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
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.

This patient has Marfan syndrome and has been operated three years prior for Bentall procedure

and he presents with recurrent acute thoracic pain. So he has classic dissection and so we decided to go ahead and treat the descending thoracic aorta going up and, I just put this in because we had problems finding the true lumen. So I don't know that's the question to the panel are there any tricks

you use if you want to find true lumen? How do you do it? Do you use IVIS? Michael, we have any comments? [BLANK_AUDIO] Well, I'll be honest I'm not proud of it.

We don't use a lot of IVIS either. >> Okay. >>In something like this I'm going to look at the CT scan at high quality has to be of course in the pelvis and sort of understand if there's one illiac look at the other maybe more ideal.

Then if I decide that the dissection goes into both iliacs and they both tear out distantly, I'm going to know what the true lumen is and I'm going to take the image intensifier and I'm going to look down right at the distal and at the dissection usually that's the only clarification and I'm going to put the image intensifier directly

parallel with the flap. So what I go up with the whatever curve cathedral tip that I have and glide wire, I know if I'm going to go left, I'm going to be on one lumen and if I go right, I'm going to be in another lumen.

And then when I get to this point, I'm going to do the injection in he abdomen. And from the CT scan I know, where does a right renal artery come up of. If it comes up the true lumen and I see it then I know I'm in the

true limits. If I don't see it I must be in the false lumen and I'm going to have to go back and try again. >> Great, super. >> [INAUDIBLE] >> Yes.

>> [INAUDIBLE] >> Also sometimes if you don't want to loose access you can use a long sheets and inject over guide wire again it's case by case but I guess the best way for us is to look at the CT and then see where we are compared to the CT scan,

that's the best way we can do it. So the true lumen was actually very small in this case we end up with the small small wire and eventually found the true lumen so the stent graft was placed and.

So the patient presents with was three years after the initial stent graft placement. Actually you can's see it quite well but, the patient had like a type one link and the initial stent graft I don't have all the images here but the initial stent graft had migrated in a little

bit down so an extension was placed, their is two stent graph in their and the reason why I'm showing this case is that, you see there's a like type one lick right their and so my question is how would you treat this?

I mean >> So first question. He's got an aortic valve what was the surgery for just the valve or with the >> No, no he had a deselection initially - >> So type

A. >> I think we got to insure that this isn't from some not necessarily the leak point I can't tell you have to tell a cause if I can see enough images, but you want to make sure that their is not some distal, proximal communication near the distal anastomosis of their graph for the type A.

As well as what you are seeing in that little. >> Well there didn't seem to be any dissection right there, okay, initially, that was clean. >> Is there a false lumen in the arch? Let's just ask that, on CT?

>> No. >> So we know that this leak is right where you showed it at, near the proximal. >> Yes exactly like just after the subclavian [BLANK_AUDIO]

So despite extending the stent graft and partially covering the left subclavian we still had that leak. So question is how would you treat this? Would you treat it? >> So is I fully understand what you're saying, I just haven't been

able to characterize. It's an under surface of the arch so the assumption is the stent graft somehow is not circumferentially- >> Yes there's no seal there. >> Audience, what would you do?

[INAUDIBLE] anchors, what do you think the endoanchors, maybe. >> Maybe. >> Anything else. I suppose you could potentially branch graph more proximal now,

if you had access to one. Anything else? What would you do? >> This case we decided to inject some Onyx. So I don't know if you have experience with that but- >> Oh percutaneous?

>> Yes. percutaneous. So that catheter with the leak, you can see that there's a vessel that comes out right there. That's the Onyx.

>> Excellent so, just curious but there was any way to come up false lumen from below all the way up there. No? >> No. Sometimes we use the technique you're describing that one of our colleagues he goes with

>> Underneath the graft. >> Yes. >> You can sort of do it from above as well [INAUDIBLE] >> No, just Onyx. Yeah.

>> [INAUDIBLE] >> We mostly use the Cook graft, but we use the GOR also and we use many grafts. So, I don't think there's a favorite one. >> What do you think?

You have any favorites? >> [INAUDIBLE] >> Yes, . >> Well, any graft can cause retrograde type A, okay. I happen to use GOR,

Here's a 51 year old female, left hip pain, instantly found to have

bilateral common iliac aneurysms on CT. This is it. She's young, now has this new diagnosis. This is what it looks like isolated to the iliacs, fairly torturous though, a little kinking in that left common iliac that's fairly severe,

almost a 180 degree kink, some ectasia with the abdominal aorta and these are the measurements of the iliac arteries. The question is what do you do? Maybe you should ask first do you even treat, how do you treat if

you and do, and do you do one side, do you do both? And we'll tell you that this patient gained a significant amount of anxiety related to this and just by the diagnosis itself even despite trying to what potentially the size may mean, so maybe

ask the panel, would you guys treat any of these, one of them or none? >> You treat both if you have to, the one is three, that size arteriole is a little bit smaller but yeah you treat them both, when you do it it's not an emergency but you do it now there's no point of surveilling or anything just treat

it. >> I agree, I think you treat, the question is young patient will surgery be okay and a good surgeon can do an aortobifem and do some bypasses to the internal iliac and I had some cases where just coiled to an internal and they did an aortobifem with a branch bypass with internal and looks great for young patient

or do an one of the crazy stuff you're gonna show us now, endovascular. I think both options are fine but I think if you have a surgeon, can do that I think we'll work fine. >> Yeah I think you should treat them both and kind of whether they're similar iliac branch but I would certainly consider using one of two.

>> Great points. We have a good relationship with our vascular surgeons, we've a survey of multi disciplinary conference, we've discussed these cases and the consensus amongst the group of vascular and interventional specialist was to treat this endovascularly and to treat both, so we did do that. We chose a staged approach to try to preserve one of the iliacs but embolize the other and that

was the plan here. So and there is some off label use, I'll explain that just a moment the first stage procedure was to embolize the left internal liac that was the set that had 180 degree kink of the common iliac artery. So we decided that was going to be the more difficult to preserve, so we went ahead and embolize that, an amplatzer plug used, very straight forward then two weeks later brought the patients

back and utilize this strategy. This is an older case, but one of our earlier cases of what I'm trying to illustrate of sandwich than grafting a technique and take it to more complex levels, but this is a utilization of the Endologix AFX,

[INAUDIBLE] bifurcated endograft, extending into both common iliacs and in the left side extending into the left external iliac that's the side that we've coilembolized the internal. And then land within the right and then go up and over because of the nature of the AFX device, cannulate the internal iliac,

place a sheath and then your self extending covered stent and then extend a limb from that side on the right and you have a sandwich procedure. These are the devices used, we use the [UNKNOWN] for our sandwich devices and this is the AFX as you can see it's seated on the

aortic bifurcation which allows you to then readily go up and over on this device as opposed to the other modular endographs that we use. So I'll show you some represntative images, the angiogram, you can see it goes quick but on the left side the amplatz plugged

there and we're going to continue to exclude that. These are select images of the aortogram, this is us placing the AFX device, it's in now, seated at the bifurcation, you can see the amplatz plug,

we then extended the limb on the left side so we've now excluded the left common iliac artery aneurysm. We're gonna do some work now to cannulate the right side, here's another angiogram. Select image. Now we are gonna go up an over.

Now because we are seated on the aortic bifurcation you can see, you have a nice view of the iliac bifurcation and we can go up and over as we've done here. You can if you have difficulty with gaining sheath access up and over you can take a second wire and snare it through your contralateral access on the right side and help support

your sheath positioning into that common iliac arteries stent or common iliac portion of the effect stent. We didn't need to do that. There is enough wire purchased within the common iliac artery. And as you can see here the sheath on the contralateral or ipsilateral side. This is the sheath normally would have a position a little bit further but

had this viabahn positioned into the main portion or the main trunk of the internal iliac artery trying to preserve as many branches as possible. Depending on the length ten centimeter may be too long, cuz in general we want the proximal end or the trailling end of the viabahn to be at the bifurcation area.

