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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
AAA Rupture, Common Iliac Occlusion, AUI Thrombosis (Post-op) | rEVAR (Aort-Uni-Iliac), Fem-Fem Bypass, Balloon Angioplasty | 81 | Female
AAA Rupture, Common Iliac Occlusion, AUI Thrombosis (Post-op) | rEVAR (Aort-Uni-Iliac), Fem-Fem Bypass, Balloon Angioplasty | 81 | Female
Infrarenal AAA | EVAR | 85 | Female
Infrarenal AAA | EVAR | 85 | Female
Infrarenal AAA, Stent Occlusion (Post-op)  | EVAR| 76 | Male
Infrarenal AAA, Stent Occlusion (Post-op) | EVAR| 76 | Male
2016accessballoonbarebasicallyBoston ScientificchimneyconicalexpandablefixationGORE MedicalguysleakmeasurementMedtronicmetaloversizeoversizingpatencypatientrenalSIRsizesizingstentsuperviabahn
Suprarenal AAA Rupture (Type 3), Periscope Occlusion (Post-op)|EVAR (Periscope Graft), Recanalization, Stenting|59|Female
Suprarenal AAA Rupture (Type 3), Periscope Occlusion (Post-op)|EVAR (Periscope Graft), Recanalization, Stenting|59|Female
2016aneurysmaortaarteriesarteryballooncarotidceliacchimneycollateralendograftEndologixGORE MedicalgraftgraftsiliacinferiorinfrarenalloopnarrowoutcomepatientrenalrenalsrupturerupturedsagittalsheathshelfSIRstent
Infrarenal AAA|EVAR (Chimney Graft)|79|Male
Infrarenal AAA|EVAR (Chimney Graft)|79|Male
2016advanceamplatzaneurysmangulatedanselaortaaorticarteriesarteryaxillaryballoonballoonsbarebranchbranchescathetercatheterschimneyclosureconduitcontrastdeploydeployeddeploymentdevicedevicesdistalendograftsendoleaksEndologixevarexpandablefavorablefenestratedfrenchGORE MedicalgraftgraftsiliacinflateinjectlumensneckorientationPatentpatientpatientsproximalrenalrupturessheathsheathsshortSIRstentstentstaperedtypicallyviabahnvisceralwirewires
Abdominal Aortic Dissection (AAA) | EVAR (Snorkel Tube Graft) | 77 | Male
Abdominal Aortic Dissection (AAA) | EVAR (Snorkel Tube Graft) | 77 | Male
2016abdominalanatomyaneurysmaortaaorticarteriesarteryballoonBoston ScientificbranchedchronicessentiallygentleGORE MedicalgraftiliacsMedtronicrenalrepairsegmentsheathsSIRslicesthoracictubevisceral
Aortic Dissection (AAA), Arch Stenosis (Intra-operative) | Bentall Procedure, EVAR | 46 | Male
Aortic Dissection (AAA), Arch Stenosis (Intra-operative) | Bentall Procedure, EVAR | 46 | Male
2016archbearcardiaccarotidceliaccomatosecontributingCook MedicaldissectiondistalgraftlumenpatientrenalSIRsurgeonsurgeonstrue
External Iliac AAA, Angulated Iliac Neck|EVAR (Contralateral Approach), Embolization|71|Male
External Iliac AAA, Angulated Iliac Neck|EVAR (Contralateral Approach), Embolization|71|Male
Juxtarenal, Infrarenal AAA|EVAR (Modified)|
Juxtarenal, Infrarenal AAA|EVAR (Modified)|
Common Iliac AAA, Stent Malalignment (Follow-up) | EVAR, Coil Embolization | 76 | Female
Common Iliac AAA, Stent Malalignment (Follow-up) | EVAR, Coil Embolization | 76 | Female
Abdominal Aortic Dissection (AAA) | EVAR (Snorkel Tube Graft) | 81 | Male
Abdominal Aortic Dissection (AAA) | EVAR (Snorkel Tube Graft) | 81 | Male
2016aneurysmangiographyarterybareboltonBolton MedicalceliacchosedistaldistallyendograftGORE MedicalgraftiliacMedtronicprettyproximalrenalSIRstentsurgicallythoracicviabahn
Abdominal Aortic Dissection (AAA), Renal Artery Occlusion | EVAR | 56 | Male
Abdominal Aortic Dissection (AAA), Renal Artery Occlusion | EVAR | 56 | Male
Type B Aortic Dissection (AAA) | EVAR, Small Bowel Resection | 42 | Male
Type B Aortic Dissection (AAA) | EVAR, Small Bowel Resection | 42 | Male

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.

The first case is and 81-year-old lady, COPD I believe she was an

homo too/g Hypertensive significant peripheral arterial disease, apparently she had a left leg angioplasty prior to presenting it to an outside hospital emergency room with a four day history of abdominal pain, peri umbilical pain and

nausea and vomiting she had hematemesis about four episodes, you can see where this case is going, aortic session. And this is the CT. Try to slow this down here.

[BLANK_AUDIO] So she was actually getting a little hypertensive, initially allergen oriented. Really fascinating case, of course this is a contained rapture.

On second glance, you can see these little bubbles here. So at our institution, this is another image in chrono, showing this area here, and again you can see another set of pictures here showing this area that's contained. Again these patients are generally pre-selected.

They make it to the ER and they're sitting there talking to you complaining of belly pain. They generally have a shot. One thing that I kinda blew through is she had a left common iliac artery occlusion. Again pertinent things to look at when you plan out these cases.

She had a right common iliac occlusion, but a patent left external access. So in these situations, maybe when I was younger, I would have been heroic and try to recanalize the right external and done a complete

bifurcative graft but of course we do this in conjunction with surgery so our plan was to do an AUI with fem fem. So initially in a lot of institutions, a lot other docs, especially the ER, they tend to freak out. But we try to think about it.

Now keys to rEVAR, now even though this is a contained rupture, I think it's pertinent to our discussion about ruptured EVAR. You should observe that the principles of hypertensive hemostasis. Do you guys know what that is? Sure.

And one of the things that really shocks me still is we don't have a lot of ruptures going through our ER, but one of the things that ER docs, and they're concerned by the patient but they love putting a central lines, hydrating the patients, considering suppressors

they call anesthesia they like intubating. Again I like to sit and talk to the patient and the family and explain to them the grave situation here. I tell them we're gonna put all the lines we can upstairs. So I don't waste a lot of time in the ER again, we are lucky that we have some product on the shelf.

That's not always been the issue. Sometimes we have to call in reps emergently. We have a coordinated response plan generally. Sometimes it depends on which IR is on call ,and which vascular surgeon is on call.

But in general, we have a coordinated plan, especially from eight to five in the daytime. In Europe I think a lot of the EVARS, selected EVARS are done awake. And these patients do great.

I strongly consider doing these cases awake. And then of course basics. Things like having occlusion balloon ready. I've only once gone to the ER, put in a sheath and put in an occlusion balloon in bedside, generally we have enough time to put this in

the IR suite. So we bring this patient to angiography, and as you'd expect, you can see this contained rupture off to the right here. And we chosen a Medtronic Endurant AUI device, again the patient had a occluded right common iliac artery so we

do wish not to waste a lot of time. And this is always an area of concern or debate when you talk about ruptured EVARs when do you heparinize? . What do you guys do? >> Do you heparinize first? >> Yeah.

Good point. Point. I don't heparinize until I have control or the team has control. But every rupture I've done I've ran into thrombus issues. >> Yeah, we've had cases where there was a rupture and didn't heparinize and end up with a bloated iliac.

So now we do a one reason we do the baby dose is it makes us feel better so you give 5,000 heparine not the full dose. I assume as we have the, we get we have the sheets and go back and forth on that one. This is what we do now.

What do you guys do? >> What we do is we ran heparinizing saline through the sheaths. It depends if the sheaths are occlusive or not. You gotta be kind of let's say, you gotta be more careful because it just makes it difficult.

But and then do you use a balloon? >> I generally don't >> Occlusion >> [CROSSTALK] Did you use aortal then, you can actually see activate the trough/g. Who uses a balloon immediately or just do you. >> In this case, he's only got one iliac to work with.

>> Yeah. Yeah .>> No it's, you can still. It depends again, if you don't see an active leak I agree you just get your device, deploy etc. But if you're just shooting at initial angiogram you see something

and your device is ready in five minutes or three minutes, two minutes you can lose a lot of blood. And it's much easier to get the balloon up there and then kind of occlude the aorta temporarily until you're ready with your device. You guys, all IRs you do trauma etc.

Depending on the extent of the bleed, 30 seconds of that sort of bleed may make the difference if the patient is gonna live or not. So we select the cases to balloon. We don't do it on everybody but its kind of a-

>> I think it's very reasonable. Normally in these cases, I have things ready to go. And the graft is going in almost instantaneously after we get access. I don't waste time doing pre-closing.

That's another area of saving time. >> One other comment. It's like this is interesting because it's occlusive on one side, but if it's bilaterally patent, you can get the balloon off from the other side, control it.

That's easier to use the balloon at that time. So you can get the main body from the other side. Deflate your balloon and deploy the graft immediately. Do you use AUI in patients with bilateral patency just to speed up things? >> I don't.

I generally go for bifurcated system. >> Bifurcated system. Okay. >> Rapture, now is everyone has been talking about it. It's been and most centers are getting more comfortable with doing ruptures and there's data about it now.

The main movement now is to use balloons more liberally, unless there's a bow/g which can be placed in the emergency room. I think more and more studies are showing people using balloon for temporary. You have be selective.

Somebody who's stable, whose pressure is in the 90s without any pressers, we'll let them be and let's just not put a balloons. But in a Frank/g extrav lower pressure may need to use the balloon, and then do under local.

That's been a huge deal. We've lost two patients over the last few years. On induction, they just basically pass because you disrupt their pressure more, and they're already hypertensive and it's just hard for them to catch up and they slam them with fluid. You go through this.

