>> So next case is a 65 year old male claudicant. Again, here's something that we see every day. Distal SFA to above-knee pop occlusion, chronic, recanalized with a catheter and wire,
placed a self-expanding non-covered stent. And he did great until four days later. He presents back with a cold leg and so again repeat left lower extremity arteriogram, demonstrates here like a shelf-like filling defect in the mid SFA and an occlusion just beyond there and reconstitution distally beyond the stent.
And so what do you guys think about next steps here? >> What stents are they using? [LAUGH] >> I think he knows our proteges. >> [LAUGH] >> I find myself at this point almost never use a bare-metal
stent in the femoral-popliteal segment. Because either you're using a specialty stent like a Supera or a PTX or more often these days is avoid stenting all together. >> Mm-hm. DCBs >> So I don't dare put a regular old bare-metal stent in the
SFA. >> [INAUDIBLE] drug-eluting balloons? >> Drug-eluting balloons or is it drug-eluting stents? >> Yeah- >> And maybe sometimes a covered stent in a long case.
>> Our practice is in a lot of smaller community hospitals who're trying to fight the battle to get some of the more advanced technologies, and it's an uphill one. But we're working towards that certainly. So for this case we ended up going with Ekos again. >> Did you consider just doing mechanical?
>> Again this is one given to me by one of my colleagues, but that's certainly something to think about. It's so fresh, you could just- >> What I would do in this case is I would put a filter below it,
A-Jet through the stent. >> Mm-hm. >> And in most cases I'd anticipate to be done, pretty quickly. >> Wow. >> [INAUDIBLE]
>> A Spider like a-. >> [COUGH] So in those cases, how often do you see the Spider having caught material? >> Often. >>Often? Okay.
All right. Yeah, I've seen The AngioJet throw clot distally quite frequently. So I'm kinda wary of about using the AngioJet in the arterial fields but- >> Yeah.
What I like to use is one of the Carmody/g devices. I use the 5 French Monorail device which tapers to an 014. So you don't have a situation where you're driving and 035 catheter over a 014 filter wire. So I used the 5 French Spireflag. It still has pretty good suction and tapers to that, so I think that reduces the snow-ploughing
effect that you might have. >> So this is after 24 hours of thrombolysis. You can see there's still residual thrombus throughout the stented portions. So we like to just proceed to another round of thrombolysis. Again you could go in there and try to do suction thrombectomy or
maybe AngioJet as well. And then this is the following day. You still see persistent shelf-like filling defect proximally and here, I think you that have several options.
You can maybe continue doing thrombolysis, although this is now two days into it, you could try aspiration thrombectomy or rheolytic with AngioJet, or try ballooning it. I don't know, what do you guys think about- >> At that point I might
consider a covered stent. >> Yeah. Viabahn's probably a good option there. >> Right. So that's exactly what we did. So we placed Viabahn over a Spider distal embolic protection device
and you can see here that the vessel looks great but the Spider is filled with some embolic material. And when we went to and try to recapture the Spider, it was so filled that we were unable to get it into the catheter. So instead of dragging it all the way back into the sheath,
we ended up putting a 5 French catheter into the basket and aspirating the material and once we did that it was able to be recaptured and looked - >> The other thing you can do is try and pull into a sheath
>> Like unless you're gonna drag it all the way back through the- >> No, you put a long sheath down. >> A long sheath. >> For example you take one of those tubular sheaths which has a dilator. So here you have a six sheath,
you can put a four sheath through that. Take it all the way down to the Spider and pull it into that. >> Oh, put it in your six french sheath. >> Right. >> Got you.
>> And then chances are you can get it out through that. >> Oh that's good- >> The other thing you can do is just pull the whole thing out. I mean the way this works is once you stitch the back end, that
top kinda narrows down. So most likely if you pull everything out, you're not gonna loose emboli. But you loose access. >> Hopefully you've done- >> [INAUDIBLE]
>> You watch it but I don't think that would happen. Cause once the top get stitched down it should catch, yeah. >> So this is, as everyone understands, this is an important point Dan's making. You don't have to retrieve the Spider with it's prescribed retriever
device. And so - >> Yeah. >> It is important when the filter is overwhelmed to use some other techniques to get it back. >> Usually, I'm able to get it with a 5 French catheter but it was
not able to be pulled out using that. So here's another case. This is a lady with - >> I'm sorry. Did you, the day after thrombosis of your stents, which otherwise looked fine two days after, did you check for Plavix resistance [INAUDIBLE]
>> Yeah, I think we load them with Plavix and gave them a prescription but I think this guy may or may not have been taking his antiplatelet therapy. So I've seen that several times before as well. >> I'm just curious [INAUDIBLE]
standard. They're in the room to check to see if someone's been taking their Plavix or if they [INAUDIBLE] >> Mm-hm. >> I've heard like up to 20%, 30% of people will be resistant
to Plavix. >> Mm-hm. >> A couple of my patients says I've had issues. [INAUDIBLE] I think that's something you should be doing more or so I mean obviously when someone stent thrombosis to the leg and have a stroke or die or have a heart attack and die. None-the-less
it's aggregating to have to go after you've had to work on this guy [INAUDIBLE] >> Right. >> I've had the same experiences where I have done it. But usually it's as a reaction to something that happens and not routinely. And then I put patients on something else if they're positive. But yeah maybe we should be doing it on everyone.
But then of course what do you do then? Put half those presents on Brilinta? Much more expensive. [BLANK_AUDIO]
So, case one, this is a 61 year old female claudicant, half block claudication, standard issue. Here this is a left lower extremity arteriogram which demonstrates mild stenosis here in the proximal CFA. There's a focal stenosis in a proximal SFA and then occlusion distally with reconstitution of the distal SFA above-knee popliteal
artery. And then the run-off looks decent, two-vessel runoff. So we do our standard thing here. We heparinized her with 4,000. She's pretty much like a normal sized female, whatever that means.
We heparinized her with our standard dose of 4,000 units of heparin recanalized the occlusion with a crossing catheter and then placed a column of self-expanding non-covered stents. And you can see here is our initial run showing recanalization of the included segment and you can see we just,
we're a little bit short on the origin here but it looks pretty good. Next round here shows more distally in the thigh. It looks pretty good, a little bit of narrowing here just beyond the stent column.
