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average age of 54 years. The average duration of symptomsuntil the time the procedure was performed was 18.2months. All patients are assessed by telephone one weekafter the procedure to determine the efficacy.

RESULTS: Patients presenting with multilevel degenerativechanges had a greater percentage of pain relief compared tothose who presented with degenerative changes localized toa single level (p value 0.0112). 50% of patients that ulti-mately required surgery for their symptoms did not reportany pain relief from the injection (p value 0.0053). Patientswho required narcotics for pain relief prior to the procedurehad a greater chance of having no pain relief from theinjection. Patients who had their injections performed at alevel other than C7-T1 also had a greater chance of nothaving any pain relief. There was no statistically significantdifference with regards to relief from pain and how it relatedto the number of procedures performed, age of the patient,and duration of symptoms. 5 patients reported side effectsfrom the steroids. The procedure could not be completed intwo patients due to increased patient anxiety and the pa-tient’s unwillingness to continue the procedure after the firstattempt at injection.

CONCLUSION: Translaminar cervical epidural steroid in-jection is a safe and effective procedure that is an excellentalternative to surgery in the management of neck pain.Clinical results are optimized when the injection is per-formed at C7-T1 in patients who have multilevel degener-ative changes and do not require narcotics for pain relief.

Scientific Session 23Vascular Interventions: AVM andExperimental

Monday, March 5, 20071:30 PM - 3:30 PMRoom: 204

1:30 PM Abstract No. 207

Long-Term Follow-up of Embolization of High-FlowPelvic Arteriovenous Malformations.S. Rao, Lenox Hill Hospital, New York City, NY, USA � R.J.Rosen

PURPOSE: To evaluate the long-term outcome of treatmentof a series of pelvic arteriovenous malformations.

MATERIALS AND METHODS: A 21-year retrospective re-view of 104 patients (37 male, 67 female) who underwenttreatment for high-flow pelvic AVM was performed. Patientdata included at least five year follow-up. Four patientsunderwent direct stick embolization; 100 patients under-went transcatheter embolization. Embolic agents utilizedincluded n-butyl cyanoacrylate (NBCA), spherical polyvi-nyl alcohol particles (PVA), and ethanol. Necessary fol-low-up procedures were noted and determined based onpresenting clinical signs and symptoms.

RESULTS: After the initial treatment procedure, thirty-sixpatients required follow-up procedures. Overall, 81 totalfollow-up procedures were performed for the 104 pelvic anduterine AVMs. There were no procedure-related deaths, butone female with a high-flow pelvic AVM died postpartumof high output failure despite multiple embolizations. Em-bolization of one high-flow pelvic AVM was complicated

by uncontrolled hematuria, requiring ten subsequent embo-lizations and eventual partial cystectomy.

CONCLUSION: In our experience, NBCA is the best optionfor treating high-flow pelvic AVMs due to minimal com-plications and acceptable recurrence rates.


Embolization of Localized Pulmonary ArteriovenousMalformations in Adults.J.-P. Pelage, Hopital Ambroise Pare Universite ParisOuest, Boulogne, Ile de France, France � C. Lagrange � S.Binsse � T. Chinet � J. Roume � P. Lacombe

PURPOSE: To demonstrate safety and efficacy of emboli-zation to treat localized pulmonary arteriovenous malforma-tions (PAVM). To emphasize technical aspects of the pro-cedure relevant to successful embolization. To defineclinical indications for embolization of PAVM.

MATERIALS AND METHODS: All consecutively seen pa-tients treated with embolization for localized PAVM havebeen enrolled in the study. Clinical presentation (dyspnea,previous history of paradoxical embolism) and characteris-tics of treated PAVM (single or multiple, location, diameterof the feeding artery and angioarchitecture (simple or com-plex) have been recorded. Specific information includingnumber of PAVM, number of coils and per-proceduralcomplications has been obtained. Clinical and imaging fol-low-up using multidetector computed tomography has alsobeen performed.

