EDE007-b Interventional Radiology Case of the Day

Transcription

1 EDE007-b Interventional Radiology Case of the Day Education Exhibits Location: NA Moderator Paula Novelli MD Nothing to Disclose VIE001-b A Review of Interventional Radiology Treatment Approaches for Unique Arterial Causes of Gastrointestinal Hemorrhage Education Exhibits Location: VI Community, Learning Center Ahmed Fadl MD (Presenter): Nothing to Disclose Amanjit S. Baadh MD : Nothing to Disclose Nicholas A. Georgiou MD : Nothing to Disclose Man Hon MD : Nothing to Disclose Obaib Shoaib : Nothing to Disclose Jason C. Hoffmann MD : Consultant, Merit Medical Systems, Inc Dipan Danda BS : Nothing to Disclose 1. Highlight the critical role of cross-sectional imaging and interventional radiology (IR) in diagnosing and managing acute arterial gastrointestinal hemorrhage. 2. Review indications for IR intervention in cases of acute arterial gastrointestinal hemorrhage. 3. Multiple transcatheter embolization options exist for mangement of acute gastrointestinal hemorrhage, including coil embolization, glue embolization, covered stent deployment, and thrombin injection. Sometimes, utilizing a combination of techniques is needed for appropriate treatment in complex cases. Discuss indications for IR intervention in cases of acute arterial gastrointestinal hemorrhage. Review of imaging findings with focus on CT scan and conventional angiography: -Contrast extravasation -Pseudoaneurysm Review transarterial techniques for managing unique causes of acute arterial gastrointestinal hemorrhage: -Coil embolization -Glue embolization -Stent graft deployment -Thrombin injection Clinical examples provided: -Standard embolization techniques -Unique combinations of therapies to manage complex arterial causes of gastrointestinal hemorrhage -Correlation with cross-sectional imaging will be provided Summary/Conclusions VIE002-b Chronic Mesenteric Ischemia and its Treatment: A Pictorial Essay Education Exhibits Location: VI Community, Learning Center Certificate of Merit Sadia Choudhery MD (Presenter): Nothing to Disclose Adam Wayne Jaster MD : Nothing to Disclose Richard William Ahn MD, PhD : Cofounder, ViXa LLC Stockholder, Vixa LLC Patrick D. Sutphin MD, PhD : Nothing to Disclose Sanjeeva P. Kalva MD : Consultant, CeloNova BioSciences, Inc Anil Kumar Pillai MD : Nothing to Disclose Matthew Eric Anderson MD : Nothing to Disclose Discuss the normal anatomy of the mesenteric arterial supply and collateral pathways involved in chronic mesenteric ischemia using pictorial illustrations. Discuss the pathophysiology, clinical presentation, and imaging findings in chronic mesenteric ischemia. Review the indications and strategies for endovascular treatment of chronic mesenteric ischemia along with current literature review of outcomes and complications associated with such treatment in comparison to surgical revascularization. Pictorial and multimodality imaging review of normal mesenteric vascular supply and collateral pathways seen in chronic mesenteric ischemia. Clinical consequences of mesenteric ischemia. Diagnostic imaging in chronic mesenteric ischemia. Indications and contraindications for endovascular treatment. Strategies for endovascular treatment (both stent placement and angioplasty). Outcomes and complications associated with endovascular treatment in comparison to surgical revascularization. VIE003-b

2 Endovascular Treatment of Active Bleeding due to Iatrogenic Injury Education Exhibits Location: VI Community, Learning Center Hyedoo Jung MD (Presenter): Nothing to Disclose Active bleeding due to iatrogenic injury that occurs after variable medical procedure or surgery can be required emergency hemostasis. In the past, surgical hemostasis was preferred, but now the endovascular treatment is prefered, because it is easy to implement and also excellent treatment result. The purpose of this exhibit is to show endovascular treatment for active bleeding due to iatrogenic injury after variable medical procedure or surgery. 1. Introduction 2. Epidemiology 3. Active bleeding after medical procedure 1) Percutaneous liver biopsy 2) RF ablation of the liver 3) Endoscopic Retrograde Biliary Drainage 4) Percutaneous biliary drainage 5) Balloon Dilatation of duodenum 6) Colonoscopic polypectomy 7) Transrectal ultrasonographic prostate biopsy 8) Dilatation and Curratage of the uterus 4. Active bleeding after surgery 1) Lobar hepatectomy 2) Pancreatectomy 3) Distal gastrectomy 4) Hartmann's operation 5) Transvaginal hysterectomy 6) Uterine myomectomy 7) Transvaginal salpingooophorectomy VIE004-b Bariatric Effects of Decreased Serum Ghrelin Levels: Literature Review and Future Applications Education Exhibits Location: VI Community, Learning Center Monzer A. Chehab MD (Presenter): Nothing to Disclose Wendy Miller MD : Nothing to Disclose Kerstyn Zalesin MD : Nothing to Disclose Purushottam Krishna Dixit MD : Nothing to Disclose 1. The role of Ghrelin as a hunger stimulating hormone has gained significant notoriety as a potential target for weight loss therapy. 2. Familiarity with the published physiologic, surgical and interventional literature on the bariatric effects of Ghrelin may help guide future therapies directed at decreasing serum Ghrelin levels such as Left Gastric Artery Embolization (LGAE). 1. Physiology of Ghrelin as an orexigenic (hunger stimulating hormone) 2. Relationship between Gastric Fundus resection and decreased serum Ghrelin levels in humans 3. Relationship between decreased serum Ghrelin levels and weight loss in humans 4. Effect of Left Gastric Artery Embolization on decreasing Ghrelin producing cells in the gastric fundus and serum Ghrelin levels in mammals 5. Future role of Left Gastric Artery Embolization as a novel therapy for weight loss in humans. VIE005-b Pictorial Overview Of Aortic Endovascular Graft Endoleaks With Correlation To Stent Graft Neck Length Education Exhibits Location: VI Community, Learning Center Firas Ramahi (Presenter): Nothing to Disclose Maria Habib : Nothing to Disclose Michael Henderson Hamblin MD : Nothing to Disclose 1 - Provide a detailed pictorial review of various aortic graft endoleaks with special focus on stent graft neck length. 2- Discuss the applicable clinical relevance and management of aortic graft endoleaks. - Review abdominal aortic aneurysm (AAA) endovascular stent graft repair cases performed at our institution since 1/1/ Identify cases with aortic stent graft endoleaks with special attention to their corresponding stent graft neck length and possible correlation. - Provide a pictorial review of the various types of endovascular stent endoleaks (type 1-5 endoleaks). - Discuss management of the endoleaks and clinical relevance. VIE006-b Endovascular Management of Arterioportal Fistulas Education Exhibits

3 Location: VI Community, Learning Center Gregory Ramsey MD : Nothing to Disclose Scott G. Smith DO : Nothing to Disclose Justin Muhlenberg MD, MBA (Presenter): Nothing to Disclose Rajeev Suri MD : Nothing to Disclose Jorge Enrique Lopera MD : Consultant, Boston Scientific Corporation Consultant, W. L. Gore & Associates, Inc At the end of this presentation the learner should have knowledge of the: Common causes and clinical manifestations of arterioportal fistulas (APFs) Diagnostic imaging findings and classifications of APFs Recommended treatments and followup of APFs Endovascular management of APFs including angiographic findings, embolization techniques, materials, contraindications, possible complications, and post-interventions followup. A. Common Causes of APFs B. Cinical Mainfestations related to APFs C. Diagnostic Imaging FIndings of APFs D. Classifications of APFs E. Recommended treatment and followup of different types of APFs F. Endovascular Management of APFs 1. Angiographic findings 2. Embolization techniques 3. Embolization materials 4. Contraindications to endovascular management 5. Possible complications 6. Post-intervention followup VIE008-b Clinical Application of Color-coded DSA in Lower Extremity Vascular Disease Treatment: A Preliminary Study Education Exhibits Location: VI Community, Learning Center Wei Qiu (Presenter): Nothing to Disclose XI GUO : Nothing to Disclose Purpose: To evaluate the feasibility of applying color-coded DSA to quantitatively assess the clinical outcome of angioplasty for lower extremity vascular disease. Material and Methods: 12 patients with lower extremity vascular disease were treated with endovascular angioplasty (11 male, 1 female, mean age 72.55±7.46).Both DSA series before and after stent implantation were analyzed with a color-coded DSA tool (syngo iflow, Siemens Healthcare, Forchheim, Germany) which quantitatively calculates the time intensity curve of each pixel on the DSA image. A reference region of interest (ROI) was set at the outflow the pigtail catheter while several other ROIs were set at distal end of the treated vessel segment. Various parameters such as ROI area, time-to-peak (TTP) value was derived to determine the vessel patency. Ankle Brachial Pressure Index(ABI) examination was conducted pre- and postoperatively with doppler ultrasound as a verification of the result from color-coded DSA technique. priciple methord prognosis conclusion VIE009-b Vascular Findings in Ehlers Danlos, Marfan and Loeys Dietz Syndrome: A Pictorial Review Education Exhibits Location: VI Community, Learning Center Arman Yaghoubian MD (Presenter): Nothing to Disclose Daniel Sheeran MD : Nothing to Disclose Patrick T. Norton MD : Nothing to Disclose Klaus D. Hagspiel MD : Research Grant, Siemens AG 1. To review the imaging spectrum of vascular findings in patients with EDS type IV, Marfan and Loeys-Dietz Syndromes. 2. To review the basic genetics and pathophysiology behind EDS type IV, Marfan and Loeys-Dietz Syndromes. Ehlers-Danlos Syndrome type IV (EDS type IV) - Autosomal dominant inheritance caused by a number of identified mutations within the COL3A1. - Multiple arterial aneurysms (especially visceral aneurysms), short segment dissections, vessel occlusion, arteriovenous fistula and/or frank rupture. Marfan Syndrome - Autosomal dominant inheritance caused by a number of identified mutations within the FBN1 gene. - Common involvement of the aortic root with annuloaortic ectasia and aortic dissection. Loeys-Dietz Syndrome (LDS) - Autosomal dominant inheritance caused by mutations of the TGF-β receptor genes. - Clinical course is more aggressive than EDS type IV and Marfan syndrome with earlier presentation and considerably worse survival though there is phenotypic overlap between the syndromes. - Almost all patients (>98%) will have aortic root aneurysms and aortic dissection is the leading cause of death. - Distant arterial aneurysms and tortuosity. - Distinguishing features including hypertelorism, cervical instability, craniosynostosis, and Chiari malformation. VIE010-b Vascular Imaging of Toxic Vasculopathies

4 Education Exhibits Location: VI Community, Learning Center Jed Alan Hummel MD (Presenter): Nothing to Disclose Ikponmwosa Iyamu MD : Nothing to Disclose Samir Kulkarni MD : Nothing to Disclose Joseph Stephen Zerr MD : Nothing to Disclose Anil Kumar Pillai MD : Nothing to Disclose Sanjeeva P. Kalva MD : Consultant, CeloNova BioSciences, Inc To discuss toxic vasculopathies with illustrative case examples The presentation will cover etiologies including cocaine, amphetamine, and heroin related vasculopathies, ergotism, chemotherapy, and thromboangiitis obliterans To briefly review the basic underlying pathophysiology of vasculitides, utilizing graphic illustration and case examples aimed at allowing the reader to better understand the mechanism that produces angiographic characteristics To review grading and classification of vasculitides based on diagnostic features including location, vessel size, and morphological appearance To review differential diagnoses and distinguishing features To discuss most appropriate imaging modalities To discuss catheter-directed therapy considerations Introduction: Review of features and basic pathophysiology of vasculitides with illustrative case examples Diagnostic clues regarding vessel size and location Angiographic appearances with case examples Grading and classification Discussion: Toxic Vasculopathies Etiologies Common and distinguishing imaging characteristics with discussion of differential diagnoses and potential mimics Clinical presentations Selection of best imaging modalities Catheter directed therapy considerations VIE012-b Dual-energy CT: Vascular Applications, Basic Physical Principles and limitations Education Exhibits Location: VI Community, Learning Center Shima Aran MD (Presenter): Nothing to Disclose Khalid Walid Shaqdan MD : Nothing to Disclose Elmira Hassanzadeh MD : Nothing to Disclose Efren Jesus Flores MD : Nothing to Disclose Hani H. Abujudeh MD, MBA : Research Grant, Bracco Group Consultant, RCG HealthCare Consulting Author, Oxford University Press Dual-energy CT (DECT) enhances the capability of single energy CT with several new applications for advanced imaging of vascular pathologies. With low kvp dataset vascular attenuation is increased and therefore it is helpful in assessment of smaller or more poorly opacified vessels. This results in reduction of contrast utilization and radiation exposure. The availability of virtual noncontrast images help in detection of vascular calcifications and endoleaks. The other key advantages of DECT for vascular imaging are the availability of advanced postprocessing application, bone subtraction and calcification removal techniques. Appropriate use of DECT techniques can save radiation dose, decrease interpretation time, or improve diagnostic accuracy. 1. Physical principles of DE or spectral CT on basis of photoelectric and Compton interactions as well as material decomposition. 2. Available techniques of DE data acquisition, for example, dual source CT scanners, fast kilovoltage switching and sandwich detector tech niques. 3. Image processing and reconstruction of DECT data. 4. Clinical application of DECT for diagnosis of vascular pathologies. 5. Sample cases. 6. Limitations of DECT such as the effects on image quality, artifacts and radiation dose. VIE013-b CT Angiography of Spontaneous Visceral Artery Dissection: A Pictorial Review Education Exhibits Location: VI Community, Learning Center Kevin Ching MD (Presenter): Nothing to Disclose Anil Kumar Dasyam MD : Nothing to Disclose Mitchell E. Tublin MD : Nothing to Disclose Matthew Thomas Heller MD : Nothing to Disclose Biatta Sholosh MD : Nothing to Disclose Amir Borhani MD : Nothing to Disclose 1. Spontaneous visceral artery dissection is an uncommon cause of abdominal pain that may involve the celiac trunk, superior mesenteric, renal, and inferior mesenteric arteries. Extension into more distal branches is also common. 2. Because the diagnosis is rarely suspected initially, visceral artery dissection is often suggested from subtle findings on portal venous phase CT. Subsequent CT angiography confirms dissection and better characterizes the extent of vascular involvement. 3. The management of spontaneous visceral artery dissection is determined by the organ involved and extent of distal malperfusion. 1. Overview of spontaneous visceral artery dissection a. Clinical presentation b. Etiologies of spontaneous visceral artery dissection. c. Association with inherited connective tissue diseases. 2. Discuss imaging work-up, CTA protocol, and pertinent findings. 3. Quality images of visceral artery dissection evaluated with 64-slice CT and 3D reconstructions: examples include the celiac axis, superior mesenteric, renal, common hepatic, and splenic arteries. 4. Complications of distal malperfusion. 5. Treatment and recommendations for follow up imaging and multi-disciplinary care.

5 VIE014-b Imaging Beyond the Lumen: Vessel Wall Imaging in Large-Vessel Vasculitis Utlizing Black-Blood MRI Education Exhibits Location: VI Community, Learning Center Mahmud Mossa-Basha MD (Presenter): Nothing to Disclose Wen Lin MD : Nothing to Disclose Myriam Guevera : Nothing to Disclose Tal Gazitt : Nothing to Disclose Grant Hughes MD : Nothing to Disclose Takayasu arteritis (TA) and Giant-cell arteritis (GCA) are relatively uncommon vascultides which may present with nonspecific clinical symptoms. Delayed diagnosis of these entities can lead to a high degree of morbidity. The purposes of this exhibit are: To review conventional imaging methods used for diagnosis and monitoring of TA and GCA To demonstrate the value of vessel wall imaging (VWI) in both the diagnosis and monitoring of TA and GCA To show how VWI can be used as a problem-solving tool when assessing clinically equivocal cases of TA and GCA Background Clinical symptomatology and pathophysiology of TA and GCA Imaging Overview Review conventional imaging modalities used in diagnosis of TA and GCA VWI Demonstrate classic imaging findings of TA and GCA using Black Blood MRI VWI Advantages Discuss ability to track response to treatment using VWI Identify ways in which VWI can be used as problem-solving tool in clinically equivocal cases Potential Pitfalls VIE015-b Small But Volatile: Review of Indications, Technical Considerations and Complications of Percutaneous Ablation of Adrenal Tumors Education Exhibits Location: VI Community, Learning Center Certificate of Merit Zoe Anne Miller MD (Presenter): Nothing to Disclose Bradley Bryan Pua MD : Nothing to Disclose Jonathan Jo : Nothing to Disclose Daisy Qinjun Huang MD : Nothing to Disclose Kyungmouk Steve Lee MD : Nothing to Disclose David Craig Madoff MD : Nothing to Disclose Percutaneous ablation in the adrenal gland is less well-studied compared to the liver and lung. Ablation techniques in these organs are not always applicable because of the unique anatomy and physiology of the adrenal gland. The purpose of this exhibit will review: Indications for adrenal ablation from primary neoplasms to pheochromocytomas Pre-ablation planning appropriate for various adrenal lesions Ablation tehcniques and complications unique to adrenal gland anatomy and physiology 1) Anatomy and physiology of adrenal gland 2) Indications for adrenal ablation Adrenal neoplasms Adrenal metastases Pheochromocytoma 3)Pre-Ablation Planning pre-ablation biopsy urine/serum hormone assays premedication protocol with alpha-adrenergic blocking drugs 4) Ablation types of ablation: RF, cryoablation, microwave appropriate intraprocedural monitoring (central and arterial lines) thermal protection of surrounding organs avoiding hypertensive crisis using a 'stepwise RF ablation protocol' (incremental RF current) 5) Post-Ablation Imaging VIE017-b US-guided Percutaneous Radiofrequency Ablation of Liver Tumors; Tips and Tricks to Ensure Safe and Successful Procedure Education Exhibits Location: VI Community, Learning Center Certificate of Merit Jin Woong Kim MD (Presenter): Nothing to Disclose Sang Soo Shin MD : Nothing to Disclose Suk Hee Heo MD : Nothing to Disclose Hyo Soon Lim MD : Nothing to Disclose Yong-Yeon Jeong MD : Nothing to Disclose Heoung-Keun Kang MD : Nothing to Disclose 1. To overview the current principles of US-guided radiofrequency ablation (RFA) of liver tumors including indications and how to do procedure 2. To illustrate various technical tips to ensure effective and successful procedure 3. To demonstrate how to minimize collateral damage during RFA

6 A. Overview of the current status of US-guided RFA of liver tumors 1. Indications 2. How to do procedure 3. Possible complications related with RFA B. Various technical tips to ensure effective and successful procedure 1. How to select RFA electrode 2. Optimal targeting route of electrode according to the location of liver tumors 3. "No- touch" technique 4. "Cutting edge" technique C. How to minimize possible complications during RFA 1. The role of artificial ascites when performing RFA 2. How to decide infusion route of artificial ascites according to the location of liver tumors. a. Perihepatic b. Sub-hepatic c. Sub-xiphoid (left subphrenic) d. Gastrohepatic (lesser sac) 3. How to effectively handle electrodes under the ultrasound a. Key factors for safe and successful placement of electrodes 1) Training on how to breathe 2) Securing of safe route 3) "Bypass" targeting 4) Several measures to reduce risk of tumoral seeding b. Leverage (lifting) technique VIE018-b Comparison of Gadolinium- versus Iron-based MRA Blood Pool Contrast Agents used in Assessment of Peripheral Vascular Disease Education Exhibits Location: VI Community, Learning Center Certificate of Merit Vignesh Amal Arasu MD (Presenter): Nothing to Disclose Warren J Gasper : Nothing to Disclose Ryan Thomas Downey MD : Nothing to Disclose Stefanie Weinstein MD : Nothing to Disclose Rizwan Aslam MBBCh : Research support, Bayer AG Thomas A. Hope MD : Speaker, Guerbet SA Research Grant, General Electric Company 1. Understand indications of gadolinium- versus iron-based blood pool contrast agents for MRA vascular examinations. 2. Understand strengths/limitations of different blood pool contrast agents in evaluation of peripheral vascular disease. I. Background a. Overiew of peripheral vascular disease and imaging techniques b. Pharamacology of agents i. Conventional extracellular fluid gadolinium-based agents ii. Blood pool gadolinium-based: Gadofoveset Trisodium iii. Blood pool iron-based: Ferumoxytol c. Indications d. Review of literature on safety and efficacy with respect to kidney function II. Technique a. Administration b. Bolus timing i. Test bolus ii. Bolus tracking iii. Time resolved acquisition iv. Dual bolus technique c. MRA acquisition parameters III. Imaging appearance a. Normal i. Conventional MRA ii. TRICKs iii. High resolution steady state imaging iv. Low resolution dynamic imaging b. Proximal lower extremity disease c. Distal lower extremity disease d. Upper extremity disease IV. Advantages/Disadvantages a. Safety profile b. Bolus timing c. Dose d. Image resolution VIE019-b Bridging the Gap: The Role of Interventional Radiology in the Management of Patients with End-Stage Liver Disease Awaiting Liver Transplantation Education Exhibits Location: VI Community, Learning Center Nazanin Hajarol Asvadi MD (Presenter): Nothing to Disclose Priyanush Kandakatla MD : Nothing to Disclose Colin J. McCarthy MD : Nothing to Disclose Arash Anvari MD : Nothing to Disclose Raul Nirmal Uppot MD : Nothing to Disclose Ronald Steven Arellano MD : Nothing to Disclose 1. To discuss the selection criteria utilized by several national organization for patients awaiting liver transplantation. 2. To describe the multifaceted role interventional radiology (IR) in the management of patients with end-stage liver disease awaiting liver transplantation. 1. Review of incidence of end-stage liver disease worldwide and liver transplantation as a definite therapy for these patients. 2. Review of Milan criteria and survival rate in HCC patients. 3. Describe United Network for Organ Sharing (UNOS) and its transplant allocation policies regarding waiting period in different regions and drop off rate while awaiting liver transplantation. 4. Discuss the role of interventional radiology (biopsy, thermal ablation, embolization, imaging) in the management of patients awaiting liver transplantation. VIE020-b Do the Differences Make any Difference? A Worldwide Comparison of Society Guidelines for FNA of Thyroid Nodules Seen On Ultrasound Education Exhibits Location: VI Community, Learning Center Priyanush Kandakatla MD (Presenter): Nothing to Disclose Anthony Edward Samir MD : Nothing to Disclose

7 1. To review the indications for FNA of thyroid nodule seen on ultrasound based on current society guidelines throughout the World 2. comparing the similarities and differences between these guidelines. 1. Description of the following guidelines for FNA of thyroid nodules seen on ultrasound: 1.1. ATA (American Thyroid Association) 1.2. AACE (American Association of Clinical Endocrinologists) 1.3. ETA (European Thyroid Association) 1.4. SRU (Society of Radiologists in Ultrasound) 1.5. KSTR (Korean Society of Thyroid Radiology) 2. A comparison of society guidelines: quoted sensitivity and specificity,similarities and differences, pros and cons. 3. Examples of cases where different guidelines may result in discordant actions. VIE022-b Dissection of the Cervical Internal Carotid Artery The Role of Doppler Ultrasonography: Pictorial Essay Education Exhibits Location: VI Community, Learning Center Lelivaldo Antonio de Britto Neto MD : Nothing to Disclose Carlos A P Ventura PhD : Nothing to Disclose Thiago De Vasconcelos Saraiva : Nothing to Disclose Diego Bortolazzi Bezerra Nunes MD : Nothing to Disclose Priscila Pimentel Collier MD : Nothing to Disclose Miguel Jose Francisco Neto MD (Presenter): Nothing to Disclose Marcelo Buarque Gusmao Funari MD : Nothing to Disclose To demonstrate the majors findings in carotid artery dissection on the Doppler ultrasonography. To review and illustrate role of Doppler ultrasonography in carotid artery dissection and their complications. What cannot miss in the ultrasonography report of carotid dissection? Cervical artery dissections (CAD) are more common in the internal carotid arteries (ICA), 70% in the cervical and petrous segments, mainly 2-3 cm distal to the carotid bulb. These segments are easily accessible by ultrasound. The Doppler ultrasound (Doppler US) can make initial screening, diagnosis and monitoring of dissection in the proximal segments of the ICA. Computed tomography (CT) and magnetic resonance imaging (MRI) are the best methods in the evaluation of CAD. The present study aims to describe by practical cases the role and major abnormalities in the Doppler US of ICA dissections. Doppler US is a low cost exam that can assist in the diagnosis and monitoring of CAD. That can demonstrate the tapering column flow with abnormal pulsed wave Doppler up to 90% of cases of dissection. Moreover, it is able to determine the flow dynamics of the dissection. CT and MRI do not allow determining the flow dynamics It is important for all radiologist know the majors abnormalities in carotid artery dissection on the Doppler US. VIE023-b Radiology and Interventional Radiology in Complex Pelvic Trauma: Suggesting a Trauma Pathway Education Exhibits Location: VI Community, Learning Center Yaron J. Berkowitz MBBChir, MRCS (Presenter): Nothing to Disclose Joel Dunn FRCR, MBBS : Nothing to Disclose Elizabeth Ann Dick MD, FRCR : Nothing to Disclose Jasvinder Daurka : Nothing to Disclose Angus Lewis : Nothing to Disclose An Thanh Ngo BMBS, MRCP : Nothing to Disclose Elika Kashef FRCR : Consultant, W. L. Gore & Associates, Inc The viewer will be able to answer the following quesions after viewing the exhibit: 1. Identify injury patterns in complex pelvic fractures. 2. What imaging modalities are appropriate in pelvic trauma? 3. When should dual phase (arterial and PV) or combined single phase 'combi' CT protocolling be used? 4. When to perform a cystogram? 5. Who need vessels embolisation and/or IVC Filter insertion? We suggest the adoption of an intelligent, step wise, one stop,multidisciplinary approach to imaging and intervention in this often multiply injured patient group. - Characterising pelvic trauma injury patterns - Dual phase versus Combined Phase CT - Cystograms, urethrograms and delayed phase CTs - Intervention (Embolisation and IVF filters) - A suggested simplified, one-stop pathway VIE024-b Endovascular Management for the Non-Matured Arteriovenous Fistula Education Exhibits Location: VI Community, Learning Center Brandon Michael Shearer DO (Presenter): Nothing to Disclose Alexander Edward Trebelev MD : Nothing to Disclose Brian Anthony Bianco DO, MBA : Nothing to Disclose

8 Nationwide measures continue to encourage the creation of arteriovenous fistulas (AVF) in patients requiring long-term dialysis. However, AVFs are plagued with high primary failure rates due to multiple causes. Salvage techniques of the non-maturing fistula are vital not only for patient care but for health-care cost containment reasons. The purpose of this educational exhibit is to provide a review of the pathophysiology of the non-matured AVF, its diagnosis, and salvage techniques with a focus on endovascular management. A pictorial case based review utilizing retrospectively identified patients with a non-maturing AVF will be presented. 1. Long-term dialysis guidelines for the creation of AV access. 2. Clinical criteria to define AVF non-maturation. 3. Common causes and pathophysiology for AVF non-maturation. 4. Clinical exam of the AVF for the diagnosis of failed maturation. 5. Review of digital subtraction angiography and ultrasound interrogation of an AVF. 6. Endovascular management options for the non-matured AVF. VIE025-b Transradial Access for Dialysis Interventions: A Pictorial Review Education Exhibits Location: VI Community, Learning Center Shaun Jeffrey Gonda MD (Presenter): Nothing to Disclose James Bret Winblad MD : Nothing to Disclose Travis McKenzie DO : Nothing to Disclose 1. To review transradial access, technical tips and patient selection. 2. To depict different dialysis access interventions that can be performed from a transradial approach. 1. Clinical findings for patient selection 2. Technique and tip for obtaining radial artery access 3. Evaluation of dialysis access from transradial approach. 4. Endovascular treatment of dialysis acces from transradial approach VIE026-b How to Make the 'Snip' Easy Education Exhibits Location: VI Community, Learning Center Zubin Irani MD (Presenter): Nothing to Disclose Rahmi Oklu MD, PhD : Nothing to Disclose This pictorial exhibit aims to educate about Port catheter problems encountered and solutions for addressing these; in particular focussing on port catheters being too long. 1. Problems long chest port catehters may create / present with. 2. Present author's step by step technique for port catheter revisions. 1. Chest Port placement demographics 2. Complication of chest port placements 3. Pictorial technique of chest port revision for catheters that are too long 4. Outcomes using the presented author's technique VIE028-b Increasing Interventional Radiology Exposure in Medical Schools Education Exhibits Location: VI Community, Learning Center Rahul Nayyar MD (Presenter): Nothing to Disclose Nicole A. Keefe MD : Nothing to Disclose Nicholson Stephen Chadwick MD : Nothing to Disclose Krishna K. Das MD : Nothing to Disclose Alok Bharat Bhatt MD : Nothing to Disclose Venkatesh Perumal Krishnasamy MD : Nothing to Disclose George Vatakencherry MD : Nothing to Disclose Chadi Zeinati MD : Nothing to Disclose A main goal for the SIR Medical Student Council (MSC) was to increase IR awareness and education. This has been done by completing a dedicated Medical Student Lecture Series. The lectures will be accessible by anyone who requests their use for educational purposes. They can be used in the basic science or clinical years of medical school. Topics include: Intro to IR,

9 educational purposes. They can be used in the basic science or clinical years of medical school. Topics include: Intro to IR, Peripheral Arterial Disease, Interventional oncology, Carotid Disease, Thoracic/Abdominal Aortic, Chronic liver disease, Leg Ulcers, DVT, IR Frontiers, GI bleeding, Varicose Veins, and Trauma IR. Members of the MSC volunteered for the different topics. A template for content organization was provided. Upon completion of the presentation, the lectures were reviewed by 2 IR physicians. The medical student lecture series, created by the SIR MSC, will expose medical students to IR throughout medical school, which will be critical with the dual certificate. This should draw more medical students to IR by exposing them to the different modalities within IR. The series stresses the clinical aspect of IR, which is something most medical students are not aware of. We will debut this lecture series with this educational exhibit and also show step by step instructions how to obtain these lectures for your institution. VIE029-b Approaching Quality Improvement in Interventional Radiology Education Exhibits Location: VI Community, Learning Center Benjamin White MD (Presenter): Nothing to Disclose Stephen Phillips Reis MD : Nothing to Disclose Seth Toomay MD : Nothing to Disclose Patrick D. Sutphin MD, PhD : Nothing to Disclose Anil Kumar Pillai MD : Nothing to Disclose Sanjeeva P. Kalva MD : Consultant, CeloNova BioSciences, Inc Recognize the difference between quality improvement and quality assurance Understand the DMAIC (Define, Measure, Analyze, Improve and Control) model, Six Sigma process, and Driver Diagram project mapping Understand the criteria that determine a strong and meaningful QI project Quality assurance (QA) versus quality improvement (QI) Define QA and QI Goals of QA vs QI Situations in which QA is important Benefits of QI over QA Using ongoing QA to help identify possible QI projects Goals of a QI Project Better outcomes Safer care Lower cost Faster service Criteria for a Successful QI Project Important to patient Meaningful to you Needs improvement Feasible (start small, definable, achievable) Reproducible metrics Examples of Quality Improvement Projects in IR Reducing Mediport waiting times Reducing Mediport infection rates Increasing inferior vena cava filter retrieval rates Reducing radiation dose during angiography procedures First case start time Time to intervention for trauma Arteriovenous fistula/graft patency and flow rates at dialysis after maintenance therapy Automated case tracking of interventional procedures VIE031-b CT-guided Autologous Blood Patch for the Post Lung Intervention Pneumothorax Education Exhibits Location: VI Community, Learning Center Anshuman Kumar Bansal MD (Presenter): Nothing to Disclose Scott J. Genshaft MD : Nothing to Disclose William T. Derry MD : Nothing to Disclose Fereidoun G. Abtin MD : Nothing to Disclose Antonio Joel Gutierrez MD : Nothing to Disclose Robert D. Suh MD : Nothing to Disclose Pneumothorax is a common complication of percutaneous thoracic interventions, complicating up to 50% of procedures. Pneumothoraces with persistent air leak can be difficult to treat, and at times require thoracic surgery for definitive management. Blood patching uses clot formation to seal persistent air leaks from the lung parenchyma. We present the use of a two-catheter image-guided blood patch technique to seal the persistent air leak, drain the intrapleural air, and oppose the pleural surfaces. 1. Overview of pneumothorax 2. Clinical assessment and management of post-intervention pneumothorax and hospital management 3. Pneumothorax prevention 4. Two-catheter technique for CT-guided pleural blood patch placement a. Percutaneous autologous blood patch b. Pneumothorax aspiration c. Thoracostomy catheter management d. Pleural blood patch placement e. Alternative management with synthetic sealants VIE032-b Implications of Lipiodol Deposition Pattern on Non-contrast CT Immediately After TACE: Correlation with Pathological Findings Education Exhibits Location: VI Community, Learning Center Nicholas Ralph Turman MD (Presenter): Nothing to Disclose Shiliang Sun MD : Nothing to Disclose Fadi Mohamad Youness MD : Nothing to Disclose

10 Fadi Mohamad Youness MD : Nothing to Disclose Sandeep T. Laroia MD : Nothing to Disclose Mark Karwal : Nothing to Disclose Thomas Collins : Nothing to Disclose Leana A. Guerin MD : Nothing to Disclose The purpose of this exhibit is to: 1. To demonstrate types of lipiodol deposition pattern on noncontrast CT performed one day after TACE and its predicting value for tumor destruction - correlated with pathology and imaging findings 2. Comparing the outcomes of the groups of patients with/without subsequent particle embolization To demonstrate types of lipiodol deposition pattern on noncontrast CT performed one day after TACE and its predicting value for tumor destruction - correlated with pathology and imaging findings Full homogeneous deposition pattern within target tumor Full heterogenous deposition pattern within target lesion Partial geographic deposition defect pattern Also comparing the outcomes of the groups of patients with/without subsequent particle embolization VIE033-b Pictorial Review of the Re-intervention Techniques after TIPS Placement (Transjugular Intrahepatic Portosystemic Shunt) According to Clinical Manifestations Education Exhibits Location: VI Community, Learning Center Certificate of Merit Bryan G. Belikoff MD, PhD (Presenter): Nothing to Disclose Seung Kwon Kim MD : Nothing to Disclose Carlos Javier Guevara MD : Nothing to Disclose Kristen Alexa Lee MD : Nothing to Disclose Guillermo Gonzalez-Araiza MD : Nothing to Disclose Recognize the clinical manifestations after TIPS placement and know the various TIPS re-intervention techniques including basic and advanced TIPS revisions, TIPS reduction, parallel TIPS, and additional procedures such as Denver shunt and BRTO procedure according to clinical manifestations Background: Transjugular intrahepatic portosystemic shunt (TIPS) is an established and effective treatment for the complications of portal hypertension. Herein, we present a pictorial review of the basic to advanced re-intervention techniques after TIPS placement according to clinical manifestations. Clinical manifestations/procedure details: 1. Initial poor clinical response - TIPS revision, parallel TIPS, Denver shunt for intractable ascites 2. Hepatic encephalopathy or hepatic failure - TIPS reduction 3. Stenosis on Doppler US with/without symptom -TIPS venogram with/without revision 4. Total occlusion of TIPS stent on Doppler US or TIPS venogram Parallel TIPS Transhepatic or Transplenic approach Thrombolysis - mechanical or catheter directed 5. Recurrent symptoms after initial clinical response TIPS revision with possible variceal embolization for bleeding Recurrent bleeding after TIPS revision with variceal embolization -- Parallel TIPS or BRTO for gastric varices VIE034-b Assessment of Mesocaval Shunts and Associated Complications: The Diagnostic and Therapeutic Role of Radiologists Education Exhibits Location: VI Community, Learning Center Jad Zouheir Chokr MD : Nothing to Disclose Bedros Taslakian MD (Presenter): Nothing to Disclose Karim Jean Rebeiz MD : Nothing to Disclose Sahar Semaan MD : Nothing to Disclose Aghiad Al-Kutoubi MD : Nothing to Disclose Walid Faraj : Nothing to Disclose Charbel Saade MS : Nothing to Disclose Mohammad Khalife MD : Nothing to Disclose Fadi M. El-Merhi MD : Nothing to Disclose Ali A. Haydar MD, FRCR : Nothing to Disclose The purpose of this exhibit is: To understand the anatomy and pathophysiology of mesocaval shunts. To illustrate the pearls and pitfalls of computed tomography, Doppler ultrasound and digital subtraction angiography in the assessment of mesocaval shunts. To demonstrate the role of the radiologist in diagnostic and interventional management of complications. Anatomy and pathophysiology Clinical indications Imaging findings Complications Interventional techniques and applications Pearls and Pitfalls VIE035-b Renal Arteriovenous Shunts: Clinical features, Imaging Appearance and Transcatheter Embolization Based on its Angioarchitectures Education Exhibits

11 Location: VI Community, Learning Center Selected for RadioGraphics Miyuki Maruno MD (Presenter): Nothing to Disclose Hiro Kiyosue MD : Nothing to Disclose Shuichi Tanoue MD : Nothing to Disclose Yoshiko Sagara MD : Nothing to Disclose Junji Kashiwagi MD : Nothing to Disclose Norio Hongo : Nothing to Disclose Shunro Matsumoto MD : Nothing to Disclose Hiromu Mori MD : Nothing to Disclose The teaching points of this exhibit are: 1. Etiology and clinical features of various types of renal arteriovenous shunts (ravss) 2. The imaging features of ravss 3. The classifications of ravss 4. The endovascular treatments for ravss based on its etiology and angioarchitectures A. Etiology and clinical features of ravss B. Imaging features of ravss Normal anatomy of renal arteries and veins Imaging features of ravss on CT, MRI and angiography C. Classifications of ravss ravms; cirsoid type, angiomatous type, aneurysmal type Traumatic ravfs D. Endovascular treatment Endovascular treatment for ravss Treatment techniques of transcatheter embolization, including selection of embolic materials, catheters, and other adjunctive techniques, based on their types and angioarchitectures Outline The ravss is a rare pathological communication between renal arteries and veins, which can cause retroperitoneal hemorrhage, massive hematuria, pain and high-output heart failure. Transcatheter embolization has been accepted as a less-invasive and effective treatment; however it has a risk of complications including renal infarction and pulmonary embolism. For the safe and effective treatment, treatment strategy based on the types and angioarchitectures of ravfs are mandatory. VIE036-b Inferior Vena Cava Embryogenesis: What Every Interventionalist Must Know before Placing an IVC Filter Education Exhibits Location: VI Community, Learning Center Dominic Semaan MD, JD (Presenter): Nothing to Disclose Matthew Osher MD : Nothing to Disclose Mehran Salari MD : Nothing to Disclose - The various congenital anomalies in the development of the Inferior Vena Cava. - IVC Filter placement options when a congenital variant arises. 1. Embryologic development of the IVC 2. Most commonly presenting IVC variants - Review fluoroscopic presentations 3. Review of the literature and options in IVC filter placement when a congenital variant is presented 4. Presentation of some slightly less common variants and suggestions on IVC filter placement 5. Conclusion VIE037-b Through the Looking Glass: Alice in Wond-IR-Land Potential Use of Google Glass in the World of IR Education Exhibits Location: VI Community, Learning Center Raul Nirmal Uppot MD (Presenter): Nothing to Disclose Synho Do PhD : Research Grant, Koninklijke Philips NV Debra Ann Gervais MD : Research Grant, Covidien AG Anthony Edward Samir MD : Nothing to Disclose Robert L. Sheridan : Nothing to Disclose Florian J. Fintelmann MD, FRCPC : Nothing to Disclose Peter Raff Mueller MD : Consultant, Cook Group Incorporated Ronald Steven Arellano MD : Nothing to Disclose Raymond W. Liu MD : Nothing to Disclose Alvin Yiu Chun Yu MD : Nothing to Disclose 1. Google Glass is a wearable computer with a optical head mounted display which has many potential uses in Interventional Radiology 2. It can potentially be used for interventional procedures, internvetional rounds, education, and monitoring. 3. Current limitations include ensuring patient privacy, HIPPA compliance, and maintaining sterility during procedures. A. Background in Development and Use of Google Glass B. Review of Gogle Glass in Medicine C. Review of Google Glass During Image-guided Interventional Pocedures. D. Review of Goggle Glass For Real Time remote consultation/education E. Review of Google Glass for Interventional Rounds. F. Review of Google Glass in monitoring IR procedure rooms G. Limitations in use of Google Glass VIE038-b

12 Prevention and Management of Air Embolism during Vascular Interventional Procedures Everything you Wanted to Know, but Were Afraid to Ask Education Exhibits Location: VI Community, Learning Center Certificate of Merit Colin J. McCarthy MD (Presenter): Nothing to Disclose Mohammad Ghasemi-rad MD : Nothing to Disclose Thabele Mbuso Leslie-Mazwi MD : Nothing to Disclose Rahmi Oklu MD, PhD : Nothing to Disclose 1. To discuss the risk and prevention of air embolus during endovascular procedures. 2. Review the physiological effects of venous and arterial air embolism. 3. Outline the initial and advanced management of air embolism. 1. Review the estimated incidence of air embolus and identify high-risk procedures in interventional radiology. 2. Discuss imaging findings and clinical presentation following air embolus, including the hemodynamic effects such as elevated pulmonary arterial pressure and resultant right heart failure. 3. Important steps to reduce the risk of air embolus 4. Outline management techniques including supportive therapy, positioning, aspiration and hyperbaric oxygen treatment (HBOT). VIE039-b Liver-on-a-chip: Personalization in Interventional Oncology? Education Exhibits Location: VI Community, Learning Center Sidhartha Tavri MBBS (Presenter): Nothing to Disclose Mohammad Ghasemi-rad MD : Nothing to Disclose Rahul Anil Sheth MD : Nothing to Disclose Richard L. Hesketh : Nothing to Disclose Berk Usta PhD : Nothing to Disclose David S. Kong PhD : Nothing to Disclose Rahmi Oklu MD, PhD : Nothing to Disclose i) to address the limitations of the current in vitro tools and animal models in the drug discovery process ii) to review recent advances in the microfluidics technology towards the development of the organ-on-a-chip platform. We will use liver-on-a-chip as the primary example. iii) to review the liver tumor-on-a-chip platform for testing anti-cancer drugs and interventions, highlighting relevance to interventional oncology. 1) Overview of the traditional drug discovery process, highlighting the current lack of predictive in vitro tools and animal models for translation from bench to bedside. 2) Organ-on-a-chip: describe advances in microfluidics and microfabrication platforms and development of 3D cell culture models to mimic in vivo human environment. 3) Discuss liver-on-a-chip devices to mimic healthy liver physiology, investigate liver diseases, and test the toxicity of potential therapeutic drugs. 4) Compare and contrast the complimentary role of tumor-on-a-chip technology in interventional oncology for biomarker discovery, chemotherapeutic sensitivity and specificity analysis, developing targeted therapy, and monitoring treatment. Novel microfluidic designs containing microscopic probes can enable the study of IRE, microwave, cryo- and RFA on tumor tissue on a chip in real-time video microscopy will be discussed. VIE040-b IR Targeted Liver Decellularization and Cell Therapy: Fantasy or Reality to Improve Liver Function? Education Exhibits Location: VI Community, Learning Center Sidhartha Tavri MBBS (Presenter): Nothing to Disclose Mohammad Ghasemi-rad MD : Nothing to Disclose Rahul Anil Sheth MD : Nothing to Disclose Richard L. Hesketh : Nothing to Disclose Basak Uygun PhD : Nothing to Disclose Berk Usta PhD : Nothing to Disclose David S. Kong PhD : Nothing to Disclose Rahmi Oklu MD, PhD : Nothing to Disclose 1) Review various methods of 'decellularization' technologies in general and specifically in liver. 2) Review the current status of stem cell therapy in regenerative medicine specifically focusing on hepatocyte derivation from pluripotent cells and fibroblasts. 1. List the current challenges in the definitive management of liver failure with orthotopic transplantation by a brief review of UNOS/OPTN data. 2. Decellularization - definition - overview of various methods of decellularizing tissue/organs including physical, chemical and enzymatic methods with their limitations, with focus on liver - briefly illustrate role of irreversible electroporation as an alternative method with literature review 3. Stem cell therapy - review the various autologous and

13 allogeneic cell sources i.e., embryonic, fetal, inducible pluripotent stem cells, adult derived stem cells, primary tissue or organ-derived cells - review seeding techniques and list the endpoints of tissue engineered organs - describe advantages of a decellularized scaffold for stem cell therapy 4. The role of interventional radiologists in targeted decellularization of tissues, targeted stem cell therapy and monitoring its fate by imaging in vivo. VIE041-b Time-Driven Activity Based Costing in Interventional Radiology Education Exhibits Location: VI Community, Learning Center Katelyn Brinegar (Presenter): Nothing to Disclose Roy Gordon Bryan MD, MBA : Nothing to Disclose Mohammad Ghasemi-rad MD : Nothing to Disclose H. Benjamin Harvey MD, JD : Nothing to Disclose Anand M. Prabhakar MD : Nothing to Disclose Robert L. Sheridan : Nothing to Disclose Peter Raff Mueller MD : Consultant, Cook Group Incorporated Rahmi Oklu MD, PhD : Nothing to Disclose 1) Demonstrate need for accurate costing in radiology operations as the healthcare environment changes. 2) Introduce Time-Driven Activity Based Costing (TDABC) as a valuable new tool to develop accurate costing processes in interventional radiology 3) Provide potential applications of TDABC in multiple imaging care processes Healthcare costs in the US total 20% of gross domestic product and focus has turned to reducing these costs. Payors are placing increasing importance on delivering value, quality care at the lowest cost and are changing payment models to support high value services in healthcare. In contrast to traditional fee-for-service models, where a specific event is reimbursed, new bundled payment models are being initiated to cover a full episode of care. With these new reimbursement models, radiologists must know their costs to ensure services provided are reimbursed fairly. Until now, costs have been allocated to services based on reimbursement, leaving physicians without an accurate assessment of what it actually takes to provide healthcare. TDABC provides a flexible and versatile method to assess the costs of delivering quality services. Without accurate costing methods IR may leave the table with a smaller share of the pie, unable to demonstrate their value throughout the patient care cycle. VIE042-b How Low Can You Go: A Pictorial Primer to Radiation Dose Reduction in Interventional Radiology Education Exhibits Location: VI Community, Learning Center Michelle Morgan RT (Presenter): Nothing to Disclose Ram Kishore Reddy Gurajala MBBS, FRCR : Nothing to Disclose Kevin Wunderle : Nothing to Disclose Charles Martin MD : Nothing to Disclose Karunakaravel Karuppasamy MBBS, FRCR : Nothing to Disclose The goal is To list dose reducing methods in an Interventional Radiology (IR) system To demonstrate simple steps that should be taken routinely To display advanced methods and warnings systems available A. Introduction: A key radiation safety principle is 'As Low As Reasonably Achievable (ALARA)'. We categorize and remind the viewers on steps they could take to reduce patient dose in an IR system. B. X-ray source-detector 1. Pulsed fluoroscopy 2. Low dose Fluoroscopy 3. Collimation and filters 4. Last image hold and cine Loops 5. Low dose/faster C-arm cone-beam CT (CBCT) 6. Reduced slab CBCT C. Patient positioning 1. Maximize distance between X-ray tube and patient 2. Minimize distance between patient and detector 3. Reduce exposing same skin area 4. Reduce oblique projections 5. Re-positioning using last image hold D. Image guidance 1. Road-map 2. Reference image fade 3. CBCT 3D display 4. Live 2D display over 3D anatomy 5. Live 3D scheme display over 2D image E. Dose reduction 1. Live skin entrance dose (SED) display 2. Dose threshold warning bell 3. Live graphical 3D SED tracking 4. Introspect high-dose events F. Cases G. Summary: This exhibit reminds viewers to be conscious of radiation dose reduction by taking simple steps and utilizing advanced tools. VIE043-b The Microenvironment in Hepatocellular Carcinoma: Mind the Gap! Education Exhibits Location: VI Community, Learning Center Richard L. Hesketh (Presenter): Nothing to Disclose Berk Usta PhD : Nothing to Disclose Mohammad Ghasemi-rad MD : Nothing to Disclose Rahul Anil Sheth MD : Nothing to Disclose Rahmi Oklu MD, PhD : Nothing to Disclose 1. Tumor microenvironment in HCC is unique both in composition, its interaction with the surrounding chronically inflamed liver and inhibits drug delivery to intracellular targets. 2. Gap junctions control intercellular communication and tumor homeostasis and are down regulated in HCC. 3. Combination of drugs and therapeutic interventions has potential to overcome the intrinsic barriers to drug delivery. 4. Regulation of gap junctions could potentially lead to enhanced effects of anti-tumor drugs.

14 barriers to drug delivery. 4. Regulation of gap junctions could potentially lead to enhanced effects of anti-tumor drugs. Significant advances in our understanding of the drivers of HCC have been possible with the advent of the 'omic age. Despite the increasing number of possible targets, drug treatment fails to induce long term remission. Specific mutations that lead to drug resistance occur but recently the role of the tumor microenvironment has been increasingly implicated in determining drug resistance. This exhibit will describe the characteristics of the tumor microenvironment that impede drug delivery and the role of gap junctions in tumorigenesis. It will emphasise future chemotherapeutic and interventional tools that have the potential to overcome these barriers and promote drug delivery and efficacy, ultimately improving survival for this silent killer. The value of microfluidic technology including liver-on-a-chip will be discussed. VIE044-b Interventional Radiology in Palliative Management of Intractable Pain in the Abdomen Education Exhibits Location: VI Community, Learning Center Certificate of Merit Naveen Kulkarni MD (Presenter): Nothing to Disclose Ashraf Thabet MD : Nothing to Disclose Raul Nirmal Uppot MD : Nothing to Disclose Mihir M Kamdar MD : Nothing to Disclose Peter Raff Mueller MD : Consultant, Cook Group Incorporated Avinash Ranesh Kambadakone MD, FRCR : Nothing to Disclose The purpose of this educational exhibit is: 1) to review the various image guided palliative procedures for management of intractable pain in the abdomen and 2) to discuss the indications, technique and patient management principles of the image guided techniques for palliative pain management. 1. Review the various image guided palliative care procedures for pain relief in the abdomen including celiac plexus neurolysis, hypogastric neurolysis and cryoablation. 2. Discuss basic principles and anatomic considerations for interventional palliative pain procedures. 3. Discuss step-by-step technique for the image guided procedures. 4. Illustrate the interventional techniques with tips for successful treatment using a pictorial review. 5. Discuss the patient care issues before, during and after procedure including management of complications. 6. Summary and Conclusions VIE100 Radiologists as Pain Relievers: Ultrasound Guided Truncal Nerve Blocks for Pelvic Cancer Pain Management Education Exhibits Location: VI Community, Learning Center Nayha Handa MBBS (Presenter): Nothing to Disclose Krithika Rangarajan MBBS : Nothing to Disclose Sanjay Thulkar : Nothing to Disclose S. Bhatnagar : Nothing to Disclose Nerve block or neurolysis is a procedure in which a chemical is injected under image guidance to ablate nerves and thus block pain.they are used to treat intractable pain in cancer patients. 1) To enlist the sites of nerve blocks with their relevant anatomy in patients with pelvic cancers. 2) To review the utility of ultrasound as a guiding modality for these procedures 3) To review their indications, contraindications and potential complications. Outline -Sites Superior Hypogastric plexus Ganglion impar Caudal epidural block -Anatomy -Indications -Technique -Role of imaging guidance :Ultrasound, CT, Fuoroscopy -Post Procedure care -Complications -Follow up VIE102 A Radioembolization Quiz: What the Radiologist Needs to Know Education Exhibits Location: VI Community, Learning Center Jason C. Hoffmann MD : Consultant, Merit Medical Systems, Inc Amanjit S. Baadh MD (Presenter): Nothing to Disclose Obaib Shoaib : Nothing to Disclose Ahmed Fadl MD : Nothing to Disclose Radioembolization is an extremely valuable interventional oncology tool in treatment of primary and metastic hepatic malignancy. This procedure allows interventional radiologists to target liver tumors with lethal radiation dose while minimizing normal hepatic parenchymal exposure. In most patients, this is extremely well-tolerated and can be performed as an outpatient. Non-target embolization (radiation-induced lung, liver, or bowel injury) is a rare, but potentially serious and life-threatening complication. It is important for radiologists to understand critical information about the procedure, including patient selection,

15 complication. It is important for radiologists to understand critical information about the procedure, including patient selection, mechanism of action, risks, and imaging that routinely is obtained before and after the procedure. Presentation will be in quiz format. Major teaching points about indications and contraindications of radioembolization will be reviewed. Differences between the two radioembolization products will be covered. Eight cases will be utilized to cover this points as well as highlight outcomes from major research studies. Cases will include: -Primary liver tumors -Metastatic disease to the liver -Highlight normal anatomy as well as key anatomical variants -Importance of mapping angiography and nuclear medicine scintigraphy -Adjunctive techniques that may aid in uptake of dose into the tumors and/or improve safety. VIE103 Acute Lower Gastrointestinal Bleeding: Evaluation, Management, and Pitfalls Education Exhibits Location: VI Community, Learning Center Jennifer Frances Feneis MD : Nothing to Disclose Raja Ramaswamy MD (Presenter): Nothing to Disclose Kevin Charles McCammack MD : Nothing to Disclose Gerant M. Rivera-Sanfeliz MD : Nothing to Disclose Overview: Acute lower gastrointestinal bleeding can lead to significant morbidity and mortality without appropriate treatment. The role of interventional radiology is crucial in patients that have persistent bleeding despite medical and endoscopic treatment. In this educational exhibit we will review the following: ACR Appropriateness Criteria for the radiologic management of lower gastrointestinal tract bleeding. The practical utilization of radiologic modalities (CT/Nuclear medicine) Underlying etiologies that can lead to lower GI bleeding The role of Interventional Radiology in the therapeutic management with endovascular angiography and transcatheter embolization Provides insight into the essential role of Interventional Radiology in the management of acute GI bleeding. Introduction Clinical evaluation and patient management Review ACR appropriateness criteria The utilization of CTA and Nuclear Medicine Angiographic evaluation and management Use of gelfoam, PVA, coils, onyx, glue in the management of lower GI bleeding Review technical approach to lower GI bleeding specifically using a case-based approach Conclusions and Future Directions VIE104 Aortic Arch: Posttherapy Imaging Evaluation of Congenital and Acquired Diseases Education Exhibits Location: VI Community, Learning Center Mariana Santos Ferreira Horta (Presenter): Nothing to Disclose Carla Rodrigues Saraiva MD : Nothing to Disclose Marcio Ferreira Madeira MD : Nothing to Disclose Ines Carmo Mendes MD : Nothing to Disclose To describe and illustrate the pre- and posttherapy MDCTA and MRA imaging findings of congenital and acquired aortic arch diseases. To detail MDCTA and MRA imaging strategies for the repaired aortic arch. To explain the surgical and endovascular approaches of the congenital and acquired condition involving the aortic arch, including procedures involving the ascending and descending aorta and the supra-aortic trunks. To display possible complications after surgical and endovascular aortic arch repair. 1.Description of CTA and MRA imaging advantages and disadvantages for the evaluation of the repaired aortic arch. 2.Spectrum of congenital (vascular rings,aortic hypoplasia,aortic coarctation,interrupted aortic arch) and acquired diseases (atherosclerotic, inflammatory and post-dissection aneurysms, type A dissections,penetrating ulcers) that often require surgical and endovascular interventions. 3.Descripition and review of the imaging findings of surgical and endovascular techniques.tevar, hybrid surgeries, elephant trunk procedure and its variants,"arch first" technique,surgical reimplantation techniques and stenting of the supra-aortic vessels. 4.Post-treatment normal aspects and complications of surgical and endovascular approaches. 5.Final considerations VIE105 Arterial Upper Extremity Run Off: Technique and Imaging Findings Education Exhibits Location: VI Community, Learning Center Prashant Nagpal MD (Presenter): Nothing to Disclose Ashish Rajendra Khandelwal MD : Nothing to Disclose Sandeep Subhash Hedgire MD : Nothing to Disclose Sachin Shyamsunder Saboo FRCR, MD : Nothing to Disclose Ayaz Aghayev MD : Nothing to Disclose Frank John Rybicki MD, PhD : Research Grant, Toshiba Corporation Michael Lally Steigner MD : Speaker, Toshiba Corporation 1. Understand the role of CT Angiography (CTA) and MR Angiography (MRA) of the upper extremity run for the diagnosis of

16 acute arterial pathologies. 2. Identify the technical factors for optimal upper extremity angiography. 3. Review imaging appearance of various common pathologies involving the upper extremity arteries. 1. Role of the CT and MR upper extremity run off, especially in appropriate clinical setting. 2. Technical parameters for optimal imaging evaluation of upper extremity arteries. 3. Case based review of various pathologies involving the upper extremity arteries with emphasis on use of CT angiography in emmergency setting. 4. Summary VIE106 Carotid Artery Stenting: Avoiding a Surgical Pain in the Neck Education Exhibits Location: VI Community, Learning Center Hebah Taufik MBBS (Presenter): Nothing to Disclose Alexander Theodore Chapman MBBS, BSc : Nothing to Disclose Allan Irvine : Nothing to Disclose Our centre has a relatively small volume of carotid artery stenting cases. A robust pathway is essential for the selection and follow-up of cases. Rigorous audit ensures that the outcomes in smaller hospitals are comparable to national figures. Carotid artery stenting (CAS) is recommended as a second-line treatment for symptomatic patients unsuitable for endarterectomy. The British Society of Interventional Radiologists (BSIR) developed the United Kingdom Carotid Artery Stent Registry (UKCASR) to monitor short and long-term outcomes of CAS. Recently published outcomes for 953 symptomatic and 201 asymptomatic cases undergoing CAS in UK hospitals between day outcomes for stroke/myocardial infarction/ death rate was 5.5% and death rate was 1.7% for symptomatic cases. For asymptomatic cases, 2.8% and 0.6%, respectively. At our district general hospital, we analysed 44 cases. 30- day outcome of stroke/ myocardial infarction/ death rate for both symptomatic and asymptomatic cases was 0%. Post-procedure duplex scans at our institute was suboptimal. 34.8% of symptomatic cases and 15.4% of asymptomatic cases were followed up within the recommended 6 week period. Using ECST, NASCET, NICE guidelines, along with the report published by UKCASR and our own experiences, we have proposed a CAS Patient Pathway. VIE107 CRUSHING the NIDUS Management Strategies of Non-CNS High Flow AVMs Education Exhibits Location: VI Community, Learning Center Donald J. Perry MD (Presenter): Nothing to Disclose Gregor Martin Dunham MD : Nothing to Disclose Sandeep Vaidya MD : Nothing to Disclose 1. Arteriovenous malformation (AVM) management variables include location, nidus size and complexity, feeding vessel size, flow speed, and patient comorbidities. 2. AVM nidus elimination is the goal of embolization. Various techniques and agents utilized to optimally permeate and obliterate the nidus. 3. Surgical resection of limited utility due to high rate of recurrence. Utilized in small and very large lesions when AVM fully resectable or too bulky for adequate embolization. 1. Approach to the Non-CNS AVM: peripheral vs. visceral, nidus size and complexity, feeding vessel, flow speed, patient co-morbidities. Depicted with 3-D reconstructions and imaging 2. Management strategies: surgery, embolization, laser, medical; flow controlling techniques and indications. Depicted by illustrations, videos, 3-D reconstructions, imaging, and gross pathology 3. Characterization and indications of embolic agents: absolute ethanol, cyanoacrylate adhesives ('glue'), ethylene vinyl alcohol copolymer (Onyx). Depicted with illustrations 4. Post-treatment response and follow-up 5. Complications: Infection, bleeding, embolism, infarction, nerve injury (permanent vs. transient), acute renal failure, skin necrosis VIE108 Deep Inferior Epigastric Artery: Often Overlooked but with Clinical Significance Education Exhibits Location: VI Community, Learning Center Anthony Dennis Mohabir MD (Presenter): Nothing to Disclose Gregory Michael Grimaldi MD : Nothing to Disclose Priya Kumar Shah MD : Nothing to Disclose Eric John Gandras MD : Nothing to Disclose Daniel Mark Putterman MD : Nothing to Disclose The purpose of this exhibit is: 1. To review the anatomy and embryology of the deep inferior epigastric artery. 2. To explain the significance of the deep inferior epigastric artery as it pertains to breast flap reconstruction surgery. 3. To demonstrate pathology involving the deep inferior epigastric artery which can be easily overlooked.

17 1. Anatomy and Embryology of the Deep Inferior Epigastric Artery 2. Use in Breast Flap Reconstructive Surgery 3. Pathology involving the Deep Inferior Epigastric Artery with subsequent intervention a. Pseudoaneurysm b. Hematoma c. Association with Aortic endoleak following Endovascular Aneurysm Repair 4. Summary VIE109 Detecting Aortic Graft Complications: A Spectrum of CT Findings Education Exhibits Location: VI Community, Learning Center Khalid Walid Shaqdan MD (Presenter): Nothing to Disclose Shima Aran MD : Nothing to Disclose Ajay K. Singh MD : Nothing to Disclose Elmira Hassanzadeh MD : Nothing to Disclose Anand K. H. Singh MD : Nothing to Disclose Hosam Nabil Attaya MD : Nothing to Disclose Hani H. Abujudeh MD, MBA : Research Grant, Bracco Group Consultant, RCG HealthCare Consulting Author, Oxford University Press Aortic graft complications greatly influence long-term morbidity and mortality rates of abdominal aortic aneurysm (AAA) repair. Increased detection of graft-related complications are achieved with a better understanding of imaging characteristics The aim of this exhibit is to describe aortic graft complications and illustrate key imaging findings Background/Literature review o Types of stent grafts Vanguard Endologix Zenith o Imaging techniques for graft surveillance: Plain radiograph CT MRI Digital subtraction angiography Ultrasound Nuclear medicine studies o Protocol in Post Endovascular Aneurysm Repair Surveillance Radiographic features of complications: o Endoleaks o Para-anastomotic aneurysm True False o Graft-enteric erosion/fistula o Graft Infection o Colon Ischemia o Graft Thrombosis o Device migration Alternative to imaging for post-evar surveillance o Pressure monitoring sensors VIE110 Embolotherapy: Identifying Risks and Choosing the Right Agent Education Exhibits Location: VI Community, Learning Center Khalid Walid Shaqdan MD (Presenter): Nothing to Disclose Shima Aran MD : Nothing to Disclose Ajay K. Singh MD : Nothing to Disclose Elmira Hassanzadeh MD : Nothing to Disclose Hani H. Abujudeh MD, MBA : Research Grant, Bracco Group Consultant, RCG HealthCare Consulting Author, Oxford University Press Embolotherapy has become an increasingly popular procedure in the field of interventional radiology. There are numerous embolic agents, each with its own characteristics that makes it ideal for certain situations. Familiarity with these characteristics can help in selecting the appropriate agent depending on the goal of embolization. The aim of this exhibit is to describe the several types of commonly used embolizing agents, and a systematic method to determine when to use each agent. Background o Embolic agents Important physical and biological properties

18 Large vessel embolic agents Coils Balloons Amplatzer vascular plug Guide wires Suture material Autologous clot Small vessel embolic agents Particulate embolic agents Liquid agents Powder substances Determining embolization agent according to: o Size of vessel o How long should the vessel stay occluded o Should embolized tissue remain viable Advantages and disadvantages of embolization o Methods to decrease certain adverse effects Complications of embolization agents VIE111 Endoleaks: The Achilles Heel of Endovascular Aortic Aneurysm Repair (An image-based Review of the Diagnosis and Management of Endoleaks) Education Exhibits Location: VI Community, Learning Center Ekow A. Mills-Robertson MD (Presenter): Nothing to Disclose 1. Discuss the different imaging options utilized for aortic aneurysm surveillance after EVAR. 2. Review the detection and characterization of different endoleak types. 3. Explain the general approach to endoleak management based on imaging findings. 1. Introduction of EVAR and its advantages/disadvantages 2. Different imaging modalities used for aneurysm size surveillance (US, CT, MRI, DSA) 3. Classification scheme for types of endoleaks 4. Case examples of different endoleak types 5. Endoleak management strategy based on imaging findings VIE112 Endovascular Treatment of Hemoptysis, Our Experience Over a 13 year Period Education Exhibits Location: VI Community, Learning Center Alex Roberto Ramirez MD (Presenter): Nothing to Disclose Paula Hernandez Mateo MD : Nothing to Disclose Juan Pablo Gibbs MD : Nothing to Disclose Jose Mendez Montero : Nothing to Disclose Javier Armijo : Nothing to Disclose Marco Leyva Vasquez Caicedo MD, MSc : Nothing to Disclose To know the importance of hemoptysis as a life-threatening condition, with a variety of underlying causes, that deserves urgent investigation and intervention. To discuss the use of computed tomographic angiography (CTA) in the detection of the site and cause of hemoptysis. To review the relevant anatomy, interventional techniques, success rate, complications and long term results of bronchial artery embolization (BAE) as endovascular treatment of hemoptysis. To present our experience in the endovascular treatment of hemoptysis, along with the results of a 13-years period. We will review the major features of the diagnostic and endovascular treatment of hemoptysis, with emphasis in our institutional experience, including: VIE113 Relevant anatomy Causes Role of the Computed Tomography Angiography (CTA) and Digital Subtraction Angiography (DSA) in the diagnosis of hemoptysis with radiological findings Indications for treatment Bronchial artery embolization technique. Outcomes including complications. Short and long term follow-up Evaluating and Managing Endoleaks Education Exhibits

19 Location: VI Community, Learning Center Joanna Kee-Sampson MD (Presenter): Nothing to Disclose Aaron Himchak MD : Nothing to Disclose At the conclusion of this exhibit, the viewer will: 1) Be able to detect and differentiate the various types of endoleaks on CT angiography and conventional angiography. 2) Have a basic understanding of the procedural aspects of endoleak repair and be familiarized with post-repair results. 3) Have an understanding of the surveillance of endoleaks. This will be presented in a quiz format: 1) Brief background on endovascular aneurysm repair (EVAR). 2) Introduction of endoleaks (clinical significance, natural history, risk factors) 3) Diagnosis and clinical surveillance of endoleaks (CT, CTA, duplex ultrasound) 4) Types I-V endoleaks will each be discussed in terms of: a. Definition b. Specific imaging findings (CTA, antiography) c. Repair of each type of endoleak i. Type I and III (balloon dilatation, relayering endograft, extending endograft, endoanchors) ii. Type II (embolization) iii. Type IV (self-limited) iv. Type V (treatment controversial, will present literature review) 5) Follow-up of endoleaks post repair VIE115 Finding the NIDUS: Detection and Work-up of Non-CNS AVMs Education Exhibits Location: VI Community, Learning Center Selected for RadioGraphics Gregor Martin Dunham MD (Presenter): Nothing to Disclose Donald J. Perry MD : Nothing to Disclose Jeffrey Harold Maki MD, PhD : Research Consultant, Merge Healthcare Incorporated Research support, Bracco Group Research support, Bayer AG Speakers Bureau, Lantheus Medical Imaging, Inc Sandeep Vaidya MD : Nothing to Disclose 1. Non-CNS lesions can occur anywhere, most commonly in the limbs and pelvis. Radiology plays a crucial role in detection, work-up, and management. 2. Complex tortuous anatomy must be delineated for proper management. 3. Ultrasound provides easy confirmation of suspected AVM and quantitative analysis. 4. Appropriate MR sequencing and proper CT and MR contrast timing vary based on location and size of AVM. 5. Angiography historically gold-standard for diagnosis, however currently reserved for management. 1. Initial presentation: patient characteristics; symptoms; dermatologic findings; syndromes- von Klippel- Trenaunay-Weber and Osler-Weber-Rendu. 2. Definition and classification: AVM vs. hemangioma vs. venous angioma vs. other vascular anomalies; Hamburg classification. Depicted with imaging and illustrations. 3. Diagnosis and Work-up: ultrasound including velocity waveform analysis and duplex doppler; MRA and CTA including sequencing, contrast timing, and 3-D reconstructions; Angiography; Radionucliotide-labeled microsphere shunt study; work-up algorithm. Depicted with imaging, video, 3-D reconstructions, and illustrations. VIE116 Flow-Diverter Devices for Intracranial Aneurysm Treatment: How, When and Why Education Exhibits Location: VI Community, Learning Center Teresa Gonzalez De La Huebra Labrador (Presenter): Nothing to Disclose Roberto Correa Soto : Nothing to Disclose Ricardo Corrales Pinzon : Nothing to Disclose Aurymar Fraino : Nothing to Disclose Jesus Garcia Alonso : Nothing to Disclose Jose Antonio de las Heras Garcia : Nothing to Disclose Luis Velasco Pelayo : Nothing to Disclose To review the indications of endovascular treatment of intracranial aneurysms, with special emphasis on the use of flow-diverter devices. To become familiar with the procedure and potential complications. - Intracranial aneurysm - Diagnostic imaging - Endovascular treatment - Flow-diverter devices:

20 VIE117 Indications Contraindications Procedure Complications Gastrointestinal Bleeding in Patients with Left Ventricular Assist Devices Interventional Radiology's Role in Diagnosis and Management Education Exhibits Location: VI Community, Learning Center Certificate of Merit Ashley Elizabeth Prosper MD (Presenter): Nothing to Disclose Michael David Katz MD : Nothing to Disclose Review the mechanics of Left Ventricular Assist Devices (LVADs) and their effects on cardiovascular physiology Discuss the multiple risk factors for bleeding in patients with LVADs Review the most likely sites of gastrointestinal bleeding in patients with LVADs Discuss an approach to the evaluation of gastrointestinal bleeding in LVAD patients and how IR plays a role Schematic review of LVADs and their mechanics Discussion of altered perfusion in patients with LVADs including continuous flow and decreased pulse pressure An explanation of coagulopathy in the LVAD patient: anticoagulation, decreased vwf, platelet destruction and angiodysplasia A stepwise approach to evaluating GI bleeding in LVAD patients Selected angiographic case review from our institution When to consider empiric embolization VIE118 How We Do It: Evaluation and Management of Acute Upper Gastrointestinal Bleeding Education Exhibits Location: VI Community, Learning Center Jennifer Frances Feneis MD (Presenter): Nothing to Disclose Raja Ramaswamy MD : Nothing to Disclose Kevin Charles McCammack MD : Nothing to Disclose Gerant M. Rivera-Sanfeliz MD : Nothing to Disclose Overview: Acute upper gastrointestinal bleeding can lead to significant morbidity and mortality without appropriate treatment. The role of interventional radiology is crucial in patients that have persistent bleeding despite medical and endoscopic treatment. In this educational exhibit we will review the following: ACR Appropriateness Criteria for the radiologic management of upper gastrointestinal tract bleeding. The practical utilization of radiologic modalities (CT/Nuclear medicine) Underlying etiologies that can lead to acute upper GI bleeding The role of Interventional Radiology in the therapeutic management with endovascular angiography and transcatheter embolization Provide insight into the essential role of Interventional Radiology in the management of acute upper GI bleeding. Introduction Clinical evaluation and patient management Review ACR appropriateness criteria The utilization of CTA and Nuclear Medicine Angiographic evaluation and management Use of gelfoam, PVA, coils, onyx, glue in the management of upper GI bleeding Review technical approach to upper GI bleeding specifically using a case-based approach Conclusions and Future Directions VIE119 Interventional Radiology (IR) in the Management of Visceral Artery Pseudoaneurysms: A Review of Techniques and Embolizing Agents Education Exhibits Location: VI Community, Learning Center Madhusudhan Kumble Seetharama MD, FRCR (Presenter): Nothing to Disclose Shivanand Ramachandra Gamanagatti MBBS, MD : Nothing to Disclose Deepnarayan Srivastava : Nothing to Disclose Arun Kumar Gupta MBBS, MD : Nothing to Disclose 1. To illustrate various techniques and embolizing agents used in the management of visceral artery pseudoaneurysms. 2. To discuss and review the performance of each technique and / or embolizing agent. 1. Brief review of pathophysiology of visceral artery pseudoaneurysms. 2. Various techniques (endovascular, percutaneous and endoscopic) and embolizing agents used in the management of visceral artery pseudoaneurysms. 3. Advantages and disadvantages or risks of each technique and / or embolizing agent.

21 VIE120 Introduction of Occlusion Balloons in Anterior Division of the Hipogastric Artery as a Prophylaxis Measure for Intraoperative Blood Loss in Cases of Placenta Accreta Education Exhibits Location: VI Community, Learning Center Neus Rus Calafell (Presenter): Nothing to Disclose Mercedes Perez-Lafuente : Nothing to Disclose Carla Gonzalez Junyent MD : Nothing to Disclose Maria Pardo-Antunez : Nothing to Disclose Miguel Angel Macedo Pascual MD : Nothing to Disclose Antoni Segarra Medrano : Nothing to Disclose Arantxa Gelabert Barragan : Nothing to Disclose - Imaging findings in the diagnosis of placenta accreta during the gestation using ultrasound and MRI. - The placement of angioplasty occlusive balloons can reduce the risk of bleeding in cases of placenta accrete The main objective is describe our experience in placement of angioplasty occlusive balloons into the anterior trunk of hypogastric arteries in order to reduce the intraoperative bleeding in patients with placenta accreta. Thus, a descriptive analysis of the procedure will be shown. Firstly, angioplasty balloons are placed into the anterior division of hypogastric arteries through bilateral catheterization of common femoral artery. Secondly, the balloons are inflated in order to check the arteries are totally occluded and, subsequently, they are attached to the arterial sheaths and these arethen set to the patient's skin. Patients undergo caesarean delivery and, if necessary, the balloons are inflated in order to get intraoperative proper hemostasy. Finally, the balloons are removed immediately after the caesarean procedure but arterial sheaths are removed 24h later depending on patient's evolution. The intraoperative blood loss can be reduced by using angioplasty balloons in patients suffering from placenta accreta. This may improve the prognosis of these patients. VIE121 It s Not Always Only Medical! Type B Aortic Dissection: What the Vascular Surgeon Wants to Know before and after the Intervention Education Exhibits Location: VI Community, Learning Center Mickael Ohana MD, MSc (Presenter): Nothing to Disclose Aissam Labani MD : Nothing to Disclose Mi-Young Jeung MD : Nothing to Disclose Yannick Georg MD, MSc : Nothing to Disclose Fabien Thaveau : Nothing to Disclose Christof Karmonik PhD : Nothing to Disclose Jean Bismuth : Nothing to Disclose Nabil Chakfe MD, PhD : Nothing to Disclose Catherine Roy MD : Nothing to Disclose Become familiar with CT and MRI acquisitions protocols used in type B aortic dissection. Be able to radiologically define a complicated acute type B aortic dissection. Exploit information from CTA and 4D-angioMRI to locate entry/reentry tears and achieve precise sizing before endovascular treatment. Learn how to follow-up type B dissections in the acute and the chronic settings, according to whether they were treated surgically or medically. 1. Introduction 1.1 Definition and physiopathology 1.2 Prevalence and prognosis 1.3 Current therapeutic management 2. Imaging protocols 2.1 CTA 2.2 MRA 3. Surgical indications 3.1 Malperfusion 3.2 Perioaortic hematoma / hemorrhagic pleural effusion 3.3 Aneurysmal evolution 4. What to look for before endovascular or open surgery 4.1 Entry/reentry tears 4.2 Sizing 5. How to follow-up these patients 5.1 Recommended CTA/MRA intervals 5.1 What to look for after open or endovascular surgery 5.2 What to look for after initial medical treatment 6. Conclusion VIE122 Minimally-Invasive Interventions in the Treatment of Non-Traumatic Splenic Disorders A Whirlwind Tour of Splenic Vascular Anomalies, Gastric Varices Secondary to Sinistral Hypertension, and Hypersplenic Thrombocytopenia Education Exhibits Location: VI Community, Learning Center Certificate of Merit John J. Park MD, PhD (Presenter): Nothing to Disclose Jinha Park MD, PhD : Speakers Bureau, Bayer AG Advisory Board, Guerbet SA Advisory Board, Koninklijke Philips NV Jonathan M. Kessler MD : Nothing to Disclose Although trauma remains a key indication for many minimally-invasive splenic interventions, other non-traumatic indications are becoming more common as advances in transcatheter techniques offer novel and viable alternatives to surgery. As a result,

22 it is important to have a firm understanding of splenic anatomy and the pathophysiology behind these other treatable types of splenic disorders. 1. Review the anatomy and pathophysiology involved in selected non-traumatic splenic disorders, including splenic vascular anomalies, gastric varices due to sinistral portal hypertension, and hypersplenic thrombocytopenia 2. Provide the reader with the various indications, diagnostic imaging, interventions, contraindications, and potential complications related to non-trauma related splenic interventions. 3. Study real case examples of different splenic interventions in order to showcase various imaging and interventional techniques in the treatment of various spleen-related disorders. A. Splenic anatomy B. Pathophysiology of selected disorders related to the spleen. C. Current indications for splenic interventions in the non-trauma settingc. D. Highlight minimally-invasive techniques employed in the treatment of disorders related to the spleen. E. Key imaging and interventional points related to splenic interventions. VIE123 Nellix Endograft Repair of Aortic Aneurysm: Pictorial Review of the Normal and Abnormal CT Appearances Education Exhibits Location: VI Community, Learning Center Certificate of Merit Alex Weller (Presenter): Nothing to Disclose Mohammad Shah MBBS : Nothing to Disclose Seyed Ameli-Renani MBBS, FRCR : Nothing to Disclose Anisha Patel MBCHB : Nothing to Disclose Graham John Munneke MBBS : Nothing to Disclose Ioannis Vlahos MRCP, FRCR : Research Consultant, Siemens AG Research Consultant, General Electric Company Robert Anthony Morgan MD : Consultant, Cook Group Incorporated Consultant, AngioDynamics, Inc Proctor, Covidien AG Nellix endoprosthesis is a novel and increasingly utilised device for aorto-iliac aneurysm repair, with unique CT appearances that alter with time and are prone to misinterpretation. We present a pictorial review based on our institutional experience of more than 60 Nellix cases. 1-Review the NELLIX device: principle, materials and procedure of deployment. 2-Understand early and long term CT features following stent insertion. 3-Outline surveillance, including CT protocols and the roles of Duplex and angiography. 4-Review device related complications. 1. NELLIX device- composition, indications, contraindications 2. NELLIX deployment technique. 3. Short and long term post insertion device appearances. 4. CT surveillance protocol and the role of ancillary imaging modalities. 5. Potential complications and their remedies. 6. Unrecognised pitfalls and future challenges. VIE124 Novel Techniques for Catheterizing the Excluded Aneurysm Sac for the Purpose of Embolization of Endoleaks Associated with Endovascular Repair of AAAs Education Exhibits Location: VI Community, Learning Center Assaf Graif MD (Presenter): Nothing to Disclose Mark Joseph Garcia MD : Nothing to Disclose Christopher Joseph Grilli DO : Nothing to Disclose Clinton W. Wrigley MD : Nothing to Disclose Daniel Andreas Leung MD : Nothing to Disclose 1. To review the pathophysiology and prognosis of endoleaks after AAA repair. 2. Discuss the benefits of Onyx (EV3 Inc., Plymouth, MN) as a liquid embolic agent, as compared to coils. 3. Pictorial description of the different approaches to endoleak repair using Onyx, while focusing on type II endoleaks. A. Short review of the 5 types of endoleaks. B. Focused review of the pathophysiology, prevalence, complications and prognosis of untreated type II endoleaks. C. Current indications for treatment of endoleaks. a. Follow-up protocols: CT and/or ultrasound b. Size criteria D. Short description of Onyx and its properties. E. Describing the different techniques of accessing the aneurysmal sac, when using onyx: a. Endovascular: i. Accessing the inferior mesenteric artery through the marginal artery of Drummond. ii. Catheterizing lumbar arteries via the internal iliac and iliolumbar arteries. b. Direct sac access: i. CT or fluoroscopic guided translumbar ii. Ultrasound guided transabdominal c. Combined endovascular/direct approach; a novel method of accessing the aneurysm sac by perigraft catheterization between the endograft and the vascular wall at an anastomotic site. F. Comparing and contrasting the different repair techniques in regards to indications, efficacy, and complications. VIE126 Postpancreatectomy Hemorrhage: Case Review of Radiologic Imaging and Intervention

23 Education Exhibits Location: VI Community, Learning Center Certificate of Merit Ellen Cheang MD (Presenter): Nothing to Disclose Danny Cheng MD : Nothing to Disclose Gary Garlup Tse MD : Nothing to Disclose David Cheng MD : Nothing to Disclose David Vegas MD : Nothing to Disclose 1. Whipple pancreatoduodenectomy has up to 50% post-operative morbidity rate. Postpancreatectomy hemorrhage is seen in 24 hours). Early hemorrhage is often caused by technical failure to achieve hemostasis. Late hemorrhage is often caused by ulcers, vascular erosions, pseudoaneurysms, fistulas or anastomotic dehiscence. 3. CT angiography may help identify the bleeding site in hemodynamically stable patients. DSA delineates vascular anatomy and also guides endovascular treatment. 4. GDA stump is the most common location of hemorrhage. Less common locations include the hepatic artery, celiac axis, splenic artery, and inferior pancreaticoduodenal artery. Bleeding from an anastomotic ulcer is rare. 5. Endovascular treatments include embolization and stent grafting. If bleeding occurs from a pseudoaneurysm, packing of the pseudoaneurysm should be avoided since the weak wall is associated with a high risk of rebleeding. 1. Review of post-whipple anatomical considerations 2. Review of common etiologies of post-whipple hemorrhage 3. Case review of endovascular treatment of post-whipple hemorrhage VIE128 Recanalization of Chronic Total Occlusions Using the Crosser Vibrational Atherectomy Catheter Education Exhibits Location: VI Community, Learning Center Alex C. Penn MD (Presenter): Nothing to Disclose Jeffrey Chil-jek Sung MD, MBA : Stockholder, Pfizer Inc Stockholder, Gilead Sciences, Inc To understand the indications, methods of use and factors which may affect technical success of the Crosser (Bard Peripheral Vascular, Tempe, AZ) high-frequency vibrational catheter for traversal of chronic total occlusions. A. Anatomy (Vascular anatomy and anatomy of occlusive lesions) B. Diagnostic Imaging (US, CTA, diagnostic angiography) C. Review of Indications, Contraindications D. Treatment (Use of the Crosser device for traversal of CTOs) E. Follow-up Management F. Outcomes (include complications) VIE129 Segmental Arterial Mediolysis (SAM): A Pictorial Review Education Exhibits Location: VI Community, Learning Center Cum Laude Jay Patel MD (Presenter): Nothing to Disclose Joanna Kee-Sampson MD : Nothing to Disclose Nishith Patel MD : Nothing to Disclose Thaddeus M. Yablonsky MD : Nothing to Disclose Sean Keith Calhoun DO : Nothing to Disclose 1. Review the history, pathophysiology and clinical presentation of SAM 2. Learn imaging features of SAM on a variety of modalities 3. Discuss the differential diagnosis and treatment options for SAM History Pathophysiology Clinical presentation CTA and MRA findings Angiographic findings Complications - thrombosis, arterial wall hemorrhage, dissection, ischemia, aneurysm rupture Differential diagnosis - vasculitis, fibromuscular dysplasia, atherosclerotic disease, arterial trauma, inflammatory pseudoaneurysm Treatment - medical/conservative therapy, angioplasty, embolization Conclusion VIE130 Slow the Flow: The Role of Interventional Radiology in Managing Obstetrical Emergencies Education Exhibits

24 Location: VI Community, Learning Center Rebecca Zener MD (Presenter): Nothing to Disclose Daniele Patrice Wiseman MD, FRCPC : Nothing to Disclose Amol Mujoomdar MD : Speaker, Cook Group Incorporated Speaker, Covidien AG The purpose of this exhibit is: 1. To review the clinical problem and diagnosis of invasive placenta 2. To discuss the role of interventional radiology in the management of invasive placenta 3. To review the role of interventional radiology in the management of post-partum hemorrhage from both invasive placenta, and other causes Clinical and diagnostic overview of the invasive placenta spectrum (placenta accreta, increta and percreta) Review of the imaging diagnosis of invasive placenta Internal iliac artery balloon occlusion for invasive placenta Role (prophylactic, emergent) Technique Cases Uterine artery embolization in managing post-partum hemorrhage Role Technique Cases Summary VIE131 Some of Peritoneal and Retroperitonial Bleedings Could be SAM! Education Exhibits Location: VI Community, Learning Center Hiroshi Kondo MD : Nothing to Disclose Yukichi Tanahashi MD (Presenter): Nothing to Disclose Hiroshi Kawada MD : Nothing to Disclose Yoshifumi Noda MD : Nothing to Disclose Satoshi Goshima MD, PhD : Nothing to Disclose Masayuki Kanematsu MD : Nothing to Disclose Segmental arterial mediolysis (SAM) is a rare condition and presents with intra-abdominal bleeding which may result in a life-threatening situation. Unruptured aneurysms were rarely exacebated and could be followed-up by contrast-enhanced CT. Understanding and recognizing radiologic features of SAM is critical for an accurate diagnosis and determination of appropriate treatments. Review the various clinical manifestations of SAM. Presentation of characteristic imaging findings of SAM including string of beads, fusiform and saccular formation of aneurysms, and arterial wall thickening and dissection. Review the clinical indications and treatment options of transcatheter arterial embolization. Discussion of the diagnostic problems and the treatment strategies. VIE132 Takayasu Arteritis: Current Status of Imaging Diagnosis Education Exhibits Location: VI Community, Learning Center Kenichi Yokoyama MD (Presenter): Nothing to Disclose Toshiaki Nitatori MD : Nothing to Disclose Masamichi Imai : Nothing to Disclose Toshiya Kariyasu : Nothing to Disclose Maiko Yoshida MD : Nothing to Disclose Mitsuteru Tsuchiya : Nothing to Disclose Makiko Nishikawa : Nothing to Disclose Yusuke Kinoshita : Nothing to Disclose Yayoi Tsukahara : Nothing to Disclose Masanaka Watanabe : Nothing to Disclose 1. Recent advances in imaging modalities allow not only early diagnosis but also detailed assessment of localization and activity of vascular lesions of Takayasu arteritis (TA) including aorta and its branches, coronary artery, and pulmonary artery. 2. These imaging modalities also provide the information of fatal or serious arterial complication of TA and may be helpful for planning and modifying treatment. The pictorial review of the imaging findings of TA and its differential diagnosis - Aorta and its branches - Coronary artery - Pulmonary artery - Iliac and femoral artery - Others Recent advances in imaging modalities for evaluating vascular lesions of TA - Multidetector-row CT or CT angiography - MRI or MR angiography - FDG-PET/CT - Others The characteristics and the role of imaging for the fatal or serious arterial complication of TA - Aortic regurgitation - Aortic aneurysm, dissection, atypical coarctation of aorta - Renal arterial stenosis - Others VIE133 Technical Recommendations for Intra-arterial Therapy in Rat Liver Tumor Model Education Exhibits Location: VI Community, Learning Center Cum Laude

25 Hideyuki Nishiofuku (Presenter): Nothing to Disclose Toshihiro Tanaka MD : Nothing to Disclose Yasushi Fukuoka : Nothing to Disclose Takeshi Sato : Nothing to Disclose Hiroshi Anai MD, PhD : Nothing to Disclose Kimihiko Kichikawa MD : Nothing to Disclose Shinsaku Maeda : Nothing to Disclose Tetsuya Masada : Nothing to Disclose Rat liver tumor models have been improved and are widely used for various preclinical studies in interventional oncology. Most of the previous studies of intra-arterial therapy were performed under laparotomy, with the insertion of catheter via gastroduodenal artery. Recently, image-guided angiographic techniques have been developed. The purpose of this exhibit is: (1) To learn about the techniques of preparation of rat liver tumor models. (2) To learn about the interventional techniques for intra-arterial therapy in rat. (3) To learn about the anatomical variations of hepatic artery in rat. Contents (1) Cell culture methodologies and tumor implantation procedures, e.g. direct injection, portal vein injection and splenic parenchymal injection. (2) Tumor cell lines and animal models in terms of hepatocellular carcinoma and colorectal cancer, e.g. McA-RH7777 in SD rat and RCN-9 in F344 rat. (3) Transcatheter arteriography techniques, carotid artery approach and femoral approach with/without the combination of laparotomy. (4) Type and frequency of the anatomical variations of hepatic artery. (5) Applications for clinical studies. Summary Image-guided intra-arterial therapy in rat liver tumor model is feasible and useful for preclinical studies in interventional oncology. VIE134 The Role of Diagnostic and Interventional Radiology in the Management of Visceral and Renal Artery Pseudoaneurysms Education Exhibits Location: VI Community, Learning Center Anthony Cox MBBS : Nothing to Disclose Priti Dutta MD (Presenter): Nothing to Disclose Anthie Maria Papadopoulou MBBS : Nothing to Disclose Anthony Goode : Nothing to Disclose Nick Woodward MBBS : Nothing to Disclose Kate Steiner MBBS : Nothing to Disclose Neil Hunter Davies MBBS : Nothing to Disclose Pseudoaneurysms arising from visceral and renal arteries are potentially life-threatening entities frequently requiring urgent or emergent treatment. State-of-the-art cross-sectional imaging with increased sensitivity in the detection of small or clinically silent lesions enables early diagnosis and prompt therapeutic intervention. Endovascular techniques now have an established role in their treatment. This poster aims to review the aetiology, clinical presentation, cross-sectional and angiographic imaging appearances of visceral and renal pseudoaneurysms according to anatomic location and to illustrate the endovascular treatment options. Visceral and renal artery pseudoaneurysms are presented according to anatomic location reviewing their aetiology and natural history, clinical presentation, cross-sectional imaging appearances and angiographic findings. Particular considerations with regards to planning endovascular treatment are reviewed and the endovascular method employed for definitive treatment is illustrated. VIE135 Transcatheter Embolization Techniques with N-Butyl Cyanoacrylate (NBCA) Education Exhibits Location: VI Community, Learning Center Hiro Kiyosue MD (Presenter): Nothing to Disclose Shuichi Tanoue MD : Nothing to Disclose Miyuki Maruno MD : Nothing to Disclose Norio Hongo : Nothing to Disclose Hiromu Mori MD : Nothing to Disclose The teaching points of this exhibit are: 1. General property of n-butyl cyanoacrylate (NBCA) 2. Basic technique of transcatheter embolization with NBCA 3. Specific and additional techniques for effective embolization for various vascular lesions A. General property of NBCA Adhesive liquid Anionic polymerization (affected by temperature, concentration, flow velocity, and concentration of anion) B. Basic technique of transarterial embolization with NBCA preparation of NBCA-lipiodol mixture selection of concentration of NBCA flushing catheter lumen with glucose injection of NBCA C. Specific and additional techniques for various vascular lesions Target vascular lesions: (Pseudo)aneurysms/extravasation, multiple arteriovenous fistulas, arteriovenous malformations with nidus, a high-flow large arteriovenous fistula, and gastroesphophageal varices) Injection techniques: sandwich injection/continuous injection, wedged catheter/free flow, low-concentration/high-concentration Additional techniques: devasculization of non-target feeder, flow control with coils or balloon, dual injection, warming NBCA VIE136

26 Vascular Complications of Pancreaticoduodenectomy (The Whipple Procedure): Diagnosis and Treatment Education Exhibits Location: VI Community, Learning Center Magna Cum Laude Steven Li-Wen Hsu MD : Nothing to Disclose Anil Kumar Pillai MD : Nothing to Disclose Stephen Phillips Reis MD : Nothing to Disclose Clayton K. Trimmer DO : Nothing to Disclose Sanjeeva P. Kalva MD : Consultant, CeloNova BioSciences, Inc Patrick D. Sutphin MD, PhD (Presenter): Nothing to Disclose 1. Review pancreaticoduodenectomy and its indications 2. Discuss vascular complications of pancreaticoduodenectomy and the associated imaging findings 3. Role of endovascular treatment in post-pancreaticoduodenectomy hemorrhage and vascular complications. Pancreaticoduodenectomy procedure and its indications Vascular complications of pancreaticoduodenectomy Review of International Study Group for Pancreatic Surgery definitions for post-pancreatectomy hemorrhage Diagnostic imaging in the characterization of vascular complications Indications and contraindications for endovascular treatment of vascular complications associated with pancreaticoduodenectomy VIE137 Vascular Complications Related to Arteriotomy Access and Closure: A Pictorial Review Education Exhibits Location: VI Community, Learning Center Rakesh Khubchand Varma MBBS, MD (Presenter): Nothing to Disclose Naganathan Bhagvathy Subra Mani MD : Nothing to Disclose Joshua David Pinter MD : Nothing to Disclose Christopher John Friend MD : Nothing to Disclose To review various techniques and approach for percutaneous arterial access. To review the vascular complications associated with arterial access and closure and their imaging features. To review management of vascular complications related to percutaneous arterial access and closure. Briefly discuss techniques to minimise vascular complications related to arterial access and closure with emphasis on noninvasive imaging. Introduction Techniques:Retrograde/Antegrade, Single/Double wall, Image guidance Approaches: Common femoral, Brachial, Radial, Axillary, Infrapopliteal Vascular Complications: Access and non arteriotomy closure device related: Hematoma, Pseudoaneurysm, Arteriovenous fistula, Dissection Arteriotomy closure device related: Acute thrombosis, Vessel obstruction due to intravascular foreign body, Pseudoaneurysm. Management: US guided thrombin injection Surgery Percutaneous interventions Techniques to minimise complications: Image guidance, pre and post physical examination, Noninvasive imaging. Summary VIE138 Vascular Compression Syndromes Seen in Athletes Education Exhibits Location: VI Community, Learning Center Jordan Gold MD : Nothing to Disclose Danielle Toussie BS : Nothing to Disclose Adam C. Zoga MD : Nothing to Disclose Christopher Geordie Roth MD : Author, Reed Elsevier Sandeep Prakash Deshmukh MD (Presenter): Nothing to Disclose After reviewing this exhibit, participants will be able to: 1. Recognize the multimodality imaging findings associated with various vascular compression syndromes seen in athletes. 2. Describe the anatomic abnormality associated with each syndrome. Each of the following areas will be discussed in regards to each disease entity: Anatomy Pathophysiology Multimodality imaging evaluation Management Disease entities will include the following: Upper extremity: Thoracic outlet syndrome Effort thrombosis Quadrilateral Space Syndrome Lower extremity: May-Thurner Illiac endofibrosis Popliteal artery entrapment VIE139 Vascular Emergency!: Mycotic Aneurysms of the Aorta and Its Branches: Multimodality Imaging Findings with Clinical Correlation and Post Treatment Follow-up Education Exhibits

27 Education Exhibits Location: VI Community, Learning Center Ignacio Beddings MD (Presenter): Nothing to Disclose Alvaro Huete Garin MD : Nothing to Disclose Sanjeev Bhalla MD : Nothing to Disclose Pablo Bachler MD : Nothing to Disclose Maria Jose Baladron MD : Nothing to Disclose Eugenio Zalaquett MD : Nothing to Disclose Matias Gustavo Vargas Araya MD : Nothing to Disclose Christine O. Menias MD : Nothing to Disclose The purpose of this exhibit is: 1. To describe the normal arterial structure and pathophysiology of mycotic aneurysms. 2. To review the clinical manifestations of mycotic aneurysms located in different parts of the aorta and its branches. 3.To depict the usual imaging findings with different modalities: ultrasound, CT, MRI and PET-CT. 4. To discuss prognosis and different treatment options. 5. To illustrate post imaging findings. 1. Normal anatomy and histology of arteries 2. Pathophysiology of infected/mycotic aneurysms. 3. Clinical presentation - Thoracic aorta - Abdominal aorta - Branches of the aorta 4. Multimodality imaging findings with sample cases - US - CT - MRI - PET CT 5. Treatment: Surgical - Endovascular - Medical 6. Prognosis 7. Follow-up imaging VIE140 Vascular Steal Syndromes: Angiographic Imaging Spectrum and Endovascular Management Education Exhibits Location: VI Community, Learning Center Justin Muhlenberg MD, MBA (Presenter): Nothing to Disclose Rajeev Suri MD : Nothing to Disclose Define vascular steal syndromes as distinct clinical entities resulting from preferential shunting of blood away from a target circulation resulting in clinical symptoms. Highlight imaging features and endovascular management of steal syndromes with a brief comment on surgical management. Intended for radiology residents, fellows and practicing radiologists, this exhibit aims to create awareness and highlight treatment options for vascular steal syndromes. Introduction and Teaching Points Pathophysiology of Vascular Steal Syndromes Common Etiologies for Vascular Steal Syndromes Discussion of Various Vascular Steal Syndromes and Endovascular Management Dialysis associated steal syndromes Sublcavian steal syndome TIPS and/or portosystemic collateral steal resulting in hepatic encephalopathy Splenic artery steal resulting in liver ischemia post liver transplant Vascular malformation associated steal causing distal tissue ischemia AAA Type II Endoleak Conclusion and Reiteration of Teaching Points VIE141 Where Is the Leak? Case Based Review of Standard Classification of Endoleaks in Patients with Endovascular AAA Repair and Diagnosing a New Variant of Endoleak Education Exhibits Location: VI Community, Learning Center Nishith Patel MD (Presenter): Nothing to Disclose Jay Patel MD : Nothing to Disclose Thaddeus M. Yablonsky MD : Nothing to Disclose Sean Keith Calhoun DO : Nothing to Disclose 1. Review the indications, patient preparation, and common approaches for various AAA repair. 2.. Learn the imaging features of conventional endoleaks with pathophysiology of complications 3. Describe a new endoleak entity that has not been previously described in the literature. 4. Discuss possible treatment options. After completing this educational exhibit, the reviewer will be familiar with the indications, patient preparation and common approaches for AAA intervention. The reviewer will also be confident in their ability to diagnose, formulate treatment options and manage common complications of endovascular repair. 1. Pathophysiology of Abdominal Aortic Aneurysms 2. Discuss the indications, patient preparation, and common approaches for AAA repair 3. Review of imaging features, treatment options and common complications of standard endovascular AAA repair. 4. Present images of endoleaks that do not fit in standard classification, the new endoleak? 5. Potential Treatment options for the adventitial supply endoleak. VIE142 Advanced Iterative Model Reconstruction in Improving Image Quality of CT Angiography Education Exhibits Location: VI Community, Learning Center

28 Kenneth K. Lau (Presenter): Nothing to Disclose Nicholas David Ardley : Nothing to Disclose Kevin Buchan : Employee, Koninklijke Philips NV Theodore Lau : Nothing to Disclose CT abdominal angiography (CTA) plays a vital role in diagnosing and monitoring conditions such as stenosis, occlusion, thrombo-embolism, aneurysm, dissection, endoleak and gastrointestinal bleed. Its advantages in comparison to digital subtraction angiography (DSA) are shorter acquisition time, non-invasive nature and less procedural complications. Vessel wall calcification may cause beam-hardening artifact that obscures the vessel lumen. The latest Iterative model reconstruction (IMR) is a knowledge-based algorithm that improves low contrast resolution, reduces image noise and artifact. The aim of this exhibit is to assess the diagnostic utility of IMR in CTA. The data sets of CTA of thoracic and abdominal aorta, pulmonary, renal, mesenteric arteries, carotid and cerebral arteries of 156 patients were reconstructed using IMR and idose IRs. 1. The vessel contours and definitions were better visualized down to small vessel with IMR than idose due to image noise reduction. 2. Less beam-hardening artifacts from vessel wall calcified plaques allow accurate luminal assessment. 3.The presence of embolism and dissection were better depicted on IMR CTA. IMR is superior to conventional iterative reconstruction and aids more accurate vascular pathology assessment. VIE143 Aortic Endoprosthesis Follow-up: How, When and Why CT Angiography? Education Exhibits Location: VI Community, Learning Center Maria Eugenia Maccarone MD : Nothing to Disclose Carlos Capunay MD : Nothing to Disclose Javier Vallejos MD, MBA (Presenter): Nothing to Disclose Patricia M. Carrascosa MD : Research Consultant, General Electric Company To describe the multiphasic CT angiography protocol study To define the follow up imaging after stent graft placement To recognize the multiphasic CT angiography as the best choice of non-invasive method to detect and classify endoleaks and other complications Complications after aortic endoprosthesis placement Classification of Endoleaks Imaging techniques: Digital angiography MR angiography Ultrasound CT angiography Follow up imaging after stent graft placement: When CT angiography? VIE144 Breast Reconstruction with DIEP and SGAP Flaps Role of Pre-Operative CT Angiogram Education Exhibits Location: VI Community, Learning Center Cum Laude Gregory Aaron Bonci MD (Presenter): Nothing to Disclose Bohdan Pomahac MD : Nothing to Disclose Dimitris Mitsouras PhD : Nothing to Disclose Stephanie A. Caterson MD : Nothing to Disclose Amir Imanzadeh MD : Nothing to Disclose Meaghan Mackesy MD : Nothing to Disclose Edward J. Caterson MD, PhD : Nothing to Disclose Frank John Rybicki MD, PhD : Research Grant, Toshiba Corporation Perforator flaps offer cosmetically superior results with significantly less morbidity than TRAM flaps. Choice of flap is dependent on patient anatomy and quality of vasculature. Pre-operative CTA effectively maps perforators, decreases operative time, and decreases morbidity/complications. Post-processing may also help to determine exact tissue volume to be harvested for more targeted reconstruction. 1. Autologous breast reconstruction basics (patient selection, aim, timing of surgery, advantages over breast implants). 2. Overview and evolution of flap options with focus on deep inferior epigastric perforator (DIEP) and superior gluteal artery perforator (SGAP) flaps. 3. Overview of pre-operative imaging including Doppler ultrasound, CTA, and MRA. Brief review of literature demonstrating the advantages of CTA with regard to duration of surgery, length of hospitalization, and complication rates. 4. Importance of angiosomes in perforator flap surgery. Alteration of imaging protocols to better determine flap vascular supply and reduce likelihood of fat necrosis. 5. Future directions include 3D printing of perforator flaps for more customized pre-operative planning. VIE145 Clinical Applications of Single-source Dual-energy CT with Fast kvp Switching in CT Angiography: What the Radiologist Needs to Know Education Exhibits

29 Location: VI Community, Learning Center Selected for RadioGraphics Haruhiko Machida MD (Presenter): Nothing to Disclose Isao Tanaka : Nothing to Disclose Rika Fukui : Nothing to Disclose Yun Shen PhD : Employee, General Electric Company Researcher, General Electric Company Takuya Ishikawa : Nothing to Disclose Eiko Ueno MD : Nothing to Disclose Etsuko Tate : Nothing to Disclose He Qing Wang MSc : Nothing to Disclose To review limitations of conventional CT angiography (CTA) To describe basic principles and various techniques in single-source dual-energy CT (DECT) with fast kvp switching to overcome these limitations To illustrate various clinical applications and advantages using these techniques by presenting clinical images Limitations of conventional CTA Iodine contrast medium (CM)/radiation dose Insufficient vessel contrast enhancement (CE) Severe calcification Limited tissue characterization/perfusion assessment Metallic/beam-hardening (BH) artifacts Basic principles and various techniques in DECT BH correction Monochromatic imaging (MI) Material density imaging (MDI) Energy level (kev)-ct value (HU) curve Effective atomic number (Z) histogram Iterative reconstruction (IR) Various clinical applications and advantages CM dose reduction/improved vessel CE: low-kev MI/iodine (water) MDI with IR Radiation dose reduction: water (iodine) MDI replacing non-ce CT/IR Calcium reduction: iodine (calcium/hydroxyapatite) MDI Lipid-rich plaque detection: fat (water) MDI/keV-HU curve/effective Z histogram Differentiation among CM, calcification, fresh hematoma: MDI Tissue perfusion assessment: iodine (water) MDI VIE146 Contrast Medium Delivery Strategies and Radiation Dose Parameters Affecting CT Angiography Education Exhibits Location: VI Community, Learning Center Charbel Saade MS (Presenter): Nothing to Disclose Fadi M. El-Merhi MD : Nothing to Disclose Ali A. Haydar MD, FRCR : Nothing to Disclose Ghaleb Ghusayni : Nothing to Disclose Salam Al-Hamra : Nothing to Disclose Mukbil H. Hourani MD : Nothing to Disclose Bedros Taslakian MD : Nothing to Disclose Hussain Al-Mohiy : Nothing to Disclose - Optimal opacification of the arteries is essential for CTA - Matching timing with vessel dynamics significantly improves vessel opacification - This leads to increased arterial opacification and reduced venous opacification - This can also lead to a reduced volume of contrast agent. - This can also lead to reduced radiation dose A. Vascular Anatomy B. contrast media parameters that affect bolus shaping C. scanner parameters that affect vascular opacification D. scanner and contrast parameters affect radiation dose E. stenosis and aneurysm effects on blood/contrast circulation F. Pearls and Pitfalls G. Outcomes VIE147 Dual Energy CT Angiography with Reduced Iodine Load: A Comprehensive and Practical Approach Education Exhibits Location: VI Community, Learning Center Certificate of Merit Patricia M. Carrascosa MD : Research Consultant, General Electric Company Carlos Capunay MD (Presenter): Nothing to Disclose Javier Vallejos MD, MBA : Nothing to Disclose Alejandro Deviggiano MD : Nothing to Disclose Gaston Rodriguez Granillo : Nothing to Disclose 1- To review the indications, diagnostic imaging, potential benefits and limitations of performing a dual-energy CT angiography with reduced iodine contrast volume. 2- To understand the advantages of dual energy CT in vascular imaging.

30 A. Introduction to dual energy CT. Physics B. Image analysis. Spectral imaging. Material decomposition. Calcium and bone subtraction. C. CT image acquisition. Technical parameters. Radiation issues D. Contrast injection protocol E. Diagnostic Imaging F. Potential indications. Outcomes VIE148 Eyes Wide Open: Impending Death Signs in Cardiovascular Disease; What Every Radiologist Should Fear Education Exhibits Location: VI Community, Learning Center Alvaro Acosta Bustillos (Presenter): Nothing to Disclose Sergio A. Criales Vera MD : Nothing to Disclose David Zamora Contreras MD : Nothing to Disclose Daniela Angulo Salazar MD : Nothing to Disclose Francisco Castillo-Castellon MD : Nothing to Disclose Luis Antonio Sosa MD : Nothing to Disclose Moises Jimenez : Nothing to Disclose 1. There are some MDCT findings of impending death in cardiovascular disease that the radiologist should be aware in order to communicate immediately to the medical and surgical team. 2. This signs are aortic rupture, collapse of the true lumen in aortic dissection, contrast-fluid levels in the vena cava, cardiac tamponade, intramural haematoma more than 3 cm, and others. 3. To provide relevant information to the medical team which might be crucial for the appropriate treatment. /AIM Review the most common signs of impending death in cardiovascular disease. Describe imaging findings in Multidetector Computed Tomography (MDCT) of impending death in cardiovascular disease. Describe relevant information for clinicians and surgeons provided by MDCT. CONTENT ORGANIZATION (Introduction) common signs of impending death in cardiovascular disease and its clinical relevance. MDCT technique requirements and special considerations. MDCT findings of impending death: of coronary arteries, heart chambers, pericardium, thoracic and abdominal aorta, supraaortic and mesenteric vessels, and IVC. Relevant information for the clinicians and surgeons that might aid in treatment planning. VIE149 Nitroglycerin Sprays Benefit the Vessel Depiction Performance Improvement in Abdominal CTA Education Exhibits Location: VI Community, Learning Center Ryusuke Kujirai RT (Presenter): Nothing to Disclose Susumu Sato RT : Nothing to Disclose Ryohei Horisawa RT : Nothing to Disclose Yutaka Suzuki RT : Nothing to Disclose Kenichi Ando RT : Nothing to Disclose Our facility is using nitroglycerin spray in for the purpose of widening the coronary artery in coronary CTA. There is work to dilate the blood vessels throughout the body as well as expand the coronary arteries to nitroglycerin. We have investigated whether also useful in abdominal CTA to use this effect. It was studied in 15 patients taken at 120kV and 80kV. without nitroglycerin (80kV/120kV) with nitroglycerin (80kV/120kV) Compared patient is 70.4 years average age. Each image was visually evaluated according to the fifth rated of image quality and vascular depiction performance displays in VR. Quality and vascular depiction performance is improved easily by using nitroglycerin. This effect is greater than the effects obtained at a low tube voltage. There was no significant difference 120KV and 80kV using nitroglycerin. It is possible to be used for different parts and integrated tube voltage. Nitroglycerin Spray is possible to enhance the depiction performance while still ensuring the quality of the CTA. VIE150 Novel Contrast-Injection Protocol for High Resolution Abdominal CT-Angiography: Vascular Visualization Improvement with Vasodilator Education Exhibits Location: VI Community, Learning Center Certificate of Merit Minori Hoshika (Presenter): Nothing to Disclose Norimi Nishiyama : Nothing to Disclose Yuki Kobayashi : Nothing to Disclose Yoshihiro Takeda MD : Nothing to Disclose

31 To review the advantages and limitations of CT-Angiography(CTA). To provide an explanation of the new examination method and conventional examination methods. Review the usefulness of abdominal CTA with vasodilator (nitroglycerin). Method and characteristic of vascular visualization in CTA. Description of the high resolution in CTA method: Comparison of GroupA (with nitroglycerin/n=23) and GroupB (without nitroglycerin/n=26) during abdominal CTA. The usefulness of CTA as an operation tool is reported. There is a limitation to the spatial resolution in comparison with Angiography, as rendering the peripheral blood vessels is difficult. In CTA with vasodilator as an operation tool, made available in nearly all cases in Group A, visualization of the pancreaticoduodenal artery and inferior pancreatic artery. Visualization in Group B (without nitroglycerin group) was only about 30% capability. We had same result in case we describe the inferior pancreatic artery. We conclude it is useful to use nitroglycerin for better describing image. Vascular depiction performance is enhanced by the use of the vasodilator. In this new method, without iodine content, flow rate was also increased, and blood vessel depiction performance is possible. VIE151 Optimal Protocol of Scanning Mode for Reducing Contrast Medium Dose and Radiation Dose in Carotid CT Angiography: Low kvp or Low kev Scan Education Exhibits Location: VI Community, Learning Center Yunjing Xue MD (Presenter): Nothing to Disclose Qing Duan MD : Nothing to Disclose Lihong Chen : Nothing to Disclose Bin Sun : Nothing to Disclose 1. To describe the basic principles and feasibility of low-tube-voltage carotid CT angiography and Spectral Imaging using ASiR reconstruction in combination with a lower contrast medium dose with clinical data and images. 2. Illustrate optimization of low dose CT scan and low dose contrast medium injection protocol. 1. Basic principle and clinical value of low-tube-voltage and GSI monochromatic carotid CT angiography. 2. Optimization of low dose contrast medium injection protocol. 3. Carotid artery image quality evaluation and ASiR optimization. 100-kVp protocol had significantly higher carotid enhancement and sharpness of the artery compared with the 120-kVp protocol. GSI protocol could provide similar image quality of carotid artery to 120-kVp protocol. 4. Both GSI and 100-kVp protocol could significantly reduce the noise of carotid and main branches of thoracic aorta images compared with that of 120-kVp protocol. 5. The GSI (60kev) scan with 50% ASiR and 3 ml/s injection velocity has lowest CM dose and can provide more information of plaque and tissue differentiation. 6. We can balance the image quality, useful information (vessel, plaque, stent,tumor), radiation dose and contrast medium dose all kinds of CT scans parameters to choose the optimized CTA protocol to achieve the best clinical effect. VIE152 Subtraction CT Angiography for Peripheral Arterial Occlusive Disease Using Semi-automated Position Matching Method Education Exhibits Location: VI Community, Learning Center Ryoichi Tanaka MD (Presenter): Nothing to Disclose Kunihiro Yoshioka MD : Nothing to Disclose Kenta Muranaka : Nothing to Disclose Akihiko Abiko : Nothing to Disclose Shigeru Ehara MD : Nothing to Disclose The aims of this exhibit are to 1) understand basic concept of subtraction CT angiography. 2) get to know the difference between manual position matching technique and semi-automated position matching technique. 3) come to know the diagnostic accuracy of subtraction CT angiography in comparison with invasive angiography. A. Back ground: the limitations in current imaging procedures for peripheral arterial occlusive disease - including invasiveness in conventional angiography, radiation dose, renal dysfunction due to arteriosclerosis, and time consuming post processing and evaluation. B. Advantage of subtraction CT angiography: its accuracy in comparison with digital subtraction angiography. C. Position matching technique for subtraction CT angiography: the basic technique required in scanning and post-processing techniques D. Clinical application: Presentation in case with severe arterial calcification including cases who underwent hemodialysis VIE153 The Application Value of Quantitative Iodine-based Substance Mappings in Diagnosing Pulmonary Embolism (PE) Education Exhibits Location: VI Community, Learning Center

32 Location: VI Community, Learning Center Tingting Lin (Presenter): Nothing to Disclose Jiang Ning Dong : Nothing to Disclose 1.To assess the value of ration-based iodine substance mappings of CT imaging in diagnosing 2.To reflect the effects of different types of PE and diameters of emboli 3.To provide more morphological and functional information for the diagnosis of PE Relationship of perfusion changes of ration iodine-based substance mappings with embolized locations of conventional CTPA, Perfusion changes of ration iodine-based substance mappings - different types of PE - diameters of emboli Future directions and summary VIE154 Upper Extremity CTA: Clinical Applications in the Subacute Setting Education Exhibits Location: VI Community, Learning Center Radhika B. Dave MD (Presenter): Nothing to Disclose Dominik Fleischmann MD : Research support, Siemens AG 1. Arterial phase images are crucial for the evaluation of aneurysm, stenosis, and occlusion in vasculitis. Delayed venous phase images are helpful to evaluate for wall enhancement. 2. Vasculitis demonstrates smoothly tapered luminal narrowing compared to irregular luminal contour seen in stenosis secondary to atherosclerotic disease. 3. Imaging with the extremity in both the adducted and abducted positions can facilitate the diagnosis of thoracic outlet syndrome. 4. Warming of the hand prior to CTA can be helpful to differentiate true arterial stenoses from vasospasm. Upper extremity CTA has found a niche in the assessment of acute vascular injury. However, its less well known subacute applications involve evaluation of vasculitis, vascular malformations, overuse syndromes, and connective tissue diseases. -Vasculitis: Aneurysms, stenosis, and wall thickening -Arteriovenous malformations: Delineation of arterial and venous supply Evaluation of subfacial and intramuscular components Relationships to neurovascular bundles -Compression syndromes such as thoracic outlet syndrome: Variations of patient positioning to facilitate diagnosis Imaging findings -Connective tissue disorders: Vascular and extravascular imaging findings Imaging techniques to facilitate diagnosis of true arterial stenoses VIE155 Arteriovenous (AV) Grafts and Fistulas for Hemodialysis Access The Role of MDCT with CT Angiography and 3-D Reconstructions in Delineating Anatomy and Identifying Complications Education Exhibits Location: VI Community, Learning Center Sameer Ahmed MD (Presenter): Nothing to Disclose Siva P. Raman MD : Nothing to Disclose Elliot K. Fishman MD : Research support, Siemens AG Advisory Board, Siemens AG Research support, General Electric Company Advisory Board, General Electric Company Co-founder, HipGraphics, Inc 1. Understand different available options for hemodialysis, including arteriovenous (AV) grafts, AV fistulas, hemodialysis catheters, and peritoneal dialysis, including the benefits and downsides of each method 2. Understand the normal imaging appeareance on MDCT of AV grafts and fistulas, including different potential locations for their placement and their relationship to adjacent vasculature. 3. Understand proper construction of a CT protocol designed to evaluate a graft or fistula 4. Recognize a number of complications of grafts and fistulas that may be visible on MDCT. 1. Introduction 2. Anatomy Different types of hemodialysis access options available and their appropriateness in different situations Detailed discussion of grafts and fistulas, including the manner in which they are placed and the difference between grafts and fistulas Locations in which grafts and fistulas can be placed Different possible vascular communications which can be created Original artwork illustrating both fistulas and grafts from our in-house medical illustrator 3. MDCT appearance of normal grafts and fistulas. 4. Complications which can be recognized on MDCT, with case examples Stenosis Thrombosis Aneurysms/Pseudoaneurysms Ischemia/Steal syndrome Infection

33 VIE156 Dialysis Access in a Nutshell Education Exhibits Location: VI Community, Learning Center Aparna Srinivasa Babu MD (Presenter): Nothing to Disclose Salmi Simmons MD : Nothing to Disclose Routes of dialysis access Relevant anatomy and physiology Pictorial illustration based instruction on types of dialysis access Recognition of different types of dialysis access routes on imaging studies "Fistula first" initiative Novel approaches and anticipated developments After establishing the magnitude of the problem that renal disease poses in today's society, we will introduce the readers to the historical perspective of dialysis. Subsequently, we will explore the anatomical and physiological principles involved in obtaining and maintaining an access route for dialysis. The "Fistula first" initiative will be discussed in this section. This will be followed by a discussion of types of dialysis access, including HD catheters, grafts, fistulas and PD catheters. Potential complications and their management will be examined. We will demonstrate multimodality imaging appearances of catheters, grafts and fistulas, with pictorial illustration of imaging findings to provide a better understanding. This section will also focus on imaging characteristics that enable recognition of different types of catheters, grafts and fistulas. Finally, we will summarize our presentation and take a brief peek into future trends and emerging innovations. VIE157 To Stent or Not to Stent? Comprehensive Review of Endovascular Stent Indications, Complications, and Controversies in Dialysis Access Education Exhibits Location: VI Community, Learning Center Michael Ginsburg MD (Presenter): Nothing to Disclose Jonathan Matthew Lorenz MD : Nothing to Disclose Sean P. Zivin MD : Nothing to Disclose 1. To review the common categories of endovascular stents 2. To describe the indications for endovascular stent placement in hemodialysis access with an up-to-date literature review 3. To learn about potential stent complications and become familiar with management of fractured, misplaced and migrated endovascular stents Dialysis Access Endovascular Stent Categories - Self-expandable stents (Bare metal stents) Stainless steel Nitinol alloys - Stent grafts (Covered Stents) - Balloon expandable stent (Mostly unsuitable for central and peripheral venous interventions) - Drug-eluting stents (Not yet evaluated clinically) Indications for Stent Placement in Dialysis Vascular Access Abnormalities, Up-to-Date Literature Review and Case Based Examples - Recurrent stenosis - Elastic lesion - Vein rupture - Venous anastomosis stenosis - Extrinsic compression - Pseudoaneurysm formation - In-stent retenosis Endovascular Stent Complications, Controversies and Case Based Illustration of Management Options - Stent Fracture - Stent Misplacement - Stent Migration VIE158 Totally Implantable Venous Access Systems (Ports): Post-procedural Complications and Management Education Exhibits Location: VI Community, Learning Center Katsuhiro Kobayashi MD (Presenter): Nothing to Disclose Rahul Nayyar MD : Nothing to Disclose Mohammed Jawed MD : Nothing to Disclose Dianbo Zhang MD : Nothing to Disclose Mark Alfred Sultenfuss MD : Nothing to Disclose Mitchell Ira Karmel MD : Nothing to Disclose 1. Review venous anatomy relevant to proper port placement 2. Describe patient-related and port placement technique-related risk factors for postprocedural port complications. 3. Discuss port-related postprocedural complications and their management. 1) Central venous anatomy relevant to proper port placement 2) Proper port placement technique with emphasis on patient-related and port placement technique-related reisk factors for postprocedural port complications 3) Postprocedudural port complications and their management - infectious (port site infection, catheter-related blood stream infection) - mechanical (catheter migration/kink/fracture, catheter fragment embolization, Twiddler's syndrome, etc.) - thrombotic (fibrin sheath formation, venous stenotic/thrombotic) 4) Diagnostic algorithm for malfunctioning ports 5) Conclusions VIE159

34 Magnetic Resonance Angiography Applications in Reconstructive Plastic Surgery Education Exhibits Location: VI Community, Learning Center Ana Fernandez (Presenter): Nothing to Disclose Ana Alvarez Vazquez : Nothing to Disclose Chawar Hayoun : Nothing to Disclose Mar Jimenez De La Pena : Nothing to Disclose Vicente Martinez de Vega : Nothing to Disclose - to know the several techniques that are available for the preoperative mapping of perforating vessels: Doppler ultrasound, computed tomography-angiography (CTA), and, more recently, magnetic resonance angiography (MRA). - to emphasize the role of MRA for being a technique free of ionizing radiation and provides accurate anatomical information. Despite being a minority issue in the field of radiology, advances in reconstructive surgery perforator flaps make it necessary to deep in the knowledge of this technique. - to know different techniques MRA and advances in non contrast enhanced MRA. -Review of MRA techniques used in mapping perforators. -MRA applications in DIEP, gluteal, thigh and lower limb flaps. VIE160 A Resident-Driven How-To Guide for the Creation of Low-Cost Gelatin Phantoms for Training in Ultrasound and Fluoroscopically Guided Percutaneous Procedures Education Exhibits Location: VI Community, Learning Center Stephen Aaron Balfour MD (Presenter): Nothing to Disclose Pratik S. Patel DO : Nothing to Disclose David Scott Pryluck MD : Nothing to Disclose The construction of gelatin-based phantoms for teaching radiology residents and medical students to perform ultrasound and fluoroscopically-guided procedures can be easily accomplished with readily available materials and little cost. By viewing this exhibit, learners will gain the fundamental knowledge to assemble a variety of phantom models, including solid visceral organs and vascular structures, for laboratory training of residents and medical students at their home institutions. This exhibit will also demonstrate a proposed curriculum for formally implementing phantom models in resident and medical student education. 1) Brief review of medical literature regarding the construction of gelatin-based phantoms for resident and medical student education. 2) Pictorial guide with detailed descriptions for assembling gelatin-based phantoms of visceral organs including liver and kidney for simulation of percutaneous procedures. 3) Pictorial guide with detailed descriptions for assembling gelatin-based phantoms of vascular structures for simulation of venous and arterial access. 4) A review of suggested training curriculum incorporating gelatin-based phantoms in radiology resident and medical student education. VIE161 Advanced Image Guided Percutaneous Technique for the Placement of Peritoneal Dialysis Catheters Education Exhibits Location: VI Community, Learning Center Certificate of Merit Todd Ellis Drasin MD, MPH (Presenter): Nothing to Disclose Paul Erik Dybbro MD : Nothing to Disclose 1. Importance of peritoneal dialysis in renal replacement therapy armamentarium 2. Advantages/disadvantages of image guided percutaneous catheter placement vs gold standard advanced laparoscopic catheter placement. 3. The pre-procedure considerations, procedural technique, and post procedure protocols that make up our advanced image guided percutaneous technique for the placement of peritoneal dialysis catheters. 4. Data supports that, in selected patients, the advanced percutaneous and laparoscopic techniques are comparable with respect to technical success, catheter survival, and complications. A. Role of peritoneal dialysis in renal replacement therapy 1) What is peritoneal dialysis? 2) Advantages/disadvantages versus hemodialysis B. Current peritoneal dialysis catheter placement gold standard - advanced laparoscopic technique 1) Critical technical components that define the 'advanced laparoscopic' technique C. Advanced image guided percutaneous technique for the placement of peritoneal dialysis catheters 1) Pros and cons relative to surgical gold standard 2) Pre-procedure considerations 3) Procedural steps with imaging correlation 4) Post procedure care D. Outcomes 1) Technical success, catheter survival, complications

35 VIE162 Billing and Coding for Procedures: A Necessary Primer for Interventional Radiologists Education Exhibits Location: VI Community, Learning Center Certificate of Merit Kevin Ching MD (Presenter): Nothing to Disclose Christopher John Friend MD : Nothing to Disclose Ernesto Santos MD : Nothing to Disclose Rakesh Khubchand Varma MBBS, MD : Nothing to Disclose Kevin Michael McCluskey MD : Nothing to Disclose 1. An astute knowledge of billing and coding is essential for interventional radiologists as under billing may jeopardize the finances of a practice while overbilling constitutes medical fraud. 2. Physicians must be informed of specific terminology, the break down of physician reimbursement, and importance of accurate billing and coding. 3. Our exhibit reviews need to know information on this topic in a straightforward and understandable format. 1) Appropriate usage of current procedural terminology (CPT) codes and modifiers 2) Relative based relative value work scale (RBRVS), Relative value units (RVU), Conversion factors (CF) and how to calculate payment 3) What makes up a Global Payment 4) Professional fees: physician work, practice expense, and malpractice expense 5) Geographic practice cost index (GPCI): why the cost of care varies by region 6) ICD-9: an appropriate indication is essential for payment 7) Global periods: what is included after the procedure and for how long 8) Coding for multiple procedure on the same day and bundling of payments 9) Current RVU's for common interventional radiology procedures 10) Key concepts will be emphasized using case examples of everyday procedures. VIE163 Choosing the Right Path: A Percutaneous Biopsy Quiz Education Exhibits Location: VI Community, Learning Center Adam DeFoe MD (Presenter): Nothing to Disclose Louis Morel MD : Nothing to Disclose Adam Stibbe MD : Nothing to Disclose Shawn Stone : Nothing to Disclose Explore the best routes for percutaneous biopsy of multiple lesions/organs via a quiz format, with emphasis on the shortest, safest path. Learn which modality to choose for percutaneous biopsy of different lesions. Learn the common risks and complications associated with percutaneous biopsies. Apply the above knowledge to future cases, including on board exams. Lesions warranting biopsy will be presented as one or more CT images, followed by multiple choice quiz questions regarding percutaneous biopsy of the lesion. These questions include: Which lesion (if multiple) will you select to biopsy? What modality would you choose for biopsy guidance? Which route will you take to access the lesion? The questions will be followed by justification for the best answer to emphasize the learning objectives, including images depicting the actual biospy. A brief discussion of risks and complications will also be included with each case. VIE164 Endovascular Management of Complicated Aortic Dissections Education Exhibits Location: VI Community, Learning Center John Bao Minh Chung MD (Presenter): Nothing to Disclose Avnesh Sinh Thakor MBBCHIR, PhD : Nothing to Disclose Richard James Cormack MD : Nothing to Disclose Roshni Pravin Patel MRCS, BSc : Nothing to Disclose Darren Klass MD, PhD : Nothing to Disclose 1.) The reader will recognize what constitutes a complicated aortic dissection. 2.) The reader will be aware of the treatment algorithm to manage patients presenting with complicated aortic dissections. 3.) The reader will understand the methodology of treating such patients endovascularly using a combination of proximal covered stents as well as non-covered dissection stents. Introduction: - Define what constitutes a complicated aortic dissection; - Discuss the prevalence of this condition and the population cohort it usually affects; - Discuss morbidity/mortality associated with untreated complicated aortic dissection.

