Chapters
Anticoagulation Guidelines  | Essentials: Anticoagulation - Categorical course
Anticoagulation Guidelines | Essentials: Anticoagulation - Categorical course
2016AngiodynamicschapterDVTfull videoguidelinessbvscienceSIRsuperficialthrombosisvenous
Objectives Methods Data Collection & Analysis  | Percutaneous microwave ablation of 100 T1a renal cell carcinoma: Short and intermediate term efficacy with emphasis on tumor complexity and mitigation of complications.
Objectives Methods Data Collection & Analysis | Percutaneous microwave ablation of 100 T1a renal cell carcinoma: Short and intermediate term efficacy with emphasis on tumor complexity and mitigation of complications.
2016anesthesiaAngiodynamicsantennasassessbiopsychaptercomplexitycomplicationsconsciousemphasisfull videomicrowavemitigationrenasbvscannerSIRtumor
Postmortem Clot in Lung | Essentials: Anticoagulation - Categorical course
Postmortem Clot in Lung | Essentials: Anticoagulation - Categorical course
2016AngiodynamicschapterDVTfull videoprophylacticsbvSIRthrombolysistreating
Diagnosing Suspected Recurrent Lower Limb DVT | Diagnosis of DVT
Diagnosing Suspected Recurrent Lower Limb DVT | Diagnosis of DVT
2016abnormalaccpAngiodynamicsanticoagulationchaptercompressibilitycompressiondiagnosticdiameterDVTextremityfindingsfull videopositiveproximalrecurrentsbvsegmentSIRsoundtesting
Progressive R Calf Claudication | Thrombectomy and Thrombolysis | 57 | M | Thrombolysis: Arterial and Venous - Scientific session
Progressive R Calf Claudication | Thrombectomy and Thrombolysis | 57 | M | Thrombolysis: Arterial and Venous - Scientific session
2016Angiodynamicsanteriorarterychapterdistaldistallyembolizationembolusfootfull videoocclusionpatencypatientperinealpersistspoplitealposteriorrunoffsbvsegmentalsingleSIRsuctionthrombustibialvesselvessels
Surgical Procedures and Outcomes | Thrombolysis: Arterial and Venous - Scientific session
Surgical Procedures and Outcomes | Thrombolysis: Arterial and Venous - Scientific session
2016amputationamputationsAngiodynamicschaptercomplicationsdeathfull videopatientspersonsrepresentingsbvSIRsurgicallysurvival
Materials and Methods - Mechanical Debulking of Target Vessels  | Thrombolysis: Arterial and Venous - Scientific session
Materials and Methods - Mechanical Debulking of Target Vessels | Thrombolysis: Arterial and Venous - Scientific session
2016Angiodynamicsarterialcatheterchaptercutedebulkingfemoralfragmentationfull videoiliacmechanicalocclusivesbvsegmentsSIR
Mechanical Endovascular Removal of Thrombi and Emboli - Aim of Perspective | Thrombolysis: Arterial and Venous - Scientific session
Mechanical Endovascular Removal of Thrombi and Emboli - Aim of Perspective | Thrombolysis: Arterial and Venous - Scientific session
2016acuteAngiodynamicschapterendovascularfull videoischemiamanagedsbvSIRsubacutesurgerythrombithrombolysis
MRI | Diagnosis of DVT
MRI | Diagnosis of DVT
2016Angiodynamicschaptercontrastfull videogadoliniumionizingpatientsproximalsbvSIRultrasound
Conclusions and Questions from the Audience | Thrombolysis: Arterial and Venous - Scientific session
Conclusions and Questions from the Audience | Thrombolysis: Arterial and Venous - Scientific session
2016acuteAngiodynamicsbasilarcalcifiedcalibercatheterchapterdebulkingendovascularfull videoischemiamechanicalocclusionocclusionsoccursbvSIRstentsubacutesurgerythrombolysisthrombosesvesselvessels
Patent Calf Vessels Before/After Therapy - Ankle Arm Index | Thrombolysis: Arterial and Venous - Scientific session
Patent Calf Vessels Before/After Therapy - Ankle Arm Index | Thrombolysis: Arterial and Venous - Scientific session
2016Angiodynamicsanklechapterdetectablefrequencyfull videoischemicmajoritypatientssbvSIRtherapytreatmentvessels
Clinical Success  | Thrombolysis: Arterial and Venous - Scientific session
Clinical Success | Thrombolysis: Arterial and Venous - Scientific session
2016Angiodynamicschapterclinicalfull videoischemicpatientssbvSIR
Compression Stockings for VTE- SOX Trial | Essentials: Anticoagulation - Categorical course
Compression Stockings for VTE- SOX Trial | Essentials: Anticoagulation - Categorical course
2016Angiodynamicschaptercompressionfull videopatientsprevalencerandomizerefluxsbvSIRtherapytrialvalvularvenous
ACCP Guidelines: CT/MR Venography | Diagnosis of DVT
ACCP Guidelines: CT/MR Venography | Diagnosis of DVT
2016Angiodynamicschapterclinicaldeepdiagnosticextremityfull videoguidelineslowerMRIpatientssbvSIRsuspectedthrombosisvenous
Techniques Used: Aspiration Thromboembolectomy and Target Vessels | Thrombolysis: Arterial and Venous - Scientific session
Techniques Used: Aspiration Thromboembolectomy and Target Vessels | Thrombolysis: Arterial and Venous - Scientific session
2016Angiodynamicsarterialchapterfull videoiliacmyocardialocclusionocclusionspatientspersonsrepresentingsbvSIRtargetthromboembolicthromboses
Outcome by Treatment Mode and Primary Safety Endpoint | Thrombolysis: Arterial and Venous - Scientific session
Outcome by Treatment Mode and Primary Safety Endpoint | Thrombolysis: Arterial and Venous - Scientific session
2016adjuvantAngiodynamicsangioplastyarterialchapterfull videohematomasinterventionmechanicalpatientsPenumbrapercentpercutaneousperfusionsbvSIRstentthrombectomytpa
Results Conclusion & Q&A | Percutaneous microwave ablation of liver tumors near the heart: safety and efficacy
Results Conclusion & Q&A | Percutaneous microwave ablation of liver tumors near the heart: safety and efficacy
2016alterationsAngiodynamicsantennaantennasapproachbeneathcardiologistcardiovascularchaptercirrhosisdifferencedischargefrequencyfull videoheartinterferencemaximizemicrowaveno transcriptpacemakerpacemakersprobessbvSIRstudytumortumorsultrasoundventricleventricular
Results After Debulking and Infrapopliteal Intervention | Thrombolysis: Arterial and Venous - Scientific session
Results After Debulking and Infrapopliteal Intervention | Thrombolysis: Arterial and Venous - Scientific session
2016adjunctiveAngiodynamicschapterdiffusefull videoischemialesionsocclusionpatientspoplitealsbvSIRthrombolysistreat
Superficial/Perforator Venous Reflux and Deep Venous Obstruction | SIR Meets American Venous Forum (AVF) - Categorical course
Superficial/Perforator Venous Reflux and Deep Venous Obstruction | SIR Meets American Venous Forum (AVF) - Categorical course
2016ablationablationsalterationAngiodynamicsautologouschapterdeepfull videoguidelinesiliacinsufficiencyligationpathologicpatientsperforatorssbvSIRstentingsuggestedulcerationvenous
Treatment- Rotarex 8F Catheter and Debulking Alone Results | Thrombolysis: Arterial and Venous - Scientific session
Treatment- Rotarex 8F Catheter and Debulking Alone Results | Thrombolysis: Arterial and Venous - Scientific session
2016Angiodynamicschapterdiametersfull videopatientspersonsrecanalizationresidualsbvSIRstenosis
Atraumatic Versatile System | Thrombolysis: Arterial and Venous - Scientific session
Atraumatic Versatile System | Thrombolysis: Arterial and Venous - Scientific session
2016Angiodynamicsaspiratedchaptereffectivefull videopatientsPenumbrapercentpercutaneousproceduresafesbvSIRthrombolysisthrombolyticsthrombus
VTE Treatment and Calf Vein Thrombosis | Essentials: Anticoagulation - Categorical course
VTE Treatment and Calf Vein Thrombosis | Essentials: Anticoagulation - Categorical course
2016AngiodynamicsanticoagulationbailoutchapterclotcolleaguesDVTfactorsfull videoguidelineshealthyimagingisolatedmobilityongoingpatientrisksbvsevereSIRstratifysymptoms
Background Purpose & Methods | Percutaneous microwave ablation of liver tumors near the heart: safety and efficacy
Background Purpose & Methods | Percutaneous microwave ablation of liver tumors near the heart: safety and efficacy
2016anesthesiaAngiodynamicsantennaantennasbeneathcardiovascularchaptercomplicationscontourdetermineenhancingfull videohearthyperimaginglivermeasuredmicrowaveno transcriptpatientsperipheralprocedurerhythmsbvSIRtumortumors
Major and Minor Complication Rates | Thrombolysis: Arterial and Venous - Scientific session
Major and Minor Complication Rates | Thrombolysis: Arterial and Venous - Scientific session
2016Angiodynamicsbleedingchapterclinicallycompartmentdilationembolisationembolizefull videogrowinghematomahematomasoccurredpatientsperforationsretroperitonealsbvSIRsyndromethrombolysisthromboses
Diagnostic Tests Without Risk Stratification | Diagnosis of DVT
Diagnostic Tests Without Risk Stratification | Diagnosis of DVT
2016Angiodynamicschaptercompressiondefensefull videopatientsproximalrepeatsbvSIRsoundstratificationtreatment
Results Complications Urinomas & Follow-up | Percutaneous microwave ablation of 100 T1a renal cell carcinoma: Short and intermediate term efficacy with emphasis on tumor complexity and mitigation of complications.
Results Complications Urinomas & Follow-up | Percutaneous microwave ablation of 100 T1a renal cell carcinoma: Short and intermediate term efficacy with emphasis on tumor complexity and mitigation of complications.
2016Angiodynamicsbiopsychaptercomplicationscortexfollowupfull videoimagingmonthsneedlepatientpatientsprocedurerecurrencesbvSIRthirtytumortumors
Disclosures  | Essentials: Anticoagulation - Categorical course
Disclosures | Essentials: Anticoagulation - Categorical course
2016Angiodynamicschapterdisclosuresfull videoguidelinessbvSIRthrombosis
Superficial Thrombophlebitis and Superficial Venous Thrombosis | Essentials: Anticoagulation - Categorical course
Superficial Thrombophlebitis and Superficial Venous Thrombosis | Essentials: Anticoagulation - Categorical course
2016Angiodynamicsanticoagulantchaptercriteriadosefull videoparadoxplaceboprophylacticrandomizedsbvSIRsuperficialthrombophlebitisthrombosisvenous
Conclusion and Questions from the Audience | Thrombolysis: Arterial and Venous - Scientific session
Conclusion and Questions from the Audience | Thrombolysis: Arterial and Venous - Scientific session
2016Angiodynamicsarchcardiologistscatheterschapterembolizationendpointfull videolyseperfusionsbvSIRspasmthrombustypically
Transcript

