Varices, Ascites, Cholestasis, Hepatic Ischaemia | Splenic Embolization | 45 | Male
Varices, Ascites, Cholestasis, Hepatic Ischaemia | Splenic Embolization | 45 | Male
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Second case is a 45 year old male with Hep c, varices, ascites, encephalopathy classic, underwent liver transplant. Now this patient developed worsening of LFT's as well and the transjagular liver biopsy was neged rejection again. However there was cholestasis and ischemia.

So this patient also underwent a doppler ultrasound, and what they found here was an elevated resistant index at .88. And they had trouble finding the hepatic arteries. This slide here, I basically outlined the classic ultrasound doppler findings.

So we're looking for increased hepatic arterial resistance waveforms. And abnormally high portal venous flow as we just kinda gonna show in that chart of how much it increases. They could not find the left hepatic artery. This is the best they could do.

And the waveforms are not convincing. The right hepatic artery also they were not able to definitely identify it. This is the best they could do for arterial waveform. So on that basis this patient was suspected of possibly having this hypoperfusion syndrome

related to the transplant. So here we are on angiography once again classic findings we barely seen any perfusion of the liver. We see a markedly in large splenic artery, marked splenomegaly. Here we embolize with coils unfortunately this wasn't carried out long enough to

show you the level of perfusion. So, fortunately we have some additional imaging. Clinically this patient did well. The LFT's stopped their upper trend and on ultrasound we find that the resistant index of the main hepatic artery is significantly decreased at this point. 0.8 is resistant in excess thought

to be a threshold for this kind of syndrome. And here they'll definitely find the hepatic artery. Here is the interior branch. We've got a a nice arterial waveform. They'll find that posterior

branch in the left hepatic artery, all of which were undiscernible previously. So, this this is kinda nice one week post intervention evidence that there's actually improvement in flow.

you're going to see obvious signs of external bleeding end-organ or extremity ischaemia a pulsatile hematoma or internal bleeding with shock...the hard signs Soft signs are diminished pulse location or proximity to an injury or an artery or

some degree of neurologic dysfunction that might potentially be due. These are kind of our clinical signs that we use in immediate examination of a patient. Venus injury generally low pressure dark blood external bleeding non

expanding hematomas and shock is rare and less associated with an arterial injury. But major venous injuries either pelvic or abdominal can present with the with some really profound symptoms. We look at blood

vessel areas partial lacerations transections contusions pseudoaneurysm or external compression. Usually those patients are the ones that have femur fractures or dislocated knees joints that can basically once

they're reduced or fixed these orthopedic injuries you'll get improvement in circulation almost rapidly. Asking should I take the patient to the operating room or do further investigations? Any patients with

the following signs should not wait. Any external bleeding obviously expanding hematoma with shock or limb ischaemia. Hospital-based iatrogenic trauma you see it with venous central venous access hematomas local or central guidewire

puncture of innominate vein SVC or right atrium. Arterioles obviously we do that all the time in the cath lab with our diagnostic and therapeutic angiograms with catheterization. You can get pseudo- aneurysm arterial dissection and

thrombosis distal embolization leading to basically limb ischaemia and of course AV fistula formation. Pseudoaneurysms - walled-off extra luminal circulation of the blood as a result of arterial wall destruction can occur also

due to shrapnel injuries in the battlefield but very commonly we all see these in the cath lab. Moving a little bit fast through this. We use conservative management for smaller sizes. Ultrasound-guided compression and

then of course duplex directed thrombin inejction and surgery. Want to show you an interesting case we have here as well. Pseudoaneurysm indications for surgical intervention ongoing bleeding limb ischaemia nerve compression anything to

need aggressive anitcoagulation or threatened skin viability and a pseudoaneurysm surrounded by large hematoma. Here's an example of a large pseudoaneurysm that's caused skin

compromise. Community-based trauma. Not dissimilar in certain sense. More knife penetrating and gunshot wound injuries and impaled objects blunt trauma or associated with a lot of orthopedic and neurologic injuries. You have an open

book pelvic fractures you have thoracic- aortic transections from MVAs from rollovers and they can be obviously more often multi-system. But once again we see this a lot in the battlefield as well particularly where it relates to soldiers driving

an uneven terrain the mountains of Afghanistan the deserts of Iraq. These vehicles are unstable with very heavy bases and a lot of these civilian type trauma vascular injuries and nonvascular injuries

we've seen in the battle is well. And that's why we've worked closely in concert with our civilian counterparts to improve these trauma outcomes. Extremity vascular injuries 10%

