ISVIR newsletter Indian Society of Vascular & Interventional Radiology Editorial

Vol.No. IV No. 1
June, 2013
ISVIR newsletter
Indian Society of Vascular & Interventional Radiology
Dear friends,
Time is precious for everyone in a hospital. For a patient, who primarily comes to a hospital for
medical treatment, the time he/she spends for being seen by clinicians, diagnostic tests, treatment, etc. is
considered “value time”. However, a large proportion of time may be spent on things like registration,
waiting, etc. which falls under the category of “waste time”. With several managerial techniques, it is possible
for the hospital management to keep the patients’ “value time” relatively more.
Interventional radiologists can probably “spend some time” for an introspection to see how the time
of patients and medical staff can be spent more meaningfully. It could be even simple things like online or
telephonic registration facility, knowing the availability of a doctor at the time of visit, a receptionist or a
clinical assistant checking whether a patient has brought all the relevant prior reports at the time of a hospital
visit, using Hospital / Radiology Information Service (HIS/RIS), protocols & checklists for the procedures,
printed information brochures, etc.
We welcome the new office bearers of ISVIR. Wish them all success for their plans in this year.
Most of the members may be meeting in Goa during July 2013 for the annual registry meeting.
I thank all the contributors for the current issue. Special thanks to Dr. Ankit J. Dumaswala and
Dr.Vyshakh Honganoor for helping to edit this issue of newsletter.
Dr. Shyamkumar N Keshava
Editor, ISVIR newsletter
CMC, Vellore.
[email protected]
ISVIR office holders - 2013 - 2014
Vice President (1)
Dr N Khandelwal
Dr Swatee Halbe
Vice President (2)
Dr Hirdesh Sahni
Joint Secretary (1)
Joint Secretary (2)
Dr Shailesh Gaikwad
Dr Ashu Seith
Dr Suyash Kulkarni
Dr Mandeep Kang
Editor ISVIR
Chairman ISVIR-REF
Dr Shyamkumar N
Dr Sanjiv Sharma
Executive Committee Members
Ex officio
Dr Deep N Srivastav
Ex officio
Dr Rammurti S
Executive Members
Dr Atin Kumar
Dr Paresh Desai
Dr Rajesh Gupta
Dr Kamlesh
Dr Balaji Patel
Dr Pankaj Banode
Vol.No. IV No. 1
June, 2013
Presidential Address
As we all aim to strengthen the foundation of Interventional
Radiology in India through concerted teamwork and enthusiastic
efforts, I feel immensely privileged to be chosen to lead the Indian
Society Of Vascular and Interventional Radiology as its president
Dr. Niranjan Khandelwal
President, ISVIR. Professor & Head,
Department of Radiodiagnosis,
Postgraduate Institute of
Medical Education and Research, Chandigarh
for the coming year. It is indeed an honour to be succeeding the
talented lot of interventionalists who have had a significant impact
on the foundation and growth of the society since its birth in 1997.
As has been proven time and again during the last couple of
decades, interventional radiology has carved its niche in the field of medicine. However, it has had its share
of highs and lows, especially during its infant years. Still today, interventional radiology has not permeated
deep to the level of medical colleges and regional hospitals and has mainly been restricted to institutes and
big medical corporate centres. There have been primarily two reasons for this slow progress. The first and
foremost is the lack of physician as well as public awareness regarding the role an interventionalist can play
in the amelioration of a wide variety of diseases through image guided minimally invasive diagnostic and
therapeutic procedures. The second is the scarcity of trained specialists who can take over these positions
at different locations across India. Both of these issues have been regularly addressed over the last few
years. However our sincere resolve as a team to achieve these goals should go on with renewed zeal. With
this appeal to all, I accept this position with utmost humility and hope that the society grows by leaps and
bounds over the coming years.
Upcoming ISVIR events
ISVIR 2014 is scheduled in the first week of February, 2014. It will be a residential conference at Hotel Renaissance,
Powai, Mumbai. Special Incentives will be available for radiology residents and fellows. Workshops planned on PVD , Ablative therapies, Highlights IR quiz for Fellows.
Everybody is encouraged to participate in the Walkathon - walk for life !
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June, 2013
From the Secretary’s Office...
Dear Colleagues,
I feel very proud of and committed to the great task Indian Society
of Vascular and Interventional Radiology (ISVIR) has granted by electing
me as the general secretary for a period of three years in the last GBM.
I am aware of the great responsibility that has been bestowed upon me and
Professor Shailesh B Gaikwad
Secretary, ISVIR
Department of Neuroradiology
Neurosciences Centre
All India Institute of Medical Sciences
New Delhi-110029
[email protected]
Mobile-9868398216, 9013233567
I hope that together with other members of the executive committee and
with the blessings of all senior and proactive members, I will be able to
contribute to yet another great constructive period in the history of ISVIR.
During this period I shall try to keep up and hopefully even surpass the level
of our previous predecessors. We know that the ISVIR’S immense success
and growth it has experienced in recent years would not be possible without
the work of the Executive Committee, the central Office in Delhi, the Delhi
state branch of ISVIR, Scientific Planning Committee for annual conferences
and other sub-committees looking after specific issues including other well-wishers of the Society. The hard work
done by our seniors has contributed greatly to making interventional Radiology and Interventional Neuroradiology
one of the most attractive specialties with a high impact on patient care and the treatment of many diseases. I look
forward to co-operation from all our members and will do my best to contribute to the society’s cause in the most
constructive manner.
KMCH hosts the 15th annual conference of the Indian Society of Vascular and Interventional Radiology
The 15th annual conference of the Indian Society of Vascular and
Interventional Radiology was a runaway success on every account. The Society
of Interventional Radiology, USA partnered with the Indian society for the first
time in India. The partnership had several distinct advantages namely the
availability of the best of Interventional Radiologists from US to come over as
faculty. In addition, the American Society was willing to offer memberships
Dr. Mathew Cherian MD PDCC
Chief of Radiology Services and
Consultant Interventional Radiologist
Kovai Medical Center& Hospital,
Coimbatore.Tamil Nadu, India-641014
91-422 2628627,
Mobile: 9600900373
and fellowships for the Indian Radiologists. The American society also played
a pivotal role in the assessment of all the competition e-posters and papers.
Further, the best six e-posters would be displayed during the American
Society’s annual conference this year.
The annual conference was conducted in the state of the art auditorium at the
Kovai Medical Centre and Hospital. Dr.Nalla G. Palaniswami, Chairman and Managing director, Kovai Medical
Centre was recognized by both the Indian and American societies for his outstanding contribution towards the
development of Interventional radiology as a speciality in India and was presented a plaque jointly by both the
societies. The Organizing Chairman, Dr. Mathew Cherian and the Organizing Secretary Dr.Pankaj Mehta said that
this was the best conference ever conducted by the society and they were happy that every aspect of the conference
went off well.
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June, 2013
The American Society partnered with the Indian Society of Interventional Radiology for the first time ever.
The conference was divided into three main categories. The early morning sessions were devoted for post
graduates and doctors who were beginning their career in Interventional Radiology and were hands on workshops
where the best of Indian interventional radiologists and the American counterparts trained them on how to start
these procedures. The mid-day sessions were devoted to cutting edge interventional radiology procedures to
go in line with the theme ‘xtreme interventions’. The most complex and demanding interventional procedures
were discussed by faculty from India, US and Europe. Some of the highlights were lectures on radioembolization
in hepatocellular carcinoma and cutting edge interventions in the management of stroke and both intra and
extracranial aneurysms. The post lunch sessions were interective case discussions again on some of the most
complex cases done around the world which fully justified the theme of the conference.
Dr. Brian Steinken, the President, International Task force, SIR and Dr. Goodwin, President elect of SIR at the
end of the meeting confessed that they could see no reason why interventional radiologists of India should ever
desire to ever get trained in US since the work done here is no way inferior to the work done in the best centres
of the world.
