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Peripheral Artery Disease, Stenosis | Recanalization, Balloon Angioplasty | Male
Peripheral Artery Disease, Stenosis | Recanalization, Balloon Angioplasty | Male
2016augmentationballoondingdiseaseduplexiliacmonophasicoccludedSIRwaveformwaveforms
Balloon Pulmonary Angioplasty | Management of Patients with Acute & Chronic PE
Balloon Pulmonary Angioplasty | Management of Patients with Acute & Chronic PE
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Case 1 - Non-healing heel wound, Rutherford Cat. 5, previous stroke | Recanalization, Atherectomy | Complex Above Knee Cases with Re-entry Devices and Techniques
Case 1 - Non-healing heel wound, Rutherford Cat. 5, previous stroke | Recanalization, Atherectomy | Complex Above Knee Cases with Re-entry Devices and Techniques
abnormalangioangioplastyarteryAsahiaspectBARDBoston Scientificcatheterchaptercommoncommon femoralcontralateralcritical limb ischemiacrossCROSSER CTO recanalization catheterCSICTO wiresdevicediseasedoppleressentiallyfemoralflowglidewiregramhawk oneHawkoneheeliliacimagingkneelateralleftluminalMedtronicmicromonophasicmultimultiphasicocclusionocclusionsoriginpatientsplaqueposteriorproximalpulserecanalizationrestoredtandemtibialtypicallyViance crossing catheterVictory™ Guidewirewaveformswirewireswoundwounds
PAD Distribution | CLI: Cause and Diagnosis
PAD Distribution | CLI: Cause and Diagnosis
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Cone Beam CT | Interventional Oncology
Cone Beam CT | Interventional Oncology
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Case 8: Retroperitoneal Hematoma- Cover Stent | Emoblization: Bleeding and Trauma
Case 8: Retroperitoneal Hematoma- Cover Stent | Emoblization: Bleeding and Trauma
angiogramarteryaxialbleedcatheterizationchaptercontrastcoronalCoverage StentembolizationembolizehematomailiaciliacsimageinjuryNoneoptionpatientpseudoaneurysmRetroperitoneal hematomastentstents
Post-intervention Non-invasive Tests | Determining the Endpoints of CLI Interventions
Post-intervention Non-invasive Tests | Determining the Endpoints of CLI Interventions
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PAD/CLI Diagnosis | CLI: Cause and Diagnosis
PAD/CLI Diagnosis | CLI: Cause and Diagnosis
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Duplex Ultrasound | Determining the Endpoints of CLI Interventions
Duplex Ultrasound | Determining the Endpoints of CLI Interventions
angioplastychaptercolordopplerduplexflowhelpfulimageimagesimagingoccludedpatientssensitivespectraltriphasicultrasoundvelocitywaveform
Geniculate Artery Embolization - Frozen Shoulder | Geniculate Artery Embolization for Arthritic Pain Why How & Results
Geniculate Artery Embolization - Frozen Shoulder | Geniculate Artery Embolization for Arthritic Pain Why How & Results
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Treatment Options- TransCarotid Artery Revascularization- TCAR | Carotid Interventions: CAE, CAS, & TCAR
Treatment Options- TransCarotid Artery Revascularization- TCAR | Carotid Interventions: CAE, CAS, & TCAR
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Disease States, Complications, and more - Curriculum Week 2 | Cath Lab Academy: An Adjunct to an Orientation Program Using an Interprofessional Approach
Disease States, Complications, and more - Curriculum Week 2 | Cath Lab Academy: An Adjunct to an Orientation Program Using an Interprofessional Approach
arterialartisatrialbasicschaptercodeexperiencehearthemodynamicmockmonitoringNonepracticingpressuresrenalssimulatingsimulationsystemtechnologistswaveformwaveforms
Endoleak Case |
Endoleak Case | "Extreme"-ly Obvious IR
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Successes of EndoAVF Creation | Pecutaneous Creation of Hemodialysis Fistulas
Successes of EndoAVF Creation | Pecutaneous Creation of Hemodialysis Fistulas
accessangioplastycathetercatheterschaptercharlestonDialysiselevationsFistulamonthspatientspercutaneousphysiciansproceduresurgeonsvascularveinweeks
MR Angiography | Determining the Endpoints of CLI Interventions
MR Angiography | Determining the Endpoints of CLI Interventions
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CTEPH Case Example | Management of Patients with Acute & Chronic PE
CTEPH Case Example | Management of Patients with Acute & Chronic PE
angiogramballoonchaptercontraindicatedCTEPHdiseasedistallyglidehydrophilicinterventionalmichiganNoneocclusionspatientperfectperfusionsegmentalstenosissurgerywirewires
Aspiration Thrombectomy | Management of Patients with Acute & Chronic PE
Aspiration Thrombectomy | Management of Patients with Acute & Chronic PE
angioAngiodynamicsAngiovac CannulaAspirex CathetercatheterschapterclotdevicedevicesfrenchIndigo ThrombectomyNonepatientPenumbraPenumbra Inc.sheathStraub Medicalthrombectomythrombustpa
The Procedure - Creating a Deep Fistula | Pecutaneous Creation of Hemodialysis Fistulas
The Procedure - Creating a Deep Fistula | Pecutaneous Creation of Hemodialysis Fistulas
anastomosisarteryAvenu MedicalballoonbrachialcephalicchaptercreationdeviceEllipsysFistulaflowflowinglinesneedleperforatingperforatorpiccproximalpuncturepuncturedradialsurgicalultrasoundvein
Surgical AV Fistula  | Pecutaneous Creation of Hemodialysis Fistulas
Surgical AV Fistula | Pecutaneous Creation of Hemodialysis Fistulas
angioplastycannulatedcathetercatheterschapterdeviceDialysisembolizationFistulafistulashemodialysismaturationpatientspercutaneousrefused
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
Scope of IR Procedures in South Africa | South African Interventional Society (SAintS)
Scope of IR Procedures in South Africa | South African Interventional Society (SAintS)
biliarycardiologistscenterschapterinterventionalInterventionsneuroparacentesisproceduressurgeonsvascular
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
IR in Egypt and Ethiopia | AVIR International-IR Sessions at SIR2019 MiddleEast & Africa Focus
IR in Egypt and Ethiopia | AVIR International-IR Sessions at SIR2019 MiddleEast & Africa Focus
ablationsaccessafricaangiographybillarybulkcardiothoracicchaptercheaperconduitscountriescryocryoablationDialysiseconomyegyptelectroporationembolizationendovascularfibroidfibroidsFistulainterventioninterventionalnanonephrologyneurononvascularoncologyportalpracticeradiologyspecialtysurgeonssurgerysurgicallythrombectomytpavascularvisceralworldwide
Massive PE | Pulmonary Emoblism Interactive Lecture
Massive PE | Pulmonary Emoblism Interactive Lecture
adenosineangiobloodbradycardiacatheterchaptercontraindicateddevicedirectedhypotensioninpatientinterventionalistsmassivematsumotopatientsPenumbrasurgicalsystemictherapythrombolysisthrombolyticthrombolyticsventricle
Case- May Thurner Syndrome | Pelvic Congestion Syndrome
Case- May Thurner Syndrome | Pelvic Congestion Syndrome
arterycatheterizecausingchapterclassiccliniccommoncommon iliaccompressioncongestionendovascularevidenceextremitygonadalhugeiliaciliac veinimagingincompetenceincompetentMay Thurner Syndromeobstructionoccludedpelvicpressuresecondarystentsymptomstreatmentsvalvularvaricositiesvaricosityveinveinsvenavenous
Angiographic Predictors of Successful Revascularization | Determining the Endpoints of CLI Interventions
Angiographic Predictors of Successful Revascularization | Determining the Endpoints of CLI Interventions
angiogramangioplastybasalbiphasicblushcalibercapillarychapterchronicallycollateralsdopplerflowhemostatincreasedischemiaizationnormaloccludedopacificationoutflowpatientsperfusionphasicpredictorsrevascularizationrevascularizesignsignaltriphasiculcerulcerationsvessel
Case 2 - 4-month delayed heal wound, Rutherford Cat. 4 | Subintimal Recanalization | Complex Above Knee Cases with Re-entry Devices and Techniques
Case 2 - 4-month delayed heal wound, Rutherford Cat. 4 | Subintimal Recanalization | Complex Above Knee Cases with Re-entry Devices and Techniques
anteriorballooncatheterchapterCordiscritical limb ischemiadeterminedeviceEnteer Re-Entry DevicehealediliacintimalischemialumenMedtronicmonophasicocclusionOUTBACK® ELITE Re-Entry Catheterpainportsre-entry devicerecanalizationstentingwaveformswirewound
Claudication vs CLI | CLI: Cause and Diagnosis
Claudication vs CLI | CLI: Cause and Diagnosis
amputationamputationsangiogramcancerscarolinachapterclaudicationcriticaldiseasefateischemialimbpalliationpatientsspecialiststabletexastreatworse
Venous Insufficiency- Imaging | Pelvic Congestion Syndrome
Venous Insufficiency- Imaging | Pelvic Congestion Syndrome
chaptercompressibleevidenceflowgonadalgrayiliacincompetentinsufficiencypelvicpelvissecondarysequelaeultrasoundvalsalvavalvevalvesvaricosevaricose veinsvaricositiesveinveinsvenous
Case 10: Peritoneal Hematoma | Emoblization: Bleeding and Trauma
Case 10: Peritoneal Hematoma | Emoblization: Bleeding and Trauma
activeaneurysmangiogramanteriorarterycatheterchaptercoilcontrastcoronalctasembolizationembolizeembolizedflowgastroduodenalhematomaimageimagingmesentericmicrocatheterNonepathologypatientperitonealPeritoneal hematomapseudoaneurysmvesselvesselsvisceral
TEVAR Case | TEVAR w/ Laser Fenestration of Intimal Dissection Flap
TEVAR Case | TEVAR w/ Laser Fenestration of Intimal Dissection Flap
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Transcript

I'll skip

those, so lets just take, in the last couple of minutes, I'll just show you one or two cases more. So this is our worksheet. We get ABI of 0.6 and 1, we know this disease on the right, look

at what happens after exercise, drops to 0.4, right side maintained, here are the waveforms, no augmentation on the right side, fem pop disease, ding ding ding, easy to say, is it occluded or not?

