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Chapters
M.O.R.E Institute Continuous Education
M.O.R.E Institute Continuous Education
2016cadavercenterschaptereducationfellowshipsfocusMedactaNASSnoindex
Discogenic Pain : Pathophysiology and Diagnosis | Disc Intervention
Discogenic Pain : Pathophysiology and Diagnosis | Disc Intervention
annuluschapterdiagnosisdiscogenicdiscographyfibersfull videomediatorsminimallyMRInervePathophysiologypercutaneous
Evolution of Metastases | Bone Ablation for Local Tumor Control
Evolution of Metastases | Bone Ablation for Local Tumor Control
2018ablationarinAVIRbonechapterfull videolymphlymphaticsmayomelanomametastaticnodespatientstherapytumorunderstanding
Male | 53 | Myeloma | Augmented/Semented Screw | Pushing the Envelope: Needle Guidance and 3D Applications in MSK Intervention
Male | 53 | Myeloma | Augmented/Semented Screw | Pushing the Envelope: Needle Guidance and 3D Applications in MSK Intervention
2018arinAVIRbonycementchaptercoronalcortexdehiscencefull videoneedleposteriorradiationramusscrewsegmentationsystemictechnologisttherapy
Evidence for Comfort Talk | Rapid Resilience for Staff and Patients in IR
Evidence for Comfort Talk | Rapid Resilience for Staff and Patients in IR
2018anchoranesthesiaarinAVIRbasedbostonchaptercomfortfull videohospitalMRIpatientpatientsreimbursementsedationsettingstimulustrainedunanticipated
Q&A: Balancing Managing Preoperative Anxiety Against Informed Consent | Rapid Resilience for Staff and Patients in IR
Q&A: Balancing Managing Preoperative Anxiety Against Informed Consent | Rapid Resilience for Staff and Patients in IR
2018arinAVIRchapterembolizationexperiencefull videoinformedlymphpainfulpromise
Indications  | Why you should care: the evolving role of IR-RT and Splenic Artery Embolization: Different Indications & Different Techniques
Indications | Why you should care: the evolving role of IR-RT and Splenic Artery Embolization: Different Indications & Different Techniques
2018aneurysmarinarteryAVIRchapterdiverseembolizingextrahepaticfocusfull videohypersplenismHypertensionoverlapportalprogramsplenictalk
Current Management Of Bleeding Hemodialysis Fistulas: Can The Fistula Be Salvaged
Current Management Of Bleeding Hemodialysis Fistulas: Can The Fistula Be Salvaged
accessaneurysmalapproachArtegraftavoidbleedingbovineBovine Carotid Artery Graft (BCA)carotidcentersDialysisemergencyexperiencefatalFistulafistulasflapgraftgraftshemodialysishemorrhageinfectioninterpositionlesionLimberg skin flapnecrosispatencypatientpatientsptfeskinStent graftsubsequentsuturetourniquetulceratedulcerationsvascular
Needle Guidance | Pushing the Envelope: Needle Guidance and 3D Applications in MSK Intervention
Needle Guidance | Pushing the Envelope: Needle Guidance and 3D Applications in MSK Intervention
2018ablationalignarinAVIRchapterfull videoguidancehydrodissectionnarrowneedleoverlayplacementstraight
Segmentation/ Volumetric Overlay | Pushing the Envelope: Needle Guidance and 3D Applications in MSK Intervention
Segmentation/ Volumetric Overlay | Pushing the Envelope: Needle Guidance and 3D Applications in MSK Intervention
2018ablatearinAVIRchaptercontourfull videomarkoverlaysectionalsegmentationvolumevolumetric
Point and Polyline Overlay | Pushing the Envelope: Needle Guidance and 3D Applications in MSK Intervention
Point and Polyline Overlay | Pushing the Envelope: Needle Guidance and 3D Applications in MSK Intervention
2018ablationablationsarinAVIRbonechaptercrossexamplesfluoroscopicfull videomarkingoverlayportalprobesciaticsectionalstructurestumor
Oligometastases Revisited | Bone Ablation for Local Tumor Control
Oligometastases Revisited | Bone Ablation for Local Tumor Control
2018arinAVIRchapterfull videometastaticpatientssystemictumors
Dealing With Pain: Communication Pitfalls & Pearls | Rapid Resilience for Staff and Patients in IR
Dealing With Pain: Communication Pitfalls & Pearls | Rapid Resilience for Staff and Patients in IR
2018arinAVIRchaptercomfortcoolfull videomeasurementspainpatientstrippingtinglingvein
Intraop Registration Correction Techniques | Pushing the Envelope: Needle Guidance and 3D Applications in MSK Intervention
Intraop Registration Correction Techniques | Pushing the Envelope: Needle Guidance and 3D Applications in MSK Intervention
2018arinAVIRchapterfluoroscopicfull videoguidanceiterativemisregistrationneedleoverlayregistration
Laser Guidance Imaging and CBCT  | Pushing the Envelope: Needle Guidance and 3D Applications in MSK Intervention
Laser Guidance Imaging and CBCT | Pushing the Envelope: Needle Guidance and 3D Applications in MSK Intervention
2018advancedarinAVIRcenterchaptercrossfluorofluoroscopicfull videoimaginglasersneedleorthogonaloverlaysiemenstechniquestrocar
Tumor Heterogeneity and Limiting Metastatic Progression | Bone Ablation for Local Tumor Control
Tumor Heterogeneity and Limiting Metastatic Progression | Bone Ablation for Local Tumor Control
2018arinAVIRbiologicbonecancerchaptercolondevelopfull videometastasesmetastasismetastaticmutationspatientspreadtumortumors
Operation
Operation "Grey Doc": Using Retired Vascular Surgeons To Train Residents
anatomycadavercentersclinicaldissectionendarterectomyendovascularfacultygrayinstrumentinstrumentsmedicalparticipatepreopproceduresresidentsreviewsimulationstudentssurgeonsurgicalsuturesuturingTherapeutic / Diagnostictrainingvascular
Technetium 99m and Tc99m Radiopharmaceuticals | Technetium-99 (Tc-99m): A Versatile Isotope
Technetium 99m and Tc99m Radiopharmaceuticals | Technetium-99 (Tc-99m): A Versatile Isotope
2018arinbodybreastchapterconnectfull videogammapatientperfusionspecializedstays
Dealing With Pain | Rapid Resilience for Staff and Patients in IR
Dealing With Pain | Rapid Resilience for Staff and Patients in IR
2018anxietyarinAVIRaxisbreastcarechaptercomfortdrugsfull videopainpainfulparanoidpatientstandardtumorworst
Status Of Transcatheter Tricuspid Valve Implantation: Initial Experience
Status Of Transcatheter Tricuspid Valve Implantation: Initial Experience
angiogramannularatrialattemptscenterscoronaryfocusimplantationmitralNavigate / TrisolNavigate cardiac structure inc/nitinolpatientsrepositionedseveretherapeutictranscathetertransjugularTricusped Valvetricuspidvalvevalvesventricularwires
Conclusion | Pushing the Envelope: Needle Guidance and 3D Applications in MSK Intervention
Conclusion | Pushing the Envelope: Needle Guidance and 3D Applications in MSK Intervention
2018arinAVIRchapterfluoroscopicfull videotechnologistverification
Transcript

the focus on education this is branded as the M.O.R.E. Institute

but the focus here is really genuine. You have the opportunity to do everything from learning centers continuous education and we get the privilege of having some fun with the cadaver lab with you first here today. This

commitment runs deep and in Dr. Francesco Siccardi one of the principles of the company really seems to feel this organically is committed to education fellowships and in fact even charitable giving and philanthropy. When was the last

time you heard a medical device talk of manufacturer talk about that. So that's

The pathophysiology of discogenic pains

is multi-factorial in complex. It includes presence of nerve fibers in the annulus fibrosus, mechanical pressure upon the nerve root, with action of chemical mediators like leukotrienes, phospholipases, prostaglandins and formation of neovascularization.