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Winning abstracts from ISVIR 2013
1. Spectrum of Hepatofugal Collaterals in Cirrhosis: Intriguing for the Diagnostic Radiologist, Caveat for an
Authors:A Arora, A Mukund, A Dev, Y Patidar, SK Sarin
Learning Objectives: To depict wide variety of typical and atypical hepatofugal collaterals in patients
with liver cirrhosis. Background: Portal hypertension is a common syndrome characterized by the
formation of hepatofugal collaterals that shunt portal-venous blood to the systemic-circulation. Detailed
information about collateral pathways is especially relevant when therapeutic interventional-procedures
(eg. paracentesis, BRTO, TIPSS) are contemplated as inadvertent collateral vessel injury can be potentially
lethal. ImagingFindings: This exhibit displays a diverse spectrum of collaterals including: left-gastric,
short-gastric, intragastric, peri-or-retrogastric collaterals; esophageal, para-esophageal and gastro-epiploic
collaterals; paraumbilical; lienorenal, gastrorenal; peri-pancreatic; mesenteric and retroperitoneal collaterals.
Atypical collaterals such as duodenal, paraduodenal; paravertebral; intrahepatic collaterals, gonadal vein
and adnexal varices; inferior-mesenteric and mesentericorenal; and splenoazygos collaterals are also
discussed and illustrated. Conclusion: This pictorial essay shall provide novice as-well-as experienced
diagnostic and interventional radiologists with comprehensive and richly-illustrated information on various
hepatofugal collaterals. Knowledge of the prevalence and CT-appearances of these collaterals has
important implications in the management of cirrhotic patients.
Dynamic imaging by ECG-gated CTA for assessing landing zone in aortic aneurysm and type B dissection
Authors:V Baliyan, S Sharma, GS Gulati, P Jagia, S Kumar, SK Chowdhari, AK Gupta
Objective: To assess dynamic changes in proximal landing zones (PLZ) prior to endovascular repair in
patients with aortic aneurysm or type B dissection. Material and methods: 56 patients underwent CT
Angiography (Definition, Siemens, Germany) with retrospective ECG gating. Group 1 (n= 28) included
patients with an aneurysm or type B dissection; Group 2 (n= 28) included patients undergoing gatedCTA for other indications. True axial images in multiple phases were generated (Group 1: PLZ; Group 21 cm proximal to innominate artery, mid arch, 1 cm distal to left subclavian artery). Aortic pulsatility
(AP, percentage change between systolic and diastolic diameters) was calculated. Vessel wall characteristics
(thickening, calcification) were identified. Relation of atherosclerosis & AP was assessed by KruskalWallis test; and between age (<40 &>40 years) and AP was assessed by Mann-Whitney U test. Results:
Variation between systolic and diastolic diameters was observed [AP of 4.66 + 4.53 and 5.11 + 4.77%
in the group 1 & 2 respectively (range, 0- 20%)]. Its relationship to atherosclerotic changes and age (>40
years) was statistically significant (p <0.001 for both). Conclusion: ECG-gated CTA is useful to assess
aortic pulsatility. Young age and absence of atherosclerotic changes show high AP. This can help optimize
device selection and prevent under-sizing.
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Fusion imaging with Electromagnetic navigation in radiological interventions- a technical innovation
Authors:N Kalra, Lawrence AJ, A Gulati, N Khandelwal
Image fusion and navigation is a novel real-time, three-dimensional visualization and navigation tool for
pre-procedural planning and intra-procedural navigation of radiological interventions. It transforms images
from CT, PET or MRI into dynamic representations which are fused with real-time ultrasound supporting
the navigation tool. During the intervention, the electromagnetic signals from sensors in the instruments are
used to display the location and orientation of tracked instruments superimposed on patient images. We
assessed the feasibility of this technique in FNAC of one patient having suspected hepatic metastases and
in pre-procedural planning for radiofrequency ablation of hepatocellular carcinoma in another patient.The
fusion imaging system used was the Philips PercuNav Image Navigation system version 3.0, integrated
with the iU22 ultrasound system. PercuNav was used to fuse CT/MRI images with real-time ultrasound.
Carotid – cavernous fistula: Imaging and intervention demonstrating a wide spectrum
Authors:Vyshakh H V, Shyam Kumar N K, V Moses, S Mammen
The treatment of choice for symptomatic carotid -cavernous fistula (CCF) is endovascular. High flow
direct CCF (type 1) is usually traumatic and should receive treatment. Low flow indirect CCF/asymptomatic
CCF can be managed conservatively till signs of ocular morbidity develop. Embolisation of the fistula can
be performed via the arterial or venous approach and occasionally direct approach like cannulation of the
draining superior ophthalmic vein is used. Embolisation can be carried out using detachable balloons, coils
or liquid embolic agents. Fistula can also be excluded by deploying a covered stent in suitable cases. We
hereby present a review and pictorial essay of all the types of CCF and their management done in our
institute over period of 10 years.
An Innovative lymphangiography technique and its utility in the interventional management of chylothorax
Authors:AV Nair,S Moorthy, Sreekumar KP, R Kannan, P K Nazar, P V Ramachandran
With increasing number of mediastinal surgeries, chylothorax is becoming a relatively frequent complication.
Imaging of thoracic duct is very important in a patient with chylothorax. Opacification of the thoracic duct
was done by bipedal lymphangiography. Direct lymphangiography is rarely performed today. Recent
studies have proved the efficiency of MRI in imaging thoracic duct. We present an innovative technique of
opacification of thoracic duct using a combined MR and fluoroscopy guided approach called ‘Percutaneous
thoracic ductography’. The indications, techniques and the potential benefits of thoracic duct embolization
are highlighted.
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A single institutional experience of safety and efficacy of Transarterialradioembolization in unresectable
hepatocellular carcinoma using yttrium 90 glass microspheres- TheraSpheres.
Authors: S Patil, SS Kulkarni, NS Shetty, APolnaya, T Dharia, R Gandhi, H Pendse, M Thakur.
Objective: In this article we evaluate safety and efficacy of radio-embolization treatment using
yttrium-90 glass microspheres (TheraSpheres) in unresectable HCC.Methods:We analysed
51 TheraSphere-treated patients at our institute between Jan 2010 to Sept 2012. Clinical and biochemical
data were obtained at baseline and 4-week intervals upto 6 months. Patients were followed for survival.
Common Terminology Criteria Adverse Events version 3.0 were used for assessment of liver toxicities.
Results: According to EASLE’s criteria, partial response in BCLC B & C patients was 94.7% & 47%
respectively. 7 of 23 (30.4%) in BCLC C had progressive disease (PD), while none of BCLC B patients
had PD. Median survival in BCLC B & C group was 14.9 & 11 months respectively. Commonest liver
toxicity was hyperbilirubinemia (8.7%). There were no cases of radiation gastritis or pneumonitis.
Conclusion:Transarterialradioembolization using Y-90 glass-microspheres (Therasphere) is safe and
effective in treatment of unresectable HCC.
Direct Carotid-Cavernous Fistulas: A Brief Review Of Endovascular Treatment Options.
Carotid-cavernous fistulas (CCFs) are an abnormal communication
between the internal or external carotid artery or its dural branches and the
cavernous sinus. Barrow et al, provided an objective angiographic method for
grouping CCF into direct or indirectdural fistulas which help determine prognosis
and planning therapy.1
Dr Vivek Gupta
Associate Professor
Department of Radiodiagnosis & Imaging
Post graduate Institute Of Medical
Education and Research (PGIMER),
Sector 12, Chandigarh, India
Type A: fistulas are direct shunts between the Internal Carotid Artery (ICA)
and cavernous sinus;
Type B: fistulas are between meningeal branches of the ICA and the cavernous
Type C: fistulas between the meningeal branches of the External Carotid Artery
(ECA) and the cavernous sinus;
Type D: fistulas between meningeal branches of both the ICA and ECA and the
cavernous sinus.
