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.
Okay. So I'm gonna talk about splenic artery embolization. And this is a subject, even on the physician side,
on the program side, SIR guests, SIRCE, Middle East, they're giving this talk to talk about, for 15 minutes, splenic artery embolization. And I don't think even the people that are putting the program actually understand as physicians, that this is a really big subject.
This is a diverse, diverse kind of group of procedures, it's not even a diverse procedure. And it all depends on actually... It's not working. Okay. It all depends on what you're treating,
and how you're treating it. This is actually the most important slide of the whole talk. If you want to focus on something, just focus and remember this slide. This is a group of indications for ...
Sorry guys. For splenic artery embolization. It's trauma, splenic artery aneurysm exclusion, NOHAH syndrome, which is splenic steal and liver transplant, HyperSplenism and portal hypertension. HyperSplenism and portal hypertension actually
overlap a lot. They're not synonymous, but they overlap a lot. Commonly, very commonly, when you find portal hypertension there's HyperSplenism, and if there's HyperSplenism sometimes there's portal hypertension, extrahepatic portal hypertension.
And the approach, technically, towards these disease processes, are different. With trauma, which I'm not gonna talk about today, because I don't have enough time for it. Trauma, you are actually going focused on a target area that's bleeding and either embolizing that
specific bleed, or embolizing the vicinity if you can't get to that specific bleed.
What is worth saying is that trans-foraminal infiltrations they may result in higher pain reduction
when compared to interlaminar epidural infiltrations. Additionally, they seem to be superior to placebo therapies and to blind interlaminar epidural infiltrations for both short- and long-term pain reduction. In one-third of the patients, trans-foraminal infiltrations are surgery-sparing interventions.
And concerning evidence-based medicine, we know that these kind of injections they have a good level of evidence for radiculitis caused by disc herniation, a fair level of evidence for radiculitis caused by spinal stenosis and things are not so good with limited level of evidence to post-surgery syndrome.
And this is a patient, he had a herniation back in 2011. He was treated with a spinal injection, a trans-foraminal infiltration. On May of 2012, you can see that the herniation was gone and what we actually did was give some time to the nature to do its job.
- [Alicia] The AVIR is pleased to announce the recipient
of this year's prestigious Shari Ullman Gold Medal Lecture award as Dr. Wael Saad. Dr. Saad completed his medical education at AnChans University in Cairo, Egypt. He then completed a vascular surgery internship at Johns Hopkins University.
His radiology residency at the University of Rochester, and his interventional fellowship at the Institute of Radiology in Washington University. Dr. Saad has been internationally recognized for his expertise in liver disease, including transplantation, hepatobiliary disease,
and portal hypertension. He has over 240 publications, as well as over 70 book chapters. He's a manuscript reviewer for numerous journals, including the Journal of Vascular and Interventional Radiology, the Journal of Clinical Imaging,
The American Journal of Roentgenology, Cardiovascular and Interventional Radiology, and Radiology. He serves on the editorial board for the American Journal of Roentgenology, and the Journal of Clinical Imaging Services.
He serves on several committees with the Society of Interventional Radiology, and the Radiologic Society of North America. One of the most obvious testaments to his passion for education has been demonstrated by his role in founding the Middle Eastern Endovascular Therapy Symposium.
It was founded in 2017, and it's hosted in Cairo, Egypt. It is the first, true regional IR and endovascular conference. MEET provides a comprehensive IR experience for its attendees through MEET IO, MEET aorta, and MEET stroke.
Subsequently, MEET has funded the Egyptian Board of IR, a two year IR fellowship, with an SIR United States IR curriculum, and SIR AVR board examiners. Dr. Saad is an avid supporter of both the AVIR and ARIN. Not only has he graciously been willing to present for the
organization on many occasions, he was an integral component of the Regional Michigan Chapter success. Those who know him can attest without hesitation that he is a natural educator, and makes tremendous effort to teach his
physician, nurse and technologist colleagues alike. For those reasons and so many more, the AVIR is humbled to have the privilege of honoring Dr. Saad as this year's Gold Medal lecturer. (audience applause) - [Dr. Saad] Well, it's truly a great honor to be here
in front of you, and receive this award, and I really appreciate that from AVIR and special thanks also to Siemens for the support for this organization. Without their support and sponsorship, this actually cannot actually happen.
I learned that by doing the conference in the Middle East that it takes a lot of work and a lot of passion and support from industry to actually support our functions. So I'm truly grateful and truly appreciative. The award is from AVIR. There are ARIN members here as well, so I did not know
that there are nurses here as well. My talk is focused primarily on AVIR but definitely we'll talk about the important role that nurses play. Another thanks that I have to give is to the University of Virginia.
I spent five of my best years at the University of Virginia as a faculty. That is a very special place with very special people that work there. And when I think of special people, I actually think of the techs, the nurses, and the physicians,
in that order, that actually work as a team, and actually help one another, and actually stick it out with one another. And as far as faculty, as far as teaching, it's a very, very special place in my heart. I'm gonna say things about IR techs,
and this is kind of my take on things.
Sometimes it is so tortuous that we can't even get a microcatheter across, and that's a problem. So what do we do there? In the old days, if you can't do that,
and you can't cross the aneurysm then the best way is to actually puncture the aneurysm self-percutaneously and put coils and thromen through the needle as well. We've been able to reduce the incidence of that by doing the Fong procedure, which is not, it's kind of like a cowboy way of doing it,
but it actually reduces the amount of times that we actually have actually gone to actually percutaneously puncture the aneurysm. What we do is we actually use glue. We actually use a very thick glue. And what we hope for is that we deploy this thick
glue plug and let it run in the aneurysm, go to the distal end and actually plug the distal splenic aneurysm-- splenic artery. And that is basically your distal coil equivalent. And then you put coils or glue to finish it off. And most of the time it works, sometimes it doesn't.
And when it doesn't, sometimes you kill the spleen. They key thing is to make thick, thick glue, okay? I know it's kind of like, 60% of the time, 100% of the time it works, or something like that. But it's pretty hairy, but we've been able to do that with minimal complications.
A thick glue, 1:1, fire it as a plug, it rotates through the aneurysm, goes distally, and then you actually coil it or glue proximally. This is an example of that. Large aneurysm. This is actually the inflow artery in the red arrow,
the outflow artery out of the aneurysm is the other red arrow, the smaller arrow at the top. And then there's another branch sneaking proximally around the aneurysm, not involving the aneurysm going to the spleen. That's good.
That's a good sign. There's a nice collateral that can grow, that actually can revive the spleen if you take out most of the spleen. That's the distal pancreatic tail. We were unable to cross this aneurysm. In fact we were barely into that aneurysm.
What we did was just deploy that thick glue. Sorry guys, it's not working for me here. This is what we have. This is actually that little piece of glue is actually in the distal outflow artery, okay? And the rest of it, this is actually in the inflow artery,
and we basically excluded this with just purely glue, without any coils. This is the kind of follow up imaging of the patient with an excluded aneurysm and a largely live spleen by actually excluding it this way.
So this is my dog, Max. He has a habit of picking up pigeon feathers off the road and he thinks he has the whole pigeon.
Similarly, even though I'm presenting five tests that are most five most common tests that we do with Technetium, it is just a small picture. It is not the big picture. It is a part of what you can do with Technetium. Disclaimer, none.
Objectives, so identifying Technetium diagnostic utility, listing five different radiopharmaceuticals as it is combined for diagnostic tests, mechanisms of action in the scan, explaining the imaging process and the policies and procedures connected to them.