What we can do for diagnosis is to combine clinical examination with imaging studies. And in the latter case we have non-invasive studies like fluoroscopy, CT, MRI and minimally invasive ones like myelography, discography and percutaneous infiltrations and actually those which are performed selectively

they can provide diagnosis for these patients.

- [Nick] Good morning everyone. My name's Nick Kurup, I'm from Mayo Clinic. And I'd just like to thank Kristin and the leadership for inviting me to speak. I'm gonna be talking about bone ablation for local tumor control, and these are my disclosures, research stuff,

and writing about this subject. So I'm mostly gonna focus on the why. Why do we do bone ablation for local tumor control and I'll talk about a rationale for focal therapy in these patients, a little bit about technique,

and then some evidence supporting ablation for these patients. So there's been an evolution in our understanding of patients with metastatic disease. Starting in the late 1800s with Dr Halsted, he described the orderly and contiguous understanding

of metastatic spread in the case of breast cancer. So the primary tumor moving through the lymphatics to the lymph nodes before spreading systemically. And he used this as justification for patients undergoing mastectomy or radiation therapy to the breast.

Another understanding of metastatic disease is that it's always widely disseminated. So if we have a patient like this that has a melanoma metastasis to the liver, if we only had more sensitive imaging techniques could really see what's going on,

we would see that there's not only the single metastasis, but really a host of other metastases, and these patients all have micrometastasis, cats out of the bag, there's nothing to do focally for these patients.

So let's look at this very last video we had about the heavy patient.

And it's a big case where, or a big example where the technologist can add a lot of value and help out a lot. So just a case example that kind of ties together. This was a 53 year old male. He's doing pretty good, except he kinda had

some progressive right hip pain for a few months, but was still walking and able to kind of do most things. Was diagnosed with myeloma. And this was his CT scan, kind of a coronal projection. You can see this large lytic destructive lesion

over his right acetabulum. With extensive kind of bony dehiscence and thinning of the cortex throughout. And so this was the plan to stabilize this. And help his pain from kind of a combined augmented screw, cement and screw approach.

These were the needle paths, and the screw paths that we used on pre-procedural imaging. You can kind of see representations of these here. So again it gives you a good idea of where these screws are gonna go, and in the case of the bottom right image

through a narrow corridor, this really allows us to achieve that. Using this live kind of overlay needle guidance. Several of these screws were placed. Again, up on the I guess top left, you can see this narrow ramus corridor,

that this kind of allows us to find. So again, just kind of more examples of how this case progressed. Registration is a key part again. This was the segmentation that I showed you earlier. And then kind of used this in real time

as we filled this entire area with cement. Again, given the bony destruction, at least the kind of posterior aspect of it was extremely difficult to see. Just under fluoroscopy, and I think without this nice contouring of our target lesion,

in cases that we've had, you know, previously, we would have stopped a lot earlier, thinking that we'd filled it. Whereas here we have kind of that confidence that there's a little bit more to go, a little bit more to fill.

So you can kinda see it, as this goes on, we are able to fill most of the target volume. And this was kind of the completion, you can kinda see that these are screws, and then the cement area here, kind of reforming almost the acetabulum roof.

So he did well, so this was all done percutaneously. He basically had three Band-aids from his three different screw entry sites. And was weight bearing within two hours. Afterwards, he underwent radiation therapy. He was on systemic therapy.

He's starting a Zometa for his kind of overall bone health, and he really doesn't have any specific right hip pain. And the biggest thing for him was that he was able to kind of move on to his systemic therapy and radiation therapy almost immediately afterwards. So a really good outcome, and one that I think that

without a lot of these advanced imaging techniques, we either wouldn't have been able to accomplish or probably would not have been able to provide as much structural reinforcement as we were.

Leave that a bit for later. While we were doing all the work in interventional radiology

we were asked to train a private practice MRI team north of Boston because they further wanted to reduce their claustrophobia rate and that's how we got into this whole issue of using Comfort Talk in the MRI setting

and what we are finding out now more and more is that patients who are claustrophobic it's PTSD. So for the one's of you who are doing nursing and are called in there, that's what it is. The situation, in one way shape or the other reminds them of past trauma.

There is now a fair amount of trauma exposure therapy, particularly these veterans who are coming back from the various wars where they go to the psychologist's office and they are re-introduced to the setting and this is reframed and then the hope is that they walk out of the office and feel better.

That's hard to do. However, when the patient shows up at your doorstep and is completely freaked out, they are in the trauma, they're in it, and all you can do is actually make it better because it is the setting where they are the very most motivated to improve it

and this is also why it kind of works. We had done a recent trial at Boston Medical Center, Tufts and Ohio State where we basically just look at what happens if you train a team in just changing their vocabulary a little bit, sometimes they would read a script

but most often not, what is gonna happen to the outcomes? And we didn't even insist that people would use the techniques, we said okay you get the training, do with it what you want but it kind of changes after you see how things work

that you are gonna see your results and then adaption becomes more. So we saw the incomplete and no show rates going down and a significant improvement in patient satisfaction and there's nothing that improves your stress level

more than if a patient comes and says, hey thank you very much you really helped me through that. Or they really express their appreciation. And we then moved on and did a randomized trial and I think that gets a bit back to the original slides I did

in you are not alone in this. You are in this environment of commercial pressures of patients who come in who are not coming and then what is happening to your practice base. The fascinating thing about this, and that was in Columbus, Ohio, that the trial,

we trained three teams in Comfort Talk and three teams we didn't and that was in one healthcare system of MRI and what had happened at time zero is a fascinating event which I call the adverse effects

that philanthropy can have. For those of you who have come from the Columbus area there is so much money out there, there are more wealthy people probably than in New York that don't show it, but there is a lot of richness, so for somebody to give a hundred million

to build a new tower for the hospital is not a big deal. So they build a new tower but then the competitor in town obviously couldn't let this go by and they also got this beautiful nine story newer tower. Obviously all of them having MRI.

Same thing happening in Boston. I mean it's amazing how many millions, hundred millions in philanthropy for new stuff and everybody has a new MRI. So now suddenly, and it was at time zero you have more scanners in an area than you have

patients to go around. And what happens, what we found is, and that's the blue line, the people who were trained in Comfort Talk, were able to keep their volume and the others lost volume. So even in big urban areas word gets around

of like where do people go or we see impact on no shows. Most no show are people are frequent offenders but in any event we saw that. So now obviously if you are working in an area where you have fewer and fewer patients showing up

your equipment utilization is going down. And keep in mind that the current regulations are you are supposed to have your equipment running 90% of time, that's what payment is based on, that CMS payment is based on. So if you see this line going down

and you work in a place like that you can count on your five fingers that somebody's gonna get fired making things even worse because that's how administrators really high up solve that situation. And what we have seen is that, in other settings

where we had trained people whose patients are happy and actually send that in, that's actually a very good insurance against being, quotation mark downsized and this is what happened with patient satisfaction. So once you stress out the personnel,

patient satisfaction is gonna go downhill and we had done that and seen that in a prior study too where, in that very first place that had hired us it was a joint venture of two hospitals for an outpatient facility and at the moment the reimbursement changed

to have more reimbursement hospital wise. They told everybody they'll get fired or transfer. That obviously did make a dip down in the patient satisfactions but then they came up again and at least throughout stayed longer than before training. I thought I'm gonna just share this

because that got published last week and our first author, who's actually at UCLA in economics, already has given three press interviews. So you might be hearing about that in the weeks to come. We trained a team at Duke and we looked at,

where do people waste, where does extra time go, where does extra expensive time go? And the two columns on the left side are the hospital based facilities and the two right columns are the free standing facilities.