Duplex could tell me that but I could tell you from reading a lot of this, unless this is an acute event, this is an occlusion. I can't guarantee it, 100% of the time but I can pretty much tell you.

Oh, wait a second, monophasic waveforms coming in. There is iliac and fem pop disease on the right side. Well, here comes a guy, this is the same patient. [UNKNOWN] disease, just an external iliac, going into his profounding

common femoral, therefore flatened monophasic dopler waveform and look at what happens down at the adductor canal, have the calcium stenosis. We balloon each of those, balloon down here, what happens now? Augments, and it returns the baseline.

talk here with something that's new on the horizon believe it or not it was actually on the horizon 20 years ago and then it went away because there were a lot of patients that were treated with a

lot of complications and it's making a resurgence and this is balloon pulmonary angioplasty or BPA for short so this is an intervention which may be feasible in non-operative candidates so I mentioned to the Jamison classification earlier

type 1 and type 2 disease should be treated with surgery again it should be treated is curative but patients with type 2 and a half or 3 disease can be treated with balloon pulmonary angioplasty in the right in the right

frame which means that a surgeon has said I cannot operate on this a medical doctor has said boy they're not going to get better with their medicine let's try something else well this is that something else and that's what involves

everyone in this room so this is these are usually staged interventions with potentially high radiation and contrast dose if you think about it it's like Venis recan and a pulmonary AVM all-in-one so it's a potentially a long

complex procedure with a lot of contrast and a lot of radiation but it can provide a lot of benefit to these patients I'm going to talk about the comp potential complications at the end which is one reason why not

everyone should do these all the time so this is a pulmonary angiogram from the literature when you're injecting a selective pulmonary artery you can see that this patient has multiple stenosis there's no real good flow there the

vessels look shriveled up like I mentioned to you before you can get a balloon across it and balloon the areas and then you can see afterwards so the image a on the left is before an image D is afterwards believe it or not this are

in the most experienced hands because the most experienced hands are for palm the BP AR in Japan they do hundreds of cases of these a year at each hospital I've personally only done five so but this is a something that I'm very

interested in and you can see how how much benefit it has for that patient another way you can see these are the webs and the bands that I mentioned to you earlier so what's interesting is that if you look on the first set of

images on the top and the images on the bottom those are the same patients it's the same view before top rows before and the bottom rows after balloon pulmonary angioplasty so the first image is a pulmonary angiogram where if you kind of

see this there's there's some area areas of haziness those are the webs and bands the image on the the middle is the blown-up views and you can see those areas and then the image on the right is intravascular ultrasound which I use

every day in my practice it's a catheter with an ultrasound on it and when you look at it on the top image image see you can see a lot of thrombus you're actually not seeing flow and on image F on the bottom you're seeing red which is

the blood flow so these patients can actually improve the luminal diameter bye-bye ballooning them you can treat occlusions again image on the left shows you a pulmonary artery with a basically an occlusion proximally and then after

you reek analyze it and balloon it you can see that they can get much more

so just a compliment what we everybody's talked about I think a great introduction for diagnosing PID the imaging techniques to evaluate it some of the Loney I want to talk about some of the above knee interventions no disclosures when it sort of jumped into

a little bit there's a 58 year old male who has a focal non-healing where the right heel now interestingly we when he was referred to me he was referred to for me for a woman that they kept emphasizing at the anterior end going

down the medial aspect of the heel so when I literally looked at that that was really a venous stasis wound so he has a mixed wound and everybody was jumping on that wound but his hour till wound was this this right heel rudra category-five

his risk factors again we talked about diabetes being a large one that in tandem with smoking I think are the biggest risk factors that I see most patient patients with wounds having just as we talked about earlier we I started

with a non-invasive you can see on the left side this is the abnormal side the I'm sorry the right leg is the abnormal the left leg is the normal side so you can see the triphasic waveforms the multiphasic waveforms on the left the

monophasic waveforms immediately at the right I don't typically do a lot of cross-sectional imaging I think a lot of information can be obtained just from the non-invasive just from this the first thing going through my head is he

has some sort of inflow disease with it that's iliac or common I'll typically follow within our child duplex to really localize the disease and carry out my treatment I think a quick comment on a little bit of clinicals so these

waveforms will correlate with your your Honourable pencil Doppler so one thing I always emphasize with our staff is when they do do those audible physical exams don't tell me whether there's simply a Doppler waveform or a Doppler pulse I

don't really care if there's not that means their leg would fall off what I care about is if monophasic was at least multiphasic that actually tells me a lot it tells me a lot afterwards if we gain back that multiphase the city but again

looking at this a couple of things I can tell he has disease high on the right says points we can either go PITA we can go antegrade with no contralateral in this case I'll be since he has hide he's used to the right go contralateral to

the left comment come on over so here's the angio I know NGOs are difficult Aaron when there's no background so just for reference I provided some of the anatomy so this is the right you know groin area

right femur so the right common from artery and SFA you have a downward down to the knee so here's the pop so if we look at this he has Multi multi multiple areas of disease I would say that patients that have above knee disease

that have wounds either have to level disease meaning you have iliac and fem-pop or they at least have to have to heal disease typically one level disease will really be clot against again another emphasis a lot of these patients

since they're not very mobile they're not very ambulatory this these patients often come with first a wound or rest pain so is this is a patient was that example anyway so what we see again is the multifocal occlusions asta knows

he's common femoral origin a common femoral artery sfa origin proximal segment we have a occlusion at the distal sfa so about right here past the air-duct iratus plus another occlusion at the mid pop to talk about just again

the tandem disease baloney he also has a posterior tibial occlusion we talked about the fact that angio some concept so even if I treat all of this above I have to go after that posterior tibial to get to that heel wound and complement

the perineal so ways to reach analyze you know the the biggest obstacle here is on to the the occlusions i want to mention some of the devices out there I'm not trying to get in detail but just to make it reader where you know there's

the baiance catheter from atronics essentially like a little metal drill it wobbles and tries to find the path of least resistance to get through the occlusion the cross or device from bard is a device that is essentially or what

I call is a frakking device they're examples they'll take a little peppermint they'll sort of tap away don't roll the hole peppermint so it's like a fracking device essentially it's a water jet

that's pulse hammering and then but but to be honest I think the most effective method is traditional wire work sorry about that there are multiple you know you're probably aware of just CTO wires multi weighted different gramm wires 12

gram 20 gram 30 gram wires I tend to start low and go high so I'll start with the 12 gram uses supporting micro catheter like a cxi micro catheter a trailblazer and a B cross so to look at here the sheath I've placed a sheet that

goes into the SFA I'm attacking the two occlusions first the what I used is the micro catheter about an 1/8 micro catheter when the supporting my catheters started with a trailblazer down into the crossing the first

occlusion here the first NGO just shows up confirmed that I'm still luminal right I want to state luminal once I've crossed that first I've now gone and attacked the second occlusion across that occlusion so once I've cross that

up confirm that I'm luminal and then the second question is what do you want to do with that there's gonna be a lot of discussions on whether you want Stan's direct me that can be hold hold on debate but I think a couple of things we

can agree we're crossing their courageous we're at the pop if we can minimize standing that region that be beneficial so for after ectomy couple of flavors there's the hawk device which

essentially has a little cutter asymmetrical cutter that allows you to actually shave that plaque and collect that plaque out there's also a horrible out there device that from CSI the dime back it's used to sort of really sort of

like a plaque modifier and softened down that plaque art so in this case I've used this the hawk device the hawk has a little bit of a of a bend in the proximal aspect of the catheter that lets you bias the the device to shape

the plaque so here what I've done you there you can see the the the the the teeth itself so you can tell we're lateral muta Liz or right or left is but it's very hard to see did some what's AP and posterior so usually

what I do is I hop left and right I turned the I about 45 degrees and now to hawk AP posterior I'm again just talking left to right so I can always see where the the the the AP ended so I can always tell without the the teeth

are angioplasty and then here once I'm done Joan nice caliber restored flow restored then we attacked the the common for most enosis and sfa stenosis again having that device be able to to an to direct

that device allows me to avoid sensing at the common femoral the the plaque is resolved from the common femoral I then turn it and then attack the the plaque on the lateral aspect again angioplasty restore flow into the common firm on the

proximal SFA so that was the there's the plaque that you can actually obtain from that Hawk so you're physically removing that that plaque so so that's you know that's the the restoration that flow just just you know I did attack the

posterior tibial I can cross that area I use the diamond back for that balloon did open it up second case is a woman

suite and we start talking about treatment of PA D we got to talk about Anatomy a little bit in levels so the

way we think about is three broad classifications we talk about a or two iliac disease which obviously involves the aorta and iliac arteries we talked about the fem-pop which involves this superficial femoral artery in the

popliteal artery and then we talk about the infra popliteal or below knee arteries and I will say more and more we discuss the infra maleo lore below ankle arteries because as our sophistication has gotten has got more progressive

we're able to not only treat sort of the arteries in the leg but the arteries actually into the foot and really reconstruct the foot arteries that are the end the the final off ramp to the ulcer so here's what we're looking at

you all see this all the time here's the distal eye order we have a common iliac arteries is a patient who's got terrible calcification in their proximal sfa you can see that there this is a superficial femoral artery that's diffusely diseased

looks terrible but that's through the thigh and this is a popliteal artery behind the knee the popliteal artery some I'm not sure anyone's heard this terminology or people use it but we talk

about p1 p2 p3 so p1 is the popliteal artery above the knee p2 is the popliteal artery at the knee p3 is the popliteal artery below the knee so sometimes we'll say you know we have to you know traverse a blowy p3 popliteal

artery segment so Bologna arteries you have three arteries as Kumar mentioned you have a tee perineal and PT it's very important that we have these arteries that especially profuse the ulcer there are a lot of anatomic variations and I

feel like my text and nurses here sort of we encounter these a lot where you have the posterior tibial artery coming off the polity or the answer tibial artery coming up high or low or whatever it is so just be aware of it this is a

classic patient where that's spaghetti there are no named arteries in that leg and so it's just nothingness and so we have to recreate what should be there again people died with diabetes patients with diabetes their distributions

different - they tend to have Bologna disease and so often we'll have a patient of the wound and we'll do an angiogram and you do the aorta you do the iliac you do the sfa you do the popliteal or the above knee popliteal

and ever in the rooms like oh sweet okay this is normal I guess we can go home and eat an early lunch and then you do the Bologna popliteal and you're like okay I guess we should cancel dinner so these patients often have just baloney

disease but it's awful Bologna nice disease again that if you close the end of the highway it's hard to reroute so this is sort of the most severe patients and unfortunately they're also the least likely to be treated okay and the reason

is Bologna artery disease is difficult it's much more difficult everyone and their cousin who's a vascular specialist cardiologist radiologist surgeon treats iliac and sfa disease there's not as many people treating Bologna disease

because it's more time consuming it's more technically challenging the patient population is difficult and unfortunately those are the ones who need it the most

