Introduction

Endobiliary radiofrequency ablation (eRFA) is expected to prolong stent patency in malignant biliary obstruction. However, data on eRFA combined with uncovered self-expanding metal stents (uSEMS) in perihilar cholangiocarcinoma (pCCA) are scarce.(1,2)

Aims & Methods

Aim of this prospective single-centre pilot study was to evaluate whether eRFA prior to uSEMS placement is feasible in patients with inoperable pCCA. This study included 10 patients with inoperable pCCA undergoing eRFA prior to endoscopic placement of uSEMS. Endobiliary RFA was performed using a temperature controlled RFA electrode at 7 watt, 90 sec, 75°C. All patients were followed up until death or the end of the study (after at least 12 months follow up). Primary endpoints were technical success, clinical success and adverse events (AEs). Secondary endpoints were time to recurrent biliary obstruction, stent patency at 6 months, and overall survival.

Results

Baseline characteristics are presented in the table. All patients underwent previous successful drainage with plastic stents and/or percutaneous in-/external drainage catheters. In 7 patients the procedure was scheduled electively, where in 3 patients there was an increase in cholestasis and/or fever in the days before the intervention.
The procedure was technically and clinically successful in all patients. One patient was admitted due to self-limiting bleeding after the intervention preceded by sphincterotomy. No other procedure related serious AEs occurred <30 days. Seven patients experienced transient abdominal discomfort after the procedure, sufficiently treated with oral analgesics. The median score on a Numeric Rating Scale (NRS) was 2 (IQR 0.25-3.75) after 1 day and the median duration of pain was 1 day (IQR 0-2.5) after the procedure.
During follow-up 7 patients experienced recurrent biliary obstruction caused by tumor ingrowth (n=6) or sludge (n=1) after a median of 6 months (range 1-8). Of the 3 patients with a patent stent at end of follow-up, two patients deceased after 2 and 6 months follow-up, the other patient still had a patent stent at the end of follow-up. Stent patency rate at 6 months follow-up was 67% (6/9). Four patients died after a median of 16 months (range 4-24) since diagnosis, not related to stent dysfunction.

Table. Baseline characteristics of 10 patients with pCCA undergoing eRFA and uSEMS placement

Conclusion

This pilot study confirms the safety and feasibility of eRFA in patients with pCCA. Risk of adverse events seems low and abdominal pain after the procedure mild. Randomised controlled trials are warranted to assess the efficacy of eRFA for pCCA.

References

1. Sofi AA, Khan MA, Das A, Sachdev M, Khuder S, Nawras A, et al. Radiofrequency ablation combined with biliary stent placement versus stent placement alone for malignant biliary strictures: a systematic review and meta-analysis. Gastrointest Endosc. 2018;87(4):944-51.e1.
2. de Jong DM, Fritzsche JA, Audhoe AS, Yi SSL, Bruno MJ, Voermans RP, et al. Comparison of Intraductal RFA Plus Stent versus Stent-Only Treatment for Unresectable Perihilar Cholangiocarcinoma-A Systematic Review and Meta-Analysis. Cancers (Basel). 2022;14(9).

Disclosure

Jeska A. Fritzsche, Mattheus C.B. Wielenga, Otto M. van Delden and Joris I. Erdmann have no conflicts of interest or financial ties to disclose.
Heinz-Josef Klümpen performed in advisory board for Janssen, Astra-Zeneca, and IPSEN. Received Speaker’s fee from CCO and MedTalks. Roy L.J. van Wanrooij performed as a consultant for Boston Scientific. Paul Fockens performed as a consultant for Olympus and Cook Endoscopy.
Cyriel Y. Ponsioen reports research grants from Gilead and Perspectum, performed as a consultant for Pliant, Takeda and Shire, and received speaker’s fees from Tillotts.
Rogier P. Voermans reports research grants from Boston Scientific and Prion Medical, performed as a consultant for Boston Scientific, and received speaker’s fee from Mylan and Zambon.
All outside the submitted work.

Introduction

Endoscopic or percutaneous bile duct brushing is often performed as first step to differentiate between benign and malignant biliary strictures. Although brush cytology has a high specificity (95-100%), the sensitivity for detection of malignancy has been reported to be poor (41-67%).(1-4) This results in repeated diagnostic procedures with potential treatment delay, adverse events, and additional costs.