Pre is before training, post is after training. Now the interesting thing is that in the hospital based places the amount of general anesthesia and conscious sedation didn't change because there are fixed slots, and every month, interestingly enough,

it's exactly the same. But that comes from the fact that places that don't have anesthesia and don't have sedation send them there until the slots are filled. But you might notice that green bar, the oral sedation went down, and particularly

disruptive motion. So the whole idea that you put somebody under general anesthesia and their breathe to you on command is not necessarily going to happen. If you look particularly at the freestanding places you've got a pretty big decrease in all these issues

that cost you extra time and run into money. So if you look at all, I think a paper that came out at Emory, what they call unanticipated events, I mean I don't call it unanticipated if a patient moves around, that's kind of life,

but if you look at those we found a drastic reduction but then also found even if you use Medicare reimbursement data quite a lot of more money. If you do 25,000 patients a year, and you make 12,800 times 25,000

that's nearly 300,000 for that you can keep some extra staff without anything else happening, or at least you can keep your structure intact or invest in new equipment. I think, since now we are all kind of really quiet,

I wasn't sure whether I would be showing you another video but I think you really need it with another great trick which is, if you're doing something and there's a repeat thing gonna happen again, some stimulus that's unpleasant,

and this actually really happened, the one we're playing now. Let's say you have the patient and let's say they're heavy and you know they take a breath in and they're gonna hit the equipment, which is kind of a bit scary for the patient,

or let's say you do a biopsy and you use the gun and it's gonna shoot all the time. So you have repeating, or you do a laser, you have a repeating stimulus coming, you can actually interestingly enough use that stimulus to make what we call an anchor.

Remember when I did the little hypnosis script with you, where I asked you to think either of a color or a sound or of a movement to anchor that with something really pleasant, the same you can use a stimulus that happens to anchor the patient in either getting more relaxed

or use that as a sign to numb the area around even more. It sounds spooky but it works.

Yes. - [Audience member] So we do lymph nodes integrity

inductions in the breast. They're extremely painful and patients come not prepared for a discussion about what's gonna happen to them. How would you give informed consent to let them know what's gonna happen

without giving them negative stimulus? - [Elvira] Well typically in those settings when you do your informed consent, whether it's something painful or where you potentially might kill somebody you still obviously have to describe what might happen

but what you're gonna do about it. Say, okay you know, and you explain what's happening, so say we'll be numbing up the skin and then we'll be injecting the material and you might feel that. Some people experience it as warm, some as hot,

some as a sense of tingling yeah, but the key thing is we want you to be comfortable and it's very, very important that you always tell me what is happening. If something, let's say your risk of killing somebody during your procedure, you say, and I've done

a fair amount of high risk cases. If, for example, while we're going through your heart and do that your heart stops we are going to resuscitate you and while we can never guarantee any outcomes I can promise you we will be doing everything known to mankind

to make this go well. I mean that is all I can promise so one can go somewhere deeper into that but I am open and some people in embolization say well, is it gonna hurt? I say well you know, different patients

experience it very different. The key thing is you are gonna let me know anytime how you feel like. I do not want you to be a hero, even if you say I do not want you to be a hero, still the hero is still in there,

I really want you to work with me and I'm gonna do whatever I can to make this a good experience for you. Which is, I mean it's honest, it's what you really want.

Okay. So I'm gonna talk about splenic artery embolization. And this is a subject, even on the physician side,

on the program side, SIR guests, SIRCE, Middle East, they're giving this talk to talk about, for 15 minutes, splenic artery embolization. And I don't think even the people that are putting the program actually understand as physicians, that this is a really big subject.

This is a diverse, diverse kind of group of procedures, it's not even a diverse procedure. And it all depends on actually... It's not working. Okay. It all depends on what you're treating,

and how you're treating it. This is actually the most important slide of the whole talk. If you want to focus on something, just focus and remember this slide. This is a group of indications for ...

Sorry guys. For splenic artery embolization. It's trauma, splenic artery aneurysm exclusion, NOHAH syndrome, which is splenic steal and liver transplant, HyperSplenism and portal hypertension. HyperSplenism and portal hypertension actually

overlap a lot. They're not synonymous, but they overlap a lot. Commonly, very commonly, when you find portal hypertension there's HyperSplenism, and if there's HyperSplenism sometimes there's portal hypertension, extrahepatic portal hypertension.

And the approach, technically, towards these disease processes, are different. With trauma, which I'm not gonna talk about today, because I don't have enough time for it. Trauma, you are actually going focused on a target area that's bleeding and either embolizing that

specific bleed, or embolizing the vicinity if you can't get to that specific bleed.

- We are talking about the current management of bleeding hemodialysis fistulas. I have no relevant disclosures. And as we can see there with bleeding fistulas, they can occur, you can imagine that the patient is getting access three times a week so ulcerations can't develop

and if they are not checked, the scab falls out and you get subsequent bleeding that can be fatal and lead to some significant morbidity. So fatal vascular access hemorrhage. What are the causes? So number one is thinking about

the excessive anticoagulation during dialysis, specifically Heparin during the dialysis circuit as well as with cumin and Xarelto. Intentional patient manipulati we always think of that when they move,

the needles can come out and then you get subsequent bleeding. But more specifically for us, we look at more the compromising integrity of the vascular access. Looking at stenosis, thrombosis, ulceration and infection. Ellingson and others in 2012 looked at the experience

in the US specifically in Maryland. Between the years of 2000/2006, they had a total of sixteen hundred roughly dialysis death, due to fatal vascular access hemorrhage, which only accounted for about .4% of all HD or hemodialysis death but the majority did come

from AV grafts less so from central venous catheters. But interestingly that around 78% really had this hemorrhage at home so it wasn't really done or they had experienced this at the dialysis centers. At the New Zealand experience and Australia, they had over a 14 year period which

they reviewed their fatal vascular access hemorrhage and what was interesting to see that around four weeks there was an inciting infection preceding the actual event. That was more than half the patients there. There was some other patients who had decoags and revisional surgery prior to the inciting event.

So can the access be salvaged. Well, the first thing obviously is direct pressure. Try to avoid tourniquet specifically for the patients at home. If they are in the emergency department, there is obviously something that can be done.

Just to decrease the morbidity that might be associated with potential limb loss. Suture repairs is kind of the main stay when you have a patient in the emergency department. And then depending on that, you decide to go to the operating room.

Perera and others 2013 and this is an emergency department review and emergency medicine, they use cyanoacrylate to control the bleeding for very small ulcerations. They had around 10 patients and they said that they had pretty good results.

But they did not look at the long term patency of these fistulas or recurrence. An interesting way to kind of manage an ulcerated bleeding fistula is the Limberg skin flap by Pirozzi and others in 2013 where they used an adjacent skin flap, a rhomboid skin flap

and they would get that approximal distal vascular control, rotate the flap over the ulcerated lesion after excising and repairing the venotomy and doing the closure. This was limited to only ulcerations that were less than 20mm.

When you look at the results, they have around 25 AV fistulas, around 15 AV grafts. The majority of the patients were treated with percutaneous angioplasty at least within a week of surgery. Within a month, their primary patency was running 96% for those fistulas and around 80% for AV grafts.

