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Transcript

coding these are the codes that are used for radio frequency and laser some of

you have used this code for embolisation procedures in general that's not what you should use for this you can use an unlisted code currently but there's an update on coding which is this in october of last year the macp teak PCPD

committee gave mocha its own specific code and that's that's good RV use have have been a s4 in early in the december two thousand fifteen and sixteen by some of you may have participated in this giving some numbers

and the idea is a similar work should you get similar reimbursement so these are questions of the society some of you may have answered it and now in late 2016 CMS is going to give some type of value to it and the idea is probably by

January less than 10 months from now you're going to have a code that you can use and get reimbursed at least for the four local because it is a specific local done or greater than them then worldwide quality of life improves minimal complications as with all of these

- Mister Chairman, ladies and gentlemen. Good morning. I am excited to present some of the data on the new device here. These are my disclosure. There are opportunities to improve current TEVAR devices. One of that is to have a smaller device,

is a rapid deployment that is precise, and wider possibilities to have multiple size matrix to adapt to single patient anatomy. The Valiant device actually tried to meet all these unmet needs, and nowadays the Navion has been designed on the platform

of the Valiant Captivia device with a completely different solution. First of all, it's four French smaller than the Valiant Captivia, and now it's 18 French in outer diameter for the smallest sizes available.

The device has been redesigned with a shorter tip and longer length of the shaft to approach more proximal diseases, and the delivery system deploys the graft in one step that is very easy to accomplish and precise.

The fabric has been changed with nowadays the Navion having the multi-filament weave of the Endurant that already demonstrates conformability, flexibility, and long-term durability of the material. It's coming with a wide matrix of options available. In terms of length, up to 225 mm.

Diameters as small as 20 mm, and tapered device to treat particular anatomical needs. But probably the most important innovation is the possibility to have two proximal configuration options: the FreeFlo and the CoveredSeal.

Both tied to the tip of the device with the tip-capture mechanism that ensures proximal deployment of the graft that is very accurate. This graft is being under trial in a global trial

that included 100 patients all over the world. The first 87 patients have been submitted for primary endpoint analysis. 40% of the patients were females. High risk patients showed here by the ASA class III and IV. Most of the patients presented

with a fusiform or saccular aneurysm, and the baseline anatomy is quite typical for these kinds of patients, but most of the patients have the very tortuous indices, both at the level of the access artery tortuosity and the thoracic aorta tortuosity.

Three-fourths of the patients had been treated with a FreeFlo proximal end of the graft, while one-fourth with the CoveredSeal. Complete coverage of the left subclavian occurred in one-fifth of the patients. Almost all had been revascularized.

Procedure was quite short, less than one and half hour, percutaneous access in the majority of cases. There were no access or deployment failures in this series. And coming to the key clinical endpoints, there were two mortality reported out of 87 patients.

One was due to the retrograde type A dissection at day one, and one was not device related almost at the end of the first month. Secondary procedures were again two. One was in the case of retrograde type A dissection, and the second one in a patient

that had an arch rupture due to septicemia. Type 1a endoleak was reported in only one case, and it was felt to be no adverse event associated so was kept under surveillance without any intervention. Major Adverse Events occurred in 28% of the cases. Notably four patients had a stroke

that was mild and not disabling, regressing in two weeks. Only one case of spinal cord ischaemia that resolved by drainage and therapy in 20 days. In summary, we can say that the design enhancement of Valiant Navion improved upon current generation TEVAR.

Acute performance is quite encouraging: no access or deployment failure, low procedural and fluoro times, low rate of endoleaks, Major Adverse Events in the range expected for this procedure.

Nowadays the graft is USA FDA approved as well as in Europe CE mark. And of course we have to wait the five years results.

so I'm gonna talk about me and shoulder embolization I'll take out my phone here so I know the timer perfect and I will try and cover everything about knee and shoulder embolization as quickly as I can so why are we doing this is really what I'm going to talk about there are

two different disease processes and the knee we're talking about arthritis and in the shoulder I'm talking about frozen shoulder so these are my disclosures obviously you know knee knee osteoarthritis is a major problem it

affects more than 30 million people in the United States and there are more than a hundred thousand hospitalizations a year just from NSAID toxicity in this patient population who takes NSAIDs for pain of course and they end up with

things like GI bleeds there are more deaths just related to ends as the United States and there are more than four million knee injections performed annually in the

United States keep this in mind there are double-blind randomized placebo-controlled studies that show that knee injections don't work and yet there are four million every year okay so what's the rationale for genicular

artery embolisation so in the knee we always learned that knee arthritis is degenerative right there's no inflammation like rheumatoid arthritis but many years ago they discovered that there's actually an

underlying synovial inflammation that leads to an increase in these cytokines being released that leads to new blood

know we're running a bit short on time so I want to briefly just touch about

some techniques with comb beam CT which are very helpful to us there are a lot of reasons why you should use comb beam CT it gives us the the most extensive anatomic understanding of vascular territories and the implications for

that with oncology are extremely valuable because of things like margin like we discussed here's an example of a patient who had a high AF P and their bloodstream which tells us that they have a cancer in her liver we can't see

it on the CT there but if you do a cone beam CT it stands up quite nicely why because you're giving levels of contrast that if you were to give them through a peripheral IV it would be toxic to the patient but when you're infusing into a

segment the body tolerates at the problem so patient preparation anxa lysis is key you have them exhale above three seconds prior to that there's a lot of change to how we're doing this people who are introducing radial access

power injection anywhere from about 50 to even sometimes thirty to a hundred percent contrast depends on what phase you're imaging we have a Animoto power injector that allows us to slide what contrast concentration we like a lot of

times people just rely on 30% and do their whole the case with that some people do a hundred percent image quality this is what it looks like when someone's breathing this is very difficult to tell if there's complete

lesion enhancement so if you do your comb beam CT know it looks like this this is trying to coach the patient and try to get them to hold still and then this is the patient after coaching which looks like this so you can tell that you

have a missing portion of the lesion and you have to treat into another segment what about when you're doing an angio and you do a cone beam CT NIT looks like this this is what insufficient counts looks like on comb beam so when you see

these sort of Shell station lines that are going all over the screen you have to raise dose usually in larger patients but this is you know you either slow down the acquisition speed of your comb beam or

you raise dose this is what it looks like after we gave it a higher dose protocol it really changes everything those lines are still there but they're much smaller how do you know if you have enhancement or a narrow artifact you can

repeat with non-contrast CT and give the patient glucagon and you can find the small very these small arteries that pick off the left that commonly profuse the stomach the right gastric artery you can use your comb beam CT to find

non-target evaluation even when your angio doesn't suggest it so this is a patient they have recurrent HCC we didn't angio from here those arteries down there where those coils were looked funny even though the patient was

quote-unquote coiled off we did a comb beam CT and that little squiggly C shape structures that duodenum that's contrast going in it this would be probably a lethal event for the patient or certainly would require surgery if you

treated that much with y9t reposition the catheter deeper towards the lesion and you can repeat your comb beam CT and see that you don't have an hands minh sometimes you have these little accessory left gastric artery this is

where we really need your help you know a lot of times everyone's focused and I think the more eyes the better for these kind of things but we're looking for these little tiny vessels that sometimes hop out of the liver and back into the

stomach or up into the esophagus there's a very very small right gastric artery in this picture here this patient post hepatectomy that rides along the inferior surface of the liver it's a little curly cube so and this is a small

esophageal branch so when you do comb beam TT this is what the stomach looks like when it enhances and this is what the esophagus looks like when it enhances you can do non contrast comb beam CTS to confirm ablation so you have

a lesion this is the comb beam CT for enhancement you treat with your embolic and this is a post to determine that you've had completely shin coverage and you can see how that correlates a response so the last thing we're going

I'm gonna talk about me and shoulder embolization I'll take out my phone here so I know the timer perfect and I will try and cover everything about knee and shoulder embolization as quickly as I can so why are we doing this is really what I'm going to talk about there are

two different disease processes and the knee we're talking about arthritis and in the shoulder I'm talking about frozen shoulder so these are my disclosures obviously you know knee knee osteoarthritis is a major problem that

affects more than 30 million people in the United States and there are more than a hundred thousand hospitalizations a year just from NSAID toxicity in this patient population who takes NSAIDs for pain of course and they end up with

things like GI bleeds there are more deaths just related to n says the United States and there are more than four million knee injections performed annually in the

