PICA Stroke, Brainstem strokes|ASA,Plavix|45|Male
PICA Stroke, Brainstem strokes|ASA,Plavix|45|Male
PICA Stroke, Brainstem strokes|ASA,Plavix|45|Male
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This patient has Marfan syndrome and has been operated three years prior for Bentall procedure

and he presents with recurrent acute thoracic pain. So he has classic dissection and so we decided to go ahead and treat the descending thoracic aorta going up and, I just put this in because we had problems finding the true lumen. So I don't know that's the question to the panel are there any tricks

you use if you want to find true lumen? How do you do it? Do you use IVIS? Michael, we have any comments? [BLANK_AUDIO] Well, I'll be honest I'm not proud of it.

We don't use a lot of IVIS either. >> Okay. >>In something like this I'm going to look at the CT scan at high quality has to be of course in the pelvis and sort of understand if there's one illiac look at the other maybe more ideal.

Then if I decide that the dissection goes into both iliacs and they both tear out distantly, I'm going to know what the true lumen is and I'm going to take the image intensifier and I'm going to look down right at the distal and at the dissection usually that's the only clarification and I'm going to put the image intensifier directly

parallel with the flap. So what I go up with the whatever curve cathedral tip that I have and glide wire, I know if I'm going to go left, I'm going to be on one lumen and if I go right, I'm going to be in another lumen.

And then when I get to this point, I'm going to do the injection in he abdomen. And from the CT scan I know, where does a right renal artery come up of. If it comes up the true lumen and I see it then I know I'm in the

true limits. If I don't see it I must be in the false lumen and I'm going to have to go back and try again. >> Great, super. >> [INAUDIBLE] >> Yes.

>> [INAUDIBLE] >> Also sometimes if you don't want to loose access you can use a long sheets and inject over guide wire again it's case by case but I guess the best way for us is to look at the CT and then see where we are compared to the CT scan,

that's the best way we can do it. So the true lumen was actually very small in this case we end up with the small small wire and eventually found the true lumen so the stent graft was placed and.

So the patient presents with was three years after the initial stent graft placement. Actually you can's see it quite well but, the patient had like a type one link and the initial stent graft I don't have all the images here but the initial stent graft had migrated in a little

bit down so an extension was placed, their is two stent graph in their and the reason why I'm showing this case is that, you see there's a like type one lick right their and so my question is how would you treat this?

I mean >> So first question. He's got an aortic valve what was the surgery for just the valve or with the >> No, no he had a deselection initially - >> So type

A. >> I think we got to insure that this isn't from some not necessarily the leak point I can't tell you have to tell a cause if I can see enough images, but you want to make sure that their is not some distal, proximal communication near the distal anastomosis of their graph for the type A.

As well as what you are seeing in that little. >> Well there didn't seem to be any dissection right there, okay, initially, that was clean. >> Is there a false lumen in the arch? Let's just ask that, on CT?

>> No. >> So we know that this leak is right where you showed it at, near the proximal. >> Yes exactly like just after the subclavian [BLANK_AUDIO]

So despite extending the stent graft and partially covering the left subclavian we still had that leak. So question is how would you treat this? Would you treat it? >> So is I fully understand what you're saying, I just haven't been

able to characterize. It's an under surface of the arch so the assumption is the stent graft somehow is not circumferentially- >> Yes there's no seal there. >> Audience, what would you do?

[INAUDIBLE] anchors, what do you think the endoanchors, maybe. >> Maybe. >> Anything else. I suppose you could potentially branch graph more proximal now,

if you had access to one. Anything else? What would you do? >> This case we decided to inject some Onyx. So I don't know if you have experience with that but- >> Oh percutaneous?

>> Yes. percutaneous. So that catheter with the leak, you can see that there's a vessel that comes out right there. That's the Onyx.

>> Excellent so, just curious but there was any way to come up false lumen from below all the way up there. No? >> No. Sometimes we use the technique you're describing that one of our colleagues he goes with

>> Underneath the graft. >> Yes. >> You can sort of do it from above as well [INAUDIBLE] >> No, just Onyx. Yeah.