If you look at the six months patency, 76% were still opened and the fistula group and around 40% in the AV grafts. But interesting, you would think that rotating an adjacent skin flap may lead to necrosis but they had very little necrosis

of those flaps. Inui and others at the UC San Diego looked at their experience at dialysis access hemorrhage, they had a total 26 patients, interesting the majority of those patients were AV grafts patients that had either bovine graft

or PTFE and then aneurysmal fistulas being the rest. 18 were actually seen in the ED with active bleeding and were suture control. A minor amount of patients that did require tourniquet for a shock. This is kind of the algorithm when they look at

how they approach it, you know, obviously secure your proximal di they would do a Duplex ultrasound in the OR to assess hat type of procedure

they were going to do. You know, there were inciting events were always infection so they were very concerned by that. And they would obviously excise out the skin lesion and if they needed interposition graft replacement they would use a Rifampin soak PTFE

as well as Acuseal for immediate cannulation. Irrigation of the infected site were also done and using an impregnated antibiotic Vitagel was also done for the PTFE grafts. They were really successful in salvaging these fistulas and grafts at 85% success rate with 19 interposition

a patency was around 14 months for these patients. At UCS, my kind of approach to dealing with these ulcerated fistulas. Specifically if they bleed is to use

the bovine carotid artery graft. There's a paper that'll be coming out next month in JVS, but we looked at just in general our experience with aneurysmal and primary fistula creation with an AV with the carotid graft and we tried to approach these with early access so imagine with

a bleeding patient, you try to avoid using catheter if possible and placing the Artegraft gives us an opportunity to do that and with our data, there was no significant difference in the patency between early access and the standardized view of ten days on the Artegraft.

Prevention of the Fatal Vascular Access Hemorrhages. Important physical exam on a routine basis by the dialysis centers is imperative. If there is any scabbing or frank infection they should notify the surgeon immediately. Button Hole technique should be abandoned

even though it might be easier for the patient and decreased pain, it does increase infection because of that tract The rope ladder technique is more preferred way to avoid this. In the KDOQI guidelines of how else can we prevent this,

well, we know that aneurysmal fistulas can ulcerate so we look for any skin that might be compromised, we look for any risk of rupture of these aneurysms which rarely occur but it still needs to taken care of. Pseudoaneurysms we look at the diameter if it's twice the area of the graft.

If there is any difficulty in achieving hemostasis and then any obviously spontaneous bleeding from the sites. And the endovascular approach would be to put a stent graft across the pseudoaneurysms. Shah and others in 2012 had 100% immediate technical success They were able to have immediate access to the fistula

but they did have around 18.5% failure rate due to infection and thrombosis. So in conclusion, bleeding to hemodialysis access is rarely fatal but there are various ways to salvage this and we tried to keep the access viable for these patients.

Prevention is vital and educating our patients and dialysis centers is key. Thank you.

So needle guidance is one of the main tools that we use. This is basically a straight line overlay.

Distinct starting and ending points. We draw this again on cross sectional imaging. Automatically, you can align the C-arm to the, to kind of align with the path that you've drawn, in either a bullseye line of sight orientation, or also a kind of tangential view.

And really you can use this for anything that has straight line geometry. Bone trocars, cement cannulae, ablation probes, screws, temperature probes, hydrodissection needles, anything that more or less is straight line geometry. Just a couple examples of this.

On the right side you can see an example of bullseye needle guidance orientation, and then a more tangential view from the side of the same pathway, so that you can have real time kind of overlay guidance of needle placement as you rotate the II, with a detector,

back and forth real time. And one of the benefits of this is to be able to achieve placements within narrow corridors. Example on the left is placing a screw through a scapular body, which

you know, is pretty thin with a narrow corridor, but this really facilitates placement in this circumstance.

Alright so now if there's still a bit of disbelief in, oh let's just look a bit how it can normally look,

and how you might be able to change it, there we go.

Segmentation or volumetric overlay is basically overlaying either a shaded volume or a contour of a volume. The edges of the overlay volume can kind of be tangential to whichever orientation of the detector,

as it changes in real time. Again, drawn on the cross sectional CT data, using kind of segmentation type software. The use of this is really to mark a volume, or kind of a curvilinear surface. So you can either use this as to mark target volumes

that you're intending to ablate or cavities that you're intending to fill with cement. But you can also mark areas that you want to stay away from. Particularly in say the joint space, or the acetabulum or such. So this is an example, kind of on the left,

of you know, two different areas, volumetric areas kind of segmented out on the cross sectional data and how this looks on the three dimensional volumetric model on the right. So the yellow would be kinda this area of tumor, and destruction in the bone that we're intending to fill,

and the red being the actual joint space itself, that we wanna stay out of.

- [Nikki] Good morning everybody. Thank you so much for having me and thank you Kristina. So, I am going to talk to you more about the very broad high level

more than just the radiology kind of competencies. Competency should be assed for all employees at three main stages. So when they're hired, which would be typical of an HR. In our department, it's career services

or nurse requirement. And that really just makes sure that folks have the things that they need in order to get their job. Do they have a nursing degree? Did they successfully passed and have a license.

Do they have CPR? Things like that. And so, those are all done before somebody is hired. The next stage is in the introductory or sometimes known as initial.

And that is usually done in the orientation phase, so when they first start through the end of their orientation. And this really just focuses on the essence of their job. And then the last stage is their on-going. So these are done every single year.

They change every year. They're fluid and they're dynamic, and then they can be very specific to the person's role or they can be very generic in, that they need to practice patient safety, hand hygiene, things like that.

So, for today's purposes, we are gonna focus on specifically the introductory phase. So many of you, I'm hoping, already have some kind of ongoing competencies outside of your required education. And if you don't, you can certainly come

and talk with Kristina and I about that. But for today, we're gonna focus on our introductory. And so, as I said, those are unit-based and they're very specific to the particular unit, because their work required for a nurse or a tech or somebody to practice independently

once they're off of orientation.

We do use, particularly in interventional radiology we use a script

that somebody reads at the beginning of the case because not everybody has to work simultaneously at the beginning and we're reading this while the patient's prepped. I mean nobody stops, if we do large core breast biopsy we also do it while the patient's being compressed.

I mean nobody stops. So let's say perhaps nursing starts putting the blood pressure on, putting the probes on and all that, the technologist may start reading and then when those roles reverse the script allows that and somebody else reads.

If let's say you're in MRI, you just kind of may use some wording of it and you should theoretically be done by the time you walk the patient from the waiting room to the procedure room. Somebody's really claustrophobic you may need

to do a little bit more. But what I thought I'm gonna do with you, the basic of the script if somebody isn't too anxious takes you 90 seconds, we once timed it. If you wanna put in some extra provisions

like in IR that you wanna get somebody ready that there might be some potentially painful stimuli then you add a few of those what they can about, either mention some hot or cold pack and work on that and then if the patients already present with pain at the onset there's an extra little option for that.

If on the other hand they're really anxious and worried out of their senses there's another little piece and then at the end how we would reorient them. In that context it already has the explanation of what you do.

So the way this works, I'm gonna give you a little example of that, but what I'm gonna do is I'm gonna include what we call an insert. If you wanna do something special, you add a little thing in the middle and since this talk is about resilience

I thought to give you a little piece for if you need to get your confidence up like right at this moment. Either to walk in that waiting room to this patient who is already crying or you're walking in to your boss and you wanna have a salary increase

or let's say your chief of surgery who is throwing a tantrum in the hallway and you're gonna explain that this is not how it goes. So okay, and so basically what we would say to patients, well, and again there's a little confusion element

in the beginning, all we want to do is we want to help you so that you can help us so that we can help you to be more comfortable through this procedure. It's just a way of focused concentration like reading a book or watching a movie

or surfing the web and kind of forgetting where the time went and most people have this experience and, you know, you're fully in control of it. If it's a book you don't like you close it, same with TV you change the channel

and just use all the sounds and noises in the room to have your own experience and use only suggestions that are helpful for you. There are many ways to do this but there's a very simple way and on one you do just one thing, you look up and on two you do two things,

you slowly close your eyes and take a deep breath in, (inhales) and on three you do three things, breath out (exhales), relax your eyes and let your body float. That's right, just floating nice and safely, floating right through your chair or the table

and with each breath in take in strength and each breath out let go whatever is not helpful. Each breath in strength (inhales) and each breath out just let go whatever is not helpful. And just floating safe and comfortably like in a bath, the lake, or a hot tub.

