Post-procedural Evaluation Research Articles

Imaging findings in Essure-related complications:a pictorial review.

Tubal sterilization with Essure inserts has become a prevalent alternative to laparoscopic sterilization because of its minimal invasiveness. It is a well-tolerated ambulatory procedure that provides reliable permanent contraception without the risks associated with laparoscopic surgery and general anesthesia. Correct positioning of the Essure device is necessary to achieve the fibrotic reaction induced by the polyethylene terephthalate fibers, subsequently resulting in tubal occlusion usually within 3 months. After uneventful procedures with satisfactory bilateral placement, only the correct position of the devices needs to be confirmed at follow-up. The imaging techniques used to asses Essure devices may vary depending on the country and its recommendations. The gold-standard test to ascertain tubal occlusion remains the hysterosalpingography but after uneventful procedures, vaginal-ultrasound proved to be a reliable alternative to confirm the proper position of the inserts. Radiologists have been increasingly confronted to post-procedural evaluations and despite the efficiency rate of the Essure device, its use still exposes to a low risk of complications and malfunctions such as unwanted pregnancies, device misplacement, tubal or uterine perforation, and chronic pelvic pain. Unintended pregnancies are mostly due to patient or physician non-compliance and misinterpretation of post-procedural examinations by radiologists which emphasizes the importance of their training in Essure device assessment. This pictorial review discusses the imaging methods used to asses Essure implants and illustrates the possible complications related to them.

Use of percutaneous bleomycin sclerotherapy for orbital lymphatic malformations

ABSTRACTPurpose: Bleomycin sclerotherapy has been shown to be a viable treatment for lymphatic malformations. However, its use for these lesions confined to the orbit is becoming increasingly documented in the literature. In this study, we summarize the clinical manifestations and outcomes observed following percutaneous bleomycin sclerotherapy for orbital lymphatic malformation.Methods: A 5-year retrospective chart review of patients with clinical, radiographic, and/or biopsy-confirmed diagnoses of orbital lymphatic malformation that received bleomycin sclerotherapy was conducted at the Emory Hospital and Clinics. Data examined included patient demographics, patient history and symptoms, clinical findings, radiographic findings, route of bleomycin delivery, and outcome.Results: Of the 10 patients who met inclusion criteria, the median age of treatment was 7 years. The most common presenting symptoms included vision change and proptosis. Nine of 10 patients demonstrated macrocysts (>1 cm) on imaging. Seven of 10 patients had histories of prior interventions including resections, cyst drainage, and debulking. Because 2 of these 10 patients were lost to follow-up, 8 patients remained for post-procedural evaluation. Four of these eight showed improvement of visual acuity after post-bleomycin sclerotherapy. In seven of eight patients, extraocular motility either improved or remained stable. Pretreatment and posttreatment exophthalmometer measurements obtained in four patients revealed an average improvement in proptosis of 65% from their average pretreatment measurements.Conclusions: Our findings suggest that percutaneous bleomycin sclerotherapy is a viable option for treatment of orbital lymphatic malformations, with potentially greater benefit to those with macrocystic features.

Spinal cord infarction: Clinical and imaging insights from the periprocedural setting

ObjectiveDescribe the range of procedures associated with spinal cord infarction (SCI) as a complication of a medical/surgical procedure and define clinical and imaging characteristics that could be applied to help diagnose spontaneous SCI, where the diagnosis is often less secure. MethodsWe used an institution-based search tool to identify patients evaluated at Mayo Clinic, Rochester, MN from 1997 to 2016 with a periprocedural SCI. We performed a descriptive analysis of clinical features, MRI and other laboratory findings, and outcome. ResultsSeventy-five patients were identified with SCI related to an invasive or non-invasive surgery including: aortic aneurysm repair (49%); other aortic surgery (15%); and a variety of other procedures (e.g., cardiac surgery, spinal decompression, epidural injection, angiography, nerve block, embolization, other vascular surgery, thoracic surgery) (36%). Deficits were severe (66% para/quadriplegia) and maximal at first post-procedural evaluation in 61 patients (81%). Impaired dorsal column function was common on initial examination. Imaging features included classic findings of owl eyes or anterior pencil sign on MRI (70%), but several other T2-hyperintensity patterns were also seen. Gadolinium enhancement of the SCI and/or cauda equina was also common when assessed. Six patients (10%) had an initial normal MRI despite a severe deficit. ConclusionsProcedures associated with SCI are many, and this complication does not exclusively occur following aortic surgery. The clinical and radiologic findings that we describe with periprocedural SCI may be used in future studies to help distinguish spontaneous SCI from alternate causes of acute myelopathy.