>> [INAUDIBLE] >> We mostly use the Cook graft, but we use the GOR also and we use many grafts. So, I don't think there's a favorite one. >> What do you think?

You have any favorites? >> [INAUDIBLE] >> Yes, . >> Well, any graft can cause retrograde type A, okay. I happen to use GOR,

>> So this was a Gunther Tulip filter and if you can see here, the

hook had been straightened by a previous retrieval attempt. So in this case, we went forward, sheathed it and it got stuck where the pedals meet the primary strut, a very common place for a Tulip to get stuck.

How many would use the laser here? Anybody use TightRail? Anybody know what TightRail is? So Tight Rail is a complimentary device that Spectranetics makes as well. [LAUGH]

It's complimentary device made by Spectranetics which is a bailout method for lead extraction. And basically it's a long sheath and it has a little clicker on it that teeth and you can put it inside of a 16 French sheath just like the laser and then then you have to snare it still and then you can click it down, and the rush group has reported some experience

with this. >> For those that don't have laser currently, what would they do? Are they able to remove these filters or are there different techniques that people are using to get them out? >> [INAUDIBLE] >> And then when

the hook straightens out and the snare comes off what's the next? >> Loop snare. >> Loop snare and then pull harder. There was an interesting abstract, I think I mentioned already that Penn, they were just using forceps in these filters particularly and they just pulled harder.

They didn't have to deal with the hook straightening out, they were able to remove them. [BLANK_AUDIO] >> How many of you think that the laser doesn't necessarily answer all the questions with this,

that pulling harder really would take meaning that the laser's over utilized. Anybody? Certainly as he alluded to the pentagroup, they don't use a laser, they use rigid endobronchial forceps and a big sheath.


I've actually encountered this a couple of times in my brief career. The first time it was a 72 year old guy. Had end stage renal disease due to Wegeners. He had acute flank pain and a large retroperitoneal hemorrhage.

He was brought to IR for a renal embolization and about 12 hours post-procedure, he developed marked symmetric sub-mandibular swelling that was non-tender and non-pruritic. So I think it's best shown with some pictures. So, as you can see, sub-mandibular glands are massively enlarged.

And, at the onset of symptoms, he was given an additional dose of steroid an antihistamine. Actually on a previous case out there he did have a history of "throat swelling" when he'd been given iodinated contrast in the past.

So he was pre-medicated with steroid and antihistamine, and he got another dose after the symptoms began. He confirmed that this "neck swelling" was identical to that which he'd had in the past. And the symptoms were managed conservatively, and he had spontaneous resolution over a one-week period. So here is the before and after.

As you can see it's a pretty dramatic reaction that he had.

This is another case. A 24 year old woman having place a tune up filter, and on follow up patient had an abdominal pain. Went to

ER and the reading physician actually couldn't really catch this and well the strat is in the bone and the patient had also having ovarian cyst. Treatment was given and the patient had continued low back pain, and this time it was caught in the torc CT. And this filter was fractured in the bone, and the rest of the filter actually retrieved and abdominal

pain or low back pain actually is gone. So in general carel

So here is a 56 year old man, that's a very recent case, with obviously past medical history of hypertension and he had coronary artery disease and this is just an outside hospital but kind of weird, two days ago at this outside hospital he had a stent to the OM and now he has chest pain associated with hypertension.

He's still in the hospital he just had his coronary extended and you can see he's got this intramural hematoma. Now there's a diagnosis and I've manipulated the window level so there's no doubt there is the oxyhaemoglobin in the wall and just to go through this, the usual time frame is by 10 days, it's usually gone, okay?

But so here you got diagnosis, 48 hours in one week just to show you how it looks and clearly as it goes out, it looks a little less discrete, a little less circumscribed and so just thought you might get a kick out of that, and what do we got here?

