To provide an update on the current progress of islet cell transplantation and its future relevance for interventional radiologists. Interest in islet cell transplantation as a cure for T1DM surged after the landmark “Edmonton Protocol” trial in 2000. Since then, clinical trials have shown consistent achievement of insulin independence. However, clinical implementation has faced many obstacles, forcing the IR and transplant fields to continually reevaluate its clinical utility. A total of 571 patients have received 1,072 infusions at a total of 33 centers from 1999-2009. While the insulin independence rate at 1 year has more than quadrupled since before the Edmonton protocol, the long-term value remains unclear. Graft function dramatically decreases over time (Table 1), and up to 70% of patients require multiple infusions. Currently, 16 centers are listed as active with open protocols, and 11 centers performed at least 1 islet cell transplant in 2009. Interestingly, from 2009 to 2010 there was a 40% increase in recipients (159) and a 30% increase in infusions (244). It is expected that a few leading centers will soon apply for a Biologic License Application (BLA), which would allow insurance coverage and widespread implementation of this procedure. To date, islet transplantation has consistently demonstrated short-term insulin independence. Long-term outcomes are less clear, but are currently being investigated. FDA approval of BLA at experienced centers will undoubtedly advance the field. Interventional radiologists are positioned to play a significant role in the future of islet transplantation, as well as future innovative cellular therapies.

*** 1.To define advanced hepatocellular carcinoma (HCC) and its classification, epidemiology, and natural history2.To review the Barcelona Clinics Liver Cancer (BCLC) staging system, including history, development, value in treatment allocation, and potential shortcomings3.To illustrate the application of transarterial chemoembolization (TACE) as well as yttrium-90 radioembolization (490Y RE) for advanced HCC4.To summarize the available literature on safety and efficacy outcomes of transarterial therapy for advanced HCC5.To describe emerging HCC staging systems The past four decades have witnessed tremendous advancement in transcatheter locoregional therapy (LRT)—including TACE and 490Y RE—for primary hepatic malignancy, and has ushered in international acceptance and widespread application of these therapies as vital components in the treatment of patients with unresectable HCC. However, current US and international treatment guidelines limit use of these procedures to intermediate stage (BCLC stage B) tumors, with sorafenib as the recommended standard of care therapy for advanced disease. Yet, the increasing number of recent publications reporting clinical outcomes of transarterial therapy for advanced HCC mandate further investigation of the safety, efficacy, and potential utility of this approach beyond intermediate stage HCC indications. This exhibit will illustrate the application of transcatheter LRT to the treatment of advanced HCC (with focus on patient selection and technique) using case examples. This poster will review the available literature on the use of transarterial therapies for BCLC stage C HCC, present the clinical outcomes demonstrated by these data, and identify evidence for expanding utilization of these therapies for advanced primary liver malignancy. Transcatheter LRTs may have an expanding role in advanced HCC treatment. An up-to-date knowledge of patient selection, technical approaches, and procedure outcomes will assist practicing IRs expand the relevance of transarterial therapies in the care of HCC patients.

Variation in imaging follow-up practices within the interventional radiology (IR) community demands an evidence basis to dictate suitable follow-up approaches. The timing of follow-up imaging after treatment should ideally be timed to capture tumors at maximal expected response, and it not known whether response manifestations occur at similar time frames for different therapies. This study aimed to characterize and compare temporal features of tumor imaging response to transarterial chemoembolization (TACE), and yttrium-90 radioembolization (Y-90 RE). The index tumors for this single-center, IRB-approved retrospective study were drawn from 188 patients who underwent conventional TACE and 56 patients treated with Y-90 RE for hepatocellular carcinoma (HCC) between 2007-2013. Medical record and imaging review was used to collect demographic and disease data and tumor response outcomes, calculated from time of first treatment. Time-to-best imaging response was compared between TACE and Y-90 RE patients in groups delineated by tumor size: small (<3 cm), intermediate (3-5 cm), and large (5-7 cm). The TACE cohort included 140 men and 48 women (mean age 60 years) with 207 index tumors (mean size 4.0 cm) treated with mean 1.5 TACE sessions. The Y-90 RE cohort included 47 men and 9 women (mean age 62 years) with 58 index tumors (mean size 6.7 cm) treated with mean 1.4 Y-90 RE sessions. 152 TACE treated tumors and 36 Y-90 RE treated tumors achieved adequate clinical follow-up for assessment. Objective response rates by necrosis (EASL) criteria were 84% among TACE patients and 89% among Y-90 RE patients. Tumor diameters were generally similar among size groups (2.0 vs. 2.3 cm, P=0.129; 3.8 vs. 4.0 cm, P=0.294; 5.5 vs. 6.0 cm, P=0.013); Time-to-best response did not differ within size groups (small: 103 vs. 103 days, P=0.990; intermediate: 98 vs. 80 days, P=0.536; large: 206 vs. 108 days, P=0.117). No differences in tumor response times were identified between TACE versus Y-90 RE treated HCC, suggesting that the same imaging follow-up protocols may be used for both. These results serve as a first step toward generating evidence to establish post-procedure follow-up guidelines.

