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Bland Embolization | Interventional Oncology
Bland Embolization | Interventional Oncology
ablationablativeadministeringagentangiogramanteriorbeadsblandbloodceliacchapterchemocompleteelutingembolicembolizationembolizedhcchumerusischemialesionmetastaticnecrosispathologicpatientpedicleperformrehabresectionsegmentsequentiallysupplytherapytumor
Case 1: Lower GI Bleeding | Emoblization: Bleeding and Trauma
Case 1: Lower GI Bleeding | Emoblization: Bleeding and Trauma
angiogrambleedbleedingbleedsbloodcatheterchaptercoilscolonoscopyembolizationembolizeessentiallygroinimaginglowerLower GI BleedmesentericNonepatientspicturepicturesprepscanseriesvessel
Inclusion Criteria | Transforming from Clinical IR to Clinical Trials with Tirapazamine (TPZ)
Inclusion Criteria | Transforming from Clinical IR to Clinical Trials with Tirapazamine (TPZ)
ablationcandidateschapterdiagnosisdysfunctionecogembolisationhcclargestlymphnoduleNonepatientsportalpriorradiofrequencyresectionsurgicaltumorvein
CT Angiography | Determining the Endpoints of CLI Interventions
CT Angiography | Determining the Endpoints of CLI Interventions
aneurysmsangiogramangiographycalcificationcalcifiedcenterschaptercontrastemoryequivalentinterventionkneemraoccludedpatientvessels
Treatment Options- TransCarotid Artery Revascularization- TCAR | Carotid Interventions: CAE, CAS, & TCAR
Treatment Options- TransCarotid Artery Revascularization- TCAR | Carotid Interventions: CAE, CAS, & TCAR
angiographyangioplastyarterybleedbloodcalcifiedcarotidchapterclaviclecommondebrisdevicedistalembolicembolizationexposurefemoralflowimageincisioninstitutionlabeledpatientprocedureprofileproximalreversalreversesheathstenosisstentstentingstepwisesurgicalsuturedsystemultimatelyveinvenousvessel
Case 4a: Renal Trauma | Emoblization: Bleeding and Trauma
Case 4a: Renal Trauma | Emoblization: Bleeding and Trauma
angioangiogramangiographyarteriovenouscenterschaptercoilscontrastembolizationembolizeembolizedextravasationFistulagradehematomahemodynamicallyimageinjurieskidneyNoneparenchymapatientspenetratingpictureposteriorrenalRenal Traumaretroperitoneumscanspleensurgicallytrauma
Indirect Angiography | Interventional Oncology
Indirect Angiography | Interventional Oncology
ablateablationablativeaneurysmangioangiographybeamBrachytherapycandidateschapterdefinitivelyembolizationentirehccindirectintentinterdisciplinaryischemiclesionographypatientportalresectionsbrtsurgicaltherapyvein
Treatment Options- CAS- Embolic Protection Device (EPD)- Distal Protection | Carotid Interventions: CAE, CAS, & TCAR
Treatment Options- CAS- Embolic Protection Device (EPD)- Distal Protection | Carotid Interventions: CAE, CAS, & TCAR
arteriesarteryaspirateballoonbasketbloodbraincapturecarotidcarotid arterycerebralchapterclinicaldebrisdevicedistaldistallyembolicfilterfiltersflowincompleteinternalinternal carotidlesionlesionsoversizeparticlespatientperfectphenomenonplaqueprotectedprotectionproximalsheathstenosisstentstentingstrokestrokesthrombustinyultimatelyvesselwire
Surgical AV Fistula  | Pecutaneous Creation of Hemodialysis Fistulas
Surgical AV Fistula | Pecutaneous Creation of Hemodialysis Fistulas
angioplastycannulatedcathetercatheterschapterdeviceDialysisembolizationFistulafistulashemodialysismaturationpatientspercutaneousrefused
Case 11: Bleeding Tracheostomy Site | Emoblization: Bleeding and Trauma
Case 11: Bleeding Tracheostomy Site | Emoblization: Bleeding and Trauma
aneurysmsangiogramarterybleedingBleeding from the tracheostomy siteblowoutcancercarotidcarotid arterychaptercontrastCoverage StentembolizationimageNonepatientposteriorpseudoaneurysmsagittalscreenstent
Introduction- Nursing Management in Prostate Artery Embolization | Nursing Management in Prostate Artery Embolization
Introduction- Nursing Management in Prostate Artery Embolization | Nursing Management in Prostate Artery Embolization
ablationsallowingarterybasicallycarechapterclinicconsultationsembolizationindicationsNonenursingpatientspractitionersprocessprostatetreatingworkup
Cone Beam CT | Interventional Oncology
Cone Beam CT | Interventional Oncology
ablationanatomicangioarteriesarteryartifactbeamchaptercombconecontrastdoseembolicenhancementenhancesesophagealesophagusgastricgastric arteryglucagonhcchepatectomyinfusinglesionliverlysisoncologypatientsegmentstomach
MEET Symposia, MEET IO, MEET Aorta, MEET Stroke | AVIR International-IR Sessions at SIR2019 MiddleEast & Africa Focus
MEET Symposia, MEET IO, MEET Aorta, MEET Stroke | AVIR International-IR Sessions at SIR2019 MiddleEast & Africa Focus
chapterdiseaseembolizationinterventionalmeetmeetingneurooncologyspeakerstechvascular
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
Hemobilia | Biliary Intervention
Hemobilia | Biliary Intervention
accessangioangiogramarchitecturearteriesarteryaureusbiliarybleedingceliacchaptercollateralizationdefectsdislodgementductembolizefistulasfrequentlygramhepatichilumintercostalinterventionistsliverparenchymalperipheralportalpreppseudoaneurysmremovethrombosestubetubesupsizeveinveinsvessels
Renal Ablation | Interventional Oncology
Renal Ablation | Interventional Oncology
ablationcardiomyopathycentimeterchaptereffusionembolizedfamiliallesionmetastaticparenchymalpatientpleuralrenalspleensurgerytolerated
Treatment Options- CAS- Embolic Protection Device (EPD)- Proximal Protection | Carotid Interventions: CAE, CAS, & TCAR
Treatment Options- CAS- Embolic Protection Device (EPD)- Proximal Protection | Carotid Interventions: CAE, CAS, & TCAR
angioplastyantegradearteryaspirateballoonballoonsbloodcarotidcarotid arterychaptercirclecirculationclampclampingcolumncommoncontralateralcrossdebrisdeflatedevicedevicesdilateddistaldistallyexternalexternal carotidfilterflowincompleteinflateinflatedinternalinternal carotidlesionmarkerspatientpressureproximalretrogradesheathstentstepwisesyringesyringestoleratevesselwilliswire
Intra Procedure | Transforming from Clinical IR to Clinical Trials with Tirapazamine (TPZ)
Intra Procedure | Transforming from Clinical IR to Clinical Trials with Tirapazamine (TPZ)
anesthesiaangiographyartifactassistedbeamchaptercombconedrawsekgelisaembolizationequipmenthcchepatocellularimaginginjectioninterventionalintraoperativemedicalNonenurseoximetrypatientphotopositioningprotectedradiologysedationspecialtiesspecialtystopcocksyringetechnologisttomographytumor
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
IR in Egypt and Ethiopia | AVIR International-IR Sessions at SIR2019 MiddleEast & Africa Focus
IR in Egypt and Ethiopia | AVIR International-IR Sessions at SIR2019 MiddleEast & Africa Focus
ablationsaccessafricaangiographybillarybulkcardiothoracicchaptercheaperconduitscountriescryocryoablationDialysiseconomyegyptelectroporationembolizationendovascularfibroidfibroidsFistulainterventioninterventionalnanonephrologyneurononvascularoncologyportalpracticeradiologyspecialtysurgeonssurgerysurgicallythrombectomytpavascularvisceralworldwide
Case 10: Peritoneal Hematoma | Emoblization: Bleeding and Trauma
Case 10: Peritoneal Hematoma | Emoblization: Bleeding and Trauma
activeaneurysmangiogramanteriorarterycatheterchaptercoilcontrastcoronalctasembolizationembolizeembolizedflowgastroduodenalhematomaimageimagingmesentericmicrocatheterNonepathologypatientperitonealPeritoneal hematomapseudoaneurysmvesselvesselsvisceral
Case- Brain Infarction | Brain Infarct After Gastroesophageal Variceal Embolization
Case- Brain Infarction | Brain Infarct After Gastroesophageal Variceal Embolization
anastomosisangiographyaphasiaapproacharrowarteryartifactbrainbronchialcalcificationcatheterschannelschapterchronicChronic portal vein thrombosuscollateralcyanoacrylatedrainembolismembolizationendoscopicendoscopistendoscopygastricGastroesophageal varixglueheadachehematemesisinjectionmicromicrocathetermulti focal brain infarctionmultipleoccludedPatentpatientpercutaneousPercutaneous variceal embolizationperformedPortopulmonary venous anastomosisprocedureproximalsplenicsplenomegalysplenorenalsubtractionsystemicthrombosistipstransformationtransitultrasonographyvaricesveinvenous
Geniculate Artery Embolization - Frozen Shoulder | Geniculate Artery Embolization for Arthritic Pain Why How & Results
Geniculate Artery Embolization - Frozen Shoulder | Geniculate Artery Embolization for Arthritic Pain Why How & Results
anatomyangiogramanteriorarteriesarterycapsulecatheterceliacchallengeschaptercircumflexdiseaseembolizationfrozenhyperimageinflammatoryinvestigationaljapankneeliningorthopedicpainpatientpatientsprostateradialshoulderstudysurgeontextbookvascularvascularityvessels
The Ways to Recanalize the Below the Knee Vessels | AVIR CLI Panel
The Ways to Recanalize the Below the Knee Vessels | AVIR CLI Panel
ablationanalogantibioticarteriesarthritisassessaveragebasicallychapterclinicaldissolveemboembolizationembolusinfarctinjectinvestigationalkneelateralmedialmrispainpalpatepatientpatientsprocedurepublishedradiofrequencyrefractoryresorbablescalestudy
Nodule in right lung | Cryoablation Case | Ablations: Cryo, Microwave, & RFA
Nodule in right lung | Cryoablation Case | Ablations: Cryo, Microwave, & RFA
ablationablationschaptercryocryoablationfreezehemorrhagelesionlungLung Noduleminutesnodulepneumothoraxprobesprotocolproximalthawtriple
Endovascular AVF creation | Twitter Case Files SIR 2019
Endovascular AVF creation | Twitter Case Files SIR 2019
6fr venous WavelinQ magnetic catheteradvanceadvancesalignarterialbrachialcatheterscenterschaptercreateselectrodeembolizeendovascularengageFistulainsertmaturationpatientpatientsstepultrasoundveinvenavendors
Case 2: Upper GI Bleed | Emoblization: Bleeding and Trauma
Case 2: Upper GI Bleed | Emoblization: Bleeding and Trauma
abnormalangiogramarteryaxisbleedingbleedsbloodcatheterceliacchaptercoilscontrastembolizationembolizeendoscopyesophagusFistulagastroduodenalhemoptysishepaticmalformationsmesentericNoneportalsuperiortipsupperUpper GI Bleedvaricesvenousvesselvesselsvomiting
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
Treatment Options | Pelvic Congestion Syndrome
Treatment Options | Pelvic Congestion Syndrome
amplatzblockblockingbloodchaptercoilcoilsembolizationembolizegluegonadalmaterialsoptionspelvicperipherallysclerosantsurgicalsuturetreatingtreatmentvalvesvaricosevaricositiesveinveins
Does Embolic Material Matter | Pelvic Congestion Syndrome
Does Embolic Material Matter | Pelvic Congestion Syndrome
amplatzchaptercoilconfluenceembolicgelfoampaucityperipherallysclerosantvein
Transcript

