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Portal Vein Thrombosis|Thrombolysis|51|Male
Portal Vein Thrombosis|Thrombolysis|51|Male
2016aggressiveangioaspirationBoston ScientificBTG-IMcatheterclotdevicedistalekosextensiveintentionallyintrahepaticlikelihoodliverpatientportalsheathSIRtipstransjugulartransplantvein
Submassive PE | Pulmonary Emoblism Interactive Lecture
Submassive PE | Pulmonary Emoblism Interactive Lecture
Complications & Pitfalls | TIPS & DIPS: State of the Art
Complications & Pitfalls | TIPS & DIPS: State of the Art
Rheolytic Thrombectomy | Management of Patients with Acute & Chronic PE
Rheolytic Thrombectomy | Management of Patients with Acute & Chronic PE
The Disease Process | TIPS & DIPS: State of the Art
The Disease Process | TIPS & DIPS: State of the Art
Mechanical Thrombectomy | Management of Patients with Acute & Chronic PE
Mechanical Thrombectomy | Management of Patients with Acute & Chronic PE
amplatzcatheterchapterclotcombidevicehelpsInari DeviceInari MedicallossNonepatientsprovestudiessuctionthrombectomythrombolytictpa
Aspiration Thrombectomy | Management of Patients with Acute & Chronic PE
Aspiration Thrombectomy | Management of Patients with Acute & Chronic PE
angioAngiodynamicsAngiovac CannulaAspirex CathetercatheterschapterclotdevicedevicesfrenchIndigo ThrombectomyNonepatientPenumbraPenumbra Inc.sheathStraub Medicalthrombectomythrombustpa
Stent Graft Deployment | TIPS & DIPS: State of the Art
Stent Graft Deployment | TIPS & DIPS: State of the Art
Ultrasound-assisted Catheter-directed Thrombolysis | Management of Patients with Acute & Chronic PE
Prospective CDT Trials | Pulmonary Emoblism Interactive Lecture
Prospective CDT Trials | Pulmonary Emoblism Interactive Lecture
Cone Beam CT | Interventional Oncology
Cone Beam CT | Interventional Oncology
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Indirect Angiography | Interventional Oncology
Indirect Angiography | Interventional Oncology
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Percutaneous Mechanical Intervention | Management of Patients with Acute & Chronic PE
Percutaneous Mechanical Intervention | Management of Patients with Acute & Chronic PE
catheterchapterclotmassivemechanicalNonepatientpatientsPig Tail Catheterpigtailpulmonarysurgerythrombolytictpa
Ideal Stent Placement | TIPS & DIPS: State of the Art
Ideal Stent Placement | TIPS & DIPS: State of the Art
anastomosiscentimeterchaptercoveredcurveDialysisflowgraftgraftshemodynamichepatichepatic veinhyperplasiaintimalnarrowingniceoccludesocclusionportalshuntshuntssmoothstentstentsstraighttipsveinveinsvenousvibe
The Last 5 Years in PE | Pulmonary Emoblism Interactive Lecture
The Last 5 Years in PE | Pulmonary Emoblism Interactive Lecture
Ablative Radioembolization | Interventional Oncology
Ablative Radioembolization | Interventional Oncology
Massive PE | Pulmonary Emoblism Interactive Lecture
Massive PE | Pulmonary Emoblism Interactive Lecture
PV Access | TIPS & DIPS: State of the Art
PV Access | TIPS & DIPS: State of the Art
accessaccessedangulationanterioranteriorlyballoonchaptercirrhosisglidehepatichepatic veinliverneedlepasspintoportalposteriorprolapsesagittalsheathshrinkagestenttractveinvenouswire
Radioembolization | Interventional Oncology
Radioembolization | Interventional Oncology
TIPS: Techniques- CO2 Venography | TIPS & DIPS: State of the Art
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51 year old man history of ulcerative colitis

PSC, he was completely asymptomatic. He had his one year screening CT that showed extensive portal vein thrombosis. No other imaging findings, he was a walkie-talkie. He actually was a maintenance man in our hospital.

