Congenital vs. Acquired | A Discussion of Tarlov Cyst Treatment with Long Term Follow Up
Congenital vs. Acquired | A Discussion of Tarlov Cyst Treatment with Long Term Follow Up
Congenital vs. Acquired | A Discussion of Tarlov Cyst Treatment with Long Term Follow Up
Related Clips

I came to the conclusion that there are essentially There are those who have as part of a connective tissue disorder and this includes diseases

Ehlers-Danlos and possibly cutis laxa sometimes neurofibromatosis And these folks have family histories of things like bicuspid aortic valves being stretchy having chronic back

cataract problems lens problems and things consistent with And then there appears And this acquired group have had an event and in their 50s approximately they begin to become symptomatic.

goal of the procedure was to achieve a platelets count above

100 so the patient could have systemic chemotherapy. Again radial approach, standard technique no anatomic variants, then we can have our cathode coming from the above. And this case is a very gentle cathode very soft tip that we can advance distally into the splenic artery sometimes even the hepatic, if needed whereas a catheter can go more distal if you need.

So again from there get a microcatheter go selective in those lower pole of the spleen, using PVA 300 and coils to embolize proximately we can get a nice embolization of the lower two thirds of the spleen and preserve the upper pole of that, that's our standard protocol. And why partial embolization?

I think that has been stressed out here but I think that's two big points that we need to consider in order to do the partial embolization. First with that we can maintain at least even a logical function to the patient which will help to decrease the chance of infarction complications later on and also that to maintain anterograde flow into the splenic vein.

And in doing that we avoid retrograde flow from the mesenteric vein into the now infarcted spleen and potential carrying some bacterias from the normal bowel fluora. So maintaining that anterograde flow into the splenic vein and maintaining some neurological functions are critical for to decrease the chance of infection later on.

So and talk about infections as I mentioned before the Spigos protocol we based our protocol on that protocol. We do something different so originally that protocol included bath the patient before the procedure, we don't do that. They would also give intramuscular injections of Penicillin and Gentamycin

six hours after the procedure, we don't do it. They used to give Penicillin and Gentamycin intra-arterially before or right during the embolization. We do do that but instead of doing Penicillin and Gentamycin we find that Vancomycin is a good option to infuse inter-arterially right before embolizing with the particles and coils.

Vancomycin has a good coverage for the skin flora and also for the GI flora so I think that's a good combination a good agent should decrease the chance of infection later on. And we also give some antibiotics after the procedure so the patient should go home with but instead of using Gentamycin and Penicillin, we use Cipro 500 milligrams for 5 days.

So we kind of do a modified Spigos protocol in our spheres that has been very helpful. Very very low incidence of abscess after embolization. And why the lower two thirds of the spleen so we tend to, first of all as it has been described here,

we feel that it decreases the chance of left pleural effusion, atelectasis and pneumonia because we avoid all the inflammatory reaction close to diaphragm preserve the upper pole of the spleen. Another good reason for that is to avoid non-target embolization of the short gastric arteries. That's a very well known connection between distal branches of the splenic artery and the short

gastric to the fundus of the stomach so in order to show that,

Okay, this next case is a patient with Metastatic Ovarian Cancer who presented with a GI bleed.

And basically we probably function like a lot of other academic centers, maybe the private practice people have a easier way with this because they understand what's going on with the patients all of the time. But we have six or seven attendings on at one time. The GI doctors came down and told the on call physician and another

physician that they saw the bleed, it's coming off the left gastric artery, just embolize the left gastric artery. It turns out it comes into the room that I'm covering and I'm doing this case with my fellow and I go to get some information and nothing better than a little hand off from another person rather than trying to reinvent

the wheel and they say just go embolize the left gastric artery, seems pretty straight forward. I gotta be honest I start with a pig tailing autogram when I do bleeding, GI bleeding and things like that I think it's probably not the norm, but I often like to get an overview of what's going on in this situation I thought was very revealing,

we can see over the left upper abdomen and you could see some clips, they have had some type of, I can't remember the surgery that they had, but they had to have surgery, but you could see a pseudoaneurysm in the left upper abdomen. Certainly to me either this was very coincidental and they had a

separate issue with a splenic artery pseudoaneurysm or maybe the left gastric artery was not the problem here, so we get into the celiac and we do this run in and again we can see that the splenic artery has a pseudoaneurysm it's the persistent enhancement here. I'll point out that this is a subtracted images, but there are some clips over here around it and those clips were placed endoscopically,

they said, oh yeah, we put clips right near it, we couldn't get it though. So it seemed to me that perhaps this left gastric artery was a little bit of a misdirection and you can see the clips' a little bit better here than the native image.

