusive sample appears to show a trend of being affected by the needle size although this was not statistically significant and a further prospective randomized trial with larger sample size is warranted to assess this effect.

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Salvage Stenting after Failed Thrombectomy in Acute Stroke: Qatar Experience

1Mohammad J H Elhissi

1Hamad Medical Corporation

Background(s):

Timely restoration of blood flow is the most effective manoeuvre for salvaging ischemic brain tissue that is not already infarcted. Nearly one-third of patients with mechanical thrombectomy are left with failed recanalization, re-occlusion or hemodynamically significant residual stenosis immediately post thrombectomy.

We present our experience, as the national institute of the state of Qatar, of salvage stenting after failed thrombectomy in acute stroke management.

Material(s) and Method(s):

Retrospective analysis of patients who underwent salvage stenting was conducted. Multiple factors were analysed; patient-factors (gender, comorbidities), stroke-factors (baseline NIHSS, site of occlusion), procedure-factors (puncture-to-recanalization time, mTICI score), and outcomes (re-occlusion rate, mortality, post-procedure hemorrhage, 90-days mRS score).

Result(s):

Total of 50 cases of salvage stenting were performed with male-to-female ratio of 43:7. Hypertension (64%) and smoking (48%) were the most encountered risk factors.

Most occlusions were at M1 level (76%) followed by M2 level (10%). Patients presented with median baseline NIHSS of 11 (4.5 – 16).

Average puncture-to-recanalization time was 75 minutes (34-91). 54% of patients achieved final mTICI score of 3 and 36% score of 2b.

Upon short-term follow up, 28% developed re-occlusion. There was 1 case (2%) of symptomatic hemorrhage, and 4 cases of mortality (8%) due to malignant infarct or cardiac arrest.

21 patients were available at 90 days follow-up, with 81% achieving mRS ≤ 2.

Conclusion(s):

Salvage stenting should be considered in patients with acute large vessel occlusion after mechanical thrombectomy failure. We believe that salvage stenting is safe and effective as it offers favourable clinical outcome, reduced mortality and comparable risk of ICH.

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Endovascular Treatment of Uterine Arteriovenous Malformation

1Mohammed Adel Elhawary,1Ahmed Attia, 1Mohamed Shahbour

1Mansoura University Hospital

Background(s):

Highlighting the role of trans-arterial embolization of uterine AVM as a uterine preserving procedure especially in childbearing period.

Material(s) and Method(s):

Diagnosis of uterine AVM by doppler study, CT angiography and some time DSA. Embolization of the AVM nidus with Histoacryl, onyx, coils, beads or even lipidol. Evaluation of technical success by post embolization angiogram and short term doppler. Evaluation of clinical success by disappearance of bleeding.

Result(s):

Our retrospective study over the last 5 years included 6 cases, one congenital and 5 acquired. 4 of them were supplied only by uterine arteries, two of them had sharing blood supply from left ovarian artery. Technical and clinical success were obtained in all cases. All cases used histoacryl with onyx in two cases.

Conclusion(s):

Trans arterial embolization is supposed to be  the first choice in treatment of uterine AVM especially  in women at reproductive period having expectation of future fertility

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Successful Endovascular Embolization of an Intralobar Pulmonary Sequestration

1Ahmad A Saadat Saeed Abdel Muhdi,1Noon Mohamed Mahgoub Elawad,

1Dubai Health Authority

Introduction(s):

Pulmonary sequestration (PS) is a rare congenital pulmonary condition. It accounts for 0.15% to 6.4% of all congenital pulmonary malformations. It is characterized by the presence of non-functional pulmonary tissue lacking a normal connection with the tracheobronchial tree or pulmonary arteries receiving its arterial supply from systemic circulation. It has two main types: intra-lobar (ILPS) and extra-lobar (ELPS). It involves the lower lobe in most cases, and it results in recurrent infections and bronchial obstruction.

Material(s) and Method(s)

Case presentation:

A 25-year-old male patient presented to the emergency department with fever, cough, and multiple episodes of hemoptysis. CT demonstrated a large systemic anomalous arterial branch emerging from the thoracic aorta. The aberrant artery was surrounded by a large left lower lobe consolidation with bronchiectasis and cystic changes, as well as a prominent vein draining into the left pulmonary vein. A diagnosis of ILPS was made. After an initial attempt of symptomatic management, the patient’s hemoptysis continued to worsen so a plan of interventional management was decided. Selective embolization using gelfoam and coils successfully achieved the complete de-vascularization of the large anomalous artery and its multiple branches. After 4 days, a repeat endovascular embolization was done involving two bronchial arteries on the ipsilateral side of the sequestration.

Technical success of the procedure was confirmed by a repeat CT scan on the 6th day after the procedure.

The patient showed drastic improvement in clinical and biochemical markers during follow-up.

Discussion(s):

Although surgical resection is considered the gold standard for treatment of PS, it is still associated with complications and morbidity. On the other hand, endovascular embolization provides an improved clinical outcome and reduces the risk of intra-operative bleeding in the case of surgical resection.

Technical success was achieved with a combination of embolic materials as well as using the distal-proximal technique of coiling. Around 1 cm segment of the feeding arterial trunk was kept without coils for the purpose of ligation in case of future surgical plans.

Another advantage of using an endovascular method for treatment of ILPS is being able to not only embolize the main aberrant vessels but also the bronchial arteries for a better clinical outcome.

Conclusion(s):

PS is a rare condition with a non-specific clinical presentation that is difficult to diagnose. Noninvasive imaging modalities, such CT Angiography is an effective way for diagnosis of PS. Present case report describes the successful outcome of endovascular embolization which can be used as a definite or preoperative treatment of ILPS in adults.

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Retrieval of Broken Central Venous Line from Ivc of Premature Low Birth Weight Infant

1Atif Iqbal Rana,1Zahid Amin Khan, 1Zahid Amin Khan, 1Haider Ali, 1Jamshaid Anwar

1Shifa International Hospital

Introduction(s):

Long term venous access in infants is now been increasingly achieved using peripherally inserted central catheters(PICC). These lines are generally considered safe however associated complications should also be kept in mind. Among those; line breakage and migration can occur in 1% which requires immediate removal to avoid life threatening complications.

Material(s) and Method(s):

To our knowledge, only scarce case reports published previously successfully retrieved intra cardiac broken PICC lines under fluoroscopic guidance in preterm low birth weight infants.  Here we present a case of successful percutaneous retrieval of 7 cm long fragment of broken PICC line from  abdominal IVC of a 950 g preterm baby boy born at 29 weeks of gestation. Retrieval was extremely challenging considering low weight baby managing hyper/hypothermia and radiation dose at the same time.

Result(s):

After informed consent, percutaneous retrieval of migrated PICC line fragment was proceeded. Under general anaesthesia and fluoroscopic guidance using aseptic measures right femoral vein was punctured and 4Fr sheath was placed. Caudal end of the broken PICC line was engaged in 3.2 F micro snare (endovascular snare system MERIT) and retrieved along with sheath.

Conclusion(s):

We retrieved broken PICC fragment in a low birth weight preterm infant percutaneously from IVC using snare technique. Broken catheter fragments can be retrieved by non surgical methods using percutaneous transcatheter method especially in low birth weight critically ill infants.

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Nationwide Trends in Utilization of Carotid Artery Stenting and Angioplasty in Tandem Occlusion Stroke

1Waseem Wahood,2Aya Akhras, 2Aya Akhras, 2Ameneh Baghestani, 3Waleed Brinjikji,

1Dr. Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, 2Mohammed Bin Rashid University of Medicine and Health Sciences, 3Department of Radiology, Mayo Clinic, MN

Introduction(s):

Tandem occlusions are concurrent occlusions of the internal carotid artery (ICA) as well as the middle cerebral artery (MCA). Historically, these occlusions were treated with thrombectomy. Endovascular management of tandem occlusions via carotid artery stenting (CAS) and/or angioplasty have been increasingly reported, however the outcomes of these studies have been conflicting. In this study, we aim to investigate the trends and in-hospital outcomes of adjunctive CAS versus angioplasty only in the management of tandem occlusions.

Material(s) and Method(s):

The Healthcare Cost and Utilization Project-National Inpatient Sample (HCUP-NIS) was queried between 2009 and 2018, for patients undergoing stenting or angioplasty for tandem occlusions stroke treated with thrombectomy (intracranial and internal carotid artery occlusions). Outcomes included inpatient mortality, non-routine discharge and patient profile. Cochran-Armitage test was conducted to assess the linear trend of utilization of CAS. Jointpoint regression was conducted to indicate infliction point in change in trend. All estimates were nationalized using discharge weights provided by HCUP.

Result(s):

There was a total of 510,169 admission involving MT with either stenting (n=6,632, 65.2%) or angioplasty (n=3,357, 34.8%) between 2006-2018. Adjusting for patient demographics, females were more likely to have stenting over angioplasty (OR: 0.74; 95% CI: 0.60-0.90; p=0.003). Comparing the trends in the two procedures, stenting remained stationary compared to angioplasty (p=0.10). Trend in CAS increased from 2006-2013 by 3.76% (95% CI: 1.91 to 5.61; p<0.001) and decreased by -1.54% per year (95% CI: -2.84 to -0.24; p=0.020) between 2013-2018. Admissions involving CAS had similar odds of non-routine discharge (OR: 0.78 p=0.063) and lower odds of inpatient mortality (OR: 0.58; p<0.001) compared to those who received angioplasty only.

Conclusion(s):

Our analysis indicated that the trend in utilization of CAS increased between 2006 and 2013 and decreased between 2013 and 2018 compared to angioplasty in our 13-year study; the odds of non-routine discharge were similar and inpatient mortality were lower in CAS compared to angioplasty. The utilization of CAS for tandem occlusions requires careful patient selection, based on demographics and risk factors, as this may influence outcomes, including non-routine discharge. A multi-disciplinary approach is encouraged when evaluating the use of CAS for the management of tandem occlusions.

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Iatrogenic Migration of Tracheal Stent into the Esophagus in Tracheoesophageal Fistula, a Mortality and Morbidity Case Report

3Shahbaz Ghazi,1,2Ahmed Albaqshi

1King Fahd University Hospital, 2King Fahd Hospital-Al-Hofuf, 3National Guard Hospital, Riyadh,

Introduction(s):

Tracheomalacia refers to diffuse or segmental tracheal weakness. Most commonly, tracheomalacia develops after prolonged endotracheal intubation or tracheostomy. Therapy is warranted in symptomatic patients with severe tracheomalacia. Relief of airway obstruction via stenting often provides immediate improvement of both airflow and symptoms. However, stent placement is associated with significant complications.

Material(s) and Method(s):

Case report

Result(s):

We present the case of a 71-year-old man who was brought to the emergency department with acute respiratory distress. The patient was known to have tracheomalacia with tracheoesophageal fistula. He had multiple medical comorbidities, including longstanding hypertension, diabetes mellitus, and asthma. The patient had progressive decline in the level of consciousness and was admitted to the intensive care unit for further management. Despite the maximum ventilatory support, the patient did not achieve adequate oxygenation level. The patient underwent tracheal stent placement by the interventional radiology team. The insertion was unsuccessful despite three attempts. The tracheal stent had migrated into the upper esophagus on the first and second insertion attempts (Image 1 a,b,c,d and Image 2 a,b,c) . Since the patient was unstable to tolerate further attempts, the multidisciplinary team recommended the insertion of an esophageal stent to cover the tracheoesophageal fistula (Image 3 a,b). Despite this, the patient continued to have air leakage with progressive worsening of his respiratory condition as he developed multiorgan failure and died.

Conclusion(s):

The management of tracheomalacia in the setting of tracheoesophageal fistula may pose several challenges. The present case highlighted an essential complication of stent placement with having the stent migrated into the tracheoesophageal fistula, which is an unusual site of migration. Multidisciplinary approach is crucial in the management of difficult cases of tracheomalacia.

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Renal Artery Embolisation in Trauma: A Systematic Review

1Basir Kunduzi, 3Rebecca Rowe, 1Samiullah Dost, 2James Walker

1Guy’s Hospital, 2King’s College London, 3Royal Papworth Hospital

Background(s):

The management options for blunt renal trauma are non-operative management (NOM), Renal Artery Embolisation (RAE) and Nephrectomy. There is currently no strong evidence for the use of RAE in patients suffering from blunt renal trauma or, if used, there is no review to indicate at which injury grade it has the maximal treatment efficacy. Therefore, the primary aim of this systematic review is to evaluate whether RAE is an useful adjunct to NOM in renal trauma patients and to investigate the differences in treatment efficacy across all grades. The American Association for the Surgery of Trauma (AAST) classification was used for grading renal injuries.

Material(s) and Method(s):

Using PRISMA guidelines, a search strategy was conducted using electronic databases (such as PubMed and Medline). Initially, abstracts then the full papers were screened by two reviewers based on the inclusion and exclusion criteria. The primary outcome was treatment failure which was defined as a need for a Nephrectomy or a repeat RAE. Secondary outcomes included mortality, need for blood transfusion and length of hospital admission. A quality assessment was conducted using the SIGN criteria to assess the studies’ methodology. The Newcastle-Ottawa Scale was used for assessing observational studies.

Result(s):

21 studies (time frame 2001-2018) were included. Among the embolisation techniques, coils were the most used technique with some studies also including the use of more than one method of RAE. Most studies indicated that NOM was used to manage patients with injury grades I and II. Studies that included renal grade III injuries, 31% received selective RAE while for grade IV and V it was 42% and 36% respectively. Success rates were similar for grades III and IV (89%, 82% respectively). Time (early intervention), having <2 concomitant organ/visceral injuries and effective multidisciplinary team coordination are salient factors in determining RAE success. Possible suggestions for RAE failures within the studies were grade/status of the kidney (shattered/separation from the renal pelvis) and iatrogenic reasons like incidental embolisation of unaffected arterial branches.

Conclusion(s):

This systematic literature review concluded that RAE was most commonly used in AAST Grade IV renal blunt trauma injuries with the majority of the selected studies demonstrating positive outcomes and recommended the use of RAE, especially in cases where conservative management failed.

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Single-Center Experiences of Preoperative Juvenile Nasal Angiofibroma Embolization with Gelfoam, Reducing Financial Burden on Patients in Developing Country

1Junaid Iqbal

1Aga Khan University Hospital

Introduction(s):

Juvenile nasal angiofibroma (JNA) is highly vascular tumor of nasopharynx. Endovascular embolization followed by surgery is the treatment of choice. The aim of this study was to determine that single catheter technique with gelfoam is an effective and safe technique for embolization to reduce the financial burden on patients in third world country.

Material(s) and Method(s):

We retrospectively reviewed the imaging, surgical and histopathological records of 108 patients that underwent pre-operative endovascular tumor embolization followed by surgical resection between March 2017 and March 2021.

Result(s):

Postembolization no major complication was observed in any patient. Complete devascularization of tumor was done in 87.8 %. Intraoperative blood loss resulting in transfusion were almost same as with other embolization technique.

Conclusion(s):

Preoperative embolization of juvenile nasal angiofibroma by using gelfoam and single catheter technique appeared to be safe and effective devascularization method to reduce peroperative blood loss and operating time. By this technique we significantly reduced the financial burden on patients as we are living in third world country with financial constraints. By avoiding microcatheter and permanent embolic agent we reduced the cost of the procedure upto 80% with good peroperative devascularization without significant complications. However selection of patients for single catheter technique for embolization during initial diagnostic angiogram is very important to avoid serious neurological complications.

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A Strategy of Delayed Repair for Blunt Thoracic Aortic Injury: Experience from a Centre in Saudi Arabia

1I. Osman,,1M. Ouhlous, 1M. Ouhlous, 1A. H. AlFallaj

1King Saud Medical City

Objective(s):

In 2016 Saudi Arabia had the highest death rate associated with road injury of any high- income country, at an estimated 28.8 per 100,000 population with a total count of fatalities at 9,031. Blunt Thoracic Aortic Injury (BTAI) is the second leading cause of death from trauma. There has yet to be reported a series and treatment outcomes from Saudi Arabia. We report our experience of a strategy of delayed treatment in management BATI from 2016 to 2021 in Riyadh, Saudi Arabia.

Material(s) and Method(s):

Prospective data of all BATI patients who underwent Thoracic Endovascular Aortic Repair (TEVAR) between May 2016 and April 2021 in a single center was collected. Records of 26 patients were subsequently reviewed.

Result(s):

26 patients (25 male / 1 female) were admitted during the study period with BATI. The mean age was 30.5 years ( range 17-83). The mean Injury Severity Score (ISS) was 45. BATI injury grading on CT was; one patient grade 2 (7.6%), Twenty one (80%) grade 3 and Three (11.5%) grade 4. TEVAR was performed after stabilization of patients and addressing other more immediate life threatening injuries if the BATI was deemed to be stable (23/26 patients). A single thoracic stent graft was deployed in all patients. The mean time from diagnosis to operation was 96 hours. The rate of procedural conversion to open surgery was 0% and the proportion of left subclavian artery coverage was 76%. One patient (3.8%) died within 30 days of surgery and 5 (19%) patients suffered Acute Kidney Injury requiring renal replacement therapy but recovered fully. There were no stent related complications.

Conclusion(s):

Current society guidelines advise early repair within 24 hours of BATI. Our series has demonstrated favorable early outcomes with a strategy of selective delayed repair. The appropriate timing of intervention has been controversial but several recent publications of pooled data have shown survival advantage from a delayed strategy approach. Our experience would support this assertion.

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Minimally Invasive Aortic Arch Repair with a Percutaneous Closure Device

1Hazem El Beyrouti,1Christoph Düber, 1Daniel-Sebastian Dohle, 1Michail Shestopal

1Johannes Gutenberg University Hospital, Mainz

Background(s):

Port implantation can be associated with an array of serious vascular complications, typically involving the subclavian artery. We report a case where implantation of a port resulted in an iatrogenic perforation of the aortic arch at the level of the left subclavian artery, which was sealed off using a percutaneous vascular closure device.

