Pulmonary Arteriovenous Malformation|Embolization|32|Male
Pulmonary Arteriovenous Malformation|Embolization|32|Male
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All right, so we talked a lot about bronchial embolization and now we're gonna shift gears and talk a little bit about pulmonary embolization and this is just a pretty straight forward example of a 32-year-old male who occasionally had epistaxis otherwise asymptomatic, he actually was a really active guy in fact run 10K's.

Clearly you know what I'm describing as the patient with HHT which this gentleman had and he came to our center because his sister was diagnosed and she had had epistaxis didn't realize that she had pulmonary BM's, got screen, got a CT, had pulmonary BM's, we treated and embolized her and she said I think my brother has this he

lived a couple of states away. And so she made him go get a CT scan, sent it to me, sure enough he had multiple pulmonary VMs including this one which was, you can see it's a pretty sizable one has a pretty big venous sack to it. So he came in for embolization. In this particular case it was pretty high flow and so we chose

to use the anchoring technique which I'll talk about more in just a second where we went to in adjacent branch with our catheter and that's where we started deploying our coils in order to prevent a none target embolization and this is what it looked like in the end where we just packed a whole bunch of coils, this was a really

Really, really high flow lesion and was able to get it completely occluded. So I don't wanna make this a big didactic on pulmonary VM's or anything so I'm just gonna hit some of the highlight. Pulmonary VM types there's really three types, there's the simple

type which you have a single artery, single draining vein just like the one I just showed you where the artery is coming down and it's going out into the vein and you may or may not have a venous sack aneurysm with it. Here's just another example single draining artery and sometimes

you'll even have multiple draining veins on this so it's not really the venous side isn't what's is important as the feeding arteries are. [BLANK_AUDIO] You can have complex AVMs in which you have multiple feeding arteries going out to these lesions and this is just again,

a diagrammatic illustration of what that would look like. These can be a little more challenging to treat, but unfortunately the majority of pulmonary VMs are simple. Here's just again, another example of a complex pulmonary VM. You can just see all these little feeding arteries within the pulmonary

VM. And then finally, the diffused type, which is the type we typically see more often in children and it kind of has this very unusual appearance is very diffusive appearance and these are just tiny, tiny little

fistulas throughout the lung parenchyma and these can be on the segmental lobe level or they can even be low bar level. So the key to successful embolization these lesions is to embolize close to the AV connection as possible and if you're using coils you wanna make sure that your coils are packed as densely

as possible. So this again and excuse my poor artwork, it is what it is. [LAUGH] But so this is, kind of what we don't wanna have happen. You put your catheter down, you get close to the Av connection,

you put your coil out and you're feeling good and then all of a sudden your coil leaves and takes off and next thing you know, your patient's had a big stroke. And so, there are some things you can do to avoid this and one of the techniques is the one that I just showed you earlier where you do the same

anchoring technique and you go into a little side branch near the ABF connection, and you start your coil there and then you coil back into the fitting artery and this will, by starting your coil on this other little branch it will stabilize the deployment.

Here's just another example. This is an older gentleman again had a very large, very high flow AVM. He didn't actually have a branch that was quite as close to the AV connection as I would have liked and it was a little

too torturous to get out there with a vascular plug or anything like that. In him I ended up having to embolize a little bit more proximally but again you can see starting the coil and the branch vessel and then coming back into the feeding artery. This is what that patient looked like post-embolization and the

reason why we want to be as close to the connection as possible is we worry about reperfusion on these lesions. They can occur in up to about 20% of cases. There was a study out in 2005 that looked at about 100 patients and found that the risk of reperfusion are gonna be based on the feeding artery diameter,

the number of coils whether the coils were over sized, proximal coil placement. Kind of the upshot is you need to have your coils as close to the connection as possible. You need to pack them in as much as possible and generally you need

to use more than one coil. Now the question comes do we retreat these? And I think this is a good one for discussion because, so say you have a patient like this,

where you've got flow going through this feeding artery but yet, you're not gonna have really significant clot that's gonna get through this coil, so what's the risk to the patient by not retreating?

I've got my own opinion but I'll like to hear from Steven Bill in terms of what they think on something like this. >> [INAUDIBLE] I agree theoretically it is kind of filtered but also could be an [INAUDIBLE] of thrombus where you see that flow and [INAUDIBLE] desirable situation [INAUDIBLE] >> Steve. >> Yeah, I agree, more and more of these given any small connection, I think it's important to shut it down, if we're worried about passing through [INAUDIBLE] >> Right and you take a case like this where you actually have a fairly lengthy vessel,

that's Unprotected distal to your coil and so I think it's within reason that thrombus could actually form distalLY to your coil pack and embolize as well. So I think my stance has always been along with those that if I see this I still treat it even though I don't really know what the risk long term is by leaving these untreated.

