Treatment | Arterial Complications After Liver Transplantation
Treatment | Arterial Complications After Liver Transplantation
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usually by coiling stent grafts the rights by the book textbook is surgical bypass extra anatomical by pat's with

something that is native vein or artery and not a gore-tex graft for example that's the that's the best thing also another surgical equivalence is actually just ligate the artery that's also a very comforting thought going into doing

an embolization because if you're if one of the alternative is just a light gate the artery then you can just screw up the artery as you like right and just embolize it completely or let its pazzo from bos but anyway that is one of

that's actually one of the alternatives and sometimes we go into these cases and all we see is just an artery bleeding into the perineum we don't see anything else and we just coil that artery it's the alternatives or the ligation until

they mobilize and they do the bypass if they want okay so this is another

think we can do this and T car is the new term that it's been used for trans

carotid artery revascularization or some of you may know it as the Silk Road procedure and that's what I want to talk a little bit about so the proof of concept is in it has been long in the making

even though this is relatively new so can you do flow reversal and decrease your stroke risk and all of these very small studies look at the major and minor strokes extremely low compared to anything in the literature so it works

flow reversal work so if you can make flow in the internal carotid artery go backwards while you're intervening on a lesion that's the best flow reversal that you can have short of putting a plant on the carotid artery and yours

the t'car procedure as we now know it so you can barely see this little incision but you make a small incision at the base of the neck you can clearly do it under local anesthesia and you establish basically an arteriovenous

fistula so if here's the carotid artery arterial sheep here's a femoral vein sheath and obviously arterial to venous flow this is the direction it's going to go there is a little flow controller and you can

control the flow rates and there's a filter in here that will catch any ambala debris that comes out so what are the advantages of the procedure clearly you can establish symbolic protection before you cross the lesion

so if you remember the list of steps that create ambala crisc it's you have to get your filter through the lesion before you're actually protected here you have protection before you actually cross the lesion and you create flow

reversal or surgical back leading as we can think about that if you just put a clamp on the common carotid artery and open up the carotid artery you'll have flow reversal down the internal and here i think is probably the biggest piece of

this whole puzzle is avoiding the aortic arch and especially as we get to older folks that number that i showed you once you get to 75 or 80 the arches become more difficult more angulated more calcified and are clearly a stroke risk

This is just a little picture of the arterial sheath here for the device. So advantages again established embolic protection before you cross the lesion. Here is another really pictorial of what happens with embolic risk again looking

at TCD data. So placing the sheath there's essentially no risk there. The wire hardly has any risk. But as you go up here with predilataion stent placement and post dilatation you clearly have embolic risk before you

have before you've crossed the lesion with your regular transfemoral stent. But with the TCAR you really establish flow reversal. Again here's your endarterectomy but a couple of things that you actually avoid. There is no

filter so is no vasospasm. So those of you that have seen transfermoral carotid stent procedures with a embolic protection device vasospasm clearly happens. And if you get enough stagnation flow you can

clearly get thrombus above your filter which is even an bigger problem. DW-MRI has been performed on a lot of patients with TCAR and the percentage of new lesions seen in TCAR versus CAS vs CEA are clearly favorable

for theTCAR patients as opposed to the transfermoral stent patient. And in case you if you're keeping up with this literature there is clearly evidence now that neurocognitive decline is associated with some of these

asymptomatic new DW-MRI hits. So what happens here. Can we really prove this so these are a list of studies and cut to the chase here this is a endarterectomy trial or the endarterectomy arm of a stent trial I should say. The percent of

patients that had new DW-MRI lesions 17%. This is transfemoral stenting look at the numbers there. This is transfemoral with proximal occlusion the MoMA device that big device that I showed you. It's kind of intermediate here

because getting that device in is an issue. And then here is the initial TCAR trial proof and we are in surgical were in the surgical realm with the number of new hits that we're seeing. So clearly it works. Avoiding the arch is

the issue and if you look at predictors of cognitive decline in stent vs endarterectomy there's a big statistically significant difference here. And again predictors of cognitive decline seen in another

pictorial. So should all patients be

and this is another patient and that things occurred kind of in a similar way this patient had end-stage liver disease

so she was the shoot regular pathak and you know these are the patients who why when we know we've been able to make pretty significant changes to our complication rates just by their kind of self-selecting patient population and

you know to that end how many how many people here are using anesthesia pretty consistently for four cases ok kind of here in there for everybody because that's all I think you're kind of losing down there but you know

unfortunately for us you know they were they were very very helpful in that you know they made a really a very reasonable argument and kind of change some of our practice policies that arm you know for for patients who you know

have the relatively short neck you know pretty significant sleep apnea morbidly obese everything else like that yeah we were there a lot quicker to contact anesthesia we kind of use that same argument with our with our

colleagues a DIC use it on the floors you know the patient has end-stage liver disease and kidney disease and they're going to go have a wagon opportunities you know instead of you guys doing those procedures send them down to us because

things just turn out kind of quickly and this is the CTA that you know that actually shows some pretty significant fluid here kind of the perineum and little bit more another kind of fun finding a kind of

getting back to our discussion earlier days anybody see anything also click really kind of a normal picture this you know this is the kidney here it's like screaming hyper again the patient actually had a cardiac

