Over the years the Film Interpretation Panelhas become one of the highlights of theCIRSE meeting; interesting cases are dis-cussed in a lively and humorous manner astwo teams battle for victory. This year's FIPwill feature Team Odin vs. Team Thor hostedby Afshin Gangi and Anthony Watkinson.

The Film Interpretation Panel will take place today at 15:00 in Room A.

The GEST Europe meeting under the auspicesof the CIRSE Foundation will take place in April2009. In 2010 there will be a further ECIO meet-ing, also organised by the CIRSE Foundation. In 2008 the European School of InterventionalRadiology (ESIR) organised more than 13 localcourses focussing on one topic each to offereasily accessible IR education to young inter-ventionists across Europe. I am happy to saythat the ESIR has also been a very successfulinitiative.

Interventional Radiology procedures are now awell accepted main stream treatment optionfor many diseases and new opportunities toapply them are on the horizon, such as in thebudding field of Interventional Oncology. Itwas therefore time to take a further step in thecreation of a truly global network for IR. CIRSEnow has 20 group members and the totalCIRSE membership has almost tripled duringthe last 3 years. Today CIRSE is 4,280 membersstrong and growing.

One of CIRSE's most important aims is to createthe first European certification forInterventional Radiology until 2010. For thisproject we are cooperating closely with boththe UEMS and the ESR. Interested persons willbe able to take the examination for this Skilland Knowledge Certificate one day prior to ourannual meeting and it will be open to all CIRSEmembers. More detailed information will beavailable through our newsletter and the CIRSEweb page.

Don't miss the FilmInterpretation Panel!

Tuesday, September 16, 2008

Join us for this year's Foundation Party and experience a night ofglamorous show acts, exquisite food and dancing until the morninghours. Being the highlight of CIRSE's social programme, the CIRSE 2008 Foundation Party will certainly be a night to remember.

With world-renowned Wallmans restaurant and theatre local hostPoul Eric Anderson has picked a fun and exciting venue which willleave no wish unfulfilled. The dinner show will combine fabulousfood with an excitingly fresh show act performed by 18 internationalartists.

Like all world-renowned Wallmans shows, its latest creation 'Passion'will offer music, singing, dancing and lots of innovative humour, allset against a backdrop of avant-garde scenography and innovativecostumes. It will take you on a passionate journey through a

CIRSE 2008 - CopenhagenMonday, September 15, 2008

C RSECardiovascular and Interventional Radiological Society of Europe

Join us for the CIRSE Foundation Party!

Rnewscongress

Hard Rock Opera, the sounds of Big Band and the great melodies ofBurt Bacharach. Glamorous show girls will dazzle you in the retro 50'snumber "Car Wash", as will the talented singers and dancers of variousother performances.

For the grand finale and by popular demand, Elvis will be back in thebuilding! The King of Rock 'n Roll and most famous entertainer of alltimes will close the show and leave the dance floor to you.

Tickets for the Foundation Party can be purchased at the hotel counter in the registration area.

Don't forget to cast your vote forthe best picture of the CIRSE 2008Photo Exhibition. To vote, pleaseproceed to the work station locat-ed in the Photo Exhibition vis-à-visthe Abbott Lounge

Jim A. ReekersCIRSE President

Dear Colleagues,

I hope you have had a good start at CIRSE 2008and you are enjoying the programme we haveput together for you. It is a great pleasure tosee that Interventional Radiology is flourishingand so many are here to learn, to communicatetheir science and to meet colleagues from allover the world. I am proud that we are able tooffer you another broad and high quality pro-gramme which enables you to make your ownselection and to assemble your own dedicatedprogramme. CIRSE has certainly become theannual meeting point for global IR.

CIRSE has further grown compared to the pre-vious years. We received a record number ofabstracts, there is more exhibition space andadditional activities. Companies see our annualmeeting as the starting point to launch newproducts and the latest breaking science is pre-sented. But CIRSE is not only the annual meet-ing. Both the CIRSE society and the CIRSEFoundation have explored many new activities.Last spring we organised a very successfulmeeting on Embolotherapy and InterventionalOncology, ET ECIO 2008, in Florence with morethan 1,300 participants. From this year onwardsGEST Europe will be part of the Foundationeducational programme to keep you updatedin the field of embolic therapy.

What is the purpose of all these activities? I feelvery strongly that CIRSE should be the drivingforce of Interventional Radiology in Europe andbeyond. We must leave the dim light of ourinterventional suites and come out into theopen. IR is probably still the most unknownmedical specialty out there. We should there-fore aim at a strong promotion of IR to patientsin addition to a strong educational and scientif-ic programme.

You will see that CIRSE 2008 is the startingpoint of yet another new activity, i.e. a patientawareness programme which was establishedby our colleagues from the Local HostCommittee headed by Poul Erik Andersen. Wewill make this patient awareness programme apermanent feature of our meeting, as a wellinformed patient is vital to our specialty. TheCIRSE website www.cirse.org also offers ampleinformation about our procedures for the inter-ested public.

CIRSE has reinvented itself in the last years tobecome a key player in the IR market. Of coursenone of this would have been possible withoutthe aid of a very enthusiastic team at the CIRSEoffice in Vienna. I have said this many timesbefore and I will say it again: "The future of IR isbright!" There is no need to be shy. We are hereto stay.

I wish you all a wonderful stay in Copenhagenand a fantastic educational meeting and lookforward to your ideas and input for futureactivities!

In our many years in radiology we have hadthe chance to attend numerous congresses,getting to know colleagues from around theworld. In these encounters we have noticedthat many of us share a hobby: photogra-phy. To us this shows that some people weresimply born to be imagers.

To share this passion with all our colleagues,CIRSE has organised the first CIRSE PhotoExhibition featuring photographs createdby its members and congress delegates. Theexhibition is located vis-à-vis the AbbottLounge at the main auditorium foyer andcan be visited throughout the congress. Tovote for your favourite picture, please usethe computer next to the exhibition. Thewinner will be announced at the FoundationParty where you will have the chance tomake a bid for the winning picture.

We hope that you will enjoy this interestingnew feature of the congress and look forwardto the Photo Exhibition and Contest becom-ing a regular feature of the CIRSE meeting !

Jim Reekers, James Spies

Photo Competition ends today - Cast your vote!

Patient Awareness Interventional Radiology: your alternative to surgery

TODAY! Monday, Sept. 15, 16:30-18:00 Medical students

For the detailed programme please refer to page 3.

. orgES RT H E D A T A B A S E F O R I N T E R V E N T I O N A L I S T S

1,900online presentations

Free of charge for CIRSE Members

24 hours - 7 days a week

CIRSE's latest

e-learning tool

now online!

As part of its efforts to offer a completerange of learning possibilities to interven-tionists, CIRSE has launched a new onlinelearning tool; www.esir.org. The comprehen-sive database contains more than 1,900titles, including high quality streamingvideos from the CIRSE 2006 and 2007 con-gresses, all recent CIRSE abstracts and EPOSposters, slide material of the CIRSE 2006 and2007 congress presentations and ESIRcourse material

· Complete range of learning possibilities· Comprehensive database with

over 1,900 titles including

· Videos· Abstracts· EPOS posters· Slide shows

· Material from previous congresses (CIRSE, ET, ECIO) and ESIR courses

· View online or download for later use

To try out www.esir.org free of charge visit the CIRSE Booth, the EPOS Corner or the Internet Café.

Free for

CIRSE members

3Stent GraftsIRnewscongress

C RSECardiovascular and Interventional Radiological Society of Europe

The development of stent-grafts and their usein the thoracic aorta has significantly changedthe management of diseases involving thedescending aorta and the aortic arch in the lastdecade or so. Thoracic aortic aneurysms, Type Bdissections and traumatic transections can nowbe treated without the need for thoracotomyand cardiopulmonary bypass with the obviouspotential advantages in terms of reduced mor-bidity and mortality. Endovascular repair of the thoracic aorta(TEVR) has become an established treatmentmodality despite a relative paucity of evidence,with a lack of the randomized trials that haveaccompanied other new vascular procedures.The majority of available data are obtainedfrom case series and registries. The aim of thisarticle is to review the outcomes of thoracicendografting and compare them with conven-tional surgery.

Descending thoracic aneurysmsThe survival of patients with untreated TAA isbleak and is estimated to be 13-39 at 5 years(1). The results of open repair in centres ofexcellence are good with 3 day mortality ratesfor all types of thoracic aneurysm below 12%and paraplegia rates below 4% (2). Communityresults which incorporate several centres aremore realistic and demonstrate 30-day mortali-ty rates approaching 20% (3).

Outcome data for endovascular repair of tho-racic aneurysms are available from severalsources. Leurs et al on behalf of the EUROSTARcollaborators reported data in 249 patientswith 30-day mortality for elective TEVR of 5.3%and paraplegia of 4% (4). A cohort of patientswith TAA who underwent endografting withthe Gore TAG device was compared retrospec-tively with the results of a cohort of 94 patientswho underwent open surgical repair. The peri-operative mortality (2.1% vs. 11.7%), paraplegia

(3% vs. 14%) and freedom from major adverseevent (48% vs. 20%) rates were all better in theendovascular group (5).

Similarly, the European Talent Registry reportedtechnical success of 98%, in-hospital mortalityin 5% (4.1% and 7.9% for elective and emer-gency procedures, respectively), paraplegia in1.7% and stroke in 3.7% (6). Similar outcomeshave been reported for the newest generationof endografts, despite the fact that the patientsin these later data series had more challenginganatomy compared with earlier series (7).

Thoracic Dissection and Acute Aortic Syndrome The management of acute Type B dissections isprincipally medical, with surgery reserved forcomplications. Overall, medical managementof patients with acute aortic dissection has amortality rate of just over 10%. This will includea mixed group of patients with uncomplicateddissection and some patients with complicateddissection who would be considered unsuit-able for surgical intervention. Surgical interven-tion in patients with complicated dissectionhas a mortality rate of approximately 30% (8).

The early results of endovascular repair ofacute complicated Type B dissections werevastly better than the open surgical alternative.Most series reported mortality rates below 10%with paraplegia rates of less than 3% (4,9-12).These findings stimulated a rapid change inmanagement and most vascular centres wouldnow regard endovascular therapy to be thefirst line treatment for acute complicated TypeB dissections.

Indications for repair of chronic dissectionshave usually been limited to the onset of com-plications, and an aortic diameter exceeding5.5-6.0 cm. The availability of data regardingthe outcomes of EVR for chronic dissections isvery poor. In the series to date the mortalityrates have been acceptable, but the long-termsuccess in preventing aortic expansion isunclear. There have been anecdotal reportsthat the false lumen below the stent may con-

tinue to expand after treatment and that therate of repeated intervention is high (7). This isan area that requires further work to facilitateeffective therapy.

Traumatic Aortic InjuryTraumatic aortic injury (TAI) is the second mostcommon cause of death in patients after bluntinjury. 15-30% of deaths from blunt traumahave aortic transaction at post mortem. Thesurgical approach to treatment has changedconsiderably in the last decade. While previous-ly it was thought that emergency repair wasmandatory due to the belief that there was ahigh risk of early rupture, recent series suggestthat the rupture risk in stable patients is only10% (13, 14).

Due to its low complication rate TEVR has inmany centres superseded surgery for TAI in thelast decade. The procedural time is short andthe operation confers very little in terms ofadditional morbidity to these severely illpatients. Due to the focal nature of the injury,only a short length of aorta requires coveringwith an endograft.

Although TEVR seems to have become the goldstandard for TAI, there are relatively limiteddata on outcomes. However, the proceduralmortality is less than 10% throughout and thereported risk of paraplegia is negligible (15-17),outcomes much improved compared with sur-gery. The main drawback concerns the unsuit-ability of the devices available for the patientswho require TEVR. TAI occurs in a relativelyyoung population with narrower aortas andmore angulated aortic arches than olderpatient. None of the devices currently availableconform very well to angulated arches. Thereare reports of endografts "sitting up" in thearch resulting in endograft collapse andpseudocoarctation (18). The other problem isthe lack of availability of small calibre endo-grafts. The smallest endograft is 22 mm, whichlimits the smallest size of aorta that can bestented to 18-19 mm.

In summary, the advent of endovascular repairfor thoracic aneurysms has changed practice.In my view, there is enough evidence to sug-gest that TEVR should be used as first line ther-

Outcomes of stent-grafts and the thoracic aorta -a great step forward for survival

Robert MorganConsultant Vascular and InterventionalRadiologist, Honorary Senior Lecturer, St. George's NHS Trust and Medical School,London, UK

References:1. Perko MJ, Norgaard M, Herzog TM, Olsen PS, Schroeder TV,

Pettersson G. Unoperated aortic aneurysm: a survey of 170patients. Ann Thorac Surg 1995;59(5):1204-9.

