Cardiovascular Radiology Research Articles

Ascending aorta pseudoaneurysm simulating mediastinal lymphoma in computed tomography, a possible diagnostic error: a case report

BackgroundAn ascending aortic pseudoaneurysm is a severe and rare complication following cardiothoracic surgery. This case report demonstrates its possible misinterpretation and the consequent importance of multidisciplinary evaluation.Case presentationWe present a case of an 18-year-old Caucasian man with Marfan syndrome who developed an ascending aortic pseudoaneurysm about 1 year after undergoing cardiac surgery with the Bentall procedure. Computed tomographic examination of the thoracic aorta and positron emission tomography–computed tomography initially suggested a lymphomatous pathology. However, these imaging results were in contrast to the transesophageal echocardiogram and the laboratory data that showed negative results for hematological pathology. A second computed tomographic scan redirected the diagnosis toward a pseudoaneurysm.ConclusionThis case demonstrates the utility of close communication and interdisciplinary consultation between cardiovascular radiologists and the cardiac surgery team, which are mandatory in order to maximize their diagnostic skills in identifying postoperative complications.

Fully automated quantification of left ventricular volumes and function in cardiac MRI: clinical evaluation of a deep learning-based algorithm

To investigate the performance of a deep learning-based algorithm for fully automated quantification of left ventricular (LV) volumes and function in cardiac MRI. We retrospectively analysed MR examinations of 50 patients (74% men, median age 57 years). The most common indications were known or suspected ischemic heart disease, cardiomyopathies or myocarditis. Fully automated analysis of LV volumes and function was performed using a deep learning-based algorithm. The analysis was subsequently corrected by a senior cardiovascular radiologist. Manual volumetric analysis was performed by two radiology trainees. Volumetric results were compared using Bland–Altman statistics and intra-class correlation coefficient. The frequency of clinically relevant differences was analysed using re-classification rates. The fully automated volumetric analysis was completed in a median of 8 s. With expert review and corrections, the analysis required a median of 110 s. Median time required for manual analysis was 3.5 min for a cardiovascular imaging fellow and 9 min for a radiology resident (p < 0.0001 for all comparisons). The correlation between fully automated results and expert-corrected results was very strong with intra-class correlation coefficients of 0.998 for end-diastolic volume, 0.997 for end-systolic volume, 0.899 for stroke volume, 0.972 for ejection fraction and 0.991 for myocardial mass (all p < 0.001). Clinically meaningful differences between fully automated and expert corrected results occurred in 18% of cases, comparable to the rate between the two manual readers (20%). Deep learning-based fully automated analysis of LV volumes and function is feasible, time-efficient and highly accurate. Clinically relevant corrections are required in a minority of cases.

Estimation of equivalent organ and effective doses to patients undergoing coronary angiography and percutaneous coronary intervention procedures using Monte Carlo simulation

The aim of the present study was to assess the patient-specific equivalent organ dose (HT) and effective dose (ED) delivered to individual patients from cardiovascular interventional radiology (CVIR) procedures and to compare these doses to those reported in the literature. The HT and EDs to 113 patients from two CVIR procedures: coronary angiography (CA) and percutaneous coronary interventions (PCI) were acquired from two major hospitals in Tanzania. The HT and EDs were estimated using the knowledge of the patient characteristics, patient related exposure parameters, geometry of examination, measurements of air kerma area product and Monte Carlo-based PCXMC software. The median HT in the present study for the lung, heart and oesophagus for the CA, were 47.1 mSv, 33.8 mSv, and 22.9 mSv, respectively, while for the PCI were 102.6 mSv, 77.5 mSv, and 51.9 mSv, respectively. The median values of ED as recommended by ICRP 103 for the CA and PCI procedures were 11.1 mSv and 24.7 mSv, respectively. The overall variations between individual EDs across the two hospitals differed by factors of up to 63.1 and 25.1, respectively for the CA and PCI procedures. The mean values of HT and EDs in the present study were, for the most part, higher than the reported values for India, Belgium and Italy, while comparable with those reported for Greece. The proposed diagnostic reference levels (DRLs) for the CA and PCI were for KAP 91.4 Gy cm2 and 129.4 Gy cm2, for fluoroscopy time 15.5 min and 28.4 min, for number of cine frames 791.5 and 1213.5, and ED 19.8 and 36.9 mSv, respectively. The observed wide range of exposure parameters and patient doses within and across the hospitals and the observed relatively high patient doses compared to those reported in the literature, call for the need to standardize examination protocols and optimise radiation dose to patients from CVIR procedures.

