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SVC Syndrome|Anticoagulation|68|Male
SVC Syndrome|Anticoagulation|68|Male
CT Angiography | Determining the Endpoints of CLI Interventions
CT Angiography | Determining the Endpoints of CLI Interventions
Duplex Ultrasound | Determining the Endpoints of CLI Interventions
Duplex Ultrasound | Determining the Endpoints of CLI Interventions
Case 10: Peritoneal Hematoma | Emoblization: Bleeding and Trauma
Case 10: Peritoneal Hematoma | Emoblization: Bleeding and Trauma
activeaneurysmangiogramanteriorarterycatheterchaptercoilcontrastcoronalctasembolizationembolizeembolizedflowgastroduodenalhematomaimageimagingmesentericmicrocatheterNonepathologypatientperitonealPeritoneal hematomapseudoaneurysmvesselvesselsvisceral
Carotid Artery Stenting- Case | Carotid Interventions: CAE, CAS, & TCAR
angioplastyarteryballoonballoonsbut want left carotid artery lesion stented firstcarotidcarotid arterychaptercommonCoronary bypass graftdistalECA balloonendarterectomyexternalexternal carotidimageinflatelesionosisproximalproximallystentstentingsurgicallyultimately
Ideal Stent Placement | TIPS & DIPS: State of the Art
Ideal Stent Placement | TIPS & DIPS: State of the Art
anastomosiscentimeterchaptercoveredcurveDialysisflowgraftgraftshemodynamichepatichepatic veinhyperplasiaintimalnarrowingniceoccludesocclusionportalshuntshuntssmoothstentstentsstraighttipsveinveinsvenousvibe
Mentice Simulator | Cath Lab Academy: An Adjunct to an Orientation Program Using an Interprofessional Approach
Balloon Pulmonary Angioplasty | Management of Patients with Acute & Chronic PE
Balloon Pulmonary Angioplasty | Management of Patients with Acute & Chronic PE
Results of the US FDA Trial | Pecutaneous Creation of Hemodialysis Fistulas
Results of the US FDA Trial | Pecutaneous Creation of Hemodialysis Fistulas
anastomosisangiogramangioplastyarteryBARDBD EverlinQ (4Fr & 6Fr)brachialcalcifiedcatheterschaptercreatedevicedevicesDialysiselectrodeembolizationembolizeendpointsenergyFistulafistulasflowfrenchmagnetsmaturationofficialpercutaneousperforatorpositionpseudoaneurysmradialradiofrequencysaddlesitssurgeonsurgicallyulnarveinvena
Introduction - Percutaneous Fistula Creation | Pecutaneous Creation of Hemodialysis Fistulas
Introduction - Percutaneous Fistula Creation | Pecutaneous Creation of Hemodialysis Fistulas
Massive PE | Pulmonary Emoblism Interactive Lecture
Massive PE | Pulmonary Emoblism Interactive Lecture
Case 11: Bleeding Tracheostomy Site | Emoblization: Bleeding and Trauma
Case 11: Bleeding Tracheostomy Site | Emoblization: Bleeding and Trauma
aneurysmsangiogramarterybleedingBleeding from the tracheostomy siteblowoutcancercarotidcarotid arterychaptercontrastCoverage StentembolizationimageNonepatientposteriorpseudoaneurysmsagittalscreenstent
Case 8: Retroperitoneal Hematoma- Cover Stent | Emoblization: Bleeding and Trauma
angiogramarteryaxialbleedcatheterizationchaptercontrastcoronalCoverage StentembolizationembolizehematomailiaciliacsimageinjuryNoneoptionpatientpseudoaneurysmRetroperitoneal hematomastentstents
TIPS Case | Extreme IR
TIPS Case | Extreme IR
antibioticsascitesbacteriabilebiliarycatheterchapterclotcolleaguescommunicationcovereddemonstrateddrainageductduodenal stent placementfull videoportalrefractoryshuntsystemthrombolysistipstunnelultrasoundunderwentvein
Difficult Biliary Access | Biliary Intervention
Difficult Biliary Access | Biliary Intervention
abdominalanticoagulantsanticoagulationaspirationCAT8 PenumbracatheterchapterclotdecideflowhematomaintrahepaticlactatelysisneedlepainportalPortal vein occlusion-scanstenosisstentthrombolysisthrombosedthrombustipstransitvein
Cone Beam CT | Interventional Oncology
Cone Beam CT | Interventional Oncology
ablationanatomicangioarteriesarteryartifactbeamchaptercombconecontrastdoseembolicenhancementenhancesesophagealesophagusgastricgastric arteryglucagonhcchepatectomyinfusinglesionliverlysisoncologypatientsegmentstomach
Surgical AV Fistula  | Pecutaneous Creation of Hemodialysis Fistulas
Surgical AV Fistula | Pecutaneous Creation of Hemodialysis Fistulas
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Successes of EndoAVF Creation | Pecutaneous Creation of Hemodialysis Fistulas
Successes of EndoAVF Creation | Pecutaneous Creation of Hemodialysis Fistulas
Malignant Biliary Strictures | Biliary Intervention
Malignant Biliary Strictures | Biliary Intervention
adventBARDcancerceliaccenterschaptercolorectalcookCordiscoveredcysticdataductextremelyfavorfavorablegoregrammalignantMeditechMemothermmetalmetastaticmultipleocclusiononcologyovergrowthpatientsperioperativeportalSmartStentstainsstentstentsstricturestumorunresectablewallstentZilver Stent
Case 11b: Embolizing a Pseudoaneurysm of the Brachiocephalic Artery | Emoblization: Bleeding and Trauma
angiogramarterybrachiocephaliccatheterchapterclickcoilcoilsembolizationmicromicrocatheterNonepseudoaneurysmPseudoaneurysm brachiocephalic arterystenttrachea
Angiographic Predictors of Successful Revascularization | Determining the Endpoints of CLI Interventions
Angiographic Predictors of Successful Revascularization | Determining the Endpoints of CLI Interventions
Case- May Thurner Syndrome | Pelvic Congestion Syndrome
Case- May Thurner Syndrome | Pelvic Congestion Syndrome
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Case- Brain Infarction | Brain Infarct After Gastroesophageal Variceal Embolization
Case- Brain Infarction | Brain Infarct After Gastroesophageal Variceal Embolization
anastomosisangiographyaphasiaapproacharrowarteryartifactbrainbronchialcalcificationcatheterschannelschapterchronicChronic portal vein thrombosuscollateralcyanoacrylatedrainembolismembolizationendoscopicendoscopistendoscopygastricGastroesophageal varixglueheadachehematemesisinjectionmicromicrocathetermulti focal brain infarctionmultipleoccludedPatentpatientpercutaneousPercutaneous variceal embolizationperformedPortopulmonary venous anastomosisprocedureproximalsplenicsplenomegalysplenorenalsubtractionsystemicthrombosistipstransformationtransitultrasonographyvaricesveinvenous
TEVAR Case | TEVAR w/ Laser Fenestration of Intimal Dissection Flap
TEVAR Case | TEVAR w/ Laser Fenestration of Intimal Dissection Flap
Endoleak Case |
Endoleak Case | "Extreme"-ly Obvious IR
Summary of Carotid Interventions | Carotid Interventions: CAE, CAS, & TCAR

