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Rad Aid- IR Nursing in Tanzania | Advancing Radiology and Nursing through Global Health Outreach
Rad Aid- IR Nursing in Tanzania | Advancing Radiology and Nursing through Global Health Outreach
angioassessmentcampuschaptercreateembolizationgooglegroundNonenursingpercutaneousprogramritesustainable
Muscoskeletal Ablation | Interventional Oncology
Muscoskeletal Ablation | Interventional Oncology
ablateablatingbonescannulatedcementchaptercryoiliacmalignancymusculoskeletalorthopedicpercutaneoustumor
Cryoablation - What it is and how it works | Ablations: Cryo, Microwave, & RFA
Cryoablation - What it is and how it works | Ablations: Cryo, Microwave, & RFA
ablationablationsargonballchaptercoolcryoablationheliuminfusednitrogenprobeprobessurroundingtissuetissues
Surgical AV Fistula  | Pecutaneous Creation of Hemodialysis Fistulas
Surgical AV Fistula | Pecutaneous Creation of Hemodialysis Fistulas
angioplastycannulatedcathetercatheterschapterdeviceDialysisembolizationFistulafistulashemodialysismaturationpatientspercutaneousrefused
The Ways to Recanalize the Below the Knee Vessels | AVIR CLI Panel
The Ways to Recanalize the Below the Knee Vessels | AVIR CLI Panel
ablationanalogantibioticarteriesarthritisassessaveragebasicallychapterclinicaldissolveemboembolizationembolusinfarctinjectinvestigationalkneelateralmedialmrispainpalpatepatientpatientsprocedurepublishedradiofrequencyrefractoryresorbablescalestudy
Nodule in right lung | Cryoablation Case | Ablations: Cryo, Microwave, & RFA
Nodule in right lung | Cryoablation Case | Ablations: Cryo, Microwave, & RFA
ablationablationschaptercryocryoablationfreezehemorrhagelesionlungLung Noduleminutesnodulepneumothoraxprobesprotocolproximalthawtriple
Summary of Ablation Modalities - Cost, Time, Risks and Rewards | Ablations: Cryo, Microwave, & RFA
Summary of Ablation Modalities - Cost, Time, Risks and Rewards | Ablations: Cryo, Microwave, & RFA
ablationablationsanesthesiachaptercryoheatissuemicrowavemodalitiesmoderatemultiplepainprobesproceduralsinkvendorzone
Case- Brain Infarction | Brain Infarct After Gastroesophageal Variceal Embolization
Case- Brain Infarction | Brain Infarct After Gastroesophageal Variceal Embolization
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CT Angiography | Determining the Endpoints of CLI Interventions
CT Angiography | Determining the Endpoints of CLI Interventions
aneurysmsangiogramangiographycalcificationcalcifiedcenterschaptercontrastemoryequivalentinterventionkneemraoccludedpatientvessels
Heat Sink Effect in RFA | Ablations: Cryo, Microwave, & RFA
Heat Sink Effect in RFA | Ablations: Cryo, Microwave, & RFA
ablationbloodchapterheatinfraredportalsinkvessel
Malignant melanoma, liver lesion | Microwave Ablation Case | Ablations: Cryo, Microwave, & RFA
Malignant melanoma, liver lesion | Microwave Ablation Case | Ablations: Cryo, Microwave, & RFA
ablationchaptercombicontrastcostalcryofluoroscopicgallbladderhepaticliverliver metastasesMalignant melanomamelanomamicrowavemicrowave ablationnerves
The Procedure - Creating a Deep Fistula | Pecutaneous Creation of Hemodialysis Fistulas
The Procedure - Creating a Deep Fistula | Pecutaneous Creation of Hemodialysis Fistulas
anastomosisarteryAvenu MedicalballoonbrachialcephalicchaptercreationdeviceEllipsysFistulaflowflowinglinesneedleperforatingperforatorpiccproximalpuncturepuncturedradialsurgicalultrasoundvein
RFA Probe types | Ablations: Cryo, Microwave, & RFA
RFA Probe types | Ablations: Cryo, Microwave, & RFA
ablationaugmentationbipolarchapterimpedanceincreasesinfuselevineMedtronicosteoOsteoCool RF Ablation Systemprobeprobessalinetemperaturetines
Kidney lesion | Cryoablation Case | Ablations: Cryo, Microwave, & RFA
Kidney lesion | Cryoablation Case | Ablations: Cryo, Microwave, & RFA
ablationballchaptercollectingcryoablationkidneylesionLesion in left kidneymedialstricturessystemtumorureter
Benefits of UFE | Uterine Artery Embolization The Good, The Bad, The Ugly
Benefits of UFE | Uterine Artery Embolization The Good, The Bad, The Ugly
arterycenterschapterembolizationfibroidgooglegynecologistgynecologistsgynecologyhysterectomieshysterectomyinterventionalMRINonepainfulpatientsprocedureproceduresseansmartersurgeryuterine
Why is Staging Important | Interventional Oncology
Why is Staging Important | Interventional Oncology
ablateablationangiogramchapterhepatocellularhyperintensityMRIshapedtumor
Introduction - Percutaneous Fistula Creation | Pecutaneous Creation of Hemodialysis Fistulas
Introduction - Percutaneous Fistula Creation | Pecutaneous Creation of Hemodialysis Fistulas
accessangioplastyarterycephalicchaptercolordisclosuresdopplerFistulafistulashemodialysispercutaneousperforatingperitonealpreoperativeradialtechnologisttotallyulnar
What is Rad Aid | Advancing Radiology and Nursing through Global Health Outreach
What is Rad Aid | Advancing Radiology and Nursing through Global Health Outreach
advancingaidsbillioncenterschapterclinicalglobalhealthinstitutionsmissionNonenursesnursingorganizationpopulationpracticingprogramsradiologicradiologistradiologyshortageskillssustainableunited
Rationale for Geniculate Artery Embolization- Knee | Geniculate Artery Embolization for Arthritic Pain Why How & Results
Rationale for Geniculate Artery Embolization- Knee | Geniculate Artery Embolization for Arthritic Pain Why How & Results
antibioticarteryarthritisbiopsybloodchapterclinicalcolorcytokinesdegenerativedissolveemboembolisationembolizationembolushospitalizationsincreasedinflammationinflammatoryinjectinjectionskneeleadsneurovascularnsaidnsaidsosteoarthritispainpatientspublishedresorbablerheumatologyshoulderslidessynovialvesselvessels
Case- Vaginal Foreign Bodies- 5 year old female | OMG: Interesting Cases in Pediatric Radiology
Case- Vaginal Foreign Bodies- 5 year old female | OMG: Interesting Cases in Pediatric Radiology
abdomenbleedingchaptermetalMRINoneobject foundultrasoundX-ray revealed object
Case 4a: Renal Trauma | Emoblization: Bleeding and Trauma
Case 4a: Renal Trauma | Emoblization: Bleeding and Trauma
angioangiogramangiographyarteriovenouscenterschaptercoilscontrastembolizationembolizeembolizedextravasationFistulagradehematomahemodynamicallyimageinjurieskidneyNoneparenchymapatientspenetratingpictureposteriorrenalRenal Traumaretroperitoneumscanspleensurgicallytrauma
Overview of Biliary Disease at John's Hopkins | Biliary Intervention
Overview of Biliary Disease at John's Hopkins | Biliary Intervention
accessangiogrambiliarychaptercolonoscopyendoscopicercphopkinsinterventionlandscapeliverpercutaneouspracticequestionspecialtiesspecialty
Creating a Deep Fistula | Pecutaneous Creation of Hemodialysis Fistulas
Creating a Deep Fistula | Pecutaneous Creation of Hemodialysis Fistulas
anatomicanatomyarterybasilicbrachialcephalicchapterdeepdevelopeddevicefishFistulafistulasflowforearminterventionalmedianneedleneedlesnerveperforatingperforatorprocedureradiologistradiusselectivelysuperficialtexastransposedultrasoundupperveinveinsvenous
Radiofrequency Ablation (RFA) - How it works | Ablations: Cryo, Microwave, & RFA
Radiofrequency Ablation (RFA) - How it works | Ablations: Cryo, Microwave, & RFA
ablationchaptercharringcoagulationconductconductioncurrentheatimpedancemicrowavemoleculesnecrosisproberadiofrequencyrapidtemperaturetissue
RFA Advantages and Disadvantages | Ablations: Cryo, Microwave, & RFA
RFA Advantages and Disadvantages | Ablations: Cryo, Microwave, & RFA
ablationburnschaptercirrhosislivermodalitiespadsradiofrequencyunpredictablezone
Keys to Good Outcomes in Ischemic Stroke | Neuro-Interventions
Keys to Good Outcomes in Ischemic Stroke | Neuro-Interventions
abnormalaspectsbloodbraincenterscerebralchaptercollateralscolorcontraindicationguidelinesheadhypoglycemicimagingintervenelumpectomymapsMRIocclusionpediatricPenumbraperfusionscalestrokestroke scalethrombectomyworkflow
Successes of EndoAVF Creation | Pecutaneous Creation of Hemodialysis Fistulas
Successes of EndoAVF Creation | Pecutaneous Creation of Hemodialysis Fistulas
accessangioplastycathetercatheterschaptercharlestonDialysiselevationsFistulamonthspatientspercutaneousphysiciansproceduresurgeonsvascularveinweeks
Results of the US FDA Trial | Pecutaneous Creation of Hemodialysis Fistulas
Results of the US FDA Trial | Pecutaneous Creation of Hemodialysis Fistulas
anastomosisangiogramangioplastyarteryBARDBD EverlinQ (4Fr & 6Fr)brachialcalcifiedcatheterschaptercreatedevicedevicesDialysiselectrodeembolizationembolizeendpointsenergyFistulafistulasflowfrenchmagnetsmaturationofficialpercutaneousperforatorpositionpseudoaneurysmradialradiofrequencysaddlesitssurgeonsurgicallyulnarveinvena
Transcript