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

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

other things that we look at tools that we use include the ankle and toe brachial indices those are these at blood pressure comparisons between the

arm and the foot or the toe the great first toe we use segmental pressures your blood pressures and multiple levels down the leg pulse volume recordings which look very similar with cuffs down the leg but they're looking at the size

of the leg per heartbeat PPG's which is basically pulse ox for the four individual toes TCP o2 which is very important and not used enough which is looking at the oxygen tension within the tissue itself and skin perfusion

pressure so ABI as I mentioned as a comparison the arm and the leg pressures and people with CLI often have an ABI less than point for the pressures gonna be less than 50 millimeters in mercury so the ABI may be falsely elevated

people who have chronic kidney disease because the vessels get calcified and they don't compress very well when you blow up the cuff increasing it above 0.45 after if it's been below that is somewhat predictive of wound healing but

not that helpful at the time of an angiogram so as the higher the two pressures is often used to calculate this because you have two pressures and each leg right you have it dorsalis pedis pressure that

you can get and you have posterior tibial so the way that you do in ABI is you look at the higher of the two and compare that to your arm pressure so just remember if your ulcer is being supplied by the vessel that's got the

lower pressure than your ABI is could be normal you could still have CLI so again not always that helpful the toe brachial indices is a it is a little bit more helpful people with diabetes only because the toe arteries tend not to

calcify as quickly in these patients less than 0.75 is considered abnormal and increasing it up into the normal range of course is predictive of fluid wound healing so limitations these only really look at

the macro vascular so that you know the named ves blood vessel patency they don't really tell you what's going on at the level of the capillaries and a recent meta-analysis suggests that neither of them can be consistently

relied upon as okay it came to a normal range we're definitely not gonna get an amputation now so I think I really do have to press both buttons each time so the systolic pressure measurements for segmental pressures you basically look

at the pressures on multiple levels of down the leg a drop of greater than 20 is considered significant and then severity of a number of lesions can't be totally determined from that again this only really tells you what's going on in

the named vessels pulse volume recordings these are cuffs that are looking at the volume of the limb with each pulse it's helpful and patients would they have non compressible vessels because the leg actually has a it's a

microscopic but detectable increase in size with each pulse and so this is better in people who have non compressible vessels and changes in PVR's often will actually precede angiographic findings CTA findings and

recent publication from the s from the society vascular surgery however calls into question their usefulness compared to a bi alone the good pictures are coming soon so this is an example what you may see in

the chart for some of your patients with critical limb ischemia so this is actually segmental pressure and pulse while recording from where I trained in Miami and basically what we're looking at is a combination of things on one of

these sheets so the pressures are listed in the middle but each sheet is going to be different depending on your institution so you're looking for a big drop and pressure from one level to the next so if you look for example in the

middle at the right leg you know there's a 176 in the arm and then there's a 126 in the high thigh normally because of gravity you should have an increase in flow at that level so that's already I have normal on the right side and then

progressing down any grade any drop greater than 20 suggested that something may be abnormal at that level PPG's these are really good for detecting what may be going on at the foot or lower levels so you transmit an infrared

signal through the toe and then try to see how much of that light comes out the other side essentially and so the amount of it it's depending on how much bloods in the digit and the flow the flow of the blood vessels so if you had a

previously flatlined signal then restoring a pulsatile signal is considered a and it you know an approved marker of tissue perfusion so this is essential in patients who have distal ulcers particularly in the level of the

toe because restoring you see you've probably all seen those of you that work in labs that do a lot of peripheral disease seen an angio graphic result where you get flow down to like the mid foot but you see no perfusion down to

the digits and unfortunately that's often not going to be enough to heal a wound so the PPG's are something I try to get in all patients who have tote tote ones so there's an example of a patient who

has flatline and all five digits on the right foot and we recant alized their anterior tibial artery and had flow all the way down there and there was a wound blush in the toe and this is the restore pulsatilla T in all five digits the next

day so at our institution now and also I've modeled after what it was with my training which is the day after the procedure we keep all these patients overnight we get an ABI i segmental pressures and pulsefire

recordings and PPG's and anyone who has flat waveforms in them in their foot level or anybody with a toll sir and if possible we try to get a duplex which you get which I'll go over next it's not always reimbursable at all institutions

if you do them in the same day though so TCP o2 as I mentioned is something that's a little underutilized I think the the task two recommendations that we actually use to stratify the different types of disease and perf arterial

disease suggest that all patients with CLI should have this testing done but it's hard because patients have to not smoke and not drink coffee or tea the morning of the exam and that's hard to get patients to do you have to keep the

room temperature controlled and so it's office availability is limited so an improvement values greater than forty millimeters of mercury in the area surrounding an ulcer suggests that it's going to have successful healing so we

often will do this before we take the patient for an angiogram as a baseline and then bring them back afterwards and if we're if we have a very large increase that you know that's a good sign but of course we're our goal is

usually to be greater than forty and it's one of the few of these tests that's actually useful in patients who don't have Doppler signals so this is a totally not fake wound on this right foot this is example of what it looks

like you basically put multiple probes around the area of the foot and you're testing for the different oxygen tensions skin perfusion pressures is analogous but slightly different basically you're inflating a cop over

different areas of tissue and until the blood flow stops and then slowly deflating it until you can detect light being transmitted through that area again greater than thirty values or predictive of wound healing a lot of

numbers and there will be a test at the end of this so this is a chart kind of showing the ischemic wounds healing likelihood is correlated with an increase in the skin perfusion pressure so if you're less than 30 you're

unlikely to heal if you're greater than 40 it's most likely not an excuse mcquown and you should start looking at other ideologies like venous disease or neuropath neuropathic disease or infection duplex ultrasound is extremely

of critical of ischemia well a lot of times it starts in our office with a physical examination so we do a risk

factor assessment and this is what happens before they get on our table with with everyone in this room and us seeing the patient assessment of intermittent claudication and it can be subtle many patients don't come in and

say oh yeah I have pain when I walk for a short time and then it I rest and it goes away a lot of times it's yeah you know my leg gives out or now it doesn't hurt it's kind of this weird feeling when I walk and it these atypical

symptoms and then obviously if they have a wound you have to a wound evaluation on physical examination things we're looking for feeling a pulse you'll be surprised how many primary care providers never feel a pulse and if we

say if you feel a pulse you may save a life because you may be the first one to say hey this patient doesn't have a pulse maybe they have got peripheral artery disease and if they prefer order these maybe have coronary artery disease

and maybe they should we start on aspirin or statin and save them from a heart attack and stroke and so you really can save a life abnormal capillary refill so in other words you've got such bad blood flow

that if you smush on their foot it takes a long time for that blood to come back because they have such poor perfusion there's something a Peugeot stess TWEN that if you lift their leg gravity alone pushes their blood isn't it overcomes

the force of blood and so there are foot becomes power becomes losing some color and then when you put them down it dilates and you get sort of this ruborous red color so that's a burger sign I just had a good example in clinic

about a week or two ago so what do we ask for patients do of any pain or discomfort in the leg thigh or butt with walking your exercise I will sell you tell you I often don't use the word pain because everyone thinks pain is

different so so some people say well it's not paying it's a key lake ease pain to me I'm a guy everything's pain to me right low low threshold but discomfort is a good way of asking it foot or toe pain

that disturbs your sleep do you have any skin ulcers or sores on your ankles feet or toes I think it's very important to know what kind of patient you're talking to in terms of Education level or in terms of just language so some patients

don't know what it all sir is and they use the term sore some people don't know what a sore is they used term wound and so just sort of you ask things different ways I think is really important when we all talk to our patients and again a lot

of classic history will miss a large majority of PAE because patients don't read the textbook the one thing I'll say is I hear this all the time well the patient had pulses and so they don't have P ad that is hashtag false and the

reason is pulse exam is insensitive so in other words even if you feel pulses they can still have peripheral artery disease okay now if you don't feel pulses they certainly have peripheral artery disease or you're just terrible

at it PID classification the way we talk about patients with PA D we use a classification scale called Rutherford it may come up so in other words patient who has PA D but asymptomatic is

Rutherford zero a patient who has got major tissue loss and is basically 1 for amputation is Rutherford 6 and then everything in between is sort of a gradation we cut off 3 to 4 so 3 is claudication pain only 4 is critical in

ischemia rest pain alright so rather for classification when we talk about wounds you may see this you don't need to go in details but there's a Wi-Fi classification that sort of Germans how bad is the ulcer and how likely are you

to to lose your leg it's sort of a prognostic I will remind you that in medicine there's differentials for everything in other words the patient comes to you with pain or you talk to your friend or whatever with pain

there's a lot of things in cause pain it could be back pain arthritis infection DVT so there's things we have to think about when I was in medical school I sort of loved this my OB GaN professor said when he sees a patient the first

thing he does is say what do I think this patient have if this were a man because you get so pigeon-holed in your specialty every patient we see as well must be vas here must be vas care but you've got to take a step back and say

okay well am I missing something maybe it's arthritis may something else so don't get pigeonholed by your own prejudices which is a good life lesson in general there's also a differential for wounds so obviously

when we see a wound we could have arterial arterial tends to be sort of the toes and distal foot it can be severe pain if you see an ulcer around the ankle that tends to be more venous so vein related which again we

can treat and then a common cause is neuropathic so if you see I'm sort of at the pressure points where people walk a lot of times patient diabetes will step on something and where you and I would be like oh man that hurts