Material(s) and Method(s):

A 56-year-old female was scheduled for chemotherapy due to nodal-positive breast cancer for which she underwent implantation of a left-sided port. However, upon first use of the implanted port, significant backflow of arterial blood indicated arterial misplacement of the catheter. Contrast enhanced CT scan confirmed the incorrect position, with the 8.5 F catheter directly penetrating the aortic arch at the level of the left subclavian artery; Additionally, there was a separate left vertebral artery originating directly from the aortic arch. Due to the location of the penetration, endovascular stenting (TEVAR) was not possible without covering the left subclavian. Open surgical repair would have included sternotomy. Therefore, we decided for a minimally invasive approach under surgical standby. First, the port chamber was explanted. Subsequently, the port tube was probed with a stiff guidewire, which tip was shaped to avoid damaging the aortic valve. After removing the tube, a suture-mediated closure device was advanced into the aorta with the tip being placed in the left ventricle (figure 1). Finally, the suture was placed and this procedure was repeated with a second percutaneous vascular closure device. Subsequently, both sutures were tightened with the pusher.

Result(s):

Post-operative control CT scanning confirmed complete closure of the arterial perforation with no signs of any residual leak. One year afterwards, the patient remains in a good general condition and is responding well to chemotherapy.

Conclusion(s):

Minimally invasive closure of an aortic arch penetration may be feasible, even if that includes advancing the closure system into the ascending aorta and the left ventricle. Interdisciplinary management is key; A backup including either TEVAR or open surgical repair is mandatory

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The Reverse Slider Technique using The Medtronic Endurant Stent Graft for Endovascular Aneurysm Repair

1Gurkirat Singh, 1Arvind Lee,

1Vascular Unit Nepean Hospital

Introduction(s):

The Reverse Slider Technique (RST) has been recently described as an option to successfully treat infrarenal aneurysms with hostile neck features. It utilises the unique advantages of the deployment mechanism of the Medtronic Endurant stent graft to minimise type1a leak. In this review we explore the technique and the short-term outcomes encountered in Nepean Hospital, Australia.

Material(s) and Method(s):

A review of the technique, explaining the deployment technique and a retrospective review of 9 patients that underwent the RST using the Endurant stent system in Nepean Hospital over a one-year period. All cases were identified at planning for the use of the technique with or without endoanchors. Neck characteristics for RST were identified as conical, short, ectatic and/or angulated necks. Primary outcomes were technical success, defined as the absence of a type 1a endoleak and the presence of an endoleak on follow up.

Result(s):

There were 6 Male and 3 Female patients. The average aneurysm size was 5.53cm. Neck length ranged from 11mm to 40mm. 4 patients (44%) had ectatic bulges in the neck, 2 (22%) had conical necks and 3 (33%) had angulated necks. 4 patients had Endosuture Aneurysm repair.

Of the 9 patients 1 patient had a typeIa endoleak upon completion of the case that spontaneously resolved. Upon follow up, there were no type I endoleaks confirmed on either US or CT, reporting a success of 100%. There were no identified complications or reinterventions, in any of the cases.

Conclusion(s):

This review highlights the value of the RST in patients with hostile neck anatomy. Long-term follow up will be required to ascertain the sustained benefit of the technique in reducing long term risk of reintervention.

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Angiojet on Acute Limb Ischemia: Nepean Review

1Gurkirat Singh

1Vascular Unit Nepean Hospital

Introduction(s):

Acute limb ischemia is often associated with high morbidity and mortality. Dormandy et al. describe ALI with an incidence of 14 in 100000 and a 30-day amputation rate of 10-30 percent. With this presentation we aim to review the outcomes of Angiojet in the context of acute arterial occlusions. A minimally invasive option especially in the comorbid..

Material(s) and Method(s):

Retrospective review between 2018 and 2021 of patients that underwent Angiojet for arterial causes at Nepean Hospital. Collating the data with primary endpoints being technical success, reintervention, major amputation rate, complications and mortality.

Result(s):

We identified 70 procedures on 65 patients. Of the 65 patients 20 were female and 45 Male with a mean age of 64.5. There was technical success in 66 cases (94%), with complication rate of 10 percent of which 8.5% were in the form of reversible Acute kidney injury. The medial Length of stay was 7 with reintervention rate of 17% (n=12) in 6 months. The progression to a Major amputation sat at 12.8 percent. A total of 2 (2.8%) patients died from the cohort neither of which was directly related to the angiojet process.

Conclusion(s):

Angiojet offers a minimally invasive surgery that can be considered in ALI. It presents an endovascular solution not only for thrombolysis but also an opportunity to address and rectify the offending lesion with an acceptable patency rate and short LOS.

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Use of Remote Proctoring System in Elective, Emergency Cases and Webinars in a Smart Neurointerventional Angiographic Suite

1Grzegorz Marek Karwacki, 1Justus Roos,1Justus Roos, 1Alexander von Hessling

1Department of Radiology and Nuclear Medicine

Background(s):

Smart angiography suites (SAS) refer to the incorporation of audio-video technology and internet connectivity into the angiography suite to enable bi-directional communication for teleproctoring. Remote streaming support (RESS) is intended to increase patient safety by supporting interventionalists with limited experience or who are practicing in geographically remote areas. The aim of this presentation is to describe the real-life experience of this system and to share practical tips considering its use and setup.

Material(s) and Method(s):

We describe the platform itself as well as its optimal placement, settings and integration in our angiography suite. We provide technical tips intended to help new and potential users in achieving an optimal experience for both neurointerventionalists and proctors. We describe both elective cases that we have performed with teleproctoring and emergencies where this system proved to be crucial during the treatment allowing for communication with a more experienced physician. Lastly, we describe a different room setup and software solutions used in live workshops.

Result(s):

Use of teleproctoring enabled involvement of proctors in cases where an already experienced interventionalist needed support in decision making process considering the sizing and deployment of devices which he was familiar with only on basic level. Excellent video feed quality and instant communication enabled for optimal preparation and in vivo implantation of those devices without the need of physical proctors’ presence. In emergency cases the system allowed a senior physician for support during cases where optimal device sizing is critical. Our usage concept of the rig allowed for monitoring of thrombectomy cases by junior physicians. During webinars remote streaming platform enabled us to conduct workshops simulating an “on-site” experience as closely as possible during COVID19 pandemic.

Conclusion(s):

Remote streaming support system is a modern teleproctoring technology and a key element of a smart angiography suite.

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The Diagnostic Value of Tirads System for Classification of Thyroid Nodules in Correlation with Fine-Needle Aspiration (Fna): A Single-Center Experience

1Ali Aldhebaib, 1Yosef Alzahrani, 1 Gharam Meshal Alotaibi, Alaa Alangry, 1 Weam Alqahtani, 1 Aisha Mubarki, 1 Rana Oqailan

1King Abdulaziz Medical City, Riyadh

Introduction(s):

There are many types of thyroid tumors, including benign thyroid tumors, and there are also malignant tumors. Nowadays, doctors prefer to use ultrasound imaging in the diagnosis stage of thyroid nodules since it’s a non-invasive method. The aim of the study is a comprehensive of unbiased comparison of the results of the ACR TI-RADS classification Diagnostic and Evaluation System, with a combination of the use of FNA.

Material(s) and Method(s):

This study is based on a method of cross sectional retrospective study. The target population were the patients who came to radiology department with thyroid FNA and ultrasound orders at NGHA, Riyadh during the period between 1-1-2019 to 12-30-2020. The study sample of the patients who match the criteria 400 patients. Data were collected, including age, gender, date of referral, number of nodules, US classification, FNA and cytopathology report for each sides of thyroid.

Result(s):

Research team notice that there is no agreement between the results of both methods. Where most of the results of the cytopathology method for examine the thyroid nodules fell within the 1st classification. While most of the results of US fell within the 4th classification.

Conclusion(s):

This study was conducted on a group of 400 patients who came to the radiology department with thyroid biopsy and ultrasound orders at King Abdulaziz Medical City, Riyadh during the period from 1/1/2019 to 12/30/2020. The medical data of this research sample was reused and the results of TIRADS and FNA were compared. And based on the results of the comparison, the results showed that TIRADS were mostly of the fourth type (suspicious), while most of the results of FNA were mostly of the first type (benign). The results of the test showed that there was no correlation between the two methods.

The results of this study conflict with the study by Manikantan Ji et al., who reported that ultrasound imaging was very effective in determining the nature of thyroid lesions, with an accuracy of 84.5%. It also contradicts the results of a study by Popli MB et al, who reported an 87.2% diagnostic accuracy using the ACR TIRDS to diagnose benign and malignant thyroid lesions.

The study suffered from several limitations, most notably:

•The study was conducted in one center.

•Each radiologist has their own way in writing the report.

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Assessment of Medical Doctors’ Awareness of Radiation Exposure in Selected Diagnostic Radiology Centers in Mogadishu, Somalia.

1Ahmed Adam Osman

Background(s):

Radiation protection in medicine has its own set of challenges and is an important part of medical practice. Radiation is used in medicine all around the world, from big cities to little clinics. The purpose of medical Radiation exposure is not to offer the smallest amount possible, but to deliver the right dose to allow the doctors to diagnose or cure a pathology. diagnostic investigations using radiation have become a critical feature of medical practice in recent times. And the possibility of doctors’ underestimation of risks of over-exposure of patients to diagnostic radiation, Many physicians have little or no training in radiation protection, In many countries including Somalia, the Usage of Medical radiation devices is only minimally regulated or not all. Therefore The purpose of this study was to evaluate Medical doctors’ awareness of radiation exposure in selected diagnostic Radiology centers in Mogadishu Somalia due to the recently increased usage of diagnostic radiation machines regardless of their risk of radiation exposure.

Material(s) and Method(s):

This was a descriptive cross-sectional study of the awareness of doctors about radiation exposure in diagnostic radiology investigations in Somalia. Online questionnaires were distributed to 200 participants through internet platforms during the COVD-19 pandemic period, between July and December 2021. Our data analysis was descriptive with a quantitative method, with univariate level analysis only for all variables.

Result(s):

Of the 200 participants, 62% had no formal training on radiation exposure. 86% of our respondents had no idea quantity of radiation a patient absorbs during a chest X-ray( 0.02mSV) Whereas only  10.5% of our respondents correctly estimated quantity of radiation a patient absorbs in single-phase abdominal computed tomography (CT) More than 70% of participants agreed that children are more sensitive to radiation, but only 11% suggested medical termination of pregnancy for a woman who had CT abdomen and pelvis with contrast according to ACR. General practitioners were the highest intended of this study as most doctors in Somalia are General practitioners.

Conclusion(s):

As a result of the high rate of poor awareness of radiation risks observed in this study, it is important that the Somali Ministry of Health and state-level health ministries must ensure that appropriate radiological examination guidelines and national radiation policies are enforced at all levels of healthcare services.

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Isolated Mesenteric and Portal Vein Thrombosis in Covid-19 Pandemic Period

1Eui Yong Jeon

1Sheikh Khalifa Specialty Hospital

Introduction(s):

Isolated mesenteric and portal vein thrombosis is caused in various conditions and oral contraceptive and clomiphene induced thrombosis is very rare. The thrombotic event became more common in COVID-19 pandemic period, and we found 2 cases related to COVID-19 infection and vaccination and medication of oral contraceptive and clomiphene. We want to present the cases with follow up result after medical treatment.

Material(s) and Method(s):

Two young patients (43 years old) without underlying disease of hypertension and diabetes presented to emergency department due to upper abdominal pain and diagnosed as having isolated mesenteric and portal vein thrombosis on abdominal CT examination. Medication history was searched with workups for systemic hypercoagulability. Follow up radiologic studies were done more than 3 months in both patients.

Result(s):

Isolated mesenteric and portal vein thrombosis were found in both patients, without evidence of mesenteric hypertension, such as ascites and bowel wall thickening on initial CT. Close workups for systemic hypercoagulability revealed negative results, other than medication of oral contraceptive in female (COVID-19 positive) and clomiphene in male (COVID-19 vaccinations 5 months before) patients. Follow up CT and ultrasonography studies revealed chronic thrombotic occlusion of mesenteric and portal veins, with cavernous transformation of portal veins.

Conclusion(s):

Hypercoagulability in COVID-19 infection can increase the prevalence of isolated mesenteric and portal vein thrombosis in patients taking medication of oral contraceptive and clomiphene. Chronic thrombotic change with obliteration of portal vein implicates more active treatment other than anticoagulation therapy in COVID-19 pandemic period.

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Congenital Absence of the Bilateral Internal Carotid Arteries: A Case Report

1,2 Ji Hoon Noh

1Samsung Medical Center, 2Seoul Veterans Hospital

Introduction(s):

Congenital absence of the bilateral internal carotid arteries (ICA) is a very rare occurrence.

Material(s) and Method(s):

Brain magnetic resonance angiography (MRA), tranfemoral cerebral angiography, carotid MRA, brain computed tomography (CT), 99mTc-ECD SPECT and perfusion MRI were performed.

Result(s):

Absence of the ICA may be associated with aneurysms of 24%-34%, compared to a 2%-4% prevalence observed in the general population. In many reported cases, the anterior communicating artery (ACOM) is the most common location of aneurysms.

Conclusion(s):

Recognition of absence of the bilateral internal carotid arteries (ICA) is important, when considering intracranial endovascular interventions in the event of thromboembolic events with revascularization, transsphenoidal surgery, and the surveillance and detection of associated cerebral aneurysms.

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Clot Ct Characteristics as Predictor Factor of Successful First-Pass Recanalization in the Treatment of Anterior Ischemic Stroke

1Elie Lteif,1Emmanuel Chabert, 1Emmanuel Chabert, 1Ricardo Moreno, 1Abderrahim Zerroug

1CHU-Gabriel Montpied

Introduction(s):

The first pass (FP) recanalization has been highlighted as a strong predictor of good clinical outcome and a benchmark to evaluate mechanical thrombectomy’s efficacy. The thrombus physical characteristics affect the efficacy of recanalization therapies of patients who suffer from an AIS. Some of these characteristics as density, perviousness, and length, can be detected and analyzed on computed tomography (CT). For instance, the thrombi vary in composition and CT characteristics which affect the recanalization rates. Our study primarily aimed to assess whether thrombus CT characteristics could influence the FP recanalization rate of mechanical thrombectomy (MT) with a stent retriever in anterior ischemic stroke (AIS).

Material(s) and Method(s):

We retrospectively studied all patients admitted to the CHU-Clermont Ferrand (France) and who suffered from an anterior acute ischemic stroke due to large vessel occlusion treated by mechanical thrombectomy with a stent retriever starting January 2015 till December 2017.

We registered the following thrombus characteristics by using the mean of three millimeter-sized regions of interest: mean unenhanced thrombus density (MUTD), thrombus attenuation increase (TAI), relative thrombus attenuation increase (rTAI), and the clot burden score. Then, we studied their association with first-pass recanalization, successful recanalization, distal emboli, and clinical outcome.

Result(s):

We included 173 patients. First pass recanalization was achieved in 41.5 %, a successful recanalization was achieved in 73.3 %. MUTD (p = 0.008), TAI (p < 0.001) and rTAI (p < 0.001) were significantly associated with a higher rate of first pass recanalization. These thrombus characteristics were also significantly associated with a higher rate of successful recanalization, (p = 0.002) for MUTD, (p < 0.001) for TAI and (p < 0.001) for rTAI.

Higher TAI (p = 0.02), higher rTAI (p = 0.003) and lower CBS (p = 0.03) were significantly associated with a better clinical outcome at 3 months in contrary of MUTD (p = 0.62).

Conclusion(s):

Higher unenhanced thrombus density and higher thrombus perviousness defined as thrombus attenuation increase on CT angiography are significantly associated with a higher rate of the first-pass recanalization and successful recanalization stent retriever mechanical thrombectomy of AIS.

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Flow Diverting Stent in Blister Aneurysm

1Ehsan Mohammad Hosseini,

1Shiraz University of Medical Sciences

Background(s):

Efficacy of FDS on blister aneurysm.

Material(s) and Method(s):

Treatment of blister aneurysm with FDS.

Result(s):

Blister aneurysm can treated with FDS with good result.

Conclusion(s):

FDS maybe safe and effective option in treatment of blister aneurysm.

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Modified Technique of using Angiojet Thrombolysis in Patients with High Thrombus Load

1Dr Saad Rehman,1Dr Mohammed Khader, 1Dr Rahil Kassamali, 1Dr Ayman Elmagdoub

1Hamad Medical Corporation

Background(s):

To stratify patients in order to provide successful single session thrombolysis.

Material(s) and Method(s):

Angiojet mechanical thrombectomy is a well-established tool in the treatment of DVT. In our institute, we use angiojet for DVT, Renal fistula, and PE thrombolysis. As we don’t have EKOS systems we worked to increase efficacy and improve results of mechanical thrombectomy. We used thrombus load scoring based on the length of involved veins and D-dimers. The patient who had a higher score were treated with modified techniques. In our technique, we used the following sequence; Thrombectomy mode — power pulse mode — balloon maceration — thrombectomy mode. This technique results in increased operating time and more radiation exposure. Hence we scored the patients and only those having higher scores were selected for this modified technique.

Result(s):

We aimed for inline flow with no significant narrowing or remaining thrombus at the end of the procedure and no further IR input was needed. 23 patients were selected. In 22 we achieved complete clearance in a single session. Only one patient required suction thrombectomy (Penumbra) to clear the clot completely. Haemoglobinuria was observed in 15 out of 23 patients with a transient rise in renal function seen in 3 patients only. No other major complication occurred.

Conclusion(s):

In our experience heavy thrombus load, venous thromboembolism can be treated with angiojet alone successfully with modified use. Patient selection criteria are important as only heavy thrombus load justifies increased radiation exposure and potential renal injury.

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Case of Coil Migration in Lung Post Carto

1Saad Rehman

1Hamad Medical Corporation

Background(s):

Coil migration during embolization is not uncommon. We encountered a case where post-CARTO coil migrated into the pulmonary artery.

Material(s) and Method(s):

BARTO/CARTO are commonly performed procedures for the treatment of gastric varices. We perform such procedures in our institute routinely. In one of the instances, all of the coils used for CARTO migrated en-mass into the left pulmonary artery. The coils were successfully removed using a combination of snares and forceps.