rate. There's a 45 year old radiology tech with a back pain and a sciatica of L5 S1 and an AVS of six out of ten. And this is his MRI. Okay, you can see the disc protrusion,

what are we going to do? Nothing? Make him work? Conservative, injectates, percutaneous disc. Well the first thing you should always try is conservative management. This is the first and foremost way of treating for these patients

so conservative management is the first thing one should try. This is one year later, you can see that the hernia has completely disappeared and has completely retracted because the disc has a natural history of resorbing itself. 17 to 19 of all persons will experience low back pain at some point

in their lives, and 80 to 90 will recover by themselves within three months, just physiotherapy, exercise and changing diet. Again disc herniation in time in the cervical level, you can see that's for an MRI and one year later where is that hernia? So the disc can resorb itself given enough time.

The question is if we have this time?

so let me just be honest you know two things about me when I speak I can't stand still if you've ever heard me talk

before so he always has to make me up but secondly I don't think I'm gonna make it through this without getting emotional I feel like if I can get through this whole spill without it being an ugly cry then I look like it's

a success and if you don't know what that is you can Google Kim Kardashian ugly cry so all right so I had the opportunity to go to Tanzania in October November of this year and be part of the first ground zero nurses on the ground

and the first IR there and let me tell you how this went down the end McNamara was really involved with rad aid before she got off our board and one day I had a wild hair and told Bruce from our management company was like hey I think

I want to do one of those trips can you hook me up with Patti over at Rite Aid and he was like yeah sure so Patti calls and she said you know I think he'd be great for a tanzania project I'm like great let's go and she's like wait now

who are you and how do we how are you even affiliated with Arab and I said no where's Tanzania so that's where it's at and if you know me I'm kinda like eh let's go and I don't even know where we're going and it's a 23 hour flight in

case you're interested but Tanzania is a country of 60 million people for you to get a perspective of what that looks like it's California and New York State's population combined and could you imagine not having an IR we've

have five IR s in Little Rock Arkansas going down one small interstate that looks like no biopsy no drain no just the very basic IR procedures that we take for granted don't exist there or didn't before we got there so in October

of 2017 the Yale read a chapter went down there and they assessed the potential for establishing an ir intends and so based on these findings they decided with went collaboration between the movie and Billy National Hospital

the orthopaedic Institute which you're actually like toothed small hospitals on the same campus or actually excuse me MNH is very large and then mo I is kind of smaller but on the same campus there University and the Rite Aid chapter they

would joint plan to start the first ir so the program consists of three components which is practical training a curriculum development and then finding a way to create some sustainable product development you're probably probably

aware you hear about people donating products to these countries but there's the sustainable how do I create a program in a process where we're not just waiting on someone to donate something where we can keep this our

system going so the program overview so this was we're going on two-week rotations over three years and the teams consist of an IR doc and RN and Artie we were the first group to go over in 2018 and so our goals are in year one to do

basic percutaneous procedures biopsies and drains year to going to vascular access and in year three doing more angio type cases like tase's embolization zan etc and developing a teaching curriculum because while there

is a radiology program for residents there was an IR specific one and they're creating that now so our goal is the first nurses on the ground was to provide this comprehensive nursing assessment to help map the project over

the next three or five years now when they went in the year before you can imagine all of the infrastructure assessment all of the you know the equipment there was so much that went into that but the nursing piece was our

job as the first people on the ground and this was so incredibly well received in Tanzania and they were so excited that we were on the front page of the Guardian you can see our doctors Eric and aza down at the bottom right who are

actually here at SAR this week on what looks like to be Good Morning America in Tanzania and when I arrived I was I found out we were having a first conference and there was a camera in my face so I'm

not sure what's which Swahili speaking news outlet I was on but I think I might have been on one and to the left you can see David Pro logo was the attending that I worked with at the same press conference so what I'm trying to say is

no pressure I was like we got it no pressure we have to create this nursing assessment and we wanted to do a good job because it was very well received in the media and we wanted to make sure this all went off really well I would

ablating things in the bones well musculoskeletal blasian we're fortunate within our practice that we have a doctor councilman Rochester who's

a probably one of the biggest world's experts on this and these are his cases that he shared but you can see when you have small little lesions and bones that are painful you can place probes in them and you freeze them the tumor dies and

musculoskeletal things remain intact what about when you have cases like this where there's a fracture going through the iliac bone on the left with an infiltrate of malignancy well you can cryo blade it and what's cool about is

you can using CT guidance do percutaneous cannulated pins and screws and a cement o plasti ver bladed cavity and when you're done the patient who initially couldn't walk now can and whose pain scale went down to one so I

think that's that's very important to realize the potential of image-guided medicine this is something that previously would have had to been done in the orthopedic lab so you know I think this is extending options where

otherwise it would have been difficult same thing applies to the spine you can ablate and fill them with cement so

to talk about cryoablation which is very commonly used in a number of organs it can essentially be used anywhere in my opinion with cryoablation as many of you know the different idea is that you have a probe and it creates this ice ball and

that's what's killing the tissues rather than heating the tissue when they first came out with cryoablation they had these really large probes and that really limited what we could do well with technology obviously those probe

size decreased and we were able to do better ablations and safer oblations in patients so it really took off at that point and the general goal once again is to decrease the temperature to about minus 20 degrees Celsius and in doing so

you kill the tissue and we'll talk about the mechanism of how that works the cold spreads Bible directly molecular transfer right so you're starting to cool around the probe and that will propagate to the surrounding tissue

unlike our FA or microwave as the ice ball grows it doesn't impede further ice ball growth right you can continue to build on that ice ball as you increase the amount of argon infused in the increase the number of probes so that's

beneficial and that you can get a massive ablation depending on how many probes you want to place well talk a little bit of how it works so it works by what's called the joule-thompson effect idea here is if any of you've

done cry before you know you have to drag those huge tanks into the room and it just runs through all gone like nothing so when we first started doing cryoablation you had to have an all gone tank and a helium tank they've gone away

with the helium and now you really just need the argon tank which is really nice and that you don't have to drag those tanks around and they're working on actually doing with nitrogen but that hasn't come to fruition yet so the idea

is that you take a high-pressure gas right so it's in the tank it's pressurized it gets run through the center of the probe and then as it comes out the tip will not out the tip of the probe and within

the tip of the probe it goes to low pressure and that change in pressure allows the temperature of the probe tip to cool right and so if you're using argon or oxygen or nitrogen that'll cool if you're using helium it'll actually

heat the tissues and so that's why we used to have argon and helium to be able to to freeze and then actively Thor so as I mentioned the argon comes from a pressurized tank you have this dual chamber probe that allows the gas to

expand and as it expanded pools heat from the surrounding tissues so as many

today okay go forward so sorry now when it says is there any commercial bias really there's only two companies that have this device so if I speak about each one clearly there's going to be a

little bit of commercial discussion but as I people always ask me which one do you prefer and I always have to tell them quickly you know I'm not a salesman for either company as a matter of fact I'm more

like a test pilot and we're still in the very early stages of this and which device may be better however you wanted to find that or easier to use or what the data is going to show we don't really know yet so but we're fortunate

that we have access to both devices for our patients a couple of things we know and dialysis patients start 80% start with catheters bad okay and catheters bad if you get anything out of this lecture catheters bad about 28 to 53

percent failure to mature means they have a fistula it's physiologically working but it never matures to be able to use for hemodialysis time to maturation three to four months

interventions per year required angioplasty you know embolization you guys know all about this stuff trying to read Evert flow back into the main channel of the fishhook and patients about 30 up to 30

percent just refused once they have our fish to them for whatever reason they refused to have it cannulated you know they don't like the pain it's in an awkward position whatever but the idea of percutaneous

which was may actually put a big dent in that Kathy first-line initiating dialysis with catheters because many times these patients come then they need to houses right away they get a catheter but if we know you know these things

usually except you know for toxic injury like ingesting antifreeze and stuff like that most you know frolla just know these patients are headed towards dialysis well in advance of the time they need it and so these calls stage

four and stage renal disease these patients can get percutaneous fistulas and when it's time then they'll have a running blood access ready and totally avoid the need to have a catheter placed

