Radiology 1) The document introduces 6 new and emerging advanced vascular and interventional radiology procedures: radiation segmentectomy, radial artery access for visceral interventions, prostate artery embolization, advanced tumor ablation, balloon-occluded retrograde transvenous obliteration, and thrombolysis for venous thromboembolic disease. 2) The procedures provide minimally invasive alternatives to open surgery with benefits of shorter hospital stays, fewer complications, and improved quality of life. 3) Case examples are presented for each procedure to illustrate clinical applications and outcomes.

1. New and Emerging AdvancedVascular
& Interventional Radiology Procedures
Bjorn Engstrom, M.D.
Vascular & Interventional Radiology
Consulting Radiologists, Ltd
Abbott Northwestern Hospital
2015 ANW Innovation Summit
September 26, 2015

2. Disclosures
• EMBA Medical: Received honorarium testing of their
Hourglass Embolization device
• I have no conflicts of interest or relevant financial
disclosures in making this presentation
• Off-label use:
– Theraspheres approved as a HUD for HCC but outside of that
off-label including for radiation segmentectomy
– Prostate artery embolization for BPH
– Use of occlusion balloons, lipiodol and sotradecol in BRTO
– Wallstent endoprosthesis in iliac veins
– Aside from ultrasound-accelerated thrombolysis, any CDI in PE

3. Objectives
• To introduce audience to 6 New and Emerging
AdvancedVascular & Interventional Radiology
Procedures:
– Radiation segmentectomy
– Radial Artery access forVisceral Interventions (RAVI)
– ProstateArtery Embolization
– AdvancedTumor Ablation
– Balloon-occluded RetrogradeTransvenous Obliteration
(BRTO)
– Thrombolysis inVenousThromboembolic disease

4. Radiation segmentectomy
• Transarterial chemoembolization (TACE): Level 1 evidence
for mortality benefit in HCC
– TAE and DEB-TACE same results w/ less toxicity
• Radioembolization:
– Infusion of microparticles containingY-90, emitting beta-
radiation
– Superior toTACE
• for down-staging
• when PVT present
• longerTTP
• less toxicity
Lo et al.Randomized controlled trial of transarterial lipiodol chemoembolization for unresectable hepatocellular carcinoma. Hepatology. 2002 May;35(5):1164-71
Llovet et al. Arterial embolisation or chemoembolisation versus symptomatic treatment in patients with unresectable hepatocellular carcinoma: a randomised
controlled trial. Lancet. 2002 May 18;359(9319):1734-9

5. Radiation segmentectomy
• Radioembolization limited to 2 or fewer segments
with higher, “ablative” dose
• Solitary HCC ≤ 5 cm in difficult locations (dome,
central, peripancreatic etc) when ablation and
resection are not options
• Complete path necrosis in > 50%
Vouche M, HabibA,WardTJ et al. Unresectable solitary hepatocellular carcinoma not amenable to radiofrequency ablation: multicenter
radiology-pathology correlation and survival of radiation segmentectomy. Hepatology. 2014 Jul;60(1):192-201

6. Radiation segmentectomy
• 63-year-old female with hepatitis C cirrhosis, and 2.9 cm LI-
RADS 5 lesion in segment 3

7. Radiation segmentectomy
6 months post-treatment: Complete responseInfusion of radioactive particles

8. Radioembolization
in different patient
Note catheter
approach

9. Radial Artery access forVisceral
Intervention (RAVI)
Benefits
- Superficial and easily
compressible with lower
bleeding rates
- Dual blood supply to hand
- Reduced mortality in STEMI
patients
- Immediate ambulation
- Cost savings
- Obese patients
- Patients with back problems
Bertrand OF, Belisle P, Joyal D, et al. Comparison of transradial and femoral approachesfor percutaneous coronary interventions: a systematic review and hierarchical Bayesian meta-analysis. American Heart J.
2012;163:632-648.
Romagnoli E, Biondi-Zoccai G, Sciahbasi A, et al. Radial versus femoral randomized investigation in ST segment elevation acute coronary syndrome: the RIFLE-STEACS (Radial Versus Femoral Randomized
Investigation in ST-Elevation Acute Coronary Syndrome) study. J Am Coll Cardiol. 2012;60:2481-2489
Mehta SR, Jolly SS, Cairns J, et al. Effects of radial versus femoral artery access in patients with acute coronary syndromes with or without ST-segment elevation. J Am Coll Cardiol. 2012;60:2490-2499
Cooper CJ, El-Shiekh RA, Cohen DJ, et al. Effect of transradial access on quality of life and cost of cardiac catheterization: a randomized comparison. Am Heart J. 1999;138(3 Pt 1):7
Fischman, Patel. The time is now for transradial intervention. Endovascular Today. April 2013; pp 50-58