2. Estrera AL, Miller CC, Azizzadeh A, Safi HJ. Thoracic aorticaneurysms. Acta Chir Belg 2006;106(3):307-16.

3. Rigberg DA, McGory ML, Zingmond DS, et al. Thirty-day mortalitystatistics underestimate the risk of repair of thoracoabdominalaortic aneurysms: a statewide experience. J Vasc Surg2006;43(2):217-22; discussion 23.

4. Leurs LJ, Bell R, Degrieck Y, Thomas S, Hobo R, Lundbom J.Endovascular treatment of thoracic aortic diseases: combinedexperience from the EUROSTAR and United Kingdom ThoracicEndograft registries. J Vasc Surg 2004;40(4):670-9; discussion 9-80.

5. Bavaria JE, Appoo JJ, Makaroun MS, Verter J, Yu ZF, Mitchell RS.Endovascular stent grafting versus open surgical repair ofdescending thoracic aortic aneurysms in low-risk patients: a multi-center comparative trial. J Thorac Cardiovasc Surg2007;133(2):369-77.

6. Fattori R, Nienaber CA, Rousseau H, et al. Results of endovascularrepair of the thoracic aorta with the Talent Thoracic stent graft: theTalent Thoracic Retrospective Registry. J Thorac Cardiovasc Surg2006;132(2):332-9.

7. Thompson M, Ivaz S, Cheshire N, et al. Early Results ofEndovascular Treatment of the Thoracic Aorta Using the ValiantEndograft. Cardiovasc Intervent Radiol 2007.

8. Hagan PG, Nienaber CA, Isselbacher EM, et al. The InternationalRegistry of Acute Aortic Dissection (IRAD): new insights into an olddisease. Jama 2000;283(7):897-903.

9. Eggebrecht H, Nienaber CA, Neuhauser M, et al. Endovascularstent-graft placement in aortic dissection: a meta-analysis. EurHeart J 2006;27(4):489-98.

10. Bortone AS, De Cillis E, D'Agostino D, de Luca Tupputi Schinosa L.Endovascular treatment of thoracic aortic disease: four years ofexperience. Circulation 2004;110(11 Suppl 1):II262-7.

11. Nathanson DR, Rodriguez-Lopez JA, Ramaiah VG, et al.Endoluminal stent-graft stabilization for thoracic aortic dissection.J Endovasc Ther 2005;12(3):354-9.

12. Chen S, Yei F, Zhou L, et al. Endovascular stent-grafts treatment inacute aortic dissection (type B): clinical outcomes during early,late, or chronic phases. Catheter Cardiovasc Interv 2006;68(2):319-25.

13. Shorr RM, Crittenden M, Indeck M, Hartunian SL, Rodriguez A.Blunt thoracic trauma. Analysis of 515 patients. Ann Surg1987;206(2):200-5.

14. Fabian TC, Davis KA, Gavant ML, et al. Prospective study of bluntaortic injury: helical CT is diagnostic and antihypertensive therapyreduces rupture. Ann Surg 1998;227(5):666-76; discussion 76-7.

15. Melnitchouk S, Pfammatter T, Kadner A, et al. Emergency stent-graft placement for hemorrhage control in acute thoracic aorticrupture. Eur J Cardiothorac Surg 2004;25(6):1032-8.

16. Waldenberger P, Fraedrich G, Mallouhi A, et al. Emergencyendovascular treatment of traumatic aortic arch rupture with mul-tiple arch vessel involvement. J Endovasc Ther 2003;10(4):728-32.

17. Fattori R, Napoli G, Lovato L, et al. Descending thoracic aortic dis-eases: stent-graft repair. Radiology 2003;229(1):176-83.

18. Hinchliffe RJ, Krasznai A, Schultzekool L, et al. Observations on thefailure of stent-grafts in the aortic arch. Eur J Vasc Endovasc Surg2007;34(4):451-6.

Thoracic aorta stenting updateSpecial Session Monday, September 15, 8:30-9:30Room C

Don't miss it !

apy for most thoracic aneurysms involving thedescending aorta and probably the aortic arch.Regarding dissection, endovascular repairshould be considered the gold standard forcomplicated acute Type B thoracic dissections.There appears to be no justification for therepair of uncomplicated acute dissections. Theindications and methodology for the treatmentof chronic dissections remain undefined. TEVRfor TAI has reduced complication rates com-pared with surgery. However, improvement inthe devices is required before it can be recom-mended as first line therapy for this indication.

Patient Awareness:Interventional Radiology: your alternative to surgery

Don't miss it !

TODAY! Mon, Sept. 15, 16:30-18:30Medical students event

16:30Welcome

Poul Erik AndersenLocal HostJim A. ReekersCIRSE President

16:40IR - The HistoryPoul Erik AndersenLocal Host

16:50Using IR - Today and in the Future

John GrønvallLocal Host Committee Member

Treatment of UFE with IRSten LangfeldtLocal Host Committee Member (tbc)

Treatment of Cancer with IRDennis Tønner Nielsen, Local HostCommittee Member

Treatment of PVD with IR

John GrønvallLocal Host Committee Member

17:30My HistoryMette PoulsenUFE patient

17:40Panel Discussions and Closing RemarksJohn GrønvallDennis Tønner NielsenSten LangfeldtMette PoulsenFacilitator:Poul Erik AndersenLocal Host

18:00Test your abilities on an IR simulator

Special Edition / CIRSE 2008 - Copenhagen

4 Advertisement Monday, September 15, 2008

Boston Scientific has recentlyadded a new Institute for TherapyAdvancement campus, locatednear Paris Charles De Gaulle,France, to its Global EducationNetwork.

What therapy areas does the Institute cover?

All the therapies covered by Boston Scientific'sproducts and solutions, with a special focus onCardiac Rhythm Management, InterventionalCardiology and Peripheral Interventions.

What profile of physician can benefit mostfrom the courses the Institute offers?

We develop courses for medical professionalswith very different levels of clinical experience.Young fellows benefit by interacting with rec-ognized opinion leaders and experts in theirchosen clinical specialty, learn the key stepsand basic principles of a new therapy andstudy the key clinical data supporting patientselection and treatment decision. Physicianswith a higher level of clinical experience learnhow to treat more complex cases and how tohandle complications in a simulated environ-ment based on an extensive database of clini-cal cases.

What kind of benefits can a physician cus-tomer expect to bring back to his or hermedical practice after attending an Institutecourse?

Our unique educational experience using a mixof hands-on sessions and theory based on thevery latest findings creates benefits directlytransferable to our customers' own medicalpractices. In turn, this leads to higher confi-dence and surer choices in treating theirpatients and thus improved patient outcomes.In addition, attending courses at the Institutefacilitates the sharing of clinical experiencesand best practices, discuss about challengingcases as well as the development and expan-sion of one's own personal network within theprofession and clinical specialty. This is a spe-cific benefit our customers tell us they enjoytremendously. We think this can only benefit both the physi-cian and his or her patient.

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What is the difference between medical edu-cation at the Institute and training in thehospital or at a Congress?

Well, one is really complimentary to the other,but the main thing that makes our courses sovaluable is the hands-on, practical trainingusing a variety of sophisticated simulationtechnologies in a risk-free environment,focused on therapies not specific products.I would also mention exposure to a deep bodyof knowledge and expertise in the area ofadvanced, innovative technologies, working insmaller groups that facilitate exchanges andthe sharing of clinical experience with peersand recognized experts. These are all invalu-able contributing factors in a successful med-ical career and practice.

What guarantees the scientific objectivity ofthe Institute's course content?

Course accreditation by official bodies, ourindependent faculty and our course contentbased on therapy education rather than prod-uct promotion.I should also mention that course content isdesigned and supervised by independentCourse Directors, experts and opinion leadersin their clinical fields. Since the pioneering daysof 2000, the Institute for Therapy Advancementcollaborated with these experts who havedeveloped a set of standards and guidelinescalled Educational Governance, which formsthe basis for regulating the relationshipbetween commercial organizations and physi-cians in the context of the educational eventsthey supervise.

Can you describe the typical profile of anInstitute faculty member?

Our faculty all share the following characteris-tics: recognized, high-level expertise in theirtherapy area(s) and a desire and proven abilityto teach.

On top of these qualities, as we can experienceeveryday, they also all share a passion for thefuture of minimally-invasive therapies andtreatments.

You insist on the practical aspect of yourtraining courses. What kind of material doyou use to simulate hands-on experience?

What really allows us to approach real life expe-rience is the Institute's state-of-the-art simula-tion technologies: Virtual Reality simulatorswith haptic feeling, or force feedback for allinterventional procedures, cardiac arrhythmiasimulators, phantoms reproducing true patientanatomies in a real cathlab environment, usingactual devices.

Philippe Champaud, Director ofBoston Scientific's Institute forTherapy Advancement(International) discusses the next-generation training centre built tobetter address the specific needsof medical professionals.

Can you define the overall mission of Boston Scientific's Institute for Therapy Advancement?

At the Institute, our aim is to deliver to medicalprofessionals the very highest-quality educa-tion focusing on minimally-invasive treatmentsand technologies. The unique educationalexperience physicians receive at the Institute isbased on the fundamental principles whichunderpin our teaching philosophy: objectivetherapy education, the sharing of best prac-tices and clinical experiences and hands-on or,practical skills training which produces added-value for the physicians in their daily practices.

This mission is a reflection of Boston Scientific'scommitment to helping healthcare profession-als around the world advance the standard ofpatient care by mastering and applying mostadvanced therapy orientations based on thelatest clinical research and data.

What would you say makes the Institute forTherapy Advancement experience unique?

Participants highlight a combination of Coursesessions based on objective therapy educationin small groups that favors exchanges togetherwith leading-edge simulation technologies,plus a world-class faculty and Course Directors. Another aspect is the access to a global net-work of Institutes and our innovative fellowprograms.

Also, we are very lucky to have the backing ofBoston Scientific, a world leader in minimally-invasive therapies and technologies committedto high-level, continuing medical educationand the improvement of patient care world-wide.

C RSECardiovascular and Interventional Radiological Society of Europe

5Stent GraftsIRnewscongress

Interventional Radiology in Denmark goes backto 1932, when the first 10 cerebral angiogra-phies were performed by a neurologist whoinjected radioactive Thorotrast contrastthrough an arteriotomy of the carotid artery.The first documented lower extremity angiog-raphy was performed in Odense in 1948.

The first examinations were performed withpuncture of both femoral arteries with thepatients under general anaesthesia lying onthe floor to get sufficient film-focus distanceand with two doctors on their knees beside thepatient. The Seldinger puncture technique wasintroduced in 1955. The first angiographycatheters were home made from a roll of plas-tic tube which was cut in appropriate lengthand pulled lengthwise until the diameter wassuitable for the guidewire. Sometimes side-holes were also made and the catheter wassterilized overnight. The cassette film changerswere prototypes made individually at each hos-pital. They usually had a capacity of 5 expo-sures in 10 sec.

The first PTA in Denmark was performed inHerlev in 1977. Many other hospitals followedin succession within the following couple ofyears. In 1991 the first stents were deployed in

several hospitals. The first carotid PTA inScandinavia was performed in Odense in 1993and the first abdominal aortic endopros-thesis was implanted in 1996. The first TIPSSprocedures were performed in 1994 (Aarhusand Copenhagen) and the first uterine fibroidembolizations in Scandinavia were performedin Odense in 1999.

The History of Interventional Radiology in Denmark

Poul Erik AndersenChairman of the CIRSE 2008 Local Host Committee

risen gradually. Today it comprises more than80 interventional radiologists, who are alsovery active in CIRSE. The initial proposal to joinCIRSE as a Group Member was approved by theDFIR General Assembly in May 2007.

It goes without saying that we are extremelyhappy about CIRSE’s decision to hold its 2008annual meeting in Denmark and we feel that it

"We feel that it is time to givesomething back to CIRSE"

is time to give something back to CIRSE,among other things by becoming a GroupMember. Group membership is mutually bene-ficial to both CIRSE and the DFIR and thereforeall Danish interventional radiologists.

CIRSE 2008 in Copenhagen will certainly be animportant milestone in the history ofInterventional Radiology in Denmark.

As you can see in many aspects Danish inter-ventional radiologists have been in the spear-head of developments in Europe. The numberof hospitals practising Interventional Radiologyhas decreased in recent years. Many proce-dures are becoming more and more centralisedand specialised; a trend that is likely to contin-ue in the years to come.

The Danish Society of Interventional Radiology(DFIR) was established in1998 with only about15 members. It was not until 2003 that thesociety became more active, establishing a twoday annual scientific meeting, which today isusually attended by around 100 interventional-ists. The number of members of the DFIR has

I would like to express my thanks to the CIRSEFoundation for awarding me one of its 2007education grants. I am also very much obligedto Professor Reekers for accepting me at theAmsterdam Academic Medical Centre.

