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So the best position for the SFA access a frog leg position, okay so if you do a frog leg position, it's gonna allow you to get into the SFA usually and the place where you can access the SFA is anywhere from the P1P2 segment all the way up to the mid SFA

to the proxi SFA, there's no problem in doing it. The issue is doing it is two things, one, obviously the vessel is deeper in certain areas and in other areas. Second, you wanna gauge the depth by figuring out what length of needle that you need before you go ahead and stick, three, if you're not working in the OR,

ample amount of local anesthesia or the patient is gonna go obviously berserk and jump and yell and scream and four, is to well, those are the first three things that you wanna prep the patient, second is, you wanna look on the fluoroscopy and please, I know a lot of you guys have done it, I'm curious on your techniques 'cause

what we use as far, there it is, thank you. So on the fluoroscopy, I don't know how this shows. What you wanna do is find your target whether it's the stint we've put here for you so say the stint in occluded, you wanna stick directly into the stint or do you wanna stick above or below the stint?

It's just depends on what you wanna do. We just gave you a target, second thing is you can also use angiographic clues such as calcium, right, if you have calcification on the SFA like the C2 case I presented, the critical limb where you can just stick directly into the calcium and then move the wire.

So those are the three things that we use for SFA.

numb up, you take your picture, you decide what your entry point is, what you wanna do is mag up really high. So when you mag up really high, you're gonna know where your target is so if you're targeting into the SFA

into the stint, then obviously you wanna really look at the entrances very well, make sure that you poke through. If you're targeting above or below the stint, then that's your target and no big deal. Second, once you enter the needle, you wanna enter the needle to on top of the vessel and then you wanna rotate

to two different views so you either wanna go to a lateral view or a medial view or whatever view opposite to the view you started on because that'll put you into the right plane in which you wanna enter the SFA. Ideally speaking in a diseased SFA, you may not be perfect on top of the vessel, you may enter the side of

the vessel, it really doesn't matter. Ideally, you want to enter right on top of the vessel and that's the goal to whether we're doing the SFA or the peroneal, okay so this guy's got a very thin leg

So the point of entry, let's say you wanna angle your point of entry here, so let's see, let's see here. If you wanna stick the stint, let's start a little higher. - Why you stick the stint? - Say you have a Restenosis case and you have a mid stint, okay and you have

approximal to the stint aclusion to the stint aclusion. Or just do the stint opedia, okay? And your wire gets underneath the stint strut. So now you're struggling, you do all your techniques. You do your O14 wire, you do different wires. Nothing is worrying, say he has only a peroneal access,

doesn't have a praxis and he's a quarti gan so at this stage you may say to yourself, I can give up now or get peroneal access, peroneal access is technically challenging, it's not like getting in the foot opposed to your tibial, changes of compartment are low but you could still screw it up especially single cell

run off for a quarti gan, right? So you could say I'm gonna direct stick the stint here and then I could come with a wire and then put my wire into my catheter and then work from above. So that's one of the reasons you could do it. Second reason is a case like mine where you obviously,

you lost wire access from above, that case was sutured off in the SFA, you have no ability, there are no vessels below the knee to get access. It's a limb salvage situation where you can do a direct SFA stick to go up. No bypass options, things like that.

Most surgeons are hesitant to bypass the quantification so I think if you just do it safely as an option, then you could do it, we had a lot of discussion about this but this is a master's course so that's why showing you a technique like this I think is worthwhile to have this in your bag.

This is not a regular go to for your SFA to say hey, I'm gonna do my SFA intervention by direct SFA stick, that shouldn't happen. Like we even talked about yesterday, deploying the sutura through the SFA stick like they do in Italy or whatever technique they call it.

I don't endorse it, I don't think anyone in America would endorse but remember they said hitting the ostium by putting it through the SFA. We just don't believe that's the right thing to do especially when you have over PTX which works well. So all these techniques are for limb salvage situations

where all other options have been burned and you're left with just a percutaneous option and you're doing extreme angioplasty so sticking a stint is never recommended, obviously, you could destroy the stint strut but I think these techniques are needed in these kind of cases, that's why, so I wanna be very clear.

You're never gonna do an intervention from this position. But you may, say you have a critical limb patient with an osteo occluded SFA, occluded iliac all the way into the common femoral, say I don't know. He's failed a fem fem bypass. He's failed the actual fem bypass

and he's not a candidate for an aortal bypass. And they're like he's relegated to an amputation and they call you and this is the access point you have. So that's a case where you can do it as long as you have control of the aorta or the iliac from contralateral limb, you could do it.

