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Portal Vein Shunt, Portal Vein Varices, Abernathy Malformation Type 2 | Iliac Artery Extension | 73 | Male
Portal Vein Shunt, Portal Vein Varices, Abernathy Malformation Type 2 | Iliac Artery Extension | 73 | Male
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TIPS: Techniques- Stent Grafts | TIPS & DIPS: State of the Art
TIPS: Techniques- Stent Grafts | TIPS & DIPS: State of the Art
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TIPS: Techniques- CO2 Venography | TIPS & DIPS: State of the Art
TIPS: Techniques- CO2 Venography | TIPS & DIPS: State of the Art
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Treatment Options | Pelvic Congestion Syndrome
Treatment Options | Pelvic Congestion Syndrome
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Massive PE | Pulmonary Emoblism Interactive Lecture
Massive PE | Pulmonary Emoblism Interactive Lecture
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Algorithm for Treatment | Pelvic Congestion Syndrome
Algorithm for Treatment | Pelvic Congestion Syndrome
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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
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Cone Beam CT | Interventional Oncology
Cone Beam CT | Interventional Oncology
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Ideal Stent Placement | TIPS & DIPS: State of the Art
Ideal Stent Placement | TIPS & DIPS: State of the Art
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Protein Losing Enteropathy | Lymphatic Imaging & Interventions
Protein Losing Enteropathy | Lymphatic Imaging & Interventions
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Venous Insufficiency- Imaging | Pelvic Congestion Syndrome
Venous Insufficiency- Imaging | Pelvic Congestion Syndrome
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Hemobilia | Biliary Intervention
Hemobilia | Biliary Intervention
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Treatment Case 2 | Pelvic Congestion Syndrome
Treatment Case 2 | Pelvic Congestion Syndrome
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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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Case- Severe Acute Abdominal Pain | Portal Vein Thrombosis: Endovascular Management
Case- Severe Acute Abdominal Pain | Portal Vein Thrombosis: Endovascular Management
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Case- Brain Infarction | Brain Infarct After Gastroesophageal Variceal Embolization
Case- Brain Infarction | Brain Infarct After Gastroesophageal Variceal Embolization
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Percutaneous Biliary Drainage  | Biliary Intervention
Percutaneous Biliary Drainage | Biliary Intervention
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Bland Embolization | Interventional Oncology
Bland Embolization | Interventional Oncology
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Case- May Thurner Syndrome | Pelvic Congestion Syndrome
Case- May Thurner Syndrome | Pelvic Congestion Syndrome
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PAD/CLI Diagnosis | CLI: Cause and Diagnosis
PAD/CLI Diagnosis | CLI: Cause and Diagnosis
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Q&A- Embolization: Trauma and Bleeding Cases | Emoblization: Bleeding and Trauma
Q&A- Embolization: Trauma and Bleeding Cases | Emoblization: Bleeding and Trauma
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The Case that Launched the Cornell PERT (PE Response Team) | Pulmonary Emoblism Interactive Lecture
The Case that Launched the Cornell PERT (PE Response Team) | Pulmonary Emoblism Interactive Lecture
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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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TIPS Case | Extreme IR
TIPS Case | Extreme IR
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Complications & Pitfalls | TIPS & DIPS: State of the Art
Complications & Pitfalls | TIPS & DIPS: State of the Art
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Ablative Radioembolization | Interventional Oncology
Ablative Radioembolization | Interventional Oncology
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The Disease Process | TIPS & DIPS: State of the Art
The Disease Process | TIPS & DIPS: State of the Art
ascitesbasicallybloodchaptercirculationcirrhosisconnectionsdipsesophagealextrahepaticgastricHypertensionlivermesenteryorganperineumpleuralportalportosystemicpressurerenalshuntshuntsslidesspleenstepsurgicaltampathoraxtipstransplanttransplantationvalvesvaricesvein
PV Access | TIPS & DIPS: State of the Art
PV Access | TIPS & DIPS: State of the Art
accessaccessedangulationanterioranteriorlyballoonchaptercirrhosisglidehepatichepatic veinliverneedlepasspintoportalposteriorprolapsesagittalsheathshrinkagestenttractveinvenouswire
Indirect Angiography | Interventional Oncology
Indirect Angiography | Interventional Oncology
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Introduction- Nursing Management in Prostate Artery Embolization | Nursing Management in Prostate Artery Embolization
Introduction- Nursing Management in Prostate Artery Embolization | Nursing Management in Prostate Artery Embolization
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Stent Graft Deployment | TIPS & DIPS: State of the Art
Stent Graft Deployment | TIPS & DIPS: State of the Art
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Transcript

face-down at work and was sent home. At home he had melenic stools

per day, collapsed. Was brought in by ambulance to an outside hospital where he was found to have a hematocrit of 27 but systolic blood pressure is in the 70s. He did respond to intravenous fluids and transfusions under an EDG that showed a large hiatal hernia as well as linear erosions

of the distal esophagus that were bleeding. He was banded but continued to have active extravasation . He was transfused a total of 18 units of packed red blood cells to maintain a systolic blood pressure in the 90s. He was put on proton-pump inhibitor and octreotide drips and transferred to us for TIPS.

Past medical history, he's got Afib but is not on anti-coagulation because of his GI issues. So he has a history of TIA's, hypertension, and hypothyroidism and hyperparathyroidism status for surgery.

He did have a GI bleed three years prior to this, which we did not have records for. He was told that he was bleeding from the GE junction. It was treated with cautery and an emergency laparotomy. We're not sure what he did.

On arrival his crit was 22, plate was 53, INR 1.3, Tbili 1 and Albumen was only 1.3. So we got a a CT, and this is the first slide. And you can already see there's something abnormal here. There is an aorta in there,

we're not sure which one is the aorta. As we come down you can see I think that's posterior aorta, he's got air fluid level in one of the other structures in there. Also has a big cyst next to the right hepatic vein.

When you keep coming down, there's still this big old thing right in the middle of his abdomen. Do 3D reconstruction you can see that that big thing is a varix coming from the portal vein. You can also see that the actual intrahepatic portal veins are tiny

and he does not have a left lobe of the liver. So we thought that this was probably congenital because of the atrophy or hypogenesis of the liver and the portal system. The shunt was about 4.2 or 4.3 centimeters in diameter. So we call this an abernethy malformation type II, even though

this guy's 73 years old. So was a TIPS right thing to do? First we got the right hepatic vein to show that it was in fact constructed by a cyst using intracardiac echo guidance and a Hawkins set. This is back in the days when they were still made and sold.

We got portal vein access to a very small intrahepatic portal vein and this is what the venogram looks like. The portosystemic gradient was as you can imagine it was very low, it was only 1. So at this point we decided well,

we could put in a 10 mm or even a 12 mm TIPS but that doesn't really compete with a 42 mm varix. So instead we did not do a TIPS, but we took a Gore iliac extender through a 12 French sheath.

These all started at 16 mm and either taper or flare to an end diameter, from our measurements we took the one that tapered to 12 mm and is and in total 7 cm in length. Balloon that, deploy that and basically shut off the feeding to the varix. The portosystemic gradient only rose to 2.

Again you can see that this is all right portal vein. There's basically nothing on the left. >> Did you gel the SMV or not? >> We did not gel the SMV. So again here's the baseline, post-op date 7,

you can see that some of the varices are thrombosed but not all. The largest one is still there, still filling. It's actually smaller probably less flow and pressure through it. Post-op date 16 he re-bled. So he bled down to a crit of 18,

platelets were actually much improved to 235 and albumen was also much improved and we ran another EGD showed an esophegeal ulcer in the hiatal hernia probably at the site of prior banding. Post-op 17, a surgeon took him to the operating room for an attempted hiatal hernia repair thinking that would help all this.

