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so alive. So Hi, guys. Thanks for coming, Teo. This eye are bike session, so we'll just give it a minute also for people to filter through. But while we're waiting, just introduce ourselves as the panel for this evening s. Oh, my name's Indra. I'm one of the radiology trainees based in Oxford on along with Nile, one of the co founders of IR Juniors, and were really pleased to have him on today. Now, I'll just let you do a quick introduction, and then we get started. You Can you hear me? Okay. Still Androgel and see the Yeah. Here. Yeah. So Hello, everyone. Thanks for thanks for joining. My name is Nile. I am an incoming radiology ST one in Edinburgh. I'm also as interested in the core founders YR Juniors on kind of add into the mix. I I was a former interventional radiology radiographers before I did medical school. So that's I guess maybe maybe justifies slightly. Why? I'm here speaking about this topic this evening. Um, but not not that that even justifies it. But I have a little bit more of a chat about that. Once we get kicked off. So injured, you want to wait another minute or should we go ahead? I think we'll go ahead and just had it. Wanted to mention This is our last eye are bites sessions and thank you for all of you have come to our previous sessions and this one as well. It's been a really great Siris, covering pretty much the whole of the surf see curriculum fry our medical students on. Of course, all of the recordings will be available. Teo View on metal. So if you've registered for the event on do you missed it, then if you just go back on the event page, you should be able to watch the catcher content and claim a certificate as well for watching the video as well. And, of course, with the academic year, I'll juniors will be back with more events and more webinar. So do you keep an eye out on our social media and our website? Because, of course, we use all of your feedback to tell us what you guys really want on. Do you know each year improve what we offer educationally on, so I'm going to stop speaking and handover denial for the presentation and talk thank you. Thank you very much. Well, I'm in a situation here on the far side where I can see nothing but my presentation. So if anyone is having issues with hearing me or any problems with the weather, neurologist put them in the chat. And But we'll keep an eye on things if we run into difficulties, which hopefully will not happen tonight. So remember, before we get kicked off. So as I said, I'm an incoming radiology training, which means that I'm not even a radiology training yet. And I'm certainly not an expert in the field of Venus intervention or any matter, any field for that matter. I guess I'm not not an expert in any area just yet. Eso I'm very much a standin speaker. I think the plan was to have somebody for more qualified to talk, but I was asked to step in in the last week or two. And what I are bites. The target audience is obviously pre trainees. So the idea here is that we kind of get medical students and pre trainees up to scratch with some topics in in interventional radiology that will hopefully help you as you go on to spend more time in the eye, are sweet and find out more about the career path. But I was, I guess, just to kind of even just to give, to give myself a little bit of reasoning as to why I might be. Here is I was, and I already offer in the hospital with a large venous workload in the past. So I have seen a lot of these procedures, um, over the years, So hopefully enjoy it. And don't be too harsh on me if it's not great, but you know, we'll move on. And if you have any questions, I'll try to answer them, but may have to get back to you in a few. So the objectives this evening or to revise venous anatomy and physiology we're going to talk about the primary process is that underlie venous pathology. So what what leads to most of the Venus pathology that we see in the hospital on? Then we're going to talk about the presentation imaging a management off both VT so that pathology that incorporates both DVT and pee and also chronic venous insufficiency Onda. Essentially, the overview is very similar to what a reject is there. The things that aren't covered this evening but are potentially relevant are super superior vena cava obstruction syndrome, Perfect congestion syndrome. Varicocele fair because veins central venous access obviously a big portion or kind of a baseline workload off the intervention radiology department and also thoracic outlet syndrome. All of these can impact on the venous system and can be potentially intervened on in the eye are sweet. But to be fair, there's actually enough to cover in the other bits that I just mentioned. So I guess I have a perspective on on this having kind of country medical school recently and now being a foundation doctor is that medical school? Obviously it appears it fairly well from management off the acute management of a pea and a DVT, often your vascular surgery blocks and most the time you actually spend that time focusing on more kind of exciting arterial presentations. Because, see, they're they're slightly more common in, and there may be little bit more exciting to to watch in theater. But the non acute management of venous disease, particularly varicose veins and things like posttraumatic syndrome, isn't elected topic in my in my mind and I feel like you know only for having gone back and had a bit of a chance to look back through this. I think it's It's difficult to know where these pathologies often lie in the kind of spectrum from acute DVT up to kind of chronic venous insufficiency phase. Hopefully, we'll kind of cover that this evening, so we're going to start with the basics, but maybe not the basics to this level. So hopefully we all know what a vein is. This is the venous system, and this is from radiology key dot com, and you can see Hear that on the left hand side. It looks at the superior venous system in the in the leg, which is largely met up off the great and the great and less lesser of cephalous veins are the great and small is it's highlighted here, essentially draining the superficial structures and then drain and then making their way into the deep structures off the deep veins of the leg. So the smallest F, it's obviously running up the posterior portion of the off the the lower limb and then into the part of draining into the popliteal and the greater Stephanus, making its way up to the seven suffered this off Emerald junction up at the groin. There is well on the right hand side, kind of a more more injected look at the deeper veins then. So we've got from the lower limb working up. You've got your anterior tibia veins and your poor Syria to move in and and then the deer, your fibula vein, which isn't really highlighted on this one, which all come together than to make your partner to your vein, which is, as I said, one of the deep ones that the lesser seven strains into making its way up into the the tie, At which point is femoral vein. And once it crosses the inguinal, the inguinal ligament, it then becomes the external iliac. So that's just some of the anatomy there, and this is also kind of a bit more of a graphical presentation over. You can see that the elements that we didn't see in terms of the external iliac try joining the common iliac and into the inferior vena cava on one that we didn't mention. There is the profundus feministas. Well, so this one that obviously just before the seven or Femara femoral junction, the Profunda Femara strains in there to the distance of the more proximal part of the femoral vein. So venous physiology, essentially the rule is off. The venous system is to provide a low pressure track for the blood to get back to the heart from the tissues it relies. The venous return Realize in a few things on a few. These are highlighted here. Obviously, as we you may remember from your histology in medical school, it's it's often times just smooth, most of proportion in veins. It's quite small, but they do have a role in and getting some some venous book back to the hair it but more importantly, the muscular venous pump. So the fact that obviously a lot of those deep veins are located inside the muscular compartments of the lower leg, um, allowing that kind of tea promote blood, return to the hair it when people are kind of ambulating and walking, and also the risperidone pump, which