I'll show you maybe an onyx here. So this is a patient with hemoptysis. Had a MAI, and there is the lesion in the lung and they wanted us to biopsy. But I've had a few cases of tuberculosis,

we're gonna move on to embolization there a couple different categories of embolization bland embolization is when

you just administering something that is choking off the blood supply to the tumor and that's how it's going to exert its effect here's a patient with a very large metastatic renal cell lesion to the humerus this is it on MRI this is it

per angiogram and this patient was opposed to undergo resection so we bland embolized it to reduce bleeding and I chose this one here because we used sequentially sized particles ranging from 100 to 200 all

the way up to 700 and you can actually if you look closely can see sort of beads stacked up in the vessel but that's all that it's doing it's just reducing the blood supply basically creating a stroke within the tumor that

works a fair amount of time and actually an HCC some folks believe that it were very similar to keep embolization which is where at you're administering a chemo embolic agent that is either l'p hi doll with the chemo agent suspended within it

or drug eluting beads the the Chinese have done some randomized studies on whether or not you can also put alcohol in the pie at all and that's something we've adopted in our practice too so anything that essentially is a chemical

outside of a bland agent can be considered a key mobilization so here's a large segment eight HCC we've all been here before we'll be seeing common femoral angiogram a selective celiac run you can make sure

the portals open in that segment find the anterior division pedicle it's going to it select it and this is after drug living bead embolization so this is a nice immediate response at one month a little bit of gas that's expected to be

within there however this patient had a 70% necrosis so it wasn't actually complete cell death and the reason is it's very hard to get to the absolute periphery of the blood supply to the tumor it is able to rehab just like a

stroke can rehab from collateral blood supply so what happens when you have a lesion like this one it's kind of right next to the cod a little bit difficult to see I can't see with ultrasound or CT well you can go in and tag it with lip

Idol and it's much more conspicuous you can perform what we call dual therapy or combination therapy where you perform a microwave ablation you can see the gas leaving the tumor and this is what it looks like afterwards this patient went

to transplant and this was a complete pathologic necrosis so you do need the concept of something that's ablative very frequently to achieve that complete pathologic necrosis rates very hard to do that with ischemia or chemotherapy

alone so what do you do we have a

patient who presents with rectal

bleeding he's had a transfusion and this is the angiogram so it's gonna be a lot easier people volunteer so who wants to say what they see what do you say what do you say show me tell everyone what you say well there's two

slides the first one you see just a little bit of blood and on the second slide you can see where he's really bleeding all right so these are the same the same patient same angiogram so one thing you guys should realize if you

don't know this already about an angiogram is an angiogram is a series of pictures over time good job by the way so a series of pictures over time so it's not just one image and the analogy I like to give is if I take my kids to

Disney World right I can have that picture of all of us in front of the castle with the Mickey hats and everyone's smiling but like one second before this one kicked that one and one second after this one smacked the other

one in the head and they're all crying but I got that one picture an angiogram is that situation it's a series of pictures over time so while you may look at that first picture on the left and maybe not see so much going on what you

should appreciate on the right is that big blobby thing of contrast over on the right side all right now what that means is that there is blood pouring out of that person's vessel all right this is a mesenteric angiogram it's a superior

mesenteric artery angiogram we put a catheter in by the groin from the groin we went into the SMA and we took some pictures and this is what we're seeing and we're appreciating hopefully that big blobby thing on the right all right

so this is what we'll call a lower GI bleed all right the patient's essentially crapping blood that's a lower GI bleed all right so given that just another hint this kind of implies that we're gonna talk about upper GI

bleeding later all right just so you know so there's lots of different causes for lower GI believes there's diverticular disease there's angiodysplasia switch our small malformations of the blood vessels

there's a ski mcdowell there's patients who maybe had radiation therapy for different cancers can be predisposed to bleeding cancer itself can cause bleeding and different inflammatory diseases like either infections or other

diseases can as lower GI bleeding now how do we work these patients up well usually I would think that most of the time these patients have hit an ir suite they've probably had a colonoscopy first and a

colonoscopy is really the first line used to assess what's going on with a lower GI bleed it's not that easy to do it's difficult to prep those of you who resolve this I am and have had a colonoscopy know that it's better when

you prep before the colonoscopy and if someone comes in with a lower GI believe they haven't been adequately prepped that makes the colonoscopy very difficult the other thing is remember you're going from the bottom up into

colonoscopy and you have blood coming at you in someone who is experiencing a lower GI bleed and that essentially means it's difficult to see so many times the colonoscopy is not really able to tell us what we need to know I would

say the next thing that usually happens is some type of imaging now of a sudden the patients are coming to radiology and what you may have is any one of three different options you might have a nuclear medicine bleeding scan you might

have a CT angiogram you might have a regular old conventional angiogram and for those of you saying who cares what's the difference just take some pictures the big difference is that the amount of bleeding that it takes to see it is

different for each of those exams so the most sensitive exam is the nuclear medicine scan that's going to pick up the lowest rates of bleeding a conventional angiogram is the worst scan we can do for GI bleed or worse imaging

we can do because you need a lot of bleeding to see it so when we saw when my friend here picked up the the blobby thing on the right would that bleed that's a big bleed like we can look at it and say aren't these really pretty

pictures but when we see it and you see that kind of bleed you have to realize that's a lot of bleeding to see it like that so our antenna has to go up and we have to start moving a little bit CTA is kind

of right in the middle and actually a lot of people are turning now to see TAS I'm not personally a huge fan of that because I think it's a waste of time and contrast in my opinion I think a CTA for GI bleeding is a way if I can translate

it is I don't feel like doing that case right now so I'm gonna get a CTA and we'll figure it out later all right that's that's my language for a CTA but in my opinion you know it has some value how do we treat them well if

you can see on colonoscopy then you can potentially treat it with colonoscopy and there's different things that they can do with their scopes obviously if there's more diffuse disease they can remove part of

the bowel that's that's a problem and then of course the answer is embolization exactly so here is the picture from our embolization procedure and what do you see all right I won't pick on anybody yet basically what we

did was you can see over there you can see the shade of our angiographic catheter there's a micro catheter now passing all the way into the actual vessel that's bleeding and now when we do an angiogram you can actually see the

vessel that's bleeding now conventionally in the old days for those of you that have been doing this for a while you probably are used to living in a world where it's not great to embolize lower GI bleeds it's better to embolize

upper GI bleeds and lower GI bleeds and the reason why is because there's less collateral flow so if we block up a blood vessel we essentially kill everything beyond where we blocked it up because there's no alternative routes

for blood to flow all right in this particular case you can actually see that long stringy thing going right to the bleed and here we were able to get into that single vessel and kind of see it right there the long think heading

towards 4 o'clock and when we embolize it you can see we put coils in there and blocked it up so the only thing we embolize there is the blood vessel going to the abnormality the risk of ischemia is low and the clinical efficacy is high

but if you can't make it all the way out there if we embolize let's say right there that entire loop of intestine would be infarct it and that would be bad so we always have to think about that when we're embolizing GI bleeds all

no way around this I'm gonna read to you the inclusion criteria right off the protocol it's kind of long so confirmed diagnosis I wrote some single line there that can help you follow along confirm diagnosis of HCC number two patients

above age 23 patients with single or multiple nodules HCC who are unsuitable or unwilling for surgical resection or RFA the largest tumor nodule should be less than 10 centimeters in the large largest diameter total volume of tumor

cannot exceed 50% of the liver patients are candidates for trans arterial embolisation no tumor invasion to portal vein or thrombosis and main and first branch of the portal vein 5 patients have no lymph node involvement or

distant metastasis 6 ECoG score at 0 to 1 with no known cardiac pulmonary or renal dysfunction 7 child pew score group a and B 7 eight patient should have measurable disease by contrast MRI nine prior local

therapies such as surgical resection radiofrequency ablation and alcohol injection are allowed as long as tumor progresses from the prior treatment and the patients are still candidates for tae 10 patients have normal organ

function based on some labs eleven patients are able to understand and willing to sign the informed consent and twelve men and women of childbearing age need to commit to using two methods of contraception and the exclusion criteria

for it's very it at centers where CTA protocols are very good it's basically equivalent to a angiography has been shown in multiple papers to be so newer studies show that

