 It is another beautiful day in New York City and we have a very interesting blog today because we're doing something a little different at the hospital and that thing is live case broadcast to the entire world. This week we're doing something called treat which is transradial arterial embolization. Something, I don't know, I'll post it up here because I forgot the name of it. So basically what we do during this course is we just essentially broadcast live cases to the entire world of some crazy, interesting transradial cases that we are doing this week. So I know it's on the docket in terms of procedures this week and I'll bring you along for the ride. Check it out everybody. The brand new hat for treat 2020. We did a new color every single year. Last year was blue. This year is a burgundy port wine color. So we are here today. It is officially Tuesday morning now and today is the big day for our live case presentation. You've now seen the new hat we get to wear today and everybody on our team wears it because today is a huge team effort and everybody has to participate to make sure everything runs smoothly. We are running one, two, three, four rooms I believe. We're going to be having cases in there the entire day, cutting to each room back and forth, back and forth and let's see how everything goes. And then he's gonna put a green screen here for the moderators. Here, he runs everything on his computer. It's pretty cool, right? There's gonna be two IT guys. They run the cameras and all. You can see the four kid camera there. That's gonna, that's sick. It's gonna film the moderators and then they have the TV up here. So that is just a little sneaky. I'll film some of the procedures and be doing procedures and all that sort of stuff and we'll see what happens. All right, so we are about to start the voice over a portion of this video which you all requested so much. So we're back in the IR suite here. This is me on the bottom right corner getting scrubbed in. That is my co-resident. He is a R3 IR resident, Dr. Tim Tarlin helping me set up for the procedure. And yes, we do set up for our own procedures in New York City, especially. A lot of programs vary with the setup but the residents and fellows tend to set up all the cases in New York City. Where I came from at University of North Carolina the tax actually set everything up for us and it was very nice to say the least. So that spin I just did was me just tying my down prior to scrubbing in completely. The patient is completely covered at this point on the IR table and we're just getting everything ready for the transradial procedure. Practicing good radiation safety here lifting the bed as high as possible to decrease the scatter and we bring the flat panel detector close to the patient as we can as well. So right now I'm getting all of the radial access supplies ready for the transradial access. There's a 21 gauge needle, a small wire, a sheath and a radial cocktail as well. That was my attending who just walked over to Dr. Aaron Fishman. He just walked over to say hello to the patient. What sedation do we have so far? We do have anesthesiology on board here sedating this patient. Right there my attendant asked what sedation the patient had for fentanyl and versed which is our usual sedation. Right now I'm getting the flush bag set up for the sheath and that stick on a burn. I just told the patient about was the lidocaine going in underneath the skin. We usually inject about one CC for transradial cases. That's pretty much all you need for this. So I'm currently trying to get access into the radial artery here. If you look closely at the ultrasound machine you see that white area that is the radial styloid and the radial artery is right on top of that. I was actually having a lot of trouble getting this access. It was a really, really, really small artery. My attendant also had trouble but we ultimately ended up getting it between the two of us. So the sheath is in at this point and I'm hooking up the flush bag to the sheath. It keeps a constant drip of heparinized saline into the sheath to make sure it doesn't clot off during the procedure. I'm flushing the sheath right now and connecting the flush bag. So now we have Dr. Blue, Dr. Fishman who are both attendants and Dr. Carlin next to my left right now. Three mites. We need Blue and Michael to have a microphone. Can I get a thousand of nitro and five milligrams of verapamil and two separate syringes? So he wants nitro and verapamil in case the arteries we encounter get into spasm we can kind of open them up during the procedure. My co-resident Matt Tangel brings me over a headset. So right now I'm advancing the wire and catheter through the radial sheath we got access in and I'm watching it as it goes around through the subplavian artery and down through the arch. We're trying to find the origin of the right prosthetic artery here. And we are about to start our live component of this case conference right now. Good morning everyone. I am here in room five with a great case for you. I'm standing next to Dr. Choline here and Dr. Blue as well as Dr. Carlin, one of our PGY3 residents and one of our PGY6 residents and then Dr. Blue is one of our partners here. So I'm going to turn the slides over to Dr. Choline who's going to present the case for you guys. All right, so we're going to set a case of prosthetic artery inhalation as you know. So as you've complained here, a lot of lower urinary tract symptoms like there are in the VPH. 20 year history of VPH which has been managed while it's been asked right. So I'm going to show what we've done so far can you see the