So this is his prior CT from a year previously and this is his follow up CT that's actually extended well into the undivided extrahepatic portal vein almost to the level of the SMV. At our institution at that point in time this precluded the individual from transplant. He wasn't on the transplant list,

he had a MELD of probably six or eight. He was a long way away from his transplant but because of this finding he would have been excluded for a future consideration. So that point in time we decided to go ahead and do thrombolysis. A couple of different ways to do it ,

you can either do it from a TIPS approach. I tend to do it from a percutaneous access. So under [INAUDIBLE] guidance we percutaneously accessed the right portal vein. It actually was relatively easy to get through.

The other question with this particularly sensitive was some contrast around it, is was a chronic clot that hit surgery tract. But it was actually fairly easy to use an L35 system. We angiojeted it including the aspiration and then stopped the aspiration and injected it with Angiojet 6 milligrams of tPA.

We did what we could to aspirate any clot which wasn't particularly helpful. And there was very significant clot burden remaining. So at that point in time we decided to go ahead and do overnight infusion. This was the first time I used EKOS.

And this becomes important in this discussion. Intentionally I wanted everything to go as, just the way it would flow from the portal vein as possible. So I didn't just wanna get the main portal vein but I also wanted to get the intrahepatic sections of the portal vein simply to

increase my likelihood of getting flow. So we start tPA to a milligram an hour which is usually what I do. Heparin 400 units and admitted to ICU, he was just fine at this point in time. This is the spot film that I took from the image. Here's your EKOS catheter. This I tributed to the distal length of my sheath and then here was,

just to extend the catheter. Patient became unstable overnight rather rapidly. The on-call team came in and the first thing they did was up size the sheath thinking that might be part of the problem. He had an Emergent CT that showed massive hemorrhage into the peritoneum. We actually got a surgeon to go ahead and

take him for a lap even though he had just been on tPA an hour before. They packed the liver that was really all they could do. The patient went into rapid DIC, multi organ failure, and expired. And again, I wanted to thank you guys for putting me up here with

this case. So when the on-call team came in, and they noticed that the EKOS catheter was essentially all the way out, they exchanged the sheath which is seen here and advanced it much more distally into the undivided right. This was his hemoperitoneum.

So likely we think what happened is that he just oozed from his liver puncture site and that he had a perihepatic subcapsular hematoma that as it expanded, retracted the sheath and the EKOS catheter to the point where the sheath was probably outside of the liver and then there was no [UNKNOWN].

That's what we were thinking. However, and this is the M&M part of this case. This is the distal extent of the sheath that was used during the up sizing by my colleague and Paul and this if you remember was the first image that I showed you from our final spot image. That's what I attributed to the distal sheath,

as it turns out as you blow that up, really the distal sheath is right here. So again I intentionally use the short sheath because I wanted intrahepatic flow, her intrahepatic tPA and I misinterpreted the image. There you go.

A little bit better, it's a little fuzzy. But again, this is the end of the EKOS catheter. >> Was that a larger remark about the EKOS catheter? [LAUGH] >> No.

No. This is- >> It only burnt once. >> This is a [UNKNOWN] So my problem with this is I used a new device and a very complex case so relatively complex case that had a high likelihood in my mind of going wrong. Especially is devastating

in this individual who the day he walked into the Angio suite, he walked into the Angio suite. The other thing, and this happens to everybody in this room, is that you feel rushed, right? This case was taken significantly longer than I thought it would by a couple of hours and as you're tiding up the room whether it's you in the room or one of your colleagues you feel

a little bit rush and you wanna get things moving. So I think a couple of issues that I learn from this case are, one, any time you're unfamiliar with a device no matter what device you're using, it's important to do two things. One is to dry lab it on the table before you use it if you can unless it's[INAUDIBLE]

And then secondly, to fluoral/g it because I really had no idea what the device looked like under fluoroscopy. I also used the sheath that I don't normally use that didn't have a radio peak/g marker on the end. So this was a consolation of mistake followed by a mistake, followed

by a mistake. And I guess I will end there and take any questions if you have. >> What do you think about transjugular in this case, I mean we had a very similar case. Actually this should have been the right thing, we did transjugular access, lysed, opened it up, left the TIPS to be nice so that it doesn't clot again,

it has that advantage as well. But then our [INAUDIBLE] his enzymes were kind of moving around and they wanted to check the [INAUDIBLE] And one of my colleagues went directly instead of checking from the existing shunt. And then that patient bled a lot and died eventually. So in these [UNKNOWN] patients,

I vary a lot coming [UNKNOWN] especially if we're doing this tPA etc. Would you in the future choose [INAUDIBLE] >> So let me take you through my thought process. My thought process was this guy had absolutely extensive TVT in every intrahepatic branch that you could think of.

