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Case: 18M MCA Aneurysm | Without A Scalpel: Neuro Intervention
Case: 18M MCA Aneurysm | Without A Scalpel: Neuro Intervention
2018aneurysmangiogramAVIRcavernomacavernomaschaptercoilembolizationendovascularfull videograymicrocatheteroccludedproximalvasculaturevenousvessel
Classification of Endoleak | Wake up for Endoleaks
Classification of Endoleak | Wake up for Endoleaks
2018actualaortaAVIRchapterendoleakfallfull videograftiiiailiacsealtalktype
Q&A: How Do IRs Become Experts in Arterial Disease? | CLI Fighters: Stop the Chop!
Q&A: How Do IRs Become Experts in Arterial Disease? | CLI Fighters: Stop the Chop!
2018AVIRcardiologistcatheterchapterendovascularfull videoguysinfectiousreferreferralresidencyspecialtysurgeonsurgeonssurgeryvascular
Introduction | Wake up for Endoleaks
Introduction | Wake up for Endoleaks
2018AVIRchapterfull videoguysinterventionalmeetingsmiamivascular
2018 Fellows Induction | AVIR 2018 Board Meeting
2018 Fellows Induction | AVIR 2018 Board Meeting
2018articleAVIRchapterchemoembolizationclinicalfellowshipfull videohccinnovationinternshipinterventionaljoinednumerouspassionprogrampursuitradiologictransarterialwisconsin
Transcript

Here's another interesting case, another young person. This is an 18 year old male college student. Basically, he had a seizure. Lab work was unremarkable. Yeah, all right, he coulda had a lot of things, right?

Obviously I wouldn't be showing you any of those things, but we're looking at AVMs, tumors, cavernomas, congenital lesions, abscesses. Here's the initial CT. You can see a lesion here, kinda strange, right? It's very round, doesn't look like it's in a place

where an aneurysm would be. We saw this, you can see this lesion, again, very round. Sort of enhances a little bit but not a lot. Here it almost looks like a cavernoma, and I think that was our preferred diagnosis at the time. This sort of has a cavernoma look, appearance to it.

Cavernomas typically present with seizures, so that was our working diagnosis, but, if you look carefully at the MRA, there's maybe a little bit of irregularity in this vessel. And pretty much everybody gets a CTA now, and this is what we found.

So on the CTA, you can see a much more prominent irregularity. He's got this inflow vessel here and outflow vessel here. We wanted to look at them more carefully, so we told 'em we would do an angiogram. Here's that lesion, looks a little bit more significant

on the angiogram, a little bigger. Kinda hangs out in the venous phase, which probably explains why it enhances. This was our 3D spin, 3D CT reconstruction here. So we want to do this, we decided to do this

through an endovascular procedure. Basically we put a catheter up in the middle cerebral artery and we did a microcatheter run right proximal to the vessel. We did this procedure awake. We microcatheterized him awake, and then while he was awake, we injected, one at a time,

Brevital and Amytal into that vessel. Brevital is basically a barbiturate, puts the gray matter to sleep. Lidocaine works to inhibit the white matter firing. The idea is that you basically numb that part of the brain to see how eloquent it is, and we didn't notice any changes,

neurological changes in him, so we felt that this would be a safe vessel to embolize. And we didn't plan on doing any distal embolization, so we just wanted to make sure what was the worst-case scenario for embolization for him. So that's the distribution of the drug

going into the microcatheter. Here's the first coil, microcatheter and coil in the aneurysm. There's my microcatheter, there are the coils. You can see I started to coil this thing, catheter's still here.

Here's the coil mass. There's where the rest of that vessel was supposed to be. And the reason I'm showing you this is a lot of times, when you do a proximal takedown of an aneurysm like this, sorry.

Thanks, nope, there it goes. All right, so I tried to do a microcatheter angiogram so you could see the aneurysm's fully occluded even with the microcatheter. No filling of the aneurysm. I'm gonna try to show these pial collaterals, so now,

I had some graphics on here but I'm gonna just point, 'cause I think it's easier to see. So that vessels's still backfilling. You see how the vessel comes? You see the contrast is not going directly through the aneurysm.

