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Retrohepatic Collection | Percutaneous Catheter Drainage (Curved Needle) | 74 | Male
Retrohepatic Collection | Percutaneous Catheter Drainage (Curved Needle) | 74 | Male
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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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Case- Severe Acute Abdominal Pain | Portal Vein Thrombosis: Endovascular Management
Case- Severe Acute Abdominal Pain | Portal Vein Thrombosis: Endovascular Management
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An Overview of PET, MRI and PET/MRI | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
An Overview of PET, MRI and PET/MRI | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
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Renal Ablation | Interventional Oncology
Renal Ablation | Interventional Oncology
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Difficult Biliary Access | Biliary Intervention
Difficult Biliary Access | Biliary Intervention
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The Disease Process | TIPS & DIPS: State of the Art
The Disease Process | TIPS & DIPS: State of the Art
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IR in Sudan | IR Today in Sudan & Kenya
IR in Sudan | IR Today in Sudan & Kenya
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Practice Guidelines | Procedural Sedation: An Education Review
Practice Guidelines | Procedural Sedation: An Education Review
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Systemic vs Catheter-based Thrombolysis | Management of Patients with Acute & Chronic PE
Systemic vs Catheter-based Thrombolysis | Management of Patients with Acute & Chronic PE
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Aspiration Thrombectomy | Management of Patients with Acute & Chronic PE
Aspiration Thrombectomy | Management of Patients with Acute & Chronic PE
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Theories on Accident Causation | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
Theories on Accident Causation | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
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The Path Forward | Uterine Artery Embolization The Good, The Bad, The Ugly
The Path Forward | Uterine Artery Embolization The Good, The Bad, The Ugly
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Pulmonary Ablation | Interventional Oncology
Pulmonary Ablation | Interventional Oncology
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Case- May Thurner Syndrome | Pelvic Congestion Syndrome
Case- May Thurner Syndrome | Pelvic Congestion Syndrome
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Endovascular AVF creation | Twitter Case Files SIR 2019
Endovascular AVF creation | Twitter Case Files SIR 2019
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MRI Safety & Screening | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
MRI Safety & Screening | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
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CTEPH Studies | Management of Patients with Acute & Chronic PE
CTEPH Studies | Management of Patients with Acute & Chronic PE
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The Impact of Twitter on Our Specialty | Twitter Case Files: Impact on our specialty and how to expand our reach
The Impact of Twitter on Our Specialty | Twitter Case Files: Impact on our specialty and how to expand our reach
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Q&A- Documentation, Before and After results, Leadership, Culture | Innovation and Application of Real Time Nursing Dashboards
Q&A- Documentation, Before and After results, Leadership, Culture | Innovation and Application of Real Time Nursing Dashboards
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Examples of Highly Viewed Tweets | Twitter Case Files
Examples of Highly Viewed Tweets | Twitter Case Files
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Indirect Angiography | Interventional Oncology
Indirect Angiography | Interventional Oncology
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Percutaneous Mechanical Intervention | Management of Patients with Acute & Chronic PE
Percutaneous Mechanical Intervention | Management of Patients with Acute & Chronic PE
catheterchapterclotmassivemechanicalNonepatientpatientsPig Tail Catheterpigtailpulmonarysurgerythrombolytictpa
TIPS: Techniques- Stent Grafts | TIPS & DIPS: State of the Art
TIPS: Techniques- Stent Grafts | TIPS & DIPS: State of the Art
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Cone Beam CT | Interventional Oncology
Cone Beam CT | Interventional Oncology
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Normal Bleeding | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
Normal Bleeding | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
activatedaspirinbindbindingbleedingcapturedcascadecellschaptercirculatingclotclottingcoagulationdoseendothelialfactorfactorsinhibitorsinjuryinterferinglabslearnedmechanismsmedicationmedicationsmoleculemonitoredneedleNoneoverviewpatientplateletplateletspracticereceptorreceptorsreleasereversiblethrombintrialstypicallyvitaminwarfarin
The Ways to Recanalize the Below the Knee Vessels | AVIR CLI Panel
The Ways to Recanalize the Below the Knee Vessels | AVIR CLI Panel
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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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Therapies for Acute PE | Management of Patients with Acute & Chronic PE
Therapies for Acute PE | Management of Patients with Acute & Chronic PE
anticoagulantanticoagulationcatheterchapterclotcoumadindefensesdirectedheparininpatientintermediatelovenoxNonepatientpatientsplasminogenprocessriskrotationalstreptokinasesystemicsystemicallythrombectomythrombolysisthrombustpa
Treatment Options- CAS- Embolic Protection Device (EPD)- Proximal Protection | Carotid Interventions: CAE, CAS, & TCAR
Treatment Options- CAS- Embolic Protection Device (EPD)- Proximal Protection | Carotid Interventions: CAE, CAS, & TCAR
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PV Access | TIPS & DIPS: State of the Art
PV Access | TIPS & DIPS: State of the Art
accessaccessedangulationanterioranteriorlyballoonchaptercirrhosisglidehepatichepatic veinliverneedlepasspintoportalposteriorprolapsesagittalsheathshrinkagestenttractveinvenouswire
Transcript

now trying to avoid items in series. So this was another patient who came to us, a 74 year old male had a history of ampullary carcinoma post Whipple and he has a low grade fever, lethargy and he's presenting with a retrohepatic collection.

Anteriorly we're limited by the liver, stomach, the xiphoid process and the left gastric artery. Posteriorly as Dr. Gupta just showed us,

we want to avoid the pleural reflection. We're definitely gonna go intercostal here. And there was no subcostal approach we could take. So we wanted to avoid the posterior approach if it all possible cuz the patient did not have an ipsilateral pleural effusion. If we took a curved needle in here in order to avoid the liver,

it would be difficult then to rotate that curved needle without lacerating the left gastric artery or potentially the stomach and even the liver. So we thought this would be another great case for that AprioMed steerable needle.

So my colleague Dr. Gupta advanced from a caudal to cranial approach, he went subxiphoid went into the hepatogastric region and then as he advanced the needle to the liver margin, we then depressed the lever of the

needle in order to kind of deflect the needle to the patient's left. And as expected it did travel longly expected trajectory. As it entered close to the collection we then brought that needle back to its neutral position, rotated it

180 degrees so that we can then deliver the radius of curvature the other direction to the patient's right. And sure enough we're able to enter into the collection avoiding any of the liver, left

gastric or the stomach. So just the teaching points. If you're going to create your own needle I think it's important that you keep in mind to bend that needle, give it a pretty fair radius to curvature,

2 to 3 cm and keep the angle

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

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

positron emission tomography is the use

of a radioactive tracer in this case FD gee her fluorodeoxyglucose to assess the metabolic activity of ourselves ftg is tagged with glucose and glucose is used by our body for energy cancer cells are thought to be our Armour hypermetabolic

so if we inject FDG to our patients it goes to areas with hyper metabolic activity this area is called a hotspot and when a hotspot is noted in a PET scan its it's thought to be cancerous this is an example of a hyper metabolic

region noted in the pelvic area of the patient this patient is diagnosed of cervical cancer and what is MRI as you all know MRI is the use of radio frequency currents produced by strong magnetic fields to provide detailed

anatomical structures it is the preferred method for imaging soft tissue organs and there's no ionizing radiation present now what is pet MRI pet MRI is a combination of these two modalities instead of going to two scans using two

scanners we have one scanner that is able to obtain pet and MRI images simultaneously so why can't we just call this pet well we run through a few problems we have fdg-pet CT where it's a PET scan with low-dose CT accompanying

it and there's fdg-pet CT with diagnostic CT we're full sequences of CT is coupled with a scan and a pet MRI always has a diagnostic MRI done with it

different applications renal ablation is very common when do we use it

high surgical risk patients primary metastatic lesions some folks are actually refused surgery nowadays and saying I'll have a one centimeter reno lesion actually want this in lieu of surgery people have

familial syndromes they're prone to getting a renal cancer again so we're trying to preserve renal tissue it is the most renal parenchymal sparing modality and obviously have a single kidney and a lot of these are found

incidentally when they're getting a CT scan for something else here's a very sizable one the patient that has a cardiomyopathy can see how big the heart is so it's you know seven centimeter lesion off of the left to superior pole

