Abstract No. 296 EE: Retrievable Inferior Vena Cava Filter Review: Routine and Difficult Removal Techniques

MATERIALS & METHODS: This study was conducted on 22 patients presenting with symptomatic cranio-facial arterio-venous malformations. CTA and/or MRI with MRA were done to each patient prior to DSA and embolization. Resectability was evaluated, together with site and numbers of feeders and venous drainage. The embolic materials were limited to gelfoam (cubes or torpedoes) and PVA particles, either separate or combined. RESULTS: Our patients were divided into two groups according to their resectability. Six patients underwent operative resection were embolized only with gelfoam cubes (1-2mm). Four patients with single feeder and delayed venous filling (more than two seconds) were embolized only with PVA particles. The remaining twelve patients where high flow and early venous filling were found, gelfoam torpedoes followed by PVA particles (350 to 700 micrometer)were used. Complete embolization was achieved in 21 patients without any significant complication, while incomplete embolization occurred in one patient with high flow auricular malformation where skin necrosis and external otitis media contraindicate the complete embolization.

Abstract No. 295 EE Image Guided Intervention for Management of Unusual Causes of Traumatic Hemorrhage. M. Hsu, A. Lainer, S. Hanks, M. Katz, V. Marx; University of Southern California, Keck School of Medicine, Los Angeles, CA. PURPOSE: To review the recent USC experience in the management of unusual cases of traumatic and iatrogenic hemorrhage. These causes of hemorrhage are rare even in a Level I trauma center, but could be encountered by interventional radiologists in a small community based practice. Review of such cases is provided to broaden the practical knowledge base of the general interventionalist. MATERIALS & METHODS: Review of clinical cases involving hemorrhage due to:

CONCLUSION: The combination of gelfoam torpedoes and PVA particles were very successful to treat high flow vascular malformation specially with early venous filling. Gelfoam embolization is a safe and simple temporary procedure before resection of the vascular malformations.

A. Non-penetrating breast trauma B. Non-penetrating gastrointestinal tract trauma C. Pathologic femur fracture D. Percutaneous nephrostomy tube E. Tracheostomy F. Paracentesis G. Thoracentesis H. Inadvertant large bore catheterization of the subclavian artery

Abstract No. 294 EE

Case discussions will include relevant anatomy, techniques and approaches for intervention, and clinical outcomes.

Inferior Vena Cava Filters on Abdominal CT: Identification, Positioning, & Complications. N. Georgiou1, M. Hon1, D.S. Katz1, D.W. Trost2; 1 Winthrop-University Hospital, Mineola, NY; 2Weill-Cornell Medical Center, New York, NY.

TEACHING POINTS: 1. Unusual causes of bleeding that are uncommonly encountered in the community can present a diagnostic and interventional challenge. 2. Familiarity with anatomic issues and practical management of these unusual types of hemorrhage can broaden the treatment options available to the general interventionalist.

PURPOSE: To demonstrate the spectrum of inferior vena cava (IVC) filters as seen on CT; to show the normal and variant positioning of IVC filters, including the incorporation of the filter into the caval wall/extension of the filter struts through the wall; and to show examples of complications of IVC filter placement using CT.

TEACHING POINTS: The radiologist should be able to recognize normal, abnormal, and variant positioning of IVC filters on CT, to recognize the different types of IVC filters on CT, and to utilize CT to evaluate for complications of IVC filter placement.

Retrievable Inferior Vena Cava Filter Review: Routine and Difficult Removal Techniques. B. Iliescu, H. Richard, D. Widlus, Z. Haskal, M. Kim, F. Moeslein, S. Elsayed; University of Maryland, Baltimore, MD. PURPOSE: Retrievable inferior vena cava filter (IVC) placement frequency has increased in patients with, or at high risk, of deep venous thrombosis (DVT) and contraindications to anticoagulation. Herein, we provide an in-depth and comprehensive review of removable IVC filters available, unique characteristics, and the range of complex (and routine) approaches to early and late IVC filter removal.

POSTER SESSIONS

MATERIALS & METHODS: IVC filters, whether temporary or permanent, are routinely identified on CT examinations of the abdomen and pelvis performed for various reasons. Usually the filters are incidental or not the primary reason the scan was performed, but occasionally CT may be obtained - either routine abdominal/pelvic CT or as part of CT venography for suspected venous thromboembolism - specifically to identify a suspected problem such as incorrect placement or associated thrombosis related to the filter, or rarely for complications such as extension to the GU or GI tract, or for acute caval perforation. CT examples of tilting of filters, purposeful positioning above the renal veins, in duplicate vena cavas, or placement of more than one filter will be demonstrated. The appearance of different models/ types of filters will be shown, as well as the spectrum of extension of struts of the filter through the caval wall, and complications of placement will also be shown. The current relevant interventional radiology/CT literature will also be reviewed.