Abstract No. 609 Imaging beyond PACS: documenting clinical photographs in the electronic medical record with a mobile application

Visual physical exam findings are essential in the pre- and postprocedure evaluation of many conditions treated through minimally invasive procedures performed by interventional radiologists. Clinical photographs help providers communicate and demonstrate the role of interventional radiologists as clinical consultants. The purpose of this study was to assess the usage frequency, among interventional radiologists, of a custom smartphone application for documenting clinical photographs in the electronic medical record. A custom native application, PhotoConsult, was written for iOS devices to securely capture digital photographs at the point of care. The application was fully integrated with the IT infrastructure of the hospital and complied with all security policies and HIPAA regulations. The application can be installed on personal or hospital owned devices. Users log in with hospital authentication or fingerprint and select a patient by medical record number or by scanning a patient barcode. Photographs captured in the application are never stored on the users’ devices. Several photos can be captured in series. Photographs can be cropped, rotated, annotated and captioned. Photographs and captions are assembled into a PDF that is securely transmitted to the electronic medical record. During the trial period between September 2016 and 2017, 170 users across 26 departments took 3389 clinical photograph sets of 2138 patients. 10 users in the interventional radiology department took 84 sets of photographs. 33 (40%) of the IR photographs were taken before or after venous sclerotherapy to document response. 11 (13%) of IR images were taken from port sites to document wound-healing concerns. Photographs were taken of dialysis circuit aneurysms, catheter skin entry sites, facial swelling before and after SVC angioplasty, and IVC filters after removal. Evaluation of physical exam findings is critical for the clinical practice of interventional radiologists. Documentation of findings in the electronic medical record can be streamlined with a secure mobile application.

Use of the Hourglass peripheral embolisation device: early experiences

We evaluated a novel intravascular plug, the Hourglass peripheral embolisation device (PED). We describe, for the first time, the use of this device and discuss its potential applications. The device was deployed in nine patients over a six-month period at a single institution by two different operators. Five patients underwent renal artery embolisation, three underwent gonadal vein embolisation for a varicocele, and a single patient underwent embolisation of the gastroduodenal artery. We recorded the indications, success rate, and the procedure-related complication rate in all patients. We also evaluated the satisfaction of the operators with the device using a post-procedure evaluation form. Technical success was achieved in 9/9 (100%) cases. Unanimous feedback was obtained from the operators (100% agreement). The usability of the delivery system, device deployment, and device visibility under fluoroscopy were rated as easy in 9/9 (100%) cases. The ease of repositioning was rated as good in both cases where this was attempted. The device trackability was rated as good in 9/9 (100%) cases. There were no procedure-related complications. The Hourglass PED is potentially useful for the embolisation of small-to-medium sized vessels.

Self-Reported Headaches in Patients with Unruptured Intracranial Aneurysms Treated with the Pipeline Embolization Device.