So we're getting ready to fix the top of the stent column at the origin and she started having some issues, some pain in her leg and took another shot of the distal thigh. And you can see we have acute thrombosis of the entire stent column all the way down into the above-knee pop.
So at this point we've got on the table thrombosis. And the question is what do we do here? Do you have any thoughts. I just gonna say Dan. Either one of you guys can answer. [LAUGH]
>> I don't know if I [COUGH] I don't know if I witnessed exactly, so I would worry that there's some unnoticed technical problem. Like was there a dissection that you didn't see or something like that. So that's the bit I would review the images and make sure I'm not missing
something. >> Mm-hm>> [COUGH] >> [INAUDIBLE] >> Mm-hm. >> So what do you do?
You get Angiomax? >> Yeah. >> So what we did here is we didn't give any more heparin but we did proceed to overnight thrombolysis with an Ekos catheter here, brought her back. Overnight she had significant amount of pain requiring a PCA.
But notably she had no changes in her sensation and her motor function. And that's obviously something that we all have to be really cognizant of, how these patients do overnight. You constantly get phone calls, I do, about patients having pain during lysis.
And as long as they don't have any significant changes in their sensation, especially motor function, then I just let them ride it out. And obviously if they started having motor loss, that's kinda when
I start getting more worried. And we have to have good communication with our surgical colleagues and make sure that everyone's on the same page with what the plan is. But she did fine in terms of that. So brought her back the next day after 20 hours of thrombolysis
and you can see the stent column is recanalized. You can still see there's persistent stenosis there where we've missed the stent. And then distal to the stent looks good. Where that narrowing was, that's resolved.
I didn't see any dissection here or anything like that may have incited the thrombus. And then the runoff, it looks like we pruned off one of our runoff vessels Vessels.
This is the nub end of the PT that was present but now is we have dominant flow to the peroneal. So we went back to readdress the proximal SFA stenosis with another stent. I guess, either you guys consider trying to go after that PT or just rely on that single dominant runoff vessel?
>> Depends on the situation I suppose. >> Yeah, I mean- >> Is it even acute? >> No this was acute cause- >> [INAUDIBLE]
>> Yeah. >> I probably would not do anything about that. >> Yeah we just left it alone. This is what it looked like prior to this. All right. So you-
>> When it first went down, did you guys think of just going back [INAUDIBLE] the proximal [INAUDIBLE] to the stent kind of [INAUDIBLE] [INAUDIBLE] >> Right, right.
To be honest with you I'm not sure what the discussion was there, why they just went straight to it, but that is a great reasonable thought. >> [INAUDIBLE] >> Correct.
>> Did you worry at all about, cause you dissect in and out when you're recanulating- >> Yeah, they didn't have any problems reentering. They actually used one of those Viance catheters so allegedly that stays intraluminal, so there was no need to do a reentry device
or anything like that so [BLANK_AUDIO] >> Would they dissolve the PTX? >> No, those were just standard. So on the table thrombosis.
You brought a great point about the heparin allergy. I was was wondering if the standard system in heparinization was an issue. If you just give 4,000 units or 5,000 units for males, is that really enough?
And I know this case actually prompted a switch back to weight-based dosing of heparin, to following ACTs, which was kind of a pain because we didn't have have a point-of-care testing available so we had to take it to a cardiac cath to do it. But that is something that changed the practice at least for a few
months. >> Any change in dosage? >> It has. We're giving more heparin now so. Well Dan you [UNKNOWN] Angiomax, right?
>> Did you ever find out if that was allergy or the proximal stent issue? >> I'm not sure about the heparin allergy, honestly. But yeah, once we put the proximal stent in, she did great.
She came back four months later and she's feeling great. >> Yeah, I do tend to use Angiomax for tibial work, whenever there's thrombus involved. >> Mm-hm. >> Like carotid, both the carotids obviously.
>> Mm-hm. >> That kinda thing. >> Yeah. >> I use it a lot. Although I just found out this morning that apparently the pre-fall/g trial has been terminated cuz they found some issues with Angiomax,
some coronary data.
I use for iliac occlusions on most patients today that has morphed overtime for a couple of reasons mainly due to complications. It's worth noting that embolization and iliac occclusion and endovascular iliac inclusion repair embolization in the literature is most common in those repairs than in any other chronic occlusion that is endovascularly
repaired and that's certainly been true in my own practice as well. So this is a patient, 59 year old waitress, multiple years of progressive right calf pain with ambulation. Over the past month, her exertional pain had rather dramatically
progressed to rest pain and as I see not infrequently when she presents she believes or somebody has told her that she has a broken toe and when you look at her toe it's not that it's broken it's that it's ischemic and she has a small wound on the fifth toe of her right foot.
These are her noninvasives. The left is close to normal and her right has a diminished AVI, degraded PVR, and you can see she has a monophasic post-obstructive common femoral artery waveform. So on her CTA, and this is something that I see not infrequently with particularly with female patients where they just have congenitally
small vessels and that's what we see here. You can see on the upper slide that she has a near flush common iliac artery occlusion on the right. She does reconstitute her external iliac artery on the right but it is super small. I mean it's like three millimeters at most.
And then her common femorals both her "good" side as well as her not good side are both tiny. And what I have started to do over time is to approach these in a similar fashion as I would a pedal access case and I'll explain what I mean by that.
So challenges in these case very small common femorals and external iliacs on the side with the occlusions small vessels on the contralateral side and very very thin patient well if you're gonna use closure device that implications as well. So this is her presenting angiogram and you can see,
as we knew from the CTA that the occlusion is not terribly long but the iliacs that are open are very small in caliber. In these patients I have migrated a way from placing a sheath on the affected side. Because what I always try to do is to think,
with whatever repair I'm gonna undertake in a patient regardless of what segment it is, is my access going to cause a problem that I didn't have at the beginning of the case? And this is definitely the sort of patient that leaving a sheath in while I revascularize that right side,
very well could end up causing complications, or if there are other complications, make it difficult for me to deal with them. So how I do this is, I do it just like I do a pedal access case. I do not place a sheath on the occluded side.
I just use a crossing catheter in this case it's a 018 rubicon, an 018 crossing wire V18 in this case, and I used that without a sheath on the right hand side. And then from the contralateral side where I have my sheath I'll snare the wire.
