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Cirrhosis, Acute EV hemorrhage|TIPS, Variceal Embolization|35|Female
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Cone Beam CT | Interventional Oncology
Cone Beam CT | Interventional Oncology
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Malignant Biliary Strictures | Biliary Intervention
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Transcript

with that, let's go to case one. This is a 35 year old, cirrhotic woman with a MELD

of 11. She has hematemesis related to acute esophageal variceal haemorrhage, you can see the red wale sign, and the endoscopy indicating recent haemorrhage. She has no other major medical comorbidity,

namely no history of encephalopathy, no congestive heart failure, no pulmonary hypertension, and her bleeding is refractory to medical/endoscopic therapy. I think we would all agree that this falls right into the

wheelhouse of TIPS, and so at our institution we would absolutely see a patient like this for that procedure. TIPS and variceal embolization was prescribed, and performed. This is an angiographic image from the TIPS procedure, you can see a right hepatic vein to right portal trunk access, for this portogram with a portal systemic gradient, measured at 21 millimeters mercury elevated, and then you can see the left gastric vein supplying esophageal varices. We

put in a 10 millimeter shunt, with reduction of the portal systemic gradient to 4 millimeters mercury, under the 12 threshold that we typically aim for. And you can see that the left gastric vein flow has reversed, no longer filling the varices. Nonetheless, we catheterized the left gastric vein, showed venographically that the esophageal varices were fed by this vessel, and then close it off with metallic coils.

The outcome of this case was bleeding cessation, an uneventful hospital discharge, and to the best of my knowledge no rebleeding to date. So this is a case of TIPS for acute esophageal variceal bleeding. What do we know about this condition? TIPS is indicated in two circumstances at present according to clinical guidelines. One is this rescue therapy for acute variceal bleeding that's

refractory to medical/endoscopic therapy, and also for esophageal variceal re-bleeding. Using the technique described with a covered stent graft, and a portal systemic gradient reduction to less than 12 millimeters

mercury, you can expect a high immediate clinical success with bleeding cessation, and low rebleeding incidents in general. In addition to the indications that I mentioned, is there a role for earlier TIPS in the process? The data would suggest that the answer is yes. These are two studies published by Garcia-Pagan, multi-center studies, one was an RCT from 2010. Both compared TIPS plus pharmacologic

therapy, to pharmacologic therapy alone, when TIPS was performed within 72 hours of presentation. And both studies showed that the one year bleeding control rate, and the one year survival rate, was improved when TIPS was added to pharmacologic and endoscopic therapy. What about variceal embolization? In the case that I showed, the variceal flow was reversed after we replaced the TIPS. Should

we embolize a varix? I think the data suggests that the answer is yes, although this is debatable. This is a meta-analysis from 2014, spanning six studies, looking at the role of variceal embolization, compared to TIPS alone for variceal hemorrhage. What the authors found was that, the odds of rebleeding

was reduced when the varices were embolized, as compared to not embolized when a TIPS was placed. So in our institution we embolize varices at the time of TIPS placement. Okay, moving on to what's new from 2015/2016. This past year saw publication, actually relatively recently in 2016, of another RCT looking at early TIPS, versus endoscopic therapy, plus pharmacologic therapy for acute

variceal hemorrhage. This study confirmed the findings of the first study I previously showed, which is that variceal rebleeding incidents was much lower when TIPS was performed, in addition to pharmacologic and medical therapy in the early time frame, compared to medical therapy alone. I apologize for the busyness of this slide, but these are two meta-analyses from this

last year as well. Again looking at early TIPS versus plus pharmacologic therapy and medical therapy versus medical therapy alone, and what I'd like to highlight is that both, show that there is benefit to the addition of early TIPS in terms of survival and rebleeding incidents. So to summarise case one, TIPS plus variceal embolization is an accepted management strategy for bleeding or rebleeding

esophageal varices. I believe that the data supports earlier TIPS within the management algorithm for variceal hemorrhage, but its been my experience that wide spread clinical practice adoption is kind of wagged and maybe that's in part to non inclusion, and guidelines at present. And the need for adjunctive

embolization, at the time of TIPS is debatable, but I think it's generally supported in literature. So with that we are going to move on to case

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

here are the treatment options and I did want to include a fourth one it says nothing about the intervention per se but it's medical management which was actually had the significant growth over the last decade and really more

aggressive medical management every treatment below this should have medical management included as part of it so I included that first that's critical if you're gonna have a carotid endarterectomy if that's what ultimately

your your physician decides then you should still have medical management before and after carotid artery stenting and then ultimately trans carotid artery stenting so carotid endarterectomy I'll show you a case example but this is a

diagram illustrating what's ultimately done that longitudinal incision and then removal of that plaque this is what the plaque looks like when it comes out as opposed to carotid artery stenting which is less invasive obviously and we place

a stent but we don't actually remove the plaque overall you know you know we can talk about why that's okay in fact the plaque itself doesn't need to come up what we need to improve the flow and stabilize that plaque from being able to

embolize small clot overall medical therapy is really just these basic things aspirin or sometimes dual antiplatelet therapy so that's aspirin and plavix in addition aggressive statin therapy so

Doc's will Vascular Docs anyone interested in this space will have you a non-aggressive statins or cholesterol-lowering medications stop smoking tight glucose control so those diabetics have to be really well

regulated and in the blood pressure control if you don't do those things no matter what you do with the carotid endarterectomy or the stenting is gonna fail so what's carotid endarterectomy

so we kind of had a bunch of portal vein cases I think we'll stick with that theme and this is a 53 year old woman who presented to the emergency room with severe abdominal pain about three hours after she ate lunch she had a ruin why two weeks prior the medications were

really non-contributory and she had a high lactic acid so she they won her a tan on consi t scan and this is you can see back on the date which is two years ago or a year and a half ago we're still seeing her now and follow-up and there

was a suggestion that the portal vein was thrombosed even on the non con scan so we went ahead and got a duplex and actually the ER got one and confirmed that portal vein was occluded so they consulted us and we had this kind of