So I got onto the splenic artery, looks pretty straightforward it might be a challenging embolization, we won't get into that just yet, but certainly there are risks to embolizing the splenic artery in the hilum like this you

could get some splenic infarct and other things like that. But my plan was to do a Cone-Beam CT and really use that to help delineate the anatomy, see how many inflow, outflow, what we can do angiographically here for this patient. But at that time I had done a mapping angiogram on a

different patient and they're ready for discharge. Well while I was doing this case, the two attendings that knew about this were sitting outside and they said, we'll take care of this, we'll work on this case for you and go see your patient.

It turns out it was a Greek patient and their family with about 15 people, and I was gone for about 45 minutes. It is what it is I was gone and I came back and they had done the Dina CT, I don't

think this is gonna rotate, I think it's embedded, but they had done the Dina CT and moved on, I walk in and this is what I'm charged with. I come in the room and the fellow is in there and the two attendings

are sitting outside and beautiful left gastric here and he's in the process of embolizing the left gastric artery. And I inquired about the Cone-Beam CT and they said, ah no, the clips weren't anywhere near the pseudoaneurysms, so it's good.

So I'm like, okay, so we finish this case and the left gastric artery was embolized, and I can't that I felt great about it, but the case was over. Again, I went home that evening and I probably took an Ambien that night to fall asleep cuz I was a little bit worried about this patient.

It turned out actually that this was early in my career. I think it was probably my first year as an attending. And in fact it was, I remember the fellows were [INAUDIBLE] He was in my first fellowship class but the next day was my birthday, and I was a single guy, my family was

the people I worked with being at work. So I go in a little early to round with the fellows, it'll be fun, and I noticed that there are people in the main [UNKNOWN] Doing a case and it's 6:30, 7 in the morning.

It looks like somebody should probably call 911 because there was blood all over the place, it looked like there was something untoward going on towards this patient in the room, and then I noticed it was the patient that we had the night before, and it turns out as you can see here,

this is now the celiac and the splenic, this patient's on Pressers, that pseudoaneurysm ruptured that night and I'd be lying if I didn't think it had something to do with us embolizing the left gastric artery and actually changing the pressures that were within it,

maybe it would have ruptured on its own, but maybe we helped it along its way and now it was a harrowing case, Earl Nemechek was doing it and he actually, one of our other attendings was in the room with him too and they were trying desperately to get into this branch and embolizing it,

it took quite a while for them to do that. As you can see they made their way out there and actually were able to embolize it here and thankfully the patient did well and he recovered from this. It takes me back to simple things but I couldn't leave that case

not thinking that the patient was bleeding from that splenic pseudoaneurysm and even I never went back and looked back at the Dina CT because I just took their word for it, indeed as this thing rotated, those clips were all over this thing, so a lot of times I find that,

people offer opinions or you have, it is different things going on but it's always my gut, my interpretation that really, I think drives me to what I do now, it took some time to get there

early in your career. Yes >> [INAUDIBLE] [INAUDIBLE] >> It had eroded into the stomach. [BLANK_AUDIO] Yeah they saw it endoscopically and they tried to bend

it inside the stomach, and that's why the [INAUDIBLE] Coming from the left gastric. >> [INAUDIBLE] >> Yeah. Comments or move on to something else.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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,

Dr. Aruny is a longtime advocate for the avir a huge contributor with helping us with our annual meeting with presentation and also an annual contributor to the cherry almond foundation he was also named our gold medal war recipient in 2009 so without

further ado my privilege to welcome back to John aruna thanks Mike pardon my little raspy voice I wish would say cuz I was out all night with you guys having a great time but I think it's just the Connecticut weather catching up with me