Aims & Methods

Aim of this study was to evaluate a change in protocol for brush cytology with optimization of handling and rating, Next Generation Sequencing (NGS), and the use of two brushes plus intraductal biopsies in patients with suspected perihilar or intrahepatic cholangiocarcinoma (pCCA/iCCA). Patients with suspicion of pCCA or iCCA were prospectively included between June 2021 and December 2023. Preferably two brushes and 2-4 intraductal fluoroscopy guided biopsies were taken during the initial procedure. Cells were dislodged in a Cytolyt container within 30 seconds of which two ''thin prep'' slides were prepared. Double reading was routinely performed by at least two expert cytopathologists. NGS was performed in samples with an uncertain diagnosis of atypia. A historical cohort (January 2017-June 2021) was used as control. In this cohort a single brush was performed without intraductal biopsies. The obtained cells were preserved in a Roswell Park Memorial Institute (RPMI) 1640 medium of which four cytospins were done. Double reading and NGS were not routinely performed. In both cohorts morphological diagnosis was assessed according to the Papanicolau society of cytopathology system for reporting pancreatobiliary cytology. Both the diagnostic category ‘suspicious for malignancy’ and ‘malignant’ were classified as results compatible with malignant disease. Final diagnosis was confirmed by either histological proof of malignancy or in case unavailable, follow-up compatible with malignant disease. Primary endpoint was the sensitivity before and after implementation of the protocol; secondary endpoints were the sensitivity of the individual steps of the modified protocol in the prospective cohort e.g. the sensitivity of only the first brush and additional value of NGS, the second brush, and intraductal biopsies.

Results

In this study, a total of 167 patients were evaluated (51 prospectively and 116 historical controls). The final diagnosis was malignant disease in 153 patients (91.6%). After implementation of the protocol, the sensitivity rose to 86% (95%CI, 72.6-93.7%) versus 48.5% (95%CI, 38.7-58.5%) prior to implementation (difference 37.5%; 95%CI, 22.3-52.6%). Specificity was 100% in both groups (1/1 vs 13/13). Sensitivity of the first brush in the prospective cohort was 76% (95%CI, 61.5-86.5%). NGS was of additional diagnostic value in 3 patients with uncertain brush cytology results, increasing the sensitivity to 82% (95%CI, 68.1-91%). A second brush was performed in 37 patients; in one of these patients, the second brush had additional diagnostic value over the first brush. Intraductal biopsies were performed in 26 patients (4 benign, 9 suspicious of malignancy, 13 malignant), leading to a malignant diagnosis in 2 out of 12 patients with false-negative brush cytology.

Conclusion

A modification in the handling of cytopathology, led to a significant improvement in the sensitivity of bile duct brushes to 76% for patients with suspected pCCA or iCCA. Furthermore, adding NGS, use of two brushes, and intraductal biopsies in the initial procedure could further increase sensitivity to 86%.

References

1. Mehmood S, Loya A, Yusuf MA. Biliary Brush Cytology Revisited. Acta Cytol. 2016;60(2):167-72.
2. Kobayashi M, Ryozawa S, Araki R, Nagata K, Tanisaka Y, Fujita A, et al. Investigation of Factors Affecting the Sensitivity of Bile Duct Brush Cytology. Internal Medicine. 2019;58(3):329-35.
3. Volmar KE, Vollmer RT, Routbort MJ, Creager AJ. Pancreatic and bile duct brushing cytology in 1000 cases: review of findings and comparison of preparation methods. Cancer. 2006;108(4):231-8.
4. Weber A, von Weyhern C, Fend F, Schneider J, Neu B, Meining A, et al. Endoscopic transpapillary brush cytology and forceps biopsy in patients with hilar cholangiocarcinoma. World J Gastroenterol. 2008;14(7):1097-101.

