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Idiopathic Thrombocytopenic Purpura | Splenic Embolization | 74 | Female
Idiopathic Thrombocytopenic Purpura | Splenic Embolization | 74 | Female
2016angiogramarteryBoston ScientificcoilsdorsalembolicembolizationMerit MedicalpancreaticproximalrefractorySIRspleensplenectomysplenic
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
Case 5: Liver Trauma | Emoblization: Bleeding and Trauma
Case 5: Liver Trauma | Emoblization: Bleeding and Trauma
activeangiogramarterybleedingbloodchaptercoilsembolizationembolizeextravasationhematomainjuryleakingliverLiver TraumamelenamicrocatheterNonenoticeportalposteriorpseudoaneurysmtraumavenousvessels
Endoleak Case |
Endoleak Case | "Extreme"-ly Obvious IR
accessaheadalgorithmaneurysmangiogramanteriorapproacharterialarterybringcablechaptercontrastendoendoleakfeedingfeeding vessel not identifiedFollow up angiogram shows a type 1b edoleakguysidentifyiliacimagingleaklimbpatientplaypuncturesheathslidestherefore planned an extension of the left aortic limbtrackingtransTranscaval approach to repair a likely type 2 endoleaktypevesselvideo
Geniculate Artery Embolization (Knee) A US Clinical Study | Geniculate Artery Embolization for Arthritic Pain Why How & Results
Geniculate Artery Embolization (Knee) A US Clinical Study | Geniculate Artery Embolization for Arthritic Pain Why How & Results
analogangiogramarteriesaspectassessbaselinebasicallybilateralchapterclinicalcomplicationsdecreasesembolicembolizationenhancementimagekneelateralmedialmedicationsmicronmonthMRImrisnervenumbnesspainpalpateparticlespatientpatientsplaceboplantarprocedurerespondshamstudiesstudysuperiorsynovialtibialtreatmentvessel
Why Do We Need Different Directions For Occlusions? | AVIR CLI Panel
Why Do We Need Different Directions For Occlusions? | AVIR CLI Panel
angiogramarteriesaxialchapterclinicalcomplicationscondyleembolicembolizationenhancementhematomaimagekneemedialmicronnervenumbnessocclusivepainparticlespatientsplantarpoplitealsynovialtibialtumorvessel
Case 6: Pelvic Fracture | Emoblization: Bleeding and Trauma
Case 6: Pelvic Fracture | Emoblization: Bleeding and Trauma
angiogramaortabottomchaptercoilscontrastcontrolembolizationextravasationfracturegoalimageimagesinjuryNoneparticlespatientpatientspelvicPelvic fracturepicturepicturesscanselectivetraumaunstable
Case 4a: Renal Trauma | Emoblization: Bleeding and Trauma
Case 4a: Renal Trauma | Emoblization: Bleeding and Trauma
angioangiogramangiographyarteriovenouscenterschaptercoilscontrastembolizationembolizeembolizedextravasationFistulagradehematomahemodynamicallyimageinjurieskidneyNoneparenchymapatientspenetratingpictureposteriorrenalRenal Traumaretroperitoneumscanspleensurgicallytrauma
Case 1 - Non-healing heel wound, Rutherford Cat. 5, previous stroke | Recanalization, Atherectomy | Complex Above Knee Cases with Re-entry Devices and Techniques
Case 1 - Non-healing heel wound, Rutherford Cat. 5, previous stroke | Recanalization, Atherectomy | Complex Above Knee Cases with Re-entry Devices and Techniques
abnormalangioangioplastyarteryAsahiaspectBARDBoston Scientificcatheterchaptercommoncommon femoralcontralateralcritical limb ischemiacrossCROSSER CTO recanalization catheterCSICTO wiresdevicediseasedoppleressentiallyfemoralflowglidewiregramhawk oneHawkoneheeliliacimagingkneelateralleftluminalMedtronicmicromonophasicmultimultiphasicocclusionocclusionsoriginpatientsplaqueposteriorproximalpulserecanalizationrestoredtandemtibialtypicallyViance crossing catheterVictory™ Guidewirewaveformswirewireswoundwounds
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
Hemobilia | Biliary Intervention
Hemobilia | Biliary Intervention
accessangioangiogramarchitecturearteriesarteryaureusbiliarybleedingceliacchaptercollateralizationdefectsdislodgementductembolizefistulasfrequentlygramhepatichilumintercostalinterventionistsliverparenchymalperipheralportalpreppseudoaneurysmremovethrombosestubetubesupsizeveinveinsvessels
Case 11b: Embolizing a Pseudoaneurysm of the Brachiocephalic Artery | Emoblization: Bleeding and Trauma
Case 11b: Embolizing a Pseudoaneurysm of the Brachiocephalic Artery | Emoblization: Bleeding and Trauma
angiogramarterybrachiocephaliccatheterchapterclickcoilcoilsembolizationmicromicrocatheterNonepseudoaneurysmPseudoaneurysm brachiocephalic arterystenttrachea
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
Case 9: Embolizing a Pseudoaneurysm Rrising from the Branch of the Inferior Epigastric Artery | Emoblization: Bleeding and Trauma
Case 9: Embolizing a Pseudoaneurysm Rrising from the Branch of the Inferior Epigastric Artery | Emoblization: Bleeding and Trauma
abdominalafibangiogramangiographyanteriorarterybruisingchaptercoilembolizationepigastrichematomainferiormicrocatheterNonepatientpseudoaneurysmPseudoaneurysm arising from the branch of the inferior epigastric arterywall
Case 4b: Embolization After a Post Biopsy Renal Bleed | Emoblization: Bleeding and Trauma
Case 4b: Embolization After a Post Biopsy Renal Bleed | Emoblization: Bleeding and Trauma
angiogramarteriesbiopsybleedbleedingchaptercoilsembolizationembolizeextravgoalhematomakidneymassNoneorganpatientpatientsPost biopsy bleedrenalretroperitonealscanvascular