is obviously related to the fact that when you take a deep breath in your interest, traffic pressure decreases and your intra abdominal pressure increases and that also promote some blood coming back into the right side of the hair, it or there, things that are mentioned in textbooks, essentially a cold location with the arteries. The fact that obviously they're often in a sheet together with an actuary and the artery pulsating on the fact that because of the valves that can only go in one direction, it will go back towards the heart and also the preference perforating veins that will kind of connect the superficial and deep systems that the way that they cross through the fascia is actually with most contraction helps that I'll get back into the deep system hours. I just touched on their very briefly, essentially their costs of in the Ileum. And this is just a a view on ultrasound over valve. But you can imagine how this can promote just one way travel of blood on more. You know, if they're functioning normally, should blood try and get back there again. The costs were close, and the Lumen essentially is included, and and it reduces obviously any pressure because the valves keep those columns of blood separated, so the pressure doesn't backfill again. This is in a a working system. Let's talk about clots. So this got obviously happened when the Bloods natural. There's an imbalance between the natural anti anticoagulation mechanisms, which we all have in our blood and something that promotes coagulation on demand. They're under the right and side is obviously virtual who came up with that triad off something going wrong with the floor. So the blood Stasis and then vessel injuries with some damage to the endothelium on, then some tendency towards increased quite ability or hypercoagulable itty more recently, August in in more recent years or decades with learned about the kind of added role of information. Obviously, this is something that's come up even more in the context of Corvette and the increased tendency towards VT. In those patients and Tom bite themselves, the actual clatter a large You met up afebrile and red blood cells, and it's obviously beyond the scope of this talk to go back into the coagulation casket. I'll save everyone that, but essentially the formation of February is the the endpoint of your coagulation class, Kate Central venous pathologies. So the fact that class are central venous pathology, So both those those acute ones VT, Soapy and DVT and also the chronic ones as well. To a large extent, there are other causes of chronic venous disease is a swell just before we moved further cause this kind of comes up quite a bit with the pathology is that we're going to talk about is posttraumatic syndrome, which I feel like I certainly didn't have a great appreciation of when I was a medical student. So chronic venous days, or it's a chronic venous sort of following a deep vein thrombosis. So the valves off these veins we've just talked about are often damaged by the inflammation that occurs when it thrombus has broken down. The license process of breaking down a large clot can actually lead to some inflammation and thereby kind of, you know, cause damage to the valves. There also also, some of the tremors may not completely lies may not lies completely so. Then you have some persistent thrombus actually preventing the valves closing and also leading to that kind of increased pressure because the columns, essentially of blood or not, separated as they were before that causes increased increased pressure in the supervision cyst in the deep system that feeds back into the Super efficient system and essentially leads to three issues that we've just talked about. So quality of life and source. You know, it's social economic impact there. A large are a big thing that aren't really considered in terms of posttraumatic syndrome, and it actually occurs. And far more people than you would think in terms of 20 to 50% is what they caught. 1 to 2 years after deeply in from Boss is that patients can end up with this kind of syndrome. The value to score is the one that's used for diagnosis and severity scoring. And it's after news in the studies that have been done to try and figure out what, how much of an improvement in symptoms patients have after intervention, so you can see there on the right hand side. This symptoms that the patient have has will be graded between absent and severe, and they're things like the pain cramps, heaviness, puritis, that kind of stuff. So itchiness of the skin. And then, obviously the clinical signs that we see changes the pigmentation. Any venous, venous, excellent redness, injure Asian of the skin. The other thing that's not mentioned there is this idea of Venus Cortication. So it's a really severe bursting pain the patients experience in their legs when they're exerting themselves. So it's, you know, intermittent claudication in the arterial system. Venous qualification is actually quite a quite a, you know, a normal problem in another indication for patients with chronic venous disease to have some intervention. So I just wanted to touch on that. They're now before we move on to their first part of the talk. So hopefully you're sticking with me. The this is the curriculum from sources, so sources medical student curriculum on Venus pathology. So the first part is venous thromboembolic disease. So we're going to talk about the presentation. We've already talked about the physiology there, and and obviously the presentations of both the DVT and a P E imaging findings was. Have a chat. True that duplex imaging that's often done and then have a look at some some cross sectional imaging as well before we move on to the treatment options, obviously anticoagulations going to form a big part of that. But this is a talk from IR juniors, and I are bites, so we're going to have a little bit of a chat around the eye are options as well. Um, and then the follow up it's and pieces there, and we'll move on to those after so deep vein thrombosis that you going to do to him of deep vein thrombosis. Excuse me, eso. It's it's much more common to happen in the lower limb. It can happen in the upper limb, but there's usually some sort of ah structure. Abnormality are under well in line that would cause the upper level ones. On that, these kind of clots form. The coagulation casket is triggered in these venous Sinuses of the calves, often by cost pockets and where there's any damage, the vessel. The thing to see his DVT is a very commonly asymptomatic on there. Just as I said, that balance between coagulation anticoagulation they usually just like spontaneously. But there are some that wound lights and can form and still stay asymptomatic. And the issue with these is they're actually quite dangerous, particularly particularly if they extend and become quite big because they're they're right there beside. It's a blood stream that's going straight to the right heart. So this is the importance, I guess, that we've all seen off the last two years of venous venous thromboembolism prophylaxis in the hospital because it's easier symptomatic ones that maybe you wouldn't pick up on. You know, your your wardrobe's in the morning that that may actually cause a clinic. Clinically significant PES classification can don't be done at anatomically or else by provoked or unprovoked anatomically, usually approximately distant. There's actually a paper recently that said that this is quite confusing, and in fairness it is approximate is anything from the popliteal vein up to the inferior vena cava, which kind of doesn't really fit that well and and and, you know, and then the more distant ones, they're just in the calf veins. And what sometimes is more useful, particularly in the things we'll be talking about, is whether it's iliofemoral or femoropopliteal Trump. This at the end of the way of kind of looking at that is, you know you're super or in for angina ones, as your your your femoral vein obviously becomes your external iliac with the provoked an unprovoked. Obviously, this is has a major impact on anti coagulation duration after the event, Onder thing to say is obviously if it is on provoked or you feel it's unprovoked, then it may be important, actually investigate for triggers. So if you kind of may suspect any underlying malignancy or some sort of a Trump affiliate type picture, then that would be the time to tell you look