I better oh my god I have a wound there I better check that out they'll never know because they don't feel their feet and so they could have this monster ulcer and finally someone inspects their feet and says you know you have like a

golf ball sized hole in your foot and that's the first time they ever notice it so how do we test ever for peripheral artery disease well a lot of it is non-invasive now we do a B is a b is is a measure of blood pressure in the foot

or leg we can do some ultrasound to actually look at the artery and obviously we can do CT and MRI when we look at ultrasound you may look at this every once a while this is a normal ultrasound Doppler waveform where we've

got good blood flow up down and back three now the reason that's important is that correlates the sounds so if you listen to a artery i'ma do my best Doppler impression out okay a normal artery goes once you start getting

peripheral artery disease you lose that triphasic waveform it becomes biphasic when you get severe peripheral artery disease you lose that biphasic waveform it becomes monophasic and when you have nothing it becomes

okay so here's want to be alert to that so ankle brachial index is important and it's helpful again some patients who have calcific us a-- fication it's not helpful for I will tell you a B eyes alone actually not only do they predict

PA D they predict death that's how important PA D is link to mortality CT and MRI is very useful you can see here we can see a good anatomic description of the arteries unfortunately patients with calcium

sometimes we can't see as well because the calcium is so bright on CT scan that it obscures the lumen so we have other problems in patients with diabetes and heavy calcification and a lot of those patients just need to go to angiogram

and as you know my techs and nurses know sometimes rarely but sometimes we do an angiogram and it's normal and we say or there's mild disease we say okay perfect we've taken that off the table we need to move on when some of these

non-invasive testings aren't as clear so alright so in summary critical of ischemia is a morbid disease and can be the first presentation of PA d clinical suspicion and accurate diagnosis is essential for early diagnosis and

treatment and a multidisciplinary team that includes vascular venture loss who know critical limb ischemia not just the SFA and iliac artery jockeys and wound care specialists do decrease amputation rates I like this quote it's not mine

but I'm going to steal it with impunity amputation is not a treatment option it is a treatment failure okay so we have to keep that in mind I appreciate everyone's attention because we can save questions to the end or you do it now if

there's pressing I think we may need new batteries or my thumb's weak which is also a possibility any questions

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

with shoulder I'll go through this hopefully in five five minutes and I'll be under like 20 so frozen shoulder we're going to shift gears so unlike

arthritis frozen shoulder is an inflammatory condition that starts out of nowhere the classic history is a 35 to 45 year old woman who wakes up in the morning and says my shoulder hurts they think they slept on it incorrectly and

the pain does not go away they take medication doesn't go away the pain is worse at night and they can't figure out why it takes him about a month or two to go to orthopedic surgeon the surgeon goes you have frozen

shoulder they can't lift their arm forward they can't lift it laterally and basically it hurts over the shoulder they don't have a rotator cuff tear they don't have an injury they're not a baseball pitcher these are just average

people who are otherwise normally healthy except sometimes it occurs in certain patient populations it's a very prevalent disease and these are some of the risk factors so being female sorry that's an increased risk factor type 1

type 2 diabetics patients with hyperthyroidism even people who have autoimmune disease because there's some inflammatory process going on there are multiple stages one to four like in every disease of course early on it's

just inflammation but you'll see as you get to stage four you get these adhesions and stiffness in the shoulder so if you see someone who's a year out from this diagnosis who's really slobbing symptoms they cannot lift

they're on many of these patients walk around just like this and you they'll go to shake their hand they can't even get their hand out any further than that and so it can be a really progressive disease and really disabling to be

honest on MRI you can see findings that suggest this so on the top two images there are arrows that show exactly what I showed you in the knee this is thickening of basically the lining of the shoulder and they see this actually

even when they do arthroscopy and they actually put a camera inside the joint in these people with frozen shoulder as well remember I showed you this slide earlier exactly what we know more blood vessels in the lining in patients with

frozen shoulder than not more nerves more blood vessels what's been done on frozen shoulder has this been done well that same doctor in Japan dr. Okun Oh had published a study a number of years ago where in 24 patients he injected the

same antibiotic and 2/3 of these patients got rapid pain relief just one week after the after the procedure he analyzed the show and 87% at a month and there was basically no worsening or recurrences in

these patients out to 36 months so very good very good results but again we wanted to replicate that here in the United States so we applied to the FDA for an investigational device exemption study we're performing this study

actually it's sponsored by Tomo and we're enrolling patients who have a diagnosis of frozen children were working very closely with an orthopedic surgeon who just specializes in shoulder joints he's actually a very well

recognized shoulder surgeon so these patients like our knee patients have to be refractory to something and what we're looking for and this is a patient in in our clinical study is that red arrow on the Left points to an image

where that synovium enhances and on the right where the synovium is thickened and same thing here this is a case where it's even worse you can even see that white capsule all the way around the joint very prominent enhancement the

problem with shoulder embolization and we thought this would be great we do all our cases radial for life you know we'll do prostates uterine fibroids y9t we're like this is gonna be great we only have to go from here to here and

everything's gonna be fantastic the problem is you'll see here from this angiogram just at the subclavian artery is that all the vessels come off pointed towards the hand nothing really comes off when you're going this way so

unfortunately when you're going in with your catheter everything looks like you're gonna be going you know reverse and that can make things really painful and you need a 2o French catheter to get into these because they're so small and

they don't make very many - Oh French pre-curved or pre shaped catheters so you have all these challenges that we thought were gonna be we didn't realize in the beginning and the other thing is write everything now has made radial -

coronary or radial two legs or radial - pelvis or celiac but the distance is you can imagine from here to here I need a 90 centimeter based catheter in a 110 or 120 micro catheter I don't really you know people make 80s and 80s aren't long

enough and people make one 10s and they're too long and so we really found this to be actually fairly more difficult than we realized there are also six arteries that you have to get into in the shoulder so it's very

tedious and you have to get into all these and when you're injecting embolic in and around the vertebral artery and you guys recognize that on the image that's on the screen that's the largest artery there so if you're going to get

reflux you want to avoid of course having a stroke so especially in these younger female patients over 35 to 45 and you're taking something and put at risk so it can be a little bit more of a challenging procedure and obviously

if you have you know physicians and a team who are used to doing things like prostate and advanced celiac embolization for example you know that kind of team will be used to this but they're definitely more challenges than

we realized and so there are six arteries that we have to get into and you can see that third one of how tiny that is and I'll go through all these really quickly this is the suprascapular artery okay this is the first branch we

actually just number them one to six and you could see over that shoulder on the left look how hyper vascular that's actually worse than the knee that's pre-imposed embolization okay this is the throttle acromial artery the

throttle chromia artery as you can imagine goes to the acromion process and the shoulder and you can see on the left it sort of drapes over the shoulder as that hyper vascularity this is the coracoid artery you will not

find this artery in any anatomic textbook anywhere when I flew to Japan to work with dr. Okun oh when I went there and he's like we're going into the coracoid I'm like where is this I'm sitting there on my cellphone like while

he's doing the case looking up the cord under I couldn't find it anywhere looked in Grey's Anatomy looked at oof lockers masculine angio textbook it's nowhere it exists and just like you think it goes right to the coracoid

process which you can see on the image on the right and you can see the degree of vascularity and it's responsible for this anterior pain that patients feel and here's the circumflex scapular artery most of you have probably seen

this in some form or another and as you can see it goes to the inferior aspect of the shoulder so that goes to the bottom of the capsule on the right you can see how it's coming right under the humeral head and then there's the

anterior and posterior humeral circumflex arteries one in front of the humeral head one behind the Hume right so these six arteries we have to get into and we have to figure out which are hyper vascular and that embolized them

and of course like in prostate like in every other place is going to be aberrant anatomy our very first case we go into I came back from Japan we're all excited to start the clinical trial I'm looking for the I'm looking for the

suprascapular artery and lo and behold it comes off the lean of the Lima and I'm like oh that's interesting you know how the heck we're getting in this and so you run into these challenges just like in any other situation and so we're

learning we're getting through this and learning about this patient population as well I will tell you so we don't I don't have any preliminary data to share because we just have done eight patients out of 20 but all but one had a dramatic

improvement I mean even far better than our knee patients they're coming in there like 10 out of 10 they're like do this I had a patient we made a video because she wants to show her orthopedic surgeon if her arms just throwing around

like this and she was like dancing in my office and I'm texting and pictures it's really remarkable and what's great about this is there's no treatment option so orthopedic surgeons said them to go get physical therapy take pain meds there's

nothing to do for these patients so this is a real opportunity hopefully by the end of you know this year we'll be finished and rolling and following up on these patients and we're hoping by maybe early 2020 which is not too far away

you'll probably see an fda-approved product even for the embolization so things are moving pretty quickly and just as just one case again if someone who has severe superior labral pain you can see the image on the right how

densely standing or vasco's it's very easy to see and I'll challenge you when you go back and you're doing a leg angiogram and you look and they do a run off and you see staining around the knee or some of that blush just reach over

and ask the patient and palpate right where it is and go do you have pain right here and I'll bet you they'll say yes you never really would have paid attention at any time before and now we do it kind of for fun when we're doing

our run offs for other reasons of course for CLI etc but it's really interesting and you'll go back and see that so in conclusion embolization really is an exciting has an exciting future really in the setting of msk related pain there

will be need to be many more larger studies of course this is still investigational we do not tell people to go out and start doing this we need to really better understand how angiogenesis really affects these

disease processes and with that I will finish thanks very much [Music]

