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Welcome, everyone. Teo, the first installment off I are bites. This talk is on peripheral arterial disease and my name's Chris. I am the host for the evening, And I really hope you guys enjoy this when you're watching it live or on catch up. And this the 1st 12 part Siris and hopefully teach you guys a little bit more about IR from the 30 curriculum. Well, for every door 100 we're know to show you on is an ST six interventional radiologist in some mountain. I I everyone nice to not meet you, but anyway, I'll start my talk. So I'm really grateful for the introduction. Chris, I think it's a great initiative on the Well. Don't put it all together. And so I'm going to be talking to you about peripheral arterial disease, The subject on everyone's mind. Um, so I've gone through the curriculum. It's not. There's not much there for you to really, um, you know, come away with in terms of hard knowledge. So off got include everything that's in, then just a bit extra in some fun cases at the end as well. So I hope you enjoy it. Um and so the object of the talk. Ah, rowing To be to run over the relevant anatomy for peripheral arterial disease on the risk factors associated with it, we're gonna be talking about how we diagnose it. Onda, um, the treatments. And I'm really just going to talk about I are treatments because I'm not qualified to talk about the surgical treatments or medical ones, for that matter and and then I'll be doing that in the form of cases. Really, I'm just a sort of forewarn you. I'm a really big fan of stock. Image is just typing objectives in getting image like this. You'll get used to it for the course of the talk. Um, so the anatomy right peripheral to is is when we talk about that, we're really concerned about lower limbs. That's what you know. That's the main thing. We're talking about chronic disease here, Acute limit. Ski me up is something that I'm not going to touch upon in this talk. It's, you know, a whole subject onto its own. So this is a chronic disease of the lower limbs. So the aorta is where we will start on lower limb vascular rto anatomy is really straightforward It's just a vessel that Spitz into on there kind of the names of really self explanatory. Well, it won't take you long to learn it at all. And so you've got the abdominal, your water, and in about the level of L4, it bifurcate suspects into into the common Iraq arteries. On day common iliac arteries carry on here, and then they spit into into the external. I lack artery and the internal Iraq artery, and we follow the external artery down a bit. And there's a ligament that runs from the ASIS. Always the way with needing synthesis. It's off where I know, right? And so, yep, there's a ligament here called the, um inguinal ligament on. As the artery passes underneath there it becomes a common femoral artery, and then we travel down the common femoral artery. So this is the same vessel here. The common femoral artery splits into again into the profunda on the superficial femoral artery on the superficial femoral artery runs down this femoral canal on. There's a point here called the Doctor hiatus, and and that's a little natural whole, that there is the artery to run in between. The at the base of the bottom of the doctor. Magnus Muscle inserts here into the medial condom. And that leaves a little gap here called the adductor hiatus as it goes to the adductor hiatus. Around to the back here becomes the popliteal artery in the popliteal fossa. And that gives off a lot of branches which supply the knee on bend. There's a dog leg branch out. So it's been there with his everyone. I think we've just had a bit of a technical issue there with Sheehan's Ah, video. Just bear with us. We'll try and more protein seems to get that back on again. Sorry about this. And the hello. Show you. Where do we get to bring you have that? You're right. No, sure, Never. If you want to reclaim the stage and yeah, where did where did we get to Christian? Remind me. Because I was. Naturally you are. Well, your slides never popped up, but was I speaking? You were speaking just fine. Yeah. Split know show out to, uh, that. Okay, um, let's get back on there. So can you see this now? Okay, so I just jumped back with objectives. Anatomy, risk factors diagnosis and the treatments. Okay, We're not gonna be talking about cutely, Myskina, because I says, I said earlier, it's a large topic by itself that we can discuss it another time. We'll do another talk on So just going through the anatomy of the lower limbs, that's what we're interested in. We've got the aorta, which bifurcate L4 splits into common Iraq arteries. Here they spit into into the external internal on their car trees, and then we have the common femoral artery, which is the same as the external artery. But it's just it's just as it passes through this inguinal ligament, which runs from the ASIS to the pubic tubercle. And then we're coming down here. Common femoral artery splits into again into the profunda Profunda means deep, and that deep Profunda branch applies the muscles of the thigh on the SFA. In a normal, healthy individual so superficial femoral artery doesn't have any branches, but when it's diseased, it does. So it travels along here in the femoral canal and as it passes through the adductor hiatus, so a whole natural hole in the adductor magnus muscle it becomes the popliteal artery. So that was positive review here that can see on the popliteal artery. We split it into three parts p one p to pee. Three. You don't need to know that, but it just means above the knee. It's p one of the level of the knee. It's p to below the knee. It's p three on Ben that splits into again into the anterior tibial artery and the tibia paraneal trunk. So that's a good name. So the anterior tibial artery is like a typical dog leg out through this interosseous membrane. Here on it runs anteriorly anterior tibial artery. Good on the tibia. Paraneal trunk is just the trunk where two arteries called paraneal artery on the posterior tibial artery arrives. So that's the tibia perineal trunk. Spitting into against the paraneal they're easy to remember is well, because the posterior tibial artery goes posteriorly. It runs medially under the medial malleolus through this thing here called the Tarsal Tunnel on. That's where you can feel the PT a pulse on yourself. You can all do that now, if you like. On the anterior tibial artery, runs anterior along the forefoot, and that's where you can feel a pulse. There is well called the Dorsalis pedis. The perineal artery sort of just fizzles out around here, and it runs in between the two, and you'll see that on the cross sectional imaging that we'll talk about. So this is just this is just more diagrams just with a bit more realistic anatomy. It's associated with it. And you can see that this is the inguinal ligament I was chatting about earlier. And that's the external iliac artery becoming the common femoral artery. The profunda branches, the SFA running down this and femoral canal through this adductor hiatus. That hole in the A, Doctor Magnus, muscle around to the back of the knee where we put the popliteal dogleg, our anterior tibial, the tibia paranoid shrunk paraneal, which you can't see here on the posterior tibial. And this is just some angiographic images. You're gonna get sick of these towards the end of this, but I just go through the common femoral artery profunda on the SFA and healthy patient with no branches coming down here. Popliteal