 Great, thank you for having me. So today I just wanted to talk to you a little bit about some new procedures that are done in eventually, particularly new emerging procedures and technologies for the treatment of prostate and kidney disease. I'm going to provide a brief overview of prostate artery embolization for benign prostatic hyperplasia in patients with lower urinary tract symptoms. I'm also going to give you a brief overview of some new technologies used for percutaneous arterial venous special creation in patients with end stage renal disease. So in order to start talking about prostate embolization, first it's important to understand what the prostate gland is. It's a walnut sized structure, it's located between the bladder and the penis, and it's important for secreting fluids that help nourish and transport seminal fluid. Now in patients with benign prostatic hyperplasia involves benign proliferation of glandular and stromal tissue in the transitional zone of the prostate. And what happens is that it causes constriction of the urethra, leading to bladder outlet obstruction and lower urinary tract symptoms. It's a very common disease that it actually increases with age, and about 70% of men over the age of 70 has this disease, and it has significant impact on patients' quality of life. Patients are affected by their sleep, they wake up multiple times during the night having to urinate, and also during the day as well. The typical symptoms that patients present or they can present with are voiding symptoms, these are hesitancy or difficulty with urination, they may have a weak stream or dribble, straining during urination, and incomplete bladder emptying. They also may complain about other symptoms which we can categorize as storage symptoms like urgency, having multiple frequency of urination, peeing multiple times at night, they have pain when they pee or super pubic pain. Now the issues with BPH is that long-term complications can lead to urinary retention, this can predispose them to urinary tract infections, bladder catalyze, and sometimes gross hematuria, and when it's severe enough it can lead to renal insufficiency and even renal failure. So the main state treatment of BPH is usually with medical therapy. With alpha 1 antagonists like prazosin or 5 alpha reductase inhibitors like finasteride, and these are usually for treatment of mild to moderate lower urinary tract symptoms. In patients who have their scoring of international prostatic symptomatic score, they usually see improvement about 3 to 7 points and they're often using combination with each other. The issues with these is that they can have significant adverse effects including retrograde ejaculation and orthostatic hypotension in patients with alpha 1 antagonist. They can also have loss of libido erectile dysfunction with 5 alpha reductase inhibitors. Now the gold standard treatment for BPH is transurethal resection of the prostate. As shown in this video clip here it's a procedure that's done by urology where they get transurethal access and essentially pouring out the inner portions of the prostate to create a larger lumen. It's usually used for prostates up to about 80 to 100 cubic centimeters and it does have significant improvement in patients' IPSS scores. You see usually 15 to 16 point improvement and marked urinary improvement flow rates as well. The issues with this is that it is associated with about 20% complications including ejaculatory dysfunction, erectile dysfunction, and since they're going transurethal there could be injury to the urethra, leading to urethral stress, urethral retention and sometimes blood loss requiring transfusion. For patients with very large prostates using about greater than 80 to 100 cubic centimeters open prostatectomy has been the historical gold standard. This has also significant improvement in patients' IPSS scores between 13 and 18 points. But it does come with significant morbidities including major bleeding, sepsis, urinary tract infection, urinary retention, urinary incontinence and also because it can also cause injury to the urethra as well and cause urethral stricture. Now over time there has been development of more minimally invasive surgical therapies called MIS. These include transurethal microwave therapy, prostatic urethral lifts, water vapor thermal therapy and green light laser therapy and all of these procedures they all function to destroy or displace the obstructing prostatic tissue. Now they do have significant less morbidity than TURP and open prostatectomy but they also have less improvement in patients' IPSS scores and higher rates of re-treatment. They're not recommended for larger prostates and also have variable effects for patients with more prominent median lobes. They do require transurethral access so again potential injuries to the urethra can cause urethral strictures or bladder nexthenosis and that can ultimately lead to urinary incontinence and require bladder catheterization. Now prostate artery embolization is a procedure that has developed by interventional radiologists for minimally invasive treatment for laryngeal tract symptoms that are attributed to BPH. It essentially involves embolization or blockage of the prosthetic arteries which leads to ischemia and reduction of the prostate gland. It also causes reduction of