Intermitent CP for 12 hours, LED Vein| Bypass, Lesions,Balloon | 78 | STEMI wake up!
Intermitent CP for 12 hours, LED Vein| Bypass, Lesions,Balloon | 78 | STEMI wake up!
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Alright so this is an old slide actually this is the patient that was not part of the... no actually this patient was in the past couple of months... so a different type of

patient seventy-year-old with intermittent chest pain for 12 hours. So the intermittency of chest pain... remember we saw that initial kind of animation actually was not an animation... I'll tell you how they did that's pretty cool. So

what they did is they took an artery and they actually sectioned it all the way up. It's the same patient so one artery...on autopsy obviously...and they sectioned the artery all the way up and they went from a normal segment to an abnormal

segment. That's actually how they got that picture. Those were like fifty hundred micron segments. So kind of cool how they got that picture. Pretty bad cause it's autopsy but that's the way it is to get great pictures. In this particular

patient we see some changes perhaps one in aVL. Very subtle. Right so this considered a lateral infarct. What's probably what would draw your eye to any EKG like this is that the depressions are greater magnitude than the lateral wall

the lateral EKG changes. And actually that is a pretty pathognomonic of a circumflex lesion. So in this patient left main. The LAD is actually a grafted vessel. This patient had bypass and the lesion's in the circumflex. So this

job was in the left AV groove. So therefore the marginals are the ones of the on the side of the heart the rounded side of the heart the left ventricle. And the changes will be in the lateral wall and that's why just changes are

seen in 1 and aVL. So kind of pretty typical for what we do this patient had a balloon and the final that was pretty. I gotta say so for myself. So pre and then the post. Even a grafted patient oftentimes has ungrafted

distributions and that's typically where see it. Vein graft occlusions interestingly enough are really complicated because they get competing flow. But in a native artery typically the changes are abrupt and

obvious. Ok so we look at targets... how far am I timewise...7 minutes...okay good. So this is the...actually I love that commercial where they're sending out the know the glasses and the

two deer in the woods. You guys don't know what I'm talking about right. Ok I love that commercial I'm trying to get a slide of that actually... and they kept saying those guys are dumb and its the two deer wearing the mask ok...

Anyway I want to go over some STEMI

Sometimes it is so tortuous that we can't even get a microcatheter across, and that's a problem. So what do we do there? In the old days, if you can't do that,

and you can't cross the aneurysm then the best way is to actually puncture the aneurysm self-percutaneously and put coils and thromen through the needle as well. We've been able to reduce the incidence of that by doing the Fong procedure, which is not, it's kind of like a cowboy way of doing it,

but it actually reduces the amount of times that we actually have actually gone to actually percutaneously puncture the aneurysm. What we do is we actually use glue. We actually use a very thick glue. And what we hope for is that we deploy this thick

glue plug and let it run in the aneurysm, go to the distal end and actually plug the distal splenic aneurysm-- splenic artery. And that is basically your distal coil equivalent. And then you put coils or glue to finish it off. And most of the time it works, sometimes it doesn't.

And when it doesn't, sometimes you kill the spleen. They key thing is to make thick, thick glue, okay? I know it's kind of like, 60% of the time, 100% of the time it works, or something like that. But it's pretty hairy, but we've been able to do that with minimal complications.

A thick glue, 1:1, fire it as a plug, it rotates through the aneurysm, goes distally, and then you actually coil it or glue proximally. This is an example of that. Large aneurysm. This is actually the inflow artery in the red arrow,

the outflow artery out of the aneurysm is the other red arrow, the smaller arrow at the top. And then there's another branch sneaking proximally around the aneurysm, not involving the aneurysm going to the spleen. That's good.

That's a good sign. There's a nice collateral that can grow, that actually can revive the spleen if you take out most of the spleen. That's the distal pancreatic tail. We were unable to cross this aneurysm. In fact we were barely into that aneurysm.

What we did was just deploy that thick glue. Sorry guys, it's not working for me here. This is what we have. This is actually that little piece of glue is actually in the distal outflow artery, okay? And the rest of it, this is actually in the inflow artery,

and we basically excluded this with just purely glue, without any coils. This is the kind of follow up imaging of the patient with an excluded aneurysm and a largely live spleen by actually excluding it this way.

We're doing this in the knee where we do the geniculate nerves. We target the medial and lateral superior geniculate nerves, as well as the inferior medial geniculate nerve.

This is the approach, you can see the probe placed right where the geniculate nerve lives in the lateral position. This is what it looks like when we're placing the probes. We place these sheath needles. We inject some bupivacaine and lidocaine,

and then we form the RFA. This is another patient where we performed the medial and lateral superior geniculate and then the inferior medial geniculate ablation with significant relief of this patient's pain.

So Medical University, we all work at SC, our physicians decided that they were gonna do their own best access trial. This is the article that was just published, I believe, in November, October, after we did all the research.

And this one kind of focused on our case procedures. What we did is a little different, we decided that we were gonna take a patients' perspective, so our study is saying what does the patient want. Not what's better for the physician, what's better for the hospital, but the patient experience.

So on our study, what we said was, and we were very selective, because we knew we had to do people with more than one treatment. And said the first time, we were either doing femoral or radial.

The second time, we're gonna do it the opposite way. The third time, we ask the patient what do you want, do you want us to go radial or do you want us to go femoral. So we put it in the patients' hands. After 124, we found that we had no conversion,

meaning that if we went femoral, we stayed femoral, if we went radial, we went radial, we didn't have complications where we had to switch sites. So pretty safe both ways. But what we found was the patient preference was 4:1.

So afterwards, patients decided that they preferred the radial approach. The 1%, from what I understand, because I wasn't around for a lot of this research, I was just coming into the program at the time, the 1% didn't care either way.

But this gave us the impetus to say yes, radial is what patients prefer. The secondary endpoint in the article talks about the overall complications, and then this goes into some of the misconceptions. So we had no adverse events on the 30 day follow up.

And that includes the hand ischemia, which is a common thought process, that you know, you might lose your hand if you do it the radial, or stroke, that's normally because people fear going over that margin. Some of the other things we found

that were incidental findings was the radiation exposure. And we're gonna look at some of the anatomy later, but it's actually quicker for us to get into the liver and to get to where we're going. If we think about it,

we're following the natural way the artery flows without working against it. Going into part of complex curves in anatomy. So we were able to get into it very quickly to treat it. And that represented less radiation. The other thing that we found was less radiation

to the doctor, the one doing the case. So I'll show you the way that we position the patient, we shield the physician and actually showed that the physician and the providers doing the care actually get less radiation exposure also. So the other thing we found is there we no difference

in contrast media, that was the other thing we were kind of looking at, do we need more contrast media. But there was no difference in those results. So the question becomes why aren't we using radial access, patients prefer it, it gets less exposure of radiation

to the physician or the people providing the care, why aren't we using it in our community. So there's a couple of reasons. The first is just the lack of general awareness the procedure is even out there. Again, misconceptions regarding the stroke risk

and the radiation dose. Lack of appropriate training on the physician's side, it's a learning curve that's pretty steep for a physician, there's a lot of nuances to radial access that are easy to overcome, but you have to take the time to learn them.

And then last is the lack of appropriate materials. Obviously, a radial artery is a lot smaller than your femoral artery. So if you don't have the equipment and tools you need, then there's no reason to access the radial site. So as technology catches up with us,

so is our ability to do these radial procedures.

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