Chapters
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Vertebral Artery Dissections: Etiology, Diagnosis And How To Treat Them
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Long-Term Results Of Carotid Subclavian Bypasses In Conjunction With TEVAR: Complications And How To Avoid Them
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Cloud Based System For Image Fusion Techniques With Mobile C-Arms (The Cydar System): How Does It Work And Advantages For All Vascular Interventions
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Superior Hypogastric Block | Nerve Blocks, Neurolysis, and Rizotomies
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Transcript

A nice tactile thing. Are you guys still hearing me by the way changed microphone around. I changed my gown. Yeah so as we were discussing the guides

come with vertebral body and posterior element models which is endlessly helpful. You get to see how they're supposed to fit on a truly hard guide because again the CT windows that are used to design the guides will go

down the bony windows so the guides are designed to sit on bone and getting the feel for how that goes down properly is important. You can visualize where the guide stanchions and contact points go on the model and then get a sense for

visualizing how they go. It has to get more around so it has to end all that chunk of tissue up there. Need a little bit more. Sort of by going back and forth can avoid over dissecting but yet dissect enough. And realizing this you can

[inaudible] [inaudible] And whether you do mostly degenerative tumor deformity work anybody who's done any deformity surgery enjoys a nice clean long segment dissection. Feeling better about the way that sitting down?

I think so. It seems to be sitting everywhere. I can see how you can toggle this way toggle that way. That seems to make sense. Doing the reality check? Yeah. May I take a look at that for a moment?

Okay so the stanchion is sitting right there on the lamina. This not up here but all the way back here on this prominence and then again out laterally. All the way to the excrescences really of the articulations of the costotransverse processes so.

Let's see. If it passes the sniff-test. So you were saying that it felt it was going on like this? Yeah. Did I get that correctly? So you know like anything else it's a guide. It's a little bit of the jiggle a little wiggle. If that seems reasonable to you

it's starting to seem reasonable to me. Yeah it does. Is there anything that you think needs to come off. A lot of the great things about starting at the lab is it's just a cadaver so you have any doubts you can fire in some Kwires prove yourself wrong learn from it.

Sam suggested having your assistant hold it I think that's reasonable. I feel like the holding is more important than driving the k-wire so I hold my own but that's up to you.

yeah I I got it only we've got plenty of real estate here so we can just start somewhere and you can always go up to T6. So you're good if we go backwards? Well yeah. so that's an important point. I'm not gonna go to 11 we can go up to 6 and back down. Perfect.

Best to grab from there? You can hand me the handle. Would you like me to stabilize for you? Or with you? No sure why not more the merrier. That's our depth. We got some fluoro Amanda? Yep we have fluoro right there. Chuck key. Chuck key. Available 45mm long. K-wire. Space between 75mm. You do enough trauma you just click it.

So I think you'll discover if you sink those wires even a little bit you can converge these slip this right off wires will stay in. Pull your guide right off.

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.

- [Narrator] First-in-human, first announcement of some new experience with a small to medium vessel embolization device. We know that embolization devices have a wide range of applications and we have a wide range of device options including coils and plugs, and there are a number

of requirements we have for embolization devices. We need to be able to deploy these very accurately, a stable position, we need the device to be conformable, provide rapid occlusion and therefore provide freedom from re-canalization. This device is the very first announcement

of our early experience with the Shape Memory Polymer Technology for embolization and the IMPEDE embolization system. It provides some of those options we needed. Targeted deployment, quick and stable occlusion, a high degree of space filling, and

excellent vessel conformity. The key components of this device is actually the shape memory polymer plug that you can see there is a proximal radio opaque marker and a guide wire pushes the device immediately behind this and then there is a

distal platinum iridium anchoring coil that prevents any migration of the device. The SMP plug expands at body temperature in aqueous environment, so in the blood stream. The advantages of this polymer are that there it's delivered in a crimped state,

but then when exposed to blood expands to a device that has a very high surface area which induces long fluid residence times and therefore leads to thrombosis. Histologically we've seen that in the subacute and chronic phase that there is

a large amount of collagen laid down with a minimal amount of red blood residual, so these lesions appear to contract with time which is a pleasing phenomenon. The current IMPEDE plug is available in three devices 05, 07, and 10. You can see these

vessels are these devices can be used to treat to vessels of varying diameters up to 10 millimeters and the largest device the plug has an expanded diameter of (cough) excuse me 12 millimeters. We've performed seven cases to date with a range of indications.

Aortic branch artery embolization prior to EVAR, tumor embolization, and varicocele embolization. The devices have been successfully delivered and deployed in all cases, and we define technical success as vessel occlusion on angiography

performed five minutes after deployment and we saw that in 100% of cases. We've seen no serious adverse events, and four of the seven cases had clinically indicated follow up imaging and they showed no re-canalization. Here's an example, a patient who had an EVAR

a number of years ago and had unexplained ongoing sac expansion that we thought was due to type one endotension transmitted through the right limb of the graft, and we'd decided to extend and embolize the hyper gastric artery. Here you can see that the coil component

of the device is being advanced via a five french terumo destination sheath into the hypogastric artery, so you can see this coiling up very nicely and predictably in the main trunk of the hyper gastric artery. There's the radio opaque marker at the back of

the plug itself and a guide wire, an 0305 guide wire that is advanced. Once that coil's completely deployed, we then release the plug by keeping the guide wire in place and pulling the sheath back and so you'll see that sheath come back to

expose the plug that is already loosened apart from that marker that marks the proximal end very nicely, and that then opens up and here you can see an angiogram at five minutes, and you can see the shouldering and conformability of this plug for this particular indication.

Here a completion angiogram, and then a one month CT, and you can see that the plug has nicely taken out the hypogastric trunk but the branch a patent. Here's a venus application. A young man with a left varicocele, and you can see again in the movie here

that we're deploying this through a five french shuttle sheath here, and you can see this large impede coil coiling up in the vein and once that's fully coiled you can see the plug itself which is already loosened apart from this radio opaque marker,

and then that's deployed and the sheath withdrawn and venogram performed at five minutes shows complete occlusion of the vein. The IMPEDE embolization system is a new technology for small to medium vessel embolization as you've seen the advantages include

quick and stable embolization, a high degree of space filling, and excellent vessel conformity. Our experience is very early, but certainly promising. Thanks very much.

- [Klaus Mathias] Chairman, ladies and gentlemen, many thanks, that are really my images. Yes, what causes carotid aneurysms? As you know, the leading cause is atherosclerosis, but there are many other reasons why you can have them. And we have not only real aneurysms, but also false aneurysms, quite a number.

Symptoms, which we observed in 41 patients, treatment options, stent placement with and without coiling and flow diverters, as is especial in the distal and the intercranial carotid, but endografts in the neck arterial segment. Here is the case of an 87 year-old gentlemen

who complained of severe pain of his carotid artery, as you see here, with edema formation. You couldn't touch his neck with the ultrasound. He cried, "Oh, it's so painful." And with simple flow diversion with a stent, within 24 hours, the pain was gone.

Very astonishing, also for us, this experience. Then, the typical atherosclerotic aneurysms, as you see it here on that CT, with some bleeding and you see it here again. His treatment excluded with an endograft.

And you see here another case, carotid dissection, occluded carotid artery on one side, also a dissection on the other side. And this young man had two aneurysms, as you see it here. Also, these two aneurysms could be excluded using a covered stent.

False carotid aneurysm after a trauma, car accident, you see it here, that was technically a little bit more demanding. The patient also suffered from vertebral artery occlusions due to this accident. And what we have done here,

the problem was after probing the distal part of the artery, yes, we have a loop here, how to stretch it. And you see, we succeeded at the end, and we could place also here, then an endograft and exclude the aneurysm. Postoperative false aneurysm,

after operation of a tongue cancer with an injured carotid artery and you see it after treatment, very simple, light carotid artery stenting. Then, postoperative false aneurysm here, after partial resection of the jaw

and you see there's a ugly situation here. Also here, we could use the covered stents and exclude it. Recurrent disease after surgery in the patient, here with an erosion of the carotid artery, due to the tumor. Also here we could stop the bleeding immediately by placing.

Are there contra-indication for this type of treatment? Yes, there are. I would not recommend to place a covered stent when you have to deal with a mycotic aneurysm. There are the results. You see that a man and woman, nearly equally distributed,

leading cause, atherosclerosis, but quite a lot of other disease entities. Technical success rate, one failure where we could not get into the distal part of the carotid artery, and otherwise, fairly good results. And when you look at the followup results,

yes, there was one recurrent filling of the aneurysm, so we had to place a second stent and a second intervention. The tumor patients died after four weeks and after 18 months. And yes, I come to conclude, there are only a few indications for open surgery.

Most of these aneurysms can today, dealt with with endovascular techniques. And yes, the distal ICA can only be treated with endovascular means. Thank you.