Result(s):

The large coil was lodged at the origin of the lower lobe branch of the left pulmonary artery. The coil was removed using a combination of snares and forceps successfully.

Conclusion(s):

Coil removal is a technically difficult procedure and should be undertaken with care. We demonstrated by using forceps with snares this can be achieved successfully without complications.

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Role of Bronchial Artery Embolization in Management of Hemoptysis in a Developing Country

1Puneet Garg,1Ayush Khandelwal, 1Ayush Khandelwal, 1Amita Malik

1VMMC & Safdarjung Hospital

Introduction(s):

Bronchial artery embolization (BAE) is a minimally invasive endovascular procedure which plays a vital role in patients of moderate to massive hemoptysis who can not be managed with conservative measures. Superselective embolization of culprit vessels with PVA particles is a promising technique to give symptomatic relief for hemoptysis and can be used as an adjunctive treatment alongwith surgery and medications to reduce the morbidity of such patients. BAE can also be considered as life saving procedure in cases of life threatening hemoptysis.

Material(s) and Method(s):

Patients of moderate to massive hemoptysis and patients of mild chronic hemoptysis not controlled on medications were included in the study from 2018 to 2021. BAE was done in DSA suite using PVA particles as embolizing agent. Technical success,complications and clinical success rates at 1month, 3 months and 6 months follow up.

Result(s):

130 patients were included in the study and 95 were males in that cohort. 43 patients had mild hemoptysis, 46 had moderate and 41 had massive category of hemoptysis with duration of symptoms ranging from 3 days to 25 years. Posterior intercostal artery was the most common culprit vessel followed by Intercostobronchial trunk. Hypervascularity was the most common angiographic finding followed by hypertrophy and tortuosity. Average of 2.5 culprit arteries were embolized per patient with range varying from 1 to 8. Technical success was achieved in 98 % of the patients. 96%, 91%, 82% and 67% clinical success rate was observed at immediate, 1 month, 3 months and  6 months follow up.  4 patients were stablized after life threatening hemoptysis episode with this procedure. Spinal cord ischemia was the most severe complication observed in one patient and chest pain was most common minor side effect of the procedure.

Conclusion(s):

BAE is a safe, prompt and effective procedure to control hemoptysis in all categories of hemoptysis refractory to medical management. It can also be a life saving procedure when other modalities have failed or warrants immediate treatment.

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Long Term Outcome of Surgical Management for Vertebral Hemangioma Presenting with Myelopathy

1Pankaj Kumar Singh,1Shashank Sharad Kale

1All India Institute of Medical Sciences, New Delhi

Background(s):

Vertebral hemangiomas are benign, highly vascular lesions of the vertebra. Asymptomatic hemangiomas are common, but they rarely enlarge in size and present with myelopathy. The aim of this study was to analyze the long-term outcome of patients of vertebral hemangioma presenting with myelopathy who were managed in a resource-constrained environment, the majority of whom were treated by our novel three-pronged strategy of alcohol injection, posterior decompression, and short segment fixation.

Material(s) and Method(s):

All patients of symptomatic vertebral hemangioma with myelopathy treated at our hospital from 2001 to 2015 with follow up till January 2018, with at least 2 year follow up were included. The operative procedure, blood loss and complications were recorded. Clinical outcomes were measured using ASIA score.

Result(s):

Out of 60 patients operated, 44 (26 males, 18 females) fulfilled the inclusion criteria. 41 hemangiomas were located in the thoracic spine two in lumbar spine and one in cervical spine. Upper thoracic spine involvement was more common than lower thoracic spine involvement. Mean age was 29.34 years (range 10 – 68 years). Mean follow up was 74.63 months (range 24 – 180 months). All patients had improvement in motor strength postoperatively. Local pain, which was present in two patients resolved, bladder symptoms present in 13 patients also resolved.

Conclusion(s):

Our experience in treating symptomatic vertebral hemangiomas, along with the long term follow up data suggests that good postoperative results can be achieved with minimal complications, in carefully selected patients.

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Ultrasound Guided Percutaneous Microwave Ablation in Treatment of small Lesions of Breast is Safe, Effective and ahead of time.

1Muhammad Fiaz

1Cancer Care Hospital and Research Centre

Introduction(s):

The objective of this study was to verify the safety and effectiveness of ultrasound (US)-guided percutaneous microwave thermal ablation as mode of treatment of small breast lesions (benign as well as malignant). Now days, breast cancer is the most frequently diagnosed life-threatening cancer in women and the leading cause of cancer death among women. Since last two decades, researches related to the breast cancer has lead to extraordinary progress in our understanding of the disease, resulting in more efficient and less toxic treatments.

Material(s) and Method(s):

With all aseptic measures, microwave antenna was inserted percutaneosly under ultrasound guidance with using linear probe. The ultrasound images, any complications and side effects were assessed during and after ablation. For assessment of ablation zone, MRI with contrast is used.

Result(s):

Nine patients underwent the treatment. One patient felt pain and severe redness after procedure which persist for 2 weeks. Follow up MRI was showing type 1 enhancement curve. Eight  patients felt some pain and the discomfort after couple of hours post ablation which rapidly disappeared.

Conclusion(s):

Today there are so many approaches, which can be made for the treatment of the cancer of breast such as surgery, radiation therapy chemotherapy, hormonal therapy and recently nanotechnology and ablation therapies. With advances in screening, diagnosis, and treatment, the death rate for breast cancer has declined. In fact, about 90% of women newly diagnosed with breast cancer will survive for at least five years.

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Ultrasound Guided Fine Needle Aspiration Cytology of Thyroid Lesions; A Pilot Study on the Spectrum of Radiologic and Histopathologic Findings

1Ebbi Donald Robinson,1Solomon Obioha, 1Kue David Soghian, 1Igani Joshua Iselema

1Rivers State University Teaching Hospital

Introduction(s):

Ultrasound guided fine needle aspiration cytology (FNAC) plays a pivotal role in the cytopathological management of thyroid disease by providing a précised evaluation of thyroid lesions. This interventional radiologic procedure is minimally invasive, readily available and affordable. The study is aimed at evaluating the spectrum of radiologic and cytologic findings of thyroid disorders using ultrasound guided fine needle aspiration cytology.

Material(s) and Method(s):

One hundred and twenty-one (121) patients referred for ultrasound guided fine needle aspiration cytology of the thyroid gland participated in the study. The study was carried out at the interventional radiology unit of the Rivers State University Teaching Hospital, Port Harcourt from September 2020 to August 2021. After obtaining informed consent, age and anthropometric parameters were taken.  Patients had standard exposure and position for the study.  Using an ultrasound machine (Logic F6, General Electric, USA, 2017), fitted with a 7.5-MHz linear transducer, the thyroid gland was scanned to locate the thyroid lesion. With a 20ml syringe and a 23G by 11/2 inch needle, cells were aspirated from the thyroid lesion. Dry and wet slide smears were immediately prepared and subsequently taken to the histopathology laboratory for analysis. The data obtained were analysed using a statistical package for social science version 21.0 (SPSS INC. CHICAGO, IL, USA).

Result(s):

Males and females constitute 23(19.01%) and 98(80.99%) respectively with a mean age (+SD) of 41.33+3.11years. Radiological evaluation revealed that 86.78% (n=105) of the thyroid glands were enlarged with radiologic diagnosis of thyroid malignancy (n=11; 9.00%), thyroiditis (n=24; 19.83%), thyroid nodule (n=47; 38.84%) and thyroid nodules with cystic degeneration (n=39; 32.23%). Cytological findings revealed, non-diagnostic sample (thy1/c) category (n=2; 1.65%), benign colloid nodule (n=52; 42.98%), follicular neoplasm (n=7; 5.79%), and thyroiditis (n=21; 17.36%).

Conclusion(s):

Image-guided FNAC is a valuable tool in the diagnosis of thyroid lesions with the majority of the thyroid lesions being benign.

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Surpass Evolve Flow Diverter in the Treatment of Intracranial Aneuryms: A Single Centre Initial Experience Study with Angiography & Clinical Results

1Jagadeesan Dhanasekaran,1Venkatesh Pothula, 1Santhosh Joseph

1Sri Ramachandra Institute of Higher Education and Research

Background(s):

Flow diverter (FD) have become a safe treatment option for intracranial aneurysms (IA), especially in fusiform and blister like aneurysms which remained challenging. Newer generation Surpass Evolve (SE) is a FD that was approved for usage since 2019 in India.

The aim of this study is to describe the initial experience and analyse the angiographic and clinical outcomes using SE in treatment of IA.

Material(s) and Method(s):

Between December 2019 to December 2021, forty four IA in 36 patients (69.4% women), mean age 51 years were treated with SE in our institute. Baseline patient clinical details, aneurysm demographics and treatment modalities were prospectively collected and results were reviewed.

Result(s):

IA was noted as an incidental finding in 69.4% patients, majority (75%) were saccular and 70% were wide necked. Apart from re-sheathing of FD, four patients required balloon angioplasty of deployed FD. Adjuvant coiling was performed in six aneurysms and two aneurysms required an extra FD to achieve proper wall apposition. Mean Aneurysm Flow Amplitude (MAFA) – Ratio obtained in 2 patients showed superior flow diversion effect of SE device. There were thromboembolic complications in two patients, which were managed successfully. We had few early reversible neurological complications and one mortality. Favourable aneurysm occlusion /O’Kelly-Marotta (OKM) grading scale D was achieved in 18/20 (90%) patients on follow-up. No FD deployment failure, intra-procedural mortality, increase in the mRS was observed.

Conclusion(s):

SE worked technically well in terms of its excellent navigability, re-sheathing, accuracy of placement and maximal flow diversion. Our initial clinical and angiographic results show good efficacy comparable to other FD.

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Pial Arteriovenous Fistula how we treat

1Umair Rashid

1Lahore General Hospital

Introduction(s):

Pial arteriovenous fistula (AVF) are not very common vascular lesions, which supplied by  arterial feeders draining directly into the venous channel or venous pouches without nidus of brain AVM. The angio architecture, clinical course and therapeutic options are all different from arteriovenous malformation (AVM), dural AVM or other intracranial vascular lesions.

Material(s) and Method(s):

In our study, we describe cases of pial AVF in the adolescent as well as in pediatric age group treated successfully with endovascular methods.

Result(s):

The treatment was successful with good clinical outcome and much improvement in patients symptoms as well. We did not encounter any peri-procedural complication. Pial AVF is a rare vascular abnormality with high degree of suspicion so to make the early diagnosis it required adequate imaging knowledge.

Conclusion(s):

Treatment of pial AVF should be done as early as possible to prevent devastating complications that can occur during the natural course of the disease.

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Coil Embolization of Pseudo Pulmonary Seqestration

1Wafa Yahya Qatomah,2Mohammad Arabi, 2Mohammad Arabi, 3Aisha Qatomah,

1King Saud Bin Abdulaziz University for Health Sciences, 2King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, 3King Khalid University

Background(s):

Pseudo pulmonary sequestration is a rare congenital anomalous. It entails systemic arterial supply to the basal segment of the lung in the absence of pulmonary arterial supply. Diagnosis is often made by radiographic appearance without clinical symptoms. The mainstay treatment is surgical resection; however, embolization can be considered as an alternative approach.

Herein, we present a report of two females, presented with nonspecific chronic chest pain. Both cases were diagnosed with Pseudo pulmonary sequestration on CT scan and completed uneventful pregnancies prior to successful management with coil embolization.

Material(s) and Method(s):

Result(s):

Conclusion(s):

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Fallopian Tube Recanalisation and Selective Salohingography, a boon to Patients with Tubal Block

1Sonali Soni

1Navya Diagnostic Center

Background(s):

Transcervical fallopian recanalisation was tried in patients diagnosed as proximal tube obstruction either on hysterosalpingography or laparoscopy , under fluoroscopic guidance.

Material(s) and Method(s):

Under fluoroscopic control special double balloon introducing catheter , a J shaped selective salpingography catheter and a hydrophillic terumo guide wire were used in recanalisation of proximal tube obstruction. four hundred fifty eight patients diagnosed as proximal tube obstruction on hysterosalpingography or laproscopy , underwent selective salpingography.If selective salpingography failed to opacify tubes then  terumoguide wire mediated fallopian tube recanalisation was done.Tube patency was again confirmed by selective salpingography & HSG. Outcome measures:Tube opacification (whether normal or diseased distal tubes),pregnancy and follow up HSG /selective salphingography for reocclusion .

Result(s):

Out of 758 patients of proximal fallopian tube occlusion,SSG was successful in 25% patients.Rest75%patients underwent guide wire mediated recanalisation.Out 638,distal occlusion and hydrosalpinx was seen in 74 patients,576 patients were followed up with intrauterine pregnancy in 35% patients and extra uterine pregnancy in 2%patients ,patent tubes on follow up in 106 cases,10 patients had re occlusion out of which 8 were again canalized ,and 92 cases are in follow up stage.

Conclusion(s):

Trancervical fallopian tube recanalisation is an effective non invasive OPD procedure as the initial diagnostic procedure for proximal tubal obstruction .It can be done prior to in vitro fertilization and microsurgery.It is recommended as initial mode of treatment for tubal blocks by American Infertility Society.

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Efficacy of Uterine Artery Embolization for Symptomatic Uterine Fibroids in Pakistani Population

1Rafay Gul, 1Ammad Hussain , 1Ammad Hussainziz

1Dr. Ziauddin University Hospital

Introduction(s):

Uterine fibroid is the most common pelvic tumour in women that leads to gynaecological haemorrhage, lower abdominal pain, dysmenorrhea and infertility. Uterine artery embolization (UAE) is one of the minimally-invasive alternatives to hysterectomy for the treatment of uterine leiomyomas.  This study aimed to evaluate the effect of uterine artery embolization on treating and reducing the size of symptomatic uterine fibroids.

Material(s) and Method(s):

It is a retrospective study done on 67 patients who had undergone uterine artery embolization for symptomatic fibroids at the Interventional Radiology department of Ziauddin University Hospital Karachi during the period from 1st June 2016 to 1st June 2021, in collaboration with the department of gynaecology and obstetrics of our institute. Clinical demographics, presenting symptoms, uterine and fibroid characteristics on pre and post-procedural imaging were analyzed.

Result(s):

67 patients underwent uterine artery embolization with pre & post MRI assessment. In terms of location of the dominant fibroids, 35 patients (52%) had transmural tumors (FIGO II-IV), 23 patients (34%) had submucosal cum intra-mural tumor (FIGO 0-I), 9 patients (14%) had tumors in sub serosal cum intra-mural location (FIGO V-VI). We classified UAE treatment response as under <30%, 30-50% &> 50% volume reduction on 6 months post embolization MRI. 6 months follow-up MRI shows >50 % of fibroid volume reduction in 23(34%) patients, 30-50% of volume reduction in 34(51%) patients and < 30% in 4(6%) no of patients. 100% technical success was obtained with complete embolization of tortuous & dilated uterine arteries with resolution of symptoms. Clinical success was achieved in 61/67 (91%) of patients. Two patients showed increase in fibroid size & volume due to very enlarged size multi-fibroid uterus. Two patients in class C shows no response to treatment. Two patients lost to follow-up.

Conclusion(s):

67 patients underwent uterine artery embolization with pre & post MRI assessment. In terms of location of the dominant fibroids, 35 patients (52%) had transmural tumors (FIGO II-IV), 23 patients (34%) had submucosal cum intra-mural tumor (FIGO 0-I), 9 patients (14%) had tumors in sub serosal cum intra-mural location (FIGO V-VI). We classified UAE treatment response as under <30%, 30-50% &> 50% volume reduction on 6 months post embolization MRI. 6 months follow-up MRI shows >50 % of fibroid volume reduction in 23(34%) patients, 30-50% of volume reduction in 34(51%) patients and < 30% in 4(6%) no of patients. 100% technical success was obtained with complete embolization of tortuous & dilated uterine arteries with resolution of symptoms. Clinical success was achieved in 61/67 (91%) of patients. Two patients showed increase in fibroid size & volume due to very enlarged size multi-fibroid uterus. Two patients in class C shows no response to treatment. Two patients lost to follow-up.

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Trans-Catheter Arterial Embolization of Pancreatico-Duodenal Arteriovenous Malformation

1Fahad Mohammed Aldawsari

1King Abdulaziz Medical City

Background(s):

Pancreatico-duodenal Arteriovenous Malformation is a rare entity and few cases reported in the literature review.Those patients have variable clinical presentations from asymptomatic to upper GI bleeding and portal hypertension.The definitive treatment is surgical especially at early stage.However, other options such as conservative, embolization,irradiation and TIPS can be effective in selective patients and situations. A 44 years old man patient presented to our Hospital with on / off abdominal pain and episode of upper GI bleeding .He is vitally is hypotensive and his laboratory investigation demonstrated dropped haemoglobin and leukocytosis.Routine CT abdomen and pelvis was done which showed contained duodenal perforation and incidental discovered of pancreatic head and body AVM.During COVID 19 crises , lockdown of operating rooms were reserved for emergency cases only therefore , multidisciplinary team was consulted and end discussion was for IR referral for further management.Diagnostic Abdominal angiography selecting  celiac and superior mesenteric artery was done which revealed pancreatic-duodenal and pancreatic body AVM with early filling of portal vein.No clear active arterial extravasation.The pancreatic-duodenal AVM which was then treated with 2 sessions of embolization using Coil and Onyx.Post embolization angiogram showed around 80% of pancreatic AVM was resolved.9 days follow-up showed clinical and imaging improvement in term of near total resolution of the AVM and healed perforation.Patient discharged with 6 month follow-up in IR clinic.

Material(s) and Method(s):

Case report study of patient conducted form 2020-2021

Result(s):

Post embolization angiogram showed around 80% of pancreatic AVM was resolved.9 days follow-up showed clinical and imaging improvement in term of near total resolution of the AVM and healed perforation. Patient discharged with 6 month follow-up in IR clinic.

Conclusion(s):

Pancreatico-duodenal Arteriovenous Malformation Embolization is safe and effective in selective patients.

