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Cholangitis (Post-Hepatic Lobectomy), Hepatic Duct Occlusion | Roux Limb Anastomosis | 60 | Female
Cholangitis (Post-Hepatic Lobectomy), Hepatic Duct Occlusion | Roux Limb Anastomosis | 60 | Female
2016ablationanastomosisaxialbeambiliarybilirubinbowelcarcinoidcholangiographycholangitisconedrainductalductshepatobiliaryinpatientjejunallftsocclusionportalposteriorradiofrequencySIRtumor
Why is Staging Important | Interventional Oncology
Why is Staging Important | Interventional Oncology
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Renal Ablation | Interventional Oncology
Renal Ablation | Interventional Oncology
ablationcardiomyopathycentimeterchaptereffusionembolizedfamiliallesionmetastaticparenchymalpatientpleuralrenalspleensurgerytolerated
The Ablation Concept | Interventional Oncology
The Ablation Concept | Interventional Oncology
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Benign Biliary Strictures | Biliary Intervention
Benign Biliary Strictures | Biliary Intervention
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PET/MRI vs PET/CT | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
PET/MRI vs PET/CT | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
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Case- Brain Infarction | Brain Infarct After Gastroesophageal Variceal Embolization
Case- Brain Infarction | Brain Infarct After Gastroesophageal Variceal Embolization
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TIPS Case | Extreme IR
TIPS Case | Extreme IR
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Percutaneous Biliary Drainage  | Biliary Intervention
Percutaneous Biliary Drainage | Biliary Intervention
angiogramaxischaptercoaxialcolordrainductductalfrequentlyhepaticinterventionalobstructionperipheralportalstructuressuccesssystemtubevein
Malignant melanoma, liver metastases | Cryoablation Case | Ablations: Cryo, Microwave, & RFA
Malignant melanoma, liver metastases | Cryoablation Case | Ablations: Cryo, Microwave, & RFA
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Case 11: Bleeding Tracheostomy Site | Emoblization: Bleeding and Trauma
Case 11: Bleeding Tracheostomy Site | Emoblization: Bleeding and Trauma
aneurysmsangiogramarterybleedingBleeding from the tracheostomy siteblowoutcancercarotidcarotid arterychaptercontrastCoverage StentembolizationimageNonepatientposteriorpseudoaneurysmsagittalscreenstent
Bland Embolization | Interventional Oncology
Bland Embolization | Interventional Oncology
ablationablativeadministeringagentangiogramanteriorbeadsblandbloodceliacchapterchemocompleteelutingembolicembolizationembolizedhcchumerusischemialesionmetastaticnecrosispathologicpatientpedicleperformrehabresectionsegmentsequentiallysupplytherapytumor
IR in Egypt and Ethiopia | AVIR International-IR Sessions at SIR2019 MiddleEast & Africa Focus
IR in Egypt and Ethiopia | AVIR International-IR Sessions at SIR2019 MiddleEast & Africa Focus
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Overview of Biliary Disease at John's Hopkins | Biliary Intervention
Overview of Biliary Disease at John's Hopkins | Biliary Intervention
accessangiogrambiliarychaptercolonoscopyendoscopicercphopkinsinterventionlandscapeliverpercutaneouspracticequestionspecialtiesspecialty
Indirect Angiography | Interventional Oncology
Indirect Angiography | Interventional Oncology
ablateablationablativeaneurysmangioangiographybeamBrachytherapycandidateschapterdefinitivelyembolizationentirehccindirectintentinterdisciplinaryischemiclesionographypatientportalresectionsbrtsurgicaltherapyvein
The Ways to Recanalize the Below the Knee Vessels | AVIR CLI Panel
The Ways to Recanalize the Below the Knee Vessels | AVIR CLI Panel
ablationanalogantibioticarteriesarthritisassessaveragebasicallychapterclinicaldissolveemboembolizationembolusinfarctinjectinvestigationalkneelateralmedialmrispainpalpatepatientpatientsprocedurepublishedradiofrequencyrefractoryresorbablescalestudy
Pulmonary Ablation | Interventional Oncology
Pulmonary Ablation | Interventional Oncology
ablationactivitycancercandidatechaptercolorectalcryodiseaselesionslobelungmetastaticnodulepatientpulmonaryrecurrecurredresectionresidualscansurgical
Muscoskeletal Ablation | Interventional Oncology
Muscoskeletal Ablation | Interventional Oncology
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Hemobilia | Biliary Intervention
Hemobilia | Biliary Intervention
accessangioangiogramarchitecturearteriesarteryaureusbiliarybleedingceliacchaptercollateralizationdefectsdislodgementductembolizefistulasfrequentlygramhepatichilumintercostalinterventionistsliverparenchymalperipheralportalpreppseudoaneurysmremovethrombosestubetubesupsizeveinveinsvessels
Cone Beam CT | Interventional Oncology
Cone Beam CT | Interventional Oncology
ablationanatomicangioarteriesarteryartifactbeamchaptercombconecontrastdoseembolicenhancementenhancesesophagealesophagusgastricgastric arteryglucagonhcchepatectomyinfusinglesionliverlysisoncologypatientsegmentstomach
Ablative Radioembolization | Interventional Oncology
Ablative Radioembolization | Interventional Oncology
adjacentadministerarterialbladecancerchaptercompletedosedosesentiregreyinvadinglesionliverlobelobectomynecrosispathologicpatientportalremnantresectionresponsesegmentsurgeontinytreattumorvein
Cryoablation Advantages and Disadvantages | Ablations: Cryo, Microwave, & RFA
Cryoablation Advantages and Disadvantages | Ablations: Cryo, Microwave, & RFA
ablationanesthesiableedingbloodchaptercryocryoablationdisadvantagefreezeliverlungmicrowavenodulespainfulprobeprobesproteinsrenalresponsesedationtissuetumorvessel
Results of the US FDA Trial | Pecutaneous Creation of Hemodialysis Fistulas
Results of the US FDA Trial | Pecutaneous Creation of Hemodialysis Fistulas
anastomosisangiogramangioplastyarteryBARDBD EverlinQ (4Fr & 6Fr)brachialcalcifiedcatheterschaptercreatedevicedevicesDialysiselectrodeembolizationembolizeendpointsenergyFistulafistulasflowfrenchmagnetsmaturationofficialpercutaneousperforatorpositionpseudoaneurysmradialradiofrequencysaddlesitssurgeonsurgicallyulnarveinvena
Malignant Biliary Strictures | Biliary Intervention
Malignant Biliary Strictures | Biliary Intervention
adventBARDcancerceliaccenterschaptercolorectalcookCordiscoveredcysticdataductextremelyfavorfavorablegoregrammalignantMeditechMemothermmetalmetastaticmultipleocclusiononcologyovergrowthpatientsperioperativeportalSmartStentstainsstentstentsstricturestumorunresectablewallstentZilver Stent
Kidney lesion | Cryoablation Case | Ablations: Cryo, Microwave, & RFA
Kidney lesion | Cryoablation Case | Ablations: Cryo, Microwave, & RFA
ablationballchaptercollectingcryoablationkidneylesionLesion in left kidneymedialstricturessystemtumorureter
Ideal Stent Placement | TIPS & DIPS: State of the Art
Ideal Stent Placement | TIPS & DIPS: State of the Art
anastomosiscentimeterchaptercoveredcurveDialysisflowgraftgraftshemodynamichepatichepatic veinhyperplasiaintimalnarrowingniceoccludesocclusionportalshuntshuntssmoothstentstentsstraighttipsveinveinsvenousvibe
Nodule in right lung | Cryoablation Case | Ablations: Cryo, Microwave, & RFA
Nodule in right lung | Cryoablation Case | Ablations: Cryo, Microwave, & RFA
ablationablationschaptercryocryoablationfreezehemorrhagelesionlungLung Noduleminutesnodulepneumothoraxprobesprotocolproximalthawtriple
Balloon Pulmonary Angioplasty | Management of Patients with Acute & Chronic PE
Balloon Pulmonary Angioplasty | Management of Patients with Acute & Chronic PE
angiogramangioplastyarteryballoonballooningbandschaptercomplicationscontrastflowHorizonimageimagesluminalNoneocclusionocclusionspatientsproximallypulmonaryradiationrecanstenosisthrombustreatedultrasoundwebs
Adrenal gland mass next to aorta | Heat sink / Cold sink | Cryoablation Case | Ablations: Cryo, Microwave, & RFA
Adrenal gland mass next to aorta | Heat sink / Cold sink | Cryoablation Case | Ablations: Cryo, Microwave, & RFA
ablationAdrenal mass next to aortaanterioraortabowelchaptercryoablationfreezemassmicrowavepancreaspancreatitisprobeprobessink
Case 1 - Non-healing heel wound, Rutherford Cat. 5, previous stroke | Recanalization, Atherectomy | Complex Above Knee Cases with Re-entry Devices and Techniques
Case 1 - Non-healing heel wound, Rutherford Cat. 5, previous stroke | Recanalization, Atherectomy | Complex Above Knee Cases with Re-entry Devices and Techniques
abnormalangioangioplastyarteryAsahiaspectBARDBoston Scientificcatheterchaptercommoncommon femoralcontralateralcritical limb ischemiacrossCROSSER CTO recanalization catheterCSICTO wiresdevicediseasedoppleressentiallyfemoralflowglidewiregramhawk oneHawkoneheeliliacimagingkneelateralleftluminalMedtronicmicromonophasicmultimultiphasicocclusionocclusionsoriginpatientsplaqueposteriorproximalpulserecanalizationrestoredtandemtibialtypicallyViance crossing catheterVictory™ Guidewirewaveformswirewireswoundwounds
Case 5: Liver Trauma | Emoblization: Bleeding and Trauma
Case 5: Liver Trauma | Emoblization: Bleeding and Trauma
activeangiogramarterybleedingbloodchaptercoilsembolizationembolizeextravasationhematomainjuryleakingliverLiver TraumamelenamicrocatheterNonenoticeportalposteriorpseudoaneurysmtraumavenousvessels
Transcript

So this will be another case. A 60 year old female with a history of left hepatic lobectomy,

hwpaticojejunostomy, underwent radiofrequency ablation of a carcinoid tumor in the right lobe of the of the liver. On follow up again, presented with cholangitis increase in bilirubin and you kind of see the air in the system.

So again we did the PTHC. Patient did have elevated LFTs and PTHC showed that right sided ductal occlusion as you can see on PTH and there's nothing is going downstream and again it has pretty much become routine for us to use these tools anywhere we find difficulty. Not only in biliary system,

in the portal system, even placing the difficult G-tubes. We'll time to time use this system just to avoid any kind of injury. And it certainly has increased our confidence and also the number of the cases that we can do at this point. So we did the cone beam CT and again you can see it kind of opacified/g

the post reductal system. There is nothing in the interior because this patient actually had two anastomosis. And the interior one was still patent to hepaticojejunostomy, but the posterior one was completely occluded.

