Join us for this year's Film InterpretationPanel and see how much fun an educationalsession can be!

Together with junior panellists senior IRswill diagnose several tricky cases. To giveyou a head start, we are showing you thecases in advance (pages 19-21).

The Film Interpretation Panel will take place today, 3 p.m. in Auditorium 1.

Don't miss the FilmInterpretation Panel!

Continuing CIRSE’s long-standing tradition of ending its annual congress with a bang, theFoundation Party 2009 will be another highlight of entertainment and socialising not to be missed!A spectacular show entitled “Fado around the World”will show you that Portugal’s most famous musicalgenre is far from its image of sad songs, but can besang and performed in a great variety of rhythms,ranging from tango all the way to capoeira and of course samba.

CIRSE 2009 - LisbonMonday, September 21, 2009

C RSECardiovascular and Interventional Radiological Society of Europe

Join us for the CIRSE Foundation Party!

Rnews

Catering to all your senses, the Foundation Party 2009will not only treat your eyes and ears, but also yourtaste buds with a delicious dinner including a variety of Portuguese specialties. After dinner and drinks you will have the chance to work it all off dancing until the morning hours Latin style.

To purchase tickets or pick up pre-ordered ones, please visit the Hotels and Social Events Booth in the registration area.

Jim A. ReekersCIRSE President

CIRSE 2009 marks the conclusion of my term asCIRSE President. Although it is tempting to lookback at all the things we have achieved in thepast two years and pat ourselves on the shoul-der, I would like to focus this address on theprojects that lie ahead. I think that this is in thespirit of interventionists, as we tend to look for-ward, searching for new challenges to be tack-led rather than resting on our laurels.

There are two projects which are particularlyclose to my heart. After laying their foundationI hope that they will be further developed andsoon come to fruition:

· A new focus on research· A European Interventional Radiology Skill

Certificate

Although these two aspects seem quite differ-ent at a first glance, I think that research andtraining are very much intertwined, as onlyskilled physicians are able to do properresearch and only sound research can provideus with the knowledge we need to teach thenext generation of IRs.

After the great response to the CIRSE 2008Photo Exhibition CIRSE 2009 is featuringanother photo contest. All medical dele-gates and industry representatives wereinvited to submit their best picture match-ing this year’s theme “World Population andFriends”.

Make sure to visit the exhibition located in Foyer C and cast your vote for yourfavourite image until 5 p.m. The winner of the photo contest will be announced at the Foundation Party.

Photo Competition ends today - Cast your vote! Tuesday, September 22, 2009

Our plan to more actively engage in researchwas put into action with a first registry on clo-sure devices. As it met with a great response, itis clear that many of you also see the need formore evidence in our specialty, and I hope thatthis project will be followed by many more ofits kind.

The other main task for us now is to make surethat interventionists across Europe not onlyreceive adequate training, but are also able tocertify it to their hospital administrators andhealthcare officials. This is why CIRSE is workingon a European Certificate of InterventionalRadiology – ECIR – which will allow interven-tional radiologists to officially document theirqualifications.

I am happy to say that our society is as soundas ever. In the past I have often mentioned itsstrong growth, but I think that a community’sstrength is not only measured by its size, butmost importantly by its actions and its con-duct. Regarding CIRSE’s actions I think we cansafely say that its many projects speak for itself.Our congresses and courses are more attractivethan ever, which can clearly be seen in the pos-itive feedback from the participating physiciansand industry as well as ever increasing dele-gate numbers. Furthermore we have devel-oped from an association centred on a con-gress to a community providing services 24/7,such as our educational website www.esir.org.

Before concluding this address I would like tothank Jan Peregrin for his support as VicePresident during the past two years, and wishhim all the best for his presidency. I am confi-dent that he will do an outstanding job and Ilook forward to his ideas and projects.

Dear Colleagues,

During the course of 2008 and 2009 CIRSE has continued to expand consider-ably, welcoming four new Group Membersto its community.

Among them are two of Europe’s biggestnations; Germany and France which have,along with Hungary, decided to join forces withCIRSE at the preferential conditions offered tosocieties joining in their entirety. Furthermore,the South American Society of InterventionalRadiology - SIDI comprising the majority of theSouth American continent all the way from theRio Grande to Fireland, has become a CIRSEmember, thus adding to our community’s glob-al character.

The continuous growth of the CIRSE familyclearly shows the wish of interventionistsworldwide to cooperate on issues that are thesame everywhere; the definition of standards,furthering clinical involvement and achieving aclear profile for Interventional Radiology.

For more information on CIRSE’s projects andgroup membership visit www.cirse.org

CIRSE Community continues to grow

CIRSE Group Members

congress

3StentsIRnewscongress

C RSECardiovascular and Interventional Radiological Society of Europe

BackgroundUnfortunately most patients with lung cancerpresent with advanced disease at the time ofdiagnosis. Moreover, up to 30% of patients withthe disease will develop central airway obstruc-tion because of endoluminal disease or externaltracheobronchial compression (1). Critical airwaystenosis may also result from post-intubation orpost-tracheostomy trauma or other benign con-genital, inflammatory or infectious etiology(Table 1). Stenting may be applied for internal airwaysplinting to alleviate malignant or benign stric-tures of the tracheobronchial tree with impend-ing asphyxia and death. Patients with advancedmalignant obstructions present with chest pain,obstructive pneumonia, hemoptysis, severe dys-pnea and stridor or a combination thereof, usual-ly on the verge of suffocation. Given the limitedlife expectancy and poor performance status ofthese patients, urgent airway stenting is a suffi-cient and effective palliative therapy thatimproves their quality of life (2, 3).

Clinical and anatomic considerationsThe procedure may be either palliative for inop-erable primary or secondary lung or neck neo-plasms encroaching, infiltrating or compressingthe trachea and the main stem bronchi, or tem-porary for benign diseases like inflammatory andanastomotic strictures (2, 3, 4, 5). Table 1 sum-marises the accepted indications for placementof tracheobronchial stents in malignant andbenign diseases. The most common malignant pathology causingcentral airway obstruction is bronchogenic carci-noma. Intraluminal encroachment or extralumi-nal compression of the trachea or the main stembronchi without involvement of the lobarbranches is the best indication for stent place-ment (3). External airway compression by a ves-sel remains a definitive contra-indicationbecause of the high risk of stent-related vesselerosion, haemorrhage and death (1). Benign airway strictures are generally best treatedsurgically with appropriate reconstruction tech-niques. Temporary tracheal stenting is reservedfor patients with severe comorbidities prohibitingopen surgical repair and usually for anastomoticstrictures in the lung-transplant patient popula-tion in specialised tertiary centres (1).Notwithstanding the emergency mandated bythe symptoms of imminent asphyxia, the site, theseverity and length of the airway stenosis shouldbe thoroughly evaluated with modern thin-sec-tion cross-sectional imaging and multiplanarreformatting before attempting stent placement(3). Volume rendering reconstructions of datasetsacquired with sub-millimetre multidetector CTscans and virtual bronchoscopic navigation with-in the distal lobar branches allow for accuratetreatment planning, especially in cases of high-grade strictures where the flexible bronchoscopecannot see beyond the stricture (6).

Procedure and TechniqueThe procedure generally involves multidiscipli-nary evaluation and execution by a team of inter-ventional radiologists, thoracic surgeons and pul-monologists. A combination of rigid or flexibleendoscopy and plain fluoroscopy under generalanaesthesia is the safest approach for accuratestent deployment with minimal complications.

Alternatively, self-expanding metal stents may beplaced under local anaesthesia and flexible bron-choscopy or even with direct transtracheal punc-ture (2, 3, 4).Under routine fluoroscopy guidance, the stric-ture is initially manipulated with standardguidewires and catheters inserted through theworking channel of the bronchoscope andavoiding excessive force and distal guidewireadvancement that may cause a pneumothorax.Hydrophilic guidewires are rarely needed totransverse a malignant stricture. Direct broncho-scopic visualisation in combination with anatom-ic landmarks like the carina and the vocal cordsare usually adequate for tracheal stenting,whereas selective bronchography with non-ioniccontrast media may be employed for more accu-rate delineation of distal bronchic strictures. Pre-dilation with undersized balloons is appliedin cases of high-grade stenoses. Sizing of self-expanding metal stents (SEMS) is typically basedon appropriate measurements of baseline CTscans and their diameter should be adequatelyoversized (10-20%) to optimise stent appositionand avoid migration. Balloon pre- or post-dila-tion should be generally exercised with cautionand as necessary because of the risk of haemor-rhage and perforation. Bronchoscopy is always applied at the end of theprocedure to confirm optimal stent placementand expansion and to identify and treat any sitesof on-going haemorrhage.Of note, with the exception of solely external air-way compression, tracheobronchial stenting maybe combined with other interventional broncho-scopic procedures, like laser resection, electro-cautery, photodynamic therapy or argon plasmacoagulation in order to debulk the tumour, max-imise luminal gain and optimise stent expansion(1, 3, 7). In case of malignant tracheoesophagealfistulae, concomitant placement of coveredesophageal and tracheobronchial stents is need-ed to effectively seal the fistulation tract (2).

StentsThe first airway stent applied, originally describedin the 1960s, was the plastic Montgomery T-tube,which has a side-arm and requires a tracheosto-my for insertion (1, 2). The first silicone plasticstent, developed by Dumon and inserted withoutthe need for tracheostomy, was a milestone ininterventional bronchoscopic therapies and is stillin clinical use (1). Modern silicone stents areinserted under rigid bronchoscopy and may beremoved as necessary [Dumon (Endoxane,Novatech SA, France), Hood (Hood Corp,Pembroke, USA), Dynamic & Polyflex (both RuschAG, Kernan, Germany)]. However, silicone stentscompletely cover the respiratory epitheliuminterrupting mucociliary clearance and sufferfrom increased rates of secretions’ retention (upto 15%) and migration (up to 20%) (2, 3, 7).Modern airway stents dedicated for malignantdisease are typically made of self-expandingmetal alloys and may be uncovered or covered[Ultraflex & Wallstent (both Boston Scientific,Natick , MA, USA), Alveolus (Alveolus Inc.Charlotte, NC, USA)]. The main advantages ofSEMS include their easy insertion through anendotracheal tube or even percutaneoustranstracheal puncture under combined bron-choscopic and fluoroscopic guidance and theirconformability to the airway anatomy withreduced risk of migration (3). Uncovered SEMS maintain patency and perfu-sion of segmental branches if placed in the lobarbronchi and gradually become epithelialisedallowing for effective drainage of respiratory cilia.However, they cannot be removed because theybecome embedded in the respiratory wall andinherently suffer from progressive tumour in-growth and granulation tissue that may compro-mise luminal patency (8).

Covered tracheobronchial stents are preferential-ly placed in the trachea prohibiting tumour in-growth, whereas uncovered SEMS are chosen inthe main stem and lobar bronchi to avoidobstructive atelectasis of segmental branches.Balloon-expandable stents like the Gianturco andthe Palmaz stent are no longer used in the air-way tree because of their inflexible design, therisk of migration and expectoration duringcoughing and the high rate of hemorrhagic com-plications (2, 3, 5).

Clinical Outcomes Technical success rates are very high 98%–100%),but clinical success rates are somewhat lower, atthe level of 88%–100% for benign conditionsand 82%–92% for malignant disease (3). Over90% of patients with malignant central airwayobstruction will experience relief of symptoms,and in about 10% of them the improvement willbe delayed occurring within 1-2 weeks afterstent placement (2). Furthermore, relief of centralairway obstruction may allow for resolution ofobstructive pneumonia so that the patient maybe eligible for chemotherapy and further onco-logical therapy may be optimised (1). Stentplacement in the setting of post-lung transplan-tation strictures has a reported 83% rate ofimmediate improvement of dyspnea (1).

Complications Similar to applications in other hollow organs,uncovered stents mostly suffer from neoplastictissue in-growth and covered ones from migra-tion. Stent-related complications are more fre-quently encountered in the long-term treatmentof patients with benign airway stenoses andinclude decreased mucociliary clearance andsputum impaction, development of granulationtissue at the stent edges, stent migration andfracture (3, 5). Development of obstructing gran-

Tracheobronchial Stents

Konstantinos KatsanosDepartment of RadiologyPatras University HospitalRion, Greece

Tarun SabharwalConsultant Interventional RadiologistGuy's and St. Thomas' HospitalLondon, UK

References:1. Chin CS, Litle V, Yun J, Weiser T, Swanson SJ. Airway stents. Ann

Thorac Surg. 2008;85(2):S792-6.2. Walser EM. Stent placement for tracheobronchial disease. Eur J

Radiol. 2005;55(3):321–330.3. Shin JH, Song HY, Shim TS. Management of tracheobronchial

strictures. Cardiovasc Intervent Radiol. 2004;27(4):314–324.4. Saito Y, Imamura H. Airway stenting. Surg Today. 2005;

35(4):265–270.5. Zakaluzny SA, Lane JD, Mair EA. Complications of tracheo-

bronchial airway stents. Otolaryngol Head Neck Surg.2003;128(4):478–488.

6. Koletsis EN, Kalogeropoulou C, Prodromaki E, Kagadis GC,Katsanos K, Spiropoulos K, Petsas T, Nikiforidis GC, Dougenis D.Tumoral and non-tumoral trachea stenoses: evaluation withthree-dimensional CT and virtual bronchoscopy. J CardiothoracSurg. 2007 Apr 12;2:18.

7. Bolliger CT, Sutedja TG, Strausz J, Freitag L.Therapeutic bron-choscopy with immediate effect: laser, electrocautery, argonplasma coagulation and stents. Eur Respir J. 2006;27(6):1258-71.

8. Nesbitt JC, Carrasco H. Expandable stents. Chest Surg Clin NAm. 1996;6(2):305-28.

Fig.1: Bronchogenic carcinoma. (a) Axial CT and(b) transparent volume-rendered view of the leftmain stem bronchus.

Fig.2: Tracheal stricture. (a) Curviplanar reformattedCT view of the trachea and (b, c) tracheal stentplacement. The radiopaque marker was superim-posed on the patient’s skin centered on the stricture.

Fig.3: Severe external compression of the tracheafrom extensive mediastinal lymphadenopathy. (a)Axial CT view and (b) stent placement under rigidbronchoscopy and fluoroscopic guidance. Theupper marker is centered on the stricture and thelower points to the level of the carina. Two over-lapping covered stents were placed.