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Thrombolysis of Bilateral Renal Artery Thrombosis in Takayasu Arteritis Patient

1Shaker Alshehri,1,2Raad Madkhali, 3Dr. Mahdi Aljawad

1King Abdulaziz Medical City, 2King Fahad Hofuf Hospital, 3King Fahad Hospital

Introduction:

We present one of the unusual and rare presentation of TA of a 47-year-old male presented with an abrupt onset of anuria for 3 days duration, with 10 days prior to presentation he was complaining of central abdominal pain.On the physical exam the lower limbs pulse was palpable but weak bilaterally. The abdominal exam revealed mild tenderness more on the right side. The remainder of the exam was normal. Patient was anuric even after Foleys catheter insertion. Non-enhanced CT showed no obstructive uropathy or renal stones. Next day of admission his creatinine level jumped to 900 mmol/L. Urgent renal Doppler ultrasound results were highly concerning for bilateral main renal artery thrombosis versus stenosis. Enhanced CT angiography revealed thrombosed abdominal aorta extending to the iliac branches and involving the proximal renal arteries, distal splenic artery, SMA and IMA with bilateral renal and splenic infarctions. The thrombosed vessels have enhancing thickened wall with progressive delayed enhancement. Interventional radiology consulted and left brachial artery access was obtained, aortogram and renal angiogram was done through a pigtail catheter, revealed chronic total aortoiliac occlusion, bilateral renal arteries and origin of the superior mesenteric arteries occlusion. Right renal artery was recanalized, 6 mg t-PA was given as bolus. Then Left radial artery access was done and Left renal artery was recanalized, 6 mg t-PA was given as bolus. 135 cm x 10 cm CRAGG MC-NAMARA catheter directed thrombolysis was placed in the right and left renal arteries. Both catheters and sheaths were fixed. Catheter directed thrombolysis was started using t-PA infusion through the catheters and heparin infusion through the sheaths.

Material(s) and Method(s):

Case Report

Result(s):

Aortogram next day demonstrated complete patency of the renal arteries bilaterally and the flow was resumed to the kidneys parenchyma. Renal Doppler ultrasound confirmed no thrombus in renal arteries.  Patient received 3 session of hemodialysis in the first few days, however after thrombolysis he start to produce urine 3L per day, he did not receive any dialysis session after that.

Conclusion(s):

Bilateral renal arteries thrombosis as a cause of acute renal failure in TA managed by catheter directed thrombolysis, lead to immediate improvement in kidney function and avoid renal ischemia and chronic renal failure.

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Giant Cerebral Aneurysm: Endovascular Theater Technical and Clinical Outcome

1Ahmed Attia A. Hassan,1Mohamed Farouk Elsherief, 1Mohamed Farouk Elsherief, 1Mohamed Adel Denewar

1Mansoura Faculty of Medicine

Objective(s):

Assessment of technical outcome during intervention set for treatment of giant cerebral aneurysm. Monitoring clinical and anatomical out come of the treated patients

Material(s) and Method(s):

Prospective cross sectional study, Clinical and radiological assessment by CT angio/ MRI and DSA, Inclusion criteria involving referred patients with giant cerebral aneurysm at Mansoura university hospital

Exclusion criteria for patients unfit for anesthesia and contrast media

Transfemoral  guiding catheter  and microcatheter set reaching target aneurysm

Coiling and or stent could be deployed

Follow up post operative DSA soon and after 6 months

Result(s):

9 patients with giant cerebral aneurysm excluding 3 patients, 2 before DSA having chronic renal disease

Case after DSA having carotid tortousity with failed distal navigation

6 cases having therapeutic procedure 3 cases flow diverter

2 cases stent assisted coiling 1 case coiling 

Complete occlusion at 3 cases

Partial occlusion at 3 cases

Conclusion(s):

Giant cerebral aneurysm having special technical and clinical out come with effective therapeutic results with different neurointervention procedures.

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The Safety And Efficacy of Uterine Artery Embolization in the Treatment of Patients with Symptomatic Fibroids, Single Tertiary Hospital Experience

1Abdullah Muharib,1Radhi Alshehri, 1Radhi Alshehri, 1Najeeb Ghanem, 1Salem Bauones

1King Fahad Medical City

Introduction(s):

Uterine leiomyomas (fibroids) are the most common gynecological tumors. Approximately 20–40 % of women are affected in their reproductive age. The vast majority of fibroids present no symptoms and are incidental findings during routine gynecological examinations. Asymptomatic uterine fibroids require no medical management beyond observation, whereas symptomatic fibroids are indicated for medical treatment. Surgery remains a first-line treatment of symptomatic uterine fibroids; however, minimally invasive techniques and pharmacological management have become more available and popular. Among minimally invasive techniques uterine artery embolization (UAE) is the most well-established uterine preserving treatment.

In our study, we are going to determine the safety and efficacy of uterine artery embolization in the treatment of patients with symptomatic fibroids in a single tertiary hospital at king Fahad medical city, Riyadh, Saudi Arabia. We are going to determine its safety by determining what are the complications related to the procedure and how frequent they are. Also, we are going to determine its efficacy by assessing the improvement in the imaging findings in the follow up with MRI.

Material(s) and Method(s):

It is a retrospective cohort study including all patients who underwent uterine artery embolization for the treatment of symptomatic fibroids who had baseline and follow up MRI at King Fahad Medical City, Riyadh, Saudi Arabia between the period of 1 January 2016 to 1 January 2021. A total of 28 female patients were found.

The outcomes included: The dominant fibroid volume before and after UAE, presence or absence of infarction in MRI, and early and delayed complications.

Result(s):

In this study, the ages of the patients ranged from 32 to 51 years, with an average of 40.7 years. 8 (28%) patients have single fibroid while 20 (72%) patients have multiple fibroids ranging from 2 to more than 10 fibroids. Radial access was used in 8 (28%) patients while the remaining 20 (72%) patients, common femoral access was used. Beads block was the embolizing agent that was used in all patients.  Technical success achieved in all patients without immediate complication. The mean MRI follow up period after UAE was 9.3 months. Only one patient (3.6%) had progression in the fibroid volume after UAE by 64 % with absence of infarction attributed to ovarian artery parasitization. The rest of the patients (96.4%) had significant volume reduction with mean of 57.6 (12.6%-99.6%), P value less than 0.001, 95% confidence interval is 69.20, 207.39. The patients with solitary fibroids had mean of fibroid volume reduction of 79.6% compared to 54.3% in patients with multiple fibroids, P value is less than 0.001.

Post discharge complications seen only in one patient (3.6%) who had postembolization syndrome. No major complications encountered.

Conclusion(s):

UAE is a safe, technically successful and effective treatment for symptomatic fibroids which could be a good alternative for surgery. All patients with symptomatic uterine fibroids considering hysterectomy and myomectomy should be counseled about UAE by an interventional radiologist. Selection of patients is important to optimize the benefits.

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Ultrasound-Guided Artery Access for Neuro Endovascular Procedures, a time Saving Factor

1Prof. Bassem Yousef Sheikh

1Madinah

Background(s):

Arterial catheterization is the first step in each and every endovascular procedure.  Failure to attain a decent access result in failure or complicated final outcome.  Although arterial access catheterization  is oftentimes performed by manual pulse palpation, ultrasound guided access has been introduced to increase catheterization success rates and to lower complications.

Identifying arterial pulse may be challenging.  Hypotensive patients, obese individuals, presence of edema, atherosclerosis, or small diameter arteries, in addition to anatomical landmark variation, all play role in cannulation failure, hematoma formation, arterial spasm, injury, thrombosis, and patient discomfort.

Ultrasound guided Arterial catheterization is advocated as a mean to decrease these difficulties.

Material(s) and Method(s):

Method: Case series hospital based population on neuro endovascular procedures.

In this report we present The type of ultrasound device used, the  ultrasound approach longitudinal or short  axis view, and outcomes including first-attempt success rate, failure rate, time to first successful attempt, and the rate of hematoma development.

Result(s):

Our experience confirmed that ultrasound guided  catheterization technique increased first-pass success and reduced failure rates.  Ultrasound guided  catheterization using combined short-long axis technique gave superior results than each separately.

Conclusion(s):

Our results advice for the routine utilization of ultrasound guided  arterial access catheterization technique.

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Multiple Utilization of Transradial Approach in Neurointerventional Procedures, the path to Success

1Prof. Bassem Yousef Sheikh

1Madinah

Background(s):

The community of Neurointerventional world is mostly in total agreement on the significant advantages of transradial approach as compared to transfemoral approach. However, the neurointerventionest showed be aware of anatomical variations that may render this approach rather difficult or riskier. Arteria lusoria, Aberrant right subclavian artery, is one of these variations that render catheter shaping and reforming to navigation into the cranial vasculature challenging. It has an incidence of 0.6–1.4%.

We are presenting a series of cases of neurovascular pathologies that were managed by endovascular techniques via the transradial approach in the presence of Arteria lusoria. The technical challenges and nuances in overcoming them are illustrated.

Material(s) and Method(s):

Method: Case series of hospital-based population on neuro endovascular procedures, that were managed via the transradial approach in the presence of Arteria lusoria.

Result(s):

Total of 362 transradial approach for different neurovascular pathology were managed in Madinah region, Saudi Arabia, since 2017. Out of these, eight cases were having Arteria lusoria. Management included thorough preoperative investigation, including arch imaging on CT angiography or MR angiography. Approach strategies included ipsilateral transradial approach, or contralateral left side approach. In all but one case, the endovascular procedure was completed successfully. In one case the approach was converted to transfemoral.

Conclusion(s):

Our results confirm the feasibility of utilizing the transradial approach in neuroendovascular procedures provided the case was fully investigated and the anomaly is thoroughly studied preoperatively

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The Efficacy of Sclerotherapy for Pelvic Congestion Syndrome after Endovascular Procedure

1Andriy Nykonenko

1Zaporizhzhia State Medical University

Background(s):

We analyzed 11 patients with pelvic congestion syndrome, who underwent endovascular coil embolization combined with sclerotherapy. Average age of patients was 43 years (from 27 to 55 years). BMI was 20,0 ± 3,1 points. Pain was scored with using of Visual Analogue Scale (VAS) and was 5 (from 4 to 8) points before the operation. The pain syndrome had the following manifestations: abdominal pain in 60%, lumbar pain in 18%, pain in the left upper quadrant – 40%, pain in the left flank – 25%, pelvic pain was observed in 80% of patients and usually worsened after physical activity.

Material(s) and Method(s):

All patients underwent standard diagnostic algorithm which include an abdominal and a transvaginal US, CT angiography. Before operation transvaginal US showed the diameter of right iliac veins: 11,3 ± 1,6 mm and left: 11,4 ± 1,6 mm, diameters of paraovarian veins from the right: 5,9 ± 1,6 mm and from the left 7,6 ± 1,6 mm, diameters of parametrium veins from the right: 5,6 ± 1,6 mm and from the left 7,0 ± 1,8 mm, and a diameter of left (8,4 ± 1,8 mm) and right (5,9 ± 1,6 mm) ovarian veins. All patients (n=11) underwent endovascular embolization of left ovarian vein combined with sclerotherapy of pelvic veins. We use right transfemoral access to common femoral vein with using a 6F introducer. After placing the catheter into the left renal vein diagnostic phlebography was performed. After that coil was placing in the lower third of ovarian vein (Tornado type in 7 cases, Nestor type in 4 cases). After installing the coil, a sclerosant foam was injected: 3% – 2 ml solution of ethoxysclerol.

Result(s):

Follow-up was in 3 – 6 months and included transvaginal US and CT imaging (in 6 month). VAS was 1 (from 0 to 2) points in 6 months after the intervention.  Tranvaginal US after treatment shows the statistically significant (p<0,005) decrease of the diameters:  iliac veins from the right: 11,1 ± 1,6 mm and from the left: 11,4 ± 1,6 mm, paraovarian veins from the right: 5,2 ± 1,2 mm and from the left 5,7 ± 1,4 mm, parametrium veins from the right: 5,4 ± 1,3 mm and from the left 4,6 ± 1,8 mm, right ovarian vein was 5,6 ± 1,0 mm. There was no visualization of left ovarian vein because of it`s obliteration. There was no blood reflux in pelvic veins in all cases. In 27% (n=3) use of additional coil was required after the injection of the sclerosant.

Conclusion(s):

A variety of unexplained chronic pain is associated with pelvic venous insufficienty, pelvic varicosities and the collateral blood flow.

  1. A variety of unexplained chronic pain is associated with pelvic venous insufficienty, pelvic varicosities and the collateral blood flow.
  2. The use of a diagnostic algorithm will allow us to exclude intrinsic disease and plan an appropriate treatment strategy in a patient with PCS.
  3. Sclerotherapy reduces the demand to use an additional embolization coils.
  4. The use of sclerosant helps to achieve the best results and total regression of symptoms in patients with pelvic congestion syndrome.
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Endovascular Treatment of Distal Posterior Cerebral Artery Infectious Aneurysm

1Manoj Bohara

1Hospital for Advanced Medicine and Surgery

Introduction(s):

Intracranial infectious aneurysms are rare entities accounting for approximately 1- 6 % of all cerebral aneurysms and have high propensity of rupture associated with mortality. The principal risk factor is infective endocarditis and the management includes antimicrobial treatment with or without obliteration of the aneurysm by microsurgical or endovascular means.

Material(s) and Method(s):

We present a young patient with intracranial infectious ruptured aneurysm who was successfully treated with endovascular coil embolization.

Result(s):

A 20-year-old female with history of rheumatic heart disease presented with subarachnoid hemorrhage due to rupture of IIA associated with infective endocarditis. Cerebral angiogram revealed right distal posterior cerebral artery aneurysm. Echocardiography showed vegetation in mitral valve and blood culture was positive for Enterococcus faecalis. Antibiotic treatment was administered for 6 weeks. The follow-up angiogram showed an enlarging aneurysm. So, the patient underwent endovascular coil embolization of the aneurysm preserving the parent artery. There were no post-procedure deficits.

Conclusion(s):

Intracranial infectious aneurysm should be considered as a differential diagnosis in a patient with infective endocarditis presenting with focal neurological deficits or altered consciousness. Early diagnosis and individualized approach are the key to successful treatment and endovascular treatment is an effective modality for such lesions.

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Scepter Mini-Assisted Embolization of Anterior Cranial Fossa Dural Arteriovenous Fistula via a Transopthalmic Approach: A Technical Report and Case Series.

1Bhavya Pahwa

1UCMS and GTB Hospital

Introduction(s):

Dural arteriovenous fistulae (dAVF) account for approximately 10-15% of all intracranial arteriovenous abnormalities. DAVF’s carry a significant risk of mortality, particularly in cases of acute hemorrhage, of up to 10%. A small proportion of these dAVF’s are found in the anterior cranial fossa (ACF), of which the rate of hemorrhage can be as high as up to 91%.  The Scepter Mini (SM) is the smallest dual-lumen balloon available for neurointerventional practice. It consists of a 2.8 French outer diameter, with a 2.2 mm x 9 mm semi-compliant balloon providing a working length of 165 cm. The SM is navigated with a 0.008-inch wire making it a particularly attractive tool accessible to the pedicles normally reached with liquid embolization microcatheters.

Material(s) and Method(s):

Five consecutive patients over a one year period between 2020 and 2021 were evaluated and treated for ACF dAVF using a liquid embolization approach using the SM balloon.  All patients were treated using Ethylene-vinyl-alcohol copolymer (EVOH), of which Squid 18 and/or Squid 12 were the chosen viscosities. Control angiograms were performed for all patients post-embolization.

Result(s):

All patients demonstrated complete occlusion of the ACF dAVF on immediate post treatment angiography. No immediate complications were encountered, particularly there were no reports of visual field deficit in any of the patients.

Conclusion(s):

The SM is a valuable adjunctive tool that can enhance the safety and efficacy of trans-ophthalmic embolization of ACF dAVF’s, providing additional protection to the retinal and posterior ciliary arteries against unwanted reflux of liquid embolic agent.

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Minimally Invasive Surgical Interventions in Nonagenarians Compared to Octagenarians

1Bhavneet Singh

1Nepean Hospital

Background(s):

With the advent of endovascular interventions, previous patients that were ineligible for lower limb revascularization can now receive treatment. As a result, the acceptable surgical candidate has a much older age. We review our recent experience and compare the outcomes of nonagenarians to octogenarians in lower leg ischemia.

Material(s) and Method(s):

Between 2019 and 2021 64 patients that were over the age of 80 had inteventions. Of these, 21 were nonagenarians and 43 were. Univariate and survival analysis comparing the age groups was preformed. An exact regression model with the dependent variable defined as death within a year after angioplasty and the following covariates; age over ninety, amputation, antiplatelet use and gender, was conducted.

Result(s):

There were 18 (86%) nonagenarians and 36 (84%) octogenarians were intervened for chronic limb ischemia (p=1.000). All the patients had lower leg angiograms (p=1.000), however 5 nanogenarians had amputations (24%) and 11 octagenerians (26%) p=0.878 had amputations. The older group had a lower use of antiplatelets (76% vs. 88%, p=0.208) but a similar rate of. anticoagulation (43% vs. 40%, p=0.788). The rate of death within a year was insignificantly different between the groups (33% vs. 23%, p=0.391) for the older and younger group respectively. Kaplan Meier analysis similarly failed to show a difference (21 vs.. 28 months, p=0.324). Exact regression revealed being a nanogenarian (p=0.6842) or other covariates was not predictive of death in a year. In fact median length of stay was trending for shorter stay for the older group 23 vs. 34 days (p=0.97).

Conclusion(s):

Our study illustrate that the outcomes for nonagenarians were comparable to octogenarians. We found that the stay tended to be shorter for the older group and that maybe due a selection bias where relatively healthier patients maybe surviving to an older age.

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Radiation Dose and Fluoroscopy Time during Endovascular Aortic Repair Procedures in a Tertiary Centre; Retrospective Analysis and Quality Improvement Initiative

1Bar Velan,1Yvonne Tsitsiou, 1Yvonne Tsitsiou, 1Sophie Peregrine, 2Rishabh Gupta, 1Rishabh Gupta, 1Mohamad Hamady

1Imperial College Healthcare NHS Trust, 2Imperial College London

Objective(s):

To assess current practice in standard and complex endovascular aortic repair (EAR) and formulate local guidelines to improve radiation protection for operators and patients.