We don't really want it trailing up too far into the abdominal aorta, I like to keep it close to the level of the common iliac, the new common iliac so to speak. In this case we had to bridge two viabahns because ten was too long

and seven and a halfs were not available, those are now available. And you can see the viabahn position here, balloon dilated little bit out of order than what we may typically do now, but you can see now the viabahn in position here, the extension on the external iliac of the limb extension into the external iliac there.

Balloon dilating that, this would in theory crush the other viabahn but then you can post dilate that cuz you leave your balloon in position, as well as the bridging portion, this was two stents. And then you continue to maintain your wire access and take your distal seal zone like you would otherwise, and now you can see the

configuration, you have your AFX device extended into the external iliac on the left, extended into the external on the right but the viabahn positioned within the internal sandwich to the level of the origin of that new right common iliac artery. And here's your angiogram and you can see you have now preservation of this exclusion and on follow up imaging no endoleak,

she's done quite well. So this is a companion case and I think I just wanted to illustrate some basic concepts that I think you'll see in potentially more complex to come but Robin earlier mentioned that maybe an iliac branch device and that's,

now recently I think in the past two weeks, was FDA approved. So this device is one that we are on trial for and this is a companion case of the essentially isolated iliac aneurysms much larger. I think there's no question for treatment here, it's 5.4 centimeters,

you can run this [BLANK_AUDIO] Patient's CT you can see essentially isolated to the iliac arteries [BLANK_AUDIO] internal- >> Patient's coming in to Wisconsin, is that what happens?

>> We see a lot of iliac artery images. >> She's related disease? >> Maybe, she's [INAUDIBLE] [LAUGH]. So we took the approach of this device, now this is an FDA approved device intended for preservation of the internal iliac artery.

So this is the main body gore excluded that you're used to, this is a bridging component, and this is the component that lies within the common iliac portion, this whole portion, the main body to this

flow divider lies within the common iliac of the side you choose to preserve and you come up and over and cannulate the internal iliac. There's wire component that helps allow you for a precannulation of this device. Extend your wire into the internal iliac and then advance this bridging or extension piece which is larger here to allow

for docking and place that within the internal iliac artery and so this is the select images from the procedure, this is the iliac branch device positioned at the common iliac, making sure that the gate, so to speak for this iliac device is positioned above the iliac bifurcation. That's the same marker that you should see on the main

body device, it's deployed, that's precannulated you can then take with wire support, or sheath up and over, you can see that sheath now here positioned right at the iliac gate extending that docking limb within the internal iliac artery,

post dilating that. [BLANK_AUDIO] Then you continue with the remainder of essentially your excluded case, bridging and docking your main body that you've positioned, traditional fashion with the iliac excluder main body device, and exclude otherwise and you then have preservation with an FDA

approved device which is not, unlike the sort of plan for the sandwich, although that's awfully what we use of off the shelf devices that are readily available. This is followup imaging, in the same patient.

[BLANK_AUDIO] You can see exclusion of the iliac artery anurysms and preservation of the internal iliacs with the iliac branch device. It's nice system, it takes specific anatomy for this work but as long as you have a landing zone withing the internal iliac artery, I think it's a nice solution for patients where the concern for a bilateral internal

iliac embolization maybe. Certainly there've been cases of patients having that done without significant sequela but it is not without some risk of complications. >> Just quickly about the precannulated gate and explain how that works, where do you get that?

>> The cannula is outside the body so then there's a cannulated segment within that, sort of the gate of the iliac branch device that you can then pre wire and then you can advance that. >> But you do it from the other side from up and over, is that what you do? >> Then you take that wire and you can then grab that and go up and over.

>> Do you snare? >> Yes. >> Okay. >> You can snare. >> Those are great cases and I think you know that certainly in terms of expediency and so forth,

coil and covering one hypo I think is pretty safe and pretty standard. Another way of treating those just for purposes of discussion would be even with just with off the shelf kind of thing, just to come from the arm into branched, into both hypos and sort of the same parallel

thing just from the arm. It is nice for us in US at least to finally have some of these little bit more advanced devices starting to trickle through and getting approved, but there are other, we can do some little bit more standard, typical, off label parallel grafting

with routine devices. >> I had a very similar case with the first case you presented and the so called double D technique, where the sandwich would be endologics AFX device and to my surprise I was worried about the internal iliac to actually the

patency of it but the patient came back actually ten days later with the stent in their external iliac thrombosed. And actually the internal iliac, so the iliac limb of the AFX, that extension was crushed by the viabahn that went into the internal iliac artery, which

was very unusual. I don't know, maybe we just went and did a thrombectomy and cleaned that up, and that was a very unusual outcome that I had but, I don't know. I've talked to a lot of people and they thought that they see that internal, but in that case, I don't know if it had something to do with sizing

or some other aspects of it but that was somewhat surprising. >> Sizing might be part of, the other thing is I just, and this is personal bias I like their graft itself, I don't like their limbs and so whenever we do an endologix AFX type case and we have to extend on one side or

the other for whatever reason, I tend to chose another vendor's whether it be medtronic or the spirals limbs or gore limbs or something, I have a personal little bit of a bias against their limbs, I like this device, the main body device,

I just don't like their limbs. >> I agree. Some basic tenants, so if you take that concept of the hypogastric preservation with a sandwich or parallel grafting technique you can extend that to the visual vessels and or renals not unlike the chimney but slightly taking it to a different level if you're going

to involve SMA and or celiac. But you need proximal and distal landing zones, you need some kind of seal zone for your aorta wherever that treatment segment may be, you'll ultimately catheter then wire, sheath and ultimately position a stent within your target vessels, all of them each before you place your endograft.

And then you position your endograft with sufficient overlap and sufficient overlap means it's gonna be initially sized to the aorta where you plan to seal proximally with enough overlap. And generally we found when we were doing sandwich or parallel grafting technique the more overlap with the viabahns,

now we're talking about a concept going in the renals, and or the SMA and preserving that, that's extending into the proximal descending thoracic aorta. At least five centimeters or so, longer overlap of that viabahn extending up, placing the abdominal endograft at

that level approximately one centimeter below the top of the viabahn. These are our rules of thumb so to speak or tips with regards to what we choose to use, I think we've had a discussion about what we like for our chimneys and our visceral stent graphs and it's self exanding so that really only leaves the viabahn as the option, fairly conformable. Apparently I have reasonable radial force to exclude a limb, which I haven't

seen before but I think they're visible enough and they have enough length and size options available, recently the seven a half centimeter length options have now become available to us in the US which is fairly handy because it can eliminate adding an additional device. In general the target vessel is

one millimeter larger is the size viabahn that you would use by diameter and at least two centimeters within the target vessel. Ideally preserve any distal branches or clearly in the SMA or in the renals you wanna preserve those if possible but generally we like to have at least two centimeters just in case that stent were to jump back so to speak, then again I already mentioned the

five centimeters of overlap with the abdominal endograft. And this is sort of a coiling of a case done for a thoracoabdominal aneurysm and you can see there's outside a cuff or a stent graft on the outside, these are the snorkels or the parallel grafts placed in the SMA in both renals and then the abdominal endograft from the outside.

And the longer segment of overlap that we have, the minimization we've seen of the concern for gutter leaks and endoleaks in these patients, this is the follow up CT scan in one such patient where a thoracoabdominal was treated by this manner. And you can see that's the proximal cuff, you can see the parallel grafts extending to their distal targets and you can see exclusion

of an aneurysm, in fact this was showing sac regression, I haven't shown you the pre-imaging but I wanted to show you the ability this technique can do to successfully exclude an aneurysm.

