Bjorn Engstrom, MD

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

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

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

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

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

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

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

8. Radioembolization
in different patient
Note catheter
approach

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

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

11. Radial Artery access forVisceral
Intervention (RAVI)

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

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

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

15. Prostate Artery Embolization

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

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

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

19. Hydro dissection anterior
and posterior liver margin

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

22. US imaging during MWA

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

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

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

26. Balloon-occluded RetrogradeTransvenous
Obliteration (BRTO)

27. Balloon-occluded RetrogradeTransvenous
Obliteration (BRTO)

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

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

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

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

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

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

37. Thrombolysis inVenousThromboembolic disease –
Submassive and Massive PE

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

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

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

42. PE ResponseTeam
PERT
Intensive
care
Cardiology
HospitalistsVIR
Emergency
Medicine

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

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

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