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Introduction Practical PAD and  Disclosures | Critical Limb Ischemia
Introduction Practical PAD and Disclosures | Critical Limb Ischemia
What Do When You See This? | Critical Limb Ischemia
What Do When You See This? | Critical Limb Ischemia
2017AVIRchapterelectiveepidemiologyfull videopatientstreat
Epidemiology and Defining CLI | Critical Limb Ischemia
Epidemiology and Defining CLI | Critical Limb Ischemia
2017acuteatherosclerosisAVIRchapterchroniccomponentdealingfull videoinpatientischaemiamedicarepressuresschemawounds
Outcomes of Patients with CLI and Classification | Critical Limb Ischemia
Outcomes of Patients with CLI and Classification | Critical Limb Ischemia
2017amputationangiographyAVIRchapterclassificationendovascularfontainefull videomultidisciplinaryoutcomespatientspercentrevascularizationsurgeonsulcerationvascular
Limb Threatening Ischemia - Acute & Criticial and Claudication | Critical Limb Ischemia
Limb Threatening Ischemia - Acute & Criticial and Claudication | Critical Limb Ischemia
2017acuteAVIRchaptercirrhoticclaudicationcomorbiditiesfull videoischaemiaischemiaischemiclimbmultidisciplinaryorthopedicspecialtieswounds
Good History and Physical | Critical Limb Ischemia
Good History and Physical | Critical Limb Ischemia
2017atherosclerosisAVIRcalcifiedchaptercliniccomorbiditydopplerevaluateexamfull videoimagingischemiapainpatientpatientspoplitealpulsepulseswound
Ankle Brachial Indices and Non - Invasive Vascular Studies | Critical Limb Ischemia
Ankle Brachial Indices and Non - Invasive Vascular Studies | Critical Limb Ischemia
2017AVIRbrachialchapterclaudicationduplexfull videoimagingmaterpatientsreproduciblesegmentalstudiesultrasoundvascular
Diagnostic Testing of Choice for PAD and Angiosome Approach | Critical Limb Ischemia
Diagnostic Testing of Choice for PAD and Angiosome Approach | Critical Limb Ischemia
Study - Indirect vs Direct Endovascular Revascularization | Critical Limb Ischemia
Study - Indirect vs Direct Endovascular Revascularization | Critical Limb Ischemia
2017AVIRcardiologistschapterclinicendovascularfull videoindirectinterventionalizationpatientsrevascularizationtherapyvascularwound
Mortality in Patients with CLI and BASIL trial | Critical Limb Ischemia
Mortality in Patients with CLI and BASIL trial | Critical Limb Ischemia
2017amputationangioplastyAVIRbypasscenterchapterdemographicsdiseasefull videopatientsrandomizationrandomizedstratifiedsurvivaltrial
Why is CLI Management Important? | Critical Limb Ischemia
Why is CLI Management Important? | Critical Limb Ischemia
2017amputationAVIRcarechapterfactorsfull videohealthkneemortalitymultidisciplinarypercentriskspectrum
Nonhealing Wound | Lateral Left Forefoot | 71 | male | Critical Limb Ischemia
Nonhealing Wound | Lateral Left Forefoot | 71 | male | Critical Limb Ischemia
2017accessangioplastyantegradearteriesAVIRballoonchapterfull videohabituslaterallesionocclusionperinealretrogradetechniquestibiatpaultrasoundwirewound
Nonhealing Heel Wound | 87 | male | Critical Limb Ischemia
Nonhealing Heel Wound | 87 | male | Critical Limb Ischemia
Nonhealing Wound - Left 1st Toe and Left Heel | 59 | female | Critical Limb Ischemia
Nonhealing Wound - Left 1st Toe and Left Heel | 59 | female | Critical Limb Ischemia
2017abisangioplastyantegradeatherectomyAVIRballoonballoonschapterexcisionalfemorisfull videomonophasicosteomyelitispatientprettyprofundareconstitutionrevascularizationtibialvesselwound
Conclusion | Critical Limb Ischemia
Conclusion | Critical Limb Ischemia
2017AVIRcarechapterdiseaseendocrinologyendovascularfull videointerventionalkatzenmultidisciplinaryorthopedicspatientspodiatryspecialtiesstrategiessurgeryvascular
Questions and Discussion - Practical PAD: All About Presentation
Questions and Discussion - Practical PAD: All About Presentation

