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Endoleak Case |
Endoleak Case | "Extreme"-ly Obvious IR
accessaheadalgorithmaneurysmangiogramanteriorapproacharterialarterybringcablechaptercontrastendoendoleakfeedingfeeding vessel not identifiedFollow up angiogram shows a type 1b edoleakguysidentifyiliacimagingleaklimbpatientplaypuncturesheathslidestherefore planned an extension of the left aortic limbtrackingtransTranscaval approach to repair a likely type 2 endoleaktypevesselvideo
Take aways  |
Take aways | "Extreme"-ly Obvious IR
anesthesiacatheterschapterdiagnosticextremelyfieldimaginginterventionalinterventionalistmedicinemodalitiesobviousterritorytransition
Transcript

my talk is titled extremely obvious IR and I think as we move through these slides you guys are going to be able to pick up really quickly on why I elected for that title so this is a patient this is a 67 year old male he had an Evo repair in 2014 in 2015 he

underwent two repairs for persistent type 2 endo leak and this was done via transsexual approach in 2018 we got a CTA that demonstrated an enlarging aneurysm sac so here's just some key critical images from the CT I had the CT

and its entirety today but I had to like panic dump a lot of slides off of my powerpoint I'm always the girl at the airport that you see transferring things from one suitcase to the other like right when it's about to get onto the

airplane so what do we notice about where we see the contrast in these in these images so is it anterior is it posterior anyone its anterior so what if I told you that we see contrast in the anterior sac but this patient has an

included ima where is it coming from so we get the CTA we see any large aneurysm sac we see it an endo leak we bring them into clinic we go through the routine things the patient denies abdominal pain they deny back pain and so we go ahead

and all of our infinite wisdom and we schedule them for a trans cable approach to repair what we call a type 2 and delete now one of the most the most important key sentences from the workup is we say this is likely a type 2 in the

leak but a feeding vessel is not identified okay so our usual algorithm at UVA if we get a patient we do a CTA we bring we see any sort of endo leak if we cannot identify a feeding vessel usually what we do and you can let me

know if this is the same at your practice or if it's different we'll bring them in and we'll do some dynamic imaging from an arterial approach and we'll try to see you know is it really type 2 can we identify a feeding vessel

and oftentimes what happens in those situations is you you identify oh it is a type 2 we just see where it was from and we're gonna have to bring them back and we're gonna have to put them prone and we're gonna

have to stick the stack directly so we thought we were gonna outsmart it this time like we we were gonna just identify that it was typed to you right from the get-go do I have the play button or do you have the play button awesome all

right so this is our trans cable access so what we're doing these days to do our trans cable access and our fenestrations is we're actually using a t lab kit so we're using the transjugular liver biopsy sheath and we're putting our

65-centimetre cheap a needle through that so everything's going great so far we see our sheath in access goes smoothly I might have gone for two slides can you hit the I'm not sure yeah go ahead and hit that nope go ahead and

go one for slide and then just play that video for me yes please awesome so this happens pretty quickly can you play that video again and just keep playing it through on a loop and so we do an injection from our microcatheter from

our trans cable approach and what do you guys noticing where are you noticing the contrast tracking yeah in the red circle [Music] it is now right so everybody at UVA is is a proficient Monday Morning

Quarterback let me tell you so we see the contrast tracking down outside of the iliac limb so now we're all going okay can you go ahead all right go ahead and play this video all right so we get access into the femoral artery

just to make sure because at this point we're hoping against hope we haven't put this on the patient we haven't put this patient on the table MANET made a trans cable puncture only to identify that this patient does in fact have a type 1

