CIRSE's Andreas Gruentzig Lecture has beengiven by some of Interventional Radiology'smost outstanding personalities. This year'slecture will be given by Riccardo Lencioniwho will speak about InterventionalOncology. We invite all of you to attend the Lecturetoday after the CIRSE meets Brazil Session at 14:15 in Auditorium 1.

During the past four years, the use of image-guided interventions in cancer treatment hasexperienced unparalleled growth. Several inno-vative techniques and devices for directtumour ablation and transarterial therapy havebeen introduced, sophisticated imaging meth-ods improving tumour targeting and treatmentmonitoring have been devised and a numberof trials have been successfully completed indifferent clinical settings. Interventional oncol-ogy procedures are increasingly used as analternate or complementary treatment for avariety of solid cancers under the commondenominator of effective local tumour controlwithout the morbidity of open surgery or thetoxicity of chemotherapy and radiation.

Image-guided percutaneous ablation is cur-rently accepted as the best therapeutic choicefor nonsurgical patients with early-stage hepa-tocellular carcinoma (HCC) (1-3). Over the pasttwo decades, several methods for chemicalablation or thermal tumour destructionthrough localised heating or freezing havebeen developed and clinically validated in HCCtreatment. Transarterial chemoembolizationhas become the accepted standard of care forpatients with multinodular disease confined tothe liver (4). The recent introduction of drug-eluting beads has been instrumental in improv-ing response rate and tolerability of the proce-dure and has opened new prospects for combi-nation strategies including chemoembolizationand image-guided ablation or chemoemboliza-tion and molecular targeted therapies (5,6).

The use of radiofrequency ablation to treatunresectable or medically inoperable patientswith liver-dominant hepatic metastatic disease,especially from colorectal cancer, was proposed10 years ago (7). Since then, several investiga-tors have refined techniques and approaches,and 8 cohort studies have reported long-termsurvival outcomes of RFA-treated patients (8).Recently, the interim results of a randomisedcontrolled trial comparing chemotherapy vs.chemotherapy plus radiofrequency ablation

have been presented at the annual meeting ofthe American Society of Clinical Oncology, pro-viding unquestionable evidence of clinical ben-efit (9).

Treatment of kidney cancer has become one ofthe most effective indications for percutaneousablation. The technique has been optimisedand reported results seem to compare verywell with those of surgical management, bothin term of clinical outcomes and treatment-related costs (10,11). The reported clinical out-comes of lung ablation have exceeded eventhe best expectations, resulting in impressiverates of complete cure and offering a viabletreatment option for the many patients whocannot have standard surgery due to reducedpulmonary function or co-morbidities (12). Interventional techniques are gaining increas-ing acceptance in the management of painfulbone metastases. The impact on quality of lifeof percutaneous procedures has been well doc-umented, and technical refinements haveallowed even critical locations to be treatedsuccessfully (13).

Much has still to be done, however. A compre-hensive, multi-pronged approach to the disci-pline of interventional oncology with a robustportfolio of clinical, basic and translationalresearch is required to achieve significant dis-covery and clinical implementation of noveland effective therapeutic approaches to bene-fit patients with cancer (14). A central convic-tion underpinning the research strategy is thatthe core approaches to cancer treatment,namely systemic drug administration and sur-gery, can and will be supplemented by mini-mally-invasive treatments for locally-dominantdisease to increase response, achieve betterside-effect profile, reduce cost and potentiallyimprove survival.

An integrated, multidisciplinary approach isinstrumental for interventional oncology to beaccepted by referring physicians, governingbodies and patients as another defined arena

C RSECardiovascular and Interventional Radiological Society of Europe

Andreas GruentzigLecture

Riccardo LencioniDirector, Division of Diagnostic Imaging and InterventionDepartment of Liver Transplantation, Hepatology, and Infectious DiseasesUniversity of Pisa, Italy

Interventional OncologyAndreas Gruentzig LectureSunday, September 20, 14:15-16:00Auditorium 1

Don't miss it !

InterventionalOncology

similar and coequal to radiation oncology, sur-gical oncology and medical oncology in thefield of clinical cancer care. Such an approachwill eventually enable interventional oncologyto have a pivotal role in the therapeutic man-agement of cancer. The incorporation of inter-ventional radiology procedures into clinicalpractice has always resulted in an importantchange in patient care. Many procedures initial-ly developed as “therapeutic alternatives” havenow become first choice treatments (15).Interventional radiology societies should take aleadership position in organising a basic andclinical research agenda for interventionaloncology and in implementing a structurededucational programme to meet the needs ofinterventionists who wish to acquire knowl-edge and skills in this emerging field. CIRSE ishighly committed to interventional oncologysupporting clinical trials and research develop-ment and carrying out registries and studies incollaboration with other professional societiesor on its own.

The CIRSE Foundation is a permanent source offunds in order to provide training programmesin the field of minimally invasive, image guidedprocedures. It has also recently started a verysuccessful continuing educational programmewith a focus on oncology, including a numberof local courses within the framework of theEuropean School of Interventional Radiologyand the first European Conference onInterventional Oncology held in spring 2008. Interventional oncology will become the fourthpillar of cancer care, along with medical oncol-ogy, surgical oncology and radiation oncology.However, the more oncologic interventions willbe recognised, the more they will become asubject of turf issues. As other specialties con-tinue to move toward minimally invasiveapproaches, a very competitive environmenthas already formed. Total patient care withdirect referral will be the key to the long-termsurvival of oncologic interventions insideInterventional Radiology and within the houseof Radiology (15).

CIRSE 2009 - LisbonSunday, September 20, 2009

References:1. Lencioni R, Allgaier HP, Cioni D, et al. Small hepatocellular carcino-

ma in cirrhosis: randomised comparison of radiofrequency thermalablation versus percutaneous ethanol injection. Radiology2003;228:235-240

2. Tateishi R, Shiina S, Teratani T et al. Percutaneous radiofrequencyablation for hepatocellular carcinoma. Cancer 2005;103:1201-1209

3. Lencioni R, Cioni D, Crocetti L, et al. Early-stage hepatocellular carci-noma in cirrhosis: long-term results of percutaneous image-guidedradiofrequency ablation. Radiology 2005;234:961-967

4. Bruix J, Sherman M. Management of hepatocellular carcinoma.Hepatology 2005;42:1208-1236

5. Varela M, Real MI, Burrel M, et al. Chemoembolization of hepatocel-lular carcinoma with drug eluting beads: efficacy and doxorubicinpharmacokinetics. J Hepatol 2007;46:474-481

6. Lencioni R, Crocetti L, Petruzzi P, et al. Doxorubicin-eluting bead-enhanced radiofrequency ablation of hepatocellular carcinoma: Apilot clinical study. J Hepatol 2008;49:217-222

7. Lencioni R, Goletti O, Armillotta N, et al. Radio-frequency thermalablation of liver metastases with a cooled-tip electrode needle:results of a pilot clinical trial. Eur Radiol 1998;8:1205-1211

8. Siperstein AE, Berber E, Ballem N, Parikh RT. Survival after radiofre-quency ablation of colorectal liver metastases. 10-year experience.Ann Surg 2007;246:559-567

9. T. Ruers, F. van Coevorden, J. Pierie, et al. Radiofrequency ablation(RFA) combined with chemotherapy for unresectable colorectalliver metastases (CRC LM): Interim results of a randomised phase IIstudy of the EORTC-NCRI CCSG-ALM Intergroup 40004 (CLOCC). JClin Oncol 2008;26:4012

10. Iguchi T, Hiraki T, Gobara H, et al. Transhepatic approach for percuta-neous computed-tomography-guided radiofrequency ablation ofrenal cell carcinoma. Cardiovasc Intervent Radiol. 2007;30:765-769

11. Rouvière O, Badet L, Murat FJ, et al. Radiofrequency ablation of renaltumours with an expandable multitined electrode: results, compli-cations, and pilot evaluation of cooled pyeloperfusion for collectingsystem protection. Cardiovasc Intervent Radiol 2008;31:595-603

12. Lencioni R, Crocetti L, Cioni R, et al. Response to radiofrequencyablation of pulmonary tumours: a prospective, intention-to-treat,multicentre clinical trial (the RAPTURE study). Lancet Oncol2008;9:621-628

13. Sabharwal T, Salter R, Adam A, Gangi A. Image-guided therapies inorthopedic oncology. Orthop Clin North Am 2006;37:105-112

14. Goldberg SN, Bonn J, Dodd G, et al. Society of InterventionalRadiology Interventional Oncology Task Force: InterventionalOncology research vision statement and critical assessment of thestate of research affairs. J Vasc Interv Radiol 2005;16:1287-1289

15. Bilbao JI, Adam A, Lammer J, Peregrin J. Cardiovascular andInterventional Radiological Society of Europe. Clinical care in inter-ventional radiology. Cardiovasc Intervent Radiol 2006;29:728-730

Rnewscongress

Fig.1: Hepatocellular carcinoma before (a) and after transarterial chemoembolization (b).

C RSECardiovascular and Interventional Radiological Society of Europe

3CryoablationIRnewscongress

C RSECardiovascular and Interventional Radiological Society of Europe

Cryotherapy achieves tumour ablation withlethal freezing temperatures ranging from -20to -40°C. Although this technique has beenknown for decades, its indications in urologiconcology remained limited. Indeed, the firstgeneration of cryodevices was using largenitrogen-driven probes which limited their useto a surgical approach. Since the developmentof new generation gas-driven cryosystems,miniaturisation of the cryoprobes was possible,thus allowing their percutaneous use in CT andMR tunnels. In urologic oncology, cryoablationallows treatment of kidney, adrenal andprostate cancers for poor surgical candidates.

MechanismGas driven cryomachines rely on the physicalrelationship between temperature and pres-sure (Joule-Thomson effect): at atmosphericpressure, most gases are cooled by expansion.Only small gases such as helium are warmed byexpansion due to reduced collisions (negativeJoule-Thompson effect).

Based on this phenomenon, high pressureargon is used for freezing and helium is usedfor active thawing. Active thawing acceleratesthe treatment process, allows for repositioningof the probe and provides additional safety byenabling rapid stopping of the ice ball forma-tion. Tumour destruction is achieved by com-bining two major mechanisms: immediate cel-lular death caused by intracellular ice crystalsthat break cell membranes and delayedischemia as intravascular ice crystals stop theblood flow in small vessel (less than 3-4 mmdiameter).

During the first freezing cycle ice crystals aremainly extra-cellular. During slow thawingwater re-crystallises and diffuses into the intra-cellular compartment due to the osmoticeffect. After a second freezing cycle, intracellu-lar crystal formation achieves membrane rup-ture and cell death. For this reason, a completefreeze-thaw-freeze cycle is needed to achievecertain cell death. Compared to radiofrequencywhich does not discriminate the ablated tis-sues, cryoablation offers a relative protection ofthe poorly hydrated tissues such as collagen.

EquipmentLast generation gas-driven cryoprobes are 17gauge mini-invasive needles that can be usedin CT and MR tunnels. These two imagingmodalities allow a precise monitoring of the iceball with multiplanar control to achieve opti-mal tumoural covering. Up to 25 cryoprobescan be activated simultaneously. Thus severalprobes can be combined to treat a large singletumour or to treat multiple small tumourssimultaneously. Different cryoprobes are avail-able, producing different sizes and shapes ofice balls.

To prevent thermal damage to adjacent struc-tures, thermal protection techniques are oftenused; dedicated thermo-sensors can be con-nected to the cryomachine to continuouslymonitor the temperature of the vulnerableorgan. Also, organ displacement and insulationcan be achieved with targeted CO2 dissectionbetween the tumour and the vulnerable struc-ture. Hydrodissection, which is a commonlyused thermal protection technique in radiofre-quequency ablation, is not suitable withcryoablation.

Indications and TechniqueIn urologic oncology, cryoablation has beenused to treat kidney, adrenal and prostatetumours. The indications and the planning ofrenal cryoablation procedures are very similarto those of radiofrequency ablation. This tech-nique is a curative alternative for tumours <4cm in poor or non-surgical candidates. Bestindications include risky partial nephrectomy,contraindication of general anaesthesia, renaldysfunction, solitary kidney, bilateral tumours,Von Hippel Lindau disease.

Absolute contra-indications include acuteinfection and uncontrollable hemostasis prob-lems. Tumours >4 cm or close contact with vul-nerable structures are relative contra-indica-tions. However, most of these cases can besolved with good knowledge of thermal pro-tection techniques.

Compared to radiofrequency ablation, renalcryoablation offers several advantages. Theprecise visual control of the ice ball with CTand MRI allows optimal tumoural covering andbetter control of adjacent vulnerable struc-tures. Peri- and post-procedural pain isreduced. The risk of thermal injury to the pyelicstructures is reduced, as collagen tissue under-lying the urothelium is less vulnerable to coldtemperatures. This last point is a major advan-tage for the treatment of renal tumours in cen-tral location.

Adrenal cryoablation can be considered as analternative technique in poor surgical candi-dates suffering either from benign hormonallyactive tumours or adrenal metastases of slowgrowing cancers. In those cases, cryoablation isperformed with a curative intent. Less often,adrenal cryoablation can be considered in apalliative intent for patients suffering frompainful adrenal metastases.

The precise visual control of the ice ball allowsoptimal tumoural covering and reduces the riskof thermal damage to adjacent vulnerableorgans (particularly bowel and pancreas).Similar to adrenal radiofrequency ablation,cryoablation of adrenal tumours is associatedwith a significant risk of hypertensive crisis dueto sudden release of active hormones. For thisreason, most adrenal cryoablation proceduresare performed under general anaesthesia witha well trained anaesthesiology team.

New perspectives in urologic cryoablationXavier BuyConsultant of Radiology in Interventional RadiologyAfshin GangiProfessor of RadiologyHervé LangProfessor of Urology

University Hospital StrasbourgFrance

Cryoablation of prostate cancer is still under eval-uation as an alternative treatment for non-surgi-cal local prostate cancers. Cryoablation is gener-ally performed by urologists under endorectalultrasound guidance. However, the visualisationof the tumour is poor and control of the ice ballincomplete. The development of MR compatiblecryomachines offers new perspectives in thetreatment of prostate cancer. Better visualisationof the tumour with MR combined with multipla-nar monitoring of the ice ball could improve thetreatment and the safety of prostate cryoablationand maybe pave the way for focal prostate can-cer therapy in selected cases.

