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Appendiceal Abscess | Percutaneous Catheter Drainage (Transgluteal)
Appendiceal Abscess | Percutaneous Catheter Drainage (Transgluteal)
2016angledapproachavoidscathetercleancreatedeepdemonstratingflushimagingpelvicreliablesheathSIRsuturetechniquetransglutealtransrectaltransvaginalultrasounduterusutilize
An Overview of PET, MRI and PET/MRI | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
An Overview of PET, MRI and PET/MRI | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
cancerchapterdiagnosticglucosehypermetabolicmodalitiesMRINonepatientpelvicpositronscantomography
Q&A Uterine Fibroid Embolization | Uterine Artery Embolization The Good, The Bad, The Ugly
Q&A Uterine Fibroid Embolization | Uterine Artery Embolization The Good, The Bad, The Ugly
adjunctiveanesthesiaarteryblockscatheterchapterconceivecontrolembolizationfertilityfibroidfibroidshormoneshydrophilichypogastricimaginginabilitylidocainemultiplenauseanerveNonepainpatchpatientpatientspostpregnantproceduralquestionradialrelaxantsheathshrinksuperior
Ideal Uterine Fibroid Embolization Candidates | Uterine Artery Embolization The Good, The Bad, The Ugly
Ideal Uterine Fibroid Embolization Candidates | Uterine Artery Embolization The Good, The Bad, The Ugly
arterycandidateschapterembolizationfibroidfibroidshysterectomyidealimagingNonepatientpatientsproceduresparingsurgerysymptomsymptomaticsymptomstreateduterineuterus
PET/MRI vs PET/CT | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
PET/MRI vs PET/CT | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
biliarycentimeterchaptercoilcoilscontraindicationscoworkersdiameterexposureimagesimagingimplantskidneyslimitationsmachinemodalityMRINonepatientpelvicpreferredradiationradiofrequencyscannerskinstructuresthoracictissue
Treatment Options- TransCarotid Artery Revascularization- TCAR | Carotid Interventions: CAE, CAS, & TCAR
Treatment Options- TransCarotid Artery Revascularization- TCAR | Carotid Interventions: CAE, CAS, & TCAR
angiographyangioplastyarterybleedbloodcalcifiedcarotidchapterclaviclecommondebrisdevicedistalembolicembolizationexposurefemoralflowimageincisioninstitutionlabeledpatientprocedureprofileproximalreversalreversesheathstenosisstentstentingstepwisesurgicalsuturedsystemultimatelyveinvenousvessel
Case- Severe Acute Abdominal Pain | Portal Vein Thrombosis: Endovascular Management
Case- Severe Acute Abdominal Pain | Portal Vein Thrombosis: Endovascular Management
abdominalanticoagulantsanticoagulationaspirationCAT8 PenumbracatheterchapterclotdecideflowhematomaintrahepaticlactatelysisneedlepainportalPortal vein occlusion-scanstenosisstentthrombolysisthrombosedthrombustipstransitvein
Introduction to Establishing Periprocedural Screening Guidelines to reduce bleeding risk associated with Image-Guided Theraputic and Diagnostic Procedures | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
Introduction to Establishing Periprocedural Screening Guidelines to reduce bleeding risk associated with Image-Guided Theraputic and Diagnostic Procedures | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
anticoagulantscampuschapterclinicclinicalcoagulationgraduatedguidedguidelineshospitalinpatientinpatientsinterventionallabsmayomedicationsneuroNonenonvascularnursenursingpatientspracticeproceduresradiologistsradiologyrochesterspecialistultrasoundvascular
Endoleak Case |
Endoleak Case | "Extreme"-ly Obvious IR
accessaheadalgorithmaneurysmangiogramanteriorapproacharterialarterybringcablechaptercontrastendoendoleakfeedingfeeding vessel not identifiedFollow up angiogram shows a type 1b edoleakguysidentifyiliacimagingleaklimbpatientplaypuncturesheathslidestherefore planned an extension of the left aortic limbtrackingtransTranscaval approach to repair a likely type 2 endoleaktypevesselvideo
Case 6: Pelvic Fracture | Emoblization: Bleeding and Trauma
Case 6: Pelvic Fracture | Emoblization: Bleeding and Trauma
angiogramaortabottomchaptercoilscontrastcontrolembolizationextravasationfracturegoalimageimagesinjuryNoneparticlespatientpatientspelvicPelvic fracturepicturepicturesscanselectivetraumaunstable
Q&A Pulmonary Embolism | Management of Patients with Acute & Chronic PE
Q&A Pulmonary Embolism | Management of Patients with Acute & Chronic PE
acuteangiogramassistedcatheterchapterchroniccontrastdiagnosticechocardiogramembolismisisNonepressurepulmonarythrombolysistreatmentultrasound
Case 4a: Renal Trauma | Emoblization: Bleeding and Trauma
Case 4a: Renal Trauma | Emoblization: Bleeding and Trauma
angioangiogramangiographyarteriovenouscenterschaptercoilscontrastembolizationembolizeembolizedextravasationFistulagradehematomahemodynamicallyimageinjurieskidneyNoneparenchymapatientspenetratingpictureposteriorrenalRenal Traumaretroperitoneumscanspleensurgicallytrauma
Ultrasound-assisted Catheter-directed Thrombolysis | Management of Patients with Acute & Chronic PE
Ultrasound-assisted Catheter-directed Thrombolysis | Management of Patients with Acute & Chronic PE
catheterchapterekosfibrinNonerequiresstudiesthrombolysisthrombustpaultrasound
UFE and Adenomyosis | Uterine Artery Embolization The Good, The Bad, The Ugly
UFE and Adenomyosis | Uterine Artery Embolization The Good, The Bad, The Ugly
accessadenomyosisarteryaxisbifurcationcardiaccathetercatheterschaptercharacteristiccomplicationsdiameterdimeembolizationfemoralfibroidfibroidshematomahydrophiliclabsNonepatientspracticeradialsheathulnaruterine
Case- Brain Infarction | Brain Infarct After Gastroesophageal Variceal Embolization
Case- Brain Infarction | Brain Infarct After Gastroesophageal Variceal Embolization
anastomosisangiographyaphasiaapproacharrowarteryartifactbrainbronchialcalcificationcatheterschannelschapterchronicChronic portal vein thrombosuscollateralcyanoacrylatedrainembolismembolizationendoscopicendoscopistendoscopygastricGastroesophageal varixglueheadachehematemesisinjectionmicromicrocathetermulti focal brain infarctionmultipleoccludedPatentpatientpercutaneousPercutaneous variceal embolizationperformedPortopulmonary venous anastomosisprocedureproximalsplenicsplenomegalysplenorenalsubtractionsystemicthrombosistipstransformationtransitultrasonographyvaricesveinvenous
An Overview of Fibroids | Uterine Artery Embolization The Good, The Bad, The Ugly
An Overview of Fibroids | Uterine Artery Embolization The Good, The Bad, The Ugly
benignbleedingcancerchapterdiseasefibroidfibroidsgrowshysterectomieshysterectomykindsmenstrualmuscleNonepelvicportionsymptomstreatmenttumorsuterineuteruswebsitewomen
Treatment Options | Pelvic Congestion Syndrome
Treatment Options | Pelvic Congestion Syndrome
amplatzblockblockingbloodchaptercoilcoilsembolizationembolizegluegonadalmaterialsoptionspelvicperipherallysclerosantsurgicalsuturetreatingtreatmentvalvesvaricosevaricositiesveinveins
Duplex Ultrasound | Determining the Endpoints of CLI Interventions
Duplex Ultrasound | Determining the Endpoints of CLI Interventions
angioplastychaptercolordopplerduplexflowhelpfulimageimagesimagingoccludedpatientssensitivespectraltriphasicultrasoundvelocitywaveform
Balloon Pulmonary Angioplasty | Management of Patients with Acute & Chronic PE
Balloon Pulmonary Angioplasty | Management of Patients with Acute & Chronic PE
angiogramangioplastyarteryballoonballooningbandschaptercomplicationscontrastflowHorizonimageimagesluminalNoneocclusionocclusionspatientsproximallypulmonaryradiationrecanstenosisthrombustreatedultrasoundwebs
Case- May Thurner Syndrome | Pelvic Congestion Syndrome
Case- May Thurner Syndrome | Pelvic Congestion Syndrome
arterycatheterizecausingchapterclassiccliniccommoncommon iliaccompressioncongestionendovascularevidenceextremitygonadalhugeiliaciliac veinimagingincompetenceincompetentMay Thurner Syndromeobstructionoccludedpelvicpressuresecondarystentsymptomstreatmentsvalvularvaricositiesvaricosityveinveinsvenavenous
Diagnostic Criteria for CTEPH | Management of Patients with Acute & Chronic PE
Diagnostic Criteria for CTEPH | Management of Patients with Acute & Chronic PE
angiogramangiographyarterialarteriesarterycapillarycatheterchapterclassificationcurativediseasedistalflushlobesmanagementmedicationNonepatientpatientspressureproximalpulmonarysegmentalsheathstenosissurgeonsurgicalthrombustreatedtypevesselswebswedge
Case 9: Embolizing a Pseudoaneurysm Rrising from the Branch of the Inferior Epigastric Artery | Emoblization: Bleeding and Trauma
Case 9: Embolizing a Pseudoaneurysm Rrising from the Branch of the Inferior Epigastric Artery | Emoblization: Bleeding and Trauma
abdominalafibangiogramangiographyanteriorarterybruisingchaptercoilembolizationepigastrichematomainferiormicrocatheterNonepatientpseudoaneurysmPseudoaneurysm arising from the branch of the inferior epigastric arterywall
Endovascular AVF creation | Twitter Case Files SIR 2019
Endovascular AVF creation | Twitter Case Files SIR 2019
6fr venous WavelinQ magnetic catheteradvanceadvancesalignarterialbrachialcatheterscenterschaptercreateselectrodeembolizeendovascularengageFistulainsertmaturationpatientpatientsstepultrasoundveinvenavendors
Venous Insufficiency- Imaging | Pelvic Congestion Syndrome
Venous Insufficiency- Imaging | Pelvic Congestion Syndrome
chaptercompressibleevidenceflowgonadalgrayiliacincompetentinsufficiencypelvicpelvissecondarysequelaeultrasoundvalsalvavalvevalvesvaricosevaricose veinsvaricositiesveinveinsvenous
Creating a Deep Fistula | Pecutaneous Creation of Hemodialysis Fistulas
Creating a Deep Fistula | Pecutaneous Creation of Hemodialysis Fistulas
anatomicanatomyarterybasilicbrachialcephalicchapterdeepdevelopeddevicefishFistulafistulasflowforearminterventionalmedianneedleneedlesnerveperforatingperforatorprocedureradiologistradiusselectivelysuperficialtexastransposedultrasoundupperveinveinsvenous
Case 11: Bleeding Tracheostomy Site | Emoblization: Bleeding and Trauma
Case 11: Bleeding Tracheostomy Site | Emoblization: Bleeding and Trauma
aneurysmsangiogramarterybleedingBleeding from the tracheostomy siteblowoutcancercarotidcarotid arterychaptercontrastCoverage StentembolizationimageNonepatientposteriorpseudoaneurysmsagittalscreenstent
Case 1: Lower GI Bleeding | Emoblization: Bleeding and Trauma
Case 1: Lower GI Bleeding | Emoblization: Bleeding and Trauma
angiogrambleedbleedingbleedsbloodcatheterchaptercoilscolonoscopyembolizationembolizeessentiallygroinimaginglowerLower GI BleedmesentericNonepatientspicturepicturesprepscanseriesvessel
Case 1 - Non-healing heel wound, Rutherford Cat. 5, previous stroke | Recanalization, Atherectomy | Complex Above Knee Cases with Re-entry Devices and Techniques
Case 1 - Non-healing heel wound, Rutherford Cat. 5, previous stroke | Recanalization, Atherectomy | Complex Above Knee Cases with Re-entry Devices and Techniques
abnormalangioangioplastyarteryAsahiaspectBARDBoston Scientificcatheterchaptercommoncommon femoralcontralateralcritical limb ischemiacrossCROSSER CTO recanalization catheterCSICTO wiresdevicediseasedoppleressentiallyfemoralflowglidewiregramhawk oneHawkoneheeliliacimagingkneelateralleftluminalMedtronicmicromonophasicmultimultiphasicocclusionocclusionsoriginpatientsplaqueposteriorproximalpulserecanalizationrestoredtandemtibialtypicallyViance crossing catheterVictory™ Guidewirewaveformswirewireswoundwounds
TIPS Case | Extreme IR
TIPS Case | Extreme IR
antibioticsascitesbacteriabilebiliarycatheterchapterclotcolleaguescommunicationcovereddemonstrateddrainageductduodenal stent placementfull videoportalrefractoryshuntsystemthrombolysistipstunnelultrasoundunderwentvein
Pulmonary Ablation | Interventional Oncology
Pulmonary Ablation | Interventional Oncology
ablationactivitycancercandidatechaptercolorectalcryodiseaselesionslobelungmetastaticnodulepatientpulmonaryrecurrecurredresectionresidualscansurgical
Case 10: Peritoneal Hematoma | Emoblization: Bleeding and Trauma
Case 10: Peritoneal Hematoma | Emoblization: Bleeding and Trauma
activeaneurysmangiogramanteriorarterycatheterchaptercoilcontrastcoronalctasembolizationembolizeembolizedflowgastroduodenalhematomaimageimagingmesentericmicrocatheterNonepathologypatientperitonealPeritoneal hematomapseudoaneurysmvesselvesselsvisceral
Transcript

The other thing to do is in this deep pelvis,

other ways to get around bony structures is to take a transgluteal approach. The mantra for transgluteal approach in my mind is to hug the sacrum and stay below the piriformis as much as you can, in which this case demonstrates.