we're okay so some of this has been taken from the are you ready or y 90 course SR has in the winter I think we're gonna do that again this winter it's looking good it's designed to help people become an authorized user arm and if you do this I was really really

strongly recommend you try to become an authorized user it makes getting things done much more simple arm so when I see patients these are the things I worry about post radioembolization syndrome happens commonly I tell everyone to be

expect to be really tired for a week or ten days not have a lot of energy liver toxicity the liver functions usually come up and come back down about three weeks out radiation do sliver damages is a different kind of Beast will talk

about that Hillary damage is relatively uncommon secondary portal hypertension is basically some scarring of the liver from treatment of pneumonitis is the longshot that gets too high and this is what keeps you up at night is GI

complications or non-target embo most radiation post radioembolization syndrome has a relatively common thing I mean it's something you'll see in about forty fifty percent of people were there is fatigue nauseous they can have belly

pain not getting an ulcer just keep that in mind at the end of an infusion sometimes you will have acute abdominal pain on the table that usually settles out about 15-20 minutes but some abdominal pain

for a week or so afterwards is not is not uncommon and in all honesty if they have it longer than that i have a low threshold to get a scope to be sure almost all those patients do not have an ulcer but it puts your mind at ease

because you're going to talk about an ulcer before you can send them and it also helps you feel more common you know everything's ok and this was this should get better on its own arm as far as incidence and management of this arm the

standard treatment is a medrol dose pack which you can repeat one time if they are diabetic be very very careful this this the screws this blood Sugar's up unbelievably you'll take someone that

they may have the TV at that point cause of blood sugar 400 nevermind the radio Radio embolization syndrome so if that's the case i give it to my talents like a break glass in case of emergency set up the other thing they go home with from

us is a proton pump inhibitor which they start three days before the infusion not the mapping but the infusion and start keep they stay on it for about a month biliary complications are pretty uncommon this does not include abscesses

in people with Whipple's this is a study from Northwestern this is glass and you see great 34 liver toxicity is about 6.8 ten percent that's kind of what we saw Jefferson we studied this arm and this is this is actually our paper from

Jefferson where we had some kind of toxicity mean great one or higher this is of liver functions in fifty-eight percent of people we had about five percent rate of great three toxicities in the one rld patient most

of these people did normalize completely back down the baseline normal labs in average about three or four weeks again that might argue to wait six weeks if you have the time to do so let's really get their legs back under them as far as

the docks this is a little bit of a higher number than I would have expected i don't think it's the lice device-specific I think it's just one of those things but you know you know by llamas are not really

common in my practice I don't know if you've seen a Bilaam instance about ten percenter like that it seems a little higher what i see so not very common in our i have had a patient get cause you know that his gallbladder out and have

microspheres in it so that can happen just you know try to be careful that and this is an example of bio- this is from wash you with a big metastatic adenocarcinoma and went ahead and treated it and just an enormous bilo

machine bloating three weeks later otherwise no symptoms we actually drain this and it would not shut down there was a officially the doc they try to your CP sphincterotomy and it just wouldn't shut down so eventually

we actually put a catheter down through here made this into an external external internal external drain so she can at least be capped off and not have you know 400 500 CC's a day out through the tube Patrick fibrosis is something