debate about what the next step might be and so we decided well like all these patients we'll put her on some anticoagulation and see how she does her pain improved and her lactate normalized but two days later when she tried to eat

a little bit of food she became severely symptomatic although her lactate remain normal she actually became hypotensive had severe abdominal pain and realized that she couldn't eat anything so then the question comes what do you do for

this we did get an MRA and you can see if there's extensive portal vein thrombus coming through the entire portal vein extending into the smv so what do we do here in the decision this is something that we do a good bit of

but these cases can get a little complicated we decided that would make a would make an attempt to thrombolysis with low-dose lytx the problem is she's only two weeks out of a major abdominal surgery but she did have recurrent

anorexia and significant pain we talked about trying to do this mechanically and I'd be interested to hear from our panel later but primary mechanical portal vein thrombus to me is oftentimes hard to establish really good flow based on our

prior results we felt we need some thrombolysis so we started her decided to access the portal vein trance of Pataca lee and you can see this large amount of clot we see some meds and tera collaterals later i'll show you the SMB

and and so we have a wire we have a wide get a wire in put a catheter in and here we are coming down and essentially decide to try a little bit of TPA and a moderate dose and we went this was late in the afternoon so we figured it would

just go for about ten or twelve hours and see what happened she returned to the IRS suite the following day for a lysis check and at that what we normally do in these cases is is and she likes a good bit but you can see there's still

not much intrahepatic flow and there's a lot of clots still present it's a little hard to catheterize her portal vein here we are going down in the SMB there's a stenosis there I'm not sure if that's secondary to her surgery but there's a

relatively tight stenosis there so we balloon that and then given the persistent clot burden we decide to create a tips to help her along so here we are coming transit paddock we have a little bit of open portal vein still not

great flow in the portal vein but we're able to pass a needle we have a catheter there so we can O pacify and and pass a needle in and here we are creating the tips in this particular situation we decide to create a small tips not use a

covered stent decide to use a bare metal stent and make it small with the hope that maybe it'll thrombosed in time we wouldn't have to deal with the long-term problems with having a shunt but we could restore flow and let that vein

remodel so now we're into the second day and this is you know we do this intermittently but for us this is not something most of the patients we can manage with anticoagulation so we do this tips but again the problem here is

a still significant clot in the portal vein and even with the tips we're not seeing much intrahepatic flow so we use some smart stance and we think we could do it with one we kind of miss align it so we

end up with the second one the trick Zieve taught me which is never to do it right the first time joking xiv and these are post tips and yo still not a lot of great flow in the portal vein in the smv

and really no intrahepatic flow so the question is do we leave that where do we go from here so at this point through our transit pata catheter we can pass an aspiration catheter and we can do this mechanical

aspiration of the right and left lobes you see us here vacuuming using this is with the Indigo system and we can go down the smv and do that this is a clot that we pull out after lysis that we still have still a lot of clot and now

when we do this run you see that s MV is open we're filling the right and left portal vein and we're able to open things up and and keep the the tips you see is small but it's enough I think to promote flow and with that much clot now

gone with that excellent flow we're not too worried about whether this tips goes down we coil our tract on the way out continue our own happened and then trance it kind of transfer over to anti platelets advanced or diet she does

pretty well she comes back for follow-up and the tips are still there it's open her portal vein remains widely Peyton she does have one year follow-up actually a year and a half out but here's her CT the tip shuts down the

portal vein stays widely Peyton the splenic vein widely Peyton she has a big hematoma here from our procedure unfortunately our diagnostic colleagues don't look at any of her old films and call that a tumor tell her that she

probably has a new HCC she panics unbeknownst to us even though we're following her she's in our office she ends up seeing an oncologist he says wait that doesn't seem to make sense he comes back to us this is 11 3 so

remember we did the procedure in 7 so this is five months later at the one year fault that hematoma is completely resolved and she's doing great asymptomatic so yeah the scope will effect right that's exactly right so so

in summary this is it's an interesting case a bit extreme that we often don't do these interventions but when we do I think creating the tips helps us here I think just having the tips alone wasn't going to be enough to remodel so we went

ahead and did the aspiration with it and in this case despite having a hematoma and all shams up resolved and she's a little bit of normal life now and we're still following up so thank you he's

I think it's important to understand what options we have in in treating patients with carotid disease or those

in our practice medical therapy is a mainstay so all these patients regardless that they get t'car carotid stenting or otherwise need to get the best medical therapy there is a role though for each of these surgical

endovascular or a hybrid such as t'car and hopefully you have a better understanding of that option and ultimately if you understand the different techniques then we can apply the best ones depending on the patient's

anatomy or current clinical scenario and and apply that to that patient thank you [Applause]

so these are a lot of slides most limited you know I'm talking I'm talking to you guys I'm talking showing you a lot of technical stuff you know and a lot of slides and I'm gonna talk mostly technical of you know how tips and dips are done kind of a step by step so even

the title it's kind of a workshop step by step of how basically you do you do tips and dips and what and and what are they so in general when you have when you have this is basically kind of out flow spleen spleen dumps blood into the

portal vein the mesentery dumps blood into the portal vein portal vein goes into liver liver does its thing and then dumps the blood into the eppadi veins to the right atrium okay for that because the liver is connected with the spleen

and the guts in series unlike any other organ basically the liver has to be a low-resistance organ because the portal circulation is low-pressure look the liver has to be a low-resistance organ with liver disease especially liver

cirrhosis you actually get increased resistance and in the liver with that disease and you get basically a backup of the blood flow in the portal circulation and increases the pressure in the portal circulation that's kind of

the genesis of or the pathogenesis of portal hypertension backing up circulation the spleen and in the guts then you get ascites and hydra thorax that's kind of think of it as weeping of fluid into the pleural space and into

the and into the perineum part of it is oncotic part of is osmotic basically think of it nutritional and pressure driven causes at the same time we all have potential portosystemic connections in other words they're there but they're

not connected or they're not opened up in plumbing they hold them bleed valves or pressure valves when the pressure is high and you know they start weeping or leaking you know in your in your basements we have the same thing