So here again this is Non-con CT, so this is hematoma in the wall, what's this? That's athero in the wall, so this is atherosclerosis within the wall, and this is the lumen. So the slow attenuating thing is the athero,

this is the de-oxyhaemoglobin. And so, let's look at this. At diagnosis you look at this and you're looking for a target. Is there any breach in the integrity? Like classically, intramural hematomas rupture the base of his arm

in the wall but there're a lot of people who're advocating saying, look, you can't even see Angio. You can't sometimes even see surgically if you're there. But in all cases, I believe you're gonna find some microscopic breach in the integrity in the wall in the intima.

So this base of his arm thing is hard to maneuver. Well, so that's a little debate. It doesn't really much matter. But in retrospect I guess you could say that right here, it does look like there's a little something there.

And by 48 hours does a little color button also there, and by one week hasn't changed much. Okay, everyone agree? And down here I'm just showing this cuz obviously you can see it gets a similar little thing here at one week.

Obviously some flattening of that contour at this level which is at the level of the PA at the level of the corina/g, you can see diagnosis 48 one week. Okay. So now you know where we are and that's what it looks like on CT with this hematoma that's extending a little over the subclavian

but certainly not into the arch itself beyond the subclavian. 25 days later, he is discharged from the hospital and he has left sided chest pain with movement. A little weird. Here's the non-con and we really don't see what we were seeing before in terms of intramural hematoma.

But you see the aortas, looking sort of a lot bigger than it did. And this is what you see now. So this is 25 days after the event and he's excavated out that area that was that collar button in the arch. And he's excavated out this area down at the level as we're going down to the PA and they actually

now these two communicate. So this is coming down from the arch and down below, this is coming up from that little thing we saw before lower down. And now this is about 5.3 centimeters.

Okay. [BLANK_AUDIO] Got it? So, obviously we've got a target and this is not necessarily show how to treat it but we're gonna treat it now and it's just to show that these things are very evanescent.

You can't let them go. You gotta watch this until you can get a profile. So that's what it looks like from the inside out. There we go. And we did a carotid subclaving, because I felt that it would be

better for everybody involved if we went over to the carotid instead of covering the subclavian without the bypass, so it all worked out well and that's that case.

Second case, and by the way if anybody has a question while I'm going through, don't hesitate to raise your hand. I don't want to get to the end and have people forget their questions, they might

not get answered. Second case was a 49 year old female with hypertension who arrived at work one morning at 8 o'clock complaining about a headache. She came out her office about half an hour later and her co-workers said that she appeared different. She was mute tremulous.

They called 911 and when she arrived at the ER, she had weakness, on the right side was aphasic, not following commands, and gaze deviation to the left side and NIH stroke scale is 24. No contraindications to TPA,

and when she arrived at our institution this was her CTA. You can see the M1 occlusion but she also had this filling defect right here in the left ICA origin. This was the perfusion map with the blood flow, up here showing decreased flow,

the blood volume, there is some infarct here but overall when you look at the mean transit time, a very large area of at risk territory. This was the first angio. This is the fetal PCA and of course your M1 occlusion. This is the initial angiogram.

Here's that filling defect. And this was after I put in a stent. The way that I did this was I had a nine French sheath at the groin put the moment device up there for [UNKNOWN] protection. I actually used the moment quite a bit for carotid stents if I'm worried at all about knocking off stuff that could embolize to

the brain. And in retrospect I wish I would not have stented, but I'll get to that. I mentioned before that we see a lot of tender occlusions and in the heat of the moment I was like okay there's something there in the coratal/g origin,

I'm just gonna stent and go and, got up there, used my micro catheter run showing no extravasation and after two passes this was the result. There's a lot better flow, but I grade as a ticky 2A. I wasn't really more aggressive at giving more of the frontal lobe here

because I knew that there based on the perfusion imaging that I had in fact of this general vicinity and I didn't want to open that up and increase the risk of hemoragic conversion. This was her MRI afterward, I think that we had these images within an hour.

So there is plenty of out of stroke. Here it's scattered around the MCA territory. The next morning this was her head CT. And most of the MCA had gone on to infarct. She also got an ultrasound.