If we tried to compare our techniques on a mano a mano basis with surgery, the answer is that first of all, we are minimally invasive
so it's better to start with a percutaneous approach and if it fails within the first year, you can move to a surgical operation. Additionally, even if we compare ourselves with minimal surgical techniques or at least what the surgeons calls minimal, you can see that
what we are doing ends up with a bandage. What they are doing ends up with something like looks like Robocop. So even for spondylodiscitis, because with percutaneous techniques, nothing comes in the air, infection is more common with surgical techniques
rather than a percutaneous one. In the literature, there are certain studies comparing percutaneous techniques with surgical in terms of efficacy and safety and one of them is concluding that at one year, a strategy of laser decompression followed by surgery if needed is resulting
in non-inferior outcomes compared with surgery. And the same results were reported in another study comparing surgical approaches with plasma ablation in the intervertebral disc. And now this are running in Europe a multi-centered trial between ozone and surgical techniques
for herniation of intervertebral discs. If we tried to compare percutaneous techniques with medical therapy we have prospective randomized trials comparing these two therapies and what it has shown is that patients on the conservative arm, they reported that pain came back on the first year
and to stable throughout the follow-up period. So percutaneous techniques, they had a longer lasting and more significant effect than conservative therapy on the pain reduction for these patients.
I can't stress, also, the importance of the nurses.
I again, like I told you, I've been in four to five universities in the United States. Uniformly, invariably, the nurses always feel that they're left out. They feel that they're a little bit on the side,
and they're not in the focus of the procedure. And unfortunately that's inevitable because you've got the physicians and the techs focusing on their monitors, while you're focusing on your monitors. They're talking technical plumbing stuff,
you're dealing with medicine. You are the people that are actually taking care and actually doing the medicine in this procedure, okay? You will highlight if there's a problem to the physician but primarily, you are actually taking off of this plane and landing this plane safely.
Taking care of these patients. You are actually the medical core of this procedure. The other guys are just doing the plumbings, okay? So that is very important as well. We need to always stress that. That you are an integral part.
You do feel left out, it's inevitable, because everybody's focusing on something that you're not focused on. If you're focusing on what they're focusing, that's not a good thing, okay? And so it is very, very important that we have
strong nurses, good nurses. Strong personality nurses that actually can step up and speak up when something's going wrong. And we do really appreciate that, especially as physicians as we mature and we actually see the input from all the members of the team.
Thank you very much.
So bone scan, we use MDP and it is used to diagnose fractures that are not seen
on plain X-rays, any malignancies, or osteomyelitis. The adult dose is 20 millicuries and for pediatric the dose is based on BSA. Now that scan is actually a normal scan. What I'm highlighting is the joints and the bladder. There's always a little bit of uptake.
So our doctors know that they know how to look for it. Bladder because it does go through the kidney and it can be eliminated through urine. It will not effect the kidneys though. - [Audience] What is mCi? I know that it's measurement, is it like meter cubics?
- Millicuries. It has low sensitivity in detecting osteolytic lesions and as such most of the time our patients get a CT scan with it to eliminate false positives. Usually, we inject the patient, have them look at the CAT scan and then come back for scanning.
The approximate time from start to end for bone scan can take up to three to four hours. That does not mean that the patient is in the scanner for that long. It just start to when it ends. - [Audience] From injection?
- To the point of scan, end of scan. Procedure, we always confirm the patient and the test, like any good nurses, right? For bone scan, 'cause I know we have patients who will be going for probably a CAT scan, so I always like to check if they have CAT scan
with or without contrast, or they have MRI or any other test that will require an IV. I work with cancer patients who have bad veins. If possible, I like to put in an IV, and leave that IV in. So I inject my dose, wrap up the IV,
and let them go to their next scan, if they have anything in between. Patient comes back to us after two to three hours for the scanning part, there is no dietary restriction, we do ask them to drink lots of water. Not only does it help with the hydration,
absorption of the isotope, it also helps get rid of any of the extra isotope that's not, it has not absorbed into their system. The scan time is 30 to 40 minutes, and this is where we make the (mumbles). They're in the scanner for longer.
This is the bone scan, and you can see the bone mets. That's where the cancer is. It's not just, you can see darkness beyond the joints. You can see it in the ribs, you can see it in the sternum, the spine, the femur, and that's how you can see. These are bone positive bone scan.
There's three phase bone scan which is a specialized bone scan. We do everything similar, but it's also considered a flow study. It is used to diagnose bone infection such as osteomyelitis and cellulitis.
The only thing you are doing different for this one is you take the patient, you put the IV in, you get the patient on the scanner, and then in collaboration with the technologist, you say, one, two, three, go, you inject your dose as they're taking pictures
of a specific site that the doctor wants. So it could be the patient is coming in because they have this new pain in the right hip. The technologist will get the camera into the appropriate area, and you inject, you flush, and they take pictures.
The picture is about like a 15-minute picture, patient gets off, they leave, come back in two to three hours for the full body bone scan. It does not replace the full body bone scan. It's just an additional picture that they want.
- [Henrik] First of all, thank you very much to the organizers, Frank for bringing me back to this lovely city. So whereas the Doppler velocity measurements for assessment of stenosis is very reproducible, imaging of carotid plaques is actually not. So what's the value of plaque morphology? Interestingly, the signal in plaque morphology is so
strong that when we test at first assessments, it's actually quite good and we see there is some evidence behind it. But if you look at morphology over time, it's not so good. And the reason is the impact of what's called the fixed elevation focus just like when you focus your camera
to make a certain image sharp, the same thing we do with ultrasound. Meaning that we only see a thin slice of the carotid artery as illustrated here. And for instance if you're going to scan this patient, what you see with this angle is nothing, and then with
the patient turns his neck a little bit, you're going to see this plaque. So this is the caveat of reproducibility of 2D, that's why we need 3D. And actually 3D is not new, David Spence's group has been pioneers in this and used it for 10 years, however,
their equipment has been research equipment. You can see handheld 3D on the top left, which is not really good for daily practice. And that equipment is actually getting out there now. The transducer seen in the middle is a so-called matrix transducer where you can do volume imaging
in real time. And what you get is, for instance, two planes, simultaneously that you see here. So when you want to do volumes, you simply do tomography like you do with a CT and you can calculate the area of the plaque in each cross section, and if you know the
distance in between, you can calculate the volume. The problem is, where does the plaque begin and where does it end? And if you look at this image, you can see it's not that easy to define where it begins and ends. So we did some work on this and I'm going to give you
the short story. This is what we ended up with, defining a patch of plaque volume centered around the thickest part, calculated from the true center line derived from the 3D image. And this work is being published in the Ultrasound in
Medicine and Biology, where we looked at the volume defined one centimeter around the thickest part of the plaque, we had two investigators scanning 37 plaques. They were blinded from each other's findings. Patients were standing in between exams. And the ultrasound machines were reset.
And you can see this very very nice correlation in these 37 cases. I will admit that there was some selection because cases with calcification were omitted from this analysis. So, looking at the declining stroke risk in asymptomatic stenosis, it is down to below 1%, and in a recent study
from Kansas where they looked at 860 patients followed over six years, all with carotid stenosis, they found that patients who were optimally treated for risk factors and preventive medications had a combined stroke TIA and revasc rate of 0.6%. It's almost gone guys.
And we in the BioImage Study for scans 6,000 Americans and followed them for three years, and among those 6,000, there were 349 with carotid stenosis, and over four years, sorry, three years, four people develop a stroke, only two of them being ipsilateral. But a lot of them had cardiovascular events.