In order to minimize the risk of vascular injury to gluteal vessels, as well as entry into the cyatic nerves so hug the sacrum, and stay below the piriformis not quite below the piriformis here, but based on the anatomy this is where we had to go, and this allowed us to get to the small collection in the deep pelvis again, we're anteriorly, and posteriole/g [INAUDIBLE] Would

have been blocked by bone, and a variant to this technique, or an extension of this technique if you will. Is to utilize the power of the angled gantry. And as radiologists we always tend to think in 90 degrees. AP or lateral, frontal or lateral, but

we don't have to think. This gets us a little bit closer to ultrasound real time imaging we have a wide variety of angles to which you can approach lesions. With most CT scanners you can get about a 20 to 25 degree angulation. And sometimes anything within that range is enough to create a window

that avoids ball, avoids vessel, avoids bone. And so in this example that we utilize that angle again, the technique to find a window that gives us what we though was the most optimal approach to these deep pelvic lesions.

So just a series of cases really to think a little bit outside the box, how to dissection, moving things away, creating different angles and different approaches to get out some deep pelvic lesions. And thank you for your attention. I'm happy if

to take questions. Okay [BLANK_AUDIO] One last section which is the other way to get access to these deep pelvic lesions are transrectal or transvaginal approaches. Demonstrating sort of a technique that we use, an ultrasound probe cover over a transvaginal or prostate ultrasound

probe. This is the sheath of a pillow. The sheath that we affix using some elastic rubber bands. And use it in the transrectal or transvaginal approach. We gain access to give us very close proximity to deep pelvic lesions, and here's a case here demonstrating a collection behind the uterus

and to the rectum. And by ultrasound imaging you can see a needle coming in and there's our catheter finally in place, running into that colder sack behind the uterus and enter into the rectum. And the thing to keep in mind

this technique is often utilized at least the transrectal approach in pediatric patients. For the transvarginal approach, one thing to keep in mind is that the vaginal cuff is very, very, thick very muscular and certainly require some force to get through that.

Discussing this case with Dr. Agostino a few days ago he emphasized the point of minimizing the use of a speculum if you can. Because the speculum often times displaces and pushes your target further away just adding another element of challenge. So hydrodissection angled entry transvaginal transgluteal approaches.

Things to keep in mind, when you are approaching [UNKNOWN] Often times it migrate down into the pelvis. Can we have our IT, are they available? Looks like we've lost our signal here. Let me see.

[BLANK_AUDIO] Sorry about that we'll find somebody here in a moment. [SOUND] Any questions or clarifications or disagreements? >> How many of you do transvaginal and rectal drainages? [SOUND]

Do you use speculum or you do it without speculum? Who does it with speculum? >> [INAUDIBLE] >> It cannot clean and you can clean the vagina, well, you're gonna clean this rectum.

>> [INAUDIBLE] [BLANK_AUDIO] >> They're trying to find somebody [INAUDIBLE] >> Okay. Any questions regarding any of the previous discussions?

>> [INAUDIBLE] So we suture all our tubes into the skin, and one of the advantages of having a big tube, and it's a little bit of a selfish reason, but sometimes they do fall out and they fall out we're usually

on call on a Saturday night and we happen to be in the ER and when you have a tract that has been occupied by 24 French tube for several weeks, that is unblood type tract. And so I've gone down to ER, taken the tube, it's usually straight shot into the cavity,

advanced the tube without a wire without anything straight into the tract. And then the pus starts coming, coming right out. But to answer the main question I do suture directly to the skin. We've evolved a little bit,

we do [INAUDIBLE] And switch it to the disk, butterfly, start lock devices and that sort of thing for all sorts of drain/g. Nothing is as reliable as a [INAUDIBLE] Although that's as you know not 100% reliable as well. >> [INAUDIBLE]

>> No, no. We just create a mesentery, just one strike through the skin, create a little mesentery and just wrap around. >> Question?

>> [INAUDIBLE] At the time [INAUDIBLE] >> Yeah our usual protocol at the time of drainage is to evacuate everything that we can and then flush with three or four [UNKNOWN] Of normal saline just to clean things up. And then for the period of time the catheter remains,

we'll flush at least twice a day about 10 CCs. Of that 10 CCs about 5 go into keeping the catheter clear and the

positron emission tomography is the use

of a radioactive tracer in this case FD gee her fluorodeoxyglucose to assess the metabolic activity of ourselves ftg is tagged with glucose and glucose is used by our body for energy cancer cells are thought to be our Armour hypermetabolic

so if we inject FDG to our patients it goes to areas with hyper metabolic activity this area is called a hotspot and when a hotspot is noted in a PET scan its it's thought to be cancerous this is an example of a hyper metabolic

region noted in the pelvic area of the patient this patient is diagnosed of cervical cancer and what is MRI as you all know MRI is the use of radio frequency currents produced by strong magnetic fields to provide detailed

anatomical structures it is the preferred method for imaging soft tissue organs and there's no ionizing radiation present now what is pet MRI pet MRI is a combination of these two modalities instead of going to two scans using two

scanners we have one scanner that is able to obtain pet and MRI images simultaneously so why can't we just call this pet well we run through a few problems we have fdg-pet CT where it's a PET scan with low-dose CT accompanying

it and there's fdg-pet CT with diagnostic CT we're full sequences of CT is coupled with a scan and a pet MRI always has a diagnostic MRI done with it

questions comments and accusations please hello this topic is very personal to me I've had it actually had a UFE so this is like one of my big things I work in the outpatient center as well as a

hospital where we perform you Effy's and frequently the radiologist will have me go in and talk to the patient it's from a personal perspective one of the issues which it may just have been from my situation was pain control post UFE

whether you normally tell your patients about pain control after the UFE someone say we are all struggling with this yeah oh it's not what's your question is going to be okay good I'm gonna get doctor Dora to answer Shawn the question

is what do you what do we do with this pain issue you know what are you doing for the home there at Emory there you know and a lot of practices we we don't rely on one magic bullet for pain control recently we've been doing

alternate procedures for two adjunctive procedures to help with pain control for example there are nerve blocks that you can do like a superior hypogastric nerve block there's there's Tylenol that can be given intravenously which is seems to

be a little more effective than by mouth there's there's a you know it and a lot of times it's it's a delicate balance right between pain post procedural pain because you can often get the pain well controlled with with narcotics opioid

with a pain pump but the problem is 12 hours later the patients is extremely nauseous and that's what keeps her in the hospital so it's a it's a balance between pain control and nausea you can you can hit the nausea

beforehand using a pain and scopolamine patch that that'll get built up in the system during the procedure and that kind of obviates the nausea issues like I said that the the nerve blocks the the tile and also there are some other

medicines that can can be used adjunctive leaf or for pain control in addition to to the to the opioids so the answer the question is there are multiple there multiple answers to the question there's not one magic bullet so

that helped it did one of the things that I tell the patients is that you know everyone is different and yet some people I've seen patients come out and they have no pain they're like perfect and then some come out and they are

writhing in the bed and they're hurting and they're rolling all around what and I always ask the acid docs are you telling them they could possibly have you know pain after the procedure because some have the expectation that

I'm going to be pain-free and that's not always the case so they have an unrealistic expectation that I'm gonna have the UFE but not have pain what I also tell them is that the pain it's kind of like an investment right and

this is easy for a guy to say that right but but it's it's an investment the worst part the worst pain you should be feeling is the first 12 12 hours or so every day I tell my patient you're gonna be getting better and better and better

with far as the pain as long as you is you follow our little cookbook of medicines that we give you on the way home and I want you to make sure that you fill these prescriptions on the way home or you have someone fill those

prescriptions for you before he or she picked you up in the hospital and lately we have been and I see that you're there as well lots of other little tricks that are out there right and again there are all

little tricks so ensure arterial lidocaine doctor there is near alluded to and if you're on si R Connect you may it may spill over on some of your chat rooms here people have been using like muscle relaxant like flexural or

robertson with some success but just know that we don't have any studies that tell us how that's supposed to do so when i have someone that is like writhing in pain i just use everything so i do it superior hypogastric nerve

vlog and i actually will do some intra-arterial lidocaine although not so much lately i have been using the muscle relaxant but i will warn you that i've had two patients with extreme anticholinergic effects where they are

now not able to pee from that so you know where we're doing that balance act I see that you're there can I take that question here first just so we're we're doing the same thing we're using the multimodal just throwing all these

things at people and we're trying the superior hypogastric blocks but we're collaborating with anesthesia to do that right now do you all do your own blocks or do you collaborate with anesthesia we do our own blocks okay it isn't it is

not that difficult I would tell you that but again it's kind of like you know you got to do if you start feeling better and then you're like we don't really need them we'll just do it on our own okay thank you again yes what's the

acceptable interval between UFE and for IBF oh that's a your question what is the interval between UFE and IVF so if you wanted to get pregnant yeah and can you have a you Fe and then have an IVF like how long would you have to wait

wait and tell you before you can have that the IBF it I guess it really depends on the age of the patient because we know that that the threshold for which patient tend to have that inability to conceive

is around 45 years old so you know it did below the you know below the age of 45 the risk of causing ovarian failure or or the inability to conceive is significantly less it's zero zero to three percent so I would say that you

know you probably want the effects of the fibroid embolization to two to take effect it takes around 12 months for these fibroids to shrink down to their most weight that they're gonna they're going to shrink down the most I wouldn't

say you need to wait 12 months to put our nine vitro fertilization there's no good there's no good literature out there I don't believe that's your next and so I would say just remember that if you came to my practice and you said you

wanted to get pregnant I will be sending you to talk to fertility specialists beforehand we do not perform embolization procedures as a way to become pregnant there's no data to support that but if you saw your

gynecologist and they said let's do this then I'm sure they'll be doing lots of adjunct things to figure out what would be an ideal time then to for you to have IVF and if I dove not having any data to inform me I would ask you to wait a year

and what will be the effect of those hormones that they gave you if for example a patient has existing fibroids what would be the effect of those hormones that IVF doctors prescribed their patients yeah so fibroids actually

can grow during pregnancy so I would say that most of those hormones are pro fertility hormones so I would expect that maybe you can see some of that effect as well yeah alright if you have any other questions you can grab me oh

you're I'm sorry go with it okay yes we we have time I don't want to keep anybody here for that so I have a two-fold question the first one is post-procedure can you use a diclofenac patch or a 12-hour pain

patch that is a an NSAID have you have any experience with that and your next question my second part of the question is there a patient profile or a psychological profile that tips you that the patient is not going to be able to

candidate because of their issues around pain so they're two separate but we have in success sending people home that first day so I'm looking to just make it better I haven't had experience with the Clos

phonetic patch it's in theory it seems ok you know these are all the these are they're all these are non-steroidal anti-inflammatory drugs so there are different potency levels for all of them they you know they range from very low

with with naproxen to to a little bit higher with toradol like that clover neck I think is somewhere in between so we found that at least I found that that q6 our our tour at all it tends to help a lot so with that said I I don't have

much experience with it with the patch in answer to your second question the only thing I can say is there there is a strong correlation between size of fibroids and the the amount of a post procedural pain and post embolization

syndrome so there really you know we often say we don't really care too much about the number of fibroids but the size of the fibroid is is is should be you know you should you should look at that on pre procedural imaging because

if it gets too big it may not be worth it for the patient because they may be in severe pain the more embolic you put into the blood supply's applying the the fibroid the the greater the pain post procedural pain

are there multiple other factors that would contribute to pain but that's that's one aspect you can you can look at post procedurally on imaging okay thank you very much yes ma'am hi what what kind of catheter do you use

to catheterize the fibroid artery when you pass by radio access yeah so over the last three years the companies have been really very good about that so there are a few things that I without endorsing one company or the other that

you need to make sure that the sheath that you're using is one of those radial sheets a company that makes a radio sheath you should not use a femoral sheath for radial access so no cheating where that's concern you may get away

with it once or twice but it will catch up to you and you need a catheter that is long enough to go from the radio to the to the groin so I'm looking for like a 120 or 125 centimeter kind of angled catheter whether it's hydrophilic the

whole way or just a hydrophilic tip or not at all you can you can choose which one in our practice most of us still tend to use a micro catheter through that catheter although if I'm using a for French and good glide calf and it

just flips into like a nice big juicy uterine artery then I may just go ahead and take that and do the embolization if the fellow is not scrubbed in as well so thanks a lot but they make they make many different kinds like that and more

of those are to come all right I'm you can please please please send us any other questions that you have thanks for your time and attention and enjoy the rest of the living

so who are the most ideal candidates for fibroid embolization obviously I would say the most ideal candidates are patients that are symptomatic and I've told you already that 80% of black women

have fibroids but guess what only half of those will be so symptomatic that they would need to be even treated so just because fibroids exist don't mean that they need to actually be treated already so you

to actually have symptoms most patients that are symptomatic will again wait to getting treatment for like three and a half to five years but when they come we want to make sure that they're symptomatic and that they're not trying

to become pregnant and I know somebody in the audience has a question around that already so let's hold your high horses I'm coming to that how about patients that don't want to have surgery or just don't have time to

have surgery they don't have time for long recovery if you don't care if you have your uterus or not then I'm not so sure that you need to be pursuing a uterine sparing procedure okay and I'm gonna pause here to address one other

thing that it's a myth it is a myth that if you do not need to have children then you do not need your uterus I beg to differ and when we talk to women they are quite upset about this preposition that the uterus is only there for

baby-making purposes in fact there have been several studies now that have come out to say that women that have had early hysterectomy even with their ovaries in place are predisposed to coronary artery disease or

cardiovascular events we would like patients that are poor surgical candidates because if they can have surgery then they may be able to have surgery or patients that do not desire future fertility patients that have

already concerns about hysterectomy because of religious reasons or don't want to have hormonal therapy and I actually like patients that have have a have obesity because if we are able to do this procedure then they're spared

more complications related to surgery so the ideal patient then and this is a very important point said all three criteria would need to be fit that if you're a patient in order to be offered embolization number one

you have to have fibroids believe it or not you have to have symptoms that are related to fibroids and then you have to have some MRI that says that the location of where your fiber it is is causing that symptom and that these

fibroids are vascular let me explain okay and I'm going to skip this so I've been working with people for a long enough time and I've work of Julie for years I've worked with Diane and Anna and some other people for like ten years