Basically peeked and shrieked but did ligate the varix on the way out to sort of complete the shutting off of flow into the varix. So this is the follow up at two months, and you can still see there's a little bit of filling of a varix wrapping around the aorta

there. At 16 months, it's all thrombosed. In 29 months, it's thrombosed and it's finally starting to regress. His upper GI bleed and the esophegeal ulcer both resolved. He was eventually put on Warfarin for anticoagulation for his Afib. Two years later he had another GI bleed but it was a lower GI bleed found to be diverticular,

has not had recurrent upper GI bleed, and most recently his crit 39, platelets 170, albumen 3.7 and basically no underlying liver disease. Perhaps most interesting though. You look at the initial CT, this coronal reformat versus the

new one. The portal vein, intra and extrahepatic have both greatly hypertrophied and it grew a left lobe with the liver. So in conclusion even after 73 years of deprivation, the liver and portal veins are plastic and capable of development.

Thank you. >> Dan you wrote a nice paper on that. It was at 2010 or 11 with Dr. Stewart on Progressive Re-modelling for Abernathy, right? >> Correct.

>> In the four or five case now. >> Correct. Yeah, thanks. >> Yeah beautiful. >> Where did that huge varix drain into? >> The azygos system.

>> The esophagus. >> Yeah. [LAUGH] >> Looked like the volcano is Alaska,

craft is basically the only FDA approved stain crafts and I'll show you a

different way of doing it as well besides the Viator especially in countries where the Viator does not does not exist okay the Viator stand sits in the liver just like just like in my hand here the bare

portion is on the portal venous circulation the covered portion is basically on the hepatic vein part of the circulation okay the bare portion is chain-linked and is very flexible that's why kind of cut can crimp like that okay

they're both self expanding the bare portion is self expanding held by the sheath only the covered portion is held by a court okay so they're both self expanding but they're constraints by two different two different two different

methods one's a sheath constraint and one is a is a cord constraint okay these are the measurements the bare portion theoretically allows portal flow to pass if you're in a branch so it doesn't cost from boses of the portal vein branch in

the covered portion is important to cover the parental tract the youth that you've created in the past you had a lot of billary leaks into the tips if it's a bear stance bile is from by genic so it causes thromboses bile also instigates a

lot of reactionary tissue such as pseudo intimal hyperplasia that actually causes the narrowings of the of these tips if you causing bear stance the coverage stance prevents the bile leaks from actually leaking into into the shunt

itself okay and that's why it has a higher patency rate okay ideally this is how it's it's a portal vein and hepatic vein you'll hear people say proximal and distal you'll he'll hear radiologists especially diagnostic

radiologist referring to proximal and distal proximal and distal some people refer to the portal venous and is proximal some people refer to the paddock venous and is proximal and vice versa okay and it

gets confusing nobody knows well what's proximal okay the people that say portal venous and is proximal there they're talking about its proximal to flow so it's basically the first thing that flow hits people that

call the paddock venous and proximal they're talking relatives of the body more central is proximal more peripheral is distal okay so they're using these the same terminology is very confusing so the best thing to use and I we tell

that to radiologists who tell that to IRS is to talk a portal venous and hepatic venous end you don't talk proximal distal everybody knows where the portal venous end is and where everybody knows where the peregrinus end

is and there's no confusion strictly speaking which is the correct one which is proximal for us as IRS tax nurses proximal is always to flow proximal is always anticipate to flow so the correct thing is actually proximal

is the portal venous ends remember P proximal P portal okay proximal is where the expected flow is coming in that's actually the correct one but just to leave e8 the confusion portal venous and hepatic venous end okay there's a new

stents which is the controlled expansion stents it's in my opinion it feels exactly like the old stance the only difference between it is that it's constrained still has the same twenty to twenty millimeter or two centimeter bare

portion chain-linked it still has that four to eight centimeter covered portion but it's constrained in the middle okay and has the same gold ring to actually market the to the to a bare portion and the cover portion self expanding portion

and is constrained down to eight millimeters you can dilate it to eight and nine and ten initially there was a constant there was a misconception that it was like a string like a purse string that you break and jumps from eight

and no this is actually truly a controlled where if you put a nine-millimeter balloon it will dilate to nine only eight balloon little dialect to eight only the only the only key thing is that the atmospheres has to

be ten millimeters at least okay so it has to be a high pressure balloon has to be at least 10 min 10 10 atmospheres okay so when you're passing that that balloon over make sure that it's that that it that at least it's burst is 10

millimeters or or EXA or more on a 10 mil on on 10 atmospheres okay next thing is when you're making a needle pass you got your target now with a co2 you got the portal vein you've got your stank craft and you know how it works okay how

do you make your needle pass okay and how do you know if your needle has hit the portal vein or not there are two schools to do this okay one school is to make a needle pass and aspirate as you pull back and when you get blood back

you basically inject contrast okay before you do all that when you make your needle pass you push saline and especially if you do if you're using a large system so there are several kits out there there is the cook kits that's

a color pinto needle that's a large gauge 14 gauge needle there is the new gore kits which is also 14 gauge needle it's a big system these large systems you need to push out that poor plug that's kind of like a biopsy you have to

push it out with saline first and then as you pull back aspirate okay the other system is a ratio cheetah or a Rocha cheetah it's actually pronounced rasa schita and that's a very small system that there won't be a core that you have

to push out okay so anyway if you're using a large system like a coop into a needle which is the cook system or the gore system you push that plug out and then there are two schools school two aspirates you get blood back you inject

contrast if you're in the hepatic in in the portal vein you basically access it with a wire the other school is to do a ptc style you actually puff contrasts as you pull back you do not ask for H saline you actually puff

contrasts as you pull back okay the latter puffing contrasts as you pull back is the minority I would say less than two percent of operators are gonna puff okay ninety-eight percent of operators at

least are gonna actually aspirate and not puff okay I'm actually in the minority I'm in the 2% and there are advantages and disadvantages like I promised you two different ways and advantages and disadvantage to each to

each one the advantages of puffing contrasts even if you missed the portal vein after a while you actually get contrast around the portal vein and you actually have a visual of the portal vein that's the advantage so when you're

actually injecting contrast and you're missing it you get contrast around the portal vein it actually goes around the portal and you actually see the portal vein and it takes training sometimes this one's easy

okay I'll show you some more difficult ones but this is a beautiful pussy typical portal vein okay in addition to that oh go back in do you see that you see that hole in the middle there see that signal signal you watch that

because you're gonna see it again and again that's usually a posterior portal vein posterior right portal vein heading heading away from you okay that's usually a good target and I'll show you that again here's a little

little bit less obvious to the untrained eye but this is actually where the portal vein sits right there okay so sometimes it needs training right just actually see where the portal vein is and once you've stained the portal vein

then you have a real-time image of where the portal vein is you can actually go go after it and it reduces your needle passes disadvantages of using contrast and puffing away is that it creates a mess okay if you make multiple passes

you and you miss on the multiple passes then you start creating a mess and even with your DSA you can't even see the portal you can't see the portal vein because you've got this great mess another disadvantage of using contrast

is that you have to stomach what you're gonna see okay you make a needle pass and you don't inject contrast you have no proof of where you've been but if you're making a needle pass and you're

injecting contrast you and everybody else is gonna see where you've been that's usually not a good thing sometimes you will see bowel you see gold bladder you'll see arteries you'll see veins you'll see all sorts of stuff

that nobody wants to see and you don't want to document okay so that's another disadvantage so I recommend especially young physicians especially young physicians in places that are not used to this especially young physicians that