- [Presenter] Thanks very much. So I'm giving this talk on behalf of Ian Loftus, from St. George's in London, who couldn't be here today. I got some disclosures for this. These are Ian's slides. So in Europe, there's been some experience using the Nellix system,

endovascular aneurysm seeding with parallel grafts for complex aneurysms on the premise that gutter endoleaks may be reduced using polymer-based technology. In terms of the St. George's group, these would be indications for possible use of chEVAS. So patients with pararenal or juxtarenal aneurysms,

those that are outside the IFU for an infrarenal Nellix, and actually the majority of patients would be those who are either anatomically unsuitable for a fenestrated custom-made graft or unsuitable on the grounds of emergent surgery. In terms of the early lessons,

St. George's has about 80 cases and the early lessons were that it's absolutely essential to plan to achieve an aortic neck in the suprarenal aorta of at least 15 millimeters, important to have a strategy for upper limb access, as I'll show you in subsequent slides,

and avoid patients who have upgoing renal arteries using a suprarenal approach. The choice of the parallel graft, whether balloon expandable or self expandable, is also crucial, and a dual anti-platelet regime

has been instituted in this institution. It's also important to realize that chEVAS is done on the same basic platform as Nellix, and therefore we know that the graft does best in aneurysms that have a large flow lumen and relatively little thrombus.

So I'll just show you some clinical results from the ASCEND registry, so this was a retrospective registry, 154 patients with primary chEVAS for suprarenal and juxtarenal aneurysms. So upper limb access strategies,

crucial in all of these cases, the George's group tends to use a brachial approach when it's one chimney, and an infraclavicular axillary approach when two or more, and the technique has evolved from sewing a conduit

on to actually doing individual punctures for each chimney with a purse-string graft. If you look at data from the ASCEND registry, having a strategy for your upper-limb access in placement of chimneys is clearly very important, you can see here on the far right-hand side,

if you do more than two chimneys, blood loss is excessive. And actually in terms of significant complications of chEVAS, you have to take into account of strokes, so there were four cases of stroke

in the 154 in the ASCEND registry, and three out of the four cases of stroke were posterior circulation, clearly reflecting manipulation around the vertebral artery. In terms of visceral artery considerations, cranial or upgoing renal arteries

are a real problem in terms of access. One obviously has to use all the adjunctive methodology that's available for cannulating the renal arteries and the visceral arteries. But a consideration is that patients do best with a minimum length of 10 millimeter seal and again,

the choice of whether to use balloon expandable or self expanding stents is crucial in ongoing strategies. In terms of durability, one sees probably better durability in the long term with patients who get self expanding stents but clearly the procedure

is easier if you use a balloon expandable stent. Most of the patients in the ASCEND registry had balloon expandable stents and you can see that nine patients required reintervention for a renal artery stenosis but overall the patency of these vessels after intervention was good.

So just to sum up then, EVAS for complex aortic disease, it's a promising use of new technology, there does appear to be a therapeutic gap, I think what's important in terms of proof of concept is testing of component interaction and understanding which branch graft to use.

In terms of good results, patient selection is absolutely key, with achieving a neck of at least 1.5 centimeters and a strategy for the management of upper limb access is absolutely crucial to avoid stroke. Clearly, the role of this therapy

is going to be defined by its long-term durability, and in the US, we hope actually to be instituting an IDE sometime next year. Thank you very much.

The stellate ganglion is one of the higher blocks and it's actually probably one of the more difficult blocks. Many of the pain specialists will do these blind which I think is kind of amazing,

considering you have the vertebral artery, you have the carotid artery, you have the esophagus in the vicinity, and so this is a block that I think should definitely be done under image guidance. There have been papers showing that when done under CT guidance, that there's a much greater accuracy

and success with this block. The stellate ganglion block is used to treat complex regional pain syndromes in the upper extremities, like reflex sympathetic dystrophy, hyperhidrosis. So if you have patients who have heavy sweating in the hands, you can use this block to address that.

It's also been used for refractory angina, which I thought was interesting. Phantom limb pain in patients that have had amputations of their upper extremity. Herpes zoster, as well as pain in the head and neck. This block also is used in Raynaud's syndrome

in a scleroderma, it's used in vasospasm syndromes, in patients that are post traumatic or have experienced frost bite, or have embolic syndromes in the upper extremity. And again, intractable angina is one that I actually learned when I was reading about this talk.

One of the indications that is not well known is the use of the stellate ganglion block for hot flashes in the setting of breast cancer. Many of these patients are on tamoxifen and other types of agents that can cause intense hot flashes and a stellate ganglion block can actually

improve those symptoms.

- [Robyn] Thank you for asking me to speak. I have no disclosures. Subclavian artery aneurysms are quite rare, making up only 5% of all aneurysms. However, they do make up 50% of all supra-aortic aneurysms. They come in two locations, first, proximal, located in the chest, these are usually

degenerative in nature and they have other conditions, such as connective tissue disorders, fibromuscular dysplasia, and vasculitis associated with them. They also commonly have concomitant thoracic aortic aneurysms. The second type that we've been discussing this last talk

are distal aneurysms, which are usually related to arterial thoracic outlet. Patients may present asymptomatic. Symptoms include pain, which usually is consistent with rupture, upper extremity ischemia, including claudication, rest pain, Raynaud's, or

thromboemboli, or possibly, posterior circulation stroke. A physical examination should be focused on evidence of distal ischemia or concomitant aneurysms, and diagnostic evaluation is usually good with a CTA for both diagnosis, as well as surgical planning, and as

we discussed in the last talk, digital subtraction imaging is needed if there's evidence of distal ischemia. Traditionally, degenerative aneurysms were treated with open surgery, the right subclavian can be approached through a median sternotomy, with possible extension into a collar incision.

The left subclavian is approached through a left anterior thoracotomy. Once inside the chest, there's multiple ways to repair the subclavian artery. If only a subclavian artery is involved, a primary aneurysmorphy may be done

versus over-sewing the aortic stump and an extra anatomic bypass, however, often, the aorta is also involved, and this may require cardiopulmonary bypass, replacement of the aortic section, and possible debranching, or extra anatomic bypass.

From the area of endovascular surgery, we can now often repair these without having to enter the chest. This can be done with primary stenting if it's just a subclavian artery, however, proximal and distal landing zone

is required proximal to the take off of the vertival artery. If there's no proximal landing zone, or the aortic arch is also involved, a TEVAR can be done with either extra anatomic bypass, a subclavian snorkel, or now, using new branched endo devices.

Due to the rarity of disease, there's not much in the literature pertaining to outcomes of these aneurysms. This study from the time of open surgery looked at 27 patients that had innominate artery aneurysm repairs, and as I discussed, many of them have concomitant diseases, and vasculitis.

About half of them required aortic artery placement, as well, and outcomes were mainly based on how the patients presented. Those that presented with a rupture had an up to 50% mortality rate, while those that presented electively had only a 5% mortality rate.

From the era of endovascular surgery, the dupe group looked at 24 patients and had similar results, with 21% of the patients having a connective tissue disorder, and about half of the patients having concomitant aortic disease.

They were able to repair 64% with endovascular techniques, and had a similar mortality rate to that seen with open surgery of 5% for elective cases. Moving on to distal subclavian aneurysms, as our last speaker discussed, they are related to thoracic outlets, and therefore,

when repairing them, attention need to be paid to first relieving the arterial compression, then removing the source of embolism, and finally, restoring distal circulation. The best approach to relieve that compression is through supraclavicular incision.

This facilitates removal of the cervical rib and gives the best arterial exposure. An infraclavicular incision may also be needed to facilitate the distal anastomosis. Particularly about cervical ribs, in the population cervical ribs are quite rare,

occurring in only about 1% of the population. However, they are seen up to about 75% of the time in arterial thoracic outlet syndrome. The cervical rib originates from C7, and commonly has fibrous bands to the first rib that lie within the middle scalene,

which cases the compression on the subclavian artery. Therefore, both the cervical rib and the first rib need to be excised together. This is in comparison to an anomalous first rib. That originates from T1, and usually can be removed on its own.

Moving on to arterial interventions as our last speaker stated, again, once the rib is removed the artery is well exposed and a traditional aneurysmorphy can usually be done to fix the subclavian artery, taking care to deal with any distal embolization

with embolectomy at the time. Looking at outcomes, our moderator, Doctor Thompson, looked at 40 patients that they did at their group, and showed that it was about 50% of the patients presented with upper extremity ischemia,

5% presented with a posterior stroke, 75% had a cervical rib, and 12% had an anomalous first rib. They had to manage 70% of patients with their subclavian artery reconstruction, which all had good long term patency. In conclusion, proximal subclavian aneurysms

are degenerative in nature, while distal subclavian aneurysms are related to thoracic outlet syndrome. Management of proximal aneurysms is complex and commonly involves repair of concomitant arch pathology, while management of distal aneurysms must include a thorough evaluation and treatment of the thoracic outlet.