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

something some case examples of where I use cryoablation right so this is a

patient who has a nodule in the in the back of their lungs in the right lower lobe and basically I'll place two probes into that notch on either side of Brackett the lesion and then three months later fall up you can see a nice

resolution of that nodule so when it comes to lung a couple things I'll mention is if the nodule is greater than eight millimeters I'll immediately go to two probes I want to make sure that I cover the lesion whereas microwave it's

pretty rare depending on what device you're using for you to put more than one probe in so some people's concern with cryo in the lung is more probes means more risk of pneumothorax but you can also see surrounding and proximal to

where we did the place you can see the hemorrhage that you see so if those of you out there that are doing the lung ablations you probably have physicians that are using something called the triple freeze protocol right so the

double freeze protocol is the idea that you go ten minutes freeze five minutes 30 minutes freeze five minutes thought well what we saw was lung early on in the studies was a very large ablation a freeze to start with caused massive

hemorrhage patients were having very large amounts of hemorrhage so what we do now in lung is something called a triple freeze protocol we'll do a very short freeze about three minutes and that'll cause an ice ball to form and

then we'll thaw that in other three minutes three minutes of thawr and as soon as that starts to thaw we'll freeze it again and we've shown us a substantial decrease in the amount of hemorrhage so if you're doing long and

you and you you're told to do a double freeze protocol perhaps suggest the triple freeze is a better idea so that's three months later so another example

of all that all the the probes and the modalities I'm sorry so RFA you can have multiple probes the cost is cheap it's quick but the ablation zone is small and you have this heat sink issue the procedural pain is moderate but the best

attribute is that it is cheap so if you don't have a lot of money for ablation RFA is the way to go cryo on the other hand you can put in multiple probes which means you can get just enormous burn

I'm sorry ablation sizes but the time is slow right so you're gonna stand there for a while while the ice forms and freezes and forms again you get a higher risk of bleeding there's a moderate issue of heat sink effect or it's really

cold sink if you will but the procedural pain as I mentioned is is low so you can do with conscious sedation and my biggest benefit of that I perceive with cryo is the ability to visualize that ice ball and then finally microwave

which is the new kid on the block will you can use single or multiple probes depending on the vendor it's it is expensive depending on the probes you use in the vendor that you use but it's very quick as I mentioned 10 minutes

usually you can get a pretty sizable ablation zone size some will advertise up to four and a half centimeters which is pretty good size you don't really want to be doing a whole lot of ablations in most organs if the lesions

more than four and half centimeters so that's very comforting to have that large ablation that's very predictable there's no issue with heat sink but the procedural pain is high so if you want to do microwave you're gonna more than

likely have to use general anesthesia or somehow find a way to mitigate that pain and that's all I have on ablation so there's any questions of entertain them

I like to talk about brain infarc after Castro its of its year very symbolic a shoe and my name is first name is a shorter and probably you cannot remember my first name but probably you can remember my email address and join ovation very easy 40 years old man presenting with hematemesis and those coffee shows is aphasia verax and gastric barracks and how can i use arrow arrow on the monitor no point around yes so so you can see the red that red that just a beside the endoscopy image recent bleeding at the gastric barracks

so the breathing focus is gastric paddocks and that is a page you're very X and it is can shows it's a page of Eric's gastric barracks and chronic poor vein thrombosis with heaviness transformation of poor vein there is a spline or inertia but there is no gas drawer in urgent I'm sorry tough fast fast playing anyway bleeding focus is gastric barracks but in our hospital we don't have expert endoscopist

for endoscopy crew injections or endoscopic reinjection is not an option in our Hospital and I thought tips may be very very difficult because of chronic Peruvian thrombosis professors carucha tri-tips in this patient oh he is very busy and there is a no gas Torino Shanta so PRT o is not an option so we decided to do percutaneous there is your embolization under under I mean there are many ways to approach it

but under urgent settings you do what you can do best quickly oh no that's right yes and and this patience main program is not patent cameras transformation so percutaneous transit party approach may have some problem and we also do transit planning approach and this kind of patient has a splenomegaly and splenic pain is big enough to be punctured by ultrasonography and i'm a tips beginner so I don't like tips in this difficult

case so transplanting punch was performed by ultrasound guidance and you can see Carolus transformation of main pervane and splenorenal shunt and gastric varices left gastric we know officios Castries bezier varices micro catheter was advanced and in geography was performed you can see a Terrell ID the vascular structure so we commonly use glue from be brown company and amputee cyanoacrylate MBC is mixed with Italy

powder at a time I mixed 1 to 8 ratio so it's a very thin very thin below 11% igloo so after injection of a 1cc of glue mixture you can see some glue in the barracks but some glue in the promontory Audrey from Maneri embolism and angiography shows already draw barracks and you can also see a subtraction artifact white why did you want to be that distal

why did you go all the way up to do the glue instead of starting lower i usually in in these procedures i want to advance the microcatheter into the paddocks itself and there are multiple collateral channels so if i in inject glue at the proximal portion some channels can be occluded about some channels can be patent so complete embolization of verax cannot be achieved and so there are multiple paths first structures so multiple injection of glue is needed

anyway at this image you can see rigid your barracks and subtraction artifacting in the promenade already and probably renal artery or pyramid entry already so it means from one area but it demands is to Mogambo region patient began to complain of headache but american ir most american IRS care the patient but Korean IR care the procedure serve so we continue we kept the procedure what's a little headache right to keep you from completing your

procedure and I performed Lippitt eight below embolization again and again so I used 3 micro catheters final angel officio is a complete embolization of case repair ax patients kept complaining of headache so after the procedure we sent at a patient to the city room and CT scan shows multiple tiny high attenuated and others in the brain those are not calcification rapado so it means systemic um embolization Oh bleep I adore mixtures

of primitive brain in park and patient just started to complain of blindness one day after diffusion-weighted images shows multiple car brain in park so how come this happen unfortunately I didn't know that Porter from Manila penis anastomosis at the time one article said gastric barracks is a connectivity read from an airy being by a bronchial venous system and it's prevalence is up to 30 percent so normally blood flow blood in the barracks drains into the edge a

ghost vein or other systemic collateral veins and then drain into SVC right heart and promontory artery so from what embolism may have fun and but in most cases in there it seldom cause significant cranker problem but in this case barracks is a connectivity the promontory being fired a bronchial vein and then glue mixture can drain into the rapture heart so glue training to aorta and system already causing brain in fog or systemic embolism so let respectively

for it's very it at centers where CTA protocols are very good it's basically equivalent to a angiography has been shown in multiple papers to be so newer studies show that

CTA and Emory are equivalent so I don't know it depends on your institution there are a lot of places that still practice with the MRA is kind of the gold standard but CTA is just so much more available that CTA is becoming kind

of the new gold standard for for quick vascular assessment often like to use it to help us plan our intervention so if we don't know what's going on above the level of the groin CTA could be helpful to see whether or

not we could even go from right to left how calcified the vessels are or whether or not there's concomitant aneurysms things that we don't like to discover at the time of the procedure because we might not have the equipment we need to

treat it one of the strengths is that it's quick and that it's cheap but of course it uses contrast and just like you know we like to minimize the amount of contrast that we're using at knee and rogram this can use anywhere from 75 to