Material(s) and Method(s):

Data was collected from PACS and electronic patient records for all patients undergoing EAR over a period of 2 years. Procedure details included; complexity, theatre time, fluoroscopy time, radiation dose, machine information and operator were collected and analysed using Microsoft Excel sheets and IBM SPSS Statistics 27. Normality tests were carried out and Kruska-Wallis Tests were used to compare non-parametric data.

Result(s):

Median fluoroscopy times of EVAR, TEVAR and Complex procedures were 18:58, 11:12 and 44:23 (mm:ss) and dose of 44.75, 69.81 and 109.5mGycm2, respectively.

Based on machine types, the radiation doses were A) 91.7mGycm2, B) 63.8mGycm2 and C) portable C-arm 20.2mGycm2 (p=0.004). Complex procedure doses were A) 179mGycm2, B)103.29mGycm2 and C) portable C-arm 25.35mGycm2 (p=0.041) respectively.

There was also inter-operator differences in fluoroscopy time during EVAR procedures (p=0.008) as well as time and doses during complex procedures (p=0.013 and p=0.03 respectively).

Conclusion(s):

TEVAR and complex procedures were associated with higher radiation doses and fluoroscopy time. Significant variations were observed in relation to machine type and inter-operator parameters. Recommendations to refine performance and machine settings will be discussed.

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Treatment of Massive and Submassive Pulmonary Embolism using the Penumbra’S Indigo Aspiration System, a Single Center Experience

1Ayden Jacob,2Nadeem Muallem. 5Geoffrey Lindblad, 3,4Abass Chamsuddin

1Aidoc Medical, 2Envision Healthcare Services, Department of Radiology, 3University of Beirut, 4University of Balamand, St. George University Hospital, 5Aventura Medical Center

Introduction:

This study evaluates the technical parameters and clinical outcomes in patients with pulmonary embolism treated with mechanical thrombectomy using the Penumbra’s Indigo Aspiration CAT 12 System.

Material(s) and Method(s):

A single-center retrospective analysis of patients undergoing mechanical thrombectomy from January 2019 to December 2020 was conducted. Computed tomography angiography was utilized to delineate submassive from massive pulmonary embolism. Patient demographics, postoperative complications, comorbidities, and duration of procedure was analyzed. 30-day readmission rates, length of stay, mortality and intensive-care unit visits were assessed.

Result(s):

Between December 1, 2020 and December 1st, 2021, 26 patients underwent mechanical thrombectomy with the Penumbra Indigo CAT 12 System for the treatment of submassive (50%) and massive (50%) pulmonary embolism. Cat 12 is a large-lumen aspiration catheter that incorporates a laser-cut hypotubebased catheter. Saddle embolus was present in 42% of patients. The mean age was 66 (range 29-92). 58% of patients were male and 42% female. 70% of patients had right heart strain. 4 patients were Covid-19 positive, and 66% had a history of hypertension. Mean in-patient length of stay was 4.36 days (range 3-12). The average duration of procedure was 54 minutes, fluoroscopy time 17 minutes, and fluoroscopic dose 215 mGy. 3/26 patients required an ICU overnight stay. 1 patient experienced in-patient mortality. All-cause 30-day readmission rate was 19%.

Conclusion(s):

Our data demonstrate that extirpation of clot in the treatment of pulmonary embolism using the Penumbra’s Indigo Aspiration CAT 12 System is an attractive alternative to catheter directed thrombolytics. The short procedure time, rapid return to normal and low complication rate makes it a potential gold standard candidate for treatment of pulmonary embolism.

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Initiating an Interventional Radiology Unit: Initial Systematic Planning based on Standard Planning Models Affects the Long-Term Quality of Services

1Ashish Verma,1Pramod Kumar Singh, 1Ram Chandra Shukla, 1Mohammad Sharoon Ansari, 1Manish Indal, 1Jyoti Dangwal, 1Harsh Anand Singh

1Department of Radiodiagnosis and Imaging, Institute of Medical Sciences, Banaras Hindu University

Background:

Interventional radiology (IR) services are now quint-essential to any hospital offering even basic health-care facilities. Ranging from diagnostic to therapeutic intervention, IR procedures find application in all walks of medical and surgical practice. The speciality is however still evolving from it’s infancy in most Asian nations and a systematic initial planning seems to be the only way to build up a robust IR unit offering quality services. Further such a facility would also be an integral component of teaching and research programs in a hospital offering radiology residency and/or doctoral programs. This clinico-scientific paper is a transcript of our experience while building up a new IR unit from scratch, in our university-based tertiary care teaching hospital using the principles of planning management. We submit that a prospective understanding of these management strategies, apart from an insight into the depths of targeted procedures to be performed in future, forms the basis of a clean successful procedure by even the most expert interventional radiologist.

Material(s) and Method(s):

In our planning stage we started with an interactive and dynamic LEAN START-UP MODEL which eventually initiated our intent of creating a financially self-sustaining IR unit. Inputs from the AGILE and WATERFALL models were also surrogated at stages.

Result(s):

The proposal of making an IR suite in this department, which erstwhile offered only basic diagnostic intervention apart from imaging services was initiated in 2018 and completed in 2019. Since its inception this unit has performed more than 500 cases in a short span of 1 year. This included high-end therapeutic interventions like coil-embolization to basic diagnostic catheter angiographies. However, an interesting addition to this was an improvement in outcome of our diagnostic samplings and basic drainage procedures..

Conclusion(s):

Non-inclusion of the feedback of physicians who would actually be performing the procedures, in the planning and procurement stage may lead to missing of fine details which later act as a hinderance in daily work-flow. On the other hand, involvement of a physician who is not conversant with basic planning models and techniques can lead to creation of a smoothly functioning and successful IR unit. Notably this experience seems to be very important as unlike diagnostic radiology time of improvisation in an interventional radiology unit is very limited.

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Facial Artery High Flow Fistula Embolization from a Right Mandibular Hypervascular ABC

1Anis Nassif

1Lebanese American University

Background:

We would like to present for discussion a rare case of a 9 y old girl of a facial artery to facial vein high flow fistula secondary a hypervascular aneurysmal bone cyst ( ABC ) in the right mandible eroding into the facial artery mimicking an AVM . We embolized the fistula with Onyx 18 liquid embolic prior to surgical resection. This young child is devastated after failing 2 previous surgical resections secondary significant blood loss in the OR.

Material(s) and Method(s):

Using a tri axis approach , we advanced a Sonic microcatherter with 25 mm detachable tip over a Hybrid .08 microwire with a J curve tip into the foot of the facial vein at the level of the fistula and embolized it with 7.5 cc or 5 vials of Onyx 18 with significant decrease in vascularity.

The microcather was pulled out and the tip was detached and left in the liquid embolic.

Result(s):

The fistula was successfully embolized and devascularised in order to allow the surgeons to resect the ABC in the right mandible in this 9 y old girl . She had failed 2 prior surgical attempts secondary high loss of blood in the operating room.

Conclusion(s):

An ABC can erode into the adjacent artery and result in a high flow fistula . Pre surgical embolization is an adequate method to successfully treat and resect the ABC and reconstruct the mandible in this young child.

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Vertebroplasty Versus Kyphoplasty. Discussing Controversies

1Anis Nassar

1Lebanese Hospital Geitawi

Objective:

To determine whether Kyphoplasty is better than vertebroplasty for pain management and procedure control of  complication rates.

Material(s) and Method(s):

Review of the literature and personal experience more than 400 cases performed.

Result(s):

Both the techniques are safe with no advantage of kypphoplasty/vertebroplasty.

Conclusion(s):

There is no advantage of kyphoplasty over vertebroplasty. On the contrary, vertebroplasty takes a shorter time, is less expensive. No increase in the complication rate is noted.

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Analysis of Factors Affecting Air Kerma Area Product obtained during Uterine Artery Embolization Procedures using Logistic Regression

1Ahmed Almutairi

1Prince Sultan Military Medical City

Background:

Uterine artery embolization (UAE) is a common interventional radiology procedure used in medicine; the procedure is safe but there is always a concern regarding radiation dose received by the patient. The aim of this study was to use multivariable logistic regression analysis (MLRA) to study a certain number of independent prognostic variables believed to provide an estimate of the likelihood of obtaining a high kerma area product (PKA) at the end of the procedure.

Material(s) and Method(s):

Radiation dose indices registered by the angiographic system structured dose report, the total fluoroscopy time (FT), the patient’ body mass index (BMI), the number of images taken during the procedures (IMGS), and the performing physician experience (EXPER) were used to drive a logistic regression model (LRM).

Result(s):

The LRM found was: Logit (PKA) = −6.1525 + 0.0416 (FT) + 0.1028 (IMGS) +0.1675 (BMI) – 0.1012 (EXPER). The prediction accuracy of the LRM was assessed using receiver operating characteristic (ROC) curve; by calculating the area under the curve (AUC), we found AUC = 0.7896, with optimal ROC point of 0.3261, 0.8036.

Conclusion(s):

The suggested LRM seems to indicate that patients with higher BMI, have taken longer FT, acquired higher IMGS and the procedure done by a less experienced performing physician is more susceptible to receive a higher PKA at the end. The proposed LRM is useful in predicting the occurrence of higher radiation exposure interventions and can be used in patients’ radiation dose optimization strategies during UAE procedures.

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Indications, Technique of Percutaneous Transsplenic Portal Vein Intervention

1Sadeer Alzubaidi

1Mayo Clinic

Background:

Multiple diseases of the portal system require effective portal vein (PV) access for endovascular management. While percutaneous transhepatic or transjugular approaches remain the standard method of PV access, the transsplenic approach has gained recognition as an effective and safe technique in patients with contraindications to traditional approaches.

Material(s) and Method(s):

Described treatments amenable to percutaneous transsplenic access (PTA) include recanalization of chronic PV occlusion, stenting of PV stenosis, portal vein embolization (PVE), embolization of gastric varices, or transjugular intrahepatic portosystemic shunt (TIPS) and post-liver transplant interventions.

Result(s):

We will provide a review of PTA indications based on existing evidence within the literature, and a summary of related PV diseases. Additionally an imaging based review of technical considerations of PTA, and discussion of potential procedural complications is also presented.

Conclusion(s):

PTA is increasingly being utilized for portal venous interventions, specifically as related to recanalization in chronic PV occlusion, stenting of portal vein stenosis, pre-operative PVE, complex TIPS procedures, and variceal embolization. In clinical scenarios in which a traditional transhepatic approach is not feasible in patients requiring portal intervention, PTA has been shown to be a generally safe technique with high technical success rates. Bleeding complications remain the primary adverse event in PTA interventions; further research is needed to clarify if an ideal method of access and tract embolization exists that may minimize postprocedural hemorrhage rates.

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Radiofrequency Ablation for Treatment of Abdominal Wall Endometriosis

1 Ali Mahdavi

1Shahid Beheshti University of Medical Sciences

Background:

Abdominal wall endometriosis (AWE) is a rare condition that usually develops in a surgical scar resulting from a Caesarean section. Its treatment options consist of the excision of the lesion and/or hormonal therapies, although wide surgical excision is the treatment of choice in the literature. Here we review a case series of abdominal wall endometriosis treated with radio-frequency ablation (RFA) under ultrasound guidance.

Material(s) and Method(s):

8 patients included in this study all of them presenting with palpable mass (es) in abdominal wall close to cesarean scar. The patients underwent full diagnostic work up including ultrasound and MRI. Written informed consents were obtained. Before RFA, the patient’s pain level was assessed using a validated visual analogue scale (VAS) for pain assessment. RFA was performed under general anesthesia with Neuro N50 generator with 500KHZ up to 99c temperature for maximum 10 minutes. The patient’s pain level was assessed one week, one month and 4 months after the procedure.

Result(s):

Before the procedure mean VAS was 8.2 and one week after the procedure reduced to 2.3, one month to 1,5 and 4 months to 1.2. Four patients reported no pain after one month (VAS=0). No major complications was observed except for moderate erythema at RFA site resolving after one week.

Conclusion(s):

Medical management of AWE often results in temporary relief. Wide surgical excision may create a defect in the abdominal wall and may increase the risk of hernia formation. RFA is used in many solid and superficial organs such as thyroid however there are no studies in the literature on the role of RFA in the treatment of pain related to endometriosis. Here we suggest that RFA could be considered as an alternative treatment for AWE.

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Uterine Artery Embolization with Gelfoam for Symptomatic Uterine Fibroids: Single Center Experience

1,2 Abdulaziz AlGharras

1 Department of Radiology, King Fahad Specialist Hospital, Buraidah, 2Department of Radiology, Unaizah College of Medicine and Medical Sciences, Al Qassim University

Background:

To evaluate the technical and clinical success rates and safety of Gelfoam uterine artery embolization (UAE) for symptomatic uterine fibroids.

Material(s) and Method(s):

Retrospective cohort study done at King Fahad Hospital in Buraydah, Qassim, Saudi Arabia. Patients who underwent UAE between September 1, 2020 and December 31, 2021 for treatment of symptomatic uterine fibroids were included in this analysis. The exclusion criteria were the patients in who refuse to undergo UAE or received other embolization particles.  Patient data was collected between the time of their initial procedure and December 31, 2021. Data extraction and chart review for baseline characteristics, procedural data, complications, secondary procedures if required, post procedural follow-up in 6 months. MRI results at 0 and 6 months. Statistical analysis was performed using SPSS (IBM, New York).

Result(s):

Ten patients included in this analysis. Mean age 42 years. Median follow-up for the UAE was 6 months. UAE success rate was 100% in both sides. Patients’ symptoms markedly improved within few days after the procedure. Single non clinically significant small hematoma at the access site encountered required overnight observation prior discharge with no requirement for transfusion. No major post procedure complication seen. Post procedure MRI at 6 months, showed 90% success rate in term of ischemia toward fibroid tissue, one patient had incomplete devasculization of the multiple fibroids required repeat treatment.

Conclusion(s):

UAE with Gelfoam in the treatment of patients with symptomatic uterine fibroids is cheaper, safe and effective as compared to standard PVA or embolization particles.

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Endovascular Revascularization as a Treatment Option for Peripheral Arterial Disease due to Diabetes in Saudi Arabia: Public Awareness Survey

4Afnan Hammad Alshammari,3Noura Hamad Alshurtan, 4Noura Hamad Alshurtan, 1Amirah Fahad Alshammeri

1College of Medicine, Hail University, Saudi Arabia, 2College of Medicine, Hail University, Saudi Arabia, 3Medical Imaging Department, Division of Vascular Interventional, 4College of Medicine, Hail University, Saudi Arabia

Objective(s):

Objectives Diabetic foot disease is a common and serious complication of diabetes that represents a major global health concern with high mortality and morbidity rates. Successful revascularization and improved perfusion have had fundamental roles in reducing the rate of amputation in diabetic foot patients over the last decade. Creating public awareness plays a key role in early treatment and prevention of amputation. The aim of this study was to determine if people are aware of endovascular revascularization as a therapeutic option for diabetes-related peripheral artery disease.

Material(s) and Method(s):

The study is a community-based observational descriptive cross-sectional study that was conducted to assess Saudi population knowledge and awareness about endovascular revascularization as a treatment option of diabetic foot disease through interventional radiology. The self-administered online survey was randomly distributed with a maximum of 20 multiple choice questions through social media channels.

Result(s):

Endovascular revascularization as a treatment of diabetes-related peripheral artery disease through interventional radiology was unknown to 90.2% of the participants. Awareness has been influenced by many factors including age, occupa- tion, and family history.

Conclusion(s):

This study highlights the importance of raising public awareness about endovascular revascularization as a treatment option for diabetes-related peripheral arterial disease in suitable patients.

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How Far is to Far in Stroke Thrombectomy? From Xl to Xs Vessel Occlusions with Radially Adjustable Stent-Retrievers – Tigertriever Xl and Tigertriever 13

1Adrien Guenego,1Boris Lubicz

1Erasme Hospital

Background:

A New class of Radially adjustable Stent-retrievers, Tigertriever XL and Tigertriever 131, 2 (Rapid Medical, Yoqneam, Israel) are respectively CE-Marked for large, and distal, medium vessel occlusions (DMVO). Despite no randomized data support distal vessels recanalization yet, we report our initial experience with the Tigertriever 13 in DMVO3 and illustrate it with a case where Tigertriever XL and 13 were needed to obtain a complete recanalization.

Material(s) and Method(s):

We performed a retrospective analysis of all consecutive acute ischemic stroke (AIS) patients with primary or secondary DMVO who underwent mechanical thrombectomy with the Tigertriever 13. Patients’ clinical, procedural and angiographic characteristics were reviewed.

Result(s): Discussion

Between November 2019 and November 2021, 24 DMVO were included (46% female, median age 63 [51-65] years). The overall successful reperfusion rate (mTICI 2b-3) was 88% (21/24) for the dedicated vessel. Follow-up imaging showed a subarachnoid-hemorrhage in 29% of the cases and a parenchymal hematoma in 8% while symptomatic Intracranial hemorrhages did not occurred. At 3 months, 62% of the patients (15/24) had a favorable outcome (mRS 0-2).

Conclusion(s):

Mechanical thrombectomy for both primary or secondary DMVO seems feasible and as safe as for LVO. Our initial experience using the Tigertriever13 is of special interest as it shows we can potentially significantly expand AIS population that can benefit from mechanical thrombectomy treatment.

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Long-Term Follow-Up of The pCONus Device for the Treatment of Wide-Neck Bifurcation Aneurysms

1Adrien Guenego

1Erasme Hospital

Background:

Wide-neck bifurcation aneurysms (WNBA) remain challenging for the neurointerventionist and/or neurosurgeon despite many recent advances. The pCONus (Phenox, Bochum, Germany) is an emerging device for endovascular neck protection, we report the first long-term results of this device.