Balloon Pulmonary Angioplasty | Management of Patients with Acute & Chronic PE
Balloon Pulmonary Angioplasty | Management of Patients with Acute & Chronic PE
angiogramangioplastyarteryballoonballooningbandschaptercomplicationscontrastflowHorizonimageimagesluminalNoneocclusionocclusionspatientsproximallypulmonaryradiationrecanstenosisthrombustreatedultrasoundwebs
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
Case 3b: Splenic Laceration | Emoblization: Bleeding and Trauma
Case 3b: Splenic Laceration | Emoblization: Bleeding and Trauma
angiogramarteriesarterychaptercoilsdelayedembolizationgastrichealhemodynamicallyinjurylacerationNonepictureproximalreconstitutionrupturespleensplenicSplenic Lacerationvessels
Case 3a: Splenic Trauma | Emoblization: Bleeding and Trauma
Case 3a: Splenic Trauma | Emoblization: Bleeding and Trauma
angiogramangiographybleedingchaptercoilscontrastembolizationembolizeextravasationgradehemodynamicallyimagelacerationlacerationsmicrocatheterNoneorganpainpatientproximalquadrantscanspleensplenicSplenic Traumatrauma
Overview of Biliary Disease at John's Hopkins | Biliary Intervention
Overview of Biliary Disease at John's Hopkins | Biliary Intervention
accessangiogrambiliarychaptercolonoscopyendoscopicercphopkinsinterventionlandscapeliverpercutaneouspracticequestionspecialtiesspecialty
The Case that Launched the Cornell PERT (PE Response Team) | Pulmonary Emoblism Interactive Lecture
The Case that Launched the Cornell PERT (PE Response Team) | Pulmonary Emoblism Interactive Lecture
adventitiaangiogramaortaarteryaspiratedbloodcatheterschapterclotdysfunctionFistulafrontalhemorrhagehypotensionhypoxiaintracraniallobelungPE in right main Pulmonary Arteryperfusionpertpigtailpressorspulmonarypulmonary arteryresectionselectivesheathspinsystolictachycardicthrombustpatranscranialtumorventricle
Case 1: Lower GI Bleeding | Emoblization: Bleeding and Trauma
Case 1: Lower GI Bleeding | Emoblization: Bleeding and Trauma
angiogrambleedbleedingbleedsbloodcatheterchaptercoilscolonoscopyembolizationembolizeessentiallygroinimaginglowerLower GI BleedmesentericNonepatientspicturepicturesprepscanseriesvessel
TIPS Case | Extreme IR
TIPS Case | Extreme IR
antibioticsascitesbacteriabilebiliarycatheterchapterclotcolleaguescommunicationcovereddemonstrateddrainageductduodenal stent placementfull videoportalrefractoryshuntsystemthrombolysistipstunnelultrasoundunderwentvein
Bland Embolization | Interventional Oncology
Bland Embolization | Interventional Oncology
ablationablativeadministeringagentangiogramanteriorbeadsblandbloodceliacchapterchemocompleteelutingembolicembolizationembolizedhcchumerusischemialesionmetastaticnecrosispathologicpatientpedicleperformrehabresectionsegmentsequentiallysupplytherapytumor
Cone Beam CT | Interventional Oncology
Cone Beam CT | Interventional Oncology
ablationanatomicangioarteriesarteryartifactbeamchaptercombconecontrastdoseembolicenhancementenhancesesophagealesophagusgastricgastric arteryglucagonhcchepatectomyinfusinglesionliverlysisoncologypatientsegmentstomach
Percutaneous Biliary Drainage  | Biliary Intervention
Percutaneous Biliary Drainage | Biliary Intervention
angiogramaxischaptercoaxialcolordrainductductalfrequentlyhepaticinterventionalobstructionperipheralportalstructuressuccesssystemtubevein
Case 8: Retroperitoneal Hematoma- Cover Stent | Emoblization: Bleeding and Trauma
Case 8: Retroperitoneal Hematoma- Cover Stent | Emoblization: Bleeding and Trauma
angiogramarteryaxialbleedcatheterizationchaptercontrastcoronalCoverage StentembolizationembolizehematomailiaciliacsimageinjuryNoneoptionpatientpseudoaneurysmRetroperitoneal hematomastentstents
Treatment Options- TransCarotid Artery Revascularization- TCAR | Carotid Interventions: CAE, CAS, & TCAR
Treatment Options- TransCarotid Artery Revascularization- TCAR | Carotid Interventions: CAE, CAS, & TCAR
angiographyangioplastyarterybleedbloodcalcifiedcarotidchapterclaviclecommondebrisdevicedistalembolicembolizationexposurefemoralflowimageincisioninstitutionlabeledpatientprocedureprofileproximalreversalreversesheathstenosisstentstentingstepwisesurgicalsuturedsystemultimatelyveinvenousvessel
Case 2: Upper GI Bleed | Emoblization: Bleeding and Trauma
Case 2: Upper GI Bleed | Emoblization: Bleeding and Trauma
abnormalangiogramarteryaxisbleedingbleedsbloodcatheterceliacchaptercoilscontrastembolizationembolizeendoscopyesophagusFistulagastroduodenalhemoptysishepaticmalformationsmesentericNoneportalsuperiortipsupperUpper GI Bleedvaricesvenousvesselvesselsvomiting
Case 10: Peritoneal Hematoma | Emoblization: Bleeding and Trauma
Case 10: Peritoneal Hematoma | Emoblization: Bleeding and Trauma
activeaneurysmangiogramanteriorarterycatheterchaptercoilcontrastcoronalctasembolizationembolizeembolizedflowgastroduodenalhematomaimageimagingmesentericmicrocatheterNonepathologypatientperitonealPeritoneal hematomapseudoaneurysmvesselvesselsvisceral
Case 7: Retroperitoneal Hematoma | Emoblization: Bleeding and Trauma
Case 7: Retroperitoneal Hematoma | Emoblization: Bleeding and Trauma
angiogramaortaarterybifurcationchaptercoilsdelayedembolizationembolizefillgramhematomaimageinjurylumbarmicrocatheterNonerastretroperitonealRetroperitoneal hematoma due to a transverse process fracturespacespinetransverse
Transcript

