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Introduction to Extreme IR | Massive Pulmonary Emoblism
Introduction to Extreme IR | Massive Pulmonary Emoblism
Massive PE Case | Massive Pulmonary Emoblism
Massive PE Case | Massive Pulmonary Emoblism
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Case 2- Massive PE | Massive Pulmonary Emoblism
Case 2- Massive PE | Massive Pulmonary Emoblism
What is ECMO | Massive Pulmonary Emoblism
What is ECMO | Massive Pulmonary Emoblism
IR-PE (ECMO) Alert | Massive Pulmonary Emoblism
IR-PE (ECMO) Alert | Massive Pulmonary Emoblism
TEVAR Case | TEVAR w/ Laser Fenestration of Intimal Dissection Flap
TEVAR Case | TEVAR w/ Laser Fenestration of Intimal Dissection Flap
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Q&A- TEVAR w/ Laser Fenestration  | TEVAR w/ Laser Fenestration of Intimal Dissection Flap
Q&A- TEVAR w/ Laser Fenestration | TEVAR w/ Laser Fenestration of Intimal Dissection Flap
Endoleak Case |
Endoleak Case | "Extreme"-ly Obvious IR
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Take aways  |
Take aways | "Extreme"-ly Obvious IR
Case- Brain Infarction | Brain Infarct After Gastroesophageal Variceal Embolization
Case- Brain Infarction | Brain Infarct After Gastroesophageal Variceal Embolization
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Reflecting on The Case | Brain Infarct After Gastroesophageal Variceal Embolization
Reflecting on The Case | Brain Infarct After Gastroesophageal Variceal Embolization
TIPS Case | Extreme IR
TIPS Case | Extreme IR
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Lessons Learned | Extreme IR
Lessons Learned | Extreme IR
Case- Severe Acute Abdominal Pain | Portal Vein Thrombosis: Endovascular Management
Case- Severe Acute Abdominal Pain | Portal Vein Thrombosis: Endovascular Management
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Case Summary | Portal Vein Thrombosis: Endovascular Management
Case Summary | Portal Vein Thrombosis: Endovascular Management

good morning avir hello my name is Eve Haskell and we have sort of the less extreme version of extreme IR have any of you been to extreme IR it's extreme in the sense that it's four and a half hours and it's extreme in that 32 faculty gave cases in that session so

from a pure logistic nightmare trying to get 32 faculty pack up and down in that time that's that's more the exhaustion of it we did this here for the first time and in a slightly more expanded version which means a little bit more

time a little bit potentially of the human aspect Amana stochastic interventions but we might still be able to punch it up a little bit so if you want to throw verbal tomatoes out from the audience or something we're up for

it all right so we've got about 6 or so cases about 10 or so approximately minutes each and two panelists who are flying in at the last second the most excellent dr. Coley and doctor Benenati will be showing up as well and my

colleagues you all know Samantha Alisha and yo chole who has been spending a little bit of time from Seoul at UVA as well he's also an associate editor at the JV IR so we got some powerhouse faculty for you here so I'm gonna lead

us off so here's the case from 2011 52 year old woman with asymptomatic PE who gets transferred for an outside hospital to the medical intensive care unit on a mid Saturday I'm at the humorous bit the University of Maryland at this point one

of my partners over there where is she right back there over there the two of them are they are hot hot hot stars right there in the back therapeutic Lee anticoagulated consulted the NICU attending calls me directly

the woman is hypoxic her blood pressure is low the something happens in PowerPoint and then we restart again this has taken its own independent control right now that's alright my back all right I get

to press the green button here we go green button has been pressed no action green button again there we go alright so her o2 saturation is low she's hypotensive she gets a lot of fluid her o2 saturation improves and supposedly

she was able to talk comfortably and they watch her so the question was maybe she should get some intravenous TPA that actually is the thing on the bottle versus in an ir calf direct intervention or heparin at 8 so they continue with

