Peripheral Artery Disease, Dissection (Iatrogenic) | Stenting | 60 | Female
Peripheral Artery Disease, Dissection (Iatrogenic) | Stenting | 60 | Female
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more often it's [INAUDIBLE] but we try to do an attempt towards initially thrombolyse after that as necessary that's- >> So go to day one I do it's set up a number on day two,

[INAUDIBLE] on day one get as much as you can out and then go. >> The longer that it takes because that isn't like that overnight so far leukemia, we don't know when that opens the thrombolysis, you're more likely to get a compartment from down the road, so

the way we look at it is that we gonna try to eliminate that [INAUDIBLE] as much as possible plus [INAUDIBLE] compartments involved. If we have a tool that can kinda [INAUDIBLE] >> I just think the whisk, the compartments in there just happen so rarely that but I understand your thought.

I'm stack with the same decision all the time. >> What would you use on this [INAUDIBLE] you would use like six I go big yeah, I definitely go big, now that we have the six and eight we go big. >> I agree.

>> On my last case 60 year old woman fully controlled hypertension referred by a ration medicine physician, she's on four medications you can see a very tight renal artery on the CTA [BLANK_AUDIO] She has a lot of calcification sevil accent that renal din't look

very calcified. During the treatment you see here I got [UNKNOWN] you see a very tight legion of renal artery and there's basically using a guide calf even one for a wire and we went ahead and positioned 5 mm stent in the origin of that renal. Dilated that and this is what we got.

I can tell you when we dilated the lesion their was a audible rip complaint from the patient. Audible complaint from the patient. Very painful and this is what we got. Any thought guys. And the bisection.

Yeah so basically looks like dissection at the end of the stent. I think it's very important if you have any questions at all. Do an oblete, this is the run. Looks as though the flow is going nicely so it's good flow so it maybe a type A dissection. But looks like a dissection.

We did an oblique and this is what we are getting here. Okay ugly looking thing. She is having pain. >> So you gotta stent that. >> >> Blood pressure is up,

now what do you do? We put a 5 mm stent here. >> I tell the fellow not to pull the wire. >> The wire is key here. So we had a 6 mm atrium, we don't have a 5 mm atrium So what do

you do here. >> [INAUDIBLE] >> You think their is a perforation their, >> I don't know it just look ugly right? >> Maybe I would have probably gone in with the micro regular express

stent maybe a four, four and a half five something like that and just lightly taken it up and going to the distal aspect of the deception and try to get out of their. >> Okay just gonna show this case quickly then second we use a 4 mm drug alluding stent. That was our result.

Okay on the table she is still having pain, blood pressure goes to 200. A combium CT which I don't have the other child of little bit of haemorrhage around the artery but not, basically it was a perinefric.

And patient was doing well so we basically took her off the table. We repeated a CT a few hours later. This is what the CT showed. Basically, there's all this perinephric fluid around the kidney. You can see the kidney has some contrastal limit so wash-out isn't great.

You can see the stent we gave from contrast good enhancement of the entire kidney. There as you can see, your stent's in place. Patient was actually the better overnight, uneventful.

The next morning the blood pressure was much better. Her pain was much better and she was discharged without much problem.

This you can actually apply these principles you can actually apply to all visceral aneurysms, especially all branches coming out of the celiac axis.

You can do that with the spleen, you can do that with the hepatic artery, for example. So here you've got a splenic artery aneurysm. Yeah. So ideally, what you wanna do with a splenic artery aneurysm is to actually exclude the aneurysm itself while

maintaining maximum flow to the spleen so you don't kill the spleen, okay? The best approach to that, if you can do that, which is not common, actually quite rare, is to actually put a stint graft across the splenic artery, excluding the aneurysm itself,

and letting it thrombose. That's the ideal situation, which is the rare situation. Rarely you can actually do that. This is more common with older people, middle-age to older people. It is also more common with women,

in childbearing or later stages in life age. With age, our splenic artery actually toils and turns more and more, it actually becomes more and more redundant and ectatic, and becomes more coiled. And it's more common to find coiling and difficult anatomy with women as well.

Theories behind that is pregnancies, estrogen, being kind of a relaxant to muscles, and actually causes more ectasia to the splenic artery. So the older you are, the more likely-- the patient is a woman, the more likely there would be actually tortuosities and this makes it very difficult to

put a stiff platform up there for a stint graft to actually cross over and actually purely exclude the aneurysm and maintaining full flow to the spleen

in that case. The next subject, which is splenic steal syndrome, which is a very complex subject.

Splenic steal syndrome, or NOHAH, that's non-exclusive hepatic artery hyperprofusion basically means that the hepatic artery's open, but there's slow flow in it, so it's not anatomical. This is a hemodynamic problem. It is not an anatomical defect.

It's not a thrombosis, it's not an aneurysm, it is not a stricture, it is not a kink. The artery is a wide open pump, but flow is going through it very slowly. The idea on this is to go as proximal as possible and is to impede flow, slow down the flow,

not necessarily shut it off, but slow down the flow significantly. Go proximal as possible to allow collaterals to keep the spleen alive. It is not a splenic artery embolization where you use particles.

So as you all know, there's many reasons for delays and I'll get to the details of the reasons for delays in our department. There's always lab delays, where patients show up with no labs

or patients have labs that aren't acceptable, leading to delays or cancellation. You have delays in consenting. Patients are not fully clinically optimized to proceed with such procedures. There's always anesthesia.

Nursing care, sometimes we don't have enough staff to do certain procedures. There's always a problem with equipment. Sometimes the physicians are unavailable or they're late. We also have patients' arrival, coming in late because they're not, basically not fully prepared.

So, as you all know, IR is basically, or IR delays are really due to a lot of human and system factors. Our current pre-procedure workflow in IR consists of many steps. Basically, these steps present for

opportunities for delays or cancellations. So one of the weaknesses that we had initially in City of Hope pre-procedure process is we didn't have one. We didn't have a pre-procedure standardized communication procedure process. So a lot of the members of our team assume that

the key steps in the workflow process has been executed without any form of verification. So with that, we had delays that contributed from multiple factors. So in the beginning of the project, I went around to different disciplines of the IR team

to basically figure out what are causing our delays. And basically, we came up with four themes. People, process and policy, equipment, and environment. As you can see, under people, there's some poor role definition among healthcare staff. That basically means that we have

one or two healthcare staff doing the same thing. So that creates a lot of confusion. Poor communication, as far as process and policies, there's always a problem with scheduling. We don't have a standardized data process collection and our workflow process wasn't standardized.

There's always equipment failure that causes delays. And as far as an environment, limited educational activities or really the lack of understanding of the impact of delays. But for the purpose of this project, I really wanted to focus on a couple of things. Because I can't, obviously, fix the whole problem.

So I wanted to focus down on improving our communication and basically standardize our workflow process and improving our data collection process.

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