Bronchial Artery Bleed|Embolization |24|Male
Bronchial Artery Bleed|Embolization |24|Male
Bronchial Artery Bleed|Embolization |24|Male
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gentleman with cystic fibrosis presented with four days of persistent lung copomostacis, CTA was done and quite prominently see a bronchial

artery in general you can see an enlarged bronchial artery that's abnormal on imaging the common dogma being if you can well see a diagnostic catheter at least that's my teaching to my trainees that's not normal, and obviously this is a high approach of fever in large bronchial artery. This patient went on to angiogram and you can see a selected catherization

and then on the next image micro catheter placed further out distally and used a moderate size PVA practical thrombolization to try to moderate the bleeding.

>> All right I'm gonna move on to case three,

this is an elderly woman with cirrhosis in her left hepatic lobe HTC. She's had prior therapy. She's status post TACE times three to other tumors. This is a virgin tumor,

has never been treated and she is a BCLC B person.Since we're talking about TACE complications, we obviously prescribed TACE in this case. The practitioner did this case selected for, actually I think it was me,

doxorubicin loaded drug-eluting beads, and this is the patient's initial hepatic arteriogram. You can see that the ciliac anatomy is conventional. We micro catheterized the left hepatic artery and you can start to see the enhancing tumor supplied by the segment three branch to the left hepatic artery.

Got the microcatheter into a more selective location, you can see the segment three hypervascular tumor. And we performed segmental TACE using 100 to 300 micron drug-eluting beads loaded with doxorubicin. This was our angiographic endpoint. This is the post-embolization ateriogram, you can see the embolized left hepatic artery segment three branch.

Complete tumor devascularization. Not much much flow to segment three of the left hepatic lobe. Probably a slightly more aggressive end point that I might have desired however nonetheless this is our outcome. [BLANK_AUDIO] In terms of course this patient had what we thought was post-embolization post-procedure.

However it was poorly controlled with pain med medications, and upon lab check was found to have profound transaminitis AST and ALT measuring over 1000 on post TACE days two and three. And that prompted a CT scan and we came to find that the patient had a left hepatic lobe infarction.

So actually, I might pose the question to the group here. Was the angiographic endpoint aggressive in your mind? [BLANK_AUDIO] >> What do you guys think? Without looking at this picture. Well who would have used conventional TACE? DEB TACE? I would have too

RFA? It is funny isn't it if you're in one institution you default to one, if you're at another institution, you default to the other. And I think the reason for that is because, other than some compelling data now with combination therapy,

I don't know that we've really proven that one therapy is better than another depending on the size of the tumor. That's why we all do it differently. >> [INAUDIBLE] >> I can't hear you, I'm sorry.

>> Why wont you ablate it? Its such a [INAUDIBLE] small lesion. [INAUDIBLE] >> Yeah. >> It's a great point. I think you'd be 100% right if you decided to ablate this lesion.

I think it would be sonographically visible. It's within size for complete ablation. So I So I think that's a perfectly appropriate approach. >> You might not be presenting it here though- >> Absolutely complications

of transarterial chemoembolization, right. Yeah? >> [INAUDIBLE] >> That's a great point. We're gonna take a look a little bit further in a second. Yeah?

>> [INAUDIBLE] >> Absolutely a possible Possible approach here, yeah. I think that would be totally feasible and appropriate. >> [INAUDIBLE] >> I think in general in our practice,

once we apply a transarterial therapy I tend to stay with it. I tend to use ablation as a first line approach and then transarterial to clean up. So we typically don't do that but I think that'd be a reasonable approach for this particular tumor.

All right, I'm gonna move on. So we've established that this patient had left hepatic lobe infarction. It's an ischemic complication of TACE. Actually the incidence in the literature is higher than I thought but that's the 3 to 12% incidence kinda spans liver and biliary system.

And the main signs and symptoms are high transaminase levels and then symptoms of weakness, fatigue, confusion, if you have poor hepatic reserve and jaundice. Again we're looking for kinda geographic hypoattenuation, non-enhancement

of liver parenchyma in a vascular distribution. And there are some risk factors for this actually, non-selective catheter position, high embolic load or dose, small beads, lack of portal venous flow which was brought up and previous hepatic surgery maybe disrupting collateral arcades.

So actually in this case going back this patient had a congenital portosystemic shunt. So you can see on this sequential CT images that the left portal vein had a direct communication with the other middle hepatic vein or IVC. This was actually demonstrated angiographically on a study that

was performed several years prior for this person. Here's an SMA gram showing portal venous flow directly into the systemic circulation by the middle hepatic vein. So actually given that finding how does that change the panel's thought about the modality selection for therapy? >> I think you treat it like PVT for the most part cuz you have no portal flow to the left. So getting back to

his point about ablation, I think that's one more reason to consider ablation. [INAUDIBLE] >> Not necessarily, I gotta be honest I didn't see the original tumor, but it's a straightforward it was a portal vein out doing Y90 will be pretty straight forward. >> I'd probably go with ablation but that's just my preference and the other risk factor is you use a Surefire anti-reflux catheter. I've seen [INAUDIBLE] report of by using that you are putting so

much more agent that you can cause infarction like this. So that would be another risk factor. >> That's a good point there. It's not just the anti-reflux catheter the surefire now, there's also we're seeing some literature and companies producing these balloon occlusion TACE.

So microcatheters with a balloon that you blow it up and you can force a lot of things in it and yesterday in an embolization session [UNKNOWN] from Europe showed a nice case where he didn't see a falciform artery and he delivered regulating beads with one of these catheters. And the patient had significant cutaneous toxicity probably because he drove a lot of this in through that process

that it might not have been delivered had he not had the balloon up, so good point. >> Well confounding the decision making in this case was the fact that the patient had tolerated three previous TACEs well albeit conventional TACE and for me in retrospect I probably would have pursued a conventional TACE instead of a drug-eluting bead TACE

in this case. This is a direct portal systemic catheterization of the vessel, and I think the combination of portal venus diversion, small particles maybe an aggressive endpoint precipitated the infarction to avoid it maybe consider less symbolic therapy ablative therapy, a lot of things that were mentioned here.

And we just treated this patient supportively, normalization of enzymes over time and then Bob I'd like to point out the nice chemo lobectomy here. So this patient, good news tumor gone, bad news the left lobe is gone too actually.

But she made it to transplant as far as I remember and this was 30 months post TACE. So I think I've taken up about 20 minutes. I'm gonna let the next speaker Don go. >> Let me ask you a question going back to your first case Ron. >> Sure.

>> That was conventional TACE. The accessory left gastric artery what if you had done drug-eluting beads or Y90 you think you would have gotten away with it? >> I don't know the answer is I don't know I think it's hard to make these sort of judgments with single few case experience,

anecdotal experience I think it's anybody's guess. Sometimes I wonder how much subclinical non-target occurs that we just don't catch and whether we're just sort of underestimating the amount of non-target that we're getting and only a few patients are manifesting. But as that case shows,

we got away with it very fortunately. I don't want it to happen so we do our best to avoid it

88-year old male, non-healing ulcers,

and most of our treatment indications are patients with critical limb ischemia for non-healing wounds, some rest pain. We rarely ever treat claudication. They're either gangrene, or ulcers, or pre-amputation, planned amputation,

to make sure that the amputation heals. This patient initially got the angiogram, planned the treatment, but had a CVA. Discharged, came back awhile later. According to the son, the wound was getting

worse, and then decided to bring his father to the hospital for the wounds. And then he's feeling better in general, but the wound, foot pain is getting worse, etc., he's not doing well in that regard. He's about to lose his leg.

So these are some history, I'm gonna skip these. We'll go to the case. This is his left lower extremity that we treated. I'm not gonna go into that one.