That's right, and just with your eyes open or your eyes closed just focus on where you imagine yourself being now, what is it like? What do you see around, what do you hear, how does it feel like?

And you can make this your safe and comfortable place, you can always return to and play a trick on this whole procedure because your body has to here but you can be anywhere where you would rather be. And right now you may just focus on the moment

where everything just works out perfectly. One of these magic moments where everything comes together. You might have worked for it a long time or it just comes like a pot of gold at the end of a rainbow, and there you say, yes this is it

and it may be a private moment or a public achievement. While you're right in that just look a bit around a look at the colors that might permeate the scene and you can make these your colors so that whenever you need to get again into this state of confidence and peace and success

you just need to think of this color or you might get a pen or a pair of socks or just something to remind you of it. Or for some it may be a sound around, perhaps a song so that every time, at a moment's notice you need to get back into that state

you just think of the song or hum it for yourself. Or perhaps you enjoy just the way things feel and you can, you know, touch your thumb and forefinger together or you can do a very discrete, just curl your toes and then anytime you need it to get back in a state of confidence,

resourcefulness and brilliance all you need to do is just think of the color or the sound or of this movement that you gave yourself as a symbol. And now this was quite a lot to assimilate because sometimes in the conscious mind we have our own thoughts about whether subconsciously

we're assimilating all that into some new learning and while consciously there are all these logic things that go through one's mind, subconsciously one really knows how to move forward and which aspects to use and to learn. And now you can again gently float back

up over yourself and perhaps count backwards from three, like at three you can relax your eyes again and on two, start opening up your eyes and on one feel absolutely refreshed and delighted and ready to go on with the day

and you can even wiggle a little bit after in your room and go around and be all alert again, ready for the day to continue. Okay everybody back in the room. It got really quiet, very quiet.

So that was the deluxe version, that had the extra insert for the confidence. By the way, anyone of you who liked the color the best to remember? Or the sound? Or the movement, you can think a little bit

about how that works. You're really nice and quiet now. (audience laughs) It's amazing, you can have that in the IR suite where suddenly everybody just does their thing. Pretty good huh?

Point overlay is pretty simple. Again drawn on cross sectional imaging. These are just specific points. Can mark bone cortex.

You can mark kind of ablation probe stations if you're doing multiple overlapping ablation zones. Again this can be very helpful when, perhaps in a tumor case where there's been some bone destruction, you don't have good bony fluoroscopic landmarks that you might have in a normal patient.

Polyline overlay is kind of a similar technique. It's basically drawing a curvilinear line, again on a cross sectional imaging. And this is for more curvilinear structures such as perhaps marking nerves or neuroforamina. Estimating ablation zones,

marking out portal veins or other targets that you might use for even non MSK procedures. These are just a couple examples of this. You can kind of see a schematic representation on the left of what an ablations zone might look like. Also, some examples on the right of marking out a

sciatic nerve particularly, and then down on the right side, it's a little bit hard to see, but some green kind of cross hair point marks, just in terms of where you're gonna pull back your ablation probe along the path.

There just kinda different ways that you can utilize these, you know, these tools. These are examples again of the kind of curvilinear marking of neuroforamina. Whether it's ablation or cementation or such. That these are maybe structures

that you wanna know where they are under fluoro and stay away from.

Alright, so you know in conclusion,

if you have a happy patient you're going to have a happy staff and the key ingredient really is this rapid rapport piece, to reframe the experience, avoid these negative suggestions and you can use a bit of this hypnotic language and it doesn't need to take extra time.

Thank you. (audience applauds)

However, in 1995 Drs. Welchselbaum and Hellman

wrote an opinion paper called Oligometastases and then rewrote on this subject in 2011 about the concept of oligometastasis, and they really described this as a distinct state in which tumors have an intermediate metastatic potential. So these patients have a limited number

and site of metastases, and these are variably defined in the literature, but usually people will say up to five metastases. And in these patients it makes sense to do focal therapy rather than systemic therapy. These patients do not have all of the changes

that are required to have distant metastatic spread.

And again I'm gonna go later a bit more in what we do in interventional radiology where we do use some script reading but sometimes it's just very important what you say or that there is something you don't say.

So let's look at a situation, at a video that you kind of all know, like you have to put this IV in. And that's no uncommon and she's actually a very, very compassionate nurse but I mean this is replayed.

So you know the big question is, what do you actually believe happens when you say oh it's not going to hurt that much? What the patient hears is hurt, they don't hear that much, or it's just a little pinch and we had, when we did our breast biopsy study,

a very hard time because the team really believe that you have to use all these negative statements so we said okay, you know what, let's just get the data. So we listened to about 160 tapes in IR, what were people saying?

Just naturally what were they saying? And we listened for their statements that included pain or heat or bad or any other undesirable sensations and we were taking pain measurements every 10, 15 minutes and anxiety measurements and what we found

that if you warn for a stimulus with these kind of words they actually are gonna experience more pain than if you didn't say it and the same with the anxiety. If afterwards you sympathize and say oh that wasn't all that bad,

or how bad was that, it doesn't affect subsequent pain experiences but it will get the anxiety up. So what can you then actually say? I'm gonna show you another little video. Oops perhaps not, one moment we'll go back here

and yeah we can show the video now. Again Comfort Talk doesn't make things longer. You noticed what she did the second time? Right, okay she didn't say anything negative. She actually got the needles out of sight a little bit from the sight

and then she used something very tricky. She said well you might, because I always say give the patient the right to their own experience. You actually don't know what they're gonna feel. I never say this is not going to hurt, I mean what do I know, I don't.

So we call this a very permissive approach, we give some options. You might feel a sensation of cool or warmth or a delicious sense of tingling which we call a confusional type of induction because nobody really knows what that is

but now the brain is suddenly thinking, is it gonna be cool is it gonna be warm or is it delicious sense of tingling? (audience laughs) And that is the really very powerful phrase you can use in two settings.

One of the technologists at Boston Medical Center we trained said she had this patient come in with a real attitude, kinda under the whole idea. Oh you're putting that IV in, since how long are you in the business, do you know how to do this, yeah I'm a really hard stick, nobody does that

I don't see how you can do it, well she just put what we always say, put the confidence on and said, oh yeah and she put it in and when she said her thing, you might feel some cool or warmth or delicious tingling she said that patient suddenly went quiet

and was extremely cooperative till everything was completed. The other time this statement is extremely helpful when you are having a procedure. Somebody told me she had a vein stripping done, I mean not stripping but vein ablation,

you know you give a lot of local along the vein all the way up and down and she actually brought one of her colleagues with her because she wanted her colleague to do some Comfort Talk for her. But just in the preparation the doc was telling her the whole time, oh it's gonna hurt

and she said don't say that to me because I'm gonna be just fine. Said no, no, no but it's gonna hurt and she said, no you got this all wrong I will have a delicious sense of tingling. (audience laughs)

And I use that with my dentist too. I kind of just makes it quiet and you can have your own experience and cruise along. When we train the teams, now it's about the book, the key thing is this instant rapport and a lot of it is the matching

and leading to a more relaxed state. You shape the experience by the kind of wording you give but again the whole idea is to help these patients help themselves, to get them on autopilot because that's when they walk out the door, that's how they'll feel

the proudest of themselves. You're not doing it for them and I think sometimes it may interfere with your image as the giving healthcare provider. This is not about you, this is helping them to do their own stuff and what it does

in a very miraculous way that it actually cuts your stress level way down. And again with the self-hypnotic experience, I'm gonna show you in a little moment what it is because I'm gonna walk you through a little script we do. You can even, once you know how to do that,

support a stable physiology, get blood pressure a bit up and down although I always say this should not be your only way of keeping your patient stable.