CTA and Emory are equivalent so I don't know it depends on your institution there are a lot of places that still practice with the MRA is kind of the gold standard but CTA is just so much more available that CTA is becoming kind

of the new gold standard for for quick vascular assessment often like to use it to help us plan our intervention so if we don't know what's going on above the level of the groin CTA could be helpful to see whether or

not we could even go from right to left how calcified the vessels are or whether or not there's concomitant aneurysms things that we don't like to discover at the time of the procedure because we might not have the equipment we need to

treat it one of the strengths is that it's quick and that it's cheap but of course it uses contrast and just like you know we like to minimize the amount of contrast that we're using at knee and rogram this can use anywhere from 75 to

150 cc's of contrast or not a small amount and if you're gonna do an intervention the same or the next day that's a lot of dough that's a lot iodine in a couple days these are examples of what we can see at the time

of the procedure there's a 3d reconstruction and a BU these are kerf planer reformatted images what basically they draw a line down the image and you can lay the entire vessel out even if it's very squiggly and then this isn't

this an angiogram and that same patient you can see that they correlate exactly another example a patient with aortic calcification you can see that it can be potentially challenging this patient with diabetes to determine whether or

not these vessels in below the level of the knee are paetynn or not because I can tell you that the one that's closest to the small bone there is actually occluded it's just all calcified you can't really tell what's going on and

the one that's behind that is actually Payton so it could be difficult to tell whether it's calcium or contrast that you're seeing this is where MRA can be

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

let's move on here is another patient who took a fall skiing we see a lot of these patients up in upstate New York and they presented with severe left-sided abdominal pain and here's the cat scan

all right who's up for it what do you think what looks bad you look like you're into it what do you think yeah the right the bottom right-hand side of the picture should be spleen and it just looks like a big pool of blood that's

pretty good you did pretty good spleens a little higher so we're gonna presume spleen is there Graham this is just one image one slice through the picture through the body so we're just not at the level of the spleen but that's the

kidney that's exactly right that white thing on the right side of the image of the patient's left side is the kidney and the one thing I'd like everyone who appreciates that doesn't look at all like the other side all right so when

you look at a cat-scan like this you want to look for symmetry that's really important all right that's the cool thing is we're kind of meant to be similar looking on both sides of our body and in this particular

case you can see that the left kidney has been pushed way forward in the body compared to the right side and there is a kind of a hematoma sitting in the retroperitoneum posterior behind the kidney that's bad

the other thing you should notice is if you look at that left kidney you notice that white squiggly line that doesn't belong there okay that's contrast that's not really constrained inside an artery that's extravagant of

contrast that's bad all right we don't want to see that all right again there's a grading system for renal trauma and you're gonna hear people talk about grade 1 2 3 4 injuries all right obviously as the number gets higher the

extents of the injury gets more significant all right so again here's that picture think you can appreciate that it's at least a grade 4 laceration of the kidney so we went in and we did an angiogram now we can watch these

patients we can surgically manage them by taking out their kidney in some ways that's the easy part excuse me it's a lot more elegant to try and embolize these patients if they're hemodynamically stable and can take you

know getting to angio and doing the case now in general we do embolization for patients with lower grade injuries and usually penetrating injuries a penetrating trauma that's seen on CT I think this is something that's changing

I if any of you work at high-volume trauma centers the reality is that we're doing more and more renal angiography for trauma than we used to because it's just becoming a more accepted thing for us to

be doing that all right so here's the angiogram and again I think you can notice it really correlates very well to what we saw on the CT scan you see that first image on the left and on the delayed image you see that that kind of

poorly constrained contrast going out into space now we were never really quite sure what this was if it was extravasation or if it was potentially an arteriovenous fistula with early filling of a renal vein regardless of

which it's not normal all right so what we did was we went in and we embolized and I only included this picture because I'm a big drawer during cases so when I'm working with a resident or a fellow I like to really

lay out our plan on a piece of paper and try and stick to the plan and this particular picture look really good so I included on the lecture but basically you can see that the coils the goal here for any embolization procedure

when it comes to trauma is to preserve as much of the normal organ as we can and to simply get you know to the source of the bleeding and to get it to stop and that's what we did there so what you can appreciate on this is kind of the

renal parenchyma or the tissue of the kidney is largely maintained you can see the dark black kind of blush within the kidney and all that really stands for properly working kidney all right and yet we embolize the pathology so that's

our goal here's a similar patient not

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]

kind of the embolic protection because I think with carotid artery stenting the stents there's a lot of different types they're all self expanding for the most

part and there's not a lot to talk about there but there is with regards to embolic protection and there so there's distal and violent protection where you have this where that blue little sheath in the common carotid artery you got a

wire through the ica stenosis and a little basket or filter distally before you put the stent in early on they used to think oh maybe we'll do distal balloon occlusion put a balloon up distally do your intervention aspirate

whatever collects behind the balloon and then take the balloon down not so ideal because you never really asked for it a hundred percent of the debris and then whatever whenever you deflate the balloon it goes back it goes up to the

brain you still have some embolic phenomenon in the cerebral vascular churn and then there's this newer concept of proximal protection where you use either flow reversal reverse the blood flow in the cerebral circulation

or you actually cause a stagnant column of blood in the ica so you can't get you don't get anything that embolize is up distally but you have this stagnant column the debris collects there you aspirate that actively before you take

down the balloons that are in position in the X carotids and common carotid artery and then you take everything out so let's walk through each of these if you really wanted to pick out the perfect embolic

protection device it's got to be relatively easy to use it's got to be stable in position so it's not moving up and down and causing injury to the vessel but even while it's in place cerebral perfusion is maintained so that

balloon the distal balloon not a great idea because you're cutting off all the blood flow to the brain you might stop something from embolizing up distally but in the process of doing that you may patient may not tolerate that you want

complete protection during all aspects of the procedure so when we place a filter as you'll see just crossing the lesion with the initial filter can cause a distal embolus so that's a problem you want to be able to use your guide wire

choice as many of you know when we go through peripheral vasculature there's your go-to wires but it doesn't always work every time with that one go-to wire so you want to be able to pick the wire that you want to use or

change it up if needed for different lesions so if you get to use your wire of choice then then that's gonna be a better system than something that's man deter and then if you have a hard time using that wire to get across the lesion

you have a problem overall and then ultimately where do you land that protection device and a few diagrams here to help illustrate this generally speaking these distal embolic protection these filters that go beyond

the lesion have been used for quite a while and are relatively safe you can see them pretty easily and geographically they have little markers on them that signify if they're open or closed and we look for that overall and

blood flows through them it's just a little sieve a little basket that collects really tiny particles micrometers in size but allows blood flow to pass through it so you're not actually causing any cessation of blood

flow to the brain but you are protecting yourself from that embolic debris and it's generally well tolerated overall we had really good results in fact when not using this device there's a lot of strokes that were occurring in use of

this device dramatic reduction so a significant improvement in this procedural area by utilization of embolic protection however distal embolic protection or filter devices are not a perfect APD as you as you may know

those of you have been involved in carotid stenting there is no cerebral protection when you cross the lesion if you have a curlicue internal carotid artery this filter doesn't sit right and and ultimately may not cause

good protection or actually capture everything that breaks off the plaque and it can be difficult to deliver in those really tortuous internal carotid arteries so ultimately you can cross the lesion but you may not get this filter

up if you don't get the filter up you can't put the stent then ultimately you're out of luck so you gotta have a different option filters may not provide complete cerebral protection if they're not fully opposed and again it does

allow passage of really tiny particles right so your blood cells have to be able to pass but even though it's less than about a hundred microns may be significant enough to cause a significant stroke if it goes to the

right basket of territory so it's not perfect protection and then if you have so much debris you can actually overload the filter fill it up in tile and entirely and then you have a point where when you capture the filter there's some

residual debris that's never fully captured either so these are concerns and then ultimately with that filter in place you can cause a vessel dissection when you try to remove it or if it's bouncing up and down without good

stability you can cause spasm to the vessel as well and so these are the things that we look for frequently because we want to make sure that ultimately if we just sent the lesion but we don't believe the vessel distal

to it intact and we're going to have a problem so here's some kind of illustrated diagrams for this here's a sheath in the common carotid artery you see your plaque lesion in the internal carotid artery and you're trying to

cross this with that filter device that's what's the picture on the right but as you're crossing that lesion you're you're liberating a little plaque or debris which you see here and during that period of time until the filters in

place you're not protected so all that debris is going up to the brain so there's that first part of the procedure where you're not protected that's one of the pitfalls or concerns particularly with very stenotic lesions or friable

lesions like this where you're not protected until that filters in place that first step you never are protected in placement of a filter here's an example where you have a torturous internal carotid artery so you see this

real kink these are kinds of carotid internal carotid arteries that we can see and if you place that filter in that bend that you can see right at the bend there the bottom part the undersurface of the carotid doesn't have good wall

my position of the filter so debris can can slip past the filter on the under under surface of this which is a real phenomenon and you can see that you can say well what if we oversize the filter if you oversize the filter then it then

it just oval eyes Azure or it crimps and in folds on itself so you really have to size this to the specific vessel that you plan to target it in but just the the physics of this it's it's a tube think about a balloon a balloon doesn't

conform to this it tries to straighten everything out this isn't going to straighten the vessel out so it doesn't fully conform on the full end of the filter and you have incomplete a position and therefore

incomplete filtration so this is another failure mode I mentioned before what if it gets overloaded so here's a diagram where you have all this debris coming up it's filling up the really tiny tiny particles go past it because this little

