CIRSE 2023: Controversies and updates in embolotherapy

November 21, 2023

Embolotherapy is a wide-reaching mainstay of IR practice which has progressed rapidly in recent years. Alongside CIRSE’s dedicated embolotherapy meeting, ET, the CIRSE annual meeting includes a robust track dedicated to embolization. In addition to a host of embolization focus sessions and case-based discussions on well-established and emerging techniques, CIRSE 2023 also saw a focus on current controversies and research updates in the world of embolotherapy. All lectures are now available via the CIRSE Library.

PAE: where we stand today

The first embolization controversy session of the meeting addressed where we stand today with PAE.

H. Moschouris spoke in favour of pre-procedural vascular mapping, beginning immediately by polling the audience on the question; 72% were in favour of pre-procedural imaging. “The greatest advantage of pre-procedural mapping is that it’s pre-procedural!” he stated, elaborating that it allows plenty of time to study vascular anatomy, plan the access route, ensure devices are available, and that it is useful for less experienced operators at the early stages of PAE practice. H. Kobeiter presented a “con” point of view, arguing that pre-imaging is the job of diagnostic radiology and that he rarely gets what he needs from it as an IR at the cost of greater expense and more radiation exposure for the patient, and that CBCT is enough in the majority of cases.

The second contrasting couplet focused on the need for steep oblique vies. A. Picel presented in favour, concluding that ipsilateral oblique images are currently the best projection to identify and catheterize the prostatic arteries. He noted that 3D roadmap embolization is promising, but not available to all operators and perhaps not worth the small dose reduction. M. Katoh spoke against steep oblique views, favouring instead CBCT, as it reduces radiation dose and CM volume, allows safe navigation, and helps avoid non-target embolization.

Concluding the session, I. Insausti spoke on the possibility of smaller particle sizes resulting in better results in PAE, but concluded that there is no clear data pointing to a better embolic agent yet, whereas N. Vascol Veloso Pereira Costa spoke against increasingly smaller particles, cautioning that smaller particles increase the rate of adverse events.

Liver venous deprivation

A second controversy session focused on liver venous deprivation, starting with B. Antonelli presenting that “volumetry is enough” to determine patients who need liver venous deprivation. The audience voted at the start of her session; 76% disagreed with her position. A. Denys provided a counterpoint presentation arguing that volumetry is not enough and function is also needed.

B. Gebauer presented from the standpoint of “portal vein is enough for most,” a position that 76% of the audience agreed with, while B. Guiu had the more difficult job of trying to convince the audience that LVD is needed for most. He implored that LVD is safe and outperforms PVE, but does need to be confirmed in RCTs and registries.

Finally, H. Pinto Marques argued that patients bleed more during surgery after LVD, though his analysis was somewhat cautious, concluding that LVD is a useful and important strategy to obtain adequate FLR before major hepatectomy and that the associated blood loss after LVD, while important to consider and recognize, is not statistically significant. B. Al Taweel presented his reasoning for declaring that surgery is fine after LVD with a contrasting statement that LVD does not result in a higher bleeding risk, intra and postoperative morbidity-mortality is comparable or lower to that of PVE, and while the complications are similar to PVE, the results are better.

Controversies in embolization

The controversies in embolization session also addressed PAE, with urologist A. Alfano having the difficult task of opening the session with a presentation against PAE. He posited that TURP is the current standard surgical procedure and that PAE is not a real alternative in many patents, but balanced his presentation by emphasising that patient selection is key. F. Carnevale followed with the “pro” presentation, comparing TURP and PAE on several levels, including safety, efficacy, grade of complexity, complications, and more. He concluded that “PAE is better than TURP, but it is the patient’s decision!”

A discussion on haemorrhoid treatment followed, with D. Mege speaking in favour of surgery, while V. Vidal delivered a talk in favour of embolization, presenting evidence for clinical success and benefits over surgery and calling for standardization.

Bariatric embolization was the last topic of this session. A. Alonso-Burgos delivered a lecture opposing embolization in obese patients, cautioning that obesity is a complex and multifactional problem, that embolization alone might not be enough in these patients, and will become less relevant with new alternatives on the market. R. Oliveira, though he is a bariatric surgeon, spoke in favour of bariatric embolization. He called for a multidisciplinary approach, but displayed the advantages of a minimally invasive procedure as a first option as opposed to bariatric surgery, which it does not preclude.

Scientific paper sessions – embolization

Two scientific paper sessions focused exclusively on the results from embolization trials, registries, and studies this year.

A session called “Embolization across the globe” included reports on several areas of embolization from a widely international group of researchers on topics such as the use of glue in PAE, small particles for bronchial artery embolization,  transcatheter arterial embolization with quick-soluble gelatin sponge particles, and more.

The session “updates in embolotherapy” Also saw talks on embolic particle size as well as the four-year follow-up of the LATION registry and interim results from the Gaucho trial, among others.

Beyond these, several more scientific paper sessions, while not wholly focused on embolotherapy, did include presentations on embolization topics. These included, “Experimental work in IR,” “Giant steps in GI IR,” “Cutting edge in gynaecological interventions,” “Bone, spine and soft tissue,” and the session on urinary tract intervention.