ConclusionIn the field of urologic oncology, cryoablationis becoming a major alternative technique forpoor surgical candidates suffering from renal,adrenal or prostate cancers. Renal cryoablationis a very promising curative technique fortumours up to 4 cm. Compared to radiofre-quency ablation, the major advantages ofcryoablation are the precise visual monitoringof the ice ball extension allowing better controlof the tumoural covering and decreased risk ofthermal injury to adjacent organs. Moreover,the better preservation of collagen tissue withcold temperatures reduces the risk of thermaldamage to the pyelic structures when ablatingcentral tumours. However, the cost of cryoabla-tion is significantly higher and radiofrequencyablation is still used for many indications.

Adrenal cryoablation is also a promising tech-nique in poor surgical patients suffering fromslow growing or painful adrenal tumours.Cryoablation of prostate cancer performedunder ultrasound guidance is still under evalu-ation. The development of MR compatiblecryo-devices offers new opportunities. MR-guidance may improve the potential ofprostate cryoablation, as it combines visualisa-tion of the tumour and multiplanar control ofthe ice ball. A good understanding of the cry-obiology principles, respect of clinical indica-tions and perfect knowledge of the techniques(particularly thermal protection techniques) arethe keys for successful treatment.

Fig.1: Left renal cancer close to the colon (a).Cryoprobes are inserted into the tumour via aposterior approach and pararenal CO2 insuffla-tion is performed to achieve thermal protection ofthe colon (b, arrow). Note the sharp visible mar-gins of the ice ball covering the tumour.

References:1. Theodorescu D. Cancer cryotherapy: evolution and biology. Rev

Urol 2004; 6 suppl 4: S9-S19.2. Buy X, Tok CH, Szwarc D, Bierry G, Gangi A. Thermal protection

during percutaneous thermal ablation procedures: interest ofcarbon dioxide dissection and temperature monitoring.Cardiovasc Intervent Radiol 2009; 32:529-534.

3. Permpongkosol S, Link RE, Kavoussi LR, Solomon SB.Percutaneous computerized tomography guided cryoablationfor localized renal cell carcinoma: factors influencing success. JUrol 2006; 176:1963-1968.

4. Janzen NK, Perry KT, Han KR, et al. The effects of intentionalcryoablation and radio frequency ablation of renal tissueinvolving the collecting system in a porcine model. J Urol 2005;173:1368-1374.

5. Atwell TD, Farrell MA, Leibovich BC, et al. Percutaneous renalcryoablation: experience treating 115 tumours. J Urol 2008;179:2136-2140; discussion 2140-2131.

6. Munver R, Del Pizzo JJ, Sosa RE. Adrenal-preserving minimallyinvasive surgery: the role of laparoscopic partial adrenalectomy,cryosurgery, and radiofrequency ablation of the adrenal gland.Curr Urol Rep 2003; 4:87-92.

7. Atwell TD, Wass CT, Charboneau JW, Callstrom MR, Farrell MA,Sengupta S. Malignant hypertension during cryoablation of anadrenal gland tumour. J Vasc Interv Radiol 2006; 17:573-575.

8. Jayram G, Eggener SE. Patient selection for focal therapy oflocalized prostate cancer. Curr Opin Urol. 2009 May;19(3):268-73.

9. Prepelica KL, Okeke Z, Murphy A, Katz AE. Cryosurgical ablationof the prostate: high risk patient outcomes. Cancer. 2005 Apr15;103(8):1625-30.

Fig.2: Right slow growing adrenal metastasis incontact with the vena cava (a). Cryoprobes areinserted into the tumour via a lateral transhepaticapproach and retroperitoneal CO2 dissection isperformed to protect the vena cava and reducethe “cold sink effect” (b and c). Complete tumour-al covering by the ice ball with slight extension tothe adjacent liver parenchyma (d).

Fig.3: MR-guided cryoablation of prostate cancerin a patient contraindicated for surgery andradiotherapy due to prior history of rectal cancer(a). Six cryoprobes and a pararectal thermosensorare inserted via a perineal approach (b).Complete covering of the prostate by the ice ball(c and d); note the warming catheters to protectthe ureter and the rectum.

The authors wearing ear protection for interven-tional MR. From left to right: Buy, Gangi and Lang

Kidney radiofrequency- and cryoablationSpecial SessionSunday, September 20, 10:00-11:00Auditorium 2

Don't miss it !

C RSECardiovascular and Interventional Radiological Society of Europe

5Thoracic Aortic AneurysmIRnewscongress

Endovascular treatment of thoracic aortic aneurysm and dissection: Expanding indications

With more experience of the technique, it isbecoming increasingly evident that more andmore patients with pathology of the thoracicaorta can be treated by endovascular tech-niques. The published evidence for many indi-cations shows that thoracic aortic endograftinghas clear advantages in terms of reduced mor-tality and morbidity and shorter hospital staycompared with open surgery.

These favourable outcomes have inspired inter-ventionalists to try these endovascular meth-ods in patients with more complex pathology,such as lesions involving the aortic arch andthe thoracoabdominal segment. The indica-tions for thoracic endografting have beenexpanded in the last few years (Fig.1). The fol-lowing account briefly describes the manage-ment approach for patients with descendingthoracic aneurysms, aortic arch aneurysms,thoracoabdominal aneurysms, complicatedaortic dissection and traumatic aortic injury.

THORACIC ANEURYSMS

Descending thoracic aneurysmsInclusion criteria for endografting are suitablelanding zones of normal aorta (42mm diameteror less, at least 20mm long) proximal and distalto the aneurysm, and adequate access arteries(iliac and femoral arteries) of at least 7mm indiameter. Endografts can be inserted underregional, local or general anaesthesia, so thatpatients who are not fit for general anaesthesiashould not be excluded from treatment.

For patients with standard aneurysms of thedescending aorta, the procedure is usuallystraightforward and quick. Technical successapproaches 100% and the main complicationsare paraplegia which is around 2%, and groincomplications related to the arteriotomy. Inmany cases patients are discharged a few daysafter the procedure. Follow-up should be byperiodic CT scans. Late complications includetype 3 endoleaks, graft strut disruption andmigration, which are all low.

Aortic arch aneurysmsPatients with aneurysms very close to or involv-ing the supraaortic vessels can be treated bysurgical bypass of one, two or all threesupraaortic vessels followed by the insertion ofendografts. This is known as hybrid treatment.The aim of surgical bypass is to create a proxi-mal landing zone for the aortic endografts. Leftsubclavian to left common carotid bypass, andright to left common carotid bypass are rela-tively straightforward procedures in experi-enced hands, with low morbidity. Aneurysmsinvolving the proximal arch require bypass of allthree supraaortic vessels which is achieved bytaking grafts from the lower ascending aorta.This involves a sternotomy, and aortic side-clamping avoids the need for cardiopulmonarybypass. Although this sounds rather drastic,complications are very low and are substantiallylower than the open surgical alternative involv-ing replacement of the entire aortic arch.

Insertion of the aortic endografts to excludethe lesion is usually performed as a separateprocedure a few weeks later. Using this hybridtechnique, many patients who were previouslyrefused conventional open surgery can now betreated. The main complications of arch hybridprocedures are stroke (7%) and paraplegia (2%)and are mainly related to endograft insertionrather than the surgical bypass procedure.

In order to avoid the need for surgical bypass, thedevice manufacturers are making great efforts todevelop branched devices for use in the aorticarch. Although several prototype devices havebeen used in selected patients, a widely availabledevice is not yet available. It is likely that the firstbranched devices for use in the arch will contain asingle branch. Devices with two or even threebranches are a much more distant prospect.

Thoracoabdominal aneurysmsSimilar to arch aneurysms, thoracoabdominalaneurysms can be treated by less invasive tech-niques compared with open surgery. Treatmentoptions include hybrid procedures, totallyendovascular procedures using branched andfenestrated endografts, and combinations ofhybrid and branched and/or fenestrated devices.The worldwide experience of the use of brancheddevices for thoracoabdominal aneurysms is limit-ed, but is increasing on an annual basis.

On the basis of the limited available data, this mostattractive treatment option seems to be effectiveand safe. The main inclusion criteria are an aorticarch of favourable morphology to enable cannula-tion and stent-grafting of the visceral vessels fromthe left arm, adequate iliac arteries for access, theability for the patient to wait 4-6 months for manu-facture and delivery of the endograft, and thefinancial ability of the patient or institution to payfor the devices. It should be stressed that the rela-tively high costs of the devices are balanced sub-stantially by the cost savings incurred by the lowercomplications and hospital stays experienced bypatients treated with this technology.

Hybrid procedures are a reasonable alternative tobranched grafts for thoracoabdominalaneurysms, especially in patients withunfavourable aortic arch morphology. The maininclusion criterion is fitness to undergo visceralartery bypass. Up to all four visceral arteries (coeli-ac artery, superior mesenteric artery and the renalarteries) can be bypassed using grafts inserted inthe common iliac artery or to the distal aorta.Clearly, any procedure involving visceral arterybypass will have a higher complication rate com-pared with a totally endovascular alternative.However, for patients with low comorbidity theresults for elective procedures are acceptable andbetter than surgical replacement of the thora-coabdominal aorta.

THORACIC DISSECTION AND ACUTE AORTICSYNDROME.

Management of uncomplicated acute type Bintramural haematoma (IMH), penetrating aorticulcer (PAU) and dissection remains conservativewith intervention reserved for complications.Patients with acute IMH and PAU should undergoserial CT scans every few days to assess forchanges in the aortic morphology. If there is per-sistent pain, an increase in the size of the lesion,the development of dissection or evidence ofrupture, the lesions should be treated by theinsertion of one or more endografts.

Patients with established acute type B dissectionshould be treated by endografts if they developsigns of rupture, malperfusion syndrome involv-ing the visceral or lower extremity arteries, or ifthere is dilatation of the aorta either at presenta-tion or on successive CT scans. A cross-sectionaldiameter of 22 mm of the false lumen is used bymany as a threshold for endografting. The aim ofendografting in acute dissection is to cover themain communication(s) in the thorax.

Thoracic aneurysm and dissectionSpecial SessionSunday, September 20, 10:00-11:00Auditorium 6

Don't miss it !

Robert MorganConsultant Vascular and Interventional RadiologistSt. George’s HospitalLondon, UK

References: 1. Bavaria JE, Appoo JJ, Makaroun MS, Verter J, Yu ZF, Mitchell RS.

Endovascular stent grafting versus open surgical repair ofdescending thoracic aortic aneurysms in low-risk patients: amulticenter comparative trial. J Thorac Cardiovasc Surg2007;133(2):369-77.

2. Fattori R, Nienaber CA, Rousseau H, et al. Results of endovascu-lar repair of the thoracic aorta with the Talent Thoracic stentgraft: the Talent Thoracic Retrospective Registry. J ThoracCardiovasc Surg 2006;132(2):332-9.

3. Thompson M, Ivaz S, Cheshire N, et al. Early Results ofEndovascular Treatment of the Thoracic Aorta Using the ValiantEndograft. Cardiovasc Intervent Radiol 2007.

4. Hagan PG, Nienaber CA, Isselbacher EM, et al. The InternationalRegistry of Acute Aortic Dissection (IRAD): new insights into anold disease. Jama 2000;283(7):897-903.

5. Eggebrecht H, Nienaber CA, Neuhauser M, et al. Endovascularstent-graft placement in aortic dissection: a meta-analysis. EurHeart J 2006;27(4):489-98.

6. Bortone AS, De Cillis E, D'Agostino D, de Luca Tupputi SchinosaL. Endovascular treatment of thoracic aortic disease: four yearsof experience. Circulation 2004;110(11 Suppl 1):II262-7.

7. Nathanson DR, Rodriguez-Lopez JA, Ramaiah VG, et al.Endoluminal stent-graft stabilization for thoracic aortic dissec-tion. J Endovasc Ther 2005;12(3):354-9.

8. Chen S, Yei F, Zhou L, et al. Endovascular stent-grafts treatmentin acute aortic dissection (type B): clinical outcomes duringearly, late, or chronic phases. Catheter Cardiovasc Interv2006;68(2):319-25.

9. Melnitchouk S, Pfammatter T, Kadner A, et al. Emergency stent-graft placement for hemorrhage control in acute thoracic aorticrupture. Eur J Cardiothorac Surg 2004;25(6):1032-8.

Regarding chronic dissection (>2 weeks afterpresentation), the main indications for endograft-ing are aneurysm formation (>5.5cm aortic diam-eter) and rupture. Because the flap becomesfibrotic and immobile with time, there is evidencethat endografts should extend to the diaphragmto achieve as little residual false lumen perfusionas possible after endografting.

The 30-day outcomes of endografting for compli-cated acute and chronic dissections remain betterthan open surgical alternatives. Most series reportmortality rates below 10% with paraplegia ratesof less than 3%. The long term outcomes foracute dissection are good. In the vast majority ofcases late aneurysm formation involving the tho-racic aorta seems to be uncommon, althoughlong term data are limited. A small cohort ofpatients goes on to develop aneurysms of theabdominal aorta which may require treatment.

In the case of chronic dissection, there is a subsetof patients who, despite endografting, continueto perfuse the thoracic false lumen and increasethe thoracic aortic diameter. This is the most chal-lenging situation faced by specialists in aorticintervention. An option being increasingly used isto close all of the communications between thetrue and the false lumen by extension of endo-graft coverage as far distally as is necessary afterbypass of the visceral vessels. Clearly, such proce-dures are very complex. However, early resultsconfirm that these patients do have a workabletreatment option and should not be denied treat-ment.

TRAUMATIC AORTIC INJURY

Due to its low complication rate TEVR has inmany centres superseded surgery for TAI in thelast decade. The procedural time is short and theoperation confers very little in terms of addition-al morbidity to these severely ill patients. Due tothe focal nature of the injury, only a short lengthof aorta requires covering with an endograft. Thepublished data are limited, although the proce-dural mortality is in most cases less than 5% andthe paraplegia rate is negligible. The main area ofresearch involves the development of endograftswhich better conform to the angulated aorticarch in younger patients who present with TAI. Atleast one manufacturer plans to release one suchdevice iteration very soon.

SUMMARYEndografting for lesions of the descending aortaseems to be here to stay. Moreover, using Hybridprocedures, branched devices, or a combinationof these methods, the indications for endograft-ing can be expanded to include lesions involv-ing the aortic arch and the thoracoabdominalsegment. It behooves us to consider thesemethods for our patients presenting with chal-lenging pathology of the aorta so that they areoffered the best option for survival.

Therefore, to offer the optimal care to ourpatients, each patient with a thoracic aorticlesion should be assessed for suitability forendovascular repair. If there is insufficient expe-rience locally, patients should be referred toother centres with recognised expertise in tho-racic aortic endografting for an opinion regard-ing suitability for endovascular treatment. In2009, it is suboptimal management to regardthe majority of patients with thoracic aneurysmsor complicated dissection as being unsuitablefor any treatment, because they are not fit toundergo open surgery.

