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Bile Duct Injury, Clamp injury (Common Bile Duct) | Hepaticojejunostomy | 45 | Female
Bile Duct Injury, Clamp injury (Common Bile Duct) | Hepaticojejunostomy | 45 | Female
2016biliarybismuthcommonductercphepaticinjuryintrahepaticpercutaneousSIRsuturedtranshepatic
IR in Egypt and Ethiopia | AVIR International-IR Sessions at SIR2019 MiddleEast & Africa Focus
IR in Egypt and Ethiopia | AVIR International-IR Sessions at SIR2019 MiddleEast & Africa Focus
ablationsaccessafricaangiographybillarybulkcardiothoracicchaptercheaperconduitscountriescryocryoablationDialysiseconomyegyptelectroporationembolizationendovascularfibroidfibroidsFistulainterventioninterventionalnanonephrologyneurononvascularoncologyportalpracticeradiologyspecialtysurgeonssurgerysurgicallythrombectomytpavascularvisceralworldwide
Balloon Pulmonary Angioplasty | Management of Patients with Acute & Chronic PE
Balloon Pulmonary Angioplasty | Management of Patients with Acute & Chronic PE
angiogramangioplastyarteryballoonballooningbandschaptercomplicationscontrastflowHorizonimageimagesluminalNoneocclusionocclusionspatientsproximallypulmonaryradiationrecanstenosisthrombustreatedultrasoundwebs
Pre, Intra, and Post Operative | Biliary Intervention
Pre, Intra, and Post Operative | Biliary Intervention
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Case 5: Liver Trauma | Emoblization: Bleeding and Trauma
Case 5: Liver Trauma | Emoblization: Bleeding and Trauma
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CT Imaging- Acute PE | Management of Patients with Acute & Chronic PE
CT Imaging- Acute PE | Management of Patients with Acute & Chronic PE
acuteangiogramappearancearrowarteriescenteredchapterclassiccontrastcoronalimaginginfarctluminalNonepatientperfusionpulmonarysagittalscansegmentalsurroundingtechnologistthrombolysisthrombusvesselview
Carotid Artery Stenting- Case | Carotid Interventions: CAE, CAS, & TCAR
Carotid Artery Stenting- Case | Carotid Interventions: CAE, CAS, & TCAR
angioplastyarteryballoonballoonsbut want left carotid artery lesion stented firstcarotidcarotid arterychaptercommonCoronary bypass graftdistalECA balloonendarterectomyexternalexternal carotidimageinflatelesionosisproximalproximallystentstentingsurgicallyultimately
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
Q&A Pulmonary Embolism | Management of Patients with Acute & Chronic PE
Q&A Pulmonary Embolism | Management of Patients with Acute & Chronic PE
acuteangiogramassistedcatheterchapterchroniccontrastdiagnosticechocardiogramembolismisisNonepressurepulmonarythrombolysistreatmentultrasound
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
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
Innovation in Interventional Radiology in China | Across the Pond: The state of Interventional Radiology in China
Innovation in Interventional Radiology in China | Across the Pond: The state of Interventional Radiology in China
atresiabiliarybillarycatheterchapterchinadirectedinnovativeinterventionalintrahepaticmedicinenecessityportalradionuclidestentsthrombustreat
Hemobilia | Biliary Intervention
Hemobilia | Biliary Intervention
accessangioangiogramarchitecturearteriesarteryaureusbiliarybleedingceliacchaptercollateralizationdefectsdislodgementductembolizefistulasfrequentlygramhepatichilumintercostalinterventionistsliverparenchymalperipheralportalpreppseudoaneurysmremovethrombosestubetubesupsizeveinveinsvessels
Case 10: Peritoneal Hematoma | Emoblization: Bleeding and Trauma
Case 10: Peritoneal Hematoma | Emoblization: Bleeding and Trauma
activeaneurysmangiogramanteriorarterycatheterchaptercoilcontrastcoronalctasembolizationembolizeembolizedflowgastroduodenalhematomaimageimagingmesentericmicrocatheterNonepathologypatientperitonealPeritoneal hematomapseudoaneurysmvesselvesselsvisceral
Benign Biliary Strictures | Biliary Intervention
Benign Biliary Strictures | Biliary Intervention
balloonbenignbiliarychaptercholangitisclinicalcontrastessentiallylivermonthsneedleobstructedobstructionspatencypatientpatientsratessharpstricturestricturesstructuresurgerytesttracktransplanttube
The Ablation Concept | Interventional Oncology
The Ablation Concept | Interventional Oncology
ablationablativebifurcationbilebiliarycelsiuschaptercolorectalcontrastcryoablationcurrendegreesductexpirationgeneratesgrayhepatectomyinvolvinglesionmicrowavemodalitiesprobesradiofrequencyrapidstricturestumortumorsureterzone
Case 3b: Splenic Laceration | Emoblization: Bleeding and Trauma
Case 3b: Splenic Laceration | Emoblization: Bleeding and Trauma
angiogramarteriesarterychaptercoilsdelayedembolizationgastrichealhemodynamicallyinjurylacerationNonepictureproximalreconstitutionrupturespleensplenicSplenic Lacerationvessels
Cone Beam CT | Interventional Oncology
Cone Beam CT | Interventional Oncology
ablationanatomicangioarteriesarteryartifactbeamchaptercombconecontrastdoseembolicenhancementenhancesesophagealesophagusgastricgastric arteryglucagonhcchepatectomyinfusinglesionliverlysisoncologypatientsegmentstomach
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
Overview of Biliary Disease at John's Hopkins | Biliary Intervention
Overview of Biliary Disease at John's Hopkins | Biliary Intervention
accessangiogrambiliarychaptercolonoscopyendoscopicercphopkinsinterventionlandscapeliverpercutaneouspracticequestionspecialtiesspecialty
Ideal Stent Placement | TIPS & DIPS: State of the Art
Ideal Stent Placement | TIPS & DIPS: State of the Art
anastomosiscentimeterchaptercoveredcurveDialysisflowgraftgraftshemodynamichepatichepatic veinhyperplasiaintimalnarrowingniceoccludesocclusionportalshuntshuntssmoothstentstentsstraighttipsveinveinsvenousvibe
Aspiration Thrombectomy | Management of Patients with Acute & Chronic PE
Aspiration Thrombectomy | Management of Patients with Acute & Chronic PE
angioAngiodynamicsAngiovac CannulaAspirex CathetercatheterschapterclotdevicedevicesfrenchIndigo ThrombectomyNonepatientPenumbraPenumbra Inc.sheathStraub Medicalthrombectomythrombustpa
TIPS Case | Extreme IR
TIPS Case | Extreme IR
antibioticsascitesbacteriabilebiliarycatheterchapterclotcolleaguescommunicationcovereddemonstrateddrainageductduodenal stent placementfull videoportalrefractoryshuntsystemthrombolysistipstunnelultrasoundunderwentvein
Treatment Options- TransCarotid Artery Revascularization- TCAR | Carotid Interventions: CAE, CAS, & TCAR
Treatment Options- TransCarotid Artery Revascularization- TCAR | Carotid Interventions: CAE, CAS, & TCAR
angiographyangioplastyarterybleedbloodcalcifiedcarotidchapterclaviclecommondebrisdevicedistalembolicembolizationexposurefemoralflowimageincisioninstitutionlabeledpatientprocedureprofileproximalreversalreversesheathstenosisstentstentingstepwisesurgicalsuturedsystemultimatelyveinvenousvessel
Examples of Pediatric Lymphangiography | Lymphatic Imaging & Interventions
Examples of Pediatric Lymphangiography | Lymphatic Imaging & Interventions
angiogramascitesatresiachaptercongenitalductlymphlymphaticsurgerythoracicthorax
Scope of IR Procedures in South Africa | South African Interventional Society (SAintS)
Scope of IR Procedures in South Africa | South African Interventional Society (SAintS)
biliarycardiologistscenterschapterinterventionalInterventionsneuroparacentesisproceduressurgeonsvascular
Most common IR procedures and disease in China | Across the Pond: The state of Interventional Radiology in China
Most common IR procedures and disease in China | Across the Pond: The state of Interventional Radiology in China
ablationbiliarybiliary cancercancerchapterchinacirrhosisfactorsgeneticguyshcchepatitisinterventioninterventionalistsInterventionslargestlifestylelunglung cancerneuropiccprevalentproceduresmokingsocietaltrained
Percutaneous Biliary Drainage  | Biliary Intervention
Percutaneous Biliary Drainage | Biliary Intervention
angiogramaxischaptercoaxialcolordrainductductalfrequentlyhepaticinterventionalobstructionperipheralportalstructuressuccesssystemtubevein
Treatment Options- CAS- Embolic Protection Device (EPD)- Proximal Protection | Carotid Interventions: CAE, CAS, & TCAR
Treatment Options- CAS- Embolic Protection Device (EPD)- Proximal Protection | Carotid Interventions: CAE, CAS, & TCAR
angioplastyantegradearteryaspirateballoonballoonsbloodcarotidcarotid arterychaptercirclecirculationclampclampingcolumncommoncontralateralcrossdebrisdeflatedevicedevicesdilateddistaldistallyexternalexternal carotidfilterflowincompleteinflateinflatedinternalinternal carotidlesionmarkerspatientpressureproximalretrogradesheathstentstepwisesyringesyringestoleratevesselwilliswire
Massive PE | Pulmonary Emoblism Interactive Lecture
Massive PE | Pulmonary Emoblism Interactive Lecture
adenosineangiobloodbradycardiacatheterchaptercontraindicateddevicedirectedhypotensioninpatientinterventionalistsmassivematsumotopatientsPenumbrasurgicalsystemictherapythrombolysisthrombolyticthrombolyticsventricle
Case 2: Upper GI Bleed | Emoblization: Bleeding and Trauma
Case 2: Upper GI Bleed | Emoblization: Bleeding and Trauma
abnormalangiogramarteryaxisbleedingbleedsbloodcatheterceliacchaptercoilscontrastembolizationembolizeendoscopyesophagusFistulagastroduodenalhemoptysishepaticmalformationsmesentericNoneportalsuperiortipsupperUpper GI Bleedvaricesvenousvesselvesselsvomiting
Transcript