RESULTS: Forty-two patients (26 women and 16 men,mean age 45 y.o.) including 36 with hereditary hemorrhagictelangiectasia have been embolized. Twenty two patients(53%) presented with dyspnea and 12 (29%) had previousparadoxical embolism prior to embolization. A total of 99PAVM (mean 2.3 per patient) have been treated using 530coils (mean 12.6 perpatient) during 47 sessions. Sixty per-cent of � PAVM were localized in the lower pulmonarylobes and 81% had a simple angioarchitecture. The meandiameter of the feeding artery was 6 mm. No perproceduralcomplication occurred. During the follow-up, 2 patients(5%) presented a paradoxical embolism (stroke and brainabscess) and 5 patients only (13%) had persistent dyspnea.Using MDCT, 92% of treated PAVM were occluded.

CONCLUSION: Embolization of localized PAVM is a veryeffective treatment to improve dyspnea and reduce the riskof paradoxical embolism. A high technical success rate canbe expected by trained interventional radiologists.


Embolization of Peripheral Vascular Malformationswith Ethylene Vinyl Alcohol Copolymer (Onyx).F. Numan, Istanbul University Cerrahpasa Medical Fac-ulty, Istanbul, Kocamustafapasa, Turkey � M. Cantasdemir �A. Hasanefendioglu Bayrak � A. Bas � M. Ozbayrak

PURPOSE: To demonstrate the feasibility and preliminaryefficacy of endovascular embolization of peripheral congen-ital vascular malformations (VMs) with use of a nonadhe-sive liquid embolic agent, namely Onyx, which is ethylenevinyl alcohol copolymer (EVOH) dissolved in dimethylsulfoxide (DMSO). Onyx comes in ready-made vials con-taining EVOH, DMSO and tantalum powder.

MATERIALS AND METHODS: Twenty patients with amean age of 24.8 years had local low-flow (n � 7), local

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high-flow (n � 8), or diffuse high-flow (n � 5) VMs locatedin the upper, lower extremities and gluteal region. In allpatients, endovascular embolization was performed via thesuperselective catheterization of arterial feeders of VMswith use of microcatheters with coaxial technique. A total of28 embolization procedures were performed with Onyx,which was composed of 6%, 8%, or 20% ethylene vinylalcohol copolymer dissolved in dimethyl sulfoxide.

RESULTS: In five of seven patients with local low-flowVMs, the lesions were embolized completely. In the othertwo patients with local low-flow VMs, embolizations wereincomplete. The remaining 13 high-flow lesions of local (n� 8) or diffuse (n � 5) types were also embolized incom-pletely. In all patients with local low-flow VMs and in threepatients with a local high-flow VMs, clinical signs andsymptoms were resolved significantly. Other patients didshow clinical benefit from embolization to varying degrees.

CONCLUSION: Onyx promises and provides important ad-vantages over conventional embolic agents in the endovas-cular transcatheter embolization of congenital peripheralVMs. As with other embolic agents, it is far from perfect.


Absolute Ethanol Sclerosis for Symptomatic VenousMalformations.M.J. Hall, Medical College of Wisconsin, Milwaukee, WI,USA � W.S. Rilling

PURPOSE: Venous malformations are the most commontype of vascular anomaly. The goal of this study is toevaluate the clinical response and complications in patientstreated with ethanol sclerosis for painful non-CNS venousmalformations. Specific points of interest include pain reliefand complications following therapy.

MATERIALS AND METHODS: A retrospective evaluationwas performed of all patients treated with ethanol sclerosisfor venous malformations presenting from 1998-2006. In-patient and outpatient records were reviewed. A total of 30patients presenting with 31 discrete symptomatic venousmalformations were included in this study. Lesions wereaccessed under ultrasound guidance via direct puncture.Contrast venography was performed to obtain pressure/volume relationships prior to alcohol injection and commu-nications with normal venous structures were controlledwith direct compression and/or tourniquet application. Themajority of patients treated for painful venous malforma-tions were women, 83% (25 out of 30). The average patientage was 29.3 years (ranging from 13-75 years). The averagemaximum dimension of lesion treated was 7.8 cm.