Riyadh has been talking a little bit more about this year where several years after treatment you can see continued change the liver volumes this was first noticed in 2008 when they noted that if they treated the right side not the left

the right side tend to shrink and the left side grew and they also secondary changes of portal hypertension where the portal vein diameter would increase in the spleen volume increased as well I talked about patients came back to

clinic with society's why I would always take a quick look at their spleen binds make sure their spleens were rapidly expanding cause that's something I was worried about nobody in this original descriptive study had clinicals equality

portal hypertension meaning specifically bleeding arm that being said we can exploit this a little bit this is a patient with the right multifocal hepatoma was originally referred for your vein embolization and

talk to our surgeons and this is like right on the right portal vein hyland i thought maybe trying to kill the party really would make sense to try first and what we ended up doing was the right lobe

fore treatment the 1280 post so it decreased by 250cc volume and the left lane expanded was over 51 percent of the total liver volume afterwards this patient was then eligible for a

hepatectomy and you may have heard this described as radiation go back to me it's effectively what we did here to help get this guy set up to to get curative surgery pneumonitis I want that take

was it how long did that take I took about six months and you know i think if you want to just pop up if you want to I particular look quickly portal vein embolization still faster I don't want to falsely advertised

anything but this guy i thought this thing was going to go into his portal vein by didn't try to kill it and I thought that if it vascular invasive HTC is a bad actor and we'll come back really quickly

after surgery so that's how that decision was made there this is something that's kind of new we're still figuring out who's best served with it abstract session yesterday it seems like it like Mount Sinai for the htc's are

doing more radiation a lobectomy is because you're not me a chemo anyway in this erotic sex it's a little tougher to make the future liver and growth portal vein embolization whereas colorectal they're still doing portal vein

embolization everybody i think it's a pretty reasonable strategy Kevin tell you that lobectomy not not with already be okay our radiation oh I'm sorry so on the northwestern group with glass

microspheres it just for the record my practice is primary HTC gets their sphere glass microspheres Nets get service fears or resin okay that doesn't mean it's that's not the Bible ok you can do it is number of people doing any

different things so I don't want to think that's a that's me saying that's the only way should be doing that but that's what we do the northwestern group had a paper out this past year I think with a look at

radiational back to me so 44 therasphere your typical dose will be a hundred twenty gray that's your target does she do that over volume i'll go through in a few minutes for the radiation a lobectomy series their target dose to

the to give us a hundred eighty they did boost a little bit arm and I don't know how that was determined prospectively retrospectively this is like we get away with this they bumped it up higher island of the exact details of that but

they were jumping the dose of little bit when they did that so we at the end of a whiny mapping we do get a l.a inject ma the patient goes nooks for a luncheon fraction on the current to cemetery models are pretty much automated to keep

you from causing this problem on the maximum recommended doses are 30 greater treatment some people suggested you can go up to 50 gray over several sessions the the residences for ifu says that you want to stay 25 gray or less

this is a real going back and looking at the patients that they treated multiple times and found 58 patients who had gotten more than 30 gray cumulative dose and had followed chest x-ray CT is part of their cock illogic follow-up 15 had

some kind of pulmonary visible imaging change or abnormality but only clinically only great one toxicities were identified so you can possibly push this up a little bit higher again starting out you know be conservative

and then you'll get comfortable with the technology before before pushing too hard there's a couple techniques that have been described a decreased lung showing these are pretty much all anecdotal so

this is a really high lung shan fraction 29-percent where the UCSD guys did keep mobilization to decrease the long Sun fraction brought the patient back there still viable tumor and that but the fraction was down to ten percent

afterwards for the record when I do do the lung shan fraction i calculate the dose like I want to give it and I look at the exposure to log ok because if you're doing a segmental infusion and you have a 20-percent lunch infraction

doesn't mean the ones going to get 30 gray right because that the whole thing about cutting down based on percentages which you know some people do is to me to protect the lungs so check and make sure the lungs aren't going to get hurt

if they're not gonna get hurt and i think i need that full dose to have an effective treatment that's what I do you just know you're going to have maybe 15 is that 10 gray but neither of those is gonna hurt hurt the patient with her

locks so just keep that in mind this is a really interesting thing we're done by the australian groups where they put a balloon up in in in a paddock being that they were getting a territory they're refusing hoping the spheres would stay

put when they put the balloon up the longshot did Rob at preliminary nuclear medicine they were able to do it I'm gonna talk about not non-target his ulcer right this is where he ends up in the stomach or

duodenum on you know the second patient i ever did with this got an ulcer and it was miserable the guy end up with the judging ostomy catheter and it was a mess so really be careful the mapping study

to me is the most of the work for this you know I I tell occasions the mapping side be an hour to an hour and a half and diffusion should be like 15 to 20-minute each because this is where you put your sweat in so when you get to the

actual fusion you're not stressing out worried about what you missed something this is no historical with external beam radiation 40 greatest stomach but you know with us where were the microspheres getting there is a symbolic effect as

well remember that the arteries the right gastric in GTA they go through the serosa and penetrate down to the mucosa so you have to have a pretty good penetration day to get all the way down

to get an ulcer but once it gets there it's really tough to get rid of this is a proper paddock order paper this is not from Stanford this is a different program where they did infusions from the proper paddock artery and the right

gastric artery is very important to this comes off the left hepatic artery probably about thirty-five to forty-five percent of time so if you have an account for that right cast recording injecting the proper your-your-your that

could be very troublesome ok and this paper they had you know 29-percent ulcers in this in this patient group most of these were in the pre pyloric stomach which goes back to the right gastric territory this program shut down

their operations after this they did this the Qi State shut down they just recently started doing this again like a year or so ago in six years without the ability to do these procedures another paper with no routine immunizations done

and patience 3-series severe officers one of the things that's important on this is none of these people had positive post-procedure spec studies for the GI tract so to me arteria grams and the experts et's I get

on the table are the important the important part of this I don't rely on the news part of that the only thing the new study does for me is lunch infraction I do not rely on that for GI contamination arm GD

embolisation you know if you have to you do this is like earlier in my career I was analyzing everybody you want to take this thing all the way up to here this is before i was using detachments now I would stick a detachable coil on their

arm I used similar stuff than I i actually Mickelson usually from my base cap and put a no 27 microcatheter in and and four coils always pushing was to start 185 word fiber Pusha balls and then detachable we have a couple

different options on the shelf I don't realize the right gastric artery and everybody but if I am NOT I am very very sure where it is before I put y 90 the patient so this is one where comes off the proximal left hepatic artery

this is a common thing there's a we talked earlier about when do you analyze these patients i am realizing that mapping for this reason getting into this vessel like this can cause a lot of spasm it can be a real battle and then

at the artery spasm down you probably have a harder time pushing all your microspheres and the time of treatment and if you get stasis your risk of also goes up as a possible reflux so one of the things you'll see

you know if you injected vessel you're not sure if it's going to stomach or not you inject it you will see drainage into the portal system the liver doesn't drain the portal system so if you inject an artery and it comes back into the

portal vein it's going to the gut somewhere ok and you want to embolize is the key to this is my zhing it close to the left of paddock artery not if you realize it way out here and

outputting coils back here not necessarily doing the right thing this is off the GDA right off the traffic ation here this is another common spot to look forward to see I've heard it's called a Kurdish a defect we

see these arteries hanging off it again selecting analyzing not that big a deal this is a little tougher so when you have this kind of thing doing like a 270-degree curve sometimes there are some angle

microcatheter is now which will use a little bit if this is turning into a struggle i have a very low threshold to select the left gastric and just try to flop a catheter and wire around here I'll up if I'm gonna do something like

this i'll swap out to 1024 smaller microcatheter and this looks bad but it you know the guide where sometimes a path will just follow the path of least resistance and gets out there sometimes it's harder but once you get the wire

out you can actually put a bunch of it into the right a paddock artery that will help you get support to get your microcatheter around and go ahead and memorize this is the second case I ever did that I talked about and in 2015 it's

very clear yeah I look at this and in kick yourself now but I mean that I didn't think this was the right gastric artery the time I made a major judgment error in judgment on you know i usually get one expert CT

over the left lobe just to see if anything's going outside the liver to the stomach and the other thing is once a while there will be a small falciform you may not have appreciated if you're you know if you're working quickly so

this got filled up and this guy got messed up and this is his EG say bye to their still spheres in the stomach this was a mess and so I I'll tell patients in clinic and the neuroendocrine population were planned embolisation you

know probably just about as good if I'm worried about treating the left side and the right side is ok i might be why 90 in the right side blamed embolisation on the left I don't think that's that's in an

appropriate way to go armed as far as refluxing and ending up places where you're going to go this is an HTC patient you can see the right gastric artery here we can we map this patient we put our microcatheter all the way up

to this bifurcation point i injected this about three or four cc's of second when we do therasphere infusions and we inject you know pretty much slower net you want to do 320 see pushes over three minutes so it's a pretty slow steady

injection we did not have a drop of reflux during that and so I decided that we did not need to analyze this right gastric artery in and the the way I talk about this to my fellow citizens I call this the landing

zone you know if it reflexes really easily here you better do something about this but this guy if these things are so vascular and such as something just pulled everything out this is another patient this patient actually

got a wine glasses welcome to the HTC his right gastric here but you can see it's still filling with the microcatheter about where we want to put it in this segment for artery i do not do a lot of Interior liver

redistribution I don't know how well that works and there seems to be a little bit of magical thinking with that arm this was a tough angle we actually ended up this is a coil that I tried to push

in there my catheter flipped out so we brought this back and put a detachable in arm if I'm a little worried about where things going to end up all use a very short coil to start because if something bad happens with a two-minute