artery dogleg out, anterior tibial artery TB. A perineal trunk. Giving the posterior tribunal artery here and then running through the middle is the paraneal So just try and remember that it's fairly straight forward if you just, you know, take a little time to remember there and asked me there and now PAAD, as I said, and we're talking about the lower limbs and it's just a gradual buildup of atheroma within the arterial wall. When it happens over time, just gradually gets more and more pronounced until you have a narrowing in the artery, which we call a stenosis, and and the narrowing get so bad that it becomes occluded. And so those are the things that we're dealing with the know sees and occlusions of these arteries. Okay, so I wanted to give this talk around. Just you guys, when you go on your taste of weeks in your relevant I our departments, you know wherever you are. So some of the terminology might here is this the aorta and I lack artery. So able to are, the axe it's commonly known, is like the inflow vessels. They're supplying the legs on the effect common femoral superficial femoral artery popliteal artery in the profunda. That's femoropopliteal disease well named and then there's all sorts of names for below the knee, you know, But mostly, you hear people who all in these arteries the tibials cruel vessels and the runoff. And if you try to be so of course you probably call it the Runoff, I guess. I don't know. That's those are the main terms you're gonna hear. And so the risk factors. So there are modifiable risk factors, things that you can change on. There are non modifiable risk factors. Yeah, the opposite. And said modifiable risk factors for peripheral vascular disease for 40 would easily sorry our diabetes smoking high B m I, um, increased cholesterol, hypertension and kidney injury. Um, Andi living a sedentary lifestyle. Oh, the non modifiable risk factor. So you go stock image is again going. So we've got being male. So this looks like a sort of a male who's just realize he's got a respect for peripheral arterial disease. Quiet. What? Somebody there? Um, you got family risk factors. It's for me if you runs in the family. So you got a nice family here. And if you're old, too old people So I think there's a good image is actually worked nicely. Um, in the house of diagnosing. Done. Well, it's done by no quite suave looking people in lab coats holding an iPad on. They test the symptoms. They can do an ankle. Break your pressure index on day and they can order imaging. And they can read the reports on these little like cats. So the symptoms I've put a symptomatic of the top there sounds stupid, but I'll explain that in a bit and claudications declawed occasion. You may or may not have heard of that term, and it's basically like a muscular pain. So an aching pain that comes on when you're doing exercise or walking on glass ically it stops or it gets. It gets better when you stop doing the exercise, so you start to take a breather and it's gone away and you can start walking again. And you can. Actually, where the cortication is kind of tells you what sort of lesion you might have to conform. Whether narrowings could be a So if you've got impotence or gluteal pain, you're maybe thinking able to get your cardiac disease. If you've got Thigpen, then you're thinking it could be very popliteal. If you've got car pain, it could be the cruel vessels. That's really kind of loose and you can have femoropopliteal disease that she give you car pain, etcetera. But those is classically what you might think off. And as localizing symptoms, um, rest pain. Now, this is really important thing, and that is basically pain when you're in bed on. What's happening is when you lose gravity, you're standing up. Gravity helps blood get down to your lower limbs. And but when you're lying down, you don't get that same help from gravity, and you get that scheming pain against. That's a really bad sign. It got bad disease and tissue loss. So that's the worst case scenario. You can have an ulcer. It could become gangrenous. You know, you may have to lose a limb, so there are some definitions associated with it. So just explain that a symptomatic thing again. So asymptomatic people they considered peripheral arterial disease, but they can have such a 70 lifestyle that they never experienced symptoms. If you never walk 200 yards, you don't get claudications and on for those people you can d'oh exercise test so you can make them walk on. Go see how long it takes for that Those symptoms too. Um rise. So that's something you can do. A breast pain and tissue loss is known a cl Are you here? Cli A little time And that sounds the critical limits Kenya. And that means something really needs to be done for that patient. Now, this is in your curriculum. There are two classifications systems for peripheral arterial disease that we tend to use, Um, Fontaine and Rutherford and I don't think we use in practice. We're not very hard and fast with these sorts of things. We try to go on a more of a broad, a clinical basis. One is deciding Patients Street, but for that just starting out, you should maybe have a look at this. And so Fontaine stages there, basically mirror each other. So stage one or Grade zero is an asymptomatic person and and then the claudications to this location. Walk in or get pains Stop. That's not walking again. It gets better. And that's mild, moderate and severe for Rutherford on. They've given distance on it. So more than 200 yards or less than 200 yards being severe in Fontaine, sick from taking them, um, pacification. This is rest Spain's. That's why I was talking about your pain. When you're lying flat, you to dangle your legs off the side of the bed to help with the pain. That's gravity helping you out there. So that's breast pain. Great for or so great, too, but category for stage. For their now, this is where they deferred. The major difference between two systems is with regard to tissue loss. So if you got tissue last you stage five in Fontaine. If you've got a small ulcer, you know, just limited to a digital something great. Three. Category five in Rutherford. And if you've got gangrene, particular expending beyond the metatarsal level, and that's great Great three or Category six in the Rutherford. And so it's worth having having in the back you mind. And what you can do for asymptomatic patients or people with cortication is assessed that ankle brachial pressure index. Um, so this gives you sort of an indication as to how bad the disease could be, and I just talk you through it, how you go about doing it. So you take. There's a break in, artery in your arm, off it's lean. That's where you normally take your BP from Onda. There's there's the dorsalis pedis in the p t. A. There. Okay, so when you're taking it for a pressure from you break your artery, you inflate cuff Onda, you can what we do here with ankle breaker pressure index. We have this Doppler probe, which makes a noise will mirrors the flow and and we inflate the cuff. And when that is obliterated that noise, it's best to hear. And it means that the pressure of the cuff has has squashed the artery. So it's overcome the pressure in the artery and that just as you do that, that tells you the force of the pressure within the artery. So you have a BP off, say, 1 20 in the breaking artery, and then you put this probe down on the cuff over the calf. Do that down at the foot on the dorsalis pedis or the posterior tibial artery, and and if it's 1 20 systolic again, then you've got a normal