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Superior Femoral Artery Stent Occlusion | Ultrasound-accelerated Thrombolysis, Aspiration Thrombectomy | 55 | Male
Superior Femoral Artery Stent Occlusion | Ultrasound-accelerated Thrombolysis, Aspiration Thrombectomy | 55 | Male
2016anastomosisanklearterialBTG-IMbypasscardiaccathetercollateraldistaldistallydroppingekosfibrinogengraftsinfusionlesionlysismultipleocclusionovernightPatentperformedpersistencepicturepoplitealproximalsheathSIRstentthrombolysisthrombosisthrombusveinwire
TIPS Case | Extreme IR
TIPS Case | Extreme IR
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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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Ultrasound-assisted Catheter-directed Thrombolysis | Management of Patients with Acute & Chronic PE
Ultrasound-assisted Catheter-directed Thrombolysis | Management of Patients with Acute & Chronic PE
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Carotid Artery Stenting- Case | Carotid Interventions: CAE, CAS, & TCAR
Carotid Artery Stenting- Case | Carotid Interventions: CAE, CAS, & TCAR
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The Last 5 Years in PE | Pulmonary Emoblism Interactive Lecture
The Last 5 Years in PE | Pulmonary Emoblism Interactive Lecture
aspiratecathetercatheterizedchapterdatadeviceembolismenrollmentinflectionmassiveoptimizedpatientspulmonaryrandomizedsystemicthrombolysisthrombolyticsthrombustrialtrials
PV Access | TIPS & DIPS: State of the Art
PV Access | TIPS & DIPS: State of the Art
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Complications & Pitfalls | TIPS & DIPS: State of the Art
Complications & Pitfalls | TIPS & DIPS: State of the Art
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Massive PE | Pulmonary Emoblism Interactive Lecture
Massive PE | Pulmonary Emoblism Interactive Lecture
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Treatment Options- Carotid Endarterectomy (CEA) | Carotid Interventions: CAE, CAS, & TCAR
Treatment Options- Carotid Endarterectomy (CEA) | Carotid Interventions: CAE, CAS, & TCAR
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Non-Invasive Ventilation | Respiratory Compromise: Use of Capnography During Procedural Sedation
Non-Invasive Ventilation | Respiratory Compromise: Use of Capnography During Procedural Sedation
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Treatment Options- CAS- Embolic Protection Device (EPD)- Distal Protection | Carotid Interventions: CAE, CAS, & TCAR
Treatment Options- CAS- Embolic Protection Device (EPD)- Distal Protection | Carotid Interventions: CAE, CAS, & TCAR
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Aspiration Thrombectomy | Management of Patients with Acute & Chronic PE
Aspiration Thrombectomy | Management of Patients with Acute & Chronic PE
angioAngiodynamicsAngiovac CannulaAspirex CathetercatheterschapterclotdevicedevicesfrenchIndigo ThrombectomyNonepatientPenumbraPenumbra Inc.sheathStraub Medicalthrombectomythrombustpa
CTEPH Studies | Management of Patients with Acute & Chronic PE
CTEPH Studies | Management of Patients with Acute & Chronic PE
acutearterieschapterchroniccpapedemainterdisciplinaryjapanmultidisciplinarymultipleNoneoperatorspatientpatientsperformedpulmonaryreperfusionrequiringthrombolysistreatedtreatmentvascular
TIPS: Techniques- CO2 Venography | TIPS & DIPS: State of the Art
TIPS: Techniques- CO2 Venography | TIPS & DIPS: State of the Art
balloonboluscapsulecatheterchaptercirculationconnectioncontrastcorrelationdiedifferencedistalfattyhepatichepatic veinimageimaginginjectleaklearningocclusionportalrefluxsegmentsteptrappingveinveinsvenogramvisualizewedgewedged
Diagnostic Criteria for CTEPH | Management of Patients with Acute & Chronic PE
Diagnostic Criteria for CTEPH | Management of Patients with Acute & Chronic PE
angiogramangiographyarterialarteriesarterycapillarycatheterchapterclassificationcurativediseasedistalflushlobesmanagementmedicationNonepatientpatientspressureproximalpulmonarysegmentalsheathstenosissurgeonsurgicalthrombustreatedtypevesselswebswedge
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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Therapies for Acute PE | Management of Patients with Acute & Chronic PE
Therapies for Acute PE | Management of Patients with Acute & Chronic PE
anticoagulantanticoagulationcatheterchapterclotcoumadindefensesdirectedheparininpatientintermediatelovenoxNonepatientpatientsplasminogenprocessriskrotationalstreptokinasesystemicsystemicallythrombectomythrombolysisthrombustpa
Stent Graft Deployment | TIPS & DIPS: State of the Art
Stent Graft Deployment | TIPS & DIPS: State of the Art
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Case 1 - Non-healing heel wound, Rutherford Cat. 5, previous stroke | Recanalization, Atherectomy | Complex Above Knee Cases with Re-entry Devices and Techniques
Case 1 - Non-healing heel wound, Rutherford Cat. 5, previous stroke | Recanalization, Atherectomy | Complex Above Knee Cases with Re-entry Devices and Techniques
abnormalangioangioplastyarteryAsahiaspectBARDBoston Scientificcatheterchaptercommoncommon femoralcontralateralcritical limb ischemiacrossCROSSER CTO recanalization catheterCSICTO wiresdevicediseasedoppleressentiallyfemoralflowglidewiregramhawk oneHawkoneheeliliacimagingkneelateralleftluminalMedtronicmicromonophasicmultimultiphasicocclusionocclusionsoriginpatientsplaqueposteriorproximalpulserecanalizationrestoredtandemtibialtypicallyViance crossing catheterVictory™ Guidewirewaveformswirewireswoundwounds
Case- May Thurner Syndrome | Pelvic Congestion Syndrome
Case- May Thurner Syndrome | Pelvic Congestion Syndrome
arterycatheterizecausingchapterclassiccliniccommoncommon iliaccompressioncongestionendovascularevidenceextremitygonadalhugeiliaciliac veinimagingincompetenceincompetentMay Thurner Syndromeobstructionoccludedpelvicpressuresecondarystentsymptomstreatmentsvalvularvaricositiesvaricosityveinveinsvenavenous
Ideal Stent Placement | TIPS & DIPS: State of the Art
Ideal Stent Placement | TIPS & DIPS: State of the Art
anastomosiscentimeterchaptercoveredcurveDialysisflowgraftgraftshemodynamichepatichepatic veinhyperplasiaintimalnarrowingniceoccludesocclusionportalshuntshuntssmoothstentstentsstraighttipsveinveinsvenousvibe
Education Strategies to Reduce Human Errors | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
Education Strategies to Reduce Human Errors | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
activeaneurysmangiographybostcerebralchapterchecklistclotconcurrentcontraindicationcontraindicationsdistallyembolizedguidelinehemorrhageheparinisismilligramNonepatientphysiciansstandardstentstentingstentsstrategiestemplatetherapeuticthrombolysistpa
Case 3 - Right iliac occlusion | Subintimal Recanalization | Complex Above Knee Cases with Re-entry Devices and Techniques
Case 3 - Right iliac occlusion | Subintimal Recanalization | Complex Above Knee Cases with Re-entry Devices and Techniques
AngioDymanicscatheterchapterCordiscritical limb ischemiadeviceenosfootguysiliacocclusionOUTBACK® ELITE Re-Entry Catheterproximalre-entry deviceSOS Omni Selective Catheterstentvessel
Prospective CDT Trials | Pulmonary Emoblism Interactive Lecture
Prospective CDT Trials | Pulmonary Emoblism Interactive Lecture
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Malignant Biliary Strictures | Biliary Intervention
Malignant Biliary Strictures | Biliary Intervention
adventBARDcancerceliaccenterschaptercolorectalcookCordiscoveredcysticdataductextremelyfavorfavorablegoregrammalignantMeditechMemothermmetalmetastaticmultipleocclusiononcologyovergrowthpatientsperioperativeportalSmartStentstainsstentstentsstricturestumorunresectablewallstentZilver Stent
TIPS: Techniques- Stent Grafts | TIPS & DIPS: State of the Art
TIPS: Techniques- Stent Grafts | TIPS & DIPS: State of the Art
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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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Systemic vs Catheter-based Thrombolysis | Management of Patients with Acute & Chronic PE
Systemic vs Catheter-based Thrombolysis | Management of Patients with Acute & Chronic PE
bleedingcatheterchaptermilligramNonepatientpatientsperiodriskslowersystemictargetedthrombolysistpaversus
Case- Brain Infarction | Brain Infarct After Gastroesophageal Variceal Embolization
Case- Brain Infarction | Brain Infarct After Gastroesophageal Variceal Embolization
anastomosisangiographyaphasiaapproacharrowarteryartifactbrainbronchialcalcificationcatheterschannelschapterchronicChronic portal vein thrombosuscollateralcyanoacrylatedrainembolismembolizationendoscopicendoscopistendoscopygastricGastroesophageal varixglueheadachehematemesisinjectionmicromicrocathetermulti focal brain infarctionmultipleoccludedPatentpatientpercutaneousPercutaneous variceal embolizationperformedPortopulmonary venous anastomosisprocedureproximalsplenicsplenomegalysplenorenalsubtractionsystemicthrombosistipstransformationtransitultrasonographyvaricesveinvenous
Mechanical Thrombectomy | Management of Patients with Acute & Chronic PE
Mechanical Thrombectomy | Management of Patients with Acute & Chronic PE
amplatzcatheterchapterclotcombidevicehelpsInari DeviceInari MedicallossNonepatientsprovestudiessuctionthrombectomythrombolytictpa
Transcript

