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The Case that Launched the Cornell PERT (PE Response Team) | Pulmonary Emoblism Interactive Lecture
The Case that Launched the Cornell PERT (PE Response Team) | Pulmonary Emoblism Interactive Lecture
adventitiaangiogramaortaarteryaspiratedbloodcatheterschapterclotdysfunctionFistulafrontalhemorrhagehypotensionhypoxiaintracraniallobelungPE in right main Pulmonary Arteryperfusionpertpigtailpressorspulmonarypulmonary arteryresectionselectivesheathspinsystolictachycardicthrombustpatranscranialtumorventricle
The Path Forward | Uterine Artery Embolization The Good, The Bad, The Ugly
The Path Forward | Uterine Artery Embolization The Good, The Bad, The Ugly
chapterembolizationfibroidfibroidsgynecologistgynecologyhysterectomyinterventionalNoneobgynPathophysiologypatientpatientsprocedureproceduresprogramsurgicallyworkup
CTEPH Case Example | Management of Patients with Acute & Chronic PE
CTEPH Case Example | Management of Patients with Acute & Chronic PE
angiogramballoonchaptercontraindicatedCTEPHdiseasedistallyglidehydrophilicinterventionalmichiganNoneocclusionspatientperfectperfusionsegmentalstenosissurgerywirewires
Benefits of UFE | Uterine Artery Embolization The Good, The Bad, The Ugly
Benefits of UFE | Uterine Artery Embolization The Good, The Bad, The Ugly
arterycenterschapterembolizationfibroidgooglegynecologistgynecologistsgynecologyhysterectomieshysterectomyinterventionalMRINonepainfulpatientsprocedureproceduresseansmartersurgeryuterine
Renal Ablation | Interventional Oncology
Renal Ablation | Interventional Oncology
ablationcardiomyopathycentimeterchaptereffusionembolizedfamiliallesionmetastaticparenchymalpatientpleuralrenalspleensurgerytolerated
Introduction to Establishing Periprocedural Screening Guidelines to reduce bleeding risk associated with Image-Guided Theraputic and Diagnostic Procedures | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
Introduction to Establishing Periprocedural Screening Guidelines to reduce bleeding risk associated with Image-Guided Theraputic and Diagnostic Procedures | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
anticoagulantscampuschapterclinicclinicalcoagulationgraduatedguidedguidelineshospitalinpatientinpatientsinterventionallabsmayomedicationsneuroNonenonvascularnursenursingpatientspracticeproceduresradiologistsradiologyrochesterspecialistultrasoundvascular
Indirect Angiography | Interventional Oncology
Indirect Angiography | Interventional Oncology
ablateablationablativeaneurysmangioangiographybeamBrachytherapycandidateschapterdefinitivelyembolizationentirehccindirectintentinterdisciplinaryischemiclesionographypatientportalresectionsbrtsurgicaltherapyvein
Aspiration Thrombectomy | Management of Patients with Acute & Chronic PE
Aspiration Thrombectomy | Management of Patients with Acute & Chronic PE
angioAngiodynamicsAngiovac CannulaAspirex CathetercatheterschapterclotdevicedevicesfrenchIndigo ThrombectomyNonepatientPenumbraPenumbra Inc.sheathStraub Medicalthrombectomythrombustpa
Cone Beam CT | Interventional Oncology
Cone Beam CT | Interventional Oncology
ablationanatomicangioarteriesarteryartifactbeamchaptercombconecontrastdoseembolicenhancementenhancesesophagealesophagusgastricgastric arteryglucagonhcchepatectomyinfusinglesionliverlysisoncologypatientsegmentstomach
What are the Options? | Uterine Artery Embolization The Good, The Bad, The Ugly
What are the Options? | Uterine Artery Embolization The Good, The Bad, The Ugly
chapterconsequencecontinuingdiseaseembolizationfibroidhydronephrosishysterectomymyomectomyNoneoptionspatientsperiodstransvaginal
Carotid Artery Stenting- Case | Carotid Interventions: CAE, CAS, & TCAR
Carotid Artery Stenting- Case | Carotid Interventions: CAE, CAS, & TCAR
angioplastyarteryballoonballoonsbut want left carotid artery lesion stented firstcarotidcarotid arterychaptercommonCoronary bypass graftdistalECA balloonendarterectomyexternalexternal carotidimageinflatelesionosisproximalproximallystentstentingsurgicallyultimately
Balloon Pulmonary Angioplasty | Management of Patients with Acute & Chronic PE
Balloon Pulmonary Angioplasty | Management of Patients with Acute & Chronic PE
angiogramangioplastyarteryballoonballooningbandschaptercomplicationscontrastflowHorizonimageimagesluminalNoneocclusionocclusionspatientsproximallypulmonaryradiationrecanstenosisthrombustreatedultrasoundwebs
CTEPH Studies | Management of Patients with Acute & Chronic PE
CTEPH Studies | Management of Patients with Acute & Chronic PE
acutearterieschapterchroniccpapedemainterdisciplinaryjapanmultidisciplinarymultipleNoneoperatorspatientpatientsperformedpulmonaryreperfusionrequiringthrombolysistreatedtreatmentvascular
Treatment Options- TransCarotid Artery Revascularization- TCAR | Carotid Interventions: CAE, CAS, & TCAR
Treatment Options- TransCarotid Artery Revascularization- TCAR | Carotid Interventions: CAE, CAS, & TCAR
angiographyangioplastyarterybleedbloodcalcifiedcarotidchapterclaviclecommondebrisdevicedistalembolicembolizationexposurefemoralflowimageincisioninstitutionlabeledpatientprocedureprofileproximalreversalreversesheathstenosisstentstentingstepwisesurgicalsuturedsystemultimatelyveinvenousvessel
Ideal Uterine Fibroid Embolization Candidates | Uterine Artery Embolization The Good, The Bad, The Ugly
Ideal Uterine Fibroid Embolization Candidates | Uterine Artery Embolization The Good, The Bad, The Ugly
arterycandidateschapterembolizationfibroidfibroidshysterectomyidealimagingNonepatientpatientsproceduresparingsurgerysymptomsymptomaticsymptomstreateduterineuterus
Case 1 - Non-healing heel wound, Rutherford Cat. 5, previous stroke | Recanalization, Atherectomy | Complex Above Knee Cases with Re-entry Devices and Techniques
Case 1 - Non-healing heel wound, Rutherford Cat. 5, previous stroke | Recanalization, Atherectomy | Complex Above Knee Cases with Re-entry Devices and Techniques
abnormalangioangioplastyarteryAsahiaspectBARDBoston Scientificcatheterchaptercommoncommon femoralcontralateralcritical limb ischemiacrossCROSSER CTO recanalization catheterCSICTO wiresdevicediseasedoppleressentiallyfemoralflowglidewiregramhawk oneHawkoneheeliliacimagingkneelateralleftluminalMedtronicmicromonophasicmultimultiphasicocclusionocclusionsoriginpatientsplaqueposteriorproximalpulserecanalizationrestoredtandemtibialtypicallyViance crossing catheterVictory™ Guidewirewaveformswirewireswoundwounds
Case Example | Management of Patients with Acute & Chronic PE
Case Example | Management of Patients with Acute & Chronic PE
acuityafibangiogramanticoagulationarterycatheterchapterclotCTEPHdistallyDVTimagesincisionleftlobelowerNoneoperationpatientspressurespulmonarypulmonary arterysegmentalstenosisthrombusuppervessels
Why is Staging Important | Interventional Oncology
Why is Staging Important | Interventional Oncology
ablateablationangiogramchapterhepatocellularhyperintensityMRIshapedtumor
Q&A Uterine Fibroid Embolization | Uterine Artery Embolization The Good, The Bad, The Ugly
Q&A Uterine Fibroid Embolization | Uterine Artery Embolization The Good, The Bad, The Ugly
adjunctiveanesthesiaarteryblockscatheterchapterconceivecontrolembolizationfertilityfibroidfibroidshormoneshydrophilichypogastricimaginginabilitylidocainemultiplenauseanerveNonepainpatchpatientpatientspostpregnantproceduralquestionradialrelaxantsheathshrinksuperior
Outcome data | Uterine Artery Embolization The Good, The Bad, The Ugly
Outcome data | Uterine Artery Embolization The Good, The Bad, The Ugly
arterybleedcentimeterchapterdatadysfunctionalembolizationfertilityfibroidfibroidsMRImyomectomyNonepatientsretainsurgeryuterineuterus
Education Strategies to Reduce Human Errors | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
Education Strategies to Reduce Human Errors | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
activeaneurysmangiographybostcerebralchapterchecklistclotconcurrentcontraindicationcontraindicationsdistallyembolizedguidelinehemorrhageheparinisismilligramNonepatientphysiciansstandardstentstentingstentsstrategiestemplatetherapeuticthrombolysistpa
Introduction to Respiratory Compromise | Respiratory Compromise: Use of Capnography During Procedural Sedation
Introduction to Respiratory Compromise | Respiratory Compromise: Use of Capnography During Procedural Sedation
anesthesiachaptercliniciancrnainterventionalmajorityMedtronicNonepresentationslides
Introduction to Carotid Interventions | Carotid Interventions: CAE, CAS, & TCAR
Introduction to Carotid Interventions | Carotid Interventions: CAE, CAS, & TCAR
carotidchapterdeviceendovascularintentocclusivestentingtalk
Q&A Pulmonary Embolism | Management of Patients with Acute & Chronic PE
Q&A Pulmonary Embolism | Management of Patients with Acute & Chronic PE
acuteangiogramassistedcatheterchapterchroniccontrastdiagnosticechocardiogramembolismisisNonepressurepulmonarythrombolysistreatmentultrasound
UFE Summary | Uterine Artery Embolization The Good, The Bad, The Ugly
UFE Summary | Uterine Artery Embolization The Good, The Bad, The Ugly
chaptercomplicationembolizationfibroidfibroidshysterectomiesNone
Massive PE | Pulmonary Emoblism Interactive Lecture
Massive PE | Pulmonary Emoblism Interactive Lecture
adenosineangiobloodbradycardiacatheterchaptercontraindicateddevicedirectedhypotensioninpatientinterventionalistsmassivematsumotopatientsPenumbrasurgicalsystemictherapythrombolysisthrombolyticthrombolyticsventricle
CT Imaging- Acute PE | Management of Patients with Acute & Chronic PE
CT Imaging- Acute PE | Management of Patients with Acute & Chronic PE
acuteangiogramappearancearrowarteriescenteredchapterclassiccontrastcoronalimaginginfarctluminalNonepatientperfusionpulmonarysagittalscansegmentalsurroundingtechnologistthrombolysisthrombusvesselview
Ideal Stent Placement | TIPS & DIPS: State of the Art
Ideal Stent Placement | TIPS & DIPS: State of the Art
anastomosiscentimeterchaptercoveredcurveDialysisflowgraftgraftshemodynamichepatichepatic veinhyperplasiaintimalnarrowingniceoccludesocclusionportalshuntshuntssmoothstentstentsstraighttipsveinveinsvenousvibe
Practice Guidelines | Procedural Sedation: An Education Review
Practice Guidelines | Procedural Sedation: An Education Review
anesthesiologistassessmentbeneficialcategorychaptercontrolenhancingequivocalevidencefindingsguidelineguidelinesinterventionallabeledliteraturemonitoringNoneobservationalopinionoutcomespatientpharmacologypracticeproceduralprocedureradiologyrandomizedrecommendationsreviewsedationstatisticallystudiestrialsversus
Transcript