into those things. If there's not a clear provoking factors. Otherwise the clinical features. Obviously, we will be aware of these, but you're kind of unilateral leg swelling or tenderness at the back of the calf. Um, the extremes of presentation and DVT are these two things that are talked about. Don't think many people really remember what there. But you have these Flagyl asthma, albuterol and and phlegm asthma. Surreal A Dolan's essentially one is a paying for white leg, and the other one is a painful blue leg. I I think that's what it is anyway, is intrigued. The surreal Dylan's one is when there's there's sinosis off the off the lower limb on that's caused by essentially a compartment syndrome off the lower leg because the venous pressure and the pressure in the compartment is to increase to such a point that there isn't actually at any arterial in flow. The one before that the step before that is the depend for white leg is where obviously, arterial flow was slightly reduced in that there's kind of reduced profusion and the leg looks a bit white. But it's not quite as advanced is that this could be to Venus. Gangrene, obviously, and Death of the Tissue and the cross is so at the part of the point, obviously, before it gets to the Venus gangrene. Still, there is some chance of if you intervene. Either. Surgically are potentially with IR is that there is some kind of leg to salvage here. The symptoms. Calf pain, pipin, swelling, redness, but sometimes asymptomatic as well as we mentioned. So DVT imaging duplex scanning is the their corporate imaging and do plex being bought. Be more ultrasound and your doctor ultrasound evaluation off the lower limits. Well, so the decision, obviously whether to proceed to ultrasound is often based on you know, the well score again. I'm not going to dwell on this too much. We're all aware of this one, essentially. But if you're pretest, probability is high enough. Then you won't bother with the D dimer, and they should just go straight for ultrasound on both features that you will see on a DPP interim bosses. This'll kind of image from radio PT up in the right hand side shows some of thumb. It's difficult, obviously because, as it says, it's anatomical and functional, so you're not able to actually do the functional elements here. But you may see particularly an acute DVT. Ah, high Pulmicort Lumen. That's none compressible when you apply pressure to the area, Um, and then there the other bits and pieces. There are obviously the floor side of things. When you have the flu on which it is there, you can see any fool to that through the vessel itself. This is very good for looking for those in for angina veins to see if there's any any any evidence of troubles there, but not so good as you move into the purpose, because those structures are quite deep. So there are a few ways of kind of looking kind of assessing these patients to see if they do have any of these of the two that are kind of in brackets down below, so you can do doctor assessment when you kind of up over the top of the leg kind of into the pelvis as you squeeze the calf to see if there's any augmentation. What should happen when you squeeze the caffeine, promote some venous return or use um, valsalva over the femoral vein, which should call cessation of flow one. If there is a a slow, kind of, ah, reduced kind of it. It takes a while for the blood flow to stop. When they do that, that's all that. That gets another indicator that there may be some more, more, uh, proximal traumas. Essentially, if there's any concern, then you need to move on and do some more. Cross section imaging visited Well, score, which is that I'm not going to talk to much about. So the names of treatment of DVTs are to control the symptoms and obviously prevent progression. We've talked about those flag flag Glasman type presentations at the sensation the symptoms obviously off off, you know, lower leg pain and that, and also to reduce the risk of PML posttraumatic syndrome. They're obviously the pee being the major kind of acute concerns. So anticoagulations we've mentioned is kind of the main main stay of treatment and did your Asian as we said, will depend on the classification. There are really older management that can be used on gets more common when there's an extensive approximate DVT on. That's where intervention radiology surgical from back to me on potentially ivc filter is come in. Ivc filter is obviously not a treatment for a DVT, but can help prevent progression just to dwell on that for a moment. Essentially, it's on ivc filter. In case anyone isn't aware is a It's like a number umbrella type device. You can kind of see a picture of it up here. Metal type of relative essentially divides the inferior vena cava on stops. Any kind of large clots making their way from the deep venous system up to the heart won't stuff all class. But it should stop the ones that will cause, you know, a massive, massive P S O. Why would you use this? You might use it if patient can't have anti coagulation or they've had some sort of a side effect of anticoagulation or they've had some VT. Despite anticoagulation nice guidance from 2020 essentially says that the's are to be used, but there should always be a strategy for their you know our strategy or a plan for their removal? A swell There's been some controversy in in recent years about these just being left in and then becoming program, but it themselves off the having a foreign body in the inferior vena cava. Um, this image just down below here is just the placement of a navy see in a patient who had quite a a large occlusion off the inferior vena cava, which was then treated and then placement off on IV. See, I'm going to give the references for this particular this article. It is quite a good one and quite pictorial if you want to have a look at things after eso imaging other way. So we've said cross sectional imaging. So ct venogram zehren important on be useful for looking at the worst kind of super um, grande DVT's, as I said on that can help in looking for any kind of external compression or masses that might be causing the issue in the first place. Um, there is a potential, so the common one would be obviously, you know, preferably in the arm giving contrast administration, and then let it go through the arterial phase and then kind of delayed scan for the venous face. But they're, you know, at that stage you're going to have some. You're going to have some enhancement off the arterial system. You're going to have some some enhancement of the venous system. The venous system may not enhance that well, because it's likely going to be, you know, you know, included along the way. So it's It's not great. There are some ways of doing direct venogram, so you can actually cannulate the feet and do a venogram that way, particularly with multi detector CT. Now that's that's a possibility. MRV then has similar advantages in terms of looking at the pelvis and those lessons down there. And and then the aging of Thomas is something that they talk about the literature as well, obviously, that there could be sometimes difficulty picking a parent of patients having acute recurrence, or they've had a DVT that's completely resolved on. Then there's another one, or as whether the promise that was there initially just never completely resolved. So this can MRV can be helpful and kind of aging. The trauma is a little bit on convention venography so on table in the in the eye are sweet are in the hybrid lab. Venography used to be the gold standard. Probably it's quite an invasive imaging procedure to have gone now just in the context of diagnosis. This is an M R venogram. It's just showing the, um, in the abdomen. It's showing the inferior sorry, the left iliac vein just in front of the vertebral body. There, you can see it's this kind of sign of what they call it, pancaking essentially with the right external iliac just on top of it and compressing there. This is a picture from one of the papers as well, which confused at the end which century shows that's going on. This is May Turner's sometimes call the central syndrome, sometimes called an anatomical variant. It's got quite a high, high proportion of the general population will have this without any issues, but it's just something to be aware of that it can lead to increased symptoms on the left hand side, particularly for patients presenting with acute DVT. So DVT