and imagine if you're working with me for ten years you know that you're probably going to be able to do this procedure too like you're scrubbing right next to me eventually like you pick these things up what I get paid for

is not to do that and for the experienced nurses and techs that are in the room you know exactly what I'm talking about you're better than the doctors half of the time you really could do this procedure but what I get

paid for is to decide who does not even get to come on the table to get this procedure done so pay attention to this slide and these this criteria is being challenged every day and we're getting more and more data to say that this is

old information that we used to say if the uterus was like more than six months then you probably shouldn't have a uterine sparing procedure but we know that we do in embolization all the time in patients that have large fibroids

anyway but there's no data to actually give us that information most of the trials that we have and we have had a lot of them they have excluded patients where their individual fibroids were greater than 12 centimeters if you have

had an indeterminate and de metrio biopsy or you're having abnormal pap smear doing a uterine sparing procedure makes no sense so we use these imaging to really help us to determine which patients really

deserve to be treated so everybody can see that that image on the Left where it says submucosal refers to and I'm gonna try and come down so I can see these images here and you can see that there is a fibroid that is in

truck hava teri do you see that that round thing that is surrounded by the white fluid that is someone that has what we would call a type zero fibroid completely within the unit of course this is going to cause bleeding but

should this person have a uterine artery embolization or a hysterectomy Gail no this patient should have like hysteroscopic resection like a D&C and they would just scrape that thing out and then their symptoms would go away or

the patient on the right that has a normal appearing uterus and then this pedunculated gigantic thing that has bled into itself that is like a sub serosa fibroid of the extreme just hanging off on the outside now should

this patient have embolization no someone can tie a string right at that little connection and take that thing out so using our imaging to help us to decide which patients should be treated is very important or this patient who

came with Oh dr. Newsome I've been bleeding for 10 weeks in a row I have reversed cycles I have bulk I have bladder symptoms and yet they have that little dot that little black thing there that little dot

at the top that is the only place where there's a fibroid so this patient should not be a candidate for embolization either because yes they have symptoms and they have that little tiny daughter for fibra but that is not what's causing

those symptoms so it is important that we're not doing procedures on patients just because we can but because we're using our imaging and the patient's symptom to decide which patients are the best candidates for these procedures

there are advantages of this modality one there's less radiation exposure for

the patient we receive about three millisieverts of background radiation every year with one PET scan a patient can get up to eight years worth of background radiation in just one skin the only exposure of radiation a patient

gets in a pet MRI is through the isotope pet MRI has a better disease characterization especially for areas in a Patou biliary region the pelvic areas and the kidneys information and the relationship between lesions and

adjacent tissue is better delineated with the pet MRI so it's easier to see which part is cancerous and which partners normal cells there are varying opinions and research studies are being done to make a determination if pet MRI

is a better modality than pet CTS well PET CT is a lower-cost skin has increased accessibility there are more PET scanners available and more more technologists are trained for this modality PET CT is a shorter skin there

are no contraindications for affairs implants pet CTS are preferred method for imaging the lungs of thoracic nodules and bone structures however with a pet MRI it's good for soft tissue organs such as the brain the muscle

delivered the kidneys the pancreas our GYN pelvic structures such as ovaries the uterus and cervix and also the prostate there are limitations of this skin one it is a much longer skin one whole body pet MRI can last at least

about an hour there are contraindications with certain implants due to the magnetic factor of the of this test and is not preferred for imaging air-filled structures because it can give off artifacts there

are weight limitations for our machine our machine holes can hold up to about 500 pounds of weight it is this our machine as smaller bore compared to the white board MRI the MRI whiteboy is about 70 centimeters in diameter

our pet MRI machine is only 60 centimeters in diameter in this picture the difference of the 10 centimeter difference doesn't seem much however if you put a patient in there and this is one of our coworkers

he is 270 pounds and 6 feet tall and the white board MRI his shoulders fit comfortably well inside it in the sky inside the scanner however in this pet MRI machine he said he did feel a little snug and a little tight inside

but you also have to take an account that we have to put coils on top of our patients that 10 centimeters does make a big difference the coils will help us give the good quality images that we like and I also have to note that we

have to put the head coil or the helmet on top of the patient's head to give good images of the brain the reason why the pet MRI scanner is smaller is because we have to make room for the pet detectors we try to make it bigger the

gradient coil on the radiofrequency coil have to be further away from the center of the magnet and that compromises the quality of our images so which patient

quick I did want to mention t-carr briefly and try to get you guys closer to back on time this is a hybrid procedure this is combining the surgical procedure we talked about first and carotid stenting it takes combined

carotid exposure at the base of the clavicle or just above the clavicle and reverses blood flow just like we talked about but tastes slightly different technique or approach to doing this and then you put the stent in from a drug

carotid access here's the components of the device right up by the neck there is where the incision is made just above the clavicle and you have this sheet that's about eight French in size that only goes in about us to 2 cm or 1 and a

half cm overall into the vessel and then that sheath is sutured to the the chest wall and then it's got a side arm that goes what's labeled number six here is this flow reversal urn enroute neuroprotection kit it reverses the

blood flow and then you get a femoral sheath in the vein right in the common femoral vein and you reverse the blood flow so this is a case a picture from our institution up on the right is the patient's neck and that's the carotid

exposure and the initial sheath is in place so the sidearm of that sheath is the enroute protection system which is going up up at the top of the image there we're gonna back bleed that let that sidearm of that sheath continue to

bleed up to the very top and then connect that to the common femoral venous sheet that we have in place there's a stepwise of that and then ultimately what we see at the end of the procedure is that filter inside that

little canister can be interrogated after and you can see the debris this is in the box D here on the bottom left the debris that we captured during the flow reversal and this is a what we call a passive and then active flow reversal

system so once the system is in place the direct exposure carotid sheath in place the flow controller and AV shunt in place you see the direction of blood flow so now all that blood flow in that common carotid artery is going reverse

direction and so when you place a sheath or wire and and ultimately through that sheath up by the carotid artery there's no risk for distal embolization because everything is flowing in Reverse here's a couple

case examples ferns from our institution this is a patient who had a symptomatic critical greater than 90% stenosis has tandems to nose he's so one proximal at the origin and one a little bit more distal we you can see the little

retractors down at the base of the image there in the sheath that's essentially the extent of the sheath from the bottom of that image into the vessel only about a cm or two post angioplasty instant patient tolerated that quite well here's

another 71 year-old asymptomatic patient greater than 90% stenosis pretty calcified lesion a little more extensive than maybe with the CT shows there's the angiography and then ultimately a post stent placement using the embolic

protection device and overall the trials have shown good good safety met profile overall compared to carotid surgery so it's a minimum minimal exposure not nearly as large the risk of stroke is less because you're not mucking around

up there you're using the best of a low profile system with flow reversal albeit with a mini surgical exposure overall we've actually have an abstract or post trip this year's meeting this is just a snapshot of that you can check it out

this is our one year experience we've had comparable low complication rates overall in our experience so in summary

so we kind of had a bunch of portal vein cases I think we'll stick with that theme and this is a 53 year old woman who presented to the emergency room with severe abdominal pain about three hours after she ate lunch she had a ruin why two weeks prior the medications were

really non-contributory and she had a high lactic acid so she they won her a tan on consi t scan and this is you can see back on the date which is two years ago or a year and a half ago we're still seeing her now and follow-up and there

was a suggestion that the portal vein was thrombosed even on the non con scan so we went ahead and got a duplex and actually the ER got one and confirmed that portal vein was occluded so they consulted us and we had this kind of

debate about what the next step might be and so we decided well like all these patients we'll put her on some anticoagulation and see how she does her pain improved and her lactate normalized but two days later when she tried to eat

a little bit of food she became severely symptomatic although her lactate remain normal she actually became hypotensive had severe abdominal pain and realized that she couldn't eat anything so then the question comes what do you do for

this we did get an MRA and you can see if there's extensive portal vein thrombus coming through the entire portal vein extending into the smv so what do we do here in the decision this is something that we do a good bit of

but these cases can get a little complicated we decided that would make a would make an attempt to thrombolysis with low-dose lytx the problem is she's only two weeks out of a major abdominal surgery but she did have recurrent

anorexia and significant pain we talked about trying to do this mechanically and I'd be interested to hear from our panel later but primary mechanical portal vein thrombus to me is oftentimes hard to establish really good flow based on our

prior results we felt we need some thrombolysis so we started her decided to access the portal vein trance of Pataca lee and you can see this large amount of clot we see some meds and tera collaterals later i'll show you the SMB

and and so we have a wire we have a wide get a wire in put a catheter in and here we are coming down and essentially decide to try a little bit of TPA and a moderate dose and we went this was late in the afternoon so we figured it would

just go for about ten or twelve hours and see what happened she returned to the IRS suite the following day for a lysis check and at that what we normally do in these cases is is and she likes a good bit but you can see there's still

not much intrahepatic flow and there's a lot of clots still present it's a little hard to catheterize her portal vein here we are going down in the SMB there's a stenosis there I'm not sure if that's secondary to her surgery but there's a

relatively tight stenosis there so we balloon that and then given the persistent clot burden we decide to create a tips to help her along so here we are coming transit paddock we have a little bit of open portal vein still not

great flow in the portal vein but we're able to pass a needle we have a catheter there so we can O pacify and and pass a needle in and here we are creating the tips in this particular situation we decide to create a small tips not use a

covered stent decide to use a bare metal stent and make it small with the hope that maybe it'll thrombosed in time we wouldn't have to deal with the long-term problems with having a shunt but we could restore flow and let that vein

remodel so now we're into the second day and this is you know we do this intermittently but for us this is not something most of the patients we can manage with anticoagulation so we do this tips but again the problem here is

a still significant clot in the portal vein and even with the tips we're not seeing much intrahepatic flow so we use some smart stance and we think we could do it with one we kind of miss align it so we

end up with the second one the trick Zieve taught me which is never to do it right the first time joking xiv and these are post tips and yo still not a lot of great flow in the portal vein in the smv

and really no intrahepatic flow so the question is do we leave that where do we go from here so at this point through our transit pata catheter we can pass an aspiration catheter and we can do this mechanical

aspiration of the right and left lobes you see us here vacuuming using this is with the Indigo system and we can go down the smv and do that this is a clot that we pull out after lysis that we still have still a lot of clot and now

when we do this run you see that s MV is open we're filling the right and left portal vein and we're able to open things up and and keep the the tips you see is small but it's enough I think to promote flow and with that much clot now

gone with that excellent flow we're not too worried about whether this tips goes down we coil our tract on the way out continue our own happened and then trance it kind of transfer over to anti platelets advanced or diet she does

pretty well she comes back for follow-up and the tips are still there it's open her portal vein remains widely Peyton she does have one year follow-up actually a year and a half out but here's her CT the tip shuts down the

portal vein stays widely Peyton the splenic vein widely Peyton she has a big hematoma here from our procedure unfortunately our diagnostic colleagues don't look at any of her old films and call that a tumor tell her that she

probably has a new HCC she panics unbeknownst to us even though we're following her she's in our office she ends up seeing an oncologist he says wait that doesn't seem to make sense he comes back to us this is 11 3 so

remember we did the procedure in 7 so this is five months later at the one year fault that hematoma is completely resolved and she's doing great asymptomatic so yeah the scope will effect right that's exactly right so so

in summary this is it's an interesting case a bit extreme that we often don't do these interventions but when we do I think creating the tips helps us here I think just having the tips alone wasn't going to be enough to remodel so we went

ahead and did the aspiration with it and in this case despite having a hematoma and all shams up resolved and she's a little bit of normal life now and we're still following up so thank you he's

I'm Nikki Jensen Nicole is what my mother calls me but that's alright thank you all for joining us today I am the clinical resource nas I work in a clinical nurse specialist position I graduated in May so I'll finally be called the clinical nurse specialist

after I passed my boards in nonvascular radiology so at Mayo Clinic Rochester we are kind of split up between I are in our IR practice where we have non vascular procedural Center CT MRI ultrasound guided procedures we'll go

over a list of our standard perform procedures as well as our neuro interventional and vascular interventional practice so Kerri and I work in the non vascular so we do not do any neuro interventional or vascular

vascular interventional procedures so these guidelines are going to focus on your LR CT or ultrasound guided procedures how many of you went to the combined session this morning great this is going to be an overview because what

we saw presented there really reiterates what we are have brought into our practice but then we're also going to share how we created nursing guidelines and how we rolled that into our practice this is Carrie Carrie is a staff nurse

in our department I worked as a staff nurse for seven years prior to this position I've been in this position now for four years and really enjoy it I do want to give a little shout-out to Carrie and I presented or sorry we

published an article in the June 28th volume 37 issue - that really coincides with our presentation today so I would encourage you to read that publication and then you'll get additional information on how we did this yes all

right we have nothing to disclose unfortunately or fortunately right so the purpose of this presentation is to help you all understand the importance of creating reviewing the literature

understanding your for one your coagulation casket as well cascade as well as anticoagulants that are out there or new up-and-coming medications and understanding that yes it's very important to establish and create these

guidelines so that within your practice you don't have differing radiologists that have differing opinions if you're working with doctor so-and-so today you need to worry about these labs if you're working with you know dr. Johnson

tomorrow he doesn't care about the labs we did this to help standardize that to help reduce the amount of questions our nurses have how many times we're interrupting our radiologists but then also we need to take into consideration

the importance of the patients and their different disease processes and we'll be going over that too so it's nice to have established guidelines but then also we need to take into consideration why patients are on certain medications this

here is our list of objectives I'm not going to read them for you you can all read them and we've provided you all with handouts too but really we want to just help kind of explain mechanism of actions and different medications and

how we established our guidelines this here is where Kari and I come from full disclosure we do have snow on the ground so these pictures were not taken before we came we are really enjoying this nice warm weather but for those of you who

are not familiar with the history of Mayo Clinic in Rochester who we have a hundred and fifty plus year tradition of implementing evidence-based care to assure the needs of our patient come first we are divided up into one

downtown campus but we have three different main areas so we have our st. Mary's Hospital this is where Kerry is based out of this is this houses most all of our ICUs as well as most all of our inpatients so we do a lot of

inpatients but we also see outpatients in this hospital Rochester Methodist Hospital this is where our he mock patients typically are we do have one ICU within Hospital as well but then right here my

office is right there this is our Mayo downtown campus so this is where most of our patients come for outside procedures or outpatient diagnostic imaging exams this here is the group that I'm part of the clinical nursing specialist group

within our clinical nursing specialist group there are 77 of us there are five like myself clinical resources as we have not graduated as of yet I'm right there in the middle w

that work in over 70 ambulatory areas in 58 inpatient areas we also support some areas in our Arizona and Florida campuses and then we have Mayo Clinic Health System hospitals that are scattered throughout Iowa