So let's look at some images related to trouble with access. So for many people

their first cases is their first exposure to flow diversion are going to be their toughest cases. And these giant cavernous aneurysms are routinely and reliably our toughest cases. We have an inflow here

this big sack where coils and wires and catheters just flopping around. And then somewhere in this nebulous region is the outflow. So you have to fish your wires around to find an outflow which is oftentimes stenotic. So it can be an

incredibly labor-some task. Can take hours. I've had several cases that the operator was unable to get the outflow and had to abandon or abort the case because of this. So this access can be an enormous issue. Here we'd spent several

hours trying to get a wire across this sac into that outflow. We were unable to do so...could never get it to engage. So we took a large compliant balloon inflated the balloon in one catheter in the aneurysm sac to help kind of pin and

deflect the wire and then we're able to deflect the wire around the catheter get it into the outflow and then track microcatheter over it. There we are with the microcatheter out of the MCA branch so internal carotid

anterior cerebral middle cerebral artery. We have a catheter tip out here. So here's another example of a giant cavernous aneurysm with a very technically challenging access. We were able to get the wire out but we were

never able to get the catheter to track over the wire into the outflow tract of the aneruysm. So in here we actually took a balloon over the wire inflated the balloon in the distal outflow and then use that the pin the wire so

that we could then track the catheter over it. Once we've got the catheter in place then we can pull back to reduce the redundancy of the catheter in the aneurysm sac to give us that straight shot.

So obviously some concern about inflating the balloon and the vessel and using that as an anchor. Obviously opportunities for parallel there. So here's another giant cavernous aneurysm. Here lateral view cavernous aneurysm

middle cerebral artery branches. So here we are after we've deployed the device we've removed the device construct. So the microcatheter...so when you deploy this device you deploy...you unsheath it over a wire and then you track the

microcatheter over the wire through the stent over the wire to recapture that distal wire. And that's how you keep your microcatheter access. The microcatheter is 0.27 so a pretty big microcatheter. The wire that stent

deploys over is 0.08. So much much much smaller than the catheter. So it is very technically difficult sometimes to get that catheter to track over that wire. If you don't...if you can't get that catheter to track of that wire you

lose access. Which can be a big deal and this is an example why that's a big deal. I don't...can you guys see that. So there's a device here that goes from here to here. There's a device that goes from here to here. Unfortunately what it

looked like in the beginning was a device that went from here to here. So this portion was the inflow of the aneurysm when we removed this distal wire in the catheter this proximal portion herniated into the aneurysm sac.

So now we have a stent that goes from here to somewhere in here in the middle of this giant aneurysm with no connection to the inflow and no ability for us to access that stent from the inflow. So this is an example of how

we're talking about needing to go from somewhere else. This patient had an intact anterior communicating artery. We went from a...we put another puncture in the left leg went up with another catheter into the right internal carotid artery.

Put a microcatheter in the internal carotid artery anterior cerebral artery across the anterior communicating artery in this anterior cerebral artery down this internal carotid artery. Put a wire into

the aneurysm sac through that stent so now you have a wire through that stent into the aneurysm sac coiled up. And then we went with a loop snare. So now we have a microcatheter with the loop snare we've snared that wire so we have a catheter

with the snare attached to a wire that comes out this. And we call this the flossing technique. So by combining a pull push technique we're able to jimmy that catheter over that wire... whoops...into so now we've

straightened the system out and then now we have that wire. We removed... we've taken out the snare. We removed this wire and we placed a wire out this MCA. Now you'll notice one of the other things techniques that we use is that

this 0.27 catheter can house two microwires. So we have a 0.14 and 0.10 wire out for extra support so this catheter will track out. We get into the MCA and then now our device is being deployed. And that's what it looks