He has complete occlusion of the SFA, and we did our access on the flouro to make sure we don't go through this stent graft here. We always check with our accesses, you don't wanna get a high access. I just saw a complication from a high access

earlier today that turned into a big mess, and eventually the patient died. It's simple as this, you should always check. Our practice is we put our micropuncture and put our wire in. Always get a fluoro image,

making sure that we're in the mid cam of it, it takes just a few seconds. If you're too high, too low it may become issue. >> You use ultrasound much for access? >> No, we use flouro. We use ultrasound sometimes on difficult

patients. We use flouro, but we check with fluoro before we proceed with the sheath. So if this access was too high, what I usually do is I just leave the wire in there as a target.

In this patient, you have the calcification still, and just use the micropuncture needle to stick exactly where I need to be. So after getting access, this is our angiogram. [BLANK_AUDIO] So it's heavily calcified, deep femoral disease, SFA is occlusive,

multiple calcifications. Going further down, not much flow or collaterals. [BLANK_AUDIO] This is just PlayView, and in addition to everything else patient does have a popliteal aneurysm which is thrombosed,

that becomes important. Has anyone done a chronic occlusion treatment through a popliteal artery aneurysm? Okay, so I thought this was interesting. So sometimes you think something is interesting, and ten people

have done it already. So this is below the knee area. We do have, [UNKNOWN] Going well for him. They're not the most healthiest, but he has an AT, peroneal and a PT.

They are kind of diseased, especially AT is severely diseased, but it goes all the way down to the foot. So we do assessment of the whole leg from aorta to the foot, before we start because all those things that you're gonna do, things may go wrong, etc. You wanna know

where your starting point was, and then to make sure you made things worse or better. So this is at the level of the foot. Kind of decent actually, better than most of our patients at this level. So we went ahead and got a magnified image to see where we're going,

so going to the SFA. Our usual technique is use a glidewire and a Berenstein catheter. Angiographic Berenstein catheter, we just try to go through. If it doesn't work then you try to use more advanced tools, or

dedicated tools like a Quick-Cross or a Zig Zag, some sort of Crossing catheter. Sometimes 014 or 018 wires, either V-18, V-14 or PT Graphix, otherwise there's a lot of them out there. All companies provide these to you, so whatever you like should work.

>> Gonna stop you for a second there. What do you guys normally for your fem-pop disease occlusions, let's say? What is your first go-to wire? Do you start O35, or do you?

>> O35, the LLT. >> Same, same. Yeah. >> I like to use the 014. I guess I'm the anomaly. >> Okay.

So just further down, as you get in there, you can see how irregular it is. There are areas of very high grade stenosis, maybe occlusions, etc., but it looks patent at least upto a level, and then you have the total occlusion with the collaterals around it that's

typical. And this is just kind of a video showing how you may get stuck at one level with the wire, just a glidewire actually. It's usually kind of my go-to wire in these scenarios. So sometimes just the wire angle doesn't work, so you have to get the

catheter in there. I use this a lot, both catheter with the wire. The combination gives you a little additional kind of ability to do stuff, and by approaching the catheter over there, you pass one of them. And this was just one of the probably ten we did until we reached

from the femoral to the popliteal, it took about an hour to get to that level. Just to demonstrate the things that you may come across. And eventually we went subintimal,

sometimes it's gonna go subintimal. There is no reason to fight it, you just have to go where it goes because the lumen may not be just crossable. So we fell into this popliteal artery aneurysm, so it's really

not gonna go anywhere from here. We ballooned everything to create a track because it's hard to push from the subintima without dilating the areas. I always balloon it with two or three balloons. So if you're gonna get another device down the road, you don't have pushability problems.

And after doing this, we were kind of floating in there, it's not going anywhere, and we ballooned it a little larger just to create a channel. And there was no way we were gonna be able to go distally from the upper and lower approach. So we got access from the lower extremity,

this is the AT after the pedal access. You can see that it's actually, this is diseased quite a bit. It doesn't look it. if you don't look at a magnified view, sometimes you don't recognize these subtle lesions.

I'd recommend everyone to get magnified images of tibial arteries. You may recanalize the whole tibial artery if you just do a completely de-mag image look at it. It's flowing fine, but there may be a few stenosis in there, tiny little ones, 90% etc. For wound healing, it's gonna become an issue.

You wanna leave no significant stenosis, and getting nice big images will allow you to assess that better. And so we went from below, again same thing. This is a hydro or a selective guidewire. You can see, this

is an issue you're gonna come across. This is I think a PT Graphix wire. So it's like a stenosis in a relatively larger lumen area. The wire doesn't follow, it gets ballooned up. It's not happening.

I changed my wire. I'm very liberal, and I don't think you should persist on something that doesn't work. I've worked with a lot of people, everyone has different approach.

I've seen somebody for example, they would try it with the same wire for about an hour until they give up. If something is not working, just move on. There's a lot of things out there. Don't waste stuff obviously,

you need to be cost-effective. But another added fluoro over here without reaching anywhere is a bigger waste than using another wire. I'm actually sorry, I think wanted to show that, how the other wire worked. So this is the heavy-tipped wire, it just went through with no problem. So on the straight areas,

I use heavy-tipped wires, there's a lot of them out there. But if you're gonna take a turn, this wire will not take a turn. What I do is I come to that angle of the anterior tibial and follow with my Crossing catheter. At that point I go back to GlideTech wire

because this wire is just gonna try to go straight. It's too heavy to reach it. And this is our angiogram at that level, showing the trifurcation kind of diseased, but patent in that area and so we tried to come from below, it's in a different plane.

You can't see how the wires opened it up, so we're subintimal. And we attempted a lot to get connected with the origin of the kind of, I don't know if you can appreciate it, but calcification is here. This is where it's connected, this area with the oblique field. Definite oblique band we had.

It just was coming out, it wasn't going in the right direction. So, attempted a little bit more. We spent quite a bit here with different wires, different catheters. It's just not reaching to the higher level, and you can push as aggressively as you want.

You're in an occlusive space, you're not gonna do harm. Sometimes it will just pop, and I will go through, it's gonna give in. Sometimes it won't happen, but the worst thing is it's not going to happen. So trying different wires, and pushing as much as you can is not

a big deal. So as you can see this is very odd, from the area. So we were set from the AT access, we're just subintimal, and at this point I think we're even outside the artery potentially. Because

subintimal, you're almost adjacent outside, but adjacent to the calcification. In this one, we were way out of the calcification. So what do you do? We have one access, we came back. I'm not gonna kind of go into those parts.

I tried to re-enter that popliteal artery with different, very different catheters, it just goes through the same track. It's just - >> Going sideways or from both sides? >> Well, but we're not able to reach the aneurysm, that's the problem. Our wire is from the AT access that I had, it's just coming out of the

vessel, and we tried different wires. I ballooned that track to create a little different path for myself. I sometimes inflate the balloon, use a rigid wire to push into a

different plane, if your current plane is not working. So that will allow you to maybe find a better path for yourself. Whatever view that it didn't happen from the AT because from the beginning of the distal end of the popliteal artery, we were always coming into the subintimal tract. And again, ballooned those areas, etc., It

didn't work, it didn't work. Then we decided to get an access from the PT. This is our PT access. This is very calcified, so you use fluoro. Most of the time we use ultrasound, but I quite often I also use flouro for this, and you can see that your wire is going through

no problem, and this is further up. So from the posterior tibial access, the reason that I did that is I thought the popliteal artery was more in line with the posterior tibial artery origin, and we were right. You can actually see, now it's actually

in the lumen of the artery over here. [BLANK_AUDIO] And this is our angiogram right there. You can see that the posterior tibial artery is as far as in the lumen of the popliteal, and the other wire is

in this plane, and so that allowed us actually to move a little bit more forward. At this point actually I left, I had to do a radiangle/g next door. Another colleague of mine came in, and he kind of progressed a little bit further. Turba came in and he got into that area. He actually advanced the wire further near the aneurysm by

pushing, pushing. Now we're in the right place, we're following the aneurysm. It's still a problem that with the three dimensionals, those wires could be like way away from each other, but we did oblique fields from the kind of fluoro. At this

location, they were within a centimeter of each other. It opened up a little bit, but it didn't open up enough that it was too far away. [BLANK_AUDIO] So, the next step is, let's move on.