AMC facilities include two angio suites. One isused for non-vascular procedures and theother one for vascular procedures. There is athird suite, which is mostly used for fluo-roscopy studies, but can be used for otherinterventions also. The AMC’s interventionalradiologists strongly cooperate with the hospi-tal’s clinicians. They often visit each other andthe best possible treatment is worked outtogether in every case. Service is fast andadaptable.

There were four main goals I wanted to achievewith my fellowship:

The first was to learn detailed methodology ofsubintimal PTA, as it is something we intention-ally only rarely do in our hospital. In the frame-work of CIRSE’s European School ofInterventional Radiology I attended a courseon the subject in 2006. Prof. Reekers was one ofthe lecturers there and I became very interest-ed in the procedure.

My second goal was to learn about UFE, as wehave only performed very few UFE proceduresin our hospital.

The third goal was to learn more about arterialembolization in haemorrhage. At OuluUniversity Hospital we perform these emboliza-tions frequently, but I personally had had thepossibility to treat only a few patients. At theAMC, I was hoping to see much moreembolization patients.

Fourthly it was important for me to observehow all of the above procedures are done inanother institute.

Having concluded my visit I can say that I havefully achieved my goals. I assisted at a numberof subintimal PTA cases and was able to per-form several cases with assistance. I gainedexperience in this interesting and exquisitetechnique and will try to implement it in ourinstitute. Although there were not very manyUFE cases at the AMC either, I still managed toacquire more experience and enough confi-dence to commence the procedure in our hos-pital. I also saw and assisted in a number ofembolization cases.

The AMC’s Department of InterventionalRadiology is very productive in all areas of IR. Isaw, assisted and partly performed a variedarray of different vascular interventions. One ofthe most interesting and educational proce-dures was the treatment of vascular malforma-tions. Professor Reekers operates an outpatientclinic for these patients and I was fortunateenough to be involved in the management ofmany of these difficult cases.

CIRSE Fellowship Grant

Terhi Nevala On the non-vascular side I also gained experi-ence in a great variety of procedures. I spentmost of my time performing vascular proce-dures. Nevertheless flexible scheduling gaveme the chance to spend some time on non-vascular cases. I learned many practical thingsand I was fortunate enough to witness severalTIPS procedures.

"I acquired enough confidence to commence UFE procedures in our hospital"

During my three months stay I was invited toattend the Subintimal Angioplasty VII Course inLeicester, England, which took place on October19th, 2007. It was a one day workshop with livecases, organised by Dr. A. Bolia and added anoth-er great experience to my educational stay.

My visit gave me an excellent opportunity tobroaden my knowledge in IR. I am very gratefulto Professor Reekers and his colleaguesProfessor J.S. Lamèris, Dr. O.M van Delden andDr. K. van Lienden for their friendliness, enthu-siasm and continuing efforts to teach me newthings. I also want to thank the interventionalsuites staff at AMC. They were extremely friend-ly and helpful. Last but not least I would like tothank CIRSE for enabling my stay at the AMCthrough a fellowship grant.

Fellowship Grants

Maria BatalovaAoife KeelingMarco Midulla Terhi NevalaMarkus ReiterCagin SentürkSteven ThomasIoannis Kapralos

CIRSE Education Grants 2007

Visiting Scholarship Grants

Eirini ManousakiNavin MathiasViktor BércziNikolas Fotiadis Emmanouil TheodoropoulosVladislav Kosyrev

In compliance with CIRSE's philosophy thatexcellent IR training is one of the cornerstones for the survival of InterventionalRadiology, the CIRSE Foundation awardedsix visiting scholarship grants and eight fel-lowship grants in 2007.

C RSECardiovascular and Interventional Radiological Society of Europe

7Stent GraftsIRnewscongress

Stent Grafts in the thoracic aorta - How far can one go?

Ajay ChavanProfessor and Head, Department of Diagnosticand Interventional RadiologyKlinikum Oldenburg, Germany

Over the past 15 years stent-grafting hasbecome an integral part of the repertoire oftherapy options for treating thoracic aorticaneurysms and dissections. The mid-termresults are encouraging. With increasing experi-ence of the interventionist, proper case selec-tion, adequate pre-procedural assessment aswell as the availability of sturdier endografts inadequate lengths and diameters, it is to beexpected that the rate of complications experi-enced so far will gradually reduce in the time tocome.

If endograft systems are made smaller and per-cutaneous vascular suture devices less cumber-some, many thoracic aortic aneurysms and dis-sections could be treated percutaneously as arule; this may reduce the morbidity associatedwith general anaesthesia and arteriotomy.Furthermore, a reduction in endograft costscould make the procedure available to a largerpatient population, especially in countrieswhere health insurance is affordable to but afew.

Against this backdrop it is worth taking a lookat how the spectrum of indications for stent-grafting has rapidly widened with the passageof time. Stent grafts were initially used fortreating atherosclerotic aneurysms of thedescending thoracic aorta. Within a few years,however, reports appeared of successful stent-grafting not only in atherosclerotic aneurysms,but also in mycotic and traumatic aneurysms aswell as in aneurysms with contained ruptures(1-5).

Close on the heels of these reports followedreports of stent-grafting in type B dissections(6,7). Clinical experience has been gathered inthis group of patients over the past few years.Controversy exists regarding the usage ofstent-grafts in chronic type B dissections. Thesame holds true for uncomplicated acute orsub acute cases. In contrast, stent-graftingappears to help in cases of contained ruptureas well as in those with persistent intractablepain (8). Distal branch vessel ischemia in theacute or sub acute setting can also be relievedby stent-grafting. However, further peripheralinterventions may be necessary to optimise theoutcome (8,9).

Let's have a look at the type A dissections, withthe risk of rupture and death increasing byapproximately 1% per elapsed hour after theacute episode. Are the type A dissectionsalways to remain a domain of open surgicalrepair? Here too, stent-grafting has madeinroads into the treatment algorithm.Retrograde type A dissections with the entrytears in the descending aorta can now be treat-ed successfully by trans-femoral stent-grafting,which has been shown to induce thrombosisand resolution of the false lumen (6,8). Theadvantage to the patient, who is spared com-plex thoracic aortic surgery, requires no furtherelaboration. The skill of the radiologist lies inbeing able to differentiate (at imaging) suchdissections from those with classical entry tearsin the ascending aorta or in the aortic arch. Asa rule, the false lumen in the ascending aortaand arch in patients with distal entry tears isnarrower than the true lumen; it may appearmerely as a thrombosed sliver in the proximalaorta.

Ihnken and colleagues reported successfulstent-grafting to seal the entry tear in theascending aorta. The patient had an acute typeA dissection, was deemed to be at high risk forsurgery and refused open surgery. A shortendograft was introduced transfemorally andplaced between the coronary ostia and thebrachiocephalic trunk (10).

How far can one go proximally? There is ampleevidence in literature that the origin of the leftsubclavian artery can be covered by the endo-graft in order to increase the length of theproximal neck, provided the circle of Willis ispatent. If indicated, a carotid-subclavian bypasscan be carried out as a second stage proce-dure, but is necessary in less than 10% of thepatients. The fact that the interventionist is par-ticipating actively in treating the aortic arch isevident from the development of hybrid endo-grafts as well as hybrid procedures.

Hybrid endografts (e.g. the "Chavan-Haverich"or the "E-Vita open" endografts) consist of aproximal non-stented and a distal stented com-ponent (Fig.1). During surgery on the ascend-ing aorta via a median sternotomy, these endo-grafts are introduced antegradely via the aorticarch into the descending aorta. The stentedportion forms the distal 'anastomosis' in thedescending aorta; the non-stented segment isused to reconstruct the aortic arch. Multi-seg-ment pathologies affecting the ascending archand descending aorta, which classically requiretwo or more operations, can thus be treated ina one-step procedure with the so called"Frozen Elephant Trunk" technique (Fig.2)(11,12).

As opposed to the hybrid endografts, hybridprocedures consist of surgically carrying out aconduit from the ascending aorta to the supra-aortic vessels followed by stent-grafting of theentire aortic arch. The procedure is especiallyuseful in pathologies of the descending aortaextending proximally into the aortic arch. As isimaginable, both procedures require closecooperation between the surgeon and theinterventionist.

To put matters in a nutshell: Presently, mosttype B dissections can be treated endoluminal-ly or conservatively, with surgery beingreserved for the few who cannot be managedwith these approaches. Retrograde type A dis-sections too respond well to stent-grafting.Avenues are being gradually opened for treat-ing certain acute type A dissections with entrytears in the ascending aorta, with the help oftrans-femoral endografts. Ruptured thoracicaortas are an emerging field for the interven-tionist.

If we are to avoid losing the aortic territorywhich we ourselves have helped carve out andestablish, a new brand of interventionists,familiar with the above mentioned techniques,will have to emerge in the future to come.Should he or she be in a position to offer roundthe clock support, his/her services are likely tobe called upon more and more frequently,especially in treating complicated dissectionsand aortic ruptures.

Thoracic aorta stenting updateSpecial SessionMonday, September 15, 8:30-9:30Room C

Don't miss it !

Fig. 1: Chavan-Haverich hybrid endograft.

Fig.2a: Pre-operative CT section of a patient withsimultaneous aneurysms of the ascending archand descending aorta.

References:1. Dake MD, Miller DC, Semba CP, et al. (1994): Transluminal place-

ment of endovascular stent-grafts for the treatment of descendingthoracic aortic aneurysms. N Engl J Med; 331: 1729-34.

2. Semba CP, Sakai T, Slonim SM, et al. (1998): Myotic Aneurysms ofthe Thoracic Aorta: Repair with Use of Endovascular Stent-Grafts.JVIR; 9:33-40.

3. Rousseau H, Soula P, Perreault P, et al. (1999): Delayed Treatmentof Traumatic Rupture of the Thoracic Aorta With EndoluminalCovered Stent. Circulation; 99:498-504.

4. Morgan R, Loosemore T, Belli AM, (2002): Endovascular Repair ofContained Rupture of the Thoracic Aorta. Cardiovasc InterventRadiol; 25: 291-294.

5. Ishida M, Kato N, Hirano T, et al. (2004): Endovascular stent-grafttreatment for thoracic aortic aneurysms: short- to midterm results.J Vasc Interv Radiol; 15(4): 361-7.

6. Dake MD, Noriyuki Kato, Mitchell RS, et al. (1999): EndovascularStent-Graft Placement for the Treatment of acute aortic dissection.N Engl J Med; 340: 1546-52.

7. Nienaber CA, Fattori R, Lund G, et al. (1999): NonsurgicalReconstruction of Thoracic Aortic Dissection by Stent-GraftPlacement. N Engl J Med; 340: 1539-45.

8. Svensson LG, Kouchoukos NT, Miller DC, et al. (2008): ExpertConsensus Document on the Treatment of Descending ThoracicAortic Disease Using Endovascular Stent-Grafts. Ann Thorac Surg;85: 1-41.

9. Chavan A, Rosenthal H, Luthe L, et al. (2008): Percutaneous inter-ventions for treating ischemic complications of aortic dissection.Eur Radiol DOI 10.1007/s00330-008-1141-4.

10. hnken K, Sze D, Dake MD, et al. (2004): Successful treatment ofStanford type A dissection by percutaneous placement of a cov-ered stent graft in the ascending aorta. J Thorac Cardiovasc Surg;127: 1810-2.

11. Karck M, Chavan A, Hagl C, et al. (2003): The frozen elephant trunktechnique: A new treatment for thoracic aortic aneurysms. JThorac Cardiovasc Surg; 125(6): 1550-3.

12. Chavan A, Karck M, Hagl C, et al. (2005): Hybrid Endograft for One-Step Treatment of Multisegment Disease of the Thoracic Aorta. JVasc Interv Radiol; 16: 823-829.

Fig.2c: Total replacement of the thoracic aorta ina one-step procedure using a hybrid endograft forthe "Frozen Elephant Trunk".

Fig.2b: Corresponding post-operative CT section;open surgical replacement of the ascending aortaand stent graft in the descending aorta.

Special Edition / CIRSE 2008 - Copenhagen

8 Advertisement Monday, September 15, 2008

The new Kimberly-Clark* MIC*, MIC-KEY*Introducer Kit redefines initial placement byenabling physicians to safely and efficientlyfacilitate the initial placement of theKimberly-Clark* MIC* and MIC-KEY*Gastrostomy, Jejunal and TransgastricJejunal feeding tubes, which provide deliv-ery of enteral nutrition to patients requiringlong term nutritional support. This innova-tive product enhances patient comfort,physician convenience, and safety for both.

"Continuing the Kimberly-Clark Health Care tradi-tion and commitment to innovation and excel-lence, this new kit features unique devices specifi-cally designed to make patients' lives better andphysicians' lives easier," states Vincent Gaspar,General Manager EMEA, Kimberly-Clark HealthCare.

