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Pancreatic Necrosis | Percutaneous Cystogastrostomy | 35 | Female
Pancreatic Necrosis | Percutaneous Cystogastrostomy | 35 | Female
2016abdominalgastricSIRstentstomachultrasound
Case- Ingested Foreign Bodies- Magnets | OMG: Interesting Cases in Pediatric Radiology
Case- Ingested Foreign Bodies- Magnets | OMG: Interesting Cases in Pediatric Radiology
abdominalAbdominal US suggests appendicitisattractchapterFistulafistulasGastroenteritisingestionmagnetmagnetsNoneperforationsrebound tendernesstendernessWorsening pain
Treatment Options- CAS- Embolic Protection Device (EPD)- Proximal Protection | Carotid Interventions: CAE, CAS, & TCAR
Treatment Options- CAS- Embolic Protection Device (EPD)- Proximal Protection | Carotid Interventions: CAE, CAS, & TCAR
angioplastyantegradearteryaspirateballoonballoonsbloodcarotidcarotid arterychaptercirclecirculationclampclampingcolumncommoncontralateralcrossdebrisdeflatedevicedevicesdilateddistaldistallyexternalexternal carotidfilterflowincompleteinflateinflatedinternalinternal carotidlesionmarkerspatientpressureproximalretrogradesheathstentstepwisesyringesyringestoleratevesselwilliswire
Case 8: Retroperitoneal Hematoma- Cover Stent | Emoblization: Bleeding and Trauma
Case 8: Retroperitoneal Hematoma- Cover Stent | Emoblization: Bleeding and Trauma
angiogramarteryaxialbleedcatheterizationchaptercontrastcoronalCoverage StentembolizationembolizehematomailiaciliacsimageinjuryNoneoptionpatientpseudoaneurysmRetroperitoneal hematomastentstents
Case- Ingested Foreign Bodies | OMG: Interesting Cases in Pediatric Radiology
Case- Ingested Foreign Bodies | OMG: Interesting Cases in Pediatric Radiology
abdominalbowelbowel restchapterconstipationdiarrheahistoryingestionIngestion of a piece of wire bristle from BBQIV antibioticslaparoscopic explorationNoneovarianpainPain continuespain palliationpalpationperitonitissurgical removal recommendedsymptomsvomitingwire
Case- Migration of Ingested Foreign Bodies | OMG: Interesting Cases in Pediatric Radiology
Case- Migration of Ingested Foreign Bodies | OMG: Interesting Cases in Pediatric Radiology
abdominalbodychaptercomplicationsingestionlumenmesomigratedmigrationneedleNonepalpaterarerectal
Case- Vaginal Foreign Bodies- 11 year old female | OMG: Interesting Cases in Pediatric Radiology
Case- Vaginal Foreign Bodies- 11 year old female | OMG: Interesting Cases in Pediatric Radiology
abdominalbodiesbodychapterdiarrheafemalesfluidforeignhematuriahistoryHysterotomy finds golf tee in uterusimagingNoneobject foundobjectspainpyelonephritisscansensitivesuspicious of UTIultrasoundvaginal
Observations working in IR in China | Across the Pond: The state of Interventional Radiology in China
Observations working in IR in China | Across the Pond: The state of Interventional Radiology in China
betadinechapterchinaclinicianfinanceshealthcareinterventionaloncologystent
Case 11b: Embolizing a Pseudoaneurysm of the Brachiocephalic Artery | Emoblization: Bleeding and Trauma
Case 11b: Embolizing a Pseudoaneurysm of the Brachiocephalic Artery | Emoblization: Bleeding and Trauma
angiogramarterybrachiocephaliccatheterchapterclickcoilcoilsembolizationmicromicrocatheterNonepseudoaneurysmPseudoaneurysm brachiocephalic arterystenttrachea
Summary of Carotid Interventions | Carotid Interventions: CAE, CAS, & TCAR
Summary of Carotid Interventions | Carotid Interventions: CAE, CAS, & TCAR
applycarotidchapterendovascularmedicalpatientsstentingtherapy
Case- Ingested Foreign Bodies- Magnets | OMG: Interesting Cases in Pediatric Radiology
Case- Ingested Foreign Bodies- Magnets | OMG: Interesting Cases in Pediatric Radiology
abdominalchapterday 3 pain reappearsdischarged with instructions that object would pass in stoolendoscopyfeverguardinghandheldingestionIV fluidsmagnetmagnetsmetalmetallicNoneobjectobservationpainpalerebound tendernessrigid abdomensurgicalsurgical consult obtained.typevomiting
Difficulties in provision of care for the Chinese Interventionalist | Across the Pond: The state of Interventional Radiology in China
Difficulties in provision of care for the Chinese Interventionalist | Across the Pond: The state of Interventional Radiology in China
accessBARDBDchapterchinachineseclinicianevaluateinterventioninterventionalpatentspatientsproductsreserestenosissendstentstentsVenovo Stentwestern
Case- Brain Infarction | Brain Infarct After Gastroesophageal Variceal Embolization
Case- Brain Infarction | Brain Infarct After Gastroesophageal Variceal Embolization
anastomosisangiographyaphasiaapproacharrowarteryartifactbrainbronchialcalcificationcatheterschannelschapterchronicChronic portal vein thrombosuscollateralcyanoacrylatedrainembolismembolizationendoscopicendoscopistendoscopygastricGastroesophageal varixglueheadachehematemesisinjectionmicromicrocathetermulti focal brain infarctionmultipleoccludedPatentpatientpercutaneousPercutaneous variceal embolizationperformedPortopulmonary venous anastomosisprocedureproximalsplenicsplenomegalysplenorenalsubtractionsystemicthrombosistipstransformationtransitultrasonographyvaricesveinvenous
Tips and Tricks | Twitter Case Files
Tips and Tricks | Twitter Case Files
adaptapplicablechaptercontentgoogleidentifyingpostroutinestenttrauma
Treatment Options- Carotid Artery Stenting (CAS) | Carotid Interventions: CAE, CAS, & TCAR
Treatment Options- Carotid Artery Stenting (CAS) | Carotid Interventions: CAE, CAS, & TCAR
antiplateletarterybraincarotidchapterdualembolicmedicareplavixprocedureprotectionproximalstenosisstentstentingtherapy
Case 3 - Right iliac occlusion | Subintimal Recanalization | Complex Above Knee Cases with Re-entry Devices and Techniques
Case 3 - Right iliac occlusion | Subintimal Recanalization | Complex Above Knee Cases with Re-entry Devices and Techniques
AngioDymanicscatheterchapterCordiscritical limb ischemiadeviceenosfootguysiliacocclusionOUTBACKĀ® ELITE Re-Entry Catheterproximalre-entry deviceSOS Omni Selective Catheterstentvessel
Most common IR procedures and disease in China | Across the Pond: The state of Interventional Radiology in China
Most common IR procedures and disease in China | Across the Pond: The state of Interventional Radiology in China
ablationbiliarybiliary cancercancerchapterchinacirrhosisfactorsgeneticguyshcchepatitisinterventioninterventionalistsInterventionslargestlifestylelunglung cancerneuropiccprevalentproceduresmokingsocietaltrained
Ideal Stent Placement | TIPS & DIPS: State of the Art
Ideal Stent Placement | TIPS & DIPS: State of the Art
anastomosiscentimeterchaptercoveredcurveDialysisflowgraftgraftshemodynamichepatichepatic veinhyperplasiaintimalnarrowingniceoccludesocclusionportalshuntshuntssmoothstentstentsstraighttipsveinveinsvenousvibe
Carotid Artery Stenting- Case | Carotid Interventions: CAE, CAS, & TCAR
Carotid Artery Stenting- Case | Carotid Interventions: CAE, CAS, & TCAR
angioplastyarteryballoonballoonsbut want left carotid artery lesion stented firstcarotidcarotid arterychaptercommonCoronary bypass graftdistalECA balloonendarterectomyexternalexternal carotidimageinflatelesionosisproximalproximallystentstentingsurgicallyultimately
TIPS Case | Extreme IR
TIPS Case | Extreme IR
antibioticsascitesbacteriabilebiliarycatheterchapterclotcolleaguescommunicationcovereddemonstrateddrainageductduodenal stent placementfull videoportalrefractoryshuntsystemthrombolysistipstunnelultrasoundunderwentvein
Venous Insufficiency- Imaging | Pelvic Congestion Syndrome
Venous Insufficiency- Imaging | Pelvic Congestion Syndrome
chaptercompressibleevidenceflowgonadalgrayiliacincompetentinsufficiencypelvicpelvissecondarysequelaeultrasoundvalsalvavalvevalvesvaricosevaricose veinsvaricositiesveinveinsvenous
HCC and IR oncology treatments | Transforming from Clinical IR to Clinical Trials with Tirapazamine (TPZ)
HCC and IR oncology treatments | Transforming from Clinical IR to Clinical Trials with Tirapazamine (TPZ)
ablationadvancedadvancingagentalbuminapproacharterialarterybeadsbilirubinbloodcarcinomacatheterchapterchemochildchroniccirrhosiscirrhoticclinicalconsideredCTcurativediabetesdiagnoseddiagnosisdiameterdiseaseeffectiveembolisationembolizationethanolhcchepatichepatic arteryhepatitishepatocellularincidenceincludeinjectedinjectioninterventionallesionslftslivermeasuresmicrospheresmicrowaveMRImultidisciplinaryNoneobesityoncologyoptimaloptionsoutcomespatientspercutaneouspercutaneouslyperformedportalprocedureprotocolradiofrequencyradiologyraterecurrenceresectionriskscoresscreeningserumsurgerysurgicalsurvivalsystemictasteteststherapiestherapytranstransplanttreatmenttumortumorsultrasoundunresectableutilizedvein
Duplex Ultrasound | Determining the Endpoints of CLI Interventions
Duplex Ultrasound | Determining the Endpoints of CLI Interventions
angioplastychaptercolordopplerduplexflowhelpfulimageimagesimagingoccludedpatientssensitivespectraltriphasicultrasoundvelocitywaveform
Cone Beam CT | Interventional Oncology
Cone Beam CT | Interventional Oncology
ablationanatomicangioarteriesarteryartifactbeamchaptercombconecontrastdoseembolicenhancementenhancesesophagealesophagusgastricgastric arteryglucagonhcchepatectomyinfusinglesionliverlysisoncologypatientsegmentstomach
Case 9: Embolizing a Pseudoaneurysm Rrising from the Branch of the Inferior Epigastric Artery | Emoblization: Bleeding and Trauma
Case 9: Embolizing a Pseudoaneurysm Rrising from the Branch of the Inferior Epigastric Artery | Emoblization: Bleeding and Trauma
abdominalafibangiogramangiographyanteriorarterybruisingchaptercoilembolizationepigastrichematomainferiormicrocatheterNonepatientpseudoaneurysmPseudoaneurysm arising from the branch of the inferior epigastric arterywall
Case- May Thurner Syndrome | Pelvic Congestion Syndrome
Case- May Thurner Syndrome | Pelvic Congestion Syndrome
arterycatheterizecausingchapterclassiccliniccommoncommon iliaccompressioncongestionendovascularevidenceextremitygonadalhugeiliaciliac veinimagingincompetenceincompetentMay Thurner Syndromeobstructionoccludedpelvicpressuresecondarystentsymptomstreatmentsvalvularvaricositiesvaricosityveinveinsvenavenous
Case- Severe Acute Abdominal Pain | Portal Vein Thrombosis: Endovascular Management
Case- Severe Acute Abdominal Pain | Portal Vein Thrombosis: Endovascular Management
abdominalanticoagulantsanticoagulationaspirationCAT8 PenumbracatheterchapterclotdecideflowhematomaintrahepaticlactatelysisneedlepainportalPortal vein occlusion-scanstenosisstentthrombolysisthrombosedthrombustipstransitvein
Treatment Options- TransCarotid Artery Revascularization- TCAR | Carotid Interventions: CAE, CAS, & TCAR
Treatment Options- TransCarotid Artery Revascularization- TCAR | Carotid Interventions: CAE, CAS, & TCAR
angiographyangioplastyarterybleedbloodcalcifiedcarotidchapterclaviclecommondebrisdevicedistalembolicembolizationexposurefemoralflowimageincisioninstitutionlabeledpatientprocedureprofileproximalreversalreversesheathstenosisstentstentingstepwisesurgicalsuturedsystemultimatelyveinvenousvessel
Case- Vaginal Foreign Bodies- 5 year old female | OMG: Interesting Cases in Pediatric Radiology
Case- Vaginal Foreign Bodies- 5 year old female | OMG: Interesting Cases in Pediatric Radiology
abdomenbleedingchaptermetalMRINoneobject foundultrasoundX-ray revealed object
Case 11: Bleeding Tracheostomy Site | Emoblization: Bleeding and Trauma
Case 11: Bleeding Tracheostomy Site | Emoblization: Bleeding and Trauma
aneurysmsangiogramarterybleedingBleeding from the tracheostomy siteblowoutcancercarotidcarotid arterychaptercontrastCoverage StentembolizationimageNonepatientposteriorpseudoaneurysmsagittalscreenstent
Malignant Biliary Strictures | Biliary Intervention
Malignant Biliary Strictures | Biliary Intervention
adventBARDcancerceliaccenterschaptercolorectalcookCordiscoveredcysticdataductextremelyfavorfavorablegoregrammalignantMeditechMemothermmetalmetastaticmultipleocclusiononcologyovergrowthpatientsperioperativeportalSmartStentstainsstentstentsstricturestumorunresectablewallstentZilver Stent
Transcript