So the next step is to get, sorry. So this is what we have from above injection, and the wire is over there, and what do you do at this stage? Any suggestions?

>> To snare. You snare it. >> Snare from where? >> From top. Get the snare down into the aneurysm, and get the wire from below and just snare it. >> But this is not in the aneurysm.

This is in the subintimal space of the popliteal aneurysm. >> But you can use a different tube, and one different from above and one different from below. >>Mm-mh. >> Make the two balloons one - >> Create a space in between in that area? >> Create the balloons, [INAUDIBLE] >> I don't know if everyone can hear that.

Sorry, it's really loud. That's actually a very good technique that he just mentioned, we use that. It's basically a kissing balloon. If you take two balloons that are in different planes, and usually you just need to overlap a very small part, but that will create a rent in the intimal and allow the wires to communicate.

In my experience, it works about 70 to 80% of the time. It's definitely worth trying cause it's easy. >> Yeah, exactly. Put one balloon here and the other balloon here, try to kind of match those. It may or may not happen. In my experience, I would say 50/50.

And since it's not working all the time, we actually stopped doing that any more. What we do is we just kind of put a snare in there, but how are you gonna get the other wire into the snare? That's the problem. Snare is the easy answer,

you have to snare it otherwise this is not gonna work. But you have to connect the wires, and you have to be able to capture it. >> So you can get an Outback? >> Exactly.

So that's what we do. So we bring an Outback from above, and then we bring the snare from below. Position that over there, and this is our micro snare. Since you're coming from below, you cannot use 75, 1 cm snares,

we have 4mm and 2mm micro snares. Those are the ones that we generally use for this, and open up the snare. And then once you puncture with the Outback, you just gently, kind of gently pull it down to see if you're actually over the needle.

If you're over the needle, then you push the wire out and then take the needle, retract the needle back and capture the wire and move forward. This was kind of testing. You normally want a lot more wire here, longer distance. Because pushing and pulling through Outback, which is a long metal

cannula tracted catheter, is not easy, there is a lot of friction. There's many cases that I lost access, not be able to pull-push at the same time. So you want to make sure that while you're pulling it, it's not pulling, it's actually pushing action. The snare is just gently bringing down

in a kind of coordinated fashion. Okay, we're almost there. Okay, and then this is just the snare going all the way down. Once we got it kind of through and through, we just stented the whole thing with wire band in this case.

Obviously nothing else probably would have worked. Balloons. This is our angiogram, and this is pre and post. In this area, it didn't look great. Time is up, so I'm gonna go really fast.

And this is like, we came from above in this area to treat that. This is subintimal of our initial, so we took that one out. We were actually able to get back into the AT from above, from the true lumen.

We snared that one to make sure we're in the right lumen, and we pulled that out, and what we did is this area was a problem. So we brought a coronary stent here while protecting the tibial peroneal trunk with a balloon from below, and placed the coronary stent and

got this result in the end. Any questions? >> Yeah. >> Go ahead. >> I'm sorry to disagree, whilst it's a fantastic technical result. >> Mm-hm, >> You started off with a very, very heavy calcification and you started out with large popliteal aneurysm. You've been at it for three hours, for four hours, with two access into micro vessels. >> Correct. >> Has he been clinically tested for these devices? >> He was evaluated for a bypass.

If you read the initial story, he's 88. He had a stroke, he was discharged, he received TPA, he doesn't have a vein. I think if you did a prosthetic bypass on this patient, the chances are he would have died. If he made it, yeah.

Next patient is a patient who has a ischemic ulcer on the left foot and again you can see that there is inflow disease. I'm just going to get through this case quickly. >> [INAUDIBLE] >> Rupture.

How to deal with raptures. In this case we had an open over sheath so it's pretty straight forward. We were able to put up a balloon. In terms of dealing with what is the ideal coverage stent here. I don't know what's the best answer is and there might be some controversy

from the panel the Viabahn is a great device it uses a smaller sheath size. One of the issues with the Viabahn is you really have to size it appropriately. If you are too much oversize the device will infold and you'll have a problem if you're under side is going to continue to bleed.

The flare [ they require a larger sheath size but you have much more ability to get away with over sizing there and the device would not in fold I think you need about a nine french sheath there. So I think the point was I have never seen a common iliac rapture. We've seen several external iliac raptures. So you really want to make sure you have covered stents in the room

and be ready for a rapture. You always monitor for pain when we're doing these procedures I think there's a problem. >> Question of that. >> Yeah. >> [INAUDIBLE]

>> We typically do most of our procedures with angiomax so we don't have that option. You can't reverse angiomax but yeah if you're using heparin I would give protamine. >> It's an approach as long as you have a balloon the main thing is to have control in this.

You do your angiogram you need to be able to pout the balloon up. If you give protamine or not if you don't have the balloon you'll still bleed but if you put the balloon up and you may have to put that balloon up five minutes etc. So you don't want to turn to bleeding, thrombosis all that hell.

We don't touch the harpization/g we don't give protamine in our practice nobody knows the answer there is no way to the trial to see which kind of cases are going to do better in this scenario but we we just make sure that one assess the balloon is up the other access its a through and through most of this cases. We do pretty much all iliac cases bilateral access and [UNKNOWN].

That way something happens you have your balloon, you pull your balloon you bring your stent immediately deploy it your bleeding time is seconds at most. >> You know, actually for aortoiliac interventions we hardly ever anticoagulate by the way,

so I think Dr. Hadson does vote, we almost never anticoagulate aortoiliac intervention. The other thing we do every single time is instantly cycle the blood pressure I think anyone who does the aortoiliac has run into this, it's rare but it does happen, so cycle your pressure off in the

patience of vagal there's usually associated pain, it's not and I agree with what Dr. Hadson said, I couldn't reverse the hesprin, you're going to have control within seconds if you manage it properly it's not going to have any

consequences. >> This isn't just a the companion case, what happened, this is what we're doing in agiograph and you're introducing the sheath and you've bleeding from the controlateral groin.

This is where you might run into more issues, if you've a large enough sheath on the right side you can put up an inclusion blew in the aorta and then go ahead and treat the last side but this patients can die very quick. I mean they'll loose liters of blood very quickly.I mean this case

will we did was we placed a balloon from the lateral side to get control and then we're able to get a catheter up and over. Let the balloon down just for a second and let the wire go across the balloon and then that allowed us to get the appropriate covered stent and place at a cross to treat that. Let me show you one more case really fast since I'm running out

of time. This is a patient with left sided buttock claudication and this patient has both hypogastric and external iliac stenosis. It's debatable. You treat both of them or not. This is one of the cases my partner did but I think it's completely

debatable here and I bet you we could probably debate it on the panel here. But what we chose to do was, he put an external iliac stent, went through the interstices of that stent and placed another balloon expandable stent in the hypogastric artery and then he ballooned

both of them and then did an angiogram an this is what he came across. >> The balloon and tent simultaneously or one after the other? >> I think he did them simultaneously. And I think it's a completely reasonable approach. I think what happened here was he didn't know where his wire was,

where the tip of the wire was. So he dissected his external iliac artery and even worse, he lost wire access. So this is a real problem so obviously don't loose wire access. Next thing he did was,

we checked with ultrasound at the left common femoral artery to see if the dissection plan extent and luckily it did not. So it was just another look at the dissection. So he's able to go ahead and puncture the common femoral artery

during angio and place a stent all the way to here. So things were finally looking good. But just when things can't get any worse, this was already like a couple hours into it. >> [LAUGH]

>> So what happened was we blamed it on the fellow, the sheath was pushed in, and if you recall in the prior image the stent goes all the way to the origin. So now we have a crumpled up stent.

There's no flow through here. He really ran in to turn one complication to another complication. So at this point he went back from above and tried to use a guide wire to get across this crumpled stent which eventually he was able to do. And tried to angioplasting it and still didn't have a great result

so finally we ended up putting a viabahn in there and the patient did well. But I think point here is you have a complication, hopefully you don't, it's easy to have one complication lead to another and to another and sometimes it's good to maybe get your partner to help out.