of doing the same thing. So that's a proximal only embolization. This second case a 74 year old female with ITP, she's refractory to medical therapy and then splenectomy in her platelet count was 19 and they were worried about blood loss during the operation.

In this case we did a splenic angiogram with a 5 inch catheter. We located the pancreatica magna and dorsal pancreatic artery which you can see right there at the corner of the splenic artery, lining up right here, so whenever you're doing particle embolization or scatter embolization,

if you're going to do that you wanna be sure that you're beyond those branches. So we did distal embolization with [UNKNOWN] in this case you can see we're taking out the whole spleen because we know the spleen is gonna be removed later this day, and then the operator chose

to also back that up with coils in the main splenic artery, and preserve those pancreatic branches. This was the intra-op photo. The one thing to keep in mind, the location of those coils they're in the mid portion of the splenic artery, is

often where the surgeons is going to divide the splenic artery and that's what happened, he actually had to divide right through the coils. He actually said it wasn't a problem but you might annoy your surgeons, so just ask your surgeons, before you do a pre op splenectomy, where are they planning on dividing the splenic artery so that

you don't put especially like a plug embolic or something that could really cause a problem in that area. And then a third case before I show you

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

24 year old patient after a car accident has lower abdominal pain and melena so blood coming out of the rectum here's the CT scan anyone want to take a stab but you can just shout it out

so this time we're looking at the liver right so the liver is the big thing on the right side of the screen and what you can see is the dark hematoma posterior to the liver but you should also notice that big white dots sitting

right in the hematoma all right that's important because that's active bleeding that's the report when you guys when you guys get called in for these cases and someone says oh this you know liver trauma with active

bleeding this is the picture that is spurring that announcement okay this is what active bleeding and the liver looks like again there's a bleeding scale there's an injury scale for a liver trauma we don't need to go into that

slides are available if you want them alright here is the angiogram now again my rule works all right if you see vessels get smaller and then big again something's abnormal so in this particular picture I want you to notice

the catheter sitting in the right hepatic artery the blood is going up into the right lobe of the liver and right near the top of the pictures that big circular kind of blobby thing now this is by definition extravasation

sometimes we use the term pseudoaneurysm to describe this I just want you to appreciate what a pseudoaneurysm means it means that there's a hole in the artery that contrasts or blood is leaking out of that hole and the body is

essentially constraining the bleeding it's not going all over the place it's being constrained that's what we call a pseudoaneurysm all right that's just one way to look at it and geographically so this is an injury to the artery blood is

leaking out of the artery but maybe one layer of a three-layered blood vessel or even just the surrounding tissue is constraining that bleeding alright so what do we want to do for this exactly exactly you're getting it all right so

here we can get our microcatheter all the way out there the closer we get to it the better now in end organs like the liver or the kidney we don't actually have to get all the way out there getting close to it's going to be good

enough but the closer we get to it the better for stopping the bleeding and preserving the function of that organ all right so look how close we literally got right into the injury and then we're able to embolize it that's the goal all

right now the liver is a nice place the treat because as you know there's two sets of blood vessels going to the liver there's the portal veins in the apat ik artery so if we just embolize a little a patek artery the

liver is not going to notice that at all because it still has the portal venous flow bringing blood to that liver but our goal is to get in there preserve as much of the liver that we can and address that injury okay here's another

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

ultimately we did it so what are

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 5 out of 10 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 6 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 are 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 the right is the whoa max scale so patients fill this out 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 in trying to 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 in 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 the 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 home 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

and you can see on this t1-weighted image that increased area of enhancement which is the area of synovial thickening you actually see this on MRI beforehand and there it is located over the lateral aspect of the knee on the axial image

and so what we're doing sorry in the medial aspect of the knee so what we're doing here on the angiogram is and you solve these leg angiograms where everyone doesn't really care about these you Nicollet arteries they're really

important when you have SMA or popliteal occlusive disease because they serve as a collateral source but otherwise and people have arthritis they can be a real pain and the pain in the knee if you will so this is a this is the superior

medial geniculate artery and always drapes over the femoral condyle and you'll see here on this image you don't really see very much but once we get into the vessel look at this it almost looks like a small about a cellular

carcinoma like when you're in the liver you get this tumor type blush vascularity that's what we're looking for that corresponds to the patient's area of pain and then after embolization this is what it looks like takes a very

small embolic we're using maybe point four two point six sometimes one CC at most of dilute embolic that we're injecting this is another case again before and after if you look here on the right and then

on the left you don't really see much until you select the vessel out once you get into that super medial vessel you can see how much enhancement there is so in our clinical study of twenty patients this is what we did you'll see on the

bottom here we used embassy and 75 micron in nine patients and eleven eleven patients got a hundred micron and I'll explain why we upsized our particles so initially we wanted to go very small because that's where dr. o

Cano had done in Japan but then we wanted to actually up size our particles and I'll explain this here in our complications so like all clinical studies the purpose of doing really good clinical research is because this is

early and we don't know if they're going to be complications and it's always fun when you're the first one to figure it out and you tell patients I don't really know what's gonna happen and this is what happens so thirteen patients had

this kind of skin discoloration over their knee now we knew this because we've been doing the embolization for about ten years in bleeding patients not necessarily arthritic patients so we had seen this before but none of these

patients in this clinical study went on to have any alteration of the skin and it resolved in all patients there was some minor side effects from basically medications and one small groin hematoma but there were two patients who

developed plantar numbness over their great toe so under their great toe basically the medial distribution of their tibial nerve they ended up getting plantar numbness and this is believed at least in our experience to probably be

related to non-target embolization to the tibial nerve the tibial nerve probably gets its blood supply from many of these Jamaican arteries so we decided after having these two cases one at our institution and one at University of