against the spleen this patient wouldn't have tolerated bleeding very much so we went ahead and embolized it beforehand using alcohol in the pide all in a coil and this is what it looks like when you have all those individual ice probes all

set up within the lesion and you can see the ice forming around I don't know how well it projects but in real time you can determine if you've developed your margin we do encompass little bit of spleen with that and you can see here

that you have a faint rim surrounding that lesion right next to the spleen and that's the necrotic fat that's how you know that you got it all and just this ablation alone caused a very reactive pleural

effusion that you can see up on the CT over there so imagine how this patient would have tolerated surgery pulmonary

and what makes things complex is when the Louie system is inhospitable to the easy procedures when the ducts are dilated I think most operators find this

really relatively easy to get a tube in but once it's under lay that it really makes it tricky you either have a disease of the Blooey systems such as sclerosing cholangitis in flammond ich ins of the power duct architecture and

the wall itself all surgeons have gone in in misadventure transected cut the wrong duct and so cholecystectomy is are frequently the most common ones we misidentified and right posterior duct inserting below

and they cut that or even cancers is there not sometimes Calandra carcinomas such as cat skins - matrix of the ones right at the middle of the tree those ones make it challenging to sometimes get through sometimes they're so severe

in the severity of a structuring that it's it's very difficult to get through and sometimes we have to use sharp organizations and then like I said post surgery and with the advent of your gastric sleeves and gastric bypass

surgery this has become a much more common place and so frequently I think bluie interventions are on the rise again whereas I think they went out of favor for a few years in the 2000 mainly the GI became so aggressive with a

slanting Denova stenting and middle stenting then and bluie disease came down somewhat in high AR but this is all on the upswing again now with much more patients with with a bariatric surgery so in terms of intervention and your

your procedures in the room for difficult access and again a unviolated Ballou systems is actually not that insignificant even very experienced operators is going to be the most challenging procedure of the day and

it's vital to actually know your options and for we will actually a pacify the blue system with anything that has yellow stuff so frequently surgical drains that are adjacent to the leaking site sometimes we will check them and

sometimes you just got to be careful not inject too much sometimes their pacifiers and obliterates a field so much so you can't see anything your procedures pretty much done I also use known in distance gee I frequently would

be the first group to go in and try address below a leaking and they'll plate in the stands even though it doesn't cross the leaking site or it's inadequate for a decompression so we frequently would just stick the

indistinct directly and start our procedure that way so we know we're going through deliver through some bad structures but you we use a very very small caliber needle and stick the in distinctly and then once we use that

sometimes we'll place a wire knowing the fact that this is not our final track to a destination we'll put a wire in and then put that into any peripheral duct and then stick our skinny wire and so that's another way another way is

actually once you original PTC's been obtained with its optimal not will use mix lidocaine jelly with contrast media and mix it and make it a real thick slurry and that sometimes is a really good way to keep

the contrast from making out really really quickly he sounds quite logical but it's actually a very cute trick so that's another thing to consider every now and then you can actually use gas because it doesn't dissipate so if you

take co2 and there's at large dilated ducts you can actually put co2 and visualize that very nicely particularly specifically in the left lobe of the liver tends to dive into Phi the ventral left duct very nicely with gas but

sometimes it's not always easy if it is gas filled intestinal tract and then use control actress and I'll show you what that looks like on a picture and then high-grade lesions every now and then we have to use sharp aura colonization and

really the packing of the wire and your who should be your Russia sheet a needle from a tip set every now and then we will use a cardiology transept or needle the skinny a needle and really that sometimes with a high-grade multi

sclerosing agent of sclerosing cholangitis sometimes that is the only way through and sometimes we will use even rfy and drove our way through with high-power so this is a little bit what what it would look like if you had a

lack called a transaction we couldn't specify the billary system from about 30 passes of a routine and ptc axis that we should be stuck a central duct we pointed the wrong way contrast we float much faster than we could to get a

second axis so we just put a wire and it immediately then we actually stuck our wire and used our wire to get down and this is a cute way of getting using just a structural element even though you don't actually managed to keep contrast

in there to allow you to identify here's an example of a patient who had a Whipple procedure and a surgical master moses leak and it was under laid it difficult to pacify patient also has rapid respiration so some of these

patients are from the ICU they breathe very very high frequency and it's actually very difficult unless you get general anesthesia sometimes the risk outweighs the benefits of putting people under

for some of these that we will just as soon as if get pacified the blue system put a wire and again another example where we stuck a wire then we actually use that to gain a second axis and pacify the other system left atrophy

this is a patient with a very very small left lobe and we use the right axis it's a very acute angle from the left hand side we actually spin just stuck put in a snare and we stuck a snare we pull the wire out from the left through the white

and out the skin and then pushed it down using a stuff and that's why I'm taking your snare from Lord lift out the let right and then put in from the right hand side up the skin then you push that all the way through into the right hand

side and how you have power lateral axis so just there are some cute tricks that you can do to and make your procedures more successful and this is the other way you may do it sometimes you can only get to the lift system from the right

the hilar cholangiocarcinoma here high central high low lesion we could get our CAFTA from the right to the left that there's no way we could get from left to right so all we did was stay our Y from right to left and it comes out the skin

and then using a peel away she you put the wire down from the right hand side then you said she go from left access all the way up the skin on the right you exchange being glide wire put it in the pillow sheath and the right stolle

feeder that aren't all the way and you pull your pillow as sheath and now you have left access and right axis and sometimes it's the only way to get our lateral axis this is commonly found when surgeons require bilateral tube for a

cholangiocarcinoma classic in Palmyra section where they use the Blooey tube to feel their way up and look at the end of the tumor and so sometimes we do

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

Sudan when I was born it used to be the largest country in Africa until 2011 and now it's a third bodies country after the split of the south population 37 million the language is Arabic the capital is Khartoum the life

expectancy averages are almost 65 years IR is very scarce economic instability there is actually a revolution on going on right now while we speak there are only two IR s in the whole country fellowship-trained one train nine years

ago and one trained a year ago I know both of them because I'd be going good for the past 15 years the interesting thing is both labs actually across the street from each other I just couldn't understand that it's remind me of the

first car accident were the only two cars in in the u.s. sometimes the proximity is kind of strange I don't understand it but sometimes also the distance sometimes is you don't want to have it too far away

so the first IR I did he has actually advanced here statistics about the cases he does better organize his a neuro interventionist I did several cases with him this last month were doing cases he does neuro I was showing how to do a

closure device but very advanced this is actual a case he did while I was there a huge aneurysm and he put pipeline flow diverter second case I did is a female who had a hypotonic syndrome she she was in a bakery and were able to

work on that dilated radial artery it's very interesting that if you have insurance or we have you could pay you get catheters which are new if you don't all the cattle go into side X and we take

the site X catheters and and do and I ask about the infection and there isn't much much difference but so this is a second ng suite built staffed still didn't become busy yet but we're going to be helping and try to get the second

lab busy a little bit about Kenya it's a

so my name's Heather I'm a nurse in interventional radiology at NYU Langone health in New York and I am the clinical resources for our department so what that means is I'm responsible for individualizing our education to meet the needs of our department and one of

the first things I wanted to look at when I took on the role was our procedural sedation practices and how we can improve by enhancing our knowledge this presentation includes many of the lessons and concepts that I learned

along the way that I think are really important to understanding how to effectively administer procedural sedation so our learning objectives are going to be a review of the guidelines pre-procedure assessment components

including airway assessment pharmacology of the medications that we give and intra procedure assessment so this is the 2018 AAS a practice guidelines for a procedural sedation by non anesthesiologist has everyone seen this

good great as so this is especially important because as you'll see the American College of Radiology and Society of interventional radiology were involved in its development so this is our guideline and I think it's really

important to look at this look at the practice recommendations and see how they align with your own practice and if there may be some changes you need to make first thing you always want to look at when you're reviewing any sort of

literature whether it's evidence-based guidelines or maybe just a review article is you want to look at the methodology that the author used to create the guideline so anybody know why that's important you just shout it out

so if I want to write a guideline for procedural sedation I could find a bunch of studies or review articles that fit my point of view and use them throw them at the bottom and that would be that but even if I use for an demise control