Okay, so this is a case that, the guy's a little bit of a complicated

patient. He has severe claudication particularly on the left and he had billateral iliac artery aneurysm so he also had a fem pop bypass graft. Actually was I think a fem iliac on one side and on the other side it was a fem pop, not a fem pop he's got an aorta fem on the right side, and on the left side he's got an aorta iliac. So he's got graph material on his aorta and that would obviously limit

me going up and over. So I was going to to put this patient in a teaching course that I had been going on which was a TurboHawk. So that requires me to use a seven French sheath, and I didn't think I could go up and over,

because of the aorta fem bypass that we had to work with. So, I made the initial decision to go antegrade. As far as non-evasive studies we didn't have them on this patient. This patient came from an outside HMO in Miami, and they will not

give you any type of leeway in performing office-based studies. So I had angiogram, brought him back and my plan was to go integrate on this guy. He was 79, a little bit of a an older guy, all these comordities that you see here. He had had abdominal aortic aneurysm which again was fixed,

and he had an aorta fem on the right, aortoiliac on the left. So my plan was to antegrade puncture even though he had a protuberant abdomen, antegrade puncture the left common femerol, go down and fix an area

which you guys will see very soon here. I'd planned to make it be a 30 minute case, get out and go to the next case which I had for my course. And as you see it will be a. So this is my puncture. I punctured the common femoral antegrade

even though he had a protuberant abdomen. It was a little bit of a high puncture. And then you can see on the next frame over on the right there's a high grade stenosis. I'll cut to the chase. We performed a TurboHawk atherectomy with a Spider distal protection device and then we hit it with a drug coated

balloon. This was about a year, a year and a half ago where we used a Lutonix seven by four, a drug coated balloon. And we had a really good result. I mean this again was one of those 25-30 minute cases.

Everybody was happy, everybody was ready to go to the next case. We'd loaded him up to the next room and I was gonna go from one room to the next. And so I elected to choose to seal with a ProGlide. So

seven French system so we thought we could make it happen. Got it in there and then had a closure malfunction, or either I didn't do it right, one of the two. You'll see on the next one. This is the far left hand panel. It

shows that there is extravasation into the retroperitoneum from the sheath. And at this point I had up-sized to a nine sheath from the closure mishap. So I said, well, we gotta bite the bullet because the guy's bleeding out, and we don't have control and so we decided to stick the right side. And I stuck the right side and got into the native vessel.

You can see here my catheter going into the native vessel. And he has a little internal iliac artery aneurysm which basically occludes. So I had to go back and puncture him again on this side. And you can see where the difference is between the bypass graft and the

native vessel. So I was able to manipulate a second puncture into the the bypass graft and then we were able then go up to the bypass graft. And you can tell this is graft material. He did have aortoiliac on this side.

Come up and over and then there's a little pseudo aneurysm on this side. And at this point we were able to place a Viabahn gate seal and I thought I have an actually pretty decent outcome. for this case even though it did take and extra 45 minutes,

and I was kinda screwing up my day. We decided then to come back over. The only thing that saved me on this one was the fact that the aorta graft was not an acute angle graft. It came off as sort of a nice oblique angle and we're able to cannulate that.

Well I came back through, I decided not to try to do any type of closure on the other side since we had two puncture sites. The patient went over to surgical recovery and we sent one of our techs over to hold pressure.

I got an emergency call about an hour later saying that the patient had closed down his bypass graft on the right side and then had become hypotensive, and the left side has closed down. So essentially had closed down both legs. At this point we call the surgeons cause I don't think there was

anything in the vascular that I could do at that point. Did you guys have any ideas of what to do thrombolysis-wise or going in there and trying to suck it out with a Penumbra or any of that stuff? Since it went all the way I think it kinda propagated all the way to the aorta.

So we called a really accomplished older surgeon at Sinai who went in and did an embolectomy. He was successful but the guy essentially spiraled downhill with respiratory failure and all kinds of other issues and then expired about two days or three days after this procedure. So basically I wanna ask you guys on the panel,

I wanna ask you guys out there, what you would have done differently. Would you have done anything differently? And how you would have managed it. If you take a look at this previous Picture here.

I think my puncture was right at the lateral epigastric coming in here, inferior epigastric right at the circumflex iliac, circumflex. So it was a pretty high puncture antegrade protuberant abdomen. It was an access complication, no matter what you worry about, one

of the things that will get you in this game is access complications. Anybody have any ideas? >> I think you bring up a great point, Every part of the procedure is critical and every part of the procedure you need to kinda assess the different risks.

This is a guy that you probably could not go up and over. So the only way to really treat him was gonna be antegrade or with a cut down. You're not gonna use some type of atherectomy device from the radial. Our devices aren't long enough. You're not gonna go down in the foot.

This is pretty much the only way to treat it. >> And the guy did have significant symptoms but he walked in. >> Yeah. >> And he got boxed out. So bottom line is you gotta always consider what you're doing. There are risks involved in what you do.

I mean the family and he wanted me to try and fix this leg because he was having lifestyle-limiting claudication on that left leg. But again the bottom line is the bottom line so. >> I don't know it's probably a practice at your [INAUDIBLE] We almost always as a routine, you get access, you get a fluoro image with the micropuncture and

the wire and make sure it's kind of in the mid column tunnel. And that way if it's too high, too low you can just leave the wire in. So that kinda [INAUDIBLE] you leave the wire and you take the micropuncture

and just stick it exactly where you want. It takes an extra 10, 15 seconds and it may prevent an issue like this. >> Yeah. >> Because once they start bleeding into the abdomen that's an issue.

If you bleed into the groin it's not. >> Yeah. Yeah. Good point. Good point it was a little high stake and I did not use the ultrasound on this. I felt like I had a good enough,

I could feel the pulse really well and the abdomen was protuberant so I thought I was, but ultrasound is an excellent point. >> It's just sometimes very difficult with those, you don't really, you tape the panis up and what have you. There could be a difference of like 2 cm just on how you position the patient,

deciding where to go. And these cases, even though it's not traditional, we may even start considering puncturing directly in the SFA- >> Yeah. >> Should be able to do the SFA.

>> Yeah. Absolutely. >> And try to just because the risk, like you said, the risks are going to be different. And maybe yeah it may not work,

maybe the SFA goes down but all that you have kind of a relative solution for. Right? >> Mm-hm. >> And if you do puncture a [UNKNOWN] if you do get some kind of bleeding into the abdomen,

these are patients who are going to be anticoagulated. >> Yeah. >> It's gonna be tough. You know it was lucky that you were able to get that Viabahn there.

>> I thought I had a pretty good save on this one and then you get from of an elation where you think you've taken care of your problem, then you have another complication on top of this from the other side. >> Any thought of just having the surgeon come in and cut down there? How would that go in your hospital?

>> At that time, we have war-ready rooms and the surgeons come in all time. I've though about that but once I saw the bifurcation of that aortic graft, I though, you know what, I can probably get over this. And it takes some manipulation because if you've ever worked inside

a graft it's not the same as working inside a compliant vessel. It was really tough getting that sheath. As you can see the sheath is going up and over from the graft material over to here. That was very difficult getting it to go in so you're just working with a different type of a substance than you will if you're working

with artery. So anyway- >> One small comment. I don't think it's,, in this setting, once things start to kind of become difficult, it's hard to do it.

But we intervene over up-and-over sharp grafts all the time. What we do is, in obese people, I think in this one we would have done antegrade too but sometimes all you have to do is put an 018 wire, just snares from the other side and push your sheath all the way down, 45 cm sheath.

And then once the flexor sheath or Terumo sheath, the ones that are not kinky- >> Yeah. >> Then you can still work through that. >> That's an excellent point.

There's a cardiologist in Jacksonville [UNKNOWN] who I know well who does that all the time, going over by-pass grafts. That's a great point. >> That's a great point. >> That's a great trick.

>> It's really, really helpful. Challenging bifurcations, getting a wire up that's serves as a rail, I would use a four French, some people even put a sheath - >> Just the wire. >> Yeah. >> Yeah.

