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The Rival Study and Matrix Trial - Cardiac Interventions | Comparison of Transradial vs. Transfemoral access for vascular interventional procedures
The Rival Study and Matrix Trial - Cardiac Interventions | Comparison of Transradial vs. Transfemoral access for vascular interventional procedures
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MUSC Best Access Trial | Comparison of Transradial vs. Transfemoral access for vascular interventional procedures
MUSC Best Access Trial | Comparison of Transradial vs. Transfemoral access for vascular interventional procedures
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Coagulopathy | Comparison of Transradial vs. Transfemoral access for vascular interventional procedures
Coagulopathy | Comparison of Transradial vs. Transfemoral access for vascular interventional procedures
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Visceral and Peipheral Interventions | Comparison of Transradial vs. Transfemoral access for vascular interventional procedures
Visceral and Peipheral Interventions | Comparison of Transradial vs. Transfemoral access for vascular interventional procedures
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Question Session | Comparison of Transradial vs. Transfemoral access for vascular interventional procedures
Question Session | Comparison of Transradial vs. Transfemoral access for vascular interventional procedures
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So first starting out,

I think we've had a lot of information the past couple days about where we came from, how this started, a lot of what we wanted in medicine is also through access. But the history of some of the catheterizations, as we go around, this comes from the cardiology world.

Some of the history and research that led our department to decide that they wanted to investigate transradial, one of the first ones was in 1997, and what this study shows, the top one, it shows you that in six French sheaths to 900 patients,

there were zero complications due to radial access for cardiac catheterization. Where with brachial and femoral, there were some complications.

The next study is a rival study that was a pretty large study,

it was over 70,000 patients. Again, this has to do with the cardiac interventional role. And what this study showed was there was a reduced cardiac mortality due to bleeding complications post intervention. The next one is the matrix trial, the matrix trial

is when they started introducing a lot of the anticoagulants, the Plavix and the other integral ones that we use nowadays. And what this study showed, you can see the numbers would've decreased, what this study showed was the radial

to the femoral complications were decreased and that radial access reduced net adverse effects due to bleeding. Bleeding at the access site, more specifically.

The last one we're gonna look at came out in 2015, and this is the European guidelines.

We get a lot of our information, get a lot of our research for the stints that we're using right now, our techniques, our catheters, and our liners. All of our physicians that are looking at this research are looking at Europe for this stuff.

So 2015, the European guidelines suggested the recommendation for a way to approach over femoral. And this is the first real research we saw where it was saying hey, this is okay, it's the same as femoral, they're saying actually, this is better for the patients.

(Static drowns out dialogue)

So Medical University, we all work at SC, our physicians decided that they were gonna do their own best access trial. This is the article that was just published, I believe, in November, October, after we did all the research.

And this one kind of focused on our case procedures. What we did is a little different, we decided that we were gonna take a patients' perspective, so our study is saying what does the patient want. Not what's better for the physician, what's better for the hospital, but the patient experience.

So on our study, what we said was, and we were very selective, because we knew we had to do people with more than one treatment. And said the first time, we were either doing femoral or radial.

The second time, we're gonna do it the opposite way. The third time, we ask the patient what do you want, do you want us to go radial or do you want us to go femoral. So we put it in the patients' hands. After 124, we found that we had no conversion,

meaning that if we went femoral, we stayed femoral, if we went radial, we went radial, we didn't have complications where we had to switch sites. So pretty safe both ways. But what we found was the patient preference was 4:1.

So afterwards, patients decided that they preferred the radial approach. The 1%, from what I understand, because I wasn't around for a lot of this research, I was just coming into the program at the time, the 1% didn't care either way.

But this gave us the impetus to say yes, radial is what patients prefer. The secondary endpoint in the article talks about the overall complications, and then this goes into some of the misconceptions. So we had no adverse events on the 30 day follow up.