Wisconsin in Minnesota as well I am the only one in radiology across all of our

my talk is titled extremely obvious IR and I think as we move through these slides you guys are going to be able to pick up really quickly on why I elected for that title so this is a patient this is a 67 year old male he had an Evo repair in 2014 in 2015 he

underwent two repairs for persistent type 2 endo leak and this was done via transsexual approach in 2018 we got a CTA that demonstrated an enlarging aneurysm sac so here's just some key critical images from the CT I had the CT

and its entirety today but I had to like panic dump a lot of slides off of my powerpoint I'm always the girl at the airport that you see transferring things from one suitcase to the other like right when it's about to get onto the

airplane so what do we notice about where we see the contrast in these in these images so is it anterior is it posterior anyone its anterior so what if I told you that we see contrast in the anterior sac but this patient has an

included ima where is it coming from so we get the CTA we see any large aneurysm sac we see it an endo leak we bring them into clinic we go through the routine things the patient denies abdominal pain they deny back pain and so we go ahead

and all of our infinite wisdom and we schedule them for a trans cable approach to repair what we call a type 2 and delete now one of the most the most important key sentences from the workup is we say this is likely a type 2 in the

leak but a feeding vessel is not identified okay so our usual algorithm at UVA if we get a patient we do a CTA we bring we see any sort of endo leak if we cannot identify a feeding vessel usually what we do and you can let me

know if this is the same at your practice or if it's different we'll bring them in and we'll do some dynamic imaging from an arterial approach and we'll try to see you know is it really type 2 can we identify a feeding vessel

and oftentimes what happens in those situations is you you identify oh it is a type 2 we just see where it was from and we're gonna have to bring them back and we're gonna have to put them prone and we're gonna

have to stick the stack directly so we thought we were gonna outsmart it this time like we we were gonna just identify that it was typed to you right from the get-go do I have the play button or do you have the play button awesome all

right so this is our trans cable access so what we're doing these days to do our trans cable access and our fenestrations is we're actually using a t lab kit so we're using the transjugular liver biopsy sheath and we're putting our

65-centimetre cheap a needle through that so everything's going great so far we see our sheath in access goes smoothly I might have gone for two slides can you hit the I'm not sure yeah go ahead and hit that nope go ahead and

go one for slide and then just play that video for me yes please awesome so this happens pretty quickly can you play that video again and just keep playing it through on a loop and so we do an injection from our microcatheter from

our trans cable approach and what do you guys noticing where are you noticing the contrast tracking yeah in the red circle [Music] it is now right so everybody at UVA is is a proficient Monday Morning

Quarterback let me tell you so we see the contrast tracking down outside of the iliac limb so now we're all going okay can you go ahead all right go ahead and play this video all right so we get access into the femoral artery

just to make sure because at this point we're hoping against hope we haven't put this on the patient we haven't put this patient on the table MANET made a trans cable puncture only to identify that this patient does in fact have a type 1

B in delete but our arterial access proved that is exactly what we did the junction of the yes we did we did a trans cable puncture to identify that it was a junction leak so that's a problem right because we have

this action going on right so we have a trans cable puncture as dr. Haskell just adapt ly summarized we have a trans cable puncture we've done nothing so far but identify that this patient has the type 2 in a week so it is a micro

catheter right it's just it's just a party foul and then it was the fellow's dream because you pull out and there's nothing to hold pressure on there's nobody's dream at that point so I want to stop here and I want to just take a

moment you guys can live my psych at night so do you ever your so my normal algorithm for my patient since I come in in the morning I look at the patient's chart I review their prior imaging and I try to

do all of these things before looking at my attendings plan because one of the things that I realized is that challenges me to try to figure out what's my plan for the patient what do I think the most appropriate inventory

would be and every once in a while you see something in the plan that doesn't quite jive and you're like there's this is likely a type 2 in the league although a feeding vessel is not identified so I have two options at this

point I either walk down to the reading room and I say hey someone tell me what's going on we don't identify that type - is it worth doing a diagnostic imaging or anyway I just roll with it and this

was a day where I elected to roll with it and so I just want to take a moment and reiterate it's always important for all of us to you know you have a voice and use it and you want to bring up these

things that's sometimes we all start going through the motions where you work with someone that you trust a lot it's really easy to say like Oh someone's smarter than me caught that right so going back it's like it's like that

terrible joke what is the radiologists favorite plant the hedge mmm that's what that is it's like well it could be but it might be and ray'll right you go ahead and play this so this is just our walk of shame as

we're casually embolizing our track out of our trans cable approach and here we are back in clinic so again this is a 67 year old manual with recent angiogram that demonstrates significant type 1b endo leak and we plan for an extension

of the left aortic lab so we bring the patient back we do a standard comment from our artery approach we get into the internal iliac we identify the iliolumbar all kit all standard things we drop an amp at Sur plug to prevent

any sort of further type to end a leak into the limb that we go ahead and extend we put in the iliac limb we balloon it open we'll go ahead and play this video and our follow-up angiogram reveals a resolved type to end a week so

ultimately we did it so what are

patient 40s year-old patient again car accident lower abdominal pain and bruising so it sounds like you guys can appreciate that's an injury alright so we'll move past that so here's a CT scan these are four separate images from the

same patient CT scan and it is a bit more subtle I'm not suggesting it's easy to see you know we can appreciate the injury but one thing that you should be able to notice again is that concept of symmetry so when our residence or even

myself or anybody reads a cat scan we always want to kind of appreciate all the differences in the symmetry that we're seeing and so what you can see here is especially on that upper left hand side you can see the penis coming

out of the patient almost coming out of the patient and if you just draw a line straight back from there you should notice that there's a bit more tissue on the left side of the patient than the right side of the patient but that's

what we're looking at and if you go to the image over to the right the top right image right at that same area there's a little bit of a white blush which just shows that there is some bleeding going on there and if you look

at the third image which is the one on the bottom left right below one of the bones or there's another area of a white contrast collection or bleeding all right you can maybe see that again on the fourth image so that's what we're

looking for on the CT that asymmetry or the thickening of the tissue and we're looking for an escape of some contrast from where we should expect it to be all right so many of these patients will be

unstable those are the patients that probably need to go right to the or but for the patients who are really you know doing okay we have a chance to intervene on them and the reason why that's important is the more unstable they are

the higher the chance of mortality especially with the pelvic fracture so pelvic fractures are a big deal if you have a hemodynamically unstable patient with a pelvic fracture that's something to take very seriously

all right many of these patients will get CTS or C if we see extravasation they often come to us for angiography so here's the angiogram again a great example if you only look at one picture or two pictures

you're not going to see the problem all right so if you look at the first two pictures you really don't see anything I would I would argue it looks normal but as you get to that third picture you see that kind of collection of contrast

on the bottom right-hand side of the picture all right that's why you need to look at all the pictures of the and reom not just one picture you watch them it's like watching a

little movie now you just stand there and watch it over and over again I get a sense of what it looks like at the beginning middle and end of the angiographic run or set of images the other thing is it's very hard to see

extravasation of contrast when you're in the aorta so many times we do an aorta gram we take some pictures and we may or may not see anything but if we know there's a pelvic fraction we know it's more on the left side we'll go into the

left internal iliac artery and do a more selective angiogram and here's a picture of that selective angiogram and now you can see the extrapolation even more clearly hopefully you can all see it the bottom kind of leftish part of the image

all right here's a more selective now we say okay we definitely see something now we're going to get a little bit further into the system here's a picture now it's very clear you can go if you don't see it all right so you should see it on

the bottom all right and now our goal is to just get as close as we can and so we got all the way down then we put some coils there and again our goal is to make sure that we get just into the vessel that we treat and embolize it now

people will say what agent should we use do we use gel foam do we use particles do we use coils do we use glue or onyx the truth is you can you can really use anything but the thing with the most control so for trauma we tend to use

coils for trauma alright because our goal is to deposit an embolic agent right at the site of the injury that's our goal if we use particles we don't have as much control or a liquid we don't have

as much control they could go somewhere we don't want it to go all right here you're dealing with the blood supply of the penis the rectum the bladder other things which you know most of us would prefer not be injured during an

angiogram all right so we don't want to do something that we don't have complete control over and coils give us that type of control

happy to take any questions or in

ultrasound we don't usually use contrast but one of the procedures were doing for the treatment management of a pulmonary embolism is the ultrasound assisted Rumble Isis do we need contrast so for the thrombolysis is the catheter itself

so you still need to give contrast two to do the procedure but while the catheter is running you don't need to give any contrast four for that is that what you're we don't usually use contrast for ultrasound but

all right when you're treating how will you know that it sliced the clot is less what you frequently do is check the pressures so that catheter allows you to check the pressure and so once you start a patient so you do a pulmonary

angiogram which requires contrast and you put the ultrasound assisted thrombolysis catheter in the eCos catheter then after 24 hours or 12 hours you can measure a pressure directly through that catheter and if the

patient's pressure is reduced you don't have to give them anymore injections yeah and if we are using ultrasound for treatment is it possible to do it for diagnostic purposes No so not for non the prominent artists for

diagnostic imaging unless you're doing an echocardiogram which is technically ultrasound in the heart but for treatment otherwise you need you will need to inject some dye oh thank you

hi I'm Katrina I'm NGH I have one more question okay for your patients with chronic PE do most of them begin with acute PE or if they very separate sort of presentations that's that's a great question so all of them

had acute PE because you can't have chronic without acute but a lot of them are not ever caught so you'll have these patients who had PE that was silent that maybe one day they woke up and had a little bit of chest pain and then it

went away couple days later they thought they had a bronchitis or a cold and then you find out five years later that they had a huge PE that didn't affect them so badly and then they have these chronic findings they usually show up to their

family practice doctor again with hey I just can't walk as far as I can I have a little heaviness they rule them out from a heart attack but it turns out that they have CTF so you you all of them had a Q PE but it takes a lot of time and

effort to find out whether they truly have chronic PE so it's usually in a delayed fashion thank you all right well thank you guys again appreciate it [Applause]

let's move on here is another patient who took a fall skiing we see a lot of these patients up in upstate New York and they presented with severe left-sided abdominal pain and here's the cat scan

all right who's up for it what do you think what looks bad you look like you're into it what do you think yeah the right the bottom right-hand side of the picture should be spleen and it just looks like a big pool of blood that's

pretty good you did pretty good spleens a little higher so we're gonna presume spleen is there Graham this is just one image one slice through the picture through the body so we're just not at the level of the spleen but that's the

kidney that's exactly right that white thing on the right side of the image of the patient's left side is the kidney and the one thing I'd like everyone who appreciates that doesn't look at all like the other side all right so when

you look at a cat-scan like this you want to look for symmetry that's really important all right that's the cool thing is we're kind of meant to be similar looking on both sides of our body and in this particular

case you can see that the left kidney has been pushed way forward in the body compared to the right side and there is a kind of a hematoma sitting in the retroperitoneum posterior behind the kidney that's bad

the other thing you should notice is if you look at that left kidney you notice that white squiggly line that doesn't belong there okay that's contrast that's not really constrained inside an artery that's extravagant of

contrast that's bad all right we don't want to see that all right again there's a grading system for renal trauma and you're gonna hear people talk about grade 1 2 3 4 injuries all right obviously as the number gets higher the

extents of the injury gets more significant all right so again here's that picture think you can appreciate that it's at least a grade 4 laceration of the kidney so we went in and we did an angiogram now we can watch these

patients we can surgically manage them by taking out their kidney in some ways that's the easy part excuse me it's a lot more elegant to try and embolize these patients if they're hemodynamically stable and can take you

know getting to angio and doing the case now in general we do embolization for patients with lower grade injuries and usually penetrating injuries a penetrating trauma that's seen on CT I think this is something that's changing

I if any of you work at high-volume trauma centers the reality is that we're doing more and more renal angiography for trauma than we used to because it's just becoming a more accepted thing for us to

be doing that all right so here's the angiogram and again I think you can notice it really correlates very well to what we saw on the CT scan you see that first image on the left and on the delayed image you see that that kind of

poorly constrained contrast going out into space now we were never really quite sure what this was if it was extravasation or if it was potentially an arteriovenous fistula with early filling of a renal vein regardless of

which it's not normal all right so what we did was we went in and we embolized and I only included this picture because I'm a big drawer during cases so when I'm working with a resident or a fellow I like to really

lay out our plan on a piece of paper and try and stick to the plan and this particular picture look really good so I included on the lecture but basically you can see that the coils the goal here for any embolization procedure

when it comes to trauma is to preserve as much of the normal organ as we can and to simply get you know to the source of the bleeding and to get it to stop and that's what we did there so what you can appreciate on this is kind of the

renal parenchyma or the tissue of the kidney is largely maintained you can see the dark black kind of blush within the kidney and all that really stands for properly working kidney all right and yet we embolize the pathology so that's

our goal here's a similar patient not

treatment is the ultrasound assisted catheter director thrombolysis or the echos divisor eCos this technique involves a slow infusion again over 12 to 24 hours

but the catheter has ultrasound built into it and that's thought to help disassociate fibrin strands and to help embed the thrombus bed the TPA into the thrombus I think most people have heard of or seeing eCos in the past

again lower doses much like the catheter directed so it's really the same type of procedure except at the end you're hooking up eCos rather than a uniform Craig Mac there is a lot of differences though in the sort of overall patient

experience because eCos as many of you know requires a lot more devices and for the patient's room so they're gonna have more pumps because it requires more fluid it requires more observation it beeps more frequently overnight but what