B in delete but our arterial access proved that is exactly what we did the junction of the yes we did we did a trans cable puncture to identify that it was a junction leak so that's a problem right because we have

this action going on right so we have a trans cable puncture as dr. Haskell just adapt ly summarized we have a trans cable puncture we've done nothing so far but identify that this patient has the type 2 in a week so it is a micro

catheter right it's just it's just a party foul and then it was the fellow's dream because you pull out and there's nothing to hold pressure on there's nobody's dream at that point so I want to stop here and I want to just take a

moment you guys can live my psych at night so do you ever your so my normal algorithm for my patient since I come in in the morning I look at the patient's chart I review their prior imaging and I try to

do all of these things before looking at my attendings plan because one of the things that I realized is that challenges me to try to figure out what's my plan for the patient what do I think the most appropriate inventory

would be and every once in a while you see something in the plan that doesn't quite jive and you're like there's this is likely a type 2 in the league although a feeding vessel is not identified so I have two options at this

point I either walk down to the reading room and I say hey someone tell me what's going on we don't identify that type - is it worth doing a diagnostic imaging or anyway I just roll with it and this

was a day where I elected to roll with it and so I just want to take a moment and reiterate it's always important for all of us to you know you have a voice and use it and you want to bring up these

things that's sometimes we all start going through the motions where you work with someone that you trust a lot it's really easy to say like Oh someone's smarter than me caught that right so going back it's like it's like that

terrible joke what is the radiologists favorite plant the hedge mmm that's what that is it's like well it could be but it might be and ray'll right you go ahead and play this so this is just our walk of shame as

we're casually embolizing our track out of our trans cable approach and here we are back in clinic so again this is a 67 year old manual with recent angiogram that demonstrates significant type 1b endo leak and we plan for an extension

of the left aortic lab so we bring the patient back we do a standard comment from our artery approach we get into the internal iliac we identify the iliolumbar all kit all standard things we drop an amp at Sur plug to prevent

any sort of further type to end a leak into the limb that we go ahead and extend we put in the iliac limb we balloon it open we'll go ahead and play this video and our follow-up angiogram reveals a resolved type to end a week so

ultimately we did it so what are

extremely as obvious or extremely obvious takeaways from our extremely obvious IR so don't cut corners we all get into the habit you know and I've been in that situation time and time

again where we we look at a CT year we look at some imaging and we decide you know today today is the day we're gonna be smarter than what's in front of us and that burns us the other thing is is be mindful of your diagnostic imaging so

I would tell all of you as technologists as you continue you know when I first came into IR it was really unique because we were starting to transition from a diagnostic field to more of an interventional field I was seeing less

and less of lower Shmi runoffs for diagnostic purposes I was seeing less ptc accesses for diagnostic purposes but as we transition into true procedure list and interventionalist always be mindful of your diagnostic imaging

training because that is truly something that sets us apart from all other modalities not only can we diagnose but then we can also subsequently do something about it and the other thing is is know when to do all these things

right so what could have made this worse is rewriting the narrative in that moment is changing something isn't wanting it to work so bad that we did some crazy and we try to treat that type to

the wrong way from the access we already had and you'll see us do that sometimes we get in a situation where here patients under anesthesia whatever the extenuating circumstances is and sometimes we try to change things

to make them work for it that day and one of the great things about IR and one of the the kind of mottos that dr. Haskell has has brought and this sort of started to implement to my practice is evidence-based medicine and so one of

the cool things about IRS we work in a field where we have expert based medicine and evidence-based medicine and sometimes you're going on what you know to be true and sometimes you're going on the skill set of the expert in the room

they know their Anatomy they know their inventory and you're forging new territory and that can be really exciting but as you're stepping through those new doors and you're going into that new territory be mindful of when is

the time to stop when is the time to ask for a help when is the time to do something else when is it time to go back to basics so that is my extremely obvious paroles for at this case this is this is a real

this is a real thing of Medicine and certainly procedural medicine like ours which is we get tunnel vision we do place tunnel catheters in all the time and they all go well and then there's one case where something isn't quite

right and you keep thinking that but it should be okay because I've done it so often but your partner who steps in obviously sees the thing that isn't happening which is the wires in the wrong place and you're now in an extra

space or something and you know how do we kind of constantly get out of that lane or not get stuck in it which is really hard and that's you know that the part of it is the are constantly asking these questions right and and that and

that means that argument is a good thing because it's a path to our truth it's not I'm calling you into question and you're challenging me and I shouldn't like I meet you today and you you you make a joke you say I'm afraid of you

because she saw extreme area which was basically just you know and I said that's great you should needle me because you know that keeps a sharp but that type of interactions are really important when in these cases because

you know we're blind to these things so I'm with you it's great [Applause]

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