Just the wire. Snare it, just enough to get your sheath. Then you can pull and pretty much hold on for a few minutes and then you can continue with your procedure. >> Anybody in the audience have any questions,

suggestions or comments on this particular case? Yes, sir. >> I think you said you were limited with insurance [INAUDIBLE] these unknown surgical, like with bifurcations and all [INAUDIBLE] >> Here, here you're preaching

to the choir and Tina knows more than anybody else down there the differences in the insurance. Some of the insurance carriers down there will not give you authorization to do anything. You see him in your office and basically you see what you get as far as a substandard ultrasound that's sent there. It basically gives

you no information. And a lot of times you just have to take them straight to angio, but I've dealt with this for a long time.

so this first case is a 72 year old female with liver disease and intractible ascites. She's got Budd Chari syndrome

Polycythemia Vera and she's status post renal transplant. She was prescribed to take Lasix 60 bid and Aldactone daily, but she's been coming back for her lasix dose because her creatinine has been bumping. has

She also has great discomfort from a new incisional hernia that she has along her midline. And the surgeons really as you hear that story a lot, they're really gonna be able to operate on these patients with intractable ascites because that can really break down the suture

line afterwards. So here's a representative image of a CT scan basically showing. the degree of ascities and here's just a gaggle of vessels where the portal should be. So the degree of cavenous transormation and just some [INAUDIBLE] nothing really solid to go after from a test perspective. Here is a coronal reconstruction again showing the ascites, [UNKOWN] and

here is just this gaggle of vessels here, essentially, and centrally. Another cut showing a splenomegaly as well. So as I'm scanning through this, again,going back to like things that had

seen in prior conferences, you look and it's like wow, look at this varex right here, it's just knocking on a door of the IBC, wouldn't be awesome if we can just bump in there and

decompress this system. So basically that's what we decided to do. What we've been doing is we've been getting arterial access in a lot of these cases cause what it allows us to to do is falling through to the SMV splenic vein, portal venous phase, give us a

better idea as to what's going on. So we have IJ access, we have access in the left ephemeral renal transplant on the right side. I'm sorry, left ephemoral artery and we also drain the ascites for anesthesia to help them ventilate the patient more adequately.

So as you can see our SMA, will run through to the SMV probing space. You can see exactly what we saw here than going through portal vein. So here is showing the coronal reconstruction, here is this gaggled vessels that we saw on a CT.

So a couple of years ago, remember seeing abstract about utilizing ice, intracadiac ecocardiography and great images and being able to utilize this quite readily. So here is the ice device going in from the ephemeral vein, it's

basically a ten French sheath that you need to use to get this up so it's not really going crazy here. So basically we've got our drainage catheter, IJ access, and left ephemeral artery and venus access. So here are the images from the ice device,

and here is that [UNKNOWN] that we saw. So when we flip that around and compare that to the CT scan, here is the IVC right here, and here is the spherics right here and you

can see these other guys floating around here. So take a puss with a needle and here you can see the needle going into this vessel, do a little bit run [UNKNOWN] little bit of a run, and then you can see here is the vessel with the needle on it, here is the floroscopic vessel with the needle on it, We thought we're pump/g free but basically the main issue here,

not being native vessel was a torch velocity and being able to get good purchase. So it took us a couple of tries to get a good 018 wire out a little further distally over which we put a smaller micro catheter and then we were able to exchange for a steeper O18 wire so here is our micro catheter out,

I'm just injecting and showing the portal venus phase. We then got the stiffer wire across, we were able to put a small balloon to balloon up the tract. The ice is right over where the waste here in the subcutaneous tissues

between the IVC and tissues between IVC and the varix. And then we place our stent across, we inject it just to confirm that we're indeed in the varices themselves. We place the 7 by 22 atrium stent, as a covered stent, balloon expandable

through which we one millimeter we place a 12 by 60 smart stent to basically anchor on both sides, on the barix side and the inferior vena cava side. So here is a run through the sheath showing strong flow from the injection, in and out of the IVC. So we did a follow up SMA run,

SMA through to the SMV phase. This is the beginning of this gaggle of vessels and then right through this shunt into the IVC. So here's pre shunt placement, post shunt placement. This is the SMV phase of the SMA run.

And you can see there's really this gaggle of vessels, essentially is not existing anymore. Here is the ice visualization in two projections of the atrium stents within the vascular shelf. And here is next day CT scan.

Here is the chronological constructions showing the proximal part of the stents within the barracks and incoming through into the SMV. Here are sagittal reconstructions showing the same thing. Here is an ultrasound we obtained before she left showing you why do we patent shunts.

Here is a nine month follow-up ultrasound again showing the shunt wide to the patent and CT scan of nine months. So this is the pre stent placement CT, pre shunt CT, ascites and here is no ascites at nine months. 30 month of follow-up clinically heard ascites is resolved.

She offered diuretics, so preserving the function of her window transplant. She's able to have successful repair surgery and she was really pump. She say I lost of size in her clothing so I think she's gonna do

well, and I think it's good to be able to see these types of cases where we see the proximity of these vessels, I think its a sort of a new realm and a new tool in your [UNKNOWN] that you can utilize. Are there any questions?

>> [INAUDIBLE] >> Sure, it was atrium stent which is this blue and expendable covered stent, 7 by 22 atrium, and through which we place a self expanding smart stent. And the smart stent again is a little larger in diameter.

Just to sort of anchor it in either side. [BLANK_AUDIO] Thank you. >> We were debating between a six or a seven , we wanted to maintain [UNKNOWN] obviously the varices were large enough to accommodate

that. We just wanted to sort of mimic what we do with the tips as much really go to eight in regards to balloon size is gonna be because that's how we finish our tips so we put a ten in but we blow them up to eight, that seven was a reasonable size

here and it ended up working out fine. With the balloon expandable we can always make it larger if we wanted to. >> [INAUDIBLE] >> She was anti-coagulated afterwards we started her on Heprin.

This case was surprisingly easy. The number of pusses were small. The only bit of [UNKNOWN] was when we were doing some changes from the IVC to the Varix, and then that ultimately was covered with a covered stent.

She had no really bleeding symptomatology initially so we felt it was safe to have the coagulator. >> [INAUDIBLE] >> We use a standard tips that has [UNKNOWN] >> [INAUDIBLE] >> I mean we're always worried especially something like this.

And a key part here actually overall, which I didn't mention is, you really have the confidence of your hepatologist, your transplant surgeon, your [UNKNOWN] surgeon because some of the stuff we're doing here is a little off the reservation here but going through those soft tissues

initially as you saw, we did a [UNKNOWN] prior to allow us to get through the tract an it was fairly tight in the soft issues there so we felt that it was going to be fine with that seven millimeter stent. Also maintaining [UNKNOWN] the whole time and that's why especially

on both sides we used a 12 smart stent to anchor it in. Okay. >> All right, excellent case. Thank you. All right, next is [UNKNOWN]

So okay, so our first case was a 74 year old who he had a 60 millimeter enlarging, triple A and multiple comorbities and he was treated with a Zenith stent graft super renal fixation 30 millimeter main body and a 26 millimeter neck and he had immediate type one. And so removing a little bit from type two to type ones and everybody says with that type ones

you can leave them, you have to fix them, we'll talk a little bit about that in a second. We sort of go back and forth, we angioplasted it with a cardio balloon,

and it persisted despite the 32 millimeter balloon. >> So this is at the time of placement. >> This is at the time of placement, and so I wanted to show, our first thing is inter-procedurely if we have a type one endoleak we go

with the Palmaz, and that is what you guys are doing and seeing and with any type one and we use this was a 39 by 10 XL loaded on a XXL balloon, actually we had this one along 25 by 4 maxi. We ballooned it and there was still an endoleak, we figured okay anticoagulation it was slower, we let him go,

brought him back to check and it showed still the endoleak. And in him were able to just repeat the angioplasty using the 32 millimeter balloon here and wound up getting, using a 32 millimeter balloon, and then we did the three month follow

up CTA that showed good sealing and so it just to start with a quick case of normal type one endoleak, type one A Palmaz, and it goes fine. Some more fronts of the same guy who just-

>> When did you do that first CTA? When did you- >> We waited, it's interesting cuz I have a one that we did quicker. We can and we do it in 30 days, unless we're treating ourselves

too, and if the patient has complains or we're worried that we're leaving some type ones. We're seeing type ones inter-procedurely with the degree of anticoagulation, we do a lot of patients with hostile necks and so some times we'll bump that 30 day up depending

on the patient. >> Are you using that Aptus device, the endo stapler? >> We are. We are and we have no protocol for when I have some case that will show we have no protocol for when this guy happened to have a nine year follow up angiogram cuz he's having re-modelling

of the neck and it showed that, the aneurysm was stable. The type one endoleak was stable. The aneurysm was growing above it, but he's got despite enlargement of the neck, there is no endoleak around it.