left foot. He has no tissue loss, no sensory or motor loss. And he does have a history of a previous SFA stent

and a below-knee pop to posterior tibial vein bypass. So he was last seen in 2014. So he's been doing well for about two years until he presented with a cold foot. So here is the left lower extremity arteriogram. It shows a patent SFA proximally

with occlusion of the distal SFA stent. Here is the little nub end and the large collateral bypassing it. There're multiple collaterals crossing the knee. And here is the calf showing multiple clips. This is where the proximal anastomosis of the below-knee pop to distal PT bypass is. Based on prior imaging we know that's where it is. And here you can see collateral vascular

of the ankle with some filling of that reconstituted PT going across the ankle. So we crossed that thrombosis with cathether and wire and we got our catheter down to where we knew the proximal anastomosis was. And were able to get an Ekos in and performed overnight thrombolysis. So the next day you can see here, this may have been inciting lesion

here. We have a stenosis in the proximal edge of the stent. And then you've got continued thrombosis of the distal portion of the stent and really no reconstitution of the pop here. So this is the picture of how we started, the occlusion here. So in this case we did angioplasty of that proximal lesion and then we went old school and

put a 6 French guide catheter actually down into the popliteal and aspirated the remaining thrombus. And here you can see this is the image after that. Now you can see the hood of the bypass here, with the by pass still occluded, a few collateral vessels going around it.

So at this point, the decision wise do we discontinue thrombolysis or try to get the bypass open or do we try to be more aggressive and try to recanalize the bypass on the table? In 2014, the by pass was widely opened, he's been fine up until this point.

So we presume this is an acute occlusion of the by pass. >> This is a different bypass right, not the three week old one? >> Right, this is >> The distal one. >> Yeah this is our below-knee pop to PT pop vein bypass so >>

Vein grafts are different from synthetic grafts in that when they thrombose they are not necessary get opened up, cause they get atretic and stuff. So you can balloon and stent all that but at the end of the day, what I found with those is after wasting all this time and money on the vein graft I just go after the native vessel

anyway. So just do that from the start. >> Right. Well, in this one, I don't think we really had a target to go after, but we decided to send this guy back for overnight thrombolysis and doing it proximally. Cause we didn't wanna cross into the bypass because we knew the size

of the bypass was small. And one thing you have to be careful with when you're dealing with thrombosed tibials if you're thinking about doing overnight thrombolysis, you are putting like a five and sometimes six French catheter into very small vessels.

And I have seen several times where when you try to lysis a distal pop or a tibial, you have no flow around the catheter and just because you are infusing high powered lytic medication, if you don't have flow you're not going to get it open. And you could even make the situation worse with propagation of the thrombosis retrograde up into the popliteal and SFA.

So in that case what we did here is we just dripped it from above the occlusion and- >> Question. >> Go ahead. >> I noticed that you are using Ekos again. >> Yes. >> What's the rational

for using Ekos and endhall/g infusion? >> That's a great question. Actually this is not the, I just had to put a picture in here for thrombolysis. This is not actually the- >> [LAUGH] >> Yeah. [LAUGH] Sorry .