36 population cohort it usually affects; - Discuss morbidity/mortality associated with untreated complicated aortic dissection. Historical Treatment Algorithm: - Outline initial medical management, followed by consideration for surgery; - Discuss traditional surgical repair and outcomes from surgical treatment. Endovascular Management Algorithm: - Outline requisite steps to stabilize patient and evaluate vascular anatomy; - Discuss how to size covered stent grafts as well as non-covered stents; - Step-by-step guide to placement of a dissection endovascular prosthesis; - Discuss our center's experience with a small patient cohort (n=6 at time of abstract submission), including clinical presentation, therapy provided, and short to medium term outcomes. VIE165 How to Improve Teaching in Interventional Radiology: Description and Comparison of Methods for Composing and Building Vessel Models for Real Life Simulation Education Exhibits Location: VI Community, Learning Center Certificate of Merit Marcus Treitl MD (Presenter): Nothing to Disclose Maximilian F. Reiser MD : Nothing to Disclose Karla Maria Treitl MD : Nothing to Disclose We developed different methods to build low cost silicone vessel models that allow for repeat production of custom made vessel trees that simulate real life patient anatomy and allow e.g. real life simulation of a future procedure. We compare hand made wax forms for production of silicone models to high tech 3D printing with silicone and low cost 3D printing with plastic and the behavior and realism of these models in a perfusion model. The steps for manufacturing of these models are described in detail and advise is given how to implement these procedures into the own departmental workflow. A. Problem of teaching interventional procedures. B. Role of custom made silicone simulators in future. C. Analysis of possible ways the build low cost silicone vessel models. D. Building reproducible wax models. E. Options for 3D design of vessel models for 3D printing out of CT data sets. F. Using desktop 3D printers with PLA plastic. F. Using 3rd party 3D silicone printers. G. Description of the behavior and haptic of the available models. H. How to set up a silicone vessel production and their use for teaching in the own department. I. Future and outlook. VIE166 Image Acquisition and Guidance Systems: An Introduction for Interventional Radiology Trainees Education Exhibits Location: VI Community, Learning Center Alex Singleton MD (Presenter): Nothing to Disclose Lulu He DO : Nothing to Disclose Michelle Morgan RT : Nothing to Disclose Ram Kishore Reddy Gurajala MBBS, FRCR : Nothing to Disclose Charles Martin MD : Nothing to Disclose Karunakaravel Karuppasamy MBBS, FRCR : Nothing to Disclose The goal of this exhibit is To help radiology residents and fellows improve equipment utilization in an interventional radiology (IR) suite. To describe commonly used image acquisitions and post processing tools. To compare the relative radiation dose and image quality of acquisition methods. To exhibit cases demonstrating different acquisition methods and their application. A. Introduction: A new user is often puzzled at the user interface in an advanced IR system. Understanding different image acquisition methods allows us to use them to our advantage. This exhibit attempts to demystify the role played by these acquisition methods. B. Digital Radiography Single digital exposure Fluoroscopy C. Digital subtraction Radiography Road-map Reference image fade D. C-Arm Cone-beam Computed Tomography (CBCT) 3D anatomical demonstration 3D-3D volumetric fusion Needle guidance system Live 2D over 3D guidance Live scheme display E. Cases F. Summary: Radiologists-in-training are often overwhelmed by the complex user interface in an interventional radiology suite. Familiarity with the basic modes of image acquisition and utilization will enhance trainee participation during procedures and their interaction within IR team. VIE167 Modular Design of a Mobile Web-app for Clinical Decision Support, Education, Reference, and Communication for Interventional Radiology Education Exhibits Location: VI Community, Learning Center Loyrirk Temiyakarn MD (Presenter): Nothing to Disclose Neil Shah MD : Nothing to Disclose Adeel Siddiqui MBBS : Nothing to Disclose Asim F. Choudhri MD : Nothing to Disclose Background The role of the modern interventional radiologist (IR) is constantly evolving. Keeping up to date with the latest techniques and criteria can be a daunting task, especially in a busy practice. Mobile decision support tools can help overcome this barrier at all

37 criteria can be a daunting task, especially in a busy practice. Mobile decision support tools can help overcome this barrier at all levels of training. Modular mobile web-apps have the potential to educate while lowering communication barriers and facilitating safe, timely, efficient, and effective patient care. Evaluation A modular mobile web-app decision support and reference tool was designed for IRs to include appropriateness criteria, grading systems, radiation dose comparison, radiation dose tracking for patients and IRs, reference material on anatomy, catheters and drugs, and patient instructions. Separate modules were optimized for different levels of training including medical students, residents, fellows, and staff physicians. Modules were also tailored for separate facilities within an academic medical center. Additional modules to aid communication included shift/call schedules, contact information, and integrated text paging. Discussion Although the quality improvement metrics are still being collected, initial feedback on the design has been overwhelmingly positive. Feedback will be used to improve and optimize the web-app and develop new modules as the demand arises. Conclusion Mobile decision support, reference, education, and communication tools have potential to benefit interventional radiologists at all training levels in providing safe, timely, efficient, and effective patient care. A modular web-app ensures dynamic, up-to-date information customizable for all levels of training and all facilities within multi-facility academic medical centers. VIE168 Multidisciplinary Approach of Vascular Anomalies: Classification, Diagnosis and Treatment Education Exhibits Location: VI Community, Learning Center Nerea Hormaza MD (Presenter): Nothing to Disclose Juliana Mesa : Nothing to Disclose Beatriz Mateos-Goni : Nothing to Disclose Ruth Gonzalez Sanchez : Nothing to Disclose Inaki Escudero : Nothing to Disclose Armando Gozalo Garcia : Nothing to Disclose Xabier Tomas Izquierdo Penafiel MD : Nothing to Disclose Maria Rosario Gonzalez-Hermosa : Nothing to Disclose -To review the spectrum of vascular anomalies according to ISSVA 1996 classification, radiological diagnosis and treatment. -To recognize some misnomers for frequently seen vascular anomalies which the radiologist should be aware of. -To remark the importance of Vascular Anomalies Committees to achieve a correct diagnostic and therapeutic management of these lesions. Vascular anomalies encompass a broad spectrum of lesions, often described using an overlapping and confusing terminology. Since 1996 there is a broadly accepted classification published by the ISSVA based on the histological characteristics. The importance of Vascular Anomalies Committees lies in the need for an unified diagnosis through the experience of multiple experts which enables a correct management. Multiple imaging techniques are available such as US-Doppler, MRI, CT, angiography, plain film: the utility of each modality is shown in this exhibit. Considering that imaging guided procedures are frequently the treatment of choice, interventional techniques are also shown. A pictorial review of vascular anomalies is made showing some complex cases that were presented in the Vascular Anomalies Committee of our institution. Imaging clues are provided to recognize and to make a proper classification of each anomaly with an appropriate terminology. VIE169 Operator Radiation Dose Reduction during Fluoroscopic Interventional Procedures in an Academic Setting Education Exhibits Location: VI Community, Learning Center Arun C. Nachiappan MD : Nothing to Disclose Gary Lloyd Horn MD (Presenter): Nothing to Disclose Ray C. Mayo MD : Nothing to Disclose David Matthew Wynne MD : Nothing to Disclose Benjamin R. Archer PhD : Nothing to Disclose John Austin Hancock MD : Nothing to Disclose Cliff J. Whigham DO : Nothing to Disclose 1) Review various sources of operator radiation dose during fluoroscopy. 2) Describe methods to decrease operator dose, which include appropriate shielding use, optimal positioning of operator and patient, collimation, lower fluoroscopic frame rate, and judicious use of digital subtraction angiography. 3) Discuss how one can institute a radiation safety educational program at one's own institution. 1) Overview of sources of radiation to which the fluoroscopy operator is exposed. 2) Review of operator and patient dose monitoring methods 3) Review of department-wide strategies to lower operator radiation dose, including lowering fluoroscopy time, setting reference levels, encouraging vendor interaction, and hands-on orientation for new resident operators. 4) Discussion of steps to monitor and reevaluate educational program and ideas to incentivize decreased operator dose. VIE170 Patient Anxiety before and Interventional Radiologic Procedures: Guiding the Radiologists

38 Towards a More Patient-centered Role Education Exhibits Location: VI Community, Learning Center Certificate of Merit Khalid Walid Shaqdan MD (Presenter): Nothing to Disclose Shima Aran MD : Nothing to Disclose Elmira Hassanzadeh MD : Nothing to Disclose Hani H. Abujudeh MD, MBA : Research Grant, Bracco Group Consultant, RCG HealthCare Consulting Author, Oxford University Press Minimally invasive procedures increasingly replace open surgery and reduce the need for general anesthesia. Although interventional radiology treatments offer less risk, pain and recovery time when compared to open surgery, patients nonetheless may be anxious about them and their outcomes. The aim of this exhibit is to explain physician etiquettes, assessment methods, environmental factors, communication techniques, and recent research findings to reduce patient anxiety and improve overall experience in the interventional practice. Background/Literature review: o Harmful effects of patient anxiety o Role of radiologists in improving patient experience ACR Imaging 3.0 campaign "Program to enhance relational communicational skills-radiology" o How other specialties deal with patient anxiety How to maintain a low anxiety environment: o Quick patient assessment Spielberger and colleagues "State Trait Anxiety Inventory (STAI)" o Standardized guidelines Physician etiquettes Bedside manners Environmental factors Discussion techniques Appropriate ways to deliver unexpected news to the patient Recent research o Video goggles worn by patient during IR procedure showing soothing non-violent videos VIE171 Percutaneous Abscess and Fluid-Collection Drainage: A Primer for Every Interventional Radiology Resident/Fellow Education Exhibits Location: VI Community, Learning Center Masashi Tamura (Presenter): Nothing to Disclose Seishi Nakatsuka MD : Nothing to Disclose Yosuke Suyama : Nothing to Disclose Jitsuro Tsukada : Nothing to Disclose Nobutake Ito MD : Nothing to Disclose Sota Oguro : Nothing to Disclose Hideki Yashiro MD : Nothing to Disclose Masanori Inoue MD : Nothing to Disclose Masahiro Jinzaki MD : Nothing to Disclose Percutaneous drainage is an effective and safe method for treating abscess and fluid-collection. We describe and illustrate the principle and various techniques of percutaneous abscess and fluid-collection drainage. By viewing this exhibit, the readers will 1. Understand when you should perform percutaneous drainage or not. 2. Be able to choose appropriate device and imaging guidance. 2. Learn how to safely perform percutaneous drainage using basic technique and to manage the catheter. 4. Get further technique for drainage of the apparently inaccessible, challenging lesion. 1. Introduction 2. Clinical Indication and Contraindication 3. Planning and Imaging Guidance 4. Device and Basic technique a. Device b. Puncture and Catheter Placement i) Seldinger Method ii) Modified Trocar Method c. Management of Catheter i) The Principle of Management of Catheter ii) Timing of Catheter Removal iii) Catheter-related Problems 5. Further Technique for Apparently Inaccessible Lesion a. Three Dimensional Puncture: Multislice CT Fluoroscopy, ISOP Method, b. Creation of Artificial Window: Hydro- or Pneumo-dissection c. Traverse of Organ d. Tractography and Progress of Catheter by Using Hydrophilic Guide Wire and Seeking Catheter VIE172 Percutaneous Spinal Cement Augmentation: Status Quo and Future Directions Education Exhibits Location: VI Community, Learning Center Cum Laude

39 Uei Pua MBBS, FRCR (Presenter): Nothing to Disclose 1) understand the indications and contraindications for cement augmentation, namely; vertebroplasty, kyphoplasty and stentoplasty (vertebral body stenting) 2) understand current techniques and advances in the area of cement augmentation By the end of the exhibit, the reader will be familiar with the following: Pre-procedural assessment for cement augmentation (case selection): 1) Imaging assessment: Conventional radiography AND MRI 2) Morphological assessment for suitability: i) AO classification of vertebral fractures ii) Tomita classification of vertebral involvement in metastatic disease 3) Clinical assessment: Visual analog scale, Oswestry Disability Index, response to conventional treatment Conventional technique and complications of cement augmentation techniques: 1) Principles fluoroscopic planes and needle trajectory 2) Tools and differences of the various techniques 3) Princples of cement filling and complications Advances and future directions in cement augmentation 1) Advances in techniques: Unipedicular approaches 2) Advances in imaging: Cone beam CT 3) Use of non-cement fillers: e.g. allogenic bone graft VIE173 Peri-Procedural Anticoagulant Management Education Exhibits Location: VI Community, Learning Center Brendan Patrick McMenomy MD (Presenter): Nothing to Disclose Anil Nicholas Kurup MD : Nothing to Disclose Patrick Wade Eiken MD : Nothing to Disclose Jonathan Michael Morris MD : Nothing to Disclose Robert McBane MD : Nothing to Disclose Thomas Duncan Atwell MD : Nothing to Disclose 1. Summary of anticoagulation medications encountered in clinical practice. 2. Suggested periprocedural guidelines for managment of different anticoagulation medications when performing percutaneous imaging-guided procedures. Anti-Platelet Agents Medication List Medication Information Suggested Periprocedural Guidelines for Antiplatelet Agents Vitamin K Antagonists Medication List Medication Information Suggested Periprocedural Guidelines for Vitamin K Antagonists Heparins Medication List Medication Information Suggested Periprocedural Guidelines for Heparin Agents Direct Thrombin Inhibitors Medication List Medication Information Suggested Periprocedural Guidelines for Direct Thrombin Inhibitors Direct Factor Xa Inhibitors Medication List Medication Information Suggested Periprocedural Guidelines for Factor Xa Inhibitors Glycoprotein IIb/IIIa Antagonists Medication List Medication Information Suggested Periprocedural Guidelines for Glycoprotein IIb/IIIa Antagonists Suggested Periprocedural Laboratory Screening Guidelines Correction of Coagulation Abnormalities VIE177 Vascular and Lymphatic Imaging for Plastic and Reconstructive Surgery: A Primer for the Radiologist Education Exhibits Location: VI Community, Learning Center Certificate of Merit Shigeyoshi Soga MD (Presenter): Nothing to Disclose Hiroshi Shinmoto MD : Nothing to Disclose Teppei Okamura MD : Nothing to Disclose Nobuyuki Yoshihara : Nothing to Disclose Tsuyoshi Soya : Nothing to Disclose Tatsumi Kaji MD : Nothing to Disclose Fumio Ohnishi : Nothing to Disclose Toshiharu Minabe : Nothing to Disclose The purpose of this exhibit is to detail: 1. Surgical anatomy and principles of microvascular flap reconstruction and lymphatic reconstructive surgery. 2. Role of vascular and lymphatic imaging 3. Comparison of imaging protocols and modalities, including CT,MR, US, lymphoscintigraphy, and fluorescence imaging. 4. Image post-processing for submillimeter vessels and lymphatics. 1. Surgical procedures Microsurgical flap procedures Lymphatic-venous anastomosis for the treatment of lymphedema Supermicrosurgery 2. Microsurgical anatomy 3. Imaging protocols and clinical impact for plastic and reconstructive surgery Vascular imaging: CT/MR angiography for reconstructive surgery, ranging from breast and head/neck reconstruction to facial transplantation Lymphatic imaging of extremities for diagnosis and surgical planning: high-resolution isotropic 3D MR lymphangiography and lymphoscintigraphy 4. Imaging and surgical findings 5. Comparison of imaging modalities (CT, MR, US, lymphoscintigraphy, and near-infrared fluorescence imaging), as well as review of existing literatures. 6. Future directions and summary VIE178

40 Who Needs Glue: Exploring New Percutaneous Biological Sealants in Interventional Radiology Education Exhibits Location: VI Community, Learning Center Certificate of Merit Vibhor Wadhwa MBBS (Presenter): Nothing to Disclose Clifford Raabe Weiss MD : Research collaboration, Siemens AG Brian Philip Holly MD : Nothing to Disclose Todd Schlachter MD : Nothing to Disclose Anobel Tamrazi MD, PhD : Nothing to Disclose 1. Review the biological sealants used in various surgical specialties and with potential use in IR procedures especially for bowel leaks and fistulae. 2. Explain with relevant case examples the utility of different biological sealants in IR. 1. List the new generation biological sealants used in various surgical specialities, with potential use in IR. 2. Present relevant cases showing the utility of these sealants. 3. Illustrate sealant preparation and deployment technique. VIE179 Case Based Review of Renal Interventions: From Indications to Completion. Primer for Radiology Residents and Fellows Education Exhibits Location: VI Community, Learning Center Selected for RadioGraphics Jay Patel MD (Presenter): Nothing to Disclose Nishith Patel MD : Nothing to Disclose Sean Keith Calhoun DO : Nothing to Disclose Thaddeus M. Yablonsky MD : Nothing to Disclose 1. Review the indications, patient preparation and equipment for various renal interventions 2. Learn multimodality features of a variety of renal pathology 3. Discuss interventional treatment options, technical considerations and common complications of these interventions The indications, patient preparation and equipment for each case will be reviewed, followed by a discussion of multimodality imaging features. Interventional treatment options, technical considerations and common complications will also be reviewed.topics presented include: Embolization: Drainage: Other: VIE180 Renal arteriovenous fistula Renal arteriovenous malformation Renal angiomyolipoma Renal cell carcinoma Renal Trauma Renal and perinephric abscesses Percutaneous nephrostomy Ureteral stenting Percutaneous transluminal angioplasty - fibromuscular dysplasia Radiofrequency ablation - oncocytoma Stenting - renal artery stenosis Percutaneous nephrolithotomy Clinical Outcome of Percutaneous Transhepatic Obliteration for Anorectal Varices Education Exhibits Location: VI Community, Learning Center Tetsuya Minami MD (Presenter): Nothing to Disclose

41 Satoshi Kobayashi MD : Nothing to Disclose Toshifumi Gabata MD : Nothing to Disclose Osamu Matsui MD : Research Consultant, Kowa Company, Ltd Research Consultant, Otsuka Holdings Co, Ltd Research Consultant, Eisai Co, Ltd Speakers Bureau, Bayer AG Speakers Bureau, Eisai Co, Ltd From anorectal varices is quite rare, but they can lead to a life-threatning hemorrhage because of their high flow rate and volume. Treatment of anorectal varices has not yet been established. We are able to control six cases of the varices by percutaneous transhepatic obliteration (PTO). From 2004 to 2013, six patients (67-80 years old) who suffered anorectal varices induced by portal hypertension ware enrolled this study. All six women were treated with balloon-occluded antegrade transvenous sclerotherapy by 5% ethanolamine oleate iopamidole (EOI) via percutaneous transhepatic approach. Four patients were successfully treated after one procedure, and one patient required twice treatment. In the case of rest one patient, the varices could be controlled by twice PTO and partial splenic embolization. This study suggests that PTO by using EOI may be good treatment for anorectal varices. Varices develop at any site of GI tract in patient with portal hypertension. Recently, the frequency of anorectal varices is reported as higher than before. bleeding from anorectal varices can lead to a life-threatning hemorrhage. No therapeutic strategy has yet been established. Our method using ethanolamine is effective treatment for anorectalvarices. VIE181 Cryoablation of Exophytic Neoplasms: Novel Minimally Invasive Approach to Treat Unresectable Tumors Education Exhibits Location: VI Community, Learning Center Luke Gerges DO (Presenter): Nothing to Disclose Maryam Gul : Nothing to Disclose Ammar Ahmed Chaudhry MD : Nothing to Disclose Jung Hwoon Edward Yoon MD : Nothing to Disclose David Schulsinger : Nothing to Disclose John Alexander Ferretti MD : Nothing to Disclose 1- Review indications, interventional methods, contraindications, complications, pearls and pitfalls of percutaneous cryoablation. 2- Cryoablation was previously not recommended for perivascular and pericolonic neoplasms due to heat sink effects and potential damage to adjacent organs. We will discuss novel approach to treat these previously 'do NOT cryoablate' lesions and how to minimize potential risks while obtaining an appropriate size ablation zone. 3- Algorithm to help determine the best treatment modality in managing renal masses. A. Anatomy- Effect of cryoablation on vessels, small and large intestines, abdominal wall, etc. B. Clinical Findings secondary to mass effect, obstruction, vessel invasion, etc. C. Highlight imaging findings (e.g. significance of fat planes) that serve as key to patient inclusion and exclusion criteria. D. Pathophysiology: Cryobiology: Intra- and extracellular mechanisms that promote tumor cell death E. Procedure Technique: discuss key do's and don'ts e.g. not crossing peritoneal reflections, not ablating needle tract, etc. F. Follow-up: Immediate post-procedure management and follow-up guidelines G. Outcomes: a. Complications: Immediate (hemorrhage, recurrence, bowel perforation, etc), Delayed (recurrence, fistulas, etc) b. Survival VIE182 How Critical is C-arm Computed Tomography(C-arm CT) for Overcoming Challenges in Patients Undergoing Trans-arterial Chemoembolization for Hepatocellular Carcinoma? Education Exhibits Location: VI Community, Learning Center Chinmay Bhimaji Kulkarni MBBS, MD (Presenter): Nothing to Disclose Srikanth Moorthy MD : Nothing to Disclose Sreekumar K P MBBS, MD : Nothing to Disclose Rajesh Ramaih Kannan MD : Nothing to Disclose Nirmalkumar Prabhu : Nothing to Disclose Basics of C-arm Computed Tomography (C-arm CT). How is C-arm CT performed? Application in patients undergiong Trans-arterial chemoembolization (TACE) for Hepatocellular carcinoma (HCC).

42 Background. Evolution of DSA technology. Basic principles of C-arm CT. How is it different from routine CT? Technique of C-arm CT in TACE for HCC: Applications in TACE for HCC: Vascular Iimaging. Parenchymal imaging. Challanges in TACE. Limitations of C-arm CT. Future trends. VIE183 Managing Complicated Acute Pancreatitis: Interventional Radiology to the Rescue Education Exhibits Location: VI Community, Learning Center Rory O'Donohoe MBBCh (Presenter): Nothing to Disclose Sinead Helena McEvoy MBBCh, FFR(RCSI) : Nothing to Disclose Lisa P. Lavelle MBBCh, FFR(RCSI) : Nothing to Disclose David Paul Brophy MBBCh : Research Consultant, Marvao Medical Limited Shareholder, Marvao Medical Limited Colin Patrick Cantwell MD : Nothing to Disclose Jeffrey William McCann MBBCh, MSc : Nothing to Disclose Edmund Ronan Ryan MBBCh : Nothing to Disclose The purpose of this exhibit is: 1. To review the complications of acute pancreatitis including the various types of vascular and non-vascular complications. 2. To discuss the indications for image guided intervention with an emphasis on clinical evaluation. 3. To review the role of MRI in the assessment of fistulae and of phlegmonous peri-pancreatic collections. 4. To illustrate the IR techniques for treatment of both vascular and non-vascular complications. 1. Overview of the complications of acute pancreatitis. 2. The types of collections associated with acute pancreatitis (using the revised Atlanta classification of pancreatitis: acute peripancreatic fluid collections, acute necrotic collections, pseudocysts, walled off necrosis), and indications for their drainage. 3. Drainage approaches and techniques, including retroperitoneal, transhepatic and transgastric drainage. 4. Fistulae and their management, including pancreaticopleural fistulae. 5. The diagnosis and treatment of arterial and venous complications, with an emphasis on endovascular therapy for pseuoaneurysms of the gastroduodenal artery, inferior pancreaticoduodenal artery and splenic artery. 6. Summary. VIE184 Non-Surgical Management for Hepatocellular Carcinoma with Vascular Tumor Thrombus Education Exhibits Location: VI Community, Learning Center Masakatsu Tsurusaki MD, PhD (Presenter): Nothing to Disclose Takamichi Murakami MD, PhD : Nothing to Disclose Nobuyuki Asato MD : Nothing to Disclose Yukinobu Yagyu MD : Nothing to Disclose Seishi Kumano MD : Nothing to Disclose Mitsuru Matsuki : Nothing to Disclose 1. To discuss the various forms of non-surgical management for unresectable hepatocellular carcinoma (HCC) with vascular tumor thrombus (VTT). 2. To present HCC with VTT cases demonstrating various treatment techniques, complications, responses and survival. A. Epidemiology of HCC with VTT B. Various non-surgical treatments for HCC with VTT, including transcatheter arterial chemoembolization (TACE), transcatheter arterial embolization (TAE) using gelatin sponge cubes only, radiotherapy combined with TACE or TAE, hepatic arterial infusion (HAI), and systemic chemotherapy C. Interventional management of complications caused by VTT, such as portal obstruction and portal hypertension E. Cases. SUMMARY Our results of both HAI and radiotherapy combined with TACE for HCC with VTT suggest that are tolerable and increase tumor response rate. This exhibit reviews a. The methods of non-surgical treatments of HCC with VTT. b. The outcomes of non-surgical treatments of HCC with VTT. c. The methods of management and outcomes by interventional procedure for complications caused by VTT. VIE185 Role of Interventional Radiology in the Management of Renal Artery Aneurysm: A Pictorial Review Education Exhibits Location: VI Community, Learning Center Christelle Chedrawy MD (Presenter): Nothing to Disclose Pedram Rezai MD : Nothing to Disclose Daniel Joseph Kay MD : Stockholder, General Electric Company Anupam Basu MD : Nothing to Disclose Daniel Anthony Falco DO : Nothing to Disclose Visceral arterial aneurysms are rare entities with a described incidence of 0.2%. Renal artery aneurysms account for 15-22% of the visceral arterial aneurysms and are generally discovered incidentally. Most of the aneurysms are less than 2 cm and are asymptomatic. Symptoms may result from rupture and thromboembolic events. A size greater than 2 cm warrants intervention. Multiple approaches have been described in the management of visceral arterial aneurysms. The primary intent of covered stent placement is to exclude the aneurysmal sac while maintaining distal perfusion. The described approach offers an alternative to

43 treat high risk patients, as well as patients with aneurysms whose size or location would make a surgical approach problematic. 1. Introduction: o Overview of Renal Artery Aneurysms o Case presentation 2. Indications and contraindications 3. Preprocedure preparation and diagnostic imaging o Renal ultrasound o Imaging features on CT scan of the abdomen o Diagnostic Angiogram 4. Procedure: Placement of covered stents. 5. Postprocedure Management and follow up. 6. Complications VIE186 The Role of Hypersplenism in Complicated Portal Hypertension Education Exhibits Location: VI Community, Learning Center Certificate of Merit Joseph Wilson Owen MD (Presenter): Nothing to Disclose Kathryn Jane Fowler MD : Research support, Bracco Group Nael El Said Saad MBBCh : Research Consultant, Veran Medical Technologies, Inc Proctor, Sirtex Medical Ltd Increased splenic flow may be a compensatory mechanism to maintain portal flow in the face of increasing hepatic resistance/portal hypertension. Hypersplenism can be due to marrow disorders, resulting in increased splenic capacity and blood flow. These high flow states can exacerbate the complications of portal hypertension. Treatment of hypersplensim may reduce overflow phenomenon in patients at risk for variceal bleeding. Associations Myelo/Lymphoproliferative Disorders Portal Hypertension (PHTN) Pathophysiology Hypertrophy Arterial Recruitment Splenic Outflow Sequelae Leuko/Thrombocytopenia Hemorrhage - Splenic/portal flow ratio may correlate with varical bleeding Post Transplant PHTN - Increased splenic flow persists, so PHTN persists despite normal hepatic resistance Treatments Partial/Complete Splenic Embolization Splenectomy TIPS/BRTO Case 1 17 y/o h/o liver transplant with post transplant PHTN Esophageal varices Biopsy- Noncirrhotic PHTN Elevated splenic flow Splenectomy vs splenic embolization Case 2 34 y/o with noncirrhotic PHTN and splenomegally Variceal hemorrhage PHTN treated with TIPS Recurent variceal bleeding Splenectomy with resolution of PHTN VIE187 Comparison between Cross-sectional and Angiographic Imaging features in Locoregional Management of Hepatocellular Carcinoma: A Pictorial Review Education Exhibits Location: VI Community, Learning Center Nirmal Kakani MD : Nothing to Disclose Hamid Reza Sadeghi Neshat MSc (Presenter): Nothing to Disclose Derek William Cool MD, PhD : Patent agreement, Eigen Aaron Fenster PhD : License agreement, Eigen 1. Angiographic appearance of tumors pre- and post-treatment 2. Comparison of angiographic and CT findings pre and post treatment 3. Comparison of angiographic and 3D/contrast US pre and post treatment 4. Pit falls to avoid during interpretation. As incidence of HCC continues to increase, multi-modality imaging protocols have allowed us to understand their vital role in its detection, treatment and follow up. The unique vascular properties of primary liver cancer allows the treatment of these tumors with trans-arterial chemo- and radio-embolization (TACE/TARE), as well as percutaneous ablation. Accurate and reliable understanding of the angiographic appearance with concurrent interpretation of the follow up scans is paramount for the success of Loco-regional therapy. This educational exhibit aims to compare the angiographic findings of the lesions with the CT, 2D/3D ultrasound, and contrast ultrasound changes pre- and post treatment. This will help the reader to understand the relation between location, vascularity and the response of the tumor to treatment across modalities. Images are selected from 50 patients recruited in an IRB approved study who underwent (DEB)TACE/TARE or microwave/radiofrequency ablation between to study role of multi-modality imaging in interventional management of focal liver tumors. VIE188 CT-guided Radiofrequency Ablation of Lung Tumors: How to Do It Education Exhibits Location: VI Community, Learning Center Tomohisa Okuma MD, PhD (Presenter): Nothing to Disclose Toshiyuki Matsuoka MD : Nothing to Disclose Shinichi Hamamoto MD, PhD : Nothing to Disclose Yukio Miki MD, PhD : Nothing to Disclose To review the indications, contraindications, imaging for treatment response, clinical outcome and potential complications of percutaneous CT-guided radiofrequency ablation.

44 A. Review of Indications, Contraindications B. Technique C. Evaluation of therapeutic effects (CT, FDG-PET, and MR imaging) D. Outcomes E. Contributing factors to local progression F. Complications (including management) VIE189 How We Do It: MRI Analysis of Tissue Imaging Outcomes Following Percutaneous Ablation of Hepatic Tumors Education Exhibits Location: VI Community, Learning Center Gregory John Woodhead MD, PhD (Presenter): Nothing to Disclose Ragni Jindal BA : Nothing to Disclose Bobby Thomas Kalb MD : Nothing to Disclose Charles T. Hennemeyer MD : Nothing to Disclose The purposes of this exhibit are: 1. To review irreversible electroporation (IRE), an evolving technique for the percutaneous ablation of malignant hepatic tumors. 2. To gain an awareness of how recent advances in abdominal MRI facilitate analysis of tissue imaging outcomes following percutaneous ablation. 3. To outline the systematic methodology employed at our institution for the characterization of post-ire tissue outcomes. I. Overview of percutaneous ablation of hepatic tumors: IRE, RFA, microwave ablation, and cryoablation. II. IRE: Applications, advantages, and technique. III. Abdominal MRI: A superior imaging modality for the characterization of hepatic tumors and evaluation of post-ablation tissue imaging outcomes: HCC and hepatic metastases. IV. "How we do it": A systematic methodology for MRI evaluation and characterization of post-ablation outcomes. V. Through case examples, interpreting physicians will be introduced to broad categories of MR imaging outcomes following IRE: (1) Devascularization, and (2) Residual enhancement. IV. Summary: Recent advances in Body MRI facilitate analysis of post-ablation tissue characteristics. This educational exhibit will outline a methodology for the systematic evaluation of MRI outcomes following IRE of malignant hepatic tumors. VIE190 Magnetic Resonance Imaging for Guidance of Hepatic Radiofrequency Ablation Education Exhibits Location: VI Community, Learning Center Stephan Clasen MD (Presenter): Nothing to Disclose Hans-Jorg Rempp : Nothing to Disclose Rudiger Hoffmann : Nothing to Disclose Philippe Lucien Pereira MD : Support, Terumo Corporation Support, Bayer AG Support, Siemens AG Advisory Board, Siemens AG Support, Bracco Group Speaker, Terumo Corporation Speaker, Bayer AG Advisory Board, Bayer AG Speaker, CeloNova BioSciences, Inc Consultant, CeloNova BioSciences, Inc Speaker, Biocompatibles International plc Research Grant, Biocompatibles International plc Speaker, Microsulis Medical Ltd Consultant, Microsulis Medical Ltd Claus Detlef Claussen MD : Nothing to Disclose Konstantin Nikolaou MD : Speakers Bureau, Siemens AG Speakers Bureau, Bracco Group Speakers Bureau, Bayer AG Capabilities of magnetic resonance (MR) imaging for guidance of different steps during hepatic radiofrequency (RF) ablation: pre- (planning), peri- (targeting, monitoring, and controlling), and post-interventional (assessment of treatment response) imaging. Beside general advantages of MR imaging like excellent soft-tissue contrast in hepatic imaging special techniques are in particular supportive for targeting and monitoring of thermal ablation. MR-fluoroscopy offers a near real-time feedback in different planes while the RF applicator is advanced into the target tissue. In relation to thermal ablation therapy, the main advantage of MR imaging is the sensitivity to thermal effects. Strategies for monitoring thermal ablation therapy are a direct temperature mapping, e.g. the proton resonance frequency shift method, or a visualization of irreversible tissue damage caused by thermally induced coagulation. Advantages and disadvantages of MR-guided RF ablation will be discussed. A. Role of imaging modality in hepatic RF ablation B. Interventional MR systems C. MR-compatible RF systems D. Capabilities of MR imaging with regard to thermal ablation: D1. Planning D2. Targeting D3. Monitoring D4. Controlling D5. Assessment of treatment response E. Discussion of advantages and disadvantages of MR imaging in RF ablation VIE191 Pulmonary Ablation: An Update on Currently Available Ablation Technologies and Their Use in the Lungs Education Exhibits Location: VI Community, Learning Center Ankaj Khosla MD (Presenter): Nothing to Disclose Stephen Phillips Reis MD : Nothing to Disclose Ali Pirasteh MD : Nothing to Disclose Thomas Alfred Pacicco : Nothing to Disclose Clayton K. Trimmer DO : Nothing to Disclose Sanjeeva P. Kalva MD : Consultant, CeloNova BioSciences, Inc

45 In a subset of patients, ablation of pulmonary nodules serves as an alternative to surgical resection of both primary and metastatic lesions in the lung. Following the results of the National Lung Cancer Screening Trial (NLCST), the number of both primary and secondary lung tumors is likely to increase after the implementation of low dose screening CT. In this exhibit we aim to describe the currently available pulmonary ablation technologies. There will be a review of the current literature on lung cancer, staging, pulmonary ablation techniques and a discussion on the indications for ablation. We will go over procedure details with demonstration from our institution and review the variety of probes used in pulmonary radiofrequency ablations. Finally, we will discuss upcoming techniques and their potential. 1. Background 2. Procedure details and indications 3. Literature review of pulmonary ablation techniques 4. Pictoral review involving a variety of probes 5. New techniques VIE192 Rare Complications after Lung Percutaneous Radio Frequency Ablation: Incidence, Risk Factors, Prevention and Management Education Exhibits Location: VI Community, Learning Center Certificate of Merit Selected for RadioGraphics Nicolas Alberti MD (Presenter): Nothing to Disclose Xavier Buy MD : Proctor, Galil Medical Ltd Nora Frulio : Nothing to Disclose Michel Montaudon MD : Nothing to Disclose Mathieu Canella : Nothing to Disclose Afshin Gangi MD, PhD : Proctor, Galil Medical Ltd Jean Palussiere MD : Travel support, Bracco Group Tumor destruction by percutaneous radiofrequency ablation (PRFA) is a minimally invasive treatment proposed in the management of lung tumors, primary or secondary, especially in inoperable patients. This technique is very well tolerated in the lung, and most of the complications, which occur in up to 50% of cases, are minor. Little is known about potential rare complications after PRFA. The aim of this educational exhibit was to a) describe b) prevent c) manage rare complications after PRFA of the lung based upon our experience in a large tertiary referral centre (more than 1000 patients during 11 years). 1) Pulmonary complications: *Bronchopleural or bronchial fistula *Pulmonary artery pseudo aneurysm *Gas embolism *Aspergilloma or delayed abcess inside post RFA cavitation 2) Thoracic wall complications: *Intercostal neuroma *Intercostal artery injury *Rib necrosis 3) Mediastinal and apical complications: *Neural damage (brachial plexus, recurrent and phrenic nerves) 4) Diaphragmatic injury (hernia) VIE194 How and When Do the Checks with Doppler Ultrasound to Patients Who Have Been Transplanted Pancreas Kidney Education Exhibits Location: VI Community, Learning Center Roberto Correa Soto (Presenter): Nothing to Disclose Teresa Gonzalez De La Huebra Labrador : Nothing to Disclose Aurymar Fraino : Nothing to Disclose Percy Alexander Chaparro Garcia : Nothing to Disclose Diego Sebastian Palominos Pose MD : Nothing to Disclose Karin Daniela Muller MD : Nothing to Disclose Cecilia Santos Monton : Nothing to Disclose Heidy Saenz Acuna MD : Nothing to Disclose The purpose of this exhibit is: To explain the possible locations, orientations and physiology of the new transplanted organ (kidney, pancreas). To review the methodology and temporal protocol of doppler ultrasound of patients transplanted pancreas-kidney. To review the radiological findings indicating good and / or poor outcome. Introduction Transplanted organs (pancreas-kidney) location, orientation, relationships, physiology. Imaging techniques and findings. Doppler ultrasound technique: protocol review, methodology, temporal protocol. 1. Radiological findings of good prognosis. 2. imaging findings of complications and poor prognosis 3. Common diagnostic pitfalls. A useful radiological report.

46 VIE195 Cases to illustrate the radiologic features. How to Hit the Bulls Eye: Tips and Tricks for a Successful Ultrasound Guided Lymph Node Biopsy Education Exhibits Location: VI Community, Learning Center Daniel Claudio Mysler MD : Nothing to Disclose Andres Kohan MD (Presenter): Fellowship funded, Koninklijke Philips NV Tiare Africa Pineiro MD : Nothing to Disclose Monica Poclava MD : Nothing to Disclose Adrian Nervo MD : Nothing to Disclose Ricardo D. Garcia-Monaco MD, PhD : Research Consultant, Siemens AG Research Consultant, BTG International Ltd federico colo : Nothing to Disclose To review clinical indications for lymph node biopsy To identify the different image guided biopsy techniques for lymph nodes To review ultrasound guided lymph node biopsy technique To review the different tips and tricks for a successful procedure and tissue sampling VIE196 Anatomy: location of the lymph nodes, best acoustic windows to image them and best point of acces for tissue sampling Pathophysiology: metastatic pathways and where to go look for the most prpbably involved lymph nodes Clinical Findings: tips from physical examination to help locate pathological lymph nodes Ultrasound guided biopsy technique: a review step by step of the appropriate biopsy procedure Indications and contraindications Tips and tricks for succesful tissue sampling: experience based tips and tricks to maximize tissue sampling and obtain a representative biopsy Possible complications and their treatment Imaging the Swollen Arm with Dialysis Access: It s Not Just DVT Education Exhibits Location: VI Community, Learning Center Magna Cum Laude Shilpa Nagarur Reddy MD (Presenter): Nothing to Disclose Meghan Boros MD : Nothing to Disclose Mindy Meislich Horrow MD : Spouse, Director, Merck & Co, Inc 1. Venous US is frequently the initial study requested to evaluate acute arm swelling in patients with dialysis access 2. While important to exclude DVT,, in the setting of swelling in an arm with chronic dialysis access, radiologists must consider a wide variety of other vascular and non-vascular causes for swelling, many of which can be appreciated or suggested using US 3. This exhibit will review anatomy of AV grafts and fistulas and how to evaluate them with US, demonstrate examples of alternative vascular and non-vascular diagnoses, and discuss when other modalities and interventions are necessary 1. Systematic approach using US for initial evaluation of swollen arm with chronic dialysis access a. History and physical examination of arm b. Type of access c. Relevant vascular anatomy with Doppler analysis d. Soft tissues 2. Venous related diagnoses a. Deep and superficial venous thrombosis b. Central venous stenosis or occlusion c. Large draining veins from fistula 3. Abnormalities intrinsic to chronic dialysis access a. Thrombosis of fistula or graft b. Steal syndrome c. PSA 4. Non-vascular diagnoses a. Soft tissue collections b. Other arm masses VIE197 It Doesn't Look Right but I'm Not Sure Why: Dissection of a Doppler Waveform Education Exhibits Location: VI Community, Learning Center Certificate of Merit Amy Davis Haberman MD (Presenter): Nothing to Disclose Erin Horsley DO : Nothing to Disclose Steven David Herman MD : Nothing to Disclose 1. Learn the specific components of spectral waveforms and their meaning with respect to physiology. 2. Learn to maximize the ultrasound unit settings to guarantee accuracy of diagnosis.

47 3. Be able to recognize normal and abnormal waveforms specific to each organ and pathology. 1. Basic physiology of hemodynamics 2. Basic Doppler techniques 3. Dissection of a spectral waveform 4. Optimizing your Doppler settings 5. Organ specific Doppler evaluation 6. Pathlogic Doppler waveforms 7. It doesn't look right but I'm not sure why. What do I do? 8. Post quiz VIE198 The Doppler Imaging Criteria for Diagnosing Stenoses in Arteries: A Comprehensive Review Education Exhibits Location: VI Community, Learning Center Ganesh Moreshwar Joshi MBBS (Presenter): Nothing to Disclose Flavius F. Guglielmo MD : Nothing to Disclose Lauren Lown : Nothing to Disclose Roger Lown : Nothing to Disclose Laurence Needleman MD : Nothing to Disclose The purpose of this exhibit is: 1. Review all arteries outside of the brain that can be evaluated with Doppler ultrasound. 2. Learn imaging criteria for diagnosing significant stenosis in each artery. 3. Learn primary and secondary signs of arterial stenosis. General principles 1. Waveform appearance within and adjacent to a significant stenosis 2. Optimizing color and spectral Doppler Head and neck arteries 1. Internal carotid- non-operated, post CEA, and post stenting 2. Common and external carotid 3. Subclavian- with TOS evaluation 4. Vertebral 5. Innominate Abdomen arteries 1. Abdominal aorta 2. Celiac- with MALC evaluation 3. SMA, IMA 4. Renal- native and transplant renal artery evaluation 5. Iliac Upper extremity arteries 1. Axillary, brachial, ulnar 2. Radial- with evaluation for radial artery dependence Lower extremity arteries 1. CFA, SFA, DFA, popliteal 2. PTA, ATA, peroneal 3. Bypass grafts, stents The major teaching points of this exhibit are: 1. There are general principles to know when evaluating arteries for stenosis within and proximal and distal to the stenosis. Adhering to them improves diagnostic accuracy. 2. Several arteries have unique imaging criteria when diagnosing stenosis. 3. In some arteries maneuvers can be performed to diagnose a stenosis. VIE199 The Role of Ultrasonography to Evaluate Complications after Endovascular Aneurysm Repair at Different Sites Education Exhibits Location: VI Community, Learning Center Joao Rafael Terneira Vicentini MD (Presenter): Nothing to Disclose Felipe Ribeiro Ferreira : Nothing to Disclose Danilo Giorgio Oliveira Azevedo Medrado MD : Nothing to Disclose Leina Ceravolo De Melo Zerey : Nothing to Disclose Carlos A P Ventura PhD : Nothing to Disclose Maria Cristina Chammas MD : Nothing to Disclose - Recognize the importance of ultrasound as a diagnostic method in the evaluation of complications after endovascular aneurysm repair, particularly endoleak - Key findings in ultrasound / Doppler examination of stents/grafts in peripheral arteries - Discuss ways to improve Doppler ultrasound technique for better results in these patients - Main advantages of ultrasound in the initial follow-up after aneurysm surgery over other imaging methods - Sample of cases evaluated and monitored with Doppler ultrasound - Special aspects of different arteries examination, such as the carotid and popliteal arteries - Security and applicability of ultrasound following endovascular correction of aneurysms - Correlation of sonographic findings and CT angiography (CTA) - Literature review on use of ultrasound and CT scan for follow-up after endovascular aneurysm repair VIE200 Ultrasound-Guided Intervention: Beyond the Guidance Tool Education Exhibits Location: VI Community, Learning Center Alexander Zachary Copelan MD (Presenter): Nothing to Disclose Anindya K. Roy MD : Nothing to Disclose Hanh Vu Nghiem MD : Nothing to Disclose Advantages of ultrasound in cross-sectional intervention have been previously described. Utilizing case-based illustrations, we will not only substantiate these traditional advantages, but will also demonstrate additional advantages, including the use of

48 ultrasound as a diagnostic, intra-procedural problem solving tool to prevent unnecessary procedures and potential complications. Illustrate and Depict: Traditional advantages of US as an image guidance tool: real-time nature, vessel visualization, portability, decreased procedure time and cost, and lack of ionizing radiation and use of iodinated contrast material Expanded advantages: i. Biopsy of small lesions, lesions not readily accessible by CT guidance, trans-rectal, trans-vaginal, and trans-perineal approaches, and pediatric intervention ii. Use of US-guided direct compression to displace bowel loops to facilitate biopsy of deep lesions, to treat pseudo-aneurysm with or without thrombin injection, and to help minimize potential post-procedural bleeding complications iii. Use of US imaging as an intra-procedural problem solving tool to help prevent unnecessary procedures and potential complications, and to urge the interventionist to recognize such instances and take the appropriate steps to ensure the safety and efficacy of image-guided intervention VIE201 Ultrasound-Guided Thoracic Interventions: Practical Guide With Tips and Tricks Education Exhibits Location: VI Community, Learning Center Jose Carmelo Albillos Merino MD (Presenter): Nothing to Disclose Susana Hernandez Muniz MD : Nothing to Disclose Javier Azpeitia Arman MD : Nothing to Disclose Rosa M. Lorente-Ramos MD, PhD : Nothing to Disclose Alvaro Paniagua MD : Nothing to Disclose To describe the main thoracic interventions that can be achieved by ultrasound guidance. To propose a tailored approach with tips and tricks. US-guided interventional procedures main advantages are that can be performed at the patient bed-side, permit a safe real-time control of the interventions without the use of ionizing radiation and are cost and time-effective. US has been considered to have a secondary role in interventions on the thorax. Nevertheless, most thoracic structures are adequately imaged by US and, as a result, interventional procedures can be safely performed with US-guidance. The main procedures that can be performed are biopsies (fine-needle and core biopsy) and drainage of fluid collections. The organs that can be reached by US are located in the chest wall, mediastinum, pericardium, pleura, pleural cavity and in the subpleural pulmonary parenchimas. We propose a guide to the interventions based on a tailored approach with real cases. Several steps must be followed: To depict the lesion with avalaible imaging techniques. To decide the best approach to the lesion. To verify correct visualization of the lesion with US. To perform the procedure with adequate technique and material. To assess absence of complications. VIE202 Utility of Ultrasound in Selected Cases in Interventional Radiology Education Exhibits Location: VI Community, Learning Center Ayman Sawas MD (Presenter): Nothing to Disclose Devang Butani MD : Nothing to Disclose Learn indications, benefits, interventional methods, and potential complications of utilizing ultrasound in interventional radiology procedures through case based presentation. This will include cases of performing direct intrahepatic protocaval shunt (DIPS) with intravascular ultrasound guidance, treating stenosis and thrombosiss of dialysis fistulas without fluroscopy, and percutaneous transhepatic cholangiogram (PTC). A. Clinical scenerio. B. Indication C. Benefits of ultrasound pretaining to the case D. Anatomy E. Interventional methods F. Outcomes including complications VIE203 CT Spectral Imaging in CT Portal Venography: Which Phase is Better, Late Arterial Phase or Portal Venous Phase Education Exhibits

49 Location: VI Community, Learning Center He Qing Wang MSc (Presenter): Nothing to Disclose Ailian Liu MD : Nothing to Disclose Yijun Liu : Nothing to Disclose Haruhiko Machida MD : Nothing to Disclose Eiko Ueno MD : Nothing to Disclose To review current CT in CT portal venography (CTPV) and its limitations The standard contrast medium injection of the multiphase contrast-enhanced in liver can be used for CTPV with spectral CT To demonstrate the improved image quality using late arterial phase as compared with that obtained using portal venous phase by presenting clinical images 1) Standard CT in CTPV and its limitations low contrast between the portal vein and liver parenchyma results in poor depiction of the intrahepatic portal veins on CTPV images CTPV images can be easily affected by various factors limited effect on the portal veins to increase the contrast medium dose and/or injection rate 2) Normal multiphase contrast enhancement in liver can be used for CTPV with spectral CT Optimal energy level of CTPV images in late arterial phase by presenting clinical images Optimal energy level of CTPV images in portal venous phase by presenting clinical images 3) CTPV images using late arterial phase is better than that obtained using portal venous phase high contrast between the portal vein and liver parenchyma in late arterial phase no hepatic veins overlapped the portal veins VIE204 "Management of Displaced Intravascular Foreign Bodies An Overview " Education Exhibits Location: VI Community, Learning Center James Burn MBBS, BSc (Presenter): Nothing to Disclose Antoni Aleksander Sergot MBBS, FRCR : Nothing to Disclose Yaron J. Berkowitz MBBChir, MRCS : Nothing to Disclose Wasim Hakim MBBS : Nothing to Disclose Steven S.M. Moser : Nothing to Disclose 1) Knowledge of the typical types, sites and risk factors of displaced intravascular foreign bodies. 2) An understanding of the associated morbidity and mortality. 3) Understanding of the various retrieval methods and equipment available - including advantages and disadvantages of each. 4) Tips/guidelines for improving outcome in intravascular retrieval/repositioning. Summary of typical displaced foreign bodies and sites of migration eg. pulmonary arteries/cardiac atria - using case examples. Risk factors for fracture/migration eg. emergency insertion / poor guide catheter or guide wire support / tortuous and calcified vessels etc. Overview of the clinical sequelae and associated mortality and morbidity of displaced/fractured intravascular foreign bodies. Summary of various retrieval equipment (eg snares, baskets or forceps) and techniques (proximal vs distal grab etc) using case examples. VIE205 The Road to Success for Adrenal Venous Sampling; Can It Be Useful to Detect Adrenal Veins on Unenhanced CT with 3D Thin Slice Data Acquisition? Education Exhibits Location: VI Community, Learning Center KIMEI AZAMA (Presenter): Nothing to Disclose Masahiro Okada MD : Nothing to Disclose Yuko Iraha : Nothing to Disclose Joichi Heianna : Nothing to Disclose Tomomi Koga : Nothing to Disclose Sadayuki Murayama MD, PhD : Nothing to Disclose The teaching points of this exhibit are: 1. To explain about adrenal venous anatomy on CT and MRI and basics of adrenal signal intensities on in-phase or opposed phase of dual-phase T1 weighted image. 2. To describe the clinical impact of adrenal venous sampling for primary aldosteronism. 3. To show the technique of adrenal venous sampling and present the utility to understand the location of adrenal veins on unenhanced CT, including 3D data acquisition. 4. Pitfalls of adrenal venous sampling are also addressed. 1) Anatomy of adrenal veins a. The shape of left/right adrenal vein b. Variations 2) Concept of primary aldosteronism Definition, Frequency, Classification 3) Significance of adrenal venous sampling For definite diagnosis To determine surgical indication 4) Identification of left/right adrenal vein on unenhanced CT How to recognize the location of adrenal veins on unenhanced CT 5) Optimal CT parameters of 3D data acquisition 6) What shape is better to insert the catheter to adrenal veins? Strategies for left/right adrenal venous sampling Technical difficulties 7) Pitfalls of adrenal venous sampling

50 Strategies for left/right adrenal venous sampling Technical difficulties 7) Pitfalls of adrenal venous sampling VIE207 The Transjugular Route to Biopsies: A Practical Guide Education Exhibits Location: VI Community, Learning Center Harshad Wankhedkar DMRD (Presenter): Nothing to Disclose Diptiman Roy MD : Nothing to Disclose Tejas Prakash Dharia MBBS : Nothing to Disclose Charul Goyal MBBS : Nothing to Disclose The Transjugular route has been used to perform biopsies of liver, kidney, intracardiac masses, pancreas and other organs A principle indication of using a transjugular route is the presence of an uncorrected bleeding disorder, when a percutaneous approach is contraindicated Transjugular route for biopsy is an established technique in high risk patients. Indications for transjugular renal biopsy, apart form bleeding disorders, include conditions than preclude the prone position, like voluminous ascitis, morbid obesity and mechanical ventilation. Transjugular route for intracardiac masses has the advantage of avoiding cardiac wall injury. Benefits of using a transjugular approach for visceral biopsies Patient Selection Organ-specific Procedure technique Pre-procedural work up Procedure Post-procedure imaging Procedure-specfic complications VIE208 Major complications Minor complications Organ specific complications Where We Have Been, Where We Are, and Where We Are Going: History and State of the Art Treatment and Management of Chronic Lower Extremity Venous Insufficiency Education Exhibits Location: VI Community, Learning Center Mustafa Syed DO (Presenter): Nothing to Disclose Eli Halpert MD : Nothing to Disclose Ronald Mark Dreifuss MD : Nothing to Disclose Christopher John Moran MD : Nothing to Disclose Describe chronic lower extremity venous insufficiency (CVI). Demonstrate a basic pathophysiologic and epidemiologic understanding. Quantifying CVI. Understanding deep/superficial/perforator venous anatomy and its importance in treatment success. Overview of older, current and novel techniques--their appropriate use in treatment and management of CVI. Introduction: Description of venous insufficiency and our role in management as interventional radiologists. Epidemiology: Who is most prone to CVI? Pathophysiology and Anatomy: What are factors that lead to venous insufficiency? What is the pathophysology? Pertinent discussion of anatomy (with diagrams) Approach to Evaluation and Treatment: CEAP Classification Sonography Discussion of older techniques such as surgical stripping and sclerotherapy. Discussion of newer techniques such as mechanical, chemical and thermal ablation--effectiveness, and appropriate subset of patients. Post-treatment follow-up: Discussion of post-treatment follow-up. Evaluating success of a therapy. Patient's options in the event of post-treatment failure. Conclusion: Discussion emphasizing the importance of understanding CVI, anatomy, it's morbidity, and great benefit to the patient in the setting of appropriate treatment. SSA23 Vascular/Interventional (IR: Biopsy/Drainage) Scientific Papers IR VA AMA PRA Category 1 Credits : 1.50 ARRT Category A+ Credits: 1.50 Sun, Nov 30 10:45 AM - 12:15 PM Location: E350 Moderator Ranjith Vellody MD : Nothing to Disclose Moderator Jafar Golzarian MD : Nothing to Disclose

51 Sub-Events SSA23-01 Rapid Pathologic Subtyping of Kidney Tumors after Ex Vivo Core Needle Biopsy Using Optical Spectroscopy Mikhail Silk BS (Presenter): Nothing to Disclose, Dmitry Dylov : Nothing to Disclose, Siavash Yazdanfar : Nothing to Disclose, Tarik Silk : Nothing to Disclose, Stephen Barnett Solomon MD : Research Grant, General Electric Company Research Grant, AngioDynamics, Inc Consultant, Johnson & Johnson Consultant, Covidien AG Director, Devicor Medical Products, Inc Director, Aspire Bariatrics, Inc, Jeremy C. Durack MD : Nothing to Disclose To develop and validate an instrument to rapidly discriminate between renal cancer neoplastic subtypes and normal core biopsy tissue using elastic light scatter spectroscopy. We performed an Institutional Review Board approved prospective study of surgically resected kidney tumors with a clear pathologic diagnosis from 1/2013-2/ Visible tumors and surrounding normal kidney were biopsied using 18G side-notch core needles. Core biopsy specimens were analyzed using a specialized light spectroscopic scatter device that rapidly scans (less than 1 minute) core needle biopsy samples while still on the needle. Spectra were normalized and distributed against geometrical means and outliers were rejected. The spectral data was decomposed into 25 principal components and a machine learning algorithm was used to differentiate between tumor subtypes and normal tissue. Receiver operating characteristic (ROC) curves were generated using pathology as the gold standard for all samples. Fifty-three kidneys were biopsied during the study period resulting in 3076 usable spectra after outlier rejection (1272 normal and 1804 tumor samples). The final pathologic diagnoses included clear cell carcinoma (1130/1804,63%), papillary carcinoma (248/1804, 14%), chromophobe carcinoma (226/1804, 13%) and oncocytoma (200/1804, 11%). Principal component analysis using the Random Forest algorithm resulted in a sensitivity of 92.6%, specificity of 93.3%, 95.2% PPV, and 89.9% NPV. Despite overall high accuracy for renal tumor subtyping, the device performed least well differentiating papillary from clear cell carcinoma and normal renal tissue from chromophobe carcinoma. Rapid tissue-preserving optical spectroscopy analysis of core biopsy samples is feasible and can successfully differentiate renal tumor subtypes with a high degree of classification accuracy. This instrument offers the potential to improve on-site biopsy assessment. Automated workflow-integrated pathologic assessment of core needle biopsies using optical spectroscopy is possible and has the potential to improve on-site biopsy assessment. SSA23-02 Intra-procedural Low-dose 18-Fluoro-deoxyglucose PET/CT-guided Biopsy Leads to Increased Accuracy in Poorly Visualized Lesions Francois Cornelis MD (Presenter): Nothing to Disclose, Haruyuki Takaki MD : Nothing to Disclose, Jeremy C. Durack MD : Nothing to Disclose, Joseph Patrick Erinjeri MD, PhD : Nothing to Disclose, Constantinos Thasos Sofocleous MD, PhD : Consultant, Sirtex Medical Ltd, Robert H. Siegelbaum MD : Nothing to Disclose, Heiko Schoder MD : Nothing to Disclose, Stephen Barnett Solomon MD : Research Grant, General Electric Company Research Grant, AngioDynamics, Inc Consultant, Johnson & Johnson Consultant, Covidien AG Director, Devicor Medical Products, Inc Director, Aspire Bariatrics, Inc To report the accuracy of percutaneous biopsies performed under intra-procedural 18-Fluoro-deoxyglucose (FDG) positron emission computed tomography (PET-CT) guidance. The IRB approved this retrospective study with a waiver of written informed consent. We reviewed 105 consecutive patients from 2011 to 2013 who had clinically indicated percutaneous PET-CT guided biopsies of 106 masses (mean size, 3.3 cm; range, cm; SD, 2.9 cm) in bones (n=33), liver (n = 26), soft tissues (n = 18), lung (n = 15) and abdomen (n=14). Recommendation for PET-CT guidance was based on existing image review and challenges anticipated using CT, MR or ultrasound modalities for procedural guidance. The biopsy procedures were performed following injection of 6.9mCi in mean (range, ; SD, 2) of FDG. Maximal standardized uptake value (SUV) of lesions was 8.8 in mean (range, ; SD, 6.3). A systematic review of the histopathological results and outcomes was performed. Descriptive statistics were used to summarize the results. Biopsies were positive for malignancy in 76 (71.7%, 76/106) cases and for benign tissue in 30 cases (19.8%, 30/106). Immediate results were considered as adequate for 100 PET-CT biopsies (94.3%, 100/106), and for

52 the 6 others (5.7%, 6/106) benign diagnoses were confirmed after surgery (n=4) or follow-up (n=2). Accuracy, sensitivity and positive predictive value (PPV) of biopsies were all 100%, with a 95% confidence interval of [ ] for PPV. Complications occurred after 4 biopsies (3.7%, 4/106). Intra-procedural PET-CT guidance appears is a safe and effective method and allows high accuracy of percutaneous biopsies for metabolically active lesions. For purposes of biopsy guidance, half of the typical FDG activity is sufficient for target visualization. PET-CT imaging guidance can be used to biopsy metabolically active lesions not well visualized on other modalities with an excellent specificity and positive predictive value. SSA23-03 Safety and Outcomes Following Percutaneous Biopsy of Hepatic Adenomas Derrick Arnold Doolittle MD (Presenter): Nothing to Disclose, Thomas Duncan Atwell MD : Nothing to Disclose, Taofic Mounajjed : Nothing to Disclose, David Maitland Hough MD : Nothing to Disclose, Grant D. Schmit MD : Nothing to Disclose, Anil Nicholas Kurup MD : Nothing to Disclose Until recently, MRI with gadoxetate disodium (Eovist) was used to distinguish benign FNH from hepatic adenoma, the latter neoplasm having a small but real propensity for both spontaneous hemorrhage and malignant degeneration. Recently, an inflammatory variant of hepatic adenoma has been described which may demonstrate MRI imaging features similar to FNH, precluding diagnostic differentiation of these tumors. Given the implications of the different pathologies, there is a resurging interest in the role of biopsy in differentiating FNH and hepatic adenoma. The purpose of this project was to determine the safety and outcomes following biopsy of hepatic adenomas. We performed a retrospective review of all patients at our institution over a 14 year interval with a confirmed biopsy proven diagnosis of hepatic adenoma. The biopsy procedure and complications of the biopsy were evaluated. Pathology-specific outcomes related to the diagnosis of adenoma were assessed. Sixty-four patients were identified (56 females and 8 males, average age of 41.5 years) with an average follow up of 883 days after biopsy. Four (6%) patients had RF ablation the same day as the biopsy and complications were not assessed for these patients. Nine of the remaining 60 (15%) patients had a minor complication. There were no major complications. Three (5%) of our 64 biopsy-proven adenomas revealed focal nodular hyperplasia upon surgical resection. One biopsy proven adenoma was rebiopsied 3 months later, with result showing well differentiated hepatocellular carcinoma. Complications of biopsy proven hepatic adenomas are rare. Although rare, discordant pathology results from biopsy and surgical resection may occur. Biopsy of hepatic adenoma is safe with rare discordant results. SSA23-04 Radiation Exposure of Medical Staff during Percutaneous Soft Tissue Interventions on a Phantom Using a Multi-axis Interventional C-arm CT System with 3D Laser Guidance Nils Rathmann MD (Presenter): Nothing to Disclose, Michael Kostrzewa MD : Nothing to Disclose, Uwe Haeusler : Nothing to Disclose, Stefan Oswald Schoenberg MD, PhD : Institutional research agreement, Siemens AG, Steffen J. Diehl MD : Nothing to Disclose The purpose of this study was to investigate absolute radiation exposure values for interventional radiologists during 3D laser guided soft tissue interventions using a multi-axis interventional C-arm CT system with 3D laser guidance (Artis Zeego, Siemens Healthcare Sector, Germany). 3D, laser supported, fluoroscopic guidance (syngo iguide) of the Siemens Artis Zeego intervention system was used to puncture sixteen lesions at different angles with a 20G biopsy-needle. The lesions were identified in a triple modality 3D abdominal phantom (model 057A, CIRS, Norfolk, VA, USA). Two 20l water containers were placed adjacent to the phantom to increase its volume. One C-arm CT (syngo DynaCT) was performed for planning of the intervention and one DynaCT was performed for post procedural evaluation to properly identify the needlepoint within the lesion. Laser supported fluoroscopy was used for needle guidance. For each intervention three thermoluminiscent dosimeters (TLDs) placed on an i.v. pole at the level of the eyes, the

53 umbilicus and the ankles were used to collect representative radiation exposure values of the interventionalist. The i.v. pole was placed next to the phantom analogue to the position of the interventionalist without lead shielding for the entire duration of the intervention. Sixteen interventions were analyzed. For proper positioning of the needle within each target lesion mean fluoroscopy time was 4.1s and mean overall procedural duration was 904s. Mean radiation value of all TLDs was 189 Sv (±59, range ). Mean radiation value of the TLDs at the level of the eye lens was 177 Sv (±44, range ), of the umbilicus 231 Sv (±29, range ) and of the ankle 150 Sv (±29, range ). Our results suggest that proper lead shielding during the interventions and leaving the intervention suite during DynaCT is of critical importance to minimize radiation exposure for the medical staff. Furthermore these results have to be systematically compared to CT-guided interventions for which lower values of radiation exposure have been reported for medical staff. These results indicate that even with modern navigation tools without lead shielding relative high radiation doses for medical staff can occur during biopsy with a clinical robot-arm assisted intervention system. SSA23-05 Image-guided Needle Aspiration versus Percutaneous Catheter Drainage in the Management of Complex Pyogenic Liver Abscesses Caused by Klebsiella Pneumonia Sivasubramanian Srinivasan MD, FRCR (Presenter): Nothing to Disclose, Hui Seong Teh MBBS : Nothing to Disclose, Manickam Subramanian MD,FRCR : Nothing to Disclose Our aim was to compare the effectiveness of percutaneous needle aspiration with percutaneous catheter drainage in the management of liver abscess caused by Klebsiella pneumonia. 64 patients (42 males, 22 females: 25-85years, mean 74years) with culture proven Klebsiella liver abscess underwent either percutaneous needle aspiration (n=28, size 3-10cm, mean 7.2cm) or catheter drainage (n=36,size 3-15cm, mean 9.5cm) along with appropriate antibiotic treatment. The abscesses were graded into four grades according to the liquefaction and loculations (grade1-unilocular abscess, 4 - solid appearing complex abscess with scanty liquefaction). In grade4 abscesses, percutaneous aspiration was performed with 18G needle in multiple locules to aspirate the contents. For catheter drainage, 8- to 12-French catheters were inserted into the abscess cavity by the Seldinger technique under imaging guidance. Outcome was assessed with clinical and lab parameters and sonographic monitoring of size of the abscesses. Percutaneous procedures were technically successful in all patients (64/64,100%) and clinical success was achieved in 62 patients (62/64,96%). Percutaneous needle aspiration was successful in first attempt in 22 (22/28,79%) patients after one aspiration and six patients(21%) needed a second procedure where as 12(12/36,33%) patients in the drainage group needed a second procedure. Then need for second procedure, especially in grade 4 abscesses was significantly lower in the aspiration group (p<0.05) compared the drainage group. Four patients with air forming Klebsiella liver abscess, were hemodynamically unstable due to septic shock had to undergo catheter drainage and one (1/4,25%) of them could not recover from the septic shock. Rercutaneous aspiration is more effective in Klebsiella abscesses with scanty liquefaction compared to catheter drainage. However emergent catheter drainage is necessary in patients with air-forming Klebsiella abscesses who usually present with hemodynamic instability due to septic shock. In Klebsiella pneumonia liver abscesses, especially in cases with scanty fluid component, needle aspiration can be considered as a first line of management with antibiotic coverage. However in patients with air-containing Klebsiella pneumonia abscesses, emergent catheter drainage will be necessary because of severe sepsis. SSA23-06 Image-guided Percutaneous Drainage for Treatment of Post-surgical Anastomotic Leak in Patients with Crohn s Disease James Donald Byrne BS (Presenter): Nothing to Disclose, Ari Joel Isaacson MD : Nothing to Disclose, Ryan Stephens MD : Nothing to Disclose, Hyeon Yu MD : Nothing to Disclose, Charles Thomas Burke MD : Nothing to Disclose Anastomotic leaks are a common complication after bowel surgery in Crohn's patients. Image-guided percutaneous drainage is an attractive alternative to reoperation because of decreased morbidity and hospital stay. Because data for this specific population is scarce, we aimed to determine the safety and efficacy of image-guided percutaneous drainage in the management of anastomotic leak in Crohn's patients by retrospectively reviewing cases at a single academic institution. The medical records of 41 patients with Crohn's disease who underwent percutaneous drain placement for the treatment of anastomotic leak from September 2004 to November 2013 were reviewed. CT imaging was also

54 reviewed to determine the number, size and locations of the drained fluid collections. Local treatment failures and complications were evaluated for all patients. The mean volume of the abscesses resulting from anastomotic leak was cm3 (median 59.5 cm3; range cm3), and the mean number of targeted fluid collections per patient was 1.5 (median 1; range 1-4); 15 of 41 (38.1%) patients were treated for multiple abscesses. The mean duration between surgery and percutaneous drain placement was 18.5 days (median 14 days; range 6-60 days), and the median drain size was 10 French, with a range of 8-16 French. Overall, the mean duration of drainage was 70.4 days (median 29 days; range days). The mean number of drain manipulations/exchanges was 1.2 (median 0; range 0-14). One of 41 (2.4%) patients experienced minor complications from drain placement, injury to a superficial abdominal artery, and no major complications occurred. Two of 41 (4.9%) patients required repeat surgeries. Image-guided percutaneous drainage for the treatment of post-surgical anastomotic leaks in Crohn's patients is effective and safe with low rates of complications and reoperations. Image-guided percutaneous drainage of anastomotic leaks after bowel surgery in Crohn's patients is a safe and effective alternative to surgical intervention, reducing morbidity and hospital stay. SSA23-07 Comparison of Unilateral versus Bilateral Biliary Drainage in Patients with Malignant Biliary Obstruction: A Prospective Study Tezbir Singh MBBS (Presenter): Nothing to Disclose, Shivanand Ramachandra Gamanagatti MBBS, MD : Nothing to Disclose, Raju Sharma MD : Nothing to Disclose, Deepnarayan Srivastava : Nothing to Disclose This study evaluated the efficacy of unilateral versus bilateral percutaneous transhepatic biliary drainage in the palliation of these patients in terms of improvement of quality of life and reduction of serum bilirubin levels A prospective, single-center study was conducted in a cohort of 49 patients with malignant biliary obstruction. The primary confluence was blocked in 33 patients and patent in 16 patients. A single, unilateral internal-external catheter or metallic stent was placed in 44 patients. Bilateral catheter or stent insertion was done in 5 patients in whom the primary confluence was blocked and contrast had opacified the contralateral duct during the procedure to prevent cholangitis. In total 28 patients (57.1%) had unilateral biliary drainage and in the rest of 21(42.9%) bilateral drainage was achieved. Patients were evaluated at one month after the procedure and, thereafter every 3 months. We studied the impact of amount of biliary drainage on the change in the European Organisation for Research and Treatment of Cancer QOL questionnaire (EORTC QLQ-C30) (version 3) scores and by liver function tests. Mean serum bilirubin level was mg/dl prior to the procedure and at one month was 6.02 mg/dl after the procedure, and at 6 months was 3.84 mg/dl, which was statistically significant (p<0.001). There was a significant improvement in all the QOL parameters (Functional, Symptomatology and Global). The mean increase in the Functional parameter at one month was (percentage increase was 46.19%). The mean decrease in the Symptomatology parameter was (percentage reduction was 38.5%). The mean increase in the Global parameter was 25.8(percentage increase was 85.8%). We found that there was no statistically significant difference in the reduction of the serum bilirubin levels (p = 0.136), and also QOL scores between the patients treated with unilateral versus bilateral drainage. Unilobar biliary drainage is safe, feasible, and achieves adequate drainage in the great majority of patients with unresectable malignant biliary obstruction in terms of improvement of quality of life and bilirubin levels as compared to bilobar biliary drainage. Unilateral percutaneous deployment of catheters or metal stents has a high clinical success rate that provides adequate palliation and improves Quality of Life substantially. SSA23-08 Wall Suction-assisted Image-guided Therapeutic Paracentesis: A Safe Alternative to Evacuated Bottles Tatiana Kelil MD (Presenter): Nothing to Disclose, Paul B. Shyn MD : Nothing to Disclose, Loraine Eng Wu MD : Nothing to Disclose, Ramin Khorasani MD : Consultant, Medicalis Corp, Stuart G. Silverman MD : Author, Wolters Kluwer nv Because evacuated bottles are expensive and in short supply, we assessed the safety of using wall suction to drain and collect large amounts of fluid during image-guided paracentesis procedures.

55 This retrospective quality improvement project was HIPAA-compliant and did not require IRB approval. In a hospital-based practice, 551 image-guided paracenteses were performed in 191 consecutive patients (61 males and 130 females, ages 21-94, mean 61) over a 10-month period, using wall suction to collect the fluid. Each patient underwent 1 to 40 (mean 8.3) procedures. The two most common primary diagnoses were malignancy in 142 (74.3%) patients and cirrhosis in 36 (18.8%) patients. Paracenteses were performed using ultrasound (n =542) or CT (n = 9) guidance, 5-French centesis catheters, extension tubing (3 m long, 5 mm diameter), and 1-3 L plastic collection canisters attached to wall suction (up to -527 mm Hg). Volume of fluid removed and complications were recorded based on review of procedure dictation reports, the electronic medical record, and quality assurance logs with a minimum 30-day follow-up. Complications were graded using Common Terminology Criteria for Adverse Events, version 4. The volume of fluid removed ranged from 35 to 11,965 ml (mean 3541 ml). Four (0.72%) complications occurred in 551 procedures; a rate similar to historical controls. Grade I complications included prolonged ascites leak (n = 1). Grade III complications included infection (n = 1), hypotension (n = 1) and atrial fibrillation (n = 1). All four complications were unrelated to the use of wall suction, and were treated successfully; no grade II, IV or V complications occurred. The small number of complications precluded adequate statistical power for comparisons to historical controls. The use of wall suction when performing image-guided therapeutic paracentesis is a safe alternative to collecting fluid with evacuated bottles. The current shortage of evacuated bottles has prompted the safe use of wall-suction to facilitate image-guided therapeutic paracentesis. SSA23-09 The Effectiveness of Image-guided Peritoneal Dialysis Catheter Placement in a Community Hospital Paul Erik Dybbro MD (Presenter): Nothing to Disclose, Todd Ellis Drasin MD, MPH : Nothing to Disclose Minimally invasive image-guided techniques allow placement of peritoneal catheters into traditionally excluded patients including acutely uremic patients, patients with low cardiac output and /or recent myocardial infarctions, and patients with hepatorenal or cardiorenal syndrome. The following study measures the effectiveness of a community-based minimally invasive image-guided interventional radiology peritoneal dialysis catheter placement service. The clinical electronic medical records of 100 consecutive image-guided peritoneal dialysis catheter placements were reviewed at a community-based hospital. Cases were performed between July 2012-March The referral based included low, medium, and high-risk patients. Cases were a random mix of elective, urgent, and emergent procedures. Two interventional radiology physicians performed all the procedures. Procedures were performed in an interventional radiology suite usually under procedural sedation; a few selected patients received local anesthesia. Ultrasound was utilized to achieve safe peritoneal entry and creation of a rectus muscle tunnel to provide catheter stability. Fluoroscopy was utilized to achieve deep mid line pelvic positioning of the curl tip portion of the catheter. Initial catheter placement success rate was 92%. There were no complications. Mechanical catheter malfunction-free rates were calculated, and were 94% (78/83) at 3 months, 91% (67/74) at 6 months and 85% (44/52) at 1 year. Excluded from the calculations were cases of peritoneal dialysis loss from psychosocial issues, infections, peritoneal membrane failure, migration to transplant status, hydrothorax, hernia formation, and patient death. Image-guided peritoneal dialysis catheter placement achieves comparable survival rates as laparoscopic catheter based services. Minimal invasive image guided techniques have documented cost advantages to laparoscopic techniques. By expanding the pool of eligible patients for peritoneal dialysis, the imaged guided techniques can increase the utilization of peritoneal dialysis in this country. Medicare costs for peritoneal dialysis average $20,000 less/patient/year compared to hemodialysis. Increasing utilization rates of peritoneal dialysis as a renal replacement therapy can result in significant cost savings. SSA24 Vascular/Interventional (IR: Advanced Vascular Imaging) Scientific Papers IR VA AMA PRA Category 1 Credits : 1.50 ARRT Category A+ Credits: 1.50

56 Sun, Nov 30 10:45 AM - 12:15 PM Location: E352 Moderator Elizabeth M. Hecht MD : Nothing to Disclose Moderator Gretchen Marie Foltz MD : Nothing to Disclose Sub-Events SSA24-01 Non-enhanced (TOF) MRA versus Ultra-low-Dose Contrast-enhanced MRA at 7T Thomas C. Lauenstein MD (Presenter): Nothing to Disclose, Anja Fischer MD : Nothing to Disclose, Michael Forsting MD : Nothing to Disclose, Mark E. Ladd PhD : Nothing to Disclose, Stefan Maderwald PhD, MSc : Nothing to Disclose, Lale Umutlu MD : Consultant, Bayer AG With recognition of a potential side effect, by the name of Nephrogenic Systemic Fibrosis, there has been a shift towards MR angiography techniques with reduction or complete omission of Gadolinium-based contrast agents. Hence, the aim of this trial was to compare the diagnostic ability of non-enhanced (TOF) versus ultra-low-dose contrast-enhanced renal MRA at 7 Tesla. 12 healthy subjects were examined on a 7T MR system (Magnetom 7T), utilizing a custom-built 8-channel RF body coil. Time-of-flight (TOF) MRA was obtained with a voxel size of 1.0 x 2.0 x 2.5 mm3. Corresponding ultra-low-dose contrast-enhanced (ce) 3D FLASH datasets were acquired with a voxel size of 1.0 x 1.5 x 1.0 mm3, obtained in unenhanced and in arterial phase after the application of mmol/kg BW Gadobutrol (Bayer Healthcare). Image subtraction was performed subsequently. Contrast ratios (CR) were measured in the corresponding datasets in the aorta and both renal arteries in correlation to adjacent psoas major muscle. Qualitative analysis with regard to delineation of the renal arterial vasculature was performed by two radiologists using a five-point-scale (5=excellent to 1= non diagnostic). Both MRA techniques offered a robust and homogenous hyperintense vessel signal of the assessed vasculature. Qualitative analysis revealed comparable results of vessel conspicuity in subjective ratings for TOF MRA (mean left renal artery = 4.5) and subtracted contrast-enhanced datasets (mean left renal artery = 4.6). Background suppression in subtracted datasets was superior to background suppression of TOF-images, reflected in superior contrast ratio values for subtracted datasets (mean aorta =0.7) compared to TOF-MRA (mean aorta = 0.4). Our results demonstrate the successful facilitation and comparable diagnostic ability for vessel assessment in TOF-MRA and ultra-low-dose renal MRA at 7T, while preserving high quality vessel assessment. Preservation of high-quality vessel assessment while facilitation of significant reduction, or respectively complete omission of contrast agent, may be of high diagnostic value for MR angiographic examinations in patients with renal insufficiency. SSA24-02 Ultra-high-Resolution Imaging of the Intracranial Arteries at 7T: TOF MRA versus Non-enhanced MPRAGE Lale Umutlu MD (Presenter): Consultant, Bayer AG, Nina Theysohn MD : Nothing to Disclose, Soren Johst : Nothing to Disclose, Michael Forsting MD : Nothing to Disclose, Marc U. Schlamann : Nothing to Disclose, Karsten Wrede : Nothing to Disclose The purpose of this study was to intraindividually compare the delineation of intracranial arterial vasculature utilizing ultra-high-resolution TOF MRA versus non-enhanced MPRAGE at 7 Tesla. 40 subjects were examined on a 7 T whole-body MR system (Siemens Healthcare) utilizing a 32-channel transmit / receive head coil (Nova Medical). TOF MRA was performed with a voxel size (vs) of 0.2 x 0.2 x 0.2 mm3, non-enhanced MPRAGE with a vs of 0.7x0.7 x0.7mm3. For qualitative analysis, two readers assessed the delineation of the following arteries and segments: (1) internal carotid artery [cervical segment, petrous segment, cavernous segment], (2) anterior cerebral artery [A1, A2], (3), anterior communicating artery, (4) middle cerebral artery [M1, M2, M3], (5) posterior communicating artery, (6) posterior cerebral artery [P1, P2], (7) basilar artery. Additionally, (1) overall image quality, (2) vessel sharpness, (3) vessel to background contrast and (4) image impairment due to artifacts was assessed. For qualitative analysis a five-point-scale was utilized for rating (5 = excellent image quality to 1 = non-diagnostic). For quantitative analysis contrast-ratios of the middle cerebral artery in correlation to surrounding grey matter were measured in both sequences. For statistical analysis a Wilcoxon signed rank test was applied.

57 Both sequences enabled high quality delineation of all assessed vessel segments with superior depiction of the vessels of the anterior circulation (meananterior circulation MPRAGE=4.6 TOF MRA=4.4) compared to the vessels of the posterior (circulation meanposterior circulation MPRAGE=4.1 TOF MRA=3.8). While TOF MRA yielded superior vessel sharpness over MPRAGE (meanvessel sharpness MPRAGE 4.3 TOF MRA 4.6), MPAGE MRI yielded superior vessel to background contrast (meanvessel contrast MPRAGE=4.6 TOF MRA=4.2), also reflected in higher CR values for MPRAGE MRI. Our results demonstrate the high diagnostic value of both non-enhanced MRA techniques, with overall superiority of MPRAGE MRI, offering a robust and artifact-free high-resolution delineation of the intracranial vasculature. 7T MPRAGE MRI may serve as a high quality diagnostic tool for high-resolution assessment of the intracranial vasculature, particularly for recurrent radiation-free follow-up imaging. SSA24-03 Contrast-enhanced Magnetic Resonance Angiography (MRA) vs. Digital Subtraction Angiography (DSA): Grading of Stenosis and Therapy Planning in Peripheral Artery Occlusion Disease (PAOD) Thomas Josef Vogl MD, PhD (Presenter): Nothing to Disclose, Clemens Wurz BA : Nothing to Disclose, Stefan Zangos MD : Nothing to Disclose, Axel Thalhammer MD : Nothing to Disclose, Thomas Schmitz-Rixen MD, PhD : Nothing to Disclose To compare contrast-enhanced magnetic resonance angiography (MRA) with conventional digital subtraction angiography (DSA) for detecting stenoses and planning of therapy in patients with peripheral artery occlusion disease (PAOD). In this retrospective study 71 patients (20 women / 51 men; mean: 68 years) with established PAOD underwent both imaging modalities in a maximum interval of 40 days. DSA was the standard of reference. The pelvic and leg arteries were divided into 31 anatomic segments, which were graded on a scale from 1-4 (1=no stenosis; 2=stenoses < 70%; 3=stenoses 70%; 4=occlusion). The pelvic and leg vessel systems were categorized with the TASC II-score into five grades (none, TASC-A, TASC-B, TASC-C, TASC-D) for detecting whether the therapeutic consequences would be the same for both imaging modalities. Evaluation was possible for 1,937 vessel segments. MRA and DSA agreed in the grading of 1,802 segments (93.03%), and differed in 69 cases in one category, in 28 cases in two and in 38 cases in three categories. In discriminating between hemodynamically relevant ( 70% / occlusion) and non-hemodynamically relevant findings (< 70% / nonstenosis) MRA achieved a sensitivity of 90.59% and a specificity of 96.61%. Evaluation of TASC II-classification for the aorto-iliacal region was possible in 56 patients. In 52 patients TASC II-class was the same for DSA and MRA (92.86%; κ=0.88), for the femoral-popliteal region the result was nearly the same, the evaluation of 56 patients showed agreement in 52 patients (92.86%; κ=0.90). There was almost perfect agreement between MRA and DSA in the TASC classification. Thus, the therapeutic consequences are predominantly the same, irrespective of the modality used. Contrast-enhanced MRA is a valid method for detecting and grading stenoses in patients with PAOD. SSA24-04 FGF-23 a Predictive Parameter in Patients with Non-occlusive Mesenteric Ischemia (NOMI) Peter Minko MD (Presenter): Speaker, Straub Medical AG Consultant, Straub Medical AG, Matthias Klingele : Nothing to Disclose, Jonas Stroeder MD : Nothing to Disclose, Heinrich Groesdonk : Nothing to Disclose, Arno Buecker MD : Consultant, Covidien AG Speaker, Covidien AG Co-founder, Aachen Resonance GmbH Research Grant, Siemens AG, Hans-Joachim Schafers MD : Nothing to Disclose, Marcus Katoh MD : Consultant, Straub Medical AG Consultant, Medtronic, Inc To correlate angiographic findings with kidney specific parameters and to investigate the predictive value of angiography with respect to the outcome in patients with NOMI.

58 In this prospective study 63 consecutive patients (mean age:73±8 years) suspected of NOMI after cardiac or major thoracic vessel surgery underwent catheter angiography of the superior mesenteric artery. Images were assessed by two experienced radiologists on consensus basis using a previously published standardized reporting system (Homburger-NOMI-Score). These data were correlated to kidney specific parameters: FGF-23, cystatin, cystatin C, creatinin and glomerular filtration rate (GFR) and outcome data (death, acute renal failure) using linear and logistic regressions, as well as nonparametric test and ROC-analysis. Significant correlations were found between FGF-23 and the overall NOMI-score (consisting of five categories namely vessel morphology, reflux of contrast medium into the aorta, contrast enhancement and distension of the intestine, as well as the time to portal vein filling; p=0.05) as well as the modified NOMI-score (consisting of three categories namely vessel morphology, reflux of contrast medium into the aorta and time to portal vein filling; p=0.02). No significant correlation was found for creatinin (p=0.07), cystatin (p=0.27), cystatin C (p=0.83) and GFR (p=0.23). Logistic regression revealed a significant correlation between death and the overall NOMI-score (p=0.006) as well as the modified NOMI-score (p<0.001). No significant correlation was found for the development of acute renal failure (p=0.268). FGF-23 significantly correlates with the development of NOMI. Furthermore the applied scoring system allows to predict fatal outcome in NOMI patients. FGF-23 plays a predictive value for the devolpment of NOMI and corelates significantly with the Homburger-NOMI-Score. SSA24-05 Clinical Routinization of Spectral CT with Individualized Scan Protocol in Abdomen: Image Quality and Radiation Dosage Comparison with Conventional 120kVp Scans Chen Xiaoxia MMed (Presenter): Nothing to Disclose, Lei Yuxin MMed : Nothing to Disclose, Tian Qian MMed : Nothing to Disclose, Jia Yongjun MMed : Nothing to Disclose, Tian Xin MMed : Nothing to Disclose To evaluate the feasibility of routinizing spectral CT in abdominal application with individualized scan protocol by comparing image noise and radiation dose of conventional 120kVp scans. Prospectively randomized 39 patients (BMI: 23.08±3.58) who require contrast-enhanced CT scans in the abdomen to 2 groups: group 1 (n=20) with 120kVp for the plain phase and spectral CT for the enhanced portal venous phase (VP); group 2 (n=19) with spectral CT for plain phase and 120kVp for VP. For the 120kVp scan, the tube current (m A) was automatically adjusted to achieve noise index (NI) of 10, and for spectral CT, a m A was selected based on the average of the min and max m A from the 120kVp m A table for NI=10. Scan ranges were 250mm for both groups. CT dose index (CTDI) and effective dose was recorded. Images of 5mm thickness were reconstructed with 50%ASIR in both groups. Image standard deviation (SD) for the liver parenchyma, erector spinae, fat and portal vein on the conventional 120kVp polychromatic images and 70keV monochromatic images from spectral CT was measured and compared with t-test. The CTDI and effective dose were (13.32±1.19mGy and 6.19±0.55mSv) for spectral CT, about 10% lower than the respective value of (14.35±4.66mGy and 6.68±2.17mSv) for the 120kVp CT. The SD values (in HU) in the spectral CT images were 5.01±0.48, 4.93±0.77, 5.16±0.93 and 5.81±1.14 for the liver parenchyma, erector spinae, fat and portal vein, respectively. These values were statistically lower than the respective values of 6.69±0.85, 6.05±1.86, 5.74±1.09 and 7.44±1.31 in the conventional 120kVp images (p<0.01). With individualized scan protocol, spectral CT provides monochromatic images with lower image noise at the same or lower radiation dose in comparison with the conventional 120kVp scans. The lower dose scan protocol makes it feasible to routinize spectral CT in abdominal applications. Spectral CT with individualized low dose scan protocol can be routinely used in abdominal applications. SSA24-06 Prediction of Renal Function Impairment of Donors after Kidney Transplantation: Analysis by Using Abdominal Aortic Calcification under Propensity Score Matching Min-Yung Chang MD (Presenter): Nothing to Disclose, Sung Yoon Park : Nothing to Disclose, Young Eun Yoon : Nothing to Disclose, Woong Kyu Han : Nothing to Disclose, Dae Chul Jung : Nothing to Disclose, Young Taik Oh MD : Nothing to Disclose To analyze whether the presence or amount of abdominal aortic calcification (AAC) could predict renal function

59 impairment of donors after kidney transplantation Between 2010 and 2013, 287 donors undergoing nephrectomy were enrolled. The calcium score (CS) of AAC was quantitatively measured with Agatston score on CT angiography. The donors were divided into AAC (CS>0, n=238) and non-aac (CS=0, n=49) groups. The propensity score matching was conducted in terms of age, sex, and body mass index. The estimating glomerular filtration rate (egfr) was measured before, and 1-week, 1-month, 3-month, and 6-month after transplantation. Between two groups, pre- and postoperative egfrs were compared before and after propensity score matching, respectively. The mean CS was ± in ACC and 0 in non-acc (p<0.05). Before propensity score matching, all of pre- and postoperative egfrs were different between two groups (p<0.05). After propensity score matching, those differences of egfr disappeared (p>0.05). The presence of AAC was not an indicator for predicting renal function impairment under propensity score matching (p>0.05). However, among AAC group, CS more than 100 was related to renal function impairment as compared to CS of 100 or less (p=0.035). In multivariable analysis, CS more than 100 (OR=12.4, p=0.017) and preoperative egfr (OR=0.829, p=0.001) were associated with the occurrence of chronic kidney disease (CKD; egfr<60ml/min/1.73 m2 at 6-month postoperatively) The calcium score more than 100 of abdominal aorta may be a predictor of CKD occurrence after kidney transplantation although the presence of abdominal aortic calcification itself may not be related to postoperative renal function impairment. In renal donors, preoperative CT evaluation in terms of abdominal aortic calcification may help predict renal function impairment after kidney transplantation, which information may allow clinicians to plan the follow-up strategy for donors SSA24-07 Non-invasive Ultrasound Elastography: Feasibility of Using Shear Stress and Axial Deformation as Parameters to Discriminate between Symptomatic and Asymptomatic Carotid Plaques Yang Ju MD (Presenter): Nothing to Disclose, Cyrille Naim MD : Nothing to Disclose, Marie-Helene Roy-Cardinal PhD, BEng : Nothing to Disclose, Marie-France Giroux MD : Research Grant, Johnson & Johnson Research Grant, BIOTRONIK GmbH & Co KG Stockholder, Abbott Laboratories, Guy Cloutier PhD : Nothing to Disclose, Gilles P. Soulez MD : Speaker, Bracco Group Speaker, Siemens AG Research Grant, Siemens AG Research Grant, Bracco Group Research Grant, Cook Group Incorporated Research Grant, Object Research Systems Inc To evaluate the ability of non-invasive vascular elastography (NIVE) shear stress and axial deformation parameter analysis to discriminate between symptomatic and asymptomatic carotid plaques. A total of sixty-four subjects including 18 women (28.1%) and 46 men (71.9 %) ages from 49 to 86 years (average of 70) with 50% or greater carotid stenosis (average of 68.8%; range from 50 to 100%) underwent doppler imaging of internal carotid arteries. A subgroup of 24 patients had neurological symptoms within three months prior to one year after initial examination and were considered as symptomatic; the remainder 40 patients were considered as asymptomatic. Carotid plaques were segmented on ultrasound images and elastograms over multiple heart cycles were computed with NIVE. The axial shear and deformation values were then estimated. Association between shear stress and deformation with symptomatology were estimated using Mann-Whitney for non-normal distribution of data. The analysis of maximum axial shear strain showed a statistically significant difference between symptomatic and asymptomatic plaques (0.36 ± 0.17 vs 0.44 ± 0.17; P = 0.020). There was also a statistically significant difference between symptomatic and asymptomatic plaques when we compared the following parameter: Minimum Axial Deformation (-0.44 ± 0.24 vs ± 0.23; P = 0.012), Maximal Axial Deformation (0.42 ± 0.23 vs 0.57 ± 0.20; P = 0.001), Range of Cumulated Axial Deformation (1.32 ± 0.82 vs 1.84 ± 0.75; P = 0.005) and Minimum Strain Rate (-1.56 ± 0.70 vs ± 1.30; P = 0.016). Ultrasound NIVE is feasible in patients with significant carotid stenosis and could be used as a tool to discriminate symptomatic from asymptomatic patients using such parameters as shear strain and axial deformation. Non-invasive vascular ultrasound could be a useful complementary tool in the identification of patients with significant carotid stenosis who could benefit from surgical treatment. SSA24-08 Ultrasound Examination after Creation of Dialysis Arteriovenous Grafts Forecasts Their Lifespan

60 Jan Malik (Presenter): Nothing to Disclose, Jaroslav Kudlicka : Nothing to Disclose The patency of arteriovenous grafts (AVG) for hemodialysis is mostly limited by stenoses. They decrease the blood flow, with the risk of dialyzed blood recirculation and of thrombosis with access failure. Some risk factors for shorter AVG lifespan are already known and include diabetes mellitus, history of repeated interventions and others. Identification of further risk factors could identify subjects, which would profit from AVG surveillance programs. We hypothesized that abnormal ultrasound (US) finding just after AVG creation would determine such subjects. We examined our AVG subjects within 40 days after AVG creation and followed them up for years with US surveillance every 3 months and recorded interventions. According to US finding the AVGs were divided into three groups: 1. normal finding, 2. non-significant stenosis and 3. hemodynamically significant stenosis. The primary endpoint of the study was cumulative AVG patency that is the time interval since creation until final AVG loss. The data were analyzed by Log-rank (Mantel-Cox) test and Student's t-test and visualized by survival graphs. Overall, we included 360 AVGs. Median follow up was 565 days. Normal ultrasonographic finding was in 265 cases (78%), non-significant stenosis was found in 46 (13%) cases and significant stenosis in 29 (9%) cases. The longest cumulative patency was observed in patients, which had normal US findings at inclusion and it was significantly longer than in non-significant stenosis (p = 0.04); the latter group had longer patency than significant stenosis patients (p=0.03). Survival of normal findings and nonsignificant stenosis groups differed significantly after 443 days (p=0.03) in favor of normal findings as well as the mean time of the first intervention [(334 vs. 147 days after AVG creation (p<0.0001), respectively]. Non-significant and significant stenosis groups differed in AVG survival after 453 days (p=0.04) in favor of the former group, which also had longer intervention/free interval (147 vs. 82 days, p=0.03). Early US examination of AVGs identifies subjects at higher risk of access loss. Further research is needed to find out if more frequent surveillance or re-do surgery could prolong the AVG lifespan of these patients. The presence of any stenosis at early ultrasonography of AVGs is associated with poorer prognosis despite its successful therapy SSA24-09 Lower Extremity Dual-energy CT Angiography: Evaluation of Ultra-low kev Calculated Monoenergetic Datasets by Means of a Frequency-split Approach for Noise Reduction at Ultra-low kev Levels Philipp Riffel MD (Presenter): Nothing to Disclose, Stefan Haneder MD : Nothing to Disclose, Holger Haubenreisser : Nothing to Disclose, Bernhard Schmidt PhD : Employee, Siemens AG, Stefan Oswald Schoenberg MD, PhD : Institutional research agreement, Siemens AG, Thomas Henzler MD : Nothing to Disclose Previous studies have demonstrated that calculated low kev monoenergetic datasets from Dual energy (DE)CT angiography of the lower extremity can significantly improve contrast-to-noise ratio (CNR) when compared to polyenergetic images (PEI). However, monoenergetic ultra-low kev datasets below 60 kev did not lead to improved CNR due to the dramatic increase in image noise at lower kev levels. The recently introduced frequency-split technique combines the lower spatial frequency stack at low kev for high contrast with the high spatial frequency stack for image noise at high kev levels to calculate noise-reduced images at ultra-low kev levels below 60 kev. The aim of this study was to evaluate the objective image quality of ultra-low kev virtual monoenergetic images (MEIs) calculated from lower extremity DECT angiography data. 20 patients (15 male; mean age 73±13 years) who underwent DECT angiography of the lower extremity were retrospectively included in this study. MEIs from 40 to 120 kev were reconstructed using the frequency-split technique. Signal intensity, noise, signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) were assessed in external iliac, femoral, popliteal, and lower leg arteries. Comparisons between MEIs and PEIs were performed using a Mann-Whitney U test. 120 arteries were evaluated. 60, 50 and 40 kev images resulted in the greatest improvements in vessel attenuation (+26%, +85%, +180% all p < 0.05) and SNR (+53%, +48%, +48%, all p < 0.05) compared to PEIs. The highest CNR values were found in 50 kev MEIs (18.6 ± 10.4 averaged over all arteries), which were significantly higher compared to PEI (11.7 ± 6.9 averaged over all arteries, all p < 0.05). Combining the lower spatial frequency stack for contrast at low kev levels with the high spatial frequency stack for noise at high kev levels leads to improved image quality of ultra-low kev monoenergetic lower extremity DECT datasets when compared to previous monoenergetic reconstruction techniques without the frequency-split technique.

61 With a frequency split approach, 40, 50 and 60 kev MEIs provide improved objective image quality in DECT lower extremity angiography compared to standard PEI and should therefore be considered for clinical use when DECT angiography of the lower extremity vessels is performed. VIS-SUA Vascular/Interventional Sunday Poster Discussions Scientific Posters IR VA AMA PRA Category 1 Credits :.50 Sun, Nov 30 12:30 PM - 1:00 PM Location: VI Community, Learning Center Moderator Ranjith Vellody MD : Nothing to Disclose Sub-Events VIS211 Arsenic Trioxide Contained Transcatheter Arterial Chemoembolization for Treatment of Unresectable Hepatocellular Carcinoma: A Prospective Multicenter Randomized Controlled Trial (Station #1) Tengchuang Ma (Presenter): Nothing to Disclose, Hai Bo Shao MD : Nothing to Disclose, Long Gao : Nothing to Disclose, Hongying Su : Nothing to Disclose, Xu Ke MD : Nothing to Disclose To evaluate the efficacy and safety of arsenic trioxide (As2O3) contained transcatheter arterial chemoembolization (TACE) for treatment of unresectable hepatocellular carcinoma (HCC). A multicenter randomized controlled trial was conducted on 223 patients with unresectable HCC at twelve tertiary referral center hospitals between January 2007 and December Patients were randomly assigned to three groups with different intra-procedure drug administration protocols (group 1: TACE-As2O3 20mg, n=69; group 2: TACE-epirubicin 40mg, n=71; group 3: TACE-two drugs combined, n=83). All TACE procedures were carried out by superselective embolization using drug-lipiodol emulsion. Repeated TACEs (mean 2.8 times) were performed at one-month intervals and followed up at three-month intervals. Therapeutic effect was evaluated by mricist criterion. The primary end point was overall survival (OS). The secondary end point was time to progression (TTP). Adverse effect (AE) observation obeyed CTCAE version. Survival analysis was performed with Kaplan-Meier method by Log-rank test. Factors associated with OS and TTP were also analyzed. There were no treatment-related deaths. By follow-up of 6 to 43 months, there was no significant difference in OS among three groups (16.0, 15.6, 17.2 months in group 1, 2 and 3, p=0.5614). However, TTP in group1 (12.9 months) and group 3 (13.8 months) was significantly longer than that in group 2 (7.7 months, P<0.01). Multivariate analysis showed that BCLC stage was an independent prognostic factor for OS and TTP. Intra-procedure drug administration protocol was a prognostic factor for TTP. On stratification analysis, As2O3 contained TACE (group 1 and 3) showed longer OS (P<0.001) and TTP (P<0.001) in patients in BCLC B stage. The proportion of - AEs in group 2 and 3 was significantly higher than that in group 1 (liver function abnormalities, P<0.05; degree toxicity incidence,p <0.05). As2O3 contained TACE improved TTP of the patients with unresectable HCC, especially the patients in BCLC B stage (both OS and TTP were prolonged). The toxicity of TACE was not increased for single or combined use of As2O3. As2O3 contained TACE may prolong TTP and OS of unresectabe HCC especially in BCLC B stage without enhancement of toxicity. VIS212 Endovascular Repair of an Isolated Common Iliac Aneurysm in 21 Patients (Station #2) Soichiro Hase (Presenter): Nothing to Disclose, Yuya Koike : Nothing to Disclose, Motoshige Yamasaki : Nothing to Disclose, Hiroshi Iwamura : Nothing to Disclose, Junichi Nishimura MD : Nothing to Disclose, Naoki Washiyama : Nothing to Disclose, Mutsumu Fukata : Nothing to Disclose, Hiroshi Nishimaki MD : Nothing to Disclose To evaluate the clinical results in endovascular aneurysmal repair (EVAR) of isolated common iliac artery

62 aneurysms (CIAAs) retrospectively. Between June 2009 and March 2014, 21 patients (17 males) underwent EVAR for isolated CIAAs. The age ranged from 52 to 90 years (mean, 69 years). Unilateral involvement of CIAA was seen in 15 patients, with bilateral involvement in the remaining 5 patients. Internal iliac artery involvement was seen in 5 patients. The maximum diameter of aneurysm ranged from 23 to 55 mm (mean, 35 mm). The bifurcated endograft in 11, the iliac limb of the aortic graft in 7, and the combination of aortic cuff and parallel-aligned iliac extender in 3 patients were used. The follow-up CT was performed at discharge, 3, 6, and 12 months and annually thereafter. The mean follow-up period was 529 days (range, ). Technical success was achieved in all 21 patients (100%). No mortality and morbidity were observed during follow-up. Follow-up CT revealed no evidence of type I/III endoleaks and aneurysmal enlargement (>5mm). In 9 CIAAs (33%), shrinkage of aneurysmal sac was observed. Endovascular repair for isolated common iliac aneurysm is feasible with a favorable mid-term result. Because side branches from a common iliac artery are infrequent, it is easier for complete exclusion of common iliac artery aneurysms than of abdominal aortic aneurysm. VIS213 Local Control Effect of Microballoon-occluded Transarterial Chemoembolization with Miriplatin for Hepatocellular Carcinoma: A Retrospective Comparison of Conventional TACE with Epirubicin (Station #3) Masakazu Hirakawa MD (Presenter): Nothing to Disclose, Yoshiki Asayama MD : Nothing to Disclose, Akihiro Nishie MD : Nothing to Disclose, Yasuhiro Ushijima MD : Nothing to Disclose, Kimitaka Miyajima MD, PhD : Nothing to Disclose, Hiroshi Honda MD : Nothing to Disclose The aim of this retrospective study is to compare the localcontrol effects of microballoon-occluded transarterial chemoembolization (B-TACE) with miriplatin (MPT) and those of conventional TACE with epirubicin (EPIR) for hepatocellular carcinoma (HCC) Sixty-five HCC cases were treated with TACE using EPIR or MPT. Forty patients (25 men, 15 women; mean age, 73.4 years) were treated using B-TACE with MPT (the MPT-B-TACE group), and 25 patients (15 men, 10 women; mean age, 72.2 years) were treated using TACE with EPIR (the EPIR-TACE group). The local control rates (modified Response Evaluation Criteria in Solid Tumors [mrecist]), time to local recurrence (Kaplan-Meier and log-rank tests), and adverse events (AEs) were evaluated. Statistical analyses were conducted to evaluate the relationship between the patient's characteristics and local recurrence after MPT-B-TACE using Pearson's Chi-squared test. Multivariate logistic regression analysis was also performed. There were no significant differences in patient's characteristics between the groups. The overall AE incidence did not significantly differ between the groups. According to the mrecist, the objective response rate including complete and partial responses, in the MPT-B-TACE group (92%) was significantly higher than that in the EPIR-TACE group (76%). Overall, local recurrences in the MPT-B-TACE group were significantly lower than in the EPIR-TACE group (p < 0.05). Excluding multiple HCC cases, the local recurrence rate in the MP T-B-TACE group was significantly lower than in the EPIR-TACE group (p < 0.05). Local recurrence after MPT-B-TACE was recognized in the 35% patients in the follow-up periods. Tumor size larger than 2cm and tumor number more than three HCCs were significant key factors in the local recurrence after MPT-B-TACE. MPT-B-TACE was associated with a higher objective response rate and lower local recurrence rate than EPIR-TACE, and both showed similar adverse effects. Tumor size larger than 2cm and tumor number more than three HCCs were risk factors of the local recurrence after MPT-B-TACE. B-TACE with miriplatin may have great potential advantages in comparison with conventional TACE with epirubicin, and might constitute a novel therapeutic option for unresectable HCC. VIS209 Complication and Diagnostic Yield Rates of Ultrasound Guided Renal Biopsies: A Retrospective Review of 832 Biopsies Performed at a Tertiary Referral Institution (Station #4) Ramaswamy Rajesh MBBS, MRCS (Presenter): Nothing to Disclose, Shueh Hao Lim MBChB : Nothing to Disclose, Robert Hunter : Nothing to Disclose, Fiona Gifford : Nothing to Disclose, Judith Margaret Anderson MD : Nothing to Disclose, Caroline Whitworth : Nothing to Disclose, Christopher Bellamy : Nothing to Disclose, Paul Lindsay Allan MD : Nothing to Disclose, Dilip Kumar Patel MBBS : Nothing to Disclose

63 To determine the complication and diagnostic yield rates of ultrasound guided native and transplant kidney biopsies over a 5-year period. Retrospective analysis of 832 biopsies performed in 735 patients who underwent ultrasound guided diagnostic renal biopsies between January 2008 and October 2012 in our institution were identified and analysed from the hospital renal and pathology data bases. Chi-square and Mann Whitney test were used and significance set at <0.05. A total of 832 biopsies were performed in 735 patients. 314(38%) biopsies were performed as emergency procedures and 518(62%) as elective. The median age of the study group was 54 years (range 10 to 90 years) and M: F ratio 57:43. The overall complication rate was 6.7% (1.3% major and 5.4% minor). The major complication rate in the emergency biopsy group was significantly higher compared to the elective group (2.5% vs 0.8%; p=0.04). Renal function was significantly worse in the major complication group (creatinine 457 umol/l vs 201umol/l, p=0.01). All 11 patients who sustained major haemorrhage received a blood transfusion and 8 underwent emergency arterial embolisation. The risk of major haemorrhage was higher in the transplant compared to native group (2.2% vs 1.0%; p= 0.25). No coagulation profile difference was noted between the major and minor complication groups. No difference was noted in the minor complication rate between the native and transplant groups. In the 30-day periprocedural period there were 2 deaths unrelated to the procedure. Overall diagnostic yield rate was 95.1%, with an average of 12.3 glomeruli in the formalin sample. In the non-diagnostic sample group (4.9%), the average number of glomeruli in the formalin sample was lower at 1.3 glomeruli. No difference was observed between the native and transplant group yield rates. The complication rate of our cohort group compares favourably with those quoted in the published literature. The major complication rate was significantly higher in the group who underwent biopsy as an emergency procedure, in patients with significantly impaired renal function and in the transplant patient group. There were no biopsy related kidney losses or deaths. Ultrasound guided diagnostic renal biopsy is a safe procedure with a high diagnostic yield. VIS210 Low Dose and Low Contrast Medium Volume CT Angiography of the Abdominal Aorta and Lower Extremity Vessels (Station #5) Yue Dong (Presenter): Nothing to Disclose, Yijun Liu : Nothing to Disclose, Ruxin Wang : Nothing to Disclose, Lifei Sun ARRT, MBBS : Nothing to Disclose, Renwang Pu MBBCh, FRCPC : Nothing to Disclose, Liang Hu : Nothing to Disclose To investigate low dose and low contrast medium volume CT angiography and to compare the image quality and diagnostic accuracy at different doses with digital subtraction angiography (DSA) in the evaluation of the abdominal aorta and lower extremity vessels. 31 patients with a clinical diagnosis of obstructive arterial disease of the extremities underwent MDCT (GE Discovery 750HD) angiography of the aorta and peripheral vessels. Group A:21 patients, 120kVp, noise index of 7,150ml of contrast medium 350 at 5ml/s. Group B:10 patients, 80kVp, noise index of 15, 80ml of contrast medium 350 at 3ml/s followed by 40ml saline flush. Two protocols used auto ma mode and AISR 30% reconstruction. The measurement of radiation dose was based on the CTDI and DLP. Image quality was analyzed by two vascular radiologists in consensus using a three-point scale(poor, better and good). The arterial system was divided into 19 anatomical segments (from abdominal aorta to ankle arteries). Each segment was evaluated for patency by using a five point scale: 1=normal, 2=moderate disease (<50% stenosis), 3=single severe stenosis (>50% stenosis), 4=diffuse severe stenosis (>50% stenosis) and 5=complete occlusion. DSA represented the reference. Mean CTDI and DLP of group B (6.8±1.7mGy, ±172.21mGy cm) were reduced by 66.7% and 62.8%, compared with group A(20.4±3.6mGy, ±362.48mGy cm). The average overall diagnostic image quality for the 2 groups was graded as good or better. No difference in image quality was seen between group A and B(p>0.05). Group A revealed a sensitivity, specificity, accuracy,ppv and NPV of 96%, 96%, 96%, 89% and 99% in the evaluation of the presence and degree of stenosis compared to 93%, 92%, 94%, 84% and 97% for Group B. Low dose scan with low contrast medium volume was a feasible option for the abdominal aorta and lower extremity vessels angiography. This technique provides less contrast medium and lower radiation exposure to the patient while maintaining optimal diagnostic accuracy.

64 For the abdominal aorta and lower extremity vessels angiography,this technique provides less contrast medium and lower radiation exposure to the patient while maintaining optimal diagnostic accuracy. VIS214 A Retrospective Evaluation of CT Radiation Dose in CT Guided Cryoablation of Renal Tumors: With and without Radiation Dose Reduction Technique (Station #6) Tze Min Wah MBChB, FRCR : Consultant, Galil Medical Ltd, Michael Min Gallagher (Presenter): Nothing to Disclose, Christopher Min Hounslow : Nothing to Disclose, Gareth Richard Iball MSC, BSC : Nothing to Disclose The aim of this study was to evaluate the CT radiation dose in CT guided cryoablation (CRYO) of renal tumors in a single large teaching institution and to assess the percentage reduction of radiation dose with and without a dose reduction technique in our intra-procedural CT CRYO treatment protocol. From 2008 to 2014, a total of 97 patients underwent CT guided CRYO of renal tumors and were included in this retrospective evaluation of their CT radiation dose during treatment. Amongst them were 56 patients (61 procedures; mean age, 65; 37 males and 29 females) without CT dose reduction technique and 41 patients (43 procedures; mean age, 73; 27 males and 14 females) with CT dose reduction technique. The group without CT dose reduction technique were scanned with the same parameters throughout whilst those with the dose reduction technique had sequential reduction of mas during scanning until the interventional radiologist deemed the increased image noise had compromised the diagnostic quality of the images. The average DLP with and without CT dose reduction technique was 6044 (+/- SD 2676) mgy-cm and 3354 (+/- SD 1308) mgy-cm. Thus the average DLP was 43.7% lower in the dose reduced group when compared to the non-dose reduced group (p<0.0001) (Figure 1). The total CTDIvol was used to estimate the patient skin dose; in the non-reduced group the maximum 'skin dose' was 1.1Gy, vs. 0.38Gy in the dose reduced group. However, there was no significant difference between the number of cryoprobes used, number of CT examination runs or total exam time between the two groups. The use of a sequential mas dose reduction strategy in our CT CRYO treatment protocol has produced significant dose reduction for patients undergoing treatment of their renal tumors. In our clinical practice, we would now advocate the use of this dose reduction strategy at all times as long as the image quality remains sufficient for the clinical purpose of the examination. It is important to use the dose reduction strategy during CT CRYO treatment of renal tumors as the radiation burden can be reduced significantly by the simple sequential mas dose reduction approach. VIE206 The Role of Adrenal Venous Sampling in Primary Hyperaldosteronism (Station #7) Carmen Zevallos Maldonado (Presenter): Nothing to Disclose, Jose Garcia-Medina MD : Nothing to Disclose, Carmen Aleman : Nothing to Disclose, Maria Carmen Alcantara MD : Nothing to Disclose, Placida Aleman : Nothing to Disclose, VICENTE GARCIA : Nothing to Disclose To describe how is performed the adrenal venous sampling in our service, and its role in the etiological diagnosis of Primary Hyperaldosteronism. -Primary Hyperaldosteronism: Clinical tests, screening, biochemical tests, ethiological diagnosis and treatment. -Aldosterone-producing adenoma and bilateral adrenal hyperplasia: Images using computerized tomography and magnetic resonance. -Anatomy of the suprarrenal veins and the angiographic patterns of the adrenal veins. -Technique of adrenal venous sampling used in our service. -Interpretation of the results and complications involved in adrenal venous sampling. -Cases in our service. VIE007-b Current State of Aortic Dissection Classification and Management (hardcopy backboard) Preston George Smith MD (Presenter): Nothing to Disclose, Anastasia Frances Barron DO : Nothing to Disclose, Ulku Cenk Turba MD : Nothing to Disclose, Bulent Arslan MD : Advisory Board, Nordion, Inc Advisory Board, Angiotech Pharmaceuticals, Inc Speakers Bureau, Nordion, Inc Speakers Bureau, W. L. Gore & Associates, Inc Consultant, Bayer AG 1. To highlight key anatomic findings of aortic dissection on CT Angiography and detection of fenestrations, now assuming increasing relevance with the rising role of endovascular repair. 2. To review the accepted classification systems of aortic dissection demonstrated on CT Angiography as well as newly proposed systems of evaluating thoracic aortic dissection.

65 1. Purpose: Emphasize important points of current models for assessment of aortic dissection. 2. Background: a. Thoracic Aortic Dissection statistics. b. Accepted classification systems i. current limitations (loopholes) c. Review newly proposed criteria 3. Example cases displaying important points from new and old criteria and common misreads based on loopholes in current classifications systems which have potential medicolegal ramifications a. Primary entry tear sites as well as extent and directional propagation of dissection i. several appearances of true lumens b. Status of the false lumen and extent and location of fenestrations c. Branch vessel involvement i. static ii. dynamic 4. Potential complications of new management approaches that may be related to endovascular management approaches. 5. Conclusion VIS-SUB Vascular/Interventional Sunday Poster Discussions Scientific Posters IR VA AMA PRA Category 1 Credits :.50 Sun, Nov 30 1:00 PM - 1:30 PM Location: VI Community, Learning Center Sub-Events VIS217 Tolerability and Efficacy of Transarterial Chemoembolization of Hepatocellular Carcinoma with µm Doxorubicin-Loaded-Drug-Eluting-Beads (Station #1) Keyan B. Marashi MD (Presenter): Nothing to Disclose, Marco A. Cura MD : Nothing to Disclose, Justin Decker Sacks MD : Nothing to Disclose, James Dale Meler MD : Nothing to Disclose To evaluate patient tolerability and efficacy of transarterial chemoembolization (TACE) with µm doxorubicin-loaded drug-eluting beads (DEB) in patients with hepatocellular carcinoma (HCC). 48 consecutive patients (36 male, mean age 62.3yo, r31-81y) with unresectable HCC who underwent 54 TACE sessions with µm doxorubicin-loaded DEB for unresectable HCC were retrospectively reviewed. 31 of 48 patients (65%) were classified as Barcelona Clinic Liver Cancer stage A, 15 (31%) were stage B, and 2 (4%) were stage C. Tumor size ranged from 1.3 cm to 8.5 cm (24 focal, 24 multifocal). Doxorubicin dose ranged from 7.5mg to 150mg. At the time of submission, follow-up imaging was available for 32 patients and was evaluated using mrecist. 42 patients underwent a single session of TACE and 6 patients underwent two sessions. One procedural complication was encountered: a dissection of the common hepatic artery. 49 sessions resulted in discharge within 24 hours of TACE. 5 sessions required admission greater than 24 hours: 1 for nausea, fever, and emesis, 3 for abdominal pain, and 1 for unrelated medical care. Of the 32 patients for which follow-up imaging was available, 7 demonstrated complete response (21.9%), 10 demonstrated partial response (31.2%), 12 demonstrated stable disease (37.5%), and 3 demonstrated progressive disease (9.4%). Mean follow-up time since DEB-TACE was 122 days (r4-940 days). 4 patients were bridged to transplant. During follow-up, one patient death was recorded secondary to complications of liver transplant. Kaplan-Meier survival at 3, 6, and 12 months was 100%, 95%, and 95% respectively. TACE with µm doxorubicin-loaded DEB appears safe and effective for treatment of patients with unresectable HCC. In our population, the procedure was tolerated well, with the majority of patients showing favorable to stable tumor response. In vivo studies show that smaller µm DEB penetrate further into tissue resulting in greater and more uniform drug coverage, but clinical studies to assess tolerability and efficacy are lacking. VIS218 Percutaneous Interventions on Intragraft Stenoses within Failing Prosthetic Arteriovenous Grafts: Analysis of Patency Rates (Station #2) Andre Barranda Bautista MD (Presenter): Nothing to Disclose, Waleska Michelle Pabon-Ramos MD : Nothing to Disclose, Michael Joseph Miller MD : Speaker, Cook Group Incorporated Speaker, Boston Scientific Corporation Advisory Board, Boston Scientific Corporation Advisory Board, C. R. Bard, Inc Speaker, Kimberly-Clark Corporation, Paul Vincent Suhocki MD : Nothing to Disclose, Tony Preston Smith MD : Nothing to Disclose, Charles Yoon Kim MD : Consultant, CareFusion Corporation Research Grant, Galil Medical Ltd Consultant, Kimberly-Clark Corporation Consultant, Cryolife, Inc While endovascular outcomes on venous anastomosis and central venous stenoses have been extensively studied, there is a paucity of data on intragraft stenoses. The purpose of this study was to evaluate outcomes of endovascular treatment of intragraft stenosis in prosthetic hemodialysis grafts.

66 Our procedural database was retrospectively reviewed for all percutaneous interventions on prosthetic AV grafts from 2005 through Specifically, AV grafts presenting with first-time intragraft interventions were identified, resulting in 186 unique AV grafts (83 males, 103 females, mean age 59.7 years). An intragraft stenosis was defined as a 50%+ luminal narrowing greater than 2 cm from the arterial and venous anastomosis requiring intervention. Post-intervention access patencies were calculated using Kaplan-Meier analysis. Lesion patency was determined based on time until angiographically proven >50% restenosis of the treated lesion. Development of the first intragraft stenosis within an access occurred at a median graft age of 20.7 months (interquartile range months). A total of 231 first-time intragraft stenoses were identified in 186 AV grafts. Graft thrombosis was present in 63%. Angioplasty was technically successful in 86%; 14% requiring stenting due to inadequate response to angioplasty. A concurrent extragraft stenosis was identified in 76% of accesses. At 3, 6, and 12 months, the post-intervention primary patency rates were 56%, 40%, and 23%, respectively. At 3, 6, and 12 months, secondary patency rates were 84%, 77%, and 67%, respectively. The lesion-specific patency rates were 78%, 52%, and 30% at 3, 6, and 12 months, respectively. Graft thrombosis was associated with significantly worse primary patencies (32% versus 53% at 6 months, p=0.014) but not secondary or lesion patency rates. Angioplasty and bailout stenting had similar patency rates. Graft age did not correlate with patency rates. Angioplasty was highly successful for treatment of intragraft stenoses. Percutaneous intervention on these first-time intragraft stenosis yielded 6-month primary, secondary, and lesion patency rates of 40, 77, and 52%, respectively. Percutaneous interventions on first-time intragraft stenoses yielded post-intervention patency rates that exceed the goals stated by the 2006 K/DOQI guidelines and are thus justified. VIS219 Endovascular Embolization of Visceral Artery Pseudoaneurysms using N-Butyl Cyanoacrylate or Glue: Preliminary Experience in a Tertiary Care Centre (Station #3) Madhusudhan Kumble Seetharama MD, FRCR (Presenter): Nothing to Disclose, Shivanand Ramachandra Gamanagatti MBBS, MD : Nothing to Disclose, T. V. Prasad MD : Nothing to Disclose, Pramod Garg MBBS, MD : Nothing to Disclose, Peush Sahni MBBS, MS : Nothing to Disclose, Arun Kumar Gupta MBBS, MD : Nothing to Disclose 1. To evaluate the feasibility, safety and efficacy of n-butyl cyanoacrylate (NBCA) in embolization of visceral artery pseudoaneurysms (PsA). 2. To illustrate and discuss the indications for the use of NBCA in visceral artery PsA. 30 patients (25 males, 5 females; age range: years) of gastrointestinal bleed with 30 visceral artery PsA embolized using NBCA between Jan 2011 and Dec 2013 were retrospectively evaluated. The reasons for not using coils, which is the embolizing agent of choice, were assessed in each case. All PsA were embolized using co-axial technique. Glue - lipiodol mixture (25% - 30% glue concentration) was injected in small aliquots ( ml) with serial flushing till the PsA was completely embolized. The technical and clinical success rates were evaluated along with the encountered minor and major complications. All patients were embolized using NBCA (100% primary technical success) at first presentation. The reasons for using glue as primary embolizing agent were PsA arising from main artery which cannot be sacrificed (18 patients), inadequate landing zone for the coils (4 patients), inability to reach close or distal to the PsA (5 patients) and failed previous coil embolization (3 patients). Mean amount of glue used per procedure was 0.24 ml. Recurrence of PsA occurred in 3 patients indicating a clinical success of 90%. All the three were embolized using coil, glue and thrombin, respectively with 100% secondary technical success. Minor and major complications were seen in 3 patients (10%) each which were managed without major consequences. NBCA is a safe and effective embolizing agent in expert hands and in selective cases where coils cannot be used or have failed. Embolization of visceral PsA with coils / microcoils may not be possible in some unusual situations and in such cases NBCA can prove to be an effective embolizing agent in experienced hands.

67 VIS215 Role of Robotic Arm in CT Guided Biopsies (Station #4) himanshu pendse : Nothing to Disclose, Suyash Kulkarni : Nothing to Disclose, Ashwin M. Polnaya MD : Nothing to Disclose, Nitin Sudhakar Shetty MBBS, MD : Nothing to Disclose, KETAN GAIKWAD : Nothing to Disclose, Kunal Bharat Gala MBBS, MD (Presenter): Nothing to Disclose, Meenakshi Haresh Thakur MD : Nothing to Disclose To explore the role of robotic arm in CT Guided Biopsies. To assess the accuracy of CT guided biopsy using a robotic device in targeting a lesion 50 patients were analyzed on whom robotic device was used to perform CT Guided biopsy. MAXIO Robotic Arm and Navigation Software (Perfint Pvt Ltd., India) was used in this study. Informed consent was taken. Plain and post-contrast CT study of the required area was performed. This was fed in the navigation software of the robotic arm. The trajectory of the needle was planned on the software. Robotic arm was programmed to align at the desired point of entry at the required angle and depth. The biopsy was performed along this guided trajectory. Later, the image of the actual trajectory taken by the needle and the planned trajectory were superimposed. The difference in the entry point and actual point reached in the lesion by the needle on the actual biopsy image and planned image by the software is compared. This error is measured in millimeters. This is then analyzed for its statistical significance 50 patients were analyzed. There were 30 males and 20 females. The mean age was years. The mean size of the lesion was 46 mm. Out of 47 patients, 26 were lung masses, 11 were pelvic masses, 2 were bone lesions, 5 were mediastinal masses, 1 each of liver, pancreatic and gastric lesions and 3 paravertebral masses. Effectiveness of Needle Placement: CT biopsy was technically possible in 47 out of 50 patients. Target off site >5mm is seen in 3 out of 47 patients leading to accuracy of 93%. The number of re-positioning were 1.46 per patient ranging from 1-3 per patient. The number of check scans were 1.5/patient. Percutaneous image guided procedure with use of a robotic arm entails various advantages over free hand techniques with improvement in accuracy and fewer number of check scans. Robotic arms may be used to target deep seated lesions which need multiple repositioning with free hand techniques. Patient motion is a major detrimental factor in execution of biopsy using robotic arm. Robotic assisted biopsies can improve accuracy, decrease the number of check scans and thus indirectly decreasing the radiation dose and time required for the procedure VIS216 The Clinical Application of Normalized Utility of Contrast Medium in Combination with BMI Dependent kvp in Abdominal CT Angiography (CTA) (Station #5) Liu Xiaoyu MD (Presenter): Nothing to Disclose, Xiaoyan Meng MD : Nothing to Disclose, Hao Tang : Nothing to Disclose To assess the clinical application of normalized utility of contrast medium and kvp based on patient body-mass-index (BMI) in abdominal CTA. Eighty patients with different BMI were enrolled to undergo unenhanced and enhanced dual-phase abdominal CT scan using 370mgI/ml concentration contrast medium. Patients were divided into 3 test groups and 1 control group based on their BMI value:group A (n=20, BMI<23) with 80kVp and a total volume of contrast medium at 200mgI/kg; group B (n=20, 23=<BMI<26), 100kVp and 250mgI/kg contrast medium; group C (n=20, BMI>=26), 120kVp and 300mgI/kg contrast medium. Group D (n=20, without BMI restriction) was scanned at 120kVp and with a total volume of contrast medium at 1ml/kg. CT number of aorta in the arterial phase (AP), portal vein in the portal phase (PP) and hepatic parenchyma in both phases was measured. Image quality was assessed and compared among the 4 groups by statistical method. There was no significant difference for the CT value (in HU) of hepatic parenchyma in AP and PP among 4 groups (group A: 81.91±8.37 and ±12.36; group B: 80.13±3.66 and ±9.39; group C: 76.32±9.17 and ±15.76; group D: 76.18±8.74 and ±14.51, all p>0.05); The CT value (in HU) of the aorta during AP in group A (305.32±76.11) was significantly higher than the other 3 groups (272.54±54.85, ±32.89, ±41.62, respectively) (p<0.05). There was no difference for the CT value of the portal vein in PP among 4 groups (160.19±22.76, ±19.97, ±21.78 and ±24.61, respectively) (p>0.05). There was no significantly difference in the subjective image quality score among 4 groups (4.55±0.51 vs. 4.75±0.45 vs. 4.65±0.48 vs. 4.73±0.46, respectively) (P>0.05). Volume CT dose index (CTDIvol, in mgy) were 33.58±4.47, 63.63±4.03, 96.06±7.12 and 98.89±7.04 for A, B, C and D groups, respectively. BMI-dependent contrast medium injection and tube voltage selection scheme substantially reduces both contrast dose and rediation dose for patients with small BMI without adversely affecting vessel enhancement

68 and image quality, compared with the conventional scan protocol. The BMI-dependent contrast medium injection and tube voltage selection scheme in CT angiography (CTA) improves patient safety without degradation of vessel enhancement and image quality VIS220 Percutaneous and Laparoscopic Cryoablation (CA) of Renal Carcinomas: Mid-term CT and MR Imaging Follow-up (Station #6) Gianpiero Cardone MD (Presenter): Nothing to Disclose, Maurizio Papa MD : Nothing to Disclose, Paola Mangili PhD : Nothing to Disclose, Giorgio Guazzoni MD : Nothing to Disclose, Giuseppe Balconi : Nothing to Disclose This study aims to determine the safety and efficacy of CA in the management of small renal carcinomas and to assess its medium term outcome. We report the mid-term CT/MR imaging follow-up in 115 pts who gained at least 5 years follow-up after CA of 96 renal carcinomas. Treatment was administered under laparoscopic US guidance in 101 pts and using percutaneous CT guidance in 14 pts. Pts were followed up clinically, biochemically and by imaging 24 hours after surgery, and subsequently every 6 months. Imaging follow-up was obtained using a 1,5T MR system in 104 cases and using CT in 11 pts with contraindications to MR. 24 hours after treatment all cryolesions were more than 1 cm larger than the original masses; cryolesions decreased in size by an average of 38% at 1 month, 64% at 6 months, 80% at 12 months and 93% at 84 months following LC. Early postprocedural MR and CT ce- images showed complete ischemia of cryolesions. Follow-up revealed no evidence of local recurrence in 111/115 pts (96%). 4 pts showed local recurrence at 12, 24 and 96 months. 12/115 pts (9%) demonstrated metachronous nodules in the same or in the contralateral kidney at 12, 24 and 48 months. 2 pts showed a pancreatic metastatic nodule at 12 and 24 months. 11/115 pts died for metastasis of a previous malignancy. 1 pt showed ureteral fistula and 1 pt showed proximal ureteral stenosis. No significant rise in creatinine level was noted postprocedurally. After surgery 11% of the cases showed small perilesional haematomas. Our experience suggests that CA is a safe, well tolerated and minimally invasive therapy for small renal carcinomas. MR is an effective tool in the imaging follow-up of renal lesions treated with CA, and the high contrast resolution of MR allows a better evaluation of vascularization of treated areas on subtracted ce images compared to CT. CT can be used as an alternative choice to MR, but lower contrast resolution of CT to MR makes it difficult to differentiate the cryolesion from the surrounding perilesional collections. A limit of CA is the difficulty to perform repeated treatments in the same kidney. CA is a safe, well tolerated and minimally invasive therapy for small renal carcinomas. MR and CT are effective imaging techniques in the follow-up of renal lesions treated with CA. VIE176 Thoracic Duct Embolization (TDE) for Chylothorax: A Clinical and Illustrative Review for the Non-Interventional Radiologist (Station #7) Kimberly Hoang MD (Presenter): Nothing to Disclose, Gabriel Mark Werder MD : Nothing to Disclose After viewing this exhibit, the learner should be able to: 1. Understand the pathophysiology and clinical presentation of chylothorax. 2. Compare TDE with alternative treatment strategies in managing chylothorax. 3. Discern the relevant operative anatomy including the cisterna chyli and its tributaries. 4. Describe the procedure and technique of ultrasound-guided intranodal lymphangiography and TDE. 5. Recognize typical post-procedural imaging findings of TDE (e.g. radiographs, CT). I. Pathophysiology and Clinical Presentation of Chylothorax II. Available Treatment Options including TDE III. Relevant Anatomy IV. Technique: Intranodal lymphangiography and TDE

69 V. Potential Outcomes and Complications VI. Post-TDE Imaging VII. Summary/Conclusions VSIO11 Interventional Oncology Series: Updates, Controversies and Emerging Questions in the Percutaneous Management of Renal Tumors Series Courses RO OI IR GU AMA PRA Category 1 Credits : 3.50 ARRT Category A+ Credits: 4.00 Sun, Nov 30 1:30 PM - 5:15 PM Location: S405AB Moderator Debra Ann Gervais MD : Research Grant, Covidien AG 1) To review management options for small renal masses as well as indications for each. 2) To review the data supporting the energy based thermal ablation modalities for ablation of renal masses. 3) To describe the role and limitations of biopsy of renal masses. 4) To review the management of benign solid renal masses. 5) To describe the evidence for ablation of T1b renal masses. Sub-Events VSIO11-02 Small Renal Mass (T1a): The Case for Ablation Jeremy C. Durack MD (Presenter): Nothing to Disclose View learning objectives under main course title. VSIO11-03 Small Renal Mass (T1a): The Case for Resection Adam Scott Feldman MD (Presenter): Consultant, Olympus Corporation 1) Understand and compare treatment alternatives for small renal masses. 2) Recognize imaging features of small renal masses that impact treatment alternatives. 3) Understand the risks and benefits of image guided renal mass ablation. VSIO11-04 Small Renal Mass (T1a): Both Cases for Intervention are Weak. Active Surveillance Will Do Just as Well Stuart G. Silverman MD (Presenter): Author, Wolters Kluwer nv View learning objectives under main course title. VSIO11-05 Predictive Value of Apparent Diffusion Coefficient in Response Evaluation for the Radiofrequency Ablated Renal Cell Carcinoma: Preliminary Experience Duangkamon Prapruttam MD (Presenter): Nothing to Disclose, Sandeep Subhash Hedgire MD : Nothing to Disclose, Yun Mao MD : Nothing to Disclose, Mukesh Gobind Harisinghani MD : Nothing to Disclose, Debra Ann Gervais MD : Research Grant, Covidien AG To assess the utility of apparent diffusion coefficient (ADC) in predicting and evaluating the response of the radiofrequency ablated renal cell carcinoma. 30 patients with 41 pathological confirmed renal cell carcinomas underwent MRI at 1.5T including diffusion weighted images before and after radiofrequency ablation. The ADC values of the tumor at b= 0, 100 and 600

70 s/mm2 were noted by drawing multiple regions of interest. Imaging features, histologic subtypes and Fuhrman grade of the tumor was also recorded. The participants were divided into 2 groups: complete treatment group (n=38) and residual disease group (n=3) based on follow up imaging and clinical notes. The variables were statistically analyzed. Of 41 RCCs, 23.3% were papillary, 57% were clear cell and 3% chromophobe types. The mean pre-treatment tumor ADC value in the complete treatment group was s/mm2 and pre-treatment ADC value of residual disease group was s/mm2 (p=0.512). Given the substantial overlap, it was not possible to use the pre-ablation ADC value as a predictor of residual disease. Fuhrman grade showed significant correlation (p=0.005) with the post RF ablation response with 100% response rate in Fuhrman grade 1. For grade 2 this rate was 83.3% and for grade 3, it was 0%. There was no significant difference between ADC value of pre- and post radiofrequency ablated renal cell carcinoma. Though mean ADC values for the group before and after ablation did not differ, some cases showed increase in ADC and others showed decrease. The range in changes was to ADC values in individual cases may increase or decrease after ablation limiting use of this marker in evaluating for viable tumor. Pre-ablation ADC did not predict outcome of ablation. Further studies are required to establish a cut of ADC value to distinguish complete responders from residual disease. ADC values in renal tumors do not appear useful in predicting outcome or in assessing residual tumor after ablation. VSIO11-07 Small Renal Mass (T1a): The Case for RFA Debra Ann Gervais MD (Presenter): Research Grant, Covidien AG View learning objectives under main course title. VSIO11-08 Small Renal Mass (T1a): The Case for Cryoblation Peter John Littrup MD (Presenter): Founder, CryoMedix, LLC Research Grant, Galil Medical Ltd Research Grant, Endo Health Solutions Inc Officer, Delphinus Medical Technologies, Inc 1) Understand the different approaches and techniques of thorough renal mass cryoablation that produces very low recurrence rates, even for larger central tumors. 2) Understand the appropriate settings to utilize protective techniques (i.e., hydrodissection, balloon interposition, ureteral stent, etc..) for adjacent calyces, bowel and ureter to avoid complications. 3) Identify major imaging follow-up criteria for ablation success and any early failures. 4) Describe the overall cost-efficacy trade-offs for cryo vs. heat-based renal ablations vs. partial nephrectomy, in relation to tumor location, complications and recurrence rates. ABSTRACT Cryoablation of smaller renal cancers (i.e., T1a, or <4 cm) is an out-patient treatment that is safe, effective and flexibility for nearly any renal location. Major cryoablation benefits include its excellent visualization of ablation zone extent, low procedure pain and flexible protection of tumor ablation sites near calyces, bowel and ureter. CT-guidance is the cryoablation guidance modality of choice due to circumferential visualization of low density ice and ready availability. US-guidance can augment renal cryoablation, especially for smaller visible masses and/or placement of interstitial metallic markers during biopsy for selected cases requiring better eventual CT localization. MR-guidance has little clinical benefit or cost-efficacy. For safety, cases will be considered for avoidance of direct calyceal puncture, selection of hydrodissection or balloon interposition for bowel protection, and protection of the uretero-pelvic junction by stent placement. Imaging outcomes of complications and their avoidance will be shown. For optimal efficacy, tumor size in relation to number and size of cryoprobes emphasize the "1-2 Rule" of at least 1 cryoprobe per cm of tumor diameter and no further than 1 cm from tumor margin, as well as cryoprobe spacing of <2cm. Thorough extent of visible cryoablation margins beyond all apparent tumor margins produces very low local recurrence rates for tumors in nearly any renal location, resulting in excellent cost-efficacy by minimizing the need for re-treatments. VSIO11-09 Small Renal Mass (T1a): The Case for Microwave Fred T. Lee MD (Presenter): Stockholder, NeuWave Medical, Inc Patent holder, NeuWave Medical, Inc Board of Directors, NeuWave Medical, Inc Patent holder, Covidien AG Inventor, Covidien AG Royalties, Covidien AG View learning objectives under main course title.