let me show you a case of massive PE

this launched our pert pert PE response team 30 year-old man transcranial resection of a pituitary tumor post-op seizures intracranial frontal lobe hemorrhage okay so after his brain surgery developed a frontal lobe

hemorrhage and of course few days after that developed hypotension and hypoxia and was found to have a PE and this is what the PE look like so I'll go back to this one that's clot in the IVC right there and

that's clot in the right main pulmonary artery on this side clot in the IVC clot in the right main pulmonary artery systolic blood pressure was around 90 millimeters of mercury for about an hour he was getting more altered tachycardic

he was in the 120s at this point we realized he was not going the right direction for some reason the surgeon didn't want to touch him still to this day not sure why but that was the case he was brought to the ir suite and I had

a great Mickey attending who came with him and decided to start him on pressors and basically treat him like an ICU patient while I was trying to get rid of his thrombus so it came from the neck because I was conscious of this clot in

the IVC and I didn't want to dislodge it as I took my catheters past it and you see the Selective pulmonary and on selective pulmonary angiogram here and there's some profusion to the left lung and basically none to the right lung

take a sheath out to the right side and do an injection that you see all this cast of thrombus you really see no pulmonary perfusion here you can understand why at this point this man is not doing well what I did at this point

was give a little bit of TPA took a pigtail started trying to spin it through aspirated a little bit wasn't getting anywhere he was actually getting worse I was starting to feel very very nervous I had remembered for my AV

fistula work that there was this thing called the cleaner I don't have any stake in the company but I said you know I don't have a lot to lose here and I thought maybe this would be better than me trying to spin a pigtail through

the clock so the important thing about the cleaners it does not go over a wire so you have to take the sheet out then take out the wire then put the cleaner through that sheath and withdraw the sheath

you can't bareback it especially in the pulmonary circulation the case reports are poking through the pulmonary artery and causing massive hemorrhage and the pulmonary artery does not have an adventitia which is the outer layer just

a little bit thinner than your average artery okay so activated it deployed it and you started to get better and this is what it looked like at the end now this bonus question does somebody see anything on this this picture here that

made me very happy on this side this picture here that made me feel like hey we're getting somewhere I'm sorry the aorta the aorta you start to see the aorta exactly and that that was something I was not seen before the

point being that even though this doesn't look that good in terms of your final image the fact that you see filling in the aorta and mine it might have been some of the stuff I had done earlier I can't I can't pinpoint which

of the interventions actually worked but that's what I'm looking for I'm looking for aortic blood flow because now I've got a hole in that in that clot that's getting blood flow to the left ventricle which starts to reverse that RV

dysfunction that we were concerned about make sure I'm okay with time so we'll

patient who did not come from the street so if you've been here for a few years

you've heard me talk about you know some of my friends this is also one of my other friends who has large fibroids but her fibroids were so big and they were not all very vascular and so I sent her to have surgery and she ended up having

a hysterectomy with removal of her cervix because of abnormal pap smears but her ovaries were left in place so our path forward after doing this procedure from 1995 a procedure that is not experimental a procedure that has

had a lot a lot of research done on it more research than most procedures that are done surgically or by interventional radiologists I'd say that it would require a partnership it is true that we can see patients on our own and we can

manage mostly everything but at the end of the day uterine artery embolization is still a palliative procedure because we don't know what causes fibroids to begin with and as long as the uterus is still there there's always a chance that

new fibroids will come back so in your practice and in mind I believe that a path forward is a sustaining program embolization program which is built on a relationship with the gynecologist that yes

I am as aggressive as any other interventionist that is out there but if this were my mom and that is my usual test for things I would say that where we would like to position ourselves is in the business of informing the

patient's as much as possible so that they can make an informed decision and that we're asking our gynecology partners to do the same is that if you're going to have a hysterectomy for a benign disease that you should demand

and we as a society and you as your sisters keeper should be asking for why am I not eligible for an embolization so si R is actually embarking on a major campaign in the next year or so it's called the vision to heal campaign and

it's all around providing education for this disease stage what I like to tell our patients and I'm almost finished here is when I talk to our gynecologist and to techs and nurses as well I said woody woody what should I expect right

that's what they want to know when I send my patient to you what should I expect and I say that what you should expect that Shawn and myself we're gonna tell the patient everything about fibroids we're gonna talk to them about

what the fibroids are the pathophysiology of it the same things I told you we're gonna tell them about the procedures that treat it we tell them about the options to do nothing we talk about all of the risk and the benefits

of the procedures especially of fibroid embolization and we start the workup to see if they're an appropriate candidate when they're an appropriate candidate we communicate with them and their OBGYN and then we schedule them for their

procedure in our practice there are a few of us who send our patients home on the same day and we let our patients know no one is kicking you out of the hospital if you can't go home that day then you'll get to stay but

most of our patients are able to go home that day and then we see our patients back in clinic somewhere between two and four months three months and six months and we own that patient follow-up their visits and after their year we have them

follow back up with their gynecologist and so that we're managing all of these sites and it comes back to that new again may not be so new for some of the people that have been doing clinical IR four years that shift that we own these

patients if you're a nurse in this room these are our patients these questions need to be answered by us in our department we do not believe that these patients should be calling their gynecologist for the answers to that

like what should I be doing right now should I be taking I haven't had a bowel movement and like that is something that we answer we're the ones that are given them the discharge instructions and we set them back up for their follow-up so

improvement so this is an example that we've treated at Michigan us a 67 year old female patient who has CTF she's gone through sort of a treatment she

turned down so she was not a good candidate for surgery because her disease is distally it's in the sub segmental branches so we went back and forth for you actually on this patient when we're

starting our program and decided that she would be the right patient to start she followed instructions she was her disease was severe enough that I was affecting her life she couldn't walk from here to the back of the room she

was on medication she didn't qualify for the surgery so we said she'd be the right wand and so we started with a pulmonary angiogram you can see there's disease it's not the worst patient that you would see because those would be

surgical but well you see those arrow heads there's areas of webs there's areas of occlusions and stenosis so she's got all the different types of pathology morphology would be great for treatment so what we did as we do in all

these cases get a wire across it if we can wreak analyze it we get a wire we never use hydrophilic wires that's actually contraindicated in these so you never use like a glide wire an O and a glide wire you never use a v 18 or any

of those types of wires because those have a higher risk of perforation frequently we actually use coronary wires from the inner from our colleagues in interventional cardiology you cross the lesion and then you balloon it with

a very very very small balloon so you do not want to get aggressive in these patients we start with a two millimeter balloon even if the vessel should be four or five millimeters we always start with the two millimeter balloon and you

can bring them back and do another intervention in a few months at without a larger sized balloon so in this patient we ballooned two branches in the right lower lobe and then this is what it looks like afterwards so you have

improved flow it doesn't look perfect we're not going for perfect we're going for profusion so if you think about that same thing with acute PE you're not going for a perfect image you just want to get perfusion distally and then the

body will figure it out afterwards so

Sean I know you have not seen these slides at all you wanted I John can talk about this with his eyes closed so it's

not like there's anything but this is the data that was published from the Jade publishing jvi are from what Sean has written and it's just the current standards relating to what you should be expecting what we tell our patients that

they should expect for outcomes as it relates to uterine artery embolization again I'm not really here to try to point this I know you can google these you can get the information yourself but just to say that all of our procedures

have risk and we need to be clear with our patients about them now I believe that with all of these risks combined the benefits of doing uterine fibroid embolization for most patients is far greater than the risk and that's why I

really do have my practice so these are the benefits right shorter hospital stay and I would say more cost-effective and that is really debatable because gynecologists have become smarter and smarter now they're doing like same-day

hysterectomies if you have a vaginal hysterectomy then maybe a UFE is not as cost-effective because they don't have to do an MRI beforehand and they don't get an MRI afterwards and do all of that anyway and if you look at the long-term

cost of that then maybe having a hysterectomy in some patients could be that but we know for sure that patients are more satisfied when they get a embolization procedure than in my MEC to me not in the beginning run because the

procedure can be very painful that is not the procedure itself is painful but post embolization syndrome which could last anywhere from five to seven days can can be very painful again this is the comparative data that was published

by dr. Spees who is our gold medal winner this year understand a lot a lot of work in this space has allowed us to have this conversation with our gynecology partners but also with our patients as we talked about like when

can you return to work how long are you going to be all for you know am I going to need extra child care or whatever how long would I be in the hospital this information helps us to inform our patients about that then on average

you'll stay in the hospital around you know a day or so and most uterine artery embolization procedures are same-day procedures and interventional radiologists are doing these in freestanding centers as well as other

providers without any issues so we're almost down to the end we know that fibroid embolization is proven to be an effective and durable a procedure for controlling patient symptoms it's minimally invasive and it's outpatient

most patients can go back to some normal activity in one to two weeks it has a low complication rates and some patients mein neatest to surgery and should have surgery so in our practice we send around 1/3 of our patients or so to

surgery and the reason that that is that high is that patients are allowed to come and see myself or dr. de riz Nia from the street they do not have to be referred from their gynecologist and so they're just coming from the street then

you will be referring them to a gynecologist because of some of the things that may not make them a good candidate for embolization such as this

different applications renal ablation is very common when do we use it

high surgical risk patients primary metastatic lesions some folks are actually refused surgery nowadays and saying I'll have a one centimeter reno lesion actually want this in lieu of surgery people have

familial syndromes they're prone to getting a renal cancer again so we're trying to preserve renal tissue it is the most renal parenchymal sparing modality and obviously have a single kidney and a lot of these are found

incidentally when they're getting a CT scan for something else here's a very sizable one the patient that has a cardiomyopathy can see how big the heart is so it's you know seven centimeter lesion off of the left to superior pole

against the spleen this patient wouldn't have tolerated bleeding very much so we went ahead and embolized it beforehand using alcohol in the pide all in a coil and this is what it looks like when you have all those individual ice probes all

set up within the lesion and you can see the ice forming around I don't know how well it projects but in real time you can determine if you've developed your margin we do encompass little bit of spleen with that and you can see here

that you have a faint rim surrounding that lesion right next to the spleen and that's the necrotic fat that's how you know that you got it all and just this ablation alone caused a very reactive pleural

effusion that you can see up on the CT over there so imagine how this patient would have tolerated surgery pulmonary