>> How many people are using Ekos in the arterial system? Some people do, okay. I'm surprised cause I don't see it that much. To me if I use it it's venous and even there not that much. >> Why not just put an infusion wire down? >> We don't have it.

>> [INAUDIBLE] >> That's- >> That's the answer here. >> Absolutely yeah. >> [INAUDIBLE] >> Cause you don't wanna be called on that, about the infusion wire not working. >> [LAUGH] >> [INAUDIBLE] >> I haven't used those in a long time. >> [INAUDIBLE] >> Yeah exactly. >> [INAUDIBLE]

>> So as you guys could probably predict this does not work. And this is basically the identical picture that we had prior to the lysis. And this is what it looked like before. So this is kind of goal that we're going after. So in this case we did get,

on that day we did get more aggressive. Got across the occlusion with a catheter and wire and performed aspiration thrombectomy with an over-the-wire device. And we did probably three passes to get it to look like this. Which revealed multiple stenoses in the proximal aspect of the bypass. Distally it looked reasonable.

And here's the distal anastomosis here. So we then performed a PTA of the proximal part of the bypass. And looks a lot better here. But the problem is down here in the distal anastomosis, we've actually lost a large branch coming off distally which back in 2014 was patent and supplied the PT below the ankles.

So we then introduced the cocktail of thrombolytics, heparin, and Nitrocine to see if that would help, it did not. And so then we, what's the definition of insanity? Doing the same thing?

So we did overnight thrombolysis and actually, again this is in-hole thrombolysis. This is just a picture to tell you that we did that. And the next day actually that bit of thrombus did melt away. Again most of the times if you're not across the thrombosis you are not gonna be successful, but in the distal arterial beds,

I've seen this this a couple of times where if you do in-hole thrombolysis you do actually get lysis of the clot, the near the ankle or near the hand if you have embolic disease in the hands. >> I agree. That's how I do it these days. Used to do like infusion wires and stuff. But even with those you see a lot of pericardial thrombus in my

experience. And I'd say in general I just do it in-hole. >> Yeah. >> For the pop. >> And that's 2014. And this is where we started from on this presentation.

>> Persistence pays. >> Yes persistence pays. [LAUGH] >> How long would either of you continue lysis? Like what's your limit? Number of hour -

>> 72 hours. >> Yeah. Me too. Don't let it go beyond three days. >> Yeah. >> What do you guys think?

[LAUGH]. >> How many milligrams an hour do you give them for three days? >> One milligram. >> To go three days? >> There's a problem. >> You didn't jot that down? >> [INAUDIBLE] >> [INAUDIBLE]

>> Right right. This guy was 55 I think. >> And is everyone checking fibrinogen, and all that jazz. >> Yeah, we do Q. 8 hours fibrinogen, cut the dose in half if it's below 150 and turn

off if it's below 100. >> So you're giving one milligram an hour for two days? >> Mm-hm. I mean it's not 72 hours consistently, we've got breaks during the procedures and -

>> [INAUDIBLE]. >> 500 units per hour through the sheath. So it's not systemic heparinization. It's basically just to keep the sheath open. >> You are able to consider dropping that down to [INAUDIBLE] >> That's what I would do.

Actually I think my standard does these days is half a milligram >> [INAUDIBLE]. >> Is anyone using anything other than TPA for thrombolysis. >> [INAUDIBLE]

>> Nice. >> Yeah, very good. >> [LAUGH] >> With your [UNKNOWN] it can go longer than three days. >> What about tenecteplase? [BLANK_AUDIO]

Anybody using that? >> [INAUDIBLE] A lot of patients dropped their fibrinogen in the first 12 to 48 hours [INAUDIBLE]. We started dropping routinely after 12 hours to half a milligram. And we've seen no difference in our success.

Half a milligram in the [INAUDIBLE], and it's been just fine. >> And have you seen a difference in the fibrinogen levels? >> Well, fibrinogen levels are much easier to manage. >> Right. >> You almost always see them stop dropping [INAUDIBLE]

[INAUDIBLE] >> I agree. >> [INAUDIBLE] [INAUDIBLE] >> You're worried [INAUDIBLE] [INAUDIBLE] or if we don't get desired results after first night,

we add an infusion of [UNKNOWN] through the sheath, and I tell you what, if I ever have an ichemic arm I start right away because I feel like it really changes the game. >> When you say infusion- >> So we use cardiac dos. So we don't give the bolus but we

give the cardiac 12-hour infusion through the sheath or through the infusion catheter directly into the site. >> With a TPA? >> With TPA. And I well you that it's a game changer in these cases that you're on the edge, really worried that they're not gonna be reversal in the arm to get a lot more digital arteries back

>> That's a good

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

treatment is the ultrasound assisted catheter director thrombolysis or the echos divisor eCos this technique involves a slow infusion again over 12 to 24 hours

but the catheter has ultrasound built into it and that's thought to help disassociate fibrin strands and to help embed the thrombus bed the TPA into the thrombus I think most people have heard of or seeing eCos in the past

again lower doses much like the catheter directed so it's really the same type of procedure except at the end you're hooking up eCos rather than a uniform Craig Mac there is a lot of differences though in the sort of overall patient

experience because eCos as many of you know requires a lot more devices and for the patient's room so they're gonna have more pumps because it requires more fluid it requires more observation it beeps more frequently overnight but what