[BLANK_AUDIO]. So to prevent reperfusion people talked about using different embolic agents and then there's some technique, things that we can also do to try to prevent reperfusion. When we talked about different embolic agents one of the ones that

has become very popular in treating pulmonary VM's is the implant's vascular plug and more recently there's the MVP vascular plug that's been released that I haven't really seen any data on and pulmonary circulation but certainly looks interesting but you can see the data's pretty sparse, fairly small studies 2011 was one of the

early studies looking at the AVP plug and they had one recarnalization after 36 months. Scott went back later and added a coil using the AVB and had no recarnalization, that's really the technique that I followed is essentially deploying the plug putting the coil behind it and that seems to be sufficient.

>> What about the [INAUDIBLE] system have you done for all that? >> For the AVPs? >> Yeah. >> So in terms of how we do our selective catherization we tend to use the white set which is a 7 French guiding catheter with with a 5 French multipurpose catheter with no 38 lumen,

so we'll use that to get as close to the AV connection as possible, occasionally have to use a micro-catheter but it's pretty unusual and then we'll put an AVP for it which will go through an 038 catheter through that and do our embolization. How are you doing anything different than

that. >> Yeah, I don't use plugs primarily, I use mostly master coils, sometimes plugs if it's really central [INAUDIBLE] the problem is if it's a bigger one the fluid goes on to a separate lumen, so you've got one where you're oversizing [INAUDIBLE] then it works >> Right, so you can use the seven french guiding catheter to deliver an AVP 2. The problems I run into are

particularly if it's a more distal one and you have a little bit of vessel tortuosity is they don't always detach. You kind of just build up torque in the releasing wire, and I've had a couple that I've tried to use and then I've had to pull it

out because it just wouldn't release, which kind of makes me uncomfortable. >> [INAUDIBLE] I like to use this for a lot of tortuosity [INAUDIBLE] I like to use a lot of them, even though they are expensive. >> Yeah >> The other thing when I first started using the plug

[INAUDIBLE] you just inject right after you place the plug where it has occluded, often times I often found ourselves using a coil behind it- >> Yeah I usually would just go ahead and head and as part of my standard practice go ahead and put a coil and behind it but you are right even with that usually will end up waiting a good couple of minutes before we do our follow up injection because plugs really don't do anything for at list two or three minutes. [BLANK_AUDIO]

So this is just showing an animation format using the plug. Again you put your catheter down as close as you can to the lesion let's see if this would work. The plugs deployed by withdrawing the catheter. And then again I tend to put a coil pack behind it and here is just been an example of a patient that we treated with

a plug. You can see this left lower lobe pulmonary VM. It's that same patient I showed you earlier she had a pretty diffuse pulmonary VM. Sometimes if you have a lot of time you can go into some of these individual connections but typically

we'll end up just treating this more proximally I don't know what you do with the complex once. >> Sort of a little bit depends on if the patient has multiple lesions and if that's the only lesion you can do whatever you [INAUDIBLE] If a patient has multiple [INAUDIBLE] can try not to knock out as necessary- >> And some of it depends on where the feeding arteries are arising so if you have a feeding artery that's coming off fairly

proxmimally and then the mouth formation is down here, then I'd be more inclined to go into the separate one. But if it's something like this where all the feeding arteries are coming of pretty peripherally then we are inclined to just do with a single embolization. And here is just a video showing us

releasing the plug it's a little hard to see. But again just unsheathing that and this was using the AVP2. And then again we put a coil back behind it. This was an early follow up. Before we had occlusion. [BLANK_AUDIO]

and then she was breathing a little bit but this vessel we finally got stasis on this vessel and interestingly after we occluded this one, we found another separate pulmonary VM, that was adjacent to it, then we went it and we put in a bunch of coils.

Probably more coils than we typically use. This is another more recent case of a patient that's got this right lower lobe pulmonary VM. We almost missed it on our initial NGO. [BLANK AUDIO].

We got more selective, deployed our vascular, plug and this is just showing us detaching it by, you can twist it counter clockwise again it feels like eternity and it takes about ten seconds. Deployed our coil, and this is what it looked like in the post and you can see we had complete occlusion.