150 cc's of contrast or not a small amount and if you're gonna do an intervention the same or the next day that's a lot of dough that's a lot iodine in a couple days these are examples of what we can see at the time

of the procedure there's a 3d reconstruction and a BU these are kerf planer reformatted images what basically they draw a line down the image and you can lay the entire vessel out even if it's very squiggly and then this isn't

this an angiogram and that same patient you can see that they correlate exactly another example a patient with aortic calcification you can see that it can be potentially challenging this patient with diabetes to determine whether or

not these vessels in below the level of the knee are paetynn or not because I can tell you that the one that's closest to the small bone there is actually occluded it's just all calcified you can't really tell what's going on and

the one that's behind that is actually Payton so it could be difficult to tell whether it's calcium or contrast that you're seeing this is where MRA can be

ablation also has a little disadvantage than that I don't know if you folks have heard of heat sink but the idea is that

if you put the probe immediately adjacent to a blood vessel that blood vessel is gonna suck the temperature away and so that you cannot oblate around blood vessels particularly well because the blood flow rate since

you just washes it out it's called heat sink effect and this is essentially showing infrared image of of an ablation how if you put a vessel nearby it stops the ablation now that can actually be used as an advantage depending on where

you're doing an ablation but truthfully if you're doing it in the liver and you're next to the portal vein or something like that it becomes a bit of a problem and any blood vessel greater than three millimeters is our concern so

tip and I'll show an example of that so

right so this is that same lady actually with the malignant melanoma she has a lesion in her liver it's sort of the circumscribed structure we're in right next to the gallbladder there so we placed the probe actually under

fluoroscopic guidance with combi Ct we have a catheter in the hepatic artery so we're gonna inject some contrast and see what the ablation zone looks like but as you can see with injection of contrast very well

delineated margins on that ablation so I could tell with a lot of reassurance like I said that that we're not burning anything that we're worried about I'd say here's an example we've burnt right up towards the gallbladder but didn't

injure the goal though so that's very very nice to know so that's the benefits of microwave ablation in essentially you can use microwave nearly anywhere people are using a lot in renal and and liver nowadays you can use it in lung although

some issues with microwave is it is painful so if you burn the chest wall with microwave you're gonna know about it afterwards whereas cryo you can do near nerves like in a costal nerves and you do just fine so just a quick summary

here a little bit okay the ellipsis device Avenue medical from California developed by Jeff Howe in Richmond ultrasound imaging only don't need

fluoroscopy everybody in the room like staff they'd off to where lid you advance the needle into the either the very distal cephalic vein or through the actual perforator under ultrasound and once you're there you

follow the tip of the needle keeping it in the center of the lumen of the vein under ultrasound guided down to the point where it's just adjacent to the radial artery and then once you're adjacent to the radial artery this may

take a little bit of torquing of the needle but you know even putting in PICC lines for what 15 years 20 years so it's nothing not more difficult than that which is you know why I tell the fellows do the PICC lines you're not doing the

PICC lines just to do pickle and you're doing them so you can do these kinds of procedures then you puncture the radial artery then you get arterial blood flow you put a wire down and you get a sheath down and you put the device down I'll

show you the device in just a second it's called tissue welding it's an electronic device that creates a anastomosis doesn't really succumb to any problems with vascular wall calcifications usually takes just 30 to

45 minutes I did the last one the other day in 15 minutes and angioplasty the anastomosis immediately following the creation of the fissure with a 5 millimeter 1/8 balloon of your choice here's the device you can see it opens

up there's like a little bit of a window there and so it goes down through the vein it crosses over into the artery you're able to see this under ultrasound you position that window as you see on the right with the artery and wall the

vein artery vein and artery walls between that space and then the debate the device closes down on them then the machine will give you a reading of what the distances you push to the button and you got a fistula and it's very pretty

straightforward then you go ahead and balloon that with a five millimeter balloon to make sure the anastomosis is open and running and that's it then you pull out and you can compress with one finger you know on the vein and here's a

look at the the anatomic and that's office Jilla that it does create you know you don't mobilize there's no surgical trauma patient goes home with a couple of band-aids here's a dissection with ultrasound of the area that you're

working in there on the right you can see the perforator coming down it's sitting over the PRA the right proximal radial artery and that's right where you're going to make your puncture from one vessel into the other and this is

what you're left with on the left of course you see a big surgical scar from a prior creation of probably in the brachiocephalic fistula and on the right you can see the very prominent cephalic vein after fish through the creation

which is getting ready to to be punctured here's the illustration of what you've just done again perforating vein going down towards the radial artery create the fish stool and now you have a brachial artery down radial

artery so you have a radial proximal radial perforating vein fistula I don't know whether it hopefully it goes up the cephalic vein if it goes up the basilic vein you may have to consider doing transpositions or elevation to get that

vein in a position of yeah so that it can't be punctured here's another ultrasound from one of our cases again showing a nice you know red to blue flow of the fistula here's another one you know I have to see these a while you say

wow it's really pretty amazing and what we do is we get velocity measurements at the time of the procedure one week later then at four weeks later and at four weeks if they're not flowing at least 500 to 600 cc's a minute then we'll go

in and do a secondary balloon or something to get things going there's that same patients actually this is our patients arm it's a different patient and you can see the flow map there and when you see that diastolic component

got halfway up the systolic that means you're flowing at about 600 500 to 600 cc's a minute it's a good indication that you've got a you've created a fistula with working potential if you have to re intervene it's a radial

puncture you go right up the the radial artery I'm sure your dad is familiar with doing that for the most part and that goes right across that and ask Tomo system so if you have to dilate the anastomosis to get a larger you're in

good position if you have to go up and redirect flow by embolization of small collaterals nor the brachial veins now you can do that all from the the radius it's nice highway right up into the fistula

and here's the results of the FDA trial

we're going probes I think many of you have used our FA there's all sorts of different probes right so the most common well one of the most common ones is a probe like a Levine probe and what it does essentially is it increases the

number of tines so you put the probe in and you deploy these tines and it increases your ablation size a lot of companies went towards just a single probe and they infuse saline through the probe which will then decrease the rate

at which the temperature increases so that you get a consistent slow increase in temperature to prevent impedance other probes will actually infuse saline into the tissues so that it propagates the ablation better and then finally

there's by polar probes where you put two probes in next to one another and the the ablation occurs just between the two probes and so that's a very controlled ablation that's the most commonly what you see when you do the

spine augmentation procedures with the osteo cool system or whatever system you're using that's the bipolar probe approach so as I mentioned the

here we have a MRI that shows a lesion in the left kidney sorry I don't have a

pointer here really but you can see the lesion in the medial part of the left kidney there couple probes are placed under CT guidance you can already see the beginning of the formation of an ice ball there this is the second probe you

can see the ice ball forming and there's a good example of the ice ball it's got good coverage of the the lesion as well as a good margin around that cryoablation tends to be less detrimental to the collecting system of

the kidney so some of the concerns when you do renal ablation is that you're gonna cause your read or strictures or urine leaks because you're burning the collecting system essentially with cryoablation you tend not to see that

you don't have to use something called pilar profusion is often right the idea with pilo profusion is you put a small catheter into the ureter and you infuse the kidney with cold saline so that the collecting system stays cold while you

while you burn the tumor well you don't often times have to do that with cryoablation so that's one benefit of it and then this is a one month later scan this is the normal appearance you can see the ablation zone that and the

resolution of the tumor will follow these up for a few years to make sure that all that tissue goes away and this

Sean I know you have not seen these slides at all you wanted I John can talk about this with his eyes closed so it's

not like there's anything but this is the data that was published from the Jade publishing jvi are from what Sean has written and it's just the current standards relating to what you should be expecting what we tell our patients that

they should expect for outcomes as it relates to uterine artery embolization again I'm not really here to try to point this I know you can google these you can get the information yourself but just to say that all of our procedures

have risk and we need to be clear with our patients about them now I believe that with all of these risks combined the benefits of doing uterine fibroid embolization for most patients is far greater than the risk and that's why I

really do have my practice so these are the benefits right shorter hospital stay and I would say more cost-effective and that is really debatable because gynecologists have become smarter and smarter now they're doing like same-day

hysterectomies if you have a vaginal hysterectomy then maybe a UFE is not as cost-effective because they don't have to do an MRI beforehand and they don't get an MRI afterwards and do all of that anyway and if you look at the long-term

cost of that then maybe having a hysterectomy in some patients could be that but we know for sure that patients are more satisfied when they get a embolization procedure than in my MEC to me not in the beginning run because the

procedure can be very painful that is not the procedure itself is painful but post embolization syndrome which could last anywhere from five to seven days can can be very painful again this is the comparative data that was published

by dr. Spees who is our gold medal winner this year understand a lot a lot of work in this space has allowed us to have this conversation with our gynecology partners but also with our patients as we talked about like when

can you return to work how long are you going to be all for you know am I going to need extra child care or whatever how long would I be in the hospital this information helps us to inform our patients about that then on average

you'll stay in the hospital around you know a day or so and most uterine artery embolization procedures are same-day procedures and interventional radiologists are doing these in freestanding centers as well as other

providers without any issues so we're almost down to the end we know that fibroid embolization is proven to be an effective and durable a procedure for controlling patient symptoms it's minimally invasive and it's outpatient

most patients can go back to some normal activity in one to two weeks it has a low complication rates and some patients mein neatest to surgery and should have surgery so in our practice we send around 1/3 of our patients or so to

surgery and the reason that that is that high is that patients are allowed to come and see myself or dr. de riz Nia from the street they do not have to be referred from their gynecologist and so they're just coming from the street then

you will be referring them to a gynecologist because of some of the things that may not make them a good candidate for embolization such as this