are new to hospitals and they're gonna they're gonna make multiple passes not to do this was they're gonna be very they'll be criticized a lot by their texts and by the institution by their colleagues as to what have you done you

know big mass artery you've hit artery but the guys and gals that are just aspirating and not injecting they're actually not documenting what they're going through but they're going through the same stuff okay

okay next up this I think this video yep

technically step by step of how tips are done okay and and the ideal tips with

every step of this procedure I'm gonna show you two ways of doing it okay and the advantages and disadvantages of the two ways in every step okay so first of all the primary thing is to get into the portal vein and how do you visualize the

portal vein okay so one way is to do co2 Vinogradova nog Rafi to hit the portal vein me with experience no I don't need co2 venography to hit the portal vein but I still do it in an in a teaching institution because I have texture that

are learning nurses they're learning and physicians are learning so I actually do the imaging for them so they actually can get the general idea of what we're doing this is our target this is where we're coming off and that's it but in an

experience hands is it necessary absolutely not okay so co2 photography very helpful for in teaching and teaching institutions so everybody and the whole team can actually know exactly what our target is so not essential like

like we discuss and there are two methods of doing this and in a funny way I'm gonna show you that's actually the same method but one is a micro of the other one okay so two ways one way is then wedge a catheter that's the old way

kind of more traditional way than let's not call it always more traditional way of doing a co2 port and the other one is using a balloon of balloon occlusion castra and this is wedging it with a four French five French catheter you

take it all the way to where the catheter is larger than the hepatic vein and now you've wedged it okay and this is kind of a mag up you see that that's a little that's a little wedge okay you wedge you inject contrast the contrast

just sits there it's wedged it's trapped okay and then this is with a balloon to your left is a balloon full of air to the right full of contrast and you basically trapped it again you fill contrast and consciousness it's there

what's the difference between this image and this image no difference the only difference is size that's all it's the same idea you're just trapping a segment of the liver the difference is this is a very

small segment and this is a larger segment okay so essentially it's actually the same technique one is just well technically when it comes to your side all one needs a four or five French calf the other one needs a balloon

occlusion caster okay same image so then you inject co2 the key thing here if you're the type of physician where you put contrasts you have a balloon sitting or a wedge and you have to count contrast there okay

rookie mistake is that they leave the contrast and then they hit the co2 okay what is that you've lost the advantage of the co2 in the beginning of your bolus is actually contrast okay so you need to bleed out the contrast and

replace it completely co2 so your entire bolus okay is co2 and not and not and not the and not the contrast okay that defeats the purpose why is co2 advantageous over contrast contrast is a thick fluid co2 is gas is viscous it's

volatile it actually can squeeze through tight spaces as it's a gas and that's what we want we want to squeeze that co2 which is a contrast through the sinusoids reflux it back into the portal circulation so we're trapping it and

we're trying to push co2 squeezing it through the sinusoids refluxing it back into the portal circulation so you can actually visualize the portal circulation okay and all and the disadvantage of a wedge is what you see

here if you're a wedge and you're immediately sub capsular and you slam you slam that co2 aggressively what you will get is an explosion you get a rip of those of the hepatic capsule scroll the glisten capsule and then you've got

a leak and if the patient is quite low is a quite low path they can actually die from this believe it or not they will die from this and not die from the needle passes okay so that's kind of co2 and that's kind of

a little a little passive air into the perineum nice imaging not a good outcome so one way to avoid this is to still wedge but wedge away from the hepatic capsule so you're out in the periphery in the paddock veins but you're deep

inside the liver you're not you're not right underneath the capsule so that's one way of doing it the other another way is to actually use a balloon okay so this is this is just another wedge here okay and you actually use a balloon I'm

just showing you a correlation with a balloon it's a little safer because you're a little distance away from from the hepatic capsule I'm just showing you a more and more image of the same thing co2 with correlation after you access

since it's a beautiful correlation with with the portal vein venogram okay there are problems with wedges and with balloons is that sometimes you get a gas you know a co2 leak you're wedged but there's hepatic veins at vadik vein

connections and all you see is a fatty veins you can't force reflux the co2 into the portal circulation so that's one problem okay so what do you do with that you change the sights just change a different different branch okay try to

avoid that connection between the badeck veins and it back veins go somewhere else where there is no connection where you can actually make a true hip wedge and force that co2 into the portal circulation okay another way this is

just a draw a drawing out whether it alone or a catheter you get that you get the escape from the Patek vein to fatty vein is to go distal go beyond that connection so if you can go distal go distal if you can't go distal then

change your branch try to find a place where there is no hepatic vein tip a degree engine attraction preferably but not necessarily not the same branches connected to because that usually goes both ways but not always sometimes

you're lucky and if that connection is kind of like a one-way valve one way street and it's not a two-way street but that's just sheer luck okay this is an example hepatic vein to about a vein connection and what we did was basically

switch to another place another vein and we actually get the portal venogram here okay next up sting crafts Viator's thank

treatment options once you've sort of isolated that there are leaky valves and the patient has typical symptoms that there are some surgical options but really embolization and catheter

directed treatment are really the mainstays of treatment both because it's an outpatient procedure you get to go home the same day and the recoveries fairly easy the factors that we consider when you embolize or block these

varicose veins are listed here you want to you want desired duration you want it to be closed forever you can't replace valves it would be nice to be able to do that but there's not a valve replacement so much like in the leg when you're

treating varicose veins you're either blocking or taking veins out so the surgical options are to take the vein out or to ligate but and the vascular options would be to block it and so I would just thought I would cover just a

little bit of embolization materials I'm sure you're all very familiar with and as I'll mention a little bit later there's there's sort of not necessarily agreement on what type of things people use to embolize gonadal veins or pelvic

varicosities but i'll show you what i do but give you a background of just generalized embolization materials so I'm sure you've all seen gel foam supplied as a sheet you can make a slurry you soak it with contraire

so that you can see it as you're putting it in some people use glue and will glue the entire gonadal vein it solidifies when it's mixed with saline or blood usually mix it with acai it also you can see it as

you're injecting it and then the standard coils which there are multiple sizes shapes detachable non-detachable Amplatz or plugs all the mechanical devices that can be used to block blood vessels and then I put on Souter deck

all because there are some people that will sort of do the sandwich technique you may have heard we'd put a coil peripherally and a coil up by the renal vein and then in between the coils you can film a sclerosant and embolize that

way the other important factor for me is using the suture deck all on the actual varicosities I'm not just necessarily treating or blocking off the the blood supply to them you know and I'll mention that a little bit more during the case

here so go through a case patient with

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

typical symptoms if you want to hit the play on this I think this is one we've probably already seen but it's it's the the algorithm that I go through for treatment so we do my renal vena Graham

there we go it's classic definitely has reflux and so next I will selectively catheterize the gonadal vein and here you see very large pelvic varicosities and so my standard is to actually treat the varicose veins with a sclerostin

much like I would sclerosis a varicose vein in the leg and there's a few reasons that I do that and so here's how I do it I'll put an occlusion blown up you see the picture on the left of the screen has an occlusion balloon it's the

same occlusion balloon we use for a tips procedure and I'll temporarily block the gonadal vein and fill up the system or the varicosities with contrast so that I get a sense for the volume of sclerosis and I would use then the picture on the

right is a venogram after I've injected the sclerostin so I've evaluated the volume and then I've replaced all that contrast by forcing it through the system to drain out the pelvic veins and filling the varicosities with

soldier column I do that because I believe and there's no data to prove it that it helps prevent superficial phlebitis in those varicosities so if we're just gonna block off the gonna dull vein then we have stagnant blood in