catheterization you have 30 just about 30 hours of prior and they're created because of the blood loss because of all kind of fluid ship their reaction was you know kind of getting high and at the outcomes that the outside hospital they

essentially this kind of dosing with korea toasting with the contract again and for us you know for fruit that to demonstrate the bleed but unfortunately the they hadn't even kind of clear that they previously had you can kind of see

that by this this kidney here just being way too down and you're just a little bit more and more fluid down here and fluid and there and there's are fighting right there he kind of catch you could kind of catch the bleep kind of coming

right off there they had a unfortunate kind of tried to perform a tourist in pieces in paris in pieces and bad things kind of happened could be kind of like one and then the other and the patient kind of blood for both and we're kinda

never we were kind of left holding the bag and here's here's a handy Graham right here we actually kinda had to perform a little bit of connect to different things but he kind of the autograph right here is a one-bar branch

kind of coming out right down here and then you catch the bleed kind of a kind of all the way out here there's just a little bit more of a persistent blush i hope its kind of projecting well enough another picture of it and it is again

and here's a kind of post future picture you can kind of catch the coil maps right there we we had to embolize that branch but unfortunately because of the the degree of zone distension this patient was actually developing an

abdominal compartment for your own so we want and we went ahead and place the catheter just to start to be compressed unfortunately grateful for this case we actually had a different patient who had had pretty significant ascites a similar

situation had pretty bad of abdominal compartment syndrome with a retroperitoneal bleed instead of an introvert nobly and because the Department of is that the pressure was so 10 the patient actually had to come

back to us on two different occasions and we were just symbolizes lumbar vessels because they were just kind of popping off the aorta from the level of pressure in the admin so well we just kind of when this one came around I just

prophylactically put it put a tube in just to kind of decompressed here it is again ok here's a here's

an example where we actually testing

things out trying to figure things out we actually put two captures a balloon occlusion capture and a diagnostic capture this is the angiogram here with slow flow in the paddock artery see that and then we actually do it balloon

occlusion test okay with the cancer adjacent to it and this is what you see so there's a test balloon occlusion before we commit to angioplasty and stenting with the doppler all sounds as well just to take a look at it

and so once it looks this is all research once it looks normal the portal vein actually slows down which is another intention is to slow down the portal vein we actually commit with putting quills and and plugs in this

kind of your posts your post results notice that the spleen is alive and well because it's actually reconstituted distally with a very large left gastric left gastric artery and that's why we embolize proximally we do not embolize

this lee we do not embolize particles this is not hyper spun ism for us to do particle embolization this is what you need is to impede flow you don't want to kill the spleen you don't want to reduce the spleen you all you tryna to is

impede flow cut that circulation that cycle so you can actually reverse that blood back to the back to deliver now in theory are you just stopping the splenic artery and diverting blood back to the liver based on the splenic field theory

or are you slowing down the portal vein and so you trying to reduce that kind of and trying to increase the category that's all theory based on the aetiology but either way breaking the cycle is the key thing to actually improve hip

adequate Irial flow whether it's a direct response or a or a reflex response to reduce portal vein I'm going

So let's look at some images related to trouble with access. So for many people

their first cases is their first exposure to flow diversion are going to be their toughest cases. And these giant cavernous aneurysms are routinely and reliably our toughest cases. We have an inflow here

this big sack where coils and wires and catheters just flopping around. And then somewhere in this nebulous region is the outflow. So you have to fish your wires around to find an outflow which is oftentimes stenotic. So it can be an

incredibly labor-some task. Can take hours. I've had several cases that the operator was unable to get the outflow and had to abandon or abort the case because of this. So this access can be an enormous issue. Here we'd spent several

hours trying to get a wire across this sac into that outflow. We were unable to do so...could never get it to engage. So we took a large compliant balloon inflated the balloon in one catheter in the aneurysm sac to help kind of pin and

deflect the wire and then we're able to deflect the wire around the catheter get it into the outflow and then track microcatheter over it. There we are with the microcatheter out of the MCA branch so internal carotid

anterior cerebral middle cerebral artery. We have a catheter tip out here. So here's another example of a giant cavernous aneurysm with a very technically challenging access. We were able to get the wire out but we were

never able to get the catheter to track over the wire into the outflow tract of the aneruysm. So in here we actually took a balloon over the wire inflated the balloon in the distal outflow and then use that the pin the wire so

that we could then track the catheter over it. Once we've got the catheter in place then we can pull back to reduce the redundancy of the catheter in the aneurysm sac to give us that straight shot.

So obviously some concern about inflating the balloon and the vessel and using that as an anchor. Obviously opportunities for parallel there. So here's another giant cavernous aneurysm. Here lateral view cavernous aneurysm

middle cerebral artery branches. So here we are after we've deployed the device we've removed the device construct. So the when you deploy this device you unsheath it over a wire and then you track the

microcatheter over the wire through the stent over the wire to recapture that distal wire. And that's how you keep your microcatheter access. The microcatheter is 0.27 so a pretty big microcatheter. The wire that stent

deploys over is 0.08. So much much much smaller than the catheter. So it is very technically difficult sometimes to get that catheter to track over that wire. If you don't...if you can't get that catheter to track of that wire you

lose access. Which can be a big deal and this is an example why that's a big deal. I don't...can you guys see that. So there's a device here that goes from here to here. There's a device that goes from here to here. Unfortunately what it

looked like in the beginning was a device that went from here to here. So this portion was the inflow of the aneurysm when we removed this distal wire in the catheter this proximal portion herniated into the aneurysm sac.