This is a 45 year old woman who presented with jaundice three days after a cholecystectomy. She went to ERCP first and we feel the common bowel duct, we feel nothing of the intrahepatic biliary tree.

So we brought her in for percutaneous transhepatic cholangiography. This is a fairly straight forward injury, the common hepatic duct has been sutured or clipped. This is a bismuth type one injury there's a long segment of common hepatic duct with the injury really occurring at the common bile duct. In our institution we manage with the rule and brought up in hepaticojejunostomy, prepared we were able to cross this and give the surgeon but in this

case even if we left an extra biliary drain above the site of injury that will be fine. This is fairly straightforward from a surgical perspective. So that's an easy starting case.

next is me talking about Egypt and Ethiopia and how I are how IRS practice in Egypt and Ethiopia and I think feather and Musti is gonna talk a little bit about Ethiopia as well he's got a

lot of experience about in about Ethiopia I chose these two countries to show you the kind of the the the the difference between different countries with within Africa Egypt is the 20th economy worldwide by GDP third largest

economy in Africa by some estimates the largest economy in Africa it's about a hundred million people about a little-little and about thirty percent of the population in the u.s. 15 florist's population worldwide and has

about a little over a hundred ir's right now 15 years ago they had less than ten IRS and fifteen years ago they had maybe two to three IRS at a hundred percent nowadays they're exceeding a hundred IRS so tremendous gross in the last 15 years

in the other hand Ethiopia is a very similar sized country but they only have three to five IRS that are not a hundred percent IRS and are still many of them are under training so there are major differences between countries within

within Africa countries that still need a lot of help and a lot of growth and countries that are like ten fifteen years ahead as far as as far as intervention ready intervention radiology

most of the practice in Ethiopia are basic biopsies drainages and vascular access but there is new workshops with with embolization as well as well as well as vascular access in Egypt the the ir practice is heavily into

interventional oncology and cancer that's the bulk that's the bulk of their of their practices you also get very strong neuro intervention radiology and that's mostly most of these are French trained and not

American trains so they're the neuro IRS in Egypt or heavily French and Belgian trains with with french-speaking influence but the bulk of the body iron that's not neuro is mostly cancer and it involves y9e tastes ablations high-end

ablations there's no cryoablation in Egypt there is high-end like like a nano knife reverse electric race electroporation in Egypt as well but there is no cryo you also get a specialty embolization such as fibroids

prostate and embroiders are big in Egypt they're growing very very rapidly especially prostates hemorrhoids and fibroids is an older one but it's still there's still a lot of growth for fibroid embolization zyou FES in Egypt

there's some portal portal intervention there's a lot of need for that but not a lot of IRS are actually doing portal intervention and then there's nonvascular such as billary gu there's also vascular access a lot of

the vascular access is actually done by nephrology and is not done by not not done by r is done by some high RS varicose veins done by vascular surgery and done by IRS as an outpatient there's a lot of visceral angiography as well

renal and transplants stuff so it's pretty high ends they do not do P ad very few IR s and maybe probably two IR s in the country that actually do P ad the the rest of the P ad is actually endovascular PA DS done by vascular

surgery a Horta is done all by vascular surgery and cardiothoracic surgery it's not done it's not done by IR IR s are asked just to help with embolization sometimes help with trying to get a catheter in a certain area but it's

really run by by vascular surgeons but but most more or less it's it's the whole gamut and I'm going to give you a little example of how things are different that when it comes to a Kannamma 'kz there's no dialysis work

they don't do Pfister grams they don't do D clots the reason for that is the vascular surgeons are actually very good at establishing fishless and they usually don't have a

lot of problems with it sometimes if the fistula is from Beau's door narrowed it's surgically revised they do a surgical thrombectomy because it's a lot cheaper it's a lot cheaper than balloons sheaths and and trying to and try a TPA

is very expensive it's a lot cheaper for a surgeon to just clean it out surgically and resuture it there's no there's no inventory there are no expensive consumables so we don't see dialysis as far as fistula or dialysis

conduits at all in Egypt and that's usually a trend in developed in developed countries next we'll talk

