Budd Chiari Syndrome|Budd Chiari Syndrome|80|Male
Budd Chiari Syndrome|Budd Chiari Syndrome|80|Male
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The second case, quick case. It's a old man, 80 years old. virus C, he had a TIPS two years ago

and now he starts developing a small ascites for three months. And he had a new episode of bleeding, endoscopy showed that it was a hypertensive gastrophaty. All the ultrasound that he performed showed patent tips, that this tip was patent.

So we decided to evaluate the stent, through the angio suite. Through the jugular approach we could categorize the hepatic vein here, we inject. But it was really impossible to get into the stent. The angle here is not

good, so we inject here. We can see it on stasis of the contrast. We cannot see the outflow of the hepatic veins and we try to introduce stent without success. We try to frame our approach and again we cannot enter the stent. We can't put through femoral or jugular approach, it was really impossible

to get into the stent. To check if the stent was really open we did an injection, there's a leak/g trunk. Here's the spleen vein, here's the portal, and here's the TIPS.

Again we see the images of the hepatic veins here, the same image but we cannot see very well the outflow from those veins. So here we could not understand what's going on, and we decided to measure the gradient and see that it was working like a Budd-Chiari

syndrome. The stent is against the wall, against the top of the wall of the vein, and it's blocking the outflow of the hepatic veins. So what to do?

We cannot enter the stent as I told you, cannot enter through jugular or femoral approach. So we think about to put a stent here, just a stent through the right vein to the cava, or we decided to make a transhepatic puncture of the

right branch of the portal vein, and put a wire here to the right hepatic vein, and is [UNKNOWN] to the jugular and we withdraw everything and make a through-and-through technique. So now we have the guidewire going through the jugular and the transhepatic approach.

Now we can put a balloon here. We put a 10 millimeters balloon, this image is after the angioplasty but we see that stenosis/g are very important [UNKNOWN] so we decide to put a stent. We used an express 10 millimeter stent, a balloon expandable stent, and here is the final image. We have no more hepatic veins and the shunt is working properly.

So the patient had a good recovery. I also stopped bleeding, it was a successful case. Thank you very much. Unfortunately the system does not work. I'm sorry. Thank you. >> [APPLAUSE]

Are you telling your story? Simple thing, you need money from the executive committee.

You need money from the board and from the foundation. So you need to invite them to come and tour your department. And one of the analogies I would use in my former place we had two different mock patient experiences that we would tour these groups through on a regular basis, a mock STEMI and a mock stroke.

And we would meet them in the ER and walk them all the way through until they came into our department, show them all the bells and whistles, show them our data, and then take them on to the next place. Generally it was usually the ICU or the CCU.

So you can come up with that. What is the thing you want to be known for? What piece are you trying to grow as a team? And put together your little show. One of the other key things here from our survey too you should think about is

we asked the interventional radiologists on our survey how would you rate your relationship with your Business Development Department. And you notice 31% of those that we surveyed didn't even know who their business development person was. That is a lost opportunity.

Open House and community fairs. So you can either tag-tail onto a heart fair or a stroke fair or you can hold your own. And when would be a good day to have this? How about on National Without a Scalpel Day? It's always on January 16.

It commemorates the very first day that the first time Dr. Dotter did the first angioplasty in 1964. It's a great day to pick. Also you could use Radiology Tech Week and Radiology Nurses Day

and AVIR and ARNA put together these great posters that you can get and use to celebrate you guys in your hospitals. And finally do you have any patient ambassadors? Are there one or two patients that absolutely love you, love the outcome?

Well get them, work with the business development person and include their stories in your advertising and invite them to your fair and have them sing your praises in front of the board. There's all these things that you can do that are very clever and unique.

So and then and finally I would just say join us. Join the Interventional Initiative. We really just at the minimum want you to be an ambassador and to direct people to our website. Champion this terminology of MIIPs speaking in plain language.

We all think we speak in plain language but go to the CDC website and take the online course for writing for the public and you'll see oh, very quickly hmm, yeah, maybe I'm really still speaking at a high school level when I need to be speaking at the sixth grade level.

You can direct patients to our website. You can link to our website from your own page. No one has more touch points with patients than you do. Whether you're shaving a groin, starting an IV, you have more opportunities to talk with patients and welcome them to IR and tell them about what you do.