management, uh, surgical options, aside from all of the anti coagulation we just talked about surgical thrombectomy is very, very rare. I think There's another paper that talked about there. Being about 26 to 45 is happening every year. Um will depend on local expertise with dependent, obviously the Theo extreme of presentation, whether this needs to be done, but not something to worry too much about. So why does I are get involved? I or mainly get involved again. It can also get involved in those acute scenarios where you know, the patient has presents with one of these Flagyl asthma, Um, phlegm easier. Sorry, presentations. Or it could be, you know, because it's now becoming quite clear that posttraumatic syndrome develops in quite a lot of patients on do. If we can kind of get rid and clear that class at a near your stage, there may be less inflammation, less structural damage done to the venous system on devalued injury as we as we just talked about. So what are the options? Catheter director Trumbull Isis is one pharmacal mechanical Trumbull. Isis. So this is this is you're going to have a little gauge in, but also some sort of other catheter based technology. Mechanical thrombectomy. So this is obviously we will have heard about. This is a bit more in there in stroke setting more recently. But there is potential for mechanical thrombectomy, and actually it's becoming quite a growing area because it negates the need for that. A little gauge in potentially and can be used in patients with contraindications for those venous angioplasty and stenting as well is also important. So who do? Who gets offered interventional radiology type treatment for DVT, so they need to be in a center where there's local expertise or be transferred, sometimes to a center? With that expertise? An iliofemoral DVT symptoms less than 14 days that kind of still in in the acute phase, and they need to have a little bleeding risk. But I've kind of talked about there being a potential first and procedures that may overcome that that barrier. So again, sorry, these airworthy slides, but essentially catheter directed thrombolysis. You get access through usually the lateral, the vein, and you have a side who? A catheter, which I'm sure a picture of in a moment. Do you then infused recumbent TTP A or similar, and it's usually mixed in with some heparin in saline on, But that's that's infused over a period of hours they then leave after you leave the eye are sweet and go to an ob observe observation bed like a huge to your bed on your there, observed for all of the potential complications such as, you know, um, such is bleeding, so they will then come back, usually at 12 to 24 hours later, and then have another venogram done to see what difference has been made. So that obviously venogram before the catheter put in when when the catheter is initially put in. Then the licenses started on then kind of revisit another venogram, then again to see what's what's changed. And then they can either go back to observation for more of an infusion or some further intervention, or essentially just take out the catheters and and kind of monitor thumb from their family. Calm a can ical Trumbull eyes is So this is where you have the little confusion and those devices, as I said, and there's multiple mechanisms used at the advantage of this one, it came on stream. First of all, was the potential to actually get these procedures done in a single session, so patients didn't have to keep coming back and forth to the lab. Um, well, I think I'm going to go to the next stage. So the CDC catheter. So this is an image of the catheter essentially showing all the side holds and where the TPN would be infused into the clot and kind of like immerse itself in the clot. Hopefully, try and break breakdown the trombone. The angiojet here is one of the PM t's The Pharmacal Mechanical from Trump Lies is type devices, so it's a it's a Jew Lumen catheter with which has these kind of streams of water coming out. These jets essentially cause a vacuum like effect, and when it's, you know, the little gauge in just mixing with the clock. But then it sucked into the catheter in. You know, there's an element off from back to me. There are least removal of the kind of lies lies to realizing plot. The other ones we just mentioned, these are just briefly mechanical from back to me. Eso the these air kind of increasing in their use in the venous system, Um, but they could potentially eliminate the need for the medications. Potentially be a good one for those patients who have any any contraindications. Tactical regulation, venous stenting. There's a great paper from from Green 2020 which, which is also reference at the end. Well, she talks about the use of Venus stents bought in the acute setting and the chronic setting. So we'll pop back to this again in a few minutes. And there are a lot of unanswered questions, both with mechanical thrombectomy and Venus stenting. That's not to say that they're not happening and there's not trial is going on, but I don't really. I want to kind of given all review of what's what's available and what's happening in and hopefully trigger a bit more reading and or even just a bit more understanding when you attend your next interventional radiology meeting. Um, so in the acute setting, if a patient has one of those kind of proximal DVT s and they're at a high risk for PT Pts, they can essentially that have anti coagulation. Some catheter director Trump Lies is on, then have a stent afterwards, so that that kind of particularly if there's any evidence that after the trouble is, is has happened that there's kind of a persistent stenosis of the vessel or some sort of an an an anatomical deformity that may have caused it in the first place. That's when it's stent might be useful. This is a DVD case, so I'm afraid I haven't obviously been in an intervention radiology department myself out and GP at the moment. More recently. So I've taken some cases from Twitter. Obviously, they're freely available to everyone, so I can't really see any issue with using them. But, you know, I wouldn't say. I guess that it's It's a useful place to look if you are trying to find out more about new procedures in that or innovative things that are happening because there's a lot of these things pollster than and give you a good idea. So we've got a patient here with phlegm. Phlegm easier. Um ah. Run to pronounce that probably before the end of this session on, then before and after pictures of century. So you can see the imaging on the way down here where you've got a completely occluded external iliac. Very likely. Yeah. Um, And then again, after Thesaurus o'clock slot retriever that was used here and then all the flat that's been taken out so quite remarkable results here. And what it was a stent put in after that. Doesn't you imagine they would have said they're waas. So the later the land for acute DVT I are I'm I'm not qualified to really talk about this, But what I will say is that there's there was a trial called Attract in 2017, which was kind of built up to be the big trial that was going to show that that I are was going to be the thing for for these kind of proximity beauties unfortunately, didn't show that or it didn't show it in very clear fashion. Um, it showed that there wasn't really a reduction in pts, overall, but it did reduce the severity of PDS and there was an increased bleeding risk in the intervention. Um, um So obviously patients had a Morton's more tendency to bleed in the if they had an IR procedure issues being that they kind of didn't split up the, you know, federal and femoral popliteal DVTs. I think there was issues recruitment. So the ended up for bringing in the femoral popular ones, which there, you know. So it's been known for quite a long time they would likely not benefit are the risk that, if it wouldn't be in favor of treating those patients on. There's other issues in terms of stenting is now quite, you know, routinely used even an acute DVT, and there was very little stenting in these patients on it was poor imaging. Follow up. These patients need to have follow up imaging to make sure that everything is still paid and and to be re intervened, if if need be in order to keep symptoms abate on now. Since then, since this paper, there's obviously these these new technologies available. Nice guidance. Sit fits with the things we said already So Catheter, Ector, Trump