RESULTS: The average number of interventions per patientwas 1.8. The average amount of absolute ethanol sclerosantinstilled into each lesion per treatment session was 10.4 cc.Postprocedural follow-up information was obtained on 28of these 30 patients. Near complete pain relief was achievedin 12 patients while partial pain relief was achieved in 16patients. Five patients experienced postprocedural compli-cations (16.7%). These complications include peripheralsensory neuropathy (2), tissue loss (2), and adjacent boneinfarct (1).

CONCLUSION: Ethanol sclerosis of venous malformationsimproves symptoms in the majority of patients and can bedone safely with limited (although potentially serious) com-plications.


Sclerotherapy for Venous Malformations: RetrospectiveAnalysis of EtOH and Sodium Tetradecyl Sulfate.A.C. Weathermon, The Hospital for Sick Children, To-ronto, ON, Canada � P. John � D. Armstrong � B. Connolly� M. Temple � J.G. Amaral

PURPOSE: To retrospectively compare the immediate clin-ical outcome of pediatric patients undergoing sclerotherapyfor venous malformations (VMs) using alcohol (n � 180)and sodium tetradecyl sulfate (STS) (n � 189).

MATERIALS AND METHODS: Institutional Ethics ap-proval was granted, including a waiver of informed consent.Computerized databases included records for 369 sclero-therapy procedures. Procedures were identified in whichonly alcohol or STS was injected. From these records, 155pediatric patients (95 female, 60 male; age range: 3months-21 years) with venous malformations who under-went sclerotherapy treatment were identified. For each pro-cedure, records of the type and amount of post-procedureanalgesic medication were compared along with the numberand type of complications. Complications were classified asmajor/minor according to SIR criteria. Lesions were classi-fied according to a validated magnetic resonance (MR)imaging classification scheme for venous malformations bytwo radiologists by consensus. Standard statistical testswere used to establish significance of comparisons.

RESULTS: Change in vitals signs did not vary between thealcohol and STS treatment groups (P � 0.05). Patientsundergoing alcohol sclerotherapy underwent significantlyfewer procedures on average (1.6 vs. 2.4 for STS, P �0.001). There was no significant difference between thetreatment groups in terms of the number of minor, major, ortotal complications (P � 0.05). Procedures from the alcoholtreatment group were more likely to require analgesic med-ication (alcohol – 114, STS – 88, P � 0.027), specificallyacetaminophen (alcohol – 68, STS – 40, P � 0.045). Therewere no statistically significant different in the dosages ofmorphine, acetaminophen or codeine administered.

CONCLUSION: Pediatric patients undergoing STS sclero-therapy for VMs required less analgesia and developedsimilar complications compared with patients undergoingalcohol sclerotherapy procedures.


Doxycycline Therapy of Congenital Lymphatic Malfor-mations: Our Two Year Experience.S. Pimpalwar, Children Hospital of Philadelphia, Phila-delphia, PA, USA � R.D. Kaye � R.T. Towbin � J.C. Hellinger� D. Low � A.M. Cahill

PURPOSE: To evaluate retrospectively the mid term clin-ical outcome of doxycycline therapy for congenital lym-phatic malformations at a single tertiary referral center.

MATERIALS AND METHODS: Over a 2-year period 19children (10F 9M) aged 4 weeks-24 years (median 4 years)underwent 48 doxycycline sclerotherapy procedures forclinically and radiologically diagnosed congenital lym-phatic malformations. The lesion distribution included headand neck (13), head and neck with mediastinal extension (3)and flank (3). The imaging and clinical records were re-viewed for each patient. This study was IRB approved.

RESULTS: All procedures were technically successful. Acombination of ultrasound and fluoroscopic guidance was

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utilized in all patients. A dose concentration of 10 mg/mlwas used with a dose range of 40-300 (median 200) mg persession. A 22g/21g needle was utilized in 36 procedures(75%) and a pigtail catheter was inserted in 12 (25%). Therewere 26 (54%) outpatient and 22 (46%) inpatient proce-dures and an equal distribution of procedures performedwith general anesthesia and deep sedation. There were twomajor complications: an anaphylactic contrast media reac-tion under general anesthesia in one child and a hypogly-cemic event with acidosis in a second, both with completerecovery. There were no minor complications. All childrenwere followed clinically in the vascular malformation clinicwhen sclerotherapy was determined to be complete. Therewas satisfactory clinical response in 16/19 children (84%)with correlative imaging follow up. In one child treatmentwas terminated due to anaphylaxis and the remaining 2children are currently in active therapy.