71 VSIO11-10 A Statistical Model of the Relationship between Iceball and Perfusion Deficit Visualized during MRI-guided Cryoablation Katherine Louise Dextraze MS (Presenter): Nothing to Disclose, Florian Maier : Nothing to Disclose, Judy Un Chong Ahrar MD : Nothing to Disclose, Yvette Teniente : Nothing to Disclose, Kamran Ahrar MD : Nothing to Disclose, R. Jason Stafford PhD : Nothing to Disclose A statistical model was investigated to quantify the extent of damage within the kidney parenchyma based on tissue position with respect to the iceball surface as visualized on images during the MRI-guided cryoablation procedure. A retrospective study of 20 patients cases was performed in order to statistically correlate the lack of perfusion seen on periprocedural contrast enhanced T1 post-treatment images with the iceball signal deficit seen on MRI-guided cryoblation monitoring images. Manual land-mark based registration and manual segmentation were performed on the data sets prior to analysis. In order to reduce variability in the segmentations, repeated segmentation trials to submitted to a truth-estimation scheme. Automated measurements of the distance between the iceball surface and the perfusion deficit edge were made and logistic regression model was fit to these measurements using original MATLAB scripts. The Kolmogorov-Smirnov test was applied to the Pearson residuals of the logistic regression model to assess goodness-of-fit of the model to the data. Measurements were restricted to renal parenchyma, where reliable registration could be applied. Using 20 patient cases and over 600 data points, the perfusion loss likelihood of renal parenchyma within the iceball was described by a unique logistic regression curve, where the parameters are alpha = and beta = From this curve, it was determined that tissue is 50% likely to lose perfusion at 0.57mm within the iceball, while perfusion loss is 95% likely at 4.28 mm within the iceball edge. The Kolmogorov-Smirnov test for goodness-of-fit confirmed that the logistic regression model reported here describes the observed data appropriately. Through a retrospective study of 20 patient cases, the relationship between likelihood of perfusion loss in renal parenchyma and distance within iceball was statistically quantified. From the statistical model, the margin for 95% perfusion loss likelihood was found to be 4.28mm within the iceball, which agrees the clinically accepted 3-5mm margin that is estimated during the procedure. The statistical model presented here could serve effectively as a quantitative approach to assessing treatment progress during the MRI-guided cryoablation procedure, rather than relying on visual estimation. VSIO11-12 Biopsy or No Biopsy Before Ablation? Biopsy Every Renal Tumor before Percutaneous Ablation William W. Mayo-Smith MD (Presenter): Author with royalties, Reed Elsevier Author with royalties, Cambridge University Press 1) Explain the expanding role of renal mass biopsy. 2) Explain why biopsy is necessary before all renal tumor ablations. 3) Demonstrate biopsy techniques. VSIO11-13 Biopsy or No Biopsy before Ablation? Don't Trouble Yourself or the Patient with the Renal Mass Biopsy - Go ahead and Ablate Steven Satish Raman MD (Presenter): Consultant, Bayer AG Consultant, Covidien AG View learning objectives under main course title. VSIO11-14 Incidence of Post Ablation Syndrome in Image-Guided Percutaneous Cryoablation (CRYO) of Renal Tumors: A Prospective Survey Tze Min Wah MBChB, FRCR (Presenter): Consultant, Galil Medical Ltd, Janette Bambrook : Nothing to Disclose, Dena Cohen MSc : Nothing to Disclose, Walter Gregory PhD : Nothing to Disclose, Jim Zhong : Nothing to Disclose, Jonathan Timothy Smith MBChB, FRCR : Nothing to Disclose, Rohit Puthan Veettil : Nothing to Disclose, Simon Min Whiteley MD : Nothing to Disclose, Peter J. Selby MD, DSc : Nothing to Disclose, Raul Nirmal Uppot MD : Nothing to Disclose, Debra Ann Gervais MD : Research Grant, Covidien AG, Peter Raff Mueller MD : Consultant, Cook Group Incorporated The historical incidence of complete post-ablation syndrome in patients undergoing radiofrequency ablation

72 (RFA) of renal tumors was 29.4% with both flu-like symptoms (malaise, myalgia and nausea) and low grade fever. This study aims: (1) to evaluate the incidence of post-ablation syndrome in the patients undergoing image-guided CRYO of their renal tumors (2) to determine its impact on the quality of life in the 10 days post-renal CRYO and compare it to the post-rfa historical data. Thirty eight patients (age years) underwent image guided CRYO for 40 renal tumors. A telephone survey using a standardized questionnaire was conducted on days 1, 3, 5, 7 and 10 following post-cryo. The patients' demographic details, temperature, degree of flu-like symptoms (malaise, myalgia, nausea/ vomiting), severity of pain and percentage of relief with oral analgesics, interference with general activity and with work were documented prospectively. The symptoms and interference of lifestyles were graded on a 0-10 Numeric Intensity Scale. Post-CRYO, 6 patients (15.8%) developed low-grade fever (range ºC), 24 (63.2%) had flu-like symptoms, and 14 (36.8%) had no symptoms. The low grade fever did not exhibit any peak but the flu-like symptoms peaked on day-3 and resolved spontaneously in most patients by day-10. Six patients (15.8%) developed the full post ablation syndrome which was lower in incidence and the symptoms were less severe when compared to the post-rfa historical data (Figure 1). Post-CRYO patients with symptoms experienced pain and interference with general and work activities, peaking on day-3 in contrast to post RFA where symptoms peaked on day-1 and completely resolved by day-10. Post-CRYO the incidence of complete post-ablation syndrome was 16% of patients with less severe symptoms compared to post-rfa. However, two third (63.2%) of the patients experienced at least one of the components of the syndrome. These symptoms were self-limiting with most symptoms peaking at day-3 and majority of the patients resumed their baseline pre-procedural levels of activity within 10 days following CRYO. Post renal-cryo, the incidence of complete post-ablation syndrome is lower and less severe than post-rfa and this information is useful when obtaining consent from patients during the consultation. VSIO11-16 Is Ablation Effective for Masses other than T1a RCC? Bernhard Gebauer MD (Presenter): Research Consultant, C. R. Bard, Inc Research Consultant, Sirtex Medical Ltd Research Grant, C. R. Bard, Inc Research Consultant, PAREXEL International Corporation 1) Appreciate the strengths and limitations of percutaneous ablation in treating renal tumors measuring larger than 4cm. ABSTRACT In the 6 edition of TNM of Union internationale contre le cancer (UICC) in 2002 the differentiation between T1a and T1b renal cell cancers (RCC) was introduced. The discrimination between T1a and T1b using a threshold of 4 cm is not justified by differences in survival, it is based on the upcoming local therapeutic options for small RCCs. In the last years techniques for local therapies for RCCs improved and multiple studies for larger RCCs beyond 4 cm in diameter were published. Especially studies concerning partial nephrectomy (PN) and thermal ablation (e.g. radiofrequency ablation (RFA) and cyoablation) are available. Psutka et. al. could show that after RFA of T1a and T1b RCCs, disease-free survival and recurrence free survival of T1b cancers in reduced, but overall survival is not significantly different. Takaki et. al. compared RFA versus PN in T1b RCCs. Cumulative RCC-related survival and disease-free survival was not significantly different. But there was a significant difference in overall survival, probably because RFA patients were older, had a worse American Society of Anesthesiologists (ASA) score and more single kidney interventions. Because the sensitivity of RCC-cells to radiation is debatable, not many study data for conventional radiation of RCCs is available. Newer radiation techniques like Stereotactic body radiation therapy (SBRT) and Cyberknife could increase the amount of radiation into the tumor and reducing the applied radiation to normal tissues. Onother technique is to place afterloading catheters into the tumor under CT-guidance and perform a brachytherapy of the tumor to achieve local tumor control. Combination of different therapies could additionally increase the therapeutic options in the individual patient and should be discussed Active Handout sec.pdf RC114 Interactive Game: Interventional Refresher/Informatics

73 IR AMA PRA Category 1 Credits : 1.50 ARRT Category A+ Credits: 1.50 Sun, Nov 30 2:00 PM - 3:30 PM Location: E350 Steven Michael Zangan MD (Presenter): Nothing to Disclose Rakesh Choudary Navuluri MD (Presenter): Nothing to Disclose 1) Recognize vascular and non-vascular conditions and their image-guided treatment in the chest, abdomen and pelvis. This interactive session will use RSNA Diagnosis Live. Please bring your charged mobile wireless device (phone, tablet or laptop) to participate. RC152 Techniques for Interventional Sonography and Thermal Ablation (Hands-on Workshop) Refresher/Informatics US IR US IR AMA PRA Category 1 Credits : 1.50 ARRT Category A+ Credits: 1.50 Sun, Nov 30 2:00 PM - 3:30 PM Location: E264 Stephen Clifford O'Connor MD (Presenter): Nothing to Disclose William Eugene Shiels DO (Presenter): President, Mauka Medical Corporation Royalties, Mauka Medical Corporation Patent holder, Mauka Medical Corporation Alda Felicita Cossi MD (Presenter): Nothing to Disclose Michael V. Krasnokutsky MD (Presenter): Nothing to Disclose Mark LeRoy Lukens MD (Presenter): Nothing to Disclose Kenneth S. Lee MD (Presenter): Research Consultant, SuperSonic Imagine Speakers Bureau, Medical Technology Management Institute Manish Natvarlal Patel DO (Presenter): Nothing to Disclose Hollins P. Clark MD, MS (Presenter): Nothing to Disclose Mark Joseph Hogan MD (Presenter): Nothing to Disclose Carmen Gallego MD (Presenter): Nothing to Disclose Mabel Garcia-Hidalgo Alonso MD (Presenter): Nothing to Disclose John David Lane MD (Presenter): Nothing to Disclose Andrew Jered Rabe DO (Presenter): Nothing to Disclose Humberto Gerardo Rosas MD (Presenter): Nothing to Disclose Kristin Marie Dittmar MD (Presenter): Nothing to Disclose Nicholas Andrew Zumberge MD (Presenter): Stockholder, Covidien AG Stockholder, Abbott Laboratories Stockholder, Abbvie Inc Stockholder, Mallinckrodt plc Stockholder, Dexcom, Inc Stockholder, Merck & Co, Inc Stockholder, Gilead Sciences, Inc Stockholder, Exact Sciences Corporation Stockholder, Cerner Corporation 1) Identify basic skills, techniques, and pitfalls of freehand invasive sonography. 2) Discuss and perform basic skills involved in thermal tumor ablation in a live learning model. 3) Perform specific US-guided procedures to include core biopsy, abscess drainage, vascular access, cyst aspiration, soft tissue foreign body removal, and radiofrequency tumor ablation. 4) Incorporate these component skill sets into further life-long learning for expansion of competency and preparation for more advanced interventional sonographic learning opportunities. RC250 Interventional Stroke Treatment: Practical Techniques and Protocols (How-to Workshop) (An Interactive Session) Refresher/Informatics NR ER IR NR ER IR AMA PRA Category 1 Credits : 1.50 ARRT Category A+ Credits: 1.50 Mon, Dec 1 8:30 AM - 10:00 AM Location: E353B Gary Ross Duckwiler MD (Presenter): Scientific Advisor, Sequent Medical, Inc Scientific Advisor, Asahi Kasei Medical Co, Ltd Stockholder, Sequent Medical, Inc Proctor, Covidien AG Joshua A. Hirsch MD (Presenter): Shareholder, Intratech Medical Ltd David John Fiorella MD, PhD (Presenter): Institutional research support, Siemens AG Institutional research support, Terumo Corporation Consultant, Covidien AG Consultant, Johnson & Johnson Consultant, NFocus Consulting Inc Owner, Vascular Simulations LLC Owner, TDC Technologies Owner, CVSL 1) Describe the diagnostic evaluation and decision making algorithms leading to urgent endovascular treatment of acute stroke. 2) Review endovascular techniques for the treatment of acute stroke from microcatheter set up to intraarterial thrombolysis to mechanical thrombectomy. 3) Discuss case examples of endovascular treatment including patient selection, technique, and pitfalls. ABSTRACT

74 Rapid advances in the evaluation, selection, treatment and management of the acute stroke patient necessitates an ongoing educational event highlighing the newest information, techniques and strategies for obtaining the best outcomes for our patients. In this session, all of these topics will be covered in a practical 'how to' and case based approach which is designed to help the practitioner implement best practices. The course is useful for those performing imaging, treatment or both. Analysis of the latest ongoing trials, devices and techniques will be presented. Endovascular tips and tricks will be discussed, as well as pitfalls in the treatment of these patients. Active Handout sec.pdf VSCA21 Cardiac Series: Transcatheter Aortic Valve Replacement (TAVR) Series Courses IR CA IR CA AMA PRA Category 1 Credits : 3.25 ARRT Category A+ Credits: 4.00 Mon, Dec 1 8:30 AM - 12:00 PM Location: S404CD Moderator Suhny Abbara MD : Research Consultant, Radiology Consulting Group Moderator Robert M. Steiner MD : Consultant, Educational Symposia Consultant, Johnson & Johnson Sub-Events VSCA21-01 TAVR The Interventionalist's Perspective Stephan Achenbach MD (Presenter): Research Grant, Siemens AG Research Grant, Bayer AG Research Grant, Abbott Laboratories Speaker, Guerbet SA Speaker, Siemens AG Speaker, Bayer AG Speaker, AstraZeneca PLC Speaker, Berlin-Chemie AG Speaker, Abbott Laboratories Speaker, Edwards Lifesciences Corporation 1) To understand the typical Implantation techniques used in TAVI. 2) To learn the infomation that the interventionalist requires from pre-procedural Imaging in order to optimize the Implantation procedure. 3) To appreciate the relevance of pre-procedural imaging for prosthesis selection and outcome. VSCA21-02 How to Optimize the Scan Acquisition for TAVR Brian Burns Ghoshhajra MD (Presenter): Nothing to Disclose VSCA21-03 Precision of CTA-based Aortic Annulus Area Measurements for Transcatheter Aortic Valve Replacement (TAVR): Effects of Reader Experience and Implications for Appropriate Device Sizing Scott K. Nagle MD, PhD (Presenter): Stockholder, General Electric Company Research Consultant, Vertex Pharmaceuticals Incorporated, Sarah Sweetman : Nothing to Disclose, Carrie Bartels : Nothing to Disclose, Giorgio Gimelli MD : Nothing to Disclose, Amish N. Raval MD, FRCPC : Nothing to Disclose, Christopher Jean-Pierre Francois MD : Research support, General Electric Company, Alejandro Munoz Del Rio PhD : Research Consultant, Cellectar Biosciences, Inc Reviewer, Wolters Kluwer nv To determine the precision of CTA aortic annulus area measurements and the impact on TAVR device selection. This retrospective study included 86 consecutive clinical TAVR screening CTAs performed on a 64-slice scanner (LightSpeed VCT, GE Healthcare) using retrospective ECG gating. A 1st year medical student (R1, after training on 10 separate CTAs), a 3D lab technologist (R2, 3 yrs experience), and a cardiothoracic radiologist (R3, 6 yrs experience) independently measured the aortic annulus in systole in a random, blinded fashion. The annular plane, containing the hinge points of all 3 valve cusps, was located using multiplanar reformats (Vitrea, Vital Images). The annular area was measured using a freely drawn contour. All measurements were repeated >2 weeks later to avoid recall bias. Bland-Altman analysis was used to assess each reader's repeatability. The difference between the 95% limits of agreement and the bias was used to estimate the measurement precision. To assess differences between readers, variance ratios (VR) were calculated along with their 95% confidence intervals and compared with an F test. The impact on device sizing was evaluated using the Edwards SAPIEN valve as an example. Annular size was grouped into 5 categories, based on the recommended device: too small, 23mm, either, 26 mm, or too large. Percent agreement between the measurements was calculated for each reader. Bias between measurements was 6 [-1,13] (R1), -3 [-11,5] (R2), and 1 [-5,7] (R3) mm2. Precision was ±64 [52,76] (R1), ±70 [57,83] (R2), and ±55 [44,66] (R3) mm2. The difference in precision between R2 and R3 was statistically significant (VR: 1.60 [1.04,2.46], p=0.03). Device size recommendations from the 2 measurements differed in 23% (R1), 29% (R2), and 22% (R3) of the cases and differed by more than 1 category in 2% (R1), 4% (R2), and 1% (R3) of the cases.

75 Within reader annular area measurement imprecision results in different TAVR device size recommendations ~25% of the time, even for an experienced cardiovascular CTA reader. Reports should include estimated measurement precision to aid in the interpretation of the results. Knowing the precision of CTA-based aortic annulus area measurements is very important for multidisciplinary TAVR treatment planning. A single point estimate of the annular area may not be sufficient. VSCA21-04 A Non-Contrast, Free-Breathing, Self-Navigated MR Technique for Aortic Root and Vascular Access Route Assessment in the Context of Transcatheter Aortic Valve Replacement Matthias Renker MD : Nothing to Disclose, Akos Varga-Szemes MD, PhD (Presenter): Nothing to Disclose, Carlo Nicola de Cecco MD : Nothing to Disclose, Stefan Baumann MD : Nothing to Disclose, Edgar Muller : Employee, Siemens AG, U. Joseph Schoepf MD : Research Grant, Bracco Group Research Grant, Bayer AG Research Grant, General Electric Company Research Grant, Siemens AG, Davide Piccini : Employee, Siemens AG, Wolfgang Rehwald : Employee, Siemens AG, Daniel H. Steinberg MD : Nothing to Disclose Because of the high comorbidity of TAVR candidates, a rapid, robust, non-contrast MR technique for assessing the aortic root complex along with the entire vascular access route would be desirable for TAVR procedural planning. We tested a newly developed non-contrast, free-breathing, self-navigated 3D (SN3D) MR sequence for assessing the entire aorta, from the root to the ilio-femoral run-off. A non-contrast steady-state free-precession (SSFP) sequence which has previously been shown to enable accurate aortic valve assessment was used for comparison. We performed non-contrast MR angiography on a 1.5T system (Avanto, Siemens) using the novel SN3D and the SSFP sequence in 6 healthy subjects. The SN3D sequence was applied to assess the aorta from its root to the ilio-femoral arteries. The parameters for the SN3D acquisitions were: FOV 220/370mm, ST 1.15mm, IM 1922, slices 192, TR 265.2ms, TE 1.5ms, and FA 90. Both the thoracic and abdominal acquisitions were ECG gated. The parameters for the SSFP sequence were: FOV 340mm, ST 6mm, IM 1922, NS 15, reconstructed phases 25, TR 39.7ms, TE 1.1ms, FA 77, averages 3, acceleration factor 2. With SSFP only the thoracic acquisitions were ECG gated. Systolic aortic root measurements and subjective image quality (5-point scale) were compared. Vessel diameter and area measurements down to the level of the ilio-femoral arteries were obtained from the SN3D dataset. Acquisition times were recorded. The mean area-derived effective diameter in the aortic annular plane was comparable between SSFP and SN3D (26.7±0.7mm vs. 26.1±0.9mm, P=0.23). Median image quality of the aortic valve was rated slightly (p=0.03) higher with SSFP (4 - interquartile ranges, IQR; 4-4) than with SN3D (3 - IQR, 2-4). No significant differences were observed between the diameter and area of the thoracic and abdominal aorta, and the ileo-femoral run-off (p>0.05). The acquisition time of the SN3D sequence for the whole aorta was 12.1±2.7min. These preliminary results in healthy volunteers suggest that the proposed SN3D acquisition technique enables rapid, free-breathing assessment of the aortic root, the aorta and the ilio-femoral arteries without the administration of contrast medium. The features of the proposed SN3D sequence appear well suited to address the requirements for TAVR procedural planning in a population which frequently suffers from renal insufficiency and dyspnea. VSCA21-05 Size of Aortic Valve Calcium with Regard to Post-Procedural Aortic Regurgitation after Transcatheter Aortic Valve Implantation with First- and Second-generation Transcatheter Heart Valves Maxim Avanesov MD (Presenter): Nothing to Disclose, Moritz Seiffert : Nothing to Disclose, Clemens Lunau : Nothing to Disclose Aortic valve calcium is a predictor for aortic regurgitation (AR) after transcatheter aortic valve implantation (TAVI) and is associated with adverse outcome. 2nd generation devices promise to reduce residual AR, so we evaluated aortic valve calcium and post-procedual AR in 1st and 2nd generation transcatheter aortic valves as well as among different 2nd generation devices. TAVI was performed using 1st and 2nd generation devices in 156 patients with severe aortic stenosis and high surgical risk. Devices implanted were Edwards SapienXT(n=52), Medtronic CoreValve (n=33), Symetis Acurate(n=25), JenaValve(n=20) and Medtronic Engager(n=26) valves. All patients received preoperative contrast-enhanced CT scans with prospective ECG gating. 3D-reconstructions were performed by 3Mensio software (3MensioMedical Imaging, Bilthoven).Calcium load was quantified within the device-landing area, sub-divided into zone 1 (left coronary artery ostium to aortic annulus and zone 2 (aortic annulus to 10mm below). A cutoff of 500HU was used to distinguish aortic calcium from intraluminal contrast agent. In another group of 138 patients receiving 2nd generation devices only, aortic calcium was measured separately for each leaflet and compared among all implanted devices with regard to residual AR.

76 The highest aortic valve calcium(zone1+2) among 1st generation devices was seen in patients with CoreValve(3141±2232mm3) whereas the Engager valve reveiled the highest calcium loads among 2nd generation valves(2396±1027mm3). Mean post-procedural AR was none/trace in 66% and greater trace in 34%, CoreValve showed the highest rate of AR greater trace with 59%. Only Engager valve had the highest calcium score (896±445mm³), while AR rates weren't significantly different among other valve types. Re-Dilatation rates increased with higher calcium load (p=0.01) while the number of pacemaker implantation didn't alter significantly TAVI using 1st and 2nd generation devices revealed good hemodynamic results, irrespective of annular calcification. CoreValve was associated with highest rate of AR greater trace, while Engager valve, mostly used in patients with higher calcium load, showed no difference in post-procedural AR. 1st and 2nd generation TAVI devices are safe irrespective of aortic valve calcium. Only Engager valve reveiled low residual AR despite significantly higher aortic valve calcium. VSCA21-06 The Role of Imaging Prior to TAVR Jonathon Avrom Leipsic MD (Presenter): Speakers Bureau, General Electric Company Speakers Bureau, Edwards Lifesciences Corporation Consultant, Heartflow, Inc Consultant, Circle Cardiovascular Imaging Inc 1) Review the role of MDCT and TEE for annular sizing and device selection. 2) Discuss the role of pre-procedural CT in identifying patients at risk of TAVR related complications such as coronary occlusion and annular rupture. 3) Discuss the evolving role of MDCT to help guide transcatheter valve in valve procedures. VSCA21-07 MDCT for Cardiac Intervention Planning Beyond TAVR Pal Maurovich-Horvat MD (Presenter): Nothing to Disclose Cardiac CT is able to evaluate coronary artery disease with high diagnostic accuracy and provide comprehensive information regarding structural heart disease. Due to its ability to reconstruct 3-dimensional images with submilimeter isotropic resolution, cardiac CT is a uniquely suited tool for planning and appropriate selection of coronary and non-coronary interventional procedures. The detailed characterisation of coronary geometry and plaque morphology might improve the evaluation of bifurcation lesions and provide important information regarding selection of CTO PCI technique. The application of computational fluid dynamic simulation in CT datasets provides novel avenues in PCI planning through virtual stenting and post-stenting CT-derived computed fractional flow reserve (FFRCT) assessment. Other structural heart interventions might benefit from CT planning, like the evaluation of left atrial appendage, paravalvular leak and atrial or ventricular septal defects in patients candidate for closure devices. VSCA row CT Transcatheter Aortic Valve Implantation Planning Using a Single Reduced Contrast Media Bolus Injection: A Prospective Study on 50 Patients Mickael Ohana MD, MSc (Presenter): Nothing to Disclose, Aissam Labani MD : Nothing to Disclose, Soraya El Ghannudi-Abdo MD : Nothing to Disclose, Mi-Young Jeung MD : Nothing to Disclose, Karim Haioun : Employe, Toshiba Corporation, Patrick Ohlmann MD, PhD : Nothing to Disclose, Catherine Roy MD : Nothing to Disclose Reduce the iodine load required for CT TAVI planning by acquiring the ECG-gated aortic root volume and the non-gated aortoiliac scan within the same single contrast media bolus injection. 50 patients (60% women, 83yo ±7) were prospectively included and underwent TAVI planning with a second-generation 320-row CT scanner. The aortic root was acquired in volume mode using retrospective ECG-gating (100kV, 0.275s rotation time, 2 beats maximum) and immediately followed by a non-gated CAP aortic ultra-fast helical acquisition (100kV, 0.275s rotation time, pitch=0.813), all within a single bolus of 40 to 70mL of Iohexol 350mgI/mL. Image quality of both cardiac and aortic acquisitions was independently assessed by two radiologists on a qualitative five-point scale, and HU enhancement measured in the aorta and the iliac arteries to calculate the signal to noise (SNR) and contrast to noise ratios (CNR). These qualitative and quantitative results were compared to 24 procedures (62% women, 84yo ±5) previously performed on a 64-row scanner with a conventional two-step protocol using two contrast media boluses. Qualitative results were analyzed by a Kruskal-Wallis nonparametric test and quantitative data were compared using a Mann-Whitney test. A p<0.05 was considered significant. Mean iodine load was commonsensically significantly lower in the 320-row group (23.1g±3.6 vs 43.2g ±8,

77 p<0.01). Image quality of the ECG-gated aortic root and the CAP aorta were equivalent (respectively 4.9 and 4.7 vs 4.4 and 4.9, p>0.05). Mean HU enhancement was similar (388 vs 400, p=0.4) while mean noise was significantly lower (24.5 vs 28.5, p<0.01), leading to a slightly improved SNR and CNR (16.3 and 13.9 vs 14.7 and 12.5, p=0.34 and 0.57). Radiation dose was significantly lower for both the ECG-gated acquisition (547mGy.cm vs 800, p<0.01) and the whole-body aortic scan (487mGy.cm vs 785, p<0.01). Second-generation 320-row CT scanner enables a 47% reduction of the iodine load in TAVI planning, by subsequently acquiring the ECG-gated aortic root and the CAP aorta within a single contrast media bolus injection, while maintaining excellent aortoiliac arterial enhancement and lowering radiation dose. TAVI planning with subsequent acquisition of the ECG-gated aortic root and the non-gated whole-body aorta is possible within a single contrast media injection when using a 320-row CT. VSCA21-09 In Vivo Assessment of Aortic Root Geometry in Normal Controls Using 3-Dimensional Analysis of Computed Tomography Dong Hyun Yang MD (Presenter): Nothing to Disclose, Joon-Won Kang MD : Nothing to Disclose, Namkug Kim PhD : Stockholder, Coreline Soft, Inc, Jae-Kwan Song MD, PhD : Nothing to Disclose, Tae-Hwan Lim MD, PhD : Nothing to Disclose In vivo geometric analysis of the normal human aortic root is lacking. The aim of this study was to obtain the comprehensive geometric data of the normal aortic root using computed tomography (CT). One hundred thirty subjects who underwent cardiac CT for atypical chest pain or health check-up were enrolled. Subjects without hypertension, diabetes, significant coronary artery disease, and cardiac valvular dysfunction were included (mean age, 51.4 years; 55 men; number of subjects in each decade - third 15, forth 20, fifth 30, sixth 21, seventh 23, and eighth 21). Mid-diastolic phase of CT images were analyzed using customized software (Omni4D). Individual volume of the aortic sinus and leaflet surface areas (LSA) of the right, left and non-coronary cusps were measured. Intercommissural (IC) distance in each aortic sinus was also investigated. All measured parameters were indexed to body surface area. The left coronary sinus showed significantly smaller geometric parameters including sinus volume, LSA, and IC distance than the other two sinuses (left/non-coronary/right: sinus volume [ml/m2] 1.54/1.95/2.08; LSA [cm2/m2] 2.56/3.03/3.03; IC distance [cm/m2] 1.84/1.94/2.23; p <0.001). Between the right- and non-coronary sinuses, there were no significant differences other than IC distance. In the older decade of age, the volume and IC distance of all coronary sinuses showed an increasing tendency on the test for trend (p < 0.05). However, no significant difference was found in the LSA and annular area with age. Detailed analysis of aortic root geometry reveals normal asymmetry in the aortic sinus and leaflet surface area. The size of left coronary sinus was smaller than the other two sinuses. The size of aortic sinus showed increasing tendency in older age group, however LSA did not changed with age. Knowledge of the normal aortic root anatomy is relevant to understand the pathophysiology of the aortic regurgitation and to improve the method of surgical aortic root reconstruction. VSCA21-10 Morphology of Left Ventricular Outflow from the Left Ventricular Outflow Tract to the Sinotubular Junction: Comparison of Patients with Normal Aortic Valves to Those with Severe Aortic Stenosis Gilda Boroumand MD (Presenter): Nothing to Disclose, Hugh White MD : Nothing to Disclose, Praneil Patel MD : Nothing to Disclose, Ethan J. Halpern MD : Nothing to Disclose The shape of the left ventricular outflow tract (LVOT), aortic annulus and aortic root may impact the proper sizing of a percutaneous aortic valve replacement (TAVR). We evaluated the sphericity of left ventricular outflow with ECG-gated coronary CTA from the LVOT through the sinotubular junction in both diastole and systole. ECG-gated CTA studies were reviewed from 52 consecutive patients with normal aortic valves and 13 TAVR candidates with severe aortic stenosis and dense valvular calcification. Using a dedicated 3D workstation, orthogonal measurements of the outflow tract were obtained to define the antero-posterior (AP) and transverse diameters (short and long axis) at 4 levels: LVOT, aortic annulus, aortic root and sinotubular junction. Sphericity was defined as the ratio of the AP to transverse diameter at each level.

78 Analysis of variance demonstrated that both the level of the measurement and the phase of the cardiac cycle were significantly associated with sphericity (p<0.0001), while the presence of aortic stenosis was non-significant (p=0.96). Mean sphericity during diastole measured 0.61 at the LVOT, 0.77 at the aortic annulus, 0.94 at the aortic root and 1.00 at the sinutubular junction (p< for comparison of any two adjacent levels). During systole, mean sphericity measured 0.69 at the LVOT, 0.81 at the aortic annulus, 0.93 at the aortic root and 1.00 at the sinutubular junction (p< for comparison of any two adjacent levels). Differences in sphericity between diastole and systole were significant at the LVOT (p<0.0001) and at the aortic annulus (p=0.0061). The shape of the left ventricular outflow changes from an oval at the level of the LVOT to a more circular shape at the level of the sinotubular junction. Although the entire outflow tract changes in size and sphericity during the cardiac cycle, this change is most pronounced at the LVOT, and is statistically significant only at the LVOT and aortic annulus levels. The sphericity of left ventricular outflow structures and the change in sphericity during the cardiac cycle is similar among patients with a normal aortic valve and those with severe aortic stenosis. The oval shape of the proximal left ventricular outflow is not altered by the presence of aortic stenosis and calcification. This shape may have important implications for the design and positioning of aortic valve implants. VSCA21-11 CT for Planning Transcatheter Aortic Valve Replacement: Accuracy for Diagnosing Obstructive Coronary Artery Disease Richard Bayer (Presenter): Nothing to Disclose, Brett S. Harris PhD : Nothing to Disclose, Felix G. Meinel MD : Nothing to Disclose, Daniel H. Steinberg MD : Nothing to Disclose, Carlo Nicola de Cecco MD : Nothing to Disclose, U. Joseph Schoepf MD : Research Grant, Bracco Group Research Grant, Bayer AG Research Grant, General Electric Company Research Grant, Siemens AG, Aleksander Krazinski : Nothing to Disclose, Kevin Dyer : Nothing to Disclose, Monique Sandhu : Nothing to Disclose, Michael R. Zile MD : Nothing to Disclose Patients referred for transcatheter aortic valve replacement (TAVR) typically undergo a CT study of the heart, aortic root and vascular access route for pre-interventional planning. In this study we evaluated the accuracy of cardiac CT, performed for TAVR planning purposes for diagnosing obstructive coronary artery disease (CAD) using coronary catheter angiography (CCA) as the reference standard. With institutional review board approval, waiver of informed consent and in HIPAA compliance we retrospectively analyzed the data of 100 consecutive TAVR candidates (61 male, mean age 79.6±9.9 years) who underwent both TAVR planning CT and CCA. The presence and degree of coronary artery stenosis was assessed at both modalities. Additionally, in patients with coronary bypass grafts these were rated as either patent or occluded. Using CCA as the reference standard, we calculated the accuracy of CT for lesion detection on a per-vessel and per-patient basis. We further analyzed the accuracy of CT for the assessment of graft patency. Our data show that in a per-vessel/per patient analysis, CT had 94.4/98.6% sensitivity and 68.4/55.6% specificity for the detection of >50% stenosis in the native coronary arteries. Negative and positive predictive values were 94.7/93.8% and 67.0/85.7%, respectively. On CT, the per-patient sensitivity for >70% stenosis was found to be 100.0%. Furthermore, all 12 vessels on which percutaneous coronary intervention was performed were correctly identified on CT as demonstrating >50% stenosis. Finally, there was good agreement between CT and CCA regarding graft patency in 114/115 grafts identified on CCA. Our study indicates that TAVR planning CT does indeed have high sensitivity and negative predictive value in excluding obstructive CAD. For prospective TAVR candidates this would suggest that an additional pre-procedural CCA study may not be required in those patients with a CT negative for obstructive CAD. Our analysis suggests a new management algorithm that would benefit the rising numbers of TAVR candidates with increases in cost effectiveness and improvements in patient safety. VSGI21 Gastrointestinal Series: Imaging of the Cirrhotic Patient Series Courses US OI MR IR GI

79 AMA PRA Category 1 Credits : 3.25 ARRT Category A+ Credits: 4.00 Mon, Dec 1 8:30 AM - 12:00 PM Location: E350 Moderator Mark Elwood Lockhart MD : Nothing to Disclose Moderator Kathryn Jane Fowler MD : Research support, Bracco Group Sub-Events VSGI21-01 MRI and MR Elastography Frank H. Miller MD (Presenter): Nothing to Disclose 1) Discuss the role of conventional MRI in the diagnosis of HCC and benign hepatic nodules. 2) Use of gadoxetate and diffusion weighted imaging in characterizing focal liver lesions in cirrhotic patients. 3) MR elastography in the assessment of fibrosis. ABSTRACT MR imaging plays in important role in the diagnosis of cirrhosis. The classic and atypical MR imaging features of hepatocellular carcinoma and the distinction from benign hepatic nodules will be discussed. The use of ancillary features of HCC will be discussed including the utility of gadoxetate and diffusion weighted imaging in characterizing focal hepatic lesions in cirrhotic patients. MR elastography, a relatively new technique will be emphasized for the staging of fibrosis and diagnosis of cirrhosis. Active Handout sec.pdf VSGI21-02 The Outcome of Hypovascular and Hypointense Nodules on Hepatocyte-phase Gadoxetic Acid-enhanced Magnetic Resonance Imaging; When Does It become a Conventional HCC?: 5 Years' Experience Katsuhiro Sano MD,PhD (Presenter): Nothing to Disclose, Utaroh Motosugi MD : Nothing to Disclose, Tomoaki Ichikawa MD, PhD : Consultant, DAIICHI SANKYO Group, Shintaro Ichikawa MD : Nothing to Disclose, Hiroyuki Morisaka MD : Nothing to Disclose, Kojiro Onohara MD : Nothing to Disclose, Tomohiro Takamura : Nothing to Disclose, Hiroshi Onishi : Nothing to Disclose Nodules that appear hypointense on hepatocyte phase of gadoxetic acid-enhanced magnetic resonance imaging (EOB-MRI) and hypovascular on arterial-phase are often encountered in clinical practice. Such nodules cannot be diagnosed using routine imaging criteria. The pupose of this study was to elucidate the natural history over a long period of hypovascular nodules that appear hypointense on hepatocyte-phase EOB-MRI by focusing on hypervascularization. In this study, 235 such nodules in 84 patients were examined. Hypovascularity of the nodules was confirmed using dynamic CT. All nodules were retrospectively examined using serial follow-up CT and MRI. examinations until hypervascularity was observed on arterial-phase dynamic CT or EOB-MRI, or CT during hepatic arteriography. The mean follow-up duration was 702 days (range: 69 to 2085 days). Of the 235 nodules, 148 (63%) developed hypervascularization. The optimal cut off value of the size of hypervascularization was 10mm. Of the 102 nodules (=10mm or >10mm), 81 (79%) developed hypervascularizaion. The size of the nodules (=10mm or >10mm) and increase in size of the nodules were independent risk factors of hypervascularization by multivariate analysis. The 1-year cumulative risks of hypervascularization were 20% (=10mm or >10mm). These values were significantly differences. About 80% of hypovascular and hypointense nodules on EOB-MRi (=10mm or >10mm) progressed to conventional hepatocellular carcinoma. Large nodular size (=10mm or >10mm) and increase in size of the nodules is the MR imaging findings that higher risk of hypervascularization. About 80% of hypovascular and hypointense nodules on EOB-MRI with the size equal to 10mm or larger 10mm. Large nodular size (=10mm or >10mm) and increase in size of the nodules are the MR imaging findings that indicate higher risk of hypervascularization. VSGI21-03 Texture Analysis of Non-enhanced and Gadoxetate Disodium-enhanced MR Images of the Liver: A

80 VSGI21-03 Comparison with Histological Grade of Liver Fibrosis Akira Yamada MD (Presenter): Nothing to Disclose, Kazuhiko Ueda MD : Nothing to Disclose, Yasunari Fujinaga MD : Nothing to Disclose, Masahiro Kurozumi MD : Nothing to Disclose, Shinichi Miyagawa : Nothing to Disclose, Masumi Kadoya MD : Nothing to Disclose To evaluate value of gadoxetate disodium on noninvasive diagnosis of liver fibrosis by texture analysis of MR images. Consecutive 46 patients who underwent preoperative gadoxetate disodium-enhanced MR imaging using 3 Tesla MR system were included in this retrospective study. The grade of liver fibrosis (the fibrosis score: F) was histologically diagnosed by surgical specimen in all patients. Pre-contrast respiratory-gated 2D fast spin echo T2-weighted images (voxel size = 0.7 x 0.7 x 5 mm), pre- and post-contrast (20 minutes after venous administration) breath-hold 3D gradient recalled echo T1-weighted images (voxel size = 0.7 x 0.7 x 3 mm) were used for evaluation. Fat-suppression was applied to all images. Region of interests sized 60 x 60 pixels were located in the liver avoiding major vessels and hepatic lesions in each MR image. Four feature values ('contrast', 'correlation', 'energy', and 'heterogeneity') of the liver were determined by texture analysis of region of interests. A stepwise liner regression analysis of the fibrosis score on the feature values obtained from texture analysis was performed using 3 different image sets (pre-contrast MR images, post-contrast MR images, and the both). ROC analysis of obtained 3 regression models in differentiation of liver fibrosis (F1-4) from normal liver (F0) was performed. The area under ROC of obtained 3 regression models in differentiation of liver fibrosis from normal liver was 0.64 for pre-contrast MR images, 0.83 for post-contrast MR images, and 0.85 for the both. Two feature values (x1: 'correlation' in post-contrast T1-weighted images, P < ; x2: 'energy' in pre-contrast T2-weighted images, P = 0.017) were significant predictors for the fibrosis score in eventual regression model (y = x x , R = 0.63, P < ). Gadoxetate disodium can add value on noninvasive diagnosis of liver fibrosis by texture analysis of MR images. The degree of liver fibrosis especially at its early stage can be predicted non-invasively by texture analysis of non-enhanced and gadoxetate disodium-enhanced MR images. VSGI21-04 State-of-Art Sonography Stephanie R. Wilson MD (Presenter): Research Grant, AbbVie Inc Grant, Johnson & Johnson Consultant, Lantheus Medical Imaging, Inc Equipment support, Siemens AG Equipment support, Koninklijke Philips NV 1) The attendee will appreciate the unique contribution of contrast enhanced ultrasound (CEUS) to imaging of HCC in terms of its real time dynamic performance, superior spatial and temporal resolution, and incomparable vascular sensitivity. 2) The attendee will analyze the imaging performance of microbubble contrast agents for liver mass characterization with CEUS, which are purely intravascular, as compared to the interstitial agents commonly used for CT and MR scan. VSGI21-05 Assessment of Hepatic Vascular Network Connectivity by Automated Graph Analysis of Dynamic Contrast Enhanced Ultrasound to Evaluate Portal Hypertension in Patients with Cirrhosis: A Pilot Study Ivan Amat-Roldan PhD (Presenter): Nothing to Disclose, Annalisa Berzigotti MD, PhD : Nothing to Disclose, Rosa Gilabert MD : Nothing to Disclose, Jaime Bosch MD : Nothing to Disclose The liver vascular network is characterized by a highly organized structure. This is progressively deranged due to fibrosis and hepatocyte drop-out in patients with chronic liver diseases, leading to portal hypertension. We hypothesised that graph analysis of vascular images obtained by dynamic contrast-enhanced ultrasound (DCE-US), would allow calculating the hepatic vascular network connectivity, which would predict the degree of organization of the liver circulation, and that this would mirror the severity of portal hypertension. This pilot study includes 4 healthy subjects and 15 well characterized patients with liver cirrhosis who underwent DCE-US and hepatic venous pressure gradient measurement (HVPG; gold standard method to assess portal hypertension in cirrhosis). Individual graph models ('vascular connectomes') were computed based on time series analysis of video sequences of DCE-US examination (disruption-reperfusion technique). Graph analysis was carried out by calculation of clustering coefficient; according to graph theory a higher clustering coefficient indicates a more organized network. Based on clustering coefficient we calculated statistical models to predict HVPG from DCE-US video sequences. Healthy subjects had a high clustering coefficient of vascular connectome suggesting a highly organized liver vascular network. Patients with cirrhosis showed a lower clustering coefficient indicating disruption of normal anatomy. Clustering coefficient decreased as HVPG increased. The correlation between the best model derived

81 from distribution of clustering coefficient (10 bins) of vascular 4 connectome and HVPG had a Pearson's correlation of and a root mean square error of 1.57 evaluated by leave one out cross-validation. Computer based graph-analysis of video sequences generated by DCE-US permits to calculate a vascular connectome that reflects the degree of organization of hepatic microvascular network This non-invasive method is able to quantify automatically the degree of liver vascular derangement and accurately mirrors the severity of portal hypertension in patients with cirrhosis. VSGI21-07 LIRADS and UNOS Classifications of Liver Lesions Cynthia Sawhney Santillan MD (Presenter): Consultant, Robarts Clinical Trials Research Group 1) To demonstrate the use of the LI-RADS and UNOS imaging categorization systems for observations seen in patients at risk for hepatocellular carcinoma with sample cases. 2) To highlight the different purposes of each categorization system. 3) To illustrate the differences and similarities in how observations are categorized with each system. VSGI21-08 A Review of LI-RADS Categorization in 201 Pathology Proven Hepatocellular Carcinomas Eric Christopher Ehman MD (Presenter): Nothing to Disclose, Spencer Caton Behr MD : Research Grant, General Electric Company, Rizwan Aslam MBBCh : Research support, Bayer AG, Benjamin M. Yeh MD : Research Grant, General Electric Company Consultant, General Electric Company, Linda Ferrell MD : Nothing to Disclose, Thomas A. Hope MD : Speaker, Guerbet SA Research Grant, General Electric Company To explore the trends in imaging appearance and differences in findings by modality for the new LI-RADS v2014 definitions in a large group of pathology proven cases of hepatocellular carcinoma. Pathology reports from liver specimens (explants and partial hepatectomies) of 605 sequential patients with cirrhosis were reviewed to identify specimens with at least one focus of viable hepatocellular carcinoma, then cross-correlated with pre-operative CT and MR imaging. Patients with completely necrotic treated tumor, those without available prior pre-treatment multiphase imaging and tumors smaller than 1 cm were excluded. Each lesion was examined, the imaging features recorded, and the lesion retrospectively graded using the LI-RADS 2014 criteria. 147 patients with a total of 201 hepatocellular carcinomas diagnosed between 12/2008 and 10/2013 were analyzed. Average time between the most recent pre-treatment prior imaging study and surgery was 13 months. 150 (75%) lesions were imaged by multiphase CT, and 51 (25%) lesions by MRI. Overall, 64 (32%) lesions measured 1cm and <2cm, while 137 (68%) were 2cm. There were 21 (13%) LIRADS-3 lesions, 75 (37%) LIRADS-4 lesions and 102 (50%) LIRADS-5 lesions. 171 (85%) of lesions exhibited arterial hyperenhancement, 136 (68%) demonstrated washout and 29 (14%) showed evidence of capsule. At CT, the rate of LIRADS-3, -4 and -5 lesions was 13%, 37% and 50% respectively. At MR, these rates were 4%, 39% and 55%. At CT, 13% of 1-2 cm lesions were graded LIRADS-5, and at MR, 38% were graded LIRADS-5. Arterial phase hyperintensity and washout appearance rates were equivalent between MR and CT, but capsule appearance was more common on MR (29%) imaging than at CT (10%), with χ2 = 10.7 (p<0.05). The rate of arterial enhancement and portal venous or delayed washout are similar between lesions diagnosed via CT and those diagnosed with MR. Capsule appearance was seen significantly more frequently at MR, resulting in a higher rate of LIRADS-5 lesions measuring 1-2 cm at MR compared to CT. Differences in sensitivity for LI-RADS 5 lesions exist for MR and CT, which may support the use of MR imaging for the evaluation of HCC over that of CT in the pre-transplant population VSGI21-09 Performance of LI-RADS Criteria for Diagnosis of Pathologically Proven Hepatocellular Carcinoma Using Gd-EOB-DTPA, and Comparisons with the Japan Society of Hepatology 2010 Criteria Stephanie Channual MD (Presenter): Nothing to Disclose, Anokh Pahwa MD : Nothing to Disclose, Katrina Richards Beckett MD : Nothing to Disclose, James Sayre PhD : Nothing to Disclose, David Shin-Kuo Lu MD : Consultant, Covidien AG Speaker, Covidien AG Consultant, Johnson & Johnson Research Grant, Johnson & Johnson Consultant, Bayer AG Research Grant, Bayer AG Speaker, Bayer AG, Steven Satish Raman MD : Consultant, Bayer AG Consultant, Covidien AG

82 Only recently has LI-RADS (LR) expanded to apply to hepatobiliary (HB) contrast agents, with lesion appearance on the HB phase considered to be an ancillary feature that favors the diagnosis of hepatocellular carcinoma (HCC). In contrast, the Japan Society of Hepatology (JSH) includes lesion appearance on the HB phase as a major criteria that favors the diagnosis of HCC. The purpose of our study was to determine the performance of LI-RADS v2014 and Japan Society of Hepatology (JSH) 2010 criteria for the non- invasive diagnosis of HCC. This was an IRB approved, HIPAA compliant retrospective study with 131 consecutive suspected HCC nodules in 114 patients confirmed by percutaneous biopsy, resection, or explant within 90 days of Gd-EOB-DTPA MRI. Nodule size, presence of a capsule, and enhancement patterns were recorded. The nodules were then categorized as LR3, LR4, or LR5 based on the LI-RADS major criteria, and categorized as either meeting or not meeting the JSH criteria (defined as arterial enhancement and venous wash out, or arterial enhancement and lack of Gd-EOB-DTPA uptake on HB phase imaging). Of the 131 nodules, 116 were pathologically confirmed HCC (88.5%). Of 131 nodules, 23 (18%), 41 (31%), and 67 (51%) were categorized as LR3, LR4, and LR5 respectively. Of these, 15/23, 37/41, and 64/67 LR3, LR4 and LR5 nodules were pathologically proven as HCC, respectively (sensitivities, 13%, 32%, and 55%, respectively; specificities, 47%, 73%, and 80%, respectively). The PPV of LR3, LR4, and LR5 were 65%, 90%, and 96%, respectively. The sensitivity, specificity, and PPV for the JSH criteria were 72.4%, 53.3%, and 92.3%, respectively. The accuracy of LR4 and LR5 combined was 83% (109/131), while the accuracy for the JSH criteria was 70.2% (92/131). Although use of LI-RADS with Gd-EOB-DTPA yields a high PPV and accuracy for diagnosing HCC, moderate sensitivity and specificity suggest that further refinement of the criteria may be necessary and percutaneous nodule biopsy may be complementary for diagnosis. However, LR4 and LR5 combined was more sensitive and accurate for diagnosing HCC compared to the JSH criteria. The use of hepatobiliary specific MR contrast agents, such as Gd-EOB-DTPA, is becoming more prevalent, and understanding its applicability with LI-RADS is essential for the noninvasive evaluation of nodules in cirrhotic livers. VSGI21-10 Ablation of Liver Lesions Fred T. Lee MD (Presenter): Stockholder, NeuWave Medical, Inc Patent holder, NeuWave Medical, Inc Board of Directors, NeuWave Medical, Inc Patent holder, Covidien AG Inventor, Covidien AG Royalties, Covidien AG 1) Understand the basic rationale for ablation of liver lesions. 2) Understand the differences between ablation of liver tumors in cirrhotic and non-cirrhotic livers. 3) Understand the differences between the different ablation technologies. VSGI21-11 Imaging Evaluation of Ablative Margin and Index Tumor Immediately after Radiofrequency Ablation for Hepatocellular Carcinoma: Comparison between Multi-detector CT and MR Imaging Jin Woong Kim MD : Nothing to Disclose, Sang Soo Shin MD (Presenter): Nothing to Disclose, Suk Hee Heo MD : Nothing to Disclose, Hyo Soon Lim MD : Nothing to Disclose, Sung Mo Kim : Nothing to Disclose, Yong-Yeon Jeong MD : Nothing to Disclose, Heoung-Keun Kang MD : Nothing to Disclose To prospectively compare multi-detector CT and MR imaging in assessment of ablative margin (AM) and index tumor within ablation zones immediately after radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC). Based on our preliminary data, necessary number of patients was estimated to be at least 30 when an α error of 0.05 and a β error of 0.2 were applied. A total of 33 consecutive patients with 42 HCCs, who had successfully undergone contrast-enhanced CT and MR imaging after RFA, was enrolled in this study. CT and MR imaging were performed within 3 and 7 hours after completion of RFA, respectively. Both CT and MR images were reviewed in consensus by two radiologists in two separate sessions regarding visual discrimination between AM and index tumor and status of AM within ablation zones. The status of AM was classified as AM plus (AM completely surrounded tumor), AM zero (AM was partly discontinuous, without protrusion of tumor beyond postulated border of ablated area) and AM minus (AM was partly discontinuous, with protrusion of tumor). Any ablation zone with AM plus or AM zero was considered as imaging evidence to predict technical effectiveness, which was based on one-month follow-up CT, as well as to represent technical success.

83 With CT and MR imaging, visual discrimination between AM and index tumor was possible in 4 (9.5%) and 34 (81%) of 42 ablation zones, respectively (P<.001). Among 4 and 34 ablation zones in which status of AM could be evaluated on CT and MR imaging, respectively, all of 4 ablation zones were classified as AM plus on CT images, whereas 34 ablation zones were categorized into AM plus (n=28), AM zero (n=5) and AM minus (n=1) on MR images. Based on CT and MR imaging, technical success was determined to be achieved in 4 (9.5%) and 33 (78.6%), respectively (P<.001). The technical effectiveness was noted in all of ablation zones on one-month follow-up CT. CT and MR imaging predicted technical effectiveness in 4 (9.5%) and 33 (78.6%), respectively, (P<.001). MR imaging was superior to multi-detector CT for assessment of ablative margin and index tumor within ablation zones immediately after RFA. MR imaging performed immediately after RF ablation can provide sufficient information regarding necessity of additional ablation after RF ablation with more confidence than contrast-enhanced CT. VSGI21-12 Thermal Ablation in the Treatment of Hepatocellular Carcinoma (HCC): Radiofrequency Ablation (RFA) vs. Microwave Ablation (MWA) Thomas Josef Vogl MD, PhD (Presenter): Nothing to Disclose, Stefan Zangos MD : Nothing to Disclose, Jorg Trojan MD : Nothing to Disclose, Nagy Naguib Naeem Naguib MD, MSc : Nothing to Disclose, Nour-Eldin Abdelrehim Nour-Eldin MD, MSc : Nothing to Disclose To prospectively evaluate and compare the therapeutic response of radiofrequency ablation (RFA) and microwave ablation (MWA) therapy of hepatocellular carcinoma (HCC). Institutional review board approval was obtained prior to this prospective study and written informed consent was obtained from all patients included in the study for both the ablation procedure and anonymous use of their data for research purposes. From September 2008 to December 2011, 53 consecutive patients (42 males/11 females; mean, 59 years; range 40-68; SD, 4.2) underwent CT-guided percutaneous RFA and MWA of 68 HCC lesions. The inclusion and exclusion criteria were in accordance with the Barcelona Clinic Liver Cancer (BCLC) criteria for indications and contraindications for ablation therapy of HCC. The morphologic tumor response (number, location and size) was evaluated by MRI. Follow-up protocol was 24 hours post ablation, then in 3-month intervals post ablation in the first year and in 6-month intervals thereafter. Complete therapeutic response was documented in 84.4% (27/32) of lesions treated with RFA and in 88.9% (32/36) of lesions treated with MWA (p=0.6). Complete response was achieved in all lesions 2.0 cm in diameter in both groups. There was no significant difference in rates of residual foci of HCC lesions between RFA and MWA groups (p=0.15, Log-rank test). Recurrence rate for 3, 6, and 9 months in patients with HCC who underwent RFA vs. MWA were 6.3%, 3.1%, 3.1% vs. 0%, 5.6%, 2.8%. Time-to-progression in patients treated with RFA compared with MWA was 6.6 vs. 8.3 months. Progression-free-survival rate for patients treated with RFA was 96.9%, 93.8% and 90.6% at 1, 2, and 3 years, for patients treated with MWA it was 97.2%, 94.5%, and 91.7%, respectively (p=0.98). In conclusion, RFA and MWA therapy showed no significant difference in the treatment of HCC regarding complete response, rates of residual foci of untreated disease and recurrence rate. RFA or MWA can be used with similar results concerning local tumor control of HCC VSIR21 Interventional Series: Embolotherapy Series Courses IR VA AMA PRA Category 1 Credits : 3.25 ARRT Category A+ Credits: 3.75 Mon, Dec 1 8:30 AM - 12:00 PM Location: S406B

84 Moderator Jafar Golzarian MD : Nothing to Disclose 1) Describe indications and technical aspects of embolization for symptomatic prostatic hypertrophy. 2) Explain the rationale and treatment of low flow malformations. 3) Describe the preparation of cyanoacrylates for embolization. 4) Describe two complications related to embolization. 5) List two important studies on embolotherapy. Sub-Events VSIR21-01 Using Glue How I Do It Yasuaki Arai (Presenter): Nothing to Disclose 1) Learn features of glue as embolic material, 2) Learn clinical situations that glue is preferable to be chosen, 3) Understand how to use glue, and 4) Be aware of pitfalls using glue in embolization. VSIR21-02 A Mixture of N-Butyl Cyanoacrylate, Lipiodol and Ethanol under Flow Control Using an Arteriovenous Malformation (AVM) Model, Is It Useful for Embolization Masaki Ishikawa MD (Presenter): Nothing to Disclose, Masahiro Horikawa MD : Nothing to Disclose, Barry T Uchida : Nothing to Disclose, Hans A Timmermans : Nothing to Disclose, John Andrew Kaufman MD : Consultant, Bio2 Technologies, Inc Consultant, Cook Group Incorporated Consultant, Covidien AG Consultant, W. L. Gore & Associates, Inc Consultant, Guerbet SA Stockholder, Hatch Medical LLC Stockholder, VuMedi, Inc Stockholder, Veniti, Inc Royalties, Reed Elsevier Advisory Board, Delcath Systems, Inc Researcher, W. L. Gore & Associates, Inc Researcher, Guerbet SA, Kazuo Awai MD : Research Grant, Toshiba Corporation Research Grant, Hitachi Ltd Research Grant, Bayer AG Research Consultant, DAIICHI SANKYO Group Research Grant, Eisai Co, Ltd, Takuji Yamagami MD : Nothing to Disclose Recently, a mixture of n-butyl cyanoacrylate, Lipiodol and ethanol at ration of 1:1:3 (NLE 113) as new embolization material was introduced. The character of this embolization material is changed because n-butyl cyanoacrylate (NBCA) polymerization can be accelerated by addition of ethanol to NBCA and Lipiodol. Controllability of embolization for AVMs remains controversial. We evaluated usability of NLE in vitro model for AVMs. An original simulation circuit component including an artificial nidus was constructed to generate pulsatile flow (Figure 1). This system was filled with heparinized swine blood. NBCA and Lipiodol mixtures at ratios of 1:1, 1:3, 1:5 and 1:10, and NLE 113 with flow control or without flow control was injected to achieve complete embolization. Results of embolization were classified as complete filled, proximal embolization, pass through or sift to distal after balloon deflation, and each session was compared (Figure 2). NLE 113 with flow control was complete filled in 6/6 cases (Figure 3). NBCA and Lipiodol mixture at ration of 1:1 with flow control was complete filled in 3/6 cases. NBCA and Lipiodol mixture at ration of 1:5 without flow control was complete filled in 3/6 cases. Other sessions did not achieve complete filled embolization. Optimal embolization control of the AVM model was best using NLE 113 with flow control. In liquid embolic materials have difficult controllability, NLE 113 have excellent controllability under flow control. NLE 113 can be acceptable as embolic material for arteriovenous malformation. VSIR21-03 Embolization Treatment for Intractable Bladder Bleeeding-Clinical Efficacy and Safety Maria Tsitskari MD (Presenter): Nothing to Disclose, Lazaros Reppas BS : Nothing to Disclose, Dimitrios Filippiadis MD, PhD : Nothing to Disclose, Kostantinos Palialexis : Nothing to Disclose, Chrisostomos Kostantos : Nothing to Disclose, Elias Brountzos MD : Nothing to Disclose We evaluated the outcomes of embolization treatment for intractable bladder bleeding after failed conservative treatment. We retrospectively studied the records of 1 woman and 10 men with a mean age of 76 years referred between February 2008 and March 2014 for bladder embolization after failed conventional therapy. The underlying pathologies included bladder cancer in 9 patients, prostate cancer in 1 and metastatic osteosarcoma of the

85 urinary bladder in 1 case. Embolization was feasible in 10 out 11 patients. It consisted of superselective embolizaion of the superior or inferior vesical arteries with particles or glue in 10 patients, and selective proximal gelfoam sponge particle occlusion of the anterior division of the internal iliac artery in 1 patient. Clinical bleeding control and post-embolization angiography findings were used to assess outcomes. The technical success rate was 90% (10 of 11 cases). In the one patient embolization was not possible, due to severe tortuosity of the iliac arteries. Bleeding was controlled after the first procedure in 8 patients, and after a repeat procedure in 2. Non target embolization of the buttocks ant the anterior abdominal wall was encountered in 1 patient. Late bleeding recurrence was reported in 2 of the 10 survivors. Mean post-embolization follow up was 30 months. During follow up 4 patients died, due to underlying conditions. Selective vesical artery embolization is effective for the control of refractory, life threatening bladder bleeding Selective angiographic embolization is safe and effective to control refractory, life threatening bladder bleeding. This procedure should be considered the treatment of choice since it usually obviates the need for emergency surgery in these severely ill patients VSIR21-04 Endovascular Treatment for Aldosterone Producing Adrenal Adenoma: A Long Term Follow-up Study Yasutaka Baba MD (Presenter): Nothing to Disclose, Sadao Hayashi MD : Nothing to Disclose, Kohei Nagasato : Nothing to Disclose, Takashi Yoshiura MD, PhD : Nothing to Disclose To investigate the efficacy of endovascular treatment for aldosterone producing adrenal adenoma (APAA) including the long term results. We retrospectively analyzed treatment results of 42 APAAs in 42 consecutive patients (12 male and 30 females; mean age, 47 years) that were treated by endovascular treatment (arterial or venous embolization) with absolute ethanol (AE) between August 1992 and June adenomas were located in the right adrenal gland while 17 were in the left. The mean size of the adenomas was 14mm (range, 8-30 mm) in diameter. Before embolization, we mapped all feeding arteries of the adenoma. Then we determine the volume of AE to use for embolization by adrenal arteriograms or CT images. Prophylactic microcoil embolization of distal feeding arteries was performed in order to avoid unintentional AE injection. In venous embolization, a balloon catheter was used to avoid the reflux of AE. In order to prevent pain and vascular spasm during arterial embolization, we injected lidocaine into the feeding arteries. In addition, we used anti-alpha blocker and calcium blocker to prevent hypertension and hypercatecholaminemia. We evaluated the technical success rate which was defined as normal range of both serum aldosterone concentration and renin activity within 1 month after treatment and acute complications. Moreover, we evaluated rates of improvement in hypertension and normalization of serum aldosterone concentration and renin activity in the follow-up period. The mean follow-up period was 1309 days. The number of treatment session was 56 and average dosage of AE was 1.8 ml. (range, ml). Technical success rate was 88% (37/42) and five patients were subsequently treated by operation. Acute complication comprised of pain (64%), unstable blood pressure (23%) and pleural effusion (11%) without major complications. Rates of improvement in hypertension, normalization of serum aldosterone concentration and renin activity in the follow-up period were 72% (27/37), 97% (36/37), and 97% (36/37), respectively. Endovascular treatment is less invasive and efficient therapeutic option for APAAs. Endovascular embolization of APAA is a promising treatment option. VSIR21-05 Embolotherapy My Best Tips and Tricks Robert Anthony Morgan MD (Presenter): Consultant, Cook Group Incorporated Consultant, AngioDynamics, Inc Proctor, Covidien AG View learning objectives under main course title. VSIR21-06 Embolization Disasters The 5 Worst Cases I've Ever Seen

86 VSIR21-06 Michael David Darcy MD (Presenter): Advisory Board Member, AngioDynamics, Inc Speakers Bureau, W. L. Gore & Associates, Inc Speakers Bureau, Argon Medical Devices, Inc Consultant, Boston Scientific Corporation 1) Learn of some potential complications that can occur with interventional procedures. 2) Be aware of how to recognize these complications. 3) Understand strategies for managing complications. ABSTRACT 5 major complications for various vascular and non-vascular cases will be presented to highlight the range of major disasters that an interventional radiologist might encounter. Discussion will cover potential causes, recognition, management of, and future prevention of similar complications, VSIR21-07 Low Flow Malformations How I Treat Them William S. Rilling MD (Presenter): Research support, BTG International Ltd Research support, Sirtex Medical Ltd Research Support, B. Braun Melsungen AG Advisory Board, Angiodynamics, Inc Consultant, Cook Group Incorporated Consultant, B. Braun Melsungen AG Consultat, Guerbet SA Consultat, Vascular Solutions, Inc View learning objectives under main course title. VSIR21-08 Embolization of Intraosseous AVM Wayne Francis Yakes MD (Presenter): Nothing to Disclose AVM of bone is a difficult management problem. Because standard embolic agents are rarely curative and only palliative, ethanol and ethanol with coils are evaluated to curatively treat bone AVMs as an alternative management strategy. Twenty-nine patients (17 f, 12 m); age range 6-48 years, mean: 19 years) presented with bone AVMs involving the upper extremity, lower extremity, pelvis, spine, and head and neck areas. All patients underwent MR, arteriography, and endovascular repair of their bone AVMs. Ethanol alone, ethanol with coils, and coils were the sole embolic agents utilized. Twenty-eight of twenty-nine patients are cured of their intraosseous AVM at follow-up (range 8 months months; mean: 54 months). One patient's therapy is on-going (mandible/maxilla/face AVMs). Complications include one coil migration to the lung (retrieved without sequelae), three patients with skin injury in the lower extremity (healed uneventfully), and one patient with chronic weakness left quadriceps femoris muscle group, which was present prior to treatment and not improved with treatment of her pelvic/iliac wing AVM. One patient had a right maxilla infection/sinusitis treated by antibiotics. Bone AVMs in the literature are rarely cured, save by amputation. Ethanol or ethanol with coils has proven to be consistent in ablating bone AVMs and are durable at long-term follow-up, in essence curing the AVM. When bone AVM is present in an extremity, multiple AVMs in that extremity can occur, an unexpected finding. Acceptable low complication rates are noted in this series. AVM of bone is a difficult management problem. Because standard embolic agents (glue, PVA, Onyx, Embospheres, etc.) are rarely curative and only palliative, ethanol and ethanol with coils are evaluated to curatively treat bone AVMs as an alternative management strategy. VSIR21-09 Acquired Non Traumatic Peripheral Arteriovenous Fistula Wayne Francis Yakes MD (Presenter): Nothing to Disclose To determine the etiology of acquired non-traumatic arteriovenous vascular fistula (AVF), evaluate their venous physiology and determine management strategies. Non-traumatic acquired AVF of the peripheral vascular system and its management has not been described or published in the world's literature. Ten patients (2 males, 8 female; age range yrs; mean age: 66 years) presented with acquired peripheral arteriovenous fistualization of veins causing swelling and venous hypertensive changes in the lower extremities and left upper extremity. All presented with enlargement and swelling of their left lower extremity. Additionally, one patient had enlargement of her left buttock; one patient had bilateral lower extremity severe swelling with venous stasis changes in the legs, one patient had gross edema of the left upper extremity, two patients had non-healing venous stasis ulcers complicated with cellulitis; and one patient had a left femoral

87 fracture that was surgically treated previously and due to a spine injury, was paraplegic. All patients had great difficulty with ambulating. No patient had a history of blunt or penetrating trauma. All patients underwent ultrasound, arteriography and lower extremity venography in their work-up. All patients were discovered to have acquired (non-congenital) extensive AVF in the pelvic, groin, leg, thigh and left shoulder; four patients had major venous chronic occlusions. After treating their AVF endovascularly, all patients had resolution of their swelling despite the venous occlusions. The non-healing ulcers totally healed. This lesion is not described in the world's literature. The only similar lesion reported in the world's literature is dural AVF of the saggital/ transvers/sigmoid/cavernous sinuses. This is the first report of this entity occurring in the periphery and successful management strategies. Cure of these difficult lesions is possible with endovascular approaches utilizing coils and by eliminating the fistulas and the venous hypertension; stenting of the disease vein segments also proved successful in eliminating the numerous AVF in the vein wall. VSIR21-10 Treatment of Peripheral Vascular Malformation (PVM): A New Concept of Low Pressure Sclerotherapy (LPS) Khawla Boughanmi (Presenter): Nothing to Disclose, Khalil Riadh Hamza MD : Nothing to Disclose Intra lesion injection of sclerosant agent and peripheral compression of venous out flow are responsible of elevation of intra lesion's pressure that can induce peripheral diffusion of the sclerosis agent. We developed the concept of (LPS) by placing multiple needles in the (PVM).These needles work as multiple valves that allow the free circulation of the sclerosant agent and the outflow of the extra injected fluid.this technique is used for the treatment of low flow vascular malformations and peripheral AVM (nidus and venous side) In a period of76months (September 2006-december 2013),170 patients were treated with this concept:122 patients with venous malformations (VM), 28 patients with lymphatic malformation(lm) including 26 patients with macro cystic LM and two patients with micro cystic LM and 20 patients with superficial (AVM).3% tetradecyl sulphate foam, and since three years, lauromacrogol 400 have been used in all cases of VM(20-60 ml)and in two case of micro cystic LM. Absolute ethanol (AE) was used in 88 patients:in 44VM complementary to foam, in 24 LM and in 20 cases of peripheral AVM. Glue (isobutyl 2 cyanoacrylate) was used in4 cases of AVM complementary to AE or before using AE.Up to7 sessions were performed per patient Technical success was reached in all cases. Loss of volume at MRI ranged from 25% to 80% except for two patients who presented with large size VM.All patients were cosmetically improved and relieved of pain. Swelling of the lesion occurred in all treated cases and it was well tolerated and controlled with NSAIDs with resolution in few days(4-7days). Significant complications occurred in 3 patients and consisted of phlyctena, fistula and necrosis.they were managed conservatively LPS concept using 3% STS foam,lauromacrogol and AE in our experience over more than six years has proven the technique to be effective with dramatic decreasing of complications.ae is used to treat macro cystic LM, superficial AVM and complementary to STS foam in some VM with extreme care concerning the volume injected Placing multiple needles in peripheral Vascular malformation allow free circulation of the sclerosing agent these needles work as multiple valves that allow an exit of the sclerosing agent.the technique is effective with dramatic decreasing of complication.actually we used this approach to treat VM, cystic LM and superficial AVM VSIR21-11 Predictive Quantification of Infarction Volume before Partial Splenic Embolization for Hypersplenism Toshihiro Tanaka MD (Presenter): Nothing to Disclose, Tetsuya Masada : Nothing to Disclose, Hideyuki Nishiofuku : Nothing to Disclose, Takeshi Sato : Nothing to Disclose, Shinsaku Maeda : Nothing to Disclose, Kimihiko Kichikawa MD : Nothing to Disclose, Hiroshi Anai MD, PhD : Nothing to Disclose, Masayoshi Inoue MD : Nothing to Disclose To obtain the optimal splenic infarction volume is the key to achieve high efficacy and to reduce the risk of complications after partial splenic embolization (PSE). We have developed a new system to predict the infarction splenic volume before PSE using computed volumetric analysis software. The aim of this study is to evaluate the accuracy of this prediction system. The data, from 12 patients with hypersplenism who had received PSE, was retrospectively analyzed.

88 3-dimensional (3-D) arteriography image was reconstructed from the contrast enhanced CT obtained before PSE. Using a 3-D image analysis system (SYNAPSE VINCENT TM ), the volume of the area supplied from each splenic branch was calculated based on the Voronoi Diagram. The estimated infarction volume was defined by the total sum of the volume supplied from each embolized branch. The actual infarction volume was calculated on the contrast enhanced CT obtained 1 week after PSE. Pearson Correlation Coefficients was used to assess the correlation between the estimated infarction volume and the actual infarction volume. The mean estimated and actual infarction volumes were 65.4±14.6% and 60.9±10.2%, respectively. The mean difference between them was 7.29±6.93%. The actual infarction volume was strongly correlated with the estimated infarction volume (ρ= 0.791, P=0.002). There were no complications in any of the patients. The mean platelet count significantly increased from /µL before PSE to /µL two weeks after PSE (the increased ratio: 259±93.9%). Our results demonstrated that infarction splenic volume can be precisely predicted before PSE using computed volumetric analysis software. This new system could be helpful for tailoring planning of PSE to achieve optimal splenic infarction volume in patients with hypersplenism. Predictive quantification of splenic infarction volume using the Voronoi Diagram method is accurate, which could be useful for planning before PSE. VSIR21-12 Technical Aspects of Prostate Embolization Why this is not UFE Jafar Golzarian MD (Presenter): Nothing to Disclose View learning objectives under main course title. VSIR Papers in 15 Minutes: Studies in Embolotherapy that Everyone Should Know Sue Ellen Hanks MD (Presenter): Nothing to Disclose 1) Describe indications and technical aspects of embolization for symptomatic prostatic hypertrophy. 2) Explain the rationale and treatment of low flow malformations. 3) Describe the preparation of cyanoacrylates for embolization. 4) Describe two complications related to embolization. 5) List two important studies on embolotherapy. SPCP21 Korea Presents: Exploring Evidence in Cardiovascular Imaging Special Courses IR CT VA AMA PRA Category 1 Credits : 1.50 ARRT Category A+ Credits: 1.50 Mon, Dec 1 10:30 AM - 12:00 PM Location: E353C Moderator Tae-Hwan Lim MD, PhD : Nothing to Disclose Moderator Arthur E. Stillman MD, PhD : Nothing to Disclose This session is part of Korea Presents at RSNA Sub-Events SPCP21A Opening Remarks RSNA President N. Reed Dunnick MD Nothing to Disclose, Tae-Hwan Lim MD, PhD Nothing to Disclose, Jongmin John Lee MD, PhD Nothing to Disclose

89 Korea and Korean Society of Radiology (KSR) This session is part of Korea Presents at RSNA ABSTRACT Korea and Korean Society of Radiology (KSR) Following dinosaurs, Homo erectus, and Homo sapiens, ;our ancestors have inhabited in and around Korean peninsula. In a history of many dynasties for 5000 years, Republic of Korea was established in 1947 AD. In 2013, the population was counted as 51,098,531 (26th / 225 countries) within 100,210 km2(111th / 208 countries). The number of medical doctor per 100,000 population has been increasing continuously up to 214 in Among medical doctors, 3,465 board-certified radiologists are registered in KSR was founded in Korean congress of radiology (KCR) has continued every year till now. From 2010, KCR was organized as an international congress with the official language of English. This year, over 75% of sessions were conducted in English. Topics for only Korean doctors and some basic educational sessions were in Korean. Additional on the regular members (76.0%), 604 resident members (13.3%) and 478 international members (10.5%) are registered in KSR (4,547 in total). During the KCR, about 10% of registrants are usually from abroad. As a diligent radiology society in Asia-Oceania region, KSR conducts diverse international activities including visiting symposium, KSR fellowship, invited speaker exchange, awarded poster exchange, joint symposium, national delegate exchange, journal collaboration, booth exchange, and visiting professorship. So far, international collaboration has been established between KSR and 20 countries or societies world-wide. The globalization of KSR is on the purpose of giving more opportunities for KSR members to improve themselves through international communication. Also KSR aims for ;a synergic evolution together with our partner societies. As a world leading radiology society, RSNA has been a source of motivation and is a chance of globalization for KSR and its members. URL SPCP21B What are Risk Factors for Stroke? Imaging Assessment of Cardiovascular Risk in Stroke Jin Hur MD (Presenter): Nothing to Disclose 1) Understand the stroke subtype and the risk factors of cardio-embolic stroke. 2) Describe the imaging modalities in the assessment of cardiovascular risk in stroke patients. 3) Describe the advantages and disadvantages of cardiac CT and MRI in the use of assessing cardio-embolic sources in stroke patient. 4) Discuss the prognostic value of cardiac CT for risk stratification in stroke patients. This session is part of Korea Presents at RSNA ABSTRACT Cardiogenic emboli have been estimated to be the causative factor in 20% to 40% of all stroke cases. Therefore, identification of a cardiac source of embolism in stroke patients is important for proper therapeutic management. Currently, transesophageal echocardiography (TEE) is considered the reference standard method for the detection of potential sources of cerebral embolism. TEE offers high resolution images of the left atrium (LA) and its appendage as well as the thoracic aorta for the evaluation of left atrial blood stasis and aortic atherosclerosis. Although TEE is widely available, it is a semi-invasive test, usually performed under conscious sedation. In current clinical practice, there is a need for a less invasive modality that is capable of assessing the cardiovascular system for embolic stroke patients. Cardiac magnetic resonance imaging (MRI) is an appealing modality to evaluate a suspected embolic stroke patient. Cardiac MRI can adequately image potential embolic sources such as LV thrombi, cardiac masses, aortic plaques or LAA thrombi. Recently introduced multidetector computed tomography (MDCT) with subsecond rotation times and a dedicated cardiac reconstruction algorithm can acquire 3-dimensional data of the heart, enabling detailed visualization of not only the coronary arteries but also other cardiac structures such as the left atrial appendage (LAA), myocardium, valves, and septa.; Therefore, MDCT can play a significant role as a noninvasive procedure in the detection of the cardioembolic origin of stroke. Radiologists should be familiar with their imaging features as identification has significant management and prognostic implications. SPCP21C Is Screening of Coronary Heart Disease with Coronary CT Angiography Necessary? Coronary CT Angiography in Asymptomatic Patients Sang Il Choi MD (Presenter): Nothing to Disclose 1) To review the use of various multimodality imaging techniques for assessing subclinical coronary artery disease. 2) To demonstrate the current multimodality appropriate use criteria for detection and risk stratification of coronary artery disease in asymptomatic subjects. 3) To recognize the potential role and limitations of coronary CT angiography as screening tool in asymptomatic subjects. This session is part of Korea Presents at RSNA SPCP21D Is CT Stress Perfusion Comparable to FFR in Assessing Ischemic Heart Disease? Multicenter Trial PERFUSE Byoung Wook Choi MD (Presenter): Nothing to Disclose

90 1) Understand the clinical role and indication of myocardial perfusion with computed tomography. 2) Acess the study design and rationale to compare myocardial perfusion with computed tomography with FFR regarding to clinical utility. 3) Able to set up a proper protocol of computed tomography for myocardial perfusion in clinical practice. 4) Assess the technical advances and consideration of computed tomography in myocardial perfusion. This session is part of Korea Presents at RSNA ABSTRACT The FAME trial demonstrated the superiority of FFR (fractional flow reserve)-guided revascularization strategy over angiography-guided treatment. The functional significance of coronary artery stenosis is now considered as the standard reference for revascularization. Non-invasive imaging for myocardial ischemia can be used for identifying functionally significant stenosis as well. Evaluation of myocardial ischemia by using CT has been reported as a new alternative non-invasive method. According to a recent study, as compared to FFR and invasive angiography, the combination of CT angiography (CTA) and CT perfusion (CTP) was highly accurate in detection and exclusion of myocardial ischemia. The PERFUSE (Stress Coronary PErfusion Versus FRactional Flow Reserve GUided PercutaneouS Coronary IntErvention) trial is a multicenter, randomized, controlled, noninferiority trial in the comparison of CTP- and FFR-guided percutaneous coronary intervention (PCI). The objective of this trial is to compare outcomes of composite of any of all cause mortality, myocardial infarction, and unplanned hospitalization with revascularization at 1 year after CTP-guided PCI to FFR-guided PCI in angina patients with coronary artery disease. The inclusion criteria is patients who referred for CTA because of angina or angina equivalent symptom and having more than 70% diameter stenosis at least one major epicardial coronary artery on CTA. A total 1000 patient will be enrolled (500 per each arm) and randomized to either FFR guided or CTP-guided groups. Twenty centers in Korea are participating in the study. SPCP21E Closing Remarks Byung Ihn Choi MD, PhD (Presenter): Research Consultant, Samsung Electronics Co Ltd, James P. Borgstede MD (Presenter): Nothing to Disclose This session is part of Korea Presents at RSNA ABSTRACT First of all, I'd like to thank members of Board of Directors of RSNA including Dr. Dunnick (President), and Dr. Baron (Chairman) and Dr. Borgstede (Liaison for international affairs) for inviting Korea to RSNA which is the most prestigious organization in the field of Radiology in the year of meaningful centennial anniversary of RSNA. During the last 30 years, I have attended RSNA more than 20 times since 1985 when I was a visiting fellow of UC San Francisco. Since then, advance of RSNA has been amazing in every aspect of the meeting not only in quality but also in quantity, about 60,000 attendants for the meeting and more than 50,000 members from all over the world. RSNA really became a global congress of Radiology. Therefore, KSR is now trying to follow this unbelievable progress of RSNA as a role model of KCR. Personally, I love RSNA because RSNA is an ideal place for me to learn recent updated knowledge and cutting edge information of radiology, and to meet old and new friends. Also, I can enjoy rich cultural environment in Chicago including music, fine art and natural resources. As an honorary member of RSNA and a past president of KSR, I'll try to do my best to enhance a mutual friendship and collaboration between RSNA and KSR. Finally, I'd like to congratulate the celebration of 100th scientific assembly and annual meeting of RSNA and wish RSNA a glorious future. SSC14 Vascular/Interventional (IR: Hepatic Tumor Embolization) Scientific Papers IR VA GI AMA PRA Category 1 Credits : 1.50 ARRT Category A+ Credits: 1.50 Mon, Dec 1 10:30 AM - 12:00 PM Location: E351 Moderator Nael El Said Saad MBBCh : Research Consultant, Veran Medical Technologies, Inc Proctor, Sirtex Medical Ltd Moderator Hyun Sik Kim MD : Nothing to Disclose Sub-Events SSC14-01 A Mechanism of Transcatheter Arterial Embolization-mediated Improvement of Drug Penetration in Liver Cancer Bin Liang (Presenter): Nothing to Disclose, Gan-Sheng Feng MD : Nothing to Disclose, Chuansheng Zheng : Nothing to Disclose Transcatheter intraarterial techniques can improve drug penetration in liver cancer and thus enhance the

91 efficacy of chemotherapy, but its mechanism remains unclear. Intratumoral interstitial fluid pressure (IFP) has been found to be an important determinant of drug penetration in solid tumors. The present study is designed to determine whether transcatheter arterial embolization modifies IFP, and to evaluate whether the modified IFP is related to the improvement of drug penetration in liver cancer. VX2 tumors were implanted in the livers of 16 rabbits. The animals were divided into 4 groups of 4 animals each. Group 1 (doxo iv) animals received doxorubicin intravenous injection; group 2 (doxo ia) animals received doxorubicin hepatic intraarterial infusion; group 3 (doxo ia + E) received doxorubicin hepatic intraarterial infusion followed by embolization; group 4 (doxo + L ia + E) received hepatic intraarterial infusion of doxorubicin mixed with lipiodol followed by the embolization. After transcatheter treatment, wick-in-needle technique (Mikro-Tip pressure catheter) was used to measure IFP in tumor tissues, and immunofluorescence technique to evaluate the distance of doxorubicin fluorescence from the nearest blood vessel (recognized by CD31). Tumors in the group 3 (doxo ia + E) and 4 (doxo + L ia + E) showed a significant decrease in IFP compared with the group 1 (doxo iv) and 2 (doxo ia) tumors (P < 0.05) within 1 hour after treatment. Embolization led to a decrease of IFP by 27.11% in group 3 and 31.81% in group 4 tumors, respectively. The change in IFP was significantly correlated with doxorubicin penetration distance (r = 0.671, P = 0.004). Transcatheter arterial embolization reduce tumor IFP, which probably is responsible for the improvement of drug penetration in liver cancer. Our results reveal a novel mechanism of transcatheter arterial embolization-mediated improvement of drug penetration in liver cancer. The decrease in tumor IFP, generated by embolization, contributes to drug penetration in liver cancer. Thus, decreasing tumor IFP could represent a promising therapeutic strategy for improving the effectiveness rates of transcatheter therapies for liver cancer. SSC14-02 Comparison of Drug Release between Conventional Chemoembolization and Drug Eluting Beads Chemoembolization Jae Hwan Lee MD (Presenter): Nothing to Disclose, Kyu Ri Son MD : Nothing to Disclose, Hyo-Cheol Kim MD : Nothing to Disclose The purpose of this study was to compare the in vitro drug release characteristics of DC bead and various kinds of Lipiodol emulsion, and to compare the tumor response in animal liver tumor model. We prepared 4 types of Lipiodol emulsion: A) 10mg of DOX in 0.5 ml of contrast media mixed with 2 ml of Lipiodol, B) 10 mg of DOX in 1.25 ml of contrast media mixed with 1.25 ml of Lipiodol, C) 10 mg of DOX in 0.5 ml of normal saline (NS) mixed with 2 ml of Lipiodol, D) 10 mg of DOX in 1.25 ml of NS mixed with 1.25 ml of Lipiodol. DC bead of µm in diameter were loaded with DOX (37.5 mg/ml) according to the manufacturer's instruction. Drug release from emulsions or DC bead was evaluated in in vitro model. Three weeks after implantation of VX2 carcinomas in the liver, TACE was performed using A) 4:1 volume ratio of Lipiodol and DOX solution, B) 1:1 volume ratio of Lipiodol and DOX solution, C) DC bead. The released amounts (%) of DOX at 24 h are as follows: ±0.20% for DC bead, ±1.51% for Lipiodol:DOX in NS = 4:1, ±2.14% for Lipiodol:DOX in Pamiray = 4:1, ±1.45% for Lipiodol:DOX in NS = 1:1, and ±2.31% for Lipiodol:DOX in Pamiray = 1:1. AUC value of group A was significantly lower than that of group B (p < 0.05), but there is no significant difference compared to that of group C. AUC value of group B was 3.43-fold higher than that of group C (p < 0.05). Cmax value of group A exhibited significant difference compared to those values of group B and C (p < 0.05). Particularly, Cmax value of group B was fold higher than that of group C (p < 0.05). stable Lipiodol emulsion can be created by excessive Lipiodol mixed with DOX dissolved in contrast media. DOX release from Lipiodol emulsion depends on volume ratio of Lipiodol and DOX solution. DC bead has more sustained DOX release than Lipiodol emulsion. (Dealing with making effective chemoembolic mixture in TACE) DOX -contrast media mixture with excessive lipiodol forms more stable emulsion, and DC bead has more sustained DOX releasing capacity than Lipiodol emulsion. These knowledge may be useful in acheving effective drug delivery to HCC in TACE. SSC14-03 Conventional Transarterial Chemoembolization versus Drug Eluting Bead-Transarterial Chemoembolization for the Treatment of Hepatocellular Carcinoma

92 Roman Kloeckner MD (Presenter): Nothing to Disclose, Friederike Prinz : Nothing to Disclose, Christian Ruckes : Nothing to Disclose, Arndt Weinmann : Nothing to Disclose, Christoph Dueber MD : Nothing to Disclose, Michael Bernhard Pitton MD : Nothing to Disclose To compare the overall survival (OS) of patients suffering from hepatocellular carcinoma (HCC) treated with lipiodol - based conventional transarterial chemoembolization (ctace) and drug eluting bead-transarterial chemoembolization (DEB-TACE). An electronic search of our radiology information system revealed a total of 674 patients receiving TACE between 11/2002 and 07/ received ctace, and 154 received DEB-TACE. In total, 424 patients were excluded due to a tumor entity different from HCC (n=91), liver transplantation following TACE (n=119), lack of histological grading (n=58), incomplete laboratory values (n=15) and other reasons (e.g. previous systemic chemotherapy, previous cisplatin-based TACE) (n=141). Therefore, 250 patients were included for comparative analysis (174 ctace; 76 DEB-TACE). Both groups were not significantly different in terms of sex, etiology of liver cirrhosis, overall status (BCLC), liver function (Child-Pugh), portal invasion, tumor load, and tumor grading (all p>0.05). Mean number of treatment sessions was 4±3.1 in the ctace group versus 2.9±1.8 in the DEB-TACE group. The median survival in the ctace group was 409 days (95% CI: days) compared to 369 days (95% CI: days) in the DEB-TACE group (p=0.76). In the subgroup of Child A patients, the median OS was 602 days ( days) for ctace versus 627 days ( days) for DEB-TACE (p=0.39). In Child B and Child C patients the OS was considerably lower with 223 days ( days) versus 226 days ( days) (p=0.53). The present study showed no significant difference in OS between ctace and DEB-TACE in a large and well-selected cohort of HCC-patients. Currently, there is no firm evidence to prefer DEB-TACE to ctace. Further prospective randomized trials with a hard endpoint are needed. SSC14-04 Chemoembolization with Dc Beads Preloaded with Irinotecan (DEBIRI) vs. Doxorubicin (DEBDOX) as a Second Line Treatment for Liver Metastases from Cholangiocarcinoma: Technical Aspects, Complications, and Efficacy Giulia Agostini (Presenter): Nothing to Disclose, Massimo Venturini MD : Nothing to Disclose, Stefano Cappio MD : Nothing to Disclose, Giulia Cammi : Nothing to Disclose, Francesco Aldo De Cobelli MD : Nothing to Disclose, Alessandro Del Maschio MD : Nothing to Disclose TACE with drug-eluting beads is routinely performed using Doxorubicin and Irinotecan in the treatment of HCC and hepatic metastases from colorectal cancer, respectively. Conversely, there is no specific drug indication in the treatment of other hypervascular liver metastases. Aim of our study was to compare the efficacy of DEBIRI vs. DEBDOX in the treatment of unresectable hepatic metastases from cholangiocarcinoma. In 2013, 10 patients affected by multiple cholangiocarcinoma hepatic metastases, resistant to the first line CT regimen, were enrolled: 5 were submitted to lobar/segmental TACE with DEBIRI (100mg Irinotecan/1vial) and 5 with DEBDOX (50mg Doxorubicina/1vial), performed every 3 weeks. Patients treated with DEBIRI received ant-pain pre-medication consisting of a 30 mg of morphine and 3-4 ml of intra-arterial lidocaine. All the procedures were performed with a trans-femoral approach using a microcatheter. Complications and efficacy of the two different types of treatment were assessed with contrast-enhanced MDCT (RECIST and mrecist criteria) performed at baseline and 72 hours after each procedure. A total of 32 TACE were performed (mean: 3,2 TACE/patient). All the treatments were well tolerated, with one only case of asymptomatic cholecystitis spontaneously recovered. Response rates assessed at the end of the treatment cycle of patients treated with DEBDOX were 5/5 PD while the ones of the patients treated with DEBIRI were 2/5 PR, 2/5 SD and 1/5 PD, with the appearance of a variable necrosis percentage. Anti-pain drug administration in patients treated with DEBIRI and the use of the microcatheter lead to a good treatment tolerability and a low complication rate. In our experience, DEBIRI was more effective than DEBDOX as a second line treatment of hepatic metastases from cholangiocarcinoma, an extremely aggressive malignancy.

93 In our experience, DEBIRI was more effective than DEBDOX as a second line treatment of hepatic metastases from cholangiocarcinoma. SSC14-05 The Effect of Age on Survival Outcomes in Unresectable Hepatocellular Carcinoma Treated with DEB-TACE: Surveillance, Epidemiology and End Results (SEER) Database vs. Tertiary Cancer Center Minzhi Xing MD (Presenter): Nothing to Disclose, Nima Kokabi MD : Nothing to Disclose, Hyun Sik Kim MD : Nothing to Disclose To evaluate the effects of age on survival outcomes in patients with advanced unresectable hepatocellular carcinoma (HCC) treated with Drug-Eluting Bead Chemoembolization (DEB-TACE) or best supportive care in a large-scale population study. Under IRB approval, our institute's cancer registry was queried for patients with advanced unresectable HCC diagnosed from Sept 2005 to Dec 2010, treated with DEB-TACE. Eighteen registries of the U.S. Surveillance, Epidemiology and End Results (SEER) database were queried for patients with advanced HCC not amenable to surgery/radiation diagnosed in the same time period. Baseline characteristics, median overall survival (OS) from HCC diagnosis and median OS from first DEB-TACE were stratified by age at HCC diagnosis. Survival analysis and 95% confidence intervals (CI) were calculated using Kaplan-Meier estimation. A total of 20,897 SEER patients with unresectable HCC who received neither radiation nor cancer-directed surgery and 231 patients who received DEB-TACE for advanced unresectable HCC were included. Of these, SEER patients and 155 DEB-TACE patients were <65 years of age at HCC diagnosis, compared with 9248 SEER and 76 DEB-TACE patients who were 65 years at diagnosis. All groups were similar for gender, race, bilobar disease, portal vein thrombosis, and mean largest tumor size (p>0.05). Median OS in patients <65 years was similar to patients 65 years at HCC diagnosis (4.1 vs. 4.0 months, p>0.05). Significant differences in median OS from HCC diagnosis between groups were observed in patients <65 years at diagnosis (SEER vs. DEB-TACE, 4.0 vs months, p<0.0001) and 65 years at diagnosis (SEER vs. DEB-TACE, 4.0 vs months, p<0.0001). In a population-based study, DEB-TACE therapy in patients with advanced, unresectable HCC demonstrated significantly greater median OS compared to best supportive care regardless of age at diagnosis. Regardless of age at HCC diagnosis, DEB-TACE therapy in patients with advanced, unresectable HCC demonstrates significant survival benefit vs. best supportive care. SSC14-06 Degradable Starch Microspheres Transarterial Chemoembolisation (DSM-TACE) of Multifocal HCC: Diffusion-weighted Magnetic Resonance Imaging (DWI) Evaluation of Therapeutic Efficacy Compared with Contrast Enhanced CT Fabrizio Chegai MD (Presenter): Nothing to Disclose, Antonio Orlacchio MD : Nothing to Disclose, Marco Nezzo MD : Nothing to Disclose, Costantino Del Giudice MD : Nothing to Disclose, Giovanni Simonetti MD : Nothing to Disclose, Daniele Morosetti MD : Nothing to Disclose To investigate usefulness of diffusion-weighted magnetic resonance imaging (DWI) for early detection of the response after transcatheter arterial chemoembolization using degradable starch microsphere (DSM)-TACE for hepatocellular carcinoma (HCC) compared with contrast enhanced computed tomography (CECT) using the modified RECIST (mrecist). Thirty patients with inoperable multifocal HCC underwent to DSM TACE. DSM TACE was performed every 4 to 6 weeks with a mixture of DSMs and Doxorubicin at a dose of 50 mg/m2 for three time. Magnetic resonance imaging (MRI) including breathhold echoplanar DWI sequences was performed prior to therapy (baseline MRI), 15 days after every DSM TACE (early MRI) as well as after 3 months (follow-up MRI). Intratumoral apparent diffusion coefficient (ADC) were measured independently by two radiologists. Relative change in ADC values (%ADC), α-fetoprotein level and tumor response on follow-up with contrast CECT after 3 months were determined. HCC lesions were divided into two groups, responder and non-responder. The correlation between %ADC and mrecist results was determined, and %ADC was compared between the two groups. Statistical analysis was performed using univariate comparison, and paired t test as well as Pearson's correlation. Median progression-free survival (PFS) was 8 months, and overall survival was 21 months. Survival analyses showed significant effects of pretreatment α-fetoprotein level (P =.03) and ADC ratio (P <.005) on PFS and substantial effects of mrecist (.05 < P <.1). After DSM TACE, the percent change in ADC (%ADC) from before to after therapy was significantly increased in non-responder lesions (79.2+/-11.4%) compared to responder

94 lesions (7.0+/-49.7%, p=0.001).positive correlations were observed for relative change between %mean ADC and complete or partial response (r = 0.536). Mean ADC were significantly greater in the responder group than in the non-responder group. The ADC ratio 1 month after DSM TACE was an independent predictor of PFS, which showed stronger association with tumor response than mrecist evaluated with CECT. In this study, therapeutic efficacy of DSM-TACE in HCC using DWI MRI analysis could be demonstrated. Diffusion-weighted magnetic resonance imaging (DWI) could be useful for early detection of response in patients with multifocal HCC treated with DSM TACE. SSC14-07 CRP as a Predictor of Response to TACE in HCC Patrick Nicholson MBBCh (Presenter): Nothing to Disclose, Kevin Murphy MBBCh, MRCS : Nothing to Disclose, Karl James MBBCh, MRCS : Nothing to Disclose, Jennifer Murphy MBBCh, MRCPI : Nothing to Disclose, David James Tuite MBBCh : Nothing to Disclose, Owen J. O'Connor MBBCh : Nothing to Disclose, Adrian Paul Brady FFR(RCSI), FRCR : Nothing to Disclose, Peter Mark MacEneaney MBBCh : Nothing to Disclose The prognostic value of C-reactive protein (CRP) in patients with hepatocellular carcinoma (HCC) is well established, but there exists relatively little data in its use in HCC patients undergoing transarterial chemoembolization (TACE). We sought to look at outcomes in our institutions in patients who underwent TACE for HCC. We further sought to evaluate the value of pre-embolization CRP levels in predicting clinical and radiological outcomes following TACE. This multi-center study involved a retrospective review of 34 patients (73±7.9 years, 29 male) who underwent a total of 100 TACE procedures over a six-year period. Pre-procedure CRP values were available in 90% of cases. Other factors evaluated included liver function tests and tumour markers (Bilirubin, Alkaline Phosphatase, transaminases (AST/ALT), gamma glutamyl transpeptidase (GGT), and alpha-fetoprotein). Following TACE, we evaluated both clinical factors (overall survival) and radiological response to TACE (as measured by modified RECIST criteria (mrecist) on follow-up CT at 3 months). SPSS was used to analyze the results via T-Test, Mann-Whitney test, Pearson correlation, Spearman correlation and Kaplan-Meier analysis Follow-up imaging was available in 85% of patients. Median follow-up was 28 months (range 1-76). No association was found between CRP and liver function tests, tumour markers, patient age or other biochemical parameters (r<0.3 for all comparisons). An abnormal pre-procedure CRP was found to be independently and significantly associated with both disease response (on a per procedure basis on follow up imaging, p<0.001) and overall patient survival. A CRP >20mg/l before first TACE treatment carried the worst prognosis (mean survival 9.25 Vs months, p=0.007). Serum CRP measurement can be used to predict response to TACE in patients with HCC. CRP is a cheap and widely-available test which can be used as a pre-procedural predictor of response to TACE in patients which HCC. It can be used to help risk-stratify those patients who would benefit from TACE. SSC14-08 Trans-Arterial EThanol Embolisation (TAETE) vs Conventional Chemoembolisation (ctace) in the Treatment of BCLC Intermediate Stage HCC Francesco Somma MD (Presenter): Nothing to Disclose, Roberto D'Angelo MD : Nothing to Disclose, Gianluca Gatta : Nothing to Disclose, Roberto Grassi : Nothing to Disclose, Francesco Fiore MD : Nothing to Disclose Hepatocellular carcinoma (HCC) is nowadays the third leading cause of cancer deaths worldwide. A variety of treatment modalities have been reported including resection, chemoembolisation, external irradiation, radiofrequency or percutaneous ethanol ablation. Our aim is to retrospectively evaluate the efficacy and safety of transarterial embolisation of intermediate HCC, using a mixture 1:1 of Ethanol and Lipiodol, that we named Trans-Arterial EThanol Embolisation (TAETE), compared with conventional Trans-Arterial Chemo-Embolisation (ctace) 87 patients (37.93% male; 62.07% female; range of age years) with documented hepatic lesions of 1.4 to 5.4 cm in size were elected to TAETE (Ethanol and Lipiodol, 1:1) or ctace (Epirubicin and Lipiodol), through a super-selective catheterization with direct injection in the tumor-feeding arteries. Both procedures were followed by the intrarterial administration of embolizing agents (70-150µ).

95 TAETE and ctace therapies were performed in 45 and 42 patients, respectively. Thirty days after the procedure, a Multislice Computed Tomography (MSCT) showed in all patients at least partial response according to RECIST1.1 and EASL criteria, while in 51/87 (58.62%) patients a complete resolution was observed, with no statistically significant difference between the two groups. On the contrary, there was significant difference in the overall incidence of side-effects, such as in the occurrence of post-embolisation syndrome (p<0.001). Compared to ctace, TAETE showed to be more effective in the size-reduction of tumoral mass with similar anti-tumor effects at thirty-day MSCT control and better toxicity profile, which makes it extremely useful in patients with more than one lesion or in case of relapse. Considering the onset of adverse events according to CTCAE version 4.0 (2009), TAETE is less invasive than ctate (p=0.019, chi2-test with Yates-correction), showing no significative difference in the radiological tumor response according to mrecist and EASL (p=0.958, chi2 test). TAETE could be used in elderly HCC patients or in case of multiple treatments SSC Y Loaded Glass Microspheres versus Sorafenib for Hepatocellular Carcinoma with Portal Vein Thrombosis: A Retrospective Study Yan Rolland MD, PhD (Presenter): Consultant, BTG International Ltd, Julien Edeline : Nothing to Disclose, Eveline Boucher : Nothing to Disclose, Etienne Garin MD : Consultant, BTG International Ltd PVT is a main negative prognostic factor for HCC patients. The goal of this study is to analyse retrospectively patients treated with ThereSphere (T) or sorafenib (S) or both TheraSphere plus sorafenib (T+S). 61 consecutive PVT patients were retrospectively included. Patients treated with sorafenib received a standard dose. Patients treated with TheraSphere were treated using a personalized dosimetric approach. Median progression free survival (PFS) and overall survivals (OS) were estimated with the Kaplan-Meier methos and compared with a log-rank test. 18 patients received T only (30%), 29 S only (48%) and 14 received both T+S (23%). Main PVT was present in 38% of the patients treated by T and 52% for those treated by S only (ns). For patients treated with T the mean lobe dose was 146Gy and 13 patients (40%) received an intensification (mean lobe dose = 197Gy). PFS was 7.7 m (IC 95% : ) in the group T vs 3.5 (IC 95% : ) in the group S only (p = 0.026). OS was 23.4 months (IC 95% : ) in the group T vs 5.1 (IC 95% : ) in the group S alone (p<0.001). In the group T, OS was not significantly different if the patients received T alone or both T+S, respectively 24.0months vs 21.5 months (p = 0,96). For patients with a maximum of 3 lesions 0S was still significantly higher for patients treated by T (23.8 months) than for those teated by S only (5.1 months, p<0.001). For patients with unilateral PVT results were still significantly better for T : OS weres 24.0 vs 6.5 months for patients treated respectively with T or S alone (p<0.001). In this retrospective study TheraSphere, using a personalized dosimetric approach and intensification, significantly increases OS of PVT patients versus sorafenib. glass microsphere radioembolization signicficantly increases overal survival for hepatocellular carcinoma with prortal vein thrombosis VIS-MOA Vascular/Interventional Monday Poster Discussions Scientific Posters IR VA AMA PRA Category 1 Credits :.50 Mon, Dec 1 12:15 PM - 12:45 PM Location: VI Community, Learning Center Moderator Gretchen Marie Foltz MD : Nothing to Disclose Sub-Events

96 VIS223 Treatment of Cesarean Scar Pregnancy: Comparison between Dilation and Curettage after Uterine Artery Chemoembolization with Laparotomy Lesion Excision (Station #1) Kang Zhou MD (Presenter): Nothing to Disclose To compare the clinical effect of dilation and curettage after uterine artery chemoembolization (UACE) and laparotomy lesion excision for treatment of cesarean scar pregnancy (CSP) A total of 77 patients with CSP were analyzed. The patients were divided into two groups: Group A included 22 patients who were treated by laparotomy lesion excision; group B included 55 patients who received UACE h before dilation and curettage. The main comparative indicators were operation time, blood loss, time for β-human chorionic gonadotrophin (β-hcg) to decline to normal values, the duration of hospital stay, complications, rate of secondary treatment and menstrual situation after operation. None of the 77 patients received hysterectomy. In group A, 1 patient had to receive UACE due to massive hemorrhage. The rate of secondary treatment was 4.55% (1/22) in group A. In group B, 1 patient received perforation repair, 1 received laparotomy lesion excision due to active bleeding. Theβ-hCG level persisted in 3 patients, 2 of them received MTX injection and 1 received dilation and curettage again. The rate of secondary treatment was 9.09% (5/55) in group B (P >0.05). The operation time in group A was more than that in group B([114.45±34.32]min vs. [35.35±20.21]min, P Dilation and curettage after UACE and laparotomy lesion excision are both safe and effective treatments for CSP. Dilation and curettage after UACE is minimally invasive, with less operation time, less blood loss in operation and less duration of hospital stay. Especially, UACE could provide remarkable clinic effect for the patients with acute vaginal bleeding. Dilation and curettage after UACE is a safe and effective treatment for CSP, with less operation time, less blood loss in operation and less duration of hospital stay than laparotomy lesion excision. VIS224 Interventional Radiology in Uterine Fbroid Treatment: Magnetic Resonance Guided Focus Ultrasound Surgery (MRgFUS) and Uterine Artery Embolization (UAE) Main Differences, Advantages and Therapeutic Response (Station #2) Fabiana Ferrari MD (Presenter): Nothing to Disclose, Anna Miccoli MD : Nothing to Disclose, Francesco Arrigoni : Nothing to Disclose, Eva Fascetti MD : Nothing to Disclose, Antonio Barile MD : Nothing to Disclose, Carlo Masciocchi MD : Nothing to Disclose, Aldo Victor Giordano : Nothing to Disclose, Sergio Carducci : Nothing to Disclose To evaluate the response in the uterine fibroid treatment, using UAE and MRgFUS, comparing these two techniques, in terms of Non Perfused Volume extent and reabsorption, complication, hospitalization time and clinical outcomes. From October 2010 to December 2012, 65 patients affected by symptomatic uterine fibroids were treated in our department. Thirty-eight of them were treated using MRgFUS and 27 with UAE. Treatment was chosen according to patients age and fibroid vascularization and accessibility. We compared patients of the same age, affected by the same number of fibroids, showing similar dimensions and localization. They were controlled three times, after 3, 6 and 12 months, respectively. We evaluated non perfused volume (NPV) extent, reabsorption time, clinical response and hospitalization time. We obtained a NPV mean value of 95%, using UAE and a mean value of 91.5% using MRgFUS. We observed a reduction of the necrotic area of 70% in patients treated with UAE and of 50% in women treated with MRgFUS after 12 months from the treatment. Twenty-five out of 27 patients (92.5%), treated with UAE, presented abdominal pain and bloating, fever and vomiting; they had a mean hospitalization time of 3 days and returned to a normal life in 25 days. Only 2 out of 27 (7.5%) returned to a normal life in 10 days. Patients treated with MRgFUS had no complications, a mean hospitalization time of 1 day, returning to a normal life in 5 days, an earlier bleeding reduction and a progressive cycle regularization. Our study demonstrates that both techniques candidate as a valid alternative to surgery. In our experience, UAE is more radical, it seems to have a shorter reabsorption time but a longer convalescence. MRgFUS is more repeatable, shows less post-treatment symptoms, a good clinical response and should be the first choice when possible. These two techniques are a valid therapeutic solution of interventional radiology in uterine fibroid treatment in terms of symptom resolution and treatment efficiency.

97 VIS225 Peri-Procedural Pain Control Following the Universal Application of Conscious Sedation and Neuraxial Analgesia in Patients Undergoing Uterine Fibroid Embolization (Station #3) Alexandros Pappas MD (Presenter): Nothing to Disclose, Dana Haddad MD, PhD : Nothing to Disclose, Harvinder S. Jagait MD : Nothing to Disclose, Alexander Vinzons MD : Nothing to Disclose, Dimitris Giannaris : Nothing to Disclose, George Trister : Nothing to Disclose, Joseph James Arampulikan MD : Nothing to Disclose Peri-procedural pain control in patients undergoing uterine fibroid embolization (UFE) utilizing conscious sedation and concurrent neuraxial analgesia (CS+NA) has been suggested to be more effective in post-procedural pain control than conscious sedation alone (CS). This study assesses the effectiveness of post-procedural pain control since the implemented the universal application of CS+NA for patients undergoing UFE at our institution. A retrospective study was performed reviewing the self reported pain rating scales (1-10) after UFE during the two year period following the universal application of CS+NA in November Since that time, a total of 19 patients underwent UFE for symptomatic uterine fibroids, 18 of which were included in the study. The mean value was assessed with a two-tailed student t-test comparing post-procedure pain levels to patients having had CS alone during the three year period from November November 2011 (21 patients). We assessed the effectiveness of the CS+NA protocol at 4 and 24 hours post procedure. The mean pain scores at the 24 hour time point was 0.7 for CS+NA and 2.5 for CS. The t-statistic of the difference in percent agreement was significant at the 0.02 critical alpha level, t(37)= , p = (t-value = , Degrees of freedom = 37, Two-tailed probability = ). The mean pain scores at the 4 hour time point was 2.2 for CS+NA and 4.4 for CS. The t-statistic of the difference in percent agreement was significant at the 0.01 critical alpha level, t(37)= , p = (t-value = , Degrees of freedom = 37, Two-tailed probability = ). The results of this retrospective study measuring the effectiveness of the universal application CS+NA at our institution to CS alone show that simultaneous neuroaxial analgesia and conscious sedation at the time of uterine fibroid embolization provides superior analgesia at both 4 and 24 hours post-procedure. This differs from previous data which demonstrated no difference in the pain levels of patients at 4 hours post-procedure. An anticipatory pain management strategy through the periprocedural application of neuraxial analgesia for uterine fibroid embolization may improve inpatient comfort, decrease time to discharge, and decrease the likelihood of readmission for pain. VIS221 Evaluation of Contrast Protocol and Tumour Delineation using Ultrafast Cone-beam Computed Tomography: Initial Experience (Station #4) Thomas Josef Vogl MD, PhD : Nothing to Disclose, Emmanuel Chukwudum Mbalisike MD : Nothing to Disclose, Bita Panahi MD : Nothing to Disclose, Jijo Paul MSc, PhD (Presenter): Nothing to Disclose To evaluate two ultrafast cone- beam CT (CBCT) imaging protocols with different acquisition and injection parameters regarding image quality and required contrast media during hepatic transarterial chemoembolization (TACE). In 62-patients (male: 34, female: 28; mean age: 56.8 years; range: 33-83) CBCT was performed during TACE for intra-procedural guidance. Imaging was performed using two ultrafast CBCT acquisition protocols with different acquisition and injection parameters (imaging protocol 1: acquisition time-2.54s, contrast-6ml with 3s delay; imaging protocol 2: acquisition time-2.72s, contrast-7ml with 6s delay). Image evaluation was performed both qualitatively and quantitative methods. Contrast injection and dose parameters were compared with values from literature. Imaging protocol 2 provided significantly better image quality than protocol 1 at the cost of slightly higher contrast load and higher X-ray dose. Although imaging protocol 1 was able to visualize the hepatic vasculature, it mostly failed to delineate the tumors. In contrary, imaging protocol 2 showed excellent enhancement of hepatic parenchyma, tumor and feeding vessels. Tumor delineation and visualization of feeding vessels are clearly possible using imaging protocol 2 with ultrafast CBCT-imaging. Due to the ultrafast CBCT-imaging a reduction of required contrast volume and dose

98 compared to previous publications could be achieved. Ultrafast CBCT is a new imaging technique used for imaging of patients during transarterial chemoembolization. Information related to ultrafast CBCT imaging is scarce in literature. Contrast material volume and radiation dose reductions were achieved using ultrafast CBCT-imaging. Ultrafast CBCT contrast material injection protocol is established during transarterial chemoembolization. VIS222 Balloon Dilation for Tuberculous Tracheobronchial Strictures: A Single-Center Experience in 113 Patients during 17 years (Station #5) Ji Sung Jang (Presenter): Nothing to Disclose, Jin Hyung Kim MD : Nothing to Disclose, Young Chul Cho BS : Nothing to Disclose, Ho-Young Song MD : Nothing to Disclose, Ji Hoon Shin MD : Nothing to Disclose, Jung-Hoon Park MS, RT : Nothing to Disclose, Eun Jung Jun PhD : Nothing to Disclose, Wei-Zhong Zhou : Nothing to Disclose To determine whether balloon dilation is a safe and long-term efficacy of treating tuberculous tracheobronchial stricture(ttbs) in a large series of 113 patients. With ethics committee approval, records for 113 consecutive patients who underwent balloon dilation for TTBS with our interventional radiology department ( ) were obtained retrospectively. Balloon dilations were performed under bronchoscopic and fluoroscopic guidance. Outcomes were number and/or frequency of balloon dilations, technical success, primary and secondary clinical success, improvement in respiratory status, airway patency rate and adjuvant treatment after balloon dilation. A total of 167 balloon dilation sessions were performed in 113 patients, with a range of 1-8 sessions per patient (mean 1.5 sessions). The balloon dilation was successful in 82 (73%) of the 113 patients after a single (n = 67) or multiple (n = 15) balloon dilations. Clinical failure occurred in 31 patients (27%). In these 31 patients, symptoms recurred 1 day months (mean, 13 months) after repeat balloon dilations, and they required adjuvant treatment such as temporary stent placement (TSP) (n = 12), cutting balloon dilation (CBD) (n = 12), radiation-eluting balloon dilation (REBD) (n = 3) or surgery (n = 4). The primary patency rates at 1, 6 months and 1, 3, 5 and 10 years were 92%, 62%, 54%, 29%, 25%, and 10%, respectively. The secondary patency rates at 1, 6 months and 1, 3, 5 and 10 years were 99%, 85%, 75%, 51%, 44%, and 24%, respectively. Pre-, immediately and post-procedural pulmonary function test (PFT) results showed significant improvements between pre and immediately after dilation in the mean forced vital capacity (FVC) (P <.001), forced expiratory volume in 1 second (FEV1) (P =.001), forced expiratory flow 25%-75% (FEF 25-75%) (P =.020) and peak expiratory flow (PEF) (P = 0.005). Balloon dilation seems to be a simple and safe primary treatment modality for TTBS. In addition, the secondary clinical success with repeat balloon dilation is acceptable. TSP, CBD and REBD may be considered in patients with TTBS resistant to balloon dilation. Balloon dilation may be a successful treatment modality for healing tuberculous tracheobronchial stricture as well as for improving pulmonary function. VIS226 Pre-procedure Apparent Diffusion Coefficient as a Predictor of Response to Drug-eluting Bead Transarterial Chemoembolization of Hepatocellular Carcinoma (Station #6) Rahul Anil Sheth MD (Presenter): Nothing to Disclose, Quanzheng Li PhD : Nothing to Disclose, Suvranu Ganguli MD : Research Grant, Merit Medical Systems, Inc Consultant, Boston Scientific Corporation, Rahmi Oklu MD, PhD : Nothing to Disclose To investigate pre-procedure intratumoral apparent diffusion coefficient (ADC) in patients with hepatocellular carcinoma (HCC) undergoing drug-eluting bead transarterial chemoembolization (DEB-TACE) as a predictor for response to therapy. An Institutional Review Board (IRB) approved retrospective evaluation of patients undergoing doxorubicin DEB-TACE for HCC was performed. Patients with no prior history of locoregional therapy and with MRI examinations that included diffusion weighted imaging performed within 3 months prior to and following their initial DEB-TACE procedure between were included. MRI imaging features including size, contrast enhancement pattern, T2 signal intensity, and ADC value were measured on the pre- and post-mri studies for tumors between 10mm and 80mm in maximal dimension. Patient characteristics including age, gender, cause of liver disease, Childs-Pugh score, and mortality were recorded as well. A total of 23 patients with 35 tumors were identified. Based upon their ADC values, tumors were classified as "low ADC" (ADC < mm2/sec; n = 14) or "high ADC" (ADC > mm2/sec; n = 21). There was no

99 statistically significant difference in patient age, gender, cause of liver disease, or tumor size between the two groups. However, there was a statistically significant (p < 0.005, Mann-Whitney test) difference in percent ADC change between the pre- and post-mri examinations, an imaging finding that predicts progression free survival. Tumors with low ADC on pre-procedure imaging demonstrated significantly less interval increase in ADC value following DEB-TACE than tumors with intrinsically high ADC value. ADC value may serve as a pre-procedure indicator for response to DEB-TACE in patients with HCC. Predicting response to minimally invasive oncologic interventions can assist in proper patient selection, patient counseling, treatment planning, and selection of the most appropriate locoregional therapy. VIE175 The Right Tool for the Job: A Review of the Various Biopsy Devices and How They Are Used (Station #7) Aaron B. Wickley MD (Presenter): Nothing to Disclose, Michael Jason Reiter DO : Nothing to Disclose, Liem Thanh Mansfield MD : Nothing to Disclose, Ryan Becton Schwope MD : Nothing to Disclose, William Russell Thomas MD : Nothing to Disclose 1. Image-guided percutaneous needle biopsy plays a crucial role in the diagnosis of malignancy. It is more accurate than fine needle aspiration due to its ability to preserve tissue architecture and is less invasive than open surgical biopsy. 2. Percutaneous biopsy permits tissue sampling of almost any body part. As such, an array of available devices exists, each with specific functionality based on the anatomic area to be biopsied. 3. Most common biopsy device categories include aspiration needles, cutting needles, trephine needles, drill-powered devices, and vacuum-assisted devices. 4. Radiologists should be familiar with the components of various biopsy devices. This improves efficiency, increases likelihood of a diagnostic sample and avoids device failure or patient harm. 1. Role of image-guided percutaneous biopsy. 2. Overview of biopsy types A. Aspiration needles B. Cutting and trephine needles C. Drill-powered devices D. Vacuum-assisted devices 3. Available devices by anatomic region A. Breast i. Core Biopsy (Achieve, etc.) ii. Vacuum-assisted (Mammotome, etc.) B. Musculoskeletal i. Core Biopsy (Bonopty, etc.) ii. Drill-powered (OnControl, etc.) C. Body i. Aspiration (Chiba, etc.) ii. Core Biopsy (Quick-core, etc.) VIE127 Prostate Artery Embolization: Clarifying a Challenging Anatomy (Station #8) Veena Radhakrishnan Iyer MD (Presenter): Nothing to Disclose, Prashant Shrestha MD : Nothing to Disclose, Gregory Snyder MD : Nothing to Disclose, Andrew Misselt MD : Nothing to Disclose, Jafar Golzarian MD : Nothing to Disclose Prostate artery embolization (PAE) is being actively studied for BPH and is used for refractory hematuria of prostatic origin. The most challenging part of PAE is identifying the prostatic artery. On review of this exhibit the reader will understand the anatomical supply of the prostate gland and origin and important anastomoses of the prostatic arteries, as relevant for embolization. The value of cone-beam CT to increase confidence of correct catheter placement is also demonstrated. We performed a retrospective review of PAE performed in 15 men (30 hemipelves) at our hospital. We describe: 1. Branching pattern of the internal iliac artery 2. Origin and number of prostate arteries in each hemipelvis. Several classic variants are described. 3. Important and dangerous anastomoses of prostatic arteries with bladder, rectum, pudendal and median sacral branches. The value of CBCT is highlighted. VIS-MOB Vascular/Interventional Monday Poster Discussions Scientific Posters IR VA AMA PRA Category 1 Credits :.50 Mon, Dec 1 12:45 PM - 1:15 PM Location: VI Community, Learning Center Sub-Events VIS229 In vitro Study of the Newly Designed Antireflux Metallic Stent for Dstal Biliary Obstruction (Station

100 VIS229 #1) Hiroshi Anai MD, PhD (Presenter): Nothing to Disclose, Yasushi Fukuoka : Nothing to Disclose, HIROKI ISHIDA : Nothing to Disclose, Mai Teranishi : Nothing to Disclose, Toshiyasu Yuba : Nothing to Disclose, Kimihiko Kichikawa MD : Nothing to Disclose Metallic stent for malignant biliary obstruction has an important role in reduction of jaundice and induction of aggressive treatment for advanced biliary or pancreatic cancer such as anticancer agent. However longer survival has been obtained due to chemotherapy and/or radiation therapy after improvement of jaundice by metallic stent, complications associated with metallic stent such as stent obstruction or reflux cholangitis have been encountered and such complications are sometimes critical to worsen quality of life and shorten survival. The main cause of such complications in the patient treated with metallic stent placed across duodenal papilla is formation of bacterial biofilm as a result of the reflux of food residue and debris formation. We have developed the newly designed anti-reflux metallic stent (ARMS). The purpose of this in vitro study was to evaluate antegrade and retrograde flow of some various size of this stent and to determine the appropriate one. This ARMS has fully covered by silicon material and has biceps valve at the duodenal side. We prepared six types of ARMS (the diameter(mm)/ the length of the valve(mm), A;10/8, B;10/5, C;10/2, D;8/8, E;8/5, F8/2). The length of each type of ARMS was 5cm. Each ARMS was set at the exit of the water tank with antegrade placement to measure the volume of the antegrade flow and next also set with retrograde placement to measure the flow resistance under various pressure (0.2, 0.5, 1, 2kPa). We evaluated using with saline and glycerin solution (60 cp) which has similar viscosity to human bile. The flow rate of antegrade ARMS placement showed highest flow rate with each condition in stent B (stent diameter; 10mm, valve length; 5mm). (Figure) The flow of retrograde ARMS placement did not show any reflux in each ARMS typeunder all pressure. One type of our developed newly designed ARMS showed good flow at antegrade fashion and no reflux at retrograde fashion. It should be evaluated at clinical use. Ideal anti-reflux metallic stent will prevent duodeno-biliary reflux and biliary drainage then can prolong the survival. So this in vitro study plays an important role in this field. VIS230 Visualization and Volume Estimation of Mouse Hindlimb Arteriogenesis Using MicroCT Imaging (Station #2) James F. Baker (Presenter): Nothing to Disclose, Michael J Zhang : Nothing to Disclose, Chin Ng PhD : Nothing to Disclose The purpose of this study was to evaluate the imaging parameters required for the accurate visualization and quantification of arteriogenesis to assess efficacy of novel therapeutics. Three sets of mice with surgically induced ischemia of the right hindlimb were imaged on a small animal CT scanner set at 80kVp, 1800ms, 500μA, and 2X2 binning. The first set of samples were injected with Microfil, a silicone based contrast agent, prepared using manufacturer's instructions and then fixed with formalin. The second set of samples were prepared in the same manner as the first set, and then decalcified using Cal Ex II for 48 hours. The third set of samples were injected with a Microfil solution thats was prepared without using the dilutent recommended by the manufacturer and then decalcified using the same process as sample set two. The samples were then analyzed using the software Analyze 11.0 and segmented via thresholding. To verify the accuracy of volume measurements, a set of MicroCT phantoms were created using a iodine based gel and PEEK tubing. The tubing was filled with the iodine gel and then cut into various lengths. The phantoms were then scanned using the same parameters as the mouse hind limbs. The first set of samples could not be accurately be segmented from the underlying bone due to the linear attenuation coefficient(lac) of bone and Microfil being very similar resulting in similar intensities and an inability to accurately measure the vascular volume. Decalcification of the second set of samples created a greater separation in LAC of the vasculature and surrounding tissue. This allowed for an accurate segmentation of the vascular network and visualization of vessels larger than small arterioles. The lack of dilution in the third set of samples created a change in intensity of the small arterioles resulting in their visualization. The analysis of the MicroCT phantoms revealed that the volume of the phantoms could be estimated with an accuracy of 96.6±2.0%. The results illustrate the ability to not only visually observe the growth and change in blood vessel number and size, but also that the volume of these changes can be measured accurately. Peripheral arterial disease (PAD) represents a continuum of disease that range from asymptomatic PAD,

101 intermittent claudication, critical limb ischemia, acute limb ischemia and amputation. VIS231 Short-term Rosuvastatin Therapy Prevents CIAKI in Female Patients with Diabetes and CKD: A Subgroup Analysis of TRACK-D Study (Station #3) Yaling Han (Presenter): Research Grant, General Electric Company, Biao Xu : Research Grant, General Electric Company, Guoliang Jia : Research Grant, General Electric Company, Tao Guo : Research Grant, General Electric Company, Dongmei Wang : Research Grant, General Electric Company, Quanmin Jing : Research Grant, General Electric Company, Xiaozeng Wang : Research Grant, General Electric Company, Yi Li : Research Grant, General Electric Company, Kai Xu : Research Grant, General Electric Company, Jie Deng : Research Grant, General Electric Company, Jing Li : Research Grant, General Electric Company The multicenter TRACK-D study demonstrated periprocedural use of rosuvastatin effectively reduced the risk of contrast-induced acute kidney injury (CIAKI) in patients with diabetes mellitus (DM) and chronic kidney disease (CKD) undergoing coronary/peripheral arterial angiography or percutaneous intervention. This analysis investigated the value of such preventive strategy for CIAKI according to sex. 1,954 of the TRACK-D population (2,998) were women. The average age of females was older than that of males (64.10 ± 7.41 vs ± 8.91, p <.01). Men had more hypertension, peripheral vascular disease, DM and anemia (all p <.05). Baseline level of serum creatinine (SCr) was higher in males (98.44 ± vs ± 25.58, p <.01). So was estimated glomerular filtration rate (74.75 ± vs ± 16.75, p <.05). Women had higher level of total cholesterol and LDL-C (p <.01). 535 females and 963 males were assigned to receive rosuvastatin 10 mg/day two days before and three days post procedure. Others were received standard-of-care. Iodixanol 320 mgi/ml was used for all procedures. CI-AKI was defined as a rise in SCr of 0.5 mg/dl ( 44 µmol/l) or a 25% increase from baseline value in 72 hours after injection. The overall incidence of CIAKI was 3.6% and 2.8% in females and males, respectively. In the control group, women had a higher rate of CIAKI (5.3% vs 3.1%, p =.04). Females treated with rosuvastatin had a significantly lower rate of CIAKI compared with controls (2.1% vs 5.3%, p <.01). A statistically significant difference in the incidence of CIAKI between the rosuvastatin group and the control group was seen in women with CKD stage 2 (1.2% vs 4.1%, p =.01), but not in those with CKD stage 3 (3.3% vs 8.4%). Untreated females were associated with a higher risk of CIAKI compared with their male counterparts. Short-term rosuvastatin treatment reduced the risk of CIAKI in women with DM and CKD, which was consistent with the results from overall TRACK-D population. The study did reconfirm that females had higher risk of CIAKI even with a better lab result before procedure. Periprocedural use of rosuvastatin is an easy and practicable preventive method. VIS228 Focal Laser Ablation of Prostate Cancer- Short Term Outcomes versus Conventional Therapy (Station #5) J Ryan Mikus MD (Presenter): Nothing to Disclose, Jacqueline Sue Aoughsten RN : Nothing to Disclose, Eric Michael Walser MD : Nothing to Disclose To assess the short-term side effect outcomes of focal laser ablation (FLA) for the treatment of prostate cancer versus conventional treatment. Records of 140 referrals for evaluation for MR-guided prostate cancer FLA were retrospectively reviewed. FLA was performed on 23 patients (16%). Clinical follow-up for patients receiving FLA was performed post-intervention, with follow-up periods ranging from 3 months to one year. Clinical course and complications were reviewed. All patients had Sexual health in men scoring (SHIM) and International prostate symptom scoring (IPSS) before and 2-12 months after FLA. 100% technical success was achieved (23/23). No major complications (including adverse effects on sexual function, urinary function, and bowel function) were observed in any of 23 patients after FLA at 2 month post-intervention (0%). 3 patients experienced minor complications after FLA-one urinary tract infection successfully treated by oral antibiotics; hematuria for 3 days, self-limited; and urinary urgency with incontinence for 3 days, self-limited. Historical data for prostatectomy, external beam radiation, and brachytherapy demonstrates at least moderate adverse effects on sexual function (29%, 30%, 39%, respectively), urinary function (59%, 28%, 34%), and bowel function (3%, 16%, 15%), at 2 months post-intervention. There was no significant difference in SHIM scores and IPSS scores before and up to 12 months after FLA (p<0.05).

102 Focal laser ablation of prostate cancer has high technical success, and the short-term effects of FLA on sexual, urinary, and bowel function are favorable in comparison to conventional therapy for prostate cancer. Focal laser ablation of prostate cancer is a promising new technique, primarily due to its superior side-effect profile, as demonstrated. Long term follow-up and efficacy data is forthcoming. VIS232 Cone-beam Computed Tomography with Three-dimensional Reconstruction Techniques versus Conventional Digital Substruction Angiography in Transcatheter Arterial Chemoembolization for Hepatocellular Carcinoma (Station #6) Long Gao (Presenter): Nothing to Disclose, Hai Bo Shao MD : Nothing to Disclose, Tengchuang Ma : Nothing to Disclose, Xu Ke MD : Nothing to Disclose To evaluate the efficacy of cone-beam computed tomography (CBCT) with three-dimensional (3D) reconstruction techniques in transcatheter arterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) compared with conventional digital substruction angiography (cdsa). This retrospective study was performed on 36 consecutive HCC patients who underwent super-selective TACE. CBCT was performed on 16 patients (35 tumors). 3D-angiography, 3D-roadmap and multi-planar reconstruction techniques were used to guide operation and evaluate embolization efficacy. The other 20 patients (44 tumors) received cdsa during TACE. Distinguishability of feeding arteries, detectability of HCC lesions, technical success of super-selective catheterization, operating time, cumulative X-ray exposure of patient, dosage of contrast agent (CA) and lipiodol depositing proportion (one-month postoperative contrast-enhanced CT as reference standard) were compared between groups. All TACE procedures were carried out fluently. There were no severe procedure related complications. All patients received one-month CT follow-up. CBCT with 3D techniques showed better efficacy in showing feeding arteries (87.5% vs. 55%, p<0.01), detectability of HCC lesions (97.14%, 34 of 35 vs %, 31 of 44, p=0.028) and technical success rate of super-selective catheterization (91% vs. 75%, p=0.043) than cdsa. Moreover, procedures with CBCT spent less CAs (28 vs. 36 ml, p=0.44). However, procedures with CBCT spent longer operating time (43 vs. 32 mins, p<0.01) and induced more X-ray dosage exposure (242 vs. 157 mgy, p=0.015) than those with cdsa. On lipiodol depositing evaluation, the coincidence rate of CBCT with one-month CT follow-up was significantly higher than that of cdsa (100% vs. 76%, p<0.01). Compared with cdsa, CBCT with 3D reconstruction techniques showed better clinical application efficacy in feeding artery distinguishability, tumor detectability, catheterization guidance and embolism efficacy evaluation in TACE for HCC patients although consuming more operating time and X-ray exposure. Application of CBCT with 3D reconstruction techniques may have potentially encouraging values in improving the efficacy of TACE for HCC patients. VIE193 What Interventional Radiologist Needs to Know about Treatment Response Evaluation of Liver Malignancies in Response to Locoregional Therapies (Station #7) Christelle Chedrawy MD : Nothing to Disclose, Daniel Anthony Falco DO : Nothing to Disclose, Bimal Bharatkumar Patel DO : Nothing to Disclose, Pedram Rezai MD (Presenter): Nothing to Disclose Surgical resection remains the treatment of choice for hepatocellular carcinoma (HCC) and metastatic liver cancer (MLC). However, only up to 25% of the patients are surgical candidates. Consequently, the majority of these patients are treated with systemic chemotherapeutic agents or locoregional therapies. The objective of this presentation is to discuss different imaging biomarkers of treatment response evaluation in HCC and MLC. An overview of anatomical imaging biomarkers such as WHO, RECIST and volumetric evaluation will be provided. Biomarkers that monitor alterations in function of neoplastic cell in response to treatment such as EORTC and DWI MR will be discussed. Eventually, liver-specific biomarkers of treatment response such as mrecist, EASL and Choi criteria will be discussed.