ankle break. Your pressure index is that it's the ankle pressure divided by the break your pressure, and if that's one, that's great. Normal. But if it's less than North 10.8 then you've got proof for our tour disease. So the pressure in the ankle is less than the pressure in the in the brachial artery. You've got peripheral artery disease somewhere. You're losing pressure along that system. If it's less than North 0.5. If it's half, then you got severe peripheral arterial disease or critical in the scheme. Yeah, interestingly, you can have really bad disease and have a higher ratio. So what I'm saying here, So if it's more than 1.2, it suggests you got calcified disease. Now, what that means is you've got your BP, your brachial artery, and then you're doing it down here. But because these vessels are really council fide, you're gonna have to inflate that probe to a higher pressure to squash those hard, calcified arteries and stop it from getting for giving you flow to the pressure in that in the foot arteries. Dorsalis pedis P T. A. R. Higher in the break your artery. That's a sign of severe disease as well. So you want it to be in this sort of ballpark here, 1.1 to 0.9. And if you find that difficult to understand You can look at videos to explain a a BP. I wanted to do one, but no one would fill me film am doing it. I've tried for a week, but no one step. Um, the next thing you can do is a Doppler ultrasound. So this is a good investigation. Good screening. It's noninvasive that, but it gives you a lot of information about the artery. So here we've got a new ultrasound probe and this is Doppler flows his color flow through the artery. Okay, And it's giving you this way for me. You don't really need to know too much about it, but when it's like this, it's triphasic up, down, up again. That tells you that the vessel you've got good systolic pressure, you've got some elastic recoils, a healthy arteries, and then it's going going forward again. That's nice on disses up the common femoral artery for this patient. So up here you got good triphasic flow. Then we take the probe further down, too superficial femoral artery area, and we can see here that you've got no flow know tracer, no flow, no color at all. So that will tell you that it's occluded or somebody is helpful. Laboard there. And now this is the interesting thing about Doppler. Um, what you can do if you've got a new occlusion or a narrowing significant narrowing and you see that below that narrowings now in the popliteal artery, you've got some flow again. How that got their, well, what's happened. What's happening is it might be squeezing through a tight stenosis or, more likely, chronic disease. New vessels will have formed around the blockage and reconnected with this popliteal artery. That won't be good Systolic. You know, try phasic flow. That would be really tricky. What we call here monophasic flow. That's an indication you've got a high grade stenosis that you need to do something about. And I'll just show you some angiographic images case. This is fluroscopy. We're injecting dye or contrast into the arteries on that. This is that level of the common femoral artery, and I'll just play that back to you. Triphasic again forward very nicely and then no down here. Distress F a blockage occluded. You can't see any quantity should be going down there, but it's no, and you can see there's that little collapsible coming off there. Where's that collateral going when I play this? So this is at the level of the popliteal artery just here. And you can't see the SFA coming down here. Okay? You've got all these wiggly collaterals, and that's filling this faint thing here. That's the popliteal artery. And there are some colorful circles around the places you should have been looking. Okay? Just see that coming in. Just a little trickle of blood in that popliteal artery there. So that's how you can assess it. We use imaging. The other type of imaging we use is CT or conventional and geography. And I can take you through CT scan. We can use MRI angiography as well. And that CT is really what we what we like to use. So what I'm gonna do now is hopefully know, lose the connection and switch screens. Um, okay. Uh, okay. Yeah. Okay. Um, okay. So hopefully now, you should be able to see this and your CT angiogram. So it's in the arterial face cause the aorta is nice and bright given contrast, and it's in the arterial phase. So this is the aorta. We're gonna come down here, and it's got all this calcified disease doesn't have very good, does it? On the's of the Iraq. So spits in two common I lack and, uh then that that vessel Smith's into again and you've got the external internal I lack. Coming under the inguinal ligament, it becomes a common femoral artery. Interestingly, this branch here is also the another a marker that you've changed. So what? This is the inferior epigastric artery, basically and then underneath the inferior epigastric artery in the common femoral artery. So you come here. I got some posterior wall calcification here on spitting into again profundus applying with my muscles SFA coming down here superficial femoral artery in this femoral canal that it's traveling in nicely. And then we go that big be collateral. They're coming off on help. That's the occlusion. We got disease on this side, but I'm just gonna fix on the circle. That's what the images we just looked at where talking about. So you got a seclusion through that popliteal segment, and here's that collateral. Now, filling that back up again slowly, and that's a popliteal artery. Um, come back down. And this is actually not a good example of normal anatomy actually got lots of blockages. So this is the tibia parent. Your trunk. If you could just believe me, there is a doctor leg out and I'll be the 80 a. This would be to be a parent, your trunk And there's a t a feeling and that's the perineal artery and the posterior tibial paraneal artery 88 down here. I'm going down into the foot. That's CT and labs at what that's about work, cause that helps us assess how we're going to be able to revascularize patient's CT. Good. So are going to now try to switch back. Okay, so it should be on here. And so I just explained here. So this is something called a reconstruction s. So what we do is we can manipulate those images to twist them into the plane of the artery and get a nice map of the artery as well. That's that's what I've done. Then you can see that sort of marries up with the angiography. Um, good claudications management. I don't think you really need to know this medical student level, but I thought I just put it in there because it's some facts. And so for cortication. Their main thing is to reduce your risk factors. To stop smoking it, reduce your cholesterol, improve your diabetes on dumb, reduce the BP to a normal level. You can go on anti platelet therapy as well once you do Or do you know, have if you do have symptoms Sorry, There are some pharmacological agents you can tell you can have take to improve your symptoms. But if that doesn't work, you're gonna have to come and see a vascular surgeon or interventional radiology is because you need to find out where that lesion is and we'll do the CT or do an MRI and we don't ultrasound. Find out what the lesion is and we'll revascularized you. Okay, because you know it's not very nice being confined tone to be being able to walk 200 yards every day. And so that's what we would try to do. Cli that critical limits Kenya. This's something that really needs intervention. And