Radiology Editorial Board: Changes for 2019

<i>Radiology</i> Editorial Board: Changes for 2019

The role of the angle of the ascending aortic curvature on the development of type A aortic dissection: ascending aortic angulation and dissection.

Type A aortic dissection (TAD), which consists of an intimal tear in the aorta, necessitates emergency surgery. Various risk factors related to aortic dissection have been defined in the literature. According to our hypothesis, a narrower angle of ascending aortic curvature (AAAC) may be an additional risk factor in relation to aortic dissection due to the increased force applied to the aortic wall. Patients undergoing ascending aortic surgery due to an ascending aortic aneurysm (AsAA) (n = 105) and patients undergoing such surgery because of the occurrence of TAD (n = 101) were enrolled in this study. The AAAC was measured using Cobb's method; the measurements were made on all patients by just 1 cardiovascular radiologist using 3-dimensional computerized tomographic imaging. This measurement was made indirectly by using the aortic valve and brachiocephalic artery to avoid obtaining misleading data as a result of distortions due to dissection. A statistical comparison was also performed relating the traditional risk factors for TAD to other clinical and echocardiographic parameters: the diameter of the ascending aorta and the AAAC. The AAAC was found to be narrower statistically in the TAD group (α = 76.2° ± 17.5°) than it was in the AsAA group (α = 92.9° ± 13°) (P < 0.001). Furthermore, mean ascending aortic diameter (P = 0.019), the presence of a bicuspid aorta (P = 0.007) and aortic valve stenosis (P = 0.005) were higher in the AsAA group. According to multivariable analyses, a narrower AAAC is a significant predictor for the development of TAD (odds ratio 0.93, 95% confidence interval 0.91-0.95; P < 0.001). Overall hospital mortality from various causes including stroke, myocardial infarction, bleeding or renal failure was 13% in the TAD group and 7% in the AsAA group. According to this study, the AAAC was significantly smaller in aortic dissection patients than in aortic aneurysm patients. This may be related to higher shear stress and elevated pressure on the ascending aorta in patients with a narrower AAAC. Thus, a narrower AAAC may be an additional risk factor in the development of TAD. Therefore, we may need to be more careful in terms of looking for the development of aortic dissection in patients with narrower AAAC.

Paclitaxel-Coated Balloons and Eluting Stents: Is There a Mortality Risk in Patients With Peripheral Artery Disease?

Paclitaxel drug-coated balloons and drug-eluting stents became commercially available for the treatment of intermittent claudication in 2015 and 2012, respectively. Both devices demonstrated superiority in limb revascularization compared with non-paclitaxel-coated devices and were rapidly accepted into clinical practice. In a recent systematic review and study-level meta-analysis, Katsanos et al reported a late all-cause mortality signal for patients in the drug-coated balloon and drug-eluting stent arms of randomized clinical trials for both devices. As a result of this safety signal, Vascular InterVentional Advances Physicians (VIVA), a not-for-profit 501c(3) organization, convened the Vascular Leaders Forum on March 1 and 2, 2019, in Washington, DC, to initiate an open and collaborative process of investigation into this finding. The Vascular Leaders Forum brought together 100 stakeholders, including an international group of representatives of cardiovascular medicine, interventional radiology, vascular medicine, and vascular surgery; oncologists; basic scientists; the Food and Drug Administration; the Centers for Medicare and Medicaid Services; and commercial manufacturers of these products. The Vascular Leaders Forum reviewed the natural history of peripheral arterial disease, the use of paclitaxel in peripheral arterial disease and other conditions, the harm signal noted by Katsanos et al, the impact of the methods chosen by Katsanos et al, possible mechanisms of harm, the role of the Food and Drug Administration in a setting like this one, and guidance for clinicians taking care of patients with symptomatic peripheral arterial disease. This document integrates the most current data to help establish an appropriate path forward to understand the risks and benefits associated with these technologies while ensuring the best treatment paradigm for patients.