103 VIE114 Fibromuscular Dysplasia: What the Radiologist Should Know (Station #8) Lionel Varennes (Presenter): Nothing to Disclose, Florence Tahon : Nothing to Disclose, Adrian Imre Kastler MD, MSc : Nothing to Disclose, Sylvie Grand MD : Nothing to Disclose, Kamel Boubagra : Nothing to Disclose, Arnaud Attye MEd : Nothing to Disclose, Frederic Thony MD : Nothing to Disclose, Alexandre Krainik MD, PhD : Nothing to Disclose The purpose of this exhibit is: 1. To increase awareness amongst radiologists about DFM. 2. To review both common and uncommon imaging findings in patients with Fibromuscular Dysplasia 3. To provide the necessary diagnostic tools in order for the radiologist to play an important role in the diagnosis A - Fibromuscular dysplasia epidemiologic reminder B - Fibromuscular dysplasia pathophysiology C - Clinical manifestation of Fibromuscular dysplasia B Review of imaging findings - Common imaging findings - Uncommon imaging findings C Role of imaging techniques in Fibromuscular dysplasia diagnosis : diagnostic strategies - Ultrasound - CT Scan - MRI - DSA D - Differential diagnosis E - Go home messages VIE011-b The Arterial Vasculature of the Stomach with a Focus on Fundal Supply: A Primer for Bariatric Embolization (hardcopy backboard) Ryan J. Brandt MD (Presenter): Nothing to Disclose, Eric K. Hoffer MD : Nothing to Disclose, Trent Shelton DO : Nothing to Disclose 1. To review the basic theory and technique for bariatric embolization. 2. To review the arterial supply of the stomach with a focus on the supply to the fundus. Bariatric embolization is a percutaneous interventional procedure in development, which seeks to help patients lose weight by targeting the ghrelin producing cells in the fundus of the stomach. Recent animal studies testing the procedure have been complicated by gastric ulceration, which makes knowledge of the arterial supply of the stomach and particularly the fundus important for developing a safe embolization technique for use in humans. A literature review was performed to identify the vascular supply to the fundus. The left gastric artery and short gastric arteries are major suppliers to the fundus. Additional sources of fundal supply include the posterior gastric artery, left inferior phrenic artery, accessory left gastric artery, left gastroepipoloic and, less commonly, the left middle suprarenal artery. Using CT angiography, graphical illustrations and digital subtracted angiography, we have demonstrated the arterial supply of the stomach. Digital subtracted angiography cine loops embedded in QR codes were used to demonstrate dynamic arterial filling. Selected illustrative cases were used to further demonstration arterial anatomy and pathology. VSIO21 Interventional Oncology Series: Hepatocellular Carcinoma Series Courses RO OI IR GI RO OI IR GI AMA PRA Category 1 Credits : 4.25 ARRT Category A+ Credits: 5.00 Mon, Dec 1 1:30 PM - 6:00 PM Location: S406B Moderator Riad Salem MD, MBA : Consultant, Bayer AG Consultant, Nordion, Inc Consultant, BioSphere Medical, Inc Advisory Board, Sirtex Medical Ltd Consultant, Merit Medical Systems, Inc 1) To learn the indications for transcatheter-based therapies for patients with HCC. 2) To understand the potential limitations, pitfalls, side effects and toxicities associated with transcatheter therapies for patients with HCC. 3) To know the results, imaging responses and survival benefit of various transcatheter therapies. 4) To know the future transcatheter therapies and understand their potential. 5) To learn the various combination therapies available and undergoing clinical evaluation for HCC. ABSTRACT 01) Staging Systems, Epidemiology, and Medical -1) Identify state-of-the art surgical treatment, non-surgical treatment, and transplantation treatment for patients with HCC. 2) Identify the most appropriate treatment for early and advanced stage of HCC. 3) Describe and discuss indications for resection in chronic liver disease. 4) Integrate interventional radiological procedures in the treatment of HCC. 02) HCC mgmt in Europe -1) To understand how HCC patients are being managed in Europe.2) To learn the decision making processes driving treatment selection for patients. 3) To review the data from the European point of view. 03) HCC mgmt in Korea -1) To understand how HCC patients are being managed in Korea.2) To learn the decision making processes driving treatment selection for patients. 3) To review the data from the Korean point of view. 04) HCC mgmt in HK/China- 1) To understand how HCC patients are being managed in China. 2) To learn the decision making processes driving treatment selection for patients. 3) To review the data from the Chinese point of view. 05) HCC mgmt in Japan- 1) To understand how HCC patients are being managed in Japan. 2) To learn the decision making processes driving treatment selection for patients. 3) To review the data from the Japanese point of view. 06) Panel Discussion: Sub-Events

104 VSIO21-01 Staging Systems, Epidemiology, and Medical Therapy Richard S. Finn MD (Presenter): Consultant, Bayer AG Consultant, Novartis AG Consultant, Amgen Inc 1) Identify state-of-the art surgical treatment, non-surgical treatment, and transplantation treatment for patients with Hepatocellular Carcinoma. 2) Identify the most appropriate treatment for early and advanced stage of Hepatocellular Carcinoma. 3) Describe and discuss indications for resection in chronic liver disease. 4) Integrate interventional radiological procedures in the treatment of Hepatocellular Carcinoma. VSIO21-02 Identifying New Staging Markers for HCC before TACE: Which Lesion Parameter on Baseline MR Imaging Is the Ideal Prognostic Marker? Julius Chapiro MD (Presenter): Nothing to Disclose, Rafael Duran MD : Nothing to Disclose, MingDe Lin PhD : Employee, Koninklijke Philips NV, Ruediger Egbert Schernthaner MD : Nothing to Disclose, Carol Thompson : Nothing to Disclose, Jean-Francois H. Geschwind MD : Consultant, BTG International Ltd Consultant, Bayer AG Consultant, Guerbet SA Consultant, Nordion, Inc Grant, BTG International Ltd Grant, F. Hoffmann-La Roche Ltd Grant, Bayer AG Grant, Koninklijke Philips NV Grant, Nordion, Inc Grant, ContextVision AB Grant, CeloNova BioSciences, Inc Founder, PreScience Labs, LLC CEO, PreScience Labs, LLC The most commonly used staging systems for hepatocellular carcinoma (HCC) (e.g. BCLC, CLIP) use the largest lesion diameter as the leading imaging biomarker for tumor status. This study tested and compared the prognostic value of lesion diameter, volume and enhancement on baseline MR imaging to predict overall survival (OS) in patients with unresectable HCC treated with transarterial chemoembolization (TACE). This retrospective analysis included 79 patients with unresectable HCC who were to receive their first TACE. Baseline arterial-phase contrast enhanced MRI (cemri) was used to measure the overall and enhancing tumor diameters. In addition, a segmentation-based 3D quantification of the overall and enhancing tumor volumes was performed in each patient (see Figure 1). Numeric cutoff values (5cm for diameters and 65cm3 for volumes) were used to stratify the patient cohort in two groups for each method. Survival was evaluated using Kaplan-Meier analysis and compared using Cox proportional hazard ratios (HR) after uni- and multivariate analysis. Median OS of the entire population was 16.4 months (95% CI, ). The stratification according to overall or enhancing tumor diameters did not result in a statistically significant separation of the survival curves (HR 1.4 [95% CI, ]; P=0.234 and HR 1.6 [95% CI, ]; P=0.080, respectively). The stratification according to overall or enhancing tumor volume achieved statistical significance (HR, 1.8 [95% CI, ]; P=0.022 and HR, 1.8 [ ]; P=0.017, respectively). Patients with enhancing tumor volumes <65cm3 survived significantly longer than patients with larger enhancing tumor volumes (P=0.013; 29.7 months [95% CI, ] vs months [95% CI, ], respectively). As opposed to tumor diameter which currently is the most commonly used staging marker, volumetric assessment of lesion size and enhancement on baseline cemri is strongly associated with patient survival after TACE. The use of volumetry-based thresholds as staging biomarkers might lead to more accurate prognostic discriminators in future staging systems. VSIO21-03 HCC Management in Europe Riccardo Antonio Lencioni MD (Presenter): Nothing to Disclose View learning objectives under main course title. VSIO21-04 Hepatocellular Carcinoma Treated by Transarterial Chemoembolization: Prediction of Treatment Failure Using Tumoral Morpho-phenotypic Features on Pre-treatment Biopsy Maxime Ronot MD (Presenter): Nothing to Disclose, Amedeo Sciarra : Nothing to Disclose, Luca Di Tommaso : Nothing to Disclose, carlotta raschioni : Nothing to Disclose, Pierre Bedossa : Nothing to Disclose, Massimo Roncalli : Nothing to Disclose, Valerie Vilgrain MD : Nothing to Disclose, Valerie Paradis MD : Nothing to Disclose 1) To identify tumoral tissue markers as potential predictors of resistance to transarterial chemoembolization (TACE) in hepatocellular carcinoma (HCC), 2) to provide a simple scoring system to be applied on pre-tace HCC biopsy, and 3) to validate the score.

105 Inclusion criteria were patients with HCC who received TACE and who had pre-tace biopsy of the tumor from 2005 to Two groups of patients were analyzed: 1) a study group composed of resected patients used to build the scoring system, and 2) a validation group of non-resected patients whom tumor response was evaluated at imaging. Resistance to TACE was defined as residual tumor >50% on resected specimen in the former and as non-complete tumor response according to mrecist in the latter. In the study group, tumor size, the immunohistochemical expression of markers related to hypoxia and angiogenesis (HIF1-α, VEGF and CD34), apoptosis (CA9), stemness phenotype (Nestin), and epithelial-mesenchymal transition (Vimentin, E-Cadherin, Twist) were analyzed. Variables associated with TACE resistance were entered as candidate variables into a stepwise logistic regression model in order to build a TACE-resistance prediction score. This score was then validated on the validation group. The study study was composed of 108 lesions from 41 cirrhotic patients (39 males (95%), mean age 58.5±8). Overall 45/108 (44%) HCC were classified as TACE-resistant. Of these, 33 (73%) had a diameter 3 cm, 28 (62%) showed a high microvessel density (CD34 staining) and 40 (89%) low VEGF expression (p<0.05). The association of these three parameters (small size,?cd34 and?vegf) in a weighted score was able to predict TACE-resistance with 87% accuracy, 87% sensitivity and 88% specificity. The validation set was composed of 28 HCC patients (23 males (82%), mean age 65,5±10). The score was predictive of TACE-resistance with 75% accuracy, 74% sensitivity, 80% specificity. Combination of VEGF and CD34 staining performed on pre-tace biopsy together with the tumor size may be useful for the prediction of TACE-resistance in HCC. Patients with HCC treated with TACE may benefit from a tumoral morpho-phenotypic analysis performed on pre-treatment biopsy VSIO21-05 HCC Management in Korea Jin Wook Chung MD (Presenter): Grant, BTG International Ltd View learning objectives under main course title. VSIO21-06 Vascular Redistribution Following Partial Hepatic Artery Embolisation for SIRT Efficacy of Delivery of Y90 Microspheres to Embolised Liver Segments Philip Borg MD, FRCR (Presenter): Nothing to Disclose, Jon Kingsley Bell MBChB, FRCR : Nothing to Disclose, Steve Philip Jeans : Nothing to Disclose, Jill Philip Tipping : Nothing to Disclose, Amarjot Chander : Nothing to Disclose, Damian P. G. Mullan FFR(RCSI), FRCR : Nothing to Disclose, Prakash Manoharan MRCP, FRCR : Nothing to Disclose, Jeremy Andrew Liste Lawrance MBChB : Nothing to Disclose To evaluate the efficacy of delivery of microsphere delivery during Selective Internal Radiation Therapy (SIRT) using SIR-Spheres to segments of the liver that have been coil embolised. Embolisation of the left hepatic artery and or its branches to prevent extra-hepatic distribution of Yttrium90 (Y90) microspheres is often performed in selective internal radiation therapy (SIRT). This has a potential to under treat portions of the liver. 158 SIRT cases over an 8 year period were reviewed. Cases with unfavorable anatomy underwent coil occlusion of part or all of the left or right hepatic arteries to ensure safe whole liver therapy. Using Xeleris imaging software analysis was made on the planar gamma and bremsstrahlung imaging. Regions of interest (ROI) for the right and left lobes of the liver were drawn and a geometric mean ratio of right:left (R:L) post administration of Tc99mMAA and post Y90 microspheres. ROIs were adjusted for background scatter. R:L liver lobe ratios in patients who had partial embolisation of the hepatic artery compared to R:L liver lobe with no embolisation. Post Tc99mMAA Non embolised patients R:L ratio mean = 8.8 Embolised patients R:L ratio mean = 20.5 Post Y90 microspheres Non embolised patients R:L ratio mean = 5.6 Embolised patients R:L ratio mean = 8.9 After injection of Y90 patients with partial hepatic artery embolisation had a larger R:L lobe ratio when compared to those not embolised. The same was true after injection of Tc99mMAA but to a greater extent. This difference in ratios, with better uptake in the left lobe after injection of Y90 can be explained by the development of intrahepatic collateral flow channels in the 2-3 week period between the Tc99mMAA scan immediately post coil embolisation and the Y90 scan. Laminar flow also affects distribution of Y90 and Tc99mMAA. These preliminary results from analysing planar imaging of 23 patients will be correlated with SPECT CT on a larger number of patients.

106 Although there is a significant decrease in treatment to the embolised segments, there is likely development of intracollateral flow channels to embolised segments, increasing delivery of radiospheres after partial coil embolisation hepatic arteries. This is an acceptable compromise to ensure safe delivery of Y90 microspheres without extrahepatic distribution. VSIO21-07 HCC Management in Hong Kong, China Ronnie T.P Poon (Presenter): Nothing to Disclose View learning objectives under main course title. VSIO21-08 Efficacy and Safety of μm Compared with μm Drug Eluting Beads in Transarterial Chemoembolization for Unresectable Hepatocellular Carcinoma: Does Size Matter? Amy Robin Deipolyi MD, PhD (Presenter): Nothing to Disclose, Shehab A. Alansari MD : Nothing to Disclose, Rahmi Oklu MD, PhD : Nothing to Disclose, Zubin Irani MD : Nothing to Disclose, Raymond W. Liu MD : Nothing to Disclose, George Rachid De Oliveira MD : Nothing to Disclose, Andrew X. Zhu MD, PhD : Nothing to Disclose, Suvranu Ganguli MD : Research Grant, Merit Medical Systems, Inc Consultant, Boston Scientific Corporation Prior work suggests that μm drug-eluting beads (DEB) for transarterial chemoembolization (TACE) compared with μm DEB are safer and more effective for hepatocellular carcinoma (HCC). We compared safety and efficacy of μm to μm DEB in TACE for HCC. In 12/2012 our DEB-TACE protocol was changed from 2 vials of μm to 1 vial of μm and 1 vial of μm DEB, which generated two groups of HCC patients for comparison selected under similar eligibility criteria. We reviewed laboratory and clinical data, post-tace course, and response on 1-2 month imaging based on modified RECIST criteria. Fisher's exact, χ2 and student's t tests analyzed group differences. Of 65 cases (54 patients) performed with μm DEB (Group 1) and 67 cases (53 patients) with μm DEB (Group 2), treatment was lobar in 60 and selective in 11 (Group 1) and lobar in 42 and selective in 7 cases (Group 2). There was no difference in pre-procedure age, stage, or liver function tests. There was a trend for greater decrease in index lesion size in Group 1 (-8 v +2%; p=0.4). Treatment response for Group 1 and 2 was similar inrates of complete response (16 v 23%), partial response (9 v 5%), stable disease (70 v 61%) and progressive disease (5 v 11%) (p=0.4). Group 1 patients were significantly more likely to be readmitted within 1 month or have prolonged hospital stay for complications related to liver dysfunction with more patients requiring treatment for ascites, symptoms of portal hypertension, and biliary disease (12 v 3; p=0.01). Two patients in Group 1 developed cholecystitis and 2 patients died within 2 months, compared to none in Group 2. Group 1 patients tended to have increased bilirubin post-procedure (+19 v -12%; p=0.07), more complications from any cause (24 v 16; p>0.05), longer hospital stay (1.5 v 1.1 days; p=0.07), and to visit doctors more frequently within 1 month (13 v 8; p>0.05). Our results suggest that despite similar efficacy by imaging, TACE with smaller, μm DEB leads to more liver-related complications, and possibly more adverse events from all causes and longer post-tace hospitalization. Transarterial chemoembolization with μm compared with μm drug eluting beads for hepatocellular carcinoma may cause more complications and longer hospitalization, despite similar efficacy. Findings suggest μm beads may be optimal. VSIO21-09 HCC Management in Japan Yasuaki Arai (Presenter): Nothing to Disclose 1) To understand how HCC patients are being managed in Japan. 2) To learn the decision making processes driving treatment selection for patients. 3) To review the data from the Japanese point of view. VSIO21-11 Intraarterial Therapies in the US: Where Are We? Jean-Francois H. Geschwind MD (Presenter): Consultant, BTG International Ltd Consultant, Bayer AG Consultant, Guerbet SA Consultant, Nordion, Inc Grant, BTG International Ltd Grant, F. Hoffmann-La Roche Ltd Grant, Bayer AG Grant, Koninklijke Philips NV Grant, Nordion, Inc Grant, ContextVision AB Grant, CeloNova BioSciences, Inc Founder, PreScience Labs, LLC CEO, PreScience Labs, LLC

107 1) Understand patient selection process. 2) Understand the patient indications and complications. 3) Understand the rationale for combining anti-angiogenic agenst with loco-regional therapies. 4) Understand the results of various catheter based intra-arterial therapies for Liver Cancer. VSIO21-12 Survival Outcomes in Patients with Advanced-stage HCC and Portal Vein Thrombosis: Comparison between Conventional and Drug-eluting Beads TACE Boris Gorodetski (Presenter): Nothing to Disclose, Julius Chapiro MD : Nothing to Disclose, Bareng Nonyane : Nothing to Disclose, Rafael Duran MD : Nothing to Disclose, MingDe Lin PhD : Employee, Koninklijke Philips NV, Jean-Francois H. Geschwind MD : Consultant, BTG International Ltd Consultant, Bayer AG Consultant, Guerbet SA Consultant, Nordion, Inc Grant, BTG International Ltd Grant, F. Hoffmann-La Roche Ltd Grant, Bayer AG Grant, Koninklijke Philips NV Grant, Nordion, Inc Grant, ContextVision AB Grant, CeloNova BioSciences, Inc Founder, PreScience Labs, LLC CEO, PreScience Labs, LLC Our study sought to compare the overall survival (OS) in patients with hepatocellular carcinoma (HCC) and portal vein thrombosis (PVT), treated with conventional (c) or drug-eluting beads (DEB) transarterial chemoembolization (TACE). This retrospective analysis included a total of 133 HCC patients with PVT that were treated with ctace (N=95) or DEB-TACE (N=38) without crossover of therapy. The extent of PVT (peripheral [p] vs. main [m] PVT) was diagnosed on contrast-enhanced MR or CT imaging. Prognostic parameters from the Barcelona Clinic Liver Cancer staging system (Child-Pugh [CP] stage, Performance Status [PS], Lesion diameter and multiplicity, PVT localization, lymph nodes, metastases) and other clinically relevant covariates (tumor type and burden, cirrhosis, sex, age) were included into the nearest-neighbor propensity score 2:1 matching, to achieve balance in treatment allocation. We then fitted a Cox proportional hazard regression model for time to death and treatment, adjusting for other covariates as potential confounders. A total of 102 patients were successfully matched (31 were excluded). A total of 34 patients were treated with DEB-TACE and 68 were treated with ctace. The distribution of parameters was almost equal between the groups, for DEB-TACE and ctace, respectively: N= 23 (67.6%) and N= 45 (66.2%) had mpvt, N=22 (64.7%) and N=41 (60.3%) had CP >A, N=28 (82.4%) and N=52 (76.5%) had PS > 0, N= 30 (88.2%) and N=60 (88.2%) had multiple lesions, N=32 (94.1%) and N=66 (97.1%) had a tumor diameter > 3cm. The median OS of the matched cohort (N=102) was 4.5 months (95% CI, ). As for the treatment groups, median OS was 5.0 months (95% CI, ) for ctace and 3.3 months (95% CI, ) for DEB-TACE (log-rank test, P=0.394).The adjusted hazard ratio from the Cox regression was 1.23 (95% CI, , P=0.46). Both ctace and DEB-TACE achieved similar survival outcomes in patients with advanced-stage HCC and PVT. A trend towards better median OS in patients treated with ctace was observed. DEB-TACE did not provide significant survival benefits in the treatment of patients with advance-stage HCC and PVT when compared to ctace. VSIO21-13 Assessment of Tumor Response Riad Salem MD, MBA (Presenter): Consultant, Bayer AG Consultant, Nordion, Inc Consultant, BioSphere Medical, Inc Advisory Board, Sirtex Medical Ltd Consultant, Merit Medical Systems, Inc 1) Review methods of response assessment. 2) Discuss limitations of current methods. 3) Describe future imaging concepts in development. VSIO21-14 Prospective Longitudinal Quality of Life Assessment in Patients with Unresectable Infiltrative Hepatocellular Carcinoma and Portal Vein Thrombosis after Yttrium-90 Radioembolization and Outcome Correlations Nima Kokabi MD (Presenter): Nothing to Disclose, Minzhi Xing MD : Nothing to Disclose, Juan Camilo Camacho : Nothing to Disclose, Faramarz Edalat MD : Nothing to Disclose, Hyun Sik Kim MD : Nothing to Disclose To investigate the effects of Y90 radioembolization on health-related quality of life (HRQOL) in patients with infiltrative hepatocellular carcinoma (HCC) and portal vein thrombosis (PVT) and to correlate baseline and early QOL trends to disease progression and survival. HRQOL trends using Short-Form 36 (SF-36) questionnaire in patients with infiltrative HCC and PVT treated with

108 glass-based Y90 were investigated in a correlative study related to a prospective phase II trial. Patients underwent baseline assessment within 1 mo prior to Y90 and follow-up assessments were performed at 1, 3 and 6 mo post-therapy. Tumor progression was determined by 3 monthly MRI's. Overall survival (OS) and time to progression (TTP) were measured using Kaplan-Meier estimation from the day of first Y90. Baseline and follow-up SF-36 scores were compared using paired t-test. Log-rank test was used to determine the effects of favorable scores at baseline and early follow-ups on TTP and OS. Thirsty patients (n=30) were treated and followed for a median of 19 mo. Decreased pre-treatment baseline scores within all domains of SF-36 were observed in patients vs. age-adjusted US controls. The physical component scores were more significantly decreased than mental components. Overall, at 1, 3 and 6 mo, scores for individual SF-36 domains, physical and mental component summaries (PCS and MCS) remained unchanged. While there was no difference in baseline SF-36 scores for patients with prolonged TTP ( 4 mo) and OS ( 6 mo), corresponding physical component scores at 1 mo were significantly higher than those with TTP < 4mo and OS <6 mo. Specifically at 1 mo, patients with normalized Physical Function, Role Physical and PCS within 2 standard deviation (SD) of US normalized score, had a significantly prolonged median OS (15.7 mo vs. 3.7 mo; p<0.001) and TTP (12.4 mo vs. 1.8 mo; p<0.001) compared those with physical component scores >2SD below normalized US population values. HRQOL in patients treated with infiltrative HCC and PVT treated with Y90 does not significantly change within 6 months post therapy. Early (1month) favorable trends in the physical components of SF-36 may be a predictor of prolonged OS and TTP. The effect of Y90 radioembolization on HRQOL in patients with infilitrative HCC and PVT and the utlility of SF-36 assessment tool as a predictor of clinical outcome are currently unknown. SSE04 Cardiac (Cardiovascular Angiography) Scientific Papers IR CT CA AMA PRA Category 1 Credits : 1.00 ARRT Category A+ Credit: 1.00 Mon, Dec 1 3:00 PM - 4:00 PM Location: S504AB Moderator Antoinette Susan Gomes MD : Stockholder, St. Jude Medical, Inc Moderator Hajime Sakuma MD : Research Grant, Siemens AG Research Grant, Koninklijke Philips NV Research Grant, General Electric Company Research Grant, Bayer AG Research Grant, Guerbet SA Moderator Karin Evelyn Dill MD : Nothing to Disclose Sub-Events SSE04-01 Anomalous Coronary Arteries: Analysis of Clinical Outcome Based upon Arterial Course and Surgical Intervention. Is Bypass Grafting Beneficial for an Older Adult with an Interarterial Coronary Course? Robert Layser MD (Presenter): Nothing to Disclose, Michael Savage MD : Nothing to Disclose, Ethan J. Halpern MD : Nothing to Disclose An anomalous coronary artery with an interarterial "malignant" course (IAC) is a recognized cause of sudden death in children and young adults. Coronary bypass grafting (CABG) is often recommended, especially for a left coronary IAC. However, the largest published review evaluated 54 subjects with an IAC and failed to demonstrate a long-term benefit from CABG (Krasuki et al. Circulation 2011;123(2):154-62). Given the increasing number of older adults with an IAC seen on coronary CT angiography (ccta), we evaluated the association of IAC +/- CABG with subsequent cardiac events in adults over age 40. Retrospective review of ccta and conventional arteriograms from our institution identified 155 patients (ages 40-91, mean 64.5 years) with an anomalous coronary artery origin from the opposite coronary sinus, including 70 patients with an IAC (mean age: 63 years). Chart review provided a mean follow-up time of 5 years. Outcome data was evaluated for hard outcomes (myocardial infarction or cardiac death) and soft outcomes (persistent angina). Although the severity of coronary disease as assessed by the number of vessels with >50% stenosis was lower among patients with vs without an IAC (0.86 vs 1.07 diseased vessels per patient, chi square for trend: p=0.3), the frequency of CABG was higher among those with an IAC (21/70) 30% vs without an IAC (15/85) 17.6%. The frequency of hard outcomes was similar among those with an IAC (12/70) 17.1% vs those without

109 an IAC (15/85) 17.6% (p=0.44). Among patients with an IAC, the frequency of hard outcomes was similar with CABG (4/21) 19% vs without CABG (8/49) 16.3% (p=0.74). The frequency of soft events among patients with an IAC was also similar with CABG (9/21) 42.9% vs without CABG (17/49) 34.7% (p=0.59). Extent of coronary disease was the only significant predictor of outcome on multivariate regression (presence of IAC, CABG and left vs right IAC were not significant, p>0.4). The frequency of both hard and soft outcomes among adult patients with anomalous coronary arteries was not significantly related to the presence of an IAC or to the history of CABG. No benefit was documented from CABG in our patients with an IAC. As an increasing number of older adults with an IAC are identified with ccta, it is important to recognize that CABG does not have a proven benefit for the treatment of anomalous coronary arteries in the older adult patient. SSE Slice Coronary CT Angiography in Patients with Atrial Fibrillation: Optimal Reconstruction Phase and Image Quality Hideaki Yuki MD (Presenter): Nothing to Disclose, Seitaro Oda MD : Nothing to Disclose, Keiichi Honda : Nothing to Disclose, Akira Yoshimura : Nothing to Disclose, Kazuhiro Katahira : Nothing to Disclose, Yasuyuki Yamashita MD : Consultant, DAIICHI SANKYO Group, Daisuke Utsunomiya MD : Nothing to Disclose, Tomohiro Namimoto MD : Nothing to Disclose, Takeshi Nakaura MD : Nothing to Disclose, Kenichiro Hirata : Nothing to Disclose, Masafumi Kidoh : Nothing to Disclose The purpose of this study was to assess the optimal reconstruction phase and the image quality of coronary CT angiographs obtained on a 256-slice CT scanner in patients with atrial fibrillation (AF). We acquired 256-slice coronary CT angiographs of 60 consecutive patients with AF (45 men and 15 women; age 72.1 ± 8.1 years) and 60 controls (43 men and 17 women; age 67.1 ± 9.9 years) in sinus rhythm. The images were reconstructed in 2% steps in all parts of the cardiac cycle (R-R interval). Two experienced radiologists determined the optimal reconstruction phase with the fewest motion artifacts and scored the motion artifacts of each coronary artery segment to determine the ability to assess each segment. Pearson's correlation analysis was performed to compare the quality of images obtained at the mean heart rate (HR) of the controls and under conditions of HR variability in the AF patients. The average HR and the HR variability during scanning were 70.3 bpm ± 15.9 and 15.4 bpm ± 6.9 in the AF patients; 60.1 bpm ± 12.9 and 1.4 bpm ± 1.1in the controls. There was a significant difference in the average and the variable HR. In 45 of the 60 AF patients (75%), the optimal reconstruction phase window was the end-diastolic phase (90-99% of the R-R interval), in 7 (11.7%) it was during the end-systolic phase (30-49% window), and in 6 (10%) it was during the mid-diastolic phase (70-89% window). In 53 of the 60 controls (88.3%) the optimal reconstruction phase was mid-diastole; it was end-systole in 4 (6.7%). There was a significant difference in the frequency of the optimal reconstruction phases between the AF patients and the controls but not in the visual scores for image quality and the number of assessable coronary segments. We observed no significant correlation between the mean HR and the visual image quality score. In AF patients there was a significant correlation between HR variability and the visual image quality scores. The optimal reconstruction phase window in most patients with AF was end-diastole (90-99% of the R-R interval); the images had fewer motion artifacts and were of better diagnostic quality. End-diastolic phase reconstruction shows fewer motion artifacts compared to the other cardiac phase reconstruction in three-fourths of patients with AF. SSE04-03 Initial Experience of Intelligent Boundary Registration in Coronary CTA Yan Xing PhD, MD (Presenter): Nothing to Disclose, wen ya liu : Nothing to Disclose, Cunxue Pan PhD : Nothing to Disclose, Gulina Azhati : Nothing to Disclose, Jun Dang : Nothing to Disclose, jing jing LI : Nothing to Disclose, Haiting Ma : Nothing to Disclose, Yan Wei Wang MD : Nothing to Disclose To investigate the feasibility of a novel intelligent boundary registration (IBR) technique to align stair-step artifacts in coronary CT angiography (CCTA). Twenty-one consecutive CCTA exams with varying degrees of coronary artery stair-step artifacts were retrospectively processed with IBR technique on workstation (Advantage Windows 4.6; GE Healthcare). Two observers evaluate stair-step artifacts on IBR on and off images on per-segment basis defined by the 15-segment American Heart Association (AHA) guidelines. The severity of stair-step artifacts was graded with a 5-point grading scale (1.severe, complete discontinuity of the proximal and distal portions of the coronary artery; 2.moderate, discontinuity >50% of the artery diameter; 3.slight, discontinuity 25%-50% of the

110 diameter; 4.minimal, discontinuity <25% of the diameter; and 5.no stair-step artifact). Images scored 1 or 2 were considered non-assessable. Comparisons of variables were performed with Wilcoxon rank sum test and McNemar test. A total of 50 stair-step artifacts were found (35 Right Coronary Artery, 12 Left Coronary Artery, 3 Left Circumflex Artery). Images with IBR on processing were rated as significantly higher image scores versus those with IBR off (Average Image score: 4.42 ±1.13 vs 2.94 ±1.10); (Z=5.681, P=0.000). Stair-step artifacts were fully corrected (Image score = 5 with IBR) in 70% (35/50) of all segments. Images with IBR off processing were rated as significantly higher non-assessable segments versus those with IBR on (Non-assessable rate: 34% vs 10% ); (χ2=8.392, P=0.004). This novel IBR technique is feasible to reduce the severity of stair-step artifacts and increase assessable segments in CCTA. The use of IBR technique may reduce the number and severity of stair-step artifacts in CCTA, potentially increasing diagnostic confidence. SSE04-04 Gadofosvest Trisodium for 100% Navigator Efficiency Coronary Magnetic Resonance Angiography at 3 Tesla Fabio Raman BS (Presenter): Nothing to Disclose, Mark Allan Ahlman MD : Nothing to Disclose, Jianing Pang : Nothing to Disclose, Debiao Li PhD : Nothing to Disclose, David A. Bluemke MD, PhD : Research support, Siemens AG Coronary magnetic resonance angiography (MRA) at 3T suffers from imaging inconsistencies compared to 1.5T despite the use of gadolinium-based contrast agents (GBCAs). Gadofosveset Trisodium (Ablavar, Lantheus Medical Imaging), with its high relaxivity and long intravascular residence time, offers greater potential over standard GBCAs to improve evaluation of the coronary arteries. The purpose of the study was to evaluate the diagnostic potential of a 0.06 mmol/kg dose of Gadofosveset compared to a standard clinical dose of 0.03 mmol/kg, using a free-breathing whole-heart coronary MRA protocol with (1.0 mm)3 spatial resolution and 100% navigator efficiency. The injection protocol was optimized for the prolonged pharmacokinetics of Gadofosveset. Thirty-eight contrast enhanced CMR scans were performed in 19 subjects [4 (21.1%) male; 29.5 ± 7 years; BMI=25.8 ± 6 kg/m2] on a 3.0T Verio Siemens scanner, using an inversion-prepared spoiled gradient-echo sequence. The two scans were separated by a day interval, using dosages of either 0.06 mmol/kg or 0.03 mmol/kg of Gadofosveset. Signal-to-noise ratio (SNR) and contrast-to-noise ratios (CNR) were measured. Qualitative AHA quality scores were evaluated in 11 subjects. Pairwise, Student's t-test and Wilcoxon rank test were performed for quantitative and qualitative assessment (MedCalc Software v12.2.1, MariaKerke, Belgium). Both SNR and CNR were greater in the coronary arteries for double- over single-dose of Gadofosveset (21.2 ± 9.5 vs ± 5.4 and 12.3 ± 8.6 vs. 7.9 ± 4.6, respectively, p<0.001). Individual coronary arteries demonstrated greater SNR enhancement for 0.06 mmol/kg vs mmol/kg for the LMS (18.7 ± 8.5 vs ± 4.9, p<0.001), LAD (24.4 ± 9.0 vs ± 4.3, p=0.001), LCX (16.3 ± 4.6 vs ± 3.5, p=0.005), and RCA (25.4 ± 11.7 vs ± 6.7, p=0.003). CNR comparisons revealed similar results. Qualitatively, a similar number of main and branch vessels were identified by two reviewers. Double dose of Gadofosveset shows improvement in coronary arterial enhancement over standard clinical dose. Patient studies are required to validate its diagnostic efficacy. Because of the small size of the coronary arteries, improved diagnostic quality of MRA is necessary in order to further develop a viable alternative to CT in the evaluation of coronary artery disease. SSE04-05 Comparative Assessment of Image Quality for Coronary CT Angiography Using 3 Iodinated Contrast Agents with Different Iodine Concentrations: A Randomized European Multicenter Trial Filippo Cademartiri MD, PhD (Presenter): Speakers Bureau, Bracco Group Consultant, Guerbet SA Speakers Bureau, Guerbet SA, Jean-Francois Paul MD, PhD : Investigator, F. Hoffmann-La Roche Ltd, Francois H. Laurent MD : Nothing to Disclose, Hans-Christoph Richard F. Becker MD, PhD : Speaker, Bracco Group Speaker, Bayer AG Speaker, Guerbet SA Speaker, Siemens AG Consultant, Amgen Inc, Andrea Laghi MD : Speaker, Bracco Group Speaker, Bayer AG Speaker, General Electric Company Speaker, Koninklijke Philips NV, Stephan Achenbach MD : Research Grant, Siemens AG Research Grant, Bayer AG Research Grant, Abbott Laboratories Speaker, Guerbet SA Speaker, Siemens AG Speaker, Bayer AG Speaker, AstraZeneca PLC Speaker, Berlin-Chemie AG Speaker, Abbott Laboratories Speaker, Edwards Lifesciences Corporation To demonstrate the non-inferiority in diagnostic efficacy of iobitridol (Xenetix 350) compared to iopromide

111 (Ultravist 370) and iomeprol (Iomeron 400) when used for coronary CT scans. Multi-center, randomized, double blind, prospective, non-inferiority phase IV trial including 468 patients with suspected coronary artery disease (CAD) and scheduled for coronary CT angiography. The primary endpoint was the CT scan evaluability for CAD diagnosis in terms of quality and interpretability of images. It was based on the full evaluation by 2 off-site independent readers of 18 coronary segments for each patient. Secondary endpoints comprised both efficacy assessment (mainly image quality, stenosis assessment, and signal quantification) as well as safety assessment, in terms of clinical and electrographic tolerance. Out of the 452 patients completed for the primary analysis, the totality of 18 coronary segments were evaluable in 92.1% of patients from the iobitridol group, versus 94.6 and 95.4% in the iomeprol and iopromide groups respectively. The non-inferiority of iobitridol for the CT evaluation of CAD was statistically demonstrated (p<0.05). Mean image quality was good to excellent for each of the 3 contrast media. No relevant differences were observed for other secondary endpoints between the 3 groups, despite the fact that the amount of iodine (in g) injected was significantly different between the 3 groups: 27.8±3.4 (iobitridol), 29.3±3.8 (iopromide) and 31.7±3.8 (iomeprol), p< Eventually, the good general safety profile of products was confirmed. Coronary CT angiography using Xenetix 350 is non-inferior to more concentrated contrast agents regarding image quality and evaluability while the amount of iodine required can be significantly reduced. Coronary CT angiography using Xenetix 350 is non-inferior to more concentrated contrast agents regarding image quality and evaluability while the amount of iodine required can be significantly reduced. SSE04-06 Comparison of Image Quality between Knowledge Based Iterative Reconstruction and Filtered Back Projection Techniques in Evaluation of Severe Calcified Vessels with Coronary CT Angiography Ling-Ling Gu : Nothing to Disclose, Hong Yu MD, PhD : Nothing to Disclose, Shiyuan Liu PhD : Nothing to Disclose, Yan Jiang MD (Presenter): Employee, Koninklijke Philips NV To compare the image quality of coronary CT angiography with severely calcified vessels between knowledge based iterative reconstruction (IMR, Philips Healthcare) and traditional filtered back projection (FBP) techniques. 43 consecutive patients (27 male and 16 female; mean age 57.3 years) with Agatston scores of at least 400 were scanned with a retrospective ECG-gated helical technique using a 256-MDCT scanner. Image data were reconstructed with both FBP and IMR techniques. Image quality evaluation was performed by two radiologists blindly according to the following features: lumen edge sharpness, contrast between vessels and surrounding tissue, blooming artifacts from calcified plaques, overall diagnostic confidence, using a five-point scale (1[poor] to 5 [excellent]).the subjective scores and image noise were compared by using paired-t test. IMR was better than FBP in lumen edge sharpness and vessel to surrounding tissue contrast (p<0.01). Blooming artifacts from plaques were reduced by IMR compared to FBP (p<0.01). There was no difference in overall diagnostic confidence between IMR and FBP images. Noise was reduced significantly by IMR (p<0.01). By enhancing lumen edge sharpness and vessel tosurrounding tissue contrast, while reducing blooming artifacts, IMR may improve the diagnostic accuracy of coronary CT angiography for severely calcified vessels. By enhancing lumen edge sharpness and vessel to surrounding tissue contrast, while reducing blooming artifacts, IMR may improve the diagnostic accuracy of coronary CT angiography for severely calcified vessels SSE16 Neuroradiology (Advances in Intracranial CT and MR Angiography) Scientific Papers MR IR CT NR AMA PRA Category 1 Credits : 1.00 ARRT Category A+ Credit: 1.00 Mon, Dec 1 3:00 PM - 4:00 PM Location: N230AB

112 Moderator Mark Edward Mullins MD, PhD : Nothing to Disclose Moderator Pina Christine Sanelli MD : Nothing to Disclose Sub-Events SSE D CE-MRA for Imaging of Unruptured Cerebral Aneurysms: A Hospital-based Prevalence Study Jing Li (Presenter): Nothing to Disclose, Bi-Xia Shen : Nothing to Disclose, Chao Ma : Nothing to Disclose, Jianping Lu MD : Nothing to Disclose This hospital-based study suggested a higher prevalence (8.8%) of unruptured cerebral aneurysms observed by three-dimensional contrast enhanced MRA than the results of previous reports. We also found the most common site of aneurysm is the carotid siphon, and most lesions (85.3%) had a maximum diameter of 3-7 mm in the patient cohort. Background Contrast enhanced MRA can help overcome the limitations of other imaging techniques to clearly display the details of cerebral aneurysms. We investigated the prevalence of unruptured cerebral aneurysms by using three-dimensional contrast enhanced MRA in a tertiary comprehensive hospital in China. Evaluation The cases were prospectively recorded at our hospital between February 2009 and October Two observers independently analyzed all MRAs on a workstation to obtain the age-specific prevalence, sex-specific prevalence and characteristics of unruptured cerebral aneurysms. Discussion Of the 3,993 patients (men:women = 2159:1834), 408 unruptured cerebral aneurysms were found in 350 patients (men:women = 151:199). The prevalence was 8.8% overall (95% CI, %), with 7.0% for men (CI, %) and 10.9% for women (CI, %). The overall prevalence of unruptured cerebral aneurysms was higher in women than in men (P<0.001) and increased with age in men and women. Prevalence peaked at age group years. Forty two patients (11.7%) had multiple aneurysms, including 10 (2.9%) male patients and 32 (9.1%) female patients. The most common site of aneurysm was the carotid siphon, and most lesions (85.3%) had a maximum diameter of 3-7 mm. SSE16-02 Color-coded Cerebral CT Angiography: Technical Feasibility and Benefits in Patients with Acute Ischemic Stroke Kolja Thierfelder MD, MSc (Presenter): Nothing to Disclose, Lukas Havla : Nothing to Disclose, Sebastian Ekkehard Beyer : Nothing to Disclose, Felix G. Meinel MD : Nothing to Disclose, Maximilian F. Reiser MD : Nothing to Disclose, Wieland H. Sommer MD : Nothing to Disclose Recently introduced dynamic CT angiography (dcta) provides additional information on cerebral hemodynamics, but small differences in the time delay of maximum enhancement are hard to detect. Our aim was to evaluate a new method of displaying dcta datasets in which the time of maximum enhancement is displayed in a range of colors (color-coded CT angiography, ccta) in different types of acute ischemic stroke. Our sample comprised 16 patients who underwent multiparametric CT due to suspected stroke. MRI-confirmed diagnoses were M1- (6), ACI- (4), both M1- and ACI- (1), and carotid t occlusion (3). Two patients had no cerebral pathology. ccta was reconstructed from whole-brain CT perfusion raw data that were acquired on a 128-slice CT with one scan acquired every 1.5s. The delay of vessel enhancement was quantified using the time-to-maximum (Tmax) of the residue functions. Tmax parameters were color-coded and then filtered. Non-enhancing areas were masked. ccta is a composite image of angiographic data superimposed by colored Tmax maps.two experienced readers evaluated whether ccta provided additional information when compared to conventional CTA alone with respect the Circle of Willis, M1-segment, M2-segement, and leptomeningeal collaterals. The visualization of the collateralization and the diagnostic confidence in determining occlusion site were rated using maximum intensity projections of 20, 40, and 60mm slab thicknesses on 5-point Likert scales. The combined use of CTA and ccta in comparison to CTA alone provided additional information in the assessment of the Circle of Willis in 6/16, the M1-segment in 12/16, the M2-segment in 14/16, and the collateralization status in 15/16 of the patients. Leptomeningeal collaterals were most favorably visualized on the 40- (3.53±0.63), followed by the 60- (3.36±0.50), and the 20mm-MIP (2.92±0.81). The occlusion site was most favorably represented on the 20- (2.71±1.12), followed by the 40- (2.54±1.09), and the 60mm-MIP (1.87±1.20). ccta yields a comprehensive and easy-to-read overview of the cerebral hemodynamics. It provides additional information with respect to collateralization status and occlusion site.

113 ccta is a simple and robust technique that demonstrates cerebral hemodynamics at a glance. It might be beneficial for a fast and reliable assessment of the collateralization status in patients with acute ischemic stroke. SSE16-03 Carotid CT Angiography: Comparison among Low-tube-Voltage Imaging, Monochromatic Imaging and Conventional Imaging with Different Contrast Injection Rate Yunjing Xue MD (Presenter): Nothing to Disclose, Qing Duan MD : Nothing to Disclose, Jin Wei : Nothing to Disclose, Lin LIN : Nothing to Disclose To compare the image quality, radiation dose and contrast medium (CM) dose of Gemstone spectral imaging (GSI) protocol with 3ml/s injection rate, a 100-kVp protocol with 4ml/s rate and a conventional 120-kVp protocol with 5ml/s rate in carotid CTA. With local ethical committee approval, 63 patients were prospectively enrolled in the study, CM (320 mg I/mL) were used: 21 were scanned with parameters of 120 kvp, 240 mas,using CM of 320 mgi/ml with 5ml/s injection rate, another 22 were scanned with 100 kvp, 288 mas, 50% ASiR, using the same CM with 4ml/s injection rate, and the other 20 were scanned with GSI mode, 315 mas, 50% ASiR with 3 ml/s injection rate. Monochromatic images of 60keV were evaluated in GSI group. Image quality (IQ) of the three groups was compared in terms of arterial enhancement, noise, signal-noise-ratio (SNR) and contrast-to-noise ratio (CNR). The effective dose (ED) of radiation and contrast dose were calculated and compared. Data were analyzed by using One-way ANOVA test. The 100-kVp group (443.28±72.58 HU) showed significantly higher enhancement in carotid artery compared to 120-kVp (376.60±62.42 HU) and GSI (365.69±69.43HU) groups (p<0.05, respectively). Both 100-kVp and GSI groups showed significantly lower noise in carotid (11.31±2.20HU, 9.78±2.88HU) and three main branches of thoracic aorta arteries (19.21±3.61HU, 19.05±6.40HU) than 120-kVp group (26.69±4.68HU) (p<0.05, respectively) whereas there was no significant difference in CNR and SNR among three groups (all of them P>0.05). Compared with 120-kVp group (3.21±0.30mSv, 67.5±13.72ml), the ED and CM dose reduced 10.9 % and % in GSI group (2.86±0.07mSv, 49.42±8.91ml), and 25.86% and % in 100-kVp group (2.38±0.002mSv, 58.80±9.81ml), respectively. There was significant difference in comparison between any two groups both in ED and CM dose (all of them P<0.05). Among these three protocols, the GSI (50%ASiR, 3ml/s) used the lowest CM dose while the 100-kVp (50%ASiR, 4ml/s) protocol had the lowest radiation dose. Both GSI and 100-kVp could reduce noise of carotid and three main branches of thoracic aorta and therefore improve IQ. Compared with the 100-kVp protocol, GSI protocol can provide more information. We can balance the image quality, useful information, radiation dose and CM dose of 100-kVp or spectral scanning and choose the optimized CTA protocol to achieve the best clinical effect. SSE16-04 Time Resolved CT Angiography of the Brain: 70kVp Outperforms 80kVp Reade Andrew De Leacy MBBS : Nothing to Disclose, Idoia Corcuera Solano MD (Presenter): Nothing to Disclose, Lawrence N. Tanenbaum MD : Speaker, General Electric Compnny Speaker, Bracco Group Speaker, Bayer AG Speaker, Siemens AG Lower kvp settings for brain CTA offer improved contrast resolution and signal to noise at lower radiation dose. We evaluated the efficacy of 70 kvp and 80 kvp time resolved/4d whole brain CTA extracted from perfusion studies obtained in patients with suspected acute stroke. The institutional review board approved this retrospective study. 37 patients who underwent CTP/ TR CTA of the brain for the investigation of stroke between 12/2012 and 11/2013 were enrolled in this study. 17 patients were imaged using an 80kVp protocol and 20 patients using a 70kVp protocol. Independent subjective assessment of image quality against expected standards of quality for CTA was performed in a blinded fashion by a consensus read of two Neuroradiologists in 16 out of 37 cases (8 from each of the 70kVp and 80kVp groups) using a 5-point scale. The remaining 21 cases could not be qualitatively assessed, as the isotropic data were not preserved in archive. CTDI values for all 37 studies were recorded and the 70 and 80 kvp studies compared. Signal to noise ratios were calculated from the peak arterial phase of the dynamic datasets. Quantitative variables were assessed using Mann-Whitney U test analysis. Qualitative variables were compared using the Student t test for unpaired samples with Welch's correction.

114 Both 70 and 80 kvp CTA groups provided image quality that matched or exceeded expectations. The 70kVp CTA provided statistically significant higher SNR with greater contrast enhancement at 45% lower CTDIvol compared to 80kVp. Time resolved CTA studies at both 70 kvp and 80kVp provide acceptable image quality in the assessment of acute stroke. The 70 kvp studies provided greater enhancement and higher SNR and were lower in dose than those at 80 kvp. Time resolved CTA can be extracted from whole brain perfusion studies avoiding the radiation and iodine dose of a dedicated exam and providing critical dynamic information unobtainable with a static study. This evaluation proves these studies are acceptable in quality and could replace dedicated CTA studies in this setting. Comparison of the efficacy of the 70 kvp studies to those obtained at 80 kvp reveals greater contrast enhancement efficacy and lower dose. This validation study may encourage the widespread adoption of 70kVp CTP/Dynamic 4D CTA techniques in patients with suspected stroke. SSE16-05 X-ray Phase-contrast Computed Tomography: Characterization and Classification of Human Carotid Atherosclerosis Holger Hetterich MD (Presenter): Nothing to Disclose, Marian Willner : Nothing to Disclose, Julia Herzen : Nothing to Disclose, Sandra Fill : Nothing to Disclose, Fabian Bamberg MD, MPH : Speakers Bureau, Bayer AG Speakers Bureau, Siemens AG Research Grant, Bayer AG Research Grant, Siemens AG, Tobias Saam MD : Research Grant, Diamed Medizintechnik GmbH Research Grant, Bayer AG, Franz Pfeiffer : Nothing to Disclose, Maximilian F. Reiser MD : Nothing to Disclose X-ray imaging of vascular pathology relies on X-ray absorption as the source of tissue contrast. However, X-rays are also subject to other physical phenomena including phase-shift, which holds promise to provide substantially improved contrast in low-absorbing materials like biological soft tissue. Techniques for plaque characterization and classification in both in-vivo and ex-vivo imaging have been a major focus in cardiovascular research in the last decade. This study aims to provide evidence for the potential of phase contrast computed tomography (PCT) for tissue characterization and plaque classification in human carotid arteries Human carotid artery specimens were examined at an experimental set-up consisting of X-ray tube (35kV) grating interferometer and detector. Histopathology served as standard of reference. In PCT important plaque components including fibrous (FIB), lipid-rich (LIP) and calcified (CAL) tissue were identified and plaques were classified according to modified AHA criteria as normal intima/type I-II, III, IV/V, VI, VII or VIII by reviewers blinded to histopathology data. Diagnostic accuracies for the detection and differentiation of plaque components and types were evaluated. In total 81 corresponding PCT/histopathology sections were evaluated. FIB, LIP and CAL were detected with sensitivity, specificity and accuracy of In histopathology normal intima/type I-II was present in 23 (28.4%), type III in 8 (9.9%), type IV/V in 12 (14.8%), VI in 10 (12.3%), type VII in 20 (24.6%) and type VIII in 8 (9.9%) of all cross-sections. Sensitivity, specificity and accuracy were high for all analyzed plaque types (all >0.88) with a good level of agreement (κ=0.81). Inter-observer variability was excellent with an intraclass correlation coefficient of 0.91 (κ=0.85). Carotid atherosclerotic plaques can accurately be evaluated by PCT in an ex-vivo setting. Future studies will have to evaluate its potential in-vivo. Phase-contrast computed tomography holds promise for improved, comprehensive assessment of cardiovascular disease including atherosclerotic plaque characterization. SSE16-06 CT Angiography of the Carotid Arteries: Comparison of Lower-tube-Voltage CTA with Lower Iodinated Contrast Injection Rate and Conventional CTA Yunjing Xue MD (Presenter): Nothing to Disclose, Qing Duan MD : Nothing to Disclose, Jin Wei : Nothing to Disclose, Lin LIN : Nothing to Disclose To investigate the clinical value of using a 100-kVp protocol with 50% adaptive statistical iterative reconstruction (ASiR) and with lower contrast injection rate (4ml/s) in carotid CTA by comparison with a conventional 120-kVp protocol with normal contrast injection rate (5ml/s).

115 With local ethical committee approval, 43 patients were prospectively enrolled in the study: 21 were scanned with parameters of 120 kvp, 240 mas, using contrast medium (CM) of 320 mg I/mL with 5ml/s injection rate, and the other 22 were scanned with 100 kvp, 288 mas, 50% ASiR using the same contrast of 4ml/s injection rate. Image quality (IQ) of the two groups was compared in terms of HU of enhanced arterial, noise, signal-noise-ratio (SNR) and contrast-to-noise ratio (CNR). The effective dose (ED) of radiation and contrast dose were calculated and compared. Data were analyzed by using Independent samples t test. The carotid artery in 100-kVp (50% ASiR, 4ml/s) group (443.28±72.58HU) demonstrated higher enhancement than that of 120-kVp group (376.60±62.42HU), (P<0.05). Both carotid and three main branches of thoracic aorta showed lower image noise in 100-kVp (11.31±2.20HU, 19.21±3.61HU) than that of 120-kVp group (14.29±2.81HU, 26.69±4.68HU), (P<0.05, respectively). The CNR and SNR of carotid artery and three main branches of thoracic aorta has no significant differences statistically between two groups (all of them P>0.05), respectively. The effective dose and contrast dose of the 100-kVp with 4ml/s protocol (2.38±0.002 msv, 58.80±9.81ml ) was 25.86% and 12.89% lower than that of the 120-kVp with 5ml/s protocol (3.21±0.30 msv, 67.5±13.72 ml), respectively. There was significant difference statistically in effective dose of radiation and contrast dose between two groups (P<0.05), respectively. The use of 100 kvp with 50% ASiR and lower injection rate of CM could provide higher artery enhancement and superior image quality than that of 120-kVp protocol with a smaller amount of iodine and a lower radiation dose. A low tube voltage with ASiR technique and lower injection rate has a potential clinical application prospect by moderately decreasing radiation and contrast agent doses with superior image quality at carotid CTA. SSE25 ISP: Vascular/Interventional (IR: Topics of Interest/GU) Scientific Papers IR GU AMA PRA Category 1 Credits : 1.00 ARRT Category A+ Credit:.50 Mon, Dec 1 3:00 PM - 4:00 PM Location: N226 Moderator James R. Duncan MD, PhD : Consultant, Novita Therapeutics, LLC Consultant, Proteon Therapeutics, Inc Moderator Robert G. Dixon MD : Nothing to Disclose Sub-Events SSE25-01 Ready or Not: Are Medical Students Prepared to Decide between Diagnostic Radiology and Interventional Radiology? Jessica Kelly Stewart MD (Presenter): Nothing to Disclose, Charles M. Maxfield MD : Nothing to Disclose, Mark Lewis Lessne MD : Nothing to Disclose In 2012, the American Board of Medical Specialties approved a new Dual Primary Certificate in Interventional Radiology and Diagnostic Radiology (IR/DR), recognizing IR as a distinct medical specialty. Independent IR/DR training programs will soon select their first trainees, requiring that medical students decide between IR/DR and DR residency programs early in their fourth year. The purpose of this study is to determine whether medical students are prepared to decide between the newly distinct residency training programs of DR and IR/DR. An electronic survey was sent to all US radiology residency programs, requesting distribution to third and fourth year (R3 and R4) residents. The anonymous survey was comprised of closed-response questions focusing on choice of fellowship, the timing of this fellowship decision, and the impact of residency rotations on this choice. 385 R3 and R4 residents completed the survey. 76% of the respondents were male and 24% were female. 35% of residents reported that they would be pursuing subspecialty training in IR. Of the R3 and R4 residents responding to the survey, 69% considered both IR and DR while deciding as

116 medical students to pursue radiology residency. Only 14% of responding residents chose a radiology residency for the sole purpose of pursuing IR. 61% of the 133 residents who plan to pursue IR subspecialty training also considered DR as medical students. 74% of R3 and R4 residents reported that IR rotations during their radiology residency were important in making the ultimate decision of whether to pursue an IR fellowship. A minority of residents planning to pursue IR fellowship training make this decision as medical students. Currently, the decision to pursue IR specialization is most often made after completing IR rotations as a radiology resident. Medical school mentors and IR and DR physicians must soon improve efforts to educate medical students and create opportunities for extensive exposure to these distinct specialties and training programs. Additionally, DR and DR/IR residency programs should anticipate requests for transfers between these programs within the same institution. Most R3 and R4 residents report that IR rotations in residency were important in choosing whether to pursue IR. Increased medical student education and exposure to IR and DR will be necessary as new IR residency programs are initiated. SSE25-02 Vascular/Interventional Keynote Speaker: Do Medical Students Know Who Interventional Radiologists Are? Robert G. Dixon MD (Presenter): Nothing to Disclose SSE25-03 Trends in Non-Vascular Interventional Radiology Procedures Performed by Advanced Practice Providers: An Analysis of Annual Medicare Claims over Two Decades Deborah Gail Walls MS, RN (Presenter): Nothing to Disclose, Michael Bowen : Nothing to Disclose, Danny Hughes PhD : Nothing to Disclose, Jennifer Marie Hemingway MS : Nothing to Disclose, Jennifer M. Wang PhD : Nothing to Disclose, Richard Duszak MD : Nothing to Disclose To evaluate national trends in non-vascular interventional procedures performed by nurse practitioners (NPs) and physicians assistants (PAs), collectively advanced practice providers (APPs). Non-vascular interventional procedures commonly performed by APPs at our two largest hospitals were used to identify index procedures for national analysis. Corresponding services were identified using Medicare Physician Supplier Procedure Summary Master Files from 1991 to National APP trends were analyzed for: paracentesis; thoracentesis; liver, renal and other abdominal biopsy; lung biopsy; superficial lymph node biopsy; and fine needle aspiration (FNA). Similar analytics were undertaken for services performed by radiologists. Between 1991 and 2012 Medicare claims by APPs increased dramatically for all targeted procedures: paracentesis from 0 to 17,967; thoracentesis from 0 to 4,141; liver, renal, and other abdominal biopsy from 0 to 1,819; lung biopsy from 0 to 25,443; superficial lymph node biopsy from 0 to 5,740; and FNA from 0 to 3,921. Overall, volumes increased for radiologists as well, but relatively less dramatically: paracentesis from 2,175 to 139,144 (+6,297%); thoracentesis from 2,084 to 35,787 (+1,617%); liver, renal and other abdominal biopsy from 9,663 to 86,423 (+794%); lung biopsy from 11,078 to 54,060 (+388%); superficial lymph node biopsy from 111 to 14,951 (+13,369%); and FNA from 531 to 96,504 (+18,074%). Although APPs perform a relatively small portion of non-vascular interventional procedures commonly provided by radiologists, successful Medicare claims have increased dramatically over two decades, and at a faster pace. Given multiple hurdles for Medicare reimbursement, such growth suggests increasing acceptance at institutional credentialing, state licensure, and payer policy levels. National acceptance of APPs performing non-vascular interventional procedures has increased dramatically. SSE25-04 Correlation of Prostate Specific Antigen Levels Obtained by Internal Iliac Venous Sampling to Radical Prostatectomy Specimens in Patients with Prostate Cancer: A Pilot Study Cormac Farrelly MD (Presenter): Research Grant, F. Hoffmann-La Roche Ltd, Priti Lal MD : Nothing to Disclose, Scott O. Trerotola MD : Royalties, Cook Group Incorporated Consultant, Medical Components, Inc Consultant, C. R. Bard, Inc Consultant, Teleflex Incorporated Consultant, W. L. Gore & Associates, Inc Consultant, B. Braun Melsungen AG Consultant, Medical Components, Inc Royalties, Teleflex Incorporated Research Grant, Vascular Pathways, Inc, Gregory Jon Nadolski MD : Nothing to Disclose, Micah M. Watts MD : Nothing to Disclose, Catherine Mc Gorrian MRCPI : Nothing to Disclose, Thomas J. Guzzo MD, MPH : Nothing to Disclose To correlate prostate specific antigen(psa) values and free to protein-bound PSA ratios(fpsa/psa) in specimens taken from peripheral upper limb, internal iliac and deep branch internal iliac veins bilaterally to prostatectomy specimens in patients with prostate adenocarcinoma and borderline elevation of PSA.

117 7 patients with biopsy proven prostate cancer had venous sampling procedure prior to prostatectomy(mean 3.2 days, range: 1-7). All had borderline elevation of PSA on prior peripheral venous sampling(4-10 ng/ml). Sampling procedure involved peripheral vein sample(pvs) taken from a 5 Fr sheath in right basilic vein. Pelvic vein samples were taken through a 5Fr catheter fluoroscopically guided into right internal iliac vein(riv), deep right internal iliac vein branch(driv), left internal iliac vein(liv), and deep left internal iliac vein branch(dliv). Venous sampling results were compared to prostatectomy surgical specimens. Mean PVS PSA was 3.9, range ng/ml. Total PSA in PVS did not differ significantly from internal iliac or deep internal iliac vein samples(p>0.05). Total PSA in RIV and driv did not differ significantly from LIV or dliv samples(p>0.05). fpsa/psa was significantly higher in internal iliac and deep internal iliac vein samples compared to PVS(p<0.05). Compared to contralateral internal iliac and contralateral deep branch internal iliac vein fpsa/psa did not correlate positively with the side of highest tumor volume(p>0.05). On pathology, 6 patients had tumor in both sides of the prostate. fpsa/psa was highest on the side ipsilateral to the highest grade of tumor in all 7 patients. 1 of 7 patients had unilateral left sided prostate cancer. This patient had a fpsa/psa ratio of 6% from PVS, 6% from RIV and 14% from LIV samples. There were no procedural complications. Free PSA, unlike total PSA, is significantly higher in pelvic vein compared to peripheral vein samples when prostate cancer is present. This prospective pilot study suggests that fpsa/psa is higher in pelvic veins ipsilateral to highest grade tumor. Larger studies including patients with higher PSA values are warranted to further investigate this counterintuitive finding. This new minimally invasive procedure could help localize prostate cancer within the pelvis thus helping to guide biopsies, select patients for new localized therapies and detect local recurrence post surgery. SSE25-05 Left Renal Vein Compression as Cause for Varicocele: Prevalence and Associated Findings on Contrast-enhanced CT Douglas Smoot Lewis MD (Presenter): Nothing to Disclose, Lars J. Grimm MD : Advisory Board, Medscape, LLC, Charles Yoon Kim MD : Consultant, CareFusion Corporation Research Grant, Galil Medical Ltd Consultant, Kimberly-Clark Corporation Consultant, Cryolife, Inc While numerous etiologies for varicocele formation have been proposed, none have been well-proven. The purpose of this study was to determine the contribution of left renal vein compression in patients with varicocele. Using a radiology report search engine, all contrast-enhanced CT scans and ultrasound examinations performed at our institution over the past 10 years with a diagnosis of varicocele were identified. Patients were included only if they had a concurrent contrast-enhanced CT scan. Analysis was performed on 101 male patients (mean age 50.3 years). On CT, the left renal vein (LRV) was analyzed for greater than 50% compression by the SMA (nutcracker morphology) or any other structures. As a control group, 99 asymptomatic patients undergoing contrast-enhanced CT as potential renal transplant donors were analyzed. A varicocele was identified on the left in 68 patients, right in 9 patients, and bilaterally in 24 patients. Compression of the left renal vein was identified significantly more commonly in patients with a left varicocele (78%) compared to patients with a right (13%, p<0.001) or bilateral (42%, p=0.002) varicocele. 64% of left renal vein compressions were due to nutcracker morphology and 36% were due to a retroperitoneal lymph node, most commonly due to pancreatic or renal cell carcinoma. In total, LRV compression by a lymph node was found in 30% of left-sided varicoceles. Excluding patients with retroperitoneal lymphadenopathy, the prevalence of nutcracker morphology was significantly higher for patients with left-sided varicocele (69%) compared to the control group (27%, p<0.001), whereas the prevalence of nutcracker morphology in patients with right (13%) or bilateral (33%) varicocele was similar to controls. Left renal vein compression by the SMA or a mass was significantly more common in isolated left-sided varicoceles compared to right-sided and bilateral varicoceles in this predominantly adult population. Furthermore, nutcracker phenomenon was identified significantly more commonly in patients with a left-sided varicocele compared to an asymptomatic control group. Both nutcracker morphology and malignant lymph nodes are significantly associated with isolated left-sided varicoceles, suggesting that attention on imaging is likely warranted.

118 SSE25-06 Internal Iliac Artery Occlusion Decreases Prostate Volume and Urologic Symptoms: Evidence for Potential Efficacy of Prostate Artery Embolization? Amy Robin Deipolyi MD, PhD (Presenter): Nothing to Disclose, Shehab A. Alansari MD : Nothing to Disclose, Shahin Tabatabaei MD : Education Advisory Board, Endo Health Solutions Inc Scientific Advisory Board, TARIS BioMedical, Inc, Suvranu Ganguli MD : Research Grant, Merit Medical Systems, Inc Consultant, Boston Scientific Corporation, Rahmi Oklu MD, PhD : Nothing to Disclose Benign prostatic hyperplasia (BPH), widely prevalent in men over 50 years old, is associated with significant disability and healthcare cost. Prostate artery embolization (PAE) has been shown to be an effective interventional radiology treatment in other countries but is not approved in the US, limiting its study here. We evaluated the impact of internal iliac artery occlusion (IIAO) on prostate volume and urologic symptoms. We reviewed 95 sequential male patients who underwent abdomen-pelvis CTA with runoff for evaluation of lower extremity claudication, including those 50 years of age and older and excluding those with prior prostate surgery, radiation or hormone therapy. We measured the diameter of both internal iliac origins and assessed for the presence of IIAO. Prostate volume was calculated from three diameters. Medical records were reviewed for PSA levels and urologic symptoms (i.e., hesitancy, frequency, urgency, nocturia) and symptoms of IIAO (buttock claudication, impotence). Statistical analyses included student's t test, Fisher's exact test and linear regression. We included 77 men, 46 with patent internal iliac arteries and 31 men with either unilateral or bilateral occlusion. There was no difference in age between groups (mean 68 vs 64 years; p>0.1). However, men without IIAO had significantly larger prostates (mean 29cc, range 12-96cc), compared with men with IIAO (mean 19cc, range 8-67cc) (p=0.01). Prostate volume correlated with average internal iliac artery diameter (r2=0.2; p 0.05). Men without IIAO were significantly more likely to have PSA levels assessed (66%) compared to men with IIAO (32%) (p=0.005). There was no significant difference in the number of men with impotence (8% vs 0; p>0.1) or with buttock claudication (17% vs 19%; p>0.1) in men without or with IIAO, respectively. IIAO is associated with a 33% decrease in prostate volume and decreased urinary complaints, suggesting that PAE is likely an effective treatment for symptoms of BPH. Our findings furthermore suggest that unilateral and proximal arterial occlusion may be sufficient for therapeutic effect. Internal iliac artery occlusion predicts reduced prostate volume, suggesting prostate artery embolization may be an effective interventional therapy for benign prostatic hyperplasia. SPSH30 Hot Topic Session: Advances in Musculoskeletal Tumor Ablation Special Courses US MR IR MK AMA PRA Category 1 Credits : 1.00 ARRT Category A+ Credit: 1.00 Tue, Dec 2 7:15 AM - 8:15 AM Location: E351 Moderator Mark Richard Robbin MD : Nothing to Disclose Sub-Events SPSH30A Update on Osteoid Osteoma Radiofrequency Ablation Mark Richard Robbin MD (Presenter): Nothing to Disclose 1) Understand the current practice and literature of Osteiod Osteoma ablation. 2) Discuss different techniques of Osteoid Osteoma ablation. 3) Review techniques of ablation of other benign Bone Tumors. SPSH30B Cryoablation and Microwave Treatment of Metastatic Disease to Bone Damian E. Dupuy MD (Presenter): Research Grant, NeuWave Medical Inc Board of Directors, BSD Medical Corporation Stockholder, BSD Medical Corporation Speaker, Educational Symposia 1) Review the current microwave and cryoablation technology. 2) Understand the current clinical indications and how both thermal technologies are applied to patients with osseous metastatic disease. 3) Learn the pearls

119 and pitfalls of implementation through clinical examples. SPSH30C MR-guided Focused Ultrasound Treatment of Painful Bone Metastases David C. Gianfelice MD (Presenter): Nothing to Disclose 1) Introduce technology of MR Guided focused ultrasound ablation 2) Specific application of this technology for painful bone metastases 3) Review of the literature and definitive Phase 3 study 4) Possible future applications RC323 Minicourse: Recording and Reporting Radiation Dose: Interventional/Angiography/Fluoroscopy Refresher/Informatics IR SQ PH AMA PRA Category 1 Credits : 1.50 ARRT Category A+ Credits: 1.50 Tue, Dec 2 8:30 AM - 10:00 AM Location: N229 Sub-Events RC323A Issues in Interventional Fluoroscopy Procedures Stephen Balter PhD (Presenter): Nothing to Disclose 1) Be able to describe effects on patient's skin, hair, eyes, and other tissues resulting from fluoroscopically-guided interventional procedures. 2) Be able to adequately communicate FGI radiation risk as part of the informed consent process. 3) Understand the use of real-time displays of radiation quantities and their relation to radiation risks. ABSTRACT Some fluoroscopically-guided interventional procedures (FGI) require the use of a substantial amount of radiation for their completion. Radiation can be regarded as a toxic agent in the same sense that contrast-media and drugs can be toxic if inappropriately used. The interventional radiologist should have reasonable knowledge of the toxic effects of radiation on patients at dose levels that may occur during IR procedures. These include short-term tissue reactions on the skin, hair loss, and radiogenic cataracts. Longer term effects such as cancer induction are of importance for some patients. Because radiation is potentially toxic, its risks should be appropriately discussed during the informed consent process. The display of reference air kerma and kerma area product provide risk information to the radiologist while performing a procedure. This is intended to provide ongoing inputs into a continuous evaluation of benefit-risk. RC323B Measurements and Dose Calculations Beth A. Schueler PhD (Presenter): Nothing to Disclose 1) Review methods of measuring patient radiation dose during fluoroscopically-guided interventional procedures. 2) Compare the advantages and limitations of dose measurement methods. 3) Understand parameters that are used to describe patient entrance dose. 4) Learn about new methods for skin dose calculation and recording. ABSTRACT The measurement of patient dose during fluoroscopically-guided interventional procedures is an important tool for assessment of individual patient radiation risk. Moreover, the display of patient dose is valuable as feedback to the operator to aid in optimization of radiation exposure. Many different methods of measuring fluoroscopy dose have been developed, including direct methods (dosimeters and film) and indirect methods (fluoroscopy time, dose-area-product meters and reference point air kerma estimation). This presentation will review the advantages and limitations of each of these methods, along with common dose metrics that fluoroscopy operators, medical physicists and technologists should be familiar with. In addition, we will discuss skin dose mapping methods that are currently being developed. Active Handout sec.pdf RC323C Establishing an Interventional Radiology Patient Radiation Safety Program

120 RC323C A. Kyle Jones PhD (Presenter): Nothing to Disclose 1) List the radiation dose descriptors that should be recorded at the conclusion of a fluoroscopy-guided procedure. 2) Describe the actions that may be taken during the three phases of a fluoroscopy-guided procedure to enhance patient safety. 3) Discuss how to recognize cases that are outside the normal control limits of an interventional radiology practice. ABSTRACT An interventional radiology patient safety program is essential to better educate patients who are scheduled to undergo fluoroscopically guided interventional radiology procedures; monitor radiation doses delivered during procedures and reduce the risk of tissue effects; ensure appropriate medical management of patients experiencing significant peak skin doses; and for practice quality improvement through analysis of procedural data and exceptional cases. The program combines preprocedure evaluation and counseling, intraprocedure monitoring, and postprocedure documentation and counseling consistent with guidelines from the National Cancer Institute and the Society of Interventional Radiology. Implementation of a patient safety program is straightforward, requires little infrastructure and few resources, and can be applied in most interventional radiology practices. RC350 CTA from Head to Toe (How-to Workshop) Refresher/Informatics VA CT CA IR AMA PRA Category 1 Credits : 1.50 ARRT Category A+ Credits: 1.50 Tue, Dec 2 8:30 AM - 10:00 AM Location: E260 Moderator Alison Wilcox MD : Speaker, Toshiba Corporation Sub-Events RC350A Cardiac CT- Pre, Peri and Post Procedural Management Bonnie Garon MD (Presenter): Nothing to Disclose 1) Review preprocedural patient preparation including appropriate patient selection, beta blockade, contraindications and alternatives beta blockers. 2) Discuss how to manage nonstandard patients (atrial fibrillation, pacemaker, young adults). 3) Periprocedural issues including vasodilation, continued heart rate control, and breathholding requirements. 4) Image acquisition including radiation dose reduction techniques, technique choice, and post CABG patient. 5) Postprocedural complications include contrast reactions and their management. ABSTRACT Cardiac CTA involve slightly more preparation than the standard CT acquisition. Heart rate control is the most important aspect that needs to be addressed prior to the patient arriving in the radiology department. Periprocedural issues mostly involved how to optimize technique while having the lowest radiation dose especially in the new age of dose reduction. Almost as important as heart rate management is how to treat postprocedural complications especially contrast reactions. This presentation will discuss these aspects and include treatment options as well as their alternatives. RC350B TEVAR/EVAR- Pre, Post and Periprocedural Evaluation Alison Wilcox MD (Presenter): Speaker, Toshiba Corporation 1) What are some clinical indications for acute aortic imaging. 2) What are some CT parameters that can aid in various diagnosis? 3) What are some of common complications seen in TEVAR and EVAR? 4) What are the important measurements and vessel variants that help guide surgical approach. 5) New suggestions for type B management. 6) What are some imaging problems and pitfall and some methods to assist. 7) Briefly discuss TAVR acquisition. ABSTRACT The acute aorta is part of a syndrome of diseases affecting the aorta with significant overlap of findings and clinical presentations. Clinically the diagnosis is difficult as there is overlap between patients with suspected coronary disease, pulmonary embolism and acute aortic syndrome. In the past several years, minimally invasive surgery with Thoracic Endovascular Aortic Repair (TEVAR) or Endovascular Aortic Repair (EVAR) have

121 become increasingly popular. The images choices include gated vs non gated studies, non-contrast imaging, and delayed imaging. The literature is mixed on how and when to use these modalities. The complications of these procedures is often complex and subtle as well. Knowledge of these vascular complications is imperative for patient management. In addition, these patients often have significant atherosclerotic disease elsewhere that might be limiting factors for stent placement, including renal insufficiency. Newer scanners and imaging techniques can reduce radiation dose, and limit the amount of contrast delivery to preserve renal function while preserving image quality. TAVR is an example of another minimally invasive technique gaining popularity that has imaging challenges. Again, newer scanning techniques with limited contrast delivery can provide excellent image quality while limiting radiation dose and preserving renal function. RC350C Peripheral CTA A How-to Ilya Lekht MD (Presenter): Nothing to Disclose 1) Enhance knowledge of normal and abnormal coronary and cardiac anatomy, with an emphasis on differentiating benign from significant variants. 2) Demonstrate the spectrum of nonatherosclerotic congenital and acquired diseases that may affect the coronary arteries. 3) Demonstrate the spectrum of non-atherosclerotic congenital and acquired diseases that may affect the heart. ABSTRACT A variety of non-atherosclerotic conditions are detectable on cardiac CT scans, including diseases of the heart, and disease processes which may affect the coronary arteries, or other vascular structures. Cardiac CT has a number of unique advantages in detecting non-atherosclerotic conditions, including congenital and acquired diseases. The focus of this presentation will be non-atherosclerotic conditions of the coronary arteries and of the heart. Variants of normal and abnormal anatomy of the coronary arteries will be discussed, including tips for identifying when coronary anatomic variants are significant. Acquired, non-atherosclerotic diseases of the coronary arteries will also be discussed. This presentation will also discuss the spectrum of non-atherosclerotic diseases of the heart which may be detected at cardiac CT, including congenital and acquired valvular and cardiac diseases. At the end of this exhibit, the viewer will have a better appreciation for abnormal coronary and cardiac anatomy and the broad spectrum of non-atherosclerotic cardiovascular diseases which may be seen at cardiac CT. RC353 3D Printing: A Powerful Tool for Applied Imaging Science Refresher/Informatics IN IR VA NR IN IR VA NR IN IR VA NR AMA PRA Category 1 Credits : 1.50 ARRT Category A+ Credits: 1.50 Tue, Dec 2 8:30 AM - 10:00 AM Location: N226 Moderator Frank John Rybicki MD, PhD : Research Grant, Toshiba Corporation 1) To review current applications for 3D printing in biomedical imaging science. 2) To discuss clinical problems in radiology for which imaging science with 3D printing can potentially improve patient care. ABSTRACT In broad terms, 3D printing can be used for to enhance clinical care and to enable investigation that would otherwise not be possible. This talk focuses on those research applications. For example, 3D models of individual phantoms will enable studies in CT that may be limited by radiation concerns, the delivery of large volumes of contrast, or both. In addition, research can be used to simulate individual organ systems. Finally, complicated pathophysiology may be amenable to 3D models and thus 3D technologies can expand current research in multiple applications. URL's Sub-Events RC353A Validation of Coronary Contrast Gradients Using 3D Coronary Phantoms Dimitris Mitsouras PhD (Presenter): Nothing to Disclose View learning objectives under main course title. ABSTRACT

122 3D printed models are poised to expand current investigations toward accurate functional CT and MR imaging that will likely open new horizons for diagnostic tool development that is not otherwise feasible due to patient considerations such as radiation burden, scan time, and monetary cost. 3D printing can produce hollow structures (e.g. vessels and airways) that, with appropriate selection of the printing technology (particularly with respect to the so-called "support" material) can replicate human physiology, including at the moment vascular compliance. Vascular phantoms have been successfully created from rotational digital subtraction angiography, CR, and MRI data sets. Early attempts begun with negative molds, namely 3D printing of a solid lumen to be used as mold around which to cure a silicon "vessel" wall. At present, the "vessel" wall can be printed with high accuracy ( RC353B Blood Flow in the Thoracic Aorta Elucidated with 3D Models Michael Markl PhD (Presenter): Nothing to Disclose View learning objectives under main course title. ABSTRACT Flow sensitive MRI offers the ability to assess anatomy as well as flow characteristics in healthy and pathological blood vessels and is therefore an attractive tool for the diagnosis of vascular diseases. However, in-vivo studies do not allow the prediction of hemodynamic changes due to vascular modifications. Realistic vascular in-vitro 3D phantoms in combination with MRI flow measurements allow to model different vascular deformations and evaluate their effect on blood flow dynamics. This presentation will provide a review of the methods for the in-vitro simulation of aortic 3D blood flow with realistic boundary conditions and review previously reported application for the simulation of common aortic pathologies and their impact on aortic hemodynamics. RC353C 3D Printing in Interventional Radiology and Vascular Surgeries Matthew D Tam FRCR (Presenter): Nothing to Disclose 1) Describe potential workstream flows from CTA to a 3D printed model of the aorta. 2) Discuss the potential role of solid and hollow models of the vasculature to aid procedure planning, procedure execution and patient outcomes. 3) Gain an insight into future developments of the 3D printing industry. ABSTRACT 3D printing has a major role to play in healthcare - procedure planning and execution, implant and device design, as well as facilitating better patient communication strategies and patient outcomes. Anatomically accurate patient-specific models of the vasculature can be constructed using 3D printing technologies. CT angiograms and DICOMS can be processed and the data converted into computer-aided design files using a range of different techniques and software. CAD files can then be 3d printed. In the setting of endovascular aneurysm repair, solid models of the lumen can be created and may be used to better understand complex anatomy. Hollow models can be created which can facilitate procedure execution through patient-specific rehearsal. 3D printing technologies will have further impact upon vascular and interventional radiology as both software, hardware and material science improves. RC353D 3D Printing in Otolaryngology Glenn E. Green MD (Presenter): Nothing to Disclose, Maryam Ghadimi Mahani MD (Presenter): Nothing to Disclose View learning objectives under main course title. RC353E 3D Printing of Viable Tissues Roger R. Markwald PhD (Presenter): Nothing to Disclose 1) Understand the development of the use of 3D applications in support of surgical reconstruction. 2) Describe the use of 3D Medical Applications in the support of Wounded Warrior Care. ABSTRACT Digital design and manufacturing technologies have been leveraged by the military in support of Wounded Warrior care since before the year A dedicated service for medical modeling was developed at the WRNMMC to provide 3D planning and manufacturing in the support of the DOD and wounded warrior care, expanding services to surgical simulations, development of surgical guides and custom implants, as well as support of research, occupational health and prosthetics world- wide. The purpose of this presentation is to present a review of the development of the use of digital design, digital manufacturing, and the establishment of 3D Medical Applications Center in support of Wounded Warrior Care.

123 URL's RC353F Future Applications in 3D Printing Frank John Rybicki MD, PhD (Presenter): Research Grant, Toshiba Corporation 1) To review the current innovative literature in 3D printing related to radiology. 2) To hypothesize and discuss future applications in 3D printing for radiology. ABSTRACT One of the main applications of 3D visualization is to enhance diagnoses for which the anatomy in question is complex. Additionally, the planning for a specific intervention often requires a volumetric assessment. 3D printing in radiology is rapidly growing as a means to realize real 3D objects in 2D surfaces. The promise of this technology in the near future has spawned several new hypotheses that may define future applications. The purpose of this lecture is to review the literature and discuss novel ways that printed models can enhance radiology diagnoses and investigations. URL's VSIR31 Interventional Series: Complications in Interventional Oncology - Avoidance, Recognition and Management Series Courses ED OI IR AMA PRA Category 1 Credits : 3.25 ARRT Category A+ Credits: 3.75 Tue, Dec 2 8:30 AM - 12:00 PM Location: E353A Moderator Charles E. Ray MD, PhD : Nothing to Disclose 1) List 2 important recent publications in interventional oncology. 2) Explain the mechanism of one complication related to thermal ablation. 3) Describe 1 pitfall of radioembolization. 4) Outline 3 complications in combination therapy for hepatocellular carcinoma. 5) List three complications of chemo-embolization. 6) Describe rationale for and against training programs in interventional oncology. Sub-Events VSIR31-01 Chemo-Embolization Cxs Charles E. Ray MD, PhD (Presenter): Nothing to Disclose View learning objectives under main course title. VSIR31-02 Effect of Intra-Arterial Therapies to Treat Liver Cancer on Portal Hypertension: Non-Invasive Assessment of Surrogate Markers of Portal Venous Pressure Rafael Duran MD : Nothing to Disclose, Julius Chapiro MD : Nothing to Disclose, Ahmet Bas MD : Nothing to Disclose, MingDe Lin PhD : Employee, Koninklijke Philips NV, Ruediger Egbert Schernthaner MD : Nothing to Disclose, Jae Ho Sohn MS (Presenter): Nothing to Disclose, Gayane Yenokyan PhD : Nothing to Disclose, Jean-Francois H. Geschwind MD : Consultant, BTG International Ltd Consultant, Bayer AG Consultant, Guerbet SA Consultant, Nordion, Inc Grant, BTG International Ltd Grant, F. Hoffmann-La Roche Ltd Grant, Bayer AG Grant, Koninklijke Philips NV Grant, Nordion, Inc Grant, ContextVision AB Grant, CeloNova BioSciences, Inc Founder, PreScience Labs, LLC CEO, PreScience Labs, LLC

124 Theoretically intra-arterial therapies (IATs) are mainly targeting tumor tissue. However, part of the payload is inevitably delivered to non-tumoral liver tissue, thus potentially causing damage over time which in return may influence the portal venous pressure (PVP). The aim of this study was to investigate potential effects of IATs on PVP using non-invasive surrogate markers of portal hypertension. This retrospective analysis included 107 patients (57 in hepatocellular carcinoma (HCC) group and 50 in metastatic group) who underwent IATs and had longitudinal pre-/post- therapy contrast-enhanced (ce)mri as well as blood work follow-up. Porto-systemic shunts, ascites, and vascular invasion were evaluated on MRI. In addition, splenic volumes were measured on portal-venous-phase cemri. Platelet count (PC; in 10 9 /L) and liver function were evaluated. Generalized linear mixed effects models with random intercept for patient and random slope for time trajectory were used to assess associations between IAT and the outcomes adjusting for potential confounders and accounting for the longitudinal nature of the data. A total of 291 IAT procedures (230 ctace, 47 DEB-TACE and 14 Y90 radioembolization) were performed. Spleen volume showed a linear increase with additional IAT sessions by on average of 17cm3/session (95%CI:7-27, p<.0001) after controlling for IAT method, diagnosis, spleen volume and ascites status at baseline. Patients treated with ctace or DEB-TACE showed an association with a higher PC as compared to Y90 radioembolization, with values of 51 (P=.02) and 75 (p=.005) units above radioembolization, respectively. There was no statistically significant difference in PC between ctace and DEB-TACE. PC showed a decrease with each additional IAT session by 12 units (95%CI:3-20, p=.008) after controlling for IAT method, diagnosis and PC at baseline. Preliminary results indicate that those IATs with larger embolic effects (ctace/deb-tace) lead to a larger increase of PVP and higher PC over time as compared to procedures with less embolic effect (Y90). IATs seemed to increase PVP over time however with low complications-rate related to increased portal hypertension. VSIR31-03 Safety of Radioembolization with 90Yttrium-microspheres Depending on Coiling or No-coiling of Aberrant/High-risk Vessels Philipp Marius Paprottka (Presenter): Nothing to Disclose, Karolin Johanna Kutter : Nothing to Disclose, Alexander Haug MD : Nothing to Disclose, Christoph Gregor Trumm MD : Nothing to Disclose, Tobias Franz Jakobs MD : Speaker, Sirtex Medical Ltd Research Consultant, Sirtex Medical Ltd Speaker, Siemens AG Speaker, Terumo Corporation Speaker, Surefire Medical, Inc, Maximilian F. Reiser MD : Nothing to Disclose, Christoph Johannes Zech MD : Research Grant, Bayer AG Speaker, Bayer AG Travel support, Bayer AG Advisory Board, Bayer AG Speaker, Bracco Group Travel support, Bracco Group To evaluate the safety of radioembolization with 90Yttrium-microspheres depending on coiling or no-coiling of aberrant/high-risk vessels. The early and late toxicities of 566 radioembolization procedures were retrospectively analyzed according to the National Cancer Institute's Common Terminology Criteria for Adverse Events (CTCAE v3.0). In 240 procedures the aberrant vessels were coiled prior to radioembolization and in 326 procedures we chose a more peripheral position to treat the right or left liver lobe. According to the CTCAE criteria clinical relevant late toxicities ( Grade 3) could only be observed in 1% of our patients. Furthermore our statistical analysis showed significant less any" (p=0,0001) and clinical relevant" (p=0,0003) early complications for no-coiling. There was no significant difference (p > 0.05) in delayed toxicities depending on actually recommended coiling of aberrant/high-risk vessels prior to treatment in comparison to choosing a peripheral treatment position. No radiation induced liver disease was noted in 566 procedures. Radioembolization with 90Yttrium-microspheres is a safe and effective treatment option. Performing of radioembolization without coiling aberrant vessels prior to treatment could be an alternative option for experienced centers. Our findings could lead to a change of the pre-interventional radioembolization work-up VSIR31-04 Evaluation for Radioembolization in HCC: CT Predictors for High Hepatopulmonary Shunt Fractions

125 VSIR31-04 and Changes Following Sorafenib Therapy Jens Matthias Theysohn MD (Presenter): Nothing to Disclose, Juliane Schelhorn MD : Nothing to Disclose, Jens-Christian Altenbernd : Nothing to Disclose, Stefan P. Mueller MD : Consultant, BTG International Ltd, Michael Forsting MD : Nothing to Disclose, Thomas C. Lauenstein MD : Nothing to Disclose A high hepatopulmonary shunt (HPS) fraction might represent a contraindication for Yttrium 90 radioembolization (RE) in patients with unresectable hepatocellular carcinoma (HCC). The protein kinase inhibitor sorafenib has been shown to possibly reduce the HPS in selected cases. Our aim was to assess if CT predictors for a high HPS exist and if these show changes after sorafenib therapy. CT images of 70 HCC patients (mean age 69.8y; 60m, 10w) scheduled for MAA scan were retrospectively evaluated by two radiologists in consensus. Two groups of patients matched for age and gender were evaluated: (a) increased HPS (>15%, n=35), (b) low HPS (<5%, n=35). Tri-phasic CTs prior to the DSA were analyzed regarding signs of early venous enhancement, venous tumor infiltration, portal vein thrombosis, and portosystemic shunts. Conspicuities were correlated with HPS values and where applicable effects of sorafenib on these were recorded before repeated MAA scan. In 16/35 patients with high HPS, early (arterial) enhancement of intrahepatic veins and/or tumor infiltration of liver veins could be appreciated; 9 more patients showed compressed/shifted liver veins. Very high HPS (>20%) was associated with early venous enhancement (n=9) more frequently than high HPS (15-20%; n=2). Patients with low HPS did not show these signs. Portal vein thrombosis occurred more often with high HPS (n=21) compared to low HPS (n=9). All other aspects occurred in both groups independent of HPS. Eight patients with high HPS received sorafenib in the aftermath, reducing early (arterial) enhancement of liver veins and/or enhancement of tumor parts infiltrating liver veins in 8/8 cases; additionally a reduction of the HPS in 7/8 cases allowed for Yttrium 90 therapy. High hepatopulmonary shunts are associated with CT predictors which may be alleviated after sorafenib therapy in selected cases. Early (arterial) enhancement of liver veins is strongly related to very high hepatopulmonary shunts. Patients with increased risk for a high hepatopulmonary shunt might be identified in CT and could be pre-treated with sorafenib prior to the first MAA scan to prevent repetitive angiographies. VSIR31-05 Comparative Study Evaluating Pain after Hepatectomy, Percutaneous Radiofrequency and Percutaneous Microwave Ablation in Patients with HCC or Metastatic Hepatic Lesions Georgios Velonakis MD (Presenter): Nothing to Disclose, Dimitrios Filippiadis MD, PhD : Nothing to Disclose, Maria Alkiviades Mademli MD : Nothing to Disclose, Katerina Malagari : Nothing to Disclose, Alexios Kelekis MD, PhD : Consultant, Benvenue Medical, Inc, Nikolaos L. Kelekis MD : Nothing to Disclose To evaluate and compare post treatment pain in patients with HCC or metastatic liver lesions treated with surgery, percutaneous radiofrequency, or percutaneous microwave ablation. During 2 years, 103 patients treated for HCC or metastatic liver lesions were divided in three groups. 37 patients (Group A) underwent surgical operation (partial hepatectomy), 32 patients (Group B) underwent Computed Tomography (CT)-guided radiofrequency ablation (Leveen needle Radiofrequency electrode 5.0) and 34 patients (Group C) underwent CT-guided microwave ablation (16G Microwave probe). In Groups B and C ablation was performed under conscious sedation. Numeric Visual Scale questionnaire for pain was used to evaluate pain daily during follow-up. The required analgesics (type and dose) for all patients were recorded. Mean pain duration post treatment was 10.76±2.80 days in Group A, 1.34±0.75 in Group B and 1.41±0.74 in Group C. Differences in mean pain duration between surgery and radiofrequency and between surgery and microwave ablation were 9.41 and 9.35 days respectively. These differences were statistically significant (p<0.001). There was no statistically significant difference in pain duration between Groups B and C. Mean pain score in Group A was 7.68±0.884 NVS units in day 1, 7.43±0.929 in day 2, 6.97±1.118 in day 3 and 6.35±1.086 NVS units in day 4. The respective pain scores in Group B were 1.66±1.894 in day 1, 0.66±0.865 in day 2, 0.03±0.177 in day 3 and 0 in day 4. In Group C mean pain scores were 1.97±1.838 NVS units in Day1, 0.62±0.817 in Day 2, 0.03±0.172 in day 3 and 0 in day 4. Differences in mean pain scores were statistically significant between surgery and percutaneous treatment for each of the 4 first days (p<0.001), but there was no statistically significant difference between radiofrequency and microwave ablation. No clinically significant complications were noticed. Pain is an important complication post hepatic resection. Both image-guided percutaneous microwave ablation and radiofrequency ablation seem to be correlated with clinically insignificant pain post treatment as opposed to hepatectomy.

126 Image guided percutaneous microwave ablation and radiofrequency ablation of HCC or metastatic liver lesions are correlated with minimal pain, and they can be easily tolerated even if repeated sessions are required. VSIR31-06 Y-90 Cxs Robert J. Lewandowski MD (Presenter): Advisory Board, Nordion, Inc Advisory Board, BTG International Ltd Advisory Board, Boston Scientific Corporation Consultant, Cook Group Incorporated View learning objectives under main course title. ABSTRACT Discern the clinical variables that make a patient a good candidate for radioembolization Recognize common vascular anatomic variants predisposing to non-target delivery of yttrium-90 microspheres Understand the concept of radiation-induced liver disease and factors predisposing to it VSIR31-07 Debate: There Should be Dedicated Training Programs Devoted to IO Only Daniel B. Brown MD (Presenter): Consultant, Cook Group Incorporated Consultant, Medtronic, Inc, Charles E. Ray MD, PhD (Presenter): Nothing to Disclose View learning objectives under main course title. ABSTRACT Interventional Oncology is the most rapidly growing area of Interventional Radiology. Achieving a satisfactory fund of knowledge of oncologic patient management as well as mastering procedural and clinical skills requires training beyond that available in traditional fellowships. Interventional Oncology is the first IR subspecialty VSIR31-08 Thermal Ablation Cxs Daniel B. Brown MD (Presenter): Consultant, Cook Group Incorporated Consultant, Medtronic, Inc View learning objectives under main course title. ABSTRACT Complications are unusual with thermal ablation but can be severe. This presentation is designed to avoid complications as well as identify untoward events early after therapy to optimize management. Techniques to manage complications will be reviewed. VSIR31-09 Combination Therapy Cxs Thuong Gustav Van Ha MD (Presenter): Nothing to Disclose View learning objectives under main course title. ABSTRACT Combination therapy utilizing both transarterial chemoembolization and thermal ablation will be discussed with an emphasis on complications. Different techniques of TACE will be shown, in combination with either radiofrequency ablation or microwave ablation. Management of complications will also be discussed. VSIR31-10 Evaluation of an Experimental Thermoprotective Gel for Hydrodissection during Percutaneous Microwave Ablation: In Vivo Results Anna Moreland MD (Presenter): Consultant, NeuWave Medical, Inc, Meghan G. Lubner MD : Nothing to Disclose, Timothy J. Ziemlewicz MD : Nothing to Disclose, J. Louis Hinshaw MD : Stockholder, NeuWave Medical Inc Medical Advisory Board, NeuWave Medical Inc Stockholder, Cellectar Biosciences, Inc, Douglas Robert Kitchin MD : Nothing to Disclose, Alex Johnson : Nothing to Disclose, Fred T. Lee MD : Stockholder, NeuWave Medical, Inc Patent holder, NeuWave Medical, Inc Board of Directors, NeuWave Medical, Inc Patent holder, Covidien AG Inventor, Covidien AG Royalties, Covidien AG, Christopher L. Brace PhD : Shareholder, NeuWave Medical Inc Consultant, NeuWave Medical Inc

127 Hydrodissection is an important technique to protect non-target structures during thermal ablation, but is hampered by the mobility of injected fluid. This study evaluated whether a thermoreversible poloxamer P407 (liquid at room temperature, gel at body temperature) can protect the diaphragm, body wall, and bowel adjacent to large microwave (MW) ablation zones in a porcine model. P407 was prepared in a 15.4% solution with 2% iohexol. Antennas were placed percutaneously into extremely superficial liver, spleen, or kidney (target tissues) under US and CT guidance in 5 pigs under general anesthesia such that the expected ablation zones would extend into adjacent diaphragm, body wall, or bowel (non-target tissues). For experimental ablations, P407 was injected into the potential space between target and non-target tissues, and presence of a gel barrier was verified on CT. No barrier was used for controls. MW ablation was performed using a single antenna at 65W for 5 minutes. Gross dissection was performed after sacrifice to inspect tissues for thermal damage, which was verified using a histologic viability stain. Antennas were placed 7 ± 3 mm from the organ surface for both control and gel-protected ablations (p<0.05). The volume of gel deployed was 49 ± 27 ml, resulting in a barrier with a thickness of 0.75 ± 0.48 cm. Ablations extended into non-target tissues in 12/14 control ablations with a mean non-target tissue burn of 3.8 cm2, but only 4/14 gel-protected ablations with a mean non-target tissue burn of 0.2 cm2 (p<0.05). The gel stayed at the injection site throughout power delivery, with interval resorption of gel and accumulation of contrast in the bladder by 2.5h post-procedure. In this extreme scenario, P407 demonstrates viability as a tool for percutaneous tissue hydrodissection, as well as efficacy in protection of non-target structures during microwave ablation. As a thermoreversible poloxamer being explored for many novel medical applications, P407 exhibits potential utility in percutaneous tissue hydrodissection, effectiveness in thermoprotection during microwave ablation, and ability for maintenance at the injection site for the duration of power application. Further comparison of P407 to existing hydrodissection fluids and continued investigations into pharmacologic properties appear warranted. VSIR31-11 Percutaneous Ultrasound Guided Irreversible Electroporation in Locally Advanced Pancreatic Cancer: Short Term Complications Anders K. Nilsson MD, PhD (Presenter): Nothing to Disclose, Christoffer Mansson MD : Nothing to Disclose, Brittmarie Karlson MD, PhD : Nothing to Disclose To determine if irreversible electroporation (IRE) can be used in patients with locally advanced pancreatic cancer without too many serious adverse effects. Between October 2011 and January 2014, 42 patients with locally advanced pancreatic cancer were treated with IRE, the primary goal being a locally complete ablation. All patients were discussed at a multidiciplinary conference and were determined to be unsuitable for surgery due to extensive vessel involvement and/or liver metastases. 3-6 IRE needles were placed in and around the tumour with distances not exceeding 20 mm. Active needle lengh was15 mm. Ablations were performed until 90 pulses had been delivered between each relevant needle pair with a current of at least 30A. The aim was to create an ablation zone with a diameter of 4-5 cm. Clinical, laboratory and imaging data were recorded to detect complications. Out of the 42 included patients, 27 no serious adverse effects. More serious complications occures in 15 patients (33%) and included duodenal perforation (1), bile duct perforation (1), bleeding (2), portal vein thrombosis (2) and pain requiring more than basic pain relief and diarrea (8). 1 patient developed a jaundice after the procedure and died during the subsequent ERCP. Ultrasound guided percutaneous IRE ablations can be used in an attempt to achieve local tumour control in patients with locally advanced pancreatic cancer.the procedure offers a reasonable alternative when surgery is not possible but has a significant complication rate. The complications seem to be due to both the needle placement and the actual ablation. IRE ablation in the region of the pancreatic head is possible without damage to vessels and other vulnerable structures and can therefore be attempted when surgery is not possible. Furthermore, as ablations in this area will affect arteries and veins as well as nerves, bile ducts, bowel walls and pancratic tissue, it can be seen as an

128 indication that IRE can be used in other areas inaccessable to thermal ablations. VSIR31-13 Literature Review: The Most Important IO Papers from Charles E. Ray MD, PhD (Presenter): Nothing to Disclose View learning objectives under main course title. VSPD31 Pediatric Series: CV/IR Series Courses PD IR VA AMA PRA Category 1 Credits : 3.25 ARRT Category A+ Credits: 3.50 Tue, Dec 2 8:30 AM - 12:00 PM Location: S102AB Moderator Rajesh Krishnamurthy MD : Research support, Koninklijke Philips NV Travel support, Koninklijke Philips NV Moderator William Eugene Shiels DO : President, Mauka Medical Corporation Royalties, Mauka Medical Corporation Patent holder, Mauka Medical Corporation Moderator John Miras Racadio MD : Research Consultant, Koninklijke Philips NV Travel support, Koninklijke Philips NV Sub-Events VSPD31-01 Peripheral Vasc Imaging Technical Tips Shreyas Shreenivas Vasanawala MD, PhD (Presenter): Research collaboration, General Electric Company Stockholder, Morpheus Imaging, Inc 1) Know an approach to the choice of contrast agent for peripheral vascular imaging. 2) Know indications for non-contrast and pre-contrast imaging. 3) Know the types of fat suppression and how to pick which method to use. 4) Know sequence parameter modifications that enable imaging within stents. ABSTRACT This presentation will focus on methods of optimizing the MR imaging of peripheral vessels, addressing four questions. The first question is which contrast agent to choose. Most MR imaging can be performed with standard extracellular gadolinium agents. However, there are some advantages and disadvantages of blood pool agents that will be discussed. Next, situations when pre-contrast or non-contrast imaging is necessary are covered. Mostly, these sequences are only necessary in situations where the technical quality of post-contrast imaging is in doubt. Third, approaches to fat suppression will be covered. The benefits and disadvantages of two-point Dixon methods compared with subtraction and spectrally selective suppression will be reviewed. Finally, MR imaging in the presence of vascular stents will be covered, including sequence modifications that enable visualization within the stents. VSPD31-02 Validation of Quantitative Phase Contrast MRI Assessment of Cerebral Haemo/Hydro Dynamics in Children Eusra Hassan (Presenter): Nothing to Disclose, John Caine : Nothing to Disclose, Stavros Michael Stivaros PhD, FRCR : Medical Director, Obsidian Health Limited Quantitative phase contrast MRI (PCMRI) enables the flow of blood or CSF to be measured over a cardiac cycle. PCMRI in children presents unique challenges in implementation relating to ECG acquisition technique and MRI scanning parameters which this study investigates. PCMRI was performed to measure flow through the right and left internal carotid and basilar arteries (rica, lica, BA), superior sagittal sinus (SSS), straight sinus vein (StrS), CSF through the foramen magnum (FM) and aqueduct of sylvius (AQ). Velocity encoding (venc) was varied based on evidence of under or or oversampling. PCMRI experiments were perfomed using central ECG gating and then repeated using peripheral pulse gating. The imaging was analysed by three experienced observers in the field of PCMRI analysis using the image analysis programme, Segment, to allow the respective flow rates to be calculated.

129 Data was collected from 16 children aged 1 to 15 years (mean 4 years 6 months). Nine children had central and peripheral pulse gating employed. The mean flow rates measured with peripheral gating was lica = 0.094mls/s, right ICA = 0.092mls/s, BA = 0.056mls/s, SSS = 0.007mls/s, StrS, = 0.001mls/s, FM = 0.01mls/s, AQ = 0.001mls/s. Mean flow rates with central ECG measurements were lica = 0.091mls/s, rica = 0.091mls/s, BA=0.057mls/s, SSS = 0.042mls/s, StrS = 0.006mls/s, FM = 0.003mls/s, AQ = 0.001mls/s. No signficant statistical difference was detected based on the acquisition technique. Compared to published adult literature, the velocity enconding gradients (venc) in our childhood cohort were significantly different with arterial =120cm/s, venous=25cm/s and CSF=16cm/s. Our data shows no significant difference with regard to peripheral versus central pulse measurement for PCMRI acquisition in children. Peripheral PCMRI acquisition is much easier to apply and better tolerated in the paediatric cohort. In addition this work provides child specific venc values for PCMRI assessment, which differs from published adult data. It is recognised that there exists a complex interaction between cerebral arterial, venous and CSF flow rates in hydrocephalus. Quantitative PCMRI allows for non-invasive assesment of these haemo/hydrodynamic flows which may one day supsercede invasive intracranial monitoring. This work looks to develop and validate paediatric focused application of PCMRI for such applications. VSPD31-03 Cardiac Phase-dependent Image Quality of the Coronaries in Pediatric Cardiac High Pitch Computed Tomography Matthias Stefan May (Presenter): Speakers Bureau, Siemens AG, Wolfgang Wust MD : Nothing to Disclose, Michael Uder MD : Speakers Bureau, Bracco Group Speakers Bureau, Siemens AG Research Grant, Siemens AG, Michael Marcus Lell MD : Research Grant, Siemens AG Speakers Bureau, Siemens AG Research Grant, Bayer AG Speakers Bureau, Bayer AG Research Consultant, Bracco Group, oliver rompel : Nothing to Disclose The purpose of this study was to retrospectively evaluate the best cardiac phase for visualization of the coronaries in children younger than 1 year undergoing Cardiac High Pitch Computed Tomography (CT). The study applies to the declaration of Helsinki. Cardiac CT was performed on a second generation Dual-Source CT in 95 Patients (median age 31 days, range days) with a high-pitch protocol (p=3,2) at 80 kvp, automatic exposure control and a total collimation of 2x64x0,6mm. The ECG-trace was used as trigger for automated heart-phase (HP) selection. Retrospective data analysis was carried out in dependence of the HP (<20%/n=9, <30%/n=17, <40%/n=10, <50%/n=26, <60%/n=14, <70%/n=13, <80%/n=6). Motion artifacts in the coronary arteries were recorded for the proximal and distal segments on a 5-point Likert scale by two radiologists. Cardiac CT was performed on a second generation Dual-Source CT in 95 Patients (median age 31 days, range days) with a high-pitch protocol (p=3,2) at 80 kvp, automatic exposure control and a total collimation of 2x64x0,6mm. The ECG-trace was used as trigger for automated heart-phase (HP) selection. Retrospective data analysis was carried out in dependence of the HP (<20%/n=9, <30%/n=17, <40%/n=10, <50%/n=26, <60%/n=14, <70%/n=13, <80%/n=6). Motion artifacts in the coronary arteries were recorded for the proximal and distal segments on a 5-point Likert scale by two radiologists. Mean heart rate was 137 bpm (andplusmn; 27 bpm) and was not statistically different between the HP-groups (p=0.629). Image quality of the coronary arteries was best at andlt;50% and worst below 20% of the HP for both, the proximal and distal segments (pandlt;0.001). Visualization was still good and without statistically significant differences at andlt;40% for the proximal (p=0.13) and at andlt;40 and andlt;60% for the distal segments (p=0.27/0.06). Inter rater agreement was substantial (andkappa;=0.701). Pediatric cardiac CT should be performed at 40-50% of the cardiac cycle in children below 1 year for best visualization of the coronaries. Technical settings undergoing pediatric cardiac CT should be optimized to obtain stable images at 40-50% of the HP. VSPD D Flow MRI Improves Hemodynamic Evaluation in Patients with D-transposition of the Great Arteries Following the Arterial Switch Operation Compared to 2D Phase Contrast MRI and Doppler Echocardiography Marleen Vonder : Nothing to Disclose, Kelly Jarvis (Presenter): Nothing to Disclose, Susanne Schnell : Nothing to Disclose, Michael Markl PhD : Nothing to Disclose, Joshua D Robinson MD : Nothing to

130 Disclose, Cynthia Karfias Rigsby MD : Nothing to Disclose, Bradley D. Allen MD : Nothing to Disclose, Alex Barker : Nothing to Disclose Pulmonary artery (PA) stenosis either at the anastomosis or in the branch PAs is the most common complication leading to intervention after the arterial switch operation (ASO) for D-transposition of the great arteries (DTGA). Accurately depicting PA stenosis is paramount for postop DTGA evaluation. 2D PC MRI (2D PC) or Doppler echo (echo) rely on velocity quantification in a single imaging plane and one-directional velocity encoding and may not detect the peak velocity across entire vessel segments. 4D flow provides 3-directional velocity encoding and full volumetric coverage of the great arteries and may improve hemodynamic evaluation. Our aim was to compare peak velocities measured by 2D PC and 4D flow with the gold standard echo in patients with DTGA s/p ASO. Eleven patients with DTGA s/p ASO who underwent 2D PC and 4D flow were included (mean age 13.2 y (range 1-30)). Peak velocities were measured in the ascending aorta (AAo), main (MPA), right (RPA), and left (LPA) pulmonary arteries. Echo data was available in 10/8/5/4 patients in the AAo/MPA/RPA/LPA. Peak velocities were measured with: 1) a single cross section for 2D PC, 2) velocity maximum intensity projections (MIPs) of the entire aorta and PAs for 4D flow and 3) spectral Doppler for echo. Significantly higher peak velocities were found with 4D flow than 2D PC in the AAo (1.27±0.37m/s vs 1.11±0.24m/s, p=0.021), MPA (2.22±1.17m/s vs 1.34±0.54m/s, p=0.006), RPA (2.20±0.67m/s vs 1.63±0.65m/s, p=0.026) and LPA (2.14±0.73m/s vs 1.64±0.69m/s, p=0.003) indicating the potential of 4D flow to provide improved stenosis assessment. Correlation analysis showed moderate to strong relationships between 4D and 2D PC in the AAo (R2=0.624), MPA (R2=0.696), RPA (R2=0.301) and LPA (R2=0.757) but consistent velocity underestimation by 2D PC (slopes of linear regression = ). No difference in peak velocity was found between 4D flow and echo for all vessels. 4D flow assessment of peak velocities in DTGA s/p ASO was similar to echo and superior to 2D PC which consistently underestimated peak velocities. Improved assessment of peak pulmonary artery velocities using 4D flow velocity MIPs in DTGA s/p ASO may more accurately depict significant stenoses. VSPD31-05 The Application of 70 kv Technique Combined with Sinogram Affirmed Iterative Reconstruction (SAFIRE) in Infants with Total Anomalous Pulmonary Venous Connections: An Experimental Study with Dual-Source CT Yan Wang MMed, MS (Presenter): Nothing to Disclose, Dapeng Shi MD : Nothing to Disclose To explore the application of dual source CT with ultra-low tube voltage (70kV) combined with iterative reconstruction algorithm (SAFIRE) in infants with total anomalous pulmonary venous connections. This prospective study was approved by institutional review board, and written informed consents were obtained from all patients' parents. Twenty three infants (13 male and 10 female, mean age 3 months, range 1-36 months, mean weight 5kg) suspected of total anomalous pulmonary venous connections (TAPCV) in our hospital, underwent cardiovascular examination with DSCT and trans-thoracic echocardiography (TTE) one week before surgery. All DSCT scans used the Flash mode with a tube voltage of 70 kv, and the tube current, amount of contrast medium and injection rate were adjusted according to patients' weight. Images were reconstructed with iterative reconstruction algorithm SAFIRE. DSCT and TTE results were compared with the results from surgery. Image quality was evaluated, and effective radiation dose (ED) was calculated. All 23 cases were confirmed as TAPVA in operations. DSCT diagnosed all 23 cases, TTE missed 1 case; however 22 cases were diagnosed correctly as TAPVA with DSCT except one mixed type case, 16 cases were diagnosed correctly with TTE, and 3 mixed type cases were misdiagnosed, 3 infracardiac were diagnosed when information from CT was considered. Seventy three anomalous pulmonary veins were identified by DSCT, which results in a detection rate of 91.6%(73/76); 65 were identified by TTE, with a detection rate of 85.5%(65/76); 39 combined malformations were detected by DSCT among all 41 malformations from surgery, with a detection rate of 95.1%(39/41), 40 combined malformations were detected by TTE, with a detection rate of 97.6%(40/41). For DSCT scans, image quality was good or excellent for 21 patients and diagnostic in 2 patients. The mean effective radiation dose ED was (0.95 ± 0.32) msv. DSCT Flash mode scans with combination of 70kV tube voltage technique and SAFIRE reconstruction algorithm can compensate for move artefacts caused by the rapid heart rate and free breathing in infants, improve the image quality, and perform CT examination with low radiation dose and less contrast medium. Flash mode on DSCT with a combination of 70kV tube voltage and iterative reconstruction algorithm SAFIRE has a good performance in infants with complicated TAPVC.

131 VSPD31-06 Cardiac Magnetic Resonance Imaging in Pediatric Patient s 18 Years with Suspected Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC): A Correlation to Genetics Wieland Staab MD (Presenter): Nothing to Disclose, Jan Martin Sohns MD : Nothing to Disclose, Martin Fasshauer MD : Nothing to Disclose, Christian Sohns : Nothing to Disclose, Joachim Lotz MD : Research Cooperation, Siemens AG, Christina Unterberg-Buchwald : Nothing to Disclose, Alexander Schwarz : Nothing to Disclose This study sought to determine the clinical influence of right and left ventricular findings in pediatric patients undergoing cardiac magnetic resonance imaging (CMRI) 18 years with suspected arrhythmogenic right ventricular cardiomyopathy (ARVC). In a consecutive series between September 2010 and December 2013 (38 months), 79 (14.0 ± 3.9 years, 46 male) young patients 18 underwent contrast-enhanced magnetic resonance imaging (CMRI) and genetic analysis after biopsy for evaluation clinically suspected ARVC. Overall, 5 patients showed major criteria due to a combination of moderate to severe RV dysfunction and dilation as well as regional akinesia. Applying the revised TFC, 6 patients showed minor abnormalities such as mild RV dilatation, dys-synchronus RV contraction or regional akinesia. Overall 11 out of 12 (92%) patients with positive genetic characteristics were found to have major or minor abnormalities applying the revised Task Force Criteria. Here, positive predictive value (PPV) was 100%, negative predictive value (NPV) was 93%, sensitivity was 93% and specificity was 100%. Mean RVEDVI/BSA was 80 ± 16 and mean EF was 51 ± 8 in the whole study population. A subgroup analysis revealed a significantly (p = 0.01) decreased mean EF of 36 ± 9 and an increased RVEDVI/BSA of 101 ± 10 in 11 patients with major or minor abnormalities according to the revised TFC. This is the first study applying the revised Task Force Criteria (TFC) regarding the detection of ARVC in young patient's 18. In the current study, CMRI revealed 11 out of 12 patient`s (major and minor TFC) with positive findings in genetics with perfect positive predictive value and specificity. Applying the revised Task Force Criteria (TFC) regarding the detection of ARVC in young patient's 18 may increase the diagnostic value of CMR in this context. VSPD D Printing of Complex Intracardiac Morphology Shi-Joon Yoo MD (Presenter): Owner, 3D HOPE Medical 1) Understand 3D printing process for heart models. 2) Know the utility of 3D printing in pediatric cardiac imaging and surgery. 3) Know the limitations of 3D printing technology. 4) Predict the future avenues of 3D printing in pediatric cardiology ABSTRACT Rapid prototyping or 3D printing is an additive manufacturing technique where the object is digitally decomposed into thin layers and the printer adds the print material layer by layer until a physical model of the whole object is built. The prototype models can be made of solid material like plastic or ceramic, or rubber like material with some resemblance of myocardial texture. Any 3D volume image data can be used for 3D printing. The most ideal is high-resolution isotropic voxel data with ECG-gating and breath-holding or respiration navigation. Breath-held and ECG-gated CT angiograms are most commonly applicable data set.;mr angiograms with ECG-gating and respiration navigation obtained after injection of a blood pool contrast agent provides uniform enhancement of the blood pool with the spatial resolution comparable to CT angiograms. Using 3D image data of contrast angiograms, 3D models of both blood pool and endocardial surface can be manufactured. The blood pool model can be reproduced from contrast-enhanced angiograms by using thresholoding technique and manual adjustment. The endocardiac surface anatomy can be reproduced by graphically adding a layer outside the blood pool.;when it is printed, the added layer is a shell of the cavity, the inner surface of which represents the endocardial surface anatomy that will be encountered with at operation. The major clinical applications of 3D printing in pediatric cardiology are planning and simulation of surgical procedures for complex congenital heart diseases such as atypical forms of double outlet right ventricle and criss-cross heart. 3D print models allow instantaneous understanding of complex anatomy and elimiates the chances of misunderstanding and inappropriate choice between biventricular and univentricular repairs. In addition, 3D print models are valuable educational resources. This presentation will show a few clinical examples where 3D printing played the major role in surgical decision. VSPD31-08 Percutaneous Drainage Procedures in Children John Miras Racadio MD (Presenter): Research Consultant, Koninklijke Philips NV Travel support, Koninklijke Philips NV 1) Review common indications for percutaneous drainage procedures in children. 2) Understand unique differences or special considerations needed in preforming percutaneous drainage procedures in children versus

132 adults. VSPD31-09 Palliative Percutaneous Cryoablation in the Pediatric and Young Adult Population Brian Faustino Baigorri MD (Presenter): Nothing to Disclose, Peter John Littrup MD : Founder, CryoMedix, LLC Research Grant, Galil Medical Ltd Research Grant, Endo Health Solutions Inc Officer, Delphinus Medical Technologies, Inc, Hussein D. Aoun MD : Nothing to Disclose, Barbara A. Adam MSN : Nothing to Disclose, Mark J. Krycia BS : Nothing to Disclose, Evan N. Fletcher MS, BA : Nothing to Disclose, Matthew Prus BS : Nothing to Disclose, Mohamed M. Jaber MD : Nothing to Disclose To assess the safety and efficacy of cryoablation for palliation and local tumor control in the pediatric/young adult oncology population. CT and/or US-guided percutaneous cryoablations were performed using established adult parameters of N+1 cryoprobes for N(cm) tumor diameter. Ablation locations were noted as head and neck, thoracic, liver, kidney, and soft tissue. Tumor type, complications, and length of stay were recorded. Tumors and ablation zones were measured in 3 planes. Complications were graded by the Common Terminology of Complications and Adverse Events (CTCAE v4.0). Patients received CT or MRI follow-up at 1, 3, 6, 12, 18, 24 months and yearly thereafter. CT and/or US-guided cryoablation was performed on 111 tumors in 36 pediatric and young adults in 82 procedures. All patients received only conscious sedation. An average age of 23 (range ) was observed in the pediatric population due to the proportion of young adult sarcoma patients. Benign tumors included 5 osteoid osteoma and 4 desmoids, and the malignant tumors included 32 alveolar soft part sarcomas, 24 renal cell carcinomas, 13 osteosarcomas, 6 synovial sarcomas, and 37 miscellaneous. Tumor ablation location was noted as: 52 thoracic, 11 liver, 12 kidney, and 36 soft tissue. Patient mortality was 0%, with all adverse events being mild/moderate except for two major complications (2.4%). One was due to a bronchopleural fistula following lung ablation of an osteosarcoma metastasis, and the other was due to anticipated facial edema requiring tracheotomy in a head and neck procedure. Local treatment failure or progression occurred in 2.7%(3/111) and satellite recurrence in 6.3%(7/111) of tumors. CT guided percutaneous cryoablation is a safe treatment alternative in the pediatric and young adult population with associated low morbidity, and should be considered in the management of oligoneoplastic disease. Multifocal use of cryoablation is safe for pediatric patients with outcomes similar for adults, also emphasizing its low peri-procedural pain. Like adults, pediatric oncology patients also suffer from the morbidities of managing localized cancer recurrence or progression. Cryoablation provides for low pain, complication and recurrence rates. VSPD31-10 CT-guided Placement of Hyperthermia Catheters to Support Regional Deep Hyperthermia for Pediatric Malignancies Rotem Shlomo Lanzman MD (Presenter): Nothing to Disclose, Rudiger Wessalowski : Nothing to Disclose, Oliver Mils : Nothing to Disclose, Philipp Heusch MD : Nothing to Disclose, Gerald Antoch MD : Speaker, Siemens Medical AG Speaker, Bayer AG Speaker, BTG International Ltd, Patric Kroepil MD : Nothing to Disclose Percutaneous hyperthermia catheter allow for the placement of Bowman probes for temperature measurements inside the tumor during deep regional hyperthermia treatment. The aim of this study was to evaluate the safety and effectiveness of CT-guided placement of percutaneous hyperthermia catheter in pediatric malignancies. Forty pediatric patients (mean age 5.8 ± 5.6 years, range 0-18 years) scheduled for regional deep hyperthermia treatment of germ cell tumors (n=20), rhabdomyosarcoma (n=11), Ewing's sarcoma (n=3), desmoplastic tumor (n=3), hepatoblastoma (n=1), nephroblastoma (n=1) and lymphoma (n=1) were included in this retrospective analysis. A total of 46 hyperthermia catheters were placed under CT-guidance into tumors in the pelvis (n=29), liver/upper abdomen (n=6), neck (n=3), lower limb (n=5) and vertebral column (n=3). In all patients, the tumor was approached using a 13G puncture sheath under CT-guidance and a 6F percutaneous hyperthermia catheter (Somatex, Medical Technologies) was placed via the sheath inside the tumor. The duration of the intervention, technical success, periinterventional complications and the distance of the probe within the tumor were analyzed. 44 of 46 (95.7%) percutaneous hyperthermia catheters were placed successfully in the tumor. Mean tumor diameter was 4.7 ± 3.5 cm and the mean catheter distance within the tumor was 3.7 ± 3.3 cm. One hyperthermia catheter was placed 8 mm below a rhabdomyosarcoma in the lower limb and one hyperthermia

133 catheter dislocated from a superficial metastasis immediately after the procedure. Mean procedure time was 39.5 ± 16.3 min. No complications were observed. CT-guided hyperthermia catheter placement is a safe and reliable method to support treatment control in deep regional hyperthermia for pediatric malignancies. Deep regional hyperthermia is a promising salvage treatment option for pediatric malignancies. CT-guidance placement of hyperthermia catheter is a safe and reliable procedure and can therefore be recommended to support temperature measurements inside the tumor during deep regional hyperthermia treatment. VSPD31-11 First Phase-1 Study in the Treatment of Duchenne Muscular Dystrophy (DMD) by Multiple Intra-Arterial Transplantations of Mesoangioblasts (MABs) in 5 Dystrophic Children: Safety, Preliminary Efficacy, and Future Perspectives Massimo Venturini MD (Presenter): Nothing to Disclose, Giulio Cossu : Nothing to Disclose, Letterio Salvatore Politi MD : Nothing to Disclose, Michele Colombo : Nothing to Disclose, Giulia Agostini : Nothing to Disclose, Alessandro Del Maschio MD : Nothing to Disclose DMD, a syndrome characterized by progressive absence of dystrophin protein, causes progressive muscle degeneration, paralysis and death. Corticosteroids are not effective, while novel therapies (gene/stem cells) are on work. Our aim was to assess MABs intra-arterial infusion in 5 dystrophic children, at escalating dose, to preliminarily assess the safety. After the approval of our institutional ethical committee and obtaining written informed consent from the children's parents, every 2 months 5 DMD children (5 males, mean age=10 years) at a different disease stage under immunosuppressive treatment (tacrolimus) were submitted to 4 HLA-identical allogeneic MABs intra-arterial infusions each (2 in lower limbs, 2 in lower and upper limbs) at escalating dose. Intra-arterial infusions were performed at the level of the common femoral arteries (lower limbs) and the axillary arteries (upper limbs) using a transfemoral approach (4-Fr catheter): arteriography was performed before and after MABs infusion. Efficacy was assessed every 2 months by quantitative strength measurements (Kin-Com-test), thighs/legs fibro-fatty degeneration/quantification (MRI), and after 8 months by gastrocnemius biopsies (dystrophin restoration). The 20 intra-arterial MABs infusions were regularly performed with no peri-procedural complications, except for a case of iliac vasospasm successfully treated. The only relevant complication was 1 focal thalamic ischemia of 1-cm (MRI) that occurred 5 hours after the fourth infusion in one child, after sporadic atrial fibrillation (ECG) (Atrial-fibrillation-related-thrombosis? Late vasospasm?), without clinical consequences. Relative stabilization/decrease in disease progression was observed in all the children. At MRI, a stabilization of fibro-fatty degeneration was more evident in a child treated at an earlier disease stage, the only that demonstrated a significant dystrophin restoration at Gastrocnemius biopsy. Our preliminary phase 1 study on MABs intra-arterial transplantation in DMD children was relative safe, partially effective with encouraging perspectives. A larger cohort of children and a longer follow up are needed. A higher MABs intra-arterial concentration, transplanted exclusively in the lower limbs, at an early disease stage, could determine an increase of dystrophin restoration and a consequent improvement of the clinical outcome. VSPD31-12 Clinical Outcomes in Pediatric Patients Who Underwent Catheter-Directed Portal and Mesenteric Vein Thrombolysis David L. Lamar MD, PhD (Presenter): Nothing to Disclose, Giri Shivaram MD : Nothing to Disclose Literature describing transcatheter portomesenteric thrombolysis in pediatric patients is lacking. The purpose of this study is to review our experience with catheter-directed thrombolysis in 8 children with a focus on etiology, presentation, and distribution of porrtomesenteric vein thrombosis and transcatheter thrombolysis technique, complications, and outcomes. Retrospective analysis of 9 cases of catheter-directed portomesenteric vein thrombolysis in 8 patients (6 female, 2 male) performed at a pediatric academic referral-center. Mean age was 15.0 years old (range= 8 to 17 years old) at the time of initial interventions performed between 2005 and A presumed etiology was determined in 5 of 8 patients and included portal hypertension from various causes (3 patients), splenic torsion, and thrombocytosis following splenectomy for idiopathic thrombocytopenic purpura. No patients had hepatic

134 transplants. For all patients, transhepatic portal access was achieved either via direct percutaneous or transjugular-transhepatic routes. Outcomes examined included resolution of symptoms, degree of lysis, complications, and sustained clot resolution at follow-up. Successful transcatheter thrombolysis was achieved in 7 of 8 patients; one patient (unknown etiology of thrombus) experienced recurrent thrombus and eventual cavernous transformation. Two patients experienced major bleeding complications requiring transfusion (hemothorax and hemoperitoneum) which were successfully treated percutaneously. Three patients required TIPS shunt placement for portal hypertension at the time of PV thrombolysis or subsequent to initial therapy. No patients died or received hepatic transplants during the follow-up interval (mean= 2.3 years, median= 1.8 years, range= 0.1 to 8.5 years). In our experience, percutaneous transhepatic catheter-directed thrombolysis in children is a safe and effective approach to address portomesenteric thrombosis from a variety of causes. Use of catheter-directed portomesenteric thrombolysis in children is underreported and our experience suggests this minimally invasive therapy is a safe and effective approach. VSPD31-13 Long-term Outcome of Percutaneous Transhepatic Balloon Angioplasty for Portal Vein Stenosis after Pediatric Living Donor Liver Transplantation Minoru Yabuta MD (Presenter): Nothing to Disclose, Toshiya Shibata MD : Nothing to Disclose, Rinpei Imamine : Nothing to Disclose, Ken Shinozuka MD : Nothing to Disclose, Hiroyoshi Isoda MD : Nothing to Disclose, Kaori Togashi MD, PhD : Research Grant, Bayer AG Research Grant, DAIICHI SANKYO Group Research Grant, Eisai Co, Ltd Research Grant, FUJIFILM Holdings Corporation Research Grant, Nihon Medi-Physics Co, Ltd Research Grant, Shimadzu Corporation Research Grant, Toshiba Corporation Research Grant, Covidien AG To retrospectively evaluate the long-term outcomes of percutaneous transhepatic balloon angioplasty for portal vein stenosis after pediatric living donor liver transplantation. Between October 1997 and December 2013, 43 patients (19 boys, 24 girls; mean age, 4.1 years) who had undergone living donor liver transplantation were confirmed to have portal vein stenosis at direct portography with or without manometry, and underwent percutaneous interventions, including balloon angioplasty with or without stent placement. Technical success, patency rates and major complications were evaluated. Follow-up periods after the initial balloon angioplasty ranged from 5 months to 169 months (mean, 119 months). Technical success was achieved in 65 of 66 sessions (98.5%) and in 42 of 43 patients (97.7%). At 1, 3, 5, and 10 years after the first percutaneous transhepatic balloon angioplasty, the rates of primary patency were 83%, 78%, 76% and 70%, respectively, and the rates of primary-assisted patency were 100%, 100%, 100% and 96%, respectively. In major complication, severe asthma attack and portal vein thrombosis subsequent to balloon angioplasty were noted. Percutaneous transhepatic balloon angioplasty for portal vein stenosis after pediatric living donor liver transplantation was safe and effective. Percutaneous transhepatic balloon angioplasty might be a safe and effective treatment for portal vein stenosis after pediatric living donor liver transplantation. VSPD31-14 Comparison between Radiation Exposures Levels Using an Image Intensifier and A Flat Panel Detector-based System in Image-guided Central Venous Catheter Placement in Pediatric Patients Weighing Less than 10 kg Roberto Miraglia MD : Nothing to Disclose, Luigi Maruzzelli MD (Presenter): Nothing to Disclose, Roberta Gerasia : Nothing to Disclose, Simona Maggio : Nothing to Disclose, Angelo Luca MD : Nothing to Disclose The purpose of this study was a comparison between the radiation exposure levels recorded during CVC placement in pediatric patients weighing less than 10 kg, in procedures performed using an image intensifier-based angiographic system (IIDS) and those performed in a flat panel detector-based interventional suite (FPDS).