alpha 1 adrenergic receptors that leads to smooth muscle relaxation. Now this has been studied since the early 2000s and it's been multiple publications on this procedure including randomized controlled trials, comparative studies, cohort studies and meta-analysis as well as review articles and essentially to sum up the literature over 23 studies from 11 countries more than 2,000 patients with BPH with laryngeal tract symptoms. It has shown that prostate artery embolization has an effective improvement in patients' ASS scores between 10 to 18 points and it is safe with minor major complications and 0.5 percent patients. There's been studies up to six and a half years showing good midterm follow-up results and in patients who either have failure of prostate embolization, they can have the option of urological treatment as well as a repeat prostate embolization with good results. Now this is just to highlight one of the more recent studies that came out. This is a Fiori randomized trial where they essentially randomized 45 patients to prostate embolization versus TURP and what they found was that there was improvement in patients' urinary flow rate which is Q-max and improvement in their prostate volume reduction and that was more with TURP but however when they looked at IPSS scores and quality of life improvements, patients had better improvement with prostate reimbolization. There was also fewer adverse events with prostate artery embolization compared to TURP. This is also another recent study in 2019 and this is very interesting in the sense that there's very few trials that can compare a treatment with a sham trial. Essentially what they did was they randomized patients to prostate embolization versus a sham and sham essentially they placed the catheters into the prostate arteries but they did not embolize the prostate arteries and they had 80 patients, 40 in the prostate reimbolization group and 40 in the sham group. All these patients had severe larynary tract symptoms secondary to VPH and what they found was that patients that underwent prostate reimbolization had greater improvements in their IPSS and quality of life scores. They also found that in about six months after the sham group did undergo prostate reimbolization as well and what they found was that there was improvement after prostate reimbolization in their IPSS and quality of life and there was no difference in adverse events. Now what are the typical safety of prostate reimbolization and what are the risks associated with it? One of the common symptoms that we see is called post embolization syndrome and this is very similar to what we see in patients with uterine fibroids that undergo uterine artery embolization or chemolization for liver cancer. Essentially patients develop pain, dysuria, increased frequency and other irritative symptoms and usually last less than one week and it's usually treated symptomatically. There is minor complications that we see less than 5% of patients including acute urinary retention that might require catheterization and urinary tract infections. Usually these are self-limited and can be treated post-procedure. Now in terms of major complications based on the prior studies, they are quite rare. There was only out of 2000 patients, six major complications as demonstrated in this table. Those include severe urinary tract infection, bladder wall ischemia, severe perineal pain, rectal ulcers, bladder wall ischemia and de novo rectus function. Most of these as you can see in the outcome resolved on their own over time. Some of these are related to what we call non-target embolizations. One of the things that now with newer technologies and especially with cone beam CT that we use for our procedures, we have reduced some of these complications substantially. Now this is a case that was performed. It was a 73-year-old gentleman, had a history of neuroendocrine tumor, the pancreas that was treated, but also was noted to have BPH and lower urinary tract symptoms for the past eight years. He was treated medically with flowmax, which is opulent antagonist, and with minimal improvement. He had a severe IPSS score of 21. His quality of life score was five, which is unhappy. We did check his PSA, which was normal. There was no evidence of prostate cancer. On exam, he had an enlarged multinational prostate. He also had a prostate biopsy again, which was negative for cancer. And his urinalysis was negative for any urinary tract infection. This was his pre-procedure CT angio that did show you can see a large prostate in the nodular. And his prostate volume was about 151. So over the 100 cubic centimeters that we see with normal turf. So in terms of the prostate immunization, it's kind of a cartoon animation that describes or shows you visualization of the procedure. We can access either the groin, the common femur artery, or the radio artery, which we use the most to time. And we can actually place in small catheters down into the pelvic arteries and into the prostate arteries. And using tiny beads or particles, we can embolize the prostate arteries. So usually we treat on one side and then we actually can treat the prostate artery on the other side. And what it does is it leads to ischemia, shrinkage of the prostate gland. And you can see opening up of the passage to urethra for urine to pass from