Direct CCFs (Type A), represent 70-90% of CCFs, are high flow fistulas.2 They usually occur after trauma
(0.2-0.3% of craniofacial trauma), most commonly blunt injury with basilar skull fractures and occasionally
penetrating orbital injuries or gunshot wounds.3
Traumatic CCFs occur most commonly in C3 and C4 segments of the intracavernous ICA followed by
C5 and C2 segments and rarely in intra-cavernous C1 segment.4 Iatrogenic trauma in treatment of trigeminal
neuralgia or in cases of trans-sphenoidal surgeries and endovascular procedures in which ICA is perforated with
a guide wire may also lead to direct CCFs. Direct CCF may occur spontaneously,although less frequently, after
rupture of intracavernous ICA aneurysms and rarely in arterial dissection, Ehler Danlos syndrome and
fibromuscular dysplasia.5
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Dural CCF (type B, C and D) are usually low flow fistulae without any antecedent trauma or manipulation of the
ICA. They are insidious in onset and 10-60% resolves spontaneously without treatment. 6 The most common
arterial feeders to these intracavernous dural AV malformations are the internal maxillary artery branch of the ECA
and the meningohypophyseal trunk from the ICA.7
Diagnosis and Treatment options:
Emergent treatment is recommended in CCF in cases of progressive vision loss, progressive paresis of extraocular
muscles or severe exopthalmos, intractable orbital pain or bruit and epistaxis.
Angiography is the confirmatory test of choice to identify the site and size of fistula, evaluate the venous drainage
of the CCF and document collateral circulation.8 The characteristic angiographic features are direct opacification
of an enlarged cavernous sinus, early filling of ophthalmic veins and diminished opacification of the distal arterial
system. Bilateral ICA, ECA and the vertebral arteries should be selectively injected in cases of indirect CCF so
that all arterial contributions to the fistula can be visualized. Subselective catheterization of the internal maxillary
artery and the ascending pharyngeal artery should be done in cases of indirect CCF. Immediate filling of the
petrosal sinus and/or the ophthalmic vein is commonly evident when intra-cavernous carotid artery is injected and
frame rates of greater than 5 frames per second may be needed to prevent obscuration of the shunt.
The Mehringer-Heishema maneuver may be useful in improving delineation of the lesion. The maneuver involves
a 2-3ml/sec injection into the ipsilateral carotid artery with manual compression of the artery below the catheter tip
in the neck. This compression allows flow control within the artery to aid in demonstrating the location of the tear.
The Huber maneuver involves an injection of the ipsilateral vertebral artery with lateral projection angiography
with manual compression of the affected carotid artery during injection. The retrograde siphon filling of the cavernous
sinus is evident and it also helps in identifying the upper extent of the fistula.
Treatment Options:
Coil embolization: has emerged as the treatment of choice in many centers including ours. This is because
of the fact that this technique is more reliable, safe; technically less challenging and cure rates are high.Here, a
micro-catheter is passed through the rent in the ICA into the cavernous sinus and after secure placement the
sinus is progressively packed with platinum coils till the flow of blood from ICA into the cavernous sinus is
arrested (figure 1).Care should be taken not to occlude the draining pathways as occlusion of the venous
pathways may redirect flow into the remaining pathways, superior ophthalmic vein- aggravating the ocular
symptoms, or cortical veins – increasing the risk of cerebral hemorrhage. Sometimes, when the rent in ICA is
large or there are multiple rents, the coils may prolapse into the ICA.To prevent this, coiling may be supported
with a balloon or a stent placement in the affected ICA.Advantages of using platinum coils include the ability to
control their placement and to easily retrieve, reposition or exchange them if necessary. They are easier to
guide into the fistula than a balloon. In cases of fistulas at sharp angle to the parent artery, it may be necessary
to curve the tip of the microcatheter with steam. These coils are very pliable and adapt to the shape of the
cavernous sinus without producing significant mass effect on intracavernous cranial nerves. It is unlikely that
embolisation with GDC will cause significant inflammatory response that could aggravate neurological symptoms.
The possibility of detachment without traction (as is the case with balloon embolization) helps to prevent
mechanical trauma in the surrounding structures and risk of perforation should be insignificant when proper
technique is used.
Balloon embolization: A balloon-mounted micro-catheter with balloon fixed at its distal tip is used. The
balloon (Gold valve balloons are most commonly used) is maneuvered into the rent with the flow. Sometimes,
when the rent is small or at very acute angle it may be difficult to cross the rent. Since no guide-wire is used to
negotiate the micro-catheter in the fistula this technique requires more experience and practice. Once the
fistula is crossed the balloon is inflated and attempt is made to wedge the balloon against the rent with major
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portion of it being in cavernous sinus (Figure 2). Care is taken to not to impede flow in the parent ICA.
Advantages of this technique are that it closes the rent effectively and is relatively cheap. However, disadvantages
are that the balloon may prematurely detach and migrate or it may deflate early thereby causing recurrence of
the fistula and also it is not an easy technique to master.
Covered stent placement- has been done in many cases of direct CCF in order to reconstruct the ICA
and to cover the rent (figure 3). This has been done when the rent is large or other treatments have failed.
Though many reports are available of this but it is still not widely accepted, as the covered stents which are
used are not low profile, are rigid and thus do not take the shape of the parent vessel adequately. This leads to
endoleak development and persistence of the fistulas. Also, these stents are prone to migration due to tortuous
nature of the artery and their rigid construction.
Parent artery occlusion- is reserved for those patients who have adequate cross flow and other treatment
options have failed or are not feasible due to any reason. Before a parent artery occlusion is attempted a
‘balloon occlusion test’ is must. This gives us vital information regarding the presence of cross flow and the
adequacy of this flow. If the patient tolerates this test, occlusion of the artery harboring the rent can be planned.
For this one needs to occlude the artery both distal and proximal to the rent. Only proximal occlusion may
result in retrograde flow of blood from the supra-cavernous ICA into the fistula and failure of the procedure.
Generally bare platinum coils are employed to occlude the vessel.
Trans-venous approach :
This may be used in cases of failure of the trans-arterial balloon/coil embolisation in direct high flow fistulas
and as the primary preferred modality for embolization of dural feeders originating from the ECA or the ICA in the
low flow Type B, C or D fistulas.
Trans-venous access to the cavernous sinus is most often achieved via the inferior petrosal sinus through
the catheterization of the jugular, facial and maxillary veins and then the pterygoid plexus. In cases the inferior
pterygoid plexus route is not possible or the pterygoid plexus is thrombosed, an anterior transvenous approach to
the cavernous sinus through the superior ophthalmic vein may be used. This may be done by surgically exposing the
SOV or the angular vein or by direct percutaneous puncture of the SOV or the retromandibular or facial vein.
Recently transfemoral route has been used to catheterize the facial vein, the angular vein and subsequently the
SOV.9 Although, trans-venous embolisation is a useful option, it can be difficult in high flow CCF as one is trying to
navigate through multi-septated venous sinuses against the direction of a high flow fistula. Greater success has been
attained in treatment of low flow indirect fistulas.
Role of Glue and Onyx :
Liquid embolizing agents are used mainly for indirect CCF’s. In case of direct CCF glue (n-butyl
cyanoacrylate) or onyx has been used to supplement coils or balloons when small residual flow remains in the
fistula after embolization. It decreases the number of coils required to seal the fistula. However these agents are not
the first line of therapy in direct CCF’s.
Complications :
Technical pitfalls associated with embolisation done with coils include risk of perforation, and difficulty of
packing them tightly. Moreover complete obliteration of these fistulas may be difficult and there is risk of impingement
on the parent vessel. A serious disadvantage of coil placement is the danger of distal coil migration owing to high
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June, 2013
shunt flow, whereas an inflated balloon as a single mass has less risk of migration.10 The complications of glue
injection include penetration of the n-BCA into the venous drainage or into the parent artery. The latter one is the
most feared drawback and can be prevented by using balloon or stent assisted glue injection. Complications of
balloon embolisation include a risk of TIA and risk of permanent neurological deficit seen in 3% and 2-4% of
patients respectively.11The most common complication is oculomotor palsies seen in 20% of patients, but most of
these resolve spontaneously within several months.12 Deflation can lead to pseudoaneurysm formation, some of
which may become symptomatic requiring sacrifice of the carotid artery.
Interventional neurovascular techniques have now come of age in treating both direct and indirect CCF.