This is the 35 year old woman with alcoholic pancreatitis,

abdominal distention with unmanageable pain and had a CT scan of the abdomen. So what are your thoughts about this? How would you, of course we showed here because we drained it? So how will you drain it? >> [INAUDIBLE]

>> Very good, excellent. You put that over there come on. Yes we did that and you can see the wire. You see if you look, unfortunately I'm not really, you see this is the stomach on ultrasound,

I prefer I do a ultrasound gastric drainage when I have the stomach plastered against the wall, and I use ultrasound because the ultrasound allows me to see the stomach and make sure that you pass both walls because many times it can happen to you and think you're through the stomach and you are

on the side. The stomach squeezes, and the problem is that when the borders of the stomach the gastric diplogatar/g is relieved/g. So [BLANK_AUDIO]

That's the wire and what we did we ballooned the communication between the stomach and the collection previously to do that, with the stent of the stomach, we put T fasteners, we secured the stomach to the abdominal wall [BLANK_AUDIO]

And we put a 14 French catheter. This is pre-drain, this is post-drain at 10 days cuz they're full evacuated and this is the follow up without the three months after without any drainage. This patient did very well with a single catheter because it was

fluid, it was all black fluid. This is a 72 year old

we're gonna move on I have Nancy for the

final piece good morning everybody so I'm going to start with attraction the attraction of magnets that children seem to have so you can see here on the right that the incidence of these types of ingestion is relatively low but what you

need to know is that there's been a major increase in the number of times that we see this because there's so many toys and other objects that contain magnets in them and the magnets that are in there are extremely high-powered so

just because it's a small magnet doesn't mean that it's less of a problem so as you can see there are packaged warning labels on them but a lot of people still don't really actually I think believe that ingesting a magnet can be fatal but

there have been several fatalities and children from magnet ingestions and this is just really cool-looking puzzle I would be attracted to it if I was a child but this contains over 200 magnetic balls in there so I like x-men

so I'm calling this the case of magneto so this is a ten year old boy with a one-day history of recurrent vomiting who basically had some abdominal pain which is you've heard multiple times this is a very common presentation and

he had some abdominal tenderness so they started treatment for gastroenteritis which seemed totally appropriate but then his pain got worse and he started to have rebound tenderness so of course they're thinking

maybe appendicitis they did in a abdominal ultrasound and then they got the x-ray and then they got the x-ray there we go any guesses on what this is like a bracelet right like a little small brace

that's what I thought when I saw this so when you see that what type of material do you think this could be if you're thinking it's a bracelet yeah like a hard plastic right so obviously we're talking about magnets so here you go

foreshadowing not really it's a magnet but when you would first look at it I think you would think maybe hard plastic or some sort of jewelry some sort of that type of metal so they took him to the operating room and this is the

segment that they took out he had one of those rainbow magnet puzzles that I showed you at the beginning so when they removed it they found 16 separate little magnet balls so what people don't understand about the magnets is when

they travel through the GI system they continue to attract each other so in this situation you can see here that there is a fistula that's developed and that's because two magnets were on the opposite side of bowel and so they

attract each other and they pressed together this can cause perforations this can cause fistula x' and this can cause necrosis of those parts of the intestine and so in this case he had seven

fistulas several perforations and they had to actually remove part of his ileum because he had so many of them and then just because this poor child he's never gonna or he or she he will never do this again he had a wound

infection afterwards so this became a very complicated thing so he's in the hospital for quite a while but was able to be discharged successfully so the question comes up about well if the problem is that there are two magnets

that attract each other and that's what causes a problem then if there's a single magnet then in theory that shouldn't be an issue it should be able to pass so when you look at some of the algorithms for treatment of magnets

it'll say that if you believe that it's a single magnet that we should attempt to let it pass so that's sort of the conventional wisdom for it

of these issues filters are generally still use or were used up until a few years ago or five years ago almost exclusively and then between five years and a decade ago there was this new concept of proximal protection or flow

reversal that came about and so this is the scenario where you don't actually cross the lesion but you place a couple balloons one in the external carotid artery one in the common carotid artery and you stop any blood flow that's going

through the internal carotid artery overall so if there's no blood flowing up there then when you cross the lesion without any blood flow there's nothing nowhere for it to go the debris that that is and then you can angioplasty and

or stent and then ultimately place your stent and then get out and then aspirate all of that column of stagnant blood before you deflate the balloons and take your device out so step-by-step I'll walk through this a couple times because

it's a little confusing at least it was for me the first time I was doing this but common carotid artery clamping just like they do in surgery right I showed you the pictures of the surgical into our directa me they do the vessel loops

around the common carotid approximately the eca and the ICA and then actually of clamping each of those sites before they open up the vessel and then they in a sequential organized reproducible manner uncle Dee clamp or unclamp each of those

sites in the reverse order similar to this balloon this is an endovascular clamping if you will so you place this common carotid balloon that's that bottom circle there you inflate you you have that clamping that occurs right

so what happens then is that you've taken off the antegrade blood flow in that common carotid artery on that side you have retrograde blood flow that's coming through from the controller circulation and you have reverse blood

flow from the ECA the external carotid artery from the contralateral side that can retrograde fill the distal common carotid stump and go up the ica ultimately then you can suspend the antegrade blood flow up the common

carotid artery as I said and then you clamp or balloon occlude the external carotid artery so now if you include the external carotid artery that second circle now you have this dark red column of blood up the distal common carotid

artery all the way up the internal carotid artery up until you get the Circle of Willis Circle of Willis allows cross filling a blood on the contralateral side so the patient doesn't undergo stroke because they've

got an intact circulation and they're able to tolerate this for a period of time now you can generally do these with patients awake and assess their ability to tolerate this if they don't tolerate this because of incomplete circle or

incomplete circulation intracranial injury really well then you can you can actually condition the patient to tolerate this or do this fairly quickly because once the balloons are inflated you can move fairly quickly and be done

or do this in stepwise fashion if you do this in combination with two balloons up you have this cessation of blood flow in in the internal carotid artery you do your angioplasty or stenting and post angioplasty if need be and then you

aspirate your your sheath that whole stagnant column of blood you aspirate that with 320 CC syringes so all that blood that's in there and you can check out what you see in the filter but after that point you've taken all that blood

that was sitting there stagnant and then you deflate the balloons you deflate them in stepwise order so this is what happens you get your o 35 stiff wire up into the external carotid artery once it's in the external cart or you do not

want to engage with the lesion itself you take your diagnostic catheter up into the external carotid artery once you're up there you take your stiff wire right so an amp lats wire placed somewhere in the distal external carotid

artery once that's in there you get your sheath in place and then you get your moment devices a nine French device overall and it has to come up and place this with two markers the proximal or sorry that distal markers in the

proximal external carotid artery that's what this picture shows here the proximal markers in the common carotid artery so there's nothing that's touched that lesion so far in any of the images that I've shown and then that's the moma

device that's one of these particular devices that does proximal protection and and from there you inflate the balloon in the external carotid artery you do a little angiographic test to make sure that there's no branch

proximal branch vessels of the external carotid artery that are filling that balloon is inflated now in this picture once you've done that you can inflate the common carotid artery once you've done that now you can take an O on four

wire of your choice cross the lesion because there's no blood flow going so even if you liberated plaque or debris it's not going to go anywhere it's just gonna sit there stagnant and then with that cross do angioplasty this is what

it looks like in real life you have a balloon approximately you have a balloon distally contrast has been injected it's just sitting there stagnant because there's nowhere for it to go okay once the balloons are inflated you've

temporarily suspends this suspended any blood flow within this vasculature and then as long as you confirm that there's no blood flow then you go ahead and proceed with the intervention you can actually check pressures we do a lot of

pressure side sheath pressure measurements the first part of this is what the aortic pressure and common carotid artery pressures are from our sheath then we've inflated our balloons and the fact that there's even any

waveform is actually representative of the back pressure we're getting and there's actually no more antegrade flow in the common carotid artery once you've put this in position then you can stent this once the stent is in place and you

think you like everything you can post dilated and then once you've post dilated then you deflate your balloon right so you deflate your all this debris that's shown in this third picture is sitting there stagnant

you deflate the external carotid artery balloon first and then your common carotid artery and prior to deflating either the balloons you've aspirated the blood flow 320 CC syringes as I said we filter the contents of the third syringe