I don't know if I can show arterial, here we go, and that stent had occluded. This is the only instance where I've had a carotid stent occlude on me afterwards in that 30 day period,

this is an 89 year old with aortic stenosis and plan for TAVR. I'm not gonna show you TAVR cases here so, but the reason I wanna show you this is now we're seeing more and more of these, and whoever reads CTAs and all that and I just Can't believe that there's so many 89 and 91 year old getting all

this complex procedures. I mean when someone comes to us for a stent at age 75 you're cringing and now, you get all thes every 89 year old in Virginia now is gonna get TAVR so. Otherwise they are fearless. So this is this patient and you see, we always do these analyses for them IRED/g, LA/g, CTAs, MRAs and you see the right side, there's nothing. There is

no common femoral and there is some collaterals and no external iliac. The left side is also very small, you know 5 mm. There's no access basically. So all these patients go through transapical TAVR, all right?

But now there's new technique that's been developed which is the transcaval access into the aorta. It was developed mostly for TAVR patients and there's a group by NIH that pioneer this study and now they mentor programs to do it. So we were one of the sites for that and then we,

as I was somewhat involved in helping them as to be a backup for this when it started. So that was the plan and this is this patient. You see him with really very calcified,

no good access, and this is the cave and this is the distance. So I'm gonna show you this case then I'm gonna show you a good typical case to know how this should look like and this is the one that didn't go as well. The distance should not be that far.

All these cases are analyzed carefully, make sure there's no calcium where you wanna access and the distance is not too far. In this case was kinda getting more comfortable with with the technique, so pushing the envelop and in this case access was obtained from the cava into the aorta.

And there's several techniques you can use. You can just use needles or in that case this technique it uses an 014 wire and have a Bovie at the outside and basically use a cuttery and just pierce through and it works out pretty well. Then you snare it and now you have access.

You balloon dilate the track then you serially dilate then you put your sheath. And now the case goes as well and at the end they use and ASD closure device to plug it. And that's it. I apologize for the images I literally went to the cath lab and took pictures of this thing so that's why there's all this

glare. But that's what it is. Now for this patient, this is at the end of it before deploying it. It's very common to see flow into the cava and that's expected because that will go away. And as long as it decompresses into the cava it's fine. The problem is when it forms a pseudoaneurysm

this means it's not good decompression. And this is what was here. So I was standing in the room and I said well and this is not looking good. I was like we see this all the time and this will die on itself and I'm not so sure that was the case but, well let's get a followup and see what happens. Well I wanna show you how it looks when it should and this

is the case that we did for a TVAR as a first angle of this case was published. It was one of the first cases of TVAR using transcaval access, again small access vessels. And this is the analysis that you get. You try to find which spot doesn't have much calcium and you measure the distance, make sure it's close enough. And this is it here. You get your access again, these are the tools that you use.

And trim the 0.14 wire and a bovie and you go with a snare. You do several angles to make sure you enter the snare and then you snare it. Probably that's one of the first image. And then this is how it looks. And they have an algorithm for what Amplatzer plug you use.

So for this the AST closure device you use and we have our [UNKNOWN] cardiologist who does all of these and works with us on these cases. You have to master that technique which I think is good for someone who knows what they're doing to do it to be honest with you. You always maintain a Buddy Wire just in case things are not going well, then you can re-access it to just close it.

And then once you're happy with the outcome you can just give up and get it out. So if there's only filling of the cava and no pseudoaneurysm that's fine. And most of these do very well afterwards. You see on the followup CT''s the filling of the cava only but you don't see

a pseudo and then that's a full die down. And this is afterwards and we waited, did another one and everything was good. So that was the good case. Going back to this case that was not

as good, you see a pseudo aneurysm. And my point was we need to treat this now, well let's get a followup, well fine that's a followup. So the followup was of course the CT was ordered in the morning, was done at 4 PM. We read it at 6 PM and became that what we had planned to do that

night did next night, when I was not on call. So now there's a pseudo aneurysm here coming out of this really, really chunky aorta. So now the patient went to IR And remember there's no right common femoral so now we have to go through the left side and that's our

only access, so that's how it is. The patient was semi-stable I would say. A lot of issues and she's not an open candidate that's why she went to TAVR so there's a lot of issues with her medically and she's older, so and everything

was very tenuous. So we did this, we went in and you see this big pseudo aneurysm and you see this is where the plug was. So we said, well simple, just put a cuff here and that should take care of it. The problem is we have sizing issues.