trials which are considered the gold standard of experimental research those randomized controlled trials could be poorly constructed randomized controlled trials so they may have introduced bias at some point into the study

that's skewed the outcome and the findings so you really want to make sure that the authors of the guideline that you're looking at appraise the research that they're using to support their recommendations and that's what the

aasa' task force did so they used randomized control trials and observational studies and then they categorize the strength and the quality of the study findings so as you're going through you'll see that statistically

significant was deemed a p-value of less than 0.01 and outcomes were designated as either beneficial harmful or equivocal equivocal meaning this findings were not significant one way or the other and then they also used

opinion based evidence from experts so they surveyed members of their task force and they did take into account some informal opinion from message boards and letters to the editor so I think a good example here is one of

their recommendations about capnography so they did a meta-analysis of randomized control trials that indicated that the use of continuous and title carbon dioxide monitoring was associated with a reduced frequency of hypoxemic

events when compared to monitoring without capnography and then you'll see at the end of the recommendations this category so for this particular recommendation they labeled it as category a1 - B evidence and what that's

telling you as category a means it was a randomized control trial which is great it was a level one meaning it's a high level of strength and quality and B is telling you that there was statistically significant findings that demonstrated

benefit to the patient now another recommendation that you may see as you're reading through would be the NPO guidelines so if you look at any of the literature about NPO recommendations it's really all expert

opinion because all of the evidence has shown equivocal findings so for example one of the studies they looked at compared the outcomes of patients who had clear liquids one hour prior to the procedure versus two hours and they

found no change in the outcome I think it's important when you're a provider and you're looking at that because you're gonna base your judgment calls on the evidence so you may have a patient come in who had tea up until one hour

prior to their procedure and you have to make a decision whether or not you want to cancel or proceed and you could look at the findings of the literature that shows that there really hasn't been a proven difference in outcomes so you may

decide to just do the procedure versus capnography there's very strong evidence showing it's beneficial to the patient always so I think this is a real big take-home point of why we do everything we do about procedural sedation all of

our assessments and enhancing our practice as a sedation is a continuum and practitioners intending to produce a given level of sedation should be able to rescue the patients whose level of sedation becomes deeper than initially

intended pre-procedure our assessment

a little bit more systemic versus catheter directed thrombolysis so once you've decided that a patient needs TPA what are the differences here well if

you give patients systemic TPA you're gonna give them a much more rapid delivery this is for those patients who have high-risk PE they're the ones who are coding for those patients you give them 200 milligrams of IV usually you

get 50 first and then another 150 over a very short time period they have a very high risk of bleeding as a result of that a catheter is much slower you're gonna infuse one milligram maybe which is what I think most people do

over several hours maybe a few maybe a day so it's slower targeted versus non targeted well catheter is much more targeted you're gonna give Pete you're gonna give the TPA right into the

pulmonary arteries that's the whole point in our in our thought process as a result you give a lot less drug so when you give a patient based off of some of the trials 24 milligrams of TPA over a 24-hour period that's a lot less than

200 milligrams in a 10 minute period and then the bleeding risk is very different for these patients catheter based treatments have a high bleeding risk but it's possibly lower than the initial bleeding risk of patients getting

systemic TPA so I wanted to go through a

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

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

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

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

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

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

riesen comes to us and he talks about

some theories on why we make mistakes so and we're gonna cover these and then we're gonna cover the Swiss cheese model which many of you may be aware of so sorry slips tend to hurt current situations that are so routine that

they've become rote so an example of a slip could be selecting the wrong drug from a drop-down alright so again slips and lapses occur when the correct plan is made but executed incorrectly so we have that drop down of drugs but we just

select the wrong one that's a slip a lapse is generally not visible because it's reflective of a memory failure so for instance we may have a patient who forgets to take their medications or we may have a prescriber that forgets to

take a drug off of a med rec so those are examples of slips or lapses mistakes or judgment failures they're more subtle and they're complex than slips and these can go undetected for a period of time and they're often left to

a difference of opinion well I don't do it the same way that Mary does it who doesn't do it the same way that sue does it so those are mistakes and their knowledge base we know the right thing to do but because we have outside things

that are occurring situations that are occurring we may have to do some workarounds and those workarounds aren't always safe or we're gonna get in and this is part of the anatomy we're gonna get into the anatomy a little bit later

and often mistakes are rule-based so we know the rules we know what we're supposed to do but for factors that are out of our control we bypass those and that's when mistakes can happen active failure failures are highly visible

errors and we usually see these because they have immediate consequences and then the latent failures their processes that are under the radar they come from not following policies and there may be a good reason why we're not following

policies but oftentimes we hear that we've always done it that way and that means they're rooted in culture so that's where the justa culture comes into play all right Swiss cheese model so this is this is probably a graphic

that's very familiar to a lot of people but it does really it's it's at the basis of a patient safety air so organizations have defenses those are the slices of cheese now those defenses although we'd like them to be solid

they're oftentimes not they're filled with holes because of human factors the human condition those active and latent failures the slips lapses and mistakes that happen to all of us it's a part of us so often some of those defenses get

penetrated but then there's another defense that stops let's take for example identifying a patient so a patient comes in and maybe they're not english-speaking they may be

spanish-speaking and so we call their name and they answer the answer yes because it's close enough right it's close just close enough and they come up we don't check anything we don't check don't verify their name and their date

of birth we pass them on to our prep recovery room and then we're getting them ready because we have confidence that Jane at our front desk she doesn't make an error she always identifies the right patient so we have a high level of

confidence in Jane it's not a bad thing that's an OK Fay but here again we're not doing what we know is in our policy so it's rule-based and that we know is the right thing to do so it's knowledge base so it becomes a

mistake that we're not checking our patients identity and date of birth and that patient gets back to let's say the interventional room and boom we stop because now we're doing a timeout and we identify that we have the wrong patient

for our procedure and it stops but sometimes these heirs line up the holes line up and it's just one of those days and we end up with a patient safety event at the end so now we come to the

patient who did not come from the street so if you've been here for a few years

you've heard me talk about you know some of my friends this is also one of my other friends who has large fibroids but her fibroids were so big and they were not all very vascular and so I sent her to have surgery and she ended up having

a hysterectomy with removal of her cervix because of abnormal pap smears but her ovaries were left in place so our path forward after doing this procedure from 1995 a procedure that is not experimental a procedure that has

had a lot a lot of research done on it more research than most procedures that are done surgically or by interventional radiologists I'd say that it would require a partnership it is true that we can see patients on our own and we can

manage mostly everything but at the end of the day uterine artery embolization is still a palliative procedure because we don't know what causes fibroids to begin with and as long as the uterus is still there there's always a chance that

new fibroids will come back so in your practice and in mind I believe that a path forward is a sustaining program embolization program which is built on a relationship with the gynecologist that yes

I am as aggressive as any other interventionist that is out there but if this were my mom and that is my usual test for things I would say that where we would like to position ourselves is in the business of informing the

patient's as much as possible so that they can make an informed decision and that we're asking our gynecology partners to do the same is that if you're going to have a hysterectomy for a benign disease that you should demand

and we as a society and you as your sisters keeper should be asking for why am I not eligible for an embolization so si R is actually embarking on a major campaign in the next year or so it's called the vision to heal campaign and

it's all around providing education for this disease stage what I like to tell our patients and I'm almost finished here is when I talk to our gynecologist and to techs and nurses as well I said woody woody what should I expect right

that's what they want to know when I send my patient to you what should I expect and I say that what you should expect that Shawn and myself we're gonna tell the patient everything about fibroids we're gonna talk to them about

what the fibroids are the pathophysiology of it the same things I told you we're gonna tell them about the procedures that treat it we tell them about the options to do nothing we talk about all of the risk and the benefits

of the procedures especially of fibroid embolization and we start the workup to see if they're an appropriate candidate when they're an appropriate candidate we communicate with them and their OBGYN and then we schedule them for their

procedure in our practice there are a few of us who send our patients home on the same day and we let our patients know no one is kicking you out of the hospital if you can't go home that day then you'll get to stay but

most of our patients are able to go home that day and then we see our patients back in clinic somewhere between two and four months three months and six months and we own that patient follow-up their visits and after their year we have them