So again we did the same 3D Cone-Beam CT scan got all kind of reconstruction axial canal surgical/g, and again the plan was to try to do the sharp recarnalization, and get to the jejunal loop, but here the path seems it was a very, very sharp angle.

So we decided after going through all kinds of calculations that it probably is not the best option for us to actually do the procedure just because there were other bowel loops that were coming. But what here this cone beam CT and cholangiography that we did CT cholangiography here did that. It clearly identified your biliary ducts and it became,

again mental over the hepatobiliary surgeons, and it did not seem like a right option for us to do this procedure but at the same time they were comfortable that with these ducts we can potentially, an ostemos/g

a bowel loop and drain the posterior ductile system. And that's actually eventually happened in this particular patient. We kind of outlined these ducts for them, then the inpatient went to the operating room, and these ducts were then used for

a second anastomosis in this patient. And this is the post optic result again, you can see the internal, external biliary drain catheter. So this was the treatment follow up. Again, you can see the [UNKNOWN] ostemosis.

so why staging important well when you go to treat someone if I tell you I have a lollipop shaped tumor and you make a lollipop shape ablation zone over it you have to make sure that it's actually a lollipop shaped to begin with so here's

a patient I was asked to ablate at the bottom corner we had a CT scan that showed pretty nice to confined lesion looked a little regular so we got an MRI the MRI shows that white signal that's around there then hyperintensity that's

abnormal and so when we did an angiogram you can see that this is an infiltrate of hepatocellular carcinoma so had I done an ablation right over that center-of-mass consistent with what we saw on the CT it

wouldn't be an ablation failure the blasian was doing its job we just wouldn't have applied it to where the tumor actually was so let's talk about

different applications renal ablation is very common when do we use it

high surgical risk patients primary metastatic lesions some folks are actually refused surgery nowadays and saying I'll have a one centimeter reno lesion actually want this in lieu of surgery people have

familial syndromes they're prone to getting a renal cancer again so we're trying to preserve renal tissue it is the most renal parenchymal sparing modality and obviously have a single kidney and a lot of these are found

incidentally when they're getting a CT scan for something else here's a very sizable one the patient that has a cardiomyopathy can see how big the heart is so it's you know seven centimeter lesion off of the left to superior pole

against the spleen this patient wouldn't have tolerated bleeding very much so we went ahead and embolized it beforehand using alcohol in the pide all in a coil and this is what it looks like when you have all those individual ice probes all

set up within the lesion and you can see the ice forming around I don't know how well it projects but in real time you can determine if you've developed your margin we do encompass little bit of spleen with that and you can see here

that you have a faint rim surrounding that lesion right next to the spleen and that's the necrotic fat that's how you know that you got it all and just this ablation alone caused a very reactive pleural

effusion that you can see up on the CT over there so imagine how this patient would have tolerated surgery pulmonary

the ablation concept in general is to provide an environment that is

completely hostile to tumor minus 40 degrees Celsius 150 degrees Celsius 500 gray which is a radiation dose we say it's very hard for it's about anything to survive but so why is it that it doesn't always work well that's a

function of all those parameters that you see there we got to make sure we pick the right patients we got to make sure that we treat tumor where we think it is and avoid trading things that don't need treatment avoid causing

damage to collateral structures and getting a reasonable margin where we actually get some of the tumor that's microscopic there are a lot of ablation modalities radiofrequency alternates electrical current very rapidly so that

generates friction within the lesion and causes heat it looks like this a lot of times you see these little times that stick out so that you can increase the size of your blasian zone and here's a one of those deployed in a patient who

had a colorectal Curren after hepatectomy cryoablation freezes things and it pushes a gas that once it goes through a pin hole tends to expand and cause rapid freezing he can also push another gas right through it and cause

rapid heating but this is just bringing tumors to that minus 20 degree minus 40 degree threshold the nice part about cryoablation is that you can visualize your ablation zone so we're right up against the bile duct here and it tends

to be a little more respectful of tissues so that's why cryoablation is chosen every once in a while we're do frequency ablation is an excellent tool we have lots of data for it but likes it sometimes it's difficult determine where

the ablation zone is interprocedural e microwave ablation there was just a randomized study that came out that compared microwave ablation to radiofrequency ablation and the results are very similar

it was a very very experienced institution doing it but the whole point here is that a lot of these tools work pretty well there's no clear superiority on them but one thing that microwave offers it's very fast so generates

temperatures to boiling within the tumor in about five minutes and so it's certainly very fast as compared to radiofrequency and you can see boiling happening within this tumor that's been accessed eventually there that gas is

actually literally fluid that is boiling away from the tumor couple of cool ones this one's reversal expiration what we do here is we place probes throughout the lesion and we pulse it to confuse the membrane on the cell to think that

it's a it has holes in it that it cannot close and so what is happening is the contents inside the cell leave and that's pretty much consistent with not being able to survive the nice part is we can accomplish all that without

thermal ablation what do we mean that we don't go over about 40 degrees Celsius so if something is involving a bile duct or involving a critical structure like the ureter it's not actually going to damage it it just basically tells all

the the cells within there to stop stop undergoing the cellular mechanisms responsible for life it's a little more finicky to place you have to place these little parallel probes here's one we did that was directly write on the

bifurcation of the main bile ducts and you can see here afterwards is an immediate post contrast scan how that whole area is ablative it does not take up contrast and this patient never developed biliary strictures that side

this is just happens to be a biliary

other classification system with bismuth how where the injury occurs and this is really germane after surgery so you'll see most of these actually after misadventure with bluish surgery and and like I said the most common ones

actually after laparoscopic surgery but we have barrier so we have oncological have two extremely complex three sections of the liver now and and we the advent and certainly rise are more balloon complications this is an example

of what we might do in the complex setting this patient had explorers in cholangitis primary cylinder current charges received a transplant and the transplant liver had a recurrence and with recurrent explorers and cholangitis

there was just no way we could cross it but even with a long-standing billy we drain frequently if you drain most obstructed systems a day or two passage across an inflamed structure it makes it much more easy and you will see their

people get brought back for their secondary tube with laryngitis sometimes this is not possible so we actually have made attempts to cross this there's no other way so we happen to use a sharp organization so we happen to use a

transept own needle and use a sharp needle go breakthrough sometimes analysis of the CT scan is a very important you really want to know what's between your one side and what's on the other side and the more even more fun

thing to do now is using our rfy off-label and we'll burn our way through and create the track that actually has a much better patency rates and even sharp organization your allow essentially coring of sort of in chronically

inflamed fibrotic tissue and allows you a chance of keeping this open it's just example of how you benchley burrow through with a shop another case with a sharp needle creating a track really that's not

natural because this is obviously a transplant patient and it's the only way through even done what we've done is stick the intestine first and then put us in a punch our way through polio stay out and

then thereby restoring the the track and they are sort of you have to be just really created with biliary disease when it comes to chronic obstructions or high-grade obstructions so like I said with benign the disease frequently it's

post-operative and so they will present in multiple different ways and most of the times they're just leaking in the intraperitoneal ich you you're you essentially peritoneal cavity will reabsorb it so patients get jaundice is

essentially it hi arrays but Rubens and you'd really can diagnose in many ways and really just dealing with this can be problematic and then so we've been dealing with bluish structures and and oh sorry benign Ballou strictures

post-operative benign Ballou strictures in a more labor-intensive way we actually leave tubes in for six months which is probably a little more than most people must be not a benign the Lewis structures are managed with three

months of stinting with a minimum of twelve French tube so that's a reason why some of these patients will get kalanchoe pasties multiple bluie a drained Rhys tenting it and tube exchanges and changed up this way and

then this is just happens to be the British is worth a typical we will get access cross the stricture kalanchoe plastic stretch out this benign structure and then place a tube in for as long as you can to keep it open and

fro asses of between three and six months there's a classic example someone who obstructed that they said this looks very smooth it doesn't look ugly and looks okay doesn't look like a cancer we sometimes what I so biopsy if it has any

suspicious appearance and then get across you can see even with a balloon how tight the structure can be with a high pressure balloon and there after placing achievement for again three to six months we actually err on the side

of caution almost our patients have six months of intubation which is quite long difficult and this is our experience what we do then is when do you remove it to actually have a sort of a step-by-step process we have a it's not

really medical clinical trials actually just if a flow clinical trial what we'll do is get the tubing bring a patient back and we actually cut the tube so there's only the access through the parenchyma of the liver is preserved but

nothing through the structure we will cap the tube is since you can maintaining access and see if the patient doesn't make sure that doesn't get fever the stricture is maintained and then we'll bring the patient back

after a week to do a balloon whiticus test that's really just a modification of a urinary radhika test we're going to take pressure measurements after slow contrast injections to make sure it remains the

patency and for us the data suggests we can essentially and predict over 90% who will be staying free if they pass the Whittaker test in keeping the monetary reading less than 20 centimeters of

water and really it allows us to manage these because of how many patients have what procedures at our institution we have a large volume of patients that we actually follow and it's a you know our fellows think it's the most common

procedure Billu intervention had this is actually not that coming everywhere else and this is what I believe tests we have a pro forma that we fill in and the contrast has been ejected in

certain rates per minute and so this test takes about 30 minutes we make sure that there's the predictive value of in less than less pressure building up over higher high contrast injection rates will give us a great prediction of no

longer needing the tube and then stone

there are advantages of this modality one there's less radiation exposure for

the patient we receive about three millisieverts of background radiation every year with one PET scan a patient can get up to eight years worth of background radiation in just one skin the only exposure of radiation a patient

gets in a pet MRI is through the isotope pet MRI has a better disease characterization especially for areas in a Patou biliary region the pelvic areas and the kidneys information and the relationship between lesions and

adjacent tissue is better delineated with the pet MRI so it's easier to see which part is cancerous and which partners normal cells there are varying opinions and research studies are being done to make a determination if pet MRI

is a better modality than pet CTS well PET CT is a lower-cost skin has increased accessibility there are more PET scanners available and more more technologists are trained for this modality PET CT is a shorter skin there

are no contraindications for affairs implants pet CTS are preferred method for imaging the lungs of thoracic nodules and bone structures however with a pet MRI it's good for soft tissue organs such as the brain the muscle

delivered the kidneys the pancreas our GYN pelvic structures such as ovaries the uterus and cervix and also the prostate there are limitations of this skin one it is a much longer skin one whole body pet MRI can last at least

about an hour there are contraindications with certain implants due to the magnetic factor of the of this test and is not preferred for imaging air-filled structures because it can give off artifacts there

are weight limitations for our machine our machine holes can hold up to about 500 pounds of weight it is this our machine as smaller bore compared to the white board MRI the MRI whiteboy is about 70 centimeters in diameter

our pet MRI machine is only 60 centimeters in diameter in this picture the difference of the 10 centimeter difference doesn't seem much however if you put a patient in there and this is one of our coworkers

he is 270 pounds and 6 feet tall and the white board MRI his shoulders fit comfortably well inside it in the sky inside the scanner however in this pet MRI machine he said he did feel a little snug and a little tight inside

but you also have to take an account that we have to put coils on top of our patients that 10 centimeters does make a big difference the coils will help us give the good quality images that we like and I also have to note that we

have to put the head coil or the helmet on top of the patient's head to give good images of the brain the reason why the pet MRI scanner is smaller is because we have to make room for the pet detectors we try to make it bigger the

gradient coil on the radiofrequency coil have to be further away from the center of the magnet and that compromises the quality of our images so which patient