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

but the heart of the program really is the second week and so we really talked about some of those disease states so renal diabetes heart failure getting into some of those basics and so the artis didn't necessarily get that in

school but we wanted to make sure that there's just a really basically a review of systems so that their understanding kind of again the whys behind like why is this important so you know why are we so

obsessed with the renals etc and contrast and then again we do more some basic ECG review day to is pretty much primarily the hemodynamic so we're looking at the heart heart cath we're looking at manipulating our human

dynamic monitoring system etc and then our third day we go into the deteriorating patient doing mock codes etc and looking at what kind of complications can happen and how to treat those or how to intervene if

you're circulating scrubbed in etc and then again day four and five is basically what they're as the clinical experience with their preceptor so again after the second week we've incorporated our real-time monitoring system how many

of you who have used the expert system monitoring system not too many okay it's okay so this is our this is what we monitor our patients with our nurses and our techs are trained to use the real-time monitoring system okay so it

is a little bit of intimidating when you see that especially if you're new to the lab so not only do you have your your normal monitoring system where you measure a lines and your arterial pressures and your blood pressures now

we're measuring waveforms cardiac rhythms possibly you know right heart pressures I'm sorry there's a lot of functions that are involved in our expert monitoring system so we really want to introduce our staff and our

learners to what they're going to expect when they hit the lab this is intimidating so we really want to focus on identifying the basics on these monitors so what is the right heart waveform look like what does right

arterial waveform look like atrial sorry right atrial pressure look like a Oh pressures etc so we really wanted to incorporate that so there's a lot of functions that we basically go over this is another example of an activity where

we ask them to identify waveforms and pressures normal and normal and the other picture is our mock code simulation we have a great simulation facility and our system we have to actually in the system and our

simulation specialists and our sim Center provide us with the one of the best facilities for practicing and simulating different scenarios we have a feedback mannequin it's a high fidelity feedback mannequin and for our

technologists who have not gone through ACLs and have BLS will experience pre learning if you will before they do receive their ACLS certification so compressions showing you effective compressions showing you how to insert

an OPA are you going deep enough are you going fast enough so this is a mock code experience for our technologists and our nurses which helps them prepare them for the lab experience and how many of you probably trained on the job like you

know here this is how we handle the code oh here it is this is what's happening so we want to really go over like what's happening you know kind of define those rules beforehand so that people can know what to expect or at least try to

anticipate what to happen or what to do when a code happens and so the last week

my talk is titled extremely obvious IR and I think as we move through these slides you guys are going to be able to pick up really quickly on why I elected for that title so this is a patient this is a 67 year old male he had an Evo repair in 2014 in 2015 he

underwent two repairs for persistent type 2 endo leak and this was done via transsexual approach in 2018 we got a CTA that demonstrated an enlarging aneurysm sac so here's just some key critical images from the CT I had the CT

and its entirety today but I had to like panic dump a lot of slides off of my powerpoint I'm always the girl at the airport that you see transferring things from one suitcase to the other like right when it's about to get onto the

airplane so what do we notice about where we see the contrast in these in these images so is it anterior is it posterior anyone its anterior so what if I told you that we see contrast in the anterior sac but this patient has an

included ima where is it coming from so we get the CTA we see any large aneurysm sac we see it an endo leak we bring them into clinic we go through the routine things the patient denies abdominal pain they deny back pain and so we go ahead

and all of our infinite wisdom and we schedule them for a trans cable approach to repair what we call a type 2 and delete now one of the most the most important key sentences from the workup is we say this is likely a type 2 in the

leak but a feeding vessel is not identified okay so our usual algorithm at UVA if we get a patient we do a CTA we bring we see any sort of endo leak if we cannot identify a feeding vessel usually what we do and you can let me

know if this is the same at your practice or if it's different we'll bring them in and we'll do some dynamic imaging from an arterial approach and we'll try to see you know is it really type 2 can we identify a feeding vessel

and oftentimes what happens in those situations is you you identify oh it is a type 2 we just see where it was from and we're gonna have to bring them back and we're gonna have to put them prone and we're gonna

have to stick the stack directly so we thought we were gonna outsmart it this time like we we were gonna just identify that it was typed to you right from the get-go do I have the play button or do you have the play button awesome all

right so this is our trans cable access so what we're doing these days to do our trans cable access and our fenestrations is we're actually using a t lab kit so we're using the transjugular liver biopsy sheath and we're putting our

65-centimetre cheap a needle through that so everything's going great so far we see our sheath in access goes smoothly I might have gone for two slides can you hit the I'm not sure yeah go ahead and hit that nope go ahead and

go one for slide and then just play that video for me yes please awesome so this happens pretty quickly can you play that video again and just keep playing it through on a loop and so we do an injection from our microcatheter from

our trans cable approach and what do you guys noticing where are you noticing the contrast tracking yeah in the red circle [Music] it is now right so everybody at UVA is is a proficient Monday Morning

Quarterback let me tell you so we see the contrast tracking down outside of the iliac limb so now we're all going okay can you go ahead all right go ahead and play this video all right so we get access into the femoral artery

just to make sure because at this point we're hoping against hope we haven't put this on the patient we haven't put this patient on the table MANET made a trans cable puncture only to identify that this patient does in fact have a type 1

B in delete but our arterial access proved that is exactly what we did the junction of the yes we did we did a trans cable puncture to identify that it was a junction leak so that's a problem right because we have

this action going on right so we have a trans cable puncture as dr. Haskell just adapt ly summarized we have a trans cable puncture we've done nothing so far but identify that this patient has the type 2 in a week so it is a micro

catheter right it's just it's just a party foul and then it was the fellow's dream because you pull out and there's nothing to hold pressure on there's nobody's dream at that point so I want to stop here and I want to just take a

moment you guys can live my psych at night so do you ever your so my normal algorithm for my patient since I come in in the morning I look at the patient's chart I review their prior imaging and I try to

do all of these things before looking at my attendings plan because one of the things that I realized is that challenges me to try to figure out what's my plan for the patient what do I think the most appropriate inventory

would be and every once in a while you see something in the plan that doesn't quite jive and you're like there's this is likely a type 2 in the league although a feeding vessel is not identified so I have two options at this

point I either walk down to the reading room and I say hey someone tell me what's going on we don't identify that type - is it worth doing a diagnostic imaging or anyway I just roll with it and this

was a day where I elected to roll with it and so I just want to take a moment and reiterate it's always important for all of us to you know you have a voice and use it and you want to bring up these

things that's sometimes we all start going through the motions where you work with someone that you trust a lot it's really easy to say like Oh someone's smarter than me caught that right so going back it's like it's like that

terrible joke what is the radiologists favorite plant the hedge mmm that's what that is it's like well it could be but it might be and ray'll right you go ahead and play this so this is just our walk of shame as

we're casually embolizing our track out of our trans cable approach and here we are back in clinic so again this is a 67 year old manual with recent angiogram that demonstrates significant type 1b endo leak and we plan for an extension

of the left aortic lab so we bring the patient back we do a standard comment from our artery approach we get into the internal iliac we identify the iliolumbar all kit all standard things we drop an amp at Sur plug to prevent

any sort of further type to end a leak into the limb that we go ahead and extend we put in the iliac limb we balloon it open we'll go ahead and play this video and our follow-up angiogram reveals a resolved type to end a week so

ultimately we did it so what are

fish through creation one is screening with ultrasound you really have to be able to look at these patients and I'm you know when I talk to our physicians they say we have a great

ultrasonographer named Megan and so I say the first thing you need to get yourself a meg everybody needs a meg and May because meg knows what to look for what to look for what's a measure where to get flows and she submits that to us

now other than the anatomic part you know at our place you know we're very particular about and selected we try to be thoughtful about you know who gets what access and that's what the new dokey guidelines are gonna say you know

the best access for the right person at the right time so for example you know if you come in with a catheter and we can you know we'd won from a 275 mile radius people come to us you know for access because you know they they've

they've been given up the cases have been given up by local people and you've got a catheter my first thing I say is how long is the catheter been in and they said well catheters been in for eight months you're not getting a

percutaneous fistula if your catheters been in for eight months I'm gonna call one of the surgeons think I am with part of my group you know we have no competition there's no turf wars we're all friends we like each other we like

working together it's a great place I say Karl Karl Willy who was recently from Tampa - Karl illustration - sick catheter for six months is okay I'm going to create they put a flick seen graphed in the

upper arm probably with a suture listen a stenosis and pull the catheter tomorrow that patient's going to be dilating with a graph where the dialyzer will be graphed you know because after six months you don't want a cath over

there when you start going down that road of infection endocarditis vascular damage all that kind of stuff if you come in and you started with a catheter because somebody wasn't looking ahead far enough and you got a catheter and

they come here for accents placement catheters been in for you know two weeks three weeks one month there's a good chance you're gonna be seriously mapped for a percutaneous special because now we have time we've got we arbitrarily

have considered the six months window that we can probably work with the catheter there's nothing to prove that there's nothing in the literature in fact I had a discussion last night with someone from one of the companies who

wants to do some type of a trial to look and see when can these catheters really do go bad and so you're gonna get worked up for a percutaneous fish and clearly if you come with stage four you know know you're not on dialysis they don't

know when you're gonna go into Alice's but they you know you're going in that direction you're gonna get seriously worked up for a percutaneous fistula one patients are still psychologically trying to wrap their head around the

fact that they're going to be on dialysis it's much easier to tell them you come in you're gonna get a puncture two punctures you're gonna go home with a band-aid and we'll take care of this we'll get this up and running over the

next six weeks eight weeks ten weeks and when you need it it's gonna be ready to go and you won't need a catheter then we tell them you don't not gonna need this catheter sticking out of your neck they're very happy and they usually

agree to do the percutaneous miss doula also since you don't get those big ropey fish - as I talked about when these patients are in dialysis you know how many people ever been to a dialysis unit that's how I tell physicians you want to

you know you want to look build a practice like this go to the dialysis unit talk to the charge charge nurse do rounds once a month or once every couple of weeks with a nephrologist and that's how you build the practice but these

patients they're in the chairs they're talking to each other right and they say hey how come you don't look like a cling-on you know with this big veins you know you where's your fistula and then they want that you know they it's

really cosmetically very pleasing these patients are so deserving and they have such horrible I was being tied to that machine three days a week so any little bit of hope we can give them I think is is worth it alright in summary it's not

a one-step procedure and then we try to make patients understand this you may need a secondary angioplasty or embolization in the future hopefully not usually about 30% of the time has great value in the stage Forge so we