>> Thanks. >> Thank you.

of this session. It's our first case, 74 year old male, history of cirrhosis and persistent thrombocytopenia. As I mentioned we start off our procedure through the radial approach, we always do an angiogram to begin with to make sure there's any anatomic variance and interesting,

we saw only the radial artery in this case. No ulnar artery was shown, we did a more forceful injection and then we're able to reflex the contrast into brachial artery and then the ulnar artery,

was just an anatomic invariance of the anatomy. So we proceed with our catheter down into the celiac trunk, this is the Jacky Catheter has a very nice curve and it's very easy to engage the celiac trunk. And a little bit different from what was presented here,

we tend to embolize our spleen, we get a microcatheter from their distal into the lower two thirds of the spleen. We use PVA 300 to achieve distal necrosis and on our way out, we embolize the proximal branch with coils.

The idea should decrease the chance of reperfusion and recurrence of thrombocytopenia on those patients. And so that's what we can see there that's the post embolization picture. We see the coils in the more proximal part of the branch and we see the preservation of the upper pole branch of the spleen and

no perfusion of the lower two thirds of the spleen. So after two weeks the patient had an increase in platelets count to 84. Our second case, patient 69 year old male history of cholangiocarcinoma and

this is an 89 year old with aortic stenosis and plan for TAVR. I'm not gonna show you TAVR cases here so, but the reason I wanna show you this is now we're seeing more and more of these, and whoever reads CTAs and all that and I just Can't believe that there's so many 89 and 91 year old getting all

this complex procedures. I mean when someone comes to us for a stent at age 75 you're cringing and now, you get all thes every 89 year old in Virginia now is gonna get TAVR so. Otherwise they are fearless. So this is this patient and you see, we always do these analyses for them IRED/g, LA/g, CTAs, MRAs and you see the right side, there's nothing. There is

no common femoral and there is some collaterals and no external iliac. The left side is also very small, you know 5 mm. There's no access basically. So all these patients go through transapical TAVR, all right?

But now there's new technique that's been developed which is the transcaval access into the aorta. It was developed mostly for TAVR patients and there's a group by NIH that pioneer this study and now they mentor programs to do it. So we were one of the sites for that and then we,

as I was somewhat involved in helping them as to be a backup for this when it started. So that was the plan and this is this patient. You see him with really very calcified,

no good access, and this is the cave and this is the distance. So I'm gonna show you this case then I'm gonna show you a good typical case to know how this should look like and this is the one that didn't go as well. The distance should not be that far.

All these cases are analyzed carefully, make sure there's no calcium where you wanna access and the distance is not too far. In this case was kinda getting more comfortable with with the technique, so pushing the envelop and in this case access was obtained from the cava into the aorta.

And there's several techniques you can use. You can just use needles or in that case this technique it uses an 014 wire and have a Bovie at the outside and basically use a cuttery and just pierce through and it works out pretty well. Then you snare it and now you have access.

You balloon dilate the track then you serially dilate then you put your sheath. And now the case goes as well and at the end they use and ASD closure device to plug it. And that's it. I apologize for the images I literally went to the cath lab and took pictures of this thing so that's why there's all this

glare. But that's what it is. Now for this patient, this is at the end of it before deploying it. It's very common to see flow into the cava and that's expected because that will go away. And as long as it decompresses into the cava it's fine. The problem is when it forms a pseudoaneurysm

this means it's not good decompression. And this is what was here. So I was standing in the room and I said well and this is not looking good. I was like we see this all the time and this will die on itself and I'm not so sure that was the case but, well let's get a followup and see what happens. Well I wanna show you how it looks when it should and this

is the case that we did for a TVAR as a first angle of this case was published. It was one of the first cases of TVAR using transcaval access, again small access vessels. And this is the analysis that you get. You try to find which spot doesn't have much calcium and you measure the distance, make sure it's close enough. And this is it here. You get your access again, these are the tools that you use.

And trim the 0.14 wire and a bovie and you go with a snare. You do several angles to make sure you enter the snare and then you snare it. Probably that's one of the first image. And then this is how it looks. And they have an algorithm for what Amplatzer plug you use.

So for this the AST closure device you use and we have our [UNKNOWN] cardiologist who does all of these and works with us on these cases. You have to master that technique which I think is good for someone who knows what they're doing to do it to be honest with you. You always maintain a Buddy Wire just in case things are not going well, then you can re-access it to just close it.

And then once you're happy with the outcome you can just give up and get it out. So if there's only filling of the cava and no pseudoaneurysm that's fine. And most of these do very well afterwards. You see on the followup CT''s the filling of the cava only but you don't see

a pseudo and then that's a full die down. And this is afterwards and we waited, did another one and everything was good. So that was the good case. Going back to this case that was not

as good, you see a pseudo aneurysm. And my point was we need to treat this now, well let's get a followup, well fine that's a followup. So the followup was of course the CT was ordered in the morning, was done at 4 PM. We read it at 6 PM and became that what we had planned to do that

night did next night, when I was not on call. So now there's a pseudo aneurysm here coming out of this really, really chunky aorta. So now the patient went to IR And remember there's no right common femoral so now we have to go through the left side and that's our

only access, so that's how it is. The patient was semi-stable I would say. A lot of issues and she's not an open candidate that's why she went to TAVR so there's a lot of issues with her medically and she's older, so and everything

was very tenuous. So we did this, we went in and you see this big pseudo aneurysm and you see this is where the plug was. So we said, well simple, just put a cuff here and that should take care of it. The problem is we have sizing issues.

So this is 12 mm, this is 9 and this is at the bifurcation and now we are getting into a tiny common femoral. And you know you can do a lot of imaging because you have access from the right. Now you have to get maybe RMAXs to do it which adds to the complex of it, the patient is getting too unstable

so we need to move fast. So we put a, wanna make sure we get a good apposition here, we put a limb. This happens to be a Cook limb and a 14-55 and just landed it just short of this really smaller component while there is still a leak. I said well it's most likely a 1B from below.

So now how much you are gonna extend? It would be nice to go in and do kissing stent in this. But you don't have access on the right. So if I had a common femoral you can recanalize but there's nothing to start from. Any thoughts or do you want me to keep going done with this disaster? >> [INAUDIBLE]

[INAUDIBLE] >> There is no right common femoral. They're gonna have to create something there. Most of the times what worries me with these kind of raptured cases and such is, even if you do that are they gonna get back filling

through into lumbars, who knows if it's still gonna fill or not even if you do and AUI. But that was a thought and we couldn't do it. So there's no option for a fem-fem. >> So come the arm and do a bilateral kissing covered small limbs or iCASTs or something

->> Into the iliacs. >> One from the ->> leg >> and one from. >> The right side of the arm and the left [INAUDIBLE] [INAUDIBLE]

>> Yeah so that's >> But that's one option I guess off the top of my head ->> Again Rob, do you have any thoughts on this? >> No I'd do exactly that. I'd put the right side's stent from the

arm and the left side's stent from the groin and I'd probably use an Atrium's iCAST. >> Yeah so we had that thought and I wanted to try a couple of things before committing into this. It was again in this situation is a big mess we have like a gazillion people and I have re-prep the arm, move the anesthesia people out

of the way, get the arm out, prep it and all that stuff. So while I have that I just try to extend with a stent as far as I can get away with and balloon it. And of course it didn't work. So there is still a leak here.

So before doing this and I thought that maybe it's worth to do what we just talked about, is see if we can embolize this. So and I ensured that these are the numbers, this is that planing that I did before putting kissing stents.

And then before doing it, it's like let me get a thought. Robin mentioned this in his talk the other day about doing some of these endoleak embolizations through access adjacent to the graft between the wall of the aorta or iliac and the graft.