all the pelvic varicosities and stating that blood wants to clot and when blood clots on its own it'll stretch and expand the vein and cause pain and so in my own personal experience that has created a little bit worse post

procedural symptoms for patients compared to the patients that I use so TRADOC all to actually treat the varicosities so that's what I start out with and then since I'm kind of an old-fashioned guy I still go with the

coils and so I coiled the whole going a ttle vein and you can use sort of whatever you want you know that's the simplest thing for me are using nester coiours coils and and fill it up some people use the long detachable shaping

coils kind of an expensive way to do it if it saves you radiation then then that's that's one of the reasons to do it but the point is in in the venous system you have to be able to and I show this slide because you can see a

collateral vein or at least a branch there a confluence point that we've coiled off too if you do not treat the entire length there's a there's a lot higher chance for recurrence and veins have a way to find their way around if

they can communicate back up then patient gets recurrent symptoms and that can happen in about ten percent of cases so in order to prevent that you treat the whole gun out of vein and that's sort of why I think some people like to

use liquid sclerosis because then they will be able to sort of profuse all those branch points that would have a chance for recurrence case number two

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

interrupting something else getting back

to a paddock with angiography something that we're starting to look at the group at University of Pennsylvania has a publication out on this as well I looked at the liver lymphatics certainly the livers where we produce a

lot of protein it goes through the lymphatics to be returned to the circulation in patients who have heart failure they tend to have increased lymphatic flow in the liver and they think that protein lost in enteropathy

protein losing a property happens when the liver lymphatic leaks into the intestines just some images from their article you see them looking at the hepatic lymphatics there and once they had a needle in the hepatic lymphatics

they actually put her scope in and they injected blue dye and as a proof-of-concept they saw the blue dye leaking into the intestine so now that they see that the blue dye leaking the intestine they say well we can embolize

that they embolize it with some glue and that's what it looked like at the end and then the algorithm levels and all these patients return to near normal so a new a new frontier and lymphatic intervention so just to summarize

lymphatic imaging the current status you know we have very effective non-invasive as well as in vases imaging in the peripheral and central lymphatics we certainly need to this allows for improved diagnosis and once we have

these diagnostic capabilities we were able to come up with these novel treatments for these diseases that were previously untreatable we still don't have good ways to consistently visualize the paddocks invasively and then and

non-invasively it would be great to be able to see that hepatic and intestine lymphatics cuz that's 80% of lymphatic flow so if we can find a way to image these under mr it could be a game-changer for a lot of diseases in

terms of lymphatic interventions Calla thorax interventions greater than 90% effective technical knowledge you know when I was a trainee was really centered to just a few major medical centers now it's defusing out to more places we've

certainly shown as a proof of concept the plastic bronchitis lymphatic flow disorders cattle societies and protein losing enteropathy are all treatable and we're getting emerging experience so don't be surprised if you start to see

more requests for this more patients at your centers these are uncommon disorders that's not to say that you still won't see them every once in a while the role of lymphatics in pathophysiology is still being studied

particularly in terms of heart failure transplant as well as in different cancers in the spread one of the cool stuff that we're looking at right now is actually sampling different lymphatic fluid in different areas of the body

trying to see how the different cancers may spread and/or possibilities in immunology immuno oncology thank you guys and just something I noticed a couple weeks ago in jeopardy clear body lymph continuing white blood cells body

fluid and you guys know what is limp that's your answer so thank you saying thank you to the avir committee and it's been a pleasure [Applause]

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

to have severe humor billion almost all all those that need your attention is about aghori portal veins though can be tremendously so the differentiation between hepatic artery and portal vein

bleeding is the big differentiator that will require you to do something about it most of the times if you injure the portal vein or hepatic vein these usually heal by themselves and it's counterintuitive the management of this

is actually to upsize your tube and they make sure the side holes are not adjacent to the bleeding vein it's crossing so it's counterintuitive that you upsize - for bleeding injure the vein more but

eventually those veins will thromboses off for that little branch the difficult situations of sahiba heavy hit an artery and here's one way we did a gram you can see the pacification the reason why you want to go into the peripheral duct I'll

show you always near the hilum is actually also very big blood are the blood vessels and the reason why we go peripheral the number of large vessels are much greater diminished so you always want in this patient was

transferred for an outside Hospital my PTC was performed by someone who obviously doesn't do a lot of these and access directly into the coma bar duct you can see all these filling defects all these filling defects in the combat

like those or clots and filled with someone who's actually had life-threatening significant he Mobilia and required what we did was they were just pacify the system get another peripheral access

right biliary system and embolize the track coming out and thereby removing the original axis that was placed by the outside hospital interventionists obviously the ones that aureus the most of the narco that will kill people is

the ones that hit our ease and pseudoaneurysm formation or tara Venus fistulas and I can be problematic in my only real ways their dresses trans cap the treatments a patient would have an angio we'd have to get into the pedagogy

find the feeding or it almost always though and we can predict way that bleeding artery is it's where your Y is crossing the architecture of the artery tree frequently you will not see it until you remove the tube so almost

always you would have to prep the right flank prep the groin to an angiogram with the tube in because you don't really want to be rushing at the beginning of your procedure you frequently do the angiogram not see

bleeding and then a second operator needs the described brake scrub get non sterile axes remove the blue tube repeat the angiogram and almost certainly then you'll see it but again it's very

predictable where it is but every now and then you get caught out and the bleeding side can be remote from where your actual Y or actual access transgressor you you do need to have a careful eye looking for that and so you

know when we looked at out and we do large numbers of blurry drainage the best predictor or and like I said Arturo Kimber Billy is actually related to your first tube and the size that you place and it's also

interesting like I said every now and then you're gonna see that bleeding arteries are actually not liver arteries and you can't bleed from the GDA internal memory from other procedures intercostal artery from where you put

your tube first needle through the liver through sorry through the ribs itself it's actually access site rather than your internal parenchymal your liver so it's actually important to also do sometimes it a water gram check the

intercostal artery because you'll miss it by doing a celiac or teragrams hepatic artery gram and don't understand why the patients still bleeding and here's just example of what a pseudoaneurysm does when we remove the

chief we can see the image on the right the blue tube has mean withdraw back and they you can see quite clearly there and sorry the pseudoaneurysm of the paddock right re and like any other immunization is important to go front door back door

implies across mainly because the liver architecture has a rich collateralization that will feed before and after and like I said the lake complication zone was or derived and related to tube maintenance and tubes

catching on to things in dislodgement and so these are just really you know your whoever answers the phones whether it's the physicians on call they have to manage with maintenance of these tubes and really just keeping these tubes open

as long as possible it's amazing how long some of these tubes do last in particular in benign but Lewis structures so management of these is really or expectant and the right advice and frequently just need to

get these tubes changements they're clogged sufficiently the difficult ones

you see again renal Dena Graham you can see a hint of the gonad of Ain selective

vena Graham again showing us the large gonadal vein and that's my post so charcoal with the occlusion balloon and then treat I showed the cartoon slide before that we look at all four of those territories so I always start with the

left but then I'm gonna look at the right gonadal vein as well as the internal iliac veins on both sides in this case the right go Natalie was normal as were the internal iliac veins so not seeing any varicosities

normal venous outflow so this patient it was only treated with a left gonadal vein embolization

