scientific session 29 angiography

Scientific Session 29 Angiography

Sunday, March 28, 2004 12:30 PM - 2:00 PM Moderator(s): Gabriel Bartal, MD

David W Hunter, MD

12:30 PM Abstract No. 152

Power Injection of Microcatheters: An In Vitro Comparison. D. Papadouris, Mallinckrodt Institute o/Radiology, St. Louis, MO, USA ·R. V. Davis·T.K. Pilgram ·D.E. Brown

P URPOSE: To determine the tolerance of 0.021 " and 0.027" microcatheters to power inj ection in an in vitro flow model.

MATERIALS AND METHODS: Twenty-two microcatheters (II each .021" and .027") were injected with Conray 60 using a power injector and high-pressure tubing through a flow model. Maximal pressure per square inch (PSI) via the injector and tubing was 1000. Catheters used included Rebar (N 0.021"=4, N 0.027"=4) (ev3, Plymouth, MN), Transit (N 0.021 "=3, N 0.027"=3) (Cordis, Miami Lakes, FL), and Renegade (N 0.021 "=4, N 0.027"=4) (Boston Scientific, Watertown MA). Through the .021" microcatheters, five second injections were performed using an initial rate ofO.7ccl sec. After five injections, catheters were inspected for breakage and injected with methylene blue to find any occult leaks. Injection rates were increased by 0.5 cclsec and the process was repeated until the PSI approached 1000 for five consecutive injections or catheter breakage occurred. The process was repeated for the .027" catheters starting at a rate of3 .4 cc/sec.

RESULTS: The 0.021" and 0.027" catheters were injected 248 and 253 times, respectively. Three catheter failures occurred: a 0.02 1" Rebar (4.4 cclsec, PSI 962), a 0.021" Renegade (1.2 cclsec, PSI 565) and a 0.027" Renegade (4.9 ccl sec, PSI 1000). All catheter breaks were at PSI greater than manufacturer recommendations. All fractures occurred at the catheter hub. Mean and median injection rates tolerated by the 0.021" catheters were 1.7 and 1.7 cc/sec. Mean and median injection rates tolerated by the 0.027" catheters were 4.1 and 4.1 cdsec (p<0.00 1 vs. 0.021 ") . Of the 0.021" catheters, the Rebar (1 .8 celsec mean) and Transit(I.7 cclsec mean) catheters performed similarly while the Renegade (104 cclsec mean) was inferior to the Rebar (p<0.05). The 0.027" Rebar (4.0 ccl sec mean), Transit (4.2 cclsec mean) and Renegade (4.2 ccl sec) all performed similarly.

CONCLUSION: The majority ofmicrocatheters can be power injected in vitro far above manufacturer recommendations . When fractures occur, they are near the hub of the catheter. Significantly greater rates of injection are possible through 0.027" catheters. All 0.027" catheters used in this study performed similarly.


Portable Dynamic Digital Storage Media for Angiography. G. Bartal, Hillel Yaffe Medical Centel; Hadera, Israel·A. Belenky ·D. David·J.JvI. Gomori

PURPOSE: Evolution of angiography systems has lead to new acquisition and post-processing techniques: "Bolus chasing", Rotational Angiography with 3D reconstruction, combined with DSA produce extremely large volumes of data

that are viewed and processed with variable parameters. Film hardcopy is expensive and does not have dynamic display and post-processing capabilities . Our purpose was to replace film with a dynamic portable digital storage media (CD or DVD) containing extensive angiographic post processing capabilities.

MATERIALS AND METHODS: We used automatic CD-DVD recording and labeling system: "CD-Printer" (CDP Ltd, Israel) which replaces film with a DrCOM compliant CD or DVD. The disks contain the original DICOM images and angiographic post-processing software that automatically runs on any PC without pre-installation.

RESULTS: Dynamic examinations such as "Rotational Angiography" and "Bolus Chase" were displayed on the referring physician's PC using the dynamic "Cine" function thus allowing better orientation and visualization than a sequence of static images. Additional tools were available including Zoom, Window Level, Automatic Contrast Enhancement and vessel size measurement. A Dynamic scene of a rotating 3D reconstructed model could be displayed while controlling the direction and speed, thus allowing the physician to virtually rotate a model of the examined vessel. The digital softcopy contained hundreds of images which are part of a continuous motion acquisition and which could not be documented on film.

CONCLUSION: Portable dynamic digital storage media allow portable storage and post-processing of any volume of acquired data. The dynamic post-processing capabilities of the embedded software enable the referring physician improved visualization, manipulation and orientation. The DICOM data from the CD can also be downloaded to any digital angiography system or workstation and used as an integral part of ongoing study. Unlike film, this portable PC based software will enable the referring physician to reproduce the subtracted images using his own preference of subtraction factor, mask images and pixel shifting.