follow back up with their gynecologist and so that we're managing all of these sites and it comes back to that new again may not be so new for some of the people that have been doing clinical IR four years that shift that we own these

patients if you're a nurse in this room these are our patients these questions need to be answered by us in our department we do not believe that these patients should be calling their gynecologist for the answers to that

like what should I be doing right now should I be taking I haven't had a bowel movement and like that is something that we answer we're the ones that are given them the discharge instructions and we set them back up for their follow-up so

blasian it's well tolerated and folks with advanced pulmonary disease there's a prospective trial that showed that

there are pulmonary function does not really change after an ablation but the important part here is a lot of these folks who are not candidates for surgical resection have bad hearts a bad coronary disease and bad lungs to where

a lot of times that's actually their biggest risk not their small little lung cancer and you can see these two lines here the this is someone who dr. du Puy studied ablation and what happens if you recur and how your survival matches that

and turns out that if you recur and in if you don't actually a lot of times this file is very similar because these folks are such high risk for mortality outside or even their cancer so patient selection is really important for this

where do we use it primary metastatic lesions essentially once we feel that someone is not a good surgical candidate and they have maintained pulmonary function they have a reasonable chance for surviving a long

time we'll convert them to being an ablation candidate here's an example of a young woman who had a metastatic colorectal met that was treated with SPRT and it continued to grow and was avid so you can see the little nodule

and then the lower lobe and we paste the placement prone and we'd Vance a cryo plugs in this case of microwave probe into it and you turn off about three to five minutes and it's usually sufficient to burn it it cavitate s-- afterwards

which is expected but if you follow it over time the lesion looks like this and you say okay fine did it even work but if you do a PET scan you'll see that there's no actually activity in there and that's usually pretty definitive for

those small lesions like that about three centimeters is the most that will treat in a lot of the most attic patients but you can certainly go a little bit larger here's her follow-up actually two years

that had no recurrence so what do you do when you have something like this so this is encasing the entire left upper lobe this patient underwent radiation therapy had a low area of residual activity we followed it and it turns out

that ended up being positive on a biopsy for additional cancer so now we're playing cleanup which is that Salvage I mentioned earlier we actually fuse the PET scan with the on table procedural CT so we know which part of all that

consolidated lung to target we place our probes and this is what looks like afterwards it's a big hole this is what happens when you microwave a blade previously radiated tissue having said that this

was a young patient who had no other options and this is the only side of disease this is probably an okay complication for that patient to undergo so if you follow up with a PET scan three months later there's no residual

activity and that patient actually never recurred at that site so what about

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

so this is our MGH page we started it about a year ago check it out if you guys like it some pretty good cases we mostly post cases some policy stuff industry and changing things it's not purely cases but certainly take a look if you like it give us a follow so what

I have today is I have two cases that I picked and you know for all the thousands of cases that all these huge academic medical centers do I tried to pick a couple that might be a little interesting and that aren't being done

in all the different centers across the institution so I'll start off with the first which is an endovascular AVF creation so what's nice about this is that you know what we see so far from this is that the length of stay impact

has been certainly reduced in certainly the maturation times and the Rhian turn re intervention rates have been reduced so I'll go through this and normally wouldn't go step by step for a few things but I think you know not all

institutions are doing this yet I think that you will I do think this is going to be a shift for a lot of the dialysis patients and everybody who works anion knows what a huge impact it is the ESRD patients is just astronomical the

numbers of them it's just continuing to rise so procedural steps the first step is you're going to access the brachial vein advance the guide Y down to the ulna insert a six French sheath and perform a vena Graham and the rationale

for that of course is to make sure you don't have any issues centrally some centers do that in advance some centers don't I will mention also that the ultrasound mapping is absolutely critical to make sure that

you get the right patient you start off by seeing them in the outpatient clinic and then you're going to go and have them have vascular ultrasound to make sure you have a good candidate so the next is you're gonna access the brachial

artery same thing advance your guide wire down to the ulna from there you're gonna insert the venous side now this is one of two approved vendors that will allow you to do an endovascular creation this was a wave link it's a to stick

system and it requires two catheters which is why you see the next step is pretty much repeated but just flipping it to the arterial side so from there there's a magnetic zone it actually has like a little canoe so it's got a

backing of a ceramic sort of a space there if you can think of sort of the older or atherectomy cut home catheters that had that little carro canoe you would actually take the debris out it's very

look into that and I'll show you that in a couple of images once you align that you're gonna sort of engage the little electrode this is an RF ablation RF created type fistula so it creates a little slit between the Adri and the

vein and what happens is is that you know of course don't forget you have to ground the patient just like any RF once you get the magnets and you get the electrode alignment you're going to engage the device for two seconds and

the fistula is created and then from there a lot of centers are actually going in there embolize in one of the brachial veins and this is basically to sum some of that stuff obviously to the superficial system for draining I have

read that there are a few places that actually go back back in through the newly-created fistula like even at the time of the procedure with the 4 millimeter balloon and just sort of open that up I'm not sure that that's 100%

necessary but I'm sure all these fine people on the panel could help us with that so here you see and I skipped all the entry steps but here you can see the Venus in the arterial catheter you know in position here and there's that little

canoe thing pointed out by the arrow that I had talked about and you use fluoro to sort of align these two things when you first start doing these cases take your time the first one was over an hour and a half for us now obviously

it's about a third at that time this is the little electrode this is when it's advanced and pretty much ready to engage can you play the video for me so this is quick so what happens is you suppress the

device the electrode actually advances and as it advances towards the veena side what happens is is that it actually just creates this fistula through the RF sort of energy from there you're gonna do a post vena graph in here you can see

after we did an initial post intagram there was enough sort of flow between the PIAT brachial so we decided to embolize one and this patient was our first patient and is doing very well so far this is done on I'm gonna say just

because you know to dr. brains point I don't want to get on the hook for certain dates and patient identification but this was done in mid-march so we saw them two weeks out and we're gonna see them again another couple weeks so just

there's a couple of trials that you can read into one is the neat one is the flex trial I think the technical success is really promising at 96% the maturation days you can see there's a massive massive comparison where they

could be ready to be dialyzed in 60 days and this could be a game-changer for many patients the six-month patency rate is what I've seen in most of the reports it's around 98% compared to about 50% with the surgical place and then you can

see that this about 3.5 interactions or re interventions that are required in about 0.5 at a year's time out from this so it's really making a big difference for these patients and I think this is what we do in i/o we continue advanced

things innovate and obviously look to do things in a more timely cost-effective minimally invasive way at the beginning when these new procedures come out the devices themselves might be at a higher price point but we'll see how that goes

moving forward as more and more vendors get into the space so the second case

MRA safety is one of our top priorities in our unit we have set up MRI zones zone one being the patient waiting area

zone two is where they change and they get screened zone three is where our control room is and anyone who passes by zone three has to get screened our pet MRI injection room is actually inside zone three and zone four is an MRI

scanner itself we assess risk in our patients for their implants we were iterate to them the importance of bringing their implant card with them just so it's easier for us to assess the compatibility of their their implants

with MRI right now we have the capability of scanning cardiac pacemakers and defibrillators it just needs more coordination with our in-house cardiology service and the implant representative rest assure

expanders and aneurysm clips are so contraindicated inside the skin we tell our patients to remove some items that they are able to remove such as dentures hearing aids piercings and prosthetics if they have it as for radiation safety

we observed the concept of Alera or as low as reasonably achievable you know before we inject the patient with the isotope we keep them comfortable we give them blankets we give them the pillows and we tell them

after they get injected that they are radioactive so we try to limit our exposure to them after they get the injection now we try to keep our distance from them and we have shielding lead shielding within the pet MRI area

now we have lead shield syringes available for the nurses use and we have dedicated a hot hot bath room a hot room and radio pharmacy we Ritter we give these puppies this injection card to the patient after they get the scan and we

were either a to them the importance of this card we have the stories from our patients where after the after they scan gone home and they passed through the tunnels or the bridges that they actually have been pulled over by the

police because the police have very sensitive radioactive detectors there was one patient who may have forgotten his card may have lost his card and he got pulled over and the police had to call our institution to confirm that he

really did have an isotope injected we

that was one example so these are there have a lot of potential complications reperfusion pulmonary edema is a very very big potential complication so you could get through the case patient does

great you open up multiple pulmonary arteries and then they start coughing up blood and then they end up started drowning in their own blood and the ICU so we do not want to push that and the initial papers that you can see down

below on that table they had a very high almost 10% in some cases pulmonary edema requiring treatment requiring patients being put on CPAP or being intubated and that is because they treated too much at one time

and so now as this when this first started in the early 2000s the operators were treating multiple segments at multiple times at one time and they were using large balloons and we figured out that that was what was killing patients

and so we changed our treatment so this is the first study that was ever performed for this it was performed by dr. Feinstein I believe this was published in circulation it was done in Harvard at MGH they had 18 patients with