so why staging important well when you go to treat someone if I tell you I have a lollipop shaped tumor and you make a lollipop shape ablation zone over it you have to make sure that it's actually a lollipop shaped to begin with so here's

a patient I was asked to ablate at the bottom corner we had a CT scan that showed pretty nice to confined lesion looked a little regular so we got an MRI the MRI shows that white signal that's around there then hyperintensity that's

abnormal and so when we did an angiogram you can see that this is an infiltrate of hepatocellular carcinoma so had I done an ablation right over that center-of-mass consistent with what we saw on the CT it

wouldn't be an ablation failure the blasian was doing its job we just wouldn't have applied it to where the tumor actually was so let's talk about

good morning thank you all for braving 8:00 a.m. and I'm sure you were in bed last night early about 8:30 and really enjoyed getting up for this lecture but here it is so this seems to be one of the you know there's a couple of buzzes around the meeting this year pardon my

voice I wish I was up to like what I wasn't and one of the buzzes percutaneous fistulas and then there's this extreme IR then there's this 3d virtual reality stuff is going around so in Orangeburg ER we're fortunate enough

to be very much involved with both of the newly approved fda devices what she also didn't mention was I was a technologist for eight years before I went to medical school so I kind of know where you're coming from that's why I

really enjoy not speaking to you if it's not for you guys and what you make us look good and I believe me so here's my disclosures someone said you should do well on these I said one I'm looking for more if anyone else is out there knows

any studies or anything they want me to do I'm happy to do them so I'm always looking for more disclosures after they office Access Institute in Orangeburg a little sleepy town about three-quarters of the way up from

Charleston towards Columbia John Ross built this amazing facility we are separate from the hospital you can see the hospital a little bit in the back a little bit in the back there but we're totally separate unit if you're

not familiar with us you've got six operating rooms totally dedicated to dialysis access know nothing else goes on there pardon me there's the clinical area waiting the preoperative and

post-operative a holding area there in the room for about 20 patients we do anywhere from 20 20 to 40 45 patients a day all things peritoneal hemodialysis access creation d clots angioplasty and percutaneous I think that was off the

first case for hemodialysis porcinis access and you see Jeff hole there the one of the developers of the ellipsis device I'm sort of just under the light and the caption is usually how many physicians does it take to put in a

percutaneous access a lot of them on the right this is a totally ultrasound mediated placement and then you can see that's what you get when you connect the artery in the vein you get that very beautiful color flow Doppler of a

perforating thing into a radial artery we'll talk about that now being down south I have had to get I've learned to get used to a chicken and biscuits for breakfast which I've never had to deal with before but it's all been quite

nicely folks been very nice to us so a little trip down memory lane and if you recognize this this is one of the first external officials for hemodialysis you know shrimper shunt and that was followed by of course many fistula sites

there you can see on the Left fistula sites up the radial radial ulnar element and radial cephalic rather of course called the breccia semitic fistula and should go up higher I want you to call your attention to right by the elbow

that area is where the site of percutaneous fistulas today are mostly created and these are deep fish to this and we'll get into what that means in just a moment and of course grafts there on the right

but it's a little bit out of the topic

So question. I do have a wonderful group of nurses, an excellent group that I get the chance to work with

and they have asked 100 questions and they've listened to me talk a few hundred times. Anyway, hopefully, they have helped to make this a clear presentation. One of our EP physicians looked over the information and he and a device nurse also agreed

and they were wonderful. I do have the samples here, the Medtronic grip Trip Walker gave me. Anyway, you're welcome to come up and take a look at them. But before I do, do you have any questions? Yes.

- [Woman] So our Medtronic rep comes and does whatever he does, we never really know. We think you said (distant indistinct muttering) okay, they're sent to eight. We sit there with pulse ox on, they get scanned. We reset to whatever they were before and they leave,

so clearly I'm going to up it a little bit after seeing this talk. But he doesn't always stay. I know. So we don't have a device nurse. It's just this Medtronic rep.

Would that be-- - And how would you access him if you had an emergency? - [Woman] I don't know. That's what I'm going to work on-- - Totally. - [Woman] He has left the building before.

(indistinct chattering) I know! (distant indistinct muttering) - No, he shouldn't-- (distant indistinct muttering) - [Woman] So if he has the rest of these slides somehow, I mean, I got most of these but (mumbles) I got three pages here but the other things

that say like (distant indistinct muttering) stuff like that. - I don't, but it's going to be on the web or whatever they do, and it will all be there. distant indistinct muttering) Mm-hmm, mm-hmm. And your physicians, our docs know on the morning

of the procedure that all the devices that are going to happen, hopefully they will have reviewed that. - [Woman] This is how it works. Our scheduling calls the MRI, MRI says okay (mumbles) pacemaker.

An MRI technologist calls Medtronic. Medtronic or the other (mumbles) companies says yay or nay, this is our device. (distant indistinct muttering) Other than the ordering doctor, there's no doctor that knows that patient's there.

The cardiologist knows-- (overlapping dialogue) - According to this consensus statement, and it's all highlighted, you know, that if you're saying, "Hey, where are our guidelines "and how are we doing this and where does this come from?"

you have a really strong statement that is a little bit confusing. They've written a very concise guideline. It doesn't say a whole lot of information about much of anything actually in my opinion. But this statement is 50-some pages.

It has clinical studies and it has information about caring for these patients and how they should be assessed and programmed. (distant indistinct muttering) It is. And it's on the back actually of your paperwork too, the name of that study.

Mm-hmm? - [Woman] Just a question about traditional and nontraditional pace. Right now we only do, yeah, they did an x-ray (distant indistinct muttering). - You can't tell that from an x-ray.

- [Woman] Right, but I mean, the look of the model just to see if it's MRI compatible (distant indistinct muttering) just the actual pacer (distant indistinct muttering) and then we have, the EP comes down, (distant indistinct muttering) nurse that comes down and interrogates

and shuts the pacer, puts them in a certain mode before we do it, but I'm just concerned about the difference between traditional and nontraditional (distant indistinct muttering) - So she's questioning about conditional or nonconditional.

You can't tell by looking at the device. You need to have information from the programmer itself telling you what the device is and if there's a lead that matches it. Like I said one time we had recently had a patient that had a nonconditional lead,

but the device was deemed conditional. But it really would then made it a nonconditional system. And that has those extra requirements according to this guideline. Now it doesn't say this is the way it has to be. It says, your institution needs to adapt

or to make their own very clear protocols so that when you go into the scanner and you're taking responsibility for that patient, you know that they have been thoroughly, you're safe, as safe as can be. (distant indistinct muttering)

Nonconditional is a device that is not FDA approved. Conditional is FDA approved, whoops. And I think we're at about a couple seconds here, so if you have questions I'm glad to answer them. Back there too, but hmmm? (distant indistinct muttering)

She's been back there since the beginning. (distant indistinct muttering) I don't know that an LVAD would be compatible by any stretch of the imagination. Reveals or those monitors are actually, are MR compatible. There's also a single or a lead-less system

that is MR compatible. I have those up here too so if you want to take a look at those, you can. They're really cool little gadgets. But LVAD would not be. Whoops.

Sorry. - Just to keep on time because we have another like her starting. If we can just step out in the hallway and have her finish addressing your questions and getting the answers.

And to reiterate, just watch for your emails coming from ARIN and you'll have access to her lecture, her slides. So for people who want to make practice changes, it'll be available. - And I did put my contact information on those papers

that I handed you. If you have any questions, please let me know. (audience applause drowns out dialog) Thank you.

or non-existent for most of the world's population according to the World Health Organization more than half of the world's population lacks adequate to basic imaging technology such as x-ray

and ultrasound and on the basis of a recent global population census of approximately seven billion people this suggests a radiologic scarcity afflicting three to four billion individuals throughout the world and in

terms of nursing's role in the context of global health the World Health Organization states that nurses are the largest group of health care providers and we account for over 50% of the global shortage of healthcare workers we

have the greatest exposure to the world's population however it is estimated that by 2030 the shortage of nurses and midwives will be about nine million with the worst shortages in Africa and Southeast Asia

so the United Nations recognized that it is imperative that nurses skills and abilities are harnessed and maximized globally and in 2015 the United Nations set forth the 2030 agenda for sustainable

development where Nursing has direct impact on several development goals including advancing health through education and clinical care supporting health promotion and disease prevention programs and advancing gender equality

and women's health programs just to mention a few so what is rad aid and how are we addressing these global health disparities we are an international nonprofit organization celebrating our 10th anniversary and are affiliated with

the World Health Organization our mission is to develop and improve radiology services where people have little access to radiology and create sustainable education programs to improve the health and well-being of

people in impoverished countries red aid was founded in 2008 by dr. Dan Melora who is a radiologist currently practicing at NIH and red aid had its first meeting held in the basement of Johns Hopkins Hospital and now it has

grown to over 30 global programs in 55 hospitals around the world our volunteers have increasingly grown over a decade chapters at leading academic

institutions throughout the United States we have multiple affiliations with professional and international medical nonprofit and corporate organizations so within this growing organization what is rad aids Nursing

mission red aids nursing program seeks to promote the advancement of Nursing Practice throughout our global programs by increasing nursing capacity knowledge and clinical skills while advocating for the health and well-being of populations

in resource-limited settings we do this by building a foundation of collaborative partnerships between our u.s. nursing institutions and organizations and our global nursing partners that together support the five

pillars of our educational programs including clinical skills training advancing the use of technology public health education health policy development and research to measure outcomes and evaluate our programs these

educational strategies are then targeted to the particular needs of each country and extend out to patients community health centers hospitals and nursing schools so how do we implement this