United States keep this in mind there are double-blind randomized placebo-controlled studies that show that knee injections don't work and yet there are four million every year okay so what's the rationale for genicular

artery embolisation so in the knee we always learn that knee arthritis is degenerative right there's no inflammation like rheumatoid arthritis but many years ago they discovered that there's actually an underlying synovial

inflammation that leads to an increase in these cytokines being released that leads to new blood vessel growth or angiogenesis and then this is the cycle of pain that occurs after that how does this actually occur and like I mentioned

it's not a new concept here as you can see this is a depiction from a 2005 article from Journal Rheumatology it just blown-up knee joint and what happens here is in the lining with that sort of peach color or light color on

the lateral aspect of the image where it says synovium gets inflamed releases these cytokines those cytokines break down the cartilage lead to new blood vessel growth and it's an inflammatory process so not just a degenerative

process and that it's that inflammation that we aim to target with genicular artery embolisation if you even take biopsies of patients who have inflammatory diseases and the joints here if you look at those two

slides on top we're all those little dark staining blood vessels there there that's a biopsy specimen from somebody with frozen shoulder to two slides below or actually biopsy specimens of someone's synovium who has just a

rotator cuff tear and you'll see there's no increased blood vessels in the two slides below but on the top there are increased blood vessels every time you have more blood vessels you have more nerves that's why they

call it a neurovascular bundle because they travel together so that's what leads to the increased pain and sensitivity so in the knee there have been studies like 2015 we published that study on 13 patients with 24 month

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

with arthritis he actually used an antibiotic not imposing EMBO sphere and any other particle he did use embolus for in a couple patients sorry EMBO zine in a couple of patients but mainly used an antibiotic so many of you know if

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

and they're resorbable so they cause a like a light and Baalak effect and then they go away he found that these patients had a decrease in pain after doing knee embolization subsequently he published a paper on 72 patients 95

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

these patients still had knee pain relief that's very impressive results for a procedure which basically takes in about 45 minutes to an hour so we

- Doctor Dangas, congrats on really putting this all together and being the champion for this technique. 13 Centers, 517 patients in the original report. We've talked about this, the follow up and some of the limitations at 17 months, primary patency 94%, Gutter Endoleak 2.9%.

What about late outcomes? That's what everybody keeps wanting to know. We've put this series together so that hopefully by next year we'll be in the, some printed literature. Two and half years follow up,

a subset analysis of patients that have had that follow up. 244 patients, 387 snorkel/chimney grafts, nearly four years mean follow up in this cohort. Mean diameter, 64 milimeters. The neck diameter, 26. And the infrarenal neck length of 4.6.

Obviously then after the chimney strategy that increases as most of them generally have gone then above the, both renal arteries. 38% right renal. 46% left renal. A couple of accessory renals. A small number of SMA and Celiac snorkels in this group.

More than half of the Endurant Graft and the rest are of mix of Zenith, Excluder, Jotec, Talent that's no longer being used. And a couple of thoracic proximal pieces. About half Viabahn. 38% iCAST or Advant of E12. And a handful of Bare Metal very early in the series.

Half with one graft, more than a third with two, 10 percent with three and a small number with four. Pre-op Mean Sac Diameter from the entire 244 sub-cohort, 64 millimeters. The latest follow up with now four years Mean follow up 55, Mean Sac Regression per patient

in the 244 eight millimeters. This is an example of one of ours. Loss of Branch Patency. Look at the Kaplan-Meier number at risk even out to four years, 136 of the 368, not the typical Kaplan-Meier where out to four years

there's like five patients left, or five renals left. Out of 48 months, 92.5% patency. Univariate analysis, no predictors including the use of different types of chimney balloon-expandable versus self-expanding, total number of chimney grafts

did not seem to have an affect. Obviously, the problem with this technology or with this strategy has still been persistent or Late Type-1a Endoleaks and Gutter Endoleaks. We found in a couple of different series individual case series many of these do resolve

by the six or 12 month follow up. In this longer term cohort, now up from 3.7 is at 48 months Mean Follow Up time at 5.9% Gutter Endoleak, needing re-interventions in half of them. What are the risk factors for developing a persistent Gutter Endoleak?

A native neck diameter of greater than 30 and the absence of Infrarenal on univariate, and on multi-variate, only the native neck diameter greater than 30. Again, suggesting this theme that I think has been throughout the meeting of larger,

of needing more proximal fixation for things. Obviously, a lot of work going into trying to prevent or find optimal strategies for Gutter Type-1a Endoleaks. Mortality for the entire cohort now with the extended follow up at four years, 71%.

Costache already went over the optimal combinations of devices, which I think this contributed to the approval CE mark, at least of the enduring graft with a balloon-expandable chimney for that. Interestingly and what, you know, I think many of us have been proposing,

one to two is obviously better than three or four, and I don't think that aligning it is necessary. So in summary, compared to meta-analysis of real world data for fenestrated, which I understand in the room there are obviously single center experts

that have better numbers than what's out there listed in the literature in terms of number of grafts, mortality Type-1a Endoleak, branch patency and need for 2nd intervention similar between these strategies. Thanks for your time.

- Thank you, I have no disclosure for this presentation. Aorotopathy is a different beast as oppose to patients with dissections that we normally see in the elderly population, but we have the same options open surgery, endovascular, and hybrid. If they all meet the indications for surgery so why not open surgery?

We know in high volumes centers the periprocedural mortality acceptable in especially high volume centers. The problem is the experience surgeons are getting less and less as we move into more and more prevalence of endovascular. And this is certainly more acceptable in lower or

moderate high risk patients. So why not be tempted by endovascular in these patients? (to stage hand) Is there a pointer up here? So the problem with aorotopathy is the proximal and distal seal zones and we've already heard some talks today about possible retrograde dissection,

we've also heard about nuendo tear distally and aorotopathy is certainly because of the fragile aorta lend itself to these kinds of problems. But it is tempting because these patients often do very well in the very short term. The other problem with aorotopathy is they often have

dissection with have problems for branch unfenestrated technology and then of course if these dissection septum are near the proximal and distal seal zones, you're going to have a lot of difficulty trying to break that septum with a ballon and possibly causing new

entry tears proximally or distally. Doctor Bavaria and his colleagues from Italy were one of the first ones to do a systematic review and these are not a large number of patients but they combined these articles and they have 54 patients. Again, the very acceptable low operative risk, 1.9%.

But they were one of the first ones to conclude and cation that TEVAR in these patients, especially Marfan's patients in this series carries a substantial risk of early and late complications. They actually cautioned the routine use of endovascular stent grafts.

One of the largest series, again stress, these are not large numbers but one of the largest series was just 16 patients and look at this alarming rate of primary failure. 56% treated successfully, 40% required conversion to open operation and interestingly enough

43% of those patients had mortality. My friend and colleague at the podium, doctor Azizzadeh was given the unbeatable task of arguing for endovascular therapy in Marfan syndrome and the best he can come up with was that midterm follow up demonstrates sizeable numbers of complications but,

he identify area where probably it was acceptable in patients with rupture, reintervention for patch aneurysms and elective interventions in which landing zone was in a synthetic graft. So why not hybrid? Well this seems to be the more acceptable version

of using TEVAR, if you can, in these aorotopathy patients. But this is not a great option because in this particular graft that you see this animation, we're landing in native aortic tissues. So really, what you have to do is you have to combine this and try to figure out a way to create a landing zone,

either proximally or distally and this is a patient and not with Marfan's this time but with Loeys-Dietz, who we had presented recently, previous ascending repair but then presented with horticultural abdominal aneurysm as a result of aneurysm habilitation of a previous dissection and here

you see a large thoracal abdominal aneurysm on the axial and coronal and as many of these patients with aorotopathy express other problems with their multisystem diseases and you can see the patients left lung is definitely not normal there, left lung is replaced with bullae and this is a patient who would not do well

with an open thoracal abdominal repair. So what do you do? You have to create landing zones and in this particular patient, he had a proximal landing zone so we were able to just use a snorkel graft from the mnemonic but distally we had to do biiliac debranching grafts to to all his vistaril arteries

and then land his stent-graft in the created distal zone and as you can see, we had an endoleak approximately and thank goodness that was just from a type II endoleak from the subclavian artery which we were able to take care of with embolization and plugs.

And there is his completion C.T. So not all aorotopathy is the same, this is a patient who presented with a bicuspid aortic valve and a coarctation and I would submit to you, this is not a normal aorta. This is probably a variant of some sort of aorotopathy,

we just don't have a name for it necessarily, and do these patients do well or do worst with endovascular stent-graft, I just don't think we have the data. This particular patient did fine with a thoracic stent-graft but this highlights the importance of following these patients and being honest with the patients family and the

patient that they really do have to concentrate on coming back and having closer follow up in most patients. So in summary, I think endovascular is acceptable in aorotopathy if you're trying to save a life, especially in an acute rupture or in an emergency situation, but I think often we prefer to land these

endovascular stent-graft in synthetic. Thank you very much.

- Thanks (mumbles) I have no disclosures. So when were talking about treating thoracoabdominal aortic aneurysms in patients with chronic aortic dissections, these are some of the most difficult patients to treat. I thought it would be interesting

to just show you a case that we did. This is a patient, you can see the CT scrolling through, Type B dissection starts pretty much at the left subclavian, aneurysmal. It's extensive dissection that involves the thoracic aorta, abdominal aorta,

basically goes down to the iliac arteries. You can see the celiac, SMA, renals at least partially coming off the true and continues all the way down. It's just an M2S reconstruction. You can see again the extent of this disease and what makes this so difficult in that it extends

from the entire aorta, up proximally and distally. So what we do for this patient, we did a left carotid subclavian bypass, a left external to internal iliac artery bypass. We use a bunch of thoracic stent grafts and extended that distally.