Mike failed to mentioned that I was technologies for eight years prior to going to medical school and so I stood in your shoes what can you walk and know exactly what you do and I think in regards to the last lecture reminded me

quite a bit of my gold medal lecture where we talked about your importance of technologists in the digital age and we really depends tremendously on you for many things and clearly we couldn't do what we do without you all so today's

the last day and I thought great well they've saved the best to last and I thought well maybe the fact that configure a lot of people have gone home already and he won't embarrass himself too much before smaller audience I know

but anyway thanks for coming and the answer to talk a little bit about the evolution of our treatment of aortic aneurysms that maybe we are still involved with aneurysm repair along with our vascular surgeons we do a lot of

cases together some of you may not some of you may do cases only with that the surgeons where you serve as the technologists in a hybrid operating room environment go so celebrities who died of aortic

aneurysms are you know most are pretty well-known you know Albert Einstein George G Scott John Ritter and Lucille Ball this disease is still out there it's still a problem and interestingly enough it goes back you know to Egyptian

time so it's not simply a disease of modern Western living and let's start in

bifurcation here. And catheters replace,

and this patient is your classic poorly compliant coming back to you at all hours of the night with this kind of complication or this one. [LAUGH] Typically 5 PM on a particular day. So traumatic dislodgements to the catheter, comes back to the ER with

a gross amount of blood in the bag, basically distending the bag. And after the last exchange which seems to have gone fine cholangiogram is performed, hemoglobin is 5.5. This is the cholangiogram, everything looks fine so are we done, do

you just send them home? [LAUGH] No. Let's change this over wire for side arm, sheath inject the biliary duct and there's the main portal, the connection is main to main right at the bifurcation, right at the point where that pesky stricture has been in the past,

this patient was under transplant list for multiple problems including elevated LFTs and the [UNKNOWN] was covered. I realized we're caging up this side but [INAUDIBLE] trumps everything else. So we did place this,

later on we did a couple of days later, put a left sided tube once we knew the patient wasn't bleeding to death, alongside that covered stent. Let the patient drain for a period of time and believe it or not, we thought the patient would go to transplant but these were removed and the

patient's LPTs was still stable at 6 months after removal of both external drains. This is gonna occlude. This was pre wall flex/g and bibil/g so we probably would have chosen a covered stent, retrievable covered stent for

you know the homographs in the kid on account of eric abdominal yarders really

couldn't keep up with the pace those pictures have had a pummel you are it again use them and so the next real milestone and the thing that push things forward into the modern age was the introduction of the Dacron knitted draft

you know first published by denton cooley and mic just went out of my mind you knowing means that you guys infected and where they described its use in the treatment of thoracic aortic aneurysms and here's a picture of a modern Dacron

graft in sight to a jamming aneurysm is still there he'll be placated over the graft Michael DeBakey Thank You Mandela and then coolly publish their first work on synthetic grafts and that really opened this up to a wider use because

they didn't have to depend on people dying and donating the era aortas transfemoral interest abdominal the endograft age begins in 1991 awam parodi and the julio julio Paula's from San Antonio published the first paper

looking at their first five patients the transparent alumina graft implantation of abdominal aortic aneurysms in their first model they took a piece of Dacron and then with a palmas dance on top the bottom was not extent that it was left

free remember they're just discovering what to be here because inspecting below the renal arteries to treat the aneurysm here's the one of the first aneurysm so that they reported and they have seminal work treated with a graft and what's

this is an 89 year old with aortic stenosis and plan for TAVR. I'm not gonna show you TAVR cases here so, but the reason I wanna show you this is now we're seeing more and more of these, and whoever reads CTAs and all that and I just Can't believe that there's so many 89 and 91 year old getting all

this complex procedures. I mean when someone comes to us for a stent at age 75 you're cringing and now, you get all thes every 89 year old in Virginia now is gonna get TAVR so. Otherwise they are fearless. So this is this patient and you see, we always do these analyses for them IRED/g, LA/g, CTAs, MRAs and you see the right side, there's nothing. There is

no common femoral and there is some collaterals and no external iliac. The left side is also very small, you know 5 mm. There's no access basically. So all these patients go through transapical TAVR, all right?

But now there's new technique that's been developed which is the transcaval access into the aorta. It was developed mostly for TAVR patients and there's a group by NIH that pioneer this study and now they mentor programs to do it. So we were one of the sites for that and then we,

as I was somewhat involved in helping them as to be a backup for this when it started. So that was the plan and this is this patient. You see him with really very calcified,

no good access, and this is the cave and this is the distance. So I'm gonna show you this case then I'm gonna show you a good typical case to know how this should look like and this is the one that didn't go as well. The distance should not be that far.

All these cases are analyzed carefully, make sure there's no calcium where you wanna access and the distance is not too far. In this case was kinda getting more comfortable with with the technique, so pushing the envelop and in this case access was obtained from the cava into the aorta.

And there's several techniques you can use. You can just use needles or in that case this technique it uses an 014 wire and have a Bovie at the outside and basically use a cuttery and just pierce through and it works out pretty well. Then you snare it and now you have access.