CONCLUSION: Conversion from absolute ethanol to doxy-cycline sclerotherapy in our practice has been successful fortreatment of congenital lymphatic malformations. Theknown ethanol related complications such as cardiopulmo-nary arrest, skin necrosis and nerve damage have not beenencountered in our patient population with comparable clin-ical success rates.


Percutaneous Sclerotherapy with Ethanolamine Oleatefor Low-Flow Vascular Malformations in the Trunk andExtremities.S.K. Cho, Samsung Medical Center, Sungkyunkwan Univer-sity School of Medicine, Seoul, Korea � Y.S. Do � S.W. Shin� K.B. Park � S.W. Choo � I.W. Choo

PURPOSE: To evaluate the efficacy and safety of percuta-neous sclerotherapy with ethanolamine oleate for low-flowvascular malformations in the trunk and extremities.

MATERIALS AND METHODS: Twenty-four patients withlow-flow vascular malformations in the trunk and extremi-ties, in whom percutaneous sclerotherapy with use of etha-nolamine oleate was performed on a out-patient basis andclinical follow-up was obtained, were included in this study.After direct puncture venography of the lesions, a mixtureof 5% ethanolamine oleate and contrast medium (ratio,5:1-5:2) was injected manually into the lesions under fluo-roscopic monitoring. A total of 49 procedures (1-5 sessions;mean, 2 sessions) were performed. The duration of clinicalfollow-up ranged from 20 days to 24 months (mean, 9.9months). The effectiveness of sclerotherapy was assessedbased on the clinical findings; for which both lesion sizesand patient symptoms were assessed at our vascular mal-formation clinic.

RESULTS: Sclerotherapy with ethanolamine oleate wasjudged effective in 19 (79%) of 24 patients. Of the fivepatients with ineffective outcome, two patients were waitingfor further session of sclerotherapy with ethanolamineoleate and one patient refused further treatment. Percutane-ous sclerotherapy with ethanol was planned in the remain-ing two patients. There were nine minor complications;three skin necrosis, three skin blisters, two transient numb-ness at the treated area, and one focal thrombophlebitis.

CONCLUSION: Percutaneous sclerotherapy with ethanol-amine oleate can be a safe and effective treatment of low-flow vascular malformations in the trunk and extremities.


Late In-Stent Stenosis & Inflammation in Cypher,Taxus & Polyzene-F Nanocoated Stents in a PorcineCoronary Model.B.A. Radeleff, University Hospital of Heidelberg, Heidel-berg, Baden-Wuerttemberg, Germany � U. Stampfl � R.Lopez-Benitez � S. Stampfl � H. Thierjung � G.M. Richter, etal.

PURPOSE: Despite their clinical success drug-elutingstents may induce specific inflammatory reactions with re-duced long-term success or late thrombosis. Therefore weinvestigated two commercial drug eluting stents versus acustom-made cobalt chromium stent with a 200 nm ultra-pure Polyzene®-F passive coat.

MATERIALS AND METHODS: In 30 mini pigs (20 – 25 kg)10 Cypher stents (Cordis, Miami Lakes, FL, U.S.A.), 10Taxus Express stents (Boston Scientific, Natick, MA,U.S.A.), and 10 Polyzene®-F (CeloNova BioSciences, Inc.,Newnan, GA, U.S.A.) coated (200 nm) CC stents wereimplanted in the right coronary artery (4 or 12 weeks followup). Quantitative angiography and light microscopy weredone to investigate late in-stent stenosis, thrombosis, vesselwall injury and inflammatory reactions.

