16:42 CET
SS 109 - Vascular interventions in visceral arteries and veins (part 1)
Interventional Radiology GI Tract
Wednesday, February 27, 08:30 - 10:00
Room: C&T 3
Type of session: Scientific Session
Topic: Interventional Radiology, GI Tract
Moderator: M. Tsitskari (Athens/GR)

Quantification of perfusion reduction by using 2D parametric parenchymal blood flow following partial spleen embolisation in patients with hypersplenism
T. Meine1, S. K. Maschke1, M. Kirstein1, J. Renne1, T. Werncke1, C. Dewald1, F. Wacker1, B. C. Meyer2, J. B. Hinrichs1; 1Hannover/DE 2Berlin/DE

Purpose: To analyze the feasibility of 2D Parametric Parenchymal Blood Flow (2D-PPBF) for the quantification of perfusion reduction following partial spleen embolization (PSE).
Methods and Materials: 15 PSE procedures in 14 patients with hypersplenism were included (2015-2018). Outcome was measured via platelet count before and after PSE. To quantify changes in spleen perfusion following PSE using 2D-PPBF, the acquired digital subtraction angiography (DSA) series were post-processed. A reference region-of-interest (ROI) in the splenic artery and a target ROI outlining the embolization territory of the splenic tissue were placed in corresponding areas on DSA pre- and post-PSE. The Wash-In-Rate (WIR), the 50%-to-Peak (Peak0.5), the Arrival-to-Peak (PeakArrival), the Mean-Transit-Time (MTT) and the Area-Under-the-Curve-per-ROI-Area (AUC) were assessed and the ratios to the reference ROI were calculated. Mean and standard deviation of the ratios were determined. Comparisons between pre- and post-embolisation data were made using a Wilcoxon signed-rank test.
Results: Platelet count increased significantly following PSE from 41.200 ± 19.468 to 103.066 ± 70.350 platelets/microliter (p=0.02). In the embolized splenic territory, the pre-/post-embolisation 2D-PPBF parameter changed significantly: WIR 1.05 ± 2.18 / 0.09 ± 0.07 (p=0.03), Peak0.5 3.30 ± 0.88 / 4.28 ± 1.18 (p=0.011), PeakArrival 1.95 ± 0.77 / 3.20 ± 1.45 (p=0.027), MTT 4.82 ± 1.23 / 6.39 ± 1.79 (p=0.005) and AUC 0.81 ± 0.79 / 0.13 ± 0.08 (p=0.01).
Conclusion: 2D-PPBF is an objective approach to quantify the perfusion reduction of embolized splenic tissue following PSE. It may be used to assess angiographic outcome and set angiographic endpoints for PSE.

Role of multidetector CE-CT before transcatheter endovascular embolisation in active arterial bleedings
A. Borzelli1, A. Paladini2, F. Amodio1, E. Cavaglià1, R. Niola1; 1Naples/IT 2Novara/IT

Purpose: Identify the role of CE-CT in active bleedings' detection according to clinical evidence and bioumoral parameters of patients.
Methods and Materials: 1480 CE-CTs were performed between June 2014 and June 2017 for suspected active bleeding (median patient age 45; 902 M, 578 F) in emergency setting, due to clinical and laboratory evidence of serum haemoglobin value lowering.
Results: In 793 CE-CT cases revealed active bleeding followed by angiography. In the remaining 687 cases, CT was negative, but due to clinical and laboratory values worsening, in 89 of them angiography was performed, revealing active bleeding in 65 patients; the latter owing to pseudoaneurysms, intracavitary bleedings or through percutaneous drainages. Among the 793 CT-positive patients, in 64, angiography did not reveal active bleedings and 28 of these were patients affected by DIC or wide small and diffuse bleedings, while in 36, CT revealed small active bleedings not detectable by the following angiography. In the last year (June 2017-February 2018) we considered CT-false-positive patients and in 31 of them angiography was not performed for wide small and diffuse bleedings or for small bleedings detected by CT, preferring clinical and laboratoristic follow-up. In 2 cases, owing to worsening of symptoms and laboratory parameters, angiography was performed, showing active bleeding followed by successful endovascular embolisation.
Conclusion: Multidetector CE-CT showed elevated accuracy in revealing active bleedings, but a correct assessment of clinical and laboratory conditions of patients is essential in the presence of mismatch between imaging findings and clinical conditions. In particular, in cases of wide small and diffuse bleedings and very small focal bleedings, only strict clinical and laboratory follow-up is appropriate, to evaluate later the necessity of diriment angiography.