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

we do drain the Louie systems we actually do this extremely successfully as interventional radiologists and it's a very high technical success like I said in this sort of supine position

from the mid-axillary line and these things are and you've seen a lot of these how these done really you need to pacify the system you get trans you most post people go trends in to cost Albany because the liver sometimes can be

tucked up way above and we usually want to make sure that the lung and the costophrenic angle doesn't come down low in nothing I take a deep inspiration first to make sure that you're not dealing with and then we now map your

track than you find some people do this with ultrasound guidance frequently with and dilated structures and most of the time it's actually much probably routine to actually do blind passes in the like I said the path of high success and to

pull back when you a passive our blue system is the only structure that doesn't wash away generally portal vein hepatic vein hepatic artery all of those structures are cylindrical

tubule alike are not are going to wash away move away and quite quickly and you can see this PDC and show in fact a left insertion of a right into your ductal system and frequently this will be something that we would have to make

people watch out like I said identification of choosing the right duct thereafter after you've identified you've performed a color angiogram is to identify how you're going to drain this and the most important thing to identify

is a peripheral duct doesn't matter which one there are ones with higher success but then within the lateral position find one market on the table then with a second axis as a to stick axis and I'm sure this is very germane

and common you've seen get into the peripheral duct and the AP fluoroscopy get a wide down you get a tube down and then eventually go it with a coaxial system getting a skinny wire converted to a larger wire and then following that

with a below a tube and your goal is to really get axis that goes transpannic through a perfect century through obstruction or no obstruction if it's just untie elated and through into the small bowel and lock a some type of

locking system it's interesting the size that you choose does make it different so if you go larger than the 12 french-trained initially the risk of bleeding actually goes above 10% for initial axis so the best is to probably

start with a 8 and 10 and that's what we typically do this is what we connect what it ends up looking like left a

we're gonna move on to embolization there a couple different categories of embolization bland embolization is when

you just administering something that is choking off the blood supply to the tumor and that's how it's going to exert its effect here's a patient with a very large metastatic renal cell lesion to the humerus this is it on MRI this is it

per angiogram and this patient was opposed to undergo resection so we bland embolized it to reduce bleeding and I chose this one here because we used sequentially sized particles ranging from 100 to 200 all

the way up to 700 and you can actually if you look closely can see sort of beads stacked up in the vessel but that's all that it's doing it's just reducing the blood supply basically creating a stroke within the tumor that

works a fair amount of time and actually an HCC some folks believe that it were very similar to keep embolization which is where at you're administering a chemo embolic agent that is either l'p hi doll with the chemo agent suspended within it

or drug eluting beads the the Chinese have done some randomized studies on whether or not you can also put alcohol in the pie at all and that's something we've adopted in our practice too so anything that essentially is a chemical

outside of a bland agent can be considered a key mobilization so here's a large segment eight HCC we've all been here before we'll be seeing common femoral angiogram a selective celiac run you can make sure

the portals open in that segment find the anterior division pedicle it's going to it select it and this is after drug living bead embolization so this is a nice immediate response at one month a little bit of gas that's expected to be

within there however this patient had a 70% necrosis so it wasn't actually complete cell death and the reason is it's very hard to get to the absolute periphery of the blood supply to the tumor it is able to rehab just like a

stroke can rehab from collateral blood supply so what happens when you have a lesion like this one it's kind of right next to the cod a little bit difficult to see I can't see with ultrasound or CT well you can go in and tag it with lip

Idol and it's much more conspicuous you can perform what we call dual therapy or combination therapy where you perform a microwave ablation you can see the gas leaving the tumor and this is what it looks like afterwards this patient went

to transplant and this was a complete pathologic necrosis so you do need the concept of something that's ablative very frequently to achieve that complete pathologic necrosis rates very hard to do that with ischemia or chemotherapy

alone so what do you do we have a

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

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

the take-home point is this that most of the time when we see a bleeding patient we're thinking of embolization we're thinking of going in looking for an

arterial abnormality going as far into the organ that we can embolizing that organ and trying to preserve as much flow to the normal parts of the tissue that we can to preserve the function of the organ today in the back of our minds

we're always thinking about putting covered stents across this but in some ways you realize that's a band-aid right with just you know the arteries that we put those covered sense and we're severely injured and there's always a

chance that flow can work around there so they could be leaks around covered sense so I still think embolization is a bit more definitive than cover stent placement but I find it when a growing number of patients cover sent placement

is definitely an option for these patients so I am here for ask any questions but I can also appreciate that you have a break it's been a long day so I will not get offended if none of you have questions all right perfect

yeah yeah no that's it's the nature so what what he asked here is is that GI bleed cases tends to be unsatisfying because you hear about them and then by the time you get them down to the NGO suite and you

do an angiogram they're negative and it does happen a lot you should know it's the nature of the pathology so what ends up happening is let's be honest I mean a lot of people who work in AI are just like to push things off sometimes so

they get a call for a GI bleed or they say oh let's get a bleeding scanner let's get a CTA by the time you see them at 6 or 7 hours later and they're negative because they've stopped bleeding and that's the nature of the

pathology so my personal philosophy is to get at these patients as quickly as I can I think it's just a better way to go if someone thinks they're bleeding the faster you get at them the greater the likelihood is that you're going to see

some some abnormality there and I think that's been true I think as we start to do these faster we're seeing more positive cases it might be nice to have a CT angiogram or a bleeding scan but I think by the time you see them after

that you know they're negative it's not anything you're doing wrong it's the nature of the pathology it's intermittent bleeding and that's what happens some people feel like they can give TPA to some of those patients like

they'll go into the SMA they'll give some TPA which let's be honest right all of us are saying what the hell that seems like a horrible idea and I agree with that I mean if the body has stopped the bleeding on its own why in the world

would I give a drug to dissolve the clot to start them from bleeding again so I don't like that idea but there are people that will do a bleeding you know kind of a challenge with TPA to see if they can open up something to identify

the bleeding to then go back in and embolize it I think my bias is coming through and how I answered that I don't know we don't used to out for that anything else yeah I think gelfoam has its place I think

gelfoam has its place for things like postpartum hemorrhage or you know some maybe some trauma and a younger patient but gelfoam in general is something that you're giving over a much larger area of territory so I think if you can identify

a bleed and just coil that particular bleed you're doing a better service for the patient but all these are obviously good hey let's see it in a lecture case in real life you may or may not see something so obvious and I think if you

have a patient that had some bleeding on a CT scan a bad pelvic fracture and you just didn't see it in geographically but you know something's wrong giving gelfoam is a legitimate thing to do all of us equate gel foam with a

temporary embolization effect the truth is we're not we're second guessing that a little bit and a lot of people who use gel foam feel that the extent of the inflammation that we get when we use gel foam is probably so great that even

though the embolic agent itself may go away the occlusion that we caused with the gel foam probably stays around longer than we think so I'm not so sure it's a it's a great temporary agent but I would say which we mostly limited to

postpartum hemorrhage patients yeah what's the cause of it usually it's a uterine rupture it's a vessel rupture I've gone three more questions than the leadership guy which is great anyone else yeah

well there's no doubt about it I think that IR is moving towards radial access I think 10 years from now the vast majority cases are going to be radial access it's the one area of our practice that I think I'm starting to feel my age

in I mean you know I think and you probably may see this at your own centers I think people that have been doing ephemeral access for a long time we're just more comfortable with that one of the issues that we're facing with

radial access as we begin to think about doing more radial access at our place is that we may be comfortable with it but places like the ER and the ICUs and the other areas that we're sending our patients back to are not yet skilled

enough as to how they manage those patients so our nurses are very frequently the ones to say I don't know if they're ready for us to send a radial access patient to whichever floor we're talking about so we have some work to do

to in service those the nurses on those floors as to how to take care of those patients first and until we do that I think we're going to be limited more to outpatient work with our radial access all right guys enjoy the rest of the