2 centimeter long coil it very very rarely will box you out from doing the entire procedure if you put like something 14 centimeters long like a like Nestor something like that in there and it pops out you may have just ended

the procedure the possibility that patient getting treated and this is the coming back we used to know 24 microcast and put some detachable xin here and we inject you can see the coils been there a week and a half and didn't cause any

problems whatsoever able to go ahead and treat sometimes you just got to know when to bail this is a segment two branch arteries to liver then you see these curly type torturous arteries up here later imaging

it looks like a navy stomach the stomach the liver doesn't go all the way up in the left upper quadrant like the stomach does so we called these off with a bunch of coils and doing this now i would start way way way out here and coil back

further and the patient came back for infusion week and a half later and it already collateralized around the coils was filling the gastric artery again I put some more coils and I went all the way

back to hear it was still collateralized we stop this is not this this guy's not getting 194 going to dosing is any questions in the last few minutes anybody somebody alright so I'm gonna give a couple

examples of dosing so just remember from my previous comment any previously i use resin / service fears from that's so that the for metastatic neuroendocrine tumor the things that go in the dosing gonna show you the form that we use in a

second which makes life pretty simple you need to know patient height weight you need to have a liver volume an infusion volume and the percentage of the infusion blind that's replaced with tumor so this gentleman each of these

little orange circles is a 100cc tumor so this gentleman is five 780 which does not exist in Nashville as a total volume ght love 1600 left loves 600 500 CC's tumor on the right 400 the

left need to know the luncheon for this as well get seven percent long shunned we're going to use the right lobe and then the left lobe six weeks later so this if you google smack smac surtex you will have this app pop-up which you

can put on your favorites or whatever and this is this is plug and fly ok so this guy's 5 foot 7 67 inches you guys hide his way total volume so if you want to see how much you gonna give total this is

totally vol nine hundred species 400-500 longshot fraction at one lunch infraction 7% estimated lung mass for every single person has not had lung surgery I put one kilogram some people ask if they've got COPD change that I'm

not smart enough to do that if they've had a pneumonectomy I you put it down 2.5 alright so the right side we're going to treat 1600 CC deliver 500 CC's a tumor and so we do this 2216 hundred 500 yet 1.49 get back rolls

ok that's right that's your infusion dose for the right side left lobe 600 cc's live performance these two more everything else same 0.65 gigabit girls which makes sense right so much smaller part of liver so what

you'll find from this when you calculate all this the BMI actually have is the predominant source of the dose on this more than the liver tumor blind you just mess around with it you'll see that uh next patients colorectal you can see the

values here you know that's not going to change this is someone who's had every chemo drug known to man ok launch Hakeem we talked about dropping dose on this so so I'm sorry so he's got to write arteries here one here

one here and the GDA comes off in between so what you can do with resin microspheres is will coil this off obviously but we infuse we're going to use this artery here and then want to take the dose it gets delivered comes in

23 get backers vile will split that into vials and this the second one's gonna get done right about here so these are the numbers right loves 1900 cc's you see the volume of each of these things I dropped the dose on on

this patient 20-percent this is anecdotal all right there was a survey paper like multicenter survey Andy Kennedy was on it reopens on it and they said a lot of the take homes that visits actually a consensus document how to do

this stuff and there's commentary in there that many people will drop those twenty percent in people with heavy chemotherapy pretreatment so that is on this app and when you enter that so we enter everything else put twenty percent

in here and it goes from on the anterior segment from 1.4 0.83 posterior segment 4.85 2.68 so this will drop that for you on there if you're worried for neuroendocrine have not had any chemo I don't do any dose reduction whatsoever

ok but when someone had all kinds of chemo breast cancer comes in they had 85 different regimens I i have a very low threshold do stuff now alright so are you calculating these volumes are you actually calculating

them individually are you estimating dividing land no she considers me a friend like you coming with volumes but uh but we have a CT tech that uh does a lot of the stuff for us just to show you pneumonectomy

cases metastatic lung cancer Robo six-foot-three 260 pounds left pneumonectomy see all the other volumes your high lunge infraction so this case is a couple other other features here

oops we're going to drop the estimated lung mass down 0.5 all this other stuff been entered the way we did before you'll see the total activity here 1.94 and there's a there's a little red highlight here it says the activity has

been reduced ok this the app here will actually reduce it for you to keep you from hurting yourself and somebody else this this equation let you calculate how much actually goes to the lungs not that I do

this for entertainment or anything but with this weekend with this dose we find that we get a total lung dose of 23.5 gray so that if you're a treat somebody multiple multiple times you probably want to know that just accumulate make

sure you don't go over a lifetime high dose but you know this will reduce the dose for you for a single infusion to make sure you don't cause harm 30 the thirties generally considered that the threshold

that's 30 / 30 great for treatment but 50 lifetime but yeah but the that's constantly evolving you know I mean so see let's do it let's go through so there appears a little bit different in that it's not about the volume of tumor

it's just about the volume of the liver that you're going to infuse and you want to give that liver us set dose to that whole territory to the theory being that the hyper basket tumor will suck up more of it than the non hyper vascular you

need to know the function fraction as well so one of the early papers on this from about 12 13 years ago the first 15 20 patients were treated with doses of 7505 gray next group retreat somewhere between a hundred ten 230 or 40 the

latter group had much better response so that's kind of where this hundred twenty great came from I'll talk about heavy dosing in a second remember you don't need to know the tumor going for this so I don't really

care what these represents so this is the plug-and-play version for glass microspheres and target volume that's your liver volume desired us around 720 x invariant central time zone so it's one hour lunch infraction of 4% it

anticipated ways it's a one-percent to fall just like put that for everybody and then you punch all this in you get different numbers so the way sir Spears is delivered comes in a vial the nuclear pharmacy will actually pull off the

appropriate amount for the bball that you then infuse their spears gets delivered on monday and sits on a shelf and decays to you get it to where you want it to be so you can do treatment you can technically treat money tuesday

wednesday thursday friday but you have to make sure it's got the right activity so if I'm gonna infuse a big right lobe I'm gonna want a lot of microspheres and that because otherwise i don't think i'm gonna saturate everything ok if i'm

going to do a very tiny subset metal fusion they want to read with your microspheres ok so by calculating this we found that we wanted to give an activity administration of three-point 64 gigabyte girls

ok so he's come in different sizes vials you have 3 5 7 10 15 20 and you can order custom so if i have a five-day Becker vile and it shows up I could infuse on monday at delivery and then I'll get me the right activities are

given my hundred twenty gray another alternative if it's a great big void that you're infusing it may be more appropriate to treat on a Friday so I do actually most of my infusions on friday why wait let it sit to the second we can