North Carolina Chapel Hill that we would then basically upsize our particles to 100 micron and we have not seen that and we're doing a second clinical study and I'm not seeing that he's either we had about a 70% reduction in pain so if you

look at our visual analog score out to six months and if you look at our disability it actually paralleled this exactly which is pretty impressive considering mostly patients had bilateral knee pain so out to six months

very good results 90% of patients were responders so two out of our twenty patients did not really respond one patient didn't respond at his one month follow-up but did wrist that is three and six so I still

consider them a clinical failure because we expect these patients to respond by one month here's just an example of a baseline MRI before and after and you can see all that joint effusion there the white that decreases just even after

a month how much it decreases and we looked at this in terms of synovial thickness and distension and even on MRI you can objectively count calculate synovitis scores and we calculated that they actually statistically decreased

this is another patient on the left the image shows diffuse white enhancement if you will of the synovium of the lining on the right it shows the fluid this is an image just of embolization and I show this image because it's really shocking

and this is actually one of our nurses who's enrolled in the clinical study is this is before this is all we did we embolized the medial aspect of the knee this is one month later 30 days in fact somebody just asked me this when I was

in the booth over at the meeting across the street and basically I said listen I don't know why this happened so quickly I have no idea we didn't tap her knee we didn't do anything else if you look at this premium post it's pretty dramatic

so clearly there's an inflammatory process that we are arresting or stopping in such a short period of time so is there a future for this I don't know it may just we may just fall down and find out that there really is in a

great future but so far we know it's at least technically successful it's the results are positive in the short term long term we're not so sure yet we do need to better understand these risks and I think in my opinion in the long

term it'll probably really really good for this 40 to 65 year old patient population who's not yet ready for knee replacement surgery this is the algorithm for our clinical study which were almost done enrolling right now

it's a randomized control study against placebo so it's two to one randomization which means one third of the patients actually get a sham procedure so we do an angiogram on their leg they're asleep they have no idea for embolizing there -

Nicola arteries are not we wake them up and they get off the table and we follow them up if they're no better they're allowed to cross over and get the treatment the other 2/3 of the patient actually get the treatment and they

don't know either if they got the treatment and then we follow these patients when we assess if you if they have improvement all pain mediated procedures must undergo sham controlled studies because pain is so right in it's

so intuitive to just yourself so you can't really if there's a placebo effect so this is why pussy bow control studies are very important I believe we have one more patient left to enroll in this clinical

study and then we should be done with that so I'll switch gears really quick

and you can see on this t1-weighted image that increased area of enhancement which is the area of synovial thickening you actually see this on MRI beforehand and there it is located over the lateral aspect of the knee on the axial image

and so what we're doing sorry in the medial aspect of the knee so what we're doing here on the angiogram is and you solve these leg angiograms where everyone doesn't really care about these Janicki lit arteries they're really

important when you have sfa or popliteal occlusive disease because they serve as a collateral source but otherwise and people have arthritis they can be a real pain and pain in the knee if you will so this is a this is the superior medial

genicular artery it always drapes over the femoral condyle and you'll see here on this image you don't really see very much once we get into the vessel look at this it almost looks like a small about a cellular carcinoma like when you're in

the liver you get this tumor type blush vascularity that's what we're looking for that corresponds to the patient's area of pain and then after embolization this is what it looks like takes a very small amount

of embolic we're using maybe 0.4 2.6 sometimes 1 CC at most of dilute embolic that we're injecting this is another case again before and after if you look here on the right and then on the left you don't really see much until you

select the vessel out once you get into that super medial vessel you can see how much enhancement there is so in our clinical study of 20 patients this is what we did you'll see on the bottom here we used embassy and 75 micron in 9

patients and 1111 patients got a 100 micron and I'll explain why we upsized our particles so initially we wanted to go very small because that's what dr. o Cano had done in Japan but then we wanted to actually up size our particles

and I'll explain this here in our complications so like all clinical studies the purpose of doing really good clinical research is because this is early and we don't know if they're going to be complications and it's always fun

when you're the first one to figure it out and you tell patients I don't really know what's gonna happen and this is what happens so 13 patients had this kind of skin discoloration over their knee now we knew this because we've been

doing knee embolization for about 10 years in bleeding patients not necessarily arthritic patients so we had seen this before but none of these patients in this clinical study went on to have any alteration of the skin and

it resolved in all patients there was some minor side effects from basically medications and one small groin hematoma but there were two patients who developed plantar numbness over their great toe so under their great toe

basically in the medial distribution of their tibial nerve they ended up getting plantar numbness and this is believed at least in our experience to probably be related to non-target embolization to the tibial nerve the tibial nerve

probably gets its blood supply from many of these generic arteries so we decided

patient 40s year-old patient again car accident lower abdominal pain and bruising so it sounds like you guys can appreciate that's an injury alright so we'll move past that so here's a CT scan these are four separate images from the

same patient CT scan and it is a bit more subtle I'm not suggesting it's easy to see you know we can appreciate the injury but one thing that you should be able to notice again is that concept of symmetry so when our residence or even

myself or anybody reads a cat scan we always want to kind of appreciate all the differences in the symmetry that we're seeing and so what you can see here is especially on that upper left hand side you can see the penis coming

out of the patient almost coming out of the patient and if you just draw a line straight back from there you should notice that there's a bit more tissue on the left side of the patient than the right side of the patient but that's

what we're looking at and if you go to the image over to the right the top right image right at that same area there's a little bit of a white blush which just shows that there is some bleeding going on there and if you look

at the third image which is the one on the bottom left right below one of the bones or there's another area of a white contrast collection or bleeding all right you can maybe see that again on the fourth image so that's what we're

looking for on the CT that asymmetry or the thickening of the tissue and we're looking for an escape of some contrast from where we should expect it to be all right so many of these patients will be

unstable those are the patients that probably need to go right to the or but for the patients who are really you know doing okay we have a chance to intervene on them and the reason why that's important is the more unstable they are

the higher the chance of mortality especially with the pelvic fracture so pelvic fractures are a big deal if you have a hemodynamically unstable patient with a pelvic fracture that's something to take very seriously

