Produced in partnership with Arterisphere, this multimedia presentation from Dr. George Adams featuring Dr. Robert Mendes, utilizes case examples and recorded content to outline a tactical approach to arterial access including contralateral antegrade tools & techniques, transcollateral tools & techniques, and retrograde crossing tools & techniques
We're joined tonight by Dr Adams and Dr Mendez, both from U N C. Rex in Raleigh, North Carolina. Um, if you joined us last time, you got to see, you know, the really fun banter back and forth. And if you missed us last time, um, you know, just a quick recap of what we touched, What we covered, You know, we covered the engine's own concepts for anatomy. We have some great case examples, case videos, um, you know, talked through, you know, the importance of access and crossing and kind of set up the recipe for success that will go into in more depth tonight with a very tactical session, which is going to be some great content. So if you did miss the session last time just to let you know that if you go to Phillips elite academy dot com, those video the not the live recording of the session. But the content that was delivered is now live for you to go back and review, and I will send an email following this session tonight with So without any further ado, when I kick it over to Dr Adams, Dr Mendez and and thank you once again for joining us, and we look forward to a fun session tonight. Thanks, Kevin. Um, it's a pleasure to be here again tonight, I think. Bobby, we have a great time. Do we need to introduce ourselves again? You know George Adams, Interventional cardiologist. Bobby Mendez. Vascular surgery. So that was easy. Yeah, we're last time. So we've just discussed the inches on concept in certain vessels. Supply certain distributions of the lower extremity. So now we've decided that we need to take the patient to the endovascular. Sweet. There's a recipe for success. There are several variables that we need to consider. Vessel size, plaque, morphology and disease length. Remember that intervention or endovascular intervention is personalized collaterals runoff status access sites possible such that if you fail from coming from one direction, that there are other ways to skin a cat. In other words, you can use trans collaterals or a retrograde approach to cross one of these chronic total inclusions and then patents the duration requirement, understanding that a lot of these patients who have wounds it takes about four times the amount of blood flow to heal a wound rather than just maintain a leg, and what I mean by that is, is a lot of these patients have have had chronic total occlusion is for a period of time. What's changed is is that they've developed a wound, and now they require more blood flood. But once you heal the wound, you can decrease the amount of blood flow that is warranted. So keeping the vessel open long enough to heal the wound is our goal. The ability to tolerate dual anti platelet therapy and then, lastly, rental function. Remember diets deleterious to renal function, and a lot of these patients are older diabetic, which adversely affects their renal function. So we have to be conscientious of this. On the other end of the spectrum is understanding. What are your failure mechanisms When you treat the vessel, The first is dissection. We try to prevent dissection by utilizing devices that actually prep the vessel by causing control breaks in the plaque so dissection doesn't occur. If that section does occur, then you would treat the dissection with a prolonged balloon inflation or a scaffold such as a stent or smaller scaffold such as a tag. The second is recall again. We try to prevent recall similarly to dissection by prepping the vessel with modalities such as focal force balloons as a threat to me and intravascular Linda Tripp. See, there are biologics to treat Recall which had been investigated, one of which is Vanna Panagiotis in the last failure mechanism is restenosis. We try to prevent and treat restenosis with biologics with drug delivery such as drug coated balloons, drug eluting stents in direct drug delivery. Some of the biologics have been studied include paclitaxel Sarah Lima's anti inflammatories such as steroids and others. So we paused the video just to see if there are any questions at this point. And if there aren't any questions that come in, we can going. Just wanted to take a quick pause and and why you're getting questions and it's interesting, you know all you know, we talk about biologics all the time, you know, in the way to deliver biologics, whether it be with drug coated balloons, whether it be with drug eluting stents. And then we mentioned some biologics where you actually deliver the biologic actually to the advantage of the vessel. Um, there's also bathing the vessel with the tapas balloon so It's very interesting looking at, you know, since that was the last piece of it with these biologics in terms of preventing restenosis and recall. Um, it's very interesting. I think it's an area that is currently being investigated further, and there's a lot more to come. George, are you seeing any of that stuff already out on the regular market over in Europe or in Asia or anything like that? Or is it still research basically worldwide? You know, it's interesting, Bobby. So I think there are some common things that are already being being used. So one is Dex, the methadone for director of delivery. Every Cath lab has it in their picks, is are in there and their pharmacy box. And why? Because of allergic reactions, it's very cheap. $4 of our the other ones. Of course, there are anti, uh, neo proliferate of agents chemo chemotherapeutic, agents, paclitaxel and Sarah Lima's um, and those are on our common Joko to balloons and drug eluting stents. In terms of these anti recall. Not yet, Um, And then the question is, can you get a combination of biologics? Because Bobby and I always talk about, you know, There's probably a personalized method. Not everybody is going to require the same biologic. Depends on where you are, what type of plant mythology you are have. If you're a woman, if you're a man, African American, Caucasian, diabetic, non diabetic. There's a whole lot of things that go into that equation that we're learning. And you know what Bobby and I were talking about just the other day? I think we think that one is probably one of the most exciting areas is stem cells. But I think stem cells may be the wave of the future. We did get one question, um, kind of backtracking a little bit. Any data for for drug eluting balloons or drug eluting stents and tibial vessels? Yet there There's data, Um, and I'm happy to speak on it. So there's a couple in terms of drug coated balloons. Um, remember that it just hasn't panned out below the knee with paclitaxel drug coated balloons. And there's been a couple of studies remembering, actually, um, the question is, is, you know, actually, it may have even caused torm, uh, with paclitaxel. In terms of Linus, we are currently investigating whether Lima's agents are beneficial. Um, there have been some below the knee direct drug delivery with decks and methadone and most recently, attacker alignments. Um, that have shown benefit with the bullfrog device. Um, I'm trying to think what other agents and whatever I was wondering. Actually, that question was planted because he was hoping that question would come to Yeah, McGee, it's all good. But I mean, as far as you know, there's not a lot of well established data yet We do have an idea that there is going to be some sort of a biologic that's going to help in the vessels. Uh, do we have the secret bullet yet? I don't think you do. I think that as you said earlier, you know, when you're talking about all the different types of morphology of