do it on monday of the second week I like having I want to have a lot of fears going to saturate the tumors because I worry that there's not enough particle sometimes this is I think it's my last case so you've heard president

talked about radiation second attack me the northwestern group talks about this this is where you only need a small infusion so they just 275 cc's a total liver and what book will boost the dose up on this to 200 gray or something

sometimes even higher just gonna make it work because it's it's a fraction of the whole liver point so you know I first became an authorized user the new Connecticut endings were double-checking my work and making sure his quality

thing which is fine i realized that i was getting rubber-stamped when I did a segment ACTU mean somebody got 320 gray to like a 150cc volume and all sudden after the case was over I got a panicked call from one of the nuclear attending

st. you really want to do 320 gray and I'm like yeah it's ok you know so thats that's when I realized that they were trusting me least up to that point so hope anyway same kind of stuff you see 275 cc's behind etcetera this is all the

same and we want to give 1.8 giga becquerels so doing this you know with a 200 200 great target you can see we can do a three go back well monday or tuesday but you see how this spreads out through the week where you can do a

second week treatment if you want to and and do it like the second weeks is this is just different ways to play with this it's it's probably a lot to absorb here in a workshop setting but really not that complicated once so i'll

stop here any other questions weren't we can go on the cabin slides and any questions they would get their face melted butter the the 14 sir texts called the smack out smec their spirit when you are

distributing have to get IRB approval for when you get that they will give you the excel spreadsheet show you calculate

In summary producing is...relation of...a real soccer sonoma has promising

...outcomes but up to fifteen, fifteen months of clinical and forty six months of imaging follow-up the declined india far was minimum and the mobility related to the operation procedure itself ...low your numbers can be avoided by using a tangential approach and avoiding direct puncture of the collecting system and,...of...include that as a single center study using one ...system and we longer follow-up.

Thank you I can take any questions...may... Yes, one question I have some a little bit confused as to what the term complexity means and how you ...yes so they really don't know from a tree score it's a standardized standardize of what it takes ...consideration is the size of the tumor the end of it like...it component

...units to the collecting system and then if it how close to the middle of the kidney it is so each one is given a number and then for the six is considered low seventy nine is moderate in above that is highly complex? So, we're using any treasury rover cooling of the questions...from ...interfering tumors were not. One thing I was curious about...wouldn't matter whether it tumor was a great for y which

can contemplate something like that. And, it displaying ...better question for fred but what I understand is that to myself as more complex if you miss just a little bit of it it's more likely to recur versus we've seen that if you actually don't have a complete margin with less complex tumors for some reason those tumors don't recur even if you don't the entire thing?

I'm going to do is summarize the guidelines have been some changes in a new version of the BTE treatment guidelines was recently published so i

thought i'd pull from that things that I thought we would all want to know either for taking care of patients or when we get home after flying to New York and our ankle is swollen so briefly i'm going to comment on several areas one is

superficial venous thrombosis and as I said this is going to be more guidelines than science but these are often what we're left with after the sausage making process goes so superficial venous thrombosis brief comment on compression

stockings for VTE cafe VTE what's new in the guidelines regarding DVT and PE and some comments about extended therapy from the guidelines so I think it's important for us to know what the guidelines are saying it because often

they lag behind the science or generate consensus opinions as opposed to

Ok, the next room,... be doctor ...rich. ...hurricanes microwave operation...one hundred...a real so carson always short and intermediate term efficacy with emphasis on tumor complexity and mitigation of complications thank you I'm ...capital medical student working with the relation team at the university of wisconsin. I have nothing to disclose my coffers may have a potential conflict of interest with related to new wave medical.

To start off...relation is eh he base their modality that kills tissues by heating it through a little temperature or...to radio frequency...heats temperatures faster. He says you faster into higher temperature. The objective of this study is to evaluate the early and...archaeological advocacy of microwave of relation for a hundred...proven to enable soccer sonoma with emphasis

...complexity and mitigation of complications. Our study is a single center retrospective studies done over for your time period ...patients had to any...online and all by fsix our biopsy proven meaning that if a biopsy was not done prior to the procedure or a patients by actually results are inconclusive they were excluded from the study. Of the operations are performed by radiologists with...nineteen years of experience.

For the procedure the patient...on a ct scanner a wide dorothy scanner under general anesthesia or deep conscious situation the seventeen engage gas called microwave probes were placed under ct and our and our alzheimer guidance the majority under ultrasound as the tumor size increased the amount the number of antennas we use increases while immediately post operation ...perform the ct a conscious enhance et to assess for to

suffer adequate margin as well as to assess for complications and all treatment intense ...curator of...done in a single session. Our data collection was fairly standard we also...the rena from adjacent score which assesses tumor complexity in our follow-up is listed as shown here.

we're talking about this surgical colleague of mine who like the surgeons like trophies so he fished this baby out

of this person's leg and posed it on the leg and recorded that and this is I i always put this slide in my talk this is obviously we're trying to prevent the post-mortem clot in a lung and this reminds me to make the point as we

contemplate treating our patients with dvt we're not treating dbt now you guys may when you do something like catheter directed thrombolysis but I never treat dbt I'm preventing the next one and it's important to remember that that's really

what we're about here with the treatment of VTE it's a prophylactic therapy so

extremity dvt how do you do with the investigations are sound diagnostic

criteria set usually proximal compression sound is the first morality and if there is compression or sound available we can compare it with the previous one that is suggested for us and if not you can do

d-dimer I say first and then do proximal compression or sound if that is positive the different findings including compressibility of the previously normal segment vain ordered an increase in diameter of the compost segment of the

weigh-in with a document promise if there is increasing the length of the trembles when compared to the previous on by five centimeters are increasing the diameter of the compressed Wayne x equal to or greater than four millimeter

then it's considered positive for reference and in recurrent dvt if the sound is negative we are supposed to do a serial testing in one week with repeat our sound are dude I'm are testing if the sound is positive then treat the

patients with anticoagulation and if the other sound is non-diagnostic but abnormal in recurrent dvt that is like if it is abnormal and the deep cut extension of the vein is like are the size of the main is not greater than 2

millimeters but less than four millimeters then you should recommend contrast monographie our cereal proximal to sound are possible d-dimer so these are all recommendation from the accp guidelines from the 9th edition which is

back into the fold this diagnostic part in patients with abnormal artists on findings in recurrent dvt if prior to sound is not available for comparison then again do of the contract monographie are d-dimer if the d-dimer

is negative no further testing is needed and if the d-dimer is positive then go ahead and do contract with toffee this is one leaf or recurrent dvt sounds a little bit busy and confusing but when you look through it

come quiet it it's pretty easy to

case a patient that had damn my pointer to there we go patient with the dip persists rai

closing the distance were visualized popliteal with runoff Peyton popliteal disc the very small intertrial single vessel posterior he'll run off to the foot after I family like therapy initially opened up this denotes an

underlying snow cesis this travis then is move distally can see poor run off display after 24 hours thermolysis very poor first distal flow with this significant distant like loosen the popliteal was just segmental filling in

the posterior tibial artery after i use the number English system we've removed all the thrombus within the popliteal and again open the anterior and posterior with a single vessel poster to run after the foot with no distal

embolization good feeling of the plant arch again a patient with a distal embolus to the popliteal artery complete occlusion and obviously a 2-0 can see the catheter in place as we're doing the suction from back to me with removal

popliteal thrombus and then opening up of the single vessel perineal run off to the foot this is kinda clot that we extract engaged and obviously remove can move a significant mark lot even in these

smaller vessels such as the popliteal in typical vessels gain popular conclusion section of thrombus set from the popularity as we move distally continue to have it is smooth and flawless and just a popular problem price

small table vessels with suction of the vacuum of those as well with zoom patency results pre and post from back

where amputations in 15 patients and the correct amis in 13 there were also seven pro Cedars surgical procedures because there they were our significant complications bleeding complications that should be treated surgically at 30

days there was one death associated with from bhalla an amputation in 15 patients representing 4.7 personalization amputation free survival was 95 persons at 12 months we have available data from 199 patients representing 87 persons of