I think, leave them be, just local anesthesia and once you're, once you secure once you put that device in, now if they wanna intubate them afterwards you can and you can finish your case afterwards. I think using the needle/g more liberally,

it's gonna allow you to actually use the bifurcated graph which is better for the patient than doing fem fem. I think that's been our approach and getting a team and getting a plan together, have devices ready, is key for dealing with

these raptured cases >> [INAUDIBLE] >> So basically put it above the celiac inflate it immediately go with your main body. And once you have the main body in place you can just go of the balloon and that part.

Even if their is active extrap/g you are talking about few minutes of deploying main body cannulating the gate/g and going from there. And even if you have trouble cannulating the gate/g you can from the input with the balloon back up while you cannulate the gate. You can go with that or you can have an AUI ready and if it's two minutes and you haven't cannulated the gate/g just put an AUI in.

It becomes an extra cost, but if you think it's a reasonable aneurysm, not very torturous, most of us kinda cannulate the gate/g pretty quickly so I think it makes a lot of sense. >> [INAUDIBLE] make sure you wanna pool back the sheath [INAUDIBLE] >> I agree.

Yes that's definitely the case. And things can get rushed here and you can cause a lot of issues cuz you're in trouble. But having the balloon up, and you see the difference immediately

on the patient. And anesthesiologist, whoever is in the room, the ICU, they're just so happy cuz the patient now is very stable. And he's like, what did you guys do? And he's like, well I haven't started yet,

but the patient is doing better. So I think that gives you a time to just breath and get your stuff ready instead of just rushing through it. And we've seen these lacerations of the iliac, cuz you're rushing

through it if you don't have a balloon. So just get the sheath and get the balloon up and that'll give you some time to think. >> You guys- >> [INAUDIBLE] the rapture >> Yeah >>

not all raptures are the same, there is some impending rapture, I said they call it a rapture versus activate strip. I think in the worst case scenario patients presses, massive transfusion going.

I usually don't like to waste time, my approach would be just go, put the balloon up immediately, [INAUDIBLE] get to the wise/g on the other side immediately and just a unit, and then when I take the balloon I have the sheath I would put on an plaster on the iliac and let the surgeon

do the fem fem. I can do that under 10, 15 minutes for the whole thing. >> Oh, yeah. And some people advocate use of the Endologix graft for ruptures because you can relatively quickly get the bifurcated graft in and

maybe plug the hole. So some people think it may be better for ruptures. Do you guys cover renals? >> If we have to. >> We got a case we just recently, somebody with a small renals and rupture

and we can just try to do it [INAUDIBLE] >> We cover renals and then we're becoming a little more bold once the patient is stable sometimes we'll try snockle/g from the arm if they become stable. During the case.

In this case we kept her awake, I've actually gotten into arguments with anesthesiologists people that I respect and actually have done complex critical old patients, but they are shocked when we wanna do this awake.

I was talking to her during this case. I wanted to make sure she was still with us. I'm not sure I even used lidocaine. I'm kidding. >> [LAUGH] >> Actually in this case,

I don't think we had time to do it. We deployed the AUI, and here you can see the AUI actually landed here in the common iliac. I'm glad it landed here because if it landed up here,

I might be tempted to do something up here. But we had a very experienced vascular surgeon with us. We ballooned it. This is gentle. I'm not really trying to look for the hole or trying to push the

graft up against the hole. And this is our completion at this point. Really not a lot of good flow here. But we were hoping that things will improve. Maybe this was occlusive. She didn't have a lot of good runoff.

It's weird to see a good portogram on an aortogram. >> So you weren't aspirating the sheath? >> I was probably too. >> And it was of [CROSSTALK] >> [LAUGH] >> Yeah, it was occlusive. So, at this point we intubated the patient.

This is another picture just showing reconstitution of this common femoral just to show the surgeon that there was a target a fem fem. It wasn't well seen on the CT. So, he did the fem fem but he noticed there wasn't lot of back-bleeding so, we went back in and again as I mentioned,

most of our ruptured case I've run into, this is a bit more than I have seen usually, but this is all thrombus kind of sitting in that AUI. So what would you guys do here? >> Thrombectomy, progressive thrombectomy.

>> Like a surgical, he's already got the granule open. >> Yeah >> Some people don't like to do it through fresh stents. I don't think it's unreasonable on a graft,

but >> Could you just re-line? >> I kind of relined it. >> Yeah, so, I just went with what was simple and quick. I took a 14 by 120 stent and we went from the renals down and then ballooned it open.

Again, we were in a situation where she was critically ill we just wanted to get flow back to her fem fem and we ballooned this. This was just a simple self expandable bare metal stent and there we go just to get flow back. >> One thing to pay attention to actually, you guys got but to make sure

that it doesn't tooth paste. You cover the- >>Right. Right. >> The valve above and the valve below those thrombus areas. >> Yeah.

> If you're near, it's just gonna go down the leg then you'll have another issue to deal with. >>Yeah. And she's a lady that would have those kind kinda issues. But hopefully her [INAUDIBLE] were occluded.

So she had distal protection. [COUGH] So this is our completion pictures. Obviously her fem fem and this is months later and you can see that I thought there would be this huge size mismatch. We put it on a 14 mm self-expanding stent inside of a 23 mm AUI. There's a size mismatch in parts but it wasn't horrible and she's

widely patent. Again that area of that aortoduodenal fistula is less impressive certainly now. We talked to the family. We explained to her what we did and she was not so impressed. It wasn't a gratifying response from the patient.

>> Do you consider bridging that electively? >> Bridging? >> Meaning putting in a another reverse bell-bottom or something or other shorter AUI. Because now - >> Oh that area.

>> Yeah. >> Well that's a good point. You're talking about this area here? >> Yeah, right there. >> Where there's fabric here and there's a lot of flow. I wasn't gonna mess with her too much.

I figured she made it through a lot and I didn't get the best read on her. So post procedure course, she stayed five days after a ruptured EVAR. Again this patient self selected. She was relatively stable but she made it through it. We got GI general surgery consults for repair and I was shocked.

No one knew when they wanted the time this repair. They were just happy the aorta was fixed. This is months later. I think this is nine months later when GI was scoping her they said your graft must have migrated. You guys have to scan her and do something right away,

and I was like, I'm pretty sure that's where we want it to be. Let's get general surgery and everybody together and figure how to fix her. But she's actually done very well,

and she's recovered. I'm not even sure she knew what she had but she did very well. >> I think these fistulas go along the lines of mycotic aneurysm or infected aneurysm or infected [INAUDIBLE]. Now there is more push to use stent grafts with these and there's always talk about the stent graft as a temporizing measure.

But actually it's not the cases and I have studied showing that if you have a true mycotic aneurysm. You don't have fevers, you negative blood cultures and if you give them enough antibiotics, then this stent graft may be a final solution

without need for surgeries. The only ones that seem to need surgical intervention are the ones with neurofibril intervention, positive left cultures or an ongoing fistula or discarded. Something that is continuously so this would fall under that category that eventually should need

where her case, when she's older and all that stuff we managed to leave her alone. But we've done several cases of doing this initially and then later getting the surgical repair. But that's something that now there's more push to use stent grafts

primarily for mycotics as a final solution if there's no fistula present.

So I'll start with this quick case. This is an 85 year old with a 5.5 cm AAA, and if you look at the aneurysm sac itself,

it's not unusual, it's got a lot of mural thrombus, it's got a calcified wall, but the real issue down here is the >> [COUGH] >> I mean this

little old lady has little old illiacs that are 4 mm, 4.5 mm at best. So, I might >> [INAUDIBLE] >> They're measuring about four and a half.

So, since you spoke up, sir how would you approach this. So, what are the options? >> I'm assuming that's that stuff. I mean having these small illiacs, I mean most devices now are,

and even the low profile devices outside TriVascular you need around 6 mm illiacs in general, five and a half you can get by, but these are small illiacs. So, what are they measuring again?

>> Four and a half. >> Four and a half, so it's small. So, you know TriVascular is one of the devices that is 14 French. Which means you can get by with 5 mm or less. And so that would be a good option for this patient.

The other option would be to do a iliac conduit surgically, or endoconduit with a Viabahn. Anyone familiar with the endoconduit who does this? So basically just put a Viabahn and usually we try to go with an- that's how I do it.

Let's see what you guys do. I use a 10 mm which is significantly oversized, and just basically rapture the vessel. We kinda of see It's gonna see what the common femoral size is.

Commonly you may have to also the embolize internal iliac if you wanna get a good landing zone to the common but, if the common size is reasonable, you may not need to do that. But I don't know how you guys been doing the endoconduit. >> I wouldn't go up to ten in this one personally.

I'd robably use a seven or something, really dilate it. And then completely agree with you embolize one iliac, use that for the main body and the contralateral site for Gore, Medtronic. They'll actually go through four and a half millimeter. That's an option- >> Or the Endologix which is only a 9 French sheath in the contralateral size. Yes, that makes sense. So the endoconduit is an option, basically blasting

open the iliac. The issue there is that yes, you're gonna be stenting with a Viabahn probably all the way down to the inguinal ligament, and you'll probably be taking out the hypogastric in the process.

But that's the approach that was taken probably before the 14 French TriVasular was available. So it's nice to have this ultra low profile endograft. And if you're not familiar with the TriVascular, but basically the reason why they can achieve this low profiles is cause you take the stent scaffolding out of the main body.

And instead, the support is provided by the injectable polymer on the top ring and along the ribs of the proximal graft. It is the lowest profile and this is demonstrating the 14 French out diameter of the TriVascular compared to basically what's at-least an 18 French outer diameter for all the other devices. The company touts the rings for a number other reasons as well.

They say there's less outward force on the neck, which leads to less neck dilatation. They have got some data that shows they hav less type 1a endoleaks because of that. I don't wanna sound like I'm selling any particular endografts so

I will talk to you about the limitations of that proximal sealing ring. This is the one study I'll show which talks about the inflow stenosis that is introduced with this proximal ring. So this sealing is achieved at the cost of about a 60% inflow diameter stenosis which is hemodynamically significant.