we have so many portosystemic connections there are about 55 named ones there are innumerable ones that are actually that are actually not named the common ones that we know are because of because of bleeding is esophageal

varices that's the connection usually between the left gastric vein and the azekah can be hazardous system you can also get gastric varices and that's usually connecting between a spleen and the left renal vein through a gas renal

shunts you can get also all sorts of connections even down in the internal hemorrhoids we get actually portal hypertension hemorrhoids and bleeding and so many numerous other shunts that we just don't have time to cut to cover

it to cover all these so the general to the general thought of treating all these complications of portal hypertension is to decompress the system to reduce the pressure and that's along the lines of years and decades of

surgery shunts that were placed and now tips ism largely replaced all these surgical shunts with the exception of Vancouver and Tampa okay that they still do some surgical actually a lot of surgical shunts most most other places

in North America converge to a tip to a tip shunt the the advantage of the tips of over surgical shunts is the usual what we hear is minimally invasive it you know it's a quick recovery less morbidity and mortality areason for

white tips has beaten the surgical shunts is the transplant era all these surgical shunts are actually extrahepatic so when you go for a transplants and liver hits the buckets they actually have to go and shut down

these shunts wherever they created them steena renal portal cable in the tips it goes out with a liver in the bucket so there's no complication of transplantation that's the real advantage of tips over surgical shunts

and that's why it's become very very prevalent in in in North America with a transplant error when approaching gastric varices just briefly another way is a BRT Oh which is to go basically into the left renal vein go up the shunt

and specifically screw rows the stomach and that's not the that's not this kind of subject of our of our discussion here I'm gonna talk to you

people were thinking about the covered

portion actually actually would be occlusive in that paddock veins a lot of people are concerned about that this could be kind of like a but carry you're gonna actually occlude flow in the paddy vein caused thromboses that didn't pan

out at least clinically okay it didn't pan out and that's another advantage of actually accessing very close to the paddock vein IVC junction that's where the biggest vein is so you don't get a lot of occlusive problems okay but

usually clinically it does not pan out so the bigger the hepatic vein the more likely you have a lot of room around your your graft you won't be occlusive to the paddock vein that's more important for for transplants than other

than others I told you it's rare this is actually a very rare case of such that where you actually have a segmental segmental kind of but carry after a tips okay and you know this is actually from a form of venous outflow from the ematic

vein this is a perfusion defect typical it's a wedge right typical perfusion defect in the liver that's how you death so you know this is vascular this is a perfusion problem but you've got hepatic artery readout artery the red arrows

running into the segments and you have portal vein running into the segments so what's the problem it's actually a paddock vein occlusion okay by the stents subclinical no no clinical complaints you let it be

in the patients usually recover okay treat the patients and not the images okay on the other side if you put their tips too deep sometimes you actually get thromboses of the portal vein branch

again you get a call from hepatology you've got portal vein thrombosis is the patient doing okay yes treat the patient and not the images they usually resolve this it's not not a big problem another technical problem

I'm gonna focus mostly on technical for you guys this is a but key area okay and the but carry especially in the acute stage the liver is not like a cirrhotic liver is big liver is actually engorged okay so it's very large usually

your needle is too short to even reach the portal vein okay that's a big problem okay because your access needle is too short for a very large engorged the portal vein so this is as deep as it

goes do I have a see that that do you see that needle tip that's as deep as the needle tip goes okay the portal vein is a good distance away okay luckily this is a co2 porta gram luckily I'm actually in a small branch right

there I just hit it on you know and on this is not the there's not a needle tract this is just luckily hitting it a little branch and on so I'm actually accessing the portal vein and I can do a co2 porta gram here okay

typical inexperienced person would say you know this looks good I'm lucky I'm in a branch but it's a nice smooth curve I'll just pass a wire down and I'll balloon it and I'll put a stent in it's a nice curve and you know so it's my

lucky day I don't need to extend my needle or get a bigger longer needle to reach the portal vein here's the problem with this and this is exactly what this is exactly what this is they pass a wire and it looks beautiful just put a stent

and go home okay here's the problem this is actually the small branch access sites this is actually where you really need to access world vane but your needle is not long enough okay

what we found out is that if you are in a small in a small portal vein no matter how much you balloon it it will come down again and it will be narrow so believe it or not if you go sideways in a portal vein and rip it open with a

balloon it will stay open but if you go down of small portal vein and balloon it open it will always contract down okay so you cannot do a tips simply by ballooning and putting a stent in in this case okay what we do is we actually

denude the vein itself we actually rip it off okay and make it a raw parenchyma and we do that with a Tortola device we literally rip off the paddock the paddock portal sorry the portal vein endothelium and media and adventitia rip

it off make it completely raw as if it's an access as if it's a liver brain coma which is which it is now and then we then we balloon dilates okay rip it off denude it angioplasty it's okay and then put the stent and see that aggression

despite all that aggression of ripping it off it still has an hour kind of an hourglass shape to the to the tips okay that little constraint there that's the hepatic venous access sites this is the parenchymal tract to see nice and open

with a balloon but the but the actual vein that we've been through despite our aggression in actually ripping it off it's still narrowed down but this is as good as it gets okay

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

guys do so when we do our screening phone calls and our pre screens before

the actual procedure there's a few factors that we look at for the patients with blood pressure the patient needs to be vitally stable before we do a procedure there may be a slightly increased risk of bleeding for kidney

biopsy if patients are hypertensive although it hasn't been noted to be statistically significant in the literature so we are always aware of patients being hypertensive we do want them to be taking their medications the

day of the procedure we also do a full medication reconciliation with the patient making sure that we're checking on any anti platelets anticoagulant medications and we have a list of our hold times that we use for a reference

we already discussed for those of you who are at this session this morning the issue of liver disease is it stable liver disease they may have adequate he stasis even though their INR is not within the normal range and so we

recommend a stable INR of less than 2.5 for those patients and in our practice a lot of the providers are going away from correcting the INR s for our patients we also screen for hematological disorders do they have some known condition that

