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Good evening, everyone. Welcome toe. I are bites. My name's Chris I f two down into wanted and Somerset and like to welcome you this evening. Teo are I are white talk on aneurysms on, but like to welcome our speaker. Doctor Drew McLean is a consultant based on in South Hampton. And it's gonna be talking to us today about an abdominal aortic and peripheral aneurysms. And how best intentional radio just contract those. So without further ado your hand you over Teo Drew. Okay. Thanks, Christian. And good evening. I'm dreaming. Claim number into radiology Standing. Sampson was. Crys said tonight we're gonna talk about that. Aneurysms. So it's something we treat a wide range of aneurysms. Grain DJing from really quite large aortic aneurysms. Time to very small, bleeding, visceral pseudoaneurysms. But she called the aneurysms retreated really important on. Then, when I was putting this talk together, I actually thought that treating aneurysms is it's one of my favorite parts of the job. Actually, I think that really comes down to why we treat aneurysms on. Because if you don't really know their two men reasons why we treat aneurysms quite simple. Number one, the aneurysm has already ruptured, and we want to stop that patient from bleeding to death essentially on pretty good reason to straighten aneurysm and number two on. But we think that aneurysm is a risk of rupture on. Do we want to stop it before it does? We want to treat it before it ruptures. There is one man exception to that which I'll cover quite early on. But those are the two reasons. So if you think about that on you, you know, you can see why it's really quite rewarding to be involved in aneurysm treatment as a consultant because you make a huge impact on the lives of these patients. Um, Andi, Um, yeah, I think the reason I was soaking person to be this presentation why I wanted to do this was because I see a lot of Junior's and a lot of medical students having the same misconceptions that I did at that stage on. I just thought, Why, maybe covering some of them, you know, I could stop making the same sex I did when I was a genius. Two reasons. I think you should definitely consider being not just a consultant intervention, radiologists, but including aneurysms, is one of the areas of treatment. The offer Number one, You need the full scale package. If you're gonna treat aneurysms, you need to be an expert. Closure device is on. Do you need to be able to track like shoots around tortuous tribal vessels? You need to be able to deploy stent grafts with millimetre accuracy on. You need to find motor skills for microcatheter manipulation for ambulance, a shin of small bleeding pseudoaneurysms or Enderle Campbell ization. The other really good reason I enjoy treaty aneurysms is and this constant new technology. I'm sure you will know this intervention with allergies on the forefront of new medical devices in technology, but particularly with aneurysms, there's a lot of new devices and new technologies Andi implement in these and safely and effectively on. But patients can actually be a really check, you know, really big challenge. It's also really nice interacting with industry, their group of people that have a quite different backgrounds, as sometimes his doctors on. It can be quite refreshing working with, you know, different group of people ever there. That the third reason I didn't put on here that I just thought of more recent is, and we weren't really closely with vascular surgeons at Southampton. We have a great bunch of basket surgeons, and it's absolutely pleasure working with them again. They're a group of people. Every different training background to us on Be working alongside thumb is what is one of the favorite parts of my job. So how I'm gonna do this tonight is first, we're going to talk about aortas. You can't really talk about Aneurysms are not a orders on intervention Radiology talk, and I'm gonna be really covered. Why? I really actually got that away. And I took that when we treat them how we treat them. And I also just wanted to cover the controversy aortic aneurysms, an endovascular treatment. Because you may well have heard a bit about this and even me as a consultant, you know, I find some of confusing, so I'm just going to try and put it in understandable terms. And then if we do have time, I'd love to cover it, then other aneurysms, and particularly pseudoaneurysms on because they're one of my favorite things to treat on how we do that on but you know, is really interesting technical point of intervention Radiology to that. When you start infantry radiology training, you you know you'll you'll learn more about. And that's one thing I really want you to start doing is start imagining yourself as a consultant interventional radiologist, because believe me, it's really not that far away. So why do we treat aneurysms like a sets? The main reason is rupture, but is one exception to this and it's really important