Dr. Joshua Weintraub, Associate Professor ofRadiology and Surgery, Division Chief ofVascular and Interventional Radiology at Mt.Sinai Medical Center in New York agrees. "Istrongly support Kimberly-Clark's new MIC*,MIC-KEY* Introducer Kits for the primary place-ment of percutaneous gastrostomy and gastro-jejustomy catheters. These will have a signifi-cant impact on improving the healthcare, com-fort and safety of patients."

The Kimberly-Clark* MIC*, MIC-KEY* Introducer Kit features:

· The pre-loaded Saf-T-Pexy* gastrointestinalsuture anchor system which incorporatesresorbable sutures and external suture locksto secure the stomach to the anteriorabdominal wall. The Saf-T-Pexy* systemeliminates the need for traditional sutureremoval, minimizes the risk of infection, andenhances stoma tract formation. Unlike tra-ditional sutures, which require an additionaloffice visit for removal, the Saf-T-Pexy* sys-tem simply resorbs and sloughs with theinternal components passing through the GItract, leaving the balloon retained tube inplace until replacement is required.

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Advertorial

Bob, you recently joined ev3 in April as theirnew President and Chief Executive Officer.Can you tell us what your view is of the busi-ness and what ev3's strategy will be?

Bob Palmisano: ev3 has a rich history of tech-nology development and innovation. We willcontinue to build upon that foundation to bethe global market leader and preferred partnerfor patients and physicians in identifying andtreating lower extremity arterial and neurovas-cular disease through innovative, breakthroughand clinically proven technologies.

How does the acquisition of FoxHollow fitinto ev3's strategy?

BP: The acquisition of FoxHollow and the addi-tion of the SilverHawk® atherectomy system toev3's existing product portfolio is a key compo-nent of our strategy to provide a full comple-ment of innovative products in the large andunderserved peripheral vascular market. We

believe that atherectomy can play an impor-tant role in the treatment options for patientswith peripheral artery disease as well as com-plement the existing treatment options thatendovascular specialists offer. However, we alsorealize that it will be important to invest in clin-ical studies to providing the right scientific datato support broad clinical adoption of atherec-tomy.

What's new in atherectomy and plaque exci-sion technology?

BP: ev3 recently launched the SilverHawkSystem with MEC (Micro Efficient Compression)Technology, which is a breakthrough advance-ment allowing greater tissue storage in the tipof the device via micro vent holes. Not onlydoes this provide an opportunity for a signifi-cant increase in packing of plaque, it alsoallows for a simplified approach, fewer catheterexchanges, and quicker procedure times.

Interview with Bob Palmisano, New President and CEO of ev3

Advertorial

ev3 recently received the CE Mark andlaunched the new RockHawk™ Plaque ExcisionSystem. This advanced atherectomy systemenables physicians to treat above-the-knee denovo and restenotic calcified and non-calcifiedlesions in the native peripheral arteries. TheRockHawk is based on our market leadingSilverHawk® platform and incorporates designchanges in the geometry and the material ofthe cutting blade to facilitate the break downof complex, hard, calcified lesions that may beresistant to conventional treatment. We expectto initiate a clinical study to study the use ofthe RockHawk System with our SpiderFXembolic protection device later this year.

What can we expect from ev3 in the comingmonths?

BP: We are looking forward to availability of 12month follow-up results for our EuropeanDURABILITY I study, the world's first prospec-tive study to specifically test the efficacy and

Professor Michael J. Lee, Professor of Radiology, Royal College of Surgeons in Ireland willpresent "Experience with the new Kimberly-Clark* Introducer Kit for Initial Placement ofthe MIC-KEY* Low Profile GastrostomyFeeding Tubes"

Date: Tuesday, September 16 Time: 08:00-08:20Room: C

integrity of long stents in long, challenging SFAlesions. It is also the first study to specificallyevaluate the use of one long EverFlex stent perpatient. One hundred fifty one patients wereenrolled in the DURABILITY I trial at 13European centers. At six months, primarypatency for our EverFlex stents was 91%, a grat-ifying and encouraging result, particularly inthis very challenging patient population, whichincluded a high percentage of diabetics and asignificant percentage of long lesions.

In addition, our top priorities will be to expandour global position in the peripheral vascularand neurovascular markets by increasing pro-cedural penetration, driving growth and expan-sion in international markets, investing in thedevelopment of our next generation of prod-ucts and pursuing a broad clinical trial agendato bring new products to market and furthervalidate the scientific foundation of ourendovascular procedures.

ev3 Europe SAS 106-108 rue La Boétie | 75008 Paris | France phone +33 156 88 59 10 | fax +33 156 88 59 12www.ev3.net

The Kimberly-Clark* MIC, MIC-Key* IntroducerKits are just one of the clinical solutions physi-cians can depend on to meet the demands oftheir fast paced world. Learn more at theKimberly-Clark Symposium:

"An Innovative Approach to Enteral Feeding"

C RSECardiovascular and Interventional Radiological Society of Europe

9Radiofrequency AblationIRnewscongress

Radiofrequency (RF) ablation has achievedimpressive results in the treatment of unre-sectable primary and metastatic liver cancer.Today RF ablation of primary and metastaticlung tumour is increasingly used and seems toprovide results at least as impressive as thosereported in the liver.

Pre-ablation work-up must be akin to a pre-operative work-up. A chest CT is needed todetermine target tumour(s) location and size.Abdominal CT is mandatory to search for dis-tant metastases. PET/CT is useful to search fordistant metastases and can be used for follow-up of treated tumours. Lung spirometry is use-ful in patients with a past history of diffuselung disease or lung surgery. In our experience,tolerance was good in patients with a FEV1 ofmore than one litre, but transitory respiratoryinsufficiency developed in about a third ofpatients with a FEV1 below one liter. In thelong-term follow-up after 2 months no differ-ence was found in the respiratory test betweenpre and post-RF.

Treatment planning is carried out in a singlesession, whatever the number of targetedtumours when the tumours are unilateral. Atwo-week interval is usual when two treatmentsessions are scheduled for bilateral disease. In afew instances bilateral treatments in a singlesession can be uneventful in patients with pre-vious lung surgery when the second lung wastreated after completion of the first lung treat-ment without any CT-depicted complication.The risk of bilateral treatment in patients with-out previous surgery has to be weighted whentreatment on the first lung is uneventful. Singlelung patients can be treated, but risk must bediscussed.

Anesthesia is in our experience nearly alwaysgeneral anesthesia which seems to providehigher feasibility than that reported with con-scious sedation where patients suffered fromperi-procedural pain in 29% of cases with treat-ment interrupted due to pain in 3% of cases.Treatment was stopped due to intractablecoughing in 5/30 patients. However, the tech-nique is possible under conscious sedation.

The size of the electrode has to be chosen inview of producing an ablation volume at least15mm larger than the largest tumour diameterif possible. Over-sizing ablation size comparedto tumour size is essential. Indeed in our expe-rience the rate of incomplete local treatment at18 months was 4% when the ratio between thearea of ground glass opacity imaged at 24 to48 hours and the tumour area before treatmentwas at least 4, and was 19% when the ratio wasbelow 4. Expandable needle electrodes allowstability of the needle in the tumour even if apneumothorax occurs and displaces thetumour. RF electrodes introduced through aguiding needle are easier to use under CT guid-ance, as they avoid breaking sterility throughcontact between the handle and the CT gantry.

Electrode positioning must be done under CTguidance for the sake of accuracy. 3D multipla-nar reconstruction is helpful to image arraysdeployment relative to tumour margins. Greatcare must be taken to avoid traversing thetumour with the electrode shaft or deployingthe arrays through the tumour without deliver-ing RF in order to minimize potential seeding.

Puncturing the tumour with the electrode shaftitself is not mandatory for small tumours aslong as the deployed arrays encompass thetumour, thus providing a volume of ablationcontaining the tumour (Fig.2). Pneumothoraxobtained on purpose with a Vérés needle andre-aspirated after treatment can be used toavoid collateral damage during ablation of sub-pleural tumours in order to separate the sub-pleural tumour from the parietal pleura or themediastinum.

RF delivery to the lung is different from theliver, as lung parenchyma is different in termsof energy deposition, electrical conductivity,heat diffusion and heat convection. An algo-rithm dedicated to the lung must be used(Table 1). Energy delivery must be adapted totumour location, as in our experience initialimpedance before ablation is significantly dif-ferent (p=0.04) for the tumours with more than50% of the tumour abutting the pleura(86.5±29.9 Ohms) and for tumours that werenot abutting the pleura (121.3±42.8 Ohms) orthe 26 tumours with less than 50% of thetumour abutting the pleura (112.6±32.9 Ohms).Indeed, a tumour surrounded by lungparenchyma is highly electrically and thermallyinsulated by the air-filled lung parenchymacompared to a tumour abutting on the pleuraand will therefore require less energy deposi-tion.

Complications are rare. Pneumothoraxoccurred in 54% of the RF sessions and mustnot be considered as a complication. It waslarge enough to require treatment in 31%.Aspiration through a 5-French side-hole needlecatheter capitalizing on CT guidance wasattempted. Finally, a 8-French chest tube linkedto a dry suction control was left in place in 9%of cases (pneumothorax recurring after aspira-tion) and maybe these 9% can be consideredcomplication, as hospital stay was prolongedby two to three days. Alveolar haemorrhageand post-procedure haemoptysis occurredrespectively in about 10% of procedures andrarely required specific treatment.

Antibiotics after treatment are questionableand among various groups it can extend from7 days regimen of clavulanate (2g/day) andofloxacine (400mg/day) to a 48 hours prophy-laxis. Very few groups performed lung RF with-out antibiotics due to the relative high rate ofpost-RF pneumopathy, which was 6% in ourexperience. Although never studied with accu-racy, it seems in our experience that post-RFpneumopathy is far more frequent after RF inprimary lung cancer than after RF for lungmetastases due to the usual underlying lungdisease in primary cancer patients

Imaging follow-up is still debated. Difficultiesto evidence incomplete local ablation arelinked to the fact that contrast enhancement isdifficult to see in lung tumours and most stud-ies only relied on size modification which is alate sign of tumour re-growth. Some morerecent studies with PET seem promising. UsingPET will reveal some pitfalls with false positives,such as peri-ablation inflammatory rim, butalso inflammatory lymphnodes or uptake atthe puncture site on the chest wall.

Local efficacy: After a minimum of 1 year offollow-up, the estimated rate of incompletelocal treatment at 18 months was 7% [IC95% =3 -14] per tumour with incomplete treatmentdepicted at 4 months (n=1), 6 months (n=2), 9months (n=2), and 12 months (n=2). Overallsurvival and lung disease-free survival at 18months were 71% and 34% respectively. Size is

a key point for tumour selection, as incompletelocal treatment is highly influenced by tumoursize. In our experience the rate of incompletelocal treatment at 18 months was 5% fortumours measuring 2cm or less and 13% fortumours larger than 2cm. Tumour size impactson survival in other reports.

ConclusionIn a manner akin to RF in the liver, RF in thelung provides a high local efficacy rate, close tothat of surgical resection. Nevertheless it willbe difficult to obtain randomized trials and thechoice between RF and surgery in case of asmall tumour nodule will be difficult. Follow-upimaging by CT is not optimal due to the latediscovery of incomplete local treatment andPET might be useful for follow-up.

RF ablation of lung tumours

Thierry de Baère Institut Gustave Roussy, Villejuif, France

Interventional oncology in lung cancerSpecial SessionTuesday, September 16, 10:00-11:00Room C

Don't miss it !

References:1. de Baere T, Palussiere J, Auperin A, et al. Mid-term local efficacy

and survival after radiofrequency ablation of lung tumours with aminimum follow-up of 1 year : Prospective evaluation. Radiology2006; 240: 587-596

2. Fernando HC. Radiofrequency ablation to treat non-small cell lungcancer and pulmonary metastases. Ann Thorac Surg 2008; 85:S780-4

3. Gillams AR, Lees WR. Radiofrequency ablation of lung metastases:factors influencing success. Eur Radiol 2008; 18: 672-7

4. Lencioni R, Crocetti L, Cioni R, et al. Response to radiofrequencyablation of pulmonary tumours: a prospective, intention-to-treat,multicentre clinical trial (the RAPTURE study). Lancet Oncol 2008;9: 621-8

5. Pennathur A, Luketich JD, Abbas G, et al. Radiofrequency ablationfor the treatment of stage I non-small cell lung cancer in high-riskpatients. J Thorac Cardiovasc Surg 2007; 134: 857-64

6. Simon CJ, Dupuy DE, Dipetrillo TA, et al. PulmonaryRadiofrequency Ablation: Long-term Safety and Efficacy in 153Patients. Radiology 2007; 243: 268-75

7. Yamakado K, Hase S, Matsuoka T, et al. Radiofrequency ablationfor the treatment of unresectable lung metastases in patients withcolorectal cancer: a multicenter study in Japan. J Vasc Interv Radiol2007; 18: 393-8

8. Yan TD, King J, Sjarif A, et al. Treatment failure after percutaneousradiofrequency ablation for nonsurgical candidates with pul-monary metastases from colorectal carcinoma. Ann Surg Oncol2007; 14: 1718-26

Table 1: Treatment algorithm applied for RF abla-tion of lung tumours using a RF 3000 geberator(Radiotherapeutics / Boston Scientific). Initialpower in Watts was chosen according to the sizeof the electrode and tumour location in relationto the pleura. Power increment is a function of thetumour location.