makes them more likely to bleed or conversely more likely to clot and that may factor into whether or not anticoagulation can be held do they have a current diagnosis of cancer are they going to be getting one of those

angiogenesis inhibitors might they have thrombocytopenia and we just do a brief review of the patient's chart before we call them to kind of look for those diagnoses do they have a history of bleeding especially if they have no one

platelet dysfunction you know a known history of bleeding can be a reliable predictor of bleeding risk for some patients and do they have a cardiac or a neurological history as we learned this morning patients that have recently had

a cardiac stent placed we can't just say yeah stop your plavix hold off 5 days it'll be fine that could be a very serious risk to the patient did they recently have a stroke have they had a PE why are they on their anticoagulation

if they're on it so we really need to be aware of the whole patient and having that pre-screening phone call with them can allow our nurses to figure out a lot of these problems and then alert the radiologists and try and troubleshoot

before the patient walks in the door and says yeah I took my warfarin this morning I'm all ready for my liver biopsy the radiologists don't like that much in it you know it's really a bad thing for our high volume area to have

that happen and this is just another chart of our oh did I get mixed up here you guys are gonna fire me from running this clicker there we go so the whole times are again based on the half-life and the mechanism of action and this is

pretty similar to what you saw in the the presentation earlier today and specifically that imbruvica that's something that we alert the radiologists who they have a discussion with the patient decide is this something that we

want to continue with and I will say that in our practice with the volume and the the level of acuity of our patients I think that a lot of our providers are fairly comfortable with a certain level of risk because that's just who our

patient population is you know we have a very large hospital two large hospitals and very sick patients so that's something that we you know some of them are more comfortable than others but it's a risk-benefit thing that they have

to decide on themselves with the patient obviously all right so here are our

and you can see on this t1-weighted image that increased area of enhancement which is the area of synovial thickening you actually see this on MRI beforehand and there it is located over the lateral aspect of the knee on the axial image

and so what we're doing sorry in the medial aspect of the knee so what we're doing here on the angiogram is and you solve these leg angiograms where everyone doesn't really care about these Janicki lit arteries they're really

important when you have sfa or popliteal occlusive disease because they serve as a collateral source but otherwise and people have arthritis they can be a real pain and pain in the knee if you will so this is a this is the superior medial

genicular artery it always drapes over the femoral condyle and you'll see here on this image you don't really see very much once we get into the vessel look at this it almost looks like a small about a cellular carcinoma like when you're in

the liver you get this tumor type blush vascularity that's what we're looking for that corresponds to the patient's area of pain and then after embolization this is what it looks like takes a very small amount

of embolic we're using maybe 0.4 2.6 sometimes 1 CC at most of dilute embolic that we're injecting this is another case again before and after if you look here on the right and then on the left you don't really see much until you

select the vessel out once you get into that super medial vessel you can see how much enhancement there is so in our clinical study of 20 patients this is what we did you'll see on the bottom here we used embassy and 75 micron in 9

patients and 1111 patients got a 100 micron and I'll explain why we upsized our particles so initially we wanted to go very small because that's what dr. o Cano had done in Japan but then we wanted to actually up size our particles

and I'll explain this here in our complications so like all clinical studies the purpose of doing really good clinical research is because this is early and we don't know if they're going to be complications and it's always fun

when you're the first one to figure it out and you tell patients I don't really know what's gonna happen and this is what happens so 13 patients had this kind of skin discoloration over their knee now we knew this because we've been

doing knee embolization for about 10 years in bleeding patients not necessarily arthritic patients so we had seen this before but none of these patients in this clinical study went on to have any alteration of the skin and

it resolved in all patients there was some minor side effects from basically medications and one small groin hematoma but there were two patients who developed plantar numbness over their great toe so under their great toe

basically in the medial distribution of their tibial nerve they ended up getting plantar numbness and this is believed at least in our experience to probably be related to non-target embolization to the tibial nerve the tibial nerve

probably gets its blood supply from many of these generic arteries so we decided

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]

it's obviously either done with general

anesthesia or perhaps a regional block at our institution is generally done with general anesthesia we have a really combined vascular well developed combined vascular practice we work closely with our surgeons as well as

you know those who are involved in the vascular interventional space as far as the ir docs and and in this setting they would do generally general anesthetic and a longitudinal neck incision so you've got that and the need for that to

heal ultimately dissect out the internal carotid the external carotid common carotid and get vessel loops and good control over each of those and then once you have all of that you hyper NIH's the patient systemically not unlike what we

do in the angio suite and then they make a nice longer-term longitudinal incision on the carotid you spot scissors to cut those up and they actually find that plaque you can see that plaque that's shown there it's you know actually

pretty impressive if you've seen it and let's want to show an illustrative picture there ultimately that's open that's removed you don't get the entirety of the plaque inside the vessel but they get as much as they can and

then they kind of pull and yank and that's one of the pitfalls of this procedure I think ultimately is you don't get all of it you get a lot more than you realize is they're on on angiography but you don't get all of it

and whatever is left sometimes can be sometimes worse off and then ultimately you close the wound reverse the heparin and closed closed it overall and hope that they don't have an issue with wound healing don't have an issue with a

general anesthetic and don't have a stroke in the interim while they've clamped and controlled the vessel above and below so here's a case example from our institution in the past year this is a critical asymptomatic left internal

carotid artery stenosis pretty stenotic it almost looks like it's vocally occluded you can see that doesn't look very long it's in the proximal internal carotid artery you can see actually the proximal external carotid artery which

is that kind of fat vessel anteriorly also looks stenotic and so it's going to be addressed as well and this is how they treated it this is the exposure in this particular patient big incision extractors place and you can see vessel

loops up along the internal and external carotid arteries distally along some early branches of the external carotid artery off to the side and then down below in the common core artery and ultimately you get good vessel control

you clamp before you make the incision ultimately take out a plaque that looks like this look how extensive that plaque is compared to what you saw in the CT scan so it's not it's generally much more

impressive what's inside the vessel than what you appreciate on imaging but it's the focal stenosis that's the issue so ultimately if yet if the patient was a candidate stenting then you just place a stent