micro sieve allows really small particles to go distal but approximately it's overloaded so now you get all this debris in there you place your stent you take your retrieval filter or catheter to take this filter out and all that

stuff that's sitting between the overloaded filter and your stent then gets liberated and goes up to the brain so you got to worry about that as well I mentioned this scenario that it builds up so much so that you can't get all the

debris out and ultimately you lose some and then when the filter is full and debris particles that are suspended near the stent or if you put that filter too close to the edge of the stent you run into problems where it may catch the

stent overall and you have all of this debris and it looks small and you don't really see it and geographically obviously but ultimately is when you do a stroke assessment and it's not always devastating strokes but mild symptoms

where he had a stroke neurologist and the crest trial or most of the more recent clinical trials we actually evaluate a patient and notice that they had small maybe sub sub clinical or mild strokes that were noted they weren't

perhaps devastating strokes but they had things that caused some degree of disability so not insignificant here's a case example of a carotid stent that was done this is a case out of Arizona proximal carotid

stenosis stent placed but then distal thrombus that developed in this case and had post rhombus removal after the epd was removed so there's thrombus overloaded the the filter you can see the filter at the very top of the center

image you can see the sort of the shadow of the embolic protection device there distally aspirated that took the filter out and then ultimately removed but you can imagine that amount of thrombus up in the brain would have been a

devastating stroke and this is what the filter looks like in real life so this is what the debris may look like so it's not this is not overloaded but that's significant debris and you can see the little film or sieve that's on the

distal part of this basket and that's what captures the debris any of that in the brain is gonna leave this patient with a residual stroke despite a successful stenting procedure so this is what we're trying to avoid so in spite

today okay go forward so sorry now when it says is there any commercial bias really there's only two companies that have this device so if I speak about each one clearly there's going to be a

little bit of commercial discussion but as I people always ask me which one do you prefer and I always have to tell them quickly you know I'm not a salesman for either company as a matter of fact I'm more

like a test pilot and we're still in the very early stages of this and which device may be better however you wanted to find that or easier to use or what the data is going to show we don't really know yet so but we're fortunate

that we have access to both devices for our patients a couple of things we know and dialysis patients start 80% start with catheters bad okay and catheters bad if you get anything out of this lecture catheters bad about 28 to 53

percent failure to mature means they have a fistula it's physiologically working but it never matures to be able to use for hemodialysis time to maturation three to four months

interventions per year required angioplasty you know embolization you guys know all about this stuff trying to read Evert flow back into the main channel of the fishhook and patients about 30 up to 30

percent just refused once they have our fish to them for whatever reason they refused to have it cannulated you know they don't like the pain it's in an awkward position whatever but the idea of percutaneous

which was may actually put a big dent in that Kathy first-line initiating dialysis with catheters because many times these patients come then they need to houses right away they get a catheter but if we know you know these things

usually except you know for toxic injury like ingesting antifreeze and stuff like that most you know frolla just know these patients are headed towards dialysis well in advance of the time they need it and so these calls stage

four and stage renal disease these patients can get percutaneous fistulas and when it's time then they'll have a running blood access ready and totally avoid the need to have a catheter placed

my last case here you have a 54 year old patient recent case who had head and neck cancer who presents with severe bleeding from a tracheostomy alright for some bizarre reason we had two of these

in like a week all right kind of crazy so here's the CT scan you can see the asymmetry of the soft tissue this is a patient who had had a neck cancer was irradiated and hopefully what you can notice on the

right side of the screen is the the large white circles of contrast which really don't belong there they were considered to be pseudo aneurysms arising from the carotid artery all right that's evidence of a bleed he was

bleeding out of his tracheostomy site so here's a CTA I think the better image is the image on the right side of the screen the sagittal image and you can see the carotid artery coming up from the bottom and you can see that round

circle coming off of the carotid artery you guys see that so here's the angiogram all that stuff that is to the right to the you know kind of posterior to the right of the screen there it doesn't belong there that's just

contrast that's exiting the carotid artery this is a carotid blowout we'll call it okay just that word sounds bad all right so that's bad so another question right what do you want to do here

I think embolization is reasonable but probably not the thing we can do the fastest to present a patient to treat a patient is bleeding out of the tracheostomy site so in this particular case this is a great covered stent case

alright and here's what it looked like after so we can go right up and just literally a cover sent right across the origin of that pseudoaneurysm and address the patient's bleeding alright

so my name is Paul I'm one of the nurse practitioners from UCI Irvine healthcare and what am i one of our minerals in there is basically working on patients for consultations doing the patient rounds writing notes ordering labs etc we also have several clinics that we run

at UCI Medical Center involving patients needing consultations for Libra direct therapies ablations and so forth and one of the more recent clinic that we started running is basically treating patients with BPH and so what we would

know inspiration is basically treating and regarding their symptoms and the procedures pretty much called a prostate artery embolization so the main purpose of this patient excuse me the main purpose of this

topics is basically to provide the general information of what the procedures are about illustrating indications risk and to hopefully help our nursing staff to better take care of these patients sorry so first and

foremost I just wanted to thank my team UC Irvine for allowing me to take some time off of work and enjoying Austin and its many food and object and and allowing me to speak to you guys a little bit about prostate ammo on our

pitchers basically you can't I don't know laser printer but our physicians dr. Karen Nelson she's one of our chief of IR dr. Dan through Fernando dr. Nadine a bitch day and dr. James Castro thesis

he's got daughter Kat Reese is our main doctor that does most of our process embolization our excellent iron nursing team and of course my fellow nurse practitioners who is holding the fort back home Pamela and Takara and watch

and Lou sorry but so our objectives for discussions basically to illustrate the indications and benefits of prostate artery embolization we're going to go over the side effects and risk complications associated with this

procedure and also recognize the value of nursing care going starting from the workup leading to the proper process in trot process and post procedure care sort of a brief outline of what we're gonna be

talking about we're just gonna go over the basic fundamentals of BPH as well as the treatment for PAE and the second portion of this lecture is going over how we walk patients up in clinic what we tell patients and we're gonna go

through the proper care and drop care ask well ask the post-op care and we're going to go through a couple of cases in there it's just to describe to you guys how we care for these special population

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

briefly about meet symposia meet symposia is basically a group of meetings or symposia there's meet IO

which is interventional oncology meet a Horta which is a auric work and vascular disease as well as meet stroke which is neuro IR as well as vascular vascular embolization for neuro as well super vascular disease there have been three

annual meetings held in January of every year this is kind of the physician attendance there with a large number of speakers half of these speakers 50 50 of these speakers lasts here three months ago were from were from the u.s. from

the USA they are this meeting is endorsed and supported with presence of leadership from guests from spectrum that's another meeting in the u.s. from SAR with a collaborative meeting as well as iMac which is a Middle Eastern

heavily Egyptian a or tech a or tech meet meeting for for aortic disease next

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

to have severe humor billion almost all all those that need your attention is about aghori portal veins though can be tremendously so the differentiation between hepatic artery and portal vein

bleeding is the big differentiator that will require you to do something about it most of the times if you injure the portal vein or hepatic vein these usually heal by themselves and it's counterintuitive the management of this

is actually to upsize your tube and they make sure the side holes are not adjacent to the bleeding vein it's crossing so it's counterintuitive that you upsize - for bleeding injure the vein more but

eventually those veins will thromboses off for that little branch the difficult situations of sahiba heavy hit an artery and here's one way we did a gram you can see the pacification the reason why you want to go into the peripheral duct I'll

show you always near the hilum is actually also very big blood are the blood vessels and the reason why we go peripheral the number of large vessels are much greater diminished so you always want in this patient was

transferred for an outside Hospital my PTC was performed by someone who obviously doesn't do a lot of these and access directly into the coma bar duct you can see all these filling defects all these filling defects in the combat

like those or clots and filled with someone who's actually had life-threatening significant he Mobilia and required what we did was they were just pacify the system get another peripheral access

right biliary system and embolize the track coming out and thereby removing the original axis that was placed by the outside hospital interventionists obviously the ones that aureus the most of the narco that will kill people is

the ones that hit our ease and pseudoaneurysm formation or tara Venus fistulas and I can be problematic in my only real ways their dresses trans cap the treatments a patient would have an angio we'd have to get into the pedagogy

find the feeding or it almost always though and we can predict way that bleeding artery is it's where your Y is crossing the architecture of the artery tree frequently you will not see it until you remove the tube so almost

always you would have to prep the right flank prep the groin to an angiogram with the tube in because you don't really want to be rushing at the beginning of your procedure you frequently do the angiogram not see

bleeding and then a second operator needs the described brake scrub get non sterile axes remove the blue tube repeat the angiogram and almost certainly then you'll see it but again it's very

predictable where it is but every now and then you get caught out and the bleeding side can be remote from where your actual Y or actual access transgressor you you do need to have a careful eye looking for that and so you

know when we looked at out and we do large numbers of blurry drainage the best predictor or and like I said Arturo Kimber Billy is actually related to your first tube and the size that you place and it's also

interesting like I said every now and then you're gonna see that bleeding arteries are actually not liver arteries and you can't bleed from the GDA internal memory from other procedures intercostal artery from where you put

your tube first needle through the liver through sorry through the ribs itself it's actually access site rather than your internal parenchymal your liver so it's actually important to also do sometimes it a water gram check the

intercostal artery because you'll miss it by doing a celiac or teragrams hepatic artery gram and don't understand why the patients still bleeding and here's just example of what a pseudoaneurysm does when we remove the

chief we can see the image on the right the blue tube has mean withdraw back and they you can see quite clearly there and sorry the pseudoaneurysm of the paddock right re and like any other immunization is important to go front door back door

implies across mainly because the liver architecture has a rich collateralization that will feed before and after and like I said the lake complication zone was or derived and related to tube maintenance and tubes