So asymptomatic carotid stenosis has very very very low risk of stroke, but a high risk of cardiovascular events, so therefore it's very important with the aggressive medical management. It is difficult to see where carotid endarterectomy and stenting has its place there today, unless of course,
high risk plaque can be identified. So 3D is a game changer because plaque volume can be reliably measured. Plaque volume may be the new surrogate to observe and follow. It allows for accurate repeated measurements,
plaque morphology can probably be assessed accurately and followed over time. Thank you for your attention.
I've been practicing IR, including training, for about over 20 years now. And I've worked in four universities in the United States, one in the United Kingdom, and three in the Middle East.
Over these 20 years, I have seen techs and nurses being treated in different ways. So let's just focus on the United States. Over these years, the techs and nurses were treated in different ways, depending on different schools and different thought processes
by the physicians. I have been to institutions where techs-- and the Michigan techs that are sitting here today have heard this talk before. This is the golden retriever talk. That's what they call it.
I've been to institutions where techs are no more than fetchers. And when I was at Virginia talking to tech students I always told them, when you're looking for jobs, beware of the hook. They told us, "What's the hook?"
and I told them the hook on the wall. That hook on the wall go inside their rooms and look if there's a hook on the wall where they go, where the tech kind of guesses, and in a better communication environment is told what they're planning to do,
and goes and starts putting what she or he predicts what the catheters and gadgets are gonna be for the procedure. Because their role, usually, in that setting is to go fetch. Go get me a cobra.
They run off, go get a cobra and come back. That's the golden retriever kind of treatment. I think, in my personal opinion, that is very old school. It is still carried today, in places that are still hanging onto the old days.
I've been in institutions where techs are, actually on the other extreme, an integral role in the procedure itself. The anatomy, what needs to be done, actually giving suggestions and actually educating physicians as well.
Off the record. They do a lot of education for physicians. I believe the new school, the latter, is actually where you need to be as techs. You have evolved to be an integral profession, involved in procedures, expecting what is next,
understanding the disease process, understanding the anatomical difficulties, and the technical difficulties and the platforms needed. Anticipating what might be next, suggesting what might be next. And I think you have evolved into this very important
and integral profession. As medicine in the United States and around the world gets stressed economically, I think this is actually in nurses' and techs' favor to step up, to be the professionals that they are, to blossom as far as the potential that you are.
Actually getting more involved with physician decisions, and with procedural decisions as well. You are no longer working with the control freak IR that you're not allowed to touch the table, you're not allowed to move the table, you're not allowed to touch anything.
All your job is to go fetch. I don't believe in that and I don't condone that. And I hope this eventually fades out throughout all our institutions. Thank you.
So Technetium, it is not a high energy isotope. It has a half life of six hours. It has intermediate energy, so what that means, that even though it may stay in your system for longer, four days, it is not as strong as FDG, which is used for PET scans.
So it does not require the same kind of precautions. Just like other isotopes, it is also pure gamma radiation, so it does need a specialized scanner. Other thing really cool about Technetium and other nuclear med scans are that they show how the, they show the functioning.
So when we are injecting how the body is functioning, rather than how body looks right now. So CAT scan, when you take the picture, it's how it looks at that point of time. With the Technetium scan it shows how the body is working. So we do flow studies, so as the isotope is going through
the body it can take pictures of that. That's pretty cool. It is Technetium can connect with different carrier, as we call them, such as MDP, sulfur colloid, and allow us to take specialized scan. The carriers will connect to Technetium and take them
to specific areas for those specific scans. Let's see, it is measured in millicuries. So this is a gamma scanner. It is pretty cool. The two plates that you see can move around the table around the patient.
So the table stays still, the patient stays still. It's the camera that's moving. It can go above and below the patient or to the side of the patient, depending on what pictures do we need. So it's an open scanner, as we call it. That's the patient on the scanner, pretty open.
Most patients do not have trouble with that, other good thing about this scanner is you can wear metal clothes so your clothes can have metals in it and it will not effect the scanning. So those are some of the radiopharmaceuticals that are there.
The most common ones that I will be talking about some of them I'm not attempting to pronounce, I'll just use how I use it in daily life. MDP, sulfur colloid, MAA, MAG 3, D.T.P.A, that we do use an aerosol as well as IV form.
I will be talking about bone scan, breast lymphoscintigraphy scan, ventilation perfusion scan, renal study and the GFR study. Also, 'cause breast lymphoscintigraphy's a mouthful, and I trip, I'll use mapping at times. (laughing)
- [Audience] What will you use? - Mapping. - Mapping, okay. - That's the layman's language, I guess, for us. - So breast mapping? - Uh-uh.
And we actually do know that spinal pathologic pain has a very high lifetime prevalence that goes up
to 80% with an annual prevalence that goes up to 45%. The peak prevalence is between 45 and 60 years old and out of these cases, intervertebral disc with discogenic pain account for approximately 40%. Actually the vast majority of these patients will not require our help.
Approximately 80 to 90% will have clinical improvement with conservative therapy and out of these patients approximately 50% will present spontaneous regression of disc herniation within six to 12 months. And this is a case. You can see a patient back in 2007 with MR imaging,
a small protusion of the intervertebral disc, the patient have minor symptoms, he require only conservative therapy. In 2011 he had a crisis, there was a herniation, still no intervention, he went for conservative therapy and in 2012 without an intervention there is no herniation.
And this is why in the literature you can find reports that after one year there is no difference in pain incidence and severity among patients who are not operated and those who went for operation.
Splenic artery aneurysms, you're basically trying to exclude the aneurysm while maintaining as much flow to the spleen as possible. Transplant, liver transplant with splenic steal,
what you're really trying to do is not necessarily block the splenic artery, but just impede the flow in the splenic artery. I'll explain all of these in following slides. HyperSplenism and portal hypertension is actually you're trying to kill parenchyma.
You're trying to reduce the actual splenic bed. You're actually, this is a distal artery, or end artery particle embolization. So this is a whole group of procedures, a whole group of technical strategies of actually treating and so you have to know exactly what you're doing
and why you're doing it. And these kind of-- I'm gonna follow with some technical things of how we proceed with this. So starting off with splenic artery aneurysms. And with splenic artery aneurysms, you'll get a lot of debates on you do a proximal embolization,
you do distal embolization, proximal's better than distal. It really depends. That's a very superficial approach to things. It depends on what the disease process is. So in general, with splenic artery aneurysms,
you try to be as proximal as possible, just proximal to the aneurysm, keeping as much collateral to the actual spleen itself. Okay? It is not a splenic reduction, it is not an end artery embolization.
- [Robyn] Good, morning, thank you, Dr. Veith, for asking me to speak. I have no disclosures over 40,000 people in the United States annually are diagnosed with head and neck cancer, 75% of these patients undergo radiation therapy. Almost 80,000 patients in the US population annually
are diagnosed with lymphoma and about 20 to 30% of these patients undergo radiation therapy to the head and neck. This gives us about 50,000 patients annually undergoing head and neck radiation. With a 25% incidence of carotid stenosis
we are diagnosing about 12,500 patients with radiation arteritis annually. This occurs due to direct endothelial cell damage from the radiation beam, which then causes platelet aggregation, fibrin deposition, obstructed capillary lumens,
and vaso vasorum, focal necrosis, and finally extrinsic compression and luminal narrowing. Patients present similar to atherosclerosis with asymptomatic disease or TIAs and strokes. Recommendation is to screen these patients with ca
there is currently no consensus on when this screening should begin after completion of the radiation therapy. Most physicians recommend five to 10 year later. Once a patient is diagnosed and if surgery is considered,
due to the uncommon location and diffuse lesions of these radiation arteritis patients, patients should undergo either MRA, CTA, or catheter-based arteriogram for preoperative planning. Management options include medical management with traditional risk factor modification
and surgical management should be considered in patients with a symptomatic lesion greater than 50%, an asymptomatic lesion greater than 60%, or deemed to be a low peri-procedural risk. However, due to the more stable morphology of radiation arteritis, most asymptomatic patients
should wait until about 80% stenosis. Looking at the Society for Vascular Surgery guidelines pertaining to carotid disease, they find that a history of neck radiotherapy, the resultant local fibrotic changes of the skin and soft tissues, to be an anatomic criteria
to consider carotid stenting. However, they do feel that carotid endarterectomy remains a safe option. When deciding between carotid endarterectomy and carotid stenting there are many anatomic and physiologic factors to help make that decision.