Given the rarity of the disease and the multitude of treatment options, literature regarding outcomes is yet to be well defined. Form the current literature, it does appear repair can be done from either an endovascular, open, or hybrid approach. Thank you.

- [Mark] Thank you very much, and thank you again, Frank. The vertebral artery of all the extracranial vessels gets very little attention. It's by the fact that there's some major, major complications from ischemia, dissection, and thrombosis.

So, alright, my disclosures. So, let's see here. Alright basically then the vertebral artery has four segments. This is the first segment, second segment, I'll explain this later,

third second, fourth segment. So four segments of the vertebral artery, and diagrammatically this explains it somewhat better. So, the vertebral artery enters right from the subclavian and C6, and then transverses in the transverse foramen,

extends up to C3, where it exits. It exits here, and this is a mobile section here, where dissection can occur. This mobility here, and then it enters through the foramen magnum and then joins to form the other vertebral, to form the basilar.

So, critical basilar here. You can see the basilar just anatomically showing you the anterior inferior cerebellar and the posterior cerebellar. So the anterior spinal artery. Obviously, the basilar artery's critical

in terms of the dissections. It'll bleed. I'll show you a few examples of that. So, basically what happens is a tear occurs in dissection and there's intra bleeding within a wall. Causes a little hematoma.

And then obviously if asymptomatic, these patients all resolve without any interventions, so they're treated medically and have not become an issue. Now, intracranial, that's a different story for dissection. Basically emboli and atherosclerosis

can result in basilar stroke. Dissection is the most common cause in the younger age group and responsible for stroke in these patients younger than 45 years of age. The most common site for vertebral dissection is at the most mobile site, which is at C2-C3,

where it exits to enter the foramen magnum. In terms of imaging, we still think that gold standard is angiography, but nonetheless MRA and CTA also, quite impressive in terms of overall evaluation. But for all purposes, to see detailed evaluation

of extra and intracranial, vertebral, we like angiogram. Basically, that at least gives you an idea of here, you can see the dissection and the double lumen here, and obviously the occlusion on this vertical CTA examination. So it gives you an idea how valuable the CTA is.

So in this situation here, origin vertebral. And then subsequently, dissection. Dissection because a Guide Wire perforated here. But the patient's asymptomatic. So there's nothing to do and obviously in three months it's back to normal dimensions.

So that's the secret in terms of the vertebral proximal artery. They don't really require anything. On the other hand, you can see here, this is an ostial lesion. So most ostial lesions may or may not

need therapy if the contralateral side supplies. But in this situation you have the ostial lesion which is treated but in addition there's a basilar. The basilar has about a 90 percent stenosis. So in this situation we would dilate the ostial first and then subsequently

dilate and stent the basilar and then subsequently come back and stent the ostial lesion. So that's how we handle a combined lesion with an acceptable result. Except, we leave this one alone, this component here, on this vertebral

is not significant enough to interfere. So we took care of the high grade stenosis in the basilar of course, and then subsequently in the origin ostial vertebral. So sometimes in symptomatic bilateral vertebral stenosis we ask ourselves,

what can we do with this? So we can do nothing with this, I mean, maybe the surgical situation proximally but certainly there's no endovascular intervention for this complex occlusion. Especially when the other side

also has a critical stenosis here, at its origin and we stent that with a satisfactory result and then on that obviously supplies adequate intracranial circulation. So again in stenting, you have to be certain that the stent's in a proper position

so it doesn't migrate otherwise it's very difficult to re-enter. So intracranial bleed is a different situation with dissection, about here you can see obviously a huge infarct to the left cerebellum and so intracranial bleed here,

so obviously then, dissection intracranially is totally different than the extracranial. And obviously significant bleed has a very high morbidity. So here you can see just a very rapid transition. You can see a high-grade stenosis in the origin that is carotid.

And stenting is a great result, stenting, but notice in the meantime that prominent occipital branch occurring because subclavian is occluded, so we obviously demonstrate that by retrograde injection here and then subsequent coming down you see

the occlusion here, and then with acceptable stenting you can see now a normal result with antegrade flow now in the vertebral. So do we have to do that? Well, we do that because there's a shunt from the basilar junction down retrograde

so obviously if we can stent that and correct that then you have antegrade flow normally in that left vertebral. So another situation, this was a patient. We had a stroke on the table while getting a coronary intervention.

So we didn't have to move the patient at all. We just then approached this with initially aspiration which wasn't totally successful but improved somewhat and then we put a Trevo in. And did not great but the sciatic would markedly improve. In all this you can see basilar filling,

posterior cerebral filling, cerebellar filling and the pica filling as well so it improved flow, not the greatest result but acceptable. So in conclusion we say endovascular treatment has largely replaced surgery for most dissections and certainly thrombus

as well and asymptomatic patients. So, best managed conservatively. Symptomatic patients with thrombosis, anticoagulants, respiration, are all acceptable in thrombosis and obviously intracranial situations are difficult.

Surgical possibility, but not much in the way of endovascular intervention intracranially. So basically then stenting, aspiration and anticoagulant is the approach we use when there's significant thrombosis where it's symptomatic, but asymptomatic

patients with dissections are best managed conservatively with best medical management. Thank you.

- [Speaker] Well, thank you very much, Dr. Manzi, and not so opposite. I'm not sure we have much of a debate. I'd agree with many of the conclusions you've already heard here this afternoon. Nothing to disclose in regards to this lecture. But I would say that, we did look at this back in the year 2006,

and we did because the plastic surgeon in my group said that he wanted the blood put to a certain particular artery where he thought the wound was located. And I said, "No, no, no, we can just bypass "to the best artery available, "and that will work just fine."

And we had this big disagreement, so we went to the cadaver lab and we actually defined in the cadaver lab six angiosomes distinct to the lower extremity, one off the dorsalis pedis, two off the peroneal, and three off the posterior tib.

Here's our cadaveric dissections. And it is actually fairly distinct in terms of these latex injections, and the borders are actually fairly distinct. Here's the two off the peroneal, and the three off of the posterior tib.

The problem is, there are indirect connections, and they're called choke vessels, and there's no question that you see these arteriographically, and you can see these in the cadaveric dissections as well.

We were able to identify them here. And there's no question they play a role, and we'll talk a little bit about more of those at the end of the talk. There's also the question of the intact pedal arch. Does the pedal arch play any role

in this particular paradigm? So we looked at 60 consecutive wounds, and as you previously saw, we only had 58 patients to actually analyze. There was some mortality. But these were patients, they were a rarefied group,

these were patients that all had a tibial bypass, all done with vein, all bypasses remain patent, and in whom we had good definition of the wound angiosome and the bypass anatomy. And as you can see, here's the tibial bypass distribution, interestingly, mostly to the anterior tibial artery.

I don't know why that happened to be, just worked out that way. And we had, if you looked at this particular group, we had about half that were done with an indirect revascularization, and half had a direct revascularization.

The important thing you have to think about when you look at some of these trials is also what kind of wound care and wound healing they had subsequent to their procedure. If you're going to look at amputation prevention and wound healing and wound healing time, as a metric,

then you need to know that they did have a standardized wound care protocol, subsequent to their revascularization. That's very important, and when you look at the methodology of some of these papers make certain that you read that.

We did have a standardized wound care protocol, and there was no difference between the groups. And this was what we found, you've seen this slide. We had more complete healing and a trend towards more rapid healing when I could perform a bypass with vein to the artery

that fed the angiosome where the wound was located. Other people have shown the same thing. You've seen the meta-analysis. I've tried to tease out some of the papers that actually have specified some of the parameters that I mentioned earlier in terms of their methodology.

This is a group from Oregon Health Sciences University, all bypasses, where they showed more complete healing in the direct group, more rapid time to healing, and thought that it was a significant predictor for healing and reduced healing time.

Another bypass group which showed more rapid healing in the direct revascularization group, and higher limb salvage, although that can also be impacted by the wound care protocols. And this group also thought

that achieving direct arterial flow, based on the angiosome concept, is important. It's not the be-all, end-all. I would never deny someone a revascularization because I can't revascularize the artery to the appropriate angiosome.

But I think it does have an impact. It also has been shown to have an impact in endovascular therapy. Here's the group from Belgium showing that they had more complete healing after direct revascularization with diabetic foot ulcers

performed with an endovascular revascularization. Here's Iida's group, also showed 203 ischemic ulcers, improved healing with endovascular therapy if the artery could be revascularized that directly fed the angiosome where the wound was located. Here's the group from Helsinki,

we already talked about this. Interestingly, if you look at some of these things, you'll also find many of these papers will indicate that, certainly, all these wounds can't be assigned to a particular angiosome so you have to consider that as well.

About, if you look in the literature, anywhere between 30 to 60% of cases will have wounds that can't be assigned to a particular angiosome. And obviously, in that context, the angiosome concept won't have as much import.