Abstract No. 296 EE

MATERIALS & METHODS: We performed database, image, procedure and medical record review for an 18 month consecutive period of patients whom received IVC filter placement, at our large level I trauma center and hospital. A total of 403 removable IVC filters were placed. This data and experience will be paired with a comprehensive literature review of all described approaches as well as hybrid techniques for difficult IVC filter retrieval, including: tilted, incorporated, extravascular leg extension, osseous incorporation, inadvertent non-target deployment and filter breakage. These data will be reviewed and illustrated for the Recovery, G2, Gu¨nther Tulip, OptEase and Celect filters. Techniques for S111

retrieval and potential complications will be illustrated, including use of curved tip introducers, loop snares, combined wire-snare techniques, single and multiple vein approaches, microdissection using forceps, parallel wire and dual sheath technique, etc. The approach to complex retrieval and a decision making tree will be provided. TEACHING POINTS: Removal of retrievable IVC filters is generally an uneventful procedure. However, complex situations arise, where an understanding of the indications for retrieval in these settings, as well as the range of secondary techniques for removal of caval filters is a necessary part of modern interventional radiology practice. Abstract No. 297 Efficacy and Safety of Repeat Arterial Closures Using Perclose Proglide Suture-Mediated Closure in Oncology Patients. P.R. Inscore, A.M. Amin, G. Vatakencherry; Kaiser Permanente, Los Angeles, CA. PURPOSE: The Perclose Suture-Mediated closure device has been demonstrated to be safe and effective in single use studies as well as preliminary research evaluating the use in repeat closures. The purpose to this study is to evaluate the safety and efficacy of Perclose in repeat arterial interventions in oncology patients. MATERIALS & METHODS: A retrospective review was performed of patients who underwent arteriotomy closure using the Perclose device following chemoembolization. A total of 132 patients underwent arteriotomy closures using the Perclose device from July 2005 to September 2008. Of these, 66 patients underwent repeat Perclose vessel closure following additional procedures. Arteriotomy closure using the Perclose device was performed according to the manufacturer’s instructions. Patients were examined immediately following arterial closure and on post-operative day 1 for complications. Efficacy and safety were defined as satisfactory hemostasis and lack of groin complications. RESULTS: Vascular interventions involving the use of the Perclose device were performed in 132 patients (total 276 closures). Repeat arteriotomy closure occurred 210 times (mean 3.2; range 2-7). Overall, successful closure occurred in 95.7% (264/276). The most common reasons for unsuccessful closure were difficulty with tracking or advancing the device into the vessel (1.81%; 5/276), small hematoma not requiring further treatment (1.09%, 3/276), and failure to close the arteriotomy (1.09%, 3/276). Absent flow through the device prior to deployment was seen in 1 patient (0.36%), for which the device was not deployed. In patients undergoing multiple procedures, there was difficulty tracking the device in 1.43% (3/210), failure to close the arteriotomy in 1.43% (3/210), and 3 small hematomas in 1.43%. No complications requiring further treatment were observed. Overall, there were not significant differences in complications between single use and multiple use (4.55% vs 3.03%, respectively, p⫽1.0). CONCLUSION: Femoral arteriotomy closure using the Perclose Proglide closure device is safe and highly effective in patients undergoing single and multiple interventions. Complication rates are low and not increased with repeat interventions. S112

Abstract No. 298 EE A Review of the Current Status and Technique of Carotid Artery Stenting. S. Iqbal1,2, S.P. Kalva1,2, P.M. Burke3, B.M. Janne d’Othee1,2, S.T. Wicky1,2, T.G. Walker1,2; 1 Massachusetts General Hospital, Boston, MA; 2Saints Medical Center - Radiology, Lowell, MA; 3Saints Medical Center - Surgery, Lowell, MA. PURPOSE: Carotid occlusive disease is an important cause of ischemic stroke, a leading cause of morbidity and mortality in the United States. The results of large, randomized, clinical trials have established the benefit of surgical revascularization with carotid endarterectomy (CEA) over medical management, in the prevention of stroke in patients with symptomatic or asymptomatic carotid stenosis that exceeds 70%. The role of carotid artery stenting (CAS) in this group of patients remains under investigation. The indications and appropriate patient selection for CAS continue to evolve and remain an area of active research and debate. Current guidelines parallel those for CEA in symptomatic patients; CAS is currently not approved in asymptomatic patients. Additionally CAS may be used in a subset of patients in whom there is a high surgical risk for CEA. There are conflicting clinical data with regard to the equivalence of CAS and CEA, although clinical trials remain ongoing. CAS has the known advantage of being less invasive than CEA, but before widespread adoption, demonstration of equivalence or superiority is required. In this educational exhibit, we examine the current status of CAS with currently approved FDA devices. MATERIALS & METHODS: We present representative cases of carotid artery stenosis that were treated with CAS. We review and illustrate, with clinical and imaging examples, the pre-procedural evaluation, periprocedural preparation and accepted technique of CAS with regard to the currently approved FDA devices. The role of embolic protection is discussed, as are the anatomic considerations, technical and clinical success rates, complications, postprocedural care, surveillance imaging and re-intervention strategies. Data from completed and ongoing clinical trials comparing CEA and CAS are examined. TEACHING POINTS: Revascularization for hemodynamically significant carotid artery stenotic disease is the accepted treatment for stroke prevention. Although CEA remains the procedure of choice, CAS has been used safely as an alternative therapy. Clinical trials to compare outcomes and resource utilization remain ongoing, in an attempt to better define the respective roles of CEA and CAS. Abstract No. 299 EE Portal Hypertension: Diagnosis & Management. S.I. Iqbal, B. Dave, G. Walker, S. Wicky, A. Waltman, S.P. Kalva; Massachusetts General Hospital, Boston, MA. PURPOSE: Recent advances in imaging, endoscopy and endovascular methods have had significant impact in the diagnosis and management of portal hypertension. The purpose of this exhibit is to review the current role of imaging (US, 3D CT, MRI), endoscopy and catheter angiography in the diagnosis of portal hypertension. We will also discuss the current management of esophageal, gastric varices, rectal varices and ascites in patients with portal hypertension. MATERIALS & METHODS: Imaging plays a significant role in the diagnosis of porto-systemic collaterals. Though