[BLANK_AUDIO] Oops, sorry.

So this is a case you should not do and I like to actually get an input from everyone. [BLANK_AUDIO] How about I play this one? >> [INAUDIBLE] >> All right.

Right here. [BLANK_AUDIO] Can I ask you guys how do you deal with this? >> So is that one renal only? >> That's a renal, yeah. >> That's a renal.

>> It's not low, it's not here, it's not here, it's down here. >> And where's the other renal? Is it higher up? >> The other renal is up here. >> Oh well. [BLANK_AUDIO]

[INAUDIBLE] >> Exactly yeah. >> So I'm not always the biggest fan of snorkel. I think this will be a long snorkel. I'd obviously counsel the patient against the potential loss of that renal,

but I'm a big fan of laser fenestration. These grafts, so I would attempt that for this case. >> How do you do that? >> Just dumb luck normally. I'm kidding. So obviously studying the CT a lot,

deploy the graft. Generally it's either the Cook or the Gore that works well and then Morph catheter with a 0.9 Spectranetics laser and then probe with an 014 wire and then complete your stent case. What's nice about the location of this renal,

there maybe a stenosis at the origin which will make it challenging but the aorta on that side is not aneurysmal. So again if you make an errant hole you probably won't get an endoleak. But I really like that technique. >> Yeah, it's not as aneurysmal but,

this diameter is definitely bigger than here or here. It's somewhat aneurysmal. It's not the widestest part of the aorta, though. We do something similar with this one so I'm just gonna quickly go into what we do is,

instead of trying to find it from the lumen with a curved sheath because it depends on the curve of the sheath. I don't think we have an ideal deflactable sheath yet that's gonna put, and you don't know it's gonna, orienting the origin of the renal artery from the lumen after it's deployed is very difficult.

And you may never have an access to it. So what we prefer to do is get inside that renal artery from the contralateral gate, put our sheath in, deploy the graft and then have a buddy wire in the renal artery and when we have a buddy wire

we pull the sheath back, we put an Outbacker or a Pioneer, we poke into the graft. And then we snare that wire. After we snare it kind of we just balloon the lumen. I did this with Dore.

Gore actually it slits. I would not do it with the Gore. >> Really? >> It does slit up because the first case that we did, the easiest one it just opens up when you balloon.

It just opens up. It's the weakest graft material but you get a leak around it which there's no way you can close it. But Medtronic and Cook are good materials they won't leak. It's just very hard to dilate them. >> I was under the impression that Endologix would be the one to

avoid doing this. >> I never tried Endologix but with the Cook and Medtronic you get a great seal. It's just that I spend an hour usually dilating that track so it's like, and then once you do that you get stent etc.

You deploy that. >> Is that an iCAST? >>That's an iCAST. Yeah. And this is our final kind of picture on that one. This patient had a two year follow up,

still patent, in this one. >>How do you deal with the [INAUDIBLE] >> Oh, Gore fenestration? Yeah, we actually followed it up, I think that patient I did at UVA that was 2007 and-

>> He's not alive anymore. >> Not alive anymore? >> [INAUDIBLE] >> [LAUGH] I think I think my surgeon was planning on converting that to open.

That patient was initially treated at an outside institution and his renal artery was coming right at the origin of the aneurysm and someone just deployed the graft, they put a Palmaz on it, they put a stent in it. It was already too complicated.

So I think he ended up having an open surgery eventually. Cause I can't think of a way endovascularly to deal with that. And this the followup CT showing that kind of stent is patent.

you guys, and the audience and how do you size these cases. That seems to be probably the biggest issues, to avoid endoleaks. We all size them, we think we did everything right,

and we still ended up with endoleaks. So this is a story CAD WD COPD five and eight, so these are the sizes, so let me tell you what they are. So 123.9 and here 122.9 so basically 23 just below the renal then it goes all the way to 29 over 50 millimeters.

Have you seen this case before? >> Yes, I'm sure. I copied all of your cases. Seems like every case looks like this, so I would like to ask you guys

Andy what size would you choose? So first, what device would you choose or does it matter? And second what size would you choose? You have. It goes from 23 to 29 over 15 millimeters. >> So, it's a short reverse conical neck,

and I believe in super renal fixation reaching up to normally aorta. So I also I'm more comfortable with deploying an endograph such as the endonet/g rather than the goer which even though it now is reconstrainable it's still a little bit less easy for me to accurately place it then for instance just bringing down a super

renal device like the endurant. And the concern is over-sizing the top versus under-sizing the bottom side, I am splitting the difference and I am kind of basically sizing based upon the average which is at second measurement I guess which is 25. >> So 25, so basically we put a 28 in here.

Okay. >> That's only by choice. I don't think the 23 was this smallest measurement I don't think 28 is in most cases too much over-sizing. >> Let me give you another measurement here, so this 23 just below

29 and there's 8 millimeter difference between the two renals. Would that change your renal approach? Or do the same you think? >> We're still the same diameter. >> Okay. But it would do anything for the renal,

snocal fancilation or something or this is enough for you to just [INAUDIBLE]? >> No, is this the same aneurysm or is this- >> It's the same aneurysm, yeah >> Here you're talking about is much more impressive interms

of difference in sizes, so you might need to- >> Yeah, because here. Here is 23 and here is 29 over 15 millimeters, and that's [CROSS_TALK]

>> It's getting a little short, so we might have to protect that left renal and extend it above. >> Okay. What do you guys think?

>> I don't think there's a neck in there. I would [INAUDIBLE] this one if the illiac access is kind of favorable if there's no access problem. If there's no access, I would consider planting the kind of chimney or biograph.

Whatever you think and I would just go from the right renal down. >> So, [CROSSTALK] >> You gonna have a leak in this, and it's not gonna be- if I have to choose a graph

I would probably consider silt 25, because one problem with the chronicle nexus, you choose over dialated. Most cystograph kind of info at the top, and the short is getting bigger then you start having that-

>> And have you seen that in falling, I mean I don't know, I mean you always worry about this in folding issue, and I think without classified neck,

and if you go for the larger size and size to it, it seems to having less of lesser of issue especially with the super in-fixation of this leak because of in folding. I know it's theoretical and we've seen it with

earlier generation, I'm not sure if we're seeing it that often, I think I've been more liberal with over sizing them before and it's been all right. >> In this case whatever size you use if you end up being below that left renal and have no issues I will be very impressed. Yeah.

>> All right, Shawn what do you think? >> I agree with what Dylan said. If you had access to [UNKNOWN] I would consider that. Otherwise I'd probably use something like an endurant or cook and land at the right renal. And I may be different than others,

I bet you can get away with a bare metal stent for the left renal. >> Yeah. >> You may not even need a [INAUDIBLE] >> Exactly. >> And that simplifies things and- >> So basically you use it like a

chimney or a fenestration. >> Yeah. >> All right. Show of hands who would do an endurant or a super [UNKNOWN] fixation with over sizing without a chimney or a fenestration? Who would just go for this?