Fig.1: Aortic lesions that can be treated with tho-racic endografts:

Fig.1a: Aneurysm of the aortic arch.

Fig.1b: Thoracoabdominal aneurysm.

Fig.1c: Acute dissection with malperfusion (left renal artery and SMA).

Fig.1d: Aneurysmal chronic dissection.

Special Edition / CIRSE 2009 - Lisbon

6 Advertisement Sunday, September 20, 2009

Q: Brian, Aorfix™ and Lombard have come along way in the last year. Can you give us anupdate?

Brian Howlett: We have made significantprogress focusing our resources on buildingthe long-term success of Aorfix™. It is now theonly product approved in Europe for the treat-ment of AAAs with peri-renal neck angulationsfrom 0–90 degrees*. We are also making solidprogress towards completing our trials and fil-ing for approvals in the important US market.Our unique label claim extension will enable usto increase sales in our target markets andgreatly assist us as we come closer to realisingthe full potential of Aorfix™ in the global AAAmarket, which is forecast to be worth over $1 billion by the end of 20101 .

On the funding side during 2008 and at thebeginning of this year, we raised additionalfunds of £14.4 million net of expenses whichhas enabled the Company to advance its corecommercial objectives.

Aorfix™ High AngIe Neck Approval and Progress: an interview with Lombard Medical CEO, Brian Howlett on 6 August 2009

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Q: What other studies are ongoing?

Brian Howlett: Data from this study (ARBITER2) complements that from Lombard Medical’sRetrospective Aorfix™ DatA Retrieval (RADAR)open, voluntary registry. This has been pre-sented at major medical conferences duringthe spring and summer and an update will begiven at CIRSE this year. The results are derivedfrom a wide spectrum of over 600 patientsfrom 16 countries. In those patients with 12month follow-up, it is clear that Aorfix™ has theability to treat successfully both standard andseverely-angled AAAs with equally good resultsas can be seen in these scans:

The Company’s Principal Investigator, Dr MarkFillinger, Dartmouth Hitchcock-Medical Centre,Lebanon, USA, one of the US’s most eminentphysicians in the field of endovascular aorticrepair (“EVAR”), stated that: “The Aorfix™ stentgraft has treated the most challenging anato-my ever attempted in a US clinical trial and hasproduced similar results to approved devicesused in straightforward cases.”

Q: What is the company’s growth lookinglike?

Brian Howlett: Sales of Aorfix™ are growingrapidly in our target markets. Over 18 monthssince full commercial launch, Aorfix™ hasalready gained 6% market share in the UK, inearly 2009 an estimated 12% in the CzechRepublic, 5% in Greece and 5% in Poland.Interestingly the RADAR registry data showsthat the majority of Aorfix™ implants (>85%)are in patients with normal vascular anatomyindicating that clinicians are not just usingAorfix™ in a niche segment of difficult to treatpatients, but are primarily recognising its supe-rior clinical performance and using the productin preference to longer established stent grafts.The number of Aorfix™ implants worldwide isnow approaching 1000, with good clinical out-comes in follow-up extending to five years.Sales of Aorfix™, outside of the US, have grownby 72% in the first half of the year.

Q: Looking ahead, what new products are inthe pipeline?

Brian Howlett: The EndoRefix™ endostaplingdevice and Thoracic Aorfix™ products are valu-able assets which could help drive the futurevalue of the Company.

In the case of EndoRefix™, the Company is col-lecting data from the 58 patients that wereenrolled in our study. Once available this datawill determine our future development andcommercial strategy for this device.

The thoracic version of Aorfix™ also continuesto be a valuable asset because of the limita-tions of the devices currently available com-mercially. The Company is planning the furtherdevelopment of this device.

Mike Karim: Thanks for the chance to discussLombard and Aorfix™; its sounds like thereis great progress.

Brian Howlett: Thanks Mike.

Q: Tell me more about the unique label claimthat Lombard has achieved and how you gotit when others have been limited to muchlower angulations and a smaller range ofpatients?

Brian Howlett: Our 0–90 degree indication*that we gained in June 2009 extends the use ofendovascular treatment to patients with chal-lenging anatomy who are often at risk in opensurgical procedures due to their age or co-mor-bidities. Furthermore, it demonstrates to clini-cians the unrivalled versatility of Aorfix™ intreating a broad spectrum of patients andachieving good clinical outcomes, regardless ofthe tortuosity of the vascular anatomy. Theapproval follows submission of clinical datafrom a study to assess Aorfix™ in the treatmentof AAAs with high-angled infra renal neckangulations of between 60 and 90 degrees.

For patients in the study who had 30-day and 6month follow-ups, there were no reports ofdevice rupture, migration, stent fracture, loss ofpatency, vessel perforation, significant obstruc-tion or conversion to open repair. Furthermore,all patients reviewed at six months were foundto have a stable or shrinking aneurysm sac,indicating that the aneurysm was under con-trol. The study reported that Aorfix™ was safeand effective in treating this group of challeng-ing patients with difficult vascular morphology.

Tortuous Iliac Arteries3

High Angle Neck Aneurysm2

*Refer to current IFU for indications of use.MLIT/002/AUG2009 Issue 1

For those who would like to know moreabout our progress and registry results withAorfix™ we have a breakfast time sympo-sium on MONDAY 21 SEPTEMBER AT ROOM 3B, 08h00 – 08h20.

The results also compare favourably with othercommercially available stent grafts for whichthe neck angle is restricted to below 60degrees.

Clinical adoption of Aorfix™ has also been sup-ported by a number of positive clinical presen-tations by leading vascular surgeons in peer-reviewed medical publications. Our team atCIRSE will have these available for review.In addition the pivotal USA study PYTHAGORAScontinues to make progress. The Company hascompleted full enrolment into the open surgi-cal control group of 75 patients and has suffi-cient patients 46, in the low-angle (below 60degrees of aneurysm neck angulation)endovascular arm of the study for 12 monthfollow-up.

Recruitment into the high-angle group current-ly stands at 100 patients out of a total of 120required to start the 12 month follow-up nec-essary for clinical submission to the FDA. Thismilestone is most likely to be met early in Q4,allowing for the clinical submission to be madeto the FDA in Q4 2010 and an approval to bereceived in Q1 2011.

1 Medtech Ventures Report 2008Courtesy of Mr A. D. McLain, Consultant

2 Vascular Surgeon, Royal Gwent Hospital, UK.Courtesy of Mr D. Morrow, Consultant Vascular

3 Surgeon, Norfolk & Norwich Hospital, UK.

C RSECardiovascular and Interventional Radiological Society of Europe

7Lung Tumour RFAIRnewscongress

Radiofrequency ablation (RFA) has achievedimpressive results in the treatment of unre-sectable primary and metastatic liver cancer.Today RFA of primary and metastatic lungtumours is increasingly used and seems to pro-vide equally impressive results.

Local efficacyRates of 70 - 90% of complete ablation arereported after RFA of small size lung tumours.The rate of complete ablation at 2 years fortumours less than 2 cm is 80 to 90% in mostreports. While several studies report a statisti-cally significant lower success rate of ablationwith tumours more than 2 to 3 cm in diameter,the overall rate of incomplete local treatment isapproximately equivalent to incomplete surgi-cal resection (12% as reported by Pastorino etal.). However, head to head comparisonbetween surgery and RFA series is impossible,as patient selection criteria differ betweenstudies.

The rate of complete ablation is highly depend-ent on the volume of ablation relative to thetumour volume and, consequently, on ablationmargins. Indeed, in our experience when theratio between the area of post-RFA groundglass opacity and the tumour area before treat-ment was at least 4, the rate of complete abla-tion was 96% -- significantly higher (p=0.02)than when this ratio was below 4, averaging81% complete ablation. Gillams et al. reportthat in 85% of incompletely ablated tumoursthere was no ground glass opacity margin onpost RFA CT. The ROC analysis constructed fromrecurrence according to ground glass opacityminimal width after ablation confirmed theusefulness of the ablation zone as a predictorof recurrence, with an estimated cut-off of4.5mm for a specificity of 100%, i.e. no localrecurrence. Hiraki et al. reported an 83% suc-cess rate of ablation at one year when the ratioof ablation volume to tumour volume was 3 orhigher, while the success rate was 61% whenthis ratio was lower than 3. These results fromthree different centres clearly emphasise thatthere is a need for over-sizing ablation zonewhen compared to the tumour. Moreoverbecause RFA tools provide volume of ablationwith the shortest diameter being around 4 to 5cm, selection of tumour below 3 cm will pro-vide better complete ablation rate.

Contact with a large vessel (>3 mm) has beenreported by Hiraki et al. and Gillams et al. as anegative predictive factor of complete tumourablation in lung tumours, in the same manner ithas been reported in liver tumours. The so-called heat sink effect which is convection cool-ing by the vessel of the ablated zone is probablyresponsible for this increased failure rate. Wehave performed technically and clinically suc-cessful, but mildly tolerated balloon occlusion ofthe pulmonary artery branch during lung RFA.As reported in lung animal study and in clinicalstudies in the liver, PBO allows an increase in thevolume of ablation and renders a more spheri-cal zone of ablation. The use of new energy suchas microwave, which has a better thermal profileby working at higher temperature and is conse-quently less subject to convection cooling,could be a valid answer to these difficulties inablation for tumour close to large vessels,although this theoretical superiority has notbeen demonstrated in clinical practice.

Survival There is no comparative study of RFA and sur-gery either for small size (stage I) NSCLC orlung metastases. Even if early reports of sur-vival after RFA seem close to rates after surgery,the data is preliminary. Ideally randomised con-trol trials are needed.

In 75 primary NSCLC (75% stage IA and 25%stage IB) Dupuy et al. demonstrated mediansurvival of 29 months (IC95% : 20-30 months)with 30 months for stage IA and 25 months forstage IB. Overall survival was 78%, 36%, and27% at 1, 3, and 5 years. Better survival wasreported for tumours 3cm or smaller with a sur-vival rate close to 50% at 5 years.

Grieco et al. combined radiation therapy andRFA in 41 patients with NSCLC (Stage IA : 21;Stage IB: 17, Stage IIB: 3). The 27 patients withthe largest tumours received external beamradiation (66Gy) while 27 and the 14 patientswith tumours less than 3cm receivedbrachytherapy through the puncture tract usedfor RFA. Combination treatment seems toimprove results in NSCLC with 57% survival at 3years. The median survival was 34.6 ± 7 monthsfor tumours larger than 3 cm and 44.4 ± 5.4months for tumours 3 cm or smaller.

Very similar overall survival has been reportedby 4 different teams (de Baere, Simon,Yamajado, Yan) in colorectal cancer lung metas-tases with an overall survival of 64 to 78% at 2years.

ImagingCT is currently the best imaging guidancemodality for lung RFA. Real time CT with footpedal control renders needle placement fasterthan other tecnologies and the proceduremore comfortable for the operator. In our prac-tice, multiplanar reconstruction is mandatoryto assess adequate needle positioning; imagingof the differences in density makes it easy todifferentiate clearly between normal lung tis-sue, tumour and needle tines.

CT images immediately following RFA show thelung tumour surrounded by ground glass opac-ity which enlarges the diameter of the hyperat-tenuating tumour to a maximum size seen 24and 48 hours post-treatment. Then an ablationvolume which does not increase in size on sub-sequent imaging is considered complete abla-tion. This method of evaluation has some draw-backs; specifically, delayed discovery of incom-plete treatment which occurred between 4 and12 months (mean±SD = 7.66 ±2.77) in ourexperience.

In order to avoid late discovery of incompleteablation, PET-CT appears promising to provideearly evaluation of treatment response.Sensitivity and specificity of PET has beenreported superior to CT in early detection ofincomplete ablation, but numerous pitfallssuch as G6PD uptake in mediastinal lymphn-odes or at the puncture site have occurred.Okuma et al. demonstrated in a pre-clinicalstudy that timing of PET after ablation is a keyfactor, as G6PD uptake is highly increased 1 to3 weeks after ablation with an SUV ratio of 5and higher between RF ablation zone to mus-cle. Consequently it is wise to avoid PET imag-ing between 1 and 4 weeks before ablation inorder not to misinterpret a post-RFA inflamma-tory reaction for active tumour.

ToleranceTolerance of the technique is reported to beexcellent, with no changes in post-ablation res-piratory test as revaluated prospectively at onemonth by de Baere, et al., and confirmed at 12months by Lencionni et al. Consequently wewere able to treat patients with FEV1 as low as0.8 liters/second without clinical modificationof the respiratory function in the mid and longterm. Obviously, some compromised patientswill have temporary worsening of respiratoryfunction with the need of oxygen therapy from1 day to 3 weeks. In our experience, no patientsrequired long term or permanent oxygen ther-

Lung tumour radiofrequency ablation:Where do we stand?

Thierry de BaèreDepartment of Interventional Radiology Institut de Cancérologie Gustave Roussy Villejuif, France

Lung RF AblationSpecial SessionSunday, September 20, 08:30-09:30Auditorium 2

Don't miss it !

References:1. de Baere T, Palussiere J, Auperin A, et al. Mid-term local efficacy

and survival after radiofrequency ablation of lung tumours witha minimum follow-up of 1 year : Prospective evaluation.Radiology 2006; 240: 587-596

2. Fernando HC. Radiofrequency ablation to treat non-small cell lungcancer and pulmonary metastases. Ann Thorac Surg 2008; 85: S780-4

3. Gillams AR, Lees WR. Radiofrequency ablation of lung metas-tases: factors influencing success. Eur Radiol 2008; 18: 672-7

4. Grieco CA, Simon CJ, Mayo-Smith WW, et al. Percutaneous image-guided thermal ablation and radiation therapy: outcomes of com-bined treatment for 41 patients with inoperable stage I/II non-small-cell lung cancer. J Vasc Interv Radiol 2006;17:1117-1124

5. Hiraki T, Sakurai J, Tsuda T, et al. Risk factors for local progres-sion after percutaneous radiofrequency ablation of lungtumours: evaluation based on a preliminary review of 342tumours. Cancer 2006;107:2873-2880

6. Lencioni R, Crocetti L, Cioni R, et al. Response to radiofrequency abla-tion of pulmonary tumours: a prospective, intention-to-treat, multi-centre clinical trial (the RAPTURE study). Lancet Oncol 2008; 9: 621-8

7. Miao Y, Ni Y, Bosmans H, et al. Radiofrequency ablation for eradica-tion of pulmonary tumour in rabbits. J Surg Res 2001;99:265-271.