Disclosure

Jeska A. Fritzsche, Esmée Smit, Otto M. van Delden, Frederike Dijk, Arantza Farina Sarasqueta, Sybren L. Meijer, Anne M. Uyterlinde, Mattheus C.B. Wielenga, IJsbrand A.J. Zijlstra, and Joanne Verheij have no conflicts of interest or financial ties to disclose.
Paul Fockens performed as a consultant for Olympus and Cook Endoscopy.
Geert Kazemier reports research support and travel fees from SAS Analytics and research grants from KWF, ZonMw, Cancer Center Amsterdam Foundation, and Bennink Foundation outside the submitted research.
Heinz-Josef Klümpen performed in advisory board for Janssen, Astra-Zeneca and IPSEN, and received Speaker’s fees from CCO and MedTalks.
Cyriel Y. Ponsioen reports research grants from Gilead and Perspectum, performed as a consultant for Pliant, Takeda and Shire, and received speaker’s fees from Tillotts.
Roy L.J. van Wanrooij performed as a consultant for Boston Scientific.
Rogier P. Voermans reports research grants from Boston Scientific and Prion Medical, performed as a consultant for Boston Scientific, and received speaker’s fee from Mylan and Zambon.
All outside the submitted work.

Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with malignant distal biliary obstruction (MBO) is associated with a 75-94% technical success rate and up to 3-18% pancreatitis rate.(1-5) Endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) potentially results in higher technical success without the risk of pancreatitis. However, currently available prospective studies regarding EUS-CDS instead of ERCP used self-expandable metal stents (SEMS), while single step lumen-apposing metal stents (LAMS) may simplify the procedure and improve outcome.

Aims & Methods

Aim of this single-centre prospective pilot study was to assess the effectiveness and safety of EUS-CDS using LAMS as primary drainage strategy in MBO. Patients with a proven MBO and bile duct diameter of at least 12mm who required biliary drainage were included, excluding patients with gastric outlet obstruction. Patients underwent EUS-CDS using a 6x8mm LAMS. Primary outcome was technical success confirmed by a cholangiogram. Secondary outcomes were clinical success, defined as 50% decrease of bilirubin or relieve of symptoms after technical success without re-intervention, procedure time, adverse events (AEs) and re-interventions within 6 months.

Results

Overall, 22 patients were enrolled (median age 69.5 years [IQR 64-75.25], 7 male [32%]). The majority was diagnosed with pancreatic ductal adenocarcinoma (n=20, 91%). All tumor stages were included (10 resectable, 6 locally advanced, 6 metastatic). Patients had a median bile duct diameter of 16 mm (IQR 13-20) and median bilirubin level of 225 µmol/L (IQR 130.75-335.25) prior to the intervention.
Technical success was achieved in 20/22 patients (91%). In one patient the stent was unintentionally placed in the cystic duct requiring a successful second EUS-CDS procedure. In the second patient the stent was maldeployed in the bile duct wall and ERCP was performed in the same procedure. Median procedure time was 11 minutes (IQR 7-16). Clinical success was achieved in 18/20 patients (90%). In the 2 remaining patients adequate biliary drainage was later achieved after additional placement of a double pigtail stent (DPS) through the LAMS.
Except for the described endoscopically treated perforation, no periprocedural adverse events occurred. Eight patients (36%) experienced a possible related adverse event within 30 days after stent placement. Six patients developed cholangitis which was considered stent dysfunction. One patient had mild intermittent abdominal pain which resolved after placement of a DPS through the LAMS and one patient developed rhabdomyolysis and kidney failure of unknown relation to the procedure which completely resolved. One patient died within 30 days due to fulminant disease progression which was considered unlikely related to the procedure.
Eleven patients (55%) experienced stent dysfunction within 6 months, presenting with either cholangitis (n=10) or jaundice (n=1). In 2 patients cholangitis was sufficiently treated with antibiotics while 9 patients needed a re-intervention.

Conclusion

The present study supports the safety and feasibility of EUS-CDS using LAMS as the primary drainage strategy in patients with MBO. However, the high incidence of stent dysfunction currently limits the use of EUS-CDS with LAMS solely as a valid alternative to ERCP with SEMS.

References

1. Bang et al. Stent placement by EUS or ERCP for primary biliary decompression in pancreatic cancer: a randomized trial (with videos). Gastrointest Endosc. 2018 Jul;88(1):9-17.
2. Paik et al. EUS-Guided Biliary Drainage Versus ERCP for the Primary Palliation of Malignant Biliary Obstruction: A Multicenter Randomized Clinical Trial. Am J Gastroenterol. 2018 Jul;113(7):987-997.
3. van der Gaag et al. Preoperative biliary drainage for cancer of the head of the pancreas. N Engl J Med. 2010 Jan 14;362(2):129-37.
4. Tol et al. Metal or plastic stents for preoperative biliary drainage in resectable pancreatic cancer. Gut. 2016 Dec;65(12):1981-1987.
5. Gorris et al. Does same session EUS-guided tissue acquisition and ERCP increase the risk of pancreatitis in patients with malignant distal biliary obstruction? HPB (Oxford). 2022 Apr;18:S1365-182X(22)00098-3.

