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Cryoablation - What it is and how it works | Ablations: Cryo, Microwave, & RFA
Cryoablation - What it is and how it works | Ablations: Cryo, Microwave, & RFA
Successes of EndoAVF Creation | Pecutaneous Creation of Hemodialysis Fistulas
Successes of EndoAVF Creation | Pecutaneous Creation of Hemodialysis Fistulas
RFA Probe types | Ablations: Cryo, Microwave, & RFA
RFA Probe types | Ablations: Cryo, Microwave, & RFA
ablationaugmentationbipolarchapterimpedanceincreasesinfuselevineMedtronicosteoOsteoCool RF Ablation Systemprobeprobessalinetemperaturetines
Nodule in right lung | Cryoablation Case | Ablations: Cryo, Microwave, & RFA
Nodule in right lung | Cryoablation Case | Ablations: Cryo, Microwave, & RFA
ablationablationschaptercryocryoablationfreezehemorrhagelesionlungLung Noduleminutesnodulepneumothoraxprobesprotocolproximalthawtriple
Overview of Biliary Disease at John's Hopkins | Biliary Intervention
Overview of Biliary Disease at John's Hopkins | Biliary Intervention
Observations working in IR in China | Across the Pond: The state of Interventional Radiology in China
Observations working in IR in China | Across the Pond: The state of Interventional Radiology in China
Why is Staging Important | Interventional Oncology
Why is Staging Important | Interventional Oncology
Kidney lesion | Cryoablation Case | Ablations: Cryo, Microwave, & RFA
Kidney lesion | Cryoablation Case | Ablations: Cryo, Microwave, & RFA
ablationballchaptercollectingcryoablationkidneylesionLesion in left kidneymedialstricturessystemtumorureter
The Ways to Recanalize the Below the Knee Vessels | AVIR CLI Panel
The Ways to Recanalize the Below the Knee Vessels | AVIR CLI Panel
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
Introduction - Percutaneous Fistula Creation | Pecutaneous Creation of Hemodialysis Fistulas
Introduction - Percutaneous Fistula Creation | Pecutaneous Creation of Hemodialysis Fistulas
Heat Sink Effect in RFA | Ablations: Cryo, Microwave, & RFA
Heat Sink Effect in RFA | Ablations: Cryo, Microwave, & RFA
RFA Advantages and Disadvantages | Ablations: Cryo, Microwave, & RFA
RFA Advantages and Disadvantages | Ablations: Cryo, Microwave, & RFA
Case- Brain Infarction | Brain Infarct After Gastroesophageal Variceal Embolization
Case- Brain Infarction | Brain Infarct After Gastroesophageal Variceal Embolization
anastomosisangiographyaphasiaapproacharrowarteryartifactbrainbronchialcalcificationcatheterschannelschapterchronicChronic portal vein thrombosuscollateralcyanoacrylatedrainembolismembolizationendoscopicendoscopistendoscopygastricGastroesophageal varixglueheadachehematemesisinjectionmicromicrocathetermulti focal brain infarctionmultipleoccludedPatentpatientpercutaneousPercutaneous variceal embolizationperformedPortopulmonary venous anastomosisprocedureproximalsplenicsplenomegalysplenorenalsubtractionsystemicthrombosistipstransformationtransitultrasonographyvaricesveinvenous
Radiofrequency Ablation (RFA) - Where it's used | Ablations: Cryo, Microwave, & RFA
Radiofrequency Ablation (RFA) - Where it's used | Ablations: Cryo, Microwave, & RFA
ablateablationablationsaugmentationBovie knifecementchapterconjunctioncryoknifekyphoplastyMedtronicmetastaticmicrowavemodalityosteopelvis
Questions and Answers | Across the Pond: The state of Interventional Radiology in China
Surgical AV Fistula  | Pecutaneous Creation of Hemodialysis Fistulas
Surgical AV Fistula | Pecutaneous Creation of Hemodialysis Fistulas
Keys to Good Outcomes in Ischemic Stroke | Neuro-Interventions
Keys to Good Outcomes in Ischemic Stroke | Neuro-Interventions
abnormalaspectsbloodbraincenterscerebralchaptercollateralscolorcontraindicationguidelinesheadhypoglycemicimagingintervenelumpectomymapsMRIocclusionpediatricPenumbraperfusionscalestrokestroke scalethrombectomyworkflow
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
Radiofrequency Ablation (RFA) - How it works | Ablations: Cryo, Microwave, & RFA
Radiofrequency Ablation (RFA) - How it works | Ablations: Cryo, Microwave, & RFA
CT Angiography | Determining the Endpoints of CLI Interventions
CT Angiography | Determining the Endpoints of CLI Interventions
Muscoskeletal Ablation | Interventional Oncology
Muscoskeletal Ablation | Interventional Oncology
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
Benefits of UFE | Uterine Artery Embolization The Good, The Bad, The Ugly
Benefits of UFE | Uterine Artery Embolization The Good, The Bad, The Ugly