But it's really key to pay attention during

you know, your procedure. Patient movement during the procedure leads to misregistration of the overlay objects. And inaccurate needle placement. And so you really have to kind of periodically verify this registration and alignment.

This an example just from a case where you can see that the overlay is off from the actual fluoroscopic image. Which means that all of the objects that are tied to that overlay are also gonna be off.

And so while the needle guidance and the advanced imaging can be helpful, you do have to kind of pay attention as a proceduralist to what you're doing, and whether it makes sense fluoroscopically. So you can see here that this

bullseye orientation needle guidance placement is really not exactly where it needs to be. It really should be shifted over a little bit more, into this AP corridor. So registration becomes kind of a iterative process during cases.

- [Instructor] Thank you for the invitation. It's great to be here, lots of energy in the room. I'm gonna talk briefly on some advanced imaging guidance that we've used in some MSK applications in the angiosuite. So really I think of this as augmented reality in the IR suite.

(laughing) Next, next says no disclosures here. Yeah, we're just gonna go over some advanced fluoroscopic overlay techniques really. Touch on needle guidance, some polyline point overlay,

volumetric segmentations, some registration. And then tie it together with a case example, just so that you guys have some exposure to this, and understand what we're doing with some of these advanced imaging techniques. So kind of the basic, one of the basic techniques

is laser guidance, that is available in our system, which is, most of these images are gonna be Siemens systems, but I know that there are other applications and other vendors and such. Really, this is orthogonal lasers that are attached to the imaging detector.

And the cross point is really in the center of the field of view. These two orthogonal lasers will cross at a point that's directly in the center of the field of view. Again, and you can line up a needle or any kind of bone trocar of sorts,

just using the lasers. So actually reduces the need for fluoroscopy. You can do a lot of needle placement, really without having fluoro on. Really the mainstay of a lot of these overlay techniques is having good cross sectional imaging.

The easiest way to do this is with cone-beam CT, at the beginning of a procedure. Automatically registers to the patient location in space, at the time of the procedure. Again this is non-contrast imaging with limited resolution.

But then on this 3D dataset, more stack of CT images, is you can then draw annotations, different objects that you can then project live on fluoroscopy.

So is there any cellular or biologic basis for this understanding? Well over the last couple of decades really, there's been a lot of scientific study into tumors on a genomic basis.

And we find that tumors really have a lot of heterogeneity. So this clump of cells that are multicolored here represent the tumor and really, we see that the metastases that develop from this to the brain, liver, and lungs, and spread from different parts of that tumor.

And each of these parts of the tumor may develop different mutations. And even the tumors that spread, like that green metastasis to the liver, then may develop further mutations that allow it to spread further.

And so if we find patients who have a limited amount of metastatic spread, potentially those patients have a single mutation as a more homogeneous tumor. In which case, we could potentially have a therapeutic window in which we can

prevent them from having spread elsewhere. So if we take this example, patient who has a colon cancer and the colon cancer had spread to the liver, those metastases then develop further mutations that spread to the lung and the bone and then the bone metastasis further spreads to the brain,

we could potentially, if we find a patient who only has a liver metastasis and a bone metastasis, if we actually treat those areas focally potentially we can limit their metastatic progression, improve survival.

Now, to become resilient and manage stress if you're in IR this is not something you can do by taking a 20 minute meditation break for yourself and typically by the time you're done with your day, your weekend,

you're coming home and there's a life too so just focusing on yourself and working really hard on meditation may not do the trick because there are other people around you who very much determine how your day goes. And we've published just last year in the JVIR

where we looked, well what happens if a patient walks in the door and they have this really negative affect. I'm getting more and more intrigued by the whole issue of mood contagion and if you look at that the people who come in like that, they actually

have more adverse events, they get about three times the amount of drugs and if you just look at anxious people it's those persons who come in and they look at you with these big, fearful eyes and they tell you I'm gonna die today,

how is that going to affect you? They are gonna experience more pain and above all, their procedures are gonna take much, much longer. The good news though is, what we've found out in this IR room with the multiple players

where there is one person feeding off the stress of the other it is enough to actually just relax one person and with that you can break this cycle. Yeah and then we have relatives that may make some pertinent remarks there

and there was actually a pretty cute study done by a NICU team where they randomized and had a simulated relative say something as kind as, oh if I would have known that you're doing here like third world medicine I would have brought my relative somewhere else.

Just something that pushes all your buttons and they found out that this whole team suddenly couldn't work as well anymore. Now it's not that easy to change what other people do but, you know, you're within this whole setup,

you may be the manager of your division or you have a manager whom you have to report to and there's a lot of other things that goes through your head. I mean this morning you heard about MACRA is in full swing, payment big time depends on it

and the satisfaction ratings and yes, you do wanna retain your staff because you need to have happy staff otherwise your patient's not gonna be happy either.

- Thank you very much, I appreciate the opportunity to be here and thanks to the program committee. I have no disclosures. I am not retired yet, so I am not seeking a position. Currently training (mumbles) paradigms mandated rapid acceleration in technical proficiency. We're not taking medical students and turning them

into vascular surgeons in five years. And what we often see now are fellows even after general surgical residency have not had extensive operative experience. To bridge that gap, simulation training has been touted as the method.

And its been incorporated into every training program. But, issues arise as to who has the time to effectively teach these sessions. The barriers for the surgeon educators are increase demands on clinical productivity, research obligations, EHR issues,

location of the simulation centers are often not conducive to clinical responsibilities. They are generally not located next to the operating room or next to your office. So there are opportunities, last year in the ACS surgical bulletin,

they put out, they discussed the retired surgeons, and there's currently 18,000 retired surgeon members in the ACS. Most live in proximity to the hospitals with training programs. They often seek out teaching opportunities.

At the University of Washington, we have Dr. John Arthur, who is in the crowd today. He should be giving this talk, but he was, he wanted me to do it. He's a retired surgeon from Bremerton, Washington. At the 2012 ACS meeting, he asked our division chief,

Dr. Ben Starnes, "Do you have anything a retired vascular surgeon can do?" And he said, "Oh boy, do we." And so we created a curriculum two days a week. Every Wednesday, we do a chapter review and Dr. Arthur participates in that,

then takes our first and second year residents for an additional hour-and-a-half and does skill training with them. He does vascular exposure, suturing techniques, things that we don't have time for. On Friday, he then does open training exposures,

VSIG training and once a month he has an industry representative come in with their product to review the IFU. Then our big course is the cadaver course that we do every December. And its cadaver dissection week, he coordinates all of the procedures that we do on this.

Including getting the instruments and having the faculty members participate in mock procedures. Didactics and reviews, so the instruments are laid out. The medical students and residents participate in this. They go over anatomy.

They go over every instrument so they understand open surgery. The endovascular portion, we have a representative come to our simulation center. They bring a simulator. They then practice deploying the graft,

review the IFU with a specific device so that they can learn this. But he oversees this. The anatomy and instrument review again is done with our vascular surgery interest group, which has really blossomed with his presence.