like again. So now we have one device two devices much more redundancy here much better coverage of the inflow and that's what the aneurysm looks like at the end of the case. So deployment...this is a self-expanding

stent it's very supple. It's is very soft it takes turns very well and opposed walls very well. But the downside of that is that it doesn't have a strong impetus to open. So we see flattening we see narrowing of the stent. So it is entirely

possible to have a device like this that goes from here to here where the midsection is severely narrowed. Now when you do an angiogram at the end of this procedure the vessel is going to look fine. But what we know is that when you

bring that patient back in six months the vessel is going to look like the stent. So we have to do something to make this stent more open or the patient's going to have a severe stenosis when we follow them up. So in this case we've

gone back through that device with a balloon...a compliant balloon...and you can see the compliant balloon opens up. We still...after this inflation...you can see still significant residual stenosis. So another example of issues related

to deployment. This is a middle cerebral artery bifurcation aneurysm here. You can see on the CAT scan image a enormous calcified largely thrombosed aneurysm. So that the lumen of the aneurysm is actually a very small part of the actual aneurysm

itself. What we know about this is with coiling...when we coil aneurysms like this they very commonly recur. Almost all of them recur because the coils just insinuate into the clot it regrows you recoil them and that happens over

and over and over again. So there was...a decision was made it to Pipeline this case. You can see the device being deployed. So here's that distal wire. Here's the device unsheathed and here's the catheter here. When we got to

the end you can see that the device doesn't want to open on the proximal end. And so we have the device open and here we are right here the device is pinched down where the catheter is. So multiple attempts to get that distal....that proximal

end open didn't work. Catheter was...the wire wasn't moving. There was no way to get this device open. It was elected to leave the device like that. This is what the initial run after removal of the wire looked like. You can see

maybe a little bit of clot. We waited over time and  you can see over time the inside of that device completely clotted. So it's very important that even if the initial imaging looks ok with these devices if the device doesn't look right

something down the road is going to happen. And this is a prime example of that. So the vessel thrombosed. Over time you can see complete thrombosis of the MCA trunk related to the vessel. This is what the MCA look like. So this is the anterior

cerebral artery which continues to fill. This is the middle cerebral artery where you can see a large portion of the exception of this branch here is absent. That patient obviously did not do well. And then this is what we're talking about with

recapture. So when we take our microcatheter which is right here through our device we take that over an O.08 wire. So there is a a big step off between the catheter and the wire. So when you push you can scrape the vessel wall

and if you push too hard you can puncture the vessel wall. So this... this case in an attempted to pass the catheter into the device there was a significant amount of resistance met at the proximal margin of the stent. The

vessel ruptured and this patient being treated for cavernous aneurysm ended up with a CC fistula. So this is a basilar artery here.... basilar artery apex aneurysm. Previous coil material in here recurrence of the

aneurysm. The decision was made to flow divert this. Again an off-label use of the device. You can see deployment of the device across the neck of the aneurysm. But when we removed the wire the distal end of the wire was not with it. So the

distal end of this wire had broken off. This was more common with the first generation we don't see it as much anymore. But you can see here...here's a native image flow diverter in place we now have a microcatheter with a loop

snare. Here's a lateral view you can see the loop snare engaging the wire tip and removing it. This is a patient who wasn't as fortunate. So here the catheter engages this wire...

so here's your catheter tip here's the wire they were never able to get the wire quilted into the catheter....it got kind of stuck or lodged at the tip of the catheter so they decided just to remove the whole thing in total.

And as they pulled the wire back through the stent...so here's your stent here in the cavernous internal carotid artery...as they pull the stent through here the wire broke off...as they pull the wire the wire broke off. The

wire was stuck in the stent. Here they are trying to remove the device...the distal wire with a alligator snare. You can see they've engaged it with the alligator but the alligator was too flimsy to pull it and it kept breaking off.