mchugh supports not looking bad at 8:30 at night some hours later I get a new call she's hypotensive now newly so despite therapy she's working harder to breathe an echo has been done it took hours to get the result her right side

of her heart is struggling which is the thing that happens with big pease a bad sign we can look at blood levels of troponin x' and things as well and she's now in IR by 8:30 at night so we move quickly at this point in the room she's

breathing comfortably on 3 to 4 liters of nasal cannula and she's able to talk to me and lie flat in the procedure suite this is a vena cava grant so I've cued us to some of the findings which is the flow is up the vena cava and

backwards into the apat of aim it's going up and it's coming back down so you can it you can flood the vena cable with so much contrast that it's going to spill back because you just overfill it but this is not that injection this is

hand injection ok so that means that something's happening downstream and that's the right heart not able to handle the load of contrast not a good sign actually 10 for 20 I made that number up

because I couldn't remember but I can tell you it wasn't over injected so the mean pulmonary pressure is 55 high low normal okay we got a we got a high sign over there from UVA basketball go so so at this point I'm anxious because she's

anxious and visibly so so we start to hustle to get into the pulmonary arteries and she's starting to do less well very quickly this isn't going to be mechanical thrombectomy I give a race 1/2 systemic bolus that's

a that's actually a high dose of TPA immediately because I'm now hoping that systemic therapy is gonna work as she's decompensating we are preparing to do thrombectomy pressors are being started I give more

TPA which is an indication of being worried she's now intubated CPR particular fibrillation she shock we code her for 40 minutes and she dies in ion so we have the pulmonary Catherine and we haven't started the therapy even

so the question of course is what did we miss beforehand and this is before her okay what sign should have happened sooner yes she was hypercoagulable plus I think a very would this have made a difference it's not so clear even

retrospect did we just pour fluids into her which will keep a blood pressure up and moving on that Starling heart curve that says you heart muscle will continue to work and then you fall off that cliff and would it been done differently on a

Saturday all those kinds of you know on

a Thursday or not a lot of questions come up I showed this case four years at places hoping that people would say smart things about it at meeting and I never got that feedback but have any of

you had this same case happened where they get into IR you're gonna do something in a pulmonary artery and disaster that's not nothing okay multiply that by a zillion practicing IRS here's 2017 in contrast it's the

back half of this this is 75 year old woman worsening PE physiology after three days of anticoagulation and it's three weeks after that back surgery as well her bps are a hundred and fourteen systolic and they dropped to 81

she starts getting pressors and increasing oxygen and we get in to start doing stuff because now it's an urgent case on that morning and nothing was really working well some of this clot was hard if you've you've seen or use

these devices you know they ain't perfect they're not like the ads where there's a picture of gauze and there's always some clot on it that like like clot porn picture of look what I took out which may have little to do actually

with clinical benefit but it's sales and she has a respiratory arrest and CPR and the difference was is that I call for I run out to another room more than it and there's an anesthesiologist and I say can you get somebody down here can we

start ECMO so she gets ECMO and I'll explain it on another slide if you haven't seen this before and we now suddenly have somebody who is being supported on the equivalent of cardiac bypass and now we can do stuff we

stopped CPR so we go from five people in the room to seven people to 20 people in the room and a whole bunch of crew in gear and she spends two days on ECMO and you can see how aggressive the case became because I don't know if there's a

pointer but that big black arrow is pointing to a wall stent and actually of a some sort of self expanding scent that I placed them to PA to basically just say make space and what wasn't opening I

wrote that first report in 1996 the use

of a stent for a clot that didn't get better and it doesn't look pretty and yet she starts to get flow and that picture is ten months later on a CT that the pulmonary arteries was sense on both side are wide open which means you will

dissolve clot on your own but we needed to get her to that point of unloading that occlusion she gets the cannulate and she's alive so what is ECMO essentially it means that blood comes out of you gets oxygenated