36 month follow-up they all improved in their ability to walk as well as their lifestyle but many of them 11 out of 18 patients had reperfusion injury so this was the first paper and at that time it became the last paper because so many

patients did poorly but here's what they're sort of what they did and the ones that did okay they you could see that they had an improvement in the New York Heart Association classification again that just means they can walk

further they're not less short of breath and that they could walk further in 6 minutes which is again our sort of first test outcomes over time whence this has become increased so you can see that study was in 2001 and then

it kind of went away for a long time and it came back in 2012 in Japan where the most operators are there they've treated up to 255 procedures now since this slide was made we're up to a thousand in Japan and those patients are doing very

well but you'll notice that they have multiple procedures so again you don't try to one-and-done these patients they come back four to six times we've treated a couple patients where I work and we've treated that was patients four

times already and so they do much better but it's a slow slow and steady treatment so I want to wrap up with saying that the IR team is very critical to patients who are getting treated for PE we're involved in the diagnosis as

the radiology team acute and chronic PE it's very important to know as I've shown you in some of the examples and some of the images which when it's acute and versus chronic doing thrombolysis on a patient with chronic PE is useless all

you're doing is putting them at a risk you're not going to be able to break up that clot it's very important to have inter and multidisciplinary approach to patient care so interdisciplinary meaning everybody in this room nurses

technologists and physicians working together to take care of that patient that's on your table right now and multi-disciplinary because you have to work with cardiology vascular medicine the ICU teams and the

referring providers whether it's neurosurgery vascular surgery whomever it is who's Evers patient gets a PE you have to work together and it's very important again to have collaborative care in these patients if we're doing a

procedure and somebody notices that the patient is desaturating that's very very important when you're working in the pulmonary arteries if somebody notices that the patient's groin is bleeding you have to speak up so it's very important

that everybody is working together which is really what we need to do for these patients so there's my references and there's my kid so thank you guys very much hopefully this was helpful I'd be

hi everyone I'm so excited to be here my name's Michelle mana B's I am a UT Houston fourth-year resident and I'll be headed to Yale for AI our fellowship in the fall and I'm happy to start us off this afternoon with the impact of Twitter on our specialty in how we can

expand our reach and so just a little bit about the platform that we've all chosen Twitter's a micro blog 280 characters for fewer images and short-form videos what this says to me is this is perfectly tailored for our

fast-paced highlights only major learning point objective when sharing about our favorite subject and just to give a little bit of perspective in 2018 206 users had hashtag irad in their bio so they were irad users right and March

of just this year we have over 1400 a few more stats for you so these are from just last week so a total of seven days we have 500 total tweets with hashtag irad and as we are an image-based specialty obviously the text with the

tweets with just attacks are not very many and but what I wanted to point out I'm really proud of there are 78 original contributors and 71 percent of those tweets were retweets so there's 78 people putting the

information out there and the rest of us are doing a really good job supporting them so what is Twitter done for our specialty three major points networking education awareness and collaboration so I'm a little more familiar with

Instagram so I have over a hundred twenty thousand followers on Instagram and so so this is not as familiar to me right and when I joined Twitter last year sar I had one follower and it was my mom and

I so I posted this on my Instagram I said I just have one Twitter follower what could I do help right and just over a year here we are the most recent stats of my page had significantly grown and that just speaks volumes on how much

we've grown together expanded growing evolved as a community and a presence on social media and I have 964 friends now if you're not friends with me let's be friends right now

oh and so next education and awareness so this page the interventional initiative if you are not following I suggest highly suggest you look into it so this is a nonprofit organization that increases awareness for minimally

invasive procedures their graphics are really patient friendly really easy to understand and this is the first thing you see when you go onto their website so if a patient were to just go on and say why how'd you know something my

doctor said something's wrong with my lungs is there a minimally invasive procedure for that most likely yes and all they have to do is just tap on the organ system that they identify with and they have an easy explanation of the

procedure that they're about to get or a procedure that they might be interested in and a finally collaboration and one of my favorite hashtags that really exemplifies this is hashtag leave your specials here at the door and I met dr.

Sabet I set this year and it unites as more as a disciplinary multidisciplinary group more than just this is my patient it is all of our patient and how can we work together to make sure that our patients have the best outcome and so we

are identifying more as patient centered and not specialty Center and so this is a really good positive aspect of collaboration between specialties and another aspect that I really love collaboration in a way that we get to

break down boundaries geographic boundaries right meet people that we necessary wouldn't get to meet be friends with people we wouldn't be friends with other Hawaiians and have a little fun do we have audio for this oh

darn well pretend Full House is playing in the back and we're are gonna we're gonna watch the whole thing it's so much cooler with the south kid so just you know bringing some fun you are especially doesn't always have

to be cases and always have to be serious and to show that we're humans too and so finally I want to speak a

about you rolled out the radiant in 2015 and all of this data is great but it's reliant on the nurses documenting it in

all their different areas so how did you did you actually when you built this dashboard did you leave blanks because you just didn't have the data available or did you circle back around and hold the nurses accountable how did you do

that trying to motivate them and engage them rather than it looking like a disciplinary action because you're showing that they're not documenting appropriately yes and that's part of our journey from 2013 we started all these

projects it became evident that document documentation was important when it came to the data and so we actually started training from our technologists and and then to our nurses we created standard work for how they documented time stamps

I'm at different points in the process we audit we audited that for a while to make sure that they were compliant with that documentation so so we embarked on a lot of projects and I did a to greenbelt projects I did one in

interventional radiology and I did one on beginning complete because you really have to start at the ground and if people's reporting is not good you have to fix it so we have a definition for beginning complete for our

technologists which cleaned their data up then we did a project with Jeannie's nurses around and Tommy did some auditing around the time stamps in their system and that took a long time so yes you have to clean your data up first

and that takes projects in order and we also did Tommy led all of us to look at our data and a data validate sort of like Gilbert's thing you know so is it really valid and so we did a lot of work around that as well

the nurses do with themselves and the nursing supervisor did it as well to make sure and the technologists help you with that because what we found is when we handed the data to the nurses and we had them do their audits it was more

impactful than when we did it how would you say your start times improved from pre project pre dashboard to current how did you measure that was the time yes so that was actually interesting especially in interventional radiology because it

it when we started rolling off the Huddle's and the dashboards we had some participation in the with the technologists and the nurses and the providers doing their Huddle's and looking at the information and then

there was a period of time when they stopped doing that and they actually and they actually saw a drop in there on time starts so when we started up they were around maybe 40% on-time start and then when they consistently did their