You balloon dilate the track then you serially dilate then you put your sheath. And now the case goes as well and at the end they use and ASD closure device to plug it. And that's it. I apologize for the images I literally went to the cath lab and took pictures of this thing so that's why there's all this

glare. But that's what it is. Now for this patient, this is at the end of it before deploying it. It's very common to see flow into the cava and that's expected because that will go away. And as long as it decompresses into the cava it's fine. The problem is when it forms a pseudoaneurysm

this means it's not good decompression. And this is what was here. So I was standing in the room and I said well and this is not looking good. I was like we see this all the time and this will die on itself and I'm not so sure that was the case but, well let's get a followup and see what happens. Well I wanna show you how it looks when it should and this

is the case that we did for a TVAR as a first angle of this case was published. It was one of the first cases of TVAR using transcaval access, again small access vessels. And this is the analysis that you get. You try to find which spot doesn't have much calcium and you measure the distance, make sure it's close enough. And this is it here. You get your access again, these are the tools that you use.

And trim the 0.14 wire and a bovie and you go with a snare. You do several angles to make sure you enter the snare and then you snare it. Probably that's one of the first image. And then this is how it looks. And they have an algorithm for what Amplatzer plug you use.

So for this the AST closure device you use and we have our [UNKNOWN] cardiologist who does all of these and works with us on these cases. You have to master that technique which I think is good for someone who knows what they're doing to do it to be honest with you. You always maintain a Buddy Wire just in case things are not going well, then you can re-access it to just close it.

And then once you're happy with the outcome you can just give up and get it out. So if there's only filling of the cava and no pseudoaneurysm that's fine. And most of these do very well afterwards. You see on the followup CT''s the filling of the cava only but you don't see

a pseudo and then that's a full die down. And this is afterwards and we waited, did another one and everything was good. So that was the good case. Going back to this case that was not

as good, you see a pseudo aneurysm. And my point was we need to treat this now, well let's get a followup, well fine that's a followup. So the followup was of course the CT was ordered in the morning, was done at 4 PM. We read it at 6 PM and became that what we had planned to do that

night did next night, when I was not on call. So now there's a pseudo aneurysm here coming out of this really, really chunky aorta. So now the patient went to IR And remember there's no right common femoral so now we have to go through the left side and that's our

only access, so that's how it is. The patient was semi-stable I would say. A lot of issues and she's not an open candidate that's why she went to TAVR so there's a lot of issues with her medically and she's older, so and everything

was very tenuous. So we did this, we went in and you see this big pseudo aneurysm and you see this is where the plug was. So we said, well simple, just put a cuff here and that should take care of it. The problem is we have sizing issues.

So this is 12 mm, this is 9 and this is at the bifurcation and now we are getting into a tiny common femoral. And you know you can do a lot of imaging because you have access from the right. Now you have to get maybe RMAXs to do it which adds to the complex of it, the patient is getting too unstable

so we need to move fast. So we put a, wanna make sure we get a good apposition here, we put a limb. This happens to be a Cook limb and a 14-55 and just landed it just short of this really smaller component while there is still a leak. I said well it's most likely a 1B from below.

So now how much you are gonna extend? It would be nice to go in and do kissing stent in this. But you don't have access on the right. So if I had a common femoral you can recanalize but there's nothing to start from. Any thoughts or do you want me to keep going done with this disaster? >> [INAUDIBLE]

[INAUDIBLE] >> There is no right common femoral. They're gonna have to create something there. Most of the times what worries me with these kind of raptured cases and such is, even if you do that are they gonna get back filling

through into lumbars, who knows if it's still gonna fill or not even if you do and AUI. But that was a thought and we couldn't do it. So there's no option for a fem-fem. >> So come the arm and do a bilateral kissing covered small limbs or iCASTs or something

->> Into the iliacs. >> One from the ->> leg >> and one from. >> The right side of the arm and the left [INAUDIBLE] [INAUDIBLE]

>> Yeah so that's >> But that's one option I guess off the top of my head ->> Again Rob, do you have any thoughts on this? >> No I'd do exactly that. I'd put the right side's stent from the

arm and the left side's stent from the groin and I'd probably use an Atrium's iCAST. >> Yeah so we had that thought and I wanted to try a couple of things before committing into this. It was again in this situation is a big mess we have like a gazillion people and I have re-prep the arm, move the anesthesia people out

of the way, get the arm out, prep it and all that stuff. So while I have that I just try to extend with a stent as far as I can get away with and balloon it. And of course it didn't work. So there is still a leak here.