And that includes the hand ischemia, which is a common thought process, that you know, you might lose your hand if you do it the radial, or stroke, that's normally because people fear going over that margin. Some of the other things we found

that were incidental findings was the radiation exposure. And we're gonna look at some of the anatomy later, but it's actually quicker for us to get into the liver and to get to where we're going. If we think about it,

we're following the natural way the artery flows without working against it. Going into part of complex curves in anatomy. So we were able to get into it very quickly to treat it. And that represented less radiation. The other thing that we found was less radiation

to the doctor, the one doing the case. So I'll show you the way that we position the patient, we shield the physician and actually showed that the physician and the providers doing the care actually get less radiation exposure also. So the other thing we found is there we no difference

in contrast media, that was the other thing we were kind of looking at, do we need more contrast media. But there was no difference in those results. So the question becomes why aren't we using radial access, patients prefer it, it gets less exposure of radiation

to the physician or the people providing the care, why aren't we using it in our community. So there's a couple of reasons. The first is just the lack of general awareness the procedure is even out there. Again, misconceptions regarding the stroke risk

and the radiation dose. Lack of appropriate training on the physician's side, it's a learning curve that's pretty steep for a physician, there's a lot of nuances to radial access that are easy to overcome, but you have to take the time to learn them.

And then last is the lack of appropriate materials. Obviously, a radial artery is a lot smaller than your femoral artery. So if you don't have the equipment and tools you need, then there's no reason to access the radial site. So as technology catches up with us,

so is our ability to do these radial procedures.

Oh, it sounds so fancy. So does everybody have their, sorry, I know it's after lunch, does everybody have their perspective of this? (static drowns out dialogue)

So that's the pannus, three layer pannus. That's your femoral right there. You can, down here, see a little bit of it, see that there? So the first benefit of radial access is our obese patients.

I don't know how long it took for us to try to move this pannus up, obviously, we didn't do a good job, but this is one of the bigger benefits for radial access, is we can get to a site that's a little safer for the patient. Imagine trying to hold the pressure

and monitor that site after the procedure. All right, and that's her wrist, that's the difference. So which one do you wanna be in the recovery room looking at assessing every 15 minutes. All right, so second one here, and this was two years ago, our group of fellows, a couple of them are here now,

and they're kind of trending on radial access, they're doing some pretty cool stuff with it, but see where I'm gonna access the femoral artery. So that's why we train people. So our medical director, actually, was doing the cases, he came in and he was like what's this,

and he got the pannus up, and it was a successful procedure, we didn't let him go there, but again, trying to find your artery. So I believe when they looked on ultrasound, she had a very deep artery,

it took us a long time to access it. We had to hold pressure for a very long time on here to ensure it was safe. And again, going back and trying to reassess that access site. And here is her radial artery.

So a lot easier to get to it. She was not a candidate for axial, she didn't have a big enough artery, and we'll get into that.

And then another example, the positioning of the pannus leads to problems.

The patient on the right here, we actually had to intubate, we had a failed attempt with both of these patients the first time we went femoral because they could not tolerate laying flat with their pannus on them, which makes a lot of sense.

How many of these people go to bed every night laying flat? So they were intubated, not candidates for radial, for different reasons.

All right, the other reason we use radial access, coagulopathies, with radial access, as long as your INR count is normal,

and normal for us can be two, below two, or around two, platelets are 50, as long as one of those are above that threshold, if the other one is abnormal, we go radial. So we use this a lot in patients

who have severe liver disease, trauma patients that they're unable to get their blood numbers back up, even with blood product infusion. So we're not waiting four, six, and eight hours to do a case.

And in the past, that's what we're doing. The other thing it helps with is we don't have to fix these coagulopathies, we're saving money on blood product infusion. Did any of us see our blood product reperfusion critical is one, one, one.

So for every pack of red blood cells, we do a platelet, and we do an FFP, and that's the policy that we're trying to do right now. And our normal time was about a four hour delay. We knew we had to do the procedure, we'd have to wait for them to order the blood,

we'd have to wait for them to do the blood, we'd have to wait for them to redraw the labs if we were gonna go femoral. With radial, what we can do is say okay, send them down with some platelets, we're gonna start. We'll work on correcting those things

as we're doing the procedure. And if we're doing the procedure for an embolization or something, we're gonna correct the problem. So this one here, just to give you an example, she started on thrombocytopenic at 16,000 platelets. Four hours later, after four packets in platelets,

she was only at 22,000. She had hypersplenism, that is what we kind of refer to as Pac-Man syndrome, the spleen is just gonna eat the platelets, we're never gonna catch up with those, we can give it all day long. The first physician that came on did not do radial access.

Another physician was then consulted, we were like it's four hours later, people would like to go home tonight. Let's get moving on this. He said what's their INR, and I think it was like 1.6, 1.8, he's like bring the patient, let's go.