Acute adverse events in cardiac MR imaging with gadolinium-based contrast agents: results from the European Society of Cardiovascular Radiology (ESCR) MRCT Registry in 72,839 patients

ObjectivesTo assess the incidence of acute adverse events (AAEs) in gadolinium-enhanced cardiac magnetic resonance (CMR) imaging.MethodsGadolinium-based contrast agent (GBCA)–enhanced CMR data from the multinational, multicenter European Society of Cardiovascular Radiology MRCT Registry was included. AAE severity was classified according to the American College of Radiology Manual on Contrast Media (mild, moderate, severe). Multivariable generalized linear mixed effect models were used to assess the likelihood of AAEs in various GBCA, adjusting for pharmacological stressor, main indications (i.e., suspected or known coronary artery disease or myocarditis), age, sex, and submitting center as a random effect.ResultsIn the study population of 72,839 GBCA-enhanced CMRs, a total of 260 AAEs were reported (0.36%), with a minority of severe AAEs (n = 24, 0.033%). Allergic-like AAEs were less likely than physiologic AAEs (29% versus 71%). Patients without pharmacological stress imaging had a lower AAE rate (0.22%) compared to stress imaging (0.75%), with the highest AAE rates for regadenoson (2.95%). AAE rates also varied by GBCA subtype (overall p < 0.001). There was significant interaction between GBCA and pharmacological stressor (interaction p = 0.025), with AAE rates ranging between 0 and 10% for certain GBCA/stressor combinations. There was further marginal evidence that higher GBCA volume was associated with higher AAE incidence (OR = 1.02, p = 0.05).ConclusionGBCA-enhanced CMR imaging demonstrates low AAE rates comparable to those of other body regions. AAE likelihood correlates with GBCA subtype, pharmacological stressor, and imaging indication. Intravenous fluid administration in patients with cardiac impairment might contribute to these findings.Key Points• Acute adverse event rates in cardiac magnetic resonance (CMR) imaging with gadolinium-based contrast agents (GBCAs) are low (0.36%), especially for severe adverse events (0.033%).• Mild and moderate adverse events are more frequent during stress CMR imaging.• Physiologic AAEs are more common than allergic AAEs in CMR imaging.

Feasibility and utility of dual-energy chest CTA for preoperative planning in pediatric pulmonary artery reconstruction.

The purpose of this study was to assess in pediatric pulmonary artery (PA) reconstruction candidates the feasibility and added utility of preoperative chest computed tomography angiography (CTA) using dual-energy technique, from which perfused blood volume (PBV)/iodine maps can be generated as a surrogate of pulmonary perfusion. Pediatric PA reconstruction patients were prospectively recruited for a new dose-neutral dual-energy CTA protocol. For each case, the severity of anatomic PA obstruction was graded by two pediatric cardiovascular radiologists in consensus using a modified Qanadli index. PBV maps were qualitatively reviewed and auto-segmented using Siemens syngo.via software. Associations between Qanadli scores and PBV were assessed with Spearman correlation (r) and ROC analysis. Effective radiation doses were estimated from dose-length product and ICRP 103k-factors, using cubic Hermite spline interpolation. 19 patients were recruited with mean (SD) age of 6.0 (5.1), 11 (57.9%) female, 11 (73.7%) anesthetized. Higher QS correlated with lower PBV, both on a whole lung (r = - 0.54, p < 0.001) and lobar (r = - 0.50, p < 0.001) basis. The lung with lowest absolute PBV was predictive of the lung with highest Qanadli score, with AUC of 0.70 (95% CI 0.47-0.93). Qualitatively, PBV maps were heterogeneous, corresponding to multifocal PA stenoses, with decreased iodine content in areas of most severe obstruction. In conclusion, dual-energy chest CTA is feasible for pediatric PA reconstruction candidates. PBV maps show deficits in regions of more severe anatomic obstruction and may serve as a novel biomarker in this population.