all right many of these patients will get CTS or C if we see extravasation they often come to us for angiography so here's the angiogram again a great example if you only look at one picture or two pictures

you're not going to see the problem all right so if you look at the first two pictures you really don't see anything I would I would argue it looks normal but as you get to that third picture you see that kind of collection of contrast

on the bottom right-hand side of the picture all right that's why you need to look at all the pictures of the and reom not just one picture you watch them it's like watching a

little movie now you just stand there and watch it over and over again I get a sense of what it looks like at the beginning middle and end of the angiographic run or set of images the other thing is it's very hard to see

extravasation of contrast when you're in the aorta so many times we do an aorta gram we take some pictures and we may or may not see anything but if we know there's a pelvic fraction we know it's more on the left side we'll go into the

left internal iliac artery and do a more selective angiogram and here's a picture of that selective angiogram and now you can see the extrapolation even more clearly hopefully you can all see it the bottom kind of leftish part of the image

all right here's a more selective now we say okay we definitely see something now we're going to get a little bit further into the system here's a picture now it's very clear you can go if you don't see it all right so you should see it on

the bottom all right and now our goal is to just get as close as we can and so we got all the way down then we put some coils there and again our goal is to make sure that we get just into the vessel that we treat and embolize it now

people will say what agent should we use do we use gel foam do we use particles do we use coils do we use glue or onyx the truth is you can you can really use anything but the thing with the most control so for trauma we tend to use

coils for trauma alright because our goal is to deposit an embolic agent right at the site of the injury that's our goal if we use particles we don't have as much control or a liquid we don't have

as much control they could go somewhere we don't want it to go all right here you're dealing with the blood supply of the penis the rectum the bladder other things which you know most of us would prefer not be injured during an

angiogram all right so we don't want to do something that we don't have complete control over and coils give us that type of control

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

here's another patient 62 year old male

patient just a similar case who had head in that cancer again after radiation therapy who experienced some bright red blood while coughing all right here's the CT scan and what I want to draw your attention to a little tough to see I

think I'll let me go up up here point it out with a mouse well I don't have a mouse so I guess not is basically you can see right in the middle of the two lungs kind of right in front of the trachea which is the black

circle alright just go right in front of that up to the top you can see the round white circle which is the brachiocephalic artery and just projecting off the back of that is another little kind of outpouching of

contrast a little nipple coming off of of the brachiocephalic artery that doesn't belong there all right here's the angiogram and it's a little difficult to see but there is a see if I can describe it better to you alright I

think this is actually a video so I'm sorry I don't know the ability to run it unless you can click on it can you guys click on the back up so if you want to look at it again you see the angiogram kind of running and just at the origin

of the brachiocephalic artery which is the first branch of the aortic arch you can see that outpouching of contrasts coming right to the right of that vessel that's a pseudoaneurysm and again we went through the same thought process we

said you know I want to put a covered stent across that but my problem was that we didn't just have the right size that would not block one of the carotid arteries and not extend too far into the aorta so we had no choice but to

consider embolization in this particular case so here's what we did here we actually put a micro catheter if you can just click I think that's a video to the left no I guess not you know what it's okay

what we did for this particular case was we went in from the arm and we put a micro catheter directly into that pseudoaneurysm because we couldn't feel we didn't feel we could put a stent across it so we put the micro catheter

in there we started to put some coils and it actually went further than we thought outside of the artery and here's the post image so you can see our final image you can see the coils that are sitting just adjacent to the

brachiocephalic artery and we preserved good flow there to end this basically

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]

60s year old patient with afib who fell and presented with abdominal pain and bruising in their anterior abdominal

wall for whatever reason we see a lot of these patients who come in with kind of bruising after they fall on their abdomen here you can see why hopefully you can see the big hematoma and the anterior abdominal wall so you can

imagine what this patient look like they have this kind of you know ball sized thing under their abdominal wall all right here's our angiogram in this particular case we went into the inferior epigastric artery which kind of

runs up from the pelvis up along the anterior abdominal wall you can see how small it is we were able to get a micro catheter in there and just in the middle just to the left of the middle of the picture you can see that kind of black

your circle that's again a pseudoaneurysm arising from the branch of the inferior epigastric artery and boom we can go in and coil it all right so that's what that looks like so now all of you kind of maybe I used to

sitting in the background we'll know when you're getting called in for these patients this is the type of pathology that we're looking at on CT and on angiography all right another patient 68 year old

similar but similar story an older patient who presented for a biopsy of a right renal mass now sometimes it's a skiing accident sometimes it's a car accident sometimes it's us that causes

these problems so here's a patient who came in for a biopsy of a renal mass here's the CT scan hopefully you can appreciate that the patient is face down or prone on this scan this by the spine is on the top side you can see our

biopsy needle going into a mass in the left kidney excuse me the right kidney and now this is the she comes back later because of some pain and now in a manner that's similar to what you said earlier on that first CT scan you can now see

the right kidney is pushed forward by a very large retroperitoneal hematoma so this is probably a post biopsy bleed this doesn't happen very often in fact as someone who does kidney biopsies once or twice every day I'm shocked that this

doesn't happen more often we're sticking big needles into vascular organs or vascular masses it's amazing that we don't have more patients come back for this it only happens about 2% of the time and usually people who have these

types of risk factors are at risk for this type of bleeding after a biopsy but we can do is we can go in do an angiogram and again I want you to just appreciate look at the picture I think everyone hopefully can see on the bottom

of the picture there's this active extrav enough contrast from the lower pol renal arteries all right lo pol renal artery and that's bad if it's great in a lecture because it's very easy for everyone to see but the reality

is it really signifies very significant bleeding and that's what everyone here should appreciate if you're managing the trauma patient or the bleeding patient if you see if this Cleary this clearly means everyone's got to move a little

faster to address it because this is a bad bleed but the great news is that we have the technology now to go all the way into the renal arteries or frankly the arteries of any organ get very far distant land just embolize it and so

look how far we got here for this patient we took care of it this patients kidney function didn't pump an inch because the reality is there was very little impact on the normal parts of the kidney so that's the goal if you guys