So this is what we liked it to do. So you see the catheter here getting around the graft that we placed and get a microcatheter all the way out into the area where there's aorta. And started by putting some onyx. Of course start going into the lumbar which was fine with and then

kept filling all the crevices around it a much as we can, to fill the area and kinda bathe where this Amplatzer or plug once was. So that all onyx around that area and actually that's did the trick and stopped it. So I think this onyx as a plug problemsolver with these leaks don't go away.

It is just poor apposition and especially with calcium. And there's usually just a few millimeter of crevices in there that just need to be filled. Once you go in and pretty much cork it with onyx you just can get rid of some these endoleaks. So it didn't take much. It just was not that hard to navigate between

the graft and the aortic wall. And once you wedge a catheter there a microcatheter can go easily and now you're free and you just fill the entire space that is not completely opposed by the graft into the aorta. Fill it with onyx and then that did the trick. And this patient did very well. We got rid of her leak that was there

and this is the follow up. And at one month she came back and, that's the plug and there's no more pseudoaneurysm, and that took care of it. One thing to consider was to use a different type of cuff,

for example the Endologix that has the cloth on the outside. We have better apposition than doing this. And that's what actually they were coming to have as a back up for these cases to have an Endologix cuff, which we didn't have it at the time.

I could have ordered and waited, but I didn't want to wait. But part of their protocol for these transcanal cases is to have an Endologix cuff as your back up because the cloth was the outside and the metal is the inside and has more likelihood to actually connect, go and they call it boller

out and have better apposition and touch the wall better. So I think the program slowed down significantly after this case unfortunately and >> [LAUGH] >> This was a poor selection that the people who were in charge of the program from NIH and advised somewhat against

this case and said well, you need to kinda wait before taking such a case on. And clearly, lessons learned, very calcified shouldn't do it but non-calcified, now we're using an all-trans cable for endoleak

embolization and I think that works out pretty well and it's very safe to do. So I think that technique s still valid, you just need to choose your patients well. >> Do you use this technique for access in the aorta for other things for example TVAR?

>> Yes. So TVAR the case I showed was from a TVAR and it was published as a technique in [UNKNOWN] few months ago. So I think it's a very good technique for that. Doing an illiac conduit is not trivial and I think sometimes like in this case needed an aortic access. If this patient had a thoracic

aneurysm such access you need to actually have to cut down to the aorta. And our surgeons have done that, actually directly accessed the aorta. So this could be a huge problem solver.

And I think it's gonna be adopted more and more. These Amplatz are plugs, these ASD closure devices. They're not as simple as all the other devices. You have two sizes and the cardiologist, the congenital cardiologist, whoever works at your institution,

is pretty good with it and if you can team up with them they'll be willing to do it and maybe help them with their TAVR programs. I think it's a very valid technique and I think we can use advantage of it. >> It's a great case, super elegant yeah.

>> [INAUDIBLE] >> Yes. >> [INAUDIBLE] >> No we'd have put the limb in. And that was the plan.

I was like we're here, we have access, let's just do it, let's just put the limb in, we'll just delay by day and I'm kinda glad we ended up doing in IR. We had other stuff ready for us, we had to use onyx and all that which was good. I don't know if AFX would have fixed, it could have.

But yeah, that was the plan. At the time that it, their protocol is that if there's a pseudoaneurysm, not just filling of the cava then you put a cuff. And that's

the plan. But it was kinda later in the day they just wanted to wrap up. But that's not the point of this discussion. I think this discussion if you see that appearance which is the pseudoaneurysm then the plan is to go in and put the cuff in. >> So mechanistically this far is the Bovie system to the wire,

they just attach the Bovie to the end, the outside end, the trailing of your 014Y against the location. >> It becomes like a hot knife and just goes through. Yes. I mean you can use anything to be honest with you.

But they just wanna use this protocol because it worked with them. They just wanna use it the same way which I think is fine. >> Cause I've used the outcome to - >> Yes. >> [INAUDIBLE] >> Endo-leak.

Yeah I'm use the, a lot of people use different, I use the transceptal needle. There's colopental needle a lot of people use different [UNKNOWN] needle. [LAUGH]

You seen it all presented.

he has fibrosis. There's a little bit of ascites

so maybe portal hypertension and a five centimeter solitary HCC. The patient has good functional status, ECOG of zero. Meaning he's active, no activity restrictions and he has good liver function.

Billirubin 0.6 and Child Pugh A. So here's his tumor, five centimeter HCC in the right liver, exophytic hanging off the edge here, and he has possible portal hypertension. So the options to consider,

resection, transplant, embolization and ablation. So for resection, his liver function is normal, and the location of the tumor looks like it's a resectable location. So he's a potential candidate for resection.

For transplant, he has underlying liver disease, NASH, he has HCC, possible portal hypertension and its a solitary five centimeter HCC so he's within the long criteria so potentially a transplant candidate. So it's important to have this patient evaluated by surgery.

So we sent the patient to surgery and they said that because of the patient's comorbidity they didn't wanna operate, so that takes resection and transplant off the list and now we're left with embolization and ablation. So for a five centimeter tumor, that's sort of at the upper limits

of what you can completely ablate, so you could potentially ablate this. If the tumor was much larger than fivr centimeters we wouldn't be ablating it and we would just be embolizing the tumor. This large solitary tumor we could embolize it.

We would wanna do a selective embolization for a solitary tumor. So in this particular case we decided to both embolization and ablation just because the size is at the upper limits of what we can completely ablate so we wanted to do sort of a double kill where we embolize it and also ablate it. So the way we do that is we do it on the same day.

We embolize first and then we ablate. Here you can see we're trying to get selective. We're in a branch of the right hepatic artery it seems like we're covering the whole tumor and in this case we did the bland embolization after we do the bland embolization we get a non contrast CT while they're still on the procedure table to see the contrast retention

within the tumor. So this is important because you can see if you missed part of the tumor maybe you have to go out for a different branch in order to cover the entire tumor. And then we use this contrast retention as a target for placing our ablation probe and this just shows one of our ablation probes post ablation.

So the reason we do the embolization first is for two reasons, one is that the contrast retention gives you a nice target for placing your ablation probe and the other reason is that embolizing the hepatic artery reduces the profusion, takes away some of the heat sync and potentially

gives you a better ablation zone. >> Can you comment on the size particles you would have used for your bland embolization and also the type and number of ablation probes you used in a five centimeter lesion? >> Yeah, okay. So let me go through that.

So I have a couple of slides here on bland embolization. So Karen Brown did a randomized trial of bland embolization versus DEB-TACE for HCC and she saw that there was no difference in response or survival. So I think what this means is that the main mechanism for these procedures is tumor ischemia since adding the chemotherapy didn't

seem to make any difference. Now, there are some potential advantages of bland embolization which is you can embolize multiple times and the hepatic atrial tree stays the same. So Joe Erinjeri looked at patients who had at least five bland embolization procedures and found that 84% of them, there

was no change in the hepatic arterial tree. In the remaining 16% there was occlusion of fourth or fifth order branches. So I think if you did five conventional TAE procedures you might start to see some pruning of the arterial tree. Now in terms of our technique for bland embolization we start with 40 to 120 micron embospheres and the reason we start with these small particles is we think

that it gives better penetration of the tumor, more tumor necrosis to use smaller particles. But if we've used five syringes and we've still haven't gotten to stasis then we start to go to larger particles 100 to 300 micron embospheres.

And the reason is that when we first started dealing bland embolization, and we were just using the 40 to 120 micron, we actually had few patient deaths and on autopsy it turns out the particles were in the lungs, and in those cases , they receive

many, many syringes of the 40 to 120. So we tried to limit the amount of small particles that were use and of course if you're seeing hepatopulmonary shunting, or if you're embolizing a large dome lesion where there might be hepatopulmonary shunting or you're embolizing the phrenic artery,

then you might wanna just start with some larger particles 100 to 300. And in terms of the embolization end point, for a bland embolization we embolized stasis. So in this case we used two probes,

we probably could have used more but I think we got a pretty good response in this case. >> Can you comment on that probe you have in that picture is going to ablate some of the chest walls- >> Yeah. >> And muscles there. >> Exactly.