So before doing this and I thought that maybe it's worth to do what we just talked about, is see if we can embolize this. So and I ensured that these are the numbers, this is that planing that I did before putting kissing stents.

And then before doing it, it's like let me get a thought. Robin mentioned this in his talk the other day about doing some of these endoleak embolizations through access adjacent to the graft between the wall of the aorta or iliac and the graft.

So this is what we liked it to do. So you see the catheter here getting around the graft that we placed and get a microcatheter all the way out into the area where there's aorta. And started by putting some onyx. Of course start going into the lumbar which was fine with and then

kept filling all the crevices around it a much as we can, to fill the area and kinda bathe where this Amplatzer or plug once was. So that all onyx around that area and actually that's did the trick and stopped it. So I think this onyx as a plug problemsolver with these leaks don't go away.

It is just poor apposition and especially with calcium. And there's usually just a few millimeter of crevices in there that just need to be filled. Once you go in and pretty much cork it with onyx you just can get rid of some these endoleaks. So it didn't take much. It just was not that hard to navigate between

the graft and the aortic wall. And once you wedge a catheter there a microcatheter can go easily and now you're free and you just fill the entire space that is not completely opposed by the graft into the aorta. Fill it with onyx and then that did the trick. And this patient did very well. We got rid of her leak that was there

and this is the follow up. And at one month she came back and, that's the plug and there's no more pseudoaneurysm, and that took care of it. One thing to consider was to use a different type of cuff,

for example the Endologix that has the cloth on the outside. We have better apposition than doing this. And that's what actually they were coming to have as a back up for these cases to have an Endologix cuff, which we didn't have it at the time.

I could have ordered and waited, but I didn't want to wait. But part of their protocol for these transcanal cases is to have an Endologix cuff as your back up because the cloth was the outside and the metal is the inside and has more likelihood to actually connect, go and they call it boller

out and have better apposition and touch the wall better. So I think the program slowed down significantly after this case unfortunately and >> [LAUGH] >> This was a poor selection that the people who were in charge of the program from NIH and advised somewhat against

this case and said well, you need to kinda wait before taking such a case on. And clearly, lessons learned, very calcified shouldn't do it but non-calcified, now we're using an all-trans cable for endoleak

embolization and I think that works out pretty well and it's very safe to do. So I think that technique s still valid, you just need to choose your patients well. >> Do you use this technique for access in the aorta for other things for example TVAR?

>> Yes. So TVAR the case I showed was from a TVAR and it was published as a technique in [UNKNOWN] few months ago. So I think it's a very good technique for that. Doing an illiac conduit is not trivial and I think sometimes like in this case needed an aortic access. If this patient had a thoracic

aneurysm such access you need to actually have to cut down to the aorta. And our surgeons have done that, actually directly accessed the aorta. So this could be a huge problem solver.

And I think it's gonna be adopted more and more. These Amplatz are plugs, these ASD closure devices. They're not as simple as all the other devices. You have two sizes and the cardiologist, the congenital cardiologist, whoever works at your institution,

is pretty good with it and if you can team up with them they'll be willing to do it and maybe help them with their TAVR programs. I think it's a very valid technique and I think we can use advantage of it. >> It's a great case, super elegant yeah.

>> [INAUDIBLE] >> Yes. >> [INAUDIBLE] >> No we'd have put the limb in. And that was the plan.

I was like we're here, we have access, let's just do it, let's just put the limb in, we'll just delay by day and I'm kinda glad we ended up doing in IR. We had other stuff ready for us, we had to use onyx and all that which was good. I don't know if AFX would have fixed, it could have.

But yeah, that was the plan. At the time that it, their protocol is that if there's a pseudoaneurysm, not just filling of the cava then you put a cuff. And that's

the plan. But it was kinda later in the day they just wanted to wrap up. But that's not the point of this discussion. I think this discussion if you see that appearance which is the pseudoaneurysm then the plan is to go in and put the cuff in. >> So mechanistically this far is the Bovie system to the wire,

they just attach the Bovie to the end, the outside end, the trailing of your 014Y against the location. >> It becomes like a hot knife and just goes through. Yes. I mean you can use anything to be honest with you.

But they just wanna use this protocol because it worked with them. They just wanna use it the same way which I think is fine. >> Cause I've used the outcome to - >> Yes. >> [INAUDIBLE] >> Endo-leak.

Yeah I'm use the, a lot of people use different, I use the transceptal needle. There's colopental needle a lot of people use different [UNKNOWN] needle. [LAUGH]

You seen it all presented.