•The survival benefit of TIPS for patients with refractory ascites remains unproven.•A case-control study was used to compare survival after TIPS versus paracentesis•Propensity score weighting was used to balance study group features.•TIPS patients showed enhanced survival at short- and intermediate-term time points.•TIPS may have a greater role for in ascites patients when medical therapy fails.

1) Review the mechanism of action of N-butyl-2-cyanoacrylate (NBCA) glue. 2) Review advantages and disadvantages of NBCA. 3) Understand proper technique for use of NBCA. 4) Review examples of peripheral NBCA use from the literature and our institutional experience. The choice of embolic agent is made on a case by case basis with factors such as vascular anatomy, pathology, desired duration of occlusion, and personal preference all playing roles. NBCA is a liquid embolic that is FDA approved for use in cerebral arteriovenous malformations (AVMs) and fistulae. The use of NBCA in peripheral applications has been increasing although few interventional radiologists (IRs) are trained in its proper use. NBCA flows downstream from the catheter conforming to the vessel wall and begins polymerizing on contact with blood. The dilution ratio of NBCA with iodized oil (lipiodol) helps to determine the time to polymerization. A methodical set-up is required to prevent inadvertent polymerization of NBCA including use of a separate glue table, thorough flushing of microcatheters with 5% dextrose, and changing gloves prior to handling the embolic. Careful attention to reflux is required to prevent gluing a catheter tip in place. NBCA offers several advantages over coils and particulate embolics. A distinct advantage is immediate vascular occlusion, which is helpful in coagulopathic patients where coils may be ineffective. NBCA can also be delivered further downstream from the catheter tip into small vascular channels inaccessible by microcatheter alone. NBCA adheres to coils allowing for occlusion of large, high flow vessels through small microcatheters. NBCA has been shown to be useful in AVMs, fistulae, aneurysms/pseudoaneurysms, portal vein embolization, endoleak treatment, and acute arterial hemorrhage from various causes. Case examples from our institution will be presented. NBCA is increasingly being used in peripheral embolization for various pathologies. Understanding techniques of using NBCA and its advantages and disadvantages will add to the armamentarium of the peripheral IR.

1To provide background information on primary sclerosing cholangitis (PSC) and the role liver transplantation plays in its management.2To discuss the potential biliary and vascular complications seen in the PSC population following liver transplantation.3To describe the interventional radiology techniques used for treatment of post-transplant PSC patients with complications. PSC is a devastating illness that leads to early liver failure. Liver failure secondary to PSC is an indication for liver transplantation. In addition to recurrence of the disease, other complications frequently arise following transplantation in this population. The goal of this poster is to provide an overview of the disease process and present a pictorial summary of the most common post-transplant complications in this group. Background information on pathology, epidemiology, and treatment algorithms for patients with PSC will be presented. Post-transplant complications that will be discussed include: recurrent PSC with stenoses, abscesses, bilomas, pleural effusions, fistulae, hepatic arterial pseudoaneurysms, and other vascular and non-vascular complications. Interventional treatments of these complications will be presented. PSC is an uncommon but potentially devastating illness with significant sequelae. PSC patients who undergo liver transplantation often present with post-operative complications. IR techniques can frequently be used as definitive therapy or as a bridge to retransplantation.