I like to talk about brain infarc after Castro its of its year very symbolic a shoe and my name is first name is a shorter and probably you cannot remember my first name but probably you can remember my email address and join ovation very easy 40 years old man presenting with hematemesis and those coffee shows is aphasia verax and gastric barracks and how can i use arrow arrow on the monitor no point around yes so so you can see the red that red that just a beside the endoscopy image recent bleeding at the gastric barracks

so the breathing focus is gastric paddocks and that is a page you're very X and it is can shows it's a page of Eric's gastric barracks and chronic poor vein thrombosis with heaviness transformation of poor vein there is a spline or inertia but there is no gas drawer in urgent I'm sorry tough fast fast playing anyway bleeding focus is gastric barracks but in our hospital we don't have expert endoscopist

for endoscopy crew injections or endoscopic reinjection is not an option in our Hospital and I thought tips may be very very difficult because of chronic Peruvian thrombosis professors carucha tri-tips in this patient oh he is very busy and there is a no gas Torino Shanta so PRT o is not an option so we decided to do percutaneous there is your embolization under under I mean there are many ways to approach it

but under urgent settings you do what you can do best quickly oh no that's right yes and and this patience main program is not patent cameras transformation so percutaneous transit party approach may have some problem and we also do transit planning approach and this kind of patient has a splenomegaly and splenic pain is big enough to be punctured by ultrasonography and i'm a tips beginner so I don't like tips in this difficult

case so transplanting punch was performed by ultrasound guidance and you can see Carolus transformation of main pervane and splenorenal shunt and gastric varices left gastric we know officios Castries bezier varices micro catheter was advanced and in geography was performed you can see a Terrell ID the vascular structure so we commonly use glue from be brown company and amputee cyanoacrylate MBC is mixed with Italy

powder at a time I mixed 1 to 8 ratio so it's a very thin very thin below 11% igloo so after injection of a 1cc of glue mixture you can see some glue in the barracks but some glue in the promontory Audrey from Maneri embolism and angiography shows already draw barracks and you can also see a subtraction artifact white why did you want to be that distal

why did you go all the way up to do the glue instead of starting lower i usually in in these procedures i want to advance the microcatheter into the paddocks itself and there are multiple collateral channels so if i in inject glue at the proximal portion some channels can be occluded about some channels can be patent so complete embolization of verax cannot be achieved and so there are multiple paths first structures so multiple injection of glue is needed

anyway at this image you can see rigid your barracks and subtraction artifacting in the promenade already and probably renal artery or pyramid entry already so it means from one area but it demands is to Mogambo region patient began to complain of headache but american ir most american IRS care the patient but Korean IR care the procedure serve so we continue we kept the procedure what's a little headache right to keep you from completing your

procedure and I performed Lippitt eight below embolization again and again so I used 3 micro catheters final angel officio is a complete embolization of case repair ax patients kept complaining of headache so after the procedure we sent at a patient to the city room and CT scan shows multiple tiny high attenuated and others in the brain those are not calcification rapado so it means systemic um embolization Oh bleep I adore mixtures

of primitive brain in park and patient just started to complain of blindness one day after diffusion-weighted images shows multiple car brain in park so how come this happen unfortunately I didn't know that Porter from Manila penis anastomosis at the time one article said gastric barracks is a connectivity read from an airy being by a bronchial venous system and it's prevalence is up to 30 percent so normally blood flow blood in the barracks drains into the edge a

ghost vein or other systemic collateral veins and then drain into SVC right heart and promontory artery so from what embolism may have fun and but in most cases in there it seldom cause significant cranker problem but in this case barracks is a connectivity the promontory being fired a bronchial vein and then glue mixture can drain into the rapture heart so glue training to aorta and system already causing brain in fog or systemic embolism so let respectively

thank you so much for inviting me and to speak at this session so I'm gonna share with you a save a disaster and a save hopefully my disclosures which aren't related so this is a 59 year old female she's lovely with a history of locally advanced pancreatic cancer back in 2016

and and she presented with biliary and gastric outlet obstructions so she underwent scenting so there was a free communication of the biliary system with the GI system she underwent chemo and radiation and actually did really well

and she presents to her local doctor in 2018 with ascites they tap the ascites that's benign and they'll do a workup and she just also happens to have n stage liver disease and cirrhosis due to alcohol abuse in her life so just very

unlucky very unfortunate and the request comes and it's for a paracentesis which you know pretty you know standard she has refractory ascites and because she has refractory ascites tips and this is a problem because the pointer doesn't

work because a her biliary system is in communication with the GI system right so there's lots of bugs sitting in the bile ducts because of all these stents that have opened up the bile duct to list to the duodenum and so you know

like any good individual I usually ask my colleagues you know there's way more smart people in the world than me and and and so I say well what should I do and and you know there was a very loud voice that said do not do a tips you

know there there's no way you should do a tips in this person maybe just put in a tunnel at drainage catheter and then there was well maybe you should do a tips but if you do a tips don't use a Viator don't use a covered stand use a

wall stunt a non-covered stunt because you could have the bacteria that live in the GI tract get on the the PTFE and and you get tip situs which is a disaster and then there was someone who said well you should do a bowel prep you

like make her life miserable and you know give her lots of antibiotics and then you should do a tips and then it's like well what kind of tips and they're like I don't know maybe you should do a covered said no not a covered tonight

and then they're you know and then there was there was a other voice that said just do a tips you know just do the damn tips and go for it so I did it would you know very nice anatomy tips was placed she did well

the next day she has fevers and and her blood cultures come back positive right and you can see in the circle that there's a little bit of low density around the tips in the liver and so they put her on IV antibiotics and then they

got an ultrasound a week later and the tips that occluded and then they got a CT just to prove that the ultrasound actually worked so this really hurt my gosh to rub it in just to rub it in just just to confirm that your tips occlude

it and so you know I feel not so great about myself and particularly because I work in an institution that defined tip seclusion was one of the first people so gene Laberge is one of my colleagues back in the day demonstrated Y tips

occludes and one of the reasons is because it's in communication with the biliary system so bile is very toxic actually and when it gets into the the lining of the tips it causes a thrombosis and when they would go and

open these up they would see green mile or biome components in the in the thrombus so I felt particularly bad and so and then I went back and I looked and I was like you know what the tips is short but it's not short in the way that

it usually is usually it's short at the top and they people don't extend it to the to the outflow of the hepatic vein here I hadn't extended it fully in and it was probably in communication with a bile duct which was also you know living

with lots of bacteria which is why she got you know bacteremia so just because we want to do more imaging cuz you know god forbid you know you got the ultrasound of her they because she was back to remake and

you know that and potentially subject they got an echo just to make sure that she doesn't have endocarditis and they find out that she has a small p fo so what happens when you have a thrombosed tips you go back in there and you do a

tips or vision you line it with a beautiful new stent that you put in appropriately but would you do that when the patient has a shunt going from one side of the heart to the other so going from the right to the left so sort of

similar to that case right and so what do we do so I you know certainly not the smartest person in the room we've demonstrated that so I go and I asked my colleagues and so the loud voice of saying you know I told you this is why

we don't practice this kind of medicine and then there was someone who said why don't we anticoagulate her and I was like are you kidding me like you know do you think a little lovenox is gonna cure this and then the same person who said

we should do a tunnel dialysis tile the tunnel drainage catheter or like a polar X was like how about a poor X in here like thanks man we're kind of late for that what about thrombolysis and then you

know the most important WWJ be deed you guys are you familiar with that no what would Jim Benenati do that's that's that's the most important thing right so so of course you know I called Miami he's you know in a but in a big case you

know comes and helps me out and and I'm like what do I do and you know he's like just just go for it you know I mean there are thirty percent of the people that we see in the world have a efo it's very small and it probably doesn't do

anything but you know I got to tell you I was really nervous I went and I talked to miner our colleagues I made sure that the best guy who was you know available for stroke would be around in case I were to shower emboli I don't even know

what he would do I mean maybe take her and you know thrombolysis you know her like MCA or something I don't know I just wanted him to be around it just made me feel good and then I talked to another one of my favorite advisors

buland Arslan who who also was at UVA and he said why don't you instead of just going in there and mucking around with this clot especially because you have this shunt why don't you just thrown belay sit and then you

know and then see what happens and so here I brought her down EKOS catheter and I dripped a TPA for 24 hours and you know I made her do this with local I didn't give her any sedation because I wanted and it's not so painful and I

just wanted her to be awake so I could make sure that she isn't you took an intervention location you turned it into internal medicine I I did work you know that's that's you know I care right you know we're clinicians and so she was

fine she was very appreciative I had a penumbra the the the Indigo system around the next day in case I needed to go and do some aspiration thrombectomy and what do you know you know the next day it all opened up and you can still

see that the tips is short the uncovered portion which is which is you know past the ring I'm sorry that which is below the ring into the portal vein is not seated well so that was my error and and there was a little bit of clot there so

what I ended up doing is I ended up balloon dilating it placing another Viator and extending it into the portal vein so it's covered so she did very

we do drain the Louie systems we actually do this extremely successfully as interventional radiologists and it's a very high technical success like I said in this sort of supine position

from the mid-axillary line and these things are and you've seen a lot of these how these done really you need to pacify the system you get trans you most post people go trends in to cost Albany because the liver sometimes can be

tucked up way above and we usually want to make sure that the lung and the costophrenic angle doesn't come down low in nothing I take a deep inspiration first to make sure that you're not dealing with and then we now map your

track than you find some people do this with ultrasound guidance frequently with and dilated structures and most of the time it's actually much probably routine to actually do blind passes in the like I said the path of high success and to

