Common Iliac AAA | rEVAR (Aorto-Uni-Iliac), Fem-Fem Bypass, Balloon Angioplasty | 78 | Female
Common Iliac AAA | rEVAR (Aorto-Uni-Iliac), Fem-Fem Bypass, Balloon Angioplasty | 78 | Female
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This is a 78 year old lady with a known AAA now growing to about 6 cm diabetic,

hypertensive, and COPD. Again these guys with COPD have a higher rupture risk. Obviously we wanted to recommend repair. This is an older case but I think it shows some good points. Here's the inferior aortic aneurysm. This is a chrono mep/g showing basically ectatic or aneurysmal

common iliacs, and not probably projecting as well but she has very small calcified iliac arteries. Torturous as well. So this a lady where I think she had a reasonable neck but her access vessels were an issue. So we brought her to

angiography. This is back in the day when we did open growing exposures. You can see this huge large common iliacs. Her neck isn't horrible but it's not perfect certainly do able. I believe this is just a 8 French sheath that's inclusive. This is her externally iliac.

Very small iliacs. So our goal is to pass the main body from the right groin. This is our endo-conduit technique where we put roughly in an 8 French sheath and either 7 to 10 mm iCAST depending on what we think we need. Just a balloon expandable stent.

Inflation that's our post picture, I believe this is an 8 mm iCAST. We are able to preserve the internal here but our main body went to the past to the groin set, left to

plan B. So we turned our attention to the left groin which I felt was the worst groin, we went to the right thinking that it would work. And again this is an older case where we were using what we thought was the slickest endo-graph at the time it was a metronic that was probably one of the lower profile cases of that year.

So we attempt to do the same here. In this case we thought that the iCAST was actually interfering with passage of the stent so we angioplasted with the external iliac with the 8 mm balloon. A little big certainly for this lady but we needed at least something in this ball park of calibar to get our graft up,

and then we found this. I really wish I hadn't seen any of this but I was thinking other things when I din't save the run, but this is- >> So you tell me when you balloon a 4 mm vessel with a 8 mm

you think it would drop? >> Sometimes if they seem to rapture in the classified little old lady [LAUGH] yeah. >> [INAUDIBLE] from the endovascular it's like there's a 5 mm external that ballooned to 10 and then raptures, I was like >> Yeah I shouldn't be surprised. I will say that whenever we do these things you want to expect things like this, the iCASTer was already ready to go.

We partially expected this. This is the unsubtracted image. Amazing how quickly blood pressure can drop when you have an angio like this. >> Did you put a stent quickly? >> No no I just talked about it, we're just talking about it.

>> [CROSS-TALK] >> So next up, a couple of options for us generally is sslamming the balloon back up there and then making sure you have iCAST. This is iCAST stenting right across here and then we had control and the patient was responding very quickly to this.

She didn't really actually require too much pressure support though her blood pressure did change. So then we wanted obviously continue with our EVAR and this is a large graft this is 2008 probably but we thought it was the smallest graft at the time and then we completed our endovascular repair and we telescoped it basically into the iCAST that we delivered,

and this is how she looked when we were done. This a CT post EVAR. She dropped her crane/g obviously and this again it's how amazing how quick she bled but she was stable so she was watched in the ICU for a while, I do believe she received two units of blood post

procedure and what would I do differently, I think there's a lot of options now, this is eight years later and we've talked about the trivascular we talked about the even the enduring as much more low profile the GORD now goes through a 16 French sheath, but also a short

discussion about adjunct devices such as the SoloPath in addition to adjuncts procedure such as the endoconduit. The S Terumo SolaPath generally allows us, initially is for TAVI I think that's where it got more popularity and TEVAR but all that stuff has come down a profile,

it's a very interesting system. I used the first and second generations, the second generations are obviously a lot better. Basically it's a balloon dialator that allows you to expand a nitinol braided stent,

right now now a nitinol braided sheath and allows you to deliver larger systems, and they come in a variety of sizes. Actually not in every size you may want. I think the biggest is the 23 French or 24 French, but again it allows you to get some other difficult cases done.

Neurosurgeons talk about a Hunt and Hess Scale. It's not a scale that we use as nurses

but it helps you identify if you're coming in to take care and have an idea of, "What is their Hunt and Hess?" If the doctor says they're a Hunt and Hess of three then you would have an idea that this person is going to be a little bit drowsy,

that they maybe have a severe headache, a little bit of local rigidity. A Hunt and Hess of four or five is designated to a very poor outcome. If they come in at a four to five they may have between a 70 and 80% chance mortality rate.