Carotid endarterectomy should be favored in patients aged greater than 70, those with a type III arch or severe arch calcification, those with carotid artery tortuosity, severe plaque calcification, ulcerated plaque, near-occlusive lesions or extensive lesions.
Carotid stenting should be favored in patients with a history of prior neck radiation or radical neck dissection, those with a tracheostomy, those with prior carotid endarterectomy or cranial nerve injury,
those with a common carotid artery stenosis proximal to the clavicle, or distal internal carotid artery stenosis distal to C2 and those with a large amount of cardiac comorbidities. If carotid endarterectomy is decided upon there are several technical tips we can recommend.
First, given the difficulty of dissection, general anesthesia is preferred. The groin should always be prepped for potential greater saphenous vein harvest, particularly if the patient has a tracheostomy or previous extensive neck dissection.
A longitudinal neck incision is preferred for the ability to extend either proximally or distally. The surgeon should anticipate a more tedious dissection and take careful time to identify the cranial nerves. Once starting the operation the surgeon should anticipate that possibly the endarterectomy plane could be obliterated
and they may require a common to internal carotid artery bypass with greater saphenous vein. If there is significant involvement of the common carotid artery a subclavian to internal carotid artery bypass maybe done with PTFE,
and the patient may need a myocutaneous flap for coverage at the end of surgery. If carotid stenting is considered, the procedural steps are identical to that used for atherosclerosis. However, the surgeon should anticipate,
due to the extensive nature of the plaque, that multiple stents may be required and there's a higher occurrence of filter clotting. Looking at results for carotid endarterectomy, most reports are single institution case reports or case series.
All of them have similar results showing 30-day stroke and death rates ranging between zero to 3%, which is similar to that what we see for atherosclerosis. However, cranial nerve injury rates up to 22% and wound complication rates up to 8% are higher. Of note, in patients that do have cranial nerve injuries,
similar to atherosclerosis, they do resolve in about six weeks. Looking at results for carotid stenting, again, these are single institution case reports and case series and show similar results for death
and stroke rates at 30 days of zero to 9%, which is similar to what we see for atherosclerosis. Here we don't have to worry about cranial nerve injuries, and we do have some groin complications, about 6% of the time. A meta-analysis was done by Davies
that showed similar results with asymptomatic and symptomatic carotid stenting and carotid endarterectomy having similar stroke and death rates at 30 days. However, there is a higher rate of re-stenosis and re-intervention, and most deaths were related to the original cancer.
In conclusion, both carotid endarterectomy and carotid stenting are technically feasible in patients with radiation arteritis. Both carotid endarterectomy and carotid stenting are just as safe as in patients with atherosclerotic disease,
and while considering carotid intervention the patient's oncological prognosis should also be considered. Thank you.
Moving on to breast lymphoscintigraphy or breast mapping.
We use sulfur colloid for this. Indications for it is the patient's probably getting the surgery, either the day of or the day after and the doctors need to know which sentinel node biopsy do they need to do. It shows the first draining lymph node.
We do two kind of mapping. One is the same day surgery mapping and the second it's a day before as it says, same day is for the patients who are having surgery today and day before is the patients who are having surgery the day, the next day.
Doses, same day surgery at 0.1 millicuries, and day before is 0.5, it's tiny. Yes, we do use that little syringe. For procedure, you confirm the patient, you confirm the order, and the breast laterality, not just with the patient but also their chart.
Because how many times has it happened, the patient is like, "But I'm getting surgery "on both breasts." The order is for right because there is a reason. They're only doing breast biopsy on the right. Also, it can eliminate them of the wrong orders
that might happen in the system. You wanna confirm. We have a tendency at MSK to look at the consents, the mammograms, the CIS order and so this pathology reports just to make sure everything is in order. I like to educate my patients beforehand.
A lot of patients come in, oh it's a test, it's a nuclear medicine test, they have no clue. I like to just go over it. Any patient that come in after I confirm everything with them, I'd tell them, "So today we are doing "breast mapping, I will be injecting
"a little bit of radioactive isotope "right underneath the skin so it's intradermal, "it goes at the six o'clock perioral, sorry, "peri-areolar area." You can show it on yourself and most patients know what six o'clock is, they're adults.
When I inject, there will be a little pinch and a burning stinging sensation. If the patient has had a recent biopsy or a recent radioactive seed placement, they are more sensitive than others, so at that point, if I know they have had it,
or they say, "Oh yeah, I have had this today," we tell them, "Yes you might be more sensitive to it "than a regular patient. "But just be patient, it will pass. "It is not that long." You inject the isotope, it's like I said,
it's intradermal, so even though that's a PPD test, it kinda looks like that. You do see a little bubble as you inject. After the injection, I'd cover it with gauze, put some paper tape on it, because I really don't want anything else, and I use a couple fingers,
put it at the point and start a pointed massage. It doesn't matter which way you move, just as well you keep it moving, so that it facilitates the isotope to go towards the first draining left node. It disperses the isotope.
I show the patient as I'm doing it, this is how you're doing it, and then I wait there for about 30 seconds to a minute to make sure they're doing it. Some patients, as soon as they start doing it, they go like this, they're caressing,
they're not actually moving it. Some people are being really vigilant and they are like just kinda digging it and you don't want them to get tired before the 10 minutes are up. I just make sure they're doing it right,
tell them, if this hand tires, you can use your second hand and then leave the room. We have, thankfully, we have volunteers whom I can say, "Hey, in 10 minutes, "at exactly this time, can you let the patient know "to get dressed and wait in the waiting area
"until one of our technologist bring them back in "for a 10 to 15 minutes scan." If I do not have the volunteers, I have used a timer, because God knows we have all forgotten whether the patient was in there for more than 10 minutes massaging their breast.
Happens, unfortunately it happens. Someone calls you for something else, and you get busy in that. This is the view, and this is actually, I especially chose this one because you can actually see almost three lymph nodes.
The first, the lower part is the point of injection, and there are a couple up there, that's the anterior and the lateral view. The next day, when the patient goes into the OR, their doctors just have to use their wand to see where the radioactive isotope is.
This picture is actually for us to make sure that it has drained into the lymph nodes.
- [Presenter] Good morning, thanks for the invitation to present. No financial disclosures. I would disclose that I'm excited and somewhat intimidated to be just debating Dr. Thompson. But Ron Fairman assures me he's taught me
everything there is to know about transaxillary first rib resections, so hopefully that's true. I think four questions and their answers are relevant to deciding what the best approach is to venous thoracic outlet syndrome.
First of all, does the vein need to be reconstructed? Is there a risk of recurrence that's greater with one approach or another? Which approach is cosmetically better? And what do you do if you're approach or your surgery doesn't work?