Disclosure

Jeska A. Fritzsche, Marc G. Besselink, Olivier R.C. Busch and Freek Daams have no conflicts of interest or financial ties to disclose.
Paul Fockens performed as a consultant for Olympus and Cook Endoscopy.
Johanna W. Wilmink reports research grants from Servier, Celgene, Halozyme, Merck, Roche, Pfizer, Amgen and Novartis, and nonfinancial support from MSD and AstraZeneca.
Rogier P. Voermans reports research grants from Boston Scientific and Prion Medical, performed as a consultant for Boston Scientific, and received speaker’s fee from Mylan and Zambon.
Roy L.J. van Wanrooij performed as a consultant for Boston Scientific. All outside the submitted work.

Introduction

EUS-guided choledochoduodenostomy (EUS-CDS) with a lumen-apposing metal stent (LAMS) is an alternative for ERCP in patients with a malignant distal biliary obstruction (MBO).(1,2) The main drawback of EUS-CDS using LAMS is the high rate of stent dysfunction which leads to cholangitis and reinterventions.(3,4) Presumably, the short length and perpendicular angle of the LAMS to the bile duct contribute to the risk of stent dysfunction.(5) Therefore, the aim was to investigate whether placement of a fully covered self-expandable metal stent (FCSEMS) through the LAMS, thereby changing the axis of biliary drainage towards the descending duodenum, will decrease the risk of stent dysfunction while maintaining high technical success and low adverse event rates.

Aims & Methods

We performed a prospective pilot study in patients with proven MBO and a bile duct diameter of at least 12mm, requiring biliary drainage, excluding patients with gastric outlet obstruction. Patients underwent biliary drainage with (as first procedure) EUS-CDS using a 6 or 8 mm LAMS with a 6 cm by 8 or 10 mm FCSEMS placed through the LAMS. Primary outcome was stent dysfunction, defined as recurrent jaundice after initial clinical success, ongoing jaundice in combination with persistent dilatation of the bile ducts, or cholangitis. Secondary outcomes were technical success, clinical success, and adverse events (AEs).

Results

Overall, 27 consecutive patients eligible for EUS-CDS were enrolled. The placement of a LAMS was successful in 24/27 patients (89%), and placement of FCSEMS through the LAMS was successful in 20/24 patients (83%), in the remaining 4 patients a coaxial double pigtail stent was placed. In 2 patients there was persistent cholestasis requiring stent revision (10%), leading to a clinical success rate of 90%. No patients developed stent dysfunction after initial clinical success.

Periprocedural AEs occurred in 3 patients (11%) due to LAMS maldeployment which was solved intraprocedurally in all patients. In 1 patient this led to biliary peritonitis and fluid collections requiring percutaneous drainage, the other 2 patients recovered uneventfully. Two patients experienced cholecystitis within 30 days after the procedure (10%), one patient who also had concomitant renal failure subsequently deceased. The other patient recovered after antibiotics and percutaneous drainage. Two other patients deceased within 30 days which was unrelated to the procedure.

Table. Baseline characteristics in 27 patients undergoing EUS-CDS

Conclusion

This study showed a stent dysfunction rate of 10% following technically successful EUS-CDS with placement of a FCSEMS through the LAMS. Improving the LAMS design may reduce the rate of stent dysfunction by improving the direction of bile flow through the stent towards the descending duodenum.