Coronary Calcium Burden in Breast Cancer Patients Receiving Adjuvant Radiation Therapy

Coronary artery calcium (CAC) score had been reported as an important imaging predictor for coronary artery disease (CAD). Even today, tangential radiotherapy (RT) in left-sided breast cancer (BC) still harbored potential harm to the heart, especially to the left anterior descending coronary artery. Previous studies took the mean heart dose as a surrogate of RT-associated cardiac toxicity, but no data were available on the radiation dose of each coronary artery. We aimed to explore the relation of CAC score and coronary radiation doses in BC patients treated with adjuvant RT. Additionally, we would like to examine the impact of other risk factors of CAD on the increment of coronary calcium burden. We retrospectively reviewed 146 BC female patients (median age at RT 50.5 years [range 24–82], median follow-up time 6.3 years [range 0.3–10.7]), treated with complete course of adjuvant RT in our institution from 2002 to 2010. All patients had received tangent field RT of 50 Gy at least to the breast or chest wall. We retrieved the following data by reviewing medical records: age, risk factors of CAD (diabetes, hypertension, hyperlipidemia, body mass index≧25), and treatment-related profiles. Pre-RT and post-RT computed tomography (CT) scans were obtained, and all CT scans were evaluated by an experienced cardiovascular radiologist in determining the absolute CAC scores of the left main artery (LM), left anterior descending coronary artery (LAD), left circumflex artery (LCX), and right coronary artery (RCA). The annual increment of CAC (CACinc) was calculated by dividing the difference of pre-RT and post-RT absolute CAC score by the time interval between two CT scans (in years). Since CT dose planning was introduced from August 2006 onwards in our institution, dosimetric data were available in 114 patients only. The contouring of each coronary artery was cooperated by two experienced cardiovascular radiologist and radiation oncologist. For left-sided BC, the mean dose and maximal dose of LAD were 1923.60 ± 906.65 cGy and 5155.59 ± 365.49 cGy (mean ± SD), respectively. The radiation doses of LAD and LCX were significantly higher in left-sided BC than those of right-sided BC (p <0.0001). However, there was no correlation between annual CACinc values and coronary radiation doses. The annual CACinc values of LAD, LCX and RCA were not significantly different in left-sided versus right-sided BC. Adjuvant chemotherapy with anthracycline- or taxane-containing regimens showed a trend of significant association with annual CACinc of LAD (p = 0.07). BC patients carrying two or more risk factors of CAD had higher annual CACinc values of LAD (p = 0.04). Our results do not support radiation-induced accelerated coronary calcium burden in BC patients treated with adjuvant RT. For BC patients undergoing adjuvant chemotherapy or carrying two or more risk factors of CAD, intensive follow of CAC increment by CT imaging may be important for early prediction of future CAD episode.

The role of ascending aortic size in outcomes of patients with uncomplicated acute type B aortic dissection