Huddle's and looked at the - would I use the information they quickly jumped to 60 65 percent so and when they stopped dropped again so it was sort of it proved that that the tools actually worked and now they're actually going

back and owning the work of their own to continue T their Huddle's and use the dashboards in real time yeah rome wasn't built in a day and would you say that this is significantly impacted employee engagement yes I will definitely say it

has previously we had a real sort of segmented nursing work you know silo's and now we have like this cohesive team of nursing and and physicians and technologists working together in IR I will say also part of

our leadership team crisp as part of this as well our senior leaders we did a job we did a change in sort of our leadership structure so before it was like the physicians they led their physicians the technologists led their

technician technologists and the nurses led theirs well we in got a team together so we have a nurse manager the chair of interventional radiology the nursing supervisor and the nursing technologist

and supervisor and we lead as a team now and so we look at volumes together we look at budgets together we look at staffing together so it's not no longer just leading in silos so with that consistency in that that that sort of

got them all together and then so then they see that you can't hit a technologist against a nurse in a physician against a nurse or a technologist because we're all one team and that was a big part of helping this

out yeah sorry before that I was just going to talk about how important leadership was in this so Chris is our operations manager and I would say she made all of this perseverance tommy's the brains I'm the Brawn so I

would like to ask you give more details on the culture like what you were just describing about becoming a multidisciplinary team sure um that's a good vision but practically how did you accomplish so the culture was really

really hard and my Greenbelt project that I did back in 2013 was not successful because of the culture and what we learned was that we had to do something about the culture Jeannie alluded to the fact that our our

department chair dr. chair Toth and our administrative director Karen Buttrey talked to me about this and and they decided it was important that they had leadership teams in each modality so every modality and radiology has a

leader it is the division director the technologists lead and if there's a nurse a nursing lead they meet once a month tommy's does the score cards for them they bring their score cards they bring their a3 reports on

their strategic plan and they sit as a group I sit with them as well and we talk about how they're aligning their strategy to their work what the culture is like and do we need help sometimes we bring HR in if we think we need help

and geney's done a lot of leadership training with the nurses she's very good at it we have Conaty so we've partnered with Dartmouth and we send different teams to Conaty to learn leadership training this

has been really this all started really in 2013 and it continues today and we work just as hard on it as we did in 2013 Neverending yeah and I was part of that Conaty training and it was phenomenal so

it was two of the IR physicians myself the business manager and another radiology technologist supervisor and so really we had to work on a project together and it really brought us together to understand each other's work

and for um I feel like probably the strongest you know asset I have is relationships and and making those connections and nursing wasn't my first career I did practice management and so I worked for a doctor's office and I

kind of know that you have to sort of make sure that everyone understands that we're all trying to get we're all trying to take care of the patient and we all have different responsibilities to do so and there's a crossover if we fight

against each other then nothing's going to work and so that was where I I feel like I probably did the best these again you know brains and brawn and I was just sort of like let's make it all work together people with it so

was that something that you had to work into the amount of hours that it takes to maintain the new task that was being asked for yes so the documentation is part of their work to take care of the patient so for a technologist for

example when they go get the patient from the waiting room they start the beginning the exam in Radian those are things they need to do - as part of the EMR to actually accomplish their work so that was by design already part of their

workflow we just had to make sure that they were all doing it at the same point in time so for example before we standardized the definitions we would have some technologists who would begin the exam when they went to go again the

patient some will do it after they had set up the rooms so we have to standardize all of it so the data was measuring at the same points and for the nurses as well as part of their documentation as they work up the

patient so it's all part of the flow the other thing we do that I want to mention quickly because we're out of time is rounding so rounding is really important so I am the operations manager I probably around three times a day in

every modality and as an example I was just in mr and I saw a red button on their dashboard and I said why aren't we 19 minutes behind and somebody had forgot to complete the exam and everybody was there and they were

talking to me about it and they said yep and they ran back and they you know so I stay engaged the supervisors Jeanne I have two other supervisors tomy rounds you have to keep the conversation going you can't just build these and think

they're gonna take care of themselves because they're not you have to really do that disciplined rounding work so thank you everyone very much yeah thank you and just some related articles that

other other institutions have used for healthcare dashboards I found really really great so I don't know if this is true but I think they're going to send the slides after yeah conference oh yeah yeah afterwards we're happy to stay here

thank you

like the number so now we're kind of moving into you know just some highly rated post so this was like number 5 for whatever year that it was and

and so kind of the anatomy of it I liked a hashtag patient or patients I don't know why it just feels something reasonable to me cancer hashtag cancer is something that I'd like to do because what you have to think is these are

searchable terms so what is a patient or referring doctor whatever gonna go in and look up cancer kidney cancer so I don't like to use things like renal cell carcinoma a paddles so have had a cellular carcinoma I don't really say

any of those things I say liver cancer and so you know I'm tagging the company btg IO you know because they're gonna have you know they used to have more followers than I did and so it's just always to tag people added more

followers than you write because then all of a sudden they like you and then they retweet and then you know that becomes the cycles like hey this is somebody that that we could follow so as we're going through as you're looking to

is you're looking at the images you know you can see kidney cancer circle right so I was doing a research project with one of my urologist a very smart individual and we were looking at images and one of the things he asked me is

like okay well the patients in prone position right he said and that's the cancer and I'm like you have got to be kidding me right like the the level that they understood the imaging was at a level that would to me was very

surprising and which is why I started to think is like I need to start circling things I need to start labeling things I need to start putting arrows on things because even our own UAB medicine count for the longest times like we don't know

what you're doing and so we don't like or retweet any of it because we don't know what is and so we kind of had to work through that together as a group so you know another one so it's funny because this this particular patient was

both number four and I think number two and I don't know what about her makes her so attractive but you know it's the same kind of thing right now again just kidney cancer just kind of posting the same things that I do every

day hashtag kidney hashtag cancer you know without a scalpel and this was when we're back at 140 characters patient irad at UAB IRC every single time I'm trying to do the same thing at UAB I our cancer patient minimally invasive

they're going home the same day we don't have complications your cancer is dead you keep pushing those same messages over and over and over again and that was like 14 000 impressions that is just free advertising so number

three right and so 18 000 impressions this was a y9t mapping that we did and it's just really interesting this is like less than 0.1% of patients and the reason that this kind of took off a little bit

because I tagged radio pedia and radio PD and followers or something like that and so once they liked it and retweeted it you know kind of started to take off a little bit like that so that's just a really good example of pushing something

I thought okay Radio PD is like kind of imaging based and there's kind of incidents and it's a website that people use especially radiology residency medical students used to be able to learn about imaging findings so I

thought that they might be interested in that and not necessarily that they're all about IR but they were about this imaging finding and because they were able to push it out to their followers you know their followers started to

follow me so I had a high impact that way and again so this is the same patient but not all it is is follow-up of that patient right like like what is it about her that she's so exciting right but there she is at 22 000 one

impressions and so I got this idea to start posting follow-up basically without responding to come some negative comments on Twitter I thought that is a valid concern because IR is all about what's new what's exciting here's this

device that I used and I was just in a session about Bill you're an endoscopy and they did a literature review and the most exciting thing that they had on a literature review is a case series of 53 patients that's not evidence to other

specialties right and so when we post those things and people say well what's the follow-up on that I thought that was a valid criticism now I would never say that to them right like I don't want to give them any validation but I started

to think I'm gonna start following up on some of these patients when I see them in clinic and put out what the follow-up is right so that they can see that we actually are having good outcomes but you can see a consistency here right

I read cancer patient surgery at UAB I are it's the same anatomy of a tweet every single time it's boring but it's effective and then as Kunwar mentioned this is kind of like the coup de Gras from last year right so like this is

because Sanjay Gupta you know retweeted or whatever but and so it was the whole thing and I think that that's a great example of changing the conversation because I gave news interviews at my at our local stations and I thought that

that was was funny is that it up to this one I said even my local news station got this right right they knew the right people to go to and so you don't have the highest amount impressions but that's basically because Sanjay Gupta

you ended up retweeting it right and so you pick up followers that way so you know those are some of this being consistent about what you're doing finding what your followers like doing more of those things and the more likes

and retweets you see about it continue to do more of those things I think some sort of consistency both by posting like every day every other day finding some sort of schedule and then the same anadi made that tweet like you know you're

gonna look at my account like Kumar doesn't even look at it anymore because he knows what are you gonna see every day I think at this point right so it's like the same thing every day so I appreciate you guys for listening and

hope you hope it was informative so [Applause]

