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IVC Filter Strut Migration (Heart)|Sternotomy, Pericardiotomy||Male
IVC Filter Strut Migration (Heart)|Sternotomy, Pericardiotomy||Male
2016cardiacconsultfilterforcepsfragmentsintravascularpatientpulledretrieveretrievedsheathSIRstrutsurgeonultrasound
Q&A Pulmonary Embolism | Management of Patients with Acute & Chronic PE
Q&A Pulmonary Embolism | Management of Patients with Acute & Chronic PE
acuteangiogramassistedcatheterchapterchroniccontrastdiagnosticechocardiogramembolismisisNonepressurepulmonarythrombolysistreatmentultrasound
General Screening Criteria (specific to bleeding risk) | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
General Screening Criteria (specific to bleeding risk) | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
acuityalertanticoagulantanticoagulationbiopsybleedingcardiacchapterchartdysfunctionhematologicalhistoryhypertensivelivermedicationsNonepatientpatientsplavixprocedureprovidersradiologistsriskstablestentthrombocytopenia
Practice Guidelines | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
Practice Guidelines | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
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Rheolytic Thrombectomy | Management of Patients with Acute & Chronic PE
Rheolytic Thrombectomy | Management of Patients with Acute & Chronic PE
angioangiojetarrhythmiaaspiratebradycardiachapterclotdevicehemodynamicheparinizedlysisNonepatientsuctionthrombectomytpawebsite
Treatment Options- CAS- Embolic Protection Device (EPD)- Distal Protection | Carotid Interventions: CAE, CAS, & TCAR
Treatment Options- CAS- Embolic Protection Device (EPD)- Distal Protection | Carotid Interventions: CAE, CAS, & TCAR
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Treatment Options- TransCarotid Artery Revascularization- TCAR | Carotid Interventions: CAE, CAS, & TCAR
Treatment Options- TransCarotid Artery Revascularization- TCAR | Carotid Interventions: CAE, CAS, & TCAR
angiographyangioplastyarterybleedbloodcalcifiedcarotidchapterclaviclecommondebrisdevicedistalembolicembolizationexposurefemoralflowimageincisioninstitutionlabeledpatientprocedureprofileproximalreversalreversesheathstenosisstentstentingstepwisesurgicalsuturedsystemultimatelyveinvenousvessel
UFE and Adenomyosis | Uterine Artery Embolization The Good, The Bad, The Ugly
UFE and Adenomyosis | Uterine Artery Embolization The Good, The Bad, The Ugly
accessadenomyosisarteryaxisbifurcationcardiaccathetercatheterschaptercharacteristiccomplicationsdiameterdimeembolizationfemoralfibroidfibroidshematomahydrophiliclabsNonepatientspracticeradialsheathulnaruterine
Introduction to Establishing Periprocedural Screening Guidelines to reduce bleeding risk associated with Image-Guided Theraputic and Diagnostic Procedures | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
Introduction to Establishing Periprocedural Screening Guidelines to reduce bleeding risk associated with Image-Guided Theraputic and Diagnostic Procedures | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
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Treatment Options- CAS- Embolic Protection Device (EPD)- Proximal Protection | Carotid Interventions: CAE, CAS, & TCAR
Treatment Options- CAS- Embolic Protection Device (EPD)- Proximal Protection | Carotid Interventions: CAE, CAS, & TCAR
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Therapies for Acute PE | Management of Patients with Acute & Chronic PE
Therapies for Acute PE | Management of Patients with Acute & Chronic PE
anticoagulantanticoagulationcatheterchapterclotcoumadindefensesdirectedheparininpatientintermediatelovenoxNonepatientpatientsplasminogenprocessriskrotationalstreptokinasesystemicsystemicallythrombectomythrombolysisthrombustpa
Renal Ablation | Interventional Oncology
Renal Ablation | Interventional Oncology
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Cone Beam CT | Interventional Oncology
Cone Beam CT | Interventional Oncology
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What's Next | AVIR CLI Panel
What's Next | AVIR CLI Panel
analogangiogramchapterclinicaldecreasesdistensioneffusionembolizationembolizedembolizingenrollingimagekneemedialmicronMRIpatientpatientsrandomizationrespondrespondersstudysynovialupsize
Indirect Angiography | Interventional Oncology
Indirect Angiography | Interventional Oncology
ablateablationablativeaneurysmangioangiographybeamBrachytherapycandidateschapterdefinitivelyembolizationentirehccindirectintentinterdisciplinaryischemiclesionographypatientportalresectionsbrtsurgicaltherapyvein
Ultrasound-assisted Catheter-directed Thrombolysis | Management of Patients with Acute & Chronic PE
Ultrasound-assisted Catheter-directed Thrombolysis | Management of Patients with Acute & Chronic PE
catheterchapterekosfibrinNonerequiresstudiesthrombolysisthrombustpaultrasound
Q&A Uterine Fibroid Embolization | Uterine Artery Embolization The Good, The Bad, The Ugly
Q&A Uterine Fibroid Embolization | Uterine Artery Embolization The Good, The Bad, The Ugly
adjunctiveanesthesiaarteryblockscatheterchapterconceivecontrolembolizationfertilityfibroidfibroidshormoneshydrophilichypogastricimaginginabilitylidocainemultiplenauseanerveNonepainpatchpatientpatientspostpregnantproceduralquestionradialrelaxantsheathshrinksuperior
Percutaneous Mechanical Intervention | Management of Patients with Acute & Chronic PE
Percutaneous Mechanical Intervention | Management of Patients with Acute & Chronic PE
catheterchapterclotmassivemechanicalNonepatientpatientsPig Tail Catheterpigtailpulmonarysurgerythrombolytictpa
The Ways to Recanalize the Below the Knee Vessels | AVIR CLI Panel
The Ways to Recanalize the Below the Knee Vessels | AVIR CLI Panel
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Q&A- Procedural Sedation | Procedural Sedation: An Education Review
Q&A- Procedural Sedation | Procedural Sedation: An Education Review
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Balloon Pulmonary Angioplasty | Management of Patients with Acute & Chronic PE
Balloon Pulmonary Angioplasty | Management of Patients with Acute & Chronic PE
angiogramangioplastyarteryballoonballooningbandschaptercomplicationscontrastflowHorizonimageimagesluminalNoneocclusionocclusionspatientsproximallypulmonaryradiationrecanstenosisthrombustreatedultrasoundwebs
CTEPH Studies | Management of Patients with Acute & Chronic PE
CTEPH Studies | Management of Patients with Acute & Chronic PE
acutearterieschapterchroniccpapedemainterdisciplinaryjapanmultidisciplinarymultipleNoneoperatorspatientpatientsperformedpulmonaryreperfusionrequiringthrombolysistreatedtreatmentvascular
Systemic vs Catheter-based Thrombolysis | Management of Patients with Acute & Chronic PE
Systemic vs Catheter-based Thrombolysis | Management of Patients with Acute & Chronic PE
bleedingcatheterchaptermilligramNonepatientpatientsperiodriskslowersystemictargetedthrombolysistpaversus
Programming for MRI  | Demystifying (Cardiac) Device Monitoring for MRI Studies: The Expanded Role of Radiology Nursing
Programming for MRI | Demystifying (Cardiac) Device Monitoring for MRI Studies: The Expanded Role of Radiology Nursing
beatscardiacchamberchapterdeviceimplantedinhibitmodeMRInativenomenclaturepacepacingpatientpositionrateresponserisksventricle
Diagnostic Criteria for CTEPH | Management of Patients with Acute & Chronic PE
Diagnostic Criteria for CTEPH | Management of Patients with Acute & Chronic PE
angiogramangiographyarterialarteriesarterycapillarycatheterchapterclassificationcurativediseasedistalflushlobesmanagementmedicationNonepatientpatientspressureproximalpulmonarysegmentalsheathstenosissurgeonsurgicalthrombustreatedtypevesselswebswedge
Endovascular AVF creation | Twitter Case Files SIR 2019
Endovascular AVF creation | Twitter Case Files SIR 2019
6fr venous WavelinQ magnetic catheteradvanceadvancesalignarterialbrachialcatheterscenterschaptercreateselectrodeembolizeendovascularengageFistulainsertmaturationpatientpatientsstepultrasoundveinvenavendors
Scope of IR Procedures in South Africa | South African Interventional Society (SAintS)
Scope of IR Procedures in South Africa | South African Interventional Society (SAintS)
biliarycardiologistscenterschapterinterventionalInterventionsneuroparacentesisproceduressurgeonsvascular
Why is the Capnography Reading Abnormal- Physiology | Respiratory Compromise: Use of Capnography During Procedural Sedation
Why is the Capnography Reading Abnormal- Physiology | Respiratory Compromise: Use of Capnography During Procedural Sedation
abnormalairwaybaselinebloodcarboncardiacchapterdioxidefeverhealthykrebslunglungsmetabolismmismatchmonitorNonenormalpatientpatientsperfusionphysiologyproducingpulmonarysedationshunttrendsvaluesventilation
Education Strategies to Reduce Human Errors | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
Education Strategies to Reduce Human Errors | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
activeaneurysmangiographybostcerebralchapterchecklistclotconcurrentcontraindicationcontraindicationsdistallyembolizedguidelinehemorrhageheparinisismilligramNonepatientphysiciansstandardstentstentingstentsstrategiestemplatetherapeuticthrombolysistpa
Aspiration Thrombectomy | Management of Patients with Acute & Chronic PE
Aspiration Thrombectomy | Management of Patients with Acute & Chronic PE
angioAngiodynamicsAngiovac CannulaAspirex CathetercatheterschapterclotdevicedevicesfrenchIndigo ThrombectomyNonepatientPenumbraPenumbra Inc.sheathStraub Medicalthrombectomythrombustpa
Transcript

this is a case where we retrieved this filter and as you can see I'll go back to the initial image there is a fractured strut here, and as we were going along the strut moved. So clearly not adherent and in the course of the case we got the filter out and the strut is now in the RV.

So we talked about cardiac surgery. We made our best effort to get this out and we couldn't so we obtained some imaging. And I'll skip to the images it's the most relevant which is this strut is in the tricuspid annulus and milliliters away from the right coronary artery. >> Sorry show [INAUDIBLE]

>> So now let me ask the question. This was a young patient under the age of 30. Had a filter placed for prophylactic reason. We see the strut, and your cardiac surgeon says I think it's okay, let's leave it. >> [LAUGH]

>> Which is true. >> Which is true this is exactly what happened. What would you do next? Find a different surgeon? I'm glad we agree on that. Now in the cause of this case.