black, uh, different types of presentations of the patient, whether that be with multiple comorbidities male or female, Um, those all play major factors, and we still have a lot to sift through right now. But we you know, we get to enjoy it because we're involved in a lot of these clinical trials here at U. N. C. Rex. But it's not yet out in the market and you don't have definitive answers yet. We do have a lot of hope for it, though. And one last thing. So remember Andrew fearing? So he did the Paradise study and what he showed. He was the only one in the country that convinced Medicare to pay him or to reimburse putting drug eluting stents below the knee he passed a couple years ago from pancreatic cancer. Really good guy. But regardless, what he showed us was that in shorter lesions, less than 40 millimeters drug eluting stents actually improved latency, um, and actually were beneficial in terms of outcomes or below the knee disease. And really, that's the only biologic that really stood out with a scaffold. Okay, so drug coated balloons have failed. Bare metal stents have failed. When you compare the balloon angioplasty, the only thing that stood out as a biologic with a scaffold envisions that are short. Yeah, well, no more questions at this time, so we should keep rolling. And then we continue my recipe for success in terms of trading critical and ischemia in the in the vascular lab, there are three things that I believe personally are crucial the first are the tools. A carpenter is only as good as his tools, depending on what type of plaque the patient has the location of plaque that treatment is personalized to you pick certain tools to treat certain pathologic types. The second is skilled techniques, for example, in terms of access, crossing in treatment are instrumental for success and then the third, his patients probably the most important. Remember, these cases can be prolonged, sometimes four hours, so patience and perseverance are key. Now I'd like to focus on the second aspect of access crossing and treatment we're going to discuss. Access in common access sites would include the common femoral artery radio break. You'll access Papa till access and tibial pedal access. We're going to discuss a tactical tactical approach to access. I hope you enjoyed this video. I think that was actually the end of that video. Until we go, there is another video that takes us directly into some of the the tactical approaches that that you mentioned. And I think we don't have any questions at this time. So I think we can go ahead and launch that next video, and, uh, we'll get going Adams. Interventional cardiologist, Raleigh, North Carolina Thank you for joining us at Rex Hospital today. Today's session is going to be a tactical session, a tactical session on access in order to save limbs. So let's start off simplistically. I typically try to think of the anatomy at three levels. The first one is the inflow of the iliac system. The second is the superficial femoral artery and papa till arteries and then, lastly, below the knee, specifically tibial and pedal anatomy. So let's start off with iliac conclusions. So commonly we access the contra lateral femoral artery. Place a catheter at the level they wouldn't take pictures. It allows us to see exactly what happens now when we see an iliac conclusion. If you have, If it's not a flush occlusion at the level of the common iliac, you may have the opportunity to come up and over. However, sometimes we lose support. And if that's the case, there's two other ways in my opinion, that we would access to cross this. The first one is a breaking or radial approach, usually the left arm, so we don't have to traverse the great vessels, and we save in length because we lose length if we come from the right arm. The nice thing about this is that it gives you a straight line into the iliac to give you support. The second access point would be the the common femoral artery on the side of the lesion, such that you come from a retrograde approach crossing the iliac conclusion. Now, if it was a flush inclusion rather than having enough length such that you could come up and over, then we would be forced to either come from a break you or common femoral artery approach. The nice thing about having the Contra lateral similar approach is that you can inject such that you can see exactly, especially in the flesh inclusion where you would place the stent if you were coming from the same side. Federal approach. Alright, we pause it again. Any any additional commentary or questions that anyone would like to ask at this point? I think, Devon, the important thing here is is when you're dealing with inclusions, you need to think outside the box. You need to think about all your access sites, right? So you got to think now radio break. He'll as well as ephemeral. And then how you gonna visualize above so you can treat from below if that's what you're gonna do or vice versa. And so there's other little things that you have to, and I'm sure we're gonna get some of these in the video. But, you know, flush conclusions versus having a site to be able to gain access, whether you call it a nubbin or a purchase site. Uh, you know it all. It all plays a factor into where your approach should be. And then the next thing is push ability and directness by which you get there. Obviously, the more tortuous your approaches, the more difficult it potentially can be. And therefore, that's where the tools really come into play. Whether you're using greater catheters, uh, different types of wires, et cetera, to be able to keep your support and your push ability So all of those things play a factor. Um, and you know, as we all say here, I mean more simple, you keep it, and the more you practice that simple approaches, the more more proficient you're gonna becoming. Taking care of the patient and one of the things you know we commonly talked about the cap morphology. Um, and when we say that you know the cap being, whether it's convex or convict concave, Um, if it's more of a kind of vex coming from above like a like a bowl, for example, your wire will go into the bowl. However, if it's pointed like this at the proximal cap and your wire is gonna is gonna flip off to either direction and more likely to go sub interval. So that's where you would want to come from A retrograde approach. This is especially important. The iliac and the reason why is your iliac star more suspended rather than being compressed by muscles? So it's more likely for you to go outside the vessel and preparations to occur Any other thoughts from vascular surgery perspective in terms of the anatomy of the iliac? No, I think that you've hit the major points there, and, you know, you always want to be aware of where you're where you're trying to get through and be prepared, you know? So being prepared for perforation, I mean, why are going out is not a big deal. I mean, obviously putting a wire out and subsequently. Ballooning is a big deal. And of course, while you're angioplasty, um, you can actually push calcium out, and then you can have eruption. You always have to be prepared for how you're going to get out of these situations so that you're not doing the emergency phone call to whoever is in the hospital. Come help out, although it's always good to have somebody ready to back you up. Um, so it's always the preparation of this whole system. I mean, when I come into a room and watch what you're doing, you have every option already planned out from the fact of getting through this simply easily, or whether it's one of those complex situations where if you do rupture or if you do tears what you have available, you already have the stents in the room. It's like you've already thought through the entire case. I think you do actually most of your homework before