I just wanted to hopefully everyone have a good lunch and enjoying the conference so far we've had a lot of great speakers this year and can continue on so we're going to discuss practical ta D and all about the presentation we want this to be also very interactive so please as

the the gentlemen are talking starts thinking of some good questions and stuff like that because that we have time at the end we definitely want to engage them and pick their brains while we have them here so our first speaker

is going to be dr. Paul Roshan he has completed medical training with Louisiana State University where he did attend chase Western University for his diagnostic radiographic residency and the Miami cardiac and vascular institute

for his VI fellowship he currently an associate professor with the University of Colorado and he's a big advocate for education and he coordinates a Malta multiple a disciplinary vascular conference and also developed a nurse

and Technology lecture series within his institute today he's going to speak with us about his treatment of critical limb ischaemia so let's go ahead and welcome him up to the podium [Applause]

it's a pleasure to be with all of you today how many of you are a soft in private practice private practice technologists we're pretty much all like a dip a couple back here and the rest of us are academic how many are doing p ad

in their practice that's great that's great I was expecting maybe a little less than that because as most know p ad is not really prevalent in ir in terms of being readily available as it used to be we're really isle heavy my rationale

for that is that kardia our cardiology colleagues and vascular surgery colleagues have you know kept the clinical going with PA d even though we were one of the first to actually practice that and then in I oh we're

actually became more clinical and that's why it's still in our arena but all that being said PID is still here and there's still a lot to go around and how do we actually capture that and still participate in that within our practices

and I still think it does have a role in our academic centers primarily through multidisciplinary care of no disclosures

so what do you do when you see something like this or this yeah yeah you hold you know sometimes but these are things that

you want to start considering for CLI these patients should be treated similar to whenever you're dealing with stroke now you don't necessarily need to come in immediately but you need to actually treat how these patients so that they

can come into your lab and be evaluated as soon as possible these aren't ones that are as elective and they can be put off until the next week therefore I know that in a lot of your practices you have that impatient board that you're trying

to treat us as much as possible some get bumped to the next day but these are ones that if you want to have a PID practice you have to have some room for these cases and we all know that these cases

may not take 12 hours sometimes it may take up to four hours and take over some room space so epidemiology of the CLI

about fifty percent of our patients will die of cardiovascular disease in five years and that's getting worse and worse

and this is five times greater than the normal population over about three years in 2011 to about 2014 there's been an increase in Medicare claims in both the inpatient and outpatient population so this is definitely a growing epidemic

one of the main problems that we face is how do we define see a lie some people think it's acute some people think that CL is chronic limits game you know it's critical in the schema but it does have a chronic chronic component you are

dealing with wounds you're dealing with atherosclerosis you're dealing with sometimes acute on chronic Bluto syndrome but this is what the challenge is and if we need to move forth with treating this a lot better we need to

come up with maybe changing the definition right now it's at schema crespi nor non-healing wounds in the presence of severe p ad and typical cut off in non-invasive image exams ankle pressures of 40 to 70 millimeters

mercury toe pressures and drop 30 to 50 and tcot is about 30 to 50 as well we'll get into a bis and in a bit now it is different from a li and dr. seryn is going to actually talk to you guys about acute limb ischaemia but CLI has a

chronic component that's what really differentiates it from the acute presentation so I'm going to be talking

a lot about outcomes and why we should be worried concerned and be active in PA d again so the outcomes of patients CLI