I use for iliac occlusions on most patients today that has morphed overtime for a couple of reasons mainly due to complications. It's worth noting that embolization and iliac occclusion and endovascular iliac inclusion repair embolization in the literature is most common in those repairs than in any other chronic occlusion that is endovascularly

repaired and that's certainly been true in my own practice as well. So this is a patient, 59 year old waitress, multiple years of progressive right calf pain with ambulation. Over the past month, her exertional pain had rather dramatically

progressed to rest pain and as I see not infrequently when she presents she believes or somebody has told her that she has a broken toe and when you look at her toe it's not that it's broken it's that it's ischemic and she has a small wound on the fifth toe of her right foot.

These are her noninvasives. The left is close to normal and her right has a diminished AVI, degraded PVR, and you can see she has a monophasic post-obstructive common femoral artery waveform. So on her CTA, and this is something that I see not infrequently with particularly with female patients where they just have congenitally

small vessels and that's what we see here. You can see on the upper slide that she has a near flush common iliac artery occlusion on the right. She does reconstitute her external iliac artery on the right but it is super small. I mean it's like three millimeters at most.

And then her common femorals both her "good" side as well as her not good side are both tiny. And what I have started to do over time is to approach these in a similar fashion as I would a pedal access case and I'll explain what I mean by that.

So challenges in these case very small common femorals and external iliacs on the side with the occlusions small vessels on the contralateral side and very very thin patient well if you're gonna use closure device that implications as well. So this is her presenting angiogram and you can see,

as we knew from the CTA that the occlusion is not terribly long but the iliacs that are open are very small in caliber. In these patients I have migrated a way from placing a sheath on the affected side. Because what I always try to do is to think,

with whatever repair I'm gonna undertake in a patient regardless of what segment it is, is my access going to cause a problem that I didn't have at the beginning of the case? And this is definitely the sort of patient that leaving a sheath in while I revascularize that right side,

very well could end up causing complications, or if there are other complications, make it difficult for me to deal with them. So how I do this is, I do it just like I do a pedal access case. I do not place a sheath on the occluded side.

I just use a crossing catheter in this case it's a 018 rubicon, an 018 crossing wire V18 in this case, and I used that without a sheath on the right hand side. And then from the contralateral side where I have my sheath I'll snare the wire.

Sometimes the wire you could direct it without needing a snare, but most of the time, it's just simply faster to snare the wire and pull it over. And then as Brett had show on an earlier case, then you have through

and through access and you can cross the bifurcation, working from left to right in this case. I will advance, I will swap sides, you can see in the third image here come back up and over with the crossing catheter.

Once I feel that I'm in a patent vessel, pull my through and through wire access and inject. You really do not have to hold pressure here long at all, a minute at most.

You get hemostasis rapidly again just like with pedal access. And then I work in an anterogade fashion. So in this case she's very small, very thin, she's an active smoker this is exactly the patent that I'm gonna use a Zilver PTX off

label but I'm gonna a Zilver PTX in her iliac vessels, I out two of them here. I can stent down as far as I want because I don't have a sheath on the affected side that's gonna affect how far distally I can place my stent. And you can see the post angiogram here and ended up using an Angio-Seal

on her left side and if somebody is very thin, what I do is I tunnel under the skin like you would a tunnel catheter before. I make the puncture into the arteriotomy which allows you to kinda bury that Angio-Seal plug in there. So the advantages for me of using the snare technique is that the

retrograde occlusion recanalization, I can still cross it retrograde but I'm not gonna repair it retrograde. There's no ipsilateral sheath that's gonna interfere with stent placement, it's not gonna potentially have a thrombotic complication because the vessel is so small and if an embolic event occurs,

I am directed the direction that the embolus is going and it facilitates treatment of the embolus in the patient. And that's it.

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.

we end up having to do a lot of embolization to get the job done. And probably made some really not so great decisions in the process of trying to do that. But so this lady had relatively young lady with hypertension had a big type A dissection requiring emergent aortic valve replacement

and replacement of the ascending aorta and she subsequently had had her descending thoracic in order to have false lumen degeneration required replacement of her descending thoracic aorta she ended up having a third [INAUDIBLE] for some reason I can't remember exactly why, but she had her chest entered by the same surgeon

three times and now she had a residual dissection of of her transverse arch that was false lumen annualism/g that was enlarging and she was actually getting substantial chest pain, so you can see that she's got dissection flap going up her left coated, a little bit

at the origin of left [INAUDIBLE] her anominant was not involved but has this big Big false lumen aneurysm of the transverse arch and you can see that the true lumen here is pretty compressed and this is her graph [UNKNOWN] thoracic kinda searching for a couple more pictures of that. So here's the entry tear into the

the dissection the false/g lumin here in the transverse arch, distal transverse arch. And so we had some discussions and thought about what we might be able to do here and so we're going to the cardio-thoracic guys did not wanna enter her chest for the fourth time.