The patient actually become symptomatic. They developed sustained SVT. So this patient went to the OR. [BLANK_AUDIO] I'll get my mouse here. There it is. >> What happened to the first surgeon?

>> That was the first surgeon. He called me at night to make his case and I said well I just received information from the cardiologist that this patient now has an arrhythmia. He's like okay, I'll take it up tomorrow. >> I think Kush deserves a lot of credit here,

the surgeon it was a day or two before they even sought in a consult, we tried calling them they weren't calling back, they never returned the pages.

Then they came by the consult was just leave it alone. But there were a little SVT here and there wasn't an ongoing thing but he was able to convince them to proceed it was more than you staying there looking over the patient than really looking to do it. >> [INAUDIBLE]

>> Yeah. >> [INAUDIBLE] >> What about using intravascular ultrasound [INAUDIBLE] >> Intravascular ultrasound or echo? >> [INAUDIBLE] >> Interesting thought.

One of the things when we tried to retrieve it and I'm not sure how many of you have tried to retrieve foreign bodies from the ventricle, I certainly don't have a lot of experience but there's a lot of structures there cordis, trabeculae, all of which can't be seen.

>> It was clear to us pretty early on that we were in over our heads with our standard techniques. We sort of escalated things when this happened. We got anesthesiologists come in and they actually were there monitoring the patient had everything they needed. And we briefly tried but opening up the snare we would get arrhythmias not really certain

what we were grabbing with the snares. It didn't take us long to realize that we shouldn't be doing this and we needed a consult that wasn't us now. Intravascular ultrasound is an interesting idea. We don't have a ton of experience at our institution with it. We could have considered it but I think the young patient that could

handle this surgery, I think that was probably the right way to go. >> I think that's an interesting question, whether you use an ice catheter or if you do transesophageal even, you get one of your cardiology colleagues to come and drop a scope and take a look that way. That's

an interesting idea. Again I'd be extraordinarily nervous about pulling a strut out of somebody's heart. If things go wrong, there's an existing dare I say standard of care here that a cardiothoracic surgeon would remove this fragment. And so I think

you're kind of matching off the reservation a little bit, I think you need to be aware of that. >> [LAUGH] >> Yes? >> The only time I've ever actually retrieved some thing from a ventricle [INAUDIBLE] The surgeon was there.

>> Yeah. >> We got it our successfully with no problem. But every time I pulled [INAUDIBLE] goes what are you doing? [INAUDIBLE] You gotta be prepared. >> I think we're gonna be done pretty soon. I just wanna make one other comment or plug for tonight. I think Cliff Vice from Hopkins with the bariatric embolization

he's gonna be on NBC Nightly News tonight and it sort of plugs the meeting that the results are gonna be done here at the SIR. So those of you who have a chance to see that and show your colleagues and it's pretty exciting for us. I'm sorry. Go ahead.

>> [INAUDIBLE] >> Just to get to the point, interesting thing is we took the filter out and the piece was there. The piece, showered it embolized while we were trying to get it.

It didn't happen at the same time. One of the things we've debated is what is the best tool to go after these fragments? Now they're not usually just free, this one did move a little bit, but many times they are somewhat embedded.

We have often used forceps, but we've also used a snare. We've debated as to what is the best and maybe other people can comment the best tool when you have these fragments like this. Is it a forceps? Is it a snare?

We've had another one it went along. And one of the things we pulled out, that other one he showed, the one that went to the lung, we pulled it, we saw it in the sheath. One of the things that we're using are these bigger sheaths. We hook them up to a pressure bag,

we run saline through them. And we were wondering if potentially if it would let go of it on the accident, or it came free in the sheath and the pressure bag was able to allow it, the flow was what pushed it back into the into the IVC, we're not sure.

Again, if people have any ideas as to which is the best tool, forceps, snare, something else in terms of taking these fragments out I'd love to hear that. >> Is there a question over here? >> Yeah, the question about once you have the forceps on [INAUDIBLE] >> Generally I think the way

all of us do it is, once you grab it you leave the forceps stationary and you let the sheath try and do the work. You don't try and move it too much lest you let go of it while manipulating it. Would you agree with that? >> Yeah.

You kinda just stabilize things with the forceps once you've got the hook or whatever it is, just push your sheath down over it. So it's like you're trying to capture the filter inside the sheath but not really pull the filter into the sheath. Does that answer your question?

happy to take any questions or in

ultrasound we don't usually use contrast but one of the procedures were doing for the treatment management of a pulmonary embolism is the ultrasound assisted Rumble Isis do we need contrast so for the thrombolysis is the catheter itself

so you still need to give contrast two to do the procedure but while the catheter is running you don't need to give any contrast four for that is that what you're we don't usually use contrast for ultrasound but

all right when you're treating how will you know that it sliced the clot is less what you frequently do is check the pressures so that catheter allows you to check the pressure and so once you start a patient so you do a pulmonary

angiogram which requires contrast and you put the ultrasound assisted thrombolysis catheter in the eCos catheter then after 24 hours or 12 hours you can measure a pressure directly through that catheter and if the

patient's pressure is reduced you don't have to give them anymore injections yeah and if we are using ultrasound for treatment is it possible to do it for diagnostic purposes No so not for non the prominent artists for

diagnostic imaging unless you're doing an echocardiogram which is technically ultrasound in the heart but for treatment otherwise you need you will need to inject some dye oh thank you

hi I'm Katrina I'm NGH I have one more question okay for your patients with chronic PE do most of them begin with acute PE or if they very separate sort of presentations that's that's a great question so all of them

had acute PE because you can't have chronic without acute but a lot of them are not ever caught so you'll have these patients who had PE that was silent that maybe one day they woke up and had a little bit of chest pain and then it

went away couple days later they thought they had a bronchitis or a cold and then you find out five years later that they had a huge PE that didn't affect them so badly and then they have these chronic findings they usually show up to their

family practice doctor again with hey I just can't walk as far as I can I have a little heaviness they rule them out from a heart attack but it turns out that they have CTF so you you all of them had a Q PE but it takes a lot of time and

effort to find out whether they truly have chronic PE so it's usually in a delayed fashion thank you all right well thank you guys again appreciate it [Applause]

guys do so when we do our screening phone calls and our pre screens before

the actual procedure there's a few factors that we look at for the patients with blood pressure the patient needs to be vitally stable before we do a procedure there may be a slightly increased risk of bleeding for kidney

biopsy if patients are hypertensive although it hasn't been noted to be statistically significant in the literature so we are always aware of patients being hypertensive we do want them to be taking their medications the

day of the procedure we also do a full medication reconciliation with the patient making sure that we're checking on any anti platelets anticoagulant medications and we have a list of our hold times that we use for a reference

we already discussed for those of you who are at this session this morning the issue of liver disease is it stable liver disease they may have adequate he stasis even though their INR is not within the normal range and so we

recommend a stable INR of less than 2.5 for those patients and in our practice a lot of the providers are going away from correcting the INR s for our patients we also screen for hematological disorders do they have some known condition that

makes them more likely to bleed or conversely more likely to clot and that may factor into whether or not anticoagulation can be held do they have a current diagnosis of cancer are they going to be getting one of those

angiogenesis inhibitors might they have thrombocytopenia and we just do a brief review of the patient's chart before we call them to kind of look for those diagnoses do they have a history of bleeding especially if they have no one

platelet dysfunction you know a known history of bleeding can be a reliable predictor of bleeding risk for some patients and do they have a cardiac or a neurological history as we learned this morning patients that have recently had

a cardiac stent placed we can't just say yeah stop your plavix hold off 5 days it'll be fine that could be a very serious risk to the patient did they recently have a stroke have they had a PE why are they on their anticoagulation

if they're on it so we really need to be aware of the whole patient and having that pre-screening phone call with them can allow our nurses to figure out a lot of these problems and then alert the radiologists and try and troubleshoot

before the patient walks in the door and says yeah I took my warfarin this morning I'm all ready for my liver biopsy the radiologists don't like that much in it you know it's really a bad thing for our high volume area to have

that happen and this is just another chart of our oh did I get mixed up here you guys are gonna fire me from running this clicker there we go so the whole times are again based on the half-life and the mechanism of action and this is

pretty similar to what you saw in the the presentation earlier today and specifically that imbruvica that's something that we alert the radiologists who they have a discussion with the patient decide is this something that we

want to continue with and I will say that in our practice with the volume and the the level of acuity of our patients I think that a lot of our providers are fairly comfortable with a certain level of risk because that's just who our

patient population is you know we have a very large hospital two large hospitals and very sick patients so that's something that we you know some of them are more comfortable than others but it's a risk-benefit thing that they have

to decide on themselves with the patient obviously all right so here are our

now that you all have an overview and a refresher of nursing school and how these medications work in our body I want to now go over our practice

guidelines and the considerations that we take into place so as you know I'm not going to go over into detail the patient populations that are prescribed these meds but kind of knowing that these are the

patients that we see in our practice that for example are on your direct direct vector 10a inhibitors patients with afib or artificial valves or patients with a clock er sorry a factor v clotting disorder these oral direct

thrombin inhibitors patients with coronary artery thrombosis or patients who are at risk for hit in even patients with percutaneous coronary intervention or even for prophylaxis purposes your p2 y12 inhibitors or your platelet

inhibitors are your cabbage patients or your patients with coronary artery disease or if your patients have had a TI AR and mi continued your Cox inhibitors rheumatoid arthritis patients osteoarthritis vitamin K antagonists a

fib heart failure patients who have had heart failure mechanical valves placed pulmonary embolism or DVT patients and then your angiogenesis inhibitors kind of like Kerry said these are newer to our practice these are things that we

had just recently really kind of get caught up with these cancer agents because there really aren't any monitoring factors for these and there is not a lot of established literature out there knowing that granted caring I

did our literature review almost two years ago now so 18 months ago there is a lot more literature and obviously we learned things this morning so our guidelines are reviewed on a by yearly basis so we will be reviewing these too

so there is more literature out there for these thank goodness so now we want to kind of go into two hold or not to hold these medications so knowing that we have these guidelines and we'll be sharing you with you the tables that

tell us hold for five days for example hold for seven days some of these medications depending on why the patient is taking them are not safe to hold so some of the articles that we reviewed showed that for sure there's absolutely

an identified risk with holding aspirin for example a case study found that a patient was taking aspirin for coronary artery disease and had an MI that was associated with holding aspirin for a

radiology procedure they found that this happened in 2% of patients so 11 of 475 patients that sounds small number but in our practice we do about 400 procedures in a week so that would be 11 patients in one week that would have had possibly