Figure 1: Coil Embolization Of Direct CCF
40yrs old man with history of trauma 6 months back with left
eye proptosis and congestion since 4 months. CTA image (A)
showing gross cortical venous reflux in the left parietal region.
Right ICA injection (B) shows good cross flow (arrow). Left
ICA injection(C) showing rent in horizontal part of cavernous
segment of ICA with early opacification of cavernous sinus.
Delayed arterial phase images (D,E) show progressive
opacification of cavernous sinus (white arrows) with almost all
the blood refluxing into cortical veins (black arrows) and non
filling of the LICA distal to the fistula. Angiogram (F) post coil
placement (black arrow) showing restoration of forward flow
in LICA (white arrow), with complete occlusion of the fistula.
Figure 2: Balloon Embolization Of The Direct CCF
Young boy, with penetrating injury to left eye (A) with a metal fragment lying along
the medial aspect of the orbit on skull x-ray (B). Pre procedure angiogram AP (C)
and lateral (E) projection showing metal fragment (black arrow) causing LICA
laceration and resultant fistula with early filling of superior ophthalmic vein. Post
treatment angiogram (D, F) showing complete occlusion of the fistula by placing a
single detachable balloon in the cavernous sinus (red arrow) wedged against the
fistulous site.
Figure 3: Covered Stent Placement For A Direct CCF
A young boy with history of traffic accident having a large direct
CCF as seen on MRA(A), and angiogram (B, C) with large cortical
venous reflux. RICA angiogram (D)done to map out LICA distal
to the fistula for placement of stent delivery system across the fistula.
A microcatheter and guidewire was placed across the fistula (arrow
in E) and through which a 4x30mm covered stent (arrow) was
placed across the fistula (F).check angiogram reveals almost
complete occlusion of fistula with a small endoleak seen anteriorly
(G). Check angiogram 3 months later no endoleak or the fistula
with good antegrade flow in the LICA.
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Legends: Barrow DL, Spector RH, Braun IF, et al.: Classification and treatment of spontaneous carotid-cavernous fistulas.
J Neurosurg 1985; 62: 248-56.
Phillips PH. Carotid-cavernous fistulas. NeurosurgClin N Am. 1999;10:653-65.
Liang W, Xiaofeng Y, Weiguo L, Wusi Q, Gang S, Xuesheng Z. Traumatic carotid cavernous fistula accompanying basilar
skull fracture: a study on the incidence of traumatic carotid cavernous fistula in the patients with basilar skull fracture and
J Trauma 2007;63:1014-20.
Phatouros CC, Meyers PM, Dowd CF, et al. Carotid artery cavernous fistulas. NeurosurgClin N Am 2000;11:67-84.
Chuman H, Trobe JD, Petty EM, Schwarze U, Pepin M, Byers PH, Deveikis JP. Spontaneous direct carotid-cavernous fistula
in Ehlers-Danlos syndrome type IV: two case reports and a review of the literature. J Neuroophthalmol 2002;22:73-4.
Lasjaunias P, Chiu M, Brugge KT, Tolia A, Hurth M, Berenstein M. Neurological manifestations of intracranial
duralarteriovenous malformations. J Neurosurg 1986; 64:724-730.
Jafar JJ, Huang PP. Surgical treatment of carotid cavernous aneurysms. NeurosurgClin N Am 1998;9:755–63
Komiyama M, Nakajima H, Nishikawa M, Kan M. Traumatic Carotid Cavernous Sinus Fistula: Serial Angiographic Studies
from the Day of Trauma. AJNR Am J Neuroradiol 1998; 19:1641–1644.
Cheng KM, Chan CM, Cheung YL. Transvenousembolisation of dural carotid-cavernous fistulas by multiple venous
routes: a series of 27 cases. ActaNeuroch (Wein) 2003;145:17–29
10. Endovascular treatment of high-flow carotid cavernous fistulas by stent assisted coiling. Moróna FE, Klucznika RP,
Mawada ME, Strothera CM. AJNR Am J Neuroradiol 2005; 26:1399-1404.
11. Lewis AI, Tomsick TA, Tew JM Jr. Management of 100 consecutive direct carotid-cavernous fistulas: results of treatment
with detachable balloons. Neurosurgery 1995;36:239-44.
12. Keltner JL, Sattersfield D, Dublin AB, et al. Dural and carotid cavernous sinus fistulas. Ophthalmol 1987; 94:1585-600.
Trans arterial embolization as a therapeutic option in the management of solid organ injury in blunt
abdominal trauma
Introduction :
Role of CT :
Trauma is the most frequent cause of death in the first four decades of life, and
it remains a major public health problem in every country, regardless of the
level of socioeconomic development. The abdomen is the third most common
injured region, with surgery required in about 25% of civilian cases. Trauma
Dr. Shuvro H Roy-Choudhury
FRCS (London), FRCR (London),
can be either blunt or penetrating. With abdominal trauma, bleeding is a cataCCST (UK), FCIRSE, EBIR
Fortis Hospital, Kolkata.
strophic emergency. Visceral hemorrhage is the principle cause of mortality in
[email protected]
the first four hours after trauma. Non bleeding internal injuries are usually compatible with survival (1). Traditionally, hemodynamically unstable patients with
suspected bleeding are taken to surgery in an attempt to control hemorrhage. Relatively stable patients undergo
diagnostic imaging. In this regard CT has emerged as the modality of choice in imaging the acute abdomen and
has fewer limitations than ultrasound (2-4), diagnostic peritoneal lavage (5) or laparoscopy (6). In a large multicenter analysis of 938 patients 11% of liver and 12% of splenic injuries on CT had no free fluid and hence may
be missed by diagnostic peritoneal lavage or ultrasound(7). Conversely, the presence of free intra peritoneal fluid
or blood as detectable on ultrasound or diagnostic peritoneal lavage may not indicate visceral injury and are no
longer unequivocal indications for laparotomy (1,7,8).
Vol.No. IV No. 1
Fig. 1
Fig. 2
June, 2013
Fig. 3
Figures: (1) Active bleeding is defined as a focus of extravascular hyperdensity, of a similar density to a
nearby vessel, often surrounded by an area of less dense haematoma; (2) Sometimes active bleeding will
appear as a layered area of high density, e.g., in the mesentery; (3) Active bleeding (black arrows) should be
differentiated from a sentinel clot (white arrowhead) that is of lower density. It used to be thought as a
marker of organ injury, but, in reality, would accumulate in dependant areas of abdomen.
CT is proven to be a very sensitive test in blunt trauma (9,10) and its increasing use has markedly reduced
the rate of negative laparotomies in the last decade (8) which has been reported to be as high as 67% (11). CT is
useful in grading the abdominal trauma, diagnose active bleeding and acts as a quick virtual laparotomy with excellent diagnostic and prognostic capabilities. This is particularly so, as most solid organ injuries without active
haemorrhage can now be managed conservatively. The most important feature that predicts subsequent management is the presence of active bleeding. Once active bleeding is diagnosed on CT, a decision needs to be taken
whether the patient needs emergency surgery or whether the patient can be managed by interventional therapies.
There is emerging evidence that even in the presence of transient instability, correctable with resuscitation(1), urgent
CT can give useful information(12) to guide appropriate therapy(13), be that surgical or endovascular intervention.
Introduction of interventional therapies has increased the success rate of non-operative management (NOM)
manifold in most series, now approaching 90%. In this article we will review the role of these interventional therapies in the setting of NOM with particular reference to the three most commonly injured solid organs in the abdomen, namely the spleen, liver and kidney.
CT features of active haemorrhage are common to all bleeding sites. The most specific feature of active
bleeding is the presence of an extra vascular focus or diffuse area of high density with attenuation similar or greater
than that of adjacent enhancing vessels (14-17) [Fig 1]. The focal form of extravasation usually takes the configuration of a bleb, streak or jet. The diffuse form [Fig 2] conforms to peritoneal spaces and indicates free bleeding into
the peritoneal cavity (18). This high density contrast extravasation is of higher density than sentinel clot [Fig 3]; a
high density blood clot of around 60 HU adjacent to an abdominal organ usually indicating bleeding from that organ
(19). In addition, CT based grading of the degree of organ injury should be performed. The commonly used system
is by the American Association of Surgery for Trauma that grades each organ by severity that has prognostic
significance. The details are outside the scope of this text but is available at
dynamic.aspx?id=1322 (20).