So this is 12 mm, this is 9 and this is at the bifurcation and now we are getting into a tiny common femoral. And you know you can do a lot of imaging because you have access from the right. Now you have to get maybe RMAXs to do it which adds to the complex of it, the patient is getting too unstable

so we need to move fast. So we put a, wanna make sure we get a good apposition here, we put a limb. This happens to be a Cook limb and a 14-55 and just landed it just short of this really smaller component while there is still a leak. I said well it's most likely a 1B from below.

So now how much you are gonna extend? It would be nice to go in and do kissing stent in this. But you don't have access on the right. So if I had a common femoral you can recanalize but there's nothing to start from. Any thoughts or do you want me to keep going done with this disaster? >> [INAUDIBLE]

[INAUDIBLE] >> There is no right common femoral. They're gonna have to create something there. Most of the times what worries me with these kind of raptured cases and such is, even if you do that are they gonna get back filling

through into lumbars, who knows if it's still gonna fill or not even if you do and AUI. But that was a thought and we couldn't do it. So there's no option for a fem-fem. >> So come the arm and do a bilateral kissing covered small limbs or iCASTs or something

->> Into the iliacs. >> One from the ->> leg >> and one from. >> The right side of the arm and the left [INAUDIBLE] [INAUDIBLE]

>> Yeah so that's >> But that's one option I guess off the top of my head ->> Again Rob, do you have any thoughts on this? >> No I'd do exactly that. I'd put the right side's stent from the

arm and the left side's stent from the groin and I'd probably use an Atrium's iCAST. >> Yeah so we had that thought and I wanted to try a couple of things before committing into this. It was again in this situation is a big mess we have like a gazillion people and I have re-prep the arm, move the anesthesia people out

of the way, get the arm out, prep it and all that stuff. So while I have that I just try to extend with a stent as far as I can get away with and balloon it. And of course it didn't work. So there is still a leak here.

So before doing this and I thought that maybe it's worth to do what we just talked about, is see if we can embolize this. So and I ensured that these are the numbers, this is that planing that I did before putting kissing stents.

And then before doing it, it's like let me get a thought. Robin mentioned this in his talk the other day about doing some of these endoleak embolizations through access adjacent to the graft between the wall of the aorta or iliac and the graft.

So this is what we liked it to do. So you see the catheter here getting around the graft that we placed and get a microcatheter all the way out into the area where there's aorta. And started by putting some onyx. Of course start going into the lumbar which was fine with and then

kept filling all the crevices around it a much as we can, to fill the area and kinda bathe where this Amplatzer or plug once was. So that all onyx around that area and actually that's did the trick and stopped it. So I think this onyx as a plug problemsolver with these leaks don't go away.

It is just poor apposition and especially with calcium. And there's usually just a few millimeter of crevices in there that just need to be filled. Once you go in and pretty much cork it with onyx you just can get rid of some these endoleaks. So it didn't take much. It just was not that hard to navigate between

the graft and the aortic wall. And once you wedge a catheter there a microcatheter can go easily and now you're free and you just fill the entire space that is not completely opposed by the graft into the aorta. Fill it with onyx and then that did the trick. And this patient did very well. We got rid of her leak that was there

and this is the follow up. And at one month she came back and, that's the plug and there's no more pseudoaneurysm, and that took care of it. One thing to consider was to use a different type of cuff,

for example the Endologix that has the cloth on the outside. We have better apposition than doing this. And that's what actually they were coming to have as a back up for these cases to have an Endologix cuff, which we didn't have it at the time.

I could have ordered and waited, but I didn't want to wait. But part of their protocol for these transcanal cases is to have an Endologix cuff as your back up because the cloth was the outside and the metal is the inside and has more likelihood to actually connect, go and they call it boller

out and have better apposition and touch the wall better. So I think the program slowed down significantly after this case unfortunately and >> [LAUGH] >> This was a poor selection that the people who were in charge of the program from NIH and advised somewhat against

this case and said well, you need to kinda wait before taking such a case on. And clearly, lessons learned, very calcified shouldn't do it but non-calcified, now we're using an all-trans cable for endoleak

embolization and I think that works out pretty well and it's very safe to do. So I think that technique s still valid, you just need to choose your patients well. >> Do you use this technique for access in the aorta for other things for example TVAR?