Sometimes the wire you could direct it without needing a snare, but most of the time, it's just simply faster to snare the wire and pull it over. And then as Brett had show on an earlier case, then you have through
and through access and you can cross the bifurcation, working from left to right in this case. I will advance, I will swap sides, you can see in the third image here come back up and over with the crossing catheter.
Once I feel that I'm in a patent vessel, pull my through and through wire access and inject. You really do not have to hold pressure here long at all, a minute at most.
You get hemostasis rapidly again just like with pedal access. And then I work in an anterogade fashion. So in this case she's very small, very thin, she's an active smoker this is exactly the patent that I'm gonna use a Zilver PTX off
label but I'm gonna a Zilver PTX in her iliac vessels, I out two of them here. I can stent down as far as I want because I don't have a sheath on the affected side that's gonna affect how far distally I can place my stent. And you can see the post angiogram here and ended up using an Angio-Seal
on her left side and if somebody is very thin, what I do is I tunnel under the skin like you would a tunnel catheter before. I make the puncture into the arteriotomy which allows you to kinda bury that Angio-Seal plug in there. So the advantages for me of using the snare technique is that the
retrograde occlusion recanalization, I can still cross it retrograde but I'm not gonna repair it retrograde. There's no ipsilateral sheath that's gonna interfere with stent placement, it's not gonna potentially have a thrombotic complication because the vessel is so small and if an embolic event occurs,
I am directed the direction that the embolus is going and it facilitates treatment of the embolus in the patient. And that's it.
kind of situation a very young man, a former smoker he has hypertension,
and he presents with buttock claudication radiating to the thighs. So this is kind of a unique situation that may not be easily picked up with none evasive testing and physical examining that kind of thing. He is actually status posed left eliac stenting and outside hospital a couple of years prior. So looking at his non-evasive studies
really pretty normal right Jim? So we exercise him and although you see a small dip, this is basically a negative exercise test, so he doesn't appear to have significant disease however he does have buttock claudication. He'd been told by some other physician of his
that he has back problems and that this is a spinal issue. But he reports that the claudication is very similar to when he had his left eliac treated. So we got a CT scan on him, CTS is very useful for inflow disease I find to plan your intervention and plan your access it's highly
useful. So here we see the stent on the left and it's not that easier tell, but you look at the origin of the internal iliac you do see that it's essentially occluded or significantly narrowed. Most high quality CT scans will be able to tell, somewhat
what the status of the internal iliac is. Here is a reconstruction and we can see it looks like an included internal iliac on this side. So what we did with this guy is took him to angiography found that he had bilaterally occluded internals the stent on the left actually
covers the internal and then he had an occlusion of the right internal [UNKNOWN] This is I think a good explanation for his buttock claudication. It does reconstitute here via collaterals so we are able to [UNKNOWN] This and stent it and he did great from that. His claudication completely went away. So that's just a side talk.
This is a fairly rare occurrence, patients who have isolated internal iliac disease but it is only to think about in patients who may have negative studies on non-invasive testing yet have claudication. What one can do in these patients and this is not something that
I've actually done. I don't know if Jim you're familiar with the exercise TCPO2 measurements but apparently this can be done in patients for bio-claudication. So you get a TCPO2 in the buttock, the thigh, and actually all the way down the leg, and you exercise them and that drops during exercise.
So this is a way of somewhat quantifying internal iliac disease. [BLANK_AUDIO] And studies have shown that using a cutoff of negative minus 15 millimeters Mercury and the sensitivity is in the 80% to 90% range so pretty decent.
0.8, 0.13, 0.67 after excise. What happens here? Inflow, Fem pop disease. Look what happens after exercise. So here is a guy, who has this disease?
We know it's not iliac, it's not femoral, it's iliac and femoral. Here's his angeogram. High grade external iliac stenosis, SFA occlusion. So what do we do for this guy?
We decide, and here is his doppler wavefrom, you see that monophasic waveform? We stent that. We stop at that point, the guy normalizes.
He only brings his ABI up to 0.46, but remember it was 0.12. But he is asymptomatic, so we don't treat his SFA, but look at his non invasive exam. Normal inflow disease but he still has his SFA occlusion,
we know that's there. But look at what happens after he exercised. So we don't ave to treat every lesion, but we can follow this guy, we know where his disease is.
So I think at this point I have a hundred of these cases, I could keep going on, but I think I'll stop and let Sanjay come and do his thing, and then if we had time, I could show you more of those.
88-year old male, non-healing ulcers,
and most of our treatment indications are patients with critical limb ischemia for non-healing wounds, some rest pain. We rarely ever treat claudication. They're either gangrene, or ulcers, or pre-amputation, planned amputation,
to make sure that the amputation heals. This patient initially got the angiogram, planned the treatment, but had a CVA. Discharged, came back awhile later. According to the son, the wound was getting
worse, and then decided to bring his father to the hospital for the wounds. And then he's feeling better in general, but the wound, foot pain is getting worse, etc., he's not doing well in that regard. He's about to lose his leg.
So these are some history, I'm gonna skip these. We'll go to the case. This is his left lower extremity that we treated. I'm not gonna go into that one.
He has complete occlusion of the SFA, and we did our access on the flouro to make sure we don't go through this stent graft here. We always check with our accesses, you don't wanna get a high access. I just saw a complication from a high access
earlier today that turned into a big mess, and eventually the patient died. It's simple as this, you should always check. Our practice is we put our micropuncture and put our wire in. Always get a fluoro image,
making sure that we're in the mid cam of it, it takes just a few seconds. If you're too high, too low it may become issue. >> You use ultrasound much for access? >> No, we use flouro. We use ultrasound sometimes on difficult
patients. We use flouro, but we check with fluoro before we proceed with the sheath. So if this access was too high, what I usually do is I just leave the wire in there as a target.
In this patient, you have the calcification still, and just use the micropuncture needle to stick exactly where I need to be. So after getting access, this is our angiogram. [BLANK_AUDIO] So it's heavily calcified, deep femoral disease, SFA is occlusive,
multiple calcifications. Going further down, not much flow or collaterals. [BLANK_AUDIO] This is just PlayView, and in addition to everything else patient does have a popliteal aneurysm which is thrombosed,
that becomes important. Has anyone done a chronic occlusion treatment through a popliteal artery aneurysm? Okay, so I thought this was interesting. So sometimes you think something is interesting, and ten people
have done it already. So this is below the knee area. We do have, [UNKNOWN] Going well for him. They're not the most healthiest, but he has an AT, peroneal and a PT.