ObjectiveRecent studies demonstrate that uncomplicated acute type B aortic dissection (uATBAD) patients with enlarged descending thoracic aortic diameters are at high risk for development of complications. This study aimed to determine the association of maximum ascending aortic diameter and area and outcomes in patients with uATBAD. MethodsAll patients admitted with uATBAD from June 2000 to January 2015 were reviewed, and those with available imaging were included. All measurements were obtained by a specialized cardiovascular radiologist, including the maximum ascending aortic diameter and area. Outcomes, including the need for intervention and mortality, were tracked over time. Data were analyzed by stratified Kaplan-Meier and multiple Cox regression analyses using SAS 9.4 software (SAS Institute, Cary, NC). ResultsDuring the study period, 298 patients with uATBAD were admitted, with 238 having available computed tomography and 131 having computed tomography angiography imaging and adequate follow-up available for analysis. The cohort had an average age of 60.96 ± 13.4 years (60% male, 53% white). Ascending aortic area >12.1 cm2 and ascending aortic diameter >40.8 mm were associated with subsequent arch and proximal progression necessitating open ascending aortic repair (P < .027 and P < .033, respectively). Ascending diameter >40.8 mm predicted lower intervention-free survival (P = .01). However, it failed to predict overall survival (P = .12). Ascending aortic area >12.1 cm2 predicted lower intervention-free survival (P = .005). However, this was not predictive of mortality (P = .08). Maximum aortic diameter along the length of the aorta >44 mm persisted as a risk factor for mortality (P < .001). Neither maximum ascending aortic diameter >40.8 mm (hazard ratio [HR], 1.09; 95% confidence interval [CI], 0.42-2.83; P = .85) nor area >12.1 cm2 (HR, 0.992; 95% CI, 0.38-2.61; P = .99) significantly predicted mortality when controlling for maximum aortic diameter along the length of the aorta >44 mm (HR, 7.34; 95% CI, 2.3-23.41; P < .001), diabetes mellitus (HR, 6.4; 95% CI, 2.17-18.93; P < .001), age (HR, 1.06/y; 95% CI, 1.03-1.10; P < .001), history of stroke (HR, 5.03; 95% CI, 1.52-16.63; P = .008), and syncope on admission (HR, 21.11; 95% CI, 2.3-193.84; P = .007). Ascending aortic diameter >40.8 mm (HR, 2.01; 95% CI, 1.03-3.95; P = .04) and maximum ascending aortic area >12.1 cm2 (HR, 1.988; 95% CI, 1.02-3.87; P = .04) on admission persisted as predictors of decreased intervention-free survival after controlling for maximum aortic diameter along the length of the aorta >44 mm (HR, 3.142; 95% CI, 1.47-6.83; P < .004), syncope on admission (HR, 26.3; 95% CI, 2.81-246; P < .004), and pleural effusion on admission (HR, 3.02; 95% CI, 1.58-5.77; P < .001). ConclusionsuATBAD patients with ascending aortic area >12.1 cm2 or maximum ascending aortic diameter >40.8 mm are at high risk for development of subsequent arch and proximal progression and may require closer follow-up or earlier intervention. Ascending aortic size (diameter and area) is predictive of decreased intervention-free survival in patients with uATBAD.

Needle placement errors: do we need steerable needles in interventional radiology?

PurposeAccurate and precise needle placement is of utmost importance in interventional radiology. However, targeting can be challenging due to, eg, tissue motion and deformation. Steerable needles are a possible solution to overcome these challenges. The present work studied the clinical need for steerable needles. We aimed to answer three subquestions: 1) What are the current challenges in needle placement? 2) What are allowable needle placement errors? and 3) Do current needles need improvement and would steerable needles add clinical value?MethodsA questionnaire was administered at the Annual Meeting of Cardiovascular and Interventional Radiology Society of Europe in 2016. In total, 153 respondents volunteered to fill out the survey, among them 125 (interventional) radiologists with experience in needle placement.Results1) Current challenges in needle placement include patient-specific and technical factors. Movement of the target due to breathing makes it most difficult to place a needle (90%). 2) The mean maximal allowable needle placement error in targeted lesions is 2.7 mm. A majority of the respondents (85%) encounter unwanted needle bending upon insertion. The mean maximal encountered unwanted needle bending is 5.3 mm. 3) Needles in interventional radiology need improvement, eg, improved needle visibility and manipulability, according to 95% of the respondents. Added value for steerable needles in current interventions is seen by 93% of the respondents.ConclusionSteerable needles have the potential to add clinical value to radiologic interventions. The current data can be used as input for defining clinical design requirements for technical tools, such as steerable needles and navigation models, with the aim to improve needle placement in interventional radiology.