to know about. And so imagine you've got on an aneurysm in a in a blood vessel like this, obviously have turbulent blood flow within their aneurysm on back in basic build up. So you get from this formation within that on then and one of two things can happen. Other bits of that acute promise come break off and go on large in the smaller vessels. So distant embolism a shin is one complication. Well, the other one is the aneurysm in just completely from bows on. Both of these can cause acute them ischemia with that being, you know, which is a really serious complication is not related to rupture on. But I mean, you may already know this, but this is why we treat popliteal aneurysms actually on. But I think it's a really important exception to mention on because, uh, because, you know, you'll come across it quite a lot. So let's let's go back to a orders on. But we divide the million for treatment into traffic in abdominal and to try and make this may be more relatable. Understandable. I'm gonna tell you about really case on game through I am due to recently and how we decided on what the best treatment was for them and how this sky was treated. So this is a 69 year old taxi driver, and his aneurysm was picked up by screening, which is how we picked up a lot of aneurysms now, so above 65 men who invited to have screening of aortic aneurysms. Um, asthmatic wrist, really? Not a previous MRI and some stents, and he was type two diabetic. So I mean, what do we do with this guy? You know, realistically, do This is aneurysm. We leave it, we surveillance. We tell him not to worry about it. I'm really if you think that is a huge number of factors that plays into this decision and essentially What we're doing for him is we're trying to balance the risk of rupture versus the risk of putting him through. An able to repair on the one statistic that is really worth bearing in mind is if his aneurysm, his aortic aneurysm, ruptures. This guy's got an 80% mortality rate day out of hospital, so that's not good on spirit, is it? So if this was 25 30 years ago, um, this guy, we've had two options. Either would be nothing for him or he has an open aneurysm on to try and put this in simple terms. Obviously, there's the upfront risk of the repair itself, and then there's a long term risk at the risk of rupture or risk of other mortality causes. Now, if you see on, if you do nothing for him, there's no additional risk to him, and it's quite low, Whereas open surgical operation has got significant risk of risk to life. Also risk of major events such a stroke pee DVT hot state. But then over time and the reason we obviously put patients through that is over time that that initial approach risk really pays off because they have a much lower risk of rupture. But what if I did? When it was first developed it about this third options. It's an endovascular aneurysm repair. You can do it. It's a minimally invasive procedure on. But the idea was Let me just let me show you this video just of how we do it. If you never seen anybody before, this will run through it in about 10 seconds. So basically, get much tennis access to the groins. We put a sheet that on, but the stent graft through that she and we uncover it self expands. And the key thing is, you want to see it below the neck, as you can see. All right on doxidan cover the renal arteries. It's You can see what people call these trials a graft because it splits from one main channel into two channels. You don't get access of the second channel just of the limb, and you put a stent into that. You can see our isn't top just indicating that you get some suprarenal fixations like a Crown springs open. Um, holds the stent graft in place. That's it, really. You know, in principle is really quite simple. and quite nice, obviously is anatomy gets bit more challenging, tortuous. Short to next, things can get really difficult. Actually, the topical that straight forwards in mind 70 day Don't take that long. It took a bit longer on Day IV. Are was seeing, really is this great thing? Because well, hold on, we've got this lower from risk, but also this lower long term risk. Um, but the long term risk of rupture and of other complications just is not as low as open surgery. And I don't know anybody would claim it's climate is. But this this area here is where all the controversy comes from, basically and deciding what's best for patients hand and how much. Um, you know the initial risk, it is worth taking it front. So let's just go go back to our patients on Go ask. So when should we repairs on your and really for him on any other patient, you should repair the aneurysm when the risk of rupture starts to outweigh that up from risk to them. Okay, that you're gonna put him through with an operation or procedure and to try and give you an idea of numbers for that. Okay, this is a pretty straightforward graphing. It's your risk of rupture. Um oh, sorry. I just seen Christmas message, but this is in the way. Very good. It's, um so