an adverse reaction to holding their aspirin and then your Cox inhibitors or your NSAIDs as Carrie already mentioned it's just really important to know that some of those the Cox inhibitors have no platelet effects and then your NSAIDs

can be helped because their platelet function is normalized within 24 to 48 hours Worf Roman coumadin so depending on the procedure type and we'll go into that to here where we have low risk versus moderate to high risk

we do recommend occasionally holding warfarin however we need to verify why the patient is absolutely on their warfarin and if bridging is an option because as you learn bridging is not always on the most appropriate thing for

your patient so when patients on warfarin and they do not have any lab values available that's when you really need to step outside of guidelines and talk with your radiologists your procedure list and potentially have a

physician to physician discussion to determine what's best for a particular patient this just kind of goes into your adp inhibitors and plavix a few of the studies that we showed 50 are sorry 63 patients who took Plex within five days

of their putt biopsy they found that there was of those one bleeding complication during a lung biopsy so minimal so that's kind of why we have created our guidelines the way we did and here's just more information

regarding your direct thrombin inhibitors as cari alluded to products is something that we see very commonly in our practice and then your direct vector 10a inhibitors this is what we found in the literature

access reowww lytic thrombectomy or the angio jet device which is the most frequently used device for this what it does is basic disrupts the clot by shooting out TPA

embeds it into the clot and then you suck it up using suction thrombectomy using the venturi effect and you aspirate some of the clot and you can see that here that's a picture from I think the angio jet website the benefit

is that it can be you can use it without TPA and just use the suction thrombectomy mode with heparinized saline and that can be helpful to help break up some clot the drawbacks is that it has a black box warning from the FDA

so we do this every once in a while in the right patient but this is definitely not recommended by the company or anyone for that matter but it does work in some cases and the main reason is that the the vibrations caused by the device can

cause significant bradycardia in addition to the bradycardia that you get from red blood cell really lysis that you get with these devices so you actually couldn't cause arrhythmia on top of bradycardia which sounds like a

bad a bad combination and these patients can get hemodynamic collapse and die right on the table just cuz you turned on the device so that being said we've all I think done it once or twice I've seen I've only done it once and I never

do it again because a patient coded one of my colleagues did it on a patient because the patient was already coding said well what's the harm and that patient survived they did better actually because we were able to break

up the clot so I will say that if you do it and the patient doesn't do well you really don't have a leg to stand on because right on the cover of the packaging it says do not use in the pulmonary arteries aspiration

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

quick I did want to mention t-carr briefly and try to get you guys closer to back on time this is a hybrid procedure this is combining the surgical procedure we talked about first and carotid stenting it takes combined

carotid exposure at the base of the clavicle or just above the clavicle and reverses blood flow just like we talked about but tastes slightly different technique or approach to doing this and then you put the stent in from a drug

carotid access here's the components of the device right up by the neck there is where the incision is made just above the clavicle and you have this sheet that's about eight French in size that only goes in about us to 2 cm or 1 and a

half cm overall into the vessel and then that sheath is sutured to the the chest wall and then it's got a side arm that goes what's labeled number six here is this flow reversal urn enroute neuroprotection kit it reverses the

blood flow and then you get a femoral sheath in the vein right in the common femoral vein and you reverse the blood flow so this is a case a picture from our institution up on the right is the patient's neck and that's the carotid

exposure and the initial sheath is in place so the sidearm of that sheath is the enroute protection system which is going up up at the top of the image there we're gonna back bleed that let that sidearm of that sheath continue to

bleed up to the very top and then connect that to the common femoral venous sheet that we have in place there's a stepwise of that and then ultimately what we see at the end of the procedure is that filter inside that

little canister can be interrogated after and you can see the debris this is in the box D here on the bottom left the debris that we captured during the flow reversal and this is a what we call a passive and then active flow reversal

system so once the system is in place the direct exposure carotid sheath in place the flow controller and AV shunt in place you see the direction of blood flow so now all that blood flow in that common carotid artery is going reverse

direction and so when you place a sheath or wire and and ultimately through that sheath up by the carotid artery there's no risk for distal embolization because everything is flowing in Reverse here's a couple

case examples ferns from our institution this is a patient who had a symptomatic critical greater than 90% stenosis has tandems to nose he's so one proximal at the origin and one a little bit more distal we you can see the little

retractors down at the base of the image there in the sheath that's essentially the extent of the sheath from the bottom of that image into the vessel only about a cm or two post angioplasty instant patient tolerated that quite well here's

another 71 year-old asymptomatic patient greater than 90% stenosis pretty calcified lesion a little more extensive than maybe with the CT shows there's the angiography and then ultimately a post stent placement using the embolic

protection device and overall the trials have shown good good safety met profile overall compared to carotid surgery so it's a minimum minimal exposure not nearly as large the risk of stroke is less because you're not mucking around

up there you're using the best of a low profile system with flow reversal albeit with a mini surgical exposure overall we've actually have an abstract or post trip this year's meeting this is just a snapshot of that you can check it out

this is our one year experience we've had comparable low complication rates overall in our experience so in summary

patients may be asking you is like what about adenomyosis and I've been hearing something about that which is not exactly fibroids right it's a different entity though the symptoms could be kind of the same and for the years and years

and years we wouldn't have any options for patients who had adenomyosis in fact the only option for patients with adenomyosis is surgery but adenomyosis can coexist with fibroids and sometimes patient presents with adenomyosis alone

so we've had some studies now that have looked at that and although the data is not as robust and not as awesome as for patients with fibroids we do provide a performing bolas Asian for those patients with particles that are little

smaller than what we would use for fibroids with results as you're seen there before now the only other new thing that's on the market and it's not so new to you guys that are probably doing radial in femorals anyway working

in cardiac labs and IR labs it's actually what we call the trophy if you go back one slide for me mr. a the person and press play then we will be able to see that radial access I do not work for Merritt they don't give me a

dime I just thought that this was a good video is there volume on that at all if not I can just talk about it and really what it says is that if you need to a radial UFE or have radial axis for a uterine embolization patients just love

it more they and especially like patients that are already just intimidated they don't want you going near their groins at all they actually could just lay on the table we don't have to put up we don't put a Foley in

they just get a radial access the same way that you would just be starting in a line except we have special types of radial catheters and and sheaves to do that and I don't offer a radial access to

patients who are too tall for our catheters or if they've had multiple prior radial access and don't have an intact ulnar artery to complete their hand but it's much like any of that femoral access that you would normally

see they make special hydrophilic sheaths now they're called from this particular company slender technology where the inner diameter of the sheath essentially the sheath is the same like five French on the outside but they have

cored out the inside so it's a bigger diameter so it's a five six so on the outside it's a five but it will take a six French in the inner inner lumen and you know my practice we do more than 80% of all our arterial punctures with a

radial access and everybody here comes dr. Sean Deroche Nia who is the leading author of that paper for SI R and one of my esteemed partners so most patients are able to get up and walk out if you are go from a radial access the access

is actually closed with just a radial band and the complications of having a hematoma or having the patient's bleed out those just all go away but radial axis have their own complications so I'm not here to say that it is not that but

in our practice we found it to be safe and effective our patients want it and it's become like a practice differentiator so if you're working in a practice that don't do radial you EFI's right now you should mention it because

if you're in a population where the other providers are only doing femoral then you will automatically get the patients that only want that so here's a patient that had a radial access you can see a catheter that is coming from the

aorta while you can't see that it's not up and over the bifurcation but maybe you do can see that and there's a catheter in the uterine artery with the characteristic

shape of the uterine artery and the characteristic curlicue vessels of of the fibroid and on the left you can see the Imogen for beforehand and the Imogen on the right of post embolization where there is stagnant flow in the main

uterine not main uterine artery in the horizontal portion of the uterine artery for greater than five cardiac beads and again there's there's no reason that you have to know that level of detail except that you're scrubbing in but if you're

in the audience you're looking at this you're like dr. Newsome I see an air bubble there as well then I'd say good because because I do see it too so you can see the preimage and you can see the post image for pre and post embolization

these these procedures can be quick these procedures are very very rewarding and and I love to do it

I'm Nikki Jensen Nicole is what my mother calls me but that's alright thank you all for joining us today I am the clinical resource nas I work in a clinical nurse specialist position I graduated in May so I'll finally be called the clinical nurse specialist

after I passed my boards in nonvascular radiology so at Mayo Clinic Rochester we are kind of split up between I are in our IR practice where we have non vascular procedural Center CT MRI ultrasound guided procedures we'll go

over a list of our standard perform procedures as well as our neuro interventional and vascular interventional practice so Kerri and I work in the non vascular so we do not do any neuro interventional or vascular

vascular interventional procedures so these guidelines are going to focus on your LR CT or ultrasound guided procedures how many of you went to the combined session this morning great this is going to be an overview because what

we saw presented there really reiterates what we are have brought into our practice but then we're also going to share how we created nursing guidelines and how we rolled that into our practice this is Carrie Carrie is a staff nurse

in our department I worked as a staff nurse for seven years prior to this position I've been in this position now for four years and really enjoy it I do want to give a little shout-out to Carrie and I presented or sorry we

published an article in the June 28th volume 37 issue - that really coincides with our presentation today so I would encourage you to read that publication and then you'll get additional information on how we did this yes all

right we have nothing to disclose unfortunately or fortunately right so the purpose of this presentation is to help you all understand the importance of creating reviewing the literature

understanding your for one your coagulation casket as well cascade as well as anticoagulants that are out there or new up-and-coming medications and understanding that yes it's very important to establish and create these

guidelines so that within your practice you don't have differing radiologists that have differing opinions if you're working with doctor so-and-so today you need to worry about these labs if you're working with you know dr. Johnson

tomorrow he doesn't care about the labs we did this to help standardize that to help reduce the amount of questions our nurses have how many times we're interrupting our radiologists but then also we need to take into consideration

the importance of the patients and their different disease processes and we'll be going over that too so it's nice to have established guidelines but then also we need to take into consideration why patients are on certain medications this

here is our list of objectives I'm not going to read them for you you can all read them and we've provided you all with handouts too but really we want to just help kind of explain mechanism of actions and different medications and

how we established our guidelines this here is where Kari and I come from full disclosure we do have snow on the ground so these pictures were not taken before we came we are really enjoying this nice warm weather but for those of you who

are not familiar with the history of Mayo Clinic in Rochester who we have a hundred and fifty plus year tradition of implementing evidence-based care to assure the needs of our patient come first we are divided up into one

downtown campus but we have three different main areas so we have our st. Mary's Hospital this is where Kerry is based out of this is this houses most all of our ICUs as well as most all of our inpatients so we do a lot of

inpatients but we also see outpatients in this hospital Rochester Methodist Hospital this is where our he mock patients typically are we do have one ICU within Hospital as well but then right here my

office is right there this is our Mayo downtown campus so this is where most of our patients come for outside procedures or outpatient diagnostic imaging exams this here is the group that I'm part of the clinical nursing specialist group

within our clinical nursing specialist group there are 77 of us there are five like myself clinical resources as we have not graduated as of yet I'm right there in the middle w

that work in over 70 ambulatory areas in 58 inpatient areas we also support some areas in our Arizona and Florida campuses and then we have Mayo Clinic Health System hospitals that are scattered throughout Iowa