I will say is that there are studies that are used that have useful information with eCos and those are actually the main studies that have been done although they're all industry-sponsored but they're very

important studies nonetheless so the only device really that exists for this right now that approved is the eCos

are in the room here's a case of an 80

year old with a previous mi had a left hand are directing me and it's gonna go for a coronary bypass graft but they want this carotid stenting significant card accenting lesion to be treated first there's the non-invasive blow

through this but there's the lesion had a prior carotid endarterectomy so had that surgery we talked about first but at the proximal and distal ends of that patch has now a stone osis from the surgical fix that's developed so we

don't want to go back in surgically that's a high resolution we want for a transfer Merle approach and from there here's what it looks like an geographically mimics what we saw on the CT scan you can see the the marker and

the external carotid artery on the right that's the distal balloon and then proximally in the common carotid artery and they're noted there and then when you inflate the balloons you can see them inflated in the second image in the

non DSA image that's the external carotid room carotid artery balloon that's very proximal the common carotid balloon is below or obscured by the shoulders and ultimately when you inflate the common carotid balloon you

just have stagnant blood flow then we treat them you can see both balloons now and the external carotid and common carotid in place we have our angioplasty balloon across the lesion and then ultimately a stent and this is what it

looked like before this is what it looks like after and tolerated this quite well and we never had risk of putting the patient for dis Lombok protection or to salamba lusts overall I'm not gonna go over this real

individually into each one of these trials but I want to just point out to you how busy the last 5 years have been because it has really caused a

resurgence in our interest in both treating PE better and what the gaps are in our knowledge so I will point out in 2014 this was an inflection point for 10 years we didn't have a major trial actually more like 12 or 15 years we

hadn't had a major trial in in PE and pytho was a 1000 patient study that informed us about how systemic thrombolytics interact with sub massive P and I'll go through the data that same year

catheterized thrombolysis is everybody familiar with catheter at the thrombolysis for submasters before Pease that's totally off the grid okay good well this was the first time we had a randomized trial for catheter directly

thrombolysis with some with some massive PE only problem was it was 59 patients in Europe so and that's all we have as far as randomized trials for CDT this is my soapbox issue I'm sorry if you've heard me say this but that's that's my

big goal is to try to change that 2015 had some follow-on CDT trials 2017 this is when we started thinking about the long term effects of PE on patients both of these studies started to examine the issue where a year after the PE patients

are not normal if you did a for example this elope long term study almost 50% of patients had an abnormal cardio pulmonary function test one year later 2018 we started to experiment with the dosage that we're

administering during CDT that's the optimized trial and we saw the first trial completed for a mechanical device called the NRA flow trailer which I'll show you later in the talk as well so that was an exciting inflection point as

well the extract PE trial which uses the indigo cat 8 device to aspirate thrombus in pulmonary embolism we just completed enrollment this year the future is hopefully bright for generating more data the PERT consortium registry is up

and running and is hopefully going to help us aggregate data and make better decisions and then you have a couple more devices coming in and I'll tell you our efforts to try to really improve the knowledge base on what CDT for sub

massive P that's the P track trial that's the last bullet point there okay

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

people were thinking about the covered

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

it's obviously either done with general

anesthesia or perhaps a regional block at our institution is generally done with general anesthesia we have a really combined vascular well developed combined vascular practice we work closely with our surgeons as well as

you know those who are involved in the vascular interventional space as far as the ir docs and and in this setting they would do generally general anesthetic and a longitudinal neck incision so you've got that and the need for that to

heal ultimately dissect out the internal carotid the external carotid common carotid and get vessel loops and good control over each of those and then once you have all of that you hyper NIH's the patient systemically not unlike what we

do in the angio suite and then they make a nice longer-term longitudinal incision on the carotid you spot scissors to cut those up and they actually find that plaque you can see that plaque that's shown there it's you know actually

pretty impressive if you've seen it and let's want to show an illustrative picture there ultimately that's open that's removed you don't get the entirety of the plaque inside the vessel but they get as much as they can and

then they kind of pull and yank and that's one of the pitfalls of this procedure I think ultimately is you don't get all of it you get a lot more than you realize is they're on on angiography but you don't get all of it

and whatever is left sometimes can be sometimes worse off and then ultimately you close the wound reverse the heparin and closed closed it overall and hope that they don't have an issue with wound healing don't have an issue with a

general anesthetic and don't have a stroke in the interim while they've clamped and controlled the vessel above and below so here's a case example from our institution in the past year this is a critical asymptomatic left internal

carotid artery stenosis pretty stenotic it almost looks like it's vocally occluded you can see that doesn't look very long it's in the proximal internal carotid artery you can see actually the proximal external carotid artery which

is that kind of fat vessel anteriorly also looks stenotic and so it's going to be addressed as well and this is how they treated it this is the exposure in this particular patient big incision extractors place and you can see vessel

loops up along the internal and external carotid arteries distally along some early branches of the external carotid artery off to the side and then down below in the common core artery and ultimately you get good vessel control

you clamp before you make the incision ultimately take out a plaque that looks like this look how extensive that plaque is compared to what you saw in the CT scan so it's not it's generally much more

impressive what's inside the vessel than what you appreciate on imaging but it's the focal stenosis that's the issue so ultimately if yet if the patient was a candidate stenting then you just place a stent

across that and he stabilized this plaque that's been removed and essentially plasti to that within the stent so it doesn't allow any thrombus to break off of this plaque and embolize up to the brain that's the issue of raw

it's the flow through there becomes much more turbulent as the narrowing occurs with this blockage and it's that turbulent flow that causes clot or even a small amount of clot to lodge up distally within the intrical in

terrestrial vasculature so that's the issue here at all if you don't take all that plaque out that's fine as long as you can improve the turbulent blood flow with this stent but this is not without risk so you take that plaque out which

looks pretty bad but there are some complications right so major minor stroke in death an asset which is a trial that's frequently quoted this is really this trial that was looking at medical therapy versus carotid surgery

five point eight percent of patients had some type of stroke major minor so that's not insignificant you get all that plaque out but if you know one in twenty you get a significant stroke then that's not so bad I'm not so good right

so but even if they don't get a stroke they might get a nerve palsy they might get a hematoma they may get a wound infection or even a cardiovascular event so nothing happens in the carotid but the heart has an issue because the

blockages that we have in the carotid are happening in the legs are happening in the coronary so those patients go through a stress event the general anesthetic the surgery incision whatever and then recovery from that I actually

put some stress on the whole body overall and they may get an mi so that's always an issue as well so can we do something less invasive this is actually a listing of the trials the talk is going to be available to you guys so I'm

not going to go through each of this but this is comparing medical therapy which I started with and surgery and comparing the two options per treatment and showing that in certain symptomatic patients if they have significant

stenosis which is deemed greater than 70% you may be better off treating them with surgery or stenting than with best medical therapy and as we've gotten better and better with being more aggressive with best medical therapy

this is moving a little bit but here's the criteria for treatment and so you have that available to you but really is

now let's look at non-invasive ventilation and I know about like five

percent of the patient population that you are seeing is on some form of non-invasive whether they're on by level ventilation or continuous positive airway pressures right so see if HAP using to stent the Airways open and