8. Nguyen CL, Scott WJ, Young NA, et al. Radiofrequency ablationof primary lung cancer: results from an ablate and resect pilotstudy. Chest 2005;128:3507-3511

9. Okuma T, Matsuoka T, Okamura T, et al. 18F-FDG small-animalPET for monitoring the therapeutic effect of CT-guidedradiofrequency ablation on implanted VX2 lung tumours in rab-bits. J Nucl Med 2006;47:1351-1358

10. Pennathur A, Luketich JD, Abbas G, et al. Radiofrequency abla-tion for the treatment of stage I non-small cell lung cancer inhigh-risk patients. J Thorac Cardiovasc Surg 2007; 134: 857-64

11. Simon CJ, Dupuy DE, Dipetrillo TA, et al. PulmonaryRadiofrequency Ablation: Long-term Safety and Efficacy in 153Patients. Radiology 2007; 243: 268-75

12. Vaughn C, Mychaskiw G, 2nd, Sewell P, et al. Massive hemor-rhage during radiofrequency ablation of a pulmonary neo-plasm. Anesth Analg 2002;94:1149-1151

13. Yamakado K, Takaki H, Takao M, et al. Massive Hemoptysis fromPulmonary Artery Pseudoaneurysm Caused by LungRadiofrequency Ablation: Successful Treatment by CoilEmbolization. Cardiovasc Intervent Radiol 2009

14. Yan TD, King J, Sjarif A, et al. Percutaneous radiofrequency ablationof pulmonary metastases from colorectal carcinoma: prognosticdeterminants for survival. Ann Surg Oncol 2006;13:1529-1537

apy as a result of RFA. Consequently, it is diffi-cult today to place a clear lower threshold ofrespiratory function for lung RFA. A major ben-efit of lung RFA to treatment of NSCLC is thatthe excellent tolerance of the treatment allowscurative treatment in non-surgical early NSCLC.Moreover, this excellent tolerance allows safetreatment of single lung patients as reported inthe oncologic intervention session 1207(Sunday 20th September, 16:15-17:15,Auditorium 4).

ConclusionRFA is a promising treatment, with high successrates of complete ablation in small primary andmetastatic lung tumours. It is already adoptedas a potentially curative treatment in non-surgi-cal candidates. RFA can be compared withsophisticated external beam radiation, such astomotherapy and gamaknife for primary NSCLC.RFA warrant evaluation versus surgery both inmetastases and primary NSCLC. However, a ran-domised trial would be difficult to conduct. Acombination of RFA with other anti-cancertreatment (radiation therapy, chemotherapy,etc.) should be evaluated further.

April 21 -24, 2010Florence, Italy

www.ecio2010.org

Second European Conference on Interventional Oncology

ECIO 2010Mark your

Calendar !

C RSECardiovascular and Interventional Radiological Society of Europe

9CIRSE meets BrazilIRnewscongress

At the end of the 80ies there were still very fewinterventionists in Brazil. Trying to disseminateand improve the new techniques, they createdan informal meeting for case discussions. Themeeting rapidly grew in size and became a reg-ular feature in Brazil’s radiological year. One ofthe meeting’s founders, Dr. Renan Uflackerdubbed it “Clube dos Angiografistas” or“Angiografer’s Club”. The Brazilian Society ofInterventional Radiology and EndovascularSurgery – SoBRICE – was founded at the 1997Clube dos Angiografistas. Since then SoBRICEhas been carrying out its activities in coopera-tion with the Brazilian College of Radiology(CBR), representing interventionist and angio-radiologists on a national level.

With the growth of the specialty in our countryand the consolidation of our society, SoBRICEstarted to do its first steps; an annual SoBRICEmeeting was created. Always aiming for a highscientific level, it soon became one of the mostimportant IR events in Latin America. Despitethe SoBRICE meeting the Clube dosAngiografistas has continued to take placeuntil today for the sake of tradition.

Interventional Radiology quickly grew in Brazil;starting out as an association of 10 to 15 activeparticipants it became a respectable nationalsociety within only a few years’ time, the annualmeeting adding hundreds of interested physi-cians. In 2001 the third annual SoBRICE meet-ing took place together with the BrazilianCongress of Radiology and in 2003 it was co-organized with the third SIDI Congress (LatinAmerican Society of Interventionism). Thanksto its invited speakers, directors and collabora-tors, but most of all thanks to the active mem-bers of the society the SoBRICE meeting keptdeveloping and in 2005 it was officially namedthe annual SoBRICE Congress.

SoBRICE’s 2008 congress took place at the won-derful beach town of Costa do Sauípe in Bahia,Northeastern Brazil. Again, we had the pleasureof organizing the meeting in cooperation withthe Latin American Society of Interventionism(SIDI) as well as the Brazilian Therapeutic andDiagnostic Neuroradiologic Society (SBNRDT).As there are so many meetings all over theworld, companies and physicians are quitehappy with the association of neurological andperipheral interventional societies. A highlightof this event was the participation of twentyforeign professors, including CIRSE members

Dierk Vorwerk, Anna-Maria Belli, Jean PierrePelage and Tobias Jakobs. This year’s facultyalso comprised eleven professors from theUnited States including our society’s foundingfather Dr. Renan Uflacker. More than 600 partic-ipants made SoBRICE 2008 the biggest annualcongress of Interventional Radiology in SouthAmerica.

During the mornings and afternoons the ses-sions took place in parallel in two rooms.Additionally there were 12 courses and 12round table discussions offering formal lessonsand informal interactive discussions on specificissues. 90 selected scientific posters wereshowed, two of which were awarded.

SoBRICE 2008 comprised a comprehensivetechnical exhibition supported by 19 compa-nies with a special participation of ev3. We arevery grateful for the participation and supportof almost all international IR companies. Themeeting provided wonderful moments for theparticipants who enjoyed a vast and high quali-ty programme.

Costa do Sauípe with its beautiful landscape,sunny beaches and numerous parties was theperfect backdrop for the scientific meeting,livening it up with Latin music and tropicaldrinks. In the official dinner Wilfrido Castañeda-Zuñiga received a well-deserved distinctionfrom our society. With the start of the New Yearwe are already organizing the 2009 congresswhich will be held in São Paulo.

Brazil is a country of continental dimensions,being the fifth biggest in the world regardingpopulation and size. The Brazilian marketmakes up more than 50% of the consumptionof specific materials in South America.Nevertheless the health system presents manydifficulties. Up until five years ago IR proce-dures were almost only offered by privatehealthcare clinics. Thanks to changes in health-care legislation the government was finallyobliged to include them in the public system,causing an exponential growth of the specialty.

In the last five years many new groupsappeared working with InterventionalRadiology and the number of physicians look-ing for a residence or fellowship in the areaincreased substantially, exceeding the capacityof the established training centres. Currentlythere are about three hundred interventionists

Interventional Radiology in BrazilFrancisco Cesar CarnevaleSoBRICE President

Gustavo AndradeSoBRICE Board of Directors

adequately certified for our population of morethan 180 million inhabitants. Unfortunately thehospitals offering IR procedures are still nothomogeneously distributed, making it almostimpossible to gain access to the procedures insome regions. Therefore some IR procedures areoffered by colleagues from other specialties.This reality is one of our greatest challenges.

The skill level in Brazil is quite good, some ofour colleagues being internationally renownexperts in their fields. This of course creates afavourable environment for trials.Unfortunately academic research is barely stim-ulated in Brazil. Nevertheless these conditionsare slowly changing and we are starting to seeBrazilian papers in international scientific jour-nals. Three books dealing exclusively withInterventional Radiology and EndovascularSurgery have been published in Brazil, one ofwhich will be translated into English shortly.

SoBRICE is working to develop diagnostic andtherapeutical procedure guidelines that willprovide better results and a more homoge-neous reality in our country, also helping tocontrol the work of professionals, services andhealthcare companies. Credential training cen-tres will assist in the training and further edu-cation of current and future interventionists. Itis in this field that SoBRICE is hoping to cooper-ate strongly with CIRSE in the future. In thiscontext we would like to thank CIRSE for itsgreat work in this field.

Being almost 12 years old now SoBRICE contin-ues to grow. It has been headed by five presi-dents who all made their particular contribu-tions. The new Executive Committee recentlyelected for 2009/2010 is planning many excit-ing projects. The new challenge is to let thesociety mature and stimulate its members toactively contribute to the development of ourspecialty. In addition to The Angiographers’Club and the Annual SoBRICE Congress, region-al meetings have been created to disseminateour specialty in regions far from the majorcities.

We have many plans for the future of our socie-ty. Most importantly we will continue to imple-ment quality programs at our meetings andoffer continuous updates and advantages toour members. Tight cooperation with biggerand more mature societies such as CIRSE willhopefully greatly help in these endeavours.

CIRSE meets BrazilSunday, September 20, 14:15-16:00Auditorium 1

Don't miss it !

CardioVascular and Interventional Radiology

RCVT h e o f f i c i a l j o u r n a l o f t h e C a r d i o v a s c u l a r a n d I n t e r v e n t i o n a l R a d i o l o g i c a l S o c i e t y o f E u r o p e

Submit your manuscript at manuscriptcentral.com/cvr

New Impact Factor:

1.721

Special Edition / CIRSE 2009 - Lisbon

10 Advertisement Sunday, September 20, 2009

Zilver PTX Stent from Cook Medical Gains CE MarkBreakthrough Drug-Eluting Stent to Treat Peripheral Artery DiseaseNow Available in Europe

Advertorial

Also, specific patient groups that are often veryhard to treat, such as diabetics and patientswith in-stent restenosis (those treated previ-ously with a noncoated stent), were shown inthe trial to benefit from the Zilver PTX. As thetrial data indicate, the superior results achievedin the first year have been largely maintainedthroughout 24 months, an important clinicalmilestone. In comparisons with other trialspublished, the Zilver PTX stent showed areduction in re-intervention of between 50 percent and 75 per cent, an important patientbenefit.

“The awarding of the CE Mark is set to herald arevolution in the treatment of peripheral arterialdisease,” comments Dr. Michael Dake. “Thisglobal study proves that the Zilver PTX has theintegrity, safety, and durability needed to success-fully address many of the well-known limitationsof current treatments for the management ofPAD.”

Rob Lyles, global leader and vice president ofCook Medical's Peripheral Intervention divisionstates, “We've specifically designed the Zilver PTXto be safer and more effective for PAD patients byengineering this device for the unique demandsof treating this disease in the SFA. It’s polymerfree, it’s fracture resistant, and through the largesttrial of its nature in history, it’s been clinicallyproven to be significantly more effective in treat-ing peripheral arterial disease in the SFA thanother treatment modalities."

"Our unique ability to adhere the drug to the stentwithout using a polymer is a major clinicaladvantage. It eliminates the risk some patientsmay face due to reactions and other potentiallypoor outcomes that are associated with polymercoatings used on current generations of drug-eluting stents. It's a truly exciting time for CookMedical and our partners, as well as for physi-cians and patients alike. With the Europeanlaunch of this first-of-its-kind 21st century medicaltechnology, we are truly at the vanguard of a rev-olution in peripheral intervention."

PAD is one of the fastest-growing and mostpervasive diseases of our time, and it is esti-mated to affect 27 million individuals in Europeand North America1,2,3. Yet, approximately onlya quarter of these people have any symptomsat all. The ‘silent’ nature of this condition canresult in a number of patients being diagnosedonly when their condition has progressed tothe severe stage. In many countries, untreatedPAD is the leading cause of leg amputation,and previous treatments such as bypass sur-gery and the use of angioplasty are much moreinvasive and/or only have shown only limitedlong-term success rates.

In a breakthrough development offering a trulymodern, highly effective medical treatment forperipheral artery disease (PAD), physiciansacross Europe have completed patient implantsof the first CE Mark approved drug-elutingstent designed specifically to treat severeblockages in the challenging and largest arteryin the leg.

Approval of the polymer-free Zilver® PTX®Drug-Eluting Peripheral Stent from CookMedical, a world leader in minimally invasivediagnostic and interventional devices, repre-sents a global landmark in effective peripheralintervention for treating PAD, a chronic diseaseaffecting tens of millions of patients worldwidethat is a leading cause of leg amputation andshortened lifespans.

Cook’s Zilver PTX is specifically designed andapproved to treat PAD affecting the main bloodvessel in the thigh, the superficial femoralartery (SFA). It is a self-expanding stent madeof nitinol, a space-age ‘shape memory’ metalthat offers unique mechanical advantages for astent in the SFA.

By eliminating the need for a polymer or plasti-cising agent to hold the drug to the stent body,Cook has created a medical breakthrough thatsolves two key problems. First, it allows target-ed delivery of a drug (paclitaxel) proven toreduce the renarrowing (restenosis) of arteriesopened using balloon angioplasty. Second, byeliminating the need for a polymer, which wasleft behind on the body of earlier drug-elutingstents after the drug dissolved into the sur-rounding tissues, Zilver PTX avoids the poten-tial patient risks posed by leaving a permanentforeign, plastic substance in the body. In addi-tion, the Zilver stent was proven during its clin-ical trial to be the most durable peripheralstent available, suggesting even greater patientsafety, according to the clinical trial data.

The CE Mark follows the world's largest-everclinical trial for a peripheral stent, led by Dr.Michael Dake, professor in the Department ofCardiothoracic Surgery at Stanford UniversityMedical School and medical director of theCath/Angio Laboratories at Stanford UniversityMedical Center, Palo Alto, California. The datacollected in the Zilver PTX registry involved 791patients from Europe, Russia, Canada, andKorea and demonstrated highly positiveresults. Only 8 per cent of patients with denovo (new) lesions needed a reintervention toreopen the artery in the first 12 months – a ratesignificantly surpassing existing treatments forPAD in the SFA, such as balloon angioplastyand bare metal (non-drug-eluting) stents.

Media ContactsAnna Gueldenhaupt / Katy Askew / Blaise Hammond

Racepoint Group UK+44 (0)20 8752 3215 / 3207 / 3203 anna.gueldenhaupt@racepointgroup.com /katy.askew@racepointgroup.com / blaise.hammond@racepointgroup.com

1 Belch JJ, Topol EJ, Agnelli G, et al. Critical Issuesin peripheral arterial disease detection andmanagement: a call to action. Arch Intern Med.2003;163(8):884–892.

2 Golomb BA, Dang TT, Criqui MH, et al.Peripheral arterial disease: morbidity and mor-tality implications. Circulation.2006;114(7):688–699.

3 Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA2005 guidelines for the management ofpatients with peripheral arterial disease (lowerextremity, renal, mesenteric, and abdominalaortic). J Am Coll Cardiol.2006;47(6):1239–1312.