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

actually do something more than just drain and even though the drain is

frequently the most important part of biliary disease and we sometimes do also get to treat and and do more things with and intraoral you actually now also help them identify the conduit of the below a tube is actually very helpful we

actually can do IVIS we can also do intra Patek Carranza how Skippy and I'll show you what some pictures of that so it really is it just a conduit to get you into the blurry system so intraoperatively like a

you know Whipple procedure it's critical to get this tubing for our patients our surgeons actually use this axis a lot to pave the way for the sort of complex surgical resection of part of the budget system gall bladder pancreas and rehook

up the patient so that they have sort of the setting and almost always postoperatively will actually be Batum and the surgeons will leave a team in to maintain access and artificially hold open this new surgical nest the mostess

in an open position for as long time as

24 year old patient after a car accident has lower abdominal pain and melena so blood coming out of the rectum here's the CT scan anyone want to take a stab but you can just shout it out

so this time we're looking at the liver right so the liver is the big thing on the right side of the screen and what you can see is the dark hematoma posterior to the liver but you should also notice that big white dots sitting

right in the hematoma all right that's important because that's active bleeding that's the report when you guys when you guys get called in for these cases and someone says oh this you know liver trauma with active

bleeding this is the picture that is spurring that announcement okay this is what active bleeding and the liver looks like again there's a bleeding scale there's an injury scale for a liver trauma we don't need to go into that

slides are available if you want them alright here is the angiogram now again my rule works all right if you see vessels get smaller and then big again something's abnormal so in this particular picture I want you to notice

the catheter sitting in the right hepatic artery the blood is going up into the right lobe of the liver and right near the top of the pictures that big circular kind of blobby thing now this is by definition extravasation

sometimes we use the term pseudoaneurysm to describe this I just want you to appreciate what a pseudoaneurysm means it means that there's a hole in the artery that contrasts or blood is leaking out of that hole and the body is

essentially constraining the bleeding it's not going all over the place it's being constrained that's what we call a pseudoaneurysm all right that's just one way to look at it and geographically so this is an injury to the artery blood is

leaking out of the artery but maybe one layer of a three-layered blood vessel or even just the surrounding tissue is constraining that bleeding alright so what do we want to do for this exactly exactly you're getting it all right so

here we can get our microcatheter all the way out there the closer we get to it the better now in end organs like the liver or the kidney we don't actually have to get all the way out there getting close to it's going to be good

enough but the closer we get to it the better for stopping the bleeding and preserving the function of that organ all right so look how close we literally got right into the injury and then we're able to embolize it that's the goal all

right now the liver is a nice place the treat because as you know there's two sets of blood vessels going to the liver there's the portal veins in the apat ik artery so if we just embolize a little a patek artery the

liver is not going to notice that at all because it still has the portal venous flow bringing blood to that liver but our goal is to get in there preserve as much of the liver that we can and address that injury okay here's another

plan as well so I wanted to talk a

little bit about imaging I know with our residents and fellows and radiology that's all we do is talk about the imaging and then when go on to IR we talked to them about the intervention but I think it's important

for everyone in this room to see more imaging and see what we're looking at because it's very important for us all to be doing on the same page whether you're a nurse a technologist a physician or anybody else in the room

we're all taking care of that patient and the more information we all have the better it is for that patient so quick primer on a PE imaging so this is a coned in view of a CT pulmonary angiogram so yeah sometimes you'll see

CTS that are that are set for a pulmonary artery's and you'll see some that are timed for the aorta but if the pulmonary arteries are well pacified you're gonna see thrombus so I have two arrows there showing you thrombus that's

sort of blocking the main pulmonary arteries on the left and right side on the patient's left so the one with the arrow that is a sort of very classic appearance of an intro luminal thrombus you can see a little rim of contrast

surrounding it and it's usually at branch points and it's centered in the vessel the one on the right with the arrow head is really at a big branch point so that's where the right lower lobe segmental branches are coming off

and you can see there's just a big amount of thrombus there you can see distal infarct so if you're looking in the long windows you'll see that there's this kind of it's called a mosaic perfusion but it also what kind of looks

like a cobweb and that's actually pulmonary infarct and maybe some blood there which actually will change what we're gonna do because in those cases freaken we will not perform PE thrombolysis it's also important to note

that acute and chronic PE which we're here to talk about today may look very similar on a CT scan and they have completely different treatment methods so here's a sagittal view from that same patient you can see the CT scan so

between the arrow heads is with the tram track appearance so you'll see that there's thrombus the grey stuff in the middle and you'll see the white contrasts surrounding it and kind of like a tram track and that's very

classic for acute PE and then of course where the big arrow is is just the big thrombus sitting there here's another view of a coronal this is actually on a young woman which I think we show some images on but you can see cannonball

looking thrombus in the main pulmonary arteries very classic variants for acute PE and then this is that same patient in a sagittal view again showing you in the left pulmonary kind of those big cannon balls of

thrombus here's some examples from the literature showing you the same thing when you're looking at an acute PE it's right centered on all the image all the way in the left if the classic thrombus is centered right in the middle of the

vessel you can usually see a rim of normal contrast around it and you can see on a sagittal or coronal view kind of like a thin strip of floating thrombus so the main therapies for acute

are in the room here's a case of an 80

year old with a previous mi had a left hand are directing me and it's gonna go for a coronary bypass graft but they want this carotid stenting significant card accenting lesion to be treated first there's the non-invasive blow

through this but there's the lesion had a prior carotid endarterectomy so had that surgery we talked about first but at the proximal and distal ends of that patch has now a stone osis from the surgical fix that's developed so we

don't want to go back in surgically that's a high resolution we want for a transfer Merle approach and from there here's what it looks like an geographically mimics what we saw on the CT scan you can see the the marker and

the external carotid artery on the right that's the distal balloon and then proximally in the common carotid artery and they're noted there and then when you inflate the balloons you can see them inflated in the second image in the

non DSA image that's the external carotid room carotid artery balloon that's very proximal the common carotid balloon is below or obscured by the shoulders and ultimately when you inflate the common carotid balloon you

just have stagnant blood flow then we treat them you can see both balloons now and the external carotid and common carotid in place we have our angioplasty balloon across the lesion and then ultimately a stent and this is what it

looked like before this is what it looks like after and tolerated this quite well and we never had risk of putting the patient for dis Lombok protection or to salamba lusts overall I'm not gonna go over this real

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

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]

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

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

medicine so very innovative though I will tell you necessity is the mother of all inventions right so if I can't get a hold of these products that I'm reading

about they they come up with some of their own products and some of their own procedures that were very innovative specially in the the world of IO SCI lastik intrahepatic biliary stands are very common over there they were

actually innovated over in China of radionuclide impregnated pillory stents imagine taking y9t shoving them in billary stents and putting them in to treat biliary cancer in atresia they do that quite readily over there we don't

do that here in the US but we're experimenting with it intravascular catheter directed gene therapy actually started in China pre portal vein thrombus to me for transplant liver functionality they do

that very commonly we just consider a very complex procedure over here catheter directed stem cell treatment for focal after mattis lesions they do that instead of doing stents over there and they're all innovated in China so as

I said necessity is the mother all of invention and when you go overseas and you get to work with some of your interventional colleagues who do not have access to what we currently have here in the Western medicine world

you'll be amazed at some of the stuff they've come up with it try to treat their patients so from American

to have severe humor billion almost all all those that need your attention is about aghori portal veins though can be tremendously so the differentiation between hepatic artery and portal vein

bleeding is the big differentiator that will require you to do something about it most of the times if you injure the portal vein or hepatic vein these usually heal by themselves and it's counterintuitive the management of this

is actually to upsize your tube and they make sure the side holes are not adjacent to the bleeding vein it's crossing so it's counterintuitive that you upsize - for bleeding injure the vein more but

eventually those veins will thromboses off for that little branch the difficult situations of sahiba heavy hit an artery and here's one way we did a gram you can see the pacification the reason why you want to go into the peripheral duct I'll

show you always near the hilum is actually also very big blood are the blood vessels and the reason why we go peripheral the number of large vessels are much greater diminished so you always want in this patient was

transferred for an outside Hospital my PTC was performed by someone who obviously doesn't do a lot of these and access directly into the coma bar duct you can see all these filling defects all these filling defects in the combat

like those or clots and filled with someone who's actually had life-threatening significant he Mobilia and required what we did was they were just pacify the system get another peripheral access