catching on to things in dislodgement and so these are just really you know your whoever answers the phones whether it's the physicians on call they have to manage with maintenance of these tubes and really just keeping these tubes open

as long as possible it's amazing how long some of these tubes do last in particular in benign but Lewis structures so management of these is really or expectant and the right advice and frequently just need to

get these tubes changements they're clogged sufficiently the difficult ones

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

of these issues filters are generally still use or were used up until a few years ago or five years ago almost exclusively and then between five years and a decade ago there was this new concept of proximal protection or flow

reversal that came about and so this is the scenario where you don't actually cross the lesion but you place a couple balloons one in the external carotid artery one in the common carotid artery and you stop any blood flow that's going

through the internal carotid artery overall so if there's no blood flowing up there then when you cross the lesion without any blood flow there's nothing nowhere for it to go the debris that that is and then you can angioplasty and

or stent and then ultimately place your stent and then get out and then aspirate all of that column of stagnant blood before you deflate the balloons and take your device out so step-by-step I'll walk through this a couple times because

it's a little confusing at least it was for me the first time I was doing this but common carotid artery clamping just like they do in surgery right I showed you the pictures of the surgical into our directa me they do the vessel loops

around the common carotid approximately the eca and the ICA and then actually of clamping each of those sites before they open up the vessel and then they in a sequential organized reproducible manner uncle Dee clamp or unclamp each of those

sites in the reverse order similar to this balloon this is an endovascular clamping if you will so you place this common carotid balloon that's that bottom circle there you inflate you you have that clamping that occurs right

so what happens then is that you've taken off the antegrade blood flow in that common carotid artery on that side you have retrograde blood flow that's coming through from the controller circulation and you have reverse blood

flow from the ECA the external carotid artery from the contralateral side that can retrograde fill the distal common carotid stump and go up the ica ultimately then you can suspend the antegrade blood flow up the common

carotid artery as I said and then you clamp or balloon occlude the external carotid artery so now if you include the external carotid artery that second circle now you have this dark red column of blood up the distal common carotid

artery all the way up the internal carotid artery up until you get the Circle of Willis Circle of Willis allows cross filling a blood on the contralateral side so the patient doesn't undergo stroke because they've

got an intact circulation and they're able to tolerate this for a period of time now you can generally do these with patients awake and assess their ability to tolerate this if they don't tolerate this because of incomplete circle or

incomplete circulation intracranial injury really well then you can you can actually condition the patient to tolerate this or do this fairly quickly because once the balloons are inflated you can move fairly quickly and be done

or do this in stepwise fashion if you do this in combination with two balloons up you have this cessation of blood flow in in the internal carotid artery you do your angioplasty or stenting and post angioplasty if need be and then you

aspirate your your sheath that whole stagnant column of blood you aspirate that with 320 CC syringes so all that blood that's in there and you can check out what you see in the filter but after that point you've taken all that blood

that was sitting there stagnant and then you deflate the balloons you deflate them in stepwise order so this is what happens you get your o 35 stiff wire up into the external carotid artery once it's in the external cart or you do not

want to engage with the lesion itself you take your diagnostic catheter up into the external carotid artery once you're up there you take your stiff wire right so an amp lats wire placed somewhere in the distal external carotid

artery once that's in there you get your sheath in place and then you get your moment devices a nine French device overall and it has to come up and place this with two markers the proximal or sorry that distal markers in the

proximal external carotid artery that's what this picture shows here the proximal markers in the common carotid artery so there's nothing that's touched that lesion so far in any of the images that I've shown and then that's the moma

device that's one of these particular devices that does proximal protection and and from there you inflate the balloon in the external carotid artery you do a little angiographic test to make sure that there's no branch

proximal branch vessels of the external carotid artery that are filling that balloon is inflated now in this picture once you've done that you can inflate the common carotid artery once you've done that now you can take an O on four

wire of your choice cross the lesion because there's no blood flow going so even if you liberated plaque or debris it's not going to go anywhere it's just gonna sit there stagnant and then with that cross do angioplasty this is what

it looks like in real life you have a balloon approximately you have a balloon distally contrast has been injected it's just sitting there stagnant because there's nowhere for it to go okay once the balloons are inflated you've

temporarily suspends this suspended any blood flow within this vasculature and then as long as you confirm that there's no blood flow then you go ahead and proceed with the intervention you can actually check pressures we do a lot of

pressure side sheath pressure measurements the first part of this is what the aortic pressure and common carotid artery pressures are from our sheath then we've inflated our balloons and the fact that there's even any

waveform is actually representative of the back pressure we're getting and there's actually no more antegrade flow in the common carotid artery once you've put this in position then you can stent this once the stent is in place and you

think you like everything you can post dilated and then once you've post dilated then you deflate your balloon right so you deflate your all this debris that's shown in this third picture is sitting there stagnant

you deflate the external carotid artery balloon first and then your common carotid artery and prior to deflating either the balloons you've aspirated the blood flow 320 CC syringes as I said we filter the contents of the third syringe

to see if there's any debris if there's debris and that third filter and that third syringe that we actually continue to ask for eight more until we have a clean syringe but there's no filter debris out because

that might tell us that there's a lot of debris in this particular column of blood because we don't want to liberate any of that so when do you not want to use this well what if the disease that you're dealing with extends past the

common carotid past the internal carotid into the common carotid this device has to pass through that lesion before it gets into the external carotid artery so this isn't a good device for that or if that eca is occluded so you can't park

that kampf balloon that distal balloon to balloon sheath distally into the external carotid artery so that might not be good either if the patient can't tolerate it as I mentioned that's something that we assess for and you

want to have someone who's got some experience with this is a case that it takes a quite a bit of kind of movement and coordination with with the physician technologists or and co-operators that

finally intraoperative considerations positioning for comb bean tpz photo

sensitivity EKG and lab draws and noting the time of tpz injection so i wanted to say a little bit about comb beam all right who has comb beam at their facility just a few less okay comb beam is medical imaging technique consisting

of x-ray computed tomography where the x-rays are divergent forming a cone the scanning software collects the data and reconstructs it producing what is termed a digital volume composed of three dimensional voxels of anatomical data

that can then be manipulated and visualized with specialized software on the left is a standard floral image and on the right is the comb beam so the red shows the vascular angiography the blue is a tumor and the yellow is a feeding

artery to the term or so dr. Abuja lays a B today is heavily involved with research so the procedure room with Combee was exclusively constructed for her so positioning for comb beam I believe

to be the bigger challenge initially comb being requires the patient to have their arms up high and using comb beam technology increases the procedural time it would be difficult for the patients to maintain that position and keep still

without anesthesia we started clinical trials with nurse assisted moderate sedation and soon learned it was very difficult the majority of our HCC embolization --zz are done with with sedation but we're

now using anesthesia for all of it so the lead in this case was Tom the radiology tech which assisted with the placement of the anesthesia equipment and patient positioning our anesthesia personnel are not only out of their

comfort zone in the I are sweet but unfamiliar with tpz trial and how the comb beam equipment rotates completely around the patient the patient is wearing two sets of leads one for anesthesia and the other for research

the leads are radio translucent to reduce artifact and imaging keeping the lid lid lead in the department took some getting used to one set got thrown away one set was found up in the ICU one set was on the

anesthesia equipment it was hard keeping track of our special equipment there so the pulse oximetry and blood pressure are on the lower extremities for cone beam again to avoid artifact and imaging when we first

started using cone beam the nursing staff administering sedation were disconnecting patients from monitoring so there were short interruptions with viewing vital signs it became risky and time-consuming to do

so during the procedure one set of EKGs triplicates are done just prior to tpz injection so the treat the EKG triplicates are basically they're two minutes apart in sets of three and lastly having to keep the tpz in a brown

bag and protected from light during the transfer nurse to position there's the photo on the left upper corner doctor busy day basically draws a tpz through a three-way stopcock under a sterile towel

while the nurse keeps the syringe in the brown bag poking a hole in the bag just to NIF to just enough to expose the tip of the syringe and attach it to the three-way this way the tpz is protected from light these reminder adjustments

however they were difficult from the standard and it took time for all the nurses and techs to adjust all right so this here is just a group photo Tom I've got Tyler on the right Thanh our technologist and ELISA and myself so I

thought this was a good photo to represent radiology many specialties consult two IR but it just isn't quite known yet by the general population and surprisingly by the medical staff as well there is a quote by dr. Rosa be

published quote the reason the public doesn't quite understand is we deal with so many disease entities and so many body parts it's hard to brand us unquote so I don't know if you guys were aware but interventional radiology is now its

own medical specialty so hepatocellular carcinoma is a primary malignancy of the liver and now the third leading cause of cancer deaths worldwide with over

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

next is me talking about Egypt and Ethiopia and how I are how IRS practice in Egypt and Ethiopia and I think feather and Musti is gonna talk a little bit about Ethiopia as well he's got a

lot of experience about in about Ethiopia I chose these two countries to show you the kind of the the the the difference between different countries with within Africa Egypt is the 20th economy worldwide by GDP third largest

economy in Africa by some estimates the largest economy in Africa it's about a hundred million people about a little-little and about thirty percent of the population in the u.s. 15 florist's population worldwide and has

about a little over a hundred ir's right now 15 years ago they had less than ten IRS and fifteen years ago they had maybe two to three IRS at a hundred percent nowadays they're exceeding a hundred IRS so tremendous gross in the last 15 years

in the other hand Ethiopia is a very similar sized country but they only have three to five IRS that are not a hundred percent IRS and are still many of them are under training so there are major differences between countries within

within Africa countries that still need a lot of help and a lot of growth and countries that are like ten fifteen years ahead as far as as far as intervention ready intervention radiology

most of the practice in Ethiopia are basic biopsies drainages and vascular access but there is new workshops with with embolization as well as well as well as vascular access in Egypt the the ir practice is heavily into

interventional oncology and cancer that's the bulk that's the bulk of their of their practices you also get very strong neuro intervention radiology and that's mostly most of these are French trained and not