The other thing to keep in mind is that some times technique can help reduce the risk of recanalization and there's been a couple of studies that have looked at venus sack embolization for these lesions. First described in 1966, and then another article came out in Japan

in 2012, but both of these articles had very very good success rates and really it's been described for patients to have large outflow vessels, short feeding arteries, this is a patient that we had at our institution that had this really very high flow, very large out flow vessel,

for a pulmonary VM and this is what, it looked like on CT. And so, in this particular case it had actually a fairly short feeding artery and we went in and we started in the venous sack and placed some very large coils and then worked our way back across the connection.

So that's for some of these that are really gonna be very tricky, and you don't have a lot of room to work, if you do have a venous aneurysm then that's also an effective technique. Okay any questions about the pulmonary VMs? Yes sir.

>> Which [INAUDIBLE] regimen do you recommend in absolute? >> So we heparinize all of our patients before we do, the embolization with just with standard heperine as long they are not allergic and I do not routinely put them on anticoagulation after the embolization. >> [INAUDIBLE AUDIO]

Well good afternoon everyone thanks for sticking around to hear me talk. It's been a real pleasure and honor to be able to do this at the request of Dave and Mike and having all of you attended is really nice. I'm going to speak about a topic that's kinda near

and dear to my heart. Over the last 10 years I've been in the Army Reserve and have had the chance to deploy to both Iraq and Afghanistan several times. And during that time as a vascular surgeon we are called upon to go as really

general trauma vascular and everything under the sun. But because of my specialization in vascular surgery I've really been able to learn a lot from these various conflicts and a lot of the trauma that that we've encountered. As

this is the AVIR meeting I'd like to include points that are more relevant to endovascular management of vascular trauma as well and how those are starting to come on the battlefield more and more and kind of depending on where

you are. Vascular trauma can be anything from a paper cut on your finger to blast injury from an improvised explosive device thats found and not uncommonly in the battlefield. We have civilian urban centres trauma

with stab wounds to the abdomen and the picture on the right showing aortic laceration. And we have vascular trauma which occurs in the cath lab with a femoral artery pseudoaneurysm as you can see on this picture. So trauma includes

you know various aspects of vascular disruption leading to potential complications of their vessel thrombosis and lack of blood flow or an aneurysm formation which can subsequently lead to either embolisation

or rupture.

we...one 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 here...here'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 defect...so 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 then...so those are the technical

last few minutes i'm going to talk about intracerebral hemorrhage. The other kind of

of hemorrhage that I showed you where the hemorrhage is in the soft tissue of the brain. Very high mortality rate. Very important to pick them up. Very important to look for an underlying blood vessel abnormality because if you do maybe you can treat it from happening again. If you don't these

patient's can re-bleed and that contributes to a very high degree of mortality. So take a look in any manner that's represented here. You have a lobar hemorrhage a basal ganglia hemorrhage temporal lobe hemorrhage a convexity parenchymal

hemorrhage. And the location of the hemorrhage doesn't tell you the underlying cause even though people used to think that it did. And up to one out of every two patients has an underlying vascular abnormalities

and this was not felt to be this high previously. That's because people were not looking for anything underneath. They thought it was due to hypertension or amyloid. So there are certain things that you can look for on the CT scan that

clues you in to there being something else underneath. Like a spot of calcium or dilated blood vessels on a CTA or a blood vessel coursing through where the hematomas is or an aneurysm that doesn't look like a star pattern bleeder or a subarachnoid bleed

but this huge pool of blood eccentric in one part of the brain. So these are just various examples that you might see that can clue you in as to there being something structurally abnormal in these scans. So here's a

patient that came to us. 76 year old man still working still very active. He presented with a seizure and when he got a CT scan you see this big left frontal lobe hemorrhage with a lot of swelling around it. We did the

angiogram we found this AVM. AVM you know is an abnormal connection between arteries and veins in an organ with a nidus that is at the crux of the vascular malformation. So this is a lateral view where you

can see branches from this artery both supply normal brain and also the AVM. So this patient came back from the hemorrhage and is now going to be treated with radiation treatment given that parts of these blood vessels supply normal brain.