>> Do you not worry about that or what do you do? >> Yeah so sometimes we'll, it's not great we probably could have done hydrodissection, the other thing that we do sometimes is we'll use bupivacaine at the liver capsule for post procedure pain when we're abating things that are near the surface.

I mean, ideally if you can go through normal liver on your way to the lesion, that's preferable. But sometimes if you can't, we do end up going directly into the

lesion. >> And what type of microwave system were you using? Do you remember? >> This one I think was imprint, but I normally use the new wave system. >> Can we see a show of hands how many people in the audience

do bland embolization for HCC? How many, okay so nobody. How many people can still get your hands on and do a conventional TACE right now? So only a few so and so is everybody else doing drug-eluting beads then?

Raise your hands if your doing drug-eluting beads. Okay. >> [LAUGH] >> There's a bunch of people that I [INAUDIBLE] >> There's also Y90

[LAUGH] >> Assuming that you have Y90 you also do chemoembolization. All right. >> Okay. All right so- >> Can I make one comment on that one?

>> Sure yeah. >> So that lesion there's so many different options you can do for treatment and there's no evidence, great evidence, saying one is better than the other. So in my institution that would be specially given your ateriogram,

an excellent case for segmentectomy. A radiation segmentectomy. You can get a really good treatment there. >> You can also do a chemoembolization segmentectomy for about one third the price. >> [LAUGH]

>> And it works just as well. A couple of comments. I mean I love doing commission therapy so you were saying you might ablate up to five centimeters. I think that is generous. I mean I wouldn't really try ablation alone for a lesion over three

centimeters unless I had some contra indication of embolotherapy cuz really your failure rate goes up pretty dramatically for a tumors above three centimeters in size. So I think above three, there was a solitary lesion like this I would do exactly what I did which is combination therapy.

In our series for a combination therapy what we do chemoembolization with lipiodol and drugs. Day one, we mint them all overnight and bring them back the next day and use the lipiodol contrast which is retained the next day to help with the try and the CT works great, and then basically just lay a series of ablation probes and

you're not gonna ablate the whole thing thermally. But the idea is that you're gonna have an area that's thermally ablated then you're gonna have a large hyperthermic zone around your probes and the hyperthermia sort of just stick with the doxorubicins you get very intense doxorubicin binding to the tumor DNA, and get very very large kill zone.

And what we found is in solitary HCC is up to eight centimeters in size, we had 80% complete kill, by combining chemoembolization with mostly RFA in that era and that for metastatic disease, we would do tumors up to six centimeters in size of the combined therapy and

we have 70% complete kill for mets up to six centimeters in size, so I think it's a very great strategy for solitary tumors that are too big to ablate alone. Question in the back. >> Do you ever take longer or do you find the synergistic effect works better or sooner I mean so do you wait a month or two for the lesion

to shrink to make it more [INAUDIBLE] >> I don't, I mean there are people who do wait a week or two after their chemoembolization before they ablate. I don't cuz A, I want to get advantage of the high drug levels, they're still there to get the synergistic effect with the hyperthemia and also it's just practical since I'm admitting my patients

anyway so I just bring them down, first case the next morning do the ablation and they can still go home the next day. That way they don't have to come back to the hospital for a secondary outpatient procedure. But there are some people who do delay, whereas there are some

people who do it the other way around, they ablate first, and then chemoembolize, for whatever is left and there is a different rationale for doing it that way. And in general that also works fairly well. Logistically it doesn't make sense in my practice since I may meet them for

the chemoembolizations. Also if you look at animal studies where they've looked at sequencing, you get a higher volume of kill if you chemoembolize first and ablate second. So that's why I do what I do. Question?

>> Do you use alcohol? >> We do use alcohol sometimes, it's a little big for alcohol, usually we're using alcohol in smaller lesions like a couple of centimeters. You could try it, I think you're gonna get a better ablation for

a big lesion with some sort of thermal ablation. >> Again sort of the same thing the efficacy of picking as ethanol injection, on average it's similar to heat ablation but you have to do multiple procedures to get the entire tumor cuz it just doesn't diffuse well enough whereas heat will get everything. I actually had a very interesting conversation with someone this

week who said I don't know why you guys bought all the expensive stuff, I just do my chemoembolizations with alcohol and lepiodol. For segmental or sub-segmental especially doing alcohol ablation transarteriorly works great, there is actually a pretty substantial Asian literature on this, I don't know we never do it, and it gets rid of the whole

drug particle issue. You're basically doing an embolization segmentectomy with ethanol which if you're again segmental or less, works great, it's very cheap.

Here is a 30 year old male bronchiectasis.

He has the middle lobe of right lung receptive for massive hemorrhage in 2008 in other hospitals and before it's from other hospitals with hemorrhage recurring up to two BAE procedures performed in the same month respectively and RBA and RIMA were implied reportedly. [BLANK_AUDIO]

That's the prior CT scan and so we saw the image, we can see that there are main coils in the upper part of the right chest. [BLANK_AUDIO] And CTA both will show the pulmonary artery and the systemic artery. We can see the patients,

the right chest is smaller, than the left chest, and there are, [BLANK_AUDIO] So the right lung architectural distortion and also we can see atelectasis and bronchiectasis and hypervascular changes including BA and NBSA.

And in 2004 we performed the first in our hospital, performed the first BAE. BAE, I don't think the AE is enough to describe this patient because [LAUGH]

>> It's big. >> It changed this idea of before and many abnormal arteries in the chest. So we use the four French Yashiro and Cobra and Progreat microcatheter to insert the coil inside. Actually the micro wire can go through the coin into the distal of the artery and then we use

100 and 200 to embolize the pathological artery. Now that's the left lung artery. There's some sample of re-check DSA. After we've embolized, performed the embolization we do a Re-check DSA that tells that the target arteries are invisible it's clear.

And then the patient keep stable for at least seven months and then another haemorrhage episode experience. So he come to our hospital for another BAE. So we found there were some vasculization in the right chest and other area. Still have a new occurent/g pathological artery,

so we use the same material to embolize this artery. [BLANK_AUDIO] And new found intercostal artery here this time. [BLANK_AUDIO] and in the 2015 8th,

August we decide to take the right lung out. So after the operation for preventing the [INAUDIBLE] breathing in the surgery we do embolization again. And that's the operating finding. The right thoracic cavity decrease significantly in size and the narrow intercostal spaces and the parietal pleura

was markedly and diffused thickening, [COUGH] The right upper loop of the lung was difficult diffusely consolidate with multi cystic lesions, and convolute and market it thickening right, bronchi artery, that's the inter operated fungi. So that's the growth lung and the growth fiber being as the same

as inter operating thriving and microscopic fiber [BLANK_AUDIO] that's from- [BLANK_AUDIO] for the show, the growth sample [BLANK_AUDIO]

The important point here, the west gutter was thickening and hyalinization are seen without intravascular foreign materials or thrombi. And luckily the lumen of small artery up to 18 mm in diameter that run along bronchi and their branches,

and those in subpleural space. This one was 7.13 subpleural among these foreign materials. That's PVA. No such foreign materials are seen within capillaries. So that's the small vessel, the small artery we've seen the lumen/g,

we can see PVA here. That's the pleural [BLANK_AUDIO] Another vessel enlarged. We can see very clearly the PVA here inside the lumen of the

artery. And that's the diameter of the small artery. The small artery [UNKNOWN] is 138 [UNKNOWN] and this one is 86.25 [UNKNOWN] There's no a such PVA in the airspace. [BLANK_AUDIO] And we found out intravascular thrombosis underwent

organization and that means the process by which foreign material replaced by granulation tissues, and recanalization I don't think it is recanalization but vascularization. The formation of new vascular space, so that's the capillary around the [UNKNOWN] plus low foreign material.