to see if there's any debris if there's debris and that third filter and that third syringe that we actually continue to ask for eight more until we have a clean syringe but there's no filter debris out because

that might tell us that there's a lot of debris in this particular column of blood because we don't want to liberate any of that so when do you not want to use this well what if the disease that you're dealing with extends past the

common carotid past the internal carotid into the common carotid this device has to pass through that lesion before it gets into the external carotid artery so this isn't a good device for that or if that eca is occluded so you can't park

that kampf balloon that distal balloon to balloon sheath distally into the external carotid artery so that might not be good either if the patient can't tolerate it as I mentioned that's something that we assess for and you

want to have someone who's got some experience with this is a case that it takes a quite a bit of kind of movement and coordination with with the physician technologists or and co-operators that

patient who experienced the heart attack who had right little quadrant pain after a cardiac catheterization all you like oh so here's the cat scan and what you should appreciate there is in the front of that first image which is the axial

image all right you can see the hematoma that's brewing kind of in the front you notice how all these pictures kind of look the same that's the good part about giving a lecture on bleeding and trauma because they all kind of look the same

so that's the hematoma on the front part of the pelvis and on the on the right image which is more of a coronal like looking at the patient image you can see it right near the right groin you can see that hematoma all right so our next

step was to do an angiogram and this is what the angiogram looks like who wants to volunteer what do they say all right I saw someone raise his hand over here some walk over here what do you think yeah well yes so it is a retro hematoma

would you say describe the angiogram for everybody right where it's at the external iliac down the common femoral looks like there's contrast going up to the left and down to the right probably close to where they accessed yeah

probably but so yeah probably probably too high but the other thing is that's probably a pseudoaneurysm that probably is the evidence that there was a bleed there we're not seeing Frank extrapolation of contrast in a literally

contrast pouring out but we are seeing the effects of an injury to the artery and the constraining of the the remaining normal tissue to hold on to that bleed so the question is what do we want to do no that was very good because

I fooled you it's not always embolization so sorry I lied so in today's world a lot of times when we see this type of pathology we have again relatively new technology available to us again we

could go into that pseudoaneurysm and embolize it and that would be a legitimate treatment but my friend here is right you know this is a great case for a covered stent so we could go in and put a stent right across that area

of injury and stent it so these days looking at coverage stands as an option for patients with arterial injury is a very legitimate option you just have to be able to deliver it has to be the right artery you have to be able to get

the stent where it needs to go we all work with vascular surgeons who are great and they can put these stents and iliacs and aortas but they can't make those turns into livers and kidneys and spleens it's got to be the right artery

this is this is the right artery okay we saw this patient and we said well we could kind of get a micro catheter into that area of injury and embolize it or we could just put a cover sent across it and all go home to have dinner with our

kids so that was option B is what we chose here so this is a great cover stent case okay here's another patient

a what this is a 16 year old who

presented to the GI clinic with a 2-day history of sharp abdominal pain and I know we all think oh my gosh a teenager with abdominal pain how often do we see that it was accompanied by sweats she'd had one episode of non bloody vomiting

decreased oral intake and some diarrhea although she no longer has vomiting and diarrhea denies fever or trauma she does have a history of irritable bowel and chronic constipation and an ovarian cyst rupture so again you have a lot going on

with the abdomen with this kiddo and you know somewhat broad symptoms so on further examination she describes this pain as clearly different from any of her pain associated with IBS and constipation she specifically said it

feels like there is a bubble that is about to burst it was exacerbated by eating coughing and sneezing her she appeared a mild distress but her vital signs were stable and her tenderness was localized to and to the right upper

quadrant with palpation and percussion so the x-ray shows a your object 13 millimeters in length adjacent to the large bowel and liver she was transferred to the emergency department where her pain continued to

intensify they got a CT the IDI doc dug for some more history this goes just you know history history is important keep digging you know as long as you don't know what's going on keep digging and then

finally when talking about food and anything that she could have eaten different they did figure out they had just gotten the grill out about a week ago and the dad had cleaned it real good and they'd been eating barbecue so they

suspected a wire ingestion from the cleaning brush for the grill surgery was consulted there was no signs or symptoms of sepsis or peritonitis so she was admitted for observation this is the CT so you well it's got a narrow good so

you can see and then down here she got to the floor they decided on bowel rest pain control and antibiotics however the pain continued to intensify again feels like a needle poking me she was very specific about the pain where

it was how it felt so surgical removal was recommended and here you see the wire brush or bristle that they removed post-op uneventful discharged after two days with no complications she did continue to be treated for her IBS again

this really just highlights a really common outpatient IDI complaint with a really uncommon diagnosis keep in mind you know we've talked about unwitnessed and kids that you know don't want to tell well this was really you know a

whole different story it was an unknown ingestion take-homes in the last decade there has been a huge increase in reported incidence of this type with wire bristle detailed history preceding the onset of acute and focal

symptoms should prompt physicians to consider unintentional foreign body ingestion and continue digging for that history and

one is a little bit more rare in that

this is a farm body that migrates so migration of the foreign body towards abdominal organ and it is rare but it can and does happen so here we have a 2 year old with a sewing needle ingestion who they followed for three months

without evidence of expulsion but this kid continued to have intermittent abdominal pain fussiness just overall crankiness and the parents decided that they were tired of just following this so they went for a second opinion and

they awry when they got for their second opinion they did indeed get more x-rays and it showed this and I'll show you in a minute they it showed the sewing needle in the lower abdominal quadrant they could not see it by practice Coupee

excuse me but what they did which in as you read along it didn't look like they had done anywhere else was they did a complete hands-on physical exam as well and they could actually palpate by rectal exam and then determined that it

had migrated and maybe you know maybe the migration had occurred over time and was not there when it was looked at earlier so this child ended up with a mini laparotomy do to the concerns of the migration out of

the lumen the needle was found in the meso : he had a significant recovery and three month post procedure follow-up showed no complication here this one's a little harder to see sorry I'm pointing problems it's the long straight can you

guys say it so again our take-home points although they are rare make em migrate outside if not removed early radiological follow-up as well as physical examination is important to identify potential complications and any

foreign body suggested to have migrated outside of the lumen should be considered for removal without delay because of the potential for traumatic complications okay alright she swallowed

in there okay so foreign bodies she put it where so females may present with

abdominal pain and what we think about with females with abdominal pain we think about constipation gastritis UTIs pyelonephritis or renal stones and we but what about a vaginal foreign body four percent of cases of girls with

genital complaints in the emergency room have been found to have a vaginal foreign body those bought foreign bodies include toilet paper hair ties safety pins pencils candy and more common in three to nine year olds of course in

history you would ask about tampon use but these foreign bodies can my great all the way up through the cervix and the signs and symptoms that they present with our vaginal bleeding dysuria hematuria foul odor and lower

abdominal pain okay so when you're looking at diagnosing vaginal foreign bodies x-rays are really less sensitive to objects that are made of wood and plastic you may not see it on an x-ray ultrasound and MRI are sensitive to

differences in water content and inflammation and again ultrasound can provide dynamic imaging so you may be able to see as that object has migrated CT scan is less sensitive especially if the objects been there for a while and

has retained fluid and the clinical picture and the imaging may not exactly reveal the diagnosis so this case is an 11 year old with menarche she has a history of ADHD she's been complaining of abdominal pain 7 on a scale of 1 to

10 and she's had a fever for two days her pain is worse with activity it's improved when she takes a warm bath she's not as active as usual and her Pio in takis is down a little bit but she has no sore throat no congestion no

coughs s pain nausea vomiting diarrhea no hematuria no dysuria no headache and no rash she's had vaginal bleeding for about two days and suspicious of a UTI her abdominal ultrasound she notes some free fluid in the pelvis and they do a

history t'me and find a golf tee found in her uterus which created an abscess and required a washout and dream and I'll show you some of that okay so we could see here you could see the foreign body noted here on CT scan and here's

the piece of the golf tee so you're able to see that I'm glad I'm doing this before lunch instead of after lunch right

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

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

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

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

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

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

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

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

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

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

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

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

interventional radiology and when

here's another patient 62 year old male

patient just a similar case who had head in that cancer again after radiation therapy who experienced some bright red blood while coughing all right here's the CT scan and what I want to draw your attention to a little tough to see I

think I'll let me go up up here point it out with a mouse well I don't have a mouse so I guess not is basically you can see right in the middle of the two lungs kind of right in front of the trachea which is the black

circle alright just go right in front of that up to the top you can see the round white circle which is the brachiocephalic artery and just projecting off the back of that is another little kind of outpouching of

contrast a little nipple coming off of of the brachiocephalic artery that doesn't belong there all right here's the angiogram and it's a little difficult to see but there is a see if I can describe it better to you alright I

think this is actually a video so I'm sorry I don't know the ability to run it unless you can click on it can you guys click on the back up so if you want to look at it again you see the angiogram kind of running and just at the origin

of the brachiocephalic artery which is the first branch of the aortic arch you can see that outpouching of contrasts coming right to the right of that vessel that's a pseudoaneurysm and again we went through the same thought process we

said you know I want to put a covered stent across that but my problem was that we didn't just have the right size that would not block one of the carotid arteries and not extend too far into the aorta so we had no choice but to

consider embolization in this particular case so here's what we did here we actually put a micro catheter if you can just click I think that's a video to the left no I guess not you know what it's okay

what we did for this particular case was we went in from the arm and we put a micro catheter directly into that pseudoaneurysm because we couldn't feel we didn't feel we could put a stent across it so we put the micro catheter

in there we started to put some coils and it actually went further than we thought outside of the artery and here's the post image so you can see our final image you can see the coils that are sitting just adjacent to the

brachiocephalic artery and we preserved good flow there to end this basically

I think it's important to understand what options we have in in treating patients with carotid disease or those

in our practice medical therapy is a mainstay so all these patients regardless that they get t'car carotid stenting or otherwise need to get the best medical therapy there is a role though for each of these surgical

endovascular or a hybrid such as t'car and hopefully you have a better understanding of that option and ultimately if you understand the different techniques then we can apply the best ones depending on the patient's

anatomy or current clinical scenario and and apply that to that patient thank you [Applause]

so on to case number two so this is a three-year-old child and you can see

very clearly he comes to the IDI and he said 24 hours of pain vomiting he's a febrile doesn't look like he's ill at all and in this case the mother recognizes this this is a little stick magnetic stick from a construction type

of toy so so it's one single piece so he's admitted for eight hours of observation just to be conservative they give him IV fluids he begins to improve he's not vomiting he's not having any pain anymore he sent home with

instructions letting them know that this should pass eventually through his stool and two days post-op on follow-up he's back at baseline as far as playing he's eating normally and everything seems fine then on day three he started to

have abdominal pain again and you can see his white blood Khaled cell count went up he's now has a rigid abdomen he's guarding and he's having a lot of pain so they decide to do a surgical consult