They are kind of diseased, especially AT is severely diseased, but it goes all the way down to the foot. So we do assessment of the whole leg from aorta to the foot, before we start because all those things that you're gonna do, things may go wrong, etc. You wanna know
where your starting point was, and then to make sure you made things worse or better. So this is at the level of the foot. Kind of decent actually, better than most of our patients at this level. So we went ahead and got a magnified image to see where we're going,
so going to the SFA. Our usual technique is use a glidewire and a Berenstein catheter. Angiographic Berenstein catheter, we just try to go through. If it doesn't work then you try to use more advanced tools, or
dedicated tools like a Quick-Cross or a Zig Zag, some sort of Crossing catheter. Sometimes 014 or 018 wires, either V-18, V-14 or PT Graphix, otherwise there's a lot of them out there. All companies provide these to you, so whatever you like should work.
>> Gonna stop you for a second there. What do you guys normally for your fem-pop disease occlusions, let's say? What is your first go-to wire? Do you start O35, or do you?
>> O35, the LLT. >> Same, same. Yeah. >> I like to use the 014. I guess I'm the anomaly. >> Okay.
So just further down, as you get in there, you can see how irregular it is. There are areas of very high grade stenosis, maybe occlusions, etc., but it looks patent at least upto a level, and then you have the total occlusion with the collaterals around it that's
typical. And this is just kind of a video showing how you may get stuck at one level with the wire, just a glidewire actually. It's usually kind of my go-to wire in these scenarios. So sometimes just the wire angle doesn't work, so you have to get the
catheter in there. I use this a lot, both catheter with the wire. The combination gives you a little additional kind of ability to do stuff, and by approaching the catheter over there, you pass one of them. And this was just one of the probably ten we did until we reached
from the femoral to the popliteal, it took about an hour to get to that level. Just to demonstrate the things that you may come across. And eventually we went subintimal,
sometimes it's gonna go subintimal. There is no reason to fight it, you just have to go where it goes because the lumen may not be just crossable. So we fell into this popliteal artery aneurysm, so it's really
not gonna go anywhere from here. We ballooned everything to create a track because it's hard to push from the subintima without dilating the areas. I always balloon it with two or three balloons. So if you're gonna get another device down the road, you don't have pushability problems.
And after doing this, we were kind of floating in there, it's not going anywhere, and we ballooned it a little larger just to create a channel. And there was no way we were gonna be able to go distally from the upper and lower approach. So we got access from the lower extremity,
this is the AT after the pedal access. You can see that it's actually, this is diseased quite a bit. It doesn't look it. if you don't look at a magnified view, sometimes you don't recognize these subtle lesions.
I'd recommend everyone to get magnified images of tibial arteries. You may recanalize the whole tibial artery if you just do a completely de-mag image look at it. It's flowing fine, but there may be a few stenosis in there, tiny little ones, 90% etc. For wound healing, it's gonna become an issue.
You wanna leave no significant stenosis, and getting nice big images will allow you to assess that better. And so we went from below, again same thing. This is a hydro or a selective guidewire. You can see, this
is an issue you're gonna come across. This is I think a PT Graphix wire. So it's like a stenosis in a relatively larger lumen area. The wire doesn't follow, it gets ballooned up. It's not happening.
I changed my wire. I'm very liberal, and I don't think you should persist on something that doesn't work. I've worked with a lot of people, everyone has different approach.
I've seen somebody for example, they would try it with the same wire for about an hour until they give up. If something is not working, just move on. There's a lot of things out there. Don't waste stuff obviously,
you need to be cost-effective. But another added fluoro over here without reaching anywhere is a bigger waste than using another wire. I'm actually sorry, I think wanted to show that, how the other wire worked. So this is the heavy-tipped wire, it just went through with no problem. So on the straight areas,
I use heavy-tipped wires, there's a lot of them out there. But if you're gonna take a turn, this wire will not take a turn. What I do is I come to that angle of the anterior tibial and follow with my Crossing catheter. At that point I go back to GlideTech wire
because this wire is just gonna try to go straight. It's too heavy to reach it. And this is our angiogram at that level, showing the trifurcation kind of diseased, but patent in that area and so we tried to come from below, it's in a different plane.
You can't see how the wires opened it up, so we're subintimal. And we attempted a lot to get connected with the origin of the kind of, I don't know if you can appreciate it, but calcification is here. This is where it's connected, this area with the oblique field. Definite oblique band we had.
It just was coming out, it wasn't going in the right direction. So, attempted a little bit more. We spent quite a bit here with different wires, different catheters. It's just not reaching to the higher level, and you can push as aggressively as you want.
You're in an occlusive space, you're not gonna do harm. Sometimes it will just pop, and I will go through, it's gonna give in. Sometimes it won't happen, but the worst thing is it's not going to happen. So trying different wires, and pushing as much as you can is not
a big deal. So as you can see this is very odd, from the area. So we were set from the AT access, we're just subintimal, and at this point I think we're even outside the artery potentially. Because
subintimal, you're almost adjacent outside, but adjacent to the calcification. In this one, we were way out of the calcification. So what do you do? We have one access, we came back. I'm not gonna kind of go into those parts.