So my concern with doing [UNKNOWN] TIPS is was I gonna be able to mechanically clear any of the intrahepatic clot? I thought the answer of that was no, which is why we went pre percutaneous. We're aggressive with the Angiojet, we were aggressive with balloon [UNKNOWN] We were aggressive with aspiration.

In retrospect, not the way to do it, I'm pretty sure. >> [APPLAUSE]









































okay next up this I think this video yep

























much more controversial so you it was pretty clear that we have to rescue

massive PD patients from death but with these statistics what are we supposed to do with sub massive PE well are we supposed to prevent mortality it's gonna be hard to do if the mortality is only 2 to 3% because you're trying to really

improvements of a very low statistic are you trying to reduce the rate of hemodynamic deterioration that's a possibility what about long-term disability if you remove clot upfront

will these patients do better six months one year or two years down the road frankly we don't know the answer to any of this and the reason is that the pytho trial made things quite difficult for us to interpret the pytho trial was the

trial that was going to answer all uncertainty this was a trial where it took some massive PD patients in that high-risk intermediate category and randomized them to receive a bolus of tenecteplase which is similar to TPA but

is not the same versus anticoagulation alone what did it show well it showed there was no difference in death between tenecteplase and placebo so they actually gave a placebo drug so that no it was a double blinded

study now if you look at the next line though a lot more patients decompensated if they receive the placebo than that's not to place this is not a bad thing you know it's not it's not great when you have to intubate somebody or initiate

pressors so if you can avoid that outcome that's it that's a pretty good thing so maybe it is the right thing to give systemic thrombolysis in the setting of sub massive PE problem was this the bleeding you look down here

there was an eleven percent rate of major bleeding in the tenecteplase arm there was a two percent rate of intracranial hemorrhage so now we've got this therapeutic window that's hard to interpret so we seem to be improving

outcomes from an efficacy standpoint but then we're also increasing the rate of bleeding so basically what we've sort of coalesced around is that systemic thrombolysis has a questionable risk benefit profile because the rate of

bleeding and the rate of really serious bleeding is makes us nervous so is that an opportunity for catheter director thrombolysis and I'll call this the poster child for Catherine throwing license if this is how it worked every

time we might have a homerun so this is gentleman looked terrible well still in the sub massive category but breathing at 35 times a minute hypoxic had his main PA systolic pressure of 60

millimeters of mercury you look over here and there's this large clot in the right upper lobe go to the left side and then there's all this clot in the left lower lobe as well so what do we do we put in bilateral infusion catheters this

can be an E Coast catheter it can be a standard catheter these areyou nafeez catheters have side holes starting from here and ending it's hard to see but there's another radiopaque marker somewhere down there on this side there

and somewhere over there and between those markers you have multiple side holes and those are put up inside the clot so you're dripping TPA at a rate of about 0.5 to 1 milligram per hour and you're getting it directly into the

clock that's the theory and so after 20 to 24 hours of that you know you're given 20 to 24 milligram of TPA that's compared to 50 or a hundred that you get was sitting with systemic thrombolysis you get something

that looks like this where the pulmonary arteries look pristine the PA still the systolic pressures come down the patient feels great now the skeptic would look at this and say well if you just tried some heparin and you just infuse saline

would you have the same result and frankly if you were to conduct the experiment you might find something interesting or not interesting but we never have conducted that experiment but you know I'll tell you a little bit

about the ultimate trial if I have time I don't want to go to overtime though

strategies so some things that we have





















people were thinking about the covered











































































so these are a lot of slides most limited you know I'm talking I'm talking to you guys I'm talking showing you a lot of technical stuff you know and a lot of slides and I'm gonna talk mostly technical of you know how tips and dips are done kind of a step by step so even

the title it's kind of a workshop step by step of how basically you do you do tips and dips and what and and what are they so in general when you have when you have this is basically kind of out flow spleen spleen dumps blood into the

portal vein the mesentery dumps blood into the portal vein portal vein goes into liver liver does its thing and then dumps the blood into the eppadi veins to the right atrium okay for that because the liver is connected with the spleen

and the guts in series unlike any other organ basically the liver has to be a low-resistance organ because the portal circulation is low-pressure look the liver has to be a low-resistance organ with liver disease especially liver