pull back when you a passive our blue system is the only structure that doesn't wash away generally portal vein hepatic vein hepatic artery all of those structures are cylindrical

tubule alike are not are going to wash away move away and quite quickly and you can see this PDC and show in fact a left insertion of a right into your ductal system and frequently this will be something that we would have to make

people watch out like I said identification of choosing the right duct thereafter after you've identified you've performed a color angiogram is to identify how you're going to drain this and the most important thing to identify

is a peripheral duct doesn't matter which one there are ones with higher success but then within the lateral position find one market on the table then with a second axis as a to stick axis and I'm sure this is very germane

and common you've seen get into the peripheral duct and the AP fluoroscopy get a wide down you get a tube down and then eventually go it with a coaxial system getting a skinny wire converted to a larger wire and then following that

with a below a tube and your goal is to really get axis that goes transpannic through a perfect century through obstruction or no obstruction if it's just untie elated and through into the small bowel and lock a some type of

locking system it's interesting the size that you choose does make it different so if you go larger than the 12 french-trained initially the risk of bleeding actually goes above 10% for initial axis so the best is to probably

start with a 8 and 10 and that's what we typically do this is what we connect what it ends up looking like left a

is example as I mentioned about doing very large ablation so this is a lady who hadn't malignant melanoma and she

had metastases to liver we basically placed six probes into this mass as you can see there on that CT the image on the right is the appearance of those six probes it's all excited about how many probes I placed in this patient

like it's a game and then I just watched an ablation talk with a guy put 16 in so that didn't really make me feel much better so so we have six probes here and you can see what we what you do when you have lesions that are in the soft

tissues and you're worried about freezing to the skin you can have injury to the skin right essentially frostburn and so frostbite sorry and so what you can do is you can take either a warm glove fill it up with saline and put it

with the fingers amongst the probes so it keeps the skin warm because you don't want to freeze the skin or what people are doing sometimes as well as they've just put some gauze around all the probes and they spray that goes with

warm saline I just take one of those leader bags of saline put it in the microwave for a couple minutes and then just fill fill the bowl up with it and just spray the gauze on that or you can do the glove technique the main idea

here once again is you don't want to get skin injury when you do these and as you can see a pretty sizable ablation around that entire tumor you can even see the lightening sign which is the low attenuation sort of lightening looking

structures within the ice ball which is cracking of the ice ball as you form but you will see what this is immediately after the procedure the patient will have a very hard ice ball under their chest and it takes about an hour

for that to melt so if you notice bleeding off towards or what is perceived as bleeding before you panic you should realize that that ice pole is going to melt and it's going to come out the holes seep out of the holes that you

created so oftentimes if it's sort of a blood tinge fluid that's really just the ice ball melting in the fluid coming out of the the sites that you've punctured

my last case here you have a 54 year old patient recent case who had head and neck cancer who presents with severe bleeding from a tracheostomy alright for some bizarre reason we had two of these

in like a week all right kind of crazy so here's the CT scan you can see the asymmetry of the soft tissue this is a patient who had had a neck cancer was irradiated and hopefully what you can notice on the

right side of the screen is the the large white circles of contrast which really don't belong there they were considered to be pseudo aneurysms arising from the carotid artery all right that's evidence of a bleed he was

bleeding out of his tracheostomy site so here's a CTA I think the better image is the image on the right side of the screen the sagittal image and you can see the carotid artery coming up from the bottom and you can see that round

circle coming off of the carotid artery you guys see that so here's the angiogram all that stuff that is to the right to the you know kind of posterior to the right of the screen there it doesn't belong there that's just

contrast that's exiting the carotid artery this is a carotid blowout we'll call it okay just that word sounds bad all right so that's bad so another question right what do you want to do here

I think embolization is reasonable but probably not the thing we can do the fastest to present a patient to treat a patient is bleeding out of the tracheostomy site so in this particular case this is a great covered stent case

alright and here's what it looked like after so we can go right up and just literally a cover sent right across the origin of that pseudoaneurysm and address the patient's bleeding alright

we're gonna move on to embolization there a couple different categories of embolization bland embolization is when

you just administering something that is choking off the blood supply to the tumor and that's how it's going to exert its effect here's a patient with a very large metastatic renal cell lesion to the humerus this is it on MRI this is it

per angiogram and this patient was opposed to undergo resection so we bland embolized it to reduce bleeding and I chose this one here because we used sequentially sized particles ranging from 100 to 200 all

the way up to 700 and you can actually if you look closely can see sort of beads stacked up in the vessel but that's all that it's doing it's just reducing the blood supply basically creating a stroke within the tumor that

works a fair amount of time and actually an HCC some folks believe that it were very similar to keep embolization which is where at you're administering a chemo embolic agent that is either l'p hi doll with the chemo agent suspended within it

or drug eluting beads the the Chinese have done some randomized studies on whether or not you can also put alcohol in the pie at all and that's something we've adopted in our practice too so anything that essentially is a chemical

outside of a bland agent can be considered a key mobilization so here's a large segment eight HCC we've all been here before we'll be seeing common femoral angiogram a selective celiac run you can make sure

the portals open in that segment find the anterior division pedicle it's going to it select it and this is after drug living bead embolization so this is a nice immediate response at one month a little bit of gas that's expected to be

within there however this patient had a 70% necrosis so it wasn't actually complete cell death and the reason is it's very hard to get to the absolute periphery of the blood supply to the tumor it is able to rehab just like a

stroke can rehab from collateral blood supply so what happens when you have a lesion like this one it's kind of right next to the cod a little bit difficult to see I can't see with ultrasound or CT well you can go in and tag it with lip

Idol and it's much more conspicuous you can perform what we call dual therapy or combination therapy where you perform a microwave ablation you can see the gas leaving the tumor and this is what it looks like afterwards this patient went

to transplant and this was a complete pathologic necrosis so you do need the concept of something that's ablative very frequently to achieve that complete pathologic necrosis rates very hard to do that with ischemia or chemotherapy

alone so what do you do we have a

next is me talking about Egypt and Ethiopia and how I are how IRS practice in Egypt and Ethiopia and I think feather and Musti is gonna talk a little bit about Ethiopia as well he's got a

lot of experience about in about Ethiopia I chose these two countries to show you the kind of the the the the difference between different countries with within Africa Egypt is the 20th economy worldwide by GDP third largest

economy in Africa by some estimates the largest economy in Africa it's about a hundred million people about a little-little and about thirty percent of the population in the u.s. 15 florist's population worldwide and has

about a little over a hundred ir's right now 15 years ago they had less than ten IRS and fifteen years ago they had maybe two to three IRS at a hundred percent nowadays they're exceeding a hundred IRS so tremendous gross in the last 15 years

in the other hand Ethiopia is a very similar sized country but they only have three to five IRS that are not a hundred percent IRS and are still many of them are under training so there are major differences between countries within

within Africa countries that still need a lot of help and a lot of growth and countries that are like ten fifteen years ahead as far as as far as intervention ready intervention radiology

most of the practice in Ethiopia are basic biopsies drainages and vascular access but there is new workshops with with embolization as well as well as well as vascular access in Egypt the the ir practice is heavily into

interventional oncology and cancer that's the bulk that's the bulk of their of their practices you also get very strong neuro intervention radiology and that's mostly most of these are French trained and not

American trains so they're the neuro IRS in Egypt or heavily French and Belgian trains with with french-speaking influence but the bulk of the body iron that's not neuro is mostly cancer and it involves y9e tastes ablations high-end

ablations there's no cryoablation in Egypt there is high-end like like a nano knife reverse electric race electroporation in Egypt as well but there is no cryo you also get a specialty embolization such as fibroids

prostate and embroiders are big in Egypt they're growing very very rapidly especially prostates hemorrhoids and fibroids is an older one but it's still there's still a lot of growth for fibroid embolization zyou FES in Egypt

there's some portal portal intervention there's a lot of need for that but not a lot of IRS are actually doing portal intervention and then there's nonvascular such as billary gu there's also vascular access a lot of

the vascular access is actually done by nephrology and is not done by not not done by r is done by some high RS varicose veins done by vascular surgery and done by IRS as an outpatient there's a lot of visceral angiography as well

renal and transplants stuff so it's pretty high ends they do not do P ad very few IR s and maybe probably two IR s in the country that actually do P ad the the rest of the P ad is actually endovascular PA DS done by vascular

surgery a Horta is done all by vascular surgery and cardiothoracic surgery it's not done it's not done by IR IR s are asked just to help with embolization sometimes help with trying to get a catheter in a certain area but it's

really run by by vascular surgeons but but most more or less it's it's the whole gamut and I'm going to give you a little example of how things are different that when it comes to a Kannamma 'kz there's no dialysis work

they don't do Pfister grams they don't do D clots the reason for that is the vascular surgeons are actually very good at establishing fishless and they usually don't have a

lot of problems with it sometimes if the fistula is from Beau's door narrowed it's surgically revised they do a surgical thrombectomy because it's a lot cheaper it's a lot cheaper than balloons sheaths and and trying to and try a TPA

is very expensive it's a lot cheaper for a surgeon to just clean it out surgically and resuture it there's no there's no inventory there are no expensive consumables so we don't see dialysis as far as fistula or dialysis

conduits at all in Egypt and that's usually a trend in developed in developed countries next we'll talk

good afternoon thank you so much for invitation to speak to you I have a privilege of working at Johns Hopkins and we have a fairly large practice we at the main hospital itself we have 11 rooms and during a day about two of them are have a biliary case actually going

on at the same time so it's actually a fairly large volume of our practice and so the gamut of bluie intervention goes from really simple stuff to really complex and it is something that our trainees specifically will come to

Hopkins for and many of times they will end up being the blurry and experts as soon as they arrive at a new practice so certainly it's something that we deal with every day I just wanted to give you a landscape overview and share some good

cases that we've done and hopefully you may something have some comments or learn something about the way we do it but I'm pretty sure throughout the country a lot of great Billu work has been done currently there's no question

though the Blooey access and access to the Blooey system has really been played out in most hospitals perth by GI and ir and obviously surgery but almost a lesser so today and the rat in at least four IR is the PTC PPD or transparent