References

1. Teoh AYB, Napoleon B, Kunda R et al. EUS - guided choledocho-duodenostomy using lumen apposing stent versus ERCP with covered metallic stents in patients with unresectable malignant distal biliary obstruction. A multi-center randomized controlled trial. (DRA-MBO trial). Gastroenterology. 2023.
2. Chen YI, Sahai A, Donatelli G et al. Endoscopic Ultrasound-Guided Biliary Drainage of First Intent With a Lumen-Apposing Metal Stent vs Endoscopic Retrograde Cholangiopancreatography in Malignant Distal Biliary Obstruction: A Multicenter Randomized Controlled Study (ELEMENT Trial). Gastroenterology. 2023.
3. Vanella G, Bronswijk M, Dell'Anna G et al. Classification, risk factors, and management of lumen apposing metal stent dysfunction during follow-up of endoscopic ultrasound-guided choledochoduodenostomy: Multicenter evaluation from the Leuven-Amsterdam-Milan Study Group. Dig Endosc. 2023.
4. Fritzsche JA, Fockens P, Besselink MG et al. Endoscopic ultrasound-guided choledochoduodenostomy using single-step lumen-apposing metal stents for primary drainage of malignant distal biliary obstruction (SCORPION-p): a prospective pilot study. Endoscopy. 2023.
5. El Chafic AH, Shah JN, Hamerski C et al. EUS-Guided Choledochoduodenostomy for Distal Malignant Biliary Obstruction Using Electrocautery-Enhanced Lumen-Apposing Metal Stents: First US, Multicenter Experience. Dig Dis Sci. 2019.

Disclosure

Jeska A. Fritzsche, Marc G. Besselink, Olivier R. Busch and Mattheus C.B. Wielenga have no conflicts of interest or financial ties to disclose. Paul Fockens performed as a consultant for Olympus and Cook Endoscopy. Freek Daams reports research grants from Medtronic, and received speaker ‘s fees from Medtronic, and proctoring fees from Intuitive. Johanna W. Wilmink reports research grants from Servier, Merck, Nordic and Astra Zeneca. Rogier P. Voermans reports research grants from Boston Scientific and Prion Medical, performed as a consultant for Boston Scientific, and received speaker’s fees from Mylan and Zambon. Roy L.J. van Wanrooij performed as a consultant for Boston Scientific. All outside the submitted work.

Introduction

EUS-guided hepaticogastrostomy (EUS-HGS) is a novel technique that allows internal drainage of the biliary system via the stomach. This approach may be of value in patients with duodenal obstruction, surgically altered anatomy, or in hilar strictures with inadequate drainage of the left hepatic duct by other techniques (1, 2). However, this procedure has a high technical complexity and until recently no dedicated stents were available exposing the patient to adverse events such as the risk of biliary leakage and stent migration (3). A partially covered self-expanding metallic stent (pcSEMS) with anti-migration flaps may overcome these risks. So far, the available data on the use of this specific stent is limited, and prospective studies are particularly missing.

Aims & Methods

Aim of this study was to assess the safety and feasibility of EUS-HGS in patients with an inoperable malignant biliary obstruction, with the use of this dedicated stent. This prospective single-center study included patients with inoperable malignant biliary obstruction that underwent an EUS-HGS. Patients were ineligible in case of uncontrolled coagulopathy, tumor infiltration in the gastric wall, intervening blood vessels or extensive amount of ascites. Procedure was performed with a 10cmx10mm pcSEMS (Giobor stent, Taewoong Medical). Primary outcome was safety, defined as rate of procedural related adverse events (AEs) and mortality <30 days. Technical and clinical success rate were evaluated as secondary endpoints, defined as successful deployment of the stent in the intended location and at least 50% decrease of bilirubin <14 days.

Results

Between January 2022 and July 2024, 25 patients (14 female [56%], median age 70 years [IQR 64-76]) were included. Reason to perform EUS-HGS included duodenal obstruction (n=12), altered anatomy (n=6) or failed drainage of the left hepatic duct by ERCP (n=7). In 21/25 patients EUS-HGS was technically successful (84%). In one patient the procedure was aborted due to a self-limiting bleeding after puncture of the bile duct, in one patient due to unsuccessful cannulation of the central bile duct and in two patients the cholangiogram showed previously unidentified intrahepatic strictures that precluded adequate drainage by EUS-HGS. No severe periprocedural AEs occurred. Three patients (14%) were re-admitted with presumed cholangitis <30 days after the procedure; two with undrained right-sided bile ducts for which a percutaneous drain was placed, and one patient due to obstruction of the bile duct branches by the covered part of the stent, for which an endoscopic re-intervention was performed replacing the Giobor stent by a fully covered and uncovered SEMS. Five patients died within 30 days due to fulminant disease progression. None of these patients experienced procedural related AEs. Clinical success was achieved in 18/19 (95%) patients with technical success and follow-up of at least two weeks. Six out of the 18 patients with clinical success developed recurrent biliary obstruction after a mean of 105 days (SD 80). Obstruction was caused by hyperplasia at the uncovered portion of the stent (n=3) and due to sludge obstructing the stent (n=3). Successful re-intervention was performed in all patients.