10. RAVI in Uterine Fibroid Embolization
41-year-old obese female w/ symptomatic uterine fibroids (bleeding + bulk), factorV Leiden disease,
recent hx PE, with worsening severe bleeding on anticoagulation  severe anemia

11. Radial Artery access forVisceral
Intervention (RAVI)

12. Prostate Artery Embolization
• PAE is a safe procedure, with low morbidity for BPH
– Outpatient procedure, moderate sedation (vs 5 days withTURP,
and 5-7 days for open prostatectomy)
– Complications not common, and usually minor (such as UTI, or
hematoma)
– No bladder neck contractures (TURP: 5% , Open: <2%)
– No impotence (TURP: 5-10%, Open: 15-20%)
– No retrograde ejaculation (TURP: 50%, Open: >80%)
– No urethral strictures (TURP: 1-29%)
– (Improved sexual function in 36% likely 2/2 cessation/reduction
of prostatic medications)
Pisco et al. Prostatic arterial embolization for benign prostatic hyperplasia: short- and intermediate-term results. Radiology. 2013
Feb;266(2):668-77. Epub 2012 Nov 30

13. Prostate Artery Embolization
• Effective therapy with good short- and intermediate term (24
months) results:
– Clinical improvement (reduction in IPSS):
• PAE better than medical rx
• Similar to minimally invasive surgeries (transurethral microwave and
transurethral needle ablation)
• Slightly less thanTURP
– Does not preclude surgical therapies
– May make surgical treatment safer (ie. in large prostate may make
patient eligible forTURP as opposed to open prostatectomy)
• As with UFE, PAE likely to become complementary to
existing therapies
Pisco et al. Prostatic arterial embolization for benign prostatic hyperplasia: short- and intermediate-term results. Radiology. 2013
Feb;266(2):668-77. Epub 2012 Nov 30

14. Prostate Artery Embolization
• 84-year-old male with Foley-
catheter dependent BPH
refractory to medical therapy,
non-surgical candidate

15. Prostate Artery Embolization

16. Prostate Artery Embolization
2 weeks later passed voiding trial after removing Foley

17. AdvancedTumorAblation
• ThermalAblation
– Radiofrequency (RFA)
– Microwave (MWA)
– Cryoablation (Cryo)
• Non-thermalAblation
– Irreversible electroporation

18. 73-year-old female w/ primary biliary
cirrhosis and a new 2.3 cm LIRADS 5B
lesion in segment 3

19. Hydro dissection anterior
and posterior liver margin

21. 18G trocar used
during ablation to
displace lesion
away from gastric
outlet and
pancreas

22. US imaging during MWA

23. *Complete response w/o residual or
recurrent disease @ 18 months
*Other advanced techniques:
Hydroinfusion, CO2 pneumoperitoneum
*Similar techniques in kidney and
lung with good outcomes

24. Balloon-occluded RetrogradeTransvenous
Obliteration (BRTO)
• Primarily for bleeding isolated
gastric varices
• May also be used in lieu ofTIPS
in gastroesophageal varices if:
– Poor hepatic reserve (MELD
>18)
– Severe encephalopathy
(as BRTO may improve both)
• Duodenal or parastomal
bleeding
• Very low risk of re-bleed (3% at 3
years)
• Does not precludeTIPS
Saad WE, Darcy MD.Transjugular Intrahepatic Portosystemic Shunt (TIPS) versus Balloon-occluded Retrograde Transvenous Obliteration (BRTO) for the Management of Gastric Varices.
Semin Intervent Radiol. 2011 Sep;28(3):339-49
Saad WE. Balloon-occluded retrograde transvenous obliteration of gastric varices: concept, basic techniques, and outcomes. Semin Intervent Radiol. 2012 Jun;29(2):118-28
Sabri et al. Balloon-occluded Retrograde Transvenous Obliteration of Gastric Varices. Endovascular Today April 2010