Fig.4: Extensive central airway stenosis involvingthe trachea and both main stem bronchi (leftpanel). Final fluoroscopic image shows a coveredstent in the trachea and two uncovered metalstents placed in the main stem bronchi with aninverse Y configuration.

ulation tissue after permanent tracheal stentingis reported in up to 28% of patients with benignstrictures, but may be successfully treated withlaser therapy and repeated balloon angioplastyor stenting. Therefore, treatment of benign dis-ease should be restricted to retrievable plastic orcovered metal stents. Bioabsorbable stent devices with elegant biome-chanical properties are currently being devel-oped and will definitely play an important role inthe future. Of note; both, plastic and coveredSEMS suffer from bacterial colonisation andbiofilm formation, though these do not alwaysresult in infection (5, 7). Other stent-related com-plications are stent fracture, stent expectorationand patient intolerance requiring early stentremoval (5).

ConclusionTracheobronchial stenting is a well-establishedpalliative therapy for patients with central airwayobstruction due to inoperable advanced neo-plastic disease with minimal serious complica-tions. The interventional radiologist should be anintegral member of a collaborative multidiscipli-nary team in charge of those critically ill patients.

Table 1: Indications for tracheobronchial stenting (1, 2, 3)

Malignant causes

Inoperable malignancy causing intrinsic criti-cal airway stenosis or obstruction, or severeextrinsic airway compressionTumor in-growth or over-growth after previ-ous stentingAdjunct to bronchoscopic tumor debulking tomaintain luminal patencyMalignant tracheoesophageal fistula Relief of obstructive pneumonia to allow otherpalliative oncological therapies

Benign causes

Post-infectious (Tuberculosis, histoplasmosis)

Post-intubation or post-tracheostomy trachealstenosisPost-surgery anastomotic strictures (Lung-transplantation, sleeve resection) TracheobronchomalaciaCongenital tracheal stenosis

C RSECardiovascular and Interventional Radiological Society of Europe

5BTK in DiabeticsIRnewscongress

Critical limb ischemia in diabetic patients is adramatic event in the course of a multifactorialdisease. According to epidemiological investi-gations this problem will further increase dueto the prognosticated rise in the number ofdiabetic patients expected in the next decades.Diabetic patients with CLI (critical limbischemia) suffer from an enormous load ofcomorbidities, and if it comes to amputationfurther dramatic physical and psychologicalburden has to be managed.

Generally lack of conduit, bad or unclear run-off at the distal outflow site and other con-traindications for surgery appear in this patientgroup. Therefore the successful and fastapproach by endovascular means have madeendovascular options the treatment of choice.Even if surgery is potentially a good techniquewith good results, the benefit/risk ratio usuallyseems too low for this patient group.Knowledge of the variety of percutaneousendovascular treatment options of BTK lesionsis therefore mandatory for successful manage-ment of this patient group.

Endovascular optionsRegarding endovascular techniques, a varietyof treatment options are available. Driven bythe urgent need for innovative treatmentmodalities, particularly in the last 5 years, avariety of techniques and innovative deviceshave been investigated. Starting from plain bal-loon angioplasty, subintimal recanalisation, cry-oplasty, cutting ballon techniques and finallyall variety of stents, such as bare metal stents,active and passive coated stents as well as bal-loon and self expandible stents have been eval-uated and can be used sufficiently.

StudiesThe use of balloon angioplasty for the recanali-sation of infrapopliteal arteries has been estab-lished during the last decade. With the intro-duction of low profile, high pressure balloonsin a vast variety of lengths it has become possi-ble to re-canalise even longer and segmentallesions. Subintimal recanalisation has found itsplace within the BTK techniques as well. Innovative devices, such as cryoplasty or cut-ting balloon techniques have also been foundfeasible for application in the lower leg. Themost innovative technique, coated balloons, isrecently under investigation.

Several trials have been established regardingthe use of stents for the treatment ofinfrapopliteal lesions, such as passive coatedstents (PCS), balloon expandable stents, bioab-sorbable stents, balloon expandable drug elut-ing stents (DES) and self expanding nitinolstents. All stents demonstrated their potentialwhen used in CLI patients using aninfrapopliteal approach.

Biondi et al. comprised all recent data from atotal of 640 patients in a meta analysis of 18studies, providing important insights on earlyand mid-term outcomes following infra-genic-ular stenting for BTK disease. Specifically, theyfound that bail-out stenting (i.e. performed forsuboptimal results of balloon-only PTA) witheither balloon-expandable or self-expandablestents was associated with satisfactory angio-graphic results with patency and clinical out-comes up to a median of 12 months of follow-up.

Sub-analyses were also performed, focusingmore precisely on device type and comparingballoon vs. self-expandable devices and bare-metal vs. drug-eluting stents. Such interactionanalyses showed that balloon- and self-expandable stents perform similarly at earlyand mid-term, at least as when employed inthe included studies (i.e. avoiding joint seg-ments or pedal vessels). In addition, the avail-able data suggest the superiority of sirolimus-eluting stents in comparison to bare-metal orpaclitaxel-eluting stents, even if such analysesshould be viewed mainly as exploratory.

Clincial outcomeThe observations in most current studies main-ly concentrate on the angiographic and numer-ic data, such as restenosis rate, late lumen lossdue to intimal hyperplasia and long termpatency. Also, dedicated devices and stents forbelow the knee (BTK) applications have onlyrecently become available and data regardingthe use of stents in the infrapopliteal arteries isstill limited. General limitations of BTK studiesare relatively small numbers of patients andhigh drop out rates, which result in decreasedstatistical power. Therefore clinical data is alsolimited and the leading question that remainsis if stents in an infrapopliteal approach mighthave an effect on the clinical outcome ofpatients and if such stents might reduce theamputation rate in these patients.

Angiographic results vs. clinical data?Regarding angiographic data alone, a discrep-ancy between clinical data and angiographicdata might indeed exist, indicating that angio-graphic results alone do not always reflect theclinical status. In our own observations wefound the use of stents for endovascular thera-py clinically most effective within the first 6months, where stent application might play animportant role to improve clinical conditions.Later on the clinical effects of stents and PTAseem to equalize.

The general clinical approach in the treatmentof critical limb ischemia is early ulcer healing.This, however, is induced by a first pass effect,and might even overcome a secondary ormidterm deterioration of the vascular situation.Our considerations underline the meaning ofthe first pass effect and we suppose that in acritical situation a short term revascularisationmight overcome ischemia and later a dimin-ished flow might be enough to maintain vitali-ty without the need of permanent patency.

Future conceptsBelow the knee (BTK) peripheral artery diseaseis characterised by a multi-level type of periph-eral artery disease involving the infrapoplitealarteries. The endovascular approach is madeeven more complex by the fact that BTK dis-ease in diabetic patients usually ends up beingvery diffuse with a high prevalence of longtotal occlusions. Therefore the endovascularapproach must include a variety of options,including all techniques of PTA as well as stent-ing and results in an individual approach toeach patient. The IR has to offer a broad knowl-edge of these techniques. Further develop-ment in this fast growing field of endovasculartherapy has to be expected and it is our duty tolearn and weigh up all forms of innovative pro-cedures.

BTK in DiabeticsThomas RandDepartment of Interventional and Diagnostic RadiologyGeneral Hospital HietzingVienna, Austria

The basic goal of treating CLI in diabeticpatients remains very simple; to reduce ampu-tation rates and improve clinical status as muchas possible. An open minded early approachand forced application of endovscular tech-niques will definitely help us reach this goal.

BTK in DiabeticsSpecial SessionMonday, September 21, 08:30-09:30Auditorium 8

Don't miss it !

Literature:1. Dorros G, Jaff MR, Dorros AM, Mathiak LM, He T. Tibioperoneal

(outflow lesion) angioplasty can be used as primary treatmentin 235 patients with critical limb ischemia: five-year follow-up.Circulation 2001;104:2057-62.

2. Adam DJ, Beard JD, Cleveland T, Bell J, Bradbury AW, Forbes JF,Fowkes FG, Gillepsie I, Ruckley CV, Raab G, Storkey H; BASIL trialparticipants. Bypass versus angioplasty in severe ischaemia ofthe leg (BASIL): multicentre, randomised controlled trial. Lancet2005;366:1925-34.

3. Dorros G, Hall P, Prince C. Successful limb salvage after recanal-ization of an occluded infrapopliteal artery utilizing a balloonexpandable (Palmaz-Schatz) stent. Cathet Cardiovasc Diagn1993;28:83-8.

4. Bosiers M, Deloose K, Verbist J, Peeters P. Percutaneous translu-minal angioplasty for treatment of ''below-the-knee'' criticallimb ischemia: early outcomes following the use of sirolimus-eluting stents. J Cardiovasc Surg (Torino) 2006;47:171-6.

5. Commeau P, Barragan P, Roquebert PO. Sirolimus for below theknee lesions: mid-term results of SiroBTK study. CatheterCardiovasc Interv 2006;68:793-8.

6. Feiring AJ, Wesolowski AA, Lade S. Primary stent-supportedangioplasty for treatment of below-knee critical limb ischemiaand severe claudication: early and one-year outcomes. J AmColl Cardiol 2004;44:2307-14.

7. Kickuth R, Keo HH, Triller J, Ludwig K, Do DD. Initial clinicalexperience with the 4-F self-expanding XPERT stent system forinfrapopliteal treatment of patients with severe claudicationand critical limb ischemia. J Vasc Interv Radiol 2007;18:703-8.

8. Peregrin JH, Smírová S, Kožnar B, Novotný J, Kováč J,Laštovičková J, Skibová J. Self-expandable stent placement ininfrapopliteal arteries after unsuccessful angioplasty failure:one-year follow-up. Cardiovasc Intervent Radiol 2008;31:860-4.

9. Rand T, Basile A, Cejna M, Fleischmann D, Funovics M,Gschwendtner M, Haumer M, Von Katzler I, Kettenbach J,Lomoschitz F, Luft C, Minar E, Schneider B, Schoder M, LammerJ. PTA versus carbofilm-coated stents in infrapopliteal arteries:pilot study. Cardiovasc Intervent Radiol 2006;29:29-38.

10. Rosales OR, Mathewkutty S, Gnaim C. Drug eluting stents forbelow the knee lesions in patients with critical limb ischemia:long-term follow-up. Catheter Cardiovasc Interv 2008;72:112-5.

11. Scheinert D, Ulrich M, Scheinert S, Sax J, Braunlich S, Biamino G,Schmidt A. Comparison of sirolimus-eluting vs. bare-metalstents for the treatment of infrapopliteal obstructions.EuroInterv 2006;2:169-74.

12. Siablis D, Karnabatidis D, Katsanos K, Diamantopoulos A,Christeas N, Kagadis GC. Infrapopliteal application of paclitaxel-eluting stents for critical limb ischemia: midterm angiographicand clinical results. J Vasc Interv Radiol 2007;18:1351-61.

13. Siablis D, Kraniotis P, Karnabatidis D, Kagadis GC, Katsanos K,Tsolakis J. Sirolimus-eluting versus bare stents for bailout aftersuboptimal infrapopliteal angioplasty for critical limb ischemia:6-month angiographic results from a nonrandomized prospec-tive single-center study. J Endovasc Ther 2005;12:685-95.

14. Tepe G, Zeller T, Heller S, Wiskirchen J, Fischmann A, Coerper S,Balletshofer B, Beckert S, Claussen CD. Self-expanding nitinolstents for treatment of infragenicular arteries following unsuc-cessful balloon angioplasty. Eur Radiol 2007;17:2088-95.

15. Giuseppe G. L. BIONDI-ZOCCAI,1 Giuseppe SANGIORGI,2 MarziaLOTRIONTE,3 Andrew FEIRING,4 Philippe COMMEAU,5Massimiliano FUSARO,6 Pierfrancesco AGOSTONI,7 MarcBOSIERS,8 Jan PEREGRIN,9 Oscar ROSALES,10 Antonio R.COTRONEO,11 Thomas RAND,12 and Imad SHEIBAN, MD1Infra-Genicular Stent Implantation For Below-The-KneeAtherosclerotic Disease: Clinical Evidence From An InternationalCollaborative Meta-Analysis On 640 Patients. J Endovasc Ther.2009 Jun;16(3):251-60.

Fig.1a: Occlusion of the ATA as singleinfrapopliteal vessel in CLI

Fig.1b: Stent application

Fig.1c: Recanalisation after PTA and Stent application

Table 1a: Clinical evaluation of patients treated with PTA vs Stent after 3 months. Data from INPERIA II

Total

Clinical improvementStable Disease orClinical worseningABI Index

PTA (32)

62,5 % (20)

37,5 % (12)0,7 ± 0,3

STENT (33)

81,8 % (27)

18,2 % (6)0,9 ± 0,1

p-value

0,008

n.sn.s

Table 1b: Clinical evaluation of patients treated with PTA vs Stent after 9 months. Data from INPERIA II

Total

Clinical improvementStable Disease orClinical worseningABI Index

PTA (24)

58,3 % (14)

41,7 % (10)0,8 ± 0,3

STENT (19)

47,4 % (9)

52,6 % (10)0,8 ± 0,1

p-value

n.s

n.sn.s

Data by Rand et al., under revision

C RSECardiovascular and Interventional Radiological Society of Europe

7Gastrostomy and GastrojejunostomyIRnewscongress

Percutaneous Gastrostomy and Gastrojejunostomy

Michael LeeConsultant Interventional Radiologist, Beaumont HospitalProfessor of Radiology, Royal College of Surgeons Dublin, Ireland

IntroductionThere are a number of ways to maintain nutri-tion in patients who cannot tolerate oral food.These include:

· Parenteral feeding via a central venous line· Enteral feeding via a nasogastric tube or

nasoenteric tube· Gastrostomy (surgical, endoscopic gastrosto-

my (PEG) or radiologic gastrostomy)· Direct jejunostomy

Parenteral feeding is useful in patients withshort gut syndrome or patients with an inactivegut, but is more commonly used as a shortterm nutrition boost in patients who have lostsignificant weight before embarking on majorsurgery. Parenteral feeding is associated withvenous stenosis, occlusion and infection andtherefore enteral feeding is preferred, if possi-ble. The advantages of enteral feeding overparenteral feeding include the fact that withenteral feeding, gut integrity and gut mass ismaintained, gut stasis is prevented, there isbetter metabolic handling of food, it is lessexpensive and has less infectious complications

Nasogastric or nasoenteric tube feeding is suit-able for patients who require feeding for lessthan thirty days. After this time period patientsare at risk of developing oesophageal stenosis.If feeding is required for more than thirty days,a gastrostomy procedure is required. Surgicalgastrostomy has been performed since theeighteen hundreds, but is now in decline, dueto the development of percutaneous endo-scopic gastrostomy (PEG) and percutaneousradiologic gastrostomy (PRG).