That is for femoral access. So as long as they were normal, that's her after the case, she has a successful embolization with radial access, and that was after we removed her compression band.

And then this just shows another example of a European study

that kind of backed up and validated the fact that we don't have to wait for these coagulopathies to be normalized before we've started the procedure. So there was no need for us to stop in adverse anticoagluated patients. And I went to the anticoagulation talk yesterday

and it sounds like they're coming out with new guidelines, so we may even start moving to neither one of them have to be normalized for us to start, which would be even really helpful in some of our GI leads and our trauma patients, which tend to be the ones that we have to end up delaying.

And this is just again, another study that kind of backs up why we are doing these procedures in the high risk patients, the decreased risk and bleeding complications afterwards.

So with our peripheral and visceral interventions, some of the benefits for radial access,

and this is one thing I have to emphasize to my physicians, because when they teach the course, they're very big on oh, the minute you're done with the procedure, they can get up and ambulate. They can get up and ambulate if they haven't been sedated and it's safe for them to get up and ambulate.

But there is an earlier ambulation time with radial. Greater patient satisfaction with recovery, as you all know, a lot of our patients are sick, they don't wanna lay on their back, rejecting chemo and radiation and things, we're killing things, they wanna roll over,

and vomiting and problems, so with radial access, they can immediately sit up, they can look at their own site and help recover themselves. It's a shorter length of stay, and we'll go into the time a little bit later. But after an hour of compression,

we start decreasing the compression band, after two hours, they can go back home. Where with non, with femoral sites, if we're not using a closure site, it's four hours recovery at least. Fewer access site complications.

The other thing that I just mentioned was that the families and the patients are very big on participating in their care, so they can look at their site when we start deflating it. If they do see any signs of anything, we can immediately notify the recovery nurse,

to say hey, let's medicate this. So they're participating in their care a lot more. And their ability to get up, use the bathroom, not having to be on a bedpan. (static drowns out dialogue) And a lot of our patients suffer from chronic back pain

so being able to throw it away is a huge satisfier. Decreasing the amount of medicines they need.

So cost savings, we're kind of going through a lot of changes to our cost initiatives.

What we discovered was about $120, that goes again, a lot to not having a closure device used. And the fact that because it's such a new technique, there isn't a lot of stuff out there, so our physicians have one choice, catheter, they have one choice of a wire,

there's not a lot of stuff you can use radial, therefore, we don't have a lot of let's try this, let's try that. We're kind of in an area right now where this is all we have, this is what we use. So not a big cost savings case,

the bigger thing that we've started to focus on, and more on the nursing side is our recovery time, our turnover of our recovery bays, and our decreased incidence of complications, which means less admissions. So a little bit more on the cost savings,

these are just two articles I pulled out where I've gotten studies, I really tried to stay away from the suppliers that give us the products, they come in and tell us oh, you can save $6,000 a case and all that.

I went through the research and what I found was we said $120, this study said about $275. And then the second one talks about you can reduce costs and it's starting to pick upon the this is really safest for the patient

but it's more cost effective for the hospital.

So again, our access trial was about patient satisfaction, so these are comments when we ask the patients who went through the first study, had it one time radial, had it one time femoral. And then the second time chose which way they went.

And as we would expect. (static drowns out dialogue) The biggest one that I take from it is the lying on the back, that is just not something our patients with big livers love to do.

The other thing that we mentioned in the beginning was the radiation safety. So you can see here, the way we position our patients is a 75 to a 90 degree angle outside the body. For tables and other procedures, cardiac removes the right side

and we'll put it right next to the patient. However, we do it this way, and then the physicians, we use our radiation shield here, so they are not being exposed to the type of radiation they would otherwise if the arm was close to the body.

And then these are the variations,

that's the typical one. Some of our new attendants that come from other hospitals start out that way. We just had a physician, he's been here about 18 months, he just gave up, and now he loves to do it this way because we just all find it's easier

to prep them this way anyway. The only thing we have to do is if the physicians want to do a cone CT, we just have to bring the arm down while they're doing the cone CT and then we just put it back up.

And I've never seen the crossing of the pelvis for radial, where they bring it to the other side. But that is apparently a way to do it. Here, they're setting up for an IV. Or actually, it was for an implant, and again, you can see where the arm is.