History is a 68-year-old man, who had a history of severe sinus node dysfunction, for which a pacemaker was implanted, back in 2010 December. And starting from approximately 2013, he began developing facial plethora. And contrast enhanced CT demonstrated thrombus, in the mid part of the

superior vena cava, as well as the superior vena cava stenosis. He was started on anticoagulation. His facial swelling was getting worse. And he had also exercise induced plethora, with some puzzle/g spinal cord edema based on imaging. And he had paresthesias which was becoming worse and debilitating.

This is the contrast enhanced CT scan, where you can see that the actual less receiver, the pacemaker leads are going, is almost just a little chink. You can see extensive collaterals in the superficial subcutaneous tissue, because of the superior vena cava syndrome.

[BLANK_AUDIO] Now for the samp question. In this individual with superior vena cava syndrome, secondary to pacemaker lead implantation, what is the most appropriate intervention? Choice A, no intervention is wanted.

Choice B, angioplasty alone. Choice C, stenting over the pacemaker leads. Choice D, removing the pacemaker leads and stenting the affected veins. Time starts. [BLANK_AUDIO]

Okay, so a little bit spread over all the choices except for A. So the most appropriate at this point, for this particular patient would be, removing the pacemaker leads and stenting the affected veins. So we'll see in a little bit, why that would be most appropriate. So initially how we or they went ahead doing the case is, they started

working on snaring the ventricular lead initially, after making the subcutaneous pocket to release the pacemaker, and then release these leads from there. You go down from the femoral approach.