Col angiogram but it's actually a recurring role and I actually speak and have a sort of special interest in transit paddock colonoscopy as well so we play scopes through the skin through the liver and do a lot of balloon

intervention I'll show you a few cases like that but in true these access points are germane to what specialty you come from and obviously endoscopic beeper oral and if you eye are usually usually through the skin and there's no

question GI now in some hospitals I'm sure you have advanced endoscopy that will go through the stomach straight into the leftover liver so there's no question of a blurry landscape is changing quickly but no question that

this is quite common but yet most patients and internal medicine specialties will be looking at blurry disease by access point through scopes through ercp so going back from the Duden up or directly through in there's

advantages disadvantages something it's fairly obvious to everybody that you know no question is selling it to a patient if it had both choices that ERCP through the mouth and nothing invasive nothing sticking out their body

is attractive yet the outcomes are very similar but nonetheless there's pros and cons and through the trance of had a crap or two percutaneous route you do definitely have tubes at least sticking out

initially and this is often solved by GI as the main differentiator at least a discomfort but yet we are able to address almost every problem at times and often where'd they pay a lot there's

to talk about is indirect angiography this is kind of a neat trick to suggest to your intervention list as a problem solver we were asked to ablate this lesion and it looked kind of funny this patient had a resection for HCC they

thought this was a recurrence so we bring the comb beam CT and we do an angio and it doesn't enhance so this is an image here of indirect port ography so what you can do is an SMA run and see at which point along the

run do you pacify the portal vein and you just set up your cone beam CT for that time so you just repeat your injection and now your pacifying the entire portal vein even though you haven't selected it and what to show

well this was a portal aneurysm after resection with a little bit of clot in it the patient went on some aspirin and it resolved in three months so back to our first patient what do you do for someone who has HCC that's invading the

heart this patient underwent 2y 90s bland embolization microwave ablation chemotherapy and SBRT and he's an eight-year survivor so it's one of those things where certainly with the correct patient selection you can find the right

things to do for someone I think that usually our best results come from our interdisciplinary consensus in terms of trying to use the unique advantages that individual therapies have and IO is just one of those but this is an important

lesson to our whole group that you know a lot of times you get your best results when you use things like a team approach so in summary there are applications to IO prior to surgery to make people surgical candidates there are definitive

treatments ie your cancer will be treated definitively with curative intent a lot of times we can save when people have tried cure intent and weren't able to and obviously to palliate folks to try to buy them time

and quality of life thermal ablation is safe and effective for small lesions but it's limited by the adjacent anatomy y9t is not an ischemic therapy it's an ablative therapy you're putting small ablative radioactive particles within

the lesion and just using the blood supply as a conduit for your brachytherapy and you can use this as a new admin application to make people safer surgical candidates when you apply to the entire ride a panic globe

thanks everyone appreciate it [Applause] [Music]

they travel together so that's what leads to the increased pain and sensitivity so in the knee there have been studies like 2015 we published that study on 13 patients with 24 month follow-up for knee embolization for

bleeding which you may have seen very commonly in your institution but dr. Okun Oh in 2015 published that article on the bottom left 14 patients where he did embolization in the knee for people with arthritis he actually used an

antibiotic not imposing EMBO sphere and any other particle he did use embolus for in a couple patients sorry EMBO zine in a couple of patients but mainly used in antibiotic so many of you know if antibiotics are like crystalline

substances they're like salt so you can't inject them in arteries that's why I have to go into IVs so they use this in Japan to inject and then dissolve so they go into the artery they dissolve and they're resorbable so they cause a

like a light and Baalak effect and then they go away he found that these patients had a decrease in pain after doing knee embolization subsequently he published a paper on 72 patients 95 needs in which he had an

excellent clinical success clinical success was defined as a greater than 50% reduction in knee pain so they had more than 50% reduction in knee pain in 86 percent of the patients at two years 79 percent of these patients still had

knee pain relief that's very impressive results for a procedure which basically takes in about 45 minutes to an hour so we designed a u.s. clinical study we got an investigational device exemption actually Julie's our clinical research

coordinator for this study and these are the inclusion exclusion criteria we basically excluded patients who have rheumatoid arthritis previous surgery and you had to have moderate or severe pain so greater than 50 means basically

greater than five out of ten on a pain scale we use a pain scale of 0 to 100 because it allows you to delineate pain a little bit better and you had to be refractory to something so you had to fail medications injections

radiofrequency ablation you had to fail some other treatment we followed these patients for six months and we got x-rays and MRIs before and then we got MRIs at one month to assess for if there was any non-target embolization likes a

bone infarct after this procedure these are the clinical scales we use to assess they're not really so important as much as it is we're trying to track pain and we're trying to check disability so one is the VA s or visual analog score and

on right is the Womack scale so patients fill this out and you can assess how disabled they are from their knee pain it assesses their function their stiffness and their pain it's a little

bit limiting because of course most patients have bilateral knee pain so we try and assess someone's function and you've improved one knee sometimes them walking up a flight of stairs may not improve significantly but their pain may

improve significantly in that knee when we did our patients these were the baseline demographics and our patients the average age was 65 and you see here the average BMI in our patients is 35 so this is on board or class 1 class 2

obesity if you look at the Japanese study the BMI in that patient that doctor okano had published the average BMI and their patient population was 25 so it gives you a big difference in the patient population we're treating and

that may impact their results how do we actually do the procedure so we palpate the knee and we feel for where the pain is so that's why we have these blue circles on there so we basically palpate the knee and figure

out is the pain medial lateral superior inferior and then we target those two Nicollet arteries and as depicted on this image there are basically 6 to Nicollet arteries that we look for 3 on the medial side 3 on the lateral side

once we know where they have pain we only go there so we're not going to treat the whole knee so people come in and say my whole knee hurts they're not really going to be a good candidate for this procedure you want focal synovitis

or inflammation which is what we're looking for and most people have medial and Lee pain but there are a small subset of patients of lateral pain so this is an example patient from our study says patient had an MRI beforehand

blasian it's well tolerated and folks with advanced pulmonary disease there's a prospective trial that showed that

there are pulmonary function does not really change after an ablation but the important part here is a lot of these folks who are not candidates for surgical resection have bad hearts a bad coronary disease and bad lungs to where

a lot of times that's actually their biggest risk not their small little lung cancer and you can see these two lines here the this is someone who dr. du Puy studied ablation and what happens if you recur and how your survival matches that

and turns out that if you recur and in if you don't actually a lot of times this file is very similar because these folks are such high risk for mortality outside or even their cancer so patient selection is really important for this

where do we use it primary metastatic lesions essentially once we feel that someone is not a good surgical candidate and they have maintained pulmonary function they have a reasonable chance for surviving a long

time we'll convert them to being an ablation candidate here's an example of a young woman who had a metastatic colorectal met that was treated with SPRT and it continued to grow and was avid so you can see the little nodule

and then the lower lobe and we paste the placement prone and we'd Vance a cryo plugs in this case of microwave probe into it and you turn off about three to five minutes and it's usually sufficient to burn it it cavitate s-- afterwards

which is expected but if you follow it over time the lesion looks like this and you say okay fine did it even work but if you do a PET scan you'll see that there's no actually activity in there and that's usually pretty definitive for

those small lesions like that about three centimeters is the most that will treat in a lot of the most attic patients but you can certainly go a little bit larger here's her follow-up actually two years

that had no recurrence so what do you do when you have something like this so this is encasing the entire left upper lobe this patient underwent radiation therapy had a low area of residual activity we followed it and it turns out

that ended up being positive on a biopsy for additional cancer so now we're playing cleanup which is that Salvage I mentioned earlier we actually fuse the PET scan with the on table procedural CT so we know which part of all that

consolidated lung to target we place our probes and this is what looks like afterwards it's a big hole this is what happens when you microwave a blade previously radiated tissue having said that this

was a young patient who had no other options and this is the only side of disease this is probably an okay complication for that patient to undergo so if you follow up with a PET scan three months later there's no residual

activity and that patient actually never recurred at that site so what about

ablating things in the bones well musculoskeletal blasian we're fortunate within our practice that we have a doctor councilman Rochester who's

a probably one of the biggest world's experts on this and these are his cases that he shared but you can see when you have small little lesions and bones that are painful you can place probes in them and you freeze them the tumor dies and

musculoskeletal things remain intact what about when you have cases like this where there's a fracture going through the iliac bone on the left with an infiltrate of malignancy well you can cryo blade it and what's cool about is

you can using CT guidance do percutaneous cannulated pins and screws and a cement o plasti ver bladed cavity and when you're done the patient who initially couldn't walk now can and whose pain scale went down to one so I

think that's that's very important to realize the potential of image-guided medicine this is something that previously would have had to been done in the orthopedic lab so you know I think this is extending options where

otherwise it would have been difficult same thing applies to the spine you can ablate and fill them with cement so

to have severe humor billion almost all all those that need your attention is about aghori portal veins though can be tremendously so the differentiation between hepatic artery and portal vein

bleeding is the big differentiator that will require you to do something about it most of the times if you injure the portal vein or hepatic vein these usually heal by themselves and it's counterintuitive the management of this

is actually to upsize your tube and they make sure the side holes are not adjacent to the bleeding vein it's crossing so it's counterintuitive that you upsize - for bleeding injure the vein more but

eventually those veins will thromboses off for that little branch the difficult situations of sahiba heavy hit an artery and here's one way we did a gram you can see the pacification the reason why you want to go into the peripheral duct I'll

show you always near the hilum is actually also very big blood are the blood vessels and the reason why we go peripheral the number of large vessels are much greater diminished so you always want in this patient was

transferred for an outside Hospital my PTC was performed by someone who obviously doesn't do a lot of these and access directly into the coma bar duct you can see all these filling defects all these filling defects in the combat

like those or clots and filled with someone who's actually had life-threatening significant he Mobilia and required what we did was they were just pacify the system get another peripheral access

right biliary system and embolize the track coming out and thereby removing the original axis that was placed by the outside hospital interventionists obviously the ones that aureus the most of the narco that will kill people is

the ones that hit our ease and pseudoaneurysm formation or tara Venus fistulas and I can be problematic in my only real ways their dresses trans cap the treatments a patient would have an angio we'd have to get into the pedagogy

find the feeding or it almost always though and we can predict way that bleeding artery is it's where your Y is crossing the architecture of the artery tree frequently you will not see it until you remove the tube so almost

always you would have to prep the right flank prep the groin to an angiogram with the tube in because you don't really want to be rushing at the beginning of your procedure you frequently do the angiogram not see

bleeding and then a second operator needs the described brake scrub get non sterile axes remove the blue tube repeat the angiogram and almost certainly then you'll see it but again it's very

predictable where it is but every now and then you get caught out and the bleeding side can be remote from where your actual Y or actual access transgressor you you do need to have a careful eye looking for that and so you

know when we looked at out and we do large numbers of blurry drainage the best predictor or and like I said Arturo Kimber Billy is actually related to your first tube and the size that you place and it's also

interesting like I said every now and then you're gonna see that bleeding arteries are actually not liver arteries and you can't bleed from the GDA internal memory from other procedures intercostal artery from where you put

your tube first needle through the liver through sorry through the ribs itself it's actually access site rather than your internal parenchymal your liver so it's actually important to also do sometimes it a water gram check the