I'm gonna talk about me and shoulder embolization I'll take out my phone here so I know the timer perfect and I will try and cover everything about knee and shoulder embolization as quickly as I can so why are we doing this is really what I'm going to talk about there are

two different disease processes and the knee we're talking about arthritis and in the shoulder I'm talking about frozen shoulder so these are my disclosures obviously you know knee knee osteoarthritis is a major problem that

affects more than 30 million people in the United States and there are more than a hundred thousand hospitalizations a year just from NSAID toxicity in this patient population who takes NSAIDs for pain of course and they end up with

things like GI bleeds there are more deaths just related to n says the United States and there are more than four million knee injections performed annually in the

United States keep this in mind there are double-blind randomized placebo-controlled studies that show that knee injections don't work and yet there are four million every year okay so what's the rationale for genicular

artery embolisation so in the knee we always learn that knee arthritis is degenerative right there's no inflammation like rheumatoid arthritis but many years ago they discovered that there's actually an underlying synovial

inflammation that leads to an increase in these cytokines being released that leads to new blood vessel growth or angiogenesis and then this is the cycle of pain that occurs after that how does this actually occur and like I mentioned

it's not a new concept here as you can see this is a depiction from a 2005 article from Journal Rheumatology it just blown-up knee joint and what happens here is in the lining with that sort of peach color or light color on

the lateral aspect of the image where it says synovium gets inflamed releases these cytokines those cytokines break down the cartilage lead to new blood vessel growth and it's an inflammatory process so not just a degenerative

process and that it's that inflammation that we aim to target with genicular artery embolisation if you even take biopsies of patients who have inflammatory diseases and the joints here if you look at those two

slides on top we're all those little dark staining blood vessels there there that's a biopsy specimen from somebody with frozen shoulder to two slides below or actually biopsy specimens of someone's synovium who has just a

rotator cuff tear and you'll see there's no increased blood vessels in the two slides below but on the top there are increased blood vessels every time you have more blood vessels you have more nerves that's why they

call it a neurovascular bundle because 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 an 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

knees 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

five-year-old with excessive vaginal bleeding bleeding has no other symptoms

her she had a normal ultrasound of the lower abdomen there was no evidence of trauma or sexual abuse again very very important part of your history to obtain so they get a decide to do an MRI of her abdomen to see what's going on because

then ultrasound was negative and the metal detector went off when she went in the scanner so they pull her out and they get an x-ray a plain abdominal film that was done later and see a foreign body anybody want to take a guess at

what that might be metal so it definitely definitely shows up whoops those are actually keys to her diary so she was writing in her diary and she didn't want her mother to find that she

was writing so she stuck the keys inside and I guess never took them out again so that was those were two keys so very interesting cases okay let's talk about

let's move on here is another patient who took a fall skiing we see a lot of these patients up in upstate New York and they presented with severe left-sided abdominal pain and here's the cat scan

all right who's up for it what do you think what looks bad you look like you're into it what do you think yeah the right the bottom right-hand side of the picture should be spleen and it just looks like a big pool of blood that's

pretty good you did pretty good spleens a little higher so we're gonna presume spleen is there Graham this is just one image one slice through the picture through the body so we're just not at the level of the spleen but that's the

kidney that's exactly right that white thing on the right side of the image of the patient's left side is the kidney and the one thing I'd like everyone who appreciates that doesn't look at all like the other side all right so when

you look at a cat-scan like this you want to look for symmetry that's really important all right that's the cool thing is we're kind of meant to be similar looking on both sides of our body and in this particular

case you can see that the left kidney has been pushed way forward in the body compared to the right side and there is a kind of a hematoma sitting in the retroperitoneum posterior behind the kidney that's bad

the other thing you should notice is if you look at that left kidney you notice that white squiggly line that doesn't belong there okay that's contrast that's not really constrained inside an artery that's extravagant of

contrast that's bad all right we don't want to see that all right again there's a grading system for renal trauma and you're gonna hear people talk about grade 1 2 3 4 injuries all right obviously as the number gets higher the

extents of the injury gets more significant all right so again here's that picture think you can appreciate that it's at least a grade 4 laceration of the kidney so we went in and we did an angiogram now we can watch these

patients we can surgically manage them by taking out their kidney in some ways that's the easy part excuse me it's a lot more elegant to try and embolize these patients if they're hemodynamically stable and can take you

know getting to angio and doing the case now in general we do embolization for patients with lower grade injuries and usually penetrating injuries a penetrating trauma that's seen on CT I think this is something that's changing

I if any of you work at high-volume trauma centers the reality is that we're doing more and more renal angiography for trauma than we used to because it's just becoming a more accepted thing for us to

be doing that all right so here's the angiogram and again I think you can notice it really correlates very well to what we saw on the CT scan you see that first image on the left and on the delayed image you see that that kind of

poorly constrained contrast going out into space now we were never really quite sure what this was if it was extravasation or if it was potentially an arteriovenous fistula with early filling of a renal vein regardless of

which it's not normal all right so what we did was we went in and we embolized and I only included this picture because I'm a big drawer during cases so when I'm working with a resident or a fellow I like to really

lay out our plan on a piece of paper and try and stick to the plan and this particular picture look really good so I included on the lecture but basically you can see that the coils the goal here for any embolization procedure

when it comes to trauma is to preserve as much of the normal organ as we can and to simply get you know to the source of the bleeding and to get it to stop and that's what we did there so what you can appreciate on this is kind of the

renal parenchyma or the tissue of the kidney is largely maintained you can see the dark black kind of blush within the kidney and all that really stands for properly working kidney all right and yet we embolize the pathology so that's

our goal here's a similar patient not

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

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

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

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

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

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

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

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

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

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

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

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

and what's available the ellipsis device

which is a startup company still hasn't been bought by anyone it was developed by an interventional radiologist named Jeff hall if you know Jeff from Richmond Virginia and it's a totally ultrasound mediated placement it only requires one

puncture into a cephalic or a perforating vein and then you go from the vein into the artery and I'll talk about that in a moment then the everline the queue device now cold wave link wave linq device i was formerly a TV a

medical developed here in Austin Texas and recently bought by bard BD both devices were FDA approved over the summer and now this goes back the whole idea of what are we doing here what we're creating what we call a deep

fistula so and that was done in response to failing forearm fistulas the radius of Halleck fissures when they started to fail people would then jump to the upper arm and start creating brachial basilic

transposed basilic vanes already oh so phallic brachial cephalic fistulas in the upper arm and then here a guy by the name of Ken grass in Illinois it's called the grass fistula I think I'm saying that right developed a fish to

where he would hook the deep veins at the forearm to the brachial artery flow would then go from the brachial artery across the fistula up what's known as a perforating vein and that perforating vein selectively would go well

selectively perhaps unselect if we go to either the basilic or the cephalic or perhaps even both and here's a nice anatomic description I don't sorry I do not have a pointer I don't even have a keyboard but if you look there we'll

start up at 11 o'clock you can see there B and C basilic vein cephalic vein or labeled you see that P going straight down from the middle of the clock down to six o'clock that's the perforator okay we all know about perforators in

the legs if you do varicose veins because they're incompetent perforated up until six months ago I never even knew there was a perforating vein there one number two I defy anyone to try to find it in an anatomy book because it

just you know it doesn't I'll show you one picture of it but it's not exactly descriptive of what it does then basically they would take that and cut the perforating vein off of the deep venous system and attach it to the

brachial arteries you can see down there four o'clock so now you have flow from the brachial artery across the perforator and up into the superficial venous system and supplying the lead basilican the cephalic veins

kind of kind of a great idea and in fact they looked at these and they compared upper arm fistula swen maintenance of dialysis with deep fistulas and the the time to use of maturation was about the same about four months there was no

significant difference in outcome among the three types of fistulas brachial cephalic transposed rinky basilic and in fact since we have flow through both both of those veins you know it's may be

tempting to speculate that you can now use both of those things actually for hemodialysis and that's currently done many times two needles one needle and ability and the break in the basilic keeps me breaking