The objective of this study was to analyze patients' perceptions of their headaches both before and after Pipeline flow diversion treatment of their unruptured intracranial aneurysms, with the goal of identifying prognostic factors associated with headache patterns to improve predictions of overall outcomes. We retrospectively identified 133 patients treated with the Pipeline embolization device (PED) between January 1, 2014, and December 31, 2016, at an academic institution in the United States. Patients with at least 6 months of clinical follow-up, who had completed a validated telephone survey assessing their headache perceptions before and after treatment of their UIAs, were included. Sixty patients (57.7%) responded to the questionnaire. Median aneurysm size was 6.3 mm. Thirty-two patients (53.3%) presented with headaches before treatment, which had a median intensity of 7 out of 10 (range, 3-10). On postprocedural evaluation, 8 patients (25%) had complete resolution of their headaches. Of the 24 (75%) patients with persistent headaches, the frequency and severity of the headaches decreased or remained the same in most (58.3%) patients. Eleven (18.3%) patients had new-onset headaches. This study found an association between aneurysm size and a reduction in headache frequency and severity after PED treatment. No significant association was found between headache persistence, severity, or frequency and patient demographics, aneurysm characteristics, and other comorbidities. An overall improvement of headaches in patients with UIAs who underwent treatment with the PED was observed, particularly in patients harboring large aneurysms and who had presented with daily headaches.

Ultrasound-Guided Popliteal Sciatic Block Provides Adequate Analgesia During Urgent Endovascular Treatment of Critical Limb Ischemia with Resting Pain.

To demonstrate feasibility and safety of ultrasound-guided popliteal sciatic nerve block for providing analgesia during urgent endovascular treatment of critical limb ischemia with resting pain. Ultrasound-guided popliteal sciatic blocks were performed by an interventional radiologist in angiography suite immediately prior to commencement of urgent endovascular treatment of 30 critical limb ischemia patients. Subjective pain levels prior to and following sciatic block were assessed using the visual analog scale (VAS). Need for any supplemental anxiolytics or analgesics during treatment was recorded. Post-procedural evaluation of patient and operator satisfaction levels regarding the intervention was also documented. Ultrasound-guided sciatic block provided adequate analgesia in all patients; VAS scores were 0 (no pain) in 87% and 1-3 (mild to annoying pain) in 13%. Two patients required anxiolytic premedication. Additional analgesia was not required during course of endovascular treatment of any patients. Time necessary to perform sciatic block ranged 3-9 (mean 5.9±1.3) min. Median number of needle attempts was 1 (range 1-3). Onset of satisfactory block ranged from 5 to 20min (mean 9.4±2.6min). Mean treatment time was 102.2±36.7min, and balloon time was 22.4±6.1min. Patient and operator satisfaction with pain control were very good in all cases. There were no procedure-related complications. Ultrasound-guided popliteal sciatic block is a feasible and safe alternative for providing adequate analgesia during urgent endovascular treatment of critical limb ischemia with resting pain. Level 4, case series.

321 - Ultrasound-Guided Hysteroscopy- and Laparoscopy-Based Treatment of Different Mullerian Anomalies

This case series reports the evaluation and ultrasound-guided management of different Mullerian abnormalities by hysteroscopy and concomitant laparoscopy. 6 patients with septate uteri diagnosed by 2D/3D ultrasound and MRI showed 2 subseptate uteri, 1 arcuate uterus, 1 complete uterine septum, 2 complete uterine septum each with oblique vaginal septum and longitudinal vaginal septum. The procedure was transcervical resection of uterine septum with concomitant laparoscopy under ultrasound control. Incision with complete resection of the oblique and longitudinal vaginal septa was done using monopolar electrode. With concomitant laparoscopy, the pelvis was evaluated for pelvic masses, adhesions, fluid spillage into the pelvic cavity for tubal patency assessment, external fundal contour and the uterine cavity on transillumination. The advantages of post procedural evaluation of the uterine cavity by transrectal ultrasound guidance during hysteroscopic septoplasty are easy estimation of fundal thickness and depth of remaining septum.

Initial Outcomes of Cyanoacrylate Closure, VenaSeal System, for the Treatment of the Incompetent Great and Small Saphenous Veins.