okay so now we see this same object right it's moved which is what should happen but there's all this free air now all around it which is different so they begin to do some IV fluid resuscitation and he's emergently taken to the or so

he had two perforations in the jejunum and what had happened was those pieces of magnet were actually covered by this outside covering and that piece that looked like it was one piece was actually five individual magnets so

inside of the GI system the whole covering basically II rotate and then these little magnets some of them stuck together but they started moving and you can see how small they are and so that's why he had those major

complications so this is one situation where we thought that there was just one magnet but in reality they were multiple so in a sense you know this has come up as an issue there's not a lot of big Studies on this because it doesn't

happen that frequently but there was one good review that was done and this was done a few years ago where looked at 80 some odd cases and they used to children's hospitals and they just tried to find out so you know what happens in

terms of the progression of the the ingestion so again 56 percent were males not a surprise that that happened and I want you to note the age so about eight years old you know you kind of start thinking maybe they would know better

but I guess not so the age I never really think too much about age as much I had some really bad ingestions with people that were developmentally normal that were 14 and 15 years old and then the other thing you need to note 67% had

multiple magnets or they had a magnet and also ingested another metallic object so there's a CO ingestion there and those definitely were the situations where they were more likely to have to have some surgical type of procedure

because there were difficulties so 39 not many presented with symptoms and the most common one was abdominal pain and that could be just about anything and so 53% initially did not have operative management and of those 38 of them 37

percent failed it and then they've 47% had an endoscopy or they would have endoscopy and surgery combination so the take home the ingestion think about magnet ingestion a lot of people don't just because the magnets are hidden in a

lot of different toys and it is definitely a problem and that could become emergent so based on that study there's now an algorithm that basically has you be somewhat watchful but to go ahead and basically unless you're a

hundred percent certain assume that there's more than one magnet there and they're more likely to actually take them to have a procedure to remove it another thing to think about there's a few articles about

this about using handheld metal detectors not just for magnets but for other metallic objects and this it can be used in the emergency department so this is just a commercial type of handheld detector and this could be

maybe the parent is refusing to have an x-ray or the child is you know really difficult to get you know any sort of cooperation to do it or it's gonna take a really long time to get this x-ray so a few places have used this to be able

to just do a quick identification and localization of whether or not there's a metal object so I don't know if any of your places are using this but if you do some things to know first of all it is not fda-approved for this purpose but

they are medical grade because they're the same ones that are approved to be used when you go through TSA so it's not going to be harmful so you want to put the child in the center of the room away from metal objects they can't have any

zippers or clasp or anything like that and you want to ask them to put their hands up in this way and then we're wandering from the top all the way down to the pubis looking for any type of sounds okay it's bizarro or bizarro

these are the difficulties that I find

in provision of care and when I talk to some Mike in China they definitely commiserate in this what they were telling me that they feel are some of the issues they have you know simonin limits access to

international based medical products it's it's coming up with protectionism they want their products utilized well unfortunately there is a perception that some of these products that were made originally in China and probably not so

much nowadays been in the past we're not exactly up to the same type of you know Quality Assurance levels as US based or European products and that made it very difficult you know guys would go and they would learn in in the Western

world they'd be doing all these different studies and research reading what we're doing over here and then they wouldn't have access to the products or the procedures to take care of their patients the second thing

it's kind of difficult is CFDA which is Chinese version of the FDA they very much limit access and is very hard to get a product from overseas from Europe or to us into China they require in China in-country clinical studies they

require multiple products to actually evaluate so if you want to send us a where we're merit since I have some of my colleagues from Mary here and you wanted to send a product to get evaluated in China they can hold on to

and take up to three years for evaluation they'll last for about 4 000 units to evaluate and then they reverse-engineer them send them back to you and deny your Chinese your CFDA application their masters reverse

engineering so medical device companies are very hesitant sometimes to send their IP products over because international patents are not really covered in Chinese law so they can't knock these products off and and I think

the hardest thing is that patients are required to pay for products that are not made in country so when you're doing intervention I came across this when I was doing intervention and I was very blessed to be able to get credentials

and do intervention over there I would be doing a mather in her case and we had been ovo stents up which I've just got the you know approval here in the US by the FDA two weeks ago they've been using him there for almost two years but the

problem that we had with that is that the patient would have had to pay for them so I'm doing intervention and Manor you have to stent mather no you cannot just balloon it it's not effective and you'll have residual restenosis I had to

stop the procedure get the patients family and explain what was going on and offer them the stent and if they couldn't pay it we got him off the table and we were done and they ended up there I'm bussing their leg off again and

unfortunately that happened you know on one of my patients in his very fresh string is a Western provider clinician who's used to having the ability to do those things you just can't so it's it was definitely a frustrating thing for

me and certainly frustrating for the Chinese physicians and interventional study are there that know what they need to do but don't have access to the products readily or can't make their patients pay for these things because

they can't afford them and also it's kind of coming from a u.s. perspective we're used to single use of products over there there's no such thing as a you know one use disposable they will restore lies things that were not made

to be rese terrorized and as a Western clinician coming over there that's totally against everything we've ever thought about but you just kind of accept that practice and realize it's what's gonna happen so it's it's kind of

interesting I've saw you know IVC filters that were sterilized and we use after being in patients they do what they got to do and so these interesting those are some of the things you need to remember think about considerations

that's different than your ideologies that you were trained in in Western

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

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

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

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

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

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

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

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

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

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

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

mean this kind of Captain Obvious thing

because everybody runs through that but I do want to say there's no identifying information and it's more than the obvious identifying information like date of birth name these different kinds of things as I think Peter mentioned

before we also had to come up with a policy at UAB because one of my partner's post the case about a 14 year old girl that got trampled by a horse and they had to do a renal artery stent well I even knew who that girl was

because she was the niece of one of my friends I mean you know it doesn't take much when you put in a weird history so if you go back and you look through my feed I rarely ever talk about the patient's X I

ever talk about the patient's age we at least have a 48 to 72-hour moratorium that we have from the time that we did it to the time that that we're allowed to post it and for me I time them out at about once a day so I'm about six weeks

out from when I did the case now at this point too when things are getting posted and I think part of that is especially like in a trauma situation or an emergent situation which you don't want is you just went and talked to the

family about some trauma intervention or whatever you did and then all of a sudden they kind of google you or whatever and then while they're waiting to see their family member and then you post the case that you just did I mean

that's just it's just it's not it's just not kosher and if it was your family member I'm not sure that that's something you'd want them to do so whatever they are you know if your institution is pushing back I mean I

think you can definitely work with some of us who have worked with our institutions about developing guidelines and when I talk about deliver applicable content and one of the biggest things that I learned is when I posted

something it gets liked and gets retweeted post more of those things okay because that's what your followers want right so I learned when I started to put arrows on tweets that those got liked and retweeted a lot more so it's like

okay well I'm gonna start doing that when I posted simpler tweets they got liked and retweeted a lot more so you have to adapt your content towards what people want so if you're posting something that it has no legs no

retweets no legs no retweets every single day you need to adapt your content to what people are what you what they're doing and also when I mean applicable it needs to be somewhat consistent it's great to go out and do

like four cases in a day and then not see you for three weeks that is not a good way to gain a good social media following so like I said I try to do one a day and even if it's routine stuff if it's routine for us it's not routine for

the people that are reading it I can promise you that okay so you know this is just kind of you know you can see a little bit I don't know what I was doing in March of 18 I was probably yes I are right yeah I mean you can kind of see

the the consistency there somewhere between 30 and 40 you know 30 30 and 40 posts and you know so that level of followers kind of goes you know up and down you know kind of according to that so that's just some of the the

background stuff and that's all for free right off the platform so so this is

there a better option this is where a carotid artery stenting was developed over a couple decades ago and this is a

less invasive viable option for treating carotid artery stenosis it was generally started off as a trends ephemeral approach but I'll show you what the new approach is that many of us are involved in it involves the use of

in volunteer tection so it's one of the unique vascular territories where embolic protection is required if you're gonna get Medicare reimbursement for this you have to involvement and bollocky protection if you do without

you can do the procedure but you won't get it you won't get reimbursed and ultimately it's it was proven to show much better outcomes if you use involved protection because even doing the procedure and trying to place the stent

there is some small embolic degree that that that shuttles off and if it happens in the foot you may or may not lose a toe but if it happens in the brain you're gonna lose brain cells and it's gonna be potentially catastrophic so

significant adjunct to the stenting procedure is doing embolic protection and there's two types of embolic protection there's distal and there's proximal I'll walk through each of those with some diagrams here and then anyone

that gets a carotid stent has to be on dual antiplatelet therapy so if they have an allergy they're unable to be on aspirin and plavix they don't get a stent because there's early stent thrombosis that can't occur in these

patients if they don't have that dual antiplatelet therapy so let's go through

her I couldn't help but throw this in

just talking about back device here's a patient that had a iliac occlusion the right it was very difficult to get past the very proximal plaque cap so in this case I did a sub into a we can remember I talked about that out back device it

has like a little L and upside down L that you can use to point into the vessel lumen so what I did was on the healthy side I put in a sauce on me this allows me to know exactly where the arches and where the right coming he

like origin is certainly I don't want to be out backing into the aorta deeply right so this allows me to identify where that location is once I've out backed into the vessel here then I just pre dilated and then stent it up into

the vessels so just sort of interesting case one thing since I am Austin there's a couple of places just you may or may not be aware of this is a Barton Creek it's actually not just a cross town lake not far from here it's about a seven

mile a little Greenbelt inside the city where basically you don't feel like getting your traffic your gaze definitely away from everything this is called the land bridge oops so there's a couple of guys right here

that's about probably about a 20-foot jump there's this guy right here who just took off from that ledge it's about a 40 50 foot drop I did try to get up to that part one time it's about it one foot with ledge so I didn't get the ax

courage to do it now I'm sort of happy because during the summer months it does get just dry up so what I noticed with this is this is about a 10 12 foot depth here this guy's jumped in something's about