American trains so they're the neuro IRS in Egypt or heavily French and Belgian trains with with french-speaking influence but the bulk of the body iron that's not neuro is mostly cancer and it involves y9e tastes ablations high-end

ablations there's no cryoablation in Egypt there is high-end like like a nano knife reverse electric race electroporation in Egypt as well but there is no cryo you also get a specialty embolization such as fibroids

prostate and embroiders are big in Egypt they're growing very very rapidly especially prostates hemorrhoids and fibroids is an older one but it's still there's still a lot of growth for fibroid embolization zyou FES in Egypt

there's some portal portal intervention there's a lot of need for that but not a lot of IRS are actually doing portal intervention and then there's nonvascular such as billary gu there's also vascular access a lot of

the vascular access is actually done by nephrology and is not done by not not done by r is done by some high RS varicose veins done by vascular surgery and done by IRS as an outpatient there's a lot of visceral angiography as well

renal and transplants stuff so it's pretty high ends they do not do P ad very few IR s and maybe probably two IR s in the country that actually do P ad the the rest of the P ad is actually endovascular PA DS done by vascular

surgery a Horta is done all by vascular surgery and cardiothoracic surgery it's not done it's not done by IR IR s are asked just to help with embolization sometimes help with trying to get a catheter in a certain area but it's

really run by by vascular surgeons but but most more or less it's it's the whole gamut and I'm going to give you a little example of how things are different that when it comes to a Kannamma 'kz there's no dialysis work

they don't do Pfister grams they don't do D clots the reason for that is the vascular surgeons are actually very good at establishing fishless and they usually don't have a

lot of problems with it sometimes if the fistula is from Beau's door narrowed it's surgically revised they do a surgical thrombectomy because it's a lot cheaper it's a lot cheaper than balloons sheaths and and trying to and try a TPA

is very expensive it's a lot cheaper for a surgeon to just clean it out surgically and resuture it there's no there's no inventory there are no expensive consumables so we don't see dialysis as far as fistula or dialysis

conduits at all in Egypt and that's usually a trend in developed in developed countries next we'll talk

patient female patient who has the sudden onset of upper abdominal pain here's the CT we did all these cases in one day it was crazy it was terrible so so here's a big hematoma a big peritoneal hematoma you

can see it anterior to the right kidney you can see the white blob of contrast right in the middle of the hematoma that's a pseudoaneurysm or even active extravagance um less experienced people would probably say it's active

extravagant I think most of us would prefer that it be called kind of a pseudoaneurysm this active extrapolation would be much more cloudy and spread out this is more constrained and you can see on the

coronal image you get a sense that there's that hematoma same type of problem all right is there more imaging that we can do to figure out the next step again I said earlier earlier in this lecture

that sometimes we use CTA now sometimes a CTA is worthwhile I do find that for a lot of these patients I think we're getting smarter and we're doing CTAs right at the beginning of this whole thing you know when a trauma

patient comes in we're getting CTAs so we can max out the amount of information that we get on the initial diagnostic imaging here's what we're seeing on the CTA and in this particular case I think it's pretty clear that you can see the

pseudoaneurysm arising from what looks like a branch of the superior mesenteric artery so this is just an odd visceral and Jake visceral aneurysm which looks like it probably ruptured I don't have an explanation for it led to a big

hematoma here's what that is and now we're gonna do an angiogram the neat thing is it just perfectly correlated with a conventional angiogram so here's our super mesenteric angiogram all right the supreme mesenteric artery

on the first image to the left is that vessel going downward towards the right side of the screen all those vessels coming off are really just collateral vessels going up to the liver through the gastroduodenal artery again that

left one looks pretty good it's not until you see the delayed image on the right that you see that area of contrast all right so that's the finding that correlates with the CT scan all right here we're able to get in there you put

a micro catheter in that vessel alright the key next step for this patient as I mentioned earlier is the whole concept of front door and back door so here we're technically in the front door the next thing that we do is we put the

catheter past the area of injury and now we embolize right across the injury because remember once you embolize one thing flow is gonna change we screw it up body the body wants to preserve its flow if we block flow

somewhere the body's gonna reroute blood to get to where we blocked it so we want to think ahead and we want to say okay we're blocking this vessel how's the body going to react and let's let's get in the way of that happening that's what

we did here so we saw the pathology we went past it we embolized all across the pathology and boom now we don't have anymore bleeding and the likelihood of recurrence is gonna be very low for that patient because we went all the way

across the abnormality and I think from

I like to talk about brain infarc after Castro its of its year very symbolic a shoe and my name is first name is a shorter and probably you cannot remember my first name but probably you can remember my email address and join ovation very easy 40 years old man presenting with hematemesis and those coffee shows is aphasia verax and gastric barracks and how can i use arrow arrow on the monitor no point around yes so so you can see the red that red that just a beside the endoscopy image recent bleeding at the gastric barracks

so the breathing focus is gastric paddocks and that is a page you're very X and it is can shows it's a page of Eric's gastric barracks and chronic poor vein thrombosis with heaviness transformation of poor vein there is a spline or inertia but there is no gas drawer in urgent I'm sorry tough fast fast playing anyway bleeding focus is gastric barracks but in our hospital we don't have expert endoscopist

for endoscopy crew injections or endoscopic reinjection is not an option in our Hospital and I thought tips may be very very difficult because of chronic Peruvian thrombosis professors carucha tri-tips in this patient oh he is very busy and there is a no gas Torino Shanta so PRT o is not an option so we decided to do percutaneous there is your embolization under under I mean there are many ways to approach it

but under urgent settings you do what you can do best quickly oh no that's right yes and and this patience main program is not patent cameras transformation so percutaneous transit party approach may have some problem and we also do transit planning approach and this kind of patient has a splenomegaly and splenic pain is big enough to be punctured by ultrasonography and i'm a tips beginner so I don't like tips in this difficult

case so transplanting punch was performed by ultrasound guidance and you can see Carolus transformation of main pervane and splenorenal shunt and gastric varices left gastric we know officios Castries bezier varices micro catheter was advanced and in geography was performed you can see a Terrell ID the vascular structure so we commonly use glue from be brown company and amputee cyanoacrylate MBC is mixed with Italy

powder at a time I mixed 1 to 8 ratio so it's a very thin very thin below 11% igloo so after injection of a 1cc of glue mixture you can see some glue in the barracks but some glue in the promontory Audrey from Maneri embolism and angiography shows already draw barracks and you can also see a subtraction artifact white why did you want to be that distal

why did you go all the way up to do the glue instead of starting lower i usually in in these procedures i want to advance the microcatheter into the paddocks itself and there are multiple collateral channels so if i in inject glue at the proximal portion some channels can be occluded about some channels can be patent so complete embolization of verax cannot be achieved and so there are multiple paths first structures so multiple injection of glue is needed

anyway at this image you can see rigid your barracks and subtraction artifacting in the promenade already and probably renal artery or pyramid entry already so it means from one area but it demands is to Mogambo region patient began to complain of headache but american ir most american IRS care the patient but Korean IR care the procedure serve so we continue we kept the procedure what's a little headache right to keep you from completing your

procedure and I performed Lippitt eight below embolization again and again so I used 3 micro catheters final angel officio is a complete embolization of case repair ax patients kept complaining of headache so after the procedure we sent at a patient to the city room and CT scan shows multiple tiny high attenuated and others in the brain those are not calcification rapado so it means systemic um embolization Oh bleep I adore mixtures

of primitive brain in park and patient just started to complain of blindness one day after diffusion-weighted images shows multiple car brain in park so how come this happen unfortunately I didn't know that Porter from Manila penis anastomosis at the time one article said gastric barracks is a connectivity read from an airy being by a bronchial venous system and it's prevalence is up to 30 percent so normally blood flow blood in the barracks drains into the edge a

ghost vein or other systemic collateral veins and then drain into SVC right heart and promontory artery so from what embolism may have fun and but in most cases in there it seldom cause significant cranker problem but in this case barracks is a connectivity the promontory being fired a bronchial vein and then glue mixture can drain into the rapture heart so glue training to aorta and system already causing brain in fog or systemic embolism so let respectively

with shoulder I'll go through this hopefully in five five minutes and I'll be under like 20 so frozen shoulder we're going to shift gears so unlike

arthritis frozen shoulder is an inflammatory condition that starts out of nowhere the classic history is a 35 to 45 year old woman who wakes up in the morning and says my shoulder hurts they think they slept on it incorrectly and

the pain does not go away they take medication doesn't go away the pain is worse at night and they can't figure out why it takes him about a month or two to go to orthopedic surgeon the surgeon goes you have frozen

shoulder they can't lift their arm forward they can't lift it laterally and basically it hurts over the shoulder they don't have a rotator cuff tear they don't have an injury they're not a baseball pitcher these are just average

people who are otherwise normally healthy except sometimes it occurs in certain patient populations it's a very prevalent disease and these are some of the risk factors so being female sorry that's an increased risk factor type 1

type 2 diabetics patients with hyperthyroidism even people who have autoimmune disease because there's some inflammatory process going on there are multiple stages one to four like in every disease of course early on it's

just inflammation but you'll see as you get to stage four you get these adhesions and stiffness in the shoulder so if you see someone who's a year out from this diagnosis who's really slobbing symptoms they cannot lift

they're on many of these patients walk around just like this and you they'll go to shake their hand they can't even get their hand out any further than that and so it can be a really progressive disease and really disabling to be

honest on MRI you can see findings that suggest this so on the top two images there are arrows that show exactly what I showed you in the knee this is thickening of basically the lining of the shoulder and they see this actually

even when they do arthroscopy and they actually put a camera inside the joint in these people with frozen shoulder as well remember I showed you this slide earlier exactly what we know more blood vessels in the lining in patients with