It's coming through these pial collaterals, and you see that little bit of flow coming right to the tip of the aneurysm, so he really had no, there was really no significant loss of vasculature in him. And I can prove that, there's aneurysms,

there's my backward pial collateral. Well, that was a post-op MRI. It's not a movie, but you'll have to take my word for it, there was no stroke. And he did well.

So, what's an endoleak and how do we classify these patients. Ooh, there's water. Thank you.

Sorry, there's a frog that showed up. Not as good as beer, but okay. Alright, so you hear people talk about that's a Type I, that's a Type II. What are these classifications. And believe it or not, we had a classification

and now people are starting to change it. So it's like things are moving around. But I'm gonna give you an idea, when we talk about Type 1, we're looking at the top or the bottom of the graft. Where you seal to the aorta, and where you seal to the iliac arteries.

When you look at a Type II, that's gonna be some kind of leak that's going around the aorta. So the way I discussed it and explained it to patients is, we just put this graft inside your aorta so that we can bypass the blood down

from the top of the aorta down to the bottom of the aorta into your legs. But that's still a living, breathing aorta. So there's still some arteries that exist in that aorta and they may still be patent, they may still create a circuit,

and that's how you get this Type II. Type 3 has to do with that graft that we're putting, that tunnel that I explained to them that's bringing the blood, or that bypass from the top to the bottom. Sometimes you can get sometimes you can get some kinda,

they call them dehiscence, they fall apart, or a hole, or a junctual separation. Type 4 has to do with the graft material, and I see it when I do a procedure, certain graft materials are more common than others. It may also be related to in the actual procedure, how anti-coagulated a patient is.

I may see these Type IV's. And then Endotension. Endotension, Type V, means I've tried everything and I haven't figured it out, I'm gonna say it's Type V. Alright? So that's an easy one. This is what people now are coming up with, these new things so Type Ia is the top, Type Ib is the bottom. Alright?

And then they talk about Type III leaks, they also talk about, well, Type IIIa is when the components fall apart, as opposed to Type IIIb, there's an actual hole or a problem with the actual component. It didn't fall apart, but there's a hole

or something in it. So it didn't come apart, but there's maybe a problem with it. Technical stuff. So why do we need to keep following

- Thank you all so much. It's always such a privilege to have you. Does anyone have any questions for the panel before we break for posters? Yes?

(man in audience speaks off mic) - Yeah, no I mean it's definitely, we always call it a turf war. And, I think generally, in the past several years, a lot of these arterial interventions for Critical Limb Ischemia are being done

by vascular surgeons and cardiologists, and until recently, it's been coming back, and IRs are doing it. Now, how do we become experts or have people refer? I mean, it's by showing good work, and doing, especially those below the knee interventions,

a lot of people will shy away from that. And, they'll just recommend amputation. So if you can show that you're preventing some amputations, more so than someone else, that can help you. I don't know if you guys? - So, for me, the first angioplasty that was ever done

was by an IR position. Which then, it got taken by everybody else, which is okay, but the reason being, IR was born out of radiologists who are typically, in the old days, really smart nerds in the dark rooms, right? They weren't ones who were seeing patients,

building patients, they were basically reading images, and every once in a while, said hey, I see images, I can do stuff. But all the patients, actually, were in the hands of the medical doctors. The cardiologists, the vessel surgeons.

So what you're seeing now, in the last five, 10 years, is all IR practices that are true IR practices have their own clinic. We see patients before and after, we demand to see that. We demand that we get a consult, not a order. And at our place, you know,

we don't get a request for a procedure, we get a consult for a problem. And then we tell them, that gives us the power to say, we're gonna do this, we're not gonna do this, this is why, here's our plan.

And because of that now, we're shifting into now, being a clinical management for the patient, which, that's the only way we build this. That's why the numbers are getting bigger and bigger. And we're training all of us. We're all learning and training the future leaders

to have a clinic, to take that phone call about the pain, the ulcer. We used to just shy away from all that stuff, say everybody else can handle it, we'll come do a procedure, good luck. Now you have to manage that patient, see him for a year,

make that wound better, and then the referrals keep coming in. You get, like we talked about yesterday, one or two referrals, that builds into multiple and multiple, and that's how we're growing this practice.