intercostal artery because you'll miss it by doing a celiac or teragrams hepatic artery gram and don't understand why the patients still bleeding and here's just example of what a pseudoaneurysm does when we remove the

chief we can see the image on the right the blue tube has mean withdraw back and they you can see quite clearly there and sorry the pseudoaneurysm of the paddock right re and like any other immunization is important to go front door back door

implies across mainly because the liver architecture has a rich collateralization that will feed before and after and like I said the lake complication zone was or derived and related to tube maintenance and tubes

catching on to things in dislodgement and so these are just really you know your whoever answers the phones whether it's the physicians on call they have to manage with maintenance of these tubes and really just keeping these tubes open

as long as possible it's amazing how long some of these tubes do last in particular in benign but Lewis structures so management of these is really or expectant and the right advice and frequently just need to

get these tubes changements they're clogged sufficiently the difficult ones

know we're running a bit short on time so I want to briefly just touch about

some techniques with comb beam CT which are very helpful to us there are a lot of reasons why you should use comb beam CT it gives us the the most extensive anatomic understanding of vascular territories and the implications for

that with oncology are extremely valuable because of things like margin like we discussed here's an example of a patient who had a high AF P and their bloodstream which tells us that they have a cancer in her liver we can't see

it on the CT there but if you do a cone beam CT it stands up quite nicely why because you're giving levels of contrast that if you were to give them through a peripheral IV it would be toxic to the patient but when you're infusing into a

segment the body tolerates at the problem so patient preparation anxa lysis is key you have them exhale above three seconds prior to that there's a lot of change to how we're doing this people who are introducing radial access

power injection anywhere from about 50 to even sometimes thirty to a hundred percent contrast depends on what phase you're imaging we have a Animoto power injector that allows us to slide what contrast concentration we like a lot of

times people just rely on 30% and do their whole the case with that some people do a hundred percent image quality this is what it looks like when someone's breathing this is very difficult to tell if there's complete

lesion enhancement so if you do your comb beam CT know it looks like this this is trying to coach the patient and try to get them to hold still and then this is the patient after coaching which looks like this so you can tell that you

have a missing portion of the lesion and you have to treat into another segment what about when you're doing an angio and you do a cone beam CT NIT looks like this this is what insufficient counts looks like on comb beam so when you see

these sort of Shell station lines that are going all over the screen you have to raise dose usually in larger patients but this is you know you either slow down the acquisition speed of your comb beam or

you raise dose this is what it looks like after we gave it a higher dose protocol it really changes everything those lines are still there but they're much smaller how do you know if you have enhancement or a narrow artifact you can

repeat with non-contrast CT and give the patient glucagon and you can find the small very these small arteries that pick off the left that commonly profuse the stomach the right gastric artery you can use your comb beam CT to find

non-target evaluation even when your angio doesn't suggest it so this is a patient they have recurrent HCC we didn't angio from here those arteries down there where those coils were looked funny even though the patient was

quote-unquote coiled off we did a comb beam CT and that little squiggly C shape structures that duodenum that's contrast going in it this would be probably a lethal event for the patient or certainly would require surgery if you

treated that much with y9t reposition the catheter deeper towards the lesion and you can repeat your comb beam CT and see that you don't have an hands minh sometimes you have these little accessory left gastric artery this is

where we really need your help you know a lot of times everyone's focused and I think the more eyes the better for these kind of things but we're looking for these little tiny vessels that sometimes hop out of the liver and back into the

stomach or up into the esophagus there's a very very small right gastric artery in this picture here this patient post hepatectomy that rides along the inferior surface of the liver it's a little curly cube so and this is a small

esophageal branch so when you do comb beam TT this is what the stomach looks like when it enhances and this is what the esophagus looks like when it enhances you can do non contrast comb beam CTS to confirm ablation so you have

a lesion this is the comb beam CT for enhancement you treat with your embolic and this is a post to determine that you've had completely shin coverage and you can see how that correlates a response so the last thing we're going

them so my particular area of interest is a blade of radium ization and what we'd like to do is to break the liver

down into a bunch of little tiny perfused volumes off of a single vascular pedicle or what we call angio zones and those are those allow us to segment out if you only have small volume disease for example like here in

segment three why do I have to treat the entire left to paddock low I can actually treat just that small portion just like it what it tastes only now I'm administering y9t but since it's expendable liver I

can administer doses that are way higher orders of magnitudes higher than what I could if our infusing into the liver just on its own so here's an example of that if you look at this lesion in the right of panic lobe you'll see these

little lines over them what we want to achieve is around a 205 GRA threshold for these lesions that's the red line everything that's south of red in terms of color orange Holly to blue is not cold enough to kill tumor so if we

administer a dose of a tea grade to the lobe we get this coverage which is to be a partial response if I administer 150 grey suddenly that red line gets larger what happens when you administer 400 grey now you've officially covered the

entire lesion and so you're going to lose the adjacent liver at those kind of doses and as well - what what the real question then is not sort of how much dose you give it's you give what you need to to ablate the tumor in its

entirety and you see what the patient's left with if someone's left with anatomically a lot of remnant liver because of how you've segmented out that lesion then go ahead and dose extremely high and that's essentially what we've

seen in pathologic results it's one of the highest things of high school pathological crosa rates you can achieve with a trans arterial therapy it's highly competitive with thermal ablation in the correctly selected bleezin

so this is an example of what it looks like when you segment out a little lesion like this and this patient ultimately went to resection and this was a complete pathologic necrosis but as you can see even it was a cirrhotic

patient we chose a very small volume of liver that we felt the patient would tolerate so that's a blade of vernalization let's take a look at what looks like in real time so we have a little capsular lesion we felt that

ablating this patient who was a potential transplant candidate we felt we can probably with a blade of radium realization so you go in and this is the comb beam CT that looks at a complete enhancement of the lesion within the NGO

zone this is what the MAA looks like when we administer it you can see how it tends to cluster within the tumor but you can see what the adverse territory is the liver adjacent to it this is what the engine room looks like how highly

selective it is the day of and this is what the wine ID actually looks like is the wine 90 doing its job and you can see how conformal it is there's no risk whatsoever to the liver that's adjacent outside of that field of

a maximum of around 11 millimeters and this is a patient at one month with a complete imaging response and this patient never developed a recurrent to the site and what's actually sole mode of treatment for this person's liver

cancer this is how you get complete pathologic response if you look at those little tiny grey dots in there those are actually the spheres within tiny little vessels within the tumor sometimes they go even to the portal branch but you can

see how they're not clustered uniformly but when you make them super hot that allows them to give range where otherwise they would be fine a little bit short so this also applies to the whole lobe this was a patient that had a

very unusual presentation of colon cancer that was invading the portal II we weren't sure what to do with this patient no one was because a very rare occurrence so we said well we would like

to resect him but there's not enough liver and we're not sure if this person's gonna survive because we've never seen portal cancer invading the portal vein so we said let's treat it with the radiation lobectomy and what's

cool here is if you look at the the arteries even though the tumor is invading the portal vein it's bringing arterial supply along with it like a vagabond and that's the conduit that allows us to treat these patients so

when we saw that we felt this patient we good candidate for irradiation lobectomy which is applying an ablative dose of y9t to the entire low not just a small segment in patients where otherwise cannot because of the anatomy the tumor

or if you're trying to shrink that lobe to get that person ready for surgery why because if you look at the size of the lobe on the left from this first image and compare it here you can see how much larger it got what happens is that part

that the surgeon ultimately tens on resecting in volutes over time and becomes completely vitalized and turns into scar tissue so we know that if a surgeon goes in afterwards to cut it out it's going to not result in liver

failure and that level of security allows people to have sir who otherwise wouldn't this patient is not going to have metastatic disease because we followed their blood level markers let me see how low they are and

is going to have enough liver remnant so the patient went to resection and this is the pathologic specimen and this was also a complete pathologic necrosis so I

of cryoablation it's gentler than both microwave and RF a you can use it in a lot of locations because of that you can visualize the ice ball with CT multiple probes means potentially huge ablation zones and I'll show you an example of

that it's not painful and for me I know that I don't know about everyone else in the room but our anesthesia assistance is is very spotty or sporadic so it's nice to do stuff with conscious sedation in which case cryoablation you can

absolutely do most places with conscious sedation it's not painful at all whereas if you've done microwave you know the moment you turn the probe on the patient wants to punch you so so it's not particularly painful you can do it with

sedation and it has this immuno genic response that we're starting to learn more about right so when you cook tissue your since you just cha reverie and you just cook all the proteins and all the membrane of the cell with cryoablation

you actually keep some of the proteins in tact so what happens is as the cell dies your immune response comes in and it recognizes those tumor antigens right those tumor proteins and there's been lots of reports of where you oblate for

instance a renal mass and the patient's lung nodules will regress because of that so that's a very nice feature of it is that's got this immuno genic response and I'll use that often times if I'm doing a lung ablation for instance and

there's other nodules you can see a regression of those nodules the disadvantage as well you need you know there's these repeated freezes right so you do these freeze thaw cycles you go ten fighting you know ten freeze five

for ten freeze five for that ends up being a pretty long freeze time right and even if you do the triple freeze protocol which I can talk a little bit in a bit here you can see it ends up adding up a lot of time so the time you

save on not putting the patient to sleep and getting general anesthesia actually lose on the backend when you're standing and staring at the probes freezing whereas my crew of ablation as me as you know 10 minutes and you're

done there is this idea of a cold sink so like RFA if you put the probe right up against the blood vessel it's unlikely that that ice bowl is going to propagate into that blood vessel and you can use

that to your advantage once again I'll show you an example of that but cold sink is technically also a disadvantage and one of the main things people worry about with cryoablation is the bleeding aspect right so unlike our fa or

microwave you're essentially cooking the tissue it's a Bovie right you're very unlikely to have bleeding whereas cryo you freeze the tissue and when you thought all those blood vessels are now very porous and they can bleed and so

one of the concerns with cryo is that you have bleeding and you you'll often see this especially in renal and long and then do some early studies where where physicians were doing large liver oblations and they were getting into

something called cryo shock which we'll talk about in a little bit that's probably overhyped from the earlier studies but for that reason many people do not use cryoablation in the liver they would prefer to use microwave

primary Africa cm point 86% matured remember what do we say before you know not what 96% so that's the answer to the surgeons why surgeon says why should I do this why don't I just create official

it takes me 20 minutes there's no surgeon in the world who can create a fistula that's gonna mature 86 percent of the time I don't that's not happening all right the endpoints were met secondary

endpoints to needle dialysis 88% I mean that just doesn't happen surgically I'm sorry and I'll show you some other data as well where the superiority of the percutaneous fistula over surgery this is the jvi are pivotal trial I with Jeff

