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
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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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

of this session. It's our first case, 74 year old male, history of cirrhosis and persistent thrombocytopenia. As I mentioned we start off our procedure through the radial approach, we always do an angiogram to begin with to make sure there's any anatomic variance and interesting,

we saw only the radial artery in this case. No ulnar artery was shown, we did a more forceful injection and then we're able to reflex the contrast into brachial artery and then the ulnar artery,

was just an anatomic invariance of the anatomy. So we proceed with our catheter down into the celiac trunk, this is the Jacky Catheter has a very nice curve and it's very easy to engage the celiac trunk. And a little bit different from what was presented here,

we tend to embolize our spleen, we get a microcatheter from their distal into the lower two thirds of the spleen. We use PVA 300 to achieve distal necrosis and on our way out, we embolize the proximal branch with coils.

The idea should decrease the chance of reperfusion and recurrence of thrombocytopenia on those patients. And so that's what we can see there that's the post embolization picture. We see the coils in the more proximal part of the branch and we see the preservation of the upper pole branch of the spleen and

no perfusion of the lower two thirds of the spleen. So after two weeks the patient had an increase in platelets count to 84. Our second case, patient 69 year old male history of cholangiocarcinoma and

So this is a 68 year old who had two prior histories of lung cancer who's a Vietnam vet and he has a 60% predicted FED1, 65% DL so not bad but had already had two cancers.

He was done having surgery. He said, I'm not doing any more of this and we found a new lesion. EBUS was again negative and it was a biopsy proven adenocarcinoma. This here is our lesion down here. Here's our aorta. Here's vertebral bodies.

You can see some of these chain sutures. Ignore the subcutaneous air for now. So what will we use and why? So right in the center in your vital structures. Who says RF? So there is some data to suggest it's okay.

How about microwave? We get a couple of people again also some data to suggests okay. How about cryo? All right. You guys know that I'm a cryo guy at this point. [LAUGH]

So the answer is in fact cryo. The reason being the adventitia or the collagen matrix of a surrounding structure in cryo is maintained, and what we would see in this particular case is that the outside of the aortic wall and the inside of the aortic wall is being maintained by continuous flow of blood,

and then also by the collagen matrix. And what we expect to see is an ice formation like this where you have the aorta causing some decreased ice formation, there's a cold sink. The bronchus here causing another cold sink and a nice ovoid shape ablation. So here that we are intra procedurally.

Notice how I kind of cheated toward the aorta, that was intentional. All right so this is a Perk 24 being placed into the lesion. The tip is beyond it and as soon as I got it to here I stuck frozen immediately and then hoped for the best.

And then we monitored the aorta very carefully, did give him some contrast to make sure it didn't have a psuedo aneurysm. Notice that we are at a tangent to the aorta to the vascular structure. You don't really pointing at the vascular structure with the cutting tip needle, its just bad form. And here we are post. Where we see the ice track being formed out here and of course you

can see that air has found its way from the inside world to the subcutaneous tissues. Didn't drop his lung because he had multiple surgeries before. And this is a good example of how to do a cryo on the aorta. Guy did great. He died four years later from heart disease.

So I'll stop there. >> No why didn't you mobilize that again because this is really- >> Could not. >> You tried? >> He was multiple surgeries already.

> You tried though? >> And even with this you could see that dropping his lung putting lots of air, it won't go any where. So he was stuck. All right. Please. >> Great. >> [INAUDIBLE] >> I did nothing.

I did a small dermotomy in the skin surface, let it all come out and did nothing. It all went away the next day. >> You don't need to do anything. >> But I did it was kind of cool because I put a [UNKNOWN] and hoped for the best.

>> [LAUGH]

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.

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

78 year old male patient with [UNKNOWN] liver disease, portal hypertension,

known large gallbladder mass. Came to the emergency room pouring out blood. Did not go to the endoscopy suite, after talking to the endoscopy folks and ER doctor. We decided that he will come directly to the IR.

Now, here you can see that patient also has biliary ductile system dilation. Here is your masked, kind of stressed out portal vein. So having this, my biggest concern here was to get into the portal. but my concern was that I might end up going into the mass first.

And it probably will be a futile exercise, and considering that he was pouring out blood I wanted to get into the portal vein as quickly and as soon as possible. So how do I go back? How do I go back sorry?

>> Just click on this. >> Okay we got it. So [BLANK AUDIO]. again using the software we kind of outlined the mass here got the outline of the hepatic vein. Outline of the right portal vein and again it's one of those cases

where it's better to be lucky than good. Luckily it was all there and once it's lined, I again gave it a shot because patient was bleeding. I had no other choice but to go in. And here is the wire. You can see and we were able to create a successful tips without

actually going into this. Had this technology not been there I would have still attempted it, but I felt a little more comfortable, a little more guided mentally prepared to go in, because I really was avoiding going

through this mass and [INAUDIBLE] you can see the masses here and here, it takes us here, and I take some cases from my colleagues. >> Thanks [INAUDIBLE] just a quick comment Doctor Kapoor/g those I/g guide lines are self drawn in cuz- >> Yeah they are drawn in.

>> You don't segment the bloodvessels so they rotate with you when you rotate the arm. >> Exactly we are somewhat lucky in a way that one of the Siemens engineer is at the clinic seven days a week [INAUDIBLE] so he might be here. Randy are you here?

He wanted to come but maybe not. >> We've used a similar vein soft way for placement of a TIPS in particularly difficult access. We've also tried for opacification of occluded HJ loop by sticking the loop percutanously just injecting, not even necessarily putting

anything large [INAUDIBLE] very skinny needle, and at least showing you both sides of obstruction. > That's a great approach thank you. >> Thanks very much. >> [APPLAUSE]

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.

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.

history of [UNKNOWN], complicated by portal vein thrombosis had

[UNKNOWN] transformation as you can see all these juicy/g colaterals here and again presented with [UNKNOWN] had a failed, tips at outside [UNKNOWN] here a lot of these colaterals. So again using the same technique, the first thing I did the SMA

angiography figure out what's the timing of these colaterals which are getting opacified. So once you have that time, then you can time your come beam CT accordingly then what to rotate your II to acquire the CT scan, and create the 3D constructions.

And here is the portal vein collaterals outlined and this is the, flural/g overlay again you can transfer this over your fluoroscopy and again I find it very useful that in some of these patients it just doesn't change the 3D images even if you rotate the II. So this relationship will stay the same and again we created this,

got into Mesentric circulation, place some grafts, so these patients

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.

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