you actually get into the case. Uh, and you you're prepared for what you're going to be doing, and that's probably I think you bring up a good point. You know, we when we titled the Lecture Tactical Approach. When you talk about tactical approach is not just crossing and access is actually thinking about what are the worst things that could happen and being prepared such that if these things do happen, then you can get yourself out of it so great. And it also keeps your case efficient. You're thinking, well, ahead of time. If you're going to be using a laser or the Phoenix or another object made of ice or a balloon or whatever you may be using. Well, I know later in this video you've got some great example in some cases that you actually talk through, You know exactly which why are you used and why there is one question and that I don't know. It's answered later, so we'll go ahead and ask it, What if the reconstitution is at the common ephemeral and there's no place to place that sheep? Have you accessed the S F A. So I have I've accessed the to, um, I've accident access to just below the common federal I've access. Did, uh, the Adductor Canal have access to the property? A region, you know. So there's a lot of different areas that you can go into and if you were here the last last time we were on this. You know, it's also we've used vessels that were already included, which reduces risk of bleeding or any kind of complications such as that. So, uh, you will see some of these as we move through some of these case studies here, Uh, some of these exotic approaches and the different things that we can do. But when there's a will, there's definitely away. And if there's an open blood vessel, there is definitely a way. Absolutely. And I think the other nice thing, too, is if you've got a good relationship with the vascular surgeon. From my standpoint, if it is a conclusion that encroaches the common federal, a lot of times Bobby will go in there doing endarterectomy claim that common federal out. And then why is there? We'll do an endovascular approach and go ahead and open up the hill yet, So it's nice to have that opportunity. Yeah, and once again, this is an assessment that you make. So it's just saying that the lesion is flushed to the common ephemeral. Do we access and do we do a retrograde approach, or do we you know, just come from anti great. Only I mean, all of those things get, they have a little bit of it. So, for example, if the patients 91 years old and not able to handle an operation and and really is not and you're talking about getting them out of rest pain and their life expectancy is eight months to a year, Uh, you're not trying to get something that's a three year durability. You're trying to get them so that they're comfortable and they are out of the discomfort and they're able to do what they want to do, be who they want to be for the next, you know, several years of life to improve their months of their life, to improve their quality. So that is a different approach, as opposed to somebody who is 50 years old and has a flush, you know, inclusion all the way down to the comment. From where, you know, you might take it to the vascular surgeon to do the endarterectomy and do something more durable. All those play tactics. Great. Thank you. Well, Alan, we will keep rolling with this video. We've got some more good content coming up. The second, uh, an anatomical distribution is the alpha and pop little conclusions. Typically, what I do is I come from a contra lateral femoral approach, and I'll try to cross from an integrated fashion. If I can't, then that's when I would go for another access site. If there's not enough room for me to place an anti great approach, and why would I use an integrated approach? It would be for stability and support to place it to come from a contra lateral federal integrate approach. You need enough room at the level of superficial femoral artery, so you need at least a neck on that superficial femoral artery to place the sheath again. If it's a flush occlusion, much like the iliac, which we discussed a minute ago, then we need to come from a retrograde approach. There's a couple of retrograde approaches. The first would be a papa till approach, and you can. You can come from a medial sopon approach where the patient is sitting, laying flat on his back and you place the needle from the medial approach and stick to papa till artery. Usually I do that under direct visualization from above the other route is flipping the patient and sticking the pop little artery directly from the back of the need. To do this, you need to make sure you have a long sheath in place coming from the contra lateral femoral approach. If that's the access site you would use to visualize from above. Or you could use a break your radio approach, such as you could visualize from above, such as you could cross and treat from below. The third section is the tibial in pedal chronic total occlusion we're going to get. I think we go ahead and probably show this case and take some more questions after the case this year tibial access. We're gonna discuss retrograde access, especially tibial access and how to get it. And geographically. Typically, if you have an ultra sonography for in your lab that is competent and actually guiding you in tibial access, I would strongly recommend it. It decreases dying radiation. However, most of the people in the world don't have access to someone that is competent and tibial access using ultrasonography. So you need to be versed in the infographic techniques to obtain this access. So for post territorial access to access it. And geographically, remember, the post tibial artery is medial. So we want to bring the camera. Since we're working on his left leg, I want to bring it in. An r e o. This is set up in at about 20 degrees. Oreo. Remember, when we take the needle, it is going to be parallel to the bean, Okay. In perpendicular to the vessel parallel to the beam, perpendicular to the vessel. So the beams are coming down. Needles parallel vessels run in this direction perpendicular to the vessel. It's so important as you're watching it and geographically. So what we've done is we've taken a, uh, flora subtracted still image of the shot, and we place it up there, and we're gonna watch it real time as the needle goes through the vessel. Okay, so let's do this. And sometimes you can feel it, pop and usually have someone watching as I do it. Mhm to see when I get blood flow. So we've got good blood flow. As you can see, it took a matter of maybe five seconds to access. Okay, So if you're comparing and geographic access to ultrasound access is just as quick. You just have to use these techniques if you look at the hardest ones to access. Typically, the posterior tibial is the hardest. Perennial is the next our next easiest and anti material is the easiest. The reason why is the anterior tibial is held in place, and it's superficial. The perennial is held in place even though it's deep. You have great landmarks being with it, being behind the atrocities membrane, so you feel one pop. And then right behind that pop is the appear Neil. But the posterior tibial, even though it's sometimes it's a very large vessel, it tends to move. It's not held in place, so it tends to roll off your needle, married any questions before we go on to the next one. Her comments, I guess, from So you know, I'll comment. You know, I live with the ultrasound in my hand, and so, um, it's one of those things where it is tremendous tool to use. Um, and the windows are very similar to what you're using with your actual imaging with your really your radiation exposure, I guess, is what you're saying. So but the ultrasound is a very useful tool to give me real time access into a vessel. I usually have it all set