Attenuation Effect of Gadodiamide Versus Different Dilutions of Iohexol: An In-Vivo Comparison Model. /VI. Itkin, University 0/ Pennsylvania, Philadelphia, PA, USA 'J.H. Won ·A.D. Maidment· WS. Stavropoulos' M O'Shea·S.O. Trerotola

PURPOSE: Gadolinium based contrast agents are used as a substitute for iodine based agents in patients with poor renal function despite decreased image quality and increased cost. Using lower concentrations of iodinated contrast has been proposed to increase the amount of contrast available for use, while minimizing total iodinated contrast dose. Our previous in vitro study demonstrated that 4 times diluted iodine contrast achieve equivalent opacification as the standard formulation of the gadolinium. This in vivo model was designed to test the in vitro find ings.

MATERIALS AND lvIETHODS: Eight average 35 kg pigs were used for the study. Right renal artery was accessed using 5 F cobra catheter. 8 mL of five different ioxenol concentrations (300 mgIlmL (full strength), 150 mgIlmL (1/2 strength), 75 mgIlmL (1 /4 strength), 35.5 mgl/mL(l /8 strength» and 0.5 mmollL gadolinium were injected into the right renal artery at the rate of 4 mLis. Injection for each dilution was repeated several times using different exposure energies. The subtracted images were acquired at 3 frame /s and at different energies. The images were then transferred to a Leonardo workstation (Siemens, Germany) and the pixel value of the main renal artery and of the background were recorded. For each trial the contrast index (Cl) [(Background mean pixel value-contrast agent mean pixel value )/background mean pixel value 1 of each agent was calculated. S197

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RESULTS: At 60 kVp gadodiamide yielded a CI of 28%, while that for Y. strength iohexol was 29%. At 90 kVp the gadodiamide still yielded a CI of28%. At the same kVp the CI for Y. strength iohexol was only 19%. The CI of gadodiamide at any energy was comparable to Y. iohexol at 50 to 70 kVp. The CI for gadodiamide was significantly greater than that of Y. strength iohexol (P<0.05, t-test) at energies of90 kVp and above.

CONCLUSION: Gadodiamide maintained a consistent Clover a wide range ofkVp. The CI ofgadodiamide was comparable to Y. strength iohexol at energies of 50-70 kVp. These results are consistent with prior in vitro tests and will help guide future in vivo studies comparing nephrotoxicity of gadodiamide versus dilute contrast in patients with renal insufficiency.

1:03PM Abstract No. 155

Staple Mediated Vascular Closure: Successful Closure in PVD, Small Vessel, & Noncommon Femoral Artery "Sticks" . D.E. Allie, Cardiovascular Institute of the South, Lafayette, LA, USA ·CJ. Hebert·M.H. Khan-A .A. Allie·R.P. Caputo ·CM. Walker, et al.

PURPOSE: "Major" and "minor" femoral access site complications (FAC) vary widely from 0.4-27% and remain a significant source of morbidity and costs. Current vascular closure devices (YCO) have not decreased FAC and are utilized in <15-20% of percutaneous procedures due to VCO limitations including: peripheral vascular disease (PVO), small vessel size (SVS) ($ 4.0 - 5.0 mm), and noncommon femoral artery (NFA) "high or low sticks" . The low profile (3mm), totally extraluminal (adventitia-media purse-string effect), immediate secure closure design, make the staple an attractive option for many patients with current VCO limitations.

MATERIALS AND METHODS: 49 patients with PVO (18), SVS (10) [5 .0 mm (6) and 4.0 mm (4)], and NFA (21) [SFA-10, profunda-4, bifurcation-6, distal external iliac "high"-I] via 6-F (15/49, 30.6%), 7-F (22/49,44.8%), and 8-F (12/49, 24.4%) sheaths underwent Angiolirrk (Taunton, MA) staple mediated arteriotomy closure. Procedural success was defmed as complete cessation of bleeding (CCB) <5 minutes. Heparin use mean 4,700 ± 2,200 units. GBIfbIIIa use 7/49 (14.2%), all PVO. Follow-up: 7 day clinical exam and duplex ultrasound (OU). All patients underwent immediate postprocedural fluoroscopic staple analysis.