Selective intraarterial embolisation as a treatment for haemorrhoid pathology: preliminary study
M. Ferrer Puchol1, A. Gregorio2, E. Esteban1, F. J. Blanco1, V. Primo2, L. Andreo2, M. Villalta Santamaria1, R. Ramiro1, J. Solaz Solaz1; 1Alzira/ES 2Denia/ES

Purpose: To present patients with bleeding haemorrhoids treated by selective intraarterial embolisation of superior rectal artery (SESRA).
Methods and Materials: We present twenty-one patients with disabling chronic rectal bleeding, evaluated by a proctologist, who indicated SESRA as the best therapeutic alternative. The mean age was 60.5 years (45-81). The stage of the haemorrhoidal disease was II/III. They were not suitable for other treatments. They were admitted the same day as embolisation. The inferior mesenteric artery was catheterized using a visceral catheter and superior rectal arteries were catheterized with microcatheter (2.7F). The occlusion of rectal arteries was made by PVA particles (300-500 microns in size) and coils 2-3 mm and particles, verifying the absence of distal flow. All patients were discharged at 24 h. After one month, the surgeon evaluated the patients clinically and with anoscopy.
Results: In 19/21 cases, the embolisation was successful, one patient presented inferior mesenteric artery spam and the procedure was suspended and other suffered infrarenal aortic aneurysm avoiding the catheterization. Clinical success was 19/21, follow-up: 2-29 months. One patient presented pain (VAS 3) that disappeared after 5 days. The rest did not experience any discomfort after the procedure. One patient presented rectal bleeding and prolapse, and he is pending surgical revision. Anoscopy performed at 1 month showed significant improvement in haemorrhoids. No complications were detected.
Conclusion: The initial results suggest that SESRA is safe and well tolerated and with advantage of absence of anorectal trauma. Additional studies were needed to evaluate treatment´s efficacy.

Post-TIPS encephalopathy: are there any predictive factors?
C. Perazzini1, P. Fonio2, A. Doriguzzi Breatta3, D. Righi2, D. Rossato2, G. Gandini2; 1Clermont Ferrand/FR 2Turin/IT 3Castelnuovo Don Bosco/IT

Purpose: To evaluate hepatic encephalopathy (HE) after trans-jugular intrahepatic porto-systemic shunt (TIPS) related to: age, international normalized ratio (INR), creatinine, bilirubin, platelets, portal thrombosis and model for End-of-stage Liver Disease score.
Methods and Materials: Retrospective study of 118 patients (53 males and 65 females, mean age 54 y/o) that from January 2008 to June 2013 underwent TIPS and a 6 and 12 months follow-up. HE staged according to West Haven criteria and simplified in moderate and severe has considered. Continuous variables tested for normality with the Shapiro-Wilks test. Comparisons employed non-parametric tests for k distributions and Anova test for n > 2 correlated distributions. Categorical variables arranged in r × c tables studied with the Chi-square or with Fisher’s exact test. Statistical significance set at two-tails p < 0.05. Analysis carried out with source software.
Results: The overall HE incidence after 6 moths is 36%: 29/118 patients present a moderate HE, 13/118 a severe one, 74/118 are not affected. Any statistical significance exists between biographical data, INR, creatinine, bilirubin, platelets, portal thrombosis and HE. Portal thrombosis has protective effect. At 12 months, 9/118 patients underwent liver transplantation, 2/118 died. 107/118 remaining have been re-evaluated: any statistical significance exists between biographical data, INR, creatinine, bilirubin, platelets and the incidence of HE. INR, lower bilirubin and a higher platelet are associated with a lower probability of HE.
Conclusion: INR, lower bilirubin, higher platelet count, without statistical significance and portal thrombosis, are associated with a lower HE incidence 12 months after TIPS.