I'm Nikki Jensen Nicole is what my mother calls me but that's alright thank you all for joining us today I am the clinical resource nas I work in a clinical nurse specialist position I graduated in May so I'll finally be called the clinical nurse specialist

after I passed my boards in nonvascular radiology so at Mayo Clinic Rochester we are kind of split up between I are in our IR practice where we have non vascular procedural Center CT MRI ultrasound guided procedures we'll go

over a list of our standard perform procedures as well as our neuro interventional and vascular interventional practice so Kerri and I work in the non vascular so we do not do any neuro interventional or vascular

vascular interventional procedures so these guidelines are going to focus on your LR CT or ultrasound guided procedures how many of you went to the combined session this morning great this is going to be an overview because what

we saw presented there really reiterates what we are have brought into our practice but then we're also going to share how we created nursing guidelines and how we rolled that into our practice this is Carrie Carrie is a staff nurse

in our department I worked as a staff nurse for seven years prior to this position I've been in this position now for four years and really enjoy it I do want to give a little shout-out to Carrie and I presented or sorry we

published an article in the June 28th volume 37 issue - that really coincides with our presentation today so I would encourage you to read that publication and then you'll get additional information on how we did this yes all

right we have nothing to disclose unfortunately or fortunately right so the purpose of this presentation is to help you all understand the importance of creating reviewing the literature

understanding your for one your coagulation casket as well cascade as well as anticoagulants that are out there or new up-and-coming medications and understanding that yes it's very important to establish and create these

guidelines so that within your practice you don't have differing radiologists that have differing opinions if you're working with doctor so-and-so today you need to worry about these labs if you're working with you know dr. Johnson

tomorrow he doesn't care about the labs we did this to help standardize that to help reduce the amount of questions our nurses have how many times we're interrupting our radiologists but then also we need to take into consideration

the importance of the patients and their different disease processes and we'll be going over that too so it's nice to have established guidelines but then also we need to take into consideration why patients are on certain medications this

here is our list of objectives I'm not going to read them for you you can all read them and we've provided you all with handouts too but really we want to just help kind of explain mechanism of actions and different medications and

how we established our guidelines this here is where Kari and I come from full disclosure we do have snow on the ground so these pictures were not taken before we came we are really enjoying this nice warm weather but for those of you who

are not familiar with the history of Mayo Clinic in Rochester who we have a hundred and fifty plus year tradition of implementing evidence-based care to assure the needs of our patient come first we are divided up into one

downtown campus but we have three different main areas so we have our st. Mary's Hospital this is where Kerry is based out of this is this houses most all of our ICUs as well as most all of our inpatients so we do a lot of

inpatients but we also see outpatients in this hospital Rochester Methodist Hospital this is where our he mock patients typically are we do have one ICU within Hospital as well but then right here my

office is right there this is our Mayo downtown campus so this is where most of our patients come for outside procedures or outpatient diagnostic imaging exams this here is the group that I'm part of the clinical nursing specialist group

within our clinical nursing specialist group there are 77 of us there are five like myself clinical resources as we have not graduated as of yet I'm right there in the middle w

that work in over 70 ambulatory areas in 58 inpatient areas we also support some areas in our Arizona and Florida campuses and then we have Mayo Clinic Health System hospitals that are scattered throughout Iowa

Wisconsin in Minnesota as well I am the only one in radiology across all of our

to talk about is indirect angiography this is kind of a neat trick to suggest to your intervention list as a problem solver we were asked to ablate this lesion and it looked kind of funny this patient had a resection for HCC they

thought this was a recurrence so we bring the comb beam CT and we do an angio and it doesn't enhance so this is an image here of indirect port ography so what you can do is an SMA run and see at which point along the

run do you pacify the portal vein and you just set up your cone beam CT for that time so you just repeat your injection and now your pacifying the entire portal vein even though you haven't selected it and what to show

well this was a portal aneurysm after resection with a little bit of clot in it the patient went on some aspirin and it resolved in three months so back to our first patient what do you do for someone who has HCC that's invading the

heart this patient underwent 2y 90s bland embolization microwave ablation chemotherapy and SBRT and he's an eight-year survivor so it's one of those things where certainly with the correct patient selection you can find the right

things to do for someone I think that usually our best results come from our interdisciplinary consensus in terms of trying to use the unique advantages that individual therapies have and IO is just one of those but this is an important

lesson to our whole group that you know a lot of times you get your best results when you use things like a team approach so in summary there are applications to IO prior to surgery to make people surgical candidates there are definitive

treatments ie your cancer will be treated definitively with curative intent a lot of times we can save when people have tried cure intent and weren't able to and obviously to palliate folks to try to buy them time

and quality of life thermal ablation is safe and effective for small lesions but it's limited by the adjacent anatomy y9t is not an ischemic therapy it's an ablative therapy you're putting small ablative radioactive particles within

the lesion and just using the blood supply as a conduit for your brachytherapy and you can use this as a new admin application to make people safer surgical candidates when you apply to the entire ride a panic globe

thanks everyone appreciate it [Applause] [Music]

thrombectomy is another popular way of treating patients there's a lot of different aspiration catheters the SPX catheter is actually not available currently in the US but what it basically is I can have the rectum a

device that spins in such backlot the Indigo thrombectomy system from penumbra is a yet another device that sucks out clot I think many of us have used that it's kind of like a vacuum cleaner but usually more like a dust

hand vac where it's going to suck up thrombus the angio vac is much more like a Hoover where you're going to use and put a patient on veno-venous bypass that requires a 22 French sheath and a 17 French sheath but that will take out

thrombus I personally prefer using NGO vac in the IVC in big large thrombus for that and not in the pulmonary arteries because it's very inflexible but it's very very useful in a few patient populations in

all of these devices there is no TPA that needs to be given you're just sucking out the clot and you're actually removing it from the patient's body rather than dissolving it and sending it downstream the drawbacks on all of these

devices is their larger access points the SP or X is around six French although that's not that much bigger penumbra device is 8 French and the as we mentioned the angio vac is 22 French

know we're running a bit short on time so I want to briefly just touch about

some techniques with comb beam CT which are very helpful to us there are a lot of reasons why you should use comb beam CT it gives us the the most extensive anatomic understanding of vascular territories and the implications for

that with oncology are extremely valuable because of things like margin like we discussed here's an example of a patient who had a high AF P and their bloodstream which tells us that they have a cancer in her liver we can't see

it on the CT there but if you do a cone beam CT it stands up quite nicely why because you're giving levels of contrast that if you were to give them through a peripheral IV it would be toxic to the patient but when you're infusing into a

segment the body tolerates at the problem so patient preparation anxa lysis is key you have them exhale above three seconds prior to that there's a lot of change to how we're doing this people who are introducing radial access

power injection anywhere from about 50 to even sometimes thirty to a hundred percent contrast depends on what phase you're imaging we have a Animoto power injector that allows us to slide what contrast concentration we like a lot of

times people just rely on 30% and do their whole the case with that some people do a hundred percent image quality this is what it looks like when someone's breathing this is very difficult to tell if there's complete

lesion enhancement so if you do your comb beam CT know it looks like this this is trying to coach the patient and try to get them to hold still and then this is the patient after coaching which looks like this so you can tell that you

have a missing portion of the lesion and you have to treat into another segment what about when you're doing an angio and you do a cone beam CT NIT looks like this this is what insufficient counts looks like on comb beam so when you see

these sort of Shell station lines that are going all over the screen you have to raise dose usually in larger patients but this is you know you either slow down the acquisition speed of your comb beam or

you raise dose this is what it looks like after we gave it a higher dose protocol it really changes everything those lines are still there but they're much smaller how do you know if you have enhancement or a narrow artifact you can

repeat with non-contrast CT and give the patient glucagon and you can find the small very these small arteries that pick off the left that commonly profuse the stomach the right gastric artery you can use your comb beam CT to find

non-target evaluation even when your angio doesn't suggest it so this is a patient they have recurrent HCC we didn't angio from here those arteries down there where those coils were looked funny even though the patient was

quote-unquote coiled off we did a comb beam CT and that little squiggly C shape structures that duodenum that's contrast going in it this would be probably a lethal event for the patient or certainly would require surgery if you

treated that much with y9t reposition the catheter deeper towards the lesion and you can repeat your comb beam CT and see that you don't have an hands minh sometimes you have these little accessory left gastric artery this is

where we really need your help you know a lot of times everyone's focused and I think the more eyes the better for these kind of things but we're looking for these little tiny vessels that sometimes hop out of the liver and back into the

stomach or up into the esophagus there's a very very small right gastric artery in this picture here this patient post hepatectomy that rides along the inferior surface of the liver it's a little curly cube so and this is a small

esophageal branch so when you do comb beam TT this is what the stomach looks like when it enhances and this is what the esophagus looks like when it enhances you can do non contrast comb beam CTS to confirm ablation so you have

a lesion this is the comb beam CT for enhancement you treat with your embolic and this is a post to determine that you've had completely shin coverage and you can see how that correlates a response so the last thing we're going

symptoms we've talked about the location so what are the options now I've kind of scared everybody enough said okay fine if my periods are last in more than

seven days if I have pain with my periods if I have clawed if I have painful sexual intercourse back pain hydronephrosis and sciatica all kinds of these little things then maybe I could be having fibrous what do I do about it

and there are several options obviously I'm here to talk about embolization but because everybody in this room is talking about informed consent every day we have to be able to talk to our patients about what are the options and