I will say is that there are studies that are used that have useful information with eCos and those are actually the main studies that have been done although they're all industry-sponsored but they're very

important studies nonetheless so the only device really that exists for this right now that approved is the eCos

patients may be asking you is like what about adenomyosis and I've been hearing something about that which is not exactly fibroids right it's a different entity though the symptoms could be kind of the same and for the years and years

and years we wouldn't have any options for patients who had adenomyosis in fact the only option for patients with adenomyosis is surgery but adenomyosis can coexist with fibroids and sometimes patient presents with adenomyosis alone

so we've had some studies now that have looked at that and although the data is not as robust and not as awesome as for patients with fibroids we do provide a performing bolas Asian for those patients with particles that are little

smaller than what we would use for fibroids with results as you're seen there before now the only other new thing that's on the market and it's not so new to you guys that are probably doing radial in femorals anyway working

in cardiac labs and IR labs it's actually what we call the trophy if you go back one slide for me mr. a the person and press play then we will be able to see that radial access I do not work for Merritt they don't give me a

dime I just thought that this was a good video is there volume on that at all if not I can just talk about it and really what it says is that if you need to a radial UFE or have radial axis for a uterine embolization patients just love

it more they and especially like patients that are already just intimidated they don't want you going near their groins at all they actually could just lay on the table we don't have to put up we don't put a Foley in

they just get a radial access the same way that you would just be starting in a line except we have special types of radial catheters and and sheaves to do that and I don't offer a radial access to

patients who are too tall for our catheters or if they've had multiple prior radial access and don't have an intact ulnar artery to complete their hand but it's much like any of that femoral access that you would normally

see they make special hydrophilic sheaths now they're called from this particular company slender technology where the inner diameter of the sheath essentially the sheath is the same like five French on the outside but they have

cored out the inside so it's a bigger diameter so it's a five six so on the outside it's a five but it will take a six French in the inner inner lumen and you know my practice we do more than 80% of all our arterial punctures with a

radial access and everybody here comes dr. Sean Deroche Nia who is the leading author of that paper for SI R and one of my esteemed partners so most patients are able to get up and walk out if you are go from a radial access the access

is actually closed with just a radial band and the complications of having a hematoma or having the patient's bleed out those just all go away but radial axis have their own complications so I'm not here to say that it is not that but

in our practice we found it to be safe and effective our patients want it and it's become like a practice differentiator so if you're working in a practice that don't do radial you EFI's right now you should mention it because

if you're in a population where the other providers are only doing femoral then you will automatically get the patients that only want that so here's a patient that had a radial access you can see a catheter that is coming from the

aorta while you can't see that it's not up and over the bifurcation but maybe you do can see that and there's a catheter in the uterine artery with the characteristic

shape of the uterine artery and the characteristic curlicue vessels of of the fibroid and on the left you can see the Imogen for beforehand and the Imogen on the right of post embolization where there is stagnant flow in the main

uterine not main uterine artery in the horizontal portion of the uterine artery for greater than five cardiac beads and again there's there's no reason that you have to know that level of detail except that you're scrubbing in but if you're

in the audience you're looking at this you're like dr. Newsome I see an air bubble there as well then I'd say good because because I do see it too so you can see the preimage and you can see the post image for pre and post embolization

these these procedures can be quick these procedures are very very rewarding and and I love to do it

I like to talk about brain infarc after Castro its of its year very symbolic a shoe and my name is first name is a shorter and probably you cannot remember my first name but probably you can remember my email address and join ovation very easy 40 years old man presenting with hematemesis and those coffee shows is aphasia verax and gastric barracks and how can i use arrow arrow on the monitor no point around yes so so you can see the red that red that just a beside the endoscopy image recent bleeding at the gastric barracks

so the breathing focus is gastric paddocks and that is a page you're very X and it is can shows it's a page of Eric's gastric barracks and chronic poor vein thrombosis with heaviness transformation of poor vein there is a spline or inertia but there is no gas drawer in urgent I'm sorry tough fast fast playing anyway bleeding focus is gastric barracks but in our hospital we don't have expert endoscopist

for endoscopy crew injections or endoscopic reinjection is not an option in our Hospital and I thought tips may be very very difficult because of chronic Peruvian thrombosis professors carucha tri-tips in this patient oh he is very busy and there is a no gas Torino Shanta so PRT o is not an option so we decided to do percutaneous there is your embolization under under I mean there are many ways to approach it

but under urgent settings you do what you can do best quickly oh no that's right yes and and this patience main program is not patent cameras transformation so percutaneous transit party approach may have some problem and we also do transit planning approach and this kind of patient has a splenomegaly and splenic pain is big enough to be punctured by ultrasonography and i'm a tips beginner so I don't like tips in this difficult

case so transplanting punch was performed by ultrasound guidance and you can see Carolus transformation of main pervane and splenorenal shunt and gastric varices left gastric we know officios Castries bezier varices micro catheter was advanced and in geography was performed you can see a Terrell ID the vascular structure so we commonly use glue from be brown company and amputee cyanoacrylate MBC is mixed with Italy

powder at a time I mixed 1 to 8 ratio so it's a very thin very thin below 11% igloo so after injection of a 1cc of glue mixture you can see some glue in the barracks but some glue in the promontory Audrey from Maneri embolism and angiography shows already draw barracks and you can also see a subtraction artifact white why did you want to be that distal

why did you go all the way up to do the glue instead of starting lower i usually in in these procedures i want to advance the microcatheter into the paddocks itself and there are multiple collateral channels so if i in inject glue at the proximal portion some channels can be occluded about some channels can be patent so complete embolization of verax cannot be achieved and so there are multiple paths first structures so multiple injection of glue is needed

anyway at this image you can see rigid your barracks and subtraction artifacting in the promenade already and probably renal artery or pyramid entry already so it means from one area but it demands is to Mogambo region patient began to complain of headache but american ir most american IRS care the patient but Korean IR care the procedure serve so we continue we kept the procedure what's a little headache right to keep you from completing your

procedure and I performed Lippitt eight below embolization again and again so I used 3 micro catheters final angel officio is a complete embolization of case repair ax patients kept complaining of headache so after the procedure we sent at a patient to the city room and CT scan shows multiple tiny high attenuated and others in the brain those are not calcification rapado so it means systemic um embolization Oh bleep I adore mixtures

of primitive brain in park and patient just started to complain of blindness one day after diffusion-weighted images shows multiple car brain in park so how come this happen unfortunately I didn't know that Porter from Manila penis anastomosis at the time one article said gastric barracks is a connectivity read from an airy being by a bronchial venous system and it's prevalence is up to 30 percent so normally blood flow blood in the barracks drains into the edge a

ghost vein or other systemic collateral veins and then drain into SVC right heart and promontory artery so from what embolism may have fun and but in most cases in there it seldom cause significant cranker problem but in this case barracks is a connectivity the promontory being fired a bronchial vein and then glue mixture can drain into the rapture heart so glue training to aorta and system already causing brain in fog or systemic embolism so let respectively

establishing a few things I know that we may have a mixed crowd here and so if I'm saying things that you're like oh come on Newsome we already know that

just just rush me along but if I'm if I'm repeating some other things that that are more interesting then you can slow me down so it is no surprise and I'm often frightened when people say that fibroids

are along the spectrum of cancer fibroids are non-cancerous tumors of the uterine muscle if you remember a little thing about Anatomy that the uterus is made of three specific layers the myometrium which is the main muscle of

the uterus the endometrium wishes the inside part of the uterus and the serosa wishes like a saran wrap of sorts that keeps the whole thing together fibroids are made of the main muscle portion of the uterus and we don't know what it is

but something happens and it turns that muscle portion of the uterus on and when it over grows it grows into a ball and we refer to that ball as a fibroid fibroids are the most common pelvic tumors in women it is the leading cause

of hysterectomy in the US and even though we've been doing hysterectomies forever one third of all hysterectomies that are done in the United States are done for benign disease and we know all kinds of sexy ways now to stop bleeding

you freeze it you make it cold you make it hot we have Lube cautery and all kinds of things and still in 2019 we can't stop the bleeding from fibroids which then result in women who are scheduled for

myomectomy to have a hysterectomy as a way of controlling the bleeding so there are a few other things that we know about fibroids we know that the symptoms are very varied depending on where these fibroids actually end up and

the symptoms of heavy bleeding still remains the most common symptom dysfunctional uterine bleeding abnormal heavy menstrual pain menstrual cycles pelvic pain and symptoms of bulk that is I cannot drink a can of coke before I've

got to go to the bathroom I know every rest stop between my house and where I've got to be every time I laugh or sneeze I pee on myself I'm doing 200 sit-ups a day and I'm wearing two Spanx if that is happening to you that's not

normal we also know that fibroids have a high impact on the quality of our patients lives and their productivity because if you can't go to work and you take off from work and you're really not able to

take your kids to the soccer game or do all the other things that you really want to do then I think that that is really quite disruptive of your life and yet women year after year suffer from these types of symptoms and do not come

to getting any type of treatment at all in fact they don't even tell their doctors about it because they just accept that as kind of normal and the average time from when women start suffering from these symptoms to when

they actually seek treatment is around three and a half years and I work in Atlanta and the average time is away above that and I would say to you that just go with me here and I'm sorry for any male that is in the audience that

will be offended but if you could imagine now now just use my own husband for example if he could not have an erection for two weeks in a row I think he would see the doctor immediately however women will wait for five years

with all kinds of symptoms and not actually seek any treatment forget an erection if they're constipated for two weeks in a row they go to see the doctor this is a real public health burden and I know that I talked about the survey in

2013 and where si are is doing a big thing called a fibroid fix it's available on the website we'll see if there's a way that we could link it to the avir website but just last year they repeated this survey of around a

thousand women but guess what these statistics had not changed around a third of the women continued to complain of this interruption in the quality of their life due to fatigue or cramping and three-quarters of these women still

prefer a minimally invasive uterine sparing procedure they still want to preserve their uterus even if fertility is not an issue and although I just told you that like 80% of black women will have fibroids by the time they're 50 and

70% of white women there's around a quarter of all women that have never ever ever even heard the term fibroids for a disease that is so common and this affects so much whim so many women and it is still so costly in terms of how

much days they have to take off from work and what they have to do in order to get treated we spend around thirty four billion dollars a year in the u.s. that is on par for the amount that we spend for colon cancer and ovarian

cancer combined for benign disease and yet not much has been done so if you're

treatment options once you've sort of isolated that there are leaky valves and the patient has typical symptoms that there are some surgical options but really embolization and catheter

directed treatment are really the mainstays of treatment both because it's an outpatient procedure you get to go home the same day and the recoveries fairly easy the factors that we consider when you embolize or block these

varicose veins are listed here you want to you want desired duration you want it to be closed forever you can't replace valves it would be nice to be able to do that but there's not a valve replacement so much like in the leg when you're

treating varicose veins you're either blocking or taking veins out so the surgical options are to take the vein out or to ligate but and the vascular options would be to block it and so I would just thought I would cover just a

little bit of embolization materials I'm sure you're all very familiar with and as I'll mention a little bit later there's there's sort of not necessarily agreement on what type of things people use to embolize gonadal veins or pelvic

varicosities but i'll show you what i do but give you a background of just generalized embolization materials so I'm sure you've all seen gel foam supplied as a sheet you can make a slurry you soak it with contraire

so that you can see it as you're putting it in some people use glue and will glue the entire gonadal vein it solidifies when it's mixed with saline or blood usually mix it with acai it also you can see it as

you're injecting it and then the standard coils which there are multiple sizes shapes detachable non-detachable Amplatz or plugs all the mechanical devices that can be used to block blood vessels and then I put on Souter deck

all because there are some people that will sort of do the sandwich technique you may have heard we'd put a coil peripherally and a coil up by the renal vein and then in between the coils you can film a sclerosant and embolize that

way the other important factor for me is using the suture deck all on the actual varicosities I'm not just necessarily treating or blocking off the the blood supply to them you know and I'll mention that a little bit more during the case

here so go through a case patient with

helpful and you know many of us use this on the table at the time of the procedure we also look at our own images because it reports are not all that helpful and what you're looking for I don't know duplex ultrasound is what is

the vessel wall look like is it narrowed is it patent are there are there large collateral so you're going to need a lookout for or what's the velocity of flow because as you know as you know you put your

finger over the end of a of a garden hose it's going to increase the velocity of the water that you're shooting at somebody and the flow direction and quality can also be detected so color Doppler imaging often changes from this

kind of smooth the uniform color with laminar flow on the on the right side to one of multi-directional flow with turbulence you'll see colored multiple different colors in the same image spectral Doppler waveforms are also

obtained with with duplex ultrasound so what you're looking for is this is the the picture equivalents of marks noises from earlier which is a triphasic waveform see that the flow goes above the line and then goes back below the

line and then comes you can wholly state that it comes back above the line here that would suggest that it was triphasic or normal and then these often just go above the line and they never go back below the line and these patients if

they're if you're looking at the ultrasound below the level and destruction so we're looking for a return from the image on the right to the image on the left we have specific number criteria that we use as a

determination of whether one we've been successful the numbers are not that important but the ant vanish is a duplex are that it's low-cost and it's highly sensitive but it it's time-consuming and depending on who the operators are that

are actually taking the images and who are the readers are you may or may not find them that helpful and it's less accurate for determining if the vessels completely occluded because they may just not have seen it they may have

missed it so it's operator dependent several papers suggest that we should be this should be our first line imaging study for following up patients after we do an intervention particularly angioplasty alone and if the initial

follow-up is normal we can usually push them out to just clinical follow-up and making sure they have a pulse exam if patients have an abnormal finding then we usually bring them back sooner and get a repeat ultrasound at two to three

months CT a very sensitive and specific

talk here with something that's new on the horizon believe it or not it was actually on the horizon 20 years ago and then it went away because there were a lot of patients that were treated with a