frozen shoulder than not more nerves more blood vessels what's been done on frozen shoulder has this been done well that same doctor in Japan dr. Okun Oh had published a study a number of years ago where in 24 patients he injected the

same antibiotic and 2/3 of these patients got rapid pain relief just one week after the after the procedure he analyzed the show and 87% at a month and there was basically no worsening or recurrences in

these patients out to 36 months so very good very good results but again we wanted to replicate that here in the United States so we applied to the FDA for an investigational device exemption study we're performing this study

actually it's sponsored by Tomo and we're enrolling patients who have a diagnosis of frozen children were working very closely with an orthopedic surgeon who just specializes in shoulder joints he's actually a very well

recognized shoulder surgeon so these patients like our knee patients have to be refractory to something and what we're looking for and this is a patient in in our clinical study is that red arrow on the Left points to an image

where that synovium enhances and on the right where the synovium is thickened and same thing here this is a case where it's even worse you can even see that white capsule all the way around the joint very prominent enhancement the

problem with shoulder embolization and we thought this would be great we do all our cases radial for life you know we'll do prostates uterine fibroids y9t we're like this is gonna be great we only have to go from here to here and

everything's gonna be fantastic the problem is you'll see here from this angiogram just at the subclavian artery is that all the vessels come off pointed towards the hand nothing really comes off when you're going this way so

unfortunately when you're going in with your catheter everything looks like you're gonna be going you know reverse and that can make things really painful and you need a 2o French catheter to get into these because they're so small and

they don't make very many - Oh French pre-curved or pre shaped catheters so you have all these challenges that we thought were gonna be we didn't realize in the beginning and the other thing is write everything now has made radial -

coronary or radial two legs or radial - pelvis or celiac but the distance is you can imagine from here to here I need a 90 centimeter based catheter in a 110 or 120 micro catheter I don't really you know people make 80s and 80s aren't long

enough and people make one 10s and they're too long and so we really found this to be actually fairly more difficult than we realized there are also six arteries that you have to get into in the shoulder so it's very

tedious and you have to get into all these and when you're injecting embolic in and around the vertebral artery and you guys recognize that on the image that's on the screen that's the largest artery there so if you're going to get

reflux you want to avoid of course having a stroke so especially in these younger female patients over 35 to 45 and you're taking something and put at risk so it can be a little bit more of a challenging procedure and obviously

if you have you know physicians and a team who are used to doing things like prostate and advanced celiac embolization for example you know that kind of team will be used to this but they're definitely more challenges than

we realized and so there are six arteries that we have to get into and you can see that third one of how tiny that is and I'll go through all these really quickly this is the suprascapular artery okay this is the first branch we

actually just number them one to six and you could see over that shoulder on the left look how hyper vascular that's actually worse than the knee that's pre-imposed embolization okay this is the throttle acromial artery the

throttle chromia artery as you can imagine goes to the acromion process and the shoulder and you can see on the left it sort of drapes over the shoulder as that hyper vascularity this is the coracoid artery you will not

find this artery in any anatomic textbook anywhere when I flew to Japan to work with dr. Okun oh when I went there and he's like we're going into the coracoid I'm like where is this I'm sitting there on my cellphone like while

he's doing the case looking up the cord under I couldn't find it anywhere looked in Grey's Anatomy looked at oof lockers masculine angio textbook it's nowhere it exists and just like you think it goes right to the coracoid

process which you can see on the image on the right and you can see the degree of vascularity and it's responsible for this anterior pain that patients feel and here's the circumflex scapular artery most of you have probably seen

this in some form or another and as you can see it goes to the inferior aspect of the shoulder so that goes to the bottom of the capsule on the right you can see how it's coming right under the humeral head and then there's the

anterior and posterior humeral circumflex arteries one in front of the humeral head one behind the Hume right so these six arteries we have to get into and we have to figure out which are hyper vascular and that embolized them

and of course like in prostate like in every other place is going to be aberrant anatomy our very first case we go into I came back from Japan we're all excited to start the clinical trial I'm looking for the I'm looking for the

suprascapular artery and lo and behold it comes off the lean of the Lima and I'm like oh that's interesting you know how the heck we're getting in this and so you run into these challenges just like in any other situation and so we're

learning we're getting through this and learning about this patient population as well I will tell you so we don't I don't have any preliminary data to share because we just have done eight patients out of 20 but all but one had a dramatic

improvement I mean even far better than our knee patients they're coming in there like 10 out of 10 they're like do this I had a patient we made a video because she wants to show her orthopedic surgeon if her arms just throwing around

like this and she was like dancing in my office and I'm texting and pictures it's really remarkable and what's great about this is there's no treatment option so orthopedic surgeons said them to go get physical therapy take pain meds there's

nothing to do for these patients so this is a real opportunity hopefully by the end of you know this year we'll be finished and rolling and following up on these patients and we're hoping by maybe early 2020 which is not too far away

you'll probably see an fda-approved product even for the embolization so things are moving pretty quickly and just as just one case again if someone who has severe superior labral pain you can see the image on the right how

densely standing or vasco's it's very easy to see and I'll challenge you when you go back and you're doing a leg angiogram and you look and they do a run off and you see staining around the knee or some of that blush just reach over

and ask the patient and palpate right where it is and go do you have pain right here and I'll bet you they'll say yes you never really would have paid attention at any time before and now we do it kind of for fun when we're doing

our run offs for other reasons of course for CLI etc but it's really interesting and you'll go back and see that so in conclusion embolization really is an exciting has an exciting future really in the setting of msk related pain there

will be need to be many more larger studies of course this is still investigational we do not tell people to go out and start doing this we need to really better understand how angiogenesis really affects these

disease processes and with that I will finish thanks very much [Music]

they travel together so that's what leads to the increased pain and sensitivity so in the knee there have been studies like 2015 we published that study on 13 patients with 24 month follow-up for knee embolization for

bleeding which you may have seen very commonly in your institution but dr. Okun Oh in 2015 published that article on the bottom left 14 patients where he did embolization in the knee for people with arthritis he actually used an

antibiotic not imposing EMBO sphere and any other particle he did use embolus for in a couple patients sorry EMBO zine in a couple of patients but mainly used in antibiotic so many of you know if antibiotics are like crystalline

substances they're like salt so you can't inject them in arteries that's why I have to go into IVs so they use this in Japan to inject and then dissolve so they go into the artery they dissolve and they're resorbable so they cause a

like a light and Baalak effect and then they go away he found that these patients had a decrease in pain after doing knee embolization subsequently he published a paper on 72 patients 95 needs in which he had an

excellent clinical success clinical success was defined as a greater than 50% reduction in knee pain so they had more than 50% reduction in knee pain in 86 percent of the patients at two years 79 percent of these patients still had

knee pain relief that's very impressive results for a procedure which basically takes in about 45 minutes to an hour so we designed a u.s. clinical study we got an investigational device exemption actually Julie's our clinical research

coordinator for this study and these are the inclusion exclusion criteria we basically excluded patients who have rheumatoid arthritis previous surgery and you had to have moderate or severe pain so greater than 50 means basically

greater than five out of ten on a pain scale we use a pain scale of 0 to 100 because it allows you to delineate pain a little bit better and you had to be refractory to something so you had to fail medications injections

radiofrequency ablation you had to fail some other treatment we followed these patients for six months and we got x-rays and MRIs before and then we got MRIs at one month to assess for if there was any non-target embolization likes a

bone infarct after this procedure these are the clinical scales we use to assess they're not really so important as much as it is we're trying to track pain and we're trying to check disability so one is the VA s or visual analog score and

on right is the Womack scale so patients fill this out and you can assess how disabled they are from their knee pain it assesses their function their stiffness and their pain it's a little

bit limiting because of course most patients have bilateral knee pain so we try and assess someone's function and you've improved one knee sometimes them walking up a flight of stairs may not improve significantly but their pain may

improve significantly in that knee when we did our patients these were the baseline demographics and our patients the average age was 65 and you see here the average BMI in our patients is 35 so this is on board or class 1 class 2

obesity if you look at the Japanese study the BMI in that patient that doctor okano had published the average BMI and their patient population was 25 so it gives you a big difference in the patient population we're treating and

that may impact their results how do we actually do the procedure so we palpate the knee and we feel for where the pain is so that's why we have these blue circles on there so we basically palpate the knee and figure

out is the pain medial lateral superior inferior and then we target those two Nicollet arteries and as depicted on this image there are basically 6 to Nicollet arteries that we look for 3 on the medial side 3 on the lateral side

once we know where they have pain we only go there so we're not going to treat the whole knee so people come in and say my whole knee hurts they're not really going to be a good candidate for this procedure you want focal synovitis

or inflammation which is what we're looking for and most people have medial and Lee pain but there are a small subset of patients of lateral pain so this is an example patient from our study says patient had an MRI beforehand

something some case examples of where I use cryoablation right so this is a

patient who has a nodule in the in the back of their lungs in the right lower lobe and basically I'll place two probes into that notch on either side of Brackett the lesion and then three months later fall up you can see a nice

resolution of that nodule so when it comes to lung a couple things I'll mention is if the nodule is greater than eight millimeters I'll immediately go to two probes I want to make sure that I cover the lesion whereas microwave it's

pretty rare depending on what device you're using for you to put more than one probe in so some people's concern with cryo in the lung is more probes means more risk of pneumothorax but you can also see surrounding and proximal to

where we did the place you can see the hemorrhage that you see so if those of you out there that are doing the lung ablations you probably have physicians that are using something called the triple freeze protocol right so the

double freeze protocol is the idea that you go ten minutes freeze five minutes 30 minutes freeze five minutes thought well what we saw was lung early on in the studies was a very large ablation a freeze to start with caused massive

hemorrhage patients were having very large amounts of hemorrhage so what we do now in lung is something called a triple freeze protocol we'll do a very short freeze about three minutes and that'll cause an ice ball to form and

then we'll thaw that in other three minutes three minutes of thawr and as soon as that starts to thaw we'll freeze it again and we've shown us a substantial decrease in the amount of hemorrhage so if you're doing long and

you and you you're told to do a double freeze protocol perhaps suggest the triple freeze is a better idea so that's three months later so another example

so this is our MGH page we started it about a year ago check it out if you guys like it some pretty good cases we mostly post cases some policy stuff industry and changing things it's not purely cases but certainly take a look if you like it give us a follow so what