right biliary system and embolize the track coming out and thereby removing the original axis that was placed by the outside hospital interventionists obviously the ones that aureus the most of the narco that will kill people is

the ones that hit our ease and pseudoaneurysm formation or tara Venus fistulas and I can be problematic in my only real ways their dresses trans cap the treatments a patient would have an angio we'd have to get into the pedagogy

find the feeding or it almost always though and we can predict way that bleeding artery is it's where your Y is crossing the architecture of the artery tree frequently you will not see it until you remove the tube so almost

always you would have to prep the right flank prep the groin to an angiogram with the tube in because you don't really want to be rushing at the beginning of your procedure you frequently do the angiogram not see

bleeding and then a second operator needs the described brake scrub get non sterile axes remove the blue tube repeat the angiogram and almost certainly then you'll see it but again it's very

predictable where it is but every now and then you get caught out and the bleeding side can be remote from where your actual Y or actual access transgressor you you do need to have a careful eye looking for that and so you

know when we looked at out and we do large numbers of blurry drainage the best predictor or and like I said Arturo Kimber Billy is actually related to your first tube and the size that you place and it's also

interesting like I said every now and then you're gonna see that bleeding arteries are actually not liver arteries and you can't bleed from the GDA internal memory from other procedures intercostal artery from where you put

your tube first needle through the liver through sorry through the ribs itself it's actually access site rather than your internal parenchymal your liver so it's actually important to also do sometimes it a water gram check the

intercostal artery because you'll miss it by doing a celiac or teragrams hepatic artery gram and don't understand why the patients still bleeding and here's just example of what a pseudoaneurysm does when we remove the

chief we can see the image on the right the blue tube has mean withdraw back and they you can see quite clearly there and sorry the pseudoaneurysm of the paddock right re and like any other immunization is important to go front door back door

implies across mainly because the liver architecture has a rich collateralization that will feed before and after and like I said the lake complication zone was or derived and related to tube maintenance and tubes

catching on to things in dislodgement and so these are just really you know your whoever answers the phones whether it's the physicians on call they have to manage with maintenance of these tubes and really just keeping these tubes open

as long as possible it's amazing how long some of these tubes do last in particular in benign but Lewis structures so management of these is really or expectant and the right advice and frequently just need to

get these tubes changements they're clogged sufficiently the difficult ones

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

this is just happens to be a biliary

other classification system with bismuth how where the injury occurs and this is really germane after surgery so you'll see most of these actually after misadventure with bluish surgery and and like I said the most common ones

actually after laparoscopic surgery but we have barrier so we have oncological have two extremely complex three sections of the liver now and and we the advent and certainly rise are more balloon complications this is an example

of what we might do in the complex setting this patient had explorers in cholangitis primary cylinder current charges received a transplant and the transplant liver had a recurrence and with recurrent explorers and cholangitis

there was just no way we could cross it but even with a long-standing billy we drain frequently if you drain most obstructed systems a day or two passage across an inflamed structure it makes it much more easy and you will see their

people get brought back for their secondary tube with laryngitis sometimes this is not possible so we actually have made attempts to cross this there's no other way so we happen to use a sharp organization so we happen to use a

transept own needle and use a sharp needle go breakthrough sometimes analysis of the CT scan is a very important you really want to know what's between your one side and what's on the other side and the more even more fun

thing to do now is using our rfy off-label and we'll burn our way through and create the track that actually has a much better patency rates and even sharp organization your allow essentially coring of sort of in chronically

inflamed fibrotic tissue and allows you a chance of keeping this open it's just example of how you benchley burrow through with a shop another case with a sharp needle creating a track really that's not

natural because this is obviously a transplant patient and it's the only way through even done what we've done is stick the intestine first and then put us in a punch our way through polio stay out and

then thereby restoring the the track and they are sort of you have to be just really created with biliary disease when it comes to chronic obstructions or high-grade obstructions so like I said with benign the disease frequently it's

post-operative and so they will present in multiple different ways and most of the times they're just leaking in the intraperitoneal ich you you're you essentially peritoneal cavity will reabsorb it so patients get jaundice is

essentially it hi arrays but Rubens and you'd really can diagnose in many ways and really just dealing with this can be problematic and then so we've been dealing with bluish structures and and oh sorry benign Ballou strictures

post-operative benign Ballou strictures in a more labor-intensive way we actually leave tubes in for six months which is probably a little more than most people must be not a benign the Lewis structures are managed with three

months of stinting with a minimum of twelve French tube so that's a reason why some of these patients will get kalanchoe pasties multiple bluie a drained Rhys tenting it and tube exchanges and changed up this way and

then this is just happens to be the British is worth a typical we will get access cross the stricture kalanchoe plastic stretch out this benign structure and then place a tube in for as long as you can to keep it open and

fro asses of between three and six months there's a classic example someone who obstructed that they said this looks very smooth it doesn't look ugly and looks okay doesn't look like a cancer we sometimes what I so biopsy if it has any

suspicious appearance and then get across you can see even with a balloon how tight the structure can be with a high pressure balloon and there after placing achievement for again three to six months we actually err on the side

of caution almost our patients have six months of intubation which is quite long difficult and this is our experience what we do then is when do you remove it to actually have a sort of a step-by-step process we have a it's not

really medical clinical trials actually just if a flow clinical trial what we'll do is get the tubing bring a patient back and we actually cut the tube so there's only the access through the parenchyma of the liver is preserved but

nothing through the structure we will cap the tube is since you can maintaining access and see if the patient doesn't make sure that doesn't get fever the stricture is maintained and then we'll bring the patient back

after a week to do a balloon whiticus test that's really just a modification of a urinary radhika test we're going to take pressure measurements after slow contrast injections to make sure it remains the

patency and for us the data suggests we can essentially and predict over 90% who will be staying free if they pass the Whittaker test in keeping the monetary reading less than 20 centimeters of

water and really it allows us to manage these because of how many patients have what procedures at our institution we have a large volume of patients that we actually follow and it's a you know our fellows think it's the most common

procedure Billu intervention had this is actually not that coming everywhere else and this is what I believe tests we have a pro forma that we fill in and the contrast has been ejected in

certain rates per minute and so this test takes about 30 minutes we make sure that there's the predictive value of in less than less pressure building up over higher high contrast injection rates will give us a great prediction of no

longer needing the tube and then stone

the ablation concept in general is to provide an environment that is

completely hostile to tumor minus 40 degrees Celsius 150 degrees Celsius 500 gray which is a radiation dose we say it's very hard for it's about anything to survive but so why is it that it doesn't always work well that's a

function of all those parameters that you see there we got to make sure we pick the right patients we got to make sure that we treat tumor where we think it is and avoid trading things that don't need treatment avoid causing

damage to collateral structures and getting a reasonable margin where we actually get some of the tumor that's microscopic there are a lot of ablation modalities radiofrequency alternates electrical current very rapidly so that

generates friction within the lesion and causes heat it looks like this a lot of times you see these little times that stick out so that you can increase the size of your blasian zone and here's a one of those deployed in a patient who

had a colorectal Curren after hepatectomy cryoablation freezes things and it pushes a gas that once it goes through a pin hole tends to expand and cause rapid freezing he can also push another gas right through it and cause

rapid heating but this is just bringing tumors to that minus 20 degree minus 40 degree threshold the nice part about cryoablation is that you can visualize your ablation zone so we're right up against the bile duct here and it tends

to be a little more respectful of tissues so that's why cryoablation is chosen every once in a while we're do frequency ablation is an excellent tool we have lots of data for it but likes it sometimes it's difficult determine where