wrist? We zoom in on the wrist maybe? All right, so we've got access with a four or five slender sheet and then we came down, you guys can see the floral fee. We came down the arch with an aqua bird, or French bird which is 125 centimeters and a pesto fly. And then you guys saw the CTA. You guys can see the anatomy here and this is actually a pretty tricky iliac anatomy. It took us a few minutes to actually get into that internal iliac on the right side, but we were able to do that with a fly wire. This was our first NGO. You guys can match that up with what we saw in the CTA. So I do a CTA pretty much every case for several reasons. I think, I know someone was talking in the previous case about planning and I think this is a key part of planning for our prosthetic inhalations to find out exactly what we're going to be dealing with. So we weren't surprised when we saw that origin. I'm going to let, we're going to sort of try to get into this arch over here. You guys can see it. So this is a 2.0 Terumo prograde micro catheter with an 016 fathom wire, okay? We are going to sort of just, oh, it looks like we're pretty deep into the vessel already. So we're going to sort of stop here and take our wire out. I'm going to do a quick little NGO. Yeah, it's very tortuous and we're basically hooked. I think you guys saw the risk, but this 125 catheter is completely hooked. We're cool, I can hear you, but I don't think you can hear me. All right, I'm using 200 hydroperol removal. That's generally been my experience. I don't think the lidocaine is that useful because we're not seeing a lot of that type of pain. Most, what's more important is nitro and then anti-inflammatories. We're starting to actually see a collateral here. You guys can see that very subtly on the monitor here. So we're going to take a 1-S as the injection test that helps sort of get a sense of what we're dealing with. We're getting close to sort of finishing this side. And then we're, you know, I was going to talk to you guys a little bit about how we finish these cases, whether we put gel foam in, whether we put coils, other things to sort of try to completely include this vessel. And I know this is, the sound is a little off right now, so I'm having a hard time sort of communicating with you guys in real time. So it's a little bit challenging. But what I will tell you is that we're going to probably put a coil in this artery at the end of the procedure. Sorry, it's four millimeters rule, four millimeters. You guys can zoom in on the detacher for us. All right, well, we're going to go to the other side. Hope that we'll come back. Chris, can you do it with us after a year? Yeah, let's go to the other side. Okay. So before we go over to the left side, we're going to place one more coil in the right. We are actually using a detachable coil system here. And you'll see me grab this green box, I place it on the end of the coil. It lights up to let it know that it's ready to be detached and then you can actually pull out the wire after that. So right now we're just making some simple adjustments before we go over to the left side to make sure we see what we're doing. We have to pull the catheter out of the right internal iliac artery. And what we'll end up doing is pulling the catheter back under fluoroscopy, injecting some contrast and then advancing it into the contralateral left common iliac artery, and ultimately into the left internal iliac artery. Two hours. Yeah, 200. Here you see Dr. Fishman asked for another vial of hydroperols that is the embolic or the particle embolic that we're using for the prosthetic artery embolization. We use 200 micron in size for this particular case. So right now we're about to do a run and what we'll end up doing is tilting the II or CRM in an ipsilateral oblique fashion to better characterize the internal iliac artery. It's four for 20. So right there, four for 20. That's our rate of contrast injection, four CCs, a second for a total of 20 CCs volume. This beep right here is the contrast going in. We're doing a digital subtraction and geography. And we usually leave the room for this because the radiation is a lot higher than just normal flora. That's okay. I mean, we're just embolizing. We're getting a great embolization on this side and we talked about endpoints. We're basically at that endpoint now. We're pretty distilled. We could probably go a little bit more distilled but I think we're filling up that bottom second of this artery very well. All right, we're done. So right now we are all finished up. We did the same thing on the left side as we did on the right side. Right now we have to take off the sterile field. We'll put on the TR band over the left wrist where we access the left radial artery. You'll see Dr. Fishman do that right now. I'm just moving the CR out of the way. So the TR band is basically a little watch we put over the radial access site and blow up a balloon. You'll see him insert 15 CCs of air right now. We slowly let down and take out the sheath and leave it up for about an hour and a half. Check for pulse after you place the TR band. You should have good hemostasis here and that's it. This video is sponsored by Skillshare. Skillshare is an online learning community with thousands of inspiring classes for creative and curious people. Explore new skills, develop existing interests and get lost in creativity. Now as you all know, I recently picked up a brand new laptop and updated my video editing software. And now I'm trying to up my game with edits and filmmaking. This is where Skillshare comes into play. 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