Cyanoacrylate closure of the saphenous vein with the VenaSeal system is a new technique just approved on December 2016 in Korea. Therefore, there are seldom reports about postprocedural outcomes of VenaSeal system in Asian countries. We report the initial outcomes of VenaSeal system for the treatment of great saphenous veins (GSVs) and small saphenous veins (SSVs) as a first report in Korea. Thirty-four patients with incompetent saphenous veins (47 GSVs and 16 SSVs) were treated at a single session. Concomitant phlebectomy was performed in 15 (44.1%) of 34 patients. All procedures were started with local anesthesia with music therapy and switched to intravenous sedation if patient requested. Patients revisited the clinic on 10 days, 1 month, and 3 months after surgery. Postprocedural evaluations including numerical pain rating score, revised Venous Clinical Severity Scores (rVCSS), and Aberdeen Varicose Vein Questionnaires were checked. Duplex ultrasound was performed on 10 days, 1 month, and 3 months. All treated veins (47 GSVs and 16 SSVs; 100%) had complete closure by duplex ultrasound during the follow-up period. Mean numerical pain rating scale of 6 hours after procedure was 2.7. The rVCSS was improved during the follow-up period. Phlebitis-like "abnormal skin reaction" in the treatment area was occurred in 8 (23.5%) of 34 patients and recovered fully in 2 weeks. Cyanoacrylate closure, VenaSeal system, is safe and effective for the treatment of incompetent saphenous veins.

Hepatic Nodules in Liver Cirrhosis: US and CEUS

Hepatocellular carcinoma (HCC) is the 6th most common malignancy worldwide, 6% of all cancer. Unfortunately, HCC is a devastating cancer with 5year survival less than 5%. Among risk factors of HCC, liver cirrhosis and hepatitis B, C Virus are most important. Liver cirrhosis is a diffuse hepatic parenchymal process with extensive fibrosis and regenerative nodule formation and irreversible. In the management of hepatic nodule in liver cirrhosis, early diagnosis and treatment is necessary. For this purpose, understanding of hepatocarcinogenesis is important. There are two pathways, one is de novo pathway and the other is multistep pathway. De novo pathway is a development of HCC without background of chronic liver disease or liver cirrhosis. Multistep pathway is a development of HCC in the background of liver cirrhosis from regenerative nodule (RN) through dysplastic nodule (DN), eHCC to advanced HCC. Cellular and histopathologic change in hepatocarcinogenesis from RN to HCC include iron, glycogen, copper, and fat, vascularity, bile duct and Kupffer cell change. These cellular and histopatologic change can be visualization on imaging. For hepatic nodule, US techniques have been continuously evolved during the recent several decades from static B-scan imaging going through real-time imaging, Doppler imaging, elastography volumetric imaging and finally to virtual US and contrast imaging. US role for hepatic nodule in liver cirrhosis includes surveillance of hepatic nodule for early diagnosis of HCC, differential diagnosis hepatic nodule, intrahepatic staging of advanced HCC, evaluation of vascular lesions and portal thrombi, evaluation of liver transplantation, and planning, guidance & monitoring of biopsy and ablation of liver cancer. For detection of hepatic nodules, gray scale US is a screening and surveillance test with acceptable sensitivity and specificity, but, US shows poor performance in advanced contracted liver cirrhosis with poor depiction rate, less than 30 %. Grayscale US is sometimes useful for the Dx of liver nodule, particularly with characteristic findings. If the lesion shows peripheral halo, mosaic pattern and lateral shadowing, these findings are indicative of HCC. But, in many cases, findings of grayscale US are not specific. Doppler US can be used, and sometimes, it is useful, but in many cases of small nodule, Doppler US is not specific. In such a case, US contrast agent is useful to make a correct Dx of hepatic nodule. With an US contrast agent, we are able to make a dx. by demonstrating hemodynamic change of hepatic nodule in multiphasic images. There are two techniques of contrast-enhanced US. One is high MI and the other is low MI imaging. High MI imaging is no longer used. Low MI imaging using second generation contrast agents such as Sonovue or Definity, is a continuous bubble imaging and is useful in vascularity assessment. Another contrast agent, Sonazoid, is available in Japan, and Korea. This agent is taken up by Kupffer cells. So, we can evaluate hepatic nodule in vascular phase as well as Kupffer (post vascular) phase with this contrast agent. Advantages of CE US over CT/MR are high sensitivity to contrast, real-time imaging, disruption-replenishment sequence, no renal excretion, no ionizing radiation, purely intravascular contrast, as you see in this diagram by Dr Wilson from Canada. Other advantages of CE US are ready availability, low cost, excellent patient’s compliance, and possible repeated exams with short intervals. Recently loco-regional treatment of HCC is rapidly progressing. For local therapy, chemical ablation including ethanol injection is now replaced by thermal ablation such as radiofrequency ablation (RFA), microwave or high intensity focused US (HIFU). For regional (intravascular) therapies, in addition to conventional TACE, TACE with drug eluting beads or radioembolization is now investigated. The role of US for Tx is planning before Tx, targeting, monitoring and controlling during Tx, and assessing response after Tx for early detection of recurrence. In summary, for focal liver lesion, US improves lesion detection, allows lesion characterization, reduces the need for CT/MR, and US has been introduced into guidelines, and improves patient management. For assessment of treatment response, US allows intra-and post-procedural evaluation, and is useful in patient follow-up after therapy as an alternative to CT/MR evaluation.