the ablation zone is interprocedural e microwave ablation there was just a randomized study that came out that compared microwave ablation to radiofrequency ablation and the results are very similar

it was a very very experienced institution doing it but the whole point here is that a lot of these tools work pretty well there's no clear superiority on them but one thing that microwave offers it's very fast so generates

temperatures to boiling within the tumor in about five minutes and so it's certainly very fast as compared to radiofrequency and you can see boiling happening within this tumor that's been accessed eventually there that gas is

actually literally fluid that is boiling away from the tumor couple of cool ones this one's reversal expiration what we do here is we place probes throughout the lesion and we pulse it to confuse the membrane on the cell to think that

it's a it has holes in it that it cannot close and so what is happening is the contents inside the cell leave and that's pretty much consistent with not being able to survive the nice part is we can accomplish all that without

thermal ablation what do we mean that we don't go over about 40 degrees Celsius so if something is involving a bile duct or involving a critical structure like the ureter it's not actually going to damage it it just basically tells all

the the cells within there to stop stop undergoing the cellular mechanisms responsible for life it's a little more finicky to place you have to place these little parallel probes here's one we did that was directly write on the

bifurcation of the main bile ducts and you can see here afterwards is an immediate post contrast scan how that whole area is ablative it does not take up contrast and this patient never developed biliary strictures that side

different patient this is an unrestrained passenger in a motor vehicle accident now that you are all

experts in looking at this CT you can see on the right side of both of those images is the spleen you can see that darker grey areas within the spleen that's bad it should look more like the the the lighter parts

and actually all the grey are on the outside is all blood or fluid in the abdomen so this is a bad laceration probably at least a grade four splenic laceration but again this was a hemodynamically stable patient all right

and here's what we saw this is the angiogram you can see the splenic artery and you can see they're kind of diffuse abnormality of the spleen it just doesn't look right under normal circumstances it just look like branches

on a tree and what we're seeing here is just kind of splotchy looking splenic ranked them up so that's not normal we just want to give it a chance to heal this is the scenario we might do a proximal splenic embolization where

we'll go in and we'll basically put a plug or some coils right at the origin of the splenic artery and I love this picture because what it shows is why we do this philosophically what I want you to notice is on the image to the left

you can see the coil right there right if you see the abrupt stopping of the splenic artery and then what you see are all those vessels going up towards the top of the picture those are arteries that are supplying

the stomach it's the left gastric artery some other vessels that then go through vessels we call the short gastric arteries and what you get is is the reconstitution of the splenic artery so on the image to the right all the way on

the right side of the picture those branches that you see are within the spleen so even though we plugged up the splenic artery right at its start the spleen is able to get blood flow through those collateral vessels all right so

that's our goal that's what a proximal splenic embolization is trying to do we just want the spleen to heal a little bit and reality what we want to do is these patients are usually fine we just don't want them to go home and have a

delayed rupture of their spleen because that's something many of us probably don't appreciate if someone has a splenic artery injury or splenic injury and they're doing fine and then we send them home there is an incidence of

delayed rupture of the spleen and what we know through lots of good papers is doing these proximal embolization procedures helps to reduce that risk of delayed splenic rupture so that's what we're trying to do there all right so

know we're running a bit short on time so I want to briefly just touch about

some techniques with comb beam CT which are very helpful to us there are a lot of reasons why you should use comb beam CT it gives us the the most extensive anatomic understanding of vascular territories and the implications for

that with oncology are extremely valuable because of things like margin like we discussed here's an example of a patient who had a high AF P and their bloodstream which tells us that they have a cancer in her liver we can't see

it on the CT there but if you do a cone beam CT it stands up quite nicely why because you're giving levels of contrast that if you were to give them through a peripheral IV it would be toxic to the patient but when you're infusing into a

segment the body tolerates at the problem so patient preparation anxa lysis is key you have them exhale above three seconds prior to that there's a lot of change to how we're doing this people who are introducing radial access

power injection anywhere from about 50 to even sometimes thirty to a hundred percent contrast depends on what phase you're imaging we have a Animoto power injector that allows us to slide what contrast concentration we like a lot of

times people just rely on 30% and do their whole the case with that some people do a hundred percent image quality this is what it looks like when someone's breathing this is very difficult to tell if there's complete

lesion enhancement so if you do your comb beam CT know it looks like this this is trying to coach the patient and try to get them to hold still and then this is the patient after coaching which looks like this so you can tell that you

have a missing portion of the lesion and you have to treat into another segment what about when you're doing an angio and you do a cone beam CT NIT looks like this this is what insufficient counts looks like on comb beam so when you see

these sort of Shell station lines that are going all over the screen you have to raise dose usually in larger patients but this is you know you either slow down the acquisition speed of your comb beam or

you raise dose this is what it looks like after we gave it a higher dose protocol it really changes everything those lines are still there but they're much smaller how do you know if you have enhancement or a narrow artifact you can

repeat with non-contrast CT and give the patient glucagon and you can find the small very these small arteries that pick off the left that commonly profuse the stomach the right gastric artery you can use your comb beam CT to find

non-target evaluation even when your angio doesn't suggest it so this is a patient they have recurrent HCC we didn't angio from here those arteries down there where those coils were looked funny even though the patient was

quote-unquote coiled off we did a comb beam CT and that little squiggly C shape structures that duodenum that's contrast going in it this would be probably a lethal event for the patient or certainly would require surgery if you

treated that much with y9t reposition the catheter deeper towards the lesion and you can repeat your comb beam CT and see that you don't have an hands minh sometimes you have these little accessory left gastric artery this is

where we really need your help you know a lot of times everyone's focused and I think the more eyes the better for these kind of things but we're looking for these little tiny vessels that sometimes hop out of the liver and back into the

stomach or up into the esophagus there's a very very small right gastric artery in this picture here this patient post hepatectomy that rides along the inferior surface of the liver it's a little curly cube so and this is a small

esophageal branch so when you do comb beam TT this is what the stomach looks like when it enhances and this is what the esophagus looks like when it enhances you can do non contrast comb beam CTS to confirm ablation so you have

a lesion this is the comb beam CT for enhancement you treat with your embolic and this is a post to determine that you've had completely shin coverage and you can see how that correlates a response so the last thing we're going

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

good afternoon thank you so much for invitation to speak to you I have a privilege of working at Johns Hopkins and we have a fairly large practice we at the main hospital itself we have 11 rooms and during a day about two of them are have a biliary case actually going

on at the same time so it's actually a fairly large volume of our practice and so the gamut of bluie intervention goes from really simple stuff to really complex and it is something that our trainees specifically will come to

Hopkins for and many of times they will end up being the blurry and experts as soon as they arrive at a new practice so certainly it's something that we deal with every day I just wanted to give you a landscape overview and share some good

cases that we've done and hopefully you may something have some comments or learn something about the way we do it but I'm pretty sure throughout the country a lot of great Billu work has been done currently there's no question

though the Blooey access and access to the Blooey system has really been played out in most hospitals perth by GI and ir and obviously surgery but almost a lesser so today and the rat in at least four IR is the PTC PPD or transparent