>> Yes. So TVAR the case I showed was from a TVAR and it was published as a technique in [UNKNOWN] few months ago. So I think it's a very good technique for that. Doing an illiac conduit is not trivial and I think sometimes like in this case needed an aortic access. If this patient had a thoracic

aneurysm such access you need to actually have to cut down to the aorta. And our surgeons have done that, actually directly accessed the aorta. So this could be a huge problem solver.

And I think it's gonna be adopted more and more. These Amplatz are plugs, these ASD closure devices. They're not as simple as all the other devices. You have two sizes and the cardiologist, the congenital cardiologist, whoever works at your institution,

is pretty good with it and if you can team up with them they'll be willing to do it and maybe help them with their TAVR programs. I think it's a very valid technique and I think we can use advantage of it. >> It's a great case, super elegant yeah.

>> [INAUDIBLE] >> Yes. >> [INAUDIBLE] >> No we'd have put the limb in. And that was the plan.

I was like we're here, we have access, let's just do it, let's just put the limb in, we'll just delay by day and I'm kinda glad we ended up doing in IR. We had other stuff ready for us, we had to use onyx and all that which was good. I don't know if AFX would have fixed, it could have.

But yeah, that was the plan. At the time that it, their protocol is that if there's a pseudoaneurysm, not just filling of the cava then you put a cuff. And that's

the plan. But it was kinda later in the day they just wanted to wrap up. But that's not the point of this discussion. I think this discussion if you see that appearance which is the pseudoaneurysm then the plan is to go in and put the cuff in. >> So mechanistically this far is the Bovie system to the wire,

they just attach the Bovie to the end, the outside end, the trailing of your 014Y against the location. >> It becomes like a hot knife and just goes through. Yes. I mean you can use anything to be honest with you.

But they just wanna use this protocol because it worked with them. They just wanna use it the same way which I think is fine. >> Cause I've used the outcome to - >> Yes. >> [INAUDIBLE] >> Endo-leak.

Yeah I'm use the, a lot of people use different, I use the transceptal needle. There's colopental needle a lot of people use different [UNKNOWN] needle. [LAUGH]

You seen it all presented.

he had a CT of the chest that was obtained to work up this pain, and it showed it three centimeter brachiocephalic aneurysm. He had a history of motor vehicle crash decades ago, he was a belted occupant doesn't really recall too much of the injury, he wasn't really

hospitalized for long after that injury. But that was the only remote history of trauma we could gain from him. He has a past medical history significant for hypertension, on exam really unremarkable no bruits, normal upper extremity pulses, no the history of neurologic event. So I unfortunately don't have his initial CT but generally when it gets

referred to that leads to angiogram. And this is our subtracted image showing a calcified circular aneurysm just at the bifurcation of the brachiocephalic. This is another look at it, we did a couple obliques and it's clearly right at the junction kind of a difficult location just at first glance. Initially we get one of this tough cases we start of with that just

not diagnostic angiography, if it's not urgent, we'll pause discuss in the multi-discplinary fashion and reconvene. Couple of more pictures, again these are the initial angiograms but I've got more recent follow up on this patient. And here's some more pictures. We didn't do rotational 3D angio

we frequently do that in the periphery, but for this case we didn't feel it would be all that helpful. >> When you start this did you have the patient's arm prepped as well as, did you prep just the groin or did you come in prepped planning to intervention or is this just-

>> This was just a work up just to, kinda really further to find what the CT showed. Because if we knew from the CT it was a difficult location we wanted to find it with angio, and again this wasn't leaking or ruptured aneurysm really other than this vague discomfort he had we didn't feel it was terribly symptomatic.