Some people go from the access itself, through the subclavian veins. But in this case, because of the severe narrowing in the superior vena cava, they decided to go from the femoral approach. There are specific type of snares, which is usually done by electrophysiology, but there are some places where the interventional radiology do it. It's a Needle Eye kind of snare, which is specifically used for pulling

these leads. And once you go from there, from the femoral approach, you snare each lead separately, and then pull them out through the femoral approach. Once that is done, you maintain access from the top, either by going across, either from a separate access,

or from your existing subclavian access. You pass down the wire. And this is all done in the hybrid OR kind of setting, with a back up person, cardiothoracic, in case the patient develops any tamponade, or any other physiology, which is gonna cause bleed in the central veins. And you can see, once we have access down the central veins,

through the brachiocephalic, and down the SVC. The initial run shows a huge collateral going down the para-aortic region, which eventually goes down to the abdomen, and then rains through the other collateral veins. And then for the work, you can see the TEE probe, then there is angioplasty balloon.

You can see a tight mearing at the place, where the lead had gone through the subclavian vein. So once you stretch out the whole thing, and maintain access, you can stent the whole thing. I guess this was a WALLSTENT which was placed, extending all the way down from the left brachiocephalic,

down to the superior vena cava cavoatrial junction. Once we have re established, and the flow is good, the pacemaker leads can be placed again. Just what they ended up doing, a new pacemaker, after placing the stent through the stent.

So why the option D was the best choice? Conservative management is reasonable. But given the severe symptomatology for this patient, and the low risk for doing the lead extraction, although there is a risk of cardiac perforation, and tamponade may not be appropriate for this patient, and the patient, apparently, was willing to take the risk. So it was okay.

Many people would have probably just angioplastied, with the stent, without the stent. But it may not provide the long lasting result, especially with the leads in place. And if we had done that, how effective that would be in the long-term is not clear. Stenting all the leads, some people have done it, and have gotten

away with it. But it would make future extraction of the leads very difficult, in case they get infected. So it's better to do it this way, where you pull the existing leads out. Make sure you stretch open the vein very well.

Place the stent. And then a new pacemaker can be, pacemaker leads can be placed through the existing stent. So like he says, it was done in the hybrid OR with a CT surgery backup, in case they had any problems with the tamponade, or any perforation during the procedure.

That's it for the first case.

for it's very it at centers where CTA protocols are very good it's basically equivalent to a angiography has been shown in multiple papers to be so newer studies show that

CTA and Emory are equivalent so I don't know it depends on your institution there are a lot of places that still practice with the MRA is kind of the gold standard but CTA is just so much more available that CTA is becoming kind

of the new gold standard for for quick vascular assessment often like to use it to help us plan our intervention so if we don't know what's going on above the level of the groin CTA could be helpful to see whether or

not we could even go from right to left how calcified the vessels are or whether or not there's concomitant aneurysms things that we don't like to discover at the time of the procedure because we might not have the equipment we need to

treat it one of the strengths is that it's quick and that it's cheap but of course it uses contrast and just like you know we like to minimize the amount of contrast that we're using at knee and rogram this can use anywhere from 75 to

150 cc's of contrast or not a small amount and if you're gonna do an intervention the same or the next day that's a lot of dough that's a lot iodine in a couple days these are examples of what we can see at the time

of the procedure there's a 3d reconstruction and a BU these are kerf planer reformatted images what basically they draw a line down the image and you can lay the entire vessel out even if it's very squiggly and then this isn't

this an angiogram and that same patient you can see that they correlate exactly another example a patient with aortic calcification you can see that it can be potentially challenging this patient with diabetes to determine whether or

not these vessels in below the level of the knee are paetynn or not because I can tell you that the one that's closest to the small bone there is actually occluded it's just all calcified you can't really tell what's going on and

the one that's behind that is actually Payton so it could be difficult to tell whether it's calcium or contrast that you're seeing this is where MRA can be

helpful and you know many of us use this on the table at the time of the procedure we also look at our own images because it reports are not all that helpful and what you're looking for I don't know duplex ultrasound is what is

the vessel wall look like is it narrowed is it patent are there are there large collateral so you're going to need a lookout for or what's the velocity of flow because as you know as you know you put your

finger over the end of a of a garden hose it's going to increase the velocity of the water that you're shooting at somebody and the flow direction and quality can also be detected so color Doppler imaging often changes from this

kind of smooth the uniform color with laminar flow on the on the right side to one of multi-directional flow with turbulence you'll see colored multiple different colors in the same image spectral Doppler waveforms are also

obtained with with duplex ultrasound so what you're looking for is this is the the picture equivalents of marks noises from earlier which is a triphasic waveform see that the flow goes above the line and then goes back below the

line and then comes you can wholly state that it comes back above the line here that would suggest that it was triphasic or normal and then these often just go above the line and they never go back below the line and these patients if

they're if you're looking at the ultrasound below the level and destruction so we're looking for a return from the image on the right to the image on the left we have specific number criteria that we use as a