That was found in this particular group which just published their paper in Journal of Vascular Surgery. They looked at their peroneal bypasses, and applied the angiosome theory to their peroneal bypasses. As you can see,

only 46% of the wounds could actually be assigned to a particular peroneal angiosome. So you must take that into account as well. This is a compilation of the data that I could compile in terms of the papers that I thought were done with methodologic good technique.

And you can see the numbers are actually pretty reproducible. So if you can perform a direct revascularization, there's fairly good homogeneity in terms of your percentage of healing compared to indirect revascularization,

whether that's done with bypass or endovascular therapy. But there are discordant results. You've heard them presented here this afternoon. There's no question about it. Why does this occur? Well, I think it occurs because, again,

not all wounds are located in a single, distinct angiosome. Their specific angiosome revascularization should be performed, I believe, when possible. And maybe, there's a paper that has proposed a new category. Maybe we need to be thinking about that. This is an indirect revascularization,

but with these choke vessel connections. And when this particular author compared those two groups, there was actually no difference between direct and indirect if they had the presence of these collateral choke vessels. It was the indirect group that could not define and show these choke vessels

that had the real difficulties. And that's maybe where we are. So I think in conclusion, revascularization of the direct angiosome does result in increased healing, I think trends towards increased healing.

I think it should be considered, although I would never deny someone a revascularization because we can't revascularize the artery where the angiosome is located. And I think when we think about it, it does make a difference,

but without sacrificing any of the other key principles that we all utilize for revascularization. Thank you very much Mr. Chairman.

- [Martin] Good morning. Thank you Dr. Veith for the invite again this year. These are my general disclosures, none specific for this talk. I'm going to speak regarding how complex carotid interventions which I would define in the middle of the slide there as treatments involving the carotid bifurcation

with carotid endarterectomy combined with treatment of longer length or tandem specific lesions of the common carotid artery, tortuous internal carotid arteries with long length disease, recurrent stenosis that require redo procedures, symptomatic posterior circulation disease

requiring a simultaneous intervention, prior head and neck cancers and radiation effects and combined opened cardiac surgery with carotid endarterectomy is a higher risk group that's been relative non-controlled and ill-defined with smaller studies done

describing singular techniques. We know certainly that carotid endarterectomy and carotid stenting have low stroke and death rates. When they're performed with these more complex groups have not been analyzed. So this is a person audit

of 325 consecutive interventions since 2009. 28% of these involving a complex carotid intervention by that definition with those treatments listed there. Comparative groups, 185 standard carotid endarterectomies, 21 carotid case during that case, during that time, and also isolated innominate

or proximal common carotid artery stenting for aneurysm or occlusive disease. Some of these patients followed with duplex imaging, many of those for the aneurysms with a chimney technique for the occlusive disease with a bare stent treatment.

Carotid repair details. My preferred technique, arteriotomies extending beyond the endarterectomy end points, routine use of a balloon tip Pruitt-Inahara shunt, conventional endarterectomy, thin wall patching in all cases,

and completion duplex scanning. Carotid stenting done transfemorally with a neuroprotective filters, IVUS-guiding with general use of larger diameter balloons at the repair sites. The specifics for the complex carotid group.

With the combined radiated or recurrent stenosis saphenous vein patch is used preferentially. Some interposition grafts used. Combined posterior circulation, these are bypasses of the subclavian or vertebral reimplants.

With long length and tortuous ICAs I'll describe briefly a technique of ICA shortening. And with ipsilateral common carotid disease, the long length mid and distal portion of the common carotid artery can be treated with a eversion endarterectomy technique

which I'll quickly describe. Near occlusions or multilength obliterations of the common carotid will require interposition grafts or bypassing from the subclavian artery. And proximal or origin stenosis done over the retrograde bare stent,

preferentially a Boston Scientific Express stent, general lengths less than three centimeters. Stenting performed first before the endarterectomy. The ICA shortening technique done after arteriotomy is made. An endarterectomy, approximately centimeter length segments cut out of the proximal ICA and then reimplantation

of the posterior wall, with a continuous suture, then patching across that site. The eversion endarterectomy technique done by dividing at the distal common carotid artery and the performing an eversion endarterectomy of the common carotid artery.

Insertion then of the shunt into the distal vessel. Endarterectomy completed up the internal carotid artery and then patching across the whole segment. With the more proximal disease, again stenting of focal disease at the arch origin vessels and complete occlusions treated with

carotid-carotid bypasses. These are the comparative results a cohort here that has 40% symptomatic presentations. Fairly rigorous image capturing and followup with mean followups out to nearly three years in this group, showing relatively equal outcomes

in the 30 day period between complex carotid group and the standard CEA subgroup, of no strokes in the carotid endarterectomy groups, either complex or standard CEA. The complications primarily in the standard CEA group due to cardiac complications.

Composite severe perioperative outcomes were equivalent and restenosis occurred at the carotid bulb in all of those cases, both complex and standard groups. One group to note is isolated common carotid artery stenting or innominate stenting for occlusive disease, up to a 10% recurrence rate, requiring reintervention.

So, can be done safely, these complex intervention with a more aggressive technique treating all of the disease on the ipsilateral side. Recurrent stenosis can be a problem, either at the bifurcation or in the proximal common intervention sites

and duplex surveillance imaging is indicated. Thank you very much.

- [Cynthia] Don, Matt, and thanks again to Dr. Veith for inviting me to this terrific meeting. I'm an unpaid consultant for Cydar. Cydar EV was born out of a clinical need identified by endovascular aortic surgeon, Tom Carrell and his partner,

radiology scientist, Graeme Penney. It was conceived of and developed as a 3D fusion imaging system for endovascular procedures that is cloud based. I'll get back to why that's important in a minute, and in fact, C-Y-D-A-R stands

for can you do another registration, which is what Tom used to shout out to Graeme in the control room as they were starting out in this process and journey. It was FDA approved for use in the United Stated in 2016, and to date, Duke is the only US site

to implement Cydar. So what is the big deal with cloud-based fusion technology? So cloud-based fusion technology makes 3D overlay technically feasible for remote, and indeed, coverage anywhere in the globe,

not for just sophisticated hybrid rooms. Digital technology improves much faster than hardware and can be updated in real time. It works with any fluoro equipment of any manufacturer, including a C arm. And there is enhanced accuracy compared

to mechanical registrations, which has been technically proven and published. The clinical workflow is pretty simple. The CT scan is uploaded about 24 hours in advance to the Cydar's cloud's software vault. You then turn on the medical-grade PC in your OR.

You type in the patient name, you press the fluoro pedal, and the fused image comes up on the screen with your fluoro image. Now when you move the fluoro image when the patient moves, the software uses vertebral body recognition, much like a smart phone might

recognize faces, to find where the patient is now. And when it's confident it has the correct position, then the new image will appear on the screen. And you can see that the visceral vessels

are circled for identification. That can be changed and modified based on the surgeon. The clinical applications are quite numerous. It can be used for any EVAR or FEVAR, and for mid-distal TEVAR.

At present, we still need to have two vertebral bodies in the field for recognition by the software. It can also be used, and is very helpful in angioplasty stenting embo of the aorta iliac system, as well.

Well any hospital administrator and any new technology has to answer to the financial question. So this is a study looking at any 3D fusion product and whether it reduces time in the OR.

And in fact, it does for both complex and standard cases. It's significant time reduction. Well what does that mean? If you assume a 420-minute OR day, if you do one complex endo case,

you don't have time, if you don't use 3D fusion, you don't have time for a second standard case. But if you do use 3D fusion, with the time reduction, you can actually get an additional standard case in, with an incremental revenue to the hospital per day of $100,000.

Similarly, without 3D fusion, you can get three standard cases. But with 3D fusion, five standard cases for $203,000 of incremental revenue. But what about Cydar? Does that translate to Cydar?

So let's talk a little bit about our experience at Duke with Cydar. Since we started Cydar, we've done approximately 36 cases of EVAR and FEVAR, and we matched those to 83 prior cases for a total of 119 cases. Most of the prior cases were done either

with no 3D or their preexisting mechanical 3D fusion system. And then you can see that the demographics are quite similar to what you would expect. With EVAR alone, we saw a statistically significant reduction in procedure time,

postoperative creatinine, and 30-day creatinine, and reduction trends, due to the small numbers in radiation dose, fluoro time, contrast volume, type II endoleak, length of stay, and 30-day mortality. Similarly, if we looked at FEVAR, where

the numbers were even lower. We saw a statistically significant reduction in procedure time, nevertheless, with trends to reduction in radiation dose, fluoro time, endoleak type II, length of stay, 30-day mortality, and creatinine.

So if we looked at all patients, we saw statistically significant reductions in procedure time, postoperative creatinine, 30-day creatinine, and then the trends that we discussed. So in summary, our preliminary data shows

that Cydar EV is associated with a statistically significant reduction in procedure time, with the potential for increased OR case volume and revenue, lower radiation dose, the potential for use of lower contrast volumes, improvement in clinical throughput in volumes,

and we'll know more as we acquire larger numbers. So stay tuned! Thank you!