So now we have a stent that goes from here to somewhere in here in the middle of this giant aneurysm with no connection to the inflow and no ability for us to access that stent from the inflow. So this is an example of how

we're talking about needing to go from somewhere else. This patient had an intact anterior communicating artery. We went from a...we put another puncture in the left leg went up with another catheter into the right internal carotid artery.

Put a microcatheter in the internal carotid artery anterior cerebral artery across the anterior communicating artery in this anterior cerebral artery down this internal carotid artery. Put a wire into

the aneurysm sac through that stent so now you have a wire through that stent into the aneurysm sac coiled up. And then we went with a loop snare. So now we have a microcatheter with the loop snare we've snared that wire so we have a catheter

with the snare attached to a wire that comes out this. And we call this the flossing technique. So by combining a pull push technique we're able to jimmy that catheter over that wire... whoops...into so now we've

straightened the system out and then now we have that wire. We removed... we've taken out the snare. We removed this wire and we placed a wire out this MCA. Now you'll notice one of the other things techniques that we use is that

this 0.27 catheter can house two microwires. So we have a 0.14 and 0.10 wire out for extra support so this catheter will track out. We get into the MCA and then now our device is being deployed. And that's what it looks

like again. So now we have one device two devices much more redundancy here much better coverage of the inflow and that's what the aneurysm looks like at the end of the case. So deployment...this is a self-expanding

stent it's very supple. It's is very soft it takes turns very well and opposed walls very well. But the downside of that is that it doesn't have a strong impetus to open. So we see flattening we see narrowing of the stent. So it is entirely

possible to have a device like this that goes from here to here where the midsection is severely narrowed. Now when you do an angiogram at the end of this procedure the vessel is going to look fine. But what we know is that when you

bring that patient back in six months the vessel is going to look like the stent. So we have to do something to make this stent more open or the patient's going to have a severe stenosis when we follow them up. So in this case we've

gone back through that device with a balloon...a compliant balloon...and you can see the compliant balloon opens up. We still...after this can see still significant residual stenosis. So another example of issues related

to deployment. This is a middle cerebral artery bifurcation aneurysm here. You can see on the CAT scan image a enormous calcified largely thrombosed aneurysm. So that the lumen of the aneurysm is actually a very small part of the actual aneurysm

itself. What we know about this is with coiling...when we coil aneurysms like this they very commonly recur. Almost all of them recur because the coils just insinuate into the clot it regrows you recoil them and that happens over

and over and over again. So there was...a decision was made it to Pipeline this case. You can see the device being deployed. So here's that distal wire. Here's the device unsheathed and here's the catheter here. When we got to

the end you can see that the device doesn't want to open on the proximal end. And so we have the device open and here we are right here the device is pinched down where the catheter is. So multiple attempts to get that distal....that proximal

end open didn't work. Catheter was...the wire wasn't moving. There was no way to get this device open. It was elected to leave the device like that. This is what the initial run after removal of the wire looked like. You can see

maybe a little bit of clot. We waited over time and  you can see over time the inside of that device completely clotted. So it's very important that even if the initial imaging looks ok with these devices if the device doesn't look right

something down the road is going to happen. And this is a prime example of that. So the vessel thrombosed. Over time you can see complete thrombosis of the MCA trunk related to the vessel. This is what the MCA look like. So this is the anterior

cerebral artery which continues to fill. This is the middle cerebral artery where you can see a large portion of the exception of this branch here is absent. That patient obviously did not do well. And then this is what we're talking about with

recapture. So when we take our microcatheter which is right here through our device we take that over an O.08 wire. So there is a a big step off between the catheter and the wire. So when you push you can scrape the vessel wall

and if you push too hard you can puncture the vessel wall. So this... this case in an attempted to pass the catheter into the device there was a significant amount of resistance met at the proximal margin of the stent. The

vessel ruptured and this patient being treated for cavernous aneurysm ended up with a CC fistula. So this is a basilar artery here.... basilar artery apex aneurysm. Previous coil material in here recurrence of the

aneurysm. The decision was made to flow divert this. Again an off-label use of the device. You can see deployment of the device across the neck of the aneurysm. But when we removed the wire the distal end of the wire was not with it. So the

distal end of this wire had broken off. This was more common with the first generation we don't see it as much anymore. But you can see's a native image flow diverter in place we now have a microcatheter with a loop

snare. Here's a lateral view you can see the loop snare engaging the wire tip and removing it. This is a patient who wasn't as fortunate. So here the catheter engages this wire...

so here's your catheter tip here's the wire they were never able to get the wire quilted into the got kind of stuck or lodged at the tip of the catheter so they decided just to remove the whole thing in total.

And as they pulled the wire back through the here's your stent here in the cavernous internal carotid they pull the stent through here the wire broke they pull the wire the wire broke off. The

wire was stuck in the stent. Here they are trying to remove the device...the distal wire with a alligator snare. You can see they've engaged it with the alligator but the alligator was too flimsy to pull it and it kept breaking off.

