Common Iliac AAA | rEVAR (Aorto-Uni-Iliac), Fem-Fem Bypass, Balloon Angioplasty | 78 | Female
Common Iliac AAA | rEVAR (Aorto-Uni-Iliac), Fem-Fem Bypass, Balloon Angioplasty | 78 | Female
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This is a 78 year old lady with a known AAA now growing to about 6 cm diabetic,

hypertensive, and COPD. Again these guys with COPD have a higher rupture risk. Obviously we wanted to recommend repair. This is an older case but I think it shows some good points. Here's the inferior aortic aneurysm. This is a chrono mep/g showing basically ectatic or aneurysmal

common iliacs, and not probably projecting as well but she has very small calcified iliac arteries. Torturous as well. So this a lady where I think she had a reasonable neck but her access vessels were an issue. So we brought her to

angiography. This is back in the day when we did open growing exposures. You can see this huge large common iliacs. Her neck isn't horrible but it's not perfect certainly do able. I believe this is just a 8 French sheath that's inclusive. This is her externally iliac.

Very small iliacs. So our goal is to pass the main body from the right groin. This is our endo-conduit technique where we put roughly in an 8 French sheath and either 7 to 10 mm iCAST depending on what we think we need. Just a balloon expandable stent.

Inflation that's our post picture, I believe this is an 8 mm iCAST. We are able to preserve the internal here but our main body went to the past to the groin set, left to

plan B. So we turned our attention to the left groin which I felt was the worst groin, we went to the right thinking that it would work. And again this is an older case where we were using what we thought was the slickest endo-graph at the time it was a metronic that was probably one of the lower profile cases of that year.

So we attempt to do the same here. In this case we thought that the iCAST was actually interfering with passage of the stent so we angioplasted with the external iliac with the 8 mm balloon. A little big certainly for this lady but we needed at least something in this ball park of calibar to get our graft up,

and then we found this. I really wish I hadn't seen any of this but I was thinking other things when I din't save the run, but this is- >> So you tell me when you balloon a 4 mm vessel with a 8 mm

you think it would drop? >> Sometimes if they seem to rapture in the classified little old lady [LAUGH] yeah. >> [INAUDIBLE] from the endovascular it's like there's a 5 mm external that ballooned to 10 and then raptures, I was like >> Yeah I shouldn't be surprised. I will say that whenever we do these things you want to expect things like this, the iCASTer was already ready to go.

We partially expected this. This is the unsubtracted image. Amazing how quickly blood pressure can drop when you have an angio like this. >> Did you put a stent quickly? >> No no I just talked about it, we're just talking about it.

>> [CROSS-TALK] >> So next up, a couple of options for us generally is sslamming the balloon back up there and then making sure you have iCAST. This is iCAST stenting right across here and then we had control and the patient was responding very quickly to this.

She didn't really actually require too much pressure support though her blood pressure did change. So then we wanted obviously continue with our EVAR and this is a large graft this is 2008 probably but we thought it was the smallest graft at the time and then we completed our endovascular repair and we telescoped it basically into the iCAST that we delivered,

and this is how she looked when we were done. This a CT post EVAR. She dropped her crane/g obviously and this again it's how amazing how quick she bled but she was stable so she was watched in the ICU for a while, I do believe she received two units of blood post

procedure and what would I do differently, I think there's a lot of options now, this is eight years later and we've talked about the trivascular we talked about the even the enduring as much more low profile the GORD now goes through a 16 French sheath, but also a short

discussion about adjunct devices such as the SoloPath in addition to adjuncts procedure such as the endoconduit. The S Terumo SolaPath generally allows us, initially is for TAVI I think that's where it got more popularity and TEVAR but all that stuff has come down a profile,

it's a very interesting system. I used the first and second generations, the second generations are obviously a lot better. Basically it's a balloon dialator that allows you to expand a nitinol braided stent,

right now now a nitinol braided sheath and allows you to deliver larger systems, and they come in a variety of sizes. Actually not in every size you may want. I think the biggest is the 23 French or 24 French, but again it allows you to get some other difficult cases done.