The thing I found was interesting with the H Susie came in and she was alert and oriented she had photophobia, they gave her a Glasgow coma score of 12.

She obeyed commands, she knew herself. She just liked a really dark room. We kept the shades down. Usually a real classic sign, you come into their room to pick them up and they've got a washcloth across their forehead,

don't they? The room's real quiet. We do want to keep these people on subarachnoid hemorrhage precautions before their aneurysm is clipped or coiled. We like to keep the room quiet.

We like to keep the blinds down. Keep the family a little bit quiet. We have an open visitation. I don't know if y'all have that in your facility but it can get to be a little bit like a three-ring circus

if everybody in the world comes and in East Texas if mama's in the hospital the kids, the grandkids, the aunts, the uncles, the adopted cousins, they all come and it's really a matter of crowd control

and in these days where people are all worried about their scores of being a friendly hospital there are many times when we have to be the big, "You know you need to get quiet "you need to get out of the room." If there's everybody around the bed she can't rest.

And if she had an urgent need I couldn't get to her so y'all need to get over on that side of the room and thankfully at my facility our rooms are rather large so we can kind of keep people a little bit further back.

If a person has a lot of co so I come in as a Hunt and Hess three but maybe I've got COPD or real bad hypertension then it would increase my Hunt and Hess score

by another grade if I had other co-morbid problems.

Next are our AV malformations, arteriovenous. With AVMs, arteries connect directly to the veins causing the blood to flow very fast through these vessels. These and because of the fast flow this makes them a potentially more aggressive vascular malformation.

The absence of capillaries, which is a network of small blood vessels that normally connect arteries to veins and deliver oxygen to cells, this creates a shortcut for blood to pass directly from arteries to veins by passing in the tissue. This can lead to tissue damage and

the death of nerve and other cells, resulting in arteriovenous shunting. When these occur in the brain they are treated in our Neuro-Interventional Radiology Suite and they're obviously of special concern because of the risk of bleeding of the AVM

and resulting potential neurological damage. Most often AVMs are congenital but they can appear sporadically. In some cases the AVM may be inherited but it's more likely typically that other inherited conditions increase the risk of a patient

developing an AVM, as we see in the case of HHT. These may look like a pseudo-capillary malformation with pulsation at palpation or you can appreciate a bruit. It may look like an enlarging red, warm, painful lesion, it could be ulcerated and bleeding. Obviously these can cause a patient significant pain.

Management of AVMs is particularly challenging due to their unpredictable course and high morbidity rate because, again, of that high flow shunting nature of AVMs.

The importance of the meta-analysis and I like to talk about this for a little bit, we call this, it's kinda like the key study that really promoted the use of meta-analysis back in 1990's

so the Streptokinase study. I know this is a busy slide. So this is a forest plot that's in a meta-analysis. You don't need to know that, what you need to look at is the P-value. So the P-values, if you notice, these are 33 studies.

If you look at the P-values, I'm sorry this is 36 studies. If you look at the P-values, 33 of those studies were non significant. So if you were to just look at those studies individually, well 33 studies were non significant and only six studies were significant.

What does that mean? So in your mind you would think Streptokinase doesn't work for thrombolysis right? Well that's what people thought for years. On the Streptokinase study, they pooled data from 33 studies over a 30 year span.

The first Streptokinase study came out in 1959 and they continually studied it until 1988. The overall conclusions from the medical community engaged in cardiac health care said that Streptokinase didn't work because there was so many studies that proved that it didn't work.

However, like I said, I misread the numbers. So 27 studies reported no significance. Six studies reported significance. Out of six out of 33, what are you gonna believe? But when they put these studies together

and performed the actual meta-analysis, it was Dr. Lao, they pulled a sample size of 36,974 patients. So they basically took all the sample sizes from all of those 33 studies and pooled them together. What they found when they pooled the numbers of patients it provided a better effect size.

So meta-analysis showed a risk reduction of 21%. The P-value was less than .000008, which is highly significant. So when they combined all the studies they actually found out that Streptokinase decreased your risk of developing a thrombotic even and dying from it

than if you did not get it. So that kind of... And this was published in 1992 and look at the date when it first started. So they should have been using Streptokinase for years but because of the lack of the meta-analysis,

they had no idea. The meta-analysis just kind of hammered that home how important meta-analysis and identifying, 'cause you may have studies that with small sample sizes that don't come out significant. However, if you start pooling a bunch

of randomized controlled trials you're going to see a definite significance if it's there.

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