So, that's the pathology diagnosis. According to this case, that's my sort one the prior has CTA can help mapping a normal systemic artery feeding the C lung, especially B-P shant, and appropriate embloic materials is very important for

effective embolization. So [UNKNOWN] is useful, and usable, and size, a safe size of embolic particle. Now the common sense is unless you've got larger than 350 mil is safe but I use a lot 100 and 200.

So, what is the safe side? I don't know. I think needs more pathological observation to prove it. And, PVA is not a permanent embolic material according to my case and VAE may confine clinical thinking and many doctors are saying VAE, is okay for control the bronchial artery breathing.

But we do a lot MBSA embolization. So we use PAE as a interventional name for hemorrhage interventinal treatment. Everything is okay. [LAUGH] So I think it's time for terminology change.

[BLANK_AUDIO] We don't think BAE is enough to be supplied this per season. >> Right. I understand what you're saying that the word Bronchial Artery Embolization implies that you're permanently blocking the arteries and stopping

bleeding, and in fact if you look at the tissue what you're saying is recanalization or vessel in growth across, and so is not permanent occlusion of the arteries. Very good >>So, that's where the CT in our hospital

now. >> We expand the courage book with the body. [BLANK_AUDIO] Okay we'll have to stop there and ask if there's any questions. Dr.

Kampi >> We get new patients who [INAUDIBLE] when you re analyze them, when you preduded them in hand. Was it the same artery completely open and did you have to reambolize that same artery? >> That's quite common.

>> That's what I thought now to follow that up then If you were to embolize the particles until there is almost stasis, almost no flow. Then you put in either blue [INAUDIBLE] either blue or or anus.

>> No. >> If you did that you think that will change the possibility of recumbolization in that statement. >> [COUGH] >> Maybe. I don't have experience about that.

>> You know of anyone who has done that? >> No >> I think that historically it's being fear of spinal artery complications which has kept people, right? But it depends where the catheter is delivering the embolic.

But the're similar pathologic findings with circle embolics. They've seen the same thing where if you look at the histology late. There's vessel growth around the embolic/g and in fact it's a permanent embolic/g but the vessels find their way back to the target tissue so this is very useful we need to work on learning better, what happens to our embolyte pathologically so I applaud your efforts

done to understand that better, thank you very much.

So the first case that I present pretty typical patient hepatitis C virus herpes carcinoma won't deliver the point this isn't a tumor board. We decided to do radioembolization I know it comes as a surprise to most of you, but the patient was a good candidate for such.

They weren't a candidate for surgery because of their coma [INAUDIBLE] Particularly their PAD. And you can see here they have this tumor here in the posterior right hepatic lobe. Now one of things that we've been doing more recently over the last several years is trying to do

radioembolization on the same day. So we bring these patients in we map, we do the long shunting and then we treat. We've ordered a dose ahead of time for this went ahead to order

a post right hepatic lobe dose and be ready to treat these patient. So this is what I was going to do here, and this is just a slide we published this concept in a few patients back in 2014 in JVIR, and it takes us about two and a half hours room time. Now we've done probably about a 100 patients and again it's about

two and a half hours of room time to do this whole process. So when they go to nuclear mess/g and they just get the player imaging for long shunting and we move along so it's a relatively quick procedure but this is a replaced anatomy here, and you could see the replaced right hepatic artery. We deliver the MAA and as we can see we get to see the hyper vascular

muscle, but hard to see [INAUDIBLE] But we can see it here and we can do Cone-Beam to show that. But as the patient so then what we do is we map things out and again there is the Cone-Beam CT. We are happy with that [INAUDIBLE]

We inject the MAA the patient. I take the catheters out I leave the sheath in, the patient goes up to NUCS med and comes back. And here's the NUCS med scan we actually did some spect imaging on that, but when they came back here is the angiogram and this is something this patient didn't get shot in, that's not a bullet but that's something we all dread seeing in our patients.

So this artery has thrombosed. I'm still to this day not exactly certain why I don't think it was from the MAA I took the catheters out. I didn't leave the catheter in the hepatic artery when I did this, but what would you do here, Chuck? What are your thoughts?

You bring them back another day put them on plavix or how do you manage this? >> [INAUDIBLE] [BLANK_AUDIO] >> Thanks. Yeah I think sometimes it's better to live to fight another day

I do think that often times when we get ourselves in a situation like this, we feel badly about it and we tend to wanna try and push things too hard on the same day, and then you just end up getting yourself in bigger trouble. So yeah I think I would probably stop for the day even though it's a dose that you're worried about wasting I don't think that should

come in the decision and I'd probably put him on antiplatelet agents to see if contrary indication to anticoagulation how bad is- >> He does not know. >> Yeah. I'm not sure about anything other than antiplatelet agent but I'd definitely stop at this point.

>> Any comments to that [INAUDIBLE] Run? >> I tend to be relatively conservative when I encounter this sort of event as well. So I agree with Chuck. I'd probably put the patient in an antiplatelet agent,

forego the dose for the day unfortunately and probably come back another day. If the vessel has not reopened you're likely to be able to still treat bi-collateral's so I'd wait it out. >> I guess I would just try to see whether I can pass a wire beyond

there. If it's easy then I might go ahead and angioplasty and see whether it opens up. If it's difficult then I would back off and bring the patient back. >> [INAUDIBLE] Stop now and [INAUDIBLE] Keep going. [INAUDIBLE]

>> Rusty you would keep going. What would you do? >> I'd try to use some water [INAUDIBLE] [INAUDIBLE] [INAUDIBLE] >> So what I ultimately decided to do was to do just that as you can see the imaging here,

it seemed over the course of a few minutes of repeating the angiogram giving a little bit nitroglycerin knowing that that's not gonna help anything upfront, but certainly not getting any better so I did administer TPA and I ended up giving 14 milligrams total, I gave it in 2 to

4 milligram boluses at a time, and things did open up some. As time went on and as I gave more it seemed to open up and I didn't know if this was going to be a process where if I waited longer it was gonna re-thrombose or not, or I should give more. One of my colleagues came walking through and said, what are you

doing? He's gonna have a hemorrhagic stroke or something. It's just one of those things that you think you're doing the right thing and you're wondering if you should've just stopped, I mean my first thought was I bring him back potentially and then as I'm doing this he's getting

better I'm feeling pretty confident and then at the back of my mind that's the last thing I wanna do I certainly haven't fully worked this patient up for TPA, but didn't have any obvious contrary indications so at this point I did Cone-Beam CT, and I was getting a chunk of the tumor so I actually delivered the dose. In terms of trying to treat this and here the patient is in one month follow up,

and you can see there's a reasonable response, there's certainly some component of it that's still enhancing that was being profused prior to this process so I brought the patient back actually not for radioembolization thinking that this is an ideal location

for a phrenic artery. So when I brought the patient back here certainly there's right inferior phrenic artery profusion, and I was able to do just blunt embolization to that component of it and got a good response as three months following treatment but I think that it added complexity I had to do another procedure for the patient, and we'll see how

robust the response is over time if there's a difference between the component that was blunt embolized and radioembolized. But again I'm not exactly certain, I haven't had this happen in many patients, how I've changed my practice is I still do the same day Y90's but I don't catheterize the segmental branches anymore

on the planning part, I will just do a low bar, do a Cone-Beam CT, inject the MAA, take everything out and come back then I will do the selective or segmental catheterizations, I don't know what's from our original catheterization,

or there's some other process. [BLANK_AUDIO] And there's the pre and the follow up as it stands we're probably about five months out from treatment now. Any comments, questions? >> Why did you choose, other than the fact that you're [INAUDIBLE] Why did you choose Y90 here instead either chemo embo or [INAUDIBLE]

>> Well I'll turn the question and ask you why you would choose chemoembolization, blind embolization, or ablation, there's certainly are a lot of different factors at play. Our evidence with radiation segmentectomy is pretty robust in terms of getting histologic, pathologic necrosis.

