Degeneration (Lumbar)|Percutaneous Facet Fusion|74|Male
Degeneration (Lumbar)|Percutaneous Facet Fusion|74|Male
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4 grade of Pfirrmann in L5S1, with discogenic and facet pain, with failure of medical and physical treatment.

And we choose another type of screws, dynamic screws. Not for fixation, but we put the screws under the facet. It's composed by a titanium anchor and a polyurethane stabilizer. The access kit is very similar to previous, but the technical is

a little bit different because we put the access needle, Kirschner wire, dilators, and the tap, and a countersink to create a space for the screws. But when we put the anchor and the stabilizer, we put the screws under the facet. Not to fix them, but to obtain a push up,

a superior push up of the facet and to limit the hyperextension. Then we repeat the procedure on the other pedicle. This is the final position of the implant, and the CT check. We can appreciate

the difference. Here the screws is under the facet not through the facet, as the case before, and the CT check confirms the correct implant of the screws. We also evaluate patient in the study with a two-year follow up.

We had a good reduction of pain evaluated by means of VAS score, and functions by means Oswestry. So we demonstrated that Percudyn system was a good of the things that I found with this device is that when you have finished putting the

device in about 25 to 50 percent of the time there's something else you need to do to make that device look better. We know that devices that don't oppose the perforator branches are going to

cause perforator strokes. We know that the vessel is going to look like the stent and six months. So if you have narrowing of the stent you need to get it to open so that there isn't flow limitation and that and also so that you

don't have blockage of perforated branches. I've seen a couple cases of people who didn't heed that advice and left the stent not well opposed at the level of the anterior choroidal artery and had anterior choroidal artery infarcts.

So the wall opposition is a very important component of this and so touch-up becomes an important part of our procedure. As you can see's a patient we put overlapping stents in for a giant cavernous aneurysm and

immediately after deployment of the second stent you see this little area of filling this is thrombus forming in the stent immediately post procedure. And we went back up with the microcatheter gave intra-arterial

Integrellin and started them on Integrity drip and you can see the clot dissolves right away. Here's that same patient at four months. Aneurysm's almost completely gone with a little tiny bit of the aneurysm

still feeling from the infralateral trunk. So here's another example of poor opposition. So here's your cavernous aneurysm...ophthalmic segment here...the you can see a wasting deformity at the level of the ophthalmic artery with poor filling

of this segment. And you can see this big sac pseudoaneurysm that the ophthalmic is coming off. So you don't want to leave that because if you leave it one of two things is going to happen. Either the aneurysm is gonna stay open because it's

going to continue to shunt through that vessel or that ophthalmic artery's going to shut down you can potentially have an ophthalmic artery stroke. And you can see why that was. So here here we do a CT...a Dyna CT which is this a CAT scan that we can

actually do on the interventional table. We do it with dilute contrast so we can see the vessels very well. And you can see this lays out the opposition of the device very well. So here we have one device and you can see

the inside the second device and there is a step off between the two. So there's significant overlap there. And you can see that again here. So we went back up with a balloon at that level inflated a compliant balloon which is a very safe

way to open up these devices...the devices aren't stiff devices and they open up very well even with compliant balloons and then we're done. You can see the lumen of the stent looks much better and we take the run. You can see that that

pseudoaneurysm outside of the vessel is not there in the ophthalmic arteries is connected or opposed to the stent and open. So those are the technical

all our cases with TCAR I'm going to show you the last case here which is a 75 year old who had a previous left carotid endarterectomy for an asymptomatic stenosis with a patch. He had a laryngeal nerve palsy which is one of the things

that clearly stent buys you advantage with with no laryngeal palsies. And 18 months later came back with a high-grade asymptomatic recurrence that you see here. But a nice looking flat type 1 arch which was then done in the GORE scaffold

trial. And I just show you this because remember i told you this is a membrane covered stent and people were worried about preserving flow to the external. But it really actually looks very nice when it's done. So here's my answer.

Thank you very much Michael for giving me this opportunity and thank you everybody for having me it's a great honor to be here. So again I'd like to thank you for your patience and attention and restructuring the schedule today so thank you.

