This is another example. This is a complex aneurysm. This is an aneurysm that's actually involved the common trunk of the SMA and the splenic artery. So we can't embolize the splenic artery. That's not a good thing.
This shows you a lot of teaching points, a lot of technical teaching points about the management of these complex aneurysms. So this is a complicated... This is a complicated aneurysm. It involves the common trunk of the SMA and the celiac axis.
So the plan is, we need, going down low, is actually the SMA, so what we need to do is to embolize the splenic artery, proximal as possible, okay, to allow as much collateral as possible to go to the spleen. Do a stint graft from the aorta into the SMA to exclude the aneurysm and then thrombose it.
The embolizing material in this case, plugs, it could be coils as well, would do the same principle of preventing back bleeding into the aneurysm. So you're kinda seeing all these principles being put together in this complex procedure.
So the first thing, we went up to the splenic artery and we embolized it with plugs, okay and that's kind of embolized, and then we went into the SMA and put balloon expandable stints and excluded the aneurysm. Here you see the aneurysm with the eggshell calcification,
see this anatomy perfectly, almost on the dead lateral. We put the stint grafts. On our follow up CT, the aneurysm had shrunk partially thrombosed, but still there is still more flow in the aneurysm. So this most likely kind of like a type 1 endo leak
into the aneurysm. The patient was on Plavix and on Aspirin. So technically, what you can do is to put another stint proximally and close that kind of type 1 endo leak. What we chose to do is actually stop the Plavix and stop the Aspirin, just stop it,
'cause they're anticoagulants, stop it for a month and follow up CT. That helps actually thrombose it. Okay so instead of subjecting a patient to another procedure, you just stop the Aspirin and Plavix for a month. Maybe that's enough to help it thrombose.
Then resume the Aspirin and Plavix, and that's all we needed to do is just stop the Aspirin and Plavix. Kind of several technical and medical teaching points
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.
- [Dr. Siskin] I hope you guys are having a good time because I know how hard Stephanie has worked on this program and it looks great and congratulations to you Stephanie for everything. So, I'm gonna talk about embolization
and I'm really gonna focus on the materials that we use during embolization procedures. So, I do think that when you look at embolization procedures, it really can be relatively straight forward. So we can look at this simplistically
or we can make it more complicated and I'm hoping to fall somewhere in the middle. So, on the simple side, you take a patient who is getting an embolization procedure, they're laying on the C-Arm there and you can put a catheter inside them
and you basically look and you see, you know, you take some pictures and you see a fibroid or you see a kidney tumor or you see a spleen and you put some stuff in it and you block up the vessel. Mission accomplished.
You go home, you go have lunch, and that's it. So we can take it that simply 'cause that's pretty much what we're doing in just about every embolization case. But, I do think that if you're going to embolize stuff, there is a couple things you have to know.
You have to understand the pathology that you're treating. You have to understand the clinical implications of using technology like embolization to treat that pathology. And need to understand the ideal technique for the particular condition that you're treating
and that includes the agent that you're using and the delivery catheter that you're using to get that agent to the target pathology. We are going to focus on the third part of that during this talk. So, I do think that it is important to remember
that, with any condition, and any embolic agent, there is a correct way to treat them. Now I will confess to you that we don't always know the exact right way to treat a particular condition with embolization. But, I think, in theory, we can all agree
that there is a right way out there. So, you're going to have different opinions and, trust me, the people you work with are gonna insist that they're right and how to do it. The real dark little secret is that we don't really know for most of the things that we do,
the exact right way to treat it. So everyone's gonna do it the way they think is best and that's gonna be based on who taught them, maybe they read an interesting article last night in the bathroom, maybe it's based on available inventory
that you guys have in your angio suites, maybe it's just based on the amount of time that they have before they have to pick up their kid at soccer practice and they have to get out. So, the way they choose to do an interventional procedure is gonna be based on all of those factors.
And so, I'm going to review my way, but I kind of just let you know that this is my way and other people may think differently.