meeting [Applause]

let me show you a case of massive PE

this launched our pert pert PE response team 30 year-old man transcranial resection of a pituitary tumor post-op seizures intracranial frontal lobe hemorrhage okay so after his brain surgery developed a frontal lobe

hemorrhage and of course few days after that developed hypotension and hypoxia and was found to have a PE and this is what the PE look like so I'll go back to this one that's clot in the IVC right there and

that's clot in the right main pulmonary artery on this side clot in the IVC clot in the right main pulmonary artery systolic blood pressure was around 90 millimeters of mercury for about an hour he was getting more altered tachycardic

he was in the 120s at this point we realized he was not going the right direction for some reason the surgeon didn't want to touch him still to this day not sure why but that was the case he was brought to the ir suite and I had

a great Mickey attending who came with him and decided to start him on pressors and basically treat him like an ICU patient while I was trying to get rid of his thrombus so it came from the neck because I was conscious of this clot in

the IVC and I didn't want to dislodge it as I took my catheters past it and you see the Selective pulmonary and on selective pulmonary angiogram here and there's some profusion to the left lung and basically none to the right lung

take a sheath out to the right side and do an injection that you see all this cast of thrombus you really see no pulmonary perfusion here you can understand why at this point this man is not doing well what I did at this point

was give a little bit of TPA took a pigtail started trying to spin it through aspirated a little bit wasn't getting anywhere he was actually getting worse I was starting to feel very very nervous I had remembered for my AV

fistula work that there was this thing called the cleaner I don't have any stake in the company but I said you know I don't have a lot to lose here and I thought maybe this would be better than me trying to spin a pigtail through

the clock so the important thing about the cleaners it does not go over a wire so you have to take the sheet out then take out the wire then put the cleaner through that sheath and withdraw the sheath

you can't bareback it especially in the pulmonary circulation the case reports are poking through the pulmonary artery and causing massive hemorrhage and the pulmonary artery does not have an adventitia which is the outer layer just

a little bit thinner than your average artery okay so activated it deployed it and you started to get better and this is what it looked like at the end now this bonus question does somebody see anything on this this picture here that

made me very happy on this side this picture here that made me feel like hey we're getting somewhere I'm sorry the aorta the aorta you start to see the aorta exactly and that that was something I was not seen before the

point being that even though this doesn't look that good in terms of your final image the fact that you see filling in the aorta and mine it might have been some of the stuff I had done earlier I can't I can't pinpoint which

of the interventions actually worked but that's what I'm looking for I'm looking for aortic blood flow because now I've got a hole in that in that clot that's getting blood flow to the left ventricle which starts to reverse that RV

dysfunction that we were concerned about make sure I'm okay with time so we'll

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

people were thinking about the covered

portion actually actually would be occlusive in that paddock veins a lot of people are concerned about that this could be kind of like a but carry you're gonna actually occlude flow in the paddy vein caused thromboses that didn't pan

out at least clinically okay it didn't pan out and that's another advantage of actually accessing very close to the paddock vein IVC junction that's where the biggest vein is so you don't get a lot of occlusive problems okay but

usually clinically it does not pan out so the bigger the hepatic vein the more likely you have a lot of room around your your graft you won't be occlusive to the paddock vein that's more important for for transplants than other

than others I told you it's rare this is actually a very rare case of such that where you actually have a segmental segmental kind of but carry after a tips okay and you know this is actually from a form of venous outflow from the ematic

vein this is a perfusion defect typical it's a wedge right typical perfusion defect in the liver that's how you death so you know this is vascular this is a perfusion problem but you've got hepatic artery readout artery the red arrows

running into the segments and you have portal vein running into the segments so what's the problem it's actually a paddock vein occlusion okay by the stents subclinical no no clinical complaints you let it be

in the patients usually recover okay treat the patients and not the images okay on the other side if you put their tips too deep sometimes you actually get thromboses of the portal vein branch

again you get a call from hepatology you've got portal vein thrombosis is the patient doing okay yes treat the patient and not the images they usually resolve this it's not not a big problem another technical problem

I'm gonna focus mostly on technical for you guys this is a but key area okay and the but carry especially in the acute stage the liver is not like a cirrhotic liver is big liver is actually engorged okay so it's very large usually

your needle is too short to even reach the portal vein okay that's a big problem okay because your access needle is too short for a very large engorged the portal vein so this is as deep as it

goes do I have a see that that do you see that needle tip that's as deep as the needle tip goes okay the portal vein is a good distance away okay luckily this is a co2 porta gram luckily I'm actually in a small branch right

there I just hit it on you know and on this is not the there's not a needle tract this is just luckily hitting it a little branch and on so I'm actually accessing the portal vein and I can do a co2 porta gram here okay

typical inexperienced person would say you know this looks good I'm lucky I'm in a branch but it's a nice smooth curve I'll just pass a wire down and I'll balloon it and I'll put a stent in it's a nice curve and you know so it's my

lucky day I don't need to extend my needle or get a bigger longer needle to reach the portal vein here's the problem with this and this is exactly what this is exactly what this is they pass a wire and it looks beautiful just put a stent

and go home okay here's the problem this is actually the small branch access sites this is actually where you really need to access world vane but your needle is not long enough okay

what we found out is that if you are in a small in a small portal vein no matter how much you balloon it it will come down again and it will be narrow so believe it or not if you go sideways in a portal vein and rip it open with a

balloon it will stay open but if you go down of small portal vein and balloon it open it will always contract down okay so you cannot do a tips simply by ballooning and putting a stent in in this case okay what we do is we actually

denude the vein itself we actually rip it off okay and make it a raw parenchyma and we do that with a Tortola device we literally rip off the paddock the paddock portal sorry the portal vein endothelium and media and adventitia rip

it off make it completely raw as if it's an access as if it's a liver brain coma which is which it is now and then we then we balloon dilates okay rip it off denude it angioplasty it's okay and then put the stent and see that aggression

despite all that aggression of ripping it off it still has an hour kind of an hourglass shape to the to the tips okay that little constraint there that's the hepatic venous access sites this is the parenchymal tract to see nice and open

with a balloon but the but the actual vein that we've been through despite our aggression in actually ripping it off it's still narrowed down but this is as good as it gets okay

them so my particular area of interest is a blade of radium ization and what we'd like to do is to break the liver

down into a bunch of little tiny perfused volumes off of a single vascular pedicle or what we call angio zones and those are those allow us to segment out if you only have small volume disease for example like here in

segment three why do I have to treat the entire left to paddock low I can actually treat just that small portion just like it what it tastes only now I'm administering y9t but since it's expendable liver I

can administer doses that are way higher orders of magnitudes higher than what I could if our infusing into the liver just on its own so here's an example of that if you look at this lesion in the right of panic lobe you'll see these

little lines over them what we want to achieve is around a 205 GRA threshold for these lesions that's the red line everything that's south of red in terms of color orange Holly to blue is not cold enough to kill tumor so if we

administer a dose of a tea grade to the lobe we get this coverage which is to be a partial response if I administer 150 grey suddenly that red line gets larger what happens when you administer 400 grey now you've officially covered the

entire lesion and so you're going to lose the adjacent liver at those kind of doses and as well - what what the real question then is not sort of how much dose you give it's you give what you need to to ablate the tumor in its

entirety and you see what the patient's left with if someone's left with anatomically a lot of remnant liver because of how you've segmented out that lesion then go ahead and dose extremely high and that's essentially what we've

seen in pathologic results it's one of the highest things of high school pathological crosa rates you can achieve with a trans arterial therapy it's highly competitive with thermal ablation in the correctly selected bleezin