They have an anatomy review, the suture lab, and he teaches our medical students to basically be scrub techs during our dissection week. During the cadaver lab week, and this is an annual event, we have preop white board sessions, procedures with the residents,

and students serving as assistants. Here you can see the pre-procedure review for a median sternotomy and a thoraco-phreno laparotomy. And going over the details. Then we kind of get after here you can see Dr. Sterns with our residents doing this

with the medical students assisting under the supervision of Dr. Arthur, making sure all the instruments and all the people are where they need to be. And again the residents then perform these procedures as if they are doing an operation,

obviously without the mask. But, you can see that being a faculty member, you get called away. And so that's when Dr. Arthur is able to take over and be there. And this is the issues that we're always faced with.

Coordinating the sessions here, we're talking about endovascular access. I was able to do the endovascular portion. Dr. Kohler then comes in and helps out. And they do procedure-based learning. They will take a person through a carotid endarterectomy

and actually remove a plaque. So this is fantastic stuff that they're doing with this. We've had five years of doing this. And the faculty are all available, but now our simulation happens as scheduled. Its increased involvements of our medical students,

the VSIG members have grown, and its really corrected bad habits that we've noted in the operating room. And its led to an additional recruitment of another Gray Doc, which is Dr. Ted Kohler or salt and pepper. So there's opportunities to engage

with enthusiastic teachers. We need to utilize these resources. They are a wealth of experience. They share their experiences not only clinical, but in their practice and life experiences. It allows us this great group a chance

to further impart their wisdom on the next generation of surgeons. Thank you very much.

So Technetium, it is not a high energy isotope. It has a half life of six hours. It has intermediate energy, so what that means, that even though it may stay in your system for longer, four days, it is not as strong as FDG, which is used for PET scans.

So it does not require the same kind of precautions. Just like other isotopes, it is also pure gamma radiation, so it does need a specialized scanner. Other thing really cool about Technetium and other nuclear med scans are that they show how the, they show the functioning.

So when we are injecting how the body is functioning, rather than how body looks right now. So CAT scan, when you take the picture, it's how it looks at that point of time. With the Technetium scan it shows how the body is working. So we do flow studies, so as the isotope is going through

the body it can take pictures of that. That's pretty cool. It is Technetium can connect with different carrier, as we call them, such as MDP, sulfur colloid, and allow us to take specialized scan. The carriers will connect to Technetium and take them

to specific areas for those specific scans. Let's see, it is measured in millicuries. So this is a gamma scanner. It is pretty cool. The two plates that you see can move around the table around the patient.

So the table stays still, the patient stays still. It's the camera that's moving. It can go above and below the patient or to the side of the patient, depending on what pictures do we need. So it's an open scanner, as we call it. That's the patient on the scanner, pretty open.

Most patients do not have trouble with that, other good thing about this scanner is you can wear metal clothes so your clothes can have metals in it and it will not effect the scanning. So those are some of the radiopharmaceuticals that are there.

The most common ones that I will be talking about some of them I'm not attempting to pronounce, I'll just use how I use it in daily life. MDP, sulfur colloid, MAA, MAG 3, D.T.P.A, that we do use an aerosol as well as IV form.

I will be talking about bone scan, breast lymphoscintigraphy scan, ventilation perfusion scan, renal study and the GFR study. Also, 'cause breast lymphoscintigraphy's a mouthful, and I trip, I'll use mapping at times. (laughing)

- [Audience] What will you use? - Mapping. - Mapping, okay. - That's the layman's language, I guess, for us. - So breast mapping? - Uh-uh.

I mean I just thought I'll show you that second clip, how natural it can actually look to cross one's arms but then she opened it up and it's very hard to then not follow along, so that's how you sometimes can save the day

in a fast way. Now dealing with pain and that's something I think that gets to all of us emotionally, I mean we are gonna be poking people and there's certain things of how we feel about

what the patient should be experiencing. We've done several large clinical trials so we had the opportunity to look at the standard of care groups of those where patients could get as many drugs as they wanted and if I were to ask you, just by show of hands,

what do you think hurts the most? Okay angiography? Large core breast biopsy? Tumor embos? Okay well it's kind of like, what I thought too. However if you plot onto this graph

on the X axis is the time zero you wheel a patient into the room and on the Y axis is their self reported pain. We ask them like every end of 15 minutes, by the way we don't say how bad is your pain, we say what is your comfort level on a scale

of zero to 10, no pain at all and worst possible, and zero no anxiety at all, 10 worst possible. And what you find out is, I mean there are these three curves going up over time and the blue line is the tumor embos, the red one is the angio renal and the yellow

is the breast biopsies, there's really no difference. And furthermore when we dug deeper into this data not only is this increase in pain over time, this trend relatively independent of how hard you poke somebody, but also independent of how many drugs they get.

Actually there's a somewhat inverse relationship between the amount of drugs people get and how much pain they experience over time that is sent. And the question is why is that the case? So from nature we are used to always assume the worst

and similar curve applies, although with some differences for anxiety but there's an increase in anxiety over time in the case under standard of care and I think it goes all down, that's one explanation (mumbles), he's a surgeon in (mumbles) uses,

he says, you know, hundreds and thousands of years our ancestors, let's say who walks through the Savannah and one behind hears a little noise and says, oh this could be a tiger, perhaps I should look around and do something about it and the other one says it's just the wind it's not a big deal.

You can see that being a little paranoid over time still probably translates into higher longevity and the ability to create offspring so we are all deriving from the somewhat more paranoid people that particularly, in a setting of ambiguity, we assume it's hurting

or it's bad or it's dangerous to us and it's a protective mechanism of the subconscious. That is going to happen. Furthermore, once there had been one painful stimulus then all subsequent stimuli are going to be interpreted as being painful or even more painful

and there have been studies done where they hook people up to a machine with little flashing lights and the first time they got a little shock and the next time just the little lights were flashing and they experiencing more and more pain with the little lights flashing even though

there weren't any more shocks. So that's what you have to deal with and this is what we all know. If you do a case that's over in 15 minutes it's not that big a deal. It's like you're in hour number one,

where you now are number two or in hour number three. That's when certainly everybody can get really, really stressed out. However, the good news is if right at the beginning you do something, you say to the patient something in words but also in your behavior

that reframes this experience this doesn't happen. And this is kind of the secret sauce, all you need to do is do something at the beginning, at time zero, and then you don't get this blue line on the standard of care where the pain keeps going up

over time, time, time, time. If you do some empathic attention the increase is not as steep but if you do some comforting words at the beginning, these are IR data in interventional radiology, you can go on for ever.

I mean it's just like a very different atmosphere in the room and very similar for anxiety. We've found similar responses in a trial we did with breast biopsies and tumor embolizations under standard of care pain to go up,

getting better if you give some empathic attention but anxiety dropping down very quickly while this patient is still on your table and actually even though the whole thing is called Comfort Talk you're gonna end up to talk much less

because the idea is to get that patient on autopilot as fast as you can, particularly in MRI. You wanna have them in there doing their own thing, having, as we shall say, their own experience while you can start to do all your paperwork

and your reconstructions and whatever you need to do.

So and now I'm just gonna show you another video where we'll, just as an example how to go about the tips because you can't get anesthesia at four in the afternoon. That's when script reading really comes in handy, okay.

- I thank very much and thank many thanks for the invitation again. Tricuspid regurgitation is frequent in patients with left heart failure and other valve disease. It is an independent predictor of mortality. It has become more important since we can treat aortic and mitral valve disease by catheter techniques.

Transcatheter tricuspid repair techniques are difficult and the results are not sufficient yet. Therefore transcatheter tricuspid valve implantation may become an alternative. I will not talk about valve in surgical valve something we do since many years.

I will not talk about ectopic valve implantation like in the inferior and superior cavalve. I will focus on this five minute talk about tricuspid valve in native valve implantation. There are actually two systems which are currently tested, the NaviGate and the Trisol system.