RESULTS: PS was 47/49 (95.9%) with mean CCB 2.43 ± 2.13 minutes (non-PS CCB 5-8 minutes). 46/49 (93 .8%) ambulated in <4 hours (2.5 ± 1.5 hours) . There were no major (surgical) complications and 2/49 (4.1 %) had minor complications «3 cm hematomas). All DU were normal without evidence of pseudoaneurysm or vascular stenosis. Fluoroscopic staple analysis revealed no fractures or migrations

CONCLUSION: The novel Angiolink staple mediated VCO is a safe and feasible option for percutaneous arteriotomy closure in patients with PVO, small vessel size «4.0-5.0mm), and NFA vascular access, "high and low sticks", therefore may expand the clinical application of vascular closure.


Arteriographic Findings of the Hand in Patients with Scleroderma. P. W Johnson, Mayo Clinic College of Medicine, Rochester, MN, USA ·E.A. Sabater·A. W Stanson

PURPOSE: The purpose of this study was to characterize the positive arteriographic findings and patterns of disease in the upper extremity in patients with systemic sclerosis (SSc), commonly known as scleroderma. The differential diagnosis in these patients can be difficult. Hand arteriography has been used to confirm the diagnosis and document the extent of the disease in symptomatic patients.

MA TERIALS AND METHODS: Between 1975 and 2002, 32 patients were identified at our institution who had upper extremity arteriograms and met established criteria for the diagnoses ofSSc. Patients included 7 men and 25 women, age range of 25-78 years, mean age 53 years. 25 patients had bilateral upper extremity arteriograms and 7 had unilateral arteriograms, resulting in 57 total exams reviewed by the authors. Hand and forearm arteries were subdivided into predetermined arterial segments.. Lesions were characterized as occlusive, stenotic, or ectatic . Lesions were al so characterized by their proximal-to-distal location, with designations offorearm, wrist, palm, or finger.

RESULTS: In all 57 studies, occlusion was found. Stenosis was found in 47 (82%) patients and ectasia was found in 38 (67%) patients. All three types of lesions were more common in the more distal locations. Of 57 total studies, 57 (100%) and 49 (86%) had occlusion present at the finger and palm level respectively, compared to 20 (35%) at the wrist and 20 (35%) at the forearm level. Stenosis and ectasia were also more common at these more distal locations, but with less prevalence than occlusion. 34/57 (60%) studies had ulnar artery occlusion and 12/57 (21 %) had radial artery occlusion. 17 of 34 (50%) ulnar occlusions were at the forearm level, along with 4 of the 12 (33%) radial occlusions.

CONCLUSION: This study provides a large single institution experience of a rarely encountered vascular procedure: upper extremity arteriography in patients with SSc. While the specific, observed arterial lesions of occlusion, stenosis, and ectasia, are common to other diseases, the constellation of these findings are somewhat unique in SSc. The radiologist not only can support the clinical suspicion of this diagnosis, but often may be the first to suggest the diagnosis.


Study Comparing the SYVEK Patch to Manual Compression for Early Ambulation after Diagnostic Arteriography. H. Ferral, University of Texas Health Science Center, San Antonio, TX, USA ·S. Ambruster-D. W Postoak·C Young·C Greig

PURPOSE: Evaluate the safety and efficacy of the SYVEK hemostatic patch compared to standard manual compression for early (3 hr) ambulation in a group of subjects undergoing diagnostic arteriography.

MATERIALS AND METHODS: This is an IRE approved, prospective, randomized study. Thirty-six patients were randomized to either receive the hemostatic patch or manual compression after diagnostic arteriography. The patch is a soft, sterile, non-woven pad of a cellulosic polymer obtained from micro algae. Standard manual compression or patch compression was applied for a minimum of 15 minutes after diagnostic arteriography. The patients were then kept in a

supine position in a holding area for 3 hours after which they were allowed to ambulate. All subjects were seen 24 hr after angiography to check for bleeding complications. Comparisons were evaluated using the chi-square test.

RESULTS: A total of 18 patients were randomized to patch compression and 18 to manual compression. Puncture sites included right femoral artery (n=28), left femoral artery (n=6) and left brachial artery (n=2). 4 F (n=2) and SF (n=34) catheters were used. The mean compression time was 16 (± 5) minutes. Two hematomas not requiring intervention were seen in the manual compression group and none in the patch group (P=0.2). Early (3 hr) ambulation was possible in 94% (34/36) subjects.

CONCLUSION: Our results in this small cohort suggest that it is safe to discharge patients three hours after diagnostic angiography. The SYVEK patch appears to be an effective and safe hemostatic agent. No patients in the patch group had a bleeding complication but the difference between the two groups did not reach statistical significance.


The Safety of Pulmonary Angiography in Patients with P ulmonary Hypertension: lO-Year Single Center Experience. A. Gupta, Johns Hopkins University School o/Medicine, Baltimore, MD, USA ·D.S Lee ·A . Arepally-S Sood·J. Eng·L. V Ho/mann

PURPOSE: Pulmonary angiography remains the gold standard in the diagnosis of pulmonary thromboembolic disease. We examined the incidence of complications in patients with pulmonary hypertension undergoing pulmonary angiography.