We talk to podiatry and say we have the same end goal. I have no option of cutting off that foot. The podiatrist doesn't want that foot to be cut, because if they refer to a surgeon, they're gonna amputate and they lose that patient and the foot. So we have the best catheter wire skills,

we will put in the six hour cases that cost a lot of money that nobody else wants to do, so we just have to align ourselves to remember that the patient's first, and we have the best skills to do that. - Step back, too, and look at it globally.

So if you look at across the US, and I can't talk about Europe and elsewhere, but if you really look at the numbers, they're about a third are cardiology, a third are surgery, and a third are IR docs. And, depending on where you go,

one specialty may be stronger, so to speak, it's all kinda ruled by politics. So to give you an example, at our place when I got there, they were doing zero PADs, zero CLI, they weren't doing anything. And before I came, the big question

was, I'm like, why aren't you doing anything? They're like well, the surgeons won't send us anything. That's where the problem lies, because in the old days, and I've been doing this 17 years, so I'm kinda old enough to know what it was like before, is that the referral pattern is really specialist

to intervention. Specialist to intervention. Whether it's GI, pulmonary, infectious disease, well, let's go the procedural basis. Gynecology for fibroids and UFEs. Surgeons for other stuff.

Well, as time went on, reimbursement's down, it becomes a money thing. If I'm a surgeon, am I really gonna send to another, a vascular surgeon doesn't send to another vascular surgeon because there's no incentive. For me, and so the argument I make,

and so when I got to Miami, what I was telling Kumar and these guys, is that you can't say you're better at doing angioplasty, better at doing these techniques we've got, 'cause there's tons of people in every specialty that are phenomenal.

I know a lot of surgeons that are great, I know a lot of cardiologists that are really good at this stuff. And so, that is over. You can't say I'm the best at doing the catheter stuff. So the play you have to make is,

who's the better vascular doc? Now, that comes from, either turnaround time, they like you, they hate you, service, does the patient like you? So it comes back to how does a cardiologist hang their shingle?

How does a dermatologist hang their shingle? It's the same thing, marketing, branding, talking, giving lectures and so forth, showing skillsets, showing that you know how to take care of this patient, communication with the referring doc, so on and so forth. The argument I make to a lot of the internists

and family practitioners, is not I'm better at technically doing this stuff, but if somebody has a heart attack or a stable angina, et cetera, who do you refer to? And of course, what do you think they all say? Oh, cardiologist.

Well, how come you don't refer to the CT surgeon? Shouldn't that be right? So, the vascular surgery model in the pre-days, were working off of a legacy referral pattern. That's really 20th-century medicine. They go from them to the vascular surgeons,

surgeon decides, ah, we should do this, we should do that, he or she says, I'm gonna try an angioplasty, doesn't work, got bypass (mumbles). So the argument I make to them is, look, we have to practice 21st-century medicine, which is, you refer to the cardiologist

because that's the endovascular expert. I kinda consider myself and endovascular expert, not an operative expert. So send them to me. I'll tell you whether they need surgery or not. In the same referral pattern that you do

for your other patients. Could you imagine if all these cardiology patients that were treated in heart (mumbles) went to surgery first? Can you imagine the number of bypasses or CABGs and stuff that would be done?

And the field wouldn't have progressed. So I think we did a bad job at selling ourselves early, but if you look at a lot of the trainees over the past five years, they're very aggressive, they grew up in a different environment, they grew up in a different world, and so on and so forth.