Hall and tip Jennings and here's the match of the secondary maturation procedures that had to be done all right some get an estimate and we angioplasty the anastomosis embolization of branches an angioplasty Stan's oh okay

here's the bar device and this is called the ever linked queue back in these six French days and now wave link device there are two catheters one goes into the brachial artery one goes into a brachial vein there's a big magnets this

is the six wrench device and you can see that little connection I hope you can that's a foot foot plate a little electrode that pops up between the two catheters it actually creates the official of this time with a

radiofrequency energy on the right you see a brachial artery angiogram and the point of official creation with six ranch was the common on our branch which you can see down there below you have the big dense radial artery coming up on

top and then you see the common arm branch and then the proper ol arm going down there at four o'clock and then the interosseous in the middle now with the the four french device you can create fistulas from the

radial vein to radial artery or radial arterial vein owner artery to ulnar vein and either one gives you a little more options about where you want to create well why would you want options well if you go down to the video of vena Graham

in the and the ulna vein and you don't see any flow up the the perforator well you can only switch to the other side and to try to find better flow put yourself in a better position to create a working fistula this does use

ultrasound to puncture but then uses fluoroscopy to position the devices its RF energy has a little bit of a problem with heavily calcified vessels who's ever seen that and in dialysis patient right so and because radiofrequency

energy goes around calcium it doesn't go through we've had one case where we did there was just no fistula creation everything went finally since no fistula and so that patient got a surgical fistula multiple angles to confirm

correct position of the device this was with the six french device the four french device is much less cumbersome because you want to make sure that that footplate that I showed you sits directly in the receiver area to create

otherwise if you go off to the side left and right they you can have a problem with creating pseudoaneurysm some things no angioplasty then ask to most us however in this case you do embolize on the way out because you've entered the

brachial vein and you embolize form just to stop any losing and to because you want to help to redirect flow towards the superficial system here are the two devices on the left into the four frames versus the six

range quite a difference much more easy to work with the four french doesn't have a bulky handle on the end like the six ranch did they're pretty easy to position and it's a a round electrode not a foot that comes up and it kind of

sits in what they call the saddle you can see there where it says square magnets underfloor french there's a saddle there that that loop electrode sits in and very easy in there to position

who's a candidate well doctor Ross says

possible even though the you know strictures actually most likely are related to the malignant frequently in large centers like the Asura actually we see more benign strictures and malignant

strictures mainly because of the post-operative and perioperative complications so strictly speaking the incidence of reduced riches is actually flipped sometimes though we do actually have to help and some more patients now

particularly in the GI Sims I think in the ten last ten years GI now places metal stents almost routinely there's almost there are people still placing skinny in those things are two plastic calibers things

but the advent of retrievable removable metal stents has really changed and so now we will place dancing much frequently in that the wall stent is actually the pre derivative of the wall flex which is the Justin that can be

removed it's got a little barb that removes it and it's what they will do is retrograde put these up and then six weeks later or even up to nine months go in and retrieve it and pull them out completely so they certainly and the

number of build with stains placement in G and IR is reduced somewhat because how aggressive gr has become but certainly will place these and particularly patients who are in the palliative stages of care and although these

applications we've used in many other ways so your goal is to get the same team this just happens to be a patient with unresectable head of pancreas cancer you can see the obstruction in the distal CBD just below the cystic

duct there's non pacified area you can see on the calendar gram as well as the celiac artery gram you can see how the portal vein sensor strictures of his patients unresectable will go in there in place

that metal stent you first place your guide why follow that up with a stent that cross bridges from open to open and open this up and we use stands between eight and ten millimeters in diameter and nowadays even covering the

cystic duct is not such a big deal and nowadays cupboards things are probably more in favor now even though the data the data actually doesn't support covering over uncovered and the data for both is actually extremely marked be

similar and it's not compelling and because of the price difference I think visit again a probably a swing back to I'm not standing every CPD stains with covered stands but no question at least from operators point of view in my point

of view it makes whole wholehearted sense to allow the tumor no interest disease to grow through but yet the outcome is still not clear that it's a favorable and cost-effective to do covered stains entirely and we actually

will place up to three drains sometimes you have these complex cancer patients with multiple strictures where almost all the segments are excluding in a extremely sick or they need their bilirubin's to come down for four to be

eligible for cut medical oncology chemotherapy and this is the selling of metastatic colorectal cancer and so that will put three up to three tubes in the right lobe before will give up and say that there's not much more decompression

we can achieve so four tiers is that probably the maximum will place in for multiple site so like I said you know malignant brutally strictures and this data and I'm not going to because it's sort of a moving target

when Gore came with the first covered stand purely because of the fabric that they have gore-tex like what's under jacket and clothing and was interesting it's one of the most improbable fabrics and the reasons why Bill Lewis stands

accrued is not so much that it's overgrowth of tumor but the in growth of bio and in growth of bacteria actually will cause a non-covered stain suit include earlier so the advent of gore and making a stent that made a big

difference and it's covered same it does to change quickly the ease at which patients could be stent in the new system so when they came on the market was really helpful and there's just example of how you can go from occlusion

all the way to having natural passage about now back into the small bar and the utility and the importance of bile salts power fluid in your GI tract is critical for absorption in almost all your metabolic

function so having this drain out externally is really not advisable so getting a natural pathway flow of bio into the GI system is extremely important but I believe strictures and

here we have a MRI that shows a lesion in the left kidney sorry I don't have a

pointer here really but you can see the lesion in the medial part of the left kidney there couple probes are placed under CT guidance you can already see the beginning of the formation of an ice ball there this is the second probe you

can see the ice ball forming and there's a good example of the ice ball it's got good coverage of the the lesion as well as a good margin around that cryoablation tends to be less detrimental to the collecting system of

the kidney so some of the concerns when you do renal ablation is that you're gonna cause your read or strictures or urine leaks because you're burning the collecting system essentially with cryoablation you tend not to see that

you don't have to use something called pilar profusion is often right the idea with pilo profusion is you put a small catheter into the ureter and you infuse the kidney with cold saline so that the collecting system stays cold while you

while you burn the tumor well you don't often times have to do that with cryoablation so that's one benefit of it and then this is a one month later scan this is the normal appearance you can see the ablation zone that and the

resolution of the tumor will follow these up for a few years to make sure that all that tissue goes away and this

stamp placement we talked a little bit about it I'm gonna talk to you a little

bit more about it and ideal stance is a straight stance that has a nice smooth curve with a portal vein and a nice smooth curve with a bad igneous end well you don't want is it is a tips that T's the sealing of the hepatic vein okay

that closes it okay and if there's a problem in the future it's very difficult to select okay or impossible to select okay you want it nice and smooth with a patek vein and IVC so you can actually get into it and it actually

has a nice hemodynamic outflow the same thing with the portal thing what you don't want is slamming at the floor of the portal vein and teeing that that floor where where it actually portly occludes your shunts okay or gives you a

hard time selecting the portal vein once you're in the tips in any future tips revisions okay other things you need it nice and straight so you do not want long curves new or torqued or kinks in your tips you

a nice aggressive decompressive tips that is nice and straight and opens up the tips shunt okay we talked a little bit you don't want it you don't want to tee the kind of the ceiling of the of the hepatic vein another problem that we

found out you want that tips stance to extend to the hepatic vein IVC Junction you do not want it to fall short of the paddock vein IVC Junction much okay much is usually a centimeter or centimeter and a half is it is acceptable

the problem with hepatic veins and this is the same pathology as the good old graft dialysis grafts what is the common sites of dialysis graft narrowing at the venous anastomosis why for this reason it's the same pathogenesis veins whether

it's in your arm for analysis whether it's in your liver or anywhere are designed for low flow low turbidity flow of the blood okay if you subject a vein of any type to high turbot high velocity flow it reacts by thickening its walls

it reacts by new intimal hyperplasia so if you put a big shunt which increases volume and increased flow turbidity in that area in that appear again the hepatic vein reacts by causing new into our plays you actually get a narrowing

of the Phatak vein right distal to the to the to the Patek venous end of the shunt so you need to take it all the way to the Big C to the IVC okay how much time do I have half an hour huh 17 minutes okay

Viator stents is one way let's say you don't have a variety or stent many countries you don't have a virus then what's an alternative do a barre covered stem combination you put a wall stent and then put a covered stance on the

inside okay so put a wall stent a good old-fashioned you know oldie but a goodie is is a 1094 okay you just put a ten nine four Wahl cent which is the go to walls down so I go to stand for tips before Viator

and then put a cover sentence inside whatever it is it's a could be a fluency it could be a could be a vibe on and and do that so that's another alternative for tips we talked about an ace tips as a central straight tips and it's not out

and fishing out in the periphery okay this is an occlusion with a wall stance this is why we use think this is why now we use stent grafts this is complete occlusion of the tips we're injecting contrast this is not the coral vein this

is actually the Billy retreat visit ptc okay that's a big Billy leaked into the into the tips okay and that's why we use covered stance I'm gonna move forward on this in early and early and experienced

something some case examples of where I use cryoablation right so this is a

patient who has a nodule in the in the back of their lungs in the right lower lobe and basically I'll place two probes into that notch on either side of Brackett the lesion and then three months later fall up you can see a nice

resolution of that nodule so when it comes to lung a couple things I'll mention is if the nodule is greater than eight millimeters I'll immediately go to two probes I want to make sure that I cover the lesion whereas microwave it's

pretty rare depending on what device you're using for you to put more than one probe in so some people's concern with cryo in the lung is more probes means more risk of pneumothorax but you can also see surrounding and proximal to

where we did the place you can see the hemorrhage that you see so if those of you out there that are doing the lung ablations you probably have physicians that are using something called the triple freeze protocol right so the

double freeze protocol is the idea that you go ten minutes freeze five minutes 30 minutes freeze five minutes thought well what we saw was lung early on in the studies was a very large ablation a freeze to start with caused massive

hemorrhage patients were having very large amounts of hemorrhage so what we do now in lung is something called a triple freeze protocol we'll do a very short freeze about three minutes and that'll cause an ice ball to form and

then we'll thaw that in other three minutes three minutes of thawr and as soon as that starts to thaw we'll freeze it again and we've shown us a substantial decrease in the amount of hemorrhage so if you're doing long and

you and you you're told to do a double freeze protocol perhaps suggest the triple freeze is a better idea so that's three months later so another example

talk here with something that's new on the horizon believe it or not it was actually on the horizon 20 years ago and then it went away because there were a lot of patients that were treated with a

lot of complications and it's making a resurgence and this is balloon pulmonary angioplasty or BPA for short so this is an intervention which may be feasible in non-operative candidates so I mentioned to the Jamison classification earlier