12 to 15 deep so it's sort of interesting the the balls enos of these guys some guys are doing backflips out there there is water there so you know if you guys have a chance check it out

if you do happen to find it I'm not encouraging it excited I wanna get sued but if you want to take a jump off have fun all right thank you [Applause]

you know the most common procedures in China this is kind of interesting I was blown away by this when I did the research on this I knew when I would go

into the hospitals and I was all over for I've been to Beijing shanghai nanjing to even the smallest little place is up in northern china and the one thing that blew me away I'm looking at the board and I'm seeing neuro case

after neuro case after neuro case I'm like it got 10 Narrows and and a pic line I'm like it's an interesting interesting Dysport of cases and the reason being is in China they consider diagnostic neuro

so neuro angio to be the primary evaluating factor for any type of neurological issue so you're not getting a CT if you come in with a headache you think you're gonna go get that cat scan now it's generally what not what they do

so you're talking about a case and I'll give you the case matrix of the break-up it's just proportionately high for a neuro very well trained in neuro and most of the guys that are trying to neuro very similar to what dr. well Saad

said a lot of the guys in Africa are trained in France so other neuro interventions have trained in France or lipstick in China and have received European training on that so you know the level of what they're doing some of

the stroke interventions some of the ways they're going after these complex APM's they'll Rob well anything you'll see here in the US so it is quite interesting to see and the second

largest is taste hepatocellular carcinoma is on the rise it's the highest level in the world is found in China and Korea for that matter and there's many reasons why we can go into it some of it is genetic factors and a

lot of societal factors alcohol is a very liberally lie baited in China and there is problems with you know cirrhotic disease and other things that we know could be particular factors for HCC so always found that very

interesting like I said I would go into a hospital and I'll see a PICC line a hemodialysis catheter and then 20 tase's on the board in one day so it is quite interesting how they do it and then biliary intervention stents tips and

then lung ablation you know the highest rates of HCC biliary cancer and lung cancer found in China and once again when we talk about lung cancer what are those contributing factors you're talking about certainly a genetic

component but mostly it's lifestyle factors smoking is prevalent in the US and in you know in Europe and in some areas in Asia we've seen obviously a big reduction in smoking which is fantastic China not so much you don't see that

it's a societal thing for them and unfortunately that has led to the the largest rates of cancer in the world in lung cancer so lung ablation is a big procedure for them over there as well so procedure breakdown this is kind of some

of that breakdown I was telling you about that cerebral procedure is some of the most commonly performed and you're talking about at very large numbers they're doing neuro intervention because they do it for die

Gnostic purposes and I would that kind of blew me away when I found out they do have cast scanners and certainly for trauma and things like that they'll do it but the majority of the stuff if you come in you have headaches you might end

up in the neuro suite so it's quite interesting how they can do that tumor intervention very high like I said you have the highest rates of HCC in the world you're getting cases they do have y9t available and in fact China just

made their largest acquisition ever with the by what you guys know a company they bought surtex there's a Chinese company now it got bought by China now the interesting is they don't currently have a whole lot of

y9t over there but they just opened up some of their own generators so they can actually start producing the white room 90 and I think you'll see probably a increase in those numbers of y9t cases but to date the number one procedure for

them is taste and they do a lot of them you know like I said on average a community hospital setting you might find 15 or 20 cases a day with three interventionalists so compared to what you guys do there's probably not many

people here unless you're working at a major institution that there's nothing but cancer doing 20 cases a day and I promise you're probably not doing it with only two interventionalists so it's amazing how fast and effective they've

gotten at and below therapy and unfortunately it is necessary because of those elevated HCC levels and like I said when we look at some of these things it's I go over there and I'm looking at the board there are very few

cases for you know PICC lines very few the frosted grams very new bread-and-butter abscess training procedures like we do here in the US they are very it's the prevalence is very simple it's neuro it stays and it's

biopsy and those are some kind of the big three for intervention in China and there it's such a large volume you get to learn a lot when you're over there and CLI PA D even though it's more prevalent in China than it is here

because smoking lifestyle factors certainly westernization of the diet in China which occurred since the 1950s and 60s has led to a lot of McDonald's and and fast food and things that weren't currently available prior to 1950s you

see a lot of PA d but it is very undertreated and certainly talking to some of my colleagues like whom are oh you'll get to see a little bit later on with CLI fighters one of the things that's kind of frustrating for them is

that it is so undertreated it's very common to see amputations in China instead of actually doing pipe in percutaneous intervention they normally like to go too far and you see a lot of amputation certainly above

normal so that's something I think as an interventional initiative when we look at these things coming from a Western perspective it's definitely something we need to pursue a little more aggressively but there it's very little

oh well you're talking about two you know two to three percent you know maybe up to six percent or PID cases very very low levels so equipment in equipment in

stamp placement we talked a little bit about it I'm gonna talk to you a little

bit more about it and ideal stance is a straight stance that has a nice smooth curve with a portal vein and a nice smooth curve with a bad igneous end well you don't want is it is a tips that T's the sealing of the hepatic vein okay

that closes it okay and if there's a problem in the future it's very difficult to select okay or impossible to select okay you want it nice and smooth with a patek vein and IVC so you can actually get into it and it actually

has a nice hemodynamic outflow the same thing with the portal thing what you don't want is slamming at the floor of the portal vein and teeing that that floor where where it actually portly occludes your shunts okay or gives you a

hard time selecting the portal vein once you're in the tips in any future tips revisions okay other things you need it nice and straight so you do not want long curves new or torqued or kinks in your tips you

a nice aggressive decompressive tips that is nice and straight and opens up the tips shunt okay we talked a little bit you don't want it you don't want to tee the kind of the ceiling of the of the hepatic vein another problem that we

found out you want that tips stance to extend to the hepatic vein IVC Junction you do not want it to fall short of the paddock vein IVC Junction much okay much is usually a centimeter or centimeter and a half is it is acceptable

the problem with hepatic veins and this is the same pathology as the good old graft dialysis grafts what is the common sites of dialysis graft narrowing at the venous anastomosis why for this reason it's the same pathogenesis veins whether

it's in your arm for analysis whether it's in your liver or anywhere are designed for low flow low turbidity flow of the blood okay if you subject a vein of any type to high turbot high velocity flow it reacts by thickening its walls

it reacts by new intimal hyperplasia so if you put a big shunt which increases volume and increased flow turbidity in that area in that appear again the hepatic vein reacts by causing new into our plays you actually get a narrowing

of the Phatak vein right distal to the to the to the Patek venous end of the shunt so you need to take it all the way to the Big C to the IVC okay how much time do I have half an hour huh 17 minutes okay

Viator stents is one way let's say you don't have a variety or stent many countries you don't have a virus then what's an alternative do a barre covered stem combination you put a wall stent and then put a covered stance on the

inside okay so put a wall stent a good old-fashioned you know oldie but a goodie is is a 1094 okay you just put a ten nine four Wahl cent which is the go to walls down so I go to stand for tips before Viator

and then put a cover sentence inside whatever it is it's a could be a fluency it could be a could be a vibe on and and do that so that's another alternative for tips we talked about an ace tips as a central straight tips and it's not out

and fishing out in the periphery okay this is an occlusion with a wall stance this is why we use think this is why now we use stent grafts this is complete occlusion of the tips we're injecting contrast this is not the coral vein this

is actually the Billy retreat visit ptc okay that's a big Billy leaked into the into the tips okay and that's why we use covered stance I'm gonna move forward on this in early and early and experienced

are in the room here's a case of an 80

year old with a previous mi had a left hand are directing me and it's gonna go for a coronary bypass graft but they want this carotid stenting significant card accenting lesion to be treated first there's the non-invasive blow

through this but there's the lesion had a prior carotid endarterectomy so had that surgery we talked about first but at the proximal and distal ends of that patch has now a stone osis from the surgical fix that's developed so we

don't want to go back in surgically that's a high resolution we want for a transfer Merle approach and from there here's what it looks like an geographically mimics what we saw on the CT scan you can see the the marker and

the external carotid artery on the right that's the distal balloon and then proximally in the common carotid artery and they're noted there and then when you inflate the balloons you can see them inflated in the second image in the

non DSA image that's the external carotid room carotid artery balloon that's very proximal the common carotid balloon is below or obscured by the shoulders and ultimately when you inflate the common carotid balloon you

just have stagnant blood flow then we treat them you can see both balloons now and the external carotid and common carotid in place we have our angioplasty balloon across the lesion and then ultimately a stent and this is what it

looked like before this is what it looks like after and tolerated this quite well and we never had risk of putting the patient for dis Lombok protection or to salamba lusts overall I'm not gonna go over this real

thank you so much for inviting me and to speak at this session so I'm gonna share with you a save a disaster and a save hopefully my disclosures which aren't related so this is a 59 year old female she's lovely with a history of locally advanced pancreatic cancer back in 2016

and and she presented with biliary and gastric outlet obstructions so she underwent scenting so there was a free communication of the biliary system with the GI system she underwent chemo and radiation and actually did really well

and she presents to her local doctor in 2018 with ascites they tap the ascites that's benign and they'll do a workup and she just also happens to have n stage liver disease and cirrhosis due to alcohol abuse in her life so just very

unlucky very unfortunate and the request comes and it's for a paracentesis which you know pretty you know standard she has refractory ascites and because she has refractory ascites tips and this is a problem because the pointer doesn't

work because a her biliary system is in communication with the GI system right so there's lots of bugs sitting in the bile ducts because of all these stents that have opened up the bile duct to list to the duodenum and so you know

like any good individual I usually ask my colleagues you know there's way more smart people in the world than me and and and so I say well what should I do and and you know there was a very loud voice that said do not do a tips you

know there there's no way you should do a tips in this person maybe just put in a tunnel at drainage catheter and then there was well maybe you should do a tips but if you do a tips don't use a Viator don't use a covered stand use a

wall stunt a non-covered stunt because you could have the bacteria that live in the GI tract get on the the PTFE and and you get tip situs which is a disaster and then there was someone who said well you should do a bowel prep you

like make her life miserable and you know give her lots of antibiotics and then you should do a tips and then it's like well what kind of tips and they're like I don't know maybe you should do a covered said no not a covered tonight

and then they're you know and then there was there was a other voice that said just do a tips you know just do the damn tips and go for it so I did it would you know very nice anatomy tips was placed she did well

the next day she has fevers and and her blood cultures come back positive right and you can see in the circle that there's a little bit of low density around the tips in the liver and so they put her on IV antibiotics and then they

got an ultrasound a week later and the tips that occluded and then they got a CT just to prove that the ultrasound actually worked so this really hurt my gosh to rub it in just to rub it in just just to confirm that your tips occlude

it and so you know I feel not so great about myself and particularly because I work in an institution that defined tip seclusion was one of the first people so gene Laberge is one of my colleagues back in the day demonstrated Y tips

occludes and one of the reasons is because it's in communication with the biliary system so bile is very toxic actually and when it gets into the the lining of the tips it causes a thrombosis and when they would go and

open these up they would see green mile or biome components in the in the thrombus so I felt particularly bad and so and then I went back and I looked and I was like you know what the tips is short but it's not short in the way that

it usually is usually it's short at the top and they people don't extend it to the to the outflow of the hepatic vein here I hadn't extended it fully in and it was probably in communication with a bile duct which was also you know living

with lots of bacteria which is why she got you know bacteremia so just because we want to do more imaging cuz you know god forbid you know you got the ultrasound of her they because she was back to remake and

you know that and potentially subject they got an echo just to make sure that she doesn't have endocarditis and they find out that she has a small p fo so what happens when you have a thrombosed tips you go back in there and you do a

tips or vision you line it with a beautiful new stent that you put in appropriately but would you do that when the patient has a shunt going from one side of the heart to the other so going from the right to the left so sort of

similar to that case right and so what do we do so I you know certainly not the smartest person in the room we've demonstrated that so I go and I asked my colleagues and so the loud voice of saying you know I told you this is why