talked about more acceptable to patients coming to grips with their future may make a significant difference with the catheter people starting with a catheter and I think whoever is going to do this really has to have a commitment to

access this is not you're not doing a procedure you're actually developing a treatment plan or a treatment system and so then these patients are yours once you do this you're following them you're keeping them working you know how do you

sell this to the surgeon you sell to the surgeons this way because if you start this program you know people are gonna start coming to you they're gonna come out of the woodwork it's like if we start doing AVM stuff that they start to

come from nowhere and you're gonna draw so many patients the in that surgeons are going to have more work and there's no question because everybody's not going to be a candidate and so I mean when bobwhite if hopkins years ago

started doing angioplasty the business of surgery increased by 15% so you're gonna see you're gonna make the pie bigger that's how you sell it you're making the pie bigger and everybody can feast on the pie leverages our expertise

as interventional radiologists and image guided procedure list to make these procedures work I think we're in a great position a really great position if you listen to Alan Matsumoto the other day at the toddler lecture we're in a great

position for the new age of medicine and it may be the ideal procedure for multidisciplinary collaboration I can't do basilic vein transpositions or elevations or brachial vein elevations so it's good to have a surgeon that

you're friendly with that will make these things happen they're all part of the group that's necessary and I think that could be it yes ah I'm from New York and I'm a shameless marketer and so I would encourage you if you're

interested or some of your attendings or interests come to the vasa practicum it's gonna be done in Houston with dr. Eric Pete and chief of vascular surgery is running the meeting you get to put your hands on all these devices and put

and stuff you can all do it I mean it doesn't have to be doctors you have big models and they'll have live cases and it's a great opportunity in 2020 since I'm the president-elect of Vassar we're gonna run the meeting in

Charleston that's gonna be held out a hell of a lot of fun so we encourage you to come to Charleston in 2020 thank you very much not questions yeah

very helpful these patients the calcium this and the vessels can be

seen through with the MRA it doesn't it doesn't cause as much artifact so it could be easier to see what's going on in calcified vessels additionally you saw an image in Marc's talk as well of this is an example of a time-resolved

image of an MRA or you can basically recreate exactly what you're seeing in an angiogram and this could be very helpful to kind of determine what kind of TVL disease you're getting yourself into

newer MRI techniques that we're using in the evaluation patients with PID functional MRI which compares the ratio of how much oxygen versus deoxygenated hemoglobin we have in a tissue so we can apply this to a pre and post exercise

scenario in patients to have claudication as well although it's not it's only approved in research protocols this is an example of what you see for that so pre intervention here's the CTA image reconstruct

in 3d with a long segment an iliac occlusion and then post intervention you can see there's a standard reconstructed vessel and the you can both chart this out and do it and superimpose it on the MRA image and you're gonna get an actual

quantitative amount of tissue reperfusion but studies are still ongoing to determine just how much increasing the amount of red that's in that image is important we don't know the answer to that yet here's just

another example a patient underwent an anterior tibial artery recanalization and you can see the improvement in the t2 star which is just one of the one of the measurements that you can use on these images so what's on the horizon

improvement so this is an example that we've treated at Michigan us a 67 year old female patient who has CTF she's gone through sort of a treatment she

turned down so she was not a good candidate for surgery because her disease is distally it's in the sub segmental branches so we went back and forth for you actually on this patient when we're

starting our program and decided that she would be the right patient to start she followed instructions she was her disease was severe enough that I was affecting her life she couldn't walk from here to the back of the room she

was on medication she didn't qualify for the surgery so we said she'd be the right wand and so we started with a pulmonary angiogram you can see there's disease it's not the worst patient that you would see because those would be

surgical but well you see those arrow heads there's areas of webs there's areas of occlusions and stenosis so she's got all the different types of pathology morphology would be great for treatment so what we did as we do in all

these cases get a wire across it if we can wreak analyze it we get a wire we never use hydrophilic wires that's actually contraindicated in these so you never use like a glide wire an O and a glide wire you never use a v 18 or any

of those types of wires because those have a higher risk of perforation frequently we actually use coronary wires from the inner from our colleagues in interventional cardiology you cross the lesion and then you balloon it with

a very very very small balloon so you do not want to get aggressive in these patients we start with a two millimeter balloon even if the vessel should be four or five millimeters we always start with the two millimeter balloon and you

can bring them back and do another intervention in a few months at without a larger sized balloon so in this patient we ballooned two branches in the right lower lobe and then this is what it looks like afterwards so you have

improved flow it doesn't look perfect we're not going for perfect we're going for profusion so if you think about that same thing with acute PE you're not going for a perfect image you just want to get perfusion distally and then the

body will figure it out afterwards so

thrombectomy is another popular way of treating patients there's a lot of different aspiration catheters the SPX catheter is actually not available currently in the US but what it basically is I can have the rectum a

device that spins in such backlot the Indigo thrombectomy system from penumbra is a yet another device that sucks out clot I think many of us have used that it's kind of like a vacuum cleaner but usually more like a dust

hand vac where it's going to suck up thrombus the angio vac is much more like a Hoover where you're going to use and put a patient on veno-venous bypass that requires a 22 French sheath and a 17 French sheath but that will take out

thrombus I personally prefer using NGO vac in the IVC in big large thrombus for that and not in the pulmonary arteries because it's very inflexible but it's very very useful in a few patient populations in

all of these devices there is no TPA that needs to be given you're just sucking out the clot and you're actually removing it from the patient's body rather than dissolving it and sending it downstream the drawbacks on all of these

devices is their larger access points the SP or X is around six French although that's not that much bigger penumbra device is 8 French and the as we mentioned the angio vac is 22 French

here a little bit okay the ellipsis device Avenue medical from California developed by Jeff Howe in Richmond ultrasound imaging only don't need

fluoroscopy everybody in the room like staff they'd off to where lid you advance the needle into the either the very distal cephalic vein or through the actual perforator under ultrasound and once you're there you

follow the tip of the needle keeping it in the center of the lumen of the vein under ultrasound guided down to the point where it's just adjacent to the radial artery and then once you're adjacent to the radial artery this may

take a little bit of torquing of the needle but you know even putting in PICC lines for what 15 years 20 years so it's nothing not more difficult than that which is you know why I tell the fellows do the PICC lines you're not doing the

PICC lines just to do pickle and you're doing them so you can do these kinds of procedures then you puncture the radial artery then you get arterial blood flow you put a wire down and you get a sheath down and you put the device down I'll

show you the device in just a second it's called tissue welding it's an electronic device that creates a anastomosis doesn't really succumb to any problems with vascular wall calcifications usually takes just 30 to

45 minutes I did the last one the other day in 15 minutes and angioplasty the anastomosis immediately following the creation of the fissure with a 5 millimeter 1/8 balloon of your choice here's the device you can see it opens

up there's like a little bit of a window there and so it goes down through the vein it crosses over into the artery you're able to see this under ultrasound you position that window as you see on the right with the artery and wall the

vein artery vein and artery walls between that space and then the debate the device closes down on them then the machine will give you a reading of what the distances you push to the button and you got a fistula and it's very pretty

straightforward then you go ahead and balloon that with a five millimeter balloon to make sure the anastomosis is open and running and that's it then you pull out and you can compress with one finger you know on the vein and here's a

look at the the anatomic and that's office Jilla that it does create you know you don't mobilize there's no surgical trauma patient goes home with a couple of band-aids here's a dissection with ultrasound of the area that you're

working in there on the right you can see the perforator coming down it's sitting over the PRA the right proximal radial artery and that's right where you're going to make your puncture from one vessel into the other and this is

what you're left with on the left of course you see a big surgical scar from a prior creation of probably in the brachiocephalic fistula and on the right you can see the very prominent cephalic vein after fish through the creation

which is getting ready to to be punctured here's the illustration of what you've just done again perforating vein going down towards the radial artery create the fish stool and now you have a brachial artery down radial

artery so you have a radial proximal radial perforating vein fistula I don't know whether it hopefully it goes up the cephalic vein if it goes up the basilic vein you may have to consider doing transpositions or elevation to get that

vein in a position of yeah so that it can't be punctured here's another ultrasound from one of our cases again showing a nice you know red to blue flow of the fistula here's another one you know I have to see these a while you say

wow it's really pretty amazing and what we do is we get velocity measurements at the time of the procedure one week later then at four weeks later and at four weeks if they're not flowing at least 500 to 600 cc's a minute then we'll go

in and do a secondary balloon or something to get things going there's that same patients actually this is our patients arm it's a different patient and you can see the flow map there and when you see that diastolic component

got halfway up the systolic that means you're flowing at about 600 500 to 600 cc's a minute it's a good indication that you've got a you've created a fistula with working potential if you have to re intervene it's a radial

puncture you go right up the the radial artery I'm sure your dad is familiar with doing that for the most part and that goes right across that and ask Tomo system so if you have to dilate the anastomosis to get a larger you're in

good position if you have to go up and redirect flow by embolization of small collaterals nor the brachial veins now you can do that all from the the radius it's nice highway right up into the fistula

and here's the results of the FDA trial

today okay go forward so sorry now when it says is there any commercial bias really there's only two companies that have this device so if I speak about each one clearly there's going to be a

little bit of commercial discussion but as I people always ask me which one do you prefer and I always have to tell them quickly you know I'm not a salesman for either company as a matter of fact I'm more

like a test pilot and we're still in the very early stages of this and which device may be better however you wanted to find that or easier to use or what the data is going to show we don't really know yet so but we're fortunate

that we have access to both devices for our patients a couple of things we know and dialysis patients start 80% start with catheters bad okay and catheters bad if you get anything out of this lecture catheters bad about 28 to 53

percent failure to mature means they have a fistula it's physiologically working but it never matures to be able to use for hemodialysis time to maturation three to four months

interventions per year required angioplasty you know embolization you guys know all about this stuff trying to read Evert flow back into the main channel of the fishhook and patients about 30 up to 30

percent just refused once they have our fish to them for whatever reason they refused to have it cannulated you know they don't like the pain it's in an awkward position whatever but the idea of percutaneous

which was may actually put a big dent in that Kathy first-line initiating dialysis with catheters because many times these patients come then they need to houses right away they get a catheter but if we know you know these things

usually except you know for toxic injury like ingesting antifreeze and stuff like that most you know frolla just know these patients are headed towards dialysis well in advance of the time they need it and so these calls stage

four and stage renal disease these patients can get percutaneous fistulas and when it's time then they'll have a running blood access ready and totally avoid the need to have a catheter placed