I always try to start off with the simplest of options doing something or doing nothing remember this is not a cancer this is a benign disease and it's important that we explain to our patients that they also have the option

of doing nothing although doing nothing has some consequences right every action has a consequence and the consequence of doing nothing includes continuing to have your disease continuing to be sick and abnormal and if you chose to do

something let's say a surgical option then obviously you can have hysterectomy or myomectomy now Maya met to me is just where you're cutting out the fibroid hysterectomy is taking the whole uterus out and then there's a whole series of

other things whether you're having it laparoscopically or transvaginal Eeyore I'm here to talk about uterine artery embolization we offer all of these options to our patients though because it's important that we at least know

that there are other options to be done

are in the room here's a case of an 80

year old with a previous mi had a left hand are directing me and it's gonna go for a coronary bypass graft but they want this carotid stenting significant card accenting lesion to be treated first there's the non-invasive blow

through this but there's the lesion had a prior carotid endarterectomy so had that surgery we talked about first but at the proximal and distal ends of that patch has now a stone osis from the surgical fix that's developed so we

don't want to go back in surgically that's a high resolution we want for a transfer Merle approach and from there here's what it looks like an geographically mimics what we saw on the CT scan you can see the the marker and

the external carotid artery on the right that's the distal balloon and then proximally in the common carotid artery and they're noted there and then when you inflate the balloons you can see them inflated in the second image in the

non DSA image that's the external carotid room carotid artery balloon that's very proximal the common carotid balloon is below or obscured by the shoulders and ultimately when you inflate the common carotid balloon you

just have stagnant blood flow then we treat them you can see both balloons now and the external carotid and common carotid in place we have our angioplasty balloon across the lesion and then ultimately a stent and this is what it

looked like before this is what it looks like after and tolerated this quite well and we never had risk of putting the patient for dis Lombok protection or to salamba lusts overall I'm not gonna go over this real

talk here with something that's new on the horizon believe it or not it was actually on the horizon 20 years ago and then it went away because there were a lot of patients that were treated with a

lot of complications and it's making a resurgence and this is balloon pulmonary angioplasty or BPA for short so this is an intervention which may be feasible in non-operative candidates so I mentioned to the Jamison classification earlier

type 1 and type 2 disease should be treated with surgery again it should be treated is curative but patients with type 2 and a half or 3 disease can be treated with balloon pulmonary angioplasty in the right in the right

frame which means that a surgeon has said I cannot operate on this a medical doctor has said boy they're not going to get better with their medicine let's try something else well this is that something else and that's what involves

everyone in this room so this is these are usually staged interventions with potentially high radiation and contrast dose if you think about it it's like Venis recan and a pulmonary AVM all-in-one so it's a potentially a long

complex procedure with a lot of contrast and a lot of radiation but it can provide a lot of benefit to these patients I'm going to talk about the comp potential complications at the end which is one reason why not

everyone should do these all the time so this is a pulmonary angiogram from the literature when you're injecting a selective pulmonary artery you can see that this patient has multiple stenosis there's no real good flow there the

vessels look shriveled up like I mentioned to you before you can get a balloon across it and balloon the areas and then you can see afterwards so the image a on the left is before an image D is afterwards believe it or not this are

in the most experienced hands because the most experienced hands are for palm the BP AR in Japan they do hundreds of cases of these a year at each hospital I've personally only done five so but this is a something that I'm very

interested in and you can see how how much benefit it has for that patient another way you can see these are the webs and the bands that I mentioned to you earlier so what's interesting is that if you look on the first set of

images on the top and the images on the bottom those are the same patients it's the same view before top rows before and the bottom rows after balloon pulmonary angioplasty so the first image is a pulmonary angiogram where if you kind of

see this there's there's some area areas of haziness those are the webs and bands the image on the the middle is the blown-up views and you can see those areas and then the image on the right is intravascular ultrasound which I use

every day in my practice it's a catheter with an ultrasound on it and when you look at it on the top image image see you can see a lot of thrombus you're actually not seeing flow and on image F on the bottom you're seeing red which is

the blood flow so these patients can actually improve the luminal diameter bye-bye ballooning them you can treat occlusions again image on the left shows you a pulmonary artery with a basically an occlusion proximally and then after

you reek analyze it and balloon it you can see that they can get much more

that was one example so these are there have a lot of potential complications reperfusion pulmonary edema is a very very big potential complication so you could get through the case patient does

great you open up multiple pulmonary arteries and then they start coughing up blood and then they end up started drowning in their own blood and the ICU so we do not want to push that and the initial papers that you can see down

below on that table they had a very high almost 10% in some cases pulmonary edema requiring treatment requiring patients being put on CPAP or being intubated and that is because they treated too much at one time

and so now as this when this first started in the early 2000s the operators were treating multiple segments at multiple times at one time and they were using large balloons and we figured out that that was what was killing patients

and so we changed our treatment so this is the first study that was ever performed for this it was performed by dr. Feinstein I believe this was published in circulation it was done in Harvard at MGH they had 18 patients with

36 month follow-up they all improved in their ability to walk as well as their lifestyle but many of them 11 out of 18 patients had reperfusion injury so this was the first paper and at that time it became the last paper because so many

patients did poorly but here's what they're sort of what they did and the ones that did okay they you could see that they had an improvement in the New York Heart Association classification again that just means they can walk

further they're not less short of breath and that they could walk further in 6 minutes which is again our sort of first test outcomes over time whence this has become increased so you can see that study was in 2001 and then

it kind of went away for a long time and it came back in 2012 in Japan where the most operators are there they've treated up to 255 procedures now since this slide was made we're up to a thousand in Japan and those patients are doing very

well but you'll notice that they have multiple procedures so again you don't try to one-and-done these patients they come back four to six times we've treated a couple patients where I work and we've treated that was patients four

times already and so they do much better but it's a slow slow and steady treatment so I want to wrap up with saying that the IR team is very critical to patients who are getting treated for PE we're involved in the diagnosis as

the radiology team acute and chronic PE it's very important to know as I've shown you in some of the examples and some of the images which when it's acute and versus chronic doing thrombolysis on a patient with chronic PE is useless all

you're doing is putting them at a risk you're not going to be able to break up that clot it's very important to have inter and multidisciplinary approach to patient care so interdisciplinary meaning everybody in this room nurses

technologists and physicians working together to take care of that patient that's on your table right now and multi-disciplinary because you have to work with cardiology vascular medicine the ICU teams and the

referring providers whether it's neurosurgery vascular surgery whomever it is who's Evers patient gets a PE you have to work together and it's very important again to have collaborative care in these patients if we're doing a

procedure and somebody notices that the patient is desaturating that's very very important when you're working in the pulmonary arteries if somebody notices that the patient's groin is bleeding you have to speak up so it's very important

that everybody is working together which is really what we need to do for these patients so there's my references and there's my kid so thank you guys very much hopefully this was helpful I'd be

would probably be how do we make our careers sustainable how do we make our lives healthy and well balanced in organizations that may not understand

what we do how do we maintain our humanism in a system that is focused on efficiency we expect a lot from our patients we send them home too soon and not all patients who go home have the environment at home that allows them

recover so they come back because there's no one to get them out of bed there's no one to get them to the bathroom there's no one to change their dressing their PICC line blocks you know simple things so we've gotten to a point

in in the excel file accountant driven behavior of things that we've forgotten that this is the about the art of wooing nature the science or the accountancy of healing and so we as a group need to

advocate for our patients and say no this person can't go home you know so when we look at our careers at our at our lives on a daily basis there are stressors that we all experience so this is one of the big challenges that we

face given what we do there's the risk and stress of what we see in our patients and the things we see the the dreadful things we see and more and more in radiology essentially were an adjunct to the emergency room and we see

terrible things I still remember the things I saw at Hopkins the the young men being embolized to maintain their cardiac output so their family could come in so they could become transplant donors stuff like this that's just

gruesome we get exposed to radiation which is not good for us one day I think radiation will be seen like asbestosis now seen we get exposed to blood and blood from infected patients with types of hepatitis that even that don't have a

member of the alphabet associated with them yet you know we get exposed to resistant Hospital organisms my wonderful dog Tessa who's dumb as a plank you know but lovely animal tore her ACL and I had to go bring it get

repaired and the vet said oh you work in a hospital well there's a 92% chance your dog will have em or sa because the vets know that if people who own the dogs work in hospitals their dogs are colonized with Mrs a in other words

we're bringing it home and our clothing we don't know this we get back injuries more more frequently because patients are getting larger and we have conflict sometimes using techs and nurses sometimes we text nurses doctors our

administrators and we have excessive overtime that's not an option and we often work in areas that are crime ridden so driving in and out is dangerous and we have financial stress so all of

this makes it a challenging life and we have to figure out ways of making this sustainable and happy and remembering why we did it and remembering why this makes a difference burnout is actually a

quick I did want to mention t-carr briefly and try to get you guys closer to back on time this is a hybrid procedure this is combining the surgical procedure we talked about first and carotid stenting it takes combined

carotid exposure at the base of the clavicle or just above the clavicle and reverses blood flow just like we talked about but tastes slightly different technique or approach to doing this and then you put the stent in from a drug

carotid access here's the components of the device right up by the neck there is where the incision is made just above the clavicle and you have this sheet that's about eight French in size that only goes in about us to 2 cm or 1 and a

half cm overall into the vessel and then that sheath is sutured to the the chest wall and then it's got a side arm that goes what's labeled number six here is this flow reversal urn enroute neuroprotection kit it reverses the

blood flow and then you get a femoral sheath in the vein right in the common femoral vein and you reverse the blood flow so this is a case a picture from our institution up on the right is the patient's neck and that's the carotid

exposure and the initial sheath is in place so the sidearm of that sheath is the enroute protection system which is going up up at the top of the image there we're gonna back bleed that let that sidearm of that sheath continue to

bleed up to the very top and then connect that to the common femoral venous sheet that we have in place there's a stepwise of that and then ultimately what we see at the end of the procedure is that filter inside that

little canister can be interrogated after and you can see the debris this is in the box D here on the bottom left the debris that we captured during the flow reversal and this is a what we call a passive and then active flow reversal