license. If it's less than 14 days, I've got a good functional status on they've got a little bleeding risk on. There's more evidence needed, as I said in those areas, like looking at specifically a little firmer DVT to actually prove that there are benefits. Their mechanical trump ectomy and Venus stenting after Area Clara, which we kind of touched on their pulmonary embolism, is quite a quick one. I'm not going to focus too much on it, but it is another emerging area. Um, so again, it's detachment of the trauma is that usually forms in the deep venous system and making it way making its way to that the pulmonary circulation? Um, we're We're all aware of the various presentations of peas and and the fact they're obviously quite a loose of sometimes so they interfere with poor circulation, gas exchange and and it can be quite difficult to figure out what's going on. But they are associated with a lot of more mortality, and morbidity on this is just the point is just kind of out of interest for myself, more than anything else is that they're commonly symptomatic as well, in the same way as DVT is raising tomatoes. So you laughed and find a symptomatic peas up to a half of patients in a DVD in patient with diagnose DVT on 70% off, patients with a P E will have an underlying DVT, which obviously fits with the pathological process there. Um, classifications. P E is based more on the risk factors more than kind of anatomical things around things like that. So and and obviously that that kind of puts them down a path of management high risk patients will have that hemodynamically him a chemical instability. Things like cardiac arrests, shock in organ hyperperfusion. So highly active, altered mental status. M I guess the troponin rise and persistent hypertension, the intermediate risk ones that scores, usually by the pet CT scores. So this, you know, either kind of quite high between three and five or the especially of one and Grazier. I'm going to show this in a second again. It's not in the context of talk for you to go too deeply into it, but it is important to look at the intermediate ones because they're they're kind of stratified between intermediate high, an intermediate low on that's actually kind of differenciate between. Those might be quite important in terms of determining which patients might be might benefit from interventional radiology. The low risk ones haven't especially of zero. These patients can often, you know, they're so I'll be asymptomatic. And we managed, often an ambulatory setting with with oral anticoagulation. This is just the Pepsi and especially scores on how their calculators clinical features. As I said, that could be quite elusive. So you need a high degree of suspicion, particularly if a patient has, like difficulty breathing, are kind of a rapid respirator or any predict chest pain. The symptoms will depend on how big the clot is. There are the the embolus is that smell its way to the to the lungs, obviously, And if it's large and central, then they may get carry a vascular collapse. Um, imaging wise again, we're aware the chest X rays are very non specific, but they can help rule out other causes. Specific be findings. A very rare, like those wedge infraction stuff that we learned about back in the day. See TV is the the imaging modality of choice, really, And it shows those filling defects in in the pulmonary artery vessels on going to control that kind of rifle regular strain, which indicates there's that back pressure from the pulmonary arteries to the right side of the hair. It also useful to have a look at the the the other structures in the chest be scanning useful or CDP is contraindicated again. The about risk balance between those is is changing a lot more people, particularly. I guess it's it's useful if this contrast our allergy a renal failure. But if it's if it's a clinically significant enough, one that after have to CTPE the management relates to the stratification risk Stratification have talked about so anticoagulation and the similar means to DVT. These patients should be on Requip anticoagulated at the first you know, instant that they may have a P or there's a chance that maybe underlying here systemic Trumbull Isis is usually for those patients at the high risk ones who are kind of either having cardiovascular collapse or risk of that in colectomy, another surgical procedure, which is rare but you know, can can happen. I haven't seen it myself, and then I r is more. Trouble is, it's thrombectomy type picture again, so similar issue to what we talked about DVT and obviously filters we've already mentioned. But that's not going to help the P that's there. It's maybe going to prevent further ones on anti coagulation. As I've talked about now, the real risk ones can be managed in amplitude care and have their CTP almost a zonal patient, systemic Trumbull Isis pretty much of cover this already. The bleeding risks are often offset by the potential benefits. Unless there's a cure. Contraindications, obviously to systemic thrombolysis, um the pulmonary embolus to me where trump places is contraindicated or not successful. And there may even be kind of a rule for intervention. Radiology to step in. Or, you know, if if the evidence becomes stronger, to use that before, kind of going down the line off to use some sort of ah. Ah. And I are going to try, um, back to me before you go to a pulmonary embolus on PT management three. So this is the i r. Again once. That's all right. Yeah. So this is the different types of things that are used it the moment again. This is this is all quite quite a new area. That lot of research ongoing at the moment. So catheter director Trumbull Isis. So this that on the right hand side of the picture is another very good paper on kind of the emergency rule of ir and pee three catheter in the middle is one of these coarse catheter is essentially which both lies is and has an ultrasonic effect on the on. Breaking down the clot as well. Um, and that is the picture that is just below it. I think I think actually the top. Be one you can have again have looked this one for yourselves. Um, that shows that was on both sides. The one on the top left is just one of these kind of trumped to me approaches with the rotational pigtail device on. Then the one below is just your I think it's just a, um just a thrombolysis type catheter. But again, I'll leave you to have a look at that. Another case here. So this is, um, a case from Dublin. This is ah, patient who has had a tram back to me. Device used to one of these. Ah, cattle category 12 ones. I can't remember the name of it again. I think it's ah, it's a number device in a way that's used. Essentially, it's It's one of these from back to the ones that that sucks out the clot. Um, and you can see, obviously that the images before hand on the the the degree of writer it strain and three catheter itself. These air quite large bore catheter is you can see the results of the clot that's been taken out there is well, so the lay of the land for acute P. I. R a. M is that there's a wrap. There's a P tract or randomized controlled trial coming up that's going to compare a catheter director. Trouble is, is to just anticoagulation alone on this is going to be specifically, I think, in the the intermediate high risk patients on two, I guess. CC, if if there is benefit to these patients from from, not just anticoagulated them, if they're not going to Trumbull eyes, they're just content. Equipment, potentially is a role for IR, and there is Well, it could also be. I think the thing about this one is it's going to look kind of down the line at 12 years to see what kind of remnant symptoms that these patients have, because obviously some degree of risperidone function decline is known to happen after pee. But that I guess there have been many studies are many other many options of what to do. So I think following these patients off will be quite interesting. The final part of the talk is on chronic venous obstruction. I hope you're still with I can see you, Um, but we'll keep going along anyway, So this is As we said, this is kind of progression, often times from the DVT, citing side of things. But there can be other causes for chronic venous obstruction or chronic venous insufficiency. And so we're going to talk a little bit about the presentation again, A little bit of our imaging. There is a good bit of overlap here and then the IR treatment