maintain a pro a Peyton airway and improving oxygenation but BiPAP and patients that need co2 elimination right need help with the by level support so there's a lot of questions that come up when we give

these talks I'm like how does capnography work effectively with these different technologies of non-invasive ventilation and especially because more and more of our patients are requiring these so we're gonna look at some of the

comparisons of co2 capnography data from three different sample sites and remember I showed you that picture so that picture I showed you with the patient wearing the sampling line with a nasal oral scoop and then there was the

mask sampling port and then there was the port on the ventilator circuit distally so that's what we're looking at here so the diamonds that go I wish I had a pointer I don't have a laser pointer I'm sorry but across the top the

diamonds represent our end tidal capnography values from one liter all the way up to eight liters so as the props are as the pressures go up for CPAP they were monitoring leak rates and what they found is the cat nog rafi

values across all of those were pretty accurate when we're monitoring right here the squares and the diamonds represent the mask sampling port and the the ventilator in the circuit distal to the mask and as you could see that

quality of our monitoring goes down as we progress okay to use yes but just know the limitations of your equipment right and again this is the same thing for our BiPAP Dave data are by level ventilation we're seeing again

across the top if we're sampling right at the airway we have pretty consistent readings but then they start to fall off and we look at the other devices that are further down the downstream what we're seeing here is our end tidal

measurements again with CPAP data and what we're looking at is the patient leak so there's always leaks right when we have these devices on and that's a question well sue if I have a leak how accurate am i okay so now the red is our

nasal oral scoop and if you look at the red graph all the way across depending on the leak rate pretty consistent values right the charcoal color is the mask sampling port and that's pretty consistent probably until about like 10

right until our patient like leak rate 10 liters per minute coming out of that mast and then that value starts to fall off and even more so even further distal down our circuit when we're sampling from the circuit at the past the mask

that's the cream color pretty accurate when there's a minimal leak but as the leak goes up that falls off pretty significantly and the same holds true for our by level ventilation pretty similar distribution here with the

patient leak and the sampling so when we're using non-invasive ventilation yes it's accurate and yes it's accurate we're using high flows and yes it's accurate if we have a huge leak only if we're sampling right where the patient

is exhaling so now I hope that clears that up with the patients that are getting supplemental pressure support with your sampling and you know in those just whatever it can sample from the mouth and the nose right at the source

of exhalation has proven to be the most reliable out of all of the different sampling devices so third evaluate your

kind of the embolic protection because I think with carotid artery stenting the stents there's a lot of different types they're all self expanding for the most

part and there's not a lot to talk about there but there is with regards to embolic protection and there so there's distal and violent protection where you have this where that blue little sheath in the common carotid artery you got a

wire through the ica stenosis and a little basket or filter distally before you put the stent in early on they used to think oh maybe we'll do distal balloon occlusion put a balloon up distally do your intervention aspirate

whatever collects behind the balloon and then take the balloon down not so ideal because you never really asked for it a hundred percent of the debris and then whatever whenever you deflate the balloon it goes back it goes up to the

brain you still have some embolic phenomenon in the cerebral vascular churn and then there's this newer concept of proximal protection where you use either flow reversal reverse the blood flow in the cerebral circulation

or you actually cause a stagnant column of blood in the ica so you can't get you don't get anything that embolize is up distally but you have this stagnant column the debris collects there you aspirate that actively before you take

down the balloons that are in position in the X carotids and common carotid artery and then you take everything out so let's walk through each of these if you really wanted to pick out the perfect embolic

protection device it's got to be relatively easy to use it's got to be stable in position so it's not moving up and down and causing injury to the vessel but even while it's in place cerebral perfusion is maintained so that

balloon the distal balloon not a great idea because you're cutting off all the blood flow to the brain you might stop something from embolizing up distally but in the process of doing that you may patient may not tolerate that you want

complete protection during all aspects of the procedure so when we place a filter as you'll see just crossing the lesion with the initial filter can cause a distal embolus so that's a problem you want to be able to use your guide wire

choice as many of you know when we go through peripheral vasculature there's your go-to wires but it doesn't always work every time with that one go-to wire so you want to be able to pick the wire that you want to use or

change it up if needed for different lesions so if you get to use your wire of choice then then that's gonna be a better system than something that's man deter and then if you have a hard time using that wire to get across the lesion

you have a problem overall and then ultimately where do you land that protection device and a few diagrams here to help illustrate this generally speaking these distal embolic protection these filters that go beyond

the lesion have been used for quite a while and are relatively safe you can see them pretty easily and geographically they have little markers on them that signify if they're open or closed and we look for that overall and

blood flows through them it's just a little sieve a little basket that collects really tiny particles micrometers in size but allows blood flow to pass through it so you're not actually causing any cessation of blood

flow to the brain but you are protecting yourself from that embolic debris and it's generally well tolerated overall we had really good results in fact when not using this device there's a lot of strokes that were occurring in use of

this device dramatic reduction so a significant improvement in this procedural area by utilization of embolic protection however distal embolic protection or filter devices are not a perfect APD as you as you may know

those of you have been involved in carotid stenting there is no cerebral protection when you cross the lesion if you have a curlicue internal carotid artery this filter doesn't sit right and and ultimately may not cause

good protection or actually capture everything that breaks off the plaque and it can be difficult to deliver in those really tortuous internal carotid arteries so ultimately you can cross the lesion but you may not get this filter

up if you don't get the filter up you can't put the stent then ultimately you're out of luck so you gotta have a different option filters may not provide complete cerebral protection if they're not fully opposed and again it does

allow passage of really tiny particles right so your blood cells have to be able to pass but even though it's less than about a hundred microns may be significant enough to cause a significant stroke if it goes to the

right basket of territory so it's not perfect protection and then if you have so much debris you can actually overload the filter fill it up in tile and entirely and then you have a point where when you capture the filter there's some

residual debris that's never fully captured either so these are concerns and then ultimately with that filter in place you can cause a vessel dissection when you try to remove it or if it's bouncing up and down without good

stability you can cause spasm to the vessel as well and so these are the things that we look for frequently because we want to make sure that ultimately if we just sent the lesion but we don't believe the vessel distal

to it intact and we're going to have a problem so here's some kind of illustrated diagrams for this here's a sheath in the common carotid artery you see your plaque lesion in the internal carotid artery and you're trying to

cross this with that filter device that's what's the picture on the right but as you're crossing that lesion you're you're liberating a little plaque or debris which you see here and during that period of time until the filters in