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?

interventional research once again China because prior to the 1950s obviously with the Communist revolution and the socialist revolution there it was a kind

of very closed off country but in the past ten years of research true interventional radiology research has increased tenfold because of the opening of domestic borders because of the more internationalization

of China they actually started submitting things into international journals started looking at their IRB processes and I think we will see even more so you're gonna see more and more complex research coming out of China

they've applied more stringent application of IRB standards which has allowed their research to be more acceptable outside of China and the one thing that makes it hard for China to actually produce a high volume of

research is that they get no government funding there's no NIH to be able to provide specific standard funding and there's no medical device company to do funding as well so it's basically academic Hospital making a decision to

do a study and paying for the study that's the one limitation they do have specifically for interventional radiology and producing more relevant and pertinent to academic studies so

what I was alluding to before no procedures a slam dunk a breeze a piece of cake or a snap you know you you can't you can't take for granted what you're

doing even though like like oh it's just another g-tube oh it's just another line I'm I'm chairman of the department I'm the chief of her interventional and I do I do the lines because widely in the audience no well one of you want to be

people Wylie I had him put my line in and he's because he was the best two days later it got infected so no no it happens you know it just happens you can't take all this stuff for granted my oncologist sister had dialysis and they

were removing a Quinton and she got an air embolus and died of 32 it was it's like you can't take this stuff for granted every procedure you think it's just a routine procedure but it's to a patient who it's their lifeline or it's

their it's it's the most important thing to them so you can't take any procedure lightly because any procedure can go wrong and then side-effects if sometimes it's not the tumor that gets you it's the it's the it's the side effects like

the massive PE that I had was from one of the drugs I was on so you have to at least alert the patient that they may have side effects and and here's another one of my things to make you laugh but I had my bone marrow transplant

and I thought my side effect was that my flatus didn't smell anymore and I was informed by the people in the room that it wasn't the flatus it was my nose that didn't smell anymore but I got to do all the UM I got I get to do all

the abscesses now because I have I lost my sense of smell right in fact this was an appendiceal abscess and it really everybody left the room but me because I was the only one who couldn't smell it and I got out there and we do in CT and

I asked the tech I said what the hell does the appendix do anyway and she said oh it hangs there and does nothing I said well after my bone marrow biopsy I have two of those now so waiting for

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

so a couple a couple of ground rules first of all I'm a fish out of water I'm not your stereotypical position and I always say that uh that that's how I ended up in New Orleans because you can get lost in New Orleans if you're crazy and I said I didn't get I didn't go to

that course where they inserted this stick in your rectum in medical school so I am not politically correct okay and I don't know if any of you know the Jimmy Valvano story but um you know he got up there in front of everybody and

said I got a hundred and fifty holes in my bone so I want to see a little red light blinking what are you gonna do to me and well I'm similar to that if I'm not politically correct and you're offended I would please leave now

because there's nothing you can do to me because I'm on my way out anyway so it doesn't matter but and it's really funny that I just walked in when Vicki marks was talking and I think I'm a product of the early days of interventional because

we would do cases for eight hours and get eight hours of flora back to back it was that when we learned in tips when we were learning and after you read oral and we just take our badge and throw it and and I swear that that's the reason

why I ended up with myeloma anyway so some of this stuff I'm going to talk about I always like to insert humor so it does so it's not morbid and there are slides sometimes I'm you know being Italian I'm

kind of a wuss I cry at raindrops and and some sometimes I cannot get through the slide because it brings back kind of kind of crummy memories but anyway so I entitled this from the other side of the glass and I actually Photoshop that's me

looking at me getting treated in CT so I

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

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

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

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

you know Global Opportunities I'm

encouraging you guys to get involved as I are colleagues technologists mid-levels physicians they want you over there and there's many different initiatives sio has a fantastic initiative which focuses on China and

Latin America some of the kos here have had the ability to travel of China and learn you know you're bringing stuff to the table they're to China and they're sharing their knowledge and information with you and knowledge exchange is key

and crucial to advancing interventional radiology now and in the future and then certainly as technologists there's great opportunities rad eight who's quite right outside I just saw them that's a great organization you're gonna get an

opportunity to go to learn to travel a place like Tanzania go to Africa and you got to see my colleague for Carol ma zouri who's a good friend and a mentor talk a little bit about what it's like to be able to perform procedures over

there reach out do something for yourself okay cuz not only when you travel you enrich yourself but you enrich the world around you and in the end that's what I'm gonna leave you with get out learn grow meet

your colleagues overseas have a laugh drink some mal Thai say goodbye thank you very much

and these are just my personal observations I'm gonna make this quick because you got a great presenter following me and I don't want to push off dr. rustling too much longer but