Whenever we deal with things above the diaphragm again we try to observe the neurointerventional principles, or neuroangiography principles of double flashing again very careful guide wire and catheter selection of these vessels. Generally these work up of these patients includes a cerebral angiography.

It's kind of like intervening in the leg. I always like to see what the runoff is first. This runoff is a little bit more precious so we like to get a baseline. I like to know what the carotids are doing. Frequently we shoot the verts. This is a posture circulation from the left.

This makes me think that his right vert ends in pica and you'll see this, I end up selecting out the verts a lot in these above diaphragm cases just to understand the what the anatomy is and also it helps us to plan on the table. This is left hemisphere.

Basically unremarkable and there's the left carotid. >> Do you heparinize during your diagnostic cerebral angio? >> I don't. There are operators at my facility that do I don't. >> Jim? >> No, we don't usually.

>> So based on our findings we entertained basically the classical tube treatment option, surgical repair. Which would involve a cardiopulmonary arrest or endovascular options and that's where we got involved. One option we were thinking of included stent grafting from the brachiocaphalic origin to the right common carotid.

We were leaning towards the need for a right carotid subclavian bypass based on what his right vert was looking like. Double barrel stenting has been described, stent coiling, another neuro technique that we've adopted in the periphery and then flow redirection. What do you guys think so far?

Have I left out any treatment options on the endo side? >> No, I think you got most of everything you can think of. >> I try to dump these patients on my partners as much as possible, that was the other option. So we do these cases with our neurointerventional colleagues, we work very closely for stroke and right at the aneurysms

whenever we get referred patients with these kinds of aneurysms. So this again October 2008, we bring him back for angiography. This is typically how we initially start off carotid stenting, stents I like to have like a cook shuttle type sheath, generally carotid stenting procedures are 014 wire systems with

distal protection. In this case we opted not use distal protection cuz there was not occlusive disease it was more of an aneurysm case based on CT that we reviewed his vessels were nice and clean and our treatment option that we selected actually was an 0.035 system. So I didn't want to attempt distal protection,

work over an 0.014 wire and run into some issues related to that. This image shows our shuttle sheath in the origin of the brachiocephalic. An 0.035 wire, this is essentially a rosen wire in the common carotid. Again pre-intervention cerebral angiography of that hemisphere just so we have a baseline.

And we opted the flow redirection option, so we looked at, again this is 2008, we chose to use a LifeStent, sized up appropriately based on CT and stent it from the common carotid and to the origin of the brachiocephalic.

This is our post stent angiography. You can see that there's still a robust turbulence flow into this brachiocephalic aneurysm but again no evidence of dissection or distal embolization post procedure. Very nice, simple procedure. Again we talked to the patient about all of his options. He was not keen on operative options and we wanted to keep this

nice and simple and see if we could observe some of the neural principles of flow rediversion and apply it to this aneurysm. So we brought the patient back at the end of the month and got a CT. You can see the CT, the stent is widely patent. There is a little bit of compression upon

the stent by the aneurysm, but by all accounts, the stent's widely patent. There is still significant flow inside the aneurysm. This is an isolated picture of stents here and here's this aneurysm. Again this is October 2008.

We bring the patient back in in December 2008 for another CTA and the stent's widely patent and we begin to see some more thrombus beginning to develop in the aneurysm. Here's a side by side comparison. This is October 2008, this is December 2008.

Now we did have the patient on dual antiplatelet therapy because of the location of the stent. We realized that was working against us probably but we felt it would be neuroprotective in this situation. Would you guys do antiplatelets in this kind of patient? >> If I look at this, I think you kinda have to have dual

antiplatelets because I think you run the risk of stroke with an endograft in the carotid artery and then I think if you're not careful, that's gonna be a bigger problem. But I guess if I had that much flow in the aneurysm in October- >> But this is open. This is an uncovered stent. >> This is an uncovered stent so it's flow directed.

>>Right, If I had that flow in that aneurysm flow right away. I don't know if I'd be comfortable just watching. I need to know it's flow directed, like I wanna see it kinda shut down. I'm kinda wondering in October when you did that-

>> Yeah, what were you thinking? >> You obviously chose to wait but kinda go through that thought process. >> Yeah so- >> What could you do, what were you thinking. >> In October when we saw that CT post intervention, we were just happy to see the stent wide open.