I tried to re-enter that popliteal artery with different, very different catheters, it just goes through the same track. It's just - >> Going sideways or from both sides? >> Well, but we're not able to reach the aneurysm, that's the problem. Our wire is from the AT access that I had, it's just coming out of the
vessel, and we tried different wires. I ballooned that track to create a little different path for myself. I sometimes inflate the balloon, use a rigid wire to push into a
different plane, if your current plane is not working. So that will allow you to maybe find a better path for yourself. Whatever view that it didn't happen from the AT because from the beginning of the distal end of the popliteal artery, we were always coming into the subintimal tract. And again, ballooned those areas, etc., It
didn't work, it didn't work. Then we decided to get an access from the PT. This is our PT access. This is very calcified, so you use fluoro. Most of the time we use ultrasound, but I quite often I also use flouro for this, and you can see that your wire is going through
no problem, and this is further up. So from the posterior tibial access, the reason that I did that is I thought the popliteal artery was more in line with the posterior tibial artery origin, and we were right. You can actually see, now it's actually
in the lumen of the artery over here. [BLANK_AUDIO] And this is our angiogram right there. You can see that the posterior tibial artery is as far as in the lumen of the popliteal, and the other wire is
in this plane, and so that allowed us actually to move a little bit more forward. At this point actually I left, I had to do a radiangle/g next door. Another colleague of mine came in, and he kind of progressed a little bit further. Turba came in and he got into that area. He actually advanced the wire further near the aneurysm by
pushing, pushing. Now we're in the right place, we're following the aneurysm. It's still a problem that with the three dimensionals, those wires could be like way away from each other, but we did oblique fields from the kind of fluoro. At this
location, they were within a centimeter of each other. It opened up a little bit, but it didn't open up enough that it was too far away. [BLANK_AUDIO] So, the next step is, let's move on.
So the next step is to get, sorry. So this is what we have from above injection, and the wire is over there, and what do you do at this stage? Any suggestions?
>> To snare. You snare it. >> Snare from where? >> From top. Get the snare down into the aneurysm, and get the wire from below and just snare it. >> But this is not in the aneurysm.
This is in the subintimal space of the popliteal aneurysm. >> But you can use a different tube, and one different from above and one different from below. >>Mm-mh. >> Make the two balloons one - >> Create a space in between in that area? >> Create the balloons, [INAUDIBLE] >> I don't know if everyone can hear that.
Sorry, it's really loud. That's actually a very good technique that he just mentioned, we use that. It's basically a kissing balloon. If you take two balloons that are in different planes, and usually you just need to overlap a very small part, but that will create a rent in the intimal and allow the wires to communicate.
In my experience, it works about 70 to 80% of the time. It's definitely worth trying cause it's easy. >> Yeah, exactly. Put one balloon here and the other balloon here, try to kind of match those. It may or may not happen. In my experience, I would say 50/50.
And since it's not working all the time, we actually stopped doing that any more. What we do is we just kind of put a snare in there, but how are you gonna get the other wire into the snare? That's the problem. Snare is the easy answer,
you have to snare it otherwise this is not gonna work. But you have to connect the wires, and you have to be able to capture it. >> So you can get an Outback? >> Exactly.
So that's what we do. So we bring an Outback from above, and then we bring the snare from below. Position that over there, and this is our micro snare. Since you're coming from below, you cannot use 75, 1 cm snares,
we have 4mm and 2mm micro snares. Those are the ones that we generally use for this, and open up the snare. And then once you puncture with the Outback, you just gently, kind of gently pull it down to see if you're actually over the needle.
If you're over the needle, then you push the wire out and then take the needle, retract the needle back and capture the wire and move forward. This was kind of testing. You normally want a lot more wire here, longer distance. Because pushing and pulling through Outback, which is a long metal
cannula tracted catheter, is not easy, there is a lot of friction. There's many cases that I lost access, not be able to pull-push at the same time. So you want to make sure that while you're pulling it, it's not pulling, it's actually pushing action. The snare is just gently bringing down
in a kind of coordinated fashion. Okay, we're almost there. Okay, and then this is just the snare going all the way down. Once we got it kind of through and through, we just stented the whole thing with wire band in this case.
Obviously nothing else probably would have worked. Balloons. This is our angiogram, and this is pre and post. In this area, it didn't look great. Time is up, so I'm gonna go really fast.
And this is like, we came from above in this area to treat that. This is subintimal of our initial, so we took that one out. We were actually able to get back into the AT from above, from the true lumen.
We snared that one to make sure we're in the right lumen, and we pulled that out, and what we did is this area was a problem. So we brought a coronary stent here while protecting the tibial peroneal trunk with a balloon from below, and placed the coronary stent and
got this result in the end. Any questions? >> Yeah. >> Go ahead. >> I'm sorry to disagree, whilst it's a fantastic technical result. >> Mm-hm, >> You started off with a very, very heavy calcification and you started out with large popliteal aneurysm. You've been at it for three hours, for four hours, with two access into micro vessels. >> Correct. >> Has he been clinically tested for these devices? >> He was evaluated for a bypass.
If you read the initial story, he's 88. He had a stroke, he was discharged, he received TPA, he doesn't have a vein. I think if you did a prosthetic bypass on this patient, the chances are he would have died. If he made it, yeah.
procedure performed on the left leg at an outside institution. And I know the interventionalist did a good job I thought and very competent fellow. Presents with left leg pain, redness, edema. He had had a intervention on an occlusion of his SFA by an interventionalist which went down immediately.
The surgeons then took him into the fem-pop bypass which looked good. But during some of these procedures, these two procedures, he had trashed his leg and his foot. And he had developed some cellulitis and some gangrene, some necrosis.
And we got him transferred to see what we could do and see if we could help him. So recent procedure. So this is what we had to start with. We got an angiogram which shows a nice aortoiliac system.
On the left side you see there's a fem-pop bypass which is open. The right leg which has a synchronous lesion to the left leg, will show you here that there is an SFA occlusion on the right side. And from the description, it was similar to the one that was on the left side which was fixed with the interventionalist. So it's a short segment, 10, 15 centimeters total occlusion that pretty
much everybody up here could get through. Even though there is a collateral we can manipulate [INAUDIBLE] for one around there and usually get through and put a stent and have a good result. But, be that as it may, the fem-pop bypass graft was placed appropriately and had a nice anastomosis distally above the knee joint. So I got him and we are taking now a look at the distal flow to
see why the guy is having pain. He has a complete occlusion of the proximal aspect of the posterior tibial. And he has slow sluggish flow with no flow distally in the anterior tibial, and that's what's causing the symptoms down in his foot. You can see further down here he's got a posterior tibial that runs
on down. The perineal is a small [UNKNOWN] vessel and then the anterior tibial basically dodges. It's not really much of anything that comes back below. My thoughts at this point was to go in with a Penumbra device, the 6 French, and try to suck out some of that clot in the posterior tibial and in the anterior tibial.