Retrograde stent implantation of the celiac artery via the pancreaticoduodenal anastomosis
F. Pedersoli, P. Isfort, M. Zimmermann, M. F. Schulze-Hagen, S. Keil, C. K. Kuhl, P. Bruners; Aachen/DE

Purpose: The antegrade recanalization of a high-grade stenosis of the celiac artery directly from the aorta may present sometimes a challenge. In fact, in the absence of vascular stump (“flash-occlusions”) or pronounced calcification of the aortic wall, the trial may remain frustrated. Therefore was investigated the possibility of a retrograde alternative in the case of difficult antegrade access from the superior mesenteric artery, via the inferior and superior pancreaticoduodenal artery, the gastroduodenal artery, and the common hepatic artery.
Methods and Materials: We performed a retrospective analysis of all patients, who underwent a stent implantation in the celiac trunk from 01/2010 to 12/2017. The data on the indication to the intervention, the access, the material used, the stent model and the follow-up were collected.
Results: In 34 patients was performed a stent implantation into the celiac trunk. The antegrade approach was successful in 30 patients (88%). An antegrade passage of the occlusion or stenosis was not possible in 4 (12%) patients. In these cases, a 5F catheter was placed in the proximal superior mesenteric artery. Then the stenosis could be overcome with 2.4 F microcatheter and micro-wire. Subsequently, the tip of the micro-wire was captured in the aorta with a snare and pulled out in the femoral introducer sheat with a rendezvous technique and then used as a guide for the antegrade implantation of a balloon-expandable stent into the celiac trunk.
Conclusion: Retrograde access to the celiac trunk by pancreaticoduodenal arcade represents a valid alternative if antegrade access is not possible

High-flow priapism: colour Doppler findings and embolisation
G. De Magistris, F. Pane, F. Corvino, F. Giurazza, M. Coppola, F. Amodio, M. Silvestre, E. Cavaglià, R. Niola; Naples/IT

Purpose: To retrospectively evaluate the efficacy of colorDoppler detectability and the safety of transcatheter arterial Embolization for High-flow Priapism
Methods and Materials: Over a 8-year period, 10 patients (mean age 32 years; range 13-65 years) admitted to our department with traumatic high-flow priapism, were reviewed. The patients were evalueted with clinical and imaging findings (colorDoppler ultrasonography and Angiography). Diagnostic Angiography demonstred fistulas between the cavernosal artery and the corpora cavernosa, these communications were embolized with coils and gelatin sponge. A colorDoppler follow-up was peformed at 2 weeks and 3-6 months after procedure
Results: At the admittance, colorDoppler detected pseudoaneurysms/fistulas in 9 patients. In 8 of 10 patients a single embolization was sufficient for complete resolution, 2 patients had recurrence of Priapism (confirmed by colorDoppler Imaging) in the subsequent 1- 3 weeks and required a second procedure. 9 patients were embolized with coils and one with spongel. At 3-6 months follow-up, colorDoppler US confirmed the absence of fistula and recanalization of the embolized cavernosal artery. All patients had normal erectile funcion at 6 months
Conclusion: ColorDoppler is useful to detect fistulas and to monitor the effectiveness of embolization. Superselective transcatheter embolization of the internal pudenda artery is efficacy, compared to other techniques, and has a high rate of preservating erectile function

Role of c-arm computed tomography-assisted adrenal vein sampling in the assessment of adrenal hypersecretion syndromes
A. Pisano, M. Tipaldi, G. Orgera, F. Laurino, A. Laghi, M. Rossi; Rome/IT