One, two, three, four Who would go with a chimney or fenestration? The three of you guys. >> If you were gonna do that then probably this is a good case for an [INAUDIBLE]

>> Yes to do that, to plan for it. >>[INAUDIBLE] >> Yes. >> [INAUDIBLE] >> Yes. >> [INAUDIBLE] >> So let's see to know your real aggressive [UNKNOWN] The issue with when you go without super renal like with this conical sometimes it doesn't exactly sit there and if there's any.

If you lose anything here, if it's not exactly at the renal your technique seems to be, you are aggressive in the renal, but if you lose any access to that left renal then you are gonna have a leak.

>> [INAUDIBLE] >> >> End illiacs. >> Something like this to reverse [INAUDIBLE] >> Yeah. That comment was for iliacs. In the aorta you have to seal the top.

That's kinda more important than anything. >> We do balloon over the renals as well. >> So I just showed this case to a lot of other interventionlists, and I can tell you and surgeons and I just split down the medal. Who would just go with the snorkel and fenestration, who would just

go for it, and I thought to just do a snorkel. I didn't think we had a good enough neck. I thought we're gonna have to oversize a lot to get it and I think that that would be a reasonable thing. So basically we've come from the arm,

kind of laid the left renal and went up and used a 32, the reason for that was to make sure that we over size enough to limit the gutter leak, and that's something to keep in mind is you have to over size to eliminate the gutter leak, maybe you over size too much here,

because this margin was 24, and we put in a Viabahn here. So what do you guys think of this, are you happy with it or not really? >> Not really. >> I am worried about Viabahns,

in certain angulations, I would probably reline that and I'm a little concerned about the size of the graph. >> It's too big? >> Maybe. >> Yeah it's too big. Think of it this way, that Viabahn or whatever stent you're gonna

go with is already narrowing the lumen. So I don't understand some people recommend this oversizing a lot when you're doing snorkeling etc. I never do that. I never had a gutter leak. >>Oh, come on you never had a gutter leak? >>

Never had a gutter leak. We had done about two, five cases- >> I have them all the time. >> Not a single gutter leak. I think people do kind of have a different way of thinking in this and it doesn't have that sort of tool and then plus the other one.

Now you have, there's less than three aluminum there, diameter wise, I think you would have more. >> I agree. I think 32 is too aggressive, and going by the measurements that is recommended, to go oversize to avoid the renal leak.

One thing that we should do here is to support it with a bare metal stent basically, ballooning spanel bare metal stent, which we didn't do especially if you go against the metal cage here, and that's where the compression happens in this spot. They should always reinforce it.

We didn't in this case. I don't know why but that was the case and we just ballooned it and it looked fine. >> What do you reinforce with? >> Balloon expandable. And then cover this stent there.

>> I'd like it with just self-expanding. >> Self-expanding. But anyways, no surprise. As was mentioned here, patient came with acute flank pain, rising corathnin that limb is down,

it was compressed by this, so had to go back in, clean it, the angio jets, pulse spray, still getting clear well, ended up having, and use different [INAUDIBLE] balloon.

Still didn't look that good, we had to actually drip it, and then hold back and reinforce it with a balloon expandable stent and it looked better, so I think the word of caution here is Viabahns are not good enough if you go against the cage of the super renal fixations, is always good to reinforce it with a balloon

expandable stent and be careful with over sizing. I think with this we joined all the group that says to oversize a lot to the many the gutter leak. I'm just playing with you [UNKNOWN] Now we are not oversizing as much to avoid that gutter leak because of the decompression of the other vessels. All right. >>

Did you get that kidney back? >> Yes. Patient did extremely well and. >> How long was the kidney dead? >> 18 hours. I think we established some flow when I drifted over

his fluid is okay but it was not that great and the patient did okay, much better than I thought and grafting is stable and we end up getting it back. So we'll learn from this,

I still think that the right choice was to take it up rather than take a risk about lining it below the renals, but something just to show that, you're gonna double with these, you're gonna lose some vessels, the patency

of these, there's a lot of studies and with one snorkel patency is about 95% but the more snorkels you have the lower the patency goes. So with one, with the single snorkel I think, I don't want to tell anybody not to do this I think it's a good thing to do but you

just have to reinforce the stents is number one any other metal with the self expandable and the expandable, and number two to be careful with over sizing. I mean under sizing is also an issue, but also in oversize,

I didn't oversize it that much. >> One comment. For long snorkels or polygraphs, whatever you call it ciliac SMA , 10 centimeter, I like wire band if I feel like I can't put a bear,

balloon expandable stent at the turn at where they would think to reinforce it, but for really short ones like this I don't think I would have used the five centimeter length stent here, is a very short distance like an I cast 27 or would have done the job and it would have kind of potentially.

>> Yeah, I'll admit it. I mean if I do this again now I just use a night cast display by Atrium balloon expandable I think it does better than that. All right it's 2:31 so thanks a lot for being here and I hope you learned something from it. Thanks a lot.

>> Thank you.

So this is another case and it's sorta goes to, I think what Adam was talking about earlier. You think you have one type of leak and end up with a whole bunch

of different kinds of problems here. This is an 87 year old guy not exactly the healthiest person in the world. Actually had the old trivascular device placed and I don't know if anybody remembers there's that device but not the one that they currently sell but the old trivascular device placed.

And then routine follow up for CTA shows basically presumed new type 1a endoleak with enlarging aneurysmal sac. Also complains of bilateral lower extremity claudication, left greater than right. So, I don't know if you guys remember,

one of the problems with that device is that the limbs were unsupported. And that will become an issue. So this is the type 1a leak at the top, pretty obvious there. And you can see here,

because of the type 1a leak, the sac is pressurized. And what it's caused is one of the limbs to collapse, because the leak's coming around the limb here. So it's a 6 centimeter endograft here. So for this

what we decided to do is just to put a cuff and we didn't have, again as we talked about, not a tonne of space, but we thought we had enough space to place the cuff without really boxing the renals here. So this is our AneuRx cuff which I don't even know if they make

anymore, this is a while ago. So this is an old AneuRx cuff again with the trivascular device, one of their things was that they could treat small necks that was one of their selling points. So again, obviously the guy didn't have a huge knack, but we were

able to get in a 20 millimeter cuff that fitted in and we thought we had it decently placed, we're ballooning it open and you can see some of it's actually coming up over the renal. [BLANK_AUDIO] And so what we decided to do was actually again sort

of the encroachment technique. We use a sauce to come in up over the graft, sort of pull the graft down a little bit and put just a Palmaz balloon. Just a balloon expandable stent there to get that to open. So now on to this next problem.

We punctured the other groin and there's a 50 millimeter gradient, so this is actually not an endoleak problem. So we just put a soft expanding stent inside there to prop open the limb. So we're like, okay this is just great, we're ready to go, let's

start to get everything out, but we do our run and what we see is a new Type 1B leak. We inject the right sheath and there's a Type 1B leak now coming up the other side. Not exactly the greatest picture here,

but it's sort of coming up around the edges of the old limb. So here, I think this shows a better, the angiogram showing the type one leak here. So this can also become another tricky problem.

So what we try to do is well maybe it's just that the limb is not supported, maybe if we put a big self expanding covered stent in there maybe that will push it open. That didn't really work those. So [LAUGH]

we were trying to skirt some steps here, probably what really needed to be done but we were like, we'll try it, didn't really work. So now we're kind of stuck,

so what we decided to do was actually quell off the hypogastric and extend it down. We put a 13 by 50 viabon/g which was deployed but had significant infolding and again part of it, the reason we chose the sizes is because we have this sort of size discrepancy between the end of

the endograft where we're putting the size of the external. So, and we put this endograft, the Viabahn in significant infolding, and so now we kind of stuck it, do you sit there and try to iron it out with a balloon that didn't really work so,

we ballooned it we still have residue type 1B after ironing it out. So we just have to put in the A just to extend a little bit further into the right limb and then that sort of sealed it up. >> Then once you cover the hypo I just take all the way down-

>> Yeah, exactly. Yeah so. And let's seal that. So, put that leaded well discharge about 48 hours returned three months. For follow up CTA, and actually looked pretty good.