So they elected just to leave it. And you can see the immediate post-procedure run with the wire remaining in along the wall of the stent. And when they brought the patient back in six months the aneurysm was gone and the wire was still there. So

there was no clinical sequelae of this despite the fact they had to leave the wire. So and then finally touch up. Once

devices and the term we use is flow diversion. And it's it's kind of a muddy terminology that we talk with flow diversion because flow diverters are stents. They're braided metal mesh tubes

just like any other stent we use. But they don't do the things that most other stents do. They act to some degree as a covered stent but as you can imagine in the brain with the brains tortuosity covered stents are way too stiff. And because

of all the perforator branches that come off all the vessels in the brain any covered stent that's placed there has about a hundred percent risk of perforator stroke. So we had to be very creative about the technology that we developed.

The flow diverters work in two different ways. The reason we don't use the word stent apparently is because the FDA or CMS won't reimburse for the use of stents in treating aneurysms. So we've muddied up the terminology when in

reality these are really just self-expanding stents that their major property of the stent is flow diversion. And so the stent does one of two things. I'm going to use the term stent to recognize that that's not an

approved term used with this device. But that's what it is so I'm going to call it a stent. So flow diversion. So the idea is that you have enough metal mesh covering the opening of the aneurysm that blood can't get through

those cells into the aneurysm and it diverts flow away from the aneurysm. And enough flow is diverted that the aneurysm doesn't shut down right away... you don't want to shut down right away... it shuts down slowly over time. And so we

look at outcomes from aneurysms at three months or six months or a year when we're talking about outcomes from this aneurysm. But there is not an expectation that this aneurysm is going to be completely gone when you finish.

And that's a paradigm change for doctors that treat aneurysms because with coil technology you want that aneurysm to be gone when you finish coiling it. And so little bit of a change there but flow diversion is the major property. And then

over time that tightly woven stent acts as a scaffolding for re- endothelialization of the blood vessel. The lining of the blood vessel growth through and over the stent and over time between the flow

diversion which causes aneurysm thrombosis and the re-endothelialization of the stent we can actually cure aneurysms. And it's actually pretty cool technology. So the indications for flow diversion...this is very important we won't be talking

about any off-label use of this device although recognize that a significant amount of the aneurysm that we are currently treating with flow diversion are done off-label because the on label uses a very small one...and

that is adults with large or wide large or giant wideneck that's 10 millimeters or greater....with a neck that's four millimeters or greater in the segment of the internal carotid artery that goes from the petrous segment

to the superior hypophyseal segment. Those of you who are estute enough to notice the superior hypophyseal segment's actually not a segment it is a the last...the super hypophyseal artery is the last artery comes off the ophthalmic segments of the

internal carotid artery. But the segment is the petrous carotid artery to superior ophthalmic or the superior hypophyseal artery. So that means posterior communicating arteries carotid terminus AComs MCAs...the majority of the aneurysms

that we see are excluded from the on label use of this device. It's contraindicated in patients that are have infections. Importantly is contraindicated in patients who and whom dual antiplatelet therapy is either

contraindicated or not tolerated. So we consider people who have ruptured brain aneurysms people who cannot currently tolerate antiplatelet therapy. So if you treat a ruptured aneurysm with a Pipeline or flow diverter you're

treating them off label. And then patients who haven't received anti platelet therapy or people who have pre-existing stents. So people who have already had a stent assisted coil in the past are not on label candidates for

Pipeline. So it's a very small patient population statistically compared to the number of aneurysms that we see. But that's the on label use of the device. So the Pipeline device...again the one that we have available to us in the United States...

it's a braided bimetallic stent it's twenty-five percent platinum seventy-five percent chromium cobalt. The 25-percent that's platinum is a 25-percent you see. So when I show you these images

things that you see are the Platinum. So one out of every four strands you see. Interestingly enough this actually isn't completely accurate there is about 5% nickel. So patients with nickel allergies who are smart enough to read about this

device will find out that there's a potential that they have adverse reactions related to this device. I've had a couple patients with nickel allergies and have not had problems with the device. The Pipeline is 48 strands

some of the newer devices that we're looking at like the Surpass are higher strand densities. The Pipeline gives about thirty to thirty-five percent surface coverage over the opening of aneurysm and they have very very small

holes. If you look at in a real-life it looks like a little piece of rolled screen. Very flexible very as you can see here it takes turns and curves in a very flexible fashion. This is an older

generation but it's a self-expanding stent that's constrained. The newer generation does not have this little coil that constrains the device and it's just like any other self-expanding stent it's opened through unsheathing. It can be

deployed through an 0.027 catheter. So very small catheter....much smaller catheters than any of the cervical self-expanding stents. Similar in size of the catheters that we use for other intracranial stands like the Neuroform

the Enterprise and Elvis. And that's all we're going to talk about with the specifics. Now let's start looking at

about stenting. this is the third time here

look that's a third restenosis so talked about stenting stenting is not is not good this is a stricture right at the right at the anastomosis so the problem with stenting on the turn is that when you put the stent in it propagates so he