determination of whether one we've been successful the numbers are not that important but the ant vanish is a duplex are that it's low-cost and it's highly sensitive but it it's time-consuming and depending on who the operators are that

are actually taking the images and who are the readers are you may or may not find them that helpful and it's less accurate for determining if the vessels completely occluded because they may just not have seen it they may have

missed it so it's operator dependent several papers suggest that we should be this should be our first line imaging study for following up patients after we do an intervention particularly angioplasty alone and if the initial

follow-up is normal we can usually push them out to just clinical follow-up and making sure they have a pulse exam if patients have an abnormal finding then we usually bring them back sooner and get a repeat ultrasound at two to three

months CT a very sensitive and specific

patient female patient who has the sudden onset of upper abdominal pain here's the CT we did all these cases in one day it was crazy it was terrible so so here's a big hematoma a big peritoneal hematoma you

can see it anterior to the right kidney you can see the white blob of contrast right in the middle of the hematoma that's a pseudoaneurysm or even active extravagance um less experienced people would probably say it's active

extravagant I think most of us would prefer that it be called kind of a pseudoaneurysm this active extrapolation would be much more cloudy and spread out this is more constrained and you can see on the

coronal image you get a sense that there's that hematoma same type of problem all right is there more imaging that we can do to figure out the next step again I said earlier earlier in this lecture

that sometimes we use CTA now sometimes a CTA is worthwhile I do find that for a lot of these patients I think we're getting smarter and we're doing CTAs right at the beginning of this whole thing you know when a trauma

patient comes in we're getting CTAs so we can max out the amount of information that we get on the initial diagnostic imaging here's what we're seeing on the CTA and in this particular case I think it's pretty clear that you can see the

pseudoaneurysm arising from what looks like a branch of the superior mesenteric artery so this is just an odd visceral and Jake visceral aneurysm which looks like it probably ruptured I don't have an explanation for it led to a big

hematoma here's what that is and now we're gonna do an angiogram the neat thing is it just perfectly correlated with a conventional angiogram so here's our super mesenteric angiogram all right the supreme mesenteric artery

on the first image to the left is that vessel going downward towards the right side of the screen all those vessels coming off are really just collateral vessels going up to the liver through the gastroduodenal artery again that

left one looks pretty good it's not until you see the delayed image on the right that you see that area of contrast all right so that's the finding that correlates with the CT scan all right here we're able to get in there you put

a micro catheter in that vessel alright the key next step for this patient as I mentioned earlier is the whole concept of front door and back door so here we're technically in the front door the next thing that we do is we put the

catheter past the area of injury and now we embolize right across the injury because remember once you embolize one thing flow is gonna change we screw it up body the body wants to preserve its flow if we block flow

somewhere the body's gonna reroute blood to get to where we blocked it so we want to think ahead and we want to say okay we're blocking this vessel how's the body going to react and let's let's get in the way of that happening that's what

we did here so we saw the pathology we went past it we embolized all across the pathology and boom now we don't have anymore bleeding and the likelihood of recurrence is gonna be very low for that patient because we went all the way

across the abnormality and I think from

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

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

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

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

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

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

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

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

































of the simulation and mentis simulator that we purchased that our system and purchased it's used in conjunction with

the cardiologists and first second third year cardiac fellows interventional fellows who also have the opportunity to practice on this but what I really liked about this and what really surprised me is how real it

is for learners and for our texts that come in our technologists using this piece to move the C arm to move it left to move it right injecting contrast which is actually air but you know we want to say it's contrast I'm moving the

table understanding how to pan the table how to move the CRM there's a lot of different functions that they can use collimation magnification so this board this panel is pretty much what they're going to do on a daily basis so this is

extraordinary and the picture next to it shows us some 3d dimension three-dimensional pictures of the coronary arteries laid out in different projections so depending on how you move your C arm you'll be able to see the

different angles of your coronary arteries again this is live real-time simulation 3d dimensions so we don't have to actually inject the contrast to visualize our coronary arteries in our a Horta there's a function button that you

can push and it automatically displays the three dimensions so it makes it easier for us to identify those arteries without having to inject and show the different views so it's fascinating in more pictures that showing doctor Lee

came who came to Phoenix Banner University Phoenix to help demonstrate so this is our first week after we've introduced the mentis to our learners and had them play with some of the functions again following up with dr.