lot of complications and it's making a resurgence and this is balloon pulmonary angioplasty or BPA for short so this is an intervention which may be feasible in non-operative candidates so I mentioned to the Jamison classification earlier

type 1 and type 2 disease should be treated with surgery again it should be treated is curative but patients with type 2 and a half or 3 disease can be treated with balloon pulmonary angioplasty in the right in the right

frame which means that a surgeon has said I cannot operate on this a medical doctor has said boy they're not going to get better with their medicine let's try something else well this is that something else and that's what involves

everyone in this room so this is these are usually staged interventions with potentially high radiation and contrast dose if you think about it it's like Venis recan and a pulmonary AVM all-in-one so it's a potentially a long

complex procedure with a lot of contrast and a lot of radiation but it can provide a lot of benefit to these patients I'm going to talk about the comp potential complications at the end which is one reason why not

everyone should do these all the time so this is a pulmonary angiogram from the literature when you're injecting a selective pulmonary artery you can see that this patient has multiple stenosis there's no real good flow there the

vessels look shriveled up like I mentioned to you before you can get a balloon across it and balloon the areas and then you can see afterwards so the image a on the left is before an image D is afterwards believe it or not this are

in the most experienced hands because the most experienced hands are for palm the BP AR in Japan they do hundreds of cases of these a year at each hospital I've personally only done five so but this is a something that I'm very

interested in and you can see how how much benefit it has for that patient another way you can see these are the webs and the bands that I mentioned to you earlier so what's interesting is that if you look on the first set of

images on the top and the images on the bottom those are the same patients it's the same view before top rows before and the bottom rows after balloon pulmonary angioplasty so the first image is a pulmonary angiogram where if you kind of

see this there's there's some area areas of haziness those are the webs and bands the image on the the middle is the blown-up views and you can see those areas and then the image on the right is intravascular ultrasound which I use

every day in my practice it's a catheter with an ultrasound on it and when you look at it on the top image image see you can see a lot of thrombus you're actually not seeing flow and on image F on the bottom you're seeing red which is

the blood flow so these patients can actually improve the luminal diameter bye-bye ballooning them you can treat occlusions again image on the left shows you a pulmonary artery with a basically an occlusion proximally and then after

you reek analyze it and balloon it you can see that they can get much more

now other causes this is a little bit different different scenario here but it's not always just as simple as all

there's leaky valves in the gonadal vein that are causing these symptoms this is 38 year old Lafleur extremity swelling presented to our vein clinic has evolved our varicosities once you start to discuss other symptoms she does have

pelvic pain happiness so we're concerned about about pelvic congestion and I'll mention here that if I hear someone with exactly the classic symptoms I won't necessarily get a CT scan or an MRI because again that'll give me secondary

evidence and it won't tell me whether the veins are actually incompetent or not and so you know I have a discussion with the patient and if they are deathly afraid of having a procedure and don't want to have a catheter that goes

through the heart to evaluate veins then we get cross-sectional imaging and we'll look for secondary evidence if we have the secondary evidence then sometimes those patients feel more comfortable going through a procedure some patients

on the other hand will say well if it's not really gonna tell me whether the veins incompetent or not why don't we just do the vena Graham and we'll get the the definite answer whether there's incompetence or not and you'll be able

to treat it at the same time so in this case we did get imaging she wanted to take a look and it was you know shame on me because it's it's a good thing we did because this is not the typical case for pelvic venous congestion what we found

is evidence of mather nur and so mather nur is compression of the left common iliac vein by the right common iliac artery and what that can do is cause back up of pressure you'll see her huge verax here and here for you guys

huge verax in that same spot and so this lady has symptoms of pelvic venous congestion but it's not because of valvular incompetence it's because of venous outflow obstruction so Mather 'nor like I mentioned is compression of

that left common iliac vein from the right common iliac artery as shown here and if you remember on the cartoon slide for pelvic congestion I'm showing a dilated gonna delve a non the left here but in this case we have obstruction of

the common iliac vein that's causing back up of pressure the blood wants to sort of decompress itself or flow elsewhere and so it backed up into the internal iliac veins and are causing her symptoms along with her of all of our

varicosities and just a slide describing everything i just said so i don't think we have to reiterate that the treatments could you go back one on that I think I did skip over that treatments from a thern er really are also endovascular

it's really basically treating that that compression portion and decompressing the the pelvic system and so here's our vena Graham you can see that huge verax down at the bottom and an occluded iliac vein so classic Mather nur but causing

that pelvic varicosity and the pelvic congestion see huge pelvic laterals in pelvic varicosities once we were able to catheterize through and stent you see no more varicosity because it doesn't have to flow that way it flows through the

way that that it was intended through the iliac vein once it's open she came back to clinic a week later significant improvement in symptoms did not treat any of the gonadal veins this was just a venous obstruction causing the increased

pressure and symptoms of pelvic vein congestion how good how good are we at

criteria for CTF means that the patient has a mean pulmonary arterial pressure which we measure intraoperatively exceeding 25 millimeters mercury at rest with the mean pulmonary capillary wedge pressure less than 15 so I'm not a

cardiologist but what that means to me is a mean capillary pulmonary wedge pressure less than 15 means that their left heart is not failing so if you have a capillary wedge pressure higher than 15 that means your left heart is not

working correctly and you can't blame it on the CTF so you can't blame it on the right side if the left side isn't working other things that matter are the abnormal pulmonary vascular resistance and having a systolic pulmonary artery

pressure greater than 40 so what I want to show you and highlight is the law the lost art of pulmonary angiography which i think is now sort of again a lost art some places do a lot of it and some places don't do very much but diagnostic

pulmonary angiography is actually the gold standard in the planning of either surgery or medical management for patients with CTF we do we do these on almost all of our patients with CTF to make that decision with the surgeons and

the cardiologists so the utility is very it's very useful you're able to measure our pressure you're able to decide whether we're the where the thrombus exists in this image here in patients with disease in the

blue and yellow outlined areas those are the patients who can have the operation the operation is curative it's not just medication that you have to take for the rest of your life you can actually remove that chronic clot it's much like

a femoral endarterectomy that are done for patients with peripheral arterial disease although it's a lot more complicated because they have to crack your chest open what's important is getting very very

good high-quality pulmonary angiogram xand so we do we used to do about we do about a hundred of these a year where I trained or actually where I work now and you get very magda up views and you're gonna show all of the vessels and so

these are the views that we use at our institution they happen to be the pipette criteria so it's the same thing you used to do for acute PE you put a flush catheter in the main pulmonary arteries when you're looking at the

upper lobes and when you're looking at the lower lobes you want to push the catheter further into the pulmonary arteries and inject usually what I do is a two to three second injection so that you can stack the images very well and

show all of them in one view this allows your surgeon to make a decision easily as to whether they can operate or they can't operate on this and then I use a higher frame rate usually because these patients are wide awake we when we do

this case we give our patients twenty five mics of fentanyl one time and that's it just to help get the sheath in I usually do this with a seven French sheath and then use a flush cap pulmonary artery catheter many of which

are currently off the market but when we do this we just give them that twenty five Mike's because they have to hold their breath and I usually go up to a high frame rate in the first run and then adjust based off of how well that

patient is holding their breath this really takes a team effort from our nursing technologists and the and the physicians in the room to make sure that this patient does a good job because it's gonna change their management so

there are a lot of different types of angiographic findings on one of these pulmonary angiogram they're really really interesting pulmonary angiogram zin these patients and they're sometimes not at all subtle so you're looking for

a pruning of distal vessels if we start in the top left where you're just not seeing the Brent normal branch pattern you look for stenosis so we're not usually used to looking at stenosis and the pulmonary arteries but this is

actually what you're looking for in CTF you're looking for webs or bands so you'll usually see little areas where you just doesn't look like there's great opacification there's little areas that there's not good at pacification those

are little webs inside the vessel believe it or not looks like a cobweb that grew inside there from that thrombus and then you're looking for areas of complete occlusion that there's just no vessels there those are all

vessels that can be treated in patients with CTF so this is the Jameson classification before we talk about the sort of the interventional management the surgical management is again the curative and dr. Jameson is the head

surgeon at University of California in San Diego which is the largest Palm CTF program in the in the world and he's done I think over 3 500 of these operations I think he's retired at this point but they named the classification

after him and so type 1 is proximal disease so it involves the main pulmonary arteries these are the ideal patients who can get the best benefit from this in their life type 2 is the next best

it's segmental proximal just type 3 is distal segmental and then type 4 is just a mess of sort of all of it but you can't really get a good surgical plane so type 1 and 2 are treated with pulmonary thromboembolism

towards balloon pulmonary angioplasty or BPA and type 4 are generally treated with medication so PT II or pulmonary

60s year old patient with afib who fell and presented with abdominal pain and bruising in their anterior abdominal

wall for whatever reason we see a lot of these patients who come in with kind of bruising after they fall on their abdomen here you can see why hopefully you can see the big hematoma and the anterior abdominal wall so you can

imagine what this patient look like they have this kind of you know ball sized thing under their abdominal wall all right here's our angiogram in this particular case we went into the inferior epigastric artery which kind of

runs up from the pelvis up along the anterior abdominal wall you can see how small it is we were able to get a micro catheter in there and just in the middle just to the left of the middle of the picture you can see that kind of black

your circle that's again a pseudoaneurysm arising from the branch of the inferior epigastric artery and boom we can go in and coil it all right so that's what that looks like so now all of you kind of maybe I used to

sitting in the background we'll know when you're getting called in for these patients this is the type of pathology that we're looking at on CT and on angiography all right another patient 68 year old

so this is our MGH page we started it about a year ago check it out if you guys like it some pretty good cases we mostly post cases some policy stuff industry and changing things it's not purely cases but certainly take a look if you like it give us a follow so what

I have today is I have two cases that I picked and you know for all the thousands of cases that all these huge academic medical centers do I tried to pick a couple that might be a little interesting and that aren't being done

in all the different centers across the institution so I'll start off with the first which is an endovascular AVF creation so what's nice about this is that you know what we see so far from this is that the length of stay impact

has been certainly reduced in certainly the maturation times and the Rhian turn re intervention rates have been reduced so I'll go through this and normally wouldn't go step by step for a few things but I think you know not all

institutions are doing this yet I think that you will I do think this is going to be a shift for a lot of the dialysis patients and everybody who works anion knows what a huge impact it is the ESRD patients is just astronomical the

numbers of them it's just continuing to rise so procedural steps the first step is you're going to access the brachial vein advance the guide Y down to the ulna insert a six French sheath and perform a vena Graham and the rationale

for that of course is to make sure you don't have any issues centrally some centers do that in advance some centers don't I will mention also that the ultrasound mapping is absolutely critical to make sure that

you get the right patient you start off by seeing them in the outpatient clinic and then you're going to go and have them have vascular ultrasound to make sure you have a good candidate so the next is you're gonna access the brachial

artery same thing advance your guide wire down to the ulna from there you're gonna insert the venous side now this is one of two approved vendors that will allow you to do an endovascular creation this was a wave link it's a to stick

system and it requires two catheters which is why you see the next step is pretty much repeated but just flipping it to the arterial side so from there there's a magnetic zone it actually has like a little canoe so it's got a

backing of a ceramic sort of a space there if you can think of sort of the older or atherectomy cut home catheters that had that little carro canoe you would actually take the debris out it's very

look into that and I'll show you that in a couple of images once you align that you're gonna sort of engage the little electrode this is an RF ablation RF created type fistula so it creates a little slit between the Adri and the

vein and what happens is is that you know of course don't forget you have to ground the patient just like any RF once you get the magnets and you get the electrode alignment you're going to engage the device for two seconds and

the fistula is created and then from there a lot of centers are actually going in there embolize in one of the brachial veins and this is basically to sum some of that stuff obviously to the superficial system for draining I have

read that there are a few places that actually go back back in through the newly-created fistula like even at the time of the procedure with the 4 millimeter balloon and just sort of open that up I'm not sure that that's 100%

necessary but I'm sure all these fine people on the panel could help us with that so here you see and I skipped all the entry steps but here you can see the Venus in the arterial catheter you know in position here and there's that little

canoe thing pointed out by the arrow that I had talked about and you use fluoro to sort of align these two things when you first start doing these cases take your time the first one was over an hour and a half for us now obviously

it's about a third at that time this is the little electrode this is when it's advanced and pretty much ready to engage can you play the video for me so this is quick so what happens is you suppress the

device the electrode actually advances and as it advances towards the veena side what happens is is that it actually just creates this fistula through the RF sort of energy from there you're gonna do a post vena graph in here you can see

after we did an initial post intagram there was enough sort of flow between the PIAT brachial so we decided to embolize one and this patient was our first patient and is doing very well so far this is done on I'm gonna say just

because you know to dr. brains point I don't want to get on the hook for certain dates and patient identification but this was done in mid-march so we saw them two weeks out and we're gonna see them again another couple weeks so just

there's a couple of trials that you can read into one is the neat one is the flex trial I think the technical success is really promising at 96% the maturation days you can see there's a massive massive comparison where they

could be ready to be dialyzed in 60 days and this could be a game-changer for many patients the six-month patency rate is what I've seen in most of the reports it's around 98% compared to about 50% with the surgical place and then you can

see that this about 3.5 interactions or re interventions that are required in about 0.5 at a year's time out from this so it's really making a big difference for these patients and I think this is what we do in i/o we continue advanced

things innovate and obviously look to do things in a more timely cost-effective minimally invasive way at the beginning when these new procedures come out the devices themselves might be at a higher price point but we'll see how that goes

moving forward as more and more vendors get into the space so the second case

so what what venous insufficiency is is really leaky valves so if you want to hit the play on that so that's all venous insufficiency that's what we

talked about it's it's leaky valves and so you can see this the valve leaflets there which are paper-thin is allowing blood to go the wrong way if you want to hit play on that one when we looked for valve

insufficiency for sure in the legs we use ultrasound and there's a bunch of different things that we look at an ultrasound you first look if you can augment blood flow so that was that first part we see if it's compressible