Col angiogram but it's actually a recurring role and I actually speak and have a sort of special interest in transit paddock colonoscopy as well so we play scopes through the skin through the liver and do a lot of balloon

intervention I'll show you a few cases like that but in true these access points are germane to what specialty you come from and obviously endoscopic beeper oral and if you eye are usually usually through the skin and there's no

question GI now in some hospitals I'm sure you have advanced endoscopy that will go through the stomach straight into the leftover liver so there's no question of a blurry landscape is changing quickly but no question that

this is quite common but yet most patients and internal medicine specialties will be looking at blurry disease by access point through scopes through ercp so going back from the Duden up or directly through in there's

advantages disadvantages something it's fairly obvious to everybody that you know no question is selling it to a patient if it had both choices that ERCP through the mouth and nothing invasive nothing sticking out their body

is attractive yet the outcomes are very similar but nonetheless there's pros and cons and through the trance of had a crap or two percutaneous route you do definitely have tubes at least sticking out

initially and this is often solved by GI as the main differentiator at least a discomfort but yet we are able to address almost every problem at times and often where'd they pay a lot there's

stamp placement we talked a little bit about it I'm gonna talk to you a little

bit more about it and ideal stance is a straight stance that has a nice smooth curve with a portal vein and a nice smooth curve with a bad igneous end well you don't want is it is a tips that T's the sealing of the hepatic vein okay

that closes it okay and if there's a problem in the future it's very difficult to select okay or impossible to select okay you want it nice and smooth with a patek vein and IVC so you can actually get into it and it actually

has a nice hemodynamic outflow the same thing with the portal thing what you don't want is slamming at the floor of the portal vein and teeing that that floor where where it actually portly occludes your shunts okay or gives you a

hard time selecting the portal vein once you're in the tips in any future tips revisions okay other things you need it nice and straight so you do not want long curves new or torqued or kinks in your tips you

a nice aggressive decompressive tips that is nice and straight and opens up the tips shunt okay we talked a little bit you don't want it you don't want to tee the kind of the ceiling of the of the hepatic vein another problem that we

found out you want that tips stance to extend to the hepatic vein IVC Junction you do not want it to fall short of the paddock vein IVC Junction much okay much is usually a centimeter or centimeter and a half is it is acceptable

the problem with hepatic veins and this is the same pathology as the good old graft dialysis grafts what is the common sites of dialysis graft narrowing at the venous anastomosis why for this reason it's the same pathogenesis veins whether

it's in your arm for analysis whether it's in your liver or anywhere are designed for low flow low turbidity flow of the blood okay if you subject a vein of any type to high turbot high velocity flow it reacts by thickening its walls

it reacts by new intimal hyperplasia so if you put a big shunt which increases volume and increased flow turbidity in that area in that appear again the hepatic vein reacts by causing new into our plays you actually get a narrowing

of the Phatak vein right distal to the to the to the Patek venous end of the shunt so you need to take it all the way to the Big C to the IVC okay how much time do I have half an hour huh 17 minutes okay

Viator stents is one way let's say you don't have a variety or stent many countries you don't have a virus then what's an alternative do a barre covered stem combination you put a wall stent and then put a covered stance on the

inside okay so put a wall stent a good old-fashioned you know oldie but a goodie is is a 1094 okay you just put a ten nine four Wahl cent which is the go to walls down so I go to stand for tips before Viator

and then put a cover sentence inside whatever it is it's a could be a fluency it could be a could be a vibe on and and do that so that's another alternative for tips we talked about an ace tips as a central straight tips and it's not out

and fishing out in the periphery okay this is an occlusion with a wall stance this is why we use think this is why now we use stent grafts this is complete occlusion of the tips we're injecting contrast this is not the coral vein this

is actually the Billy retreat visit ptc okay that's a big Billy leaked into the into the tips okay and that's why we use covered stance I'm gonna move forward on this in early and early and experienced

thrombectomy is another popular way of treating patients there's a lot of different aspiration catheters the SPX catheter is actually not available currently in the US but what it basically is I can have the rectum a

device that spins in such backlot the Indigo thrombectomy system from penumbra is a yet another device that sucks out clot I think many of us have used that it's kind of like a vacuum cleaner but usually more like a dust

hand vac where it's going to suck up thrombus the angio vac is much more like a Hoover where you're going to use and put a patient on veno-venous bypass that requires a 22 French sheath and a 17 French sheath but that will take out

thrombus I personally prefer using NGO vac in the IVC in big large thrombus for that and not in the pulmonary arteries because it's very inflexible but it's very very useful in a few patient populations in

all of these devices there is no TPA that needs to be given you're just sucking out the clot and you're actually removing it from the patient's body rather than dissolving it and sending it downstream the drawbacks on all of these

devices is their larger access points the SP or X is around six French although that's not that much bigger penumbra device is 8 French and the as we mentioned the angio vac is 22 French

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

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

these kids just to show a couple cases from our study this was a three-month-old who'd had a congenital Kyle thorax as well as congenital ascites and you see that we're starting

be lymph angiogram it certainly looks very bizarre certainly not like anything else I'm showing you so far and you see if this child was actually born can generally without a thoracic duct or central lymphatic so this was a an

example of thoracic duct atresia unfortunately not compatible with life very rare thing that has published every couple years this was another child a little bit older 15 year old we wonder with scoliosis a corrective surgery lots

of screws had a great outcome from surgery unfortunately noticed right there that one of the screws went right through the thoracic duct so not a surprise this kid had recurrent Kyllo thorax we certainly didn't oblique here

to prove that it also went right through that structure we got our wire up and in all the way across and put our catheter up we'll put some coils right at the top and then place some glue across the whole thoracic duct and you see the two

areas where the site of injury were the two arrow heads at the bottom of the screen there so plastic bronchitis is a

higher procedures that get done in the country so they are from being basics such as being para sentences and in some

centers being quite complex in Euro work and there are centers where these none of all those that IR procedures being available so it's a very unequal distribution of provision of IR services and like I mentioned earlier on vascular

surgeons and cardiologists have basically taken over the peripheral vascular work and iogic work and other known neuro speciality such as bid early interventions for example saying that these two surgeons who are in some

remote centers who are doing their own provision as biliary basic interventions there is one neuro surgeon who went and had neuro imaging and then your interventional training who is now hundred percent doing a mural

intervention so as far as procedures go my day can be in diagnostic work and you might be dreaming you doing a paracentesis the next thing you might be doing some some I our basic IR and on the same day you might be doing a set

procedure so quite varied but not available in all centers as one would want as fine stuff goes the technology

you know the most common procedures in China this is kind of interesting I was blown away by this when I did the research on this I knew when I would go

into the hospitals and I was all over for I've been to Beijing shanghai nanjing to even the smallest little place is up in northern china and the one thing that blew me away I'm looking at the board and I'm seeing neuro case

after neuro case after neuro case I'm like it got 10 Narrows and and a pic line I'm like it's an interesting interesting Dysport of cases and the reason being is in China they consider diagnostic neuro

so neuro angio to be the primary evaluating factor for any type of neurological issue so you're not getting a CT if you come in with a headache you think you're gonna go get that cat scan now it's generally what not what they do

so you're talking about a case and I'll give you the case matrix of the break-up it's just proportionately high for a neuro very well trained in neuro and most of the guys that are trying to neuro very similar to what dr. well Saad

said a lot of the guys in Africa are trained in France so other neuro interventions have trained in France or lipstick in China and have received European training on that so you know the level of what they're doing some of

the stroke interventions some of the ways they're going after these complex APM's they'll Rob well anything you'll see here in the US so it is quite interesting to see and the second

largest is taste hepatocellular carcinoma is on the rise it's the highest level in the world is found in China and Korea for that matter and there's many reasons why we can go into it some of it is genetic factors and a

lot of societal factors alcohol is a very liberally lie baited in China and there is problems with you know cirrhotic disease and other things that we know could be particular factors for HCC so always found that very

interesting like I said I would go into a hospital and I'll see a PICC line a hemodialysis catheter and then 20 tase's on the board in one day so it is quite interesting how they do it and then biliary intervention stents tips and

then lung ablation you know the highest rates of HCC biliary cancer and lung cancer found in China and once again when we talk about lung cancer what are those contributing factors you're talking about certainly a genetic

component but mostly it's lifestyle factors smoking is prevalent in the US and in you know in Europe and in some areas in Asia we've seen obviously a big reduction in smoking which is fantastic China not so much you don't see that

it's a societal thing for them and unfortunately that has led to the the largest rates of cancer in the world in lung cancer so lung ablation is a big procedure for them over there as well so procedure breakdown this is kind of some

of that breakdown I was telling you about that cerebral procedure is some of the most commonly performed and you're talking about at very large numbers they're doing neuro intervention because they do it for die