Wisconsin in Minnesota as well I am the only one in radiology across all of our

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

PE the first one of course is

anticoagulation so heparin and bridging the patient to coumadin or now aid a direct oral anticoagulant is really the mainstay of treatment most patients again 55 percent of patients with PE have low risk PE all of those patients

should be on according to the chest guidelines three months of anticoagulation so they're gonna get heparin as an inpatient if they even need it and they're gonna get sent home on lovenox bridge to coumadin or they're

gonna get the one of the new drugs like Xarelto or Eliquis but here's all the other things that we do so these patients that are in the intermediate high risk so I'm gonna try to keep saying those terms to try to kind of put

that in everyone's brain because I think the massive and sub massive PE is what everyone used to talk about but we want to keep up with our colleagues in cardiology who are using the correct terminology we're gonna say high risk

and an intermediate but in those patients - intermediate high risk or Matt or the high risk PE patients we're gonna be treating them with systemic thrombolysis catheter directed thrombolysis ultrasound assisted

thrombolysis and maybe some real lytic and elected me or thrombectomy there's other techniques that we can use for one-time removal of clot like rotational and electa me suction thrombus fragmentation and then of course

surgical mblaq t'me so when anticoagulation is not enough so I like to show this slide because it shows the difference between anticoagulation and thrombolysis they are very different and sometimes I think everybody in this room

understands the difference but I think our referring providers don't and so when we when we get consulted and we recommend anticoagulation they're like yeah TPA well that's not the right thing so anticoagulation stops the clotting

process so when you start a patient on a heparin drip they should theoretically no longer before new thrombus on that thrombus so when you have thrombus in a vessel you get a cannon you get a snowball effect more

and more thrombus is gonna want to form heparin stops that TPA however for thrombolysis actually reverses the clouding process so that tissue plasminogen activator or streptokinase or uro kindness will actually dissolve

clot so there you're stopping new clot forming versus actually dissolving clot anticoagulation allows for natural thrombolysis so your body has its own TPA and so when you put a patient on heparin you're allowing your natural

body defenses to work you're giving it more time TPA accelerates that process so you give TPA either systemically or through a catheter you're really speeding up that process anticoagulation on its own has a

lower bleeding risk you're putting a patient on heparin or Combe it in it's it is less but it is still real thrombolysis however is a very very high bleeding risk patients when I when I consult a patient for thrombolysis I

tell them that we are about to do give them the absolute strongest blood clot thinning agent or an reversal agent which is the TPA and we're gonna just run it through your veins for hours and hours

um and that sort of gives them an idea of what we're doing anticoagulation in and of itself is really not invasive you just give it through an IV or even a pill thrombolysis however is given definitely through an IV through

systemic means and a large volume there thereafter or catheter directed so again

different applications renal ablation is very common when do we use it

high surgical risk patients primary metastatic lesions some folks are actually refused surgery nowadays and saying I'll have a one centimeter reno lesion actually want this in lieu of surgery people have

familial syndromes they're prone to getting a renal cancer again so we're trying to preserve renal tissue it is the most renal parenchymal sparing modality and obviously have a single kidney and a lot of these are found

incidentally when they're getting a CT scan for something else here's a very sizable one the patient that has a cardiomyopathy can see how big the heart is so it's you know seven centimeter lesion off of the left to superior pole

against the spleen this patient wouldn't have tolerated bleeding very much so we went ahead and embolized it beforehand using alcohol in the pide all in a coil and this is what it looks like when you have all those individual ice probes all

set up within the lesion and you can see the ice forming around I don't know how well it projects but in real time you can determine if you've developed your margin we do encompass little bit of spleen with that and you can see here

that you have a faint rim surrounding that lesion right next to the spleen and that's the necrotic fat that's how you know that you got it all and just this ablation alone caused a very reactive pleural

effusion that you can see up on the CT over there so imagine how this patient would have tolerated surgery pulmonary

know we're running a bit short on time so I want to briefly just touch about

some techniques with comb beam CT which are very helpful to us there are a lot of reasons why you should use comb beam CT it gives us the the most extensive anatomic understanding of vascular territories and the implications for

that with oncology are extremely valuable because of things like margin like we discussed here's an example of a patient who had a high AF P and their bloodstream which tells us that they have a cancer in her liver we can't see

it on the CT there but if you do a cone beam CT it stands up quite nicely why because you're giving levels of contrast that if you were to give them through a peripheral IV it would be toxic to the patient but when you're infusing into a

segment the body tolerates at the problem so patient preparation anxa lysis is key you have them exhale above three seconds prior to that there's a lot of change to how we're doing this people who are introducing radial access

power injection anywhere from about 50 to even sometimes thirty to a hundred percent contrast depends on what phase you're imaging we have a Animoto power injector that allows us to slide what contrast concentration we like a lot of

times people just rely on 30% and do their whole the case with that some people do a hundred percent image quality this is what it looks like when someone's breathing this is very difficult to tell if there's complete

lesion enhancement so if you do your comb beam CT know it looks like this this is trying to coach the patient and try to get them to hold still and then this is the patient after coaching which looks like this so you can tell that you

have a missing portion of the lesion and you have to treat into another segment what about when you're doing an angio and you do a cone beam CT NIT looks like this this is what insufficient counts looks like on comb beam so when you see

these sort of Shell station lines that are going all over the screen you have to raise dose usually in larger patients but this is you know you either slow down the acquisition speed of your comb beam or

you raise dose this is what it looks like after we gave it a higher dose protocol it really changes everything those lines are still there but they're much smaller how do you know if you have enhancement or a narrow artifact you can

repeat with non-contrast CT and give the patient glucagon and you can find the small very these small arteries that pick off the left that commonly profuse the stomach the right gastric artery you can use your comb beam CT to find

non-target evaluation even when your angio doesn't suggest it so this is a patient they have recurrent HCC we didn't angio from here those arteries down there where those coils were looked funny even though the patient was

quote-unquote coiled off we did a comb beam CT and that little squiggly C shape structures that duodenum that's contrast going in it this would be probably a lethal event for the patient or certainly would require surgery if you

treated that much with y9t reposition the catheter deeper towards the lesion and you can repeat your comb beam CT and see that you don't have an hands minh sometimes you have these little accessory left gastric artery this is

where we really need your help you know a lot of times everyone's focused and I think the more eyes the better for these kind of things but we're looking for these little tiny vessels that sometimes hop out of the liver and back into the

stomach or up into the esophagus there's a very very small right gastric artery in this picture here this patient post hepatectomy that rides along the inferior surface of the liver it's a little curly cube so and this is a small

esophageal branch so when you do comb beam TT this is what the stomach looks like when it enhances and this is what the esophagus looks like when it enhances you can do non contrast comb beam CTS to confirm ablation so you have

a lesion this is the comb beam CT for enhancement you treat with your embolic and this is a post to determine that you've had completely shin coverage and you can see how that correlates a response so the last thing we're going

after having these two cases one in our institution and one at University of North Carolina Chapel Hill that we would then basically upsize our particles to

100 micron and we have not seen that and we're doing a second clinical study and I'm not seeing that as either we had about a 70% reduction in pain so if you look at our visual analog score out to six months and if you look at our

disability it actually paralleled this exactly which is pretty impressive considering mostly patients had bilateral knee pain so out to six months very good results 90% of patients were responders so two

out of our twenty patients did not really respond one patient didn't respond at his one-month follow-up but did respond at his three and six so I still consider him a clinical failure because we expect

these patients to respond by one month here's just an example of a baseline MRI before and after and you can see all that joint effusion there the white that decreases just even after a month how much it decreases and we looked at this

in terms of synovial thickness and distension and even on MRI you can object objectively count calculate synovitis scores and we calculated that they actually statistically decreased this is another patient on the left the

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

who's enrolled in a clinical study is this is before this is all we did we embolized the medial aspect of the knee this is one month later 30 days in fact somebody just asked me this when I was in the booth over at the meeting across

the street and basically I said listen I don't know why this happened so quickly I have no idea we didn't tap renu-it into anything else if you look at this premium post it's pretty dramatic so clearly there's an inflammatory process

that we are arresting or stopping in such a short period of time so is there a future for this I don't know it may just we may just fall down and find out that there really is in a great future but so far we know it's at least

technically successful it's the results are positive in the short term long term we're not so sure yet we do need to better understand these risks and I think in my opinion in the long term it'll probably be really really good for

this 40 to 65 year old patient population who's not yet ready for knee replacement surgery this is the algorithm for our clinical study which were almost done enrolling right now it's a randomized control study against

placebo so it's two to one randomization which means one third of the patients actually get a sham procedure so we do an angiogram on their leg they're asleep they have no idea for embolizing they're genetical it arteries or not we wake

them up I think about the table and we follow them up if they're no better they're allowed to cross over and get the treatment the other 2/3 of the

to talk about is indirect angiography this is kind of a neat trick to suggest to your intervention list as a problem solver we were asked to ablate this lesion and it looked kind of funny this patient had a resection for HCC they

thought this was a recurrence so we bring the comb beam CT and we do an angio and it doesn't enhance so this is an image here of indirect port ography so what you can do is an SMA run and see at which point along the

run do you pacify the portal vein and you just set up your cone beam CT for that time so you just repeat your injection and now your pacifying the entire portal vein even though you haven't selected it and what to show

well this was a portal aneurysm after resection with a little bit of clot in it the patient went on some aspirin and it resolved in three months so back to our first patient what do you do for someone who has HCC that's invading the

heart this patient underwent 2y 90s bland embolization microwave ablation chemotherapy and SBRT and he's an eight-year survivor so it's one of those things where certainly with the correct patient selection you can find the right

things to do for someone I think that usually our best results come from our interdisciplinary consensus in terms of trying to use the unique advantages that individual therapies have and IO is just one of those but this is an important

lesson to our whole group that you know a lot of times you get your best results when you use things like a team approach so in summary there are applications to IO prior to surgery to make people surgical candidates there are definitive

treatments ie your cancer will be treated definitively with curative intent a lot of times we can save when people have tried cure intent and weren't able to and obviously to palliate folks to try to buy them time

and quality of life thermal ablation is safe and effective for small lesions but it's limited by the adjacent anatomy y9t is not an ischemic therapy it's an ablative therapy you're putting small ablative radioactive particles within

the lesion and just using the blood supply as a conduit for your brachytherapy and you can use this as a new admin application to make people safer surgical candidates when you apply to the entire ride a panic globe

thanks everyone appreciate it [Applause] [Music]

treatment is the ultrasound assisted catheter director thrombolysis or the echos divisor eCos this technique involves a slow infusion again over 12 to 24 hours

but the catheter has ultrasound built into it and that's thought to help disassociate fibrin strands and to help embed the thrombus bed the TPA into the thrombus I think most people have heard of or seeing eCos in the past

again lower doses much like the catheter directed so it's really the same type of procedure except at the end you're hooking up eCos rather than a uniform Craig Mac there is a lot of differences though in the sort of overall patient

experience because eCos as many of you know requires a lot more devices and for the patient's room so they're gonna have more pumps because it requires more fluid it requires more observation it beeps more frequently overnight but what