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]

catheter some other things that we can do is mechanical intervention so if you have a patient usually with massive PE

or the inner or the high-risk B you got to do something to help them out so what we do is put a pigtail catheter and inject a little bit of TPA on the table and then twirl the pigtail or put a wire through the side part of the pigtail and

make it sort of a mechanical fragment fragmentation the problem with that is that fragmented clot goes downstream so when it's in a main pulmonary artery it actually has less surface area than it is when it is in a distal pulmonary

capillary so when you break that clot up you have to be careful because it can actually make the patient worse the benefit there there's no thrombolytic so if we're doing this we we generally are doing it in patients who can't either

receive TPA at all frequently we get patients with who have have had recent spine surgery who get a massive PE had brain surgery get a massive PE and you have to try to treat them without any TPA or even heparin the drawbacks are

that again it increases pulmonary vascular resistance by sending all those little pieces of clot into the small pulmonary arteries and capillaries and it makes it actually much worse in some patients again there's no control trials

and sometimes you need to have a bigger

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

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

Kerry go into kind of a refresher from

this morning for you all this is a video from a liver biopsy and let's just start that no we actually don't know how to play this from the clicker okay

so this is just a short clip to show normal bleeding everybody bleeds and all the procedures that we do involve placing needle in the patient so we are going to have some amount of bleeding and it can range from seconds to minutes

and hopefully it's a fairly minimal amount of blood loss typically what happens is the needle is inserted into the patient the body detects the injury clotting mechanisms are activated hemostasis is restored which sounds

pretty simple but as you may remember from this morning there are a lot of different mechanisms involved that make that happen and we wanted to just provide a brief overview for those of us that have been out of nursing school for

a little while so we thought it would be helpful to start with just a brief generalized overview the first step obviously is the endothelial injury platelet plug forms the coagulation cascade starts we get a clot and then we

have the Ambo thrombotic control mechanisms and the fibrinolysis in our practice we're really just concerned with the first two we really just want to make sure that the patient has the ability to clot so here's a fairly

simplified version of the coagulation cascade the factors are the Roman numerals and to keep it simple we've just included a few of them so we have a wound occurring the endothelial cells release the tissue factor which combines

with some factors we get factor 10 release produces thrombin and eventually fibrin we also have this amplification loop that's happening at the same time so we need some of these factors we need the thrombin for this all to work

so at this point we have thrombin being generated by the pathways more being created by the amplification process and that thrombin then binds to these platelet para scepters up here and that initiates cofactors assembling on the

platelets which makes them sticky causing them to adhere to the site of injury when the platelets are activated we have the adenosine diphosphate molecule or ADP that's also binding to some receptors specifically I didn't

include the p2y on this but the p2 y 12 which then eventually winds up activating this molecule down here that molecule is normally this complex I should say is normally folded over but when the platelet is activated it

unfolds and it allows the fibrinogen to bind and then that secures the platelets to each other so with the medications that we run into in our in our practice one of the ones that you learned about this morning where the direct factor 10

inhibitors we typically see Xarelto and Eliquis the most in our practice and as you can see by the red stop signs there are two places that these inhibitors work here and here they bind to the thrombin while the while the drug is

circulating in the blood which essentially removes that factor Xa from the equation if we don't get thrombin we don't get a thrombus we don't have a plat no these things do have a relatively short half-life and in our

practice we do not monitor these with routine labs the direct thrombin inhibitors Pradaxa is the one that we see the most work one step further down the chain these are actually interfering with the power receptors so they bind to

those and that prevents the platelet activation and aggregation these can be monitored with a PTT although research tells us that it doesn't necessarily correlate with the actual levels circulating in the

blood and the different methods of sampling aren't consistent so this is not something that we routinely monitor with labs in our practice as well and I do have agents and clinical trials on here they were in trials I believe at

the time we started doing this research but as we learned this morning some of them are currently available and these do have a short half-life so their effect is relatively limited and they are reversible so the inhibitors that

work on this p2y twelve receptor are actually binding to that receptor and this is irreversible so this is going to affect the playlet for the life of the platelet seven to ten days and as we learned this morning there's a certain

amount of turnover happening all the time so there are always new platelets being produced so if we stop this we don't necessarily need to hold it for the entire seven to ten days but it is something that's going to take a while

for the patient's body to overcome and the thing that we wanted you to note about this this is an inhibitor it's an inhibitory effect so it's not necessarily captured that accurately by lab values the platelets are still there

they just don't work as well and so you can do a platelet count but it's not going to show you how well those platelets are functioning so again this is another medication that doesn't really get captured with lab values

sorry little operator error here on the remote control so the Cox inhibitors aspirin is the one that we're probably most familiar with same kind of thing aspirin is permanently affecting the platelet over its lifespan of seven to

ten days the ibuprofen the naproxen or Aleve the effect is much more limited for these medications so we're going to hold these again these are medication that will not necessarily be accurately reflected by a lab value so in our

practice we rely on oral confirmation of the last dose we literally ask the patient when was your last dose of advil when was your last dose of aspirin and we can compare it to our procedural guidelines

we also talked about these a little bit this morning we have the vitamin K antagonists warfarin is the one that you hear about you also hear about it called to mannan by the other name the liver is producing these clotting factors which

are reliant on a reaction that happens with vitamin K these things actually work by interfering with the vitamin K cycle now if you put more vitamin K in this reaction can still happen or if we add FFP that already has these factors

in it the patient has the ability to clot so this is reversible we can also choose to not reverse patients that are on warfarin Nikhil talked a little bit about the bridging that we sometimes do with patients that are on warfarin but

this is one that we still encounter pretty frequently and typically it is monitored with the pt/inr and we are currently screening for angiogenesis inhibitors in our practice these are used to treat different kinds of cancer

the one that we are primarily concerned with is the imbruvica the mechanism of action how this causes bleeding isn't fully understood but it's thought that since these inhibit the development of endothelial cells those cells aren't

available to release the factors needed to start the clotting cascade and especially if these are used in conjunction with anti platelets or anticoagulation they can really have a it can really have an effect on the

patient's bleeding risk and they can also cause thrombocytopenia thank you

they travel together so that's what leads to the increased pain and sensitivity so in the knee there have been studies like 2015 we published that study on 13 patients with 24 month follow-up for knee embolization for

bleeding which you may have seen very commonly in your institution but dr. Okun Oh in 2015 published that article on the bottom left 14 patients where he did embolization in the knee for people with arthritis he actually used an

antibiotic not imposing EMBO sphere and any other particle he did use embolus for in a couple patients sorry EMBO zine in a couple of patients but mainly used in antibiotic so many of you know if antibiotics are like crystalline

substances they're like salt so you can't inject them in arteries that's why I have to go into IVs so they use this in Japan to inject and then dissolve so they go into the artery they dissolve and they're resorbable so they cause a

like a light and Baalak effect and then they go away he found that these patients had a decrease in pain after doing knee embolization subsequently he published a paper on 72 patients 95 needs in which he had an

excellent clinical success clinical success was defined as a greater than 50% reduction in knee pain so they had more than 50% reduction in knee pain in 86 percent of the patients at two years 79 percent of these patients still had

knee pain relief that's very impressive results for a procedure which basically takes in about 45 minutes to an hour so we designed a u.s. clinical study we got an investigational device exemption actually Julie's our clinical research

coordinator for this study and these are the inclusion exclusion criteria we basically excluded patients who have rheumatoid arthritis previous surgery and you had to have moderate or severe pain so greater than 50 means basically

greater than five out of ten on a pain scale we use a pain scale of 0 to 100 because it allows you to delineate pain a little bit better and you had to be refractory to something so you had to fail medications injections

radiofrequency ablation you had to fail some other treatment we followed these patients for six months and we got x-rays and MRIs before and then we got MRIs at one month to assess for if there was any non-target embolization likes a

bone infarct after this procedure these are the clinical scales we use to assess they're not really so important as much as it is we're trying to track pain and we're trying to check disability so one is the VA s or visual analog score and

on right is the Womack scale so patients fill this out and you can assess how disabled they are from their knee pain it assesses their function their stiffness and their pain it's a little

bit limiting because of course most patients have bilateral knee pain so we try and assess someone's function and you've improved one knee sometimes them walking up a flight of stairs may not improve significantly but their pain may

improve significantly in that knee when we did our patients these were the baseline demographics and our patients the average age was 65 and you see here the average BMI in our patients is 35 so this is on board or class 1 class 2

obesity if you look at the Japanese study the BMI in that patient that doctor okano had published the average BMI and their patient population was 25 so it gives you a big difference in the patient population we're treating and

that may impact their results how do we actually do the procedure so we palpate the knee and we feel for where the pain is so that's why we have these blue circles on there so we basically palpate the knee and figure

out is the pain medial lateral superior inferior and then we target those two Nicollet arteries and as depicted on this image there are basically 6 to Nicollet arteries that we look for 3 on the medial side 3 on the lateral side

once we know where they have pain we only go there so we're not going to treat the whole knee so people come in and say my whole knee hurts they're not really going to be a good candidate for this procedure you want focal synovitis

or inflammation which is what we're looking for and most people have medial and Lee pain but there are a small subset of patients of lateral pain so this is an example patient from our study says patient had an MRI beforehand