Gnostic purposes and I would that kind of blew me away when I found out they do have cast scanners and certainly for trauma and things like that they'll do it but the majority of the stuff if you come in you have headaches you might end

up in the neuro suite so it's quite interesting how they can do that tumor intervention very high like I said you have the highest rates of HCC in the world you're getting cases they do have y9t available and in fact China just

made their largest acquisition ever with the by what you guys know a company they bought surtex there's a Chinese company now it got bought by China now the interesting is they don't currently have a whole lot of

y9t over there but they just opened up some of their own generators so they can actually start producing the white room 90 and I think you'll see probably a increase in those numbers of y9t cases but to date the number one procedure for

them is taste and they do a lot of them you know like I said on average a community hospital setting you might find 15 or 20 cases a day with three interventionalists so compared to what you guys do there's probably not many

people here unless you're working at a major institution that there's nothing but cancer doing 20 cases a day and I promise you're probably not doing it with only two interventionalists so it's amazing how fast and effective they've

gotten at and below therapy and unfortunately it is necessary because of those elevated HCC levels and like I said when we look at some of these things it's I go over there and I'm looking at the board there are very few

cases for you know PICC lines very few the frosted grams very new bread-and-butter abscess training procedures like we do here in the US they are very it's the prevalence is very simple it's neuro it stays and it's

biopsy and those are some kind of the big three for intervention in China and there it's such a large volume you get to learn a lot when you're over there and CLI PA D even though it's more prevalent in China than it is here

because smoking lifestyle factors certainly westernization of the diet in China which occurred since the 1950s and 60s has led to a lot of McDonald's and and fast food and things that weren't currently available prior to 1950s you

see a lot of PA d but it is very undertreated and certainly talking to some of my colleagues like whom are oh you'll get to see a little bit later on with CLI fighters one of the things that's kind of frustrating for them is

that it is so undertreated it's very common to see amputations in China instead of actually doing pipe in percutaneous intervention they normally like to go too far and you see a lot of amputation certainly above

normal so that's something I think as an interventional initiative when we look at these things coming from a Western perspective it's definitely something we need to pursue a little more aggressively but there it's very little

oh well you're talking about two you know two to three percent you know maybe up to six percent or PID cases very very low levels so equipment in equipment in

we do drain the Louie systems we actually do this extremely successfully as interventional radiologists and it's a very high technical success like I said in this sort of supine position

from the mid-axillary line and these things are and you've seen a lot of these how these done really you need to pacify the system you get trans you most post people go trends in to cost Albany because the liver sometimes can be

tucked up way above and we usually want to make sure that the lung and the costophrenic angle doesn't come down low in nothing I take a deep inspiration first to make sure that you're not dealing with and then we now map your

track than you find some people do this with ultrasound guidance frequently with and dilated structures and most of the time it's actually much probably routine to actually do blind passes in the like I said the path of high success and to

pull back when you a passive our blue system is the only structure that doesn't wash away generally portal vein hepatic vein hepatic artery all of those structures are cylindrical

tubule alike are not are going to wash away move away and quite quickly and you can see this PDC and show in fact a left insertion of a right into your ductal system and frequently this will be something that we would have to make

people watch out like I said identification of choosing the right duct thereafter after you've identified you've performed a color angiogram is to identify how you're going to drain this and the most important thing to identify

is a peripheral duct doesn't matter which one there are ones with higher success but then within the lateral position find one market on the table then with a second axis as a to stick axis and I'm sure this is very germane

and common you've seen get into the peripheral duct and the AP fluoroscopy get a wide down you get a tube down and then eventually go it with a coaxial system getting a skinny wire converted to a larger wire and then following that

with a below a tube and your goal is to really get axis that goes transpannic through a perfect century through obstruction or no obstruction if it's just untie elated and through into the small bowel and lock a some type of

locking system it's interesting the size that you choose does make it different so if you go larger than the 12 french-trained initially the risk of bleeding actually goes above 10% for initial axis so the best is to probably

start with a 8 and 10 and that's what we typically do this is what we connect what it ends up looking like left a

of these issues filters are generally still use or were used up until a few years ago or five years ago almost exclusively and then between five years and a decade ago there was this new concept of proximal protection or flow

reversal that came about and so this is the scenario where you don't actually cross the lesion but you place a couple balloons one in the external carotid artery one in the common carotid artery and you stop any blood flow that's going

through the internal carotid artery overall so if there's no blood flowing up there then when you cross the lesion without any blood flow there's nothing nowhere for it to go the debris that that is and then you can angioplasty and

or stent and then ultimately place your stent and then get out and then aspirate all of that column of stagnant blood before you deflate the balloons and take your device out so step-by-step I'll walk through this a couple times because

it's a little confusing at least it was for me the first time I was doing this but common carotid artery clamping just like they do in surgery right I showed you the pictures of the surgical into our directa me they do the vessel loops

around the common carotid approximately the eca and the ICA and then actually of clamping each of those sites before they open up the vessel and then they in a sequential organized reproducible manner uncle Dee clamp or unclamp each of those

sites in the reverse order similar to this balloon this is an endovascular clamping if you will so you place this common carotid balloon that's that bottom circle there you inflate you you have that clamping that occurs right

so what happens then is that you've taken off the antegrade blood flow in that common carotid artery on that side you have retrograde blood flow that's coming through from the controller circulation and you have reverse blood

flow from the ECA the external carotid artery from the contralateral side that can retrograde fill the distal common carotid stump and go up the ica ultimately then you can suspend the antegrade blood flow up the common

carotid artery as I said and then you clamp or balloon occlude the external carotid artery so now if you include the external carotid artery that second circle now you have this dark red column of blood up the distal common carotid

artery all the way up the internal carotid artery up until you get the Circle of Willis Circle of Willis allows cross filling a blood on the contralateral side so the patient doesn't undergo stroke because they've

got an intact circulation and they're able to tolerate this for a period of time now you can generally do these with patients awake and assess their ability to tolerate this if they don't tolerate this because of incomplete circle or

incomplete circulation intracranial injury really well then you can you can actually condition the patient to tolerate this or do this fairly quickly because once the balloons are inflated you can move fairly quickly and be done

or do this in stepwise fashion if you do this in combination with two balloons up you have this cessation of blood flow in in the internal carotid artery you do your angioplasty or stenting and post angioplasty if need be and then you

aspirate your your sheath that whole stagnant column of blood you aspirate that with 320 CC syringes so all that blood that's in there and you can check out what you see in the filter but after that point you've taken all that blood

that was sitting there stagnant and then you deflate the balloons you deflate them in stepwise order so this is what happens you get your o 35 stiff wire up into the external carotid artery once it's in the external cart or you do not

want to engage with the lesion itself you take your diagnostic catheter up into the external carotid artery once you're up there you take your stiff wire right so an amp lats wire placed somewhere in the distal external carotid