And you are experts in your field. You should not be waiting to be invited to speak. You should be reaching out and going up and speaking to the staff in the nursing units and in Dietary and in Lab because they potentially or their family members

could be your next patient. And if they know what you're doing they're gonna share that information as well. And now I'm going to turn it over to Michele Tessmer.

or at one month we have the CTA. How good is the CTA? It's fairly good, it's not great. So when someone says, "Oh we're gonna do a Type II endoleak" you still have to assume you're really not sure what type of endoleak it is. So you're gonna do an angiogram really to help you make sure,

understand what the endoleak is. A lot of the time in CTs, you'll say, "Well I think it involves these lumbars that" (mic cuts out) So what do we treat them, Type I what we talked about. Extend, maybe do an angioplasty, particularly if you're at the time of doing it

you can place a stent or an anchor, we talked about, or you have to try to change reconfiguration. Extend it, place some type of parallel graft, a chimney or a snorkel, what have you. Type III you're gonna have to re-line that hole or that distracted piece. Type IV or Type V

we usually re-line. Type V is that endotension. And then Type II you try to embolize. And that's really the controversy. What do we do with Type IIs and how many times do we wanna try. So I'm gonna show you real quickly some of the pictures.

Here's a patient that had, that placed a graft.

Okay, so let's go back to the case. So I knew the patient needed the same procedure.

I don't know why that happened, I'm so sorry. But that was about, I did the left iliac, let me go back. If I may. So, oh shit. I'm so sorry.

(audience laughing) I'm not paying attention, I'm so sorry. Okay so as you can see, I'm putting the stamp on the left side, doing the ballon angioplasty at 9:05. And here is the balloon angioplasty, and I keep asking the CRNA how's everything going,

that is a habit I have, I cannot just stop asking how is everything going. And they keep saying "everything is perfect, everything goes great." After I finish the second balloon angioplasty, how is the patient doing?

They reply, I'm not making it up, was patient is loving it. Okay. So I just proceeded with the case. So about 9:14 hours that day, suddenly the CRNA stands up with a very confused face.

By the way, he had been in the room for about 10 minutes for a bathroom break. He's the one who said everything is fine, patient is loving it. And suddenly at 9:14 he stands up and starts hitting the monitor like that.

And I said "what are you doing?" He says "can someone check the leads?" The blood pressure just plummeted. I have no blood pressure. And I said "what are you talking about? Are you okay?"

I mean, I said "the monitor is perfect. Is everything okay?" No, not everything was okay. This is what happened after that situation. I got your attention now, right? (audience laughing)

Guess what the CRNA was doing. Was texting while we were doing the case. Because he came to the IR to cover for somebody for 10 minutes and during these 10 minutes he couldn't put aside the text. He was making plans to have lunch.

I'm not making it up. So this is my complication, don't take it the wrong way. I am the one who was doing the case. But what was the complication? That it took seven minutes for him to realize there was a problem.

When the patient practically caught it on the table because I had exsanguinated. The patient was under general, so no pain. No defense mechanism. And the patient just bled out. So, what I did was put a balloon,

and then bring fortunately have the big sheathe, have the change the sheathe. and then what I did was to place a cover the stent. I knew exactly where the rupture was. You can see all the contrast accumulated. The patient at this moment practically had no pressure.

This is immediate outcome. So I did the angio right after putting the cover the stent. It's perfectly sealed, almost nothing. But now it's obvious that the right iliac is so significant that it's blocking off this flow.

So the anesthesiologist is fighting with me, we need to bring the lady to the OR. The surgeon telling me you have to fix this right side. Both sides of my brain fighting, what do I do? And I sided with the surgeon. And I said we need to fix this first.

So this is what we did. We brought the, put the stents in place. And then finally this was the outcome after the procedure. So the patient now had flow on the right, and the iliac had thoroughly strong.

I opened up the flow again, found out there was this blockage here and most of the transition from the external to the CFA. So, what did I do? I did, pulled the sheathe down as much as I could, and treated that with just a balloon angioplasty.

And this is at 9:34. So thirty minutes after the complication had occurred. So what happened to this lady? She does well the next 24, 36 hours after the procedure. She required four units of blood.

She went into full hypovolemic shock. Had to stay in ICU several days. The first 24 hours were so, I mean, the family was devastated because the patient had some degree of hypoxic brain injury. Actually she recuperated.

But the next day, the patient had a foot drop. Complete foot drop. She required fasciotomies all over the left left. And eventually she required, within the next 24 hours, a right to left fem-pop bypass. Fem-fem bypass.

Not fem-pop, and fem-fem bypass. The patient was finally stabilized and she was discharged home after surgery. I saw her once after this event in the clinic, and the patient continues to have... The patient of course doesn't want to have

anything else done to her, but she survived. And actually she is alive to the present time.

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