deploys stent like that and a vessel that's really floating the angulation redundancy actually propagates around us and then you jail the stance and then you then you then you're in a lot of trouble okay because you can't get

around and get into the stents anymore so you have to be very careful in putting any any stents in a sharp turn in a hepatic artery if you're forced to do that the best thing is to put a self-expanding stent and to buttress the

artery itself and then put a balloon expandable inside of it just to to take that curve and try to straighten out that curve instead of putting a short balloon expandable standard just jails and the redundancy just

basically curls around the stent like i drew it out initially hepatic artery thrombosis usually seen

catheter we use it just happens to be AngioDynamic's version you know I don't there are several companies that make this I just happen to have this on the shelf which is why I took the picture of it

and again that's the picture what it looks like and our target for the microcatheter is probably going to be going to get over here I probably usually get the microcatheter back down to about here now if I only

got two here I suppose that would be fine i would really be reluctant to embolize if I was at this level where I'd have to be extremely careful getting around this curve and getting down into here somewhere is probably where you really

want to be I think and we're going to use particulate embolics you're going to may have to force the material not force it but injected positively it is Bob made the point yesterday he like's to get a free-flow embolisation which I agree with

unfortunately don't always get a free flow embolization the ovarian artery you think the uterine arteries are subject to spasm the ovarian arteries are unbelievable you don't want to go through that sort of you know curved

segment down and try to get passed the ovary you know I once saw Dave he's a good friend I you know yeah I always go down passed the ovary that way I don't have to worry about the ovary I said how the heck do you do that

He said I don't have any problem doing it so I was visiting him when he started telling me all this he went in to do a case and he spent like two and a half hours trying to get down that overian.. you know and he came out and said maybe you're right it's like anyway

some people use a nitroglycerine I tend not to use nitroglycerine mostly because it requires someone to go and find it and get it all mixed up not so but using nitroglycerine is okay but you're going to use particle embolics and I don't

think i ever my entire life have used more than one container on a side and usually it's half a container of embospheres or embozene and whatever it is you're using use PVA you can even use the gel-foam slurry although i kinda like the idea of

particles because you can get them to float in a free-flowing embolization you can get them to go down and they will go to the fibroids and what you want to do is kind of go until you don't see the uterus anymore and once you don't see

the uterus anymore you don't need anymore as long as you have a stable endpoint and you know oftentimes you'll still see some branches going to do the ovary but you just want to prune off those branches down distally you do not need

to occlude the entire ovarian artery ok so inferior mesenteric supply kind of

big light bulb in the middle of the abdomen and that's basically anastomotic

pseudoaneurysm that is a that is basically you know a bomb waiting to go off so you have to fix that and the best way to treat it by the book is because it's infected is a surgical as a surgical bypass extra anatomical okay

it's basically an aortal hepatic conduits and you don't do an end to end because that whole hilum is infected so you do it you to a conduits from from the aorta to the to deliver and it's usually you cannot use a graph it has to

be something native is it a vein or a vein or artery ms your typical class book textbook exam answer extra anatomic bypass in the real world we would temporize this with a sink raft or or with or with coils they're not

uncommonly associated with a paddock artery stenosis by the way

Here's a 51 year old female, left hip pain, instantly found to have

bilateral common iliac aneurysms on CT. This is it. She's young, now has this new diagnosis. This is what it looks like isolated to the iliacs, fairly torturous though, a little kinking in that left common iliac that's fairly severe,

almost a 180 degree kink, some ectasia with the abdominal aorta and these are the measurements of the iliac arteries. The question is what do you do? Maybe you should ask first do you even treat, how do you treat if

you and do, and do you do one side, do you do both? And we'll tell you that this patient gained a significant amount of anxiety related to this and just by the diagnosis itself even despite trying to what potentially the size may mean, so maybe

ask the panel, would you guys treat any of these, one of them or none? >> You treat both if you have to, the one is three, that size arteriole is a little bit smaller but yeah you treat them both, when you do it it's not an emergency but you do it now there's no point of surveilling or anything just treat

it. >> I agree, I think you treat, the question is young patient will surgery be okay and a good surgeon can do an aortobifem and do some bypasses to the internal iliac and I had some cases where just coiled to an internal and they did an aortobifem with a branch bypass with internal and looks great for young patient

or do an one of the crazy stuff you're gonna show us now, endovascular. I think both options are fine but I think if you have a surgeon, can do that I think we'll work fine. >> Yeah I think you should treat them both and kind of whether they're similar iliac branch but I would certainly consider using one of two.