After you fail from the brachial access, all these type of things, so sometimes you also want areas of dual access, seeing that kind of patient, we have a common femoral iliac occlusion with the contralateral and you tried from the brachial but you have a wire from the brachial or radial at the top to give you

a chance to meet the wires, then you get access here because then if you perch the iliac, you have control of the aorta from either the brachial or from the other side. So I think it gives you a lot of options in terms of thinking about where you need to get access to start.

So these are the kind of clinical scenarios where I see this fitting in, I don't know, I know you've done it. When do you use this kind of situation? (man inaudibly mumbling) Right, right and a lot of times popliteal is very uncomfortable for the patient too.

Because even here, you have to rotate their leg even more to get into the pop but here it's pretty comfortable even if they're a big person, you can really get this. I would probably go a little bit even lower than this

but just to demonstrate here, I just wanna show this so this way so you wanna go in, so can you angle out the other way

please, can you angle out toward you, I just wanna show. And this is the highest mag here, so you see in this view and this view, you're kinda comin' out. I would probably reinsert the needle here but I'm just gonna go down and what you wanna do is try to move the vessel right before you go ahead and enter

the vessel so when you try to move the vessel, now you're on top of the vessel and then you just go ahead and poke in, that's it, now you're in the vessel.

You're never gonna use and O14 wire and you're never gonna use a small gauge needle like this.

You're gonna use a large gauge needle. You're gonna need a glide wire. And you're support catheter, you could insert a sheath but that's again in extreme cases where all things have been burned, at this stage, what we normally do is use a trum or navi cross with a glide wire

because even though it's a little slick, it's able to get through the skin, able to get through the soft tissue, able to get into the stint, does create a hole, in my opinion not as big as obviously a sheath so I think it allows you to work and the reason for getting the access is to cross the legion, not necessarily to treat.

If you had to treat through this for whatever reason, then you could put a sheath but then you'd be dealing with obviously hemostasis but the only time I've had problems with hemostasis with this approach is if the vessel is heavily calcified and is not able to recoil so therefore you end up with having to put

a balloon across and then when you put a balloon across, generally it does stop so let's get the wire here.

so what's gonna happen, I wanna tell you technically when you enter the stint, the stint is occluded, remember that's all ISR tissue so you have to push so when you push the wire you wanna get a loop but at that

stage, I want you to go to two different views to make sure you go through and through the stint and get underneath the stint because now then you're in trouble again underneath the stint, aha, another needle, beautiful. So I think that's also important, can you put that into that case so nobody gets hurt.

With a bigger needle, yeah, I generally use it with an 18 gauge needle. - Below the knee?

- [Narrator] No, below the knee would be the smaller needle, yes, absolutely, now find it. Now remember this is gonna be a little tougher 'cause obviously it's suparious. Go on top, now remember, what did you forget to do? You forgot two views so go to another view for me.

You could do this, I'm not saying you can't. I just want you to be more efficient. So when you go to a second view, someone come toward us, you see how you're off, see? So those two views will help you because when you're struggling on the floor, you're so close to it, right?

No, no, you wanna reenter the skin. So you wanna reposition and reenter the skin there. So sometimes you could also do this. You could take this if he's a skinny person and push down. Well, you can't really see it here and see which area, now go to the other view, please and see, here I'm far

away so maybe come a little bit more. I was right here, right, now come down a little lower. So I would enter in this view right here. See this, so this way I'm going right in. I'm actually moving the stint so this is the area I would enter, where I did the last time but again, this is not

as effective for the SFA because sometimes you might have a big leg and you're not gonna be able to see the indentation of the skin into the vessel. You're good, go forward there, let me see, there you go. Right in, you should move the stint. Go towards you, sir, not as easy as it looks.

- [Student] It's not, it looks real easy. - [Narrator] Well just, there you go, see. Now remember, don't go perpendicular, when you go perpendicular, you're gonna go right through and through the stint so you wanna enter in this angle, you wanna go through the stint and you wanna sit

in the middle so that your glide wire doesn't poke all the way through because your angle of entry is also gonna dictate how your glide wire behaves, right? You should be in, if you're not, we'll figure it out. So then you hold it and the first time you have your assistant hold a wire or send a wire and then you'll see.

Laura, now slow, as you enter, remember, the other thing is when you enter into the stint, I don't think you're quite in, see that or okay, two things, do what you just push it through, two things, so now this can be either your through and through and either you're coming out the other end or it could be that you're coming out the

side, maybe you perfed the side wall so here you're just gonna have to go either pull back, remember how Miguel did that fetal access, he kept pulling back, pulling back, pulling back till he fell into the vessel and then push. There you go, see that, that's it, great.