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

PE the first one of course is

anticoagulation so heparin and bridging the patient to coumadin or now aid a direct oral anticoagulant is really the mainstay of treatment most patients again 55 percent of patients with PE have low risk PE all of those patients

should be on according to the chest guidelines three months of anticoagulation so they're gonna get heparin as an inpatient if they even need it and they're gonna get sent home on lovenox bridge to coumadin or they're

gonna get the one of the new drugs like Xarelto or Eliquis but here's all the other things that we do so these patients that are in the intermediate high risk so I'm gonna try to keep saying those terms to try to kind of put

that in everyone's brain because I think the massive and sub massive PE is what everyone used to talk about but we want to keep up with our colleagues in cardiology who are using the correct terminology we're gonna say high risk

and an intermediate but in those patients - intermediate high risk or Matt or the high risk PE patients we're gonna be treating them with systemic thrombolysis catheter directed thrombolysis ultrasound assisted

thrombolysis and maybe some real lytic and elected me or thrombectomy there's other techniques that we can use for one-time removal of clot like rotational and electa me suction thrombus fragmentation and then of course

surgical mblaq t'me so when anticoagulation is not enough so I like to show this slide because it shows the difference between anticoagulation and thrombolysis they are very different and sometimes I think everybody in this room

understands the difference but I think our referring providers don't and so when we when we get consulted and we recommend anticoagulation they're like yeah TPA well that's not the right thing so anticoagulation stops the clotting

process so when you start a patient on a heparin drip they should theoretically no longer before new thrombus on that thrombus so when you have thrombus in a vessel you get a cannon you get a snowball effect more

and more thrombus is gonna want to form heparin stops that TPA however for thrombolysis actually reverses the clouding process so that tissue plasminogen activator or streptokinase or uro kindness will actually dissolve

clot so there you're stopping new clot forming versus actually dissolving clot anticoagulation allows for natural thrombolysis so your body has its own TPA and so when you put a patient on heparin you're allowing your natural

body defenses to work you're giving it more time TPA accelerates that process so you give TPA either systemically or through a catheter you're really speeding up that process anticoagulation on its own has a

lower bleeding risk you're putting a patient on heparin or Combe it in it's it is less but it is still real thrombolysis however is a very very high bleeding risk patients when I when I consult a patient for thrombolysis I

tell them that we are about to do give them the absolute strongest blood clot thinning agent or an reversal agent which is the TPA and we're gonna just run it through your veins for hours and hours

um and that sort of gives them an idea of what we're doing anticoagulation in and of itself is really not invasive you just give it through an IV or even a pill thrombolysis however is given definitely through an IV through

systemic means and a large volume there thereafter or catheter directed so again

of these issues filters are generally still use or were used up until a few years ago or five years ago almost exclusively and then between five years and a decade ago there was this new concept of proximal protection or flow

reversal that came about and so this is the scenario where you don't actually cross the lesion but you place a couple balloons one in the external carotid artery one in the common carotid artery and you stop any blood flow that's going

through the internal carotid artery overall so if there's no blood flowing up there then when you cross the lesion without any blood flow there's nothing nowhere for it to go the debris that that is and then you can angioplasty and

or stent and then ultimately place your stent and then get out and then aspirate all of that column of stagnant blood before you deflate the balloons and take your device out so step-by-step I'll walk through this a couple times because

it's a little confusing at least it was for me the first time I was doing this but common carotid artery clamping just like they do in surgery right I showed you the pictures of the surgical into our directa me they do the vessel loops

around the common carotid approximately the eca and the ICA and then actually of clamping each of those sites before they open up the vessel and then they in a sequential organized reproducible manner uncle Dee clamp or unclamp each of those

sites in the reverse order similar to this balloon this is an endovascular clamping if you will so you place this common carotid balloon that's that bottom circle there you inflate you you have that clamping that occurs right

so what happens then is that you've taken off the antegrade blood flow in that common carotid artery on that side you have retrograde blood flow that's coming through from the controller circulation and you have reverse blood

flow from the ECA the external carotid artery from the contralateral side that can retrograde fill the distal common carotid stump and go up the ica ultimately then you can suspend the antegrade blood flow up the common

carotid artery as I said and then you clamp or balloon occlude the external carotid artery so now if you include the external carotid artery that second circle now you have this dark red column of blood up the distal common carotid

artery all the way up the internal carotid artery up until you get the Circle of Willis Circle of Willis allows cross filling a blood on the contralateral side so the patient doesn't undergo stroke because they've

got an intact circulation and they're able to tolerate this for a period of time now you can generally do these with patients awake and assess their ability to tolerate this if they don't tolerate this because of incomplete circle or

incomplete circulation intracranial injury really well then you can you can actually condition the patient to tolerate this or do this fairly quickly because once the balloons are inflated you can move fairly quickly and be done

or do this in stepwise fashion if you do this in combination with two balloons up you have this cessation of blood flow in in the internal carotid artery you do your angioplasty or stenting and post angioplasty if need be and then you

aspirate your your sheath that whole stagnant column of blood you aspirate that with 320 CC syringes so all that blood that's in there and you can check out what you see in the filter but after that point you've taken all that blood

that was sitting there stagnant and then you deflate the balloons you deflate them in stepwise order so this is what happens you get your o 35 stiff wire up into the external carotid artery once it's in the external cart or you do not

want to engage with the lesion itself you take your diagnostic catheter up into the external carotid artery once you're up there you take your stiff wire right so an amp lats wire placed somewhere in the distal external carotid

artery once that's in there you get your sheath in place and then you get your moment devices a nine French device overall and it has to come up and place this with two markers the proximal or sorry that distal markers in the

proximal external carotid artery that's what this picture shows here the proximal markers in the common carotid artery so there's nothing that's touched that lesion so far in any of the images that I've shown and then that's the moma

device that's one of these particular devices that does proximal protection and and from there you inflate the balloon in the external carotid artery you do a little angiographic test to make sure that there's no branch

proximal branch vessels of the external carotid artery that are filling that balloon is inflated now in this picture once you've done that you can inflate the common carotid artery once you've done that now you can take an O on four

wire of your choice cross the lesion because there's no blood flow going so even if you liberated plaque or debris it's not going to go anywhere it's just gonna sit there stagnant and then with that cross do angioplasty this is what

it looks like in real life you have a balloon approximately you have a balloon distally contrast has been injected it's just sitting there stagnant because there's nowhere for it to go okay once the balloons are inflated you've

temporarily suspends this suspended any blood flow within this vasculature and then as long as you confirm that there's no blood flow then you go ahead and proceed with the intervention you can actually check pressures we do a lot of

pressure side sheath pressure measurements the first part of this is what the aortic pressure and common carotid artery pressures are from our sheath then we've inflated our balloons and the fact that there's even any

waveform is actually representative of the back pressure we're getting and there's actually no more antegrade flow in the common carotid artery once you've put this in position then you can stent this once the stent is in place and you

think you like everything you can post dilated and then once you've post dilated then you deflate your balloon right so you deflate your all this debris that's shown in this third picture is sitting there stagnant

you deflate the external carotid artery balloon first and then your common carotid artery and prior to deflating either the balloons you've aspirated the blood flow 320 CC syringes as I said we filter the contents of the third syringe

to see if there's any debris if there's debris and that third filter and that third syringe that we actually continue to ask for eight more until we have a clean syringe but there's no filter debris out because

that might tell us that there's a lot of debris in this particular column of blood because we don't want to liberate any of that so when do you not want to use this well what if the disease that you're dealing with extends past the

common carotid past the internal carotid into the common carotid this device has to pass through that lesion before it gets into the external carotid artery so this isn't a good device for that or if that eca is occluded so you can't park

that kampf balloon that distal balloon to balloon sheath distally into the external carotid artery so that might not be good either if the patient can't tolerate it as I mentioned that's something that we assess for and you

want to have someone who's got some experience with this is a case that it takes a quite a bit of kind of movement and coordination with with the physician technologists or and co-operators that

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

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