Learning Objectives1) To present common vascular anastomoses and their imaging findings used during liver transplantation. 2) To discuss clinical indicators of potential IVC stenoses. 3) To discuss technical aspects of IVC stent procedures used in this patient population. 4) To present outcomes from patients treated in this manner at our institution and those reported in the literature.BackgroundObstruction of the hepatic venous outflow can occur as a result of anastomotic strictures in the post-operative period after liver transplantation. This complication can be seen with either standard vena caval anastomoses or with the piggy-back technique. Imaging results are often misleading, and a formal venogram is often needed to diagnose the complication. Although surgical corrections can be performed in some cases, they tend to be associated with high morbidity and mortality. Venous stenting is one procedure that may be beneficial as definitive therapy for this post-operative complication.Clinical Findings/Procedure DetailsAnatomic caval anastomoses following liver transplantation will be reviewed, as will clinical and imaging findings associated with post-transplant vena caval stenoses. Endovascular options will be discussed. Primary data from our institution will also be briefly presented.Conclusion and/or Teaching PointsIVC stent placement is an important option in the treatment of post-liver transplantation caval stenoses. Familiarity with the technique and outcomes of the procedure are vital for interventional radiologists, diagnostic radiologists, and transplant surgeons. Learning Objectives1) To present common vascular anastomoses and their imaging findings used during liver transplantation. 2) To discuss clinical indicators of potential IVC stenoses. 3) To discuss technical aspects of IVC stent procedures used in this patient population. 4) To present outcomes from patients treated in this manner at our institution and those reported in the literature. 1) To present common vascular anastomoses and their imaging findings used during liver transplantation. 2) To discuss clinical indicators of potential IVC stenoses. 3) To discuss technical aspects of IVC stent procedures used in this patient population. 4) To present outcomes from patients treated in this manner at our institution and those reported in the literature. BackgroundObstruction of the hepatic venous outflow can occur as a result of anastomotic strictures in the post-operative period after liver transplantation. This complication can be seen with either standard vena caval anastomoses or with the piggy-back technique. Imaging results are often misleading, and a formal venogram is often needed to diagnose the complication. Although surgical corrections can be performed in some cases, they tend to be associated with high morbidity and mortality. Venous stenting is one procedure that may be beneficial as definitive therapy for this post-operative complication. Obstruction of the hepatic venous outflow can occur as a result of anastomotic strictures in the post-operative period after liver transplantation. This complication can be seen with either standard vena caval anastomoses or with the piggy-back technique. Imaging results are often misleading, and a formal venogram is often needed to diagnose the complication. Although surgical corrections can be performed in some cases, they tend to be associated with high morbidity and mortality. Venous stenting is one procedure that may be beneficial as definitive therapy for this post-operative complication. Clinical Findings/Procedure DetailsAnatomic caval anastomoses following liver transplantation will be reviewed, as will clinical and imaging findings associated with post-transplant vena caval stenoses. Endovascular options will be discussed. Primary data from our institution will also be briefly presented. Anatomic caval anastomoses following liver transplantation will be reviewed, as will clinical and imaging findings associated with post-transplant vena caval stenoses. Endovascular options will be discussed. Primary data from our institution will also be briefly presented. Conclusion and/or Teaching PointsIVC stent placement is an important option in the treatment of post-liver transplantation caval stenoses. Familiarity with the technique and outcomes of the procedure are vital for interventional radiologists, diagnostic radiologists, and transplant surgeons. IVC stent placement is an important option in the treatment of post-liver transplantation caval stenoses. Familiarity with the technique and outcomes of the procedure are vital for interventional radiologists, diagnostic radiologists, and transplant surgeons.