So let me just go over the theory of tibial

and then you guys can go to town here. So in the positioning. - When they pull back we entered too deep? - Through and through. Now remember you're dealing with an artery that's open and a soft artery, when you're dealing with a hard artery, it's gonna be totally different feel but I think sometimes

if you guys wanna learn is what you do is you start with an O14 needle and just stick it and then see how the wire goes if your first time you're doing it. You could even take a regular small gauge needle and use a V18 rather than an O35 so this way you don't created too much damage, a V18 will give you

a little more, the support you need to track a catheter, at the same time not give you as much damage to the stint as this would so for the peroneal the important thing

is the positioning of the leg, how do you position the leg in a peroneal, what do you normally do? (student mumbling)

Okay so what you wanna do is the position is this way. This is the area of the intraosseous membrane so what you wanna do is you wanna pierce through the intraosseous membrane in the peroneal so last thing you wanna do is go through the muscle, all the muscle. You can if it's a limb salvage and it's the only access

you wanna go to, you wanna go to the position where you go through the intraosseous membrane and then you're able to stick so what's the best position for the intraosseous membrane, you think? (student mumbling) Well, there's one, this you can do it either this way

if you're very low, let me show you come down. You can do it very, very low, little lower sir. Ah, this is the problem, okay, this is important. Go to low mag now, the other thing here is you wanna use the bone when you're sticking the peroneal, right? So you need to obviously raise the table so we're

at a disadvantage here so you can see. Okay, you can kind of see, what is that bar? Is that a bar or something underneath, oh, it's on the table, alright, let's try, can you come toward you now? Okay great, now come up. Now this is a very skinny leg, guys.

So because it's very skinny you use any position to get the peroneal, generally speaking if this guy or girl was a big muscular girl with a large gastrocnemius you would have to choose the position in which you're not going through as muscle or tissue in order to get the peroneal, I generally rotate the other way.

But we'll try it this way, let's see. Let's give a little more dye. Hopefully the peroneal's open in this case. You got the peroneal, come down to the foot, show me the foot, I don't think that's the peroneal. Okay, peroneal's out, no, that's not even anything.

Oh, it's going out into the toe, I think, show me here. Whatever that vessel is will stick, show me higher. That is the peroneal, nice, okay good, come down. We're lucky, alright, right there, let's start here. So in this position, same thing so remember I just wanna show you angiographically how it looks

so in this way you have the two bone spread, it allows you to stick, take their muscle, obviously you're not gonna go. I'm gonna flip it over this way, okay, this way toward you, same situation, much shorter approach right through the muscle so it depends.

The other view you're not gonna do. Now say you have a guy who's a football fan who has a great huge tibialis anterior, it's gonna bother you to go this way as well. Generally speaking this is more easy to go in avoiding a lot of tissue to enter.

So you could do it either way, it's fine with me but I think there's no real defined way to do it.

So again, same kinda thing, right? Find the needle in the point, let's find where we are. Hold on, you don't have to move, I'll figure it out. Okay great, now come down lower for me.

(chatter) You should be able, lower with the peroneal is difficult compared to upper, even though it's a little bit deeper there's more ability for you to go in, you have more space between the bones to be able to see because you're always doing this under direct.

We'll show it the other way, let's show it the other way. (chatter) You can, I've never done it but you can. So here, come over here and feel. You gotta feel the tibia, go ahead. And you'll feel the fibula and do it flora,

hit flora for him, hit flora, yup. See the gap and you can feel the artery. This is a very skinny leg so you can do either or.

Let's just get into the skin here. Okay can you show me down a little bit, please.

And then now go to another view. Meaning go LAR or RAO, uh huh, LAR or RAO. Okay the other way, okay, right on top of the vessel there. Okay that's good, stop, that's good, now moving the vessel around, remember we talked about tenting the vessel. Now remember guys, you could be on top of the vein.

You may get the vein, you have to deal with that when you do fluoroscopy, don't get upset. So at this stage, I'm not gonna stick. I want you guys to stick, you go ahead and you pierce him and the same kind of thing, once you're in because once that stick is gonna extract, I don't wanna do that.

So once you're in, you wanna again, the way Doctor Monterra showed you, once you're in, your needle may be in the posterior wall. At that stage, advance the wire slowly in fluoroscopy like I showed you in my tibial access under angio slides. When you hit the pusher wall, the wire will not go.

So don't just push, pull back the wire and then advance it up, that's it, so you can do from here all the way to here without a problem depending on the leg. I used the micro needle below. So why don't you guys split up into groups and I'll rotate around, perfect.

We can go to all the other c longs and start. Just divide up into groups. (chatter)

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