So at Penn, all patients get a preoperative diagnositc venogram and at that time get an angioplasty, percutaneous mechanical thrombectomy or thrombolysis as needed. We'll call this venogram
and percutaneous treatment VPT going forward. Usually within 30 days the patient undergoes transaxillary first rib resection and then gets postoperative anticoagulation for a defined time period, usually a month. If the vein can't be crossed at the time
of the preoperative VPT then the patient's not offered first rib resection. Patient's only undergo postoperative VPT, venogram or any intervention if their symptoms recur early or their postoperative duplex demonstrates a significant clot burden.
Over 10 years we've done 120 cases of first rib resection from the transaxillary approach for Paget-Schroetter Syndrome. Patients underwent first rib resection between seven days and 18 years after their initial presentation. So there's a good mix of acute and chronic patients.
No patient underwent venous reconstruction or bypass. And at last follow-up 119 of 120 axillosubclavian veins were patent by duplex ultrasound. So we don't think that the vein needs to be reconstructed in almost any circumstance. I'm going to show you a case because I think it'll demonstrate
the robust nature of our approach. This is a 58 year old woman who's very physically active and had arm swelling initially one year prior, was put on Warfarin and then presents with recurrent and ongoing debilitating symptoms. She has a chronic occlusion of her subclavian vein
which is very tenacious and required the backend of a glide wire to cross. But balloon angioplasty and percutaneous mechanical thrombectomy were pretty successful in getting the vein open. Couple days later she went to the OR
for transaxillary first rib resection. That went well. And two years later the vein is widely patent. So I think this demonstrates our approach being pretty robust. Now that patient didn't have to go back
to the operating room, to the interventional suite postoperatively for any postoperative re-thrombosis or residual clot in the vein. But about 20 of our 120 patients have had to go back for repeat venogram and sometimes re-intervention
and usually that's just touching up the vein. But no patient has suffered a delayed recurrence of their disease. And the question about recurrence, I don't think is really applicable here. I think that the reports of high recurrence rate
for transaxillary first rib resection is relevant mostly to the neurogenic thoracic outlet syndrome patient. This series from UCLA demonstrated a high primary failure rate with transaxillary rib resection but again that's not our patients.
So we don't think that there's a high risk of recurrence with transaxillary first rib resection. We do think that cosmetically the transaxillary approach is preferred. This is a really discrete incision in the axil and in general no one knows the patient has a scar there.
And then finally, if you're unsuccessful decompressing the vein or opening up the vein through a transaxillary approach or providing long term vein patency, again which, something we have not experienced. But if you are, or if the patient later develops neurogenic symptoms and needs a neurolysis,
you can always go back through an anterior approach and perform a neurolysis or reconstruct the vein. But again, our patients have not required that. So we believe that transaxillary first rib resection is the preferred approach for venous thoracic outlet syndrome
and I'll cede my last 40 seconds to Dr. Thompson.
Nowadays, as you have seen from William, Combimsity actually has really entered our lives
and we are using it in most of the cases. I'm sorry that the video is not playing, but what we actually need is a technologist who is active and is inside in the room with us because after the combimsity, we need somebody to be there for us to provide us with the right angulations
so we can see where the needle are and we can be certain what we are doing.
- [Alicia] I would like to introduce Dave Douthit. Dave Douthit is gonna talk to us a little bit about Shari Ullman. Our inaugural kick off lecture every year is the Shari Ullman Gold Medal lecture. And, it's named after a technologist who is integral in founding the AVIR.
And in honor of her we present every year every award to a physician who has been an integral component in the education of both technologists and nurses. And so without further adieu I would like to introduce a long standing board member Dave Douthit so he can tell you a little bit more
about this prestigious award. (audience applause) - [Dave] Good morning everybody. Thank you very much for having me up here. And thank you for this meeting to be in place. If we could put up the slides for the AVIR Gold Medal
not that one Shari Ullman Gold Medal. Anyhow, while he's trying to find my slides, I can always make it up from the hip. I knowing me, I'll come up with something or other. But just for all of us AVIR and the ARIN for the organizations to be together
this is the 28th annual scientific meeting I think that we have up here going on today. So, this thing has been around since 1990. And believe it or not, as we started this meeting, the first one was, I believe, out here on the west coast. Although, maybe a little north of here in San Francisco.
But in 1990 we began. You can move to the next slide. In all this, as we move through this, people that we've all had founding people that have helped these organizations get to when we are today,
the one person that always was true for us at AVIR was Shari Ullman. She was a technologist for 25 years. She absolutely, always patient driven. She retired due to some health issues. But, even in her absence, while she was at home,
on with her health issues, she worked on trying to put together policies and joint commission things to help her, not only help her hospital, but to help all of us to establish some type of guidelines so that we can live by.
You can go to the next slide. And all the things she did was in the beginning she was part of one of the founding fathers that are members, that actually moved us forward. This was a long time ago, along with Dr. Hunter. And, there was probably one or two people still
in this room today that were in as part of this group that went there to put this thing together. She took on immediate leadership, and she was instrumental in putting our bylaws together, and the policies that we live by. We at that time in the early 90s also worked
to put a standard together so that the guidelines could but out there. We did this in conjunction with the ASRT at this point, and however, we're moving forward to come out with more of those in the near future. Next slide.
She became immediate, as I said, in leadership, the secretary treasurer. She was vice president. She stayed as director at large, constantly being involved in the organization. In 1998 she was president,
and she worked with different external liaisons as we have. You can go to the next slide. And part of all this, even in everything she was doing, even after she was president, she became very good friends, like all of us, but this Board of Directors that you just met
with the nurses, and the Board of Directors that you met with the technologists, these people become long lasting friends. And that's part of what we hope everybody in this room does, whether you're a nurse, whether you're a tech. Join, get involved, and it's a long lasting relationship
that could become for each and every one of you. Shari, back to her, and we're moving on to this next. You can go to the next slide. But, she was so involved with her family in everything that she did. And part of her last domain was to be in every continent
as I pointed out in the last slide. And, when she made this comment about when we honored her by making this, the Gold Medal Lecture, in honor of her, it truly meant those words. It meant a world to her. The first one we awarded was back at the 19th annual,
again we're at the 28th annual meeting right now. So, it's, you know, part of what we try to do with this foundation and Shari Ullman is try to help out with students and things like that. You got one more slide, I think. And so, what I'd like to say is she dedicated a lot
of her time and effort to it, and believe it or not, I don't know, I might have skimmed over it, but she is one of the local girls from this city. So, she brought meaning. I see no more perfect way than to recognize our speaker,
that I have to bring Alicia back up for, to introduce. But thank you very much for the time and effort for you all to be here. (audience applause)
Next approach, which is the most common approach and the most technically feasible approach usually is to actually cross the splenic artery,
go distal, coil embolize the spleen, splenic artery distal to the aneurysm and then pull back and coil embolize proximal to the aneurysm itself and that's the most common one and that's the most technically feasible because you can do that with more flexible, lower platforms with microcatheters and catheters.
With younger physicians, I'm gonna show you a procedure. You will find that they're actually coiling in the aneurysm itself and putting a lot more coils in the aneurysm itself, which there's nothing wrong with that, you're just putting a lot-- too much coils in procedure. But ideally, this is what you need to do.
And the reason for that is you need to go as distal as possible in the splenic artery, but just proximal to the aneurysm to provide collateral flow to actually circumvent or bypass the aneurysm and actually continue to revive and keep the spleen alive.