ABOUT COOK MEDICAL

Cook Medical was one of the first companiesto help popularise interventional medicine,pioneering many of the devices now com-monly used worldwide to perform minimallyinvasive medical procedures. Today, the com-pany integrates device design, biopharma,gene and cell therapy, and biotech toenhance patient safety and improve clinicaloutcomes in the fields of aortic intervention;interventional cardiology; critical care medi-cine; gastroenterology; radiology, peripheralvascular, bone access and oncology; surgeryand soft-tissue repair; urology; and assistedreproductive technology, gynaecology andhigh-risk obstetrics. Cook is a past winner ofthe prestigious Medical Device Manufacturerof the Year Award from Medical Device &Diagnostic Industry magazine.

For more information, visitwww.cookmedical.com.

Following more than 1,200 patients treatedworldwide during its clinical evaluation and CEMark approval on 24 July 2009, the first com-mercial implantations of the Zilver PTX stentwere conducted yesterday in a coordinatedeffort by physicians in the United Kingdom,Germany, France, Holland, Belgium, Sweden,Switzerland and Spain. In the United States, theZilver PTX drug-eluting stent is an investiga-tional device not available for sale.

In the UK Dr. Nick Chalmers from theManchester Royal Infirmary participated in thefirst commercial use.

Cook licenses the rights to use paclitaxel onperipheral stents and other noncoronary med-ical devices from Angiotech Pharmaceuticals,Inc., of Vancouver, British Columbia, Canada(www.angiotech.com, NASDAQ: ANPI, TSX:ANP).

“Cook is to be congratulated for succeeding wheremany others have failed in making drug-elutingstent technology a reality for patients with periph-eral vascular disease,” said Bill Hunter, Ph.D.,president and CEO of Angiotech. “The Zilver stentplatform has shown tremendous durability andperformance in clinical trials, and when combinedwith the proven benefits of paclitaxel in the pre-vention of restenosis, the Zilver PTX is poised tobecome the first choice for interventionalists in themanagement of this common medical condition.”

C RSECardiovascular and Interventional Radiological Society of Europe

11Biliary DrainageIRnewscongress

Biliary Drainage: How we do it and how we deal with arterial haemobilia

Technique (Fig.1) : Percutaneous transhepaticbiliary drainage (PTBD) consists in lodging acatheter inside the biliary duct proximal to theobstruction, which enables drainage of bile tothe exterior. Generally, it is an elective proce-dure for obstructions resulting from neoplasias,and in pre-surgery. Urgent procedures includeacute severe cholangitis and in cases of break-down of endoscopic biliary drainage. Patientpreparation needs to include coagulationassessment, prophylactic antibiotics, as well ascareful evaluation of the clinical history andavailable imaging tests.

In our opinion, the safest technique (and, assuch the standard in our centre) is that of dou-ble puncture. The first puncture is with a fineneedle (21-23G) to establish percutaneoustranshepatic cholangiography (PTC) which willserve to select and to guide the access to anideal bile duct in which to place the drainagecatheter.

Usually, the PTC is performed via a lateralaccess, the selected puncture point beingbetween the lines of the median and posterioraxilla, under fluroscopic control (avoiding theinterposition of the costophrenic sinus and thehepatic angle of the colon). Under certain cir-cumstances there may be the need to accessthe left hepatic lobe (LHL) from an anteriorroute (anterior abdominal wall, below the ribcage or the sternum).

After achieving PTC, and to perform the PTBDcorrectly, we need to access a peripheral bileduct at a minimum distance from the skinpuncture and with a favourable angle (>90º).Once the duct is selected and to prepare forthe second puncture, we place the intra-opera-tive fluoroscopy (C-arm) in the lateral positionwith the intensifier alongside and we mark thepoint of puncture on the skin. The needle canbe progressed in the lateral position with thehelp of a covering to avoid radiating the hand.The distance covered by the second needleinto the liver should not exceed 3-5 cm.

Having crossed the selected bile duct we placethe C-arm in the A-P position and, if needed,we withdraw the fine needle until its pointremains within the interior of the lumen of theduct. We then pass the 0.018” guidewire as dis-tally as possible up to the principal bile duct(PBD). Subsequently, we introduce the single-puncture system onto the 0.018” guidewire, upto the entrance of the bile duct and with onlyits plastic components proceeding beyond thispoint.

A preformed catheter and a hydrophilicguidewire may be needed to reach the bileduct where the drainage is to be located. Toproceed, we exchange the hydrophilicguidewire for a rigid guide and we slide thedrainage catheter over it (while keeping theretention systems at the puncture at all times).Once the drainage catheter is correctly placed,we aspirate the greatest quantity of bile possi-ble and withdraw the needle from the firstpuncture.

The drainage catheter needs to have an appro-priate sized bore (generally we use 8.5F) andthe longest possible distance from the interiorof the bile duct to ensure greater stability.

DiscussionPTBD is the quickest, safest, most efficient andeconomical method for the drainage of bilethat is frequently infected in patients with bil-iary route obstruction. It can be a one-off pro-cedure (for example, acute cholangitis withpoor response to conservative medical treat-ment) or the first intervention enabling subse-quent interventional procedures in cases ofcholedocholthiasis or biliary-pancreatic neo-plasias.

Having PTBP available around the clock is ofspecial importance in cases of severe acutecholangitis with inadequate response to antibi-otic treatment. For these patients, PTBP may bethe only therapeutic option and, if the proce-dure is delayed, can be fatal.

Arterial Haemobilia: How to deal with it Technique (Fig.2): If there is a suspicion ofhaemobilia of arterial origin (intense sharp painthat may be accompanied by haemodynamicinstability, immediate outflow of any contrastmedium introduced into the biliary tract, pul-sating blood flow from skin puncture), theangiographic diagnosis needs to be performedas soon as possible so that the first therapeuticoption (i.e. embolisation) can be performed, ifpossible, at the same time as the diagnosticarteriography. The single branch involvementof the hepatic artery in the arteriographicassessment may be identified as: 1) pseudoa-neurysm; 2) segmental arterial stenosis (pseu-dospasm); 3) extravasation of contrast medium.These lesions are associated with hepatichaematomas and, frequently, with flow ofblood into the intestine (haematemesis/mele-nas).

Once the lesion has been identified, theembolisation is performed as selectively aspossible by accessing the lesioned vessel witha microcatheter. The most frequently usedmaterials for embolisation are the PVA micros-pheres and microcoils.

If a venous vascular lesion is suspected, thediagnostic procedure is different. The drainagecatheter is substituted by an 8 or 9F introducervia two guidewires (a safety guidewire of0.018” and a working guidewire of 0.035”). Weintroduce a catheter across the working guideand which, while being withdrawn, has con-trast medium injected; the intention being toassess the trajectory of the damage. Once iden-tified, the tract proximal to the site of lesion isembolised with microcoils (if the venous struc-ture is a portal branch we can introduce part ofa coil into its interior). The safety guidewire willbe changed and will serve for the placement ofa new bile drainage catheter.

DiscussionThe most stressful complications of PTBD arehaemorrhagias, the most severe being those ofarterial origin. If the techniques and access tothe biliary tract are appropriate, most haemor-rhagias will have their origin in the manipula-tion of the guidewires and catheters or inlesions in small veins and, as such, will be self-limiting and of low clinical significance.

The haemobilias caused by vascular lesions areof greater severity, especially those of arterialorigin which can put the life of the patient indanger. The probability of producing severehaemobilias by vascular lesion is related direct-ly to the biliary tract access. The more peripher-al the access, the lower the probability of pro-ducing a vascular lesion, which if produced willbe less severe.

Biliary access, as a function of risk of vascularlesion, can be classified as:

Right Hepatic Lobe• Ideal: Sub-segmented ducts. Considered

minimum risk• Acceptable: Segmented ducts• Dangerous: Central ducts (anterior or poste-

rior segments)• Prohibited: Common hepatic duct. It is not

justified to place a drainage catheter underany circumstances

Left Hepatic Lobe• Ideal: Peripheral segment III duct (anterior-

lateral)• Acceptable: Posterior-lateral segmented duct II• Dangerous: Left principal duct• Prohibited: Common hepatic duct

Biliary DrainageFoundation CourseSunday, September 20, 10:00-11:00Auditorium 1

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Carlos LanciegoInterventional Radiology Unit Complejo Hospitalario de ToledoToledo, Spain

Fig.2: Haemobilia of arterial origin: a) External bil-iary drainage (arrow), filling defects correspon-ding to haemobilia at the end of the procedure (circles); b) Cholangiography at 48h; c) Rapid andmassive outflow of contrast medium from the bil-iary tract on withdrawal of the drainage 0.035”guidewire (the start of the point is marked by thearrow); d) Substitution of the drainage by the vas-cular introducer, and injection of contrast medi-um through the hepatic tract (broad arrow), dark-ening arterial branches of the right hepatic duct(narrow arrows); e) Hepatic arteriography inwhich a pseudoaneurysm (circle) is identifiedadjacent to the access to the intra-hepatic biliarytract. Sub-hepatic haematoma (arrow); f )Selective catheterisation of the right hepaticartery and of the lesioned branch

Fig.1: Percutaneous transhepatic biliary drainage.a) Fine needle transhepatic cholangiography, A-Pprojection; b) Selection of access point for the 2ndpuncture; c) 2nd puncture performed in lateral pro-jection with fine needle (arrow); d) Position of theneedle point in the interior of the biliary canalicu-lus (arrow), A-P projection; e) Passage of the 0.018”guidewire ; f) Advance of the single-puncture sys-tem, retaining the metal component in the accesspoint of the biliary canaliculus (arrow).

References and suggested reading: 1. García García L, Lanciego C. Percutaneous treatment of biliary

stones. Sphincteroplasty and Occlusion balloon for the clear-ance of bile duct calculi. AJR 2004; 182;663-670

2. Mauro M, Murphy KP, Thomson KR, Venbrux AC, Zollikofer C.Image-Guided Interventions. Section 22: The Biliary tract Chap-134-138, pags 1425-1490. 2008, Ed. Saunders-Elsevier (ExpertRadiology collection)

3. Brountzos E, Ptochis N, Panagiotou I, et al. A Survival analysis ofpatients with malignant biliary strictures treated by percutae-nous metallic stenting. Cardiovasc Intervent Radiol2007;30(1):66-73

4. Burke D, Lewis CA, Cardella JF, et al. Quality improvementguidelines for percutaneous transhepatic cholangiography andbiliary drainage. JVIR 2003;14:s243-s246

5. Williams HJ, Bender CE, May GR. Benign postoperative biliarystrictures: dilation with fluoroscopic guidance. Radiology1987;163:629-634

6. Gibson RN, Adam A, Yeung E, et al. Percutaneous techniques inbenign hilar and intrahepatic strictures. JVIR 1988;3:125-130

7. Lee MJ, Mueller PR, Saini S, et al. Percutaneous dilatation ofbenign biliary strictures: single-session therapy with generalanesthesia. AJR 1991;157:1263-1266

8. Citron SJ, Martin LG. Benign biliary strictures: treatment withpercutaneous cholangioplasty. Radiology 1991;178:339-341

9. Muchart J, Perendreu J, Casas JD, Diaz Ruiz MJ. Balloon cathetersphincteroplasty and biliary stone expulsion into the duode-num in patients with an indewelling T-tube. Abdom Imaging1999;24:69-71

10. Gil S, De la Iglesia P, Verdú JF, España F, Arenas J, Irurzun J.Effectiveness and safety of balloon dilation of the papilla andthe use of an occlusion balloon for clearance of bile duct cal-culi. AJR 2000;174:1455-1460

11. Berkman WA, Bishop AF, Pallagallo GL, Cashman MD.Transhepatic balloon dilatation of the common bile duct andampulla of Vater for removal of calculi. Radiology 1988;167:453-455

12. García-Vila J, Redondo-Ibañez M, Díaz-Ramón C. Balloonsphincteroplasty and transpapillary elimination of bile ductstones: 10 years´ experience. AJR 2004;182:1451-1458

13. Park YS, Kim JH, Choi YW, Lee Th, Hwang CM, Cho YJ, et al.Percutaneous treatment of extrahepatic bile duct stones assist-ed by balloon sphincteroplasty and occlusion balloon. Korean JRadiol 2005;6(4):235-240

14. Lee KH, Lee DY, Kim KW. Biliary intervention for cholangiocarci-noma. Abdom Imaging 2004;29(5):581-589

15. Ho CS, Voss MD. Self-expandable metallic biliary stents withpermanent access. AJR 2005;184(2):410-414.

16. Chen JH, Sun CK, Liao CS, Chua CS. Self-expandable metallicstents for malignant biliary obstruction: efficacy on proximaland distal tumors. World J Gastroenterol 2006;12(1):119-122

17. García Sanchez MV, Lopez Vallejos P, Pérez de Luque D, et al.Bilio-pancreatic tumors: patient survival and quality of life alterpalliative treatment. Rev Esp Enf Dig 2004;96(5):305-314.

18. Silva MA, Tekin K, Aytekin F, et al. Surgery for hilar cholangiocar-cinoma: a 10-year experience of a tertiary referral centre in theUK. Eur J Surg Oncol 2005;31(5):533-539

19. Park H, Kim MH, Choi JS, et al. Covered versus uncoveredWallstent for malignant extrahepatic biliary obstruction: acohort comparative analysis. Clin Gastroenterol Hepatol2006;4(6):790-796

20. Yoon WJ, Lee JK, Lee KH, et al. A comparison of covered anduncovered Wallstent for the management of distal malignantbiliary obstruction. Gastrointest Endosc 2006;63(7):996-1000.

21. Isayama H, Kamatsu Y, Tsujino T, et al. A prospective randomisedstudy of “covered” versus “uncovered” diamond stents for themanagement of distal malignant biliary obstruction. Gut2004;53:729-734.

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C RSECardiovascular and Interventional Radiological Society of Europe

13Biliary MalignanciesIRnewscongress

Covered Metallic Stents for Palliation of Biliary Malignancies

Despite the gigantic achievements of theoncology oriented specialties in medicine, bil-iary and pancreatic malignancies are still notdetected early enough to be resectable.Surgical palliation is linked to high morbidityand mortality and therefore endoscopic or per-cutaneous metallic stent placement is likely tobe the best option, particularly when jaundiceoccurs. Metallic stent technology is an excitingresearch area of medicine. In the case of pallia-tion of malignant jaundice, covered metallicstents have been developed in the effort toprevent stent re-occlusion from tumouringrowth. The successful placement of a cov-ered stent depends on the appropriate stentand patient selection.