and follow up. So this is, uh, an image taken from Germany. It is here. Essentially, these are things that we may be familiar with again from medical school, so that the skin changes and kind of tissue changes that can be seen in chronic venous disease. So from Venus excema to like a dermatitis sclerosis toe venous ulcer, and we'll come back to this in a minute. So whether chronic venous disease is the disease are it's insufficiency or two disorder is it's obviously a spectrum, depending on how severe the patient's symptoms are. There's obviously papers that kind of talk about it is a chronic venous disorder rather than a disease. Um, the cause is of chronic venous insufficiency. Our venous thromboembolic disease we've talked about, that is posttraumatic syndrome can also happen where there's just venous hypertension potentially do to right heart failure. Or if there's external compression in the in the pelvis, for example, due to a mass or adjacent structures on important thing that's come up and it's mentioned and papers quite a bit. It's just more to make people aware, so that you're if you're looking at the literature that you kind of know what they're talking about. Is these niveles there? Nontraumatic iliac veins lesions? As as I said, the idea between but behind, like May Turner's being potentially an anatomic of variation rather than a syndrome is that there is a high prevalence of off this in in the general population on often, these pain was not often, but up to a quarter may have an appearance to nurses that that would be kind of what what would cross the threshold for intervention or stenting, and so that may be leading to over treatment. And it's obviously important to make sure that you feel that the symptoms that they're presenting with definitely align with with the the imaging that you're seeing and this is they feel that either so intravascular ultrasound is quite useful here in decision making and actually getting in turn of view of the vessel can can be a little bit more sensitive. For those you know, stenotic lesions posttraumatic syndrome. I'm going to touch on one more time because I feel like that's the one thing that we should all take from this and why Interventional radiology is is involved here. So it's related to this kind of either architectural damage damage, so damage to the valves or some persistent obstruction and the venous hypertension that results. So those risk factors, they're kind of a little bit obvious if you have approximately DVT, the chances of this developing, obviously you know greater because you've got a more proximal occlusion and therefore the effects with the greater A. Previous. It's the lateral DVT. So a DVD on the same side before if they've had private, previous venous and incompetence. Obviously obesity in older age also factor in there as well, So the pathway is generally there's increased this hypertension, the venous system that leads to a Dema. There's an inflammatory reaction because all this fluid is coming out into the tissues and it gets fibrotic and you get to see things like that term. It'll like for Dermasil schools is on. Then the skin loses its viability because of all these changes going on. And then that's when you developed the skin changes like ulceration. So what? The patients that we talked about the other bits. But the patients talk about pain, heaviness, fatigue, itching, cramping, venous, claudications. All those things that we came up with in the theater, scoring as well. In terms of the signs, we there's there's this kind of grading system. It's called the C E a P grading, which comes up again in some papers that you read. It's essentially the clinical. It'll article Anatomical and pathaphysiology kel way off off, scoring the's chronic venous insufficiency patients so it can go from a seizure. Oh, so no visible changes at all all the way up to an active ulcer. And it's mainly these these patients in the last few sections here that are the ones that will be who could potentially benefit from interventional radiology. So chronic venous disorders, ju plex, ultrasound again and then some sort of cross sectional imaging. This is just another Radio pedia image taken from here, and it just shows the popliteal vein, which which is trembles. If you believe me, maybe have a look back through the video again. This trauma's looks more echogenic than the one before. Obviously, it's none compressible. We can say that for sure, because we're not actually holding the probe but were told that it is. And the floor is very poor around the trumpets is Well, this is quite a well established thrombus in the in the popliteal. Then then next against Venography and I I've It's we've talked about. They're they're useful if there's kind of going to be intervention happening on just a show you some images of interest intravascular ultrasound to some down here on the left hand side. So this is essentially you get a circumferential of you from inside the things that you can imagine how that's very useful, particularly in comparison to fine ah, graffiti. When you're either just getting at an AP view from the front and then some obliques where is you actually at at one time can actually see a circumferential view from inside the inside the vessel. So this one is showing just to go back to this one again and again that I'm going to highlight this paper at the end. So from verse well established and flow around the outside of us, you can see here this kind of hyper hypo hyper a quick thrombus in the area on then this is the post procedure one. So you can see that the compressibility is actually this is without compression and this is with compression. So that's returned again with after intervention, Um, on then. So just to talk about follow up with this is this is important and it's it's kind of one of the issues with the papers that are out there at the moment is that these patients do need if the stents replaced, they need to have ultrasound when they're just before their discharge. And also they need to have frequent ones thereafter to make sure that the stent is staying up. So there may be an indication to go back in and do an angioplasty on these stents are just too obviously T. Make sure that there's no kind of in in stent thrombosis forming. This is the very This is a very common one that you see it's entry. So you've got ah, lot of collaterals around here that have formed non compressible, non caressed vein on this side. This is the CT venogram. Want to get not a great picture, but you You could probably trust me that there's a bit of thrombus and they're, um this all the collaterals balloon. So I think that was initially some thrombectomy down here than that balloon put up. And you can see a little bit of lesion here and a stent, and you can see the floor back to there again. So the chronic venous insufficiency is often managed conservatively, conservatively, so compression stockings anticoagulations can help with symptoms Intervention. Radiology, as I said, can be useful for the We'll see three to see six patients. Or if there's that venous you know, they may not necessarily have the skin changes, but they have that really severe venous cortication type presentation or leg pain that could be attributed to venous outflow obstruction, same way as the other two are, um, and then what did they do? So generally it will be and your last e and stenting is the core management. But there may be an element of kind of using some Catherine director Trumbull Isis first to break down any acute bits of the plot or any bits, any bits of the more chronic cough that are likely to break down because there there is this element off. It might be chronic. And but you have to get kind of obviously have to get a wire through the lesion in order to put up a balloon or a stent. So anything that kind can kind of help from that. That point of view in terms of using some trouble ices um, I haven't seen any kind of firm of chemical trouble Isis or mechanical thrombectomy you on chronic. But that's not to say it doesn't happen, so, you know, keep an eye out for that on this is another case against this is from obviously the pretty exciting intervention radiology page as this Waas again Very similar. So when we saw a lot of collaterals in a and then we have the IV is picture here is well, which shows a very classic me turn or type lesion. So you've got this pancake and completely flattening off the off