So for TCAR I think it's probably
worth considering in all CAS patients. I think there are some that are more likely to benefit than others. So clearly the unfavorable arch the older patients the ones that have a lot of disease at their art vessel origins even though it
may be a type-1 arch if there's a lot of disease there and clearly in symptomatic patients. So we have really embraced this in our practice and we're now up to you know sixty-eight patients some in the initial trial ROADSTER 2 is the ongoing
trial. There's now some that this is an approved device so there are commercial patients that can be done as long as they're high risk and symptomatic as defined by CMS. And the proof really is in the filters. So when you do these
cases and you cut the filter open at the end I think it is very impressive what actually comes out of these carotids. And I would venture to say that some of the baskets that we used in transfemoral cases with an embolic filter this would
overwhelm the filter if it got... if it you know... if it was being done with a distal protection device. And just remember that stuff unfortunately does get by these filters and so it's a little bit sad but I think it's the
proof is in the pudding...alright you saw it. So I want to talk a little
another example you can see the arrow is pointing to the blockage and after doing...in 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.
a big intervention. Ok different EKG. 48 year old with new onset chest and jaw pain. Anybody see any abnormalities. Yes we got some ST segment elevation
1 and aVL a little bit in v2 and v3 maybe a little bit in v4. The difference here of course is you see it in a lot of leads. And that's that sometimes confusing but it's the greatest magnitude that matters. So
indeed it's the lateral leads that we're seeing those changes in mostly. A little bit in the anterior not so much in these lateral leads. So what vessel. Actually it is also the LAD but it includes a very large diagonal. So we see
the lesion here. Left main circumflex LAD this is a septal perforator. And we see a very tight stenosis. It is not occlusive. And so we take a long wire long balloon. And we make that look like that. And fortunately we've got some... this is a really
small vessel. It's a really funky little little vessel. Very typical of a diabetic. Seventy-eight year-old female presents with
of that. So in someone who is not having new symptoms or if you mean from a safety standpoint.
No there's no...you can do it...you can do an MRI immediately after from a safety standpoint. There are...it'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 trial...it 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 Microvention...my 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 mean...so 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.