system so once the system is in place the direct exposure carotid sheath in place the flow controller and AV shunt in place you see the direction of blood flow so now all that blood flow in that common carotid artery is going reverse

direction and so when you place a sheath or wire and and ultimately through that sheath up by the carotid artery there's no risk for distal embolization because everything is flowing in Reverse here's a couple

case examples ferns from our institution this is a patient who had a symptomatic critical greater than 90% stenosis has tandems to nose he's so one proximal at the origin and one a little bit more distal we you can see the little

retractors down at the base of the image there in the sheath that's essentially the extent of the sheath from the bottom of that image into the vessel only about a cm or two post angioplasty instant patient tolerated that quite well here's

another 71 year-old asymptomatic patient greater than 90% stenosis pretty calcified lesion a little more extensive than maybe with the CT shows there's the angiography and then ultimately a post stent placement using the embolic

protection device and overall the trials have shown good good safety met profile overall compared to carotid surgery so it's a minimum minimal exposure not nearly as large the risk of stroke is less because you're not mucking around

up there you're using the best of a low profile system with flow reversal albeit with a mini surgical exposure overall we've actually have an abstract or post trip this year's meeting this is just a snapshot of that you can check it out

this is our one year experience we've had comparable low complication rates overall in our experience so in summary

so who are the most ideal candidates for fibroid embolization obviously I would say the most ideal candidates are patients that are symptomatic and I've told you already that 80% of black women

have fibroids but guess what only half of those will be so symptomatic that they would need to be even treated so just because fibroids exist don't mean that they need to actually be treated already so you

to actually have symptoms most patients that are symptomatic will again wait to getting treatment for like three and a half to five years but when they come we want to make sure that they're symptomatic and that they're not trying

to become pregnant and I know somebody in the audience has a question around that already so let's hold your high horses I'm coming to that how about patients that don't want to have surgery or just don't have time to

have surgery they don't have time for long recovery if you don't care if you have your uterus or not then I'm not so sure that you need to be pursuing a uterine sparing procedure okay and I'm gonna pause here to address one other

thing that it's a myth it is a myth that if you do not need to have children then you do not need your uterus I beg to differ and when we talk to women they are quite upset about this preposition that the uterus is only there for

baby-making purposes in fact there have been several studies now that have come out to say that women that have had early hysterectomy even with their ovaries in place are predisposed to coronary artery disease or

cardiovascular events we would like patients that are poor surgical candidates because if they can have surgery then they may be able to have surgery or patients that do not desire future fertility patients that have

already concerns about hysterectomy because of religious reasons or don't want to have hormonal therapy and I actually like patients that have have a have obesity because if we are able to do this procedure then they're spared

more complications related to surgery so the ideal patient then and this is a very important point said all three criteria would need to be fit that if you're a patient in order to be offered embolization number one

you have to have fibroids believe it or not you have to have symptoms that are related to fibroids and then you have to have some MRI that says that the location of where your fiber it is is causing that symptom and that these

fibroids are vascular let me explain okay and I'm going to skip this so I've been working with people for a long enough time and I've work of Julie for years I've worked with Diane and Anna and some other people for like ten years

and imagine if you're working with me for ten years you know that you're probably going to be able to do this procedure too like you're scrubbing right next to me eventually like you pick these things up what I get paid for

is not to do that and for the experienced nurses and techs that are in the room you know exactly what I'm talking about you're better than the doctors half of the time you really could do this procedure but what I get

paid for is to decide who does not even get to come on the table to get this procedure done so pay attention to this slide and these this criteria is being challenged every day and we're getting more and more data to say that this is

old information that we used to say if the uterus was like more than six months then you probably shouldn't have a uterine sparing procedure but we know that we do in embolization all the time in patients that have large fibroids

anyway but there's no data to actually give us that information most of the trials that we have and we have had a lot of them they have excluded patients where their individual fibroids were greater than 12 centimeters if you have

had an indeterminate and de metrio biopsy or you're having abnormal pap smear doing a uterine sparing procedure makes no sense so we use these imaging to really help us to determine which patients really

deserve to be treated so everybody can see that that image on the Left where it says submucosal refers to and I'm gonna try and come down so I can see these images here and you can see that there is a fibroid that is in

truck hava teri do you see that that round thing that is surrounded by the white fluid that is someone that has what we would call a type zero fibroid completely within the unit of course this is going to cause bleeding but

should this person have a uterine artery embolization or a hysterectomy Gail no this patient should have like hysteroscopic resection like a D&C and they would just scrape that thing out and then their symptoms would go away or

the patient on the right that has a normal appearing uterus and then this pedunculated gigantic thing that has bled into itself that is like a sub serosa fibroid of the extreme just hanging off on the outside now should

this patient have embolization no someone can tie a string right at that little connection and take that thing out so using our imaging to help us to decide which patients should be treated is very important or this patient who

came with Oh dr. Newsome I've been bleeding for 10 weeks in a row I have reversed cycles I have bulk I have bladder symptoms and yet they have that little dot that little black thing there that little dot

at the top that is the only place where there's a fibroid so this patient should not be a candidate for embolization either because yes they have symptoms and they have that little tiny daughter for fibra but that is not what's causing

those symptoms so it is important that we're not doing procedures on patients just because we can but because we're using our imaging and the patient's symptom to decide which patients are the best candidates for these procedures

so just a compliment what we everybody's talked about I think a great introduction for diagnosing PID the imaging techniques to evaluate it some of the Loney I want to talk about some of the above knee interventions no disclosures when it sort of jumped into

a little bit there's a 58 year old male who has a focal non-healing where the right heel now interestingly we when he was referred to me he was referred to for me for a woman that they kept emphasizing at the anterior end going

down the medial aspect of the heel so when I literally looked at that that was really a venous stasis wound so he has a mixed wound and everybody was jumping on that wound but his hour till wound was this this right heel rudra category-five

his risk factors again we talked about diabetes being a large one that in tandem with smoking I think are the biggest risk factors that I see most patient patients with wounds having just as we talked about earlier we I started

with a non-invasive you can see on the left side this is the abnormal side the I'm sorry the right leg is the abnormal the left leg is the normal side so you can see the triphasic waveforms the multiphasic waveforms on the left the

monophasic waveforms immediately at the right I don't typically do a lot of cross-sectional imaging I think a lot of information can be obtained just from the non-invasive just from this the first thing going through my head is he

has some sort of inflow disease with it that's iliac or common I'll typically follow within our child duplex to really localize the disease and carry out my treatment I think a quick comment on a little bit of clinicals so these

waveforms will correlate with your your Honourable pencil Doppler so one thing I always emphasize with our staff is when they do do those audible physical exams don't tell me whether there's simply a Doppler waveform or a Doppler pulse I

don't really care if there's not that means their leg would fall off what I care about is if monophasic was at least multiphasic that actually tells me a lot it tells me a lot afterwards if we gain back that multiphase the city but again

looking at this a couple of things I can tell he has disease high on the right says points we can either go PITA we can go antegrade with no contralateral in this case I'll be since he has hide he's used to the right go contralateral to

the left comment come on over so here's the angio I know NGOs are difficult Aaron when there's no background so just for reference I provided some of the anatomy so this is the right you know groin area

right femur so the right common from artery and SFA you have a downward down to the knee so here's the pop so if we look at this he has Multi multi multiple areas of disease I would say that patients that have above knee disease

that have wounds either have to level disease meaning you have iliac and fem-pop or they at least have to have to heal disease typically one level disease will really be clot against again another emphasis a lot of these patients

since they're not very mobile they're not very ambulatory this these patients often come with first a wound or rest pain so is this is a patient was that example anyway so what we see again is the multifocal occlusions asta knows

he's common femoral origin a common femoral artery sfa origin proximal segment we have a occlusion at the distal sfa so about right here past the air-duct iratus plus another occlusion at the mid pop to talk about just again

the tandem disease baloney he also has a posterior tibial occlusion we talked about the fact that angio some concept so even if I treat all of this above I have to go after that posterior tibial to get to that heel wound and complement

the perineal so ways to reach analyze you know the the biggest obstacle here is on to the the occlusions i want to mention some of the devices out there I'm not trying to get in detail but just to make it reader where you know there's

the baiance catheter from atronics essentially like a little metal drill it wobbles and tries to find the path of least resistance to get through the occlusion the cross or device from bard is a device that is essentially or what

I call is a frakking device they're examples they'll take a little peppermint they'll sort of tap away don't roll the hole peppermint so it's like a fracking device essentially it's a water jet

that's pulse hammering and then but but to be honest I think the most effective method is traditional wire work sorry about that there are multiple you know you're probably aware of just CTO wires multi weighted different gramm wires 12

gram 20 gram 30 gram wires I tend to start low and go high so I'll start with the 12 gram uses supporting micro catheter like a cxi micro catheter a trailblazer and a B cross so to look at here the sheath I've placed a sheet that

goes into the SFA I'm attacking the two occlusions first the what I used is the micro catheter about an 1/8 micro catheter when the supporting my catheters started with a trailblazer down into the crossing the first

occlusion here the first NGO just shows up confirmed that I'm still luminal right I want to state luminal once I've crossed that first I've now gone and attacked the second occlusion across that occlusion so once I've cross that

up confirm that I'm luminal and then the second question is what do you want to do with that there's gonna be a lot of discussions on whether you want Stan's direct me that can be hold hold on debate but I think a couple of things we

can agree we're crossing their courageous we're at the pop if we can minimize standing that region that be beneficial so for after ectomy couple of flavors there's the hawk device which

essentially has a little cutter asymmetrical cutter that allows you to actually shave that plaque and collect that plaque out there's also a horrible out there device that from CSI the dime back it's used to sort of really sort of

like a plaque modifier and softened down that plaque art so in this case I've used this the hawk device the hawk has a little bit of a of a bend in the proximal aspect of the catheter that lets you bias the the device to shape

the plaque so here what I've done you there you can see the the the the the teeth itself so you can tell we're lateral muta Liz or right or left is but it's very hard to see did some what's AP and posterior so usually

what I do is I hop left and right I turned the I about 45 degrees and now to hawk AP posterior I'm again just talking left to right so I can always see where the the the the AP ended so I can always tell without the the teeth

are angioplasty and then here once I'm done Joan nice caliber restored flow restored then we attacked the the common for most enosis and sfa stenosis again having that device be able to to an to direct