we don't practice this kind of medicine and then there was someone who said why don't we anticoagulate her and I was like are you kidding me like you know do you think a little lovenox is gonna cure this and then the same person who said

we should do a tunnel dialysis tile the tunnel drainage catheter or like a polar X was like how about a poor X in here like thanks man we're kind of late for that what about thrombolysis and then you

know the most important WWJ be deed you guys are you familiar with that no what would Jim Benenati do that's that's that's the most important thing right so so of course you know I called Miami he's you know in a but in a big case you

know comes and helps me out and and I'm like what do I do and you know he's like just just go for it you know I mean there are thirty percent of the people that we see in the world have a efo it's very small and it probably doesn't do

anything but you know I got to tell you I was really nervous I went and I talked to miner our colleagues I made sure that the best guy who was you know available for stroke would be around in case I were to shower emboli I don't even know

what he would do I mean maybe take her and you know thrombolysis you know her like MCA or something I don't know I just wanted him to be around it just made me feel good and then I talked to another one of my favorite advisors

buland Arslan who who also was at UVA and he said why don't you instead of just going in there and mucking around with this clot especially because you have this shunt why don't you just thrown belay sit and then you

know and then see what happens and so here I brought her down EKOS catheter and I dripped a TPA for 24 hours and you know I made her do this with local I didn't give her any sedation because I wanted and it's not so painful and I

just wanted her to be awake so I could make sure that she isn't you took an intervention location you turned it into internal medicine I I did work you know that's that's you know I care right you know we're clinicians and so she was

fine she was very appreciative I had a penumbra the the the Indigo system around the next day in case I needed to go and do some aspiration thrombectomy and what do you know you know the next day it all opened up and you can still

see that the tips is short the uncovered portion which is which is you know past the ring I'm sorry that which is below the ring into the portal vein is not seated well so that was my error and and there was a little bit of clot there so

what I ended up doing is I ended up balloon dilating it placing another Viator and extending it into the portal vein so it's covered so she did very

so what what venous insufficiency is is really leaky valves so if you want to hit the play on that so that's all venous insufficiency that's what we

talked about it's it's leaky valves and so you can see this the valve leaflets there which are paper-thin is allowing blood to go the wrong way if you want to hit play on that one when we looked for valve

insufficiency for sure in the legs we use ultrasound and there's a bunch of different things that we look at an ultrasound you first look if you can augment blood flow so that was that first part we see if it's compressible

to make sure there's not a clot in it that's this part you can see the vein winking at you and then finally we look at valsalva or some type of way to determine if the valves are competent or incompetent and what this figure is

showing is that when a patient valsalva Zoar tenses up their abdominal muscles you see the gray line for the ultrasound crossing the access and going the opposite way all that means is it's got opposite directional flow which you

should not be able to do if your valves work so if your valves work you would not see that ultrasound picture crossing the line here it would just continue right there or would just stop and then flow would start again once you stop fel

salving so that's how we check in a leg but for pelvic venous insufficiency that's kind of hard to ultrasound the deep pelvic veins I could certainly look for varicosities with a an ultrasound of the pelvis but you can't really find the

source of an usually the source veins are the internal iliac veins or the gun at Elaine's and those are tough to ultrasound so secondary evidence of incompetence or leaky valves in those systems is varicosities

and so in the case of pelvic venous insufficiency those varicosities are in the pelvis and you see on the slide here you got varicose veins deep in the pelvis here and here and see some larger ones in that same

area on that CT scan so that'll tell us varicose veins that doesn't necessarily tell you whether the issue is with a gonadal vein or an internal iliac vein it just tells you that there are sequelae of varicosities much like in

the leg you might have varicose veins in the ankle but the problem is really higher up in the leg at this afterno femoral Junction so that gives us secondary evidence but it hasn't really told us the cause of the varicose veins

this is just a CT image that it also may show a large gonadal vein right here so you normally should not see it that big it's right there also secondary evidence that the valve is incompetent but it doesn't really test the valve itself

it's it just gives you the idea that veins enlarge and the valves gonna be leaky this is a cartoon schematic of the

today's objectives I'll start with reviewing hepatocellular carcinoma HCC

and the current treatment options I'll share the protocol inclusion and exclusion criteria and I will discuss the research treatment protocol briefly and next transitioning to research the preparation taken in the department with

staff members for trial lastly I will talk about what's involved intraoperatively from a nursing standpoint so hepatocellular carcinoma HCC is the most common primary liver manely malignancy and is a leading cause

of cancer-related deaths worldwide cirrhosis is a condition in which there is scarring to the liver causing permanent damage chronic medical conditions such as diabetes mellitus and obesity lead to chronic liver disease

obesity is a risk factor to diabetes and diabetes directly affects the liver because of the essential role the liver plays in glucose metabolism both cirrhosis and chronic liver disease remain the most important risk factor

for the development of HCC a which viral hepatitis and excessive alcohol intake are the leading risk factors of cirrhosis non-alcoholic fatty liver disease and non-alcoholic steatohepatitis which is nash our

conditions in which fat builds up in your liver thus having inflammation and liver cell damage along with fat in your liver these are other risk factors for HCC the incidence of HCC will continue to escalate as hepatitis C and obesity

become more prevalent in the United States so unfortunately the diagnosis of HCC is too often made with advanced liver disease when patients have become symptomatic and have some degree of

liver impairment at this late stage there is virtually no effective treatment that would improve survival in addition the morbidity associated with therapies unacceptably high modalities available for HCC screening include both

radiographic tests and serological markers radiological tests commonly used for surveillance include ultra sonography multi-phase CT and MRI with contrast ultrasound has historically been utilized to identify intrahepatic

lesions since the early 1980s both the photograph above shows a cirrhotic liver versus a normal liver there are visible differences in the portal and hepatic veins between the cirrhotic liver when compared to the non cirrhotic liver so

AFP alpha-fetoprotein has been used as a serum marker for the detection of HCC an AFP level of less than 10 is normal for adults an extremely high level of AFP in your blood greater than 500 could be a sign of liver tumors liver function

tests or lfts look at the part of your liver that is not affected by cancer to see how well your liver is working the lfts will be considered for diagnosis and determining the stage of HCC the tests look for levels of certain

substance in your blood such as bilirubin albumin ALP ast alt and GGT despite advances in prevention techniques screening and new technologies in both diagnosis and treatment incidence and mortality

continue to rise so treatment options for HCC can be divided into three categories surgical options non-surgical options and systemic therapy patients are screened diagnosed and treated accordingly of

these three options interventional radiologists offer the non-surgical approach which include trans arterial embolisation percutaneous ethanol injection radiofrequency ablation and microwave ablation so I want to talk

about the child pu classification the child pious core consists of five clinical measures and is used to assess the prognosis of liver disease and cirrhosis including the required strength of treatment and necessity of

liver transplant the child piu score was originally developed in 1973 to predict surgical outcomes in patients presenting with bleeding esophageal varices today it continues to provide a forecast of the increased increasing severity of

your liver disease and you're expected survival rate the Chao few score is determined by scoring five clinical measures of liver disease the five clinical measures are total bilirubin serum albumin prothrombin time ascites

and hepatic encephalopathy once scores are available in each of the five clinical measures all scores are added and the result is a child piu score their interpretation of the clinical measure is as follows so Class A would

be five to six points lease liver disease with one to five year survival weight at 95 percent Class B seven to nine points moderately severe liver disease one to five year survival rate at seventy five percent and Class C ten

to fifteen points most severe liver disease one to five year survival rate at fifty percent so which child pew scores do I our patients fall into for a research with the CPC and the majority of the HCC child pew scores a and B

seven with the survival rate of one to five years for 95% the best outcomes are achieved when patients are carefully selected for each treatment option regardless of the treatment approach

patients with HCC require a multidisciplinary approach to care to ensure optimal outcomes what we refer to as tumor board tumor board are meetings where specialists from surgery medical oncology radiation oncology

interventional radiology and others collaboratively review a patient's condition and determine the best treatment plan through this multidisciplinary approach patients have access to a diverse team of experts

instead of relying on a single opinion each specialty will have unique contributions to ensure optimal long term outcomes for patients with HCC so there are various algorithms for HCC treatment I actually have one on top of

the other there just to show you that if you're interested in the process you can look it up it's there's a few out there all right so how are the patients selected for treatment like I said tumor board and moving on now to the surgical

options there are two surgical options liver resection and liver transplant surgical resection is currently considered to be the definitive treatment for HCC and the only one that offers the prospect of cure or at least

long-term survival however most patients have unresectable disease at presentation because of poor liver function the overall resect ability rate for HCC is only 10 to 25 percent and even among those who undergo surgical

resection with curative intent there is a recurrence rate of it to 80% at five years post resection survival rates are in the range of 80 to 92% at one year sixty-one to 86 three years and 41 to 74 at five years

the most common sight of post resection recurrence is a remaining liver for patients who are not surgically resectable liver transplant is the only other potentially curative option virtually all patients who are

considered for liver transplant are unresectable because of the degree of underlying liver dysfunction rather than tumor extent down staging using local regional therapies can also be used to increase eligibility for orthotopic

liver transplant while on the transplant list patients disease progress and meeting criteria gets complicated so patients on the transplant list are and do get some other therapies

which I will later discuss so we're surgical resection is not possible for poor liver function liver transplant is a treatment of choice prior to 2008 no systemic therapy was available that demonstrated an improvement in survival

with the publication of two randomized placebo-controlled phase 3 trials the oral multi targeted tyrosine kinase inhibitor sorafenib has become the new standard of treatment for advanced HCC with an increased median survival from

seven point nine months and the placebo group to ten point seven months in the treatment group systemic therapy can be difficult to tolerate because of the side effects dose reduction or treatment interruption is often needed

despite the side-effects treatment is recommended and to be continued into a progression of the tumor is demonstrated the majority of diagnosed patients with HCC present with advanced disease oral therapy has taken two pills twice daily

equaling 400 milligrams B ID so interventional radiology it's like surgery only magic so I I always think about this when patients come in and pre-op beam and they think they're having surgery you know it's well a lot

of benefits to ir what we're doing so interventional radiology is where the magic happens and non-surgical approach procedures are performed percutaneous local ablation include ethanol injection and radiofrequency ablation microwave

ablation is utilized both percutaneously and intraoperatively and lastly there is trans arterial embolisation which depending on the embolization agent can either be chemo bland or radioisotopes percutaneous ethanol injection known as