across that and he stabilized this plaque that's been removed and essentially plasti to that within the stent so it doesn't allow any thrombus to break off of this plaque and embolize up to the brain that's the issue of raw

it's the flow through there becomes much more turbulent as the narrowing occurs with this blockage and it's that turbulent flow that causes clot or even a small amount of clot to lodge up distally within the intrical in

terrestrial vasculature so that's the issue here at all if you don't take all that plaque out that's fine as long as you can improve the turbulent blood flow with this stent but this is not without risk so you take that plaque out which

looks pretty bad but there are some complications right so major minor stroke in death an asset which is a trial that's frequently quoted this is really this trial that was looking at medical therapy versus carotid surgery

five point eight percent of patients had some type of stroke major minor so that's not insignificant you get all that plaque out but if you know one in twenty you get a significant stroke then that's not so bad I'm not so good right

so but even if they don't get a stroke they might get a nerve palsy they might get a hematoma they may get a wound infection or even a cardiovascular event so nothing happens in the carotid but the heart has an issue because the

blockages that we have in the carotid are happening in the legs are happening in the coronary so those patients go through a stress event the general anesthetic the surgery incision whatever and then recovery from that I actually

put some stress on the whole body overall and they may get an mi so that's always an issue as well so can we do something less invasive this is actually a listing of the trials the talk is going to be available to you guys so I'm

not going to go through each of this but this is comparing medical therapy which I started with and surgery and comparing the two options per treatment and showing that in certain symptomatic patients if they have significant

stenosis which is deemed greater than 70% you may be better off treating them with surgery or stenting than with best medical therapy and as we've gotten better and better with being more aggressive with best medical therapy

this is moving a little bit but here's the criteria for treatment and so you have that available to you but really is

after having these two cases one in our institution and one at University of North Carolina Chapel Hill that we would then basically upsize our particles to

100 micron and we have not seen that and we're doing a second clinical study and I'm not seeing that as either we had about a 70% reduction in pain so if you look at our visual analog score out to six months and if you look at our

disability it actually paralleled this exactly which is pretty impressive considering mostly patients had bilateral knee pain so out to six months very good results 90% of patients were responders so two

out of our twenty patients did not really respond one patient didn't respond at his one-month follow-up but did respond at his three and six so I still consider him a clinical failure because we expect

these patients to respond by one month here's just an example of a baseline MRI before and after and you can see all that joint effusion there the white that decreases just even after a month how much it decreases and we looked at this

in terms of synovial thickness and distension and even on MRI you can object objectively count calculate synovitis scores and we calculated that they actually statistically decreased this is another patient on the left the

image shows diffuse white enhancement if you will of the synovium of the lining on the right it shows the fluid this is an image just of embolization and I show this image because it's really shocking and this is actually one of our nurses

who's enrolled in a clinical study is this is before this is all we did we embolized the medial aspect of the knee this is one month later 30 days in fact somebody just asked me this when I was in the booth over at the meeting across

the street and basically I said listen I don't know why this happened so quickly I have no idea we didn't tap renu-it into anything else if you look at this premium post it's pretty dramatic so clearly there's an inflammatory process

that we are arresting or stopping in such a short period of time so is there a future for this I don't know it may just we may just fall down and find out that there really is in a great future but so far we know it's at least

technically successful it's the results are positive in the short term long term we're not so sure yet we do need to better understand these risks and I think in my opinion in the long term it'll probably be really really good for

this 40 to 65 year old patient population who's not yet ready for knee replacement surgery this is the algorithm for our clinical study which were almost done enrolling right now it's a randomized control study against

placebo so it's two to one randomization which means one third of the patients actually get a sham procedure so we do an angiogram on their leg they're asleep they have no idea for embolizing they're genetical it arteries or not we wake

them up I think about the table and we follow them up if they're no better they're allowed to cross over and get the treatment the other 2/3 of the

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

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

more rare condition that some of you may not have heard of but certainly something that wasn't familiar to me a

few years ago but basically people present by coughing up these rubbery casts of their Airways and what these rubbery casts are basically is a collection lymphatic food that's dried out and it just slowly fills in the

airways and they cough up these big things obviously an embarrassing thing to happen have happened to you at dinner can certainly affect your quality of life but I had one patient who saved who

saved a napkin and brought it to me to show me it and the clinic and I was like wow that's impressive please throw that away I believe you but you'll see patients congenital heart disease with COPD asthma tuberculosis cystic fibrosis

etc any of these patients can present with this particular issue what we found out by doing some of these mr so if we embolize these lymphatic vessels or find a way to bypass them the patients will have resolution of their symptoms and

it's an amazing change in quality of life it's only been done in adults as well as pediatrics I'll show you guys an example from the University of Michigan we did lymph and geography this gentleman was actually 500 pounds so I

couldn't do a mr on him and you see this weird tuft of lymphatic vessels right around his airway there on the left side bronchoscopy had already shown that that's where he was having his casts I was able to actually puncture him from

his neck and go retrograde he was a bit too big for me to go through the abdomen but he sees lymphatic duct looks all really fairly standard normal-looking anatomy with exception of that tuft of vessels we actually went down with a

sheath we put a stent graft a vibe on stent graft across that area we excluded those or normal vessels and his condition resolved within a month it's something he'd been living with for several years so fairly dramatic outcome

for this patient uncommonly I say we see maybe one of these patients a year but it's actually known - how to treat it and how to work it up it's very critical