I have today is I have two cases that I picked and you know for all the thousands of cases that all these huge academic medical centers do I tried to pick a couple that might be a little interesting and that aren't being done

in all the different centers across the institution so I'll start off with the first which is an endovascular AVF creation so what's nice about this is that you know what we see so far from this is that the length of stay impact

has been certainly reduced in certainly the maturation times and the Rhian turn re intervention rates have been reduced so I'll go through this and normally wouldn't go step by step for a few things but I think you know not all

institutions are doing this yet I think that you will I do think this is going to be a shift for a lot of the dialysis patients and everybody who works anion knows what a huge impact it is the ESRD patients is just astronomical the

numbers of them it's just continuing to rise so procedural steps the first step is you're going to access the brachial vein advance the guide Y down to the ulna insert a six French sheath and perform a vena Graham and the rationale

for that of course is to make sure you don't have any issues centrally some centers do that in advance some centers don't I will mention also that the ultrasound mapping is absolutely critical to make sure that

you get the right patient you start off by seeing them in the outpatient clinic and then you're going to go and have them have vascular ultrasound to make sure you have a good candidate so the next is you're gonna access the brachial

artery same thing advance your guide wire down to the ulna from there you're gonna insert the venous side now this is one of two approved vendors that will allow you to do an endovascular creation this was a wave link it's a to stick

system and it requires two catheters which is why you see the next step is pretty much repeated but just flipping it to the arterial side so from there there's a magnetic zone it actually has like a little canoe so it's got a

backing of a ceramic sort of a space there if you can think of sort of the older or atherectomy cut home catheters that had that little carro canoe you would actually take the debris out it's very

look into that and I'll show you that in a couple of images once you align that you're gonna sort of engage the little electrode this is an RF ablation RF created type fistula so it creates a little slit between the Adri and the

vein and what happens is is that you know of course don't forget you have to ground the patient just like any RF once you get the magnets and you get the electrode alignment you're going to engage the device for two seconds and

the fistula is created and then from there a lot of centers are actually going in there embolize in one of the brachial veins and this is basically to sum some of that stuff obviously to the superficial system for draining I have

read that there are a few places that actually go back back in through the newly-created fistula like even at the time of the procedure with the 4 millimeter balloon and just sort of open that up I'm not sure that that's 100%

necessary but I'm sure all these fine people on the panel could help us with that so here you see and I skipped all the entry steps but here you can see the Venus in the arterial catheter you know in position here and there's that little

canoe thing pointed out by the arrow that I had talked about and you use fluoro to sort of align these two things when you first start doing these cases take your time the first one was over an hour and a half for us now obviously

it's about a third at that time this is the little electrode this is when it's advanced and pretty much ready to engage can you play the video for me so this is quick so what happens is you suppress the

device the electrode actually advances and as it advances towards the veena side what happens is is that it actually just creates this fistula through the RF sort of energy from there you're gonna do a post vena graph in here you can see

after we did an initial post intagram there was enough sort of flow between the PIAT brachial so we decided to embolize one and this patient was our first patient and is doing very well so far this is done on I'm gonna say just

because you know to dr. brains point I don't want to get on the hook for certain dates and patient identification but this was done in mid-march so we saw them two weeks out and we're gonna see them again another couple weeks so just

there's a couple of trials that you can read into one is the neat one is the flex trial I think the technical success is really promising at 96% the maturation days you can see there's a massive massive comparison where they

could be ready to be dialyzed in 60 days and this could be a game-changer for many patients the six-month patency rate is what I've seen in most of the reports it's around 98% compared to about 50% with the surgical place and then you can

see that this about 3.5 interactions or re interventions that are required in about 0.5 at a year's time out from this so it's really making a big difference for these patients and I think this is what we do in i/o we continue advanced

things innovate and obviously look to do things in a more timely cost-effective minimally invasive way at the beginning when these new procedures come out the devices themselves might be at a higher price point but we'll see how that goes

moving forward as more and more vendors get into the space so the second case

right now here's a different case is a 49 year old male who presented to the emergency department after vomiting a lot of blood vomiting was the key word there it's going the other direction so that's an upper GI bleed all right and

when we talk about upper GI bleeds there's a lot of different causes for upper GI bleeds the most common are ulcers but there's mallory-weiss tears of the esophagus there's just esophagitis or gastritis

there's different cancer vascular malformations fistula is varices which I'm not going to talk about but varices on the venous side in a patient with portal hypertension these are all causes of upper GI bleeding now

once again we might treat them medically we might look at them with endoscopy and potentially cauterize something embolization usually is used when and when endoscopy is not successful all right or certainly surgery but an upper

GI bleeds embolization is a lot more attractive of an option all right so here's another picture what do you think you up for it nope you turned me down all right who wants to who wants to tell me what they see how about you how about

you guys you can team up together what do you think so what do you seeing so let's look at that together so this is a seal EF is an anagram of the celiac axis you want to think it through you want to volunteer you see a filter we don't care

about that yeah all right that's fair so you see the catheter going up right in the middle and it's going right into the celiac axis all right what I want to draw your attention to is right in the middle of the screen a little bit over

to the left is again a blobby thing all right that's extravagant of contrast and the vessel that that's coming off of is the gastroduodenal artery so I want you to see that if you look at the catheter you

can see the shadow of the catheter right up going up from the bottom that's going into the celiac axis and the big vessel going over to the left side of the screen is the proper hepatic artery that the common hepatic artery excuse me and

the first vessel heading south from there is the gastroduodenal artery that blood vessel is supplying the end of the stomach and the beginning of the small intestine and what you see is the extravagant coming off now what it's

very important if you're dealing with bleeding patients whether it's in dusky whether it's hemoptysis or GI bleeding anything like that we're looking for that type of blob appearance which just mean the contrast is no longer

constrained by the artery it's free into space okay usually the way we were built is that the blood vessels the biggest they ever are near the heart as they leave the heart they get progressively smaller until they reach

the tips of your fingers and the tips of your toes if there's any place that you see where it gets big small then big again that's not normal okay that's not normal and now we just got to figure out what's

the abnormal part is it the small part or the big part all right in this particular case it's that big blob that's big it doesn't belong there all right but in the upper GI system there's lots of collateral vessels so we can

just go in and we can put coils right in the gastroduodenal artery and we can embolize that and we can do it safely because we know that there is alternative routes for blood to flow now the one thing we have to do here and

this is an important concept for any abnormal bleeding whether it's trauma or other causes is we always look for the backdoor so in this particular patient we did an angiogram of the superior mesenteric artery there's another vessel

going to the intestines and it's nice cuz we have the coils there you can get a sense that it's possible for blood to flow from a branch of the superior mesenteric artery backwards into the GDA and so we just want to make sure that

that's not happening because we can do the best job ever with an embolization procedure but if we don't get the front door and the back door we're gonna fail patients will come back with recurrent bleeding and at least in my experience

that's a big reason why people do come back so we think we do a great job in two or three days later people come back with abnormal bleeding it's weak because we didn't address both sides of the pathology all right so here's another

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

treatment options once you've sort of isolated that there are leaky valves and the patient has typical symptoms that there are some surgical options but really embolization and catheter

directed treatment are really the mainstays of treatment both because it's an outpatient procedure you get to go home the same day and the recoveries fairly easy the factors that we consider when you embolize or block these

varicose veins are listed here you want to you want desired duration you want it to be closed forever you can't replace valves it would be nice to be able to do that but there's not a valve replacement so much like in the leg when you're

treating varicose veins you're either blocking or taking veins out so the surgical options are to take the vein out or to ligate but and the vascular options would be to block it and so I would just thought I would cover just a

little bit of embolization materials I'm sure you're all very familiar with and as I'll mention a little bit later there's there's sort of not necessarily agreement on what type of things people use to embolize gonadal veins or pelvic

varicosities but i'll show you what i do but give you a background of just generalized embolization materials so I'm sure you've all seen gel foam supplied as a sheet you can make a slurry you soak it with contraire

so that you can see it as you're putting it in some people use glue and will glue the entire gonadal vein it solidifies when it's mixed with saline or blood usually mix it with acai it also you can see it as

you're injecting it and then the standard coils which there are multiple sizes shapes detachable non-detachable Amplatz or plugs all the mechanical devices that can be used to block blood vessels and then I put on Souter deck

all because there are some people that will sort of do the sandwich technique you may have heard we'd put a coil peripherally and a coil up by the renal vein and then in between the coils you can film a sclerosant and embolize that

way the other important factor for me is using the suture deck all on the actual varicosities I'm not just necessarily treating or blocking off the the blood supply to them you know and I'll mention that a little bit more during the case

here so go through a case patient with

does the embolic material matter I'm showing the picture of an amp lats are

here this was a patient that was treated with a few different things you see coils peripherally there there was sclerosant and then in Amplatz are up near the confluence with the renal vein doesn't matter

a little is the short answer looking at as many studies that are published which are few it looks like you get a little bit better result with coil and or mixed methods meaning sclerosis and with coil and gelfoam compared to glue oil or foam

sclerostin alone however you know with the paucity of data take that with a grain of salt i think if you get good at something and you can treat the entire length of the vein I think you're successful and you have the best

chance to improve symptoms I think that's where I'll end if anybody has questions I'm happy to answer great thank you

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