one needle in the basilic one needle in the cephalic and then you can alternate those needles so you don't have the problems of vein injury by frequent cannulation at the same spot well here's the one anatomic picture I ever found

with the perforating vein this is from the sobota Atlas which medical students know very well and you can see right in the middle there it says perforating vein and it's ducking down there below the fashion who knows where the hell

it's going but you don't know it from here and here you can see on ultrasound this is pretty much you know what it looks like that's the perforating vein and I guarantee whew go back and grab your ultrasound machine in your

departments and you all have to do is put it on color when you follow the basilic vein down or the and they'll meet the cephalic vein kind of a V and then just below that you'll see your perforator diving deep towards the

brachial artery alright and so now you'll all know where the action is going on and the you know since I think this procedure really is ideal for interventional radiologists I mean it really leverages everything that we do

you know ultrasound fluoroscopy multiple oblique angulations complex angulation is to position the device correctly I mean this procedure is really made for us so I suspect that some of your your attendings may want to begin a program

like this and if you cover the ORS and you're dealing with vascular surgeons or interventional nephrologist I'm sure they will probably want to get involved and so you know get ready guys here it comes so here is a obviously an

illustration of the the forum you can see there's the brachial artery going down take particular attention to the median nerve you can see this with ultrasound it's a very hyper echoic focal structure but when you're

puncturing that brachial artery load down at the elbow you want to make sure that they see the Brig a break heel and pardon me the median nerve because you can injure it if you put a five or six French sheet through it and that's one

of the potential complications of this procedure but as a radiologist we know ultrasound we can see it and we just have to do a complex needle I'm sure you know angling the ultrasound probe around it so he can get them to

the brachial artery then if you follow the cephalic Emily basilic vein down you can see they meet in the center median cubital vein and then the antecubital median antebrachial vein and then but they don't really show here is the

perforator but the point I wanted you to make it and to make you is them the median nerve is right in your target very often you don't want to tangle it now there's a lot of variation in the cue you know and whenever you get down

to anatomic structures this small which when you're doing these procedures you want to be aware of you can see that some people if you look all the way to the right type for there's no perforating vein and these people are

deemed to be anatomically unsuitable for this type of procedure you have to have a good quality and we'll talk about size usually about two two and a half millimeters perforating vein to get that blood from the brachial or radial or own

or artery up into the superficial system to a point where the fish so it can be cannulated but the anatomy here is variable and so you have to be aware that if you don't see it it just may not be there may just be you know a variant

tip Jennings down in Texas now the only person who knew about perforating veins was Bart - Oh max I talked to him the other day goes yeah I knew it because tip Jennings was doing all these deep fistulas down in Texas when he was down

there but tip is kind of when one of the proponents of deep fist shows why because when the proximal or the the distal radius of how a fistula fails the deep fistula can be made and still you don't have to tangle with the

superficial cephalic or basilic vein and also the deep fish avoids steel people don't steal blood when they have a deep fish to them and just because the the the size two or three millimeters of the perforator I think chronic keeps a check

on the blood flow that actually goes through trying to snip up the action

so the idea with cryoablation as I mentioned you create ice crystals in this the tissues outside the cells and then the water rushes out of the cell the ice forms then within the cell and when you thaw the water rushes back in

and this is essentially this whole shift of fluid from one to the other it causes the cell to die but the cell doesn't die like it does with microwave it going to go something called apoptosis which essentially means the

cell decides it wants to die right so it dissolves all of its membranes and whatever else the proteins are then left available for your immune system to help clean things up and that's for the immuno genic response that we talked

about earlier other things you worry

deal with radiofrequency ablation is that you have a probe which acts as the

calf the current you then have the pads which act as the anode and when you place the probe in turn it on essentially there's a very small cross-sectional area and there's high flux of energy so lots of

current and then it spreads out over the patient's body and it grounds itself to the grounding pad in so the way is since she works is you generate this very very large alternating current right so the water molecules want to stay in

conjunction with that that current their dipoles arrangement they have positive and minuses and so they're gonna flip around to stay in alignment with that current and that rapid oscillation of those water molecules causes the the

tissue to heat up the way a cinch it works is by coagulation necrosis what does that mean well it's basically cooking a steak it just dies and and that's your your your death related to coagulation necrosis so with our FA

what's important to know is that the molecules immediately next to the probe are what heat up and then everything from there on out heats sort of by passive conduction and I'll describe how microwave works and that's different to

that but the probe tip never gets hot but the molecules immediately adjacent to the probe get hot and and everything propagates from there on out why is that important well it's important because if you rapidly heat the tissue with RFA

you're gonna get charring but some of you might have experienced this when you do the cases the tissue basically gets charred then it increases the the impedance or the ability to conduct it in which case you you limit your ability

to create an ablation all right so charring is a problem and it increases your impedance which is essentially the resistance to making an ablation cavity and then that decreases the ablation size and so that's really

one of the main reasons why people started moving away from RFA is that you really need tissue that's going to conduct this electrical current well and it's difficult to predict what tissue that's gonna be and so the goal with RFA

as with any other thermal ablation is to get the tissue temperature to between 50 and 100 degrees Celsius and then slow temperature rises are best right so however you want to achieve that slow temperature rise you want to do it

slowly rather than a rapid increase which is the opposite really of microwave ablation radiofrequency

advantages of radiofrequency ablation or that there's the most research on this

right so if you look up ablation research there's a whole lot of data and research on this as it's been the longest studied so that's always beneficial when you're trying to convince people that they should get an

ablation it's cheap right although some of the problem with that is a lot of manufacturers aren't making some of the devices anymore so to get replacement probes and that sort thing is difficult but it is certainly much cheaper than

the other modalities its gentler than microwave right so it's a slower increase in temperature and you can control it the disadvantages as we mention right so the ablation zone this is probably the worst part about

radiofrequency ablation is that the ablation zone is unpredictable right now we're trying to go towards this idea where we can predict the exact size of the ablation and really with RFA it was more experience related right so if

someone I've been doing them for 20 they can have a good idea how it's gonna it's gonna blade but that ablation zone is very unpredictable it's very tissue dependent right so if you have cirrhosis and the liver is

really scarred down you're gonna get a different ablation as to someone who has a normal appearing liver you have the heatsink effect which as I mentioned can be used as an advantage but usually as a disadvantage and then large large burns

are difficult right so anything greater than 4 centimeters even that is difficult to achieve with RFA it is possible to get skin burns at the grounding pad so if you're gonna do RFA make sure that the patient doesn't have

a hip prosthesis for instance and make sure you know it sometimes patients get sweat underneath the the pads and that can increase skin burns and those pads so that's one of another downside of a radiofrequency ablation so we'll move on

good outcomes now the stroke care is a total team approach I mean everyone's working together different Doc's ER

neurology whoever's doing the intervention you know the EMTs are involved I mean they're the ones who first assess the stroke and they call the hospital and say I think we have a large vessel

occlusion and so things are already getting ramped up in radiology ICU texts and nurses all that stuff we're working together to get these patients on the table and intervened and then all the post stroke management too so it's

always been shown to I mean everyone is looking at times it's almost like a STEMI where everything is recorded and especially for neuro and Stroke lumpectomy hospitals in order to maintain their certification need to

record everything so as long as you're involved early in the workflow things are helping and we're still trying to make make our times better even just a couple minutes shaved off here and there it can help now

there's guidelines out there this thing is 255 pages and who wants to read 255 pages and it's pretty long but their guidelines and just to kind of review some things that no one really even follows the guidelines now I mean there

has been strokes in pediatric patients that people will intervene on all these different words NIH SS that's a stroke scale assessment aspects is there's different things that I'm going to show you all of these things are guidelines

so now no one even really follows these numbers I mean they're a good way to start but you can really change your management again on that perfusion so probably perfusion is one of the most important aspects and you know a lot of

things can mimic stroke he actually had a whole stroke activation for a patient one time at my hospital and we did the whole CT and everything everything looked fine and then it was found that the blood glucose was 34 I mean so

there's these things a patient looked like he was having a stroke but he was just hypoglycemic so a lot of times you have have things like that now even your INR are your platelets being below you can still

intervene and and pretty much nothing stops they have renal failure it doesn't matter you just it's then they start talking about neurons over nephrons and so they just put a really high priority on getting the thrombectomy because it

is life changing and imaging is so important so they you know I'll stress again and again this is what perfusion has really changed you know your selection for a stroke candidate and we use CT most centers use CT you can do