up before I get in. Uh, the staff gets the ultrasound prepped and ready to go. So when I start that I'm very similar to Georgia just takes a few seconds to gain access. Um, and then you can really get down to some very tiny vessels. I mean, we can get into vessels that are less than a millimeter in size that allows us to gain access and to do some pretty exotic things with it. Um What? I think you're hitting the nail on the head. I think you know, we were just giggling a little bit because most people believe that perennial accesses the hardest. Right? And and Bobby made the comment. You know, the post material tends to move on you. It always tends to roll on you, and it makes it harder to stick Whether you use an expat sculpture sound. Are you using any geographic visualization? So typically, in my opinion, that's the hardest. So granted the perennials deeper and there may be more risk. Um, because the p t n a t r superficial. I think it's easier to hit. Great. We had one question on if the posterior tibial is not visible on angio, do you use ultrasound and watch the needle go in alone with the wire? Right. And that's exactly exactly my point. The nice thing about the ultrasound is I don't I don't need to use, you know, any kind of flow to be able to determine where the vessel is, because frequently you can see the vessel. You can see calcium around its outer limits. Um, and it really is an easy access for you once you're once you get to be proficient with the ultrasound. And, uh, but George is right, you know? Still, most of the world doesn't use ultrasound, and very few of us do. But, you know, it's still a great technique to use for this, and it's safer. No question, there is safer and safer for the patient. And it's safer for the operator. Certainly. Favor for you with your Yeah. Yeah, hands there underneath it. But I mean, look at Bobby looks 10 years older than I'm Actually, I'm actually 70. Thanks, Devin. Yeah. All right. Well, let's go ahead and go to the next case that we can take some more questions after this next one. All right, so we're set up for perennial access. So let me show you how to do this. The first thing we're gonna do is take a flora subtracted shots so we know exactly where we're going. Um, and then we're going to access the leg. That's good. The perennial. Remember, we're going to play our camera l A s. This is the left leg. So you split the tibia and fibula, the parents will run right in between it, and then we're gonna take a micro puncture. Uh, needle will go through, will fill one pop as we're going in. Okay, that pop will be the interest, this membrane, and then the second part will be the perennial audio. It lays right behind it. So what we've got now is we've got the perennial access in place. Did you get this tape handle Access in place, who is pretty straightforward. Took us less than 10 seconds to get it. Remember, the needle should be parallel to the beam perpendicular to the vessel. You'll hit the vest. You'll hit the atrocities membrane, which will be your first pop and then right behind the atrocities membranes appear Neil again. This is a great technique, and everyone should become first at it, especially from an and geographic approach. It's very difficult from an extra vascular ultrasound approach to visualize the pair, Neil. So again, and geographic visualization and understanding this technique is important. Oh, so question on what is the landmark for the Paranal access that you use? Great question so and geographically. So what you're gonna do is you're gonna rotate your camera lateral, just as if you're gonna access and answer your tibial. And what it does is it's plays the two bones, the tibia and fibula. So the more lateral you go, the more the bones will be splayed and the panel will run down the clear space between the two bones. And then what you're gonna want to do is wherever you've rotated that camera to your needle is gonna come into that same angle. Remember again? I was saying parallel to the being perpendicular to the vessel so good parallel to wherever your camera beam is to access. In terms of the landmark, it depends on where it reconstitutes, so it may be low. It may be high, so it just depends on what you're given with the patient. Unless, of course, you're using it as a vessel that's already included. And you're just using interest rate access, then Absolutely the best. And then you pretty much using over. So I guess sometimes you've also used it with radiation and being able to just broke the calcium disease. So yeah, and the other thing I think is important is that with the A t m p t. Once you gain access and once you treat, you can hold pressure from the outside. How do you How do you gain him a Stasis with appear? Neil, you can't. You can't really push from the outside. But what I What I do is I use a balloon from the inside. How do you like to do it? I agree. Internal tampon on. So you're still holding pressure? You're just holding it from inside out, and I usually hold 2 to 3 minutes. Bring the balloon down, inject, see if there's any residual perp that there is. I go up with the balloon again. Hold it two minutes and usually it's gone so real quickly. I mean, so for those that haven't really been doing any retrograde access yet. Um, how do they set this up? So you gain access, you put a small little micro puncture in there. You get your wire, you stare at this safe, we'll go through all that later. But we gain access. Now, how do we get this control on the way out? You come from on top. You come now. Anti grade. You pass a wire past your catheter where you would access your perennial. Now that that wires in place, you can remove and you go down with the balloon Inflate. So would you like to move your small balloon first before you remove the capital? Do you prefer? Yeah, great question. So I usually have my wire passed and I already had my balloon loaded on the wire. So as as you remove the sheep, I advanced the balloon and then pass the sheet. If I can't, if it's if it's big enough, I'll take the balloon by right. But if it's not, then I'll pull the sheet, advanced the balloon and then go up almost leaving the wire in place until you know the balloons across. And then you can pull the wire once you know the balloons in a good position. Okay, but that's kind of the way I do it as well, right? Well, we can. We can move on to the next video, and we'll take some more questions after that next one. Right now, we've successfully gained access. Now let's talk about crossing the lesion there. Typically three scenarios. The first is when we've gotten Contra lateral or integrate. Access, depending on where the lesion is, will determine in general what type of crossing devices will use. So if the lesion is distal, they were going to need longer devices to reach it, Um, as well as smaller profile devices. If the lesion is more proximal, you won't need as longer devices, and they won't have to be as small if we specifically talk about wires. They typically range from an 014 inch to one oh 35 inch platform when we're approaching a lesion. That is significant. Or if we're approaching a chronic total occlusion and just trying to get to the proximal camp will take more of a benign wire, meaning that it has a floppy tip with a strong backbone. If we're trying to cross the chronic, total occlusion will then switch out for a wire that again has a strong backbone that can support the support the catheters but also has a heavy graham tip and maybe hydro filic in nature such that it decreases the orthogonal friction when coursing through this chronic total occlusion. As you can see below, I've given you some recommendations both on floppy and stiff wires in terms of crossing catheters. Remember that when we use the crossing catheter behind one of these wires, it