so this is an example of what it looks like when you segment out a little lesion like this and this patient ultimately went to resection and this was a complete pathologic necrosis but as you can see even it was a cirrhotic

patient we chose a very small volume of liver that we felt the patient would tolerate so that's a blade of vernalization let's take a look at what looks like in real time so we have a little capsular lesion we felt that

ablating this patient who was a potential transplant candidate we felt we can probably with a blade of radium realization so you go in and this is the comb beam CT that looks at a complete enhancement of the lesion within the NGO

zone this is what the MAA looks like when we administer it you can see how it tends to cluster within the tumor but you can see what the adverse territory is the liver adjacent to it this is what the engine room looks like how highly

selective it is the day of and this is what the wine ID actually looks like is the wine 90 doing its job and you can see how conformal it is there's no risk whatsoever to the liver that's adjacent outside of that field of

a maximum of around 11 millimeters and this is a patient at one month with a complete imaging response and this patient never developed a recurrent to the site and what's actually sole mode of treatment for this person's liver

cancer this is how you get complete pathologic response if you look at those little tiny grey dots in there those are actually the spheres within tiny little vessels within the tumor sometimes they go even to the portal branch but you can

see how they're not clustered uniformly but when you make them super hot that allows them to give range where otherwise they would be fine a little bit short so this also applies to the whole lobe this was a patient that had a

very unusual presentation of colon cancer that was invading the portal II we weren't sure what to do with this patient no one was because a very rare occurrence so we said well we would like

to resect him but there's not enough liver and we're not sure if this person's gonna survive because we've never seen portal cancer invading the portal vein so we said let's treat it with the radiation lobectomy and what's

cool here is if you look at the the arteries even though the tumor is invading the portal vein it's bringing arterial supply along with it like a vagabond and that's the conduit that allows us to treat these patients so

when we saw that we felt this patient we good candidate for irradiation lobectomy which is applying an ablative dose of y9t to the entire low not just a small segment in patients where otherwise cannot because of the anatomy the tumor

or if you're trying to shrink that lobe to get that person ready for surgery why because if you look at the size of the lobe on the left from this first image and compare it here you can see how much larger it got what happens is that part

that the surgeon ultimately tens on resecting in volutes over time and becomes completely vitalized and turns into scar tissue so we know that if a surgeon goes in afterwards to cut it out it's going to not result in liver

failure and that level of security allows people to have sir who otherwise wouldn't this patient is not going to have metastatic disease because we followed their blood level markers let me see how low they are and

is going to have enough liver remnant so the patient went to resection and this is the pathologic specimen and this was also a complete pathologic necrosis so I

so these are a lot of slides most limited you know I'm talking I'm talking to you guys I'm talking showing you a lot of technical stuff you know and a lot of slides and I'm gonna talk mostly technical of you know how tips and dips are done kind of a step by step so even

the title it's kind of a workshop step by step of how basically you do you do tips and dips and what and and what are they so in general when you have when you have this is basically kind of out flow spleen spleen dumps blood into the

portal vein the mesentery dumps blood into the portal vein portal vein goes into liver liver does its thing and then dumps the blood into the eppadi veins to the right atrium okay for that because the liver is connected with the spleen

and the guts in series unlike any other organ basically the liver has to be a low-resistance organ because the portal circulation is low-pressure look the liver has to be a low-resistance organ with liver disease especially liver

cirrhosis you actually get increased resistance and in the liver with that disease and you get basically a backup of the blood flow in the portal circulation and increases the pressure in the portal circulation that's kind of

the genesis of or the pathogenesis of portal hypertension backing up circulation the spleen and in the guts then you get ascites and hydra thorax that's kind of think of it as weeping of fluid into the pleural space and into

the and into the perineum part of it is oncotic part of is osmotic basically think of it nutritional and pressure driven causes at the same time we all have potential portosystemic connections in other words they're there but they're

not connected or they're not opened up in plumbing they hold them bleed valves or pressure valves when the pressure is high and you know they start weeping or leaking you know in your in your basements we have the same thing

we have so many portosystemic connections there are about 55 named ones there are innumerable ones that are actually that are actually not named the common ones that we know are because of because of bleeding is esophageal

varices that's the connection usually between the left gastric vein and the azekah can be hazardous system you can also get gastric varices and that's usually connecting between a spleen and the left renal vein through a gas renal

shunts you can get also all sorts of connections even down in the internal hemorrhoids we get actually portal hypertension hemorrhoids and bleeding and so many numerous other shunts that we just don't have time to cut to cover

it to cover all these so the general to the general thought of treating all these complications of portal hypertension is to decompress the system to reduce the pressure and that's along the lines of years and decades of

surgery shunts that were placed and now tips ism largely replaced all these surgical shunts with the exception of Vancouver and Tampa okay that they still do some surgical actually a lot of surgical shunts most most other places

in North America converge to a tip to a tip shunt the the advantage of the tips of over surgical shunts is the usual what we hear is minimally invasive it you know it's a quick recovery less morbidity and mortality areason for

white tips has beaten the surgical shunts is the transplant era all these surgical shunts are actually extrahepatic so when you go for a transplants and liver hits the buckets they actually have to go and shut down

these shunts wherever they created them steena renal portal cable in the tips it goes out with a liver in the bucket so there's no complication of transplantation that's the real advantage of tips over surgical shunts

and that's why it's become very very prevalent in in in North America with a transplant error when approaching gastric varices just briefly another way is a BRT Oh which is to go basically into the left renal vein go up the shunt

and specifically screw rows the stomach and that's not the that's not this kind of subject of our of our discussion here I'm gonna talk to you

so this shows you this shows you how so this typically you've accessed the portal vein now and you're in next up you basically pass the wire down this just gives you a little depiction of

what you're what you're what you're doing here this think of this is a sagittal and Deliver okay hepatic vein and portal vein it's the sagittal and what you're trying to do is

and if you're in the right hepatic vein you need to pass your needle anteriorly to hit the right portal vein okay and the right portal vein is usually anterior and interfere to the Patek vein okay so you pass your wire you're you

NEET your needle and when if you're missing the portal vein usually what's happening is that you're scooping behind it okay your posterior to it and sometimes you'll find the operators will actually increase the curve in the

needle so they can actually reach anterior anterior and actually hit the portal vein because usually usually if you if you know you're in the right place that the right hepatic vein not in the middle of petting vain and

you're missing the portal vein you need to reach anterior more so they put a little extra curve in the kelp into needle to actually catch that right portal vein okay with liver cirrhosis you get shrinking shrinkage of the liver

size the liver decreases the portal vein starts moving more anterior and more superior and closer to that paddock vein okay and it becomes more and more difficult to actually hit it so the smaller the liver the harder the liver

the smaller the space and you've got a thick mat piece of metal okay it's very difficult to hit that okay it becomes more and more challenging with with smaller levels to hit to hit the portal vein especially centrally okay this is

an access kit a new access kit by Gore it's basically the similar to the similar to the Cal Pinto needle it's a little longer with a little bit increase angulation compared to the traditional ring kits or the Cole Pinto needle but

once accessed you pass a wire okay into the portal circulation there are two ways of doing this okay there's a traditional old-school way that's my way is that to use a Benson wire okay the youngsters the Millennials are using

glide wires okay so if you're dealing with a millennial physician they're usually going for the glide okay if you're dealing with them with an older you know guy or gal they're using usually using a Benson wire okay the

advantage of the Benson wire is that has a floppy tip it actually you just push it in and hits the wall it prolapses into the main portal vein right away as you can see just prolapse and portal vein if you're using a glide where