No, I'm kidding. We thought we give it a little bit more time. One of the option was to go back in and put another layer of stent in and I was actually favoring that initially but we opted to bring the patient back several months later for a followup.

This patient was also very educated and really had been through a lot of other medical procedures and he was also willing to wait. He understood the risks that we described and he was willing to wait follow up imaging. >> I'm impressed with your patience. I commend you on this out of the box in a very sort of dangerous

vascular territory, but I think it's actually from the standpoint of looking at this intervention. Part of interventional radiology is get in, get out, get away with it, and what you're saying is we're gonna kinda pay this forward and I'm okay with surveillance.

When you talk about patient education, cuz you're talking about thrombus that's encroaching upon a bare-metal stent, if you will, what did you warn the family about from the standpoint of stroke? Wakes up and it's not going well, you need to call 911. >> Again very educated patient and family.

We described, unfortunately used the term catastrophic stroke when consenting him, and again, this isn't something you walk into. I try to make friends with the patient and the family, describe the worst case scenario and that's part of the reason we as a an

institution frequently do diagnostic angiography first, discuss everything with the family and then figure out together what our plans are. Cuz this is again out of the box and though it's well described but a little

bit out of the box. Again the stent was placed in October 2008. This is a CT from March 2009, and you can see that our grey vessels are widely

patent significantly more thrombus but still a lot of flow in this aneurysm. This is a side by side comparison from December 2008 to March 2009. It doesn't look that impressive but trust me there was actually a lot more thrombus in here. I couldn't bring the 3Ds here.

>> [INAUDIBLE] >> No. >> Yeah, if this was an incidental [INAUDIBLE] it's probably not gonna rupture. >> Right that was the other thing. >> [INAUDIBLE] >>Given the history, yeah. >> [INAUDIBLE] >> We also felt that point calcified probably been

there since that MVC many decades ago, yeah that's very reasonable. >> What size of the LifeStent? >> 8 by 60. >> Eight? >> Eight millimeter diameter.

January 2010, so he did very well relatively asymptomatic, a little gun shy about coming in for angiography monthly, but we brought him back in again one of the things we learned about some self expending stents in the MFA, I've run into is the fracture rate. This was an area I wasn't sure how much flexion would be going on in the artery in this area, but we did a spot image looking for fracture, center

fracture again this is an unusual location. I can't say that there is a significant fracture and separation as you know fracture of [UNKNOWN] stent is implicated with stent occlusion. >> There's a vert back behind there. >> This is the subtracted angio, you can see that there's a lot less flow. Decent sized vert actually on the right but based on imaging- >>

Is that the vert or is that deep cervical? >> That's vert. >> Okay. >> Yeah. >> I'm just noticing the branches, are those two branches coming off of it?

>> I think they're overlapping. I think the origin of those branches are probably more over here but the vert's behind and you can see that there is certainly less filling of that aneurysm at least on angiography. March 2011 now, he's doing very well and this what our subtracted angios look like now, again widely patent stents much less if any

maybe you can see a little bit of filling here, outside the stent patent, but looks relatively stenotic subheading origin but he was not complaining of arm claudication or any of those upper extremisty type symptoms. And this our comparison from where we started in September 2008, when we give him the treatment options and then this is our follow up angiogram using this principle.

Now the patient I talked to him this week, he's asymptomatic, I think the other key to this is long term longitudinal follow up of these patients, no obvious neurological symptoms. One of the question I drill them on, is episodes consuming for vertebral basillar insufficiency. He had one episode of dizziness but we really couldn't pin it down

on VBI, there's no arm claudication, he's now following doppler, again I'm not sure how valuable doppler is but he is really hesitant to come in for repeat angiography, and the risk of repeated CT's. The ultrasound shows that the stent is widely patent with normal

velocities, no obvious leak. But again I don't have a valuable ultrsound in this location with me. I literally begged him to come in for a CT so I can show it to you guys but, again, he's a little gun shy with CT's.

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