Any way in this case it worked out really well. The patient with very small iliacs, the ones that I showed you, with the good repair

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 patients had a ruptured suprarenal aneurysm 59 year old female presented to emergency last June, seems like yesterday with abdominal pain and

hypertension lot of comorbidity. Here's what it looks like so its a thorac-abdominal aneurysm extends to the visceral arteries which you see here with sort of normal calibre infrarenal aorta, and this would look like on [UNKNOWN] imaging, see this is the celiac trunk comes of the inferior margin of

the aneurysm and this is just some axial cuts. So here's above it/g going through it. Here's your celiac trunk, here SMA, renals here so quite a narrow aorta below the aneurysm in fact 17 millimeters which is quite narrow.

So this was a ruptured type three thoracoabdominal aneurysm, again the options open surgery are very challenging and not fit for it. Celiac trunk and SMA were more or less inferior component the aneurysm and the real arteries as you saw off at normal caliber aorta.

And the inrarenal aorta is very narrow so not suitable off the shelf fenestrated grafts, so we have off the shelf [fenestrated grafts in Europe. Do have them here. >> No. >> And we hardly ever use them,

I think we've used them in about one patient and we also have off the shelf branch grafts which we do you use occasionally but obviously this patient was not suitable for branch graft because it no room for the [UNKNOWN] and renal branches and again this is a chimney graft case. So this is slightly similar to the previous case but single Nellix endograft in this

case because there is no room for two, three periscope grafts to the renal and the SMA. And we simply covered the celiac trunk. We're never going to get four periscopes. So here is the answer to your question about the occclusion balloon here is

the occlusion balloon here, sagittal imagining, These are wires and sheathes and the real artery , here's a sheath and the SMA. SMA renal sheath Viabahns from below and now advance in the Nellix graft into the aorta. So as I said before we support

the deployed stent grafts while we deploy the Nellix, these are sagittal images and here is blowing up the Nellix and the graft and contrast in the endobags this time so this isn't the completion angiogram which you see there. So a single Nellix endograft going through the aneurysm with three

renal periscopes. So good job great result. You would have thought but one day later develops problems in the ITU elevated lactate and their is no contrast going through the SMA periscope, and here it is in the aorta and use it in the SMA. And so just let SMA patients but you got an included periscope so

- >> What do you suppose was the Celiac situation, I missed that.>> Sorry >> Was the silliac discovered or >> Yes discovered the silliac.

>> You have to coil it >> Just covered it. >> When coming of the aneurysm Yes maybe should have called it. It wasn't really an issue. >> How was the rupture

>> Best practice we should have called it. >> At least you can push it I guess? >> Well feeding that we didn't call it to different because the endobag would have [UNKNOWN]. We do quite lot of iliac artery aneurysms put that in [INAUDIBLE] endografts into the external and the endobag occludes the internal iliac artery.

>> You used a single Nellix in this case, right. >> Yes, this is just the Nellix tube graft bridging the aneurysm. >> And those you can dialiate up to 10. And we've never done that we were on the trial, we were using some kissing fashion and traditional infrarenal. Can you post [UNKNOWN]

more than 10. >> No. >> No. >> If you don't have the Nellix, because its time to going to think of put the rest of us who see such a case if you don't have the You don't have the Nellix what other device would do. [CROSS-TALK].

>> I think with one of the iliac. I don't know what the proximal [UNKNOWN] with. So the infrarenal layer for the 17 so you need something like the 20, 22 and that was a tube graft. >> And always the proximal. It was slightly wider.

>> So you could have your tapered graft thoracic tape of graft potentially. >> Yeah. >> I got two grafts. >> That would have worked I think.>> Yeah. we don't have Nellix. We are not fancy like you guys.

>> Yeah sorry to show you two Nellix cases. It's like bigger than it is down there. >> Okay. >> Anyways, so I have to worry about the theater and put a balloon down and cleared it. >> How did he clear that?

>> Just ballooned it. >> Yeah. That's [UNKNOWN]. >> Ballooned it. Didn't suck any thrombus out, just ballooned it. >> You got to recannulate that from below. >> Yeah.

>> Wow. >> because that one of the issue that I see where the with chimneys and the outcome of being good but the problem when they go down and then they go down and then it's so hard to cannulate that's been documented and has been shown that the outcome has been worse within higher numbers of chimneys you know one is better

than two definitely better than three. Some talk about if you going to do more than two, then try to not to do them all in the same angle like do two down one up or two up one down instead of having all three go in same direction because the crowding and potential for occlusion. But again in the rupture setting,

this is a great result you just need to go with what you need to go. >> It wasn't really as for me their is not really enough room for the three, for the periscopes, yeah. And is got long distance to place a chimney from above read through

the aneurysm, >> It was really long. >> Yeah. >> At this point, that once you had that opening and did you, it looks like there was another,

is there another stent in there? Did you stent reinforce the periscope into the SMA then? >> Yeah, we put another bare sent in. >> Yeah. But it didn't really work. So patient had ITU stay for 13 days,

stroke, multiorgan failure and died. So It was a good try. >> It was an elegant solution both have. >> So the aorta's too narrow for three periscopes. And there was no obvious alternative option.

And maybe a sandwich graft but you still got the problem of the narrow aorta >> Yes >> Did you, when you, before you decided to cover this celiac, you checked that there's collateral from that. I mean, in this case, we probably don't have time but you check

for collateral from the GDA. >> Normally we do, we didn't in this This case but so because, it would really have affected what we did. A hybrid procedure would've been an option, but the patient was very sick.

>> This patient had unfortunately they die, I mean when they come with the rupture they're already behind the eight ball/g, and whatever you do, you may just do everything right and you get rid of the

all the leaks and all the vessels are open they may still not do well and then they get out of it, but if you get the choice between the SMA and the renals and that becomes an issue. You try to do all three of the above but sometimes, and I had a

case of a rupture and the renals were small, the patient's already at end stage of renal disease and there's no time just cover the renals I was like, there is no time, just cover the renals and [INAUDIBLE] the SMA [CROSSTALK] >> Because it's two carotid for three can you do one kidney and SMA instead of three,

like in retrospect the technical result look phenomenal to be honest with you just going through all that stuff is excellent, but just since with the outcome going back and dissecting and trying to see if you get this presented, this case what would you do differently?

Will just do one renal and SMA or- >> Yeah because of the carotid issues. >> Yes, its the problem here with the carotid issue. Right [UNKNOWN] >> [UNKNOWN] issue is the [UNKNOWN] Slower so it has to go down and up and them SMA- >> Its just the

room in the aorta for three, four grafts. >> But if SMA was pointing upwards. I'm just- >> Yes it might be help. You can see the SMA chimney was really quite compressed.

>> And then the endobag I have never used one of these devices. Can you explain a little about how you fill the endobag and is it liquid. >> It's a liquid that sets so I mean its injected through the - >> [INAUDIBLE] Pardon. >> Is there a probability in its [INAUDIBLE] >> No.

Well, the bag can [UNKNOWN] a little bit like a few millimeters but the polymer is contained the bag so it doesn't [INAUDIBLE] anywhere you shouldn't go. There are reports of the endobags breaking but really that's extremely rear >> Very rare. >> Yeah.

>> Bags are attached to the balloon expandable stent to pre-fill them with saline until you get the right volume and you get the [UNKNOWN] volume then you aspirate that and its the polyethylene glycol that sets literally in minutes. >> Yep. [UNKNOWN] >> Yes. [INAUDIBLE] >> Yeah. >> [INAUDIBLE]

>> That's one of the issues with these, you start to gauge exactly which angle you took and you do it and especially when you use of these like sandwich technique and you put a graft and several overlapping grafts and how this stent ends you just look at it end up doing going around a loop to get into the SMA and

that kind of makes you worry. It's so hard to once you have all devices and it just take your chances and do it and then it's never going to be perfect just goes down into the renal, takes a loop to go sometimes to the renal, so you kind of have to live with it. For these long chimneys it's an issue so

short ones would do much better.

So this 79 year old male, who is 65 millimeter abdominal aortic aneurysm which was discovered on routine imaging. Risk factors are as you see there, ischemic heart disease, smoker, hypertension.

This is what the aneurysm and is looks like. So as you can see its got to short very angulated proximal neck. These are selected axial slices through the celiac trunk, SMA, and the renal arteries which you can see come off the same level and here what happens to the aorta immediately blow the renal arteries and this is just a coronal view show in how angulated that neck is in the natural plane

and in the AP plane. So, the treatment options which run through our minds each time we look at these, sort of patient, are open surgery. He's significant comorbidity is not really fit for open surgery. As we said before, conventional EVAR , the neck is really too

short and angulated, its too short certainly too angulated for a fenestrated endograft. You send it off to cook, you will send that straight back to and the aorta is too narrow for branches so none of those options are useful. So we've been using chimneys for these sort of patient for sometime.

Now the chimneys extend the landing zone more proximally, and this is what we decided to do in this case. We've been using the Nellix device Some of you or all of you will be aware of. So I'm just going to show you few slides on the Nellix we will be using the Nellix and combination with chimneys on quite a lot of patients

there. So here's the Nellix device its two balloon expandable stainless steel stents, and each stand extends to the non-aneurysma aorta proximally into the iliac arteries distally, and then there's an endobag which surrounds each stent which you fill with polymer and this fills the lumen of the sac around the margins you see on the yellow arrow heads. Here's the device which you see on the bench,

before you put it in so you got to, yes. Two stent grafts 17 french outer delivery catheters with guard wire lumens and injection lumens and you attach the endografts to these connectors and inject through these once you've deployed the endografts. This is this schematic guide wires and stents

undeployed, bloat the balloons and the deploys the stents and then fill the space in the sacs with endobags. Here's a case, so catheters and wires up into the supraneal aorta, advance your stent grafts to your design deployment location, deploy the stents and then inject the polymer. So this is the procedure of that patient to general anesthesia.