I think that seem reasonable although this is a young lady and actually despite the fact that she's always in operation she was pretty active and probably had other than this thing had a pretty good life expectancy. So we want to try to do something that was durable as well but this was a challenging anatomic/g situation. One of our colleagues on surgery.

Mike Malinowski took her to the operating room and did a first remapped route here. So this was her initial angiogram. Sorry. I gotta get this thing over here. So you can see her proximal aorta,

replacement aortic valve her great vessels with dissection going up her left carotid you can't really see the pack going in, the subclavian although here now injecting into the false/g lumin/g which was actually really easy to get into with even a [INAUDIBLE] catheter coming from below.

You can see the dissection flap going up her Carotid then a little bit up into the subclavian. So you guys have any thoughts about have you faced things like this at all? These are difficult situations. >> [INAUDIBLE] [INAUDIBLE].

>> Yeah and in order to do a full sort of deep branching kind of thing they would have to enter her chest again. So we're trying to come up with solutions where we wouldn't have to enter a chest and I guess go ahead. >> [INAUDIBLE].

>> And we are concerned somewhat about some of those approaches because of some of the. It's difficult to think about how you would size this, the graft/g because true lumen/g was really small compared to the [INAUDIBLE] distally and even ascending the other way.

So sort of thinking about how you would put together a graph system that would do this well was challenging I think. So anyway we first she got actually [INAUDIBLE] bypass of her great vessels search where she's got a carotid [INAUDIBLE] subclavian bypass, and she tolerated that extremely well, was only in a hospital

a couple days. And then we brought her back with the intent of now that we embolizing her left carotid. And we probably not so brilliantly thought that we'd be able to close that entry tire in the [UNKNOWN] now with an amplatzer.

And any experience with using plugs in that sort of an atomic distribution anybody? It's I think anybody whose done [UNKNOWN] realizes that a force is involved, in the thoracic aorta and the flow is way different than it is in the [UNKNOWN]. And I think we probably should have recognized that to begin with

but when we got in here first, we embolized the left carotid and then got the amplatzer up there, you can see it was a 22mm amplatzer. And we deployed it, it was actually relatively straightforward to get where we wanted it to be and we confirmed with combi MCT that

we had it lobs in the false lumen/g and then just the one they are trailing and before we let it go was in the true lumen/g which is exactly where we wanted it. And as soon as we let it go we got to watch it kind of squawk forward and now you can see that it went forward with the flow and only

the one trailing initial lobe was in and the rest of it it's kind of bouncing around really not looking so happy on [INAUDIBLE] especially in the descending thoracic aorta there. And I really thought that at any time this was gonna just squirt through and embolize distally. But we knew that this was not gonna be a good long term solution

for her. So we brought her back and just bit the bullet so we're gonna have to try to put an endograft and just sort of exclude this. And we did two-piece overlapping two piece and I'm sorry I missed some of my images here.

I'll show you some pictures of the endograft later. But we put the two pieces overlapping. She tolerated actually really well. But on follow up she came back a couple of months after that and she still had obviously a big endo/g leak here in this false lumen/g aneurysm, it was starting to get a little smaller and actually

her substernal chest pain was getting better. But she still had an endo/g leak and you can see here's the amplatzer device smooched against the wall of the aorta out of the way now. So we brought her back for an angiogram and using reverse [UNKNOWN] catheters we were actually able to get around the graft and we found that unfortunately when we had done the initial left carotid

embolization we had only embolized the true lumen/g, But we had not embolized the false lemuns so we had to go back up and embolize the rest of the left coratid, and then the left subclavian artery which was supposedly surgically ligated was actually not ligated, and was another source of endo/g leak and with all this

flow that was going through and actually coming back retrograde into the false lumen through the left subclavian stamp. And so we were able to get into that also and embolize that and this was her eventually her follow up scan that we were able to to get this thing completely sealed off and she actually went a few months after this she went on a vacation in Mexico.