You can see we tapered down more distally. We used an EVAR device to come from below. And then a bunch of parallel grafts to perfuse our renals and SMA. I think a couple take-home messages from this is that clearly you want to preserve the branches

up in the arch. The internal iliac arteries are, I think, very critical for perfusing the spinal cord, especially when you are going to cover this much. And when you are dealing with these dissections, you have to realize that the true lumens

can become quite small and sometimes you have to accommodate for that by using smaller thoracic endografts. So this is just what it looks like in completion. You can see how much metal we have in here. It's a full metal jacket of the aorta, oops.

We, uh, it's not advancing. Oops, is it 'cause I'm pressing in it or? All right, here we go. And then two years post-op, two years post-op, you can see what this looks like. The false lumen is completely thrombosed and excluded.

You can see the parallel grafts are all open. The aneurysm sac is regressing and this patient was successfully treated. So what are some of the tips and tricks of doing these types of procedures. Well we like to come in from the axillary artery.

We don't perform any conduits. We just stick the axillary artery separately in an offset manner and place purse-string sutures. You have to be weary of manipulating around the aortic arch, especially if its a more difficult arch, as well as any thoracic aortic tortuosity.

Cannulating of vessels, SMA is usually pretty easy, as you heard earlier. The renals and celiac can be more difficult, depending upon the angles, how they come off, and the projection. You want to make sure you maintain a stiff wire,

when you do get into these vessels. Using a Coda balloon can be helpful, as sometimes when you're coming from above, the wires and catheters will want to reflux into that infrarenal aorta. And the Coda balloon can help bounce that up.

What we do in situations where the Coda doesn't work is we will come in from below and a place a small balloon in the distal renal artery to pin the catheters, wires and then be able to get the stents in subsequently. In terms of the celiac artery,

if you're going to stent it, you want to make sure, your wire is in the common hepatic artery, so you don't exclude that by accident. I find that it is just simpler to cover, if the collaterals are intact. If there is a patent GDA on CT scan,

we will almost always cover it. You can see here that robust collateral pathway through the GDA. One thing to be aware of is that you are going to, if you're not going to revascularize the celiac artery you may need to embolize it.

If its, if the endograft is not going to oppose the origin of the celiac artery in the aorta because its aneurysmal in that segment. In terms of the snorkel extent, you want to make sure, you get enough distal purchase. This is a patient intra-procedurally.

We didn't get far enough and it pulled out and you can see we're perfusing the sac. It's critical that the snorkel or parallel grafts extend above the most proximal extent of your aortic endograft or going to go down. And so we take a lot of care looking at high resolution

pictures to make sure that our snorkel and parallel grafts are above the aortic endograft. This is just a patient just about a year or two out. You can see that the SMA stent is pulling out into the sac. She developed a endoleak from the SMA,

so we had to come in and re-extend it more distally. Just some other things I mentioned a little earlier, you want to consider true lumen space preserve the internals, and then need to sandwich technique to shorten the parallel grafts. Looking at a little bit of literature,

you can see this is the PERCLES Registry. There is a number of type four thoracos that are performed here with good results. This is a paper looking at parallel grafting and 31 thoracoabdominal repairs. And you can see freedom from endoleaks,

chimney graft patency, as well as survival is excellent. This was one looking purely at thoracoabdominal aneurysm repairs. There are 32 altogether and the success rates and results were good as well. And this was one looking at ruptures,

where they found that there was a mean 20% sac shrinkage rate and all endografts remained patent. So conclusion I think that these are quite difficult to do, but with good techniques, they can be done successfully. Thank you.

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

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

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

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

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

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

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

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

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

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

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

so the first treatment is basically no treatment and a lot of this no

treatments basically for patients who does not want to or not ready to pursue a therapy or someone who is just mildly or maybe moderately asymptomatic from Luntz so a lot of patients will adjust or they can just be recommended to

minimize their fluid intake or just our fluid intake according to their lifestyle or their schedule you could also advise them to decrease caffeinated beverages or alcohol alcoholic beverages sometimes can

trigger a retention as well as color nergic medications as a matter of fact we have a lot of patients that would come to us that you know they would be on their medications they will go to a wedding

and have a few drinks and they couldn't urinate and end up having to the ER to get a Foley placed so the first line of therapy for BPH is usually medications and it's been like this at least since the 1990s and the more the more popular

ones that we're probably familiar are the alpha blockers the alpha 1 block excuse me and alpha the 5 alpha reductase inhibitor they also call that v a RI now the alpha blockers are had been made now to be more selective

meaning that is geared to cost less side effects however the patients still have with side effects with these type of medications including hypertension headaches or sexual dysfunction and it's

it's it's a function is to relax the smooth muscle to allow urine to flow a lot more freely the next popular one is the 5 alpha reductase inhibitors and this basically blocks the enzyme that we discussed earlier that can cost the

formation of DHT and really the goal is to shrink the prostate and it's known to to reduce the prostate about 32% volume however though you may take some time for this to actually work it doesn't work right away you may take about six

months or more for this to actually work or have some effects on the decreasing size decreasing size of the prostate again this medication has its side effects number one complaint with patients sexual dysfunction decreased

libido and also can cause gynecomastia and some of the small populations patients can also be in combination therapy other medications that are discussing literature are the beta-2 agonists and anticholinergics however

though unfortunately about 25% of men will discontinue the medications and usually because of the dissatisfied and from its side effects so despite medical therapy it'sit's been mentioned at least 30% of men will still require

some type of surgical procedure and the mainstay of therapy right now is well it's all we all know is the transfer urethral resection of the prostate also called Terp and it's usually meant for someone who has a prostate volume of 80

grams however though even though our turf procedures has gotten better compared to many years ago it still has this comorbidities associated with them so nearly half the patient or more than how the patient will have some symptoms

of exactly dysfunction bleeding bladder injury or incontinence other surgical therapies that are open there are the basically that total prosthetic t'me these are usually meant for someone who has a very large parts of volume more

than hundred grams and one of the newer one is called a prostatic urethra left this basically it's meant to be an outpatient procedure but it's meant to cost traction of those prostate lobes allowing you enter for - to flow freely

and basically getting rid of obstruction the you to live has been somewhat popular because it doesn't involve cutting of the nerves so it's been mentioned in literature that it can actually preserve a sexual dysfunction

percent of this sexual dysfunction unlike other surgical therapies so because of this because of the many comorbidities and sexual dysfunction associated with a lot of this or somewhat aggressive surgical procedures

a lot of them minimally invasive procedures have come up in the last several years briefly there's been some transurethral ablation therapy also they can use laser or heat where the doctors couldn't basically stick a special probe

near the urethra and burn the prostate costing obstructions along the urethra but well we're really going to be focusing about it the prostate artery embolisation the processor artery embolisation has been

first described at least back and or at least is being used at least in the 1980s and it's usually meant to control bleeding with patients who have bleeding from a recent processor procedure surgery any bleeding related prostate

cancer however the PAE and relates to be Patriot Lutz was first described by bleep I didn't married in 2000 where they actually embolized some guy who has a very large prostate I don't recall

what but they also know the obviously noted as hematuria has resolved but they also noted that his IPSS score has dropped from 24 to about 12 12 months after and they also noted this got to have a reduce prostate volume about 40%

and his PSA had dropped from I think 40 to about a four so how does the prostate

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

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

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

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

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

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

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

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

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

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

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

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

alone so what do you do we have a

we're going probes I think many of you have used our FA there's all sorts of different probes right so the most common well one of the most common ones is a probe like a Levine probe and what it does essentially is it increases the

number of tines so you put the probe in and you deploy these tines and it increases your ablation size a lot of companies went towards just a single probe and they infuse saline through the probe which will then decrease the rate

at which the temperature increases so that you get a consistent slow increase in temperature to prevent impedance other probes will actually infuse saline into the tissues so that it propagates the ablation better and then finally

there's by polar probes where you put two probes in next to one another and the the ablation occurs just between the two probes and so that's a very controlled ablation that's the most commonly what you see when you do the

spine augmentation procedures with the osteo cool system or whatever system you're using that's the bipolar probe approach so as I mentioned the

- [Lu Qingsheng] I have no disclosures. We know for indication of EVAR we need favorable proximal neck anatomy but if it not unfavorable maybe we are some Type 1a endoleak it's a serious complication for EVAR. So for prevent and treat Type 1a endoleak

especial for some juxtarenal aneurysm maybe we use the chimney fenestration branch and some sac bag. Could we find a simple safe cheap and effective method? So we find from open surgery we were introduced this fibrin glue

means its complex of thrombin and fibrinogen, it's used hemostasis in open surgery so we put that into inject that into the sac, we call it fibrin glue sac embolization. I will show you some cases.

For this case is very short neck and not quality of deck and after deploy the stent graft, of course very serious Type 1a endoleak. But fortunately, we put a catheter before we deploy the stent graft so this catheter is into the sac of the aneurysm

then we use up a long controlled blood flow and we inject from the catheter into the sac of the aneurysm and we inject the fibrin glue. And you can find the contrast not moved after we withdraw balloon. Then we do the angiogram.