place you're not protected so all that debris is going up to the brain so there's that first part of the procedure where you're not protected that's one of the pitfalls or concerns particularly with very stenotic lesions or friable

lesions like this where you're not protected until that filters in place that first step you never are protected in placement of a filter here's an example where you have a torturous internal carotid artery so you see this

real kink these are kinds of carotid internal carotid arteries that we can see and if you place that filter in that bend that you can see right at the bend there the bottom part the undersurface of the carotid doesn't have good wall

my position of the filter so debris can can slip past the filter on the under under surface of this which is a real phenomenon and you can see that you can say well what if we oversize the filter if you oversize the filter then it then

it just oval eyes Azure or it crimps and in folds on itself so you really have to size this to the specific vessel that you plan to target it in but just the the physics of this it's it's a tube think about a balloon a balloon doesn't

conform to this it tries to straighten everything out this isn't going to straighten the vessel out so it doesn't fully conform on the full end of the filter and you have incomplete a position and therefore

incomplete filtration so this is another failure mode I mentioned before what if it gets overloaded so here's a diagram where you have all this debris coming up it's filling up the really tiny tiny particles go past it because this little

micro sieve allows really small particles to go distal but approximately it's overloaded so now you get all this debris in there you place your stent you take your retrieval filter or catheter to take this filter out and all that

stuff that's sitting between the overloaded filter and your stent then gets liberated and goes up to the brain so you got to worry about that as well I mentioned this scenario that it builds up so much so that you can't get all the

debris out and ultimately you lose some and then when the filter is full and debris particles that are suspended near the stent or if you put that filter too close to the edge of the stent you run into problems where it may catch the

stent overall and you have all of this debris and it looks small and you don't really see it and geographically obviously but ultimately is when you do a stroke assessment and it's not always devastating strokes but mild symptoms

where he had a stroke neurologist and the crest trial or most of the more recent clinical trials we actually evaluate a patient and notice that they had small maybe sub sub clinical or mild strokes that were noted they weren't

perhaps devastating strokes but they had things that caused some degree of disability so not insignificant here's a case example of a carotid stent that was done this is a case out of Arizona proximal carotid

stenosis stent placed but then distal thrombus that developed in this case and had post rhombus removal after the epd was removed so there's thrombus overloaded the the filter you can see the filter at the very top of the center

image you can see the sort of the shadow of the embolic protection device there distally aspirated that took the filter out and then ultimately removed but you can imagine that amount of thrombus up in the brain would have been a

devastating stroke and this is what the filter looks like in real life so this is what the debris may look like so it's not this is not overloaded but that's significant debris and you can see the little film or sieve that's on the

distal part of this basket and that's what captures the debris any of that in the brain is gonna leave this patient with a residual stroke despite a successful stenting procedure so this is what we're trying to avoid so in spite

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

criteria for CTF means that the patient has a mean pulmonary arterial pressure which we measure intraoperatively exceeding 25 millimeters mercury at rest with the mean pulmonary capillary wedge pressure less than 15 so I'm not a

cardiologist but what that means to me is a mean capillary pulmonary wedge pressure less than 15 means that their left heart is not failing so if you have a capillary wedge pressure higher than 15 that means your left heart is not

working correctly and you can't blame it on the CTF so you can't blame it on the right side if the left side isn't working other things that matter are the abnormal pulmonary vascular resistance and having a systolic pulmonary artery

pressure greater than 40 so what I want to show you and highlight is the law the lost art of pulmonary angiography which i think is now sort of again a lost art some places do a lot of it and some places don't do very much but diagnostic

pulmonary angiography is actually the gold standard in the planning of either surgery or medical management for patients with CTF we do we do these on almost all of our patients with CTF to make that decision with the surgeons and

the cardiologists so the utility is very it's very useful you're able to measure our pressure you're able to decide whether we're the where the thrombus exists in this image here in patients with disease in the

blue and yellow outlined areas those are the patients who can have the operation the operation is curative it's not just medication that you have to take for the rest of your life you can actually remove that chronic clot it's much like

a femoral endarterectomy that are done for patients with peripheral arterial disease although it's a lot more complicated because they have to crack your chest open what's important is getting very very

good high-quality pulmonary angiogram xand so we do we used to do about we do about a hundred of these a year where I trained or actually where I work now and you get very magda up views and you're gonna show all of the vessels and so

these are the views that we use at our institution they happen to be the pipette criteria so it's the same thing you used to do for acute PE you put a flush catheter in the main pulmonary arteries when you're looking at the

upper lobes and when you're looking at the lower lobes you want to push the catheter further into the pulmonary arteries and inject usually what I do is a two to three second injection so that you can stack the images very well and

show all of them in one view this allows your surgeon to make a decision easily as to whether they can operate or they can't operate on this and then I use a higher frame rate usually because these patients are wide awake we when we do

this case we give our patients twenty five mics of fentanyl one time and that's it just to help get the sheath in I usually do this with a seven French sheath and then use a flush cap pulmonary artery catheter many of which

are currently off the market but when we do this we just give them that twenty five Mike's because they have to hold their breath and I usually go up to a high frame rate in the first run and then adjust based off of how well that

patient is holding their breath this really takes a team effort from our nursing technologists and the and the physicians in the room to make sure that this patient does a good job because it's gonna change their management so

there are a lot of different types of angiographic findings on one of these pulmonary angiogram they're really really interesting pulmonary angiogram zin these patients and they're sometimes not at all subtle so you're looking for

a pruning of distal vessels if we start in the top left where you're just not seeing the Brent normal branch pattern you look for stenosis so we're not usually used to looking at stenosis and the pulmonary arteries but this is

actually what you're looking for in CTF you're looking for webs or bands so you'll usually see little areas where you just doesn't look like there's great opacification there's little areas that there's not good at pacification those

are little webs inside the vessel believe it or not looks like a cobweb that grew inside there from that thrombus and then you're looking for areas of complete occlusion that there's just no vessels there those are all

vessels that can be treated in patients with CTF so this is the Jameson classification before we talk about the sort of the interventional management the surgical management is again the curative and dr. Jameson is the head

surgeon at University of California in San Diego which is the largest Palm CTF program in the in the world and he's done I think over 3 500 of these operations I think he's retired at this point but they named the classification

after him and so type 1 is proximal disease so it involves the main pulmonary arteries these are the ideal patients who can get the best benefit from this in their life type 2 is the next best

it's segmental proximal just type 3 is distal segmental and then type 4 is just a mess of sort of all of it but you can't really get a good surgical plane so type 1 and 2 are treated with pulmonary thromboembolism

towards balloon pulmonary angioplasty or BPA and type 4 are generally treated with medication so PT II or pulmonary