Pei has a long track record and is very effective in destroying HCC tumors that are less than or equal to 2 centimeters in diameter performed under percutaneous ultrasound guidance a needle is placed into the tumor and absolute alcohol is

injected over recent years radiofrequency ablation referred to as RFA has largely replaced Pei at most centres RFA's also performed percutaneously advancing a specially designed electrode into the tumor and

applying radiofrequency energy to generate a zone of thermal destruction that encompasses the tumor and a 1 centimeter margarine surrounding liver RFA is thus preferable to ethanol injection for patients with solitary

tumors 2 to 4 centimeters in size for tumors smaller than 4 centimeters RFA can achieve initial complete response rates of over 90% in microwave ablation MWA microwaves are created from the needle to create small

regionals regions of heat the heat destroy the liver cancer cells RFA and microwave are effective treatment options for patients who might have difficulty with surgery or those whose tumors are less than one and a half inch

in diameter the success rate for completely eliminating small liver tumors is greater than 85% so can I get a show of hands from the audience on who what facilities are doing chemo embolization everybody pretty much are

you guys doing them next to the gentleman yeah okay so this is gonna be a boring review here alright so trans arterial embolisation a minimally invasive procedure performed to restrict to tumors blood supply it is performed

by advancing and angiography catheter into the branches of the hepatic artery supplying the tumor and injecting an agent mixed with orally contrast followed by a cluding agent known as beads the beads which range from 100 to

300 micrometers in diameter are carried by the circulation into the terminal hepatic arterioles where they lodge and include the vessel resulting in the schema tumor necrosis the procedure is done using moderate sedation patients

are monitored for 23 hours or less for pain and post embolization syndrome trans arterial chemo embolization thus is where the chemo therapeutic agent mixed with beads is injected to the tumor

these particles both blocked the blood supply and induced cytotoxicity attacking the tumor in several ways taste is the treatment of choice when the tumor is greater than four centimeters or there are multiple

lesions within the liver taste takes advantage of the fact that while the liver is refused by both the portal vein and the hepatic artery HCC survives its blood supply almost entirely hepatic artery tastes has been shown to

prolong survival in patients with intermediate stage HCC and objective responses were observed in the majority of patients tear trans arterial radioembolisation is a form of catheter directed internal radiation that

delivers small microspheres with Radio isotopes directly into the tumor y9t microspheres are administered and a procedure similar to taste the procedure has been shown to be safe and effective in cirrhotic patients with HCC the side

effects are usually well title tolerated one major advantage of y9t over taste is that it is indicated in the case of portal vein neoplastic thrombosis while taste traditionally has been considered a contraindication all right so there's

helpful and you know many of us use this on the table at the time of the procedure we also look at our own images because it reports are not all that helpful and what you're looking for I don't know duplex ultrasound is what is

the vessel wall look like is it narrowed is it patent are there are there large collateral so you're going to need a lookout for or what's the velocity of flow because as you know as you know you put your

finger over the end of a of a garden hose it's going to increase the velocity of the water that you're shooting at somebody and the flow direction and quality can also be detected so color Doppler imaging often changes from this

kind of smooth the uniform color with laminar flow on the on the right side to one of multi-directional flow with turbulence you'll see colored multiple different colors in the same image spectral Doppler waveforms are also

obtained with with duplex ultrasound so what you're looking for is this is the the picture equivalents of marks noises from earlier which is a triphasic waveform see that the flow goes above the line and then goes back below the

line and then comes you can wholly state that it comes back above the line here that would suggest that it was triphasic or normal and then these often just go above the line and they never go back below the line and these patients if

they're if you're looking at the ultrasound below the level and destruction so we're looking for a return from the image on the right to the image on the left we have specific number criteria that we use as a

determination of whether one we've been successful the numbers are not that important but the ant vanish is a duplex are that it's low-cost and it's highly sensitive but it it's time-consuming and depending on who the operators are that

are actually taking the images and who are the readers are you may or may not find them that helpful and it's less accurate for determining if the vessels completely occluded because they may just not have seen it they may have

missed it so it's operator dependent several papers suggest that we should be this should be our first line imaging study for following up patients after we do an intervention particularly angioplasty alone and if the initial

follow-up is normal we can usually push them out to just clinical follow-up and making sure they have a pulse exam if patients have an abnormal finding then we usually bring them back sooner and get a repeat ultrasound at two to three

months CT a very sensitive and specific

know we're running a bit short on time so I want to briefly just touch about

some techniques with comb beam CT which are very helpful to us there are a lot of reasons why you should use comb beam CT it gives us the the most extensive anatomic understanding of vascular territories and the implications for

that with oncology are extremely valuable because of things like margin like we discussed here's an example of a patient who had a high AF P and their bloodstream which tells us that they have a cancer in her liver we can't see

it on the CT there but if you do a cone beam CT it stands up quite nicely why because you're giving levels of contrast that if you were to give them through a peripheral IV it would be toxic to the patient but when you're infusing into a

segment the body tolerates at the problem so patient preparation anxa lysis is key you have them exhale above three seconds prior to that there's a lot of change to how we're doing this people who are introducing radial access

power injection anywhere from about 50 to even sometimes thirty to a hundred percent contrast depends on what phase you're imaging we have a Animoto power injector that allows us to slide what contrast concentration we like a lot of

times people just rely on 30% and do their whole the case with that some people do a hundred percent image quality this is what it looks like when someone's breathing this is very difficult to tell if there's complete

lesion enhancement so if you do your comb beam CT know it looks like this this is trying to coach the patient and try to get them to hold still and then this is the patient after coaching which looks like this so you can tell that you

have a missing portion of the lesion and you have to treat into another segment what about when you're doing an angio and you do a cone beam CT NIT looks like this this is what insufficient counts looks like on comb beam so when you see

these sort of Shell station lines that are going all over the screen you have to raise dose usually in larger patients but this is you know you either slow down the acquisition speed of your comb beam or

you raise dose this is what it looks like after we gave it a higher dose protocol it really changes everything those lines are still there but they're much smaller how do you know if you have enhancement or a narrow artifact you can

repeat with non-contrast CT and give the patient glucagon and you can find the small very these small arteries that pick off the left that commonly profuse the stomach the right gastric artery you can use your comb beam CT to find

non-target evaluation even when your angio doesn't suggest it so this is a patient they have recurrent HCC we didn't angio from here those arteries down there where those coils were looked funny even though the patient was

quote-unquote coiled off we did a comb beam CT and that little squiggly C shape structures that duodenum that's contrast going in it this would be probably a lethal event for the patient or certainly would require surgery if you

treated that much with y9t reposition the catheter deeper towards the lesion and you can repeat your comb beam CT and see that you don't have an hands minh sometimes you have these little accessory left gastric artery this is

where we really need your help you know a lot of times everyone's focused and I think the more eyes the better for these kind of things but we're looking for these little tiny vessels that sometimes hop out of the liver and back into the

stomach or up into the esophagus there's a very very small right gastric artery in this picture here this patient post hepatectomy that rides along the inferior surface of the liver it's a little curly cube so and this is a small

esophageal branch so when you do comb beam TT this is what the stomach looks like when it enhances and this is what the esophagus looks like when it enhances you can do non contrast comb beam CTS to confirm ablation so you have

a lesion this is the comb beam CT for enhancement you treat with your embolic and this is a post to determine that you've had completely shin coverage and you can see how that correlates a response so the last thing we're going

60s year old patient with afib who fell and presented with abdominal pain and bruising in their anterior abdominal

wall for whatever reason we see a lot of these patients who come in with kind of bruising after they fall on their abdomen here you can see why hopefully you can see the big hematoma and the anterior abdominal wall so you can

imagine what this patient look like they have this kind of you know ball sized thing under their abdominal wall all right here's our angiogram in this particular case we went into the inferior epigastric artery which kind of

runs up from the pelvis up along the anterior abdominal wall you can see how small it is we were able to get a micro catheter in there and just in the middle just to the left of the middle of the picture you can see that kind of black

your circle that's again a pseudoaneurysm arising from the branch of the inferior epigastric artery and boom we can go in and coil it all right so that's what that looks like so now all of you kind of maybe I used to

sitting in the background we'll know when you're getting called in for these patients this is the type of pathology that we're looking at on CT and on angiography all right another patient 68 year old

now other causes this is a little bit different different scenario here but it's not always just as simple as all

there's leaky valves in the gonadal vein that are causing these symptoms this is 38 year old Lafleur extremity swelling presented to our vein clinic has evolved our varicosities once you start to discuss other symptoms she does have

pelvic pain happiness so we're concerned about about pelvic congestion and I'll mention here that if I hear someone with exactly the classic symptoms I won't necessarily get a CT scan or an MRI because again that'll give me secondary

evidence and it won't tell me whether the veins are actually incompetent or not and so you know I have a discussion with the patient and if they are deathly afraid of having a procedure and don't want to have a catheter that goes

through the heart to evaluate veins then we get cross-sectional imaging and we'll look for secondary evidence if we have the secondary evidence then sometimes those patients feel more comfortable going through a procedure some patients

on the other hand will say well if it's not really gonna tell me whether the veins incompetent or not why don't we just do the vena Graham and we'll get the the definite answer whether there's incompetence or not and you'll be able

to treat it at the same time so in this case we did get imaging she wanted to take a look and it was you know shame on me because it's it's a good thing we did because this is not the typical case for pelvic venous congestion what we found

is evidence of mather nur and so mather nur is compression of the left common iliac vein by the right common iliac artery and what that can do is cause back up of pressure you'll see her huge verax here and here for you guys

huge verax in that same spot and so this lady has symptoms of pelvic venous congestion but it's not because of valvular incompetence it's because of venous outflow obstruction so Mather 'nor like I mentioned is compression of

that left common iliac vein from the right common iliac artery as shown here and if you remember on the cartoon slide for pelvic congestion I'm showing a dilated gonna delve a non the left here but in this case we have obstruction of

the common iliac vein that's causing back up of pressure the blood wants to sort of decompress itself or flow elsewhere and so it backed up into the internal iliac veins and are causing her symptoms along with her of all of our

varicosities and just a slide describing everything i just said so i don't think we have to reiterate that the treatments could you go back one on that I think I did skip over that treatments from a thern er really are also endovascular

it's really basically treating that that compression portion and decompressing the the pelvic system and so here's our vena Graham you can see that huge verax down at the bottom and an occluded iliac vein so classic Mather nur but causing

that pelvic varicosity and the pelvic congestion see huge pelvic laterals in pelvic varicosities once we were able to catheterize through and stent you see no more varicosity because it doesn't have to flow that way it flows through the

way that that it was intended through the iliac vein once it's open she came back to clinic a week later significant improvement in symptoms did not treat any of the gonadal veins this was just a venous obstruction causing the increased

pressure and symptoms of pelvic vein congestion how good how good are we at

so we kind of had a bunch of portal vein cases I think we'll stick with that theme and this is a 53 year old woman who presented to the emergency room with severe abdominal pain about three hours after she ate lunch she had a ruin why two weeks prior the medications were

really non-contributory and she had a high lactic acid so she they won her a tan on consi t scan and this is you can see back on the date which is two years ago or a year and a half ago we're still seeing her now and follow-up and there

was a suggestion that the portal vein was thrombosed even on the non con scan so we went ahead and got a duplex and actually the ER got one and confirmed that portal vein was occluded so they consulted us and we had this kind of

debate about what the next step might be and so we decided well like all these patients we'll put her on some anticoagulation and see how she does her pain improved and her lactate normalized but two days later when she tried to eat

