Bronchial Artery Bleed|Embolization |24|Male
Bronchial Artery Bleed|Embolization |24|Male
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gentleman with cystic fibrosis presented with four days of persistent lung copomostacis, CTA was done and quite prominently see a bronchial

artery in general you can see an enlarged bronchial artery that's abnormal on imaging the common dogma being if you can well see a diagnostic catheter at least that's my teaching to my trainees that's not normal, and obviously this is a high approach of fever in large bronchial artery. This patient went on to angiogram and you can see a selected catherization

and then on the next image micro catheter placed further out distally and used a moderate size PVA practical thrombolization to try to moderate the bleeding.

of that. So in someone who is not having new symptoms or if you mean from a safety standpoint.

No there's can do can do an MRI immediately after from a safety standpoint. There's an MRI safe device for 1.5 and 3 Tesla. And you can do it immediately. I don't routinely get...I used to get MRIs

and all these patient at three months to make sure the aneurysm was shrinking to make sure it wasn't getting pressurized and running the risk of rupturing. I stopped doing that. So I don't routinely get MRIs now unless they have symptoms afterwards. But

they're safe to have it right away. Both very good questions and we were talking a little bit about that before. I have used a Surpass. I haven't used the FRED. So the Surpass and the FRED are the two that we have access to here

through trials. The Surpass is stiffer. It's got more strands. It delivers through a larger catheter but my limited experience within and in speaking with other people it opens up more reliably. So it's

tougher to access its tougher to get to the places that you need to get to and start the deployment but the deployment seems to be less finicky than with this device. I have heard nothing about the outcomes of the Surpass trial as it

relates to FDA approval and that sort of stuff. I know it took them longer I think to get enough devices to be for the took a longer time. The FRED you can only put one device in for FRED. And I think the FRED which is Microvension...

So the Pipeline is Micro- vention...or Medtronics. FRED is Micro- vention and Surpass is Striker. So those are the three companies right now that kind of have a hand in flow diversion or intramural flow diversion.

The FRED from understanding is that opens up fairly similarly to the Elvis which is their regular stent but you can only put one in. So they they're not using multiple stents which I think is it is an

enormous limitation of that device. And I again I don't know the outcomes from that. And then I think from the peripheral standpoint I think there are applications particularly for renal artery you know visceral aneurysms and

torturous devices in torturous locations. It's a I think a pretty ideal flexible stent that that you can preserve vessels and you don't put coils in. I know there's some research into looking at for AAAs. And I

think just from a theoretical standpoint think that would be a harder device to work for AAAs because of all of the the vessels that are attached to the sac of the aneurysm. I think leads to much more complicated physiology

with something like that. Other questions? Thank you guys so much for having me.

another example you can see the arrow is pointing to the blockage and after this case we just did suction thrombectomy. You can see that the configuration of

the clot mirrors the bifurcation. And that's what we pulled out with suction thrombectomy and this patient also did very well. The unique thing about this patient is that four days ago the patient had

CABG for symptomatic coronary artery disease. So when the patient was discovered in the morning 15 minutes prior to discovery with stroke symptoms she was fine. Talking moving everything. 15 minutes later somebody

walked in she was doing nothing. Couldn't move couldn't talk. So we couldn't give her tPA because she post surgical. The risk would be unacceptable. So we brought her in and this is what we found and we did aspiration thrombectomy and that's

what we pulled out. And she went from a stroke score of 22 which is very severe for a stroke score of 1 the next day. So again examples that show that we now have a very effective way to treat ischemic strokes. The key here is that it

needs to be timely identified. And that's that's what you know it's still a work-in-progress nationwide but now we have technologies to treat these people that improves outcome and decreases mortality.

treated. 77-year old guy comes in with slurred

speech. Left side of the face left side of the arm they're both weak. Patient was last known well sometime at night and has hypertension cholesterol. Has had a history of heart attack and heart failure takes Plavix.