The PEG technique involves the placement of agastrostomy tube with the aid of an endo-scope. The stomach is first transluminated withthe endoscope, which defines the point ofpuncture for gastrostomy tube placement. Thetube is then either placed by a push or pulltechnique.

IndicationsThe main indications for enteral feedinginclude patients with swallowing disorderssuch as those with stroke, multiple sclerosis ormotor neuron disease, patients who haveincreased nutritional requirements such asthose with cystic fibrosis and burn patients orpatients with upper GI tract obstruction suchas patients with oro-pharyngeal or laryngealcancer. Other indications are rarer. In terms ofcontraindications colonic interposition, gastrec-tomy and gastric varices are absolute.

It is also important to consider whether or notthe patient’s demise is imminent. There is notmuch point in perfroming a PRG in patientswho are likely to die in a few weeks. Relativecontraindications include partial gastrectomy,coagulopathy and ascites. Note: if a gastrosto-my tube is to be placed in patients with ascites,the ascites will need to be regularly drained toprevent migration of the tube out of the stom-ach.

Percutaneous Radiologic GastrostomyThere are a number of techniques to place radi-ologic tubes. Fluoroscopy is the mainstay ofimage guidance. A nasogastric tube is insertedinto the stomach for stomach inflation duringthe procedure. This is the key step in the proce-dure, in that gastric inflation needs to be main-tained during the procedure. A gastropexy (fix-ing the stomach to the anterior abdominalwall) is performed to form a seal around thegastrostomy tube. These are usually performedwith T-fasteners (BALT or Kimberly Clark). Afterthe gastropexy has been performed, the stom-ach is punctured in the centre of the gas-tropexy area and a stiff guidewire inserted intothe stomach. The tract is dilated and a tubeplaced.

Current tubes available for radiologic gastros-tomy are either derivations of abscess drainagecatheters or Foley catheters. These are general-ly inadequate for long-term feeding. However,they are simple to place. Laterally, intervention-al radiologists have moved away from placingthese tubes and have moved either towardsprimary placement of button type gastrostomytubes (Mic-Key, Kimberley Clarke or CorfloCubby, Corpak) or placement of PEG tubes.

PEG tubes can be placed by interventional radi-ologists without the use of an endoscope.These are more robust and associated with amuch better long-term patency. They also havebetter fixation devices, so that they do not dis-lodge easily. The rate limiting step with thisprocedure is cannulating the GE junction fromthe stomach. This can be achieved by eitherpuncturing the stomach from the anteriorabdominal wall and cannulating the GE junc-tion with an angiographic catheter andhydrophillic guidewire or putting an angio-graphic catheter and guidewire through thegastroesophegeal junction from the mouthand using a snare to achieve a through andthrough access. Once a through and throughaccess from the mouth to the anterior abdomi-nal wall is created, a pull type gastrostomytube can be pulled from the mouth throughthe oesophagus and stomach and out theanterior abdominal wall to create a PEG.

The placement of gastrostomy buttons is anovel technique for gastrostomy. Gastrostomybuttons are preferred by patients, as they areflush with the skin. They are designed for inser-tion in mature tracks, but can be inserted denovo into immature tracks. T-fastener gas-tropexy is mandatory. The measurement oftrack length is also mandatory to devise a cor-rect button length. A kit is provided by onecompany (Kimberely Clark, Fig. 1) which con-tains all the equipment necessary for buttonplacement.

Alternatively, a homemade kit can be made up,using an angioplasty balloon to measure thetrack length and also dilate the track. The but-ton can then be placed over a stiff guidewire,using an inner small fascial dilator to helpguide the button over the wire (Fig. 2). In theKimberley Clark kit, a telescoping dilator with apeel-away sheath, T-fasteners and tract measur-ing balloon are all included.

Gastrostomy and Gastrojejunostomy Foundation CourseMonday, September 21, 10:00-11:00Auditorium 1

Don't miss it !

ResultsTechnical success for PRG approches 100%compared to 97% - 98% for endoscopicallyplaced PEG tubes. However, the rate of block-age and dislodgement is much higher for theold type radiology gastrostomy tubes (Table 1).

Major complications such as aspiration, peri-tonitis, perforation, haemorrhage and majorwound sepsis occur in approximately 6% ofradiologic gastrostomy tubes compared to 10%with PEG tubes and 20% with surgical tubes(Table 2). Minor complications such as dislodge-ment and superficial wound infection or pain atthe site occur much more frequently with radio-logic tubes than with PEG tubes (Table 3).

GastrojejunostomyWe perform gastrojejunostomy when there is ahistory of reflux, hiatus hernia, gastroparesis orhistory of aspiration. The key step in gastroje-junostomy is to angle the puncture of the stom-ach towards the pylorus to facilitate cannulationof the pylorus with a hockey-stick catheter andhydrophillic wire. A gastrojejunostomy tube canthen be placed in the jejunum, or indeed a gas-trojejunal button can be used (Kimberely Clark)

Fig.1: Kimberly Clark gastrostomy button set containing T fasteners, track measurement balloon and telescopic dilator with peel-away sheath. Note the gastrostomy buttons come in different lengths (1.5 to 5 cms) and are chosen after track measurement.

Radiologic, surgical and endoscopic tubes canalso be converted to gastrojejunal tubes by inter-ventional radiology. The key step in these proce-dures is to insert a peel-away sheath into thestomach to redirect the track towards the pylorus.

Difficult AccessOccasionally CT ultrasound guidance may benecessary to access the stomach. Generally, theindications for CT/ultrasound guidance arepatients with complete oesophageal obstruc-tion, kyphoscoliosis or partial gastrectomy. Thestomach can be inflated using a percutaneousneedle with a second access used for gastrosto-my tube placement. I emphasise, however, thatCT/ultrasound guidance is rarely needed.

ConclusionInterventional radiologists can now offer pri-mary button gastrostomy tube placement, PEGtube placement or gastrojejunal placement. Ibelieve that this places interventional radiolo-gists in a unique position in providing enteralnutrition. A regular screeing room can be usedfor gastrostomy and the procedure takesapprox 30 mins. Is should be a routine IR proce-dure in all IR departments.

Table 1: Complications

Author

O’Keeffe SainiHalkierHicksBellRyan

Pat

100125252158519316

Success (%)

10099991009599

Complications (%) Mortality (%)

000.820.40.3

Major 01.61.661.30.9

Minor 159.54.4122.93.2

Table 2: PEG vs PG

Method

PGPEGSurg

Pat

8374194721

Success (%)

99.295.7

100

Complications (%) Mortality (%)

0.30.52.5

Major 5.99.419.9

Minor 7.85.99.0

Table 3: Radiologic PEG/PIG

Technical SuccReplacementInfectionAspirationBlockage

50 PEG (%)

981218100

50 PRG (%)

100202010

60 RadPEG (%)

10003.33.30

24 radiologic PEG in failed PEGS Endoscopy detected peptic disease in 21%· Laasch et al. Clin Rad 2003;58:398-405

Wollman et al. Radiology 1995;197:699

Special Edition / CIRSE 2009 - Lisbon

8 IR in Portugal Monday, September 21, 2009

Vascular and Interventional Radiology inPortugal dates back to the late 1920s, when themost innovative and productive developmen-tal period in diagnostic radiology took place.This was due to a group of brilliant Portuguesephysicians who were responsible for the devel-opment of diagnostic angiography, togetherwith the introduction of the first organic radio-opaque contrast medium by the youngAmerican urologist Moses Swick, synthesizedby Binz and Rath in Berlin, and thanks toWerner Forssmann’s heroic catheterization ofhis own heart in Berlin in 1929.

The Portuguese School of experimental andclinical investigators was led by the 1949 NobelPrize Winner in Physiology and Medicine EgasMoniz, a distinguished inaugural professor ofneurology and psychiatry at Lisbon University.

It was Moniz’s goal to develop cerebral arteri-ography to localize cerebral tumours and totreat neurological disorders by intra-arterialinjections. He planned a great number ofexperiments on monkeys, rabbits, dogs andhuman cadavers in an attempt to discover asafe intra-arterial radiological contrast agentand a suitable technique for clinical cerebralarteriography. His first successful human clini-cal carotid arteriogram was performed on June28th, 1927 using 25% sodium iodide. He subse-quently utilized colloidal thorium dioxide, butlater abandoned it due to its delayed carcino-genic properties, replacing it with the neworganic iodine media introduced by Swick.

Moniz’s success stimulated his talented clinicalcolleagues to extend the new arteriographictechnique into new territories. Reynaldo dosSantos, Augusto Lamas and J. Pereira Caldasintroduced aortography and peripheral arteri-ography; Lopo de Carvalho, Almeida Lima andEgas Moniz developed pulmonary and cardiacangiography;

Hernani Monteiro developed lymphography;João Cid dos Santos introduced clinical periph-eral phlebography; A. Sousa Pereira developedabdominal and portal venography and N. Airesde Sousa conceived the technique of angioky-mography and contributed to the PortugueseSchool of angiography by his remarkable workon microangiography.

These researchers were not only interested inthe purely diagnostic aspects of their newlycreated science, but also in the therapeuticpotential of intra-arterial therapy. This was atruly remarkable and probably unique recordof medical innovation by a small group of bril-liant investigators from the Portuguese schoolwho within a few years established an entirelynew dimension of vascular and organ imagingin anticipation of Interventional Radiology.

To my knowledge the first PTA in Portugal wasperformed in Lisbon in 1981. Many other hos-pitals followed this practice in the consecutiveyears with the first stent deployed in 1987. Thefirst TIPSS procedures were done in 1992 inCoimbra and Lisbon. The first uterine fibroidembolization on Portuguese soil was per-formed in Lisbon in 1996, the first carotidangioplasty was carried out in Coimbra in 1997.In 1999 the first abdominal aortic endoprothe-sis was implanted in Lisbon. Oporto andCoimbra followed one year later.

In this context I would also like to mention theFirst International Symposium on InterventionRadiology that was held at Algarve in 1979, M.Martins da Silva and J.A. Veiga-Pires being thechairmen of that event.

As you can see, Portuguese interventional radi-ologists have been in the forefront of IR devel-opments in Europe in many aspects and I amconfident that the new generations willachieve the fulfilment of their scientific ambi-tions, their spirits being lifted by the memoryof Egas Moniz who achieved so much with sofew resources.

The History of Interventional Radiology in Portugal

Paulo Vilares MorgadoCIRSE 2009 Host Committee Chairman

The number of hospitals practicingInterventional Radiology has increased inrecent years despite the more heavy duty pro-cedures mostly being carried out in specializedGeneral and University hospitals.

At the 1995 General Assembly of thePortuguese Society of Radiology and NuclearMedicine (SPRMN) the Portuguese Section ofVascular and Interventional Radiology (SRVI) aswell as the Magnetic Resonance Imaging andPediatric Imaging Sections were established.Today the SRVI has more than one hundredand sixty active members. It is a well estab-lished section organizing thematic meetings,case-based discussions, hands-on workshopsas well as a regular general assembly. It activelyparticipates in the biennial meeting and otherscientific activities organized by the SPRMN.

We are extremely happy about CIRSE’s decisionto come back to Portugal in 2009 thirteen yearsafter the CIRSE’s Annual Meeting in Madeira.We feel it is time to give something back toCIRSE and are therefore considering, amongother things, becoming a CIRSE GroupMember. We feel that this will be mutually ben-eficial to both CIRSE and the SRVI and as aresult to all Portuguese interventional radiolo-gists.

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

Austrian Society of Interventional Radiology (ÖGIR)

Brazilian Society of Interventional Radiology and Endovascular Surgery (SoBRICE)

British Society of Interventional Radiology (BSIR)

Cardiovascular and Interventional Society of Turkey (TGRD)

Chinese Society of Interventional Radiology (CnSIR)

Czech Society of Interventional Radiology (CSIR)

Danish Society of Interventional Radiology (DFIR)

Dutch Society of Interventional Radiology (NGIR)

Finnish Society of Interventional Radiology (FSIR)

German Society of Interventional Radiology (DeGIR)

Indian Society of Vascular and Interventional Radiology (ISVIR)

Interventional Radiology Section of the Polish Medical

Society of Radiology (PLTR)

Israeli Society of Interventional Radiology (ILSIR)

Japanese Society of Angiography and Interventional Radiology (JSIR)

Russian Society of Interventional OncoRadiology (SIOR)

The Official Journal of

C RSECardiovascular and Interventional Radiological Society of Europe

9Varicose VeinsIRnewscongress

Varicose veins are a very common problemaffecting up to 40% of the adult population inthe Western world. Their managementthroughout the 20th century was patchy to saythe least and remained so despite the moveaway from treatment largely by general sur-geons to management solely by vascular spe-cialists. Over the last decade several new, officebased, local anaesthetic, ultrasound guidedcatheter techniques have been developedwhich are very popular with patients due toreduced pain, early return to normal activities,absence of cuts and scars, lower risks, goodsymptom relief and cosmetic results as well aslow recurrence rates.

The poor results of traditional surgery withhigh recurrence and low patient satisfactioncan be attributed to several factors. Firstly, eventhe best surgical technique in the best hands inmany cases inevitably results in neo-vasculari-sation and recurrence. Secondly, varicose veinswere often perceived as less important, lessdemanding and less interesting than arterialproblems. As a consequence of this many vari-cose vein operations were commonly delegat-ed to the most junior members of the surgicalteam with little or no supervision. Thirdly, pre-operative treatment planning has often beensuboptimal with very few vascular surgeonsundertaking a duplex ultrasound scan them-selves.

With the advent of effective image guidedcatheter techniques for the management ofvenous insufficiency we as interventional radi-ologists are falling into the trap of replicatingthe past attitudes of surgeons towards venousdisease. Aortic aneurysms and arterial insuffi-ciency are viewed as sexy, important and chal-lenging, whereas varicose veins and venousinsufficiency in general are regarded as boring,easy and unimportant.