>> Great points. We have a good relationship with our vascular surgeons, we've a survey of multi disciplinary conference, we've discussed these cases and the consensus amongst the group of vascular and interventional specialist was to treat this endovascularly and to treat both, so we did do that. We chose a staged approach to try to preserve one of the iliacs but embolize the other and that

was the plan here. So and there is some off label use, I'll explain that just a moment the first stage procedure was to embolize the left internal liac that was the set that had 180 degree kink of the common iliac artery. So we decided that was going to be the more difficult to preserve, so we went ahead and embolize that, an amplatzer plug used, very straight forward then two weeks later brought the patients

back and utilize this strategy. This is an older case, but one of our earlier cases of what I'm trying to illustrate of sandwich than grafting a technique and take it to more complex levels, but this is a utilization of the Endologix AFX,

[INAUDIBLE] bifurcated endograft, extending into both common iliacs and in the left side extending into the left external iliac that's the side that we've coilembolized the internal. And then land within the right and then go up and over because of the nature of the AFX device, cannulate the internal iliac,

place a sheath and then your self extending covered stent and then extend a limb from that side on the right and you have a sandwich procedure. These are the devices used, we use the [UNKNOWN] for our sandwich devices and this is the AFX as you can see it's seated on the

aortic bifurcation which allows you to then readily go up and over on this device as opposed to the other modular endographs that we use. So I'll show you some represntative images, the angiogram, you can see it goes quick but on the left side the amplatz plugged

there and we're going to continue to exclude that. These are select images of the aortogram, this is us placing the AFX device, it's in now, seated at the bifurcation, you can see the amplatz plug,

we then extended the limb on the left side so we've now excluded the left common iliac artery aneurysm. We're gonna do some work now to cannulate the right side, here's another angiogram. Select image. Now we are gonna go up an over.

Now because we are seated on the aortic bifurcation you can see, you have a nice view of the iliac bifurcation and we can go up and over as we've done here. You can if you have difficulty with gaining sheath access up and over you can take a second wire and snare it through your contralateral access on the right side and help support

your sheath positioning into that common iliac arteries stent or common iliac portion of the effect stent. We didn't need to do that. There is enough wire purchased within the common iliac artery. And as you can see here the sheath on the contralateral or ipsilateral side. This is the sheath normally would have a position a little bit further but

had this viabahn positioned into the main portion or the main trunk of the internal iliac artery trying to preserve as many branches as possible. Depending on the length ten centimeter may be too long, cuz in general we want the proximal end or the trailling end of the viabahn to be at the bifurcation area.

We don't really want it trailing up too far into the abdominal aorta, I like to keep it close to the level of the common iliac, the new common iliac so to speak. In this case we had to bridge two viabahns because ten was too long

and seven and a halfs were not available, those are now available. And you can see the viabahn position here, balloon dilated little bit out of order than what we may typically do now, but you can see now the viabahn in position here, the extension on the external iliac of the limb extension into the external iliac there.

Balloon dilating that, this would in theory crush the other viabahn but then you can post dilate that cuz you leave your balloon in position, as well as the bridging portion, this was two stents. And then you continue to maintain your wire access and take your distal seal zone like you would otherwise, and now you can see the

configuration, you have your AFX device extended into the external iliac on the left, extended into the external on the right but the viabahn positioned within the internal sandwich to the level of the origin of that new right common iliac artery. And here's your angiogram and you can see you have now preservation of this exclusion and on follow up imaging no endoleak,

she's done quite well. So this is a companion case and I think I just wanted to illustrate some basic concepts that I think you'll see in potentially more complex to come but Robin earlier mentioned that maybe an iliac branch device and that's,

now recently I think in the past two weeks, was FDA approved. So this device is one that we are on trial for and this is a companion case of the essentially isolated iliac aneurysms much larger. I think there's no question for treatment here, it's 5.4 centimeters,

you can run this [BLANK_AUDIO] Patient's CT you can see essentially isolated to the iliac arteries [BLANK_AUDIO] internal- >> Patient's coming in to Wisconsin, is that what happens?

>> We see a lot of iliac artery images. >> She's related disease? >> Maybe, she's [INAUDIBLE] [LAUGH]. So we took the approach of this device, now this is an FDA approved device intended for preservation of the internal iliac artery.

So this is the main body gore excluded that you're used to, this is a bridging component, and this is the component that lies within the common iliac portion, this whole portion, the main body to this

flow divider lies within the common iliac of the side you choose to preserve and you come up and over and cannulate the internal iliac. There's wire component that helps allow you for a precannulation of this device. Extend your wire into the internal iliac and then advance this bridging or extension piece which is larger here to allow

for docking and place that within the internal iliac artery and so this is the select images from the procedure, this is the iliac branch device positioned at the common iliac, making sure that the gate, so to speak for this iliac device is positioned above the iliac bifurcation. That's the same marker that you should see on the main

body device, it's deployed, that's precannulated you can then take with wire support, or sheath up and over, you can see that sheath now here positioned right at the iliac gate extending that docking limb within the internal iliac artery,

post dilating that. [BLANK_AUDIO] Then you continue with the remainder of essentially your excluded case, bridging and docking your main body that you've positioned, traditional fashion with the iliac excluder main body device, and exclude otherwise and you then have preservation with an FDA

approved device which is not, unlike the sort of plan for the sandwich, although that's awfully what we use of off the shelf devices that are readily available. This is followup imaging, in the same patient.

[BLANK_AUDIO] You can see exclusion of the iliac artery anurysms and preservation of the internal iliacs with the iliac branch device. It's nice system, it takes specific anatomy for this work but as long as you have a landing zone withing the internal iliac artery, I think it's a nice solution for patients where the concern for a bilateral internal

iliac embolization maybe. Certainly there've been cases of patients having that done without significant sequela but it is not without some risk of complications. >> Just quickly about the precannulated gate and explain how that works, where do you get that?