Lee's visit he's the one that questioned our staff our learners and reiterated what Michael and I have taught in the first week so basically just understanding and reiterating everything that we went through and having our

learners hear it again from the physician what does he want how does he expect his staff to participate in how do his how does he expect his so what are the expectations of our learners so he was really forward he

asked them great questions they answer them because we taught them but we also showed that he also was able to show them some techniques that they as physicians would like the learners to know right so um he is the clinical

expert obviously so it was really nice to see them interacting together and answering questions again just another photograph of one of our learners using the mentis and showing the actual x-ray view on the left and showing the 3d

dimension on the right these are this is our photograph so we took these pictures during our last week of our programs so this is our final wrap-up putting it all together so we basically took them to the lab we we borrowed one of the labs

we asked our operational leaders if we could borrow one of the labs they weren't using that day and we came in and we set it all up we wanted to make sure they knew how to open a tray how does that how to set the table how to

set the back table how to prep the table how to get their power injections their med rads or their assists put together so we really went from A to Z during this wrap up final simulation study so our learners gound and glove they put on

their PPE and we did have the mentis underneath the drape so they were able to drape as if it was a real patient and also manipulating those wires so we had our cardiology fellow interventional fellow first I think it was first year

in second year who came to assist they were gracious enough to come in and help us assist that piece while Michael and I could focus on the learners helping them navigate through that lab calling out for supplies calling out for wires

calling out for stents calling out for balloons so it was pretty realistic and I think I think our learners really enjoyed that this is just another view of our table being set up one of our learners

scrubbed in she was an RN and she was learning kind of moved the table again you don't really get to do that in real life but in simulation all is game so they got to play and here's an image of our cardiology fellow it's not playing

so what it shows is the simulation of the angio angiogram of the coronary arteries so while we inject the contrast you can see the arteries filling in that simulation unfortunately we can't seem to get it to play again more pictures of

me teaching them how to move the table and the position that they needed to be in so and so we also wanted to make it
















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

good morning thank you all for braving 8:00 a.m. and I'm sure you were in bed last night early about 8:30 and really enjoyed getting up for this lecture but here it is so this seems to be one of the you know there's a couple of buzzes around the meeting this year pardon my

voice I wish I was up to like what I wasn't and one of the buzzes percutaneous fistulas and then there's this extreme IR then there's this 3d virtual reality stuff is going around so in Orangeburg ER we're fortunate enough

to be very much involved with both of the newly approved fda devices what she also didn't mention was I was a technologist for eight years before I went to medical school so I kind of know where you're coming from that's why I

really enjoy not speaking to you if it's not for you guys and what you make us look good and I believe me so here's my disclosures someone said you should do well on these I said one I'm looking for more if anyone else is out there knows

any studies or anything they want me to do I'm happy to do them so I'm always looking for more disclosures after they office Access Institute in Orangeburg a little sleepy town about three-quarters of the way up from

Charleston towards Columbia John Ross built this amazing facility we are separate from the hospital you can see the hospital a little bit in the back a little bit in the back there but we're totally separate unit if you're

not familiar with us you've got six operating rooms totally dedicated to dialysis access know nothing else goes on there pardon me there's the clinical area waiting the preoperative and

post-operative a holding area there in the room for about 20 patients we do anywhere from 20 20 to 40 45 patients a day all things peritoneal hemodialysis access creation d clots angioplasty and percutaneous I think that was off the

first case for hemodialysis porcinis access and you see Jeff hole there the one of the developers of the ellipsis device I'm sort of just under the light and the caption is usually how many physicians does it take to put in a

percutaneous access a lot of them on the right this is a totally ultrasound mediated placement and then you can see that's what you get when you connect the artery in the vein you get that very beautiful color flow Doppler of a

perforating thing into a radial artery we'll talk about that now being down south I have had to get I've learned to get used to a chicken and biscuits for breakfast which I've never had to deal with before but it's all been quite

nicely folks been very nice to us so a little trip down memory lane and if you recognize this this is one of the first external officials for hemodialysis you know shrimper shunt and that was followed by of course many fistula sites

there you can see on the Left fistula sites up the radial radial ulnar element and radial cephalic rather of course called the breccia semitic fistula and should go up higher I want you to call your attention to right by the elbow

that area is where the site of percutaneous fistulas today are mostly created and these are deep fish to this and we'll get into what that means in just a moment and of course grafts there on the right

but it's a little bit out of the topic














my last case here you have a 54 year old patient recent case who had head and neck cancer who presents with severe bleeding from a tracheostomy alright for some bizarre reason we had two of these

in like a week all right kind of crazy so here's the CT scan you can see the asymmetry of the soft tissue this is a patient who had had a neck cancer was irradiated and hopefully what you can notice on the

right side of the screen is the the large white circles of contrast which really don't belong there they were considered to be pseudo aneurysms arising from the carotid artery all right that's evidence of a bleed he was

bleeding out of his tracheostomy site so here's a CTA I think the better image is the image on the right side of the screen the sagittal image and you can see the carotid artery coming up from the bottom and you can see that round

circle coming off of the carotid artery you guys see that so here's the angiogram all that stuff that is to the right to the you know kind of posterior to the right of the screen there it doesn't belong there that's just

contrast that's exiting the carotid artery this is a carotid blowout we'll call it okay just that word sounds bad all right so that's bad so another question right what do you want to do here