basically all we need to think about here is are they a candidate for surgery or intervention or not? Because if they're not s, so if they're not, then they're going to have Teo just have pain killers, and hopefully that helps. If they are, they can have revascularization. And if they can, if they can't have revascularization, they can't tolerate the pain control. They will have to have an amputation below the level of the blockage. And so it's not very good news. And so treatment options. And there are lots of treatment options in interventional radiology and basket surgery. It really depends on lots of factors. So it goes through the M D T vascular MDT whenever we have a case. Because these patients aren't just your normal patients. As you can see, the from the risk factors they usually got high BP, diabetes. They probably had a stroke before or a heart attack. And so they don't make very good surgical candidates, so we'll make a decision. Are they very good surgeon kind or know if they're not? Then let's try the less invasive endovascular option. And if the lesions really long is probably not gonna be able to probably not gonna be able to get through it and oh vascular Lee and they will have to have a surgical intervention if it's in the groin. The common femoral artery, the surgeons can easily access that area surgically and clear out the blockage or an open operation so that open operations that they would do is an endarterectomy. If you don't know what that is, it's basically they cut down onto the usual just the common femoral artery. To be honest with you making incision, clamp the vessel from above and below and they will pick out. It's a very delicate operation that's quite satisfying to watch them do it. They just peel away the calcified disease from within the the common femoral artery, and they will just either so that back up or they also want a patch to make it a little bit bigger and a bypass that is another option. So if you got a long occlusion of one superficial femoral artery, for example, they can harvest a vein that you're not really using in the leg, provided you have one on there you can so that on from above and below the occlusion. And so that's the surgical options, Really, so you know, if you don't have a vein, you know, a surgical candidate, either they can give you a graft. Ah ah PTFE graph, which is just sort of synthetic material graft. But they don't send to have the bet a skid outcomes or longevity as just having a vein. So anyway, no, that's about IR stuff, because that's what we do. Um, going to case one. So but I do a lot of this switching now. I'm afraid, um that Ah. Okay, so this is luckily the same guy. And so here we go, coming through it. So can you see that big a lot more? Yeah. Eso Well, I'll talk you through what you can see here. So And when we're when we're accessing inside the arteries, we leave. This thing called a sheath is basically a tube. It comes in several different sizes. You could be four French. It goes all the way up. But for peripheral arterial work, you'll go up to usually about eight. French is the largest. We would tend to put in a camper bigger ones in for going northwards. Onda French is basically one third of a millimeter, so, you know, divided by three and you've got the actual diameter of the tube. And that sort of gives got this side are more we can inject contrast, doing that we can go through this bit, which is got a little valve in it. And that's where we can introduce our wires and our catheters so other small tubes through and help negotiate arteries. Here we go. Start here. Gone antegrade puncture. So antegrade means the way off the flow. So we're going down the leg that flows going this way since and two great culture superficial femoral artery, profunda or artery there doesn't look too bad, really does it. And here you go, your sickness lesion now showed it to you in the other case is you got this Normally disease collateral, spindly collaterals fills back in popliteal. Okay, so that's the lesion we want to treat. And if you remember the CT, um, you remember that we had a bit of an 80 80 a anterolateral artery to be a perineal trunk hair Aneel artery. He's moved there. And so you've got the best images there. That's the anterior tibial artery. That's perineal artery. Anyway, that's just that's a normal angiogram that we would do. I'm just Teo, make a map of what's going on, what we want to treat, and we usually want to treat the most part proximally gyn. And so we'll go across that, um, lesion with a wire, and then we inflated balloon just to open it out. Um, and you can see that's a nice result. You've opened that whole vessel outside. Go from where? Where we were initially looked like that. And now it's nice and open. And that's kind of where we left it with that. Because we don't want to do too much talk about going into these vessels with some of the other cases. Okay, right. Let's go back, you know? Yeah. Go. So case to got 74 year old mouth who's unfit and he's got right cli tissue loss. Okay, they're just load that up. Okay? I'm going to go across again. Okay? So again, antegrade puncture what you'll see here. This is actually not a really good puncture by May. This is low. You got the profunda here. You have a superficial femoral artery, and I'm just punctured there when you a good puncture is basically over the femoral head. You want a puncture right up here? Because if you need to stop the bleeding, you can just press on that bed and it'll be against bone. You can stop the bleeding nicely down here. It's a bit loose and you won't be able to stop the bleeding or might not be able to stop the bleeding very easily. But we can put closed voice in those sorts of things That can be difficult because the patients got a large belly and I can actually get up there. Um okay, so we do an angiogram here, running down in these areas of whiteness. Okay, You can sort call them filling defects if you like. And and that's just really hard calcium. Okay, it's calcium. They're blocking up the arteries. Not very nice. It all. It's like basically traversing the whole league whole artery. They're not bad distantly. Um, go all this stuff here. Um and actually, you concede this is the 80 a when it's not going down conk. You can't see anything past their nobly disease in the in the posterior tibial. And that paraneal artery doesn't a very good let's run down the foot. Now all he's got is that paraneal artery between the two. That 88 should be here. P t a. Should be there. They're not there. Just got that single vessel runoff. That's the terminology for it on this is down in his foot. This a lateral view of his foot and you can see no very much, not very much to all there to deal with. So that's probably why he's got really bad faith feet. Eso get across the lesion is very straightforward. Get of wire in a catheter across the lesion on we managed to get through through the Lumen of this vessel. Um, Andi again looks a bit repressive, but anyway, that's the SFA treated. The flow is much better, but this is what I want to show you here. It's got a lot of this stuff, okay, this is when you get down to below the knee. It's actually quite difficult to treat because these vessels are really friable. They're really sensitive. So if you touch it with a wire that like to spasm on down arrow there about 2 to 3 millimeters and sometimes even area. Um, and if you knock something off, you can block these arteries off really easily, and then you're in a, you know, worse situation, and that's