You can see the arm, they're prepping the box but the arm is out here, away from the radiation source.

So is radial access suitable for everybody? No, again, we don't have the technology right now. We did last week, or the week before, just start a study using 240 skin liners and catheters.

Because we have to account for going over the arch, so I believe the rep told me it's about 14 feet of wire. So that'll be interesting to see one of us standing outside the room holding a wire. Because one of the drawbacks is that we cannot do anything below the SFA.

We can do the upper SFA, but we really can't get anything below here, we just don't have the technology and the length to get down there. So depending on what your height is is kind of how far we can get down to the site we're working on.

So any trauma is pretty okay unless they're extra tall, especially pelvics. But sometimes, we get the femorals that we have to go in and treat. And if they're too tall, we just can't reach it.

And then there are some contra-indications right now for us. People over 70 years of age, we take a lot of caution with. Any kind of history of a stroke, we're very cautious with. And anybody that we already know has a calcified aortic arch.

One of the reasons why we're not that worried about the stroke, because we access left radial, we're actually coming up the artery here and going down and avoiding the aortic arch. So we're not going near that area where we can not come off.

We're traditionally in the cardiac where they're coming up the right, and they're going over it. So a couple other things, you have to have a good radial artery and good hand circulation before we will access it.

We are very safe in what we do, there's a lot of free evaluations that are done by the physicians. The first thing we do is a simple Allen's test, and that's just how to ensure that the palmer arch is complete.

The next one we do is a Barbeau's test. And this was named after a gentleman from the cardiology world. And what they do is really, we're looking at the waveform. So we're very caught on looking at the actual number, that 99%.

But what we do is we look at the dampened pleth wave, while the radial and ulnar arteries are occluded. And then we release the ulnar artery and we look to see if that pleth wave comes back. Not so focused on the 99 number, we're focused on the pleth wave.

So what that ensures us is we have dual circulation to the hand, so this is abnormal a lot of times and physicians will not go radial. The third thing that we do, and this just shows that we can do the Barbeau test, this is one of my physicians doing it in clinic.

So it's very easy to pre-assess these patients for possible radial.

The last one we do is we do an ultrasound to ensure we have a good diameter. And then we measure the diameter for the radial. So right now, the smallest we can do is 1.6,

the average for people is about a 2.6, what limits us with 1.6 is we have to use a smaller catheter, eliminating some of the things we can do. So if there's any voluminum or stenting that needs to be done,

then sometimes we can't.

And one of the things the technology I talked about earlier, the technology has started to catch up with us, what we use is called slender technology. So the outer diameter of the sheaths are the same. The inner diameters are hollowed out,

so you have a six French sheath with a five French outer diamater. So we get to cheat up, so our five French slenders have a six french inner diameter. Our six French slenders

have a seven French inner diameter, so we get to cheat a little bit with that. And it doesn't compromise the integrity of the catheter.

The other thing that's good about radial artery is the actual anatomy. Because of where the radial arteries sit,

the physician can use a landmark to access it so that they can then help with the compression by using that bone. Where if you have, remember some of those other pictures of the extremely obese, if you do have to compress,

it's very hard to compress something when you've got inches of adipose tissue to go down. And that's just showing where anatomically, they go in right over the little munch there. The other thing we have to consider with radial artery is spasming, it does happen.

It depends on the degree, that's what makes it important. What we use is what's called hydrophilic sheaths. So there's no difference in the sheaths length, but the coating on it helps to keep spasming from occurring. And I didn't put all the articles up for that. The other thing for spasm prevention is medications.

So when we first get radial access, we will inject, we will give the physicians nitroglycerin, they'll give 200 micrograms at the beginning of the case intra-arterially while we're giving normally 3000 units of heparin IV. Some of our physicians do a cocktail of nitro, verapamil,

and heparin, and they do it all intra-arterially, it's just where they were trained. And then we as nurses monitor the pulse ox, but during the whole procedure, the pulse ox is on the index finger, so we need to monitor for spasm. So that's a little difference in training

is learning to watch that. And know watching it and not worried that they're not having a bit of oxygen saturation, we're watching for that spasm so the physicians can treat it if it's occurring.