I think embolization is reasonable but probably not the thing we can do the fastest to present a patient to treat a patient is bleeding out of the tracheostomy site so in this particular case this is a great covered stent case

alright and here's what it looked like after so we can go right up and just literally a cover sent right across the origin of that pseudoaneurysm and address the patient's bleeding alright

patient who experienced the heart attack who had right little quadrant pain after a cardiac catheterization all you like oh so here's the cat scan and what you should appreciate there is in the front of that first image which is the axial

image all right you can see the hematoma that's brewing kind of in the front you notice how all these pictures kind of look the same that's the good part about giving a lecture on bleeding and trauma because they all kind of look the same

so that's the hematoma on the front part of the pelvis and on the on the right image which is more of a coronal like looking at the patient image you can see it right near the right groin you can see that hematoma all right so our next

step was to do an angiogram and this is what the angiogram looks like who wants to volunteer what do they say all right I saw someone raise his hand over here some walk over here what do you think yeah well yes so it is a retro hematoma

would you say describe the angiogram for everybody right where it's at the external iliac down the common femoral looks like there's contrast going up to the left and down to the right probably close to where they accessed yeah

probably but so yeah probably probably too high but the other thing is that's probably a pseudoaneurysm that probably is the evidence that there was a bleed there we're not seeing Frank extrapolation of contrast in a literally

contrast pouring out but we are seeing the effects of an injury to the artery and the constraining of the the remaining normal tissue to hold on to that bleed so the question is what do we want to do no that was very good because

I fooled you it's not always embolization so sorry I lied so in today's world a lot of times when we see this type of pathology we have again relatively new technology available to us again we

could go into that pseudoaneurysm and embolize it and that would be a legitimate treatment but my friend here is right you know this is a great case for a covered stent so we could go in and put a stent right across that area

of injury and stent it so these days looking at coverage stands as an option for patients with arterial injury is a very legitimate option you just have to be able to deliver it has to be the right artery you have to be able to get

the stent where it needs to go we all work with vascular surgeons who are great and they can put these stents and iliacs and aortas but they can't make those turns into livers and kidneys and spleens it's got to be the right artery

this is this is the right artery okay we saw this patient and we said well we could kind of get a micro catheter into that area of injury and embolize it or we could just put a cover sent across it and all go home to have dinner with our

kids so that was option B is what we chose here so this is a great cover stent case okay here's another patient

































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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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
















































today okay go forward so sorry now when it says is there any commercial bias really there's only two companies that have this device so if I speak about each one clearly there's going to be a

little bit of commercial discussion but as I people always ask me which one do you prefer and I always have to tell them quickly you know I'm not a salesman for either company as a matter of fact I'm more

like a test pilot and we're still in the very early stages of this and which device may be better however you wanted to find that or easier to use or what the data is going to show we don't really know yet so but we're fortunate

that we have access to both devices for our patients a couple of things we know and dialysis patients start 80% start with catheters bad okay and catheters bad if you get anything out of this lecture catheters bad about 28 to 53

percent failure to mature means they have a fistula it's physiologically working but it never matures to be able to use for hemodialysis time to maturation three to four months

interventions per year required angioplasty you know embolization you guys know all about this stuff trying to read Evert flow back into the main channel of the fishhook and patients about 30 up to 30

percent just refused once they have our fish to them for whatever reason they refused to have it cannulated you know they don't like the pain it's in an awkward position whatever but the idea of percutaneous

which was may actually put a big dent in that Kathy first-line initiating dialysis with catheters because many times these patients come then they need to houses right away they get a catheter but if we know you know these things

usually except you know for toxic injury like ingesting antifreeze and stuff like that most you know frolla just know these patients are headed towards dialysis well in advance of the time they need it and so these calls stage

four and stage renal disease these patients can get percutaneous fistulas and when it's time then they'll have a running blood access ready and totally avoid the need to have a catheter placed


































fish through creation one is screening with ultrasound you really have to be able to look at these patients and I'm you know when I talk to our physicians they say we have a great