and then returned back to you at at very high speed so big catheters big cannula that essentially allow you a low continuous mean pressure which is why CPR stops and this is complete oxygenation support the hardest

basically put at rest and for some people with big Peas this alone as a therapy actually while you're waiting for them to clean out as well so I I have always been thinking about that 2011 case and what would happen about it

and we took on this project which is I want an alert which is like an aortic or stroke alert in which I can get people to appear for ECMO instead of three hours of begging and trying to figure out how to do it which is what it was

for the other ECMO cases that came after this one so a whole lot of people came together what this does is you get the oxygen in your blood to come out these are big catheters they seemed foreign because part rays get open but in actual

fact we know how to place these catheters and the ECMO asks where but other people come and talk you through it so but the insertion our interventional things and we actually now have an ECMO alert and here's the

cool thing it's called IR PE or burpee July and we call the co team and say IR PE and a blast page to all these different teams automatically go out and our people make phone calls and cardiac cath people and cardiologists and /

fusions and all this stuff assembles and within 90 minutes there will be a perfusionist team at a max of 90 minutes in a specific room to either standby or potentially initiated it's very cool just called one a couple of weeks ago

they just stood by it we didn't have to do it so it's the first of its kind a per team decides after we have a call whether this might be something that needs ECMO everybody's around it they're available within this sort of time pages

go to all these kinds of people that you go by that you see that get sort of called teams are behind it and if your hospital has ECMO you can do this you can get people around this to see the logic of it catheter directly

dimensions are absolutely growing and getting bigger they're not going away and there are the subsets of massive massive PE patients who have 5 to 7 fold mortality and then there's a sub fraction of supermassive versa you know

so my Xtreme ir case is a TVR with on a patient with a type you tie section and then we use laser to find a straight the dissection flap and I just want to before I start I just want to give a big shout-out to my attending dr. Kasia and Rudy pump Adi on our IR resident Rudy

put these really cool illustrations together as you will see on these upcoming slides and dr. Kaja he did this case and basically it helps me with everything so since your old male patient presenting with history of

chronic type UTI section um he was medically managed with and I'll G Saxena antihypertensives and then he came into the ER a couple months later and it was complaining of severe back and chest pain so a CTA was

performed and and they found that there was a significant growth in the descending thoracic aorta and so we have a couple images here we have a 3d reconstruction of the aorta as well as the sagittal image of that CTA and does

anyone notice anything about this 3d on aorta no so this patient has a variant he has a bull vine arch actually so the left common carotid is coming off the right you nominate um but vessel the arteries so it's nice for us when we're

placing that and negraph we have more more of a landing zone so we're not covering any of important structures other than the less left subclavian artery and so we're the two arrow heads are on the sagittal image you will see

that there's reentry tears so if you look at the 3d image so the dissection is that line right in the middle and so it's starting at the origin of near the LSA and ending at the level of the celiac artery okay so we obtained right

and left common femoral access and you obtain left brachial access as well and the reason for left particular access is once we get our enter graph gen we're going to go ahead and I'm pass the wire through and a laser through and find us

to find a straight through that under graft so you can have flow but I will talk about that later so we put a twenty French dry seal sheath and the right groin and in the left groin we had a 8 by 45

she's and that was basically to accommodate IVA so they can kind of get a feel for what we're doing it just like another resource we have so we have two IVs images here the one on the left with the yellow arrow basically is just

showing us that thickened dissection flap and the Ibis on the right is the love of the celiac artery so the celiac artery is where that green arrow is pointing to and the white arrow head is basically just showing us that reentry

tear at that level and so through the right through the right the sheet on the right hand side the 20 French try seal sheets we placed the 7 by a 55 Aptus on steerable tour tour guide sheath so that basically can angle up to 180 degrees so

we place that up to sheath in the true lumen of the aorta and pointing towards the false lumen and then I just put some pictures up of what a dissection looks like I don't know if a lot of people a lot of you guys on do dissection their