the left iliac vein on the right iliac artery overlying it. And there was This was after this is just after some trouble Isis was used. And then this is after the office of this helps helps to get your wires up to that area on then this is after the stent was put up. So the case for Venous and I are it's a dynamic and developing area. Um, there is need for more research. It's, you know, I put a question mark behind beside this because obviously I I find a little bit interesting. But it is interesting. And after me and partisan a gee, that maybe isn't focused on so much medical school. The work is very rewarding because you often kind of build reports with your patients. And there's a high level of clinical involvement and following these patients off, obviously with imaging and that on Obviously it's It's great because it's such a multi disciplinary team involved in terms of vascular surgeons and hematologists and oncologists. And obviously, your your internal medical team is well, so hopefully kind of from this all review and I don't, uh I hope it come across is if I'm I'm speaking from any, you know, place of authority. But I just kind of wanted to give people an overview of what What the topic involves, I hope for your kind of, you know, find find some orbits at at National Conference is in that about venous ir that you might find interesting. So we've talked about venous thromboembolic disease and chronic venous obstruction, and essentially, we have covered everything that the search see medical student curriculum wants you to cover on. This is one of the interventional initiatives from the you from the us just about how you know, treating DVT through a pinhole. And it's in that they make a lot of really kind of, um, pictorial, really nice pictorial presentation for patients about information on the disease in that as well. So keep an eye out, for those are even good for medical students to get that initial introduction to what it's about. Twitter with views of few cases from Twitter BSI are and I are. Junior is obviously a great there's there's a particular people, and you find your owner's as you kind of get an end to the Twitter space. These are three in particular. If you want to have a look at her, do a lot of Venus work, so they're often kind of post in cases and talking about open coming research as well, so that they're good people to follow. A few found the names is interesting. There was quite a few references, but the acute. So there's a few paper. These are the papers that I would recommend having look at, particularly the European society of Ask her surgery. They've got two papers, one on chronic and one on venous thrombosis. More generally on they have really you don't. They're like, 40 or 50 pages long, so don't freak out when you open them. But there are really nice sections on just the background kind of anatomy and pathophysiology that a lot of what I've talked about is based on the IR role and p. E. So that that paper of talking to Bremerhaven have a look at that one as well. That's that's available free access this paper by Dr Bringing and Goes that Thomas is about venous stenting Andre, the an overview. So this is like a consensus statement from all the the UK vascular surgeons and I ours about where, how, how to manage acute and chronic iliofemoral venous outflow, obstruction. So again, if you find it on, if you feel in any of that. Interesting. Have a look on the last one is that kind of pictorial review with some reading pictures. There is well by Hindi and which was in the Journal of Clinical Imaging Science. Some radio PDM years of use as well. And that is me, I think so. I will leave it there on backorder injury, and I'm also going to be able to Hopefully everyone heard of that. Well, thanks now for a great overview of Venus is he's not. It's ah, it's a relatively new area. I mean, there are quite a few centers who are doing it now. Actually, even Oxford they don't post a much on Twitter. They didn't want to. Do you have it with your account, but they did quite a bit of Venus work as well. So it's good to just gonna get another view. I'm gonna start with a couple of questions just to get your thoughts on on a quick discussion, and then we'll go to the the questions from the chat. So a lot of some of the audience will be in coming off one. So in about a month's time, And so one question which I wanted to get your opinion on would be. When should you refer a DVT or epee to interventional radiology, particularly the acute setting? Because I think most def ones would. We'll see lots and lots of patients with plots, particularly piece, you know, on call. So when would you say would be the time where you should think? Should I refer this to interventional radiology? Yeah, so I guess it's It's, you know, it's never going to be a decision. That's thing not to freak out on the F ones out there. It's not. It's never going to be a decision left left to yourself. I think we'll talk about DVT is first. I think the evidence is much more for the proximal one. So a patient with a you know who presents the extremes of the very obvious If they come in with one of those flag Maisy ones, you know, it's it's quite care that they need, you know, they need to be dealt with by somebody more than just the left one number one, but that they might be somebody if if surgery isn't isn't being considered or even in instead of surgery, sometimes but the more kind of classic ones. If it's just kind of tender calf in their desire is elevators, and they don't have kind of, you know, you know, symptoms that going up to involve the whole leg. But I guess if somebody does have symptoms involving, they're all like that might be When you think about, if they have their their duplex scan done. And it shows that it tells you that there's no evidence of a proximal femoral vein thrombosis on potentially extending up there again, that's when you'd want to kind of have a chat. But after those patients, obviously, well, didn't go and have a C T V or a name RV, and then hopefully Brady ology will let interventional radiology in or two. Yeah, the other. Quite the other Sorry do of you know, I guess with the Peas, then this is kind of It's emerging, really. But I think the obviously the hemodynamically high, unstable, high risk ones, you know that that's not again for you to be managing. But ah, Dale often be Trumbull eyes. If there's any contraindications for that and maybe an indication to have a chat with intervention radiology to see if they can do something for you. And but it's those particular ones that that the P track trial are going to look at. Those kind of intermediate theater mediate higher risk patients. So if their scoring kind of high on their pet see scores, you know, 3 to 5 on, then they have got, like, evidence of right ventricular dysfunction, so that that'll be one thing. If you're getting a CT pa back and there's there's RV, the some some element of kind of disruption are increased pressure in the right ventricle. You know, I think could could they should be anticoagulated already, But could they be somebody who you could talk to? I are about yeah, just away. And on that I think, practically speaking, most people with unconscious try and pee because probably that's what most F want our hours would be more likely to encounter rather than a acute DVT that needs treatment. So most people we find on anti coagulation, so even if they have a pa, if they hemodynamically stable, then the first port, of course, always gonna be anti coagulation treatment dose delta, part of whatever your trust uses for BT treatment, it's only if the patients are hemodynamically unstable that have a high risk of bleeding like, say, they're already on anticoagulation, then you can't just keep trucking anti coagulation, so that needs to be a escalation of treatment. So typically, when you're thinking about the management, I mean first thing is anti coagulation with the caveat that if they've already got increased risk of bleeding, then the money to escalate, and then with these unstable patients, really, I think you can group them into, like, massive. And some massive, massive pee is going to present, like most likely with cardiac arrest or pretty much on death's door. So you have to go down, you're a less algorithm first and then discuss it with IR for cardiothoracic surgery is the subclasses P, which has now said, like they've got a big peewee evidence