135 A retrospective review of 96 image-guided CVC placements, between January 2008 and October 2013, in 49 pediatric patients weighing less than 10 kg was performed. Mean age was 8.2±4.4 months (range 1-22 months). Mean weight was 7.1±2.7 kg (range kg). The procedures were classified into 2 categories: non-tunneled and tunneled CVC placement. Thirty-five procedures were performed with the IIDS (21 non-tunneled CVC, 14 tunneled CVC); 61 procedures were performed with the FPDS (47 non-tunneled CVC, 14 tunneled CVC). For non-tunneled CVC mean DAP was 113.5±126.7 cgy cm² with the IIDS and 15.9±44.6 cgy cm² with the FPDS (p< 0.001). For tunneled CVC mean DAP was 84.6±81.2 cgy cm² with the IIDS and 37.1±33.5 cgy cm² with the FPDS (p=0.02). The statistically significant differences of DAP between the two angiographic systems adjusted for the effect of the fluoroscopy time was confirmed by using a multiple generalized linear regression model. In all procedures image quality was considered adequate by a different interventional radiologist other than the operator with no trade-off between satisfactory image quality and procedural outcome. Technical success was obtained in all procedures without major complications. The use of flat panel angiographic equipment reduces radiation exposure in small children undergoing image-guided CVC placement. Our data suggests that the use of flat panel angiographic equipment reduces radiation exposure in small children undergoing image-guided CVC placement and should be considered first line for pediatric interventional radiology procedures. The systematic recording of DAP and fluoroscopy time at the end of every procedure is also an essential step in determining local and/or general radiation exposure reference levels in this particular group of patients. VSPD31-15 Percutaneous Treatment of Aneurysmal Bone Cysts William Eugene Shiels DO (Presenter): President, Mauka Medical Corporation Royalties, Mauka Medical Corporation Patent holder, Mauka Medical Corporation 1) Identify 2 sites of aneurysmal bone cyst solid tumor localization for large gauge percutaneous core or scrape biopsy yielding diagnostic histologic tissue. 2) Define 3 mechanisms of action for doxycycline foam as a tumor ablation agent targeting aneurysmal bone cyst as a neoplasm. 3) Describe the role of tricalcium phosphate bone graft substitute in the successful treatment of aneurysmal bone cyst. SPCP31 Canada Presents: Beyond Diagnosis How Cardiovascular Imaging Research in Canada Is Improving Clinical Outcomes Special Courses MR IR CT BQ VA AMA PRA Category 1 Credits : 1.50 ARRT Category A+ Credits: 1.50 Tue, Dec 2 10:30 AM - 12:00 PM Location: E353C Moderator Bruce B. Forster MD : Investor, Doyen Medical Incorporated Moderator Jonathon Avrom Leipsic MD : Speakers Bureau, General Electric Company Speakers Bureau, Edwards Lifesciences Corporation Consultant, Heartflow, Inc Consultant, Circle Cardiovascular Imaging Inc 1) Discuss recent practice changing cardiovascular imaging trials from across Canada with a focus on clinical outcomes and therapeutic impact. 2) Define novel opportunities for Trans-Canadian collaboration in cardiovascular outcomes research enabled by imaging networks and shared data registries. 3) Review the potential benefits and limitations that the Canadian Healthcare delivery model may have on outcomes focused imaging research. This session is part of Canada Presents at RSNA Sub-Events SPCP31A Opening Remarks RSNA President N. Reed Dunnick MD Nothing to Disclose

136 This session is part of Canada Presents at RSNA SPCP31B The Impact of Integration of a Multidetector Computed Tomography Annulus Area Sizing Algorithm on Outcomes of Transcatheter Aortic Valve Replacement: A Prospective, Multicenter, Controlled Trial Jonathon Avrom Leipsic MD (Presenter): Speakers Bureau, General Electric Company Speakers Bureau, Edwards Lifesciences Corporation Consultant, Heartflow, Inc Consultant, Circle Cardiovascular Imaging Inc 1) Discuss historical sizing algorithms for the balloon expandable prostheses. 2) Review the methods for measuring the annulus with MDCT. 3) Define an MDCT area/perimeter based sizing algorithm for balloon expandable TAVR and review the data supporting its integration. This session is part of Canada Presents at RSNA SPCP31C Refining the Phenotype of Genetic Hypertrophic Cardiomyopathy with Cardiac MRI Andrew Michael Dominic Crean MD (Presenter): Nothing to Disclose 1) To understand the histopathologic basis of late gadolinium enhancement in HCM and how best to measure it. 2) To appreciate the added value of late gadolinium enhancement in prognostication in HCM. 3) To learn about several under-appreciated phenotypic signs of HCM that may be present even in so-called Œgene-positive phenotype-negative¹ HCM. This session is part of Canada Presents at RSNA SPCP31D A New Paradigm for Cardiac CT Imaging: Quantitative Assessment of Perfusion and Late Enhancement Ting-Yim Lee MSc, PhD (Presenter): Research Grant, General Electric Company Royalties, General Electric Company 1) Using quantitative CT perfusion and late enhancement imaging to identify different tissue states in acute myocardial infarction. 2) Technical requirements for generation of these quantitative functional maps with clinical CT scanners. 3) Pitfalls in quantitative CT perfusion and late enhancement imaging. 4) Further applications of quantitative cardiac CT imaging. This session is part of Canada Presents at RSNA SPCP31E Modeling of Abdominal Aortic Aneurysm before, during and after Endovascular Repair: Potential Impact on Patient Management Gilles P. Soulez MD (Presenter): Speaker, Bracco Group Speaker, Siemens AG Research Grant, Siemens AG Research Grant, Bracco Group Research Grant, Cook Group Incorporated Research Grant, Object Research Systems Inc 1) Know the risk factors of abdominal aortic aneurysm (AAA) rupture and the role of maximal diameter (D-max) measurement in therapeutic algorithm. 2) Discuss the variability of D-max measurement and the importance of standardized measurement to improve reproducibility. 3) Understand the challenge of AAA segmentation on CT scanner examination before and after endovascular repair (EVAR) and on unenhanced studies. 4) Understand the utility of AAA modeling for automated D-max and AAA volume measurements. 5) Understand the future developments in AAA modeling to predict AAA rupture, improve endovascular repair (EVAR) planning, EVAR rehearsal, and patient follow-up after EVAR. This session is part of Canada Presents at RSNA ABSTRACT Aneurysm size is the most important predictive factor for AAA rupture. Accordingly, rupture risk increases with size, with a 3-15% risk per year for those with a 5-6 cm aneurysm, 10-20% for 6-7 cm aneurysms, 20-40% for 7-8 cm aneurysms, and 30-50% for those with a diameter greater than 8 cm. AAA growth rate is correlated to its diameter and to the risk of rupture. The main indications for a procedure are Dmax ;5.5 cm in men, ;5.0 to 5.4 cm in women, or symptomatic AAA.; Computer modeling have raised the possibility of patient specific risk prediction based on AAA geometry. After computer modeling, AAA with a higher bulge location (P<.020) and lower mean averaged area (P<.005) are associated with AAA rupture however the addition of these indices in a predictive model based on current treatment criteria modestly improved the accuracy to detect aneurysm rupture. AAA segmentation is the first step before AAA modeling. CT-scanner is the modality of choice for AAA evaluation before and after endovascular repair (EVAR). AAA lumen segmentation can be easily performed after contrast injection but thrombus segmentation is far more challenging. Considering the high incidence of renal failure in this population, patient follow-up after EVAR with unenhanced CT-scanner is needed. Semi- automated segmentation of AAA on unenhanced CT-scanner can also be achieved with a high reproducibility. This open the door to patient follow-up with low-dose unenhanced CT-scanner. In this setting, Dmax or AAA volume measurement can be calculated while minimizing exposure to iodine contrast and ionizing radiation to exclude EVAR failure. AAA modeling is a necessary step for EVAR planning and stent selection. AAA can be used to enable a 2D/3D image registration between preoperative CT scanner and fluoroscopy to improve guidance

137 during EVAR procedure and mimize fluoroscopy time and contrast injection. Finally, modeling of AAA can be combined with finite element analysis to enable EVAR reharsal. SPCP31F Fast and Furious: Imaging to Recanalization in Acute Stroke Mayank Goyal MD, FRCPC (Presenter): Shareholder, Calgary Scientific, Inc Research Grant, Covidien AG Consultant, Covidien AG Shareholder, NoNO Inc Investigator, Covidien AG It is clear that in acute ischemic stroke: Time is brain. Also, based on the results of recent trials including IMS3, we as a collective have been unable to show the benefit of endovascular treatment over standard of care. As such many new trials are being designed and/or conducted. In view of the data from recent trials, there need to be strategies that allow for appropriate patient selection for endovascular treatment using imaging that is widely available and not time consuming. Once selected, organization of workflow to rapidly achieve recanalization is going to be the key to success. This talk expands on both these ideas: rapid imaging and patient selection, rapid workflow and intervention for endovascular recanalization. This session is part of Canada Presents at RSNA ABSTRACT The topic will be divided into three sub topics: 1. Imaging: balancing information vs time. I would discuss varioius imaging strategies and their pros and cons. Also, I would aim to introduce the basic concepts of Bayesian analysis for decision making 2. Workflow: moving the patient fast through the system including blood work, consent, getting team together and reaching the angio suite 3. Fast recanalization: tips and tricks to achieve rapid and good quality recanalization while keeping the procedural complication rate low. SPCP31G Prevalence of Extracranial Venous Narrowing on Catheter Venography in People with Multiple Sclerosis, Their Siblings, and Unrelated Healthy Controls: A Blinded, Case-control Study Darren Klass MD, PhD (Presenter): Nothing to Disclose 1) Discuss the incidence of MS and its impact on healthcare in Canada. 2) Discuss the design of the assessor-blinded, case controlled study and the difficult task of ensuring the strict blinding protocol was adhered to. 3) Discuss the findings, the strength of the blinding in the study and the impact of the study results on future interventional radiology studies related to the subject. 4) Discuss the importance of working in a well-functioning interventional radiology team. This session is part of Canada Presents at RSNA ABSTRACT Background Chronic cerebrospinal venous insufficiency has been proposed as a unique combination of extracranial venous blockages and haemodynamic flow abnormalities that occur only in patients with multiple sclerosis and not in healthy people. Initial reports indicated that all patients with multiple sclerosis had chronic cerebrospinal venous insufficiency. We aimed to establish the prevalence of venous narrowing in people with multiple sclerosis, unaffected full siblings, and unrelated healthy volunteers. Methods: An assessor-blinded, case-control, multicentre study of people with multiple sclerosis, unaffected siblings, and unrelated healthy volunteers was conducted. Study participants were enrolled between January, 2011 and March, 2012, and they comprised 177 adults: 79 with multiple sclerosis, 55 siblings, and 43 unrelated controls, from three centres in Canada. Catheter venography data were available for 149 participants and ultrasound data for 171 participants. Findings: This study revealed a low incidence of chronic cerebrospinal venous insufficiency in all groups; 2% of people with multiple sclerosis, 2% of siblings and 3% of unrelated controls (p=1 0 for all comparisons). Greater than 50% narrowing of any major vein was present in 74% of people with multiple sclerosis, 66% of siblings (p=0 41 for comparison with patients with multiple sclerosis), and 70% of unrelated controls (p=0 82). The ultrasound criteria were fulfilled in 44% of participants with multiple sclerosis, 31% of siblings (p=0 15 for comparison with patients with multiple sclerosis) and 45% of unrelated controls (p=0 98). Conclusions: Chronic cerebrospinal venous insufficiency occurs rarely in both patients with multiple sclerosis and in healthy people. Extracranial venous narrowing of greater than 50% is a frequent finding. The significance of venous narrowing to multiple sclerosis symptomatology remains unknown. SPCP31H Panel Discussion Jonathon Avrom Leipsic MD (Presenter): Speakers Bureau, General Electric Company Speakers Bureau, Edwards Lifesciences Corporation Consultant, Heartflow, Inc Consultant, Circle Cardiovascular Imaging Inc, Andrew Michael Dominic Crean MD (Presenter): Nothing to Disclose, Ting-Yim Lee MSc, PhD (Presenter): Research Grant, General Electric Company Royalties, General Electric Company, Gilles P. Soulez MD (Presenter): Speaker, Bracco Group Speaker, Siemens AG Research Grant, Siemens AG Research Grant, Bracco Group Research Grant, Cook Group Incorporated Research Grant, Object Research Systems Inc, Mayank Goyal MD, FRCPC (Presenter): Shareholder, Calgary Scientific, Inc Research Grant, Covidien AG Consultant, Covidien AG Shareholder, NoNO Inc Investigator, Covidien AG, Darren Klass MD, PhD (Presenter): Nothing to Disclose

138 This session is part of Canada Presents at RSNA SPCP31I Closing Remarks James P. Borgstede MD (Presenter): Nothing to Disclose This session is part of Canada Presents at RSNA SSG02 Cardiac (TAVR and Other Interventions) Scientific Papers IR CT CA AMA PRA Category 1 Credits : 1.50 ARRT Category A+ Credits: 1.50 Tue, Dec 2 10:30 AM - 12:00 PM Location: S504AB Moderator Karen Gomes Ordovas MD : Nothing to Disclose Moderator Phillip Matthew Young MD : Nothing to Disclose Sub-Events SSG02-01 The Impact of Calcium Volume and Distribution in Aortic Root Injury Related to Balloon-Expandable Transcatheter Aortic Valve Replacement Jonathon Avrom Leipsic MD (Presenter): Speakers Bureau, General Electric Company Speakers Bureau, Edwards Lifesciences Corporation Consultant, Heartflow, Inc Consultant, Circle Cardiovascular Imaging Inc, Bruce Precious MD : Nothing to Disclose, Rekha Raju : Nothing to Disclose, Nicolaj Hansson : Nothing to Disclose, Philipp Blanke MD : Nothing to Disclose, Bjarne Norgaard : Consultant, Edwards Lifesciences Corporation We sought to further delineate the impact of calcium volume and distribution on aortic root injury using a new method of detailed quantitative calcium analysis 33 patients from 16 centers experiencing aortic root injury were compared to consecutive control of 156 patients without root injury. Quantitative calcium analysis using patient-specific calcium detection thresholds and detailed 3-dimensional regional analysis on contrast-enhanced pre-tavr MDCT scans was performed. Calcium quantified volumetrically in relation to the three aortic cusps in three regions: 1) aortic valve/ sinus of Valsalva calcium (from the aortic annulus to the left coronary ostia), 2) overall left ventricular outflow tract (LVOT) calcium (from the aortic annulus and 10 mm into the left ventricle) and 3) high LVOT/subannular calcium (from the aortic annulus and 2 mm into the left ventricle). Median (interquartile range) overall LVOT and high LVOT/subannular calcium volumes were higher in the rupture group 74 (5-326) mm3 vs. 4 (0-63) mm3 (p<0.0001), and 29 (3-66) mm3 vs. 0 (0-9) mm3 (p<0.0001). No difference between groups in aortic valve/sinus of Valsalva calcium volume, 848 ( ) mm3 vs. 546 ( ) mm3 (p=0.09). High LVOT/subannular calcium volume was more predictive of aortic root injury than overall LVOT calcium volume, (AUC) of 0.78 (95% confidence interval [CI]: ) vs (95% CI: ) (p=0.002). Aortic valve/sinus of Valsalva calcium volume did not predict aortic root injury (AUC: 0.57; 95% CI: ). High LVOT/subannular calcium underneath the non-coronary cusp was significantly more predictive of aortic root injury (AUC: 0.81; 95% CI: ) compared to calcium underneath the right cusp (AUC: 0.67; 95% CI: ; p=0.02), or the left cusp (AUC: 0.65; 95% CI: ; p=0.02). Prosthesis oversizing >20% (likelihood ratio test p=0.048) and redilatation (likelihood ratio test p=0.009) significantly improved prediction of root injury by high LVOT/subannular calcium. High LVOT/subannular calcium volume, particularly located below the non-coronary cusp, is more predictive of aortic root rupture than overall LVOT calcium. Prosthesis oversizing >20% and redilatation augments the impact of high LVOT/subannular calcium on the risk of root injury. These findings may help identify patients at risk of aortic root injury during balloon-expandable TAVR. SSG02-02 Multicenter Evaluation of Transcatheter Aortic Valve Replacement Using Either SAPIEN XT or CoreValve: Degree of Device Oversizing and Clinical Outcomes

139 Jonathon Avrom Leipsic MD (Presenter): Speakers Bureau, General Electric Company Speakers Bureau, Edwards Lifesciences Corporation Consultant, Heartflow, Inc Consultant, Circle Cardiovascular Imaging Inc, Danny Dvir : Nothing to Disclose, Philipp Blanke MD : Nothing to Disclose, Nicolo Piazza : Consultant, Medtronic, Inc, Marco Barbanti : Nothing to Disclose, John Webb MD, FRCPC : Consultant, Edwards Lifesciences Corporation Data on degree of device oversizing associated with optimal clinical outcomes after transcatheter aortic valve replacement (TAVR) is limited. A multicenter analyses of consecutive transfemoral TAVR procedures using either SAPIEN XT or CoreValve was utilized. Oversizing zones were defined for SAPIEN XT (5-20% area oversizing or % perimeter oversizing) and for CoreValve (20-35% area oversizing or % perimeter oversizing). "favorable-sapien XT" (FXT) zone and "favorable- CoreValve" (FCV) zone included annular sizes for which implantation of either a SAPIEN XT or a CoreValve, respectively, allowed for presumed favorable oversizing. A total of 368 patients were included in the study: 178 patients in the FCV zone (treated by either CoreValve, n=90 or SAPIEN XT, n=88) and 190 patients in the FXT zone (treated by either SAPIEN XT, n=78, or CoreValve, n=112). In FCV zone, those treated by SAPIEN XT had more annular rupture and conversion to cardiac surgery in comparison with those treated by CoreValve (3.4% vs. 0, p=0.04 and 4.5% vs. 0, p=0.02, respectively). In FXT zone, those treated by CoreValve had more post balloon dilatation and 30-day major stroke in comparison with those treated by SAPIEN XT (16.1% vs. 7.7%, p=0.04 and 8% vs. 1.3%, p=0.02, respectively). Optimal clinical performance of CoreValve and SAPIEN XT appears to be reached with different degrees of device oversizing. An individualized-device-approach during TAVR, utilizing a specific device for a specific annulus size, enabling favorable degree of oversizing, may improve clinical outcomes. This approach should be further validated in future trials. An individualized-device-approach during TAVR, utilizing a specific device for a specific annulus size, enabling favorable degree of oversizing, may improve clinical outcomes SSG02-03 Effect of Annular Calcification on Area and Perimeter Measurements in Systole and Diastole: Implications for Device Sizing Darra Thomas Murphy MD, FRCPC (Presenter): Nothing to Disclose, Philipp Blanke MD : Nothing to Disclose, Shalan Alaamri : Nothing to Disclose, Bruce Precious MD : Nothing to Disclose, Cameron John Hague MD : Nothing to Disclose, Jonathon Avrom Leipsic MD : Speakers Bureau, General Electric Company Speakers Bureau, Edwards Lifesciences Corporation Consultant, Heartflow, Inc Consultant, Circle Cardiovascular Imaging Inc, Ronen Rubinshtein MD : Fellowship funded, Koninklijke Philips NV, Adam Berger : Nothing to Disclose, Rekha Raju : Nothing to Disclose, Jennifer Deryn Ellis MD : Nothing to Disclose, Gregor Pache MD : Nothing to Disclose, David Wood MD, FRCPC : Consultant, Edwards Lifesciences Corporation Consultant, St. Jude Medical, Inc, John Webb MD, FRCPC : Consultant, Edwards Lifesciences Corporation CT based sizing has been shown to reduce paravalvular leak following transcatheter aortic valve replacement (TAVR). However there is conflicting data on the extent of annular dynamism throughout the cardiac cycle. The objective of the current study is to assess the degree of variability of aortic annular measurements in systole and diastole using MDCT and to evaluate the impact on device sizing. In this retrospective, multicenter analysis, ECG-gated retrospective CT data of 357 patients were analyzed. Aortic annulus dimensions were assessed on systolic and diastolic reconstructions by planimetry and using a smoothing algorithm not previously described, yielding values for both area and perimeter. Extent of annular calcification was graded using a semi-quantitative 4-point scale (0-3). Hypothetic device sizing was performed by area and perimeter. There was an overall significant difference between systolic and diastolic reconstructions in both perimeter and area measurements (perimeter 3.52%, p<0.0001; area 7.98%, p > ), however these measurements lost statistical significance with increasing LVOT calcification (grade 2 and 3 LVOT calcium for both perimeter and area). Diastolic measurements would result in a smaller valve in 82 cases by area and 78 by perimeter with one perimeter case which diastole would recommend a larger valve using Vancouver guidelines for area and Kasel for perimeter.

140 Annular dimensions are subject to dynamic changes throughout the cardiac cycle, resulting in changes to the cross-sectional area, perimeter and subsequently derived diameters. This has implications for accurate valve sizing. The dynamic changes become less significant with increasing calcium burden in the LVOT. Clinically significant changes in both annular area and perimeter are seen between systolic and diastolic phase cardiac CT imaging acquisitions. Utilisation of diastolic phase images for either perimeter or area derived measurements would result in a change of valve size in a substantial number of patients which could result in increased complications. The change in measured valve parameters appears less significant with increasing LVOT calcification. SSG02-04 Underestimation of Effective Aortic Orifice Area after TAVR due to LVOT Ellipticity Impact on Patient-prosthesis Mismatch Classification Philipp Blanke MD (Presenter): Nothing to Disclose, Rekha Raju : Nothing to Disclose, Bruce Precious MD : Nothing to Disclose, Darra Thomas Murphy MD, FRCPC : Nothing to Disclose, Cameron John Hague MD : Nothing to Disclose, Jonathon Avrom Leipsic MD : Speakers Bureau, General Electric Company Speakers Bureau, Edwards Lifesciences Corporation Consultant, Heartflow, Inc Consultant, Circle Cardiovascular Imaging Inc, Robert Moss : Nothing to Disclose, Christopher Thompson : Nothing to Disclose, Kris Nowakowski : Nothing to Disclose, John Webb MD, FRCPC : Consultant, Edwards Lifesciences Corporation To define the influence of left ventricular outflow tract (LVOT) geometry on calculation of the effective orifice area (eoa) and classification of patient-prosthesis mismatch (PPM) after transcatheter aortic valve replacement (TAVR). 86 patients (52 male, mean age 82.1±7.6 years, mean BSA 1.9±0.22) status post TAVR underwent both transthoracic echocardiography and contrast enhanced cardiac computed tomography. LVOT dimensions were assessed by means of planimetry on systolic CT reconstructions with subsequent calculation of an area-derived LVOT diameter. EOA was calculated according to the continuity equation, based on transaortic measurements by continuous-wave Doppler and LVOT measurements obtained by pulsed-wave Doppler (EOATTE). In addition, a modified EOA was calculated using the area-based LVOT diameter by CT (EOACT). Moderate and severe PPM were defined as an indexed EOA (ieoa) 0.85 cm2/m2 and 0.65 cm2/m2, respectively. Postprocedural aortic valve area (AVA) was assessed by TEE planimetry. Mean LVOT diameters were 2.4±0.3mm by TTE and 2.0±0.2mm by CT (p<0.001). Mean EOATTE was significantly lower (1.7±0.4cm2) than EOACT (2.4±0.7cm2, p<0.001). By ieoatte, 20 patients (29%) were graded as moderate PPM and 4 (6%) as severe PPM. By ieoact, PPM grade was reclassified in 21 patients, with 4 patients (6%) graded as moderate PPM and no patients (0%) graded as severe PPM. Postprocedural AVA was significantly higher than EOATTE (p<0.001) but similar to EOACT (p=n.s.). LVOT ellipticity and subsequent underestimation of true LVOT dimensions by TTE results in lower calculated eoa values and high frequencies of estimated PPM after TAVR. Cardiac computed tomography allows for individual correction of the calculated eoa and reclassification of the PPM grade. Information provided by cardiac computed tomography can be used for individual correction of the calculated eoa and reclassification of the PPM grade SSG02-05 Low kv MDCT Angiography for Transcatheter Aortic Valve Implantation (TAVI) Planning: Image Quality and Radiation Dose Exposure Fabrizio Del Buono MD : Nothing to Disclose, Davide Ippolito MD : Nothing to Disclose, Cammillo Roberto Giovanni Leopoldo Talei Franzesi : Nothing to Disclose, Pietro Andrea Bonaffini MD : Nothing to Disclose, Davide Fior MD (Presenter): Nothing to Disclose, Sandro Sironi MD : Nothing to Disclose To evaluate image quality and radiation dose exposure of low-kv (100KV) CT angiography (CTA) in patients candidate to Transcatheter Aortic Heart Valve Implantation (TAVI), in comparison with standard CT angiography protocol. A total of 49 patients (18 males; mean age 83.8 years, range years), candidate for TAVI, were prospectively enrolled in this study and examined with 256-row scanner (ict, Philips) with 80mL of iso-osmolar contrast medium volume (350mgI/mL). Twenty-eight patients (group A; 8 males;mean age 83.6 years,range years) were evaluated using low-kw (100kV) retrospective ECG-gated protocol, with automated tube current modulation, while 21 patients (group B; 10 male;mean age 84.3 years,range years) underwent a

141 standard CTA study (120kV;retrospective ECG-gated protocol;automated tube current modulation). Overall image quality was evaluated using a 4-point scale (4 excellent, 3 good, 2 acceptable, 1 low). Vascular enhancement(hu) was then assessed in each patient by manually drawing on axial arterial images multiple regions of interest (ROIs) in lumen of aortic root, ascending aorta, arch, descending and abdominal aorta, common and external iliac arteries. The radiation dose exposure of both groups, in terms of dose-length product (DLP, mgy*cm), was calculated and all data were compared and statistically analyzed. On low-kv protocol significant higher mean attenuation values were achieved in all the measurements (aortic root HU; external iliac arteries HU) as compared to the standard kv protocol (aortic root HU; external iliac arteries HU). There were no significant differences in the image quality evaluation in both groups (groupa 3.7 vs groupb 3.8). Mean DLP of groupa was significantly lower (mean DLP 1600mGy*cm) than in groupb (mean DLP 2044mGy*cm), with an overall radiation dose reduction of 22%. Low-kV CTA protocol permits to correctly perform TAVI planning with high quality images and significant reduction of radiation dose exposure, as compared to standard CTA protocol. Low-kV CTA may be a valid imaging tool for the pre-operative assessment of thoraco-abdominal aorta and iliac arteries in patients candidate to TAVI, with a reduced radiation dose exposure. SSG02-06 Computed Tomography Evaluation of Subvalvular Soft Tissue in Patients Who underwent Valve Replacement Surgery during Immediate Postoperative Period Sangik Park MD (Presenter): Nothing to Disclose, Dong Hyun Yang MD : Nothing to Disclose, Joon-Won Kang MD : Nothing to Disclose, Tae-Hwan Lim MD, PhD : Nothing to Disclose Subvalvular soft tissue (pannus) formation has been known to be a cause of high transvalvular gradient and necessitate reoperation of valvular replacement. There was lack of data regarding the prevalence of subvalvular pannus during immediate postoperative period. This study aimed to evaluate prevalence and hemodynamic significance of subvalvular pannus in computed tomography (CT) during immediate postoperative period in patients who underwent valve replacement surgery. During two years, 1057 patients underwent cardiac valve replacement surgery. Among them 203 patients (mean age, 58; 131 men) underwent ECG-gated cardiac CT within 30 days from operation (aortic valve=180, mitral valve=26, tricuspid valve=3, pulmonary valve=1). Presence of subvalvular pannus was evaluated using multiphase cardiac CT images in dedicated workstation. Hemodynamic parameters such as transvalvular pressure gradient and peak velocity of transaortic flow were evaluated using echocardiography and compared them between patient with and without pannus formation. Valve type- and size-matched comparison between pannus and non-pannus groups were done to evaluate the hemodynamic significances of pannus. Geometric profiles of mechanical valves including diameter of valve and opening angle were evaluated. Subvalvular pannus was identified in 31 of the 210 valves (14.8%). Among them, 30 were in the aortic location, while the other one was in the mitral location. The mean length, maximal thickness, and involvement angle of pannus were 11.3 mm ± 4.4, 3.1 mm ± 1.2, and 54.8 ± 19.3, respectively. Echocardiographic measurements of peak velocity (pannus group vs. non-pannus group, 2.4 m/s vs. 2.3 m/s, p=0.665), maximum pressure gradient (24.0 mmhg vs mmhg, p=0.5297), and mean pressure gradient (12.6 mmhg vs mmhg, p=0.4671) across the prosthetic aortic valve did not show a significant difference statistically. Even in immediate postoperative period, subvalvular pannus was not uncommon in this retrospective study group. However, the extent of subvalvular pannus seemed to be small as compared with results of previous study. Patients with subvalvular pannus during immediate postoperative group showed insignificant hemodynamic parameters on echocardiography as compared with non-pannus group. Cardiac CT was feasible method to demonstrate subvalvular pannus in pateints with prosthetic cardiac valve. SSG02-07 Clinical Impact of Valsalva Sinus Distensibility in Aortic Stenosis: Quantification by 256-slice Coronary CT Angiography Yamato Shimomiya (Presenter): Nothing to Disclose, Michinobu Nagao MD : Research Grant, Bayer AG Research Grant, Koninklijke Philips NV, Satoshi Kawanami MD : Research Grant, Modest Research Grant, Bayer AG Research Grant, Koninklijke Philips NV, Masato Yonezawa : Nothing to Disclose, Yuzo Yamasaki MD : Nothing to Disclose, Hiroshi Honda MD : Nothing to Disclose, Shinya Takarabe RT : Nothing to Disclose, Masatoshi Kondo : Nothing to Disclose, hiroshi hamasaki : Nothing to Disclose, Takashi

142 Shirasaka BS : Nothing to Disclose, Masayuki Tachibana : Nothing to Disclose, Yasuhiko Nakamura RT : Nothing to Disclose When treating aortic stenosis (AS), accurate aortic valve area (AVA) measurement is critical for appropriate patient selection and successful transcatheter aortic valve implantation. CT could detail the AVA shape and length, but it is limited by motion and calcification artifacts. Therefore, we propose a new objective index to determine the AS severity. A total 33 patients (mean age, 78 years) diagnosed with AS who underwent surgical aortic valve replacement and ECG-gated 256-slice coronary CT angiography and echocardiography were retrospectively reviewed. In addition, 12 patients (mean age, 65 years) with no cardiac disease history or coronary stenosis on CT were enrolled as controls. The valsalva sinus distensibility (VD) index was defined the ratio between the Valsalva sinus area (mm2) and the minor axis of aortic annulus (mm) at end-systole using multiplanar reconstructed CT. The volume of valve caps measuring >800 Hounsfield units was designated as the calcium volume (mm3) at end-diastole. Severe AS was defined as an AVA The VD index was significantly lower in the AS patients than in the controls (34 ± 6 vs. 41 ± 4, p = ). ROC analysis revealed a 39 optimal VD index for identifying AS patients with a 0.85 C-statistics, 79% sensitivity, and 83% specificity. In 33 patients with AS, the VD index was significantly lower in patients with an AVA <75 mm2 than those with an AVA >75 mm2 (31 ± 5 vs. 37 ± 7, p < 0.05). There was no significant difference in the calcium volume between the two groups (257 ± 256 mm3 vs. 190 ± 175 mm3). ROC analysis identified a 34 optimal VD index for identifying AS patients with an AVA < 75 mm2, 0.75 C-statistics, 78% sensitivity, and 70% specificity. Decreased Valsalva sinus distensibility is a characteristic feature of AS. The VD index may enable an accurate assessment of aortic stenosis in calcified valve caps. Valsalva sinus distensibiity is an objective measurement for AS severity and is useful in therapeutic planning of transcatheter aortic valve implantation. SSG02-08 Accuracy of Semi Automated Workflow in Reconstruction of CT Angiography prior to Transcatheter Aortic Valve Implant Manuel Belgrano (Presenter): Nothing to Disclose, Alexia Rossi MD : Nothing to Disclose, Antonio Giulio Gennari : Nothing to Disclose, William Toscano MD : Nothing to Disclose, Cristina Cercato : Nothing to Disclose, Maria Assunta Cova MD : Nothing to Disclose To evaluate the accuracy of semi-automated reconstruction workflow in the evaluation of CT-angiography of patients candidated to Transcatheter Aortic Valve Implant (TAVI) in comparison with manual reconstruction performed by an experienced radiologist. We retrospectively evaluated the whole body CT-angiography of 35 consecutive patients who underwent TAVI procedure comparing the manual measures of aortic root and peripheral vessels with the measures obtained with a semi automated workflow provided on a off line workstation (intuition, Terarecon Inc. Santa Clara USA). The reconstruction time within the two groups was registered. A good correlation between the two methods (P > 0.05) was observed. The reconstruction time was significantly lower (P < 0.05) with the automated workflow. The semi-automated reconstruction workflow for TAVI patients is accurate and reliable and simplify a complex procedure in easy small steps, significantly reducing the post processing time. The semi automated reconstruction workflow allows to optimize the clinical management of the TAVI patients, reducing the post processing complexity and the reconstruction time. SSG02-09 Use of Computed Tomographic Angiography to Determine Extent of Danger Zone for Phrenic Nerve Injury during Left Atrial Ablation Therapy Benoit Desjardins MD, PhD (Presenter): Nothing to Disclose, Fabien Squara MD : Nothing to Disclose, Greg Supple MD : Nothing to Disclose, Francis Marchlinski MD : Nothing to Disclose A complication of left atrial ablation therapy for atrial fibrillation is injury to the right phrenic nerve (RPN). The location of the RPN is estimated during the ablation procedure by attempted electrical excitation of the RPN from multiple locations inside the left atrium. Locations where excitations are captured by the RPN are assumed to be in close proximity to the path of the RPN. This determines a danger zone where ablation lesions are at risk of causing RPN injury. The purpose of this project is to determine the size of this danger zone from Computed Tomographic Angiography (CTA) datasets.

143 In 19 consecutive patients undergoing left atrial ablation therapy, the path of the RPN was estimated by electrical excitation of the RPN at 10mA and 50mA from different points at the endocardial surface the left atrium. Palpation of diaphragm contraction was used to determine whether there was capture or non-capture of the excitation by the RPN. After the procedure, the 3D path of the RPN was identified and segmented from CTA datasets using either visualization of the RPN or the right pericardiophrenic artery. The segmented RPN was then merged with the cardiac ablation dataset, and minimal distance of each electrical excitation site to the path of the RPN was determined and correlated with capture or non-capture of each electrical excitation by the RPN. The mean distance between the RPN and the electrical excitation sites at 50mA was 15.5 ± 5.9mm for captured sites vs ± 7.2mm for non-capture sites (p There is good correlation between minimal distance between the left atrial electrical excitation site and the RPN and capture versus non-capture of the electrical excitation by the RPN. This data helps determine the size of the danger zone around the path of the RPN where ablation lesions at different intensities are at risk of affecting the RPN and causing possible injury. CTA is often performed before ablation therapy to assess pulmonary vein anatomy. In addition, radiologists can also identify the path of the RPN from CTA datasets, and use this information to describe the extent of a danger zone around which ablation lesions could injure the RPN. VIS-TUA Vascular/Interventional Tuesday Poster Discussions Scientific Posters IR VA AMA PRA Category 1 Credits :.50 Tue, Dec 2 12:15 PM - 12:45 PM Location: VI Community, Learning Center Moderator Hyeon Yu MD : Nothing to Disclose Sub-Events VIS235 Protection Against Radiation-induced Brain Tumors in Interventional Professionals (Station #1) Luke Anthony Byers DO (Presenter): Nothing to Disclose, William Werner Orrison MD : Consultant, RadSite Consultant, World Wide Innovations & Technologies, Peter Cartwright BS : Nothing to Disclose Individuals involved in interventional procedures are chronically exposed to ionizing radiation, the only unequivocal risk factor for developing intracranial neoplasms. A recent report identified 31 interventionalists who developed brain cancer with the concern that physicians performing interventional procedures have disproportionate left-sided brain tumors. This study was designed to evaluate the effectiveness of using a novel personal cranial radiation protection surgical cap as a means of reducing the risk of radiation induced cerebral neoplasms. Following IRB waiver disposable surgical caps containing various levels of protective lead-free radiation shielding (No Brainer -RADPAD, Kansas City, KS) were used to protect the cranium in one interventionalist and one assistant during multiple fluoroscopic procedures. Radiation monitoring during the fluoroscopic procedures was accomplished using real-time radiation detectors (UNFORS, Billdal, Sweden). Simultaneous monitor recordings were performed with radiation detectors positioned identically above and below the protective material at the level of the anterior left cranium (above the left eye). Four levels of radiation protection were tested (lead equivalency at 90 kvp): 1) Red mm, 2) Orange mm, 3) Yellow mm and 4) Blue mm. A total of 34 patient procedures were completed. Average distance from the calvarium to the Image intensifier was approximately 1 meter. The interventionalist and the assistant reported that the surgical caps were minimally different from those typically worn for interventional procedures and there was no reported discomfort even after multiple hours (day long) wearing. Dose reductions for the procedures are as follows: Overall (92%), Red (100%), Orange (100%), Yellow (96%) and Blue (78%). The "No Brainer"is aptly named, as this simple inexpensive approach to cranium protection is easy to use, comfortable and highly effective at decreasing brain radiation exposure. This device should stem the increasing number of interventionalists reported with cerebral malignancies.

144 Comfortable disposable surgical caps containing a lead-free radiation protection barrier can serve as a means of reducing the risk of radiation induced cerebral neoplasms. VIS236 Incidence of Significant Non-vascular Findings (Neoplastic and Non-neoplastic) in Patients Who Have Undergone Endovascular Aortic Aneurysm Repair (EVAR) (Station #2) Mark Quentin Smith MD (Presenter): Nothing to Disclose, W. Brian Hyslop MD, PhD : Nothing to Disclose, Louise Michelle Henderson : Nothing to Disclose, Hyeon Yu MD : Nothing to Disclose, Julia R. Fielding MD : Nothing to Disclose To determine the incidence of clinically significant non-vascular findings on contrast-enhanced CT angiography in patients who have undergone EVAR. We retrospectively reviewed the radiology reports of the initial abdominopelvic contrast-enhanced 64-slice MDCT scans in 1000 patients who presented with an abdominal aortic aneurysm between January 1, 2008 and December 31, We followed the imaging results for a minimum of two years to determine the significance of each finding. Incidental findings that were benign or unlikely to undergo follow-up were placed into the low significance group. Benign findings that had the potential to warrant medical or surgical intervention were classified as having moderate importance. Findings that required specialized imaging, biopsy or therapeutic intervention as well as indeterminate findings were placed within the high significance category. We examined the proportion of incidental findings in each of these categories by age and location and calculated the 95% confidence intervals to assess differences among subgroups. There were a totla of 2374 incidental findings in 847 patients: 1877 were of low significance, 357 were of moderate significance, and 140 were grouped in the high significance category. There were no differences in the proportion within each category of incidental findings by age group (<65 versus 65+). Of the high significance findings, 32 incidental malignancies (3.2%, 95% CI: %) were found, with renal cell carcinoma being the most common (n=11), followed by metastatic disease (n=5). 22 of the 32 patients had N0M0 disease at initial staging. Our rate of incidental cancers found on abdominopelvic imaging of 3.2% is low, but is greater than the % reported in virtual colonoscopy studies. This may be secondary to the older mean age of this population. In addition, contrast-enhanced scans allow for definitive diagnosis of malignant lesions. The presence of incidental cancers on endovascular CT angiography highlights the need for careful radiologic review of all vascular imaging studies. VIS237 Realizing Radiation and Iodine Dose Reduction in Coronary CT Angiography by Using Adaptive Statistical Iterative Reconstruction (Station #3) Xiao-ying Wang (Presenter): Research Grant, General Electric Company, Mengxi Jiang : Research Grant, General Electric Company, Mingyu Zou PhD : Research Grant, General Electric Company, Chuang Yi : Research Grant, General Electric Company, Gang Hu : Research Grant, General Electric Company, Rui Wang : Research Grant, General Electric Company, He Wang MD : Research Grant, General Electric Company, Baocui Zhang : Research Grant, General Electric Company, Fusheng Gao MD : Research Grant, General Electric Company, Jian Luo : Research Grant, General Electric Company, Jian Jiang : Research Grant, General Electric Company, Chenglin Zhao : Research Grant, General Electric Company To investigate the feasibility of low kvp and low iodine scan protocol in coronary computed tomography angiography (CCTA) to reduce radiation dose without undermining image quality. 200 consecutive patients with body mass index (BMI) kg/m2 undergoing prospectively electrocardiogram-triggered CCTA were randomized into four groups at 4 sites. Group A: using 80kVp and iodixanol 270 mgi/ml with 60% adaptive statistical iterative reconstruction (ASiR); group B: using 100kVp and iodixanol 270 mgi/ml with 30-40% ASiR; group C: using 100kVp and iodixanol 320 mgi/ml with 30-40% ASiR; group D: using 120kVp and iopromide 370 mgi/ml with filtered back projection. 60 ml contrast was given at 5 ml/s intravenously. CT values of 18 coronary artery segments were measured. Image quality was assessed by 2 experienced radiologists blinded to examination, using a 4-point scale (1-4: nondiagnostic-excellent). An assigned score of 1 in any segments was graded the image as nondiagnostic. Noise, contrast-to-noise (CNR), signal-to-noise ratio (SNR) and size-specific dose estimate (SSDE) were also calculated.

145 163 subjects completed study. CT values of all segments in all groups met clinical diagnostic requirement. There was no significant difference in image quality among the four groups (3.4 ± 0.7, 3.5 ± 0.5, 3.6 ± 0.4, 3.6 ± 0.3 respectively).the average CT value in group A (n=37) was higher than that in group B (n=45), C (n=40) and D (n=41) (all p < 0.05). Noise in group A (40.6 ± 8.5 HU) was significantly higher than that in group B (28.8 ± 6.7 HU), C (28.5 ± 4.6 HU) and D (29.1 ± 4.8 HU) (all p < 0.001), while CNR and SNR in group A was lower than that in group C and D (both p < 0.001). Compared with group D, the mean SSDE was reduced by 56.2%, 34.7%, and 34.3% in group A, B, C respectively. All low kvp scans achieved a good image quality with significantly reduced radiation dose. 80 kvp with iodixanol 270 mgi/ml in prospectively electrocardiogram-triggered CCTA for patients with a normal BMI is practicable. With a prospective comparison, the study result has solidified the use of low tube voltage and low iodine enhancement in CCTA. It is time to promote 80 kvp CCTA protocol in clinical to benefit patients from 50% reduction of radiation dose. VIS234 Prophylactic Temporary IVC Filter Retrieval following Major Spinal Reconstruction Surgery: Comparison between Scoliosis and Non-scoliosis Patients (Station #5) Hilary A. Brazeal MD (Presenter): Nothing to Disclose, Jay Desai MD : Nothing to Disclose, Carlos Javier Guevara MD : Nothing to Disclose, Seung Kwon Kim MD : Nothing to Disclose Prophylactic IVC (inferior vena cava) filter placement was initiated for all 'high-risk' spinal surgery patients after a pilot study demonstrated decreased VTE-related morbidity and mortality. Given increased angulation of the IVC filter in patients with scoliosis, there is higher chance of IVC filter tilting, leading to increased difficulty of IVC filter retrieval. The purpose of this study is to compare filter retrieval between scoliosis and non-scoliosis patients who had temporary IVC filter placement before major spinal reconstructive surgery. Patients were identified by a computerized search of the radiology information system for prophylactic temporary IVC filter placement before major spinal reconstructive surgery and filter retrieval after surgery from 2005 to Jan These patients were divided into two groups: a scoliosis surgery (SS) group and a non-scoliosis surgery (NSS) group. Type of filter, attempted filter retrieval, indwelling time of filter, sedation time of the filter retrieval procedure, and success of attempted filter retrieval were compared between the two groups. From 2005 to Jan 2014, 134 IVC filters were placed prior to spine surgery. 116 (84.9%) of those were retrievable filters. Retrieval was attempted on 53 (45.7%) of the retrievable filters. Retrieval was successful in 45/53 (84.9%) of those attempts, including a single case that was successful on the second attempt. Indwelling time of IVC filter at time of attempted retrieval was significantly higher in the SS group (SS group = 59.4 days, NSS group = 31 days) (p=0.006). Success rate of attempted filter retrieval in the SS group (78.1% (25/32)) was lower than the NSS group (95.2% (20/21)) (p=0.13). Average retrieval sedation time of a successful retrieval in the SS group (44.8 minutes) was higher than the NSS group (28.2 minutes) (p= 0.15). Type of filters in failed retrievals were Günther Tulip (4/25) and Option (4/17). IVC filter retrieval requires increased procedure time and has decreased success rates in the SS group compared with the NSS group. Longer IVC filter indwelling time in scoliosis surgery patients leads to increased difficulty and decreased success of IVC filter retrieval. VIS238 Transarterial Chemoembolization (TACE) as a Palliative Treatments Option for Liver Metastases from Lung Cancer: Indications, Outcomes and Role in Patient s Management (Station #6) Tatjana Gruber-Rouh (Presenter): Nothing to Disclose, Nagy Naguib Naeem Naguib MD, MSc : Nothing to Disclose, Nour-Eldin Abdelrehim Nour-Eldin MD, MSc : Nothing to Disclose, Martin Beeres MD : Nothing to Disclose, Julian Lukas Wichmann MD : Nothing to Disclose, Stefan Zangos MD : Nothing to Disclose, Thomas Josef Vogl MD, PhD : Nothing to Disclose To evaluate local tumor control and survival data after TACE with three different chemotherapeutic protocols in the palliative treatment of patients with liver metastases from lung cancer

146 The study protocol was approved by the ethical committee, and informed consent was obtained from all patients prior to treatment. A total of 44 patients (mean age, 55.2 years; range, years) with unresectable liver metastases of lung cancer who did not respond to systemic therapy were repeatedly treated with TACE in 4-week intervals. In total, 176 chemoembolization procedures were performed (mean, 4 sessions per patient; range, 3-6 sessions). The local chemotherapy protocol consisted of mitomycin alone (22.7%; n=10), mitomycin with gemcitabine (22.7%; n=10) or mitomycin, gemcitabine and cisplatin (54.6%, n=24). Embolization was performed with lipiodol and degradable starch microspheres. Local tumor response was evaluated by MRI according to the RECIST criteria. Survival data were calculated according to the Kaplan-Meier method. The local tumor control was: partial response (PR) in 15.9% (n=7), stable disease (SD) in 56.8% (n=25) and progressive disease (PD) in 27.3% (n=12) of patients. The 1-year survival rate after chemoembolization was 70%, and the 2-year survival rate was 38%. The median and mean survival times from the start of TACE treatment were 20 and 31.8 months. There was no statistically significant difference between the three treatment protocols. Chemoembolization is a potentially palliative treatment option in achieving local control in selected patients with liver metastases from lung cancer. Chemoembolization is a potentially palliative treatment option in achieving local control in selected patients with liver metastases from lung cancer. VIE125 Popliteal Artery Entrapment Syndrome (PAES): Types and Dynamic Imaging Protocol (Station #7) Karel F. Wallecan MD (Presenter): Nothing to Disclose, Mohamed Ouhlous MD, PhD : Nothing to Disclose, Adriaan Moelker MD : Nothing to Disclose 1. To describe normal anatomy of the popliteal fossa 2. Current classification of anatomic and functional popliteal artery entrapment 3. To assess weaknesses and strengths of different imaging modalities 4. Discuss emerging role of dynamic contrast enhanced CTA for diagnosing PAES. Normal anatomy of the popliteal fossa Anatomic versus functional popliteal entrapment Radiographic evaluation of PAES with Ultrasound, MRI/MRA and Angiography Dynamic CTA for suspected PAES: - Advantages - how we do dynamic scanning on CT Clinical cases Summary VIE101 Selective Internal Radiation Therapy (SIRT) A Review on the Principle, Work-up and Overview of Published Data in Selective Internal Radiation Therapy with Yttrium-90 Microspheres (Station #8) Henry Ho Ching Tam MBBS (Presenter): Nothing to Disclose, Ying Chen MBBS : Nothing to Disclose, Dow-Mu Koh MD, FRCR : Nothing to Disclose, Adil Al-Nahhas : Nothing to Disclose The incidence of both primary and secondary liver malignancies is increasing. Although surgery or minimally invasive intervention e.g. radiofrequency ablation results in the best outcomes, these approaches are limited by the burden and site of disease. Selective internal radiation therapy (SIRT) is a promising technique in patients deemed unsuitable for surgery. Despite its increasing popularity, radiologists may not be familiar with this treatment. Review the principle of SIRT with yttrium-90 (90Y) microspheres Review the literature with regards to treatment outcomes. Although morphological imaging is usually used to assess disease burden and treatment response, the potential for functional imaging techniques is discussed. Physics and biological basis of SIRT with yttrium-90 Comparison of the properties of SIR-spheres with Theraspheres Patient selection/contraindications Patient preparation: visceral angiography (Fig. 1); hepatopulmonary shunt (Fig. 2 and 3); dosimetry Adverse reactions and complications Special consideration in patients with portal vein thrombosis and malignant biliary obstruction Morphologic and functional imaging techniques for response assessment and prediction (Fig. 4 and 5) Review of published data supporting use of 90Y-SIRT: response rate and long-term outcome VIE021-b Ultrasound Guided Percutaneous Thrombin Injection for Treating Femoral Artery Pseudoaneurysms: When and How to Do it; When Not to Do it (hardcopy backboard) Eleni Antypa : Nothing to Disclose, Demosthenes D. Cokkinos MD (Presenter): Nothing to Disclose, Konstantinos Iosifidis MD : Nothing to Disclose, Kalliopi Melaki : Nothing to Disclose, Despina Kriketou MSc, MD : Nothing to Disclose, Ploutarhos A Piperopoulos MD, PhD : Nothing to Disclose To present a guide to ultrasound (US) guided percutaneous injection of thrombin for the treatment of femoral artery pseudoaneurysms. To review the indications, technique, possible complications and limitations. To assess

147 relevant guidelines in order to seek alternative treatment when this technique fails. Description of predisposing factors for femoral artery pseudoaneurysm formation, clinical features and Doppler US diagnosis. Meticulous description of the technique, including step by step US guided femoral artery catheterisation, thrombin preparation and administration, variation of the procedure according to the size, form and number of the pseudoanurysm's lobes. Specific points that should be kept in mind in order to maximise success rates and avoid complications. Outline of post procedure follow up, need for possible repetition of treatment and guideline flowchart in order to abandon the technique for surgical repair when needed are also explained. US images from our Institution's experience. VIS-TUB Vascular/Interventional Tuesday Poster Discussions Scientific Posters IR VA AMA PRA Category 1 Credits :.50 Tue, Dec 2 12:45 PM - 1:15 PM Location: VI Community, Learning Center Sub-Events VIS241 Novel Subtracted CT Angiography Imaging Using Non-rigid Registration for Better Visualization of Spinal Dural Arteriovenous Fistulas (Station #1) Tatsuya Nishii MD (Presenter): Nothing to Disclose, Atsushi K. Kono MD,PhD : Nothing to Disclose, Mizuho Nishio MD, PhD : Research Grant, Toshiba Corporation, Hiromi Hashimura MD : Nothing to Disclose, Noriyuki Negi RT : Nothing to Disclose, Atsushi Fujita : Nothing to Disclose, Junya Konishi : Bayer Pharma FUJIFILM RI Pharma Co. Ltd., Eiji Kohmura MD, PhD : Nothing to Disclose, Kazuro Sugimura MD, PhD : Research Grant, Toshiba Corporation Research Grant, Koninklijke Philips NV Research Grant, Bayer AG Research Grant, Eisai Co, Ltd Research Grant, DAIICHI SANKYO Group CT angiography (CTA) prior to digital subtraction angiography (DSA) is useful for detecting the feeders of spinal dural arteriovenous fistulas (SDAVFs). However, identifying these feeders is sometimes time-consuming because they are small and run close to osseous structures. Non-rigid registration provides precise subtraction that can compensate for organ motion or transformation between two datasets. Thus, we hypothesized that subtracted CTA imaging using non-rigid registration (R-CTA) would facilitate the diagnosis of SDAVF feeders. The aim of this study was to evaluate the utility of R-CTA in patients with SDAVFs in comparison with conventional CTA imaging (C-CTA). The records of 10 consecutive patients (63±13 years old, 1 female) who had undergone CTA and DSA for clinically suspected SDAVFs were retrospectively reviewed. From repeated CTAs performed at the arterial and late-arterial phases, deformed images of the late-arterial phase were obtained using non-rigid registration adjusted to the arterial phase images. Registration was performed using open-source Advanced Normalization Tools software. Next, R-CTA images were obtained by subtracting the deformed images from the arterial phase images. Both R- and C-CTA were analyzed with DSA results as a reference standard. The time required for detecting the SDAVFs' feeders, and their detectability, were analyzed for each patient. For each intervertebral foramen, the diagnosis likelihood of the feeders was scored on a 5-point scale (1=definitely negative, 5=definitely positive), and the accuracy was calculated. The difference between R-CTA and C-CTA was assessed by an ANOVA test and McNemar's Chi-square test. The required time to detection, and the detectability of, feeders using C-CTA vs. R-CTA were 96.1±39.1s vs. 49.3±27.3s (P<0.01), and 60% vs. 80% (P=0.15), respectively. When a feeder was scored 4, the accuracy in C-CTA vs. R-CTA was 94.5% (189/200) vs. 97.5% (195/200) (P=0.01), respectively. R-CTA reduced the time required for detecting SDAVF feeders, and had better accuracy than C-CTA. Our subtracted CTA imaging technique using non-rigid registration helps clinicians to assess SDAVF feeders more quickly and accurately than the conventional method. VIS242 Troubling TAVR Studies: Incidental Findings in Patients Undergoing CT Angiography for Transcatheter Aortic Valve Replacement (Station #2) Phil Wu (Presenter): Nothing to Disclose, Farhood Saremi MD : Nothing to Disclose, Christopher Lee MD : Nothing to Disclose

148 To determine the prevalence of significant incidental findings (SIF's) on CT angiography (CTA) in patients undergoing evaluation for transcatheter aortic valve replacement (TAVR). To evaluate the implications of SIF's on clinical practice. 181 patients underwent CTA of the chest, abdomen, and pelvis for TAVR evaluation between January 2011 and January CTA's were retrospectively reviewed for concerning imaging findings (CIF's). Electronic medical records were reviewed to determine which CIF's represented SIF's, with SIF defined as: (a) no clinical or imaging history of CIF prior to CTA and (b) no follow-up disproving the imaging finding. SIF's were assigned to the following categories: possible malignancy, cardiovascular, non-malignant thoracic, non-malignant gastrointestinal, and non-malignant genitourinary. 112 of 181 patients (61.9%) were men; the mean age was 82.7±8.8 years. 90.6% (164/181) of patients had at least one CIF. 4.5% of CIF's had clinical follow-up, surveillance imaging, or other diagnostic studies. Of the CIF's that were followed-up, 42.2% resulted in new diagnoses or therapeutic interventions. 11% of CIF's were known prior to CTA or were disproven on follow-up. 84.5% of CIF's were not followed-up at our institution for the following reasons: immediate follow-up was not deemed clinically necessary as severe aortic valve disease was the primary determinant of patient prognosis, patients were often referred to our institution solely for TAVR, and 16 patients died within 3 months of CTA. Possible malignancy SIF's were present in 54.7% (99/181), cardiovascular SIF's in 52.5% (95/181), non-malignant thoracic SIF's in 17.7% (32/181), non-malignant GI SIF's in 22.7% (41/181), and non-malignant GU SIF's in 6.6% (12/181) of patients. Attached table summarizes findings. Although CTA evaluation of TAVR candidates is primarily utilized to characterize the anatomy of the aortic root and aortoiliofemoral arteries for candidate selection and procedural planning, CTA frequently reveals SIF's that may alter the pre- or post-procedural management of TAVR candidates. Even if management is not altered per se, SIF's can result in new diagnoses with implications on overall prognosis. As SIF's can alter patient management and prognosis, radiologists should carefully examine preoperative CTA's for CIF's. VIS243 Kinetic Assessment of the Intimal Flap in Acute or Chronic Aortic Dissection Using Cne CPR and MPR Images Acquired by ECG-gated CT (Station #3) Noritaka Kamei (Presenter): Nothing to Disclose, Norio Hongo : Nothing to Disclose, Shinji Miyamoto : Nothing to Disclose, Rieko Shuto MD : Nothing to Disclose, Shunro Matsumoto MD : Nothing to Disclose, Satomi Ide : Nothing to Disclose, Mika Okahara MD : Nothing to Disclose, Shinya Ueda : Nothing to Disclose, Hiro Kiyosue MD : Nothing to Disclose, Hiromu Mori MD : Nothing to Disclose Our purpose is to assess the 4D data acquired from retrospective electrocardiographically(ecg) gated computed tomography(ct) using cine multiplanar reformation(cine MPR), and to characterize and define the kinetics of the intimal flap in acute or chronic aortic dissections. Twenty eight consecutive cases with Debakey III aortic dissection without prominent intramural thrombus who underwent ECG-gated CT from January 2010 to September 2013 were included in this study. Each CT scan was retrospectively reconstructed into sequential 10 axial datasets. Cine cross-sectional MPR images of the whole descending aorta were created. The maximum(dmax) and minimum(dmin) diameter of the true lumen at all time points was measured at each anatomic level. Maximum diameter change was calculated using following formula (Dmax-Dmin)/Dmax. The Dmax in the proximal descending aorta reached its peak in early systole. There was a gradual and delayed wavelike movement of the peak toward the distal abdominal aorta. Dmax in the lower abdominal aorta was seen in diastolic phase. In an acute dissection group, the maximum diameter change, with collapse of the true lumen, was most frequently seen at the level of third lumbar vertebral body in systole. That was more prominent in the cases having no re-entry lower than the level of third lumbar spine, which included two cases with limb ischemia. There was less motion of the intimal in the chronic group than in the acute group. Assessments of cine MPR images of the whole descending aorta acquired by ECG-gated CT revealed the complicated dynamic movement of the intimal flap in acute and chronic aoric dissections. This reserch addresses the unknown dynamic behavior of the septum in acute and chronic aortic dissections. The assessment of the motion of the intimal flap and the location of the re-entry described using CT may inform our clinical management of patients with Debakey III dissection. VIS239 Proximal vs. Distal Occlusion of the Internal Iliac Artery Prior EVAR: Evaluation of Efficacy and

149 VIS239 Clinical Outcome (Station #4) Alexander Dierks MD (Presenter): Nothing to Disclose, Alexander Sauer MD : Nothing to Disclose, Franziska Wolfschmidt MD : Nothing to Disclose, Nicole Hassold MD : Nothing to Disclose, Thorsten Alexander Bley MD : Nothing to Disclose, Ralph Kickuth MD : Nothing to Disclose Prior to endovascular aortoiliac aneurysm repair (EVAR) occlusion of the internal iliac artery (IIA) may be necessary to prevent an endoleak type II. We compared efficacy and clinical outcome after proximal occlusion of an unaffected IIA (ProxEmbx) using the Amplatzer vascular plug I (AVP) vs. distal occlusion of aneurysmatic IIA with coils and plugs (DistEmbx). Between 04/2009 and 12/ patients (mean age 74±8 years) underwent EVAR. In 9 patients with unaffected IIA occlusion was performed by a single AVP. In 13 patients with aneurysmatic IIA more distal embolization was conducted by using several coils and additional AVPs. The follow-up (mean 15±12.4 months) was based on clinical and radiological examinations (CTA and CEUS). Retrospectively, technical success, clinical outcome and complications were evaluated. Embolization of the IIA was successful in all patients. Three patients with more distal embolization of aneurysmatic IIAs suffered from new onset sexual dysfunction after occlusion without statistically significant difference (p>0.05). Transient buttock claudication was observed in three patients in each group. Bowel ischemia did not occur. The procedure time in the ProxEmbx group was significantly lower (43±20 vs. 73±29 minutes; p=0.013). Fluoroscopy time for the ProxEmbx was also lower (14.6±4 vs. 29.2±7 minutes; p=0.038). There was no significant difference concerning radiation exposure (p>0.05), which was related to different BMI in both groups. There was no difference in the amount of contrast media (p>0.05). Proximal occlusion of an unaffected IIA as well as more distal occlusion of an aneurysmatic IIA prior to EVAR have both the same technical and clinical outcome. However, proximal plug embolization has a significant lower procedure and fluoroscopy time. Proximal plug embolization of an unaffected IIA prior to EVAR is associated with shorter procedure and fluoroscopy time in comparison to more distal embolization of aneurysmatic IIAs. VIS240 Optional IVC Filter Quality Improvement Project: Using the Electronic Medical Record (EMR) Problems List to Increase Retrieval Rates and Decrease Time to Filter Retrieval (Station #5) Melissa Chittle MS (Presenter): Nothing to Disclose, Stephan Wicky van Doyer MD : Nothing to Disclose, George Rachid De Oliveira MD : Nothing to Disclose, Suvranu Ganguli MD : Research Grant, Merit Medical Systems, Inc Consultant, Boston Scientific Corporation, Raymond W. Liu MD : Nothing to Disclose, Rahmi Oklu MD, PhD : Nothing to Disclose, Zubin Irani MD : Nothing to Disclose, Thomas Gregory Walker MD : Nothing to Disclose, Gloria Maria Martinez Salazar MD : Nothing to Disclose To compare retrieval rates and number of days to retrieval in patients with optional IVC filters before and after adding the notation "Retrievable IVC filter" to the patients electronic medical record "Problems" list In this IRB-approved retrospective study, 314 patients (age years; 142 females, 171 males) who underwent IVC filter placement for temporary indications between 01/11/2011 and 03/10/2014 were studied. Our study group (n=154) consisted of patients in whom a notation was made to the EMR Problems list following filter implantation that stated: "Retrievable IVC filter: This should be retrieved when no longer indicated for PE protection". The control group (n=160) had no such notation. All patients' demographics, filter placement indications, procedure dates (filter placement/retrieval), complications, days to retrieval, retrieval rates and referral rates (patients who were referred by a clinician to IR for filter retrieval) were recorded. Statistical analysis was performed using a Fischer's exact test and unpaired t test. There were no significant differences in demographics and filter placement indications between the control (n=160) and study groups (n=154). IVC filter retrieval rates in the study group (69/154; 42%) were significantly higher (p=0.0001) than the control group (31/160;19%). Direct patient referrals from clinicians for filter retrieval increased significantly in the study group (27/154; 18%;p=0.0001), as compared to the control group (5/160;3%). The number of days from insertion to filter retrieval in the study group (Mean 132.2, SD , SEM 7.96) was significantly less (p=0.001) than in the control group (Mean days, SD 189.8, SEM 15.00) In this study, adding the notation "Retrievable IVC Filter" to the patients' electronic medical record "Problems" list significantly increased patient referral to IR for filter retrieval, increased the overall filter retrieval rates and decreased the number of days to filter retrieval

150 There are complications secondary to indwelling IVC filters(migration, fracture and DVT) in patients with optional filters. Therefore, continuous monitoring is paramount to ensure timely filter retrieval. VIS244 Dual-phase Cone Beam CT Improves Identification of Cholangiocarcinoma Lesions during Trans-arterial Chemoembolization (Station #6) Ruediger Egbert Schernthaner MD (Presenter): Nothing to Disclose, MingDe Lin PhD : Employee, Koninklijke Philips NV, Rafael Duran MD : Nothing to Disclose, Julius Chapiro MD : Nothing to Disclose, Zhijun Wang MD : Nothing to Disclose, Jean-Francois H. Geschwind MD : Consultant, BTG International Ltd Consultant, Bayer AG Consultant, Guerbet SA Consultant, Nordion, Inc Grant, BTG International Ltd Grant, F. Hoffmann-La Roche Ltd Grant, Bayer AG Grant, Koninklijke Philips NV Grant, Nordion, Inc Grant, ContextVision AB Grant, CeloNova BioSciences, Inc Founder, PreScience Labs, LLC CEO, PreScience Labs, LLC To evaluate the impact of dual-phase cone-beam CT (CBCT) on the identification of cholangiocarcinoma (CCC) lesions during transarterial chemoembolization (TACE) compared to conventional DSA, in relation to pre-interventional contrast-enhanced magnetic resonance imaging (CE-MRI) of the liver. This retrospective study included 17 consecutive patients (10 men, 7 women; mean age 64) with CCC who underwent pre-interventional CE-MRI of the liver and intra-procedural dual-phase (early and delayed arterial) CBCT just before the chemotherapeutic drug delivery. The degree of visibility of each CCC lesion was graded on a three rank scale (complete, partial and none) on dual-phase CBCT and DSA images and compared to CE-MRI. Lesions < 5 mm diameter or outside the CBCT's field of view were excluded from evaluation. Statistical analysis was performed with Wilcoxon signed-rank test and Friedman test. At total of 61 CCC lesions was included. The sensitivity of DSA for the complete or partial depiction of CCC lesions was only 45.9%, whereas early and delayed arterial phase CBCT had significantly higher sensitivity of 73.8% and 93.4%, respectively (p<0.01). There was only one lesion (1.6%) that was depicted by DSA, but not by dual-phase CBCT due to severe streak artifacts caused by a mitral valve replacement. Conversely, out of the 33 lesions not visible on DSA, 18 (54.5%) and 30 (90.9%) were revealed on early and delayed arterial phase CBCT images, respectively. Early arterial phase CBCT showed no additional lesions compared to delayed arterial phase CBCT. Delayed arterial phase CBCT identified significantly more lesions (n=12, 19.7%, p<0.01) than early arterial phase CBCT. Especially with regard to the complete delineation of lesions, delayed arterial phase CBCT yielded significantly higher sensitivity (78.7%) compared to early-phase CBCT (31.1%) and DSA (21.3%)(p<0.01). Dual-phase CBCT significantly improved the identification of CCC lesions during TACE. Delayed arterial phase CBCT yielded the highest sensitivity for the complete delineation of CCC lesions. Dual-phase CBCT should be used as standard imaging technique during TACE in CCC patients. Dual-phase CBCT can help to identify CCC lesions during TACE thus preventing some lesions to be overlooked for optimal treatment. VIE174 Radiation Cataractogenesis in Interventional Radiology: A Review for the Interventional Physician (Station #7) Kevin Frederick Seals MD (Presenter): Nothing to Disclose, Ramsey al-hakim MD : Nothing to Disclose, Christopher H. Cagnon PhD : Nothing to Disclose, Stephen Thomas Kee MD : Nothing to Disclose, Edward Wolfgang Lee MD, PhD : Nothing to Disclose The purpose of this exhibit is: 1. To provide a comprehensive overview of radiation cataractogenesis in interventional radiology 2. To review the operator lens doses seen in common IR procedures and the data linking cataract development with interventional work 3. To describe optimal lens protection for the IR physician and strengths and weaknesses of each protection technique Background ICRP threshold guidelines, data motivating the 2011 threshold change [Figure 1] Mechanistic basis of radiation cataract, including the role of radiation genotoxicity Assessment of the stochastic versus deterministic nature of radiation cataractogenesis [Figure 2] Data linking radiation exposure and cataract development in interventional physicians [Figure 3] Multiple studies showing a statistically significant increase in cataract risk in interventionists

151 Factors modulating this risk Lens dose in common IR procedures [Figure 4] Physician lens dose in TIPS, CT guided biopsy and drainage, vertebroplasty, chemoembolization, neurointerventional techniques, etc. Critical analysis of lens protection strategies [Figure 5] Leaded eyeglasses Ceiling-suspended shields Complex commercial shielding devices Real-time dosimetry Radiation education MSAS33 Management of Portal Hypertension (Sponsored by the Associated Sciences Consortium) (An Interactive Session) Multisession Courses IR GI AMA PRA Category 1 Credits : 1.50 ARRT Category A+ Credits: 1.50 Tue, Dec 2 1:30 PM - 3:00 PM Location: S105AB Moderator David Brent Nicholson : Nothing to Disclose Moderator Steven P DeColle : Nothing to Disclose Sub-Events MSAS33A TIPS (Tranjugular Intrahepatic Portal Systemic Shunts) Harneil Singh Sidhu MD (Presenter): Nothing to Disclose 1) When are indications for a TIPS procedure? 2) Pre-procedure workup for a TIPS procedure? 3) How is a TIPS performed. 4) What are some post procedure issues that occur. MSAS33B BRTO/BATO Balloon Occluded Retrograde Tranvenous Obliteration of Varicose Veins/Balloon Occluded Antegrade Transvenous Obliteration of Varicose Veins Jun Koizumi MD, PhD (Presenter): Nothing to Disclose 1) Summarize the pathologic anatomy and hemodynamics associated with gastric and ectopic varices. 2) Describe the varying techniques of portosystemic collateral embolization, and balloon occluded transvenous obliteration (BRTO and BATO) for the management of gastric varices. 3) Identifiy the skillset and tactics for practice builging and clinical patient selection. 4) Describe the techniques for transvenous sclerosis of ectopic varices will be described. ABSTRACT This session will describe the pathologic anatomy and hemodynamics associated with gastric and ectopic varices. The varying techniques of portosysteic collateral embolization and balloon occluded transvenous obliteration (BRTO and BATO) for the management of gastric varices are also reviewed. Practice builging and clniical patient selection will also be addressed. Advanced techniques for transvenous sclerosis of ectopic varices will be described. MSAS33C Portal Hemodynamics - Post Intervention Wael E. A. Saad MBBCh (Presenter): Research Grant, Siemens AG Research Consultant, Siemens AG Consultant, Boston Scientific Corporation Consultant, Getinge AB Consultant, Merit Medical Systems, Inc

152 1) The attendees will know the various types of percutaneous portal procedures performed. 2) The attendees will understand the hemodynamic definitions and concepts of inflow and outflow. 3) The attendees will understand that increasing antegrade portal venous does not necessarily increase the functional inline portal venous flow to the liver hepatocytes. 4) The attendees will understand what procedures are categorized as procedures that would increase or decrease inline portal venous inflow. 5) The attendees will understand the correlations between nominal portal pressures, pressure gradients and portal flow (velocity, volume and direction). ABSTRACT Abstract: Portal interventions include: Transjugular Intra hepatic PortoSystemic Shunts (TIPS), portal vein angioplasty / Stenting, Balloon-occluded retrograde Transvenous obliteration (BRTO), hepatic venous interventions for Budd-Chiari, para umbilical vein occlusion and extrahepatic PortoSystemic shunt occlusion. The lecture will discuss the effects of these procedures on nominal portal pressures, pressure gradients and portal flow (velocity, volume and direction) and inline portal blood flow to the functional liver (hepatocytes). VSIO31 Interventional Oncology Series: Liver Metastases Series Courses RO OI IR GI RO OI IR GI AMA PRA Category 1 Credits : 4.25 ARRT Category A+ Credits: 5.00 Tue, Dec 2 1:30 PM - 6:00 PM Location: S405AB Moderator Michael Christopher Soulen MD : Royalties, Cambridge University Press Consultant, Guerbet SA Research support, Guerbet SA Consultant, BTG International Ltd Research support, BTG International Ltd Consultant, Merit Medical Systems, Inc Speaker, Sirtex Medical Ltd This session will review the multidisciplinary management of liver metastases from colorectal cancer and neuroendocrine tumors, the unique feature affecting assessment and triage of each tumor type, and integration of image-guided therapy with systemic therapies. Didactic material will be reinforced by tumor board style review of clinical cases. ABSTRACT see individual lecture abstracts Sub-Events VSIO31-01 Setting the Stage: NCCN/ESMO Guidelines for mcrc Mary F. Mulcahy MD (Presenter): Nothing to Disclose View learning objectives under main course title. VSIO31-02 Going for Cure: Multidisciplinary Conversion to Resectability Robert E. Roses MD (Presenter): Nothing to Disclose 1) Describe the contemporary paradigm for the management of hepatic metastases (with an emphasis on colorectal cancer liver metastases). 2) Describe criteria for resectability. 3) Discuss the interplay between systemic chemotherapy and surgical approaches. 4) Discuss the interplay between interventional radiology techniques and surgical approaches. 5) Discuss alternative treatment sequences for patients with synchronous liver metastases. ABSTRACT The last decade has witnessed an expanding role for resection in the management of metastatic colorectal cancer. Traditional exclusion criteria for liver resection have largely been abandoned. The contemporary paradigm for the management of liver metastases emphasizes the preservation of a sufficient liver remnant. Assessment of resectability depends on a careful review of preoperative imaging and is facilitated by volumetric measurement. In addition, because of the greater efficacy of chemotherapy, a subset of patients who are initially unresectable are downstaged to resectability. Systemic therapy may also allow for the more rational application of aggressive surgical approaches. Interventional approaches, in particular portal vein embolization may further expand the number of resection candidates or allow for safer application of extended hepatectomy. In patients with synchronous metastases reverse sequencing, and combined resections are increasingly utilized. FInally, two-stage hepatectomy may allow for complete resection of bilobar metastatic disease. VSIO31-03 DW-MRI vs. PET/CT for Assessment of Early Treatment Response of Liver Metastases to

153 VSIO31-03 Y90-Radioembolisation: First Results Alexandra Barabasch MD (Presenter): Nothing to Disclose, Nils Andreas Kraemer : Nothing to Disclose, Alexander Ciritsis : Nothing to Disclose, Nienke Lynn Hansen MD : Nothing to Disclose, Philipp Bruners MD : Nothing to Disclose, Christiane Katharina Kuhl MD : Nothing to Disclose We report on the first results of an ongoing study that aims at comparing the accuracy of liver DW-MRI to PET/CT for early response-assessment after trans-arterial Y90-radioembolisation (Y90-RE). Between June-2010 and December-2013, 145 Y90-RE in 85 patients were performed. Patients who (1) had liver-metastases from solid cancers, and (2) had at least 3 measurable target-lesions in the right liver lobe were included. 25 patients (16 colorectal, 8 breast and 1 CUP) met the inclusion criteria and underwent PET/CT and DW-MRI of the liver within 6 weeks before and within 4-8 weeks after Y90-RE. An increase in mininmal ADC (ADCmin) and a decrease in maximal SUV (SUVmax), respectively, of at least 30% after Y90-RE was regarded as positive response. In diverging response classifications, the final outcome of the patient was used to distinguish true from false response-classifications. Two patients (2/25, 8 %) were FDG-negative on pre-therapeutic PET, leaving 23 for DWI/PET-correlation. After Y90-RE, overall SUVmax decreased from 7.90 ± 2.75 to 5.47 ± 2.06 (p<0.0001). Minimal ADC (ADCmin) increased from 0.53 ± 0.14 *10-3 mm2/s to 0.73 ± 0.29 *10-3 mm2/s (p=0.0035). A strong inverse correlation was observed for post-therapeutic ADCmin and SUVmax (r=-0.73). Concordant response-classification was observed in 19/23 patients (83 %), discordant in 4/23 (17 %). In 3/4, response based on DWI was confirmed by follow-up. PPV to predict presence of response was 14/15 (93 %) for MRI and 11/10 (91 %) for PET. NPV to predict absence was 10/10 (100 %) for MRI and 10/14 (71 %) for PET. The sensitivity for detecting response was significantly higher for MRI (100 %; 14/14) than for PET (71%; 10/14) (p<0.004). DW-MRI appears to be significantly more sensitive than PET/CT for demonstrating early response after Y90-RE in patients with secondary liver tumors. DW-MRI should be preferred for early response assessment after Y90-RE, since it appears to be significantly more sensitive compared to PET/CT. VSIO31-04 Going It Alone: Ablation for Cure Luigi Solbiati MD (Presenter): Nothing to Disclose View learning objectives under main course title. ABSTRACT For hepatic metastases from colorectal cancer ablation is generally used in small volume liver disease in inoperable patients. For many years survival data following ablation (median survival of 3 years and 5-year survival approaching 30%) have been better than any published chemotherapy alone data and slightly worse than those achieved after liver resection. More recently, thanks to further improvements of ablation technologies and techniques, it has been demonstrated that local control of colorectal metastases within the 2-cm and the 2-3 cm size ranges approaches respectively 100% and 85-90%, thus being comparable with most surgical series. In addition, in recent reports, long-term follow-up results up to 10 years in patients with appropriately selected hepatic metastases from colorectal cancer were essentially equivalent to those from surgical resection, even preserving the traditional advantages of ablation vs surgery (less invasiveness, repeatability, lower complication rates, etc..). These findings highlight the viability of ablation as an alternative treatment not only in the large number of patients who are ineligible for surgical resection, but also for patients who could undergo surgery, provided that accurate selection of cases is applied and the most advanced technologies and techniques to guide and perform ablations are employed. Of course, combinations of ablations and chemotherapy are by far preferable to ablation alone, but ablation should still be offered to patients who cannot receive chemotherapy. VSIO31-05 Palliative Embolotherapy: New Technology, New Promises? Tobias Franz Jakobs MD (Presenter): Speaker, Sirtex Medical Ltd Research Consultant, Sirtex Medical Ltd Speaker, Siemens AG Speaker, Terumo Corporation Speaker, Surefire Medical, Inc 1) Palliative embolization for different tumor entities. 2) Indications for palliative embolotherapy. 3) Products and devices for embolotherapy. ABSTRACT

154 Embolisation has become an accepted modality of cancer treatment in patients with a variety of clinical scenarios. It is commonly used in clinical practice in the treatment of hepatocellular carcinoma, hepatic metastases from colorectal and breast cancer and neuroendocrine tumors. This review summarizes the current evidence for the efficacy of embolotherapy in these clinical settings, together with the associated complications and future options. VSIO31-06 Transarterial Chemoembolization in Soft-Tissue Sarcoma Metastases to the Liver The Use of Imaging Biomarkers as Predictors of Patient Survival Julius Chapiro MD (Presenter): Nothing to Disclose, Rafael Duran MD : Nothing to Disclose, MingDe Lin PhD : Employee, Koninklijke Philips NV, Ruediger Egbert Schernthaner MD : Nothing to Disclose, Zhijun Wang MD : Nothing to Disclose, Jean-Francois H. Geschwind MD : Consultant, BTG International Ltd Consultant, Bayer AG Consultant, Guerbet SA Consultant, Nordion, Inc Grant, BTG International Ltd Grant, F. Hoffmann-La Roche Ltd Grant, Bayer AG Grant, Koninklijke Philips NV Grant, Nordion, Inc Grant, ContextVision AB Grant, CeloNova BioSciences, Inc Founder, PreScience Labs, LLC CEO, PreScience Labs, LLC To evaluate the role of imaging biomarkers of tumor response in soft-tissue sarcoma (STS) metastases to the liver treated with conventional transarterial chemoembolization (ctace). This study was a retrospective analysis of 25 patients with STS metastases to the liver treated with ctace. Each patient underwent contrast-enhanced MRI (cemri) within 6 weeks before and after therapy. Tumor response of the largest target lesion was assessed on arterial-phase MRI in each patient using RECIST, modified RECIST and EASL guidelines. In addition, a segmentation-based 3D quantification of the enhancing tumor volume (quantitative [q] EASL) was performed. For each method, patients were classified as responders (R) and non-responders (NR) and evaluated using Kaplan-Meier analysis. Overall survival (OS) and progression-free survival (PFS) of the entire cohort were calculated. Clinical parameters (performance, tumor status, treatment history) were included into a multivariate analysis of Cox proportional hazard ratios (HR). A total of 65 procedures (mean, 2.6/patient) were performed. Median OS of the entire cohort was 21.2 months (95% CI, ) and PFS was 6.3 months (95% CI, ). No patient was classified as R according to RECIST, while 11 (44%), 12 (48%) and 12 (48%) patients were R according to EASL, mrecist and qeasl, respectively. Multivariate analysis identified tumor response according to mrecist and qeasl as reliable predictors of improved patient survival (P=0.019; HR 0.3 [ ] and P=0.006; HR 0.2 [ ], respectively). This study demonstrated the advantages of enhancement-based tumor response assessment over size-based RECIST analysis of STS metastases to the liver and validated qeasl as the most predictive assessment method after ctace. The validation of mrecist and qeasl as prognostically relevant imaging biomarkers of tumor response might help to identify non-responders sooner for potential re-treatment in this rare disease. VSIO31-07 mcrc Tumor Board Mary F. Mulcahy MD (Presenter): Nothing to Disclose, Robert E. Roses MD (Presenter): Nothing to Disclose, Luigi Solbiati MD (Presenter): Nothing to Disclose, Tobias Franz Jakobs MD (Presenter): Speaker, Sirtex Medical Ltd Research Consultant, Sirtex Medical Ltd Speaker, Siemens AG Speaker, Terumo Corporation Speaker, Surefire Medical, Inc 1) Apply knowledge regarding interventional oncology treatment options for colorectal cancer to clinical practice. 2) Enhance awareness regarding the potential benefits and limitations of interventional oncology therapies to more effectively treat patients with colorectal cancer. 3) Describe the best sequence of treatment options for patients diagnosed with colorectal cancer and apply knowledge gained to improve overall survival. ABSTRACT Patients who benefit most from multidisciplinary decision making are patients who do not have a clear option for treatment based on marginal indication for surgery, poor theoretical success of systemic therapies, and potential treatment with unproven therapeutic options. Locoregional therapy by interventional radiology frequently arises in these situations and it is important that interventional radiology be a part of this team to explain how interventional oncology techniques complement traditional medical, radiation, and surgical options. As cancer therapeutics continue to change, interventional radiology will be central in both the diagnostic and therapeutic aspects of targeted and personalized therapy. VSIO31-08 Setting the Stage: Triage of mnet Michael Christopher Soulen MD (Presenter): Royalties, Cambridge University Press Consultant, Guerbet SA Research support, Guerbet SA Consultant, BTG International Ltd Research support, BTG International Ltd Consultant, Merit Medical Systems, Inc Speaker, Sirtex Medical Ltd

155 1) Review current assessment and grading of gastroenteropancreatic neuroendocrine tumors. 2) Outline a system for triage of patients with liver metastases. 3) Discuss integration of image-guided and systemic therapies. ABSTRACT Once considered rare, the incidence and prevalence of neuroendocrine tumors (NET) have increased rapidly, with a more than five-fold increase in incidence in the United States from 1973 to 2004 and an prevalence that is two- to five-times that of esophageal cancer, gastric cancer, pancreatic cancer, and hepatobiliary cancer. The typically long delay in diagnosis of NETs and their propensity for hepatic metastases create an important role for liver-directed therapies. Challenged by the shortage of physicians experienced in the diagnosis and management of this disease, these long-lived patients often access strong advocacy groups and web-based support sites which direct them to centers of excellence with physician teams that offer a complete understanding of the spectrum of their disease. It is essential that interventional oncologists develop an intimate knowledge of the characteristics and management of neuroendocrine tumors in order to know how and when best to apply the armamentarium of image-guided therapies, and guide patients in integrating these with surgical, systemic and supportive therapies. VSIO31-09 Role of Aggressive Surgery in mnet Robert E. Roses MD (Presenter): Nothing to Disclose 1) Discuss the role of resection of a primary NET in the setting of metastatic disease. 2) Discuss the evidence for for resection of metastatic NET 3) Discuss the management of complex patients with multiple sites of disease or bilobar liver metastases. ABSTRACT Neuroendocrine tumors include a diverse group of clinical and pathologic entities. Treatment priorities much be personalized and reflect spectrum of disease, symptoms and tumor biology. Notwithstanding, a convincing role for aggressive surgical management has emerged and can benefit patients with early and disseminated disease. Resection of the primer tumor is often indicated, even in the presence of metastases. Aggressive liver resection appears to be of benefit; particularly if all visible disease can be removed. For patients with disseminated disease a multidisciplinary approach and judicious application of interventional approaches is essential in achieving favorable outcomes. VSIO31-10 Cone-Beam Computed Tomography Angiography for Depiction of Tumor-feeding Vessels during Chemoembolization of Malignant Liver Tumors: Comparison of Conventional and Dedicated-software Analysis Maxime Ronot MD (Presenter): Nothing to Disclose, Mohamed Abdel-Rehim MD : Nothing to Disclose, Viseth Kuoch MD : Nothing to Disclose, Antoine Hakime MD : Nothing to Disclose, Marion Roux : Nothing to Disclose, Melanie Chiaradia MD : Nothing to Disclose, Valerie Vilgrain MD : Nothing to Disclose, Thierry J. De Baere MD : Consultant, Terumo Corporation Speaker, Covidien AG Speaker, Terumo Corporation Speaker, General Electric Company Consultant, General Electric Company Consultant, Guerbet SA Speaker, Guerbet SA, Frederic Deschamps : Nothing to Disclose To compare the ability of a dedicated software and conventional cone beam computed tomography (CBCT) analysis to identify tumoral feeders in a series of malignant liver tumors treated with transarterial chemoembolization (TACE). Between January 2011 and January 2012, 66 hypervascular malignant liver tumors from patients who underwent TACE with contrast-enhanced CBCT at the arterial phase were included (51 HCC, 13 NET and 2 adrenal cancer metastases). Data were analyzed by 6 interventional radiologists blinded to each other analyses (2 junior and 4 experienced readers). Readers were asked to identify tumor feeders by performing 1) a conventional analysis using post-processing tools such as maximum intensity projection, multiplanar reconstruction, volume rendering, 2/ a computer-aided analysis using FlightPlan for liver (referred to as raw-fpfl), and 3) a review of this computer aided analysis for which reader were asked to validate or invalidate each feeder detected by the software (referred to as reviewed-fpfl). Analyses were compared to a "Reference Reading" established by two study supervisors in consensus. Sensitivities, positive predictive values (PPV), and false positive ratios (FPR) were compared using Mac-Nemar, Chi-square and exact Fisher tests. Analysis durations were compared using a Mann-Whitney U test. Inter-readers agreements were assessed by mean of percentage of agreement. A total of 179 feeding vessels were identified in the 'Reference Reading'. The sensitivity of raw-fpfl was significantly higher than that of both reviewed-fpfl and conventional analyses (90.9% vs. 83.2% and 82.1%, p<0.0001), with lower PPV (82.9% vs. 91.2% and 90.6%, respectively (p<0.0001), higher FPR (17.1% vs. 9.4% and 8.8%, respectively (p<0.0001), and higher inter-reader agreement (92% vs. 80 and 79%, respectively, p<0.0001). The conventional analysis was significantly longer than that of both raw- and reviewed-fpfl (<0.0001).

156 Contrast-enhanced CBCT with software analysis enabled accurate and sensitive detection of tumor feeders of malignant liver tumors before TACE. The review of the software analysis was responsible for a significant decrease in the number of identified feeders. Dedicated software analysis of contrast-enhanced CBCT images should be used when performing transarterial chemoembolization of liver tumors. VSIO31-11 Embolotherapy for mnet: When and How? Sarah Beth White MD (Presenter): Consultant, Guerbet SA Consultant, Vascular Solutions, Inc Research support, Seimens AG 1) Assessment and triage of metastatic NETs. 2) Review of image guided therapies for mnets. 3) Integration of systemic therapy with image guided therapies for mnets. ABSTRACT Neuroendorine tumors (NETs) describe a family of tumors that mainly arise from the gastrointestinal tract. The incidence is estimated to be between per 100,000, two thirds of which are small intestine carcinoids. NETs can be clinically silent (unless hormone producing) and are often found incidentally. However, once they metastasize to the liver, the vasoactive substances they release can enter the systemic circulation and cause carcinoid syndrome, which clinically manifests as flushing and diarrhea. Treatment for metastatic NET (mnet) includes systemic therapies that range from monthly octreotide injections (a well-tolerated somatostatin analog) in mild cases to cytotoxic chemotherapies such as 5-FU and doxorubicin in aggressive cases. Emblotherapy has also started to play a role in the treatment of mnet; however, controversy still remains about which type of therapy is the most efficacious, bland embolization vs. conventional chemoembolization vs. drug eluting bead chemothembolization vs y-90 radioembolization. The objective of this session is to discuss the role of emblotherapy for the treatment of mnet and how to integrate it with systemic therapies. VSIO31-12 Coming to America: PRRT Daniel Pryma MD (Presenter): Research Grant, Siemens AG Research Grant, Molecular Insight Pharmaceuticals, Inc Speaker, IBA Molecular Advisory Board, Bayer AG 1) To understand the various available permutations of PRRT and their relative risks and benefits. 2) To appreciate the current research availability and potential for future availability of PRRT. ABSTRACT PRRT is a mainstay in the treatment of GEPNETS worldwide, but has very limited availability as an investigational therapeutic in the United States. The various permutations of radioisotopes and somatostatin analogs used for PRRT will be reviewed along with an understanding of their potential risks and benefits. The process of PRRT will be discussed including expectations for outcomes and toxicity. Finally, the availability of PRRT for American patients will be discussed. VSIO31-13 Liver-Directed Therapy for Metastases from Breast Cancer: Outcomes Analysis Amy Marie Fowler MD, PhD (Presenter): Nothing to Disclose, Stephanie Markovina MD, PhD : Nothing to Disclose, Angela Hirbe : Nothing to Disclose, Christina Koo Speirs MD, PhD : Nothing to Disclose, Alejandro Munoz Del Rio PhD : Research Consultant, Cellectar Biosciences, Inc Reviewer, Wolters Kluwer nv, Todd DeWees : Nothing to Disclose, Cynthia Ma : Nothing to Disclose, Jeffrey R. Olsen MD : Consultant, DFINE, Inc Travel support, DFINE, Inc Speaker, ViewRay, Inc, Nael El Said Saad MBBCh : Research Consultant, Veran Medical Technologies, Inc Proctor, Sirtex Medical Ltd To determine the clinical outcomes for breast cancer patients with chemorefractory liver metastases treated with locoregional therapy. This HIPAA-compliant, IRB-approved study is a single-institution, retrospective chart review. Twenty-nine consecutive female breast cancer patients (mean age 55 years; 35-77) with unresectable liver metastases progressing despite systemic chemotherapy were included who were treated with radiofrequency (RF) ablation (n=7), chemoembolization (n=6), or 90 Y radioembolization (n=16) from January 1999 to March Follow-up data was obtained through June Treatment response was evaluated on follow-up imaging which consisted of CT, MRI, and/or PET/CT. Overall survival (OS) time and time to progression (TTP) of disease was measured from the time of first liver-directed therapy. OS and TTP curves were generated using the Kaplan-Meier method and compared with the log rank test. Median OS was 21 months (1-81 months) for all patients and was 34, 15.5, and 16 months for patients treated

157 with RF ablation, chemoembolization, and radioembolization, respectively. Longer OS was measured for those treated with RF ablation compared to chemoembolization (p=0.04) or radioembolization (p=0.03). Median follow-up was 16 months (1-81 months) with one death from liver failure prior to follow-up imaging. Median TTP was 4 months (1-26 months) for all patients and was 2, 1, and 6 months for patients treated with RF ablation, chemoembolization, and radioembolization, respectively. Longer TTP was measured for patients treated with radioembolization compared to RF ablation (p=0.04). Survival was comparable for patients treated with chemo- and radioembolization, but was prolonged for those treated with RF ablation, presumably from reduced pre-therapy disease burden. While this study is small with a heterogeneous retrospective cohort, the results support a palliative indication for radio- and chemoembolization with potential prolonged survival provided by RF ablation. Identification of patient and tumor biomarker criteria that best predict survival and consideration of earlier utilization of embolization at lower amounts of disease burden may improve outcomes. A matched-pair analysis with patients treated with systemic chemotherapy alone is in progress. VSIO31-14 mnet Tumor Board Michael Christopher Soulen MD (Presenter): Royalties, Cambridge University Press Consultant, Guerbet SA Research support, Guerbet SA Consultant, BTG International Ltd Research support, BTG International Ltd Consultant, Merit Medical Systems, Inc Speaker, Sirtex Medical Ltd, Robert E. Roses MD (Presenter): Nothing to Disclose, Sarah Beth White MD (Presenter): Consultant, Guerbet SA Consultant, Vascular Solutions, Inc Research support, Seimens AG, Daniel Pryma MD (Presenter): Research Grant, Siemens AG Research Grant, Molecular Insight Pharmaceuticals, Inc Speaker, IBA Molecular Advisory Board, Bayer AG 1) To present a variety of clinical scenarios highlighting the multidisciplinary options for management of liver metastases from neuroendocrine tumors through a 'tumor board' of experts representing each of the major oncologic disciplines. SSJ05 Chest (Interventional I) Scientific Papers IR CT CH AMA PRA Category 1 Credits : 1.00 ARRT Category A+ Credit: 1.00 Tue, Dec 2 3:00 PM - 4:00 PM Location: S404CD Moderator Jo-Anne O. Shepard MD : Consultant, Agfa-Gevaert Group Moderator Fereidoun G. Abtin MD : Nothing to Disclose Sub-Events SSJ05-01 Incidence and Predictors of Pulmonary Hemorrhage in Patients Undergoing Percutaneous Computed Tomography (CT)-Guided Transthoracic Needle Lung Biopsy (TTNLB): Single Institution Experience of 1,175 Cases Ryan Tai MD (Presenter): Nothing to Disclose, Ruth M. Dunne MBBCh : Nothing to Disclose, Beatrice Trotman-Dickenson FRCR, MRCP : Nothing to Disclose, Rachna Madan MD : Nothing to Disclose, Francine L. Jacobson MD, MPH : Nothing to Disclose, Andetta Rotilla Hunsaker MD : Nothing to Disclose To evaluate the incidence of pulmonary hemorrhage during TTNLB and investigate possible predictors for significant hemorrhage. Records of 1,113 patients who underwent 1,175 TTNLB procedures from January 1, 2008 to April 22, 2013 were retrospectively reviewed after IRB approval. Studied patient-related factors included pulmonary artery systolic (PASP) and pulmonary artery (PAP) pressures from echocardiogram and cardiac catheterization data; medications including anticoagulants, antiplatelets, and steroids; coagulation studies; and history of pulmonary hypertension, bleeding diathesis, or immunodeficiency. CT images and reports were reviewed for biopsy-related factors including lesion size, location, morphology, and distance to pleura; needle gauge; angulation to pleura; number of passes; pulmonary artery (PA) size; and chronic lung disease. Post-biopsy images were evaluated for pulmonary hemorrhage, which was graded: 0, none; 1, 2cm around needle tract; 2, >2 cm but sublobar; 3, lobar; 4, >lobar or hemothorax. Primary outcomes were pulmonary hemorrhage or documented hemoptysis.

158 Univariate analysis with chi-square, Fisher's exact, and student's t tests was used to evaluate study variables as predictors for pulmonary hemorrhage. Grade 1 hemorrhage occurred in 282 cases (24%). Significant hemorrhage, defined as greater than grade 1 hemorrhage, occurred in 200 cases (17%). Twenty (1.7%) had documented hemoptysis and four (0.3%) were admitted due to hemorrhage. Significant hemorrhage was more likely to occur in females (p=0.0017), with older age (p=0.0005), emphysema (p=0.0036), coaxial technique (p=0.039), and lesion size <3cm (p<0.0001), and less likely with subpleural lesions (p<0.0001). Hemorrhage occurred more frequently in subsolid lesions and less commonly in consolidation (p=0.0002). PA size, elevated PAP or PASP, immunodeficiency, and use of antiplatelets, anticoagulants, or steroids were not predictors for pulmonary hemorrhage. Significant pulmonary hemorrhage is more likely in females, with coaxial technique, older age, and smaller and subsolid lesions, and less likely with subpleural lesions. Patients with suspected pulmonary hypertension may not be at increased risk for pulmonary hemorrhage after TTNLB. Pulmonary hemorrhage is common after TTNLB, but rarely requires intervention. TTNLB can be performed safely in patients with suspected pulmonary hypertension. SSJ05-02 Preliminary Clinical Experience with a Dedicated Interventional Robotic System for CT-guided Biopsies of Lung Lesions: A Comparison with the Conventional Manual Technique Michele Anzidei MD (Presenter): Nothing to Disclose, Renato Argiro : Nothing to Disclose, Andrea Porfiri MD : Nothing to Disclose, Fabrizio Boni : Nothing to Disclose, Mario Bezzi MD : Nothing to Disclose, Carlo Catalano MD : Nothing to Disclose To evaluate the clinical performance of a robotic system for CT-guided biopsy of lung lesions in comparison to the conventional manual technique. 100 patients (63 males, 37 females, age range years, mean age 65 +/-4 years) referred for CT-guided lung biopsy of previously diagnosed lung lesions were randomly assigned to group A (robot-assisted procedure with the ROBIO EX system, Perfint Healthcare - India) or group B (conventional procedure). Biopsies were performed by two operators with 2 and 8 years of experience. The size, distance from entry point and position in lung of target lesions were evaluated to assess potential homogeneity differences between the two groups. Procedure duration, dose length product (DLP), precision of needle positioning, diagnostic performance of the biopsy, rate of complications and operator preference were evaluated for significant differences between the two groups to assess the clinical performance of the robotic system as compared to the conventional technique. All biopsies were successfully performed. The size (p=0.41), distance from entry point (p=0.86) and position in lung (p=0.32) of target lesions were similar in both groups (p=0.05). Procedure duration and radiation dose were significantly reduced in group A as compared to group B (p=0.001). Precision of needle positioning, diagnostic performance of the biopsy and rate of complications were similar in both groups (p=0.05). Robot-assisted CT-guided lung biopsy can be performed safely and with high diagnostic accuracy, reducing procedure duration and radiation dose in comparison to the conventional manual technique. CLINICAL RELEVANCE: The precision in lesions targeting, the diagnostic performance of the biopsy sampling and the rate of complications in the robot-assisted procedures were superimposable to those of conventional biopsies. The use of the robot significantly reduced procedure duration and radiation dose in comparison to the unassisted technique. APPLICATION: Operators with different levels of experience may benefit from robot assistance in daily clinical routine, but the use of interventional robotic systems will be probably even more beneficial in clinical settings in which less expert, non-interventional operators perform simple imaging-guided procedures. SSJ05-03 CT-guided Localization of Small Pulmonary Nodules Using Microcoils prior to Video-assisted Thoracoscopic Surgical Resection Tianhao Su (Presenter): Nothing to Disclose, Long Jin : Nothing to Disclose To describe and optimize small peripheral pulmonary nodule localization method prior to video-assisted surgical (VATS) resection.

159 This study enrolled 92 patients with 101 pulmonary nodules. Microcoils were placed next to the nodules using two random methods (with or without leaving microcoil end on the surface of pleura) under computed tomography guidance. The complications and efficacy of the implantation were evaluated. VATS resection of lung tissue containing pulmonary lesion and microcoil were performed by the direction of the microcoil marker. Histopathologic analyses of the pulmonary lesions were documented. CT-guided microcoil implantation were successful in 99 (99/101, 98.0%) nodules within 1cm from the nodules but without disrupting them, while 2 (2/101, 2%) microcoils were found to be dislodged during operation. There were no difference between entire implantation (58/99, 58.6%) and leaving-microcoil-end implantation (41/99, 41.4%) method for the complications and efficacy. All nodules were removed by VATS successfully. Asymptomatic pneumothorax occurred in 16 patients, and mild pulmonary hemorrhage occurred in 9 patients, none of these patients needed further surgical treatment. The histopathologic results of the pulmonary lesions included adenocarcinomas (n =77), neuroendocrine carcinoma (n =1), metastatic carcinoma (n =1). atypical hyperplasia (n =11), hamartoma (n =1), granuloma (n =1), reactive lymph node (n =5), fibrotic hyperplasia (n =2), carbon power deposit (n =2). Preoperative localization of small pulmonary nodules using percutaneous CT-guided microcoils implantation was useful and safe in successful VATS resection of pulmonary lesion. A refined localization method of pulmonary nodule using microcoil is a minimal and safe interventional approach, and is recommended prior to VATS in order to make definitive resection easy and possible. SSJ05-04 Value of CT-guided Core-needle Biopsy in Diagnosis of Nonresolving Air Space Consolidation Zhiwei Wang MD (Presenter): Nothing to Disclose, Xiaoguang Li MD : Nothing to Disclose To evaluate the value of CT-guided core-needle biopsy in diagnosis for patients with nonresolving pulmonary air space consolidations From March 2008 and June 2013, 69 patients (42 men, 27 woman; age range, 17 to 77 years; mean age, 46.2±16.4 years) presenting with nonresolving pneumonia persisting more than 2 months (mean, 4.7 months; range, 2 to 16 months) underwent CT-guided core needle biopsy using an automated core needle (18-gauge). 42 patients had underwent fiberscopic exminations with negative results before CT-guided biopsy. Histologic and bacteriologic evaluations were obtained from CT-guided biopsy. The diagnostic performance of CT-guided biopsy was assessed through comparison of surgical pathology or clinical follow-up. CT-guided biopsy complications were recorded. Specimens adequate for histopathologic evaluations were obtained in 67 (97.1%) cases. Specific diagnoses were established in 60 (89.6%) patients, while 7 (10.4%) were nonspecific. The specific diagnoses were adenocarcinoma (n=13), lymphoma (n=13), organizing pneumonia (n=11), infectious pneumonia (tuberculosis, n=13; aspergillus, n=6; cryptococcosis, n=2 ), and lipoid pneumonia (n=2). A mixture of chronic inflammation and fibrosis (n=6) was the most common nonspecific diagnosis. No malignancy was diagnosed on a subsequent biopsy in that cases showed non-specific chronic inflammation and fibrosis. Immediate pneumothorax was present in 6 patients of cases, but only 1 patients required pleural drainage. Among patients with nonresolving pulmonary air space consolidation, CT-guided core needle biopsy is safe and shows high degree of diagnostic accuracy. CT-guided core needle biopsy is an appropriate diagnostic method for patients with nonresolving pulmonary air space consolidation. SSJ05-05 C-arm Cone-Beam CT Virtual Navigation Guided Percutaneous Transthoracic Localization of Small Pulmonary Nodule Taeho Kim MD (Presenter): Nothing to Disclose, Chang Min Park MD, PhD : Nothing to Disclose, Sang Min Lee : Nothing to Disclose, Hyun-Ju Lee MD, PhD : Nothing to Disclose, Jin Mo Goo MD, PhD : Research Grant, Guerbet SA

160 To describe out initial experience with cone-beam CT virtual navigation guided percutaneous Lipiodol localization of small pulmonary nodules in 31 consecutive cases. From February 2013 to August 2013, 29 consecutive patients (15 male, 14 female; mean age, 61 years) with 31 small pulmonary nodules (mean size, 14.14mm; range, mm) underwent preoperative Lipiodol localization under CBCT virtual-navigation guidance system and included our study population. Lipiodol (mean amount, 0.19 ml; range, ml) was injected around the pulmonary nodules through 21-gauge needle. Procedure details-including radiation dose, diagnostic accuracy and complication rates of CBCT virtual-navigation-guided percutaneous Lipiodol localization-were described. All nodules were localized within 12 mm (mean distance, 2.26 mm; range, 0-12mm) from the lipiodol marking (mean diameter, mm; range, 6-19 mm). The CT findings of pulmonary nodules were 16 pure groud glass nodules, 13 part solid nodules, and 2 solid nodules. The mean number of CT acquisitions, total procedure time, and estimated radiation exposure during lipiodol marking were 3.5, 15.9 minutes, and 5.72 msv ± 2.64, respectively. Post-procedural complications occurred in 4 (12.9%) cases, all of which was pneumothorax. All lipiodol markings were easily visible on intraoperative fluoroscopy, and all the target nodules were completely resected. There were no difficulties on pathologic examination and their results of the target nodules included 19 invasive adenocarcinoma, 5 adenocarcinoma-in-situ, 4 atypical adenomatous hyperplasia, 1 metastatic chondrosarcoma and 2 benign lesions. CBCT virtual-navigation-guided percutaneous lipiodol marking can be accurate, effective and safety pre-operative localization procedure, enabling highly accurate resection and safe diagnosis of small or faint pulmonary nodules. Cone-beam CT virtual navigation guided percutaneous transthoracic localization of small pulmonary nodule could accurately and effectively play an important role before the video assisted thoracic surgery. SSJ05-06 How to Discriminate Malignancies Falsely-diagnosed as Non-specific Benign Lesions after Percutaneous Transthoracic Needle Biopsy from True Benign Lesions Jung Im Kim MD (Presenter): Nothing to Disclose, Chang Min Park MD, PhD : Nothing to Disclose, Sang Min Lee : Nothing to Disclose, Kwang Gi Kim PhD : Nothing to Disclose, Jin Mo Goo MD, PhD : Research Grant, Guerbet SA To identify the distinguishing features of malignancies falsely-diagnosed as non-specific benign lesions in pathologic examinations obtained from percutaneous transthoracic needle biopsy(ptnb) from true benign lesions. From January 2009 to December 2011, 1108 consecutive patients (633 males and 475 females; mean age, 62.4 years) with 1116 lung lesions (mean size, 2.7cm ± 1.7) underwent C-Arm Cone-Beam CT (CBCT)-guided PTNB using an 18-gauge coaxial cutting needle. Among them, 285 lesions (mean size, 2.4 cm ± 1.4) in 283 patients (154 males and 129 females; mean age, 59.2 years) were diagnosed as non-specific benign lesions at pathologic evaluation. The malignancy rate of these non-specific benign pathologies was investigated. To evaluate the discriminating clinical, radiological and pathological findings of these malignancies falsely-diagnosed as non-specific benign lesions from true benign lesions, univariate and multivariate logistic regression analyses were performed. Among 285 lesions, 24 (8.4%) were finally diagnosed as malignant, 202 (70.9%) as benign and 59 (20.7%) as indeterminate. The negative predictive value (NPV) of the non-specific benign lesions was 89.4% (202/226). For 81 lesions in which the pathologic results were granulomatous inflammation and 141 lesions with negative CT reports for lung cancer, NPVs were 100% and 99.3%, respectively. Multivariate analysis revealed that positive CT reports for lung cancer (odds ratio (OR), 29.7; P<0.001) and granulomatous inflammations on PTNB (OR, 0.03; P=0.018) were significant discriminating factors of these malignancies falsely-diagnosed as benign lesions from true benignancies with excellent differentiating accuracy (area under the ROC curve, 0.944). Among pulmonary lesions showing non-specific benign pathologies on PTNB, positive CT reports for lung cancer and pathologic results of granulomatous inflammations on PTNB were significant discriminating factors for malignancies falsely-diagnosed as non-specific benign lesions. Among non-specific benign biopsies, false negative and true negative lesions can be accurately discriminated through evaluation of diagnostic CT and pathologic reports of PTNB.

161 SSJ19 Neuroradiology (Neurointerventional Radiology) Scientific Papers IR NR AMA PRA Category 1 Credits : 1.00 ARRT Category A+ Credit: 1.00 Tue, Dec 2 3:00 PM - 4:00 PM Location: N228 Moderator Colin P. Derdeyn MD : Consultant, MicroVention Inc Consultant, Penumbra, Inc Consultant, Silk Road Medical Stock options, Pulse Therapeutics, Inc Moderator Kristine Blackham MD : Nothing to Disclose Sub-Events SSJ19-01 Carotid Angioplasty and Stenting: Long-term Outcomes in Radiation Associated Stenosis Chun Kit Shiu MBBS, FRCR (Presenter): Nothing to Disclose, Joyce Pui Kwan Chan : Nothing to Disclose, Sherman Sheung Ming Lo MBBS, MPH : Nothing to Disclose, Wai Lun Poon MBBS, FRCR : Nothing to Disclose This retrospective study aims at comparing the short-term and long-term outcomes of carotid angioplasty and stenting (CAS) between patients suffering from radiation-associated carotid stenosis and those with atherosclerosis-associated stenosis. All consecutive patients who underwent CAS in our institution for carotid stenosis between Jan 2008 and Dec 2013 were identified. According to any history of head and neck irradiation, patients were stratified into radiation treatment (XRT) or non-xrt group. All CAS were performed by a dedicated team of neurointerventionists. Standardized post-operative clinical and Doppler ultrasound follow-up were undertaken for all patients. Diagnostic angiograms were performed to confirm the restenosis (>70%) detected by Doppler studies. Procedural and clinical records were reviewed and any periprocedural events and long-term recurrent stroke were documented. Univariate and Kaplan-Meier analyses were performed for both groups. 114 CAS procedures were identified. There were 41 patients with 46 CAS in XRT group and 68 patients with 78 CAS in non-xrt group. 15 patients received bilateral CAS. Median follow-up for XRT and non-xrt were 25.6 and 24.8 months. XRT patients were younger (63.5 vs years; p<0.001) and with significantly less vascular risk factors. 37 (90%) XRT patients had irradiation for nasopharyngeal carcinoma. More XRT patients had CCA stenosis (52.1% vs. 6.4%; p<0.001) and significantly longer segment of stenosis. The perioperative events including stroke, myocardial infarction and mortality did not differ significantly between the two groups but only 1 (2.2%) patient in XRT had stroke compared with 8 (10.3%) in non-xrt. Although there was no statistically significant difference in long-term mortality and ipsilateral stroke between XRT and non-xrt group, likely due to a small sample size, a trend towards better outcomes in XRT group can be observed. Restenosis was significantly more common in XRT compared with non-xrt (p=0.043). Majority of the restenosis were asymptomatic. This study shows the perioperative and long-term outcomes of CAS in radiation-associated stenosis are comparable to that in atherosclerotic stenosis, except for a higher restenosis rate. CAS in radiation-associated stenosis is probably safe and efficacious and we recommend a more frequent follow-up in these patients due to a higher restenosis rate. SSJ19-02 Intracranial Aneurysms Treated by Flow Diverting Stents: Results of Long-term Follow-up with Contrast-enhanced MR-angiography Maximilian Patzig (Presenter): Nothing to Disclose, Lorenz Michael Ertl MD : Nothing to Disclose, Robert Forbrig : Nothing to Disclose, Hartmuth Brueckmann : Nothing to Disclose, Gunther Fesl MD : Nothing to Disclose Long-term data on aneurysm treatment with flow-diverting stents are still sparse and follow-up protocols differ widely between institutions. We present long-term results, with a focus on the usefulness of 3T-MRI including contrast-enhanced MR-angiography (cemra).

162 Patients with aneurysms treated by flow - diverting stents without additional coiling and follow-up MRI after at least six months were included. 3T-MRI protocol included dedicated cemra in arterial and venous phase. Aneurysm thrombosis, size of the aneurysmal sac and complications were evaluated. Additionally, we graded the ability of MRI with cemra to visualize these parameters on a 1-3 scale. Twenty-one patients were included. Aneurysms were incidental in 15 cases and symptomatic in six cases (all cranial nerve palsies, no acute subarachnoid haemorrhage). Stenting was performed with 'Pipeline' in 17 cases and 'Silk' stents in four cases. Four technical complications occurred, one of which caused clinically apparent ischaemia. Duration of follow-up was more than two years in 16 patients. Complete occlusion of the aneurysm occurred in 18 cases (86 %). Of 13 cases in which a three-month-follow-up was available, seven were occluded at that time (54 %). At six months, 18 aneurysms were occluded (86 %). The aneurysmal sac shrinked in 16 of the 18 occluded aneurysms, in 11 cases to less than 50 % of the original size. On follow-up, one small perianeurysmal haemorrhage and one in-stent stenosis were found on MRI. Three of the symptomatic patients improved clinically. CeMRA assessability of aneurysmal thrombosis and size of the aneurysmal sack was graded as good in all cases. Where available, no discrepancies were found between cemra and digital subtraction angiography regarding aneurysm perfusion. Assessability of the stent lumen was reduced in cases treated with 'Pipeline' and good in cases treated with 'Silk'. Flow - diverter treatment can achieve high occlusion rates and cause major aneurysm shrinkage in many cases. MRI with cemra proved highly valuable regarding imaging of the aneurysm and late complications. The assessability of the stent lumen on cemra depends on the stent type. Our study adds to the understanding of the development of aneurysm thrombosis and shrinkage after flow - diverter treatment and presents 3T-MRI with cemra as a highly valuable follow-up imaging tool. SSJ19-03 Microembolism after Endovascular Treatment of Unruptured Cerebral Aneurysms: Incidence and Risk Factor Analysis Joo Yeon Lee (Presenter): Nothing to Disclose, Jung Cheol Park : Nothing to Disclose, Jae Kyun Kim MD : Nothing to Disclose, Dae Yoon Kim : Nothing to Disclose, Choong Gon Choi MD : Nothing to Disclose, Deok Hee Lee MD : Nothing to Disclose To analyze the incidence and risk factors of microembolic lesions on diffusion-weighted imaging (DWI) after endovascular coiling of unruptured intracranial aneurysms. From Jul to Jun. 2013, we had 271 consecutive cases (70 men and 201 women, median age of 57 with a range of 23-79) of unruptured aneurysm embolization. Aneurysm location was in the anterior circulation in 226 and posterior circulation in 45. Multiple aneurysms were seen in 37. Maximum diameter of the index aneurysm was 5 mm in median (range: ). Procedures were done by simple coiling (n=91), stent assisted (n=105), balloon assisted (n=16), or multiple microcatheters (n=59) using various types of detachment coils. Total number of coils was 5 in median (range, 2-23). Procedure duration ranged from 20 to 235 (median, 61) minutes. Any coil loop herniation was seen in 37. Overt thromboembolic phenomenon which required use of thrombolytics was noted in 5. Intra-procedural rupture occurred in 4. DWI was obtained the following day to see occurrence of any microembolic lesion. 2 independent reviewers were analyzed the presence of any microembolic lesion and counted the lesion number. Multivariate analysis was done to find independent risk factors of microembolism. Microembolic lesions were noted in 101 (37.3%). The number was less than 5 in 70.3%. Multivariate analysis showed various statistically significant factors which included age (OR: 1.04, p=0.01), diabetes (OR: 3.21, p=0.002), previous history of ischemic stroke (OR: 3.58, p=0.044), white matter FLAIR HSI (OR: 5.48, p=0.001), multiple aneurysms (OR:3.08, p=0.018), and stent-assisted technique with Enterprise stent (OR: 10.7, p<0.001) Previously known risk factors such as prolonged procedure duration, aneurysm size, or decreased antiplatelet function did not show any significant influence. The incidence of DWI high signal lesions after coiling of unruptured aneurysms was not low even though most of them were asymptomatic. It occurred more frequently in patients with vulnerable vascular status. Multiplicity of aneurysm and stent type also influenced its occurrence. Care should be taken to reduce the incidence of post-procedural microembolic lesions after coiling of unruputred cerebral aneurysms in patients with vulnerable vacular status.

163 SSJ19-04 Delayed Complications after Flow-diverter Stenting: Reactive In-stent Stenosis and Creeping Stents John Moshe Gomori MD (Presenter): Consultant, Medymatch Technology Ltd, Jose Enrique Cohen MD : Nothing to Disclose Assess the frequency and severity of changes in stent configuration and location, and patterns of in-stent stenosis of flow diverter stents. : Retrospective review of consecutive data from October 2011 to July 2012 of Silk flow diverter [Balt Extrusion, Montmorency, France] and Pipeline embolization device [ev3/coviden, Minneapolis, MN, USA]. Routine 2, 6, 9-12, and month follow-up angiograms were compared, with a focus on changes between stent configuration and location immediately after deployment and on angiographic follow-up, and the incidence and development of in-stent stenosis. Thirty-four patients with 42 aneurysms met inclusion criteria. The Silk device was implanted in 16 patients (47%, single device in 15), the Pipeline device in 18 (53%, single device in 16). On first follow-up angiography, in-stent stenosis was observed in 38% of Silk devices and 39% of Pipeline devices. In-stent stenosis was asymptomatic 12/13 patients. One woman presented with transient ischemic attacks and required stent angioplasty due to end tapering and mild, diffuse in-stent stenosis. Configuration and location changes such as stent creeping and end tapering were seen in 2/16 patients (13%) with Silk devices, and 0/18 patients with Pipeline devices. We describe stent creeping and end tapering among the unusual findings with potential for delayed clinical complications. In-stent stenosis, with a unique behavior, is a frequent angiographic finding observed after flow-diverter stent implant. The stenosis is usually asymptomatic; however, close clinical and angiographic monitoring is mandatory for individualized management. Stent creeping and end tapering is more common with Silk devices. Silk diverter stents are less stable than Pipeline devices. Both devices show instent stenosis and need careful monitoring. SSJ19-05 Large and Giant Intracranial Aneurysms Treated with Pipeline Embolization Device MR-MRA Imaging Primary Findings: A Single Center Experience Carolina Parada MD (Presenter): Nothing to Disclose, Jorge Pablo Chudyk MD : Nothing to Disclose, Hector Eduardo Lambre MD : Nothing to Disclose, Pedro Lylyk MD : Consultant, Medtronic, Inc Consultant, Surpass Medical Ltd Consultant, Cardiatis SA Data including long-term follow up imaging using MR-MRA in the evolution of large and giant intracranial aneurysms treated with PED is still missing. We report our experience in the review and analysis of the primary MR-MRA findings on the evolution of these challenging aneurysms after treatment. From a total of 570 intracranial aneurysms treated with PED in a period between 2006 and 2013 a total of 92 were included with the following criteria: 1) large and giant intracranial aneurysms treated with PED and 2) MR-MRA follow up. All imaging studies were performed every 6 months the first year, and annually after that, with a 3T magnet (Philips Healthcare, Best, the Netherlands) and included FLAIR, T1, T2, MRA and postgadolinium T1. 76% aneurysms were located in the anterior circulation being 58% supraclinoid and the remaining 24% originated at the posterior circulation with 64% at the basilar trunk. The MRA showed complete occlusion in 66% with most of them occluded in a six month period after treatment, 79% of these from the anterior circulation and 21% from the posterior circulation. The postgadolinium T1 from the DSA confirmed occluded group showed enhancement of the sac in 31% in less than one year after treatment, finding that could be related to complete endothelialization. 34% aneurysms showed signs of residual neck or sac with a predominance of the C7 segment. The MRA also revealed shrinkage and total regression of the aneurysms in 60% with a dominance of the supraclinoid segment (40%) while 32% remain without changes in size and 8% showed an increase of size with predominance of the anterior circulation (80%). The aneurysms parenchymal environment was examined reporting 79% with no surroundings alterations and 21% with perilesional edema that showed resolution after treatment. MRA absence of signal intensity of the occluded aneurysms after treatment that show postgadolinium T1 enhancement of the sac does not mean permeability of the lumen although could suggest complete endothelialization. The results also support the reliability of the use of PED in the treatment of this challenging aneurysms.

164 Our data provide good correlation to DSA follow up supporting MR-MRA as an effective non-invasive method which should be considered for initial follow up. SSJ19-06 Comparison of Recent Volume of Percutaneous Endovascular Neurointerventions among Radiologists, Neurosurgeons, Neurologists, and Other Physicians: Who is Doing Them? Mougnyan Cox MD (Presenter): Nothing to Disclose, David C. Levin MD : Consultant, HealthHelp, LLC Board of Directors, Outpatient Imaging Affiliates, LLC, Laurence Parker PhD : Nothing to Disclose, Vijay Madan Rao MD : Nothing to Disclose Historically, cerebral catheter angiography and endovascular neurointerventions (ENI) were developed, refined and practiced by early pioneers in the field of neuroradiology. Recently, rapid developments in the safety and efficacy of ENI have resulted in other physician specialties expressing a strong interest in performing these procedures. Our purpose was to compare trends in performance ENI among the various specialties, as well the overall utilization trends from the years 2000 to Data from the Center for Medicare and Medicaid Services Physician/Supplier Procedure Summary Master Files for 2000 to 2012 were used. The Current Procedural Terminology, 4th edition (CPT) codes for percutaneous neurointerventions were used to obtain the volume of procedures performed in the Medicare fee-for-service population. Using the provider specialty codes, we classified the physicians performing ENI into 6 groups; radiologists, neurosurgeons, neurologists, vascular surgeons, other surgeons, cardiologists and other physicians. The utilization trends for 2000 to 2012 were studied. Overall, the volume of percutaneous neurointerventions increased from 2439 in 2000 to 7181 in Radiologists' volume increased from 1956 in 2000 to 3939 in Neurosurgery ENI volumes increased from 237 in 2000 to 2377 in Neurology volumes increased from 1 in 2000 to 646 in Cardiologists' volumes went from no ENI procedures performed in 2000 to 31 in ENI volumes for vascular surgeons increased from 1 in 2000 to 44 in 2012, and the ENI volumes for all other physicians went from 244 in 2000 to 144 in Radiologists continue to maintain a strong presence in the field of Neurointerventional radiology, performing 55% of the total number of procedures in 2012, down from 80%. However, neurosurgery has made significant inroads into ENI procedures, with their volume increasing from 10% in 2000 to 33% in The overall volume of ENI continues to rise at a steady pace from 2000 to Radiologists continue to maintain a strong presence in the field of neurointerventional radiology, performing the majority (55%) of percutaneous neurointerventions. SSJ25 Vascular/Interventional (IR: Aortic Imaging and Intervention) Scientific Papers IR CT VA AMA PRA Category 1 Credits : 1.00 ARRT Category A+ Credit: 1.00 Tue, Dec 2 3:00 PM - 4:00 PM Location: E352 Moderator Himanshu Shah MD : Consultant, Cook Group Incorporated Consultant, C. R. Bard, Inc Moderator Charles Yoon Kim MD : Consultant, CareFusion Corporation Research Grant, Galil Medical Ltd Consultant, Kimberly-Clark Corporation Consultant, Cryolife, Inc Sub-Events SSJ25-01 Endovascular Renal Chimney Stent-graft Technique in Patient with Hostile Proximal Neck: Technique and Acute/Mid-term Results Vladimir Gavrilovic MD : Nothing to Disclose, Gianluca Piccoli MD (Presenter): Nothing to Disclose, Massimo Sponza : Nothing to Disclose, Alessandro Vit : Nothing to Disclose, Massimo Bazzocchi MD : Nothing to Disclose, Daniele Gasparini : Nothing to Disclose

165 To evaluate feasibility, safety and efficacy of Chimney-EVAR (Ch-EVAR) technique in patient with hostile proximal neck for standard EVAR. From March 2009 until December 2013, 43 patients considered at high surgical risk underwent Ch-EVAR. Balloon-expandable or self-expandable stent-graft were implanted in the renal arteries, of which 10 bilaterally and 33 unilaterally. In all 43 patients 6-15 ml of fibrin glue were injected into the sac using a 5F catheter to obtain complete thrombosis and reduce the risk of late type-2 leak. The results of the Ch-EVAR procedure were evaluated at 1, 6 and 12 months and annually by CT angiography (CTA), and clinically (serum creatinine) at 24h, 1 month and 6 months and annually thereafter. Ch-EVAR technique was feasible in all patients. Final angiogram proved the exclusion of the sac, and no type 1 endoleaks. Mean follow-up was 16 (1-38) months. Average serum creatinine before the procedure and at 1, 6 and 12 months follow-up (FU) was respectively 1.4, 1.9, 1.5 and 1.3 ml/dl. In five patients creatinine increased significantly within 24h post-procedure, and a CT angiogram showed renal stent thrombosis; three patients were revascularized successfully whereas the two were considered not revascularizable. Eight patients died during the follow-up (non aortic death); all other patient were alive in stable clinical condition at FU. According to our preliminary experience, Ch-EVAR technique is feasible, safe, and effective to treat patients with hostile proximal neck in AAA. Acute stent thrombosis is quite rare but possible complication, dayli serum creatinine monitoring is mandatory in the postoperative period. Ch-EVAR technique is good option for non-surgical, and AAA patients with hostile proximal neck. It is complex and high skills demanded procedure. The most frequent complication is acute stent thrombosis. SSJ25-02 Impact of Thoracic Endografting on the Native Aortic Haemodynamics: Quantitative Comparative Analysis of the Functional Assessments by CT-computational Fluid Dynamics (CFD) Imaging before and after the Device Implantation Marco Midulla MD, PhD (Presenter): Nothing to Disclose, Ramiro Moreno MS : Nothing to Disclose, Stephan Haulon : Nothing to Disclose, Franc Nicoud : Nothing to Disclose, Christophe Demattei : Nothing to Disclose, Jean-Paul Beregi MD : Nothing to Disclose, Anne Negre-Salvayre : Nothing to Disclose, Jean-Pierre Pruvo MD, PhD : Nothing to Disclose, Herve Pierre Rousseau MD : Nothing to Disclose Endovascular repair has dramatically changed the physicians approach to the thoracic aortic pathology. Although the advancements in clinical experience, little is known about the impact of the implantation on the native aortic functional status. The aim of this study is to evaluate the haemodynamic modifications before and after the endografting by proposing a comparative analysis of the quantitative assessments by a CT-based Computational Fluid Dynamics Imaging. 40 patient-specific aortic geometries were obtained from an image dataset of pre and postoperative angio CT acquisitions in 20 consecutive patients treated by thoracic endografting for different aortic pathologies (11 TAA, 5 False Aneurysms, 3 Penetrating Ulcers, 1 ATAR). After image processing, a commercially available software system (XFlow, Next Limit Technologies) using a particle-based meshless approach was adopted to obtain the numerical simulations of the flow behaviour. WSS (Pa) and vorticity (Hz) values were measured at the proximal and distal landing zones and the median pre-postoperative ratios were registered. Haemodynamic simulations were obtained for all the patients and quantitative analyses were accomplished (technical success 100%). Median WSS ratios respectively at the proximal and distal landing zone were: 0.96 (median values 4.19, 4.90 Pa) and 0.83 (median values 1.66, 2.06). Concerning the vorticity, median ratios were respectively 1.01 (proximal zone; median values 40.38, Hz) and 0.80 (distal zone; median values 15.16, 17.22). Statistical analysis showed a difference in WSS (P=0.02) and vorticity (P=0.03) at the proximal landing zone depending on the specific anatomical implantation site (Z2-Z4). A CT-based CFD approach is a promising imaging tool to obtain haemodynamic simulations of the thoracic aortic environment. The approach adopted in this experience allowed to accomplish a preliminary quantitative analysis comparing the pre and postoperative functional status which encourages next larger studies to gain better understanding of the impact of the endovascular treatment on the native vessel.

166 To provide an imaging tool for the investigation of the thoracic aorta haemodynamics in order to weigh up the functional impact of endografting on the native vessel. SSJ25-03 Additional Value of Venous Phase to Whole-body CT Angiography in Patients with Aortic Aneurysm Yukichi Tanahashi MD (Presenter): Nothing to Disclose, Satoshi Goshima MD, PhD : Nothing to Disclose, Hiroshi Kondo MD : Nothing to Disclose, Yoshifumi Noda MD : Nothing to Disclose, Nobuyuki Kawai MD : Nothing to Disclose, Hiroshi Kawada MD : Nothing to Disclose, Haruo Watanabe MD : Nothing to Disclose, Kota Sakurai : Nothing to Disclose, Masayuki Kanematsu MD : Nothing to Disclose To evaluate the diagnostic performance of added venous phase for the detection and characterization of incidentaloma in patients with aortic aneurysm. IRB approval and written informed consent was obtained. Consecutive 243 patients (209 men, 34 women; mean age, 75.6 years) underwent whole-body contrast-enhanced CT in arterial- and venous- phase, following unenhanced image, for the assessment of aortic aneurysm. Two observers independently and randomly reviewed images in two separate image set; 1 st, unenhanced and arterial phase images, and 2 nd, unenhanced, arterial-, and venous-phase images, for the evaluation of incidentaloma. Incidentalomas were scored by a five-point rating scale for the confidence level of malignancy probability. Sensitivity, specificity and areas under the receiver operating characteristic curve (AUC) for the detection of visceral malignant lesion between two image sets were evaluated. Diagnosis of visceral malignant tumors in 15 patients were established pathologically (n = 10) and diagnostic imaging (n = 14). The sensitivity and specificity for the detection of visceral malignant tumor were significantly higher in 2nd image set (80% and 94%) than those in 1st image set (60% and 77%) in observers overall. AUCs for Observer 1 and 2 were significantly higher in 2nd image set (0.93 and 0.95) than in 1st image set (0.83 and 0.81) (P = 0.03 and 0.01). Diagnostic performance of incidental visceral malignancy was significantly improved by adding venous-phase to whole-body CT angiography. The prevalence rate of malignancy in the patients with aortic aneurysms was higher because they are commonly at an old age. Our result demonstrated the additional value of venous-phase to whole-body CT angiography for the detection and characterization of incidentaloma. This information might be beneficial for the assessment of these patients. SSJ25-04 Incidence and CT Angiographic Characteristics of Aortic Re-Dissection: A 10-Year Single Center Experience Anne Shu-Lei Chin MD (Presenter): Nothing to Disclose Patients with prior aortic dissection remain at risk for repeat events, particularly those with hereditary aortopathy. CT angiographic (CTA) findings of acute aortic lesions superimposed on prior chronic dissection may be difficult to interpret. Our aim is to evaluate the incidence of aortic re-dissection in the clinical setting of acute aortic syndrome (AAS), and describe CTA imaging characteristics and clinical outcomes. CTAs from Jan 1, Dec 31, 2012 in 497 patients presenting to a single instituion with AAS were retrospectively reviewed by two cardiovascular radiologists. Aortic re-dissection was defined as an acute aortic lesion occurring in the same aortic segment affected by a prior aortic dissection, greater than 30 days after the inital aortic event. Patients with age-indeterminant lesions were excluded. A total of 513 AAS occurred over the 10-year study period. The incidence of aortic re-dissection was 2.3% (12/513). The time interval between the historic event and the acute re-dissection ranged from days. The mean age of patients with re-dissection was 55.2 years (range years); a third had a history of Marfan's syndrome. There were 7 new classic aortic dissection (AD) and 5 intramural hematoma (IMH) re-dissections. There were 2 type A and 10 type B lesions. One re-dissection was complicated by aortic rupture. AD re-dissections had the unique CTA characteristic of 2 intimal-medial flaps and 3 flow lumens, typically involving the original false lumen. IMH re-dissections had acute extensive intramural hemorrhage within the

167 false lumen of prior chronic AD. Both type A and 4/10 type B lesions underwent surgical repair. Aortic re-dissection within a chronic dissection is rare, but can present with AAS indistinguishable from the first event. CTA imaging characteristics are unique given persistent findings of the initial dissection, but can confirm the presence of a new acute aortic lesion. The false lumen of re-dissections often expands quickly, and urgent treatment is required. While the true incidence of rupture and death from re-dissection remains unknown, these lesions tend to be unstable requiring surgical repair Aortic re-dissection is rare but can present as an acute aortic syndrome. CTA can confirm the presence of a new acute aortic lesion in the same aortic segment, despite persistence of the prior chronic dissection. SSJ25-05 To Assess the Feasibility and Value of Multiphasic Dynamic Scan Protocol in Aortic Dissection Yike Diao (Presenter): Nothing to Disclose, Chun-Yan Lu : Nothing to Disclose, Xiaohui Zhang : Employee, Siemens AG, Zhenlin Li MD : Nothing to Disclose To assess feasibility and additional diagnostic value of low dose multiphasic CT dynamic protocols (Shuttle mode and Flash-4D mode) in aortic dissection (AD) compared to a standard tri-phase protocol on a dual source CT (DSCT) scanner. 54 consecutive patients with known or suspected AD (age range:30-77 years) referred for aortic CTA were randomly, equally assigned into three groups and scanned on a DSCT scanner (SOMATOM Definition Flash, Siemens). For group A,a shuttle mode (Siemens) of multiphasic image acquisition (range: 48cm, time resolution 6s, 4 phase, 80kV, 125mAs/rot), for group B a high-pitch (pitch=3.0) mode of multiphasic image acquisition (range from the entrance of bony thorax to the plane of symphysis pubis, time resolution 12s, 4 phases, CARE kv, ref 80kV, 100mAs/rot), for group C the standard tri-phasic acquisition (range from the entrance of bony thorax to the plane of symphysis pubis, 100kV, 210mAs/rot) was used. Radiation dose were recorded. One-way ANOVA was used for statistical analysis. In all 54 cases CTA can exactly display the true and false lumen, intimal flap, the entry tear and the involvement of branches of AD. Compared to standard tri-phasic protocol (un-enhanced, arterial and portal scans), additional diagnostic information was obtained by multiphasic CT dynamic protocols as followed: the enhancement delay between the true and false lumen (group A=18; group B=18); the degree of membrane oscillation (group A=8; group B=14); dynamic ejection of contrast material from the true into the false lumen (group A=6; group B=7). Mean effective radiation dose (group A: 8.08±0.12mSv, group B: 11.60±0.3mSv, group C: 23.86±1.31mSv) of the three groups were shown statistically different (P<0.05).Scan length range of Flash-4D CTA is approximately 62.63±4.44 cm, longer than shuttle mode (fixed 48cm). Multiphasic dynamic CTA covering the entire aorta is feasible. Compared to standard tri-phasic protocol, both multiphasic scan protocols can provide more reveal pathological and anatomical features of AD with relative low radiation dose. In Flash-4D mode larger scan range can be provided, however, shuttle mode has a better time-resolution. Multiphasic protocols can exactly reveal pathological and anatomical features of AD with relative low radiation dose and offer more diagnostic information for surgical operation. SSJ25-06 Treatment of Native Coarctation of the Aorta in Adult and Adolescents Using Covered-Stent Implantation Xiaoyong Huang (Presenter): Nothing to Disclose, Jiaqing Fu : Nothing to Disclose, Lianjun Huang : Nothing to Disclose, XI GUO : Nothing to Disclose, Xin Pu : Nothing to Disclose Coarctation of the aorta (CoA) is a common congenital malformation leading to a life expectancy of about 35 years unless corrected. This study was to investigate the safety and effectiveness of treatment of native CoA in adults and adolescents using covered-stent implantation. A retrospective analysis was performed in 33 patients (mean age: 21.3±9.1 years, mean weight: 52.7±8.3 kg) diagnosed with native CoA by CT angiography and who accepted stent implantation from April 2005 to June Mean CoA diameter was 4.2±1.8 mm and mean length was 14.63±4.64 mm. Blood pressure monitoring, and CT angiography were performed 6, 12 and 24 months after surgery.