artery once that's in there you get your sheath in place and then you get your moment devices a nine French device overall and it has to come up and place this with two markers the proximal or sorry that distal markers in the

proximal external carotid artery that's what this picture shows here the proximal markers in the common carotid artery so there's nothing that's touched that lesion so far in any of the images that I've shown and then that's the moma

device that's one of these particular devices that does proximal protection and and from there you inflate the balloon in the external carotid artery you do a little angiographic test to make sure that there's no branch

proximal branch vessels of the external carotid artery that are filling that balloon is inflated now in this picture once you've done that you can inflate the common carotid artery once you've done that now you can take an O on four

wire of your choice cross the lesion because there's no blood flow going so even if you liberated plaque or debris it's not going to go anywhere it's just gonna sit there stagnant and then with that cross do angioplasty this is what

it looks like in real life you have a balloon approximately you have a balloon distally contrast has been injected it's just sitting there stagnant because there's nowhere for it to go okay once the balloons are inflated you've

temporarily suspends this suspended any blood flow within this vasculature and then as long as you confirm that there's no blood flow then you go ahead and proceed with the intervention you can actually check pressures we do a lot of

pressure side sheath pressure measurements the first part of this is what the aortic pressure and common carotid artery pressures are from our sheath then we've inflated our balloons and the fact that there's even any

waveform is actually representative of the back pressure we're getting and there's actually no more antegrade flow in the common carotid artery once you've put this in position then you can stent this once the stent is in place and you

think you like everything you can post dilated and then once you've post dilated then you deflate your balloon right so you deflate your all this debris that's shown in this third picture is sitting there stagnant

you deflate the external carotid artery balloon first and then your common carotid artery and prior to deflating either the balloons you've aspirated the blood flow 320 CC syringes as I said we filter the contents of the third syringe

to see if there's any debris if there's debris and that third filter and that third syringe that we actually continue to ask for eight more until we have a clean syringe but there's no filter debris out because

that might tell us that there's a lot of debris in this particular column of blood because we don't want to liberate any of that so when do you not want to use this well what if the disease that you're dealing with extends past the

common carotid past the internal carotid into the common carotid this device has to pass through that lesion before it gets into the external carotid artery so this isn't a good device for that or if that eca is occluded so you can't park

that kampf balloon that distal balloon to balloon sheath distally into the external carotid artery so that might not be good either if the patient can't tolerate it as I mentioned that's something that we assess for and you

want to have someone who's got some experience with this is a case that it takes a quite a bit of kind of movement and coordination with with the physician technologists or and co-operators that

about massive PE so let's remember this slide 25 to 65 percent mortality what do we do with this what's our goal what's

our role as interventionalists here well we need to rescue these patients from death you know this it's a coin flip that they're going to die we need to really that there's only one job we have is to save this person's life get them

out of that vicious cycle get more blood into the left ventricle and get their systemic blood pressure up what are our tools systemic thrombolysis at the top catherine directed therapy at the right and surgical level that what

unblocked me at the left as I said before the easiest thing to do is put an IV in and give systemic thrombolysis but what's interesting is it's very much underused so this is a study from Paul Stein he looked at the National

inpatient sample database and he found that patients that got thrombolytic therapy with hypotension and this is all based on icd-10 coding actually had a better outcome than those who didn't we have several other studies that support

this but you look at this and it seems like our use of thrombolytics and massive PE is going down and I think into the for whatever reason that that the specter of bleeding is really on people's minds and and for and we're not

using systemic thrombolysis as often as we should that being said there are cases in which thrombolytics are contraindicated or in which they fail and that opens the door for these other therapies surgical unblocked demand

catheter active therapy surgical unblocked mean really does have a role here I'm not going to speak about it because I'm an interventionist but we can't forget that so catheter directed therapy all sorts

of potential options you got the angio vac device over here you've got the penumbra cat 8 device here you've got an infusion catheter both here and here you've got the cleaner device I haven't pictured the inari float

Reaver which is a great new device that's entered the market as well my message to you is that you can throw the kitchen sink at these patients whatever it takes to open up a channel and get blood to the left ventricle you can do

now that being said there is the angio jet which has a blackbox warning in the pulmonary artery I will never use it because I'm not used to using it but you talk to Alan Matsumoto Zieve Haskell these guys have a lot of experience with

the androgen and PE they know how to use it but I would say though they're the only two people that I know that should use that device because it is associated with increased death within the setting of PE we don't really know you know with

great precision why that happens but theoretically what that causes is a release of adenosine can cause bradycardia bradycardia and massive p/e they just don't mix well so

right now here's a different case is a 49 year old male who presented to the emergency department after vomiting a lot of blood vomiting was the key word there it's going the other direction so that's an upper GI bleed all right and

when we talk about upper GI bleeds there's a lot of different causes for upper GI bleeds the most common are ulcers but there's mallory-weiss tears of the esophagus there's just esophagitis or gastritis

there's different cancer vascular malformations fistula is varices which I'm not going to talk about but varices on the venous side in a patient with portal hypertension these are all causes of upper GI bleeding now

once again we might treat them medically we might look at them with endoscopy and potentially cauterize something embolization usually is used when and when endoscopy is not successful all right or certainly surgery but an upper

GI bleeds embolization is a lot more attractive of an option all right so here's another picture what do you think you up for it nope you turned me down all right who wants to who wants to tell me what they see how about you how about

you guys you can team up together what do you think so what do you seeing so let's look at that together so this is a seal EF is an anagram of the celiac axis you want to think it through you want to volunteer you see a filter we don't care

about that yeah all right that's fair so you see the catheter going up right in the middle and it's going right into the celiac axis all right what I want to draw your attention to is right in the middle of the screen a little bit over

to the left is again a blobby thing all right that's extravagant of contrast and the vessel that that's coming off of is the gastroduodenal artery so I want you to see that if you look at the catheter you

can see the shadow of the catheter right up going up from the bottom that's going into the celiac axis and the big vessel going over to the left side of the screen is the proper hepatic artery that the common hepatic artery excuse me and

the first vessel heading south from there is the gastroduodenal artery that blood vessel is supplying the end of the stomach and the beginning of the small intestine and what you see is the extravagant coming off now what it's

very important if you're dealing with bleeding patients whether it's in dusky whether it's hemoptysis or GI bleeding anything like that we're looking for that type of blob appearance which just mean the contrast is no longer

constrained by the artery it's free into space okay usually the way we were built is that the blood vessels the biggest they ever are near the heart as they leave the heart they get progressively smaller until they reach

the tips of your fingers and the tips of your toes if there's any place that you see where it gets big small then big again that's not normal okay that's not normal and now we just got to figure out what's

the abnormal part is it the small part or the big part all right in this particular case it's that big blob that's big it doesn't belong there all right but in the upper GI system there's lots of collateral vessels so we can

just go in and we can put coils right in the gastroduodenal artery and we can embolize that and we can do it safely because we know that there is alternative routes for blood to flow now the one thing we have to do here and

this is an important concept for any abnormal bleeding whether it's trauma or other causes is we always look for the backdoor so in this particular patient we did an angiogram of the superior mesenteric artery there's another vessel

going to the intestines and it's nice cuz we have the coils there you can get a sense that it's possible for blood to flow from a branch of the superior mesenteric artery backwards into the GDA and so we just want to make sure that

that's not happening because we can do the best job ever with an embolization procedure but if we don't get the front door and the back door we're gonna fail patients will come back with recurrent bleeding and at least in my experience

that's a big reason why people do come back so we think we do a great job in two or three days later people come back with abnormal bleeding it's weak because we didn't address both sides of the pathology all right so here's another

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