Transthoracic Echocardiography to Assess Aortic Regurgitation after TAVR: A Comparison with Periprocedural Transesophageal Echocardiography

Background: We aimed to compare periprocedural transesophageal echocardiography (TEE) with postprocedural transthoracic echocardiography (TTE) for the diagnosis of aortic regurgitation (AR). Methods and Results: TEE and TTE images of 163 transcatheter aortic valve replacement (TAVR) patients (mean age 81 ± 8 years; 56% men) were reviewed separately and blinded to each other as well as to all clinical data. The median time between TEE during TAVR (TEE/TAVR) and TTE was 4 days (IQR 2-10 days). After TAVR, 48% of the patients had at least trace AR by TEE, 56% by angiography and 67% by TTE. The majority of AR was paravalvular (78%). More patients were classified with mild-to-moderate AR by TTE than by TEE (44 vs. 22%, p < 0.01). When examining the 46 patients with AR by TTE which was not at TEE/TAVR, both systolic and diastolic blood pressure (SBP and DBP) were significantly higher during TTE than during TEE (mean ΔSBP = 9 ± 4 mm Hg and mean ΔDBP = 6 ± 2 mm Hg, p < 0.01 for both). No differences in BP between TEE and TTE were found among patients with no AR or among those who had AR in both studies. At a median follow-up of 185 days (IQR 39-424 days), the overall mortality was 17%, but this was not associated with the presence of AR on TTE or TEE. Conclusions: Patients' hemodynamic conditions may result in underdiagnosis of paravalvular regurgitation in periprocedural TEE. Our findings suggest that a postprocedural evaluation for AR by TTE could serve as a reasonable alternative to TEE for the evaluation of AR.

Post-Procedure Evaluation of Microwave Ablations of Hepatocellular Carcinomas Using Electrode Displacement Elastography

Microwave ablation has been used clinically as an alternative to surgical resection. However, lack of real-time imaging to assess treated regions may compromise treatment outcomes. We previously introduced electrode displacement elastography (EDE) for strain imaging and verified its feasibility in vivo on porcine animal models. In this study, we evaluated EDE on 44 patients diagnosed with hepatocellular carcinoma, treated using microwave ablation. The ablated region was identified on EDE images for 40 of the 44 patients. Ablation areas averaged 13.38 ± 4.99 cm2 on EDE, compared with 7.61 ± 3.21 cm2 on B-mode imaging. Contrast and contrast-to-noise ratios obtained with EDE were 232% and 98%, respectively, significantly higher than values measured on B-mode images (p < 0.001). This study indicates that EDE is feasible in patients and provides improved visualization of the ablation zone compared with B-mode ultrasound.

Simultaneous Bilateral Carotid Stenting for Symptomatic Bilateral High-Grade Carotid Stenosis: A Retrospective Clinical Investigation.