229 with 22 amputations and a death that we are not associated with mechanical therapy amputation free survival was 85 persons major complications occurred in

316 constitutive patient's 302 hundred and three with a cute local industry Mia and 113 with a cute local in peace Khemia for mechanical debulking of

bypasses a auto iliac and femoral pto arterial segments use the rotor x catheter in all patients amount of actions of this catheter is mechanical fragmentation of occlusive material aspiration at its removal from vessel

ok mr. chairman ladies and gentlemen dear colleagues i will start my lecture with the question why mechanical endovascular removal of thrombi annamalai and the answer is that we believe that this way we can reduce mortality and morbidity rates associated

with surgery and thrombolysis in the therapy of acute and subacute ischemia of lower limbs the aim of this perspective independent study was to evaluate whether limb-threatening acute and subacute ischemia can be managed

without from policies or open vascular surgery from 2009 2015 we have managed

which is used to power a diagnosis of DP numbers which includes a non-contrast time-of-flight phase contrast imaging or it can be done with mr vinegar free using gadolinium contrast agent there is another less used technique discard as

mr derek traumas amazing techniques which can be useful in occasional cases when we are evaluating for dps thomas's full intensity of all the studies available is higher for the proximal DVD similar to ultrasound but it is higher

at 91.5 person and the specificity is 94.8 person it a wide ionizing radiation completely and can be used in patients who have contracts allergy and it can be used in patients who are pregnant it is more costly not readily available

in many places and it is time consuming

mechanical debulking cannot fully replace open surgery and thrombolysis in

the therapy of acute and subacute is keep me out of lower limbs mechanical barking used as an initial treatment can substantially decreased mortality rate in acute and subacute ischemia patient with therapeutic efficacy comparable to

thromboses and surgery and finally mechanical barking can shift open surgery and thrombolysis into the category of generative techniques thank you for your attention SI any questions from the audience think

i just got one question i'm in terms of the I guess the vascular injuries i guess is this device I don't you know is used over a guide wire and can you give us any ideas as to what vessels were injured when when that did occur i

gather that you were able to control in all cases but when injures what which vessel worker occurred and was it the size of the vessel you think or well well what is important this is that the rotrox cathegory is used in the vessels

with caliber larger than three millimeters and intra luminol passage of the guide wire and catheter is essential so if you are moving you know sub intimately you cannot use or if you believe that you are so intimately you

don't you cannot use it so in this case if you can do this you go straight to the soft relatively easy to the thoughts of the occlusion there are no problems usually between a very short moments you can clean nearly everything and the

problem can occur if you treat chronic occlusions highly calcified so and if if the lumen of the care of the vessel is about three millimeters and you use a french catheter so in this moment there is a not-so-good amount of the blood

running around the cavity to the rotating head and there may be a vacuum performed by the catheter with collapsing the vessel wall into the windows of the catheter and can happen that it's make their free but you know i

have to say that if you are familiar if you do it very you know slowly a normal way there are no company thank you very much i will move on to the next speaker who is the doctor yo Ruth whoa from australia sydney

australia who we talk to us about outcomes of endovascular treatment of basilar artery occlusion in the stent retriever era systematic review and meta-analysis

Baton car vessels before and after the therapy was open nine before and 1.9 in average after the therapy frequency analyzes has shown that majority of patients came without baton car vessels

with the number of patients with one two or three baton car vessels where nearly equal after the treatment we can see that there were only minority of patients without open cough vessel also ankle our index measured by diaper it

increased significantly significantly from opal one before the treatment to open eight after the treatment again frequency analyzes has shown that the majority of patients came without detectable referral pressures and with

ankle our index up to open for after the treatment we can see that majority of patients had inked alarm index higher than 0 point for acute ischemic symptoms

we're relieved in 182 patients representing 19 persons in a cute global

in peacekeeping operations and sub-acute limp ischemic patients mean clinical category improved from 3.8 you one point 23 it means in clinical sense something between rest pain to my qualification surgical no seeders the most frequent

has been a mainstay of therapy in both

acute and chronic venous disease for most of us took a big blow when the sox trial was published two years ago this was an attempt to randomize patients to either compression stocking therapy or placebo with to

prevent post-traumatic syndrome as you can see there was virtually no difference between the compression therapy group and the non compression therapy group specifically there was no difference in the occurrence of venous

ulcers the rate of recurrent plot the prevalence of valvular reflux at 12 months or quality of life measures so basically a resoundingly negative study there are some problems with it not the least of which was that the adherence

rate was was quite low I'm not exactly sure how you effectively remedy that problem both for patients and in a clinical trial so the new

talk about the what are the guidelines for the diagnostic part of the deep venous thrombosis and the current guidelines recommend against the routine

use of CT and MRI monographie in patients who have been suspected to the first time lower extremity deep venous thrombosis the use of CD NMR is considered if r2 sounds such as a public link large or if there is high clinical

suspicion with extensive unexplained swelling in the lower extremity so the recommendations are in a patients with suspected lower extremity DVD the first choice of diagnostic test process should be guided by the clinical

assessment off Rita's clinical probability rather than by performing the same diagnostic testing all patients

the second mechanical techniques we used was typical or classical aspiration thromboembolic t'me used in 123 patients representing 39 patients it was in 39 persons it was used to remove residue plots and interoperability of acute

occlusions and myocardial biopsy device was used to extract the recalcitrant thrown by an amble I short eccentric residues the noses in 26 patients the most frequently a hurry canalized target vessel was female population segment in

231 patient representing 73 persons of patients the others were bypassing different kind of bypasses in 75 patients auto iliac arterial segments in 37 stations deep femoral artery and thirty-two patients

target illusion was located totally on or partially in stand in 74 patients representing 23 persons mean occlusion lands was 23 centimeters and the caution of aqua target illusion was thromboses in 81 persons of manage populations for

you look again about fifty percent of those patients that were treated with a penumbra integral frontline only to me

two or three posted to go number into your treatment of from over eighty-one percent after intervention over ninety-five percent TPA and then use the number indigo again even slightly better results no significant change after

intervention with angioplasty and stent placement also as far as mechanical come back to me prior to remember again about the same with hundred percent perfusion post both usable for adjuvant TPM account therapies obviously these are

patients that we started out with those patients that we couldn't get lice we couldn't use a get other mechanical thrombectomy devices to use went to the number is the last ditch effort and obviously a hundred percent of patients

then we establish flow safety there was procedurally SI es in about seven percent of patients obviously none of those were device-related this is obviously a percutaneous arterial intervention vast majority of those four

hematomas at the site mostly in patients that are already previously had from political or other mechanical thrombectomy thermolysis so really none device related complications at all

What we found is that there was no significant difference in the number of or in the tumor types between the two groups? The tumor size was also not significantly different. And, the distance from the heart was difference different just based on the study design itself with the mean tumor size of only one point three centimeters from the heart itself.