the bladder out to the penis. It's usually done in our interventional radiology suite. Sometimes these patients do need fully catheter placement prior to the procedure. We also give antibiotics before and after the procedure. And this is all done with moderate sedation. We can access, as mentioned from the wrist, transradial approach. This allows to improve patient comfortability and also in terms of anticoagulations. Some of these anticoagulations, we do not need to stop for the procedure if we go transradial access. We use small catheters or micro catheters to get into these tiny prosthetic vessels. And this is an example of showing the perfusion to the prostate with the catheter in the prostate arteries. You can see early and late perfusion. And then after the embolization, you see decreased perfusion to the prostate. And this is also similar findings you see on the right side. The particles that we're using are small in size or microscopic. They're usually 300 to 500 micron in size or smaller. So in this patient, the endowind procedure embolization is followed up after the procedure. His IPS showed significant improvement from 21, which is severe, down to 3, which is mild. His quality of life score went from 5 down to 0. And you can see on his post-procedure imaging, he has decreased prostate volume from 151 down to 39. And interesting enough, as mentioned, that you can actually visually see areas of ischemia within the prostate gland shown in this dark areas. So what are ideal candidates for prostate artery embolization? One of the things we look for is patients who can't undergo surgical procedure or are not a candidate for a miss. These are patients who have poor surgical candidates. Patients who have urinary retention, have long-term indwelling bladder catheters. This procedure is also used for patients who have refractory hematuria of prosthetic origin. So this may be, for example, from traumatic fully with chronic bleeding and requiring transfusions. Patients who have poor surgical, prior surgical history. So they may have had a turp that has failed. Maybe potential candidates for prostate embolization. Also, large prostates. Again, those patients who are not a candidate for a turp and who may not want open prostatectomy. And then in terms of exclusion, patients, we don't perform this procedure for patients with prostate cancer. Or patients who have unsuitable vascular anatomy, like vascular artery atherosclerotic disease or occlusion that's severe that may have chronic occlusion of the prostate arteries. Patients who are renal insufficiency or have severe acute renal failure. Patients with urethal strictures or other causes of symptoms of low urinary tract symptoms, including large bladder stones or urinary tract infections. You recommend treating these first. So in conclusion, just about prostate embolization and this kind of a run through. But just wanted to highlight this new procedure that is safe and has been shown to be effective and for the minimally invasive treatment of urinary tract symptoms related to BPH. It has shown good short-term and mid-term durability up to six and a half years. And based on these new randomized controlled trials, does show that they have similar results to turp with fewer adverse events. Now, before I start there, I just want to just open this up to any questions that you have about prostate embolization. And then we can potentially talk. We can go to our next portion on percutaneous arterial venous fissure creation. If not, we can also see the questions at the end as well. I'm going to go ahead and move on to the next portion of the talk. And again, if there's any questions that do come up, feel free to put them in the chat box for me to review. Okay. The next part I want to talk to you about is kidney disease. This might be relevant to some of you in your practice out there. But as you know, kidney disease in the United States is a very common disorder. And it affects about one in seven patients or people in the United States. That equates about 15% of the U.S. adults and 37 million people. And it's a disease that affects patients as they increase in age, especially patients 65 years and older. And it's not just a disease in the United States. It's a disease world, prevalent disease worldwide. About 2.3 million people in the world have end stage renal disease. And that is increasing by 7% annually. Now, what's the current problems with patients with end stage renal disease? Well, patients sometimes need immediate hemodialysis access. And central venous dialysis catheters are usually placed. We place them in our interventional suites. And they do have benefits like providing immediate access, but they also come with increased risk of infection and overall cost. There's about two to three-fold increased risk of hospitalization related to infection and death for tunnel dialysis catheters compared to AV fishelars and AV crabs. And that equates about 1.1 to 1.5 episodes of catheter-related bloodstream infections per 1,000 catheter days. So the longer that these catheters are in patients, the higher the risk of infection. Now, surgical AV fishelars or AV crabs are the preferred method for hemodialysis. They decrease to have a decreased risk of infection compared to tunnel dialysis catheter. But for surgical AV fishelars, there is longer