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

now other causes this is a little bit different different scenario here but it's not always just as simple as all

there's leaky valves in the gonadal vein that are causing these symptoms this is 38 year old Lafleur extremity swelling presented to our vein clinic has evolved our varicosities once you start to discuss other symptoms she does have

pelvic pain happiness so we're concerned about about pelvic congestion and I'll mention here that if I hear someone with exactly the classic symptoms I won't necessarily get a CT scan or an MRI because again that'll give me secondary

evidence and it won't tell me whether the veins are actually incompetent or not and so you know I have a discussion with the patient and if they are deathly afraid of having a procedure and don't want to have a catheter that goes

through the heart to evaluate veins then we get cross-sectional imaging and we'll look for secondary evidence if we have the secondary evidence then sometimes those patients feel more comfortable going through a procedure some patients

on the other hand will say well if it's not really gonna tell me whether the veins incompetent or not why don't we just do the vena Graham and we'll get the the definite answer whether there's incompetence or not and you'll be able

to treat it at the same time so in this case we did get imaging she wanted to take a look and it was you know shame on me because it's it's a good thing we did because this is not the typical case for pelvic venous congestion what we found

is evidence of mather nur and so mather nur is compression of the left common iliac vein by the right common iliac artery and what that can do is cause back up of pressure you'll see her huge verax here and here for you guys

huge verax in that same spot and so this lady has symptoms of pelvic venous congestion but it's not because of valvular incompetence it's because of venous outflow obstruction so Mather 'nor like I mentioned is compression of

that left common iliac vein from the right common iliac artery as shown here and if you remember on the cartoon slide for pelvic congestion I'm showing a dilated gonna delve a non the left here but in this case we have obstruction of

the common iliac vein that's causing back up of pressure the blood wants to sort of decompress itself or flow elsewhere and so it backed up into the internal iliac veins and are causing her symptoms along with her of all of our

varicosities and just a slide describing everything i just said so i don't think we have to reiterate that the treatments could you go back one on that I think I did skip over that treatments from a thern er really are also endovascular

it's really basically treating that that compression portion and decompressing the the pelvic system and so here's our vena Graham you can see that huge verax down at the bottom and an occluded iliac vein so classic Mather nur but causing

that pelvic varicosity and the pelvic congestion see huge pelvic laterals in pelvic varicosities once we were able to catheterize through and stent you see no more varicosity because it doesn't have to flow that way it flows through the

way that that it was intended through the iliac vein once it's open she came back to clinic a week later significant improvement in symptoms did not treat any of the gonadal veins this was just a venous obstruction causing the increased

pressure and symptoms of pelvic vein congestion how good how good are we at

quick I did want to mention t-carr briefly and try to get you guys closer to back on time this is a hybrid procedure this is combining the surgical procedure we talked about first and carotid stenting it takes combined

carotid exposure at the base of the clavicle or just above the clavicle and reverses blood flow just like we talked about but tastes slightly different technique or approach to doing this and then you put the stent in from a drug

carotid access here's the components of the device right up by the neck there is where the incision is made just above the clavicle and you have this sheet that's about eight French in size that only goes in about us to 2 cm or 1 and a

half cm overall into the vessel and then that sheath is sutured to the the chest wall and then it's got a side arm that goes what's labeled number six here is this flow reversal urn enroute neuroprotection kit it reverses the

blood flow and then you get a femoral sheath in the vein right in the common femoral vein and you reverse the blood flow so this is a case a picture from our institution up on the right is the patient's neck and that's the carotid

exposure and the initial sheath is in place so the sidearm of that sheath is the enroute protection system which is going up up at the top of the image there we're gonna back bleed that let that sidearm of that sheath continue to

bleed up to the very top and then connect that to the common femoral venous sheet that we have in place there's a stepwise of that and then ultimately what we see at the end of the procedure is that filter inside that

little canister can be interrogated after and you can see the debris this is in the box D here on the bottom left the debris that we captured during the flow reversal and this is a what we call a passive and then active flow reversal

system so once the system is in place the direct exposure carotid sheath in place the flow controller and AV shunt in place you see the direction of blood flow so now all that blood flow in that common carotid artery is going reverse

direction and so when you place a sheath or wire and and ultimately through that sheath up by the carotid artery there's no risk for distal embolization because everything is flowing in Reverse here's a couple

case examples ferns from our institution this is a patient who had a symptomatic critical greater than 90% stenosis has tandems to nose he's so one proximal at the origin and one a little bit more distal we you can see the little

retractors down at the base of the image there in the sheath that's essentially the extent of the sheath from the bottom of that image into the vessel only about a cm or two post angioplasty instant patient tolerated that quite well here's

another 71 year-old asymptomatic patient greater than 90% stenosis pretty calcified lesion a little more extensive than maybe with the CT shows there's the angiography and then ultimately a post stent placement using the embolic

protection device and overall the trials have shown good good safety met profile overall compared to carotid surgery so it's a minimum minimal exposure not nearly as large the risk of stroke is less because you're not mucking around

up there you're using the best of a low profile system with flow reversal albeit with a mini surgical exposure overall we've actually have an abstract or post trip this year's meeting this is just a snapshot of that you can check it out

this is our one year experience we've had comparable low complication rates overall in our experience so in summary

well switch gears and start talking about Kyllo societies histology the

etiology of Callao societies historically used to be malignancy in tuberculosis first described in the 1600s in a two-year-old who had a tuberculous peritoneal disease more recently now we see it due to aggressive

surgery whether it's renal resections for kidney cancer lymph node resections etc it can also be due to cancer the incidence is climbing rapidly this is just a graph of the incidence at different hospitals from 1930s and 1980s

I can I don't have the data for the 2000s this was a graph that I actually generated from based on several studies just to show you how profound the leak can be in these patients well looking at what we do with

maduk college societies fairly similar to what we do elsewhere we map it out we have three major Studies on that right now and a lot of smaller studies so the total nineteen manuscripts ninety six patients and in those eighty two

patients had to report whether or not they saw a leak they saw a leak in 60 of those eighty two patients and when we saw a leak we were able to cure 70 of them just by doing than paying geography and eighty eight percent when we were

able to actually embolize it so again going from in ninety percent mortality at one year if you have caused societies due to cancer or forty percent for any other cause to cure with the simple procedures is pretty amazing just to

kind of show you an example this was 55 year old gentleman who had removal of his left kidney they found a seven centimeter renal cell carcinoma incidentally while he was being worked up for a kidney stone it had been six

months of constant Kyllo societies and loss of 63 pounds before he saw me here's a lymph angiogram showing fairly typical anatomy until you see this little leak and you see the surgical clips there where his kidney was and all

of the hollow pile spilling around and surrounding his spleen I'm doing this and then we did an embolization right around that area he sent me an email two months ago just before I left the University of Michigan thanking me for

changing his life and saving his life another example this gentleman had had major debulking surgery for for testicular cancer he also has had prior bone metastasis with a hip replacement there and you see a bilateral leaks he

see multiple drains they couldn't control his fluid and we embolize all of these small leaks around his pelvis and also fixed him as well and just she see all the focal areas of leak throughout this was a three year old who'd had a