So they elected just to leave it. And you can see the immediate post-procedure run with the wire remaining in along the wall of the stent. And when they brought the patient back in six months the aneurysm was gone and the wire was still there. So

there was no clinical sequelae of this despite the fact they had to leave the wire. So and then finally touch up. Once

treated with TCAR and is that where carotid stenting has gone. I'm not sure that's the right answer but clearly in many patients it is because with transfemoral CAS

you've got arch manipulation leading to new DW lesions and are some of those strokes. Well clearly if you see them on MRI they're a stroke even though they're asymptomatic but is neuro cognitive decline a real issue and I

would tell you that it is. So there are more and more papers coming out that say these essentially asymptomatic hits are not good for the brain. So here's the a little data on TCAR. The ROADSTER trial was the U.S. IDE trial looking at at TCAR.

So it's a prospective single-arm multicenter trial 14 sites were in the US and obviously we were one of them. Using the transcarotid neuro protection system. Pivotal trial enrolled a 140 patients... sorry

18 sites..Some they were symptomatic and asymptomatic patients. This was a high surgical risk trial so not acceptable risk only high surgical risk is defined by CMS for all of the other chronic stent trials. And then we looked at

30-day stroke death MI. And again to cut to the chase the numbers are very very low so these are the best numbers that have been seen in really any carotid stent trial. So this is the intention-to-treat group

which 141 there was 5 patients that really fell out per protocol. So if you look at those the numbers are even better. But even if you focus on the entire group that was treated stroke and death was 2.8% and

that's lower than any other stent trial carotid stent trial out there at this point. So is this the new bar for carotid stenting and is this were we now are. So here are the high-risk patients seen for endarterectomy and carotid stenting

in the SVS data or the Society for Cascular Surgery database. So carotid endarterectomy is somewhere around 3.6% carotid stenting is almost 5%. Here's the trials on standard surgical risk were still

higher than our ROADSTER data of 1.4% for stroke. 12-month outcomes in patients who we think are even higher risk. So if you look at age 75 there were no strokes no deaths

excuse me no minor strokes death here so stroke and death rate of 3%. So quite a bit lower than the high-risk group seen for SVS and the other trials. And then the symptomatic patients who we all think have these lesions that are

probably at higher risk were even low. Octogenarian. So the patients who have those bad arches clearly have increased neurological events and more DWI lesions seen in these older patients as documented in the number of trials. And

here's why. So we get and we get more elongated arches with more calcium and increased risk of embolic events. And as you see as we get older look what happens to the type of arch. So the nice flat arch that we all want to

see for transfemoral stenting just keeps getting less and less and more and more of these type 3 elongated arches that are more difficult. But again TCAR data for octogenarians and symptomatic patients was actually quite good. So

again here's the question what's happened. Should all patients with carotid lesions be treated with TCAR. And I would tell you that all of these femoral stent trials as the technology has gotten better we've gotten better

at all of these things. So even from the groin I think carotid stenting is not a bad procedure at this point but I would venture to say that TCAR is probably a little bit safer. Again not going through all of these data but if

you look at the numbers TCAR the early data with ROADSTER you know this is right in the realm of better or at least equivalent to some of the of the transfemoral stents. And I would say that ACT 1 is probably the

important one to correlate this with. But remember ACT 1 are acceptable risk patients and these are all high-risk patients. So to have the equivalent numbers I think is impressive.

everything we talked about. Flow diversion I do think...I use it I get to watch a lot of people use it...I think that is a very promising technology. I think that it is the first device that's

been put in my hands that's allowed me to offer a cure for endovascular aneurysms which is the major selling point for open surgeons to continue to be able to clip aneurysms. I think that in the current iteration of

these devices there are still significant pitfalls...technical pitfalls that we have to learn that we have to overcome and certainly technical pitfalls related to the device and the aneurysm disease process itself that

still make the complication rate something that we need to pay attention to in our decision making. So for right now coil technology is still a very strong technology still very commonly used and they're obviously aneurysms that

coil technology is still ideal for use. I think as our technologies grow we're going to see this application used more and more. Flow diversion is also now....so the next generation of flow diversion is looking

at limiting some of these complications. But there's also flow diversion technology that we call intra-sacular flow diversion which is taking this sort of technology and instead of putting it intraluminally...which is inside the blood

vessel...you actually put mesh inside the aneurysm. So it's for aneurysms that can't tolerate intraluminal flow diversion like ruptured aneurysms bifurcation aneurysms aneurysms that we see that we just don't

want....aren't effectively treated with flow diversion right now. So questions for me about any

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