Almost all the cases we do are percutaneous access, we use Perclose for these cases for this cases. For the chimneys there's an axillary artery cut down and then you puncture the axillary artery for each chimney that you want. If you do two chimneys you do, two separate punctures put three chimneys in use, three separate punctures. And we have long stem french Ansel sheaths and catherterise both renal arteries from above and put to exchange

Amplatz Superstiff Guide wires into both renal arteries and advance the sheaths into each renal artery and here's the situation at that point, he's got Ansel sheath in each renal artery and so we used Viabahn, so deploy Viabahn in each renal artery with a proximal extending above the renal artery origins and then,

Just stop shuttering of the distal and the endograft in the renal artery we put overlapping bare metallic stents just poke them out through the end of the Viabahns and then to protect the Viabahns deployment to the Nellix grafts inflate balloons inside the Viabahns, insert the Nellix grafts into the aorta and with the renal balloons inflated the inflate Nellix endografts.

And then do the completion so, this is what you desire to see and this is what occurred in that procedure so chimney grafts patent and the Nellix endografts deployed we tend to use little bit of contrast you often see contrast in the endobags but not in this particular patient.

So this is the hospital journey, patient was admitted on the 4th of July last year, had his EVAR the next day. Went to the ITU one night which is not routine, and the patient was discharged three days post procedure.

[BLANK_AUDIO] And this is the CTA and our standard follow up protocol which we discussed is a single phase arterial scan pre-discharged and at 3, 6, 12 and 24 months etc. And this is a problem and patients get followed up with both CTA and bi color Doppler ultrasound,

those intervals you see before you, and this is the patient's 12 months later. No endoleaks, patent endografts and stable sac diameter. And this is what it looks like, so little bit of contrast in the angiogram, which is more apparent on the CT, than it is thoracoscopically,

and here you have the two Nellix devices floating in the endobags it is no real cavity. In the sac, you almost never see type two endoleaks in these patients. You do see them occasionally. And these are the chimney grafts. So with the words of the chimney EVAR certainly for

difficult cases or for emergency cases, they are certainly off the shelf and this little planning compared with fenestrated and branch procedures, you can use them for typical anatomy as in this case, reduce cost compared with fenestrated and the branch endografts and you can use them for ruptures and we do use them

for ruptures, and we use them also for fenestrated and branch unsuitable suitable cases. So that's my first case which I've rattled through and do we have any question please. >> [INAUDIBLE] >> Certainly for all the chimney cases that we do they are all

axillary artery cut downs and see if it using closed devices for those or just to sew them up. >> [UNKNOWN] who joined us here as well. He and I were in the same group same practice and so for anything we do of any complexity from above such as a case like Rob showed those surgeon preference for those is to create and axillary conduit and then work through the conduit.

Which I think has some value and have some benefit I think of rather than just puncturing directly in to the exposed axillary artery and then repairing the arteries then just create a conduit then you can basically within limits of the 10 millimeter either Goretex or Dacron conduit basically whatever you can get through there you can get through

there. In terms of as many sheaths as you need which is pretty nice then when they are done they just oversew it and typically leave a little nubbing of it but just oversew with a running/g to a closure of 5.0 prolene and then just then close the incision. So ours all done by axillary conduit. >> Well I think they're only different if your a doing the single

chimney, if you can't get away with six french, I think that six french with some of the new Viabahns you can use an .018. So you can get away with the six french and just basically holding it out. Use closure devices with varying successes in the arm and are some of the other closure devices are more favorable in the arm

than others but in general we've been just holding pressure and in a six french is some what of a limit to that. If we feel we need to go seven and bigger we do a cut down basically or auxiliary with conduit. And at most of the time end up doing more than one chimney and for that case you know a condor would be the way to go.

>> For a single branch or that's the case I can show you, just a single precutaneous [INAUDIBLE] puncture. >> Just had a question in general in and this is tell the discussion about your preferred stent to use for chimney's, that always a question

that comes up in all meetings so, still used a Viabahn and use the 035 rather than 08 which could have a provided a low profile. What's your take on this and interested to see, you said you re-enforce them with bare metal, is that balloon expandable or self expanding?

What your algorithm for these? >> So honestly these are all done under cut down the chimney, the chimney access. We don't use the .018 they are all .035 Viabahns and the best supporting stent is the self expanding Zilver.

>> So why not use a balloon expandable, you think that is an issue with that or- >> Its just the flexibility. They've never conformed around the curve. Simply that really. >> What about you guys? >> I think it depends a little bit on the orientation of your branched vessel but you know but I think there are certainly situations where you could perhaps get by with a balloon

expandable, cover stent in that setting however having said that I, we use Viabahns for the all of our branches for most part. I would absolutely say and I have two cases kind of paired companion cases to show where you have to be very compulsive making sure that if there's any question that you just stent reinforce them. I don't stent reinforce in other words bare metal,

if the blue expandable or self expanding reinforce all of my branches. But I think you have to have an extremely low threshold for doing just that. The .018, .035 question at the beginning despite having excellent

access and so forth with the axillary conduit we did have some experience and actually two complications that I could go through with the .018 system and I have really migrated and prefer the .035 system as well for branches I mean its just despite the slight increase in profile, its just more stable access. I tend to use a Rosen wire typically for those invest so typically it gives you enough support and then

that nice tight little JBN/g. Typically works out pretty well. If you're concerned however about purchase I don't think I would hesitate using implants. I certainly will not use the very short tapered implants but you just have to be very careful if your using them.

>> It's exactly what we use. >> You just got to be careful. I guess but depends on your length of your renal, or your length of your SMA [INAUDIBLE] SMA I would prefer having a longer tapered Amplatz and get it further down rather than short but certainly in a renal I can definitely see it will be little more favorable to use the short tapered, but you do need

to watch the tip of that wire. >> Absolutely. >> That can be a weapon. >> Yeah we tend not to advance much like maybe it's slightly misleading and we tend not to advance the wire while we put the catheter in then- >> [INAUDIBLE]>> and put in the Amplatz that way.

>> One other thing that maybe distinction if you're extending your graft into an aneurysmal area it's like your neck depending if you are doing like one these thorac-abdominal, then I think the Viabahns did pretty well, sometimes you may not need to reinforce

them because they are going into an aneurysm they are not necessarily going to be crushed against the wall because they are going into aneurysm. While it's the neck and especially if their is a suprarenal fixation and the reinforcing makes more sense and that's when some of these balloon expandables may do well you have to do two stents you can jut do one so that's

been canal preference. >> We reinforced the distal end of the catheter not the proximal so the bit that sticks in the kidney. >> [INAUDIBLE] >>8 Go ahead I have a question. >> I have a couple of questions. One is how do you manage the aortic occlusion balloons during ruptures when you're doing chimneys, it can be a little bit cumbersome [INAUDIBLE]

>> There's no easy answer to that. They are cumbersome. You have to deflate the balloon then you move it, you move the chimneys then re-inflate. So it's a very just any easy answer I have. >> I agree. >> [INAUDIBLE] >> Just above the renals,

just above the visceral arteries. If you are using the visceral arteries for cannulation. >> And then the second was you are trying to decide Whether to start a fenestrated program or use more fenestrated grafts. From my literature searches I've seen that outcomes between Ch-EVARs and fenestrated devices are pretty much equivalent.

What are the advantages of using a fenestrated graft like obviously not for ruptures but [INAUDIBLE]. >> Well think you are right, I think that the literature on Ch-EVARs is much better than people would have predicted when we started using chimney EVAR and yes there are gutter endoleaks but they

don't seem to as frequent or as problematic as people used to think they were. We use in the chimneys with a Nellix of course, we see almost no gutter endoleaks because the gutter is filled by the endobags so there's no gutter really in the vast majority of patients.

I think that we've reduced our fenestrated volume in terms of patients since we started doing chimney EVAR. But we still use fenestrated and branch grafts for some patients. Obviously the disadvantage for fenestrated grafts are well known. There's the time and planning with cost etc and fenestrated grafts, we've seen, few of them migrating fairly over time.

So, long term follow up can be a bit tricky in some patients. >> The other thing is the orientation of your renal arteries. I think there's in my mind at least some impact on whether I'm going to branch them or use a ZFEN and fenestrate them. Downward going renals you could do it but they can be a real challenge. So if you have really steaply down going renal arteries,

everything else being equal I would choose to branch that without a question. The other things is access. The ilial femoral access systems though for the ZFENs, you need 20 french sheath effectively was your contraside to be able to get

your fens in right, and in some patients that's a problem. In women that can be a huge problem just in general but even in some men that can be a problem it's a big sheath. >> And I agree. So that the main turn down reasons for fen graft are anglation

of the aorta at the level of [UNKNOWN] and the access we need really good two good iliac arteries do this.