We find no any endoleak. Another case showed is angulated neck as this patient. Of course after we deployed stent graft have a lot of endoleak. And we do again this technique. And control the balloon, control the blood flow,

then inject the fibrin glue, and we check all that and withdrew the balloon, there are no any movement about the sac. And we do the angiogram and no any endoleak. Till now, we did, we begin this technique 2002, so we follow long time that we can show it's safe.

So till now we treat 156 cases and proximal less then short proximal neck is 75 cases even some of less than 10 millimeters. And angulation more than 60 degree even some cases more than 75 degree.

Most of them more than 98% of patients' endoleak was resolved. And during our follow up, the mean time more than 100 months, only three patients died of aneurysm related sac enlargement.

The mean maxim aneurysm diameter decreased and no recurrent Type 1 endoleak so we have confidence that it's safe and no any sealant-related complication for example renal failure and aplasia other things. So we discuss the mechanism

it's not only embolization for endoleak but also coagulating all sac of aneurysm like this in shows how it worked. And we also measure the pressure in the sac. Intrasac pressure decreased significantly in treated cases. And how about that technique we need occlusion

proximal blood flow and protect branch ateliers and prevent distal embolization. And we also treated into the rupture aneurysm and it can treat any type of endoleak as these cases it's a rupture aneurysm we do the EVAR emergency.

And after we deploy this devices, we find this endoleak. We don't make sure which kind of endoleak but anyway we just do that, control the blood flow use the balloon then inject the fibrin glue in that.

And all the sac of aneurysm. Then we do the angiogram and endoleak disappeared. We'll be treat any type endoleak of the rupture EVAR we prevent rupture post-EVAR and we decreased abdominal compartment syndrome. So the conclusion is

fibrin glue sac embolization is a simple and effective treatment method. And this method could expand the current indication of EVAR. For selective the length maybe can to the 5 millimeters, angle maybe can to the 90 degree,

and for emergency we seen it should be into the older EVARs for rupture aneurysms. Thank you very much.

artery embolisation work so I'm going to cut through this like like fancy words so basically what happens is because an infarction of the prostate that

decreases a lot of this excuse me it did subsequent cost is shrinker prostate by decreasing tht and hopefully will she's a prostate he also has to do with the innervation and decreasing the sensitivity of the alpha-1 receptors

which actually does is actually smooth the muscle around a process allowing urine to flow freely so just to give you an example even though patient has a prostate volume 150 grams mute if we were to

shrink it just a little bit it doesn't mean that their symptoms would be relieved actually because the smooth muscle relaxation around the prostate a lot of the symptoms may actually get better so this this procedures indicated

for some of us who may be at high risk for any surgical procedure someone who's refractory to medical therapy or does not want to consume medical therapy or someone who obviously hat with a high IPSS score

the thing with PAE is obviously technically it's very challenging because as you go under proceed the artists get smaller and smaller so you have to consider the elderly who may have some atherosclerosis disease and

there's also risk of non-target embolization where we could potentially embolize the penis or the bladder or direct them as far as strict factors we want to consider patients age someone has diabetes chronic renal failure we

want to make sure that patient doesn't have any recent infection stones or any instrumentation regarding their neurological system so what are the

about RF a is that it was the first

ablation that we came up with all those that used it was first used in 1981 and it was really for the first liver ablation that we did RFA if any of you know about a Bovie knife the idea is the same the modality works the same as a

Bovie knife and still the main modality used in many parts of the world in the United States a lot of people will use it in certain areas but it's it's being slowly replaced by microwave ablation with time so as I mentioned some areas

are still using a fair amount of RF aimost or not I can honestly say that I haven't used much RF a at all I was sort of born into the generation of cryo and microwave places where we do use it or very commonly our Nerada meas for pain

control as well as spine ablations if any of you do the osteo cool system with Medtronic will do kyphoplasty in conjunction with an ablation that would be RFA and then Bowden oblations in conjunction with cement organizations

elsewhere right so in the pelvis if there's metastatic disease to the pelvis and you're going to ablate the lesion and then to cement augmentation the I

primary Africa cm point 86% matured remember what do we say before you know not what 96% so that's the answer to the surgeons why surgeon says why should I do this why don't I just create official

it takes me 20 minutes there's no surgeon in the world who can create a fistula that's gonna mature 86 percent of the time I don't that's not happening all right the endpoints were met secondary

endpoints to needle dialysis 88% I mean that just doesn't happen surgically I'm sorry and I'll show you some other data as well where the superiority of the percutaneous fistula over surgery this is the jvi are pivotal trial I with Jeff

Hall and tip Jennings and here's the match of the secondary maturation procedures that had to be done all right some get an estimate and we angioplasty the anastomosis embolization of branches an angioplasty Stan's oh okay

here's the bar device and this is called the ever linked queue back in these six French days and now wave link device there are two catheters one goes into the brachial artery one goes into a brachial vein there's a big magnets this

is the six wrench device and you can see that little connection I hope you can that's a foot foot plate a little electrode that pops up between the two catheters it actually creates the official of this time with a

radiofrequency energy on the right you see a brachial artery angiogram and the point of official creation with six ranch was the common on our branch which you can see down there below you have the big dense radial artery coming up on

top and then you see the common arm branch and then the proper ol arm going down there at four o'clock and then the interosseous in the middle now with the the four french device you can create fistulas from the

radial vein to radial artery or radial arterial vein owner artery to ulnar vein and either one gives you a little more options about where you want to create well why would you want options well if you go down to the video of vena Graham

in the and the ulna vein and you don't see any flow up the the perforator well you can only switch to the other side and to try to find better flow put yourself in a better position to create a working fistula this does use

ultrasound to puncture but then uses fluoroscopy to position the devices its RF energy has a little bit of a problem with heavily calcified vessels who's ever seen that and in dialysis patient right so and because radiofrequency

energy goes around calcium it doesn't go through we've had one case where we did there was just no fistula creation everything went finally since no fistula and so that patient got a surgical fistula multiple angles to confirm

correct position of the device this was with the six french device the four french device is much less cumbersome because you want to make sure that that footplate that I showed you sits directly in the receiver area to create

otherwise if you go off to the side left and right they you can have a problem with creating pseudoaneurysm some things no angioplasty then ask to most us however in this case you do embolize on the way out because you've entered the

brachial vein and you embolize form just to stop any losing and to because you want to help to redirect flow towards the superficial system here are the two devices on the left into the four frames versus the six

range quite a difference much more easy to work with the four french doesn't have a bulky handle on the end like the six ranch did they're pretty easy to position and it's a a round electrode not a foot that comes up and it kind of

sits in what they call the saddle you can see there where it says square magnets underfloor french there's a saddle there that that loop electrode sits in and very easy in there to position

who's a candidate well doctor Ross says

- So thank you to the organizers and to Dr. Veith, and thank you to Dr. Ouriel for giving me the introduction of the expense of an unsuitable procedure for pain patients. We have no disclosures.

I think when you look at MRV or Venous interventions, you can look at it as providing you a primary diagnosis, confirming a diagnosis if there's confusion. Procedural planning, you can use it as a procedural adjunct,

or you can use it as a primary procedural modality. In general, flow-dependent MRI has a low sensitivity and a slow acquisition time, making it practically impractical. Flow-independent MRI has become more popular, with sensitivity and specificities

rounding at 95 to 100%. There's a great deal of data on contrast-enhanced MRI, avoiding adanalenum using the iron compounds, and you'll hear later from Dr. Black about Direct Thrombus Imaging. There has been significant work on Thrombus Imaging,

but I will leave it up to him to talk about it. MR you can diagnose a DVT, either in both modalities, and you can see here with the arrows. It will also provide you data on the least inaccessible areas for duplex and other modalities,

such as the iliac veins and the IVC, as can be seen here. It is also perhaps easier to use than CTV, because at least in my institution CTV always comes out as a CTA, and I can't help that no matter what happens.

MR can also show you collaterals, which may be very important as you are trying to diagnose a patient. And in essence it may show you the smaller vein that you're more interested in, particularly in pelvic congestion syndrome,

such as this patient with an occluded internal iliac vein. It can also demonstrate, for those of you who deal with dialysis access, or it's central line problems, central venous stenosis and Thrombus. But equally importantly

it may show you that a stenosis is not intrinsic to the wall, but it's actually intrinsic to extravascular inflammation, as in this patient with mediastinal fibrosis, and which will give you a different way of what you wish to do and treat.

The European guidelines have addressed MR in it's future with chronic venous disease and they give it a 1C rating, and they recommend that if doesn't work you should proceed to Ibes. It can be used for the diagnoses of pulmonary embolism,

it can eliminate the use of ECHO, one can diagnose both the presence of the Thrombus, the dilatation of the ventricul, and if one is using Dynamic MR Imaging one can also see mcconnell sign or the equivalent on the septum between the two ventricles.