In a prior publication, significant changes in the IR literature over a 10-year period (1992–1993 to 2002–2003) were reported. The current study is a follow-up study performed five years after the last evaluation. Three American radiology journals (JVIR, AJR, and Radiology) from 2007–2008 were evaluated for content related to IR. Exclusions included articles on breast intervention, nonpercutaneous gastrointestinal intervention, and primary neurointervention; review articles, case reports, pictorial essays, technical descriptions, letters to the editor, and editorials were also excluded. Data collected on each article included the demographics of the primary author and primary institution, and declared funding. Additionally, the nature of the research and its primary focus were evaluated. Primary comparisons from the current literature dataset were made to the 2002–2003 data published previously, in order to determine whether or not significant changes in the literature have occurred over the past 5 years; secondary comparisons were made to the 1992–1993 data. There was a trend (p = 0.12) demonstrating an increase in authors from the US, and from Asia; there was a significant decrease in the percentage of authors from Western Europe. There was a significant decrease in the percentage of authors who claimed “radiology” as their primary department (80.5 vs 69.5%), but a highly significant number of authors claiming IR as their departmental affiliation (3.3 vs 17.3%). Two primary fields of interest demonstrated a significant increase (embolization/ablation, venous therapy), while five areas demonstrated a significant decrease (noninvasive vascular imaging, oncologic interventions, biopsy/drainage, devices, other). Funded studies increased significantly (23.0 vs 34.7%), and the number of studies funded by corporate support nearly doubled. There have been multiple changes in the American IR literature over the past 5 years, including a reversal of the trend for primary authors coming from outside of the US, changes in the focus of the articles, and an increase in funded investigations.

1) To discuss the history of detachable coils, 2) to review commercially available detachable coils, 3) to review of utility of detachable coils for peripheral vascular indications, 4) to discuss costs of available detachable coils. Around 1990, the first detachable coils utilizing an electrolytic release mechanism were developed for the treatment of cerebral aneurysm. Over the past two decades, multiple types of detachable coils utilizing multiple controlled release mechanisms have been developed for both neurologic and peripheral use. Currently, peripheral use of detachable coils is a mix of coils specifically designed for peripheral use and coils designed for cerebral applications. Understanding the available detachable coils and the utility of each is vital to the practice of vascular interventional radiology. Detachable coils come in a wide variety of materials, sizes, and release mechanisms. This presentation will present a brief review of the history of the detachable coil in medicine. The technical specifications of detachable coils currently commercially available in the US will be discussed. Clinical scenarios in which detachable coils may prove beneficial will also be presented through case presentations. A simple cost analysis will be presented comparing currently available devices. Detachable coils represent an important embolic option in both neuron and peripheral interventional practices. Understanding the available detachable coils and the utility of each is vital for interventional radiologists performing embolization procedures.

To determine what clinical, laboratory, or procedural variables predict the need for TIPS revisions in individuals with PTFE-covered TIPS. Between 2003–2009, a total of 141 patients underwent TIPS venographic evaluation following TIPS placement with PTFE-covered stents. Of these, a total of 43 patients required TIPS revisions. Twenty-three (23) different variables were modeled using univariate analysis, and then evaluated using a Cox proportional hazards model. Of the variables tested, only the presence of a previous intervention predicted the need for further interventions (p=0.03). This variable also had an interaction with time (e.g. the hazard ratio increased over time), so that there was a greater likelihood of a need for a second revision as the time from the previous intervention increased. Other variables, including the size of the stent, etiology of portal hypertension, post-TIPS portosystemic gradient, and intrahepatic stent location failed to predict the need for future interventions. Individuals requiring one TIPS reinterventions should be aggressively screened for TIPS failures because of the increased likelihood that they will require another intervention. No correlation with other clinical, laboratory, or procedural variables was noted with the need for TIPS revisions.