Tube Graft EVAR repair on this 77-year old man, a lot of comorbidities and other issues, who had a remote history of open Abdominal Aortic Aneurysm repair, a tube graft repair of his aortic

aneurysm. He now has a 5.5 cm juxtarenal/juxtanastomotic aneurysm on a CT which was performed again for a nonspecific specific abdominal pain. So this is an incidental finding. He also has mild Chronic Renal Insufficiency. So, pre-op CT here of volumetric

imaging and then on this coronal image you this is right at the renal arteries, a pretty large aneurysm. This is part of his aortic tube graft repair from his previous open surgery. You see the same thing here, and just some representative axial slices here, SMA, renals and then this is just essentially one or two

slices down from here. So there's really no neck here, so obviously this is outside of the range of any conventional repair. I'd also point out that really his iliacs are tortuous and somewhat diseased, but all of this is really pretty pristine and beautiful. So there are obviously a lot of ways potentially of fixing this with Branch,

perhaps even a ZFEN-type technique or some other ways of doing. Although I don't know that you need really to do anything with his distal aorta or with his iliacs because they're fine. So here's a catheter angiogram showing the same thing, the location of the renal arteries here, of course we don't see the aneurysm

quite as well. So through an auxiliary conduit here because of the essentially very little distance, and I said ZFEN probably not a great case for him, right? Just in the sense that his SMA is so close to his renal artery origins, as Rob has previously pointed out as one of the problems obviously with trying to get a ZFEN. So through left auxiliary conduit, we have our three sheaths in for our SMA and

bilateral renal artery access. Now just make a point here before I go any further, if you are going to be doing complex aneurysm repair, this guy had a CT that showed this juxtanastomotic aneurysm fine, fair enough. You can do a lot of the planning from here. But if you're going to be

doing something from above, in other words a branched or snorkel technique, just please take my advice and get a CTA chest, abdomen, and pelvis. Because you really need to know what the anatomy of the thoracic aorta is like, you need to know what his subclavian arteries are like. It doesn't always have to be left side, sometimes the right is more favorable. I was just talking of a cute case, if I get to it I'll show you of

where we actually did something kind of clever from the right side. But you should really know what that anatomy is like, so you don't get yourself in a situation where you could do the patient harm because you don't understand the anatomy of the super visceral aorta, thoracic aorta. So wires out into the various branched vessels here,

kind of last stage here. Someone asked the question about sequences. This is at the very end. I sometimes will do just a gentle, very gentle on the aortic wound, but just a very gentle kind of simultaneous thing. But the point of this is, with the sheaths in the visceral arteries, so renals, SMA, SMA, renal. With the sheaths in, the endograft is in place, whatever

you're using, with that all set, established that's when you want to put your balloon in and dilate this proximal fixation zone of your main body endograft. Then deflate that, keep it in position. Inflate these, and then I'll sometimes do just a very, very gentle, a little kiss of all those three, and remember that you're quite bit oversized, right? You're about 30% oversized, so you wanna be pretty cautious about

doing that. Now, the other cautionary tale that we've touched on earlier, and Rob showed in his cases about stent-supporting. If there's anything that looks a little bit fishy about any one of your branches, pay attention to that and just fix this at the time. And so other sort of take home point to this is that your wire access to these branches

or to your Fens that is the last, loss of that access is the last thing happens in my mind at the end of the case. I don't if the panelists have any thoughts or comments on that. Agree or disagree,

or? >> I completely agree, absolutely. >> But that's like the last stage of the, it's like a G-tube, the wire coming out is sort of the last thing that happens. The same thing for here, you just wanna make sure that you don't lose access. So we actually

reinforce this with a very short segment, just a bare metal balloon expandable stent just to try and iron that out a little bit. And then here's our completion angiogram. And again we just put in a thoracic graft, a Valiant thoracic graft. This works really great in this setting. But again another caution

from someone who's made this mistake, don't ever expect a thoracic graft used in the abdominal aorta to behave the way a cuff, an abdominal aortic cuff behaves. And if you're trying to land that

thoracic tube graft into the abdominal aorta in an area of significant angulation, please don't expect that to land and stay where you intend for it to stay. I've had them come back. And so if you're doing something and you need a shorter segment coverage and you're planning on using, for whatever reason, just sort of a

straight graft in that the location. Be very, very careful of thoracic grafts used in just the visceral segment of the aorta, if you're hoping for that to be your primary seal. Obviously this is a branched endograft, so there's other seal involved. Just a reminder on follow up eventually he had some mild chronic renal insufficiencies, so this was an unenhanced CT scan follow up just developed serially, but this is just a selected

image from his one-year follow up. You see that essentially the very same level here SMA, SMA good resolution of that juxtanastomotic aneurysm.

>> Okay, my last one is a 46 year old male, presents to the ER with severe thoracic pain, has T-segment alleviation

on the EKG Cardiac enzymes are elevated. He's actually hypotensive not hypertensive. Rest of the CVTs are unremarkable and take a look at the CT. [BLANK_AUDIO]

Any comments on this? >> Well, looks like, celiac is dissection flap going into it. They look like, they're two left renal arteries and one right renal artery. Right's coming off the true. SMA didn't appear to be involved in the flap.

>> Let's replay it again if you want to look at it. >> Okay, let's see. IMA is off. Yeah. [BLANK_AUDIO] SMA's fine.

There is the IMA of the true and then bisection goes in both the way.>> So the problem is more proximal as well. So if >> Proximally you mean A sending that's the prime concern right now Okay, so he goes to OR. He has a Bentall.

[BLANK_AUDIO] So Bentall procedure up to the hemorrhage. 48 hours post stop. >> So when you say hemorrhage. This is >> They didn't

>> We need to be more specific. >> So they dint do anything with the vessels coming of the they just replace- >> So open distal anastomosis hemi-arch. >> Yeah. >> You guys are some subtleties this here since there's one surgeon

I know. I don't know if anyone else is a surgeon in here. But the deal is when you say hemi-arch, you get the bill for hemi-arch. Billing in the US for hemi-arch is more than just a [INAUDIBLE] repair. So basically what a hemi-arch to most cardiac surgeons it means

you crawl up under the innominate about as much as you can and sorta get a little on the underside as far as you can. And you say, hemi-arch for the open distal anastomosis. Which is fair. No big deal. They're not try to to gain the system but they certainly can build

from more when they say hemi-arch. >> Okay. So here they didn't touch all of the arch vessels, so they didn't do elephant truck or anything like that. This is in 2008.

>> So everything is going wrong actually the patient becomes comatose and their is even discussion of stooping everything. Obviously you don't want to do that. so this >> What did the surgeons think was going on, any idea?

since they sort of touched him and put their hand on them and prepare [INAUDIBLE] and now everything is going to hell here. >> I can tell you that they don't want to touch him again because he's in the DIC he's >> I was involved in this case and they pretty much new that they may have solved the problem right at the origin

of the arch, but they know that their is more bisection, little farther and the involvements of the arch vessels, they don't want to go back in. So they're a little bit out of options because they feel the patient's

not going to go through another operation. And we're having discussions about what can be done. I don't know if you have more imaging. >> What did everyone think had happened, I guess is what I'm getting

to? They don't want to go in, they don't want to do surgery. Got it. What can we do? Well what we can do depends on what we need to do.

What's causing this guy's all of a-sudden rapid deterioration? >> That true lumen is >> We're assuming he's had interval increase in true-lumen collapse such as is critical. And so- do we have a CT? >> Yeah.

>> Okay. >> [INAUDIBLE] >> Yes, of course. >> [INAUDIBLE] >> Not sure my be we can figure it out on the images. No we can't

>> It doesn't look like. >> I think they just replaced just portion like a tube graph. >> Okay let's see [INAUDIBLE] [BLANK_AUDIO] It doesn't look that much changed, so here there's

an ischemic colitis and the liver is suffering. >> [INAUDIBLE] >> So his celiac is choking out what about his SMA? >> SMA wasn't too bad I don't have it? Right, no. >> Okay so, who knows but he's obviously,

his renal problems with the up gratin is not necessarily vascular, it's just a response to this terrible overwhelming problem he's got. Which is relayed through the celiac so we've got that extra celiac. >> Okay.

>> Because he doesn't have true lumen collapse. right. >> Yeah no his true lumen is not that bad. Can actually, you're right. What do we do with the arch? How do we try to open everything up?

>> But his arch, I think we just sorta went through this, we sorta thought that most of his symptoms are side effects, focusing on the celiac and the liver- >> He's also comatose so it's not going

profusing very well here. >>The comatose I'm not sure. That could be multi factorial. I don't what happened there, but don't see any. Do you see any vascular compromise that would be significant in

the arch. Look at that picture right there. That's a single image keep going. >> We can go in the one cause it hasn't changed so we can read run this one. [BLANK_AUDIO]

let's just do this. Okay I know where I'm being led by you I will go with that which is, that this thing in that right in there is critical or more critical than it was and we are going to and at this all the down stream stuff is kind of not only because we know the celiac is got a problem you could see that.

But on top of that you are telling us that arch narrowing is at least contributing to his problems. >> That's what we felt that the arch was still problematic. To be the surgery he had and so it's hard to tell how much it's contributing but since she is really not doing well and he's comatose and the surgeons initially felt that if they went back in they

would try to fix this. So that's when we decided that maybe we should try to find a way to fix this and - >> So how would you fix it audience. We are not going to argue about whether it needs to be fixed or not but there is a lot of evidence,

that because of the comatose and this apparent that they want to make this bigger. [BLANK_AUDIO] It's all yours >> [LAUGH] >> All right.

[BLANK_AUDIO] So it's 2008 so there's no branch graft or stuff like that so they decided They decided to put a bear stent, you know those cooked dissection bear stent, all the way up to the graft,

the two graft and extend it distally [BLANK_AUDIO] I think the procedure was a, what happened to the patient after? >> Well actually we put a tube in the gallbladder and we didn't do anything to the celiac or mesenteric vessels,

we just did this and the patient improved very quickly and we just followed him. >> So the follow up. That was 2008, this is 2016, the patient is doing well except that you'll see that then another problem is going to eventually come up cause he's still young.

There is a big dilatation of the aorta. It's gal bladder was eventually removed. And there is not anything in the kidneys. he's probably suffered a little bit, ultra fit a little bit but nothing is else is a big problem.

>> Celiac heal very nicely. >> And do you have the carotid to carotid in I have the whole imaging in here. [BLANK_AUDIO] >> It's one bear dissection.

So maybe sometimes just opening up that true lumen can give. results. >> So the question is what are we going to do now that's what you are asking. Surgically there's a lot of promise because we got a lot of hardware up in the arc.

So that complicates it then. It's not to say he's a young guy we can just go do surgery, cause surgery is not going to well you help the surgeon out certainly. So may be now they'll have to figure out a way to deal with the bear stents up their in the arch.

>> All right so will wait and see. >> I don't know unless you got does anyone have a good endovascular solution to this. >> [INAUDIBLE] elephant trunk >> What you can do it but he's got, they've got this big bare stent up there,

the surgeons going to have to figure out how to deal with that, either cut it out or do something if you're going to elephant trunk in. >> Or rebranch the whole yeah it's a whole debranching. >> [INAUDIBLE]

>> Well, yeah that's a possibility. This is the idea that, everyone sort of get to. Once it gets to be a chronic problem problem like this, it becomes much more difficult and complex to deal with than dealing with

something early on. Because even if you do all that there's no guarantee that you going to fix the bottom of it and it's not going to retrograde flow and all this work later, you still have an issue. So, I think people are sort of coming to this.