25. Balloon-occluded RetrogradeTransvenous
Obliteration (BRTO)
Sabri et al. Balloon-occluded Retrograde Transvenous Obliteration of Gastric Varices. Endovascular Today April 2010

26. Balloon-occluded RetrogradeTransvenous
Obliteration (BRTO)

27. Balloon-occluded RetrogradeTransvenous
Obliteration (BRTO)

28. Balloon-occluded RetrogradeTransvenous
Obliteration (BRTO)
Sabri et al. Balloon-occluded Retrograde Transvenous Obliteration
of Gastric Varices. Endovascular Today April 2010

29. Balloon-occluded RetrogradeTransvenous
Obliteration (BRTO)
Sabri et al. Balloon-occluded Retrograde Transvenous Obliteration
of Gastric Varices. Endovascular Today April 2010

30. Thrombolysis inVenousThromboembolic
disease – Iliofemoral DVT
• Level 1 evidence of reduced risk of Post-Thrombotic Syndrome
(PTS) and recurrent DVT
• Society ofVascular Surgery recommendations:
– First episode of acute iliofemoral DVT
– Symptoms <14 days duration
– Low risk of bleeding
– Ambulatory with good functional capacity and acceptable life
expectancy
– Limb-threatening venous ischemia
Meissner et al. Early thrombus removal strategies for acute deep venous thrombosis: clinical practice guidelines of the Society for
Vascular Surgery and the AmericanVenous Forum. JVasc Surg. 2012 May;55(5):1449-62.Epub 2012 Apr 1

31. 34-year-old female with extensive left lower extremity iliofemoral DVT
and free floating IVC thrombus and pulmonary embolism

35. Asymptomatic and no
evidence of residual or
recurrent DVT at 1 yr

36. Thrombolysis inVenousThromboembolic disease –
Submassive and Massive PE
Case: 48-year-old male w/ extensive bilateral PE, including saddle PE, hypotensive upon
presentation with syncope with brief stabilization on anticoagulation, then hypotensive
overnight with RV strain on echo, troponin leak

37. Thrombolysis inVenousThromboembolic disease –
Submassive and Massive PE

38. Thrombolysis inVenousThromboembolic disease –
Submassive and Massive PE
Post pigtail fragmentation with local tpa infusion

39. Thrombolysis inVenousThromboembolic disease –
Submassive and Massive PE
Lysis check 12 hrs later
Was discharged same day!!!

41. Endovascular approach to acute PE -
PERFECT registry
• Average tpa dose: 28 mg (+/- 11)
• IVC filter placed in ~2/3
• Outcome: Clinical success
– Definition: Survival, HD stabilizationAND improved R heart strain
• 85.7% for massive PE
• 97.3% for submassive PE
• No major procedural complications, bleeding or ICH
Kou et al. Pulmonary Embolism Response to Fragmentation, Embolectomy, & CatheterThrombolysis (PERFECT): Initial results from a
Prospective Multicenter Registry. Chest 2015 [Epub ahead of print]

42. PE ResponseTeam
PERT
Intensive
care
Cardiology
HospitalistsVIR
Emergency
Medicine

43. The MultidisciplinaryTeam
• Radiation segmentectomy
• Multidisciplinary liver group (HBP surgery, Hepatology, GI, Pathology, Oncology,VIR)
• Radial Artery access forVisceral Interventions (RAVI)
• Cardiology,VIR,Vascular Surgery
• OB/GYN , Family medicine and VIR in UFE
• Prostate Artery Embolization
• Urology,VIR, Family medicine
• AdvancedTumorAblation
• Liver: Multidisciplinary liver group
• Renal: GU and VIR
• Lung: Multidisciplinary lung group
• Balloon-occluded RetrogradeTransvenous Obliteration (BRTO)
• Hepatology, GI andVIR
• Thrombolysis inVenousThromboembolic disease
• Multi-specialty (Hospitalist, Intensivist, Cardiology, ED,VIR,Vascular Surgery)