There is almost an embarrassment amongsome who think of varicose veins as just a cos-metic vanity issue rather than a genuine med-ical problem. Although many patients do justfind them ugly, the small proportion of a mas-sive population who have serious symptoms,ulceration and dangerous bleeding still meanthat the overall impact on the health of ournations and the associated costs exceeds thatof peripheral arterial disease.

These attitudes are compounded by the poten-tial turf battles in healthcare systems wherepersonal income is involved. Many vascular sur-geons rely on “veins” to pay private school feesand exotic holidays. To avoid such turf battlesthe majority of interventional radiologists haveleft the management of venous insufficiency totheir surgical colleagues justifying their unwill-ingness to enter the field to themselves andothers by the “facts” that such work is boring,easy and unimportant and in any case theyhave too much else to do and hence no time.These are just the same attitudes which led tosuch poor surgical results in the past. Thereshould be no need to be concerned about turfhere; there will always be plenty of venouswork to keep us all busy.

With a widespread shortage of interventionalradiologists to provide an adequate cover foremergencies we cannot afford to turn awayhigh volume elective work on the pretext thatwe have too much to do already. This may helpin the short term, but in the long term we willhave insufficient income to pay for the num-bers of interventional radiologists required toprovide 24/7 emergency care. To survive as aspecialty it is widely recognised that we needto morph into “proper” clinicians with outpa-tient clinics and properly assess and follow upthe patients we treat. A venous clinic is an idealroute into such clinical interventional radiolo-gy, enabling referral patterns with primary andsecondary care physicians to be established asa springboard for other conditions.

On top of all this is our responsibility topatients. Without a shadow of a doubt thosetrained and experienced in the use of ultra-sound to make diagnoses and to guide needlepunctures and wire and catheter manipulationthrough often hostile vascular territory arethose best able to provide safe and effectivecatheter based venous therapy. We as interven-tional radiologists have just those skills inabundance and we owe it to patients to offerthese treatments and be at the forefront ofservice provision and future developments. Inaddition it is only us who have the experienceof fluoroscopically guided embolisation whichmany patients require.

In an IR venous practice all patients can betreated safely and effectively without surgery.This is what they want and this is what theyget. Compare that to the online patient infor-mation on varicose veins from the VascularSociety of GB and Ireland (mainly vascular sur-geons) which claims that the new non-surgicaltreatments are only suitable for 70% of thosewith no previous surgery and only 20% ofthose who had had previous surgery.

I can only assume that these figures are a resultof the practitioners avoiding difficult cases (tor-tuous, short and spasm prone veins, obesepatients, etc.). Such cases are just those whichinterventional radiologists find an enjoyablechallenge. Certainly the technical skills requiredto undertake venous intervention successfullyare just as demanding as those required forarterial work.

Effective management of venous insufficiencyrequires detection of all sources of reflux usual-ly by duplex ultrasound scanning and thenobliteration of the reflux starting proximallyand moving distally. The most common veinswhich contribute and require ablation are inter-nal iliac, ovarian, truncal (great and smallsaphenous, anterolateral thigh) perforators andbranch varicosities. The majority of patientsrequire truncal ablation, best dealt with usingthermal methods and obliteration of branchvaricosities by foam sclerotherapy ormicroavulsions.

Foam/Laser/RF for varicose veins(Why we should get involved)

Foam sclerotherapySclerotherapy using intravenous injections ofliquid sclerosants like STD and polidocanol hasbeen used for the last 50 years or so but wanedin popularity towards the later part of the 20thcentury following the publication of a 10 yearRCT showing high recurrence rates. Morerecently developments using foamed liquidand gas combinations and ultrasound guid-ance of the injections have led to something ofa resurgence of interest.

Despite this, however, the results of foam scle-rotherapy for truncal incompetence are signifi-cantly worse in most hands than surgery, laseror RF and most practitioners reserve foam scle-rotherapy for the treatment of branch varicosi-ties after truncal ablation. For this application itis very effective. The foam is made by mixing 1part sclerosant with 4 parts air or CO2/oxygenmix, using the Tessari method of rapid injectionfrom one syringe to another through a partclosed 3 way tap. This is then injected into thevaricosities and massaged through the veinsfollowed by two weeks of class 2 compressionhosiery. One treatment session is usually suffi-cient, but it can be repeated if necessary.Complications are rarely serious, but there is avery small risk of cerebral embolus leading tovisual disturbance and potentially a full blownstroke. Skin staining is common, but usuallyresolves with time. Phlebitis can occur andoccasionally requires aspiration of retainedcoagulum.

Thermal ablationThis involves the use of an intravenous catheterto deliver thermal energy either by way of laserlight (EVLA) or RF (RFA). Both techniques areguided by ultrasound and involve the insertionof a catheter into the incompetent truncal veinat the point where the lowest varicose tributaryarises.

This is either done Seldinger style or through avascular sheath. The catheter is advanced tojust below the superficial/deep vein junctionand in the case of laser a fibre is threaded upand left protruding from the end of thecatheter. Local anaesthetic is injected aroundthe vein along its length. The laser fibre or RFcatheter is then withdrawn down the vein asenergy is delivered at a rate dependant on sizeof vein. A compression stocking is applied andworn for 2 weeks. Injections or avulsions of thebranch varicosities are undertaken either at thetime of truncal ablation or more commonly atfollow up after 6 weeks.

There is much discussion about the relativemerits of RF or laser, most of which is of dubi-ous scientific basis and largely commercial inorigin. The major companies have investedhugely in protecting and growing their marketsresulting in much mutual criticism and someoveregging of their own claims. There is goodevidence that both the major thermal tech-niques work remarkably well with few sideeffects.

David WestConsultant interventional radiologistUniversity Hospital North StaffordshireStoke-on-Trent, UK

Fig.1: Gross varicose veins before treatment

Venous DiseaseSpecial SessionWednesday, September 23, 08:30-09:30Auditorium 6

Don't miss it !

Fig.2: The same patient after EVLA

The actual treatments are very well toleratedand virtually pain free. Laser does cause someminor pain usually around 5 days, but is below2 on a 1-10 pain scale. RF causes even less pain.Laser causes more bruising than RF, but it hasusually gone by 2 weeks which is when thestockings are removed. More serious sideeffects with laser are virtually unknown, but RFdoes have a higher and significant incidence ofDVT, nerve injury and skin burns. Laser’s greatadvantages are its low inherent cost (a simplebare fibre) and its small size and flexibilitywhich enable it to effectively ablate virtuallyany vein however tortuous or however much inspasm. RF has limitations with treating shortsegments and accessing tortuous and nar-rowed veins.

Capital equipment costs are similar betweenthe two and most manufacturers will loan amachine free of charge in the hope of making agood profit on the consumables. Most manu-facturers (laser and RF) insist on their own kitsbeing used on their machines. The most costeffective option is to choose a generic laserand shop around for the best deal on fibres.Don’t be put off by the RF manufacturer’sclaims that laser regulations are difficult toabide by. At most you will need to cover upwindows and mirrors with blinds, have a lockon the door and access to a laser protectionadvisor which most hospitals already have.

C RSECardiovascular and Interventional Radiological Society of Europe

11EVAR IRnewscongress

Nearly 2 decades ago the deployment of the firstendovascular graft in an abdominal aorticaneurysm by Parodi ushered in a new era in thetreatment of an extremely deadly vascular condi-tion. Since then, there has been significant evolu-tion in both, devices and technique with increasingamounts of data available to the lineated out-comes in various types of procedures. More recent-ly both, devices and operators have begun push-ing the boundaries of what has been traditionalendovascular aneurysm repair (EVAR). Additionally,there has been a steady increase in the utilizationin EVAR, likely associated with a decline in themean annual number of AAA ruptures and mortal-ity for intact and ruptured AAAs (1).

In the United States, according to MedicarePart B data sets, the number of EVAR cases hasshown 162% growth from 2001 to 2006(11,028-28,937), while surgical AAA repairsdecreased by 51% (31,965 to 15,665) duringthe same period of time. The overall frequencyof treatment of AAA has remained stable (2).This trend has also shown to be more and lesssimilar in European studies (3). Currently, basedon manufacturer provided data, 64% of AAAsin the United States and 40% in Europe arebeing treated with EVAR.

EVAR vs. Open Repair A number of historic trials comparing EVAR toopen surgery (DREAM & EVAR 1) and one ran-domised trial comparing EVAR to no interven-tion (EVAR 2) in "unfit" patients have alreadybeen completed (4-6). DREAM and EVAR 1 trialsclearly demonstrated an early perioperativemortality benefit for EVAR. According to theEVAR 1 trial, blood product use and length ofhospital stay also favoured EVAR. Although thetrend towards an early mortality advantage forEVAR was lost within 2 to 4 years in these stud-ies, aneurysm related death remained less(3.5% EVAR vs. 6.3% OS) than OS (5).

The Open Versus Endovascular Repair (OVER)trial, which is ongoing in the United States, is a9 year old study that began in 2002 comparingEVAR with standard open surgery using amulti-centre randomised trial through theDepartment of Veteran Affairs (VA). Theresearchers enrolled 881 patients and random-ly assigned 444 patients to undergo EVAR for

aneurysms ≤5 cm and 437 patients to openrepair. Its primary results which wereannounced this year at the Society for VascularSurgery Meeting (Denver 2009, OVER: EVARassociated with lower post-procedural mortali-ty. Cardiology Today: June. 2009) showed thatEVAR is associated with less post-proceduraland 30-day mortality than open repair (0.2%EVAR versus 2.3% OS; P=0.006), while mortalitywas lower for both procedures than in earliertrials. Secondary procedures and abdominalaortic aneurysm-related hospitalisations andclaudication were more frequent after EVAR,but not significant according to the author,Frank A. Lederle, MD (7).

Yet, based on current data, EVAR has proven itssuperiority in short term results and showed atleast comparable long term outcomes to OS,which seems convincing to be considered asthe first treatment in appropriate candidates.This has been reflected in large administrativedata bases in the United States, which havedocumented a trend towards AAA repair usingEVAR technique (2).

EVAR & Small AneurysmsA few retrospective studies suggested that theoutcomes after EVAR are better in patients withsmaller (4-5 cm) vs. larger (>5.5 cm) aneurysms(8-10). This has advocated the idea that EVARmight actually improve survival in patients withsmall aneurysms while previous randomisedclinical trials (ADAM and UKSAT) failed to showsuch benefit in early open surgical repair (11).Two randomised clinical trials, one in Europe(CAESAR) and one in United States (PIVOTAL),are ongoing to provide objective evidence toguide the use of EVAR for small AAAs (12).

EVAR & Ruptured AneurysmsUse of EVAR for ruptured AAAs (RAAA) has alsoshown promise, yielding survival results com-parable with open repair for rupture (13). Arecent study on National Inpatient Sample (NIS)in the United States showed that from an esti-mated 27,750 hospital discharges for RAAAbetween 2001 and 2006, 11.5% were treatedwith EVAR. Additionally, despite the relativelyinsignificant change in incidence of aneurys-mal rupture, the percentage of patients under-going EVAR for RAAA increased from 5.9% in

EVAR - Updates on ResultsBarry T. KatzenBaptist Cardiac & Vascular InstituteMiami, USA

Vahid EtezadiBCVI Cook Research ScholarBaptist Cardiac & Vascular InstituteMiami, USA

2001 to 18.9% in 2006. Furthermore, the overallcrude mortality following EVAR and OR for rup-tured AAA was 31.7% and 40.7% respectivelywhile these mortality rates were significantlylower at the centres with high annual volumeof AAA repairs (20% vs. 37%), suggesting thatthe experience of the centre is a strong predic-tor of survival (14).

Another literature review study showed anoverall 94.9% technical success rate in 531patients undergoing EVAR for rupturedaneurysm and a short-term mortality of 30.2%with 4.9% mortality reduction for each 10%increase in the proportion of cases doneendovascularly (15). Whether the results of thisstudy are due to selection bias is open todebate. Yet, well defined criteria of EVAR treat-ment for ruptured aneurysms and randomisedtrials in this setting are needed.

EVAR & Complex AnatomyAnatomy is the single most important factor indeciding whether to treat the AAA with EVARor open repair. Although their long term followups are yet to come, the advent of new tech-niques and devices such as fenestrated andmulti-branch endografts has shown promisingresults in patients with a short, angulated orotherwise challenging proximal neck. A fewnew endograft designs are currently under trialattempting to improve issues such as deliver-ability, fixation, flexibility and durability (16).

EVAR techniques have also been subject toconsiderable changes. Hybrid procedures haveshown the potential for extension of stent graftapplications to the aortic arch, ascending aorta,and thoraco- abdominal aortic pathologies.Furthermore, randomised clinical trials areunder way to determine whether the generallyaccepted threshold of 5.5 cm for elective openAAA repair should be decreased in EVAR candi-dates (13).

However, there are still many patients withanatomies, such as unfavourable neck, tortuosity,or difficult access that preclude them from candi-dacy or cause them to have sub-optimal resultskeeping a wide open field for device manufactur-ers and physicians to refine existing platforms andconceive of possible next-generation solutions.