ultrasonographer named Megan and so I say the first thing you need to get yourself a meg everybody needs a meg and May because meg knows what to look for what to look for what's a measure where to get flows and she submits that to us

now other than the anatomic part you know at our place you know we're very particular about and selected we try to be thoughtful about you know who gets what access and that's what the new dokey guidelines are gonna say you know

the best access for the right person at the right time so for example you know if you come in with a catheter and we can you know we'd won from a 275 mile radius people come to us you know for access because you know they they've

they've been given up the cases have been given up by local people and you've got a catheter my first thing I say is how long is the catheter been in and they said well catheters been in for eight months you're not getting a

percutaneous fistula if your catheters been in for eight months I'm gonna call one of the surgeons think I am with part of my group you know we have no competition there's no turf wars we're all friends we like each other we like

working together it's a great place I say Karl Karl Willy who was recently from Tampa - Karl illustration - sick catheter for six months is okay I'm going to create they put a flick seen graphed in the

upper arm probably with a suture listen a stenosis and pull the catheter tomorrow that patient's going to be dilating with a graph where the dialyzer will be graphed you know because after six months you don't want a cath over

there when you start going down that road of infection endocarditis vascular damage all that kind of stuff if you come in and you started with a catheter because somebody wasn't looking ahead far enough and you got a catheter and

they come here for accents placement catheters been in for you know two weeks three weeks one month there's a good chance you're gonna be seriously mapped for a percutaneous special because now we have time we've got we arbitrarily

have considered the six months window that we can probably work with the catheter there's nothing to prove that there's nothing in the literature in fact I had a discussion last night with someone from one of the companies who

wants to do some type of a trial to look and see when can these catheters really do go bad and so you're gonna get worked up for a percutaneous fish and clearly if you come with stage four you know know you're not on dialysis they don't

know when you're gonna go into Alice's but they you know you're going in that direction you're gonna get seriously worked up for a percutaneous fistula one patients are still psychologically trying to wrap their head around the

fact that they're going to be on dialysis it's much easier to tell them you come in you're gonna get a puncture two punctures you're gonna go home with a band-aid and we'll take care of this we'll get this up and running over the

next six weeks eight weeks ten weeks and when you need it it's gonna be ready to go and you won't need a catheter then we tell them you don't not gonna need this catheter sticking out of your neck they're very happy and they usually

agree to do the percutaneous miss doula also since you don't get those big ropey fish - as I talked about when these patients are in dialysis you know how many people ever been to a dialysis unit that's how I tell physicians you want to

you know you want to look build a practice like this go to the dialysis unit talk to the charge charge nurse do rounds once a month or once every couple of weeks with a nephrologist and that's how you build the practice but these

patients they're in the chairs they're talking to each other right and they say hey how come you don't look like a cling-on you know with this big veins you know you where's your fistula and then they want that you know they it's

really cosmetically very pleasing these patients are so deserving and they have such horrible I was being tied to that machine three days a week so any little bit of hope we can give them I think is is worth it alright in summary it's not

a one-step procedure and then we try to make patients understand this you may need a secondary angioplasty or embolization in the future hopefully not usually about 30% of the time has great value in the stage Forge so we

talked about more acceptable to patients coming to grips with their future may make a significant difference with the catheter people starting with a catheter and I think whoever is going to do this really has to have a commitment to

access this is not you're not doing a procedure you're actually developing a treatment plan or a treatment system and so then these patients are yours once you do this you're following them you're keeping them working you know how do you

sell this to the surgeon you sell to the surgeons this way because if you start this program you know people are gonna start coming to you they're gonna come out of the woodwork it's like if we start doing AVM stuff that they start to

come from nowhere and you're gonna draw so many patients the in that surgeons are going to have more work and there's no question because everybody's not going to be a candidate and so I mean when bobwhite if hopkins years ago

started doing angioplasty the business of surgery increased by 15% so you're gonna see you're gonna make the pie bigger that's how you sell it you're making the pie bigger and everybody can feast on the pie leverages our expertise

as interventional radiologists and image guided procedure list to make these procedures work I think we're in a great position a really great position if you listen to Alan Matsumoto the other day at the toddler lecture we're in a great

position for the new age of medicine and it may be the ideal procedure for multidisciplinary collaboration I can't do basilic vein transpositions or elevations or brachial vein elevations so it's good to have a surgeon that

you're friendly with that will make these things happen they're all part of the group that's necessary and I think that could be it yes ah I'm from New York and I'm a shameless marketer and so I would encourage you if you're

interested or some of your attendings or interests come to the vasa practicum it's gonna be done in Houston with dr. Eric Pete and chief of vascular surgery is running the meeting you get to put your hands on all these devices and put

and stuff you can all do it I mean it doesn't have to be doctors you have big models and they'll have live cases and it's a great opportunity in 2020 since I'm the president-elect of Vassar we're gonna run the meeting in