and the art really don't want to damage. Here's the parent because that's the only thing that's going down to his foot. So I'll take a listen to incineration before thinking about treating him. Um, so then we This is ah, run of the for after we just improved that superficial femoral artery. So it's actually already you can see it's a little better, but it's still no great. And so get into the 80 a into trouble artery with them with a catheter. Come through here, Think, Shall we revascularized all of this? Yeah, I know. So got across with these really with why that's really thin. So normal wires come in a size, which is, oh, 35.35 Often inch and these wise are even smaller than that. So there 0.18 and, oh, 14 wires. So they're really, really small, like hairs. But there's a lot of technology and then which I explained in a minute. And these catheters of these tubes that you try to use so we'll track over them are really you know, well engineered is well, they're tapered. They're slippery there, strong in certain bits. They've got different shaped ends and stuff is well, so then we get into this. Um, Got got past that nasty 80 occlusion. We've got a long balloon here on. We've come a long way up to the top. Let's see if that does anything. Oh, no, that's That's pretty good, isn't it? Was pretty good. Opened up quite nicely. It was nothing there before. So we've improved that vessel. Think Shall we just take that and get a work? Leave? Well, should we see if we can get there? Don't know that some of the, um so yet in down here and you can just focus down here. It's hard to see. I don't if it's projecting well, but there you go. We've got a way down that non existent artery, Um, and inject contrast here. So it down below that distal P t a at the below the tarsal tunnel level. So that medial malleolus level where you're supposed to be able to feel the pulse you won't be able to on this guy. Um, he's visiting a little bit long. Balloon up that again. Let's see what that does. We'll check now. Check on that in a bit. This is just me fiddling around trying to get into the paraneal artery. Get in. We just angioplasty this top of that paraneal artery. Looks like it's gonna work. There you go that we've opened up really well. So now we got three vessels. We journey, had one. Now we've got three. Still doesn't look great here. So interrupt. End have not really got much going on in the foot. See if we can get past it. So we got all the way down here and you can see through this mesh of collaterals is actually he's got an arch here, so this is really important. This arch is called the door so large on it basically connects the anterior tibial artery dorsalis pedis round here and then down underneath the foot to hear That's your communication in the foot and everything comes off of their supplies for if you can link this up, you've done a great job. It's almost like, you know, they've got a normal circulation again. Um, so managed to get one of those really thin wise all the way down there, which I was really happy with on dumb. We've inflated a balloon. I mean, it's pretty straight. We just get cross in fluently anyway. They get a Hey, Presto. So from here, you can't see anything. Teo, this I think that's pretty good on a completion run. Uh, is this one and this is just taken from the top here, you can see that so much better. Mawr supply. Now it's coming fast, and it's going everywhere. We've restored some of the arch at least anyway, that's a pretty good result. So that's the tibials and just show you a kit that we might use for that. So these are the things I mean, this is only just, you know, he's just a few examples I could find. So there's a lot of technology and these really find why why is that? We and that we use down in the tibial arteries that have to be soft. They have to be strong. We have to be able to push them over a long distance. You imagine if it was really flimsy when really when you try to push against the accounting, we won't go any where they've got, like, these really gnarly materials like skin Taney, Um, whatever that is on. Do you know, uh and you know this is only one a oven inch and they've got some coils in there that makes it a traumatic. And they have waited tips. You chondroit through things. It's really quite impressive the stuff that you can use. Yeah. I mean, it probably doesn't sound like a great AM deal of interest to you probably know, But you can get quite noted out by some of the wires that wise and catheters that you can use down in these vessels. Because the reason why I say that is because if you just went down there with a standard why you'd make an absolute mess, it would be a disaster on. So you such appreciate these? These call that wise the next case. 63 year old male again, right? See, a lot of history's aren't really that, you know, they're all those right c l i n the chronic hallux loss as well. So he's got tissues. Also, that should be, um, So Alex means toe, um right. I just get in that case up now. And so this is all these cases show a diff a slightly different type of approach as well. So bear with me, Okay? Right now, before you start going mad, it's not the same case. It looks similar, but it's no okay. And so he got antegrade Puncture. Let's go down here, Profunda. Yeah, yeah. And you got that Collusion. It's not the same. Case looks the same, but it's no and okay, it's that other case that we that we saw the very beginning, actually. And so you got that popliteal filling in here these collaterals on. But if we come down here, poor supply down to the foot, that's just the posterity's got really good posterior tibial. Actually, that's pretty strange. Um, on until it'll feeling in late. Not really that cool. Um, so we get down to this level on D. I want to try and get across the natural area, the natural path of the artery, which is occluded. We managed to get across. So that way you get across this. If it's occluded like that issue with sub in two more path, I'm going to explain what that means. But basically, you travel through the the muscular layer, all most of the artery to try and get across, and then you break back into a healthy part of the artery. So you're short saw in the image Before that, Popliteal was healthy. You try and break in around the Popliteal area, this knee area into normal artery again. And that's going to leave you with a problem because you've got this. You know you're not gone in the natural whole you've gone through through. Your bypassed it in a way, and and I'll show you what? That what? That will result in any way. The small runs, blah, blah, blah. I'll skip through some of these ones that aren't really that important. And so we get across and we angioplasty up where we've come on D influence and balloons, influence and balloons. Let's do a run, See if that's worked. That should have worked, but it hasn't really worked, and you won't be able to see this properly, I think actually can. But here there's that little filling defect again, Um, so this sort of whiteness since off they it's not really well defined, not like the cows and we saw earlier, which would really wait well defined. There's some sort of filling defect here, Remember I told you we went sub intimately, okay? Through the wall. And that is just a flap that's been lifted up that's wafting around in the artery, and it's not flow emitting. Cause contrast is getting through it. But it could flap over and shut the whole vessel down, which is a bit of a problem. Eso we need to really address that. So what we