Abstract No. 469 Representation of developing countries in interventional radiology research

The developing world accounts for greater than ¾ of the global population, yet prior studies have shown a disproportionately low representation of developing countries in the medical literature. No prior study has assessed the participation of authors from the developing world in interventional radiology (IR) journals. The purpose of this study was to determine the representation of studies from developing countries in two influential IR journals. We reviewed all articles published from January 2014 through December 2016: 1) Journal of Vascular and Interventional Radiology (JVIR) and 2) CardioVascular and Interventional Radiology (CVIR). The country of origin of the first author was identified for each study. Each country was grouped into either “developed” or “developing” based on designations provided by the International Monetary Fund. We compared representation of developing countries by journal and year using Chi-Square tests with Freeman-Halton extension, as appropriate. 1300 articles were reviewed from 2014 to 2016, of which 153 (12%) were from developing countries. The most prevalent developing country was China with 88 articles (58%), followed by Turkey with 24 (16%), India with 13 (8%), and Brazil with 9 (6%). Excluding China, only 5% of articles were from Developing countries. In contrast, the United States accounted for 462 articles (36%), followed by Japan with 113 (9%). There was significantly less representation of developing countries in JVIR (9%) compared with CVIR (15%) (p = 0.003). There was no significant difference in representation of developing countries between the years (p = 0.3). Developing countries are disproportionately under-represented in two influential IR journals. Further study is needed to determine reasons for this low representation and to develop strategies to increase the number of IR publications from parts of the world where the disease burden is greatest.

Immediate Allergic Reactions to Gadolinium-based Contrast Agents: A Systematic Review and Meta-Analysis.

Immediate Allergic Reactions to Gadolinium-based Contrast Agents: A Systematic Review and Meta-Analysis.

Detection of coronary artery calcification with nontriggered computed tomography of the chest.

Objective To evaluate the accuracy of visual analysis and of the coronary artery calcium (CAC) score in nontriggered computed tomography (CT), in comparison with that of the CAC score in electrocardiogram-triggered CT, in identifying coronary calcification.Materials and Methods A total of 174 patients for whom CT was indicated for CAC scoring underwent nontriggered and triggered CT in a 64-channel multislice scanner, in a single session without a change in position. The images were interpreted by a radiologist with seven years of experience in thoracic and cardiovascular radiology. The measurement of coronary calcium was carried out by three methods: CAC score with dedicated software in nontriggered CT, CAC score with dedicated software in triggered CT, and visual analysis without dedicated software in nontriggered CT.Results In nontriggered CT, the CAC score presented an accuracy of 95.98% (95% CI: 91.93-98.04). The visual analysis showed an accuracy of 97.13% (95% CI: 93.45-98.77).Conclusion Nontriggered CT showed excellent accuracy in the identification and exclusion of coronary calcification, either the CAC score was determined with dedicated software or through visual analysis.

Aortic Dissection after Transcatheter Aortic Valve Replacement: Conservative Approach with Good Outcome

An 80-year-old man with severe aortic stenosis, who declined aortic valve replacement several times since 2011 and had recurrent syncope after balloon aortic valvuloplasty, was admitted because of symptomatic aortic stenosis. A percutaneous strategy for his aortic stenosis was decided. Transcatheter aortic valve replacement using a balloon-expandable Edwards Sapien XT valve was performed under rapid ventricular pacing. After valve deployment, an aortic dissection of ascending aorta was noticed. There was no coronary flow compromise, no acute aortic root and ascending aorta dilatation, no pericardial effusion, and paravalvular aortic regurgitation was mild. After consultation with cardiovascular surgeon, interventional radiologist and invasive cardiologist we decided for conservative approach, with very good outcome and no additional disabilities in the follow up of more than two years.

Publication rates of abstracts presented at major interventional radiology conferences.