Charleston that's gonna be held out a hell of a lot of fun so we encourage you to come to Charleston in 2020 thank you very much not questions yeah





















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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

here's another patient 62 year old male

patient just a similar case who had head in that cancer again after radiation therapy who experienced some bright red blood while coughing all right here's the CT scan and what I want to draw your attention to a little tough to see I

think I'll let me go up up here point it out with a mouse well I don't have a mouse so I guess not is basically you can see right in the middle of the two lungs kind of right in front of the trachea which is the black

circle alright just go right in front of that up to the top you can see the round white circle which is the brachiocephalic artery and just projecting off the back of that is another little kind of outpouching of

contrast a little nipple coming off of of the brachiocephalic artery that doesn't belong there all right here's the angiogram and it's a little difficult to see but there is a see if I can describe it better to you alright I

think this is actually a video so I'm sorry I don't know the ability to run it unless you can click on it can you guys click on the back up so if you want to look at it again you see the angiogram kind of running and just at the origin

of the brachiocephalic artery which is the first branch of the aortic arch you can see that outpouching of contrasts coming right to the right of that vessel that's a pseudoaneurysm and again we went through the same thought process we

said you know I want to put a covered stent across that but my problem was that we didn't just have the right size that would not block one of the carotid arteries and not extend too far into the aorta so we had no choice but to

consider embolization in this particular case so here's what we did here we actually put a micro catheter if you can just click I think that's a video to the left no I guess not you know what it's okay

what we did for this particular case was we went in from the arm and we put a micro catheter directly into that pseudoaneurysm because we couldn't feel we didn't feel we could put a stent across it so we put the micro catheter

in there we started to put some coils and it actually went further than we thought outside of the artery and here's the post image so you can see our final image you can see the coils that are sitting just adjacent to the

brachiocephalic artery and we preserved good flow there to end this basically

predictors of a successful or vascular ization there are several so obviously you know you have a great result Andrew

graphically when you say hey the vessels back that wasn't there before so Payton see if a previously occluded vessel is a good sign but what else improve vessel caliber so after an angioplasty the vessel becomes you know more normal and

caliber the flow velocity increases or the outflow improves you see less collateral so that's a good sign that you've done something good because those collaterals have only gotten large because of increased pressure and the

normal outflow vessel and then increased distal branch opacification Perry procedurally things that you can look at that indicators of success are if the pulses returned or if you have a Doppler signal

that either comes back or goes from a mono phasic I'm not gonna repeat those sounds they were way above my pay grade but go from a mono phasic signal back to a normal triphasic or sometimes even biphasic is pretty close to normal

particularly in diabetics skin discs skin coloration you sit you may see a foot pink up relatively quickly after a good revascularization and actually some patients may develop rube or if they've had prolonged ischemia because their

capillaries are chronically dilated so you now sending flow into chronically dilate a capillary bed and they may get rubriz capillary refill time as you mentioned earlier may decrease to a normal range to less than 5 seconds and

ulcerations I've seen them just begin weeping or bleeding right on the table if you do a really good job upon awaking from sedation patients who have rest paint off and indicate that the pain is gone but you have to remember that

patients with wounds may actually wake up and be in a lot of pain because you're reap refusing an area that's been dead for or dying for a long time so the wound blush is something that I'm always looking for and I'm frustrated if I

don't see it and basically this is analogous to when the when the ulcer begins bleeding after a good revascularization you may see Andrew graphically that there's now a contrast blush in the area of the ulcer and so I

like to mark on the patient usually with a hemostat or something the area of the ulcer and take my final angiogram just to kind of know where it is and to be looking for that it may it not always be visible as it may take time for the

capillary network to adapt to the new flow pathways and for basal spasm to resolve but this is an example of a patient has an ulcer underneath the base of their big toe after revascularize them and you can see

that there's increased perfusion to that area so this is a sign of a good result
























































































ultimately we did it so what are

I think it's important to understand what options we have in in treating patients with carotid disease or those

in our practice medical therapy is a mainstay so all these patients regardless that they get t'car carotid stenting or otherwise need to get the best medical therapy there is a role though for each of these surgical

endovascular or a hybrid such as t'car and hopefully you have a better understanding of that option and ultimately if you understand the different techniques then we can apply the best ones depending on the patient's

anatomy or current clinical scenario and and apply that to that patient thank you [Applause]

