normally do to address that is try and track it back down to we just inflate balloons again, try and track that thing back down and hopefully stick it back down so it doesn't go anywhere. But actually, it's still there. So this is really annoying. Um, Can't really leave it like that. Don't think so. Try can desperate. Now, please go back. You won't go back. Okay, so then we, um per stent across it. So these are better. They're metal stents on. There's all sorts of different stents again. They all useful in different ways. This is something called a superior stent. You don't really need to know it, but it's quite flexible, and it's really strong s so it's good for these off parts of the artery where there's a lot of movement. Okay, so this is the doctor canal coming up here. That's where you bend your knee a lot. And you get a lot of movement is that kind of needs to be strong. That's superior strength stent that we've deployed there and you see, now are that looks pretty good up here, doesn't it? But actually, the flaps still going on down here, which has been annoying and currently relieve that. So I end up paying another one in, um, another one on they go. So this is slightly smaller because you don't want one. The same size arteries get smaller as they go down, We put a stent within the standard. We've got a good flow there. Okay, so that's that. I don't think we need to go on any more. In that case, just talk a little bit about the things that we use it all the techniques they use for that, I think say, um And so this is something called this is this is basically what we what we did here. So this is something to order section. It's a diagram I found off us. And case report of just what's up into mortification really looks like So what happens here? You've got the intimal layer of the artery and this occlusion you've got the media. So the muscular layer And then you got the external tunic external. So what you want to do is go. You can't get through this. It's blocked. Can't the why I won't go. So you you've got this occlusion here. So you dig your wire in underneath the into more layer and try to take a loop down t bunker in with the sharp end of the white. At this loop down which lung dissect sits way down that sub into more track you can see here. So dissecting its way through that some intimal tractor once. And then when you were in back in normal Lumen, your bus back out of there. Okay, That's actually a lot harder than you think. To just get back into the Lumen where you want to get back into the Lumen. Um Andi, you've got this nice channel. Now, what you can do with that channel is exactly why did inflated balloon squash als this stuff back and see if that works. If it doesn't, you have to put a stent along this to make this channel the new channel that you're going to use. Um on. We didn't use this in this case, but there are lots of things and said, Remember I said, It's not very straightforward trying to break in where you want to break in on. Do you want to break into the Lumen? So there are lots of these cool devices that you can use to do that. This's something called Outback Catheter. And so, basically, you come down this sub in two more layers with where your wire is with this catheter and then your intake, that using the imaging so that you think you know you're pointing into the Lumen and then you flick out this this needle into the laymen through that needle. Ah, really fine. While will come and go into the Lumen. You take this out over the wire and you've got your access back into the room. It's that's really good. And there are other ones where you can inflate a balloon and puncture rack into the room and as well. There are lots of devices where you can do this, say, and it's it's It's quite interesting, I think, and right the next case, 70 year old male by natural court occasion. What's price and right? Let's get this case up a Q day. Okay, Sorry. Just getting the images that that I want to get up on. Let's go back to sharing of the screen. So I would have just put these in the presentation. But you don't get the same quality of imaging when you just put simulates on something, it's better just to use the pack station you have. Okay, So if you receive a CT scan of this patient bilateral quadication case, you got the aorta that's was down here and worry about stuff calcified. They're quite narrow. And you've got this calcified disease of the common in excellent, measured this. But you can see that now. That's narrow. That's no, that's all right. You look out. Big patient is going to really narrow on. Their cash is calcified. Barely. See aluminum there. That's barely See that. And he's also got disease. They're they're all the way down is on the act. Basically, it doesn't look very good. So what we're going to do Well, we're gonna have to treat those. So this sort of area is really hard for surgeons to get to, because the patients really quite large. Getting down to them is an effort anyway, The the vessels, every small they're calcified. So calcified vessels are a nightmare for surgeons because they can't really clamped down into the really crispy and friable and see if they've got their area to really clamp to get control, they have to. When you dissecting down into something, you need to draw the blood flow. So you have to put clumps around and you can't really anywhere here. And the bypass option would be to like so something onto a nice, healthy bit of a water, maybe there to know that's really high and difficult to get to and then plug back into a normal artery somewhere down lower. It's not a good operation. And so, um, we could do something endovascularly obviously. And so what would do is, um this is littered with measurements that I'm going to kill time for And okay, so we've got bilateral retrograde access, the case, and now we're going against the flow of the blood. Yeah, there's our sheet here pointing upwards. So we've got into the common femoral artery pointing out this is a hip replacement here on Tom's. Managed to negotiate why is already up, um, into the distal a water here, Andi. He's put a catheter across one up one side and injected contrast of Now we're getting flow from the top all the way down. That's what we can see. And now you can see a list doesn't very good. That's narrowed there. Now it There. Now there. This is really narrowed. That's really narrow. Doesn't a very nice tool. So we're gonna have to, um, angioplasty this or stenting these. You don't need to know too much about this, but there's a current theory is basically when you get in the early actually need to stent first on your prostate isn't really enough. You say we need to be really careful about how you size thie, um, the stents. Because if you make them too big, the calcified that calcium has to go somewhere. If you push it out with the oversized tent, you could rupture the vessel. And if you rupture that vessel in a really large person or in anyone for that matter, and cause high volume bleeding in the retroperitoneum, where those arteries life, the surgeons are going to happy with you. Okay, so you got be really careful. It's quite dangerous territory territory here, although technically quite straightforward procedure from my point of view, but dangerous and okay, so ah, get across on do these things are balloon mounted stents before that appearance stent. If that sort of stent is extend, that's inside like a sheath. And then, as you pull the sheath back, it unravels on forms. It's shape that's called a self expandable metal