168 The procedures were successful in all cases, without major complications. Peak systolic pressure gradient decreased from 63.8±17.6 mmhg to 6.5±2.1 mmhg (P=0.005). Mean CoA diameter increased from 4.2±1.8 mm to 18.9±1.9mm (P=0.001). Eight patients with patent ductus arteriosus had no persistent left-to-right shunt after covered Cheatham-Platinum stent implantation. Pressure gradient was still present after implantation in one case with combined aortic arch dysplasia, and a longer bare stent was implanted to overlap the Cheatham-Platinum stent. Mean follow-up was 37.4±21.9 months. During this period, one patient with sustained hypertension needed medical control, without retraction observed on CT angiography. All other patients had improved symptoms and good hypertension control. There was no significant difference in peak systolic pressure between upper and lower extremities (P>0.05). Covered-stent implantation in adults and adolescents with native CoA is efficient and safe, with good intermediate result. Covered-stent implantation is an efficient and safe method in the treatment of native CoA in adults and adolescents,with a good intermediate result. SSJ26 Vascular/Interventional (IR: Venous Disease and Intervention) Scientific Papers IR VA AMA PRA Category 1 Credits : 1.00 ARRT Category A+ Credit: 1.00 Tue, Dec 2 3:00 PM - 4:00 PM Location: N230AB Moderator Naganathan Bhagvathy Subra Mani MD : Nothing to Disclose Moderator S. William Stavropoulos MD : Research, Cook Group Incorporated Research, B. Braun Melsungen AG Consultant, C. R. Bard, Inc Sub-Events SSJ26-01 Feasibility and Safety of Image-guided Percutaneous Ablation for Treatment of Symptomatic Vascular Malformations Following Failed Percutaneous Sclerotherapy Scott M. Thompson BA (Presenter): Nothing to Disclose, Matthew Raymond Callstrom MD, PhD : Research Grant, Thermedical, Inc Research Grant, General Electric Company Research Grant, Siemens AG Research Grant, Galil Medical Ltd, Michael A. McKusick MD : Nothing to Disclose, David Arthur Woodrum MD, PhD : Nothing to Disclose To determine the feasibility and safety of image-guided percutaneous ablation for treatment of symptomatic vascular malformations An IRB-approved retrospective review was undertaken of all patients who underwent image-guided percutaneous ablation of symptomatic vascular malformations (VMs) that failed percutaneous Sotradecol or ethanol sclerotherapy. Ablations were performed under general anesthesia with US/CT or MRI-guided cryoablation or MRI-guided laser ablation. Cryoprobes or laser fibers were placed under intermittent CT or MR imaging. Intraprocedural monitoring was performed with intermittent CT or MRI during cryoablation to monitor ice-ball formation or with proton-resonance frequency MR thermometry every seven seconds during laser ablation to monitor thermal changes. Post-ablation monitoring varied between observation or hospital admission. Clinical follow-up began at one month post-ablation. Seven patients (ages 10 to 48; 4 female) with eight VMs (N=7 intramuscular; N=1 subcutaneous) were treated with US/CT (N=3) or MRI-guided (N=2) cryoablation or MRI-guided laser ablation (N=3) for pain (N=6) or diffuse bleeding secondary to hemangioma-thrombocytopenia syndrome (N=1). The median (range) of the maximal diameter was 9 cm (6.5 to 11.1 cm) for VMs undergoing cryoablation and 2.5cm (2.3 to 5.3 cm) for laser ablation. Seven VMs were ablated in one session and one in a planned two-stage session. Two laser fibers and 3 to 10 cryoprobes were used per ablation session. The number of hospital days ranged from 1 to 3 for cryoablation and 0 to 1 for laser ablation. Minor complications included a small hematoma, which did not require further intervention (laser) and numbness of the dorsal aspect of first toe (cryoablation). There were no major complications. There was no recurrence of bleeding at four years post ablation in the patient with hemangioma-thrombocytopenia syndrome and 5 of 6 patients with painful VMs reported symptomatic pain relief beginning as early as one month post ablation.

169 Image-guided percutaneous ablation of symptomatic vascular malformations is feasible and safe in patients who have failed percutaneous sclerotherapy and provides symptomatic relief for the majority of patients at short-term follow-up. Image-guided percutaneous ablation warrants further investigation as a therapeutic modality for treatment of symptomatic vascular malformations. SSJ26-02 Complications Related to Inferior Vena Cava Filters: A Retrospective Analysis Utilizing Computed Tomography Dominic Semaan MD, JD (Presenter): Nothing to Disclose, Matthew Osher MD : Nothing to Disclose, Ashish Vyas MD : Nothing to Disclose, Aaron Joseph Burgin MD : Nothing to Disclose, Roger L. Gonda MD : Nothing to Disclose, Laurie Marie Vance MD : Nothing to Disclose The purpose of our review is to determine the incidence of complications related to IVC filter placement, as well as to determine which type of IVC filters have the greatest incidence of complications, utilizing subsequent post-deployment computed tomography. A retrospective analysis was performed of all IVC filters placed at our institution between 6/1/2010 and 6/21/2013, including the medical records and related imaging. This query totaled 621 filters deployed by our department, of which 188 of those filters had subsequent computed tomography performed at our institution. The incidence of IVC filter brand, caval penetration, migration and strut fracture was recorded. The incidence of IVCF caval penetration was determined pursuant to the SIR practice guidelines. A total of 188 filters were reviewed. Of those, 88 (36.2%) had caval penetration, 3 migrated from original placement, 3 filters had a fractured strut. Major caval penetration into adjacent viscera/aorta was seen in 6 of the filters deployed. Incidentally, 3 patients developed caval thrombosis. Chi-square analysis demonstrated a statically significant difference in the incidence of caval penetration between the various filters deployed (p= <.001). Of the various types of filters utilized by our institution (Günther Tulip N=28, Celect N=47, Option N=97, Trapese N=10, Eclipse N=2), the Günther Tulip demonstrated the greatest incidence of caval penetration at 71.4%. While only 32.0% of Option filters demonstrated caval penetration, two filters had struts penetrate into the adjacent aorta. The Option demonstrated the highest incidence of migration, with 2 (2.1%) filters averaging 2.4 cm of cephalic migration. Two Celect and one Trapese filter had fractured struts, which could potentially serve as a source of future embolism. Interventional radiologists must be evermore cognizant of potential risks of filter deployment. IVC filter placement is not a benign procedure and carries risk to the patient, both intra- and post-procedural. Patients and referring physicians should be educated regarding these risks and the decision to implant an IVC filter, often for the remainder of the patient's life, is not one that should be taken lightly. IVC filter placement must be carefully evaluated prior to filter placement, to determine if the risks (including caval penetration) are outweighed by the benefits. SSJ26-03 Pharmacomechanical Catheter-directed Thrombolysis in Patients with IVC Filters John Peter Karageorgiou MD (Presenter): Nothing to Disclose, Kathryn Jane Fowler MD : Research support, Bracco Group, Suresh Vedantham MD : Research support, Covidien AG Research support, Bayer AG Research support, F. Hoffmann-La Roche Ltd Research support, BSN medical GmbH, Nael El Said Saad MBBCh : Research Consultant, Veran Medical Technologies, Inc Proctor, Sirtex Medical Ltd To evaluate the authors' experience with pharmacomechanical catheter-directed thrombolysis (PCDT) in patients with inferior vena cava (IVC) filters. Retrospectively queried radiology reports from 1/2005-2/2014 identified patients with IVC filters undergoing PCDT (catheter-directed thrombolysis, mechanical thrombectomy, balloon maceration, angioplasty and stenting). Patient electronic medical records were reviewed for: demographic, anticoagulation, symptoms, extremities involved, extent of thrombosis, therapies received, number of sessions, technical and clinical success, complications, need for subsequent lysis and long-term status. Statistic analyses were performed using SPSS software. Eighty-two patients met criteria (53yrs; range 18-96, M:66%). The most common indication for PCDT was lower extremity pain and edema (68%) with ulceration, phlegmasia, and compartment syndrome, combined

170 accounting for 16% and pulmonary embolism for 12% of patients. Of the 80 patients with lower extremity symptoms, 60% were bilateral, resulting in 129 extremities at risk. Catheter venography demonstrated IVC thrombus in 89% with extension above the filter in 22% of patients. Thrombus was confined to extremities in 5%, while IVC with both iliac vessel involvement was identified in 64% of patients. Treatment mostly involved combined mechanical and lytic therapy with angioplasty and stenting in 57% and 50% of patients, respectively. PCDT was technically successful in restoring flow in 88% and clinically successful in improving symptoms in 80%. IVC filters remained functional in 70%. By SIR criteria, 85% had no or minor complications. There were 2 deaths from intracranial hemorrhage. On follow up (458 days avg; D), 6% of patients died from thrombosis related events, 17% underwent repeat lysis procedures within our hospital system and 54% of patients had resolved/improved symptoms. The complication rates in the patients with single versus bilateral lower extremity involvement were similar. Long-term thrombosis related death was 17% in patients with thrombus extending above the filter vs. 3% in patients with no thrombus extension above the filter. Pharmacomechanical catheter-directed thrombolysis is an effective and safe treatment in patients with pre-existing IVC filters. Aid the proceduralist in treating DVT in patients with IVC filters. Data helps guide informed consent. SSJ26-04 Effectiveness of Simulation-based IVC Filter Placement Training for Radiology Residents: A Pilot Study Ji Young Buethe MD (Presenter): Nothing to Disclose, Nicholas L. Fulton MD : Nothing to Disclose, Daniel B. Gans MD : Nothing to Disclose, Stephen E. Dreyer MD : Nothing to Disclose, Jon Davidson MD : Nothing to Disclose, Mark Richard Robbin MD : Nothing to Disclose To assess whether high-fidelity simulation-based training is more effective than standard didactics to train radiology residents in IVC filter placement and the perceptive validity of simulation-based training. This is an IRB approved prospective pilot study using a high-fidelity endovascular simulator. Between 9/1/13-3/1/14, 20 radiology residents (R1-R4) were randomized into a siulation group(sg, n=10) vs a control group (CG, n=10). All underwent a pretest including procedure simulation and written knwledge test. Both groups received didactic resources on IVC filter placement, but only SG underwent 3 simulation training sessions. Both groups underwent a posttest simulation, written test, and a subjective questionnaire. Simulation tests were evaluated by a blinded board certified interventional radiologist using a task-specific checklist and a 5 point Likert scale technical competence score. Total procedure time, fluoroscopy time, and written test scores were also recorded. Non-parametric tests and unpaired two-tailed t test were used to compare performance outcomes between two groups. The SG demonstrated significant improvement in all parameters including technical competence (mean +2.1 points; P<0.01), procedure time (-8.08 min; P<0.01); fluoroscopy time (-1.03 min ;P=0.04), and written test score (+26%; P<0.01). The CG demonstrated significant improvement in only the procedure time (-7.21min; P=0.02) and written test score(+18%;p<0.01). Only the difference in technical competence score between the groups reached a statistical significance (P<0.01). Mean survey scores (SG,CG) were as follows: simulation realism(4.7,3.6), confidence after study completion(4.8,3.5), overall utility of simulation-based IVC filter training (4.8,4.2), benefit of simulation training in IR procedures(4.9,4.7). Self-confidence in IVC filter placement significantly improved in SG compared to CG (P<0.01). Simulation based IVC filter placement training can be more effective than conventional teaching in gaining technical proficiency and self-confidence among radiology residents. This pilot study provides evidence to support further investigation of simulation-based IR training in clinical practice. Simulation-based IR training may improve procedural skills, physician confidence, decrease procedure time and fluoroscopic time without patient morbidity or trainee radiation exposure. SSJ26-05 Cost Analysis of Chest Port Insertion: Interventional Radiology vs. Surgical Placement Jennifer LaRoy BA (Presenter): Nothing to Disclose, Thejus Jaykrishnan : Nothing to Disclose, Sarah Beth White MD : Consultant, Guerbet SA Consultant, Vascular Solutions, Inc Research support, Seimens AG, Stephanie Dybul : Nothing to Disclose, Thomas Duris : Nothing to Disclose, Dirk Ungerer : Nothing to Disclose, Kiran Turaga : Nothing to Disclose, Parag J. Patel MD : Consultant, Medtronic, Inc Consultant, C. R. Bard, Inc Consultant, Cook Group Incorporated Speakers Bureau, Medtronic, Inc Consultant, Penumbra, Inc In the face of changing health care reimbursements toward bundled care, the issue of minimizing cost is pertinent. While there has been a 20,510% increase in the number of chest ports (CP) placed by interventional radiologists from , surgery continues to dominate in placement of long term central venous access devices. This study compares the cost of CP insertions performed by interventional radiology (IR) vs. surgical implantation (OR) at a single institution.

171 Cost data on 100 IR and 49 OR consecutive Medicare outpatients that had isolated chest port insertions between 3/2012-2/2013 was obtained for both the operative services (IR suite vs OR) and pharmacy. The costs incurred by the hospital were divided into variable labor, supplies, room, and fixed costs for each case. Each cost was summarized as mean and standard deviation. Non-parametric tests for heterogeneity were performed using Kruskal-wallis method. Alpha was fixed at 0.05 for statistical significance. Overall mean charges to place a CP were significantly higher in the OR, both in room and pharmacy costs (p < ). The overall average cost to place chest ports in an OR setting was almost twice that of placement in the IR suite. There was not a single identifiable cause for this difference. Rather, every category of cost (labor, supply, variable and fixed room cost) was higher in the OR (see Figure 1). Furthermore, the costs in each category varied minimally between IR cases but demonstrated a much greater variance between OR cases. This pattern also holds true for pharmacy costs. Again, the pharmacy costs were greater and varied more for OR cases in every cost category except for pharmacy labor. Cost incurred to the hospital demonstrated significant differences between surgeons and interventional radiologists. Given that our prior work shows that complication rates in CP insertions in these two services are similar,1 it can be concluded that IR services are more cost effective for chest port insertion. 1 LaRoy J, et al. Morbidity Analysis of Chest Port Insertion: Interventional Radiology vs. Surgical Placement. J Vasc Interv Radiol 2014;25(3S):S100. Our findings suggest that there is a significantly lower cost associated with chest port placement performed in the IR suite. SSJ26-06 Flouroquinolone Based Surface Modifying Molecules Reduce Venous Thrombosis Rates Associated with PICC Lines Gordon McLennan MD (Presenter): Data Safety Monitoring Board, B. Braun Melsungen AG Research Grant, C. R. Bard, Inc Consultant, C. R. Bard, Inc Consultant, Medtronic, Inc Consultant, Siemens AG Consultant, Eli Lilly and Company Scientific Advisory Board, Surefire Medical, Inc Scientific Advisory Board, Rene Medical, Maria Kertesz RN : Nothing to Disclose, Nancy A. Obuchowski PhD : Research Consultant, Siemens AG Research Consultant, Hologic, Inc Research Consultant, CVUS Research Consultant, Elucid Bioimaging Inc, Mark Jason Sands MD : Nothing to Disclose To compare thrombosis rates between flouroquinolone surface modified polyurethane PICCs and polyurethane PICCs From 11/6/2012 through 2/6/2013, 1203 consecutive patients had 890 PICCs (642 Polyurethane [PU] and 246 Surface Modified Polyurethane [SM]) and 485 Midline catheters (481 PU and 5 SM). Catheter type was determined by preference of the placing nurse. In 10 patients, the type of PICC used was not recorded so these were excluded. Using multivariable logistic regression, rate of venous thrombosis associated with the catheter was compared between the two groups and correlated with variables such as age, gender, side of catheter placement, size of catheter, # of lumens, vein used, catheter length, whether the vein reached its desired target (SVC in PICC and Axillary Vein in Midlines), and an ICD-9 cancer diagnosis. Central Line Associated Bacterial Systemic Infections (CLABSI) were also collected. In univariate analysis of PICCs, left side of insertion and cancer diagnosis were predictors of thrombosis (5.5% v. 2.1% for left v. right p=0.008 and 50% v. 2.5% p< for cancer). In multiple-variable analysis correcting for age, side of placement and cancer diagnosis, there were 24 thromboses in 642 PU PICCs while there were only 3 in 248 SM PICCs 3.7% v. 1.2% with an odds ratio of 6.2 (p=0.01). In 5 F catheters, the odds ratio was 5.0 (p=0.012). When 179 5F SM catheters were compared to 387 4F PU catheters the thrombosis rates were similar (p=0.272). There was no difference between 4F and 5F SM catheters. Thrombosis rate in PU midline catheters was higher than in PU PICCs (5.4% v. 3.7%). Side of placement was not a predictor of thrombosis. Shorter catheter length (p=0.014) and cancer diagnosis (p=0.002) were predictors of thrombosis in midlines. While no SM midlines thrombosed, the sample size was too small (n=5) for a generalizable comparison of midline catheters. There were no CLABSI events in either group. Surface modification of PICCs reduces thrombosis by a factor of 6.2 overall and by a factor of 5 in 5F PICCs. Left sided PICC placement and cancer diagnosis increase the risk of venous thrombosis. Midline PU catheters have a higher associated thrombosis rate than PU PICC lines and while side of placement is not an independent risk factor for thrombosis, shorter length and cancer diagnosis are. Surface modified PICC lineshave lower thrombosis rates which will improve patient safety.

172 RC403 Interpreting Coronary Artery CTA Refresher/Informatics IR CT CA IR CT CA AMA PRA Category 1 Credits : 1.50 ARRT Category A+ Credits: 1.50 Tue, Dec 2 4:30 PM - 6:00 PM Location: N228 Sub-Events RC403A Standardized Reporting of Coronary CTA Jill E. Jacobs MD (Presenter): Nothing to Disclose 1) To understand the advantages of standardized reporting. 2) To understand the components of a standardized cardiac CT report. RC403B Imaging and Interpreting Re-vascularized Coronary Arteries (I: Bypass Grafts) Smita Patel MBBS (Presenter): Nothing to Disclose 1) To review the basic approach of evaluating coronary artery bypass grafts on CT. 2) To review normal surgical anatomy and pathology of coronary artery bypass graft conduits on CT. RC403C Imaging and Interpreting Re-vascularized Coronary Arteries (II: Stents) Marc Dewey MD (Presenter): Research Grant, General Electric Company Research Grant, Bracco Group Research Grant, Guerbet SA Research Grant, Toshiba Corporation Speakers Bureau, Toshiba Corporation Speakers Bureau, Guerbet SA Speakers Bureau, Bayer AG Consultant, Guerbet SA Author, Springer Science+Business Media Deutschland GmbH Editor, Springer Science+Business Media Deutschland GmbH Institutional research agreement, Siemens AG Institutional research agreement, Koninklijke Philips NV Institutional research agreement, Toshiba Corporation 1) Review the issues involved in detecting coronary in-stent restenosis by CT angiography. 2) Get an overview of the diagnostic accuracy of CT angiography for coronary stents. 3) Understand the potential advantages of iterative reconstruction and perfusion assessment by CT for stents. URL's Handout:Marc Dewey stent rsna 2014.pdf RC403D Deciphering Coronary Anomalies and Fistulas Jonathan Dermot Dodd MD (Presenter): Nothing to Disclose 1) Review the basic classification of coronary anomalies and fistulas. 2) Understand the most clinically important anomalies and fistulas. RC414 Venous Disease Refresher/Informatics IR IR

173 AMA PRA Category 1 Credits : 1.50 ARRT Category A+ Credits: 1.50 Tue, Dec 2 4:30 PM - 6:00 PM Location: S102D Anne C. Roberts MD (Presenter): Researcher, Elbit Imaging Ltd Research Consultant, Guerbet SA Research Consultant, General Electric Company Gerant M. Rivera-Sanfeliz MD (Presenter): Nothing to Disclose 1) Decide on the appropriate patients to undergo venous ablation. 2) Know various tools used for venous ablation. 3) Understand some of the issues of large vein occlusions and possible treatments. 4) Gain familiarity with the presentation pelvic congestion and varicocele. 5) Have a familiarity with the treatment of pelvic congestion and varicoceles. ABSTRACT Lower leg varicosities are a very common problem. Over the last 10 years there has been increasing interest in the percutaneous treatment of varicosities. The patient population with varicosities, the presentation of varicosities, and the treatment of varicosities will be presented. Other venous anomalies can worse the symptoms of varicosities and may need to be treated. These include May-Thurner syndrome, pelvic congestion, and the male variant of pelvic congestion syndrome (varicoceles). The patient population, symptoms and presentations, and the treatment of these other venous abnormalities will also be discussed. Active Handout Sec.pdf RC420 Role of Stereotactic Ablative Radiotherapy (SABR) and Interventional Radiology in the Management of Oligometastases Refresher/Informatics IR OI RO IR OI RO AMA PRA Category 1 Credits : 1.50 ARRT Category A+ Credits: 1.50 Tue, Dec 2 4:30 PM - 6:00 PM Location: S403A Moderator Simon Shek-Man Lo MD : Research support, Elekta AB Speaker, Varian Medical Systems, Inc Travel support, Varian Medical Systems, Inc 1) Understand the role, eligibility criteria, expected treatment outcomes and toxicities of stereotactic ablative radiotherapy (SABR) for lung oligometastases. 2) Understand the role, eligibility criteria, expected treatment outcomes and toxicities of SABR for liver oligometastases. 3) Understand the role, eligibility, expected outcomes and toxicities of SABR for spinal oligometastasis. 4) Understand the role of interventional radiology in the management of oligometastases. ABSTRACT It has been a notion that once distant metastases occur, cancer is typically widely disseminated. Hellman and Weichselbaum from University of Chicago have proposed the state of oligometastasis where the metastatic disease is limited in number and site. There is clinical evidence to suggest that local aggressive therapy such as surgical resection may prolong survival and may even achieve a cure. Most recently, non-surgical therapies such as stereotactic ablative radiotherapy and image-guided ablative therapies for oligometastases have emerged, appearing to yield promising results based on multiple retrospective studies and single arm clinical trials. There are certainly controversies with regard to the use of local aggressive therapies for oligometastases. To establish this strategy as the standard of care for oligometastasis, a randomized controlled trial comparing conventional care and local aggressive therapy would be ideal. The potential toxicities associated with these therapies have to be seriously considered before offering them to patients. Currently, there is an ongoing international randomized trial comparing SABR and conventional treatment enrolling patients in Canada and Europe and the results of this trial are eagerly awaited. Sub-Events RC420A SABR for Lung Oligometastases Simon Shek-Man Lo MD (Presenter): Research support, Elekta AB Speaker, Varian Medical Systems, Inc Travel support, Varian Medical Systems, Inc 1) To appreciate the technical requirements for lung SABR. 2) To appreciate the current outcomes for local control and survival. 3) To appreciate the challenges in response assessment. 4) To appreciate the toxicities associated with lung SABR. ABSTRACT There is clinical evidence to suggest that local aggressive therapy such as surgical resection may prolong survival and may even achieve a cure in selected patients with lung oligometastasis. Stereotactic ablative radiotherapy (SABR) has emerged as an alternative treatment option for lung oligometastases and promising results have been observed in multiple retrospective studies and single arm clinical trials. More research is

174 needed to better define the role of SABR in the management of lung oligometastasis. RC420B SABR for Liver Oligometastases Michael Lock MD (Presenter): Research Consultant, Accuray Incorporated 1) Discuss the reason primary and secondary liver cancer will become an important and growing proportion of patients seen in your clinic. 2) Review the rationale and outcome for radiotherapy in oligometastatic disease. 3) Compare the various methods to treat liver lesions in terms of evidence, outcome and practicality. 4) Understand the problems and solutions for motion management and image-guidance in this area. Review the options and selection of technology 5) Understand why we need t.o be aware of new toxicities and safety parameters. ABSTRACT ID: (Track 20) Title: SABR for Liver Oligometastases The learner will be able to: 1. discuss the reason primary and secondary liver cancer will become an important and growing proportion of patients seen in your clinic. 2. review the rationale and outcome for radiotherapy in oligometastatic disease 3. compare the various methods to treat liver lesions in terms of evidence, outcome and practicality 4. understand the problems and solutions for motion management and image-guidance in this area. Review the options and selection of technology 5. understand why we need to be aware of new toxicities and safety parameters. RC420C SABR for Spinal Oligometastases Arjun Sahgal (Presenter): Speaker, Medtronic, Inc Speaker, Elekta AB 1) To appreciate the technical requirements for spine SABR. 2) To appreciate the current outcomes for local control. 3) To appreciate the challenges in response assessment. 4) To appreciate the toxicites associated with spine SABR. ABSTRACT The aim of this session is to describe the technical requirements for spine SABR and to review outcomes for spinal metastases. The current challenges in response assessment will be reviewed and the effort to standardize response criteria. Lastly, there are several serious late toxicities that can result from spine SABR and these will be reviewed. RC420D Interventional Radiology in the Management of Oligometastases Sandeep Vaidya MD (Presenter): Nothing to Disclose View learning objectives under main course title. RC421 Medical Physics 2.0: Fluoroscopy Refresher/Informatics PH IR AMA PRA Category 1 Credits : 1.50 ARRT Category A+ Credit: 1.00 Tue, Dec 2 4:30 PM - 6:00 PM Location: S502AB Sub-Events RC421A Fluoroscopy Perspective Ehsan Samei PhD (Presenter): Research Grant, Siemens AG Research Grant, General Electric Company Research Grant, Carestream Health, Inc 1) To become familiar with major trends in fluoroscopy technology. 2) To understand transitions in technology that requires new and advanced evaluations. 3) To appreciate how a medical physicist is to effectively engage with clinical practice.

175 ABSTRACT Just like other medical imaging modalities, fluoroscopy has been undergoing a number of technological transitions. Those include transitions from II to flat panel detectors and from 2D to 3D imaging. While these advances offer improvements and new possibilities, they challenge the conventional way a system is to be tested. In addition, given the interventional nature of the modality, there is an increasing need for the medical physicist to be more operationally engaged with the use and optimization of the technology. This lecture aims to offer a historical perspective on these topics and an outline of major priorities for fluoroscopic physics service. RC421B Fluoroscopy 1.0 Beth A. Schueler PhD (Presenter): Nothing to Disclose 1) Review basic fluoroscopy imaging system performance evaluation tests. 2) Compare measurement procedures for fluoroscopic exposure assessment. 3) Become familiar with test procedures designed to assess fluoroscopic image quality. 4) Learn about implementation of patient dose management processes for fluoroscopic procedures. ABSTRACT This segment will provide a review of customary medical physics support activities for fluoroscopic imaging systems. Quality control testing procedures for image quality evaluation, radiation dose measurement and other mechanical performance characteristics are essential for optimizing equipment performance and ensuring patient and staff safety. Test equipment, phantoms, measurement methods and recommended performance criteria for these tests will be summarized as they apply to different types of fluoroscopic equipment, from angiographic imaging systems to radiographic-fluoroscopic (RF) tables and mobile C-arms. In addition, the medical physicist's role in clinical implementation of fluoroscopic systems will be discussed, including ensuring appropriate configuration of anatomical program settings, recommendations for patient dose management and methods for patient dose estimation. Active Handout sec.pdf RC421C Fluoroscopy 2.0 Keith J. Strauss MS (Presenter): Research Consultant, Koninklijke Philips NV Speakers Bureau, Koninklijke Philips NV 1) Understand need for and advantages of quantitative (as opposed to qualitative) analysis of image quality. 2) Identify and understand new tools becoming available for evaluating fluoroscopic equipment performance. 3) Identify appropriate configuration of acquisition parameters as a function of patient size. 4) Be able to configure the radiation dose to the detector to ensure diagnostic image quality at properly managed patient dose. ABSTRACT Abstract Steps that are required to turn physics support of fluoroscopy from a compliance focused to operationally focused program will be discussed. New metrics and analytics to better quantify high contrast resolution, low contrast resolution, temporal resolution, and 3D imaging will be examined. Changes in testing protocols necessary to address new hardware technologies, new acquisition methods, state-of-the-art image processing and analysis will be reviewed. A recently developed "physics testing mode" that the vendors will provide in the near future will be described. Proper management of patient dose metrics will be reviewed. The presentation concludes with clinical implementation of these new strategies. Proper training and communication is critical. Proper configuration of acquisition parameters (focal spot size, voltage and added filter, tube current, pulse width, pulse rate, scatter removal) as a function of patient size from the smallest neonate to the largest bariatric patient is key to providing diagnostic image quality at properly managed radiation doses. In addition, one must ensure that the detector dose as a function of filter type and thickness, pulse rate, field of view, and complexity of the examination is properly configured. RC450 Vertebral Augmentation (How-to Workshop) Refresher/Informatics MK IR MK IR MK IR AMA PRA Category 1 Credits : 1.50 ARRT Category A+ Credits: 1.50 Tue, Dec 2 4:30 PM - 6:00 PM Location: E260 A. Orlando Ortiz MD, MBA (Presenter): Nothing to Disclose Bassem Adeeb Georgy MD, MSc (Presenter): Consultant, Johnson & Johnson Consultant, DFINE, Inc Medical Advisory Board, SpineAlign Medical, Inc Stockholder, DFINE, Inc Stockholder, SpineAlign Medical, Inc Stockholder, Spine Solutions, Inc

176 SpineAlign Medical, Inc Stockholder, DFINE, Inc Stockholder, SpineAlign Medical, Inc Stockholder, Spine Solutions, Inc Allan L. Brook MD (Presenter): Advisor, Johnson & Johnson Advisor, Medtronic, Inc Afshin Gangi MD, PhD (Presenter): Proctor, Galil Medical Ltd Todd Stuart Miller MD (Presenter): Nothing to Disclose Sudhir Kathuria (Presenter): Research Grant, Toshiba Corporation Research Grant, Siemens AG 1) Discuss appropriate algorithms for patient selection. 2) Review anatomic and technical considerations for vertebral augmentation. 3) Present an update of the recent advances in vertebral augmentation including sacroplasty. 4) Emphasize safety issues and how to avoid complications. 5) Understand the applications of vertebral augmentation in osteoporotic and neoplastic spine pathology. 6) Update participants with respect to advances in equipment and biomaterials. ABSTRACT 1. Patient selection for vertebral augmentation Indications and Contraindications 2. New devices and techniques in vertebral augmentation 3. Vertebral augmentation for osteoporotic and pathologic vertebral compression fractures 4. Sacroplasty (sacral augmentation) 5. Complications avoidance 6. Efficacy Vertebral augmentation is an image-guided (fluoroscopy or CT) percutaneous procedure in which a bone needle is inserted into a painful osteoporotic or pathologic fracture within the spinal axis. Biopsy, cavity creation or lesion ablation may then be performed under imaging guidance depending on the nature of the pathology that is being treated. Subsequently a radioopaque implant, usually an acrylic bone cement, is carefully injected into the vertebra or sacral ala under imagining guidance, These procedures have been shown to provide pain relief by stabilizing the fractured vertebra or sacrum. As with any other invasive procedure, they carry a small risk (<<1%) of complication including bleeding, infection, neurovacular injury, or cement embolus. Appropriate patient seleciton and a detailed understanding of the technical aspects of the procedure along with active clinical patient follow-up are paramount to a successful outcome. This workshop will utilize short lectures, case examples and interactive audience participation in order to further explore critical topics in vertebral augmentation. URL's SPSC44 Controversy Session: Vertebroplasty: Science or Séance? Special Courses IR NR AMA PRA Category 1 Credits : 1.00 ARRT Category A+ Credit: 1.00 Wed, Dec 3 7:15 AM - 8:15 AM Location: S405AB Moderator Peter George Kranz MD : Research Consultant, Cephalogics, LLC Research Consultant, Biogen Idec Inc David F. Kallmes MD (Presenter): Research support, Terumo Corporation Research support, Covidien AG Research support, Sequent Medical, Inc Research support, Benvenue Medical, Inc Consultant, General Electric Company Consultant, Covidien AG Consultant, Johnson & Johnson A. Orlando Ortiz MD, MBA (Presenter): Nothing to Disclose 1) To discuss the effectiveness of vertebral augmentation in patients with painful osteoporotic vertebral compression fractures. 2) To review the literature and update attendees with an analysis thereof. 3) To discuss the impact of published clinical trials on the practice of vertebral augmentation. 3) To discuss whether patient selection may impact success vertebral augmentation procedures. SPSH40 Hot Topic Session: Prostate Interventions - Fused US/MRI Guidance Special Courses US MR IR GU US MR IR GU US MR IR GU AMA PRA Category 1 Credits : 1.00 ARRT Category A+ Credit: 1.00 Wed, Dec 3 7:15 AM - 8:15 AM Location: E351 Moderator Peter L. Choyke MD : Researcher, Koninklijke Philips NV Researcher, General Electric Company Researcher, Siemens AG Researcher, icad, Inc Researcher, Aspyrian Therapeutics, Inc Researcher, ImaginAb, Inc Researcher, Aura Moderator Julia R. Fielding MD : Nothing to Disclose 1) Learn current clinical applications for MR/US fusion biopsy of the prostate. 2) Describe elements of 2 fusion systems important to the radiologist. 3) Compare use of MR/US fusion systems with visual targeting of prostate cancers. Sub-Events SPSH40A Fused MR/US Prostate Biopsy with a Single Vendor System: How and When to Use It Andrew B. Rosenkrantz MD (Presenter): Nothing to Disclose

177 View learning objectives under main course title. SPSH40B Prostate Biopsy Using Two Fused MR/US Systems: Clinical Use and Comparison Daniel Jason Aaron Margolis MD (Presenter): Research Grant, Siemens AG View learning objectives under main course title. Active Handout sec.pdf RC507 Advancements in Renal Tumor Treatment: What We Need to Know Before and After Therapy Refresher/Informatics IR GU IR GU AMA PRA Category 1 Credits : 1.50 ARRT Category A+ Credits: 1.50 Wed, Dec 3 8:30 AM - 10:00 AM Location: E451A Ronald Jay Zagoria MD (Presenter): Nothing to Disclose Debra Ann Gervais MD (Presenter): Research Grant, Covidien AG 1) Attendees will learn the current treatment options for RCC, including partial nephrectomy and tumor ablation. 2) Attendees will be able to articulate the benefits and drawbacks of treatment options, specifically complications and outcomes. 3) Attendees will understand the steps of renal tumor ablation and considerations to assure ablation success. 4) Attendees will be able to report salient imaging findings before and after RCC treatment, especially partial nephrectomy and tumor ablation. ABSTRACT This course will provide an introduction to trends in imaging of RCC, imaging appearances of different tumor types, and clinical decision making in selecting appropriate patient management. Current treatment options (partial nephrectomy, tumor ablation) and how they are performed will be discussed and the benefits and drawbacks of each will be detailed. Important imaging findings when interpreting studies before and after treatment will be reviewed. RC512 Imaging and Endografts Refresher/Informatics IR VA AMA PRA Category 1 Credits : 1.50 ARRT Category A+ Credits: 1.50 Wed, Dec 3 8:30 AM - 10:00 AM Location: E353A Sub-Events RC512A TEVAR Indications and Outcomes Michael David Dake MD (Presenter): Scientific Advisory Board, W. L. Gore & Associates, Inc Scientific Advisory Board, Abbott Laboratories Scientific Advisory Board, TriVascular, Inc Research Consultant, Cook Group Incorporated Research support, Cook Group Incorporated Consultant, Medtronic, Inc 1) Understand the current applications of thoracic endografts for management of thoracic aortic pathologies. 2) Recognize the benefits and existing limitations of current endograft technologies for treatment of different aortic lesions. 3) Identify the complications and failure modes of TEVAR. 4) Know the current outcome metrics typically evaluated after TEVAR treatment of thoracic aneurysms and aortic dissections. 5) List the important imaging findings and criteria currently used to assess the suitability of aortic anatomy for TEVAR. RC512B New Endografts for AAA Constantino Santiago Pena MD (Presenter): Speakers Bureau, W. L. Gore & Associates, Inc Speakers Bureau, Cook Group Incorporated Speakers Bureau, Koninklijke Philips NV Advisory Board, C. R. Bard, Inc Advisory

178 Board, Boston Scientific Corporation Advisory Board, Guerbet SA 1) Discuss the status of established AAA endografts. 2) Discuss new endografts for the treatment of AAA. Particularly discuss areas of improvement over established endografts. 3) Present data on novel endografts being developed. RC512C Post Endograft Essentials Geoffrey D. Rubin MD (Presenter): Consultant, Fovia, Inc Consultant, Heartflow, Inc Consultant, Informatics in Context, Inc Research Consultant, General Electric Company 1) To better select the best imaging modality for assessing stent-grafts. 2) To assure that CT acquisition technique is optimized for endoleak detection. 3) To learn how to identify structural failures in endografts. RC516 AAWR/RSNA Instructional Session: Integration of Radiology and Radiation Oncology in Fighting Lung Cancer (In Conjunction with the American Association for Women Radiologists) Refresher/Informatics RO OI IR CH AMA PRA Category 1 Credits : 1.50 ARRT Category A+ Credits: 1.50 Wed, Dec 3 8:30 AM - 10:00 AM Location: S102C Moderator Feng-Ming Kong MD, PhD : Nothing to Disclose Sub-Events RC516A Imaging in Early Diagnosis and Detection Norman B. Thomson MD (Presenter): Stockholder, Nuance Communications, Inc 1) Understand new and evolving screening and staging imaging techniques for early detection of lung cancer. 2) Understand the controversies, risks, and benefits of Low Dose Computed Tomography screening of lung cancer in high risk individuals. RC516B Imaging Guided Radiation Therapy for Lung Cancer Feng-Ming Kong MD, PhD (Presenter): Nothing to Disclose 1) Review the role of imaging in treatment decision making. 2) Understand and expand the role of imaging guided radiation therapy (IGRT). 3) Explore the potential of mid-treatment PET-CTguided personalized adaptive treatment. RC516C The Role of Imaging in Surgical Resection Carsten Schroeder MD, PhD (Presenter): Nothing to Disclose 1) Determine key studies for surgical decision making and role of imaging. 2) Understand the surgical/anatomical decision making process and its dependency on imaging. 3) Provide an interdisciplinary approach to surgical procedure planning. RC516D Imaging to Assess Response and Toxicity Following Radiation Therapy Laurie E. Gaspar MD (Presenter): Consultant, Eli Lilly and Company

179 1) Analyze imaging to assign the grade of toxicity following radiation therapy. 2) Analyze imaging to assess treatment response. 3) Comprehend common pitfalls of imaging following radiation therapy. RC531 Small Parts Interventional Ultrasound (Hands-on Workshop) Refresher/Informatics US IR US IR AMA PRA Category 1 Credits : 1.50 ARRT Category A+ Credits: 1.50 Wed, Dec 3 8:30 AM - 10:00 AM Location: E263 William Eugene Shiels DO (Presenter): President, Mauka Medical Corporation Royalties, Mauka Medical Corporation Patent holder, Mauka Medical Corporation Peter L. Cooperberg MD (Presenter): Nothing to Disclose Veronica Josephine Rooks MD (Presenter): Nothing to Disclose Alda Felicita Cossi MD (Presenter): Nothing to Disclose Nathalie J. Bureau MD (Presenter): Equipment support, Siemens AG James Walter Murakami MD (Presenter): Nothing to Disclose Paolo Minafra MD (Presenter): Nothing to Disclose Paula Beth Gordon MD (Presenter): Stockholder, OncoGenex Pharmaceuticals, Inc Scientific Advisory Board, Hologic, Inc Consultant, Seno Medical Instruments, Inc Hollins P. Clark MD, MS (Presenter): Nothing to Disclose Carmen Gallego MD (Presenter): Nothing to Disclose Mabel Garcia-Hidalgo Alonso MD (Presenter): Nothing to Disclose Michael A. Dipietro MD (Presenter): Nothing to Disclose Horacio Munsayac Padua MD (Presenter): Nothing to Disclose Patrick Warren MD (Presenter): Nothing to Disclose Robert Douglas Lyon MD (Presenter): Nothing to Disclose Stephen Clifford O'Connor MD (Presenter): Nothing to Disclose Michael Andrew Mahlon DO (Presenter): Nothing to Disclose 1) Identify basic skills, techniques, and pitfalls of freehand invasive sonography, with specific focus on small part applications. 2) Define and discuss technical aspects, rationale, and pitfalls involved in musculoskeletal, breast, head and neck, and pediatric interventional sonographic care procedures. 3) Successfully perform basic portions of hands-on US-guided procedures in a tissue simulation learning model, to include core biopsy, small abscess coaxial catheter drainage, cyst and ganglion aspiration, lymphatic malformation macrocyst access, soft tissue foreign body removal, and intraarticular steroid injection. 4) Incorporate these component skill sets into further life-long learning for expansion of competency and preparation for more advanced interventional sonographic learning op RC550 Targeted Treatment and Imaging of Liver Cancers: Basic to Advanced Techniques in Minimally-Invasive Therapies and Imaging (How-to Workshop) Refresher/Informatics GI IR OI GI IR OI AMA PRA Category 1 Credits : 1.50 ARRT Category A+ Credits: 1.50 Wed, Dec 3 8:30 AM - 10:00 AM Location: E260 Moderator John J. Park MD, PhD : Nothing to Disclose Moderator Jinha Park MD, PhD : Speakers Bureau, Bayer AG Advisory Board, Guerbet SA Advisory Board, Koninklijke Philips NV Jonathan M. Kessler MD (Presenter): Nothing to Disclose Steven Satish Raman MD (Presenter): Consultant, Bayer AG Consultant, Covidien AG Marcelo Guimaraes (Presenter): Consultant, Cook Group Incorporated Consultant, Baylis Medical Company Consultant, Terumo Corporation Patent holder, Cook Group Incorporated Jinha Park MD, PhD (Presenter): Speakers Bureau, Bayer AG Advisory Board, Guerbet SA Advisory Board, Koninklijke Philips NV 1) Discuss the role of the interventional radiologist in the treatment and management of patients with primary and metastatic liver cancer as part of the multidisciplinary team. 2) Learn best practice techniques in the treatment of liver cancers, with emphasis on both locoregional and focal therapeutic approaches, and indications for treatment. 3) Explore various tips and tricks for each treatment modality and learn how to avoid complications through good patient selection, choosing the appropriate techniques, and knowing what common mistakes to avoid. 4) Learn about newer and developing techniques and devices, their potential roles and indications, and potential pitfalls. 5) Explore advanced imaging modalities in the detection of tumors and for monitoring treatment response. VSIR41

180 Interventional Series: Non-Vascular Interventions Series Courses IR AMA PRA Category 1 Credits : 3.25 ARRT Category A+ Credits: 3.75 Wed, Dec 3 8:30 AM - 12:00 PM Location: E352 Moderator Peter Raff Mueller MD : Consultant, Cook Group Incorporated 1) Describe the technique of thoracic duct embolization. 2) Explain the rationale for genomic analysis. 3) Describe two techniques to treat refractory abscesses. 4) List pros and cons of bedside non-vascular intervention. 5) Describe one MR guided intervention. 6) Describe two palliative interventions. Sub-Events VSIR41-01 Thoracic Duct Embolization Albert A. Nemcek MD (Presenter): Consultant, B. Braun Melsungen AG View learning objectives under main course title. VSIR41-02 Radiation Dose, Accuracy and Speed of Needle Interventions Using a Laser Navigation System (LNS) Compared with Conventional Method Tatjana Gruber-Rouh (Presenter): Nothing to Disclose, Boris Schulz MD : Nothing to Disclose, Nagy Naguib Naeem Naguib MD, MSc : Nothing to Disclose, Katrin Eichler MD : Nothing to Disclose, Thomas Josef Vogl MD, PhD : Nothing to Disclose, Julian Lukas Wichmann MD : Nothing to Disclose, Martin Beeres MD : Nothing to Disclose, Stefan Zangos MD : Nothing to Disclose To analyse the radiation dose, accuracy and speed of needle interventions using a laser navigation system (LNS) compared with conventional method (control group) in the first study with patients In the prospective randomized comparison study 58 patients (19 w: 39m; mean age, 62.9 years; range, years) were punctured either with LNS (n=29) or with conventional method with a mark of the puncture site using a pen (n=29). In the LNS method the injection site has been marked with laser without taking X-ray images at the mark. The needle intervention of thorax and abdomen was respectively performed in 30 and in 28 patients. Fifteen patients got drainage, 43 patients had a needle biopsy of tumors. Radiation dose and time of the procedures were analysed. All interventions could be performed successfully. Mean target access path within the patients in LNS-group was 6.0 cm (min 3.0cm, max 10.1cm) und in conventional group 6.0 cm (min 1.0 cm, max 10.3 cm), time duration of complete intervention in LNS-group was 28:00 min (min 14:00min, max 57:00min) and in control-group was 29:09 min (min 12:00min, max 53:00min). The radiation dose (DLP) of intervention scan of LNS-group was 42.3 mgycm (min 10 mgycm, max 125. mgycm), and of control-group 59.7 mgycm (min 25 mgycm, max mgycm). When using the LNS in an intervention suite, faster needle-based interventional punctures are possible with a low dose. When using the LNS in an intervention suite, faster needle-based interventional punctures are possible with a low dose. VSIR41-03 Fusion Image-guided and Ultrasound-guided Fine Needle Aspiration in Patients with Suspected Hepatic Metastases Lawrence AJ : Nothing to Disclose, Naveen Kalra MBBS, MD (Presenter): Nothing to Disclose, Srinivasan Radhika : Nothing to Disclose, Ajay Gulati MD : Nothing to Disclose, Rakesh Kapoor MD : Nothing to Disclose, Yogesh Chawla : Nothing to Disclose, Niranjan Khandelwal MD : Nothing to Disclose

181 To compare the diagnostic adequacy of CT-ultrasound fusion image-guided fine needle aspiration (FNA) with ultrasound-guided FNA in patients with suspected hepatic metastases which were conspicuous on ultrasound. Prospective study of 30 patients who had suspected hepatic metastases on ultrasound and triphasic CT imaging (64- or 128-slice CT). CT-ultrasound fusion image-guided FNA of the largest hepatic lesion was done with 20G needle using electromagnetic tracking. Two passes were obtained using coaxial system. Free hand ultrasound-guided FNA of the same lesion was done in the same sitting using 20G needle and two passes were obtained. The sequence of the methods was determined using computer-generated random table. Diagnostic adequacy of the smears was objectively assessed by a scoring system based on the cellular material, background blood or clot, degree of cellular degeneration or trauma and retention of architecture. The cytologist was blinded to the method of aspiration. Multiple lesions were seen in 28 patients and single lesion was seen in 2 patients. The size of the lesions sampled ranged from 1-10 cm (mean 4.12 cm, median 4.1 cm). The depth of location of the lesions ranged from cm (mean 5.35 cm, median 5.35 cm). The fusion fitness values ranged from mm. Technical success of needle placement was achieved in all patients using both methods. The scores of the smears did not correlate with lesion size, depth of location and fusion fitness value. Diagnostic adequacy was seen in 90% lesions sampled by fusion image guidance and in 93.3% lesions sampled by ultrasound guidance. This difference was not statistically significant. All the lesions which yielded inadequate smears using fusion guidance were deep seated lesions (> 5cm). All the lesions which yielded inadequate smears using ultrasound guidance were small lesions (<3cm). No serious complications were seen in any of the patients. Fusion image-guided FNA is a safe procedure with a high diagnostic adequacy rate. It is not better than ultrasound-guided FNA in patients with hepatic metastases which are conspicuous on ultrasound. CT-ultrasound fusion image-guided FNA is a safe procedure with a high diagnostic adequacy rate but is not better than ultrasound-guided FNA for conspicuous hepatic lesions. VSIR41-04 Percutaneous Biopsy for Genomic Analysis What You Need to Know Steven Michael Zangan MD (Presenter): Nothing to Disclose View learning objectives under main course title. VSIR41-05 Approaching the Refractory Abscess Peter Raff Mueller MD (Presenter): Consultant, Cook Group Incorporated View learning objectives under main course title. VSIR Papers in 10 Minutes: Studies in Non-Vascular Intervention That You Should Know Ronald Steven Arellano MD (Presenter): Nothing to Disclose View learning objectives under main course title. VSIR41-07 Debate Beside Interventions Ronald Steven Arellano MD (Presenter): Nothing to Disclose, Steven Michael Zangan MD (Presenter): Nothing to Disclose View learning objectives under main course title. VSIR41-08 Change in Management as a Result of Culture Obtained during CT-Guided Drainage in Patients Who Receive Pre-Drainage Antibiotics

182 Kathryn L. McGillen MD (Presenter): Nothing to Disclose, Ruvandhi Nathavitharana MD : Nothing to Disclose, Alexander Brook PhD : Spouse, Research Grant, Guerbet SA, Maryellen Ruth Morris Sun MD : Investigator, Bracco Group Investigator, Glaxo SmithKline plc, Bettina Siewert MD : Nothing to Disclose, Vassilios D. Raptopoulos MD : Nothing to Disclose, Robert A. Kane MD : Nothing to Disclose, Robert G. Sheiman MD : Nothing to Disclose, Olga Rachel Brook MD : Research Grant, Guerbet SA To evaluate the clinical impact of pre-drainage antibiotics on culture yield from samples obtained during CT-guided drainage. This retrospective, HIPAA-compliant, IRB-approved study evaluated 300 consecutive patients that underwent CT-guided aspiration or drainage for suspected infection (11/2011-9/2013) at a single institution. Patient imaging and clinical characteristics were evaluated by an abdominal imaging fellow and culture results and patient management were evaluated by an infectious diseases fellow. Sixteen patients were excluded because they either received no pre-procedure antibiotics or samples for culture were not obtained. 284 patients constituted the final study cohort, with average age of 55±16 yrs and M:F ratio of 54:46. Leukocytosis was present in 165/284(58%) and fever in 65/284(23%). The average collection size was 8.5±4.2cm, gas was present in 141/284(50%) of collections, average amount drained was 108±209mL, and purulent material was obtained in 174/284(62%). 85% (242/284) of collections received drains and the remainder were aspirated. Cultures were positive in 209/284(74%) with change in management in 186/284(65%). The change in management included change of antibiotics in 72/186(39%), narrowing the regimen in 97/186(52%) and cessation of antibiotics in 17/186 (9%). Multidrug resistant bacteria were cultured in 53/284 (19%). The following factors were found to be statistically significant predictors of positive cultures (p<.05): leukocytosis (sens 62%, spec 53%), gas (sens 59%, spec 77%), purulent material (sens 76%, spec 76%), and presence of polymorphonuclear cells in the specimen. Patients with positive cultures had shorter median time difference between antibiotic initiation and drainage than patients with negative cultures (1.0 vs. 3.7 days, p<.001). CT-guided drainage has a high yield of positive cultures despite pre-drainage antibiotic therapy and the resulting culture information has a positive impact on patient management change. Leukocytosis, gas, polymorphonuclear cells and purulent material in the specimen are significant predictors of positive culture. Also, a shorter interval between starting antibiotics and the procedure results in more positive cultures. Pretreatment with antibiotics should not preclude specimen collection at the time of CT-guided drainage, as it has high potential to change clinical management. VSIR41-09 Cryoneurolysis in Patients with Chronic Peripheral Refractory Neuropathic Pain William Henry Moore MD : Research Grant, EDDA Technology, Inc Medical Board, EDDA Technology, Inc Research Grant, Galil Medical Ltd Research Grant, Endo Health Solutions Inc, Adam T. Ryan MD : Nothing to Disclose, Vadim Grechushkin MD : Nothing to Disclose, Armen Aivazi : Nothing to Disclose, Jung Hwoon Edward Yoon MD (Presenter): Nothing to Disclose To evaluate the safety and efficacy of cryoneurolysis in patients with refactor peripheral neuropathic pain. A prospective study was performed from July 2012 to April Patients were recruited who were referred for cryoneurolysis of the lower extremities. Ultrasound guidance of the involved nerves was used for imaging guidance. Percutaneous ablations were performed using an Percryo-17-R device (Endocare, Healthtronics, USA). The ablation technique was a single 3 minute freeze cycle with a single thaw cycle. Maximum negative temperature was documented during the procedure and complications were also documented. Patients pain levels were recorded on a 0-10 visual analog scale, before and immediately after the procedure then at 1 week, and at 1,3,6,9 and 12 months. A total of 11 patients were recruited to this study. All underwent cryoneurolysis under-ultrasound guidance involving the nerves of the lower extremity including the posterior tibial, sural nerve, digital nerves, and saphenous nerves. The mean pain scale prior to the intervention was 9.0 +/ The visual analog scale immediately after treatment was 2.0 +/- 1.8 with a pain score at 6 months with a pain score of 3.3 +/ A wilcoxon rank sum test was performed and showed statically significant decrease in pain score comparing per and post procedural visual analog scale. There were no complications from these procedures. There is a statically significant decrease in self-reported pain scale in patients with chronic refractory neuropathic pain. This decrease in pain level is sustained up to 9 months. In our experience the neuropathic pain will recur and repeat therapy is equally effective.

183 Cryoneurolysis is an additional therapy which can be alleviate severe chronic neuropathic pain in patients who are refectory to standard treatments. VSIR41-10 Peritoneovenous (Denver) Shunt use for Management of Chylous Ascites in Cancer Patients Hooman Yarmohammadi MD (Presenter): Nothing to Disclose, Lynn Alison Brody MD : Nothing to Disclose, Joseph Patrick Erinjeri MD, PhD : Nothing to Disclose, Anne Mara Covey MD : Nothing to Disclose, Constantinos Thasos Sofocleous MD, PhD : Consultant, Sirtex Medical Ltd, Jeremy C. Durack MD : Nothing to Disclose, Majid Maybody MD : Nothing to Disclose, Robert H. Siegelbaum MD : Nothing to Disclose, Karen Teresa Brown MD : Nothing to Disclose, Raymond Howard Thornton MD : Nothing to Disclose, Stephen Barnett Solomon MD : Research Grant, General Electric Company Research Grant, AngioDynamics, Inc Consultant, Johnson & Johnson Consultant, Covidien AG Director, Devicor Medical Products, Inc Director, Aspire Bariatrics, Inc, George Isaac Getrajdman MD : Medical Advisory Board, CareFusion Corporation Management of intractable chylous ascites in cancer patients remains a challenge. Both nutritional status and quality of life are adversely affected. Denver shunts have been used to manage both malignant and chylous ascites. The purpose of this study was to evaluate the efficacy of Denver shunt placement in treating intractable chylous ascites in cancer patients. This is a retrospective review of patients with refractory chylous ascites who had Denver shunts placed between February 2003 and July Demographic characteristics, technical success rate, efficacy in providing symptomatic relief, shunt survival time, and complications were recorded and analyzed. Symptomatic relief was defined as absence of discomfort from abdominal distention. Control of ascites was assessed on follow up imaging and physical examination. Univariate logistic regression was performed to determine factors correlating with complications, complete resolution of ascites and shunt removal. 23 Denver shunts were placed in 11 men and 12 women with a mean age of 49±13 years (Range: years). Shunts were successfully placed in all 23 patients (100% technical success) and provided symptomatic relief in all patients (100%). Chylous ascites completely resolved in 10 patients (43%) leading to shunt removal in 160±90 days (range days). Ascites did not recur after removal in any of these patients during mean follow-up of 15±11 months. Chylous ascites completely resolved in all patients with testicular cancer (n = 7). The most common complication was shunt malfunction; clogging or obstruction of the venous or peritoneal limb requiring shunt removal occurred in 2/23 patients (8.7%). Two other shunts had to be removed due to right internal jugular vein thrombosis and superior vena cava thrombosis. There was no case of disseminated intravascular coagulation. Diagnosis, type of surgery, changes in platelet count, and fibrinogen level were unrelated to adverse events (p>0.05). Denver shunts successfully managed chylous ascites in cancer patients, particularly in the setting of post-operative patients with testicular cancer, leading to complete resolution of ascites and allowing shunt removal. When dealing with ascites, Denver shunt placement can safely and efficiently treat and managing ascites. VSIR41-11 MR Guided Intervention Aytekin Oto MD (Presenter): Research Grant, Koninklijke Philips NV Consultant, Guerbet SA 1) Limitations of the current paradigm for diagnosis and management of prostate cancer. 2) Terminology and basic technical details of biopsy techniques using MR images and/or guidance. 3) Different MR guided focal treatment methods for prostate cancer. 4) Future developments in MR guided prostate interventions and the importance of radiologist's involvement. ABSTRACT TITLE: MR guided Prostate Interventions MR guided or directed prostate biopsy and MR guided therapy are being increasingly utilized for the diagnosis and management of prostate cancer. This lecture will highlight the limitations of the current paradigm for diagnosis and treatment of prostate cancer and introduce the emerging paradigm of targeted biopsy and focal treatment in prostate cancer. Targeted biopsy techniques based on visualization of the cancer on MRI (cognitive registration, fusion of MR and TRUS images, MR guided biopsy) will be reviewed. The essential technical details of different MRI guided focal therapy methods will be discussed. Future developments in the area of MRI guided prostate interventions including robotic assistance and opportunities for involvement of radiologists will be explored. VSIR41-12 Non-Vascular Palliative Interventions Charles Thomas Burke MD (Presenter): Nothing to Disclose

184 View learning objectives under main course title. VSNR41 Neuroradiology Series: Stroke Series Courses ER IR NR AMA PRA Category 1 Credits : 3.25 ARRT Category A+ Credits: 3.75 Wed, Dec 3 8:30 AM - 12:00 PM Location: E451B Moderator Erin Simon Schwartz MD : Nothing to Disclose Moderator Vincent Paul Mathews MD : Speakers Bureau, Eli Lilly and Company Sub-Events VSNR41-01 Non-atherosclerotic CNS Vasculopathies Pina Christine Sanelli MD (Presenter): Nothing to Disclose 1) Provide a brief review of CNS vasculopathies highlighting the key diagnostic features. 2) Review pertinent differential diagnoses of neuroimaging cases. 3) Provide important imaging pearls for differentiating CNS vasculopathies. ABSTRACT A review of of CNS vasculopathies highlighting the key diagnostic features will be provided. The pertinent differential diagnoses of neuroimaging cases will be reviewed. Important imaging pearls for differentiating CNS vasculopathies will be provided. VSNR41-02 The Value of High-Resolution T2-Weighted Vessel Wall MR Imaging for the Differentiation of Intracranial Vasculopathies Mahmud Mossa-Basha MD (Presenter): Nothing to Disclose, William D. Hwang MD : Nothing to Disclose, Tom Hatsukami : Research Grant, Koninklijke Philips NV, Adam de Havenon MD : Nothing to Disclose, David Tirschwell MD, MSc : Nothing to Disclose, Yoshimi Anzai MD : Nothing to Disclose, Niranjan Balu PhD : Nothing to Disclose, Daniel S. Hippe MS : Research Grant, Koninklijke Philips NV Research Grant, General Electric Company, Chun Yuan PhD : Research Grant, Koninklijke Philips NV Consultant, Bristol-Myers Squibb Company Consultant, Koninklijke Philips NV To assess the contribution of high-resolution T2-weighted vessel wall MR (VWI) sequences for differential diagnosis of intracranial vasculopathies. Consecutive patients with intracranial arterial stenosis who had undergone 3T high-resolutioin MR VWI were retrospectively selected. 2D T2-weighted sequences (.4 x.4 mm in-plane resolution, 1 mm thick slices) were scanned and assessed in both axial plane and a plane perpendicular to the artery lumen. Relative vessel wall thickness, eccentricity of disease and signal characteristics were assessed in areas of arterial stenosis or irregularity as seen on luminal imaging by a double blinded rater. Classification of patients was based on the following clinical and imaging criteria: atherosclerosis (>2 atherosclerosis risk factors without evidence of systemic or CSF inflammation or clinical evidence of vasospastic process/reversibility), vasculitis (clinical evidence of CSF infection/inflammation and/or systemic inflammatory disease without atherosclerosis risk factors or clinical evidence of vasospastic process) and reversible cerebral vasoconstriction syndrome (RCVS) (classic clinical presentation, with reversibility of the imaging findings and no evidence of systemic or CNS inflammatory disease). There were 21 atherosclerosis cases with 45 plaques, 4 vasculitis cases (VZV, PACNS, TB and Behcet vasculitis) with 14 stenoses and 4 RCVS cases with 19 stenoses that could adequately be assessed on T2-weighted VWI. A linear T2 hyperintense band along the intimal surface (presumed to represent fibrous cap) was seen in 36/45 atherosclerotic, 0/14 vasculitic and 0/19 RCVS lesions. All of the atherosclerotic lesions showed appreciable wall thickening, as compared to 11/14 vasculitis and 4/19 RCVS lesions. 42/45 atherosclerotic plaques, 2/14 vasculitis and 2/19 RCVS lesions showed eccentric wall thickening. High resolution T2-weighted VWI can complement T1 and PD pre and post-contrast VWI for the differentiation of intracranial stenosing vasculopathy, based on disease eccentricity, presence of a T2 hyperintense intimal band and appreciable wall thickening.

185 High-resolution T2 VWI should be incorporated into intracranial VWI protocols, as this technique can provide complementary information to T1 and PD-weighted techniques. VSNR41-03 Whole Brain 3D-T1w-Black-Blood 3T-MRI for the Diagnosis of Intracranial CNS Vasculitis and Horton's Disease: A Pilot Study Nora Navina Kammer MD (Presenter): Nothing to Disclose, Eva Maria Coppenrath MD : Nothing to Disclose, Karla Maria Treitl MD : Nothing to Disclose, Hendrik Kooijman : Employee, Koninklijke Philips NV, Maximilian F. Reiser MD : Nothing to Disclose, Tobias Saam MD : Research Grant, Diamed Medizintechnik GmbH Research Grant, Bayer AG 2D-T1w black-blood sequences are used in atherosclerotic plaque imaging and for the assessment of inflammatory changes of intracranial vessels. However, sequences are limited due to long acquisition times which limits the number of acquired slices and thus the coverage (coverage often 3 cm or less). Aim of the study was to evaluate a commercially not available gadolinium-enhanced isotropic 3D-whole-brain-black-blood T1w-TSE sequence with variable flip angles (T1w-VISTA) for the diagnosis of intra- and extracranial vasculitis. We prospectively included 26 patients with suspected vasculitis, 3 patients with Sickle-cell disease and 15 tumor patients without any evidence of vascular disease. All patients received a standardized protocol (T1w preand post contrast, TOF, DIFF, T2, FLAIR) and a T1w 3D-BB-VISTA sequence pre- and post contrast (resolution=0.8 mm3 isotropic, scan time 4:43 minutes). Left and right arteries of the anterior and posterior circulation (176 segments) and right/left temporal artery (88 segments) were evaluated for the presence of stenosis, wall thickening (eccentric/concentric) and contrast enhancement of the vessel wall (3-point Likert scale). 6 out of 104 arterial segments in patients with suspected intracranial vasculitis (3x right/1x left middle cerebral artery, 1x right and left vertebral artery) and 6 out of 88 temporal arteries showed focal circumferential, concentric wall thickening, luminal narrowing and strong contrast enhancement These findings were found in 8 distinct patients in which vasculitis was clinically confirmed. One patient with sickle-cell disease presented with a stenosis and concentric wall thickening without contrast enhancement. None of the 60 arterial segments of the tumor patients showed vasculitis like lesions but 6 segments (distal vertebral artery) showed an eccentric wall thickening and none to moderate contrast enhancement due to atherosclerotic plaques. Whole-brain-black-blood MRI is feasible in less than 5 minutes scan time and allows to accurately diagnosing CNS vasculitis and Horton's disease. Future studies will be necessary to evaluate the utility of this sequence for other vascular pathologies, such as arterial dissection and atherosclerosis. Whole-brain-black-blood MRI is a relevant additional tool for diagnosing and monitoring cranial vasculitis. VSNR41-04 Identification of an Impaired Cerebrovascular Reactivity by Use of Arterial Spin Labeling in Patients with Moyamoya Disease Tae Jin Yun MD (Presenter): Nothing to Disclose, Jin Chul Paeng : Nothing to Disclose, Chul-Ho Sohn MD : Nothing to Disclose, Beom Su Kim MD : Nothing to Disclose, Seung Hong Choi MD, PhD : Nothing to Disclose, Ji-hoon Kim MD : Nothing to Disclose We aimed to assess the ability of arterial spin labeling (ASL) to identify an impaired cerebrovascular reactivity (CVR) relative to single photon emission computed tomography (SPECT) in patients with moyamoya disease (MMD). The institutional review board of our hospital approved this prospective study and written informed consent was obtained from all patients. We conducted a prospective study to determine the ability of ASL to identify CVR relative to SPECT in 78 subjects with MMD. Among these patients, 31 patients performed unilateral direct arterial anastomosis, and in these patients, follow up ASL perfusion MR and SPECT were performed additionally (for ASL, 1 weeks, 3 months, and 6 months after operation; for SPECT, 6 months after operation). Volumes of interests based on internal carotid artery territories were applied to the cerebral blood flow maps from the basal stress ASL and SPECT. And, the concordance between the CVR indexes (CVRIs) from ASL and SPECT was assessed using Bland-Altman analysis, and the area under the receiver-operating characteristic curve (AUC) was used to evaluate diagnostic accuracy of ASL relative to that of SPECT using various CVRI cutoff points. The CVRI from ASL had a negative bias as compared to the CVRI from SPECT (systemic bias, -3.5%). In addition, the differences between the CVRI from ASL and SPECT tended to be larger when the CVRI is more impaired. The analysis of the diagnostic accuracy of ASL for detecting the impaired CVR revealed an AUC of 0.81 with a sensitivity of 81%, a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 12%. ASL performed in 6 months after anastomosis showed significant increase in CVRI than that performed preoperatively as well as SPECT (for ASL, -2.7 ± 7.3 and ± 9.3, P < 0.001; for SPECT, -3.7 ±

186 2.9 and -6.2 ± 5.2, P = 0.013, respectively). ASL can identify impaired CVR with excellent performance in patients with MMD and has the potential to serve as a non-invasive imaging tool for determining CVR in patients with cerebrovascular disease. 1. ASL can identify impaired CVR with excellent performance in patients with MMD 2. ASL has the potential to serve as a non-invasive imaging tool for determining CVR in patients with cerebrovascular disease. VSNR41-05 Assessing the Hemodynamic Insufficiency Model of Stroke Risk in Children with Sickle Cell Disease Using MR-based Measures of Cerebrovascular Reactivity Przemyslaw Kosinski BS (Presenter): Nothing to Disclose, Jackie Leung : Nothing to Disclose, Manohar Meghraj Shroff MD : Nothing to Disclose, Suzan Williams : Nothing to Disclose, Gabrielle deveber : Nothing to Disclose, Andrea Kassner PhD : Nothing to Disclose The most devastating complication of sickle cell disease (SCD) is overt stroke, which occurs in more than 10% of children. Patients with cerebral blood flow velocities (CBFv) >200cm/s on Transcranial Doppler (TCD) are at highest risk of stroke. There are two models that explain how increased CBFv in SCD increases risk of stroke: the vasculopathy-stenosis and the hemodynamic insufficiency (HI) models. The stenosis model was originally used to attribute stroke onset to high CBFv. However, in the STOP trial, 79% of children with SCD had minor/no stenosis. This favours the HI model, which postulates that cerebral vessels have only a finite capacity to dilate, which is compromised in SCD due to chronic anemia. As a result it poises the cerebral vasculature for ischemia and subsequent stroke. The aim of the study was to investigate the HI model in children with SCD by quantifying the capacity of vasodilation using an MR- based cerebrovascular reactivity (CVR) defined as a change in cerebral blood flow (CBF) in response to a vasoactive stimulus. We hypothesize that CVR is reduced and correlates with the degree of anemia. 30 SCD patients (10-18 years) were imaged on a clinical MRI system. A hypercapnic challenge (CO2) was administered in synchrony with a blood-oxygen-level dependent (BOLD) MRI to measure relative CBF changes. Anatomical images were also acquired and reviewed by a radiologist to exclude with significant stenosis, large white matter lesions or vascular abnormalities. CVR maps were generated by correlating the BOLD MRI signal change with the corresponding CO2 values. Mean CVR values were then calculated based on gray and white matter segmentation. Hct values were obtained from hematology records. Pearson correlation coefficients were calculated for CVR and hct as well as CVR and CBF. CVR demonstrated a moderately strong correlation with hct, r=0.68 (p=0.01). The correlation between CVR and gray matter CBF was moderately strong, r=-0.63 (p=0.021). Our results show that CVR is associated with the degree of anemia in children with SCD who do not have a stenosis. This seems to support the HI model of stroke risk in this population. The degree of anemia needs to be considered when assessing stroke risk in SCD. CVR seems to be superior to TCD measures of high CBFv, as CVR can fully describe the status of the cerebral vasculature. VSNR41-06 New Insights in Pediatric Stroke A. James Barkovich MD (Presenter): Research Consultant, General Electric Company 1) Understand how to protocol imaging studies for a child with new onset of localized neurologic impairment and, in particular, when ultrasound or CT may be useful as opposed to performing MRI as the initial procedure. 2) Recognize which studies and, in particular, what sequences should be performed on MRI and in what order. 3) Understand the causes of pediatric stroke, which are different from those in adult stroke. 4) The stroke is easy to identify; to find the cause of the stroke is not easy in children, but will be easier after attending this session. ABSTRACT Localized stroke is an important cause of morbidity and mortality in childhood and one of the top ten causes of childhood death. Approximately 25% of all pediatric strokes occur in neonates and approximately 50% occur in children less than 1 year of age. Despite these numbers, the misconception remains that stroke is a rare and relatively unimportant illness in childhood. Fortunately, the medical community has recently become more aware of this entity and its importance in pediatric health. Presenting signs and symptoms depend upon the

187 region of brain affected and the age of the patient at the time of the infarct. Perinatal/prenatal stroke is much more common than generally recognized, with a prevalence of 1 in live births. Patients may present with neonatal encephalopathy or seizures or may remain undetected until early hand preference is manifested. In older children, presentation is one of abrupt onset of seizure or neurological deficit. Once a stroke is suspected, clinically or by imaging, it is imperative to determine whether hemorrhage is present in order to determine whether anticoagulation is in order. Vascular imaging is essential and in either case should be obtained with high resolution, as dissections and post-infectious vasculopathy can be extremely subtle and both require anticoagulation. If the stroke is hemorrhagic and if there are regions of increased diffusivity, venography should be obtained. If vasculopathy is suspected because of location of the infarct or history of recent illness, we obtain vascular wall imaging with 1mm partition size after administration of contrast to look for irregularity or enhancement of the arterial wall; the latter seems to be associated with inflammation. If dissection is identified in the vertebral artery at the upper cervical level, careful attention should be paid to anomalies of the upper cervical vertebrae that may stretch or damage the vessel with abrupt head motion, usually secondary to trauma. VSNR41-07 Emergency Stroke Triage Greg Zaharchuk MD, PhD (Presenter): Research Grant, General Electric Company 1) Understand the concept of the diffusion-perfusion (DWI-PWI) mismatch concept in acute stroke. 2) Review the recent results of stroke trials using the DWI-PWI concept. 3) Appreciate the potential role of other markers, such as collateral flow, oxygenation, ph, and resting-state fmri for assessing the ischemic brain. VSNR41-08 Clot Characteristics on Baseline Imaging Predicts Recanalization with IV tpa in the IMS III Trial Bijoy Menon MBBS, MD (Presenter): Nothing to Disclose, Sharon Yeatts PhD : Consultant, F. Hoffmann-La Roche Ltd, Sachin Mishra : Nothing to Disclose, Emmad Qazi : Nothing to Disclose, Anurag Trivedi : Nothing to Disclose, Vivek Nambiar : Nothing to Disclose, Volker Puetz MD : Nothing to Disclose, Michael D. Hill MD : Nothing to Disclose, Lydia Foster : Nothing to Disclose, Liqiong Fan : Nothing to Disclose, Pooja Khatri : Support, Penumbra, Inc Support, F. Hoffmann-La Roche Ltd, Ruediger Von Kummer MD : Research Consultant, H. Lundbeck A/S Research Consultant, SYNARC Inc Speakers Bureau, Boehringer Ingelheim GmbH Speakers Bureau, Penumbra, Inc Research Consultant, Penumbra, Inc Research Consultant, Covidien AG, David S. Liebeskind : Consultant, Stryker Corporation Consultant, Covidien AG, Thomas A. Tomsick MD : Nothing to Disclose, Mayank Goyal MD, FRCPC : Shareholder, Calgary Scientific, Inc Research Grant, Covidien AG Consultant, Covidien AG Shareholder, NoNO Inc Investigator, Covidien AG, Joseph P. Broderick MD : Support, F. Hoffmann-La Roche Ltd Support, Merck & Co, Inc Research funded, F. Hoffmann-La Roche Ltd Travel support, Boehringer Ingelheim GmbH, Andrew Demchuk MD : Nothing to Disclose In IMS-III trial patients, we evaluate if clot characteristics on baseline non-contrast CT (NCCT) or CT-angio (CTA) determine recanalization with IV-tPA using classification and regression tree analysis (CART). IMS-III protocol is published. Two readers assessed clot characteristics on NCCT [hyperdense(hd) sign location, length, ratio of maximal Hounsfield Unit (HU) HDS/contralateral MCA (rhu)] and CTA [Clot burden score, length, residual flow through clot, ratio of contrast HU at proximal/distal clot interface (cirhu)] by consensus. Very early arterial weighted CTAs were excluded; appropriate imputation techniques used whenever distal clot interface was not measured. Early recanalization with IV-tPA was assessed on first angio (only in the endovascular arm) while 24-hour recanalization with IV-tPA was assessed on follow-up CTA (only in the IV-tPA alone arm). Of 263 patients with anterior circulation clots on baseline CTA, after excluding patients with missing data, 64 in the IV-tPA and 175 in the endovascular arm were analyzed. CART models for early and 24-hr recanalization with IV-tPA are shown in Figures 1 and 2 respectively. Clot characteristics on NCCT and CTA can help physicians estimate a range of early and late recanalization rates with IV-tPA. Clot characteristics on both NCCT and CTA can help determine the effecay of tpa and should be considered when deciding to treat patients with tpa over endovascular. VSNR41-09 Predictors of Reperfusion in Acute Ischemic Stroke Patients Alexander D. Horsch MD, MRCS (Presenter): Nothing to Disclose, Jan Willem Dankbaar MD, PhD : Nothing to Disclose, Yolanda Van Der Graaf : Nothing to Disclose, Willem P. Mali MD, PhD : Nothing to Disclose, Birgitta Katinka Velthuis MD : Research Consultant, Koninklijke Philips NV Speakers Bureau, Koninklijke Philips NV Acute ischemic stroke studies emphasize a difference between reperfusion and recanalization but predictors of

188 reperfusion have not been elucidated. This study aims to identify predictors of reperfusion and to investigate the relation between recanalization and reperfusion. From the XXX trial 178 patients were selected with a middle cerebral artery territory perfusion deficit on admission CT perfusion (CTP) and complete day 3 follow-up CTP and CT-angiography (CTA). Reperfusion and recanalization were evaluated on the follow-up imaging. The association between reperfusion and recanalization was calculated using absolute and relative risks. Patient admission and treatment characteristics as well as admission CT imaging parameters regarding occlusion site and stroke severity were collected. Their association with complete reperfusion was analyzed using logistic regression. Absolute risk for complete reperfusion was 0.60 in the complete recanalization group and 0.23 in the incomplete recanalization group, with a relative risk of 2.60 (CI ), but around 40% showed a discrepancy between recanalization and reperfusion status. Lower clot burden (OR 1.35, CI ), more distal thrombus location (OR 2.28, CI ) and good collateral score (OR 2.84, CI ) increased the odds of complete reperfusion whilst higher NIHSS score (OR 0.95, CI ), larger infarct core size (OR 0.32, CI ) and larger total ischemic area (OR 0.31, CI for mm2 and OR 0.16, CI for >5000 mm2) decreased the odds of complete reperfusion. None of the patients with ipsilateral intracranial ICA occlusion showed complete reperfusion. Recanalization and reperfusion are strongly related but not always equivalent in acute ischemic stroke. Lower clot burden, distal thrombus location, collateral score, NIHSS score, infarct core size and total ischemic area are predictors of reperfusion. Lower clot burden, distal thrombus location, collateral score, NIHSS score, infarct core size and total ischemic area are predictors of reperfusion and can be used to aid treatment decisions in acute ischemic stroke patients. VSNR41-10 How Can We Make Stroke Imaging Better around the World? :Global Survey of Radiologists in 18 Countries Bhavya Rehani MD (Presenter): Nothing to Disclose Stroke poses a major health challenge in today's world. "Time is Brain" in stroke and every minute counts in stroke management. To what extent are we able to provide timely imaging to these patients globally and if not what can be done? Our aim was to survey radiologists across developing countries in Asia, Europe and South America to assess the stroke care and find out what in their opinion are the most effective ways to improvise imaging and management. A standardized questionnaire containing 18 questions was sent to radiologists in 20 developing countries across the world. Radiologists from 18 countries responded (response rate=90%). These include Kenya, Algeria, Rwanda, Sri Lanka, Malaysia, Costa Rica, Macedonia, Bulgaria, Mexico, China, India, Uruguay, Burma and Venezuela among others. Survey results indicated that most of the countries (72%), lack access to CT scanners. Intravenous tissue plasminogen activator (t PA) is the standard of care of ischemic stroke and cannot be given unless hemorrhage is excluded on CT. Also, this can only be administered for a specific time window after symptom onset. To maximize patients who can benefit from thrombolysis, the key is to have a short Emergency Room Door to CT scan time. Unfortunately, Door to CT scanner time is more than 30 minutes in 83% (95% CI being %). Moreover, 77% of the countries had shortage of the drug tpa. Overall, radiologists rated their knowledge as "average" in reading stroke imaging and 77% (95% CI being %) believed that further training would be helpful. Minority had access to Neurointerventionalist (33%) and Telestroke services (27%). When questioned about the three most powerful ways to improvise stroke imaging in their respective countries, the highest rated choices were: training prrograms on stroke imaging to improvise knowledge among radiologists, campaigns to increase awareness in the community and improvising access to CT. This survey helps radiologists around the world communicate the imaging needs in stroke in their respective countries and how can they be met. This can help radiologists who want to reach out in their humanitarian efforts to improve imaging around the world. Global outreach programs can use this survey to determine more effective ways of improving stroke imaging and care in developing countries. VSNR41-11 The Prediction of Prognosis Using ADC Volume in Endovascular Revascularization Therapy for Acute Ischemic Stroke

189 Miran Han MD (Presenter): Nothing to Disclose, Jin Wook Choi MD : Nothing to Disclose, Sun Yong Kim MD : Nothing to Disclose, Jin Soo Lee : Nothing to Disclose, Young Keun Sur MD : Nothing to Disclose, Seon Young Park MD : Nothing to Disclose The recent shift of endovascular treatment (ET) methods for acute ischemic stroke towards better outcome. We hypothesized that bigger core volume may be tolerable to further ET. This study was retrospectively designed to predict the prognosis using ADC volume in endovascular revascularization therapy for acute ischemic stroke. Patients with acute ischemic stroke in anterior circulation territory and intra-arterial (IA) revascularization therapy were retrieved. ADC volume taken before the IA therapy was calculated quantitatively with the margin thresholds of ADC value as 700x10-5 mm 2 /s. Futile prognosis was defined as modified Rankin Scale 5-6 at 3 months. We divided patients into 3 groups. Group 1 represented with ADC volume less than 50 cm 3, group 2 with 50 to 100 cm 3 and group 3 with more than 100 cm 3. Baseline characteristics (age, initial NIHSS score), imaging data (successful revascularization, TICI 2a-3) and clinical outcomes (good outcome, mrs 0-2 at 3months; poor outcome, mrs 5-6) were compared among groups. Logistic regression and Receiver Operating Characteristic (ROC) curve analyses were done. Finally, 76 patients were enrolled in this study. There is no difference of age and successful revascularization among the groups. Larger volume group show significantly high initial NIHSS score (p=0.027) and poor outcome (p < 0.001). ADC volume more than 100 cm3 was significantly associated with futile prognosis (p=0.001, Odds ratio, 25.4 [95%CI, ]). The area under the ROC curve for ADC volumes was (p=0.009). For predicting futile prognosis, sensitivity and specificity were 57.6% and 69.8% at ADC volume 50 cm3, 48.5% and 95.3% at 100 cm3 and 33.3% and 97.7% at 150 cm3, respectively. A huge DWI volume was associated with the futile prognosis. This imaging marker, however, could not be a single sign for stopping further aggressive IA treatment for acute ischemic stroke because the area under the ROC curve was relatively small. When IA therapy is considered, well known harmful factors including old age, high NIHSS score and huge ADC volume should be combined altogether for 'no more to go'. Recent progress of ET methods might be attributed to a tolerance of bigger ADC volume than previously recommended. VSNR41-12 Endovascular Treatment for Stroke: What do we do Now? M. Imran Chaudry MD (Presenter): Stockholder, Medina Medical Stockholder, Blockade Medical, Inc Proctor, Covidien AG Consultant, Penumbra, Inc Consultant, Johnson & Johnson Fellowship Funding, MicroVention Inc Fellowship Funding, Stryker Corporation 1) Assess the impact of recent stroke clinical trials. 2) Compare the outcomes with various thrombectomy devices. 3) Develop a simple systematic approach to thrombectomy. SSK15 Musculoskeletal (Interventional) Scientific Papers IR MK AMA PRA Category 1 Credits : 1.50 ARRT Category A+ Credits: 1.50 Wed, Dec 3 10:30 AM - 12:00 PM Location: E451A Moderator Martin Torriani MD : Nothing to Disclose Moderator Michael John Tuite MD : Nothing to Disclose Sub-Events SSK15-01 Comparing the Lateral Mortise Approach and the Anterior Approach to Fluoroscopically Guided Tibiotalar Joint Injections Ambrose J. Huang MD (Presenter): Nothing to Disclose, Connie Y. Chang MD : Nothing to Disclose,

190 Frank J. Simeone MD : Nothing to Disclose, Martin Torriani MD : Nothing to Disclose, Miriam Antoinette Bredella MD : Nothing to Disclose, Susan V. Kattapuram MD : Nothing to Disclose, William E. Palmer MD : Nothing to Disclose To compare the newer lateral mortise and more traditional anterior approaches to fluoroscopically guided tibiotalar joint steroid injections with respect to fluoroscopy time and radiation dose. For this IRB-approved, HIPAA-compliant, retrospective study, the study population consisted of all patients referred to the MSK Division for fluoroscopically guided tibiotalar joint steroid injections from 11/1/ /31/2013. Images were reviewed on a PACS workstation to determine the injection approach (lateral mortise vs anterior) and to confirm intra-articular adminstration of injectate. Fluoroscopy time (minutes), radiation dose (mgy), and dose area product (ugy-m^2) were recorded. Their means and standard deviations were calculated and compared using student t-tests. P < 0.05 was considered statistically significant. 246 patients underwent the lateral mortise approach, and 252 underwent the anterior approach. 4 patients were excluded from the lateral mortise group because a) no contrast was administered due to the patient's contrast allergy (n=2), b) injectate was mostly extra-articular (n=1), or the joint could not be accessed due to severe osteoarthritis (n=1). Mean fluoroscopy time was 0.7±0.5 minutes n the lateral mortise group and 1.2±0.8 minutes in the anterior group (P<0.0001). Mean radiation dose was 2.1±3.7 mgy in the lateral mortise group and 2.5 ± 3.5 mgy in the anterior group (P=0.2400). Mean dose area product was 11.5±15.3 μgy-m2 in the lateral mortise group and 13.5 ± 17.3 μgy-m2 in the anterior group (P=0.1739). The lateral mortise approach for fluoroscopically guided tibiotalar joint injection requires statistically significantly less fluoroscopy time than the anterior approach (approximately 40% less). Radiation dose and dose area product were also on average less for the lateral mortise approach than the anterior approach, though these did not reach statistical significance. Both the lateral mortise and the anterior approaches are effective methods of performing fluoroscopically guided tibiotalar joint injections. Knowledge of both techniques increases the likelihood of success when performing these injections, since one approach or another may be superior for a particular patient. The lateral mortise approach requires approximately 40% less fluoroscopy time and is technically easier to perform and to teach compared to the anterior approach. SSK15-02 Prospective Randomized Comparative Trial between Standard and Augmented Vertebroplasty in Extreme Vertebral Fractures (Split or Incomplete Burst Fractures and Large Osteonecrotic Cavities) Dimitrios Filippiadis MD, PhD (Presenter): Nothing to Disclose, Georgios Velonakis MD : Nothing to Disclose, Argyro Mazioti MD : Nothing to Disclose, Elias Brountzos MD : Nothing to Disclose, Nikolaos L. Kelekis MD : Nothing to Disclose, Alexios Kelekis MD, PhD : Consultant, Benvenue Medical, Inc To compare safety, efficacy and long term stability between standard and augmented vertebroplasty in patients with symptomatic extreme vertebral fractures (split or incomplete burst vertebral fractures or large osteonecrotic vertebral cavities). During the last 36 months, we prospectively studied and compared 2 groups (12 patients each) suffering from painful extreme vertebral fractures. Group A underwent standard vertebroplasty. Group B underwent augmented vertebroplasty with implantation of biocompatible peek cage (KIVA implant). Standard x rays and CT scans were performed during follow-up. Pain prior, the morning after and at the last follow-up (average follow-up 12 months) were compared by means of numeric visual scale (NVS) questionnaire. Cement or implant migration were recorded. Statistical analysis was performed with Chi-Square Tests, Related Samples Wilcoxon Signed Rank Tests and Tests of within Subjects Effects. In Group A, there was progress of the vertebral body damage (including widening of the fracture line or PMMA migration and subsequent vertebral fracture) in 3/12 patients (25%) with 2/12 being surgically operated (16.7%). In Group B there was no implant change or migration observed. No symptomatic or clinically significant extravasations occurred in both Groups. Group A presented a mean pain value of 9.00±1.04 prior and 2.33±3.74 NVS units post treatment, with a mean decrease of 6.67±1.49 NVS units (p=0.005). Group B presented a mean pain value of 8.66±1.07 prior and 1.33±1.55 NVS units post treatment, with a mean decrease of 7.33±1.49 NVS units (p=0.002). Pain reduction difference between the two Groups was not statistically significant (p=0.545). PMMA versus implant migration in the two groups was marginally insignificant in the statistic analysis (p=0.064). Overall mobility improved in 10/12 patients in Group A and 12/12 patients in Group B. Both standard and augmented vertebroplasty seem to be effective concerning pain reduction in patients with split or incomplete burst vertebral fractures or large osteonecrotic vertebral cavities. Preliminary results show

191 potential tendency for widening of fracture line or PMMA migration and subsequent vertebral fracture in the vertebroplasty Group. In augmented vertebroplasty, the implant seems to function as internal cast providing mechanical and structural support and height restoration. SSK15-03 Percutaneous Laser Disc Decompression: Clinical Outcome and MR Evaluation Venkatesh Hosur Ananthashayana MD (Presenter): Nothing to Disclose, Deepnarayan Srivastava : Nothing to Disclose, Sanjay Sharma MD : Nothing to Disclose, Sanjay Thulkar : Nothing to Disclose, R MALHOTRA : Nothing to Disclose, Vijay Kumar : Nothing to Disclose 1. To evaluate the role of image guided Percutaneous Laser Disc Decompression in patients with low back pain due to disc herniation. 2. Role of magnetic resonance imaging in the evaluation of pre and post procedural morphology of the intervertebral disc and to determine a possible mechanism of action of the procedure in relief of symptoms. We performed a prospective, single centre study of 32 patients who underwent Percutaneous Laser Disc Decompression for chronic discogenic low back pain. Patients with contained lumbar disc herniation on MRI who did not respond to 6 weeks of conservative treatment were included. All procedures were performed under fluoroscopic guidance using a Flat panel DSA unit with 3D rotational X-ray imaging facility along with 980nm Diode laser system and 360µm PLDD laser fibre. Follow-up clinical outcomes were assessed by modified MacNab criteria at 1, 3 and 6 month. We prospectively reviewed the pre and postoperative MR images of all the patients. According to modified MacNab criteria, excellent to fair response was seen in 18 out of 32 patients with overall success rate of 56%. In a group of patients with disc herniation smaller than 1/3 of the spinal canal diameter (20/32), success rate was 65% and another group of patients with disc herniation more than 1/3 of the spinal canal diameter (12/32), success rate was 35%. Only 2 of the 18 patients who had a successful result had a reduction in the size of the herniated segment. Subchondral marrow changes were identified in 8 of 32 Percutaneous Laser Disc Decompression patients. Preoperative imaging studies and selection of patients with disc herniation smaller than 1/3 of the spinal canal diameter predict the clinical outcome of Percutaneous Laser Disc Decompression. Postprocedural subchondral marrow changes were not associated with inflammation of the adjacent disc space and did not affect surgical outcome. Lack of morphological changes in the disc indicates that a chemical or humoral change rather than a mechanical change accounts for the success of the Percutaneous Laser Disc Decompression. Percutaneous Laser Disc Decompression (PLDD), a valid alternative for those selected patients with contained lumbar disc herniation, who do not respond to conservative treatment, avoiding in many cases need for surgery. SSK15-04 Balloon-assisted Osteoplasty of Periacetabular Tumors Following Percutaneous Cryoablation Anil Nicholas Kurup MD (Presenter): Nothing to Disclose, Jonathan Michael Morris MD : Nothing to Disclose, Thomas Duncan Atwell MD : Nothing to Disclose, Grant D. Schmit MD : Nothing to Disclose, Peter Rose MD : Nothing to Disclose, Matthew Raymond Callstrom MD, PhD : Research Grant, Thermedical, Inc Research Grant, General Electric Company Research Grant, Siemens AG Research Grant, Galil Medical Ltd Percutaneous osteoplasty has been described as a method to alleviate pain and to provide structural support for osteolytic tumors at risk of fracture. However, cement extravasation outside the bone may occur with severe bony erosion or destruction, We describe a new technique using kyphoplasty balloons to promote targeted delivery of cement into the pathologic lesion. After IRB approval, the radiology departmental ablation database was searched for cases of combined cryoablation and balloon-assisted osteoplasty performed to treat tumors in the periacetabular region between March 2013 and February Procedures were performed under general anesthesia with CT guidance and neurophysiologic monitoring. Balloon-assisted osteoplasty was performed in the same session as or the day following cryoablation. One or more 20-mm kyphoplasty balloons were inflated in the ablation defect prior to cement instillation. Cement was then injected in typical fashion under CT-fluoroscopic guidance. Images were reviewed for cement leakage outside of the tumor cavity.

192 14 combined procedures were performed in 14 patients (9M:5F) with median age of 66 years (range, 43-81). 7 cases were performed primarily for palliation of pain, while 7 were performed solely for risk of impending fracture. 10 (71%) patients had metastases treated, and 4 (39%) had primary bone tumors (myeloma, fibrous dysplasia). Periacetabular tumors were located superiorly in 5, posterosuperiorly in 3, posteriorly in 1, anteriorly in 3, and anteromedially in 2 patients. Median tumor size was 4.0 cm (range, ), and median estimated tumor volume was 24 ml (range, 9-148). Mean number of balloons used was 2 (range, 1-4). Median cement volume instilled in the ablation cavities was 14 ml (range, 8-35 ml). Median percentage tumor fill was 59% (range, 24-96%). Minimal extravasation (less than 1 ml) was identified in 4 cases. Balloon-assisted periacetabular osteoplasty following percutaneous cryoablation is feasible, may minimize the risk of cement extravasation, and may improve the degree of filling of the osteolytic defect. Osteolytic tumors in the periacetabular region are frequently painful and at risk of fracture. Use of kyphoplasty balloons to create space for cement filling following cryoablation may minimize the risks of this procedure and allow safe consolidation of these challenging tumors. SSK15-05 Palliative Treatment of Painful Bone Metastases with MR Imaging guided Focused Ultrasound Surgery: A Two-centre Study Alessandro Napoli MD (Presenter): Nothing to Disclose, Alberto Bazzocchi MD : Nothing to Disclose, giulia brachetti : Nothing to Disclose, Gaia Cartocci MD : Nothing to Disclose, Paolo Spinnato MD : Nothing to Disclose, Ugo Albisinni MD : Nothing to Disclose To evaluate the efficacy of non-invasive high intensity MR guided focused Ultrasound Surgery (MRgFUS) for pain palliation of bone metastasis in patients who had exhausted EBRT or refused other therapeutic options. this prospective, single arm, two-centre study received IRB approval. 72 patients (female: 24, male: 48, mean age: 61.6) with painful bone metastases were enrolled. 87 non-spinal lesions underwent MRgFUS treatment using ExAblate 2100 system (InSightec). European Organization for Research and Treatment of Cancer QLQ- BM22 was used for clinical assessment additionally to Visual Analog Scale (VAS), at baseline and 1,3 and 6 months after treatment. All patients underwent CT and MRI before treatment and 3-6 months afterward. No treatment-related adverse events were recorded. 34/72 (47.2%) patients reported complete response to treatment and discontinued medications. 29/72 (40.3%) experienced a pain score reduction >2 points, consistent with partial response. Remaining 9 (12.5%) patients had recurrence after treatment. Statistically significant differences between baseline (6, 95%CI 5-8) and follow-up (2, 95%CI 0-3) VAS values and medication intake were observed (p<0.05). Similarly a significant difference was found for QLQ- BM22 between baseline and follow-up (p<0.05). MRgFUS can be safely and effectively be adopted for treatment of painful bone metastases. MRgFUS can be safely and effectively used as totally noninvasive treatment for pain palliation of bone metastasis in patients who had exhausted EBRT and also in patients not previously treated with EBRT. SSK15-06 MRI, CT, Na18F-PET, and Histopathological Monitoring of Bone Remodeling Following MR-guided High-intensity Focused Ultrasound Matthew Dwayne Bucknor MD (Presenter): Nothing to Disclose, Viola Rieke PhD : Nothing to Disclose, Youngho Seo PhD : Research Consultant, sanofi-aventis Group, Andrew Horvai : Nothing to Disclose, Loi Do : Nothing to Disclose, Randall A. Hawkins MD, PhD : Nothing to Disclose, Sharmila Majumdar PhD : Research Grant, Merck & Co, Inc, Thomas M. Link MD, PhD : Research funded, General Electric Company Research funded, InSightec Ltd, Maythem Saeed DVM, PhD : Nothing to Disclose To monitor bone remodeling following MR guided high-intensity focused ultrasound (MRgHIFU) of the normal swine femur with MRI, CT, Na18F-PET and histopathology, as a function of sonication energy. Experimental procedures received approval from the local institutional animal care and use committee. MRgHIFU ablations were created in the distal and proximal right femur of eight pigs. Energy dosed distally was

193 higher (419±19 J) than the proximal target (324±17 J). Imaging was obtained before and after ablation using MRI (3T) and CT (64-slice). Animals were evaluated again at 3 and 6 weeks on MRI (n=8), CT (n=8), Na18F-PET (n=4) and histopathology (n=4). Ablation dimensions were measured on contrast enhanced MRI and cortical bone remodeling was measured on CT images. MRI bone ablation sizes at 3 and 6 weeks following MRgHIFU were similar between distal (high energy) and proximal (low energy) lesions (average 8.7 x 21.9 x 16.4 mm). However, distal (high energy) ablations (n=8/8) demonstrated evidence of subperiosteal new bone formation on CT, with a subtle focus of new bone at 3 weeks and a larger ossification at 6 weeks. These morphologic changes were associated with increased uptake on Na18F-PET in 3/4 animals and confirmed by histopathology in 4/4. In contrast, proximal (low energy) ablations (8/8) demonstrated endosteal fat necrosis and subcortical osteonecrosis, but did not show evidence of new bone formation. MRgHIFU ablation of bone can result in progressive remodeling with both subcortical necrosis and subperiosteal new bone formation. The exact pattern may be related to the energy dose used. MRI, CT and PET are suitable noninvasive techniques to monitor bone remodeling following MRgHIFU. Specific parameter changes during MRgHIFU of bone could potentially be used to change the pattern of chronic remodeling after treatment. Higher energies might be preferable to stimulate new bone growth, for example, when treating a lytic bone metastasis, while relatively lower energies might be preferable for treatment of benign conditions. SSK15-07 Manual Needle Versus Powered Drill for CT- Guided Bone Marrow Aspiration and Biopsy: A Comparison of Diagnostic Utility Sonali Lala MD (Presenter): Nothing to Disclose, Netanel Berko MD : Nothing to Disclose, Karen Ellen Sperling MD : Nothing to Disclose, Alan H. Schoenfeld MS : Nothing to Disclose, Esperanza Villanueva-Siles MD : Nothing to Disclose, Nogah Haramati MD : Investor, Kryon Systems Ltd Investor, OrthoSpace Ltd Investor, BioProtect Ltd Board Member, Kryon Systems Ltd Board Member, OrthoSpace Ltd Board Member, BioProtect Ltd Consultant, AFC Industries, Inc Advisory Board, General Electric Company, Beverly A. Thornhill MD : Nothing to Disclose, Shlomit Goldberg-Stein MD : Research Consultant, Intrinsic Therapeutics Inc CT-guided bone marrow biopsy and aspiration is conventionally performed using a manual needle, requiring physical pressure and rotation. We report our experience using a novel battery-powered rotatory bone drill in comparison with our prior use of a manual needle. After IRB approval, 20 CT-guided bone marrow aspiration and biopsy procedures were retrospectively reviewed. Ten were performed with a 13 Gauge manual needle and ten were performed with an 11 Gauge battery-powered bone drill. Patient demographics, procedure time, number of CT scans, and core sample size were recorded. Estimated radiation dose was calculated for each procedure by a physicist blinded to needle type. A blinded pathologist reviewed pathology reports and rated core samples as diagnostic/optimal, diagnostic/suboptimal, or non-diagnostic in consideration of overall quality and crush artifact. Median values and interquartile ranges (25th and 75th percentile) were calculated. Statistical analysis was performed using Fisher's Exact test and Mann-Whitney U Test. No evidence for significant difference was found between the manual needle and drill groups with respect to patient age, gender, procedure time, number of scans, or estimated radiation dose. Estimated radiation dose (total DLP in mgy-cm) was (430.18, ) for the manual group and (306.39, ) for the drill group. Four of 10 manual group cores (40%) were of diagnostic/optimal quality, compared to 10/10 drill group cores (100%, p= 0.01). There were significantly more diagnostic/suboptimal (n=4) or non-diagnostic (n=2) cores in the manual group (6/10) compared to the drill group (0/10, p= 0.01). Median core length was 0.7 cm (0.38, 0.95) for manual group and 1.4 cm (1.30, 1.65) for drill group. Drill group cores were significantly longer than manual group cores (p<0.03). Use of a battery-powered drill for CT-guided bone marrow biopsy provided significantly longer core biopsy samples (p<0.03) and significantly more optimal quality core samples (p=0.01) when compared to use of a manual needle, without increasing procedure time or radiation dose. Bone marrow biopsy cores obtained using a powered drill are significantly longer and more often of optimal quality, when compared to cores obtained using a manual needle approach. This is the first report of outcomes using a drill for CT-guided bone marrow biopsy and aspiration. SSK15-08 CT Guided Dual Site Nerve Infiltration for Chronic Refractory Pudendal Nerve Neuralgia: Results of a Single Center in 79 Patients and 129 Procedures

194 Adrian Imre Kastler MD, MSc : Nothing to Disclose, Bruno Alfred Kastler MD, PhD (Presenter): Nothing to Disclose To assess the outcome of patients with typical refractory pudendal neuralgia who underwent dual site CT guided pudendal nerve infiltration. Between 1995 and 2014, 302 pudendal infiltrations were performed in 167 patients in our Unit. Only patients suffering from typical clinical pudendal neuralgia were included and only the first infiltration in each patient was considered for analysis. Therefore, 79 patients who underwent 129 procedures were assessed. Pain was assessed using Visual Analogue Scale scores (0-10) and self reported estimated improvement, expressed as a percentage. Efficacy of procedure was assessed at 1 month follow up and was defined as a 50% decrease of VAS score. Minimum follow up period was 6 months. All procedures were performed under CT Guidance and on an outpatient basis. Dual site infiltration was performed in each case at both ischial spine and Alcock's canal sites using a mixture of fast and slow acting anesthetic (1 ml lidoca ne hydrochloride 1% and 2 ml ropivaca ne chlorhydrate) along with a half dose of 1.5 ml of cortivazol (3.75 mg). Our cohort consisted of 79 patients (53 females (67,1%) 26 males (32.9%)) with a mean age of 53 years old (range 24-86). Mean pain prior procedure was 7.25/10. Patients suffered from bilateral pain in 50 cases and unilateral pain in 29 cases. Technical success of procedure was 100%. Mean procedure time was minutes in case of unilateral infiltration and minutes in cases of bilateral infiltration. Clinical success as defined at 1 month was 63 % of all performed procedures. Mean efficacy following procedure in cases of positive response was 3.3 months (ranging from 1 to 48 months). Mean self reported 1 month estimated improvement was 70% in patients with a positive response. CT guided dual site infiltration of the pudendal nerve is an effective treatment in patients suffering from chronic pudendal neuralgia. Pudendal neuralgia is a debilitating condition with a high socio-economic impact. Treatments for this condition are sparse and pudendal neuralgia may become refractory. CT guided dual site infiltration presents satisfactory mid term results alleviating pain in these patients suffering from intractabe pain SSK15-09 Sacral Radiofrequency Neurolysis (RF) for the Management of Sacroiliac Joint-related Pain: A Comparison of 3 Techniques Andrew Michael Pagano MS, BA : Nothing to Disclose, A. Orlando Ortiz MD, MBA (Presenter): Nothing to Disclose, Stanley Golovac MD : Nothing to Disclose To compare the utility, efficacy, and safety of 3 different sacral denervation techniques in the management of sacroiliac joint (SIJ) pain that is refractory to conservative medical management. 94 patients underwent radiofrequency (RF) neurolysis for the treatment of SIJ pain over a 56-month period. 8 patients were treated with cooled RF. 20 patients underwent bipolar RF. And 70 patients underwent multi-lesion RF (47 were treated at a second institution). Eligible patients suffered at least 7/10 SIJ pain, were on analgesic therapy, and had a favorable, but temporary response to SIJ injections. Clinical presentation, procedure time, fluoroscopy time, anesthesia, complications, pre- and post- pain scores, and analgesic requirements were recorded. Patients were followed up at 3 week, 3 month, and 1 year intervals. In cooled RF patients, the mean pre-procedure pain score was 8.9, and all experienced complete long-term resolution of SIJ pain. The average procedure time was 2.5 hours and the average fluoroscopy time was 10 minutes. For patients who had received bipolar RF, The mean pre-procedure pain score was 9.1. Post-procedure, all but 1 patient experienced complete resolution of SIJ pain. The average procedure time was 1.5 hours and average fluoroscopy time was 6 minutes. In multi-lesion RF patients, the mean pre-procedure pain score was 8.9 at the primary institution. All patients experienced complete resolution of their SIJ pain. Patients at the second institution experienced similar, dramatic outcomes. The average procedure time was 30 minutes and the average fluoroscopy time was 1.5 minutes. All sacral RF procedures were effective in providing pain relief with a reasonable safety profile in properly selected patients. The sacral multi-rf procedure, however, was more efficient with the shortest average procedure time and the shortest average fluoroscopy time.

195 Among all causes of lower back pain for patients of any age, SIJ pain represents a major contributor. The goals of treatment for SIJ pain include long-term efficacy, safety, reproducibility, and efficiency. Radiofrequency neurolysis provides a procedure that is minimally invasive with excellent patient outcomes. The three RF techniques examined in this study represent different levels of technical complexity and analogous differences in procedure time and fluoroscopy time. SSK24 Vascular/Interventional (IR: Liver Ablation) Scientific Papers IR GI AMA PRA Category 1 Credits : 1.50 ARRT Category A+ Credits: 1.50 Wed, Dec 3 10:30 AM - 12:00 PM Location: N227AB Moderator Kenneth J. Kolbeck MD, PhD : Nothing to Disclose Moderator Debra Ann Gervais MD : Research Grant, Covidien AG Sub-Events SSK24-01 Hepatocellular Carcinoma (HCC) Invading Portal Venous System in Cirrhosis: 7 Years Results of Percutaneous Radiofrequency Ablation of HCC and Main Portal Vein Tumor Thrombus (MPVTT) Antonio Giorgio (Presenter): Nothing to Disclose, Giorgio Calisti : Nothing to Disclose, Carmine Coppola : Nothing to Disclose, Ferdinando Scarano : Nothing to Disclose, Umberto Scognamiglio : Nothing to Disclose, Luca Montesarchio : Nothing to Disclose, Piero Gatti : Nothing to Disclose, Paolo Matteucci : Nothing to Disclose, Valentina Giorgio : Nothing to Disclose To report 7 years results on radiofrequency ablation (RFA) of single hepatocellular carcinoma (HCC) and the accompanying main portal vein tumor thrombus (MPVTT) in patients with compensated liver cirrhosis. From January 2005 to January 2012, among 3144 consecutive cirrhosis patients, 772 had HCC and MPVTT; of these, 70 had a single HCC with MPVTT. 48 patients (38 men; mean age 69 years) with 48 HCC nodules cm in diameter- invading main portal trunk (MPT) underwent RFA. 22 matched patients (18 men; mean age 69 years) with 22 HCC nodules cm in diameter- extending into the MPT, refused RFA and composed the control group. Efficacy of RFA was defined complete when both complete necrosis of HCC and complete re-canalization of the MPT and its branches were achieved. 1, 3, 5 and 7-year cumulative survival rates of treated patients were 62, 29, 18 and 5%, respectively. The 12-months cumulative survival rate of un-treated patients was 0%. The difference was statistically significant (p < 0.001; hazard ratio 2.88; 95% CI ). The disease-free survival rates in treated group were 52, 38, 35 and 23% at 1, 3, 5 and 7 year, respectively. No death occurred. RFA of HCC and the accompanying MPVTT significantly prolongs long-term survival compared with no treatment. The procedure is safe and should be considered as a new and effective tool in the treatment of advanced HCC. RFA of HCC and the accompanying MPVTT in patients with compensated liver cirrhosis significantly prolongs long-term survival compared with no treatment. SSK24-02 Radiofrequency Ablation versus Non-anatomical Resection: Propensity Score Analyses of Long-term Outcome in 580 patients Tae Wook Kang : Nothing to Disclose, Hyunchul Rhim MD, PhD : Nothing to Disclose, Seong-Yoon Ryu MD (Presenter): Nothing to Disclose, Min Woo Lee : Nothing to Disclose, Hyo Keun Lim MD : Nothing to Disclose, Young-Sun Kim : Nothing to Disclose

196 To compare the long-term therapeutic outcomes of radiofrequency ablation (RFA) with non-anatomical resection (NAR) in patients with a small hepatocellular carcinoma (HCC) 3cm as a first-line treatment. The data of 580 patients with a small HCC ( 3cm) underwent ultrasonography-guided percutaneous RFA (n=438) or NAR (n=142) as a first-line treatment, were reviewed. For comparison of therapeutic efficacy between RFA and NAR groups, local tumor progression (LTP), intrahepatic distant recurrence (IDR), disease-free survival (DFS) and overall survival (OS) rates were analyzed using a 1-to-1 propensity score match. In addition, major complications and post-operative hospital stay were compared. Before propensity score matching (n=580), 5-year cumulative LTP (20.9% vs. 12.7%, p = 0.093) and OS rates (85.5% vs. 90.9%, p = 0.194) were comparable between two groups while 5-year cumulative IDR (62.7% vs. 36.6%, p < 0.001) and DFS rates (31.7% vs. 61.1%, p < 0.001) in NAR group were significantly better than that in RFA group. After the matching (n=198), there were no significant differences in terms of all therapeutic outcomes including 5-year cumulative IDR (47.0% vs. 40.2%, p = 0.240) and DFS rates (48.9% vs. 54.4%, p = 0.201) in both groups. RFA was superior to NAR in terms of major complication rate (5.6% vs. 2.1%, p = 0.016) and post-operative hospital stay (p < 0.001). In patient with a small HCC ( 3cm) as a first-line treatment, there was no significant difference in LTP, IDR, DFS and OS between RFA and NAR. However, RFA yielded less invasiveness than NAR. There was no significant difference between RFA and NAR in terms of long-term therapeutic outcomes including Local Tumor Progression, Intrahepatic Distant Recurrence, Disease Free Survival, and Overall Survival in patients with a small HCC 3cm (BCLC very early/early-stage HCC) as a first-line treatment. SSK24-03 Microwave Thermoablation of Hepatic Tumors Using a Semi-automatic Robotic Guidance Approach Jijo Paul MSc, PhD (Presenter): Nothing to Disclose, Emmanuel Chukwudum Mbalisike MD : Nothing to Disclose, Martin Beeres MD : Nothing to Disclose, Katrin Eichler MD : Nothing to Disclose, Thomas Josef Vogl MD, PhD : Nothing to Disclose, Stefan Zangos MD : Nothing to Disclose To evaluate robotic guidance and manual approaches during microwave thermal ablation based on real-time planning, intra-procedural guidance, procedural accuracy as well as patient dose. The study was prospectively performed between June 2013 and Feburary 2014 using 70 patients. 40 patients were treated with manual approach and the remaining 30 were treated with a semi-automatic robotic guidedapproach. Parameters evaulated were accuracy (number of readjustment, applicator active point deviation, applicator active point final position after readjustment), total procedural time (planning time, insertion time, ablation time), quantitative/qualitative image quality and patient dose (). Wilcoxon s matched paired test and two sided student s t-test were used to test the significance of the data and p-values < 0.05 was considered to be of statistical significance. Accuracy parameters was significantly higher in group 2 (all p<0.05) than group 1. Total procedural time showed mean time difference of 3 mins (group 2> group 1). Volume CT dose-index, and dose-length-product were significantly lower for group 2 compared to group 1 (all p<0.05) for CT fluoroscopy imaging. Total procedural performance score was higher for group 2 compared to group 1 (p=0.0001). Image quality parameters were insignificant between examined groups. Using the semi-automatic robotic guided approach improved accuracy of targeting the target tumor, reduce patient dose and increase procedural performance (which influences the procedural safety) is achieved during ablation. The robotic guided approach improved accuracy of targeting the target tumor SSK24-04 Radiofrequency Ablation for the Treatment of Hepatocellular Carcinoma in Patients with Transjugular Intrahepatic Portosystemic Shunts Shota Yamamoto MD (Presenter): Nothing to Disclose, Jonathan Keon Park MD : Nothing to Disclose, Quazi Al-Tariq MD : Nothing to Disclose, Taryar Min Zaw MD : Nothing to Disclose, Steven Satish Raman MD : Consultant, Bayer AG Consultant, Covidien AG, David Shin-Kuo Lu MD : Consultant, Covidien AG Speaker, Covidien AG Consultant, Johnson & Johnson Research Grant, Johnson & Johnson Consultant, Bayer AG Research Grant, Bayer AG Speaker, Bayer AG

197 To assess radiofrequency (RF) ablation efficacy, as well as the patency of transjugular intrahepatic portosystemic shunts (TIPS), in patients undergoing RF ablation for hepatocellular carcinoma (HCC) Retrospective database review of patients with pre-existing TIPS undergoing RF ablation for HCC was conducted over a 147-month period. TIPS patency before and after RF ablation was assessed by US, angiography and/or contrast-enhanced CT or MRI. CT and/or MRI were performed within 1 day of RF ablation. Assessment of ablation efficacy was performed according to an updated image-guided tumor ablation consensus statement. 19 patients with 21 lesions undergoing 25 RF ablation sessions were included. Child-Pugh class A, B, and C scores were seen in 1, 13, and 5 patients. 11 patients ultimately underwent liver transplantation. All lesions (100%) demonstrated imaging evidence of HCC. All ablation sessions showed immediate technical success without residual tumor enhancement (100%). No patients (0%) suffered liver failure within 1 month of ablation. For 21 total ablated lesions, primary technical efficacy rate was 15/21 (71.4%). Local progression was seen in the 6 other lesions (28.6%); however, only 3/21 (14.6%) lesions demonstrated local progression without successful retreatment and/or transplant. Furthermore, only 2/6 of lesions demonstrating local progression (33%) were located within 1 cm of TIPS stent-graft. 1, 2, and 3-year survival for patients not undergoing transplantation (8/19, 42%) was 100%, 80%, and 67%. Pre-ablation TIPS patency was demonstrated in 22/25 sessions (88%). In 7 cases, lesions ablated were within 1 cm of the TIPS. Of 22 cases with patent TIPS prior to ablation, post-ablation patency was demonstrated in 22/22 (100%) on immediate post-ablation imaging and in 21/22 (95%) at last follow-up. No immediate complications following RF ablation were observed. Ablation efficacy did not differ significantly from cited literature values for patients without TIPS. Furthermore, TIPS patency was preserved in the majority of cases. Patients with both portal hypertension and HCC are not uncommonly encountered, and a pre-existing TIPS does not appear to be a definite contraindication for RF ablation. RF ablation for HCC in patients with TIPS can be performed with similar efficacy to standard patients while preserving TIPS patency. SSK24-05 Microwave versus Radiofrequency Ablation for the Treatment of HCC: A Comparison of Efficacy and Safety at a Single Center Theodora Anne Potretzke MD (Presenter): Nothing to Disclose, Timothy J. Ziemlewicz MD : Nothing to Disclose, J. Louis Hinshaw MD : Stockholder, NeuWave Medical Inc Medical Advisory Board, NeuWave Medical Inc Stockholder, Cellectar Biosciences, Inc, Meghan G. Lubner MD : Nothing to Disclose, Douglas Robert Kitchin MD : Nothing to Disclose, Christopher L. Brace PhD : Shareholder, NeuWave Medical Inc Consultant, NeuWave Medical Inc, Parul Agarwal : Nothing to Disclose, Fred T. Lee MD : Stockholder, NeuWave Medical, Inc Patent holder, NeuWave Medical, Inc Board of Directors, NeuWave Medical, Inc Patent holder, Covidien AG Inventor, Covidien AG Royalties, Covidien AG To compare the safety and efficacy of radiofrequency (RF) ablation to high-powered gas-cooled microwave (MW) ablation for the treatment of hepatocellular carcinoma (HCC) at a single center. This IRB-approved retrospective review included 68 tumors in 53 patients treated by RF (12/ /2011) and 135 tumors in 90 patients treated by MW (12/2010-3/2014). Treatments occurred at a single institution and were performed by the same group of operators. Patient demographics, tumor size, rate of local tumor progression (LTP), and procedure-related complications were compared between groups. Complications were recorded according to the Clavien-Dindo classification. Comparisons of proportions between groups were done using a Fischer's Exact Test with p<0.05 considered statistically significant. There was no significant difference in patient demographics or size of treated tumors. Mean tumor size was 2.2 cm in the RF group ( ) and 2.1 cm in the MW group ( ). The majority of treated tumors in both groups were < 3 cm (76.5% in RF group and 86.7% of MW group). Median follow up period was longer for the RF patients (31 months versus 13 months for the MW group). The overall rate of local tumor progression was statistically significantly higher for RF than for MW (17.6% versus 5.9%, p=0.012). The rate of LTP for tumors < 3 cm was greater for RF than MW (13.5 vs. 6% respectively) but this difference was not statistically significant (p=0.13). The rate of LTP for tumors 3 cm was also greater for RF than MW (31.3 vs. 5.6% respectively), but the difference was not statistically significant due to the small sample size (p=0.08). There were few serious ( grade III) complications in either group (2 RF - symptomatic small hemothorax requiring thoracentesis, intraperitoneal bleed requiring exploratory laparotomy; 1 MW - intra-procedural pneumothorax treated with pleural blood patch) (p=0.28). MW ablation of HCC offers a safe alternative to RF ablation with improved local tumor control at short term follow up.

198 Microwave ablation has theoretical heating profile advantages over RF ablation and this study demonstrates this may lead to improved local tumor control with treatment of hepatocellular carcinoma. SSK24-06 Single Center Experience with Hepatic Cryoablation: Safety and Efficacy Nael El Said Saad MBBCh : Research Consultant, Veran Medical Technologies, Inc Proctor, Sirtex Medical Ltd, Rebecca J. Mueller MD : Nothing to Disclose, Kathryn Jane Fowler MD : Research support, Bracco Group, Joseph Wilson Owen MD (Presenter): Nothing to Disclose Cryoablation may be used as a means of local tumor control in the liver. Little data is available on hepatic cryoablation. The purpose of our study was to evaluate the safety and outcomes of cryoablation for both primary and metastatic liver tumors in a high volume tertiary care center. Retrospective review of all hepatic cryoablation procedures from 10/2006-7/2013. Laboratory data, follow-up imaging, and clinical information were used to determine complications (SIR standards) and outcomes (RECIST). Percutaneous CT guided hepatic cryoablation was performed (1-8 probes based on tumor size and location). Two freeze cycles were performed in 62 of 66 procedures, remainder used three cycles. All patients were admitted overnight for monitoring. 54 patients underwent 66 ablations (4 cholangiocarcinoma, 1 sarcoma, 1 hemangioendothelioma (HEH), 14 HCC, 32 metastases). Average (range) tumor size was 2.3( ) cm. Follow up ranged (average) 0-45 (17) months. Local tumor progression was seen in 29 patients, the remainder had complete response. The average (median) time to local progression was 207 (148) days. Two patients were lost to follow up. The OS and DFS were not significantly different based on tumor type. 21 complications: 6 major (2 subcapsular hematoma requiring transfusion, 2 pseudoaneurysm requiring embolization, subcutaneous necrosis requiring surgical debridement, hypotension and bradycardia requiring atropine) and 15 minor were identified. Higher number of probes and increased probe:tumor size ratio were associated with cases of bleeding, however, the trend did not reach statistical significance (p 0.61 and p 0.78). Hepatic cryoablation can be achieve local tumor control and durable complete response in up to 43% of patients. Complications were seen in approximately 30% of cases with major complications in 9%. Further research is needed to determine the comparative efficacy and ideal role of hepatic cryoablation in the setting of different tumor types. Our study evaluates the safety and efficacy experience of hepatic cryoablation for liver tumors in a tertiary care center. SSK24-07 Liver Cryoablation: Safe Outcomes when Limiting Ablation Size per Session Peter John Littrup MD : Founder, CryoMedix, LLC Research Grant, Galil Medical Ltd Research Grant, Endo Health Solutions Inc Officer, Delphinus Medical Technologies, Inc, Hussein D. Aoun MD : Nothing to Disclose, Barbara A. Adam MSN : Nothing to Disclose, Evan N. Fletcher MS, BA : Nothing to Disclose, Brian Faustino Baigorri MD : Nothing to Disclose, Mohamed M. Jaber MD : Nothing to Disclose, Mark J. Krycia BS : Nothing to Disclose, Matthew Prus BS : Nothing to Disclose, Fatima Memon MD (Presenter): Nothing to Disclose To assess complication factors for liver cryoablation in relation to tumor/ablation volume and vessel proximity, in primary hepatocellular carcinoma (HCC) and metastatic tumors. Focus upon hematologic complications was also assessed for single vs. multiple tumors per procedure. CT and/or CT-US fluoroscopic-guided percutaneous cryoablations were performed in 292 procedures on 393 tumors (66 HCC and 327 metastatic carcinomas) in 186 patients. Tumor ablation zones were measured in 3 planes and location noted according to vessel proximity. There were 179 tumors that were targeted in the same procedure and outcomes noted separately. Complications were graded by the National Institutes of Health, Common Terminology of Complications and Adverse Events (CTCAE). Patients received CT or MRI at 1, 3, 6, 12, 18, 24 months and yearly thereafter. Results: All patients required only conscious sedation. Ablation zones and tumors averaged 5.2 and 2.9 cm, respectively. Grade >3 complications were associated with larger tumor size, for 21.5% (15/70) >4cm vs. 5% (11/222) 4cm for (p<.00001). Major types of complications included 12 hemoglobin (CTCAE 3), 13 platelet (2 grade 3, 8 grade 4, 3 grade 5), 1 ARDS (CTCAE 5), 4 pleural effusion (CTCAE 3), and 3 hematomas and 1 pneumothorax (CTCAE 3). In HCC patients with a pre-procedure platelet count <75,000/uL or Hb <10g/dL, major complications were significantly greater at 33% (4/12) vs. 2.4%(1/42) in patients with starting hematologic values above these levels (p<0.005). No significant difference in major complications was noted between single tumor ablation (9.0%, 20/221) compared to the multiple tumor ablation group (8.5%, 6/71; p>0.05) when controlling for total ablation volume. Re-grading according to Clavien-Dindo system lowered rate of major complications.

199 Major complication rate was significantly higher for larger tumors, but there was no significant difference based on location or treatment of multiple tumors when controlling for total ablation volume. HCC patients with low platelets and anemia should be avoided. Major complication rate was significantly higher for larger tumors, but there was no significant difference based on location or treatment of multiple tumors when controlling for total ablation volume. SSK24-08 Irreversible Electroporation (IRE) of Malignant Liver Tumors Close to Major Portal or Hepatic Veins: Is It Safe and Effective? Martina Distelmaier (Presenter): Nothing to Disclose, Alexandra Barabasch MD : Nothing to Disclose, Nils Andreas Kraemer : Nothing to Disclose, Christiane Katharina Kuhl MD : Nothing to Disclose, Philipp Bruners MD : Nothing to Disclose IRE has been proposed as a non-thermal ablation procedure that offers specific advantages over thermal methods, notably absence of heat sink effect, and to help avoid thermal damage to vessels or bile ducts. Our aim was to verify this concept by investigating the local efficacy and complications of CT-guided percutaneous IRE for hepatic malignancies located immediately adjacent to major portal and hepatic veins and bile ducts. 24 metastes in 19 patients (mean age 62 ± 12 y) suffering from liver tumors (9 colorectal, 4 breast, 1 hepatocellular, 1 renal cell, 1 GIST, 1 mesothelioma, 1 oesophageal) with a mean size 17 ± 10.5 mm, range 7-44 mm, underwent percutaneous hepatic IRE. All lesions were located immediately adjacent to major hepatic veins (n = 12), portal vein branches (n = 6) or both (n = 6) and therefore not suitable for RF ablation. Between 3 and 5 IRE probes with an active tip length of cm were placed strictly parallel under CT-guidance. IRE was performed with 70 pulses per probe pair, a pulse length of 75 µs and a maximum voltage of 3000 V. All patients undergo systematic follow-up CT and MR imaging; follow-up so far is up to 24 months. Complete ablation of the target lesion was achieved in 22/24 (92%) cases with a safety margin of 5-10 mm as confirmed by CT and MRI. In 24/24 cases, the adjacent major portal or hepatic vein branches remained perfused at long term follow up. No major procedure-related complications were observed. In 4/22 cases (18%), local recurrence adjacent to the ablation zone was observed between 1 and 12 months after treatment. In one patient, a small, clinically asymptomatic arterio-portal fistula developed on f/u that did not require treatment. One patient, with a metastasis located on the portal bifurcation developed mild left-sided cholestasis, not requiring treatment. In this small series, IRE for primary and secondary hepatic malignancies located adjacent to large portal or hepatic veins proved to be both, safe as well as efficient with regards to local control. CT-guided IRE appears to be a useful for percutaneous ablation of primary and secondary liver tumors that are not amenable to RFA. SSK24-09 Long-term and Progression-free Survival in Colorectal Cancer Liver Metastases after Thermal Ablation Using MR-guided Laser-induced Thermotherapy in 594 Patients: Analysis of Prognostic Factors Thomas Josef Vogl MD, PhD (Presenter): Nothing to Disclose, Alena Dommermuth BS : Nothing to Disclose, Britta Heinle : Nothing to Disclose, Nour-Eldin Abdelrehim Nour-Eldin MD, MSc : Nothing to Disclose, Thomas Lehnert MD : Nothing to Disclose, Stefan Zangos MD : Nothing to Disclose, Wolf-Otto Bechstein : Nothing to Disclose, Nagy Naguib Naeem Naguib MD, MSc : Nothing to Disclose To evaluate the prognostic factors for long-term survival and progression-free survival (PFS) after treatment of colorectal cancer (CRC) liver metastases with MR-guided laser-induced thermotherapy (LITT). We included 594 patients (mean age, 61.2 years) with CRC liver metastases who were treated with LITT. The statistical analysis of long-term survival and PFS were based on the Kaplan-Meier method. The Cox regression model tested different parameters that could be of prognostic value. The tested prognostic factors were the following: sex, age, location of primary tumor, number of metastases, maximum diameter and total volume of

200 metastases and necroses, quotient of total volumes of metastases and necroses, time of appearance of liver metastases and location in the liver, TNM classification of CRC, extrahepatic metastases, and neoadjuvant treatment. Median survival was 25 months starting from the date of the first LITT. The 1-, 2-, 3-, 4-, and 5-year PFS rates were 51.3%, 35.4%, 30.7%, 25.4%, and 22.3%, respectively. The number of metastases and their maximum diameter were the most important prognostic factors for both long-term survival and PFS. Long-term survival was also highly influenced by the initial involvement of the lymph nodes. For patients treated with LITT for CRC liver metastases, the number and size of metastases, together with the initial lymph node status, are significant prognostic factors for long-term survival. MR-guided LITT allows an excellent local control of liver metastases in colorectal cancer SSK25 Vascular/Interventional (IR: MR Angiography) Scientific Papers MR IR VA AMA PRA Category 1 Credits : 1.50 ARRT Category A+ Credits: 1.50 Wed, Dec 3 10:30 AM - 12:00 PM Location: E353A Moderator Thomas-Evangelos G. Vrachliotis MD, PhD : Nothing to Disclose Moderator James Christopher Carr MD : Research Grant, Astellas Group Research support, Siemens AG Speaker, Siemens AG Advisory Board, Guerbet SA Sub-Events SSK25-01 Magnetic Resonance Venography of Abdomen and Pelvis Using Albumin Binding Blood-pool Gadolinium Contrast Agent: Comparison with Standard Contrast Agent and Non-contrast Time of Flight and Gradient Echo Techniques Tariq Arshad Hameed MD (Presenter): Research Grant, Koninklijke Philips NV, Radya GamalEldin Osman MBBS, MD : Nothing to Disclose, Aashish A. Patel MD : Nothing to Disclose To assess if magnetic resonance (MR) imaging using albumin binding gadolinium based blood pool agent is superior to standard contrast agent or non-contrast techniques in the assessment of deep veins of the abdomens and pelvis. Retrospective review of MR venography of abdomen and pelvis with gadofosveset and equal number of consecutive cases utilizing gadobenate dimeglumine was performed. These examinations also included pre-contrast Axial 2-D Time of flight (ToF) and TrueFISP (True fast imaging with steady state free precession) techniques. Post contrast examination included time resolved multiphase coronal T1W examination to optimize timing for maximum enhancement of deep veins with subtraction and axial thin section T1 weighted post contrast images. Quantitative analysis was performed by measuring signal intensity in the IVC or iliac veins. Contrast to noise ratio (CNR) was calculated by obtaining signal intensity in muscle and standard deviation in air. Qualitative evaluation of image quality was performed by two radiologists on a 4 point Likert scale. Presence or absence of suspected low signal artifacts or thrombus was recorded. 24 MR examinations with Gadofosveset (15 females, 9 males, mean age 47 years) compared with 24 examinations with gadobenate meglumine (16 females, 8 males, mean age 50 years). ToF and TrueFISP sequences for all 48 examinations were compared. The CNR for TrueFISP (469) and ToF (313 ) was significantly higher compared to CNR of gadofosveset (90) as well as CNR of gadobenate meglumine (66.8) with P value < CNR of gadofosveset was higher compared to gadobenate (P 0.472). On qualitative evaluation mean score was 3. 5 for TrueFISP, 3.3 for ToF, 3.5 and 3.6 for gadofosveset on time-resolved non subtracted and subtraction images respectively compared with 2.7 and 3.7 for gadobenate meglumine. Low signal artifacts were noted in TrueFISP and ToF (Tof >TrueFISP). A combination of non contrast techniques provides diagnostic quality comparable to contrast enhanced studies.