So this is this is the graph that's really important. Basically, along the side, you can see the chance of rupture on the bottom. You can see as the aneurysm size increases, so does the chance of rupture. So less than 4, 45 centimeters you can. You're very low risk of fracture, less than 10% and then around 5 to 6 centimeters. That's when it starts to approach an area where, you know, you might be bit uncomfortable. It's somebody with an aneurysm. It's about a 10% chance of rupture. And then up to, you know, above eight centimeters, you got 50 50 yearly chance of rupture on Personally. Wouldn't be too thrilled with those odds, Onda. And so it's the kick. The first thing I want to mention about this crap is days. It's only done on size. Actually, if you think about an aneurysm on on how many different factors will contribute to that risk of rupture, that size is only just is one of thumb. So things like BP on thickness of the wall thickness of thrombus um, location of the aneurysm, the morphology of it on to take just one of these and go on size is really day, you know, is not taking the full picture into account. On the other hand, is really simple on diffuse. Try to make decisions about which ones we treat. It's quite it's really quiet. So what we actually do This is what we This is what everybody does in the UK is we draw a line bang slapped down middle of this group of 5 to 6 centimeters aneurysm. When you say when you get to 5.5 centimeters, we consider repairing your your aneurysm, Okay, we would so below that, we wouldn't consider that above we would doesn't mean you definitely get an aneurysm repair to see their A lot for the factors, but it means at least we might consider it. Okay, on, that's a killer. Any point is just if you're gonna remember one number tonight, remember 5.5 centimeters because that's a threshold for elective repair. The problem with doing that is, if you see below the line. There's patients than here. The actual you know, people who have, um, aneurysm. That's ruptured, Okay? And we haven't offered them a repair, which just goes to show that the size threshold doesn't catch everybody. The two exceptions, that which is another key learning point it should always remember, is exceptions to the rule is if their aneurysm is symptomatic. So if they have abdominal pain, basically, or if the aneurysm is growing quickly, so more in the centimeter a year, then we still repair in that group. So they're high risk patients with my group. The ever negative of this strategy that we have is that there's you can see there's a big gap here where patients you have an aneurysm we offer repair to, but that aneurysm will never rupture. You know they'll die of something else on down, and, you know, that's so so no great thing, is it so? I mean, whenever you have something that's maybe more complex than we can easily appreciate, it's always a situation I start thinking is, is there some kind of algorithm or artificial intelligence that we should be using on? But there are a lot of papers on this, actually, but I just don't think it's gained enough evidence or momentum or traction to really be because you think it has to be something that's easily usable for everybody in the UK to use her papers out there that use computational flow dynamics within the aneurysms on do a lot more accurate working out which aneurysms we're gonna rupture. But it's just no easily on transferrable across the whole of the UK The one thing I was really gay not want to share with you tonight it's something I think is really cool on. It's where we do use an algorithm, and it's actually it's not radiologists or intervention radiologists or surgeons that cannot it It's a neat tests, and it's to do with the risk off the long term risk for these patients, but also the upfront risks of repair. And it's well to do the cardiopulmonary exercise test. Okay, the CPAP So most patients who have an aneurysm considered repair will have these. They certainly do it. So Hampton on. Basically, they get put on an exercise bike to start here, and they get attached to loads of leads on. It's essentially of the 02 Max test, and these these old guys sometimes get pushed to their limit. Basically, on the bike, it's harder, harder to pedal, and I have to keep going on. But then we get the numbers. The numbers that we get out of that gets fed into something cook of Carlyle predict, and it was done by underneath this junk collar on day. One of things I love about this is it just made it accessible for everybody to use. So basically, when he published this, he put a link to the drop box, which anybody can go. But I mean, this is how access that found the paper. I clicked on the link, and you have access to all his his algorithm in his data. It's really nice because it gives you described graph, which is perfect to show patients. These are the inputs again, and if you can well, you can see that. But it's just based. It's just basic characteristics off the patient on down the