As long as you can do no harm with this, and not provoke retro [UNKNOWN] and stuff, it may be easier to treat these people with sub-acute phase cause once they become chronic, everything become much more difficult. Whether its thoracal/g or abdominal.

>> Okay >> Great case All right. Vincent.[ BLANK_AUDIO] >> So I'll just show one quick case and then you can talk.

>>This is just a a very angulated neck and how to approach to these

angulated neck. The iliac is aneurysmal obviously. So in this one since the other iliac is okay we just embolizing and then like extend it to the external iliac since we're not compromising the other side. And this is the angiogram showing the angulation. It's

not the worst one but it's kind of borderline over there. And you can see that the iliacs are very tortuous as well. The left main body is obviously this side is more appropriate instead of coming from all this.

And one thing to pay attention is sometimes depending on the case if there is not enough neck, if there's a short neck and there is an angulation like this at the same time, I try to go contralateral to the higher looking renal. Because these grafts hit the wall and open up downwards.

They don't open from the middle to both sides. They catch one wall and then they'll just flare down. So, by doing it this way, it will flare down here as opposed to if I had the graft here coming from the right side,

it would open up like this. And in short neck, it will be a problem. So that's one trick that I'm sure you guys, to the experienced sounds familiar but if you haven't thought about it, it's something to

pay attention to. So this is again same thing afterwards, extension to the limb. And that was fine. And this is the other side after embolizing with a single Amplatzer and I'm like extending into the external iliac. And then the followup looks pretty good actually.

It's a long video, we did not have any endoleak. >> You wanna comment just for a minute about your choice in the short neck, your choice of endograft and what influences your choice? Do you believe in suprarenal fixation as a preferred approach and in terms of the controlled delivery of some grafts over others?

>> I think we used Medtronic's [UNKNOWN] for 10 millimeter and if it's really short we now go with fenestrated Zenith graft. If it's really short, if it's less than 10 millimeters. Especially if it's angulated, definitely fenestrated graft. And if it's 10 millimeters

straight we use Endurant or Zenith regular. We prefer Endurant in general because it's a lower profile, it tracts better. The only problem we experience with that one is the top cap. It sometimes catch to the suprarenal stents. You need to know how to

deal with it. I sometimes have to pull the wire out all the way because if you have Amplatzer wire over there this things over, catches the stents. That's only issue we have. Otherwise, that's a very easy to use kind of everyday graft. But in terms of their patency and a Type 1 leak rates, I don't think there is difference between Zenith and Endurant even though

one is approved for 10 the others is approved for 15 millimeter. And TriVascular, they claim up to 7 seven millimeter you can kind of seal the neck better, but you know the potential advantages and disadvantages of that one. And if it's a nice very straight forward case Gore's the easiest one to use.

But if it's a complicated case, I tend to stay away from Gore graft because it's a little less controlling than the other ones. But their next generation is better and the first generation was kind of [CROSSTALK] >> Can I ask about the sizing.

Would you guys consider with an angulated neck to oversize more because of the, cause usually its not gonna, if you do a central line measurement you get a 25, that gets it 28. But you know its not gonna sit in the central line. It's gonna sit more that way which means its gonna

touch more of the wall. And would you oversize more? And that's gonna you, the Type 1 leaks for these cases it seems to be mostly from undersizing. I don't know. Do you go higher on the size with the- >> I generally seem to oversize

a little bit more with the short necks, again not very aggressively over sizing. And with an angulated neck sometimes it's a game time decision. We'll do an aortogram and if we may repeat measurement rarely we do IVIS in those situations. But either sizing it according to IFU maybe next size up. But normally it's the short necks that I oversize.

>> Ever take advantage of the Aptus endo staples? >> Mm-hm. Yeah.

[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.

which is the flare bell-bottom technique. This is a patient who I treated a year ago with this ectatic and aneurysmal and short

right common iliac. And I chose just to use a flared Endurant limb, I believe this was 24 millimeter limb in an aneurysm that started out , a common iliac that started out at 20 and tapers down to about 14. >> Sorry, can you just point out to the audience which iliac you're

talking about >> This is the MRA of this patient who has a right common iliac aneurysm that's short and stubby. And rather than embolize or try a chimney technique, in this case we thought we'd get away with a flared Medtronic Endurant limb.

This was an Endurant case. Endurant was chosen in this case because it does have the biggest flare of 28 millimeters. In this case we didn't use the biggest flare though. We just used

the 24 millimeter flare. >> Would you try it today? >> No because when we tried it >> [LAUGH] >> In this case this is what we saw a year later.

Big endoleak, and you can tell in its early arterial phase that this is not a type 2 endoleak. It's closely to the opposed to the graft, it's dense and big on the early arteriole phase, and when we did the follow up angigram,

this is what we saw. And I was just amazed with it. This is one year later. Look how much more aneurysmal dilatation we have now in that right common iliac. I can't help but think that this has a lot to do with the pressure

being exerted on the aneurysm by this flared limb. Are you guys seeing this kind of a- >> Well, one comment on that. If you look at your initial angiogram, it's not only aneurysmal, it's

tapering down to the bifurcation of the internal nexus, it's like a reverse shape. So if ever I am gonna do for one or other a kind of a bell-bottom technique I would at least like to have that iliac uniform. >> Mm-hm

>> In this one it's very hard to choose the right graft. Let's say 26, 24, 18, at the tip so do you put a 24 or a 28 graph in the 18 or it's very hard to get kind of a nice seal. It's a very challenging case. >> It's not any easier because results are very short [CROSSTALK] artery.

>> I think the length is key and I think for these bell-bottoms my thought is, they've been problem solvers if you have a very long iliac, not very long, at least longer than four centimeters and then you have an area that is at the distal end measures 20, then these bell-bottoms which are large limbs have been problem solvers, you can use them.

But with that short of an iliac I'm not sure if that's good enough for the seal throughout to get the seal that you need when the common iliac is that short. Short and aneurysmal seems to be like a bad combination. >> Exactly, we did have a seal that lasted for six months and this is 12 months

>> [LAUGH] >> And so now I think it's clear that the next step is to embolize and extent distally. It's about the only thing I think you can do here. And just is a matter of a technical tip, this was a Steerable sheath that worked really well in this instance. This is the same after-sheath that they used for deploying the endostaples

and you can use it like aMorph catheter to get into this very steep iliac bifurcation. We used a few Nester coils and extended with another extension limb. So we've already talked about embolization of the internal iliac arteries. Buttock claudication is just one problem but fortunately rarer but more fiercesome complications do occur

with embolization of the internal iliac arteries. >> Before you go to the next case, you know we've discussed a lot of issues with iliacs and small access and embolization aneurysm. Let's just make this more interactive. We have a small group here towards the end of the day. So any thoughts,

or any questions about what you've heard so far before we go to the next case? Yes please. >> [INAUDIBLE] >> No we just used another Endurant limb and I believe this was might have been about a bit of 20 millimeter flare initially.

Sometimes you need to get a bridging stent you know to get it but I think in this case an Endurant limb, I think they make a 24 promal that can just extend and then taper down, taper down distally. >> Actually all the Endurance are 16 proximally and then the distal can be narrower or larger.

So the larger, the bell-bottom part is about three centimeter, three to four centimeters segments only. So all you have to do is when you're putting the new one, which is also 16 proximally,

you have to bypass that bell-bottom part, you have to bridge with the narrower portion. And then you'll have the graft outside but you will achieve a seal inside by bridging that way. >> So lots of overlapping.

>> Just go all the way around. >> Yes? >> [INAUDIBLE] >> Bridging without embolization? >> [INAUDIBLE] >> I think it does the same as an embolization-

>> I don't know- >> The way you're describing it is you're excluding- >> Effectively there's no interiliac flow, I think-

>> Yeah. Well- >> [INAUDIBLE] >> But one problem, if I understood it correctly with that be, if there's a leak and if that internal and common iliac continues to grow, now you

close your access for embolization. >> [INAUDIBLE] >>But you haven't necessary closed the back door. So I think there's a theoretical- >> [INAUDIBLE] >> I appreciate that.


Any thoughts on that? >> Yeah, you might be able to do a secondary type of chimney technique. So, we'll talk a little bit about that.

Here's the second verse, same as the first, just a little bit of a variety here. This is an 81-year old guy who'd had pretty complex surgery in the past. Descending open thoracic aortic aneurysm repair, enlarging 6 cm paravisceral component. A bunch of pretty significant comorbidities, including

Stage III chronic renal disease. Now some pre-op imaging here showing this paravisceral aneurysm here, a CO2 angiogram. This is his SMA. What you are not seeing here is he actually has a thoraco-celiac bypass. So he had a surgically created bypass to his iliac artery from

his thoracic aorta. So if you know that, you just need to make sure that obviously you're paying attention to that because it was done for the reason this guy did not have good collateralization between his celiac and SMA distribution. So although that's not shown here, that's something to pay attention to.

He does have a left kidney. It's not shown here, but it was very small. He has split function renal still showing here. This was not really contributory in any meaningful way, so just in the idea of a little bit of expediency and making the operation a little bit easier. We chose to ignore his left renal artery, and we just recovered that portion of his aorta.

So this was going to be a two-branched graft. And I guess just comments just on this configuration, I've already sort of hinted at what we did. But any comments on, given distance, giving angulation, giving orientation of these arteries? You already know what I've done,

but does that seem like a reasonable idea? Periscope right, renal and snorkel of the SMA? >> Yes. >> Yeah, sure. >> It makes a lot of sense. It makes it much easier to manage the R-matrix on the left, and just do it that way. >> Exactly,

yeah. >> In the previous case for example, he had great arsenal/g, but then with the tube grafting there it could have, and had one of them go down and ->> >> It certainly could have, yeah absolutely. It certainly could have, yeah absolutely. Absolutely.