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

strategies so some things that we have

in place right now our peer review Grand Rounds CPOE this is one of my one of my favorite process improvements is is making the right thing the easiest thing and you do that through standardization of processes so that's standard work so

that's your order sets that's the things pop-ups although you don't want to get into pop-up fatigue but pop-ups help our providers for little gentle reminders to guide them to what's right for the patient and to cover everything that we

need we need to cover to ensure the safety of our patient so recently in the fall of last year we had a TPA administration err that occurred it involved a 69 year old patient who two weeks prior had had some stenting in her

right SFA she presented to our clinic when our clinics with some heaviness in her leg and some pain and when she was looked at from an ultrasound standpoint it was determined that her stents were from Bost so she was immediately taken

to the cath lab and it was after angiography did indeed show that there was clot inside these stents they did start catheter directed thrombolysis in the cath lab they also did started concurrent heparin often oftentimes done

with CDT what's usual for our institution is that we have templates that pull in the active problem list for a patient in this case the active problem list or a templated HMP was not used had they

used the template at agent p they would have found that the second active problem on this patients list was a cerebral aneurysm so some physicians will tell you some ir docs will tell you that's an absolute

contra contraindication for TPA however the SI r actually lists it as a relative contraindication so usually we're used to when you when you start a final Isis case you know you're gonna be coming in every 24 hours to check in

that patient in this case we started the the CDT on a Thursday the intent was to bring her back on Monday the heparin many ir nurses will know that we will run it at a low rate usually 500 units an hour and we keep the patient sub-sub

therapeutic on their PTT although current literature will show you that concurrent heparin can also be nurse managed keeping the patient therapeutic in their PTT which is what was done in this case so what ended up the the

course progression of this patient was that so remember we started on Thursday on Saturday she regained her distal pulses in her right leg no imaging Sunday she lost her DP pulse it was thought that it was part of a piece of

that clot that was in the the stent had embolized distally so they made the decision with the performing physicians they consulted him to increase the TPA that was at one milligram an hour to 2 milligrams by Sunday afternoon the

patient had an altered mental status she went to the CT scan which showed a large cerebral hemorrhage they ain't we intubated to protect her airway and by Monday we were compassionately excavating her because

she me became bred brain-dead so in the law there's something that's called the but for argument so the argument can be made that this patient would not have died but for the TPA that we gave her in a condition that she should not have had

TPA for namely that aneurysm so this shows how standard work can be very important in our care of our patients and how standard work drives us down the right way making the easiest thing the safest thing so since that time

we've had a process improvement group that we've established an order set specifically for use and thrombolysis from a peripheral standpoint and then also put together a guideline that was not in place so it's some of that Swiss

cheese that just kind of we didn't have a care set we didn't have a guideline you know we didn't use our template so all those holes lined up and we ended up with a very serious patient safety event so global human air reduction strategies

oops sorry let's go back these are listed in a weaker two stronger and some of what we're using in that case is some checklists so we developed a checklist that needs to be done to cover the

absolute contraindications as well as the relative and it's embedded in the Ulta place order that the physician has to review that checklist for those contraindications and also there to receive a phone call from pharmacy

just to double-check and make sure that they have indeed done that that it's not somebody just checking it off so we have a verbal backup sorry so the just

her I couldn't help but throw this in

just talking about back device here's a patient that had a iliac occlusion the right it was very difficult to get past the very proximal plaque cap so in this case I did a sub into a we can remember I talked about that out back device it

has like a little L and upside down L that you can use to point into the vessel lumen so what I did was on the healthy side I put in a sauce on me this allows me to know exactly where the arches and where the right coming he

like origin is certainly I don't want to be out backing into the aorta deeply right so this allows me to identify where that location is once I've out backed into the vessel here then I just pre dilated and then stent it up into

the vessels so just sort of interesting case one thing since I am Austin there's a couple of places just you may or may not be aware of this is a Barton Creek it's actually not just a cross town lake not far from here it's about a seven

mile a little Greenbelt inside the city where basically you don't feel like getting your traffic your gaze definitely away from everything this is called the land bridge oops so there's a couple of guys right here

that's about probably about a 20-foot jump there's this guy right here who just took off from that ledge it's about a 40 50 foot drop I did try to get up to that part one time it's about it one foot with ledge so I didn't get the ax

courage to do it now I'm sort of happy because during the summer months it does get just dry up so what I noticed with this is this is about a 10 12 foot depth here this guy's jumped in something's about

12 to 15 deep so it's sort of interesting the the balls enos of these guys some guys are doing backflips out there there is water there so you know if you guys have a chance check it out

if you do happen to find it I'm not encouraging it excited I wanna get sued but if you want to take a jump off have fun all right thank you [Applause]

these are our prospective CDT trials it's a lot to go through them so I'm not going to suffice it to say that the only one of these that is randomized is the

one in the top left the ultimate trial with 59 patients the rest of these are single set are single arm studies the optimized trial was randomized but the key arm it did not have was a control arm so all it did was vary the amount of

drug but there was no control arm to tell us how are people doing if they just get heparin well and I'll show you one result from these trials that is the most important result and that is up from the ultimate trial at 24 hours CDT

catheter to thrombolysis reduces the RV to lv ratio to a greater extent than heparin alone what does that mean so you saw all those pictures with the big dilated right ventricles our surrogate measure for right ventricular

dysfunction is the ratio of the diameter the inner diameter of the right ventricle to the left ventricle what we found in this study was that that ratio got reduced to a greater extent at 24 hours in the CDT arm compared to heparin

alone that means that CDT seems to reduce our V dysfunction faster than heparin now importantly 30 days later the echos looked identical so really it's a question of time which is not surprising what we've noticed in

our practice is that patients feel better faster okay I'm gonna go through the rest of this because I'm out of time but I want to give you a little bit of a sense of where we're going because there's bleeding associated with CDT and

maybe I'll show you this that in the Seattle to trial there was an 11% major bleeding rate now this was a pretty conservative definition but there were some serious bleeds and there were no intracranial