Wilms tumor resection we're mapping them out and you see the area of leak in the center there and was able to fix this child as well discharged and continued on his merry way cured protein losing

treatment options once you've sort of isolated that there are leaky valves and the patient has typical symptoms that there are some surgical options but really embolization and catheter

directed treatment are really the mainstays of treatment both because it's an outpatient procedure you get to go home the same day and the recoveries fairly easy the factors that we consider when you embolize or block these

varicose veins are listed here you want to you want desired duration you want it to be closed forever you can't replace valves it would be nice to be able to do that but there's not a valve replacement so much like in the leg when you're

treating varicose veins you're either blocking or taking veins out so the surgical options are to take the vein out or to ligate but and the vascular options would be to block it and so I would just thought I would cover just a

little bit of embolization materials I'm sure you're all very familiar with and as I'll mention a little bit later there's there's sort of not necessarily agreement on what type of things people use to embolize gonadal veins or pelvic

varicosities but i'll show you what i do but give you a background of just generalized embolization materials so I'm sure you've all seen gel foam supplied as a sheet you can make a slurry you soak it with contraire

so that you can see it as you're putting it in some people use glue and will glue the entire gonadal vein it solidifies when it's mixed with saline or blood usually mix it with acai it also you can see it as

you're injecting it and then the standard coils which there are multiple sizes shapes detachable non-detachable Amplatz or plugs all the mechanical devices that can be used to block blood vessels and then I put on Souter deck

all because there are some people that will sort of do the sandwich technique you may have heard we'd put a coil peripherally and a coil up by the renal vein and then in between the coils you can film a sclerosant and embolize that

way the other important factor for me is using the suture deck all on the actual varicosities I'm not just necessarily treating or blocking off the the blood supply to them you know and I'll mention that a little bit more during the case

here so go through a case patient with

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

there a better option this is where a carotid artery stenting was developed over a couple decades ago and this is a

less invasive viable option for treating carotid artery stenosis it was generally started off as a trends ephemeral approach but I'll show you what the new approach is that many of us are involved in it involves the use of

in volunteer tection so it's one of the unique vascular territories where embolic protection is required if you're gonna get Medicare reimbursement for this you have to involvement and bollocky protection if you do without

you can do the procedure but you won't get it you won't get reimbursed and ultimately it's it was proven to show much better outcomes if you use involved protection because even doing the procedure and trying to place the stent

there is some small embolic degree that that that shuttles off and if it happens in the foot you may or may not lose a toe but if it happens in the brain you're gonna lose brain cells and it's gonna be potentially catastrophic so

significant adjunct to the stenting procedure is doing embolic protection and there's two types of embolic protection there's distal and there's proximal I'll walk through each of those with some diagrams here and then anyone

that gets a carotid stent has to be on dual antiplatelet therapy so if they have an allergy they're unable to be on aspirin and plavix they don't get a stent because there's early stent thrombosis that can't occur in these

patients if they don't have that dual antiplatelet therapy so let's go through

leave you the image you can see from an airplane on this image can you see prominent vein this is a prominent beam so at the time in this image pulmonary vein was or pacified so we should not hiss but we missed fortunately the patient got over our headache and visual disturbance discovered within seven days and for the next six months no variceal bleeding and he got a liver transplantation so how to

prevent this serious complication 1 to 2 or 1 to 3 thick mixture of colonial applied a mixture should have been used or butter the flow should be concealed being controlled by putting catheter or several coils it should have been used at first and then and cool injections should have been done I don't know or instead of Paris embolization tips or liver transplantation should have been considered the first I don't know I'm not Monday Morning Quarterback and this

is my last slide thank you for your attention

about massive PE so let's remember this slide 25 to 65 percent mortality what do we do with this what's our goal what's

our role as interventionalists here well we need to rescue these patients from death you know this it's a coin flip that they're going to die we need to really that there's only one job we have is to save this person's life get them

out of that vicious cycle get more blood into the left ventricle and get their systemic blood pressure up what are our tools systemic thrombolysis at the top catherine directed therapy at the right and surgical level that what

unblocked me at the left as I said before the easiest thing to do is put an IV in and give systemic thrombolysis but what's interesting is it's very much underused so this is a study from Paul Stein he looked at the National

inpatient sample database and he found that patients that got thrombolytic therapy with hypotension and this is all based on icd-10 coding actually had a better outcome than those who didn't we have several other studies that support

this but you look at this and it seems like our use of thrombolytics and massive PE is going down and I think into the for whatever reason that that the specter of bleeding is really on people's minds and and for and we're not

using systemic thrombolysis as often as we should that being said there are cases in which thrombolytics are contraindicated or in which they fail and that opens the door for these other therapies surgical unblocked demand

catheter active therapy surgical unblocked mean really does have a role here I'm not going to speak about it because I'm an interventionist but we can't forget that so catheter directed therapy all sorts

of potential options you got the angio vac device over here you've got the penumbra cat 8 device here you've got an infusion catheter both here and here you've got the cleaner device I haven't pictured the inari float