There is a standardized way of assessing these patients symptom severity and that's called the NIH Storke Scale. It goes from 0 to 42 points and this patient's number of points is 12. And it's an under-representation of the severity of

the patient's symptoms because the way you measure this is weighted for right sided symptoms rather than left sided symptoms. Anyway the patient gets IV tPA to thrombolyze because if the patient came in

within a three to four and a half hour window. He was eligible and he got tPA. The tPA reduces the disability score from 12 to 9. It did not decrease any further. Why is that. Well it's like saying that the kitchen fire extinguisher should be

able to be as equally effective as a fire truck that comes to put out a very massive fire. Small fire in your kitchen can be handled by the kitchen fire extinguisher. But if you have a building on fire that kitchen fire extinguisher isn't

going to do anything. So in this case the way to think about this is the clot is big for what tPA can be expected to handle. So the pointer is not working and I don't think you can see the arrow. But the circle on the picture that shows

the CT scan of that patient's brain is dusky within the circle compared to other areas. Dusky brain is brain that is ischemic. It is on its way to die unless you do something. The scan on the other side with the arrow

pointing to is the blockage of a blood vessel that supplies that area of the brain. So if you can open up the blockage in a timely fashion you can prevent that dusky brain turning into completely dark brain which means it's dead brain.

Ok so people have looked at this and said okay tPA is a good medicine its FDA approved for patients who come in with stroke symptoms of who don't have bleeding in the head who could be having ischemic strokes. It works. But just like

the example that I used it can't be expected to be effective for every clot size. And that's that that's what the figure shows. ICA MCA Stem MCA division and MCA branch are all different distances from where the carotid bifurcates. Ok.

The farther out you go in the blood vessels branch the smaller it gets. Which means a small clot will cause a small branch to be occluded but not a large branch to be occluded. So therefore if you have a small clot in a small branch

tPA has a better chance of breaking that clot up than a large clot which is stuck in a more proximal branch. And that's intuitive. But somebody actually looked at those numbers and they said well you know what what we thought

turns out to be true. If you give tPA to all comers with ischemic stroke it has a less than one in three chance of being effective and opening that blood vessels. And if you look at the location of the blood clot to where

the branches as you go farther out into smaller branches and block that blood vessel and then give tPA the more effective tPA is for the smaller clot than it is for the larger clot. So that's intuitive and that's what this study shows. So this

explains why maybe the gentleman who came to our ED...77-year old man...didn't fully respond to tPA. So if this were about 12 years ago we would have used the device that's on the left called MERCI device. It's like a cork screw on a

catheter end of a wire end which is fed through the catheter to the area the blockage and you engage the clot and you pull it out. As you move along the timeline more and more devices started to become available for thrombectomies.

So the next device is Penumbra. You've heard that device in the previous talk. And it has that little separator wire that's got a little bulb which distrupts the clot mechanically as the other catheter goes up and down which is

connected to a suction device. They were effective but by the time they actually open the blood vessel that didn't seem to make a whole lot of difference. Not as effective. Patients didn't do all that well despite having spent the time. So the

field continue to work towards something that was more effective in opening up blood vessels. Then came 2011 there abouts when 2012 two devices came out that are both called stent retriever both Solitaire and Trevo and the picture is

what you see. It's a collapsible stent that you cannot leave. It's not a detachable stent that you advance against the clot beyond the clot and unsheath. And engage the clot so that you can retrieve the whole stent back.

And when you retrieve it back you find that the clot has also been retrieved. Ok so there are two devices they're both FDA approved. And there is now overwhelming data that mechanical thrombectomy is very successful and

effective in opening up these large vessel occlusions. There's one more device that has since undergone a iteration in development and that's the Penumbra 5MAX ACE and there are few additional devices. They're nothing

more than if you think about it like a Dyson vacuum cleaners. it's a large-bore aspiration catheter that you go ahead and park in the face of the clot turn on the suction canister which is connected to this

aspiration catheter and you engage the clot with this vacuum and the aspiration catheter. Wait a few minutes and then retrieve the clot back. So with these new technologies we have actually seen great improvement in how

we can benefit our patient. So what we did in the 77-year old gentleman is you can see there is that arrow showing on this side of the screen where there is blockage. You see that the central blood vessels fill but the ones going

towards the side of the screen the MCA branches don't. On the other side where there's the circle that's the lateral view showing that the branch is going to the top of the head fill but the ones going towards the side of the head

right over here they don't fill. So in this case we went ahead and deploy a stent retriever. I can't remember whether it was Solitaire or Trevo it was one of the two. And the red line on that image outlines where the stent is spanning