So I bring the Penumbra down on the second day, I mean the first day and we suck it out. And once we suck it out we get a pretty good result here. There's a little dissection in that proximal posterior tibial, but there is
as good antegrade flow and there's decent flow here in the anterior tibial as well. >>[INAUDIBLE] >> I see. [BLANK_AUDIO] Yeah, there's an [UNKNOWN] here too as well.
You're right. So that may have come from the manipulation of the [UNKNOWN]. And during the procedure, it did not, I mean this according to the timeline was acute thrombus. Within a week,
a week and a half, it should have sucked up nicely. I got into some difficulty here and it did not come out as nicely as I had hoped it to. We ran the Penumbra for a while using that little wire that goes through it, the separator.
And it did not work and I thought we had a dissection here too. So I ended up putting in a coronary drug-eluting stent right here to try to fix it. And we played around for a while and then I took the Penumbra down to the anterior tibial distally and tried to suck out some stuff. And I really didn't get much in the way
of clot out. I wasn't really happy with what I had. So we thought we'd bring the guy back the next day, or the day after that and try to do some more. Well this guy, apparently he'd had enough of hospitalization
so he signed an AMA and left us. And so I said okay. Well you know what, at least we got the posterior tibial open. Well he comes back a week and a half later, and now he has a complete occlusion of his fem-pop bypass. And you've got the profunda
here which is going down this side. And essentially nothing is coming back distally, at all. So we decided to start thrombolysis. By history it was a week, a week and a half out, so his foot by the way is looking horrible at this time. He's started to demarcate to his ankle,
and it does not look good. Anyway we start the thrombolysis on him and we proceed for 24 hours of lytics. There's some decent flow here, there's some flow but it's sluggish down here.
And then basically this is the next day that we bring him back after thrombolysis for 24 hours. He has no flow at all from the post into the popliteal down here. The leg looks horrible. He's actually demarcated all the way up
to here. Ends up getting a fem-pop bypass. I'm sorry, he ends up getting an above the knee amputation, midway up his left thigh. From this procedure, I don't know what I could have done differently, what we could have tried to do any more or less.
This is a scenario that thank God doesn't happen all the time. Usually you can bring somebody back that's had an acute event and thrombolyse him, and still get pretty good antegrade flow. I don't know if the guy had some coagulopathy, he's got some sort of
vasospastic phenomena. Usually if you use these Penumbra devices on an acute thrombus, it's gonna suck it out and you're gonna get great flow. With this case, I don't have an explanation for this. Anybody in the panel have an explanation?
>> I bet this is a non-compliant patient. He wasn't taking his [UNKNOWN] whatever he was on. >> No he didn't take anything. He was one of those guys that smokes continually and he's a- >> That doesn't help-
>> He's a tough guy. So basically at the end of day, I mean the family is concerned and upset that father went in to open up his leg because he was having claudication, and then he ends up losing his leg midway up his thigh. My take home from this is I'm not touching that right leg. You can't
pay me enough money to fix that right leg on this guy. So I told him in no uncertain terms not to let a surgeon or an interventionalist work on his other leg. But that still doesn't change the fact that usually when you go through this paradigm of how you thrombolyse and how you perform an aspiration thrombectomy,
you usually get decent results. This is one that just went circling around the toilet bowl and ended up going in. I don't know. Anybody got any suggestions? >> I think all these cases show how important it is to have a conversation
with the patient, letting them know the risk of anything we do. Understanding that always be prepared for the risk. And if you don't wanna be having this conversation with the patient after the fact, you wanna have it before the fact, especially in some
of these patients that are very sick. It's very difficult and what you have to do the next thing and knowing that things are going to spiral. If you've got a patient that's non-compliant, that's also very important. Should we be doing these procedures?
Some of them we have to do or some of them the patients, they're [INAUDIBLE]. We have to get it done, but how can we convince them. And again is that part of the whole conversation with them? >> Yeah, yeah. >> Do we understand how important it is?
That you're gonna lose your leg if you don't [INAUDIBLE] >> Yeah, I mean you get hit with this all the time. I'm sure you get people transferred to you that have had previous procedures and you look at it just from the surface when you get the patients, say well, I'll be
able to clean this out. I mean this is an acute thrombotic event that occurred within a week. I can go in there with a Penumbra, and aspirate and suck this out and then end up getting, it just did not behave or feel to me like it was an acute event.
You just don't know but he's absolutely right. You gotta be straight up with these guys when you talk to them, and tell them that even though most of the time it works like this, and this is the way that I proceed with my algorithm, things can change.
So first patient 78 year old patient, left thigh and buttock claudication for a couple of years. You can see that there's depression of the PVRs at the left thigh
levels compatible with inflow disease and here's the patient's CTA. So we see it there's a left external iliac occlusion which extends right up to the left hypogastric artery which is at the end. So there's multiple ways of treating this and I bet, if I were to survey the panel here would probably have a different way but I'll
tell you kind of our approach here. Now you can certainly go either ipsilateral or use a crossover approach. We favor utilizing a ipsilateral approach, utilizing the groin for imaging and the
purpose for that is if you end up going subintimal and creating a dissection plane, you're going opposite the flow of the blood in the aorta so you're probably not going to have a probably not going to have a problem, whereas if you create a long dissection long and over, you can potentially damage the common femoral artery.
So that's our typical approach. But if you don't have enough running room on the left then you're probably going to have to go up and over to treat this. In terms of stent type we typically use a self-expanding stent for most external iliac lesions because they tend to be long lesions and they often are torturous.
We like to the hypo-gastric artery if we can but that's not always feasible. So here's the angiogram. From the right common femoral approach and you can see reconstitution of the left external iliac there. So again we utilized the imaging from the right.
We use this right cerebral NLT wire that nobody in the world ever heard of. I'm telling you it's the best wire ever made. It's cheap and its great for crossing chronic occlusions. And I'm telling you nobody heard of it outside of our institution.
And there's nothing special to it you just push and it goes through. I would tell you 80% of the time it'll go through the lesion intraluminal. This is not just for aortoiliac. >> Is it comparable to something we may be familiar with? >> It's like a stiff Benson/g almost. Yeah.
And we utilize it for SFA lesions. And sometimes we use it for proximal tibial lesions as well. So anyway, here in this case we went across put in a self-expanding stent here. End point of intervention. What is the best end point?