times for maturation. It can take over three months before a surgical AV fishelar can be used. This is an example of a surgical AV fishelar creation. This is done in the OR, usually with either local or anesthesia. They make an incision in the arm to get accessed into the vessels. After dissecting down and avoiding injury to any other vessels or nerves, they eventually identify the artery that they're making their incision. They have to clamp the arteries before to get hemostatic control. And then after making that incision, they actually form an anastomosis. You can see the surgical sutures. You can also, again, see the clamping. And if they've created an anastomosis between the artery and the vein, they can release the clamps, and they have a surgical AV fishelar. Now, the current problems with surgical AV fishelars is that there is high primary failure rate, about 23% of patients. And these fishelars require multiple re-interventions. Use about three to four interventions per year to maintain their function. There's also a one-year primary patency rate of surgical AV fishelars, only between 43% to 55%. So, again, even though they are beneficial in decreasing infection and can provide hemodalysis access, you require time for them to be used. Now, newer technologies have come out. This is since 2018 percutaneous AV fishelars. There's two types of technologies out there in the market today. This is one of them. It's called the ellipsis system. This is one that we use currently at the University of Maryland. This is an FDA-approved, it's a single catheter system that works over the wire. It requires only venous access. Everything's done under ultrasound guidance. And it uses a low thermal energy to create a fusion between the artery and the vein. And there's essentially no implant that's left behind. So there's no surgical sutures or staples. And essentially, this is how the procedure is done. It's done as an outpatient setting. But we can access one of the veins perforating vein under ultrasound guidance. And from under ultrasound guidance, from the perforating vein, enter into the proximal radial artery. Once we have access into the radial artery, we place a wire to maintain access. And then we place in a vasculose teeth that goes over the wire. And it goes through the perforating vein into that proximal radial artery. And so we have access between the two vessels. We remove the inner dilator. And over that wire, we place in this ellipsis catheter. As you can see, it has kind of one portion of the catheter is going to go into the artery. And the other portion is going to go into the vein, as demonstrated here. And essentially, it acts as someone like a spot welder, where using thermal energy, it burns and fuses the artery and vein together. Again, this is all done under ultrasound guidance. So there's no X-ray or fluoroscopy. It's all under image guidance. And so you essentially created an anastomosis and fused fusion between the two vessels to allow blood flow from the proximal radial artery to go into the perforating vein and into the superficial system of the arm. And creating arterial veins especially. We also ballooned that anastomosis at the time of creation. And then everything is removed and a patient leaves home with a bandaid. It takes about 15 to 30 minutes for the actual procedure. So it's a minimally invasive procedure. It creates a automated side-to-side anastomosis between the two vessels. As you can see, there's no, as with surgical efficiencies, manipulation of the vessels. There's no trauma in terms of clamping. Everything's done using the patient's own anatomy. There's no foreign material, no sutures or staples that are left behind. And it doesn't have the typical traditional surgical incision. So this has been studied since 2017. Actually the lead author, Dr. Hall, who helped create this device was an interventional radiologist. He actually studied several trials in the U.S. There was also trials done in Europe as well. And the more recent study I'll highlight, but I just want to kind of just talk to you about what they found in their initial studies. They found excellent functional patency at one year, about 92 to 94 percent. Patients were able to get two-needle dialysis, which is ultimately what they need for a hemodialysis. And it was about 88 percent. There was also improved time to cannulation, meaning patients can get hemodialysis, functional hemodialysis earlier, as early as 10 days, but on average, use these six weeks. This is faster than compared to surgical efficiencies where it takes, you know, kind of be up to three months before a working fish fluid can be used. Since it's a smaller diameter hole, it creates a less, there's less risk for steel syndrome that you can see with surgical efficiencies. There's also reduction in AB fish of the failures to 5 percent. And there's less need for re-interventions because, again, there's less trauma to these vessels that you see with surgical efficiencies that you don't get the just an axtamodic stenosis that you typically see with surgical efficiencies related to or abnormal an axtamodic connection between the vessels. So there's there's definitely less interventions and as I showed you, that have had effects with patients in terms of cost for them in the hospital. There's also higher safety profiles. This was