Material(s) and Method(s):

We performed a retrospective analysis of all consecutive intracranial WNBA treated with the pCONus. Patients’ characteristics were reviewed, procedural complications, angiographic (Roy-Raymond scale) and clinical outcomes were documented.

Result(s): Discussion

Between January 2016 and September 2019, 43 patients (74% female, median age 56 [49-66] years) with 43 WNBA (mean width of 6.8+/-2.1mm, dome/neck ratio of 1.3+/-0.2 and neck of 5.2+/-1.3mm) were included. A procedural angiographic complication was reported in 5 patients (12%), no patient presented a post-operative neurological deficit or long-term complication, mortality rate was 0%. At last follow-up (median of 46.5 months [38.3-51.7]), an adequate occlusion (complete and neck remnant) was observed in 37/43 patients (86%) and an aneurysm remnant in 6/43 (14%). Four patients (9%) needed retreatment. No in-stent stenosis or branch occlusion were depicted.

Conclusion(s):

pCONus device provides a safe and efficient alternative for endovascular wide-neck bifurcation aneurysms management, with long-term stability.

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Early Neurological Improvement Predicts Clinical Outcome After Thrombectomy for Distal Medium Vessel Occlusions

1Adrien Guenego, ,1Boris Lubicz

1Erasme Hospital

Background:

Good clinical outcome predictors have been established in mechanical thrombectomy (MT) for acute ischemic stroke (AIS) caused by large vessel occlusion (LVO). An early neurological improvement (ENI), defined as a reduction of ≥8 on the National-Institutes of Health Stroke-Scale (NIHSS) compared with the baseline score, or an NIHSS of 0 or 1 at 24 hours after MT, is a strong predictor of favorable outcome. We aimed to study the impact of ENI after MT for distal, medium vessel occlusions (DMVO).

Material(s) and Method(s):

We retrospectively analyzed the data of consecutive patients who underwent MT for a primary DMVO in one large academic center. We compared clinical outcomes between DMVO patients stratified by ENI. Multivariate analyses were performed to determine the impact of ENI on good 90-day outcome (modified Rankin scale of 0-2) and identify factors contributing to ENI.

Result(s): Discussion

Between January 2018 and January 2021, 61 patients underwent a MT for an AIS with a primary DMVO.

An ENI was seen in 24 (39%) patients (ENI+). Outcomes were significantly better in ENI+ patients, with 83% achieving a good outcome at 3 months versus 43% for ENI- patients (p=0.019). ENI was an independent predictive factor of good clinical outcome even after adjusting for potential confounding factors (Odds-ratio 12.49 [1.49-105.01], p=0.020). Use of IVtPA (Odds-ratio 6.59 [1.82-23.89], p=0.004) was a positive predictor of ENI.

Conclusion(s):

ENI at day 1 following MT for DMVO stroke is a strong independent predictor of good to excellent 3-months clinical outcome.

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Optimal Parameter for Predicting Final Infarct Volume and Outcome after Complete Recanalization of Medium Vessel Stroke

1Adrien Guenego

1Erasme Hospital

Background:

We sought to assess the optimal parameter and best threshold on baseline computed-tomography-perfusion (CTP) to predict final-infarct-volume, infarct progression and clinical outcome after successful endovascular recanalization of acute ischemic stroke (AIS) with primary distal, medium vessel occlusions (DMVO).

Material(s) and Method(s):

We performed a retrospective analysis of consecutive AIS patients who underwent an initial CTP, were successfully recanalized by thrombectomy for DMVO and underwent a follow-up MRI. We evaluated the correlation of baseline infarct and TMax volumes with final-infarct-volume and infarct progression between CTP and follow-up MRI, as-well-as 3 months good clinical outcome (modified Rankin Scale score of 0 to 2).

Result(s): Discussion

Between January 2018 and January 2021, 38 patients met inclusion criteria (76% [29/38] female, median age 75 [66-86] years). Median final-infarct-volume and infarct progression were respectively, 8.4 mL [IQR: 5.2-44.4] and 7.2 mL [IQR: 4.3-29.1].

TMax>10sec volume had the strongest correlation with final-infarct-volume and infarct progression (respectively, r=0.831 and r=0.771, p<0.0001) as-well-as good clinical outcome (-0.5, p=0.001).

 Higher baseline TMax>10sec volumes increased the probability of higher final-infarct-volume and infarct progression (respectively, r²=0.690, coefficient=0.83 [0.64-1.00], p<0.0001 and r²=0.595, coefficient=0.77 [0.56-0.98], p<0.0001), whereas it decreased the probability of 3 months good clinical outcome (ODDs ratio = -0.67 [-1.17 to -0.18], p=0.008).

ROC curves identified a TMax>10sec volume <33mL as the optimal threshold to predict a low final-infarct-volume (AUC=0.802), low infarct progression (AUC=0.735) and good clinical outcome (AUC=0.786).

Conclusion(s):

TMax>10sec volume on baseline CTP predicts final-infarct-volume and progression as-well-as clinical outcome after MT recanalization for AIS with DMVO.

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Direct-Puncture Duct Embolization of Lymphatic Malformation of the Thigh: Technique and Early Experience

1Sultan Alamri,1Mohammed Badran

1King Faisal Specialist Hospital and Research Center

Introduction:

Cystic lymphatic malformations (LMs) are benign abnormal embryologic development of slow-flow vascular lesions composed of dilated lymphatic channels or cysts lined by endothelial cells, occurring anywhere in the fetal body. (1) The overall incidence of LMs range from 1 out of 2000 to 20,000 live births. (2) They occur most commonly in the nuchal region (75%) and least common in the limbs and bones (2%) and lastly mediastinum (1%). They could be microcystic (diameter of <1 cm), macocystic (diameter of >1 cm)  or mixed. (1) Presenting symptoms primarily depends on the location and severity of the lesion with LMs being more prone to infections, as compared with other vascular malformations.  Doppler ultrasonography (US) is traditionally used as the primary screening method, especially prenatally, which classically demonstartes absence of blood flow, in contrast to hemangioma. Magnetic resonance imaging (MRI) is essential in evaluating anatomy and the extent of the vascular malformation. (2) Conventionally, most lymphatic anomalies were observed, and if clinically indicative, treated with either aspiration or complete or partial surgical resection. Given the difficulty of treating LMs and in cases where surgery is not feasible, conservative standard treatments have been used, such as percutaneous sclerotherapy (i.e., doxycycline, bleomycin, ethanol, and others) or ablation and laser therapy. (3,4) Evolving treatments have also been experimented, including medications. Owing to the rarity of case reports demonstrating such endovascular management, the authors herein describe this novel treatment technique via direct-puncture lymphangiogram followed by duct glue embolisation of a thigh congenital lymphatic malformation in an adult patient showing promising results.

Material(s) and Method(s):

Case Report:
A 25-year-old male patient who was referred to our hospital in 2011 as a case of congenital microcystic LM of the right lower thigh (Elephantiasis nostra verrucosa). The patient also had a history of road traffic accident (RTA), for which he was surgically treated with intramedullary nails of the femur and tibia at the age of 12 years old, where the presence of malformation complicated his management further. A plethora of diagnostic modalities were used to reach the diagnosis. Doppler US was initially done, which was inconclusive. Subsequently, femur MRI was done but aborted midway, for the patient could not tolerate the exam; however, conclusion was consistent with lymphatic malformation. Additionally, multiple nuclear medicine lymphangiograms to rule out lymphatic obstruction took place, all of which showed no overt obstruction. On follow-ups, the patient’s known LM showed gradual increase in size until it affected his quality of life, preventing him from easily moving due to its heavy weight. Therefore in 2016, the decision was made by his orthopedic surgeon to go on with surgical excision and primary closure. The patient was then followed up by dermatology. Upon follow-up after excision, there was recurrence of the known LM with history of recurrent infections. Hence, another excision with primary closure took place in 2017. Consequently, gradual regrowing of the lesion was noticed in his subsequent follow-ups; therefore, it was decided that conservative management was favorable. Then, interventional radiology (IR) was consulted. The patient had a long course of sclerotherapy sessions starting from 2018 until 2021. Sclerotherapy agents including bleomycin and doxycycline were used with persistent recurrence. Additionally, the patient has been on oral Sirolimus since 2017, with dose modifications. In one of the patient’s IR follow-ups and under general anesthesia, the patient was in supine position and under US and fluoroscopic guidance, it was decided to proceed with intranodal lymphangiogram; the right groin lymph node was accessed under US guidance using 25G needle. Lipidol was injected, which showed a large lymphatic duct parallel to the superficial femoral vein refluxing inferiorly toward the known LM. Then, the posterior tibial vein was accessed using a micropuncture set and sheath, afterwards, venogram was done showing a patent femoral vein running parallel to the femoral lymphatic duct with no clear communication. Consequently, under fluoroscopic guidance and in multiple projections, the femoral lymphatic duct was accessed directly at the mid-thigh using 22G spinal needle, lymphangiogram was done to confirm the needle’s location within the duct, followed by duct embolization using 0.5 ml glue (25%). The medial aspect of the lower thigh, popliteal fossa and upper medial calf were targeted. A total of 1000mg doxycycline was injected through multiple punctures distributed along the malformation using gravity technique. The patient was then discharged home in good health without immediate complications. On short-term follow-up, the patient continued on oral Sirolimus and was satisfied with the result. MRI follow-up was recommended.

Result(s): Discussion

This report describes a case of right thigh congenital LM in an adult patient who received combined sclerotherapy and surgical treatment to no avail. Eventually, the decision was made to do a direct-puncture lymphangiogram with evidence of refluxing lymphatic duct, which embolised utilizing glue, showing significant regression in size. The management of LMs have recently been dealt with in a conservative approach which includes observation, sclerotherapy, and surgery. Additionally, new medications such as Sirolimus, an mTOR inhibitor, which our patient has been on, have been reported recent literature as efficacious, though prospective randomized trials are still lacking. (5) In regard to interventional radiology-related treatments, a study done by Gilony et al. which included 45 patients showed that 95% of patients had excellent to fair response to conventional sclerotherapy (i.e., Picibanil (OK-432)) alone. (6) It is essential to note that despite the plethora of sclerosing agents, there is no consensus on which one is optimal as of yet. (5) On the other hand, the efficacy of sclerotherapy in treating microcytic LMs has been established in an array of published reports. (7)  Our novel technique which targeted the patient’s lymphatic duct using direct-puncture lymphangiogram and then embolisation with 0.5 ml glue has only been described in the literature by Dionisio et al. A case of leaking central conducting lymphatic malformation in a neonate, in which the author attempted, twice, percutaneous n-Butyl cyanoacrylate (n-BCA) glue for embolisation of the disrupted lymphatic channels. The patient, however, experienced a protracted course, unlike our case, complicated by pleural effusion, adrenal hemorrhage, acute kidney injury, and multimicrobial infections, that warranted multiple subsequent surgeries. (2) Other reports described using a similar treatment technique in a case of orbital lymphatic-venous malformation with concomitant fistula, in which glue embolization was utilized. (8)  In terms of complications, our patient had no immediate complications, though long-term follow-up is needed in order to establish a strong evidence. In terms of complications, glue embolization could generally lead to glue migration leading to pulmonary embolism, lower extremity swelling or diarrhea. (2) Here is a single case of cystic LM of the thigh, with a history of numerous failed attempts of surgical and sclerotherapy treatments.

Conclusion(s):

To the authors’ knowledge, this progressive approach of managing thigh intractable LM demonstrated by direct-puncture lymphangiogram and duct glue embolisation is effective and considered a potential treatment of choice for extremity LM.

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The Role of Interventional Radiology in the Management of Urologic Complications Post Renal Transplant: A Single Center Experience

1Hassan Alqarni,2Abdullah Linjawi, 1Abdullah Linjawi, 1Dalia Alshear, 1Almamoon I Justaniah, 1Almamoon I Justaniah, 1Majed Ashour

1KFSH&RC, Jeddah, 2East Jeddah Hospital

Objective:

The prevalence of urologic complications after renal transplant ranges from 2.6 – 13%, which can result in graft loss. The aim of this study is to assess the safety and efficacy of interventional radiology procedures for urologic complications post renal transplant.

Material(s) and Method(s):

1000 consecutive renal transplant patients were retrospectively reviewed at our institution from January 2016 till October 2021. Patients with no urologic complications were excluded. Clinical and procedural records were reviewed for patients with nonvascular urologic complications whom required procedures by Interventional Radiology. Technical and clinical success rates, as well as complications, were recorded.

Result(s):

35/1000 (3.5%) patients had non vascular urologic complications (ureteric obstruction 31/35 (88%), urinary leak 4/35 (11%). Mean time for manifestation of leak and obstruction was 7 days and 3.3 years, respectively. Mean follow up was 43.3 months ( (Range from 4-102 months). All patients underwent nephrostomy placement (100%),while ureteric stents were placed in 34/35 (97%) patients, ureteroplasty was performed in 13/35 (37%) patients. Technical success was 100% for nephrostomy and 97% for ureteric stent placement. 94% of patients demonstrated clinical success by eGFR improvement in 5-7 days. 2/35 (5%) patients had renal pelvis perforation which was managed conservatively. 4/35 (11%) patients lost their grafts due to prolonged obstruction 2/35 (5%), and rejection 2/35 (5%).

Conclusion(s):

Interventional radiology procedures are safe and effective in managing non-vascular urologic complications in renal transplant patients.

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Utilization of Cone Beam Ct and Embolization Guidance Technique During Chemoembolization of HCC

1Muath A. Alobaid,1Sultan R. Alharbi,

1King Saud University

Objective:

To illustrate the cone-beam CT and embolization guidance techniques during chemoembolization of HCC.

Material(s) and Method(s):

Hepatocellular carcinoma (HCC) is the most common primary cancer of the liver and the third most common cause of cancer death worldwide. Transarterial chemoembolization (TACE) is the first-line treatment option for intermediate unresectable HCC without vascular invasion or extrahepatic metastasis according to the Barcelona clinic liver cancer (BCLC) staging system. There is huge variation of TACE outcome with median survival range 13-43 months. This variation is partially due to technical variation of TACE therapy. Standardization of TACE technique and vascular mapping of arterial feeding arteries of HCC lead to better response and patient survival. Multiple angiographic runs of hepatic arteries are usually required to identify the arterial feeder of HCC. Cone beam CT is a technique used during TACE to obtain cross-sectional three-dimensional images of the hepatic arteries and delineate the HCC arterial feeder. Volume rendering images of the cone-beam CT are used as embolization guidance of the HCC feeder arteries.

Result(s):

Procedure details: In this educational exhibit, we will present cone beam CT technique in different HCC patients during TACE as well as different embolization guidance technique with different catheter location.

Conclusion(s):

Cone beam CT and embolization guidance techniques are useful during TACE with a tendency to decrease procedure time and contrast.

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Percutaneous Port a Catheter Insertion in Pediatric Patients by Interventional Radiology: A Single-Centre Experience

1Abeer Faisal Aldhawi,2Mohammed Altolub, 3Mohammed Altolub, 3Weal H. Almaghthawi, 3Mohammed Alshlyyel

1King Fahd Medical City, 2king Khalid Hospital, 3Prince Sultan Military Medical City

Background:

Summery: Implantable central venous access ports (ICVAPs) are used commonly in current medical practice for long-term central venous access for a variety of reasons. Several studies are evaluating the safety and the complication rate after inserting the device. Our study was done in a single centre focusing on evaluating the outcome after inserting the port Cath by an interventional radiologist in a pediatric population.

Objective: The current study aims to report our early experience in image-guided percutaneous implanted central venous port systems insertions by interventional radiologists regarding the safety, applicability, and complication rate.

Material(s) and Method(s):

Records based retrospective chart reviewing study will be conducted in Prince Sultan Military Medical City in Riyadh, Saudi Arabia, from the period of July 2014 to December 2020 conducted at the interventional Radiology department of prince sultan military medical city in Riyadh city utilizing hospital electronic medical record system and PACS for all pediatric patients (0 – 14 years) underwent chest porta catheter. A total of 35 pediatric patients met inclusion and exclusion criteria’s.

Data analysis: After data were extracted, it was revised, coded, and fed to statistical software IBM SPSS version 22(SPSS, Inc. Chicago, IL).  All statistical analysis was done using two-tailed tests. P-value less than 0.05 was statistically significant. Descriptive analysis based on the frequency and per cent distribution was done for all variables including children’s data, clinical diagnosis, indications for ICVAPs, site of the catheter, size of caterer and associated complications. Crosstabulation was used to assess the distribution of children who experienced catheter-related complications by their bio-demographic data. Relations were tested using the Pearson chi-square test and exact probability test for small frequency distributions.

Result(s):

A total of 35 children fulfilling the inclusion criteria were included. Children ages ranged from 4 months to 14 years with a mean age of 6.3 ± 4.0 years old.  Exact of 21 (60%) children were males

As for diagnosis, 6 children (17.1%) had ALL followed by 5 (14.3%) had Neuroblastoma.

Regarding indications of ICVAPs, it was inserted for chemotherapy among 28 (80%) children and Regular exchange transfusion among 7 (20%) children, most lines were inserted in the Internal jugular vein among 33 (94.3%), most of them was the size of 6.6 F among 18 (51.4%) children.

Only 3 (8.6%) children experienced redness and swelling at the catheter site, the three children had minor complications where the line was removed with antibiotics were given for all.

Conclusion(s):

PACs can be safely and accurately placed under imaging guidance using  percutaneous puncture of  vein without major complication.

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Percutaneous Management of Pyometra Utilizing Minimally Invasive Technique: A Case Report

1Abdulaziz Al Mulhim,1Salman Refat, 1Salman Refat

1Ministry of Health (KSA)

Introduction:

Percutaneous balloon dilatation of the cervix in cases of stenosis or occlusion and percutaneous drainage of endometrial collection is a minimally invasive, safe procedure that can be offered as an alternate option and can open the door for further interventions.

Material(s) and Method(s):

While percutaneous drainage has mostly replaced surgical and medical interventions, in this case it was paired with a percutaneous  cervical balloon dilation to remove the fluid buildup through a natural route outside the body and flipping the drainage access to a trans-vaginal one after cervix dilatation and removal of the percutaneous access.