Table 2: Evolution of the largest tumour diameter(before RF) and then RF ablation area along timeon follow-up CT demonstrated an ablation areawhich remains as large as the targeted tumour at12 months. The only criterion for incomplete localtreatment is an increase in size between two fol-low-ups.

Fig.2:Immediately after ablation faint ground glassopacity is seen encompassing the treated tumour

Fig.3:Two days later the ground glass opacity can beseen more easily

Fig.4:Frontal MPR reconstruction of lung metastasistreated with expandable RF needle

Fig.5:The same tumour is seen on the sagital MPR. Onecan appreciate than the tines go beyond theperiphery of the tumour and that consequentlyablation margins will be achieved

Fig.1:Single right lung metastasis before RF ablation

Tumour location

PowerSize of the RF electrode

2cm 3cm 3,5cm 4cm

Surrounded ofparenchyma

initial Power 5W 10W 15W 20W

increment 5W every minute

Pleural con-tact <50%

initial Power 10W 20W 30W 40W

increment 5W every minute

Pleural con-tact >50%

initial Power 30W 40W 50W 60W

increment 10W every minute

Special Edition / CIRSE 2008 - Copenhagen

10 Advertisement Monday, September 15, 2008

Background:CHU La Timone (Marseille, France) is amongstthe first hospitals in Europe to be equippedwith the Innova 3100 digital flat panel angiog-raphy system (GE Healthcare). The Innova 3100system has a 30 cm x 30 cm digital detectordesigned to perform general vascular andinterventional procedures, and allows for rota-tional flat detector computed tomography(3D/CT), with volume post-processing on amulti-modality Advantage Workstation. TheInnova 3D/CTapplications are used for proce-dures such as peripheral aneurysm emboliza-tion, complex peripheral angioplasty, peripher-al arterio-venous malformation assessment orvisualization of perivascular structures likebone or soft-tissue.

IntroductionSkull base defects are congenital or acquired(traumatic or iatrogenic), and can result inCerebro Spinal Fluid leaks, with meningitis as apotential life-threatening complication. Risk ofCSF leak secondary to functional endoscopicparanasal sinus surgery varies from 0.5 to 3%.Accurate preoperative imaging is essential forsurgical planning and has become especiallyimportant since the emergence of minimallyinvasive endoscopic surgical techniques ofleakage closure. 1.5T MRI, especially heavily T2-weightedsequences (pseudo-cisternography) can detectCSF leak, and it is the best modality to detectmeningocele or meningoencephalocele; but itlacks visualization of the bony structures. High-resolution multidetector computed tomogra-phy (MDCT) is the primary imaging modalityfor localization of skull-base defects. It often isthe only test needed for diagnosis however it islimited to identifying defects in bone. Partialvolume averaging can cause both false-positiveand false-negative findings. Plain CT scans havea 9.5% false-positive identification of a bonydefect in inactive CSF fistulas. CT-cisternogra-phy is also limited by the CT slice-thickness andthe voxel size.The value of flat-panel CT was assessed in 2patients in whom 64 rows MDCT and 1.5T MRIexamination did not demonstrate the locationof a proven CSF fistula.

Flat-panel 3D/CT cisternography procedure:Patient lies in a lateral decubitus on theangiography table; a lumbar puncture is per-formed under fluoroscopic guidance and aftera depletion of 6-10 ml of CSF, we slowly inject15 ml of non-ionic iso-osmolar iodinated con-trast. The patient is then put in prone positionwith a pelvis elevation. When the contrastmedia reaches the posterior cerebral fossa(seen under fluoroscopy), we perform a rota-tional flat-panel CT acquisition with the follow-ing parameters: patient in prone position withheadrest, rotation speed=10°/s, acquisitionfield =16 x 16 cm, reconstruction matrix 5123,

reconstruction filter=Sharp, voxelsize=0.12mm³. Isotropic voxels allow for high-quality multiplanar oblique reconstructions,performed on Advantage Workstation.

Case n°1A 42 year-old male underwent 5 months agofunctional endoscopic sinus surgery (middleturbinate resection and middle meatal antros-tomy); nasal drip appeared 2 weeks after sur-gery. Cerebrospinal fluid (CSF) rhinorrhea wasconfirmed by laboratory analysis but locationof CSF fistula was not revealed either on high-resolution multidetector CT (64 detector, slicethickness 0.4mm) or on MRI (1.5T). His surgeonpresumed that during endoscopic surgery, theanterior skull base was penetrated with aninstrument. After 1 week of inefficient conser-vative treatment, the surgeon attempted aminimally invasive leakage repair via a nasalendoscopic approach. Because of diffusemucosa inflammation, the location of the leak-age was not clearly identified and a small graftwas put on the left ethmoid roof. UnfortunatelyCSF rhinorrhea reappeared 1 week later.Because of the risk of meningitis, this patientwas referred in our institution for an invasiveendonasal leakage repair, which has a high riskof anosmia. We decided to perform a flat-panel3D/CT cisternography. This examinationdemonstrated a very thin contrast leak to leftnasal fossa, located in the left cribriform plate,on the posterior third of the olfactory groove(figures 1-4). This very precise localizationallowed for minimally invasive endonasal sur-gery. 10 months after this third intervention,the patient does not show any sign of recur-rence.

Case n°2A 37 year-old female was referred in our institu-tion for endoscopic resection of an ethmoidroof osteoma. During surgical intervention, afracture of the anterior skull base occurred, withmassive CSF fistula. The surgeon placed a graftto treat this fistula, and the ethmoid osteomacould not be totally resected. 2 weeks after sur-gery, the patient still presented profuse CSF rhi-norrhea. A 1.5T MRI demonstrated a smallmeningoencephalocele, laterally to the graft,and a new surgical intervention was performedto resect this brain herniation and to put a larg-er graft on the leakage. 5 weeks after this sec-ond surgical intervention, the patient still pre-sented nasal drip that proved to be CSF. A newMRI (1.5T) did not show meningocele recur-rence or patent CSF leak. We performed a flat-panel 3D/CT cisternography that clearlydemonstrated a CSF leak, medially to the graftmaterial, located in the lateral cribriform lamella(figures 5-8). This precise location allowed forprecise minimally invasive endonasal leakagerepair. 4 months after this intervention, thepatient did not show any sign of recurrence.

Innova CT clinical benefit in detection andlocalization of small Cerebrospinal leak

Figure 6 (Case 2): Reformatted coronal viewshowing contrast leakage medially to the graftmaterial, through lateral cribriform lamella(Arrow)

Figure 4 (Case 1): consecutive axial views of theCSF fistula tract, located at the posterior third ofleft cribriform plate (Arrows)

Figure 8 (Case 2): Consecutive axial views throughthe CSF fistula tract (Arrows)

Figure 2 (Case 1): Enlarged coronal view showingthe thin CSF fistula (Arrow)

Advertorial

Dr. F. Cohen, Dr. V. Vidal, Prof. J.M. Bartoli, Prof. G. Moulin, Department of RadiologyCentre Hospitalier Universitaire La Timone,Marseille, FranceB.Wimille, P.Gobert, GE Healthcare, Buc, France

Discussion:The most common site of traumatic bonedefect is the cribriform plate of the ethmoid.This bony structure is very thin, and has multi-ple small perforations (transmission of neuralfibers into the nasal cavity) that can cause par-tial averaging volume effects on MDCT imag-ing.The Innova CT acquisition, with its improvedspatial resolution, allowed us to explore thiscomplex anatomic area with voxels two-timessmaller than our 64 rows detectors CT, withgood contrast enough between bone, iodineand air, and acceptable scatter artifacts.

Conclusion:Key for the management of CSF leakage is thelocalization of the fistula. Small isotropic 0.12mm³ voxels of Innova CT seem to be an impor-tant clinical benefit in detection and localiza-tion of small CSF leaks, especially in the cribri-form plate of the ethmoid.

Figure 5 (Case 2): Reformatted coronal viewshowing residual osteoma of the right ethmoïd(Arrow head) and graft material located on theright ethmoïd roof (Arrows).

Figure 3 (Case 1): Reformatted sagittal view show-ing the thin CSF fistula (Arrow)

Figure 7 (Case 2): Reformatted sagittal obliqueview through the CSF fistula tract (Arrow)

Fig 1 (Case 1): Reformatted Coronal View, show-ing middle meatal antrostomy and middleturbinate resection (Asterisk). Arrow shows con-trast leak (CSF fistula) at the level the left cribri-form plate.

C RSECardiovascular and Interventional Radiological Society of Europe

11CryoablationIRnewscongress

Cryoablation refers to the application ofextreme cold to destroy diseased tissue, includ-ing cancer cells. Research in the field of cryobi-ology has demonstrated that critical tempera-ture below -20°C achieves cell death. First gen-eration cryodevices were limited to intra-oper-ative use. Indeed, the use of liquid nitrogen fortissue cooling with lack of well-insulatedprobes and large diameters of the cryoproberequired laparoscopic interventions. With thedevelopment of percutaneous miniaturised gasdriven probes (17 gauge) cryoablation is nowfeasible in CT or MR tunnels and allows treat-ment of prostate, liver, bone and kidney can-cers.

MechanismGas driven cryomachines rely on the physicalrelationship between temperature and pres-sure (Joule-Thomson effect): at atmosphericpressure, most gases are cooled by expansion.Only small gases such as helium are warmed byexpansion, due to reduced collisions (negativeJoule-Thompson effect). High pressure argon(300 bars) is used for freezing. Helium is usedvia the same probe to warm it and thaw the iceball. Thus, it accelerates the treatment process,allows for repositioning of the probe and pro-vides additional safety by enabling rapid stop-ping of the ice ball formation.

The biological destructive effects of cryoabla-tion can be grouped into two major mecha-nisms (1):

· Immediate cellular injury: During the firstfreezing cycle, ice crystals are mainly extra-cellular. During slow thawing, water diffusesinto the intracellular compartment due tothe osmotic effect. After a second freezingcycle, intracellular crystal formation achievesmembrane rupture and cell death.

· Delayed vascular injury, as freezing inducesintravascular crystallisation with microthrombi and ischemia.

Compared to radiofrequency which does notdiscriminate the ablated tissues, cryoablationoffers relative protection of the collagen struc-tures.

EquipmentOne of the major advantages of last generationcryosystems is the possibility to insert multipleprobes (up to 25) and use them simultaneous-ly. Thus, several probes can be combined totreat a large single tumour or to simultaneouslytreat multiple small tumours. Different cry-oprobes producing various sizes and shapes ofice balls are available. Moreover, several ther-mosensors can be connected if thermal moni-toring of adjacent vulnerable structures isneeded.

Patient Selection and TechniqueCryoablation has been used to treat liver, kid-ney, prostate and bone tumours. The indica-tions and the planning of the procedure arevery similar to those of radiofrequency abla-tion. The learning phase is shorter, but the riskof damaging surrounding tissue sill exists.

Cryoablation procedures are performed undersedation or general anaesthesia. However, per-

cutaneous cryoablation appears to require lessanalgesia than RFA, particularly for bonetumour ablation. Cryoablation of tumours is atime-consuming procedure, as generally two10-minutes freeze cycles, separated by a 10minute passive thaw cycle, are performed perposition. Spiral CT with multiplanar reconstruc-tion is used intermittently to monitor the iceball.

What results at the tip of the probe is an "iceball" which has a predictable geometry basedon the length and diameter of the expansionroom at the tip of the probe. For completenecrosis of the tumour, it is important toextend the margins of the ice ball to a mini-mum of 3-5 mm distance beyond the tumourmargins in order to ensure complete cell death.

This ice ball can be visualised by various imag-ing techniques including ultrasound, CT andMR imaging. Ultrasound, though very practicalfor certain applications, does not permit visual-isation deep into the most superficial portionof the ice ball. Most institutions do not havethe capability to employ MR imaging duringthe treatment process. This leaves CT imagingas the most practical and widely employedmodality for this purpose. Successful procedurerelies on the imaging to precisely visualise theextension of the ice ball, to adapt the size ofthe probes and their spatial positioning with 2cm being the ideal distance between probes.