STENT SELECTION

1. Type of covering material

The main goal of the covering material is toprevent tumour ingrowth. Several materialshave been tested throughout the years andseveral theories have been developed.Initially covered stents were “home made”by fixing a coverage membrane on theavailable bare stents. In 1994 Saito et al.used biliary Gianturco-Rosch Z-stents cov-ered with a Gore-Tex membrane (1) andreported satisfactory medium- to long-termresults in a study of six patients.

In 1996 Thurnher at al. reported their expe-rience with the first type of coveredWallstent (2). The coverage was a 0.015mmthick polyurethane membrane that was alsoused by Rossi et al. in 1997 (3) andHausegger et al. in 1998 (4). Both reportedthat the 0.015mm polyurethane membranewas eroded by tumour and gastric juice.Similar results were also presented byKanasaki et al. in 2000. In this case nitinolStrecker stents were used with the samecoverage (5). A 0.035mm polyurethanemembrane was used in homemade coveredGianturco-Rosch Z-stents and spiral Z-stentsfrom Miyayama et al. in 1997 with betterresults (6).

Han et al. reported a 71% patency at 20weeks using a 0.030mm thick polyurethanemembrane in covered Niti-S stents (7).Using 0.040-0.050mm thick polyurethane-covered Wallstents Isayama et al. did notreport tumour ingrowth (8) and presentedeven improved results with a 0.050-0.060mm polyurethane membrane in cov-ered Diamond stents (9).

In 2002 Bezzi et al. (10) described the resultsof the use of a nitinol covered stent withePTFE/FEP coverage. The microporousmaterial was contrasting the tendency thatthe thicker membrane would be more effec-tive in preventing from tumour ingrowth. In2007 in the study of Hatzidakis et al. (11)ePTFE/FEP has shown to be effective in pre-venting from tumour ingrowth and mayactually be considered as the most suitablestent coverage material in the palliation ofmalignant jaundice.

2. Migration rate

Migration has always been a problem withcovered stents. In the study of Saito et al.(1994) with Gore-Tex covered Gianturco-Roesch Z-stents, stent migration wasobserved in two out of six patients (1), whileThurnher et al. reported migration in 20% ofthe cases (2). Fully covered Wallstents werealso prone to migrate, but newer versionswith uncovered portions have been devel-oped which were less likely to do so. Thepresence of anchoring fins in the Viabil stenthas limited migration cases only to those inwhich the endoprosthesis may slip beforegetting fully deployed.

3. Flexibility and radial force

Flexibility permits appropriate stent place-ment without kinking or fracture problems,whereas radial force permits better expan-sion and less sludge formation, both offer-ing longer stent patency. Covered stentshave been evolved together with uncoveredones regarding flexibility and radial force.The stainless-steel alloy covered Wallstenthas shown to be relatively flexible, but withlower radial force than the recently devel-oped covered nitinol stents. Nitinol coveredstents, like the uncovered ones, gain theirfinal diameter 24 hours after placement anddo not get shortened thereafter. It is there-fore suggested that the proximal and distalmargins should have a 2cm distance fromthe tumour’s proximal end in order to avoidtumour overgrowth.

PATIENT SELECTION

1. Anatomical considerations

Covered stents are not suitable for allpatients with malignant jaundice.Anatomical considerations include stricturelocation, location and patency of the intra-hepatic, cystic and pancreatic ducts. Usuallyonly Bismuth type I strictures are suitablefor covered stent placement (Fig. 1), where-as specific covered stents may be placed insome cases of type II. The covered portionshould not be advanced in the intrahepaticducts in order to avoid cholangitis.

The same principal should be followed forthe cystic duct, but less for the pancreaticduct, since pancreatitis may less frequentlyoccur and the location of the pancreaticduct is not a true limit in stent placement.For this purpose covered stents with sideholes have been developed. The holedregion does not prevent from tumouringrowth and it is also not extending proxi-mally enough to prevent from tumour over-growth as a bare stent would. Nevertheless,side holes permit placement in anatomicallycomplicated cases avoiding cholangitis orcholecystitis.

Biliary DrainageFoundation CourseSunday, September 20, 10:00-11:00Auditorium 1

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Miltiadis KrokidisFellow in Interventional RadiologyGuy’s and St Thomas’ Hospital, London, UK

Adam HatzidakisAssistant Professor of Interventional RadiologyMedical School of Heraklion, University of CreteGreece

References:1. Saito H, Sakurai Y, Takamura A, Horio K. Biliary endoprosthesis

using Gore Tex covered expandable metallic stents: preliminaryclinical evaluation. Nippon Igaku Hoshasen Gakkai Zasshi. 1994;54:180-2

2. Thurnher SA, Lammer J, Thurnher MM, et al. Covered self-expanding transhepatic biliary stents: clinical pilot study.Cardiovasc Intervent Radiol 1996; 19 :10-14

3. Rossi P, Bezzi M, Salvatori FM, et al. Clinical experience with cov-ered Wallstents for biliary malignancies: 23-month follow-up.Cardiovasc Intervent Radiol 1997; 20:441-447

4. Hausegger KA, Thurnher S, Bodendorfer G, et al. Treatment ofmalignant biliary obstruction with polyurethane coveredWallstents. AJR 1998; 170:403-408

5. Kanasaki S, Furukawa A, Kane T, et al Polyurethane- coverednitinol Strecker stents as primary palliative treatment of malig-nant biliary obstruction. Cardiovasc Intervent Radiol 2000;23:114-120

6. Miyayama S, Matsui O, Terayama T, et al. Covered Gianturcostents for malignant biliary obstruction: preliminary clinicalevaluation. J Vasc Interv Radiol 1997; 8: 641-648

7. Han YM, Jin GY, Lee S, et al. Flared Polyurethane-covered Selfexpandable Nitinol Stent for Malignant Biliary Obstruction. JVasc Interv Radiol 2003; 14: 1291-1301

8. Isayama H, Komatsu Y, Tsujino T, et al. Polyurethane-coveredmetal stent for management of distal malignant biliary obstruc-tion. Gastrointest Endosc 2002; 55: 366-370

9. Isayama H, Komatsu Y, Tsujino T, et al. A prospective random-ized study of “covered” versus “uncovered” diamond stents forthe management of distal malignant biliary obstruction. Gut2004; 53: 729-734

10. Bezzi M, Zolovkins A, Cantisani V, et al. New ePTFE/FEP-coveredstent in the palliative treatment of malignant biliary obstruc-tion. J Vasc Interv Radiol 2002; 13:581-589

11. Hatzidakis A, Krokidis M, Kalbakis K, et al. ePTFE/FEP-coveredmetallic stents for palliation of malignant biliary disease: cantumor ingrowth be prevented? Cardiovasc Intervent Radiol2007; 30 :950-958

12. Krokidis M, Fanelli F, Orgera G et al. Percutaneous Treatment ofMalignant Jaundice Due to Extrahepatic Cholangiocarcinoma:Covered Viabil Stent Versus Uncovered Wallstents. CardiovascIntervent Radiol. 2009 Jun 4. [Epub]

2. Tumour type and staging

In a recent randomised study conducted byour group it was shown that the Viabilstents may offer better clinical results interms of re-intervention and patency ratesthan bare Wallstents (12) (Fig. 2). The studywas performed only for cases of extrahepat-ic cholangiocarcinoma. This is the onlystudy in the literature offering a comparisonbetween covered and uncovered stents fora particular type of malignancy. In additiononly patients with a performance statushigher than three according to the EasternCooperative Oncology Group Scale wereincluded.

We believe that similar results may beobtained for cases of pancreatic tumours inpatients with expected survival above sixmonths, whereas we do not consider appro-priate covered stent placement in stricturesfrom lymphnodes or when patient survivalis estimated less than six months.

In summary, covered stents seem to offer avalid option for palliation of malignant jaun-dice. Careful stent and patient selection arenecessary in order to avoid complications andmantain the procedure cost effective.

Fig.1a: Percutaneous TranshepaticCholangiography shows dilatation of the biliarytree due to a Bismuth type I stricture. Note thatthe cystic duct is infiltrated.

Fig.1b: Drainage catheter followed by

Fig.1c: Placement of a 10X60mm Viabil coveredstent without side holes

Fig. 2: Kaplan- Meier analysis of patency in daysfor Viabil stents compared with Wallstents incases of extrahepatic cholangiocarcinoma(p=0.046).

14 Trauma Sunday, September 20, 2009

Special Edition / CIRSE 2009 - Lisbon

Trauma – The time is right for Interventional Radiology to shine

Interventional Radiology provides patients withtreatments that avoid some of the invasiveproblems associated with open surgery.However, it is not immune from complicationsand over the years techniques have beendeveloped to manage many of these problems.

A number of situations may arise which requiretreatment of the trauma inflicted by these pro-cedures, so-called iatrogenic trauma. Theseinclude bleeding from biopsy sites, pseudoa-neurysms associated with arterial access, arteri-al and venous disruption and reopening of vas-cular beds. The techniques developed are notonly applicable to treatment of complicationsof Interventional Radiology procedures, butalso extend to interventions performed at opensurgery (or other places within hospitals) andto trauma sustained in the community, such asroad accidents.

Whilst these techniques are very familiar toInterventional Radiologists and are indeedused regularly to maintain the high degree ofsafety associated with Interventional Radiologyprocedures, other clinicians are often unawareof the opportunities that exists to manageproblems generated both from within the hos-pital and from outside. In addition the adventof arterial closure devices, which providemechanical closure of the remote arterialaccess site used to deliver these treatments,means that minor degrees of clotting abnor-mality are of relatively little consequence. Thisis of great use when considering the manage-ment of patients who have undergone majortrauma, and may have disorders of clotting as aresult of the blood loss and replacement. Suchadvantages make IR approaches even moreuseful, as in these circumstances open surgeryis often contraindicated.

Endovascular approaches to treatment of trau-ma have been described in many circum-stances, including hepatic and splenic injuries(1-3), renal trauma (4-5), pelvic and limbinjuries (6) and many less common sites oftraumatic bleeding (7). IR’s have a duty topatients to make other clinical groups aware ofwhat can be offered and to ensure that the cir-cumstances (rotas) are such that these life sav-ing interventions can be offered when they areneeded (24 hours a day). This may require IR’sto work in groups, teams and networks and itcertainly will require that IR’s take a more directrole in the clinical management of patients andraise their profile within institutions.

At present many doctors treating patients whohave undergone trauma give little thought toconsidering IR treatments for their patients (8).The consequences for those patients may beprolonged bleeding, unnecessary transfusionof blood products and the cardiovascular con-sequences of major blood loss.

Whilst trauma can be conveniently consideredas either that resulting from medical proce-dures (iatrogenic) or from outside, the IR treat-ment options are usually based around

• embolisation• stent-grafts• stents

Embolisation for Trauma

Embolisation is the process whereby a bloodvessel is blocked, thereby interrupting the flowin that vessel, with the purpose of either stop-ping bleeding or reducing the blood flow to atumour. In the context of trauma, it is usuallythe former that is intended. Embolisation maybe achieved by the delivery of particles, liquids,or devices which are designed to block theblood flow. In the earliest descriptions patient’sown blood was removed, allowed to clot, andthis was then reintroduced via a catheterplaced as closely as possible to the bleedingsite. In some ways this was a most elegantmethod of embolisation, as the material usedwas not a foreign body, there was no risk of anallergic reaction and there was no risk of exter-nal infection. However, in the field of traumathe application was limited, as the clottedblood was of unpredictable dimensions andeffected a very temporary occlusion, as thepatient’s endogenous lytic agents caused it todissolve and allowed blood flow to re-establish.

Since then a variety of embolic agents havebeen developed which may be temporary orpermanent and are available in a variety ofsizes. In this way if an artery that is bleedingcan be identified, the segment of the vesselthat has a defect can be identified and theblood flow to it stopped. At the time of trau-matic bleeding the supply to the bleeding ves-sel may be a part of an end organ supply, inwhich case interrupting the in-flow to thatregion will effectively treat the bleeding (Fig. 1).

This may be the intention so long as the vascu-lar bed embolised is not critical to the patient’ssurvival. In such circumstances a non-perma-nent embolisation is ideal, giving the patienttime to heal the defect, and allow revasculari-sation at some time in the future. A non-per-manent agent such as gelfoam is well suited tosuch circumstances allowing for healing andrepair prior to the agent dissolving away (Fig.2).

One of the limitations of gelfoam is that it hasto be cut by hand prior to use and the sizes ofparticles are generally both relatively large andvariable. In addition its use with micro-catheters is significantly limited which meansthat it has to be delivered from relatively largearteries. This almost inevitably means that it isrelatively distant from the bleeding point. More

Trauma Foundation CourseSunday, September 20, 08:30-09:30Auditorium 1

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Trevor Cleveland Consultant Vascular RadiologistSheffield Vascular InstituteSheffield, UK

References:1. Place of arterial embolization in severe blunt hepatic trauma: a

multidisciplinary approach. Monnin V. Sengel C. Thony F. BricaultI. Voirin D. Letoublon C. Broux C. Ferretti G. Cardiovascular &Interventional Radiology. 31(5):875-82, 2008 Sep-Oct.

2. The impact of splenic artery embolization on the management ofsplenic trauma: an 8-year review. Ekeh AP. Izu B. Ryan M. McCarthyMC. American Journal of Surgery. 197(3):337-41, 2009 Mar.

3. Imaging and transcatheter arterial embolization for traumaticsplenic injuries: review of the literature. [Review] [73 refs]Raikhlin A. Baerlocher MO. Asch MR. Myers A. Canadian Journalof Surgery. 51(6):464-72, 2008 Dec.

4. Selective renal artery embolization following blunt renal trau-ma: case report and current treatment recommendations forrenal trauma. DeFade BP. Tierney JP. Stone PA. Truxillo RR. WestVirginia Medical Journal. 105(1):20-2, 2009 Jan-Feb.

5. Minimally invasive endovascular techniques to treat acute renalhemorrhage. Breyer BN. McAninch JW. Elliott SP. Master VA.Journal of Urology. 179(6):2248-52; discussion 2253, 2008 Jun.

6. Update on the roles of angiography and embolisation in pelvicfracture. [Review] [21 refs] Frevert S. Dahl B. Lonn L. Injury.39(11):1290-4, 2008 Nov.

7. Successful angiographic embolisation of bleeding into the chest wallafter chest drain insertion. Khalil MW. Cleveland TJ. Sarkar PK. Rao J.Interactive Cardiovascular & Thoracic Surgery. 8(1):166-7, 2009 Jan.

8. Damage Control Resuscitation for Patients with Major Trauma.Jansen J O. Thomas R. Loudon MA, Brooks A. BMJ, 338: 1436-1440

recently particles with a greater degree of sizereliability have become available, howeverthese tend to be more permanent, which mustbe taken into account when choosing theembolic agent. However, they are suitable foruse with micro-catheters, allowing for a muchmore sub-selective delivery of the agents.