I will say is that there are studies that are used that have useful information with eCos and those are actually the main studies that have been done although they're all industry-sponsored but they're very

important studies nonetheless so the only device really that exists for this right now that approved is the eCos

questions comments and accusations please hello this topic is very personal to me I've had it actually had a UFE so this is like one of my big things I work in the outpatient center as well as a

hospital where we perform you Effy's and frequently the radiologist will have me go in and talk to the patient it's from a personal perspective one of the issues which it may just have been from my situation was pain control post UFE

whether you normally tell your patients about pain control after the UFE someone say we are all struggling with this yeah oh it's not what's your question is going to be okay good I'm gonna get doctor Dora to answer Shawn the question

is what do you what do we do with this pain issue you know what are you doing for the home there at Emory there you know and a lot of practices we we don't rely on one magic bullet for pain control recently we've been doing

alternate procedures for two adjunctive procedures to help with pain control for example there are nerve blocks that you can do like a superior hypogastric nerve block there's there's Tylenol that can be given intravenously which is seems to

be a little more effective than by mouth there's there's a you know it and a lot of times it's it's a delicate balance right between pain post procedural pain because you can often get the pain well controlled with with narcotics opioid

with a pain pump but the problem is 12 hours later the patients is extremely nauseous and that's what keeps her in the hospital so it's a it's a balance between pain control and nausea you can you can hit the nausea

beforehand using a pain and scopolamine patch that that'll get built up in the system during the procedure and that kind of obviates the nausea issues like I said that the the nerve blocks the the tile and also there are some other

medicines that can can be used adjunctive leaf or for pain control in addition to to the to the opioids so the answer the question is there are multiple there multiple answers to the question there's not one magic bullet so

that helped it did one of the things that I tell the patients is that you know everyone is different and yet some people I've seen patients come out and they have no pain they're like perfect and then some come out and they are

writhing in the bed and they're hurting and they're rolling all around what and I always ask the acid docs are you telling them they could possibly have you know pain after the procedure because some have the expectation that

I'm going to be pain-free and that's not always the case so they have an unrealistic expectation that I'm gonna have the UFE but not have pain what I also tell them is that the pain it's kind of like an investment right and

this is easy for a guy to say that right but but it's it's an investment the worst part the worst pain you should be feeling is the first 12 12 hours or so every day I tell my patient you're gonna be getting better and better and better

with far as the pain as long as you is you follow our little cookbook of medicines that we give you on the way home and I want you to make sure that you fill these prescriptions on the way home or you have someone fill those

prescriptions for you before he or she picked you up in the hospital and lately we have been and I see that you're there as well lots of other little tricks that are out there right and again there are all

little tricks so ensure arterial lidocaine doctor there is near alluded to and if you're on si R Connect you may it may spill over on some of your chat rooms here people have been using like muscle relaxant like flexural or

robertson with some success but just know that we don't have any studies that tell us how that's supposed to do so when i have someone that is like writhing in pain i just use everything so i do it superior hypogastric nerve

vlog and i actually will do some intra-arterial lidocaine although not so much lately i have been using the muscle relaxant but i will warn you that i've had two patients with extreme anticholinergic effects where they are

now not able to pee from that so you know where we're doing that balance act I see that you're there can I take that question here first just so we're we're doing the same thing we're using the multimodal just throwing all these

things at people and we're trying the superior hypogastric blocks but we're collaborating with anesthesia to do that right now do you all do your own blocks or do you collaborate with anesthesia we do our own blocks okay it isn't it is

not that difficult I would tell you that but again it's kind of like you know you got to do if you start feeling better and then you're like we don't really need them we'll just do it on our own okay thank you again yes what's the

acceptable interval between UFE and for IBF oh that's a your question what is the interval between UFE and IVF so if you wanted to get pregnant yeah and can you have a you Fe and then have an IVF like how long would you have to wait

wait and tell you before you can have that the IBF it I guess it really depends on the age of the patient because we know that that the threshold for which patient tend to have that inability to conceive

is around 45 years old so you know it did below the you know below the age of 45 the risk of causing ovarian failure or or the inability to conceive is significantly less it's zero zero to three percent so I would say that you

know you probably want the effects of the fibroid embolization to two to take effect it takes around 12 months for these fibroids to shrink down to their most weight that they're gonna they're going to shrink down the most I wouldn't

say you need to wait 12 months to put our nine vitro fertilization there's no good there's no good literature out there I don't believe that's your next and so I would say just remember that if you came to my practice and you said you

wanted to get pregnant I will be sending you to talk to fertility specialists beforehand we do not perform embolization procedures as a way to become pregnant there's no data to support that but if you saw your

gynecologist and they said let's do this then I'm sure they'll be doing lots of adjunct things to figure out what would be an ideal time then to for you to have IVF and if I dove not having any data to inform me I would ask you to wait a year

and what will be the effect of those hormones that they gave you if for example a patient has existing fibroids what would be the effect of those hormones that IVF doctors prescribed their patients yeah so fibroids actually

can grow during pregnancy so I would say that most of those hormones are pro fertility hormones so I would expect that maybe you can see some of that effect as well yeah alright if you have any other questions you can grab me oh

you're I'm sorry go with it okay yes we we have time I don't want to keep anybody here for that so I have a two-fold question the first one is post-procedure can you use a diclofenac patch or a 12-hour pain

patch that is a an NSAID have you have any experience with that and your next question my second part of the question is there a patient profile or a psychological profile that tips you that the patient is not going to be able to

candidate because of their issues around pain so they're two separate but we have in success sending people home that first day so I'm looking to just make it better I haven't had experience with the Clos

phonetic patch it's in theory it seems ok you know these are all the these are they're all these are non-steroidal anti-inflammatory drugs so there are different potency levels for all of them they you know they range from very low

with with naproxen to to a little bit higher with toradol like that clover neck I think is somewhere in between so we found that at least I found that that q6 our our tour at all it tends to help a lot so with that said I I don't have

much experience with it with the patch in answer to your second question the only thing I can say is there there is a strong correlation between size of fibroids and the the amount of a post procedural pain and post embolization

syndrome so there really you know we often say we don't really care too much about the number of fibroids but the size of the fibroid is is is should be you know you should you should look at that on pre procedural imaging because

if it gets too big it may not be worth it for the patient because they may be in severe pain the more embolic you put into the blood supply's applying the the fibroid the the greater the pain post procedural pain

are there multiple other factors that would contribute to pain but that's that's one aspect you can you can look at post procedurally on imaging okay thank you very much yes ma'am hi what what kind of catheter do you use

to catheterize the fibroid artery when you pass by radio access yeah so over the last three years the companies have been really very good about that so there are a few things that I without endorsing one company or the other that

you need to make sure that the sheath that you're using is one of those radial sheets a company that makes a radio sheath you should not use a femoral sheath for radial access so no cheating where that's concern you may get away

with it once or twice but it will catch up to you and you need a catheter that is long enough to go from the radio to the to the groin so I'm looking for like a 120 or 125 centimeter kind of angled catheter whether it's hydrophilic the

whole way or just a hydrophilic tip or not at all you can you can choose which one in our practice most of us still tend to use a micro catheter through that catheter although if I'm using a for French and good glide calf and it

just flips into like a nice big juicy uterine artery then I may just go ahead and take that and do the embolization if the fellow is not scrubbed in as well so thanks a lot but they make they make many different kinds like that and more

of those are to come all right I'm you can please please please send us any other questions that you have thanks for your time and attention and enjoy the rest of the living

catheter some other things that we can do is mechanical intervention so if you have a patient usually with massive PE

or the inner or the high-risk B you got to do something to help them out so what we do is put a pigtail catheter and inject a little bit of TPA on the table and then twirl the pigtail or put a wire through the side part of the pigtail and

make it sort of a mechanical fragment fragmentation the problem with that is that fragmented clot goes downstream so when it's in a main pulmonary artery it actually has less surface area than it is when it is in a distal pulmonary

capillary so when you break that clot up you have to be careful because it can actually make the patient worse the benefit there there's no thrombolytic so if we're doing this we we generally are doing it in patients who can't either

receive TPA at all frequently we get patients with who have have had recent spine surgery who get a massive PE had brain surgery get a massive PE and you have to try to treat them without any TPA or even heparin the drawbacks are

that again it increases pulmonary vascular resistance by sending all those little pieces of clot into the small pulmonary arteries and capillaries and it makes it actually much worse in some patients again there's no control trials

and sometimes you need to have a bigger

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

are there any questions yeah yes that's a really good sure so the question was do you have any rules or guidelines in my institution about how long the procedure can be before you start

talking about anesthesia versus sedation is that right and positioning prone supine we did come up with a guideline with within our department we looked at a little bit of research but honestly was more expert opinion just best

practice and experience I in in general I would say if the procedure is 3 plus hours the patient should know they're going to be on the table not asleep for three plus hours and talk to them about what that means and if they're ok with

that I just think again that comes into setting realistic expectations that's one of the reasons actually that we're very interested in using Dex med otama Dean because that's going to be a better

drug for those longer procedures first was giving functional and versed for four hours it's just not it's not appropriate but you know and some people would say we'll just get an anesthesiologist them but a lot of these

patients are really thick so in our institution anesthesia is just really super regulated and they require all of these clearances for their involvement no matter what they're giving sometimes they'll require all these clearances and