of heart strain but a little bit unstable. Those are probably the patients which should immediately think, Yes, we're going to do anticoagulations, but that probably isn't going to cut it. So I've got to discuss it with them by our slush cardiothoracic because it depends on what center and what services. So I think that's kind of the sweet spot for for discussion with IR, so you hope that helps any kind of incoming and Flonase. If you know, obviously, anti coagulation is your first part of cold. But you know, a lot of patients are more complicated than that. We'll need escalation. Treatment say That's kind of the thoughts on that. We'll just go through a couple of three audience questions. The first one is for the for the catheter license with the TPN. A dosage depend on the side of the size of the clock or is it done by the weight of the patient? So imagine that's that's referring to That is probably around the time we were talking about the the in your femoral DVTs and you sit here, Mandria. Yeah, yeah. Um, so the I'm not sure to sit, to tell you the straightforward answer. Maybe Inderal know, But I don't think we do, I think the idea being here, that it's very likely based on patient's weight rather than the size of the clot, because it's the infusion where they kind of continue over a period of time. Eso it can go for 24 hours, come back and do a venogram again and then kind of If if need be there, then continue on that same infusion, which I imagine it's kind of a balance between, you know, the risk and benefits or to be much more are based on patients with it rather than kind of Lord and every patient with the same amount. So, depending on the size, the class, I think, would you be on a on if if it is based on weight and not the size of a clock that I presume I haven't seen it for your family DVT. But I presume it's the same. I can't imagine why would be any different in the same question is what is the risk of an embolism for this procedure? I mean, there there is That is one of the risks that you can send the patient for and because it is a risky procedures, why you don't do in everybody. But you know, so everything is a balance Sorry. Now I feel like a stolen syndrome. You hear everything is a balance between risk and benefits. So you know, if if the patient got severe symptoms or say for the pee that's not responding to under coagulation then is just a risk that you accept. But if you give license treatment and the clot is smaller than the body, is probably more likely to resolve it themselves. Or, you know, the big problem P is that you have a huge clot in the main pulmonary artery. But if it breaks up and you just have a small amount that you know, clot or infarct it, I mean, yeah, it was a bit of a problem, but it is an improvement compared to the the baseline. So, yes, there is that risk. But it is weight up in the decision to treat the the risk benefit ratio. Essentially, yeah, I think I think, look, because I did have a look at this as well, because it's a question that I always ask when I see these procedures, See somebody talking about. But there is no indication, for example, to put in and I DC filter before you like from that point of view, that's not an indication to put an IV see filter like pre intervention in for the vast majority of patients now, that's not to say that doesn't happen. Sometimes if there's kind of notably worrying trumpets are quite a you know, you know, particularly suspicious looking Thomas. They may do that, but it's not kind of common place that all these patients would need to have on ivc filter toe because of that risk. More for these interventions. Um, next question is following catheter Lysis is the follow up imaging with a CT venogram. I'm are venogram, so I think so. Catheter from allies at least appears usually done for the acute. Setting on follow up is done with a check license just 24 hours later, so that is the check to see whether the treatment has worked. But you don't follow them up afterwards. That's really done by clinical assessment, because this is the reason you're doing. It is to essentially to do an emergency treatment. So you've kind of already assessed that whether your treatment has worked. And so then once that's done, then return to the regular follow up for somebody who's got a P or post post people's DVT. If that makes sense, I think that depends a little bit injury on on where on where it is. I know, I know. The guidance, particularly that consensus paper was, was that like this? Probably not enough imaging of these patients being done afterwards. So you know the check ones? Fair enough. They say, essentially, if they're having a stent put in, they should have, um, you know, in some sort of imaging after the stent before their discharge is with the new stent. But then I guess the the routine follow up, as you say, probably will follow back to just that duplex scanning at regular intervals. Because that will be the first sign is long as when they're discharged, that there is, you know, patency and all of that going on in the lower limit things that if that then in the follow up scan starts to look like there's redevelopment off. You know, venous are some sort of a venous obstruction. Then the duplex imaging will initially well, usually be good enough to pick it up, and then they can kind of go on from there. So I wouldn't say a C T, V E R M R O V would be routine in the follow up off off, particularly the DVT patient. That would be ultrasound. And then, if there's any worries that something's redeveloping didn't want to have on one last question from from the chaps. So would interventional radiology be considered in patients? You've got a DVT, or P, but can't be anticoagulated because they're platelet. It's tricky because obviously, platelets are one of the, you know, looking at plated. Stopping antiplatelets is important before you do any sort of an interventional procedures. Well, so they obviously, even even though you're using a pin hole there is that potential to cause bleeding. So I don't know if I can really answer that one. I guess if you could correct their platelets to a point that you could maybe then do the procedure within, like office. If it's an acute situation, that's not an issue that's not a possibility. And but in terms of if, if the risk for anti coagulation was because they you know they had recent surgery or that had some sort of a hemorrhagic stroke, there are in El Mechanical from back to me, options that don't involve litigations, that can be, you know, that that can be used instead of using the litigations, which obviously in and of themselves because you know, have that in turn, inherent risk of bleeding in terms of low platelets. I, I don't know, injured. You have anything on that one? I mean, that's a tricky case, and it's always what you have to have. Um, like medicine, hematology. I are all in the same call, really to discuss that. I mean, as now said, these are invasive procedures. So if the platelets are low enough to prohibit anticoagulation that probably low enough to not put a needle. So that's why it's a very complicated thing. Is that same risk factor that stops them. Having anti coagulation might even stop them having the procedure. Which is why it's not quite simple decision. And it has to be kind of ah risk kind of film, an individual case 40. I've never seen a case with that situation, but it's, um yeah up. One thing that I think that's way above are paid grades and really need to consult multi consultant. And I guess if they have low platelets and that developed some sort of a thrombus, you imagine that there should be hematologist on board there somewhere. Teo help you make those decisions, but that's any other questions in her. We know I think we're done for questions and that we've just come to time. So it's good timing. Cook, uh, again, hopefully that waas in some way enjoyable for people to watch And even just to get a bit of an overview of the background of Venus pathology and that so thank you for joining. Well, thanks. Thanks, everyone for joining you should get an automated linked to the feedback form to claim it certificates. A swell. Just want to say thank you now and thank you to all of our presenters and audience for the whole series because that's the last one fire bites on. Yeah, Thank you for attending on you, Just for you to catch up content. And, uh, yeah, we'll see for the next next ones, but by