BackgroundThis retrospective clinical investigation aimed to evaluate the short-term effectiveness and safety of SBCAS for symptomatic bilateral high-grade CS.Material/MethodsFrom 2009 to 2014, 145 patients were recruited. Among them, 70 underwent SBCAS, and other 75 patients underwent SAMM and served as controls. The immediate postprocedural complications and postprocedural neurological evaluation, as well as restenosis at 6-month and 1-year follow-ups in the SBCAS group are reported. Additionally, baseline risk factors for ischemic stroke, adverse effects of drugs, and outcomes at 30-day, 6-month, and 1-year follow-ups were compared between the 2 groups.ResultsOur data did not reveal significant differences between the 2 groups in baseline risk factors for ischemic stroke. In the SBCAS group, both HPS (5.7%) and HD (40%) occurred, but they were not very severe, and no patients had postprocedural neurological deficit. Moreover, restenosis only occurred in 3 patients at 3 stent placement sites (4.3%) at 1-year follow-up. Adverse effects of drugs did not occur in SBCAS group, but adverse effects of Bayer aspirin and Lipitor occurred in 4 patients (5.4%) and 18 patients (24.3%), respectively, at 6-month follow-up in the control group. Furthermore, there were significant differences in outcomes between the 2 groups at 30-day, 6-month, and 1-year follow-ups, in that NIHSS, CS ratio, and incidence of endpoint events, as well as 1-year cumulative probability of endpoint events, were all lower in the SBCAS group than in the control group (p<0.05).ConclusionsCompared to SAMM, we found that SBCAS was more effective and safer for symptomatic bilateral high-grade CS.

The role of cardiovascular magnetic resonance in the assessment of severe aortic stenosis and in post-procedural evaluation following transcatheter aortic valve implantation and surgical aortic valve replacement.

Degenerative aortic stenosis (AS) is the most common valvular disease in the western world with a prevalence expected to double within the next 50 years. International guidelines advocate the use of cardiovascular magnetic resonance (CMR) as an investigative tool, both to guide diagnosis and to direct optimal treatment. CMR is the reference standard for quantifying both left and right ventricular volumes and mass, which is essential to assess the impact of AS upon global cardiac function. Given the ability to image any structure in any plane, CMR offers many other diagnostic strengths including full visualisation of valvular morphology, direct planimetry of orifice area, the quantification of stenotic jets and in particular, accurate quantification of valvular regurgitation. In addition, CMR permits reliable and accurate measurements of the aortic root and arch which can be fundamental to appropriate patient management. There is a growing evidence base to indicate tissue characterisation using CMR provides prognostic information, both in asymptomatic AS patients and those undergoing intervention. Furthermore, a number of current clinical trials will likely raise the importance of CMR in routine patient management. This article will focus on the incremental value of CMR in the assessment of severe AS and the insights it offers following valve replacement.

SCAI expert consensus statement: 2016 best practices in the cardiac catheterization laboratory: (Endorsed by the cardiological society of india, and sociedad Latino Americana de Cardiologia intervencionista; Affirmation of value by the Canadian Association of interventional cardiology-Association canadienne de cardiologie d'intervention).

The SCAI Expert Consensus Statement: 2012 Best Practices in the Cardiac Catheterization Laboratory provides standards for preprocedure, intraprocedure, and postprocedure evaluation and management, and served as a patient-centered approach to safety and quality in the cardiac catheterization laboratory (CCL) [1]. It was noted that the CCL is a setting in which elective, urgent, and emergent percutaneous procedures are performed, and that high throughput and increasing patient complexity demand optimal periprocedural communication, clinical management, documentation, and protocol. Regulations primarily targeted at open surgical suites have the potential to negatively impact the quality of care because they shift the focus to performance measures that are not necessarily relevant to the CCL. Accordingly, directives were tailored to the percutaneous setting in order to assure quality and optimal patient safety while maintaining efficiency.

Fenestrated Transcatheter ASD Closure in Adults with Diastolic Dysfunction and/or Pulmonary Hypertension: Case Series and Review of the Literature.