work with people who say oh we don't have to get that far out just throw some coils you know near the origin it's fine it'll accomplish the same goal but at the same time they will have killed half of the patients kidney so it is always

worth making some effort to get as far as you can into the organ that you're treating but at the same time you don't want to take an hour to do that because the patient's bleeding pretty heavily and you have to address it so that's our

goal during these procedures next case

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

different patient this is an unrestrained passenger in a motor vehicle accident now that you are all

experts in looking at this CT you can see on the right side of both of those images is the spleen you can see that darker grey areas within the spleen that's bad it should look more like the the the lighter parts

and actually all the grey are on the outside is all blood or fluid in the abdomen so this is a bad laceration probably at least a grade four splenic laceration but again this was a hemodynamically stable patient all right

and here's what we saw this is the angiogram you can see the splenic artery and you can see they're kind of diffuse abnormality of the spleen it just doesn't look right under normal circumstances it just look like branches

on a tree and what we're seeing here is just kind of splotchy looking splenic ranked them up so that's not normal we just want to give it a chance to heal this is the scenario we might do a proximal splenic embolization where

we'll go in and we'll basically put a plug or some coils right at the origin of the splenic artery and I love this picture because what it shows is why we do this philosophically what I want you to notice is on the image to the left

you can see the coil right there right if you see the abrupt stopping of the splenic artery and then what you see are all those vessels going up towards the top of the picture those are arteries that are supplying

the stomach it's the left gastric artery some other vessels that then go through vessels we call the short gastric arteries and what you get is is the reconstitution of the splenic artery so on the image to the right all the way on

the right side of the picture those branches that you see are within the spleen so even though we plugged up the splenic artery right at its start the spleen is able to get blood flow through those collateral vessels all right so

that's our goal that's what a proximal splenic embolization is trying to do we just want the spleen to heal a little bit and reality what we want to do is these patients are usually fine we just don't want them to go home and have a

delayed rupture of their spleen because that's something many of us probably don't appreciate if someone has a splenic artery injury or splenic injury and they're doing fine and then we send them home there is an incidence of

delayed rupture of the spleen and what we know through lots of good papers is doing these proximal embolization procedures helps to reduce that risk of delayed splenic rupture so that's what we're trying to do there all right so

case I can make up the ages anyway so it doesn't matter so 43 year old patient on a motorcycle that collided with a deer all right presents with left upper quadrant abdominal pain and now we're looking at a cat scan all right who

wants to look at a cat scan you look like you're up for it what do you think what do you see no no you're not sure so we're looking so the key is the left upper quadrant pain right the patient presented with left-sided pain you

should know that whenever we're looking at a study like this we're looking as if we're talking to the person so the right side is on the left the image the left is on the right side and so if you look on the these are two

images if you look at the right side of the image you can actually see the spleen that's like that beam shape thing towards the back of the patient and what we should see is a homogeneous appearance of the organ but what we're

seeing are some kind of dark grayish lines going through it that's essentially a laceration of the screen that's what we're looking at that's the pathology that will prompt us doing a procedure like this and when we ever we

see a patient with splenic trauma we try and grade the trauma so one thing you're going to hear about is it's a patient with a grey 2 laceration or a great 4 laceration or something like that and that basically just describes the extent

of the laceration through the spleen the further through the spleen it goes the higher the number is the worse it is for the patient okay we tend to get involved with patients who who essentially have grade 3 or higher lacerations and are

hemodynamically stable so in this particular patient this was thought to be a grade 3 splenic laceration but there was not a whole lot of blood around the spleen so we thought this patient had some time to come to

angiography and embolization so here's the angiogram lo and behold what we see is again a blobby thing which is the theme of this lecture remember this is bleeding so we're looking for blobby things and all the way on the right side

of that image you can see that cloud of contrasts that black contrast that's extravasated of contrast that's not normal all the way to the right you guys see it are you good so going all the way to the right that's

what we're trying to do now when we do splenic embolization there's two ways we think about this do we want to go all the way to where the bleeding is all the way out into the screen and embolize one little branch that's injured or do we

want to do something called the proximal splenic embolization we would just put like some coils or plugs right at the origin of the splenic artery with the goal of being to slow down the flow and allow the spleen to heal a lot of it is

just what's possible maybe what time it is how tired we are things like that all factors that weigh into it but here's a little bit of a better view you can see the area of extravasation now here's another picture now we put

our microcatheter out there now you're getting a bit more of a sense of what's going on there you can see the extravagance II the vessel that it's coming from and then we put our catheter all the way out there and now we're

right at the source of the bleeding so our philosophy is if we see bleeding we want to go as far as we can towards the source of the bleeding keeping in mind that whenever we don't get as close to the bleeding as possible we're

sacrificing normal parts of the organ that we're treating and that's the philosophical leap that we make during these procedures so we were able to get out there and then we embolize leaving a lot of flow through the rest of the

spleen and the patient was able to survive like we never did anything alright that's our goal now here's a

good afternoon thank you so much for invitation to speak to you I have a privilege of working at Johns Hopkins and we have a fairly large practice we at the main hospital itself we have 11 rooms and during a day about two of them are have a biliary case actually going

on at the same time so it's actually a fairly large volume of our practice and so the gamut of bluie intervention goes from really simple stuff to really complex and it is something that our trainees specifically will come to

Hopkins for and many of times they will end up being the blurry and experts as soon as they arrive at a new practice so certainly it's something that we deal with every day I just wanted to give you a landscape overview and share some good

cases that we've done and hopefully you may something have some comments or learn something about the way we do it but I'm pretty sure throughout the country a lot of great Billu work has been done currently there's no question

though the Blooey access and access to the Blooey system has really been played out in most hospitals perth by GI and ir and obviously surgery but almost a lesser so today and the rat in at least four IR is the PTC PPD or transparent