they give exactly what we were going to give so you know it's it's really a juggling act I would say in our department we really just make sure the patient knows what the expectation is and then we'll usually say to the

provider to if if something goes like if anything looks a little concerning during the case we're stopping and they have to be ok with that and they are they really are but that took a lot of work to get everybody on board with that

type of communication yeah we don't know so they I know I think Sloane is anyone here from Sloane no I think Sloane has with dedicated anesthesiologists they work really closely with them and it's easier for

them to get cases scheduled they will give us they will assign us an anesthesiologist for the day but if we don't have any anesthesia cases they get reassigned somewhere in the o.r and it's a different analysis every time it tends

to be the same group some are stricter than others some will have a patient say I really want anesthesia and we can call up the provider and there they say no problem let me do a quick chart review whereas the next day the provider goes

no absolutely not send them for clearances that's a little tricky yeah right so what I showed you is from the american society of anesthesiology i am not affiliated with them at all i just think they bide non anesthesiologist

sedation so i rely heavily on what they say and they recommend waiting till peak effects so i would look at the pharmacokinetics so for versed it's 3 to 5 minutes so i would wait at least 3 minutes before your readmit a stirring I

think a good example with that is when diazepam with the sedative of choice the on the peak effect for diazepam is 1 minute so when midazolam came onto the market there were a lot of adverse outcomes

with patients because providers administering it weren't familiar with the pharmacokinetics and assumed that the peak effect for versed was the same for diazepam so in theory you could give a patient in 5 minutes 5 milligrams of

versed so by the time that fully hits them they could be in a negative 5 on your raft scale so you know just look at those pharmacokinetics look at that peak effect and I would use that to drive your dosing scheme Atlee that's what I

do and I think since we've done that we've seen better meet info cities and better safety outcomes yes okay yeah we don't do that we do one thing with uterine fibroid embolization swear they'll do a superior mesenteric block

but otherwise we don't do any other type of regional blocks but I have read about that I think that's really are the IR providers giving the block okay right I've seen two with uterine fibroid embolization we'll do an epidural in

advance some I think some institutions or some literature exists about that it's interesting it would be interesting if the IR providers could actually give it though I'm not sure if that's kosher in the anesthesia world but they're

certainly qualified to do it they they do already kind of do it really but so I mean that's certainly something interesting and if you have a provider that is comfortable taking that on and their institution I think it's worth

looking at because anything that's sort of I think mixes things up and and provides a different Avenue especially for high-risk patients is worth looking into definitely yes I believe it yeah

mm-hm right so I'll just repeat what she said so just jumping on the talk about blocks so in her institution they the providers to administer blocks and I think you said

coleus estas Tamizh and PTC's and biliary dream placements they'll use that and it will decrease the amount of sedation that's required sedation being versed and fentanyl that's required during the case which like yes like you

said is really great for patients who are already on opioids previously and habit aller ins yes [Music] something right so we again he left same provider though had a patient on Groupon

or Fein and it was our first experience within about a year ago and it was terrible and she did not have realistic expectations going in of how sedated she would be and she was very very unhappy

afterwards so we talked a lot about that and in that guideline I had mentioned that we made about when we involve anesthesia and when we don't there's a caveat about that that says that if a patient is on

methadone or buprenorphine that a discussion needs to take place making them aware that they will probably not feel very sedated but we will try our best and if they're not comfortable with that we reschedule the procedure with

anesthesia but they have to know going into it that they they may not feel completely sedated and we just keep that open and honest communication but we haven't really come up with a scheme of what's best we did actually try with her

we had her come in one day having taken her buprenorphine the day of the procedure and she seemed okay with that and then we tried having her go off of it so that the receptors wouldn't be blocked she was not happy with that

experience so that's really when a person like that probably would do great with propofol but we can't give propofol so you know if the and if the patient tells us no then we just reschedule with the anesthesia

right - hmm right right right you could at least if they're if they're on an opioid uh if they're on people nor Fein then in theory they should respond to the verse said you could go heavier hand it on the

versed just to get them sedated but they will probably still feel pain but it they hopefully won't remember it that's true I you know with the Richmond agitation sedation scale that's not going to fit every patient that's a

really good point I gave a patient seven of versed during an adrenal vein sampling and she was just talking my ear off I got I fed are you okay you know do you need me to give you anything else no no I'm good I'm good and then I wheeled

her out we got her in the recovery area and she goes sit over I said yeah she said wow I don't I don't remember anything the power of her said that that was like a true and music effect I hadn't seen that so strongly in a

patient before but if you if I had done you know I was documenting that she was a zero it looked like I wasn't doing much for her but then I was putting comments you know patient comfortable denying needing any more sedation so

won't fit every patient so it is good to look at that but yeah as far as the buprenorphine I mean it's it's it's tough yeah if they have an addiction specialist I would say talk to them and they might be

able to come up with a scheme that works for them and if there's a lot of pain expected afterwards those patients are gonna have to be on parenteral opioid therapy they'll probably have to stay you know if you're in a hospital they

would have to stay overnight so those are all things you have to consider yeah yes hmm yeah I'm like it so Adam and Alexa are nurse practitioners that we work with and I'm looking at Adam because

this is actually was a very hot topic for us in the last six months so we actually cheat we met with our sedation committee that's run by that in a physiologist who's blocking us from using pres of X and discuss with him

that in the protocol that guides our practice it's said that you did the timeout and then gave sedation but Ari anesthesiologists don't do that right so they intubate the patient and everything and then and they and then the provider

comes in and does the timeout right before the puncture or incision so we talked about to him about how well if we're gonna do the latency to peak effect it's not enough time right so we do now bring the patient in and start

sedation right away our orders are put in in advance I know some by the attending or the Li P so we have a PRN dose and with an a certain number of occurrences and a titrate to a certain Ross scale

yes yeah so and that our anesthesiologist mentions that our providers are present but it's it's a certain use of the language I think it might be like direct observation or immediately available and our providers

are immediately available it's up to your hospital so our profit our providers aren't like down the street on their way in to work with coffee and street clothes and we're sedating they're they're just down the hall maybe

or the way our department looks is we have a control area and it's like the you know the Central Station and you can see all of the rooms so they might be in the Central Station but just haven't gone in to do the time out yet that

being said I always talk to them before I bring the patient in and say what's the goal Rath and I address any concerns that I have and I think people think I'm a little kooky when I do that for every case but it I think it works really well

and I think the providers really like it so we just already start from the Gecko our line of communication I tell them the patient seems really anxious this is my plan what do you think agree disagree yes the procedural if does the procedure

list or the Lak but I've sedated the patient so the patient if you look at what Jayco describes in the universal protocol it's ideal if they can participate in the timeout however not required because then when they do the

timeout they're right there stabbing them with lidocaine so I like to you know I mean I would argue that by starting I would argue about that by starting at the sedation earlier and getting the patient into a comfortable

state you're more safe because you're doing the dosing appropriately according to the a sa yeah correct right right right

okay I think it's important to say though it's not about getting around Joint Commission this is what Joint Commission says you may feel uncomfortable with it and that's okay

but it is what our accrediting body says is okay we're also not intimating the patient and paralyzing them like an Asst the anesthesiologist is now having said that it's not like we walk the patient in and we go oh I think you're mr. Jones

we throw you on the table there is an initial timeout that's done with the nurse and the technologist and the other people in the room shaking his head yes as so the acceptable amount of time after reversal

yes so if it happens if it happens mid procedure you need to it's I believe the language the a sa uses that you have to have a discussion amongst the care team about whether or not you're going to proceed if it happens after the

procedure in the recovery area or it happens mid procedure and you abort then it has to be at least two hours before you discharge that patient or move them back to their unit where they came from because of that recitation effect and

because you can have really adverse effects from sedation like flumazenil can cause serious delirium I had a patient like that one time it was it was awful and it can cause serious cardiac arrhythmia so at least two hours if you

continue with the procedure I would just make sure everyone knows that you have to be really careful with recitation effects and and all of the adverse effects that you'd be looking at yes I think one more question I'm sorry

with hyperkalemia I have come across I want to say it was in perioperative guidelines when I was looking at the labs that we do cuz we do a lot of unnecessary labs in our department you guys might - I feel like we just really

overdo it I believe the perioperative recommendations are to check a serum potassium if the patient has a reason to have hyperkalemia however right if their hyperkalemic and

they develop a cardiac arrhythmia you know could hypoxia also precipitate that cardiac arrhythmia the results from the hyperkalemia maybe I just went in I wouldn't take an ounce

I would I would consider hyperkalemia severe hyperkalemia and unstable patient because that patient could go into a fatal arrhythmia so I would correct that before you bring them into an elective Percy what's often an elective procedure

so if you're doing a fistula gram you know right five point yeah why are we will go up to five point eight we personally will go up to five point eight because a lot of times they're hyperkalemic

because they're fish too less clothes now and we need to open it right so just again it I don't think there's ever going to be any hard and fast data that you see it's all about making sure everyone knows this patient has a serum

potassium of five point eight we're going to be really closely watching the ECG monitoring yeah thank you everyone thank you so much [Applause]

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

that was one example so these are there have a lot of potential complications reperfusion pulmonary edema is a very very big potential complication so you could get through the case patient does

great you open up multiple pulmonary arteries and then they start coughing up blood and then they end up started drowning in their own blood and the ICU so we do not want to push that and the initial papers that you can see down

below on that table they had a very high almost 10% in some cases pulmonary edema requiring treatment requiring patients being put on CPAP or being intubated and that is because they treated too much at one time

and so now as this when this first started in the early 2000s the operators were treating multiple segments at multiple times at one time and they were using large balloons and we figured out that that was what was killing patients

and so we changed our treatment so this is the first study that was ever performed for this it was performed by dr. Feinstein I believe this was published in circulation it was done in Harvard at MGH they had 18 patients with