a little bit of food she became severely symptomatic although her lactate remain normal she actually became hypotensive had severe abdominal pain and realized that she couldn't eat anything so then the question comes what do you do for

this we did get an MRA and you can see if there's extensive portal vein thrombus coming through the entire portal vein extending into the smv so what do we do here in the decision this is something that we do a good bit of

but these cases can get a little complicated we decided that would make a would make an attempt to thrombolysis with low-dose lytx the problem is she's only two weeks out of a major abdominal surgery but she did have recurrent

anorexia and significant pain we talked about trying to do this mechanically and I'd be interested to hear from our panel later but primary mechanical portal vein thrombus to me is oftentimes hard to establish really good flow based on our

prior results we felt we need some thrombolysis so we started her decided to access the portal vein trance of Pataca lee and you can see this large amount of clot we see some meds and tera collaterals later i'll show you the SMB

and and so we have a wire we have a wide get a wire in put a catheter in and here we are coming down and essentially decide to try a little bit of TPA and a moderate dose and we went this was late in the afternoon so we figured it would

just go for about ten or twelve hours and see what happened she returned to the IRS suite the following day for a lysis check and at that what we normally do in these cases is is and she likes a good bit but you can see there's still

not much intrahepatic flow and there's a lot of clots still present it's a little hard to catheterize her portal vein here we are going down in the SMB there's a stenosis there I'm not sure if that's secondary to her surgery but there's a

relatively tight stenosis there so we balloon that and then given the persistent clot burden we decide to create a tips to help her along so here we are coming transit paddock we have a little bit of open portal vein still not

great flow in the portal vein but we're able to pass a needle we have a catheter there so we can O pacify and and pass a needle in and here we are creating the tips in this particular situation we decide to create a small tips not use a

covered stent decide to use a bare metal stent and make it small with the hope that maybe it'll thrombosed in time we wouldn't have to deal with the long-term problems with having a shunt but we could restore flow and let that vein

remodel so now we're into the second day and this is you know we do this intermittently but for us this is not something most of the patients we can manage with anticoagulation so we do this tips but again the problem here is

a still significant clot in the portal vein and even with the tips we're not seeing much intrahepatic flow so we use some smart stance and we think we could do it with one we kind of miss align it so we

end up with the second one the trick Zieve taught me which is never to do it right the first time joking xiv and these are post tips and yo still not a lot of great flow in the portal vein in the smv

and really no intrahepatic flow so the question is do we leave that where do we go from here so at this point through our transit pata catheter we can pass an aspiration catheter and we can do this mechanical

aspiration of the right and left lobes you see us here vacuuming using this is with the Indigo system and we can go down the smv and do that this is a clot that we pull out after lysis that we still have still a lot of clot and now

when we do this run you see that s MV is open we're filling the right and left portal vein and we're able to open things up and and keep the the tips you see is small but it's enough I think to promote flow and with that much clot now

gone with that excellent flow we're not too worried about whether this tips goes down we coil our tract on the way out continue our own happened and then trance it kind of transfer over to anti platelets advanced or diet she does

pretty well she comes back for follow-up and the tips are still there it's open her portal vein remains widely Peyton she does have one year follow-up actually a year and a half out but here's her CT the tip shuts down the

portal vein stays widely Peyton the splenic vein widely Peyton she has a big hematoma here from our procedure unfortunately our diagnostic colleagues don't look at any of her old films and call that a tumor tell her that she

probably has a new HCC she panics unbeknownst to us even though we're following her she's in our office she ends up seeing an oncologist he says wait that doesn't seem to make sense he comes back to us this is 11 3 so

remember we did the procedure in 7 so this is five months later at the one year fault that hematoma is completely resolved and she's doing great asymptomatic so yeah the scope will effect right that's exactly right so so

in summary this is it's an interesting case a bit extreme that we often don't do these interventions but when we do I think creating the tips helps us here I think just having the tips alone wasn't going to be enough to remodel so we went

ahead and did the aspiration with it and in this case despite having a hematoma and all shams up resolved and she's a little bit of normal life now and we're still following up so thank you he's

quick I did want to mention t-carr briefly and try to get you guys closer to back on time this is a hybrid procedure this is combining the surgical procedure we talked about first and carotid stenting it takes combined

carotid exposure at the base of the clavicle or just above the clavicle and reverses blood flow just like we talked about but tastes slightly different technique or approach to doing this and then you put the stent in from a drug

carotid access here's the components of the device right up by the neck there is where the incision is made just above the clavicle and you have this sheet that's about eight French in size that only goes in about us to 2 cm or 1 and a

half cm overall into the vessel and then that sheath is sutured to the the chest wall and then it's got a side arm that goes what's labeled number six here is this flow reversal urn enroute neuroprotection kit it reverses the

blood flow and then you get a femoral sheath in the vein right in the common femoral vein and you reverse the blood flow so this is a case a picture from our institution up on the right is the patient's neck and that's the carotid

exposure and the initial sheath is in place so the sidearm of that sheath is the enroute protection system which is going up up at the top of the image there we're gonna back bleed that let that sidearm of that sheath continue to

bleed up to the very top and then connect that to the common femoral venous sheet that we have in place there's a stepwise of that and then ultimately what we see at the end of the procedure is that filter inside that

little canister can be interrogated after and you can see the debris this is in the box D here on the bottom left the debris that we captured during the flow reversal and this is a what we call a passive and then active flow reversal

system so once the system is in place the direct exposure carotid sheath in place the flow controller and AV shunt in place you see the direction of blood flow so now all that blood flow in that common carotid artery is going reverse

direction and so when you place a sheath or wire and and ultimately through that sheath up by the carotid artery there's no risk for distal embolization because everything is flowing in Reverse here's a couple

case examples ferns from our institution this is a patient who had a symptomatic critical greater than 90% stenosis has tandems to nose he's so one proximal at the origin and one a little bit more distal we you can see the little

retractors down at the base of the image there in the sheath that's essentially the extent of the sheath from the bottom of that image into the vessel only about a cm or two post angioplasty instant patient tolerated that quite well here's

another 71 year-old asymptomatic patient greater than 90% stenosis pretty calcified lesion a little more extensive than maybe with the CT shows there's the angiography and then ultimately a post stent placement using the embolic

protection device and overall the trials have shown good good safety met profile overall compared to carotid surgery so it's a minimum minimal exposure not nearly as large the risk of stroke is less because you're not mucking around

up there you're using the best of a low profile system with flow reversal albeit with a mini surgical exposure overall we've actually have an abstract or post trip this year's meeting this is just a snapshot of that you can check it out

this is our one year experience we've had comparable low complication rates overall in our experience so in summary

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

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

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

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

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

my last case here you have a 54 year old patient recent case who had head and neck cancer who presents with severe bleeding from a tracheostomy alright for some bizarre reason we had two of these

in like a week all right kind of crazy so here's the CT scan you can see the asymmetry of the soft tissue this is a patient who had had a neck cancer was irradiated and hopefully what you can notice on the

right side of the screen is the the large white circles of contrast which really don't belong there they were considered to be pseudo aneurysms arising from the carotid artery all right that's evidence of a bleed he was

bleeding out of his tracheostomy site so here's a CTA I think the better image is the image on the right side of the screen the sagittal image and you can see the carotid artery coming up from the bottom and you can see that round

circle coming off of the carotid artery you guys see that so here's the angiogram all that stuff that is to the right to the you know kind of posterior to the right of the screen there it doesn't belong there that's just

contrast that's exiting the carotid artery this is a carotid blowout we'll call it okay just that word sounds bad all right so that's bad so another question right what do you want to do here

I think embolization is reasonable but probably not the thing we can do the fastest to present a patient to treat a patient is bleeding out of the tracheostomy site so in this particular case this is a great covered stent case

alright and here's what it looked like after so we can go right up and just literally a cover sent right across the origin of that pseudoaneurysm and address the patient's bleeding alright

possible even though the you know strictures actually most likely are related to the malignant frequently in large centers like the Asura actually we see more benign strictures and malignant

strictures mainly because of the post-operative and perioperative complications so strictly speaking the incidence of reduced riches is actually flipped sometimes though we do actually have to help and some more patients now

particularly in the GI Sims I think in the ten last ten years GI now places metal stents almost routinely there's almost there are people still placing skinny in those things are two plastic calibers things

but the advent of retrievable removable metal stents has really changed and so now we will place dancing much frequently in that the wall stent is actually the pre derivative of the wall flex which is the Justin that can be

removed it's got a little barb that removes it and it's what they will do is retrograde put these up and then six weeks later or even up to nine months go in and retrieve it and pull them out completely so they certainly and the

number of build with stains placement in G and IR is reduced somewhat because how aggressive gr has become but certainly will place these and particularly patients who are in the palliative stages of care and although these

applications we've used in many other ways so your goal is to get the same team this just happens to be a patient with unresectable head of pancreas cancer you can see the obstruction in the distal CBD just below the cystic

duct there's non pacified area you can see on the calendar gram as well as the celiac artery gram you can see how the portal vein sensor strictures of his patients unresectable will go in there in place

that metal stent you first place your guide why follow that up with a stent that cross bridges from open to open and open this up and we use stands between eight and ten millimeters in diameter and nowadays even covering the

cystic duct is not such a big deal and nowadays cupboards things are probably more in favor now even though the data the data actually doesn't support covering over uncovered and the data for both is actually extremely marked be

similar and it's not compelling and because of the price difference I think visit again a probably a swing back to I'm not standing every CPD stains with covered stands but no question at least from operators point of view in my point

of view it makes whole wholehearted sense to allow the tumor no interest disease to grow through but yet the outcome is still not clear that it's a favorable and cost-effective to do covered stains entirely and we actually

will place up to three drains sometimes you have these complex cancer patients with multiple strictures where almost all the segments are excluding in a extremely sick or they need their bilirubin's to come down for four to be

eligible for cut medical oncology chemotherapy and this is the selling of metastatic colorectal cancer and so that will put three up to three tubes in the right lobe before will give up and say that there's not much more decompression

we can achieve so four tiers is that probably the maximum will place in for multiple site so like I said you know malignant brutally strictures and this data and I'm not going to because it's sort of a moving target

when Gore came with the first covered stand purely because of the fabric that they have gore-tex like what's under jacket and clothing and was interesting it's one of the most improbable fabrics and the reasons why Bill Lewis stands

accrued is not so much that it's overgrowth of tumor but the in growth of bio and in growth of bacteria actually will cause a non-covered stain suit include earlier so the advent of gore and making a stent that made a big

difference and it's covered same it does to change quickly the ease at which patients could be stent in the new system so when they came on the market was really helpful and there's just example of how you can go from occlusion

all the way to having natural passage about now back into the small bar and the utility and the importance of bile salts power fluid in your GI tract is critical for absorption in almost all your metabolic

function so having this drain out externally is really not advisable so getting a natural pathway flow of bio into the GI system is extremely important but I believe strictures and

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