CT Protocol
Our standard CT protocol involves scanning the abdomen from the diaphragmatic dome to symphysis
pubis with a slice selection profile of 1.0 mm. 100-150 ml of intravenous contrast (Ultravist 300, Schering Health
Care, West Sussex, UK) is given using a power injector at a rate of 3 - 4.5 ml/sec. Typically a delay of 70 seconds
is used in most trauma cases to achieve peak and homogeneous enhancement of both liver and spleen; the two most
commonly involved viscera in abdominal bleeding. Arterial phase images may be added when a higher slice CT is
used. Delayed images are performed if a renal laceration is seen, or, instability is not an issue. No positive oral
contrast is used.
Vol.No. IV No. 1
June, 2013
Non-operative management (NOM) of blunt splenic injuries is now the treatment modality of choice in
hemodynamically stable patients, irrespective of the grade of injury (see below), patient age, or the presence of
associated injuries (21). Recognition of the immune function of the spleen and the risk of overwhelming
post-splenectomy infection has led to the development of spleen-preserving surgery and NOM.
In a prospective multicenter study of 269 patients with splenic trauma comparing splenectomy to spleen
preserving techniques, splenectomy was an independent risk factor for early infectious complications (22). Trans
arterial embolization (TAE) is the most commonly used spleen preserving technique that has been used to try to
reduce failure of conservative management and preserve splenic function. Selective embolization has been shown
to have 90% - 94% splenic salvage rate in the presence of vascular injury (23) and can significantly decrease the
failure rate of NOM. In a series of 368 patients undergoing planned non-operative treatment with embolization
as adjunct, overall splenic salvage rate was 94% with 80% salvage in high grade injuries (24). In a large metaanalysis on NOM, 68.4% of the 10,157 patients were managed non-operatively. The overall failure rate of
NOM was 8.3%. The NOM failure rate without TAE increased from 4.7% to 83.1% in splenic injury grade 1 to
5 patients. The overall failure rate estimate of TAE was 15.7% and did not vary significantly from splenic injury
grades 1 to 5(25).
Most centers routinely perform TAE when contrast blush or a vascular abnormality is noted on the CT,
irrespective of the injury grade or hemodynamic stability as there is a strong correlation of contrast blush with
active bleeding on subsequent angiogram. However, the absence of contrast blush in high-grade (IV-V) splenic
injury does not reliably exclude active bleeding or the risk of rebleeding. This may be the reason for the relatively
high reported failure rates (15%) of NOM in high-grade (IV-V) splenic trauma because TAE is not typically
performed in the absence of contrast blush. A large series of 1056 patients suggested that all hemodynamically
stable high-grade (IV-V) injuries should undergo TAE regardless of contrast blush to optimize the success and
safety of NOM (26). Therefore, in our current practice, all hemodynamically stable splenic trauma patients are
candidates for NOM with selective TAE for high-risk patients with grade IV to V injuries, contrast blush on initial
computed tomography, and/or decreasing hemoglobin levels.
Patients presenting with hemodynamic (HD) instability and peritonitis still warrant emergent operative
intervention, although the evidence is rapidly changing where 24 hour interventional radiology is available and
easily accessible. Timely intervention in these patients is of essence, since delay to treatment is associated with an
increased risk of mortality. In a series of 96 patients, the median number of transfused packed red blood cells
was 8 in HD unstable patients treated with TAE versus 24 in the surgery group (p=0.09). No interventionrelated complications occurred in the TAE group and one in the splenic surgery group (p=0.88). Time to intervention did not differ significantly between HD unstable patients treated with TAE and patients treated with
splenic surgery. Although no difference was observed with regard to intervention-related complications and the
need for a re-intervention, a trend towards lower transfusion requirement was observed in patients treated with
TAE compared to patients treated with splenic surgery (27).
TAE can be performed proximal [Fig 4] to hilar branching (28-29) or super selective to the point of
bleeding with equivalent salvage rates (30). Proximal TAE reduces perfusion pressure significantly and stops the
haemorrhage whilst preserving distal splenic circulation. Distal targeted embolization requires longer, smaller
catheters and causes segmental infarction. In a total of 479 embolized patients comparing the two techniques, the
overall failure rate of angioembolization was 10.2% (31). This study and the available literature is inconclusive as
to whether proximal or distal embolization should be used to avoid significant rebleeding. However, both techniques have an equivalent rate of infarctions and infections requiring splenectomy. Minor complications occur
Vol.No. IV No. 1
Fig. 4a
Fig. 4b
June, 2013
Fig. 4c
Figure 4: Multiple areas of active extravasation within a traumatised spleen. seen as focal active bleeding (a),
confirmed on the angiography (b). This was treated with proximal (beyond pancreatica magna branches)
splenic artery embolisation (c).
more often after distal embolization. Maintenance of splenic perfusion pressure in a small proportion of patients
(mostly patients with coeliac stenosis or altered perisplenic collaterals) explains why rebleeding occurs in a small
proportion of cases following TAE (26).
Complications are few and include rebleeding, infection, abscesses, post embolization syndrome, pancreatitis and, of course, infarctions. Most splenic infarcts resolve without sequelae (29) although the white cell
count and temperature may be persistently elevated. Splenic immune function, measured by T-cell subset, generated only in the presence of an immunocompetent spleen, is preserved to near normal after embolization for
splenic trauma (main or segmental) and is much higher than post splenectomy (32). Normal levels of immunoglobulins and memory B cells, absence of H-J bodies and preserved splenic size and intraparenchymal blood flow
suggest that embolization has only minor impact on splenic function and that immunization probably is unnecessary. The cost effectiveness of this therapy has also been proven (33).
Liver :
Management of liver injury is more complex with more role for damage control surgery in higher grade
injuries, although non operative management is highly successful in most patients with less severe injuries. Intravenous contrast enhanced CT scan is the diagnostic modality of choice and guides subsequent therapy, particularly
if a contrast blush is detected. Despite an increase in high-grade liver injuries, the incidence of primary nonoperative management (NOM) more than doubled over two observed periods in a study, from 33% to 72%. The
failure rate of primary liver trauma treatment dropped from 18% to 11%. Complication rates dropped from 23%
to 16%. Liver-related mortality rates dropped from 10% to 3% reflecting improved results (34).
NOM of blunt hepatic injuries currently is the treatment modality of choice in hemodynamically stable
patients, irrespective of the grade of injury or patient age. Patients presenting with hemodynamic instability and
peritonitis warrant emergent operative intervention (bleeding can often be venous) with TAE (35) having an
important adjunctive role (23/183 patients in one series).
There are two principal indications of TAE in the acute post trauma setting:
a) primary hemostatic control in hemodynamically stable or stabilized patients with radiologic computed
tomography evidence of active arterial bleeding
b) adjunctive hemostatic control in patients with uncontrolled suspected arterial bleeding despite emergency lap
Vol.No. IV No. 1
June, 2013
In one series embolization was successful in controlling hemorrhage from various sources in 24 of 26
cases within 24 hours with one further case showing delayed success (36). Early use of embolization showed a
trend towards decreasing mortality when compared to operated or late embolization groups, and showed a
statistically significant reduction in the amount of blood required and subsequent liver related surgery (37). 538
cases was admitted with high grade liver injury over 5 years in Baltimore, 22% underwent angiography and 13%
underwent embolization, sometimes after laparotomy (13,38,39). Unlike in the spleen, major symptomatic hepatic necrosis does occur post TAE along with biliary and infective complications.
Kidney :
Non operative management is now established as the treatment of choice in almost all cases of renal trauma. This
conservatism is based on evidence that nephrectomy rate is higher among patients who undergo operative exploration (35%) than those who are observed (12.6%) (40). Surgery is reserved for patients with concurrent
injuries, renal injury grade 4 to 5 (20), with pedicle injury or multiple sources of active bleeding detectable on CT.