Col angiogram but it's actually a recurring role and I actually speak and have a sort of special interest in transit paddock colonoscopy as well so we play scopes through the skin through the liver and do a lot of balloon

intervention I'll show you a few cases like that but in true these access points are germane to what specialty you come from and obviously endoscopic beeper oral and if you eye are usually usually through the skin and there's no

question GI now in some hospitals I'm sure you have advanced endoscopy that will go through the stomach straight into the leftover liver so there's no question of a blurry landscape is changing quickly but no question that

this is quite common but yet most patients and internal medicine specialties will be looking at blurry disease by access point through scopes through ercp so going back from the Duden up or directly through in there's

advantages disadvantages something it's fairly obvious to everybody that you know no question is selling it to a patient if it had both choices that ERCP through the mouth and nothing invasive nothing sticking out their body

is attractive yet the outcomes are very similar but nonetheless there's pros and cons and through the trance of had a crap or two percutaneous route you do definitely have tubes at least sticking out

initially and this is often solved by GI as the main differentiator at least a discomfort but yet we are able to address almost every problem at times and often where'd they pay a lot there's

let me show you a case of massive PE

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

patient who 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

thank you so much for inviting me and to speak at this session so I'm gonna share with you a save a disaster and a save hopefully my disclosures which aren't related so this is a 59 year old female she's lovely with a history of locally advanced pancreatic cancer back in 2016

and and she presented with biliary and gastric outlet obstructions so she underwent scenting so there was a free communication of the biliary system with the GI system she underwent chemo and radiation and actually did really well

and she presents to her local doctor in 2018 with ascites they tap the ascites that's benign and they'll do a workup and she just also happens to have n stage liver disease and cirrhosis due to alcohol abuse in her life so just very

unlucky very unfortunate and the request comes and it's for a paracentesis which you know pretty you know standard she has refractory ascites and because she has refractory ascites tips and this is a problem because the pointer doesn't

work because a her biliary system is in communication with the GI system right so there's lots of bugs sitting in the bile ducts because of all these stents that have opened up the bile duct to list to the duodenum and so you know

like any good individual I usually ask my colleagues you know there's way more smart people in the world than me and and and so I say well what should I do and and you know there was a very loud voice that said do not do a tips you

know there there's no way you should do a tips in this person maybe just put in a tunnel at drainage catheter and then there was well maybe you should do a tips but if you do a tips don't use a Viator don't use a covered stand use a

wall stunt a non-covered stunt because you could have the bacteria that live in the GI tract get on the the PTFE and and you get tip situs which is a disaster and then there was someone who said well you should do a bowel prep you

like make her life miserable and you know give her lots of antibiotics and then you should do a tips and then it's like well what kind of tips and they're like I don't know maybe you should do a covered said no not a covered tonight

and then they're you know and then there was there was a other voice that said just do a tips you know just do the damn tips and go for it so I did it would you know very nice anatomy tips was placed she did well

the next day she has fevers and and her blood cultures come back positive right and you can see in the circle that there's a little bit of low density around the tips in the liver and so they put her on IV antibiotics and then they

got an ultrasound a week later and the tips that occluded and then they got a CT just to prove that the ultrasound actually worked so this really hurt my gosh to rub it in just to rub it in just just to confirm that your tips occlude

it and so you know I feel not so great about myself and particularly because I work in an institution that defined tip seclusion was one of the first people so gene Laberge is one of my colleagues back in the day demonstrated Y tips

occludes and one of the reasons is because it's in communication with the biliary system so bile is very toxic actually and when it gets into the the lining of the tips it causes a thrombosis and when they would go and

open these up they would see green mile or biome components in the in the thrombus so I felt particularly bad and so and then I went back and I looked and I was like you know what the tips is short but it's not short in the way that

it usually is usually it's short at the top and they people don't extend it to the to the outflow of the hepatic vein here I hadn't extended it fully in and it was probably in communication with a bile duct which was also you know living

with lots of bacteria which is why she got you know bacteremia so just because we want to do more imaging cuz you know god forbid you know you got the ultrasound of her they because she was back to remake and

you know that and potentially subject they got an echo just to make sure that she doesn't have endocarditis and they find out that she has a small p fo so what happens when you have a thrombosed tips you go back in there and you do a

tips or vision you line it with a beautiful new stent that you put in appropriately but would you do that when the patient has a shunt going from one side of the heart to the other so going from the right to the left so sort of

similar to that case right and so what do we do so I you know certainly not the smartest person in the room we've demonstrated that so I go and I asked my colleagues and so the loud voice of saying you know I told you this is why

we don't practice this kind of medicine and then there was someone who said why don't we anticoagulate her and I was like are you kidding me like you know do you think a little lovenox is gonna cure this and then the same person who said

we should do a tunnel dialysis tile the tunnel drainage catheter or like a polar X was like how about a poor X in here like thanks man we're kind of late for that what about thrombolysis and then you

know the most important WWJ be deed you guys are you familiar with that no what would Jim Benenati do that's that's that's the most important thing right so so of course you know I called Miami he's you know in a but in a big case you

know comes and helps me out and and I'm like what do I do and you know he's like just just go for it you know I mean there are thirty percent of the people that we see in the world have a efo it's very small and it probably doesn't do

anything but you know I got to tell you I was really nervous I went and I talked to miner our colleagues I made sure that the best guy who was you know available for stroke would be around in case I were to shower emboli I don't even know

what he would do I mean maybe take her and you know thrombolysis you know her like MCA or something I don't know I just wanted him to be around it just made me feel good and then I talked to another one of my favorite advisors

buland Arslan who who also was at UVA and he said why don't you instead of just going in there and mucking around with this clot especially because you have this shunt why don't you just thrown belay sit and then you

know and then see what happens and so here I brought her down EKOS catheter and I dripped a TPA for 24 hours and you know I made her do this with local I didn't give her any sedation because I wanted and it's not so painful and I

just wanted her to be awake so I could make sure that she isn't you took an intervention location you turned it into internal medicine I I did work you know that's that's you know I care right you know we're clinicians and so she was

fine she was very appreciative I had a penumbra the the the Indigo system around the next day in case I needed to go and do some aspiration thrombectomy and what do you know you know the next day it all opened up and you can still

see that the tips is short the uncovered portion which is which is you know past the ring I'm sorry that which is below the ring into the portal vein is not seated well so that was my error and and there was a little bit of clot there so

what I ended up doing is I ended up balloon dilating it placing another Viator and extending it into the portal vein so it's covered so she did very