a two-year cumulative patency study that was done. It was a retrospective analysis looking at two years. This is the largest so far longest term study so far that we have. It was published in 2020 this year. It looked at five access centers in the United States, over 105 patients. And what they found was that patients after the procedure had physiologically mature AB fish. What that means is that the fish had greater than five millimeter diameter. It was over 500 milliliters per minute flow in 98 percent of these fishers. But what's important is that the clinical functionally fish, being fish that can actually be used for hematosis, they found that was successful in 95 percent of patients. They had eight cases of failures or failure to mature out of the 105 patients. And their overall cumulative patency, so you can see it six months was about 97 percent. And up to two years was about 92 percent or 93 percent at 24 months. So it does show good cumulative patency compared to surgical AB officials that have been previously published. And they did also a survey after the procedure about patient satisfaction. And they found that patient at a high level of satisfaction related to this procedure, especially patients enjoy the cosmetic effect of seeing that there's no large incision that they would have if they underwent a surgical AB official. So in terms of patient benefits, so one of the things, so this is kind of the traditional timeline of a patient getting a surgical AB official where they, from day zero, they may have their hematosis catheter place, then you get may refer it up to 15 days to 30 days before they finally see a surgeon. It could take them to a month before seeing a vascular access surgeon. And then a time that this actually created may take an additional three months or more for a fissure to be workable. So you can imagine up to 90 days before a patient can get a working fissure. And there's also multiple visits they have to see if they need anesthesia, they may have to see anesthesiologist. They're gonna need vein mapping and surgical consultation. So possibly reducing these steps by doing a percutaneous AB official can help get their access much quicker and also reduce the number of catheter days that they have a ton of DOS catheter. This is all done as an outpatient procedure. The procedure is fairly short, about 10 to 15 minutes for the actual procedure, plus or minus recovery time. And this is a good option for patients who either can get a surgical AB official or want other options. In terms of additional benefits, the patients leave with a band-aid, there's no surgical scar or disfigurements that sometimes you can see with surgical AB official is secondary to the procedure. Now in terms of hospital benefits, there was a study that looked at endovascular creation of AB officials versus for a surgical AB official, it takes about four interventions per year to maintain them. And this has significant long-term costs. Over one year it can cost up to $14,000 to maintain this fistula. Compared to endovascular fistula, which takes about less than one intervention or 0.46 interventions per year, you can see the cost is much reduced in terms of about only $1,000 to maintain this fistula. So by having fewer re-interventions, it can help lower the cost to both the patient and to the healthcare system. Additional benefits is that with catheters, there are multiple issues that can happen. You can have catheter occlusions, infection, and all these leads to increased hospitalization and cost as well in potential death. So if you can get patients in with a fistula faster, reduce the number of need for catheter dialysis, this potentially decrease the risk of catheter-related line infections, bacteremia, and increased hospitalization. You also can reduce the need for central venous catheter malfunction and replacement. So what are ideal candidates for percutaneous AV fistula? Patients that have or need long-term hemodialysis, patients who are not candidates or do not want to undergo surgical AV fistulas, this is a potential option for them, especially those patients with chronic kidney disease stage four or five that may need elective hemodialysis. Usually all these patients do get vein maps prior to the procedure to make sure they're suitable candidates. Patients have to have target vein diameters greater than two millimeters, as well as a proximal radio artery has to be greater than two millimeters. The distance between the two vessels also needs to be within 1.5 millimeters. This is the limitation of the device to make sure that the artery and vein are close together for a nastimosis. And they should have a life expectancy greater than one year. So in conclusion with percutaneous AV fistula, it is a new and innovative technology that does so far in the up to two years provide reliable and functional vascular access. Further studies of course are currently being worked out and looking at the longer term impact of this new technology. It does provide a quicker access for AV fistula creation and the benefits to patients in terms of not only quicker access but also you don't have the typical incision or scar that you see with surgical AV fistulas. And there's shown excellent two-year cumulative patency and high level of patient satisfaction. So with that I just wanted to conclude