So I want to talk about some of the key things that we do in the neuro world. Neuro world is about two broad concepts. If there's a blood clot you want to get rid of it. If there's a blood vessel abnormality that is either at risk or has caused

hemorrhage you want to trying and take care of it. So the talk is going to exemplify many different cases that fall in one of these two categories. And when this happens...either the blood clot or hemorrhage... you really have a stroke. And the sooner

you can treat it the less disability the brain suffers. Because time is brain and stroke is a neurologic emergency. ...It's not on....can you hear me now... Okay well let me say stroke is a neurological emergency and the two categories of

strokes that fall into that are ischemic and hemorrhagic. So I'll be presenting different examples of cases that we deal with and these run the gamut and I've tried to highlight by picking cases that exemplify what we do. So both

ischemic and hemorrhagic strokes are brain emergencies. And recent studies have shown that an ischemic stroke you can actually revolutionize patient's outcome by selecting patients and using modern technology to treat

them. Intracerebral hemorrhage is no different and Dr. Gaughen actually set the stage for aneurysms as being an example of that. I'll show you some cases there. It's important to recognize that you don't

stop the subarachnoid hemorrhage when it comes to hemorrhagic disease you also have been intracerebral hemorrhage. And there are multiple underlying vascular abnormalities that actually cause our intracerebral hemorrhage and it's

important to be vigilant and pay attention and pick up these entities that you can treat. So stroke is a

let's move forward along the timeline of

brain aneurysm treatments. So the first brain aneurysm was effectively treated in 1933 by a physician of the name of Dot who went in did a craniotomy and surgically wrapped material around the aneurysm. The first durable treatment

was by Dr. Dandy in 1938 with an aneurysm clipping. So these are open surgical approaches where we do a craniotomy we find the aneurysm which is a weakness in the blood vessel the balloons out like a water balloon they disconnect that

aneurysm from the blood vessel with a clip. Now that remained the mainstay of treatment up until the 1990s. 1979 was our first endovascular aneurysm treatment it was the Serbeninko balloon which is a detachable latex

balloon that we could either put into the aneurysm sac or into the vessel to occlude the vessel. 1990 was when many people believe that the world of neuro interventional surgery actually began and that was the first coiling

case worldwide of a cerebral aneurysm that was done at UCLA. And since that time a lot of the technological improvements in aneurysm brain areas of treatment have revolved around coil technology. So the GDC or

Guglielmi Detachable Coil was FDA approved in 1995. The neuroform sent got HUD designation meaning that the neuroform stent which we use for stent assisted coiling was approved in 2000. We started to

develop data in the early 2000s regarding the outcomes of endovascular aneurysm treatments. So the ISAT the International Subarachnoid Aneurysm Trial came out that showed that aneurysms treated endovascularly...

ruptured aneurysms that were treated endovascularly in the short-term did better than aneurysms treated surgically. We had balloons that were developed for the technique of balloon remodeling where we take a balloon up across the neck of the

aneurysm inflate it put coils into the aneurysm sac while that balloon's inflated then detach the or then remove the... balloon deflate and remove the balloon. And that allows us along with the stents that we develop ways to treat wide neck

aneurysms that coils wouldn't stay in. So over this 20-year period we were developing ways to increase the number of patients that we could treat endo- vascularly with coil technology and its adjuncts. And then the first alteration

in that pathway was the development of flow diversion. In the United States that was Pipeline. The Pipeline embolization device was FDA approved in 2011 for treated treatment of large and giant unruptured intracranial aneurysms in a

certain part of the brain. And it was heralded as a disruptive technology. Meaning it is a technology that's completely different than coil technology for treating brain aneurysms. So the rest we're going to talk about

flow diversion. Like I said we have one FDA approved device. In Europe we can experiment on patients much more haphazardly. So we actually have a number of devices there that are approved for use including the

Silk the Pipeline the Surpass the FRED. There are actually a couple others. The Surpass and the FRED are currently under FDA trials right now to gain approval in the United States. We have not gotten there yet. That data should not be too far down the

road. So what is the purpose of these

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