201 Contrast enhanced examinations with blood pool agents provide better image quality compared to standard contrast agents. Diagnostic quality MR venography can be performed without intravenous contrast. Contrast enhanced examination may be obtained as problem solving in case of suspected artifacts or to evaluate for collateral flow pattern in case of occlusion. SSK25-02 Three-dimensional T1- and T2-weightet Turbo Spin-echo Technique: A Viable Alternative to Contrast-enhanced MRI for the Diagnosis of Deep Vein Thrombosis Karla Maria Treitl MD (Presenter): Nothing to Disclose, Marcus Treitl MD : Nothing to Disclose, Nora Navina Kammer MD : Nothing to Disclose, Eva Maria Coppenrath MD : Nothing to Disclose, Elena Suderland : Nothing to Disclose, Maximilian F. Reiser MD : Nothing to Disclose, Tobias Saam MD : Research Grant, Diamed Medizintechnik GmbH Research Grant, Bayer AG To evaluate the feasibility of a novel T1w three-dimensional (3D) isotropic-resolution turbo spin-echo (TSE) technique for the diagnosis of deep vein thrombosis (DVT) in comparison to contrast-enhanced magnetic resonance imaging (CE-MRI). Nine consecutive patients with proven DVT in compression duplex ultrasound (CDUS) and 2 patients with pulmonary embolism and suspicion for DVT (6 male, years) were imaged at 3.0 T using 0.75-mm isotropic-resolution TSE (3D) Volumetric ISotropic TSE Acquisition (VISTA) using standard body coils. Thrombus signal (SNRthrombus) and thrombus signal-to-noise-ratio (SNRthrombus), sensitivity (SE), specificity (SP), positive and negative predictive values (PPV, NPV), Cohen`s kappa (κ) and accuracy of VISTA-MRI were calculated using contrast-enhanced MRI (CE-MRI) as a standard of reference. Image quality and diagnostic confidence were assessed on a four-point scale. The image quality of CE-MRI was significantly better than VISTA-MRI (3.56 ± 0.55 vs ± 0.57, P<0.013); the diagnostic confidence level did not differ significantly (3.87 ± 0.37 vs ± 0.50; P=0.06). VISTA-MRI provided 26.8% and 17.3% improvement in Sthrombus and SNRthrombus. Using CE-MRI as gold standard, there was high agreement with 3D- VISTA images for the detection of DVT, with κ=0.99 for reader I and κ=0.97 for reader II (both P<0.001). This resulted in SE, SP, PPV, NPV and accuracy of 100.0%, 99.6%, 97.6%, 100,0% and 99.7% for reader I and 97.6%, 99.6%, 97.6%, 99.6% and 99.3% for reader II. Comparing CDUS and VISTA-MRI there was less agreement with κ=0.78 (P<0.001) and 81.0%, 95.4%, 87.9%, 92,2% and 91.1% for both readers after a spare time of 4,1 (0-10) days. 3D-T1w-VISTA-MRI is able to diagnose DVT with excellent agreement compared to CE-MRI and good agreement compared to CDUS and might be useful when use of contrast media is prohibited and in patients with suspected thrombosis of the iliac veins, which can be hard to detect in sonography. Black blood MRI using a high-resolution T1-weighted 3D-VISTA sequence allows the diagnosis of deep vein thrombosis. Black blood MRI allows the diagnosis of deep vein thrombosis without the application of contrast medium. Black blood MRI could be a valid alternative in pregnant patients, in patients with renal insufficiency or in patients / vessels, which cannot be examined with sufficient quality in duplex sonography. SSK25-04 MRI with a Weak Albumin Binding Contrast Agent has Additional Value for the Detection of Endoleaks in Patients with Enlarging Aneurysm after Endovascular Repair Jesse Habets MD (Presenter): Nothing to Disclose, Herman J.A. Zandvoort : Nothing to Disclose, Frans L. Moll MD, PhD : Nothing to Disclose, Lambertus W. Bartels PhD : Nothing to Disclose, Evert-Jan Vonken MD, PhD : Nothing to Disclose, Joost van Herwaarden MD, PhD : Research Consultant, Koninklijke Philips NV, Tim Leiner MD, PhD : Speakers Bureau, Koninklijke Philips NV Research Grant, Bayer AG Research Grant, Bracco Group The purpose of this study was to examine the additional diagnostic value of Magnetic Resonance Imaging (MRI) after administration of a weak albumin-binding contrast agent in post-evar patients with aneurysm growth. MR imaging was performed in all patients with AAA growth >=5 mm after EVAR and no or uncertain endoleak on CTA in the period between April 2011 and August All MRI scans were performed on a 1.5-T clinical MRI scanner after administration of the weak albumin-binding contrast agent gadobenate dimeglumine. The presence of endoleaks was assessed by visually comparing pre-contrast and post-contrast T1-weighted fat-saturated images. Post-contrast images were acquired 5 and 15 minutes after contrast administration. Endoleaks were observed in 25/29 patients (86%) on the post-contrast MRI images. Sixteen (55%) patients had a type II endoleak visualized by MRI and occult on delayed CT images. In 6/22 patients (27%, Figure 1), both MRI and delayed CT imaging revealed a type II endoleak. However, MRI had also complementary value in these

202 5/6 patients (83%) by visualizing more feeding lumbar arteries (n=3) (important for treatment purposes) and by improving the visualization of the extent of the endoleak (n=3). In one patient, MRI detected a type II endoleak originating from the inferior mesenteric artery (IMA) in addition to the type 2 endoleak from a lumbar artery also detected by CTA. Three (10%) patients had additional type III/IV endoleaks at the level of the aneurysm sac (n=1) and iliac legs (n=2). In patients with enlarging aneurysms of unknown origin after EVAR, MRI with a weak albumin binding contrast agent has additional diagnostic value for both the detection and determination of the origin of the endoleak. This can have important (interventional) treatment implications. Endoleak is a common complication in patients after endovascular treatment of an abdominal aortic aneurysm (EVAR). In patients with aneurysm growth, the detection of endoleaks can have important clinical implications. CT angiography including delayed phase imaging can fail to detect endoleaks in patients with aneurysm growth (endotension). MRI after administration of an albumin-binding contrast agent can detect additional endoleaks in these patients and can guide interventional treatment. SSK25-05 Non-contrast Quiescent Interval Single Shot Arterial Spin Labeled MRA: Feasibility for Pedal Artery Imaging in Diabetic Patients with Symptomatic Peripheral Arterial Disease Adrienne Lam MBBS (Presenter): Nothing to Disclose, Matthew William Lukies MBBS : Nothing to Disclose, Dinesh Gerard Ranatunga MBBS : Nothing to Disclose, Yuliya Perchyonok MBBS : Nothing to Disclose, Emma Hornsey : Nothing to Disclose, Brenden McColl : Nothing to Disclose, Jason Chuen : Nothing to Disclose, Pei-Heng Ko : Nothing to Disclose, Robert R. Edelman MD : Research support, Siemens AG Royalties, Siemens AG, Ruth P. Lim MBBS, MMed : Nothing to Disclose, Jason Heidrich : Nothing to Disclose To assess feasibility of non-contrast quiescent interval single shot arterial spin labeled MRA (QISS-ASL MRA) for pedal artery evaluation. 5 subjects, comprising 1 healthy (67y) volunteer and 4 diabetic patients (mean 81y) with symptomatic peripheral arterial disease (PAD) were prospectively recruited for bilateral foot QISS-ASL MRA at 1.5T. Imaging was performed using a head-coil with two consecutive QISS acquisitions: a) slice-selective saturation to suppress non-arterial signal, and b) non-selective saturation. Subsequently, subtraction of the two datasets (a-b) was performed. Total imaging time was approximately 8 minutes. Two radiologists independently analysed anonymized source and subtraction datasets for: image quality (IQ), 1=non-diagnostic, 3=sufficient for diagnosis, 5=excellent; and, presence of hemodynamically significant ( 50%) stenosis in defined arterial segments, including the dorsalis pedis and plantar arteries. Weighted kappa statistics were performed to evaluate inter-rater agreement for stenosis assessment. DSA correlation of stenosis assessment was performed where available. All subjects completed QISS-ASL MRA. 64 segments were identified in 10 feet. 60/64 segments and 53/64 segments were diagnostic for readers 1 and 2 respectively, with susceptibility artifact from orthopaedic hardware and image noise degrading image quality in the remainder. Mean IQ scores were 3.8±0.6 and 3.0±0.7 for readers 1 and 2 respectively. Inter-rater agreement for hemodynamically significant stenosis was DSA was available in 19 segments (n=2 patients) with 17/19 demonstrating hemodynamically significant stenosis at the reference standard. MRA concordance in identifying hemodynamically significant stenosis was 14/19 and 15/19 for readers 1 and 2 respectively. QISS-ASL MRA is feasible for visualisation of pedal segments in diabetic patients with severe PAD. It provides a potential alternative to contrast-enhanced techniques, which are challenging and carry associated risk in renal impairment. Further evaluation in a larger clinical population is required to assess accuracy and effectiveness of the technique. QISS-ASL MRA is a safe, feasible non-contrast alternative for analysis of distal bypass targets in diabetic patients with symptomatic peripheral arterial disease. SSK25-06 MR Imaging of Intraplaque Vasa Vasorum during Lipid-Lowering Therapy to Carotid Plaque with Thin Fibrous Caps: A Prospective Study in Chinese Patients Bao Cui (Presenter): Nothing to Disclose, Lu Ma : Nothing to Disclose, Ruixue Du : Nothing to Disclose, Xu Han : Nothing to Disclose, Ping Ye : Nothing to Disclose, Jianming Cai : Nothing to Disclose To evaluate whether the intensive lipid therapy could reduce the intraplaque vasa vasorum perfusion in the carotid plaque overlaid thin fibrous caps by the dynamic contrast-enhanced (DCE) MRI. Study Population: Between March 2009 and March 2012, the prospective study, Rosuvastatin Evaluation of

203 Atherosclerotic Chinese Patients (REACH Study, NCT ), recruited 32 subjects with advanced lesions( 3 mm thickness without >50% calcification), matched MRI scans and acceptable image quality. All subjects received rosuvastatin 5~20 mg/d to lower low-density lipoprotein cholesterol levels to < 80 mg/dl over the 24-month follow-up period. MR Imaging Protocol: Carotid standardized protocol and DCE-MRI were underwent at baseline and 3, 12, 24 months at a 3.0T MR scanner. DCE-MRI using double inversion recovery technique was performed on six selected axial slices chosen from T1W imaging set at 15 times separated by a repetition interval of 16 seconds. The acquisition of the forth time was coincident with the initiation of the intravenous injection of 0.2 mmol/kg gadolinium-based contrast agent at a rate of 2 ml/sec through a power injector. Data analysis: The analysis of intraplaque vasa vasorum perfusion was performed using the population arterial input function and Patlak model to calculate pharmacokinetic parameters Ktrans and Vp based on its temporal changes in intensity on the 3 mm thick slice. In total, 6 cases had thin fibrous caps without intraplaque hemorrhage. After 12 and 24 months of treatment, there was a obvious reduction was found in mean plaque Ktrans ( ± [standard deviation] to ± , ± ), no statistically significant trend between baseline and 3 months( ± ). The thinning of fibrous caps might be gradually thickening within the first one year after treatment. In conclusion, evaluation of effects of lipid-lowering therapy on atherosclerotic plaque with thinning fibrous caps should be focused on inflammatory activity rather than plaque burden. Intraplaque pharmacokinetic parameters of DCE-MRI has the most possibility to become the biomarker in vivo, noninvasively. Imaging markers of inflammation by the DCE-MRI may monitor the early response of the beneficial therapy to carotid plaque overlaid thin fibrous caps, in vivo. SSK25-07 Vessel Wall Changes in Patients with Systemic Lupus Erythematosus Compared to Controls: A Preliminary MR Imaging Study in Carotid Artery Wei Zhang (Presenter): Nothing to Disclose, Jie Sun : Nothing to Disclose, Bin Zhou : Nothing to Disclose, Jianrong Xu : Nothing to Disclose, Chun Yuan PhD : Research Grant, Koninklijke Philips NV Consultant, Bristol-Myers Squibb Company Consultant, Koninklijke Philips NV Patients with systemic lupus erythematosus (SLE) have markedly increased risk of cardiovascular events. In this preliminary study, we sought to use MR imaging to examine any abnormalities in fine structures of carotid vessel wall in patients with SLE by comparing them to age- and sex-matched controls. We evaluated bilateral carotid arteries of 43 SLE subjects and 18 controls, who were without documented cardiovascular disease, using a 3T scanner and carotid surface coils. Black-blood vessel wall imaging, including non-contrast T1-, T2- and proton-density-weighted sequences as well as a T1-weighted dynamic contrast-enhanced sequence (in 28 SLE subjects and 12 controls with contrast injection), was performed to detect: 1) any focal or diffuse wall thickening in the segment (3.2 cm) around carotid bifurcation;and 2) vessel wall enhancement in the common carotid artery. Per-slice measurements from control subjects were used to establish the 95% upper limits of maximum wall thickness and maximum-to-minimum wall thickness ratio for each of the three sub-segments(common carotid, carotid bulb, internal carotid),which were subsequently used as reference to define wall thicknening in all subjects. Percent wall enhancement at a given time point (180 seconds after contrast injection) was calulated using signal intensity measurements on post-and pre-contrast images. Any wall thickening (in common carotid,carotid bulb or internal carotid; in left or right carotid) defined using segment-specific thresholds of absolute wall thickness or wall thickness ratio was found in 18 (41.9%) subjects with SLE compared to 2 (11.1%) in the control group (p=0.02). In the subset of study sample with contrast injection,substantial wall enhancement was observed in subjects with SLE but not in controls (p=0.012). This represents one of the first attempts that use novel cardiovascular imaging approaches to understand the pathological basis of increased cardiovascular risk in patients with SLE. MR imaging,as a useful way in detecting early prematured atherosclerosis,can guide the therapy in clinic and improve survival in SLE patients. SSK25-08 Competing with the Gold-standard: Ultra-high-Resolution TOF MRA at 7T versus DSA for Assessment of Arteriovenous Malformations Lale Umutlu MD (Presenter): Consultant, Bayer AG, Karsten Wrede : Nothing to Disclose, Christoph

204 Moenninghoff MD : Nothing to Disclose, Philipp Dammann : Nothing to Disclose, Soren Johst : Nothing to Disclose, Michael Forsting MD : Nothing to Disclose, Marc U. Schlamann : Nothing to Disclose With digital subtraction angiography remaining to be the gold-standard, 1.5 Tesla TOF MRA is known to offer high-quality, non-invasive assessment of AVM. Nevertheless, 1.5 TOF MRA shows limitations due to its restricted spatial resolution. Hence, the aim of this trial was to compare the diagnostic competence of ultra-high-resolution 7 Tesla TOF MRA with digital subtraction angiography (DSA) for assessment of AVM. 17 patients with known AVM underwent pretreatment DSA and a 7T MR examination (Magnetom 7T, Siemens Healthcare) obtaining an ultra-high-resolution TOF MRA (voxel size of 0.2 x 0.2 x 0.2mm3). Two readers in consensus evaluated the delineation of the AVM regarding the (1) nidus, (2) feeder, (3) drainer, (4) relationship between AVM and the adjacent brain structures, (5) vessel-tissue contrast as well as (6) artifact impairment for both datasets using a 5-point scoring system. Wilcoxon rank test was applied for assessment of statistical significance. Both imaging modalities provided high-quality vessel delineation, showing comparably high ratings for the assessed features (DSA: mean nidus = 4.7; 7T: mean nidus = 4.6 // DSA: mean feeder vessel = 4.9; 7T mean feeder = 4.8). Furthermore, 7T TOF MRA allowed for high-quality assessment of the relationship between AVM and adjacent brain structures. Signal variations led to minor non-significant impairments of TOF MRA (mean 4.5). Based on high vessel-tissue contrast and high spatial resolution, 7T TOF MRA bears the potential to be an equivalent non-invasive alternative to DSA with the benefit of sparing ionizing radiation and the application of contrast agent. Furthermore, it offers additional diagnostics of the relationship between AVM and adjacent brain structures. 7T TOF MRA may serve as a high-quality non-invasive alternative for assessment, pretherapeutic planning and follow-up of AVM, sparing ionizing radiation and the application of iodinated contrast agent. SSK25-09 Utility of TWIST Magnetic Resonance Angiography for Pre-ablation Planning in Patients with Atrial Fibrillation: Comparison with Traditional Techniques Adeel Shahid MD (Presenter): Nothing to Disclose, Linda Chi Hang Chu MD : Nothing to Disclose, Saman Nazarian MD : Scientific Advisor, Johnson & Johnson Research funded, Johnson & Johnson, Ihab R. Kamel MD, PhD : Nothing to Disclose, Stefan L. Zimmerman MD : Nothing to Disclose Bolus timing is critical to optimal magnetic resonance angiography (MRA) acquisitions but can be challenging in some patients. Our purpose was to evaluate whether contrast-enhanced time-resolved interleaved stochastic trajectories (TWIST), a dynamic multiphase sequence that does not rely on bolus timing, is a viable alternative method to three-dimensional fast-long angle shot (FLASH) in patients with atrial fibrillation. Coronal subtracted MRA images from 20 patients with TWIST MRA performed for vascular mapping prior to atrial fibrillation ablation were compared to 20 patients with 3D FLASH MRA. The default TWIST protocol was modified to maximize spatial resolution at the expense of temporal resolution (7.4 sec). In-plane spatial resolution for both TWIST and FLASH was 1.0 x 1.0 mm. TWIST slice thickness was 1.5 mm; FLASH was 1.2 mm. Contrast dose was 0.2 mmol/kg, injected at 5 ml/sec for TWIST and 2 ml/sec for FLASH MRA. Left atrial signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) were measured for the FLASH MRA and for the phase of the TWIST MRA demonstrating the best atrial enhancement. Quality was assessed in a blinded fashion on a 1-5 scale for relative left atrial opacification, left atrial contrast uniformity and overall study quality. TWIST SNR was significantly higher than that of 3D FLASH MRA (13.7 ± 3.3 vs 8.5 ± 2.1, p<0.001). TWIST CNR was not different than that of 3D FLASH MRA (p=0.08). Qualitative uniformity of left atrial enhancement was significantly higher with TWIST than FLASH MRA (4.8 ± 0.4 vs 4.2 ± 0.4, p<0.001), whereas relative atrial opacification (4.7 ± 0.5 vs 4.1 ± 1.3, p=0.06) and overall study quality were not different between TWIST and FLASH MRA (p=0.17). TWIST modified to maximize spatial resolution offers an alternative method for performing high quality MRA examinations in patients with atrial fibrillation. TWIST offers greater signal-to-noise ratio and improved left atrial enhancement compared to traditional FLASH MRA techniques, without the challenges of proper bolus timing.

205 TWIST can be used instead of traditional 3D MRA to image patients undergoing vascular mapping prior to atrial fibrillation ablation. Without the need for proper bolus timing, TWIST offers a straightforward push-button method for capturing optimal left atrial opacification due to its dynamic multiphase acquisition. VIS-WEA Vascular/Interventional Wednesday Poster Discussions Scientific Posters IR VA AMA PRA Category 1 Credits :.50 Wed, Dec 3 12:15 PM - 12:45 PM Location: VI Community, Learning Center Moderator Kenneth J. Kolbeck MD, PhD : Nothing to Disclose Sub-Events VIS249 Optimal Energy Level of Monochromatic Imaging to Improve Vessel Delineation and Image Quality in Abdominal CT Angiography of Mesenteric Vasculature by Single-source Dual-energy CT with Fast kvp Switching (Station #1) Takuya Ishikawa (Presenter): Nothing to Disclose, Haruhiko Machida MD : Nothing to Disclose, He Qing Wang MSc : Nothing to Disclose, Etsuko Tate : Nothing to Disclose, Yun Shen PhD : Employee, General Electric Company Researcher, General Electric Company, Eiko Ueno MD : Nothing to Disclose, Rika Fukui : Nothing to Disclose, Isao Tanaka : Nothing to Disclose To investigate the optimal energy level of monochromatic images (MIs) for CT angiography (CTA) of mesenteric vasculature by single-source dual-energy CT (ssdect) with fast kvp switching. In 38 consecutive patients (20 men, 18 women; mean age, 64 ± 15 years; mean body mass index, 22.8 ± 3.1 kg/m2) undergoing CTA during the arterial phase by ssdect (tube voltage: 80 and 140 kvp, switched during a single projection in as little as 0.25 msec; helical pitch: 1.375; collimation: mm; noise index: 10 HU for 5-mm reconstruction; contrast medium dose: 600 mg I/kg; injection time: 30 sec), we measured averaged CT value of the abdominal aorta and its proximal branches (CT1) and the psoas muscles (CT2), standard deviation of CT value in the psoas muscles as objective noise (SD), and signal-to-noise ratio (SNR) as CT1 / SD and contrast-to-noise ratio (CNR) as (CT1 - CT2) / SD between the arteries and muscles on MIs at kev. Two radiologists independently graded from one (poor) to five (excellent) the delineation of distal branches of the superior mesenteric artery, artifacts, and overall noise on maximal intensity projection CTA at 40, 55, 60, 70, and 85 kev. We compared those results among different energy levels using Tukey-Kramer test. We quantified inter-reader agreement regarding the subjective results using Cohen's κ-statistics. The CT value (CT1) steadily increased to 40 kev ( ± HU); objective noise (SD) showed a trough at 71 kev (13.8 ± 2.1 HU) and increased to 40 kev (38.0 ± 6.0 HU); SNR was highest at 40 (27.7 ± 8.0) and 65 kev (27.2 ± 8.2) and CNR, at 40 (25.2 ± 8.2) and 61 kev (23.1 ± 8.1). The averaged subjective branch delineation was significantly higher at 40 (4.7 ± 0.6) than kev (2.6 ± ± 0.7); artifacts and noise improved significantly from 40 (3.8 ± 0.5; 3.6 ± 0.5, respectively) to 55 (4.4 ± 0.6; 4.6 ± 0.5) to kev (4.9 ± 0.3; 4.9 ± ± 0.2). The inter-reader agreement was substantial to excellent (kappa = ). The optimal energy level for CTA in the evaluation of mesenteric vasculature by ssdect is 40 or approximately 60 kev. In CTA of mesenteric vasculature by ssdect, MIs at 40 kev should be used to depict small peripheral branches and diseases; otherwise, approximately 60 kev, as the standard of choice. VIS250 CT Angiography of Profunda Artery Perforating Arteries before Free Flap Breast Reconstruction (Station #2) Daniel Rodriguez Bejarano MD (Presenter): Nothing to Disclose, Jose Antonio Narvaez MD : Nothing to Disclose, Javier Hernandez Ganan : Nothing to Disclose, Anna Lopez Ojeda : Nothing to Disclose, Tiago Gomes Rodrigues : Nothing to Disclose Profunda Artery Perforator (PAP) flap is a new therapeutic alternative in autologous breast reconstruction. Is an excellent option in patients with surgical contraindications to abdominal tissue transfer (previous abdominoplasty), thinness or patient s wish. Our purpose is to describe the imaging features of these branches

206 and their correlation to suitable perforants intraoperatively. Since the introduction of this new surgical technique in our hospital, a preoperative CTA was done in all cases. The CTA evaluation of the perforating arteries was performed with use of specific postprocessing and display techniques. A retrospective review of CTA and surgical findings of 20 patients, in which a PAP flap was performed between October 2012-March 2014, was done. Clinical data, CTA findings (number, size, location, relation with surrounding muscles, intramuscular and subcutaneous course of perforating arteries) and surgical reports were reviewed in all cases. Patient age ranged from 27 to 71 yr. In 3 cases a bilateral surgery was performed, being the initial procedure in all cases (no previous breast reconstructions). In all cases profunda artery perforators were identified. The average number of perforants was 1.2/patient, with an average diameter of 1.57mm. Most of the perforants were located near adductor magnus (73% of cases), coming out from adductor magnus muscule or from the fascial plane between gracilis/adductor magnus muscles, with an average distance from midline of 4.1cm. The average distance between gluteal fold and point of fascial exit was 3.5cm. Preoperative imaging findings correlated with suitable perforators intraoperatively in all cases. PAP flap is a good alternative in autologous breast reconstruction, mainly in patients with abdominal tissue not available, either for surgical causes (previous abdominal surgeries) or nonsurgical causes (thin patients, patient s wish). CT angiography plays a key role identifying perforators preoperatively, having an excellent correlation with intraoperative findings, giving an adequate guide to surgeons to make an adequate flap choice and incision design. Therefore, avoids a potential negative surgical exploration. CT Angiography in PAP flap provides information that helps the surgeon to optimize surgical planning, giving a guide to localize these branches, avoiding complications and negative explorations. VIS251 Evaluation of Vascular Images Using with MDCT (Multi Detector Computed Tomography) Reconstructed by Multi-Phase Volume Interpolation Technology (Station #3) Hiroichi Yokoyama MS (Presenter): Nothing to Disclose, Kensuke Fujiwara RT : Nothing to Disclose, Toru Kimura RT : Nothing to Disclose, Satoshi Fujita : Nothing to Disclose, Shinzo Nishi MD, PhD : Nothing to Disclose Reconstruction of Computed Tomography (CT) Cine mode images are not established yet, otherwise Magnetic Resonance (MR) images which has high quality of contrast, and/or Echo images with real time can be seen, are very useful for clinical examination.the quality of thoracic aortic fourth dimensional (4D) images with ECG-gated are not so enough. because of the radiation exposure.so we have reconstructed the blood flow CT images using with the new algorithm, Multi-Phase Volume Interpolation Technology (MVIT),then evaluated with the original images and new technical images. MVIT has two purposes for the images, a non-rigid registration based algorithm, 4D volumetric imaging simply presents the volume grid of voxels and fades from one phase to the next to show apparent motion. This voxel-to-voxel mapping of information enables the employment of additional algorithms that reduce noise, improve motion coherence, and measure function. First, we have studied the image quality of noise, using with the water phantom, standard deviation(sd) values were evaluated the original and the MVIT images. The results were mean SD values, 35.3/20.1 (original/mvit), and with clinical CT images of the thoracic aortic aneurysm with dissection, which parts of the cardiac muscle, left ventricle and descending aortic artery. The results were40.3,38.1,33.6/34.3,30.8,24.5 (original / MVIT).We have evaluated the quality of 4D images of thoracic aneurysm with dissection, reconstructed the enhanced CT examination with the ECG-gated images from 0% to 90% phases, total 10 phases axial images.the 3D / 4D blood flow images was evaluated with these axial images, using with the algorithm of 4D motion analysis which quantifies regional displacement and velocity color mapping of blood flow of thoracic aneurysm with dissection. MVIT can improve the image quality by reducing noise, and 3D/4D images reveal very reality and with clearly visible view. Furthermore we have demonstrated functional blood flow with aortic dissection. This algorithm suggestions that may be widely applied in near future. Using with the algorithm of MVIT, it could be made the visualization of turbulence flow image by MDCT. VIS245 Combined Therapy of TACE and RFA for Medium-sized Hepatocellular Carcinoma: Is Treatment Efficacy Affected by Amount of Lipiodol Uptake within the Tumor? (Station #4) Jin Woong Kim MD (Presenter): Nothing to Disclose, Sang Soo Shin MD : Nothing to Disclose, Suk Hee Heo MD : Nothing to Disclose, Hyo Soon Lim MD : Nothing to Disclose, Yong-Yeon Jeong MD : Nothing to Disclose, Heoung-Keun Kang MD : Nothing to Disclose

207 To evaluate the effect of the amount of lipiodol uptake within HCC, which were infused during TACE before RFA, on treatment efficacy when performing combined therapy of TACE and RFA for medium-sized HCC. A total of 106 consecutive patients (mean age, 63 years) with 124 HCCs (mean± SD, 3 cm ± 0.8), who underwent combined therapy of TACE and RFA for HCCs, were included in this study. All patients had single (n=88) or two (n=18) HCCs ranging between 2 cm and 5 cm. According to amount of lipiodol uptake within HCC, which was evaluated on angiographic CT images, patients were classified into 3 groups [compact (> 75%), defective (25% ~ 75%), faint or no uptake (<25%)]. Patients were followed up for 1.1 ~ 68.6 months (mean± SD, 26.1 ± 13.4). Among 3 groups, technical success, technical effectiveness and rates of local tumor progression were compared according to per-lesion-based analyses. Three groups were compared regarding incidence of complications, rates of recurrence-free survival and overall survival rates based on per-patient-based analyses. Statistical analyses were conducted with Chi-square test, one-way ANOVA statistics and Kaplan-Meier method. Regarding amount of lipiodol uptake, 106 patients and 124 HCCs were classified as compact (n=59 and 67, respectively), defective (n=35 and 43, respectively), faint or no uptake (n=12 and 14, respectively) group. There were no significant differences in patients' demographics and characteristics of HCCs among 3 groups (P > 0.05). The technical success and effectiveness were achieved in 124 (100%) and 122 (98.4%), respectively, of 124 HCCs. The local tumor progression occurred in 5 (7.5%) of 67 HCCs with compact uptake, 6 (14%) of 43 HCCs with defective uptake, and 1 (7.1%) of 14 HCCs with faint or no uptake (P > 0.05).There were no statistically significant differences among 3 groups regarding incidence of complications, rates of recurrence-free survival and overall survival rates(p > 0.05). The amount of lipiodol uptake within HCC played little role in terms of treatment efficacy when performing combined therapy of TACE and RFA for medium-sized HCC. Synergistic effects of combined therapy of TACE and RFA for medium-sized HCC appear to root from decreased arterial blood flow induced by TACE, irrespective of the amount of lipiodol uptake within the tumor. VIS246 Diagnostic Accuracy of Contrast-enhanced T1 Free-breathing Gradient Echo Sequences in the Assessment of Aortic Disease: Comparison with Standard T1 Breath-hold Gradient Echo 3D Angiographic Sequences (Station #5) Cammillo Roberto Giovanni Leopoldo Talei Franzesi (Presenter): Nothing to Disclose, Davide Ippolito MD : Nothing to Disclose, Pietro Andrea Bonaffini MD : Nothing to Disclose, Davide Fior MD : Nothing to Disclose, Andrea Nasatti : Nothing to Disclose, Sandro Sironi MD : Nothing to Disclose To compare the diagnostic performance of contrast-enhanced T1 free-breathing gradient echo sequences with standard MR-angiographic sequences in the assessment of aortic disease. From January 2012 to December 2013,41 patients(16women;25men;mean age60.1;range,31-80 years) with known or clinical suspicious of aortic disease were evaluated. All patients underwent an MR angiography(mra) study of aorta on 1.5T magnet(achieva,philips),using a phased array multi-coil, after the intravenous injection of 0,1mL*Kg of gadobutrol, with standard protocol and acquiring 3D-angiographic T1 gradient-echo fat-suppressed(3d-hr) sequences. Moreover multiplanar T1 free-breathing gradient-echo fat-suppressed (THRIVE-FB) sequences were also performed. For each patient two blinded radiologists independently compared the diagnostic quality of the different angiographic sequences, in terms of aortic wall and lumen and main branches visualization. The vascular diameters at different aortic levels were also calculated, compared and statistically analyzed between the different sequences. The interobserver agreement was then evaluated using the Intraclass Correlation Coefficient(ICC). The THRIVE-FB sequences showed high diagnostic accuracy in the evaluation of vascular diameter and walls, with a significant higher sensitivity and specificity in the assessment of vascular plaques, thrombus and adjacent structures, in comparison with 3D-HR. The 3D-HR sequences better visualized the vascular lumen with lower flow artifacts, than THRIVE-FB sequences. Not significant differences were obtained in terms of diagnostic quality between 3D-HR and THRIVE-FB sequences and a high interobserver agreement was found, with an ICC of 0,97. Contrast-enhanced T1 free-breathing gradient-echo fat-suppressed sequences (THRIVE-FB) were able to correctly visualize and evaluate the aorta and its major branches, with not significant differences in comparison

208 with standard breath-hold angiographic sequences, allowing to cover large volume, even in not compliant patients. Free-breathing angiographic protocol permits to correctly evaluate thoracic and abdominal arteries, without any significant breathing artifacts, representing a useful tool in not compliant patients. VIS248 Can Patient Radiation Dose Be Drastically Reduced for Monitoring CT Guided Catheter Placement? (Station #6) Yasir Andrabi MD, MPH (Presenter): Nothing to Disclose, Jorge Mario Fuentes MD : Nothing to Disclose, Mukta Dilipkumar Agrawal MBBS, MD : Nothing to Disclose, Dushyant V. Sahani MD : Research Grant, General Electric Company Increased utilization of image guided catheter placement especially for no-cancer indications has increased concerns for radiation exposure. Image quality (IQ) expectations in follow up (F/U) exams are much lower than initial diagnostic exam. We investigated the performance of low dose follow up CT exams for IQ and radiation doses compared to baseline abdomen-pelvic CT exams in patients undergoing CT guided catheter placement. Between December 2012 to December 2013, 264 patients (M:F=135:129; BW=77.5kg, Age=61.5) had initial and F/U CT exams performed for CT guided catheter placement on 2 GE Healthcare scanners [LightSpeed Pro-16 (FBP=133) and Discovery 750HD(ASiR=130)]. The scanning parameters for F/U exams included weight based kvp (FBP:100/120, IR: 80/100), low ma(75-350) and NI(FBP:25, IR:30) Patient demographics and radiation dose (CTDI, SSDE, DLP, Effective dose(icrp 103), dose per organs) were retrieved using an automated dose tracking software (exposure, Radimetrics) and were compared with the baseline CT exam. Subjective IQ assessment of F/U exams to determine diagnostic acceptability was done. The overall IQ was acceptable for interpretation in F/U exams. Mean SSDE for F/U exams were 3.8 mgy compared to 9.4 mgy for baseline CT exams corresponding to nearly 65% dose reduction (p<0.0001). Mean radiation doses (SSDE) were 73% lower in F/U exams performed with ASiR technique compared to 48% with FBP technique (mgy, ASiR=2.6, FBP=4.9; p<0.0001). Doses are nearly 80% lower than ACR reported doses for routine abdomen CT exams. Customizing scan protocols for F/U indications enables substantial dose reduction (65%) compared to baseline diagnostic CT exams. These dose reduction benefits are more drastic in scanners with IR algorithms (73%) compared to FBP exams (48%). Continuous protocol optimization based on image quality expectations and clinical indications is integral for adherence to ALARA principle. These are especially true for indications with lower IQ expectations and exams needing repeated follow ups. VIS247 Nonenhanced Peripheral 3D-TSE-MR-Angiography: Optimizing Resolution and Trigger Delays (Station #7) Thomas Josef Vogl MD, PhD (Presenter): Nothing to Disclose, Carl Hormes : Nothing to Disclose, Adel Maataoui MD : Nothing to Disclose, Frank Hubner MS : Nothing to Disclose, Martin Beeres MD : Nothing to Disclose To optimize resolution and trigger delays in a nonenhanced electrocardiogram (ECG)-triggered flow sensitive 3D-TSE sequence for the distal lower extremities in healthy subjects. 120 MR angiographies of 20 healthy volunteers (10 males, 10 females; mean: 33 years) were assessed with six different acquisition setups in a 1.5 T MRI scanner (Siemens Avanto). Setups consisted of the combination of a specific isovolumetric voxel size (A = 0.9 mm3, B = 1.25 mm3, C = 1.5 mm3) with a particular trigger delay (1 = peak - 30ms, 2 = beginning of the peak). Images were rated using a 5-point-scale by two experienced radiologists in 6 anatomical regions of each leg (A. poplitea III, outlet A. tibialis ant., A tibialis ant., outlet A. tibialis post., A. tibialis post., A. fibularis). Signal-to-noise (SNR) ratio was evaluated. Intraclass correlation (0.755) was taken to show interrater reliability between the two readers. Evaluation of the setups indicated a significant difference (p<0.000). Setup combination B.1. showed best image quality: none or minor venous overlay in 95% and none or minor artifacts in 85%. Combination B.1 showed significant improvement in comparison to the other combinations A.2. (p<0.000), C.2. (p<0.000), and B.2. (p 0.017). SNR evaluation underlined these results.

209 Non-enhanced 3D-TSE-MR angiography is a good imaging modality for the lower extremities and showed good results in healthy volunteers. Combination setup B.1. demonstrated a significant superiority over the other evaluated setups with a solid robustness against venous overlay and image artifacts. 3D-TSE MR sequence allows a precise visualization of pathologies of distal lower extremities. VIS252 Evaluation of In-situ Nanocarbon-Assisted Microwave Therapy (NAMT) Causing Cytotoxic Thermal Ablation of Human Prostate Tumor Cells in Nude Mice (Station #8) Ana Marija Franceschi MD (Presenter): Nothing to Disclose, Mark Desantis DO : Research Grant, Clean Technology International Corporation, Wilbur B. Bowne MD : Nothing to Disclose, John Alexander Ferretti MD : Nothing to Disclose, Thomas Dalessandro MD : Nothing to Disclose, Jonathan Gross MD : Nothing to Disclose, Valmore Suprenant MD : Nothing to Disclose, Atul Kumar MD : Nothing to Disclose, Thomas E. Zimmerman DVM : Nothing to Disclose, Katlyn E. Dolan : Nothing to Disclose Evaluation of long term toxicity of a spherical nanocarbon (Grafex) injected into known Human Prostatic carcinoma. It is known that NAMT increases the absorption of microwave energy, specifically into tumor cells. This study evaluated the use of NAMT as primary treatment in human prostate tumor. Additionally, we assessed the toxic burden of nanocarbon used during treatment. 10 Nude nu/nu isolated mice were injected with DU145 (ATC#HTB-81) 1x 10^7 Human Prostate carcinoma cells introduced into the dermis and allowed to grow to >1cm. Afterwards, 8 mice received treatment with the microwave and 292 molar concentration of nanocarbon, 1 control received no treatment, and 1 control received only an injection of 292 nanocarbon. In the 'treatment' group, nanocarbon and viscous carrier were injected into the tumors. Medwave generators with microwave probes were used for thermal ablation, with short cycle power using 10 watts at 15 sec as baseline settings. Target temperature within the tumor was 60 C. 5/8 (62.5%) of the treated mice were alive at 18 months with no signs of toxicity or tumor recurrence. One mouse had a non-treated skin ulcer from the non-cooled microwave probe during the treatment process and was euthanized, but was responding to treatment. 2/8 (25%) were alive at 22 months, which is well above their expected life span of 6 months to 1 year. The control non-treated mouse was euthanized due to metastatic prostate cancer 3 weeks after initial injection. The mouse which received only nanocarbon treatment had no change in tumor size. The treated mice were observed to have no toxic effects from the nanocarbon. NAMT maximizes energy transfer, with the conversion of microwave energy causing thermal ablation of cancer cells. By using shorter treatment times and lower power output of the microwave generator, NAMT reduces heat sink effect and surrounding tissue damage. Grafex NAMT appears to be not only successful in treatment of human prostate carcinoma, but also nontoxic in this small animal study. A larger study is under way. Nanocarbon-assisted microwave therapy provides increased thermal energy transfer, shorter treatment times and non-toxic treatment of human prostate tumor cells, and may represent a powerful new tool in cancer therapy. VIS-WEB Vascular/Interventional Wednesday Poster Discussions Scientific Posters IR VA AMA PRA Category 1 Credits :.50 Wed, Dec 3 12:45 PM - 1:15 PM Location: VI Community, Learning Center Sub-Events VIS257 Dual-Energy CT Angiography for the Assessment of Lower Extremity Peripheral Arterial Disease (Station #1) Torel Ogur MD (Presenter): Nothing to Disclose, Patrick T. Norton MD : Nothing to Disclose, Klaus D. Hagspiel MD : Research Grant, Siemens AG

210 To evaluate the effect of automatic bone and plaque removal on image quality and grading of stenoocclusive lesions in peripheral arterial disease (PAD) patients undergoing dual energy CT angiography (DE-CTA) of the lower extremity (LE) and to compare with digital subtraction angiography (DSA) as the reference standard. Twenty one PAD patients underwent both DE-CTA and DSA (13 men, 8 women, mean age 62.8 years; range 40-91). DE-CTA (Siemens Somatom Definition Flash, Siemens Medical Solutions, Forchheim, Germany) was performed within a month of the intraarterial DSA (Axiom Artis Siemens Medical Systems, Forchheim, Germany). We compared the results of image interpretation based on axial source images and MPR images without (SIMPR) and with dual energy bone and plaque removal (DEBPR) with DSA. Fifteen arterial segments per lower extremity were analyzed with the segments classified into 3 groups - inflow, outflow and runoff. The sensitivity (SE), specificity (SP) and diagnostic accuracy (ACC) for the detection of relevant stenosis (>69%) or occlusions for each set of images were calculated against DSA findings as the reference standard. A total of 323 segments for 21 patients (25 LE arteries) were evaluated. For inflow vessels; SE, SP, and ACC were 83.33%, 98.18% and 96.72%, respectively for SIMPR, and 100% for all three for DEBPR. For outflow vessels SE, SP, and ACC were 76.19%, 94.12% and 89.88% for SIMPR, and 100%, 91.18% and 93.25% for DEBPR. For runoff vessels we found 67.24%, 80.87% and 76.30% for SIMPR, and 91.38%, 70.43% and 77.45% for DEBPR. DECT based plaque and bone removal improves the sensitivity, specificity and accuracy of lower extremity CTA, particularly for the inflow and outflow vessels. The automated plaque removal tool improves luminal assessment and the automated bone removal tool allows reliable segmentation of bone. Dual energy based automated bone and plaque subtraction allows to improve the sensitivity, specificity and accuracy of lower extremity CTA over conventional CTA, particularly in the iliofemoral and popliteal arteries. VIS258 Depiction of Transplant Renal Vascular Anatomy and Complications: Un-enhanced MR Angiography by Using Spatial Labeling with Multiple Inversion Pulses (Station #2) Hao Tang (Presenter): Nothing to Disclose, Zi Wang : Nothing to Disclose, Xiaoyan Meng MD : Nothing to Disclose To evaluate ability to depict anatomy and complications of renal vascular transplant with unenhanced magnetic resonance (MR) angiography with spatial labeling with multiple inversion pulses (SLEEK), and to compare the results with color Doppler (CD) ultrasonography (US), digital subtraction angiography (DSA), and intraoperative findings. This study was approved by the institutional review board and written informed consent was received before examination. Seventy-five patients who underwent renal transplant were examined with unenhanced MR angiography with SLEEK and CD US. DSA was performed in 15 patients. Surgery was performed in eight patients. The ability of SLEEK to show transplant renal vascular anatomy and complications was evaluated by two experienced radiologists who compared the results with CD US, DSA, and intraoperative findings. Patients successfully underwent SLEEK MR angiography. Transplant renal vascular anatomy was assessed in 87 arteries and 78 veins. Twenty-three patients were diagnosed with renal vascular complications from transplantation, which included 14 with arterial stenosis, three with arterial kinking, two with arteriovenous fistulas, two with venous stenosis, one with pseudoaneurysms, and one with fibromuscular dysplasia. Three patients had two renal transplants and nine patients had nine accessory renal arteries. More accessory renal arteries were detected with SLEEK than with CD US. Correlation was excellent between the stenosis degree with SLEEK and DSA (r= 0.96; P Unenhanced MR angiography with SLEEK preliminarily proved to be a reliable diagnostic method for depiction of anatomy and complications of renal vascular transplant. It may be used for evaluation of patients with renal transplantation, and in particular for those with renal insufficiency. Unenhanced MR angiography by using SLEEK may be a reliable diagnostic method for depiction of transplant renal vascular anatomy and complications; furthermore, it does not carry the risk of nephrogenic systemic fibrosis and contrast-induced nephropathy in patients with renal insufficiency. VIS259 Intra-individual Comparison of Gadofosveset Trisodium and Gadobenate Dimeglumine for Contrast-enhanced MRA of Pancreas Transplants at 3T (Station #3) Lucia Flors MD (Presenter): Nothing to Disclose, Marta Gonzalez MD : Nothing to Disclose, Patrick T. Norton MD : Nothing to Disclose, James Patrie MS : Nothing to Disclose, Klaus D. Hagspiel MD : Research Grant, Siemens AG

211 To compare the image quality and diagnostic performance of gadofosveset trisodium (GT) and gadobenate dimeglumine (GD) for contrast-enhanced MRA of pancreas transplants on first pass (FPI) and very high-spatial resolution steady state imaging (SSI) at 3T 18 patients (11men; 43.4±7 years) were studied with both agents; a total of 42 studies -21 intraindividual comparison pairs- were available for review. SNR and CNR were measured on FPI and SSI images for pancreatic parenchyma, arteries and veins. Results were adjusted for patient weight, voxel volume and delay time. Two independent readers subjectively assessed the overall image quality, the presence of artifact due to respiratory motion or peristalsis, and the quality of the bolus timing using a 4-point scale. Highest order visible side branch, vessel patency (5-point scale) and level of confidence (4-point scale) were recorded. In case of disagreement, the diagnosis was reached by consensus. Inter-reader agreement was calculated. Pancreatic parenchyma, aorta and pancreatic artery SNRs were higher for GD on FPI (p<0.08), and did not differ on SSI (P>0.1). Pancreatic vein, IVC and muscle SNRs were comparable for FPI and SSI (p>0.1). Pancreatic artery CNR was higher for GD (p=0.030) on FPI, whereas GD and GT were comparable (p=0.35) on SSI. Pancreatic vein CNR was comparable for FPI and SSI (p>0.11). There was no difference between the two agents in image quality, presence of artifacts and bolus timing (p>0.2) for both FPI and SSI. Highest order of side branches and vessel patency (p=0.167 and p>0.13) did also not differ, with the exception of splenic vein patency (p=0.04; 2± 1.3 GT vs 1.3±1.1 GD). Level of confidence did not differ (p=0.139) and there was also no significant difference in the odds of reader agreement between contrast agents. GT and GD delivered overall similar image quality, but CNR and SNR were greater with GD on arterial-phase Despite the potential benefits of the intravascular contrast agent GT, CNR and SNR in FP ce-mra of pancreas transplants are higher with GD and they are comparable for both GD and GT on SSI. Therefore, the use of the more expensive contrast agent GT for cemra of pancreas allografts is not justified. VIS253 Evaluation of Fluorescent Stains as Real-time Assessment of Incomplete Ablation of Colon Cancer Liver Metastases (Station #4) Vlasios S. Sotirchos MD (Presenter): Nothing to Disclose, Efsevia Vakiani MD : Nothing to Disclose, Sho Fujisawa PhD : Nothing to Disclose, Yevgeniy Romin : Nothing to Disclose, Mesruh Turkekul : Nothing to Disclose, Karen Teresa Brown MD : Nothing to Disclose, Elena Nadia Petre MD : Nothing to Disclose, Stephen Barnett Solomon MD : Research Grant, General Electric Company Research Grant, AngioDynamics, Inc Consultant, Johnson & Johnson Consultant, Covidien AG Director, Devicor Medical Products, Inc Director, Aspire Bariatrics, Inc, Alessandra Garcia : Nothing to Disclose, Katia Manova-Todorova : Nothing to Disclose, Constantinos Thasos Sofocleous MD, PhD : Consultant, Sirtex Medical Ltd To evaluate live cell fluorescent assessment as an immediate biomarker of complete ablation of colorectal cancer liver metastases (CLMs). This NIH-supported IRB-approved prospective study analyzed live tissue collected from the center and the margin of the percutaneous ablation zone of CLMs gauge core biopsy specimens collected from the ablation zone underwent fluorescent staining that generated composite images of nuclear Hoechst and MitoTracker Red stains within 30 minutes from radio frequency ablation. Subsequently, the exact same tissue samples were fixated and stained with standard HandE morphologic stains. A blinded pathologist classified the composite fluorescent images into viable tumor vs. coagulation necrosis and normal liver cells. These were correlated with the blinded interpretation of the standard HandE morphologic stain. Initial results from 25 collected specimens in 14 patients with 15 ablated CLMs demonstrated a concordance rate of 88% (22/25) when assessing for the presence of tumor cells. Fluorescent stain sensitivity was 80% (4/5) for specimens positive on standard HandE for tumor cells; Specificity was 90% (18/20). Given the documented prognostic value of tissue characteristics on local tumor progression-free and overall survival in patients with CLMs, ablation zone evaluation with fluorescent stains may provide an immediate assessment of the ablation success and guide immediate or future additional therapies. Fluorescence imaging of liver tissue from the ablation zone may provide intraprocedural assessment of technical failure and guide decisions for additional therapy.

212 VIS255 CT-angiography with Low kv and Low Contrast Medium Volume Using a 256 Multi-detector CT Scanner in the Evaluation of Thoracic and Abdominal Aorta Disease: Diagnostic Efficacy and Radiation Dose Reduction (Station #5) Cammillo Roberto Giovanni Leopoldo Talei Franzesi (Presenter): Nothing to Disclose, Davide Ippolito MD : Nothing to Disclose, Pietro Andrea Bonaffini MD : Nothing to Disclose, Davide Fior MD : Nothing to Disclose, Pietro Allegranza MD : Nothing to Disclose, Sandro Sironi MD : Nothing to Disclose To assess the diagnostic quality and the radiation dose exposure of low-kv CT angiography study (100kV), by using ultra low contrast medium volume (40mL), for thoracic and abdominal aorta disease. From July 2011 to November 2013, 89 patients (33 women;mean age 65.7years;range,35-83years;BMI<30),with thoracic or abdominal aortic disease,were prospectively examined with 256-MDCT scan(brilliance ict;philips) using low-dose protocol(100kv;automated tube current modulation) and ultra low-contrast volume(40ml;4ml/s;350mgi/ml).for the evaluation of ascending aorta, an ECG-gated retrospective protocol was performed. A control group of 61 patients (21women;mean age 66.4years;range,34-86years), who underwent on the same scanner standard CT-angiography protocol (120kV;350mAs),with standard contrast volume(80ml), was also evaluated.density measurements were performed manually drawing a region of interest(roi) on lumen of ascending aorta,arch,descending and abdominal aorta,renal arteries and common iliac arteries.the radiation dose exposure(dose-length product,dlp) was also calculated for both groups.then,the obtained data were compared and statistically analyzed. In all patients we could correctly visualize and evaluate lumen and walls of thoracic and abdominal aorta and main arterials branches. No significant difference of density measurements was achieved between low-kv group (mean attenuation value of thoracic aorta 321HU,abdominal aorta 332HU and renal arteries 338HU) and control group (mean value of thoracic aorta 316HU,abdominal aorta 327HU and renal arteries 307HU).The radiation dose exposure was significantly lower(p<0,05) in low-kv protocol(mean DLP thoracic 490mGy*cm;abdominal 335mGy*cm) than in control group(mean DLP thoracic 820mGy*cm;abdominal 952mGy*cm),with an overall reduction of 41% in the thoracic and 65% for abdominal study. Low-kV CT angiography protocol maintain a high diagnostic performance similar to standard protocol, with a significant decrease of the radiation dose exposure as well as the contrast material volume, reducing also the risk of contrast-induced nephropathy. Low-kV and low-contrast volume CT-angiography allows to significant reduce the radiation exposure, maintaining high diagnostic quality and reducing the risk of renal impairment. VIS254 Impact of Low Dose Protocols on Cumulative Radiation Dose in Patients Undergoing Repetitive Follow Up CT Exams for Image Guided Catheter Placement: Impact of Dose Modified Protocols on the Cumulative Radiation Dose in Patients Undergoing Repeat Abdome (Station #6) Yasir Andrabi MD, MPH (Presenter): Nothing to Disclose, Jorge Mario Fuentes MD : Nothing to Disclose, Koichi Hayano MD : Nothing to Disclose, Manuel Patino MD : Nothing to Disclose, Mukta Dilipkumar Agrawal MBBS, MD : Nothing to Disclose, Dushyant V. Sahani MD : Research Grant, General Electric Company Repeat CT exams following image guided catheter placement in the abdomen can result in substantial increase in cumulative radiation dose (CRD) exposure to patients. We have introduced dose modified protocols (DMP) to evaluate the success of IR catheter. We investigated the impact DMP on CRD in patients undergoing repeated catheter F/U exams. Between December 2012 to December 2013, 130 patients (M:F=68:62, BW=78.5 Kgs, Age= 59 Years) underwent F/U CT exams for image guided catheter placement on 64-slice GE Healthcare scanner (Discover CT750 HD). The scanning parameters for F/U exams included weight based kvp (80/100), low ma(75-350) and NI=30, while for baseline Abd-Pelvis CT exams included kvp=120, ma=(75-450), NI= Patient demographics, number of repeated exams and CRD were retrieved using an automated dose tracking software (exposure, Radimetrics). On an average, 3 F/U CT exams were performed per patient (Range 1-5) while average number of CT exams per patient/year was 6.5 (range: 1-26 exams). The mean CRD was mgy-cm (range: ,200) with a linearity in number of CT exams and CRD (R2 =0.82, P<0.0001). With the increase in the number of CT exams performed per patient, an exponential decrese (R2=0.77) in the impact of DMP CT on CRD was noted (mean dose reduction=13%, Range: 5-80%, p=xx). A substantial impact DMP on CRD was noted for less than four CT exams performed per patient (33% reduction).

213 Using dose modified protocols in F/U CT exams can serve its intended purpose while lowering the cumulative radiation dose in patients undergoing repeated exams for image guided catheter placement followup. These dose reduction benefits are considerable for <4 repeated CT exams performed per patient. Repeated CT exams are associated with considerable CRD and significant radiation related side effects. Customizing protocols based on the clinical indication can significantly lower CRD especially in less complicated patients undergoing repeated CT exams for non-cancer indications. VIS256 Dynamic CT Scanning and Enhancing Parameters Impact on Contrast Bolus Geometry during First-pass Arterial Enhancement: Well-controlled in Vitro Evaluation Using a Pulsatile Flow Model (Station #7) Jongmin John Lee MD, PhD (Presenter): Nothing to Disclose, Ju-Young Kwon BSC : Nothing to Disclose, Jongmin Park : Nothing to Disclose, Jihoon Hong : Nothing to Disclose, Eun-Ju Kang : Nothing to Disclose, Sung Won Youn MD : Nothing to Disclose For compounder-less evaluation of the impact by scanning and enhancing parameters on the first-pass contrast bolus geometry during dynamically enhanced CT angiography A self-made closed-circuit pulsatile flow system was used for simulating pulmonary-aortic circulation. Heart rate setting ranged from 50 to 90bpm. The other flow parameters were set to be constant. Contrast injection rate was 1-5ml/sec and injection duration was fixed to 2 seconds. Iodine concentration of contrast media was mg/cc. CT tube voltage was set as 80, 100, and 120kVp. The other CT scanning parameters were fixed as constants. After bolus enhancement, at scanning module in flow system, 0.45-sec interval, single slice 16-channel CT scan repeated for 90 seconds. A time-hu curve was plotted on aortic lumen at every data set. Time-HU curve parameters were compared with input variables using a step-wise multiple regression analysis. Total 135 data sets were acquired. The peak enhancement increased mainly by faster iodine deliver rate (IDR) and additionally by lower tube voltage (R2=0.816 and 0.919, p<0.001). Whereas, iodine concentration of contrast media and heart rate showed no incremental impact on peak enhancement. The time-to-peak enhancement was shortened by higher heart rate and additionally by faster IDR (R2=0.860 and 0.900, p<0.001). The bolus expansion ratio was decreased by higher heart rate (R2=0.807, p<0.001). This influence increased by sequentially adding IDR and iodine concentration. Significantly influencing factors to the maximum ascending and descending gradients were IDR, tube voltage, and heart rate (p<0.001). Recirculation density was influenced by IDR, tube voltage, heart rate, and iodine concentration (p<0.022). Among four input variables in this study, IDR and heart rate were critical variables to bolus geometry during first-pass arterial enhancement. Next, the tube voltage influenced on bolus geometry significantly, whereas iodine concentration of contrast media was revealed as an insignificant factor. Proper kvp and IDR would generate proper bolus geometry independently on the formulation of iodine contrast media. The iodine delivery rate and kvp, rather than iodine concentration, are critical parameters for superior bolus geometry during dyanmically enhanced CT. VIE027-b Pre-procedural Care in Vascular and Interventional Radiology: What Every Resident Should Know (hardcopy backboard) Bedros Taslakian MD (Presenter): Nothing to Disclose, Aghiad Al-Kutoubi MD : Nothing to Disclose The purpose of this exhibit is: To provide a comprehensive systematic approach to the essential steps in pre-procedural care. To review key history and physical examination findings and discuss the essential laboratory tests required in the pre-procedural period. To emphasize the importance of advance planning in achieving good outcome. To stress the fact that reviewing previous imaging studies and clinical data can aid in planning the procedure, suggesting alternative approach and avoiding complications. To provide a simple preparation plan for challenging cases. Introduction: Practice of modern interventional radiology Key questions in advance planning Patient referral and contact Patient referral: how to approach? Patient contact: why vital? Review of history and physical examination

214 Review of previous laboratory data and imaging findings Indications and informed consent Laboratory tests and correction of relevant abnormalities Renal function Coagulation parameters Patient preparation Diet and hydration Medications Contrast allergy pretreatment Contrast-induced nephropathy prophylaxis Prophylactic antibiotics VSIO41 Interventional Oncology Series: Mechanisms Matter: Basic Science Every IO Should Know Series Courses RO OI IR RO OI IR AMA PRA Category 1 Credits : 3.50 ARRT Category A+ Credits: 4.00 Wed, Dec 3 1:30 PM - 5:00 PM Location: S405AB Moderator S. Nahum Goldberg MD : Consultant, AngioDynamics, Inc Research support, AngioDynamics, Inc Research support, Cosman Medical, Inc Consultant, Cosman Medical, Inc 1) Gain an appreciation of the basic scientific underpinnings of interventional oncology. 2) Understand how and why these mechanistic studies can have an impact on both daily clinical practice and future therapeutic paradigms. 3) Characterize and appreciate the most important advances of interventional oncology over the last two decades. 4) Identify key challenges, and greatest opportunities facing the interventional oncology community. ABSTRACT The first half of the session has been organized into a thematic unit entitled: "Mechanisms Matter: Basic science every IO should know" and will be dedicated to gaining an appreciation of the basic scientific underpinnings of interventional oncology and understand how and why such studies can have an impact on both daily clinical practice and future therapeutic paradigms. This will include an initial lecture outlining the many insights and lessons that can be directly applied from radiation therapy and hyperthermia, followed by lectures that center upon key mechanistic pathways that are being used to improve transcatheter embolization and tumor ablation. Two presentations will then outline our current understanding of the potential systemic implications of post-procedure, cytokine-mediated inflammation - the negative effects of leading to tumorigenesis and the potential beneficial immune (abscopic) effects of IO therapies. The second half of the session entitled "Interventional Oncology: Progress, Challenges and Opportunities" will be dedicated to providing the most cutting-edge update of the four main additional basic research areas in which interventional oncology has made substantial progress over the last two decades. Accordingly speakers will initially present the 3-5 most important advances that have occurred over the last decade for Ablation devices, Transcatheter therapy, Procedural Image-guidance, and Post-Ablation Follow-up. For each topic, this will be followed by a critical assessment of the most pressing current challenges facing and the greatest opportunities presented to advance these key components of current interventional oncologic practice. For ablation devices, two separate lectures will highlight thermal and electroporative technologies. Transcatheter advances will center upon new strategies for drug delivery. Finally, the session will conclude with an complementary additional presentation of a key potential area for collaborative clinical Sub-Events VSIO41-01 Radiofrequency Hyperthermia-Enhanced Local Chemotherapy of Esophageal Squamous Cancers: Monitoring with Dual-Modality Imaging yaoping shi (Presenter): Nothing to Disclose, Xiaoming Yang MD, PhD : Nothing to Disclose, Feng Zhang MD, PhD : Nothing to Disclose, zhibin bai : Nothing to Disclose, Jianfeng Wang MD : Nothing to Disclose, Long-Hua Qiu : Nothing to Disclose, Yanfeng Meng MD : Nothing to Disclose To determine whether radiofrequency (RF) hyperthermia could enhance the therapeutic effect of cisplatin and 5-fluorouracil (5-FU) on esophageal squamous cancers (ESC). Human ESC cells (ESCC) were first labeled with red fluorescent protein (RFP) via a lentivirus transfection approach. For both in vitro confirmation and in vivo validation studies, RFP-ESCCs and 24 RFP-ESC-engrafted mice were divided into four study groups with various treatments of (i) combination therapy with chemotherapy (cisplatin and 5-FU) plus MR imaging-heating-guidewire (MRIHG)-mediated local RF hyperthermia; (ii) chemotherapy only; (iii) RF hyperthermia only; and (iv) phosphate-buffered saline (PBS). In vitro cell proliferation was quantified by MTS assay, while in vivo validation with size changes of ESC masses and RFP-ESC signals among different treatment groups were monitored by ultrasound imaging and optical imaging over time with subsequent pathology correlation. Of in vitro experiments, MTS assay demonstrated lowest cell proliferation of combination therapy compared to those of three control groups (41±6% VS 59±4% VS 92± 2% VS 100±2%, p < 0.05). Of in vivo experiments,

215 ultrasound imaging showed smaller tumor volumes with combination therapy than those with three control treatments (0.55±0.07mm3 VS 1.28±0.07mm3 VS 2.42±0.45mm3 VS 2.67±0.39mm3). Optical imaging demonstrated a decrease of RFP-ESC signals for the combination therapy group in comparison to those for three control groups (0.61±0.16 photon/sec/mm2 VS 1.31±0.13photon/sec/mm2 VS 2.08±0.43 photon/sec/mm2 VS 2.69±0.26photon/sec/mm2), which were correlated with histologic confirmation. Local RF hyperthermia can enhance chemotherapeutic effect on human ESCs, which may open a new avenue for efficient management of esophageal malignancies. Local RF hyperthermia can enhance chemotherapeutic effect on human ESCs, which may open a new avenue for efficient management of esophageal malignancies. VSIO41-02 Beyond "just" TACE: Targeting Glycolysis, Apoptosis, and the VEGF Pathway Jean-Francois H. Geschwind MD (Presenter): Consultant, BTG International Ltd Consultant, Bayer AG Consultant, Guerbet SA Consultant, Nordion, Inc Grant, BTG International Ltd Grant, F. Hoffmann-La Roche Ltd Grant, Bayer AG Grant, Koninklijke Philips NV Grant, Nordion, Inc Grant, ContextVision AB Grant, CeloNova BioSciences, Inc Founder, PreScience Labs, LLC CEO, PreScience Labs, LLC View learning objectives under main course title. VSIO41-03 Pilot Study of Early Changes in Proangiogenic Biomarkers Following DEB-TACE Gary Garlup Tse MD (Presenter): Nothing to Disclose, Danny Cheng MD : Nothing to Disclose, Kunal Sidhar MD : Nothing to Disclose, Kathleen Ai-Lan Khong MD : Nothing to Disclose, Paul Dong MD : Nothing to Disclose, Karun V. Sharma MD, PhD : Nothing to Disclose To investigate acute changes in proangiogenic biomarkers within the first 24hrs after drug eluting bead chemoembolization (DEB-TACE). In this prospective pilot study, we recruited 10 patients with unresectable hepatocellular carcinoma eligible for DEB-TACE. Plasma samples were collected before, after, and at 1, 4, and 24 hrs following DEB-TACE. Levels of Serum Amyloid A (SAA), CRP, ICAM-1, VCAM-1 were assayed in triplicates using the Meso Scale Discovery (MSD) Multiplex Panel and analyzed using a SECTOR IMAGER 2400 and MSD DAT software. Increase in proangiogenic biomarkers were seen in nearly all patients. A sharp increase in plasma levels of SAA and VCAM-1 were seen in 8/10 patients at 24 hrs after DEB-TACE. Only 2/10 had decreased biomarker levels in both these groups. CRP also increased sharply in 9/10 patients after DEB-TACE and only 1/10 showed a decrease in CRP. ICAM-1 did not demonstrate a consistent or significant change during the first 24 hrs post DEB-TACE; 5/10 patients had minimal increase and 4/10 had minimal decrease. Acute changes in plasma levels of proangiogenic biomarkers are detectable following DEB-TACE. The magnitude and direction of change (increase or decrease) suggest a complex angiogenic and inflammatory response following DEB-TACE, which may play a pertinent role in post-embolization neoangiogenesis. Two out of the four factors assayed demonstrated significant increase at 24 hours with a third factor that approached statistical significance. These findings should be confirmed in a larger cohort and in the future, may help to direct periprocedural anti-angiogenic therapy. Some patients experience early failure post-tace. Since embolization is known to promote angiogenesis, upregulation of proangiogenic biomarkers may influence disease response. VSIO41-04 Combination Ablation with Nanodrugs: Free Radicals, Heat Shock Proteins, Hif-1a and beyond S. Nahum Goldberg MD (Presenter): Consultant, AngioDynamics, Inc Research support, AngioDynamics, Inc Research support, Cosman Medical, Inc Consultant, Cosman Medical, Inc View learning objectives under main course title. VSIO41-05 Heat Shock Protein 90 (HSP90) Overexpression Correlates with Poor Hepatocellular Carcinoma Patient Survival and Targeted Inhibition of HSP90 Enhances Heat Stress Induced HCC Killing by Apoptosis and Autophagy

216 Scott M. Thompson BA (Presenter): Nothing to Disclose, Matthew Raymond Callstrom MD, PhD : Research Grant, Thermedical, Inc Research Grant, General Electric Company Research Grant, Siemens AG Research Grant, Galil Medical Ltd, Kim Butters : Nothing to Disclose, Danielle Jondal : Nothing to Disclose, David Proia PhD : Employee, Synta Pharmaceuticals Corp, Ju-Seog Lee : Nothing to Disclose, Snorri Thorgeirsson : Nothing to Disclose, Lewis R. Roberts MBChB, PhD : Research Grant, Ariad Pharmaceuticals, Inc Research Grant, Bayer AG Research Grant, Bristol-Myers Squibb Company Research Grant, Gilead Sciences, Inc Consultant, Gilead Sciences, Inc Research Grant, Inova Diagnostics, Inc Consultant, Inova Diagnostics, Inc Consultant, Nordion, Inc Research Grant, Nordion, Inc Research Grant, Wako Life Sciences, Inc Consultant, Wako Life Sciences, Inc, David Arthur Woodrum MD, PhD : Nothing to Disclose Heat shock protein 90 (HSP90) regulates numerous oncogenic signaling pathways, thereby inhibiting cancer cell death and promoting cell survival under conditions of cell stress such as thermal ablation. The aim of the present study was to test the hypothesis that inhibition of HSP90 enhances heat stress induced hepatocellular carcinoma (HCC) cell killing. All studies approved by the Institutional Review Board. Microarray analysis was performed on 139 pairs of tumor and benign liver samples from primary human HCCs to assess for HSP90α/β mrna expression and survival by HSP90α/β expression was analyzed by Kaplan Meier method. The poor prognostic N1S1 and better prognostic AS30D HCC cell lines were pre-treated with a dose-titration of the HSP90 inhibitor ganetespib or vehicle followed by sublethal heat stress (45.0 C) or control (37 C) for 10 minutes. Cell viability and clonogenic survival were assessed using WST-1 and colony formation assays (N=3). Cell death and heat stress induced oncogenic signaling were assessed using Caspase-Glo 3/7 assay and western immunoblotting. HSP90α and HSP90β were overexpressed in tumor compared to benign adjacent tissue in 72% and 58% of HCC patients, respectively, and patients with high tumor expression of HSP90α had a significantly worse overall survival (p<0.01). Inhibition of HSP90 enhanced heat stress induced HCC cell killing over heat stress or drug alone in both cell lines (p<0.01) and prevented clonogenic survival following sublethal heat stress. Ganetespib in combination with heat stress induced a 4-fold increase in caspase 3/7 activity in the AS30D but not the N1S1 cell line. Western immunoblotting demonstrated that HSP90 inhibition increased expression of autophagy and apoptosis markers LC3B and cleaved caspase 3 and blocked heat stress induced AKT and ERK signaling in the AS30D cell line and increased LC3B expression in the N1S1 cell line. These data demonstrate that HSP90α is overexpressed in a majority of HCC patients which correlates with poor prognosis. Inhibition of HSP90 with the small molecule inhibitor ganetespib enhances heat stress induced HCC cell killing by apoptosis and/or autophagy depending on the molecular subtype of HCC. HSP90 inhibition with ganetespib in combination with thermal ablation may be a promising therapeutic strategy to enhance ablation induced HCC cell killing across diverse molecular subtypes of HCC. VSIO41-06 Post-ablation Cell Survival: AKT and c-met Pathways David Arthur Woodrum MD, PhD (Presenter): Nothing to Disclose 1) Gain an understanding of why AKT and c-met pathways are important to interventional treatment of cancer. 2) Understand how disruption of these pathways could enhance ablation treatment strategies. 3) Understand what drugs in clinical trials may soon be available to promote synergism with ablation. 4) Identify challenges to implementation of combination therapies within Interventional Oncology. ABSTRACT As interventional oncology continues to evolve, it is essential to gain a better understanding of how dysregulated intracellular signaling pathways in cancer cells may alter the tumor responsiveness. This presentation will seek convey (1) why c-met/akt pathway is important to cancer cells, (2) why we should be concerned about this pathway as Interventional Radiologists, and (3) how modulation of this pathway can enhance cancer cell death secondary to interventional techniques. Interventional oncologic therapies have become crucial options in the multidisciplinary care of cancer patients, but many times our ablation strategies suffer from tumor recurrence and confounded by poor overall survival. There remains a critical need to gain further understanding of how the dysregulated intracellular molecular signaling pathways within cancer cells contribute to survival, recurrence and tumor progression after interventional oncologic treatments. c-met and AKT signaling are critical mediators of cell proliferation and survival. Furthermore, these pathways are dysregulated in many cancers. Modulation of the c-met and AKT pathways can potentially enhance cancer death secondary to interventional treatments. Ultimately, a greater understanding of the intracellular cancer signaling pathways can lead to greater treatment efficacy and potentially better survival after interventional oncologic treatments. VSIO41-07 Systemic Implications of IO Therapies: Increased Tumorigenesis? Muneeb Ahmed MD (Presenter): Nothing to Disclose

217 View learning objectives under main course title. VSIO41-08 Systemic Implications of IO Therapies: Beneficial Immune Effects? Joseph Patrick Erinjeri MD, PhD (Presenter): Nothing to Disclose View learning objectives under main course title. VSIO41-11 Thermal Ablation Devices Christopher L. Brace PhD (Presenter): Shareholder, NeuWave Medical Inc Consultant, NeuWave Medical Inc View learning objectives under main course title. VSIO41-12 IRE - What Lessons Have We Learned from the Lab Stephen Barnett Solomon MD (Presenter): Research Grant, General Electric Company Research Grant, AngioDynamics, Inc Consultant, Johnson & Johnson Consultant, Covidien AG Director, Devicor Medical Products, Inc Director, Aspire Bariatrics, Inc View learning objectives under main course title. VSIO41-13 Intraprocedural Image-guidance Luigi Solbiati MD (Presenter): Nothing to Disclose View learning objectives under main course title. VSIO41-14 Biologically based Imaging Follow-up Constantinos Thasos Sofocleous MD, PhD (Presenter): Consultant, Sirtex Medical Ltd View learning objectives under main course title. VSIO41-15 Driving the Personalized Medicine Revolution (Biomarkers) Bradford J. Wood MD (Presenter): Researcher, Koninklijke Philips NV Researcher, Celsion Corporation Researcher, BTG International Ltd Researcher,, W. L. Gore & Associates, Inc Researcher, Delcath Systems, Inc Pending research funded, Perfint Healthcare Pvt Ltd Patent agreement, VitalDyne, Inc Intellectual property, Koninklijke Philips NV Intellectual property, BTG International Ltd View learning objectives under main course title. SSM05 Chest (Interventional II) Scientific Papers IR CT CH AMA PRA Category 1 Credits : 1.00 ARRT Category A+ Credit: 1.00 Wed, Dec 3 3:00 PM - 4:00 PM Location: S406B

218 Moderator Edith Michelle Marom MD : Nothing to Disclose Moderator Laura Elizabeth Heyneman MD : Nothing to Disclose Sub-Events SSM05-01 Percutaneous Lung Biopsies Using an Ultra Low-dose Protocol on 16-slice CT: A Preliminary Study Result Guan-Min Quan MD (Presenter): Nothing to Disclose, Yang Liu : Nothing to Disclose, Tao Yuan MD : Nothing to Disclose, Shengyong Wu MD, PhD : Consultant, Qmetrics Technologies To explore the value of the dose reduction technology during lung biopsies with an ultra-low-dose (ULD) protocol. A total of ninety consecutive patients (BMI<33kg/m2)who underwent CT-guided (GE lightspeed CT,USA) percutaneous lung biopsy were enrolled and randomised into ULD group(120kv,10ma), low dose group(120kv,50ma)and the standard dose group(120kv,auto-ma); There was no significant difference about lesion features (size, location and the length of the needle path)( P>0.05). Volume CT dose index, dose length product were recorded and the effective dose was calculated.positive rate of biopsy,the incidences of total complications, incidence of intrapulmonary hemorrhage and the incidence of pneumothorax were also recorded.radiation doses were compared by using ANOVA; Positive rate of biopsy and the incidences of complications were compared by using chi-square test. The effective dose were 0.31±0.07mSv in ULD groups, 2.69±1.34mSv in low dose group, 7.29±2.71mSv in standard dose groups(f=124.16,p= ). The effective dose of ULD groups were 11.5%, 4.3% of the low dose groups and the standard dose groups.the positive rate of biopsy,the total incidences of complications,the incidence of pneumothorax and pulmonary hemorrhage were 86.7%,16.7%,13.3% and 3.3% in ULD groups,93.3%,13.3%,3.3% and 10% in low dose groups,90.0%,16.7%,16.7% and 0% in standard dose groups. The positive rate of biopsy(χ2=0.74, P=0.69),the accuracy in classification and grading of lung cancer(χ2=0.257, P=0.88), the incidences of total complications (χ2=0.17, P=0.92)had no significant difference among three groups. Radiation dose during CT-guided percutaneous lung biopsies are reduced greater through the use of a ULD CT protocol without significant difference in technical success and the incidences of complications compared with the low dose groups and the standard dose groups. Fig.1 Image of a 76-year-old woman (BMI of 24) with squamous cell carcinoma.low-dose protocol (120KV,50mA).The effective dose was 2.42mSv.Images scoring 5. Fig.2 Image of a 40-year-old man (BMI of 22) with adenocarcinoma.ultra-low-dose protocol (120KV,10mA).The effective dose was 0.2mSv.Images scoring 5. Fig.3 Image of a 70-year-old man (BMI of 21.8) with adenocarcinoma.standard dose protocol (120KV,150mA).The effective dose was 4.5mSv.Images scoring 5. SSM05-02 The Preliminary Study of Perfusion CT in Guiding Percutaneous Lung Biopsies Using Low-dose Protocol and ASIR Technology Guan-Min Quan MD : Nothing to Disclose, Yang Liu : Nothing to Disclose, Shengyong Wu MD, PhD (Presenter): Consultant, Qmetrics Technologies, Tao Yuan MD : Nothing to Disclose To explore the value of low dose perfusion CT in guiding percutaneous lung biopsies using low-dose protocol and adaptive statistical iterative reconstruction (ASIR) technology. A total of 120 consecutive patients who underwent CT-guided percutaneous lung biopsy were enrolled and randomised into group 1 (low dose perfusion),group 2(standard dose perfusion), group 3(contrast enhancement) and group 4(non-contrast-enhanced CT); there was no significant difference about lesion features. Positive rate of biopsy, the accuracy in classification and grading of lung cancer and the incidences of complications were recorded. Positive rate of biopsy, the accuracy in classification and grading of lung cancer and the incidences of complications,and radiation doses were compared between these groups. The positive rate of biopsy and the accuracy in classification and grading of lung cancer were 96.7% and 100% in group 1, 93.3% and 100% in group 2, 93.3% and 83.3% in group 3, 73.3% and 75% in group 4. The differences about the positive rate of biopsy were not statistically significant between the group 1 and 3 (χ2=0.351, P=0.554), the positive rate of biopsy of group 2 was the same with that of group 3. The accuracy in classification and grading of lung cancer of group 1 was higher than that of group 3 (χ2=4.537,p=0.033). The

219 accuracy in classification and grading of lung cancer of group 1 was the same with that of group 2. The positive rate of biopsy of group 1,2 and 3 were higher than that of group 4 (P<0.05). The incidences of total complications were 10% in group 1, 20% in group 2, 16.7% in group 3, 46.7% in group 4. The incidences of total complications of group 1,2,3 were lower than that of group 4 (P<0.05). The incidences of total complications of group1, 2 and 3 had no significant difference between each other (χ2=1.184, P=0.553). The effective dose were 4.25±0.72 msv in group1, 9.94±1.93 msv in group 2(t= ,P= ). The application of low dose perfusion CT during lung biopsies can improve the positive rate of biopsy and the accuracy in classification and grading of lung cancer with the reduction of incidences of complications. Radiation dose during CT-guided percutaneous lung biopsies is reduced greater through the use of low dose perfusion compared with standard dose perfusion group. low dose CTP of squamous cell carcinomas case SSM05-03 Does Perfusion CT Play a Role in the Evaluation of Percutaneous Microwave Ablated Lung Tumors? Nassim Parvizi MBBS, BSC (Presenter): Nothing to Disclose, Daniel Yiu Fai Chung MBBS, FRCR : Nothing to Disclose, Mark William Little MBBS, MSc : Nothing to Disclose, Fergus Vincent Gleeson MBBS : Alliance Medical Ltd Consultant, Ewan Mark Anderson MBBCh : Nothing to Disclose 1. To assess changes in perfusion CT (pct) parameters following microwave ablation (MWA) of lung tumors. 2. To determine the utility of direct visualization of perfusion maps and pct parameters to confirm adequate treatment and predict local tumor progression (LTP). Patients with primary and metastatic lung tumors who underwent pct studies immediately pre and post MWA were included. LTP was defined as nodular, enhancing tissue in continuity within the ablation zone at 6 months post MWA. Perfusion maps of the tumors were constructed using Advantage Windows Workstation and CT perfusion 3 software (GE, Milwaukee, US). Regions of interest were drawn on sequential axial sections to extract the pct parameters blood flow (BF), blood volume (BV) and mean transit time (MTT), from the entire tumor volume. Direct visualization of perfusion maps pre and post MWA was performed by two experienced observers blinded to outcome. Data was analyzed using the Student's t-test. 32 patients with a mean age of 73.5 (48-90) years, with 34 lung tumors (11 primary and 21 metastatic) underwent pct scans immediately pre and post MWA. The median tumor diameter was 20mm (10-52mm). 4 patients developed LTP, with a larger mean size at baseline compared to adequately treated tumors (28mm vs 20mm, p=0.006). pct outcome parameters for all patients pre and post MWA were BF 97 vs 62 ml/min/100g, BV 4.1 vs 2.5 ml/100mg (p=0.02) and MTT 5.3 vs 5.2 s respectively. BV was significantly reduced for patients with no recurrence pre and post MWA 4.0 vs 2.4 ml/100mg (p=0.02), respectively. Direct visualization of pct maps gave information on treatment adequacy and potential LTP. There was moderate agreement for direct visualization between the two observers (kappa coefficient 0.5). Adequate treatment was correctly determined in 26/34 lesions, with a sensitivity of 87% (CI 69-96%), specificity 75% (20-96%), PPV 96% (81-99%) and NPV 43% (10-81%). BV is the most reliable quantitative pct parameter for determining adequate treatment with MWA and in predicting LTP. Direct visualization of the perfusion maps may allow identification of areas requiring further treatment at the time of the procedure. Lack of ground glass opacification at the time of procedure hampers assessment of adequacy of microwave ablation in the lung. pct may be a useful assessment tool immediately following MWA of lung tumors. SSM05-04 Pre-operative Lung Nodule Microcoil Localization without Pleural Marking: A Novel Modification of an Established Technique Lan-Chau Thi Kha MD, MSc (Presenter): Nothing to Disclose, Kate Hanneman MD : Nothing to Disclose, Taebong Chung MD : Nothing to Disclose, Laura Donahoe MD : Nothing to Disclose, Narinder S. Paul MD : Research funded, Toshiba Corporation, Kazuhiro Yasufuku MD, PhD : Nothing to Disclose, Andrew Pierre MD : Nothing to Disclose, Shafique Keshavjee MD : Nothing to Disclose, Elsie Nguyen MD : Nothing to Disclose To evaluate the safety and efficacy of CT-guided percutaneous microcoil lung nodule localization prior to video-assisted thoracoscopic surgical (VATS) excision, comparing a novel approach without pleural marking to an established technique with pleural marking. 63 consecutive patients (66.6% female, mean age 61.6±11.4 years) with 64 lung nodules resected between October 2008 and January 2014 were retrospectively evaluated; 29.7% (n=19) had standard microcoil deployment with marking of the pleura and 70.3% (n=45) had microcoil deployment without marking of the pleura. Clinical, pathological and imaging characteristics, radiation dose, CT procedure and operating room

220 time, complete resection rates, procedural and surgical complications were compared using two-sample t-test and Fisher's exact test. There was no significant difference in pulmonary nodule size (12.6±6.3 vs. 11.8±4.5mm, p=0.55) or nodule depth from the pleural surface (9.3±6.2 vs. 7.1±6.7 mm, p=0.22) between procedures with pleural marking compared to those without. However, mean procedure duration (53.6±18.3 vs. 72.8±25.3min, p=0.001) and total effective radiation dose (5.1±2.6 vs. 7.1±4.9mSv, p=0.039) were significantly lower in the group without pleural marking compared to those with pleural marking. There was no significant difference in total complication rate between the two groups (p=0.48), including rate of pneumothoraces (p=0.77) and pulmonary hemorrhage (p=1.00). Operating room time (p=0.91) and complete resection rates (100% with pleural marking, 98% without pleural marking, p=0.52) were similar. A single case of positive resection margins was due to severely fibrotic lungs that posed technical challenges during resection. Most frequent pathology included lung adenocarcinoma (34.4%, n=22), metastases (25.0%, n=16), and adenocarcinoma in-situ (20.3%, n=13). CT-guided pre-operative lung nodule microcoil localization performed without visceral pleural marking results in shorter procedure time and lower radiation dose, with no significant difference in operating time, complete resection rates or complications. A modified pre-operative lung nodule localization technique without pleural marking is safe and effective, with shorter procedure time and lower radiation dose. SSM05-05 Does an Intra-parenchymal Blood Patch Decrease the Rate of Pneumothorax-related Complications in Patients Undergoing Image-guided Lung Biopsy? J. Louis Hinshaw MD (Presenter): Stockholder, NeuWave Medical Inc Medical Advisory Board, NeuWave Medical Inc Stockholder, Cellectar Biosciences, Inc, Scott Bissell Loomis MD : Nothing to Disclose, Meghan G. Lubner MD : Nothing to Disclose, Timothy J. Ziemlewicz MD : Nothing to Disclose, Perry J. Pickhardt MD : Co-founder, VirtuoCTC, LLC Stockholder, Cellectar Biosciences, Inc, Fred T. Lee MD : Stockholder, NeuWave Medical, Inc Patent holder, NeuWave Medical, Inc Board of Directors, NeuWave Medical, Inc Patent holder, Covidien AG Inventor, Covidien AG Royalties, Covidien AG, Douglas Robert Kitchin MD : Nothing to Disclose, David H. Kim MD : Consultant, Viatronix, Inc Co-founder, VirtuoCTC, LLC Medical Advisory Board, Digital ArtForms, Inc There have been multiple smaller studies evaluating the role of an intraparenchymal blood patch (IPB) during lung biopsy, but they have shown mixed results and controversy remains as to the true efficacy of this technique. Therefore, the purpose of this study was to determine whether an autologous IBP reduces the rate of pneumothorax-related complications during CT-guided lung biopsies. We reviewed all CT-guided lung biopsies performed between Aug 2006 and Sept Patients were excluded if no aerated lung was crossed. Data collected included: Number of pneumothoracies, and number of pneumothoracies requiring intervention (all catheter placements), as well as more advanced interventions (e.g. chest tube placement and hospital admission or pleural blood patch). The patients were assigned to two groups. Those that received an IBP and those that did not. The rate of pneumothorax, intervention, and advanced intervention were compared between the two groups. 839 patients were included in the study. Patients that received an IBP had a significantly decreased rate of pneumothorax, pneumothorax-related intervention, and advanced intervention ((142/482) 29% vs (154/357) 43%, p Autologous IPB placement is associated with a decreased rate of pneumothorax, and, more importantly, pneumothorax requiring intervention after CT-guided lung biopsies. Although this benefit has not resulted in a significant decrease in chest tube placement and hospital admission in our practice, this can be accounted for by the success of a pleural blood patch in obviating the need for hospital admission for many of these patients. Autologous IPB placement has remained somewhat controversial due to mixed results in published series, but this large series confirms that there is a benefit, with a decreased rate of pneumothorax, and, more importantly, pneumothorax requiring intervention after CT-guided lung biopsies. SSM05-06 Ultrasonography-guided Biopsy of Supraclavicular Lymph Nodes for Diagnosis of Metastasis and Identifying Harboring Epidermal Growth Factor Receptor (EGFR) Mutation in Lung Cancer Jooae Choe MD (Presenter): Nothing to Disclose, Mi Young Kim MD, PhD : Nothing to Disclose, Chang-Min Choi : Nothing to Disclose, Hwa Jung Kim : Nothing to Disclose, Jung Hwan Baek : Nothing to Disclose To evaluate the role of ultrasonography(us)-guided supraclavicular lymph node(scn) for detecting metastasis and epidermal growth factor receptor(egfr) mutation in lung cancer.

221 This retrospective study was approved by the institutional review board. We enrolled 253 consecutive patients (167 men, 86 women; years) who underwent US-guided core biopsy (using 18G cutting needle) of SCN from Jan to Dec Two independent radiologists measured sizes of SCNs in short and long dimensions on US and chest CT images. Gold standard for the evaluation of target SCN was combination of CT, FDG-PET/CT, US-guided biopsy, pathology, and subsequent CT after treatment. TNM stages, SUV on FDG-PET/CT, and findings of SCNs on US and CT were compared between the positive(disease group) and the negative(control group) for metastasis. Diagnostic performance was compared between US-guided biopsy and CT. The prevalence of EGFR mutations of SCNs harboring adenocarcinoma and biopsy-related morbidity were evaluated. Final diagnoses were adenocarcinoma (n = 183), squamous cell carcinoma (n = 54), other non-small cell lung cancer (n = 11), and small cell cancer (n = 5). Disease group (n = 207, 82%) was associated with higher frequency of adenocarcinoma (n = 158, p =.009), higher TNM stages (p = for T, p <.001 for N, p <.001 for M, respectively), larger mean short (10 vs 6 mm)/long (15 vs 11 mm) dimensions on US (p <.001), larger mean short (10 vs 7 mm)/long (15 vs 11 mm) dimensions on CT (p <.001), and higher SUVs (7.2 vs 2.7, p <.001) than control group (n = 46, 18%). Interclass correlation coefficient was to SCN metastasis was missed on CT in 57 patients(22.5%), and among them, 33 patients(13.0%) were positive for malignant cells on US-guided biopsy. Analysis of EGFR mutation in SCN was feasible in 122(71.5%) of 181 patients. EGFR mutations were positive in 40 patients(32.8%) [28(23.0%) in exon 19, 10(8.1%) in exon 21, 2(1.6%) in exon 18]. None of patients had biopsy related morbidity. US-guided SCN biopsy is a reliable and safe method for tissue confirmation of metastatic lung cancers and evaluation of mutations. The metastasis rate of SCN is higher with adenocarcinoma, larger sizes, higher SUVs, and higher TNM stages. US-guided biopsy might substitute invasive percutaneous or bronchoscopic biopsy of patients who have initially advanced lung cancer with enlarged SCN. SSM24 Vascular/Interventional (IR: Radiation Safety) Scientific Papers SQ IR VA AMA PRA Category 1 Credits : 1.00 ARRT Category A+ Credit: 1.00 Wed, Dec 3 3:00 PM - 4:00 PM Location: E352 Moderator Sarah Beth White MD : Consultant, Guerbet SA Consultant, Vascular Solutions, Inc Research support, Seimens AG Moderator Robert G. Dixon MD : Nothing to Disclose Sub-Events SSM24-01 Should the Informed Consent Process for Interventional Radiology Procedures include the Risk of Radiation Exposure: The Interventional Radiology Patient Perspective Rebecca Zener MD (Presenter): Nothing to Disclose, Daniele Patrice Wiseman MD, FRCPC : Nothing to Disclose, Amol Mujoomdar MD : Speaker, Cook Group Incorporated Speaker, Covidien AG Radiation exposure is inherent in interventional radiology procedures. A potential exposure of 1 msv has been suggested as a cutoff for provision of risk information, as it corresponds to a 1 in cancer risk. Informed consent requires disclosure of rare yet potentially significant risks, yet patient knowledge of these risks is lacking. The purpose of this study is to explore patient perception of cancer-related risk exposure and whether inclusion of radiation risks in the informed consent is warranted. A multiple-choice survey was prospectively administered to 26 adult interventional radiology patients at a tertiary care centre (patient mean age = 61.4 years; 64% female,; 36% male). 58% of patients had previously undergone an IR procedure. Statistical analysis with Fisher Exact test (p<0.05) was performed. Most patients want to be informed if there is a radiation-related 3% increased cancer risk over 5 years (89%), or if the associated risk is 1 in 1000 (79%) or 1 in (63%). While half of the cohort considers 3% small, 35% want to further discuss the risks and alternate options, and 15% would only proceed if it were a life-saving procedure. Only 62% of patients were aware they were going to be exposed to radiation, irrespective of previous IR history. Most patients believe radiation consent should be routine for IR procedures (85%) and

222 include radiation-related cancer risks (88%). A majority (62%) believes that the referring physician and the interventional radiologist are responsible for informing patients, and verbal radiation consent is sufficient. No significant difference was present between groups based on previous IR history (p>0.05). Patient awareness of radiation exposure is suboptimal. Based on this survey, a majority of patients want to discuss cancer-related radiation risks in order to make informed decisions. Interventional radiologists should consider including radiation consent in the informed consent for procedures with anticipated doses above 1 msv. Interventional radiology patients want to discuss cancer-related radiation risks in order to make informed decisions, and interventional radiologists should consider including radiation consent in the informed consent for procedures with anticipated doses above 1 msv. SSM24-02 Substantial X-ray Dose Reduction in Intra-arterial Therapy for Liver Cancer: A New Angiographic Imaging Technology Ruediger Egbert Schernthaner MD (Presenter): Nothing to Disclose, MingDe Lin PhD : Employee, Koninklijke Philips NV, Julius Chapiro MD : Nothing to Disclose, Rafael Duran MD : Nothing to Disclose, Boris Gorodetski : Nothing to Disclose, Jean-Francois H. Geschwind MD : Consultant, BTG International Ltd Consultant, Bayer AG Consultant, Guerbet SA Consultant, Nordion, Inc Grant, BTG International Ltd Grant, F. Hoffmann-La Roche Ltd Grant, Bayer AG Grant, Koninklijke Philips NV Grant, Nordion, Inc Grant, ContextVision AB Grant, CeloNova BioSciences, Inc Founder, PreScience Labs, LLC CEO, PreScience Labs, LLC To investigate potential x-ray dose reduction, without compromising image quality, of fluoroscopy and digital subtraction angiography (DSA) of a new angiographic imaging system in patients undergoing intra-arterial therapy (IAT) for liver cancer. In this ongoing prospective trial, 25 consecutive patients underwent hepatic IAT on a new imaging platform (AlluraClarity, Philips Healthcare, Best, The Netherlands). For detailed dose-logging, a radiation dose structured reporting (RDSR) system was setup that included air kerma (AK) and dose area product (DAP) for each run (fluoroscopy, digital subtraction angiography (DSA),single shot exposure and Cone Beam CT). The dose from this imaging platform was compared to 25 other consecutive patients who underwent similar procedures on the predecessor imaging platform (Allura, Philips Healthcare). DSA image quality for both imaging platforms was assessed on a five-rank-scale in a randomized and blinded fashion. Paired t-test was performed for BMI and fluoroscopy time, Mann-Whitney U test was used to compare image quality and dose of each type of run between the two imaging platforms. Both patient cohorts showed no difference with regard to BMI (p=0.87) and fluoroscopy time (p=0.98). The new system resulted in a significant dose reduction in total AK and DAP of 58% and 60% compared to the old platform (median of 0.47 Gy and Gy*cm2 vs Gy and Gy*cm2, respectively (p<0.01)). Specifically, DAP for fluoroscopy and DSA decreased significantly by 60% and 77%, respectively (p<0.01). During the procedures, no relevant problems due to image quality were reported. Likewise, the blinded evaluation of image quality revealed no differences between the new and the old imaging platforms (mean score 1.16 vs 1.24; p=0.48). The new imaging platform allowed for significant x-ray radiation dose reduction in patients undergoing IAT for liver cancer without compromising image quality. During the last decade, the use of hepatic IAT has steadily increased. Thus, the reduction of x-ray dose for both patients and clinicians is essential for radiation protection. SSM24-03 Occupational Radiation Exposure during Endovascular Aortic Repair Anna Margaretha Sailer MD, MBA (Presenter): Nothing to Disclose, Geert Willem H. Schurink MD, PhD : Nothing to Disclose, Martine Bol : Nothing to Disclose, Michiel W. De Haan MD, PhD : Nothing to Disclose, Wim Van Zwam MD : Nothing to Disclose, Joachim Ernst Wildberger MD, PhD : Nothing to Disclose, Cecile R. L. Jeukens PhD : Nothing to Disclose Aim of this study was to evaluate the radiation exposure to operating room personnel and its determinants during endovascular aortic repair procedures.

223 Occupational radiation exposure was prospectively evaluated during forty-four endovascular aortic repair procedures. Procedures were performed between 07/2013 and 01/2014 on our hybrid operating room (Allura Xper with ClarityIQ, Philips Medical Systems, Best, The Netherlands). Twenty-two infrarenal aortic procedures (EVAR), eleven thoracic aortic procedures (TEVAR) and eleven fenestrated or branched aortic procedures (FEVAR) were included. Real-time over-lead dosimeters attached to the left breast pocket (DoseAware, Philips) were used to measure personal doses for operators (first (FS) and second (SS) surgeon), radiology technicians (RT), scrub nurses (SN), and anesthesiologists (AN). Besides protective apron and thyroid collar, no radiation shielding was used. Procedural dose area product (DAP), iodinated contrast volume, fluoroscopy time, patients' weight and angulation of the C-arm were documented. Results were analyzed using regression coefficient and Kruskal-Wallis test. Average procedural over-lead dose and standard deviation was 0.17 ±0.21 msv for the FS, ±0.045 msv for the SS, ±0.042 msv for the RT, ±0.031 msv for the SN and ±0.007 msv for the AN. FS doses were significantly higher during FEVAR compared to EVAR and TEVAR (mean FS dose during FEVAR: 0.34 ±0.28 msv, EVAR: 0.11 ±0.21 msv, TEVAR: 0.06 ±0.05 msv; p= 0.003). There was a significant correlation between the dose of the FS and procedural DAP (R= 0.686, p< 0.001) and iodinated contrast volume (R= 0.672, p< 0.001) and a weak correlation with fluoroscopy time (R= 0.396, p= 0.049). Usage of left anterior C-arm projections >60 degrees was associated with significantly higher FS doses (p= 0.02). For EVAR procedures, a significant correlation between FS dose and patient's weight was found (R= 0.561, p= 0.024). SS dose and AN dose were significantly correlated with the FS dose (R= 0.668, p= and R= 0.838, p< 0.001). Strong predictors for high personal doses are procedural DAP, iodinated contrast volume, patient weight and left lateral C-arm angulation >60 degrees. The first surgeon received an average procedural dose of 0.17 msv, which was on average a factor four higher than the second surgeon who received the second highest average dose. SSM24-04 Patient Radiation Dose Reduction during Transarterial Chemoembolization Using a Novel X-ray Fluoroscopy Imaging Acquisition and Processing Platform Ryan Michael Kohlbrenner MD (Presenter): Nothing to Disclose, Kanti Pallav Kolli MD : Research Grant, Koninklijke Philips NV, Andrew Grenville Taylor MD, PhD : Nothing to Disclose, Maureen Pearl Kohi MD : Nothing to Disclose, Nicholas Fidelman MD : Nothing to Disclose, Jeanne M. Laberge MD : Nothing to Disclose, Robert K. Kerlan MD : Nothing to Disclose, Robert G. Gould DSc : Research Grant, Koninklijke Philips NV To compare the patient radiation doses during transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) performed with Philips Allura Xper versus Philips Allura Clarity imaging platforms. Total fluoroscopy time, cumulative air kerma, and cumulative dose area product data were retrospectively collected for 129 TACE procedures performed to treat HCC. The first 85 procedures were performed in an interventional radiology suite equipped with the Philips Allura Xper imaging platform. The subsequent 44 procedures were performed in the same suite following installation of the Philips Allura Clarity imaging platform. To confirm similarities in patient size, the anteroposterior diameter of the upper abdomen at the level of the portal vein bifurcation was assessed on CT or MRI for all patients in both groups. Mean values were compared using two-tailed t-tests. Following installation of the Philips Allura Clarity platform, a 43.7% reduction in mean cumulative dose area product ( versus mgy-cm2, p < ) and a 29.5% reduction in mean cumulative air kerma ( versus mgy, p < 0.001) were found in comparison to procedures performed with the Philips Allura Xper platform. Total fluoroscopy time was 20% greater ( versus seconds, p <.05) for procedures performed with Allura Clarity compared with Allura Xper. Patient size was similar between the two groups (Anteroposterior thickness of versus mm, p =.70). The Philips Allura Clarity imaging acquisition and processing platform significantly reduces patient radiation dose when compared to Philips Allura Xper in patients of comparable size undergoing TACE for HCC treatment. Dose reduction was achieved despite an increase in average fluoroscopy time. Further studies are necessary to determine whether the increase in fluoroscopy time is related to image quality or bias in patient selection to treat more difficult cases in the new low-dose room. TACE procedures can be successfully performed at patient radiation doses significantly below current norms.

224 SSM24-05 Radiation Dose Reduction in Two Common Interventional Procedures Following Allura ClarityIQ Upgrade Jaydev Kardam Dave PhD, MS (Presenter): Nothing to Disclose, David J. Eschelman MD : Consultant, Guerbet SA, Carin F. Gonsalves MD : Nothing to Disclose, Eric Laurence Gingold PhD : Nothing to Disclose To investigate radiation dose reduction post installation of an image processing upgrade for an interventional x-ray system. Philips Allura ClarityIQ upgrade provides automatic motion artifact reduction, temporal and spatial noise reduction, and contrast enhancement, allowing a reduction in radiation dose. Air kerma rate (AKR) measurements were made with acrylic simulating 9-27cm patient thickness for 19"-6" magnification modes and 2 dose modes, before and after ClarityIQ upgrade. Dose indicators (cumulative air kerma (CAK) and dose area product (DAP)) for two types of interventional procedures (chemo/immuno-embolization and routine catheter check/change) were analyzed for patients who were treated, before and after ClarityIQ upgrade, as part of their standard of care. Two experienced interventional radiologists (blinded to dose values) selected cases matching in complexity, number of digital acquisitions and fluoroscopy time, and provided a subjective evaluation of image quality. For acrylic measurements, AKR was reduced by 25-77% after ClarityIQ upgrade. Thirteen chemo/immuno-embolization patients and 20 patients with routine catheter procedures were identified. There were no statistical differences in fluoroscopy time or digital acquisitions between the procedures for each patient (p>0.05). The mean reduction for the embolization procedures in CAK was 347 mgy (95% CI: mgy; p<0.001) and in DAP was mgy.cm2 (95% CI: mgy.cm2; p<0.001) when ClarityIQ was used; resulting in a 37-79% reduction in CAK and 51-84% in DAP on a per patient basis. For routine catheter procedures, the mean reduction in CAK was 33 mgy (95% CI: mgy; p<0.001) and in DAP was mgy.cm2 (95% CI: mgy.cm2; p<0.001) when ClarityIQ was used, resulting in a reduction of 27-81% in CAK and 14-89% in DAP on a per patient basis. Subjective evaluation of patient images revealed no loss in image quality when ClarityIQ was used. ClarityIQ upgrade resulted in a 14-84% reduction in radiation dose indicators to patients for the procedures considered in this study, consistent with expectations based on phantom measurements, without loss in perceived image quality. An image processing upgrade for an interventional radiology system allows reduced radiation dose in both fluoroscopy and digital acquisition modes, reducing potential risks to both patients and staff. SSM24-06 Significant Acquisition Dose Reduction Maintains Diagnostic Quality of Biplane Cerebral Digital Subtraction Angiography Amir Reza Honarmand MD (Presenter): Nothing to Disclose, Ali Shaibani MD : Nothing to Disclose, Michael Charles Hurley MBBCh : Nothing to Disclose, Christina Louise Sammet PhD : Nothing to Disclose, Sameer A. Ansari MD, PhD : Shareholder, RaPID Medical Technologies, LLC We aimed to investigate the feasibility of reducing the radiation exposure dose in diagnostic cerebral DSA examinations while preserving the overall image quality for diagnostic purposes. Following IRB approval, a prospective study was performed on patients undergoing diagnostic cerebral DSA using biplane flat detector angiography unit. DSA images were acquired using a predefined manufacturer standard program by selecting detector dose of 3.6 μgy/frame (mean typical tube voltage (TTV): 80.6 kvp, mean tube current (TC): ma, using focal spot size (FS) of 0.6 and inherent filtration) and reduced detector dose of 1.2 μgy/frame (mean TTV: 73.6 kvp, mean TC: ma, using FS of 0.3 with additional 0.1/0.2 copper filter) dose protocols for each patient. Using identical contrast agent, contrast injection rate, and fluoroscopy time, randomly selected internal carotid or vertebral arteries and their contralateral equivalent arteries were injected to obtain standard radiation dose and low radiation dose AP and lateral DSA images, respectively. Image quality assessment was performed independently by two neurointerventionalists. A 5 point scale was used for qualitative evaluation of arterial, capillary, and venous phases of DSA images respectively. The total score was defined as the overall diagnostic value. Paired sample t-test and Wilcoxon's signed rank test compared the kerma-area product (KAP) and scores assigned to image quality parameters, respectively. P value <0.05 was considered statistically significant. Twenty-three DSA image series were obtained from nine patients (8M/1F, mean age: 65.9) undergoing diagnostic DSA. Mean KAP was significantly reduced by 60% or 2.5 fold ( ± μgy/m2 versus ± μgy/m2, P <0.0001). No significant difference was observed between image quality scores

225 assigned by the observers while assessing arterial (observer 1(O1): P=1.0; observer 2 (O2): P=0.24), capillary (O1: P=0.54; O2: P=0.3), venous (O1: P=0.14; O2: P=0.7) phases, and overall diagnostic value (O1: P=0.34; O2: P=0.8). Radiation exposure dose can be reduced significantly without compromising image quality for diagnostic purposes in cerebral DSA studies. Significant reduction of radiation exposure dose is feasible while maintaining image quality for diagnostic and therapeutic purposes in intracranial endovascular procedures. SSM25 Vascular/Interventional (IR: CTA) Scientific Papers IR CT VA AMA PRA Category 1 Credits : 1.00 ARRT Category A+ Credit: 1.00 Wed, Dec 3 3:00 PM - 4:00 PM Location: E450B Moderator Hyeon Yu MD : Nothing to Disclose Moderator Gordon McLennan MD : Data Safety Monitoring Board, B. Braun Melsungen AG Research Grant, C. R. Bard, Inc Consultant, C. R. Bard, Inc Consultant, Medtronic, Inc Consultant, Siemens AG Consultant, Eli Lilly and Company Scientific Advisory Board, Surefire Medical, Inc Scientific Advisory Board, Rene Medical Sub-Events SSM D CTA for the Evaluation of Arteriovenous Malformations A Pilot Study Peter Veendrick MD (Presenter): Nothing to Disclose, Ritse Maarten Mann MD, PhD : Speakers Bureau, Bayer AG, Carine Van der Vleuten MD, PhD : Nothing to Disclose, Frederick Jan Anton Meijer MD : Nothing to Disclose, Dietmar Ulrich MD, PhD : Nothing to Disclose, Bas Verhoeven MD, PhD : Nothing to Disclose, Marc Wijnen MD, PhD : Nothing to Disclose, Wendy Busser MMedSc : Nothing to Disclose, Frank DeLange PhD : Nothing to Disclose, Leo Schultze Kool MD : Nothing to Disclose Digital subtraction angiography (DSA) is considered the gold standard in evaluating arteriovenous malformations (AVMs). In recent years four-dimensional CT-angiography (4D-CTA) has emerged as a new modality to image vascular anatomy and flow characteristics. The objective of the study was to evaluate the applicability of 4D-CTA in patients with AVMs for treatment planning considering dose and image quality compared to DSA. In this cohort study 23 4D-CTA scans were obtained in 18 patients from June 2011 to March All 4D-CTAs were acquired using a 320 detector row CT-scanner (Toshiba Aquilon ONE). Effective dose was calculated using dose-length product and standard dose conversion factors. The angiographies were performed on a high-end angiography system (Philips Alura). Effective dose was calculated using the dose-area product. Alternate reading of the DSA and 4D-CTA images was performed by two experienced observers to assess which modality offered the best diagnostic information. A subjective scale was used to compare the DSA and 4D-CTA images. Additionally, 8 of the 23 4D-CTA scans were recalculated to 10 frames per second (fps) and compared to standard 2 fps 4D-CTAs. Diagnostic information and treatment planning using 4D-CTA was superior to DSA in 11 of the 18 patients (61%), equal to DSA in 4 patients (22%) and inferior to DSA in 3 patients (17%). The 8 4D-CTAs with 10 fps provided better evaluation of the AVM in all patients compared to standard 2 fps 4D-CTA. Average effective dose of the 4D-CTAs was msv ( , median 5.53). Average effective dose of the DSAs was 18.3 msv ( , median 10.5). The large variance in dose values is caused by the differences in imaged anatomic regions and their differences in conversion factors. 4D-CTA seems to be a promising new imaging modality to evaluate an AVM. In our opinion 4D-CTA images allow for better treatment planning of the AVM in a majority of patients compared to diagnostic DSA. 4D-CTA recalculated to 10 fps gave more insight into the angio-architecture than a standard 2 fps 4D-CTA. Dose comparison revealed a lower average and median effective dose for 4D-CTA than for DSA.

226 4D-CTA scans allow for better treatment planning of the AVM in a majority of patients compared to DSA with lower average effective dose. SSM25-02 Dynamic CT Angiography of Arterio-venous Fistulas: Feasibility and Impact on Therapy Management in Comparison to Ultrasound Mathias Meyer (Presenter): Nothing to Disclose, Holger Haubenreisser : Nothing to Disclose, Sonja Sudarski MD : Nothing to Disclose, Stefan Oswald Schoenberg MD, PhD : Institutional research agreement, Siemens AG, Thomas Henzler MD : Nothing to Disclose To prospectively evaluate the feasibility and potential impact on therapy management of dynamic computed tomography angiography (dcta) in patients with forearm arterio-venous fistula (AVF). Fifteen patients with malfunctioning forearm AVFs were examined with ultrasound and a dcta protocol on a 3rd generation dual-source CT using the following scan parameters: 21 phases; 2.5s/phase, 80kV, 100mAs, volume of contrast medium 45mL, flow rate 5.0mL/s. Forearm AVFs were classified into high-flow shunts, stenotic shunts (>50%) or non-stenotic shunts (<50%) by two radiologist. Further, therapy management was evaluated using only ultrasound examination and again by using dcta in a consensus read by a radiologist and a vascular surgeon. Contrast arrival times and HU values were evaluated by placing regions-of-interest in arterial, venous and muscle structures of the arm. All imaging studies were completed without any complications and contrast enhancement was rated as sufficient in all patients. Eight patients were scanned with their arms above their head and the other 7 patients with their arms aligned next to their body. Six patients were classified as having high-shunt flow and 6 were classified as having stenotic AVF grafts. The highest mean AVF enhancement was achieved 17 seconds after contrast media application (mean 412±84 HU). Utilizing the information from the dcta protocol lead to a change in therapy management in5 patients when compared to ultrasound alone. Dynamic CTA provides adequate AVF contrast enhancement as well as valuable additional clinical information, improving diagnostic confidence and leading to changes in therapy management when compared to ultrasound alone. 3rd generation dual-scource CT enables dcta which is especially important as dcta allows -next to stenotic lesion evaluation- also the evaluation of abnormalities like high-flow shunts. SSM25-03 Impact of a Novel CT-based Iliac Artery Calcium Scoring System on Renal Transplant Outcomes Bradley Carl Davis MD (Presenter): Nothing to Disclose, Daniele Marin MD : Nothing to Disclose, Matthew Ellis MD : Nothing to Disclose, Bradley Collins MD : Nothing to Disclose, Lynne Michelle Hurwitz MD : Research Grant, Siemens AG Research Grant, General Electric Company, Charles Yoon Kim MD : Consultant, CareFusion Corporation Research Grant, Galil Medical Ltd Consultant, Kimberly-Clark Corporation Consultant, Cryolife, Inc To assess whether a novel composite calcium score of the iliac arteries correlates with outcomes after renal transplantation Retrospective review of renal transplant recipients who underwent CT scanning of the pelvis within 2 years prior to surgery revealed 131 patients (mean age 52, 75 male, 56 female). A semiquantitive calcium score (0-12) incorporating calcium morphology, length and circumferential involvement was generated for each common and external iliac arteries. Operative and clinical notes were reviewed to determine the complexity of the operation. High complexity operations were defined as those requiring nonstandard technique such as intra-operative vascular surgical consultation, inspection of more than one arterial segment due to concern for suboptimal arterial anastomotic target, or any other adjunct arterial surgery. Additionally, all arterial complications such as arterial dissection, anastomotic stenosis, pseudoaneurysm, or hemorrhage were identified. Laboratory values were reviewed to identify delayed graft function (DGF) (need for dialysis within the first week post transplant) and renal function at 1 year based on the egfr. Renal allograft survival (based on return to dialysis or retransplant) and patient survival were calculated using the Kaplan-Meier technique. Out of 131 patients who underwent renal transplantation with available CT imaging, 38 patients had their allograft anastomosed to an external iliac artery with some degree of calcification. Seven patients had an arterial complication, 23 were classified as high-complexity, and 17 had DGF. A calcium score of 5+ of the anastomosed external iliac artery correlated with significantly higher rates of DGF (25% vs 8%, p=0.015) and high-complexity operations (46 vs 4%, p<0.001). However, the calcium score did not correlate significantly with arterial complications, the 1-year egfr or graft survival. Patients with any degree of iliac arterial calcification had significantly lower 1-year patient survival after transplant (92% vs 98%, p=0.05, logrank

227 test). The proposed novel calcium scoring system correlated significantly with renal transplant case complexity and episodes of delayed graft function Routine pre-transplant CT for arterial calcium scoring may enable optimal artery selection for anastomosis and ensure appropriate operative planning to reduce surgical complexity SSM25-04 Recently Ruptured Carotid Plaques Demonstrate an Increased Content of Soft Atheroma on CTA Compared to Asymptomatic Carotid Lesions Joseph Luka MD (Presenter): Nothing to Disclose, Linda Le MD : Nothing to Disclose, Hernan Bazan MD : Nothing to Disclose Increasing evidence suggests carotid plaque composition may play an important role in predicting future ischemic events aside from stenosis severity. Soft atheroma has been associated with an increased risk of atherosclerotic plaque rupture. We hypothesized that patients undergoing 'urgent CEA' for acute neurological symptoms have a larger amount of soft atheroma compared to patients with asymptomatic high-grade carotid stenosis. Plaque analysis using the TeraRecon Aquarius software was done on pre-operative CTA images of 'urgent' (n=43) and asymptomatic (n=38) CEA patients from Soft atheroma (0-150 Hounsfield Units, HU), contrast ( HU), and calcium ( HU) volumes were measured. Non-paired two-tailed t-test was used to determine significance. The volume of soft atheroma was greater in the 'urgent' compared to the asymptomatic group (32.36±2.85% vs ±2.27%, p = 0.048); no difference was found in the amount of calcium between groups (14.8% vs %, p=0.62). The volume of soft atheroma compared to calcified plaque was greater in the 'urgent' group (32.36±2.85%, 14.08±2.16%, p < ) and in the asymptomatic group (24.94±2.27%, 15.64±2.32%, p = 0.005; Figure). An increased volume of soft atheroma representing a large lipid component is found in patients presenting with acute neurological symptoms, compared to patients with asymptomatic high-grade carotid stenosis. These data suggests that CTA quantification of soft atheroma may be a useful non-invasive marker to assess carotid plaque vulnerability. Analysis of carotid plaque morphology can have significant implications for the selection of patients who would benefit from carotid revascularization. To study the vulnerable plaque, we determined whether there are differences between urgently performed CEAs for acute neurological symptoms and in patients undergoing CEA for asymptomatic high-grade carotid stenosis. We demonstrate the novel finding that acutely symptomatic carotids have a greater amount of soft atheroma, compared to patients with asymptomatic carotid stenosis. Since the lipid-rich/soft atheroma component of a carotid plaque is likely an important predictor of stroke risk in patients with carotid stenosis, future studies based on this methodology may help to further risk stratify patients with asymptomatic carotid disease at risk for plaque rupture. SSM25-05 Accuracy of MDCT Angiography of the Anterior Abdominal Wall in the Planning of the Mammary Reconstruction with DIEP-Flap in Mastectomized Patients Francesco Carbonetti MD (Presenter): Nothing to Disclose, Antonio Cremona : Nothing to Disclose, Pierluigi Aloisio : Nothing to Disclose, Nicola Maltzeff : Nothing to Disclose, Giuseppe Argento : Nothing to Disclose, Carlo Capotondi MD : Nothing to Disclose, Vincenzo David MD : Nothing to Disclose Objective of the study was to prove accuracy and feasibility of MDCT Angiography of the anterior abdominal wall in the planning of breast reconstruction with DIEP flaps in mastectomized patients. 34 nulliparous (average age 54 yrs.) and 20 multiparous ( average age 48 yrs.) underwent MDCT Angiography of the abdominal anterior wall to study the deep inferior epigastric arteries (DIEA) and its perforating branches. (GE 16X0.625,pitch 1.3,120KV, Xenetix 350) With MPR,MIP and VR reconstructions were evaluated the caliber and integrity of DIEA,the caliber of the perforating arteries at the emergence of the anterior fascia of the rectus abdominis muscle, respectively, and their distance from the transverse umbilical line and the linea alba. The collected data were verified by surgeons in the operating room. A standardized BMI was used for each patient.

228 For the deep inferior epigastric artery (DIEA) Moon and Taylor classification was used. A correspondence of 100% of the number and location of the perforating arteries was found between the results obtained at the MDCT-Angiography and the surgical results. It was recorded an average caliber size of 1.2 mm for the medial perforating vessels and 0.9 mm for the lateral. In 10/54 patients the caliber of the vessels was overstimated at the MDCT-Angiography, the most frequent complications during surgery were related to venous necrosis of the vessels. Nullipaours showed greater calibers of the arteries compared to multiparous, overweight and obese patients showed greater calibers compared to normal weight patients.p-value was calculated and data were statistically significant. MDCT-Angiography is a valid technique in the planning of the mammary reconstruction with DIEP flap which permit an accurate evaluation of the perforating vessels and the possibility to decrease the time of the surgery. MDCT-Angiography could be used to detect with an high accuracy the vessels needed to perform the DIEP-Flap in order to reduce the operating time and avoid complications, nullipaourous female, overweighed and obese patients (both nulliparous and mutliparous ) should be found to have greater calibers of the perofrating vessels compared to the normal weighted patients SSM25-06 The Role for Radiological Evaluation of Geniculate Flow in Trauma Patients Sean Keith Johnston MD (Presenter): Nothing to Disclose, Nagaramesh Chinapuvvula MBBS : Nothing to Disclose, Anahita Dua MD, MS : Nothing to Disclose, Sapan S. Desai MD, PhD : Nothing to Disclose, Jennifer H. Johnston MD : Nothing to Disclose, Shelia Coogan MD : Nothing to Disclose Assesment of limb viability after injury is clasically based on clinical examination and distal vessel perfusion on CT-angiography (CTA).The purpose of this study was to correlate geniculate artery (GA) perfusion with limb salvage outcomes to determine if GA perfusion status should be part of the standard CTA report in the setting of trauma to assist in evaluating limb viability Patients with lower extremity injury were identified retrospectively using the institutional trauma database at a level I trauma center. Patients without CTA, missing records, or under the age of 16 were excluded. Datapoints included demographics, injury severity score (ISS), mechanism of injury, popliteal and GA flow (superior medial, superior lateral, medial, inferior medial, and inferior lateral) on CTA, and limb salvage outcome (amputation vs no amputation). Statistical analysis was completed using analysis of variance (ANOVA) for continuous variables and chi-squared for categorical variables. P <0.05 was considered statistically significant. Values are presented as mean +/- standard deviation where possible. From , 84 patients with CTA-confirmed distal extremity injury were identified.there were no significant differences between groups with regard to demographic factors, mechanism of injury, or severity of injury.amputation rates tended to increase as the number of perfused geniculate arteries decreased.patients with 3 patent GA's as opposed to 2 or 1 regardless of the specific arteries involved were less likely to have an amputation (P<0.05).Patients who underwent amputation and had popliteal artery occlusion had fewer intact GA's than those with successful limb salvage (2.4 vs. 2.7, P=0.36).This trend remained consistent in patients with any popliteal artery injury (2.4 vs. 2.8, P=0.23).No patients with 3 or 5 patent GA's underwent an amputation (r = -0.76). There appears to be a inverse relationship between number of patent geniculate arteries and lower extremity amputation after traumatic injury.geniculate collateralization may be a key marker of limb viability.reporting the number of perfused geniculate arteries on CTA for mangled extremities may aid in clinical decision-making. CTA assesment of genculate artery perfusion in trauma may play a key role in assesment for surgical intervention, and should be included in the CTA report when appropriate. MSCP51 Case-based Review of Pediatric Radiology (An Interactive Session) Multisession Courses PD IR MK GI AMA PRA Category 1 Credits : 1.50 ARRT Category A+ Credits: 1.50 Thu, Dec 4 8:30 AM - 10:00 AM Location: S406A

229 Director Sudha Ayyala Anupindi MD Nothing to Disclose 1) Access the results of new research and assess their potential applications to clinical practice. 2) Improve basic knowledge and skills relevant to clinical practice. 3) Practice new techniques. 4) Assess the potential of technological innovations and advances to enhance clinical practice and problem-solving. 5) Apply principles of critical thinking to ideas from experts and peers in the radiologic sciences. Sub-Events MSCP51A Abdominal Masses in Children Sudha Ayyala Anupindi MD (Presenter): Nothing to Disclose 1) Identify the common types of abdominal tumors in children and the practical pathway of imaging. 2) Analyze the common features of these abdominal tumors in a case based format. 3) Discuss the differential diagnosis and therapeutic options for each case. ABSTRACT During this session we will be presenting cases of common pediatric abdominal tumors. The following are the learning objectives: At the end of the session the participant will be able to: 1) Identify the common types of abdominal tumors in children and the practical pathway of imaging 2) Analyze the common features of these abdominal tumors in a case based format 3) Discuss the differential diagnosis and therapeutic options for each case MSCP51B Interventional Procedures in Infants and Children Ricardo Restrepo MD (Presenter): Nothing to Disclose View learning objectives under main course title. MSCP51C Pediatric Bone Marrow Imaging Kirsten Ecklund MD (Presenter): Nothing to Disclose 1) Apply conventional and advanced MR techniques to design adequate protocols for assessment of pediatric bone marrow disorders. 2) Recognize normal age related variations in bone marrow signal intensity throughout the skeleton. 3) Identify primary and secondary marrow abnormalities that accompany focal and systemic disorders of the musculoskeleton. RC611 Update on Radionuclide Therapies Refresher/Informatics OI NM IR AMA PRA Category 1 Credits : 1.50 ARRT Category A+ Credits: 1.50 Thu, Dec 4 8:30 AM - 10:00 AM Location: S505A Sub-Events RC611A New Guidelines for I-131 Therapy of Thyroid Cancer Don C. Yoo MD (Presenter): Consultant for Endocyte 1) Describe why thyroid cancer is increasing. 2) Review guidelines for the use of I-131 in the treatment of thyroid cancer. 3) Review the controversies in thyroid cancer treatment. ABSTRACT The purpose of this educational activity is to review the reasons why the incidence of thyroid cancer has risen so rapidly over the last 40 years and discuss the role of radioiodine ablation in patients with thyroid cancer. Issues that will be discussed include controversies in the extent of thyroid surgery and the appropriate use of

230 radioiodine ablation in patients with thyroid cancer which is controversial in low risk and intermediate risk patients. The incidence of thyroid cancer in the United States has almost tripled since the early 1970s with unchanged mortality principally due to overdiagnosis. The extent of surgery performed for thyroid cancer is controversial especially in small cancers but only patients with complete thyroidectomy are candidates for radioiodine ablation. Recently lower doses of I-131 have been shown to be effective for radioiodine ablation of remnant thyroid tissue after thyroidectomy. High risk patients will benefit from radioiodine ablation with decreased recurrence and improved mortality. Radioiodine ablation in low risk patients is very controversial and has not been shown to improve mortality. RC611B Ra-223 Therapy for Bone Metastases Eric Michael Rohren MD, PhD (Presenter): Nothing to Disclose 1) Review the chemistry and mechanism of action of Ra ) Understand the approved indication for Ra ) Illustrate the techniques and procedures for radium administration using a case-based approach. ABSTRACT Radium-223 is an alpha-emitting radiopharmaceutical approved for use in men with castration-resistant prostate carcinoma. THe use of radium in a clinical setting will be discussed, including the rationale, patient eligibility, administration, and follow-up, as well as radiation safety precautions and handling. Illustrative cases will be presented. RC611C Hepatic Artery Infusion Therapy with Y90 Microspheres Charles Yoon Kim MD (Presenter): Consultant, CareFusion Corporation Research Grant, Galil Medical Ltd Consultant, Kimberly-Clark Corporation Consultant, Cryolife, Inc 1) Review range of malignancies treated with Y90 microsphere infusion. 2) Discuss the types of Y90 therapy and dosimetric considerations. 3) Describe the procedures and technical steps involved in Y90 therapy. 4) Recognize pertinent scintigraphic findings associated with Y90 therapy. ABSTRACT Intra-arterial Yttrium-90 (Y90) therapy is an important treatment modality for a variety of hepatic tumors. While numerous types of embolotherapies are employed by interventional radiologists for treatment of cancer, Y90 therapy is unique in its multimodality and multi-procedural nature. Not only does this treatment effect rely on deposited ionizing radiation therapy, but scintigraphic imaging is also an integral component of treatment. Two types of Y90 therapies are available, made by two different manufacturers. The differences between the two types are subtle, but there are differences in administration and manufacturer-recommended dosimetric calculation. These various differences will be highlighted. Y90 therapy is comprised of several steps and is frequently subclassified into a "planning" phase and "treatment" phase. In the planning phase, detailed angiographic imaging is performed to delineate arterial anatomy, determine tumoral distributions, and redistribute vascular flow if indicated. Scintigraphic imaging is an integral component of this planning phase, in order to help identify angiographically occult arterial anomalies, confirm appropriate infusion site, and to quantify the hepatopulmonary shunt fraction. From this information, as well as other factors, the appropriate treatment doses can be determined. In the treatment phase(s), the Y90 dose is administered to the appropriate portions of the liver with subsequent scintigraphic imaging for confirmation. RC617 MR-Guided High Intensity Focused Ultrasound (HIFU) Refresher/Informatics IR US MR AMA PRA Category 1 Credits : 1.50 ARRT Category A+ Credits: 1.50 Thu, Dec 4 8:30 AM - 10:00 AM Location: S504CD Moderator Pejman Ghanouni MD, PhD : Research Grant, General Electric Company Research Grant, InSightec Ltd Sub-Events RC617A Body Applications of MR-Guided High Intensity Focused Ultrasound Wladyslaw Michal Witold Gedroyc MBBS, MRCP (Presenter): Nothing to Disclose 1) Where Can FUS be applied. 2) What are the current and future applications of FUS in the general body area.

231 3) What are the technological problems of FUS in this field. 4)How may these problems be overcome. 5) What requirements does a prostate FUS system require for safe and effective application. 6) What are the potential complications of prostate MR guided FUS. 7) What are the technological requirements necessary to improve MR guided focused ultrasound therapy to the liver. 8) What other areas can MR guided focused ultrasound potentially be applied to in the body. ABSTRACT The largest area of FUS application has been of uterine fibroids but this application has shown the potential for similar procedures to be carried out in other areas of the body.. Because of the outpatient non-invasive nature of the procedure FUS becomesa highly cost-effective method of achieving destruction of abnomal tissue without invasion. Percutaneous destruction of liver tumours in a completely non-invasive manner would change therapy to the liver radically. FUS holds out such a prospect but the technological improvements required to our current machinery are substantial. The barrier of the FUS absorbing rib cage is hard to overcome and to date MR guided focused ultrasound has only been able to reach lesions that are not covered by ribs. The movement produced by respiration presents a significant problem currently addressed by controlled ventilation during FUS. Technological improvements are slowly being implemented to address these areas. Similar constraints apply to other upper abdominal organs which move with respiration and technological improvements to allow liver FUS equally apply to kidneys and spleen. New endorectal MR guided transducers which can ablate areas of the prostate under accurate MR targeting and thermal control are in phase 1 studies treating low risk prostate carcinoma and looking at safety and early efficacy. These results will be discussed. A brief discussion of MR guided focused ultrasound application to the breast and soft tissue tumours will also be presented as well as the possibility of FUS utilisation in soft tissues. RC617B Neurologic Applications of MR-guided HIFU Max Wintermark MD (Presenter): Research Grant, General Electric Company Research Grant, Koninklijke Philips NV 1) To understand the neuro applications of HIFU. 2) To understand the challenges of applying HIFU for neuro applications. 3) To review the ongoing trials of neuro applications of HIFU. RC617C Treatment of Fibroids with MR-guided HIFU Matthias Matzko MD (Presenter): CEO, Imaging Service AG Shareholder, Imaging Service AG 1) To become familiar with the basic physical principles of HIFU and the potential of MR guidance. 2) To approach selection criteria in MRI screening examinations for accurate indications and identify contraindications and non-suitable patients. 3) To appreciate current results and potential therapy regimens. 4) To understand recent technical developments and their potential. RC617D Palliation of Painful Metastases to Bone Pejman Ghanouni MD, PhD (Presenter): Research Grant, General Electric Company Research Grant, InSightec Ltd 1) Therapeutic options for palliation of painful metastases to bone. 2) Patient selection for MR guided focused ultrasound palliation of painful bone metastases. 3) Results of Phase III pivotal study of ExAblate MR guided focused ultrasound for palliation of painful bone metastases. 4) Technical aspects of successful patient treatment. 5) Immediate post-treatment imaging-based assessment of results. 6) Future applications of MR guided focused ultrasound for the management of osseous metastatic disease. ABSTRACT Cancer patients commonly have metastases to bone; as the survival of cancer patients is prolonged by more effective therapies, the prevalence of patients with metastases to bone is also increasing. Bone metastases are often painful, and often diminish the quality of life. Radiation therapy (RT) is the standard of care for the treatment of bone metastases, but a significant subset of patients do not respond to RT. MR guided focused ultrasound non-invasively achieves localized tissue ablation and provides a proven method of pain relief in patients who do not respond to radiation therapy. MR imaging provides a combination of tumor targeting, real-time monitoring during treatment, and immediate verification of successful treatment. The results of the pivotal Phase III trial that led to FDA approval of the ExAblate MR guided focused ultrasound device for the palliation of painful metastases to bone will be reviewed. In particular, patient selection, the technical aspects of successful patient treatment, and post-treatment assessment of results will be described. Concepts for future development of this technology with regard to the management of osseous metastatic disease will also be presented. RC631 Tumor Ablation beyond the Liver: Practical Techniques for Success (How-to Workshop) Refresher/Informatics

232 GI IR GI IR AMA PRA Category 1 Credits : 1.50 ARRT Category A+ Credits: 1.50 Thu, Dec 4 8:30 AM - 10:00 AM Location: S502AB Debra Ann Gervais MD (Presenter): Research Grant, Covidien AG Terrance T. Healey MD (Presenter): Nothing to Disclose Anil Nicholas Kurup MD (Presenter): Nothing to Disclose Muneeb Ahmed MD (Presenter): Nothing to Disclose 1) Gain knowledge as to how to approach tumor ablation in extrahepatic sites. 2) How to avoid and manage organ specific complications. 3) Review results of tumor ablation in the lung, kidney, and bone. ABSTRACT Pulmonary malignancies, and specifically lung cancer, are a leading cause of death worldwide. Utilization of best current therapies results in an overall five-year relative survival rate for all stages combined to be only 15%, necessitating the use of alternative therapies. Image-guided ablation of lung malignancies is a revolutionary concept whose clinical applications are just beginning to be developed. It has some advantages over traditional radiotherapy and chemotherapy. Its safety profile is similar to percutaneous image guided lung biopsy. Almost all image-guided ablative procedures can be performed in an outpatient setting, mostly with conscious sedation. Multiple applications can be performed without any additional risks. Contraindications are few and include uncontrollable bleeding diathesis and recent use of anticoagulants. Image-guided ablation of lung malignancies is performed with two basic rationales. In the first group it is used with an intention of achieving definitive therapy. These are patients who are not candidates for surgery because of co-morbid medical contraindications to surgery, like poor cardiopulmonary reserve or patients refusing to undergo operation. This cohort could potentially derive significant benefit form a minimally invasive alternative therapy. In the second group it is used as a palliative measure as follows: (a) to achieve tumor reduction before chemotherapy (b) to palliate local symptoms related to aggressive tumor growth, such as chest pain, chest wall pain or dyspnea (c) hematogenous painful bony metastatic disease (d) tumor recurrence in patients who are not suitable for repeat radiation therapy or surgery Image-guided ablation is expanding treatment options for the local control of non-small cell lung cancer and metastatic disease. RC650 Image-guided Biopsy of the Spine (Hands-on Workshop) Refresher/Informatics NR MK IR NR MK IR AMA PRA Category 1 Credits : 1.50 ARRT Category A+ Credits: 1.50 Thu, Dec 4 8:30 AM - 10:00 AM Location: E260 Moderator John L. Go MD : Nothing to Disclose 1) Discuss and demonstrate spine biopsy techniques including CT and fluoroscopic approaches, anatomic landmarks, needle selection, special technical considerations for dealing with soft tissue masses, and fluid accumulations, lytic and blastic lesions, and hypervascular conditions. 2) Hands on exposure will be provided in order to familiarize participants with the vast number of biopsy devices that are clinically available. 3) Training models will also be used in order to teach technical skills with respect to approach and technique. 4) Advantages and disadvantages of various biopsy devices and techniques, and improve their understanding of how to maximize the reliability and safety of these spine biopsy procedures. ABSTRACT Sub-Events RC650A Pre- and Postbiopsy Assessment Richard Silbergleit MD (Presenter): Nothing to Disclose 1) Be familiar with all required aspects of the pre-biopsy work-up, including medications, laboratory values, and review of relevant prior imaging. 2) Be familiar with solutions to address to complications or other unexpected events which may arise during the course of spine biopsy. 3) Be comfortable in performing the post procedure assessment of the patient after spinal biopsy. RC650B Equipment Used for Image-guided Biopsies of the Spine Michele Hackley Johnson MD (Presenter): Committee member, Boston Scientific Corporation 1) Demonstrate the types of needles used for spine biopsy. 2) Selecting the proper types of needles used for spine biopsy. 3) Case demonstration of the proper use of single or coaxial needle sets for spine biopsy and the advantages or disadvantages of each.