you're catching all sorts of things you'll have small branches you don't know where you're going your V's even sometimes dissecting outside of the portal vein they're second-guessing themselves all the time but actually the

good way with a little bit of more different skillset is that you use use actual good old fashioned Benson wire actually goes in prolapses right away into the ends of the main into the main portal vein rarely would I actually use

light or switch to a glare that's usually if I'm coming in in a small in a small branch or an orchid angle where I have to use a glide right to try to get around the angle because I don't have enough room for a Benson to actually hit

the wall and prolapse is very really really tight space so tights Bates funny angles I'll switch to a glide where if it's a straight forward a Benson as very is very straight forward okay try to get the sheath as much into the portal vein

over the over the needle over the wire as possible and then you balloon your tract okay through the sheath okay some people will balloon with a six millimeter boom some people will balloon with an eight millimeter blue eye

balloon with an eight four okay at night and I make sure it's a four so that I actually use the balloon as the measurements for this four centimeters actually you I actually use the balloon to measure my to measure my Viator's

stance okay with the balloon there there'll be two waists there's a portal venous entry site and the Ematic venous entry site so you actually gauge that and take a picture of it so you actually see how long your tract is where's your

hepatic venous access who has your portal venous axis actually gives you a lot of anatomy here been engaging in actually putting where your Viator stent is okay usually high pressure balloon I use it and ate some people will use a

six or even a seven millimeter balloon

to talk about is indirect angiography this is kind of a neat trick to suggest to your intervention list as a problem solver we were asked to ablate this lesion and it looked kind of funny this patient had a resection for HCC they

thought this was a recurrence so we bring the comb beam CT and we do an angio and it doesn't enhance so this is an image here of indirect port ography so what you can do is an SMA run and see at which point along the

run do you pacify the portal vein and you just set up your cone beam CT for that time so you just repeat your injection and now your pacifying the entire portal vein even though you haven't selected it and what to show

well this was a portal aneurysm after resection with a little bit of clot in it the patient went on some aspirin and it resolved in three months so back to our first patient what do you do for someone who has HCC that's invading the

heart this patient underwent 2y 90s bland embolization microwave ablation chemotherapy and SBRT and he's an eight-year survivor so it's one of those things where certainly with the correct patient selection you can find the right

things to do for someone I think that usually our best results come from our interdisciplinary consensus in terms of trying to use the unique advantages that individual therapies have and IO is just one of those but this is an important

lesson to our whole group that you know a lot of times you get your best results when you use things like a team approach so in summary there are applications to IO prior to surgery to make people surgical candidates there are definitive

treatments ie your cancer will be treated definitively with curative intent a lot of times we can save when people have tried cure intent and weren't able to and obviously to palliate folks to try to buy them time

and quality of life thermal ablation is safe and effective for small lesions but it's limited by the adjacent anatomy y9t is not an ischemic therapy it's an ablative therapy you're putting small ablative radioactive particles within

the lesion and just using the blood supply as a conduit for your brachytherapy and you can use this as a new admin application to make people safer surgical candidates when you apply to the entire ride a panic globe

thanks everyone appreciate it [Applause] [Music]

so my name is Paul I'm one of the nurse practitioners from UCI Irvine healthcare and what am i one of our minerals in there is basically working on patients for consultations doing the patient rounds writing notes ordering labs etc we also have several clinics that we run

at UCI Medical Center involving patients needing consultations for Libra direct therapies ablations and so forth and one of the more recent clinic that we started running is basically treating patients with BPH and so what we would

know inspiration is basically treating and regarding their symptoms and the procedures pretty much called a prostate artery embolization so the main purpose of this patient excuse me the main purpose of this

topics is basically to provide the general information of what the procedures are about illustrating indications risk and to hopefully help our nursing staff to better take care of these patients sorry so first and

foremost I just wanted to thank my team UC Irvine for allowing me to take some time off of work and enjoying Austin and its many food and object and and allowing me to speak to you guys a little bit about prostate ammo on our

pitchers basically you can't I don't know laser printer but our physicians dr. Karen Nelson she's one of our chief of IR dr. Dan through Fernando dr. Nadine a bitch day and dr. James Castro thesis

he's got daughter Kat Reese is our main doctor that does most of our process embolization our excellent iron nursing team and of course my fellow nurse practitioners who is holding the fort back home Pamela and Takara and watch

and Lou sorry but so our objectives for discussions basically to illustrate the indications and benefits of prostate artery embolization we're going to go over the side effects and risk complications associated with this

procedure and also recognize the value of nursing care going starting from the workup leading to the proper process in trot process and post procedure care sort of a brief outline of what we're gonna be

talking about we're just gonna go over the basic fundamentals of BPH as well as the treatment for PAE and the second portion of this lecture is going over how we walk patients up in clinic what we tell patients and we're gonna go

through the proper care and drop care ask well ask the post-op care and we're going to go through a couple of cases in there it's just to describe to you guys how we care for these special population

okay stent graft deployments once you've ballooned you basically pass the sheath over the balloon all the way down to the portal circulation the reason for that

is the Viator stance has a bare portion that's captured by the sheath so your sheath has to be deep into the portal circulation so when you unsheath it it opens up and then you pull back so it snags on your portal venous entry so

it's a feel thing and a visual at the same time for the operator okay so your sheath has to be deep in the portal circulation so that dilates put your sheath all the way down this is a run just to make it look pretty for you guys

and then you basically deploy the Viator stent via tourists and like I said has a bear portion that's captured by the plastic here and that plastic sheath basically transfers the capture of the bare

portion from plastic to your entry or access sheath okay as a ring to it and put it in has a feel to it that ring has to be right there it's very common for people starting off to deploy it inside the sheath up so it's a kind of a feel

thing to actually make sure that it's actually in there snug with it with the sheath okay then you push the stents all the way into the sheath now the bare portion is captured by the sheath you remove the plastic it's over over and

done with and then you pass pass your your stent all the way down to the portal vein and then unsheath it like a wall stents let it open pull everything back till it snags on the portal venous entry sites and then unsheathed the rest

of it which is the covered portion and that stays constrained by the cord and then you pull then you pull the cord keep key portion here is this is the ideal tips and ideal ace tips is a tips from the portal vein bifurcation to the

a patek vein IVC junction okay that's an ace tips it's usually a straight tips it's the straightest tips you'll see it runs parallel to the caiva okay rookies will be doing tips down out in the

periphery and Deliver okay they'll be fishing for small portal veins out of his small hepatic veins and at the end their tips is gonna be like a big seat like a big C loop okay it'll be a longer tips with more stance and it won't be an

aggressive decompressive tips okay but an ace tips is a more aggressive central tips straights it comes from the portal vein bifurcation to the paddock vein IVC Junction that's kind of like an ace tips

okay unsheath it and then and you and then you pull the cord to basically deploy it and this is kind of a reenactments the Styrofoam cup is the portal vein the sheath is in there now over the wire there's no wire in the in

the reenactments and then you unsheath the bear portion so it opens up okay and then you pull everything back till it catches on the portal vein okay you move the sheath all the way back and

then you pull the cord you see the cord right there you pull the cord and it basically opens up the covered portion okay and it opens up from the portal venous end so it actually capped catches it right away catches that portal venous

entry sites there's no slippage and so basically rips open tip to hub okay and that's kind of your final product and then you go in and and then you go in and balloon okay so here it is ballooning put the sheath

over the balloon sheath is deep into the portal circulation you put the tips in your unsheath to cut the the the bare portion let it flower open you pull everything back to like snags you unsheath the rest of the stunt and then

you pull the cord okay and then you dilate with 8 or 10 or whatever so this is visit with the debilitation and that's kind of your final product ideal

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