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

higher procedures that get done in the country so they are from being basics such as being para sentences and in some

centers being quite complex in Euro work and there are centers where these none of all those that IR procedures being available so it's a very unequal distribution of provision of IR services and like I mentioned earlier on vascular

surgeons and cardiologists have basically taken over the peripheral vascular work and iogic work and other known neuro speciality such as bid early interventions for example saying that these two surgeons who are in some

remote centers who are doing their own provision as biliary basic interventions there is one neuro surgeon who went and had neuro imaging and then your interventional training who is now hundred percent doing a mural

intervention so as far as procedures go my day can be in diagnostic work and you might be dreaming you doing a paracentesis the next thing you might be doing some some I our basic IR and on the same day you might be doing a set

procedure so quite varied but not available in all centers as one would want as fine stuff goes the technology

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

next is me talking about Egypt and Ethiopia and how I are how IRS practice in Egypt and Ethiopia and I think feather and Musti is gonna talk a little bit about Ethiopia as well he's got a

lot of experience about in about Ethiopia I chose these two countries to show you the kind of the the the the difference between different countries with within Africa Egypt is the 20th economy worldwide by GDP third largest

economy in Africa by some estimates the largest economy in Africa it's about a hundred million people about a little-little and about thirty percent of the population in the u.s. 15 florist's population worldwide and has

about a little over a hundred ir's right now 15 years ago they had less than ten IRS and fifteen years ago they had maybe two to three IRS at a hundred percent nowadays they're exceeding a hundred IRS so tremendous gross in the last 15 years

in the other hand Ethiopia is a very similar sized country but they only have three to five IRS that are not a hundred percent IRS and are still many of them are under training so there are major differences between countries within

within Africa countries that still need a lot of help and a lot of growth and countries that are like ten fifteen years ahead as far as as far as intervention ready intervention radiology

most of the practice in Ethiopia are basic biopsies drainages and vascular access but there is new workshops with with embolization as well as well as well as vascular access in Egypt the the ir practice is heavily into

interventional oncology and cancer that's the bulk that's the bulk of their of their practices you also get very strong neuro intervention radiology and that's mostly most of these are French trained and not

American trains so they're the neuro IRS in Egypt or heavily French and Belgian trains with with french-speaking influence but the bulk of the body iron that's not neuro is mostly cancer and it involves y9e tastes ablations high-end

ablations there's no cryoablation in Egypt there is high-end like like a nano knife reverse electric race electroporation in Egypt as well but there is no cryo you also get a specialty embolization such as fibroids

prostate and embroiders are big in Egypt they're growing very very rapidly especially prostates hemorrhoids and fibroids is an older one but it's still there's still a lot of growth for fibroid embolization zyou FES in Egypt

there's some portal portal intervention there's a lot of need for that but not a lot of IRS are actually doing portal intervention and then there's nonvascular such as billary gu there's also vascular access a lot of

the vascular access is actually done by nephrology and is not done by not not done by r is done by some high RS varicose veins done by vascular surgery and done by IRS as an outpatient there's a lot of visceral angiography as well

renal and transplants stuff so it's pretty high ends they do not do P ad very few IR s and maybe probably two IR s in the country that actually do P ad the the rest of the P ad is actually endovascular PA DS done by vascular

surgery a Horta is done all by vascular surgery and cardiothoracic surgery it's not done it's not done by IR IR s are asked just to help with embolization sometimes help with trying to get a catheter in a certain area but it's

really run by by vascular surgeons but but most more or less it's it's the whole gamut and I'm going to give you a little example of how things are different that when it comes to a Kannamma 'kz there's no dialysis work

they don't do Pfister grams they don't do D clots the reason for that is the vascular surgeons are actually very good at establishing fishless and they usually don't have a

lot of problems with it sometimes if the fistula is from Beau's door narrowed it's surgically revised they do a surgical thrombectomy because it's a lot cheaper it's a lot cheaper than balloons sheaths and and trying to and try a TPA

is very expensive it's a lot cheaper for a surgeon to just clean it out surgically and resuture it there's no there's no inventory there are no expensive consumables so we don't see dialysis as far as fistula or dialysis

conduits at all in Egypt and that's usually a trend in developed in developed countries next we'll talk

about massive PE so let's remember this slide 25 to 65 percent mortality what do we do with this what's our goal what's

our role as interventionalists here well we need to rescue these patients from death you know this it's a coin flip that they're going to die we need to really that there's only one job we have is to save this person's life get them

out of that vicious cycle get more blood into the left ventricle and get their systemic blood pressure up what are our tools systemic thrombolysis at the top catherine directed therapy at the right and surgical level that what

unblocked me at the left as I said before the easiest thing to do is put an IV in and give systemic thrombolysis but what's interesting is it's very much underused so this is a study from Paul Stein he looked at the National

inpatient sample database and he found that patients that got thrombolytic therapy with hypotension and this is all based on icd-10 coding actually had a better outcome than those who didn't we have several other studies that support

this but you look at this and it seems like our use of thrombolytics and massive PE is going down and I think into the for whatever reason that that the specter of bleeding is really on people's minds and and for and we're not

using systemic thrombolysis as often as we should that being said there are cases in which thrombolytics are contraindicated or in which they fail and that opens the door for these other therapies surgical unblocked demand

catheter active therapy surgical unblocked mean really does have a role here I'm not going to speak about it because I'm an interventionist but we can't forget that so catheter directed therapy all sorts

of potential options you got the angio vac device over here you've got the penumbra cat 8 device here you've got an infusion catheter both here and here you've got the cleaner device I haven't pictured the inari float

Reaver which is a great new device that's entered the market as well my message to you is that you can throw the kitchen sink at these patients whatever it takes to open up a channel and get blood to the left ventricle you can do

now that being said there is the angio jet which has a blackbox warning in the pulmonary artery I will never use it because I'm not used to using it but you talk to Alan Matsumoto Zieve Haskell these guys have a lot of experience with

the androgen and PE they know how to use it but I would say though they're the only two people that I know that should use that device because it is associated with increased death within the setting of PE we don't really know you know with

great precision why that happens but theoretically what that causes is a release of adenosine can cause bradycardia bradycardia and massive p/e they just don't mix well so

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

predictors of a successful or vascular ization there are several so obviously you know you have a great result Andrew

graphically when you say hey the vessels back that wasn't there before so Payton see if a previously occluded vessel is a good sign but what else improve vessel caliber so after an angioplasty the vessel becomes you know more normal and

caliber the flow velocity increases or the outflow improves you see less collateral so that's a good sign that you've done something good because those collaterals have only gotten large because of increased pressure and the

normal outflow vessel and then increased distal branch opacification Perry procedurally things that you can look at that indicators of success are if the pulses returned or if you have a Doppler signal

that either comes back or goes from a mono phasic I'm not gonna repeat those sounds they were way above my pay grade but go from a mono phasic signal back to a normal triphasic or sometimes even biphasic is pretty close to normal

particularly in diabetics skin discs skin coloration you sit you may see a foot pink up relatively quickly after a good revascularization and actually some patients may develop rube or if they've had prolonged ischemia because their

capillaries are chronically dilated so you now sending flow into chronically dilate a capillary bed and they may get rubriz capillary refill time as you mentioned earlier may decrease to a normal range to less than 5 seconds and

ulcerations I've seen them just begin weeping or bleeding right on the table if you do a really good job upon awaking from sedation patients who have rest paint off and indicate that the pain is gone but you have to remember that

patients with wounds may actually wake up and be in a lot of pain because you're reap refusing an area that's been dead for or dying for a long time so the wound blush is something that I'm always looking for and I'm frustrated if I

don't see it and basically this is analogous to when the when the ulcer begins bleeding after a good revascularization you may see Andrew graphically that there's now a contrast blush in the area of the ulcer and so I

like to mark on the patient usually with a hemostat or something the area of the ulcer and take my final angiogram just to kind of know where it is and to be looking for that it may it not always be visible as it may take time for the

capillary network to adapt to the new flow pathways and for basal spasm to resolve but this is an example of a patient has an ulcer underneath the base of their big toe after revascularize them and you can see

that there's increased perfusion to that area so this is a sign of a good result

who came in with just over she had a four month with delayed heal wound she finally presented at us after the wound

healed because she had rest pain that wasn't recognized they thought the pain was due to the the wound the wound healed and they realized oh she still has pain well that's because she has crippled limb ischemia and so she was

she was brought in for that just you know she has bilateral disease I'm just gonna concentrate on talking about the right leg for for today's discussion but she does have inflow disease in these types of patients I do get

cross-sectional imaging so I can determine just how extensive the iliac diseases or if it involves the aorta to then determine what it what to make sort of jumping into it so the right leg again she has about a 10-7

occlusion of the bright SFA this occlusion here's the femur for reference the knee is actually down way down here so this is actually just above the a doctor again tried to use in this case I did do wire work I got past a good

portion of it here's my wire right here and here's the O pacified lumen so what you can see is the wires actually adjacent to the lumen so at this point I'm re said suspecting that I'm sub intimal I confirm that by removing the

wire do little puff there's blushing that blush is up intimal so I know I'm sub intimal so at this point what were the things you can do obviously the first things you do try to pull that back try to find a different space a

different location to wreak analyze when that's not successful then you start thinking about southern super recanalization multiple devices for that there's the outback device which is a little hook that you can try to spear

yourself into the main lumen and pass a wire there's also device from Medtronic about the anterior device what this is it's a balloon that you inflate to sort of stick yourself into that wall it has two ports that are on the side one

points one direction one points the other direction it allows you to find that open lumen and we use a re-entry angled wire to get back in so in this case just as a cartoon here's the the anterior device place downward this is

would be the balloon inflated you would basically jab into the port into the into the main lumen so that's sort of basically what I did here again here's the agile device each of the ports you can see as a little divot once you put

it sideways you can determine which we are going to stick there's my wire right into the lumen and there it is down further into the rest of the the vessel subsequent to that pre-dive it with a three and then overlapping

since were used finally here is her post i did treat both legs but you can see just the dramatic difference going from the monophasic waveforms to tri-phasic waveforms restoration table api's for her I couldn't help but throw this in