Purpose: Adrenal Vein Sampling (AVS) is a gold standard procedure in the diagnostic work up of adrenal hypersecretion syndromes. However, it is burdened by high failure rates due to technical issues and in particular for the right vein catheterization. Therefore, we investigated the impact of C-arm Computed Tomography-Assisted AVS (C-AVS) in comparison to standard AVS.
Methods and Materials: From September 2010 to January 2018, a total of 40 procedures were retrospectively reviewed: 23 AVS (group A) and 17 C-AVS (group B). Overall, 36 patients (90%) had primary hyperaldosteronism clinical features, and 4(10%) suffered from ACTH-independent Cushing’s Syndrome with bilateral macronodular hyperplasia.
All patients were infused with 50 microL/h cosyntropin 30 minutes prior the procedure.After catheterization of the right and left adrenal vein, C-arm-CT was performed in group B during CE selective injection, to confirm correct catheter position. Technical success was defined by adequate bilateral sampling, intended as a selectivity index (SI) >3.
Results: Technical success was obtained in 52,2% of group A (12pt), while in 47,8% of the cases sampling did not prove diagnostic. On the other hand, technical success was achieved in 82,4% of group B (14pt), whereas 11,7% of them did not meet SI criteria and 1 procedure was aborted due to contrast-media reaction.Technical success was significantly higher in group B than in group A (82,4% vs. 52,2%; p-value <0.05). There was no procedure-related complication.
Conclusion: Despite limited data, C-AVS improved the overall success rate of AVS, as it proves crucial for an optimal catheterization of adrenal veins.

Long-term follow-up of giant visceral artery aneurysms endovascular treatment: a single centre experience
M. Tipaldi1, M. Pignatelli1, G. Orgera1, F. Laurino2, A. Laghi1, M. Rossi1; 1Rome/IT 2Eboli/IT

Purpose: Purpose of this study is to assess the immediate and long-term safety and effectiveness of Giant visceral artery aneurysms (visceral aneurysm> 5cm) endovascular treatment in a single center case series.
Methods and Materials: Eight cases of GVAAs (7M, 1F) have been treated in our institution, between August 2006 and June 2017, and were retrospectively reviewed. Embolization was performed with coiling and/or fragment of guidewires and/or embolic agents and/or stents.Technical success was defined as the correct exclusion of the sac at the last angiogram, while clinical success was defined as the complete relive of clinical symptoms, if previously present.Follow-up was performed with CT angiography at 1,3, 12 and 24 months or phone survey if patients were referred to other centers.
Results: Technical and clinical success were obtained in 100% of the cases. One minor complication, consisting in an asymptomatic ischaemia of the spleen, and one major complication, consisting in a 4cm splenic abscess concurrently with a small infarctual area, occurred. The median time follow-up was 48 months (range 6 to 84 months) and demonstrated the correct exclusion of the sac in 100% of the cases. One patient died five years after the treatment for causes not related to the procedure.
Conclusion: The first line treatment of visceral artery aneurysms is, nowadays, the endovascular one rather than open surgery. Our series have shown that this indication, thanks to the low morbidity and mortality rates associated with, should be expanded even for GVAAs.

Transjugular portal vein stenting: an original approach for palliative treatment of portal vein stenosis/occlusion in neoplastic patients
A. Mazzaro1, F. L. Gatti1, R. Bettini1, N. Mandruzzato2, A. Contro1, G. Mansueto1; 1Verona/IT 2Trieste/IT

Purpose: To evaluate risks and benefits of portal vein stenting as a palliative procedure in a pool of oncologic patients.
Methods and Materials: Between April 2014 and August 2018 we treated 12 patients with neoplastic portal vein stenosis/occlusion performing portal vein stenting. In 5 of them was used a transhepatic access and in 7 a transjugular access. Portal stenting has less than 200 cases reported in the literature, most of them with transhepatic access. Transjugular access is an original/unique variant. To evaluate the procedure we considered technical and anatomical success, procedural complications and mortality, 30 days mortality, modifications in clinical and laboratory parameters (haemoglobin, haematocrit, albumin, ALT, bilirubin and INR). Technical success was assessed with intra-procedural portography while complications and anatomical success with follow-up MDCT.
Results: In all the procedures technical and anatomical success was achieved with no intraprocedural or early mortality. Two patients treated with transhepatic access developed complications (hepatic abscess and hepatic haematoma). No patient with transjugular access developed complications. All patients showed improvement of clinical conditions and of laboratory parameters (four or more of the six parameters considered) in 30 days, even those who developed complications.
Conclusion: Portal vein stenting in oncologic patients was performed safely, it resolved portal vein’s stenosis/occlusion leading to a relief of portal hypertension-related symptoms and an improvement in the quality of life. In our experience transjugular access is less invasive and reduces the risk of hepatic bleeding, however it has to be performed by TIPS procedure expert operators.