that device allows me to avoid sensing at the common femoral the the plaque is resolved from the common femoral I then turn it and then attack the the plaque on the lateral aspect again angioplasty restore flow into the common firm on the

proximal SFA so that was the there's the plaque that you can actually obtain from that Hawk so you're physically removing that that plaque so so that's you know that's the the restoration that flow just just you know I did attack the

posterior tibial I can cross that area I use the diamond back for that balloon did open it up second case is a woman

so I'm gonna show an example this is a 57 year old male who presented with a dis neo

he had World Health Organization functional class 3 meaning it's significantly affected his life he can't walk up the flight of stairs really tired walking from the parking lot of his favorite restaurant back to this car

can't really walk around the grocery store he had a history of DVT and PE also had afib he actually went to the ER and was diagnosed with upper respiratory tract infection which many of these patients are they've put him on

antibiotics then for pneumonia he had a VQ after one of his doctors just felt like he just wasn't getting better and it found multiple mismatch defect I'm sorry I don't have those pictures he was actually started on home oxygen after

all of that work up it was found that he had CTF and this required I think three different hospital visits and every time got kicked up to sort of a higher acuity place and then he ended up at our place so these are his pulmonary angiogram

images here I don't know if I can play these but the still images kind of show you that the images on the right show that there's basically no vessels going out distally so I mentioned pruning of vessels there's no branches in the right

upper lobe if you look at the right lower lobe at the tip of the catheter there's areas of stenosis right where the segmental arteries start and on the left you can see that the left pulmonary artery is denuded essentially the entire

left upper low branch is excluded by a rim of thrombus and in the left lower lobe the image on the bottom my bottom right there's actually no branches going to the left lower lobe into the lingula so this is a patient that has had very

bad CTF their main the pulmonary artery pressures are listed there of 77 where the normal high is 25 so three times the normal pulmonary artery pressure so this patient went on to an operation so the image on the right the photograph is

actually the clot that they removed from the operation and that patients pressures improved from 77 to 22 immediately after the operation so they go to the ICU they have a swan-ganz catheter left in place and you can

measure their pressure right afterwards and you can see that that clot they grabbed it it looks like a bunch of fingers well what they do is they crack the chest open like with a mini sternotomy they make an incision in the

pulmonary artery after they put them on bypass and then they basically grab they use they're a little deBakey's the DeBakey forceps and they grab this little elevator and they just start scooping

out the clot and they try to grab it as one big piece take it out and then you get that nice photograph on the side if they break off pieces it's actually worse because that's an area that a pulmonary artery dissection can occur so

it's a very complex operation but you get very nice results and afterwards these patients are sent home usually on lifelong anticoagulation thereafter so

so why staging important well when you go to treat someone if I tell you I have a lollipop shaped tumor and you make a lollipop shape ablation zone over it you have to make sure that it's actually a lollipop shaped to begin with so here's

a patient I was asked to ablate at the bottom corner we had a CT scan that showed pretty nice to confined lesion looked a little regular so we got an MRI the MRI shows that white signal that's around there then hyperintensity that's

abnormal and so when we did an angiogram you can see that this is an infiltrate of hepatocellular carcinoma so had I done an ablation right over that center-of-mass consistent with what we saw on the CT it

wouldn't be an ablation failure the blasian was doing its job we just wouldn't have applied it to where the tumor actually was so let's talk about

questions comments and accusations please hello this topic is very personal to me I've had it actually had a UFE so this is like one of my big things I work in the outpatient center as well as a

hospital where we perform you Effy's and frequently the radiologist will have me go in and talk to the patient it's from a personal perspective one of the issues which it may just have been from my situation was pain control post UFE

whether you normally tell your patients about pain control after the UFE someone say we are all struggling with this yeah oh it's not what's your question is going to be okay good I'm gonna get doctor Dora to answer Shawn the question

is what do you what do we do with this pain issue you know what are you doing for the home there at Emory there you know and a lot of practices we we don't rely on one magic bullet for pain control recently we've been doing

alternate procedures for two adjunctive procedures to help with pain control for example there are nerve blocks that you can do like a superior hypogastric nerve block there's there's Tylenol that can be given intravenously which is seems to

be a little more effective than by mouth there's there's a you know it and a lot of times it's it's a delicate balance right between pain post procedural pain because you can often get the pain well controlled with with narcotics opioid

with a pain pump but the problem is 12 hours later the patients is extremely nauseous and that's what keeps her in the hospital so it's a it's a balance between pain control and nausea you can you can hit the nausea

beforehand using a pain and scopolamine patch that that'll get built up in the system during the procedure and that kind of obviates the nausea issues like I said that the the nerve blocks the the tile and also there are some other

medicines that can can be used adjunctive leaf or for pain control in addition to to the to the opioids so the answer the question is there are multiple there multiple answers to the question there's not one magic bullet so

that helped it did one of the things that I tell the patients is that you know everyone is different and yet some people I've seen patients come out and they have no pain they're like perfect and then some come out and they are

writhing in the bed and they're hurting and they're rolling all around what and I always ask the acid docs are you telling them they could possibly have you know pain after the procedure because some have the expectation that

I'm going to be pain-free and that's not always the case so they have an unrealistic expectation that I'm gonna have the UFE but not have pain what I also tell them is that the pain it's kind of like an investment right and

this is easy for a guy to say that right but but it's it's an investment the worst part the worst pain you should be feeling is the first 12 12 hours or so every day I tell my patient you're gonna be getting better and better and better

with far as the pain as long as you is you follow our little cookbook of medicines that we give you on the way home and I want you to make sure that you fill these prescriptions on the way home or you have someone fill those

prescriptions for you before he or she picked you up in the hospital and lately we have been and I see that you're there as well lots of other little tricks that are out there right and again there are all

little tricks so ensure arterial lidocaine doctor there is near alluded to and if you're on si R Connect you may it may spill over on some of your chat rooms here people have been using like muscle relaxant like flexural or

robertson with some success but just know that we don't have any studies that tell us how that's supposed to do so when i have someone that is like writhing in pain i just use everything so i do it superior hypogastric nerve

vlog and i actually will do some intra-arterial lidocaine although not so much lately i have been using the muscle relaxant but i will warn you that i've had two patients with extreme anticholinergic effects where they are

now not able to pee from that so you know where we're doing that balance act I see that you're there can I take that question here first just so we're we're doing the same thing we're using the multimodal just throwing all these

things at people and we're trying the superior hypogastric blocks but we're collaborating with anesthesia to do that right now do you all do your own blocks or do you collaborate with anesthesia we do our own blocks okay it isn't it is

not that difficult I would tell you that but again it's kind of like you know you got to do if you start feeling better and then you're like we don't really need them we'll just do it on our own okay thank you again yes what's the

acceptable interval between UFE and for IBF oh that's a your question what is the interval between UFE and IVF so if you wanted to get pregnant yeah and can you have a you Fe and then have an IVF like how long would you have to wait

wait and tell you before you can have that the IBF it I guess it really depends on the age of the patient because we know that that the threshold for which patient tend to have that inability to conceive

is around 45 years old so you know it did below the you know below the age of 45 the risk of causing ovarian failure or or the inability to conceive is significantly less it's zero zero to three percent so I would say that you

know you probably want the effects of the fibroid embolization to two to take effect it takes around 12 months for these fibroids to shrink down to their most weight that they're gonna they're going to shrink down the most I wouldn't

say you need to wait 12 months to put our nine vitro fertilization there's no good there's no good literature out there I don't believe that's your next and so I would say just remember that if you came to my practice and you said you

wanted to get pregnant I will be sending you to talk to fertility specialists beforehand we do not perform embolization procedures as a way to become pregnant there's no data to support that but if you saw your

gynecologist and they said let's do this then I'm sure they'll be doing lots of adjunct things to figure out what would be an ideal time then to for you to have IVF and if I dove not having any data to inform me I would ask you to wait a year

and what will be the effect of those hormones that they gave you if for example a patient has existing fibroids what would be the effect of those hormones that IVF doctors prescribed their patients yeah so fibroids actually

can grow during pregnancy so I would say that most of those hormones are pro fertility hormones so I would expect that maybe you can see some of that effect as well yeah alright if you have any other questions you can grab me oh

you're I'm sorry go with it okay yes we we have time I don't want to keep anybody here for that so I have a two-fold question the first one is post-procedure can you use a diclofenac patch or a 12-hour pain

patch that is a an NSAID have you have any experience with that and your next question my second part of the question is there a patient profile or a psychological profile that tips you that the patient is not going to be able to

candidate because of their issues around pain so they're two separate but we have in success sending people home that first day so I'm looking to just make it better I haven't had experience with the Clos

phonetic patch it's in theory it seems ok you know these are all the these are they're all these are non-steroidal anti-inflammatory drugs so there are different potency levels for all of them they you know they range from very low

with with naproxen to to a little bit higher with toradol like that clover neck I think is somewhere in between so we found that at least I found that that q6 our our tour at all it tends to help a lot so with that said I I don't have

much experience with it with the patch in answer to your second question the only thing I can say is there there is a strong correlation between size of fibroids and the the amount of a post procedural pain and post embolization

syndrome so there really you know we often say we don't really care too much about the number of fibroids but the size of the fibroid is is is should be you know you should you should look at that on pre procedural imaging because

if it gets too big it may not be worth it for the patient because they may be in severe pain the more embolic you put into the blood supply's applying the the fibroid the the greater the pain post procedural pain

are there multiple other factors that would contribute to pain but that's that's one aspect you can you can look at post procedurally on imaging okay thank you very much yes ma'am hi what what kind of catheter do you use

to catheterize the fibroid artery when you pass by radio access yeah so over the last three years the companies have been really very good about that so there are a few things that I without endorsing one company or the other that

you need to make sure that the sheath that you're using is one of those radial sheets a company that makes a radio sheath you should not use a femoral sheath for radial access so no cheating where that's concern you may get away

with it once or twice but it will catch up to you and you need a catheter that is long enough to go from the radio to the to the groin so I'm looking for like a 120 or 125 centimeter kind of angled catheter whether it's hydrophilic the

whole way or just a hydrophilic tip or not at all you can you can choose which one in our practice most of us still tend to use a micro catheter through that catheter although if I'm using a for French and good glide calf and it

just flips into like a nice big juicy uterine artery then I may just go ahead and take that and do the embolization if the fellow is not scrubbed in as well so thanks a lot but they make they make many different kinds like that and more