frustrations I mean your practice but I just thought it would be nice to show and so once we have the Aptus sheep up in the true lumen and have it pointed towards on the false women we confirmed with the eye this just to make sure

we're on the right spot and we're not we're not going to harm any other structures when we laser so once we have that up we use laser to kind of poke a hole and fenestrated create that's here and once we did that we dragged while

the laser was on we dragged the baptists sheath down 4 centimeters and created a large terror so the whole goal is to open up that dissection so we could eventually place that under graph so once and that there's a florist got the

image of ibis and apt the Aptus sheath and all that and so we created a large tiara and then what we did was we passed the 18 wire into the false live and we angioplasty with the 14 by 4 centimeter balloon and as you can see that there is

some waste on that balloon and then eventually it dilated up to you know now I'm gonna burst rate which was 18 and so that Ibis is basically showing us that's here that we just made in our dissection flap

okay am I not there we go okay so once we angioplasty be repeated the same thing so we put the laser back up get a small tear right underneath large penetrations here that we just said and then we angioplasty it so once we

angioplasty we connected that top tier and bottom tear together we opened it all up and we angioplasty it again after that so once that I mean go back so once the angioplasty so right underneath that big tear that we just made so between

the tear that we just made and the re-entry is here at the level of a celiac you still have that little piece of a dissection flap that we still need to open to place our under graft so once we did that once we angioplasty through

the right groin we passed up a glide catheter and the true lumen and pointed it towards the false women and through on the tear that we just made we passed the v18 wire and through the left groin we went up with a 20 millimeter loop

snare and so we grabbed the the 18 wire and so that loop snare went and that reentry tear and like into the false lumen so our whole point is to get through and through access with that wire so we can use as a wire cutter to

cut the remaining flaps so that's what we did so we we grabbed that snare we grab that v18 with the snare we pulled it out of the left groin and we obtained through and through access okay so you're just ripping it down yeah

basically it's like it she goes somewhere yeah yeah you got it yeah that's exact don't ask a question to what you don't want the answer so basically that's what we did so once we got through into access we advanced both

sheets and we kind of like pull down to to cut the remaining flap so once we did that we basically had everything open so we were ready to place our under graft so we did angiography and then we ended up

deploying the descent and then so once we would deploy the stent we basically covered that LSA the left subclavian artery so that's exactly why we got brachial access so we pass the wire through and got to the origin of the LSA

and then we ended up putting the laser down and then we turn the laser on poked a hole and so now we have this hole and this endograft so once we did that we angioplasty it and then we deploy the stents okay and so now we have a diagram

of the pates and LSA following stenting so we sent in the aorta and where the dissection was and then resented the LSA so we have nice nice flow the REC lab donal angiogram basically is just demonstrating feeling of the celiac in

superior mesenteric artery as you can see in that middle image distally so one of our missions that Rudy made which is pretty awesome so illustration of fenestrated t-bar with LSA sensing and adequate just so Co following the

dissection flap that we usually there's open so BAM there you go so that's Rudy and I in the middle my one of my co-workers Kevin and when my mentor is dr. Kaja dr. Marley and myself so thank you hi dr. Kasia thanks for joining

actually I have a quick question for you so we had a similar case last week at UVA and was a 32 year old female and she had connective tissue disorder and she had had an eighth inning repair five years ago and she subsequently developed

a type V dissection okay and this type B dissection they have been just basically monitoring for a couple years and so now we have this or chronic dissection flap and I actually made drop to dr. Kasia because we were

planning on doing an T bar and propping open the true limit but my concern is because that's the technologists are always thinking like if this doesn't work what am I gonna have available in the room and so I was thinking if we

prop up in this true lumen and we collapse the false lumen which was feeding a good bit of the viscera how am I going to successfully finish straight open this this chronic dissection flap and I don't have any experience with

laser we usually use the colon to needle we use that kind of approach and so my question is do you guys routinely use this in both chronic and okay well we don't use doing a B arcade typically but this was something new that we did dr.