More interestingly it can also be used now in the chronic thrombuc, pulmonary hypertension, where it can show both the legions that are treatable and untreatable, as some of you may have heard from Dr. Roosevelt

earlier in the day, where they're now treating the outlying lesions with balloon angioplasty serial sessions. It can also look at the ventricul and give you some idea of where the ventricul stands with regard to it's performance,

we're looking at and linking this to the lungs. It can also show you the unusual, such as atresia of the IVC or it can help with you the diagnosis of Pelvic Congestion Syndrome. And it is extremely valuable

in dealing with AVM's, although it may take one, two, or three sessions with differing contrast bulosus to identify both the arterial, the intrinsic lesion, and the outflow lesions,

but a very valuable adjunct. In renal carcinoma it has two values, one is that it can may diagnosis venous invasion, and it may also let you understand whether or not you are dealing with bland thrombus or tumor thrombus,

which can change the staging for the patient and also change the actual intervention that you may perform. If you use flash imaging one will get at least an 89% sensitivity of the nature of thrombus,

whether it's bland or tumor thrombus, which may change what you need to do during the procedure. It could also tell you whether there's actual true wall invasion, which will require excision of the IVC

as opposed to the simple thromboendarterectomy. And this can run up to a specificity of 88% to exclude it. In the brain it's commonly used to diagnose the intra tumor vasculature. Diagnosing between veins and arterial systems, which can be helpful

particularly if one is considering percutaneous or other interventions. With regard to central venous stenosis there is some data and most people are now using an onlay technique where they take the MRI,

they develop the lines for the vessels and then use that as guide in one or two dimensions with fusion imaging to achieve access with a wire, catheter and balloon, as opposed to a blind stick technique.

There is data to show that you can image with the correct catheter balloons within the vessels and do serial MR's to show that it works. And finally with guidance catheters EP is now able to guide the catheter further and further in to achieve from the,

either the jugular or the venous access across the septum and to burn the entrium as appropriate. And finally, one can use MR to actually gain access, burn, and then actually use the MR to look at the specific tissue,

to show that you've achieved a burn at the appropriate area within the cardiac system and thus prove that your modality has achieved it. So in summary, we can use it for primary diagnosis, confirmatory diagnosis,

procedural planning, and procedural adjunct, but we're only still learning how to use it as a primary procedural modality. Thank you so much.

- Thank you very much, Professor Torsello, dear Chairmen, ladies and gentlemen. After the publication of the PERICLES Registry, collecting the published world-wide experience from 13 US and European centers, a nonindustry founded project, we focused on several appealing topics,

which have to do with the chimney technique, and I would like to present you a nice overview of these new findings. Here is a flowchart, you see. After the publication of the PERICLES Registry, five new topics and publications,

and let's start and speak about the gutters. So regarding gutters, this is always a nice topic to be discussed after ch-EVAR, also presented as Achilles' heel of the technique, we classified the phenomenon of gutters based on causative mechanisms,

so we found three, as you see here, patterns, which are responsible for the persistence gutters type 1A endoleak, so two of them have to do with the oversizing, so we have seen cases with excessive oversizing of more than 30% of the aortic stent graft,

leads to this enfolding of the device, and this is a reason for our persistent endoleak as we see here. Another crucial causative mechanism is the undersized aortic endograft, which is often to be seen in case of large neck diameters or multiple chimneys,

so you see that in these cases, we have a gap. We don't have enough fabric material to wrap up the chimney grafts, and we have a persistent type 1 endoleak, and third reason for these phenomenon is a very short sealing zone.

The next key point, or the next appealing topic, was the incidence and factors for several vascular events after ch-EVAR. We published that in JVS. We analyzed this phenomenon, and actually we found a really low incidence of clinical relevant

cerebrovascular events of almost 2%. What we have seen in a very nice analysis is that the bilateral axis from the upper extremity seems to have a significant association with cerebrovascular events, and this is how we perform and administer a double chimney, so we avoid the exposure of the right

and the left upper extremity artery. We prefer the exposure of the axillary artery and double puncture, avoiding the bilateral access from above. Another nice topic is the treatment of type 1A endoleaks after EVAR.

The group from Rome published that in JEVT, and here is an example showing the utility of this technique in type 1A endoleaks. We have mainly migration of the device due to undulated necks as we see here, and for these anatomies the chimney technique performs well

because we use flexible tubes. As here you can see the Endurant device with single chimney for the right renal artery, so we create a new sealing zone, and we treat the challenging pathology like that, or here a ruptured triple A due to type 1A endoleak,

which treated also here again with tube and single chimney for the right renal artery, and we see here no evidence of type 1 endoleak in the follow-up. Another important point was the identification of optimal device combination.

The group from Florida published this topic in JVS in 2018, and we identified that the combination of the Endurant and the Advanta, a combination of a nitinol endoskeleton with a stainless steel, balloon-expandable copper stents, have a significant better performance

regarding mortality and patency as we see here in these very nice overview of the Kaplan-Meier curves. Last but not least, the impact of the technique in gender is also important. We know from the published literature from the group from Professor Timaran that female patients have

a greater risk for more renal function deterioration, reintervention, if they be treated by FEVAR. So we sought to analyze these phenomenon or these option with the chimney technique, and here is an overview between male and female patients. You see that the female patients underwent mostly placement

of flexible self-expanding covered stent, probably due to the tortuosity of the renal arteries, and if we see the outcomes, we didn't observe significant differences between female and male patients regarding the 30-day mortality renal failure late type 1A endoleaks, but also regarding

the chimney graft patency and reintervention, and this is probably to be explained due to the fact that we use devices with a low profile, flexible devices which probably fits better in the anatomy of the female patients as we see here. So in summary, we have seen that the use of chimneys

for juxtarenal pathologies has benefits for female patients showing no statistical differences regarding mortality, renal failures, patency and complications rate. So the new findings about ch-EVAR from the PERICLES Registry cohort were based in the classification of gutter-related endoleaks.

We have seen low incidence of clinical-driven cerebrovascular events, and it looks that the bilateral access as in case of multiple chimneys has a high risk of increased MACE rate, and successful use of this approach in excessive type 1A endoleaks and also female patients with triple A with short necks.

Thank you very much for your attention.

no way around this I'm gonna read to you the inclusion criteria right off the protocol it's kind of long so confirmed diagnosis I wrote some single line there that can help you follow along confirm diagnosis of HCC number two patients

above age 23 patients with single or multiple nodules HCC who are unsuitable or unwilling for surgical resection or RFA the largest tumor nodule should be less than 10 centimeters in the large largest diameter total volume of tumor

cannot exceed 50% of the liver patients are candidates for trans arterial embolisation no tumor invasion to portal vein or thrombosis and main and first branch of the portal vein 5 patients have no lymph node involvement or

distant metastasis 6 ECoG score at 0 to 1 with no known cardiac pulmonary or renal dysfunction 7 child pew score group a and B 7 eight patient should have measurable disease by contrast MRI nine prior local

therapies such as surgical resection radiofrequency ablation and alcohol injection are allowed as long as tumor progresses from the prior treatment and the patients are still candidates for tae 10 patients have normal organ

function based on some labs eleven patients are able to understand and willing to sign the informed consent and twelve men and women of childbearing age need to commit to using two methods of contraception and the exclusion criteria

are just a couple examples you know this is a little bit of older data but our uterine fibroid embolization have gone up by 60 percent from when we started to where we are now or filter retrieval

program gone up by 400 percent you know our ablations have gone up by over 50% you know and that's it's not saying that's all because of social media but it's partially because of that because we do get patients that come into our

clinic because of that and then on top of that I'll tag when I'm doing an ablation I'll tag my urologist or I'll tag de aslv you know and then all of a sudden sometimes they like it which pushes it to their followers or they'll

retweet it which directly pushes it to their followers and then in which case you're putting yourself in the consciousness of people that can refer you cases and all of a sudden now you become indispensable in the realm of

ablation at least in my case because everybody sees me posting about it right so everybody in our institution is sending me ablation cases and that's a really great thing for us so you know I

next is me talking about Egypt and Ethiopia and how I are how IRS practice in Egypt and Ethiopia and I think feather and Musti is gonna talk a little bit about Ethiopia as well he's got a

lot of experience about in about Ethiopia I chose these two countries to show you the kind of the the the the difference between different countries with within Africa Egypt is the 20th economy worldwide by GDP third largest

economy in Africa by some estimates the largest economy in Africa it's about a hundred million people about a little-little and about thirty percent of the population in the u.s. 15 florist's population worldwide and has

about a little over a hundred ir's right now 15 years ago they had less than ten IRS and fifteen years ago they had maybe two to three IRS at a hundred percent nowadays they're exceeding a hundred IRS so tremendous gross in the last 15 years

in the other hand Ethiopia is a very similar sized country but they only have three to five IRS that are not a hundred percent IRS and are still many of them are under training so there are major differences between countries within

within Africa countries that still need a lot of help and a lot of growth and countries that are like ten fifteen years ahead as far as as far as intervention ready intervention radiology

most of the practice in Ethiopia are basic biopsies drainages and vascular access but there is new workshops with with embolization as well as well as well as vascular access in Egypt the the ir practice is heavily into

interventional oncology and cancer that's the bulk that's the bulk of their of their practices you also get very strong neuro intervention radiology and that's mostly most of these are French trained and not