Use of Onyx (ethylene vinyl alcohol copolymer) in haemorrhage embolisation procedures
R. Marcello, G. Assegnati, A. Di Blasi, F. Cortese, D. Konda, E. Pofi; Rome/IT

Purpose: The purpose of our study was the evaluation of the effectiveness and reliability of the "Onyx" device (ethylene vinyl alcohol copolymer) in the treatment of bleeding by trans-catheter embolization technique.
Methods and Materials: 14 Patients in our retrospective analysis underwent transcatheter embolization for bleeding control. All patients underwent diagnostic angiography with trans-femoral access to confirm the findings obtained with US and ce-TCMS investigation work-up.The coaxial technique was always applied in performing all procedures with a 5 Fr diagnostic catheter (Sim 1 Imager, Boston Scientific, USA) combined with a microcatheter 2.7 Fr. (Progreat Terumo, JAP).In all cases "Onyx" (ethylene vinyl alcohol copolymer) was used as embolization material. The source of the bleeding was duodenal ulcer in 5 cases, 2 gluteal haematomas, 1 haemorrhoidal pseudoaneurysm, 2 intraparenchymal renal aneurysms in one case, 1 vascular malformation of the gastric fund, 1 haemorrhage after hip prosthetic replacement, 1 renal angiomyolipoma, 1 abdominal wall haematoma and 1 retroperitoneal haematoma.
Results: Prompt cessation of bleeding was achieved in all patients. No immediate or late complications were observed with regards to all procedures carried out. No unwanted embolization of other vascular areas was observed.
Conclusion: According to our retrospective analysis, the reliability and effectiveness of "Onyx" (ethylene vinyl alcohol copolymer) as embolization material emerged during many bleeding trans-catheter embolization procedures in different anatomical sites.

Tips and tricks of emergency TIPS in patients affected by severe portal hypertension
A. Borzelli1, A. Paladini2, F. Amodio1, E. Cavaglià1, R. Niola1; 1Naples/IT 2Novara/IT

Purpose: To evaluate the main causes of failure in TIPS performed in emergency setting in critical patients affected by severe portal hypertension.
Methods and Materials: Between Jan 2014 and Jan 2018, we retrospectively considered 72 TIPS performed in emergency setting in critical patients (medium patient age 52; 45 M, 27 F) with severe portal hypertension and affected by variceal bleeding (42), refractory ascites with hepatorenal syndrome (15)and hepatic coma (15). In all cases, we used an e-PTFE-covered stent and in all cases we employed a US-assisted technique to reach the portal vein system once catheterised one of the hepatic veins.
Results: In 12 cases, TIPS was not possible. In 7 patients, we observed a marked distortion in liver anatomy due to chronic liver disease with loss of normal anatomic relationship between portal vein system and hepatic veins, which were too thin. In 3 cases, due to anatomic distortion, it was possible to reach only a small peripheral portal vessel, with subsequent impossibility to make the shunt; in 1 case, we noticed a iatrogenic lesion of portal vein during the procedure with subsequent thrombosis of the stent; in 1 case, malpositioning of the stent with early thrombosis not solved by proximal and distal extension of the shunt.
Conclusion: The main cause of technical success of emergency TIPS performed in critical patients with severe portal vein hypertension is the marked anatomical distortion of the liver, in particular, its vascular anatomy. It is necessary to reduce the failure rate, to employ a US-assisted approach and, if required, a percutaneous sentinel catheter into the main branch of portal vein, to guide the radiologist during the procedure.

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