The NaviGate Tricuspid Valve is made of a nitinol tapered stent, height is 21 mm. It has annular winglets and leaflet anchors. Comes in sizes between 36 and 52 mm. Requires a 35 French sheath with an OD of 42 French. It's a trans jugular or right atrial axis.

The delivery system has two degrees of tip motion and allows a very controlled valve release. This is one of our patients. The patient also had a mechanical valve in mitral position. RV angiogram shows a very severe tricuspid regurgitation. You can see right atrial access has been obtained

via lateral mini thoracotomy. Stiff wires in the right atrium, right ventricul, and pulmonary artery. Coronary wires in the right coronary artery for fluoro guidance and the navigate valve at this point is just prior to deployment.

This is during deployment. The ventricular tines are exposed and this is after deployment the release of this valve. You can see the ECHO the TE before severe TR and after are close to zero residual TR in this patient. Thirty four attempts in 32 patients in 13 centers

around the globe have been attempted. When you look at the baseline demographics there are many risk factors which basically I cannot go through details here but I just showing this to you to make it clear that this is a very sick patient population.

The acute results attempts are as I said 34 attempts in 32 patients. Successful implant could be achieved in 24 patients. Success implantation not successful in 5 mainly due to access problems. And 5 additional patients had to be converted to surgery.

When you look at the implanted valve size you see a trend toward bigger valves which also shows and indicates that we are missing larger valves which means many patients had to be excluded because the appropriate valve size was not relatable.

Tricuspid regurge obviously before the procedure severe to very severe and after valve implantation non trivial in almost 80% of these patients and you can see on the right side of this slide the improvement in heart failure class. This is a busy slide showing the outcome

of all individual patients. You just maybe, just focus on the mortality overall after 30 days was 12.5%. When you focus on only those patients who received the valve. In those patients the survival more than 30 days was 75%.

The other concept which is still in animal trials is the Trisol valve. It's a very unique valve design as you can see here on the left upper side of the side. It's a transjugular approach, 30 French delivery system. The valve anchors on the leaflets.

It can be repositioned and retrieved again. It's still in animal trials. So basically tricuspid valve implantation has taken off. Thank you very much for your attention.

And you kinda see in, in real time, in fluoro, this is at the same point and time, but from different projections

that these different contours actually project differently based on how the detector is rotated, so that you can kind of have, in a real time feedback as to where the edges of your intended ablation or cement fill are.

And sometimes again, and this can be very hard to tell, using just fluoroscopy in a pelvis or a bone that's had extensive destruction. Where you don't have good cortico kind of markers under fluoroscopy. Registration is really a key to all this,

and a big part of where the technologist come into play. This is really the process of aligning one data set with another. There's different ways you can do this. Two dimensional, three dimensional,

or three dimensional, three dimensional registration. What this allows you to do is potentially draw those objects of overlays on a separate 3D data set, so maybe a pre-procedural imaging study that has contrast, where you can actually see your targets a little bit clearer.

And then be able to fuse or register this with you know, real time, time of procedure, cone-beam CT. So that you can kind of then stack and fuse those objects that you've drawn on a more detailed study before.

So in conclusion, recent fluoroscopic software advances enable these various forms of,

ends up kind of being augmented fluoroscopy. The points, lines, volumes, really you can apply these in a lot of different creative ways. Dataset registration, verification is critical. Advanced imaging ends up being trusting the computer. And so a knowledgeable technologist is really invaluable

in terms of making sure that things are done correctly from the workstation standpoint and the registration as a case kind of goes along. So, thanks for your attention.

- [Audience member] How about children?

- [Elvira] Children, the beauty with children is that they have a very great imagination. I mean they are Batman, they are whatever they want to be and you can get them very quickly into their state. So for a kid, all you may need to do is,

oh what do you like to do? And then when they tell you what they like to do we use a little, how shall we say, ego strengthening piece in it. So for example, we do work a lot with Toronto Hospital for SickKids

and obviously what kids love there to do is play hockey, and so they go and play hockey and all the sounds there is your fans cheering you on and then they're gonna hit a goal and that kind of makes them really proud. What I may also add to that,

I've been thinking about this earlier to include in that is landscape in medicine is really, really shifting and what is happening that nursing and technologists, frontline staff are gonna be determining what is happening with patients.

We see this more and more, I mean doctors don't have really that much to say anymore and at Toronto Hospital for SickKids the nurse is running an absolutely landmark study. She's 11 patients away from 170 and this is gonna be the very first trial

that shows can you actually, if you decrease pre-operative anxiety, and that's kids who have cardiac ablations under general anesthesia, can the pre-intubation anxiety reduction, is that gonna result in better post operative behavior? Because there's a lot of research that you basically

create PTSD in these kids who come, they're in this environment the next time it's gonna be worse and worse. So she follows them up. But the other thing too is there always has been some thought about how much do patients

actually hear? When they are under, so with those kids we're actually also looking at not only a script at the onset but right before extubation. How is that gonna affect how they recover in recovery? What's it gonna do afterwards, what's it gonna do

for the whole safety? So I think particularly in kids, anesthesia is a problem because brain development can be affected depending on the age so we are very much into, hopefully soon, knowing exactly what is happening

in the pediatric population on a broad scale there.

So what I thought is perhaps to just look a little bit

around and think a little bit of what happens when you are in a situation let's say, where you do feel comfortable, where things kind of go their usual ways and what do you do then, what are your coping mechanisms in that?

So I'm just watching something very interesting, there is three ladies in the third row and one of them took her arm up and the next one did exactly the same and you're looking at me somewhat astonished and scared. (audience laughs)

But this is something people to tend to do when they're in rapport. We do this very, very intuitively and you may perhaps even look a little bit around of how you're sitting there, the two ladies there who have their arms just like perfectly folded

in the right way, I mean one of them is completely not watching what her neighbor does because she's doing her iPhone but both of them are having their hands exactly in the same way. So you know while you're sitting there it's kinda of like a little spooky thing

of what we do when we feel safe and comfortable we do tend to match the body positions of others. So now, okay you gotta work now. So I would like now every second person of you to get up, if you don't have a partner look behind you, every second person gets up and you're gonna be

playing yourself and the person who remains sitting is going to be your patient in the waiting room. Okay, it's work time, yeah yeah work time. Little stretch time, so find yourself a patient victim and the idea is that your patient has been waiting patiently for getting their PICC line

and you had all these emergencies come in and they've already been in the waiting room for over an hour and now you got this neuro case being wheeled in and you're gonna explain now this is gonna take at least another hour, you can't even say how long it's gonna take,

and your patient is allowed to misbehave. So let's go, see how this works. Just keep talking to them, I mean you do, you've got that lingo down all the time. (audience chatters) Alright, and now just kind of freeze in

the body position you have. How much matching is going on right now? (audience chatters) So number one, your patient is kind of sitting and you are, many of you, standing. So you're right on top of them

and there's actually some research that shows that if you sit down, people think you spent more time with them. So, if now you all sit down and this may feel a little unnatural, match whatever your patient's doing. If they do that, you can do that a little bit.

If they do that, you can be a little copying it. The whole thing they tell you in medical school about this open positive section and never raise your voice, does not work. You do want to match, that is like the big secret. So you match a little bit in the beginning.

Now the idea is not that both of you are screaming at the end, but you just follow it a little bit. Oh really, you have to wait long and then you go and go down. If on the other hand your patient is deeply depressed, oh I can't do that, and then you say, ah and then

take your breath up. Okay I'll give you two minutes to continue your conversation with your unwilling patient. So also if your patient has their legs crossed you cross them, if they don't have the legs crossed you uncross yours.

Just do what they do and then the patients you can try to stay nasty but see what happens in trying to stay nasty or unhelpful if the other person matches you.

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