I would like to convince you that

claudication is a different disease than critical limb ischemia even though it's the same on you're lying principle it's a different disease and here's why what is the fate of a Claude account so in five years

most Claude Akins are stable now I'm not saying they're living without pain I'm not trying to diminish their symptoms they may say look I can I can't live my life because I'm you know it hurts to walk from here to there and I'm sorry

but at the end of the day most of them will be stable they're not gonna dot they're not gonna get worse and they're not gonna have an amputation only a small percentage progress to critical of ischemia now let's look at the fate of a

critical limb ischemia patient in one year the majority are either dead or have another amputation have a bilateral heba have lost one of their legs and a lot of them have lost both their legs and so this is a serious mortal morbid

disease in fact if you look at it compared to some cancers critical of ischemia has a worse overall survival than a lot of common cancers and when I was trained my mentor used to say CLI critical mass Kimia is cancer by another

name we just have to treat it like palliation okay and that becomes important the way we treat things so when I treat a Claddagh Kent I am really looking toward their entire life you know is this treatment worth it I don't

want to make you worse with a critical limb ischemia patient I am all hands on deck we're gonna do everything we can and why every 20 seconds a lower limb is lost to diabetes patients with rest pain or gangrene really need to see a

specialist I've asked your specialist not any vascular specialist a basket specialist who knows how to do critical an ischemia okay so I'm from North Carolina or I live in North Carolina now cardiovascular disease rates were you

know obviously toward toward the south hi here's the amputation rates we are right there in the amputation belt if you look at the dark blue they sort of along the south and into Texas and we're all in the amputation belt right now

because we're all in Texas and so we do way way too many amputations sadly over 50% of patients who have an amputation never had an angiogram so in other words that doesn't mean someone tried and failed which is at least respectable you

know at least tried it's we never looked we never even bothered now there's a lot of amputations that should if someone's septic and dying or sure or limbs unsalvageable of course yeah you don't just take the like I understand

that but that's not 50% that is a lot of patients who no-one's even bother looking so how do we make the diagnosis

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

patient female patient who has the sudden onset of upper abdominal pain here's the CT we did all these cases in one day it was crazy it was terrible so so here's a big hematoma a big peritoneal hematoma you

can see it anterior to the right kidney you can see the white blob of contrast right in the middle of the hematoma that's a pseudoaneurysm or even active extravagance um less experienced people would probably say it's active

extravagant I think most of us would prefer that it be called kind of a pseudoaneurysm this active extrapolation would be much more cloudy and spread out this is more constrained and you can see on the

coronal image you get a sense that there's that hematoma same type of problem all right is there more imaging that we can do to figure out the next step again I said earlier earlier in this lecture

that sometimes we use CTA now sometimes a CTA is worthwhile I do find that for a lot of these patients I think we're getting smarter and we're doing CTAs right at the beginning of this whole thing you know when a trauma

patient comes in we're getting CTAs so we can max out the amount of information that we get on the initial diagnostic imaging here's what we're seeing on the CTA and in this particular case I think it's pretty clear that you can see the

pseudoaneurysm arising from what looks like a branch of the superior mesenteric artery so this is just an odd visceral and Jake visceral aneurysm which looks like it probably ruptured I don't have an explanation for it led to a big

hematoma here's what that is and now we're gonna do an angiogram the neat thing is it just perfectly correlated with a conventional angiogram so here's our super mesenteric angiogram all right the supreme mesenteric artery

on the first image to the left is that vessel going downward towards the right side of the screen all those vessels coming off are really just collateral vessels going up to the liver through the gastroduodenal artery again that

left one looks pretty good it's not until you see the delayed image on the right that you see that area of contrast all right so that's the finding that correlates with the CT scan all right here we're able to get in there you put

a micro catheter in that vessel alright the key next step for this patient as I mentioned earlier is the whole concept of front door and back door so here we're technically in the front door the next thing that we do is we put the

catheter past the area of injury and now we embolize right across the injury because remember once you embolize one thing flow is gonna change we screw it up body the body wants to preserve its flow if we block flow

somewhere the body's gonna reroute blood to get to where we blocked it so we want to think ahead and we want to say okay we're blocking this vessel how's the body going to react and let's let's get in the way of that happening that's what

we did here so we saw the pathology we went past it we embolized all across the pathology and boom now we don't have anymore bleeding and the likelihood of recurrence is gonna be very low for that patient because we went all the way

across the abnormality and I think from

so my Xtreme ir case is a TVR with on a patient with a type you tie section and then we use laser to find a straight the dissection flap and I just want to before I start I just want to give a big shout-out to my attending dr. Kasia and Rudy pump Adi on our IR resident Rudy

put these really cool illustrations together as you will see on these upcoming slides and dr. Kaja he did this case and basically it helps me with everything so since your old male patient presenting with history of

chronic type UTI section um he was medically managed with and I'll G Saxena antihypertensives and then he came into the ER a couple months later and it was complaining of severe back and chest pain so a CTA was

performed and and they found that there was a significant growth in the descending thoracic aorta and so we have a couple images here we have a 3d reconstruction of the aorta as well as the sagittal image of that CTA and does

anyone notice anything about this 3d on aorta no so this patient has a variant he has a bull vine arch actually so the left common carotid is coming off the right you nominate um but vessel the arteries so it's nice for us when we're

placing that and negraph we have more more of a landing zone so we're not covering any of important structures other than the less left subclavian artery and so we're the two arrow heads are on the sagittal image you will see

that there's reentry tears so if you look at the 3d image so the dissection is that line right in the middle and so it's starting at the origin of near the LSA and ending at the level of the celiac artery okay so we obtained right

and left common femoral access and you obtain left brachial access as well and the reason for left particular access is once we get our enter graph gen we're going to go ahead and I'm pass the wire through and a laser through and find us

to find a straight through that under graft so you can have flow but I will talk about that later so we put a twenty French dry seal sheath and the right groin and in the left groin we had a 8 by 45

she's and that was basically to accommodate IVA so they can kind of get a feel for what we're doing it just like another resource we have so we have two IVs images here the one on the left with the yellow arrow basically is just

showing us that thickened dissection flap and the Ibis on the right is the love of the celiac artery so the celiac artery is where that green arrow is pointing to and the white arrow head is basically just showing us that reentry

tear at that level and so through the right through the right the sheet on the right hand side the 20 French try seal sheets we placed the 7 by a 55 Aptus on steerable tour tour guide sheath so that basically can angle up to 180 degrees so

we place that up to sheath in the true lumen of the aorta and pointing towards the false lumen and then I just put some pictures up of what a dissection looks like I don't know if a lot of people a lot of you guys on do dissection their

frustrations I mean your practice but I just thought it would be nice to show and so once we have the Aptus sheep up in the true lumen and have it pointed towards on the false women we confirmed with the eye this just to make sure

we're on the right spot and we're not we're not going to harm any other structures when we laser so once we have that up we use laser to kind of poke a hole and fenestrated create that's here and once we did that we dragged while

the laser was on we dragged the baptists sheath down 4 centimeters and created a large terror so the whole goal is to open up that dissection so we could eventually place that under graph so once and that there's a florist got the

image of ibis and apt the Aptus sheath and all that and so we created a large tiara and then what we did was we passed the 18 wire into the false live and we angioplasty with the 14 by 4 centimeter balloon and as you can see that there is

some waste on that balloon and then eventually it dilated up to you know now I'm gonna burst rate which was 18 and so that Ibis is basically showing us that's here that we just made in our dissection flap

okay am I not there we go okay so once we angioplasty be repeated the same thing so we put the laser back up get a small tear right underneath large penetrations here that we just said and then we angioplasty it so once we

angioplasty we connected that top tier and bottom tear together we opened it all up and we angioplasty it again after that so once that I mean go back so once the angioplasty so right underneath that big tear that we just made so between

the tear that we just made and the re-entry is here at the level of a celiac you still have that little piece of a dissection flap that we still need to open to place our under graft so once we did that once we angioplasty through

the right groin we passed up a glide catheter and the true lumen and pointed it towards the false women and through on the tear that we just made we passed the v18 wire and through the left groin we went up with a 20 millimeter loop

snare and so we grabbed the the 18 wire and so that loop snare went and that reentry tear and like into the false lumen so our whole point is to get through and through access with that wire so we can use as a wire cutter to

cut the remaining flaps so that's what we did so we we grabbed that snare we grab that v18 with the snare we pulled it out of the left groin and we obtained through and through access okay so you're just ripping it down yeah

basically it's like it she goes somewhere yeah yeah you got it yeah that's exact don't ask a question to what you don't want the answer so basically that's what we did so once we got through into access we advanced both

sheets and we kind of like pull down to to cut the remaining flap so once we did that we basically had everything open so we were ready to place our under graft so we did angiography and then we ended up

deploying the descent and then so once we would deploy the stent we basically covered that LSA the left subclavian artery so that's exactly why we got brachial access so we pass the wire through and got to the origin of the LSA

and then we ended up putting the laser down and then we turn the laser on poked a hole and so now we have this hole and this endograft so once we did that we angioplasty it and then we deploy the stents okay and so now we have a diagram

of the pates and LSA following stenting so we sent in the aorta and where the dissection was and then resented the LSA so we have nice nice flow the REC lab donal angiogram basically is just demonstrating feeling of the celiac in

superior mesenteric artery as you can see in that middle image distally so one of our missions that Rudy made which is pretty awesome so illustration of fenestrated t-bar with LSA sensing and adequate just so Co following the

dissection flap that we usually there's open so BAM there you go so that's Rudy and I in the middle my one of my co-workers Kevin and when my mentor is dr. Kaja dr. Marley and myself so thank you hi dr. Kasia thanks for joining

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