We aimed to determine the publication rate and factors predictive of publication of oral presentations at the annual meetings of the Cardiovascular and Interventional Radiology Society of Europe (CIRSE) and the Society of Interventional Radiology (SIR). Keywords and authors from oral presentation abstracts at the 2012 CIRSE and SIR annual meetings were used to search PubMed and GoogleScholar for subsequent publication. Logistic regression was performed to identify whether number of authors, country of origin, subject category, methodology, study type, and/or study results were predictive of publication. A total of 421 abstracts (CIRSE-126, SIR-295) met the inclusion criteria. The overall publication rate across both conferences was 44.9%. Time from conference presentation to publication was 15±8.9 months for CIRSE and 16.3±8.8 months for SIR (P > 0.05), with a combined time interval of 15.9±8.8 months for both. The median impact factor of published abstracts was 2.075 (interquartile range, 2.075-2.775) for CIRSE and 2.093 (2.075-2.856) for SIR (P > 0.05). The most common country of origin for published abstracts was Germany (27.1%) at CIRSE and the United States (69%) at SIR. Logistic regression did not identify factors that were predictive of future publication. Publication rates were similar for CIRSE and SIR. Factors such as country of origin, topic of study and study results were not predictive of future publication. Authors should not be discouraged from submitting their work to journals based on these factors.

Strategies for radiation dose reduction in nuclear cardiology and cardiac computed tomography imaging: a report from the European Association of Cardiovascular Imaging (EACVI), the Cardiovascular Committee of European Association of Nuclear Medicine (EANM), and the European Society of Cardiovascular Radiology (ESCR).

Strategies for radiation dose reduction in nuclear cardiology and cardiac computed tomography imaging: a report from the European Association of Cardiovascular Imaging (EACVI), the Cardiovascular Committee of European Association of Nuclear Medicine (EANM), and the European Society of Cardiovascular Radiology (ESCR).

The European Board of Interventional Radiology Examination: A Cross-Sectional Web-Based Survey.

The Cardiovascular and Interventional Radiology Society of Europe established the European Board of Interventional Radiology (EBIR) as an international examination in Interventional Radiology (IR), in 2010. The main objective of this study was to examine candidates' variables which could influence examination success. The secondary objective was to evaluate candidate feedback. This study was a cross-sectional web-based survey incorporating 30 questions which reviewed candidates' demographics; use of English language; education; and radiology training. Free-text responses provided perspective on the examination process and any potential career implications. This survey was distributed via SurveygizmoTM and emailed to 227 candidates, and the results were then anonymised and analysed. A total of 115 candidates responded to the survey. 4.4% (N=5/115) of candidates were women, and 38.3% (N=44/115) of candidates were fluent in English. Over 45.2% (N=52/115) of the respondents achieved a distinction, or >70% equivalent in their medical degree, and 60.8% (N=70/115) achieved some form of higher degree after medical school. 54.8% (N=63/115) spent time in other medical specialties, of which the majority (33.8%, N=39/115) was in surgery. 67.5% (N=77/114) completed a dedicated fellowship in IR. 61.9% (70/113) felt the EBIR qualification helped their career, for example with academic promotion or increased clinical privileges. EBIR applicants were predominantly male (>95%). Clinical training, prior to radiology training, was very common in this cohort. Overall, most candidates expressed satisfaction with the examination process, and many felt this qualification helped their career. The recent recognition by national accreditation bodies should hopefully improve the profile of the examination greatly.

Current trends in the interventional treatment of hepatocellular carcinoma: A cross-sectional survey of transarterial embolization techniques.