increases the graham strength about 3.5 to 4 times the characteristics I typically look for or choosing. My crossing catheter is what type of lesion and where is it. So if I need something, a catheter that's more stiff so it would be on a straight platform or a straight vessel, for example, approaching the lesion, Um, then I would typically pick the strongest on the market, which is a knave across, which comes in an 035 and I won a platform. The other type is one that is hydro Felix. So if I'm trying to cross through a chronic total occlusion for example, I may use one that's Hydro Felix, such as the C X I and then the transparency of some of these profit crossing catheters such as the quick cross. The advantage of these is if we are attacking or trying to address a distillation, and we buried our wire distantly and typically the wires the longest length or 300 centimeters. If we use 150 centimeter catheter, sometimes we lose our wire in the catheter. So if you can actually see the wire in the catheter, then you feel confident that you aren't pushing that wire forward. If you were starting to push the wire forward, you would have to float the wire by putting a syringe with water on behind it and float the wire inside the catheter so it came out the end of the syringe. Now let's discuss, why are escalation? There was a question earlier that I've held until now. Um, do you start with an 014 and go straight to an eight? Um oh, 35 if you fail for Cal specific iliac cto and I think you yeah, let's see. Let me remind you that you've got a cardiologist sitting here to the left and a vascular surgeon sitting here to the right. So we're probably gonna give you two different answers, and they're not. Not one is right. Not one is wrong. Yeah, well, Bobby is probably right. So let me give you the right answer first. Because that's how it do is I would use an 01 for I use an 014 inch wire on every lesion, whether it be an iliac or whether it be a distal aortic or, uh, toe a digital. Okay. And the reason I do that is someone I feel comfortable with them just because of coronary procedures. But the other thing is, is when you look at all the products on your shell, Okay, when I use an 014 inch platform, I can use every product on my shell when I get to an 18 inch platform. Then only can you use two thirds of my product when I get to one. Oh, 35 a third of my product. So it just leaves all my options open. But if I need more support and more body, then I'll escalate up. What do you think. I think you made a very valid statement there. And that is what you're comfortable with you so that you'd like to go with the Owen for because you're very comfortable with the Owen for, um in the larger vessels, I stay with all three fires. Um, and if I have and it's very rare that I have difficulty getting across. But if I have to use, for example, a pioneer, that's when I will go to no one for to re enter if I'm in the in the Southern people space in the iliac vessel or the common thermal after crossing the opposite direction. So to me, I stay large wire large catheters and yes, uh, you know, you have less tools, but I feel like the tools I have get across and take care of my lesions 90 plus 95% plus of the time when I start going below the knees. When I started going to my smaller wires, uh, and the exotic wires and exotic catheters, Uh, so, yeah, I guess. I mean, we're very different, but it's all about what you're comfortable with and what you were trained with to begin with and that's the bottom line. If you're comfortable with it, you can make it work well, Israel. Alright, we're all our next video speaks directly to wire escalation and you've got some examples. And, um, so we'll go ahead and roll that, and then we'll take some more, uh, more questions. The goal of therapy will be to improve flow by opening up the chronic total occlusion in the significant stenosis in the right superficial for monitoring. I typically always start with an 014 caliber wire because it leaves all my tools available that are on my workbench. If I cannot cross the 014 cool tip wire typically escalate to an 014 polymer coated jacket wire. Typically, that would be a victory wire by Boston. And then, if that doesn't cross, then I would use a higher diameter wire and no. 18 uh, tipped wire, usually going to a 30 g tip that's usually an Estado wire. Once I popped through, then I typically switch out for a benign wire such as a run through wire. We'll take questions after we're in position across the chronic total occlusion, typically with all chronic total occlusion My workhorse wire is a cool tip. Wire the Approach No. 14 CTO wire. The nice thing about this wire again, it's 300 centimeters in length. It's a cold tip wire, which gives you good tactile sensation. I typically put a hockey stick curve on the end of it, and then as I crossed the leash and I do 180 degree turns, as you can see here, Okay, I'm pushing forward with my left hand, filling the cap and then drilling through the cap. Okay, again, this is a cool tip wire, so it gives me good, tactile sensation. It's almost as if I can take my finger. Put it all the way down to the end. The cap and I can feel the end of the cap with the tip of my finger. At least that's the way I think of this wire. The second thing to also remember is that when I use the support catheter against a proximal cap, it increases your tip load probably 3.5 to 4 times. So if this, considering this is an 18 g tip, multiplying that by four is close to 80 g or a little bit less than 80 g. So let's see how easy it is to cross. So just quick pause before we go into into the example. Obviously, we heard from Dr Adams in the video with his some of his favorite wires. Specifically didn't know. Dr. Mendez, you know, talking about some of your favorite wires. Um, yours are the same or different examples. Very similar. But, you know, we were just talking about how young George looked in that video. You know, he asked me. He asked me how old I thought he was, like, you got to be around 2025. And that video, it's hard to tell for sure, but, you know, the wires change. Uh, it more. Although, I think George, you still use the approach. Me? Oh, and so I don't know. I mean, I've moved from different wires I used to use the I don't know, I've gone from everything from the Grand slam all the way through to, you know, using a B 18, or even sometimes the advantage or 18 And things for me changed quite a bit. And, uh, you know, when you really want to get down to the picky details of each one of these wires. The man to be really talking to is man to my left here because I think you've even developed several of these wires. So so and again, I think it depends on on what you want the wire to do, right? So you know, whether you talk about a 1435 inch platforms. But then the question is, how about the grand strength of the wire? Right. We talked about that with putting a catheter 10 million or uh 10 millimeters behind it increases your brand strength four times. You know, in the past, like Bobby said, we used your typical conventional coronary wires. You know, you had a confidence to. Now we have these kinds of pro. That's right. Hey, man, what? We had some. We still use those. But now we've gone to hire Graham streets because we know it 18 30 40 g, and another one for platform. In fact, if you used to back into the wire is 650 g and we do that sometimes if we know where we are, so that's That's another characteristics. The other characteristic gets the hydro Felicity of the wire. Do you have a polymer coated jacket? You have to have a hydro Philly jacket Or is it just bear coded right to give you more tactile sensation? Um, so and then the body of the way we could go into wire design, you know, further later. But I think depending on which you're trying to tackle