In comparison to other forms of percutaneousablation, cryoablation offers the additionaladvantages of direct visualisation of the ice balland less peri- and post-procedural pain.Cryoablation is also efficient in painful scleroticbone metastases and the ice ball can extendbeyond the cortical bone. If cryoablation is per-formed in a weight bearing bone such as a ver-tebral body, additional consolidation withcementoplasty must be considered. For suchcases, cement should not be injected beforecomplete thawing and return to the tissue'snormal temperature in order to avoid leakage.

Patient OutcomePercutaneous cryoablation seems to be a safeand effective method for tumour ablation. Therisk of post-procedural haemorrhage hasdropped since the use of 17 gauge probes. Thetreatment intent can be curative (kidneytumour) or palliative (painful bone metastasis).Successful tissue ablation depends on four cri-teria: excellent monitoring of the process; fastcooling to a lethal temperature; slow thawingand repetition of the freeze-thaw cycle (twocycles minimum). Repetition of the treatmentcycle is associated with more extensive andmore certain tissue destruction, as cells aresubjected to additional deleterious physico-chemical changes after they are already weak-ened by damage sustained in the first cycle.The longer the thaw duration, the greater thedamage to the cells; current data suggest thatslow thawing is a more important mechanismfor cell death than rapid cooling.

Careful monitoring of the cryoablation ismandatory to avoid freezing of any nearbyneurovascular structures and the skin. If ther-mal protection of surrounding organs is

Cryoablation: advantages and limits

Xavier BuyConsultant of Radiology in InterventionalRadiology, University Hospital StrasbourgAfshin GangiProfessor of Radiology at the University HospitalStrasbourg, France

required, it is ideally performed with CO2 insuf-flations. Fluid instillation is not a suitable ther-mal protection technique for cryoablation, as itimmediately freezes in contact with the ice ball.For superficial tumours, skin can be thermallyprotected by applying sterile gloves filled withwarm saline directly on the skin.

In comparison to RFA, large vessels may act asa "cold sink effect" with higher risk of residualtumour in contact with vascular structures. Theprecise visual control of the ice ball and themore predictable shape of the ablated areaincrease the safety when performing ablationclose to vulnerable structures. A temporaryneuropraxia may develop in nerves if they areinadvertently incorporated into the peripheryof the ice ball with a temperature below 5°C,which should resolve with time. If in the centreof the ice ball, where temperatures of -40°C orlower predominate, permanent neurologicaldamage may result. To prevent pathologicalfractures a consolidation is necessary.

For soft tissue and bone tumours the visualcontrol of the ice ball is a major advantage forsuccessful ablation with maximum precision(Fig.1). Precise delimitation of the ice ballallows reducing complication with adjacent tis-sue damage, particularly nerve roots (2).Thermosensors and insulation techniques canbe added to increase the safety. Moreover,musculoskeletal cryoablation is less painfulthan radiofrequency ablation. In spinal oracetabular tumours, a percutaneous cemento-plasty should be associated to cryoablation toavoid compression fractures (Fig.2). The cementis injected after complete thawing of the iceball or the day after the cryoablation.

For liver tumours, cryoablation is feasible butrequires larger margins to accomplish com-plete ablation (3). It could be promising fortumours close to common bile duct. A syn-drome of multi-organ failure and disseminatedintravascular coagulation ("cryoshock phenom-enon") following large hepatic cryoablation hasbeen described. It may be due to secondaryrelease of liver cytokines, but has not beenreported for other organ cryoablation.

For kidney tumour ablation, the clear visualcontrol of the ice ball and the relative protec-tion of collagen structures (4) make cryoabla-tion the technique of choice, particularly forcentral lesions. Indeed to risk of thermal dam-age to pyelic structures is less compared toradiofrequency ablation (Fig.3). For thoracictumours, cryoablation of parenchymal tumoursis still under evaluation. However, for chest wall(Fig.4) and paramediastinal tumours, cryoabla-tion seems very promising (5).

References:1. Baust JG, Gage AA. The molecular basis of cryosurgery. BJU Int

2005; 95:1187-1191.2. Callstrom MR, Atwell TD, Charboneau JW, et al. Painful metastases

involving bone: percutaneous image-guided cryoablation--prospective trial interim analysis. Radiology 2006; 241:572-580.

3. Bageacu S, Kaczmarek D, Lacroix M, Dubois J, Forest J, Porcheron J.Cryosurgery for resectable and unresectable hepatic metastasesfrom colorectal cancer. Eur J Surg Oncol 2007; 33:590-596.

4. Janzen NK, Perry KT, Han KR, et al. The effects of intentionalcryoablation and radio frequency ablation of renal tissue involvingthe collecting system in a porcine model. J Urol 2005; 173:1368-1374.

VertebroplastyHands-on WorkshopMonday, 16:30-18:30, Rigshospitalet

Don't miss it !

Fig.1: Right painful paravertebral metastasis oflung cancer. The extent of the ice ball (oval-shaped hypodensity) is precisely monitored withCT guidance.

Fig.4: Cryoablation of painful thoracic wallmetastasis. Precise monitoring of the ice ball withCT. Cryoablation is less painful compared toradiofrequency ablation.

Fig.3: Renal tumour cryoablation. Precise moni-toring of the ice ball with CT. The risk of thermaldamage to the pyelic system is less than withradiofrequency ablation.

Fig.2: Same patient as in Fig.1. If vertebral consoli-dation is required, additional vertebroplasty isperformed after complete thawing of the ice ball.

C RSECardiovascular and Interventional Radiological Society of Europe

13Ultrasound SurgeryIRnewscongress

Ablation technologies have become increas-ingly commonplace in the last five years asmethods of destroying tumour tissue withinsolid organs using minimally invasive proce-dures to deliver this type of therapy. Focusedultrasound is the latest technology in this evo-lution of therapies and has the potential ofbeing so minimally invasive that in fact it is notinvasive at all, with no percutaneous needles orprobes required to deliver thermally destruc-tive heat to tissues. Like all good ideas it wasfirst proposed by our fathers and grandfathersin the mid 1940s (1) with the original sugges-tions to use high power ultrasound to deliverheat as destructive power to tissues originat-ing. It is only more recently however that othertechnologies such as image guidance havecaught up with these principles to allow a safeutilisation of this technology (2).

Described in its most basic terms focused ultra-sound uses ultrasonic power of approximately5,000 to 10,000 times the power of convention-al diagnostic ultrasound focused to a very smallpoint deep in tissues (3). The molecules in thearea of focus are rapidly vibrated and as aresult the area is heated. Once the temperatureis elevated beyond 55°C for one second, cellu-lar proteins are coagulated, the cell can nolonger function and dies. Although its vascula-ture is still in place, perfusion to the cell is shutdown.

This type of energy can be delivered to deeptissues provided there is an appropriateacoustic window allowing safe deposition ofpower in the target area. Obviously havingstructures such as gas within the bowel orbone in the acoustic beam the pathway causessevere problems with the former causinglocalised reflection and potential excessive tis-sue damage, the latter problem causing com-plete absorption of the ultrasound beam withno energy available beyond.

Many different manufacturers are involved inthe development of this technology andinevitably their approaches still differ quite alot. There are a variety of focused ultrasoundmachines available which use conventionaldiagnostic ultrasound to guide and control theutilisation of focused ultrasound power. Thedrawback of these techniques is that targetingcan be quite difficult and that no real usefulthermal feedback can be obtained using ultra-sound. It is unequivocally true that changes intissues are seen with ultrasound as the heat isapplied, but it is also evident that currently theextent of these changes are not in any way cor-related with the tissue results and the tempera-ture produced in the tissues. Therefore usingultrasound to monitor the area heated pro-vides no predictive information as to the extentof damage produced.

The technology described in this article con-sists of a combination of an MR machine and afocused ultrasound delivery system in one inte-grated component. This means that thefocused ultrasound delivery mechanism that isutilised in the very hostile environment of highfield MR must be completely MR compatible inall respects with no ferromagnetic componentsand no electrical machinery producing signifi-cant radiofrequency energy leakage whichcould distort MR images. Figure 1 shows the

system in action with the machine table that isnormally used completely replaced by a similartable containing a degassed water bath withinwhich the electronic array of transducers thatproduce the focused ultrasound energy isplaced. This array can be translated across thefield of view and can also be pitched and rolledto provide a suitable acoustic pathway to thetarget area (Figure 2).

MR imaging is used to provide the best possi-ble visualisation of the target lesion and thesurrounding tissues using the superb soft tis-sue contrast that is inherent to MR. This pro-vides optimal targeting of tissue whilst provid-ing a safe beam pathway with maximum oper-ator reassurance allowing a very accurate dep-osition of destructive energy at the desired site.Accurate targeting is combined with thermalimaging to provide a read out of tissueresponse multiple times during each sonication(4). Thermal mapping allows the operator toadjust sonication parameters in response tovisualised tissue thermal changes. There isimmense variability in tissue response bothbetween patients and within the same area ofheating due to variations in vascularity, fat con-tent, etc. Visualising these changes as they hap-pen allows the operator to titrate input powerin such a way as to create an appropriate ther-mal lesion.

The most common area of application ofMRgFUS around the world to date has been inthe treatment of uterine fibroids (5, 6). It is easyto obtain a suitable acoustic window with size-able uterine fibroids via the anterior abdominalwall and large areas of destruction can be pro-duced within these benign tumours with rela-tive ease. Conventional indications suggestthat fibroids of up to 20 cm can be treatedalthough fibroids between 10 and 20 cm indiameter are usually pre-treated by GNRH ago-nists which cause some reduction in size andreduce vascularity, thus allowing large fibroidsto be treated when they are in a smaller state (7).

Using these criteria, studies indicate that 80%of patients show a significant symptomaticresponse following MRgFUS treatment at threeand six months. More recently it has becomeclear that if more than 60% of the targetedfibroid is successfully treated, the requirementfor further procedures of any sort to treat thepatient's fibroids at 24 months is 11% (8),which compares very favourably with a muchhigher rate reported 24 months post myomec-tomy (conventional gold standard). Furtherstudies are emerging with longer follow-upssuggesting that symptomatic responses follow-ing MRgFUS are entirely comparable to thoseseen with other treatment modalities over a 24month follow-up.

As MR gFUS in this context is an entirely non-invasive outpatient procedure with almost nopost-procedural pain, it has immense advan-tages over other existing treatment modalities.It is also likely that MRgFUS will have advan-tages for women wishing to preserve their fer-tility. While no randomised comparative dataexist in this field so far. More than 40 relativelyuncomplicated pregnancies amongst womenfrom around the world who have received thistreatment have been recorded to date with nonoted instances of uterine rupture or othersimilar complications.

Uterine fibroids are of course only the firstmajor application of this type of technology.MRgFUS provides the potential of a thermaldestructive modality which can be controlledby image guidance in a very accurate manner.It is therefore obvious that it can potentially be

MR guided focused ultrasound surgery

applied in many other areas, especially in thefield of oncology to destroy tumours in solidorgans. There is early work available on thebreast indicating that MRgFUS can be easilyapplied to breast cancers to replace wide localexcision, thus minimising surgical breast trau-ma (9).

Painful bone secondaries can be treated rela-tively easily for pain palliation with MR GFUS inthe non axial skeleton. In this situation ultra-sound is very avidly absorbed by the perios-teum and cortical margins, so that neurogenicfibres in the periosteum are rapidly destroyedby the heat. This leads to significant improve-ment in the pain secondary to metastaticdeposits and can be performed as a one offoutpatient procedure with long-lasting painrelief. This type of procedure is currently purelypalliative and does not treat the underlyinglesion (10).

Early work is being piloted in the use ofMRgFUS in the liver. Unfortunately most of thetime the ribs get in the way, shielding the liverand disrupting the ultrasound beam which cur-rently has a quite wide footprint. Pilot informa-tion is therefore only available when lesions areaccessible either below the right rib line or inthe left lobe uncovered by ribs. Early work sug-gests that it is relatively easy to produce effec-tive areas of thermal destruction in amenableparts of the liver which would be expected,given the successful experience with thermalablation of liver tumours.

It is anticipated that within 12 months muchlarger transducers will be available which candeliver energy between ribs and take respira-tion motion into account, overcoming the cur-rent limitations. In the future focused ultra-sound guided with MR is likely to be applied tomany other accessible areas within the body,allowing non-invasive therapeutic interven-tions to be performed as outpatient proce-dures without associated hospitalisation.

The potential cost savings of this type of thera-py more than offset the initially higher capitaloutlay for the appropriate machinery. Earlycost-effectiveness studies in uterine fibroidswithin the NHS in the UK (11) have already indi-cated that MRgFUS is a more cost-effectivetechnique for the treatment of fibroids thansurgery or uterine artery embolization becauseof its rapid restoration of patient quality of lifewith very few side effects.