This study aims to evaluate the safety and efficacy of transcatheter fenestrated ASD closure and to summarize the literature regarding the published techniques and outcomes of transcatheter partial ASD closure. Patients with left ventricular diastolic dysfunction (LVDD) or right ventricular (RV) dysfunction and/or pulmonary hypertension (PHT) may suffer untoward consequences of complete closure of an ostium secundum atrial septal defect (ASD). Therefore, for patients that fall under these categories we suggest partial occlusion of the defect, which may be better tolerated than complete defect closure. After obtaining IRB approval, a search for patients that have undergone percutaneous ASD closure was performed in the Ahmanson/UCLA Adult Congenital Heart Disease Center database to identify which patients received a fenestrated ASD closure device. Eight consecutive patients ranging between 22 and 83 years of age (mean 48 years) with PHT and/or LVDD or RV dysfunction who underwent fenestrated transcatheter ASD closure at UCLA were identified. None of the subjects experienced complications related to the procedure. Postprocedure clinical evaluation showed improvement in symptoms and exercise capacity. Available follow-up transthoracic echocardiography data (mean 4 months, range 0-20 months) demonstrated patent fenestrations in four of eight patients. None of the patients had thromboembolic or infectious complications and there were no device migrations, erosions or embolizations. Partial ASD occlusion in patients with diastolic dysfunction or RV dysfunction and/or PHT is safe and may be better tolerated than complete ASD closure in selected patients.

3:18 PMAbstract No. 338 - Pre and post-procedural evaluation of imaging biomarkers after radioembolization for hepatocellular carcinoma as an indicator of progression

The purpose of this study is to evaluate possible imaging biomarkers on contrast-enhanced CT and MRI exams that predict local progression per modified Response Evaluation Criteria in solid tumors (mRECIST) criteria post radioembolization of hepatocellular carcinoma (HCC). Among patients who underwent radioembolization for HCC between May 1, 2005 and May 1, 2015 at a single institution, 34 patients had adequate pre and at least 2 post-procedural exams. Local response to treatment was classified as progressive (PD) or stable disease (SD) using mRECIST. Imaging markers, including portal venous phase enhancement (PVE), lobulated enhancement (LE), presence of arterioportal shunting (APS), and portal vein thrombosis (PVT) were assessed in each imaging examination. Wilcoxen Rank-Sum (WRS) and log-rank analyses were performed to establish statistically significant differences in local progression free survival (LPFS). The mean imaging follow-up time was 12.64 months. Local progression was seen in 25 patients (73.5%) following radioembolization. Average time to progression was 2.9 months. PVT, APS, and PVE seen on pre or post-procedural imaging were not significant predictors of LPFS. LE on immediate post-procedural imaging was a significant predictor of progression by WRS (p=0.039) and log-rank analysis (p=0.037), however LE on pre-procedural imaging was not a significant predictor. 9 patients with and 0 patients without progression showed LE on pre or post-procedural imaging, respectively. PVT, APS, and portal venous enhancement were not statistically significant predictors of local progression, whereas immediate post-procedural LE demonstrated a statistically significant decrease in LPFS in patients with hepatocellular carcinoma treated with radioembolization.

A Novel Inherently Radiopaque Bead for Transarterial Embolization to Treat Liver Cancer - A Pre-clinical Study.

Purpose: Embolotherapy using microshperes is currently performed with soluble contrast to aid in visualization. However, administered payload visibility dimishes soon after delivery due to soluble contrast washout, leaving the radiolucent bead's location unknown. The objective of our study was to characterize inherently radiopaque beads (RO Beads) in terms of physicomechanical properties, deliverability and imaging visibility in a rabbit VX2 liver tumor model.Materials and Methods: RO Beads, which are based on LC Bead® platform, were compared to LC Bead. Bead size (light microscopy), equilibrium water content (EWC), density, X-ray attenuation and iodine distribution (micro-CT), suspension (settling times), deliverability and in vitro penetration were investigated. Fifteen rabbits were embolized with either LC Bead or RO Beads + soluble contrast (iodixanol-320), or RO Beads+dextrose. Appearance was evaluated with fluoroscopy, X-ray single shot, cone-beam CT (CBCT).Results: Both bead types had a similar size distribution. RO Beads had lower EWC (60-72%) and higher density (1.21-1.36 g/cc) with a homogeneous iodine distribution within the bead's interior. RO Beads suspension time was shorter than LC Bead, with durable suspension (>5 min) in 100% iodixanol. RO Beads ≤300 µm were deliverable through a 2.3-Fr microcatheter. Both bead types showed similar penetration. Soluble contrast could identify target and non-target embolization on fluoroscopy during administration. However, the imaging appearance vanished quickly for LC Bead as contrast washed-out. RO Beads+contrast significantly increased visibility on X-ray single shot compared to LC Bead+contrast in target and non-target arteries (P=0.0043). Similarly, RO beads demonstrated better visibility on CBCT in target arteries (P=0.0238) with a trend in non-target arteries (P=0.0519). RO Beads+dextrose were not sufficiently visible to monitor embolization using fluoroscopy.Conclusion: RO Beads provide better conspicuity to determine target and non-target embolization compared to LC Bead which may improve intra-procedural monitoring and post-procedural evaluation of transarterial embolization.