One of the safety mechanisms developed bymany parts of the body is the collateral circula-tion which protects against the loss of anartery. This allows for blood to flow in areversed direction from an alternative arterialsource and therefore to maintain tissue perfu-sion. This is potentially problematic from theperspective of embolisation. If a traumaticevent occurs which causes an artery wall to lac-erate, blood can potentially reach this site fromthe normal antegrade approach. However, ifthis is occluded by embolisation, bleeding cancontinue via the collateral supply. Therefore, forembolisation to be effective both, the collateral(“back door”) supply and the antegrade (“frontdoor”) supply must be blocked.

It is usual for a bleeding point to beapproached along the line of the normal flow,therefore it is important that the deliverycatheter be passed such that it is possible toembolise (usually with coils) the collateral sup-ply (known as embolising the back door) first,the catheter can then be withdrawn to allowembolisation of the “front door” (Fig. 3). Shouldthe “front door” be closed first, it is usually verydifficult or impossible to achieve access to the“back door”. If this were to occur, then effectiveembolisation would not be achieved. Indeed itis always worth remembering that coil emboli-sation is often a very effective procedure. However, once an artery has been coiled, it willno longer be possible to access that artery dis-tal to the coils.

Stent Grafts

One of the problems of embolisation for trau-ma is that arteries and veins are deliberatelyoccluded, often in a permanent fashion. Thishas the potential to be harmful for a patient.The recent development of stent-grafts (cov-ered stents) has offered an alternative methodfor sealing a hole/laceration produced in anartery as a result of trauma. Covered stentswere originally developed to treat aneurysmaldisease. However, the fact that they are a metalframe upon which a covering is mounted orincorporated means that they are well suited tosealing arterial tears whilst maintaining an arte-rial lumen and therefore perfusion to the arteri-al bed distally. In general terms stent-grafts aremore bulky to deliver that their uncoveredequivalents and are less flexible. As a result itmay be difficult to place stent-grafts into thenecessary place to effect treatment, and this isparticularly so as arteries become smaller and

more difficult to access. Therefore stent-graftsare very well suited to treatment of larger ves-sels such as the aorta (Fig. 4), but may be lessapplicable to smaller arteries where access ismore difficult.

Uncovered Stents

Not all of the endovascular treatment for trau-ma centres on the cessation of bleeding. Insome circumstances trauma results in disrup-tion of the arterial wall and this in turn leads toan intimal tear, which causes the lumen to beoccluded. In some situations this results in endorgan ischemia which needs to be relieved. Inthese situations it is often possible to pass aguidewire in either an antegrade or retrogradeapproach to cross the occluded segment andjoin the two patent regions. Once this has beenachieved, the intimal disruption can be pushedback into position by the placement of an openmesh stent. In this way antegrade (normaldirection) blood flow can be re-established(Fig. 5).

Conclusions

As indicated above, Interventional Radiologyhas a great deal to offer in the field of trauma,both in the cessation of life-threatening bleed-ing and the re-establishment of tissue perfu-sion. There remain two very significant hurdlesto widespread use of these techniques in rou-tine trauma practice. Firstly is the appreciationby trauma surgeons and specialists that IR hasmuch to offer in this area of patient care. Thesecond hurdle is the availability (and willing-ness) of suitably trained individuals and teamsof IR’s to provide this facility. Unfortunately it isa fact of life that trauma occurs at unsocialhours and presents clinical teams with stressfuland difficult clinical scenarios. It is the responsi-bility of IR’s to make ourselves available,through sustainable and organised rotas, inorder to provide the trauma care that patientsneed and deserve.

C RSECardiovascular and Interventional Radiological Society of Europe

15TraumaIRnewscongress

Fig.1a: Active bleeding seen from a splenic arterybranch (arrow) following a road accident

Fig.1b: A microcatheter has been passed to thebleeding site

Fig.1c: A coil has been placed to stop the bleeding(arrow)

Fig.2a: Right hepatic artery angiogram in apatient who has sustained a liver laceration whichwas not controlled by a laparotomy. There isactive bleeding into the gall bladder (arrow 1) anda pseudoaneurysm deep in the liver (arrow 2).

Fig.2b: Following gelfoam embolisation of thehepatic artery, both bleeding sources have beenexcluded

Fig.4a: Aortogram of an 18 year old back seatpassenger in a road accident, showing a thoracicaortic transection

Fig.4b: Aortogram folowing placement of a stent-graft

Fig.5a: Left subclavian angiogram showing anocclusion of the subclavian artery (arrow) due toa traumatic dissection after a motor cycle injury.

Fig.5b: The occluded segment has been treatedwith a stent

Fig.3: A laceration of the superior gluteal artery asa result of a knife wound. Embolisation requiredclosure of both the “back door” (arrow 1) and the“front door” (arrow 2)

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societyCardiovascular and Interventional Radiological Society of Europe

CIRSE members are cordially invited to pick up a FREE CIRSE laptop sleeve and mouse padat the CIRSE booth on the first floor.

C RSE

Not yet a member? Don’t wait any longer! JOIN US at the CIRSE booth and become part of the ever growing CIRSE Family.

GOOD TO BE A MEMBER !

16 Advertisement Sunday, September 20, 2009

Special Edition / CIRSE 2009 - Lisbon

Innova 3D clinical benefits for vascular interventions

Advertorial

curved planar reconstructions of the RICA, it wasnot possible to see whether the lumen was par-tially or completely occluded by the dissection. A DSA acquisition was performed to evaluatethe patency of the RICA, the extent of the dis-section and the direction of the intracranialflow. Using a right femoral approach, a 4FBerenstein catheter (Angiodynamics,Queensbury, NY) was selectively placed in theright common carotid artery. The acquisitionwas performed (Fig. 3) with 10 cc of contrastmedia (300 mg I/ml) at 5 cc/s.After sub selective placement of the catheter atthe origin of the RICA, an Innova 3D acquisitionis launched at 40°/s, using 16 cc of contrastmedia (300 mg I/ml) at 4 cc/s and an X-raydelay of 1 second.On the AW, the 3D images were processed with3D Volume Rendering (3DVR) (Fig.4 and Fig.6)and Maximal Intensity Projection (MIP) (Fig.5),through the dissection of the RICA and 3D CTimages in axial plane (Fig.7)The origin of the dissection is seen in the distalsegment of the cervical, extracranial internalcarotid artery. The false lumen, created by thedissection of the vessel wall has a re-entry inthe true lumen of the RICA in the carotid chan-nel of the petrosal bone. This re-entry point is clearly depicted on theaxial thin MIP reconstruction images.

ConclusionIn this case the high quality of the 3DVR andaxial cross-section images acquired with theInnova 3D acquisition gives an accurate andprecise anatomical and diagnostic informationon the dissection and vessel wall (re-entry) inplanning an eventual endovascular treatment. The Innova 3D acquisition with intra-arterialcontrast injection in the RICA provides more

BackgroundThe General Hospital ASZ in Aalst, Belgium isequipped with the Innova 3100IQ digital flatpanel angiography system.The Innova 3100IQ system, installed by GEHealthcare has a 30cmx30cm digital detectordesigned to perform interventional proceduresin radiology, neuroradiology, cardiology, gas-tro-enterology and anaesthesiology.Digital subtraction angiography (DSA), 3DAngiography and 3D CT imaging modalitieswere used to fully understand the followingcase study.

Patient HistoryA 45-y-old man suffered from severe right sidedheadache since a few days. No other neurologi-cal abnormalities were found with clinical exam-ination by a staff neurologist.A CT-scan of the brain was performed toexclude an intracranial haemorrhage. There was no intracranial bleeding, but the con-trast enhanced CT scan (CECT) revealed a dis-section of the right internal carotid artery (RICA).

Procedure and discussionThe initial CECT, performed on 64-slice CT, wasimported on the multi-modality AdvantageWorkstationTM Volume Share 2 and post-processed (Fig.1 and Fig.2). On the axial and

GORE VIABAHN® Endoprosthesis: The Continuous Evolution of Performance

Advertorial

Fig.1: 64-slice-CT axial view at carotid channel level.It shows the absence of luminal contrast in the RICA.

Fig.2: Curved planar reconstruction is highly suggestivefor complete occlusion of the petrosal part of the RICA.

Fig.3: DSA, showing the lateral view of the RICA.

Fig.4: Innova 3D VR showing the RICA.

Fig.5: Innova 3D MIP Showing the dissection

Fig.6: Innova 3D VR Showing the re-entry point

Fig.7: Axial view: True lumen (in black) and rim ofcontrast on the false lumen

Dr O.FrançoisHead of Department Interventional RadiologyGeneral Hospital ASZ Aalst, Belgium

Gore’s ongoing commitment to deliveringinnovative devices has allowed the rapidevolution of the GORE VIABAHN®Endoprosthesis with PROPATEN BioactiveSurface to address a broad range of physi-cian and patient needs for sustained clinicalperformance.

Interventionalists treating patients sufferingfrom Peripheral Vascular Disease (PVD) consis-tently look to the Medical Products Division ofW. L. Gore & Associates, Inc. for innovative ther-apeutic solutions required to ensure patientsafety and satisfaction.

The GORE VIABAHN® Endoprosthesis is the onlystentgraft approved by the US Food and DrugAdministration (FDA) for the treatment ofpatients suffering from PVD in superficialfemoral artery (SFA) lesions and iliac arterylesions. The device is constructed with adurable, reinforced, biocompatible, expandedpolytetrafluoroethylene (ePTFE) liner attachedto an external nitinol stent structure. The flexi-bility of the GORE VIABAHN® Endoprosthesisenables it to traverse tortuous vasculature andto conform closely to the complex anatomy ofthe artery.

Introduced in 1996Gore has recently made a series of modifica-tions to the product, demonstrating the com-pany’s commitment to its customers with inno-vative, nextgeneration devices. Since the intro-duction of the original GORE HEMOBAHN®Endoprosthesis in Europe in 1996, Gore hasbeen committed to advancing manufacturingprocesses and implementing design enhance-ments.

W. L. Gore & Associates, Inc. • Flagstaff, AZ 86004 • goremedical.com

Products listed may not be available in all mar-kets. GORE, HEMOBAHN®, PROPATEN, VIABAHN®and designs are trademarks of W. L. Gore &Associates. © 2009 W. L. Gore & Associates, Inc.AN0738-EN1 JULY 2009

Learn more at CIRSE – Booth #25

A History of InnovationIn 2002 Gore introduced TIP to HUB deploy-ment on 5 – 8 mm devices. In 2008, Gorereduced delivery profile and, in 2009, addedthe PROPATEN Bioactive Surface. Also in 2009,manufacturing process were implemented thatprovided a contoured edge at the end of theendoprosthesis which may improve flowdynamics under conditions of oversizing *.

Next Generation Now Available for Large Diameters The most recent design for device diameters 9 – 13 mm is now also approved, enabling thesame streamlined TIP to HUB deploymentdirection over an 0.035” guidewire as the 5 – 8 mm sizes. This latest change transitions all GORE HEMOBAHN® Devices into the GORE VIABAHN® Device family * *.

* Data on file** Pending CE approval

and (extra)luminal information in comparisonwith a intravenous 64-slice CECT scan in eligi-ble patients for interventional neurovascularprocedures.

GORE VIABAHN® Endoprosthesis with PROPATENBioactive Surface

C RSECardiovascular and Interventional Radiological Society of Europe

17African GrantIRnewscongress

CIRSE African Grant - A Report

At last I was in Amsterdam! After many e-mailsand letters and a two hour delay at Frankfurtairport I had arrived in the Netherlands andfinally got to meet Professors Reekers andLameris. After a quick introduction to myinstructors it was time to go to bed after a longand tiring trip, but it was only an hour later thatI could find my apartment on that cold winternight, so the first day of my educational staywas quite exhausting.

Wow! - that was my initial impression of theinterventional radiology suites at the AMCwhich undoubtedly must be one of the besthospitals in Europe; twelve weeks of livingwithin the pages of a text book had begun.

With countless opportunities to assist in vari-ous kinds of procedures, I got to attempt a fewmyself. The most common procedures includedultrasound guided biopsies mainly of intraabdominal tumours and lymph nodes. The lux-ury of having a cytologist right there, in the IRsuite, meant that we could almost instantly besure whether we had a good sample or not. Ihad never experienced that.

The Rotex screw needles were my personalfavourite. (Ursus should give me free samplesfor this free publicity, ha ha!). I was alsoexposed to the use of several other biopsyguns including stereotactic biopsy as well as CTguided biopsy for breast and other lesions. Onmy first weekend I had the opportunity towatch a fluoroscopy guided bone biopsy fromthe 12th thoracic vertebra via the pedicle per-formed right before my eyes. This was to be fol-lowed by one of the most fascinating proce-dures I ever imagined; a transjugular hepaticbiopsy which I again had the privilege to assist.I had a go at a percutaneous gastrostomy aswell.

I greatly enjoyed working with my Dutch col-leagues and soon we had special nick namesfor each other. The times I spent in the vascularsuite were even more exciting, as I had theopportunity to assist in cases of thrombosuc-tion and the deployment of vena caval filters.The dream to see a UAE and other arterialembolizations became a reality. Assisting inmany angiographic procedures performed byProf. Reekers at different times was a greatlearning experience which I will cherish forever.Training the recanalization of stenosed AVshunts for patients on dialysis was of immensevalue considering the fact that we have a grow-ing number of patients on dialysis in Ghana aswell.

A quick tour through the IR store, however,reminded me of the reality, of how hard itwould be to transfer such sophistication to theordinary person in Africa. A microcathetherpriced at € 800 for one procedure is obviouslybeyond the reach of an ordinary middleincome worker in Africa. Then I rememberedProf. Lameris saying “I am always thankful I donot have to think whether the patient canafford it or not. I just use it when I need it”. Hispatients are lucky enough to be entirely cov-ered by a good health care system.Back home I have to rely on a few donatedpacks and procure a few more catheters fromthe US via a relative who resides there to makeIR possible in Ghana and Kumasi where I ambased. At $ 35 or more per set, one procedurecosts the patient close to $ 60. As IR proceduresbecome more popular, hopefully the newlyestablished health insurance schemes in mycountry will accept to run with these costs onbehalf of their patients. Donations will also begladly accepted. Hopefully some day I will beable to say what Prof. Lameris said for mypatients as well.

Back home I have been busy with introducingand promoting IR with great acceptance espe-cially from the departments of surgery, childhealth and internal medicine, in that order. It ismy hope that adjuvant IR procedures will beintroduced for patients with prolonged smallbowel perforation resulting from typhoid fever,which is quite prevalent.