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

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

we do drain the Louie systems we actually do this extremely successfully as interventional radiologists and it's a very high technical success like I said in this sort of supine position

from the mid-axillary line and these things are and you've seen a lot of these how these done really you need to pacify the system you get trans you most post people go trends in to cost Albany because the liver sometimes can be

tucked up way above and we usually want to make sure that the lung and the costophrenic angle doesn't come down low in nothing I take a deep inspiration first to make sure that you're not dealing with and then we now map your

track than you find some people do this with ultrasound guidance frequently with and dilated structures and most of the time it's actually much probably routine to actually do blind passes in the like I said the path of high success and to

pull back when you a passive our blue system is the only structure that doesn't wash away generally portal vein hepatic vein hepatic artery all of those structures are cylindrical

tubule alike are not are going to wash away move away and quite quickly and you can see this PDC and show in fact a left insertion of a right into your ductal system and frequently this will be something that we would have to make

people watch out like I said identification of choosing the right duct thereafter after you've identified you've performed a color angiogram is to identify how you're going to drain this and the most important thing to identify

is a peripheral duct doesn't matter which one there are ones with higher success but then within the lateral position find one market on the table then with a second axis as a to stick axis and I'm sure this is very germane

and common you've seen get into the peripheral duct and the AP fluoroscopy get a wide down you get a tube down and then eventually go it with a coaxial system getting a skinny wire converted to a larger wire and then following that

with a below a tube and your goal is to really get axis that goes transpannic through a perfect century through obstruction or no obstruction if it's just untie elated and through into the small bowel and lock a some type of

locking system it's interesting the size that you choose does make it different so if you go larger than the 12 french-trained initially the risk of bleeding actually goes above 10% for initial axis so the best is to probably

start with a 8 and 10 and that's what we typically do this is what we connect what it ends up looking like left a

patient who experienced the heart attack who had right little quadrant pain after a cardiac catheterization all you like oh so here's the cat scan and what you should appreciate there is in the front of that first image which is the axial

image all right you can see the hematoma that's brewing kind of in the front you notice how all these pictures kind of look the same that's the good part about giving a lecture on bleeding and trauma because they all kind of look the same

so that's the hematoma on the front part of the pelvis and on the on the right image which is more of a coronal like looking at the patient image you can see it right near the right groin you can see that hematoma all right so our next

step was to do an angiogram and this is what the angiogram looks like who wants to volunteer what do they say all right I saw someone raise his hand over here some walk over here what do you think yeah well yes so it is a retro hematoma

would you say describe the angiogram for everybody right where it's at the external iliac down the common femoral looks like there's contrast going up to the left and down to the right probably close to where they accessed yeah

probably but so yeah probably probably too high but the other thing is that's probably a pseudoaneurysm that probably is the evidence that there was a bleed there we're not seeing Frank extrapolation of contrast in a literally

contrast pouring out but we are seeing the effects of an injury to the artery and the constraining of the the remaining normal tissue to hold on to that bleed so the question is what do we want to do no that was very good because

I fooled you it's not always embolization so sorry I lied so in today's world a lot of times when we see this type of pathology we have again relatively new technology available to us again we

could go into that pseudoaneurysm and embolize it and that would be a legitimate treatment but my friend here is right you know this is a great case for a covered stent so we could go in and put a stent right across that area

of injury and stent it so these days looking at coverage stands as an option for patients with arterial injury is a very legitimate option you just have to be able to deliver it has to be the right artery you have to be able to get

the stent where it needs to go we all work with vascular surgeons who are great and they can put these stents and iliacs and aortas but they can't make those turns into livers and kidneys and spleens it's got to be the right artery

this is this is the right artery okay we saw this patient and we said well we could kind of get a micro catheter into that area of injury and embolize it or we could just put a cover sent across it and all go home to have dinner with our

kids so that was option B is what we chose here so this is a great cover stent case okay here's another patient

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

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 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

all right another patient 52 year old patient ATV accident we get a lot of

lunatics on ATVs in our area and they presented with severe back pain here's the cat scan you see that white thing kind of in the back on the right side it almost looks exactly like that liver one I showed you two patients ago the

difference is that that's not conscious that's a part of the patient's bone that's the spine that fractured off and is now sitting in the middle of a big hematoma so that's why my kids don't have ATVs all right so basically that's

a big retroperitoneal hematoma due to a transverse process fracture all right in light of an ATV injury here's the angiogram now look at the picture on the left first that's an aorta gram you see the renal

artery at the top you see the bifurcation of the aorta kind of in the middle going down to each side and maybe just on that first image you see a hint of maybe some cloudy extravasated on the left side of the spine excuse me the

right side of the spine the left side of the image now remember I just I know I keep hammering this point home but you need the delayed image to make the diagnosis that's normally going to tell you if there's a real problem and on

that image on the right which is a bit more delayed you can see the extravagant Rast next to where the spine was that's an injury that's a lumbar artery injury and as we get closer all right we put a micro catheter in that lumbar artery now

you see the extraction and the question always comes up how much of that space do we need to fill that's an abnormal space that's just receiving all the blood that's leaking out of the artery and basically we don't have to fill all

of it we try we try to but it takes a lot to fill that up so we'll go in there you can see we put a lot of coils in this space and then we started packing coils back into the artery that was injured and I know it looks really big

on that image but if you go back into a finally orna gram you can appreciate that we were in a very small artery there but the technology that we have now allows us to get very far into very small arteries and that I think is

what's changed over the 20 years that I've been doing this at the very beginning of my career we wouldn't think about doing any of these things since we didn't have the tools to get that far out we had to

embolize these vessels very close to their origin and that led to a failure rate and an adverse injury rate that we don't see now that we can get this far out keypoint another case we have an older

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