Early right ventricular response to cardiac resynchronization therapy: impact on clinical outcomes.

Right ventricular (RV) dysfunction has been associated with a worse outcome in heart failure patients undergoing CRT. However, evidence on the RV response to CRT is controversial and there are no data regarding the early effects of CRT on RV function (RVF). We sought to investigate whether a CRT device favourably influences the RVF acutely after implantation, impacting on long-term outcomes. Patients who successfully underwent CRT device implantation from January 2005 to January 2014 were retrospectively analysed. RV dysfunction was defined by an RV fractional area change <35%. Post-procedural echocardiographic evaluation was performed at a median time of 2 days (interquartile range 1-6 days). The primary endpoint was a composite of all-cause mortality and urgent heart transplantation. A total of 194 patients with available pre- and post-procedural RVF assessment were included. Sixty-two (32%) presented an impaired RVF before the procedure. Of them, 32% showed prompt normalization of RVF following CRT. This occurred in parallel with a large improvement in pulmonary arterial pressure, mitral regurgitation, E/E' ratio, and diastolic function. Pre-implantation independent predictors of early RVF normalization were LBBB (P = 0.034) and higher systolic blood pressure (P = 0.026). Improvement in RVF was independently associated with a better long-term prognosis at multivariable analysis [hazard ratio 0.124; 95% confidence interval 0.016-0.966, P = 0.04). Acute normalization of RVF can be observed after CRT along with haemodynamic improvement, and therefore can be used as an independent predictor of transplant-free survival.

Abstract 12113: Early Right Ventricular Response to Cardiac Resynchronization Therapy: Impact on Clinical Outcomes

Introduction: Right ventricular (RV) dysfunction has been associated with a worse outcome in heart failure (HF) patients undergoing cardiac resynchronization therapy (CRT). However, evidences on the RV response to CRT are controversial and there are no data regarding the early effects of CRT on RV function (RVF). Hypothesis: We sought to investigate whether CRT favorably influences the RVF acutely after implantation, impacting on long-term outcomes. Methods: Patients who successfully underwent CRT implantation from January 2005 to January 2014 were retrospectively analyzed. RV dysfunction was defined by a RV-fractional area change&lt;35%. Post-procedural echocardiographic evaluation was performed at a median time of 2 days (IQR 1-6). Primary end-point was a composite of all-cause mortality and urgent heart transplantation. Results: A total of 194 patients with available pre- and post-procedural RVF assessment were included. Sixty-two (32%) presented an impaired RVF before procedure. Of them, 32% promptly normalized RVF following CRT. This occurred in parallel with a large improvement in pulmonary arterial pressure, mitral regurgitation, E/E’ ratio and diastolic function. Pre-implantation independent predictors of early RVF normalization were left-bundle branch block (p=0.034) and higher systolic blood pressure (p=0.026). Improvement in RVF was independently associated with a better long-term prognosis at multivariable analysis (HR 0.124; 95% CI 0.016-0.966, p=0.04), significantly increasing the accuracy of the long-term risk stratification compared to the baseline Cox model (p=0.04 at 48 months and p=0.048 at 96 months). Conclusions: Acute normalization of RVF can be observed after CRT along with hemodynamic improvement, resulting as independent predictor of transplant-free survival.