stent. The's stents of crimped down onto a balloon. When you inflate the balloon, they assume they're normal size. And then when you deflate the balloon, they're stuck on to the vessel in there Open. That's what these are and and you use these to get so is inflated one there and one that you can't really see it here. But you see it on the digital subtraction and job for your D S. A. And you can see now that's really opened up quite nicely. He's but those balloon expandable stents there, and these are really good because they allow you to be very accurate. You just put the balloons where you want to. You see the markers on you, deploy them and they stay where you want them to. If you're having to pull something back to one sheet that you can imagine That you will move the vessel a little bit. Um, which is an ideal. Um um, that's good. Um, so we still got more disease here down here. More disease down here. So he's angioplasty. That doesn't really work. Um, so he's in Flint. That's and self a responsible stent he's done. They're still bit crimped. So infects plane. Um, Andi. There you go. Got another one in there as well. And itself is available. Metal stent there. Cool, right? Eh, So you can see that's really improved flow down, so that hopefully should get some benefit from that. Um, next, I'm gonna move through these cases. It fast now is worried running out of time and okay, so just explain these stents. So these are the blue expand. Well, since, like I say, they suck. Come crimped down. When you take the balloon they form, they're normal size, and they're really good. So you can be accurate if you've got a lesion right up there. The aortic defecation. If you're not very accurate with your sending you deployed bit too far up, then you could shut this vessel off the force of this stent concertos that our whole other limb down seem to be very accurate. That's perfect placement of the balloon expandable stent there. Um, right. This is just a really cool toy. Such want to throw this in here? Central mayor. Right? See, I see a lot of whatever. He's had a stent before for a cli. He's carried on smoking. So when you gotta have a stent, he's going do antiplatelet therapy like you do for a heart stent and you have to stop smoking. There was a well block. That's exactly what's happened in this dude. So we'll go. Teo case, let that ah saying okay. So really quickly. I went labor the point, But let's start here. You can see you can just about see, um, know shed So you can just about see the stents here, there and there, and it's completely blocked. You got this little cone that you can dig into here and what we've done is we. That's sort of just some machine called a row to wrecks. Cool name on. What it does is just There's a hole through that. We've got across it with a wire. It just sort of carbs out a looming for you. So there you go. There's that Lumen that we just carved out on. Then if you we balloon that that blooming as well, and then we're left with this a nice Peyton stent again, just and that's the device. So this is Rotarix device. There are lots of these kinds of devices. Got little gate in in a corkscrew, and then it's got a little window. So it sucks. Think this this cautery creates like a vortex, and it sucks things into it. If you look over here, it was just munch its way through there, sort of taking all the thrombus away or the clot away and through the channel. And that's that's really cool device that we can use. And so that's another chap with Byetta Cortication. I think this is a really good case. I'll just share this one as well. You know, we are pushed for time. Um, so I've put in my notes here the ultimate in flow case. You probably will never see a case like this. Um, I certainly haven't. Um, it's 78. Okay, Right. So here on the screen here, basically, this is NPR and multiplane reformatting, and we've got a sagittal view. So down Central Access Corona viewed on the Corona Lexus on an actual view. Okay, Onda, I'll try and skip to the interesting bit. This guy's got bilateral cortication on, but he's got this complete occlusion of the aorta on it's calcified. Look at that eagle eyes amongst you might see. Always got a little bit. You could probably get through that short. Know this is a really, really hard operation for anyone to do because it's a high occlusion up by the other Kidney's not very good, and you can see here on the Saturday to reformat. There we go is completely blocked and it's calcified how we're going to open that up. I don't know. Well, I'll just add to that. So he's got this. I lack diseases. Was got this nasty cart calcified external in some common iliac disease as well, so I got to treat that as well. And so then my colleagues, true and mow, had he tackled desk. They came up with interesting solution to the problem. Try to burn their way through because he saw they they saw this and that little soft bit through the calcium. Maybe there was a gateway through, and I'll run through these images for you. Just keep into the interesting ones. Bilateral retrograde access again flushed. That's completely occluded. This is a distended lumbar artery, so they also gives rise the lumber arteries. And that's the way he would have been perfusing himself. They would have bypassed the closure and going around these lumber arteries back down and into a normal bear vessels. That's what that that thing is there, um, and managed to wiggle a wire through there. Put a big she through there, and he's wearing his way through on their through. So you got a sheet with in the sheath within the sheet, and so that there's like a Russian Dole kind of model he's really trying to push through. Managed to get through, which is incredible. Um, this This is a hybrid case with vascular surgeons around, by the way, because things could go very wrong very quickly. Remember I said about calcium when you try to expand it, it's got to go somewhere on diffuse put. If we try to angioplasty this now, this could be disastrous. And so this balloon is called a little trip. See balloon, I think. Well, they use a little trip. See balloon on here. I'll get explain what that is. But it basically, once you get through it allows a shock wave to go through the calcium, and it spreads it up into small bits inside the arterial wall so that when you do inflatable, you nor a stent that should be squashed back nicely into the artery wall. That's what they've done there. Got through. Here we go, measuring stuff. Need to be careful here and at the patient's fine. Ah, good. There's a stent wide open that's brilliant on. They use those balloon expandable stents again, um, down handsomely that scrimping it more. These are the balloon expandable stents deployed them when the sensor in this formation is called kissing stents kissing, I'll accidents. They meet in the middle of inside the aorta, and what that helps to do is the radial force of each one of them. Doesn't shutter the other ones you placed in the same level when they will stay there if you put one higher than the other or it'll shutter it. So that's why that's important. And I show you the CT scan, please. They did just afterwards, Um and you can now see that he's got a patent stent. That calcium is actually kind of, like, just crushed out the way quite nicely with that lithotripsy. And you got those highly accidents they're keeping everything going to. That's pretty in case. And let me just okay back, Okay? We'll rush through this. The last ones. That's the lithotripsy underinflated. This medial war calcification