That's basically the whole idea of doing this. The distal embolization is for prevention of back bleeding from these collaterals. So whenever you're embolizing in any celiac axis branch, it's not only the splenic, it's the splenic, the hepatic, the GDA, pancreatic audidenal,
you always have to embolize, whether it's a bleed or an aneurysm, distal and proximal because of all those collaterals and that back bleeding that you actually will pre-fill or re-bleed from the bleed, so this is a typical example where you don't have to go distal to prevent that back bleeding from
filling up that aneurysm. This is an example of a very tortuous splenic artery, with a large splenic artery aneurysm, with an eggshell calcification. So this is the aneurysm here, and what they did was embolize right across the splenic aneurysm from distal
in the aneurysm as well as proximal. And that's the aneurysm kind of excluded.
And what are the cases you can have a Black Swan Effect. These are the 12 cases of paraplegia reported out of the hundreds of thousands of spinal injections performed. And the most logical pathophysiological explanation was the particles in the steroid where are injected intervascularly and they acted as an emboli
resulting in paraplegia of the patient. The success rate for all these injections ranges between 75 and 87% in the literature in clinical practice. I guess that the magic number is around 70%.
- [Diego] Good morning, ladies and gentlemen. I'd like to thank you very much for the opportunity to present this topic: the complete endovascular aortic arch treatment using the transapical approach. These are my conflicts. As you may know, open surgery is still the gold standard for treatment of aortic arch disease.
But it requires a lot of steps, like deep hypothermia, circulatory arrest, and some kinds of brain cerebral protections. And even in a skew for hands, mortality can be as high as 12%, making it prohibitive in high-risk patients. Over the past few years, Tevar have become
the gold standard in treating descending lesions like true aneurysm, and dissections over the last few years. But the arch is still a frontier. In order to overcome these, a lot of alternatives have been proposed, like debranching, parallel prosthesis, single branch, in situ physician fenestrations,
and many others. Besides that alternatives other drawbacks is to persists like the endoleaks, migration, risk of retrograde type A dissections, femoral access problems, the need for open sternotomy, axial adjustments, and even aortic clamping sometimes is required
for that type of correction. In this scenario, a lot of companies have proposed some kind of branched prosthesis. But even then, a lot of limitations still persist, like stroke, coaxial adjustment, incomplete arch reconstructions, access problems, and the need of
cerebral blood flow maintenance during implant. So what could be the ideal solution for the arch? In our opinion, the ideal solution is a complete endovascular aortic arch three branch treatment using a transapical approach from Braile Biomedical. But why transapical?
Because transapical is in close proximity to the arch. The coaxial adjustment is easier, branch connection is easier, access to the branches is also easier, besides being more invasive when comparing to the transfemoral approach.
So what's the clinical scenario of this case? It's a 70-year old female deemed at risk for conventional surgery due to multiple risk factors, who have dissection lesions on the ascending and descending aorta as you can see here on the computer tomography and on 3D reconstruction.
The workflow for the case was that. Computer tomography was imported in the DICOM file inside OsiriX, and then exported to an STL file allowing us to print a 3D model of the aorta of the patient, and based on the 3D model we built a custom prosthesis with three branches
of the arch. A total of 40 days from the computer tomography to the final prosthesis model. The surgery was performed in a hybrid OR using a transapical and a transfemoral access with brachial and carotid punctures in order to aid
the navigation of the guide wires, and everything on TEE Echo monitoring, especially to monitor arch insufficience during the pass of the introducer sheath. These are deployment key steps. Here we can see the deployment of the main body
as low deployment without pacemaker. We can see that there are radio-opaque marks that define the branch for the left subclavian for the left carotid, and for the brachiocephalic trunk. Here we can see final deployment in this low fashion of the main body of the prosthesis.
Here we can see the transducer coming from the apex and a pigtail coming from the femoral artery. We can also see on the other video the catheterization of the left carotid artery. And then the deployment of VIABAHN to connect the left carotid to the main body of the prosthesis.
After that, a second VIABAHN was introduced through the apex as you can see here in this video connecting the brachiocephalic trunk to the main body again. On the next video you can see the deployment of the second VIABAHN with two thirds of the arch completely reconstructed now.
And on the next video you see the positioning of the last VIABAHN connecting the left subclavian artery to the main body of the prosthesis. The final angiography show the three branches connected to the main body with no endoleak, and a second main body treating the descending lesion
on the descending aorta. This is the final control computer tomography. We've no endoleak, the patient discharged after two days, and this computer tomography's for one year followup. As you can see here, no endoleak, and all the three branch splendid.
So transapical total endovascular aortic arch reconstruction's feasible, a faster recovery, decreased length of stay, and is really an alternative in high-risk patients. In the future we'll be now total endobental procedure that will be done on the next few weeks
in South America allowing us a new frontier in endovascular treatment of ascending aorta and the arch. Thank you very much.
The pathophysiology of discogenic pains
is multi-factorial in complex. It includes presence of nerve fibers in the annulus fibrosus, mechanical pressure upon the nerve root, with action of chemical mediators like leukotrienes, phospholipases, prostaglandins and formation of neovascularization.
What we can do for diagnosis is to combine clinical examination with imaging studies. And in the latter case we have non-invasive studies like fluoroscopy, CT, MRI and minimally invasive ones like myelography, discography and percutaneous infiltrations and actually those which are performed selectively
they can provide diagnosis for these patients.
The third (mumbles) for intervertebral disc herniation includes four steps. We can start with conservative therapy course of four to six weeks. We can move on to percutaneous infiltrations
then to percutaneous decompression techniques and finally to endoscopic or surgical techniques. Obviously we can combine infiltrations with conservative therapy or with percutaneous decompression techniques. Starting with injections in the spine, do we actually need the imaging guidance?
According to the literature, imagine guidance increases the technical and clinical efficacy and decreases potential complication rate. It has been written that blind interlaminar epidural infiltrations are inaccurate in more than one third of the cases.
And if we go to clinical cases, these are two examples of injections which were performed blindly. On the upper row you can see it was an attempt for an ozone injection of the facet joint by an orthopedic surgeon. It was a blind attempt and you can see that the oxygen,
ozone transforms to oxygen after three minutes, is everywhere in the retroperitoneal space, but it's not in the facet joint. And the lower row you can see a blind attempt of epidural infiltration by anesthesiologist. The patient after the injection was reporting
severe headache, that is the center scan and you can see air inside the ventricular system of the brain. Percutaneous infiltrations can be performed through a trans-foraminal access to an interlaminar paramedial access through the sacro-coccigial hiatus and in all cases, you can use contrast or air control
before your steroid injection. These injections they go way back to 1950s and in 1970s you have the first trans-foraminal nerve root blocks. What we're actually injecting is long-acting corticosteroid and we do need the imaging for particulate ones because they can cause some complications
as we will see later. We do tend to combine corticosteroids with local anesthetic and we need contrast medium to verify the proper position of the needle. In all cases, when you are using contrast medium, you should be using agents approved for myelography.
Corticosteroids actually provide an anti-inflammatory effect, a direct neural membrane stabilization effect and they do modulate peripheral nociceptor input. On the other hand, local anesthetic interrupts the pain-spasm cycle, interrupts the transmission of the noxious stimuli and resets the nerve itself.
Contraindications include the patient who is unwilling to consent to the procedure, local or systemic infection, hemorrhagic diathesis or anticoagulant therapy and an allergy to any component mixture. As far as I'm concerned, I do prefer to apply three to four sessions of steroid injections
within 12-months period with a maximum of two infiltrations per session. And in all cases, we are using imaging guidance. We can use fluoroscopy, we can use CT or even MRI guidance and here we are using air or contrast medium to verify proper needle position.