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

I think carotid stenting is here to stay maybe not in the same iteration that we talked about 4 or 5 years ago where everything was transfemoral...it's the only way we could do it. But I think it is here to stay and it's an exciting time

to be in the field. So thank you very much for the invitation and I'm happy to answer any questions. Thanks. Leading question. And sure the answer is yes. It will be different so i think it's

not just the arch though I think once you get past that and get into your carotid clearly you've got a lot of other steps but you know Magellan and the catheters are going to allow us maybe to use proximal protection.

Which i think is a big piece of it not just getting there but if you believe that proximal protection you've protected the brain before you cross the lesion is also a big piece of it. So we'll still need to if you're going to

use a filter you're still gonna have to go through that lesion. So. Yeah. Great great question. And so and out of all of these patients we've not had a stenosis at the access site. And you know

it's still in the common carotid so we can see it with duplex. So yeah. And then all of the stents and everything are the same so that data is out there and those stents are performing well. Alright. Thank you.

devices and the term we use is flow diversion. And it's it's kind of a muddy terminology that we talk with flow diversion because flow diverters are stents. They're braided metal mesh tubes

just like any other stent we use. But they don't do the things that most other stents do. They act to some degree as a covered stent but as you can imagine in the brain with the brains tortuosity covered stents are way too stiff. And because

of all the perforator branches that come off all the vessels in the brain any covered stent that's placed there has about a hundred percent risk of perforator stroke. So we had to be very creative about the technology that we developed.

The flow diverters work in two different ways. The reason we don't use the word stent apparently is because the FDA or CMS won't reimburse for the use of stents in treating aneurysms. So we've muddied up the terminology when in

reality these are really just self-expanding stents that their major property of the stent is flow diversion. And so the stent does one of two things. I'm going to use the term stent to recognize that that's not an

approved term used with this device. But that's what it is so I'm going to call it a stent. So flow diversion. So the idea is that you have enough metal mesh covering the opening of the aneurysm that blood can't get through

those cells into the aneurysm and it diverts flow away from the aneurysm. And enough flow is diverted that the aneurysm doesn't shut down right away... you don't want to shut down right away... it shuts down slowly over time. And so we

look at outcomes from aneurysms at three months or six months or a year when we're talking about outcomes from this aneurysm. But there is not an expectation that this aneurysm is going to be completely gone when you finish.

And that's a paradigm change for doctors that treat aneurysms because with coil technology you want that aneurysm to be gone when you finish coiling it. And so little bit of a change there but flow diversion is the major property. And then

over time that tightly woven stent acts as a scaffolding for re- endothelialization of the blood vessel. The lining of the blood vessel growth through and over the stent and over time between the flow

diversion which causes aneurysm thrombosis and the re-endothelialization of the stent we can actually cure aneurysms. And it's actually pretty cool technology. So the indications for flow diversion...this is very important we won't be talking

about any off-label use of this device although recognize that a significant amount of the aneurysm that we are currently treating with flow diversion are done off-label because the on label uses a very small one...and

that is adults with large or wide large or giant wideneck aneurysm...so that's 10 millimeters or greater....with a neck that's four millimeters or greater in the segment of the internal carotid artery that goes from the petrous segment

to the superior hypophyseal segment. Those of you who are estute enough to notice the superior hypophyseal segment's actually not a segment it is a the last...the super hypophyseal artery is the last artery comes off the ophthalmic segments of the

internal carotid artery. But the segment is the petrous carotid artery to superior ophthalmic or the superior hypophyseal artery. So that means posterior communicating arteries carotid terminus AComs MCAs...the majority of the aneurysms

that we see are excluded from the on label use of this device. It's contraindicated in patients that are have infections. Importantly is contraindicated in patients who and whom dual antiplatelet therapy is either

contraindicated or not tolerated. So we consider people who have ruptured brain aneurysms people who cannot currently tolerate antiplatelet therapy. So if you treat a ruptured aneurysm with a Pipeline or flow diverter you're

treating them off label. And then patients who haven't received anti platelet therapy or people who have pre-existing stents. So people who have already had a stent assisted coil in the past are not on label candidates for