36 month follow-up they all improved in their ability to walk as well as their lifestyle but many of them 11 out of 18 patients had reperfusion injury so this was the first paper and at that time it became the last paper because so many

patients did poorly but here's what they're sort of what they did and the ones that did okay they you could see that they had an improvement in the New York Heart Association classification again that just means they can walk

further they're not less short of breath and that they could walk further in 6 minutes which is again our sort of first test outcomes over time whence this has become increased so you can see that study was in 2001 and then

it kind of went away for a long time and it came back in 2012 in Japan where the most operators are there they've treated up to 255 procedures now since this slide was made we're up to a thousand in Japan and those patients are doing very

well but you'll notice that they have multiple procedures so again you don't try to one-and-done these patients they come back four to six times we've treated a couple patients where I work and we've treated that was patients four

times already and so they do much better but it's a slow slow and steady treatment so I want to wrap up with saying that the IR team is very critical to patients who are getting treated for PE we're involved in the diagnosis as

the radiology team acute and chronic PE it's very important to know as I've shown you in some of the examples and some of the images which when it's acute and versus chronic doing thrombolysis on a patient with chronic PE is useless all

you're doing is putting them at a risk you're not going to be able to break up that clot it's very important to have inter and multidisciplinary approach to patient care so interdisciplinary meaning everybody in this room nurses

technologists and physicians working together to take care of that patient that's on your table right now and multi-disciplinary because you have to work with cardiology vascular medicine the ICU teams and the

referring providers whether it's neurosurgery vascular surgery whomever it is who's Evers patient gets a PE you have to work together and it's very important again to have collaborative care in these patients if we're doing a

procedure and somebody notices that the patient is desaturating that's very very important when you're working in the pulmonary arteries if somebody notices that the patient's groin is bleeding you have to speak up so it's very important

that everybody is working together which is really what we need to do for these patients so there's my references and there's my kid so thank you guys very much hopefully this was helpful I'd be

a little bit more systemic versus catheter directed thrombolysis so once you've decided that a patient needs TPA what are the differences here well if

you give patients systemic TPA you're gonna give them a much more rapid delivery this is for those patients who have high-risk PE they're the ones who are coding for those patients you give them 200 milligrams of IV usually you

get 50 first and then another 150 over a very short time period they have a very high risk of bleeding as a result of that a catheter is much slower you're gonna infuse one milligram maybe which is what I think most people do

over several hours maybe a few maybe a day so it's slower targeted versus non targeted well catheter is much more targeted you're gonna give Pete you're gonna give the TPA right into the

pulmonary arteries that's the whole point in our in our thought process as a result you give a lot less drug so when you give a patient based off of some of the trials 24 milligrams of TPA over a 24-hour period that's a lot less than

200 milligrams in a 10 minute period and then the bleeding risk is very different for these patients catheter based treatments have a high bleeding risk but it's possibly lower than the initial bleeding risk of patients getting

systemic TPA so I wanted to go through a

Okay, this is another very delightful category, and I love casing nomenclature. So are these programming letters Greek? It sounds like it. It sounds like a code, VVI, DOO, OVO. But actually, it's a code that's fully understandable.

When I say 32619, you don't even calculate that. You just think, oh, that's today. There's a chart, and you have it in your paperwork. It's the NASPE chart, and this is how programming nomenclature comes about. The first chamber is position I,

and that's the chamber that pace is. So if a patient has several responses, it can pace no chambers, it can pace the A or the atrium, it can pace V or ventricle or it can pace dual, D, which is the atria and ventricle. Position II is the sensing chamber.

And again, it has those same options as a response. Position III, and that's as many as I'm going to go through, is the response to sensing. It has a response to have no response to what is sensed. It has a response to inhabit or to trigger, or it can do D, which is both to inhibit and to trigger.

Now these numbers, letters are used in determining the device programming. There are a few options. One is the option of an inhibitive mode. We don't really use inhibited too much at UVA. However, it's in this consensus statement

so I want to make sure and review it. This is a mode where if native beats occur, the device doesn't pace, it just inhibits. If there is not a native beat sensed, the device will pace and it will pace the appropriate chamber at the rate that its programmed.

The heart rate will be no lower than the set rate. So a patient that is programmed VVI, V is the first position and that's the ventricle. So it tells you that lead is in your ventricle and it would pace the ventricle. The second position is the position that it senses,

which is also the ventricle. Of course it's the lead that, you know, it's in. So it will sense the activity in the ventricle. If it senses that the patient has any of their native beats, it will inhibit or not pace. So that nomenclature is used in general programming,

but these are MRI options as well. Now asynchronous pacing is one that we do use fairly regularly. That patient would be paced at a non-competing rate that's faster than their native rate. So if the patient had a heart rate of 60,

we may or the device nurse would program them to be doing the study at a rate of 80. So the thought is that the patient normally beats at 60 and that's where they've been running, they would override that so to that wouldn't have any need to be paced during that study.

And it paces at this programmed rate. Say they're pacing them at a rate of 80, it will pace regardless of what's happening underneath. It will mostly override it. So probably nothing will happen underneath. But it's going to pace all the time,

and you would anticipate that you would be paced at the programmed rate and now below. Now an example, I'm using the ventricle again. So that second example is VOO. It would pace the ventricle. It would not sense what's happening in the ventricle,

and it would not respond to anything that it of course then sensed. So the other mode is the non pacing mode, and that's a mode for a patient who has a strong underlying rhythm. Maybe they had an ICD implanted

and their ICD was implanted because they had a sudden cardiac death but they have no issues. Or it's just (mumbles) because they're high risk for sudden cardiac death, but no pacing needs. So the pacing indicator or the pacing need is turned off.

So they only have their native rhythm. You would expect that patient to have a variable rate and rhythm because that's what you and I do. All rate response, of course an ICD shocking therapy and tachy therapies are turned off for an MRI, always turned off for an MRI

and I want to mention that again because it's important that we talk over that with the person that's doing the programming prior to their MRI. Now do risks exist for patients that are having an MRI? Yes.

There are concerns, and these concerns are several. One is the device reset with the batteries getting low. So that's why important to make sure that the person has a good battery. Any potential heatings at the lead, at the tissue interface. This is (mumbles) determine to not be

significantly clinically significant. There could be a failure to sense or a failure to pace. Those are some things that we'll talk about. Or inappropriate shocking. Or there is also the option at the device study because of artifacts might increase,

or decrease rather the image quality. Clinical studies however have shown that MRI is safe for both MR conditional and MR nonconditional patients when proper precautions are taken. The risks are rare.

However, with having a well-established monitoring protocol, these risks are minimized, we're prepared for them.

criteria for CTF means that the patient has a mean pulmonary arterial pressure which we measure intraoperatively exceeding 25 millimeters mercury at rest with the mean pulmonary capillary wedge pressure less than 15 so I'm not a

cardiologist but what that means to me is a mean capillary pulmonary wedge pressure less than 15 means that their left heart is not failing so if you have a capillary wedge pressure higher than 15 that means your left heart is not

working correctly and you can't blame it on the CTF so you can't blame it on the right side if the left side isn't working other things that matter are the abnormal pulmonary vascular resistance and having a systolic pulmonary artery

pressure greater than 40 so what I want to show you and highlight is the law the lost art of pulmonary angiography which i think is now sort of again a lost art some places do a lot of it and some places don't do very much but diagnostic

pulmonary angiography is actually the gold standard in the planning of either surgery or medical management for patients with CTF we do we do these on almost all of our patients with CTF to make that decision with the surgeons and

the cardiologists so the utility is very it's very useful you're able to measure our pressure you're able to decide whether we're the where the thrombus exists in this image here in patients with disease in the

blue and yellow outlined areas those are the patients who can have the operation the operation is curative it's not just medication that you have to take for the rest of your life you can actually remove that chronic clot it's much like

a femoral endarterectomy that are done for patients with peripheral arterial disease although it's a lot more complicated because they have to crack your chest open what's important is getting very very

good high-quality pulmonary angiogram xand so we do we used to do about we do about a hundred of these a year where I trained or actually where I work now and you get very magda up views and you're gonna show all of the vessels and so

these are the views that we use at our institution they happen to be the pipette criteria so it's the same thing you used to do for acute PE you put a flush catheter in the main pulmonary arteries when you're looking at the

upper lobes and when you're looking at the lower lobes you want to push the catheter further into the pulmonary arteries and inject usually what I do is a two to three second injection so that you can stack the images very well and

show all of them in one view this allows your surgeon to make a decision easily as to whether they can operate or they can't operate on this and then I use a higher frame rate usually because these patients are wide awake we when we do

this case we give our patients twenty five mics of fentanyl one time and that's it just to help get the sheath in I usually do this with a seven French sheath and then use a flush cap pulmonary artery catheter many of which

are currently off the market but when we do this we just give them that twenty five Mike's because they have to hold their breath and I usually go up to a high frame rate in the first run and then adjust based off of how well that

patient is holding their breath this really takes a team effort from our nursing technologists and the and the physicians in the room to make sure that this patient does a good job because it's gonna change their management so

there are a lot of different types of angiographic findings on one of these pulmonary angiogram they're really really interesting pulmonary angiogram zin these patients and they're sometimes not at all subtle so you're looking for

a pruning of distal vessels if we start in the top left where you're just not seeing the Brent normal branch pattern you look for stenosis so we're not usually used to looking at stenosis and the pulmonary arteries but this is

actually what you're looking for in CTF you're looking for webs or bands so you'll usually see little areas where you just doesn't look like there's great opacification there's little areas that there's not good at pacification those

are little webs inside the vessel believe it or not looks like a cobweb that grew inside there from that thrombus and then you're looking for areas of complete occlusion that there's just no vessels there those are all

vessels that can be treated in patients with CTF so this is the Jameson classification before we talk about the sort of the interventional management the surgical management is again the curative and dr. Jameson is the head

surgeon at University of California in San Diego which is the largest Palm CTF program in the in the world and he's done I think over 3 500 of these operations I think he's retired at this point but they named the classification

after him and so type 1 is proximal disease so it involves the main pulmonary arteries these are the ideal patients who can get the best benefit from this in their life type 2 is the next best

it's segmental proximal just type 3 is distal segmental and then type 4 is just a mess of sort of all of it but you can't really get a good surgical plane so type 1 and 2 are treated with pulmonary thromboembolism

towards balloon pulmonary angioplasty or BPA and type 4 are generally treated with medication so PT II or pulmonary

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

higher procedures that get done in the country so they are from being basics such as being para sentences and in some

centers being quite complex in Euro work and there are centers where these none of all those that IR procedures being available so it's a very unequal distribution of provision of IR services and like I mentioned earlier on vascular

surgeons and cardiologists have basically taken over the peripheral vascular work and iogic work and other known neuro speciality such as bid early interventions for example saying that these two surgeons who are in some

remote centers who are doing their own provision as biliary basic interventions there is one neuro surgeon who went and had neuro imaging and then your interventional training who is now hundred percent doing a mural

intervention so as far as procedures go my day can be in diagnostic work and you might be dreaming you doing a paracentesis the next thing you might be doing some some I our basic IR and on the same day you might be doing a set

procedure so quite varied but not available in all centers as one would want as fine stuff goes the technology

is my cap nog Rafi reading actually I want to back up a little bit here do I want to back up no I don't I don't want to back up so um let's look at the first

question why is my cap nog Rafi reading abnormal so let's first talk about physiology so a question I get a lot of times is sue the patient comes down for a procedure to the floor I put a sample line set on

them I plug them into the monitor and I'm getting a value of 28 29 30 why are my values abnormal anyone ever see this is anyone still awake okay so there's a few reasons the patients that we are dealing with generally aren't

healthy right I mean sometimes I go to work and I get chest pain I'm like can I just be in an ambulatory gallbladder room today because the patients that are coming from down to IR are sick what their physiology is sick too so we have