So here we are during the case, so here's our access here into his SMA. Here's our right renal artery access from below, as we had used a Bolton Relay graft, overlapping Bolton Relay graft. So here's the first graft that was deployed distally in his abdominal aorta. This is covering our right renal periscope, comes up to the level of our snorkel from above into his SMA.

Here's the leading end, the most proximal end of that second graft completion angiography that you see playing here. It just caught my eye and kinda concerned me a little bit that this right renal periscope seemed like it was pretty sluggish. This is his entire renal function at this point because not only

was this his best functioning kidney, but now his left renal artery is covered. So again, wire access, that's the last thing that you lose obviously. So we took a little bit closer look at that, and there is a real pretty significant kink here at the origin in our long Viabahn in the right renal periscope. So actually we just chose to put in a relatively

long bare metal self-expanding stent, an 860 bare metal self-expanding stent into that renal just to try and make sure that we settled that. So again, if there's any hesitation I don't routinely stent all of my branches or periscopes. But I think periscopes, I'm probably more likely in fact to stent reinforced than even some of the branches from above. But if there's any questions,

like a lumbar puncture in a sick child, an ED or something, I think that you just do it before you get yourself in trouble. >> Well here you had your periscope go to the distal in the aorta, above the bifurcation. Do you ever take it, and if you had to go into the iliac, do you ever take it next to the iliac lymph? Do you have any issues with that? >> I have not done that.

I have not had to take it into an iliac lymph. Rob, have you put periscopes down into the iliac? >> No, I've not. >> No. Yeah, so this is just trailing just a little bit distal to our first main body, Bolton thoracic endograft component. >> I've done it once for an accessory renal that was somewhat large and going right side by side by the iliac, and surprisingly it stayed open. We just did it to see if it stayed open,

surprisingly it did stay open. >> Sure, excellent. Yeah, excellent, very good. And so here's our follow up CT, just a little bit of that extra stent of course in his right renal periscope, but all these are open. And he had some pretty good remodelling in subsequent imaging, which in the

interest of time I chose not to show.

56 year old male. A little bit of the same thing. His not known for any connective tissue disorders. Presents to the ER with thoracic pain and his main complaint is

left leg pain. History of hypertension Diabetes lab values are normal, once again the lactates are fine, the creatinine is fine everything's okay and images will look a little bit like the previous patient.

>> So if you measure that tear, right? >> Well, that one? >> Yeah. >> You just sorta eyeballing that, you know it looks more than a

centimeter right? would you say and that tends to be the cut off or something that is going to be a bad risk factor, so I would classify that and again, the tears can move all over the place and this is just one scan, but in this one scan this looks over a centimeter,

so I put him in a high risk category. Now, if we went up and down, paged up and down through his and saw this is really a big deal, we're going to be at risk for true lumen

collapse down straight. >> Okay. So, we're going down. >> Which factors would you consider to favor treatment, just at when you look at the imaging. >> The first thing you have to do is profile a patient and that

doesn't bother some degree. Complicated versus uncomplicated. If you find something that's complicated, meaning not anatomic exclusively, but anatomic with some physiologic correlate/g like he's you know, got pain in his leg like this guy does or he's got belly pain or

something like that, then he's complicated and he's going to treat him. So if we go, what we're really discussing is kind of the uncomplicated right? And the uncomplicated, that's sort of what I was saying earlier,

we can list all the these factors which may or less be prognostic of early degeneration, but many people now are thinking as long as anatomically something there's not a feature of this that looks like it could result in a complication of the procedure we're just going to treat them all and we're going to treat them

sub acutely, so in my mind right now no one's running in and treating uncomplicated hype in the hyper acute state, but if this guy has a complication he's going to get treated right away. >> Mm-hm. >> Right?

>> So you're advocating to follow them up really closely clinically and if there's a sign of any sign of decompensation you would go ahead and treat them? >> Absolutely, yeah. Yeah. I mean you're trying to get the profile on this guy and not only

the time of onset when you first diagnose it, but over time you need these data points, you need imaging. We're going to image them one more time before he leaves the hospital. And depending on if he's in compliant or not we'll have him back

in a month and then he's already sort of gotten his mind that we make, we're going to treat him sooner or after. >> Okay we continue. So the true lumen is not very big, the celiac and SMA will come off the true lumen but

There is extension that dissection flap in it in both the SMA and the celiac and also in both renal arteries. >> You see now some people would look at and say the true lumen's gone right? but you see that little punctate, period sign in the true lumen

that, that's the lumen. >> Yeah. >> And just like in the iliac when you said that you can go up, you can you go up there no problem it's not occluded that shouldn't be, I mean it's intimidating to look at but you shouldn't think that oh! I can't do anything coz the lines all clotted there.

>> Mm-hm. [INAUDIBLE] >> It just flies. So, it extends also in the right side but there's a reentry. Okay, 24 hours They elected actually to wait and see.

They gave him heparin and he had no more leg pain. But 24 hours later, he started getting abdominal pain. Creatinine levels go up. Liver function once again, not doing very well but the lactates are normal so, there's expecting probably SMA still perfusing pretty

well. And there's another CT scan that's done actually at that moment. You see that the liver does, it's nor perfused very well. It's very hypo-densed compared to what we usually see. And we can see pretty well that there's right side of the kidney

malperfusion and but the bowels are fine. You don't see any stranding next to it. They're not dilated. >> What you don't see straining but that bowel starting to get a little thick there and it's- >> That's actually if you look at

the other CT scans, that's probably just fat. So, it's not thickening of the bowel. What do we do? [BLANK_AUDIO] >> [INAUDIBLE] >> Earlier, yes.

It's not always our decision unfortunately. But, >> [INAUDIBLE] >> Here, because the lactate levels were normal, they didn't opt for a lap at that moment. But we-

>> Can we go back to the- >> Which one? >> Right there. >> This one? Yeah. [BLANK_AUDIO]

want to see before? Just that. >> No, I was just looking at it. Okay. [INAUDIBLE] >> You know what. >> That could be bad for this very thick

you can see. >> Yeah. >> [INAUDIBLE] >> Okay so this is from the right side. >> You got to admit though that he is a little unusual and then all this flap he's got this gnarly sort of balled up stuff.

You saw it going into the left renal and sort of tongue, tissue- >> Mm-hm. >> And even in both iliacs. It was just, kinda looked like scrambled eggs in there, you know? So it's a little different.

[BLANK_AUDIO] >> So difficulty coming up from the right, went from the left and stent graft will be put in. [BLANK_AUDIO] After that, there's not very good perfusion still

of the celiac. So then, the stent graft was done in the OR. In the OR, the quality of imaging is not necessarily that good. So the patient was taken then to the Angiosuite to have a better look at these visceral arteries which are problematic.

You can't even see the right kidney here. There's a severe stenosis of the celiac trunk and we know that there's suffering of the liver. [BLANK_AUDIO] This is what the renal artery looks like and kind of had a dead tree sign of that kidney.

So we were talking about the stents earlier, what kind of stents would we prefer? Should we put Covered stents ? Should we put balloon expandable stents,

, self expanding stents? >> And that lumen looks really weird. It almost looks like it's feeling effect do you think there was clotting in there or do you think it's false lumen? >>It's irregular. So I think there is probably some clot in there cause if it's just

the flap with the false lumen that's thrombosed you still expect to have, fairly smooth imaging. So, this is clot. >> No question, there looks like it's severely stenotic. You couldn't see any perfusion in the right kidney when you did the aortagram.

So, I guess, reperfusing the right kidney is certainly a good option but I think the question is, should we use self expanding stent vs balloon and covered vs uncovered? What do you think Mike? You probably have the most experience.

>> Well, I agree with you. I'm worried there's some sort of clot that are regularities you pointed out is abnormal. Obviously, if we had the appropriate self expanding stent graph, that would be good. But if we can't put viabond on there,

really cause the shortest one you got is too long right? You can't throw a 5cm stent in there. So what are you going to do? It looks like, you've gone to a balloon expandable stent. I don't know, I mean,

the kidney's in, as you said this is suffering. I'm not even sure how much of this is even viable but I might cover the whole thing initially. Instead of of putting- >> [CROSSTALK]

>> Balloon expandable stents. Meaning a self expanding stent in there. >> Okay. So what was chosen was balloon expandable stents and proximal one was put in and a diastole one will be put in as well cause it doesn't look great after, but the result is okay I don't think their is

any trash in here. Because of the liver function decided actually to put also a stent in the illiac. With a good result. Now this is the left sided kidney. Who would stent this? [BLANK_AUDIO]

I do but I didn't put in. It's flowing pretty nicely. >> [INAUDIBLE] >> We do. >> [INAUDIBLE]

Yeah probably right after the stent graph well you can see it here. >> [BLANK_AUDIO] >> We assume the catheter tips in the true lumen right. So that other got to be the false lumen. And so that's going out almost of the highland right.

And what we are not really seeing is the flow through here. but I did here you say that everything is going through the temple, it's pretty nice. I think you are safe enough to watch it if you wanted to. I necessary want to put a stent all the way, out their I don't think

it would do any good to out a stent necessary just up the [INAUDIBLE] So we opted not to stent at this point. And the perfusion of the SMA. You can see the there is a die section here,

but the flow is good as well. So would you any one with anyone stent this? His lactates are normal we don't think that their is any problem. >> Problem is that technically it's staff to stent there and sometimes you may end up worse than >> Locking of normal branches.

>> If everything flows nicely it's I think the safe option is to just flow it up. >> I agree. One year post. [BLANK_AUDIO] The other thing we haven't discussed is the sizing

of the stents. On the initial exam, the angiogram, the stents looked properly sized, and if you look one year later, you get a feeling that the stent is kind of

Small compared to the artery. The stent in the right kidney looks fine, but the one in the celiac looks kind of a small in that artery. So how do you size the stent these, how do you size these stents?