they begin with revascularization about fifty percent of our patients some get medical treatment some actually will get a primary amputation but as they go along only about twenty-five percent of sea lions resolved and most of these

patients get worse is at five percent mortality some will have more invitations and continuing CLI in terms of the classification some of you have heard of the weather for classification or Fontaine basically is

patients who may present with rest pain ulceration or gangrene and at this point we are trying to figure out well what do we do in this presentation you saw those ugly pictures sometimes there's no endovascular role that's why there's

multidisciplinary care with your vascular surgeons even though our vascular surgeons are doing in to vascular work this patient may need some type of amputation considering other things in terms of bypass is also

something that we want to consider whenever we're doing our diagnostic angiography we don't want to burn any bridges there's a clinical trial that I'll talk about in a second that will allow us to figure out what what is the

best way to do it so limb-threatening

ischemia this is pretty much my only slide talking about acute limb ischaemia but let's focus on CL I it's about greater than two weeks and people may think it's longer than that presentation

at the cirrhotic underlying process ischemic resting with with or without wounds no acute motor or sensory deficits and usually it's an urgent treatment now see live versus claudication again claudication is more

of an elective procedure but CLI you have a high risk of limb loss you want to get these patients in there are a lot of limb preservation limb restoration programs in our particular institution one of the ways that we are actually

getting involved more involved with PID it's from our orthopedic colleagues sure there's a showing a lot of wounds and things are not healing out of hardware on components but a lot of times they want to understand is there anything

bachelor that can be done in this this case now in terms of getting back to our building a practice in PA d it requires you to be available these meetings that they ask go to or 630 in the morning once a week

so that adds on to a day of work but one out of maybe ten cases that are presented maybe a vascular case may be a case that we're bringing back to our lab which makes it exciting that's what I work in our technique technical skills

actually get us excited but it's a clinical aspect and working together with other specialties that really is moving with medicine today and our CLI patients have tons of comorbidities that we have to deal with therefore

multidisciplinary care evaluation

practically with these patients always starts with a good history and physical and hopefully this is done before they actually show up in our lab hopefully we actually look at their feet before they

come into our lab you want to key in on the type of pain or discomfort that the patients are having listened to them figure out what what is causing this some may not even have any pain provoking or leaving factors what makes

it worse what makes it better does it occur at rest so they have depended rogue or looking at the feet and again I'm moving towards pants shoes and socks off you cannot evaluate a patient unless you're looking at the legs a lot of

times when yes some practitioners do it oh you have pain okay let me just move on to a CTA now that's just not the right way to do it you need to evaluate the patient and in the clinic to do that you need to get a great pulse exam and

that is taking a pulse of the common femoral popliteal and also there's a cell is the pedal pulses if you can feel it you should have a Doppler in the room at all times and if the patients are presenting with any type of wound you

want to document that because those patients will be coming in to see you those patients will need adequate wound care aggressive room care i may have to add to that and you want to document it in the electronic medical record or

whatever medical records you have so that you can see how if it's getting worse or if it's getting better and what you're stopping point maybe this is maybe a little hard to see but this is just an algorithm for

looking at the suspicion for CLI and it's based around the pulse exam if the patient has abnormal pulses with all the risk factors for atherosclerosis or the comorbidity symptoms physical exam findings guess what we're going to

critical limb ischemia and figuring out what the next best thing for the patient may be otherwise there are other objective measures that they have normal pulses and then possibly going through some type of imaging CTA if it's not as

urgent now we have to remember a lot of you guys may still do CT CT or have done it in your training but these patients have calcified arteries and it may be really difficult to evaluate these patients with this calcify disease does

we're moving on to maybe mr sometimes it's hard to get the patient's doing more and the protocols may not be sufficient therefore most of the patients who are coming to us need space in our diagnostic and geography lab we

want to do a run off and at that same time our referring physicians are asking us hey you have the patient on the table you better be ready to treat there for blocking out at least maybe three to four hours if you need to actually treat