bottom. There, you can see it's got our aneurysm diameter. Okay, then it's got also how they did on the test, and then it's got some of their comorbidities heart failure for for material disease on breathing function, things like that. Um, basically, what this gives us is what their risk is. Estimated risk of mortality and morbidity for the operation for open or endovascular, which is really nice to go show patients that. But then the best thing is is is this which is the graph on of survival from Burti for that patient, which is such a good visual aid. And you can see the black line is if we did nothing for that patient on, but they wouldn't even reach six years before they had a 50% chance. You know, they're 50% chance of reaching 5.5 years, basically, which isn't great because of aneurysm ruptures. And she the red busted line is evil if they haven't done the vascular repair on the the continuous red line is open surgical repair. So I just want to highlight to start the graph here because you can see, obviously, on day zero, if you have nothing, you've got the best chance of survival cause, you know, coming into hospital. You know, I think procedure, and just below that is IV are because it's safe. But it's not completely. Nothing is completely safe and then blow that you've got this solid red line, which is what happens if you have open repair. So you take that initial hit to your survival probability, but you can see it's not too long before those two lines cross the even open repair line. And it's about three years before open starts to be a better option for you in terms of water. There's also something called the people some, which is another risk predicted that we can do to give patients and idea of their morbidity if they were to have open or even on this. And of course, the other thing that I'm a patient needs. He needs a CT scan. We need to plan exactly what the options are. Thin is an endovascular repair possible doesn't have to be open and then to just to give you a flavor of exactly how we make these decisions based on these patients will discuss the MDT on. Do we have the CT scan? We have the anything with CPAP, and we have the surgeon who knows the patient on how it normally works is I will run through the CT scan and describe on the anatomy and what might be possible even on open wise on. Then the test basically comes in with the CPAP and says, Let these his chances on if he has open if he has even And then the surgeon says, Well, you know, this is what the patient was thinking in clinic Onda eventually really green on basically what we would offer the patient, what options we think we could put to the patient we think are acceptable risks. And then the patient, of course, you know, makes the final decision. It's all about shared decision. So let me just show you this patient scan, okay? Hopefully, this is going to play. It's just no doing okay on what we'll do is just to give you a flavor of how this actually happens in the empty to you. I'll try and took threats Force present. So what I would do is I divide the measured it before or just read the report what it said. So it's a 5.8 centimeter infrarenal aortic aneurysm on. We will say how many ring arteries got single renal arteries bilaterally in cecum you, I would say the I like arteries are normal caliber know, and there's more Peyton intern, my neck arteries on. Then you also checked the excess vessel seven from investors. That's a patient on not significantly calcified family lessons, because the but you're looking at or the one of the sides is quite calcified. Posteriorly. Where you're going is through the anterior part of vessels. So for clothes devices, sometimes they just don't work as well if the anterior part on. Then we talk about the CPAP with the patient, and then we decide of those three options. What we're going often. So, as I said before, this guy's a taxi driver, he you know that's still his livelihood. He enjoys driving his taxi. He wanted to get back to doing that soon as possible, and so he was really keen on an evil. We decided it was a reasonable thing to offer him on. We went up with that. Obviously, doing nothing for him is not is not an option, because you can't drive a car with with an aneurysm, a risk of rupturing. So then what happens to him if he comes in a few weeks later? Two. A day of surgery units on ways, you know, putting it down. It's got cannula in. He's seen again by a surgeon and anything, and it comes through the hybrid theater, which, if you haven't seen one, looks like this on so it's a big room. It's got full surgical operational capacity. But also it's got this giant X ray machine, which is controlled by, as you can see, one of these arms these the same arms that they build cars with in factories. So this could easily crush she s. So you need a good reading here. You're on the right side of you is going to crush you with the with the c on Basically, but they're brilliant. They're they're great rooms on, but they're really important