The way that these tumors were approached was no different between whether they were located beneath...versus within the periphery of deliver away from the heart. Of both...number of antennas was approximately two the ...our and duration was not significantly different and as a result the ...size was no different suggesting that there's a negligible effect from the credit

heat sync on the tumor...volume and there was no significant cardiac or other complication within the group of tumors treated beneath the heart. Cardio-vascular alterations was also no difference between the two groups and there was no ventricular arithmetic that developed between the two groups during the procedure. Afterwards before the patient is discharge there was no it difference in number

of cardiovascular or human dynamic alterations while the patient was on the floor. And, there was no evidence ...patient developed...after discharge within the study period. Median imaging follow-up with similar between the group two groups and there is a low local tumor regression rate which was not significantly different. To case examples to conclude a sixty one-year-old woman with pepsi cirrhosis had a three-point-four

centimeter...segment to the lever as you can see just beneath the right atrium this tumor was approach that ultrasound guidance as we're ninety percent of the cases in ...study you can see the proximity of the antenna next to the right ventricle on the interprocedure ultrasound images and how...of castle approach was needed two position the probes in this position immediately after the relation you can see how the operations on ...the tumor...seven months there's no evidence of local tumor

...on the post...actual tone and the subtraction image? Ok, and, to concludemicrowave the relations beneath the heart can be approach the same technique as those tumors remote from heart associate with a similar low risk of local to our progression ...low-risk cardiovascular complications I'd be happy to take any questions. Coming up to the microphone please thanks.

...closeness tangential to the heart on all the cases or where they? Typically what we found to maximize the geometry that from the appalachian ...actually best point directly at the heart at the base of the patrick ...that way because you only have about with the probes we most commonly used ...have about three millimeters of the microwave field extending beyond

the tip so if you if you point at right at the base the heart within the tumor you can maximize the emission point opposition within the tumor and have a very low risk for...much beyond that? Would you do what you do these cases in...with pacemakers? Good question and we looked at our data to see if any of our patients had a pacemaker that we...plated and just by chance they had it but it would not serve

as an exclusion criteria for these cases so I have a case that some of the people in this room may have seen that with radio frequency appalachian I have a movie and as I turn on the our you see the heart slow down ...about thirty five beats something like that ...called the cardiologist and he said that he can survive with thirty so I did the... And, there have been papers that if compared microwave radio frequency impatiens that I've had

pacemakers one by...pushy and what they found is that with three frequency you certainly have to have a cardiologist...cardio cardiologist technician two-d activated for the procedure that certainly that there's, there's interference and that's study how they found that there was no interference microwave and, it's just based on basically the mechanism of heating and how there's probably? No, interference with microwave on pacemaker function so I don't think in our practice

we would consider that an exclusion...patient. Okay, thank you very much appreciate.

different adjunctive techniques like a PTA standings with 100 person overall technical success there was no pro

series of the open surgery to treat ischemia because it was not necessary or it was not possible also thrombolysis was not required to treat target lesions in 195 patients representing 62 persons of 316 they were present significant in

for popliteal lesions we have to use BTS and standing also aspiration and biodome extraction usually but also from bhalla in twenty-eight patients because of diffuse in tropical occlusion and that we're not we were not able to

remove by mechanical means number of

patients who are at high risk for venous stasis alteration again the co-op for b/c up five patients with pathologic perforators again they would undergo

ablation of those types of things what do we mean by ablation of them we mean ultrasound-guided vascular therapy for the perpetrators and of course the end of thermal ablations for the patients with infringement deep venous

obstruction again you have several options that have been described in the literature before again the evidence is fairly low it's only to see for most of these you have the option of doing a Venus bypass and awful back to me one of

the areas that were suggested against however in patients who have deep venous insufficiency the guidelines went against deep venous ligation for patients with in changes were felt to be high risk for ulceration of war with

open alteration of the again Venus Dale repair is also entertaining and suggested in the guidelines however is only to see and also Venus transposition or transportation was also suggested there are a whole variety of

techniques that have described with repairing veins or doing autologous valve substitutes and again these are suggestion patients with c4 be up to c6 classification for iliac vein stenting

treatment we use ate french rotor ex-captain through from insulator approach in Boston majority of patients and the mean number of rotary expanses was 3.4 and monroe directs activation time two point three minutes

The Barking alone resulted in recanalization in all target vessels in fifty-two patients without residues two noses in 138 patients with residue diameters the noses between 0 to 30 persons and residual mean diameters the

noses was 39 persons mean length of residual stenosis for 3.8 centimeters

a traumatic versatile system shown to be

safe and effective in the removal of thrombus in the peripheral visual material inclusions successfully achieve a civilization as we said in 96.5 percent with just aspirated to go up or penumbra aspiration only almost ninety

percent of patients we established a commuter to me three flow also effective obviously in those patients that we failed with initial thrombolysis from and Kendall throwback to me i was able to use it as I said started out as a

secondary procedure done really to a primary procedure as I said fifty percent of those patients where user frontline are used safe we had no device-related serious adverse events go through a 6 or possibly need French

percutaneous Eve much like we do in these patients are been on exposure thrombolytics overnight hospital stay things that increase the complication rate of the growing conclusions that it

guidelines actually recommend against the use of compression stockings and

acute dvt caffeine clot and this is actually one of the most common cause i get from colleagues about themselves and specifically i can't i have run out of fingers when i try to count the number of colleagues who come home from and

actually the worst was not the length of trips to conferences but I think there's a high correlation between participation in the study section at the NIH and the incidence of class that one of my colleagues not only spent two days

traveling to and from but ends in such isolation and with such lack of movement for the days that she was there ended up with a caffeine dbt and so the question often comes up in healthy people healthy active people what do you do for this

the guidelines say that if it is isolated and of course thing one is that must be a complete imaging study done because there's at least a 15-percent can confident their attack readiness clot

presents so but if it's isolated to the CAF and there no severe symptoms or risk factors it's perfectly reasonable to treat with symptomatically but imperative that you get repeat imaging if you do the guidelines specify that if

the symptoms are severe or their ongoing risk factors and I think that's the most important thing then it's probably a reasonable to go ahead with anticoagulation and I tend to think of patients based on provocation if I can

identify it and the presence or absence of ongoing provocation or risk factors specifically the risk factors that the guidelines bailout are that can help strat risk stratify a patient with isolated caffeine dbt as a positive

d-dimer extensive amount of Claude if it's superficial as i said or proximity to the saffron ephemeral junction again whether there's some other ongoing risk factors such as in mobility or limit mobility active cancer or history of VT

these are all risk factors and obviously hospitalized patient is a different patient and has an ongoing risk for clap so so I wanted to touch on some of the

These are disclosures. So, per case microwave operation...a steps treatment option for both malignant and benign liver tumors as we know it's used as a bridge to liver transplant

this...population it's also affected for the treatment of I'll go magnetic disease deliver it's even been shown to be useful for symptomatic command geometry and... However, it's use beneath the heart in the liver dome has not been well-studied for instance is there a risk of cardiovascular complications related to appalachian in such close proximity to the heart and is the year

...risk of a decrease in ...own volume related to the extensive heat sync provided by the heart of this result in a higher risk of local to...progression? Therefore the purpose of this study was to evaluate the complications ...of pertaining simulation of these tumors located beneath the heart. To do this we did a retrospective analysis over

a five-year period and all peripheral microwave regulations so we defined a peripheral live regulation as one that result in ...extending to five millimeters or less from deliver capsule. From this population those ...which extended to five millimeters or less from the heart procedure imaging form the study group.

Whereas remainder formed a control group. There was no difference between the two groups in mean patient age or gender ratio or in the number of patients who had a pre-existing a rhythm our ...induction disorder such as a bundle branch block. What we did is we first noted histology of the tumor that was avoided? We measured the tumor size based on procedure imaging using recessed one-point-one criteria.