Result(s):

Patients’ clinical complaints, such as dysuria and abdominal pain, as well as radiological imaging, have improved significantly after pairing balloon dilatation with percutaneous drainage.

Conclusion(s):

Percuatenous endometrial collection drainage and balloon dilatation of cevix stenosis is a safe and effective method in treating pyometra.

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Abernethy Malformation Masquerading as Congenital Heart Disease: A Boy with Cyanosis, Clubbing and Hypoxia.

1Rohit Agarwal,1Abhai Verma, 1Abhai Verma, 1Gaurav Chauhan

1Medanta the Medicity

Background:

Abernethy malformation is an extrahepatic congenital portosystemic shunt (CPSS), an extremely rare condition characterized by the diversion of portal blood away from the liver. In this anomaly blood from splanchnic circulation drains into the inferior vena cava (IVC) through a shunt bypassing the liver, thereby causing an alteration in the metabolism of pulmonary vasoactive substances resulting in pulmonary vasodilatation, diffusion-perfusion mismatch, and eventually hypoxemia. The clinical manifestations of Abernethy malformation are highly variable and can be asymptomatic or symptomatic due to the shunting of blood such as hepatic encephalopathy or hepatopulmonary syndrome (HPS). Abernethy malformation can be classified into two types. Type I is defined by an absence of intrahepatic portal veins, and a lack of liver perfusion with portal blood. In type Ia, superior mesenteric and splenic veins drain separately into the IVC and in type Ib splanchnic blood drain via the common trunk into IVC [4]. Type II is defined by side to side anastomosis of the portal vein (PV) with IVC in which hypoplastic intrahepatic portal vein supplies some degree of portal flow to liver parenchyma. Prolonged untreated severe hypoxemia can result in irreversible changes in the pulmonary vasculature and its consequences become incapacitating for the patient. Early shunt closure resolves hypoxemia and clinical symptomatology.

Material(s) and Method(s):

Endovascular plug embolization of the porto systemic shunt.

Result(s):

Complete blockage of congenital porto systemic shunt leading to improvement in symptoms of hypoxia and exercise tolerance.

Conclusion(s):

Abernathy malformation is masquerader and most of the times early diagnosis is missed and patient keep visting cardiothoracic department for suspected treatment of cyanotic heart disease. However, with good clinical vigil and suspicion these patients can be easily diagnosed and most of the times can be treated with pin hole surgery with simple embolization technique.

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Endovascular Embolization of a Complex Mandibular AVM: Transarterial and Transvenous Approach, how do we Choose?

1Amrin Israrahmed,1Gaurav Chauhan

1Nedanta Medcity

Background:

To discuss the pre-procedure imaging, different modified techniques and approaches involved in the planning endovascular treatment of complex mandibular AVM lesions.

A 21 year old lady presented to the hospital with complains of severe tooth pain since 1 month. She was planned for root canal treatment. However, on the day of the procedure the dental surgeon observed areas of disproportionate bleeding from the root of left molar region. She was referred to the interventional radiology department for further management. She underwent CT angiogram of the face, which showed a left sided mandibular AVM with large ectatic dilated venous pouches. MRI angiogram was done to look for the soft tissue involvement of the lesion. Digital subtraction angiogram showed multiple feeders to the AVM from bilateral facial, internal maxillary, lingual arteries followed by a nidus and large ectatic draining veins with dominant drainage via left internal jugular vein.

Material(s) and Method(s):

To discuss pre procedure planning, various endovascular approaches, embolic agents to treat complex mandibular AVMs.

She was planned for Transarterial embolization with onyx (Ethyl vinyl alcohol copolymer). However, in the first embolization setting significant reflux of embolic material could not be achieved in the venous pouches. A second setting was planned wherein, both transarterial as well as transvenous approaches were taken

With help of micro-catheter transarterial embolization was done for all the major feeders with PVA particles and N-butyl cyanoacrylate to reduced flow into the AVM. Following this two micro catheters were placed via transvenous approach. The proximal microcathter was used for deployment of large detachable microcoils and the distal micro catheter (catheter closer to the AVM) was used to inject onyx into the large ectatic venous pouches. Thus, by a combined hybrid transarterial and transvenous approach near total embolization of the lesion was possible.

Result(s):

The patient has completed 11 months of follow up and is doing well with no evidence of any recurrence or residual lesion.

Conclusion(s):

Conservative pharmacologic treatment is not possible for mandibular AVM and surgical treatment is associated with significant functional and aesthetic deficit. Endovascular management of these mandibular AVMs is a safe and minimally invasive approach. We would like to discuss the pre-procedure imaging, different modified techniques and approaches involved in the planning endovascular treatment of these complex lesions.

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Outcome of Trans-Arterial Embolization in HCC Patients at Rehman Medical Institute Peshawar

1Aman Nawaz Khan,1Ayesha Hamid, 1Ayesha Hamid, 1Ummara Siddique Umer

1Rehman Medical Institute

Objective(s):

To determine outcomes of Transarterial embolization (TAE) in HCC patients at Rehman Medical Institute.

Material(s) and Method(s):

A retrospective analysis of patients undergoing TAE in Rehman Medical Institute, Interventional radiology department from April, 2016 till October 2021 done. Total 152 TAE performed in patients with HCC as palliative and bridging technique to liver transplant. Through a common femoral artery, selective catheterization and arteriogram of the celiac trunk and of the superior mesenteric artery performed with a 5 F catheter. The hepatic artery was selectively catheterized, followed by a super selective feeding branch tumor catheterization with a 2.8 F microcatheter. PVA was selectively injected into the feeding artery at the most distal location possible. The data was retrieved from electronic database system for all HCC patients and then analyzed

Result(s):

The data collected showed that out of 152 patients who had undergone TAE, 67% were male and 33% were females. 35 patients (23%) showed complete radiological response, 46 patients (30%) showed partial radiological response, 49 patients (32%) showed no response / disease progression and 22 patients (14%) did not have follow up.

Conclusion(s):

Our result showed that by proper selection of patients and proper follow up, TAE has proved to be promising palliative and bridging technique to liver transplant and is better treatment option in patient with HCC.

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Pain Management in Uterine Fibroid Embolisation: Pharmacological and Interventional Approaches

1Dr Bhavna Pitrola

1Imperial college Healthcare NHS Trust

Introduction:

Uterine artery embolization for the treatment of symptomatic fibroids has become a key option for female patients and also adenomyosis. This minimally invasive procedure has a short recovery period with a high success rate for symptom relief, namely heavy menstrual blood loss, passage of large clots and pressure effects exerted on the urinary bladder. Patient can experience significant pain and management protocols with respect to analgesia are highly variable and centre-dependent.

Material(s) and Method(s):

The aim of the educational poster is to demonstrate spectrum of options for pain management in uterine artery embolisation for symptomatic fibroids.

Conclusion(s):

Invasive pain management include hypogastric nerve block. In this educational review we will describe the technique for hypogastric nerve block as well as potential pitfalls.  Pharmacological include pre, peri and post procedural medications. Paracetamol, NSIAD and an opioids are used most frequently and can be commenced pre, peri and post procedure. We will also discuss the appropriate personalised pathways dependant on type, size and burden of fibroid.

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A Three-year Comprehensive Stroke Centre Development Journey: Improving Door-to-Groin Puncture Time and Patient Outcomes for Mechanical Thrombectomy in Nottingham University Hospitals in the United Kingdom

1Joshua Wong,1Ashit Kumar Shetty, 1Ashit Kumar Shetty

1Nottingham University Hospitals NHS Trust

Introduction:

In patients with strokes caused by large vessel occlusions (LVO), delays in door-to-groin puncture time (DGPT) are associated with worse clinical outcomes. Nottingham University Hospitals (NUH) provides the East Midlands’ Mechanical Thrombectomy (MT) service in the United Kingdom. We present results from a series of changes leading to the development of the NUH Comprehensive Stroke Centre with a view to show improvement in DGPT and patient outcomes.

Material(s) and Method(s):

242 patients admitted from eight hospitals across the Trust’s referral network underwent Mechanical Thrombectomy (MT) between January 2019 and January 2022. The development of the NUH Comprehensive Stroke Centre included a relocation of the stroke services from Nottingham City Hospital to Queens’ Medical Centre (QMC), a major trauma centre where interventional services including MT and neurosurgery are based, as well as the integration of stroke assessment within the QMC Emergency Department pathways.

Result(s):

Comparing the outcomes before (n=131) and after (n=111) our interventions in patients with a mean age of 69.9 and 70.2 years respectively demonstrated a reduction in DGPT time from 5.6 to 3.4 hours, improvement in the average modified Rankin Score on discharge from 3.71 to 3.67 and NIHSS improvement at 24 hours post-MT from 8.43 to 8.46.

Conclusion(s):

Our interventions led to a reduction in DGPT time and better functional outcomes. A comparable NIHSS improvement may be due to an increase in the proportion of patients eligible for MT (e.g. change in the selection criteria to beyond 6 hours after symptom onset). Further studies are required to establish the effects of our interventions in the long term.

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Role of a Radiologist in Uterine Vascular Malformation: Imaging Workup And Endovascular Management, Our Experience

1Dr. Kulsoom Fatima,1Shahmeer Khan, 1Shahmeer Khan, 1Dr. Raza Sayani, 1Dr. Tanveer Ul Haq, 1Dr. Tanveer Ul Haq, 2Dr. Ayesha Shoukat, 1Dr. Muhammad Sami Alam

1The Aga Khan University, 2Ziauddin University

Objective(s):

To review various types of uterine vascular malformations.

Overview of role of various imaging modalities including U/S, CT and MRI in workup of uterine vascular malformations.

To describe the role of digital subtraction angiography in differentiating true uterine arteriovenous malformations from other types of uterine vascular malformations.

To discuss Endovascular management of uterine vascular malformations.

Material(s) and Method(s):

Retrospective study conducted at department of radiology, Aga Khan university, which include 15 patients who presented for endovascular management of uterine vascular malformation identified on ultrasound, CT scan and MRI examination.

Result(s):

15 female patients mean age 28, 8 patients had isolated uterine hyperemia, hyperemia with tiny aneurysm n = 1, pseudoaneurysm n – 2, true AVM n = 3 and hypervascular fibroid = 1.Minor complications post intervention = 5, Major complication = 0
Parity Achieved in 8/15 with normal term delivery

Outcome of the malformation = Post procedure ultrasound showed resolution of the malformation on in 12 patients who underwent post procedure imaging, other 3 patient were doing clinically well with resolution of symptoms

Conclusion(s):

Acquired vascular malformation is a potentional cause of per vaginal bleeding with history of prior surgical intervention. Endovascular management is a superior option compared to hysterectomy with major advantage of preservation of chances of conception. Ultrasound is the first line screening imaging tool, with efficacy at detection of vascular malformation, however may not always be characterize the type of vascular malformation. CT and MRI can help in further evaluation. Digital subtraction angiography should be performed with intent is therapeutic. In our experience the expected success rate of trans arterial embolization is excellent with minimal chance of minor complications.

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Determining the Suitability Of Endovascular Repair in Trauma Patients Based on Pre-Intervention Characteristics: A Cross-Sectional Study Based on a Proposed Algorithm in Saudi Arabia

Abdulaziz AlSharydah

Introduction:

Trauma and motor vehicle collisions (MVCs) are the two most significant causes of mortality and morbidity worldwide.1 In 2004, deaths from MVCs were globally ranked second after deaths from ischemic heart diseases. According to World Health Organization (WHO), in 2018, there were 28.8 fatalities from MVCs per 100,000 population in Saudi Arabia, which exceeded the fatality rates in the USA, UK, and Australia. The continuous assessment and triaging of the various injuries according to the severity of the damage and based on the extent of vital organ involvement enables proper medical care, and efficient management of trauma patients can be achieved by the implementation of a standardized workflow algorithm by the multidisciplinary trauma team.

Diagnostic radiology (DR) and interventional radiology (IR) play a major role in the diagnosis and management of patients injured in MVCs. Since their revolutionary introduction in the 1970s, endovascular techniques have contributed to important developments in medical equipment, damage-control strategies, and procedures, and IR has become an integral part of the medical care provided by the trauma team. The Society of Interventional Radiology recommended that endovascular interventions (EI) in trauma require the availability of an IR-ready team within 60 minutes of the decision to proceed with angiography.

The American Association for the Surgery of Trauma–World Society of Emergency Surgery (AAST-WSES) guideline preferentially recommends non-operative management (NOM) for hemodynamically stable patients without lesions that require surgical interventions, such as hollow viscus injuries or isolated grades 1 to 3 AAST vascular or viscus injuries without active extravasations detectable on imaging. Diagnostic and IR teams should recognize the spectrum of traumatic injuries and learn to manage mass casualty incidents using radiological equipment. Imaging examinations, including ultrasound (US), radiography (XR), Technetium-labeled RBC scintigraphy (Tc-99m RBC scan), and computed tomography (CT), are prioritized modalities for improving triaging accuracy.

Alternatively, conventional catheter angiography can be used for defining vascular injuries and problem-solving in therapeutic scenarios.

This study was conducted with a primary aim to bridge a gap in the literature with regard to the determination of patient characteristics of victims of trauma in whom IR was used, and secondary objective to identify demographic and clinical factors, including acuity levels, coagulopathies, blood transfusions, and length of hospital stays, that may be of interest in endovascular therapies.

Material(s) and Method(s): Data collection

Data were retrospectively obtained through multistage collection using the keyword “trauma” in the International Classification of Diseases 10th Edition (ICD-10) coding system, as well as the codes S20–S39, related to injuries to the thorax, abdomen, lower back, lumbar spine, and pelvis, to identify the relevant patient charts from the electronic medical record archival system at King Fahad Hospital of the University (KFHU). Next, the hospital’s radiology department’s database was reviewed using the PACS system to screen the data collected over the past 10 years (from December 2010 to December 2020), including pertinent radiography, sonography, digital subtracted angiography, and computed tomography imaging studies. The list thus obtained was perused to identify cases that met the inclusion criteria of this study, and1000 adult and pediatric trauma, from both sexes, were confirmed and retrospectively enrolled. An extensive chart review of each case was performed using both digital and paper-based data to collect the study-related variables over an 8-month period.

Setting

The study was conducted at KFHU, a tertiary-care, 650-bed, university teaching hospital located in the Eastern Province of Saudi Arabia. The academic hospital in the Eastern Province of Saudi Arabia is accredited by the Joint Commission International (JCI) and The Saudi Central Board for Accreditation of Healthcare Institutions (CBAHI). According to the 2018 annual report, the hospital received approximately 270,000 annual outpatient (OPD 21,767 and emergency room [ER] 247,331) visits. The radiology department was operational since 1981, and the IR division, comprising four modern angiography suites operated by seven trained interventional radiologists, was established in 2010. In 2017, approximately 800 patients benefited from the IR unit, compared to 700 patients in 2016.

Result(s):

Assessment of demographics

Among 790 participants, the majority were adolescents (age, mean±SD [range] 20±13 [11–21] years), and Saudi Arabians (n=693 [81%]; Table 1) including 501 (63.42%) males and 289 (36.58%) females.

Assessment of injury type

Based on their injures, participants were categorized as motor vehicle collision (MVC) victims (n=630 [79,75%]) or non-MVC victims (n=160 [20,25%]). Iatrogenic injuries (97/160 [60,62%]) represented the majority of non-MVC patients, followed by patients with stab wounds (63/160, [39,37%]). In the diagnostic modalities, liver injuries were the most frequent acute solid-organ injuries (n=158 [20%]), with hemoperitoneum (n=317 [40.8%]) representing the most commonly associated finding

Assessment of circulation stability

In the study cohort, 242 (30.63%) participants were “hemodynamically unstable”15 on ER arrival. Hypotension (n=550 [69.62%]) was the most contributory vital sign in patients with altered stability. (“(un)stability” was defined based on available objective criteria (blood pressure, cardiac output, rate of vasopressor, or inotrope)).

Assessment of laboratory results

No significant age-related differences in the laboratory test results of the trauma victims were observed (Table 2); less than half of the patients (n=340 [43.03%]; P=0.07) had coagulopathies and, among them, 119 (35%) were on routine anticoagulants (P=0.09), and only 173 (22%) were corrected (i.e., discontinuation of anticoagulant and administration of antidote) before the EI. Creatinine levels and premedication for possible allergic reactions were documented suboptimally before the EI (n=526 [66.6%] and n=71 [8.9%], respectively). Baseline hemoglobin and hematocrit levels were obtained in all patients.

Assessment of fluid volume and resuscitation

Crystalloid intravenous fluids (normal saline or Ringer’s lactate) were administered for initial volume correction of the participants (n=660 [83.54%]; P=0.005, one-sample t-test). Aggregated data on fresh-frozen plasma and platelets concentrate were collected (n=196 [24.8%]; P=0.1, one-sample t-test). Paired t-test comparisons showed significantly higher mean pre-intervention than post-intervention packed red blood cell transfusions (4.2 units vs. 0.7 units; P<0.0005).

Assessment of diagnostic imaging

The majority of plain radiographs (n=767 [97.14%]) and CT scans (n=513 [64.93%], [85% with intravenous contrast) were interpreted by a non-interventional radiologist (n=765 [96.8%]). The Focused Assessment with Sonography for Trauma (FAST) scans (n=774 [97.97%]) were performed and interpreted by non-radiologists. Tc-99m RBC scans were not performed at our institution. CT was the most advantageous diagnostic modality for identifying hemorrhage (P=0.007, one-way ANOVA) and was superior to sonography and fluoroscopy

Assessment of outcomes

No immediate procedural mortality occurred in the interventional suites; post-interventional in-hospital mortality was 4.05%. The mean length of the hospital stay was 18 days.

Conclusion(s):

The role of IR in the management of acutely injured polytrauma patients is gaining magnitude. However, not all patients are equally suited for EI; thus, the early recognition and considerations of operative versus EI are essential for optimizing patient outcomes. A multidisciplinary decision on the best treatment should be made on a case-by-case basis. Many patients are hemodynamically unsuitable for endovascular embolization and management should be optimized to achieve higher operative success rates. Therapeutic embolization by endovascular routes is the next benchmark in the NOM and considerably decreases the morbidity and duration of hospital stay. The interventionalists were primarily radiologists who advocated their contribution as trauma team members, and reported trauma cases with vascular injuries with concise preoperative planning. Therefore, it is imperative to develop internal operational guidelines, standardized workups, and management protocols based on the available resources.