for aneurysm repair. And so he had his procedure and he goes to recovery afterwards. Um, normally will go to the vascular overnight and home the next day, which is why even such patients of them followed up generally with some kind of scan in about six. You know, 4 to 6 weeks on. But hopefully this is playing for you. Here we go. So this is follow up skin. So now you can see the IV are averting the flow through the aneurysm. It's not filling back. It's not going to rupture. The key things we look for are just that this excises stable, that it's not increasing on, that there's no end of week on delete is not concerned. If the sex eyes isn't increasing more than about five millimeters in a year, it's something worthwhile. That's great easy on. But obviously they're not all that straight forwards on. Yeah, we do have challenging cases where often the aneurysm is a high risk of rupturing minutes and large aneurysm being nothing is not an option. Open surgery is an option, probably due to patient comorbidities. Or maybe they've had extensive previous abdominal surgery, and standard evil eye isn't an option. So for these patients, there's something called complex evil, which is just worthwhile knowing about on the most common indication for complex, even though the standard devise, because the neck Lynn you need about 15 millimeters of neck, which is just a learning point. Obviously there are a lot of other factors, like ambulation or whether it's comical or stuff like that. But it's the neck that's usually the problem, and in those cases, as you can see the image that we can just put in the standard. Eva. What we have to do is either put in something like some of the ways of bury like it may have heard of a fenestrated graft, which is a custom built device with holes for the visceral artery so you can extend the seal on safely. Experian's okay, I don't spend too long talking back there controversy, but it's coming up. I really thought was important to mention of between my aneurysms because you may have heard a bit about the whole controversy behind IV are on aneurysm repairs and the nice guidelines on. But it was a frantic, quite difficult to decide what I was going to say about this because they're too quite different viewpoints. And I can completely see where, but coming from basically on day. So I'm gonna try and be a simple partial is possible and really comes down to our graph here. Okay, it comes down to the two lines, even on the open, and you can clearly see that, you know, after a certain period of time, that's open is gives you the better chance of survival that's first. The question is, with no modern devices, better seal, you know I'm and more durable results are these lines places on, Therefore, our patients probably getting better. Initial survival probability with IV are on maybe slightly more of a negligible on day long term result. So just before the Pandemic 2019, basically and nice said, Look, we have it in the guidelines vary with aneurysm infrarenal aneurysm repair. For a while, you know, there's been a few new studies. Maybe we should redo them on. So they got together this expert committee, vascular surgeons, intervention, radiologists and lots of other people. And they said, Right here is the evidence you're gonna write some guidelines on on dot So how it works is they also drafted guidelines it sent out to loads of people. And they say, you know whether they think it's good. Whether happy they'll be is basically a stakeholder engagements what it's called on. They come back with comments, and sometimes they get incorporated into the guidelines. Sometimes the day. Basically, these draft guidelines were really controversial because they said, don't do evil. Okay, you know, and you think about him. IV eyes very common practice and and basically, it said, um, look, um, if you could fit enough to have unopened repair your seven open, Um, if you're not fit enough to have an open repair, then even doesn't offer you good enough benefits, you know, and you'll probably die of something else. Um, they said, even maybe in an emergency, because there is There is evidence that if you have a ruptured aneurysm and urine older person that evolves the right thing for you. Okay, but if in the elective setting said, Don't give up on. But so when they then went to the stakeholder engagement, there was a big backlash. There's a lot of controversy. I mean, I'm not saying it's all because of that, but you can imagine their, uh, their, uh, multi billion multimillion and billion dollar and pound companies that produce these things rafts, you know, and there's a lot of money involved in this on, but also, you know, a lot. People really believe that IV eyes, the better option on the issue that everybody raised is that evidence that's on says that even is not as good is open and the evidence that says that even is not as good is just not being if you're not fit enough for Unopen on is based on trolls from my at the two thousands. And they