The success rate of NOM can be significantly improved by timely TAE. The combination of CT criteria for
contrast extravasation & extent of perirenal hematoma (rim distance >25 mm), and breech of Gerota's fascia
show the highest accuracy for predicting the need for TAE (41). In patients with active bleeding, angiographic
embolization with coils or particles is the treatment of choice to maximise salvage of renal parenchyma (42). In a
series of 44 patients successful embolization was performed in 43. The unsuccessful case had bleeding from the
main renal vein (43). Even if primary embolization fails, a repeat attempt can be successful before considering a
nephrectomy (44), as renal parenchymal conservation is always worthwhile, even if partial. Increased transfusion requirement in the first 24 hours is an indicator for those who might fail embolization and needs either a
second session or operative management. High success are seen even in grade 5 injuries with 100% technical
and clinical success rate being reported in a small series. Following embolization, in the intermediate term follow
up even grade 5 injuries show no significant adverse events in terms of renal function and development of hypertension (46). Long term follow up shows functional and morphological improvements in the embolized renal
Note also needs to be made about the need for renal protection as contrast nephropathy can occur in
these patients with hypovolemia and administered intravenous contrast during CT and embolization (47,48).
Other solid organs :
Traumatic pancreatic pseudoaneurysms can be managed by selective embolization or percutaneous thrombin
injection. Adrenal trauma usually presents with an adrenal or retroperitoneal haematoma. If large, expanding or in
the presence of contrast blush, this can be selectively embolized. In fact, TAE is the treatment of choice of almost
all actively bleeding retroperitoneal and pelvic injuries as well as diaphragm injuries, as exploratory laparotomy
may release the tamponade caused by the confined retroperitoneal space. Detailed discussion of hollow organ
injury or penetrating trauma is outside the scope of this article where surgery is the almost exclusive line of
Conclusion :
Trans arterial embolization (TAE) has been in vogue for blunt solid organ trauma for over 15 years and is an
established technique. In patients with visceral bleeding angiographic embolization can obviate surgical intervention thus contributing to the changing hierarchy of conditions to be treated surgically. TAE has significantly improved the success rate of non-operative management particularly in the setting of the splenic, liver and renal
Vol.No. IV No. 1
June, 2013
injuries. Recent evidence and guidelines suggest that TAE should be the modality of choice above surgery and is
finding place as such in the newer guidelines. In large level 1 trauma centres where 24/7 embolization services are
available, organ salvage rates of 93% is being achieved with relative minor complications. In good centres, even
in patients with transient instability, it is becoming the treatment of choice except in the liver, where, exploratory
surgery is still the treatment of choice.
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Vol.No. IV No. 1
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advantage of VAB is that it allows faster acquisition of multiple, large and
contiguous tissue cores with a single needle insertion into the breast. As
more tissue is retrieved,VAB has greater accuracy than CNB in terms of
frequency of histological underestimation, false negatives and need for rebiopsy1. VAB, however is not widely available, more expensive than CNB
using biopsy gun and has a definite learning curve.
Another important advantage of VAB is that it allows placement of radioopaque marker clips at the biopsy site before removing the probe from the
breast (fig 3). If the small lesion is completely removed during the biopsy Figure 3: Metallic marker clip (Mammomark®)
and histopathology result is positive, this clip can be used to direct deployed at the biopsy site (arrow) after a
VAB is seen on post biopsy mammogram.
preoperative hookwire placement which is then used to guide breast
conservation surgery. Placement of marker clip is also important for breast mass of any size that is being considered
for neoadjuvant chemotherapy2. After chemotherapy, some breast cancers may completely disappear on imaging.
Tumour site can then be identified with marker clip only and the surgery can be performed after performing hookwire
localization of the marker clip.
Ultrasound Guided Breast Biopsy
Wide availability, low cost, and ease of convenience to both the radiologist and the
patient makes ultrasound the preferred modality for breast biopsy. Linear, 7.5 MHz
(or more) transducer should be used. After preliminary scanning, skin puncture site is
determined. The skin is prepared and draped. Transducer surface is also cleaned or
covered with sterile cover as per the local practice. After local anaesthesia, a small
skin incision is given using number 11 scalpel blade. Needle is then inserted and the
lesion is approached with needle maintained parallel to the chest wall. This helps avoid
chest wall injury and improves needle visualization. The needle tip is just inserted in the
lesion and fired to obtain the sample. It is then withdrawn and sample is retrieved (fig
4). Procedure is repeated to obtain multiple, at least 4-5 samples. After the biopsy,
firm compression is applied at the biopsy sitefor about 10 minutes.
Technique of ultrasound guided VAB is similar to that of ultrasound guided CNB using
biopsy gun. The skin incision should be little wider (about 0.5 to 1 cm) so as to
accommodate the large calibre VAB probes.
Figure 4: Ultrasound guided CNB.
(a) Area of sample notch is seen
within the centre of the mass
indicating accurate positioning and
sampling (b) open sample notch
with harvested biopsy specimen.
Stereotactic Breast Biopsy
The principle of stereotactic biopsy is based on the trigonometric
determination of depth of the target lesion in the breast. Stereotactic biopsy
equipment is of two types: dedicated prone table and add-on erect types.
In dedicated prone table unit, the patient lies prone on the table with breast
hanging down through the opening in the table (fig 5a). The patient is
comfortable and does not see the procedure. This reduces the chances of
vasovagal reaction. There is also more space for the biopsy device and the
radiologist to work conveniently. However, dedicated prone table
stereotactic biopsy units are very expensive and cannot be used for
diagnostic mammography. Add-on stereotactic biopsy device is actually
Figure 5 : Stereotactic biopsy being performed
an accessory device which can be attached to standard diagnostic on dedicated prone table equipment (Mutlicare®,
mammography unit to perform the stereotactic biopsyin erect (sitting) Hologic) using Atec® VAB device.
position (fig 5b). It is cheaper and cost effective but is inconvenient to both
the patient and the radiologist. The patient closely watches the approach and insertion of a large needle in her breast
leading to a higher chance of fainting/vasovagal reaction.
Vol.No. IV No. 1
Figure 6 : Stereotactic biopsy
equipment being performed on
add-on erect biopsy unit using
a sitting position.
June, 2013
Figure 7: Stereotactic biopsy: (a) Post-fire images show that the needle has traversed the target
which is a cluster of calcifications. (b) Specimen
radiography of samples shows retreival of calcifications in multiple cores, confirming accurate
targeting and sampling.
The technique of stereotactic biopsy is same for both types of units. The breast is positioned and compressed with
a compression plate having an open window. An initial spot image is obtained without tube angulation to ensure
that the lesion is seen in the window. Once this is confirmed, a pair of stereo images with +15 and -15 tube
angulations is obtained without removing breast compression. Single or multiple targets are then marked with the
mouse clicks in both images and transmitted to the device. x,y and z co-ordinates are calculated and displayed by
the unit. The needle holder position is then moved and adjusted to appropriate position.
Skin is prepared and the needle is inserted through the needle holder in its selected position. A pre-fire pair of
stereo images areobtained with needle fully inserted to verify the needle position in both images. After that, the gun
is fired and another set of stereo images (post-fire) are obtained (fig 7a). The biopsy gun is them removed and
sample retrieved. Subsequently, each target is selected; transmitted and fresh core is obtained. When biopsy is
being performed with vacuum assisted probe, the probe is rotated in the same position to obtain multiple cores
from all directions around the probe. At the end, the needle is withdrawn from the breast and compression
released. If the target lesion has calcifications, specimen radiography of the harvested cores is essential to document
retrieval of calcifications in the specimen (fig 7b). Specimen mammography of cores is not required when the
target is a mass lesion without calcification.
MRI guided breast biopsy
MRI guided breast biopsy is required for lesions seen on MRI only. It is more difficult, time-consuming and
expensive. It requires special hardware in the form of special imaging coil (with window for biopsy) and localization
device. It also requires MR compatible needles. Many of the MR positive breast lesions can be demonstrated on
targeted ultrasound examination after MRI, and ultrasound guided biopsy can be done for them3.