to make sure there's not a clot in it that's this part you can see the vein winking at you and then finally we look at valsalva or some type of way to determine if the valves are competent or incompetent and what this figure is

showing is that when a patient valsalva Zoar tenses up their abdominal muscles you see the gray line for the ultrasound crossing the access and going the opposite way all that means is it's got opposite directional flow which you

should not be able to do if your valves work so if your valves work you would not see that ultrasound picture crossing the line here it would just continue right there or would just stop and then flow would start again once you stop fel

salving so that's how we check in a leg but for pelvic venous insufficiency that's kind of hard to ultrasound the deep pelvic veins I could certainly look for varicosities with a an ultrasound of the pelvis but you can't really find the

source of an usually the source veins are the internal iliac veins or the gun at Elaine's and those are tough to ultrasound so secondary evidence of incompetence or leaky valves in those systems is varicosities

and so in the case of pelvic venous insufficiency those varicosities are in the pelvis and you see on the slide here you got varicose veins deep in the pelvis here and here and see some larger ones in that same

area on that CT scan so that'll tell us varicose veins that doesn't necessarily tell you whether the issue is with a gonadal vein or an internal iliac vein it just tells you that there are sequelae of varicosities much like in

the leg you might have varicose veins in the ankle but the problem is really higher up in the leg at this afterno femoral Junction so that gives us secondary evidence but it hasn't really told us the cause of the varicose veins

this is just a CT image that it also may show a large gonadal vein right here so you normally should not see it that big it's right there also secondary evidence that the valve is incompetent but it doesn't really test the valve itself

it's it just gives you the idea that veins enlarge and the valves gonna be leaky this is a cartoon schematic of the

and what's available the ellipsis device

which is a startup company still hasn't been bought by anyone it was developed by an interventional radiologist named Jeff hall if you know Jeff from Richmond Virginia and it's a totally ultrasound mediated placement it only requires one

puncture into a cephalic or a perforating vein and then you go from the vein into the artery and I'll talk about that in a moment then the everline the queue device now cold wave link wave linq device i was formerly a TV a

medical developed here in Austin Texas and recently bought by bard BD both devices were FDA approved over the summer and now this goes back the whole idea of what are we doing here what we're creating what we call a deep

fistula so and that was done in response to failing forearm fistulas the radius of Halleck fissures when they started to fail people would then jump to the upper arm and start creating brachial basilic

transposed basilic vanes already oh so phallic brachial cephalic fistulas in the upper arm and then here a guy by the name of Ken grass in Illinois it's called the grass fistula I think I'm saying that right developed a fish to

where he would hook the deep veins at the forearm to the brachial artery flow would then go from the brachial artery across the fistula up what's known as a perforating vein and that perforating vein selectively would go well

selectively perhaps unselect if we go to either the basilic or the cephalic or perhaps even both and here's a nice anatomic description I don't sorry I do not have a pointer I don't even have a keyboard but if you look there we'll

start up at 11 o'clock you can see there B and C basilic vein cephalic vein or labeled you see that P going straight down from the middle of the clock down to six o'clock that's the perforator okay we all know about perforators in

the legs if you do varicose veins because they're incompetent perforated up until six months ago I never even knew there was a perforating vein there one number two I defy anyone to try to find it in an anatomy book because it

just you know it doesn't I'll show you one picture of it but it's not exactly descriptive of what it does then basically they would take that and cut the perforating vein off of the deep venous system and attach it to the

brachial arteries you can see down there four o'clock so now you have flow from the brachial artery across the perforator and up into the superficial venous system and supplying the lead basilican the cephalic veins

kind of kind of a great idea and in fact they looked at these and they compared upper arm fistula swen maintenance of dialysis with deep fistulas and the the time to use of maturation was about the same about four months there was no

significant difference in outcome among the three types of fistulas brachial cephalic transposed rinky basilic and in fact since we have flow through both both of those veins you know it's may be

tempting to speculate that you can now use both of those things actually for hemodialysis and that's currently done many times two needles one needle and ability and the break in the basilic keeps me breaking

one needle in the basilic one needle in the cephalic and then you can alternate those needles so you don't have the problems of vein injury by frequent cannulation at the same spot well here's the one anatomic picture I ever found

with the perforating vein this is from the sobota Atlas which medical students know very well and you can see right in the middle there it says perforating vein and it's ducking down there below the fashion who knows where the hell

it's going but you don't know it from here and here you can see on ultrasound this is pretty much you know what it looks like that's the perforating vein and I guarantee whew go back and grab your ultrasound machine in your

departments and you all have to do is put it on color when you follow the basilic vein down or the and they'll meet the cephalic vein kind of a V and then just below that you'll see your perforator diving deep towards the

brachial artery alright and so now you'll all know where the action is going on and the you know since I think this procedure really is ideal for interventional radiologists I mean it really leverages everything that we do

you know ultrasound fluoroscopy multiple oblique angulations complex angulation is to position the device correctly I mean this procedure is really made for us so I suspect that some of your your attendings may want to begin a program

like this and if you cover the ORS and you're dealing with vascular surgeons or interventional nephrologist I'm sure they will probably want to get involved and so you know get ready guys here it comes so here is a obviously an

illustration of the the forum you can see there's the brachial artery going down take particular attention to the median nerve you can see this with ultrasound it's a very hyper echoic focal structure but when you're

puncturing that brachial artery load down at the elbow you want to make sure that they see the Brig a break heel and pardon me the median nerve because you can injure it if you put a five or six French sheet through it and that's one

of the potential complications of this procedure but as a radiologist we know ultrasound we can see it and we just have to do a complex needle I'm sure you know angling the ultrasound probe around it so he can get them to

the brachial artery then if you follow the cephalic Emily basilic vein down you can see they meet in the center median cubital vein and then the antecubital median antebrachial vein and then but they don't really show here is the

perforator but the point I wanted you to make it and to make you is them the median nerve is right in your target very often you don't want to tangle it now there's a lot of variation in the cue you know and whenever you get down

to anatomic structures this small which when you're doing these procedures you want to be aware of you can see that some people if you look all the way to the right type for there's no perforating vein and these people are

deemed to be anatomically unsuitable for this type of procedure you have to have a good quality and we'll talk about size usually about two two and a half millimeters perforating vein to get that blood from the brachial or radial or own

or artery up into the superficial system to a point where the fish so it can be cannulated but the anatomy here is variable and so you have to be aware that if you don't see it it just may not be there may just be you know a variant

tip Jennings down in Texas now the only person who knew about perforating veins was Bart - Oh max I talked to him the other day goes yeah I knew it because tip Jennings was doing all these deep fistulas down in Texas when he was down

there but tip is kind of when one of the proponents of deep fist shows why because when the proximal or the the distal radius of how a fistula fails the deep fistula can be made and still you don't have to tangle with the

superficial cephalic or basilic vein and also the deep fish avoids steel people don't steal blood when they have a deep fish to them and just because the the the size two or three millimeters of the perforator I think chronic keeps a check

on the blood flow that actually goes through trying to snip up the action

my last case here you have a 54 year old patient recent case who had head and neck cancer who presents with severe bleeding from a tracheostomy alright for some bizarre reason we had two of these

in like a week all right kind of crazy so here's the CT scan you can see the asymmetry of the soft tissue this is a patient who had had a neck cancer was irradiated and hopefully what you can notice on the

right side of the screen is the the large white circles of contrast which really don't belong there they were considered to be pseudo aneurysms arising from the carotid artery all right that's evidence of a bleed he was

bleeding out of his tracheostomy site so here's a CTA I think the better image is the image on the right side of the screen the sagittal image and you can see the carotid artery coming up from the bottom and you can see that round

circle coming off of the carotid artery you guys see that so here's the angiogram all that stuff that is to the right to the you know kind of posterior to the right of the screen there it doesn't belong there that's just

contrast that's exiting the carotid artery this is a carotid blowout we'll call it okay just that word sounds bad all right so that's bad so another question right what do you want to do here

I think embolization is reasonable but probably not the thing we can do the fastest to present a patient to treat a patient is bleeding out of the tracheostomy site so in this particular case this is a great covered stent case

alright and here's what it looked like after so we can go right up and just literally a cover sent right across the origin of that pseudoaneurysm and address the patient's bleeding alright

patient who presents with rectal

bleeding he's had a transfusion and this is the angiogram so it's gonna be a lot easier people volunteer so who wants to say what they see what do you say what do you say show me tell everyone what you say well there's two

slides the first one you see just a little bit of blood and on the second slide you can see where he's really bleeding all right so these are the same the same patient same angiogram so one thing you guys should realize if you

don't know this already about an angiogram is an angiogram is a series of pictures over time good job by the way so a series of pictures over time so it's not just one image and the analogy I like to give is if I take my kids to

Disney World right I can have that picture of all of us in front of the castle with the Mickey hats and everyone's smiling but like one second before this one kicked that one and one second after this one smacked the other

one in the head and they're all crying but I got that one picture an angiogram is that situation it's a series of pictures over time so while you may look at that first picture on the left and maybe not see so much going on what you

should appreciate on the right is that big blobby thing of contrast over on the right side all right now what that means is that there is blood pouring out of that person's vessel all right this is a mesenteric angiogram it's a superior

mesenteric artery angiogram we put a catheter in by the groin from the groin we went into the SMA and we took some pictures and this is what we're seeing and we're appreciating hopefully that big blobby thing on the right all right

so this is what we'll call a lower GI bleed all right the patient's essentially crapping blood that's a lower GI bleed all right so given that just another hint this kind of implies that we're gonna talk about upper GI

bleeding later all right just so you know so there's lots of different causes for lower GI believes there's diverticular disease there's angiodysplasia switch our small malformations of the blood vessels

there's a ski mcdowell there's patients who maybe had radiation therapy for different cancers can be predisposed to bleeding cancer itself can cause bleeding and different inflammatory diseases like either infections or other

diseases can as lower GI bleeding now how do we work these patients up well usually I would think that most of the time these patients have hit an ir suite they've probably had a colonoscopy first and a

colonoscopy is really the first line used to assess what's going on with a lower GI bleed it's not that easy to do it's difficult to prep those of you who resolve this I am and have had a colonoscopy know that it's better when

you prep before the colonoscopy and if someone comes in with a lower GI believe they haven't been adequately prepped that makes the colonoscopy very difficult the other thing is remember you're going from the bottom up into

colonoscopy and you have blood coming at you in someone who is experiencing a lower GI bleed and that essentially means it's difficult to see so many times the colonoscopy is not really able to tell us what we need to know I would

say the next thing that usually happens is some type of imaging now of a sudden the patients are coming to radiology and what you may have is any one of three different options you might have a nuclear medicine bleeding scan you might

have a CT angiogram you might have a regular old conventional angiogram and for those of you saying who cares what's the difference just take some pictures the big difference is that the amount of bleeding that it takes to see it is

different for each of those exams so the most sensitive exam is the nuclear medicine scan that's going to pick up the lowest rates of bleeding a conventional angiogram is the worst scan we can do for GI bleed or worse imaging

we can do because you need a lot of bleeding to see it so when we saw when my friend here picked up the the blobby thing on the right would that bleed that's a big bleed like we can look at it and say aren't these really pretty

pictures but when we see it and you see that kind of bleed you have to realize that's a lot of bleeding to see it like that so our antenna has to go up and we have to start moving a little bit CTA is kind

of right in the middle and actually a lot of people are turning now to see TAS I'm not personally a huge fan of that because I think it's a waste of time and contrast in my opinion I think a CTA for GI bleeding is a way if I can translate

it is I don't feel like doing that case right now so I'm gonna get a CTA and we'll figure it out later all right that's that's my language for a CTA but in my opinion you know it has some value how do we treat them well if

you can see on colonoscopy then you can potentially treat it with colonoscopy and there's different things that they can do with their scopes obviously if there's more diffuse disease they can remove part of

the bowel that's that's a problem and then of course the answer is embolization exactly so here is the picture from our embolization procedure and what do you see all right I won't pick on anybody yet basically what we

did was you can see over there you can see the shade of our angiographic catheter there's a micro catheter now passing all the way into the actual vessel that's bleeding and now when we do an angiogram you can actually see the

vessel that's bleeding now conventionally in the old days for those of you that have been doing this for a while you probably are used to living in a world where it's not great to embolize lower GI bleeds it's better to embolize

upper GI bleeds and lower GI bleeds and the reason why is because there's less collateral flow so if we block up a blood vessel we essentially kill everything beyond where we blocked it up because there's no alternative routes

for blood to flow all right in this particular case you can actually see that long stringy thing going right to the bleed and here we were able to get into that single vessel and kind of see it right there the long think heading

towards 4 o'clock and when we embolize it you can see we put coils in there and blocked it up so the only thing we embolize there is the blood vessel going to the abnormality the risk of ischemia is low and the clinical efficacy is high

but if you can't make it all the way out there if we embolize let's say right there that entire loop of intestine would be infarct it and that would be bad so we always have to think about that when we're embolizing GI bleeds all

so just a compliment what we everybody's talked about I think a great introduction for diagnosing PID the imaging techniques to evaluate it some of the Loney I want to talk about some of the above knee interventions no disclosures when it sort of jumped into

a little bit there's a 58 year old male who has a focal non-healing where the right heel now interestingly we when he was referred to me he was referred to for me for a woman that they kept emphasizing at the anterior end going

down the medial aspect of the heel so when I literally looked at that that was really a venous stasis wound so he has a mixed wound and everybody was jumping on that wound but his hour till wound was this this right heel rudra category-five

his risk factors again we talked about diabetes being a large one that in tandem with smoking I think are the biggest risk factors that I see most patient patients with wounds having just as we talked about earlier we I started

with a non-invasive you can see on the left side this is the abnormal side the I'm sorry the right leg is the abnormal the left leg is the normal side so you can see the triphasic waveforms the multiphasic waveforms on the left the

monophasic waveforms immediately at the right I don't typically do a lot of cross-sectional imaging I think a lot of information can be obtained just from the non-invasive just from this the first thing going through my head is he

has some sort of inflow disease with it that's iliac or common I'll typically follow within our child duplex to really localize the disease and carry out my treatment I think a quick comment on a little bit of clinicals so these

waveforms will correlate with your your Honourable pencil Doppler so one thing I always emphasize with our staff is when they do do those audible physical exams don't tell me whether there's simply a Doppler waveform or a Doppler pulse I

don't really care if there's not that means their leg would fall off what I care about is if monophasic was at least multiphasic that actually tells me a lot it tells me a lot afterwards if we gain back that multiphase the city but again

looking at this a couple of things I can tell he has disease high on the right says points we can either go PITA we can go antegrade with no contralateral in this case I'll be since he has hide he's used to the right go contralateral to

the left comment come on over so here's the angio I know NGOs are difficult Aaron when there's no background so just for reference I provided some of the anatomy so this is the right you know groin area

right femur so the right common from artery and SFA you have a downward down to the knee so here's the pop so if we look at this he has Multi multi multiple areas of disease I would say that patients that have above knee disease

that have wounds either have to level disease meaning you have iliac and fem-pop or they at least have to have to heal disease typically one level disease will really be clot against again another emphasis a lot of these patients

since they're not very mobile they're not very ambulatory this these patients often come with first a wound or rest pain so is this is a patient was that example anyway so what we see again is the multifocal occlusions asta knows

he's common femoral origin a common femoral artery sfa origin proximal segment we have a occlusion at the distal sfa so about right here past the air-duct iratus plus another occlusion at the mid pop to talk about just again

the tandem disease baloney he also has a posterior tibial occlusion we talked about the fact that angio some concept so even if I treat all of this above I have to go after that posterior tibial to get to that heel wound and complement

the perineal so ways to reach analyze you know the the biggest obstacle here is on to the the occlusions i want to mention some of the devices out there I'm not trying to get in detail but just to make it reader where you know there's

the baiance catheter from atronics essentially like a little metal drill it wobbles and tries to find the path of least resistance to get through the occlusion the cross or device from bard is a device that is essentially or what