these patients a lot of these patients may be in your institutions are coming from a long way away a lot of them have difficulty with transportation so you need to make sure that there's a process to streamline these patients in through

your clinic your your vascular lab your imaging and also in your ir sweeps going

to ankle brachial indices higher DP or PT over your higher break yo for each leg and pretty much we're looking at the mater mater actually too severe a vis

those less than point for ABI is a good screening test it's cheap it's not as good for functional limitations though claudication arresting ABI may be normal and you may need arrest using an exercise ABI

in the vascular lab and see line doesn't account for really enjoyed zones will talk about it a little bit more about Andrews ohms and that concept a little bit later for our non-invasive vascular studies they're more than just a B is

the PVR segmental limb pressures duplex ultrasound taking all of these into consideration before we're moving on to the next imaging study or intervention and it's appropriate for defining the level of disease and these non-invasive

imaging studies are again cheap they're reproducible and you gave these patients in quickly however just like we're trying to get patients into our laps in a experienced fashion our vascular technologists are also finding the same

way if we want to have a CLI program we need to carve out some time and don't place it until the last minute for patients that may need to come in sorry

terms of diagnostic testing of choice

for PID for our aorta iliac problems or suspicions see TMR may be good for fem pop duplex and when we're getting to the tibial paranoia on the pedo vessels we're probably needing to get some capital base angiography patients have

calcified vessels you may not be able to see them with duplex imaging and we need to see what type of collateralization will type of reconstitution these images are really important for our vascular surgeons if the patients may be bypassed

candidates the ngos ohm approach has anyone kind of heard about this before okay so this is actually first described by our plastic surgery colleagues in 1998 talking about a theory of the target artery perfusing an area of

ischaemia so you have all the different colors of the answer for the plantar surface lateral and medial aspect and the tibial arteries are thought to actually profuse those particular areas and if we the thought is if we target

andhra vast relies that particular vessel where that ulcer or or lesion maybe we should get better healing and there have been a lot of studies and literature's focusing on this and this is approach that most

people are using however its controversial because most of these rooms affect several angio zones but there's a lot of software that's coming out these days that will allow us to treat CLI better but a lot of

practitioners across the board of vascular medicine or looking at this

approach this is a study that looked at the indirect versus direct in the vascular vascular ization a retrospective study about seven eighteen

patients with CLI and what it showed that patients who had direct in the vascular therapy non-diabetic and diabetics had a higher freedom from major at verse limb events than those that did not have the head indirect

endovascular therapy so this thought is important because what we want to do is try to improve these wounds and decrease our rates of amputation following revascularization it's not over and this is where whenever I first was talking

about will why did most IRS lose p ad it's the follow-up there's a lot more that goes into this you really have to be involved and and invested in this process there's wound management a lot of our patients will come straight from

the room clinic and they're going to go back to the wound clinic so you want to make sure you have a good rapport with them or maybe working with them in the clinic nutrition is a factor for wound healing diabetes management infection

control having ID on board surveillance prevention measures Prevention's of MI and CVS all the medical therapy so you can see why our cardiologists may be involved in this a lot more than interventional radiologists we do a lot

of things and that's another reason so I'm gone off on a little tangent that most practices are starting to form niches with the practitioners that you have in your lab some will actually go mostly vascular some will go I oh when

they're on call you pretty much do just about every but in order to be champions in these disease processes you need to form those niches and those service lines mortality

and patients with CLI again it's rising

this is from 1999 it's a lot it's about forty to fifty percent in two years right now in 1999 is about thirty two percent the basil trial is something that we look at a lot and this was prior to the new best CLI trial in 2005 about