between from the distal end to the proximal end where the clot is. After five minutes we removed the stent retriever and what you see is fragments of clot that are brought back. And now that blood vessel that was included is

fully open as you can see where the arrow shows. And the circle outlines what was missing its now fully filled in. So this gentleman comes back to see me in clinics a month later. Walking in no deficits. How representative is this

of the results that we saw in the trials. There were five major trials. Now there are more that have all shown that somebody who comes in has a large blood vessel occlusion like this gentleman did if you treat them in this fashion

there is a roughly sixty to seventy percent chance that they will be independent after such treatment. Previously the independent score was at best high thirties. So this is a big revolution in the way we treat the

ischemic stroke patients. Now there are other this is not just a one-off there may be such examples that we see daily. You have a blood vessel here that's the carotid artery and it stops at the skull base.

Beyond that there is no blood flow. So we use not just a stent retriever but a combination of stent retriever and aspiration catheters and after using these devices in multiple passes were completely able to open up that blood

vessel. Ok. What this patient was left with was that area that's demarcated in a circle that's all the stroke that he has. And he actually walked out of the hospital. And what we pulled out is laid out on

the bottom and those are the different clot fragments each time we did this procedure we recovered. And it measures several centimeters actually. So again this patient also went some from very high disabling numbers to actually no

deficit at the time of discharge. Here is

world problem. And stroke is very much a problem in the US. And this is us...and the more purple we are the higher the risk

of death stroke. And though these numbers are from census data from 2007-2009 this purple color and intensity of this purple color has not changed. This map has really not changed. So this tells us how serious this problem is. And we need to

do everything we can to identify patients quickly and get them to the right place so that they can get the right treatment. So this is a cartoon that lays out what we're dealing with when we talk about different types of stroke. This is a

blood vessel cartoon which is blocked up. And when either it's blocked here or the blockage breaks off and occludes an artery in the brain you have a ischemia and infarct. And you have an ischemic stroke. Hemorrhagic stroke in this

cartoon there's an aneurysm that ruptures and blood leaks out in the brain and now we have a hemorrhagic stroke. But they're not fifty-fifty in disease prevalence. We have way more four times more ischemic disease than

hemorrhagic disease that contributes to stroke. But they're both equally important for obvious reasons. If you suffer a stroke the number...the amount of disability that you have is very severe. It is the leading cause of

disability in the U.S. We spend about 80 billion dollars...80 million dollars...every year paying for various aspects of stroke care. So it's it's a problem that's very important to all of us. So talking about ischemic stroke one of the key things

in our minds we are dealing with this is where did the clot comes from. Did it come from the heart did it come from the aortic arch did it come from a plaque that's sitting in the carotid bifurcation or is the

intracranial vasculature already at atherosclerotic and becoming norrow and forming an in-situ thrombus. These are just some examples and the prevalence of this is in this chart. The vast majority of them...more than a third of

them...we still don't know where the clot comes and that requires a lot of investigation on the back end when the patient is admitted. One-in-six are because of carotid disease. One-in-five because of a clot that forms in the

heart or somehow gets to the heart. And one-quarter of them are because of very small blood vessels that are getting smaller and smaller due to long-standing issues like high blood pressure diabetes cholesterol and smoking. And there is still

a fair segment where you don't really know why they had the stroke. So ischemic stroke is not one disease. Its causes are varied. And based on symptoms timing how they present that all goes into your thought process as to how you're going to treat

them. Ultimately regardless of where the clot came from the problem that you're dealing with that time is ticking away when the brain is suffocating for oxygen and energy. This is an example of a brain that is

got ischaemia and infarct. The dark areas are areas of the brain that are dead. So when this patient comes to the emergency room and can't speak and can't move part of the brain is already dead. What we're trying to save by attending

to the patient in a timely fashion is the areas and various shades of blue from turning into dark. So we're trying to penumbra. Okay. The most striking way to think about it is if there is something that's on fire

there's already damaged that's happened. What you're trying to prevent is the damage from spreading further and becoming irreversible. Same idea applies here and each minute that passes where the brain does not have

oxygen is a problem because you're losing two million neurons each minute that you don't have blood flow. And the brain ages for every hour that it's not reperfused about four years. So this is a very

important concept because time is brain. And that's what we're trying to do to save when you're trying to reperfuse these patients with various technologies. So here's the case. Somebody that we

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