>> The cannula is outside the body so then there's a cannulated segment within that, sort of the gate of the iliac branch device that you can then pre wire and then you can advance that. >> But you do it from the other side from up and over, is that what you do? >> Then you take that wire and you can then grab that and go up and over.

>> Do you snare? >> Yes. >> Okay. >> You can snare. >> Those are great cases and I think you know that certainly in terms of expediency and so forth,

coil and covering one hypo I think is pretty safe and pretty standard. Another way of treating those just for purposes of discussion would be even with just with off the shelf kind of thing, just to come from the arm into branched, into both hypos and sort of the same parallel

thing just from the arm. It is nice for us in US at least to finally have some of these little bit more advanced devices starting to trickle through and getting approved, but there are other, we can do some little bit more standard, typical, off label parallel grafting

with routine devices. >> I had a very similar case with the first case you presented and the so called double D technique, where the sandwich would be endologics AFX device and to my surprise I was worried about the internal iliac to actually the

patency of it but the patient came back actually ten days later with the stent in their external iliac thrombosed. And actually the internal iliac, so the iliac limb of the AFX, that extension was crushed by the viabahn that went into the internal iliac artery, which

was very unusual. I don't know, maybe we just went and did a thrombectomy and cleaned that up, and that was a very unusual outcome that I had but, I don't know. I've talked to a lot of people and they thought that they see that internal, but in that case, I don't know if it had something to do with sizing

or some other aspects of it but that was somewhat surprising. >> Sizing might be part of, the other thing is I just, and this is personal bias I like their graft itself, I don't like their limbs and so whenever we do an endologix AFX type case and we have to extend on one side or

the other for whatever reason, I tend to chose another vendor's whether it be medtronic or the spirals limbs or gore limbs or something, I have a personal little bit of a bias against their limbs, I like this device, the main body device,

I just don't like their limbs. >> I agree. Some basic tenants, so if you take that concept of the hypogastric preservation with a sandwich or parallel grafting technique you can extend that to the visual vessels and or renals not unlike the chimney but slightly taking it to a different level if you're going

to involve SMA and or celiac. But you need proximal and distal landing zones, you need some kind of seal zone for your aorta wherever that treatment segment may be, you'll ultimately catheter then wire, sheath and ultimately position a stent within your target vessels, all of them each before you place your endograft.

And then you position your endograft with sufficient overlap and sufficient overlap means it's gonna be initially sized to the aorta where you plan to seal proximally with enough overlap. And generally we found when we were doing sandwich or parallel grafting technique the more overlap with the viabahns,

now we're talking about a concept going in the renals, and or the SMA and preserving that, that's extending into the proximal descending thoracic aorta. At least five centimeters or so, longer overlap of that viabahn extending up, placing the abdominal endograft at

that level approximately one centimeter below the top of the viabahn. These are our rules of thumb so to speak or tips with regards to what we choose to use, I think we've had a discussion about what we like for our chimneys and our visceral stent graphs and it's self exanding so that really only leaves the viabahn as the option, fairly conformable. Apparently I have reasonable radial force to exclude a limb, which I haven't

seen before but I think they're visible enough and they have enough length and size options available, recently the seven a half centimeter length options have now become available to us in the US which is fairly handy because it can eliminate adding an additional device. In general the target vessel is

one millimeter larger is the size viabahn that you would use by diameter and at least two centimeters within the target vessel. Ideally preserve any distal branches or clearly in the SMA or in the renals you wanna preserve those if possible but generally we like to have at least two centimeters just in case that stent were to jump back so to speak, then again I already mentioned the

five centimeters of overlap with the abdominal endograft. And this is sort of a coiling of a case done for a thoracoabdominal aneurysm and you can see there's outside a cuff or a stent graft on the outside, these are the snorkels or the parallel grafts placed in the SMA in both renals and then the abdominal endograft from the outside.

And the longer segment of overlap that we have, the minimization we've seen of the concern for gutter leaks and endoleaks in these patients, this is the follow up CT scan in one such patient where a thoracoabdominal was treated by this manner. And you can see that's the proximal cuff, you can see the parallel grafts extending to their distal targets and you can see exclusion

of an aneurysm, in fact this was showing sac regression, I haven't shown you the pre-imaging but I wanted to show you the ability this technique can do to successfully exclude an aneurysm. of the things that I found with this device is that when you have finished putting the

device in about 25 to 50 percent of the time there's something else you need to do to make that device look better. We know that devices that don't oppose the perforator branches are going to

cause perforator strokes. We know that the vessel is going to look like the stent and six months. So if you have narrowing of the stent you need to get it to open so that there isn't flow limitation and that and also so that you

don't have blockage of perforated branches. I've seen a couple cases of people who didn't heed that advice and left the stent not well opposed at the level of the anterior choroidal artery and had anterior choroidal artery infarcts.