Koch oh yeah so this is something new right you've never done a laser fenestration before yep bigger voice [Music] the laser septum II is something that we thought of I think which was a new thing

we also are kind of planning new ways to do that I think the main point that Sam mentioned is you want to create a total a single lumen that gets a full seal so you don't have persistent retrograde perfusion and I know from Y training at

UVA that we used to do the used to do T bars and hope that that overtime remodels but you still get a lot of retrograde flow and then you can get false lumen degeneration and then aneurysmal formation and by doing it

this way you don't get that anymore from anybody else this is open and back and forth no hard questions just joking I got I got my backup I got dr. Kajal I got Rudy and Anthony and magnetized okay

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

ultimately we did it so what are

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

leave you the image you can see from an airplane on this image can you see prominent vein this is a prominent beam so at the time in this image pulmonary vein was or pacified so we should not hiss but we missed fortunately the patient got over our headache and visual disturbance discovered within seven days and for the next six months no variceal bleeding and he got a liver transplantation so how to

prevent this serious complication 1 to 2 or 1 to 3 thick mixture of colonial applied a mixture should have been used or butter the flow should be concealed being controlled by putting catheter or several coils it should have been used at first and then and cool injections should have been done I don't know or instead of Paris embolization tips or liver transplantation should have been considered the first I don't know I'm not Monday Morning Quarterback and this

is my last slide thank you for your attention

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

well and the lessons I learned were that you know it's really good to ask

people's opinions you know and I think that's what I love about my institution it's very multidisciplinary and I love talking to my friends and advisors and mentors elsewhere but ultimately you know it's your patient it's your case

and you're responsible and so what we do not want to get into the habit of is like you're just throwing your hands up in there and be like well sorry why don't we put in a tunnel drainage catheter because that would have helped

her too but she's so much more grateful that I opened up the tips and believe it or not the bacteremia resolved as soon as the tips was covered and she finished her course of antibiotics and she's doing really well

so patient-centered care is also really important just because the you know papers and algorithms exist saying that you shouldn't do tips potentially in patients with communication of the biliary tree you

know you gotta you got to do what's right for the patient sometimes and if sometimes you have to go against algorithms and guidelines but you know but that's again a case-by-case basis thank you

thanks Maureen

so we kind of had a bunch of portal vein cases I think we'll stick with that theme and this is a 53 year old woman who presented to the emergency room with severe abdominal pain about three hours after she ate lunch she had a ruin why two weeks prior the medications were

really non-contributory and she had a high lactic acid so she they won her a tan on consi t scan and this is you can see back on the date which is two years ago or a year and a half ago we're still seeing her now and follow-up and there

was a suggestion that the portal vein was thrombosed even on the non con scan so we went ahead and got a duplex and actually the ER got one and confirmed that portal vein was occluded so they consulted us and we had this kind of

debate about what the next step might be and so we decided well like all these patients we'll put her on some anticoagulation and see how she does her pain improved and her lactate normalized but two days later when she tried to eat

a little bit of food she became severely symptomatic although her lactate remain normal she actually became hypotensive had severe abdominal pain and realized that she couldn't eat anything so then the question comes what do you do for

this we did get an MRA and you can see if there's extensive portal vein thrombus coming through the entire portal vein extending into the smv so what do we do here in the decision this is something that we do a good bit of

but these cases can get a little complicated we decided that would make a would make an attempt to thrombolysis with low-dose lytx the problem is she's only two weeks out of a major abdominal surgery but she did have recurrent

anorexia and significant pain we talked about trying to do this mechanically and I'd be interested to hear from our panel later but primary mechanical portal vein thrombus to me is oftentimes hard to establish really good flow based on our

prior results we felt we need some thrombolysis so we started her decided to access the portal vein trance of Pataca lee and you can see this large amount of clot we see some meds and tera collaterals later i'll show you the SMB