hemorrhages in this study but we have realized that CDT is not risk-free it's not like we've all of a sudden gained all of the advantages of systemic thrombolytics and none of the disadvantages now the rate of

intracranial hemorrhage seems to be about tenfold less but it does happen about 0.2 to 0.4% of the time the rate of major bleeding seems to be about 5% which is about half the rate of major bleeding that we see with system or

thrombosis so bleeding is still there it just doesn't seem to be as frequent so that's where some of these other devices are coming in then our a float Reaver the the the extra penumbra indigo cat 8 device and so the the float Reaver is

has actually gone through the full trial and the results are about to be published what is this thing well it's this pretty big hose which is about 20 French and it goes through the right heart and goes up there and it takes

this clot and literally aspirates it out and these are some of the things that will come out and that's sort of your post picture right there the data showed something similar to what we saw with the catheter directed thrombolysis

trials they had looked at 106 patients are vlv ratio was reduced again there's no comparator arm here so this is just the device on its own with a 3.8 percent adverse event rate and so now we're talking about mechanical devices that

don't use a clot-busting medication therefore you're gonna you can expect less bleeding but you're trading some of that off for a mechanical device that can cause injury to either myocardial structures or to the pulmonary artery so

that's something we have to be highly cognizant of as they're introduced into the market this is the penumbra cat 8 this is from Jim Benenati publication basically showing a couple things that's the separator that is the actual

catheter and that's the sheath back there so you've got poor profusion because of a clot in the inter lobar pulmonary artery and then at the end of it you have better perfusion for lung down there so we actually just completed

enrollment into the extract PE trial 120 sub massive PE patients the same efficacy endpoint you have to remember that has been established by the FDA as a way to get approval this is not the final

study nor should it be the final study when we evaluate these devices so to summarize sub massive PE what does the data not tell us CDT probably reduces the RV to LV ratio at 24 hours that is the main outcome that I want you

guys to remember from the ultimate trial it's associated you didn't see this data so don't worry about that we do see major bleeding and sometimes rarely but sometimes we see intracranial bleeding with CDT as well so what we're missing

from catheter directed thrombosis for sub massive PE is what are the clinical outcomes the RV to LV ratio is a surrogate outcome what about death what about clinical deterioration what about recurrent hospitalization what

about recurrent VTE how are people doing in the long term are they walking as well as they were before we don't know any of this none of the data right so far can tell us any of this information so where do we go from here for sub

possible even though the you know strictures actually most likely are related to the malignant frequently in large centers like the Asura actually we see more benign strictures and malignant

strictures mainly because of the post-operative and perioperative complications so strictly speaking the incidence of reduced riches is actually flipped sometimes though we do actually have to help and some more patients now

particularly in the GI Sims I think in the ten last ten years GI now places metal stents almost routinely there's almost there are people still placing skinny in those things are two plastic calibers things

but the advent of retrievable removable metal stents has really changed and so now we will place dancing much frequently in that the wall stent is actually the pre derivative of the wall flex which is the Justin that can be

removed it's got a little barb that removes it and it's what they will do is retrograde put these up and then six weeks later or even up to nine months go in and retrieve it and pull them out completely so they certainly and the

number of build with stains placement in G and IR is reduced somewhat because how aggressive gr has become but certainly will place these and particularly patients who are in the palliative stages of care and although these

applications we've used in many other ways so your goal is to get the same team this just happens to be a patient with unresectable head of pancreas cancer you can see the obstruction in the distal CBD just below the cystic

duct there's non pacified area you can see on the calendar gram as well as the celiac artery gram you can see how the portal vein sensor strictures of his patients unresectable will go in there in place

that metal stent you first place your guide why follow that up with a stent that cross bridges from open to open and open this up and we use stands between eight and ten millimeters in diameter and nowadays even covering the

cystic duct is not such a big deal and nowadays cupboards things are probably more in favor now even though the data the data actually doesn't support covering over uncovered and the data for both is actually extremely marked be

similar and it's not compelling and because of the price difference I think visit again a probably a swing back to I'm not standing every CPD stains with covered stands but no question at least from operators point of view in my point

of view it makes whole wholehearted sense to allow the tumor no interest disease to grow through but yet the outcome is still not clear that it's a favorable and cost-effective to do covered stains entirely and we actually

will place up to three drains sometimes you have these complex cancer patients with multiple strictures where almost all the segments are excluding in a extremely sick or they need their bilirubin's to come down for four to be

eligible for cut medical oncology chemotherapy and this is the selling of metastatic colorectal cancer and so that will put three up to three tubes in the right lobe before will give up and say that there's not much more decompression

we can achieve so four tiers is that probably the maximum will place in for multiple site so like I said you know malignant brutally strictures and this data and I'm not going to because it's sort of a moving target

when Gore came with the first covered stand purely because of the fabric that they have gore-tex like what's under jacket and clothing and was interesting it's one of the most improbable fabrics and the reasons why Bill Lewis stands

accrued is not so much that it's overgrowth of tumor but the in growth of bio and in growth of bacteria actually will cause a non-covered stain suit include earlier so the advent of gore and making a stent that made a big

difference and it's covered same it does to change quickly the ease at which patients could be stent in the new system so when they came on the market was really helpful and there's just example of how you can go from occlusion

all the way to having natural passage about now back into the small bar and the utility and the importance of bile salts power fluid in your GI tract is critical for absorption in almost all your metabolic

function so having this drain out externally is really not advisable so getting a natural pathway flow of bio into the GI system is extremely important but I believe strictures and

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

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

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

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

another device that's new in the market

is the inari device it is a combi combination of suction thrombectomy and mechanical thrombectomy and it you can see it looks like three Amplatz or plugs on a catheter but that blue catheter is actually a very nice suction system as

well so you can go beyond the clot pull it in and then suck it into the catheter this is very useful because you can pull clot out without giving any TPA and you have a lot less blood loss so if you can take the clot out with a lot less blood

loss I think you can out patients again the benefit is that there's no thrombolytic and the patients have less bleeding drawbacks like many of these devices is there's really no studies to prove that they work we can prove that

they can remove clot from the patient's body but that we don't know that that actually helps in the long run so what we really want to know in all the studies which we're actually going to show three of the main studies is

whether this actually helps patients life in the long term do they does it improve their mortality so the first

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