So let's just talk briefly about the evidence and I'll use metastatic renal cell carcinoma as a model case. Different tumor histologies will have different evidence and different studies to support them. So in this case of a patient who has a right renal mass

and develop this renal metastasis and we ablate that with the ice ball you can see very well. So does this oligometastatic state even occur in renal cell carcinoma met, patients? Well, it does. Most patients actually present

with limited metastatic disease. More than half the patients, when they present with metastases, have just a single site of disease, and that proportion actually increases as patients age. So the patients who are the most elderly,

the most frail, the least suited to surgery, actually are the most likely to have a single site of disease to treat. Is there a survival benefit from surgery if we extrapolate those data? Well, if patients have a wide or radical surgical resection

as opposed to a marginal, they're just pinning that metastasis, those patients do better who have a wide radical surgery. And if patients at the end of their surgery actually are free of disease, they don't have other sites of metastasis,

if we can actually treat all of their disease, they live longer.

So we've looked at our experience in treating musculoskeletal limited metastatic disease for complete remission, and we looked at 52 metastases in 40 patients. A quarter of them were renal cell in this case. Had about two years followup,

and 87% were able to achieve local tumor control. And these patients live a long time. The median survival of these patients was almost four years with two years survival of 84% with acceptable complication rate. We looked at specifically in renal cell carcinoma,

treating those in multiple different sites. And you know, most of these patients did have locations in bone and soft tissue. So if we used those data to say is there evidence to support this? Well, in these 82 tumors the recurrence

resurvival was very high in 94%, and the patient's overall survival 83% were still alive two years later. In our local tumor control about 88% with an acceptable complication rate. So it is possible to treat these patients

and continue to have them live a long time without systemic therapy. Others have certainly looked at this. This is a group in Detroit that's looked at the same thing, renal cell carcinoma metastasis ablation, and they found the same thing,

median survival over two years in this group. And they actually did a little bit of a cost analysis and said what's the estimated cost even if we have to ablate these people twice and their cost per life year gained was $26,000, which is very reasonable

and compares favorably to systemic therapy, these patients who are put on systemic therapy, the cost is 30 to 45,000 in their study. I've seen estimates over $60,000 for a year. So it's certainly reasonable to do that. This is a busy chart that just shows

that there's a lot of evidence for treating musculoskeletal tumors for local tumor control for a variety of histologies from lung cancer to renal cell cancer to a mixed populations, and breast cancer, whether it's in the spine or other areas in the bone,

a variety of ablation modalities, cryoablation versus heat and the local tumor control rates are reasonable, 70 to 98% depending on the patient population we're looking at. And these data have been compelling enough that the National Cancer Care Network's guidelines

had been revised for patients with stage four renal cell carcinoma. Now that if they are not surgical candidates, ablative techniques in these metastases should be considered.

- Our group has looked at the outcomes of patients undergoing carotid-subclavian bypass in the setting of thoracic endovascular repair. These are my obligatory disclosures, none of which are relevant to this study. By way of introduction, coverage of the left subclavian artery origin

is required in 10-50% of patients undergoing TEVAR, to achieve an adequate proximal landing zone. The left subclavian artery may contribute to critical vascular beds in addition to the left upper extremity, including the posterior cerebral circulation,

the coronary circulation if a LIMA graft is present, and the spinal cord, via vertebral collaterals. Therefore the potential risks of inadequate left subclavian perfusion include not only arm ischemia, but also posterior circulation stroke,

spinal cord ischemia, and coronary insufficiency. Although these risks are of low frequency, the SVS as early as 2010 published guidelines advocating a policy of liberal left subclavian revascularization during TEVAR

requiring left subclavian origin coverage. Until recently, the only approved way to maintain perfusion of the left subclavian artery during TEVAR, with a zone 2 or more proximal landing zone, was a cervical bypass or transposition procedure. As thoracic side-branch devices become more available,

we thought it might be useful to review our experience with cervical bypass for comparison with these newer endovascular strategies. This study was a retrospective review of our aortic disease database, and identified 112 out of 579 TEVARs

that had undergone carotid subclavian bypass. We used the standard operative technique, through a short, supraclavicular incision, the subclavian arteries exposed by division of the anterior scalene muscle, and a short 8 millimeter PTFE graft is placed

between the common carotid and the subclavian arteries, usually contemporaneous with the TEVAR procedure. The most important finding of this review regarded phrenic nerve dysfunction. To exam this, all pre- and post-TEVAR chest x-rays were reviewed for evidence of diaphragm elevation.

The study population was typical for patients undergoing TEVAR. The most frequent indication for bypass was for spinal cord protection, and nearly 80% of cases were elective. We found that 25 % of patients had some evidence

of phrenic nerve dysfunction, though many resolved over time. Other nerve injury and vascular graft complications occurred with much less frequency. This slide illustrates the grading of diaphragm elevation into mild and severe categories,

and notes that over half of the injuries did resolve over time. Vascular complications were rare, and usually treated with a corrective endovascular procedure. Of three graft occlusions, only one required repeat bypass.

Two pseudoaneurysms were treated endovascularly. Actuarial graft, primary graft patency, was 97% after five years. In summary then, the report examines early and late outcomes for carotid subclavian bypass, in the setting of TEVAR. We found an unexpectedly high rate

of phrenic nerve dysfunction postoperatively, although over half resolved spontaneously. There was a very low incidence of vascular complications, and a high long-term patency rate. We suggest that this study may provide a benchmark for comparison

with emerging branch thoracic endovascular devices. Thank you.

Moving on to percutaneous decompression techniques for the discs, we can have decompression and we can have regeneration techniques for the discs. Specifically for the decompression techniques we can have thermal techniques using laser, continuous or pulsed radiofrequency and plasma energy ablation.

We can have mechanical decompression using a wide variety of devices and we can have chemical decompression by means of Discogel or ozone intradiscal injections. All these techniques, what they are actually based on is that fact that a intervertebral disc is a closed hydro-ablic space and when you are removing a small

part from the nucleus, you are actually causing a significant decrease in the intradiscal disc and this disc pressure actually is what makes the herniation move inwards. And we have these techniques from back in the 1940s. The indications for these kind of treatments

in the intervertebral discs include patients who are capable of providing consent with a symptomatic small to medium-sized herniation and when we are speaking about the size of the herniation, if you have a theoretical line between the facet joints, all herniations which do not cross this line,

they can be percutaneously treated. And when we are speaking about symptomatic cases, symptoms should be consistent with the segmental level where the herniation is located on the MR imaging. For example, if you have a left L4-L5 foraminal herniation, you are expecting the patient

to report a left L4 root neuralgia. Absolute contraindications include sphincter dysfunction, extreme sciatica and progressive neurologic deficit. And actually all these are indications for surgery. Additional absolute contraindications include sequestration or the presence

of asymptomatic herniation, local or systemic infection, spondylosthesis and stenosis of the vertebral canal, anticoagulants, coagulation disorders and the patient refusing to provide informed consent. Most of these techniques are performed under fluoroscopy so we (mumbles) projection with 45-degrees angulation

of the fluoroscopy beam and as far as the lumbar spine is concerned, we perform a direct posterior lateral (mumbles) in the disc. In the final position, we need to have the needle in the anterior third of the disc in the lateral projection towards the midline in the AP projection and you can see

how important the technologist is because we need to have good visualization of what we are doing. Once you are there, you have access to the disc and you can insert any kind of product that you are familiar with, starting from thermal, going to mechanical or chemical decompression.

The magic number for all these techniques concerning success rate is around 80%. The complication rate is very low, between 0.5%. What we do know so far from the literature is that there are no studies of evidence of superiority of one technique over the other.

As we've already said, complications are really rare. Spondylodiscitis is the most fearsome one with a percentage of 0.24% per patient.

- Thank you. I have two talks because Dr. Gaverde, I understand, is not well, so we- - [Man] Thank you very much. - We just merged the two talks. All right, it's a little joke. For today's talk we used fusion technology

to merge two talks on fusion technology. Hopefully the rest of the talk will be a little better than that. (laughs) I think we all know from doing endovascular aortic interventions

that you can be fooled by the 2D image and here's a real life view of how that can be an issue. I don't think I need to convince anyone in this room that 3D fusion imaging is essential for complex aortic work. Studies have clearly shown it decreases radiation,

it decreases fluoro time, and decreases contrast use, and I'll just point out that these data are derived from the standard mechanical based systems. And I'll be talking about a cloud-based system that's an alternative that has some advantages. So these traditional mechanical based 3D fusion images,

as I mentioned, do have some limitations. First of all, most of them require manual registration which can be cumbersome and time consuming. Think one big issue is the hardware based tracking system that they use. So they track the table rather than the patient

and certainly, as the table moves, and you move against the table, the patient is going to move relative to the table, and those images become unreliable. And then finally, the holy grail of all 3D fusion imaging is the distortion of pre-operative anatomy

by the wires and hardware that are introduced during the course of your procedure. And one thing I'd like to discuss is the possibility that deep machine learning might lead to a solution to these issues. How does 3D fusion, image-based 3D fusion work?