American trains so they're the neuro IRS in Egypt or heavily French and Belgian trains with with french-speaking influence but the bulk of the body iron that's not neuro is mostly cancer and it involves y9e tastes ablations high-end

ablations there's no cryoablation in Egypt there is high-end like like a nano knife reverse electric race electroporation in Egypt as well but there is no cryo you also get a specialty embolization such as fibroids

prostate and embroiders are big in Egypt they're growing very very rapidly especially prostates hemorrhoids and fibroids is an older one but it's still there's still a lot of growth for fibroid embolization zyou FES in Egypt

there's some portal portal intervention there's a lot of need for that but not a lot of IRS are actually doing portal intervention and then there's nonvascular such as billary gu there's also vascular access a lot of

the vascular access is actually done by nephrology and is not done by not not done by r is done by some high RS varicose veins done by vascular surgery and done by IRS as an outpatient there's a lot of visceral angiography as well

renal and transplants stuff so it's pretty high ends they do not do P ad very few IR s and maybe probably two IR s in the country that actually do P ad the the rest of the P ad is actually endovascular PA DS done by vascular

surgery a Horta is done all by vascular surgery and cardiothoracic surgery it's not done it's not done by IR IR s are asked just to help with embolization sometimes help with trying to get a catheter in a certain area but it's

really run by by vascular surgeons but but most more or less it's it's the whole gamut and I'm going to give you a little example of how things are different that when it comes to a Kannamma 'kz there's no dialysis work

they don't do Pfister grams they don't do D clots the reason for that is the vascular surgeons are actually very good at establishing fishless and they usually don't have a

lot of problems with it sometimes if the fistula is from Beau's door narrowed it's surgically revised they do a surgical thrombectomy because it's a lot cheaper it's a lot cheaper than balloons sheaths and and trying to and try a TPA

is very expensive it's a lot cheaper for a surgeon to just clean it out surgically and resuture it there's no there's no inventory there are no expensive consumables so we don't see dialysis as far as fistula or dialysis

conduits at all in Egypt and that's usually a trend in developed in developed countries next we'll talk

vessel growth or angiogenesis and then this is the cycle of pain that occurs after that how does this actually occur

and like I mentioned it's not a new concept here as you can see this is a depiction from a 2005 article from Journal Rheumatology it just blown-up knee joint and what happens here is in the lining with that sort of peach color

or light color on the lateral aspect of the image where it says synovium gets inflamed releases these cytokines those cytokines break down the cartilage lead to new blood vessel growth and it's an inflammatory process so not just a

degenerative process and that it's that inflammation that we aim to target with genicular artery embolisation if you even take biopsies of patients who have inflammatory diseases and the joints here if you look at those two slides on

top where all those little dark staining blood vessels there that's a biopsy specimen from somebody with frozen shoulder to two slides below or actually biopsy specimens of someone's synovium who has just a rotator cuff tear and

you'll see there's no increased blood vessels in the two slides below but on top there increased blood vessels everytime you have more blood vessels you have more nerves that's why they called a neurovascular bundle because

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

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

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

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

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

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

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

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

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

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

thanks everyone appreciate it [Applause] [Music]

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

- Thank you, and thank you to Dr. Veith for his kind invitation. These are my disclosures. Basically, we took a single center two-year outcomes for the use of fenestrated grafts and compared to parallel grafts in treating patients with complex aortic aneurysms.

These included fenestrated grafts and parallel grafts for juxtarenal, suprarenal, and thoracoabominal aneurysms. And the usual risk factors, morbidity, mortality, patency, and re-intervention rates were evaluated. This is a retrospective review of a prospectively maintained database.

All consecutive patients were included with exception of those presenting with rupture. Symptomatic patients were included. The type of repair was the single surgeon decision based on urgency and the patient's anatomy. And the parameters, as we discussed, were measured.

The fenestrated technique is fairly well-described and as we found the standard the technique of using fenestrated grafts. We have a Zeego hybrid suit Siemens that we used for all our implants. Most of these patients were done are local anesthesia

with percutaneous access. iCast or VBX stents were used for the bridging stents. An SMA was selectively self-extended with a self expanding stent in the Zfen cases alone. We look at the parallel graft. We had some bias in that we put no more than

two parallel grafts at any one level such as you see here. We came in and put a stent and then cautherize the celiac and the SMA, deployed the stents here. Then put a bridging RA thoracic endograft and then came in with a second endograft down to the level of the renals and the second set.

This is to decrease the instance of gutter leaks and need for reintervention. This analysis was formed with Kaplan-Meier and with p value of 0.05 being considered significant. Results. Basically, we had a 117 complex aneurysms

that were performed with a 100% technical success rate. We didn't look to the patients with significant branch special involvement, not just an isolated vessel. And we see in the parallel grafts, we had good distribution between renal, SMA, and celiac.

Obviously with a fenestrated graft, we had a stronger bias to the celiac not being involved in the SMA and renals being more commonly involved. Demographics are similar between the two groups. And the comorbidities were similar with the highest is hypertension and tobacco use.

The mortality was not statistically different with about a 3% to 2.6% perioperative mortality. Again that's one patient in each group. We had reinterventions. It was higher in the parallel graft group and that was later in the series at 7% compared to 5.3%.

Again not statistically significant. The reinterventions were similar for the fenestrated group. We had two renal stent occlusions, one colonic ischemia, one iliac limb occlusion, requiring reintervention, and one perinephric hematoma from a wire perforation.

And then in the parallel group, we had three endoleaks, two renal graft thrombosis, one celiac thrombosis, one renal stent kink, and one gutter leak. So again, using those two parallel grafts only at one level tended dramatically decreased our instance of gutter leak

compared to the reported literature. Freedom from aortic mortality. They were not different. We had 97% freedom from aortic mortality in those patients with fenestrated, 94% in those patients with parallel grafts.

Overall survival again was the same at 78% going out to two and a half years in both groups. Reintervention we saw again as we mentioned in the fenestrated graft once they plateaued around 12 months they seemed to fairly stable. But those going with the parallel graft,

we did see further late need for reintervention. So in conclusion, I think certainly in this retrospective review of parallel and fenestrated grafts, they have an acceptable perioperative mortality noted for juxtarenal, suprarenal, and thoracoabdominal aneurysms.

Parallel graft and technology has acceptable patencies with a low rate of reintervention and very low rate of gutter leaks in this series. The snorkel-sandwich technique is a very viable option especially when four vessels are involved or a sense of urgency when you don't have time

to get a fenestrated graft if it's available in your institution. And we certainly if we have a type two or three thoracoabdominal in parallel grafts we tended to stage those to decrease the paraplegia rate. Thank you very much for your attention.

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

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

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

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

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

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

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

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

- Thank you very much. Thank you, Frank, for inviting me again. No disclosures. We all know Onyx and the way it comes, in two formulas. We want to talk about presenter results when combining Onyx with chimney grafts. The role of liquid embolization or Onyx is listed here.

It can be used for type I endoleaks, type II endoleaks and more recently for treatment of prophylaxis of gutters. So what are we doing when we do have gutters? Which is not quite unusual. We can perform a watchful waiting policy, pro-active treatment in high flow gutters,

pro-active treatment low flow gutters, or we can try to have a maximum overlap, for instance with ViaBahn grafts 15 centimeters in length or we can use sandwich grafts in order to reduce these gutters in type I endoleaks. Here, a typical example of a type I leak treated with Onyx.

And here we have an example of a ruptured aneurysim treated with a chimney graft. And here is what everybody means when they're talking about gutters. Typical examples, this is what you get. You can try to coil these

or you can try to use liquid embolization. Here's the end result after putting a lot of coils into these spaces. What are these issues of the chimney-technique type I endoleak? Which are not quite infrequent as you see here.

Most of these resolve, but not all of them. So can we risk to wait until they resolve? And my bias opinion is probably not. Here, the incidents of these type endoleaks is still pretty high. And when you go up to the Arch

the results can even be different. And in our own series published here, type I endoleak at the Arch were as high as 28%. A lot of these don't resolve over time simply because it's a very high flow environment. Using a sandwich technique is one solution

which helps in a lot of cases but not all of these simply because you have a longer outlet compared to a straightforward chimney graft. You can't rely on it. So watchful waiting? There are some advocates who

prefer watchful waiting but in high flow gutters this is certainly not indicated. And the more chimneys you have, like in a thoracoabdominal aneurysm with four chimneys, the less you can wait. You have to treat these very actively,

like you see here, in these high flow areas. Here a typical example, again symptomatic aneurysm with sealing. Here Onyx was used but without any success. So what we did is we had to add another chimney and plus polymer sealing and then we had a good result.