Learning Objectives1) To review available vascular closure devices including device specific indications/contraindications, 2) to discuss the literature regarding evidence for use and complications of vascular closure devices, 3) to discuss techniques for large vessel closure.BackgroundComplications after vascular access procedures are a significant problem that can lead to increased room turnover time, longer hospital stays, and decreased patient satisfaction. Over the past several decades, multiple hemostasis aides and vascular closure devices have been designed utilizing numerous mechanisms for obtaining hemostasis. The vascular closure devices currently available vary greatly not only in their mechanism of action but also in their intended use, method of deployment, and device specific complications.Clinical Findings/Procedure DetailsThe history of closure devices and the devices currently available will be reviewed. Although many designs are available, a few models tend to dominate the market, likely secondary to physician familiarity and perceived complication rates. This presentation will discuss these complications and device failures as reported in the literature. Technical and troubleshooting pearls specific to devices will also be discussed.Conclusion and/or Teaching PointsA wide variety of hemostasis aids and vascular closure devices are currently available allowing physicians to tailor their use to appropriate situations and clinical indications. A thorough knowledge of device indications, potential complications, and proper usage can help improve outcomes in patients and decrease complication rates in a field of increasingly complex vascular practice. Learning Objectives1) To review available vascular closure devices including device specific indications/contraindications, 2) to discuss the literature regarding evidence for use and complications of vascular closure devices, 3) to discuss techniques for large vessel closure. 1) To review available vascular closure devices including device specific indications/contraindications, 2) to discuss the literature regarding evidence for use and complications of vascular closure devices, 3) to discuss techniques for large vessel closure. BackgroundComplications after vascular access procedures are a significant problem that can lead to increased room turnover time, longer hospital stays, and decreased patient satisfaction. Over the past several decades, multiple hemostasis aides and vascular closure devices have been designed utilizing numerous mechanisms for obtaining hemostasis. The vascular closure devices currently available vary greatly not only in their mechanism of action but also in their intended use, method of deployment, and device specific complications. Complications after vascular access procedures are a significant problem that can lead to increased room turnover time, longer hospital stays, and decreased patient satisfaction. Over the past several decades, multiple hemostasis aides and vascular closure devices have been designed utilizing numerous mechanisms for obtaining hemostasis. The vascular closure devices currently available vary greatly not only in their mechanism of action but also in their intended use, method of deployment, and device specific complications. Clinical Findings/Procedure DetailsThe history of closure devices and the devices currently available will be reviewed. Although many designs are available, a few models tend to dominate the market, likely secondary to physician familiarity and perceived complication rates. This presentation will discuss these complications and device failures as reported in the literature. Technical and troubleshooting pearls specific to devices will also be discussed. The history of closure devices and the devices currently available will be reviewed. Although many designs are available, a few models tend to dominate the market, likely secondary to physician familiarity and perceived complication rates. This presentation will discuss these complications and device failures as reported in the literature. Technical and troubleshooting pearls specific to devices will also be discussed. Conclusion and/or Teaching PointsA wide variety of hemostasis aids and vascular closure devices are currently available allowing physicians to tailor their use to appropriate situations and clinical indications. A thorough knowledge of device indications, potential complications, and proper usage can help improve outcomes in patients and decrease complication rates in a field of increasingly complex vascular practice. A wide variety of hemostasis aids and vascular closure devices are currently available allowing physicians to tailor their use to appropriate situations and clinical indications. A thorough knowledge of device indications, potential complications, and proper usage can help improve outcomes in patients and decrease complication rates in a field of increasingly complex vascular practice.

Interventional radiologists employ a wide variety of drugs on a daily basis to improve patient experiences and outcomes during interventional procedures. The expectation is for the interventionalist to be well-versed in all pharmaceuticals used in the interventional suite. In this article, the authors review the following classes of common miscellaneous pharmaceutical agents used in interventional radiology: vasodilators, vasoconstrictors, antiemetics, bowel antiperistalsis agents, and prothrombotics.