And, we also measured a...on size that followed each... Next we measured the outer contour of the enhancing tumor or in cases of hyper vascular tumor correct on that for instance the edge of the tumor itself from the enhancing mile carting them. We also review the procedure notes to determine how many antennas were used the our

and the duration that they were run and the distance between the heart and the antenna tip. These cases are performed with anesthesia who throughout the procedure monitors the patients cardiac rhythm and ...also obtain vital signs routinely we use these records to determine if an arithmetic...during the procedure and also the number of episodes of any sort of cardiovascular alteration whether it's a sinus

...pretty card hyper hypertension between the two groups and then after the procedure when they were admitted usually for an overnight ...before they were discharge we reviewed the nursing notes to determine the frequency ...cardio-vascular alterations between the two groups which are typically more but patients so cardio-vascular fluctuations aren't uncommon.

11 patients representing 3.5 persons there was one day you to interest arable

bleeding and thrombolysis significant bleeding growing hematomas and retroperitoneal bleeding and compartment syndrome in three patients minor complications occurred in fifty-nine patients most frequently peripheral

embolisation in 40 but fortunately all of those embolize were removed by mechanical means during the procedures they were also six RT perforations related to rotor ex that were treated by long-term balloon dilation or by

implementation of colored stance clinically insignificant growing hematoma thromboses compartment syndrome MERS occurred in 36 patients conclusions

some patients you can't do the risk stratification sometimes and it's not available to do the dimerization stuff in those patients approximately our compression of the sound is done over

other tests such as contrasted another fear d time or are more amazing if there is a negative proximal compression or sound then you go ahead and do a d-dimer and repeat proximal to sound and appropriate patients in one week our

whole Lake are sewn in that order of preference if the proximal to sound whole leg is positive then go ahead and created if it is past 21 leave for this to DVD repeat in one week to look for propagation of the defense tumbles over

treatment but in some patients they would straightaway prefer to go for treatment of their lotus for reading

Here are patient characteristics now that we had a fairly morbid population as well as a high...the tumors are also fairly complex with fifty

...being moderate to highly complex and you can see here that the decline india far was insignificant. Technical success. Was a hundred-percent and cancer specific survival...also ...hundred-percent with no evidence of medicine attic recurrence...any of our patients today. We experienced eleven early complications according to the

craving general system which are within the first thirty days ...procedure three the three involved were directly related to the procedure majority of...the main the bad complications where due to patients core abilities, for example, this patient had a stroke seven days after the procedure but he had past history of stroke and number four shows my according on...twenty three days ...procedure in a patient with severe coronary artery disease.

We did have six-year ...that were detected incidentally I'm followup more than thirty days plus procedure three which were associated with critical atrophy. Here you can see that all technique that we use the probes... Too deep into the collecting system and actually penetrated into the...sinus. You can see here.

The...the ...extends from the real sinus through the cortex into the pairing of space and this allows for the...to leak through in accumulate. And, twenty four months follow-up imaging ...the situated sequence you can see the enormous running the kidney...in the ...the prince you can see this completely the vascular...tumor...the year...is surrounding it.

Here's another example with the probes pointed toward the...here...not penetrating the sinus. So, although we don't like to do this anymore this is nap associated with your ...additionally if you coming from a tangential approach in the brain extends into the collecting system this also was not associated with your enormous. However, to avoid that we now use... here we come from the side and since we implemented this

...twenty fourteen we have no...enormous today. So, showing that data when the...pointed...collecting system? And, physics humor's six of the patients...whereas when we use the tangential approach zero percent of the patience of our tournaments with the same tumor complexity. Here's our follow-up we have nineteen months nineteen months of clinical follow-up with sixteen months of imaging follow-up we had one local team

regression and this was in a patient ...a needle biopsy was permitted to he was ...follow-up and came back we sell local recurrence so he went ...radical...me an x plants histology was graded as affirming great for which is an aggressive tumor that we normally do not like to a plate so due to the needle biopsy sample we probably it probably was

a it was affirming great for to begin with and this is a two-minute initially went to a plated so that accounts for the local recurrence most likely. Primary patients pass away due to conditions not related to the relation itself, for example, one patient died of an mri another gi ...another of subsets. Giving us...cancer specifics, specifics survival of a hundred-percent.

You can see are certified patient follow-up we have thirty six patients with less than one year of ...follow-up...with thirty, thirty six month of imaging follow-up sorry excuse me thirty six patients with one or two years of imaging follow-up twenty with two to three and six patients with greater than three are continuing to follow up all these patients are...our follower term.

this case so now we're going to go from the sublime to the ridiculous you've heard from three great scientist to real experts in thrombosis I'm a health services researcher and I was asked to review the guidelines and as we all know there's an interesting

process that occurs between the science like you've been hearing about in the development of guidelines but as with the FDA process that Jeff alluded to it's a little inscrutable these are my disclosures and I i do in talking about

dou X we do sometimes talk about off-label indications but mostly what

superficial thrombophlebitis there's this randomized trial in the new england journal now about six years ago the inclusion criteria were people who had a

superficial plot without any deep think lat but the clot had to be of significant size the entry criteria was five centimeters and a low dose of fun the paradox compared to placebo was associated with significantly improved

outcomes the guidelines based on those data suggest that patients with superficial venous thrombosis that is significant in length or and or near this afternoon ephemeral junction is probably best treated with a

prophylactic dose of anticoagulant and they go on to actually express a preference for found a paradox over low-molecular-weight heparin in this

works obviously uses we use it

throughout multiple vascular beds also significant improvement and Timmy scores when compared to other previous treatments and obviously safe study was a multi-center single arm and one complaint may be the end of not to

intubate core lab adjudication of the Gimme Falls that we're kind of the institution level thank you any questions yeah I actually have a question so I mean there's not a lot of cardiologists

in the room people aren't all that familiar with Timmy flow but you categorized the successes is Timmy to timmy three but I think in the cardiology world most people say your goal is really to me three

not to me too so and it's a relatively subjective the endpoint how did you guys decide to go with 23 as opposed to just three flow and do you think most of them were more towards the three side or more towards the TV to most of three and

actually that's a good way because we have this conversation frequently because there's no way good system at this point to measure removal of thrombus and it really is as we all know they're all 20 mean they're included

they're all from boast we really don't quit until we get to timmy three you know Timmy to is not acceptable and again it's not a very good system to compare to the periphery it's much more a cardiac with decreased peripheral food

perfusion we used it obviously as best we could the vast majorities obvious to me three because in the arterial bed we really want to move all the thrombus we possibly can including those cases that I said so

typically wouldn't stop until we got pretty much everything there's a 305 french catheter so really if we have a distal embolization just like I showed in the previous letter cases we go chase that into the plant

arch because these catheters will go away to the planter arch and just one of the real quick question at just a curiosity really the from back to me portion of your procedure do you have any sense of approximately what the

average time was from starting the throne back to me to finishing we talking minutes or hours minutes from back to which is one reason why i typically went to frontline first line with the throne back to me it's very

easy to put a multi-site whole infusion Catherine and get the patient on the table and send him upstairs to lyse procedural time over relatively short however they're also coming back and also give those phone calls all night

long that they have a blini tama you know they have hypertension I can't lay flat have to put a fully Catherine that he materia all those things go away so typically one of my reasons to use it is because i can actually suck all the clot

out i can be done i can do my intervention and oftentimes these patients aren't overnight at all the hospital also likes that because it's much cheaper to be able to do a single set and in

put these patients in the ICU or intermediate care unit where you have to do thermolysis great thanks very much i think was very adamant use i don't typically this is relatively a traumatic and this is really based on what we used

to use the birds still use in the brain so I really rarely see any a reason spasm even currently using a french it's called the cat ate even with a relatively large we really don't even with the separator which we generally

talk about really see any spasm thank you much

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