Well, you start, of course with your pre-operative CT dataset and then you create digitally reconstructed radiographs, which are derived from the pre-op CTA and these are images that resemble the fluoro image. And then tracking is done based on the identification

of two or more vertebral bodies and an automated algorithm matches the most appropriate DRR to the live fluoro image. Sounds like a lot of gobbledygook but let me explain how that works. So here is the AI machine learning,

matching what it recognizes as the vertebral bodies from the pre-operative CT scan to the fluoro image. And again, you get the CT plus the fluoro and then you can see the overlay with the green. And here's another version of that or view of that.

You can see the AI machine learning, identifying the vertebral bodies and then on your right you can see the fusion image. So just, once again, the AI recognizes the bony anatomy and it's going to register the CT with the fluoro image. It tracks the patient, not the table.

And the other thing that's really important is that it recognizes the postural change that the patient undergoes between the posture during the CT scan, versus the posture on the OR table usually, or often, under general anesthesia. And here is an image of the final overlay.

And you can see the visceral and renal arteries with orange circles to identify them. You can remove those, you can remove any of those if you like. This is the workflow. First thing you do is to upload the CT scan to the cloud.

Then, when you're ready to perform the procedure, that is downloaded onto the medical grade PC that's in your OR next to your fluoro screen, and as soon as you just step on the fluoro pedal, the CYDAR overlay appears next to your, or on top of your fluoro image,

next to your regular live fluoro image. And every time you move the table, the computer learning recognizes that the images change, and in a couple of seconds, it replaces with a new overlay based on the obliquity or table position that you have. There are some additional advantages

to cloud-based technology over mechanical technology. First of all, of course, or hardware type technology. Excuse me. You can upgrade it in real time as opposed to needing intermittent hardware upgrades. Works with any fluoro equipment, including a C-arm,

so you don't have to match your 3D imaging to the brand of your fluoro imaging. And there's enhanced accuracy compared to mechanical registration systems as imaging. So what are the clinical applications that this can be utilized for?

Fluoroscopy guided endovascular procedures in the lower thorax, abdomen, and pelvis, so that includes EVAR and FEVAR, mid distal TEVAR. At present, we do need two vertebral bodies and that does limit the use in TEVAR. And then angioplasty stenting and embolization

of common iliac, proximal external and proximal internal iliac artery. Anything where you can acquire a vertebral body image. So here, just a couple of examples of some additional non EVAR/FEVAR/TEVAR applications. This is, these are some cases

of internal iliac embolization, aortoiliac occlusion crossing, standard EVAR, complex EVAR. And I think then, that the final thing that I'd like to talk about is the use with C-arm, which is think is really, extremely important.

Has the potential to make a very big difference. All of us in our larger OR suites, know that we are short on hybrid availability, and yet it's difficult to get our institutions to build us another hybrid room. But if you could use a high quality 3D fusion imaging

with a high quality C-arm, you really expand your endovascular capability within the operating room in a much less expensive way. And then if you look at another set of circumstances where people don't have a hybrid room at all, but do want to be able to offer standard EVAR

to their patients, and perhaps maybe even basic FEVAR, if there is such a thing, and we could use good quality imaging to do that in the absence of an actual hybrid room. That would be extremely valuable to be able to extend good quality care

to patients in under-served areas. So I just was mentioning that we can use this and Tara Mastracci was talking yesterday about how happy she is with her new room where she has the use of CYDAR and an excellent C-arm and she feels that she is able to essentially run two rooms,

two hybrid rooms at once, using the full hybrid room and the C-arm hybrid room. Here's just one case of Dr. Goverde's. A vascular case that he did on a mobile C-arm with aortoiliac occlusive disease and he places kissing stents

using a CYDAR EV and a C-arm. And he used five mils of iodinated contrast. So let's talk about a little bit of data. This is out of Blain Demorell and Tara Mastrachi's group. And this is use of fusion technology in EVAR. And what they found was that the use of fusion imaging

reduced air kerma and DSA runs in standard EVAR. We also looked at our experience recently in EVAR and FEVAR and we compared our results. Pre-availability of image based fusion CT and post image based fusion CT. And just to clarify,

we did have the mechanical product that Phillip's offers, but we abandoned it after using it a half dozen times. So it's really no image fusion versus image fusion to be completely fair. We excluded patients that were urgent/emergent, parallel endographs, and IBEs.

And we looked at radiation exposure, contrast use, fluoro time, and procedure time. The demographics in the two groups were identical. We saw a statistically significant decrease in radiation dose using image based fusion CT. Statistically a significant reduction in fluoro time.

A reduction in contrast volume that looks significant, but was not. I'm guessing because of numbers. And a significantly different reduction in procedure time. So, in conclusion, image based 3D fusion CT decreases radiation exposure, fluoro time,

and procedure time. It does enable 3D overlays in all X-Ray sets, including mobile C-arm, expanding our capabilities for endovascular work. And image based 3D fusion CT has the potential to reduce costs

and improve clinical outcomes. Thank you.

The superior hypograstric block is becoming kind of more commonly seen. In those practices that are doing it, a lot of uterine artery embolization, this is a really nice way to improve patients'

crampy abdominal pain or crampy pelvic pain that's related to uterine ischemia after uterine artery embolization. There have been authors that have proposed that to do UAE as an outpatient procedure, that we should couple the UAE procedure with this block.

It's good for pelvic pain, both uterine contractile pain, but also for cervical, vaginal pain, rectal, as well as bladder related pain. For those cancer patients, this is also a good block to consider. These are all palliative interventions

that are very simple to perform and can really improve patients' quality of life. Again, getting back to this really busy slide, if you target this lower hypogastric region, you're basically picking up the splanchnic nerves that innervate the large intestine,

the small intestine, the ovaries, the scrotum, the urinary bladder, and the perineum. On the right hand side, you can see the fluoroscopic guided way to do this, which is basically just to target the disc space between L5 and S1.

The other way that people do it is that during their uterine artery embolization, they'll take a catheter and put it up and over the bifurcation so that you basically then outline where the bifurcation is and then you just stick your needle right there in the V of your aortic bifurcation.

You take the needle just underneath the aortic bifurcation and dock it up against the vertebral body, pull your needle back, do your block, and you have a significant improvement in the patient's pain.

This is the technique under CT guidance. This was an actual patient who had chronic pain in the left shoulder with arm pain. This diagnostic block is to determine whether there is a sympathetic component.

You bring your needle down, avoiding the carotid and sometimes you do have to pass through the jugular vein, but that's okay because you're using a small needle. And then as we're getting closer to the spine at the T1 level you also have to avoid the vertebral artery. So we bring the needle down and we basically dock the needle

just lateral to the esophagus at the junction between the rib head and the T1 vertebral body and that's exactly where the stellate ganglion lives. We inject a little contrast to make sure that we're not intervascular, and then the lidocaine and bupivacaine mixture.

Patients often get immediate relief on the table. This patient did well with this block. We've had several patients that have undergone this block for hot flashes and have had improvement in their symptoms. We've had some failures, but this is one that is not often offered and can really help

in some of these complex pain patients.

So when we're doing this technique, what do we need before we get started? We need adequate preprocedural imaging. So if we're seeing this tumor that's in a bit of a scary location in the proximal femur,

sometimes if we treat that too aggressively that can fracture, but this looks like it's isolated into the medullary cavity. But these patients have multiple imaging modalities and these help. So if we have functional imaging, in this case a PET scan,

we can see it's actually a bilobe lesion that actually is a little bit higher than we might just suspect from the CT alone. And so when we're ablating we make sure to cover that entire territory when we're in this indication

of trying to locally control that disease. Likewise, if we have a patient like this who has sclerotic metastases, prostate or breast cancer, they've been treated. It's a little bit hard to know which of these are actually active disease.

Have they already been treated? Because they'll look like this for the rest of their life. And we do a PET scan and we actually see there's really only one tumor that has FDG uptake or choline uptake and is actually active disease, and so we actually target that tumor.

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.

Lumbar sympathetic block and neurolysis is another block that's not often used and actually can solve a lot of difficult problems.

In the lower extremities, if you have non-reconstructible vascular disease, patient can't have a bypass or a stent. If you have vasospasm, again if you have frostbite, if you have some of these more rare entities like Buerger's disease or these arteritis syndromes,

you can use this block to improve pain control. Phantom limb pain if you've had an amputation, peripheral neuropathies. But also this can be good for patients that have pain related to their kidneys, ureters, or genitalia. If you have somebody who has a terrible kidney stone

and they're not being controlled well with their narcotics, you can actually do this block and temporarily improve their pain. The lumbar sympathetic chain is just there, lateral and anterior to the vertebral body, just behind the aorta and the IBC.