will help you pick what type of where you want to use to tackle that region. But just to point out, you're going to get a couple of wires that you're going to become familiar with that are going to seem to work in your hands and you're gonna tend towards those almost every single time. While I might sit there and say I would never have used that wire, I use this one instead. So you know it is using the array and listening to people like George and seeing the types of wires that they use. Try a few of them out and then get familiar with one that you're comfortable with and you believe or not, you're gonna you're gonna settle into a couple of wires that are yours that you would like to use and it's pretty evident around our labs. I mean, with the labs that you're in, your wires are in that area. Whereas labs I work in just across the hall. That's where my wires are. And it's amazing how we start to learn and really kind of deviate in different areas. Like the example that you gave earlier that you had so much tactile feedback that you felt like you were almost all the way down on the vessel, touching the conclusion that, you know, you could feel it to that degree. So uh huh. All right, well, let's let's keep rolling and and we'll take some more questions in a second again. Nice 1 80 degree turns slow pressure with my left hand working through the stenosis. Yeah, mhm. Alright. Having difficulty crossing with a cool tip wire, So I'm gonna switch out for polymer Cody jacket wire. So I'm now selected 18 grand victory wire. This is an 014 caliber, 300 centimeter polymer coated jacket wire. The nice thing about this is the polymer coated jacket. I give up some tactile sensation, but, uh, its easier to cross very tight lesions. So let's see how this wire works. So again, this is gonna be 100 and 80 degree turns with our talker As I went all through the stenosis. Yeah, it keeps kicking off that cap wants to go sub optimal, pull up trying to direct it into the vessel. Yeah, I can feel the distal cap. Yeah. So one of the things that you'll notice is the complexity of the distal camp makes it very difficult to re enter. So typically, what I do from this standpoint, because my 18 grand victory keeps kicking off the distal cap because I'm gonna switch out for, uh oh, in a 30 g Estado taking my quick cross down to the distal cap and pop back in. Let's see how that works. Okay. Mhm. Yeah. All right. So this is a 30 g Estado. This is an 018 caliber wire for the 30 g tip again. 300 centimeters, and you can see I put a hockey shaped tip on the end of it. So my goal is to get down to the distal camp, which I can easily visualize under Flora subtraction and then pop back into the vessel. Let's see how it works. I can feel that tip. And I'm I'm just whistling through the tip. Mm. And now we're in the vessel, I think. Oh, maybe not. That's it. Mhm. Yeah. Mhm. A lot of trouble crossing that proximal cap. Mhm. Yeah, Yeah. Thank for their Don't Mhm. Yeah. Okay, so this is called a spinner. We're gonna hook this on the end of the wire. The reason why is this is this spends a lot faster the tip of that wired across chronic total inclusions. So I'm gonna show you how it works. It's really a gun that you press back and forth as you can see here. And it rotates the wire in multiple, 360 degree fashions and then back 360 degree fashions in a very fast manner much faster than I can roll with. Just a talker. So let me show you how this works. So typically you pull it back. Is this you? Loosen it and then you put the tip your wire. Yeah, through the end, as you can see here it comes out the end. Grab it. That Okay, then I bring it up and then I tighten it to the wire. You can use this for no one for wire 018 wire, Whatever. Whatever suits you. So we'll take you down to the end, then. I'm gonna just roll it. Yeah, again, using this to spend through the vessel and slight forward movement. So looks like this has helped us get through. So now what we do is we're gonna take this out, I'm gonna loosen it. And I'm just going to confirm placement because the last thing I want to do is to provide cheap and not know exactly where I am. So my removed the 30 grand wire he got. So I feel like we we know where we are, but I'm not getting good blood flow coming through the quick cross. So I'm gonna switch out for a course there, just to see if it's just the catheter. So we've removed are quick cross before grabbing another crossing catheter, and it was included. So again, we want to make sure we're in the right place. So we're gonna we're gonna flush the quick cross well, and then after we get this flush, then we'll, um we'll go back in and confirm placement. This is what was in the quick cross. As you can see here and was including flow, we flushed it. Now we're going to go back in. We've sort of performed some at directed me slash thrown back to me with the quick cross catheter. Now, let's see if we get a good flushing and confirm placement. So now we get good blood flow, as you can see here. All right, we like to see that. And now I'm going to confirm that we are where we think we are. Uh huh. Mhm. All right. So before we launched the next video, we've got two more videos left, one on trans collateral and one for retrograde. But, uh, any questions or comments, you know, questions from the from the attendees are or additions that you guys would like to make. So while we're waiting for the questions to come You know, when we were showing that first half, I asked George if we're going to actually start talking about the spinner because, you know, he sat there originally, was just using the torture and going back and forth, and and that he was just saying how much that spinner basically has saved his life as far as you know, reducing the number of times he had to rotate the actual capital back and forth. That device has really been beneficial. It's been a big deal for him. Yes, especially for long. Chronic total occlusion is literally it takes it takes off the orthogonal friction on the wire so it will glide right down. The thing is, you just got it. When you're when you're rotating with your left hand, you feel the wire. So if there's any tension or you feel it pops out of the vessel, you need to pull it back, redirected and then go again. Once again, it's the comfort you have to really get comfortable with these devices. So I'm gonna sit here and recommend that when you're starting out with this stuff, you should really try these devices. And, uh, you know, I wouldn't start with the spinner in a 50 centimeter inclusion. I would try it with a 4 to 5 centimeter inclusion and get familiar with it and build yourself up to the longer and more complex lesions. And that way you can develop this tactile sensation that George is talking. We don't have any I'm sorry. No questions at this time. I know, Devon, I think the other thing is important. I mean, sometimes when I sit there and watch myself go through the struggles of picking different wires, the thing that's most important is to make sure you don't rush and you don't just all of a sudden say you know what? I'm just gonna pick another 35 We're Now, just bend it up and try to push it forward, because what it's gonna do is it's gonna dissect the best one. You're gonna make a big sub internal plane. You're never going to get through and you got to switch your access so you have to You have to keep your vision straight. You know your path and go down. That that that thought process so that this wire doesn't work? I'm going to this wire, this wire, this wire. I think you just had a very good point. There is is the shape of your wires. It's moving through this tissue and and the fact that you want to keep it as natural looking as possible. You don't want to see a lot of deviations. You don't want to see a lot of loops or