said, like these graphs of improvement acidly and so and the survival must be better. And the problem is, you know, I don't think we've really repeated the same level of studies equally, even has kind of become standard of practice. And it's quite difficult to do high level studies when something has become standard practice. So I mean, what happened was pretty controversial. Basically a nice kind of just, I think stopped, uh, involving the committee that had written the draft guidelines. Onda and they were looking for some kind of an over, you know, big cover story to take the take the heat sensation, Of course. Then the pandemic came along, which was perfect. So the pandemic it on down Nice. Released. These guidelines basically say, you know, you could do open if you want, and you can do IV. I've if you if you don't want to do it, um, without really involving the committee. So there was, you know, it was pretty controversial thing to do on bets so even is still there on people. It was very much still do it, and I'm personally, I think it's a really good option for a lot of patients on. So you take take from that what you will. It's pretty. It's pretty and pretty GC and situation. I'll be honest. Okay? And so the next. I'm kind of running on a bit more than I thought. So I'm just gonna I'm gonna do one more case, okay? And which demonstrates? Threats can use from repair on this lady Basically presented to our any and a few weeks ago, 75 year old she had to collapse with chest pain and in a anything they noticed that she had a palpable aortic aneurysm. So there, wheeling around two CT whole crashed team of there with her on D has a near arrest in the CT scanner. So, vascular surgeon is there a swell? And he says she's clearly gotten aortic aneurysm. Less know, bother going through with CT. When she's, you know, about to die. Let's take a straight to the Attar's and repair. So she's taking straight to deter, and they open your abdomen and they find an aneurysm there. It has interruptions. I mean, can you Can you imagine on a surprise? So she's stabilized at this point. So I thought, right route. It's gonna be something else. Let's take it back to CT and see what's going on. So she had two CT scan. I miss. Is it Hopefully you can see that. Okay, on what you conceive is pretty clearly there. Can I just come back up? Is 92 chefs abdominal aneurysm? She's got this thoracic aortic aneurysm on this chest. Discomfort chest is full of blood. So that's the aneurysm that's ruptured. You can see a lot of gas, not free gas from the laparotomy. She's out there and said she's had a rupture. Faster Canyon is, um, instead. So And she was taken back up to date, too. She's an older patient. She's not going to survive and open on. So So this is what we did. This is how you do a throat sick and the vascular and your repair basically do an angiogram once you've got the sheet. So you size the the you size the stent graft on the CT on. Did you do an angiogram with stent graft ready to deploy. You can see that having that quest was here, Onda and surprisingly, it's It's actually okay if you want to get your six. So you need about two centimeters of seal for these on. Do you can actually get away with covering the left subclavian artery? Onda surgeons can do a carotid subclavian bypass on to keep the arm perfused if it if it's needed. So and this is the stent deployed. We've landed it right on the left common carotid, which is still patent. And you can see we've cut, uh, left subclavian there. Um, so we've covered the rupture side basically. And then this is her follow up CT so you can see again aneurysms not filling. It's just filling through the stent graft. And this is just a three D reconstruction, basically, of how it sits, which is pretty cool on these great and basically electively. You would think maybe we'd use a different threshold for thrush. Scanner is, um's, but the guidelines say 5.5 centimeters, you know? So it's easy to remember that number on again. If you have a ruptured thoracic aneurysm, consider, you know, endovascular if you can. He's a lot more difficult, obviously, if they involve the ascending aorta because, um, you know, the patient needs open surgery in that because they have seen need add the neck vessels, all of them being perfused. You could get away with covering the left subclavian, but not the others really on. That's That's a lot, and thrust can use. Um's on hell over Got Okay, I'm just conduct couple of minutes on pseudoaneurysms because I think this is a really common misconception that that one that they're no shouldn't be worried about much on. Actually, there's just a technicality in the difference the aneurysms on. Do you see this? This is from Radio Pedia and you know, it just looks like pseudoaneurysms just a different type of aneurysm, Really. But that's not the case. And I think pseudoaneurysm really should have a lot more urgency around them when they're they're managed. Let's so for, like, femoral pseudoaneurysms. Because