The other thing that makes radial artery access

very safe for their hands is what's called patent hemostasis. So patent hemostasis is the pressure to maintain flow tough the artery, but prevent intra-arterial bleeding. So when we do pressure, you can see here, if we're applying pressure,

we're applying just enough pressure where there's arterial flow, but we're not allowing it to flow, to bleed outside the vessel, so no hematoma. And then this is some examples of the different concepts of just patent hemostasis. So here, there's too much pressure,

and over here, you're hitting it where there is some occlusion as well. What we're going for is minimal occlusion. So how we achieve that is through various compression devices, this happens to be the one that we use at my hospital,

it's a bracelet that you blow up. There are various other ones out there.

And what our physicians do is at the time that they're finished, right before we're getting ready to remove the sheath, we'll give them another 200 of nitroglycerin,

intra-arterially, they will pull out the needle, they will blow the compression band up all the way. And then they will start to release it until they see a little bit of blood coming out, and then they will blow it up again

so they know they're right at that threshold of where that patent hemostasis is. For the average adult 10 to 15 centimeters of air is normally what we put in the TR band. 12 is the average.

After the procedure, we write the amount of air

that's in the syringe on the syringe, we hand the syringe to the patient, we put it in his hands, a special syringe that you can only release the air from, you just can't use any syringe to do that. So we put it in the patient's hand.

We give a handoff report to the nurse as what time we deployed the TR band. And then there's different protocols for how you release it. Cardiology, we do it, they do it a totally different way, we wait an hour and then we release a quarter of the air

every 15 minutes. So within two hours, all of the air should be released. If we do start seeing bleeding again, we just increase back up to the three cc's, whatever, and we wait another 15 minutes. If there are any complications,

and I didn't have a picture, I've only had one person that had a little bit of a hematoma right above the site. It was probably caused more by me not paying as much attention when she was moving back over onto the stretcher.

She kind of used her hand to help prop her over. So I actually had to take her down to med, I saw the hematoma, a little bit of one, notified the physician, he came down with an ultrasound, ensured that everything was still, still had the patent hemostasis,

make sure there wasn't any bleeding, and we just watched it. So far, that's the only complication I know about all the nurses, there was no reason. But lesson learned, you have to kind of remind them not to use their hand, put pressure on it.

Coming back to the complications, pseudoaneurysm, which is kind of what happened with me, I have not seen any of the other incidences. I do know that we share, one of the hospitals, we share recovery with the cardiac world, they tend to have a lot more complications,

but they're also given a lot more anticoagulants. And that would be an example of a distal hematoma. Radial artery occlusion as a potential complication, we have had, and we thought the lady was going through a hit at the time, we have had some arterial spasming

and we've lost the pleth on our pulse ox, so during the case, we will treat that very aggressively with heparin and TPA. Admit them to the ICU and watch them overnight. And two or three, that part of, have all been very successful.

But we do take the complications very seriously. So the TPA, I think we used 20 milligrams of TPA on the one lady and watched her overnight. Just to make sure there wasn't any other problem. The other one that I wouldn't mention, except it just happened the other day

was we are trialing these longer sheaths and catheters, and our physician was working in the lower extremities, doing the balloon, so they brought in this longer length balloon and it was for a six French, so they deployed the balloon,

didn't realize that the balloon wasn't gonna shrink down to the exact six French and our physician spent about an hour having to try to remove that sheath. Again, admitted her to the ICU, watched her overnight, there were no complications.

But that was one of the issues of why we're trialing this new stuff. Because now we can go back to the company and the rep was there and we can say might need to fix that.

Yes? (static drowns out dialogue) Right now, we're in a teaching hospital,

so the fellows do it. But our techs will pre-do it. We wanna get moving. So we'll do a quick check, we check for arteries, we'll check it and then we'll let them come in and re-check it.

But it can be done by anybody. Yes? (static drowns out dialogue) Sheath that we were trying to pull out. - [Woman] Yeah, the doctor spent one hour trying to get them out?