Here some results, only small serious primary gutter sealing using Onyx with good results in a type I leak. But again, this is only a small series of patients. Sandwich technique already mentioned. When you use, like we did here for chimney grafts in the arteries, you do need Onyx otherwise you

always get problems with these gutters and they do not seal over time. Another example where liquid polymer was used. And here again, you see the polymer. The catheter in order to inject the polymer is very difficult to see but with a little bit of experience

you know where you are. And again, here it is, the Onyx, a typical example. Here another example of the Arch, bird beacon effect, extension, chimney graft. Again the aneurysm gets bigger. And so a combination of using proximal extensions

plus chimneys plus liquid embolization solves this problem after quite a long period of time. And here typically is what you see when you inject the Onyx. This does not work in all cases. Here we used Onyx in order to seal up the origin of the end tunnel.

This works very nicely but there is so ample space for improvement and in some cases it's probably better to use a fenestrated branch graft or even the opt two stabler instead of using liquid embolization. Thank you very much.

- Thank you, Mr. Chairman. Thank you, Dr. Veith for inviting again to this great meeting. It's my disclosures. Well, as we know and heard this meeting, there are some certain limitations of current EVAR (mumbles) anatomical procedure and economical reasons,

and I would like to present a relatively new device which may address current EVAR limitations with a simple low profile system, and basically, ALTURA consists of two parallel stent graft systems. ZEUS No Gate Cannulation is needed and unique features include D-shaped proximal stents

and suprarenal fixation. Multi-purpose (mumbles) possibilities as well, and the system of utilize 14 French delivery system. And as aortic components can be deployed offset to accommodate the offset renals, and then the limbs are also unique

because they're deployed retrograde from distal proximally, and this allows precise positioning, both proximally and distally. Well, as the ALTURA clinical experience includes the very first human implants as well as more recent case performed

with a fully commercial device, and a total of 90 patients with a AAA were enrolled between 2011 and 2015, and follow-ups are taken at 30 days, six months, and annually to five years, and this presentation gives a current status of follow-up, and our results with a 12-month follow-up were published earlier this year.

Our clinical data were collected in total of in 11 sites. It includes 90 patients. And you see here, the patient demographics and anatomy do a typical, which are typical for all EVAR patients and the mean follow-up was 2.7 years. And procedure of success was 99%.

Only one patient, one of the first patient was Gen1 was not implanted, and 50% patients were done percutaneously, and majority of them underwent regional or local anesthesia. So when you look into the results, we see that there was only one case of AAA ruptured,

which occurred at three years due to type II endoleak and sac enlargement as the patient, which refused treatment due to type II endoleak. And all other deaths are paired to no original causes, and two patients had device migration at two years. The same patients appear at three-year period,

and basically these were undersized grafts was sort of our learning curve, and there was no any migration later on. Four patients had type I endoleaks visible on CT, and read by independent committee between 30 days and one year.

None have required secondary treatment and have been no aneurysm enlargement observed. And at one year, not surprisingly for this kind of devices, there was 17% type to endoleaks, but only one patient required secondary procedure due significant sac expansion.

Well, wasn't, of course, what we saw, I expected majority of patients has had shrinkage. There was a four-year period. And this is a patient who was recorded with the type IA endoleak at 30 days, caused by the last calcified nodule,

as you he's here probably none of the other device would tolerate that, but the endoleak did not extended into into the sac and had a leak result spontaneously without sac enlargement through a four-year follow-up period, as we're seeing here. Well, here another patient with type IB endoleak,

due to (mumbles) generation was treated with coils and glue an extension with additional stent graft to external iliac artery. What's interesting was the device. Device can tolerate small distal aortas and five patients who were treated

with small distal aortas and the very first patient was not dilated enough and stents were not deployed, simultaneously causing some stenosis which was easily treated with PTA afterwards, so we learned but it's very great, unique feature to treat the small distal aortas for the device.

And of course, sensing what happening with them, septal endoleaks, because everybody being concerned what happening with that, and nevertheless, there were no septal endoleaks observed during the follow-up period. In conclusion, Mr. Chairman, ladies and gentlemen,

I would like to say this Novel Altura endograft concept has potential to play major role in mainstream EVAR cases and potential benefits include predictability, reposition ability to place the device very, very, very precisely, offset renals, to maximize use of the neck, and low profile

overcomes current and anatomic limitations like tortuous iliacs, narrow bifurcation or access vessels and no limbic inhalation is needed, and basically, I truly believe that this offers option for EVAR day surgery and ruptured aneurysms. Of course, first results are very encouraging.

We need more data. Thank you very much.

today's objectives I'll start with reviewing hepatocellular carcinoma HCC

and the current treatment options I'll share the protocol inclusion and exclusion criteria and I will discuss the research treatment protocol briefly and next transitioning to research the preparation taken in the department with

staff members for trial lastly I will talk about what's involved intraoperatively from a nursing standpoint so hepatocellular carcinoma HCC is the most common primary liver manely malignancy and is a leading cause

of cancer-related deaths worldwide cirrhosis is a condition in which there is scarring to the liver causing permanent damage chronic medical conditions such as diabetes mellitus and obesity lead to chronic liver disease

obesity is a risk factor to diabetes and diabetes directly affects the liver because of the essential role the liver plays in glucose metabolism both cirrhosis and chronic liver disease remain the most important risk factor

for the development of HCC a which viral hepatitis and excessive alcohol intake are the leading risk factors of cirrhosis non-alcoholic fatty liver disease and non-alcoholic steatohepatitis which is nash our

conditions in which fat builds up in your liver thus having inflammation and liver cell damage along with fat in your liver these are other risk factors for HCC the incidence of HCC will continue to escalate as hepatitis C and obesity

become more prevalent in the United States so unfortunately the diagnosis of HCC is too often made with advanced liver disease when patients have become symptomatic and have some degree of

liver impairment at this late stage there is virtually no effective treatment that would improve survival in addition the morbidity associated with therapies unacceptably high modalities available for HCC screening include both

radiographic tests and serological markers radiological tests commonly used for surveillance include ultra sonography multi-phase CT and MRI with contrast ultrasound has historically been utilized to identify intrahepatic

lesions since the early 1980s both the photograph above shows a cirrhotic liver versus a normal liver there are visible differences in the portal and hepatic veins between the cirrhotic liver when compared to the non cirrhotic liver so

AFP alpha-fetoprotein has been used as a serum marker for the detection of HCC an AFP level of less than 10 is normal for adults an extremely high level of AFP in your blood greater than 500 could be a sign of liver tumors liver function

tests or lfts look at the part of your liver that is not affected by cancer to see how well your liver is working the lfts will be considered for diagnosis and determining the stage of HCC the tests look for levels of certain

substance in your blood such as bilirubin albumin ALP ast alt and GGT despite advances in prevention techniques screening and new technologies in both diagnosis and treatment incidence and mortality

continue to rise so treatment options for HCC can be divided into three categories surgical options non-surgical options and systemic therapy patients are screened diagnosed and treated accordingly of

these three options interventional radiologists offer the non-surgical approach which include trans arterial embolisation percutaneous ethanol injection radiofrequency ablation and microwave ablation so I want to talk

about the child pu classification the child pious core consists of five clinical measures and is used to assess the prognosis of liver disease and cirrhosis including the required strength of treatment and necessity of

liver transplant the child piu score was originally developed in 1973 to predict surgical outcomes in patients presenting with bleeding esophageal varices today it continues to provide a forecast of the increased increasing severity of

your liver disease and you're expected survival rate the Chao few score is determined by scoring five clinical measures of liver disease the five clinical measures are total bilirubin serum albumin prothrombin time ascites

and hepatic encephalopathy once scores are available in each of the five clinical measures all scores are added and the result is a child piu score their interpretation of the clinical measure is as follows so Class A would

be five to six points lease liver disease with one to five year survival weight at 95 percent Class B seven to nine points moderately severe liver disease one to five year survival rate at seventy five percent and Class C ten

to fifteen points most severe liver disease one to five year survival rate at fifty percent so which child pew scores do I our patients fall into for a research with the CPC and the majority of the HCC child pew scores a and B

seven with the survival rate of one to five years for 95% the best outcomes are achieved when patients are carefully selected for each treatment option regardless of the treatment approach

patients with HCC require a multidisciplinary approach to care to ensure optimal outcomes what we refer to as tumor board tumor board are meetings where specialists from surgery medical oncology radiation oncology

interventional radiology and others collaboratively review a patient's condition and determine the best treatment plan through this multidisciplinary approach patients have access to a diverse team of experts

instead of relying on a single opinion each specialty will have unique contributions to ensure optimal long term outcomes for patients with HCC so there are various algorithms for HCC treatment I actually have one on top of

the other there just to show you that if you're interested in the process you can look it up it's there's a few out there all right so how are the patients selected for treatment like I said tumor board and moving on now to the surgical

options there are two surgical options liver resection and liver transplant surgical resection is currently considered to be the definitive treatment for HCC and the only one that offers the prospect of cure or at least

long-term survival however most patients have unresectable disease at presentation because of poor liver function the overall resect ability rate for HCC is only 10 to 25 percent and even among those who undergo surgical

resection with curative intent there is a recurrence rate of it to 80% at five years post resection survival rates are in the range of 80 to 92% at one year sixty-one to 86 three years and 41 to 74 at five years