gets blasted with shock wave. And then when you come through with a higher pressure balloon, it will sort of squish it out. Basically, Um, good. And okay, seven is the last case now. Okay, so, you know, you guys getting bored, but, um, I think this is an important lesson is I just showed you cases where it's a little gravy. Everything's going really well, really hard cases ago that these things don't always go really well on there are risks associated with doing in the vessel, er procedures. It's not low risk at all. Um, so just okay through this 14 year quickly. So he got this patient has, um, got run down here, go to the interesting bits. Okay. If it loads. So we're We're worried about this side, but I just go to tell you what this is here. So this is that by bypass, I was telling you about something to the common for right. He's historically had a bypass into the camel for your arteries. So taking a vein, they sewed onto the common femoral artery. And he's now got this new channel down on the left, and they sewed it on distantly. Okay, And that's on this side. He's got this occlusive disease. So this is what I call flush occlusion. So when artery bifurcate and it's clue, did the one of branches includes a flush occlusion? So there's a profound er. The SFA is gone completely gone. It's completely gone, Okay, it's really hard. Case comes back in later at the popliteal artery, and I just show you what the angiogram looks like for that. Okay, here we go. There's no SFA should be here. There's a lot of these mad collaterals. There's a popliteal artery. So we want to do is break in at some point and get into that. Okay, I'll just show you This is a reference. These are his cruel vessels. They don't look too bad to remember that they don't look too bad here. Um, they look quite back there, but, um right, So after much digging around, we manage Teo, get through. And it's really hard. I tell you that to gauge is okay on inflate a small balloon. It wouldn't take anything. Contract Anything bigger because it's hard to push things through. Space is that don't exist. That is really small balloons. At first, nothing's working like that's not working dry. Get cross skin, put bigger balloon Not working. Yeah, course again to, um on. Do you have another balloon now it and replace it with a proper size balloon all the way up. Hopefully, that's gonna work. No, nothing's happening. In fact, that's try again. Let's try. Let's go up. Open up, Inflates two balloons source of getting there, but not really on. Actually, this one now shows that where we had a popliteal artery for It's gone. So your left the dialysis dissection flap, which is shut off that artery. That's it is Austin. So what we've done is deployed a stent in the luminous try and open up this that superior stent, um, try to go again. Okay? Nothing. Onda, more stenting. Nothing. It's really wiggly. And now look what's happened. Remember those tibial arteries before I show you them up here? That's what they looked like before. Now they look like this. Some clot slowing down them. So he's in a worst situation now. Then you started, and that's no great it'll. But what we can do is try what we got Some self solve this situation. This cap, this thing is called, um and and Joe Jams. You can explain what that is, but you traverse the vessels with that on, you basically suck out acute from, but it's it's nice and soft back. You from this on, we saw back to a better situation. Now we've sucked a lot of it out. That's still no out of the woods. So you have to go on heparin overnight to try and help that situation on. Let's just go back to the main thing now, uh, named it stoop. Um, so that's this. Okay, so these there's lots of these devices that Androgel what it does you go across with a wire, you lace the area with ah from Bill Isis. Agent impregnates the from bus and then you go through again. You suck it out with this vortex. Other things like the prenup for device can you can got a suction thing here past that. Only trying to suck out the acute from this is all. There's lots of these devices. He's just too easy on it. Case A million. Because that went on for ages. I have so many more cases. We do joint cases of the vascular surgery all the time, where we'll angioplasty a bit and they will bypass a little bit. So let's so that work is on hybrid theaters, which we are lucky enough to have. Most places are now, but it's really interesting field. And I hope you enjoyed the talk. Thank you. Thank you so much. I, uh that was absolutely fascinated. So I think you just got a couple of questions from the chap. So one quite specific question just asking about the length and diameter of the balloons use for a lonely 100 plastic. Yeah. So below the knee. You Congar. Up to about three or 3.5. It really depends. If you got a little lady, you probably do a 2.5 millimeter balloon, and they packed down really nicely, so you can get much longer lengths. So what I should say is the size of the balloon means it has to go through a bigger sheaf. Um, so you don't want to be making a bigger hole in the artery if you don't need to at the top. And these are really small, so they travel down. You can get a nice and long, um, so they can be anywhere up to 200 millimeters long. Cause I had that answered, your question was stuffer on. We've got one more just about anti coagulation after stenting and from Maria, she's asking, Do you always put them on Dapsone life long? Or is it? Sometimes it's a bit of a different Well, we saw, I think I think that's an interesting question. I I think it's sort of changing a little bit. It used to be for life. You used to have July of aspirin, capital, water, gargle or but now people are starting to use Dove Axe, and I think it's a really everywhere. Things are changing at the moment, and probably when you graduated from medical school be completely different. but they do need to be on some antiplatelet therapy shown. Can I ask a question about the fifth case where you use that? There was the instant stenosis and you used the order X to go through. Is there a relative risk of distribution? Is a shin with that or is the vortex again? It's kind of sucking everything off you have. Have you ever seen this little ization with that? We have not seen it because it creates that like you say, that that corkscrew inside creates of war techs and it sucks things in. So you haven't seen it with that. But there are other devices where the blades on the outside and there is a risk off you as you're winding down that you call some distant embolization with those ones. I mean, that I got say that that case, it looks really cool that we opened it up. But it doesn't always work. It's those devices really dependent on a lot of things, like it needs constant flow. It was short our it can't get through county and very well, so it might look a whole year. You can get from anything you can't always It depends on a lot of factors. That's the case where it works really nicely. Think I think you're a sound of X's? Well, may maybe maybe medicine better than, say, I'm I think we're probably come to the end now. And thank you so much for for running this session and I hope to have you back for a future. I are bite next week we've got and I believe fibroid embolization from a doctor in jiujitsu handle. Say, make sure to tune in next week is over and, uh, feel free to watch this back. And as a recording, I'm gonna stop broadcasting now. Um, feel free to ask any questions in the chapped. Now on, we'll try and answer them cool.