I call is a frakking device they're examples they'll take a little peppermint they'll sort of tap away don't roll the hole peppermint so it's like a fracking device essentially it's a water jet

that's pulse hammering and then but but to be honest I think the most effective method is traditional wire work sorry about that there are multiple you know you're probably aware of just CTO wires multi weighted different gramm wires 12

gram 20 gram 30 gram wires I tend to start low and go high so I'll start with the 12 gram uses supporting micro catheter like a cxi micro catheter a trailblazer and a B cross so to look at here the sheath I've placed a sheet that

goes into the SFA I'm attacking the two occlusions first the what I used is the micro catheter about an 1/8 micro catheter when the supporting my catheters started with a trailblazer down into the crossing the first

occlusion here the first NGO just shows up confirmed that I'm still luminal right I want to state luminal once I've crossed that first I've now gone and attacked the second occlusion across that occlusion so once I've cross that

up confirm that I'm luminal and then the second question is what do you want to do with that there's gonna be a lot of discussions on whether you want Stan's direct me that can be hold hold on debate but I think a couple of things we

can agree we're crossing their courageous we're at the pop if we can minimize standing that region that be beneficial so for after ectomy couple of flavors there's the hawk device which

essentially has a little cutter asymmetrical cutter that allows you to actually shave that plaque and collect that plaque out there's also a horrible out there device that from CSI the dime back it's used to sort of really sort of

like a plaque modifier and softened down that plaque art so in this case I've used this the hawk device the hawk has a little bit of a of a bend in the proximal aspect of the catheter that lets you bias the the device to shape

the plaque so here what I've done you there you can see the the the the the teeth itself so you can tell we're lateral muta Liz or right or left is but it's very hard to see did some what's AP and posterior so usually

what I do is I hop left and right I turned the I about 45 degrees and now to hawk AP posterior I'm again just talking left to right so I can always see where the the the the AP ended so I can always tell without the the teeth

are angioplasty and then here once I'm done Joan nice caliber restored flow restored then we attacked the the common for most enosis and sfa stenosis again having that device be able to to an to direct

that device allows me to avoid sensing at the common femoral the the plaque is resolved from the common femoral I then turn it and then attack the the plaque on the lateral aspect again angioplasty restore flow into the common firm on the

proximal SFA so that was the there's the plaque that you can actually obtain from that Hawk so you're physically removing that that plaque so so that's you know that's the the restoration that flow just just you know I did attack the

posterior tibial I can cross that area I use the diamond back for that balloon did open it up second case is a woman

thank you so much for inviting me and to speak at this session so I'm gonna share with you a save a disaster and a save hopefully my disclosures which aren't related so this is a 59 year old female she's lovely with a history of locally advanced pancreatic cancer back in 2016

and and she presented with biliary and gastric outlet obstructions so she underwent scenting so there was a free communication of the biliary system with the GI system she underwent chemo and radiation and actually did really well

and she presents to her local doctor in 2018 with ascites they tap the ascites that's benign and they'll do a workup and she just also happens to have n stage liver disease and cirrhosis due to alcohol abuse in her life so just very

unlucky very unfortunate and the request comes and it's for a paracentesis which you know pretty you know standard she has refractory ascites and because she has refractory ascites tips and this is a problem because the pointer doesn't

work because a her biliary system is in communication with the GI system right so there's lots of bugs sitting in the bile ducts because of all these stents that have opened up the bile duct to list to the duodenum and so you know

like any good individual I usually ask my colleagues you know there's way more smart people in the world than me and and and so I say well what should I do and and you know there was a very loud voice that said do not do a tips you

know there there's no way you should do a tips in this person maybe just put in a tunnel at drainage catheter and then there was well maybe you should do a tips but if you do a tips don't use a Viator don't use a covered stand use a

wall stunt a non-covered stunt because you could have the bacteria that live in the GI tract get on the the PTFE and and you get tip situs which is a disaster and then there was someone who said well you should do a bowel prep you

like make her life miserable and you know give her lots of antibiotics and then you should do a tips and then it's like well what kind of tips and they're like I don't know maybe you should do a covered said no not a covered tonight

and then they're you know and then there was there was a other voice that said just do a tips you know just do the damn tips and go for it so I did it would you know very nice anatomy tips was placed she did well

the next day she has fevers and and her blood cultures come back positive right and you can see in the circle that there's a little bit of low density around the tips in the liver and so they put her on IV antibiotics and then they

got an ultrasound a week later and the tips that occluded and then they got a CT just to prove that the ultrasound actually worked so this really hurt my gosh to rub it in just to rub it in just just to confirm that your tips occlude

it and so you know I feel not so great about myself and particularly because I work in an institution that defined tip seclusion was one of the first people so gene Laberge is one of my colleagues back in the day demonstrated Y tips

occludes and one of the reasons is because it's in communication with the biliary system so bile is very toxic actually and when it gets into the the lining of the tips it causes a thrombosis and when they would go and

open these up they would see green mile or biome components in the in the thrombus so I felt particularly bad and so and then I went back and I looked and I was like you know what the tips is short but it's not short in the way that

it usually is usually it's short at the top and they people don't extend it to the to the outflow of the hepatic vein here I hadn't extended it fully in and it was probably in communication with a bile duct which was also you know living

with lots of bacteria which is why she got you know bacteremia so just because we want to do more imaging cuz you know god forbid you know you got the ultrasound of her they because she was back to remake and

you know that and potentially subject they got an echo just to make sure that she doesn't have endocarditis and they find out that she has a small p fo so what happens when you have a thrombosed tips you go back in there and you do a

tips or vision you line it with a beautiful new stent that you put in appropriately but would you do that when the patient has a shunt going from one side of the heart to the other so going from the right to the left so sort of

similar to that case right and so what do we do so I you know certainly not the smartest person in the room we've demonstrated that so I go and I asked my colleagues and so the loud voice of saying you know I told you this is why

we don't practice this kind of medicine and then there was someone who said why don't we anticoagulate her and I was like are you kidding me like you know do you think a little lovenox is gonna cure this and then the same person who said

we should do a tunnel dialysis tile the tunnel drainage catheter or like a polar X was like how about a poor X in here like thanks man we're kind of late for that what about thrombolysis and then you

know the most important WWJ be deed you guys are you familiar with that no what would Jim Benenati do that's that's that's the most important thing right so so of course you know I called Miami he's you know in a but in a big case you

know comes and helps me out and and I'm like what do I do and you know he's like just just go for it you know I mean there are thirty percent of the people that we see in the world have a efo it's very small and it probably doesn't do

anything but you know I got to tell you I was really nervous I went and I talked to miner our colleagues I made sure that the best guy who was you know available for stroke would be around in case I were to shower emboli I don't even know

what he would do I mean maybe take her and you know thrombolysis you know her like MCA or something I don't know I just wanted him to be around it just made me feel good and then I talked to another one of my favorite advisors

buland Arslan who who also was at UVA and he said why don't you instead of just going in there and mucking around with this clot especially because you have this shunt why don't you just thrown belay sit and then you

know and then see what happens and so here I brought her down EKOS catheter and I dripped a TPA for 24 hours and you know I made her do this with local I didn't give her any sedation because I wanted and it's not so painful and I

just wanted her to be awake so I could make sure that she isn't you took an intervention location you turned it into internal medicine I I did work you know that's that's you know I care right you know we're clinicians and so she was

fine she was very appreciative I had a penumbra the the the Indigo system around the next day in case I needed to go and do some aspiration thrombectomy and what do you know you know the next day it all opened up and you can still

see that the tips is short the uncovered portion which is which is you know past the ring I'm sorry that which is below the ring into the portal vein is not seated well so that was my error and and there was a little bit of clot there so

what I ended up doing is I ended up balloon dilating it placing another Viator and extending it into the portal vein so it's covered so she did very

blasian it's well tolerated and folks with advanced pulmonary disease there's a prospective trial that showed that

there are pulmonary function does not really change after an ablation but the important part here is a lot of these folks who are not candidates for surgical resection have bad hearts a bad coronary disease and bad lungs to where

a lot of times that's actually their biggest risk not their small little lung cancer and you can see these two lines here the this is someone who dr. du Puy studied ablation and what happens if you recur and how your survival matches that

and turns out that if you recur and in if you don't actually a lot of times this file is very similar because these folks are such high risk for mortality outside or even their cancer so patient selection is really important for this

where do we use it primary metastatic lesions essentially once we feel that someone is not a good surgical candidate and they have maintained pulmonary function they have a reasonable chance for surviving a long

time we'll convert them to being an ablation candidate here's an example of a young woman who had a metastatic colorectal met that was treated with SPRT and it continued to grow and was avid so you can see the little nodule

and then the lower lobe and we paste the placement prone and we'd Vance a cryo plugs in this case of microwave probe into it and you turn off about three to five minutes and it's usually sufficient to burn it it cavitate s-- afterwards

which is expected but if you follow it over time the lesion looks like this and you say okay fine did it even work but if you do a PET scan you'll see that there's no actually activity in there and that's usually pretty definitive for

those small lesions like that about three centimeters is the most that will treat in a lot of the most attic patients but you can certainly go a little bit larger here's her follow-up actually two years

that had no recurrence so what do you do when you have something like this so this is encasing the entire left upper lobe this patient underwent radiation therapy had a low area of residual activity we followed it and it turns out

that ended up being positive on a biopsy for additional cancer so now we're playing cleanup which is that Salvage I mentioned earlier we actually fuse the PET scan with the on table procedural CT so we know which part of all that

consolidated lung to target we place our probes and this is what looks like afterwards it's a big hole this is what happens when you microwave a blade previously radiated tissue having said that this

was a young patient who had no other options and this is the only side of disease this is probably an okay complication for that patient to undergo so if you follow up with a PET scan three months later there's no residual

activity and that patient actually never recurred at that site so what about

patient female patient who has the sudden onset of upper abdominal pain here's the CT we did all these cases in one day it was crazy it was terrible so so here's a big hematoma a big peritoneal hematoma you

can see it anterior to the right kidney you can see the white blob of contrast right in the middle of the hematoma that's a pseudoaneurysm or even active extravagance um less experienced people would probably say it's active

extravagant I think most of us would prefer that it be called kind of a pseudoaneurysm this active extrapolation would be much more cloudy and spread out this is more constrained and you can see on the

coronal image you get a sense that there's that hematoma same type of problem all right is there more imaging that we can do to figure out the next step again I said earlier earlier in this lecture

that sometimes we use CTA now sometimes a CTA is worthwhile I do find that for a lot of these patients I think we're getting smarter and we're doing CTAs right at the beginning of this whole thing you know when a trauma

patient comes in we're getting CTAs so we can max out the amount of information that we get on the initial diagnostic imaging here's what we're seeing on the CTA and in this particular case I think it's pretty clear that you can see the

pseudoaneurysm arising from what looks like a branch of the superior mesenteric artery so this is just an odd visceral and Jake visceral aneurysm which looks like it probably ruptured I don't have an explanation for it led to a big

hematoma here's what that is and now we're gonna do an angiogram the neat thing is it just perfectly correlated with a conventional angiogram so here's our super mesenteric angiogram all right the supreme mesenteric artery

on the first image to the left is that vessel going downward towards the right side of the screen all those vessels coming off are really just collateral vessels going up to the liver through the gastroduodenal artery again that

left one looks pretty good it's not until you see the delayed image on the right that you see that area of contrast all right so that's the finding that correlates with the CT scan all right here we're able to get in there you put

a micro catheter in that vessel alright the key next step for this patient as I mentioned earlier is the whole concept of front door and back door so here we're technically in the front door the next thing that we do is we put the

catheter past the area of injury and now we embolize right across the injury because remember once you embolize one thing flow is gonna change we screw it up body the body wants to preserve its flow if we block flow

somewhere the body's gonna reroute blood to get to where we blocked it so we want to think ahead and we want to say okay we're blocking this vessel how's the body going to react and let's let's get in the way of that happening that's what

we did here so we saw the pathology we went past it we embolized all across the pathology and boom now we don't have anymore bleeding and the likelihood of recurrence is gonna be very low for that patient because we went all the way

across the abnormality and I think from

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