the most common sight of post resection recurrence is a remaining liver for patients who are not surgically resectable liver transplant is the only other potentially curative option virtually all patients who are

considered for liver transplant are unresectable because of the degree of underlying liver dysfunction rather than tumor extent down staging using local regional therapies can also be used to increase eligibility for orthotopic

liver transplant while on the transplant list patients disease progress and meeting criteria gets complicated so patients on the transplant list are and do get some other therapies

which I will later discuss so we're surgical resection is not possible for poor liver function liver transplant is a treatment of choice prior to 2008 no systemic therapy was available that demonstrated an improvement in survival

with the publication of two randomized placebo-controlled phase 3 trials the oral multi targeted tyrosine kinase inhibitor sorafenib has become the new standard of treatment for advanced HCC with an increased median survival from

seven point nine months and the placebo group to ten point seven months in the treatment group systemic therapy can be difficult to tolerate because of the side effects dose reduction or treatment interruption is often needed

despite the side-effects treatment is recommended and to be continued into a progression of the tumor is demonstrated the majority of diagnosed patients with HCC present with advanced disease oral therapy has taken two pills twice daily

equaling 400 milligrams B ID so interventional radiology it's like surgery only magic so I I always think about this when patients come in and pre-op beam and they think they're having surgery you know it's well a lot

of benefits to ir what we're doing so interventional radiology is where the magic happens and non-surgical approach procedures are performed percutaneous local ablation include ethanol injection and radiofrequency ablation microwave

ablation is utilized both percutaneously and intraoperatively and lastly there is trans arterial embolisation which depending on the embolization agent can either be chemo bland or radioisotopes percutaneous ethanol injection known as

Pei has a long track record and is very effective in destroying HCC tumors that are less than or equal to 2 centimeters in diameter performed under percutaneous ultrasound guidance a needle is placed into the tumor and absolute alcohol is

injected over recent years radiofrequency ablation referred to as RFA has largely replaced Pei at most centres RFA's also performed percutaneously advancing a specially designed electrode into the tumor and

applying radiofrequency energy to generate a zone of thermal destruction that encompasses the tumor and a 1 centimeter margarine surrounding liver RFA is thus preferable to ethanol injection for patients with solitary

tumors 2 to 4 centimeters in size for tumors smaller than 4 centimeters RFA can achieve initial complete response rates of over 90% in microwave ablation MWA microwaves are created from the needle to create small

regionals regions of heat the heat destroy the liver cancer cells RFA and microwave are effective treatment options for patients who might have difficulty with surgery or those whose tumors are less than one and a half inch

in diameter the success rate for completely eliminating small liver tumors is greater than 85% so can I get a show of hands from the audience on who what facilities are doing chemo embolization everybody pretty much are

you guys doing them next to the gentleman yeah okay so this is gonna be a boring review here alright so trans arterial embolisation a minimally invasive procedure performed to restrict to tumors blood supply it is performed

by advancing and angiography catheter into the branches of the hepatic artery supplying the tumor and injecting an agent mixed with orally contrast followed by a cluding agent known as beads the beads which range from 100 to

300 micrometers in diameter are carried by the circulation into the terminal hepatic arterioles where they lodge and include the vessel resulting in the schema tumor necrosis the procedure is done using moderate sedation patients

are monitored for 23 hours or less for pain and post embolization syndrome trans arterial chemo embolization thus is where the chemo therapeutic agent mixed with beads is injected to the tumor

these particles both blocked the blood supply and induced cytotoxicity attacking the tumor in several ways taste is the treatment of choice when the tumor is greater than four centimeters or there are multiple

lesions within the liver taste takes advantage of the fact that while the liver is refused by both the portal vein and the hepatic artery HCC survives its blood supply almost entirely hepatic artery tastes has been shown to

prolong survival in patients with intermediate stage HCC and objective responses were observed in the majority of patients tear trans arterial radioembolisation is a form of catheter directed internal radiation that

delivers small microspheres with Radio isotopes directly into the tumor y9t microspheres are administered and a procedure similar to taste the procedure has been shown to be safe and effective in cirrhotic patients with HCC the side

effects are usually well title tolerated one major advantage of y9t over taste is that it is indicated in the case of portal vein neoplastic thrombosis while taste traditionally has been considered a contraindication all right so there's

- The only disclosure is the device I'm about to talk to you about this morning, is investigation in the United States. What we can say about Arch Branch Technology is it is not novel or particularly new. Hundreds of these procedures have been performed worldwide, most of the experiences have been dominated by a cook device

and the Terumo-Aortic formerly known as Bolton Medical devices. There is mattering of other experience through Medtronic and Gore devices. As of July of 2018 over 340 device implants have been performed,

and this series has been dominated by the dual branch device but actually three branch constructions have been performed in 25 cases. For the Terumo-Aortic Arch Branch device the experience is slightly less but still significant over 160 device implants have been performed as of November of this year.

A small number of single branch and large majority of 150 cases of the double branch repairs and only two cases of the three branch repairs both of them, I will discuss today and I performed. The Aortic 3-branch Arch Devices is based on the relay MBS platform with two antegrade branches and

a third retrograde branch which is not illustrated here, pointing downwards towards descending thoracic Aorta. The first case is a 59 year old intensivist who presented to me in 2009 with uncomplicated type B aortic dissection. This was being medically managed until 2014 when he sustained a second dissection at this time.

An acute ruptured type A dissection and sustaining emergent repair with an ascending graft. Serial imaging shortly thereafter demonstrated a very rapid growth of the Distal arch to 5.7 cm. This is side by side comparison of the pre type A dissection and the post type A repair dissection.

What you can see is the enlargement of the distal arch and especially the complex septal anatomy that has transformed as initial type B dissection after the type A repair. So, under FDA Compassion Use provision, as well as other other regulatory conditions

that had to be met. A Terumo or formerly Bolton, Aortic 3-branch Arch Branch device was constructed and in December 2014 this was performed. As you can see in this illustration, the two antegrade branches and a third branch

pointing this way for the for the left subclavian artery. And this is the images, the pre-deployment, post-deployment, and the three branches being inserted. At the one month follow up you can see the three arch branches widely patent and complete thrombosis of the

proximal dissection. Approximately a year later he presented with some symptoms of mild claudication and significant left and right arm gradient. What we noted on the CT Angiogram was there was a kink in the participially

supported segment of the mid portion of this 3-branch graft. There was also progressive enlargement of the distal thoracoabdominal segment. Our plan was to perform the, to repair the proximal segment with a custom made cuff as well as repair the thoracoabdominal segment

with this cook CMD thoracoabdominal device. As a 4 year follow up he's working full time. He's arm pressures are symmetric. Serum creatinine is normal. Complete false lumen thrombosis. All arch branches patent.

The second case I'll go over really quickly. 68 year old man, again with acute type A dissection. 6.1 cm aortic arch. Initial plan was a left carotid-subclavian bypass with a TEVAR using a chimney technique. We changed that plan to employ a 3-branch branch repair.

Can you advance this? And you can see this photo. In this particular case because the pre-operative left carotid-subclavian bypass and the extension of the dissection in to the innominate artery we elected to...

utilize the two antegrade branches for the bi-lateral carotid branches and actually utilize the downgoing branch through the- for the right subclavian artery for later access to the thoracoabdominal aorta. On post op day one once again he presented with

an affective co arctation secondary to a kink within the previous surgical graft, sustaining a secondary intervention and a placement of a balloon expandable stent. Current status. On Unfortunately the result is not as fortunate

as the first case. In 15 months he presented with recurrent fevers, multi-focal CVAs from septic emboli. Essentially bacteria endocarditis and he was deemed inoperable and he died. So in conclusion.

Repair of complex arch pathologies is feasible with the 3-branch Relay arch branch device. Experience obviously is very limited. Proper patient selection important. And the third antegrade branch is useful for later thoracoabdominal access.

Thank you.

here are the treatment options and I did want to include a fourth one it says nothing about the intervention per se but it's medical management which was actually had the significant growth over the last decade and really more

aggressive medical management every treatment below this should have medical management included as part of it so I included that first that's critical if you're gonna have a carotid endarterectomy if that's what ultimately

your your physician decides then you should still have medical management before and after carotid artery stenting and then ultimately trans carotid artery stenting so carotid endarterectomy I'll show you a case example but this is a

diagram illustrating what's ultimately done that longitudinal incision and then removal of that plaque this is what the plaque looks like when it comes out as opposed to carotid artery stenting which is less invasive obviously and we place

a stent but we don't actually remove the plaque overall you know you know we can talk about why that's okay in fact the plaque itself doesn't need to come up what we need to improve the flow and stabilize that plaque from being able to

embolize small clot overall medical therapy is really just these basic things aspirin or sometimes dual antiplatelet therapy so that's aspirin and plavix in addition aggressive statin therapy so

Doc's will Vascular Docs anyone interested in this space will have you a non-aggressive statins or cholesterol-lowering medications stop smoking tight glucose control so those diabetics have to be really well

regulated and in the blood pressure control if you don't do those things no matter what you do with the carotid endarterectomy or the stenting is gonna fail so what's carotid endarterectomy

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