and and so we have a wire we have a wide get a wire in put a catheter in and here we are coming down and essentially decide to try a little bit of TPA and a moderate dose and we went this was late in the afternoon so we figured it would

just go for about ten or twelve hours and see what happened she returned to the IRS suite the following day for a lysis check and at that what we normally do in these cases is is and she likes a good bit but you can see there's still

not much intrahepatic flow and there's a lot of clots still present it's a little hard to catheterize her portal vein here we are going down in the SMB there's a stenosis there I'm not sure if that's secondary to her surgery but there's a

relatively tight stenosis there so we balloon that and then given the persistent clot burden we decide to create a tips to help her along so here we are coming transit paddock we have a little bit of open portal vein still not

great flow in the portal vein but we're able to pass a needle we have a catheter there so we can O pacify and and pass a needle in and here we are creating the tips in this particular situation we decide to create a small tips not use a

covered stent decide to use a bare metal stent and make it small with the hope that maybe it'll thrombosed in time we wouldn't have to deal with the long-term problems with having a shunt but we could restore flow and let that vein

remodel so now we're into the second day and this is you know we do this intermittently but for us this is not something most of the patients we can manage with anticoagulation so we do this tips but again the problem here is

a still significant clot in the portal vein and even with the tips we're not seeing much intrahepatic flow so we use some smart stance and we think we could do it with one we kind of miss align it so we

end up with the second one the trick Zieve taught me which is never to do it right the first time joking xiv and these are post tips and yo still not a lot of great flow in the portal vein in the smv

and really no intrahepatic flow so the question is do we leave that where do we go from here so at this point through our transit pata catheter we can pass an aspiration catheter and we can do this mechanical

aspiration of the right and left lobes you see us here vacuuming using this is with the Indigo system and we can go down the smv and do that this is a clot that we pull out after lysis that we still have still a lot of clot and now

when we do this run you see that s MV is open we're filling the right and left portal vein and we're able to open things up and and keep the the tips you see is small but it's enough I think to promote flow and with that much clot now

gone with that excellent flow we're not too worried about whether this tips goes down we coil our tract on the way out continue our own happened and then trance it kind of transfer over to anti platelets advanced or diet she does

pretty well she comes back for follow-up and the tips are still there it's open her portal vein remains widely Peyton she does have one year follow-up actually a year and a half out but here's her CT the tip shuts down the

portal vein stays widely Peyton the splenic vein widely Peyton she has a big hematoma here from our procedure unfortunately our diagnostic colleagues don't look at any of her old films and call that a tumor tell her that she

probably has a new HCC she panics unbeknownst to us even though we're following her she's in our office she ends up seeing an oncologist he says wait that doesn't seem to make sense he comes back to us this is 11 3 so

remember we did the procedure in 7 so this is five months later at the one year fault that hematoma is completely resolved and she's doing great asymptomatic so yeah the scope will effect right that's exactly right so so

in summary this is it's an interesting case a bit extreme that we often don't do these interventions but when we do I think creating the tips helps us here I think just having the tips alone wasn't going to be enough to remodel so we went

ahead and did the aspiration with it and in this case despite having a hematoma and all shams up resolved and she's a little bit of normal life now and we're still following up so thank you he's

great case and it's sort of a great book

end to what we opened with when I showed you a case of a woman with a massive P you've got some stents and there was still clot but it follow up all the rest of the clot disappears because once you create a flow channel people then life

by making their own endogenous TPA and that's essentially what you've leveraged over there enough flow that with anticoagulation she cleaned out veins that you hadn't even touched including the splenic vein so and created and what

I used to call an obsolescent tips a short-timer that you can now release her from complete follow-up from which is a really kind of elegant final closure you can leave her for her oncology follow-up for her non tumor so any closing

comments that you want to make for kind of cool collection of cases anything from the audience as we as we wrap you up we're know we're a couple minutes over time so from us this has been great fun and we're very happy that you had us

here and hopefully this was interesting for you folks as well thank you very much on behalf of all of us

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