In our practice we utilize pressure gradients. It doesn't matter what it looks like. We want there to be good flow, you can see there is a little dissection here at the bottom here. But there was no pressure gradient,
we left it alone. And we have normalization of PVRs now and a triphasic way from the common thermal artery. >> One question. >> Yeah. >> You guys prefer uncovered self expanding or uncovered?
>> Yeah that's a good question. So for external iliac arteries we typically will use uncovered self expanding stents. In this case especially we used a self expanding uncovered stent because you can see the stent goes a little bit across the hypogastric artery.
There was no way to really spare that. So we want to make sure that we didn't cover it.
So here's our next case, similar history, claudication in the left lower extremity, left thigh and calf.
You could see that there's depression of the high thigh way forms on the left side, and monophysic waveforms and left common from the artery. Here's a patient's CTA as well as our reformat so you can see there's occlusion of the left common iliac artery with the reconstitution at the hypogastric and the external iliac being pin/g.
This patient actually had a history of a phantom bypass which was down. So here's a case where it will be difficult to go up and over to cross this lesion because you're not going to have much running room. So we'll also try to go, other potential approaches here will be
a radial or a branchial approach which will be perfectly reasonable approach. A cook has 110 centimeter sheath which you can actually, it's the longest sheath available and you could actually utilize it to treat a iliac lesion.
We could treat all the way up to the proximal SFA, in shorter patients you might get a little bit further than that. In this case we went from the counter lateral side. I used a balloon to try to straighten the wire but it didn't really work I don't think that's really a well described
approach anyway. Here you know trying to go from above and you could see there's really no pushability here, we weren't making any progress here. So in a case like this what we did is we utilized the right side for imaging again and we ended up going subintimal. So what are
our options when you go on a subintermal plane here. Well, we certainly have a bunch of crossing devices which are available but it's definitely even a visa approved for pretty much any indication, but typically isn't for SFA lesions or [INAUDIBLE] lesions, but you can certainly use them in the iliac circulation as well,
the ones that we most commonly use on our own practice or the outback made by Cordis or the pioneer which is a Volcano, but there's some of the other devices available. So here in this case we utilize the pioneer device and for those
of you who might not be familiar with it, utilizing intravascular ultrasound. I don't want to even though we utilize a lot of outbacks and it's a pretty good device, I wanted to make sure that we didn't end up puncturing this many times because if we end up with a bleeding complication here,
it could be really problematic here. So the way this device works is, you introduce it in the subintimal plane and you turn the device. This is the flow in the artery and you just turn the device until
the native arterial flow is at 12 O'clock these are nine millimeter markers and then you can adjust the pioneer needle to either three five or seven millimeters. So in this case I would adjust it to five millimeters and fire the needle. This is actually real time in this case and sometimes you could
actually see the needle firing you'll see it in a second here. There you go. You don't always see that but this is kind of a nice case where you actually did. And at this point you introduce your guide wire and catheter. We typically would utilize this small balloon to get the three millimeter
balloon to dilate the subintimal tract, introduce the catheter, doing the injection jut to confirm that we are intraluminal and then subsequently we typically will use balloon expandable stents of common iliac arteries. The one kind of good rule of thumb that I tell our fellows is,
any vessel that comes off the aorta utilize the expandable stent to have the precise placement as well as to have the maximum radial force. And I prefer utilizing a covered stent if we're going to utilize these reentry devices because even though I haven't seen any significant
bleeding, we've certainly done some cone beam CTs in patients when we utilize the outback, when we've stuck it multiple times and you all seen some shadiness or haziness around the aorta. And again the patient had no pressure gradient in here. >> So far I think that the Pioneer's a wonderful place.
Unfortunately right now I believe it's off the market? >> Correct. It's currently on recall. I'm not sure why. I was told that one of the thought leaders thought that there was some problem with the device. I don't what problem he or she was having.
I think I think it's an excellent device I've never had a problem with it. In my opinion it's one of the best reentry devices on the market. It is a little bit more expensive than the other ones but if you have IVIS, it takes all the guesswork out of it. And we talked about this again for common iliac lesions,
for TACE CND lesions, covered stents had better outcomes than task a and b lesions. >> One comment about that is covered stents actually do better in the iliacs as long as the outflow is okay. They have higher thrombosis rates.
If you have a [INAUDIBLE] externally iliac common femoral, then their outcomes are not as good. So that's what we do. If you have a perfect external iliac like this one, it's great.
That stent will be open forever probably but if you do have disease outflow, then you may want to think twice. A bare-metal stent may give you a better outcome because it's not going to thrombose. It may restentilize but it won't have that thrombotic complication. >> I think that's a great point
And if we have significant common femoral disease, we'll quickly do these as hybrid procedures where we'll do a common femoral endarterectomy and stent the iliac. If the patient is at really high surgical risk, sometimes we'll
do thoractomy or drug-coated balloons in that location. I think that's also true for SFA lesions if we're dealing with via bonds with poor outflow we've had poor results and higher thrombosis rates. These are the multiple devices that are available on the market.
Next patient is a patient who has a ischemic ulcer on the left foot and again you can see that there is inflow disease. I'm just going to get through this case quickly. >> [INAUDIBLE] >> Rupture.
How to deal with raptures. In this case we had an open over sheath so it's pretty straight forward. We were able to put up a balloon. In terms of dealing with what is the ideal coverage stent here. I don't know what's the best answer is and there might be some controversy
from the panel the Viabahn is a great device it uses a smaller sheath size. One of the issues with the Viabahn is you really have to size it appropriately. If you are too much oversize the device will infold and you'll have a problem if you're under side is going to continue to bleed.
The flare [ they require a larger sheath size but you have much more ability to get away with over sizing there and the device would not in fold I think you need about a nine french sheath there. So I think the point was I have never seen a common iliac rapture. We've seen several external iliac raptures. So you really want to make sure you have covered stents in the room
and be ready for a rapture. You always monitor for pain when we're doing these procedures I think there's a problem. >> Question of that. >> Yeah. >> [INAUDIBLE]
>> We typically do most of our procedures with angiomax so we don't have that option. You can't reverse angiomax but yeah if you're using heparin I would give protamine. >> It's an approach as long as you have a balloon the main thing is to have control in this.