References:1. Giles KA, Pomposelli F, Hamadan A. et al. Decrease in total

aneurysm-related deaths in the era of endovascular aneurysmrepair. J Vasc Surg 2009;49(3):543-50

2. Levin DC, Rao VM, Parker L. et al. Endovascular repair vs opensurgical repair of abdominal aortic aneurysms: Comparative uti-lization trends from 2001 to 2006. J Am Coll Radiol.2009;6(7):506-9

3. Wanhainen A, Bylund N, Bjorck M. Outcome after abdominalaortic aneurysm repair in Sweden 1994-2005.Br J Surg.2008;95:564-90

4. Blankensteijn JD, de Jong SE, Prinssen M. et al. DutchRandomised Endovascular Aneurysm management (DREAM).Two-year outcomes after conventional or endovascular repairof abdominal aortic aneurysms. N Engl J Med. 2005;352:2398-2405

5. EVAR Trial Participants. Endovascular aneurysm repair versusopen repair in patients ith abdominal aortic aneurysm (EVARtrial 1): randomised controlled trial. Lancet. 2005;365:2179-2186

6. EVAR Trial Participants. Endovascular aneurysm repair and iout-come in patients unfit for open repair of abdominal aorticaneurysm (EVAR trial 2): randomised controlled trial. Lancet.2005;365:2187-2192

7. Society for Vascular surgery Meeting -Denver 2009. OVER: EVARassociated with lower post-procedural mortality. CardiologyToday:Jun. 2009

8. Zarins CK, Crabtree T, Bloch DA. et al. Endovascular Aneurysmrepair at 5 years: Does aneurysm diameter predict outcome? JVasc Surg.2006;44:920-9

9. Welborn MB, Yau FS, Mordall JG.et al.Endovascular repair ofsmall abdominal aortic aneurysms: A paradigm shift? VascEndovasc Surg 2005;39:381-91

10. EUROSTAR Collaborators. Diameter of abdominal aorticaneurysm and outcome of endovascular aneurysm repair: doessize matter? J Vasc Surg 2004;39:288-97

11. Lederle FA, Wilson SE, Johnson GR. et al. Immediate repair com-pared with surveillance of small abdominal aortic aneurysms. NEngl J Med 2002;346:1437-44

12. Oriel K, The PIVOTAL study: A randomised comparison ofendovascular repair versus surveillance in patients with smallerabdominal aortic aneurysms.J Vasc Surg 2009;49(1): 266-69

13. Eliason JL, Upchurch GR. Endovascular treatment of aorticaneurysms: state of the art. Curr Treat Options Cardiovasc Med.2009;11(2):136-45

14. MCPhee J, Eslami MH, Arous EJ. et al. Endovascular treatment ofruptures abdominal aortic aneurysms in United States (2001-2006): a significant survival benefit over open repair is inde-pendently associated with increased institutional volume. JVasc Surg 2009;49(4):817-26

15. Azizzadeh A, Villa MA, Miller CC. et al. Endovascular repair ofruptured aortic aneurysms: Systemic Literature Review.Vascular; 2008;16(4):219-224

16. Deaton DH. The next generation of aortic endografts.Endovascular today 2009: 8(1): 40:52

AAASpecial SessionMonday, September 21, 10:00-11:00Auditorium 6

Don't miss it !

Standards of Practice Committee ChairmanThierry de Baère and his committee arehappy to announce that CIRSE has recentlyreleased two new standards of practice doc-uments.

Fabrizio Fanelli from the Sapienza University inRome and Michael Dake from the StanfordUniversity School of Medicine, California, havedrawn up a comprehensive SOP document onthe endovascular treatment of thoracic aortic

All CIRSE SOP documents can be viewed atwww.cirse.org

Standards of Practice

The Future of EVARThe future of EVAR as the potential gold stan-dard for aortic aneurysm therapy is highlydependent on the vision and creativity of both,interventionists and technology innovators.The next generation of aortic endografts withmore flexibility and lower profile as well asapplication of new techniques such as electro-magnetic (EM) tracking systems, 3D navigation,real- time MRI guidance and robotic technolo-gy could facilitate visualisation, improve accu-racy, reduce contrast requirements and simplifythe follow up, bringing EVAR even closer to theideal AAA treatment.

aneurysm and type B dissection and portalvein embolization which will be published inCVIR shortly. Another new standards documentwas elaborated by Alban Denys and NicolasDemartines from the University of Lausanne,Switzerland in cooperation with FredericDeschamps and Thierry De Baère from theFrench Institut Gustave Roussy. Afshin Gangi,Georgia Tsoumakidou and Xavier Buy’s guide-line on bone tumour management has recentlybeen made available online at the CIRSE web-site.

A document on Percutaneous AblativeTechniques of Intervertebral Discs by AlexisKelekis and a document on Liver RFA byThierry de Baère and Laura Crocetti are aboutto be completed. All documents will be avail-able in CVIR shortly and can be viewed atwww.cirse.org.

Together with the SIR CIRSE is working onguidelines on embolization, patient radiationdose management and the treatment of lowerextremity superficial venous insufficiency withambulatory phlebectomy.

Acute peripheral arterial occlusion is responsi-ble for a wide variety of complications culmi-nating in limb loss or death. The incidence ofacute limb ischemia is still unsettled, but it isassessed at 14/100.000 people and accountsfor 10-16% of the vascular workload.

Various causes for acute occlusions of theperipheral arteries have been described: · thrombosis of a native artery with athero-

sclerotic stenoses· thrombosis of an arterial bypass graft· embolism from the heart· aneurysm· atherosclerotic plaque· thrombosed popliteal aneurysm

Generally speaking acute arterial occlusion ismainly provoked by embolism and thrombosiswhose differentiation is difficult and clinicallyimpossible in 10-15% of cases. The severity ofacute peripheral arterial occlusion primarilydepends on location and extent of luminalobstruction by a new thrombus or embolusand the capability of the existing collateral bedto let the blood flow around the obstruction.

Three different stages of the disease are clini-cally classified:

I-ViableII-Treated III-Irreversible

The sudden onset of hypoperfusion of the legrapidly leads to systematic acid-base and elec-trolyte disorders that impair cardiopulmonaryfunction. Successful revascularization mayinduce a severe injury, causing further neuro-muscular damage within the extremity.Thrombolytic agents have been clinicallyemployed since 1955. In the early 1970s throm-bolytic agents were administered by intra-venous route; Streptokinase and Urokinase areeffective in restoring the patency of acuteoccluded arteries in about 75% of cases.The high risk of bleeding complications of sys-temic infusion has increased the catheter-direct thrombolytic therapy.

Thrombolytic therapy can be used in case ofacute thrombosis of a patent by-pass graft ornative artery, acute arterial embolus not acces-sible to embolectomy, acute thrombosis of apopliteal artery aneurysm resulting in severeischemia and acute thromboembolic occlusionwhen surgery involves a high degree of mortal-ity risk. Contraindications to thrombolysis canbe divided into:

Absolute - active bleeding diathesis, acute gas-troduodenal ulcers, recent gastrointestinalbleeding within previous 10 days, history ofstroke, neurosurgery or intracranial traumawithin 3 monthsRelative - uncontrolled hypertension, intracra-nial neoplasm, intracerebral vascular malforma-tions, antiplatelet therapyMinor - renal or hepatic insufficiency

Patients with an acute, severe, irreversible limbischemia and no evidence of collateral circula-tion are not candidates for thrombolysis.Indeed in these cases the rapid restoration ofthe blood flow increases the risk of the rare(<1%) but serious reperfusion syndrome. Intra-

arterial thrombolysis is based on the originaltechnique described by Mc Namara and Fisherin 1985. In patients with femoral and iliacocclusion the favourite access site is the con-trolateral femoral artery. Access through theipsilateral femoral is preferred for thrombi inthe superficial femoral artery, popliteal arteryor tibial arteries.

By using the ipsilateral limb access, potentialcatheter-related complications in the intactlimb are avoided. If no femoral artery can beused, a brachial approach may be considered.The thrombolytic agent can be infused througha catheter with the tip at the level of the proxi-mal part of the thrombus or with the catheteradvanced within the thrombus. Several studieshave documented that forceful infusion of thethrombolytic agent into the entire length ofthe thrombus accelerates thrombolysis.

A successful passage of the guidewire throughthe thrombus predicts >95% likelihood of suc-cessful lysis, whereas inability to pass thethrombus reduces the chance of success. Apositive outcome is more frequent in prosthet-ic graft (78%) and native arterial occlusion(72%) than in vein graft thromboses (53%). Anefficacious procedure is based on the aggres-sive initial lacing of the entire length of thethrombus with a high dose bolus of lytic agent,followed by a continuous low-dose infusion.

Another technique is based on the use of apulse-spray infusion of forceful periodic injec-tion of thrombolytic agent into the thrombusin order to fragment it and increase the surfacearea available for the action of the lytic agent.Different types of plasminogen activators havebeen used, such as Streptokinase, Urokinase,Tissue-type Plasminogen Activators (rt-PA),Recombinant Glycosylated Pro-Urokinase andRecombinant Staphylokinase.

Nowadays in most centres Urokinase is pre-ferred, as it achieved a higher initial clinical suc-cess rate with a lower incidence of bleedingcomplications. Several studies have alsodemonstrated the validity of rt-PA (Alteplase)especially in case of fresh thrombus. It permitsa more aggressive treatment, but an accurateanalysis of the clinical history of the patient ismandatory to avoid intracranial hemorrhagiccomplications. Rt-PA seems to induce a morerapid thrombolysis than urokinase, but statisti-cally there is no difference either in the numberof patients achieving complete lysis at 24h orin the clinical outcomes at 30 days.

A non randomized retrospective analysis hasbeen performed to compare the efficacy andsafety of local infusion of Streptokinase,Urokinase and rt-PA (Table 1). However, cost-analysis studies comparing rt-Pa and Urokinaseare not available for the present. New throm-bolytic agents with a superior fibrin-specificityare currently subject to an extensive investiga-tion with the main target to decrease thebleeding complication rate of intra-arterialthrombolysis.

The percutaneous treatment of acute thrombo-sis can be associated with some technical com-plications related to intra-arterial catheterinsertion including pericatheter thrombosis(3%). To minimise the risk of pericatheter

Management of acute femoro-popliteal thrombosis

thrombosis it is necessary to maintain a thera-peutic anticoagulation and to avoid any unnec-essary prolongation of the infusion. Other com-plications are represented by distal emboliza-tion of thrombus fragments during treatment,causing a sudden onset of pain or loss of distalpulse. This can occur with an incidence ≥5%.Most such emboli are resolved prolonging thelytic therapy.

Compartment syndrome, a complication sec-ondary to a rapid reperfusion of the limb,occurs in 2% of patients. It is clinically manifest-ed with pain, tenseness over the anterior mus-cle compartment and progressive loss of mus-cle and nerve function. Fasciotomy successfullyrelieves the high compartment pressures.Death is a rare complication (<1%) and is oftensecondary to intracranial, intraperitoneal haem-orrhage or reperfusion syndrome. Surgicalrevascularization is indicated in case of pro-foundly ischemic limb.

Embolectomy should be performed in case ofacute ischemia with loss of sensitivity, dis-colouration of the skin, decreased skin tempera-ture and moderate rigor of the muscles. Whenischemia becomes irreversible, blotchy cyanoticdiscolouration is observed, the calf muscle has afirm consistency and there is anaesthesia andparalysis of the extremity. Primary amputationrepresents the treatment of choice.Embolectomy can be performed via arterioto-my of the femoral artery using Fogartycatheters. Multiple passages of the catheter arerecommended to avoid any residual embolicmaterial being left. An angiogram should beperformed at the end of the procedure, as resid-ual stuff has been found in 25-40% of cases.

References:1. Ansel GM, Botti CF, Mitchell JS. Treatment of acute limb ischemia

with percutaneous mechanical thrombectomy-based endovas-cuklar approach: 5-year limb salvage and serviva results from asingle center series. Cath Caridiovasc Intervent 2008;72:325-330

2. Rutheford RB. Clinical staging of acute limb ischemia as thebasis for choice of revascularization method: when and how tointervene. Semin Vasc Surg 2009;22:5-9

3. Cooke JP. Critical determinants of limb ischemia. J Am Coll car-diol 2008;52:394-6

4. Costantini V, Lenti M. Treatment of acute occlusion of peripheralarteries. Thrombosis Research 2002;106:285-294

5. Slovut DP, Sullivan TM. Critical limb ischemia: medical and sur-gical management. Vascular medicine 2008;13:281-291

6. Amonkar SJ, Cleanthis M, Nice C, et al. Outcomes of intra-arterialthrombolysis for acute limb ischemia. Angiology 2008;58:734-42

7. Suggs WD, Cynamon J, Martin B, et al. When is Urokinase treatmentan effective sole or adjunctive treatment for acute limb ischemiasecondary to native artery occlusion? Am J Surg. 1999;178:103-106

8. Barbato JE, Wholey MH. Use of Angiojet mechanical thrombec-tomy for acute peripheral ischemia associated with stent frac-ture. Cath Cardiovasc Interv 2007;70:795-798

9. Robinson WP, Belkin M. Acute limb ischemia due to poplitealartery aneurysm: a continuing surgical challenge. Semin VascSurg 2009;22:17-24

10. Ravn H, Bjorck M. Popliteal artery aneurysm with acuteischemia in 229 patients. Outcome after thrombolytic and sur-gical therapy. Eur J Vasc Endovasc Surg 2007;33:690-69

Fabrizio FanelliVascular and Interventional Radiology Unit“Sapienza” University Rome, Italy

Special Edition / CIRSE 2009 - Lisbon

12 Management of acute femoro-popliteal thrombosis Monday, September 21, 2009

SFA Special SessionTuesday, September 22, 08:30-09:30Auditorium 6

Don't miss it !

Many surgeons still consider surgery to be thebest treatment option, despite reports of highmortality (20 to 30%) and morbidity. A largeprospective randomized trial (TOPAS –Thrombolysis or Peripheral Arterial Surgery) com-paring lytic therapy (Urokinase) and operativeintervention (thromboembolectomy) has shownthat both forms of treatment have similar resultsin terms of amputation-free survival. However,the exact role of the lytic treatment is unclear.Percutaneous thrombolysis can be considered anappropriate and valid therapeutic option espe-cially in case of acute condition. Surgical proce-dure should be selected only in case of acutesevere ischemia or profoundly ischemic limb.However, an accurate evaluation of the patient’sclinical conditions is fundamental to correctlyselect the lytic agent and consequently reducethe incidence of bleeding complications.

Table 1: Non randomized retrospective analysis comparing results of local infusion of Streptokinase, Urokinase and rt-Pa

Complete ThrombolysisMajor HemorrhageDeathIntracranial Hemorrhage

Streptokinase (%)

602842

Urokinase (%)

911220

Rt-PA (%)

95602

Interventional Radiology patient informa-tion - request your brochures now!

Patient information brochures available now

CIRSE members in good standing are entitledto receive interventional radiology brochuresto distribute among patients and referringphysicians.

This is a wonderful opportunity to inform thepublic about interventional radiology in gen-eral as well as UFE, PVD and interventionaloncology.

Please be advised that the brochures are available in English only.

For more information, please go tohttp://www.cirse.org/index.php?pid=4 or e-mail us at alomar@cirse.org.

C RSECardiovascular and Interventional Radiological Society of Europe

13Thoracic stent graftingIRnewscongress

Over the past decade and a half endograftinghas revolutionized the management of thoracicaortic disease. Reports of successful stent graft-ing of descending thoracic aortic aneurysmswere quickly followed by the demonstration oftheir utility in type B aortic dissections.

Whereas atherosclerotic aneurysms generallypresent in patients above 65 years of age, aor-tic dissections have a peak incidence between45 and 70. Younger patients, often below 45,predominate in the group with traumatic aorticinjuries. Evidence in favour of stent-grafting asfirst line therapy in these patients is ample andever increasing (1-7). Procedure related mortali-ty (2.1 % vs. 11.7 %) and paraplegia (3 % vs. 14%) rates with endovascular therapy are lowerthan in surgical series (8).