RESULTS: No thrombosis occurred in any stent. The Po-lyzene®-F nanocoated stents showed an angiographic reste-nosis of 15.3% at four and 19.3% at 12 weeks, the Cypher®Select™ stent showed 14.7% at four and 12.6% at 12weeks, and the Taxus® Express™ stent of 6.2% at fourweeks and 10.3% at 12 weeks (not significant). The neoin-timal height was 63.54 �m at four and 152.2 �m at 12weeks in the Polyzene®-F nanocoated stents, 105.03 �m atfour and 115.19 �m at 12 weeks in the Cypher® Select™,and 74.86 �m at four and 165.73 �m at 12 weeks in theTaxus® Express™ stents (statistically significant differenceat four weeks for Cypher® vs. Taxus® p � 0.0431). Theinflammation score for Polyzene®-F nanocoated stents wassignificantly lower compared with the Taxus® stent at fourweeks (p � 0.0431). Otherwise, no statistically significantdifferences were noted.

CONCLUSION: Ultrapure Polyzene®-F stent coatings pre-vent thrombosis and peri-strut inflammation. They reducelate in-stent stenosis to the level of the two commercialdrug-eluting stents. Inflammatory changes are more pro-nounced in the Taxus® stent than the Cypher® stent.


Intraoperative, Real-Time Monitoring of Coagulationwith Laser Spectroscopy.E.M. Walser, Mayo Clinic, Jacksonville, FL, USA � A.Dogariu � E. Baleine � D. Miller

PURPOSE: We assess the use of a novel laser device tomeasure coagulability in patients undergoing vascular sur-gery or percutaneous procedures as compared to the cur-rently used standard, the activated clotting time (ACT).

MATERIALS AND METHODS: Recent investigations intobroad-spectrum laser fibers show that laser sensing of bloodcan evaluate a patient’s propensity for clot formation on areal time basis. The laser fiber used in in vitro experimentsis a 125 micron graded index laser fiber operating from alow-coherence laser source. In vitro experiments confirmthat coherence-gated dynamic light scattering can assess thestructure, flow, and viscosity of blood and can function as agauge of clotting propensity. Traditionally, this has been

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done by subjecting blood to lab analysis, which may takeseveral minutes and is prone to the inaccuracies of bloodcollection. We tested the ability of a laser fiber to replaceACT testing and monitor the coagulation status of patientsduring on a real-time basis. During intra-procedural bloodcollection for ACT, a very small laser fiber was positionedwithin the vascular sheath. As the blood was withdrawnfrom the patient, it contacted the laser fiber, where measure-ments were obtained at the same instant the blood samplewas submitted for an ACT determination. We noted thetimes and doses of anticoagulant therapy during the proce-dure and correlated ACT results and data from the laserfiber for 10 patients, with at least 4 data points obtained perpatient per procedure. In two patients, we drew ACT sam-ples with the fiber on and off to ensure that the activatedlaser did not affect ACT values.

RESULTS: The frequency spectrum obtained from the laserfiber correlated well with the patient coagulation status, asthe slope of the laser spectral distribution closely followedthe ACT values by scatterplot analysis. The activated laserfiber itself did not significantly affect blood ACT.

CONCLUSION: Small laser fibers operating at low powercan evaluate a patient’s coagulation status on a real-timebasis. Due to its small diameter, the intravascular use ofsuch a device may prove useful in the evaluation of bloodflow and viscosity in vascular disease before and aftertreatment.


Quantitative Analysis of Vascular Stenosis Morphology:Comparison between Catheter Directed CTA and Con-ventional DSA.D.P. Lum, University of Wisconsin Hospital and Clinics,Madison, WI, USA � R.K. Paul � D.W. Consigny � J.R. Grinde� T.M. Grist

PURPOSE: To evaluate the congruence of vascular stenosismeasurements between catheter directed intra-arterial com-puted tomography angiography (IA-CTA) and conventionaldigital subtraction angiography (DSA).