Krebs cycle we take oxygen in right it circulates to ourselves it participates in aerobic metabolism we get the byproducts of heat and energy and we get carbon dioxide as a by-product carbon dioxide really diffuse about diffuses

into our blood travels to the lungs and gets exhaled where we measure it so let's talk metabolism really quickly so if someone has a fever if their metabolism is ramped up you think they're gonna be producing more carbon

dioxide yes let's say they're a little hypothermic maybe they're gonna be producing a little bit less you see it for sure in the car patients who are cardiac arrest that are cool to status post cardiac

arrest right those values go way down normal physiology normal physiologic response somebody comes down and they're mildly hypoxic they've got pneumonia or some sort of VQ mismatch and they're hyperventilating to UM debeso

compensate for their hypoxia do you think there's co2 values gonna be a little lower at baseline yeah so these are the patients that you're seeing right so we have reasons that patients could be hyper cap neck like metabolism

right somebody who's in pain someone who's developing a fever early stages of sepsis they may actually have a little bit of a higher value somebody who's sedated or hypoventilating may have a higher value and when we talk about

perfusion is the blood moving round and round is that circulating co2 coming back to the core do we have increased cardiac output with continuous constant ventilation and certainly we can we're gonna look at equipment issues next and

the same goes true more probably in your cases of the hypocapnia patient so someone who is not fully exhaling someone who's in bronchospasm or a COPD or you're not getting that nice square waveform you're only getting some of the

mixed gas ventilation that they're exhaling rights and the conducting airway is mixing with the alveolar gases someone's a little hypothermic someone who's been NPO for 24 hours right it's the opposite of carb-loading right so

you kind of throw them into a little bit of like acidosis you know they're kind of not burning carbs for fuel are they gonna be producing as much carbon dioxide not so much right so when you're coming so when

patients come down to you and you put them on the monitor consider these things so ventilation perfusion gradients so we have what we call our VQ matches and our body is designed beautifully right so when everything is

working great it works great so the way we ventilate all of our lungs owns is very closely matched to the perfusion of all of our lungs ohms so by me standing up here I'd like to think I'm pretty healthy if you did a blood gas and you

put me on one of those filter line sets right now you would hopefully see a gradient that's very small the normal gradient between a PA co2 on a blood gas so the level of carbon dioxide on a blood gas in the arterial blood and what

you see when I fully exhale into the monitor should be between two and five millimeters so these are your patients come down healthy physiology you put them on and you get a value of like 32 then you

could assume that if they were healthy two to five millimeters okay their blood gas would probably like 35 for POC to everyone follow now does any of our patients read the physiology tech books textbooks no they typically don't so

when you have patients come down they may have shunt right so they may have we have our little airway here a and B you're out like picture them as lungs and lung a is blocked so we have no ventilation going to lung a but blood is

still chugging through right so blood is still going through the pulmonary circuit so we're gonna have Patapsco a dia depending on the size of the shunt is this the end of the world are we gonna cancel the case no but just being

aware of the patient's physiology would explain to you why I put this patient on this and I'm getting a value of 30 you follow and it's not the end of the world you document 30 and you monitor for trends as you're going along with your

sedation same thing goes through with dead space dead spaces were ventilating but we have an area of the lung that is not being perfused pulmonary emboli other circulations some medications hypovolemia shocky patients same thing

the VQ mismatch not the end of the world it's part of the patient's physiology maybe part of the reason why they're down there just being aware of these things though so the technology works right our equipment works if just amazed

it's picking up something that we don't connect all the dots on physiologically that sometimes confuses us a little bit so I hope that clears up part of it so when we're monitoring capnography certainly ventilation is what we think

of first and it's important co2 being expired by the lungs that's what we're looking for but if we back up and look at the physiology of carbon dioxide production in the body we are also inferring that

it's being metabolized and being created from Krebs cycle and aerobic metabolism and that we have perfusion occurring okay I'm sure if some of us have seen in our you know nursing careers patients who are kind of peri-arrest and

the capnography kind of drops off it's like a poor man's swan you're watching cardiac output drop in real time because carbon carbon dioxide is not being delivered to the lungs so when we're looking at our patients when

they first come down we first want to establish a baseline value we want to put on a monitor have a patient take some nice deep breaths full ventilations not just one but a few you want to you know have them take a few and look at

their other vital signs their mental baseline status and we're gonna look for trends in their carbon dioxide value so if someone starts off at twenty nine I don't care that they're not 35 to 45 which is textbook normal this person may

not have the stimulus to breathe if I let too much co2 accumulate so we're really looking for the trends okay now somebody will say well how much of you know how much should we look for 10 to 20 percent change from your baseline is

somewhere where you want to start paying attention to what's going on okay maybe like titrating your sedation or just being a little bit more cautious with how much more sedation but again it's more important to look at the trend

value behavior of your carbon dioxide than it is the absolute numbers themselves so first you having a problem let's consider the patient's physiology

So an ICD is implanted for basically two main reasons. One is primary prevention, and I call it prevention. It means that the patient has a high risk for sudden cardiac death, which is SCD, Vtach or Vfib,

but they've never actually had an episode. The ejection fraction is either less than or equal to 35%. So ejection fraction is the pumping action of the heart and it just means that with each beat, a low percentage of blood is being extracted

and that patient, when that happens, it's been proven that a low ejection fraction person with a low EF has a higher risk of sudden cardiac death. Now I call the other one treatment, but it's actually named secondary prevention. It means that patient has actually survived

an episode of sudden cardiac death, and there's no known correctable cause. They didn't have a severe electrolyte imbalance that caused them to have a cardiac arrest. They didn't happen an MI and they've been stented and reopened and they would no longer be

a candidate for a device because of that reason. Congenital reasons are also another reason for implanting a device, an ICD. Now a patient who requires an ICD, as I said, an ICD can both do pacing and shocking functions, but they may also have pacing needs.

So the ICD (mumbles) implanted because it can do both.

strategies so some things that we have

in place right now our peer review Grand Rounds CPOE this is one of my one of my favorite process improvements is is making the right thing the easiest thing and you do that through standardization of processes so that's standard work so

that's your order sets that's the things pop-ups although you don't want to get into pop-up fatigue but pop-ups help our providers for little gentle reminders to guide them to what's right for the patient and to cover everything that we

need we need to cover to ensure the safety of our patient so recently in the fall of last year we had a TPA administration err that occurred it involved a 69 year old patient who two weeks prior had had some stenting in her

right SFA she presented to our clinic when our clinics with some heaviness in her leg and some pain and when she was looked at from an ultrasound standpoint it was determined that her stents were from Bost so she was immediately taken

to the cath lab and it was after angiography did indeed show that there was clot inside these stents they did start catheter directed thrombolysis in the cath lab they also did started concurrent heparin often oftentimes done

with CDT what's usual for our institution is that we have templates that pull in the active problem list for a patient in this case the active problem list or a templated HMP was not used had they

used the template at agent p they would have found that the second active problem on this patients list was a cerebral aneurysm so some physicians will tell you some ir docs will tell you that's an absolute

contra contraindication for TPA however the SI r actually lists it as a relative contraindication so usually we're used to when you when you start a final Isis case you know you're gonna be coming in every 24 hours to check in

that patient in this case we started the the CDT on a Thursday the intent was to bring her back on Monday the heparin many ir nurses will know that we will run it at a low rate usually 500 units an hour and we keep the patient sub-sub

therapeutic on their PTT although current literature will show you that concurrent heparin can also be nurse managed keeping the patient therapeutic in their PTT which is what was done in this case so what ended up the the

course progression of this patient was that so remember we started on Thursday on Saturday she regained her distal pulses in her right leg no imaging Sunday she lost her DP pulse it was thought that it was part of a piece of

that clot that was in the the stent had embolized distally so they made the decision with the performing physicians they consulted him to increase the TPA that was at one milligram an hour to 2 milligrams by Sunday afternoon the

patient had an altered mental status she went to the CT scan which showed a large cerebral hemorrhage they ain't we intubated to protect her airway and by Monday we were compassionately excavating her because

she me became bred brain-dead so in the law there's something that's called the but for argument so the argument can be made that this patient would not have died but for the TPA that we gave her in a condition that she should not have had

TPA for namely that aneurysm so this shows how standard work can be very important in our care of our patients and how standard work drives us down the right way making the easiest thing the safest thing so since that time

we've had a process improvement group that we've established an order set specifically for use and thrombolysis from a peripheral standpoint and then also put together a guideline that was not in place so it's some of that Swiss

cheese that just kind of we didn't have a care set we didn't have a guideline you know we didn't use our template so all those holes lined up and we ended up with a very serious patient safety event so global human air reduction strategies

oops sorry let's go back these are listed in a weaker two stronger and some of what we're using in that case is some checklists so we developed a checklist that needs to be done to cover the

absolute contraindications as well as the relative and it's embedded in the Ulta place order that the physician has to review that checklist for those contraindications and also there to receive a phone call from pharmacy

just to double-check and make sure that they have indeed done that that it's not somebody just checking it off so we have a verbal backup sorry so the just

thrombectomy is another popular way of treating patients there's a lot of different aspiration catheters the SPX catheter is actually not available currently in the US but what it basically is I can have the rectum a

device that spins in such backlot the Indigo thrombectomy system from penumbra is a yet another device that sucks out clot I think many of us have used that it's kind of like a vacuum cleaner but usually more like a dust

hand vac where it's going to suck up thrombus the angio vac is much more like a Hoover where you're going to use and put a patient on veno-venous bypass that requires a 22 French sheath and a 17 French sheath but that will take out

thrombus I personally prefer using NGO vac in the IVC in big large thrombus for that and not in the pulmonary arteries because it's very inflexible but it's very very useful in a few patient populations in

all of these devices there is no TPA that needs to be given you're just sucking out the clot and you're actually removing it from the patient's body rather than dissolving it and sending it downstream the drawbacks on all of these

devices is their larger access points the SP or X is around six French although that's not that much bigger penumbra device is 8 French and the as we mentioned the angio vac is 22 French

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