MATERIALS AND METHODS: A retrospective review was performed over a 10-year period at a single institution for all patients undergoing pulmonary angiography. Patients with moderate hypertension (30 mm Hg ::; PA pressure < 60 mm Hg) and severe pUlmonary hypertension (PA pressure ~ 60 mm Hg) served as the study popUlation. Demographic data, clinical indication, pre and post contrast pulmonary arterial pressure measurements, type of pulmonary hypertension, contrast volume, complications, and ASA classification were recorded for all patients and compared.

RESULTS: Two hundred two of 612 patients that underwent pulmonary angiography had pulmonary hypertension. Moderate pulmonary hypertension was present in 155 (77%) patients and severe pulmonary hypertension in 47 (23%) patients. There were 4 (2.0%) complications, three of which were fatal. All fatal complications occurred in patients with acute pulmonary hypertension due to acute right ventricular failure . Patients with complications had a higher mean ASA score than those without complications (4 .0 vs. 3.0, p=0.03). The complication rate was higher in patients with severe pulmonary hypertension compared to patients with moderate pUlmonary hypertension, but not statistically significant (6.3% vs. 0.6%, p=0.63). In our series there were 9 patients with PA pressures> 90 mmHg, none of whom had a complication. The four complications occurred in patients with systolic pressures between 58 and 85 mmHg, with as little as 10 cc of contrast material injected.

CONCLUSION: The complication rate of pulmonary angiography in patients with pulmonary hypertension is low. However, severely ill patients with acute pulmonary hypertension should undergo pulmonary angiography with extreme caution.

Scientific Session 30 UAE

Sunday, March 28, 2004 12:30 PM - 2:00 PM Moderator(s) : Scott C. Goodwin, MD

Gaylene Pron, PhD


FJ.:AITI~EI> ABSTRACT

Commentator: Jean-I'iern' Pelage. \It>

Endovascular Versus Surgical Treatment of Uterine Ffuroids in Women Planning Pregnancy - Prelimjnary Results. 1. Iltkiskova, University Ho ;pilal, Prague, Czech !Republic ·M. Mara·Z. Put ikoVQ

IPURPOSE: To report first results o1'a pro pective randomized sttidycomparingembolization and myomectomy in treatment o[utenne fibroids in women planning pregnancy.

MA TERIALS A D METHODS: Prospective randomized controlled trial started in 2002 designed for 70 women planning pregnancy with intramural myoma. Reproductive and perinatal outcomes are the principal long- term results. From the 1/2002 to 7/2003 34 women were enrolled to this stl.ldy-15 were emboli7..ed, J9 treated by myomectomy. The mean age in both groups was 31 years. Size of the biggest fib roid

as 62 mm rcsp.57 mm. All fibroid were intramurally located. II patients were treated either (or infertility or dy ferti I ity. mbolization· was performed via transfemoral approach

through coaxially placed microcathetcr using Embosphere in dia!lleter range from 300 to 1200J.l.m. Myomectomy was done by laparoscopy or mini laparotomy. Follow up i performed by dynamic US findings I and 6 months after the procedure, hormones and Ca-125 level after I and 6 months and myoma-relaled symptom evaluation after 6 months. In case of minimal or insu fficient effect of UAE after 6 month the secondary myomectomy is recommended. Patients try to conceive 3-6 months after AE and at least 6 months afte myomectomy.

RESULTS: .Table I: periprocedural embolization

echnical success ~arly complications /euCOcyles 2nd day ~RP2ndday Hb level 2nd day ·No pis Hb beiow 100 days of hospital stay

able 2: follow-up

late complications

necesSily of further therapy symptoms regression pregnancy

embolization (n=15) 12(80%)3x unllaterat amb. o 8.9(5,9-15.7) 18.0(5-54) 121 .6(96-138) 1(7%) 3,8(2-7)

myomectOmy(n=19) . 18(95%) o 7.8{2.7-13.7) 37.1(1~1) 103.5(84·126) 9(47%) 6,0{3,.9)

3(20%ral! lernporary·1)c translenl ovarian fallure,2x 6WeeiIs amenormea 6(32%)

1 (5%)

1(5%) 77% 83%

2 (4 are trying) 2 (4 are trying)

CONCLUSION· Oplimalmanagement in young women with uterine t'ibroidl is a controversial i ue. New uterus sparing therapeutic alternatives have appeared recently and have to be compared. First results of our study uggest that lIlerine artery embolization can be the option comparable with surgical procedures as myomectomy ..

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scientific session 29 angiography

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