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A Novel Approach for Palliation of Malignant Ascities using Tunneled Peritoneal Split Catheter

1Maria Rauf,1Atif Iqbal Rana, 1Atif Iqbal Rana, 1Haider Ali, 1Jamshaid Anwar

1Shifa international hospital

Objective(s):

Malignant ascites (MA) refers to accumulation of fluid in peritoneal cavity and effects quality of life negatively. Efficacy and safety of only certain types of tunneled peritoneal catheters is documented in literature. However due to the extent of peritoneal disease and adhesions of the bowel to the anterior abdominal wall, placement of a conventional tunnelled ascitic drainage catheter is not always possible.

Material(s) and Method(s):

We offered an alternative approach for palliation of malignant ascites using a tunneled HemoSplit catheter. After obtaining the informed consent from the patient, catheterization was performed in our interventional radiology suite under sonographic and fluoroscopic guidance. The entire procedure was performed using only local anaesthesia as a day case procedure.

Result(s):

The catheter was placed in the most dependent part of the pelvic cavity via an approach from the left flank. Catheter infection a significant complication related to all types of non-tunneled drainage catheters was thus minimized. The catheter tip of the Hemosplit catheter was preferred over other tunneled dialysis catheters available in the market. Potential future blockage of the catheter can also be addressed by regular daily flushing of both lumens with normal saline and the use of a hydrophilic guidewire could be contemplated should the need arise.

Conclusion(s):

Tunneled Hemosplit catheter can be used safely for palliation of malignant ascites.

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Lipiodol Lymphangiography and Glue Embolization for Vulvar and Vaginal Lymphorrhea

1Alali Meshari Ali,2Ji Hoon Shin,, 2Ji Hoon Shin,, 3Chengshi Chen, 2Jeoung In Shinaria

1AlMajmaah University College of Medicine, 2University of Ulsan College of Medicine, 3The Affiliated Cancer Hospital of Zhengzhou University

Background:

This case report is for 26-year-old woman who had an 18-year history of vulvar and vaginal lymphorrhea which confirmed by  MRI, and Conventional lipiodol lymphangiography. Patient was treated successfully via percutaneous puncture of this tubular lymphatic and embolization.

We believe that our case report makes a significant contribution to the literature because it shows that feasibility and efficacy of conventional lipiodol lymphangiography and adjunctive glue embolization for vulvar and vaginal lymphorrhea.

Material(s) and Method(s):

A 26-year-old woman had an 18-year long history of vulvar and vaginal lymphorrhea and multiple millet-like lesions on her vulva. On magnetic resonance image, multiple T2 high signal intensities were noted at the bilateral vulvar areas and pelvic cavity. Conventional lipiodol lymphangiography showed lymphatic reflux to the vulvar areas, possibly originating from prominent tubular lymphatics in the right lower abdominal wall. After percutaneous puncture of this tubular lymphatic structure, its distal portion was embolized using microcoils to prevent upward glue propagation; this was followed by glue embolization of the tubular lymphatic structure. The patient was without skin lesions or symptoms at follow-up of one year after the procedure.

Result(s):

Good clinical outcome was achieved in the patient in this case because lymphatic flow into the vagina and vulva was effectively blocked by percutaneous NBCA embolization. Minimal amount of reflux can persist after the embolization procedure, but the minimal amount of refluxed lymphatic fluid can be resorbed; therefore, symptom improvement or resolution can be expected. When blocking abnormal lymphatic channels with NBCA embolization at a certain level, reducing the upward lymphatic flow with distal coil embolization may facilitate greater NBCA embolization of targeted reflux, as seen in this patient.

Conclusion(s):

This report demonstrated feasibility and efficacy of conventional lipiodol lymphangiography and adjunctive glue embolization for vulvar and vaginal lymphorrhea..

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Tailored Approach To Central Venous Occlusion In Dialysis Patients

Nashwan  Ahmed  Alattab

Background:

ESRD patients suffered from burned out access due to long term Permacath inside the central veins besides puncturing of veins during admissions for Drugs and iv fluid injections and also thrombosed Av fistula  after multiple times usage or episodes of hypotension.

Material(s) and Method(s):

Case series

Result(s):

There is no single approach to patients who has burned out access or central vein occlusion in dialysis access

Conclusion(s):

This study has shown that almost a third of the students rated their knowledge of IR as poor, which indicate an inadequate level of knowledge among medical students; however, this is developing in clinical students who also are more teManagement approach to dialysis patients with burned out access should be tailored according to patients condition and time of presentation.

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Awareness Of Interventional Radiology Among Riyadh Medical Students In Clinical And Pre-Clinical Years

1Norah Albdaya,1Hanan Alruwaybia, 1Hanan Alruwaybia, 1Samar Alanazi, 1Muhammad Alharthi, 1Muhammad Alharthif

1Imam Muhammed Ibn Saud Islamic University

Introduction:

The study aims to report our very early experience with prostate artery embolisation in patients with benign prostatic hypertrophy (BPH) in Shifa International HosInterventional radiology is a minimally invasive method to detect damage and illness. Besides, conducting a wide variety of interventional surgical procedures as well as a diagnostic approach by the use of different radiological techniques. Interventional radiology is considered the most cost-effective approach in the medical field. Interestingly, the demand for interventional radiology is increasing as this field progresses but the apparent lack of knowledge between medical students, as shown by the literature, caused the low number of interventional radiologists despite the increasing demand. Medicine has been around for as long as humans existed and it has been evolving to meet the massive need for innovations and specialties in the field of health and medicine. In the last century, it witnessed the emergence of many specialties in the medical field, this aims to meet the novel message of medicine, to provide better outcomes for individuals and societies as well as improving the overall quality

Objective:

To assess the level of interventional radiology knowledge among medical students and compare it between undergraduate students in pre-clinical and clinical years and compere level of IR knowledge between the four public medical universities in Riyadh, Kingdom of Saudi Arabia

Material(s) and Method(s):

This cross-sectional study was conducted among undergraduate medical students in clinical and pre-clinical years from September 2020 to October 2020 . After the approval by the institutional review board (IRB) of Imam Mohammad Ibn Saud Islamic University. The data was collected via a self-administered questionnaire that was distributed online using social media. The questionnaire consisted of 17 items about interventional radiology awareness and students’ interest, training paths, and hospital responsibilities

Result(s):

A total of 562 medical students participated in the survey from different universities in Riyadh in which 52.3 % of students were in pre-clinical years while 47.7 % were in clinical year. 31.7 % of students rated their level of knowledge as poor, 15.3 % as having no knowledge of IR, 31.3 % having adequate knowledge, 14.2 % as good knowledge and only 7.5 % of them rated themselves as having excellent knowledge about IR. Knowledge was higher in clinical students than preclinical students with significant correlation (P-value < 0.00) and clinical students had more tendency to have a career in both IR and radiology than preclinical students. clinical research projects, self-directed research and problem-based learning tutorials are the most favored tools that reported by students to learning IR (mean scores =4.87, 4.52 and 4.34 respectively).

Conclusion(s):

This study has shown that almost a third of the students rated their knowledge of IR as poor, which indicate an inadequate level of knowledge among medical students; however, this is developing in clinical students who also are more tend to have a career in radiology and IR than students of pre-clinical students. Moreover, we recommend application of different tools as self-directed research, lectures from interventional radiologist and radiology elective in order to increase level of knowledge and increasing interesting of students toward having a career in radiology and IR.

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Prostate Artery Embolization: An Initial Experience In Shifa International Hospitalprostate Artery Embolization: An Initial Experience In Shifa International Hospital

1Raana Kanwal, 1Zahid Amin Khan, 1Maria Rauf

1Shifa International Hospital

Objective(s):

The study aims to report our very early experience with prostate artery embolisation in patients with benign prostatic hypertrophy (BPH) in Shifa International Hospital setting.

Material(s) and Method(s):

This retrospective study was approved by the Institutional Ethical Review Board, and informed consent was obtained from all the patients. This single-center study was conducted on 7 patients with prostate volumes ranging from 39–100 g. Prostate volume, uroflowmetry and the International Prostate Symptom Score (IPSS) were used to assess clinical and functional outcomes. Five patients with lower urinary tract symptoms due to benign prostatic hyperplasia. Among seven of them, two patients had indwelling penile catheters due to BPH. Follow-up was obtained at 3 months. Bilateral prostatic arterial embolisation was performed in 5 cases and unilateral embolisation in 2 cases. One patient who presented with an indwelling catheter had persistent symptoms despite shrinkage of his prostate and was later found to have had a preexisting uretheral stricture not initially diagnosed. No major complications were seen in any patient. One patient had a resistant UTI which responded to a change of antibiotics following his urine C&S reports.

Result(s):

Patients with a mean age of 67.5 years underwent prostate artery embolization. It was successful in all the cases. Bilateral embolization was performed in 7 patients and unilateral approach in 2 patients. Clinical improvement was characterized by a mean prostate volume reduction of 53 % and marked improvement in their IPSS score. All preexisting medications were no longer in use.

Conclusion(s):

The initial experience with prostate embolization has been very rewarding and it is a great alternative treatment for BPH. It is a very safe and effective procedure but requires advanced endovascular skills and appropriate patient selection. It is especially indicated in patients in whom the prostate volume is more than 80 cc to avoid open prostatectomy, in those in whom antiplatelets therapy cannot be stopped due to significant co-existing cardiac issues, those unfit for general anesthesia or in younger men who are sexually active.

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Evaluation Of Efficacy And Safety Of Trans-Arterial Chemo-Embolization For Hepatocellular Carcinoma And Liver Metastasis Utilizing Novel Radiopaque Bead (Lc Bead Lumi™) Loaded With Doxorubicin; A Tertiary Center Experience In Saudi Arabia

1Radhi Ali Alshehri,1Abdullah Almuharib, 1Abdullah Almuharib, 1Abdulaziz Alshoeabi, 2Abdulhadi Alqahtani, 1Abdulhadi Alqahtani

1Department of Medical Imaging and Interventional Radiology, 2Clinical Research Department, Research Center

Objective(s):

This study aims to evaluate the effectiveness and safety of a novel drug-eluting radiopaque beads (LC Bead LUMI) loaded with Doxorubicin for treatment of HCC and liver metastasis.

Material(s) and Method(s):

This was a retrospective study of the outcomes of first 14 TACE procedures done for treatment of 14 tumors in 12 patients at our center utilizing novel drug-eluting radiopaque beads, between March 2019 and Jun 2021.

Radiological findings were collected pre- and post-treatment for assessment of embolization effectiveness and technical success based on mRECIST and gross necrosis criteria using variables include changes in tumor volume, enhancement pattern, tumor density, visibility of beads within the embolized territory and MRI diffusion.

Evaluation for safety was by observing the complications, mortality, need for prolonged hospital stay and survival rate after the procedure. Data of all patients who subsequently underwent ablation procedures is recorded.

Result(s):

14 TACE procedures were performed for 12 patients having 14 tumors, with a median age of 71.6 years (range 51-79), 7(58.3%) male and 5(41.6%) female, 10/12(83.3%) patients have liver cirrhosis, 13 primary hepatic malignancies – HCC (92.9%) and 1 metastatic lesion from colon cancer (7.1%), median lesion volume was 69.3cm3 (range 0.5-130 cm3). The median early follow-up duration was 58 days and for last follow up was 353 days. Mean post procedure tumor volume was 67cm3 after 58 days average follow up and 33cm3 after 353 days follow up.

The response rate at 2 months average follow up was as following: complete response in 8/14 tumors (57.1%), Partial response in 5/14 (35.7%) and no response in 1 (7.14%) tumor because the beads are delivered outside the tumor. The total response rate including complete and partial response at 3,6 and 12 months follow up was seen in 85.7% of tumors. Local recurrence after complete response observed in 1/8 (12.5%) tumor after 444 days follow up. The technical success was achieved in 92.8% of procedures.

The radiopaque beads were visible on intra-operative and follow-up CT images in all patients (100%).

Complications of CIRSE Grade II or above are zero. One adverse event was noticed after using the standard embolic mixture that contains 75mg of Doxorubicin in 2mL of LUMI beads mixed with only 5mL of contrast. After infusion, high viscosity of the embolic mixture restricted the movement of beads, resulting in proximal arterial embolization leading to segmental infarction and atrophy in 1/14 procedure (7.14%). In the following 13 procedures, this complication was completely avoided by adding 15-20 ml of contrast instead of only 5 ml to embolic mixture.

As a result of this technical change, the beads became able to travel to the distal feeding branches and achieve super-selective embolization.

Mortality at early follow up was zero. 1/12 patients died due to unrelated cardiac arrest after 4 months. All patients with partial response were planned for further treatment.

Result(s):

14 TACE procedures were performed for 12 patients having 14 tumors, with a median age of 71.6 years (range 51-79), 7(58.3%) male and 5(41.6%) female, 10/12(83.3%) patients have liver cirrhosis, 13 primary hepatic malignancies – HCC (92.9%) and 1 metastatic lesion from colon cancer (7.1%), median lesion volume was 69.3cm3 (range 0.5-130 cm3). The median early follow-up duration was 58 days and for last follow up was 353 days. Mean post procedure tumor volume was 67cm3 after 58 days average follow up and 33cm3 after 353 days follow up.

The response rate at 2 months average follow up was as following: complete response in 8/14 tumors (57.1%), Partial response in 5/14 (35.7%) and no response in 1 (7.14%) tumor because the beads are delivered outside the tumor. The total response rate including complete and partial response at 3,6 and 12 months follow up was seen in 85.7% of tumors. Local recurrence after complete response observed in 1/8 (12.5%) tumor after 444 days follow up. The technical success was achieved in 92.8% of procedures.

The radiopaque beads were visible on intra-operative and follow-up CT images in all patients (100%).

Complications of CIRSE Grade II or above are zero. One adverse event was noticed after using the standard embolic mixture that contains 75mg of Doxorubicin in 2mL of LUMI beads mixed with only 5mL of contrast. After infusion, high viscosity of the embolic mixture restricted the movement of beads, resulting in proximal arterial embolization leading to segmental infarction and atrophy in 1/14 procedure (7.14%). In the following 13 procedures, this complication was completely avoided by adding 15-20 ml of contrast instead of only 5 ml to embolic mixture.

As a result of this technical change, the beads became able to travel to the distal feeding branches and achieve super-selective embolization.

Mortality at early follow up was zero. 1/12 patients died due to unrelated cardiac arrest after 4 months. All patients with partial response were planned for further treatment.

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Successful Transcatheter Arterial Radioembolization Of Hepatocellular Carcinoma Via Left Internal Mammary Artery: A Case Report

1Abdulmohsen Ahmed Alhussaini,1Yousof A AlZahrani, 1Yousof A AlZahrani

1National Guard Hospital

Background:

The Gulf nations were among the first in the world to implement the COVID-19 vaccination. Regional guidelines like MENACTRIMS endorse tA 57-year-old female known with liver cirrhosis presented with segment 4 subcapsular exophytic hepatocellular carcinoma. The patient underwent Transarterial chemoembolization three times with no significant response. A decision was made to switch to Transarterial Radioembolization as a bridging therapy for liver transplantation. Hepatic artery mapping showed tumoral blush supplied by the left internal mammary artery. Radioembolization was performed utilizing 0.72 GBq Y-90 SIR-sphere (SIRtex) via the left internal mammary artery. Three months later, a CT scan of the abdomen showed complete response of the tumor with post radioembolization changes. Parasitic supply to hepatocellular carcinoma lesions is reported in 17% of patients. The left internal mammary artery represents only 0.5% of the extrahepatic supply to tumors. While Transarterial chemoembolization approach to treat left internal mammary artery parasitic supply has been extensively reported in the literature, herein we report that Transarterial Radioembolization is a safe and feasible alternative to Transarterial chemoembolization for Hepatocellular carcinoma.

Material(s) and Method(s):

A 57-year-old female known with liver cirrhosis presented with segment 4 subcapsular exophytic hepatocellular carcinoma. The patient underwent Transarterial chemoembolization three times with no significant response. A decision was made to switch to Transarterial Radioembolization as a bridging therapy for liver transplantation. Hepatic artery mapping showed tumoral blush supplied by the left internal mammary artery. Radioembolization was performed utilizing 0.72 GBq Y-90 SIR-sphere (SIRtex) via the left internal mammary artery. Three months later, a CT scan of the abdomen showed complete response of the tumor with post radioembolization changes. Parasitic supply to hepatocellular carcinoma lesions is reported in 17% of patients. The left internal mammary artery represents only 0.5% of the extrahepatic supply to tumors. While Transarterial chemoembolization approach to treat left internal mammary artery parasitic supply has been extensively reported in the literature, herein we report that Transarterial Radioembolization is a safe and feasible alternative to Transarterial chemoembolization for Hepatocellular carcinoma.

Conclusion(s):

ThA 57-year-old female known with liver cirrhosis presented with segment 4 subcapsular exophytic hepatocellular carcinoma. The patient underwent Transarterial chemoembolization three times with no significant response. A decision was made to switch to Transarterial Radioembolization as a bridging therapy for liver transplantation. Hepatic artery mapping showed tumoral blush supplied by the left internal mammary artery. Radioembolization was performed utilizing 0.72 GBq Y-90 SIR-sphere (SIRtex) via the left internal mammary artery. Three months later, a CT scan of the abdomen showed complete response of the tumor with post radioembolization changes. Parasitic supply to hepatocellular carcinoma lesions is reported in 17% of patients. The left internal mammary artery represents only 0.5% of the extrahepatic supply to tumors. While Transarterial chemoembolization approach to treat left internal mammary artery parasitic supply has been extensively reported in the literature, herein we report that Transarterial Radioembolization is a safe and feasible alternative to Transarterial chemoembolization for Hepatocellular carcinoma.

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