Pipeline. So it's a very small patient population statistically compared to the number of aneurysms that we see. But that's the on label use of the device. So the Pipeline device...again the one that we have available to us in the United States...

it's a braided bimetallic stent it's twenty-five percent platinum seventy-five percent chromium cobalt. The 25-percent that's platinum is a 25-percent you see. So when I show you these images

things that you see are the Platinum. So one out of every four strands you see. Interestingly enough this actually isn't completely accurate there is about 5% nickel. So patients with nickel allergies who are smart enough to read about this

device will find out that there's a potential that they have adverse reactions related to this device. I've had a couple patients with nickel allergies and have not had problems with the device. The Pipeline is 48 strands

some of the newer devices that we're looking at like the Surpass are higher strand densities. The Pipeline gives about thirty to thirty-five percent surface coverage over the opening of aneurysm and they have very very small

holes. If you look at in a real-life it looks like a little piece of rolled screen. Very flexible very as you can see here it takes turns and curves in a very flexible fashion. This is an older

generation but it's a self-expanding stent that's constrained. The newer generation does not have this little coil that constrains the device and it's just like any other self-expanding stent it's opened through unsheathing. It can be

deployed through an 0.027 catheter. So very small catheter....much smaller catheters than any of the cervical self-expanding stents. Similar in size of the catheters that we use for other intracranial stands like the Neuroform

the Enterprise and Elvis. And that's all we're going to talk about with the specifics. Now let's start looking at

bit about some other options though because it's not all just about TCAR. So this is the arch that we all want to avoid and this is what they look like

and why we get scared about going through those. But there's other options so you know Dr. Vingen talked about radial access for most things well why not for carotid stenting. Access site complications are one of the

most common adverse events after CAS from a femoral approach. And most technical failures when you go from the groin are related to a complex arch. So why not try and take the arch out of the issue and if you can do a carotid stent like this

like we did last week it's pretty nice. And the patient's really like being stuck at the wrist instead of in the groin. So you know there's all kinds of guides and catheters that can be use to access an arch

the access to carotis. So here's obviously a right radial approach going down into the innominate and then back up into the carotid. You've avoided the arch. And so you can you know put a stiff wire in the external so that you can get support to

get your sheath in. And then before and after. You can go here i would say you're not avoiding the arch but what if you had a patient that had bad a aortoiliac disease and didn't have femoral pulses and you need to go from above to get to

the arch. You can go from the right side to the left side and so right wrist or left wrist access is possible. And here's one coming from the left side going up the right side. So I think you can do this safely we have enough good radial

access sheaths at this point. And certainly the devices have gotten small enough that you can put an EPD and a stent in through 6 Fr and even sometimes 5 Fr systems without too much trouble. So wrist access clearly

this is kind of the same list that Harlin showed. So there are advantages. Clearly bleeding risk is minimal anticoagulation is not an issue I think you do have some reduced costs and I think outpatient performance

who knows maybe we can at some point. But there are some disadvantages. So most of us unless you're a cardiologist don't have much experience do radials. And so I think there is a learning curve if you have a type one arch

maybe it takes a little longer to do it from the wrist than the groin but that's a toss-up. This is the issue. You can't use proximal protection in larger devices. So I think if you believe truly in proximal

protection and if you have a lesion that you know a symptomatic lesion that looks ugly and you really want proximal protection so again you don't want to cross it with your filter before you treat it

this is probably not a great idea. And there is a radial artery occlusion rate of about 10% when you look through the literature so I think it's feasible and it can be safe. It's easy access in some difficult

anatomies. It does eliminate some issues. So to end I'm going to show you just a

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