normally they you know, they're they're safer in, but less likely to rupture pseudoaneurysms elsewhere. Particular visceral abdominal pseudoaneurysms should be seen as a contained rupture. Um, and they should be seen as anergic situation, so I'm just very quickly breakthrough case on 39 year old guys a young guy. Previously for a while he collapsed at home, have abdominal pain, was hypertensive. And it's really just not one of those and causes of Onda. If I pose a linear than you, then you think about So I remember this morning very well because actually was one of the first. My first weeks is a consultant intervention radiologist on, you know, just under a year ago I was coming into work, thought I had a pretty relaxed morning list, and instead what I found in the department was this and slightly panicked looking anything which, you know, it's quite rare to see you worried looking in the distant, so that made me very worried on Day said, Let this guy this young guys just have the CT scan, and he's really not. Well, I. Then I'm not sure he's gonna make it back up to the unit. Can you have a look and see if there's anything to treat on? Basically, he'd had this skepticism issue can in the night, and it shows if you can see it would be on the right side of his abdomen. He's got this really big hematoma on if I I'm probably not going to stop it on the right side, but he's got a tiny pseudoaneurysm on me, see if I can. I mean, it's very difficult to pick up, but he's got a tiny pseudoaneurysm, which has caused all this bleeding on. Basically, he's got a hole in the side of one of his vessels on Do the pseudo aneurysm like a sad directions contained rupture. So this was the second scan he'd had, Um, after nothing had been done about the first one during the night on. But now you can see that hematoma is even bigger, and he's got what is essentially active bleeding at the hole in his blood vessel on. But as you can imagine, if if they try to operate on this, it opened the abdomen. They find a massive hemotomas a member at the way and it would start bleeding again. And the chances of finding the bleeding point before patient blood today a very light. And this is one of the areas that this is one of my favorite cases. I love being involved in intervention really before this, so he came straight to I are on we did in the emergency embolization. So, you know, you breathe the team, you say, Look, we have to be quick. These This is the equipment I need on patients coming straight around so quickly show you the images. It's a low from the procedure. Basically, I've upped a reverse curve catheter into his super, um, isn't Erica Artery intern. And you, Gram found vessel, and you can see this this But here, this irregular vessel here, this is the sooner I use, um, that's bleeding. Watched now so that you can see that I bet the vessel. So this is where you need to find motor microcatheter skills. And I got it right up to the aneurysm, but I just couldn't get it across it. And the problem is, is if I just block the vessel before it. What happened is the vessel vessel, the other side of it. So if we block just down here, vessel would just start back leading, and you'll continue to believe so this is a really important concept. Backdoor frontal. So you need to embolize the other side of the aneurysm sac before you treat this side as well. So if you can't get you microcatheter across if you need something cool. I used loop sickly and you just inject the blue and you hope it doesn't go everywhere and you hope it boots the vessel. And so what you can see here is I'm injecting after I've injected Blue Onda just over here. That's what blue in the pseudo aneurysm on this guy had a long I see you stay, but eventually he went home on down. He's fine, so it's a really nice thing to be involved in. And these are some of my favorite places. Basically soon. Okay, in somebody aneurysms really important. They're very rewarding part of being an interventional radiologist on. I would definitely consider on treating aneurysms as part of your practice. Remember, 5.5 centimeters. It's threshold for elective repair. British by no means perfect. As we talked about on totally, one of you will go on to event some amazing artificial intelligence algorithm that will help us to treat only the patients that need treating. We do use an algorithm for risk prediction, which I think is really cool, but it's most of the anesthetist lately that but it's really helpful, and it's a great example of technology helping, um, modern medicine. They're still controversy evolve. This is open. I'm fully I, you know, put you in the picture a little bit about it. It's difficult to know what to say about it, to be honest. The one thing I just wanted to mention that if I didn't wasn't clear about it. If you've got a ruptured aortic aneurysm and the patient is older, you always do any virus possible I ever open repair on. Finally, one of my bugbears is visceral pseudoaneurysms. They are