There's an old doc, that, I won't give names, because I might killed but, years ago, surgery came to a lot of the IR chairmen or doctors at the universities and stuff, and said look, we wanna work with you, we wanna merge, we wanna fuse with you,

and so on and so forth, and the response at that time, was well, I'm the expert at this stuff, you're the expert on operating. You operate, we're gonna do this. So you can imagine what happened,

they just went over to cardiology. And they joined cardiology. And so the point I'm making, is we can't push I'm a better technician. You have to push, I can do the same stuff that somebody else that treats vascular disease can do,

and that's how you lecture, and that's how you present it. And you'll be amazed. So we went from zero, we do about 100 legs a year. Which at a place where, and I get zero referrals from vascular surgeons. Most of mine are from cardiologists,

who also do peripheral stuff. But they kinda refer a lot of patients. Non-invasive cardiologists, infectious disease, pathology, podiatry, internists, PCPs, dermatologists, plastic surgeons, so you basically just have to go and compete,

just like a surgeon has to compete with other surgeons at the same hospital, I gotta compete on the same level. So I kinda think of it from that perspective, that's what I try to teach (mumbles). Hopefully that wasn't too--

- And for those of you who are not at academic centers, and you're at community hospitals, you also have to realize that there's an IR residency now. So in the last 20 years of medicine, there hasn't been a new residency, and there is one now. So they're getting rid of the fellowship,

and they're allowing residency to form. So it's gonna be a lot more ubiquitous and other physicians training at those hospitals, their colleagues are gonna be IRs, they're gonna learn about their value in the hospital, as I think, with time, it's gonna happen on its own,

but I think we all need to put in efforts to make that happen faster. - Just to add really quickly to that, and you guys alluded to it several times throughout your talk, from a technologist's perspective, the building, the clinic,

and the behind-the-scenes and all of that kind of stuff that these guys do all of the legwork for, that's not really our wheelhouse. But our wheelhouse is inside of those procedure rooms. And I always go back to know your anatomy, know your inventory, and these guys, they joked about it,

like prep the foot, but after you've been somewhere for four hours, sometimes prepping the foot, I mean, it can be a really daunting thing. But just like they said, we can be such an asset to the room. We can be a limiting factor, too.

If you give them the side eye, or you don't have stuff available, or we don't get things in the right order, we don't expedite the process, that can be really debilitating to all of the legwork that happened prior to that.

So we always, thank you guys for sort of pushing that point home for us, and helping to remind us that we are an integral part to the growth of this field. And especially this #StopTheChop. (laughs)

All right, thank you guys very much. (applause) - Thank you.

- Good morning everybody, it's my pleasure to introduce Dr. Pena, who I've known for about 20 years. We go way, way back, kind of dating ourselves but certainly had some great memories over the years. So Dr. Pena got his undergrad degree at Stanford University, finished his graduate degree there and then moved on to Yale to complete his medical school

before coming to Mass General Hospital where he completed his residency in Fellowship and Vascular Interventional Radiology. He's currently in attending and the Director of Vascular Interventional Imaging at the Miami Vascular Institute

and he's a national and international expert in Vascular Radiology. What I think that you'll see from this talk is just his amazing personality and excitement. And the thing you look for in an I-Rad, which is just an absolute true passion for what he does

so, with that I'll ask Tino to get started with us and I appreciate you coming down, thank you so much. (audience claps) - Thanks Rob. It's a pleasure to be here, I'd like to start off a plug. And that is I think this and these meetings

are so important, alright? And the way we continue to grow these meetings is you guys right there in the seats, alright? Go out, let people know in your hospital, in your town, in your state the importance it is to come out to these meetings,

to come out and network, okay? With each other to get this kind of quality education, to be able to network with us, come to this meeting, come to other meetings that offer this type of educational opportunity. I mean, I think this is really important.

We have local programs, which I'm always involved with in Miami and going to those local programs. Then we have other regional programs have meetings, and then this is to me the national meeting. This is where you want to get people out. So, it's really up to you guys to let people know,

hey, you know what? It was really good, it was worth our time, this is what I learned out of this. So that your hospital can hopefully also help you guys come here, which I think is really critical, and that's where our next step where we need to go.

'Cause I think that we all gotta go together and it's really important, okay?