Reaver which is a great new device that's entered the market as well my message to you is that you can throw the kitchen sink at these patients whatever it takes to open up a channel and get blood to the left ventricle you can do

now that being said there is the angio jet which has a blackbox warning in the pulmonary artery I will never use it because I'm not used to using it but you talk to Alan Matsumoto Zieve Haskell these guys have a lot of experience with

the androgen and PE they know how to use it but I would say though they're the only two people that I know that should use that device because it is associated with increased death within the setting of PE we don't really know you know with

great precision why that happens but theoretically what that causes is a release of adenosine can cause bradycardia bradycardia and massive p/e they just don't mix well so

strategies so some things that we have

in place right now our peer review Grand Rounds CPOE this is one of my one of my favorite process improvements is is making the right thing the easiest thing and you do that through standardization of processes so that's standard work so

that's your order sets that's the things pop-ups although you don't want to get into pop-up fatigue but pop-ups help our providers for little gentle reminders to guide them to what's right for the patient and to cover everything that we

need we need to cover to ensure the safety of our patient so recently in the fall of last year we had a TPA administration err that occurred it involved a 69 year old patient who two weeks prior had had some stenting in her

right SFA she presented to our clinic when our clinics with some heaviness in her leg and some pain and when she was looked at from an ultrasound standpoint it was determined that her stents were from Bost so she was immediately taken

to the cath lab and it was after angiography did indeed show that there was clot inside these stents they did start catheter directed thrombolysis in the cath lab they also did started concurrent heparin often oftentimes done

with CDT what's usual for our institution is that we have templates that pull in the active problem list for a patient in this case the active problem list or a templated HMP was not used had they

used the template at agent p they would have found that the second active problem on this patients list was a cerebral aneurysm so some physicians will tell you some ir docs will tell you that's an absolute

contra contraindication for TPA however the SI r actually lists it as a relative contraindication so usually we're used to when you when you start a final Isis case you know you're gonna be coming in every 24 hours to check in

that patient in this case we started the the CDT on a Thursday the intent was to bring her back on Monday the heparin many ir nurses will know that we will run it at a low rate usually 500 units an hour and we keep the patient sub-sub

therapeutic on their PTT although current literature will show you that concurrent heparin can also be nurse managed keeping the patient therapeutic in their PTT which is what was done in this case so what ended up the the

course progression of this patient was that so remember we started on Thursday on Saturday she regained her distal pulses in her right leg no imaging Sunday she lost her DP pulse it was thought that it was part of a piece of

that clot that was in the the stent had embolized distally so they made the decision with the performing physicians they consulted him to increase the TPA that was at one milligram an hour to 2 milligrams by Sunday afternoon the

patient had an altered mental status she went to the CT scan which showed a large cerebral hemorrhage they ain't we intubated to protect her airway and by Monday we were compassionately excavating her because

she me became bred brain-dead so in the law there's something that's called the but for argument so the argument can be made that this patient would not have died but for the TPA that we gave her in a condition that she should not have had

TPA for namely that aneurysm so this shows how standard work can be very important in our care of our patients and how standard work drives us down the right way making the easiest thing the safest thing so since that time

we've had a process improvement group that we've established an order set specifically for use and thrombolysis from a peripheral standpoint and then also put together a guideline that was not in place so it's some of that Swiss

cheese that just kind of we didn't have a care set we didn't have a guideline you know we didn't use our template so all those holes lined up and we ended up with a very serious patient safety event so global human air reduction strategies

oops sorry let's go back these are listed in a weaker two stronger and some of what we're using in that case is some checklists so we developed a checklist that needs to be done to cover the

absolute contraindications as well as the relative and it's embedded in the Ulta place order that the physician has to review that checklist for those contraindications and also there to receive a phone call from pharmacy

just to double-check and make sure that they have indeed done that that it's not somebody just checking it off so we have a verbal backup sorry so the just

okay stent graft deployments once you've ballooned you basically pass the sheath over the balloon all the way down to the portal circulation the reason for that

is the Viator stance has a bare portion that's captured by the sheath so your sheath has to be deep into the portal circulation so when you unsheath it it opens up and then you pull back so it snags on your portal venous entry so

it's a feel thing and a visual at the same time for the operator okay so your sheath has to be deep in the portal circulation so that dilates put your sheath all the way down this is a run just to make it look pretty for you guys

and then you basically deploy the Viator stent via tourists and like I said has a bear portion that's captured by the plastic here and that plastic sheath basically transfers the capture of the bare

portion from plastic to your entry or access sheath okay as a ring to it and put it in has a feel to it that ring has to be right there it's very common for people starting off to deploy it inside the sheath up so it's a kind of a feel

thing to actually make sure that it's actually in there snug with it with the sheath okay then you push the stents all the way into the sheath now the bare portion is captured by the sheath you remove the plastic it's over over and

done with and then you pass pass your your stent all the way down to the portal vein and then unsheath it like a wall stents let it open pull everything back till it snags on the portal venous entry sites and then unsheathed the rest

of it which is the covered portion and that stays constrained by the cord and then you pull then you pull the cord keep key portion here is this is the ideal tips and ideal ace tips is a tips from the portal vein bifurcation to the

a patek vein IVC junction okay that's an ace tips it's usually a straight tips it's the straightest tips you'll see it runs parallel to the caiva okay rookies will be doing tips down out in the

periphery and Deliver okay they'll be fishing for small portal veins out of his small hepatic veins and at the end their tips is gonna be like a big seat like a big C loop okay it'll be a longer tips with more stance and it won't be an

aggressive decompressive tips okay but an ace tips is a more aggressive central tips straights it comes from the portal vein bifurcation to the paddock vein IVC Junction that's kind of like an ace tips

okay unsheath it and then and you and then you pull the cord to basically deploy it and this is kind of a reenactments the Styrofoam cup is the portal vein the sheath is in there now over the wire there's no wire in the in

the reenactments and then you unsheath the bear portion so it opens up okay and then you pull everything back till it catches on the portal vein okay you move the sheath all the way back and

then you pull the cord you see the cord right there you pull the cord and it basically opens up the covered portion okay and it opens up from the portal venous end so it actually capped catches it right away catches that portal venous

entry sites there's no slippage and so basically rips open tip to hub okay and that's kind of your final product and then you go in and and then you go in and balloon okay so here it is ballooning put the sheath

over the balloon sheath is deep into the portal circulation you put the tips in your unsheath to cut the the the bare portion let it flower open you pull everything back to like snags you unsheath the rest of the stunt and then

you pull the cord okay and then you dilate with 8 or 10 or whatever so this is visit with the debilitation and that's kind of your final product ideal

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

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

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

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

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