cirrhosis you actually get increased resistance and in the liver with that disease and you get basically a backup of the blood flow in the portal circulation and increases the pressure in the portal circulation that's kind of

the genesis of or the pathogenesis of portal hypertension backing up circulation the spleen and in the guts then you get ascites and hydra thorax that's kind of think of it as weeping of fluid into the pleural space and into

the and into the perineum part of it is oncotic part of is osmotic basically think of it nutritional and pressure driven causes at the same time we all have potential portosystemic connections in other words they're there but they're

not connected or they're not opened up in plumbing they hold them bleed valves or pressure valves when the pressure is high and you know they start weeping or leaking you know in your in your basements we have the same thing

we have so many portosystemic connections there are about 55 named ones there are innumerable ones that are actually that are actually not named the common ones that we know are because of because of bleeding is esophageal

varices that's the connection usually between the left gastric vein and the azekah can be hazardous system you can also get gastric varices and that's usually connecting between a spleen and the left renal vein through a gas renal

shunts you can get also all sorts of connections even down in the internal hemorrhoids we get actually portal hypertension hemorrhoids and bleeding and so many numerous other shunts that we just don't have time to cut to cover

it to cover all these so the general to the general thought of treating all these complications of portal hypertension is to decompress the system to reduce the pressure and that's along the lines of years and decades of

surgery shunts that were placed and now tips ism largely replaced all these surgical shunts with the exception of Vancouver and Tampa okay that they still do some surgical actually a lot of surgical shunts most most other places

in North America converge to a tip to a tip shunt the the advantage of the tips of over surgical shunts is the usual what we hear is minimally invasive it you know it's a quick recovery less morbidity and mortality areason for

white tips has beaten the surgical shunts is the transplant era all these surgical shunts are actually extrahepatic so when you go for a transplants and liver hits the buckets they actually have to go and shut down

these shunts wherever they created them steena renal portal cable in the tips it goes out with a liver in the bucket so there's no complication of transplantation that's the real advantage of tips over surgical shunts

and that's why it's become very very prevalent in in in North America with a transplant error when approaching gastric varices just briefly another way is a BRT Oh which is to go basically into the left renal vein go up the shunt

and specifically screw rows the stomach and that's not the that's not this kind of subject of our of our discussion here I'm gonna talk to you

















another device that's new in the market

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

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

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

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

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
























PE the first one of course is

















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

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

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

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

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

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






















































































































thanks everyone appreciate it [Applause] [Music]



































































systemic TPA so I wanted to go through a







and sometimes you need to have a bigger

















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

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

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

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

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

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

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

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

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

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

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



























































six or even a seven millimeter balloon

patient like this you have a very large left lateral HCC that's invading the left the patek vein and extending into the heart since when we get into things like radioembolisation if you have

multifocal liver disease if you want to apply radiation therapy to that's very difficult to do that because it actually requires more radiation dose to kill HCC than it does the adjacent normal liver the liver is actually that ready

sensitive so you can do things like SBRT and pick an individual lesion you can do things like a imrt which is you know survey 8 non focus generalize low dose but what's interesting Malaysian is that if you administer

particles they only shoot about two millimeters worth of the raishin field around it so of what used is that with one not much but if you put eight to forty million of them within the bloodstream they Auto sort themselves

based off of the vascular flow preferential that exists with tumors tumors actually emit hormones pull in blood supply that you weren't born with and that actually tends to pull beads from the bloodstream preferentially

towards it so this is an example where you stain a tumor with two types of wax one the portal that's blue one the artery that's red and you can see how much that preferential exists so what ends up happening is these spheres

cluster within the tumor and then provide local dose radiation that's very hot where the tumor is and low elsewhere so here's an example of that this is a patient with metastatic neuroendocrine disease multifocal liver lesions you can

see that vascular flow preferential this is what it looks like on the maa when we jecht a protein particle surrogate that has a technician I should have assigned to it just as a visualization of how the particle is

going to sort out and the post y9t bremsstrahlung CT is over there and you can see how intense the necrosis is within the tumor and how much it's spared the normal liver however you do get some radiation damage they don't

live a regardless that's why choosing the timing of when you're gonna do this is important this is a patient that was treated with tastes above and one session of y9u beneath so you can see that they do have different types of

therapeutic mechanisms they're not the same even though they look very similar in terms of when we're administering

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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