contained. Rupture. They're not benign entity, and they need urgent treatment. Thanks for listening. That was really nasty talk. Really interesting cases, actually. And so thank you for sharing those. And the presentation itself was, Yeah, really slick. And there's this CT slides over. Fantastic. So thank you for the FDA put in to put together We've got a questions and on risk prediction, actually for say, it asks about nice guidance and recommending only see pet and not other risk calculators such as the Carlisle calculator and other tools. And I wonder if he can tell us what's wise. So what? So but that is a nice, nice and we're the benefits of nice is they need, You know, they only recommend something if there's really strong evidence for it and have a very high threshold. So although, and you know, John Colon has done a lot of work on it and publish lot papers and you know it does involve a lot of patients, it's just I mean, they've evaluated it, evaluated a lot of risk predictive. And you can see that you know that how they assessed it. And they they quite ruthless and brutal in their assessment of whether something's good enough on although, you know, So even if you mentioned by nice, I think you know, you've you've done pretty well, but, um, so I think they just tend to get on the fence a bit more until there is almost overwhelming evidence for something because they know the impact. Yeah, okay, so in reality that these calculators on by risk algorithms are used as well. It's so nice. Guideline. Exactly. So they're nice that death work that you need it. They kind of leave it open on a half hour. It's, you know, most places I've worked use it on, and I think it's they just they just don't want to, you know, make people have to use it. If you see me when that when the strength of the evidence isn't isn't there complete lies? Okay, we've got another question. Unless anyone else has, I need more in that they want to drop in the chat sei. And if there's a pseudo I'm here is a post cardiac angiogram. Do you treat them on on what can use for treatment on Does fiber an injection help for some intensity? Losing patience? Say, if I can Maybe it's not easy. You should be appropriate from the shop. Uh, Marcel. So if there's a pseudoaneurysm post cardiac angiogram due to risk wrist access, do we treat them what treatment can use? I mean, I have to say, for I've pretty limited, um, experience with the radio ones, I think because the compression bands work so effectively, we really don't see them as often as federal ones. On go with something that's so superficial. What we what we would probably do because we do see it would break your access Sometimes is we would get a CT or really good ultrasound and you assess the aneurysm neck on on. But if it's if it's a really now a neck and it's on drizzle is being there just for a short period of time. I mean, we're talking days if it gets past seven days, normally that it it forms. Kind of like a pseudo capsule and even injecting on be injecting fiber and it's gonna help. So, um, on, obviously, what you got to realize is that area so easily accessible surgically, you just cut down on to it on. So So we don't routinely treat those. Actually, I think surgery often is a really good option. Um, okay, Yeah, I'm back and got one question just regarding screening. Think you can see it? So about sound ct being different? Okay, I understand. Thesafeside. Yeah. Yes. Oh, good. I mean, it's a good This is a really good point from Hannah. There's something about CT. Not so. So basically all the guidelines are based on ultrasound measurement Outer, not an inner to inner of the aneurysm war. Okay, so, you know, even I get these mixed up since on, But of course, what do we do? A lot of the time is you know, the patient has the ultrasound is referred for treatment, and then we measure it on CT and we measure out to out That's what everybody does. Um, I mean, what I'd say is is like we looked at that graph and we saw that. So So basically, the the answer to your question is it's on ultrasound, and it's and it's supposed to be in a to inner aneurysm. Measurement is what the guidelines are based on, but in reality we looked at that graph and we said that it's really just going on. Size is not perfect. It's a really, you know, it's a helpful approach because it's very simple first use. But in reality it's no, it's not the best. It's certainly not the best way. Um, so I would say, Don't get too worried or quarter those aspect of it because it's really you know, you're you're splitting hairs on an imperfectly Onda method of sorting. Aneurysm is basically so um so yeah, it's ultrasound and it's in. It's in ER, but Sizes isn't isn't great. Cool and well, I think that's all the questions now say, just once a a massive Frankie DRI and given up your your time on? Um, yeah. It was a really fantastic talk. So I have everyone watching Is is against them from it. And hopefully many more people will. And by watching your capture, say thank you.