MATERIALS AND METHODS: 10 swine with artificialstenoses at the left common carotid, right renal, and leftexternal iliac arteries were examined in a combined angiog-raphy/CT suite (GE Innova 4100/16-slice Lightspeed). Mul-tiple view DSA and IA-CTA (140 kV, 380 mA, 0.5 srotation, pitch � 1.375, 16 � 0.625 mm, 13.75 mm/s tablespeed) was performed with selective injection (dilute io-hexol 350) at each lesion. IA-CTA vessel path trajectorywas defined and cross section contours segmented to pro-duce mean diameter % stenosis. Vessel contours were de-tected in the DSA frame of maximal opacification, and %stenosis calculated accounting for geometric magnification(catheter calibration technique). The reference diameter wasmeasured at the most normal appearing adjacent segment.Results were compared with Bland-Altman analysis andPearson’s product correlation.

RESULTS: 29 lesions (10 carotid/10 renal/9 iliac) wereanalyzed. The % stenosis (DSA (mean � STD): 53.7% �11.7, range 26.3-80.6%; IA-CTA (mean � STD): 52.1% �12.8, range 23.2-72.8%) was weakly correlated (r � 0.523,p � 0.0032). Bland Altman plots comparing % stenosis(bias � 1.59%; 95%CI[-2.95,6.13]; limits of agreement-22.30% to 25.48%) showed poor agreement. Meanwhile,the reference diameter (DSA: 3.6 mm � 0.8, range 2.4–5.5mm; IA-CTA: 3.6 mm � 0.9, range 2.1–5.6 mm) was

highly correlated (r � 0.818, p � 0.0001). Bland Altmanplots (bias � 0.073 mm; 95%CI[-0.12,0.27]; limits ofagreement -0.94 mm to 1.08 mm) showed good agreementbetween the two techniques.

CONCLUSION: DSA and IA-CTA produce comparablemeasurements of the reference diameter of small normalvessels. The weak correlation and wide range for limits ofagreement for % stenosis indicates that DSA and IA-CTAproduce different measurements of % stenosis for eccentriclesions. Evaluation of a lesion’s cross section characteristicsmay contribute to differences in % stenosis between IA-CTA and DSA. Additional studies to validate the accuracyof IA-CTA are warranted.

Scientific Session 24

Oncology: Radiotherapy

Monday, March 5, 20071:30 PM - 3:30 PMRoom: 205


Functional MR Imaging Assessment of Tumor Responseafter TheraSpheres in Patients with Unresectable HCC.I.R. Kamel, Johns Hopkins Hospital, Baltimore, MD, USA� D.K. Reyes � E. Liapi � J. Hebert � D.A. Bluemke � J.-F.H.Geschwind

PURPOSE: To assess the utility of functional perfusion anddiffusion MR imaging in assessing early (1 month) responseof unresectable HCC to a single treatment with Yttrium-90labeled microspheres (TheraSpheres).

MATERIALS AND METHODS: MR imaging studies beforeand 1 month after single selective TheraSphere treatment on13 consecutive patients were evaluated. All patients hadcirrhosis and pathologically proven HCC. Patients wereimaged using a 1.5-T MR scanner and a phased array torsocoil. Images were evaluated by consensus of 2 radiologists.Tumor size, arterial and venous enhancement, and apparentdiffusion coefficient (ADC) values were recorded beforeand after treatment. One targeted tumor in the treated lobeof the liver was included in each patient. In patients whoalso had lesions in the contralateral lobe of the liver asecond tumor was included as non-targeted tumor for com-parison of tumor response.

RESULTS: A total of 21 tumors (mean size, 9.4 cm) wereevaluated in 13 male patients (mean age, 62 years). Meantumor burden was 25% of the total liver volume, and meanTheraSpheres dose was 127 Gy. Targeted tumors (n � 13)demonstrated mean decrease in arterial enhancement of22% (p � 0.013), mean decrease in venous enhancement of25% (p � 0.012), and mean increase in ADC value of 18%(p � 0.001). Targeted tumors had no change in size aftertreatment (p � 0.492), and therefore, were considered non-responders based on size criteria. Six patients had contralat-eral non-targeted tumors. These tumors had no change insize (p � 0.100), arterial enhancement (p � 0.182), venousenhancement (p � 0.182), or ADC value (p � 0.105) aftertreatment.

CONCLUSION: Early after treatment with TheraSpheres,tumors demonstrated decrease in arterial and venous en-hancement and increase in ADC, without statistically sig-

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