References:1. LynnJG, Zwemer RL, Chick AJ, Miller AE. A new method for the gen-

eration and use of focused ultrasound in experimental biology. Jgen Physiol 1942; 26: 179 - 193

2. Hynynen K, Darkazanali, A, Unger E, Schenk JF. MRI -- guided non-invasive ultrasound surgery. Med Phys 1993; 20 :107 - 115

3. Hunt JW, principles of ultrasound used for generating delocalizedhypothermia. Field SB, Fanconi C, eds. Physics and technology ofhyperthermia. Boston, MA: Martinus Nijhoff Publishers 1997: 354 -389

4. Gedroyc W, V Magnetic resonance guidance of thermal ablation.Top Magn Reson Imaging. 2005 Oct;16(5):339-53.

5. Stewart EA, Rabinovici J, Tempany CM, Inbar Y, Regan L, Gostout B,Hesley G, Kim HS, Hengst S, Gedroyc WM. Clinical outcomes offocused ultrasound surgery for the treatment of uterine fibroids.Fertil Steril. 2006 Jan;85(1):22-9

6. Hindley J, Gedroyc WM, Regan L, Stewart E, Tempany C, Hynyen K,Mcdannold N, Inbar Y, Itzchak Y, Rabinovici J, Kim HS, GeschwindJF, Hesley G, Gostout B, Ehrenstein T, Hengst S, Sklair-Levy M,Shushan A, Jolesz F. MRI guidance of focused ultrasound therapyof uterine fibroids: early results. AJR Am J Roentgenol. 2004Dec;183(6):1713-9

7. Smart OC, Hindley JT, Regan L, Gedroyc WG. Gonadotrophin-releasing hormone and magnetic-resonance-guided ultrasoundsurgery for uterine leiomyomata. Obstet Gynecol. 2006Jul;108(1):49-54.

8. Stewart EA, Gostout B, Rabinovici J, Kim HS, Regan L, Tempany CM.Sustained relief of leiomyoma symptoms by using focused ultra-sound surgery. Obstet Gynecol. 2007 Aug;110(2 Pt 1):279-87.

9. Furusawa H, Namba K, Thomsen S et al. magnetic resonance guid-ed focused ultrasound surgery or breast cancer: reliability andeffectiveness. J Am Coll Surg 2006; 203: 54 - 63

10. Catane R, Beck A, Inbar Y et al. M. R. guided focused ultrasoundsurgery for the palliation of pain in patients with bone metastases-- preliminary clinical experience. Annals of Oncology, October2006

11. Zowall H, Cairns JA, Brewer C, Lamping DL, Gedroyc WM, Regan L.Cost-effectiveness of magnetic resonance-guided focused ultra-sound surgery for treatment of uterine fibroids. BJOG. 2008Apr;115(5):551-3.

Wladyslaw GedroycMedical Director MRI Units St. Mary's Hospital, UK

Fig. 4: Ablation procedure applied to metastaticdeposits in the buttock. This is a subtraction fatsaturated gradient echo T1 image post contrastshowing an area of decreased enhancement inthe centre of the enhancing tumour which hasbeen produced by one short session of focusedultrasound directed at this area. Residual tumourremains close to the sciatic nerve.

Fig. 2: Schematic of patient within the bore of theMR scanner with breast applied to the water bathcontaining transducer allowing an acoustic path-way to the target site with no gas or other struc-ture intervening.

Fig. 3: Moderate sized uterine fibroid post-proce-dure. This is a fat saturated T1 gradient echoimage post contrast. The central non enhancingarea is the ablation destruction with the sur-rounding normal myometrium enhancing nor-mally.

Fig. 1: Conventional MR G. FUS setup with normalMR table replaced by a modified table containingFUS transducer and water bath. The whole opera-tion of focused ultrasound and MR guidance iscontrolled by a workstation that enslaves normalMR controls.

C RSECardiovascular and Interventional Radiological Society of Europe

15Stem Cells for Treatment of Critical Limb IschemiaIRnewscongress

BackgroundCritical limb ischemia (CLI) is an end-stage dis-ease provoked by progressive obstruction ofthe peripheral arteries. Most patients have amulti-system and multi-level disease within theinvolved extremity with long segments ofinvolvement and with additional distal vesselinvolvement (1-3). This makes it difficult to per-form surgical or endovascular revascularization.Only 20-30% of these patients have a suitableanatomy for surgical or endovascular revascu-larization. In the remaining cases, palliativemedical treatment is usually resorted to, withamputation becoming unavoidable in the nearterm. Amputation is almost certain in absenceof prompt intervention. In patients in whomsurgical or endovascular revascularization isnot feasible or has failed, induction of thera-peutic angiogenesis by stem cell implantationcould provide therapeutic benefit and may beinstrumental in limb salvage.

Pre-clinical studies have shown that angiogenicgrowth factors promote development of collat-eral arteries (4-6). Neogenesis of both car-diomyocytes and coronary capillaries withsome functional improvement was reported byseveral investigations using bone marrowderived cells in experimental infarction (7-15).Similar data was also reported in surgicallytreated chronic ischemic disease (16-19).Preliminary studies in small groups of patientswith CLI have shown encouraging results withthis approach in the management of CLI, usual-ly by employing local intramuscular injectionsfor delivery of stem cells (20-24). An alternativeendovascular route for delivery of stem cells ispossible, but not well studied. Further, at thistime no data exist on the optimal dosage ofstem cells required for clinical benefit.

We have tested the hypothesis that combinedautologous bone marrow-derived stem cellsinjected intra-arterially in the affected limb atthe site of arterial occlusion along with aggres-sive medical management results in better out-comes as compared to aggressive medicalmanagement alone in a group of patients withCLI who are not candidates for surgical orendovascular revascularization. We have alsoevaluated the outcomes after injection of grad-ed doses of stem cells for this treatment.

MethodStudy design Randomized controlled study with parallelgroup design and with blinded interpretationof the outcomes. We enroll patients with unilat-eral or bilateral CLI who are not suited for surgi-cal or endovascular revascularization.Randomization is done by computer generatedmodels. The study design is approved by theInstitute Ethics Committee. Informed writtenconsent is obtained from each patient. Pre-defined statistical methods are used to evalu-ate the outcomes.

Inclusion criteria

1) Clinicala) Rest pain requiring analgesia for >2 weeks

and/or non healing ischemic ulcersb) Absent or weak peripheral pulsesc) No response to smoking cessation for at

least 3 months prior to evaluationd) Not suited for surgical/ endovascular revas-

cularizationd) Unilateral or bilateral involvemente) Claudication distance of <100 meters

2) Hemodynamica) Doppler study showing an occluded superfi-

cial femoral, popliteal or infra-poplitealartery with no or poor distal flow as evi-denced by a monophasic, low velocity, col-lateralized flow pattern.

b) Contrast-enhanced magnetic resonance anddigital subtraction angiography demonstrat-ing the site of occlusion, status of distal run-off and the extent of collateralization

c) Ankle systolic pressure <50 mm Hgd) A resting ankle brachial pressure index <0.5

in the affected limb on 2 consecutive exami-nations done at least 2 days apart

Exclusion criteria

a) Poorly controlled diabetes mellitusb) Evidence of a malignancy during the last 5

yearsc) Renal dysfunction or other contraindication

to injection of contrast media d) Continued smoking e) Limitation to exercise due to any reason

other than claudication Age, Sex or any other clinical parameters arenot used to exclude patients.

Pre-Procedure AssessmentThis includes detailed clinical examination foroptimal documentation of multi-system dis-ease and of the extremity arteries to define theextent of multi-level disease within theinvolved extremity. Pertinent past history relat-ed to drug intake, smoking, risk factors for ath-erosclerosis and previous history of interven-tions (medical, surgical or endovascular) isrecorded. At base-line ABI, duplex ultrasound(US), MRA and an intra-arterial digital subtrac-tion angiography (IA-DSA) are performed toobtain adequate information on the site &extent of the disease and the status of distalrun-off vessels.

Stem Cell IsolationUnder local anesthesia, bone marrow (up to100 ml) is aspirated from the iliac crest using adisposable bone marrow aspiration needleunder sterile aseptic condition. Mononuclearbone marrow cells (BMC) are separated byFicoll density separation method. Briefly, BMCare layered over lymphocyte separation medi-um and centrifuged at a speed of 1,500 rpm for30 minutes. Mononuclear cells are aspiratedand washed thrice in heparinized normal salineto remove the traces of Ficoll. The entire proce-dure is done under strict aseptic conditions.The harvested mononuclear BMC are evaluatedfor viability of cells by Trypan blue dye exclu-sion test, flow cytometry and for MNC mor-phology by Giemsa staining.

Intra-arterial InjectionPercutaneous intra-arterial injection of thesecells at the site of occlusion from contra-lateralapproach by using a 5 F multi-purpose catheteris done within one hour of harvesting stemcells. IA-DSA is performed immediately beforeand after stem cell injection. The desired

Induction of therapeutic angiogenesis byendovascular application of autologous bone-marrow derived stem cells in patientswith critical limb ischemia

amount of cells is injected into the artery at thesite of occlusion after US-guided manual occlu-sion of ipsi-lateral common femoral vein. IA-DSA is performed using a standardized amountof iodinated contrast material, acquisitionframe rate and table-screen distance to ensureoptimal comparison of images during follow-up for evaluation of collateral density.

Post Procedure evaluationThis includes assessment of the treated limb forany local signs of inflammation up to 72 hoursafter injection. Biochemical evaluation is alsodone to evaluate hematological, renal & hepat-ic parameters during follow-up. Imaging fol-low-up includes ABI at 1, 3 and 6 months andduplex US, MRA & IA-DSA at 6-month follow-up. Assessment for collateral vessel develop-ment is graded as no collateral (Grade 0), slight(Grade 1), moderate (Grade 2) and rich devel-opment (Grade 3).

End-PointsPre-defined end-points, primary for safety &efficacy of the treatment and secondary for fol-low-up outcomes, are used for analysis of theresults of treatment. Outcome analysis is per-formed as per the pre-determined protocols forassessing the efficacy of this treatment. Twotrained observers with over five years of experi-ence in interpreting these images read theimages independently blinded to the treatmentand to each other. The differences in interpreta-tion, if any, are resolved by consensus.

ResultsThe procedure is well tolerated by all patients.We have not encountered any procedure-relat-ed complications at puncture site, treatmentsite or in remote location. All procedures weretechnically successful. Whereas in the controlgroup, no clinical or imaging improvement wasseen in any patient, benefit in terms of clinical,ABI and imaging improvement is seen in mostpatients who have received stem cells by intra-arterial route. Overall, 70-100% of patientsshow varying degrees of clinical and/or imag-ing improvement after stem cell therapy.During follow-up, no patient has shown anyevidence of malignancy, arterio-venous fistulaor malformation in the affected limb after treat-ment with stem cells. The clinical benefit is sus-tained over time during follow-up in mostpatients.

Use in other disease states & future scopeWe have pioneered this concept of endovascu-lar delivery of autologous stem cells at the siteof disease and applied it to various diseasestates, including diabetes mellitus, renal failure,cerebral palsy, muscular dystrophies, dilatedcardiomyopathy and spinal cord injuries,among others. In each of these disease stateswe use a similar study design, as described forCLI, approved by the Institute EthicsCommittee. At this time we have treated over300 patients with above diseases by thisapproach. The preliminary results have beenencouraging with adequately documentedimprovements without complication amongselected patients. Long term outcomes withclinical and imaging follow-up to evaluate theefficacy of this therapy and its safety in termsof longer term adverse events need to bedetermined before its place in the manage-ment algorithm of these diseases can be estab-lished. Stem cell therapy has the potential tochange the way we treat patients in selecteddisease states.

References:1. European working group on critical limb ischemia, second

European Consensus Document on Chronic Critical LegIschemia Circulation(suppl) 1991; 84: 1-26

1. Criqui MH, Fronek A, Barrett-Connor E, Klauber MR, Gabriel S,Goodman D. The prevalence of peripheral arterial disease in adefined population. Circulation 1985; 71: 510-515.

2. Reunanen A, Takkunen H, Aromaa A. Prevalence of intermittentclaudication and its effect on mortality. Acta Med Scan 1982;211: 249-256.

3. Prockop DJ. Marrow stromal cells as stem cells for non-haematopoeitic tissues. Science 1997;276;71-74.

4. Asahara T, Masuda H, Takahashi T, et al. Bone marrow origin ofendothelial progenitor cells responsible for postnatal vasculo-genesis in physiological and pathological neovascularization.Circ Res 1999; 85:221-28.

5. Bodo E. Strauer, MD; Michael Brehm, MD; Tobias Zeus, MD et alRepair of Infarcted Myocardium by Autologous IntracoronaryMononuclear Bone Marrow Cell Transplantation in Humans

6. Orlic D, Kajstura J, Chimenti S, et al. Bone marrow cells regener-ate infracted myocardium. Nature. 2001;410:701-705.

7. Orlic D, Kajstura J, Chimenti S, et al. Mobilized bone marrowcells repair the infarcted heart, improving function and survival.Proc Natl Acad Sci U S A.2001;98:10344-10349.