of those are to come all right I'm you can please please please send us any other questions that you have thanks for your time and attention and enjoy the rest of the living

new data of the Emmy trial that came out last year our ten-year results saying

that after ten years after ten years women who wanted to retain their uterus they looked at them in ten years three-quarters of those women were still very very satisfied and also were still able to retain their uterus so ten-year

data came out randomizing people for uterine artery embolization versus hysterectomy of the women who chose you to an artery embolization ten years later they were still very happy so I tell my patients that this is what you

should expect that you will have symptomatic improvement in 12 months around 85 to 95 percent of the patients are pretty happy there is a entry intervention rate it is not zero and it can be higher than ten

depending on what kind of Imogen is seen ahead of time and that we know that dysfunctional uterine bleed tend to do a little bit better than bulk type symptoms and that's partly because of subjective nature of that so this is one

of the patients that I treated when I was in in Virginia and Riverside and she's a former miss Brazil and she came to see us with what she also called reversed cycles like she would bleed more than she would not and she was

wearing depends and it took everything to just coach her out of the car to come inside to do a consultation because she was so afraid that if she got out she would be sitting in a pool of blood and she had an MRI showing what looked like

a eleven point seven centimeter fibroid she had embolization and that was her six month follow-up MRI to the right which looks like a very impressive result they don't all look this way which is why I save this image something

that looks like a normal uterus now I for the persons that I told to hold your high horse here is the time okay so what happens if I want to have a baby because these are the things you remember we're being ambassadors for this procedure we

need to be having the answers for the things that are our friends and family members are going to be asking us so if you want to have a baby I would say that the data that informs us as to what to do with you is still very weak but the

only randomized prospective trial that we have out there says that you should actually have myomectomy and a Cochrane review was also done and it still says that there's very low level evidence suggesting that myomectomy may be

associated with better fertility outcomes as opposed to UAE but more research is needed and we still require more research so at the very least what I have to do and now you feel compelled to do is to send my patients to see

someone who is a fertility specialist in consultation so we can make this decision together so if your poor surgical candidate if you have the gazillion fibroids and if you've had surgery before a hostile

abdomen and the patient says you know what dr. Newsome there's nothing that you can tell me ever to say that I'm going to have surgery then we're going to be doing something else that is not surgery okay the other thing that your

strategies so some things that we have

in place right now our peer review Grand Rounds CPOE this is one of my one of my favorite process improvements is is making the right thing the easiest thing and you do that through standardization of processes so that's standard work so

that's your order sets that's the things pop-ups although you don't want to get into pop-up fatigue but pop-ups help our providers for little gentle reminders to guide them to what's right for the patient and to cover everything that we

need we need to cover to ensure the safety of our patient so recently in the fall of last year we had a TPA administration err that occurred it involved a 69 year old patient who two weeks prior had had some stenting in her

right SFA she presented to our clinic when our clinics with some heaviness in her leg and some pain and when she was looked at from an ultrasound standpoint it was determined that her stents were from Bost so she was immediately taken

to the cath lab and it was after angiography did indeed show that there was clot inside these stents they did start catheter directed thrombolysis in the cath lab they also did started concurrent heparin often oftentimes done

with CDT what's usual for our institution is that we have templates that pull in the active problem list for a patient in this case the active problem list or a templated HMP was not used had they

used the template at agent p they would have found that the second active problem on this patients list was a cerebral aneurysm so some physicians will tell you some ir docs will tell you that's an absolute

contra contraindication for TPA however the SI r actually lists it as a relative contraindication so usually we're used to when you when you start a final Isis case you know you're gonna be coming in every 24 hours to check in

that patient in this case we started the the CDT on a Thursday the intent was to bring her back on Monday the heparin many ir nurses will know that we will run it at a low rate usually 500 units an hour and we keep the patient sub-sub

therapeutic on their PTT although current literature will show you that concurrent heparin can also be nurse managed keeping the patient therapeutic in their PTT which is what was done in this case so what ended up the the

course progression of this patient was that so remember we started on Thursday on Saturday she regained her distal pulses in her right leg no imaging Sunday she lost her DP pulse it was thought that it was part of a piece of

that clot that was in the the stent had embolized distally so they made the decision with the performing physicians they consulted him to increase the TPA that was at one milligram an hour to 2 milligrams by Sunday afternoon the

patient had an altered mental status she went to the CT scan which showed a large cerebral hemorrhage they ain't we intubated to protect her airway and by Monday we were compassionately excavating her because

she me became bred brain-dead so in the law there's something that's called the but for argument so the argument can be made that this patient would not have died but for the TPA that we gave her in a condition that she should not have had

TPA for namely that aneurysm so this shows how standard work can be very important in our care of our patients and how standard work drives us down the right way making the easiest thing the safest thing so since that time

we've had a process improvement group that we've established an order set specifically for use and thrombolysis from a peripheral standpoint and then also put together a guideline that was not in place so it's some of that Swiss

cheese that just kind of we didn't have a care set we didn't have a guideline you know we didn't use our template so all those holes lined up and we ended up with a very serious patient safety event so global human air reduction strategies

oops sorry let's go back these are listed in a weaker two stronger and some of what we're using in that case is some checklists so we developed a checklist that needs to be done to cover the

absolute contraindications as well as the relative and it's embedded in the Ulta place order that the physician has to review that checklist for those contraindications and also there to receive a phone call from pharmacy

just to double-check and make sure that they have indeed done that that it's not somebody just checking it off so we have a verbal backup sorry so the just

thank you Michael thank you to Medtronic for having me and thank you to the AI a your organization for having me today I seem to be having a little trouble advancing my slides so I'm just gonna get started with my introduction here we go

so I'm here's my disclosures basically I am sponsored by Medtronic to provide this Lunch and Learn for you but I am an active clinician I work actively at Yale as a CRNA and I do provide the majority of my anesthesia in what we call our off

floor locations meaning interventional radiology EP lab GI endoscopy r zh' in the operating room so I understand the challenges you face I do you know the sedation in those rooms myself so I understand the positioning concerns the

monitoring concerns and so I'm really I'm honored to be here today and I hope that I add value to your conference while you're having lunch I won't talk about anything that is off-label use everything I will present today is

evidence-based medicine and had been proven I'm not here to sell you any products or talk you into buying anything I just really strictly clinician to clinician so starting out we only have

an hour and I really want to make sure I get through everything today so I'm gonna ask if you have any questions to please hold them to the end and that's for a couple reasons because if you have a question I might even be covering that

material in subsequent slides and I want to make sure I get through the whole presentation the beginning of the talk is going to be some review material for some of you we're gonna move through the first 30 slides pretty quickly because I

understand that the majority of you are already using capnography and I want to spend the majority of our time in this presentation talking about the stuff that the advanced level the problem solving the troubleshooting and the

things that are really pertinent to your practice so that you have value that is gained from attending this presentation today

I was tasked or asked to give a talk on carotid interventions and and there's actually been some change you know I've given to carotid talks over the years I've been doing this now eleven years at the Medical College and there wasn't a lot of innovation for a period of time

and then there's been a sudden kind of tic upwards with the last acronym here t car so we're gonna talk about these three ceac s and T car how many other room are involved with carotid stenting at the local institution I'm gonna do T

car all right so it's not gonna be brand new that's great but there's still I think for some of you pardon me an opportunity to kind of see a new device that's been brought to market over the last few years so with

that what are we gonna talk about these are the objectives it's not really gonna be a data talk this is not the intent I wanna bore you with data there will be a little bit of just sort of what's the purpose for why we do things you know

and percentage of what not but I'm not gonna go through clinical trials the intent here is really to discuss the three main treatment options for carotid occlusive disease and then review the indications for intervention so why

would we treat to symptomatic asymptomatic and then finally review the the endovascular devices or the approaches in general for carotid artery stenting in a strictly endovascular environment or in a hybrid environment

which is what the t'car device is so why

happy to take any questions or in

ultrasound we don't usually use contrast but one of the procedures were doing for the treatment management of a pulmonary embolism is the ultrasound assisted Rumble Isis do we need contrast so for the thrombolysis is the catheter itself

so you still need to give contrast two to do the procedure but while the catheter is running you don't need to give any contrast four for that is that what you're we don't usually use contrast for ultrasound but

all right when you're treating how will you know that it sliced the clot is less what you frequently do is check the pressures so that catheter allows you to check the pressure and so once you start a patient so you do a pulmonary

angiogram which requires contrast and you put the ultrasound assisted thrombolysis catheter in the eCos catheter then after 24 hours or 12 hours you can measure a pressure directly through that catheter and if the

patient's pressure is reduced you don't have to give them anymore injections yeah and if we are using ultrasound for treatment is it possible to do it for diagnostic purposes No so not for non the prominent artists for

diagnostic imaging unless you're doing an echocardiogram which is technically ultrasound in the heart but for treatment otherwise you need you will need to inject some dye oh thank you

hi I'm Katrina I'm NGH I have one more question okay for your patients with chronic PE do most of them begin with acute PE or if they very separate sort of presentations that's that's a great question so all of them

had acute PE because you can't have chronic without acute but a lot of them are not ever caught so you'll have these patients who had PE that was silent that maybe one day they woke up and had a little bit of chest pain and then it

went away couple days later they thought they had a bronchitis or a cold and then you find out five years later that they had a huge PE that didn't affect them so badly and then they have these chronic findings they usually show up to their

family practice doctor again with hey I just can't walk as far as I can I have a little heaviness they rule them out from a heart attack but it turns out that they have CTF so you you all of them had a Q PE but it takes a lot of time and

effort to find out whether they truly have chronic PE so it's usually in a delayed fashion thank you all right well thank you guys again appreciate it [Applause]

being your sister's keeper this is my last two slides uterine fibroid embolization is effective and it's durable we do know that we although 300 000 hysterectomies are done in the country Stella for benign disease of

fibroids we are making dent in that doing around 30 000 UFE procedures annually in the u.s. we know that the procedure is clinically successful for bleeding in bulk and there are several several clinical studies that have shown

that compared to surgery that you can have less recovery time and complication that outpatient service is going to now become the standard of what the population is asking for no one wants to be in the hospital unless they have to

do it and that we could return patients to a better quality of life faster going back to work and around a week with a low complication rate thank you for your time and for your attention and doctor and I would be available for questions