It runs on both sides of the vertebral body all the way down into the pelvis. A block at three levels followed by injection of alcohol effects this neurolysis. We basically disrupt the sympathetic chain and you get reflex vasodilatation

in the lower extremity that you've treated. In this particular patient who has rest pain and can't have a bypass, we do this block and lo and behold, you get this reflex vasodilatation. It's a little bit subtle based on my poor photography, but there was definite hyperemia,

definite improved blood flow. This has been shown to reduce the incidence of amputations. It gets people out of rest pain and can be a nice bridge if you're waiting for your stent or other procedure. Just a nice simple way to help a patient and improve their quality of life and pain control.

That's basically what I just said, so let's skip that slide.

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.

- [Ramon] When we need to revascularize across the midline, the retropharyngeal pathway provides a route which is one half of the length of the traditional pretracheal route. It also allows the direct transposition of one common carotid artery to the other, and this technique does not interfere

with swallowing or with a median sternotomy that the patient might need in the future. The transposition... Of the proximal subclavian to the common carotid artery is the most efficient way to cure embolization from proximal subclavian plaque into the

vertebrobasilar system or into the arm. This the rare surgical intervention that has a 100% patency rate and has not resulted in a single stroke or death in a 15 year longitudinal followup. Additionally the transposition technique

obviates the need for a prosthetic bypass between the subclavian and the carotid. The next speaker, my friend Mark Morash will make better than I, the case for this operation. Let me just say that the excellent results

of this operation are not shared at all with the angioplasty and stent of the subclavian artery. The full exposure of the a high carotid plaque may require the retrojugular approach to the bifurcation because it avoids the obstacle created by the 12 nerve. While by now plenty has been written

about the eversion technique for an endarterectomy of the carotid bifurcation be that Type 1, or Type 2 This technique simplifies and shortens the operation in the carotid and of course obviates the need for a patch.

Operating on symptomatic vertebral arteries is less risky and has better outcomes than the stent procedures done in them. In my experience with 417 proximal vertebral reconstructions there were no strokes or deaths and their primary patency rate was 99.8% in 15 years.

Conversely angioplasty and stent of the proximal vertebral artery is fraught with complications. The stent fracture, restenosis, and dissection, and that should prescribe it's use. The symptomatic vertebral artery lesions above the level of C-6 are usually full of closures

or temporary ones that occur with rotation of the neck. And for this pathologist there is not any indication for angioplasty or a stent. To revascularize the vertebral artery beyond it's second segment I have advocated a carotid distal vertebral bypass

and this is the anterolateral approach which we follow to isolate the vertebral artery at the level of C-2. If a segment of saphenous vein is not available, you can resort to transposing the external carotid aretery to the distal vertebral.

And finally, the vertebral artery at C2 can also be revascularized by transposing indirectly to the high internal carotid artery. Finally another pathology that requires surgical remedy, is the compression of the vertebral artery between the posterior arch of the atlas

and the occipital bone. Symptoms in these patients appear when the neck is rotated and extended. The suboccipital approach that I have used for this problem is shown here. This is the suboccipital vertebral

after removing the arch of the atlas and if you need to bypass the vertebral artery in the suboccipital segment as it could happen in vertebral dissection you can also do it from this infrapetrocial carotid used in this posterior approach.

Thank you.

- Thank you, Dr. Veith, for this kind invitation. Aberrant origin of the vertebral artery is the second most common aortic arch anomaly. It is more common in patients with thoracic aortic disease when compared to the general population. It's usually of no clinical significance,

except when encountered while treating cerebro-vascular disease or aortic arch pathology. And that's when critical decision-making to preserve its perfusion becomes necessary. This picture illustrates the most common

types of aortic arch anomalies. Led by bovine arch, isolated vertebral artery, and aberrant right side. In this study, it shows a significant correlation with thoracic aortic disease. We first should evaluate the origin

of the vertebral artery. On the right side of the screen you can see the most common type and it's when it's between the left subclavian and the left common carotid artery origin. This is an example of the left vertebral artery

aberrant associated with a mycotic aneurysm of the aortic arch. And this one is a right aberrant vertebral artery associated with a descending thoracic aneurysm and center retroesophageal location. We then look at the variation of

the vertebral artery and posterior circulation. Most commonly dominant left or hypoplasia of the right vertebral artery as shown in the picture. For termination in the posterior inferior cerebellar artery, or PICA.

Or occlusive lesion on the right side, which necessitates perfusion of the left side. This study shows that vertebral artery variations that could need perfusion is up to 30% of patients

with thoracic aortic disease. There are, unfortunately, minimal literature in the vascular, mostly case reports or series. And most of this says procedure data comes from the neurosurgical literature for occlusive disease that shows in this study,

for example, low morbidity, mortality. Complications include thoracic duct injury, recurrent laryngeal nerve, Horner's and CVAs. And they showed high patency rates. The SVS guidelines for left subclavian revasculatization, although low quality,

shows they indicated routine revascularization and they mention some of the indications for left vertebral artery revasculatization. And extrapolating from that, from those guidelines, we summarize the indications for vertebral artery

revascularization dominant ipsilateral left or hypoplastic right. Incomplete circle of Willis, or termination of the left in the PICA artery. Diseased or occluded contralateral vertebral artery.

Extensive aortic coverage or inability to evaluate the circle of Willis prior to intervention. Some technical tips, we use a routine supraclavicular incision. We identify the vertebral artery posterior-medial

location to the common carotid. We carefully preserve the recurrent laryngeal nerve or non-recurrent laryngeal nerve, which is common in aortic arch anomalies. Thoracic duct on the left side. Transpose it to the posterior surface

of the common carotid. And then clamp distal to the anastomosis and to avoid prolonged ischemia to the posterior circulation. This is a completion aortagram that shows patent left vertebral artery transposed

to the common carotid. And then one month follow-up shows that the left vertebral artery is patent with a complete repair of the aorta. So in our experience, we did six vertebral transpositions over

the last couple years, four on the left, two on the right. No perioperative complications. One lost follow-up. And up to 27 months of the patent vessels. In summary, aberrant vertebral artery is uncommon

finding, but associated with thoracic aortic disease. The origin and the course of the vertebral artery should be thoroughly evaluated prior to treatment. Revascularization should be considered in certain situations to avoid

posterior circulation ischemia. But more data is needed to establish guidelines. Thank you.

- [Speaker] Thanks very much. So three clinical scenarios: a 35 year old women with pelvic fullness, pain a a patient with lower extremity swelling that we need to evaluate the deep

and can I remove this IVC filer? Starting with the first one. So this is a classic pelvic congestion syndrome. Picture, you see this reflexing gonadal veins. As you go to the next catheter venography,

it's confirmed on the diagnosis, with direct venography. But what I would like to focus a little bit more on, is a rare etiology for PCS, the nutcracker syndrome, in which the left renal vein is compressed, resulting in venous hypertension, hematuria/flank pain and this reflux.

So this is a classic nutcracker case. You can see where the arrow points out the SMA and aorta pinching off the mid-left renal vein. And here are some more pictures. And then this last one shows some collaterals, through which the left kidney is being decompressed.

The retroaortic left renal vein, with the posterior nutcracker can be a variant of this and it's shown here, where the left renal vein is passing posterior to the aorta into the IVC. So what MRV tells me in the setting of Pelvic congestion syndrome is the direction of flow,

the size of the ovarian vein, characteristics of the ovarian vein in terms of tortuosity, duplications, that might inform the intervention, unilateral versus bilateral disease, it can be helpful in that distinction, degree of peri-uterine venous plexus engorgement,

the presence or significance of a nutcracker lesion, always important to look up by that area, and then the question of a May-Thurner that may be contributing. Moving onto the next clinical history. A patient with lower extremity swelling in which the

deep pelvic veins and IVC need to be evaluated. So what is happening in this man's pelvis, well this was his MR, done with LAVA blood pool imaging, you can see this is a May-Thurner variant in which the external iliac artery is compressing the external iliac vein, and the vertebral bodies behind it.

What does blood pool imaging offer? Basically it's a Gadolinium containing agent that binds to albumin. It keeps the contrast agent intravascular and reduces extravascular distribution. Allows for high resolution steady state imaging

where venous contamination is what you want. And can be used in tandem with MR angiography. This is another picture that I like very much. It shows very clearly a classic May-Thurner lesion right where that arrow is, on two separate images. And then this is a reformation which shows that iliac artery

making that indentation where we would expect it to be. What MRV tells me in the setting of deep venous disease the presence of an iliocaval obstruction, the degree of that obstruction, and then the presence of a luminal irregularity such as a venous web which can be seen in this calf vein right there.