bends. These kind of things actually create more trouble. Um, not the fact that it can't maybe pop you back in lower down because sometimes you do. But it's harder to do that. Number one. But number two uh, then you've gone in and out of some internal planes and then keeping the lesion open afterwards becomes a lot more def. And so I think it's very important, you know, that tactile sensation and that that necessity, I think, to keep your wire in a true shape, true form rather than going and getting loops and other things like that. Say, Well, thank you. Well, let's, um, let's roll the next one and then we'll take some more questions. So let's discuss the second scenario in terms of crossing it would be a trans collateral approach. So imagine you have a chronic total occlusion and you look outside the box and you find another route that you can actually go around the lesion and come retrograde and come through the lesion through the back door. This is trans collateral, So in terms of the equipment that you would use in general, you won't want low profile. Equip equipment long and flexible in terms of the wires. Usually want a benign wire, which has a floppy tip and no one for platform hydra filic or polymer coated and has a strong body so you can carry your equipment through this collateral. These are some of the recommendations that I would recommend in terms of the support catheters, similar characteristics, flexible, low profile and hydra filic. And these are some examples here. So now we've been able to course through the trans collateral, and now we pointed our wire up, and what I would do now is I would switch out the wire caliber or switch out the type of wire for one that has a stiff tip, because we're going to come through the chronic total occlusion in a retrograde fashion. It's hydra filic or polymer coated 014 platform or an 014 inch and sometimes an 018 inch and something that has a strong body so I can carry equipment over it. And these are some of the recommendations as, uh, as you can see here below and then the techniques. So once we're able to cross through this chronic total occlusion. Now, how do you effectively treat? And there's some techniques and we will show these specifically and in later slides. But these techniques would include a wrapping wire technique, a double balloon technique, um, finger God or reverse cart and third dimension or sneering. So let's talk about a case. So this is a probably about a 50 year old African American woman who's very active. She's actually had a below the knee amputation and now has developed a wound on her stump, and she can't wear a prosthesis to exercise. So as you can see here and geographically, she's actually occluded her superficial femoral artery of its osmium. And she has a large D film, a lower price fund, to In the second slide, she has reconstitution of an island of the S F A through a collateral, very small collateral coming off the deep ephemeral. And then it re includes again. And then it reconstitutes at the level of the popular till extending to the level of the stump, as you can see. So what we did again is we identified the route going through the deep ephemeral through this profundity collateral and then coming back up through this island through the chronic total occlusion of the superficial femoral artery. This is after we had failed trying to come from a contra lateral retrograde approach. We couldn't come through the esteem of the S f A. So how do we do it? Well, the tools that we use, we use the floppy tipped wire were able to get through Um, the trans collateral. As you can see here, we used to quick cross catheter, as you can see here for support. Were you able to extend the the quick cross around the trans collateral and then switched out for a chronic total occlusion wire and more or less were able to to traverse with this? Oh, 14 Hydra Filic heavy Graham tipped wire and came through the back door of the chronic. Total occlusion were able to successfully get through the chronic total occlusion here. As you can see, the wire coming through the deep federal back up the S f A. And then we were able to balloon. We ballooned from around the trans collateral came back up in balloon the Osti Um and then we took a second wire in, and as you can see the wires actually are wrapping each other. You have one. Oh, 14 wire coming up in a retrograde fashion. Then I took a second. Oh, 14 wire down from an integrated fashion And wires have a natural affinity for each other. So I wrapped the anti grade wire around the retrograde wire and put it in the normal. Lumen, as you can see here now, we're able to remove our retrograde wire and work over the integrated wire. We then performed balloon angioplasty. As you can see, it resulted in a dissection. We did stenting that we have in line flow, at least to the level of the distal SFe occlusion. As you can see here, this is the dissuasive occlusion. I now switched out for chronic total occlusion wire again cross the chronic total occlusion distantly and performed balloon angioplasty. And this was our final result. I think as you can appreciate. Now this is approximately half a in the mid sf a within line flow. It comes down into the mid East Westphalian proximal populate ill. And the nice thing here is we come through the popular till to the level of the stump you now see now, see blushing of the wound, which we didn't see before, which ultimately will promote healing. So one question for the wire wrapping are you rotating 180 degrees to get that wire to wrap? Yeah, so yeah, so it's a rotating back and forth, and what you'll see is the retrograde wire will dance. It'll start dancing with your auntie grade wire and you know, you know you're wrapping around it so you'll see the retrograde wire bounce, and that's how you know. But you know, there was. There was actually this has only been reported once. You know, people have talked about wires cross talking. You know, we typically see it in the coronaries who weren't going down a branch and the second wire to protect the main vessel, and they'll wrap with each other. And it's just it's a nuisance sometimes, but you can use it to your vantage from an integrated, reintegrated, retrograde approach. There is a paper out of M I. T. Describing this phenomenon with medals, and they do actually have an actual attraction to each other, which I think very interesting. Now that is interesting. Yeah, well, we've uh, you guys laughing at me? We, uh, behind time with our last video is about five minutes. So if you're willing to hang on for a few more minutes, we'll we'll play through the last one. Okay, great. So now let's talk about the third scenario in regards to crossing. This would be one of where we have to come retrograde. So we've accessed retrograde. Now, what are the tools and techniques that we would use? Well, in general, in terms of the tools, we would want long tools that are low profile in terms of the wires. We would usually use a 014 inch or an 018 inch platform, something with a stiff tipped across the chronic total occlusion. It would be Hydra filic or a polymer coated and have a strong rail or a strong body so we could carry equipment over it. These are some of the recommendations in terms of support catheters, similar, uh, to, as we've discussed in the trans collateral, we would want something that's flexible, something that's stiff if it's if it's straight and in line something that's low profile and hydro fillet again. These are some of the recommendations that I would use in terms of the techniques very similar to a trans collateral approach. We would use a wrapping wire technique, double balloon technique and again that could be called Finger of God or reverse cart, as well as taking out the third dimension or sneering the wire. So let's go through