Otherwise we would take it out endo- vascularly. This example is such an example where we did take it out endo- vascularly. So this is a 61 year-old gu he was a school school security guard came in with this hemorrhage. Very odd looking

hemorrhage. Had headache and some memory loss. So we did do the angiogram. We didn't find anything when he first came so we went back and look again at three months. When we did that you can see that this artery here supplies branches

and here it's actually filling early an arterialized vein which drains into one of the sinuses. You really shouldn't be seeing any of this in an arterial phase which is what the rest of the scan shows.

So we went ahead and took progressively smaller catheters and ultimately this microcatheter that we parked as close to the fistula point of this vascular malformation and from here injective a substance that would fill that connection

so you would not be able to continue... you would prevent the shunting from happening anymore thereby decreasing the risk of re-rupture again. So here is the video that should show that and here's the microcatheter and

at the end of it is glue or NBCA. And I'll play that again because it goes pretty quickly and it is that quick. In fact I've slowed this down for the purposes of the video. Here it come. And there's the glue cast which looks like what you see before we actually

embolized. And after the embolization the final rung looks like this. Where previously you had this fistula right here you no longer see it and the cast formed by the NBCA is in the location where

the patient initially had the bleed. Untreated this has a rupture...re-rupture risk anywhere upwards of fifty percent. So if you didn't look for this you wouldn't be able to identify it and treat this. And this guy who was

independent would loose his independent or his life if this were to happen again. So he's actually back in school doing his job and doing very well actually. Here's a 33-year old guy with another hemorrhage

and came in headache and weakness in the right side and some confusion. He had some funny looking features on a CT scan so we undertook an angiogram. This angiogram shows a blood vessel going to an AVM right here with pseudoaneurysms

within this AVM. These pseudoaneurysms is what ruptured. That area is difficult to get surgically so we went ahead and put in a microcatheter and did something very similar to what I showed you. So what you're seeing here is the glue

cast that's pretty much what the blood vessel looks like. And here's the 3D of the same. Here's the AVM with pseudoaneurysms. The glue cast shows you the same appearance of the blood vessel because that's what we took down. And again this video

ok the video is not going to play but effectively it shows the glue going from here to the pseudoaneurysm and filling back to this point right about here. How did that patient do. Well there is

the...you saw the rupture in the previous scan right here. Not all of it is the malformation. Only part of it is because of blood just ruptured everywhere from the AVM. So the glue cast itself is within the

crux of the AVM itself. And this is the post-treatment injection where you don't...you see very little of this AVM left at this point and we expect it might actually thrombose in due time. Here's another pattern of blood.

This is actually multi-compartment hemorrhage in the 62 year-old lady who presented with headache nausea and dizziness. She actually had an AVM with some flow related aneurysms and this was sitting right in the hematoma bed. So we went ahead

put in microcatheters...catheter through which microcatheters were advanced and coiled off the aneurysm. She also had two additional flow related aneurysms. These aneurysms are actually very malignant. They don't tolerate all

that excess flow through the vascular bed. And they are at very high risk of bleeding especially in a patient whose already had rupture. So here is the other artery that's supplying feeders to this AVM with

very dysplastic segment and aneurysms here. So we went ahead and injected Onyx...this is the cast that's left behind by that... which is within these magnified views of the aneurysm and dysplastic segment and the pseudoaneurysm. And she'd done well

after surviving the hemorrhage and the treatment and she has come back to clinic and she's contemplating getting the AVM treated. So in conclusion

Good morning. Thank you Mike. It's a pleasure to speak you all. I realize you don't get a chance to see cardiologists here very often. Great. How many of you here have done intervention with a cardiologist in acute MI? Raise your hand.

Ok so not that many. So I tried to tailor my lecture to kind of cover some of the issues that those who do do it might see and might learn and for those you who do not to interest you to come to the dark side. Which is the cardiology world. I will say

that our patients tend to really love us and so it's it's a nice thing. I'm gonna run kind of quickly because I know I'm separating you from your break. This is essentially the common thread in almost every intervention that we do in

the vascular system. And its an occlusive thrombus. It may be a embolic it may be indigenous to a lesion within the arterial system. But fundamentally this is what we're dealing with. So the I took out the slide about

disclosures to minimize the size of your handout which appears to be very large. I'm a handout kind of guy because I usually take notes. Quickly we're gonna I'm gonna try and go over the need for urgency in the acute MI. I i think it very much

correlates with the acute stroke. I'm going to review some of the options for treatment. For those of you who are not familiar I'm going to go over some of the patterns that get us to an acute MI. Some of the anatomy and then of course the

intervention. I will go over common procedural complications if we have time. But this is fundamentally what we deal

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