So, there's no type 1A, this is actually a little bit smaller now actually, and did great >> That's a great case because the trivascular type 1,

endoleaks are almost impossible to treat. You can't treat them with the Palmaz. >> So the old ones you could, the new ones you can't? >> Yeah

>> I don't know, anyone putting in a new trivascular devices? Yeah, so we've had one case, you know it will never happens, but we've had one case of a type Type 1A and we don't know how to fix it, so we've actually set back. We conveyor to get converted,

so have you guys seen. >> Trying to fix it. >> Yeah. >> They claim the type ones but when they happen they are not fixable. >> You guys are putting in that healthy endograft radiant, what's

that That thing, that two double-barrel stents that, Nellix. >> Nellix. >> Yeah. >> The Nellix is great. It's not an endograft.

It's. >> The endobag and whatever. >> Endobag, endofill because if it works like they think it's going to work, it's going to eliminate and endoleak because you're filling the entire set with a palmer. >> Yeah.

>> But we've put in a few years. >>Yeah. Anyone here I guess outside the US, but anyone putting in the analytics device for foot place? No.

Okay. Cool >> It's difficult. It's a process. I don't know if it will get better but Yeah, Cool.

All right, So that's actually my last case, so anyone have any questions or concerns? Nope? All right, sounds good. >> Thank you guys for showing up,

This is kind of a cute case, this is a 84-year old guy. Previous AFX, that's not entirely true. It's what the powerglider or whatever at that point, but anyway it's Endologix main body bifurcated single component device. Like Parag showed

during his iliac snorkel case, he had that done for an elective ER for an aneurysm. One week, and I don't make things up, one week prior to this, he saw his surgeon at an outside hospital, who did his endograft and the surgeon said, you are ten years out from your endograft surgery. You no longer need to be followed.

One week later, he showed up to that same outside hospital, acute onset severe abdominal pain and a CT showing this massive endoleak. He came to us, it was on a Saturday afternoon, about 3 or 4 in the afternoon. So here's his endoleak kinda here. His aneurysm was now 5, it previously

had been significantly smaller. So all this contrast obviously outside of his endograft. Endograft comes pretty close to the renals. There's a little bit of room there that I'll show you a little bit later. So now what we have here is all this contrast outside. The massive contrast,

abdominal pain, you put all this together and this has to be some sort of a significant leak. It looks as though there was a good seal proximally and distally, so this is obviously some degeneration. This is not a brisk type II endoleak or something, so don't let anybody try and talk you out of the fact that this is anything other than an extremely significant finding.

So a little pre-close image here, here's our catheter angiogram. Again, showing just this incredibly massive leak filling his sac. So Endologix graft, any concerns from the panelists in terms of what graft we could use, should use?

Are there things we need to watch out for when working in this setting trying to regraft this? >> Well as mentioned earlier Cyrus, that Endologix is an endoskeleton device, so if the graft is on the outside and these stent segments are on the inside. So this is in place ten years ago, but when you're cannulating this, you need to be sure you're not going through those stent

entrances to see if it's gonna create an issue for you. >> Yeah. You wanna weave your way, or braid your way through the graft. So obviously, get a wire up through and then just a small balloon, an 8 mm balloon. Just inflate it gently, and then just telescope that up over your wire through the whole graft, making sure that you're actually through the lumen of the graft.

And not braided as Parag said, through the inner skeleton of the endograft. >> The location of the endoleak is expected for top three endoleaks because of the process. >> It is, it's right there. >> It is at the bottom, where

the bottom end of the aortic pump, is where the leak is going on. >> Yeah, exactly right, and I'm not bad mouthing this graft, it's an excellent graft and we use it actually. It's not our primary graft, but it's not infrequently that we use it, but

this is not the first one that's been seen or reported. Rob, have you seen delayed complications? >> Yeah. Well, we were part of the Ventana trial when they released the Fenestrated Graft, and we had a lot of problems with them, which required re-intervention. And getting catheters through this graft is a nightmare because it just goes every which way and not the

right way, and it's not fun trying to get catheters through the loom to the graft because you'll keep going outside. >> Yeah, agreed. I may not have just shown representative images of it, it didn't go that quickly. But the point is making

sure that you have a balloon that's inflated, that you're sure that you're through. Yeah, I think in terms of choice of the graft, I think no matter what you put in, in my mind, you want to put in a graft that is completely encapsulated.

Otherwise you just have to have long sheaths because you have to make sure the sheath is all the way past where you want the graft to ultimately end up. So we chose to realign this with a Medtronic Endologix graft, which we did here. Here's our completion result here, we put in an Endologix. Actually once we knew we were through and were certain that

we were through, everything went fine. We actually gained a little bit of neck here as well. But to your post-follow up here, compared to his initial presentation outside hospital CT. Again noncontrast given his renal issues, it shows really nice sac remodeling following this repair.

So just switching gears. This is a case of a patient with congenital problems leading to diffuse hepatic fibrosis and she had undergone a TIPS attempt at another hospital, which had failed. She was transferred emergency to our center, had her TIPS done there,

and had been doing well from the standpoint of freedom from bleeding, just backing up to original TIPS. She had an initial gradient of 26 and the post tip gradient was six and that was eight millimeter dilation of a ten millimeter viotol/g. So she did well, and then gradually what happened each time she

would come back to clinic her encephalopathy just kinda kept getting worse, and worse, and worse, her hepatology was very concerned, she was kinda maxed out on lactose/g xifaxan was added to that regimen, really made no real help for her.

She actually had to take a leave of absence from college and she would come into the clinic and her mother would say, she's just sleeping all day. So obviously she has now developed later expansional TIPS and has been tipped over from the standpoint of overshanting she's now clearly

now overshanted. So her labs were [UNKNOWN] Still down around 11, ammonia is up a little. So our plan was this, we've actually had a number of patients where

if they have a large gastrinal shant and lots of gastric varices with a lot of shanting through that gastinal shant will actually be [UNKNOWN] And this is something Will Saad/g University of Michigan has talked about, is a means by which you can augment portal flow, and thereby help with [UNKNOWN] Without having to do a TIPS

reduction cuz TIPS reduction is, although not very difficult to do, it's sometimes very difficult to work that fairly fine balance between overshanting and undershanting, especially in a bleeding patient. So in a patient who is cytis/g if you reduce the TIPS and overdid

it, the cytis comes back, it's not the end of the world. It's different if you had a patient who nearly bled to death then you overdo it with the TIPS reduction. So our plan was to evaluate her varices, via her left renal vein and if she at this point you're out harbored,

lots of shants a big gastrinal shant, we would do a BRTO with this diversion plan. So if that didn't work we were gonna do a TIPS reduction and this is a partial schematic this was from tailored just appeared in literature techniques in the last month or so very nice article.

So this is a partial list of some of the means by which you can do a tips reduction. You can constrain a stent graft with sucher. You can deploy an eye cast stent partly, and then pull back not dialect the middle and then flair the upper end so you've also created sort of a dumbbell shaped stent.