Conclusion

This prospective study shows that EUS-HGS with a dedicated partially covered stent is feasible and safe. Tissue hyperplasia in the uncovered part of the stent and sludge obstruction may compromise long-term stent patency. Larger, comparative studies addressing stent design and timing of EUS-HGS are eagerly awaited.

References

1. Pawa, S., et al., American Society for Gastrointestinal Endoscopy guideline on the role of therapeutic EUS in the management of biliary tract disorders: summary and recommendations. Gastrointest Endosc, 2024.
2. van der Merwe, S.W., et al., Therapeutic endoscopic ultrasound: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy, 2022. 54(2): p. 185-205.
3. Binda, C., et al., Efficacy and safety of endoscopic ultrasound-guided hepaticogastrostomy: a meta-regression analysis. Endoscopy, 2024. 56(9): p. 694-705

Introduction

Malignant biliary obstruction/MBO/is generally managed by biliary stenting however major following problem is stent patency. Recent studies show the advantages of endoscopic retrograde cholangiopancreatography-guided intraductal radiofrequency ablation/ ERCP ID-RFA/ as adjunctive therapeutic modality.

Aims & Methods

Aims: To evaluate the efficacy and safety of ID-RFA in terms of stent patency,symptom–free survival and adverse events/AE/.Primary endpoints–evaluating the period of stent patency and survival;secondary endpoints-assessing AE.
Methods: We performed retrospective analysis of a prospective database including all consecutive patients who underwent ID-RFA for the period July 2021 – December 2022.17 procedures in 16 patients who were unresectable or poor surgical candidates were performed followed by stenting in the study period.

Results

Endobiliary RFA/EB-RFA /catheter (ELRA, STARmed, Taewoong Medical) and RF generator system (VIVA combo, STARmed) were used in 15 of the procedures. In two cases ID-RFA was performed with Habib EndoHPB catheter/Boston Scientific.After passing a guidewire the catheter was positioned at the targeted lesion, followed by 120 s of ablation (target temperature 80°C, 7–10 W,temperature control mode)–in two to three sessions,unilaterally or bilaterally depending on the type and lenght of the stenosis verified by the proceding cholangiogram. The mean period of stent patency defined as time between the date of the procedure and the last follow up of the patient without signs of stent occlusion was 144,36 ± 89.3 days. In this period all of the patients were symptom–free with good quality of life and without any signs of cholangitis.The indications were:10 patients with CCA,two patients/n=2-12.5%/ with intraductal extension of papillary adenoma-both poor surgical candidates -one with HGD;one with HGD with intramucosal carcinoma who underwent endoscopic snare papillectomy /ESP/ followed by endoscopic ID-RFA and placement of stents,2 patients with gallbladder cancer,2 patients with bile duct occlusion due to metastasis.In 9 of the patients with CCA /90% of patients with CCA ;56,25 % of the total number/chemotherapy with Cisplatina/Gemcitabine followed with no interruption of the courses during the period of treatment; one refused chemotherapy.In three of the patients/18.75%/ we performed ID RFA in order to prolong stent patency in occluded by tumor ingrowth metal stents.The rate of the AE was 18.75%/n=3/ - 1 patient with self-limited bleeding;1 patient with postprocedural cholangitis and 1 patient with liver abcess – managed percutaneously.There were no deaths or ICU admissions. We experienced two stent occlusions – in one in patient with papillary adenoma with HGD–on day 169– managed with second session of ID- RFA followed by metal stent placement - asymptomatic up to the last follow up,the second with tumor ingrowth from endobiliary metastasis in previously placed metal stent -the patency after RFA was 116 days – managed with metal stent in stent placement

Conclusion

ID-RFA is a promising new tool which provides improved outcomes in patients with MBO both in stent patency and symptom free survival.It has many advantages – easy delivery of controlled temperature application and good safety profile.Therefore ID-RFA can be proposed as adjunctive treatment in patients with MBO although more randomized studies are needed.