>> Well the celiac was tough because there was a lot of post stenotic dilatation which means, I start questioning, why it was even there but it's tough because the dilatation, they weren't parallel walls. So I don't know what to really tell you.

I tend to size them up to CT scan. That's [INAUDIBLE] >> Actually, the right kidney looks a little smaller but pretty good, if we look at what we were The type of angiogram we had during the procedure.

That kidney is still well functioning. It's probably a 40% but I think it was a good salvage of that right kidney. And the lumen is opened pretty well. We still see that flap going to the left but I don't think it causes any problem to the flow of that kidney.

So, any other comment on this case? >> [INAUDIBLE]

So the first case is a 40 year old male that doesn't have abnormal history besides the fact that he's a smoker, and a little bit of hypertension, a little bit overweight. Classic symptoms of sharp pains,

stabbing back pains, and sudden onset. >> So here's another guy 42, so we're going to be on the look out now. >> Not known for any connected tissue disease, so fewer measures

and then I'll have the whole exam. So it's a typical type B, but you can see compared to some other exams that we saw earlier the true lumen is here, severely compressed, almost non existent,

although we have to be careful that these are Our static images and the flaps are dynamic so depending on what time we take the image towards the systoly distoly, it can be different. But clearly you see the not too well the percification of probably

the celiac and distally the kidneys they look like they are suffering a little bit as well. The right leg, patient didn't complain of any right leg pain but obviously it's not going too well in that leg right now. So if I just click on it, its going to scroll down and first questions

we can ask ourselves is, the patient is hypertensive obviously he was something like 160. The symptoms are not too bad and for these patients there's always a wait time. A wait and see what happens and then

This an area they're going to try to control their blood pressure and we all understand the fact that if you decrease the blood pressure you might have an opening of that true lumen. But at the same time I think that can also backfire on you in a sense that if it doesn't open and your organs are already under perfused and you can be then in a lot of trouble.

So if you see something like this the question is should you treat, should you be more aggressive in treating or do we still do the wait and see what happens. So any take on that? [BLANK_AUDIO] >> Audience, want some more information?

Do you have any other pains anywhere? >> His pain is actually pretty well controlled with medication. They did Did bring his systolic blood pressure to under 140. But there is still a concern if you look at that. His creatinine levels at first were I'd say mildly high,

but not increasingly, he's not anywhere near renal failure. >> One questions I'd ask. Tell me again how soon after this onset of symptoms, is he being evaluated on?

>> Less than 48 hours. I'd say probably 24 hours. >> Oh, okay. I would consider that a little long actually. >> No, consider- >> What I see I see bowel and it's not dilated.

It's not super gassy, so he doesn't have an alias. And if he had really bad ischemia at this time, you would expect gas, you'd expect an alias. He, and that one static image of the primary tear looks pretty small

but on this you can see the primary tear is quite extensive. You know, at the top, so that makes sense Sense for he's got some relative true lumen collapse and down at the bottom where I interpret this, is just like the last case in

his right iliac, he's got a no re-entry of the false lumen into the right iliac. You tend to see this in younger patients. The older people where you have more, sort of homogeneous degeneration in the media, they tend to rip out and double barrel flow.

But when you get people who are young, and they have branch vessel involved with the flaps gong into them more often than in older people, they do not re-enter. You can have a multiplicity of branches that could be very severely ischemic because that does not re-enter so,

he's a big guy. He's fat, he's 44. We've got to put it together and I guess the question is if we just sit here and wait on him, is he going to get worse right before our eyes and start to develop increased lactate-

>> Because right now his symptoms->> Tranaminases, it's hard to tell. So, I guess that's a tough call because by the 24 to 48 hours, I would

expect him, again it's increasing true lumen collapse that he would be exhibiting some signs of mesenteric ischemia, or ischemia to the liver or something by now. I usually think when some guy comes to us after 11 to 12 hours by bouncing around outside hospitals and he's got something bad he's

usually in big trouble. >> Mh-hm. >> But, everybody's different and this guy could be in the middle of evolution right now. >> So, waited then didn't do anything right of the bat. That was when he came in.

His labs were pretty normal. 72 hours later, complains of abdominal pain. The creatinine levels, this is Canadian so I'm sorry, 600. Lactate levels are Getting high.

>> This is few days later.>> Few days is 72. 72 hours, three days later. His liver functions are going down and you're thinking when you look at this maybe he has pancreatitis, so what are the blood the

celiac trunk, how does it look. Well we knew that on the first exam the celiac trunk wasn't perfused well at all so we're suspecting. So we do another exam, no actually because of that we didn't redo the CTA, we just decided to go directly in the OR to put a stent

graft. Now the thing we were discussing earlier is do we plan to do right off the celiac, the renal arteries or just try to put a stent graft and see what happens. Again the question is do we We do as two step procedure or try to do just a stent graft and

see what happens. >> What's the two step? I got the stem graft as step one, what are you promoting for this step- >> Second step would be to put a stent in the celiac trunk

or the anal arteries cause you're having discord problems. >> Well I see this just throw it out try and be throw yourself out there on a limb but this to me looks like dynamic branch vessel involved instead of static. I would assume that the stent graft alone is going to do it but it again you are obligated when you have abdominal symptoms to

then do an abdominal aortagram and see if you got a result that looks better and you might want to do an abdominal aortagram before. I know in this situation I do. It's the first thing I do. Before I do a thoracic aortagram, I go up to the diaphragm pigtail,

see what that looks like in the abdomen and I can tell you in this case it's not going to look very good. Your going to have what's called floating viscera. You'll see the branches coming off the true lumen without much True lumen in the aorta. >> Okay.

So I don't have the whole run, just selected imaging. >> Yes. >> But the flow is not, yeah, next question sorry. >> [BLANK_AUDIO]

>> Yeah, we use zero intravascular ultrasound for Or many issues. The main one would probably be a cost issue for us, but that's not in our tool bag unfortunately. >> [INAUDIBLE]

>> Yeah, so that would be another question with which side should be You want to get into the true lumen as easily as possible. And I think what happened here, is they tried in from one side and it wasn't going up.

So we ended up going on the other side to make sure we were in true lumen. >> [INAUDIBLE] >> Yeah.>> [INAUDIBLE] >> Yeah.

>> [INAUDIBLE] >> I think the CT scan helps you a lot with that. In a sense that you know when you're puncturing that common femoral artery. You know that you're entering depending where the flap is, you know

that you're entering the true lumen and then you go up and I think you have to do an aortogram to make sure you are still in that true lumen as well because you don't want to have to go in through openings all the time. >> I think I agree with you Mark in general if we're just planning what we think a skin graft is going to be salutary for most of these

conditions. Well go in the ischemic side. You can see the effacement. In the right iliac here which represents the false lumen pressure on the true lumen. And again the false lumen is a sausage casing, it didn't re-enter,

okay? So if you could puncture the groin and go up and you're watching as the wire goes up and you're not too forceful, you're just getting the wires that's going to push everything inside as long as you don't create a re-entry if you will.

Yes? >> [INAUDIBLE] >> There's always with the anesthetist is there all the time so we do the transesophageal all the time . but that will tell you that turned the true lumen proximally but it won't tell you distally where you are.

>> So, Patrick go back to slide. Let's to that abdominal aortagram. Forward the slide. >> This one. >> Very good. Look a that for a second.

So we see similar effacement of the infrarenal aorta, we see that the catheter is at the top of the field of view which is really just a centimeter or so above the celiac. Right? >> Uh-huh.

>> I have no idea what you injected but with even a hand injection you will relieve that velcro compression of the true lumen enough to fill the branch vessels but you can still see that that aortic lumen and I know we don't have the whole run, but I'm going to go on a limb and say that this is again an effacement of the true lumen.

>> Okay, so we continue the procedure. it's going to to be a covered stent . We're going to cover the subclavian artery here and with a fairly good result because the patient had lactate levels that were high, they decided to do on the table a laparotomy to see if there was a ischemic

bowel and they also did a Dopller right after the stent to see if there was good Dopller signals in the celiac, the SMA and the renals. The Dopller was actually very good, there was a no balancing pulse in all those arteries,

but the small bowels was very patchy but since they had good profusion they decided to wait and have a second look after 48 hours and Most of the small bowel recuperated but they had to do a segmental resection, a 20 centimeter resection of the small bowel, so we

have to CT scan post op. [BLANK_AUDIO] And you see that there was damage done to the pancreas patients in pancreatitis, but other than that, this is one year later, but on the CT scan here you see that there are changes that the true lumen was

fairly open compared to what we saw in the pre implant of the stent graft. >> But that right renal, what what's going on with his right kidney? >> So, the right kidney. We knew that there was a flap,

right? But actually his creatinine level was actually normal two weeks later. Well, maybe it's the other kidney that's taking all the load but If you take a look at this CT scan, you can see what that kidney

looks like. [BLANK_AUDIO] >> So that looks pretty good. >> Yeah, so just doing stent graft without having to stent this [CROSSTALK] >> You know, I guess this just adds more in my mind.

Every time you see right at the level of the SMA where you almost can't even discern the true lumen. That's not really a systolic, diastolic thing. That's almost a stock of flap against the anterior aortic wall. I wish I'd have been stronger when you're saying this is the time

to do something cause by waiting, we actually risked a lot, got his pancreas [INAUDIBLE] and other things. But in the distal descending you see the sistolic, diastolic thing you're describing but typically when you get true lumen collapse,

as you approach the diaphragm, the true lumen takes an anterior resident is it is oriented, giving off the celiac in SMA in most cases and then right when you get to those viscera vessels it's just almost gets sumped/g up like velcro adhesed to the interior wall.

When you see that like we did on that first one, even though the guy, when you showed me, he was totally a asymptomatic. >> Yeah. >> No gas, no nothing and it was 48 hours.

>> Yep. >> Why hasn't he in 48 hours, it's just very dynamic and I'm kinda mad at myself didn't say absolutely no question, you should treat him right then.

>> Well you'll get another chance,

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