So the wall opposition is a very important component of this and so touch-up becomes an important part of our procedure. As you can see's a patient we put overlapping stents in for a giant cavernous aneurysm and

immediately after deployment of the second stent you see this little area of filling this is thrombus forming in the stent immediately post procedure. And we went back up with the microcatheter gave intra-arterial

Integrellin and started them on Integrity drip and you can see the clot dissolves right away. Here's that same patient at four months. Aneurysm's almost completely gone with a little tiny bit of the aneurysm

still feeling from the infralateral trunk. So here's another example of poor opposition. So here's your cavernous aneurysm...ophthalmic segment here...the you can see a wasting deformity at the level of the ophthalmic artery with poor filling

of this segment. And you can see this big sac pseudoaneurysm that the ophthalmic is coming off. So you don't want to leave that because if you leave it one of two things is going to happen. Either the aneurysm is gonna stay open because it's

going to continue to shunt through that vessel or that ophthalmic artery's going to shut down you can potentially have an ophthalmic artery stroke. And you can see why that was. So here here we do a CT...a Dyna CT which is this a CAT scan that we can

actually do on the interventional table. We do it with dilute contrast so we can see the vessels very well. And you can see this lays out the opposition of the device very well. So here we have one device and you can see

the inside the second device and there is a step off between the two. So there's significant overlap there. And you can see that again here. So we went back up with a balloon at that level inflated a compliant balloon which is a very safe

way to open up these devices...the devices aren't stiff devices and they open up very well even with compliant balloons and then we're done. You can see the lumen of the stent looks much better and we take the run. You can see that that

pseudoaneurysm outside of the vessel is not there in the ophthalmic arteries is connected or opposed to the stent and open. So those are the technical

of debated concepts within the world of flow diversion so all patients that receive flow diversion like most stents get dual antiplatelet therapy. There's a pretty...the majority of physicians that do this type of procedure test their

antiplatelets to make sure they work. So all you guys probably know that thirty percent of people don't...are sub-responders or non-responders to Plavix. Maybe five just ten percent of aspirin users are sub-therapeutic or

non-therapeutic responders. So we want to make sure that our patients are adequately antiplateletized. But there's a lot of discussion about how long you keep those patients on antiplatelets how aggressively test you for it. There's no

consensus on that right now. A big discussion about whether or not to use coils with this technology. As I've laid out earlier on this is a competitive technology to coil technology. Some people coiled it and if you're going to coil

them how much you coil them. Do you go ahead and coil the whole aneurysm. Do you just put a couple coils in for stasis. Do you not coil aneurysms because they're competitive technologies and you're adding potential complications of coil

technology and flow diversion technology together without a really strong understanding that you help out with the rupture risk. A big discussion about the number of devices that we use. So if you look at the worldwide literature

they're using one device. So if you can put 1 device in and treat an aneurysm people are putting in one device. If you look at the PUFs study which was done as our approval device they put in on average 3.1 devices. And there are a

couple reasons probably why they put in 3.1 devices. One is the one of their main points was complete aneurysm obliteration at six months. And I think they felt that they would get that more reliably with multiple devices. Second

the person that invented a device was one of the major primary investigators so maybe some secondary financial interest in having multiple devices used. But if you look at all the literature there is a pretty strong movement towards using

less devices it in the majority of cases. So more people using a single device rather multiple devices. And then a lot of discussion about all the catheters that we use to access. I use a tri-axial system which means I put my 6Fr sheath into the carotid artery and then I put an intermediate catheter into the intracranial internal carotid artery and then use a microcatheter deploy it. Many people use that technology although

certain people certainly use micro...or use guiding catheters don't you sheaths don't you tri-axial techniques. So there's a lot... a lot of wiggle room in how we use these devices. So this is an example that represents

this these clinical conundrums that we have. You can see here a giant cavernous... or a giant posterior communicating artery aneurysm you can see the posterior communicating artery coming out here. There's your aneurysm on a lateral view.

Here's device deployment you can see the distal wire here this is the device being unsheath. And here's tip of the microcatheter as it unsheathes it. Here's the intermediate catheter in the cavernous segment of the internal carotid artery.

Here's the device deployed or almost completely deployed you can see it opening very well. Here's the device...the post run after the device has been can see it's very well opposed throughout the vessel. There's a

microcatheter that was jailed can see this distribution of the jet of flow into the aneurysm sac. So a lot of stasis already. And then two coils were placed to promote...quote-unquote promote stasis in the aneurysm...on this

unruptured aneurysm. Patient woke up great. Did great. Went upstairs. Precipitously declined. Became comatose. Brought down emergency for a head CT and you can see the head CT here for any they're familiar with looking at

head CTs. All these areas that are filled with bright stuff should be filled with dark stuff which is CSF. All this bright stuff is blood so you can see this big round object here is the aneurysm. This is an external ventricular drain that has

been placed.... I'm sorry this is I think some of the stent...and then you can see diffuse subarachnoid hemorrhage. So the important thing here you can see here is your stent. Here's the aneurysm.

And that coil that was filling the aneurysm has now been squished and pushed back outside the aneurysm. So the whole coil mass was extruded. So the back wall of the aneurysm ripped open. Adam Arthur who's the endovascular

neurosurgeon in Memphis calls it the "fat man pants syndrome". So the aneurysm just split all the way along the back wall the entire coil mass was extruded from the aneurysm. This is not a survivable subarachnoid

hemorrhage. So you can see's the immediate post-procedure image with coils filling that aneurysm sac. And here's a CT image with the device here with this space here and coils squished back through the aneurysm into the

subarachnoid space. So to summarize

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