Thoracic aortic aneurysmsDescending thoracic aortic aneurysms withadequate anchoring zones (≥ 15 mm) distal tothe left subclavian and proximal to the celiactrunk have long become the domain of endo-grafting. Increasing experience with coveringof the left subclavian artery in order to increasethe length of the proximal neck has shown thatsuch a manoeuvre is well tolerated by morethan 90 % of patients, provided the circle ofWillis intracranially is patent. A carotid-subcla-vian bypass as a second stage procedure isnecessary in less than 10 % of the patients.

The fact that interventionists are participatingactively in treating the aortic arch is evidentfrom the development of hybrid endografts aswell as hybrid-procedures. Hybrid endograftsconsisting of a proximal non-stented and a dis-tal stented component are introduced ante-gradely via the aortic arch into the descendingaorta while repairing the ascending aorta. Thestented portion forms the distal `anastomosis´in the descending aorta; the non-stented seg-ment is used to reconstruct the aortic arch.Multi-segment pathologies affecting theascending aorta, aortic arch and descendingaorta, which classically require two or moreoperations, can thus be treated in a one-stepprocedure with the so called “Frozen ElephantTrunk” technique (9,10). As opposed to thehybrid endografts, hybrid procedures consist ofsurgically carrying out a conduit from theascending aorta to the supra-aortic vessels fol-lowed by transfemoral stent-grafting of theentire aortic arch. The procedure is especiallyuseful in pathologies of the descending aortaextending proximally into the aortic arch. Bothprocedures combine open surgery and endolu-minal stent-grafting.

At the distal end, thoraco-abdominalaneurysms pose a challenge to the surgeonand the interventionist alike. Reports ofbranched endografts, with endograft sleeves tothe celiac trunk and the superior mesentericartery for treating thoraco-abdominalaneurysms have appeared in the past fewyears. The mid-term patency rates of branchvessels (one of the main issues) are about 90 %.The implantation procedure however can belengthy and complex, and presently, the proce-dures are performed only at limited centres ofexcellence (11).

Aortic DissectionsClinical experience has been gathered inpatients with type B dissections over the pastfew years (6,7). Controversy exists regardingthe usage of stent-grafts in chronic type B dis-sections. The same holds true for uncomplicat-ed acute or sub acute cases. In contrast, stent-grafting appears to help in such cases withcontained rupture or persistent intractable pain(12). A further indication is a rapid increase indiameter of the false lumen. Distal branch ves-sel ischemia in the acute or sub acute settingcan also be relieved by stent-grafting. However,further peripheral interventions may be neces-sary to optimise the outcome (12,13).

Stent-grafting of retrograde type A dissectionswith entry tears in the descending aorta hasbeen shown to induce thrombosis and resolu-tion of the false lumen (6,12). Anecdotalreports exist of successful sealing of entry tearsin the ascending aorta in acute type A dissec-tions using a short endograft introduced trans-femorally and placed between the coronaryostia and the brachiocephalic trunk (14).

Traumatic aortic injuryPatients in this group are generally youngerwith smaller aortas and access vessels as com-pared to those of other patients undergoingstent-grafting. Often only a short aortic seg-ment around the isthmus requires to be cov-ered by the endograft. With the endograftscommercially available at present, aortas withdiameters below 18 mm cannot be stentedoptimally. Selection of endograft size can bedifficult. Endografts with smaller diameters fit-ting the aorta at the time of treatment maybecome too small with advancing age, with theassociated risk of dislocation. Individual, case-specific solutions may have to be resorted to.Although the mid-term results of endograftingin these patients are encouraging, only timecan tell how these endografts hold out withthe passage of time. Procedural mortality ofstent-grafting in these patients is below 10%and the reported risk of paraplegia is negligible(3,4,15,16,17).

Stent-GraftsAt present about six endograft systems arecommercially marketed (Bolton Medical, Cook,Gore, Jotec, Le Maitre, and Medtronic) inEurope. Off-the-shelf endografts with diame-ters ranging between 22 and 46 mm andlengths between 95 and 250 mm are available.Made to order endografts to suit individualpatient anatomies are offered by most manu-facturers. Consequently, too large an aorticdiameter in the landing zones and too long anaortic segment to be covered by the endograftare no longer significant issues. The endograftskeleton is made of either nitinol or stainlesssteel, whereas the graft material is either poly-ester or ePTFE (polytetrafluorethylene). On thebasis of the data available so far, a clear cutsuperiority of any one material over the othershas not been proven. A factor which may be ofrelevance to the final outcome, however, is thesize of the introducer system. Outer diametersof the introducer systems should be consideredwhen choosing the endograft system. To myknowledge, the Medtronic devices have a slim-mer profile than the other introducer systems.

Thoracic stent grafting: Which patients, which stent-grafts, which technique?

TechniqueMost stent-graft systems still necessitate afemoral arteriotomy. Care should be taken toexpose the common femoral artery and as faras possible avoid using the superficial femoralartery. This renders the introduction of thedevice easier and helps reduce the incidence ofpost-operative surgical complications. In cen-tres with large volumes, suture devices arebeing used more and more often for perform-ing the procedures percutaneously. Should theaccess vessels be too small or tortuous, theintroduction of the device can be facilitated bysurgically suturing a conduit to the commoniliac artery or to the abdominal aorta (Fig.1).

In patients with aneurysms, oversizing theendograft by 10-15 % in relation to the healthyaortic landing zone provides an optimal seal. Incases with type B dissections, the diameter ofthe non-dissected aortic arch should be usedas reference diameter and over-sizing shouldbe kept below 10 %. Ballooning of the endo-graft in cases with dissections may lead to fur-ther tears of the intimal flap and should beavoided. If correctly placed, the inherent radialexpansion of the endograft normally seals theentry tear in the course of time.

To summarise, the answers in a nutshell:

Which patients?· Those with descending thoracic aortic

aneurysms and traumatic aortic injury.· Thoracoabdominal aneurysms – with branched

endografts – but only at centres of excellence.· Aortic arch aneurysms and dissections - with

a combination of open surgery and endo-grafting.

· Retrograde type A dissections with entrytears in the descending aorta.

· Complicated acute or sub-acute type B dis-sections with persistent intractable pain,contained rupture, rapidly expanding falselumen or distal branch vessel ischemia.

Which stent-graft?· This is a tough one! I would say the one with

which the interventionist feels most comfort-able.

· In patients with small or tortuous access ves-sels, go in for a low profile system.

· Use hybrid endografts to facilitate one-steptotal aortic replacement in multi-segmentaortic pathologies.

Ajay ChavanProfessor and Head of the Department ofDiagnostic and Interventional RadiologyKlinikum OldenburgGermany

Fig.1: Thoracic endoluminal device being introduced via a dacron sleeve attached to the abdominal aorta.

References:1. Dake MD, Miller DC, Semba CP, et al. (1994): Transluminal place-

ment of endovascular stent-grafts for the treatment ofdescending thoracic aortic aneurysms. N Engl J Med; 331: 1729-34.

2. Semba CP, Sakai T, Slonim SM, et al. (1998): Myotic Aneurysmsof the Thoracic Aorta: Repair with Use of Endovascular Stent-Grafts. JVIR; 9:33-40.

3. Rousseau H, Soula P, Perreault P, et al. (1999): DelayedTreatment of Traumatic Rupture of the Thoracic Aorta WithEndoluminal Covered Stent. Circulation; 99:498-504.

4. Morgan R, Loosemore T, Belli AM, (2002): Endovascular Repairof Contained Rupture of the Thoracic Aorta. CardiovascIntervent Radiol; 25: 291-294.

5. Ishida M, Kato N, Hirano T, et al. (2004): Endovascular stent-grafttreatment for thoracic aortic aneurysms: short- to midtermresults. J Vasc Interv Radiol; 15(4): 361-7.

6. Dake MD, Noriyuki Kato, Mitchell RS, et al. (1999): EndovascularStent-Graft Placement for the Treatment of acute aortic dissec-tion. N Engl J Med; 340: 1546-52.

7. Nienaber CA, Fattori R, Lund G, et al. (1999): NonsurgicalReconstruction of Thoracic Aortic Dissection by Stent-GraftPlacement. N Engl J Med; 340: 1539-45.

8. Bavaria JE, Appoo JJ, Makaroun MS, et al. (2007): Endovascularstent grafting versus open surgical repair of descending tho-racic aortic aneurysms in low-risk patients: a multi-center com-parative trial. J Thorac Cardiovasc Surg; 133(2): 369-77.

9. Karck M, Chavan A, Hagl C, et al. (2003): The frozen elephanttrunk technique: A new treatment for thoracic aorticaneurysms. J Thorac Cardiovasc Surg; 125(6): 1550-3.

10. Chavan A, Karck M, Hagl C, et al. (2005): Hybrid Endograft forOne-Step Treatment of Multisegment Disease of the ThoracicAorta. J Vasc Interv Radiol; 16: 823-829.

11. Kaviani Amir; Greenberg Roy (2006): Current status of branchedstent-graft technology in treatment of thoracoabdominalaneurysms. Seminars in vascular surgery; 19(1): 60-5.

12. Svensson LG, Kouchoukos NT, Miller DC, et al. (2008): ExpertConsensus Document on the Treatment of Descending ThoracicAortic Disease Using Endovascular Stent-Grafts. Ann ThoracSurg; 85: 1-41.

13. Chavan A, Rosenthal H, Luthe L, et al. (2009): Percutaneousinterventions for treating ischemic complications of aortic dis-section. Eur Radiol; 19: 488-494.

14. Ihnken K, Sze D, Dake MD, et al. (2004): Successful treatment ofStanford type A dissection by percutaneous placement of acovered stent graft in the ascending aorta. J Thorac CardiovascSurg; 127: 1810-2.

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

16. Waldenberger P, Fraedrich G, Mallouhi A, et al. (2003):Emergency endovascular treatment of traumatic aortic archrupture with multiple arch vessel involvement. J endovasc Ther2003; 10(4): 728-32.

17. Fattori R, Napoli G, Lovato L, et al. (2003): Descending thoracicaortic diseases: stent-graft repair. Radiology; 229(1): 176-83.

Which technique?· If possible, percutaneously, if not, via a

femoral arteriotomy. · Bypass non-negotiable access vessels using a

surgical conduit to the common iliac arteryor to the abdominal aorta.

· Oversize the endografts about 10-15 % inaneurysms and below 10 % in aortic dissec-tions.

· Avoid ballooning in cases with dissections.

Thoracic stent grafting: Which patients,which stents, which technique WorkshopMonday, September 21, 17:30-18:30Auditorium 8Wednesday, September 23, 11:30-12:30Room 3.A

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C RSECardiovascular and Interventional Radiological Society of Europe

15Pancreatic Islet Cell TransplantationIRnewscongress

Type 1 dependant diabetes mellitus (T1D) isconsecutive to loss of insulin production due tothe autoimmune destruction of β pancreaticcells (islets of Langerhans). Classical treatmentis based on insulin therapy to normalise bloodglucose levels and prevent acute and chroniccomplications of type 1diabetes.

Transplantation of human islets began in the1970s, but it was not until 1989 than the firstpatient was able to stop exogenous insulin. Thesuccess rate improved dramatically in 2000with the “Edmoton Protocol” based on theneed to transplant high quality islets in suffi-cient number and the use of steroid-freeimmunosuppressive therapy (4,10). Generallyadmitted criteria for allogenic islet cell trans-plantation are C-peptide negative type 1 dia-betes for more than 5 years with previous kid-ney transplantation or T1D with poor diabetescontrol including episodes of severe hypogly-caemia, hypoglycaemia unawareness, wideswings of blood glucose levels or consistentlyhigh HbA1c levels (>8%)(6,7,11).

Islets isolation is performed in a specialised lab-oratory by a dedicated team. Islets areprocessed from pancreases procured fromcadaveric heart-beating donors. The procedureof islets isolation consists in placing the har-vested pancreas in a digestion chamber afterinjection of an enzyme (collagenase or lib-erase) in the main pancreatic duct. Islets arepurified from the obtained preparation by gra-dient in a cell separator. Islets are then culturedin adapted solution. All the processing is doneunder sterile conditions. To be suitable fortransplantation, the islet preparation isolatedfrom a donor must contain more than 250,000islet equivalents and viability must be of up to80% (12). The goal is to infuse 10,000 isletsequivalent/kg of body mass of the recipient,although it is frequently necessary to performone or two subsequent grafts.

The transplantation of islets is performed in aheterotopic location in the liver via the portalvein (8). The procedure is carried out under theresponsibility of the interventional radiologist

when performed percutaneously. The access tothe portal vein is obtained by either trans-hepat-ic venous catheterisation or through a mesen-teric vein during a mini-laparotomy. The percuta-neous image-guided trans-hepatic route is main-ly used. This procedure can be done under localanaesthesia and conscious sedation. An intra-hepatic portal branch is generally punctured inthe right lobe of the liver. Ultrasonic guidanceallows succeeding and securing the puncture.

The remaining procedure is performed underfluoroscopic control. A guide wire is placedthrough the needle in the portal vein and a 4to 6 French catheter is then pushed up to theportal trunk. Prior to islets infusion, anangiogram is performed to check the positionof the catheter, the distribution and the paten-cy of the portal tree (Fig.1). The pancreaticislets (size about 150μm) suspended in albuminsolution are infused by gravity, along withheparin to embolise in the whole liverparenchyma. Portal pressure monitoring usual-ly shows a slight elevation during cell infusion.At the end of the delivery, as the catheter iswithdrawn, the trans-hepatic tract is usuallyoccluded with an embolic agent. A prophylac-tic anticoagulation is continued for several daysto reduce the likelihood of an instant bloodmediated inflammatory reaction (9).

Exogenous insulin is given in the early posttransplant period to prevent islet damagecaused by hyperglycaemia.

The majority of serious adverse events related tothe infusion procedure mainly consists in bleed-ing complications (13% of procedures) and, morerarely, in portal vein thrombosis (4%, partial orcomplete). The use of heparin has been shown tolimit the incidence of thrombosis but to increasethe rate of procedural bleeding. Sealing the intra-hepatic tract has demonstrated a reduction ofthe incidence of post-procedural bleeding (13).The most frequently administered immunosup-pressive protocol uses Sirolimus and Tacrolimusin combination as maintenance therapy (5, 7)and one or more induction agents (i.e. anti IL-2receptor) at the time of the first islet infusion.