450 patients with CLI and infer angle of disease were randomized to both angioplasty and bypass follow-up was about six years and primary outcomes with amputation free survival a little bit about them the methods the disease

needs to be amenable to bypass on angioplasty and again patients were getting diagnostic angel grams to begin with this and to continue treating and randomization was stratified particular by the center tissue loss and ankle

pressures 50 millimeters Mercker less demographics are diabetic patients about half of them both male and female so this is a population again that we need to be targeting because they are known to have small vessel disease and this

study however there was a note that no difference in amputation freesat vile annotation free survival with those treated with bypass versus angioplasty it's a very interesting concept why is

CLI management important because CLI

confirms a high risk of amputation and those risks of amputation patients have a higher mortality higher mortality with those above knee amputation as well it closed the risk for health care concerns psychological quality of life and it's a

large impact on our health care dollars and economy just a little bit more information about their mortality 30-day mortality and BK is about five percent that's pretty much about our risk factors for most of our procedures it's

kind of high boot cut we want to stay one percent of below but above knee amputation sixteen percent I take anything above 10 it's pretty major and everything else that goes along with that now the

spectrum of co I care amputation first there's a lot of risk factors with that but whenever we go down to the right chronic wound care alone there's a lot of health impacts of the patient takes multidisciplinary work so the spectrum

of CLI care needs to happen but needs definitely multidisciplinary work and we need better technology to help us with that we're going to go through some

cases right now and maybe just talk about some techniques maybe you guys can

talk about some tools that you use back in your labs that may actually work you know you're working wire a choice that you actually graph in the shelf so a 71 year old males long-standing diabetes non-healing wound lateral foot for foot

the womb was about 1 to 2 centimeters took precious were taken and your grand three years ago was done for a first tool wound and the patient was known to have some tibia occlusion and lateral plantar occlusion these are some images

showing the disease perineal and also the plants are archers not their onion and the PT is actually out as well midway down via the calf how would your lap actually approach this whenever you ask about access I mean these are the

types of questions that I want to maybe get from you guys it doesn't need to be specifics on what you would do with the lesion but what would your access usually be for those who are still doing PID hurt up and over what else up and

over anyone's doing integrate access ok what's the limitation for antegrade on I do up and over as well a lot but why do you think that people are not doing antegrade access a lot body size ya body habitus think people are thinking radio

for these maybe in the future but we don't have a the length of devices so who knows we may be we maybe go back so cross antegrade with the wire and basically we're using simple techniques first you're 14 or 18 wire and a

catheter sometimes you're using a balloon to to try to traverse the lesion but just simple mechanics of just Ron across the lesion how many people are going retrograde through the pedal vessels yes good you have to think about

that the safari methods usually if you're having trouble getting from the antegrade it's a lot easier maybe to get from the retrograde of course it's not an ideal access that all of us do but thing is we have image guidance even if

you're not feeling the pulse you can get into the artery with with with ultrasound a lot of our colleagues that we work closely with in cardiology are pretty much just using fluoroscopy they're not using ultrasound so we have

those skills so cross the PT antegrade and came around the loop of the arch and pretty much just did balloon angioplasty and you got this good result now I would have to say that we whenever we're dealing with with CLI it's just not

mainly balloons and wires we want to think about what are we dropping in the Indies arteries I mean these arteries may spasm on us so we may give nitro at the time we may give TPA so you want to give these cocktail of medications to

open them up and to preserve them second

case at 87 year old male we're in the Rocky Mountain region so we have a lot of patients who come down from surrounding states was referred to a podiatrist for non-healing wounds

underwent debridement in the OR got wound culture ID was involved duplex and Andrea and performed showed a Papa tool occlusion and the patient was transferred to our tertiary Center for revascularization patient had you know

cardiovascular disease pacemaker was demented on the cardiovascular prevention meds on statins things like that he was a remote smoker and social system he had involved daughter his part nigga exam the PT had a weak

signal on the riot but no signal on the left and he had a wound this is the room looked like and this is a good image of what you should be doing you in your wound center you want to have a ruler to measure that wound every single time you

are looking at it and you want to describe it as well so coaches were taken x-ray no osteo inflammatory markers were also i'm taking in a do place again show Papa to occlusion this is just a PVR study I'm not going to get

into how you would read this but if you look at the waveforms on the left there pulsatile and not as pulsatile so post out on your ride but not as pulsatile on the left so you would note that that's what the patient has a disease and the