You do your angiogram you need to be able to pout the balloon up. If you give protamine or not if you don't have the balloon you'll still bleed but if you put the balloon up and you may have to put that balloon up five minutes etc. So you don't want to turn to bleeding, thrombosis all that hell.
We don't touch the harpization/g we don't give protamine in our practice nobody knows the answer there is no way to the trial to see which kind of cases are going to do better in this scenario but we we just make sure that one assess the balloon is up the other access its a through and through most of this cases. We do pretty much all iliac cases bilateral access and [UNKNOWN].
That way something happens you have your balloon, you pull your balloon you bring your stent immediately deploy it your bleeding time is seconds at most. >> You know, actually for aortoiliac interventions we hardly ever anticoagulate by the way,
so I think Dr. Hadson does vote, we almost never anticoagulate aortoiliac intervention. The other thing we do every single time is instantly cycle the blood pressure I think anyone who does the aortoiliac has run into this, it's rare but it does happen, so cycle your pressure off in the
patience of vagal there's usually associated pain, it's not and I agree with what Dr. Hadson said, I couldn't reverse the hesprin, you're going to have control within seconds if you manage it properly it's not going to have any
consequences. >> This isn't just a the companion case, what happened, this is what we're doing in agiograph and you're introducing the sheath and you've bleeding from the controlateral groin.
This is where you might run into more issues, if you've a large enough sheath on the right side you can put up an inclusion blew in the aorta and then go ahead and treat the last side but this patients can die very quick. I mean they'll loose liters of blood very quickly.I mean this case
will we did was we placed a balloon from the lateral side to get control and then we're able to get a catheter up and over. Let the balloon down just for a second and let the wire go across the balloon and then that allowed us to get the appropriate covered stent and place at a cross to treat that. Let me show you one more case really fast since I'm running out
of time. This is a patient with left sided buttock claudication and this patient has both hypogastric and external iliac stenosis. It's debatable. You treat both of them or not. This is one of the cases my partner did but I think it's completely
debatable here and I bet you we could probably debate it on the panel here. But what we chose to do was, he put an external iliac stent, went through the interstices of that stent and placed another balloon expandable stent in the hypogastric artery and then he ballooned
both of them and then did an angiogram an this is what he came across. >> The balloon and tent simultaneously or one after the other? >> I think he did them simultaneously. And I think it's a completely reasonable approach. I think what happened here was he didn't know where his wire was,
where the tip of the wire was. So he dissected his external iliac artery and even worse, he lost wire access. So this is a real problem so obviously don't loose wire access. Next thing he did was,
we checked with ultrasound at the left common femoral artery to see if the dissection plan extent and luckily it did not. So it was just another look at the dissection. So he's able to go ahead and puncture the common femoral artery
during angio and place a stent all the way to here. So things were finally looking good. But just when things can't get any worse, this was already like a couple hours into it. >> [LAUGH]
>> So what happened was we blamed it on the fellow, the sheath was pushed in, and if you recall in the prior image the stent goes all the way to the origin. So now we have a crumpled up stent.
There's no flow through here. He really ran in to turn one complication to another complication. So at this point he went back from above and tried to use a guide wire to get across this crumpled stent which eventually he was able to do. And tried to angioplasting it and still didn't have a great result
so finally we ended up putting a viabahn in there and the patient did well. But I think point here is you have a complication, hopefully you don't, it's easy to have one complication lead to another and to another and sometimes it's good to maybe get your partner to help out.
>> Thanks. >> Thank you.
All these patients are diabetics for the most part. Okay, the vast majority of them. This one happens also to be on hemodialysis coming in with ulceration.
This is the greatest radiograph of osteomyelitis I have ever seen. So, that's why I had to throw it in here. obviously here is the non invasive cc pretty much a biphasic way from the posterior tibial and then monophasic in the dorsalis pedis. So here's what the angiogram
looks like we top's completely normal. You see obviously a severely and [UNKNOWN] TP trunk lesion. It's calcified, and then below you have single vessel run off the perennial artery. So a lot of work to do here, and actually you don't see any of the dorsalis pedis distally it's not reconstituted whatsoever.
So decided to use angioscope balloon here. This is a balloon that actually has a helical scoring elements, it's similar to a cutting balloon although it's not [UNKNOWN] these aren't razor blades, these are sort of less sharp tipped. They have a higher rated burst pressure. They're a little more flexible.
They track a little bit better than your typical cutting balloons. So I like to use them with [UNKNOWN] lesions. So that was used there, skip through that but this is what it looked like afterwards. So then after that we're going to tackle the posterior tibial artery which
you see here. You see a large collateral coming off. At above the proximal third of the daises. So the goal here is to just cross and reconnect the dots, and then this happens. So I'm using regalia guide wire to hydrophilic tip or the one
for wire. And I'm probing gently with finesse, and then we have this, obviously unfavorable what do you guys do. Obviously this is proliferation, no doubt about it. >> Do nothing.
>> Do nothing. So just continue from above? >> Continuing from below or whatever, continue your procedure [CROSSTALK] >> I do follow ACTs I get this patient probably 8000 [UNKNOWN] and I do not reverse. I just immediately go from below the foot's already prep.
Go from below, pass the wire and the wire just ran right up, no problem. Snare it from above. There's actually a loop snare there, pull through and through so now I have floss.
Put up the balloon. This is probably a two and a half by 200 balloons or something balloon below this is what it looks like and this is what you're left with. So you've got a dissection, sort of maybe some residual. What do you guys do?
You guys leave this? You like it? It's okay. >> How about a corner stent short. >> Yes, so I agree with you here, this is one of the best uses of I think coronary drug eluding stent in this location, okay
so there's a lot of data out there, initially the impetus to use these in the tibial cranial vessels was the coronary data in the spirit trials but they're now since that time, they've been a lot of other trials that have shown that they're valuable in the [UNKNOWN]
vasculature, balloon mounted ever aligned these stents [UNKNOWN] I use designs from Avit/g and here it is here, post stent placement so. Again I use drug eluding stents for focal lesions obviously is their short stents are meant to be used in the coronary arteries, so they come in 2 cm,
3 cm, that sort of length. So for focal spot lesions like that, I like to use the drug eluding
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