compassion and smile are universal I didn't need to speak Mandarin to be able to understand what was going on and certainly when I'm at that scrub table and I'm performing procedures on patients we all could smile and laugh

and figure out what was going on very quickly without too much into discussion and so that's the one thing I would always say when you go smiles contagious wherever you are in this world everyone likes to smile

second thing is everything is your usable what you think it should be or not doesn't matter you can reuse it I found that one out betadine is amazing everything is reusable overseas you'll figure that one out quickly informed

healthcare is at a higher level in China and what I mean by that is when you have to have your patient pay for a $2000 stent yeah informed healthcare is amazing because you're gonna pull the patient's family in and you're gonna

talk to them and they're gonna have to make very important decisions about healthcare which is dependent on what type of finances they have and it's kind of sad unfortunately you know I would hope we

can go into a big long debate about US healthcare and everything else but in the end the sheet you put that Stinton if I need to put that stent in and then we'll worry about the finances later on it's

not that way over in there so that can be very frustrating for a clinician he's trying to do what he feels is best or if she feels is best for their patient and they can't you'll find no better MacGyver's than in china and then in

overseas because they will make it work no it's gonna fit no matter what what size fit you have it doesn't matter we'll make it work so it's it is amazing you will find some macgyvering going over there that's

quite fascinating more tase's and i've ever seen in my life you want to learn interventional oncology and you haven't done a taste procedure go to China for a week you're gonna come back and be an expert whether you want to be or not

that's de-facto and certainly the younger I are physicians strong knowledge base of clinically what's going on and excited to plug into their colleagues overseas they want to know what we're doing here in the US

they want to know what they're doing in Europe they want to know about the latest studies and that's exciting to me as a clinician to be able to share that and see that that future there is a strong and bright future for

interventional radiology and when

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

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

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

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

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

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

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

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

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

about RF a is that it was the first

ablation that we came up with all those that used it was first used in 1981 and it was really for the first liver ablation that we did RFA if any of you know about a Bovie knife the idea is the same the modality works the same as a

Bovie knife and still the main modality used in many parts of the world in the United States a lot of people will use it in certain areas but it's it's being slowly replaced by microwave ablation with time so as I mentioned some areas

are still using a fair amount of RF aimost or not I can honestly say that I haven't used much RF a at all I was sort of born into the generation of cryo and microwave places where we do use it or very commonly our Nerada meas for pain

control as well as spine ablations if any of you do the osteo cool system with Medtronic will do kyphoplasty in conjunction with an ablation that would be RFA and then Bowden oblations in conjunction with cement organizations

elsewhere right so in the pelvis if there's metastatic disease to the pelvis and you're going to ablate the lesion and then to cement augmentation the I

any questions at all so it's very diversified you know most physicians as I stated they don't have a residency I

out you know our fellowship so technologists are in most cases more integrated than cases than you would think here in the US you know a lot of fellowship and residency programs as you know when you have a resident fellow

there their Co scrubbing or they're doing the primary case by themselves whereas they're because you don't have that type of formalized residency structure the interventional technologies is doing all the case

within a physician and that's one of those things that one of the initiatives I'm working on is giving some I are technologists over to help train some of these guys show them how we do it here in the US share and kind of give back

and forth information something that's desperately you need to over in China any other questions thank you guys very much you guys made it through congratulations

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

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

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

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

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

certainly the face of interventional radiology in China is actually a very

good place to be right now you're talking about young physicians that are really getting involved in the field 58% of all Chinese IR physicians are under 40 years of age and status from 2017 you know 40% are under 35 you're talking

about very young doctors who are growing up in the IR you know field and actually you know really building a young base of physicians to carry IR into the next 20 years 41 percent of those physicians also have degrees outside their their

primary medical degree so master's degrees and doctors that's quite high you'll find out here in the US no like I said in China you don't necessarily have a traditional MD you don't you're not an MD actually it's a

bachelor's of Medicine very similar to the European model but a lot of them and majority of them almost have have advanced degrees so you're talking about very intelligent very young very aggressive people trying to carry this

ball and move it forward and try to join the international community of advancing IR and that was very heartwarming for me and made me feel very good to be with those colleagues and realize where the future lies for that kind of tree and

then 72% are bilingual or multilingual which is certainly much better than the u.s. because the Lord knows I can speak anything I can say come by and and Niihau so bottom line is you have very intellectual people that can communicate

very rarely did I have an issue in getting along and communicating with my colleagues in China and in the end we all speak the same universal language which is I are when I'm at a table and I'm scrubbing with those physicians we

didn't have to talk at all okay we knew what we were looking at we knew what needed to be done and we just did it and that's one thing that's always amazing about this field is that we all can speak the same language regardless of

where we come from so my observations

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

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

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

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