I understand why ablation can be good this is an extro phytic tumor, there is a patient that we didn't want to put under, we put patients under a generalized seizure for ablations not everybody does but he had enough risk factors with his triple A e.t.c. that it was not something

we were gonna consider, so ablation from that stand point is a little bit bigger than I like to ablate, certainly people ablate bigger tumors you can consider combination therapies, but the ablation factor with the anesthesia weren't going to do in terms of it's not a tumor border or things like that but in terms of what intra

arteriole therapy is best certainly there can be discussion but we favor proforal solitary tumor prefers segmentectomy radiation. [BLANK_AUDIO]

next case is a 39 year old female with

multiple episodes of dbt really complicated patients suspended from a Turner and presents with right lower extremity pain after what she said was a roto-rooter procedure and this was coming from an outside institution and

it is actually going to one of our vascular surgery colleagues and we became involved in fact while one of our presenters dr. Johnson was involved in this case so an initial angiogram was performed and demonstrated a abnormality

in the posterior tibial vain draining being here and this is just a close-up so actually soon an injury from a procedure of trying to either access or get into the posterior tibial vein so at this point the vascular surgeon did been

mapping to possibly bypass but after some discussion on with our team it was decided to just go ahead and embolize this so the patient was brought back the next day and from an antegrade in retrograde approach this lesion was

actually coil implies and what was the second successfully done decreasing the inflow so whether this was a roto-rooter not directly into a vein you name it you just need to have to be cautious whenever doing this

because these veins are you can say we call that the thrombus Burnham in them actually make them abnormal so you want to decrease the risk of baby officials and our student aneurysms and follow-up the patient was doing well with no rest

again it's interesting, the whole session on embolization of chest is cool, because it's not something that comes up everyday. So a lot of times as with this case you kind of have to figure things out as you go because these aren't necessarily things that we do

on a real regular basis. I mean we're not doing bronchial embolization everyday, we're not treating chest wall vascular malformations everyday. So this is the lady who had a cough, it wasn't getting better, she kept

chest x-ray and had this right infrahilar mass here and of course we're not to have a CT scan and you can see here that she's got massively hypertrophied bronchi arteries here and this structure here which looks a little strange. And so get some 3D reconstructions of this, so you can see this

incredible nest of hypertrophied bronchi arteries here, and then this aneurysm, so eventually we kind of figured out from the recons that this was actually a bronchi artery to pulmonary artery fistula. No history of trauma or infection just probably congenital with a big bronchial artery aneurysm right next to the fistula.

And that's the only way that you would get obviously a bronchial artery to get to be that big if you have shunting from a high flow to a low flow high pressure structure, so this is definitely something that the surgeon weren't really excited about looking at.

This was a relatively young lady, and even though she was healthy and everything, they said let's see whether we can embolize this. And just, I think basic principle whenever, except the pulmonary AVMs, which I really architecturally AV fistula when you're treating

AV fistula, it's always nice to be able to get access from both sides to have control of the situation as best you can. So in this situation, we went first. So here's coming from the aorta side from the bronchial artery side. Just the really predicted well by the CT.

Again, huge aneurysm here after this just a few turns of the bronchial artery and then a big fistula between the bronchial artery aneurysm and the pulmonary artery. So we started by after that ago, went on pulmonary artery side and we found our way back into this aneurysm and this diameter

here of this connection between the bronchial artery aneurysm and pulmonary artery was 24 millimeters, it was huge. And we so obviously way too big for any [UNKNOWN] actually not too big potentially for an ASD occlusion device, but the problem was that

the delivery system to try and get an ASD occlutor across, that's what she actually tried to do, wouldn't make this last big turn, into this structure. So we kind of aborted that, we couldn't close it that way, and went

to work then starting to really basically embolize this from both directions so we first of all tried with a microcatheter as far as we could from the, the arterial side and tried put some coils we shot one through all the way into the pulmonary artery and it didn't do anything so then started working from the pulmonary artery side to close down

that big aneurysm and just packed a bunch of 20 millimeter next to another other coils into the aneurysm and then also left a bunch of coils in the bronchial artery and this was the sort of end result of that and she actually had, it was hard to follow her obviously with CT cause of the coil, cause of the artifact from all the

coils and everything but she did actually really well and we followed her for a couple of years in clinic and then discharged her because she was doing great and there was no evidence recurrence. So kind of a weird case but I think one of the principals from this is whenever there is an AV fistula you can have access from both sides.

It gives you the options Just that you need to really be able to have control of the situation and try to fix it. Because ever seen anything like this kind of a weird,

Here's the second verse, same as the first, just a little bit of a variety here. This is an 81-year old guy who'd had pretty complex surgery in the past. Descending open thoracic aortic aneurysm repair, enlarging 6 cm paravisceral component. A bunch of pretty significant comorbidities, including

Stage III chronic renal disease. Now some pre-op imaging here showing this paravisceral aneurysm here, a CO2 angiogram. This is his SMA. What you are not seeing here is he actually has a thoraco-celiac bypass. So he had a surgically created bypass to his iliac artery from

his thoracic aorta. So if you know that, you just need to make sure that obviously you're paying attention to that because it was done for the reason this guy did not have good collateralization between his celiac and SMA distribution. So although that's not shown here, that's something to pay attention to.

He does have a left kidney. It's not shown here, but it was very small. He has split function renal still showing here. This was not really contributory in any meaningful way, so just in the idea of a little bit of expediency and making the operation a little bit easier. We chose to ignore his left renal artery, and we just recovered that portion of his aorta.

So this was going to be a two-branched graft. And I guess just comments just on this configuration, I've already sort of hinted at what we did. But any comments on, given distance, giving angulation, giving orientation of these arteries? You already know what I've done,

but does that seem like a reasonable idea? Periscope right, renal and snorkel of the SMA? >> Yes. >> Yeah, sure. >> It makes a lot of sense. It makes it much easier to manage the R-matrix on the left, and just do it that way. >> Exactly,

yeah. >> In the previous case for example, he had great arsenal/g, but then with the tube grafting there it could have, and had one of them go down and ->> >> It certainly could have, yeah absolutely. It certainly could have, yeah absolutely. Absolutely.

So here we are during the case, so here's our access here into his SMA. Here's our right renal artery access from below, as we had used a Bolton Relay graft, overlapping Bolton Relay graft. So here's the first graft that was deployed distally in his abdominal aorta. This is covering our right renal periscope, comes up to the level of our snorkel from above into his SMA.

Here's the leading end, the most proximal end of that second graft completion angiography that you see playing here. It just caught my eye and kinda concerned me a little bit that this right renal periscope seemed like it was pretty sluggish. This is his entire renal function at this point because not only

was this his best functioning kidney, but now his left renal artery is covered. So again, wire access, that's the last thing that you lose obviously. So we took a little bit closer look at that, and there is a real pretty significant kink here at the origin in our long Viabahn in the right renal periscope. So actually we just chose to put in a relatively

long bare metal self-expanding stent, an 860 bare metal self-expanding stent into that renal just to try and make sure that we settled that. So again, if there's any hesitation I don't routinely stent all of my branches or periscopes. But I think periscopes, I'm probably more likely in fact to stent reinforced than even some of the branches from above. But if there's any questions,

like a lumbar puncture in a sick child, an ED or something, I think that you just do it before you get yourself in trouble. >> Well here you had your periscope go to the distal in the aorta, above the bifurcation. Do you ever take it, and if you had to go into the iliac, do you ever take it next to the iliac lymph? Do you have any issues with that? >> I have not done that.

I have not had to take it into an iliac lymph. Rob, have you put periscopes down into the iliac? >> No, I've not. >> No. Yeah, so this is just trailing just a little bit distal to our first main body, Bolton thoracic endograft component. >> I've done it once for an accessory renal that was somewhat large and going right side by side by the iliac, and surprisingly it stayed open. We just did it to see if it stayed open,

surprisingly it did stay open. >> Sure, excellent. Yeah, excellent, very good. And so here's our follow up CT, just a little bit of that extra stent of course in his right renal periscope, but all these are open. And he had some pretty good remodelling in subsequent imaging, which in the

interest of time I chose not to show.

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