e15627 Background: Since two randomized controlled trials demonstrated the superiority of Transarterial chemoembolization (TACE) to supportive care, it has been a mainstay of treatment for unresectable hepatocellular carcinoma (HCC). The technical aspects of the TACE procedure, including drug type, embolic agent, bead type and size, procedural endpoint and follow up are heterogeneous throughout the literature, making meaningful comparisons less impactful. The goal of this study was to determine the common technical practices in the interventional therapy of HCC over several geographical areas. Methods: An anonymous 18 question online survey was distributed via email to practicing members of the Cardiovascular and Interventional Radiology Society of Europe (CIRSE), Chinese Society of Interventional Radiology (CSIR), Japanese Society of Interventional Radiology (JSIR), Korean Society of Interventional Radiology (KSIR), and the Society of Interventional Radiology (SIR). An estimated 15,700 surveys were distributed and 1160 responses obtained from 62 countries for a total response rate of 7.4%. Results: Excluding bead size, responses were statistically different by region (p &lt; 0.05). Doxorubicin was more commonly used among SIR, CIRSE, and KSIR members than JSIR and CSIR members (p &lt; 0.05). A fixed dose of cytotoxin was favored by SIR and CIRSE members, while dosing dependent on tumor-size was used by KSIR, JSIR, and CSIR members (p &lt; 0.05). Drug eluting bead-TACE (DEB-TACE) was most popular in SIR and CIRSE, while classical TACE (cTACE) was most popular in Japan, Korea, and China (p &lt; 0.05). For DEB-TACE procedures, the favored bead size was 100 μm – 300 μm for all groups. Procedural endpoint, type of embolic agent, and use of additives and antibiotics varied among groups (p &lt; 0.05). CT was the most commonly used modality for follow up amongst all respondents, but MR was used more by SIR members than all other groups (p &lt; 0.05). Conclusions: This study demonstrated that there is clear evidence that the TACE technique differs by region. Understanding and reporting the current practice trends is an important step to optimize and standardize future randomized controlled trials.

PC020 The Role of Ascending Aortic Size in Outcomes of Patients With Uncomplicated Acute Type B Aortic Dissection

Recent studies have shown that patients with uncomplicated acute type B aortic dissection (uATBAD) who have enlarged descending thoracic aortic diameters are at high risk of developing complications. This study aimed to determine the effect of maximum ascending aortic diameter and area on outcomes in patients with uATBAD. All patients admitted with uATBAD from June 2000 to January 2015 were reviewed, and those with available imaging were included. All measurements were obtained by a specialized cardiovascular radiologist. The maximum ascending aortic diameter and area were measured. Outcomes, including the need for intervention and mortality, were tracked over time. Data were analyzed by stratified Kaplan-Meier and multiple Cox regression analysis using SAS 9.4 software. During the study period, 304 patients with uATBAD were admitted, with 245 having noncontrast computed tomography and 131 having computed tomography angiography imaging and adequate follow-up available for analysis. The cohort had an average age of 60.9 years (60% male, 53% Caucasian). Ascending aortic area >12.1 cm2 was highly associated with subsequent arch/proximal progression (P < .0006). Ascending diameter >40.8 mm predicted lower intervention-free survival (P = .01). Ascending aortic area >12.1 cm2 predicted lower intervention-free survival (P = .005). Maximum aortic diameter along the length of the aorta >44 mm persisted as a risk factor for mortality (hazard ratio [HR], 7.34; P = .0008) after adjustment for diabetes mellitus (6.4; P = .0008), age (1.06/year; P = .0006), history of stroke (HR, 5.03; P = .0081), syncope on admission (21.11; P = .007), and ascending diameter >40.8 mm (1.09; P = .85). Max ascending aortic diameter failed to predict overall survival when two groups were compared >40.8 and < 40.8 (P = .12). However maximum aortic diameter along the length of the aorta >44 mm held true as previously demonstrated (P = .0009). Maximum aortic diameter along the length of the aorta >44 mm persisted as a risk factor for decreased intervention-free survival (hazard ratio, 3.142; P = .0038), syncope on admission (26.3; P = .004), pleural effusion on admission (3.02; P = .0008), and ascending diameter >40.8 mm (2.01; P = .04). uATBAD patients with ascending aortic area >12.1 cm2 are at high risk of developing subsequent arch/proximal progression and may require closer follow-up or earlier intervention. Ascending aortic size (diameter and area) is predictive of decreased intervention free survival in patients with uATBAD.