And proper needle position does not mean only in the right spot, but you should have the needle outside a vessel. You will cause complication and problems to the patient if you perform intervascular injection of particulate corticosteroids.
in that case. The next subject, which is splenic steal syndrome, which is a very complex subject.
Splenic steal syndrome, or NOHAH, that's non-exclusive hepatic artery hyperprofusion basically means that the hepatic artery's open, but there's slow flow in it, so it's not anatomical. This is a hemodynamic problem. It is not an anatomical defect.
It's not a thrombosis, it's not an aneurysm, it is not a stricture, it is not a kink. The artery is a wide open pump, but flow is going through it very slowly. The idea on this is to go as proximal as possible and is to impede flow, slow down the flow,
not necessarily shut it off, but slow down the flow significantly. Go proximal as possible to allow collaterals to keep the spleen alive. It is not a splenic artery embolization where you use particles.
- [Henrik] Thank you very much, thank you Frank. I don't know what I did to get that title, for it's certainly long. If some of you were here 6:40 this morning you may recognize some of the slides, because I had a similar title at that time. The risk of stroke in asymptomatic patients
is low, and you can see from this publication that shows the annual risk declining, with the year of the publication. Just a few months ago there was this publication from Kansas where a group looked at 864 with 1400 Stenotic Carotid arteries,
followed them for seven years, and they looked at how many goals of risk reduction were accomplished, and you can see that the step-wise reduction in the black bar, which is the combined end point of Stroke TIA or Carotid Revasc, how that is lowered
from 3.5 to .6% annually if you reach all the goals of healthy lifestyle and take the right drugs. Interestingly also looked at how the risk of stenosis progression similarly was reduced step-wise. They concluded that the risk of TIA, Stroke and Revasc becomes extremely low if risk factors are treated
appropriately, and I would say progression of carotid stenosis is a sign of insufficient risk factor control, and preventive treatment rather than sign of increased risk of stroke. And similarly, we looked at 7,000 patients in the bio image study, where we scanned the carotids,
and we found that 6% had a carotid stenosis, they were followed for three years, and four had a stroke, of which two were ipsilateral. However, a lot had cardiovascular events, which we know. For Asymptomatic Carotid Stenosis, very, very low risk of stroke, maybe .3 to .4%.
It's a high risk of cardiovascular events instead, so therefore, it's very important with preventive treatment and the lifestyle adjustment. And Carotid endarterectomy, or CAS, in general is not warranted, unless a high risk plaque can be identified, of course.
And together, with one of the Chairman, we looked at that a couple of years ago, and published in European journal, and notice how stenosis progression is actually the least important of those listed here. However, these data are also ancient since most of these studies included patients that were gathered
or investigated 10 - 20 years ago, so the risk today is probably less than half of what is shown there or maybe even less. Presence of Carotid Stenosis does not tell it all. We need 3D Ultrasound. And the previous speaker
is a pioneer of this and up in the zeros, published a number of papers, and this is just one of them, using a research tool as you can see in the top left, is handheld, but demonstrated to be very reproducible, but now we can get these as what's called Matrix Transducers where we instead of having just
one array as you see here, we have multiple arrays in both dimensions, and therefore we can do volume imaging, or we can have two plain simultaneously as you see in this slide. We recently looked at how accurate can you measure plaque volume using an instrument like this, and it's simply
tomography as you're used to with CT, you take slices and you look at the area in each slice, you know the difference, sorry the distance in between you can calculate the volume. We did that, and this is what came out when we had two blinded investigators scan the same 37 PAD patients.
The patient was up standing in between exams, the ultrasound machines was reset, so this is fully blinded two independent acquisitions. This is actually much more accurate than if you do two LDL blood tests, what you see here. I shall admit that these patients were a little bit
selected because patients with calcified plaques were excluded. 3D will improve plaque qualification, both volume and morphology. Assessment of degree of stenosis, will be better because the angle-compensation can be done
more accurately in 3D. Speed of examination will increase, and will be more easy to perform a good scan. What can we use it for? For risk assessment in carotid disease , who to operate will be more accurate, we can do better morphology
using this technique, and we can also monitor if we treat the patients appropriate with general prevention. Is the plaque stabilized? And maybe more important, has the atherosclerotic burden stopped growing, and I would suspect or expect
that this method may replace LDL measurement in the future when you want to see if the preventive treatment works. Thank you for attention. (clapping)
- [Presenter] I will share with you some tricks, what do to when the complex stent grafts fail intraoperatively and this will be mainly about accidentally over-stented side branches of the aorta and about intraoperative leaks. When it comes to the over-stented side branches, this, I believe, is the very first chimney graft ever
in 1999, in Gothenburg, where we over-stented the renal, and that chimney stayed patent throughout the life of the patient, which was 14 years. We then used the technique on numerous occasions in the arch where we happened to over-stent the common carotid artery.
Because it is so simple to place a chimney on such occasions, it is definitely simpler than any of the open external carotid bypasses. Although, they are also seemingly simple in the neck. Much simpler in the abdomen. But still, I've seen all the various complications
from that type of procedure. When it comes to the renals, it happens when you place stent grafts very accurately that you over-stent the renals, and on most occasions, you will be able to use that same chimney technique from below
coming back into the renals, placing coverage stents, and opening up the renal arteries. But it's a different ballgame when it comes to the complex stent grafts, the fenestrated and branch stent grafts. Here's a quadruple fenestrated stent graft
where the renal arteries have been successfully cannulated through the fenestrations, and so has the celiac trunk, but the SMA seems gone, and we were unable to pass the wires through the SMA fenestration. On this occasion, it was, however, possible to go outside the stent graft, and park a long chimney
to re vascularize the SMA. That is the antegrade chimney. In this fenestrated stent graft, again, the renals are fine, but the SMAs are gone. And here it was impossible to go outside the stent graft from above,
so here we did a retrograde chimney by laparotomy where a branch of the SMA was isolated and then punctured with a micropuncture set, passing an 018 wire retrograde into the aorta prior to the aortic stent graft, snaring it form above. And then, over there to body-floss wire,
inserting a chimney with this type of end result. When it comes to the renals, again, the retrograde chimney technique can be used in a similar manner. Here is the Medtronic stent graft that was excellent to displaced cranially because it wouldn't detach
from the deployment mechanism. And both renals were over-stented. We were unable to get back into them from above, and instead, via laparotomy, renal artery was punctured, cannulated retrograde into the aorta, snared from above, and chimneys were inserted from above
with this type of end result. And this is one year follow-up of that particular patient. I think this offers less trauma than open various surgical solutions to that difficult problem. So when it comes to the over-stented branches,
I think you should avoid drastic bypasses, they are too much of a trauma. Chimneys and snorkels are an option in this difficult scenario. You can use retrograde puncture via laparotomy if you can't get back to the aortic side branch.