44. References
• Lo et al. Randomized controlled trial of transarterial lipiodol chemoembolization for unresectable hepatocellular carcinoma. Hepatology. 2002 May;35(5):1164-71
• Llovet et al. Arterial embolisation or chemoembolisation versus symptomatic treatment in patients with unresectable hepatocellular carcinoma: a randomised controlled
trial. Lancet. 2002 May 18;359(9319):1734-9
• Salem et al. Radioembolization results in longer time-to-progression and reduced toxicity compared with chemoembolization in patients with hepatocellular carcinoma.
Gastroenterology. 2011 Feb;140(2):497-507
• Romagnoli E, Biondi-Zoccai G, Sciahbasi A, et al. Radial versus femoral randomized investigation in ST segment elevation acute coronary syndrome: the RIFLE-STEACS
(Radial Versus Femoral Randomized Investigation in ST-Elevation Acute Coronary Syndrome) study. J Am Coll Cardiol. 2012;60:2481-2489
• Mehta SR, Jolly SS, Cairns J, et al. Effects of radial versus femoral artery access in patients with acute coronary syndromes with or without ST-segment elevation. J Am Coll
Cardiol. 2012;60:2490-2499
• Cooper CJ, El-Shiekh RA, Cohen DJ, et al. Effect of transradial access on quality of life and cost of cardiac catheterization: a randomized comparison. Am Heart J. 1999;138(3
Pt 1):7
• Bertrand OF, Belisle P, Joyal D, et al. Comparison of transradial and femoral approaches for percutaneous coronary interventions: a systematic review and hierarchical
Bayesian meta-analysis. American Heart J. 2012;163:632-648
• Fischman, Patel. The time is now for transradial intervention. Endovascular Today. April 2013; pp 50-58
• Resnick et al. Uterine artery embolization using a transradial approach: initial experience and technique. J Vasc Interv Radiol. 2014 Mar;25(3):443-7.
• Pisco et al. Prostatic arterial embolization for benign prostatic hyperplasia: short- and intermediate-term results. Radiology. 2013 Feb;266(2):668-77. Epub 2012 Nov 30
• Simon et al. Microwave ablation: Principles and Applications. RadioGraphics 2005; 25:S69–S83
• Saad WE, Darcy MD.Transjugular Intrahepatic Portosystemic Shunt (TIPS) versus Balloon-occluded Retrograde Transvenous Obliteration (BRTO) for the Management of
Gastric Varices. Semin Intervent Radiol. 2011 Sep;28(3):339-49
• Saad WE. Balloon-occluded retrograde transvenous obliteration of gastric varices: concept, basic techniques, and outcomes. Semin Intervent Radiol. 2012 Jun;29(2):118-28
• Sabri et al. Balloon-occluded Retrograde Transvenous Obliteration of Gastric Varices. Endovascular Today April 2010
• Enden et al. Long-term outcome after additional catheter-directed thrombolysis versus standard treatment for acute iliofemoral deep vein thrombosis (the CaVenT study): a
randomised controlled trial. Lancet. 2012 Jan 7;379(9810):31-8. Epub 2011 Dec 13
• Meissner et al. Early thrombus removal strategies for acute deep venous thrombosis: clinical practice guidelines of the Society for Vascular Surgery and the American Venous
Forum. J Vasc Surg. 2012 May;55(5):1449-62.Epub 2012 Apr 1
• Sharifi M, Bay C, Mehdipour M, Sharifi J; TORPEDO Investigators.Thrombus Obliteration by Rapid Percutaneous Endovenous Intervention in Deep Venous Occlusion
(TORPEDO) trial: midterm results. J Endovasc Ther. 2012 Apr;19(2):273-80
• Kou et al. Pulmonary Embolism Response to Fragmentation, Embolectomy, & Catheter Thrombolysis (PERFECT): Initial results from a Proscpetive Multicenter Registry.
Chest 2015 [Epub ahead of print]

45. Thank you!
Bjorn Engstrom, M.D.
Vascular & Interventional Radiology
Consulting Radiologists, Ltd
Abbott Northwestern Hospital
Email: bjorn.engstrom@crlmed.com or
bjorn.engstrom@allina.com
Phone: 612.863.9668 (office) or
617.650.3219 (cell)