ABI on the left was 2.5 7c so let me go back may need to actually click these for me so we'll get some elevator music and you guys may understand that we're just watching waiting this is a CLI tibial so wait for it wait for word

don't move don't move don't move or we're gonna have to do it again so the first image actually just showed the Papa to occlusion I'm sorry yep popsicle occlusion and on your right show the reconstitution at the 80 so a little bit

work to do what would you guys again up and over access for the most part assume that that's what most people are doing let's talk about what type of wires not specific companies or anything but what type of wires are you guys asked to grab

or you may actually recommend to grab roadrunner ok what's that comienza ok v18 yep CSI Kathy otha a case it shows that too so there's a lot of options to use and a lot of these options are based upon the

experience of the operator and what type of outcomes they're having so yes you can have these expensive tools and yes some of them work some people use them a lot but just use maybe a start off with a glide wire and see what that does for

you and we're still waiting for this may need to click it for me yep start all over again so again just trying to get the pedo vessels and you just see that there's a lot of disease there but trying to get an idea of what to do

we'll move on so what is your next step this patient does have options would you just do chronic wound care alone after I guess doing the angiogram would you try to revascularization was on the table would you just sit okay go home we'll

come back and talk about it oh this is patient need an amputation I know we're in a venture lyst will probably go for it right okay but sometimes we need to discuss it with our vascular surgeon and that's the practice that we are actually

implementing in terms of a CLI call schedule involving everyone yes our vascular surgeons can do in the vascular work but involving us as well just in case the patient may need to have an amputation because remember all of these

cases are not without risks we're consuming the patient for limb loss things can go wrong and you guys have seen that in your lap so just a little list of what was done antegrade left CFA access we've got cement amol retrograde

left DP access did cart that's just a controlled way of using a balloon to get through like a dissection scoring or just prepping the vessel using the job coda ballooned is a lot of technology technology

balloons these days especially in the fetal vessels papa toh vessels and now looking at SMA should we send everything short lesions maybe not we know that since what will go down even with our drug-coated stance and you know uses

that whenever you need to and the drug tecnico de technology has proved to be beneficial so a little this is the drug called extent that we use was used the lateral angio shows a little irregularity there but definitely patent

and then the next what's going on with this one this was supposed to show how the aren't there we go so just getting better at pacification of that that DP so the patient could have better wound healing so again it's not over follow up

with the patient but there may be some limitations especially if patients are coming from afar going to a sniff compliance you know understanding so meeting them the tertiary care and just communicating with those those

facilities and can communicate with the multiple providers that's really important honestly it takes a lot out of the practice so just because we are running a 12-hour day in the lab doesn't mean that our day is over whenever we're

trying to communicate or communicating between cases another case see Sean how

long do you need yeah 20 minutes okay we're getting there so 59 year-old male with long-standing diabetes know that perdon past medical history remote

smoker but another room patient with the wound the bps monophasic left PT apps signal yet that ugly-looking foot again PVR showing 0 point 57 on the left abis ID consulate was done always want to rule any osteomyelitis to determine the

patient may need specific antibiotic therapy but you want to cover these patients anyway so revascularization of the SFA first of all the inflow looks good getting across the SS a reconstitution we see from the

profunda femoris vessel remember the fund ephemeris artery is actually the workhorse vessel SFA you want to keep it open especially and try to open it if the patient has any type of critical in Miss Khemia an excisional atherectomy

was done with scoring PTA and a drug called a balloon I mean in the past before DC bees who would have maybe just into this patient but the patient is failing the angioplasty a lot of recoiling that we may see in the tibial