So this is a patient I saw in whom she had extensive chronic thrombus from the left common iliac vein to the calf veins. This is what she looked like before. After a considerable amount of work this is what she looked like after she came back to my clinic.

I actually entered her into research studies. She was doing quite well but I wanted to see if I could see her stents with MR. And this is one imaging modality called FIESTA. And here it looks as if the stent is perhaps not open but then on the time of flight,

as you pass through the abdomen and pelvis, you can see that they clearly are. So there are some modalities that can see through nitinol stents particularly. Stainless steel is a little more difficult is what we found in our experience.

Can you remove this IVC filter? So imaging IVC filters, the challenge is this: you have this number of filters and they can do all sorts of things in the abdomen. So IVC filter questions: What is the status of this filter? Is there tilt?

Penetration? Thrombus? Or fracture? And then what is the status of the cava in patients who have a symptomatic caval stenosis, and what is that degree of that stenosis? And what is the status of the iliacs?

So this is a particular case which I think we've all seen, where the filters penetrating through the cava, it's tilted, it's going to be quite a difficult scenario for the patient and for the retriever. And this is another case in which, even without contrast, you can see the difference between the suprarenal

and infrarenal IVC, as well as collaterals, which certainly can inform your interventions. So in conclusion, for gonadal vein pathologies, time resolved contrast MR venography confirms the diagnosis, helps with treatment planning, looks for compressive lesions.

Deep venous pathologies, blood pool contrast-enhanced MR can influence whether an intervention is necessary. IVC filters I believe are truly best evaluated by CT Thank you.

The pudendal nerve block is also sort of a deeper block that can help in perineal pain. It's the block that's used actually by the obstetricians in child delivery if you're not having an epidural. They do an internal block through the cervix and vagina

and basically block the pudendal nerve there just medial to the acetabulum and the ischium. We can do this block under CT guidance and you can see I've done the block here on the right hand image from a posterior approach, avoiding the sciatic nerve, obviously,

and injecting a little bit of contrast and then the bupivacaine and the lidocaine and you can get a nice deep block. This is an actual case of a patient who had profound rectal cancer invading the perineum and actually passing through the skin, unfortunately.

The patient was in extreme pain, couldn't get out of bed, just absolutely miserable. And by doing the block and then neurolysis where we actually inject alcohol, you can actually improve this patient's pain syndrome and that in fact is what happened.

- I'd like to thank Dr. Veith and the committee for the privilege of presenting this. I have no disclosures. Vascular problems and the type of injuries could be varied. We all need to have an awareness of acute and chronic injuries,

whether they're traumatic, resulting with compression, occlusion, tumoral and malformation results, or vasospastic. I'd like to present a thoracoscopic manipulation of fractured ribs to prevent descending aortic injury

in a patient with chest trauma. You know, we don't think about this but they can have acute or delayed onset of symptoms and the patient can change and suddenly deteriorate with position changes or with mechanical ventilation,

and this is a rather interesting paper. Here you can see the posterior rib fracture sitting directly adjacent to the aorta like a knife. You can imagine the catastrophic consequences if that wasn't recognized and treated appropriately.

We heard this morning in the venous session that the veins change positions based on the arteries. Well, we need to remember that the arteries and the whole vascular bundle changes position based on the spine

and the bony pieces around them. This is especially too when you're dealing with scoliosis and scoliotic operations and the body positioning whether it's supine or prone the degree of hypo or hyperkyphosis

and the vertebral angles and the methods of instrumentation all need to be considered and remembered as the aorta will migrate based on the body habits of the patient. Screws can cause all kinds of trouble.

Screws are considered risky if they're within one to three millimeters of the aorta or adjacent tissues, and if you just do a random review up to 15% of screws that are placed fall into this category.

Vertebral loops and tortuosity is either a congenital or acquired anomaly and the V2 segment of the vertebral is particularly at risk, most commonly in women in their fifth and sixth decades,

and here you can see instrumentation of the upper cervical spine, anterior corpectomy and the posterior exposures are all associated with a significant and lethal, at times, vertebral artery injuries.

Left subclavian artery injury from excessively long thoracic pedicle screws placed for proximal thoracic scoliosis have been reported. Clavicular osteosynthesis with high neurovascular injury especially when the plunge depth isn't kept in mind

in the medial clavicle have been reported and an awareness and an ability to anticipate injury by looking at the safe zone and finding this on the femur

with your preoperative imaging is a way to help prevent those kinds of problems. Injuries can be from stretch or retraction. Leave it to the French. There's a paper from 2011 that describes midline anterior approach

from the right side to the lumbar spine, interbody fusion and total disc replacement as safer. The cava is more resistant to injury than the left iliac vein and there's less erectile dysfunction reported. We had a patient present recently

with the blue bumps across her abdomen many years after hip complicated course. She'd had what was thought to be an infected hip that was replaced, worsening lower extremity edema, asymmetry of her femoral vein on duplex

and her heterogeneous mask that you can see here on imaging. The iliac veins were occluded and compressed and you could see in the bottom right the varicosities that she was concerned about. Another case is a 71-year-old male who had a post-thrombotic syndrome.

It was worsened after his left hip replacement and his wife said he's just not been the same since. Initially imaging suggests that this was a mass and a tumor. He underwent biopsy

and it showed ghost cells. Here you can see the venogram where we tried to recanalize this and we were unsuccessful because this was actually a combination of bone cement and inflammatory reaction.

Second patient in this category, bless you, is a 67-year-old female who had left leg swelling again after a total hip replacement 20 plus years ago. No DVTs but here you can see the cement compressing the iliac vein.

She had about a 40% patency when you put her through positioning and elected not to have anything done with that. Here you could see on MR how truly compressed this is. IVA suggested it was a little less tight than that.

So a vascular injury occurs across all surgical specialties. All procedures carry risk of bleeding and inadvertent damage to vessels. The mechanisms include tearing, stretching, fracture of calcific plaques,

direct penetration and thermal injury. The types of injuries you hear are most common after hip injuries, they need to be recognized in the acute phase as looking for signs of bleeding or ischemia. Arterial lesions are commonly prone then.

Bone cement can cause thermal injury, erosion, compression and post-implant syndrome. So again, no surgery is immune. You need to be aware and especially when you look at patients in the delayed time period

to consider something called particle disease. This has actually been described in the orthopedic literature starting in the 70s and it's a complex interaction of inflammatory pathways directed at microparticles that come about

through prosthetic wear. So not only acute injury but acute and chronic symptoms. Thank you for the privilege of the floor.

- [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 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.

But I'm really gonna focus on percutaneous ablation because it's particularly well suited to this application, minimally invasive for these potentially frail and elderly patients,

as well as high kill rate with tumors of many different histologies. So when we're choosing, this is the technique, so how do we do it? If we were facing a metastasis in the scapula like this, we can treat it with heat,

radiofrequency, or microwave ablation, or we can treat it with cryoablation, extreme cold temperatures, extreme cold or extreme heat, they'll both kill the tumor. How do we decide? Well, if we compare cryoablation versus microwave ablation

or radiofrequency ablation, ease of use, the heat-based therapies are certainly easier to use. They're generally faster, so the procedure duration is quite a bit shorter, but the energy transmission into bone is better with cryoablation.

It'll go through the cortex, whereas heat is limited in that regard. The predictability of the ablation zone, the cryoablation. As you can see in that scapular picture, we can actually see the edge of the ablation with several different modalities, CTMR and ultrasound.

Our ability to monitor that ablation then and prevent it from escaping into adjacent collateral structures. And then the ablation zone size, we can usually treat a larger area with cryoablation, and patient tolerance, their pain scores are generally less

after a cryoablation than a heat-based therapy. So in general, most of us who are treating for local tumor control would use cryoablation. These factors are a little less true these days where there are newer bipolar radiofrequency devices that are designed specifically for bone

so have better ability to control tumors within these sites.

When we're treating these tumors for local tumor control we're really aggressive in ablating them. So we have a rib metastasis here, and we won't just put one probe in it and call it a day. We have to make sure that we have adequate cold temperatures surrounding the entire tumor with margin

to make sure that we can provide a long-lasting effect for these patients, rather than this case in which patient has a spinal metastasis, we put one probe in part of it and leave a little corner of tumor

when our goal is local tumor control that's not really adequate. And local recurrence really matters so in this study this is one example study of a patient who had surgical replacement of renal cell carcinoma, bone metastases.

And in this study they show that threefold higher hazard ratio of death in patients who develop local tumor recurrence at the site of the resection. So if we can, extrapolating that surgical data to ablation we wanna make sure we get that local control.

Unfortunately as we treat aggressively we are more at risk for developing complications. In this large metastasis that's in the supra-acetabulum here we try to be very cautious that we don't actually have that ice ball encroach upon the femoral head,

as opposed to this equally large metastasis in the supra-acetabulum where we actually have the ice that if you extrapolate those into that femoral head and then several months later the patient develops femoral head collapse and fracture, and their pain recurs.

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