MR guided breast biopsy is performed with special breast coils and needle guide known as aiming device. Two
types of aiming devices are available. Most commonly used is a grid type device. It has a plate with multiple holes.
The other type of aiming device has a bar and column, which can be moved in horizontal and vertical directions
Postbiopsy Care
After core biopsy of the breast, a continuous light pressure is maintained over the biopsy site (and not at the skin
puncture site) at least for 10 minutes to achieve the hemostasis. After that the incision is closed using sterile
adhesive tape. The patient should be advised to avoid strenuous arm movements for 24 hours and keep the watch
for obvious bleeding or sudden breast enlargement; the latter would indicate internal bleed and hematoma formation.
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Complications of Breast biopsy
Percutaneous core biopsy breast is a safe procedure and complications are rare. Vasovagal reaction is a potential
but unpredictable risk of breast biopsy. It is characterized by complaints of light-headedness or fainting and signs
of sweating, skin flushing and bradycardia. If vasovagal reaction occurs, patient should be immediately placed in a
supine position with feet raised and pulse and blood pressure is monitored. This is usually adequate and treatment
with atropine is not generally required.
Pre-Operative Needle Localization
Figure 8: Pre-operative hookwire localization: (a) Kopan’s needle hookwire assembly. It consists of a 20G
needle and a hookwire. (b) (B) Needle is inserted vertically. (c) Medio-lateral view obtained thereafter shows
that the needle tip has just crossed the lesion (arrow). Hook-wire is inserted and the needle withdrawn. (d)
Specimen radiograph of the excised tissue confirms accurate removal of the lesion (arrow).
This procedure was commonly performed before surgical excision biopsy of non-palpable lesions. However, after
advent of stereotactic biopsy, it is mainly used as a pre-operative localization procedure for therapeutic excision
(breast conservation surgery) of already diagnosed but non palpable breast cancer. Needle localization prior to
breast conservation surgery helps to precisely resect the cancer with clear margins. Various needle-hookwire
combinations are used for this procedure. Kopan’s needle-hookwire assembly is most widely used. It consists of
a 20G needle and a thin flexible wire which can be introduced through it. The distal end of the wire is folded back
forming a sharp angle (fig 8a). Another type of needle hookwire assembly has a retractable curved J tip instead of
the angled hook. Needle localization is usually performed under mammographic or ultrasound guidance. MR
compatible needle hookwire assemblies are also available to localize the lesions seen only on MRI.
Needle localization can be performed on all standard mammography machines. Only requirement is the special
compression plate with open window and alpha-numeric markers. An approximate area of lesion is determined
based on the baseline films. Breast is then compressed and cranio-caudal view obtained, keeping lesion area in the
open window. If the lesion is seen within the window, its x and y axis location is determined using the alpha-numeric
markers in the image. The skin entry point is marked and with breast still compressed in the same position,
localization needle without hookwire is then inserted vertically into the breast (fig 8b). Another CC view is obtained
at this point. With perfect positioning, the needle is seen en-face in the form of a dot superimposed on the lesion.
Then compression is released and orthogonal (medio-lateral) view is obtained (fig 8c). The needle should be seen
crossing the lesion with tip about 1 cm beyond the lesion in this image. If this is not the case, necessary needle
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June, 2013
adjustment is made. The hookwire is then inserted into the needle till a black mark on the wire reaches the hub. The
outer wire is then firmly held in position and needle withdrawn over it, releasing the hook in the breast. After
hookwire deployment, a medio-lateral film is obtained for the surgeon; Small gauze is kept on the breast from
where the wire is coming out.
Specimen Radiography
The surgeon dissects the breast using hookwire as a guide. Approximate part of the breast tissue around the hook
and the thickened wire segment is resected and sent to the mammography room for specimen radiography. The
specimen radiography is done on the mammography unit with minimal exposure factors. It should confirm that the
target lesion, along with good margins, has been removed within the resected specimen (fig 8d). Successful lesion
removal is then communicated to the surgeon, who is waiting in the OT, so that the breast is closed and sutured.
Special techniques of localization
Placement of two or more hookwires in same breast may be required for multiple lesions or to mark the extent of
a large lesion before breast conservation surgery4. This is known as hookwire bracketing.
Radio-guided occult lesion localization (ROLL) is another technique in which a radioisotope containing colloid
(same which is used for sentinel lymph node mapping) is injected into the tumour. Tumour is then localized intraoperatively using hand held gamma probe5.
Miscellaneous Breast Interventions
Ultrasound guided axillary lymph node FNAC
All patients with breast cancer require axillary lymph node dissection for pathological staging of the nodal status,
however, this procedure is morbid. Sentinel lymph node mapping helps to avoid axillary lymph dissection in some
patients who do not have axillary lymphadenopathy clinically. In this procedure, a dye and radionuclide (Tc99m
labelled sulphur colloid) is used to identify and remove the first node draining the tumour. However, the technique
of sentinel lymph node staging is cumbersome, time consuming and expensive.
Ultrasound of axilla in clinically node negative patients, with ultrasound guided FNAC of abnormal lymph nodes so
detected, is fast gaining acceptance. Patients with confirmed axillary lymph node involvement can then be spared of
sentinel lymph node staging and directly taken for axillary lymph node dissection.
Ablative procedures for breast cancer
Radiofrequency ablation of small breast cancer is feasible and complete ablation of tumour and adjacent margin of
breast parenchyma can be achieved. Major advantage of RFA of breast cancer, is minimally invasive treatment of
breast cancer with best cosmetic outcome. High intensity focused ultrasound (HIFU) is also useful for thermal
ablation of small breast cancers6,7.RFA and HIFU for breast cancers are still considered investigational as confirmation
of complete tumour ablation is difficult to document reliably and long term results are not known. However, these
procedures have potential to become an option for minimally invasive treatment of breast cancer in future.
Shah VJ Raju U, Chitale D, et al. False negative core needle biopsies of the breast: an analysis of clinical, radiologic and pathologic findings
in 27 consecutive cases of missed breast cancer. Cancer 2003;1519:1824-31
Nadeem R, Chagla LS, Harris O, et al. Tumour localization with a metal coil before administration of neoadjuvant chemotherapy. Breast
LaTrenta LR, Menel JH, Morris EA, et al. Breast lesions detected with MR imaging: utility and histopathologic importance of identification
with ultrasound. Radiology 2003;227:85-61
Kirstien LJ, Rafferty E, Spencht MC. Et al. Outcome of multiple wire localization for larger breast cancers: when can mastectomy be
avoided? J Am CollSurg 2008;207:342-46
Nadeem R, Chagla LS, Harris O, et al. Occult breast lesions: a comparison between radioguided occult lesion localization (ROLL) vs. wire
guided lumpectomy (WGL). Breast 2005;14:283-89
Manenti G, Bolacchi F, Perretta T, et al. Small breast cancers: in vivo percutaneous US-guided radiofrequency ablation with dedicated cooltip radiofrequency system. Radiology 2009;251:339-46
Zhao Z, Wu F. Minimally invasive thermal ablation of early-stage breast cancer: a systematic review. Eur J SurgOncol 2010;36:1149-55
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Figure 2:Intraprocedure lateral projection of right vertebral artery DSA showing balloon across the fenestrated segment with microcatheter
in situ(A), following placement of the first coil (B), with partially inflated balloon and coil mass in situ (C), following placement of the
third coil (D) and final control DSA demonstrating complete aneurysm occlusion (E).
Fenestration has been classically described as the division of the arterial lumen into two separate channels, each
having its own endothelial and muscularis layer with or without a common adventitia (1). Basilar artery fenestration
follows vertebral artery fenestration in frequency and is reported in 0.6% of angiograms (2) and in about 5% of
autopsy series.The incidence of an aneurysm being presentwhen a fenestration is noted is reported to be 7%(3);
however, the incidence of a fenestrationwhen a vertebrobasilar junction aneurysm ispresent is reported to be
35.5% (4). Therefore,when a vertebrobasilaraneurysmispresent,an associated fenestration should bestrongly
suspected.The lateral walls of the fenestrated artery have a normal intrinsic architecture. The medial walls, however,
have focal defects at both ends of the fenestration that make these segments weak and prone to aneurysm formation
similar to cerebral artery bifurcations. Here, the media layer is absent and in addition, the subendothelium is thin
and there is discontinuity of the elastin layer (4). Other proposed explanations of aneurysm formation have been
hemodynamic stresses, genetic (5) and other environmental factors.