You can take a flairs stent, bird flair which at the flair dent is actually 12 millimeter in diameter so you can very simply use that as the means by which you tempered it to an 8 millimeter outflow. So the distoland is gonna 8 millimeter and the flair Dan will oppose

to your 10 millimeter covered stent that you have in the original TIPS. And then there is the technique that Dan see it describe this parallel technique where you have a bear metal stent next to a second via tour of slightly shorter via tour that you have interleaved in the original via tour and the extrinsic compression on the outflow

of that bear metal stent, effectively narrows the tips. And then if you still have too low of a port systematic gradient, you still have too much shunting, you can actually take a bigger balloon and rapture this up another millimeter and then recheck

your flows and your gradients. So we started out as the original of her gradient the time of TIPS was six. She's had late expansion of her stent so the gradient is now one. We actually then started looking around to see what the extent of the gastric pharasis/g were for the RTO,

not much coming off the left gastric vein, fairly unremarkable. We nevertheless went up the left renal vein and looked around again. Just very, very underwhelming shanting. So we thought the BRTO plan was probably not gonna do her any

benefit. Just some more venography, we actually did it with a balloon occlusion just to make sure we weren't missing anything, even with the balloon occluded venography through the gastrinal shant there just wasn't

a lot to see. So what we did is then went to the plan b which is the TIPS revision and for this you need a 12 French sheath and you need to get that 12 French sheath all the way down into your main portal vein. Then you're going to over two wires,

an O35 wire and an O18 wire, or an 014. You're gonna back off your sheath so that the TP is now in the right atrium. You're gonna then over your 035 wire, you're going to deploy a second slightly shorter, usually,

typically one centimeter shorter, the original one was a sevens millimeters covered segment so this is a six, and then parallel to that, you're going to deploy this happens to be a genesis but any similar balloon expandable stent. So you align, deploy your endograft,

and then if there has never been an issue with not being able to get a low profile, bare metal stent, [UNKNOWN] On a low profile balloon. It's really not an issue. Some people

talk about putting it down sort of more at the sea of your curves, of your TIPS, but then that can be difficult if you need to get back in there with the balloon and widen that. If you've gone too much or if you still have too much flow through your TIPS and you wanna make that a bigger diameter.

And then this is what it looks like. It's kinda underwhelming to look at it, but as we all know flow is proportional to the full power of the radius so even taking down the outflow of your TIPS by a couple of your millimeters can have profound effects on the flow.

So you check the gradient at this point, if the gradient is too low, you have the ability to go back, ratchet up the stent, I'd recommend you only go one millimeter at a time, and then you can

recheck your gradient and your flow. And this is what it looks like afterwards. So, she had had a poor systemic gradient of one, we took her up to ten, her original TIPS was six, so we kinda thought, well, let's

just make sure she is in that sweet spot so below 12 higher than six. So we're pretty happy with the ten millimeter gradient. She had an absolutely remarkable transformational change, I think of all the TIPS reductions I've ever done for a patient,

I've never seen anybody bounce back, she was like a normal person going to the gym, exercising, she was a little bit on maintenance [UNKNOWN] She was no longer on [UNKNOWN] Her liver function was great, no

bleeding, and it was interesting. She was a very engaging person, she had two pen medical students who were doing some kind of reality show with her, following very odd.

So I went out to see her once in the waiting area before coming back in the clinic room and there is this TV crew and these two students, they're interviewing her, and it was kind of very fun. Here she is a year later, and again these are just series of views

through the TIPS and again this is of all the shant reduction techniques and I've tried them all. I found this one to be most consistent and easiest to do, the most straightforward of the available techniques for a shant reduction and it gives you the ability to titrate which is very nice.

Tim are you leaving us for Hollywood next, or is that, you never know. She was like this star patient, we're doing some kind of show about her. >>

I'll tell you, we did one a couple of months ago and I'll tell you how not to do one, so Tim and I were co fellow together. So old stent school stuff and so one of the ways you can do it is to partially deploy self expanding stent and put a palmers around it between the sheath and the stent and then you deploy, so the

palmers is on the outside of the stent, and then you can dilate as you wish. It's pretty cleaver when that works. So we thought we try that with a via-tour. So this was a patient that had portal hypertension and needed and afrectomy but the cirrhotic so we had to TIPS him

before the nephrectomy, and then the nephrectomy went well Susan's cephalopathic cuz we didn't know that well they wanted us to narrow the TIPS and we narrowed it alright. And then so what happened is we tried that trick, we put the palmaza outside viatour, and then I guess we forgot that when

you pull the string it's actually on the outside of the viatour so it cut the palmers/g and pulled everything back to the origin hepatic vein, jumbled everything up into a ball, and occluded the TIPS. It's good we narrowed it 100%. We didn't really needs the TIPS,

we were trying to be even more cleaver than necessary, but don't do that with that one because it totally cut the parmers and everything pulled back and it was just like a jumbled ball at that the hepatic vein, and of the tips and it occluded pretty fast. And sephalopathy/g went away and he was fine but it was a good case. >> The problem I found with the self expanding stents with that external,

I find that you are watching and it deploys and it just opens all the way up. Completely expands to the middle stent and then you now put a second stent and another para-mental stent. But if you keep doing that,

keep repeating it eventually it's like layers of a tree you will get it narrow. >> It's pretty clever. >> [INAUDIBLE] >> The actual stent was a 5 by I8 genesis, or 5 by 22 on an O18 over the wire and then the viatour is

the same, but it has to be through a 12 French sheath. So the typical 10 French sheath that you would put it through is not gonna be enough for you to have your body wires. So you have a 12 French sheath down in the main portal vein. Put down your two wire, you 018 wire and your 035 wire back it off

deploy via tour come down along side the outflow put in your little expandable stent. >> [INAUDIBLE] >> No problem, no problem you can sneak it right past.

And this is sort of a picture of a hostile neck and in this one we did not, but you have the angulation here of the infrarenal aorta greater than 60 degrees, you have a conical

neck, his neck was about 24, 25 millimeters so it's not greater than 28 but it was still at the time of treatment, it was a difficult aneurysm and we treated him with a 28 millimeter and during stent graft device and there was a type one.

And if you look, this was a hard placement, it didn't wind up being a perfect placement cuz this is the higher renal and we're pretty far below it and as the immediate type one. And so went on to put in a cuff here in the procedure, we put in a

30 millimeter cuff and with these cuffs, this was a 30 by 28 so you're only getting in an extra couple of millimeters but we're just sort of trying to inch it up. And there was still a small endoleak there following this and then we finished the procedure. But immediately

post op we had abdominal pain, worst thing abdominal pain and so in the hospital we got a CT and there's a pretty decent endoleak the anticoagulation at this point has stopped, you really should have a seal. It's not frequent that we're getting CTAs within that 30

day period but we would imagine, that post procedural endoleak that would have resolved of the anticoagulation you see the gas in the aorta and this is showing the endoleak here. >> So what did you think that was a type one. >> We thought it was a type one,

he had a type one, even though you don't see it coming down. He had a type one, post procedurally that didn't resolve and because we didn't love with that neck, the placement of the graft, so we brought him back

in and figured we need to do an angiogram to see if he has a type one. If he didn't have pain he just had that then we would have left him. You do have some of these patients complain of abdominal pain after stent graft replacement, but not many we see the white count bump but there's not such an inflammatory reaction to the stent

grafts that we see a tremendous amount of patients with that pain. So we brought him back in and we said okay, we failed with the cuff so let's try another cuff. What fails once maybe won't fail twice which is usually isn't the case but this time it did work and we extended it with a second

cuff, this time we were getting higher and with a little bit normal small aorta. We used a 28 millimeter cuff and then ballooned it with a 32 millimeter coda balloon and got a nice seal following that. And so that would have been a good case for anchors probably just because the angulation of the neck and

is anybody out there using, have an experience with the Aptus anchors? And they're great and we're using them sometimes more to fix type ones, sometimes at the time of endograft placement and it's an anchoring system, it's for the abdominal aorta, it's 16Fr

diameter device and it's in an angled sheath that comes in two different lengths, 22 millimeter and 26 millimeter angulation of the neck and you use anywhere between four and we've used up to nine. It comes with ten anchors in the kit,

there are about three millimeters in diameter by four and a half millimeters long and the goal of those is to penetrate the aortic wall by about half a millimeter to one millimeter.

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