type 1 and type 2 disease should be treated with surgery again it should be treated is curative but patients with type 2 and a half or 3 disease can be treated with balloon pulmonary angioplasty in the right in the right

frame which means that a surgeon has said I cannot operate on this a medical doctor has said boy they're not going to get better with their medicine let's try something else well this is that something else and that's what involves

everyone in this room so this is these are usually staged interventions with potentially high radiation and contrast dose if you think about it it's like Venis recan and a pulmonary AVM all-in-one so it's a potentially a long

complex procedure with a lot of contrast and a lot of radiation but it can provide a lot of benefit to these patients I'm going to talk about the comp potential complications at the end which is one reason why not

everyone should do these all the time so this is a pulmonary angiogram from the literature when you're injecting a selective pulmonary artery you can see that this patient has multiple stenosis there's no real good flow there the

vessels look shriveled up like I mentioned to you before you can get a balloon across it and balloon the areas and then you can see afterwards so the image a on the left is before an image D is afterwards believe it or not this are

in the most experienced hands because the most experienced hands are for palm the BP AR in Japan they do hundreds of cases of these a year at each hospital I've personally only done five so but this is a something that I'm very

interested in and you can see how how much benefit it has for that patient another way you can see these are the webs and the bands that I mentioned to you earlier so what's interesting is that if you look on the first set of

images on the top and the images on the bottom those are the same patients it's the same view before top rows before and the bottom rows after balloon pulmonary angioplasty so the first image is a pulmonary angiogram where if you kind of

see this there's there's some area areas of haziness those are the webs and bands the image on the the middle is the blown-up views and you can see those areas and then the image on the right is intravascular ultrasound which I use

every day in my practice it's a catheter with an ultrasound on it and when you look at it on the top image image see you can see a lot of thrombus you're actually not seeing flow and on image F on the bottom you're seeing red which is

the blood flow so these patients can actually improve the luminal diameter bye-bye ballooning them you can treat occlusions again image on the left shows you a pulmonary artery with a basically an occlusion proximally and then after

you reek analyze it and balloon it you can see that they can get much more

and then one more example just to sort of illustrate the idea of a heat sink or

a cold sink right so this patient has a mass in their left adrenal gland right next to the aorta it's just anterior to the kidneys so the problem here is if you put a microwave ablation probe right next to the aorta you're likely to burn

the aorta and if you want to point the microwave ablation probe directly at the aorta well there isn't really a good window for that right you would have to go through the kidney you'll go through bowel and on route to getting there so

really I elected to do cryoablation right so that's the mass that's the aorta so you're obviously worried about injuring any order you place two probes into the lesion they obviously are streaking us out right now but that's

the aorta right there so we are four millimeters away from the aorta with these two probes you would think you'd be concerned about damaging it but using that cold sink effect you can see how the ice boss actually carves around the

aorta so you can get a really nice ablation on to that structure with that Waring that you're damaging the aorta or any nearby big vascular structure now that doesn't happen with pancreas if you freeze into pancreas you're going to get

a pancreatitis and if you freeze into bowel your bowel is going to have a perforation so that really just is with blood vessels that you can do that

so just a compliment what we everybody's talked about I think a great introduction for diagnosing PID the imaging techniques to evaluate it some of the Loney I want to talk about some of the above knee interventions no disclosures when it sort of jumped into

a little bit there's a 58 year old male who has a focal non-healing where the right heel now interestingly we when he was referred to me he was referred to for me for a woman that they kept emphasizing at the anterior end going

down the medial aspect of the heel so when I literally looked at that that was really a venous stasis wound so he has a mixed wound and everybody was jumping on that wound but his hour till wound was this this right heel rudra category-five

his risk factors again we talked about diabetes being a large one that in tandem with smoking I think are the biggest risk factors that I see most patient patients with wounds having just as we talked about earlier we I started

with a non-invasive you can see on the left side this is the abnormal side the I'm sorry the right leg is the abnormal the left leg is the normal side so you can see the triphasic waveforms the multiphasic waveforms on the left the

monophasic waveforms immediately at the right I don't typically do a lot of cross-sectional imaging I think a lot of information can be obtained just from the non-invasive just from this the first thing going through my head is he

has some sort of inflow disease with it that's iliac or common I'll typically follow within our child duplex to really localize the disease and carry out my treatment I think a quick comment on a little bit of clinicals so these

waveforms will correlate with your your Honourable pencil Doppler so one thing I always emphasize with our staff is when they do do those audible physical exams don't tell me whether there's simply a Doppler waveform or a Doppler pulse I

don't really care if there's not that means their leg would fall off what I care about is if monophasic was at least multiphasic that actually tells me a lot it tells me a lot afterwards if we gain back that multiphase the city but again

looking at this a couple of things I can tell he has disease high on the right says points we can either go PITA we can go antegrade with no contralateral in this case I'll be since he has hide he's used to the right go contralateral to

the left comment come on over so here's the angio I know NGOs are difficult Aaron when there's no background so just for reference I provided some of the anatomy so this is the right you know groin area

right femur so the right common from artery and SFA you have a downward down to the knee so here's the pop so if we look at this he has Multi multi multiple areas of disease I would say that patients that have above knee disease

that have wounds either have to level disease meaning you have iliac and fem-pop or they at least have to have to heal disease typically one level disease will really be clot against again another emphasis a lot of these patients

since they're not very mobile they're not very ambulatory this these patients often come with first a wound or rest pain so is this is a patient was that example anyway so what we see again is the multifocal occlusions asta knows

he's common femoral origin a common femoral artery sfa origin proximal segment we have a occlusion at the distal sfa so about right here past the air-duct iratus plus another occlusion at the mid pop to talk about just again

the tandem disease baloney he also has a posterior tibial occlusion we talked about the fact that angio some concept so even if I treat all of this above I have to go after that posterior tibial to get to that heel wound and complement

the perineal so ways to reach analyze you know the the biggest obstacle here is on to the the occlusions i want to mention some of the devices out there I'm not trying to get in detail but just to make it reader where you know there's

the baiance catheter from atronics essentially like a little metal drill it wobbles and tries to find the path of least resistance to get through the occlusion the cross or device from bard is a device that is essentially or what

I call is a frakking device they're examples they'll take a little peppermint they'll sort of tap away don't roll the hole peppermint so it's like a fracking device essentially it's a water jet

that's pulse hammering and then but but to be honest I think the most effective method is traditional wire work sorry about that there are multiple you know you're probably aware of just CTO wires multi weighted different gramm wires 12

gram 20 gram 30 gram wires I tend to start low and go high so I'll start with the 12 gram uses supporting micro catheter like a cxi micro catheter a trailblazer and a B cross so to look at here the sheath I've placed a sheet that

goes into the SFA I'm attacking the two occlusions first the what I used is the micro catheter about an 1/8 micro catheter when the supporting my catheters started with a trailblazer down into the crossing the first

occlusion here the first NGO just shows up confirmed that I'm still luminal right I want to state luminal once I've crossed that first I've now gone and attacked the second occlusion across that occlusion so once I've cross that

up confirm that I'm luminal and then the second question is what do you want to do with that there's gonna be a lot of discussions on whether you want Stan's direct me that can be hold hold on debate but I think a couple of things we

can agree we're crossing their courageous we're at the pop if we can minimize standing that region that be beneficial so for after ectomy couple of flavors there's the hawk device which

essentially has a little cutter asymmetrical cutter that allows you to actually shave that plaque and collect that plaque out there's also a horrible out there device that from CSI the dime back it's used to sort of really sort of

like a plaque modifier and softened down that plaque art so in this case I've used this the hawk device the hawk has a little bit of a of a bend in the proximal aspect of the catheter that lets you bias the the device to shape

the plaque so here what I've done you there you can see the the the the the teeth itself so you can tell we're lateral muta Liz or right or left is but it's very hard to see did some what's AP and posterior so usually

what I do is I hop left and right I turned the I about 45 degrees and now to hawk AP posterior I'm again just talking left to right so I can always see where the the the the AP ended so I can always tell without the the teeth

are angioplasty and then here once I'm done Joan nice caliber restored flow restored then we attacked the the common for most enosis and sfa stenosis again having that device be able to to an to direct

that device allows me to avoid sensing at the common femoral the the plaque is resolved from the common femoral I then turn it and then attack the the plaque on the lateral aspect again angioplasty restore flow into the common firm on the

proximal SFA so that was the there's the plaque that you can actually obtain from that Hawk so you're physically removing that that plaque so so that's you know that's the the restoration that flow just just you know I did attack the

posterior tibial I can cross that area I use the diamond back for that balloon did open it up second case is a woman

24 year old patient after a car accident has lower abdominal pain and melena so blood coming out of the rectum here's the CT scan anyone want to take a stab but you can just shout it out

so this time we're looking at the liver right so the liver is the big thing on the right side of the screen and what you can see is the dark hematoma posterior to the liver but you should also notice that big white dots sitting

right in the hematoma all right that's important because that's active bleeding that's the report when you guys when you guys get called in for these cases and someone says oh this you know liver trauma with active

bleeding this is the picture that is spurring that announcement okay this is what active bleeding and the liver looks like again there's a bleeding scale there's an injury scale for a liver trauma we don't need to go into that

slides are available if you want them alright here is the angiogram now again my rule works all right if you see vessels get smaller and then big again something's abnormal so in this particular picture I want you to notice

the catheter sitting in the right hepatic artery the blood is going up into the right lobe of the liver and right near the top of the pictures that big circular kind of blobby thing now this is by definition extravasation

sometimes we use the term pseudoaneurysm to describe this I just want you to appreciate what a pseudoaneurysm means it means that there's a hole in the artery that contrasts or blood is leaking out of that hole and the body is

essentially constraining the bleeding it's not going all over the place it's being constrained that's what we call a pseudoaneurysm all right that's just one way to look at it and geographically so this is an injury to the artery blood is

leaking out of the artery but maybe one layer of a three-layered blood vessel or even just the surrounding tissue is constraining that bleeding alright so what do we want to do for this exactly exactly you're getting it all right so

here we can get our microcatheter all the way out there the closer we get to it the better now in end organs like the liver or the kidney we don't actually have to get all the way out there getting close to it's going to be good

enough but the closer we get to it the better for stopping the bleeding and preserving the function of that organ all right so look how close we literally got right into the injury and then we're able to embolize it that's the goal all

right now the liver is a nice place the treat because as you know there's two sets of blood vessels going to the liver there's the portal veins in the apat ik artery so if we just embolize a little a patek artery the

liver is not going to notice that at all because it still has the portal venous flow bringing blood to that liver but our goal is to get in there preserve as much of the liver that we can and address that injury okay here's another

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