Surgery had been the conventional mode of treatment of such aneurysms in the pre-endovascular era.With the
advent of endovascular approach, nearly all such aneurysms command coiling as the first line of management.Both
the limbs are precious at this location as both often give rise to brainstem perforators (6). A Pubmed search shows
less than 100 cases of aneurysms at the fenestrated basilar artery segment with most of them been tackled with by
endovascular methods with or without the use of assist devices. The results have ranged from good clinical recovery
to residual neurological deficits. In the index case, once the anatomy of the involved region became clear, it was just
a matter of a disciplined approach towards the aneurysm sac with preservation of fenestrated limb that was
required for successful coiling. Our two major endeavours were preservation of the limb of the fenestration and
prevention of coil prolapse into the main artery due to the wide neck which we achieved with a precise technique
and balloon aid. It should thus be realized that an elaborate pre procedure planning is of utmost importance in such
types of patients. This case reiterates that aneurysms of the basilar artery fenestration can be undertaken for coiling
and an endovascular balloon significantly helps in remodeling the aneurysm and the parent artery.
1. Parmar H, Sitoh YY, Hui F. Normal variants of the intracranial circulation demonstrated by MR angiography at 3T. Eur J Radiol
56: 220-228, 2005.
2. Takahashi M, Tamakawa Y, Kishikawa T, et al. Fenestration of the basilar artery. Radiology 1973; 109:79–82.
3. van Rooij SB, van Rooij WJ, Sluzewski M, Sprengers ME. Fenestrations of intracranial arteries detected with 3D rotational
angiography. Am J Neuroradiol.2009 ;30(7):1347-50.
4. Finlay HM, Canham PB. The layered fabric of cerebral artery fenestrations. Stroke 1994; 25:1799–806
5. Weinsheimer S, Goddard KA, Parrado AR, et al. Association of kallikrein gene polymorphisms with intracranial aneurysms.
Stroke 38: 2670-2676, 2007.
6. Grand W, Budny JL, Gibbons KJ, et al. Microvascular surgical anatomy of the vertebrobasilar junction. Neurosurgery 1997;
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38th Annual Scientific Meeting of the Society of Interventional Radiology - A personal experience
The 38th Annual Scientific Meeting of the Society of Interventional
Radiology was held at Ernest N Morial Convention Centre New Orleans
USA between 13-18 April 2013. There were a number of Indian
Interventional radiologists who attended the meeting. I was fortunate to attend
the meeting as a SIR international scholar.
Dr Paresh K Desai, MD
Senior Consultant - Diagnostic and
Interventional Radiology Apollo Victor
Hospital, Margao, Goa - India
The Society of Interventional Radiology offers international scholarship
programme to the interventional radiologists outside USA as a part of its
international outreach programme. It gives a grant of US$ 2000 towards
travel and accommodation. The scholarship programme consists of:
1. Attending the Annual scientific meeting – complimentary registration
Observership at a US centre of excellence in interventional radiology
Complimentary corresponding membership of SIR for one year
Annual subscription of JVIR for that year
Because of time constraints I personally could not take the benefit of a long enough observership this time. I plan
to take up such learning experience in the near future.
The SIR meeting is one of the largest interventional meeting in the world with multiple concurrent sessions.
Some of the unique sessions in the 2013 SIR meeting were:
> Meet the professor sessions for fellows and trainees – to have a chance of interacting with stalwarts
> Hands on workshops – IVC filters, AAA, lower limb revascularisations, ablation therapies etc.
> In the trenches sessions – included trips and tricks of starting and building practices of venous interventions,
Peripheral arterial diseases, cosmetic IR to name a few
One of the most popular sessions was an exciting film panel session – in a quiz format which ISVIR may consider
in the long run as a part of its annual meeting.
The duration of each of the talk was 10-15 minutes during the entire meeting and there were no repetitions –
between the speakers. This was very commendable.
During the International scholars event we also had an opportunity to express our views and put forth the kind of
IR practice we are involved in.
The international scholars are also offered to join JVIR as reviewers.
The winning posters from the ISVIR 2013 annual conference were displayed prominently at the Trade exhibit
entrance for everyone to notice.
As a whole it was an enriching experience in New Orleans.
I thank the Society of Interventional Radiology, the sponsors of this international scholarship programme
– COOK, Nordion, Delcath and Sirtax.
Special thanks to Dr S Rammurti for guidance and help during the application process for the scholarship.
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Developing clinical practice in Interventional Radiology in Non metro cities of India
(personal experience)
Interventional Radiology (IR) is a difficult ‘brand’ to market. As opposed
to other traditional specialty, IR offers broad range of treatments.
Interventional radiologists should act as the patient’s primary doctor for
treating disease process-rather than merely performing
angiographyprocedures. We should be a cognitive, office based,
competitive specialty capable of competing with Cardiologists& Vascular
Dr.Mangesh P. Tarte
Fellow Vascular & Interventional Radiology
(K.E.M-Mumbai), Consultant Vascular &
Interventional Radiologist
Material and Methods :
In order to become clinical specialist, IR must set up outpatient office to
see patients before & after IR procedures. Clinics should be located in the
center of the city &should include a small OPD within the hospital premises
where IR procedures are performed.
Writing articles in regional or vernacular languages; in daily newspapers, magazines, health supplement, etc.
Brochure, pamphlets, booklets, advertisement in local language for common public as well as easy to understand
presentations explained to patients.
Appearing on FM Radio channel, cable network, media interview, national TV channels.
Economical treatment package, free follow ups, insurance coverage, getting maximum benefits from hospital.
Circulating procedure list, Rate card, Referral Notepads to all family physicians & consultants.
Mouth to mouth publicity of successful procedures.
Keeping medical records in electronic & writing format.
Tele calling system for tracking down patient since consultation. Telephonic free consultation & guidance to
Giving sufficient time to patients queries, clarifying his belief & disbelieves. Satisfactory answers to cross
examining Doctors & patient’s relations, friends etc.
Forming a good rapport with patients family rather than professional, Egoistic approach & economical
calculations in mind.
Conducting free vascular diseases camp, free medicine samples to poor patients and conducting CME, seminars
for general practitioners.
Spreading knowledge & IR knowhow by conducting seminar, CME, workshop with the help of Medical
pharmaceutical, surgical andcath-lab hardware companies.
Video conferencing, live workshop& showing procedure demonstrationsfrom cathlab to Audience hall.
“Medical counselor’s role”: Training staff (assistant doctor or secretary) as official spokesperson to represents
you, to solve any medical problem. It becomes very important for counseling prior/post procedures and for
drawing patient for IR procedure.
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ISVIR Registry Meet 2013
Dear ISVIR members,
I take pleasure to inform you that the next annual registry meeting of ISVIR will be held on July 27-28,
2013 in Goa. You are requested to submit the registry data for the calendar year 2012 (January-December)
latest by June 30, 2013. The revised format for submission is available online at and includes, as
decided in the last registry meeting, a previous overview form and specific disease data sheets for Hemoptysis,
UAE, Critical limb ischemia, carotid artery stenosis and renal artery stenosis among others. Please be kind to
provide the necessary information in all forms. The sponsorship will be as per the practice followed in the
previous years. The speakers will receive travel support (shortest air travel by super apex fare) provided that
they have submitted the registry data in time. Accommodation in the conference hotel will be provided for a
maximum of two nights to those who have submitted the registry data in time, and as per the ISVIR guidelines of
data submission. The meeting timings will be as follows:
July 27- 9 AM-8 PM
July 28- 9 AM-4 PM
Venue- Radisson Blu Resort, Goa
The theme of the meeting will be complications in IR procedures.
The provisional program will be available at the site by the end of May, 2013.
Looking forward to meeting you in Goa this July.
Kind regards and best wishes,
Sanjiv Sharma
[email protected]