MRI - but MRI you know slower and not always available and so most people will just do what they call it triple scan which is a non-contrast CT head and that's to see if you have any blood that's one of the things that will

probably be a contraindication to stroke thrombectomy and then the CT a head and perfusion so you always see the docs like looking at these color maps they look nice but they're really important so these are

the color maps I mean I think anyone can see that there's all this red on that side of the brain and that's the red that's what we call penumbra and so what we are always looking at so CBF is cerebral blood flow MTTs mean transit

time just means how much time does it take for blood to get there so the longer it is the red and that's that's why that value is abnormal and then cerebral blood volume so when the volume is in tact that means your collaterals

are giving enough flow to that area so that's showing that this the CVV map is normal and MTT is abnormal so all that brain is at risk so potentially if you can take out that clot you'll save that entire side of the brain and that's

where this perfusion imaging comes about and you know we use all these numbers aspects mr-s Stroke Scale and you don't have to know them per se but just to know that the higher the number is usually worst except for aspect so

always ask you what's the abscess score and that just tells you on a very you know primitive way on a non-contrast CT what brain is at risk and now you know whenever I get called about a stroke these are the the questions that

go through my head you know when did this when did the symptoms start what's the stroke scale you know but even though all these questions that are in my head all I'm really caring about is a profusion map and it's not that's

really gonna guide me to what what goes where and so you know what part of the

fish through creation one is screening with ultrasound you really have to be able to look at these patients and I'm you know when I talk to our physicians they say we have a great

ultrasonographer named Megan and so I say the first thing you need to get yourself a meg everybody needs a meg and May because meg knows what to look for what to look for what's a measure where to get flows and she submits that to us

now other than the anatomic part you know at our place you know we're very particular about and selected we try to be thoughtful about you know who gets what access and that's what the new dokey guidelines are gonna say you know

the best access for the right person at the right time so for example you know if you come in with a catheter and we can you know we'd won from a 275 mile radius people come to us you know for access because you know they they've

they've been given up the cases have been given up by local people and you've got a catheter my first thing I say is how long is the catheter been in and they said well catheters been in for eight months you're not getting a

percutaneous fistula if your catheters been in for eight months I'm gonna call one of the surgeons think I am with part of my group you know we have no competition there's no turf wars we're all friends we like each other we like

working together it's a great place I say Karl Karl Willy who was recently from Tampa - Karl illustration - sick catheter for six months is okay I'm going to create they put a flick seen graphed in the

upper arm probably with a suture listen a stenosis and pull the catheter tomorrow that patient's going to be dilating with a graph where the dialyzer will be graphed you know because after six months you don't want a cath over

there when you start going down that road of infection endocarditis vascular damage all that kind of stuff if you come in and you started with a catheter because somebody wasn't looking ahead far enough and you got a catheter and

they come here for accents placement catheters been in for you know two weeks three weeks one month there's a good chance you're gonna be seriously mapped for a percutaneous special because now we have time we've got we arbitrarily

have considered the six months window that we can probably work with the catheter there's nothing to prove that there's nothing in the literature in fact I had a discussion last night with someone from one of the companies who

wants to do some type of a trial to look and see when can these catheters really do go bad and so you're gonna get worked up for a percutaneous fish and clearly if you come with stage four you know know you're not on dialysis they don't

know when you're gonna go into Alice's but they you know you're going in that direction you're gonna get seriously worked up for a percutaneous fistula one patients are still psychologically trying to wrap their head around the

fact that they're going to be on dialysis it's much easier to tell them you come in you're gonna get a puncture two punctures you're gonna go home with a band-aid and we'll take care of this we'll get this up and running over the

next six weeks eight weeks ten weeks and when you need it it's gonna be ready to go and you won't need a catheter then we tell them you don't not gonna need this catheter sticking out of your neck they're very happy and they usually

agree to do the percutaneous miss doula also since you don't get those big ropey fish - as I talked about when these patients are in dialysis you know how many people ever been to a dialysis unit that's how I tell physicians you want to

you know you want to look build a practice like this go to the dialysis unit talk to the charge charge nurse do rounds once a month or once every couple of weeks with a nephrologist and that's how you build the practice but these

patients they're in the chairs they're talking to each other right and they say hey how come you don't look like a cling-on you know with this big veins you know you where's your fistula and then they want that you know they it's

really cosmetically very pleasing these patients are so deserving and they have such horrible I was being tied to that machine three days a week so any little bit of hope we can give them I think is is worth it alright in summary it's not

a one-step procedure and then we try to make patients understand this you may need a secondary angioplasty or embolization in the future hopefully not usually about 30% of the time has great value in the stage Forge so we

talked about more acceptable to patients coming to grips with their future may make a significant difference with the catheter people starting with a catheter and I think whoever is going to do this really has to have a commitment to

access this is not you're not doing a procedure you're actually developing a treatment plan or a treatment system and so then these patients are yours once you do this you're following them you're keeping them working you know how do you

sell this to the surgeon you sell to the surgeons this way because if you start this program you know people are gonna start coming to you they're gonna come out of the woodwork it's like if we start doing AVM stuff that they start to

come from nowhere and you're gonna draw so many patients the in that surgeons are going to have more work and there's no question because everybody's not going to be a candidate and so I mean when bobwhite if hopkins years ago

started doing angioplasty the business of surgery increased by 15% so you're gonna see you're gonna make the pie bigger that's how you sell it you're making the pie bigger and everybody can feast on the pie leverages our expertise

as interventional radiologists and image guided procedure list to make these procedures work I think we're in a great position a really great position if you listen to Alan Matsumoto the other day at the toddler lecture we're in a great

position for the new age of medicine and it may be the ideal procedure for multidisciplinary collaboration I can't do basilic vein transpositions or elevations or brachial vein elevations so it's good to have a surgeon that

you're friendly with that will make these things happen they're all part of the group that's necessary and I think that could be it yes ah I'm from New York and I'm a shameless marketer and so I would encourage you if you're

interested or some of your attendings or interests come to the vasa practicum it's gonna be done in Houston with dr. Eric Pete and chief of vascular surgery is running the meeting you get to put your hands on all these devices and put

and stuff you can all do it I mean it doesn't have to be doctors you have big models and they'll have live cases and it's a great opportunity in 2020 since I'm the president-elect of Vassar we're gonna run the meeting in

Charleston that's gonna be held out a hell of a lot of fun so we encourage you to come to Charleston in 2020 thank you very much not questions yeah

primary Africa cm point 86% matured remember what do we say before you know not what 96% so that's the answer to the surgeons why surgeon says why should I do this why don't I just create official

it takes me 20 minutes there's no surgeon in the world who can create a fistula that's gonna mature 86 percent of the time I don't that's not happening all right the endpoints were met secondary

endpoints to needle dialysis 88% I mean that just doesn't happen surgically I'm sorry and I'll show you some other data as well where the superiority of the percutaneous fistula over surgery this is the jvi are pivotal trial I with Jeff

Hall and tip Jennings and here's the match of the secondary maturation procedures that had to be done all right some get an estimate and we angioplasty the anastomosis embolization of branches an angioplasty Stan's oh okay

here's the bar device and this is called the ever linked queue back in these six French days and now wave link device there are two catheters one goes into the brachial artery one goes into a brachial vein there's a big magnets this

is the six wrench device and you can see that little connection I hope you can that's a foot foot plate a little electrode that pops up between the two catheters it actually creates the official of this time with a

radiofrequency energy on the right you see a brachial artery angiogram and the point of official creation with six ranch was the common on our branch which you can see down there below you have the big dense radial artery coming up on

top and then you see the common arm branch and then the proper ol arm going down there at four o'clock and then the interosseous in the middle now with the the four french device you can create fistulas from the

radial vein to radial artery or radial arterial vein owner artery to ulnar vein and either one gives you a little more options about where you want to create well why would you want options well if you go down to the video of vena Graham

in the and the ulna vein and you don't see any flow up the the perforator well you can only switch to the other side and to try to find better flow put yourself in a better position to create a working fistula this does use

ultrasound to puncture but then uses fluoroscopy to position the devices its RF energy has a little bit of a problem with heavily calcified vessels who's ever seen that and in dialysis patient right so and because radiofrequency

energy goes around calcium it doesn't go through we've had one case where we did there was just no fistula creation everything went finally since no fistula and so that patient got a surgical fistula multiple angles to confirm

correct position of the device this was with the six french device the four french device is much less cumbersome because you want to make sure that that footplate that I showed you sits directly in the receiver area to create

otherwise if you go off to the side left and right they you can have a problem with creating pseudoaneurysm some things no angioplasty then ask to most us however in this case you do embolize on the way out because you've entered the

brachial vein and you embolize form just to stop any losing and to because you want to help to redirect flow towards the superficial system here are the two devices on the left into the four frames versus the six

range quite a difference much more easy to work with the four french doesn't have a bulky handle on the end like the six ranch did they're pretty easy to position and it's a a round electrode not a foot that comes up and it kind of

sits in what they call the saddle you can see there where it says square magnets underfloor french there's a saddle there that that loop electrode sits in and very easy in there to position

who's a candidate well doctor Ross says

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