Okay. So this year, we also have the additional, very special honor, of inducting someone into an

AVIR fellowship. The AVIR fellowship is designed to recognize and honor interventional radiographers who demonstrate a continued pursuit of excellence in the IR profession. An AVIR fellowship is reserved for individuals

who've established themselves as leaders through education, publication, peer and colleague recognition. This year, the AVIR is honored to induct Kristen Welch as an AVIR fellow. Kristen graduated from the Wheaton Healthcare

All Saints School of Radiologic Technology in 2012. From there, she began what has been an already astounding career at Freighter and the Medical College of Wisconsin. In 2014, Kristen joined the staff of the IR internship program at Freighter

and the Medical College of Wisconsin as a clinical instructor. She had routinely lectures IR interns on a variety of IR topics from fundamentals of IR to more complex, innovative procedures. Additionally, she's intimately involved

in the students' clinical instruction. In addition to her educational role, Kristen has also become a research coordinator at Freighter in 2016. Her passion for innovation and continued pursuit of better patient outcomes is evident in the

multiple research projects that she's championed. Kristen joined the AVIR as a member in 2013 and she immediately became an active supporter of the AVIR functioning as the local southeastern Wisconsin chapter program director from 2013 until 2017. During this time, Kristen supported regional growth

in education by providing numerous lectures to both her local chapter as well as other regional chapters such as the Virginia AVIR and the Chicago chapter. Just three years later, in 2016, she joined the AVIR Board of Directors as the program chair and she brought her

talent for innovation and her passion for IR to the AVIR's national meeting. Kristen orchestrated an incredible annual meeting program that year. She provided our memberships an unforgettable week of world class lectures.

She was instrumental in the introduction of breakout sessions and she was also a leader in the introduction of the AVIR poster session. She provided a platform for technologists to showcase their individual accomplishments in both research and education.

In 2017, Kristen served as the vice president of the AVIR. In her role as education chair, she worked tirelessly, maybe you shouldn't type words you can't say. (laughs) She worked really hard

(laughs) to improve the AVIR's educational offerings, promoting not only the AVIR but the field of IR as a whole. She functioned as a critical liaison between the AVIR and other esteemed organizations such as the ARRT and RSNA.

She's published numerous articles for the AVIR Informer. She actively engages with her IR colleagues through social media platforms such as Twitter and LinkedIn. On a personal note, during my term as president of

the AVIR, Kristen has been absolutely invaluable to me. She's served as my right hand and she is a professional inspiration and an incredible friend. She's demonstrated the tireless work ethic, character, and passion required of an AVIR fellow

and it is our incredible honor and privilege to induct her into the fellowship class of 2018. (applause) - Excuse me. First off, even being recognized with this group of individuals is an incredible honor.

I first found out about IR probably about a year before I applied for x-ray school. There was an article that was released by the hospital that I attended for x-ray school to the general public online and that article highlighted the transarterial chemoembolization procedure.

I was completely mesmerized by this article that I had read. I ended up later going to the library at the hospital that I currently worked at and did research on this and I found this article for HCC that I later found out was written by the father of interventional oncology,

Michael Soulen. That article that I read in JVIR, I think it was authored in 2002, made me apply for x-ray school. Fast forward, I'm sitting in my interview and my to-be program director asks me

why I want to be an x-ray tech. I continue to tell her all about the literature that I had read on liver directed therapy, and I think she looked at me and thought I was probably insane. She said, "You do understand you're here to learn

"how to take x-rays, correct?" And to be completely frank at that time, I really didn't understand what I was getting myself into. I still feel that same excitement every day when I walk into work.

And I'm really excited about everything that we've accomplished with the AVIR over the last year and I'm really excited to see where that leads to this year with our incoming board. So, I'd like to welcome the rest of the board up here as we lead into the business meeting.

Disclaimer: Content and materials on Medlantis are provided for educational purposes only, and are intended for use by medical professionals, not to be used self-diagnosis or self-treatment. It is not intended as, nor should it be, a substitute for independent professional medical care. Medical practitioners must make their own independent assessment before suggesting a diagnosis or recommending or instituting a course of treatment. The content and materials on Medlantis should not in any way be seen as a replacement for consultation with colleagues or other sources, or as a substitute for conventional training and study.