a case. So this is a 68 year old female insulin dependent diabetic hypertensive hypercholesterolemia with a non healing wound on the right great toe. So which artery would you think? Thinking about Angie's OEMs. Yep, I'd probably want to. You go after an improved blood flow to the interior tibial. So this is what we're given. So the inflow, at least the vessels above the knee, look good. There's no significant blockages. But once we get to the knee at the level of the P two segment, as you can see here, there's a significant stenosis. The anterior tibial comes off and again, this is the vessel that we were concerned about. It looks good approximately. The TP trunk has some stenosis, Um, and then, as you can see, uh, the anti This is the anterior tibial that comes down. It includes at the level of the ankle. The posterior tibial peroneal include approximately. We then see a reconstitution of the doors house PDS with these two islands on the top of the foot and there looks to be a trans collateral or maybe even a sliver, a vessel that's still open, the supplying one of these islands. When we when we take the camera and put in an angular, hated view this collateral is not connecting to the islands. So we actually try from a, uh, integrate approach to cross this distal anterior tibial inclusion and were unsuccessful. So now what do we do? Access? Retrograde. So what we did is we actually took a micro puncture needle and stuck the more proximal island with the needle. So we then use an 18 inch wire. It's when this 80 centimeters in the link that has a preformed tip this night and all. And I tried to cross the lesion. Um, but as you can see, I was in a sub internal plane from above. I have a quick cross catheter and you see the tip of it here. Um and I injected to see exactly where I was. So now What do I do? We actually are in the Lumen approximately and in a sub internal playing distantly. So what technique do we get, uh, to bring the lumens together? Yep. A double balloon technique, as you see here. So more or less, what I did is I took a balloon, um, over and no 14 platform wire. This is a micro balloon through a 2.9 French sheet and then took a small balloon above. I pulled the wires inside the balloon. I blew the balloons up simultaneously, and ultimately, what happens is it rips the two vessels, and more or less finished rates. The Lumen such that. Now I can come from below and take a wire through a crossing catheter, and then I take the wire and flip it into an angle catheter from above. Okay. And this is what I mean by taking out a third dimension. As you can see, I've taken an angled catheter, and I pointed in one direction. I took another wire that has a hockey stick, uh, type of tip to it that I put on it and pointed it in the same direction. And then I was able to flip the wire into the catheter is similar to as you load devices on your fingers outside the body. Remember, when you load a device on a wire? Well, the reason we press it up against our fingers so you actually take out one of the dimensions. You can put it on easily. That's very similar to what we've done here. So when you point the two angle regulated devices in the same plane, you actually take out one of the dimensions that it makes it easy to cross it into the catheter were then able to extend the wire through the catheter through the integrated sheath such that. Now we're flossing. So we got one tip of the wire coming out, one in one tip of the wire coming out the other end. And now we can work from above to ultimately open up the lesions. So that's what we've done here. We actually balloon approximately, and then what we did is once we balloon approximately. Then I removed the 2.9 French sheath and extended a wire. More distantly, perform balloon angioplasty in the mid segment of the door Salis Penis. And as you can see, now we've actually reconstituted flow to the pedal loop, ultimately to the great toe. So now we've got good flow to the great toe, ultimately healing the wound. That last example. It's just it's just so great. I love watching it. Um, so So one question. Would you do that double balloon technique? Um, you Then you then do, Do you stent Always. Is that always something that you're looking to do with the card or reverse card? No. A lot of times you can pin it up with a with a balloon. I just pull on capacity is what I use. Yeah, and one of the things Devon that you're concerned about when you get more distal you got, especially the anti activity. You've got two ligaments, they cross over that anterior shin, Um, and it'll crush a stent. However, I will tell you that there has been some recent evidence when you look at Scaffold and I'll bring up intact the small tax, they actually a third of the tax use, and they're below the new trial were actually in that third. If you broke the the lower leg up into thirds, a third of those tax replaced in the lower third, Um, which is very interesting. And they had results. So there may be something to placing the scaffold in the future if we need it. But that was just for dissections. It just saying, Well, I just want to remind all the attendees, um, the next session, we really dive into treatment. And you know the strategy there. So talking more about, you know, this one was all about the tactics of crossing. And once you once you've crossed, now you can move into treatment. Um, but, you know, I know we run over time a little bit, but one at least say any last questions over what we just discussed that we could kind of wrap up on anything If it isn't clear that we just discussed before we leave for the night, one quick question came in. What balloon size do you use to do the double balloon technique so you should see needs something that can get to a 2.9 friends sheet. You usually need a micro balloon. Even the coronary over the wire balloons have trouble going through that sheet. So I would say, usually a 20 or 25 balloon from below and then from above, I'll use something very similar, especially in the mid distal tubules. So I think you know that question. It depends upon exactly where you're located. You wanna you wanna be able to match to the size of your vessel because the whole purpose of this is to actually create a registration between the two balloons, Uh, you know, to be able to open up that area. And so I mean, obviously, if you're in a proximal anterior tibia, I I go to 3 to 3.5 in that area. Uh, distal anterior tibial. I'm around 2 to 2.5. Um, Papa Teal, I'm usually around five s f a six, sometimes seven, depending on the size of the vessel. But I'm looking at Yeah, great. Thank you. And I was, of course, right for recognizing the size of that vessel. Shameless plug. Uh huh. Yeah. Already. Um, well, again, I think I think we've We've kept you guys over a couple of extra minutes and we don't have any other questions flying and off the shelf. So, um so? Well, that will say that you know, the third session. Um, we will dive into more of the use of the use of all of us to personalize care. Um, and then treatment strategy. Well, thank you guys so much again. You know, the next session, the third session, we'll get an email out. I'll get an email out tonight about about the were recorded content that is available and thank you both so much. And, uh, really enjoy this. And thanks to Philips chief for supporting this, then you guys are doing a great job getting a lot of this education out there while we are quarantined in our areas. Despite the fact that he's too close to me right now. Like you got to see him all the time so well again. I mean, last year, you know, we were when we were talking about the ultrasound last year, we were there. And you know Dr Mendez we had to be there with ultrasound traffic access. Um, I got 2021. You know, people are on the prize. Thank you guys so much.