8. Kocher AA, Schuster MD, Szabolcs MJ, et al. Neovascularizationof ischemic myocardium by human bone-marrow-derivedangioblasts prevents cardiomyocyte apoptosis, reduces remod-eling and improves cardiac function.Nat Med. 2001;7:430-436.

9. Tomita S.Mickle DA, Weisel RD, et al. Improved heart functionwith myogenesis and angiogenesis after autologous porcinebone marrow stromal cell transplantation. J Thorac CardiovascSurg. 2002; 123: 1132-1135; 84: 1-26.

10. Wang JS, Shum-Tim D, Chedrawy E, et al. The coronary deliveryof marrow stromal cells for myocardial regeneration: patho-physiologic and therapeutic implications. J Thorac CardiovascSurg. 2001;122:699-705.

11. Sussman M. Cardiovascular biology: hearts and bones. Nature.2001;410: 640-641.

13. Toma C, Pittenger MF, Cahill KS, et al. Human mesenchymalstem cells differentiate to a cardiomyocyte phenotype in theadult murine heart. Circulation. 2002;105:93-98.

14. Kamihata H, Matsubara H, Nishiue T, et al. Implantation of bonemarrow mononuclear cells into ischemic myocardium enhancescollateral perfusion and regional function via side supply ofangioblasts, angiogenic ligands, and cytokines. Circulation.2001;104:1046-1052.

15. Ferrari G, Cusella-De Angelis G, Coletta M, et al. Muscle regener-ation by bone marrow-derived myogenic progenitors. Science.1998;279:1528-1530.

16. Quaini F, Urbanek K, Beltrami AP, et al. Chimerism of the trans-planted heart. N Engl J Med. 2002;346:5-15.

17. Kawamoto A, Gwon HC, Iwaguro H, et al. Therapeutic potentialof ex vivo expanded endothelial progenitor cells for myocardialischemia. Circulation. 2001;103:634-637.

18. Robinson SW, Cho PW, Levitsky HI, et al. Arterial delivery ofgenetically labelled skeletal myoblasts to the murine heart:long-term survival and phenotypic modification of implantedmyoblasts. Cell Transplant. 1996; 5: 77-91.

19. Bittner RE, Schofer C, Weipoltshammer K, et al. Recruitment ofbonemarrow-derived cells by skeletal and cardiac muscle inadult dystrophic mdx mice. Anat Embryol (Berl). 1999; 199:391-396 controlled trial; Therapeutic Angiogenesis using CellTransplantation (TACT) Study Investigators

20. Iba O, Matsubara H, Nozawa Y: Angiogenesis by Implantation ofPeripheral Blood Mononuclear Cells and Platelets Into IschemicLimbs. Circulation. 2002; 106:2019-2025.

21. Al-Khaldi A, Al-Sabti H, Galipeau J: Therapeutic angiogenesisusing autologous bone marrow stromal cells: Improved BloodFlow in a Chronic Limb Ischemia Model. Ann Thorac Surg2003a; 75: 204-9.

22. Takahashi T, Kalka C, Masuda H et al: Ischemia and cytokine-induced mobilization of bone marrow derived endothelial cellsfor neovascularization. Nat Med 5:434-438, 1999

23. Yamamoto K, Kondo T, Suzuki S et al: Molecular Evaluation ofEndothelial Progenitor Cells in Patients with Ischemic Limbs-Therapeutic Effects by Stem Cell Transplantation. ArteriosclerThromb Vasc Biol. 2004; 24: e192-e196

24. Tateishi-Yuyama E, Matsubara H, Murohara T, Ikeda U, ShintaniS, Masaki H, Amano K, Kishimoto Y, Yoshimoto K, Akashi H,Shimada K, Iwasaka T, Imaizumi T -Therapeutic angiogenesis forpatients with limb ischaemia by autologous transplantation ofbone-marrow cells: a pilot study and a randomized control trial.Lancet 2002; 360:427-35.

Sanjiv SharmaProfessor and Head of the Department of CardiacRadiology, All India Institute of Medical Sciences,New Delhi, India

Fig.1a: IA-DSA in a patient with critical limbischemia before treatmentFig.1b: IA-DSA 6 months after treatment withautologous stem cells delivered intra-arteriallyshowing improvement in collateral flow

Late Breaking AbstractsFree Paper SessionMonday, September 15, 17:30-18:30Room B

Don't miss it !

Special Edition / CIRSE 2008 - Copenhagen

16 Film Interpretation Panel Monday, September 15, 2008

Film Interpretation Panel

Weight loss & abdominal pain

· 64 year old female, 1year history of unexplained weight loss· Intermittent abdominal pain· Referred for a CT scan

Case 5

What does this show?

Left sided discomfort

· 47 year old male marathon runner· Left sided discomfort· Ultrasound scan demonstrated an abnormality in the right kidney· CT was performed

Case 6

Diagnosis?Treatment options?

Film Interpretation Panel Join us to witness the fight of Team Odin versus Team Thor today at 3pmin Room A. For those of you who like to get a head start we have puttogether this year's cases.

What does this show?

Investigations

· Otherwise normal CT scan· Normal OGD, Colonoscopy· Normal small bowel meal – no source of intussuseption· Contrast ultrasound

· Focal stenosis of branch ? Ileocolic artery or rt colic artery?

· Irregularity of proximal SMA· Irregularity of proximal IMA

Referred for angiography

Selective right renal angiography

What to do now?

C RSECardiovascular and Interventional Radiological Society of Europe

17Film Interpretation PanelIRnewscongress

Film Interpretation PanelMonday, 15:00, Room A

Don't miss it !

Lower back pain

· 80 year old female· Sudden onset of severe lower back pain· On opiates. Unable to get out of bed· Referred for vertebroplasty

Case 7

Findings?Diagnosis?Treatment?

Congestive heart failure

· 88 year old female patient · Congestive heart failure· Arterial hypertension· External MRI of the heart

Case 8

Diagnosis?Treatment options?

Odin vs. ThorToday, 15:00 in Room A

Next step: In-house contrast-enhanced CT

C RSECardiovascular and Interventional Radiological Society of Europe

19The Alternative Guide to DenmarkIRnewscongress

As you have probably noticed by now,Copenhagen can safely be called one ofEurope's most interesting cities. Despite beinghome to more than a fifth of the Danish popu-lation and the headquarters of numerousmultinationals, it has the cosy, homey feel of auniversity town, but more importantly it hasone of the highest densities of cafés, restau-rants and clubs in all of Europe, so get ready toDane it up! Here are some of the sites not to bemissed:

Nyhavn

Built in 1671-1673 to allow trading access toKongens Nytorv, Nyhavn (lit. New Harbour) wasinitially a business community. After 1800 themerchants moved out and the harbour becamea place of pubs, sailors and all the STD carryingfun usually associated with them. The northside (where the bars are) is still known as "thenaughty side", although all the sailors havelong left (sorry, ladies).

Today Nyhavn is one of Copenhagen's majortourist attractions, the half mile long harbourpacked with excellent restaurants and chicroadside cafés. If you have to watch your budg-et (which given Danish prices you probablywill) and it is a nice day out, you can bring yourown beer and join an exuberant crowd of peo-ple from all over the world sitting along theharbour. If you feel you should do somethingcultural before starting to sample a variety ofbeverages, check out house number 9 -Nyhavn's oldest building - and house number18 in which Hans Christian Andersen lived formany years.

The Little Mermaid

The world famous Little Mermaid Statue sits ona rock in the Copenhagen harbour atLangelinie. It was commissioned in 1909 byCarl Jacobsen, son of the founder of Carlsberg,after he had been fascinated by a ballet aboutthe fairytale (although I have the suspicion thathe did it in order to make girls swoon about hisromanticism).

The statue is only 1.25 metres high and veryclose to the shore, which has made it the targetof repeated acts of vandalism. Throughout thedecades its head has been sawn off severaltimes and in 2003 the entire statue was blowninto smithereens, possibly with dynamite. It istherefore not surprising that the Copenhagenauthorities are considering moving the statuefurther out to the sea.

Copenhagen Opera House

If you have some spare time during your stay inCopenhagen, I highly recommend visiting theimposing and very stylish Opera Building.When I first heard that it was donated by oneof the founders of the world's biggest contain-er ship operator, the Møller-Maersk Group, Iwas impressed by what seemed to be a verygenerous act. Of course I soon realised that arich industrialist actually giving back to thecommunity was too good to be true. Since the"donation" of the opera house was taxdeductible, the Møller Foundation was practi-cally forcing the government to buy the build-ing - No wonder the guy got so rich!

The Copenhagen Opera is one of the mostexpensive opera houses ever built, its construc-tion costs exceeding 500 million dollars. It isone heck of a building though, I have to say,and if you are not Danish, you get to enjoy itwithout the nagging feeling that your taxmoney paid for it. If you are Danish, I guessnothing can upset you anyways.

Freetown Christiania

The famed Freetown of Christiania, one ofEurope's last hippie strongholds, is a partiallyself-governing neighbourhood that startedwhen a group of free spirits squatted whatused to be a military area in 1971. Today it isinhabited by about 850 residents, most ofwhich spend the better part of their day staringfascinated at the back of their hands, due toone of the more outstanding characteristics ofChristiania; its flourishing cannabis trade.

The government has been trying to normalisethe legal status of the community, but noagreement has been reached, which is why theChristianians gleefully continue in a legal greyzone. Considering that Christiania's residentshave been smoking up for the last 35 years itwill be pretty hard to force them into pinstripesuits and get them to buy minivans, so it willbe interesting to see what the Copenhagenauthorities will come up with.

If you are staying in Copenhagen for severaldays, Christiania is definitely worth a visit. Iwould not recommend going there after night-fall, though - mostly because you might seri-ously start questioning why on earth you go towork every day.

Danish delights (that won't make you fat)

Tivoli Gardens

Many tour books refer to Tivoli as a pleasuregarden. It is a fun place, that's for sure, but"amusement park" is probably a more accuratedescription, so please do keep your clothes on.

Contrary to most other amusement parks -mere collections of roller coasters and theoccasional kid tossing his cookies after going inthe super-blaster - Tivoli is everything anamusement park should be; a pleasant gardenwith fun rides, good restaurants, 19th centurypavilions and a lake for boat rides and soberingup drunk people. If after a day of absorbing sci-entific lectures you feel like killing off someneurons through vigorous shaking, I recom-mend getting a day pass, which is much cheap-er than paying for each individual ride.

Petra MannCIRSE Office Christiansborg Palace

Christiansborg Palace is home to Denmark'sthree supreme powers and the only building inthe world encompassing the legislative, theexecutive and the judicial powers of a nation.This of course makes life much easier fordemonstrators and people who are not surewhich hand they have to grease for the particu-lar favour they need. Apparently it also makeslife much easier for arsonists, as the buildingsuffered two great fires. As a result of thesefires Christiansborg Palace now comprises ele-ments of three eras of Danish architecture; latebaroque, neo-baroque and neo-classical style.

Strøget

In the centre of Copenhagen lies Strøget,Europe's largest pedestrian shopping areawhich starts at Rådhuspladsen (City HallSquare) and runs all the way to KongensNytorv. Before you make a run for it, though, Ido have to tell you that prices there are stratos-pherical; many of Copenhagen's most famousand expensive stores, including IllumsBolighus, Magasin du Nord and the RoyalCopenhagen Porcelain Manufactory are locat-ed on Strøget. It is also well-known for its streetentertainment, mostly consisting of touristswho have gone mad after realising how muchmoney they just spent.

Canal Tours

A tour of Copenhagen's canals is an attractionnot to be missed, as it will give you the oppor-tunity to explore the city's unique geographyand, more importantly, conduct various experi-ments regarding the floatability of the littlemermaid souvenirs you bought in a weakmoment and that you are now having secondthoughts about. From the boat you will seemany of Copenhagen's landmarks, such as theOpera House, the royal palace Amalienborgand of course the Little Mermaid statue.Depending on the route of your tour boat, youmight also be able to see a statue entitled "thegenetically modified mermaid", a modern (andsomewhat scary) version of the iconic original.

Although the tour boat owners in Copenhagenwill spare you the ear-numbing auditory expe-rience their Venetian counterparts bestow ontheir guests, they do stick to the universalbelief that they have to help you part with awad of cash big enough to buy a small familyhome in exchange for an hour long ride. It'swell worth it, though. Having enough moneyto pay for food and rent is overrated anyways.

IR Congress News is published as an additional source of information for all CIRSE 2008participants. The articles and advertorials in this newspaper reflect the authors' opinion.CIRSE does not accept any responsibility regarding their content. If you have any questions about this publication, please contact us at mann@cirse.org.

Editors in Chief: Poul Erik Andersen, Afshin GangiManaging Editor: Petra Mann, CIRSE OfficeGraphics/Artwork: LO O P. E N T E R P R I S E S media