The first PTC was to be attempted in a 30 yearold woman with what I suspect could beretroperitoneal fibrosis presented with suchsevere obstructive jaundice. This was not to be,as her clotting profiles were so delayed by thelaboratory that she died before I could attemptthis procedure.

I had assisted and been coached during threeof such procedures at the AMC and given threesets biliary drainage sets. Of course it was agreat disappointment when nevertheless thisyoung patient passed away. However with theskills I was able to acquire and my new knowl-edge in catheter and stent placement a suc-cessful procedure is surely beckoning. I hope toshare my success story with you soon.

The second non palpable breast carcinoma wassuccessfully operated after effectively and sin-gle-handedly placing a wire under ultrasoundguidance.

My newly acquired knowledge in drainage ofhydatid cysts allowed me to successfully drainand sclerose three intra-abdominal simple cys-tic lesions of tremendous volumes, the last onebeing 1600 mls. All patients are up and aboutagain.

I have been able to drain large and longstand-ing intra abdominal abscesses achieving greatoutcomes. The abscess patients usually comefrom the hinterland where they are not diag-

This 9 year old with an omental cyst couldfinally be diagnosed and the cyst drained.

Assisting a thrombosuction in the angiosuite

At work in the emergency unit at the AMC

Back home in Ghana: success at draining apercutaneous intra-abdominal abscess

Dr Quansah admiring the CT scanner atLieden Medical Center

Learning to introduce a guide wire properly

Learning through discussions

One of Dr. Quansah's patients in Ghana

nosed until late. The most recent reported casewas a two week old baby with a volume of1500 mls of frank pus. The satisfaction ofachieving instant relief with clinical improve-ment has simply been amazing.

I have recently done a US guided biopsy of anintra abdominal mass. Sadly I have not had thepossibility to attempt any vascular IR proce-dures. Using the facilities in one of our newlybuilt theatres for IR procedures may avail methe opportunity of trying something simplesoon, such as vena cava filter placement forlower limb DVT and some venograms.

I wish to thank CIRSE and everybody at theAMC most sincerely for sponsoring this threemonth fellowship in Interventional Radiologyand for the opportunity to see, experience andinteract with a “higher form” of Radiology thanwhat I was used to.

I feel it is my duty to disseminate these invalu-able skills to colleagues in other cities andregions of Ghana with the assistance of allthose interested in spreading this “gospel” tohelp the poor and needy who suffer so much atthe hands of quacks. My greatest appreciationgoes to Prof. Dr. Jim Reekers for this initiative tohave me trained, to Prof. Dr. J.S. Lameris foropening his department to me and allowingme to avail myself of this immense knowledge.My sincere thanks also go to the staff of the IRunit in AMC, Drs Van Lieden, Otto Van Delden,Mark Meier and Elham Ghazi. Thank you somuch for your time and willingness to shareyour knowledge! Thank you also to Kenneth (Ihope you read this) and the CIRSE staff inVienna. And of course I would like to thank Dr.Elizabeth Joekes and Dr. Harmien Zonderlandfrom the bottom of my heart; you started it all.

Ato Quansah

Advertisement

19Interventional QuarterIRnewscongress

CIRSE Supports Major European Campaignfor Interventional Radiology

… And Interventional Radiology fares no differently.

Interventional radiologists everywhere should be bursting with pride at thethought of the discipline’s progress since its beginnings in the late 1950s. Itssuperiority in terms of preserving the integrity of the body as well as its limit-less scope have made it a most inspiring area to be a part of in any capacity.

CIRSE has always provided substantial backing for appropriate projects whichaim to raise awareness of Interventional Radiology and this is one of the mostsignificant to date.

The brand new magazine Interventional Quarter places minimally invasive med-icine under the floodlights, making it visible not only to radiologists and refer-ring physicians but also hospital administrators, healthcare politicians, themedical insurance industry and healthcare providers. It provides accurate,independent, unbiased coverage of all aspects of minimally invasive medicineensuring all voices are heard loudly and clearly.

The launch edition of Interventional Quarter addresses the role of minimallyinvasive techniques in diabetes care. The reality of diabetic life, the availabletreatments, what role interventional medicine can play, and the political andeconomic issues surrounding this condition are all discussed.

Interventional Quarter will have a circulation of around 35,000, comprisingmedical professionals, hospital management and some of the most influentialdecision-makers in healthcare today.

If you think any of your colleagues, be they referring physicians, hospitaladministrators, or local healthcare politicians, etc. could benefit from receivingInterventional Quarter, please visit www.intervention-iq.org to add theirdetails to the mailing list.

Interventional Quarter: expanding the reach of the discipline

A copy of Interventional Quarter can be found in all congress bagsas well as at the Interventional Quarter booth (78)

“Doing business without advertisingis like winking at a girl in the dark.You know what you are doing, butnobody else does.”Steuart Henderson Britt

QY o u r p o r t a l t o m o d e r n m e d i c i n eI n t e r v e n t i o n

Special Edition / CIRSE 2009 - Lisbon

20 Film Interpretation Panel Sunday, September 20, 2009

Male, 44 y.o.

· HCV + cirrhosis, drug abuse· Suspected hypercoagulable disorder

- Progressive liver insufficiency- Diagnosis of Budd-Chiari syndrome

- Hepatorenal syndrome, anuria, stage IV hepatic encephalopathy- Bilateral pleural effusion and ascites- TIPS was proposed

Case A

Film Interpretation Panel

Join us for this year's Film Interpretation Panel and see how much fun an educational session can be!

Together with junior panellists senior IRs will diagnose several tricky cases.

To give you a head start, we are showing you the cases in advance.

Rt jugular vein thrombosis Lt jugular vein thrombosis

What is your diagnosis?

C RSECardiovascular and Interventional Radiological Society of Europe

21Film Interpretation PanelIRnewscongress

What is your diagnosis?

Female, 32 y.o.· Laparoscopic cholecystectomy for gallstones· Leak from subhepatic drain after 12-24 hrs.· ERCP done after 3 days.

- Little sludge, no stones, no leak, normal biliary tree. - Endoscopic sphincterotomy performed.

· No improvement after other 2 days. - Leak persists. Fever (37.8°C)

· MRCP

Case B

Female, 27 y.o.· Routine chest X-ray taken as part of pre-employment exams

- no symptoms, no history of trauma

Case C

What is your diagnosis?

Film Interpretation Panel Monday, September 21, 15:00-16:00Auditorium 1

Don't miss it !

Special Edition / CIRSE 2009 - Lisbon

22 General Information Sunday, September 20, 2009

Members' LoungeC a r d i o v a s c u l a r a n d I n t e r v e n t i o n a l R a d i o l o g i c a l S o c i e t y o f E u r o p e

Located in the foyer on the first floor it provides all CIRSE members wish-ing to relax between sessions in a comfortable atmosphere and around

As a special service to its members, CIRSE is offering a CIRSE Members Lounge at CIRSE 2009

On the occasion of CIRSE 2009CIRSE is celebrating the achieve-ments of Nobel Prize LaureateEgas Moniz and the PortugueseSchool of Angiography with anexhibition about the discoveries ofthis remarkable group of physi-cians.

We warmly invite you to visit theexhibition including the table firstused in cerebral angiography byEgas Moniz, located in front ofAuditorium 6.

Don’t go hungry! Catering at CIRSE 2009

Opening Hours

Restaurant (first floor) 12:30-15:30Café Bar (ground floor) 08:00-18:00Café Bar (first floor) 08:00-18:00

Entrance Level First Floor

Exhibition on the Pioneers of Angiography

the clock catering. For those who wish to use their breaks to catch up onsome work or check their e-mails, W-LAN is available.

Complementary coffee will be served here at the following times:

Saturday, September 19 11:00-11:30 15:30-16:00Sunday, September 20 11:00-11:30 16:00-16:30Monday, September 21 11:00-11:30 16:00-16:30Tuesday, September 22 11:00-11:30 14:45-15:15Wednesday, September 23 11:00-11:30

Internet Café

Café

CaféRestaurant

�Access to Members' Lounge*

* Around the clock catering will beoffered here for all CIRSE members

C RSECardiovascular and Interventional Radiological Society of Europe

IRnewscongress

C RSECardiovascular and Interventional Radiological Society of Europe

23An Alternative Guide to PortugalIRnewscongress

The Age of Discovery was the time at whichEuropeans, mainly the Portuguese, Spanish andEnglish, explored the world oceans searchingfor trading partners and exotic goods, such asspices and cheap knock-off watches. Portugal’scolonial ambitions began when Portuguesenavigators started exploring the coast of Africaas early as 1419, helped by recent develop-ments in navigation, cartography and maritimetechnology. According to history text booksthe Age of Discovery lasted until the 17th cen-tury. If you ask me, it hasn’t ended yet, as adecent tasting diet coke or a comfortable planeseat have yet to be found.

Another important factor for the onset of theAge of Discovery was the development of thecaravel, a small, highly manoeuvrable two orthree mast ship with lateen sails. Commissionedby Henry the Navigator, it was based on the so-called qarib used by Muslim Andalusian explor-ers in the 13th century, obviously a time beforecopyright.

Since seafaring in the 15th and 16th centurieswas not exactly a walk in the park, explorerswere often hard-pressed to find anyone whowould be willing to stay locked up on a ship formonths with the only entertainment beingbird-poop dodging. The chances of survival forthe average sailor, which were sometimes asbad as three to one, did not exactly make agreat selling point either. This is why some ofthe more assertive employers restored to“shanghaiing” to persuade the unknowing pub-drunk of the advantages of a career at sea. Itwould consist in, let’s say, “over-serving” the tar-geted individual in a tavern. Later his uncon-scious body would be provided with shelter ona boat which just so happened to embark on avery long and treacherous journey.

Now imagine waking up with the hang-over ofa lifetime and discovering that a. you live in a time before aspirin,b. the place where you are headed is uncharted

territory marked “Good luck!” on the map,c. you have just been volunteered for a month

if not year long trip, possibly ending inscurvy, the loss of a couple of limbs or quitepossibly death,

d. you are pretty sure you left your ironplugged in.

THE WHO-IS-WHO OF PORTUGUESESEAFARING

Henry the NavigatorHenry the Navigator, who ruled Portugal in theearly 15th century, is considered the foundingfather of the Portuguese Empire, having a greatpassion for seafaring and the necessary cash togo along with it. He first started exploring thecoast of Africa in the pursuit to stop the piratescoming from there to capture Portuguese astheir slaves. Henry then figured that while hewas already there, he might as well keep goingdown the coast and dip into the gold trade, asa king can never have too much bling.

As a result of Henry’s ambitions Portugueseexplorers discovered the Madeira Islands whichare still part of Portugal. Technically speakingthe islands were discovered by accident whentwo of Henry’s captains were stranded there ina storm. Later they returned to claim theislands for Portugal by sticking a flag in it, notunlike claiming a doughnut by licking it.Shortly after, the Azores were discovered, sure-ly destroying Madeira’s real estate market.

Vasco da Gama Vasco da Gama was the commander of the firstships to sail directly from Europe to India in1497/98, a time when Christopher Columbuswas still wondering why the people he calledIndians could not cook up a decent curry.

Vasco da Gama has two alternating birth dates,depending on the different historic reports,quite similarly to most women past 50. What iscertain though is that da Gama set out fromLisbon for his famed voyage to India in July of1497. He left port with four ships and 170 menout of which only 54 returned (really makesyou wonder what his job advertisements musthave looked like).

Once he had reached the East African coast, daGama realised that before crossing Muslim con-trolled waters he better make some friends,which is why he met with the Sultan ofMozambique. Having nothing to offer butsome left over pickles and 6 months worth oftoe-nail clippings, it didn’t take long until theexplorer and his men were chased out of thesultanate. Their response? Firing their canonsback at the city, because you just don’t messwith a bunch of men who haven’t seen afemale or at least a decent drink in half a year!Since they were already at it, da Gama’s menalso looted several Arab merchant ships, arather inglorious detail often forgotten in histo-ry books.

The Age of Discovery – A slice of Africa anyone?

The fleet arrived in Calicut on May 20, 1498,only 10 months and 12 days after departingfrom Lisbon, a feat most charter airlines haveyet to achieve.

Pedro Álvarez CabralKnowing that Pedro Álvarez Cabral hadreceived excellent nautical training, KingManuel I. commissioned him to continue Vascoda Gama’s work. The king also wanted Cabral tointroduce Christianity wherever he went "usingforce of arms if necessary”, because nothingsays love thy neighbour like a head on a fencepost, plus I’m pretty sure this would make thetrips tax deductable.

In 1500 Cabral set out to re-trace Vasco daGama’s route, but trying to avoid the calmwaters of the Gulf of Guinea drifted off just anotch, making him the first European to landon the coasts of Brazil. Like most explorers ofthe time (and men in general) Cabral had noclue where his short cut had landed him andnamed the newly found land Vera Cruz. At first,Portugal had very little interest in Brazil, as itcould not contribute to the lucrative spicetrade and Samba hat not yet been invented.

Ferdinand MagellanFerdinand Magellan was born around 1480.Originally stemming from Portugal he lateradopted the Spanish nationality to sail for theSpanish court, which his why both countrieslike to claim him for themselves. Despite hismany other voyages, Magellan is of coursemost famous for being the first person to cir-cumnavigate the earth. What is less commonlyknown is that he died halfway through the tripin a battle in the Philippines, but doing the restof the trip as a corpse apparently counts, too.

Only a few months after having set out on hisjourney, Magellan had to fight off a mutiny,executing one of its instigators and marooningtwo other, i.e. leaving them behind on a desert-ed island without provisions or suntan lotion.Magellan and his crew then became the firstEuropeans to enter the Pacific, rounding the tipof South America and giving the strait betweenChile and Tierra del Fuego the name Strait ofMagellan.

Petra MannCIRSE Office

Out of the 237 men who had set out to circum-navigate the earth only 52 returned, destroyingMagellan’s chances to become employer of theyear.

Life on board was not for the squeamish, harshpunishments being imposed for mutiny, stealingprovisions and asking “Are we there yet?”

IR Congress News is published as an additional source of information for all CIRSE 2009participants. The articles and advertorials in this newspaper reflect the authors' opinion.CIRSE does not accept any responsibility regarding their content. If you have any questions about this publication, please contact us at mann@cirse.org.

Editors in Chief: Afshin Gangi, Paulo Vilares Morgado Managing Editor: Petra Mann, CIRSE OfficeGraphics/Artwork: LO O P. E N T E R P R I S E S media / www.loop-enterprises.com

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