- [Paula] Yeah, so she's asking why it took so long for-- - [Woman] Because it's an overwired balloon, right? - [Paula] Yes, but they had to pull it out of the sheath, the introducor sheath. (static drowns out dialogue) So what we thought happened

was because it was new technology, we thought that the catheter, the introducor, not the balloon, once we pulled it out, we had realized what happened, but what my physician feared was that the sheath had folded in over itself,

and that's why they were being so careful in removing it, because they weren't sure why it wasn't coming out as soon we did the balloon. So once the balloon hit the sheath, that's when we started having all the problems. And the other question was who checks the Barbeau test,

so anybody can check it. Just because we're a teaching facility, we let the fellows do the work with it. (static drowns out dialogue) You would think. So yes, the answer is yes, they like the one with the knot,

but there is a five minute video. It is, I think, a lot easier to take care of somebody with this than feeling down here and trying to figure out if that's a hematoma, what am I feeling. But we do have a five minute video online,

we go to the PACUs, our prep and recovery, and the floors that we think are commonly gonna see them, and do train them. We do get some pushback from them, but it's lower than a YouTube video. So we do do the training for them.

(static drowns out dialogue) I've not seen a sheath that impedes and I believe that it's because the radial artery is just too small, we don't go below 1.6. (static drowns out dialogue)

No, we do not, we have trialed some of, there are some that they make now. We are in the procedure, it positions it. And then after the procedure, you turn it, and it becomes a hand immobilizer. They're kind of costly,

we haven't found any real need for them. If we do need to immobilize it, we just use the same ones they use for those ones, that we already keep in stock. But that blowing up air kind of helps to keep them from moving it.

(static drowns out dialogue) No, we don't. So I have a very aggressive medical director, and he brought this with him, he actually trained with the hospital I work for, he trained under a very innovative,

interventional radiologist, and he's not worried about what the current doctors are doing, he's looking to the three to five year future. So our whole philosophy is we're looking forward and bringing in the people that wanna have the same innovation that we have here.

So whatever we're working on now, he had other plans for other stuff. But currently, we have six attendants, all of our fellows are trained in radial access. All of the fellows that we've had that have been trained in radial access

go out and do radial access. Three of our physicians do it and three of them choose not to at this time. (static drowns out dialogue) Well, we're just starting to do them because of the length of the catheters.

So the furthest we can get is to the upper, like, SFA area. So right now, the answer is not many. But we are in a trial with 10 other, my physician is in trial, nine other physicians to trial the longer catheter so we can start doing the lower extremity work,

which is one of his big roles, is to do more PBD or the PAD. Either. Depending on the level of training on the floor. Our hospital, we have over 900 beds. So some of the floors are warm and tingling,

if it is a floor that is not used to seeing people in the first hour and monitor, and we will lead to the first 15 minutes. After the first 15 minutes, if it's not bleeding, we're okay with sending them up to the floor for the last 45.

Yeah, the nurse on the floor. Yeah, that's a video, and we have our nurse educator go up, show them the product. Trial and all, so we encourage them to come and watch the procedures. Two of my physicians and I are going to the floors

to do lectures to kind of introduce intervention radiology to the rest of the hospital so they can understand what our procedures are and kind of be a little less fearful of what they're getting. (static drowns out dialogue)

Our hour isn't based on heparin dosage, our hour is based on time of inhalation. We do very, most of our procedures, our physicians have become very fluent in doing this, most of our procedures take about 30 minutes when we do these.

So we're only giving the initial 3000 mils of heparin. So we do have, I mean, we do have some longer cases, but they've really gotten this whole radial down. Yes? Sorry. (static drowns out dialogue)

Yeah, I put this. (static drowns out dialogue) She's saying is there a video available. We have a video on transradial interventions at the MUSC website, if you go to that, you can find a lot of this information.

If you'd like the video on the compression device, I can give that to you. It's on YouTube, I just didn't put it up here because it says specific. And they don't care.

(audience laughs) It takes this. And doctors get very, it's very frustrating, you can't catch up. But they can get in there and get back. Especially the people that have had TASOs,

a lot of our TASOs were doing their fifth, sixth, seventh procedure. And they've just gotten down into whatever the method. Not all of them, I mean, some of our cases take a little bit longer. But our repeat guys get really quick.

(static drowns out dialogue) There's two different types of cases, it's the ones with mitomycin that we use when being admitted, the ones with (static drowns out dialogue) can go up on the same day. So it depends on who's, what their little average

depends on which chemo they use. And then some of the sedatives, we are now trying like after four to six hours, if they feel like they can go home, they can go home. Once they've had the mitomycin a couple times, they're kind of nettled.

Most of our patients wanna be home, they don't like hospitals. Any other questions? If you'd like any more information, I can give you my email address or the address that we use,

we have a lot of good information for the people that come to our hospital to learn this process. So we'll be more than happy to share, thank you.

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