Pancreatic Islet Cell Transplantation

Due to the application of the EdmontonProtocol the results of Islet cell transplantationhave dramatically improved since 2000. Thereport published by the Collaborative IsletTransplant Registry (CITR) in 2008 on 325 recip-ients of 624 islets infusions shows 23% insulinindependence at three years, 29% insulindependence with detectable C-peptide, 26%loss of graft function and 22% missing data(Fig.2). Severe hypoglycaemic events decreaseddramatically from 85% of patients before trans-plantation to less than 5% in the first year (1).High numbers of infusion, greater number ofislet equivalents infused, lower pre-transplantHbA1c, a processing centre related to the trans-plant centre and larger islet size are factorsfavouring the primary outcomes. In our Swiss-French multicentre study GRAGIL 2 concerning18 patients (34 infusions), we report significantdecrease of HbA1c levels (≤7%) in 67% of recip-ients, decrease of insulin requirement ≥30% in89%, C-peptide ≥0,5ng/ml in 83% and nosevere hypoglycaemia in 67% at one year aftertransplantation (2,3).

Conclusion : Transplantation of isolated pancre-atic islets has presently become a clinicaloption to be considered in the treatment ofT1D after kidney transplantation or in case ofunstable T1D despite optimal insulin therapy.

Michel GregetInterventional RadiologyUniversity Hospital StrasbourgFrance

Fig.1: Pre-infusion portal angiogram in a combinedLung-Islet transplantation. A patient with end-stage cystic fibrosis and related type 1 diabetesmellitus benefited from double lung transplanta-tion followed 7 days later by intra-portal Islet trans-plantation using the pancreas of the same donor.

Future TechnologySpecial SessionWednesday, September 23, 08:30-09:30Room 3.A

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Fig.2: Results of Islet cell transplantation.Persistence of insulin independence (black) andpersistence of graft function (red) months after lastinfusion in Islet Alone recipients (from Alejandro R,Barton FB, Hering BJ et al. 2008 Update from theCollaborative Islet Transplant Registry.Transplantation 2008 27; 86(12) : 1783-1788).

The CIRSE Foundation is delightedto invite interested CIRSEMembers from Europe and MiddleEast to apply for one of theremaining 2 days Hands-OnCourses including theoreticalintroduction and practical train-ing on simulators. The courseswill be held in the facilities of ourcorporate partners.

In cooperation with our corporatepartners the CIRSE Foundation willprovide CIRSE Members with a suc-cessful application, financial sup-port for flight and hotel accommo-dation. The participation of thecourses is limited, early applica-tion is therefore recommended.

Introduction to Peripheral Vascular InterventionsOctober 12-13, 2009, Hamburg (DE)

Advanced Techniques treating PAOD October 22 - 23, 2009, Diegem (BE)

Introduction to Peripheral Vascular InterventionsDecember 1-2, 2009, Hamburg (DE)

For further details and registration please visit our homepage atwww.cirse.org

References:1. Alejandro R, Barton FB, Hering BJ et al. 2008 Update from the

Collaborative Islet Transplant Registry. Transplantation 2008 27;86(12) : 1783-1788.

2. Badet L, Benhamou P Y, Wojtusciszyn A et al. Expectations andstrategies regarding islet transplantation: metabolic data fromthe GRAGIL 2 trial. Transplantation 2007 Jul 15; 84(1) : 89-96.

3. Benhamou P Y, Oberholzer J, Toso C et al. Human islet trans-plantation network for the treatment of type 1 diabetes : firstdata from the Swiss-French GRAGIL consortium group (1999-2000). Diabetologia 2001; 44 : 859-864.

4. Berney T, Ferrari-Lacraz S, Bühler L et al. Long-term insulin-inde-pendence after allogeneic islet transplantation for type 1 dia-betes: over the 10-year mark. American Journal ofTransplantation 2009; 9 : 419-423.

5. Faradji R N,Tharavanij T Messinger S et al. Long-term insulinindependence and improvement in insulin secretion after sup-plemental islet infusion under exenatide and etanercept.Transplantation 2008; 86: 1658-1665.

6. Fiorina P, Shapiro A M, Ricordi C et al. The Clinical Impact of IsletTransplantation. American Journal of Transplantation 2008; 8 :1990-1997.

7. Meloche R M. Transplantation for the treatment of type 1 dia-betes. World J Gastroenterol 2007;13(47): 6347-6355.

8. Merani S, Toso C, Emamaullee J, Shapiro A M J. Optimal implan-tation site for pancreatic islet transplantation. British Journal ofSurgery 2008; 95: 1449-1461.

9. Pawelec K, JuszczakM J, KumarA et al. Time course of islet lossafter intraportal transplantation.Immunology of Diabetes V:Ann. N.Y. Acad. Sci. 1150: 230-233 (2008).

10. Tharavanij T,Betancourt A, Messinger S et al. Improved long-term health-related quality of life after islettransplantation.Transplantation 2008 ; 86 : 1161-1167.

11. Vaithilingam V, Sundaram G,TuchB E. Islet cell transplantation.Curr Opin OrganTransplant 2008; 13 : 633-638.

12. Vantyghem MC, Marcelli-Tourvielle S, Fermon C et al.Intraperitoneal insulin infusion versus Islet transplantation:Comparative study in patients with type 1 diabetes.Tranplantation 2009; 87: 66-71.

13. Villiger P, Ryan E A, Owen R et al. Prevention of bleeding afterIslet transplantation: Lessons learned from a multivariate analy-sis of 132 cases at a single institution. American Journal ofTransplantation 2005; 5: 2992-2998.

CIRSE

Members

only!

In cooperation with

Hands-on Courses

Special Edition / CIRSE 2009 - Lisbon

16 Diabetes Monday, September 21, 2009

CIRSE joins forces with the InternationalDiabetes Federation (IDF), the EuropeanAssociation for the Study of Diabetes (EASD)and the Danish-based World DiabetesFoundation (WDF).

Together, we are dedicated to further theresearch of diabetes and its complications, andthrough close work with other medical soci-eties or industry partners, look set to increasethe scope of our influence in the area of dia-betes awareness and management.

A venture of particular interest is this year’s col-laboration between CIRSE and the EASD. Weare working together to promote both aware-ness of medical solutions to diabetic complica-tions and research into further treatmentoptions. Within this framework, prominentopinion leaders offer an exclusive account ofdiabetes at “CIRSE Meets EASD” at 1pm tomor-row, Tuesday September 22.

Collaboration between CIRSE and the IDFWorking Group on the Diabetic Foot is alsounderway with the purpose of revising theexisting guidelines for the treatment of thecondition, as well as launching an educationalprogramme which will deal with such issues ashow to set up a diabetic foot clinic.

The decision to form such a joint venture wastaken on the grounds that vascular disease isthe major cause of death in people with dia-betes, and is an area in which interventionalRadiology is making incredible progress.

The mutual efforts of CIRSE and the major dia-betes associations aim to raise awareness ofthe benefits of multidisciplinary care clinics,and encourage individual hospitals, diabetolo-gists and interventional radiologists to estab-lish such institutions.

www.cirse.orgwww.idf.orgwww.easd.org

For years the number of people sufferingfrom diabetes has been rising at alarmingspeed. According to the World HealthOrganization, the number of patients withdiabetes will double by 2030. Out of thenumerous complications caused by dia-betes, PVD is one of the most severe. It isestimated that it accounts for approximately70% of all non-traumatic amputations.

It is clear that diabetes will constitute one ofthe major medical challenges of the future.It has also been abundantly shown thatInterventional Radiology can assume animportant role in the fight against the dis-ease, providing minimally invasive solutionsto intermittent claudication and PVD. Thequestion is how well physicians from thevarious fields dealing with the treatment ofdiabetes will cooperate in their fight againstthis crippling disease.

In an effort to foster this much needed coop-eration, the “CIRSE Meets” session at 1pmtomorrow will feature the EuropeanAssociation for the Study of Diabetes(EASD).

CIRSE talks to Andrew J.M. Boulton, Vice President and Director of InternationalPostgraduate Education European Associationfor the Study of Diabetes.

Q: What have been the milestones in the his-tory of the EASD?A: The EASD was founded in Montecatini, Italy,in 1965. Its initial aim was to bring together sci-entists, physicians, laboratory workers, nursesand students with an interest in diabetes inEurope and it has expanded greatly over thelast 44 years. Its main activities are the organi-zation of an annual meeting that attracts up to1,800 individuals and providing postgraduateeducation on diabetes and its complications. Ithas a high impact factor journal – Diabetologia– and it organises a number of other activities,the most important of which has been theestablishment of the European Foundation forthe study of diabetes which is a grant givingbody.

One not to miss!

CIRSE meets EASD

Tuesday, September 2213:00-14:45

Auditorium 1

Interventional Radiology’s Increasing Role in Diabetes Management

C RSE

Universal Symbol of DiabetesInternational Diabetes Federation

08:30-09:30BTK in diabetics Special SessionAuditorium 8

Moderators: D. Henroteaux (Liège/BE), J.A. Reekers (Amsterdam/NL)

Factors and time line of healing of the diabetic footS. Morbach (Soest/DE)

Update on results of PTAK. Katsanos (Patras/GR)

Update on results of stentsT. Rand (Vienna/AT)

Long infrapopliteal occlusionsA. Bolia (Leicester/UK)

More on the treatment of the diabetic foot. Don’t miss today’s session….

C RSECardiovascular and Interventional Radiological Society of Europe

17DiabetesIRnewscongress

In the Middle Ages, they used to taste urineto test for diabetes; 90 years ago, experi-ments on dogs paved the way for insulintreatment and in 1963, Dotter’s theorybehind angioplasty proved a medical break-through in limb salvation.

Diabetes is predicted to reach pandemic lev-els within 15 years, but what are the realfacts and figures? What needs to be done toprevent its spread? Interventional Radiologyhas come very far in diabetes treatment andcontinues to do its bit to reduce the impactof this life threatening disease.

THE STATS· Diabetes causes as many deaths each year as

HIV / AIDS.· In 1985, there were an estimated 30 million

diabetics worldwide, 246 million in 2007 anda predicted 380 million in 2025.

· Cardiovascular disease is the major cause ofdeath in diabetes, accounting for some 50%of all diabetes fatalities, and much disability.

THE TEAM· Diabetologists· Podiatrists· Orthopaedics· Interventionists· Vascular Surgeons· Technicians· Nurses

The most effective diabetic care clinics arethose that are multidisciplinary and there isstrong evidence that such an approach canreduce amputation rates by a sizable percent-age.

THE ECONOMICS· The cost of 16 amputations is more than the

cost of managing 120 active ulcer cases or834 preventative cases.

· The direct costs of 8 below-knee amputa-tions is equal to the combined annual salaryof a medical team of 3 doctors, 5 nurses, 1dietician, 1 secretary and 3 auxiliary staff.

A great proportion of these costs are attributa-ble to amputation, prolonged hospitalisationand aftercare.

Clearly, even from a budget perspective, pre-vention is far better than cure. Early interven-tion and proper treatment is key, and offersgood value for money.

THE POLITICSInterventional Radiology holds many clinicaland economic benefits within the field of dia-betes. Raising awareness of these benefits aswell as a review of the medical structures willprove indispensible to the progression of thediscipline and can bring much needed devel-opments to fruition.

· Standardisation of IR training· Greater interdisciplinary cooperation· Suitable referral system· Direct patient contact· Appropriate clinical facilities

THE FUTUREThe discovery of insulin and the insulin produc-ing beta cells of the pancreatic islets hasproved to be an essential step in the search fora cure. As research into possible cures is beingcarried out in various fields of medicine, physi-cians could be on the brink of finding a defini-tive cure.

The minimally invasive treatment of pancreaticislet transplantations offers patients an effec-tive alternative to open surgery with the addedbenefits of being less painful and more cost-effective. With advances such as the EdmontonProtocol being made into decreasing the risk ofimmunosuppressant drugs, pancreatic islettransplantations could well be a key future dia-betic cure.

Minimal Invasion, Maximum Impact

References:1. International Diabetes Federation2. World Health Organization3. Assal J.P., 1995 in Van Acker K., The Diabetic Foot. Antwerp 20014. Apelqvist J., et al, The global burden of diabetic foot disease.

Lancet 2005; 366:1719-24

Today the membership of the EASD comprisesmore than 7,000 individuals from over 130countries and the EFSD has raised over €60,000,000 for European Diabetes Research inpartnership with industry and the JuvenileDiabetes Research Federation as well asthrough independent funding. The first grantswere awarded in 2001 and regular calls forgrant applications are made each year. Anotheractivity of the EASD is its study groups. Peoplewith particular interests have regular meetings,e.g. for the area of most interest to CIRSE; thediabetic foot.

Q: What is your main membership?A: Our main membership comprises healthcareprofessionals with an interest in diabetes.Diabetes awareness is promoted through post-graduate education and more recently throughthe introduction of webcasts which are avail-able for free on the internet.

Q: Do you think that the number of patientswith diabetes will continue to rise the way ithas in recent years?A: We are currently facing an epidemic of type 2 diabetes and it is projected that therewill be more than 350,000,000 patients world-wide with diabetes by 2025, although this ismost probably a gross underestimate. Sadlythe numbers do indeed continue to rise and itis likely that, for example in India, there aremore people with diabetes (both known andunknown) than the whole population of theUnited Kingdom.

Q: Do you have any patient support initia-tives?A: Patient support initiatives are generally car-ried out by National Societies such as, forexample, Diabetes UK.

Be sure to visit tomorrow’s exclusive session: CIRSE Meets the European Association for theStudy of Diabetes (EASD)

CM 2401 CIRSE meets the European Association for the Study of Diabetes (EASD)

Moderators: A.J.M. Boulton (Manchester/UK), J.A. Reekers (Amsterdam/NL)

2401.1 The diabetic foot in 2009 - an overviewA.J.M. Boulton (Manchester/UK)

2401.2 Medical aspects of peripheral vascular disease in diabetesN. Schaper (Maastricht/NL)

2401.3 Arterial bypass versus angioplasty in diabetic peripheral vascular diseaseM. Lepäntalo (Helsinki/FI)

Q: Do you think that awareness campaignswill be able to slow down this developmentand which efforts can yield the best results(healthy eating campaigns, lobbying govern-ment, diabetes training courses for GPs, etc.)?A: There is no doubt that promoting awarenessamongst high risks groups and healthcare pro-fessionals is essential in tackling the worldwideepidemic of type 2 diabetes. Healthy eatingcampaigns and government lobbying are ofcourse important and as noted above we dorun postgraduate courses for GPs and otherhealthcare professionals. More recently, wehave embarked upon international postgradu-ate education and regularly run courses indeveloping countries and recently we have hadsuch courses in South America, Vietnam andIndia. The EASD also runs regular postgraduatecourses in China.