vessels then we may actually do bailouts tensing later on we talked about CSI our cardiology colleagues use a lot of that and we're starting to use that because we're trying to collaborate with the CLI program and also night Noah cage

angioplasty balloons the chocolate balloons that are pretty new revascularization that's probably what was going to be the way to go because antegrade we were going cementum oh we're extracting going on getting out of

the vessel going up all the way to maybe that where the wound is and then trying to just use plain old balloon angioplasty showing that we have a better arch there now a lot of times it may not look pretty we we like to take

pretty pictures we like to have good images at the end but again we want clinical success and outcomes so following out that patient this may be good enough for him to heal now wrapping

this up what's the best way to treat CLI

we really don't know will it be through bypass and surgery it's in the vascular the best way this best CLI trial has about eight hundred patients in right now I think they're going for 2100 no showing you guys aside for this as well

so we're trying to get that and understand his surgical options best or endovascular and this is where we need to collaborate with all special these and push turf aside this is for our patients is not about who can

actually own this disease this disease pretty much owns us multidisciplinary care again vascular surgery is no particular order of hierarchy interventional radiology investor cardiology vascular medicine wound care

podiatry infectious disease endocrinology orthopedics all of these are players and you always want them at your table there's something new that was actually talked about at the ice at meeting this year this courtesy of dr.

Katzen the CLI global society which has some experts and really heavy hitters across all specialties and looking at the mission to improve the quality of life by preventing amputation and death to the CLI because it's an alarming

increasing weight rate and how can we fix the problem again a new definition for CLI public and professional effort to prevent it increase in clinical cooperation improving the standard of care for prevention and reducing the

time from symptom onset to the definitive care again almost thinking like a stroke team these days to bring these patients in it's going to change our practice a lot and may actually get IRS more into the game so some take-home

points it's a growing epidemic that requires where refocus approach at treatment strategies even though there's a lot of things I didn't get into a lot of the technical things but we know that there's a lot of ways to treat these

patients in the vascular efforts being made to form alliances and to gather information on these strategies to be part of the game however multidisciplinary approach is necessary just check your ego at the door let's

talk about this patient and there's work together with it and this disease process again is not exempt from I are as a team we need to continue to adjust this problem and be part of the solution thank you guys for your time


does anyone have any questions really gentlemen a quick one there I know we're cutting it close on time but those of you have made it a very key points in your lecture to bring up about the teamwork and working closely with other modality especially like vascular do you

find that over time now working so closely with vascular that it is changing your approach to your treatments like how aggressive you and may have been in the past compared to how you are now okay I feel that you

know everyone brings different skills to the table everyone trains different places usually have I changed some of my practices some I guess it i would say i would change it with the evidence that's actually coming out right now i'm still

using some basic techniques i'm working more with maybe a cardiology and they are using more you know different tools they use a lot of atherectomy and we don't use as much at directory so using their techniques they do a lot of

coronary work so sometimes knowing what they have on their shelf or the coronaries may actually help us out with our tools that we need for below the new work i would say it made me more aggressive because i can see a lot of

surgeons that don't want to operate and they tried their endows technique so i'm a big fan of pushing the limits of endo first I think it's just better for the patient's thank you I've used the the bard but I mean they

are I mean there are a number of balloons out there and I would say just like you know the different since they all have the drug on there so I don't think there's any particular balloon more companies are probably going to try

and come out with you know what different types of jobs that they're placing on it and this technology but I guess it all depends upon you know what you can actually mark it and get on your shelf for confinements and things like

that I do either of you have any experience with stents below the knee yep we we spent it but we don't do a lot of it yeah a drug-eluting stents are it's well described and certainly in the critical limb ischaemia population it's

very reasonable to do what do you think the percentages of the patients that you treat that you would stent it slow I generally use it as a bailout or a very calcified lesions that doesn't respond to anything else including atherectomy

but it's low it's the i would say ten twenty percent maybe in that ballpark thank you any other question thank you guys thank you guys [Applause] [Music]

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