Thanks

about massive PE so let's remember this slide 25 to 65 percent mortality what do we do with this what's our goal what's

our role as interventionalists here well we need to rescue these patients from death you know this it's a coin flip that they're going to die we need to really that there's only one job we have is to save this person's life get them

out of that vicious cycle get more blood into the left ventricle and get their systemic blood pressure up what are our tools systemic thrombolysis at the top catherine directed therapy at the right and surgical level that what

unblocked me at the left as I said before the easiest thing to do is put an IV in and give systemic thrombolysis but what's interesting is it's very much underused so this is a study from Paul Stein he looked at the National

inpatient sample database and he found that patients that got thrombolytic therapy with hypotension and this is all based on icd-10 coding actually had a better outcome than those who didn't we have several other studies that support

this but you look at this and it seems like our use of thrombolytics and massive PE is going down and I think into the for whatever reason that that the specter of bleeding is really on people's minds and and for and we're not

using systemic thrombolysis as often as we should that being said there are cases in which thrombolytics are contraindicated or in which they fail and that opens the door for these other therapies surgical unblocked demand

catheter active therapy surgical unblocked mean really does have a role here I'm not going to speak about it because I'm an interventionist but we can't forget that so catheter directed therapy all sorts

of potential options you got the angio vac device over here you've got the penumbra cat 8 device here you've got an infusion catheter both here and here you've got the cleaner device I haven't pictured the inari float

Reaver which is a great new device that's entered the market as well my message to you is that you can throw the kitchen sink at these patients whatever it takes to open up a channel and get blood to the left ventricle you can do

now that being said there is the angio jet which has a blackbox warning in the pulmonary artery I will never use it because I'm not used to using it but you talk to Alan Matsumoto Zieve Haskell these guys have a lot of experience with

the androgen and PE they know how to use it but I would say though they're the only two people that I know that should use that device because it is associated with increased death within the setting of PE we don't really know you know with

great precision why that happens but theoretically what that causes is a release of adenosine can cause bradycardia bradycardia and massive p/e they just don't mix well so

plan as well so I wanted to talk a

little bit about imaging I know with our residents and fellows and radiology that's all we do is talk about the imaging and then when go on to IR we talked to them about the intervention but I think it's important

for everyone in this room to see more imaging and see what we're looking at because it's very important for us all to be doing on the same page whether you're a nurse a technologist a physician or anybody else in the room

we're all taking care of that patient and the more information we all have the better it is for that patient so quick primer on a PE imaging so this is a coned in view of a CT pulmonary angiogram so yeah sometimes you'll see

CTS that are that are set for a pulmonary artery's and you'll see some that are timed for the aorta but if the pulmonary arteries are well pacified you're gonna see thrombus so I have two arrows there showing you thrombus that's

sort of blocking the main pulmonary arteries on the left and right side on the patient's left so the one with the arrow that is a sort of very classic appearance of an intro luminal thrombus you can see a little rim of contrast

surrounding it and it's usually at branch points and it's centered in the vessel the one on the right with the arrow head is really at a big branch point so that's where the right lower lobe segmental branches are coming off

and you can see there's just a big amount of thrombus there you can see distal infarct so if you're looking in the long windows you'll see that there's this kind of it's called a mosaic perfusion but it also what kind of looks

like a cobweb and that's actually pulmonary infarct and maybe some blood there which actually will change what we're gonna do because in those cases freaken we will not perform PE thrombolysis it's also important to note

that acute and chronic PE which we're here to talk about today may look very similar on a CT scan and they have completely different treatment methods so here's a sagittal view from that same patient you can see the CT scan so

between the arrow heads is with the tram track appearance so you'll see that there's thrombus the grey stuff in the middle and you'll see the white contrasts surrounding it and kind of like a tram track and that's very

classic for acute PE and then of course where the big arrow is is just the big thrombus sitting there here's another view of a coronal this is actually on a young woman which I think we show some images on but you can see cannonball

looking thrombus in the main pulmonary arteries very classic variants for acute PE and then this is that same patient in a sagittal view again showing you in the left pulmonary kind of those big cannon balls of

thrombus here's some examples from the literature showing you the same thing when you're looking at an acute PE it's right centered on all the image all the way in the left if the classic thrombus is centered right in the middle of the

vessel you can usually see a rim of normal contrast around it and you can see on a sagittal or coronal view kind of like a thin strip of floating thrombus so the main therapies for acute

stamp placement we talked a little bit about it I'm gonna talk to you a little

bit more about it and ideal stance is a straight stance that has a nice smooth curve with a portal vein and a nice smooth curve with a bad igneous end well you don't want is it is a tips that T's the sealing of the hepatic vein okay

that closes it okay and if there's a problem in the future it's very difficult to select okay or impossible to select okay you want it nice and smooth with a patek vein and IVC so you can actually get into it and it actually

has a nice hemodynamic outflow the same thing with the portal thing what you don't want is slamming at the floor of the portal vein and teeing that that floor where where it actually portly occludes your shunts okay or gives you a

hard time selecting the portal vein once you're in the tips in any future tips revisions okay other things you need it nice and straight so you do not want long curves new or torqued or kinks in your tips you

a nice aggressive decompressive tips that is nice and straight and opens up the tips shunt okay we talked a little bit you don't want it you don't want to tee the kind of the ceiling of the of the hepatic vein another problem that we

found out you want that tips stance to extend to the hepatic vein IVC Junction you do not want it to fall short of the paddock vein IVC Junction much okay much is usually a centimeter or centimeter and a half is it is acceptable

the problem with hepatic veins and this is the same pathology as the good old graft dialysis grafts what is the common sites of dialysis graft narrowing at the venous anastomosis why for this reason it's the same pathogenesis veins whether

it's in your arm for analysis whether it's in your liver or anywhere are designed for low flow low turbidity flow of the blood okay if you subject a vein of any type to high turbot high velocity flow it reacts by thickening its walls

it reacts by new intimal hyperplasia so if you put a big shunt which increases volume and increased flow turbidity in that area in that appear again the hepatic vein reacts by causing new into our plays you actually get a narrowing

of the Phatak vein right distal to the to the to the Patek venous end of the shunt so you need to take it all the way to the Big C to the IVC okay how much time do I have half an hour huh 17 minutes okay

Viator stents is one way let's say you don't have a variety or stent many countries you don't have a virus then what's an alternative do a barre covered stem combination you put a wall stent and then put a covered stance on the

inside okay so put a wall stent a good old-fashioned you know oldie but a goodie is is a 1094 okay you just put a ten nine four Wahl cent which is the go to walls down so I go to stand for tips before Viator

and then put a cover sentence inside whatever it is it's a could be a fluency it could be a could be a vibe on and and do that so that's another alternative for tips we talked about an ace tips as a central straight tips and it's not out

and fishing out in the periphery okay this is an occlusion with a wall stance this is why we use think this is why now we use stent grafts this is complete occlusion of the tips we're injecting contrast this is not the coral vein this

is actually the Billy retreat visit ptc okay that's a big Billy leaked into the into the tips okay and that's why we use covered stance I'm gonna move forward on this in early and early and experienced

so my name's Heather I'm a nurse in interventional radiology at NYU Langone health in New York and I am the clinical resources for our department so what that means is I'm responsible for individualizing our education to meet the needs of our department and one of

the first things I wanted to look at when I took on the role was our procedural sedation practices and how we can improve by enhancing our knowledge this presentation includes many of the lessons and concepts that I learned

along the way that I think are really important to understanding how to effectively administer procedural sedation so our learning objectives are going to be a review of the guidelines pre-procedure assessment components

including airway assessment pharmacology of the medications that we give and intra procedure assessment so this is the 2018 AAS a practice guidelines for a procedural sedation by non anesthesiologist has everyone seen this

good great as so this is especially important because as you'll see the American College of Radiology and Society of interventional radiology were involved in its development so this is our guideline and I think it's really

important to look at this look at the practice recommendations and see how they align with your own practice and if there may be some changes you need to make first thing you always want to look at when you're reviewing any sort of

literature whether it's evidence-based guidelines or maybe just a review article is you want to look at the methodology that the author used to create the guideline so anybody know why that's important you just shout it out

so if I want to write a guideline for procedural sedation I could find a bunch of studies or review articles that fit my point of view and use them throw them at the bottom and that would be that but even if I use for an demise control

trials which are considered the gold standard of experimental research those randomized controlled trials could be poorly constructed randomized controlled trials so they may have introduced bias at some point into the study

that's skewed the outcome and the findings so you really want to make sure that the authors of the guideline that you're looking at appraise the research that they're using to support their recommendations and that's what the

aasa' task force did so they used randomized control trials and observational studies and then they categorize the strength and the quality of the study findings so as you're going through you'll see that statistically

significant was deemed a p-value of less than 0.01 and outcomes were designated as either beneficial harmful or equivocal equivocal meaning this findings were not significant one way or the other and then they also used

opinion based evidence from experts so they surveyed members of their task force and they did take into account some informal opinion from message boards and letters to the editor so I think a good example here is one of

their recommendations about capnography so they did a meta-analysis of randomized control trials that indicated that the use of continuous and title carbon dioxide monitoring was associated with a reduced frequency of hypoxemic

events when compared to monitoring without capnography and then you'll see at the end of the recommendations this category so for this particular recommendation they labeled it as category a1 - B evidence and what that's

telling you as category a means it was a randomized control trial which is great it was a level one meaning it's a high level of strength and quality and B is telling you that there was statistically significant findings that demonstrated

benefit to the patient now another recommendation that you may see as you're reading through would be the NPO guidelines so if you look at any of the literature about NPO recommendations it's really all expert

opinion because all of the evidence has shown equivocal findings so for example one of the studies they looked at compared the outcomes of patients who had clear liquids one hour prior to the procedure versus two hours and they

found no change in the outcome I think it's important when you're a provider and you're looking at that because you're gonna base your judgment calls on the evidence so you may have a patient come in who had tea up until one hour

prior to their procedure and you have to make a decision whether or not you want to cancel or proceed and you could look at the findings of the literature that shows that there really hasn't been a proven difference in outcomes so you may

decide to just do the procedure versus capnography there's very strong evidence showing it's beneficial to the patient always so I think this is a real big take-home point of why we do everything we do about procedural sedation all of

our assessments and enhancing our practice as a sedation is a continuum and practitioners intending to produce a given level of sedation should be able to rescue the patients whose level of sedation becomes deeper than initially

intended pre-procedure our assessment

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