Q: How do you think the EASD and CIRSEcould best cooperate in the fight againstdiabetes related complications?A: Co-operation is essential between our twoorganisations, as vascular disease is the majorcause of mortality in people with diabetes. Inaddition to joint symposia at our annual meet-ings, the possibility of joint research activities isalso an important one.

Q: Do you think endocrinologists and inter-ventionists could join forces to treat dia-betes? What form could this partnershiptake?A: Naturally I believe that diabetologists andinterventional radiologists should join forces towork together and one area is the possibility ofhaving joint clinics which could be run periodi-cally, attended by both specialties for patientswho have particular vascular problems.

Q: Do you dispose of statistics on IR treat-ment of diabetic complications in Europe –referral rates/channels, policy, numbers ofclinics, etc?A: Unfortunately the EASD does not collect sta-tistics on interventional radiological treatmentfor diabetic complications in Europe, althoughthe diabetic foot study group of the EASD islooking into the possibility of having such aregistry.

Jim A. ReekersCIRSE President

J.M. BoultonVice President European Association for the Study of Diabetes

Atherectomy has experiencedincreased interest as a treatmentin the peripheralarteries. Recentdata indicates that plaque excisionis an effective solution for patientssuffering from PAD that can resultin excellent patency, limb salvage,wound healing and pain reduction.As a leader in peripheral vasculardisease technology, ev3 remainscommitted to conducting clinicalstudies using the SilverHawkTM

Plaque Excision Device. In 2008,ev3 began investing in several clinical trials as a part of theirstrategy to continue enhancingthe data available on atherectomy.

Initiated in April 2009, DEFINITIVE LE(Determination of Effectiveness of SilverHawkTM

Peripheral Plaque Excision System for theTreatment of Infrainguinal Vessels/LowerExtremities) is the largest study to date to inves-tigate the utility of minimally invasive plaqueexcision (atherectomy) for peripheral artery dis-ease (PAD) as a frontline therapy. With anexpected enrollment of up to 800 patients at50 sites in the United States and Europe, thisprospective, multicenter, single-arm study willevaluate 1-year patency rates in patients withclaudication and limb salvage in patients withcritical limb ischemia (CLI) after treatment withev3’s catheter-based SilverHawkTM PlaqueExcision System. Because of the study’sunprecedented large scope and hard endpointwith core-laboratory adjudication, it is expect-ed to generate robust data to support the useof plaque excision in a wide variety of PADpatients.

DEFINITIVE LE may be the first large-scale studythat will demonstrate where plaque excisioncan be used effectively in a wide series ofpatients. It is really an all-comers study lookingat the simple claudicant with mild, moderate,or severe disease and also gleaning a tremen-dous amount of data for patients with CLI.

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Programs are tailored to the different needsand levels of expertise of participants with anaim to equip them with the tools to achieveexcellent patient outcomes. Many of these programs are CME-accredited.

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"The Crossroads Institute offers best-in-class medical education on interventional treatmentoptions for cardiac and vascular disease,” said Dr. Luc Stockx, M.D., medical education programdirector for the Crossroads Institute. “Our objectiveis to equip attendees with the best skills andknowledge, through teaching imparted bythought leaders in interventional procedures, toachieve the best outcomes for their patients.”

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DEFINITIVE LE is examining patency rates afteratherectomy, which is a standard endpoint inperipheral studies, but limb salvage, woundhealing, are all critical when dealing with CLIpatients with threatened limbs. The rate ofwound healing, in particular, is being looked atin this study.

A large series such as DEFINITIVE LE, with multi-ple investigators at varying levels of ability willprovide a very realistic interpretation of whatthe technology can do; it will allow to go inand actually look at these patients and performan overall analysis as well as a subset analysisto more closely evaluate specific issues.

Another very interesting area that DEFINITIVELE will look at is the comparison of the diabeticand non diabetic patient population and theiroutcomes.

Diabetics have a very high proportion of coro-nary and peripheral arterial disease, and theirrisk of limb loss is higher than that of patientswho do not have diabetes.

There have been several kinds of glimpses intodiabetics with plaque excision. The originalTALON registry, which confirmed plaque exci-

Providing Evidence for Plaque Excision

sion with the SilverHawkTM as an effective treat-ment for patients with significant blockagesabove and below the knee, showed a fairlygood result with diabetics who did just as wellwith plaque excision. Subsequent studies, bothEuropean and more recently the Columbiadataset, suggested that the TALON data werenot outliers, and that plaque excision may havea role with diabetics who may respond just aswell as nondiabetic patients with PAD. DEFINI-TIVE LE will advance the knowledge of the dia-betic patient population and whether or notclaudicants or CLI patients benefit by this typeof therapy. DEFINITIVE LE will also include asubstudy focused on protein and gene analysisof the plaque that has the potential to add newinsight on the biology of the disease processand the potential differences between diabet-ics and nondiabetics.

· For nurses, technicians, pharmacists and purchasing staff, modular programs areoffered in the form of Crossroads Institute-in-a-Box. These programs aim to increaseknowledge of the support staff to make themmore effective in their daily responsibilities.

Abbott Vascular and Crossroads also supportand collaborate with ESIR – The EuropeanSchool of Interventional Radiology, to offerspecific courses.

2. FOCUS ON TECHNOLOGIES

In clinical practice, one of the most importantfactors that any healthcare professional faces ispatient safety. The ability to react with goodjudgment comes with experience, especially in unexpected or critical situations. Experiencecan only be gained from continuous practice.This is why Crossroads has developed programsthat develop skills by training through:

· SimulationSimulators provide valuable hands-on opportunities that enhance the interventionalexperience, reducing risk to the patient.

· Cath lab experienceUsing the latest imaging technology, this model

Special Edition / CIRSE 2009 - Lisbon

18 Advertisement Monday, September 21, 2009

Information contained herein is for outside theU.S. and Japan only. Please check the regulatorystatus and availability of the products mentionedin area where CE marking is not the regulation inforce. Additional information on Abbott Vascular,its products, clinical trials and news is availableon the company's website at www.abbottvascular.com.

AP2930698 Rev. A

C RSECardiovascular and Interventional Radiological Society of Europe

19Film Interpretation PanelIRnewscongress

Female, 70 y.o.

· History of hypertension· Atherosclerotic aneurysm of thoracic aorta· No dissection · EVAR is undertaken

Case D

Film Interpretation PanelJoin us for this year's Film InterpretationPanel and see how much fun an educationalsession 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.

5 days after placement, vague abdominal pain – c.e.CT

5 days after placement, vague abdominal pain – c.e.CT

5 days after placement, vague abdominal pain – c.e.CT

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

Don't miss it !

Special Edition / CIRSE 2009 - Lisbon

20 Film Interpretation Panel Monday, September 21, 2009

Female, 26 y.o.

· Patient with Fanconi anaemia and inoperable oesophageal cancer· Treated with palliative chemo-radiotherapy and plastic polyflex oesophageal stent· Presented two months after stent insertion with total dysphagia

Case E

What has happened?What can you do?

Female, 61 y.o.

· Chronic dissection· Pre-procedure C-C bypass

Case F

Contrast swallow demonstrated overgrowth which was treated with balloon dilation andrestenting

· Two uncovered 23mm x 10cm ultraflexstents inserted

· Severe chest pain post procedure

1 hr post-procedure· Epileptic fit· No arm pulses· Angio

What has happened?What can you do?

4 hr post - check swallow

C RSECardiovascular and Interventional Radiological Society of Europe

21Film Interpretation PanelIRnewscongress

Male, 32 y.o.

· Presents with- anaemia- recurrent melena

· No relevant Past Medical History

Case G (Courtesy of Johannes Lammer)

What do you see?

What else is interesting? (1)

Sagittal reconstruction

What else is interesting? (2)

See you today!Come & play!

Coronal reconstruction

Today, 15:00-16:00Auditorium 1

· Technical Focus Sessions· Clinical Focus Sessions· Workshops· Multidisciplinary Tumour Board· ECIO meets ESMO· ECIO meets ILCA· ECIO meets WCIO

MAIN TOPICS

· Tumour ablation· Advances in image guidance· Intra-arterial treatments· Radioembolization· Hepatocellular carcinoma· Lung/Kidney/Bone tumours· Current and future research

in interventional oncology

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

23The Alternative Guide to LisbonIRnewscongress

What to do in Lisbon

Tram line 28In order to get a first overall-impression of thecity I highly recommend taking the 28 tramcrossing the city from East to West. You mightthink that you’d rather walk, but when they sayLisbon was built on seven hills, unlike in othercities they really mean it. A short walk througha small neighbourhood can therefore some-times require the stamina of an alpinist, so ifyou have left your climbing axe at home, docatch a tram and enjoy a beautiful ride throughLisbon’s most famous districts, such as Baixaand Alfama.

Except for one line, all of Lisbon’s trams haveremained almost unchanged since their intro-duction in the 19th century when they were firstimported from America, hence giving themtheir original name americanas. Today mostLisboners refer to them as eléctricos. In order toget through Lisbon’s winding and often verysteep roads, they consist of a single car, whichis why you might sometimes have to wait forthe next tram, unless you want to get to knowthe Lisboners from up close, REALLY close.

Unfortunately the corresponding taverns havelong gone and so have the sailors (Sorry, girls!).

Legend has it that Vasco da Gama and his menspent the night in prayer at the site of themonastery before departing for India in 1497.Upon da Gama’s return from the successfulvoyage (well, successful for the lucky third ofthe crew who survived it, I guess) Manuel I.commissioned the construction of JerónimosMonastery to commemorate the epic feat. Thevery distinct architecture of the monastery isManueline style, named after said emperor. Itsmain features are inspired by seafaring and thecountries discovered during Portugal’s Age ofExploration, thus incorporating rope-like struc-tures, palm-tree shaped columns and such,although you will look for tattooed sailors andladies of the night in vain.

In 1755 the strongest earth quake ever recordedin European history hit Lisbon, causing a mas-sive tsunami and countless fires on top of itsestimated magnitude 9 on the Richter scale andalmost completely wiping Lisbon off the face ofthe earth. Miraculously Jerónimo’s Monasterysurvived the seism almost undamaged, themissing statues on some of its columns beingthe only evidence of the catastrophe.

Lisbon experiences light earthquakes quite fre-quently, so if you feel the ground shaking, thismight not necessarily be the consequence ofan early happy hour. I was assured that theselight quakes are a good sign, though, as “bigones” are preceded by a lack of seismic move-ment. If it is a big one, an elevated alcohol levelis probably better anyway.

Christo Rei Although not as big and imposing as Rio deJaneiro’s Christ the Redeemer statue (andtherefore probably coming with less redemp-tion), Lisbon’s Christo Rei is still quite animpressive landmark. The funny thing is that itwas built under Salazar’s dictatorship, onceagain showing the strange desire of totalitarianregimes to use religious figures as their pinups.

Another interesting fact is that the 28m statuewas placed on a base three times as tall as thestatue itself, so if you like concrete the waythey did in the fifties, do go there! From theobservation deck below the statue you will beable to enjoy a wonderful view of the city ofLisbon, the Tagus River and the 25 de AbrilBridge named after the date of the CarnationRevolution bringing an end to Salazar’s regime.

Basilica de EstrelaThis beautiful church in late baroque/neoclassicalstyle is located on a hill in the Western part ofLisbon and can easily be reached with the 28tram. It was commissioned by Queen Maria I.who had vowed to build a church if she gave sonto an heir. She must have prayed a little too hardfor her wish, though, as after the desired heir shegave birth to five more children, hence becom-ing the 18th century equivalent of octo-mom.

MORE TITBITS ON LISBON

· CoffeeIf you feel like an espresso while on a break, askfor a bica. The Lisboners around you will surelybe very impressed and applaud your commandof the Portuguese language. That is, of course,until you have to say anything else. Coffee isreferred to as bica only in Lisbon, though, asBica is the name of the city’s neighbourhoodwhere it was first sold as a great novelty fromthe Brazilian colonies.

· FadoAlthough fado music (literally meaning fate ordestiny) can be about anything, it is mostfamous for its songs about the sea, the life ofthe poor and saudade – the nostalgia felt whenmissing someone who has usually gone to seaor left “to get cigarettes” and not returnedsince.

Petra MannCIRSE Office

As the 28 line is usually filled with tourists gapingat the beautiful views, you might unwittinglyhave acquired the services of a personal pick-pocket with your ticket, so make sure to keep aneye on your belongings!

The Cristo Rei Statue; nothing says salvation like41 thousand tons of concrete!

Make sure to reserve one night of your stay togo to one of the many establishments playingfado. In Lisbon you can applaud a fado per-formance by clapping, while in the city ofCoimbra people cough as if clearing theirthroats to show that they liked a song. I amactually serious!

The best places to listen to live fado are in theAlfama district, for example A Baiuca or GrupoExcursionista Vai Tu, where the locals will oftensing along with the artist. As a tourist youmight stick out a little, but the Lisboners gath-ering there will certainly appreciate your inter-est in Portugal’s most popular musical genre.Please make sure you don’t have one port winetoo many and start mistaking it for a karaokebar, though, because fado is NOT, and I cannotstress this often enough, the Portuguese ver-sion of your take on "Love me tender". Let’s allagree on that.

· Mosaic sidewalksWhen walking through Lisbon you will noticethe beautiful mosaics on the sidewalks, particu-larly on the big boulevards. Legend has it thatwhen Vasco da Gama returned from India,Manuel I. commissioned the first mosaic side-walks to make sure that a man of da Gama’simportance would not have to walk across dirtstreets. Sure beats a red carpet, if you ask me.

Calçadas – the 18th century way of putting a littleglamour in everyday life.

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

Jerónimos MonasteryWhen entering Lisbon from the West you willfirst get to the Belém disctrict. Literally mean-ing Bethlehem, this is the part of town moststrongly linked to Portugal’s seafaring past.