And this is a durable technique with less trauma than open surgical repair. The other thing I want to discuss was leaks. Even after the complex stent grafts, you do see leaks. You then may need to extend the stent graft. The problem here is you have the fenestrated branches
protruding into the aortic lumen. It's not just renals, it's also the SMA branches, etc. It's not so easy to place a fenestrated stent graft into this type of device. And here again, the snorkle technique, the chimney reversed technique,
is an option, which you then can over-stent to extend your device. Another option that we have heard about when it comes to the dislodged branches that simply fall out, I think Tim Chuter mentioned this,
in this type of scenario, usually you are able to pass a wire back in and then extend the branch into that target vessel. The problem now is that the renal arteries are short, and you tend to get relatively deep into the renal artery. Then you create that type of kink
that Tim discussed beautifully, and the routine treatment for that today is that you extend with a soft bare stent. The problem with that, again, then, is that in this scenario, you get pretty close to the hilus of the kidney,
and I believe that this, probably, is risk for late thrombosis as is mentioned by other speakers. So, in conclusion, ladies and gentlemen, when it comes to bailout of the complex stent grafts, I don't think you should primarily do massive open surgery. When it comes to over-stented branches,
they can usually be fixed with chimneys or snorkels, antegrade or retrograde. And when it comes to the leaks, you need to re-line or extend the stent graft, which then again can be facilitated by the chimneys. Thank you for your attention.
- Thank you Mr. Chairman. Ladies and gentleman, first of all, I would like to thank Dr. Veith for the honor of the podium. Fenestrated and branched stent graft are becoming a widespread use in the treatment of thoracoabdominal
and pararenal aortic aneurysms. Nevertheless, the risk of reinterventions during the follow-up of these procedures is not negligible. The Mayo Clinic group has recently proposed this classification for endoleaks
after FEVAR and BEVAR, that takes into account all the potential sources of aneurysm sac reperfusion after stent graft implant. If we look at the published data, the reported reintervention rate ranges between three and 25% of cases.
So this is still an open issue. We started our experience with fenestrated and branched stent grafts in January 2016, with 29 patients treated so far, for thoracoabdominal and pararenal/juxtarenal aortic aneurysms. We report an elective mortality rate of 7.7%.
That is significantly higher in urgent settings. We had two cases of transient paraparesis and both of them recovered, and two cases of complete paraplegia after urgent procedures, and both of them died. This is the surveillance protocol we applied
to the 25 patients that survived the first operation. As you can see here, we used to do a CT scan prior to discharge, and then again at three and 12 months after the intervention, and yearly thereafter, and according to our experience
there is no room for ultrasound examination in the follow-up of these procedures. We report five reinterventions according for 20% of cases. All of them were due to endoleaks and were fixed with bridging stent relining,
or embolization in case of type II, with no complications, no mortality. I'm going to show you a couple of cases from our series. A 66 years old man, a very complex surgical history. In 2005 he underwent open repair of descending thoracic aneurysm.
In 2009, a surgical debranching of visceral vessels followed by TEVAR for a type III thoracoabdominal aortic aneurysms. In 2016, the implant of a tube fenestrated stent-graft to fix a distal type I endoleak. And two years later the patient was readmitted
for a type II endoleak with aneurysm growth of more than one centimeter. This is the preoperative CT scan, and you see now the type II endoleak that comes from a left gastric artery that independently arises from the aneurysm sac.
This is the endoleak route that starts from a branch of the hepatic artery with retrograde flow into the left gastric artery, and then into the aneurysm sac. We approached this case from below through the fenestration for the SMA and the celiac trunk,
and here on the left side you see the superselective catheterization of the branch of the hepatic artery, and on the right side the microcatheter that has reached the nidus of the endoleak. We then embolized with onyx the endoleak
and the feeding vessel, and this is the nice final result in two different angiographic projections. Another case, a 76 years old man. In 2008, open repair for a AAA and right common iliac aneurysm.
Eight years later, the implant of a T-branch stent graft for a recurrent type IV thoracoabdominal aneurysm. And one year later, the patient was admitted again for a type IIIc endoleak, plus aneurysm of the left common iliac artery. This is the CT scan of this patient.
You will see here the endoleak at the level of the left renal branch here, and the aneurysm of the left common iliac just below the stent graft. We first treated the iliac aneurysm implanting an iliac branched device on the left side,
so preserving the left hypogastric artery. And in the same operation, from a bowl, we catheterized the left renal branch and fixed the endoleak that you see on the left side, with a total stent relining, with a nice final result on the right side.
And this is the CT scan follow-up one year after the reintervention. No endoleak at the level of the left renal branch, and nice exclusion of the left common iliac aneurysm. In conclusion, ladies and gentlemen, the risk of type I endoleak after FEVAR and BEVAR
is very low when the repair is planning with an adequate proximal sealing zone as we heard before from Professor Verhoeven. Much of reinterventions are due to type II and III endoleaks that can be treated by embolization or stent reinforcement. Last, but not least, the strict follow-up program
with CT scan is of paramount importance after these procedures. I thank you very much for your attention.
Okay, so at MSK we call our nuclear medicine division Molecular and Imaging Therapy Service. At the main center right now we have eight nuclear medicine registered nurses, 15 technologists, we have three PET CT scanners, seven gamma scanners, one spec CT scanner, and we recently acquired
one MRI PET scanner, that is currently housed in our MRI division. On average, on our main campus, we do about 40 to 50 PET scans, that's about 10,000 to 11,000 PET scans in a year. 10 to 20 bone scans, 10 breast lymphoscintigraphy scans,
four V/Q scans, two to six MIBG, three renal, three cardiac, two GFR, two liver and other miscellaneous scans. I'm not talking about any of the RESA scans that we recently started, like our C11 or dotatate PET scans.
- [Gianluca] Thank you, Mr. Chairman. Thanks to Frank (mumbles) for the very kind invitation. I have nothing to disclose regarding this presentation and silent cerebral infarct is a small, radiologically detected infarction with no history of acute neurological dysfunction given by the lesion.
And they are usually associated with the degree of carotid stenosis, the number of microemboli at TCD and the plaque histology. In the general population, they affect almost 20% of the population
and they are significantly associated with early stroke and long term stroke rate. For that reason, the presence of silent cerebral infarcts is considered an adjunctive risk in patients that undergoing carotid endarterectomy.
And this was already demonstrated by this work by Cao, in which patient with the presence of silent cerebral infarct had a higher risk of postoperative stroke and long term stroke incidence after carotid endarterectomy.
When we looked at a series of patients, both symptomatic and asymptomatic, after carotid endarterectomy. We saw that the presence of brain infarcts was one of the carotid risks that associated with increased stroke rate after endarterectomy,
no matter where the infarct was located, as you can see from this table. So for that reason, we further expanded our analysis to only asymptomatic patients admitted to carotid endarterectomy with this work. And again we saw that silent cerebral infarcts
are significantly associated with early postoperative stroke and that was an independent factor of postoperative stroke in this series of patient. And this effect was sustained at long term either for ipsilateral stroke and combined stroke and death.
And again, this was an independent risk factor of long term stroke rate after carotid endarterectomy. What about carotid stenting? Actually, the literature, there are no paper dealing specifically with this topic.
So we made an analysis on 420 consecutive carotid stenting patient treated for asymptomatic stenosis and all those patients were evaluated with a preoperative CT scan. And if you look at this graph,
you see that there was no difference in patient submitted to stenting with or without the present of silent cerebral infarct. If we look at the two groups of patient, patient with positive presence, the presence of carotid lesion
before endarterectomy and stenting, there was no difference in the two groups. Whereas, if we look at the patient with no evidence of infarction before endarterectomy or stenting, there was a trend toward greater incidence of stroke
in patient undergoing stenting. So, in conclusion, silent cerebral infarcts increase the risk of postoperative events after carotid endarterectomy and this risk should be considered in indication to revascularization of our patient.
In the stenting group, this effect is less pronounced, but this is probably due to the higher overall risk of neurologic event after stenting. In conclusion, to answer to the answer at the beginning, should all asymptomatic carotid stenosis patients
get head CT scan? The question is definitely yes. Thank you.
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