And she went zip lining in Mexico in the jungle so she's alive and well and we're following her now on a yearly basis with CT scans but it was a challenging anatomic case. How many of you guys know [UNKNOWN] thoracic endografts at your place?

Good good. You see any of these sort of transverse arch [UNKNOWN] dissections they can be a real big problem. Sorry [INAUDIBLE] >> Yeah yeah they're not fun [LAUGH]

Yes. >> After you showed [INAUDIBLE] [INAUDIBLE] I didn't understand why you chose the [INAUDIBLE] >> Yeah I think well that was a mistake. We were intimidated a little bit again by and I still have a lot of trouble thinking about and wrapping my head around sizing endografts And dissections especially chronic dissections with true lumen and

false lumen and trying to figure out and just we don't do a tonne of them so it's a little bit of a challenge in here, the mismatch between size of the true lumen and the [UNKNOWN] and trying to put that together was a little bit intimidating which is why we kind of try to do this alternative solution which didn't work so-

>> [INAUDIBLE] >> We actually did another CT and it was still the same but that's an interesting thought. This certainly can be dynamic situations so, good questions.

So these complications that we're talking about as well, with really good technique, with employing multiple sort of adjuvant things

to how you do your embolization can actually be reduced. So here's a patient that was embolized prior to my working at the University of Colorado. It's a 43 year old female on chemo for metastatic rectal cancer. She has to keep getting her chemo cancelled because she keep's showing up with her platelets too low, they can't get them up despite transfusing her with platelets and so they have

to keep cancelling chemo appointments and so she asked is there anything we can do and one of our oncologist sent the patient to us. This patient was embolized by one of my partners. She was referred for partial embolization, you can see she has quite a large spleen, it was 18 centimeters at the time and that was probably due to a combination

of lots of chemo and previous selective internal radiation therapy and this was sort of in the time before people were doing lobar to try to decrease the portal hypertension caused by cert. And then so this is sort of the angiogram that was done, she isolated the lower pole, she embolized that whole lower pole with about

half a vile of beads a one to three of three to five hundreds and then she took the rest of it and just kinda flashed it into the main splenic artery. And she ended up getting a decent result from the stand point of the amount of spleen that was devascularized you can see what it looked

like at one week and then following ten months. The problem is this patient spent two weeks in the hospital had a couple of parecentesis, a couple of thoracentesis and was on a dilaudid PCA for a week and so not exactly our favorite thing to ever happen but that was kinda how it worked.

She then came back ten months later Later and this is images from her ultra sound of the devascularized portion of the spleen in the associated ascites adjacent to it. And prior to this embolization, her platelets were 39 immediately following they went up to 155,

but she actually recurred a year later which you can kind of expect if you had actually, done the volumes on the spleen. She actually took about 40% of the spleen and most of the data says if you don't take at least 50% you are going to recur with respect to the thrombocytopenia.

Platelets 89 at this time referred for another splenic embo. So I brought her to the suite and I did it a little bit different than my partner to try to reduce these complications. This is the hematology patient who basically has a normal liver function and so I can do a lot of tricks in this patient that I

can't do in my liver patients. In particular I gave her inter arterial toradol right before I started the procedure. I started the steroid taper with the first dose given in the holding room prior to starting the procedure and then I did a seven day steroid taper, I gave two weeks of antibiotics and then for patients who can get nonsteroidal anti-inflammatories, I give three days

of burst NSAIDs so I give 800 tid of Ibuprofen. And it's amazing the difference that that makes relative to what you normally see with these splenic embo patients and nonsteroidals just they work better in these patients, I don't know why but they do. And so I basically did an angiogram just like that, picked on another

lower pole vessel, embolized it to stasis with 500 to 700 micron particles cuz again the pain can be related to the size of the particles you use. The smaller you use the more likely you are to have pain but you don't want to use too big a particle because, There was a nice study published in the pre transplant literature

from Europe, which demonstrated that if you use particles larger than 800, you tended to get more recurrence of the thrombocytopenia, because they develop intra-splenic collaterals. And so this patient was put on a PCA overnight, didn't need the PCA in the morning.

Went home with her non steroidals, and actually came back and saw me a month later in clinic, and was just fine. And then she actually did fine until later. You can actually see this a lot colon cancer that's in her liver.

So, she actually died five months following or four months following the procedure? Yeah. Four months following the procedure platelets 255 immediately following the procedure, ann 155 at the time of her death. Probably in part due to her spleen but also because she was getting

chemo at the time, right up to the point of her death.

There are more videos in this playlist...
Upgrade to an unlimited account to access full playlists & more!