Learning Objectives1. To introduce the importance of cost-effectiveness analyses (CEA) in the current medical environment.2. To discuss the components of a successful CEA, and introduce the models commonly used by investigators in the field.3. To provide a template for critical reading of the CEA literature.BackgroundCost-effectiveness analyses are becomingly increasingly important in the field of interventional radiology (IR) (1Hunink M.G. Appraising Decision and Cost-effectiveness Analyses.J Vasc Interv Radiol. 2001; 12: 783-787Abstract Full Text Full Text PDF PubMed Google Scholar). It is expected with the current socio-political environment that CEA will help to guide decision making regarding many IR procedures (2Keen J.D. Dunne P.M. Kee R.R. Langer B.G. Proximity arteriography: cost-effectiveness in asymptomatic penetrating extremity trauma.J Vasc Interv Radiol. 2001; 12: 813-821Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 3Shetty S.K. Rosen M.P. Raptopoulos V. Goldberg S.N. Cost-effectiveness of percutaneous radiofrequency ablation for malignant hepatic neoplasms.J Vasc Interv Radiol. 2001; 12: 823-833Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar). Familiarity with the basic concepts of CEA is vital for practicing IR physicians.)Clinical Findings/Procedure DetailsThis educational exhibit will discuss background information necessary in understanding CEA; introduce the models used by investigators when performing CEA; discuss in some detail the three analyses most commonly used in the literature; and provide an analysis template to be used when critically reading the literature.Conclusion and/or Teaching Points1. Critical analysis of a CEA requires a basic understanding of the fundamentals of the CEA model.2. The CEA model can be dissected into three components: the clinical question, the model, and the analysis3. A simple systematic approach involving all three components is effective in the analysis of CEA. Learning Objectives1. To introduce the importance of cost-effectiveness analyses (CEA) in the current medical environment.2. To discuss the components of a successful CEA, and introduce the models commonly used by investigators in the field.3. To provide a template for critical reading of the CEA literature. 1. To introduce the importance of cost-effectiveness analyses (CEA) in the current medical environment. 2. To discuss the components of a successful CEA, and introduce the models commonly used by investigators in the field. 3. To provide a template for critical reading of the CEA literature. BackgroundCost-effectiveness analyses are becomingly increasingly important in the field of interventional radiology (IR) (1Hunink M.G. Appraising Decision and Cost-effectiveness Analyses.J Vasc Interv Radiol. 2001; 12: 783-787Abstract Full Text Full Text PDF PubMed Google Scholar). It is expected with the current socio-political environment that CEA will help to guide decision making regarding many IR procedures (2Keen J.D. Dunne P.M. Kee R.R. Langer B.G. Proximity arteriography: cost-effectiveness in asymptomatic penetrating extremity trauma.J Vasc Interv Radiol. 2001; 12: 813-821Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 3Shetty S.K. Rosen M.P. Raptopoulos V. Goldberg S.N. Cost-effectiveness of percutaneous radiofrequency ablation for malignant hepatic neoplasms.J Vasc Interv Radiol. 2001; 12: 823-833Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar). Familiarity with the basic concepts of CEA is vital for practicing IR physicians.) Cost-effectiveness analyses are becomingly increasingly important in the field of interventional radiology (IR) (1Hunink M.G. Appraising Decision and Cost-effectiveness Analyses.J Vasc Interv Radiol. 2001; 12: 783-787Abstract Full Text Full Text PDF PubMed Google Scholar). It is expected with the current socio-political environment that CEA will help to guide decision making regarding many IR procedures (2Keen J.D. Dunne P.M. Kee R.R. Langer B.G. Proximity arteriography: cost-effectiveness in asymptomatic penetrating extremity trauma.J Vasc Interv Radiol. 2001; 12: 813-821Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 3Shetty S.K. Rosen M.P. Raptopoulos V. Goldberg S.N. Cost-effectiveness of percutaneous radiofrequency ablation for malignant hepatic neoplasms.J Vasc Interv Radiol. 2001; 12: 823-833Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar). Familiarity with the basic concepts of CEA is vital for practicing IR physicians.) Clinical Findings/Procedure DetailsThis educational exhibit will discuss background information necessary in understanding CEA; introduce the models used by investigators when performing CEA; discuss in some detail the three analyses most commonly used in the literature; and provide an analysis template to be used when critically reading the literature. This educational exhibit will discuss background information necessary in understanding CEA; introduce the models used by investigators when performing CEA; discuss in some detail the three analyses most commonly used in the literature; and provide an analysis template to be used when critically reading the literature. Conclusion and/or Teaching Points1. Critical analysis of a CEA requires a basic understanding of the fundamentals of the CEA model.2. The CEA model can be dissected into three components: the clinical question, the model, and the analysis3. A simple systematic approach involving all three components is effective in the analysis of CEA. 1. Critical analysis of a CEA requires a basic understanding of the fundamentals of the CEA model.