233 RC650C Thoracic and Lumbar Biopsies John L. Go MD (Presenter): Nothing to Disclose 1) Review the anatomy of the thoracic and lumbar spine relevant to spine biopsy. 2) Describe the approaches used to approach various anatomical regions within the thoracic and lumbar spine. 3) Provide case examples of various approaches used to biopsy the thoracic and lumbar spine. ABSTRACT RC650D Cervical Spine Biopsies A. Orlando Ortiz MD, MBA (Presenter): Nothing to Disclose 1) Demonstrate the various approaches used to biopsy lesions of the cervical spine. 2) Determine the selection of the proper needles to use to biopsy the spine. 3) Provide case examples of cervical biopsies and the thought process used to perform these procedures. ABSTRACT Cervical spine biopsies can be challenging procedures to perform, hence they tend to be performed by a limited number of proceduralists. C-spine biopsy is often performed to evaluate potential neoplastic or infectious processes of the cervical spine. The key to performing these procedures effectively and safely is in appropriate patient selection, careful image analysis in order to properly position the patient and choose an approach, identification of critical structures (such as the carotid artery) and neck spaces that should be avoided, and use of coaxial biopsy techniques. The procedure can be safely performed with CT and/or CT fluoroscopy. Specimen sampling principles and specimen handling are also discussed they can help to optimize this procedure. RC650E Disc Biopsy and Aspiration Amish H. Doshi MD (Presenter): Nothing to Disclose View learning objectives under main course title. RC652 Techniques for Interventional Sonography and Thermal Ablation (Hands-on Workshop) Refresher/Informatics IR US IR US AMA PRA Category 1 Credits : 1.50 ARRT Category A+ Credits: 1.50 Thu, Dec 4 8:30 AM - 10:00 AM Location: E264 Patrick Warren MD (Presenter): Nothing to Disclose William Eugene Shiels DO (Presenter): President, Mauka Medical Corporation Royalties, Mauka Medical Corporation Patent holder, Mauka Medical Corporation Veronica Josephine Rooks MD (Presenter): Nothing to Disclose Humberto Gerardo Rosas MD (Presenter): Nothing to Disclose Corrie Marlene Yablon MD (Presenter): Nothing to Disclose Andrada Roxana Popescu MD (Presenter): Nothing to Disclose Linda J. Warren MD (Presenter): Shareholder, Hologic, Inc Hisham A. Tchelepi MD (Presenter): Nothing to Disclose John Miras Racadio MD (Presenter): Research Consultant, Koninklijke Philips NV Travel support, Koninklijke Philips NV Neil T. Specht MD (Presenter): Nothing to Disclose Mahesh M. Thapa MD (Presenter): Nothing to Disclose Kristin Marie Dittmar MD (Presenter): Nothing to Disclose James Walter Murakami MD (Presenter): Nothing to Disclose Neil David Johnson MD (Presenter): Royalties, Merge Healthcare Incorporated Stephen Clifford O'Connor MD (Presenter): Nothing to Disclose 1) Identify basic skills, techniques, and pitfalls of freehand invasive sonography. 2) Discuss and perform basic skills involved in thermal tumor ablation in a live learning model. 3) Perform specific US-guided procedures to include core biopsy, abscess drainage, vascular access, cyst aspiration, soft tissue foreign body removal, and radiofrequency tumor ablation. 4) Incorporate these component skill sets into further life-long learning for expansion of competency and preparation for more advanced interventional sonographic learning opportunities.

234 interventional sonographic learning opportunities. VSIR51 Interventional Series: Peripheral and Visceral Occlusive Disease Series Courses IR VA AMA PRA Category 1 Credits : 3.25 ARRT Category A+ Credits: 3.75 Thu, Dec 4 8:30 AM - 12:00 PM Location: N226 Moderator Parag J. Patel MD : Consultant, Medtronic, Inc Consultant, C. R. Bard, Inc Consultant, Cook Group Incorporated Speakers Bureau, Medtronic, Inc Consultant, Penumbra, Inc 1) Describe recent evidence concerning the use of renal denervation for malignant hypertension. 2) Explain the use of radial artery access. 3) Outline 3 recommendations for endovascular treatment of peripheral vascular disease. 4) List two important studies published on vascular disease in the past year. 5) Describe 2 uses of stent grafts. Sub-Events VSIR51-01 Radial Artery Access: Why? When? How? Marcelo Guimaraes (Presenter): Consultant, Cook Group Incorporated Consultant, Baylis Medical Company Consultant, Terumo Corporation Patent holder, Cook Group Incorporated View learning objectives under main course title. VSIR51-02 Limitations and Complications of Trans-brachial Arterial Access for Endovascular Treatment of the Peripheral Vasculature: A Contemporary and Prospective Comparison to Trans-femoral Access Karla Maria Treitl MD (Presenter): Nothing to Disclose, Maximilian F. Reiser MD : Nothing to Disclose, Marcus Treitl MD : Nothing to Disclose Trans-brachial (TB) access for intervention is still believed to be dangerous, despite its advantages for the interventionalist and patient. The Aim of the study was to prospectively assess current limitations and complication rates of the TB access technique for endovascular treatment of peripheral vascular pathologies in comparison to the trans-femoral (TF) access technique for the first time. In total, 300 patients (202 m; age 68.7 ± 11.0yrs) with arterial occlusive disease underwent endovascular therapy via a TB or TF access. Peri-procedural data (sheath size, dose area product, fluoroscopy, examination time) were analyzed. Post-procedural complications of the puncture sites were categorized as minor (local hematoma, pseudoaneurysm, embolization, dissection, minor bleeding) and major (thrombotic occlusion, hematoma requiring surgery, major bleeding, nerve injury) and analyzed by the Fisher`s exact and the Chi2-test according to the target lesions. The minor and major complication rates of both groups did not significantly differ (21/14.0% vs. 26/17.3%, P=0.26; 4/2.7% vs. 3/2.0%, P=0.50). The dose area product and the fluoroscopy time were significantly higher in the TB-group ( ± cgycm2 vs ± cgycm2; P=0.00; 24.3 ± 18.4 min vs ± 12.6 min; P=0.01), though examination times were comparable (121.8 ± 48.9 min vs ±44.2; P=0.57). Results and complication rates of the TB-access are comparable to the TF-access for endovascular treatment of target lesions in peripheral or visceral artery occlusive disease, making it a safe and important alternative to TF access in selected cases. It is associated with a higher radiation exposure. Alternative access routes than the TF approach are necessary with increasing complexity of peripheral vascular disease or for certain peripheral artery targets Puncture of the brachial artery is believed to have a higher risk for long term complications like nerve injury or vessel occlusion Prior studies lack a direct comparison of TB and TF access complications and / or lack a standardized follow-up In this prospective and comparative observation: o the minor and major complications rates of TB and TF access are comparable o thetb access leads to a higher radiation exposure o thetb access still is a valid alternative in patients, who cannot be examined or treated trans-femorally

235 VSIR51-03 Long-term Results after Balloon Angioplasty of the Crural Arteries: Which Variables Influence Limb Salvage and Patient Survival? Inge Kaare Tesdal MD (Presenter): Nothing to Disclose, Christian Krzemien MD : Nothing to Disclose, Christel Weiss : Nothing to Disclose To evaluate the technical and clinical success rates, procedure-related complications, and long-term results for patients who underwent angioplasty of the crural arteries. Retrospectively we evaluated all patients who underwent angioplasty of the crural arteries due to critical chronic limb ischemia or severe claudication in the time period from 1/2002 to 12/2005. These patients were contacted in the time period from 1/2009 to 12/2010, and a follow-up examination including angiography was performed or telephone interviews were conducted with patients, relatives and referring doctors for follow-up. The primary end points were the limb salvage rate and patient survival rate. The secondary end points included the complication rate, technical success rate, and patency rate. The prognostic relevance of treatment and selected variables with respect to limb salvage and patient survival were analyzed with multiple logistic regression 212 patients with a mean age of 77.8 years (99 women and 113 men) underwent crural angioplasty on 239 limbs. 78 patients (32.6%) suffered from severe claudication (Rutherford category 3) and all others had critical chronic limb ischemia (category 4 to 6, resp. Fontaine-stage 3 and 4). The technical success rate was 98.4 % and the complication rate (SIR classification) was 9.1 % (5.2 % major). After a mean follow-up of 3.7 years, 48 patients (22.6 %) experienced minor- or major-amputation on 53 legs (22.2 %). The limb salvage rate (Kaplan-Maier estimation) was 85.4 % after 5 years. The mean survival rate according to Kaplan-Meier was 79.7 %, 72.2 %, 67.3 % and 51.4 % after 1, 2, 3 and 5 years, respectively. Results of multiple logistic regression analysis showed that negative prognostic variables with respect to patient survival were amputation (p=0.0017) and dialysis (p=0.0011) and with respect to limb salvage dialysis (p<0.0001) and non-patent peroneal artery (p<0.0001). Balloon angioplasty of the crural arteries shows a high technical success rate with an acceptable complication rate. Dialysis and non-patent peroneal artery are negative prognostic variables for the clinical long-term success. However, the survival rate was limited by the co-morbidity and the high age in this patient group. Peroneal artery should be the preferred crural artery to be recanalized VSIR51-04 Evaluation of a Novel Bioabsorbable and Non-synthetic Vascular Closure Device: FISH in Daily Routine Marcus Treitl MD (Presenter): Nothing to Disclose, Maximilian F. Reiser MD : Nothing to Disclose, Karla Maria Treitl MD : Nothing to Disclose Vascular closure devices are typically made of synthetic materials, inducing an inflammation of the vessel wall that can cause scaring over of the access vessel. A novel femoral introducer sheath and hemostatic device (FISH) introduces small intestinal submucosa (SIS), that is known from treatment of burn wounds, as a closing agent into the vessel wall. In contrast to other devices this is meant to induce wound healing instead of scaring over. We present first results of the usage of this novel closure device in daily routine. 132 consecutive patients (88 m; mean age 71,5yrs) with indication for endovascular treatment of peripheral artery disease received the FISH device for closure of the access vessel. Technical success of device deployment, the time to hemostasis, as well as the time to ambulation were recorded. Control of the access site was done by clinical examination and duplex ultrasound the following day. Small hematomas and bleedings were assessed as minor complications, whereas pseudoaneurysms or bleedings requiring surgical intervention were assessed as major complications. Technical success was achieved in 97%. Device failure occurred in 2 cases. 2 patients developed a pseudoaneurysm that could be treated conservatively. No complication requiring surgical intervention has been observed. Mean time to hemostasis was 45 +/- 91 sec. Mean time to ambulation was 60 min. Most patients were on ASA. Mean INR was Re-puncture of the vessel was done the next day in 6 cases without any complications. An intravascular device deployment or embolization was never observed. Re-puncture after several months was done in 12 cases without observation of scaring of the access vessel. The novel FISH device is a safe and potent vascular closure device with excellent performance and an comparable low complication rate of 0.8%. In contrast to synthetic devices it seems to induce less scaring of the access vessel and allows immediate re-puncture without the risk of embolization. FISH - has a broader range of suitable vessel diameters - is not contraindicated in case of calcification - is made of biologic material known from wound therapy - is believed to induce less scaring over of the access vessel. It

236 is therefore an important alternative and new device for vascular closure after peripheral intervention. VSIR51-05 Update on Recommendations for Endovascular Treatment of PVD in 2014 "This is what to do and why to do it." Martin A. Funovics MD (Presenter): Speakers Bureau, Werfen Life Group SAU Speaker, W. L. Gore & Associates, Inc Consultant, Abbott Laboratories Research Grant, Abbott Laboratories Proctor, Werfen Life Group SAU Proctor, Medtronic, Inc Travel support, W. L. Gore & Associates, Inc Travel support, Medtronic, Inc Travel support, JOTEC GmbH Travel support, Cook Group Incorporated Travel support, Werfen Life Group SAU 1) Know the results of Balloon Angioplasty, Stenting, drug-eluting stents, and drug-eluting balloon in the iliac arteries, the femoral artery and below the knee as put forward in recent major studies. 2) Put interventional therapy and results into perspective with surgical options. 3) Be able to select the optimal treatment strategy depending on lesion and patient characteristics. 4) Be aware of procedural costs and know the main factors influencing resource allocation. VSIR51-06 Renal Denervation Now What? Dheeraj Kumar Rajan MD (Presenter): Consultant, TVA Medical, Inc Consultant, Johnson & Johnson 1) Describe what renal denervation is. 2) Summarize prior relevant pivotal studies for renal denervation and results of the HTN-3 study. 3) What clinical potential still exists for renal denervation. VSIR51-07 Renal Sympathicolysis by Percutaneous Periarterial Injection of Vincristin A Feasibility Study in Pigs Patrick Freyhardt MD (Presenter): Nothing to Disclose, Ricardo Donners : Nothing to Disclose, Alex Riemert : Nothing to Disclose, Joerg Schnorr : Nothing to Disclose, Nicola Stolzenburg : Nothing to Disclose, Jan-Leo Rinnenthal : Nothing to Disclose, Rolf Wilhelm Guenther MD : Nothing to Disclose, Bernd K. Hamm MD : Research Consultant, Bayer AG Research Consultant, Toshiba Corporation Stockholder, Siemens AG Stockholder, General Electric Company Research Grant, Toshiba Corporation Research Grant, Koninklijke Philips NV Research Grant, Siemens AG Research Grant, General Electric Company Research Grant, Elbit Medical Imaging Ltd Research Grant, Bayer AG Research Grant, Guerbet AG Research Grant, Bracco Group Research Grant, B. Braun Melsungen AG Research Grant, KRAUTH medical KG Research Grant, Boston Scientific Corporation Equipment support, Elbit Medical Imaging Ltd Investigator, CMC Contrast AB, Florian Streitparth : Nothing to Disclose To evaluate feasibility, safety and efficacy of renal sympathetic denervation with CT-guided needle-based percutaneous periarterial injection of vincristin in pigs. Percutaneous unilateral periarterial injection of 10 ml of a mixture of Vincristin 0,1 mg dissolved in 0,9% Saline, Bupivacaine and Accupaque 250 (ratio 7:2:1) was performed in 6 normotensive pigs. Needle placement and injections were performed under CT-guidance in all animals. Blood pressure measurements and CT scans of the kidneys perirenal structures were performed immediately pre- and post intervention and 4 weeks after treatment. After euthanasia Norepinephrine (NE) concentration of both kidneys was determined. The renal arteries and the surrounding tissue were examined histologically to look for induced nerve fibre degeneration. All procedures were technically successful with good periarterial distribution of the injectant. No major events occurred. No postinterventional complications were observed. NE concentration of the renal parenchyma was significantly lower on the treated side in all pigs with a mean decrease of 53,5% (min: 43%, max: 66%) compared to the contralateral untreated kidney. Histological examination revealed neural degeneration in all animals. CT-guided needle-based percutaneous periarterial Vincristin injection for renal sympathetic degeneration was feasible, effective and safe. This approach may be an alternative to the catheter-based techniques in the treatment of therapy resistant hypertension. Renal sympathicolysis by percutaneous periarterial Vincristin may be an alternative to catheter-based techniques. Apart from efficacy the procedure is less invasive and faster than RFA-based methods. VSIR51-08 Accuracy of Simple Visual Estimation in Grading Peripheral Arterial Stenosis Is Eyeballing Enough? Melanie B. Schernthaner MD (Presenter): Nothing to Disclose, Matthew Benenati : Nothing to Disclose, Reza Rajebi MD : Nothing to Disclose, Gail Walker PhD : Nothing to Disclose, Constantino Santiago Pena MD : Speakers Bureau, W. L. Gore & Associates, Inc Speakers Bureau, Cook Group Incorporated Speakers Bureau, Koninklijke Philips NV Advisory Board, C. R. Bard, Inc Advisory Board, Boston Scientific Corporation Advisory Board, Guerbet SA

237 To evaluate accuracy, inter-observer and intra-observer reliability of simple visual estimation (SVE) in grading peripheral arterial stenosis compared to calibrated measurements. 23 interventionalists with a wide range of experience (1-30 years) and subspecialty training (IR (13), Neuro-IR (2), interventional-cardiology (4) and vascular surgery (4)) reviewed 42 angiographic images of peripheral and carotid arteries in two sessions. Images where shuffled between readings. An independent team measured all lesions using manual calipers. A +/- 5% error was considered as threshold for accurate visual estimation. Lesions were categorized by clinical significance ( 80% severe). SVE was compared for agreement by weighted kappa statistics. Reliability was assessed by intraclass correlation. Overall accuracy of SVE in grading stenosis was 28.3% and 27.4% for the two assessments. Errors in excess of +/- 5% occurred in 71.7% and 72.6% respectively. Agreement with respect to clinical category was fair with a weighted kappa of in the first testing session and in the second. 92.6% and 93.8% of severe lesions, 40.9% and 41.5% of significant lesions and 71.5% and 73.3% of insignificant lesions were correctly identified in the first and second sessions respectively. In the first session 53.0% of significant and 4.4% of insignificant lesions were categorized as severe stenosis. 49.9% of significant lesions and 4.6% of insignificant lesions were overestimated as severe in the second session. Intra-rater reliability was good (0.990) and inter-rater reliability was fair for assessment of peripheral arteries (0.823, 0.809), and carotids (0.748, 0.708). Accuracy did not differ in relation to years of experience or specialty. Despite good intra-observer reliability, inter-observer reliability was fair. Estimation of peripheral arterial stenosis often results in overestimation of stenosis, most pronounced in the 60-80% range. There were no significant differences based on years of experience in practice or specialty. Visual estimates of stenosis potentially lead to therapeutic decisions based on inaccurate information. Clinical decision making should be based on caliper measurements especially in non-significant stenoses. VSIR51-09 Evaluation of Infrapoplitial Blood Flow Changes During Endovascular Revascularization Using 2D X-ray Perfusion Software: A Pilot Study Michelle D.M.E. Meeks MSc : Research Consultant, Koninklijke Philips NV, Julie Mayer : Nothing to Disclose, Pascal Desgranges : Nothing to Disclose, K You : Nothing to Disclose, Jean-Francois Deux (Presenter): Nothing to Disclose, Hicham Herve Kobeiter MD : Nothing to Disclose To evaluate a 2D X-ray Perfusion software to quantify infrapoplitial blood flow changes during endovascular revascularization of femoropopliteal lesions. Fifteen patients undergoing endovascular revascularization were included in this study. Forty-one vessels were analyzed using 2D Perfusion software (Philips Healthcare, Best, The Netherlands). 2D Perfusion images could be collected after regular DSA, without additional radiation or contrast usage. A region of interest was drawn in the distal part of the 3 tibial arteries. Parameters: -time to peak (TTP), -wash in rate (WIR) and -arrival time (AT) were calculated. Parametric differences, before and after revascularization and between Rutherford classes, were statistically compared using paired and one-sample Student's t-test, respectively. Eight patients suffered from Rutherford class <3 and 7 from Rutherford class 3. Ten patients underwent SFA stent placement, the remaining five were treated with balloon angioplasty of the SFA and/or popliteal tibial arteries. Results demonstrated significant differences after revascularization in TTP (7% decrease), WIR (41% decrease) and AT (35% increase). Sub analysis showed a significant difference (p=0.004) in arrival time in CLI patients when compared to PAD patients, respectively a 40% decrease and 2.7% increase after revascularization. 2D Perfusion software allows for hemodynamic measurement of flow differences after endovascular revascularization. CLI patients, at rest, demonstrate a faster arrival time after revascularization when compared to PAD patients. This could be explained by the symptomatic appearance of vascular disease in PAD patients during physical exercise. Further research is needed to prove whether these hemodynamic differences are related to clinical outcome and tissue reperfusion. 2D X-ray Perfusion Software is a promising post-processing imaging technique to increase our knowledge on blood flow characteristics in patients with Peripheral Artery Disease. VSIR51-10 Updates in Vascular Disease Parag J. Patel MD (Presenter): Consultant, Medtronic, Inc Consultant, C. R. Bard, Inc Consultant, Cook Group

238 Incorporated Speakers Bureau, Medtronic, Inc Consultant, Penumbra, Inc View learning objectives under main course title. VSIR51-11 Stent Grafts Explained Lindsay S. Machan MD (Presenter): Medical Advisory Board, Boston Scientific Corporation Medical Advisory Board, Arsenal Medical Inc Steering Committee, Cook Group Incorporated Stockholder, Analytics 4 Life Stockholder, Calgary Scientific, Inc Stockholder, Harmonic Medical Stockholder, IKOMED Technogies Inc Stockholder, Nitinol Devices & Components, Inc View learning objectives under main course title. MSCP52 Case-based Review of Pediatric Radiology (An Interactive Session) Multisession Courses PD IR MK GI AMA PRA Category 1 Credits : 1.50 ARRT Category A+ Credits: 1.50 Thu, Dec 4 10:30 AM - 12:00 PM Location: S406A Director Sudha Ayyala Anupindi MD Nothing to Disclose 1) Access the results of new research and assess their potential applications to clinical practice. 2) Improve basic knowledge and skills relevant to clinical practice. 3) Practice new techniques. 4) Assess the potential of technological innovations and advances to enhance clinical practice and problem-solving. 5) Apply principles of critical thinking to ideas from experts and peers in the radiologic sciences. Sub-Events MSCP52A Congenital and Acquired Thoracic Vascular Disorders in Children Edward Yungjae Lee MD, MPH (Presenter): Nothing to Disclose 1) Discuss practical imaging techniques for evaluating congenital and acquired thoracic vascular disorders in children. 2) Review helpful clinical aspects and imaging findings of pediatric thoracic vascular diseases. 3) Learn characteristic imaging findings to narrow the differential diagnoses of various pediatric thoracic vascular disorders. MSCP52B Pediatric Abdominal Infectious and Inflammatory Disorders Thaddeus W. Herliczek MD (Presenter): Nothing to Disclose 1) Recognize the imaging appearance of conditions causing pediatric right lower quadrant pain. 2) Recognize the characteristic magnetic resonance imaging features of pediatric appendicitis. 3) Understand the imaging appearance, complications and etiologies of pediatric pancreatitis. 4) Describe the imaging features of pediatric infectious hepatobiliary disease. MSCP52C Pediatric Musculoskeletal Neoplasms Jung-Eun Cheon MD (Presenter): Nothing to Disclose 1) Discuss the imaging approach to pediatric musculoskeletal neoplasms. 2) Discuss the role of different imaging modalities in the evaluation of pediatric musculoskeletal neoplasms. 3) Identify the common location and characteristic imaging findings of pediatric musculoskeletal neoplasms.

239 ABSTRACT Frequency, location, and imaging characteristics are important diagnostic clues in pediatric bone and soft-tissue tumors, either benign or malignant. MR imaging has evolved as the most important diagnostic tool for local staging of primary bone and soft tissue tumors, for monitoring response to chemotherapy, and for detecting postoperative tumor recurrence. A detailed discussion of all bone and soft tissue tumors is well beyond the scope of this review; instead, we highlight the initial evaluation and staging of primary pediatric musculoskeletal neoplasms. SSQ10 ISP: Genitourinary (Intervention in the GU Tract) Scientific Papers US MR IR GU AMA PRA Category 1 Credits : 1.50 ARRT Category A+ Credits: 1.50 Thu, Dec 4 10:30 AM - 12:00 PM Location: E450B Moderator Cary Lynn Siegel MD : Nothing to Disclose Moderator Parvati Ramchandani MD : Nothing to Disclose Sub-Events SSQ10-01 Genitourinary Keynote Speaker: Fibroid Expert Topic MR Guided Focal Cryoablation for Native and Recurrent Prostate Cancer David Arthur Woodrum MD, PhD (Presenter): Nothing to Disclose Abstract In 2014, the American Cancer Society (ACS) estimates that 233,000 new cases of prostate cancer will be diagnosed in the United States. Most men are managed with either radiation therapies or surgery with recurrence rates as high as 25-40%. No matter how expertly done, these therapies carry significant risk and morbidity to the patient's health related quality of life with impact on sexual, urinary and bowel function. For this reason, focal or regional treatments for low risk native and recurrent prostate cancer patients are beginning to be adopted. Although questions remain, focal therapies are becoming more attractive to patients who are demanding more options. MR imaging provides the best lesion visualization for both native and recurrent prostate cancer. However, until recently treatment in the MR suite has not been possible. Now MR guided cryoablation, laser ablation and focused ultrasound are possible. We will discuss the use of MR guided cryoablation in treatment of native and recurrent prostate cancer. SSQ10-02 MRI-Guided Transurethral Ultrasound Ablation for Treatment of Localized Prostate Cancer Maya B. Mueller-Wolf MD (Presenter): Nothing to Disclose, Matthias Roethke MD : Nothing to Disclose, Sascha Pahernik MD : Nothing to Disclose, Boris Hadaschik : Nothing to Disclose, Timur Kuru MD : Nothing to Disclose, Gencay Hatiboglu : Nothing to Disclose, Ionel Valentin Popeneciu MD : Nothing to Disclose, Joseph Chin MD : Nothing to Disclose, Michele Billia MD : Nothing to Disclose, James D. Relle MD : Nothing to Disclose, Jason M. Hafron MD : Nothing to Disclose, Kiran R. Nandalur MD : Nothing to Disclose, Mathieu Burtnyk DIPLPHYS : Nothing to Disclose, Heinz-Peter Schlemmer MD : Nothing to Disclose MRI-guided transurethral ultrasound ablation (MR-TULSA) is a novel minimally-invasive technology to treat organ-confined prostate cancer (PCa), aiming to provide local disease control with a low side-effect profile. Directional plane-wave high-intensity ultrasound generates a continuous volume of thermal coagulation shaped accurately to the prostate using real-time MR-thermometry and active temperature feedback control. A prospective, multi-institutional Phase I clinical study investigated safety, feasibility, and assessed efficacy of MR-TULSA treatment for PCa. 30 patients with biopsy-proven, low-risk prostate cancer (age 65y, T1c/T2a, PSA 10ng/ml, Gleason 6 (3+3)) were enrolled. MR-TULSA was performed for whole-gland prostate ablation using the PAD-105 (Profound Medical Inc., Canada) and a 3T MRI (Siemens, Germany). One treatment session was delivered under general anaesthesia and 3D active MR-thermometry feedback control. Thermal coagulation was confirmed on CE-MRI immediately after MR-TULSA and at 12 months. MR-TULSA was well-tolerated by all patients. There were no intraoperative complications. Normal micturition resumed after catheter removal. Median (range) treatment time and prostate volume were 36 (24-61) min and 44 (21-95) ml, respectively. Maximum temperature measured during treatment depicted a continuous region of heating shaped accurately to the prostate to within 0.1 ± 1.3 mm, with average over- and under-targeted volumes of 0.8 and 1.0 ml, respectively. Immediate post-treatment cell kill, visualized by the peripheral region of enhancement surrounding the non-perfused volume, correlated well with the acute cell kill regions on MR-thermometry. Successful treatment was further indicated by a median PSA decrease from 5.8 to 0.7 ng/ml

240 at 1 month (n=24), remaining stable to 0.7 ng/ml at 6 months (n=12). MRI-guidance enables accurate treatment planning, real-time dosimetry and control of the thermal ablation volume. The Phase I clinical trial showed that whole-gland ablation of the prostate for localized PCa is feasible, safe, and accurate using MR-TULSA. Whole-gland ablation can be safely and accurately achieved using MR-TULSA, which represents a minimally-invasive treatment option for organ-confined prostate cancer. SSQ10-03 Non-invasive Focal Therapy of Organ Confined Prostate Cancer: Phase I Study Using Magnetic Resonance Guided Focused Ultrasound Technology and Excision Pathology for Efficacy Assessment Pier Luigi Di Paolo MD (Presenter): Nothing to Disclose, Gaia Cartocci MD : Nothing to Disclose, Fulvio Zaccagna MD : Nothing to Disclose, Gianluca Caliolo : Nothing to Disclose, Valeria Panebianco MD : Nothing to Disclose, Alessandro Napoli MD : Nothing to Disclose To assess safety and initial effectiveness of non-invasive high intensity 3T MR guided focused Ultrasound (MRgFUS) treatment of localized prostate cancer in a phase I, treat and resection designed exploratory study. On the basis of a power analysis, 11 patients with biopsy proven focal T2 prostate cancer (low-to-intermediate risk: PSA max 12 and Gleason max 3+4), confirmed on a previous multiparametric MR exam (Discovery 750, GE) including dynamic contrast enhanced (DCE) imaging (Gd-BOPTA, Bracco), underwent MRgFUS ablation (ExAblate, InSightec). All patients were scheduled to radical laparoscopic prostatectomy; MRgFUS treatment was carried out on the MR identifiable lesion (max 2) using a patient specific energy ( J) and real time MR thermometry monitor for correct treatment location. Non-perfused volume (NPV) in the post-ablative MRI was than compared with excision pathology for necrosis assessment. No significant complications were observed in all subjects during or immediately after the procedure. Procedure was validated by pathologist, that demonstrated extensive coagulative necrosis at the site of sonication surrounded by normal prostatic tissue with inflammatory changes; these features positively compared with immediate post-ablative MRI scan and NPV. At histology 10 patients were free of residual viable tumor within the treated area; in the remaining patient, 10% of residual tumor was observed within the NPV. There was a variable amount of isolated cancer tissue (Gleason max 7, 3+4) within the non-treated parenchyma that was neither identifiable at MRI nor at biopsy. Results of our Phase I study suggest MR guided Focused Ultrasound as a safe and effective modality to determine >90% necrosis of identifiable prostate cancer; other prospective studies are needed to extend success rate in larger cohort. MR guided Focused Ultrasound is a safe and effective modality to determine >90% necrosis of identifiable prostate cancer. SSQ10-04 Long Term Results Of Optimized Focal Therapy Of Prostate Cancer: Average 10-Year Follow-up in 70 Patients Gary Mark Onik MD (Presenter): Nothing to Disclose Following the lead of lumpectomy for breast cancer, focal therapy for prostate cancer was introduced in order to limit morbidity while providing good cancer control. Focal therapy is now an established trend in prostate cancer management, but long term data has not been available. This report presents results on 70 patients treated with focal cryoablation, followed for an average of 10 years. Between May 7, 1996 and December 28, patients were treated with focal cryoablation. All patients were staged using an additional prostate biopsy. Transperineal 3D Prostate Mapping Biopsy (3D-PMB) was used in 63 patients. All patients were then treated with percutaneous focal cryoablation of all known tumor(s). All known cancers regardless of tumor size or Gleason score were treated. Biochemical disease free status was determined by the Phoenix criteria. Potency was determined by ability to have vaginal penetration and satisfaction with sexual functioning. Continence was determined by pad free status.

241 Disease specific survival was 64/64(100%). Overall biochemical disease free survival (BDFS) was 62/70 (89%). BDFS results stratified according to the D'Amico criteria were: 8/9 (89%) high risk; 28/32 (88%) medium risk; 26/29 (90%) low risk. There was no statistically significant difference between the risk levels. 19/20 (95%) bilaterally but focally treated patients were BDF. In total 10/70 (14%) patients had a local recurrence that needed re-treatment (none in the treated area), and 9/10 (90%) remain BDF. Continence after the first treatment was 100% (no pads). Potency including re-treatments was 74%. No other complications occurred. There was no instance of significant bleeding and no instance of rectal damage. Within the limitations of our study, the long term cancer control results of focal therapy using cryoablation appears competitive with radical whole gland treatments in low risk patients and superior in medium and high risk patients in achieving cancer free status. It achieves this with extremely low morbidity compared to whole gland treatments. If these results are confirmed, focal therapy as we have outlined could significantly lower the morbidity and mortality associated with prostate cancer. Focal therapy has the potential to completely change the paradigm of prostate cancer management. SSQ10-05 Cryotherapy for Renal-cell Cancer: Evaluation of the Efficacy of the Treatment with Contrast-Enhanced Ultrasonography (CEUS) Michele Bertolotto MD (Presenter): Nothing to Disclose, Fulvio Stacul MD : Nothing to Disclose, Calogero Cicero : Nothing to Disclose, Francesca Cacciato : Nothing to Disclose, Salvatore Siracusano MD : Nothing to Disclose, Maria Assunta Cova MD : Nothing to Disclose, Matilde Cazzagon : Nothing to Disclose, Antonio Celia : Nothing to Disclose To evaluate the diagnostic accuracy of contrast enhanced ultrasound (CEUS) in the early detection of residual tumor after cryoablation. Twenty-six patients with 31 renal tumors (20 men, 6 women; mean age, 69 years; range, years) underwent percutaneous cryoablation between August 2011 and July All tumors were treated with CT guidance. Patients underwent CEUS before, within 1 day (early follow-up CEUS), 1 month and 3 months after the ablation. In patients with persistent lesion vascularity at early follow-up CEUS the test was repeated also 1 week after the treatment. Reference standard was MRI/CT performed every 6 months after cryoablation for the first two years, and then yearly. The mean tumor size was 20 mm (range, 6-37 mm). One patient was lost to follow up. Twenthy-five patients with 30 renal tumors were followed-up for at least 6 months and all underwent CEUS. MRI was perfomed in 21 patients, CT in 4 patients who had contraindications to MR scanning. The mean follow-up period was 15 months (range, 6-24 months). Early CEUS follow-up displayed a completely avascular lesion in 24/30 renal lesions. Minimum to mild perilesional enhancement was present in 4 cases, which disappeared progressively during the follow-up. One type IV cystic tumor had two intralesional vegetations (10 and 20 mm, respectively), which were still vascularized early after cryoablation and during the follow-up and were categorized as residual tumor. Severe comorbidities precluded from repeated cryoablation. Two lesions were vascularized in the early CEUS follow-up while the CEUS investigation repeated 1 week and 1 month after the treatment documented progressive devascularization of the mass. CEUS is an effective alternative to CT and MRI for the early diagnosis of residual tumour after renal percutaneous cryoablation. Care should be taken, however, in interpreting persistent vascularity in the early CEUS follow-up as residual tumor. Repeated CEUS investigations allow to differentiate between a late devascularization of a successfully ablated tumor and persistent disease. CEUS is able to monitor the result of cryoablation of renal tumors. Early features after the treatment, however, should be interpreted with caution to avoid misdiagnosis of persistent disease. SSQ10-06 CT-guided Biopsy for the Entirely Endophytic Small Renal Mass: Comparison of Diagnostic Rate and Complication between Standard-dose and Low-dose Protocol Group Mi-Hyun Kim (Presenter): Nothing to Disclose, Jeong Kon Kim MD : Nothing to Disclose, Myung-Won You MD : Nothing to Disclose, Hyuck Jae Choi MD : Nothing to Disclose, Kyoung-Sik Cho MD : Nothing to Disclose To compare the diagnostic rate and complication between standard-dose and low-dose protocol group in the CT-guided biopsy for the entirely endophytic small renal masses (SRM)

242 A total of 56 patients underwent CT-guided biopsy for the entirely endophytic SRM ( 4 cm) from May 2011 to March Biopsy was performed with standard-dose protocol (reference mas, 210) in 37 patients and low-dose protocol (reference mas range, 40-80; mean±standard deviation, 43±9.5) in 19 patients. The diagnostic rate, histologic finding, radiation dose, complication rate, and procedure time were assessed from the retrospective chart and image reviews and compared between two groups. In the low-dose protocol group, all 19 patients had diagnostic results (14 renal cell carcinomas, 2 metastases, 1 urothelial carcinoma, 1 oncocytic neoplasm, and 1 angiomyolipoma). In the standard-dose protocol group, 36 (97%) patients had diagnostic results (24 renal cell carcinomas, 2 metastases, 1 lymphoma, 4 angiomyolipomas, 4 inflammations, and 1 cyst) and one patient had non-diagnostic result. No serious complication such as active bleeding was occurred in two groups. The standard-dose protocol group had statistically greater value of the dose length product (DLP) than low-dose protocol group (560±221 vs. 180±61 mgy*cm, P <.05). Mean procedure time was equally 21 minutes in two groups. Low-dose protocol CT-guided biopsy for the entirely endophytic SRM has comparable diagnostic result to the standard-dose protocol group without increasing complication rate or procedure time. Endophytic renal tumors have been related to higher surgical complexity and higher postoperative complication rate than exophytic lesions, and the number of biopsies in these endophytic lesions is increasing in our institution. Low dose protocol CT-guided biopsy may be sufficient for the histologic diagnosis of the endophytic SRM and can reduce the radiation dose to the patient. SSQ10-07 Ultrasound-guided Transvaginal Core Biopsy of Pelvic Masses: Feasibility, Safety and Short-term Follow-up Jung Jae Park MD (Presenter): Nothing to Disclose, Chan Kyo Kim MD, PhD : Nothing to Disclose, Byung Kwan Park MD : Nothing to Disclose Although several previous studies reported the utility of transvaginal approach for endometrial biopsy or fine needle aspiration of pelvic lesions, few studies have demonstrated the feasibility of transvaginal technique for biopsy of pelvic masses. The aim of our study was to evaluate the diagnostic accuracy and safety of ultrasound (US)-guided transvaginal core biopsy for pelvic masses. Forty-nine pelvic masses (mean size, 4.2 ± 2.8 cm) in 49 women (median age, 59 ± 12.7 years) who received US-guided transvaginal core biopsy between 2009 and 2013 were enrolled in this retrospective study. On pre-biopsy CT or MR imaging, the lesions were identified in vaginal stump (n = 25), rectovaginal or vesicovaginal pouch (n = 11), adnexa (n = 8), or distal ureter (n = 5). The biopsy was performed using a probe equipped with a guide and an 18 gauge Tru-cut needle with an automatic biopsy gun (Ace-cut) after local anesthesia. We evaluated the diagnostic accuracy and complication rate of the procedure. All acquired specimens were adequate and sufficient for pathologic analysis. Overall diagnostic accuracy of US-guided transvaginal core biopsy was 91.8% (45/49 patients). Of these, 39 lesions were diagnosed as malignancies and five lesions that revealed active or chronic inflammation without evidence of malignancy regressed spontaneously on follow-up imaging. The remaining one lesion was diagnosed as ovarian sex cord-stromal tumor. Of the four non-diagnostic lesions, two were identified as fibrothecoma and recurrent leiomyosarcoma after surgery, respectively and the remaining two were clinically regarded as recurrent ovarian and endometrial cancer due to increases in size on follow-up imaging, respectively. None of these biopsies resulted in major complications. As minor complications, vaginal bleeding immediately after the biopsy and gross hematuria were found in 10 patients (20.4%) and three patients (6.1%), respectively, but these complications were stopped spontaneously in all 13 patients without further treatment or transfusion. US-guided transvaginal core biopsy appears to be reliable and safe procedure for the histologic diagnosis in patients with pelvic masses. As a reliable and safe technique, US-guided transvaginal core biopsy can be used for clinical decision making and selecting optimal treatment strategies in patients with pelvic masses. SSQ10-08 Retrospective Study of Uterine Fibroid Treatment Using MRgFUS: Correlations between Age, Recurrence Rate and Clinical Outcomes Fabiana Ferrari MD (Presenter): Nothing to Disclose, Anna Miccoli MD : Nothing to Disclose, Francesco Arrigoni : Nothing to Disclose, Eva Fascetti MD : Nothing to Disclose, Antonio Barile MD : Nothing to Disclose, Carlo Masciocchi MD : Nothing to Disclose

243 To evaluate the efficacy of MRgFUS in the uterine fibroids treatment analysing the recurrence rate after 12 months from the treatment. This study correlates the age of patients to the clinical and imaging results. 38 patients, with symptomatic uterine fibroids were treated using MRgFUS from September 2011 to December Twenty-two of them were aged between 40 and 50 (group 1), 10 patients between 30 and 40(group 2) and 6 patients between 20 and 30 (group 3). Single fibroids were found in 13 patients while 25 patients presented multiple fibroids. Patients were submitted to one treatment alone. We submitted the patients to c.e. MRI respectively before treatment, after 10 days, 3 months, 6 months and 12 months. We made a morphological analysis of the images, an evaluation of the treated volume extension and the possible recurrence of the pathology in the area of the treatment. Clinical evaluation was performed by SSS-questionnaire, comparing the pre-treatment score to the one obtained after 12 months. All patients had a non-perfused-volume mean value of 91.5 %. Thirty-four women belonging to Group 1, Group 2 and Group 3 (89.5% of patients) showed a complete reabsorption of the necrotic area without any fibrotic tissue in the treatment area after 12 months. Four younger women (10.5 % of patients) belonging to Group 3, aged between 24 and 30 years, showed hypointense tissue in the peripherical part of the treated area after 3-6 months from the treatment. One of them, who underwent myomectomy, showed a mixed tissue made of necrotic cells and fibrotic tissue. Clinically, after 12 months from the treatment, Group 1, Group 2, and Group 3 showed a SSS-Q mean value of 7.8, 8.1, and 6.4, respectively. We did not appreciate clinical differences of statistical relevance between the groups. MRgFUS is an effective technique in younger and older women. We found excellent morphological results and clinical outcomes in patients belonging to group 1 and 2. In Group 3, the excellent clinical response was not associated to significant morphological results, this however not impairing the final response to the treatment. We evaluate the efficacy of the uterine fibroid treatment using MRgFUS correlating the morphological and clinical results in younger and older women obtaining in both groups good therapeutic results. SSQ10-09 Genitourinary Keynote Speaker: Oncologic Applications of HIFU in 2014 Current State-of-the Art and Future Directions Aradhana Mukherjea Venkatesan MD (Presenter): Institutional research agreement, Koninklijke Philips NV Abstract High intensity focused ultrasound (HIFU), also known as focused ultrasound (FUS) is a non-invasive image-guided therapy, which has been primarily employed in the clinical realm for non-invasive thermal ablation of benign and malignant neoplasms. Real time imaging guidance, treatment monitoring and therapy control is achieved with ultrasound (US) or magnetic resonance imaging (MRI) guidance. Clinical experience in the GU tract has been described in the treatment of leiomyomata, adenomyosis, prostate and renal tumors, although, to date, widespread adoption of HIFU thermoablation remains limited. Ongoing technical challenges include the feasibility of treating large tumors within a finite treatment time, treating targets prone to motion or those for which the acoustic window is restricted by intervening anatomy. A range of provocative bio-effects of therapeutic ultrasound beyond thermoablation also have the potential to be leveraged in the care of the oncology patient. Hyperthermic effects can potentiate the release of thermosensitive drugs, enhance the permeability and retention of chemotherapeutic agents, and potentially enable gene delivery within tumors. Mechanical effects of HIFU, including stable and inertial cavitation play a role in heat sensitive drug and gene delivery and have the potential to be employed as adjuvant effects for more efficient ablation of large tumors. Ongoing and promising oncologic research is directed toward optimization of HIFU's thermoablative capabilities and greater elucidation of its non-thermal effects. This keynote presentation will describe the principles governing oncologic applications of HIFU and present current state-of-the art and future GU interventional applications of this innovative image-guided therapy. SSQ19 Vascular/Interventional (IR: Non-hepatic Tumor Ablation) Scientific Papers IR AMA PRA Category 1 Credits : 1.50 ARRT Category A+ Credits: 1.50 Thu, Dec 4 10:30 AM - 12:00 PM Location: N227AB Moderator Ronald Steven Arellano MD : Nothing to Disclose Moderator Stephen Barnett Solomon MD : Research Grant, General Electric Company Research Grant, AngioDynamics, Inc Consultant, Johnson & Johnson Consultant, Covidien AG Director, Devicor Medical Products, Inc Director, Aspire Bariatrics, Inc Sub-Events SSQ19-01 Interim Results of Phase II Clinical Trial for Evaluation of MRI-guided Laser Induced Interstitial

244 SSQ19-01 Thermal Therapy (LITT) for Low-to-Intermediate Risk Prostate Cancer Aytekin Oto MD (Presenter): Research Grant, Koninklijke Philips NV Consultant, Guerbet SA, Ambereen Yousuf MBBS : Nothing to Disclose, Shiyang Wang PhD : Grant, Koninklijke Philips NV, Tatjana Antic : Nothing to Disclose, Gregory Stanislaus Karczmar PhD : Nothing to Disclose, Scott Eggener : Research Grant, Visualase, Inc Speakers Bureau, Johnson & Johnson To assess the oncologic efficacy and safety of MRI-guided laser-induced interstitial thermal therapy of biopsy confirmed and MR-visible prostate cancer. 17 patients with biopsy proven low-to-intermediate risk prostate cancer underwent MRI guided laser ablation of the cancer using Visualase laser ablation device. All patients had a pre-procedure endorectal MRI which showed suspicious foci concomitant with the positive sextant on TRUS guided biopsy. The area of interest was targeted transperineally using 1.5 T Philips MRI scanner and Visualase ablation device. Ablation was monitored by real time MR thermometry using Visualase MRI thermometry software. Perioperative, early and late complications and adverse events were recorded. Follow-up was performed with 3- month MRI examination and MR-guided biopsy and validated quality of life questionnaires to assess urinary and sexual function. MRI guided laser ablation of prostate cancer was successfully performed in all 17 patients without significant peri-procedural complications. All patients were discharged home the same day. Average duration of the procedure was 3 hours 39 minutes and average duration of a single laser ablation was 1 minute 21 seconds. Total number of ablations per patient ranged from 2-7, with a median of 4. The treatment created an identifiable hypovascular defect in all cases. Post procedure complications were minor and included urinary symptoms, perineal bruising and erectile dysfunction, all of which self-resolved. MR-guided biopsy of the ablation zone performed at the 3-month time point showed no cancer in all patients. Validated quality of life urinary and sexual questionnaires obtained before and 3 months after the procedure did not reveal any significant differences (p 0.05). Very early results of MRI-guided focal laser ablation for treatment of clinically localized, low-to-intermediate risk prostate cancer appear promising. It may offer a minimally invasive procedure for selected patients that does not appreciably alter sexual or urinary function. Interim results of our phase II trial show that MRI-guided focal laser ablation can be a safe and feasible option for treatment of low-to-intermediate risk prostate cancer. SSQ19-02 Lung Nodule Treatment with Cryoablation versus Radiofrequency Ablation versus Stereotactic Ablative Radiotherapy: A Survival Study George Mikhail MD (Presenter): Nothing to Disclose, Ammar Ahmed Chaudhry MD : Nothing to Disclose, Jung Hwoon Edward Yoon MD : Nothing to Disclose, Thomas Bilfinger MD : Nothing to Disclose, William Henry Moore MD : Research Grant, EDDA Technology, Inc Medical Board, EDDA Technology, Inc Research Grant, Galil Medical Ltd Research Grant, Endo Health Solutions Inc Compare frequency of recurrence and major complications in patients with lung nodules treated with cryoablation, radiofrequency ablation (RFA) or Stereotactic Ablative Radiotherapy (SABR). A retrospective IRB-approved analysis of patients who underwent cryoablation, RFA or SABR for primary stage 1 lung cancer performed from January 2007 to March 2013 was performed in this study. All procedures were performed using general anesthesia and CT guidance. Follow-up imaging with CT of the chest was obtained at 1, 3, 6, 12, 24, 36, 48 and 60 months post-procedure to evaluate the ablated lung nodule. Nodule surface area, density (in Hounsfield units) and size of cavitations were recorded. Degree of nodule enhancement was also recorded. 80 patients underwent SABR out of which 6 had disease recurrence as evidenced by metastatic disease within first six months,1 within 6 to 12 months, 3 within 12 to 24 months, 1 after 24 months. 49 patients underwent cryoablation out of which 2 had disease recurrence as evidenced by metastatic disease in the first 6 months, 1 between 6 to 12 months, 1 between 12 to 24 months and 1 after 24 months. 9 patients underwent RFA out of which 1 patient had disease recurrence which reccurred between 12 to 24 months. There were no recurrences in the 0-6 month period, 6-12 month period, or greater than 24 months period. In terms of major complications, 67/80 patients in the SABR group went on to develop radiation fibrosis in the ablation zone. None of the patients required hospitalization post SABR. 1/9 patients developed respiratory distress post RFA, requiring greater than 48 hour hospitalization. 1/49 patients develop large pulmonary hemorrhage requiring ICU admission.

245 Our study shows that patients who underwent cryoablation had a lower frequency of metastatic disease recurrence (10.2%) as compared to RFA (11.1%), and SABR (13.75%). This study shows metastatic disease recurrence rates of cryoablation are lower than those of SABR, providing compelling evidence to use cryoablation as primary non-surgical intervention to treat lung nodules due to its lower metastatic progression rate. SSQ19-03 Thoracic Cryoablation Is Safe and Effective for Multiple Tumors per Procedure Peter John Littrup MD (Presenter): Founder, CryoMedix, LLC Research Grant, Galil Medical Ltd Research Grant, Endo Health Solutions Inc Officer, Delphinus Medical Technologies, Inc, Hussein D. Aoun MD : Nothing to Disclose, Barbara A. Adam MSN : Nothing to Disclose, Brian Faustino Baigorri MD : Nothing to Disclose, Mohamed M. Jaber MD : Nothing to Disclose, Evan N. Fletcher MS, BA : Nothing to Disclose, Mark J. Krycia BS : Nothing to Disclose, Matthew Prus BS : Nothing to Disclose To assess efficacy and complication outcomes for cryoablation of primary and metastatic thoracic tumors based on location. Tumor and ablation size, complications, and location were also assessed for single vs. multiple tumors per procedure. CT fluoroscopic-guided percutaneous cryoablation was performed on 384 tumors in 283 procedures in 169 patients, noting tumor and ablation volumes, location, abutting vessels >3mm, recurrences, complications, and tumor type. In procedures with treatment of a single tumor, locations were designated as chest wall/pleural-based (n=113), pulmonary (n=53), and central (N=39). In addition, there were 179 tumors in procedures where multiple tumors were targeted in the same lung and outcomes noted separately. Complications were graded by the National Institutes of Health, Common Terminology of Complications and Adverse Events (CTCAE). All patients required only conscious sedation. Overall tumor and ablation mean size was 2.6cm and 4.8cm, respectively. Total major complication rates were low at 5.3% (15/283). Tumor mean size was significantly larger in procedures with major complications (5.2cm) compared to those without (2.5cm, p<0.001). No significant difference in major complications was noted between locations for the 3 groups of single tumor ablation, as well as no difference between the combined single tumor ablation (5.9%, 12/205) compared to the multiple tumor ablation group (3.8%, 3/78; p>0.05). Total local tumor recurrence rates were low at 5.2% (20/384) and were not dependent upon tumor size or location, vessel proximity, or between single or multiple ablations per procedure. CT guided thoracic cryoablation provides a low morbidity alternative for complex patients, particularly for central and chest wall/pleural-based tumors. Major complication rate was significantly higher for larger tumors, but there was no significant difference based on location or treatment of multiple tumors. Recurrence rates were not dependent upon any assessed factors. Thoracic cryoablation has low recurrence and complication rates, even for multiple tumors in the same lung. Larger tumors may have lower complications if done in more than one session. SSQ19-04 Transpulmonary Chemoembolization (TPCE) and Transarterial Chemoperfusion (TACP) in the Interventional Treatment of Primary and Secondary Lung Cancer Thomas Josef Vogl MD, PhD (Presenter): Nothing to Disclose, Sonja Frewert : Nothing to Disclose, Nagy Naguib Naeem Naguib MD, MSc : Nothing to Disclose To evaluate tumor response after treating primary and secondary lung cancer with transpulmonary chemoembolization (TPCE) or transarterial chemoperfusion (TACP) in a curative, neoadjuvant, palliative or symptomatic intention. From 2005 to 2013, 417 patients (202 males/215 females) were treated with a mean of 5.29 (range:1-25) TPCE or TACP sessions in 4-week intervals. Patients suffered from primary lung tumors (small cell carcinoma (n=9), non-small cell carcinoma (n=62), bronchial carcinoma with unknown histology (n=34) and lung metastases from different primaries (colorectal carcinoma (n=117), breast cancer (n=40), renal cellular carcinoma (n=17), and others (n=138)). In case of embolization the femoral vein was punctured and tumor-supplying pulmonary arteries were explored. A combination of different chemotherapeutic drugs, lipiodol and microspheres were applied via balloon protection. In case of perfusion the femoral artery was punctured

246 and the catheter was placed in the thoracic aorta above the tumor feeding bronchial and intercostal arteries which were identified with DSA and C-arm CT. Chemotherapeutic drugs were applied manually with a speed of injection according to patient pain level. Treatment was well tolerated in all patients without any major complications. After evaluation of the tumor volume partial response (PR) was achieved in 17.75% (n=74), stable disease (SD) in 33.09% (n=138) and progressive disease (PD) was found in 49.16% (n=205) according to the RECIST criteria. 1.68% (n=7) of all patients were treated in a curative intention, 42.86% of who had PR (n=3) or SD (n=3), 14.29% (n=1) PD. Of the patients treated in neoadjuvant intention (n=26; 6.24%) 46.15% (n=12) had PR, 34.62% (n=9) SD and 19.23% (n=5) PD % of the patients (n=348) treated in palliative intention 16.33% (n=57) had PR, 33.52% (n=117) SD and 50.14% (n=175) PD. Of the 36 patients (8.63%) treated in a symptomatic intention 2 patients showed PR (5.52%), 27.78% (n=10) had SD and 66.67% (n=24) PD. TPCE and TACP are well-tolerated treatment options for patients with primary and secondary lung tumors, especially in palliative and symptomatic intentions. Even in neoadjuvant and curative intentions they seem to be a proper preparation for tumor downsizing for following thermal ablation. TPCE and TACP provide good treatment option in patients with primary and secondary lung cancer SSQ19-05 False-positive Tumor Enhancement after Cryoablation in Renall Cell Carcinoma: A Prospective Study Haruyuki Takaki MD (Presenter): Nothing to Disclose, Koichiro Yamakado MD, PhD : Nothing to Disclose, Atsuhiro Nakatsuka MD : Nothing to Disclose, Francois Cornelis MD : Nothing to Disclose, Junji Uraki MD : Nothing to Disclose, Takashi Yamanaka MD : Nothing to Disclose, Masashi Fujimori MD : Nothing to Disclose, Takaaki Hasegawa : Nothing to Disclose, Kiminobu Arima : Nothing to Disclose, Yoshiki Sugimura : Nothing to Disclose, Hajime Sakuma MD : Research Grant, Siemens AG Research Grant, Koninklijke Philips NV Research Grant, General Electric Company Research Grant, Bayer AG Research Grant, Guerbet SA To prospectively evaluate the frequency and duration of false positive tumor enhancement after cryoablation in patients with renal cell carcinoma (RCC). Thirty-three patients who underwent cryoablation for the treatment of RCCs smaller than 7 cm were enrolled in this IRB-approved prospective study after a written informed consent was obtained from each of them. Contrast-enhanced MR studies were performed at 6 different time point (3 days, 7 days, 1, 3, 6, 12 months) after cryoablation. The false-positive rates to detect residual tumors were evaluated at each time point. Factors affecting false-positive tumor enhancement was evaluated. A planned MR protocol was completed in 30 patients (90.9%, 30/33). Residual tumor was histologically proven in 5 patients (16.7%). False-positive rates at each time points were 60.0% (12/25) at 3 days, 52.0% (13/25) at 7 days, 4.0% (1/25) at 1 month, 0% (0/25) at 3 months, 0% (0/25) at 6 months, and 0% at 12 months, respectively. The false-positive tumor enhancement rate at 7 days was significantly higher in patients with RCC with clear cell carcinoma (63.2%, 12/19) than those with other histology (16.7%, 1/6) (p=0.0469). Either tumor size or tumor geometry did not affect false positive tumor enhancement. Tumor enhancement frequentry remains even in completely ablated RCCs up to one month after cryoablation, in particular in clear cell carcinoma. Residual tumor enhancement is frequently observed within one month after cryoablation for RCC, and this finding is more common in clear cell carcinoma. SSQ19-06 Cryoablation of Pelvic Masses: A Low Morbidity Alternative in Selected Patients Hussein D. Aoun MD (Presenter): Nothing to Disclose, Peter John Littrup MD : Founder, CryoMedix, LLC Research Grant, Galil Medical Ltd Research Grant, Endo Health Solutions Inc Officer, Delphinus Medical Technologies, Inc, Barbara A. Adam MSN : Nothing to Disclose, Mohamed M. Jaber MD : Nothing to Disclose, Brian Faustino Baigorri MD : Nothing to Disclose, Matthew Prus BS : Nothing to Disclose, Evan N. Fletcher MS, BA : Nothing to Disclose, Mark J. Krycia BS : Nothing to Disclose

247 To assess the technical feasibility and complication rates of percutaneous pelvic mass cryoablation with respect to tumor size and location. Despite the difficulties of adjacent bowel and lower extremity nerves, we hypothesized that cryoablation could contribute to local tumor control in select patients. CT and/or CT-US fluoroscopic-guided percutaneous cryoablation was performed in 69 procedures on 82 tumors in 50 patients. Tumor and ablation volumes, location, recurrences, and major complication rates (CTCAE) were collected. Locations were noted as sub-cutaneous, bone, intraperitoneal or retroperitoneal. Patients were excluded if the any bowel appeared adherent or motor nerves couldn't be avoided by ablation zone. Hydrodissection, balloon displacement of intraperitoneal bowel and urethral warming balloon for a prostate case were used for tissue protection as needed. All patients required only conscious sedation. Median tumor and ablation diameter was 3.6 cm and 5.6 cm, respectively. Of the 82 of tumors, 35 were in the subcutaneous region, 8 intraperitoneal, 28 retroperitoneal and 11 within bone. There was 1 urachal tumor and 81 metastases which were from sarcoma (16), colorectal (14), ovarian (11), melanoma (9), renal (9) or miscellaneous (22). Of the 69 total procedures, 12 procedures had more than 1 tumor ablated. The low total tumor recurrence rate of 9.8% (8/82) as not significantly affected by tumor size or location with an average followup time of 1.2 yrs. Total major complication rate as low at 5.8% (4/69), despite some tumors initially abutting vital structures that could be adequately protected (ie: sciatic/femoral nerve, urinary bladder and bowel.) Of the complications, 2 were fistulas, 2 were anticipated neurological changes in non-operative patients. CT guided percutaneous cryoablation of pelvic tumors provides an effective and low morbidity alternative to surgery or radiation, particularly for patients who may require exenteration for local tumor control. Cryoablation of pelvic tumors has low recurrence and complication rates even for deep locations. Oligometastatic tumor control may avoid morbid pelvic surgeries in selected patients. SSQ19-07 Percutaneous Adrenal Cryoablation: A Safe, Well Visualized and Effective Treatment Hussein D. Aoun MD (Presenter): Nothing to Disclose, Peter John Littrup MD : Founder, CryoMedix, LLC Research Grant, Galil Medical Ltd Research Grant, Endo Health Solutions Inc Officer, Delphinus Medical Technologies, Inc, Barbara A. Adam MSN : Nothing to Disclose, Mohamed M. Jaber MD : Nothing to Disclose, Brian Faustino Baigorri MD : Nothing to Disclose, Matthew Prus BS : Nothing to Disclose, Evan N. Fletcher MS, BA : Nothing to Disclose, Mark J. Krycia BS : Nothing to Disclose To assess the technical feasibility, efficacy and complication rates of CT guided percutaneous cryoablation of adrenal masses. 27 Ct fluoroscopic-guided percutaneous cryoablations were performed on 28 metastatic tumors, in 22 patients, noting tumor size and type, abutting vessels >3mm, recurrences, complications, need for hydrodissection of surrounding vital structures and anesthesia-managed hypertension monitoring by arterial catheter. Complications followed the grading system of the National Institutes of Health, Common Terminology of Complications and Adverse Events (CTCAE). Local tumor recurrence and involution was monitored over time with 1, 3, 6, 12 month and annual scans thereafter. All patients required only conscious sedation. Average tumor and ablation size was 4.0 cm and 5.7 cm respectively. Of the 28 tumors, tumor origin was non-small cell lung (11), renal (11), sarcoma (3) ovarian cancer (1), colorectal (1) and small cell lung (1). Multiple tumors were ablated in 2 of total 24 procedures. Local recurrence rate was 17.9% (5/28) for an average followup time of 1.6 yrs. Other than 1 patient with leiomyosarcoma of the inferior vena cava having 2 re-treatments for local recurrence vasculature did not appear to effect recurrence rate. The major complication (> grade 3) rate was 3.7% (1/27), with 0 major complications attributable to the procedure. One death was due to a pulmonary embolism unrelated to the ablation procedure. Transient severe hypertension (>260/120) was noted in 3 cases which was rapidly managed by labetalol and nitroglycerin drips with no sequales. CT guided percutaneous cryoablation is a safe, effective and low morbidity alternative for patients with adrenal tumors. Transient hypertension is related only to residual viable adrenal tissue but can be safely managed. Oligometastatic disease is becoming more common with improved systemic treatments. Adrenal cryoablation contributes to improved local control for many tumor types, with greater probe density required near major

248 vasculature. SSQ19-08 MR Imaging-guided Brain Metastases Cryoablation: Initial Experience in 6 Patients Chengli Li MD, PhD (Presenter): Nothing to Disclose Evaluate the feasibility and effective of our initial experience with MRI-guided cryoablation of metastatic brain tumors. With approval from the local ethics committee and patient consent. Between Sept Jan. 2012, 7 brain mets in 6 consecutive patients (5 women, 1 men, mean age 53 years) were treated using cryoablation under conscious sedation. A 0.23T open MRI device mounted with optical tracking system was used for procedural imaging and instrument guidance. Once planning the intervention route, a 2-3mm burr-hole was drilled under sterile conditions and local anesthesia out of the 5 gauss line. Cryoablation was performed by using an MR-compatible, argon-based cryoablation system with 1.47mm probs according to the size of tumor. Multi-sites or multi-angles were performed if necessary to make the ice ball engulf the tumor and arrive to conformal ablation. For cystic lesions, aspirating fluid was performed first, then advancing the biopsy needle to acquire pathology specimen prior to the cryoablation. Two freeze-thaw cycles (10-minute freeze, 5-minute thaw, 10-minute interval) were performed for each site. In 7 sessions, seven tumors in six patients were treated with 11 cryoablations.the ice around the probe tip was continuously and clearly visible as an ellipsoid-like signal-free area in MR images.one patient was died of pneumonia and high fever at the 12 days after cryoablation. Two patients had symptoms possibly related to intracranial hypertension.the mean operative time was 120 minutes. MRI-guidance and monitoring cryoablation is safe, feasible, and effective for certain brain metastases patients. MRI-guided cryoablation can be used to substitute more invasive procedures in selected patient groups. Excellent MR Guidance and Visualization. Generally,technically feasible and effective treatment option of brain metastases. Decrease viable tumour. SSQ19-09 New Intravascular Elution Device for the Interventional Radiological Treatment of Pancreatic Neoplasms. In vitro an in vivo First Results Ruben Lopez-Benitez MD (Presenter): Nothing to Disclose, Levent Kara MD : Nothing to Disclose, Gregory Cruise : Nothing to Disclose To characterize gemcitabine loaded hydrogel elution devices (GLH-elution devices) using in vitro and in vivo methods as first intravascular prototypes for local treatment in pancreatic tumors. To determine the in vitro elution, the GLH-elution devices were placed in 0.9% saline at 37 C. Periodically, the saline was collected and analyzed for gemcitabine content using liquid chromatography. To determine the in vivo elution of gemcitabine a10 cm, 35-system gemcitabine-loaded hydrogel device was placed into the gastroduodenal artery of every pig. Blood samples were collected periodically for gemcitabine and 2',2'-difluoro-2'-deoxyuridine quantitation using liquid chromatography/mass spectroscopy. Follow-up angiography was performed at 30 days post-embolization. Harvested tissues were evaluated histologically. All the evaluated devices demonstrated a certain degree of gemcitabine elution, in vitro as in vivo. The in vitro elution of gemcitabine from the embolic device was rapid, as elution ceased after 2 hours. All 6 pigs were successfully embolizated and survived the 30-day period. Similar to the in vitro elution, the plasma levels of gemcitabine spiked within 15 minutes of embolization and returned to baseline levels by 1 week post-embolization. As expected, the plasma levels of 2',2'-difluoro-2'-deoxyuridine peaked later than gemcitabine, between 1 and 3 hours post-embolization. Histologically, no evidence of inflammatory changes were observed. The first local elution devices designed for a porcine model with possible future applications in cases of pancreatic neoplams showed during the first experimental phase positive local drug elution.

249 With this model, it will be feasible to deliver a targeted therapy nearby pancreatic tumoral areas, with sustained local drug release. VIS-THA Vascular/Interventional Thursday Poster Discussions Scientific Posters IR VA AMA PRA Category 1 Credits :.50 Thu, Dec 4 12:15 PM - 12:45 PM Location: VI Community, Learning Center Moderator Charles Thomas Burke MD : Nothing to Disclose Sub-Events VIS263 Association of Aortic Compliance and Brachial Endothelial Function with Cerebral Small Vessel Disease in Type 2 Diabetes Mellitus Patients: Assessment with 3.0T MRI (Station #1) Yan Shan (Presenter): Nothing to Disclose, Jiang Lin MD, PhD : Nothing to Disclose, Pengju Xu : Nothing to Disclose, Mengsu Zeng MD, PhD : Nothing to Disclose To assess the possible association of aortic compliance and endothelial function with cerebral small vessel disease in type 2 diabetes mellitus(dm2) patients by using 3.0T high resolution magnetic resonance imaging. Sixty two DM2 patients (25 women and 37 men, mean age: 56.84±7.46 years) were prospectively enrolled for noninvasive MR examinations of the aorta, brachial artery, and brain. Aortic distensibility(ad), aortic arch pulse wave velocity (PWV), flow-mediated dilation(fmd) of brachial artery, lacunar brain infarcts, and periventricular and deep white matter hyperintensities (WMHs) were assessed. Pearson and Spearman correlation analysis were performed to analyze the association of aortic arch PWV, AD and FMD with clinical data and biochemical test results. Univariable logistic regression analyses were used to analyze the association of aortic arch PWV, AD and FMD with cerebral small vessel disease. Multiple logistic regression analyses were used to find out the independent predictive factors of cerebral small vessel disease. Mean aortic arch PWV was 6.73±2.00 m/s, ascending aorta AD (AA-AD) was 2.64± mm Hg-1, proximal thoracic descending aorta AD (PDA-AD) was 3.08± mm Hg-1, distal descending aorta AD (DDA-AD) was 3.69± mm Hg-1, FMD was 16.67±9.11%. After adjustment for age, sex, smoke situation, diabetes duration and hypertension, PWV was statistically significantly associated with lacunar brain infarcts (OR=2.00, 95%CI: , p<0.05) and FMD was statistically significantly associated with periventricular white matter hyperintensities(or=0.82, 95%CI: , p<0.05). Quantitative evaluation of aortic compliance and endothelial function by using 3.0 T high-resolution MRI may contribute to stratify the cardiovascular risk factors of DM2 patients with a potential risk of cerebral small vessel disease. Our results suggested that high-resolution MRI may help stratify cardiovascular risks in DM2 patient with direct quantification of both aortic stiffness and endothelial dysfunction. VIS264 Hyperemic Fractional Microvascular Blood Plasma Volume Is Related to Arterial Flow Reserve in Patients with Arterial Disease (Station #2) Bharath Ambale venkatesh PhD (Presenter): Nothing to Disclose, David A. Bluemke MD, PhD : Research support, Siemens AG, Joao A. C. Lima MD : Research Grant, Toshiba Corporation, Chikara Noda : Nothing to Disclose Lower-extremity hyperemic skeletal muscle perfusion and popliteal arterial flow reserve measures could be valuable for diagnosing peripheral artery disease (PAD) and evaluating treatments that promote angiogenesis and tissue regeneration.

250 The Patients with Intermittent Claudication Injected with ALDH Bright Cells (PACE) study is a randomized, double-blind, placebo-controlled multi-center clinical trial, to assess the clinical safety and efficacy of autologous bone marrow derived aldehyde dehydrogenase-bright cells. In a preliminary analysis of 16 PAD patiens with an ankle-brachial index <0.9 and significant stenosis in the infrainguinal arteries at baseline as part of this study, MRI-derived measures of hyperemic calf muscle perfusion from dynamic contrast-enhanced (DCE) MRI and hyperemic popliteal artery flow from phase-contrast (PC) MRI were evaluated. Scans were performed in 1.5-T and 3-T scanners (GE, Siemens and Philips) across multiple centers using 0.05 mmol/kg Magnevist, and using a 5-minute occlusion of femoral artery flow by inflating a thigh cuff to suprasystolic pressures on the asymptomatic leg to induce hyperemia. DCE-MRI was performed at 8 slices at mid-calf using 3D SPGR sequences (spatial resolution: 1x1x5 mm, temporal resolution <5ms) and was preceded by a variable flip angle method to measure T1. Semi-quantitative measures and quantitative measures were obtained from the modified Tofts' model post-hyperemia: area under the gadolinium curve at 60s (iauc) and fractional blood plasma volume (Vb). The arterial flow reserve (AFR) was obtained as difference in peak flow (ml/s) after and before induced hyperemia from PC-MRI. The patients were on average 66 years, with mean Vb = 4.5±5.2%, iauc = 1.097±0.43 mmol/l*s and AFR = 1.144±1.15 ml/s. The iauc was correlated with the absolute AFR - r = 0.55, p= The difference in average velocity at hyperemic and resting states was correlated to both the iauc (r=0.51, p=0.045) and Vb (r=0.6, p=0.015). Hyperemic blood flow rates measured with PC-MRI were related with hyperemic fractional blood plasma volume and tissue contrast uptake from DCE-MRI in PAD patients. This helps in indentification of skeletal muscle perfusion in relation to blood flow. VIS265 Detection of Endoleaks after Endovascular Aortic Repair Using Unenhanced MR Imaging: Diagnostic Accuracy of Balanced Turbo Field Echo Sequence with Motion-sensitized Driven Equilibrium (Station #3) Kensaku Mori MD (Presenter): Nothing to Disclose, Tsukasa Saida MD : Nothing to Disclose, Fujio Sato : Nothing to Disclose, Katsuhiro Nasu MD, PhD : Nothing to Disclose, Toshitaka Ishiguro MD : Nothing to Disclose, Takahiro Konishi MD : Nothing to Disclose, Yoko Uchikawa MD : Nothing to Disclose, Sodai Hoshiai MD : Nothing to Disclose, Takashi Hiyama MD : Nothing to Disclose, Manabu Minami MD, PhD : Nothing to Disclose To evaluate the diagnostic accuracy of unenhanced balanced turbo field echo sequence (BTFE) with motion-sensitized driven equilibrium (MSDE) for detecting endoleaks after endovascular aortic repair (EVAR). We included 26 patients (20 men and 6 women; mean age, 72.5 years; age range, years) who had undergone EVAR for aortic and/or iliac arterial aneurysms. All patients underwent contrast-enhanced CT and unenhanced MR imaging including ordinary BTFE, BTFE with MSDE using no velocity encoding (VENC) (bright blood imaging), and BTFE with MSDE using VENC of 5 cm/s (black blood imaging). The interval between the contrast-enhanced CT and unenhanced MR imaging ranged from 0 to 6 days (mean, 0.6 days). Two independent observers, unaware of the contrast-enhanced CT results, reviewed the unenhanced MR images and the subtraction images reconstructed from the bright and black blood imaging. The confidence levels for the presence of endoleaks were assigned on a 5-point scale. The diagnositc accuracy was assessed by the receiver operating characteristic (ROC) analysis. The contrast-enhanced CT results served as the reference standard. The interobserver agreement was evaluated by the kappa statistics. Additionally, the artifact levels on subtraction images were assigned as no, minimal, moderate, or severe. On contrast-enhanced CT, 1 and 5 patients had type-1 and type-2 endoleaks, respectively. The respective area under the ROC curve, accuracy, sensitivity, and specificity for detecting endoleaks on unenhanced MR imaging were 0.983, 92.3%, 100%, and 90% for the observer 1 and 0.992, 96.2%, 100%, and 95% for the observer 2. The kappa value was 0.651, indicating good interobserver agreement. No, minimal, moderate, and severe artifact was assigned in 19, 4, 3, and 0 patients by the observer 1 and in 13, 9, 4, and 0 patients by the observer 2, respectively. Endoleaks can be accurately diagnosed on BTFE with MSDE without use of contrast medium. BTFE with MSDE is a truly non-invasive method to detect endoleaks after EVAR, requring neither contrast-medium injection nor radiation exposure. Thus, this technique will help to reduce invasiveness of follow-up imaging after EVAR, especially in patients with renal dysfunction.

251 VIS261 Clinical Outcomes in Primary Hyperaldosteronism Treatment: Radiofrequency Ablation vs. Adrenalectomy vs. Medical Therapy (Station #4) Ammar Sarwar MD (Presenter): Nothing to Disclose, Ari Charles Sacks MD : Nothing to Disclose, Olga Rachel Brook MD : Research Grant, Guerbet SA, Erica Alice Gupta MD : Nothing to Disclose, Nahum Goldberg : Nothing to Disclose, Barry A. Sacks MD : Nothing to Disclose, Muneeb Ahmed MD : Nothing to Disclose, Salomao Faintuch MD : Nothing to Disclose To report and compare outcomes in patients undergoing radiofrequency ablation (RFA), surgical and medical treatment for primary hyperaldosteronism. In this IRB-approved, HIPAA-compliant retrospective study 117 consecutive patients undergoing adrenal vein sampling (AVS) were included in the study. Follow-up data was available in 92/117 patients (age 52±12, 44% female). 41/92 (44%) patients had medical treatment, 37/92 (40%) had adrenalectomy and 14/92 (15%) had RFA. Changes in systolic and diastolic blood pressure (SBP, DBP), number of anti-hypertensive medications (anti-htn) and plasma renin to aldosterone ratios (ARR) were recorded on clinical follow-up. RFA group: Clinical follow-up was performed 73±40 days post-rfa. Blood pressure decreased from 148±18/92±15 pre-rfa to 135±22/82±12 post-rfa (SBP: p<0.05, DBP: p=ns. Number of anti-htn drugs decreased from 3.1±1.4 pre-rfa to 1.9±1.7 post-rfa (p=0.01). Adrenalectomy group: Clinical follow-up was performed 33±40 days after surgery. Blood pressure decreased from 145±9.7/89±8.6 pre-surgery to 137±20/83±11post-surgery (SBP: <0.0001, DBP: NS). Pre-adrenalectomy patients were on 2.6±1.0 anti-htn vs. 1.1±1.1 after surgery (p<0.0001). Medical treatment group: Clinical follow-up was available in all patients, 48±255 days after AVS. Pre-AVS blood pressure was 144±19/88±12 vs. 136±20/83±11 post therapy (SBP: p=0.02, DBP: p=0.006). The patients on medical therapy were on an average of 3.1±1.8 anti-htn medications prior to the AVS and an average of 3.3±1.8 on follow-up (p=n.s.). Whereas there was a decrease in hypertension and anti-htn needed for control after treatment, in the surgical group (p<0.001) and the RFA group (p=0.003) compared to the medical therapy group, there was no significant difference in the change in anti-htn after treatment between the surgical and RFA group (p=0.07). The percentage of responders-to-therapy (Figure 1) in the surgical and RFA group were similar (p=0.06) but lower in the medical therapy group. RFA is a successful treatment for AVS-proven aldosterone producing adenomas with clinical outcomes comparable to adrenalectomy. RFA is a successful treatment for primary hyperaldosteronism lateralizing to one gland on AVS with outcomes comparable to adrenalectomy, with the advantages of no incision, same day discharge and early return to daily activities. VIS262 Efficacy of MR Guided Focused Ultrasound Surgery in Treating Adenomyosis: Study of 19 Indian Patients (Station #5) Sameer Surendra Soneji DMRD (Presenter): Nothing to Disclose, Ritu Manoj Kakkar MBBS : Nothing to Disclose, Shrinivas Balaji Desai MD : Nothing to Disclose To assess the efficacy of MR guided focused ultrasound surgery (MRGFUS) in treating adenomyosis by evaluation of non-perfused volumes (NPV) and symptom severity score (SSS). 19 Indian women with significant symptomatic adenomyosis (SSS > 21) were selected. Patients underwent evaluation of the adenomyosis with post contrast MRI of pelvis. Those with focal and diffuse adenomyosis with definable treatable areas were treated by MRGFUS. Post treatment post contrast MRI pelvis was performed to assess the NPV. 6 months follow up with SSS questionnaire and MRI pelvis with contrast. MRgFUS treatment of adenomyosis resulted in significant reduction in SSS in 74% patients. The post treatment SSS at 6 months and reduction in score was 16± 4.8 (SD) and 12.6 ± 5.4 (SD) respectively which showed strong correlation with the NPV and percentage of adenomyosis reduction (p < 0.01). NPV had a strong and highly positive correlation with reduction in SSS (p<0.01, r= 0.92). The unpaired t-test determined that there was significant difference in NPV values in patients who had clinically significant reduction in SSS (p < 0.01). The ROC of NPV with reduction in SSS showed that an NPV > 22% resulted in significantly reduced SSS. Nearly 80% of our patients were adverse event free with the remaining having self-limited complications like abdominal pain, early menses and back pain. There was 1 patient of 1st degree burn due to previous surgery scar which also resolved within a month of the treatment.

252 MRgFUS can provide effective treatment of adenomyosis. The treatment is able to achieve NPV values that will result in clinically significant reduction in symptoms. The reduction in the SSS and percentage of adenomyosis reduction follows the NPV very closely and linearly, which means that achieving greater NPV will essentially result in significant symptom reduction. This procedure is safe with minimal adverse effects. MRgFUS should be used to treatment focal or diffuse adenomyosis where a treatable area can be defined. NPV more than 20% should be therapeutic, however highest possible NPV that can be safely achieved should be sought for better symptom reduction. VIS266 Doppler Sonographic Findings of Splenic Steal Syndrome after Liver Transplantation (Station #6) Chaolun Li (Presenter): Nothing to Disclose, Weiping Wang MD : Nothing to Disclose, Eunice Kim Moon MD : Nothing to Disclose, John Fung : Nothing to Disclose, Koji Hashimoto MD : Nothing to Disclose The purpose of this retrospective study is to compare the most commonly used Doppler parameters between splenic steal syndrome (SSS) patients after orthotopic liver transplantation and the control group to investigate the findings and the value of Doppler ultrasound in the diagnosis of SSS and follow-up after treatment. A total of 51 patients with angiographic confirmed SSS (40 men, 11 women, average age of 57.7±9.9 years, age range years) were enrolled in this study. The control group consisted of 50 liver transplant patients (40 men, 10 women, average age of 55.8±10.4 years, age range 8-75 years) with normal liver enzyme levels from the same period. The clinical data and ultrasound examination records were reviewed. All the patients were treated with proximal splenic artery embolizaion after the diagnosis of SSS was established. All the patients with SSS underwent Doppler ultrasound examination before and after the treatment. The following parameters were documented and analyzed in both groups: portal venous velocity (PVV), peak systolic velocity (PSV) of hepatic artery, resistance index (RI) of hepatic artery, and the size of spleen. RI of the SSS group (0.94±0.08) was significantly higher than those of the control group (0.80±0.10) (P< ). RI>0.91 is the optimal threshold for the diagnosis of SSS with sensitivity of 72.0%, specificity of 80.8%, PPV of 78.9%, and NPV of 74.3% (AUC=0.81, P<0.0001). Moreover, RI tends to remain a high level in SSS patients, while it will normalize in the control group. Therefore, it may be more helpful for the diagnosis to observe the change of RI dynamically over time. There was no significant difference of PVV and PSV of hepatic artery between the two groups. After the SAE, RI significantly decreased from 0.94±0.08 to 0.77±0.11 (P< ), and PVV decreased from 87.9±25.2 cm/s to 43.1±17.7 cm/s (P< ). PSV of hepatic artery increased from 68.0±37.7 cm/s before SAE to 72.1±41.6 with no statistically significant difference (P=0.14). A persistent high resistance hepatic arterial waveform should lead to the suspicion of SSS. RI and portal vein velocity are better indicators than hepatic arterial PSV for successful treatment of SSS. Doppler ultrasound imaging is a useful screening method for both the diagnosis of SSS and the follow-up after treatment. VIS267 A New Approach in the Treatment of Bone Metastases: Efficacy of CT-guided Cryotherapy Combined with Radiotherapy (Station #7) Lorenzo Maria Gregori : Nothing to Disclose, Francesco Arrigoni (Presenter): Nothing to Disclose, Fernando Smaldone MD : Nothing to Disclose, Luigi Zugaro : Nothing to Disclose, Antonio Barile MD : Nothing to Disclose, Carlo Masciocchi MD : Nothing to Disclose Aim of this study was to evaluate the role of percutaneous CT-guided cryoablation in the synergistic treatment with radiotherapy in the management of painful bone metastases. From July 2011, one hundred and two oncologic patient, with histologically and radiologically confirmed painful bone metastases were included in the study. All subjects experienced pain localized to the site of the bone metastases with a score >5 on the validated visual analogue scale (VAS). Cryoablation was performed in 38 subjects. Eighteen of them underwent a radiation course (20 Gy in 5 daily fraction) 10 days after the ablation. These subjects were retrospectively matched with a group of subjects treated by CA or RT. Exclusion criteria were the presence of other visceral or not-visceral metastasized sites. The rate of pain relief in terms of complete (CR) and partial (PR) response and the changes in self-rated Quality of life (QoL) were measured 3 months after treatments. A significant higher proportion of subjects treated by CA (37%) (p=0.016) or CA followed by RT (72%) (p< 0,01) experienced a CR compared to patients treated by RT alone (13%). Interestingly, the addition of RT to CA significantly improved the rate of CR compared to CA alone (p=0.034). The higher rate of CR observed in patients treated by CA or CA-followed RT paralleled with an improved self-rated QoL. Thirty-seven (84%)

253 patients were successfully ablated without complications with the rate of major complications of 16%. Patients had pain relief for a period ranging from 3 to 24 months (mean 7.8 months). Technical success was 100%. Combined treatment of CT-guided cryoablation and radiotherapy improves relief from pain due to bone metastases. In the treatment on painful bone metastases, combined treatment of CT-guided cryoablation and radiotherapy offer the best therapeutic outcomes. VIE016-b Comparing Percutaneous Tumor Ablation Modalities: Microwave Ablation, Radiofrequency Ablation, Cryoablation, and Irreversible Electroporation (hardcopy backboard) Seyed Amin Astani MD, MBA (Presenter): Nothing to Disclose, Kevin McGill MD, MPH : Nothing to Disclose, Scott E. Schwartz MD : Nothing to Disclose To compare the current indications, contraindications, technique, advantages, and mechanism of action of the 4 most commonly used percutaneous ablation modalities (microwave ablation, radiofrequency ablation, cryoablation, and irreversible electroporation). Compare the microwave ablation, radiofrequency ablation, cryoablation, and irreversible electroporation in: Mechanism of action and physics behind them Indications and contraindications Techniques Advantages, challenges, and disadvantage Complications Cost VIS-THB Vascular/Interventional Thursday Poster Discussions Scientific Posters IR VA AMA PRA Category 1 Credits :.50 Thu, Dec 4 12:45 PM - 1:15 PM Location: VI Community, Learning Center Sub-Events VIS270 Migration of Retrievable, Expandable Metallic Stents Inserted for Malignant Esophageal Strictures: Incidence, Management, and Prognostic Factors in 332 Patients (Station #1) Wei-Zhong Zhou (Presenter): Nothing to Disclose, Ho-Young Song MD : Nothing to Disclose, Jung-Hoon Park MS, RT : Nothing to Disclose, Ji Hoon Shin MD : Nothing to Disclose, Jin Hyoung Kim MD : Nothing to Disclose, Young Chul Cho BS : Nothing to Disclose, Jong Kun Jang : Nothing to Disclose, Eun Jung Jun PhD : Nothing to Disclose Focused on evaluating the factors that influence stent migration following placement of single design stent was not previously reported. The purpose of this study was to evaluate the incidence, prognostic factors, and secondary management of stent migration in patients with malignant esophageal strictures. A retrospective cohort study was performed in a single, tertiary-referral, university hospital to identify the incidence, management, and prognostic factors for stent migration in 332 consecutive patients with placement of a retrievable, expandable, metallic stent for malignant esophageal strictures. Stent migration was classified into four patterns as locations of a migrated stent when migrated stents were detected. A multivariate logistic regression model was used to identify the independent predictive factors associated with stent migration. Stent migration occurred in 42 (12.6%) of 332 patients. Migration was partial (n=21) or complete (n=21), and nine, 12, 11, and 10 patients had patterns I, II, III, and IV, respectively. Multivariate analysis identified the following prognostic factors: esophagogastic junction strictures caused by cancer of the gastric cardia (OR, 3.330; 95% CI, ; p = 0.004), patients who underwent anti-cancer treatment after stent placement (OR, ; 95% CI, ; p < 0.001), and patients with a longer survival time (OR, 2.994; 95% CI, ; p < 0.001). Secondary management was needed for 33/42 (79%) patients. The strictures in the remaining nine patients improved throughout the follow-up. Stent migration occurs most commonly in patients with cancer of the gastric cardia, longer survival time and who underwent anti-cancer treatment following stent placement. Stent migration is successfully managed by further intervention.

254 Accurate knowledge of the pattern of stent migration is important for its successful management. VIS272 Patency of Central Veins in Dialysis Patients with Tunneled PICC Lines (Station #3) Shima Goswami MD (Presenter): Nothing to Disclose, Rosanne DeAngelis : Nothing to Disclose, Maryna Kuznetsov MD : Nothing to Disclose, Suken Shah MD : Nothing to Disclose, Jeffrey L. Lautin MD : Nothing to Disclose Determine the effect of tunneled peripherally inserted central venous catheter (PICC) lines on central vein patency in patients with chronic kidney disease (CKD). A prospective trial involving adults (>18 years old) who have CKD (GFR less than 30) and require long-term, non-dialysis, venous access. 5-French Bard Power PICC lines with small anchoring Dacron cuffs were placed under ultrasound and fluoroscopic guidance. Patients had an ultrasound prior to catheter placement and at removal to document jugular vein size, respiratory variation with Doppler waveforms, and imaging of the innominate vein patency. A paired t test was performed to analyze the data. Fifty-two patients from our institution were enrolled into and completed the study over an 18 month period. Three patients died from unrelated causes prior to catheter removal and ten were lost to follow-up. Of the remaining 39 enrollees there was an 8.8 percent risk of developing narrowing of the central veins greater than 60 percent of the original diameter post tunneled PICC (3/39 patients, p=0.002). Furthermore, of the patients whose central veins remained even partially patent, only four even developed webs in the central veins post tunneled PICC, a proportion of patients so small as to not render them statistically significant (p=0.028). The data supports our null hypothesis that central vein patency is rarely sacrificed in the setting of tunneled PICC line insertion. Considering the frequent need for tunneled and non-tunneled dialysis catheters in patients with CKD, tunneled catheters can be used safely for long-term, non-dialysis, venous access while preserving peripheral arm veins for dialysis access. Tunneled catheters allow preservation of peripheral arm veins in patients who will likely require future dialysis access and our data confirms central vein patency. VIS268 Preliminary Comparative Study between Thyroidectomy and Radiofrequency Ablation on Nodular Goiter (Station #4) Che Ying MD (Presenter): Nothing to Disclose, Jung Hwan Baek : Nothing to Disclose 1.to compare and evaluate the difference and efficacy of two treatment methods of nodular goiter,radiofrequency ablation and thyroidectomy; 2.to evaluate the clinical application value of RFA on nodular goiter 200 nodular goiter patients underwent open surgery operation (group A) and 200 patients treated with radiofrequency ablation(group B)were selected and proceed one year of follow-up. The posttreatment complications, thyroid function, nodules residues and recurrence situation as well as hospital stays and cost were evaluated and compared. The surgical complications incidence of group A was higher than that of group B (7.0%, 1.0%, P=0.002); 75.5% of the Group A patients removed more than 70% of their normal thyroid gland (unilateral or bilateral), 71.5% of whom need to exogenous thyroid hormone supplement, group B do not need the exogenous thyroid hormone; The focus were removed directly in group A group but inactivated in situ and absorbed gradually in group B with 12 months absorption rate 84.84±17.06%; The rate of multiple lesions residual nodules was 11.9% in group A and 2.9% in group B(P=0.004); One year recurrence rate was 2.5% in group A and 0.5% in group B, P=0.099, no statistically significant difference; Hospitalization days was 5-7 days of group A and 2-3 days of group B, the total cost was ± yuan and ± yuan in the above two groups but there was no statistically significant difference (P>0.05). Both surgical resection and radiofrequency ablation are effective in the treatment of nodular goiter. Compared with surgery treatment, the radiofrequency ablation method shows the advantage of complete tumor

255 inactivation, easy in operation, fewer complications, thyroid function maintenance, neck intact without scar, and shorter hospitalization time, which suggests a wide prospect of clinical application by this safe and effective minimally invasive treatment method. Radiofrequency ablation is a safe, effective and minimal invasive treatment method of nodular goiter with a wide prospect of clinical application. VIS269 Screening MRI for Uterine Fibroids, Treatment Selection: MR-guided High Intensity Focused Ultrasound (MRgFUS), Uterine Artery Embolization (UAE) and Surgery. A per Group Analysis of Outcomes (Station #5) Federica Ciolina MD (Presenter): Nothing to Disclose, Fulvio Zaccagna MD : Nothing to Disclose, Francesco Sandolo : Nothing to Disclose, Carola Palla : Nothing to Disclose, Fabrizio Andrani : Nothing to Disclose, Alessandro Napoli MD : Nothing to Disclose To retrospectively evaluate the outcome of patients affected by uterine leiomyoma and treated using either Magnetic Resonance Focused Ultrasound (MRgFUS), Uterine Artery Embolization (UAE) and Surgery. 451 women(group A)affected by uterine leiomyoma (mean age 39±5) referred our department for treatment of uterine fibroids with MRgFUS (July 2010-March 2014).Pre-treatment evaluation was done in order to assess symptoms and fibroids MR characteristics for MRgFUS viability.patients not eligible for MRgFUS were addressed to UAE (group B) or surgery (group C).Primary endpoints were Symptoms Severity Score (SSS) (48.6±13.4), volume shrinkage (Group A and B) and the necessity for further treatment.satisfaction related to different treatment was evaluated using a 5 point scale. 131/451 patients underwent MRgFUS (29%;Group A),320 were excluded(70%) and therefore assigned to Group B (123/451, 27%) and Group C (157/451, 35%).Remaining 40% patients (8%) were lost at follow up or refused the proposed treatment. In group A 112/131 patients (86%) showed a decrease in SSS(19.3±6.8),an average NPV of 70±15% (P=0.001), a volume shrinkage of 20±15% and an excellent satisfaction related to treatment. In 7/131 (5%) treatment was stopped at the beginning (bowel loops interposition or absence of compliance).4 patients had a pregnancy;3 patients experienced minor adverse events.in 12/131 patients (9%) we obtained NPV< 60% and patients needed surgical treatment.in group B patients showed a decrease in SSS (15.3±5.6), an average NPV of 98%(P=0.001), a volume shrinkage of up to 70% and a good satisfaction related to treatment.the major dissatisfaction was related to post-procedural pain that needed analgesic therapy. No pregnancy was observed.in Group C 80 patients underwent myomectomy,40 hysterectomy while the remaining refused other treatment.3 pregnancy were observed. MRgFUS treatment of uterine fibroids is a reliable,noninvasive method for treatment symptomatic uterine fibroids;clinical success is directly related to NPV ratio.eligibility is limited to 30% of screened women with symptomatic fibroids. All patients not suitable for this treatment should necessarily undergo surgery or UAE both with significant lower patient tolerance. Screening MRI allow patients selection for successful MRgFUS treatment and enable to refer patients with uterine fibroids to the most appropriate kind of treatment. VIS271 Experience of Diagnosis and Management of Splenic Steal Syndrome after Liver Transplantation (Station #6) Chaolun Li (Presenter): Nothing to Disclose, Weiping Wang MD : Nothing to Disclose, Eunice Kim Moon MD : Nothing to Disclose, John Fung : Nothing to Disclose, Koji Hashimoto MD : Nothing to Disclose This retrospective study investigated the clinical presentations, diagnosis, and treatment of splenic steal syndrome (SSS) based on our one center experience. From January 2007 to August 2013, the clinical data records of patients with SSS confirmed by angiography were reviewed. A total of 51 patients (40 men, 11 women, average age of 57.7±9.9 years, age range years) were enrolled in this study. Patients with hepatic artery stenosis or celiac artery stenosis were exluded. A whole liver graft was used in 49 patients, and split right lobe of liver was used in the other two patients. TIPS was performed in 4 patients before OLT. The onset time varies from 1 to 192 days (median 4days) after OLT. Forty-six patients (90.2%) presented this syndrome within 15 days after OLT. The most common clinical

256 presentation is high resistance index and/or diastolic reversal flow in hepatic arteries detected by US, which was found in 35 patients. Persistent ascites was observed in 9 patients, in which 5 also presented high RI on US and another 1 had concomitant hyperbilirubinemia. Seven patients presented elevated aspartate aminotransferase (AST), alanine aminotransferase (ALT) and/or total bilirubin. Among the seven patients, five also presented high RI on US. Forty-three patients with SSS showed high RI (RI > 0.8) 24 hr after OLT. RI of the SSS group ranged from 0.67 to 1.0, with mean of 0.94±0.08. All the patients were diagnosed by celiac angiography showing sluggish flow in hepatic artery and brisk flow in splenic artery without any mechanical cause of vascular obstruction. All the patients were treated with splenic artery embolization (SAE) after the diagnosis was confirmed. Proximal SAE was performed in 42 patients. Middle to distal SAE was performed in 9 patients. In the 14 patients embolized with coils, coils migrated to the hilum of spleen in 3 patients. Patients showed improved hepatic blood flow on both angiography immediate after SAE and US post treatment. One patient developed hepatic artery thrombosis one day after SAE. Biliary stent was placed in 7 patients after SAE. Splenic steal syndrome occurs shortly after liver transplantation. Persistent high RI detected in hepatic artery may lead to the clinical suspision of this disease. It can be reversed by proximal SAE. Proximal SAE is an effective and safe method to treat SSS with very low rate of complication. VIS273 Role of MRI Chest in the Assessment of Tumor Response Post Microwave Ablation of Pulmonary Metastases (Station #7) Nour-Eldin Abdelrehim Nour-Eldin MD, MSc (Presenter): Nothing to Disclose, Nagy Naguib Naeem Naguib MD, MSc : Nothing to Disclose, Julian Lukas Wichmann MD : Nothing to Disclose, Ahmed Fathy Emam MBBCh : Nothing to Disclose, Mohammed Ahmed Alsubhi BMBS : Nothing to Disclose, Thomas Josef Vogl MD, PhD : Nothing to Disclose To determine the value contrast enhanced (CE-MRI) follow-up in the assessment of tumor response of microwave (MW) ablated pulmonary metastases by correlating the results with CE-CT. This prospective study included 130 ablation sessions for pulmonary metastases in 80 patients. CE-MRI Chest scanning was performed 1week before the ablation and at 24hours, 3, 6, 9 and12months post ablation. Thin section CT Volumetric measurement of the lesions was performed at the same time periods as a second parameter for comparison. The lesion MRI enhancement intensity in each study was estimated, and the ratio to the paraspinal muscle enhancement intensity at the same level was measured (Lesion Muscle Signal (LMS ratio).the correlations between post ablation follow-up CT volume of tumors and CE-MRI LMS ratio at the follow-up periods were assessed. The preablation tumor volumes range: cm (mean: 1.5cm³, SD:1.3). LMS ratio < 1was associated with post ablation reduction of tumor volume (denoting scaring),while LMS ratio>1were noted in: preablation due to high contrast enhancement of the tumor,in24h post ablation due to the inflammatory response associated with the thermal ablation and due to tumor residue or progress. Weak correlation was detected between the LMS-ratios and CT-volumetric changes in 24h post ablation. Strong correlation between the LMS ratios was estimated between the follow up periods of 3months(SpearmanR:0.62,p=0.0021),6months (SpearmanR:0.66,p=0.001),9months(SpearmanR:0.61,p<0.001)and 12months (Spearman R:0.7, p< ). CE-MRI follow up of the MW ablated lung tumors can be used effectively to assess the tumor response to ablation using LMS ratio as a parameter of assessment. CE-MRI may be used for the evaluation of tumor response post pulmonary ablation therapy. VSIO51 Interventional Oncology Series: Lung and Bone Series Courses RO OI IR MK CH AMA PRA Category 1 Credits : 4.25 ARRT Category A+ Credits: 5.00 Thu, Dec 4 1:30 PM - 6:00 PM Location: S405AB Moderator Matthew Raymond Callstrom MD, PhD : Research Grant, Thermedical, Inc Research Grant, General Electric Company Research Grant, Siemens AG Research Grant, Galil Medical Ltd

257 Sub-Events VSIO51-01 MW vs RFA vs Cryo for Lung Mass Ablation Which/When/Where? Damian E. Dupuy MD (Presenter): Research Grant, NeuWave Medical Inc Board of Directors, BSD Medical Corporation Stockholder, BSD Medical Corporation Speaker, Educational Symposia 1) Understand differences between the various thermal technologies as applied to lung tumors. 2) Review current clinical thermal ablation data with regard to the treatment of lung tumors. 3) Comprehend the usage of the various thermal modalities with clinical examples of lung tumor treatment. VSIO51-02 Latest Advances in Lung Surgery for Metastic Disease Francis C. Nichols MD (Presenter): Nothing to Disclose 1) Identify appropriate patients who are felt to benefit from pulmonary metastasectomy. 2) Discuss the pros and cons of pulmonary metastasectomy done via a traditional open thoracotomy versus minimally invasive Video-Assisted Thoracic Surgery (VATS). 3) Describe a localization technique for the small difficult to locate pulmonary metastasis(es). 4) Discuss the rationale for mediastinal lymphadenectomy during pulmonary metastasectomy and its prognostic implications. VSIO51-03 Quantitative Validation of Thermal Ablation: An Improved Image Fusion Algorithm to Reflect Treatment Coverage David Thomas Glidden BS (Presenter): Nothing to Disclose, Grayson L. Baird MS : Nothing to Disclose, Derek Merck : Nothing to Disclose, Damian E. Dupuy MD : Research Grant, NeuWave Medical Inc Board of Directors, BSD Medical Corporation Stockholder, BSD Medical Corporation Speaker, Educational Symposia To propose the foundation of a quantitative method for validation of thermal ablations. 24 patients (M:F= 10:14) with solitary lung tumors underwent microwave ablation under CT-guidance. Each tumor was treated with one of four MW applicators (BSD Medical, Salt Lake City, UT, Neuwave Medical, Madison, WI) for 5-15 minutes according to the manufacturers' specifications. Each case included a CT scan pre- intra- and post-procedure. Tumor volumes were manually segmented from pre-scans and ablation volumes from post-scans using the ground glass halo surrounding the tumor. Pre-scans were fused onto post-scans using two algorithms-a rigid registration, and a rigid plus deformable registration. Volume overlap resulting from both algorithms were calculated. Bland-Altman plots and Deming regression were used to identify possible differences in these image fusion techniques. The volume overlap between tumors and ablation zones increased proportional to tumor size when deformable registration was applied (p < 0.001). Deming regression showed a significant deviation from perfect concordance between rigid and deformable registration (95 % CI: [1.13, 1.39]) in which more volume overlap was attributable to deformable registration. Quantitative validation of thermal ablation margin analysis remains challenging due to inherent tumor position and morphology changes after ablation. Rigid registration techniques rarely reflect how an ablation zone covers the tumor and margin because of movement (e.g. respiratory, tumor displacement, patient position). The addition of deformable registration may more accurately reflect how the tumor and ablation zone overlap, thus improving local control outcomes. Improved fusion between pre- and post-scans using deformable registration will provide a basis for quantitative validation of thermal ablations by correcting for anatomical movement. VSIO51-04 Lung Mass SBRT Current Results and Ongoing Trials Kenneth Richard Olivier MD (Presenter): Nothing to Disclose 1) Review definitions of SBRT. 2) Discuss results of SBRT for pulmonary nodules. 3) Review current and proposed clinical trials for pulmonary nodules. 4) Review currently accepted indications for SBRT. ABSTRACT

258 Stereotactic Body Radiotherapy (SBRT), also known as Stereotactic Ablative Radiotherapy (SABR) has become an important new tool for oncologists looking to treat patients with primary lung cancers or pulmonary metastases. In this talk we will discuss some of the fundamentals of SBRT, review relevant literature, and current indications of SBRT for either primary lung cancers or metastases. VSIO51-05 Percutaneous Microwave Ablation of Pulmonary Malignancies: Survival, Imaging Follow-up, and Complications Mark William Little MBBS, MSc (Presenter): Nothing to Disclose, Daniel Yiu Fai Chung MBBS, FRCR : Nothing to Disclose, Eoghan John Patrick McCarthy MBBCh : Nothing to Disclose, James Henry Briggs MBChB, FRCR : Nothing to Disclose, Philip Boardman MBChB : Nothing to Disclose, Fergus Vincent Gleeson MBBS : Alliance Medical Ltd Consultant, Ewan Mark Anderson MBBCh : Nothing to Disclose Survival analysis, technical success, safety and imaging follow-up of malignant pulmonary nodules treated with a novel high power microwave ablation system. Over a three year period, 55 patients, 33 male, mean age 64 years (31-88) with 92 unresectable pulmonary malignancies of mean diameter 18mm (6-59mm) underwent computed tomography (CT)-guided percutaneous microwave ablation in 72 ablation sessions. Primary non-small cell bronchogenic carcinoma was treated in 28 lesions, whilst metastatic tumors were ablated in the remainder (colorectal=28, renal=9, sarcoma=17, adrenal=3, esophageal=2, melanoma=3, breast=1, tcc=1). Tumors were diagnosed by biopsy, or PET avidity (median SUV max = 9.5) and interval growth. Technical success was defined as needle placement in the intended lesion without death or serious injury. Adequacy of ablation was assessed at 24 hours on contrast-enhanced CT, for a circumferential solid or ground glass margin > 4mm. Patients were followed with contrast-enhanced CT 3-monthly until death, or local tumor progression (LTP), or for at least 12 months post procedure. LTP was defined as contiguous enlargement or a change in the shape of the ablation zone or the development of contrast enhancement in part of the zone. Survival rate was evaluated by Kaplan-Meier analysis. Microwave ablation was technically successful in n=88 (96%) of lesions. Mean ablation duration was 4 minutes (1-22 minutes). 21(29%) pneumothoracies were diagnosed on chest x-ray after 72 ablation sessions; chest drain was required in 8 (11%) sessions. 30-day mortality rate was 0%. The mean hospital stay was 1.1 days (1-11 days). Local tumor progression was present in 6 tumors; for tumors under 4cm (n=88), LTP was identified in 3 (3%) at a median follow up of 13months. The mean diameter of lesions with LTP were significantly larger than those without (mean diameter 41mm vs 17mm; p=0.009). The cancer-specific survival was 79% (95%CI ) at 1 year, and 66% (95% CI ) at 2-years. Microwave ablation of pulmonary malignancies is a safe, successful technique. Local control rates and survival analysis are encouraging, with rapid treatment times Primary and metastatic lung tumors are extremely common; surgical options are often limited due to advanced disease and or poor respiratory function. Microwave ablation offers a robust method of local disease control VSIO51-06 Ablation for Primary Lung Cancer What Does the Data Support Robert D. Suh MD (Presenter): Nothing to Disclose 1) Discuss long term outcomes of image-guided ablation for early stage lung cancer. 2) Discuss local control rates of image-guided ablation for early stage lung cancer. 3) Understand the factors in image-guided ablation influencing survival and local control. 4) Understand treatment options and relative outcomes of image-guided ablation compared to alternative therapies for early stage lung cancer. ABSTRACT Although the literature on thermal ablation demonstrates heterogeneous, sometimes markedly so, reporting, thermal ablation confers increasingly improved local control and survival benefits in carefully selected patients: RF ablation with long-term results comparable to competitive therapies, particularly in the high-risk patient population. Despite advances in thermal energy devices, specifically microwave and cryoablation, delivery and combination therapy leading to improved local control, gains in survival will be limited for this high-risk population, given the limitations of radiographic staging and presence of already microscopic lymph nodal and distant disease at the time of image-guided ablation, a risk inherently present with all local therapies. Thus far, thermal ablation remains a safe therapeutic and effective option to treat 1 lung malignancies. VSIO51-08 Ablation for Metastatic Lung Cancer Is Ablation Competitive with Surgery or SBRT? Thierry Debaere (Presenter): Consultant, Terumo Corporation Speaker, Terumo Corporation Consultant, Guerbet SA Speaker, Guerbet SA Consultant, General Electric Company Speaker, General Electric Company Proctor, Galil Medical Ltd 1) To know results of percutaneous ablation of lung metastases in term of local efficacy and survival. 2) To

259 know predictive factors of RFA for lung metastases. 3) To know results of surgery and stereotaxic radiation therapy for lung metastases. ABSTRACT Since first report of RFA in lung tumor in year 2000, RFA has been demonstrated to provide 80 to 90% complete ablation for tumors less than 2 cm, with decrease in efficacy for larger tumors. Percutaneous ablation is today a valid option for lung metastases in non surgical candidates with overall survival reported after RFA is in between 56 to 67% at 3 years. Such survival reported is comparable to what reported in large surgical series even if no comparative data exists. Age, disease free interval, tumor size and tumor numbers are independent predictor of survival after RFA of lung metastatses. The same predictive factors have been reported as predictive of survival after surgical metastasectomy. One of the advanteg of RFA over other technique such as surgery and SBRT is that it can be easily repeated in case of occurrence of new metastases which is difficult with surgery due to the aggressively of the procedure. Subsequent surgical resection are limited by pulmonary reserve. The same applies to stereotaxic radiation therapy where multiple irradiation results in toxicity lo lung parenchyma, skin or mediastinum. Consequently, RFA is today part of routine practice armentarium against lung metastases. However, better determination of the role of RFA relative to other therapies are needed. In addition, the need and benefit from combining local ablation and systemic therapy must be evaluated. Future trends in treatment of pulmonary metastases will favor minimal aggressive treatments and percutaneous ablation have a role to play. Evidence based medicine supporting the use of lung RFA metastatic disease and defining what is the best population to target with ablation or SBRT. For today the ideal candidate has less than 3 tumors less than 3 cm. VSIO51-09 Lung Tumor Board Moderator Matthew Raymond Callstrom MD, PhD : Research Grant, Thermedical, Inc Research Grant, General Electric Company Research Grant, Siemens AG Research Grant, Galil Medical Ltd 1) Describe the characteristics of lung and bone tumors amenable to interventional oncologic treatment. 2) Describe new techniques for the percutaneous treatment of lung tumors and bone metastases. 3) Describe the role of percutaneous ablation for lung tumors and bone metastases in the context of other treatments including surgery and radiation oncology. VSIO51-10 Treatment of Complex Benign Skeletal Disease Afshin Gangi MD, PhD (Presenter): Proctor, Galil Medical Ltd 1) Identify the best indications of percutaneous technique and list them. 2) Describe the methods used in treatment of benign skeletal tumors and the advantages and limits of each of them. 3) Identify the risks of the percutaneous procedures and their limits. 4) Explain the measures used to protect the surrounding tissues to avoid major complications. 5) Learn how to follow up the patients and analyze the results. URL's VSIO51-11 Pain Palliation of Bone Metastases and Local Tumor Control with Magnetic Resonance Guided Focused Ultrasound Surgery (MRgFUS) Treatment Brachetti Giulia MD : Nothing to Disclose, Valeria De Soccio : Nothing to Disclose, Fabrizio Andrani : Nothing to Disclose, Gianluca Caliolo : Nothing to Disclose, Fulvio Zaccagna MD : Nothing to Disclose, Alessandro Napoli MD (Presenter): Nothing to Disclose to evaluate the efficacy of MRgFUS for treatment of painful bone metastases and its potential for local tumor control. after IRB approval 42 patients were scheduled for treatment using the Exablate system (InSightec). Before and 1, 2 and 3 months after MRgFUS treatment, pain scores were assessed according to Brief Pain Inventory-Quality of Life (BPI-QoL) criteria. Imaging (CT and cemr: Bracco) follow-up was obtained at 1 and 3 months; in survivals, follow-up was extended at 6 and 12 months. For local tumor control, imaging changes were evaluated with the MD Anderson (MDA) criteria. Patients were classified in responder and non-responders. The extent of necrosis within the ablated metastasis was evaluated using non-perfused volume (NPV). All 42 patients underwent MRgFUS (20 recurrence post-rt; 22 primary treatment). Statistically significant difference between baseline and follow-up values for both pain severity and pain interference scores was observed (p<0.05; no statistical difference between the post-rt and primary treatment group). Stable pain score (VAS<2) was observed in survival group at 6 (15 patients) and 12 (9 patients) month control. Increased bone density was observed in 10 (23,8%) patients. Complete response was found in 20 (47,6%) patients;

260 partial response was found in 22 (52,3%) patients (pain recurrence in 3 patients), according to both the MDA and clinical criteria. NPV values ranged between 23% and 94%. There was no difference in non-perfused volume between responders and non-responders (p=0.7). No adverse events were recorded MRgFUS is an effective and durable treatment for pain palliation of bone metastasis; moreover, a positive role in local tumor control and bone restoration was demonstrated. MRgFUS can be safely and effectively used as treatment for pain palliation of bone metastasis in patients who had exhausted EBRT and also in patients not previously treated with EBRT. The treatment creates bone metastasis necrosis and so might have a positive role in local tumor control and bone restoration.the major advantages of the technique include its non-invasive nature. The treatment can be performed in a single session, does not use ionizing radiation and utilizes MR guidance for precise targeting and thermal control. VSIO51-12 Radiofrequency Ablation of Spinal Disease Jack William Jennings MD (Presenter): Speakers Bureau, DFINE, Inc Consultant, DFINE, Inc 1) Metastatic spine overview 2) Patient selection and treatment evaluation 3) Current guidelines for treatment of metastatic spine lesions 4) Imaging of lesions 5) Role of vertebral augmentation in metastatic disease 6) Targeted Radiofrequency ablation (RFA) 7) RFA and radiotherapy (RT) 8) Multi-disciplinary treatment algorithm ABSTRACT Bone metastases are a major cause of morbidity in patients with cancer and represent a common occurrence in these patients. The vertebral column is the most common site for bone metastases with an incidence of 30-70% in patients with metastatic cancer and is likely related to the high hematopoietic activity and vascularization of the spine. Management of these patients is challenging and traditionally involves a combination of radiation and chemotherapy in adjunct with analgesics. Surgery has remained a mainstay of treatment in patients with neurologic deficit, instability requiring stabilization, or with a longer life expectancy. Surgical options in these patients with decreased life expectancy are often morbid and present a therapeutic dilemma. Minimally invasive procedures, including thermal ablation, are safe and effective treatments of painful osseous metastatic lesions in patients who are not surgical candidates or have exhausted or are unable to have radiation therapy. Radiofrequency ablation (RFA) has been increasingly utilized in management of osseous metastases. In the spine, this treatment has traditionally been limited to lesions within the anterior vertebral body since this location is more accessible and further away from sensitive neural elements. Many spinal tumors will continue to grow and cause pain after radiation therapy. Posterior vertebral body lesions will often progress and extend through the posterior cortex into the spinal canal making therapeutic options very limited. The development of an articulating bipolar electrode has allowed for targeted RFA and the ability to treat posterior spinal lesions via a transpedicular approach. Review of the existing literature and current treatment guidelines demonstrates the need for future prospective studies of spine tumor ablation and for the development of a treatment algorithm defining its role with the current accepted treatment options. VSIO51-13 Sequential Interventional Treatment of Pelvic/Sacral Tumors via Angiographic Embolization, Cryoablation, and Stabilization Plasty Combinational Therapy Sri Hari Sundararajan MD (Presenter): Nothing to Disclose, Marisa Giglio : Nothing to Disclose, Sudipta Roychowdhury MD : Consultant, Johnson & Johnson, Vyacheslav Gendel MD : Nothing to Disclose, Gaurav Gupta MD : Nothing to Disclose, John L. Nosher MD : Nothing to Disclose The purpose of the study is to review the treatment experiences of patients treated at our institution with combination angiographic embolization, cryoablation or thermal ablation, and stabilization plasty for their pelvic/sacral tumor burden. This study hopes to assess if such combinational interventional therapy has the potential to become a mainstay treatment option in managing pelvic and sacral neoplasms. A combined interventional paradigm was employed in 8 patients thus far over the last year: Phase I: Angiographic embolization of neoplasm Phase II: Cryoablation of solid tumor, followed by supportive sacroplasty Phase III: Image-guided drainage/tpa flush, followed by sclerosis of residual bed Procedures were performed under general anesthesia. Phase I was within 1 day to 1-2 weeks prior to Phase II and III dependent on lesion location and patient tolerance. Neurological monitoring were utilized in Phases 2 and 3 to assess integrity of sacral nerve function during procedures. Each patient underwent pretreatment CT and/or MRI examination prior to therapy. All patients have undergone post-therapy follow-up imaging within 1-3 months. Medical records and imaging portfolios for these patients will be reviewed. A reassessment of pre and post procedure lesion measurements and quality of life outcomes will be performed. Linear regression will be performed to correlate results of imaging and quality of life assessment. It is hypothesized that patients undergoing sequential combinational therapy will demonstrate significant decrease in lesion growth, as well as improved pain control and quality of life. It is unclear if survival will be affected by such measures, as patients with terminal disease pursued such procedures more so for symptomatic relief. An interventional paradigm consisting of combinational implementation of angiography-mediated embolization,

261 thermal/radiofrequency ablation, and mechanical drainage followed by cavity sclerosis is expected to become a mainstay treatment option of pelvic and sacral neoplasms. The results of our review is expected to provide insight into its use in patients needing physical and symptomatic reduction of their pelvic/sacral tumor burden. Sequential incorportation of several effective interventional treatments may play a role in the treatment paradigm of pelvic and sacral neoplasms. VSIO51-14 Avoiding Complications with Bone and Soft Tissue Ablation Anil Nicholas Kurup MD (Presenter): Nothing to Disclose 1) Identify critical anatomic structures to be avoided during bone and soft tissue tumor ablation. 2) Apply displacement techniques to minimize risk of collateral damage during bone and soft tissue ablation. 3) Understand radiographic and neurophysiologic monitoring techniques that may be employed during bone and soft tissue ablation. 4) Recognize the role of bone consolidation as an adjunct to bone ablation. VSIO51-15 Treatment of Oligometastatic Disease: What Is the Role of Ablation? Peter John Littrup MD (Presenter): Founder, CryoMedix, LLC Research Grant, Galil Medical Ltd Research Grant, Endo Health Solutions Inc Officer, Delphinus Medical Technologies, Inc 1) Understand how ablation of limited, or oligo-, metastases could produce a major impact on numerous cancer types. 2) Describe the major anatomic locations that are considered common oligometastatic sites. 3) Describe the outcomes for procedure complication and recurrence rates for the major anatomic sites. 4) Describe the potential economic impacts of ablation as part of palliative care for major cancer types (e.g., renal, lung, colorectal, ovarian). VSIO51-16 Preoperative Embolization in Surgical Treatment of Spinal Metastases: Single-Blind, Randomized Controlled Clinical Trial of Efficacy in Decreasing Intraoperative Blood Loss Caroline Clausen MD (Presenter): Nothing to Disclose, Benny Dahl MD, PhD : Nothing to Disclose, Susanne Christiansen Frevert MD : Nothing to Disclose, Lars Valentin MD : Nothing to Disclose, Michael Bachmann Nielsen MD, PhD : Nothing to Disclose, Lars Lonn MD, PhD : Nothing to Disclose To assess whether preoperative embolization reduces intraoperative blood loss, the need for blood transfusion, and operative time in the surgical treatment of symptomatic metastatic spinal cord compression. A single-blind, randomized (balanced 1:1), controlled, parallel-group trial conducted as a single-center study; 48 participants were included from May 2011 until March scheduled for decompression and posterior thoracic/lumbar instrumented spinal instrumentation because of symptomatic metastatic spinal cord compression were randomly assigned to either preoperative arteriography and embolization - the intervention group or preoperative arteriography - the control group. Primary outcome: intraoperative blood loss. Secondary outcomes: Intra- plus postoperative blood loss, blood transfusion and duration of surgery. Outcomes were reported as intention-to-treat analyses (ITT) including all randomized patients with a standing consent to participate and meeting the inclusion criteria. Of the 48 randomized patients, 45 (23:22) were available for the ITT after exclusion of patients violating inclusion criteria. Mean intraoperative blood loss did not differ significantly between the embolization group (618 ml; SD 282 ml) and the control group (735 ml; SD 415 ml). This was also the case for intra- plus postoperative blood loss and the need for blood transfusion. The duration of surgery was shorter in the embolization group compared to the control group (p=0.031); median 90 minutes (range ) vs. 124 minutes (range ). Preoperative embolization does not result in a reduction of intraoperative blood loss and blood transfusion, but reduces the duration of surgery. The general routine use of preoperative embolization cannot be recommended in decompression and posterior instrumented spinal instrumentation for symptomatic metastatic spinal cord compression. This randomized controlled clinical trial displays that preoperative embolization has the advantage of reducing the duration of surgery for symptomatic metastatic spinal cord compression.

262 VSIO51-17 Bone Metastases Tumor Board Moderator Matthew Raymond Callstrom MD, PhD : Research Grant, Thermedical, Inc Research Grant, General Electric Company Research Grant, Siemens AG Research Grant, Galil Medical Ltd 1) Describe the characteristics of lung and bone tumors amenable to interventional oncologic treatment. 2) Describe new techniques for the percutaneous treatment of lung tumors and bone metastases. 3) Describe the role of percutaneous ablation for lung tumors and bone metastases in the context of other treatments including surgery and radiation oncology. SPDL51 RSNA Diagnosis Live : Musculoskeletal/Pediatric/Interventional Radiology Special Courses PD IR MK AMA PRA Category 1 Credits : 1.00 ARRT Category A+ Credit: 0 Thu, Dec 4 3:00 PM - 4:00 PM Location: E451B Paul J. Chang MD (Presenter): Co-founder, Stentor/Koninklijke Philips Electronics NV Technical Advisory Board, Amirsys, Inc Research Contracts, Koninklijke Philips NV Medical Advisory Board, lifeimage Inc Medical Advisory Board, Merge Healthcare Incorporated Neety Panu MD, FRCPC (Presenter): Nothing to Disclose Kate Ann Feinstein MD (Presenter): Nothing to Disclose Brian S. Funaki MD (Presenter): Nothing to Disclose 1) The participant will be introduced to a series of radiology case studies via an interactive team game approach designed to encourage "active" consumption of educational content. 2) The participant will be able to use their mobile wireless device (tablet, phone, laptop) to electronically respond to various imaging case challenges; participants will be able to monitor their individual and team performance in real time. 3) The attendee will receive a personalized self-assessment report via that will review the case material presented during the session, along with individual and team performance. This interactive session will use RSNA Diagnosis Live. Please bring your charged mobile wireless device (phone, tablet or laptop) to participate. SPSH51 Hot Topic Session: Tendon Injections: Which One Works Best? Special Courses IR MK IR MK AMA PRA Category 1 Credits : 1.00 ARRT Category A+ Credit: 1.00 Thu, Dec 4 3:00 PM - 4:00 PM Location: E353B Moderator Martin Torriani MD : Nothing to Disclose 1) Learn the indications of ultrasound-guided percutaneous tendon treatments such as tendon dry needling, autologous platelet-rich plasma and hyperosmolar dextrose injections, among others. 2) Discuss the technical requirements to perform ultrasound-guided percutaneous tendon treatments. 3) Review the state of the science in percutaneous tendon treatments. ABSTRACT The range of applications for ultrasound-guided percutaneous tendon treatments, such as dry needling, autologous platelet-rich plasma and hyperosmolar dextrose injections is rapidly increasing in the practice of musculoskeletal intervention. These novel procedures have specific indications and technical demands, which may influence clinical outcomes. This session will highlight common applications and techniques for percutaneous tendon treatments and review the current clinical evidence-based literature. Sub-Events SPSH51A Tendon Fenestration Jon A. Jacobson MD (Presenter): Consultant, BioClinica, Inc Royalties, Reed Elsevier Equipment support, Terumo Corporation Equipment support, Arthrex, Inc View learning objectives under main course title.

263 SPSH51B Platelet-Rich Plasma Therapy of the Tendon Kenneth S. Lee MD (Presenter): Research Consultant, SuperSonic Imagine Speakers Bureau, Medical Technology Management Institute View learning objectives under main course title. SPSH51C Other Tendon Treatments Mary Margaret Chiavaras MD, PhD (Presenter): Nothing to Disclose View learning objectives under main course title. SPSH53 Hot Topic Session: Imaging of Oncologic Surveillance in the Era of Local Targeted Therapies Special Courses OI IR GI AMA PRA Category 1 Credits : 1.00 ARRT Category A+ Credit: 1.00 Thu, Dec 4 3:00 PM - 4:00 PM Location: S404AB Moderator David H. Kim MD : Consultant, Viatronix, Inc Co-founder, VirtuoCTC, LLC Medical Advisory Board, Digital ArtForms, Inc Sub-Events SPSH53A Surveillance Imaging Following Focal Ablative Therapies (Microwave, Radio-frequency Ablation, Cryoablation) J. Louis Hinshaw MD (Presenter): Stockholder, NeuWave Medical Inc Medical Advisory Board, NeuWave Medical Inc Stockholder, Cellectar Biosciences, Inc 1) Understand the expected imaging findings after image-guided tumor ablation. 2) Understand the typical findings of complications, local tumor progression, and disease progression. 3) Learn about newer imaging modalities/methods for identifying local tumor progression. ABSTRACT Image-guided tumor ablation is a rapidly advancing minimally invasive targeted therapy for the treatment of both malignant and benign tumors. Even if you are not actively involved in performing this procedure, you will almost certainly see follow-up imaging performed to evaluate for both local tumor progression and metastatic disease. Following this discussion, you should have a basic understanding of the typical indications for image-guided tumor ablation and the imaging findings associated with normal evolution of the ablation zone as well as findings suspicious for recurrent disease. Of course, this varies depending on the target organ/disease, as well as the underlying malignancy. For example, colorectal carcinoma metastatic to the liver tends to be relatively hypovascular and similar in attenuation to the avascular ablation zone on portal venous phase imaging. Therefore, the primary indicator of recurrence in this clinical setting is asymmetric change/growth one or more of the ablative margins. In contrast, hepatocellular carcinoma is most frequently hypervascular. Since the ablation zone should be avascular, any evidence of vascular enhancement within/around the ablation zone on follow up imaging can be suspicious for residual or recurrent disease. The imaging findings also vary depending upon the ablation modality utilized, particularly when MRI is used for the imaging follow up and we will go through the signal changes that occur over time following an ablation. In addition, we will discuss standardized nomenclature to describe the follow up imaging for tumor ablation. Although the nomenclature is descriptive and extremely helpful, particularly to ensure consistency and improve reporting for research purposes, the terms are not always intuitive. SPSH53B Surveillance Imaging Following Arterial-directed Regional Therapies for the Treatment of Liver Tumors (Yttrium and Embolization) Anne Mara Covey MD (Presenter): Nothing to Disclose 1) Review the different criteria to measure radiographic response, including WHO, EASL, RECIST, mrecist, and understand the appropriate application for each. 2) Understand which imaging modalities are useful to assess treatment response following different arterially directed therapies. 3) Recognize imaging features of

264 treatment effect and be able to differentiate treatment effect from tumor recurrence and other complications related to treatment. RC714 Pain and Sedation in 2014 Refresher/Informatics IR IR AMA PRA Category 1 Credits : 1.50 ARRT Category A+ Credits: 1.50 Thu, Dec 4 4:30 PM - 6:00 PM Location: E353A Max Paul Rosen MD, MPH (Presenter): Stockholder, Everest Scientific Inc Consultant, PAREXEL International Corporation Stockholder, Cynvenio Biosystems, Inc Medical Advisory Board, Cynvenio Biosystems, Inc Fred E. Shapiro DO (Presenter): Nothing to Disclose Richard D. Urman MD, MBA (Presenter): Nothing to Disclose Hesham H. Malik MD (Presenter): Consultant, Guerbet SA 1) Learn up-to-date CME and SAM requirements needed to administer and maintain sedation privileges. Also learn how survive a joint commission visit. 2) Learn what is required to provide moderate and/or deep sedation, including a review of rescue drugs. 3) Learn what is minimal sedation and the associated ramifications of only providing minimal sedation. 4) Learn when to involve Anesthesiologists in the care of Radiology patients, and learn how to keep your Anesthesiologists happy. 5) Learn how to avoid sedation disasters as well as the medico-legal ramifications of conscious sedation. ABSTRACT The safe and effective sedation of patients during interventional Radiology procedures requires an in depth knowledge of how to administer conscious sedation. Even more important, however, is the skill set to be able to accurately assess each patient's clinical status prior to the procedure, be able to formulate a comprehensive sedation plan, and recognize which patients would be better served by involvement of an Anesthesiologist. This course will review the institutional requirements for providing minimal, moderate or deep sedation. We will also outline how to develop a procedural sedation (PS) policy, including recognition of the role that team training contributes to a safe environment. We will review the use of the Institute for Safety in Office Based Surgery (ISOBS) safety checklist as well as its customization to the IR setting We will provide an evidenced-based review of the current literature re: QA, risk management, and process improvement using the ISOBS checklist as well as a review of drugs commonly used for procedural sedation. RC752 US-guided Interventional Breast Procedures (Hands-on Workshop) Refresher/Informatics US IR BR US IR BR AMA PRA Category 1 Credits : 1.50 ARRT Category A+ Credits: 1.50 Thu, Dec 4 4:30 PM - 6:00 PM Location: E264 Jocelyn A. Rapelyea MD (Presenter): Research Consultant, Siemens AG Consultant, General Electric Company Margaret M. Szabunio MD (Presenter): Nothing to Disclose Liane Elizabeth Philpotts MD (Presenter): Nothing to Disclose Shambhavi Venkataraman MD (Presenter): Nothing to Disclose Angelique C. Floerke MD (Presenter): Nothing to Disclose Rachel Frydman Brem MD (Presenter): Board of Directors, icad, Inc Board of Directors, Dilon Technologies LLC Stock options, icad, Inc Stockholder, Dilon Technologies LLC Consultant, U-Systems, Inc Consultant, Dilon Technologies LLC Consultant, Dune Medical Devices Ltd Karen S. Johnson MD (Presenter): Research Consultant, Siemens AG Nicole Sondel Lewis MD (Presenter): Nothing to Disclose 1) Describe the equipment needed for ultrasound guided interventional breast procedures. 2) Review the basic principles of ultrasound guidance and performance of minimally invasive breast procedures. 3) Practice hands-on technique for ultrasound guided breast interventional procedures. ABSTRACT This course is intended to familiarize the participant with equipment and techniques in the application of US guided breast biopsy and needle localization. will have both basic didactic instruction and hands-on opportunity to practice biopsy techniques on tissue models with sonographic guidance. The course will focus on the understanding and identification of: 1) optimal positioning for biopsy 2) imaging of adequate sampling confirmation 3) various biopsy technologies and techniques 4) potential problems and pitfalls RC831